ORIGINAL ARTICLE

Increased incidence of iron deficiency anemia secondaryto inadequate iron intake in institutionalized, young patientswith cerebral palsy

Athanasios Papadopoulos Æ George Ntaios Æ Georgia Kaiafa Æ Fotios Girtovitis ÆZoi Saouli Æ Zisis Kontoninas Æ Michael D. Diamantidis Æ Christos Savopoulos ÆApostolos Hatzitolios

Received: 11 September 2008 / Revised: 25 September 2008 / Accepted: 6 October 2008 / Published online: 11 November 2008

� The Japanese Society of Hematology 2008

Abstract We observed high incidence of anemia in

patients with cerebral palsy sheltered in a specialized

institution in Thessaloniki, Greece. Therefore, we decided

to investigate its cause. We studied 108 patients, and

assessed complete blood cell count, peripheral blood

smear, serum iron, ferritin, folate, B12 and the presence of

hemoglobin or parasites in the stools. In all cases, anemia

was hypochromic and microcytic. Approximately 33% of

patients suffered from hypochromic anemia, whereas 38%

were iron deficient. There was no statistical difference in

the incidence of iron deficiency between different age

groups. All tests for fecal occult blood or intestinal para-

sites were negative. Folic acid and B12 levels were within

normal range in all cases. We also found that 87 and 95.6%

of patients on liquid diet were anemic and iron deficient,

respectively, compared to only 18.8 and 22.3% of patients

on normal diet. The high incidence of anemia was attrib-

uted to iron deficiency which was secondary to inadequate

iron intake and decreased iron absorption. Thus, it would

not be irrational to consider iron supplementation as the

first measure in such patients and postpone endoscopic

procedures for a later stage, unless there are clinical or

laboratory findings (such as fecal occult blood) suggestive

of gastrointestinal blood loss.

Keywords Iron deficiency � Hypochromic microcytic

anemia � Cerebral palsy � Institutionalized patients �Iron supplementation

1 Introduction

Iron deficiency constitutes one of the most frequent causes

of anemia [1]. Most usually, iron deficiency is attributed to

chronic blood loss from genito-urinary or gastrointestinal

tract [1]. On the contrary, iron deficiency anemia secondary

to inadequate iron intake is extremely rare [2]. There are

some reports of epidemics of iron deficiency due to low

intake in certain vegan populations [3], in populations with

high incidence of hookworm infection [4], as well as in

severely disabled hospitalized patients [5, 6]. Thus, we

thought it would be interesting to investigate our obser-

vation of high incidence of iron deficiency anemia among

patients with cerebral palsy sheltered in a specialized

institute of our city.

2 Patients and methods

We studied 108 patients (55 males, 53 females) ranging

between 8 and 29 years that were hosted in a specialized

institute in Thessaloniki, Greece, due to cerebral palsy.

In most cases, cerebral palsy resulted from perinatal

hypoxemia; other causes included craniocerebral traumas,

infections of the central nervous system and hereditary

disorders.

We assessed complete blood cell count, peripheral blood

smear and anemia-related biochemical parameters, such as

serum iron, ferritin, folate, B12. Moreover, all patients

A. Papadopoulos � G. Ntaios (&) � G. Kaiafa �F. Girtovitis � Z. Saouli � Z. Kontoninas �M. D. Diamantidis � C. Savopoulos � A. Hatzitolios

First Propedeutic Department of Internal Medicine,

AHEPA Hospital, Aristotle University,

54636 Thessalonı́ki, Greece

e-mail: ntaiosgeorge@yahoo.gr

123

Int J Hematol (2008) 88:495–497

DOI 10.1007/s12185-008-0191-3

were investigated for the presence of hemoglobin or par-

asites in the stools.

3 Results

Table 1 presents the incidence of anemia in our sample. In

all anemic patients, the examination of peripheral blood

smear revealed hypochromic and microcytic erythrocytes,

whereas mean cell volume (MCV), mean cell hemoglobin

(MCH) and mean cell hemoglobin concentration (MCHC)

values were below normal (normal values for MCV, MCH

and MCHC are 80–99 fl, 27–32 pg and 32–35 g/dl,

respectively). In the same table, we also present the inci-

dence of patients with decreased levels of serum ferritin. In

particular, 33.3% of patients presented with hypochromic

anemia (30.9% of males and 35.8% of females), whereas

38% were iron deficient (35.8% of males and 40% of

females). Both anemia and iron deficiency were more

frequent in females, although this difference was not

statistically significant.

Table 2 presents the mean values of hemoglobin, serum

iron and ferritin levels as well as MCV, MCH and MCHC

in anemic patients. All these parameters showed a trend to

decrease in anemic females compared to anemic males,

although this difference was not statistically significant.

In Table 3, we present the incidence of anemia or iron

deficiency relative to the type of diet. Higher incidence of

anemia and iron deficiency was detected in patients on

liquid diet (due to inability to chew) compared to those

on normal diet. In particular, 87 and 95.6% of patients on

liquid diet were found to be anemic and iron deficient,

respectively, compared to only 18.8 and 22.3% of patients

on normal diet.

Table 4 presents the incidence of iron deficiency in

different age groups. There was no statistical difference in

the incidence of iron deficiency between different age

groups.

All tests for fecal occult blood or intestinal parasites

were negative. Folic acid and B12 levels were within

normal range in all cases.

4 Discussion

We ascertained high incidence of iron deficiency anemia in

our patients. The incidence of iron deficiency anemia was

similar between males and females (Table 1), as well as

between different age groups (premenstrual or not),

something that leads to the conclusion that menstrual blood

loss was not the underlying cause. Moreover, gastrointes-

tinal blood loss and parasitic infection were ruled out since

fecal occult blood tests were all negative and no parasites

were detected. Thus, we concluded that iron deficiency was

not secondary to iron losses.

The institute was preparing two different menus daily:

the first was in liquid form and was prepared for patients

that were unable to chew, whereas the second was a

common menu in solid form. Both menus, and especially

the first one, included various types of food, some of which

are either poor in iron (such as milk, cheese, cream,

Table 1 Incidence of anemia and iron deficiency

Males (n = 55) Females (n = 53) Total (n = 108)

Anemia 17 (30.9%) 19 (35.8%) 36 (33.3%)

Iron deficiency 19 (35.8%) 22 (40%) 41 (38%)

Table 2 Mean values of hemoglobin, iron, ferritin, mean cell volume

(MCV), mean cell hemoglobin (MCH) and mean cell hemoglobin

concentration (MCHC) in anemic patients

Males

(n = 17)

Females

(n = 19)

Total

(n = 36)

Hemoglobin (g/dl) 10.7 9.03 9.6

Serum iron (lg/dl) 49.7 34.3 42.1

Serum ferritin (ng/ml) 21.2 6.8 13.7

MCV (fl) 74.5 73.8 74.0

MCH (pg) 24.7 24.1 24.5

MCHC (g/dl) 30.6 30.2 30.4

Normal values for hemoglobin: [11.5 g/dl for children aging 2–

12 years, [13 g/dl for adolescent boys, [12 g/dl for adolescent girls,

[13.5 g/dl for adult men and [12 for adult women. Normal values

for iron:[50 lg/dl for children,[65 lg/dl for adult men and[50 lg/dl

for adult women. Normal values for ferritin: [7 ng/ml for children,

[20 ng/ml for adult men and [10 ng/ml for adult women. Normal

values for MCV, MCH and MCHC are 80–99 fl, 27–32 pg and

32–35 g/dl, respectively

Table 3 Incidence of anemia and iron deficiency according to the

type of diet

Liquid diet (n = 23) Normal diet (n = 85)

Anemia 20 (87%) 16 (18.8%)

Iron deficiency 22 (95.6%) 19 (22.3%)

Table 4 Incidence of iron deficiency in different age groups

Age (years) Iron deficient patients (n)

8–10 4/10 (40.0%)

10–15 5/12 (41.6%)

15–20 12/28 (42.8%)

20–25 12/36 (33.3%)

25–29 8/22 (36.4%)

496 A. Papadopoulos et al.

123

yoghurt and rice) or inhibit iron absorption (such as vege-

tables, pulses, grains and cereals). Thus, we assumed that

iron deficiency could be secondary to both inadequate iron

intake and decreased iron absorption. The extremely high

incidence of iron deficiency anemia in patients on liquid

diet (which was poor in meat) hints towards our hypothesis

(Table 3).

In order to confirm it, we calculated the iron content of

the two menu types of the institute. We found that a

standard liquid menu contained 6.7 mg of iron on average,

whereas a standard solid menu contained 9 mg. The rec-

ommended daily intake of iron is 10, 12 and 15 mg in

children, adolescent males and females, respectively [7].

Fertile women need approximately 15 mg daily, whereas

postmenopausal women and adult men need approximately

10 mg [7]. Obviously, in all cases, both menus were low in

iron, supporting our conclusion that iron deficiency anemia

was due to inadequate iron intake. The fact that female

patients were more anemic than males (Table 2) was

attributed to the additional effect of menstruation on iron

balance.

In general, iron deficiency anemia due to inadequate

iron intake is rare. There are some reports of such epi-

demics in areas with high incidence of hookworm infection

[4], or in areas with low consumption of meat in which

nutrition is based mainly on vegetables, cereals and rice

[8]. Such foods contain phytates and polyphenols which are

strong inhibitors of iron absorption [9]. However, iron

deficiency anemia due to low iron intake is extremely rare

in Western countries. In 1979, Vir et al. [6] found that

33.3% of males and 12.3% of females institutionalized in

Belfast, Ireland were anemic. Similarly, in 1988, Williams

et al. [5] showed that severely disabled hospitalized

patients with multiple sclerosis may be at risk of iron

deficiency.

Summarizing, we detected increased incidence of iron

deficiency anemia in patients with cerebral palsy.

Moreover, we showed that anemia was not secondary to

chronic blood loss but due to low iron intake. We believe

that this finding is of importance since such patients do not

easily tolerate invasive techniques such as gastroscopy and

colonoscopy. Thus, it would not be irrational to consider

iron supplementation as the first measure in such patients

and postpone endoscopic procedures for a later stage,

unless there are clinical or laboratory findings (such as

fecal occult blood) suggestive of gastrointestinal blood

loss.

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