In this episode of The Flow, Dr. Meghan Pike, MD, FRCPC, Pediatric Hematologist, IWK Health/Dalhousie University, Halifax, discusses anemia and iron deficiency in adolescents. She offers information on symptoms and how to manage iron deficiency. Dr. Pike also discusses the benefits of her WeThrive app which is available to download.

Thanks so much for having me.

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My name is Megan Pike.

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I'm a pediatric hematologist in

Halifax, and I will be sharing some

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information with you today about anemia

and iron deficiency in adolescents.

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So here's what we'll cover today.

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We'll talk about the role of iron in

our bodies, and then I'll define for

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you what iron deficiency And and anemia

mean I'll talk about some of the causes

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and iron of iron deficiency and anemia,

especially those that are most common in

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teenagers and then I'll share with you

some common symptoms of iron deficiency

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or anemia and how you and your health

care provider can make a diagnosis.

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And then I'll review some treatments for

our deficiency and anemia and some pros

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and cons of each of the different options.

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So what is the role of iron in our bodies?

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So iron is a molecule that serves

as a building block for something

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called ATP, which is an energy

molecule that all of our cells use.

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So iron essentially is essential

to generate energy in our body.

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Iron is also a part of hemoglobin.

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Hemoglobin makes up red blood cells, and

red blood cells are what circulate in our

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blood to bring oxygen all over our body.

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So to provide oxygen to all of our

muscles and tissues and all of our organs.

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Um, so hemoglobin carries oxygen

on a red blood cell, but it

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requires iron in order to do that.

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And so what causes iron deficiency?

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So iron deficiency means that

someone has low iron, and usually

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that happens when the body's

demand for iron exceeds the supply.

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So there isn't enough iron to keep

up with the body's energy needs.

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Um, this actually affects almost

40 percent of adolescents and is

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more common in females than males.

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Iron levels can be measured by

calculating a circulating iron.

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So that means that, um, a healthcare

professional would take your blood work

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and measure the amount of iron circulating

in your blood at any given time.

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This isn't very accurate because if

you just ate a steak, for example,

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and then had your iron checked, Um,

it could be high, but that's not a

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reflection of your iron stores and iron

stores are how we use iron for energy.

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So, the way we measure iron

stores is by measuring something

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in the blood called ferritin.

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That's a blood test that your

health care provider would order.

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And the ferritin gives

an idea of iron stores.

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Here in Canada, We accept a ferritin

greater than 20 or 30, um, and ideally,

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especially if someone is having

symptoms of iron deficiency, I sometimes

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target a ferritin greater than 50.

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It's not uncommon for teenagers,

especially females who are having regular

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periods to have a ferritin in the 20s

and 30s, unless they're symptomatic,

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it doesn't need to be treated.

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So the ideal ferritin level

really depends on the person.

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Iron deficiency, if left untreated,

can cause anemia, so it can cause

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hemoglobin to be low, and iron is

essential to building hemoglobin.

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And so iron deficiency

and anemia are different.

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It is possible to be iron

deficient and not anemic.

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So if you're worried about iron

deficiency, it's not enough

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just to measure hemoglobin.

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Um, you should also ask your health

care provider to measure a ferritin.

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So what can cause iron deficiency

that can lead to anemia?

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By far the most common causes in growing

teenagers are decreased iron in the

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diet and heavy menstrual bleeding.

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So that's heavy periods.

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Some teenagers live with what we

call bleeding disorders, which means

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that they're more likely to bleed.

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For example, they may have frequent

nosebleeds, they may bleed from their

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mouth when they're brushing their teeth,

or they may bleed into muscles and joints.

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Those patients are at risk of iron

deficiency because they're losing

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iron in the blood that they're losing.

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Decreased iron in the diet is

the most common during periods of

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rapid growth, which is why it's

especially true for teenagers because

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your body is growing so quickly.

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And people that drink a lot of

milk, especially infants drinking,

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um, close to a liter per day can

interfere with iron absorption.

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But by far the most common causes of

iron deficiency in teens are decreased

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iron in the diet and heavy periods.

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So that just brings me to an aside.

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Given that heavy periods are one of the

most common causes of iron deficiency,

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how do you know if you have heavy periods?

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Well, luckily, there's an app for that.

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So two years ago, I released an app

called WeThrive, which is designed

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for adolescents to answer that exact

question, are my periods normal?

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Downloading We Thrive can guide you

into tracking your menstrual cycle,

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or by answering a questionnaire

that asks questions about your

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quality of living, and that can help

identify heavy menstrual bleeding.

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So if you follow the instructions

on the app, it will do it for you.

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So you can follow us at we thrive app.

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We're also on tick tock and there's

some really helpful posts there

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to show you how to use the app to

identify heavy menstrual bleeding.

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I also put together a little memory

tool for some screening questions that

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might help identify heavy periods.

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So if you answer yes to any

of these questions, you may be

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someone that has heavy periods.

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So do you pass large clots,

like greater than a centimeter

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clots with your menstruation?

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Have you ever bled every day during

your period for seven days or more?

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Have you ever had a period so heavy that

it stops you from doing something that

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you want to do, such as going to play

sports, swimming, or going to school?

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Have you ever had to change your

product more frequently than every hour?

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Have you ever flooded past your product

onto your clothes, your pajamas, or

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your bedsheets overnight, or had to wake

up overnight to change your product?

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Have you ever doubled up on products?

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So have you ever worn two pads or a

pad and a tampon at the same time?

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And have you ever soaked through

your product onto your pants?

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So sometimes soaking onto the underwear

can be very normal, but if you've soaked

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past your product and past your underwear,

that's a warning sign for heavy periods.

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So how might you know if you

have iron deficiency or anemia?

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Some patients don't feel any different,

but we are able to detect iron

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deficiency or anemia on blood work.

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However, the most common symptom with

iron deficiency or anemia is fatigue.

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And that's because, as I showed you, iron

is used as a building block for energy.

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And when we can't build

enough energy, we feel tired.

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In addition, if someone has anemia,

they might feel short of breath,

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lightheaded, or more prone to fainting.

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Patients with iron deficiency may

experience headache, and patients

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with anemia may look pale, so their

skin may look lighter than usual.

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And sometimes patients that have

really severe anemia will complain

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that their heart is racing.

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So it feels like their heart

is beating out of their chest.

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Sometimes their health care provider

can even hear what we call a heart

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murmur, which is the sound of blood

flowing really quickly through the heart.

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And that can be an indicator

for your health care provider

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that you may have anemia.

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So if you have iron

deficiency, how is it treated?

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These are the things that

your doctor should do.

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So the first is to confirm the diagnosis

of iron deficiency with blood work.

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So measuring hemoglobin

and measuring ferritin.

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The second is to identify

the cause of iron deficiency.

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So it's not enough just to give iron.

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It's also important that your healthcare

providers seek to understand why

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it is that you are iron deficient.

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For example, screening for heavy menstrual

bleeding or asking questions about your

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diet in order to manage the cause, we

have to understand what that cause is.

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And so, um, after knowing what's

causing your iron deficiency,

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your provider can help you.

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Um, with addressing the underlying cost.

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So sometimes we actually shut down periods

for a while, meaning we give a medication

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that stops a teenager from having

periods for a few months so that we can

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provide iron and replete someone's iron.

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And then the next step is to

provide iron replacement therapy.

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Most of the time we do this

with an oral medication, which

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means it's taken by mouth.

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Sometimes we provide iron through an IV

or intravenous, which is through a needle.

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And I'll show you some examples

of when we might use that.

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And then after about 3 months of

treatment with iron, your physician

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will confirm that the therapy was

successful by both assessing your

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symptoms and repeating your blood work.

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One of the best ways to treat iron

deficiency, regardless of its cause,

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is by increasing iron in your diet.

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And sometimes we can even prevent

growing teenagers from becoming

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iron deficient by optimizing the

amount of iron in their diet.

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So I just gave some examples

here of some foods that I think

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are acceptable to teenagers, um,

that are high in iron content.

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Um, one of them is dark

chocolate, actually.

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So you can tell your parents

to stock up on dark chocolate.

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Some cereals are really rich in

iron, like raisin bran and many weeds

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shreddies, they're iron fortified.

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So that can be really helpful if you'd

like to eat cereal in the morning.

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Um, spinach is a really

great source of iron.

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I really encourage patients to

put a handful of spinach in their

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smoothies, whether it be like for

breakfast in the morning or after

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their activities, um, because you

can't really taste it if you put it

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in a smoothie with some good fruits.

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Red meats, including pork and beef,

uh, lamb are really high in iron.

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And, um, some vegetables like broccoli

and most nuts, including cashews and

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almonds are fairly high in iron content.

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So these are just some examples

of foods that are rich in iron.

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Your provider may prescribe

oral iron that's taken by mouth.

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Um, they use certain, uh,

calculations to pick a dose.

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In general, it's around three to six

milligrams per kilogram per day of iron.

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So your physician would have

to know your weight in order

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to appropriately dose iron.

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Most people take their iron once a day.

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It is also acceptable to

take it every second day.

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And I always recommend that people

take their iron supplement at least

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an hour away from any milk products.

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So that's like yogurt, cheese, and

milk because milk can interfere

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with the absorption of iron.

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It is awesome if someone can remember

to take their iron with vitamin C

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because vitamin C actually increases

the absorption of iron and you can do

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that by taking the pill with a glass of

apple juice or a glass of orange juice.

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It's really important if you

are prescribed oral iron that

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you do not miss any doses.

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Unfortunately, the most common cause

of oral iron not working is that

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someone's not taking it every day.

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It's important that you take it every

day or every second day as prescribed

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for a minimum of three months.

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Sometimes people can't tolerate this

because it's hard on the stomach.

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So sometimes teenagers will tell me

that it makes their stomach hurt,

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causes nausea or constipation.

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Really important to let your

provider know that because There

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are a variety of different iron

supplements available, and they all

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have a different side effect profile.

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I usually start with something

called ferrous sulfate,

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which is the third row down.

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And if someone can't tolerate

that, then there's other types

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like ferrous fumarate I can use

that can be gentler on the stomach.

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So really important that you

take your iron as prescribed.

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And if it's causing you a stomach upset

to let your provider know that, rather

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than just not taking it, because if you

don't take it, that may be a reason to

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give IV iron, and that requires a needle.

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Um, there are some patients

for whom we give IV iron.

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Rather than the oral iron, even from

the start, and that's because they

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have either chronic kidney disease.

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Or a genetic condition called

a RITA, which is very rare, but

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both of those things require

that iron be given through an IV.

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Sometimes patients that have lots

of inflammation in their bodies from

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diseases like celiac disease, or like

Crohn's disease require IV iron because

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their gut can't absorb oral iron.

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The other few reasons, um, to

give IV iron is intolerance to,

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sorry, I should say to oral iron.

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So if someone has really bad

side effects with oral iron,

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we sometimes switch them to IV.

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Or if their iron deficiency

doesn't improve with oral iron,

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then we'll switch to an IV.

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And usually we test this first by

doing what we call an oral challenge

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where we actually measure an iron level

before and after giving oral iron.

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So, All that to say, there are

some patients for whom we wouldn't

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even offer oral iron, and we

would just go right to an IV.

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But for most patients, they can do well

on oral iron, and only if that doesn't

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work, would we consider doing an IV.

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IV iron is a big deal because it

does require that you come into our

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clinic for a needle for every dose.

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If someone is, weighs more than about

100 pounds, we can do one dose, but

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if they're less than 100 pounds,

we need to do multiple doses of

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IV iron, sometimes up to 6 doses.

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So it does mean time off school,

getting a needle every time you come

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in, spending the day in our clinic.

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The reason that we do this in clinic

is to monitor for allergic reactions,

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which sometimes can be something

as common as chills and flushing or

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redness of the face, but it can be a

true allergy that requires an EpiPen.

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Um, where someone has trouble breathing,

and so this is why we don't do IV

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iron if the oral iron can work.

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And actually, there has been some really

good studies that demonstrate that

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oral iron is as effective as IV iron,

as long as it's taken as prescribed.

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So, just to summarize then, iron

deficiency is common amongst adolescents

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and can lead to anemia if it's untreated.

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The most common symptom of iron deficiency

or anemia is fatigue, and the most common

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cause in teenagers is heavy periods.

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Iron deficiency can be managed

with increasing iron in the

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diet and or providing medication

such as oral or IV iron.

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Thanks so much for your attention and

I would be happy to take any questions.

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This is the email for the WeThrive app

and I answer lots of questions there

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about heavy menstrual bleeding and iron

deficiency and also happy to answer any

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questions you might have about the app.

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Thank you.