FEATURE

Treatment of Anemia in the Adolescent Female Linda P. Grooms, RN, NC; Michelle Walsh, PhD, CPNP; and Laura E. Monnat, MS, RD

any adolescents are at an in- need for iron to compensate for men- DRAWBACKS OF ORAL creased risk for anemia due strual blood loss and increased growth, IRON THERAPY Mto their rapid growth and in- many young women are preoccupied When we developed a program for creasing muscle mass. However, ado- with body image.³ The combination of females with HMB at the Adolescent lescent females with heavy menstrual heavy menstrual bleeding (HMB) and Hematology Clinic at Nationwide bleeding are at an even greater risk for an inadequate diet frequently leads to Children’s Hospital, anemia quickly anemia. Heavy menstruation in ado- iron deficiency in young women. became a very prevalent concern de- lescent females not only has negative effects on health-related quality of life and school attendance, but also has major health implications such as iron deficiency anemia. About 75% of teen girls do not meet the Recommended Dietary Al- lowance (RDA) for iron, due in part to busy lifestyles, and self-imposed trendy diets.1-3 At a time in their lives when young women have an increased

Linda P. Grooms, RN, NC, is a Nurse Clinician, Division of Pediatric Hematology/Oncology and Bone Marrow Transplant, Nationwide Children’s Hospital. Michelle Walsh, PhD, CPNP, is a Pediatric Nurse Practitioner, Division of Pediatric Hema- tology/Oncology and Bone Marrow Transplant, Nationwide Children’s Hospital. Laura E. Monnat, MS, RD, is a graduate student at The Ohio State University. Address correspondence to: Linda P. Grooms, RN, NC, Division of Pediatric Hematology/Oncol- ogy and Bone Marrow Transplant, Nationwide Children’s Hospital, 700 Children’s Drive, Colum- bus, OH 43205; email: Linda.grooms@nation- widechildrens.org. Disclosure: The authors have no relevant fi- nancial relationships to disclose. doi: 10.3928/00904481-20121221-17 © Shutterstock

36 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:1 | JANUARY 2013 FEATURE spite the intervention of oral iron Food Sources of Iron therapy. Most of the patients seen in clinic had tried oral iron therapy due Iron is an important mineral that helps our bodies function normally, but certain conditions to its easy accessibility and low cost. can increase the body’s need for iron. We cannot make iron for our bodies; therefore we need Such supplementation is most effec- to consume iron from our diet. tive if the patient adheres to a regimen Good Better Best of multiple pills per day, for several months; only then are measurable re- Raisins Oatmeal and Beef sults likely to be observed in labora- Dried fruit Beans, peas, and lentils: green; kidney; Fish and shellfish: tuna; tory tests. Because of the frequently lima; navy (white); black; pinto; salmon; shrimp; lobster; crab; garbanzo (chickpea); black-eyed oysters; clams reported unpleasant side effects, (ie, nausea and constipation) as well as the Potatoes (with skin) Nuts and nut butters: pine; walnuts; Pork frequency and length of the required peanuts; cashews regimen, adherence to iron supplemen- Tomato juice • Bread • Sunflower seeds Chicken tation proved difficult for our patients. • Eggs • Pumpkin seeds Turkey • Pasta • Tortillas AGE-APPROPRIATE EDUCATION • • Cooked spinach In an attempt to provide age-appro- priate education to adolescent females Eat Iron-Rich Foods with anemia, we started by first con- with Foods Containing Vitamin C, such as: ducting a fairly extensive literature search using key words including ane- Some foods can increase the absorption of iron. Foods containing vitamin C should be eaten mia, education, prevention, treatment, along with iron-rich foods to increase the body’s ability to absorb iron. and therapy for teens and/or adoles- Bell peppers Mango cents. This search resulted in only a few potentially useful articles, and, out Oranges and orange juice Tangerine of those, most were from international Papaya Baked potato with skin sources. With the assistance of a nutrition Grapefruit Green leafy vegetables student, we researched information Tomatoes currently available to develop writ- ten educational tools that were easy Broccoli Cauliflower to read, as well as relevant to the pa- Melon Cabbage tient’s lifestyle. Most existing resourc- es listed foods such as oysters, beef liver, and giblets as the best sources of Consume These Foods Separately from Iron-Rich Foods iron. These foods are rarely in a teen- Some foods can block the absorption of iron. However, many of these foods are still important to age girl’s vocabulary, let alone in their consume in the diet (ie, milk and dairy products). Therefore, such foods should be consumed at refrigerator. Using the latest edition of different times throughout the day (separate meals or snacks from those with iron-rich foods). Krause’s Food & Nutrition Therapy4 and other well-respected sources for Milk, cheese, yogurt , raspberries, blackberries nutrition information,2,5 we devel- Coffee Grapes oped a “Good/Better/Best” handout for the patients and their families that Tea Popcorn included a list of popular iron forti- Soy Tofu fied food choices, as well as a short list of foods that enhance and inhibit Chocolate Pomegranate iron absorption (see Figure 1). The majority of children and adolescents, Grooms, RN, NC. Reprinted with permission. Figure courtesy of Linda P. Figure 1. Handout for patients and their families showing a list of foods high in iron as well as lists of especially females, receive the bulk of foods that enhance or inhibit iron absorption.

PEDIATRIC ANNALS 42:1 | JANUARY 2013 Healio.com/Pediatrics | 37 FEATURE

Iron-Rich Breakfast Cereals

GOOD BETTER BEST Brand Type Brand Type Brand Type General Mills General Mills General Mills GRAHAMS TOTAL, , cranberry General Mills , General Mills General Mills FIBER ONE CINNAMON TOAST General Mills TOTAL, whole grain General Mills FRANKENBERRY General Mills CRUNCH ; honey nut, frosted, CHEX: corn; rice; honey nut; General Mills KABOOM General Mills multi-bran; frosted General Mills cinnamon, berry burst, fruity General Mills CHEERIOS, yogurt burst General Mills CHEERIOS, multigrain General Mills CURVES, fruit & nut crunch Kellogg’s General Mills HARMONY General Mills Kellogg’s CORN FLAKES General Mills General Mills WHEATIES, raisin bran ; plain; Kellogg’s Kellogg’s chocolatey delight; red General Mills berries; vanilla almond FROSTED MINI : General Mills Kellogg’s plain; maple & brown ; Kellogg’s delight General Mills KIX, berry berry Kellogg’s ; fruit & nut ALL BRAN COMPLETE wheat General Mills BOO BERRY Kellogg’s flakes General Mills COUNT CHOCULA Kellogg’s General Mills COOKIE 7 WHOLE GRAIN NUGGETS Kellogg’s COMPLETE bran flakes General Mills CRUNCH SMART strong heart PEANUT BUTTER TOAST Kellogg’s General Mills antioxidants CRUNCH Post RAISIN BRAN General Mills Kellogg’s HONEY BUNCHES OF General Mills REESE’S PUFFS Post , with almonds Kellogg’s

ALL BRAN; original with extra Post BANANA NUT CRUNCH Kellogg’s fiber Malt-O-Meal PUFFED WHEAT Kellogg’s CRUNCH Post GRAPE NUT FLAKES Malt-O-Meal PLAIN Kellogg’s RICE KRISPIES; frosted, berry Malt-O-Meal PUFFED RICE Kellogg’s FRUIT LOOPS Quaker LIFE: plain; cinnamon Malt-O-Meal FROSTED MINI SPOONERS Kellogg’s Malt-O-Meal CRISPY RICE Quaker HONEY GRAHAM OH!S Kellogg’s RAISIN BRAN Malt-O-Meal CHOCOLATE OATMEAL SQUARES, Malt-O-Meal HONEY GRAHAM SQUARES Kellogg’s Quaker cinnamon FRUIT HARVEST, strawberry, Malt-O-Meal TOASTY O’S Kellogg’s Quaker OAT BRAN Quaker CRISPY CORN PUFFS Malt-O-Meal COCOA-ROOS Kashi MIGHTY BITES, honey crunch Malt-O-Meal MARSHMELLOW MATEYS Many breakfast cereals are fortified with iron and other nutrients. Cereals can act as a quick and Malt-O-Meal APPLE ZINGS easy source of iron, especially for people on the run. Just pour some iron-fortified dry cereal into Malt-O-Meal CINNAMON TOASTERS a baggie for breakfast or a simple snack. TOASTY O’S; apple cinnamon, Ranking of cereals based on milligrams of iron present in 100 g of dry cereal. Malt-O-Meal honey nut Malt-O-Meal BLUEBERRY MUFFIN TOPS Malt-O-Meal TOOTIE FRUITIES COLOSSAL CRUNCH; original, Malt-O-Meal berry Malt-O-Meal FROSTED FLAKES

Post TOASTIES; corn flakes Grooms, RN. Reprinted with permission. Figure courtesy of Linda P.

Quaker CINNAMON CRUNCH Quaker HONEY NUT OATS

Figure 2. Fact sheet for patients and their families showing iron-fortified breakfast cereals.

38 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:1 | JANUARY 2013 FEATURE their dietary iron from fortified grain most local stores, in vending machines, CONCLUSION products such as breakfast cereals.6 or at sporting event concession stands. Adolescent females with heavy Using the Nutrition Calc software Patients of the HMB clinic were in- menstrual bleeding are at a greater risk (McGraw-Hill Higher Education, New structed on how to read nutrition labels for anemia. Existing educational re- York, NY), along with manufacturers’ to determine iron-rich food sources, sources for iron-rich foods are not con- nutrition labels on individual boxes, a and were encouraged to verbally dem- ducive to adolescents’ lifestyles and fact sheet for cereals was also devel- onstrate their understanding in clinic. eating preferences. A teen-friendly ap- oped in the “Good/Better/Best” format While the teens seemed to be very proach to teaching was demonstrated (see Figure 2, page 38). in a clinical setting with visual, tactile, During the first year, 34 females and edible selections of foods. Simple with HMB who attended the Adoles- Teens were unfamiliar educational handouts can greatly en- cent Hematology Clinic completed a hance the treatment of anemia in ado- questionnaire regarding iron-rich food with how to identify iron lescent females. consumption. The results revealed the content on food labels, most commonly consumed meats to and with how iron can REFERENCES be beef and chicken, consistent with 1. Centers for Disease Control and Prevention. published literature.6 Participants re- impact their anemia. Recommendations to prevent and control ported consuming breakfast cereals, iron deficiency in the . MMWR breads, and pasta more frequently Morb Mortal Wkly Rep. 1998;47 (RR-3):1- 36. than meat. Nutrition goals were estab- familiar with locating calorie content 2. National Institutes of Health, Office of Di- lished with 26 patients and follow-up prior to nutrition counseling, they were etary Supplements. Dietary Supplement communication via phone interview unfamiliar with how to identify iron Fact Sheet: Iron. 2007. Available at: ods. od.nih.gov/factsheets/Iron-HealthProfes- was completed with 11 girls. content on food labels, and with how sional. Accessed Dec. 7, 2012. Common nutrition goals set by pa- iron can affect their anemia. These vi- 3. Anemia.org. Anemia in Adolescents: tients included: 1) try to consume dry sual, tactile, and edible teaching tools The Teen Scene. 2009. Available at: ane- mia.org/patients/feature-articles/content. cereal as a breakfast or snack at school; were discussed with each patient and php?contentid=000348. Accessed Dec. 7, 2) combine iron-rich foods with foods family, and discussion quickly turned 2012. high in vitamin C to increase iron ab- to other food possibilities that the pa- 4. Escott-Stump LKMS. Krause’s Food & Nu- sorption; 3) eat iron-rich foods sepa- tient and family could take “on the trition Therapy. 12th ed. Philadelphia: Else- vier Health Sciences; 2007. rate from iron inhibitors throughout go.” This brief demonstration and dis- 5. Iron and Iron Deficiency. 2011. Available at: the day; and 4) consume breakfast cussion gave both patients and fami- www.cdc.gov/nutrition/everyone/basics/vi- more often. Of the 11 girls contacted lies the knowledge and skills needed tamins/iron.html. Accessed Dec. 7, 2012. 6. Briefel RR, Johnson CL. Secular trends in in follow-up, the majority reported to make better choices at the grocery dietary intake in the United States. Annu success in implementing established store to increase their oral iron intake. Rev Nutr. 2004;24:401-431. nutrition goals. Nutrition education at this clinic for girls with HMB has been positively received thus far, and the AD INDEX majority of patients and families have expressed a sincere interest in receiv- SLACK INCORPORATED ing continued nutrition counseling. 6900 Grove Road, Thorofare, NJ 08086 Healio.com/Pediatrics...... C3 In the clinical setting, whenever pos- Infectious Diseases in Children® Education Lab...... C4 sible during a patient’s visit, we present- ed them with a colorful gift bag of in- While every precaution is taken to ensure accuracy, Pediatric Annals cannot guarantee against occasional changes dividually wrapped iron fortified foods or omissions in the preparation of this index. such as crackers with peanut butter, or a nutrition bar, and a single serving box of cereal. Also included in the bag was a small individual serving of a drink high in vitamin C. These types of foods are affordable, as well as easily accessible at

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