Pagophagia (Ice cube eating): A little recognized sign of anemia and possibly cancer!

Pagophagia (a form of pica, a craving to eat unnatural articles such as rocks, paint or dirt) is a little known term that is not known by many physicians. It describes the act of ingesting excessive amounts of ice cubes. An initial study of pagophagia appeared in the JAMA "Pica, pagophagia, and anemia" by L. G. Keith; C. D. Rosenberg; E. Brown JAMA. 1969;208:535. When I first saw this article I chuckled because I had seen a case of pagophagia two years before in medical school in Buffalo, New York with my mentor in hematology Dr. Ben Fisher and we were unaware of the phenomenon at the time. We had seen a young girl who was severely iron deficient from blood loss anemia and she so eloquently described to us how she so adored to eat ice cubes and how she would eat two to three trays of ice cubes daily. She said that the best part of an ice cube was the opaque center where the small bubbles coalesced. We walked away chuckling and assumed that the girl was a bit nuts.

However a few years later an article by Keith and Rosenberg appeared in the Journal of the American Medical Association and confirmed that what Ben and I had witnessed was a case of pagophagia due to severe iron deficiency anemia.

I am writing this blog today to alert patients and physicians to the symptom of pagophagia and its variants. Pagophagia is never volunteered by patients it must be pursued by questioning. When asking an anemic patient about diet you should always inquire about ice cube eating. Now that there are new water bottles ice cube eating has been modified by some to bottle freezing. The patient will often take their water bottle and place it in the freezer and when just right the inside of the bottle will be liquid and ice cold. I have been told by patients that that is the best water there is. Other patients will go to fast food portals and order extra large iced tea or cokes with a large amount of added ice just to get their teeth into the ice cubes for as long as they last. Others will just sip on a glass filled with plain ice cubes.

Well what's going on here? No one knows for sure however we do know that severe iron deficiency (in adults always caused by bleeding) causes esophageal mucosal changes and it is conjectured that cold liquids in some way sooth the esophageal discomfort. Even though we don’t understand the phenomenon, once recognized it is an invaluable clinical pearl of information. In my experience if pagophagia is present it always defines true iron deficiency. If you pursue nutritional inquiry with “do you like to chew on ice cubes, eat the scraped-off frost from freezer shelves or drink very cold liquids don't be surprised to have the patient’s jaw drop while staring at you with the “how did you know that” stare.

The importance of pagophagia is that it is a clue that the patient is bleeding and may very well not know it.

In the absence of excessive bleeding from abnormal menstrual periods when ever iron deficiency is present upper and lower gastrointestinal endoscopy should be considered.

By the way after iron is replaced the ice craving will stop.