Int J Hematol (2008) 88:495–497
DOI 10.1007/s12185-008-0191-3
ORIGINAL ARTICLE
Increased incidence of iron deficiency anemia secondary
to inadequate iron intake in institutionalized, young patients
with cerebral palsy
Athanasios Papadopoulos Æ George Ntaios Æ Georgia Kaiafa Æ Fotios Girtovitis Æ
Zoi Saouli Æ Zisis Kontoninas Æ Michael D. Diamantidis Æ Christos Savopoulos Æ
Apostolos Hatzitolios
Received: 11 September 2008 / Revised: 25 September 2008 / Accepted: 6 October 2008 / Published online: 11 November 2008
Ó 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.
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
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
123
496 A. Papadopoulos et al.

Table 1 Incidence of anemia and iron deficiency Table 3 Incidence of anemia and iron deficiency according to the
type of diet
Males (n = 55) Females (n = 53) Total (n = 108)
Liquid diet (n = 23) Normal diet (n = 85)
Anemia 17 (30.9%) 19 (35.8%) 36 (33.3%)
Iron deficiency 19 (35.8%) 22 (40%) 41 (38%) Anemia 20 (87%) 16 (18.8%)
Iron deficiency 22 (95.6%) 19 (22.3%)

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

(MCV), mean cell hemoglobin (MCH) and mean cell hemoglobin Table 4 Incidence of iron deficiency in different age groups
concentration (MCHC) in anemic patients
Age (years) Iron deficient patients (n)
Males Females Total
(n = 17) (n = 19) (n = 36) 8–10 4/10 (40.0%)
10–15 5/12 (41.6%)
Hemoglobin (g/dl) 10.7 9.03 9.6
15–20 12/28 (42.8%)
Serum iron (lg/dl) 49.7 34.3 42.1
20–25 12/36 (33.3%)
Serum ferritin (ng/ml) 21.2 6.8 13.7
25–29 8/22 (36.4%)
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
In Table 3, we present the incidence of anemia or iron
Normal values for hemoglobin: [11.5 g/dl for children aging 2–
deficiency relative to the type of diet. Higher incidence of
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 anemia and iron deficiency was detected in patients on
for iron:[50 lg/dl for children,[65 lg/dl for adult men and[50 lg/dl liquid diet (due to inability to chew) compared to those
for adult women. Normal values for ferritin: [7 ng/ml for children, on normal diet. In particular, 87 and 95.6% of patients on
[20 ng/ml for adult men and [10 ng/ml for adult women. Normal
liquid diet were found to be anemic and iron deficient,
values for MCV, MCH and MCHC are 80–99 fl, 27–32 pg and
32–35 g/dl, respectively respectively, compared to only 18.8 and 22.3% of patients
on normal diet.
Table 4 presents the incidence of iron deficiency in
were investigated for the presence of hemoglobin or par- different age groups. There was no statistical difference in
asites in the stools. the incidence of iron deficiency between different age
groups.
All tests for fecal occult blood or intestinal parasites
3 Results were negative. Folic acid and B12 levels were within
normal range in all cases.
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, 4 Discussion
whereas mean cell volume (MCV), mean cell hemoglobin
(MCH) and mean cell hemoglobin concentration (MCHC) We ascertained high incidence of iron deficiency anemia in
values were below normal (normal values for MCV, MCH our patients. The incidence of iron deficiency anemia was
and MCHC are 80–99 fl, 27–32 pg and 32–35 g/dl, similar between males and females (Table 1), as well as
respectively). In the same table, we also present the inci- between different age groups (premenstrual or not),
dence of patients with decreased levels of serum ferritin. In something that leads to the conclusion that menstrual blood
particular, 33.3% of patients presented with hypochromic loss was not the underlying cause. Moreover, gastrointes-
anemia (30.9% of males and 35.8% of females), whereas tinal blood loss and parasitic infection were ruled out since
38% were iron deficient (35.8% of males and 40% of fecal occult blood tests were all negative and no parasites
females). Both anemia and iron deficiency were more were detected. Thus, we concluded that iron deficiency was
frequent in females, although this difference was not not secondary to iron losses.
statistically significant. The institute was preparing two different menus daily:
Table 2 presents the mean values of hemoglobin, serum the first was in liquid form and was prepared for patients
iron and ferritin levels as well as MCV, MCH and MCHC that were unable to chew, whereas the second was a
in anemic patients. All these parameters showed a trend to common menu in solid form. Both menus, and especially
decrease in anemic females compared to anemic males, the first one, included various types of food, some of which
although this difference was not statistically significant. are either poor in iron (such as milk, cheese, cream,

123
Increased incidence of iron deficiency anemia secondary to inadequate iron intake
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.
497
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.
References
1. Clark SF. Iron deficiency anemia. Nutr Clin Pract. 2008;23:128–
41. doi:10.1177/0884533608314536.
2. Rosenbaum E, Leonard JW. Nutritional iron deficiency anemia in
an adult male. Report of a case. Ann Intern Med. 1964;60:683–8.
3. Waldmann A, Koschizke JW, Leitzmann C, Hahn A. Dietary iron
intake and iron status of German female vegans: results of the
German vegan study. Ann Nutr Metab. 2004;48:103–8. doi:
10.1159/000077045.
4. Pasricha SR, Caruana SR, Phuc TQ, Casey GJ, Jolley D, Kingsland
S, et al. Anemia, iron deficiency, meat consumption, and
hookworm infection in women of reproductive age in northwest
Vietnam. Am J Trop Med Hyg. 2008;78:375–81.
5. Williams CM, Lines CM, McKay EC. Iron and zinc status in
multiple sclerosis patients with pressure sores. Eur J Clin Nutr.
1988;42:321–8.
6. Vir SC, Love AH. Nutritional status of institutionalized and
noninstitutionalized aged in Belfast, Northern Ireland. Am J Clin
Nutr. 1979;32:1934–47.
7. Bothwell TH. Nutrition and anaemia. In: Lechner K, Gadner H,
editors. Hematology trends 1993. Stuttgart: Schattauer; 1993.
p. 177–92.
8. Heywood PF, Marks GC. Nutrition and health in South-East Asia.
Med J Aust. 1993;159:133–7.
9. Gillory M, Bothwell TH, Torrance JD, et al. The effects of organic
acids, phytates and polyphenols on the absorption of iron from
vegetables. Br J Nutr. 1983;49:331–47. doi:10.1079/BJN19830042
.
123