Pediatric Annals

Feature 

Treatment of Anemia in the Adolescent Female

Linda P. Grooms, RN, NC; Michelle Walsh, PhD, CPNP; Laura E. Monnat, MS, RD

Abstract

Many adolescents are at an increased risk for anemia due to their rapid growth and increasing muscle mass. However, adolescent females with heavy menstrual bleeding are at an even greater risk for anemia. Heavy menstruation in adolescent 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 Allowance (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 need for iron to compensate for menstrual blood loss and increased growth, many young women are preoccupied with body image.³ The combination of heavy menstrual bleeding (HMB) and an inadequate diet frequently leads to iron deficiency in young women.

When we developed a program for females with HMB at the Adolescent Hematology Clinic at Nationwide Children’s Hospital, anemia quickly became a very prevalent concern despite the intervention of oral iron therapy. Most of the patients seen in clinic had tried oral iron therapy due to its easy accessibility and low cost. Such supplementation is most effective if the patient adheres to a regimen of multiple pills per day, for several months; only then are measurable results likely to be observed in laboratory tests. Because of the frequently reported unpleasant side effects, (ie, nausea and constipation) as well as the frequency and length of the required regimen, adherence to iron supplementation proved difficult for our patients.

In an attempt to provide age-appropriate education to adolescent females with anemia, we started by first conducting a fairly extensive literature search using key words including anemia, education, prevention, treatment, and therapy for teens and/or adolescents. This search resulted in only a few potentially useful articles, and, out of those, most were from international sources.

With the assistance of a nutrition student, we researched information currently available to develop written educational tools that were easy to read, as well as relevant to the patient’s lifestyle. Most existing resources listed foods such as oysters, beef liver, and giblets as the best sources of iron. These foods are rarely in a teenage girl’s vocabulary, let alone in their refrigerator. Using the latest edition of Krause’s Food & Nutrition Therapy4 and other well-respected sources for nutrition information,2,5 we developed a “Good/Better/Best” handout for the patients and their families that included a list of popular iron fortified food choices, as well as a short list of foods that enhance and inhibit iron absorption (see Figure 1). The majority of children and adolescents, especially females, receive the bulk of their dietary iron from fortified grain products such as breakfast cereals.6 Using the Nutrition Calc Plus software (McGraw-Hill Higher Education, New York, NY), along with manufacturers’ nutrition labels on individual boxes, a fact sheet for cereals was also developed in the “Good/Better/Best” format (see Figure 2).

Figure 1. Handout for patients and their families showing a list of foods high in iron as well as lists of foods that enhance or inhibit iron absorption.Figure courtesy of Linda P. Grooms, RN, NC. Reprinted with permission.

Figure 2. Fact sheet for patients and their families showing iron-fortified breakfast cereals.Figure courtesy of Linda P. Grooms, RN. Reprinted with permission.

During the first year, 34 females with HMB who attended the Adolescent Hematology Clinic completed a questionnaire regarding iron-rich food consumption. The results revealed the most commonly consumed meats to be beef and chicken, consistent with published literature.6 Participants reported consuming breakfast cereals, breads, and pasta more frequently than meat. Nutrition goals were established with 26…

Many adolescents are at an increased risk for anemia due to their rapid growth and increasing muscle mass. However, adolescent females with heavy menstrual bleeding are at an even greater risk for anemia. Heavy menstruation in adolescent 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 Allowance (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 need for iron to compensate for menstrual blood loss and increased growth, many young women are preoccupied with body image.³ The combination of heavy menstrual bleeding (HMB) and an inadequate diet frequently leads to iron deficiency in young women.

Drawbacks of Oral Iron Therapy

When we developed a program for females with HMB at the Adolescent Hematology Clinic at Nationwide Children’s Hospital, anemia quickly became a very prevalent concern despite the intervention of oral iron therapy. Most of the patients seen in clinic had tried oral iron therapy due to its easy accessibility and low cost. Such supplementation is most effective if the patient adheres to a regimen of multiple pills per day, for several months; only then are measurable results likely to be observed in laboratory tests. Because of the frequently reported unpleasant side effects, (ie, nausea and constipation) as well as the frequency and length of the required regimen, adherence to iron supplementation proved difficult for our patients.

Age-Appropriate Education

In an attempt to provide age-appropriate education to adolescent females with anemia, we started by first conducting a fairly extensive literature search using key words including anemia, education, prevention, treatment, and therapy for teens and/or adolescents. This search resulted in only a few potentially useful articles, and, out of those, most were from international sources.

With the assistance of a nutrition student, we researched information currently available to develop written educational tools that were easy to read, as well as relevant to the patient’s lifestyle. Most existing resources listed foods such as oysters, beef liver, and giblets as the best sources of iron. These foods are rarely in a teenage girl’s vocabulary, let alone in their refrigerator. Using the latest edition of Krause’s Food & Nutrition Therapy4 and other well-respected sources for nutrition information,2,5 we developed a “Good/Better/Best” handout for the patients and their families that included a list of popular iron fortified food choices, as well as a short list of foods that enhance and inhibit iron absorption (see Figure 1). The majority of children and adolescents, especially females, receive the bulk of their dietary iron from fortified grain products such as breakfast cereals.6 Using the Nutrition Calc Plus software (McGraw-Hill Higher Education, New York, NY), along with manufacturers’ nutrition labels on individual boxes, a fact sheet for cereals was also developed in the “Good/Better/Best” format (see Figure 2).

Handout for patients and their families showing a list of foods high in iron as well as lists of foods that enhance or inhibit iron absorption.Figure courtesy of Linda P. Grooms, RN, NC. Reprinted with permission.

Figure 1. Handout for patients and their families showing a list of foods high in iron as well as lists of foods that enhance or inhibit iron absorption.Figure courtesy of Linda P. Grooms, RN, NC. Reprinted with permission.

Fact sheet for patients and their families showing iron-fortified breakfast cereals.Figure courtesy of Linda P. Grooms, RN. Reprinted with permission.

Figure 2. Fact sheet for patients and their families showing iron-fortified breakfast cereals.Figure courtesy of Linda P. Grooms, RN. Reprinted with permission.

During the first year, 34 females with HMB who attended the Adolescent Hematology Clinic completed a questionnaire regarding iron-rich food consumption. The results revealed the most commonly consumed meats to be beef and chicken, consistent with published literature.6 Participants reported consuming breakfast cereals, breads, and pasta more frequently than meat. Nutrition goals were established with 26 patients and follow-up communication via phone interview was completed with 11 girls.

Common nutrition goals set by patients included: 1) try to consume dry cereal as a breakfast or snack at school; 2) combine iron-rich foods with foods high in vitamin C to increase iron absorption; 3) eat iron-rich foods separate from iron inhibitors throughout the day; and 4) consume breakfast more often. Of the 11 girls contacted in follow-up, the majority reported success in implementing established nutrition goals. Nutrition education at this clinic for girls with HMB has been positively received thus far, and the majority of patients and families have expressed a sincere interest in receiving continued nutrition counseling.

In the clinical setting, whenever possible during a patient’s visit, we presented them with a colorful gift bag of individually wrapped iron fortified foods 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 most local stores, in vending machines, or at sporting event concession stands.

Patients of the HMB clinic were instructed on how to read nutrition labels to determine iron-rich food sources, and were encouraged to verbally demonstrate their understanding in clinic. While the teens seemed to be very familiar with locating calorie content prior to nutrition counseling, they were unfamiliar with how to identify iron content on food labels, and with how iron can affect their anemia. These visual, tactile, and edible teaching tools were discussed with each patient and family, and discussion quickly turned to other food possibilities that the patient and family could take “on the go.” This brief demonstration and discussion gave both patients and families the knowledge and skills needed to make better choices at the grocery store to increase their oral iron intake.

Conclusion

Adolescent females with heavy menstrual bleeding are at a greater risk for anemia. Existing educational resources for iron-rich foods are not conducive to adolescents’ lifestyles and eating preferences. A teen-friendly approach to teaching was demonstrated in a clinical setting with visual, tactile, and edible selections of foods. Simple educational handouts can greatly enhance the treatment of anemia in adolescent females.

References

  1. Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. MMWR Morb Mortal Wkly Rep. 1998;47 (RR-3):1–36.
  2. National Institutes of Health, Office of Dietary Supplements. Dietary Supplement Fact Sheet: Iron. 2007. Available at: ods.od.nih.gov/factsheets/Iron-HealthProfessional. Accessed Dec. 7, 2012.
  3. Anemia.org. Anemia in Adolescents: The Teen Scene. 2009. Available at: anemia.org/patients/feature-articles/content.php?contentid=000348. Accessed Dec. 7, 2012.
  4. Escott-Stump LKMS. Krause’s Food & Nutrition Therapy. 12th ed. Philadelphia: Elsevier Health Sciences; 2007.
  5. Iron and Iron Deficiency. 2011. Available at: www.cdc.gov/nutrition/everyone/basics/vitamins/iron.html. Accessed Dec. 7, 2012.
  6. Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004;24:401–431. doi:10.1146/annurev.nutr.23.011702.073349 [CrossRef]
Authors
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 Hematology/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/Oncology and Bone Marrow Transplant, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205; email: Linda.grooms@nationwidechildrens.org.
Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00904481-20121221-17

Sign up to receive

Journal E-contents