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Many adolescents are at an in-creased risk for anemia due to their rapid growth and in-

creasing muscle mass. However, ado-lescent females with heavy menstrual bleeding are at an even greater risk for anemia. Heavy menstruation in ado-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

need for iron to compensate for men-strual 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 de-

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

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

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spite 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 effec-tive if the patient adheres to a regimen of multiple pills per day, for several months; only then are measurable re-sults likely to be observed in labora-tory 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 supplemen-tation proved difficult for our patients.

AGE-APPROPRIATE EDUCATIONIn an attempt to provide age-appro-

priate education to adolescent females with anemia, we started by first con-ducting a fairly extensive literature search using key words including ane-mia, education, prevention, treatment, and therapy for teens and/or adoles-cents. 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 writ-ten educational tools that were easy to read, as well as relevant to the pa-tient’s lifestyle. Most existing resourc-es listed foods such as oysters, beef liver, and giblets as the best sources of iron. These foods are rarely in a teen-age 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 devel-oped a “Good/Better/Best” handout for the patients and their families that included a list of popular iron forti-fied 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

Food Sources of Iron

Iron is an important mineral that helps our bodies function normally, but certain conditions

can increase the body’s need for iron. We cannot make iron for our bodies; therefore we need

to consume iron from our diet.

Good Better Best

Raisins Oatmeal and breakfast cereal Beef

Dried fruit Beans, peas, and lentils: green; kidney; lima; navy (white); black; pinto; garbanzo (chickpea); black-eyed

Fish and shellfish: tuna; salmon; shrimp; lobster; crab; oysters; clams

Potatoes (with skin) Nuts and nut butters: pine; walnuts; peanuts; cashews

Pork

Tomato juice • Bread • Sunflower seeds

• Eggs • Pumpkin seeds

• Pasta • Tortillas

• Rice • Cooked spinach

Chicken

Turkey

Eat Iron-Rich Foods with Foods Containing Vitamin C, such as:

Some foods can increase the absorption of iron. Foods containing vitamin C should be eaten

along with iron-rich foods to increase the body’s ability to absorb iron.

Bell peppers Mango

Oranges and orange juice Tangerine

Papaya Baked potato with skin

Grapefruit Green leafy vegetables

Strawberries Tomatoes

Broccoli Cauliflower

Melon Cabbage

Consume These Foods Separately from Iron-Rich Foods

Some foods can block the absorption of iron. However, many of these foods are still important to

consume in the diet (ie, milk and dairy products). Therefore, such foods should be consumed at

different times throughout the day (separate meals or snacks from those with iron-rich foods).

Milk, cheese, yogurt Blueberries, raspberries, blackberries

Coffee Grapes

Tea Popcorn

Soy Tofu

Chocolate Pomegranate

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.

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Iron-Rich Breakfast Cereals

BETTER

Brand Type

General Mills WHEATIES

General Mills CHEX, wheat

General Mills CINNAMON TOAST CRUNCH

General Mills KABOOM

Kellogg’s COCOA KRISPIES

Kellogg’s CORN FLAKES

Kellogg’sSPECIAL K; plain; chocolatey delight; red berries; vanilla almond

Kellogg’s FROSTED FLAKES

Kellogg’s JUST RIGHT; fruit & nut

Kashi 7 WHOLE GRAIN NUGGETS

Post RAISIN BRAN

Post HONEY BUNCHES OF OATS, with almonds

Post BANANA NUT CRUNCH

Post GRAPE NUT FLAKES

Quaker LIFE: plain; cinnamon

Quaker HONEY GRAHAM OH!S

Quaker OATMEAL SQUARES, cinnamon

Quaker OAT BRAN

Quaker CRISPY CORN PUFFS

BESTBrand TypeGeneral Mills TOTAL corn flakes

General Mills TOTAL, raisin bran, cranberry crunch

General Mills TOTAL, whole grain

General Mills CHEX: corn; rice; honey nut; multi-bran; frosted

General Mills CHEERIOS, yogurt burst

General Mills CHEERIOS, multigrain

General Mills KIX

Kellogg’s CRISPIX

Kellogg’sFROSTED MINI WHEATS: plain; maple & brown sugar; strawberry delight

Kellogg’s ALL BRAN COMPLETE wheat flakes

Kellogg’s PRODUCT 19

Kellogg’s COMPLETE oat bran flakes

Kellogg’s SMART START strong heart antioxidants

Kellogg’s RICE KRISPIES

Kellogg’s SHREDDED WHEAT

Malt-O-Meal PUFFED WHEAT

Malt-O-Meal PLAIN

Malt-O-Meal PUFFED RICE

Malt-O-Meal FROSTED MINI SPOONERS

Malt-O-Meal CRISPY RICE

Malt-O-Meal CHOCOLATE

Malt-O-Meal HONEY GRAHAM SQUARES

Malt-O-Meal TOASTY O’S

Kashi MIGHTY BITES, honey crunch

Many breakfast cereals are fortified with iron and other nutrients. Cereals can act as a quick and

easy source of iron, especially for people on the run. Just pour some iron-fortified dry cereal into

a baggie for breakfast or a simple snack.

Ranking of cereals based on milligrams of iron present in 100 g of dry cereal.

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

GOODBrand TypeGeneral Mills COCOA PUFFS

General Mills CINNAMON GRAHAMS

General Mills FIBER ONE

General Mills FRANKENBERRY

General MillsCHEERIOS; honey nut, frosted, apple cinnamon, berry burst, fruity

General Mills CURVES, fruit & nut crunch

General Mills HARMONY

General Mills GOLDEN GRAHAMS

General Mills WHEATIES, raisin bran

General Mills LUCKY CHARMS

General Mills CINNAMON TOAST CRUNCH

General Mills KIX, berry berry

General Mills BOO BERRY

General Mills COUNT CHOCULA

General Mills COOKIE CRISP

General Mills FRENCH TOAST CRUNCH

General MillsPEANUT BUTTER TOAST CRUNCH

General Mills TRIX

General Mills REESE’S PUFFS

Kellogg’sALL BRAN; original with extra fiber

Kellogg’s EGGO CRUNCH

Kellogg’s RICE KRISPIES; frosted, berry

Kellogg’s FRUIT LOOPS

Kellogg’s APPLE JACKS

Kellogg’s RAISIN BRAN

Kellogg’s SMORZ

Kellogg’sFRUIT HARVEST, strawberry, blueberry

Malt-O-Meal COCOA-ROOS

Malt-O-Meal MARSHMELLOW MATEYS

Malt-O-Meal APPLE ZINGS

Malt-O-Meal CINNAMON TOASTERS

Malt-O-MealTOASTY O’S; apple cinnamon, honey nut

Malt-O-Meal BLUEBERRY MUFFIN TOPS

Malt-O-Meal TOOTIE FRUITIES

Malt-O-MealCOLOSSAL CRUNCH; original, berry

Malt-O-Meal FROSTED FLAKES

Post TOASTIES; corn flakes

Quaker CINNAMON CRUNCH

Quaker HONEY NUT OATS

PEDIATRIC ANNALS 42:1 | JANUARY 2013 Healio.com/Pediatrics | 39

FEATURE

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 devel-oped in the “Good/Better/Best” format (see Figure 2, page 38).

During the first year, 34 females with HMB who attended the Adoles-cent 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 re-ported consuming breakfast cereals, breads, and pasta more frequently than meat. Nutrition goals were estab-lished with 26 patients and follow-up communication via phone interview was completed with 11 girls.

Common nutrition goals set by pa-tients 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 ab-sorption; 3) eat iron-rich foods sepa-rate 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 receiv-ing continued nutrition counseling.

In the clinical setting, whenever pos-sible during a patient’s visit, we present-ed them with a colorful gift bag of in-dividually 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 in-structed on how to read nutrition labels to determine iron-rich food sources, and were encouraged to verbally dem-onstrate 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 vi-sual, tactile, and edible teaching tools were discussed with each patient and family, and discussion quickly turned to other food possibilities that the pa-tient and family could take “on the go.” This brief demonstration and dis-cussion gave both patients and fami-lies the knowledge and skills needed to make better choices at the grocery store to increase their oral iron intake.

CONCLUSIONAdolescent females with heavy

menstrual bleeding are at a greater risk for anemia. Existing educational re-sources for iron-rich foods are not con-ducive to adolescents’ lifestyles and eating preferences. A teen-friendly ap-proach to teaching was demonstrated in a clinical setting with visual, tactile, and edible selections of foods. Simple educational handouts can greatly en-hance the treatment of anemia in ado-lescent 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 Di-etary Supplements. Dietary Supplement Fact Sheet: Iron. 2007. Available at: ods.od.nih.gov/factsheets/Iron-HealthProfes-sional. Accessed Dec. 7, 2012.

3. Anemia.org. Anemia in Adolescents: The Teen Scene. 2009. Available at: ane-mia.org/patients/feature-articles/content.php?contentid=000348. Accessed Dec. 7, 2012.

4. Escott-Stump LKMS. Krause’s Food & Nu-trition Therapy. 12th ed. Philadelphia: Else-vier Health Sciences; 2007.

5. Iron and Iron Deficiency. 2011. Available at: www.cdc.gov/nutrition/everyone/basics/vi-tamins/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.

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SLACK INCORPORATED6900 Grove Road, Thorofare, NJ 08086Healio.com/Pediatrics .............................................................................................................................................. C3Infectious Diseases in Children® Education Lab ..............................................................................................C4

While every precaution is taken to ensure accuracy, Pediatric Annals cannot guarantee against occasional changes or omissions in the preparation of this index.

Teens were unfamiliar with how to identify iron

content on food labels, and with how iron can impact their anemia.