Iron Deficiency, Stress, Infections Among the More Common Causes of Telogen Effluvium in Children.

Iron Deficiency, Stress, Infections Among the More Common Causes of Hair Shedding in Children.

Similar to adults, children and adolescents can present with an array of different types of hair loss. Telogen effluvium is a relatively common hair disorder, reported in 2-17% of children presenting with alopecia. The types of pediatric hair loss conditions that a practitioner might see will depend on the prevalence of certain conditions in the population. In general, hair loss conditions such as alopecia areata, tinea capitis, trichotillomania, telogen effluvium and androgentic hair loss are frequently diagnosed in children presenting with hair loss.

A Canadian study by Thomas et al set out to retrospectively review patients 18 years or younger, assessed for telogen effluvium at a tertiary care dermatology clinic between 1996 through 2019 to identify nutritional deficiencies.

42 patients were included in the study with a mean age of 11 years. 82 % of patients were female (35/42; 82%). The following were felt to be triggers:

a) 30 % had systemic conditions as the trigger (inflammatory bowel disease in 5, and rheumatologic disease in 4)

b) 19 % had an infectious trigger

c) 19 % had iron deficiency

d) 14% had vitamin D deficiency

d) 9 % had emotional stress from school and exams as a trigger

Lab Abnormalities

Interestingly, 30% of patients with TE did not undergo any laboratory investigations.

IRON DEFICIENCY:

Low ferritin levels were detected in 8 of twenty (40%) patients tested. That represents documented iron deficiency in 19 % of children with TE overall.

VITAMIN D DEFICIENCY:

Vitamin D deficiency was identified in 6 of 13 (46%) of patients tested which represents 14 % of the overall group experiencing TE.

ZINC DEFICIENCY

Two of three patients who underwent testing for zinc deficiency were found to be deficient. One of these children had no underlying comorbidities at all .

Conclusion

Telogen effluvium is a fascinating condition. This study is interesting and I’d like to highlight a few important points about telogen effluvium in general and TE in children.

1) First, this study supports the notion that infections, low iron and stress are among the more common causes of TE.

This study does not prove these are the causes but rather pairs the two together. It’s often challenging to definitively prove something caused a TE.

Sometimes it is clear of course. A child that has a fever 104F and flu and stays home from school in January for two week and then has hair shedding in March probably had TE from infection. But if you think this information proves it 100% - it doesn’t. Perhaps it was the stress. Perhaps it was the child’s medication that was used at the time or a few months before.

Often we can give best guess probabilities about TE. There is a very high probability that fever was the trigger.

2) As physicians, we love to be able to draw definitive conclusions, but sometimes we need to be humble that this might not be the right approach to take.

Imagine parents and child (let’s call her Laila), in front of you, wanting to know why their child had shedding. You see a ferritin of 28 and you think to yourself “I once learned that ferritin should be over 40 for healthy hair.” Guess what you say to the parents?

“Laila had shedding from low iron. We’ll boost the iron and everything will be fine”

Can you be really confident the iron was the cause here? Well, not at all. It seems possible, but you are kidding yourself if you think this is proof.

In 25-50 % of cases of TE we don’t really know the cause. Sometimes we think we do but the reality is sometimes we really don’t.

We need to be careful about assigning cause. It’s okay to say “It’s possible that low iron was the trigger for Laila so let’s try a very safe treatment to bring the iron levels up and we’ll see where we’re at in 3-5 months. It’s possible there are other causes that came and went and your child will grow back hair anyways”

If the ferritin is quite low, then it makes alot of sense to fuss about this. The lower and lower the ferritin drops under 20 the more and more we need to pay attention about this all. If the low ferritin is combined with low hemoglobin as well as other symptoms (fatigue, poor eating, poor school performance, headaches, diarrhea, constipation), then we need to think about all causes.

It’s a bit of an art and a bit of science to know the approach to take. Telling mom and dad that Laila’s hair shedding is due to low iron when the ferritin is 28 is probably not the right way to go. Telling mom and dad that Laila’s hair shedding is due to low vitamin D when the vitamin D levels are just a bit under the cut off is probably not the right way to go.

As a practitioner, we need to choose our words carefully sometimes. What you don’t realize is Laila might be about to hear weeks and months (and perhaps years) of “you have low iron and you need to eat better or you need to take these pills.”

A far better approach, in my opinion, is to go with “Sally is healthy. Lots of children have low iron of 28 and we don’t know for sure if it’s related. I’d like her to take a supplement to bring up iron. Again, we can’t say for sure it’s related but I’m going to follow this with you and make sure we do everything we can to keep her hair really healthy.

In summary, it’s difficult to prove definitively in this study or anywhere that a child’s shedding is due to the low vitamin D result or the low iron result or the low zinc result that appears in the lab test results.

3) This study was at a tertiary centre

The causes of hair shedding in children that come into a massive academic teaching hospital are going to be slightly different than the causes of shedding in children out in the community setting. So we need to keep that in mind. Children with various chronic diseases may have differences in nutrition, physical activity, and stress.

Children with certain types of chronic illness are more likely to have deficiencies in micronutrients,

REFERENCE

Thomas et al. A Single Centre Retrospective Review of Nutritional Deficiencies Associated With Telogen Effluvium in the Paediatric Population in Canada J Cutan Med Surg 2022 Jan 28 (online)