When eating paper reveals a nutritional deficiency

Pica, defined as the persistent ingestion of non-nutritive substances, is a clinical sign in pediatrics that should raise alarm about potential nutritional deficiencies. Although its association with iron deficiency anemia is well-known, it can be a marker of more complex issues, especially in children with selective eating patterns.

We present the case of a two-year-old girl with a history of a restrictive diet, who attended a Primary Care clinic for compulsive ingestion of paper. Physical examination revealed pallor and a flattening of the weight and height growth curve. The initial laboratory workup confirmed microcytic anemia with low iron stores. Despite initiating treatment with oral iron, the symptoms persisted, partly due to irregular adherence. A second evaluation six months later not only revealed ongoing iron deficiency but also a previously undetected folic acid deficiency.

The final diagnosis was a mixed deficiency anemia in the context of a pediatric feeding disorder. This case highlights the importance of considering multiple nutritional deficiencies when the response to initial treatment is not as expected in a patient with dietary risk factors.