When eating paper reveals a nutritional deficiency

Pica, defined as the persistent ingestion of non-nutritive substances, is a clinical sign that, in pediatric patients, 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 brought to a primary care clinic due to compulsive ingestion of paper. The physical examination revealed pallor and plateauing of the weight and height growth curves. 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 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.