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Are the Findings in This Boy Signs of Malnutrition? - Part 2

Ron Shaoul, MD, and David Bader, MD, MHA
Bnai Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel

Shaoul R, Bader D. Are the findings in these boys signs of malnutrition? Consultant for Pediatricians. 2013;12(1):40-42.

The mother of a 4-year-old boy is concerned about his habit of eating stones and wall plaster; the habit has persisted for the past year. The child has a tendency toward constipation. He recently had abdominal pain and some discomfort with defecation. Small pebbles have been noted in the child’s stool. His family is of low socioeconomic status; his mother, a single parent, receives social assistance.

Physical examination findings are unremarkable. An abdominal radiograph is obtained.

Abdominal scan

What caused these radiographic anomalies?

(Answer and discussion on next page.)


ANSWER: Pica Associated With Iron Deficiency

The radiograph shows multiple round densities, suggestive of pebbles. Air is present throughout the bowel; there is no sign of obstruction. Laboratory studies reveal a hemoglobin level of 11.3 g/dL, an iron level of 28 µg/dL, and a ferritin level of 5 ng/mL. Mean corpuscular volume was 74 fL, mean corpuscular hemoglobin concentration, 32.2 g/dL; red blood cell count, 47,200/µL; and platelet count, 484,000/µL.

Abdominal scan

Pica involves repeated or chronic ingestion of nonnutritive substances (such as plaster, charcoal, clay, wool, ashes, paint, and dirt) for at least 1 month.1,2 Its name comes from Pica hudsonia, the Latin term for magpie—a bird that is believed to eat almost anything.3 The basis of this unusual craving for nonfood items remains obscure.

Specific nutritional deficiencies of particular trace elements may trigger the behavior.1 Iron deficiency is frequently associated with pica.3 In addition, pica is common in infants and children who require prolonged (more than 1 month) total parenteral nutrition and receive no enteral nutrition.

There can be many adverse medical consequences of pica depending on the type of substance ingested. Accumulation of ingested pebbles in the colon can lead to intestinal obstruction.4

This child was treated with parenteral iron, because he refused oral iron. His GI symptoms gradually resolved, as did his pica. The iron deficiency was thought to be the cause of his pica. Consultations with a mental health counselor and nutritionist were recommended.


  1. Schnuelle P, Oberheiden T, Hohenadel D, et al. An unusual case of severe iron deficiency anaemia. Gut. 2006;55:1060.
  2. Hergüner S, Ozyildirim I, Tanidir C. Is pica an eating disorder or an obsessivecompulsive spectrum disorder? Prog Neuropsychopharmacol Biol Psychiatry. 2008;32:2010-2011.
  3. Borgna-Pignatti C, Marsella M. Iron deficiency in infancy and childhood. Pediatr Ann. 2008;37:329-337.
  4. Narayanan SK, Akbar Sherif VS, Babu PR, Nandakumar TK. Intestinal obstruction secondary to a colonic lithobezoar. J Pediatr Surg. 2008;43:e9-e10.