Patient Presentation
A 15-month-old female came to clinic for her health supervision visit. Her family had immigrated to the US when she was 6 months old from a low-income South-East Asian country. Her mother was worried that she “had a vitamin or mineral deficiency” because the American doctors hadn’t prescribed vitamins and now she had had 3 viral infections since she had started childcare about 3 months ago. She said that the doctors in her home country usually give vitamins to the children. Her mother also thought she looked “small and pale.”

The past medical history showed an uneventful pregnancy where the mother had routine prenatal care and “took her vitamins.” The child had been breast fed until 1 month of age and then was transitioned to formula. At one year of age she was transitioned to whole milk and her diet history showed her eating a variety of age- and culture-appropriate foods. She was not described as a picky eater. Her chart showed a normal hemoglobin and lead testing at 12 months of age. She had had one ear infection as well before 1 year of age. She had no failure to thrive, emesis/diarrhea, or unusual infections.

The pertinent physical exam revealed a smiling child with normal vital signs and weight and length at the 25-50% for age. HEENT showed normal complexion without pale conjunctiva. She also had some mild rhinorrhea and her ears had a small amount of clear fluid at the bases bilaterally. The rest of her examination was normal.

The diagnosis of a healthy appearing female with what appeared to be serial viral infections due to exposure at childcare. The diet and medical history were uneventful for significant dietary deficiencies and she appeared to be eating a good toddler diet for her age. The pediatrician discussed viral infection exposure due to childcare. Despite discussing the unlikelyhood of a significant dietary deficiency the mother wanted more laboratory testing and a prescription for vitamins. The pediatrician politely refused the testing but noted that if the mother was very insistent, that using a general liquid multivitamin likely would not hurt the child. He also noted that it likely would not change the number of viral infections the child had too.

Discussion
Nutrients are needed to sustain biological life. Macronutrients are those needed “…in large amounts to provide energy, produce hormones, synthesize molecules and regulate metabolic pathways. They include protein, carbohydrates and lipids. Micronutrients are needed in trace amounts for biochemical processes such as gene transcription, enzymatic reactions and protection against oxidative stress. Vitamins and minerals are the two main classes of micronutrients. Both are essential as they cannot be synthesized and must be obtained from the diet.

Vitamins are organic compounds and are further classified as fat or water soluble which affects their storage. Fat soluble are Vitamins A, D, E, and K. Stored in fat they are available to the body longer. Water soluble vitamins are the B vitamins (1,2,3,5,6,7,9,12) and Vitamin C. They are washed out with water and therefore not available to the body for a long time.

Inadequate nutrition continues to be a world-wide problem. Multiple micronutrient deficiencies in an energy-replete diet is referred to as the hidden hunger. Hidden hunger is one of the three components of the triple burden of malnutrition. The triple burden of malnutrition is when within a single or community population there are individuals with overnutrition (obesity), undernutrition (underweight, starvation) and micronutrient deficiencies. Limited micronutrient intake can often occur because of consuming energy-dense but nutrient poor diets. These are often “…where there is reliance on low-cost staples and where the diet is monotonous, and choices are limited by poverty.” For example, low-cost, energy-dense foods would be items such as potatoes, rice and wheat. Ways to improve micronutrient intake include fortification (the micronutrient is added to the food such as iron and/or B vitamins added to flour, or iodine added to table salt), supplementation (giving the micronutrient separate from the food, in a pill or similar forms such as a general multivitamin), biofortification (where the food is bioengineered or grown in an environment where the plant is able to increase the content of the micronutrient), and diet diversification (an increased range of different foods is consumed). Diet diversification is one of the easiest and best ways to ensure that all macro- and micronutrients are consumed, but can be limited because of poverty, food access, health literacy, etc.

Learning Point
Minerals are inorganic micronutrients. They are important in “…enzymes structure or catalytic properties and participate in cellular energy transduction second-messenger pathways, and acid-base balance.”
The most common micronutrients that are deficient around the world are Vitamin A, folate (B9), iodine, iron and zinc. Iron is the most common micronutrient deficiency globally.
Some of the more common minerals are:

• Boron
  • Low: bone mineralization, problems with use of Vitamin D, calcium and magnesium
• Calcium
  • Low: problems with bone metabolism, cardiovascular disease, pregnancy complications and cancers
  • High: generally not a problem but can have increased risk of nephrolithiasis or myocardial infarction
• Cobalt
  • Low: problems with Vitamin B12 and glucose regulation
• Chromium
  • Low: impaired glucose and cholesterol regulation
• Copper
  • Low: impaired bone, cardiovascular immune and neurological system functions
  • High: rare – cell damage or death
• Chloride
  • Low: rare – gastrointestinal problems, hypokalemic metabolic alkalosis, growth failure
  • High: uncommon
• Iodine
  • Low: hypothyroidism, cognitive impairment, congenital abnormalities
  • High: gastrointestinal problems, diarrhea, nausea/emesis, cardiovascular problems, thyroid problems
• Iron – most common micronutrient deficiency globally
  • Low: microcytic hypochromic anemia
  • High: gastrointestinal symptoms such as diarrhea, constipation, nausea/emesis
• Magnesium
  • Low: very common and is estimated that 50% of US population is deficient. Can have problems with metabolic, cardiovascular, psychiatric and respiratory systems, can have arrhythmias and muscle spasms
  • High: rare but can have bradycardia, hypotension and coma
• Manganese
  • Low: extremely rare, only reported under experimental conditions
• Molybdenum
  • Low: not reported due to dietary deficiency
  • High: only reported in unusual soil conditions and present with joint or gout-like problems
• Phosphorus
  • Low: bone demineralization, nervous system dysfunction with muscle weakness and tremors
  • High: rare, can see cardiovascular disease, calcification and endothelial dysfunction
• Potassium
  • Low: rare, hypertension, cardiovascular disease
• Selenium – has narrow range of safety
  • Low: cognitive problems, impaired immune system, fetal development problem, infertility, thyroid dysfunction
  • High: hypotension, tremor, tachycardia, muscle spasms
• Sodium
  • Low: hyponatremia
  • High: hypertension
  • Source: most common food is processed food not table salt
• Zinc
  • Low: rash, cheilitis, impaired immune system, hypogonadism, impaired taste
  • High: rare – nausea/emesis

Questions for Further Discussion
1. What are some of the causes of food insecurity in your local area?
2. Under what circumstances do you test for mineral deficiencies?
3. What types, and number of infections, make you consider an immune deficiency?
4. What do picky eaters not really eat? A review can be found here

Related Cases

Disease: Minerals | Viral Infections | Vitamins

Symptom/Presentation: Frequent or Recurrent Infections

Specialty: Nutrition / Dietetics

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Malnutrition and Vitamins.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Heffernan SM, Horner K, De Vito G, Conway GE. The Role of Mineral and Trace Element Supplementation in Exercise and Athletic Performance: A Systematic Review. Nutrients. 2019;11(3):696. doi:10.3390/nu11030696

Lowe NM. The global challenge of hidden hunger: perspectives from the field. Proc Nutr Soc. 2021;80(3):283-289. doi:10.1017/S0029665121000902

Oh C, Keats EC, Bhutta ZA. Vitamin and Mineral Supplementation During Pregnancy on Maternal, Birth, Child Health and Development Outcomes in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients. 2020;12(2):491. doi:10.3390/nu12020491

Dubey P, Thakur V, Chattopadhyay M. Role of Minerals and Trace Elements in Diabetes and Insulin Resistance. Nutrients. 2020;12(6):1864. doi:10.3390/nu12061864

Espinosa-Salas S, Gonzalez-Arias M. Nutrition: Micronutrient Intake, Imbalances, and Interventions. In: StatPearls. StatPearls Publishing; 2025. Accessed May 12, 2025. http://www.ncbi.nlm.nih.gov/books/NBK597352/

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa