iodine is an essential   component of 
 thyroid hormones and critical to normal brain development in newborn infants 
 and children .
iodine nutrition in the united states is 
 considered to be sufficient for most populations despite significant reductions 
 in urinary iodine values between the early 1970s and the early 1990s .
the 2001 - 2002 us national health and 
 nutrition examination survey ( nhanes ) results suggest that iodine nutrition has 
 stabilized ,   but levels are barely above the recommendation for the average 
 which means that a significant number of people remain at risk .
women of childbearing age and pregnant women 
 are widely accepted as high - risk groups for inadequate iodine intake , but there 
 is valid concern that additional high - risk groups remain [ 3 , 4 ] .
three cases of iodine deficiency as a result 
 of restrictive diets in children have been reported in the literature [ 57 ] .
this case report illustrates a unique case of 
 iodine deficiency in the us and suggests the need for a greater emphasis on promoting and evaluating the 
 nutritional adequacy of the diets of children with multiple food allergies or 
 perceived food allergies or sensitivities .
he had developmental delay diagnosed at 
 approximately 2 years of age and was thought to have some form in the autism 
 spectrum .
his family history was 
 positive for a brother with life - threatening peanut allergies .
his past medical 
 history was significant for multiple food allergies , including four 
 anaphylactic episodes .
he was tested at 
 6 months of age and was found to be allergic to peanuts and soy .
additional allergy tests determined allergies 
 to soy , eggs , dairy , wheat , seafood , peanuts , legumes , white potatoes , corn , 
 spinach , and strawberries .
the patient had a nutrition evaluation with a 
 registered dietitian at this time , which did not reveal any significant 
 nutrition concerns . at age 10 , due to 
 concerns about iodized table salt containing cornstarch , the family switched to 
 using sea salt .
his diet is further 
 restricted from citrus fruits , pork due to concern regarding additives , and 
 beef due to potential processing with milk .
his current dietary intake includes 
 almost exclusively chicken and turkey , rice cakes , apples , applesauce , apple 
 juice , bananas , raisins , blueberries , carrots , broccoli , sweat potatoes , olive 
 oil , and sea salt .
multivitamins are 
 avoided due to bulking agents , which sometimes contain cornstarch . on initial 
 examination , he had no signs or symptoms of hyperthyroidism or 
 hypothyroidism .
the right lobe measured 7.4  4.0  2.6 cm 
 for a total volume of 41 cc . the left 
 lobe measured 7.8  3.2  2.9 for a total volume of 38 cc .
his thyroid function was as follows : free 
 triiodothyronine ( free t3 ) 476 pg / dl ( normal 335480 ) , free 
 tetraiodothyronine ( free t4 ) 0.2 ng / dl ( normal 0.82.0 ) , total 
 tetraiodothyronine ( total t4 ) 1.6 g / dl ( normal 4.510.0 ) , and thyrotropin ( tsh ) 
 16.5 iu / ml 
 ( normal 0.504.50 ) .
a 24-hour 
 urine collection for iodine was less than 10 g ( normal 100460 g / specimen ) .
specific dosing information for treating iodine 
 deficiency was difficult to find since prevention is strongly encouraged .
the dietary reference intake for males 913 
 years is 120 g 
 daily and the tolerable upper intake level is 600 g daily . in dosing potassium iodine ,
the saturated solution of potassium iodine 
 contains 50 mg or 50.000 g 
 per drop .
this form of iodine 
 replacement was chosen to avoid allergic reaction to other ingredients that may 
 be included in other multivitamin - mineral supplements .
the patient was treated with one drop of 10% 
 solution potassium iodine in the allergists ' office to provide 5 mg of 
 iodine .
after the patient tolerated 
 this , the dose was increased to 15 mg per day because of the slow response to 
 his thyroid function tests .
after three 
 months of supplementation , his thyroid function tests have normalized and his 
 goiter has decreased dramatically in size to almost normal .
the patient 's iodine intake is maintained on a supplement containing 3.6 mg iodine taken once per month and urinary iodine is being monitored .
in the us , iodized 
 table salt is considered to be a primary food source for iodine .
other food sources include saltwater fish , 
 seaweed , and to a lesser extent egg yolks , dairy products , commercially baked 
 breads , meat , and poultry .
iodination of 
 salt is not mandatory in the united 
  states , and recent tests of iodized table 
 salt samples found that 53% did not meet the us food and drug administration 's 
 recommendation for iodine levels .
additionally , americans have reduced their 
 overall salt consumption for health reasons such as preventing hypertension ; 
 are using designer table salts more frequently , such as sea salt or kosher salt 
 which do not contain significant amounts of iodine ; and are consuming a 
 significant amount of processed and fast foods which may not be prepared with 
 iodized salt .
the iodine content of 
 dairy products and commercially baked bread is dependent on the use of 
 iodophors ( iodine containing substances , such as dairy cleansers or bread dough 
 conditioners ) in processing , making iodine levels in these foods highly 
 variable [ 10 , 11 ] .
iodine in meat and 
 poultry is also highly variable depending on the amount of iodine added to animal 
 feed .
only 50% of 
 adult multivitamins , 45% of children multivitamins , and no infant liquid 
 multivitamins contain iodine .
furthermore , only 1/3 of over - the - counter and 2/3 of prescription 
 prenatal vitamins contain iodine . with all of these factors
present , valid concerns regarding iodine 
 intake remain for high - risk groups despite the most recent nhanes report .
this patient 
 developed severe iodine deficiency disorder ( idd ) due to his extremely 
 restricted dietary intake from multiple food allergies , particularly the 
 elimination of seafood and finally iodized salt .
food allergies occur in an estimated 68% of 
 children , and perceived prevalence of food allergy may lead to the use of some 
 form of elimination diet in an estimated 20% of children .
children with multiple food allergies have 
 been found to be shorter than those with one food allergy and to have less than 
 adequate intakes of calcium , vitamin d , and vitamin e . the use of allergy formulas may help to supplement 
 iodine in children with multiple food allergies ( see table 1 ) , but additional 
 supplementation may still be necessary depending on the restrictions of the 
 diet .
additionally , quantities sufficient to 
 prevent iodine deficiency are often difficult to consume by small 
 children .
children with multiple food 
 allergies or those following elimination diets due to a perceived food allergy 
 should have regular nutrition assessments by a registered dietitian . another evaluation after the elimination of 
 iodized salt at age 10 may have identified a lack of iodine in the diet .
these children should also be added as a 
 high - risk group for idd in the us . in presenting 
 this case study at a recent regional pediatric endocrinology meeting , concerns 
 were raised regarding an increase in newborn tsh values among infants born in 
 the state .
similar results have been 
 found across the us and coincide with declining urinary iodine status of pregnant women . in a recent study by moleti et al .
, maternal 
 iodine insufficiency was significantly lower in women consuming iodized salt 
 for at least 2 years compared with women consuming iodized salt upon becoming 
 pregnant .
these results further 
 stress the importance of adequate iodine intake prior to and during pregnancy 
 and the potential long - term consequence to children born to iodine insufficient 
 mothers .
the national academy of 
 sciences recently made the recommendation for the addition of iodine to all 
 prenatal vitamins , and the american thyroid association also recommends daily 
 iodine supplementation for all pregnant and lactating women .
public health 
 efforts for adequate iodine nutrition should be increased in all children and 
 pregnant and breastfeeding women , particularly among high - risk populations and 
 anyone who does not use iodized salt or consume seafood regularly .
research efforts should focus on the effects 
 of suboptimal iodine nutrition in high - risk groups and identification of additional 
 high - risk groups . continued and routine 
 monitoring of iodine nutrition in the us may also prove prudent given the 
 limited number of iodine rich food sources .
 severe iodine deficiency results in impaired thyroid hormone synthesis and thyroid enlargement . in the united states , 
 adequate iodine intake is a concern for women of childbearing age and pregnant women . beyond this high risk group iodine deficiency 
 is not considered to be a significant problem . 
 this case report describes a 12-year - old male with severe iodine deficiency disorder ( idd ) resulting from restricted dietary intake due to multiple food allergies . 
 we describe iodine replacement for this patient and continued monitoring for iodine sufficiency . 
 children with multiple food allergies , in particular those with restrictions to iodized salt and seafood , should be considered high risk for severe iodine deficiency . 
1. Background
2. Case Report
3. Discussion