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Pica
Introduction
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines pica as eating nonnutritive, nonfood substances over a period of at least one month. The term is derived from "pica-pica," the Latin word for the magpie bird, because of the bird's indiscriminate gathering and eating a variety of objects for the sake of curiosity.[1] For diagnosis, the behavior must persist for at least one month, not be in keeping with the child's developmental stage (and age cut off of 24 months or more is suggested by DSM V), and not be socially normative or culturally acceptable behavior. The nature of ingested items is variable, including but not limited to earth (geophagy), raw starches (amylophagy), ice (pagophagia), charcoal, ash, paper, chalk, cloth, baby powder, coffee grounds, and eggshells.[2]
Although pica is seen in children, it is also a common eating disorder in patients who are intellectually impaired. In women, it is most often seen during pregnancy. In some parts of the world, the consumption of non-nutritive substances is culturally accepted. Pica usually occurs as an isolated disorder but there are instances when it may co-exist with schizophrenia, OCD, and trichotillomania.
It is important to understand that in order to diagnose pica, the individual must be at least 2 years of age. It is not unusual to notice that younger children are frequently eating nonnutritive substances.
Etiology
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Etiology
Many factors have been implicated in the etiology of pica; however, no direct causality has been established. Studies of psychological factors have reported an association between pica and stress, child neglect and abuse, and maternal deprivation.[3]. Iron deficiency anemia has also been implicated.[4] Many population-based studies have found a low level of serum iron/ferritin (and other micronutrients) among patients with pica.[5][6][7]. Despite this, studies conducted on substances consumed by pica patients failed to show increased iron bioavailability among these substances. This suggests that the idea that these cravings stem from a need for serum iron is an inadequate pathophysiological explanation for this phenomenon.[8] Another proposed hypothesis that is gaining more attention is that pica for non-nutritive substances offers protection from harmful toxins during the most vulnerable stages of human cell replication and embryogenesis (childhood and pregnancy).[9][10][11] The proposed mechanism of protection is binding to toxins and decreasing their intestinal absorption.[12][13][14] In pagophagia, a Japanese study hypothesized that when a patient with anemia chews ice, it increases perfusion thus improving brain function. They contributed that to the activation of the dive reflex which would lead to peripheral vasoconstriction and an increase in central perfusion. Another explanation would be sympathetic activation which would also increase blood flow to the brain.[15]
While the causes of Pica remain unknown, some of the risk factors for developing the disorder include the following:
- Stress
- Cultural factors
- Learned behavior
- Low socioeconomic status
- Underlying mental health disorder
- Nutritional deficiency
- Child neglect
- Pregnancy
- Epilepsy
- Familial psychopathology
Epidemiology
A variety of reasons make it challenging to estimate the exact prevalence of pica; for example, studies use variable definitions of pica, under-reporting is common among affected subjects, and a strong cultural and social influence adds further difficulty to detection.[16] For the most part, the condition seems to affect women who are pregnant and young children.[17] A German prevalence study of 804 children found that 99 children (12.3%) have engaged with a pica behavior at some point in their lives.[18] A meta-analysis of studies of the prevalence of pica during pregnancy estimated that 27.8% of pregnant women reported experiencing pica. The study also stated that the sample was heterogeneous throughout the world, with a higher prevalence in Africa compared to other continents.[19] A high prevalence of pica seems to be reported in patients with mental retardation (approximately 10%); it correlates with the severity of mental retardation.[20]
History and Physical
A comprehensive history should be pursued along with caregiver interviews. The details of the exposure should be sought, including the type of substance, amount, duration of exposure, settings where behavior usually happens, the source of the substance, any co-ingestions, and symptoms of toxicity.[21]
While, in most cases, the physical exam will be normal,[22] one should look for signs of poisoning or complications. Bezoar ingestion could lead to obstruction and, possibly, ulceration and perforation. Lead poisoning manifests with neurological signs such as lethargy, headache, seizure, encephalopathy, cranial nerve palsy, and papilledema. Infectious agents that could present in clay include Toxocara and Ascaris. Signs of such parasitic infections include fever, cough, myocarditis and encephalitis, hepatomegaly, and visual disturbance.[21][23][24]
Evaluation
Laboratory evaluation should be tailored according to the suspected substances ingested. Iron studies in patients with pica should be performed, especially in women who are pregnant, and children. Lead (in pica for paint and chalk) and zinc levels should be checked where appropriate.[25] A basic metabolic panel should be obtained, especially in clay ingestion which can cause metabolic disturbances such as hypokalemia.[26]
Imaging studies are usually required when patients have abdominal symptoms. This may include plain abdominal x-rays, barium studies, and endoscopy. In many cases, serial studies are needed to ensure that the substance has passed.
Treatment / Management
Primary prevention should be utilized to identify at-risk patients such as children who live in old homes with lead paint and woman who are pregnant. This could be achieved by screening for the condition among such populations.[27][28][29] Strategies should be utilized to decrease exposure to the craved substance, such as reducing access or providing an appropriate substitute with a similar texture.[30] Iron, zinc, and other nutrient supplementation should be provided when a deficiency is identified.[31][32][33] Behavioral and aversive treatment might be effective in patients with mental disabilities.[34] Differential reinforcement is a commonly used strategy to induce different patient responses to pica by redirecting the undesired behavior to other activities.[35](B2)
There are no medications specifically for the treatment of pica. While there are anecdotal reports about antipsychotic use to reduce pica behaviors, these drugs also cause constipation and other adverse effects.
Besides the removal of the substance from the environment, it is important to assess the cultural traditions and beliefs that promote pica behavior.
Differential Diagnosis
Careful screening should be performed for mental health problems in the setting of pica. Several psychiatric illnesses should be considered in the differential diagnosis including other eating disorders, schizophrenia and psychosis, autism and developmental delay in children, substance abuse, and addiction.[36][37]
Prognosis
Pica is usually a benign disorder if it is short-term. In pregnant women and children, the condition spontaneously disappears without any sequelae. However, in individuals with intellectual impairment, it may persist for years. When Pica is long term it can result in bowel obstruction, bezoars, and even toxicity. Ingestion of dirt and paint can lead to infections and heavy metal toxicity. Many reports exist of people who have had to undergo surgery to relieve bowel obstruction, perforation, and ulcers.
Complications
The complications of pica can be categorized according to the type of substance ingested:
- Geophagia: Clay ingestion is a very common form of pica. It can lead to constipation, hypokalemia with myopathy, and nutritional deficiencies.[38][26][39] Clay can also be a source of many infectious agents such as parasites. Lead poisoning can be a serious complication with clay ingestion.
- Pagophagia: Ice ingestion could lead to iron deficiency, especially during pregnancy.[36] Other complications include tooth decay and sensitivity.[40]
- Amylophagia: Excessive starch consumption has been associated with iron deficiency. It also can cause high blood sugar and obesity due to its high carbohydrate content.[41]
- Other substances: Ingested materials can contain a wide variety of toxic contaminants such as lead, mercury, arsenic, fluoride, and many others. Exposure to such items can lead to a wide range of toxic effects such as lead poisoning.[42] Lead poisoning could have dire consequences, particularly among women who are pregnant, and high levels can result in seizures.[43]
Fetal Toxicity
Pica during pregnancy can have dire consequences on the growing fetus. There are case reports of intrauterine toxicity due to maternal pica. Lead poisoning has been implicated in long-term neurological disability.[44] Maternal geophagy has been associated with childhood motor function delay.[45]
Enhancing Healthcare Team Outcomes
Treatment of patients with pica should utilize an interprofessional team approach. A team consisting of a physician, psychiatrist/psychologist, behavioral therapist, social worker, and dietitian. Patients should be treated in a nonjudgmental manner, with particular attention to their cultural and social background.[46]
Patient education is vital. Failure to educate patients on healthy eating habits is a common reason why pica can be prevalent in some populations. Parents need to be educated about the harms of ingesting nonnutritive substances by their children and the need for limiting such exposure. In some jurisdictions, landlords have to ensure that lead-based painting is removed. A dietary consult may benefit some families. Close follow-up by the nurse practitioner may be required to ensure that the pica behavior is not continuing.
Clinicians should communicate with each other so that the same message is sent to the parent or caregiver.
References
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