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Pica

Editor: Ali J. Alsaad Updated: 6/26/2023 9:09:13 PM

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


[1]

Walker HK, Hall WD, Hurst JW, Johnson BE. Pica. Clinical Methods: The History, Physical, and Laboratory Examinations. 1990:():     [PubMed PMID: 21250098]


[2]

Young SL. Pica in pregnancy: new ideas about an old condition. Annual review of nutrition. 2010 Aug 21:30():403-22. doi: 10.1146/annurev.nutr.012809.104713. Epub     [PubMed PMID: 20420523]


[3]

Singhi S, Singhi P, Adwani GB. Role of psychosocial stress in the cause of pica. Clinical pediatrics. 1981 Dec:20(12):783-5     [PubMed PMID: 7307412]


[4]

López LB, Ortega Soler CR, de Portela ML. [Pica during pregnancy: a frequently underestimated problem]. Archivos latinoamericanos de nutricion. 2004 Mar:54(1):17-24     [PubMed PMID: 15332352]


[5]

Nchito M, Geissler PW, Mubila L, Friis H, Olsen A. Effects of iron and multimicronutrient supplementation on geophagy: a two-by-two factorial study among Zambian schoolchildren in Lusaka. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2004 Apr:98(4):218-27     [PubMed PMID: 15049460]

Level 1 (high-level) evidence

[6]

Geissler PW, Shulman CE, Prince RJ, Mutemi W, Mnazi C, Friis H, Lowe B. Geophagy, iron status and anaemia among pregnant women on the coast of Kenya. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1998 Sep-Oct:92(5):549-53     [PubMed PMID: 9861377]

Level 2 (mid-level) evidence

[7]

Cavdar AO, Arcasoy A, Cin S, Babacan E, Gözdasoğlu S. Geophagia in Turkey: iron and zinc deficiency, iron and zinc absorption studies and response to treatment with zinc in geophagia cases. Progress in clinical and biological research. 1983:129():71-97     [PubMed PMID: 6657708]

Level 3 (low-level) evidence

[8]

Hooda PS, Henry CJ, Seyoum TA, Armstrong LD, Fowler MB. The potential impact of soil ingestion on human mineral nutrition. The Science of the total environment. 2004 Oct 15:333(1-3):75-87     [PubMed PMID: 15364520]


[9]

Young SL, Wilson MJ, Miller D, Hillier S. Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PloS one. 2008 Sep 5:3(9):e3147. doi: 10.1371/journal.pone.0003147. Epub 2008 Sep 5     [PubMed PMID: 18773081]


[10]

Johns T. Detoxification function of geophagy and domestication of the potato. Journal of chemical ecology. 1986 Mar:12(3):635-46. doi: 10.1007/BF01012098. Epub     [PubMed PMID: 24306904]


[11]

Johns T, Duquette M. Detoxification and mineral supplementation as functions of geophagy. The American journal of clinical nutrition. 1991 Feb:53(2):448-56     [PubMed PMID: 1989412]


[12]

Dominy NJ, Davoust E, Minekus M. Adaptive function of soil consumption: an in vitro study modeling the human stomach and small intestine. The Journal of experimental biology. 2004 Jan:207(Pt 2):319-24     [PubMed PMID: 14668315]


[13]

Khalil SA, Daabis NA, Naggar VF, Motawi MM. The in vitro adsorption of some antibiotics on antacids. Die Pharmazie. 1976:31(2):105-9     [PubMed PMID: 8784]

Level 3 (low-level) evidence

[14]

Minnich V, Okçuoğlu A, Tarcon Y, Arcasoy A, Cin S, Yörükoğlu O, Renda F, Demirağ B. Pica in Turkey. II. Effect of clay upon iron absorption. The American journal of clinical nutrition. 1968 Jan:21(1):78-86     [PubMed PMID: 5237295]


[15]

Hunt MG, Belfer S, Atuahene B. Pagophagia improves neuropsychological processing speed in iron-deficiency anemia. Medical hypotheses. 2014 Oct:83(4):473-6. doi: 10.1016/j.mehy.2014.07.016. Epub 2014 Aug 5     [PubMed PMID: 25169035]


[16]

Mills ME. Craving more than food: the implications of pica in pregnancy. Nursing for women's health. 2007 Jun:11(3):266-73     [PubMed PMID: 17883773]


[17]

Young SL, Sherman PW, Lucks JB, Pelto GH. Why on earth?: Evaluating hypotheses about the physiological functions of human geophagy. The Quarterly review of biology. 2011 Jun:86(2):97-120     [PubMed PMID: 21800636]

Level 3 (low-level) evidence

[18]

Murray HB, Thomas JJ, Hinz A, Munsch S, Hilbert A. Prevalence in primary school youth of pica and rumination behavior: The understudied feeding disorders. The International journal of eating disorders. 2018 Aug:51(8):994-998. doi: 10.1002/eat.22898. Epub 2018 Sep 2     [PubMed PMID: 30175409]


[19]

Fawcett EJ, Fawcett JM, Mazmanian D. A meta-analysis of the worldwide prevalence of pica during pregnancy and the postpartum period. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2016 Jun:133(3):277-83. doi: 10.1016/j.ijgo.2015.10.012. Epub 2016 Feb 3     [PubMed PMID: 26892693]

Level 1 (high-level) evidence

[20]

McAlpine C, Singh NN. Pica in institutionalized mentally retarded persons. Journal of mental deficiency research. 1986 Jun:30 ( Pt 2)():171-8     [PubMed PMID: 3735412]


[21]

McNaughten B, Bourke T, Thompson A. Fifteen-minute consultation: the child with pica. Archives of disease in childhood. Education and practice edition. 2017 Oct:102(5):226-229. doi: 10.1136/archdischild-2016-312121. Epub 2017 May 9     [PubMed PMID: 28487433]


[22]

. Screening for elevated blood lead levels. American Academy of Pediatrics Committee on Environmental Health. Pediatrics. 1998 Jun:101(6):1072-8     [PubMed PMID: 9614424]

Level 1 (high-level) evidence

[23]

Woodhall DM, Garcia AP, Shapiro CA, Wray SL, Shane AL, Mani CS, Stimpert KK, Fox LM, Montgomery SP. Assessment of U.S. Pediatrician Knowledge of Toxocariasis. The American journal of tropical medicine and hygiene. 2017 Oct:97(4):1243-1246. doi: 10.4269/ajtmh.17-0232. Epub 2017 Aug 18     [PubMed PMID: 28820703]


[24]

Dold C, Holland CV. Ascaris and ascariasis. Microbes and infection. 2011 Jul:13(7):632-7. doi: 10.1016/j.micinf.2010.09.012. Epub 2010 Oct 8     [PubMed PMID: 20934531]

Level 3 (low-level) evidence

[25]

Poy MS, Weisstaub A, Iglesias C, Fernández S, Portela ML, López LB. [Pica diagnosis during pregnancy and micronutrient dificiency in Argentine women]. Nutricion hospitalaria. 2012 May-Jun:27(3):922-8. doi: 10.3305/nh.2012.27.3.5598. Epub     [PubMed PMID: 23114955]


[26]

Ukaonu C, Hill DA, Christensen F. Hypokalemic myopathy in pregnancy caused by clay ingestion. Obstetrics and gynecology. 2003 Nov:102(5 Pt 2):1169-71     [PubMed PMID: 14607045]

Level 3 (low-level) evidence

[27]

Roberts JW, Dickey P. Exposure of children to pollutants in house dust and indoor air. Reviews of environmental contamination and toxicology. 1995:143():59-78     [PubMed PMID: 7501867]


[28]

Hauptman M, Bruccoleri R, Woolf AD. An Update on Childhood Lead Poisoning. Clinical pediatric emergency medicine. 2017 Sep:18(3):181-192. doi: 10.1016/j.cpem.2017.07.010. Epub     [PubMed PMID: 29056870]


[29]

Ezzeddin N, Zavoshy R, Noroozi M, Jahanihashemi H, Riseh SH. Prevalence and risk factors for pica during pregnancy in Tehran, Iran. Eating and weight disorders : EWD. 2015 Dec:20(4):457-63. doi: 10.1007/s40519-015-0198-8. Epub 2015 Jul 5     [PubMed PMID: 26143570]


[30]

Matson JL, Hattier MA, Belva B, Matson ML. Pica in persons with developmental disabilities: approaches to treatment. Research in developmental disabilities. 2013 Sep:34(9):2564-71. doi: 10.1016/j.ridd.2013.05.018. Epub 2013 Jun 7     [PubMed PMID: 23747942]


[31]

Roy A, Fuentes-Afflick E, Fernald LCH, Young SL. Pica is prevalent and strongly associated with iron deficiency among Hispanic pregnant women living in the United States. Appetite. 2018 Jan 1:120():163-170. doi: 10.1016/j.appet.2017.08.033. Epub 2017 Aug 31     [PubMed PMID: 28864256]


[32]

Sadeghzadeh M, Khoshnevisasl P, Sadeghzadeh S. The relation between pica and iron deficiency in children in Zanjan, Islamic Republic of Iran: a case-control study. Eastern Mediterranean health journal = La revue de sante de la Mediterranee orientale = al-Majallah al-sihhiyah li-sharq al-mutawassit. 2017 Aug 20:23(6):404-407     [PubMed PMID: 28836652]

Level 2 (mid-level) evidence

[33]

Kelkitli E, Ozturk N, Aslan NA, Kilic-Baygutalp N, Bayraktutan Z, Kurt N, Bakan N, Bakan E. Serum zinc levels in patients with iron deficiency anemia and its association with symptoms of iron deficiency anemia. Annals of hematology. 2016 Apr:95(5):751-6. doi: 10.1007/s00277-016-2628-8. Epub 2016 Mar 2     [PubMed PMID: 26931116]


[34]

Albin JB. The treatment of pica (scavenging) behavior in the retarded: a critical analysis and implications for research. Mental retardation. 1977 Aug:15(4):14-7     [PubMed PMID: 895511]


[35]

Call NA, Simmons CA, Mevers JE, Alvarez JP. Clinical Outcomes of Behavioral Treatments for Pica in Children with Developmental Disabilities. Journal of autism and developmental disorders. 2015 Jul:45(7):2105-14. doi: 10.1007/s10803-015-2375-z. Epub     [PubMed PMID: 25636679]

Level 2 (mid-level) evidence

[36]

Rabel A, Leitman SF, Miller JL. Ask about ice, then consider iron. Journal of the American Association of Nurse Practitioners. 2016 Feb:28(2):116-20. doi: 10.1002/2327-6924.12268. Epub 2015 May 5     [PubMed PMID: 25943566]


[37]

Kar SK, Kamboj A, Kumar R. Pica and psychosis - clinical attributes and correlations: a case report. Journal of family medicine and primary care. 2015 Jan-Mar:4(1):149-50. doi: 10.4103/2249-4863.152277. Epub     [PubMed PMID: 25811011]

Level 3 (low-level) evidence

[38]

McKenna D. Myopathy, hypokalaemia and pica (geophagia) in pregnancy. The Ulster medical journal. 2006 May:75(2):159-60     [PubMed PMID: 16755950]

Level 3 (low-level) evidence

[39]

Setime MA, Sesay S, Cainelli F, Vento S. A case of severe hypokalemic myopathy due to clay ingestion. The Israel Medical Association journal : IMAJ. 2013 Sep:15(9):524-5     [PubMed PMID: 24340849]

Level 3 (low-level) evidence

[40]

Johnson CD, Koh SH, Shynett B, Koh J, Johnson C. An uncommon dental presentation during pregnancy resulting from multiple eating disorders: pica and bulimia: case report. General dentistry. 2006 May-Jun:54(3):198-200     [PubMed PMID: 16776414]

Level 3 (low-level) evidence

[41]

Edwards CH, Johnson AA, Knight EM, Oyemade UJ, Cole OJ, Westney OE, Jones S, Laryea H, Westney LS. Pica in an urban environment. The Journal of nutrition. 1994 Jun:124(6 Suppl):954S-962S. doi: 10.1093/jn/124.suppl_6.954S. Epub     [PubMed PMID: 8201446]

Level 2 (mid-level) evidence

[42]

Diawara MM, Litt JS, Unis D, Alfonso N, Martinez L, Crock JG, Smith DB, Carsella J. Arsenic, cadmium, lead, and mercury in surface soils, Pueblo, Colorado: implications for population health risk. Environmental geochemistry and health. 2006 Aug:28(4):297-315     [PubMed PMID: 16752202]


[43]

Shannon M. Severe lead poisoning in pregnancy. Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association. 2003 Jan-Feb:3(1):37-9     [PubMed PMID: 12540252]

Level 3 (low-level) evidence

[44]

Mycyk MB, Leikin JB. Combined exchange transfusion and chelation therapy for neonatal lead poisoning. The Annals of pharmacotherapy. 2004 May:38(5):821-4     [PubMed PMID: 15026564]

Level 3 (low-level) evidence

[45]

Mireku MO, Davidson LL, Zoumenou R, Massougbodji A, Cot M, Bodeau-Livinec F. Consequences of prenatal geophagy for maternal prenatal health, risk of childhood geophagy and child psychomotor development. Tropical medicine & international health : TM & IH. 2018 Aug:23(8):841-849. doi: 10.1111/tmi.13088. Epub 2018 Jun 22     [PubMed PMID: 29876999]


[46]

Williams DE, McAdam D. Assessment, behavioral treatment, and prevention of pica: clinical guidelines and recommendations for practitioners. Research in developmental disabilities. 2012 Nov-Dec:33(6):2050-7. doi: 10.1016/j.ridd.2012.04.001. Epub 2012 Jun 28     [PubMed PMID: 22750361]