PICA

226 McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121

AbstrAct Pica is defined as the persistent ingestion of non-nutritive substances for more than 1 month at an age at which this behaviour is deemed inappropriate. It occurs most commonly in children, in patients with learning disabilities and in pregnancy. The aetiology of pica is poorly understood and is probably multifactorial. Clinical assessment can be difficult. History and examination should be tailored to address potential complications of the substance being ingested. Complications can be life threatening. Pica often self-remits in younger children. In those with learning disabilities, however, pica may persist into adulthood. Management strategies should involve a multidisciplinary approach, and interventions are primarily behavioural in nature. There is limited evidence to support pharmacological interventions in the management of children with pica.

IntroductIon Pica is the persistent ingestion of non-nu- tritive substances for more than 1 month at an age at which this behaviour is deemed inappropriate1 (see box 1). The term originates in the Latin word for magpie, a bird famed for collecting and hoarding unusual objects.2

Pica can be classified according to the particular substance ingested. Common subtypes are listed in table 1. Ingestion of non-food substances may also be associ- ated with cultural practices. Geophagia, including the ingestion of kaolin (white clay), is seen in sections of the Afri- can-American population in the USA and is common practice in parts of Africa.3 Although often described as pica in the literature, these practices may actually be deemed to be socially normative practice and therefore do not fit the diagnostic criteria outlined in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).

Pica is most commonly seen in children aged 2 or 3 years old. It may persist into

adolescence when it is usually associated with learning difficulties.4 Studies suggest pica can be present in between 5% and 25% of children with learning difficulties. Pica is also common in pregnancy, occur- ring in up to 28% of cases. It typically occurs in younger women in their first pregnancy.5 This article provides an over- view of the possible causes and poten- tial complications of pica. In addition, it discusses important aspects of the clinical assessment, investigation and manage- ment of a child presenting with pica.

AetIology The aetiology of pica is poorly understood and is probably multifactorial. Proposed mechanisms range from psychosocial to biochemical.

An association between pica and micro- nutrient deficiencies, including iron, calcium and zinc has been well described. A recent meta-analysis confirmed the association between anaemia, low plasma zinc levels and pica.6 Children with pica may ingest substances rich in the nutrients in which they are deficient. However, there has been limited success in preventing pica in cases where nutri- tional deficiencies have been identified and treated.

The higher incidence of pica noted in children with learning and develop- mental disabilities, including autistic spec- trum disorder, was traditionally believed to result from an inability to differen- tiate between food and non-food items. However, current thinking suggests that this is more likely to be secondary to learned behaviours.4 7

Pica in children has also been associated with deprivation, parental neglect and malnutrition.2 It may present in the pres- ence of a coexisting psychiatric disorder, and there is increasing evidence that it may be associated with conditions leading to malabsorption, poor nutritional status or anaemia. Recent literature, for example, has highlighted concerns regarding the

Best practice

Fifteen-minute consultation: the child with pica

Ben McNaughten, thomas Bourke, andrew thompson

Royal Belfast Hospital for Sick Children, Belfast, UK

Correspondence to Dr Ben McNaughten, Royal Belfast Hospital for Sick Children, 180-184 Falls Road, Belfast BT12 6BE, UK; bmcnaughten095@ hotmail. com

Received 30 November 2016 Revised 15 February 2017 Accepted 28 February 2017 Published Online First 9 May 2017

To cite: McNaughten B, Bourke T, Thompson A. Arch Dis Child Educ Pract Ed 2017;102:226–229.

McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121 227

Best practice

Table 1 Common subtypes of pica according to the substance ingested

Subtypes of pica Substance ingested

Acuphagia Sharp objects Coniophagia Dust Coprophagia Faeces Emetophagia Vomit Hyalophagia Glass Lithophagia Stones Pagophagia Ice Plumbophagia Lead Tricophagia Hair, wool or other fibres Xylophagia Wood

increased incidence of pica among children with sickle cell disease.8 9

clInIcAl presentAtIon History taking The clinical presentation of pica is highly variable and depends on the particular substance being ingested and the potential associated complications. History taking should focus on the substance ingested. If there is a risk of poisoning, the history should focus on the consequences of that poisoning. Enquire about symp- toms of anaemia, such as pallor, shortness of breath, palpitations and lethargy. Ask about coexisting medical conditions that may predispose to pica. Take a thor- ough developmental and social history. Explore the patient’s living environment, for example, the risk of exposure to lead.

Challenges may arise in consultations with older children, who might deny pica or show reluctance to disclose information. This may limit the clinician’s ability to make an accurate diagnosis and prediction regarding potential complications.

clinical examination Examination will often be normal in children with pica. Clinical signs are usually secondary to compli- cations of the substance that has been ingested. These can be classified into four main groups (see figure 1): 1. Manifestations of toxic ingestion:

– Lead poisoning is the most common poisoning associated with pica.

– Most patients are asymptomatic, and the signs can be very subtle.10

2. Manifestations of infection or parasitic infestation: – Toxocariasis and ascariasis are the most common

parasitic infections associated with pica. – The clinical manifestations relate to the number of

larvae ingested and the organs to which the larvae migrate.11

3. Gastrointestinal manifestations: – Manifestations may be a result of mechanical bowel

problems, perforations and intestinal obstructions caused by bezoar formation around indigestible substances.

4. Dental manifestations: – Manifestations may include severe abrasion and other

mechanical damage to tooth substance.12

InvestIgatIons Pica is a clinical diagnosis based on the DSM-V diag- nostic criteria. Investigations may be useful in screening for potential causes and complications. The meta-anal- ysis examining micronutrient status and pica noted a strong association between pica and anaemia.6 Check a full-blood picture and iron studies in all children.

Further investigations should be tailored according to the substance ingested and the clinical findings. The American Academy of Pediatrics recommends that routine screening of blood lead concentrations be performed in children who live in residential areas where at least 27% of the houses were built before 1950.10 The prevalence of lead piping in domestic water supplies in the UK has decreased significantly in recent years. However, it is still common in older houses, and knowledge of the local environment is important.13 Check blood lead concen- tration in children:

► with signs or symptoms of poisoning (figure 1) ► with a history of ingestion of lead based paints ► when environmental exposure is suspected. There is little evidence to suggest an ideal set of

investigations in children presenting with faltering growth.14 Consider checking at least urea and electro- lytes, liver function tests, calcium, phosphate magne- sium and trace elements in these children.

Imaging studies may be useful if there is a suspicion that abrasive objects have been ingested or there are clinical signs of gastrointestinal obstruction. Plain film of the abdomen may show signs suggestive of trichophagia. However, if there is a palpable mass or signs of obstruction, a contrast study or CT are the investigations of choice.15

MAnAgeMent Although pica in young children and pregnancy normally remits spontaneously, it is a potentially deadly self-injurious behaviour. This is particularly true when it persists into adolescence and adulthood. Social stigmatisation may also occur. Pica is best managed using a multidisciplinary team approach.16 The team

Box 1 DSM-V (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria for the diagnosis of pica

► The eating of non-nutritive, non-food substances is persistent over a period of at least 1 month.

► The eating of such substances is inappropriate to the developmental level of the individual.

► The eating behaviour is not part of a culturally supported or socially normative practice.

► If the behaviour occurs within the context of another mental disorder or medical condition, it is sufficiently severe to warrant independent clinical attention.1

McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121228

Best practice

Figure 1 Potential complications of pica and their clinical manifestations.

Figure 2 Behavioural interventions for pica.

may include physicians, social workers, dieticians, psychologists and dentists. When devising a treatment plan, consider the symptoms and complications that the child is experiencing. Parents and patients should receive education around sound nutritional practices and be made aware of the potential severity of the condition. Treat any nutritional deficiencies identified.

Additional treatment options can be divided into two main groups: behavioural interventions and phar- macological interventions. A variety of behavioural interventions exist (see figure 2):

► positive reinforcement if pica is not attempted; ► discrimination training0 between edible and inedible

substances; ► visual screening, that is, eyes are covered for a short

period, if pica is attempted; ► aversive presentation if pica is attempted, for example, a

bitter taste, such as lemon juice; ► Physical interventions:

– Self-protection devices that prohibit placement of objects in the mouth;

– Time-out if pica is attempted. Although studies in the existing literature are limited

to small sample sizes, it is commonly believed that these methods can be highly effective treatments for pica.16–18

Pharmacological interventions are rarely indicated in pica. The use of selective serotonin reuptake inhibitors has

been reported in three adolescents with pica and learning difficulties.19 A further case report describes resolution of pica following the use of methylphenidate to treat comorbid attention-deficit hyperactivity disorder.20

McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121 229

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Figure 3 Flow chart depicting literature search.

Key messages

► Pica is the persistent ingestion of non-nutritive substances for more than 1 month at an age at which this behaviour is deemed inappropriate.

► It occurs most commonly in children, in patients with learning disabilities and in pregnancy.

► The aetiology is poorly understood. ► History and examination should be tailored to address potential complications of the substance being ingested.

► Complications can be life threatening. ► Interventions should involve a multidisciplinary approach and are primarily behavioural in nature.

Contributors BM wrote the first draft. TB and AT reviewed the content and suggested amendments that BM incorporated. All authors approved the final version.

Competing interests None declared.

Provenance and peer review Commissioned; externally peer reviewed.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

RefeRences 1 American Psychiatric Association. Diagnostic and statistical

manual of mental disorders. 5th edn. Arlington, VA: American Psychiatric Association, 2013.

2 Rose EA, Porcerelli JH, Neale AV. Pica: common but commonly missed. J Am Board Fam Pract 2000;13:353–8.

3 Lar UA, Agene JI, Umar AI. Geophagic clay materials from Nigeria: a potential source of heavy metals and human health implications in mostly women and children who practice it. Environ Geochem Health 2015:37:363–75.

4 Hagopian LP, Rooker GW, Rolider NU. Identifying empirically supported treatments for pica in individuals with intellectual disabilities. Res Dev Disabil 2011:32:2114–20.

5 Fawcett EJ, Fawcett JM, Mazmanian D. A meta-analysis of the worldwide prevalence of pica during pregnancy and the postpartum period. Int J Gynaecol Obstet 2016:133:277–83.

6 Miao D, Young SL, Golden CD. A meta-analysis of pica and micronutrient status. Am J Hum Biol 2015:27:84–93.

7 Pica SP. Developmental disability. JABFM 2001;14:80–1. 8 Aloni MN, Lecerf P, Lê PQ, , et al. Is pica under-reported in

children with sickle cell disease? A pilot study in a Belgian cohort. Hematology 2015:20:429–32.

9 O'Callaghan ET, Gold JI. Pica in children with sickle cell disease: two case reports. J Pediatr Nurs 2012:27:e65–70.

10 Committee on Environmental Health. Screening for elevated blood lead levels. Pediatrics 1998;101:1072–8.

11 American Academy of Pediatrics. Toxocariasis. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red book®: 2015 Report of the Committee of Infectious Diseases. Washington, DC: American Academy of Pediatrics, 2015:786–7.

12 Johnson CD, Shynett B, Dosch R, et al. An unusual case of tooth loss, abrasion, and erosion associated with a culturally accepted habit. Gen Dent 2007:55:445–8.

13 Watt GC, Britton A, Gilmour HG, et al. Public health implications of new guidelines for lead in drinking water: a case study in an area with historically high water lead levels. Food Chem Toxicol 2000;38(1 Suppl):S73–9.

14 Shields B, Wacogne I, Wright CM. Weight faltering and failure to thrive in infancy and early childhood. BMJ 2012;345:e5931.

15 Learning Radiology. http:// learningradiology. com/ archives2011/ COW% 20437- Bezoar/ bezoarcorrect. htm (accessed Jan 2017).

16 Williams DE, McAdam D. Assessment, behavioral treatment, and prevention of pica: clinical guidelines and recommendations for practitioners. Res Dev Disabil 2012;33:2050–7.

17 Blinder BJ, Salama C. An update on Pica: prevalence, contributing causes, and treatment. Psychiatric Times 2008;25:66–73.

18 Call NA, Simmons CA, Mevers JE, et al. Clinical outcomes of behavioral treatments for pica in children with developmental disabilities. J Autism Dev Disord 2015:45:2105–14.

19 Singh NN, Ellis CR, Crews WD, et al. Does diminished dopaminergic neurotransmission increase pica? J Child Adolesc Psychopharmacol 1994;4:93–9.

20 Hergüner S, Hergüner AS. Pica in a child with attention deficit hyperactivity disorder and successful treatment with methylphenidate. Prog Neuropsychopharmacol Biol Psychiatry 2010:34:1155–6.

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