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Current Pediatric Reviews, 2019, 15, 164-169 REVIEW ARTICLE

Pica: A Common Condition that is Commonly Missed - An Update Review

Alexander K.C. Leung1,* and Kam Lun Hon2

1Department of Pediatrics, The University of Calgary, Alberta Children’s Hospital, Calgary, Alberta, AB, Canada; 2Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong

A R T I C L E H I S T O R Y

Received: January 30, 2019 Revised: February 22, 2019 Accepted: March 06, 2019 DOI: 10.2174/1573396315666190313163530

Abstract: Background: Pica is a common condition in childhood that is commonly missed.

Objective: To familiarize physicians with the clinical evaluation and management of children with pica.

Methods: A PubMed search was completed in Clinical Queries using the key term "pica" OR “dirt- eating”. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

Results: Pica refers to the persistent, compulsive craving for and the ingestion of substances usu- ally considered inedible and the behavior is discordant with cultural practices and continues beyond the normal developmental phase of occasional indiscriminate and experimental mouthing and swal- lowing over a period of at least one month. The condition is more common among children in lower socioeconomic classes and those who are mentally handicapped or emotionally deprived. Pica is a significant cause of anemia and lead poisoning. Pica generally resolves in children of normal intelligence after they have been trained to discriminate between edible and inedible items and proper supervision is provided. While relief of family economic and housing difficulties is an adjunct, attention to the individual’s emotional needs and stresses is of paramount importance. Children with iron deficiency anemia should be treated with iron replacement therapy. Complica- tions such as gastrointestinal obstruction and lead poisoning should be promptly recognized and treated.

Conclusion: Pica is often an overlooked phenomenon and its association with iron deficiency and lead poisoning has been known for centuries. The underlying cause and complications should be treated if possible. Primary care physicians should be aware of pica and proactively seek informa- tion about pica in patients that belong to the high-risk groups.

Keywords: Pica, anemia, lead poisoning, malnutrition, mental retardation, dirt-eating.

1. INTRODUCTION

The term “pica” is derived from “Pica pica”, the Latin word for the brown-billed magpie [1, 2]. This bird is famed for its habit of indiscriminate gathering and eating a variety of objects to satiate its hunger and curiosity. Pica refers to the persistent, compulsive craving for and the ingestion of substances usually considered inedible and the behavior is discordant with cultural practices and continues beyond the normal developmental phase of occasional indiscriminate and experimental mouthing and swallowing over a period of at least one month [3, 4]. The condition is usually benign in children with normal intelligence but might have life- threatening consequences.

*Address correspondence to this author at The University of Calgary, Alberta Children’s Hospital, #200, 233 - 16th Avenue NW, Calgary, Alberta, Canada T2M 0H5; Tel: (403) 230 3300; Fax: (403) 230-3322; E-mail: [email protected]

A PubMed search was completed in Clinical Queries using the key term "pica" OR “dirt-eating”. The search strat- egy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only pa- pers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

2. EPIDEMIOLOGY

Pica occurs worldwide. The prevalence is greatest in children aged 18 months to six years [1]. The condition is more common in blacks than whites [1]. Pica is slightly more common in boys than girls [5]. Population studies have shown that 20 to 30% of children from one to six years have practiced pica; the prevalence decreases with age [6, 7]. The prevalence rates vary greatly which can be attributed to dif- ferent diagnostic criteria, different methodologies, different

1875-6336/19 $58.00+.00 © 2019 Bentham Science Publishers

Pica Current Pediatric Reviews, 2019, Vol. 15, No. 3 165

studied populations, different cultural practices, regional differences, and underreporting [7, 8]. Pica is more common than is generally appreciated either because the condition may be overlooked by physicians or under-reported by pa- tient/parents [3, 9]. Hartman et al. conducted a prevalence study on 804 German children aged 7 to 14 years in the greater area of Leipzig and found that 99 (12.31%) children have engaged in pica at least once in their life-time [5]. Murray et al. conducted an epidemiologic survey on the prevalence of pica and rumination in 1,430 children aged 7 to 13 years in Switzerland [10]. One hundred forty three (10%) children reported pica behavior only and 44 (3.1%) children reported both pica and rumination behavior. Arde- shirian and Howarth assessed the prevalence of pica in an Australian rural community, using a questionnaire given to parents of 223 children aged 2 to 10 years attending the five general practices in Esperance, Western Australia [11]. The investigators found that pica occurred in 50 (22.4%) of the 223 children. The prevalence of pica is higher in Africa com- pared to the rest of the world [12]. The prevalence rate of pica could be as high as 77% in African children [11]. Pica is more common among children in lower socioeco- nomic classes, immigrants, and refugees [1, 2, 6, 13, 14]. The incidence is increased in children whose siblings or mothers have pica [1]. Pica is also common in pregnant women [3, 8, 15]. A meta-analysis of the worldwide prevalence of pica during pregnancy and postpartum period (70 studies) showed an aggregate prevalence estimate of 27.8% (95% confidence interval: 22.8 to 33.3) [8].

3. ETIOLOGY AND PATHOGENESIS

Since pica occurs in association with a wide variety of different and seemingly unrelated disorders, it seems that a single etiologic explanation is unlikely. Several theories have been postulated to explain the etiology of pica. Various studies have shown that pica occurs more fre- quently in children from areas of poverty in which social disorganization at home and inadequate parental supervision are common [1, 14]. Hunger may be a motivation for eating starch, which serves as a replacement for inaccessible foods [6]. Frequent concomitants of such an environment are large families, uninformed parents, and inadequate childcare. Of- ten, a disturbance in the mother-child relationship may result from an emotional problem of the mother, separation from the mother, child neglect or abuse, or a lack of a good per- sonal relationship with the child. Relief of anxiety and emo- tional stress in the child by oral gratification is often a psy- chological response to an absent or poorly functioning mother [6]. Pica can be viewed as an infantile hand-to-mouth behavioral response to family stress or as an expression of oral fixation. There is some evidence that pica is an atten- tion-seeking device; the high incidence of working mothers and families with several young children may suggest that this is so. In this regard, increased parental attention is asso- ciated with a striking diminution in the habit of pica [1]. Pica is common in mentally handicapped children and the prevalence correlates with the severity of mental retarda- tion [1, 3, 13-18]. In animal studies, monkeys with abated

temporal lobes may indulge in hyperphagia and can be in- duced to swallow inedible objects. In humans, lesions in the hypothalamus and anterior cingulate gyrus may lead to hy- perphagia [1, 19]. Thus, abnormalities in the eating center of the hypothalamus may result in pica in some individuals, particularly those with brain damage. Alternatively, the men- tally handicapped child remains at a more infantile develop- mental level for a longer time than the normal child, and this, combined with relatively more advanced locomotor activity, may lead to pica. Pica is also more common in those with autistic spectrum disorder, attention-deficit hyperactivity disorder, schizophre- nia, obsessive compulsive disorder, and depression [4, 6, 12, 20-24]. Epidemiologic evidence shows an association between pica and iron deficiency [12, 25, 26]. Much discussion of this association has been of the chicken-or-the egg variety: which comes first? Does iron deficiency cause pica or does pica lead to iron deficiency? Animal studies have demon- strated the self-selection of necessary nutrients by deficient animals, for example, bone-eating by cattle deficient in cal- cium and phosphates [1]. It has been postulated that iron deficiency may prompt the ingestion of clay [27]. On the other hand, geophagy may lead to iron deficiency as the minerals in soil can bind iron in the gastrointestinal tract, thereby reducing absorption of iron [11,12,28]. In addition, pica may induce iron deficiency by replacing sources of iron in the diet [12]. Children with sickle cell anemia are at greater risk for developing pica than those without sickle cell anemia [29, 30]. In one study, 31 (56.4%) of 55 children with sickle cell anemia practiced pica on a regular basis [29]. Compared with the non-pica children (n = 24), children who practiced pica were younger and more anemic (mean hemoglobin 8.3 g/dl versus 9.1 g/dl; p <0.01) [29]. Work primarily in the Middle East has shown an associa- tion between the eating of clay and zinc deficiency [31]. It is not clear whether this clay-eating is an etiologic factor con- tributing to zinc deficiency or a feature attributed to a pre- ceding zinc deficiency. A meta-analysis of 43 studies includ- ing 6,407 individuals with pica and 10,277 controls showed that pica was associated with 2.35 times greater odds of anemia (95% confidence interval: 1.94 to 2.85; p < 0.001) and lower plasma zinc levels (-34.3 µg/dl; 95% confidence interval: -59.58 to -9.02; p = 0.008) [32]. Pet-keeping encourages pica as children may eat pet food by imitation [1, 2]. Pica may be a learned behavior. Occa- sionally, pica may be associated with medications such as risperidone, olanzapine, and tramadol [33]. In animal stud- ies, cisplatin can induce pica behavior in certain strains in mice [34].

4. CLINICAL MANIFESTATIONS

Most children with pica tend to be highly selective; each exhibiting a craving for only a few of the aforementioned items. The materials ingested as a result of pica depend on their availability in the environment as well as conscious selection factors. Various substances may be craved, includ- ing clay (geophagia), raw starch (amylophagia), dirt (co-

166 Current Pediatric Reviews, 2019, Vol. 15, No. 3 Leung and Hon

niophagia or chthonophagia), ice (pagophagia), raw, raw potatoes (gemelophagia), hair (trichophagia), fibrous plant roots (phytobezoar), paint chips (plumbophagia], sand, peb- bles/stones (lithophagia), sharp objects (acuphagia), glass (hyalophagia), uncooked rice (ryzophagia), paper (xy- lophagia), soap (sapophagia), burned matches (cautopy- reiophagia), feces (coprophagia), vomitus (emetophagia), wooden materials, sponge, polyurethane foam, grass, leaves, paper, chalk, baby talcum powder, crayons, pencil erasers, cigarette butts, ashes, charcoal, coins, buttons, cloth, egg- shells and insects [2, 4, 9, 20, 35-51]. Certain types of pica, in particular, coprophagia and emetophagia typically occur in individuals with neuropsychiatric disorders [52, 53]. By far, geophagia and amylophagia are among the most com- mon types of pica [9, 54]. In the majority of cases, the physical examination will be normal. Some children with pica may appear malnourished, exhibit developmental delay, or experience abdominal dis- comfort or pain if large quantities of inedible substances are ingested [55, 56]. Other clinical manifestations are highly variable and often depend on the particular substance being ingested and the potential complications [4]. Pallor, if pre- sent, suggests anemia which may result from iron deficiency or lead poisoning. In addition to pallor, children with iron deficiency anemia may present with anorexia, easy fatigabil- ity, poor appetite, and if severe enough, tachycardia and a soft ejection systolic flow murmur [1]. Children with lead poisoning may present with lethargy, abdominal pain, con- stipation, lead-line at the junction of the gums and teeth, de- velopmental delay, cognitive impairment, encephalopathy, and peripheral neuropathy [57]. Bezoar may lead to intestinal obstruction which may manifest as vomiting, abdominal pain, abdominal distension, and constipation [58, 59].

5. CLINICAL EVALUATION

The Diagnostic and Statistical Manual of Mental Disor- ders, Fifth Edition (DSM-V) published by the American Psy- chiatric Association defines pica as the eating of non- nutritive, non-food substance persistent over a period of at least one month; the eating of such substances is inappropri- ate to the developmental level of the individual; and the eat- ing behavior is not part of a culturally supported or socially normative practice [60]. A detailed history and complete physical examination are recommended for any child with pica, regardless of the type. Exploration of the housing, fam- ily, and social situation is mandatory. Also, physicians need to be aware of pica and should inquire about pica at diagno- sis of iron deficiency or iron deficiency anemia when the cause is otherwise unexplained. This is especially so in high- risk groups such as refugees, immigrants, mentally retarded individuals, and individuals with autistic spectrum disorders [7]. A high index of suspicion with prompt diagnosis and treatment of pica is pivotal to minimize complications.

6. LABORATORY FINDINGS

Laboratory tests should be selected according to the sus- pected substances ingested. A peripheral smear, complete blood count, and differential white cell count may be re- quired to determine whether iron deficiency anemia (hypo- chromic, microcytic anemia), parasitic infestation (eosino-

philia), or lead poisoning (punctate basophilia) is present. If parasitism is suspected, fecal samples should be examined for ova and parasites should be considered. Serologic testing for Toxocara should be considered when indicated. Blood lead levels are the single most useful diagnostic test for lead poisoning. When increased lead absorption is suspected, X- ray examination of long bones may reveal bands of increased density at the metaphyses known as “lead lines”. A plain abdominal film should be considered in children with recur- rent vomiting, abdominal pain, abdominal distension, and/or constipation. The radiograph may show the presence of fill- ing defects or radio-opaque materials in the gastrointestinal tract, distended gastric antrum, and dilated small bowels [43, 58, 59]. Rapunzel syndrome refers to the continuance of the trichobezoar tail-shaped extension over the duodenum and jejunum [61]. The syndrome is named after Rapunzel, the long-haired girl, in the fairy tale by the Brothers Grimm. Abdominal ultrasonography can be performed to show the size, nature, and position of the mass.

7. COMPLICATIONS

Complications depend on the substance ingested. Iron deficiency anemia is a common complication, particularly in patients with geophagia [62]. It is likely that the ingested material induces a secondary iron deficiency anemia either by binding the iron to the clay particles or by acting as an ion exchange resin. The ingestion of clay and cellulose in paper may also provide bulk in the diet low in iron [14]. Pa- gophagia, especially during pregnancy, may lead to iron de- ficiency anemia [3, 47, 63]. Pica is a risk factor for accidental ingestion of toxic sub- stances. The most well known one is lead intoxication, espe- cially in industrial, polluted environments [11, 64, 65]. Chil- dren with pica may develop lead poisoning if lead is avail- able in the child’s environment [66]. Flaking, lead- containing paint inside the home and pencils and toys coated with lead-containing paint are good examples [56]. Geophagia is an important cause of lead poisoning [3]. Both lead poisoning and iron deficiency can lead to impaired neu- rocognitive development [13, 57, 67]. Malnutrition may result from pica. Malignant or cachec- tic pica is found in association with extremely inadequate diets. The victims often die of malnutrition. This type of pica, which was a serious problem among slaves in the 19th century, is extremely rare nowadays. On the other hand, food pica associated with amylophagia or compulsive eating may lead to obesity [3]. At times, pica may lead to electrolyte abnormalities such as zinc deficiency, hypokalemia, hyperkalemia, hyperphos- phatemia and metabolic alkalosis [3, 13, 31]. The latter may result from pica with baking soda. Electrolyte disturbance is more common in patients with chronic renal disease [6, 31]. Parasitic infestation (e.g., toxocariasis, toxoplasmosis, ascariasis, giardiasis, cysticercosis) is another complication associated with pica [14, 68]. Toxocariasis and toxoplasmo- sis may follow the ingestion of soil contaminated with the excreta of dogs and cats. Ascariasis is a common parasitic infestation resulting from pica. Cysticercosis caused by lar-

Pica Current Pediatric Reviews, 2019, Vol. 15, No. 3 167

val cysts of the pork tapeworm (Taenia solium) as a result of pica has also been reported [69]. Tooth abrasion, decay, erosion, and loss may occur as a result of pica, especially with pagophagia [4, 28, 70]. Severe aggressive periodontitis characterized by significant and relatively rapid destruction of periodontal tissues has been reported in patients with pica [71]. Constipation and intestinal obstruction can occur as a result of ingestion of paper, toys, clothes, rags, hair, fibrous plant roots, or pebbles [18, 45, 59, 72-75]. Sharp or metallic objects may cause gastrointestinal bleeding and perforation of the bowel [43, 76]. Complications such as intestinal ob- struction and perforation may require surgical intervention [44, 75]. Pica may have an adverse effect on quality of life of the child and/or parents as social stigmatization may occur [4]. The condition can be a source of considerable embarrass- ment and ridicule. At times, fatalities may result from intes- tinal obstruction, bowel perforation, infections (bacterial, parasitic), poisoning (lead, mercury, arsenic, phosphorous), and electrolyte imbalances (hypokalemia, hyperkalemia) [7, 77, 78].

8. MANAGEMENT

Pica generally resolves in children of normal intelli- gence after they have been trained to discriminate between edible and noneditable items and proper supervision is pro- vided. While relief of family economic and housing diffi- culties is an adjunct, attention to the individual’s emotional needs and stresses is of paramount importance. An under- standing and supportive attitude towards the mother may enable her to provide better care for the child. If such a measure fails to stop pica, behavioral therapy, family coun- seling, and psychotherapy should be considered [7, 17]. In the mentally handicapped, efforts to relieve loneliness and boredom are helpful. It has been shown that behavioral therapy can reduce the severity of pica by 80% in mentally handicapped individuals [79]. Strict supervision of what goes into the mouth is essential, since children with mental retardation have little ability to discriminate for themselves. In these mentally handicapped children, pica may persist into adulthood. Pica in pregnancy typically remits sponta- neously [4]. The underlying cause and complications should be treated if possible. Children with iron deficiency anemia should be treated with iron replacement therapy. Complica- tions such as gastrointestinal obstruction and lead poisoning should be promptly recognized and treated. Anticipatory guidance on teaching children the dangers of pica in communities where pica is common may have a role in the prevention of pica.

CONCLUSION

Pica is often an overlooked phenomenon and its associa- tion with iron deficiency and lead poisoning has been known for centuries. The underlying cause and complications should be treated if possible. Primary care physicians should

be aware of pica and proactively seek information about pica in patients that belong to the high-risk groups.

CONSENT FOR PUBLICATION� Not applicable.

FUNDING� None.�

CONFLICT OF INTEREST� The authors declare no conflict of interest, financial or otherwise.�

ACKNOWLEDGEMENTS� Professor Alexander K.C. Leung is the principal author. Professor Kam Lun Hon is a coauthor. All the authors con- tributed to drafting and revising the manuscript and approved the final version submitted for publication.

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