Pica
Pica
Definition
Pica is the persistent craving and compulsive eating of nonfood substances. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, classifies it as a feeding and eating disorder of childhood.
Description
The puzzling phenomenon of pica has been recognized and described since ancient times. Pica has been observed in ethnic groups worldwide, in both primitive and modernized cultures, in both sexes, and in all age groups. The word pica comes from the Latin name for magpie, a bird known for its unusual and indiscriminate eating habits. In addition to humans, pica has been observed in other animals, including the chimpanzee.
Pica in humans has many different subgroups, defined by the substance that is ingested. Some of the most commonly described types of pica are eating earth, soil or clay (geophagia), ice (pagophagia) and starch (amylophagia). However, pica involving dozens of other substances, including cigarette butts and ashes, hair, paint chips, and paper have also been reported. In one unusual case, the patient ingested transdermal patches of fentanyl, an opioid medication given for severe pain. Eating the skin patch increased the patient's dose of the drug by a factor of 10.
Although pica can occur in individuals of any background, a higher incidence of pica is associated with:
- pregnancy
- developmental delay and mental retardation
- psychiatric disease and autism
- early childhood
- poor nutrition or low blood levels of iron and other minerals
- certain cultural or religious traditions
Causes and symptoms
Evidence suggests that there may be several causes of pica. One widely held theory points to iron deficiency as a major cause of pica. Several reports have described pica in individuals with documented iron deficiency, although there has been uncertainty as to whether the iron deficiency was a cause of pica or a result of it. Because some substances, such as clay, are believed to block the absorption of iron into the bloodstream, it was thought that low blood levels of iron could be the direct result of pica. However, some studies have shown that pica cravings in individuals with iron deficiency stop once iron supplements are given to correct the deficiency. Another study looked specifically at the rate of iron absorption during pica conditions and normal dietary behavior, and showed that the iron absorption was not decreased by pica. In addition, low blood levels of iron commonly occur in pregnant women and those with poor nutrition, two populations at higher risk for pica. Such findings offer strong support of iron deficiency as a cause, rather than result, of pica.
Other reports suggest that pica may have a psychological basis and may even fall into the spectrum of obsessive-compulsive disorder. Pica has a higher incidence in populations with an underlying diagnosis involving mental functioning. These diagnoses include psychiatric conditions like schizophrenia, developmental disorders including autism, and conditions with mental retardation. These conditions are not characterized by iron deficiency, which supports a psychological component in the cause of pica.
Cultural and religious traditions may also play a role in pica behavior. In some cultures, nonfood substances are believed to have positive health or spiritual effects. Among some African Americans in the south, ingesting a particular kind of white clay is believed to promote health and reduce morning sickness during pregnancy. Other cultures practice pica out of belief that eating a particular substance may promote fertility or bring good luck.
The hallmark feature of pica, consistently consuming nonfood substances, often does not present publicly. People may be embarrassed to admit to these unusual eating habits, and may hide it from their family and physician. In other cases, an individual may not report the pica to a physician simply because of a lack of knowledge of pica's potential medical significance.
Because the eating behaviors of pica are not usually detected or reported, it is the complications of the behavior that bring it to attention. Complications vary, depending on the type of pica. Geophagia has potential side effects that most commonly affect the intestine and bowel. Complications can include constipation, cramping, pain, obstruction caused by formation of an indigestible mass, perforation from sharp objects like rocks or gravel, and contamination and infection from soil-dwelling parasites.
Amylophagia usually involves the consumption of cornstarch and, less frequently, laundry starch. The high caloric content of starch can cause excessive weight gain, while at the same time leading to malnutrition, as starch contributes "empty" calories lacking vitamins and minerals. Amylophagia during pregnancy can mimic gestational diabetes in its presentation and even in its potential harmful effects on the fetus.
Pica involving the ingestion of substances such as lead-based paint or paper containing mercury can cause symptoms of toxic poisoning. Compulsive consumption of even a seemingly harmless substance like ice (pagophagia) can have negative side effects, including decreased absorption of nutrients by the gut.
Diagnosis
In order for the diagnosis of pica to be made, there must be a history of persistent consumption of a nonfood substance continuing for a minimum period of one month. Infants and toddlers are typically excluded from this diagnosis since mouthing objects is a normal developmental behavior at that age. Individuals with mental retardation who function at or below an approximate cognitive level of 18 months may also be exempt form this diagnosis.
Pica is most often diagnosed when a report of such behaviors can be provided by the patient or documented by another individual. In other cases, pica is diagnosed after studies have been performed to assess the presenting symptoms. For example, imaging studies ordered to assess severe gastrointestinal complaints may reveal intestinal blockage with an opaque substance; such a finding is suggestive of pica. Biopsy of intestinal contents can also reveal findings, such as parasitic infection, consistent with pica. Pica may also be suspected if abnormal levels of certain minerals or chemicals are detected in the blood.
Pica in pregnant women is sometimes diagnosed after childbirth because of a health problem in the newborn caused by the substance(s) ingested by the mother. In one instance reported in Chicago, a newborn girl was treated for lead poisoning caused by her mother's eating fragments of lead-glazed pottery during pregnancy.
Treatment
Treatment of pica will often depend on the cause and type of pica. Conventional medical treatment may be appropriate in certain situations. For example, supplementation with iron-containing vitamins has been shown to cause the unusual cravings to subside in some iron-deficient patients.
Medical complications and health threats, including high lead levels, bowel perforation or intestinal obstruction, will require additional medical management, beyond addressing the underlying issue of pica.
Alternative treatment
Because most cases of pica do not have an obvious medical cause, treatment with counseling, education, and nutritional management is often more successful and more appropriate than treatment with medication. Some therapists specializing in eating disorders may have expertise in treating pica.
Prognosis
The prognosis for individuals with pica varies greatly, according to the type and amount of substance ingested, the extent of presenting side effects, and the success of treatment. Many of the side effects and complications of pica can be reversed once the behavior is stopped, while other complications, including infection and bowel perforation, pose significant health threats and if not successfully treated may result in death.
When seen in children, pica behavior tends to lessen with age. However, individuals with a history of pica are more likely to experience it again. Counseling and nutritional education can reduce the risk of recurrence.
Prevention
There are no known methods of preventing pica. However, once pica is known or suspected, measures can be taken to reduce further ingestion of nonfood substances. Removing the particular substance from readily accessible areas can be helpful. Close observation of the individual with pica may limit inappropriate eating behaviors.
KEY TERMS
Amylophagia— The compulsive eating of purified starch, typically cornstarch or laundry starch.
Geophagia— The compulsive eating of earthy substances, including sand, soil, and clay.
Pagophagia— The compulsive eating of ice.
Resources
BOOKS
American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. 4th ed, revised. Washington, DC: American Psychiatric Association, 2000.
Beers, Mark H., MD, and Robert Berkow, MD., editors. "Anemias." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Beers, Mark H., MD, and Robert Berkow, MD., editors. "Malnutrition." Section 1, Chapter 2 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.
PERIODICALS
Jackson, W. Clay. "Amylophagia Presenting as Gestational Diabetes." Archives of Family Medicine 9 (July 2000): 649-652.
Kirschner, Jeffrey. "Management of Pica: A Medical Enigma." American Family Physician 63, no. 6 (March 15, 2001): 1169. 〈http://www.aafp.org/afp/20010315/tips/9.html〉.
Liappas, I. A., N. P. Dimopoulos, E. Mellos, et al. "Oral Transmucosal Abuse of Transdermal Fentanyl." Journal of Psychopharmacology 18 (June 2004): 277-280.
Moya, J., C. F. Bearer, and R. A. Etzel. "Children's Behavior and Physiology and How It Affects Exposure to Environmental Contaminants." Pediatrics 113 (April 2004): 996-1006.
Mycyk, M. B., and J. B. Leikin. "Combined Exchange Transfusion and Chelation Therapy for Neonatal Lead Poisoning." Annals of Pharmacotherapy 38 (May 2004): 821-824.
ORGANIZATIONS
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. 〈http://www.aacap.org〉.
OTHER
"Pica: Dirt Eating or 'Geophagy'." Support, Concern and Resources For Eating Disorders, 2000. 〈http://www.eating-disorder.org/pica.html〉.
"Pica." KidsHealth. The Nemours Foundation, 2001. 〈http://kidshealth.org/parent/emotions/behavior/pica.html〉.
Pica
Pica
Definition
Pica is a term that refers to cravings for substances that are not foods. Materials consumed by patients with pica include dirt, ice, clay, glue, sand, chalk, beeswax, chewing gum, laundry starch, and hair.
Description
Pica is the craving or ingestion of nonfood items. The cravings found in patients diagnosed with pica may be associated with a nutritional deficiency state, such as iron-deficiency anemia; with pregnancy; or with mental retardation or mental illness. The word pica is derived from the Latin word for magpie, a species of bird that feeds on whatever it encounters.
The mental health professional’s handbook, the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision (2000), which is abbreviated as DSM-IV-TR, classifies pica under the heading of “Feeding and Eating Disorders of Infancy or Early Childhood.” A diagnosis of pica requires that the patient must persist in eating nonfood substances for at least one month. This behavior must be inappropriate for the child’s stage of development. Further, it must not be approved or encouraged by the child’s culture.
Causes and symptoms
Causes
The cause of pica is not known. Many hypotheses have been developed to explain the behavior. These have included a variety of such factors as cultural influences; low socioeconomic status; deficiency diseases; and psychological disorders.
Malnutrition is often diagnosed at the same time as pica. A causal link has not been established. Eating clay has been associated with iron deficiency; however, whether decreased iron absorption is caused by eating clay or whether iron deficiency prompts people to eat clay is not known. Some cultural groups are said to teach youngsters to eat clay. Persons with iron deficiency anemia have also been reported to chew on ice cubes. Again, the mechanism or causal link is not known.
Eating paint is most common among children from families of low socioeconomic status. It is often associated with lack of parental supervision. Hunger also may result in pica.
Among persons with mental retardation, pica has been explained as the result of an inability to tell the difference between food and nonfood items. This explanation, however, is not supported by examples of nonfood items that were deliberately selected and eaten by persons with limited mental faculties.
Pica, iron deficiency, and a number of other physiological disturbances in humans have been associated with decreased activity of the dopamine system in the brain . Dopamine is a neurotransmitter, or chemical that helps to relay the transmission of nerve impulses from one nerve cell to another. This association has led some researchers to think that there may be a connection between abnormally low levels of dopamine in the brain and the development of pica. No specific underlying biochemical disorders have been identified, however.
Risk factors for pica include the following:
- parental/child psychopathology
- family disorganization
- environmental deprivation
- pregnancy
- epilepsy
- brain damage
- mental retardation
- pervasive developmental disorders
Symptoms
Infants and children diagnosed with pica commonly eat paint, plaster, string, hair, and cloth. Older children may eat animal droppings, sand, insects, leaves, pebbles and cigarette butts. Adolescents and adults most often ingest clay or soil.
The symptoms of pica vary with the item ingested.
- Sand or soil is associated with gastric pain and occasional bleeding.
- Chewing ice may cause abnormal wear on teeth.
- Eating clay may cause constipation.
- Swallowing metal objects may lead to bowel perforation.
- Eating fecal material often leads to such infectious diseases as toxocariasis, toxoplasmosis, and trichuriasis.
- Consuming lead can lead to kidney damage and mental retardation.
Demographics
Pica tends to taper off as children grow older. The disorder occasionally continues into adolescence but is rarely observed in adults who are not disabled.
Pica is observed more commonly during the second and third years of life and is considered to be developmentally inappropriate in children older than 18-24 months. Research findings indicate that the disorder occurs in 25%-33% of young children and 20% of children in mental health clinics. Among individuals with mental retardation, pica occurs most often in those between the ages of 10-20 years. Among young pregnant women, the onset of pica is frequently
associated with a first pregnancy in late adolescence or early adulthood. Although pica usually stops at the end of the pregnancy, it may continue intermittently for years.
Pica usually occurs with equal frequency among males and females. It is relatively uncommon, however, among adolescent and adult males of average intelligence who live in developed countries.
Diagnosis
Pica is often diagnosed in a hospital emergency room, when the child or adolescent develops symptoms of lead poisoning, bowel perforation, or other medical complications caused by the nonfood items that have been swallowed. Laboratory studies may be used to assess these complications. The choice of imaging or laboratory studies depends on the characteristics of the ingested materials and the resultant medical problems.
The examining doctor may order a variety of imaging studies in order to identify the ingested materials and treat the gastrointestinal complications of pica. These imaging studies may include the following:
- abdominal x rays
- barium examinations of the upper and lower gastrointestinal (GI) tracts
- upper GI endoscopy to diagnose the formation of bezoars (solid masses formed in the stomach) or to identify associated injuries to the digestive tract
Films and studies may be repeated at regular intervals to track changes in the location of ingested materials.
Treatments
As of 2002, there is no standard treatment for pica. Currently, the most effective strategies are based on behavior modification, but even these treatments have achieved limited success. Pica associated with a nutritional deficiency often clears up when the missing nutrient is added to the patient’s diet.
Few studies have examined the efficacy of drug treatments for pica. Ongoing research, however, is exploring the relationship between pica and abnormally low levels of the neurotransmitter dopamine. This line of research may help to identify new medications for the treatment of pica. There is some evidence that medications used to manage severe behavioral problems in children may be useful in treating coexisting pica.
KEY TERMS
Behavior modification —An approach to therapy based on the principles of operant conditioning. Behavior modification seeks to replace undesirable behaviors with preferable behaviors through the use of positive or negative reinforcement.
Bezoar —A hard ball of hair or vegetable fiber that may develop in the stomach of humans as the result of ingesting nonfood items.
Chelation —A method of treating lead or mercury poisoning by giving medications that remove heavy metals from the bloodstream. The medications that are used are called chelating agents.
Dopamine —A chemical in brain tissue that serves to transmit nerve impulses (is a neurotransmitter) and helps to regulate movement and emotions.
Neurotransmitter —A chemical in the brain that transmits messages between neurons, or nerve cells.
Toxocariasis —Infection with roundworm larvae, commonly transmitted by the feces of dogs and cats.
Toxoplasmosis —A parasitic infection caused by the intracellular protozoan Toxoplasmosis gondii. Humans are most commonly infected by swallowing the oocyte form of the parasite in soil (or kitty litter) contaminated by feces from an infected cat; or by swallowing the cyst form of the parasite in raw or undercooked meat.
Trichuriasis —Infection with the larvae of round-worms. These parasites may live for 10–20 years in humans.
Lead poisoning resulting from pica may be treated by chelating medications, which are drugs that remove lead or other heavy metals from the bloodstream. The two medications most often given for lead poisoning are dimercaprol, which is also known as BAL or British Anti-Lewisite; and edetate calcium disodium (EDTA). A medical toxicologist (a doctor who specializes in treating poisoning cases) may be consulted regarding children’s dosages of these drugs.
In some cases, surgery may be required to remove metal objects from the patient’s digestive tract or to repair tissue injuries. It is particularly important to remove any objects made of lead (fishing weights, lead shot, pieces of printer’s type, etc.) as quickly as possible because of the danger of lead poisoning.
Prognosis
Pica frequently ends spontaneously in young children and pregnant women. Untreated pica, however, may persist for years, especially in persons with mental retardation and developmental disabilities.
Prevention
There is no known way to prevent pica at the present time. Educating people, particularly young couples with children, about healthy nutritional practices is the best preventive strategy.
Resources
BOOKS
American Psychiatric Association. “Pica.” In Diagnostic and Statistical of Mental Disorders, 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.
Herrin, Marcia, and Nancy Matsumoto. The Parent’s Guide to Childhood Eating Disorders. New York: Henry Holt and Company, 2002.
Palmer, Robert L. Helping People With Eating Disorders: A Clinical Guide to Assessment and Treatment. New York: John Wiley and Sons, 2002.
Woolsey, Monika M. Eating Disorders: A Clinical Guide to Counseling and Treatment. Chicago: American Dietetic Association, 2002.
PERIODICALS
Grewal P. and B. Fitzgerald. “Pica with learning disability.” Journal of the Royal Society of Medicine 95, no. 1 (2002): 39-40.
Hamilton S., S. J. Rothenberg, F. A. Khan, M. Manalo, and K. C. Norris. “Neonatal lead poisoning from maternal pica behavior during pregnancy.” Journal of the National Medical Association 93, no. 9 (2001): 317-319.
Roberts-Harewood M. and S. C. Davies. “Pica in sickle cell disease: ‘She ate the headboard.”’ Archives of Diseases of Children 85, no. 6 (2001): 510.
ORGANIZATIONS
American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. Telephone: (913) 906-6000. Web site: http://www.aafp.org
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. Telephone: (847) 434-4000. Fax: (847) 434-8000. Web site: http://www.aap.org/default.htm
American College of Physicians, 190 N Independence Mall West, Philadelphia, PA 19106-1572, Phone: (800) 523-1546, x2600 or (215) 351-2600, Web site: http://www.acponline.org
American Medical Association. 515 N. State Street, Chicago, IL 60610. Telephone: (312) 464-5000. Web site: http://www.ama-assn.org
OTHER
Anorexia Nervosa and Related Eating Disorders, Inc.: http://www.anred.com/pica.html
Support, Concern and Resources For Eating Disorders: http://www.eating-disorder.org/pica.html
L. Fleming Fallon, Jr., M.D., Dr.P.H.
Pica
Pica
Definition
Pica is a term that refers to cravings for substances that are not foods. Materials consumed by patients with pica include dirt, ice, clay, glue, sand, chalk, beeswax, chewing gum, laundry starch, and hair.
Description
Pica is the craving or ingestion of nonfood items. The cravings found in patients diagnosed with pica may be associated with a nutritional deficiency state, such as iron-deficiency anemia; with pregnancy; or with mental retardation or mental illness. The word pica is derived from the Latin word for magpie, a species of bird that feeds on whatever it encounters.
The mental health professional's handbook, the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision (2000), which is abbreviated as DSM-IV-TR, classifies pica under the heading of "Feeding and Eating Disorders of Infancy or Early Childhood." Adiagnosis of pica requires that the patient must persist in eating nonfood substances for at least one month. This behavior must be inappropriate for the child's stage of development. Further, it must not be approved or encouraged by the child's culture.
Causes and symptoms
Causes
The cause of pica is not known. Many hypotheses have been developed to explain the behavior. These have included a variety of such factors as cultural influences; low socioeconomic status; deficiency diseases; and psychological disorders.
Malnutrition is often diagnosed at the same time as pica. A causal link has not been established. Eating clay has been associated with iron deficiency; however, whether decreased iron absorption is caused by eating clay or whether iron deficiency prompts people to eat clay is not known. Some cultural groups are said to teach youngsters to eat clay. Persons with iron deficiency anemia have also been reported to chew on ice cubes. Again, the mechanism or causal link is not known.
Eating paint is most common among children from families of low socioeconomic status. It is often associated with lack of parental supervision. Hunger also may result in pica.
Among persons with mental retardation, pica has been explained as the result of an inability to tell the difference between food and nonfood items. This explanation, however, is not supported by examples of nonfood items that were deliberately selected and eaten by persons with limited mental faculties.
Pica, iron deficiency, and a number of other physiological disturbances in humans have been associated with decreased activity of the dopamine system in the brain . Dopamine is a neurotransmitter, or chemical that helps to relay the transmission of nerve impulses from one nerve cell to another. This association has led some researchers to think that there may be a connection between abnormally low levels of dopamine in the brain and the development of pica. No specific underlying biochemical disorders have been identified, however.
Risk factors for pica include the following:
- parental/child psychopathology
- family disorganization
- environmental deprivation
- pregnancy
- epilepsy
- brain damage
- mental retardation
- pervasive developmental disorders
Symptoms
Infants and children diagnosed with pica commonly eat paint, plaster, string, hair, and cloth. Older children may eat animal droppings, sand, insects, leaves, pebbles and cigarette butts. Adolescents and adults most often ingest clay or soil.
The symptoms of pica vary with the item ingested.
- Sand or soil is associated with gastric pain and occasional bleeding.
- Chewing ice may cause abnormal wear on teeth.
- Eating clay may cause constipation.
- Swallowing metal objects may lead to bowel perforation.
- Eating fecal material often leads to such infectious diseases as toxocariasis, toxoplasmosis, and trichuriasis.
- Consuming lead can lead to kidney damage and mental retardation.
Demographics
Pica tends to taper off as children grow older. The disorder occasionally continues into adolescence but is rarely observed in adults who are not disabled.
Pica is observed more commonly during the second and third years of life and is considered to be developmentally inappropriate in children older than 18–24 months. Research findings indicate that the disorder occurs in 25%–33% of young children and 20% of children in mental health clinics. Among individuals with mental retardation, pica occurs most often in those between the ages of 10–20 years. Among young pregnant women, the onset of pica is frequently associated with a first pregnancy in late adolescence or early adulthood. Although pica usually stops at the end of the pregnancy, it may continue intermittently for years.
Pica usually occurs with equal frequency among males and females. It is relatively uncommon, however, among adolescent and adult males of average intelligence who live in developed countries.
Diagnosis
Pica is often diagnosed in a hospital emergency room, when the child or adolescent develops symptoms of lead poisoning, bowel perforation, or other medical complications caused by the nonfood items that have been swallowed. Laboratory studies may be used to assess these complications. The choice of imaging or laboratory studies depends on the characteristics of the ingested materials and the resultant medical problems.
The examining doctor may order a variety of imaging studies in order to identify the ingested materials and treat the gastrointestinal complications of pica. These imaging studies may include the following:
- abdominal x rays
- barium examinations of the upper and lower gastrointestinal (GI) tracts
- upper GI endoscopy to diagnose the formation of bezoars (solid masses formed in the stomach) or to identify associated injuries to the digestive tract
Films and studies may be repeated at regular intervals to track changes in the location of ingested materials.
Treatments
As of 2002, there is no standard treatment for pica. Currently, the most effective strategies are based on behavior modification , but even these treatments have achieved limited success. Pica associated with a nutritional deficiency often clears up when the missing nutrient is added to the patient's diet.
Few studies have examined the efficacy of drug treatments for pica. Ongoing research, however, is exploring the relationship between pica and abnormally low levels of the neurotransmitter dopamine. This line of research may help to identify new medications for the treatment of pica. There is some evidence that medications used to manage severe behavioral problems in children may be useful in treating coexisting pica.
Lead poisoning resulting from pica may be treated by chelating medications, which are drugs that remove lead or other heavy metals from the bloodstream. The two medications most often given for lead poisoning are dimercaprol, which is also known as BAL or British Anti-Lewisite; and edetate calcium disodium (EDTA). A medical toxicologist (a doctor who specializes in treating poisoning cases) may be consulted regarding children's dosages of these drugs.
In some cases, surgery may be required to remove metal objects from the patient's digestive tract or to repair tissue injuries. It is particularly important to remove any objects made of lead (fishing weights, lead shot, pieces of printer's type, etc.) as quickly as possible because of the danger of lead poisoning.
Prognosis
Pica frequently ends spontaneously in young children and pregnant women. Untreated pica, however, may persist for years, especially in persons with mental retardation and developmental disabilities.
Prevention
There is no known way to prevent pica at the present time. Educating people, particularly young couples with children, about healthy nutritional practices is the best preventive strategy.
Resources
BOOKS
American Psychiatric Association. "Pica." In Diagnostic and Statistical of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.
Herrin, Marcia, and Nancy Matsumoto. The Parent's Guide to Childhood Eating Disorders. New York: Henry Holt and Company, 2002.
Palmer, Robert L. Helping People With Eating Disorders: A Clinical Guide to Assessment and Treatment. New York: John Wiley and Sons, 2002.
Woolsey, Monika M. Eating Disorders: A Clinical Guide to Counseling and Treatment. Chicago: American Dietetic Association, 2002.
PERIODICALS
Grewal P. and B. Fitzgerald. "Pica with learning disability." Journal of the Royal Society of Medicine 95, no. 1(2002): 39-40.
Hamilton S., S. J. Rothenberg, F. A. Khan, M. Manalo, and K. C. Norris. "Neonatal lead poisoning from maternal pica behavior during pregnancy." Journal of the National Medical Association 93, no. 9 (2001): 317-319.
Roberts-Harewood M. and S. C. Davies. "Pica in sickle cell disease: 'She ate the headboard.'" Archives of Diseases of Children 85, no. 6 (2001): 510.
ORGANIZATIONS
American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. Telephone:(913) 906-6000. Web site: <http://www.aafp.org>.
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. Telephone: (847) 434-4000. Fax: (847) 434-8000. Web site: <http://www.aap.org/default.htm>.
American College of Physicians, 190 N Independence Mall West, Philadelphia, PA 19106-1572, Phone: (800) 523-1546, x2600 or (215) 351-2600, Web site: <http://www.acponline.org>.
American Medical Association. 515 N. State Street, Chicago, IL 60610. Telephone: (312) 464-5000. Web site: <http://www.ama-assn.org>.
OTHER
Anorexia Nervosa and Related Eating Disorders, Inc.: <http://www.anred.com/pica.html>.
Support, Concern and Resources For Eating Disorders: <http://www.eating-disorder.org/pica.html>.
L. Fleming Fallon, Jr., M.D., Dr.P.H.
Pica
Pica
Definition
Pica is the persistent craving and compulsive eating of non-food substances.
Description
The puzzling phenomenon of pica has been recognized and described since ancient times. Pica has been observed in ethnic groups worldwide, in both primitive and modernized cultures, in both sexes, and in all age groups. The word pica comes from the Latin name for magpie, a bird known for its unusual and indiscriminate eating habits. In addition to humans, pica has been observed in other animals, including the chimpanzee.
Demographics
True pica affects people of all ages, although it is more common in children. There are some regional variations concerning specific substances. For example, eating clay is more prevalent among women in the American southeast than in other areas of the country. Adolescents may chew ice due to peer pressure or because they are deficient in iron. Without a blood test for serum iron, there is no way to differentiate these causes.
Causes and symptoms
Pica in humans has many different subgroups, defined by the substance that is ingested. Some of the most commonly described types of pica are eating earth, soil, or clay (geophagia); ice (pagophagia); and starch (amylophagia). However, pica involving dozens of other substances, including cigarette butts and ashes, hair, paint chips, and paper have also been reported.
Although pica can occur in individuals of any background, a higher incidence of pica is associated with:
- pregnancy
- developmental disabilities
- mental retardation
- psychiatric disease and autism
- early childhood (under age three)
- poor nutrition or low blood levels of iron and other minerals
- certain cultural or religious traditions
When to call the doctor
A health care professional should be consulted whenever a child over the age of three repeatedly ingests non-food substances for a period over one month. The behavior might be merely habitual, but it can become a compulsion that needs treatment.
Diagnosis
In order for the diagnosis of pica to be made, there must be a history of persistent consumption of a non-food substance continuing for a minimum period of one month. Infants and toddlers are typically excluded from this diagnosis since mouthing objects is a normal developmental behavior at that age. Individuals with mental retardation who function at or below an approximate cognitive level of 18 months may also be exempt from this diagnosis.
Pica is most often diagnosed when a report of such behaviors can be provided by an individual or documented by another person. In other cases, pica is diagnosed after studies have been performed to assess the presenting symptoms. For example, imaging studies ordered to assess severe gastrointestinal complaints may reveal intestinal blockage with an opaque substance; such a finding is suggestive of pica. Biopsy of intestinal contents can also reveal findings, such as parasitic infection, consistent with pica. Pica may also be suspected if abnormal levels of certain minerals or chemicals are detected in the blood.
Treatment
Treatment of pica will often depend on the cause and type of pica. Conventional medical treatment may be appropriate in certain situations. For example, supplementation with iron-containing vitamins has been shown to cause the unusual cravings to subside in some iron-deficient people.
Medical complications and health threats, including high lead levels, bowel perforation or intestinal obstruction, will require additional medical management, beyond addressing the underlying issue of pica.
Because most cases of pica do not have an obvious medical cause, treatment with counseling, education, and nutritional management is often more successful and more appropriate than treatment with medication. Some therapists specializing in eating disorders may have expertise in treating pica.
Prognosis
The prognosis for individuals with pica varies greatly, according to the type and amount of substance ingested, the extent of presenting side effects, and the success of treatment. Many of the side effects and complications of pica can be reversed once the behavior is stopped, while other complications, including infection and bowel perforation, pose significant health threats and if not successfully treated may result in death.
When seen in children, pica behavior tends to lessen with age. However, individuals with a history of pica are more likely to experience it again. Counseling and nutritional education can reduce the risk of recurrence.
Prevention
There are no known methods of preventing pica. However, once pica is known or suspected, measures can be taken to reduce further ingestion of non-food substances. Removing the particular substance from readily accessible areas can be helpful. Close observation of the individual with pica may limit inappropriate eating behaviors.
Nutritional concerns
Pica may be a symptom of an underlying nutritional deficiency. Correcting the deficiency usually stops the pica.
Parental concerns
Parents should monitor the food and other substances that their children eat. Repeated ingestion of non-food substances may be cause for concern. An evaluation by a pediatrician is recommended in such circumstances. Parents should be especially careful of children who eat paint chips, because this can cause lead poisoning if the paint is from an older home in which lead paint was used.
KEY TERMS
Amylophagia —The compulsive eating of purified starch, typically cornstarch or laundry starch.
Geophagia —The compulsive eating of earth substances, including sand, soil, and clay.
Pagophagia —The compulsive eating of ice.
Resources
BOOKS
Heird, William C. "Food Insecurity, Hunger and Undernutrition." In Nelson Textbook of Pediatrics. 17th ed. Ed. by Richard E. Behrman, et al., Philadelphia: Saunders, 2003, 167-172.
Matthews, Dawn D. Eating Disorders SourceBook Detroit, MI: Omnigraphics, Incorporated, 2001.
Walsh, B. Timothy. "Eating Disorders." In Harrison's Principles of Internal Medicine. 15th ed. Ed. by Eugene Braunwald et al., New York, McGraw Hill, 2001, 486-90.
West, Delia S. "Eating Disorders." In Cecil Textbook of Medicine. 22nd ed. Ed. by Lee Goldman, et al. Philadelphia: Saunders, 2003, 1336–8.
PERIODICALS
Dreyer MJ, Chaushev PG, and Gledhill RF. "Biochemical investigations in geophagia." Journal of the Royal Society of Medicine 97, no. 1 (2004): 48-53.
Kuhn DE and Matson JL. "Assessment of feeding and mealtime behavior problems in persons with mental retardation." Behavior Modification 28, no. 5 (2004): 638–48.
Lavoie PM and Bailey B. "Lead poisoning from "lead-free" paint." Canadian Medical Association Journal 170, no. 6 (2004): 956–8.
Moya J, Bearer CF, and Etzel RA. "Children's behavior and physiology and how it affects exposure to environmental contaminants." Pediatrics 113, no. 4 Supplement (2004): 996–1006.
ORGANIZATIONS
National Eating Disorders Organization (NEDO). 6655 South Yale Ave, Tulsa, OK 74136. (918) 481-4044. Hotline: (800) 931.2237. Web site: <www.NationalEatingDisorders.org>.
OTHER
"Children and Eating Disorders." Vanderbilt University. Available online at <www.vanderbilt.edu/AnS/psychology/health_psychology/childrenandED.html>.
"Eating Disorder: Pica." eMedicine. Available online at <www.emedicine.com/ped/topic1798.htm>.
"Eating Disorders." Encyclopedia.Com. Available online at <www.encyclopedia.com/html/e1/eatingdi.asp>.
"Pica." Web MD Health. Available online at <http://my.webmd.com/hw/health_guide_atoz/nord214.asp>.
L. Fleming Fallon, Jr., MD, DrPH
pica
pi·ca1 / ˈpīkə/ • n. Printing a unit of type size and line length equal to 12 points (about 1/6 inch or 4.2 mm). ∎ a size of letter in typewriting, with 10 characters to the inch (about 3.9 to the centimeter).pi·ca2 • n. Med. a tendency or craving to eat substances other than normal food (such as clay, plaster, or ashes), occurring during childhood or pregnancy, or as a symptom of disease.
Pica
Pica
Pica is defined as a compulsion to consume nonfood substances. Persons with pica crave items such as dirt, clay, paint chips, plaster, chalk, cornstarch, laundry starch, baking soda, coffee grounds, cigarette ashes, burnt match heads, cigarette butts, and rust. The cause of pica is poorly understood, but this strange behavior is often seen in those who are iron-deficient, particularly pregnant woman, even though none of the craved items contain significant amounts of iron. Pica can be dangerous during pregnancy, since consuming large amounts of some substances may cause nutrient deficiencies, intestinal problems, or lead to toxicity, placing both mother and baby at risk.
see also Cravings; Pregnancy.
Beth Fontenot