Pica resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[2]

Overview

Pica is defined as the compulsive craving for or eating non-nutritive or non-food substances for at least a period of one month. Pica may be a part of a cultural phenomenon, during childhood, in persons or children who are mentally disabled or even in pregnancy[1]. Iron deficiency anemia is also an important cause of pica. Pica is treated by a multifocal approach which includes reduction of cravings, addressing the social and emotional issues faced by the individual and treating the anemia if present. Pica is further divided based on the type of substance ingested such as ice, lead, feces, soil, etc.[2]

Causes

Diagnosis

  • The diagnosis of pica includes a detailed history and physical examination, appropriate laboratory investigations.
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:
❑ Duration of symptoms
❑ What is the substance being ingested?
❑ When does the patient exhibit this behaviour?
❑ Is it during periods of emotional or physical stress?
What is the source of the substance?

According to the DSM5, the following 5 criteria must be met to diagnose someone with pica[5]:
❑ Person must be eating non-nutritive or non-food substances for at least one month.
❑ This behaviour must be considered abnormal for their stage of development.
❑ This behaviour must not be considered as a part of a cultural practice, and should be normal in the social context of that person.
❑ For a person with an existing condition like mental disability or pregnancy, this behaviour
is considered as pica only when it is dangerous or requires medical investigations and attention.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination
While physical examination might be unrevealing in most cases, importance must be given to elicit
signs and symptoms of possible poisoning or other complications such as the following:
Signs of lead ingestion
* Headache
* Insomnia
* Tremor
* Kidney failure in chronic ingestion
Signs of parasitic infestation
* Fever
* Hepatomegaly
* Cough
* Encephalitis
Signs of bezoar ingestion
* Pain per abdomen
* Gastrointestinal obstruction and
* Ulceration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial investigations
Complete blood count
Iron studies
Zinc level
Basic metabolic panel
❑ Psychiatric evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Iron deficiency anemia
 
 
 
 
 
Pregnancy
 
Pica in children
 
 
 
Differential diagnoses
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laboratory findings
❑ Low hematocrit
❑ Low MCV
❑ Low MCHC
❑ Low serum iron
❑ Increased TIBC
❑ Low ferretin
Reticulocytopenia
 
 
 
 
 
❑ Check hemoglobin
❑ Check zinc level
❑ Check serum iron level
 
Laboratory findings
❑ Low hemoglobin
❑ Low serum iron
❑ Check serum lead levels
❑ Check for worm infestation in children who eat soil
❑ Perform Ultrasound of the abdomen in children suspected of trichophagy
Nutritional status assessment
 
 
 
Consider differential diagnoses
Autism spectrum disorder
Schizophrenia
❑ Kleine-Levin syndrome
Substance abuse
Alcoholism
Child abuse/neglect
❑ Cultural phenomenon

Management

Management of pica is summarised in the algorithm below.

 
 
 
 
 
 
Comprehensive history, physical examination and laboratory investigations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment of iron deficiency anemia
 
 
Treatment of pica in pregnancy
 
Treating pica in childhood
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Oral iron replacement therapy
Intravenous iron therapy
Blood transfusion in severe cases
 
 
❑ Monitor iron and zinc levels
❑ Substituting cravings with chewing gum etc
❑ Pica during pregnancy is usually self resolving
❑ If pica persists beyond pregnancy, behavioural therapy may be of benefit
 
❑ Correcting iron deficiency anemia if present
❑ Chelation therapy with succimerin pica presenting with lead ingestion
❑ Family education
❑ Aversion therapy
❑ Storing trigger foods out of reach
Positive reinforcement
❑ Deworming with albendazole in children who eat dirt

Do's

  • Check for lead levels in children with pica, particularly those living in houses built during and before 1960.
  • Screen for parasitic infections such as Toxocara and Ascaris in people exhibiting geophagia (ingestion of soil, sand or clay).[6]
  • Basic metabolic tests should be done, particularly when hypokalemia is suspected as it is seen in people ingesting clay or chalk.
  • Rule out substance abuse in adults with pica.

Dont's

  • Don't forget to educate patients about healthy eating habits.
  • Don't make a diagnosis of pica in cultural phenomena like clay eating in some communities.

References

  1. Fawcett EJ, Fawcett JM, Mazmanian D (2016). "A meta-analysis of the worldwide prevalence of pica during pregnancy and the postpartum period". Int J Gynaecol Obstet. 133 (3): 277–83. doi:10.1016/j.ijgo.2015.10.012. PMID 26892693.
  2. Geissler PW, Prince RJ, Levene M, Poda C, Beckerleg SE, Mutemi W; et al. (1999). "Perceptions of soil-eating and anaemia among pregnant women on the Kenyan coast". Soc Sci Med. 48 (8): 1069–79. doi:10.1016/s0277-9536(98)00409-2. PMID 10390045.
  3. Leung AKC, Hon KL (2019). "Pica: A Common Condition that is Commonly Missed - An Update Review". Curr Pediatr Rev. 15 (3): 164–169. doi:10.2174/1573396315666190313163530. PMID 30868957.
  4. Hergüner S, Ozyildirim I, Tanidir C (2008). "Is Pica an eating disorder or an obsessive-compulsive spectrum disorder?". Prog Neuropsychopharmacol Biol Psychiatry. 32 (8): 2010–1. doi:10.1016/j.pnpbp.2008.09.011. PMID 18848964.
  5. Hoek HW, van Elburg AA (2014). "[Feeding and eating disorders in the DSM-5]". Tijdschr Psychiatr. 56 (3): 187–91. PMID 24643829.
  6. Woodhall DM, Garcia AP, Shapiro CA, Wray SL, Shane AL, Mani CS; et al. (2017). "Assessment of U.S. Pediatrician Knowledge of Toxocariasis". Am J Trop Med Hyg. 97 (4): 1243–1246. doi:10.4269/ajtmh.17-0232. PMC 5637614. PMID 28820703.