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| ! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Pica Resident Survival Guide Microchapters}}
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pica resident survival guide#Overview|Overview]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pica resident survival guide#Causes|Causes]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pica resident survival guide#Diagnosis|Diagnosis]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pica resident survival guide#Treatment|Treatment]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pica resident survival guide#Do's|Do's]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pica resident survival guide#Don'ts|Don'ts]]
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| {{CMG}} {{AE}} {{NS}}
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| {{SK}} Approach to pica, Pica workup, Pica management
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| == Overview ==
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| 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]]<ref name="pmid26892693">{{cite journal| author=Fawcett EJ, Fawcett JM, Mazmanian D| title=A meta-analysis of the worldwide prevalence of pica during pregnancy and the postpartum period. | journal=Int J Gynaecol Obstet | year= 2016 | volume= 133 | issue= 3 | pages= 277-83 | pmid=26892693 | doi=10.1016/j.ijgo.2015.10.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26892693 }} </ref>. [[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.<ref name="pmid10390045">{{cite journal| author=Geissler PW, Prince RJ, Levene M, Poda C, Beckerleg SE, Mutemi W | display-authors=etal| title=Perceptions of soil-eating and anaemia among pregnant women on the Kenyan coast. | journal=Soc Sci Med | year= 1999 | volume= 48 | issue= 8 | pages= 1069-79 | pmid=10390045 | doi=10.1016/s0277-9536(98)00409-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10390045 }} </ref>
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| == Causes ==
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| * Pica is commonly seen in children over 2 years of age.<ref name="pmid30868957">{{cite journal| author=Leung AKC, Hon KL| title=Pica: A Common Condition that is Commonly Missed - An Update Review. | journal=Curr Pediatr Rev | year= 2019 | volume= 15 | issue= 3 | pages= 164-169 | pmid=30868957 | doi=10.2174/1573396315666190313163530 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30868957 }} </ref>
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| * [[Iron deficiency anemia]]
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| * [[Pregnancy]]
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| * [[Autism]] and other developmental disabilities
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| * Lower socioeconomic status
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| * [[Epilepsy]]
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| * [[Schizophrenia]]
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| * Recently, [[obsessive compulsive disorder]] has also been implicated as a cause <ref name="pmid18848964">{{cite journal| author=Hergüner S, Ozyildirim I, Tanidir C| title=Is Pica an eating disorder or an obsessive-compulsive spectrum disorder? | journal=Prog Neuropsychopharmacol Biol Psychiatry | year= 2008 | volume= 32 | issue= 8 | pages= 2010-1 | pmid=18848964 | doi=10.1016/j.pnpbp.2008.09.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848964 }} </ref>.
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| == Diagnosis ==
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| * The [[diagnosis]] of pica includes a detailed history and physical examination, appropriate laboratory investigations.
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| {{familytree/start}}
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| {{familytree | | | | | | | | | | | | | A01 | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Obtain a detailed history:'''<br>❑ Duration of symptoms <br>❑ What is the substance being ingested? <br>❑ When does the patient exhibit this behaviour? <br>❑ Is it during periods of emotional or physical stress? <br> What is the source of the substance? <br>
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| ----
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| According to the [[DSM]]5, the following 5 criteria must be met to [[diagnose]] someone with pica<ref name="pmid24643829">{{cite journal| author=Hoek HW, van Elburg AA| title=[Feeding and eating disorders in the DSM-5]. | journal=Tijdschr Psychiatr | year= 2014 | volume= 56 | issue= 3 | pages= 187-91 | pmid=24643829 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24643829 }} </ref>: <br>❑ Person must be eating non-nutritive or non-food substances for at least one month. <br>❑ This behaviour must be considered abnormal for their stage of development. <br>❑ This behaviour must not be considered as a part of a cultural practice, and should be normal in the social context of that person. <br>❑ For a person with an existing condition like [[mental retardation|mental disability]] or [[pregnancy]], this behaviour<br> is considered as pica only when it is dangerous or requires medical investigations and attention. </div>}}
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| {{familytree | | | | | | | | | | | | | |!| |}}
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| {{familytree | | | | | | | | | | | | | B01 |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Physical examination''' <br> While physical examination might be unrevealing in most cases, importance must be given to elicit<br> [[signs]] and [[symptoms]] of possible poisoning or other [[complications]] such as the following: <br>❑ '''[[Signs]] of lead ingestion''' <br>* [[Headache]] <br>* [[Insomnia]] <br>* [[Tremor]] <br>* [[Kidney failure]] in chronic ingestion <br>❑ '''[[Signs]] of [[parasitic]] infestation''' <br>* [[Fever]] <br>* [[Hepatomegaly]] <br>* [[Cough]] <br>* [[Encephalitis]] <br>❑ '''Signs of [[bezoar]] ingestion''' <br>* [[Pain]] per abdomen <br>* [[Gastrointestinal]] obstruction and <br>* [[Ulcer]]ation </div>}}
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| {{familytree | | | | | | | | | | | | | |!| | | |}}
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| {{familytree | | | | | | | | | | | | | C01 |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Initial investigations''' <br>❑ [[Complete blood count]] <br>❑ [[Iron]] studies <br>❑ [[Zinc]] level <br>❑ [[Basic metabolic panel]] <br>❑ Psychiatric evaluation </div>}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | |}}
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| {{familytree | |,|-|-|-|-|-|-|-|v|-|-|-|+|-|-|-|-|.| | | | | |}}
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| {{familytree | D01 | | | | | | D02 | | D03 | | | | D04|D01='''[[Iron deficiency anemia]]'''|D02='''[[Pregnancy]]'''|D03='''Pica in children'''|D04='''Differential diagnoses'''}}
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| {{familytree | |!| | | | | | | |!| | | |!| | | | | |!|}}
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| {{familytree | E01 | | | | | | E02 | | E03 | | | | E04 |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Laboratory findings''' <br>❑ Low [[hematocrit]] <br>❑ Low [[MCV]] <br>❑ Low [[MCHC]] <br>❑ Low serum [[iron]] <br>❑ Increased [[Total iron binding capacity|TIBC]] <br>❑ Low [[ferretin]] <br>❑ [[Reticulocytopenia]]|E02=<div style="float: left; text-align: left; line-height: 150% ">❑ Check [[hemoglobin]] <br>❑ Check [[zinc]] level <br>❑ Check serum [[iron]] level|E03=<div style="float: left; text-align: left; line-height: 150% ">'''Laboratory findings''' <br>❑ Low [[hemoglobin]] <br>❑ Low serum [[iron]] <br>❑ Check serum [[lead]] levels <br>❑ Check for worm infestation in children who eat soil <br>❑ Perform [[Ultrasound]] of the [[abdomen]] in children suspected of [[trichophagy]] <br>❑ [[Nutrition]]al status assessment|E04=<div style="float: left; text-align: left; line-height: 150% ">'''Consider differential diagnoses''' <br>❑ [[Autism spectrum disorder]] <br>❑ [[Schizophrenia]] <br>❑ Kleine-Levin syndrome <br>❑ [[Substance abuse]] <br>❑ [[Alcoholism]] <br>❑ [[Child abuse]]/[[Child neglect|neglect]] <br>❑ Cultural phenomenon </div>}}
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| {{familytree/end}}
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| == Treatment ==
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| Management of pica is summarised in the algorithm below.
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| {{familytree/start}}
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| {{familytree | | | | | | | A01 |A01= Comprehensive history, physical examination and laboratory investigations}}
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| {{familytree | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | |,|-|-|-|-|+|-|-|-|.|}}
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| {{familytree | | B01 | | |B02| | B03 |B01='''Treatment of [[iron deficiency anemia]]'''|B02='''Treatment of pica in [[pregnancy]]'''|B03='''Treating pica in childhood'''}}
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| {{familytree | | |!| | | | |!| | | |!|}}
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| {{familytree | | C01 | | | C02 | | C03 |C01=<div style="float: left; text-align: left; line-height: 150% ">❑ Oral [[iron]] replacement therapy <br>❑ [[Intravenous]] [[iron]] therapy <br>❑ [[Blood transfusion]] in severe cases|C02=<div style="float: left; text-align: left; line-height: 150% ">❑ Monitor [[iron]] and [[zinc]] levels <br>❑ Substituting cravings with chewing gum etc <br>❑ Pica during [[pregnancy]] is usually self resolving <br>❑ If pica persists beyond [[pregnancy]], behavioural therapy may be of benefit|C03=<div style="float: left; text-align: left; line-height: 150% ">❑ Correcting [[iron deficiency anemia]] if present <br>❑ Chelation therapy with [[succimer]]in pica presenting with lead ingestion <br>❑ Family education <br>❑ Aversion therapy <br>❑ Storing trigger foods out of reach <br>❑ [[Positive reinforcement]] <br>❑ Deworming with [[albendazole]] in children who eat dirt}}
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| {{familytree/end}}
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| == Do's==
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| * Check for [[lead]] levels in children with pica, particularly those living in houses built during and before 1960.
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| * Screen for [[parasitic]] [[infection]]s such as [[Toxocara]] and [[Ascaris]] in people exhibiting geophagia (ingestion of soil, sand or clay).<ref name="pmid28820703">{{cite journal| author=Woodhall DM, Garcia AP, Shapiro CA, Wray SL, Shane AL, Mani CS | display-authors=etal| title=Assessment of U.S. Pediatrician Knowledge of Toxocariasis. | journal=Am J Trop Med Hyg | year= 2017 | volume= 97 | issue= 4 | pages= 1243-1246 | pmid=28820703 | doi=10.4269/ajtmh.17-0232 | pmc=5637614 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28820703 }} </ref>
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| * Basic metabolic tests should be done, particularly when [[hypokalemia]] is suspected as it is seen in people ingesting clay or chalk.
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| * Rule out [[substance abuse]] in adults with pica.
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| == Don'ts ==
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| * Don't forget to educate patients about healthy eating habits.
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| * Don't make a diagnosis of pica in cultural phenomena like clay eating in some communities.
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| *
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| == References ==
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| {{Reflist|2}}
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| [[Category:Hematology]]
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| [[Category:Primary care]]
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