Pica

Pica

Definition

Pica refers to behaviorally and culturally inappropriate eating of nonnutritional substances for at least 4 weeks. It is most often as-sociated with poverty related nutritional deficiencies and mental retardation.

Epidemiology

Pica is a common, but frequently missed problem. The onset of pica is usually during the toddler age between 12 and 24 months. Because infants commonly mouth objects, it is difficult to make the diagnosis in young infants. Estimates of the prevalence of pica among institutionalized mentally retarded individuals range from 10 to 33%.

Children with pica are more susceptible to malnutrition, anemia, diarrhea or constipation, and worm infestation. It has been noted that pica is highest in a group of children hospitalized for accidental poisoning and that more than 60% of mothers with children with pica have pica themselves.

Etiology

Organic, psychodynamic, socioeconomic and cultural factors have been implicated in the cause of this disorder. Some authors have suggested that inadequate dietary intake of iron and calcium leading to abnormal cravings may induce pica. Other authors have implicated psychosocial stress, maternal deprivation, parental neglect and abuse, and disorganized and impoverished family situations in the etiology of pica. In certain population groups, cultural acceptance of pica has been considered an important factor in the etiology of this disorder as well.

Most helpful clinically is a multifactorial etiology, whereby constitutional, developmental, familial, socioeconomic and cultural factors interact with each other. Children who en-gage in pica often experience frequent separations from one or both parents followed by replacement of rapidly changing, in-adequate caretakers who seemed to encourage oral gratification in response to the child’s distress. These children show a high degree of other oral activities (e.g., thumb-sucking or nail-biting) and may be seeking gratification caused by the lack of parental availability and nurture.

Diagnosis

Because mouthing of objects is still common in toddlers between 1 and 2 years, the diagnosis of pica should be made only if the behavior is persistent and inappropriate for the child’s develop-mental level. The diagnosis of pica should be explored in children with accidental poisoning, with lead intoxication, or with worm infestation. Young children with signs of malnutrition or iron de-ficiency should also be considered for the diagnosis of pica.

The assessment should include the history of the child’s development in general, and feeding in particular. Special atten-tion should be given to other oral activities that the child may use for self-soothing and relief of tension. In addition, the home en-vironment and the parents’ relationship with each other and with the child need to be explored to assess the parents’ availability to nurture and supervise the child. Above all, mother and child should be observed during a meal and during play to gain a better understanding of their relationship and how the symptoms of pica can be understood in the context of that relationship.

If the diagnosis of pica is established, it is critical that the child undergo a thorough physical examination to rule out any of the complications associated with this disorder, such as nu-tritional deficiencies (especially iron deficiency), lead poisoning, intestinal infections (toxoplasmosis or intestinal parasites), or gastrointestinal bezoars.

Course and Natural History

In many instances, the disorder is believed to be self-limited and to remit spontaneously after a few months. However, there may be a developmental impact of the disorder in some children. For example, younger children may be somewhat retarded in the use of their speech and show conflicts about their dependency needs and aggressive feelings. Adolescents may evidence some degree of depression, borderline personality disorders, other forms of disturbed oral activities and the use of tobacco, alcohol, or drugs. There may be a strong relationship between pica in childhood and symptoms of bulimia nervosa in adolescence.

Treatment

In treating pica, one must consider the various factors that appear to contribute to the development of pica as well as its complica-tions. It is important to treat the child medically while addressing the psychosocial needs of the child’s family as well. The mothers need to be made aware of the dangers of pica and should be en-listed in providing a childproof environment. This might include removing lead from paint in old substandard housing units or instituting anthelmintic therapy for family pets. A psychoeduca-tional treatment approach that, in addition to teaching the moth-ers the dangers of pica, would also provide social support to help them become more available to their children is preferable.