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'''For patient information, click [[Pica (patient information)|here]]'''
=== '''For patient information, click [[Pica (patient information)|here]]''' ===
{{SI}}
{{CMG}}; {{AE}} {{MHP}}
 
{{SK}} Pica syndrome, geophagia eating disorder, geophagy
 
==Overview==
[[Pica]] is a condition characterized by the persistent consumption of non-nutritive substances, such as ice, dirt, clay, or paper. It is most commonly observed in children, pregnant women, and individuals with [[developmental disorders]] or [[mental health]] conditions. Pica has been associated with various adverse health outcomes. In pregnant women, pica practices have been linked to lower [[hemoglobin]] levels and negative pregnancy outcomes. The etiology of pica is believed to be multifactorial. It has been associated with factors such as [[iron deficiency anemia]], and [[restless legs syndrome]] (RLS). Other factors that have been associated with pica include stressors such as emotional trauma and familial issues. The treatment of pica involves addressing the underlying causes and providing appropriate interventions. In general, treatment may involve a multidisciplinary approach that includes nutritional counseling, behavioral therapy, and addressing any underlying medical conditions.
 
==Historical Perspective==
 
*Pica is derived from the Latin word 'pica pica' which means magpie, a bird known for its behavior of gathering and eating almost everything.
 
*It was first documented in the 13th century in Latin work of Bartholomeus de Glanville, although the actual term was not used.<ref name="pmid1562860">{{cite journal |vauthors=Parry-Jones B, Parry-Jones WL |title=Pica: symptom or eating disorder? A historical assessment |journal=Br J Psychiatry |volume=160 |issue= |pages=341–54 |date=March 1992 |pmid=1562860 |doi=10.1192/bjp.160.3.341 |url=}}</ref>
*The first time term ‘Pica’ was mentioned in a medical context was in 1563 in a surgical work, ‘''An Excellent Treatise of Wounds made with Gonne Shot’, by Thomas Gale'', where pica was addressed in pregnant women and children.<ref name="pmid1562860">{{cite journal |vauthors=Parry-Jones B, Parry-Jones WL |title=Pica: symptom or eating disorder? A historical assessment |journal=Br J Psychiatry |volume=160 |issue= |pages=341–54 |date=March 1992 |pmid=1562860 |doi=10.1192/bjp.160.3.341 |url=}}</ref>
*Historically, clay ingestion had been used for medical purposes probably due to its effect on gastrointestinal (GI) system. It was particularly suggested as a treatment of intestinal infection and spasm.<ref name="pmid11001006">{{cite journal |vauthors=Rose EA, Porcerelli JH, Neale AV |title=Pica: common but commonly missed |journal=J Am Board Fam Pract |volume=13 |issue=5 |pages=353–8 |date=2000 |pmid=11001006 |doi= |url=}}</ref>
 
==Classification==
Pica may be classified according to the name of the eaten substance; the most common types by far are geophagia and amylophagia:
 
*Acuphagia (sharp objects)
*Amylophagia (purified starch)
*Cautopyreiophagia (burnt matches)
*Coniophagia (dust, dirt)
*Coprophagia (feces)
*Emetophagia (vomit)
*Geomelophagia (raw potatoes)
*Geophagia (earth, soil, clay, chalk)
*Hyalophagia (glass)
*Lithophagia (stones)
*Metallophagia (metal)
*Mucophagia (mucus)
*Pagophagia (ice)
*Plumbophagia (lead, paint chips)
*Trichophagia (hair, wool, fibers)
*Urophagia (urine)
*Hematophagia (blood)
*Xylophagia (wood, paper)
*Hyalophagia (glass)
*Ryzophagia (raw rice)
*Sapophagia (soap)
 
==Pathophysiology==
The exact pathogenesis of Pica is not fully understood. However, there are different theories on developing Pica:
 
===Nutritional Theory===
 
*Children with [[anemia]] and low plasma [[zinc]] levels may develop Pica and crave for substances rich in the insufficient nutrients.<ref name="pmid25156147">{{cite journal |vauthors=Miao D, Young SL, Golden CD |title=A meta-analysis of pica and micronutrient status |journal=Am J Hum Biol |volume=27 |issue=1 |pages=84–93 |date=2015 |pmid=25156147 |pmc=4270917 |doi=10.1002/ajhb.22598 |url=}}</ref>
*Kaolinite, a clay mineral, which has negative surface charge commonly ingested in Pica and can absorb the ions with positive surface charge, such as iron and causes iron-deficiency [[anemia]].<ref name="Ali2009">{{cite journal|last1=Ali|first1=Zainab|title=Pica in people with intellectual disability: a literature review of aetiology, epidemiology and complications|journal=Journal of Intellectual & Developmental Disability|volume=26|issue=3|year=2009|pages=205–215|issn=1366-8250|doi=10.1080/13668250020054486}}</ref> <ref name="pmid18838005">{{cite journal |vauthors=von Garnier C, Stünitz H, Decker M, Battegay E, Zeller A |title=Pica and refractory iron deficiency anaemia: a case report |journal=J Med Case Rep |volume=2 |issue= |pages=324 |date=October 2008 |pmid=18838005 |pmc=2567333 |doi=10.1186/1752-1947-2-324 |url=}}</ref>
*There is not enough evidence to determine whether Pica is the cause of nutritional deficiency or nutritional deficiency leads to Pica development.<ref name="Ali2009">{{cite journal|last1=Ali|first1=Zainab|title=Pica in people with intellectual disability: a literature review of aetiology, epidemiology and complications|journal=Journal of Intellectual & Developmental Disability|volume=26|issue=3|year=2009|pages=205–215|issn=1366-8250|doi=10.1080/13668250020054486}}</ref> <ref name="pmid30868957">{{cite journal |vauthors=Leung AKC, Hon KL |title=Pica: A Common Condition that is Commonly Missed - An Update Review |journal=Curr Pediatr Rev |volume=15 |issue=3 |pages=164–169 |date=2019 |pmid=30868957 |doi=10.2174/1573396315666190313163530 |url=}}</ref>
 
===Gastrointestinal Distress===


{{Infobox_Disease |
Geophagia causes increase in gastrointestinal PH. This effect can soothe [[gastric]] [[pain]] and [[gastroesophageal reflux disease]].<ref name="pmid15694906">{{cite journal |vauthors=Kettaneh A, Eclache V, Fain O, Sontag C, Uzan M, Carbillon L, Stirnemann J, Thomas M |title=Pica and food craving in patients with iron-deficiency anemia: a case-control study in France |journal=Am J Med |volume=118 |issue=2 |pages=185–8 |date=February 2005 |pmid=15694906 |doi=10.1016/j.amjmed.2004.07.050 |url=}}</ref> It also results in reduction of bioavailability of pathogens and toxins in gastrointestinal tract<ref name="pmid20595493">{{cite journal |vauthors=Young SL, Khalfan SS, Farag TH, Kavle JA, Ali SM, Hajji H, Rasmussen KM, Pelto GH, Tielsch JM, Stoltzfus RJ |title=Association of pica with anemia and gastrointestinal distress among pregnant women in Zanzibar, Tanzania |journal=Am J Trop Med Hyg |volume=83 |issue=1 |pages=144–51 |date=July 2010 |pmid=20595493 |pmc=2912591 |doi=10.4269/ajtmh.2010.09-0442 |url=}}</ref>, a phenomenon on which a hypothesis is based. The hypothesis states that non-nutritive substances bind to toxins and lead to less toxins absorption. This event occurs in the most vulnerable period of cell replication and growth (childhood and pregnancy) in order to protect the body from dangerous toxins.<ref name="pmid18773081">{{cite journal |vauthors=Young SL, Wilson MJ, Miller D, Hillier S |title=Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials |journal=PLoS One |volume=3 |issue=9 |pages=e3147 |date=September 2008 |pmid=18773081 |pmc=2522275 |doi=10.1371/journal.pone.0003147 |url=}}</ref><ref name="pmid1989412">{{cite journal |vauthors=Johns T, Duquette M |title=Detoxification and mineral supplementation as functions of geophagy |journal=Am J Clin Nutr |volume=53 |issue=2 |pages=448–56 |date=February 1991 |pmid=1989412 |doi=10.1093/ajcn/53.2.448 |url=}}</ref><ref name="pmid14668315">{{cite journal |vauthors=Dominy NJ, Davoust E, Minekus M |title=Adaptive function of soil consumption: an in vitro study modeling the human stomach and small intestine |journal=J Exp Biol |volume=207 |issue=Pt 2 |pages=319–24 |date=January 2004 |pmid=14668315 |doi=10.1242/jeb.00758 |url=}}</ref>
  Name          = {{PAGENAME}} |
  Image          = |
  Caption        = |
  DiseasesDB    = 29704 |
  ICD10          = {{ICD10|F|50|8|f|50}}, {{ICD10|F|98|3|f|90}} |
  ICD9          = {{ICD9|307.52}} |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = |
  eMedicineSubj  = |
  eMedicineTopic = |
  MeshID        = D010842 |
}}


{{SI}}
===Neurological Theory===
{{CMG}}; {{AE}} {{KS}}


{{SK}} Pica syndrome
*Various human studies revealed that lesions in eating center of [[hypothalamus]] and anterior [[cingulate gyrus]] may lead [[hyperphagia]] and Pica especially in individuals with history of [[brain]] damage.<ref name="pmid30868957">{{cite journal |vauthors=Leung AKC, Hon KL |title=Pica: A Common Condition that is Commonly Missed - An Update Review |journal=Curr Pediatr Rev |volume=15 |issue=3 |pages=164–169 |date=2019 |pmid=30868957 |doi=10.2174/1573396315666190313163530 |url=}}</ref><ref name="pmid28704833">{{cite journal |vauthors=Rangwala SD, Tobin MK, Birk DM, Butts JT, Nikas DC, Hahn YS |title=Pica in a Child with Anterior Cingulate Gyrus Oligodendroglioma: Case Report |journal=Pediatr Neurosurg |volume=52 |issue=4 |pages=279–283 |date=2017 |pmid=28704833 |doi=10.1159/000477816 |url=}}</ref>
*Animal studies indicated that rats with [[iron deficiency anemia]] have fewer D2 receptors in the [[central nervous system]] ([[CNS]]). This proposes a theory stating that reduction of dopaminergic neurotransmission leads to development of Pica, and not the [[iron deficiency anemia]].<ref name="SinghEllis1994">{{cite journal|last1=Singh|first1=Nirbhay N.|last2=Ellis|first2=Cynthia R.|last3=Crews|first3=W. David|last4=Singh|first4=Yadhu N.|title=Does Diminished Dopaminergic Neurotransmission Increase Pica?|journal=Journal of Child and Adolescent Psychopharmacology|volume=4|issue=2|year=1994|pages=93–99|issn=1044-5463|doi=10.1089/cap.1994.4.93}}</ref>


==Overview==
===Psychiatric Theory===
'''Pica''' is an [[appetite]] for non-nutritive substances (e.g., [[coal]], [[soil]], [[chalk]], paper etc.) or an abnormal appetite for some things that may be considered [[food]]s, such as food ingredients (e.g., flour, raw [[potato]], [[starch]]).<ref>* [http://www.emedicine.com/ped/topic1798.htm emedince.com article on "Eating Disorder: Pica"]</ref>  In order for these actions to be considered pica, they must persist for more than one month, at an age where eating such objects is considered developmentally inappropriate. The condition's name comes from the [[Latin]] word for the magpie, a bird which is reputed to eat almost anything. Pica is seen in all ages, particularly in [[pregnancy|pregnant women]] and small children, especially among children who are [[developmentally disabled]], where it is the most common eating disorder.


Pica in children, while common, can be dangerous. Children eating painted plaster containing [[lead]] may suffer brain damage from [[lead poisoning]]. There is a similar risk from eating dirt near roads that existed prior to the phaseout of [[tetra-ethyl lead]] in gasoline or prior to the cessation of the use of contaminated oil (either used, or containing toxic [[PCBs]] or [[dioxin]]) to settle dust. In addition to poisoning, there is also a much greater risk of [[bowel obstruction|gastro-intestinal obstruction]] or tearing in the [[stomach]]. This is also true in animals. Another risk of dirt eating is the possible ingestion of animal feces and the accompanying [[parasites]].
A hypothesis states that Pica can be attributed to obsessive-compulsive spectrum disorders because Pica-related behaviors are mostly involuntary, recurrent, and persistent to soothe the [[anxiety]] and distress, and resistance to stop the behaviors causes increased level of [[anxiety]] and distress.<ref name="pmid18848964">{{cite journal |vauthors=Hergüner S, Ozyildirim I, Tanidir C |title=Is Pica an eating disorder or an obsessive-compulsive spectrum disorder? |journal=Prog Neuropsychopharmacol Biol Psychiatry |volume=32 |issue=8 |pages=2010–1 |date=December 2008 |pmid=18848964 |doi=10.1016/j.pnpbp.2008.09.011 |url=}}</ref><ref name="pmid9180801">{{cite journal |vauthors=Stein DJ, Bouwer C, van Heerden B |title=Pica and the obsessive-compulsive spectrum disorders |journal=S Afr Med J |volume=86 |issue=12 Suppl |pages=1586–8, 1591–2 |date=December 1996 |pmid=9180801 |doi= |url=}}</ref> This hypothesis is supported by studies that have found that Pica has the same treatment as OCD, i.e selective serotonin reuptake inhibitors.<ref name="BhatiaGupta2009">{{cite journal|last1=Bhatia|first1=Manjeet S.|last2=Gupta|first2=Ravi|title=Pica responding to SSRI: An OCD spectrum disorder?|journal=The World Journal of Biological Psychiatry|volume=10|issue=4-3|year=2009|pages=936–938|issn=1562-2975|doi=10.1080/15622970701308389}}</ref>


==Causes==
==Causes==
The scant research that has been done on the root causes of pica suggests that the majority of those afflicted tend to suffer some biochemical deficiency and more often [[Iron deficiency (medicine)|iron deficiency]].  The association between pica and [[iron deficiency anemia]] is so strong, that most patients with iron deficiency will admit to some form of pica.  Often the substance eaten by those with the disorder does not contain the [[mineral]] of deficiency.  If a mineral deficiency is not identified as the cause of pica, it often leads to a misdiagnosis as a mental disorder.


Pica may also be a symptom of a [[hookworm]] infection.
The cause of Pica has not been identified. To review risk factors for the development of Pica, click [[Pericarditis causes#Overview|here]].
 
==Differentiating ((Page name)) from other Diseases==
Pica must be differentiated from other [[psychiatric]] diseases including [[autism]], [[schizophrenia]], other [[eating disorders]], [[developmental delay]] in children, [[substance abuse]].<ref name="pmid25943566">{{cite journal |vauthors=Rabel A, Leitman SF, Miller JL |title=Ask about ice, then consider iron |journal=J Am Assoc Nurse Pract |volume=28 |issue=2 |pages=116–20 |date=February 2016 |pmid=25943566 |pmc=4635104 |doi=10.1002/2327-6924.12268 |url=}}</ref><ref name="pmid25811011">{{cite journal |vauthors=Kar SK, Kamboj A, Kumar R |title=Pica and psychosis - clinical attributes and correlations: a case report |journal=J Family Med Prim Care |volume=4 |issue=1 |pages=149–50 |date=2015 |pmid=25811011 |pmc=4366992 |doi=10.4103/2249-4863.152277 |url=}}</ref>


Unlike in humans, in dogs or cats, pica may be a sign of [[Warm autoimmune hemolytic anemia|Immune-mediated hemolytic anemia]], especially when it involves eating substances such as tile grout, concrete dust, and sand.  Dogs exhibiting this form of pica should be tested for anemia with a complete [[Complete blood count|CBC]] or at least [[Hematocrit]] levels. <ref>{{cite book | last = Plunkett | first = Signe J.  | date = 2000  | title = Emergency Procedures for the Small Animal Veterinarian | publisher = Elsevier Health Sciences | pages = 11 | isbn = 0702024872}}</ref><ref>{{cite book | last =  Feldman | first = Bernard F. | coauthors = Joseph G. Zinkl, Nemi Chand Jain, Oscar William Schalm  | date = 2000  | title = Schalm's Veterinary Hematology  | publisher = Blackwell Publishing | pages = 506| isbn = 0683306928}}</ref>
==Epidemiology and Demographics==
*The [[prevalence]] and [[incidence]] of Pica is challenging to estimate due to several reasons such as: under-reporting the cases, cultural and social issues, different definition of Pica in studies.<ref name="pmid17883773">{{cite journal |vauthors=Mills ME |title=Craving more than food: the implications of pica in pregnancy |journal=Nurs Womens Health |volume=11 |issue=3 |pages=266–73 |date=June 2007 |pmid=17883773 |doi=10.1111/j.1751-486X.2007.00156.x |url=}}</ref>


==Differential Diagnosis==
*Pica is more common in [[pregnant]] women and young children.<ref name="pmid21800636">{{cite journal |vauthors=Young SL, Sherman PW, Lucks JB, Pelto GH |title=Why on earth?: Evaluating hypotheses about the physiological functions of human geophagy |journal=Q Rev Biol |volume=86 |issue=2 |pages=97–120 |date=June 2011 |pmid=21800636 |doi=10.1086/659884 |url=}}</ref>
*[[Anorexia nervosa]]
*[[Factitious disorder]]
*Non suicidal self-injury
*Non suicidal self-injury behaviors in personality disorders


==Epidemiology and Demographics==
*The [[incidence]] of Pica decreases with age. Studies show 20-30% of children who are between 1-6 years old have developed Pica.<ref name="pmid25198212">{{cite journal |vauthors=Mishori R, McHale C |title=Pica: an age-old eating disorder that's often missed |journal=J Fam Pract |volume=63 |issue=7 |pages=E1–4 |date=July 2014 |pmid=25198212 |doi= |url=}}</ref
===Prevalence===
The majority of Pica cases are children with low socioeconomic classes, immigrants and refugees. <ref name="pmid8350239">{{cite journal |vauthors=Castiglia PT |title=Pica |journal=J Pediatr Health Care |volume=7 |issue=4 |pages=174–5 |date=1993 |pmid=8350239 |doi=10.1016/0891-5245(93)90041-f |url=}}</ref><ref name="pmid20226051">{{cite journal |vauthors=Khan Y, Tisman G |title=Pica in iron deficiency: a case series |journal=J Med Case Rep |volume=4 |issue= |pages=86 |date=March 2010 |pmid=20226051 |pmc=2850349 |doi=10.1186/1752-1947-4-86 |url=}}</ref><ref name="pmid28476302">{{cite journal |vauthors=Moore DJ |title=Sapophagia: A Case of Irish Spring Soap Pica |journal=J Emerg Nurs |volume=43 |issue=3 |pages=281–283 |date=May 2017 |pmid=28476302 |doi=10.1016/j.jen.2017.03.009 |url=}}</ref>


*Boys are slightly more affected by Pica than girls.<ref name="pmid29675593">{{cite journal |vauthors=Hartmann AS, Poulain T, Vogel M, Hiemisch A, Kiess W, Hilbert A |title=Prevalence of pica and rumination behaviors in German children aged 7-14 and their associations with feeding, eating, and general psychopathology: a population-based study |journal=Eur Child Adolesc Psychiatry |volume=27 |issue=11 |pages=1499–1508 |date=November 2018 |pmid=29675593 |doi=10.1007/s00787-018-1153-9 |url=}}</ref>


*The majority of Pica cases are reported in Africa.<ref name="pmid26892693">{{cite journal |vauthors=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 |volume=133 |issue=3 |pages=277–83 |date=June 2016 |pmid=26892693 |doi=10.1016/j.ijgo.2015.10.012 |url=}}</ref>


==Risk Factors==
==Risk Factors==
*Developmental delay
Common [[risk factors]] in the development of Pica include:<ref name="pmid26236386">{{cite journal |vauthors=Tokue H, Takahashi Y, Hirasawa S, Awata S, Kobayashi S, Shimada T, Tokue A, Sano R, Kominato Y, Tsushima Y |title=Intestinal obstruction in a mentally retarded patient due to pica |journal=Ann Gen Psychiatry |volume=14 |issue= |pages=22 |date=2015 |pmid=26236386 |pmc=4521501 |doi=10.1186/s12991-015-0060-4 |url=}}</ref><ref name="pmid23747942">{{cite journal |vauthors=Matson JL, Hattier MA, Belva B, Matson ML |title=Pica in persons with developmental disabilities: approaches to treatment |journal=Res Dev Disabil |volume=34 |issue=9 |pages=2564–71 |date=September 2013 |pmid=23747942 |doi=10.1016/j.ridd.2013.05.018 |url=}}</ref><ref name="pmid21109307">{{cite journal |vauthors=Mischoulon D, Eddy KT, Keshaviah A, Dinescu D, Ross SL, Kass AE, Franko DL, Herzog DB |title=Depression and eating disorders: treatment and course |journal=J Affect Disord |volume=130 |issue=3 |pages=470–7 |date=May 2011 |pmid=21109307 |pmc=3085695 |doi=10.1016/j.jad.2010.10.043 |url=}}</ref><ref name="pmid12201164">{{cite journal |vauthors=Kendall-Tackett K |title=The health effects of childhood abuse: four pathways by which abuse can influence health |journal=Child Abuse Negl |volume=26 |issue=6-7 |pages=715–29 |date=June 2002 |pmid=12201164 |doi=10.1016/s0145-2134(02)00343-5 |url=}}</ref><ref name="pmid30335275">{{cite journal |vauthors=Al Nasser Y, Muco E, Alsaad AJ |title= |journal= |volume= |issue= |pages= |date= |pmid=30335275 |doi= |url=}}</ref>
*Lack of supervision
*Neglect<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


==Natural History,Complications and Prognosis==
*Nutritional deficiency
*Pregnancy
*Stress
*Child abuse, child neglect, family problem, parental separation, low socioeconomic status
*Cultural factors
*Mental disorders
*Learning and developmental disability such as autistic spectrum disorder, attention-deficit hyperactivity disorder
*Epilepsy


==Screening==
There is insufficient evidence to recommend routine screening for Pica.


==Natural History, Complications, and Prognosis==
If left untreated, patients with Pica may progress to develop:
*Iron deficiency anemia especially during pregnancy.<ref name="pmid25943566">{{cite journal |vauthors=Rabel A, Leitman SF, Miller JL |title=Ask about ice, then consider iron |journal=J Am Assoc Nurse Pract |volume=28 |issue=2 |pages=116–20 |date=February 2016 |pmid=25943566 |pmc=4635104 |doi=10.1002/2327-6924.12268 |url=}}</ref> This complication may occur due to binding of clay particle to iron or acting as an ion exchanger resin.<ref name="pmid30868957">{{cite journal |vauthors=Leung AKC, Hon KL |title=Pica: A Common Condition that is Commonly Missed - An Update Review |journal=Curr Pediatr Rev |volume=15 |issue=3 |pages=164–169 |date=2019 |pmid=30868957 |doi=10.2174/1573396315666190313163530 |url=}}</ref>
*Lead poisoning <ref name="pmid30335275">{{cite journal |vauthors=Al Nasser Y, Muco E, Alsaad AJ |title= |journal= |volume= |issue= |pages= |date= |pmid=30335275 |doi= |url=}}</ref>
*Parasite infection (e.g. ,toxocariasis, toxoplasmosis, ascariasis, giardiasis, cysticercosis)<ref name="pmid28476302">{{cite journal |vauthors=Moore DJ |title=Sapophagia: A Case of Irish Spring Soap Pica |journal=J Emerg Nurs |volume=43 |issue=3 |pages=281–283 |date=May 2017 |pmid=28476302 |doi=10.1016/j.jen.2017.03.009 |url=}}</ref><ref name="pmid28864734">{{cite journal |vauthors=Tucker MH, Holmes J, Harley S, Garcia MR, Custodio H |title=Case 1: Fever and Ataxia in a Toddler with Pica |journal=Pediatr Rev |volume=38 |issue=9 |pages=435–436 |date=September 2017 |pmid=28864734 |doi=10.1542/pir.2016-0189 |url=}}</ref>
*Electrolyte abnormalities such as zinc deficiency, hypokalemia, hyperkalemia, hyperphosphatemia and metabolic alkalosis.<ref name="pmid24340849">{{cite journal |vauthors=Setime MA, Sesay S, Cainelli F, Vento S |title=A case of severe hypokalemic myopathy due to clay ingestion |journal=Isr Med Assoc J |volume=15 |issue=9 |pages=524–5 |date=September 2013 |pmid=24340849 |doi= |url=}}</ref><ref name="pmid11001006">{{cite journal |vauthors=Rose EA, Porcerelli JH, Neale AV |title=Pica: common but commonly missed |journal=J Am Board Fam Pract |volume=13 |issue=5 |pages=353–8 |date=2000 |pmid=11001006 |doi= |url=}}</ref>
*Constipation and intestinal obstruction, bleeding and perforation.<ref name="pmid30319211">{{cite journal |vauthors=Kalgaonkar SR, Ramakantan R |title=Pica and the radiologist - beyond the radiology report … digging deeper |journal=Indian J Radiol Imaging |volume=28 |issue=3 |pages=330–332 |date=2018 |pmid=30319211 |pmc=6176668 |doi=10.4103/ijri.IJRI_48_18 |url=}}</ref><ref name="pmid26236386">{{cite journal |vauthors=Tokue H, Takahashi Y, Hirasawa S, Awata S, Kobayashi S, Shimada T, Tokue A, Sano R, Kominato Y, Tsushima Y |title=Intestinal obstruction in a mentally retarded patient due to pica |journal=Ann Gen Psychiatry |volume=14 |issue= |pages=22 |date=2015 |pmid=26236386 |pmc=4521501 |doi=10.1186/s12991-015-0060-4 |url=}}</ref>
*Social stigmatization especially in children.<ref name="pmid28487433">{{cite journal |vauthors=McNaughten B, Bourke T, Thompson A |title=Fifteen-minute consultation: the child with pica |journal=Arch Dis Child Educ Pract Ed |volume=102 |issue=5 |pages=226–229 |date=October 2017 |pmid=28487433 |doi=10.1136/archdischild-2016-312121 |url=}}</ref>
*Tooth decay and sensitivity.<ref name="pmid16776414">{{cite journal |vauthors=Johnson CD, Koh SH, Shynett B, Koh J, Johnson C |title=An uncommon dental presentation during pregnancy resulting from multiple eating disorders: pica and bulimia: case report |journal=Gen Dent |volume=54 |issue=3 |pages=198–200 |date=2006 |pmid=16776414 |doi= |url=}}</ref>
*High blood sugar and obesity due to amylophagia.<ref name="pmid8201446">{{cite journal |vauthors=Edwards CH, Johnson AA, Knight EM, Oyemade UJ, Cole OJ, Westney OE, Jones S, Laryea H, Westney LS |title=Pica in an urban environment |journal=J Nutr |volume=124 |issue=6 Suppl |pages=954S–962S |date=June 1994 |pmid=8201446 |doi=10.1093/jn/124.suppl_6.954S |url=}}</ref>
*Maternal Pica may lead to neurological disability and delayed motor function in newborns.<ref name="pmid15026564">{{cite journal |vauthors=Mycyk MB, Leikin JB |title=Combined exchange transfusion and chelation therapy for neonatal lead poisoning |journal=Ann Pharmacother |volume=38 |issue=5 |pages=821–4 |date=May 2004 |pmid=15026564 |doi=10.1345/aph.1D475 |url=}}</ref><ref name="pmid29876999">{{cite journal |vauthors=Mireku MO, Davidson LL, Zoumenou R, Massougbodji A, Cot M, Bodeau-Livinec F |title=Consequences of prenatal geophagy for maternal prenatal health, risk of childhood geophagy and child psychomotor development |journal=Trop Med Int Health |volume=23 |issue=8 |pages=841–849 |date=August 2018 |pmid=29876999 |pmc=6103800 |doi=10.1111/tmi.13088 |url=}}</ref>


==Diagnostic Criteria==
==Diagnosis==
===Diagnostic Study of Choice===


===DSM-V Diagnostic Criteria for PICA<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
The diagnosis of Pica is based on the criteria from Diagnosis and Statistical Manual of Mental Disorders (DSM-5),<ref name="HartmannBecker2012">{{cite journal|last1=Hartmann|first1=Andrea S.|last2=Becker|first2=Anne E.|last3=Hampton|first3=Claire|last4=Bryant-Waugh|first4=Rachel|title=Pica and Rumination Disorder inDSM-5|journal=Psychiatric Annals|volume=42|issue=11|year=2012|pages=426–430|issn=0048-5713|doi=10.3928/00485713-20121105-09}}</ref> which include:
{{cquote|


*A. Persistent eating of non nutritive, non food substances over a period of at least 1 month.
1.Person must have been eating non-nutritive nonfoods for at least one month.


'''''AND'''''
2.This eating must be considered abnormal for the person's stage of development.


*B. The eating of non nutritive, non food substances is inappropriate to the developmental level of the individual.
3.Eating these substances cannot be associated with a cultural practice that is considered normal in the social context of the individual.


'''''AND'''''
4.For people who currently have a medical condition (e.g.: pregnancy) or a mental disorder (e.g.: autism spectrum disorder), the action of eating non-nutritive nonfoods should only be considered pica if it is dangerous and requires extra medical investigation or treatment on top of what they are already receiving for their pre-existing condition.


*C. The eating behavior is not part of a culturally supported or socially normative practice.  
===History and Symptoms===
Symptoms of Pica are variable and depend on the material which is ingested.


'''''AND'''''
Physicians should seek the details of the exposure, including<ref name="pmid28487433">{{cite journal |vauthors=McNaughten B, Bourke T, Thompson A |title=Fifteen-minute consultation: the child with pica |journal=Arch Dis Child Educ Pract Ed |volume=102 |issue=5 |pages=226–229 |date=October 2017 |pmid=28487433 |doi=10.1136/archdischild-2016-312121 |url=}}</ref>:
*the substance type,
*the amount of substance,
*duration of exposure,
*situations where behavior usually happens,
*any co-ingestions, and
*symptoms of toxicity


*D. If the eating behavior occurs in the context of another mental disorder (e.g., [[intellectual disability]] [intellectual developmental disorder], [[autism spectrum disorder]], [[schizophrenia]])or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.
===Physical Examination===
Patients with Pica usually appear normal<ref name="pmid9614424">{{cite journal |vauthors= |title=Screening for elevated blood lead levels. American Academy of Pediatrics Committee on Environmental Health |journal=Pediatrics |volume=101 |issue=6 |pages=1072–8 |date=June 1998 |pmid=9614424 |doi= |url=}}</ref>. However, sings of poisoning and complications of the ingested substance should be sought:<ref name="pmid28487433">{{cite journal |vauthors=McNaughten B, Bourke T, Thompson A |title=Fifteen-minute consultation: the child with pica |journal=Arch Dis Child Educ Pract Ed |volume=102 |issue=5 |pages=226–229 |date=October 2017 |pmid=28487433 |doi=10.1136/archdischild-2016-312121 |url=}}</ref><ref name="pmid28820703">{{cite journal |vauthors=Woodhall DM, Garcia AP, Shapiro CA, Wray SL, Shane AL, Mani CS, Stimpert KK, Fox LM, Montgomery SP |title=Assessment of U.S. Pediatrician Knowledge of Toxocariasis |journal=Am J Trop Med Hyg |volume=97 |issue=4 |pages=1243–1246 |date=October 2017 |pmid=28820703 |pmc=5637614 |doi=10.4269/ajtmh.17-0232 |url=}}</ref><ref name="pmid20934531">{{cite journal |vauthors=Dold C, Holland CV |title=Ascaris and ascariasis |journal=Microbes Infect |volume=13 |issue=7 |pages=632–7 |date=July 2011 |pmid=20934531 |doi=10.1016/j.micinf.2010.09.012 |url=}}</ref>
*Ingestion of some substances may lead to bezoar formation and consequently, intestinal obstruction, ulceration, and perforation,
*Lead poisoning symptoms include:<ref name="pmid29026055">{{cite journal |vauthors=Hon KL, Fung CK, Leung AK |title=Childhood lead poisoning: an overview |journal=Hong Kong Med J |volume=23 |issue=6 |pages=616–21 |date=December 2017 |pmid=29026055 |doi=10.12809/hkmj176214 |url=}}</ref>
**lethargy,
**headache,
**seizure,
**encephalopathy,
**cranial nerve palsy,
**papilledema,
**cognitive impairment,
**peripheral neuropathy,
**abdominal pain and constipation,
**lead-line at the junction of gums and teeth, and
**developmental delay in children.
*Signs of parasitic infections (Toxocara and Ascaris) due to clay ingestion include:
**fever,
**cough,
**myocarditis,
**encephalitis,
**hepatomegaly, and
**visual disturbance.  
*Malnourishment, especially in children<ref name="pmid21328077">{{cite journal |vauthors=Chatzimavroudis G, Christopoulos P, Atmatzidis S, Papadakis G, Nalbanti P, Papaziogas B, Koutelidakis I, Atmatzidis K |title=Pica: an uncommon cause of acute abdominal pain in children |journal=Indian J Pediatr |volume=78 |issue=7 |pages=886–7 |date=July 2011 |pmid=21328077 |doi=10.1007/s12098-011-0376-2 |url=}}</ref><ref name="pmid17906991">{{cite journal |vauthors=Sabouraud S, Testud F, Descotes J, Benevent M, Soglu G |title=Lead poisoning following ingestion of pieces of lead roofing plates: pica-like behavior in an adult |journal=Clin Toxicol (Phila) |volume=46 |issue=3 |pages=267–9 |date=March 2008 |pmid=17906991 |doi=10.1080/15563650701639014 |url=}}</ref>
*Signs of iron deficiency anemia:
**pallor,
**easy fatigability,
**poor appetite,
**tachycardia and a soft ejection systolic flow murmur in severe cases.
*Dental complications such as severe abrasion and tooth damages.<ref name="pmid17899724">{{cite journal |vauthors=Johnson CD, Shynett B, Dosch R, Paulson R |title=An unusual case of tooth loss, abrasion, and erosion associated with a culturally accepted habit |journal=Gen Dent |volume=55 |issue=5 |pages=445–8 |date=2007 |pmid=17899724 |doi= |url=}}</ref>


}}
===Laboratory Findings===
Laboratory findings consistent with the diagnosis of Pica include:<ref name="pmid11872770">{{cite journal |vauthors=Woywodt A, Kiss A |title=Geophagia: the history of earth-eating |journal=J R Soc Med |volume=95 |issue=3 |pages=143–6 |date=March 2002 |pmid=11872770 |pmc=1279487 |doi=10.1258/jrsm.95.3.143 |url=}}</ref><ref name="pmid1562860">{{cite journal |vauthors=Parry-Jones B, Parry-Jones WL |title=Pica: symptom or eating disorder? A historical assessment |journal=Br J Psychiatry |volume=160 |issue= |pages=341–54 |date=March 1992 |pmid=1562860 |doi=10.1192/bjp.160.3.341 |url=}}</ref><ref name="pmid8197741">{{cite journal |vauthors=Griffith JP, Bhanot VK |title=Geophagia in a chronic hemodialysis patient |journal=W V Med J |volume=90 |issue=3 |pages=106–7 |date=March 1994 |pmid=8197741 |doi= |url=}}</ref>
*CBC (anemia)
*Electrolyte and nutrient evaluation (zinc deficiency, hyperkalemia)
*Liver function test
*Stool exam for parasite infections
*Blood lead concentration


===Electrocardiogram===
There are no ECG findings associated with Pica.
===X-ray===
There are no x-ray findings associated with Pica. However, an x-ray may be helpful in the diagnosis of complications of Pica, which include lead lines at the metaphysis of long bones<ref name="pmid30868957">{{cite journal |vauthors=Leung AKC, Hon KL |title=Pica: A Common Condition that is Commonly Missed - An Update Review |journal=Curr Pediatr Rev |volume=15 |issue=3 |pages=164–169 |date=2019 |pmid=30868957 |doi=10.2174/1573396315666190313163530 |url=}}</ref> and foreign bodies in chest or abdominal x-ray.<ref name="pmid8539196">{{cite journal |vauthors=Waller BR, Pendergrass LB |title=Index of suspicion. Case 3. Strangulated hernia of the small intestine |journal=Pediatr Rev |volume=16 |issue=11 |pages=433, 435–6 |date=November 1995 |pmid=8539196 |doi= |url=}}</ref>
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with Pica. However, an ultrasound  may be helpful to reveal the location, size and the nature of the substance.<ref name="pmid30868957">{{cite journal |vauthors=Leung AKC, Hon KL |title=Pica: A Common Condition that is Commonly Missed - An Update Review |journal=Curr Pediatr Rev |volume=15 |issue=3 |pages=164–169 |date=2019 |pmid=30868957 |doi=10.2174/1573396315666190313163530 |url=}}</ref>
===CT scan===
There are no CT scan findings associated with Pica.
===MRI===
There are no MRI findings associated with Pica.
===Other Imaging Findings===
There are no other imaging findings associated with Pica.
===Other Diagnostic Studies===
There are no other diagnostic studies associated with Pica.
==Treatment==
==Treatment==
Treatment emphasizes psychosocial, environmental, and family guidance approaches. Treatment options include: discrimination training between edible and nonedible items, self-protection devices that prohibit placement of objects in the mouth, sensory reinforcement involving screening (covering eyes briefly), contingent aversive oral taste (lemon), contingent aversive smell sensation (ammonia), contingent aversive physical sensation (water mist), brief physical restraint, and overcorrection (correct the environment, or practice appropriate or alternative responses).
===Medical Therapy===
The majority of cases of Pica are self-limited and require only supportive care.<ref name="pmid30335275">{{cite journal |vauthors=Al Nasser Y, Muco E, Alsaad AJ |title= |journal= |volume= |issue= |pages= |date= |pmid=30335275 |doi= |url=}}</ref>
Supportive therapy for Pica includes:
*nutrient supplements such as iron and zinc in case of deficiency.<ref name="pmid28864256">{{cite journal |vauthors=Roy A, Fuentes-Afflick E, Fernald LCH, Young SL |title=Pica is prevalent and strongly associated with iron deficiency among Hispanic pregnant women living in the United States |journal=Appetite |volume=120 |issue= |pages=163–170 |date=January 2018 |pmid=28864256 |doi=10.1016/j.appet.2017.08.033 |url=}}</ref><ref name="pmid28836652">{{cite journal |vauthors=Sadeghzadeh M, Khoshnevisasl P, Sadeghzadeh S |title=The relation between pica and iron deficiency in children in Zanjan, Islamic Republic of Iran: a case-control study |journal=East Mediterr Health J |volume=23 |issue=6 |pages=404–407 |date=August 2017 |pmid=28836652 |doi=10.26719/2017.23.6.404 |url=}}</ref><ref name="pmid26931116">{{cite journal |vauthors=Kelkitli E, Ozturk N, Aslan NA, Kilic-Baygutalp N, Bayraktutan Z, Kurt N, Bakan N, Bakan E |title=Serum zinc levels in patients with iron deficiency anemia and its association with symptoms of iron deficiency anemia |journal=Ann Hematol |volume=95 |issue=5 |pages=751–6 |date=April 2016 |pmid=26931116 |doi=10.1007/s00277-016-2628-8 |url=}}</ref>
*Behavioral therapy, psychotherapy and family counseling particularly in children.<ref name="pmid25198212">{{cite journal |vauthors=Mishori R, McHale C |title=Pica: an age-old eating disorder that's often missed |journal=J Fam Pract |volume=63 |issue=7 |pages=E1–4 |date=July 2014 |pmid=25198212 |doi= |url=}}</ref><ref name="pmid23747942">{{cite journal |vauthors=Matson JL, Hattier MA, Belva B, Matson ML |title=Pica in persons with developmental disabilities: approaches to treatment |journal=Res Dev Disabil |volume=34 |issue=9 |pages=2564–71 |date=September 2013 |pmid=23747942 |doi=10.1016/j.ridd.2013.05.018 |url=}}</ref>


This involves associating negative consequences with eating non-food items and good consequences with normal behavior. Medications may be helpful in reducing the abnormal eating behavior, if pica occurs in the course of a developmental disorder, such as mental retardation, or pervasive developmental disorder. These conditions may be associated with severe behavioral disturbances, including pica. These medications enhance dopaminergic functioning, which is believed to be associated with the occurrence of pica.
===Surgery===
Surgical intervention is not recommended for the management of Pica Unless it causes severe obstruction or perforation.


==Examples==
===Primary Prevention===
* [[Amylophagia]] (consumption of [[starch]])
Effective measures for the primary prevention of Pica include:
* [[Coprophagia]] (consumption of excrement)
*Identifying high- risk populations such as pregnant women and children who live in old house with lead paint,<ref name="pmid7501867">{{cite journal |vauthors=Roberts JW, Dickey P |title=Exposure of children to pollutants in house dust and indoor air |journal=Rev Environ Contam Toxicol |volume=143 |issue= |pages=59–78 |date=1995 |pmid=7501867 |doi=10.1007/978-1-4612-2542-3_3 |url=}}</ref><ref name="pmid29056870">{{cite journal |vauthors=Hauptman M, Bruccoleri R, Woolf AD |title=An Update on Childhood Lead Poisoning |journal=Clin Pediatr Emerg Med |volume=18 |issue=3 |pages=181–192 |date=September 2017 |pmid=29056870 |pmc=5645046 |doi=10.1016/j.cpem.2017.07.010 |url=}}</ref><ref name="pmid26143570">{{cite journal |vauthors=Ezzeddin N, Zavoshy R, Noroozi M, Jahanihashemi H, Riseh SH |title=Prevalence and risk factors for pica during pregnancy in Tehran, Iran |journal=Eat Weight Disord |volume=20 |issue=4 |pages=457–63 |date=December 2015 |pmid=26143570 |doi=10.1007/s40519-015-0198-8 |url=}}</ref>
* Geophagy (consumption of [[soil]], [[clay]], or [[chalk]])
*Nutrition education in at-risk populations about the danger and consequences of Pica,<ref name="WilliamsKirkpatrick-Sanchez2009">{{cite journal|last1=Williams|first1=Don E.|last2=Kirkpatrick-Sanchez|first2=Sharon|last3=Enzinna|first3=Christie|last4=Dunn|first4=Jacqueline|last5=Borden-Karasack|first5=Deborah|title=The Clinical Management and Prevention of Pica: A Retrospective Follow-Up of 41 Individuals with Intellectual Disabilities and Pica|journal=Journal of Applied Research in Intellectual Disabilities|volume=22|issue=2|year=2009|pages=210–215|issn=13602322|doi=10.1111/j.1468-3148.2008.00490.x}}</ref><ref name="YoungRasmussen2010">{{cite journal|last1=Young|first1=Sera L.|last2=Rasmussen|first2=Kathleen M.|last3=Kavle|first3=Justine A.|last4=Farag|first4=Tamer H.|last5=Hajji|first5=Hamad|last6=Khalfan|first6=Sabra S.|last7=Pelto|first7=Gretel H.|last8=Stoltzfus|first8=Rebecca J.|last9=Ali|first9=Said M.|last10=Tielsch|first10=James M.|title=Association of Pica with Anemia and Gastrointestinal Distress among Pregnant Women in Zanzibar, Tanzania|journal=The American Journal of Tropical Medicine and Hygiene|volume=83|issue=1|year=2010|pages=144–151|issn=0002-9637|doi=10.4269/ajtmh.2010.09-0442}}</ref>
** Consumption of dust or sand has been reported among iron deficient patients.
*Educating parents to supervise their children and make their home and environment safe.<ref name="pmid11001006">{{cite journal |vauthors=Rose EA, Porcerelli JH, Neale AV |title=Pica: common but commonly missed |journal=J Am Board Fam Pract |volume=13 |issue=5 |pages=353–8 |date=2000 |pmid=11001006 |doi= |url=}}</ref>
* [[Hematophagy]] (ingestion of [[blood]])
* Hyalophagia (consumption of [[glass]])
* [[Pagophagia]] (pathological consumption of [[ice]])
* Self-cannibalism (rare condition where body parts may be consumed; see also [[Lesch-Nyhan syndrome]])
* [[Trichophagia]] (consumption of [[hair]] or wool)
* [[Urophagia]] (consumption of [[urine]])
* [[Xylophagia]] (consumption of [[wood]])


== In popular culture ==
===Secondary Prevention===
* Michel Lotito has made a career in entertainment of eating chopped "inedibles" like a Cessna 150 small airplane.
There are no established measures for the secondary prevention of pica.
* A patient suffering from Pica was featured in the Season Four premiere of Grey's Anatomy.


==References==
==References==
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[[es:Pica (enfermedad)]]
[[fr:Pica (maladie)]]
[[it:Pica (patologia)]]
[[nl:Pica (gedrag)]]
[[ja:異食症]]
[[no:Pica]]
[[pl:Łaknienie spaczone]]
[[pt:Pica (transtorno)]]
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Latest revision as of 08:24, 29 August 2023

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]

Synonyms and keywords: Pica syndrome, geophagia eating disorder, geophagy

Overview

Pica is a condition characterized by the persistent consumption of non-nutritive substances, such as ice, dirt, clay, or paper. It is most commonly observed in children, pregnant women, and individuals with developmental disorders or mental health conditions. Pica has been associated with various adverse health outcomes. In pregnant women, pica practices have been linked to lower hemoglobin levels and negative pregnancy outcomes. The etiology of pica is believed to be multifactorial. It has been associated with factors such as iron deficiency anemia, and restless legs syndrome (RLS). Other factors that have been associated with pica include stressors such as emotional trauma and familial issues. The treatment of pica involves addressing the underlying causes and providing appropriate interventions. In general, treatment may involve a multidisciplinary approach that includes nutritional counseling, behavioral therapy, and addressing any underlying medical conditions.

Historical Perspective

  • Pica is derived from the Latin word 'pica pica' which means magpie, a bird known for its behavior of gathering and eating almost everything.
  • It was first documented in the 13th century in Latin work of Bartholomeus de Glanville, although the actual term was not used.[1]
  • The first time term ‘Pica’ was mentioned in a medical context was in 1563 in a surgical work, ‘An Excellent Treatise of Wounds made with Gonne Shot’, by Thomas Gale, where pica was addressed in pregnant women and children.[1]
  • Historically, clay ingestion had been used for medical purposes probably due to its effect on gastrointestinal (GI) system. It was particularly suggested as a treatment of intestinal infection and spasm.[2]

Classification

Pica may be classified according to the name of the eaten substance; the most common types by far are geophagia and amylophagia:

  • Acuphagia (sharp objects)
  • Amylophagia (purified starch)
  • Cautopyreiophagia (burnt matches)
  • Coniophagia (dust, dirt)
  • Coprophagia (feces)
  • Emetophagia (vomit)
  • Geomelophagia (raw potatoes)
  • Geophagia (earth, soil, clay, chalk)
  • Hyalophagia (glass)
  • Lithophagia (stones)
  • Metallophagia (metal)
  • Mucophagia (mucus)
  • Pagophagia (ice)
  • Plumbophagia (lead, paint chips)
  • Trichophagia (hair, wool, fibers)
  • Urophagia (urine)
  • Hematophagia (blood)
  • Xylophagia (wood, paper)
  • Hyalophagia (glass)
  • Ryzophagia (raw rice)
  • Sapophagia (soap)

Pathophysiology

The exact pathogenesis of Pica is not fully understood. However, there are different theories on developing Pica:

Nutritional Theory

  • Children with anemia and low plasma zinc levels may develop Pica and crave for substances rich in the insufficient nutrients.[3]
  • Kaolinite, a clay mineral, which has negative surface charge commonly ingested in Pica and can absorb the ions with positive surface charge, such as iron and causes iron-deficiency anemia.[4] [5]
  • There is not enough evidence to determine whether Pica is the cause of nutritional deficiency or nutritional deficiency leads to Pica development.[4] [6]

Gastrointestinal Distress

Geophagia causes increase in gastrointestinal PH. This effect can soothe gastric pain and gastroesophageal reflux disease.[7] It also results in reduction of bioavailability of pathogens and toxins in gastrointestinal tract[8], a phenomenon on which a hypothesis is based. The hypothesis states that non-nutritive substances bind to toxins and lead to less toxins absorption. This event occurs in the most vulnerable period of cell replication and growth (childhood and pregnancy) in order to protect the body from dangerous toxins.[9][10][11]

Neurological Theory

Psychiatric Theory

A hypothesis states that Pica can be attributed to obsessive-compulsive spectrum disorders because Pica-related behaviors are mostly involuntary, recurrent, and persistent to soothe the anxiety and distress, and resistance to stop the behaviors causes increased level of anxiety and distress.[14][15] This hypothesis is supported by studies that have found that Pica has the same treatment as OCD, i.e selective serotonin reuptake inhibitors.[16]

Causes

The cause of Pica has not been identified. To review risk factors for the development of Pica, click here.

Differentiating ((Page name)) from other Diseases

Pica must be differentiated from other psychiatric diseases including autism, schizophrenia, other eating disorders, developmental delay in children, substance abuse.[17][18]

Epidemiology and Demographics

  • The prevalence and incidence of Pica is challenging to estimate due to several reasons such as: under-reporting the cases, cultural and social issues, different definition of Pica in studies.[19]
  • Pica is more common in pregnant women and young children.[20]
  • The incidence of Pica decreases with age. Studies show 20-30% of children who are between 1-6 years old have developed Pica.[21][22]
  • Boys are slightly more affected by Pica than girls.[23]
  • The majority of Pica cases are reported in Africa.[24]

Risk Factors

Common risk factors in the development of Pica include:[25][26][27][28][29]

  • Nutritional deficiency
  • Pregnancy
  • Stress
  • Child abuse, child neglect, family problem, parental separation, low socioeconomic status
  • Cultural factors
  • Mental disorders
  • Learning and developmental disability such as autistic spectrum disorder, attention-deficit hyperactivity disorder
  • Epilepsy

Screening

There is insufficient evidence to recommend routine screening for Pica.

Natural History, Complications, and Prognosis

If left untreated, patients with Pica may progress to develop:

  • Iron deficiency anemia especially during pregnancy.[17] This complication may occur due to binding of clay particle to iron or acting as an ion exchanger resin.[6]
  • Lead poisoning [29]
  • Parasite infection (e.g. ,toxocariasis, toxoplasmosis, ascariasis, giardiasis, cysticercosis)[22][30]
  • Electrolyte abnormalities such as zinc deficiency, hypokalemia, hyperkalemia, hyperphosphatemia and metabolic alkalosis.[31][2]
  • Constipation and intestinal obstruction, bleeding and perforation.[32][25]
  • Social stigmatization especially in children.[33]
  • Tooth decay and sensitivity.[34]
  • High blood sugar and obesity due to amylophagia.[35]
  • Maternal Pica may lead to neurological disability and delayed motor function in newborns.[36][37]

Diagnosis

Diagnostic Study of Choice

The diagnosis of Pica is based on the criteria from Diagnosis and Statistical Manual of Mental Disorders (DSM-5),[38] which include:

1.Person must have been eating non-nutritive nonfoods for at least one month.

2.This eating must be considered abnormal for the person's stage of development.

3.Eating these substances cannot be associated with a cultural practice that is considered normal in the social context of the individual.

4.For people who currently have a medical condition (e.g.: pregnancy) or a mental disorder (e.g.: autism spectrum disorder), the action of eating non-nutritive nonfoods should only be considered pica if it is dangerous and requires extra medical investigation or treatment on top of what they are already receiving for their pre-existing condition.

History and Symptoms

Symptoms of Pica are variable and depend on the material which is ingested.

Physicians should seek the details of the exposure, including[33]:

  • the substance type,
  • the amount of substance,
  • duration of exposure,
  • situations where behavior usually happens,
  • any co-ingestions, and
  • symptoms of toxicity

Physical Examination

Patients with Pica usually appear normal[39]. However, sings of poisoning and complications of the ingested substance should be sought:[33][40][41]

  • Ingestion of some substances may lead to bezoar formation and consequently, intestinal obstruction, ulceration, and perforation,
  • Lead poisoning symptoms include:[42]
    • lethargy,
    • headache,
    • seizure,
    • encephalopathy,
    • cranial nerve palsy,
    • papilledema,
    • cognitive impairment,
    • peripheral neuropathy,
    • abdominal pain and constipation,
    • lead-line at the junction of gums and teeth, and
    • developmental delay in children.
  • Signs of parasitic infections (Toxocara and Ascaris) due to clay ingestion include:
    • fever,
    • cough,
    • myocarditis,
    • encephalitis,
    • hepatomegaly, and
    • visual disturbance.
  • Malnourishment, especially in children[43][44]
  • Signs of iron deficiency anemia:
    • pallor,
    • easy fatigability,
    • poor appetite,
    • tachycardia and a soft ejection systolic flow murmur in severe cases.
  • Dental complications such as severe abrasion and tooth damages.[45]

Laboratory Findings

Laboratory findings consistent with the diagnosis of Pica include:[46][1][47]

  • CBC (anemia)
  • Electrolyte and nutrient evaluation (zinc deficiency, hyperkalemia)
  • Liver function test
  • Stool exam for parasite infections
  • Blood lead concentration

Electrocardiogram

There are no ECG findings associated with Pica.

X-ray

There are no x-ray findings associated with Pica. However, an x-ray may be helpful in the diagnosis of complications of Pica, which include lead lines at the metaphysis of long bones[6] and foreign bodies in chest or abdominal x-ray.[48]

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with Pica. However, an ultrasound may be helpful to reveal the location, size and the nature of the substance.[6]

CT scan

There are no CT scan findings associated with Pica.

MRI

There are no MRI findings associated with Pica.

Other Imaging Findings

There are no other imaging findings associated with Pica.

Other Diagnostic Studies

There are no other diagnostic studies associated with Pica.

Treatment

Medical Therapy

The majority of cases of Pica are self-limited and require only supportive care.[29] Supportive therapy for Pica includes:

  • nutrient supplements such as iron and zinc in case of deficiency.[49][50][51]
  • Behavioral therapy, psychotherapy and family counseling particularly in children.[52][26]

Surgery

Surgical intervention is not recommended for the management of Pica Unless it causes severe obstruction or perforation.

Primary Prevention

Effective measures for the primary prevention of Pica include:

  • Identifying high- risk populations such as pregnant women and children who live in old house with lead paint,[53][54][55]
  • Nutrition education in at-risk populations about the danger and consequences of Pica,[56][57]
  • Educating parents to supervise their children and make their home and environment safe.[2]

Secondary Prevention

There are no established measures for the secondary prevention of pica.

References

  1. ↑ 1.0 1.1 1.2 Parry-Jones B, Parry-Jones WL (March 1992). "Pica: symptom or eating disorder? A historical assessment". Br J Psychiatry. 160: 341–54. doi:10.1192/bjp.160.3.341. PMID 1562860.
  2. ↑ 2.0 2.1 2.2 Rose EA, Porcerelli JH, Neale AV (2000). "Pica: common but commonly missed". J Am Board Fam Pract. 13 (5): 353–8. PMID 11001006.
  3. ↑ Miao D, Young SL, Golden CD (2015). "A meta-analysis of pica and micronutrient status". Am J Hum Biol. 27 (1): 84–93. doi:10.1002/ajhb.22598. PMC 4270917. PMID 25156147.
  4. ↑ 4.0 4.1 Ali, Zainab (2009). "Pica in people with intellectual disability: a literature review of aetiology, epidemiology and complications". Journal of Intellectual & Developmental Disability. 26 (3): 205–215. doi:10.1080/13668250020054486. ISSN 1366-8250.
  5. ↑ von Garnier C, Stünitz H, Decker M, Battegay E, Zeller A (October 2008). "Pica and refractory iron deficiency anaemia: a case report". J Med Case Rep. 2: 324. doi:10.1186/1752-1947-2-324. PMC 2567333. PMID 18838005.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Leung A, 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. Vancouver style error: initials (help)
  7. ↑ Kettaneh A, Eclache V, Fain O, Sontag C, Uzan M, Carbillon L, Stirnemann J, Thomas M (February 2005). "Pica and food craving in patients with iron-deficiency anemia: a case-control study in France". Am J Med. 118 (2): 185–8. doi:10.1016/j.amjmed.2004.07.050. PMID 15694906.
  8. ↑ Young SL, Khalfan SS, Farag TH, Kavle JA, Ali SM, Hajji H, Rasmussen KM, Pelto GH, Tielsch JM, Stoltzfus RJ (July 2010). "Association of pica with anemia and gastrointestinal distress among pregnant women in Zanzibar, Tanzania". Am J Trop Med Hyg. 83 (1): 144–51. doi:10.4269/ajtmh.2010.09-0442. PMC 2912591. PMID 20595493.
  9. ↑ Young SL, Wilson MJ, Miller D, Hillier S (September 2008). "Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials". PLoS One. 3 (9): e3147. doi:10.1371/journal.pone.0003147. PMC 2522275. PMID 18773081.
  10. ↑ Johns T, Duquette M (February 1991). "Detoxification and mineral supplementation as functions of geophagy". Am J Clin Nutr. 53 (2): 448–56. doi:10.1093/ajcn/53.2.448. PMID 1989412.
  11. ↑ Dominy NJ, Davoust E, Minekus M (January 2004). "Adaptive function of soil consumption: an in vitro study modeling the human stomach and small intestine". J Exp Biol. 207 (Pt 2): 319–24. doi:10.1242/jeb.00758. PMID 14668315.
  12. ↑ Rangwala SD, Tobin MK, Birk DM, Butts JT, Nikas DC, Hahn YS (2017). "Pica in a Child with Anterior Cingulate Gyrus Oligodendroglioma: Case Report". Pediatr Neurosurg. 52 (4): 279–283. doi:10.1159/000477816. PMID 28704833.
  13. ↑ Singh, Nirbhay N.; Ellis, Cynthia R.; Crews, W. David; Singh, Yadhu N. (1994). "Does Diminished Dopaminergic Neurotransmission Increase Pica?". Journal of Child and Adolescent Psychopharmacology. 4 (2): 93–99. doi:10.1089/cap.1994.4.93. ISSN 1044-5463.
  14. ↑ Hergüner S, Ozyildirim I, Tanidir C (December 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.
  15. ↑ Stein DJ, Bouwer C, van Heerden B (December 1996). "Pica and the obsessive-compulsive spectrum disorders". S Afr Med J. 86 (12 Suppl): 1586–8, 1591–2. PMID 9180801.
  16. ↑ Bhatia, Manjeet S.; Gupta, Ravi (2009). "Pica responding to SSRI: An OCD spectrum disorder?". The World Journal of Biological Psychiatry. 10 (4–3): 936–938. doi:10.1080/15622970701308389. ISSN 1562-2975.
  17. ↑ 17.0 17.1 Rabel A, Leitman SF, Miller JL (February 2016). "Ask about ice, then consider iron". J Am Assoc Nurse Pract. 28 (2): 116–20. doi:10.1002/2327-6924.12268. PMC 4635104. PMID 25943566.
  18. ↑ Kar SK, Kamboj A, Kumar R (2015). "Pica and psychosis - clinical attributes and correlations: a case report". J Family Med Prim Care. 4 (1): 149–50. doi:10.4103/2249-4863.152277. PMC 4366992. PMID 25811011.
  19. ↑ Mills ME (June 2007). "Craving more than food: the implications of pica in pregnancy". Nurs Womens Health. 11 (3): 266–73. doi:10.1111/j.1751-486X.2007.00156.x. PMID 17883773.
  20. ↑ Young SL, Sherman PW, Lucks JB, Pelto GH (June 2011). "Why on earth?: Evaluating hypotheses about the physiological functions of human geophagy". Q Rev Biol. 86 (2): 97–120. doi:10.1086/659884. PMID 21800636.
  21. ↑ Khan Y, Tisman G (March 2010). "Pica in iron deficiency: a case series". J Med Case Rep. 4: 86. doi:10.1186/1752-1947-4-86. PMC 2850349. PMID 20226051.
  22. ↑ 22.0 22.1 Moore DJ (May 2017). "Sapophagia: A Case of Irish Spring Soap Pica". J Emerg Nurs. 43 (3): 281–283. doi:10.1016/j.jen.2017.03.009. PMID 28476302.
  23. ↑ Hartmann AS, Poulain T, Vogel M, Hiemisch A, Kiess W, Hilbert A (November 2018). "Prevalence of pica and rumination behaviors in German children aged 7-14 and their associations with feeding, eating, and general psychopathology: a population-based study". Eur Child Adolesc Psychiatry. 27 (11): 1499–1508. doi:10.1007/s00787-018-1153-9. PMID 29675593.
  24. ↑ Fawcett EJ, Fawcett JM, Mazmanian D (June 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.
  25. ↑ 25.0 25.1 Tokue H, Takahashi Y, Hirasawa S, Awata S, Kobayashi S, Shimada T, Tokue A, Sano R, Kominato Y, Tsushima Y (2015). "Intestinal obstruction in a mentally retarded patient due to pica". Ann Gen Psychiatry. 14: 22. doi:10.1186/s12991-015-0060-4. PMC 4521501. PMID 26236386.
  26. ↑ 26.0 26.1 Matson JL, Hattier MA, Belva B, Matson ML (September 2013). "Pica in persons with developmental disabilities: approaches to treatment". Res Dev Disabil. 34 (9): 2564–71. doi:10.1016/j.ridd.2013.05.018. PMID 23747942.
  27. ↑ Mischoulon D, Eddy KT, Keshaviah A, Dinescu D, Ross SL, Kass AE, Franko DL, Herzog DB (May 2011). "Depression and eating disorders: treatment and course". J Affect Disord. 130 (3): 470–7. doi:10.1016/j.jad.2010.10.043. PMC 3085695. PMID 21109307.
  28. ↑ Kendall-Tackett K (June 2002). "The health effects of childhood abuse: four pathways by which abuse can influence health". Child Abuse Negl. 26 (6–7): 715–29. doi:10.1016/s0145-2134(02)00343-5. PMID 12201164.
  29. ↑ 29.0 29.1 29.2 Al Nasser Y, Muco E, Alsaad AJ. PMID 30335275. Missing or empty |title= (help)
  30. ↑ Tucker MH, Holmes J, Harley S, Garcia MR, Custodio H (September 2017). "Case 1: Fever and Ataxia in a Toddler with Pica". Pediatr Rev. 38 (9): 435–436. doi:10.1542/pir.2016-0189. PMID 28864734.
  31. ↑ Setime MA, Sesay S, Cainelli F, Vento S (September 2013). "A case of severe hypokalemic myopathy due to clay ingestion". Isr Med Assoc J. 15 (9): 524–5. PMID 24340849.
  32. ↑ Kalgaonkar SR, Ramakantan R (2018). "Pica and the radiologist - beyond the radiology report … digging deeper". Indian J Radiol Imaging. 28 (3): 330–332. doi:10.4103/ijri.IJRI_48_18. PMC 6176668. PMID 30319211.
  33. ↑ 33.0 33.1 33.2 McNaughten B, Bourke T, Thompson A (October 2017). "Fifteen-minute consultation: the child with pica". Arch Dis Child Educ Pract Ed. 102 (5): 226–229. doi:10.1136/archdischild-2016-312121. PMID 28487433.
  34. ↑ Johnson CD, Koh SH, Shynett B, Koh J, Johnson C (2006). "An uncommon dental presentation during pregnancy resulting from multiple eating disorders: pica and bulimia: case report". Gen Dent. 54 (3): 198–200. PMID 16776414.
  35. ↑ Edwards CH, Johnson AA, Knight EM, Oyemade UJ, Cole OJ, Westney OE, Jones S, Laryea H, Westney LS (June 1994). "Pica in an urban environment". J Nutr. 124 (6 Suppl): 954S–962S. doi:10.1093/jn/124.suppl_6.954S. PMID 8201446.
  36. ↑ Mycyk MB, Leikin JB (May 2004). "Combined exchange transfusion and chelation therapy for neonatal lead poisoning". Ann Pharmacother. 38 (5): 821–4. doi:10.1345/aph.1D475. PMID 15026564.
  37. ↑ Mireku MO, Davidson LL, Zoumenou R, Massougbodji A, Cot M, Bodeau-Livinec F (August 2018). "Consequences of prenatal geophagy for maternal prenatal health, risk of childhood geophagy and child psychomotor development". Trop Med Int Health. 23 (8): 841–849. doi:10.1111/tmi.13088. PMC 6103800. PMID 29876999.
  38. ↑ Hartmann, Andrea S.; Becker, Anne E.; Hampton, Claire; Bryant-Waugh, Rachel (2012). "Pica and Rumination Disorder inDSM-5". Psychiatric Annals. 42 (11): 426–430. doi:10.3928/00485713-20121105-09. ISSN 0048-5713.
  39. ↑ "Screening for elevated blood lead levels. American Academy of Pediatrics Committee on Environmental Health". Pediatrics. 101 (6): 1072–8. June 1998. PMID 9614424.
  40. ↑ Woodhall DM, Garcia AP, Shapiro CA, Wray SL, Shane AL, Mani CS, Stimpert KK, Fox LM, Montgomery SP (October 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.
  41. ↑ Dold C, Holland CV (July 2011). "Ascaris and ascariasis". Microbes Infect. 13 (7): 632–7. doi:10.1016/j.micinf.2010.09.012. PMID 20934531.
  42. ↑ Hon KL, Fung CK, Leung AK (December 2017). "Childhood lead poisoning: an overview". Hong Kong Med J. 23 (6): 616–21. doi:10.12809/hkmj176214. PMID 29026055.
  43. ↑ Chatzimavroudis G, Christopoulos P, Atmatzidis S, Papadakis G, Nalbanti P, Papaziogas B, Koutelidakis I, Atmatzidis K (July 2011). "Pica: an uncommon cause of acute abdominal pain in children". Indian J Pediatr. 78 (7): 886–7. doi:10.1007/s12098-011-0376-2. PMID 21328077.
  44. ↑ Sabouraud S, Testud F, Descotes J, Benevent M, Soglu G (March 2008). "Lead poisoning following ingestion of pieces of lead roofing plates: pica-like behavior in an adult". Clin Toxicol (Phila). 46 (3): 267–9. doi:10.1080/15563650701639014. PMID 17906991.
  45. ↑ Johnson CD, Shynett B, Dosch R, Paulson R (2007). "An unusual case of tooth loss, abrasion, and erosion associated with a culturally accepted habit". Gen Dent. 55 (5): 445–8. PMID 17899724.
  46. ↑ Woywodt A, Kiss A (March 2002). "Geophagia: the history of earth-eating". J R Soc Med. 95 (3): 143–6. doi:10.1258/jrsm.95.3.143. PMC 1279487. PMID 11872770.
  47. ↑ Griffith JP, Bhanot VK (March 1994). "Geophagia in a chronic hemodialysis patient". W V Med J. 90 (3): 106–7. PMID 8197741.
  48. ↑ Waller BR, Pendergrass LB (November 1995). "Index of suspicion. Case 3. Strangulated hernia of the small intestine". Pediatr Rev. 16 (11): 433, 435–6. PMID 8539196.
  49. ↑ Roy A, Fuentes-Afflick E, Fernald L, Young SL (January 2018). "Pica is prevalent and strongly associated with iron deficiency among Hispanic pregnant women living in the United States". Appetite. 120: 163–170. doi:10.1016/j.appet.2017.08.033. PMID 28864256. Vancouver style error: initials (help)
  50. ↑ Sadeghzadeh M, Khoshnevisasl P, Sadeghzadeh S (August 2017). "The relation between pica and iron deficiency in children in Zanjan, Islamic Republic of Iran: a case-control study". East Mediterr Health J. 23 (6): 404–407. doi:10.26719/2017.23.6.404. PMID 28836652.
  51. ↑ Kelkitli E, Ozturk N, Aslan NA, Kilic-Baygutalp N, Bayraktutan Z, Kurt N, Bakan N, Bakan E (April 2016). "Serum zinc levels in patients with iron deficiency anemia and its association with symptoms of iron deficiency anemia". Ann Hematol. 95 (5): 751–6. doi:10.1007/s00277-016-2628-8. PMID 26931116.
  52. ↑ Mishori R, McHale C (July 2014). "Pica: an age-old eating disorder that's often missed". J Fam Pract. 63 (7): E1–4. PMID 25198212.
  53. ↑ Roberts JW, Dickey P (1995). "Exposure of children to pollutants in house dust and indoor air". Rev Environ Contam Toxicol. 143: 59–78. doi:10.1007/978-1-4612-2542-3_3. PMID 7501867.
  54. ↑ Hauptman M, Bruccoleri R, Woolf AD (September 2017). "An Update on Childhood Lead Poisoning". Clin Pediatr Emerg Med. 18 (3): 181–192. doi:10.1016/j.cpem.2017.07.010. PMC 5645046. PMID 29056870.
  55. ↑ Ezzeddin N, Zavoshy R, Noroozi M, Jahanihashemi H, Riseh SH (December 2015). "Prevalence and risk factors for pica during pregnancy in Tehran, Iran". Eat Weight Disord. 20 (4): 457–63. doi:10.1007/s40519-015-0198-8. PMID 26143570.
  56. ↑ Williams, Don E.; Kirkpatrick-Sanchez, Sharon; Enzinna, Christie; Dunn, Jacqueline; Borden-Karasack, Deborah (2009). "The Clinical Management and Prevention of Pica: A Retrospective Follow-Up of 41 Individuals with Intellectual Disabilities and Pica". Journal of Applied Research in Intellectual Disabilities. 22 (2): 210–215. doi:10.1111/j.1468-3148.2008.00490.x. ISSN 1360-2322.
  57. ↑ Young, Sera L.; Rasmussen, Kathleen M.; Kavle, Justine A.; Farag, Tamer H.; Hajji, Hamad; Khalfan, Sabra S.; Pelto, Gretel H.; Stoltzfus, Rebecca J.; Ali, Said M.; Tielsch, James M. (2010). "Association of Pica with Anemia and Gastrointestinal Distress among Pregnant Women in Zanzibar, Tanzania". The American Journal of Tropical Medicine and Hygiene. 83 (1): 144–151. doi:10.4269/ajtmh.2010.09-0442. ISSN 0002-9637.

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