Pica resident survival guide

Pica Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

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

Synonyms and keywords: Approach to pica, Pica workup, Pica management

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. 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.

Causes

• Pica is commonly seen in children over 2 years of age.
• Iron deficiency anemia
• Pregnancy
• Autism and other developmental disabilities
• Lower socioeconomic status
• Epilepsy
• Schizophrenia
• Recently, obsessive compulsive disorder has also been implicated as a cause .

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: ❑ 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

Treatment

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).
• 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.

Don'ts

• 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.