226 McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121

AbstrAct Pica is defined as the persistent ingestion of non-nutritive substances for more than 1 month at an age at which this behaviour is deemed inappropriate. It occurs most commonly in children, in patients with learning disabilities and in pregnancy. The aetiology of pica is poorly understood and is probably multifactorial. Clinical assessment can be difficult. History and examination should be tailored to address potential complications of the substance being ingested. Complications can be life threatening. Pica often self-remits in younger children. In those with learning disabilities, however, pica may persist into adulthood. Management strategies should involve a multidisciplinary approach, and interventions are primarily behavioural in nature. There is limited evidence to support pharmacological interventions in the management of children with pica.

IntroductIon Pica is the persistent ingestion of non-nu- tritive substances for more than 1 month at an age at which this behaviour is deemed inappropriate1 (see box 1). The term originates in the Latin word for magpie, a bird famed for collecting and hoarding unusual objects.2

Pica can be classified according to the particular substance ingested. Common subtypes are listed in table 1. Ingestion of non-food substances may also be associ- ated with cultural practices. Geophagia, including the ingestion of kaolin (white clay), is seen in sections of the Afri- can-American population in the USA and is common practice in parts of Africa.3 Although often described as pica in the literature, these practices may actually be deemed to be socially normative practice and therefore do not fit the diagnostic criteria outlined in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).

Pica is most commonly seen in children aged 2 or 3 years old. It may persist into

adolescence when it is usually associated with learning difficulties.4 Studies suggest pica can be present in between 5% and 25% of children with learning difficulties. Pica is also common in pregnancy, occur- ring in up to 28% of cases. It typically occurs in younger women in their first pregnancy.5 This article provides an over- view of the possible causes and poten- tial complications of pica. In addition, it discusses important aspects of the clinical assessment, investigation and manage- ment of a child presenting with pica.

AetIology The aetiology of pica is poorly understood and is probably multifactorial. Proposed mechanisms range from psychosocial to biochemical.

An association between pica and micro- nutrient deficiencies, including iron, calcium and zinc has been well described. A recent meta-analysis confirmed the association between anaemia, low plasma zinc levels and pica.6 Children with pica may ingest substances rich in the nutrients in which they are deficient. However, there has been limited success in preventing pica in cases where nutri- tional deficiencies have been identified and treated.

The higher incidence of pica noted in children with learning and develop- mental disabilities, including autistic spec- trum disorder, was traditionally believed to result from an inability to differen- tiate between food and non-food items. However, current thinking suggests that this is more likely to be secondary to learned behaviours.4 7

Pica in children has also been associated with deprivation, parental neglect and malnutrition.2 It may present in the pres- ence of a coexisting psychiatric disorder, and there is increasing evidence that it may be associated with conditions leading to malabsorption, poor nutritional status or anaemia. Recent literature, for example, has highlighted concerns regarding the

Best practice

Fifteen-minute consultation: the child with pica

Ben McNaughten, thomas Bourke, andrew thompson

Royal Belfast Hospital for Sick Children, Belfast, UK

Correspondence to Dr Ben McNaughten, Royal Belfast Hospital for Sick Children, 180-184 Falls Road, Belfast BT12 6BE, UK; bmcnaughten095@ hotmail. com

Received 30 November 2016 Revised 15 February 2017 Accepted 28 February 2017 Published Online First 9 May 2017

To cite: McNaughten B, Bourke T, Thompson A. Arch Dis Child Educ Pract Ed 2017;102:226–229.

McNaughten B, et al. Arch Dis Child Educ Pract Ed 2017;102:226–229. doi:10.1136/archdischild-2016-312121 227

Best practice

Table 1 Common subtypes of pica according to the substance ingested

Subtypes of pica Substance ingested

Acuphagia Sharp objects Coniophagia Dust Coprophagia Faeces Emetophagia Vomit Hyalophagia Glass Lithophagia Stones Pagophagia Ice Plumbophagia Lead Tricophagia Hair, wool or other fibres Xylophagia Wood

increased incidence of pica among children with sickle cell disease.8 9

clInIcAl presentAtIon History taking The clinical presentation of pica is highly variable and depends on the particular substance being ingested and the potential associated complications. History taking should focus on the substance ingested. If there is a risk of poisoning, the history should focus on the consequences of that poisoning. Enquire about symp- toms of anaemia, such as pallor, shortness of breath, palpitations and lethargy. Ask about coexisting medical conditions that may predispose to pica. Take a thor- ough developmental and social history. Explore the patient’s living environment, for example, the risk of exposure to lead.

 

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