Pica
September 7, 2004, KidsHealth.org

Caleb, a young boy with autism, would repeatedly place items such as little beads, small toys, sand, and dirt in his mouth and would often swallow them.

During her pregnancy, Laura craved not pickles and ice cream but soap. Frightened by this strange urge, she called her doctor.

Caleb and Laura were diagnosed with pica, an eating disorder characterized by persistent and compulsive cravings to eat non-food items that last for 1 month or longer.

What Is Pica?
The name "pica" comes from the Latin word for magpie, a bird known for its large and indiscriminate appetite.

Persons with pica most frequently crave and consume non-food items such as dirt, clay, paint chips, plaster, chalk, cornstarch, laundry starch, baking soda, coffee grounds, cigarette ashes, burnt match heads, cigarette butts, and rust. Glue, hair, buttons, paper, sand, toothpaste, soap, oyster shells, and broken crockery also have been cited in pica cases.

Although consumption of some items may be harmless, pica is considered to be a serious eating disorder, sometimes resulting in serious health problems such as lead poisoning and iron-deficiency anemia.

Who Gets Pica?
Most frequently, pica occurs in women before or during their pregnancies or while they are breast-feeding. The incidence of pica during pregnancy has been reported to range from 0 to 68%, depending on the patient population. It has been suggested that pica during pregnancy occurs more frequently in people who exhibited similar practices during their childhood and non-pregnant states. Pica also has been found among small children and people with epilepsy, mental retardation, and mental illness. Sometimes, several household members may share these cravings, and those in lower socioeconomic groups seem to have more non- food cravings than those in higher socioeconomic groups.

As many as 10% to 20% of children experience pica at some point before adulthood. In children, pica most often accompanies a developmental disorder, such as autism or mental retardation, says Harvey Weinberg, PhD, a psychologist. Pica also may surface in children who have had a brain injury affecting their development.

"Younger children often eat paint chips, plaster, string, hair, or cloth, whereas older children will eat animal droppings, sand, insects, leaves, or pebbles," says Dr. Weinberg, who sees about one to two cases of pica in children each year at his practice.

Among adults with developmental disabilities suffering from pica, cigarette butts are most commonly craved. Up to 26% of people in residential centers for developmental disabilities have pica, and a large portion of these adults crave cigarette butts.

In addition, pica is also found in people who diet; they may attempt to ease hunger cravings with low-calorie and non-food substances. Sometimes, people with pica have family, ethnic, or religious customs that include eating a particular non-food substance.

Causes of Pica
The specific causes of pica are unknown. "No specific biological abnormality is known to cause pica, but certain conditions increase one's risk for it," Dr. Weinberg says. "These include poverty, neglect of parental supervision, and developmental delays."

Theories about what causes pica abound, including nutritional, sensory, physiologic, psychosocial, and cultural explanations. Most commonly, doctors suspect that emotional disturbances and deficiencies of iron or zinc may lead to the condition.

The nutritional theory suggests that appetite-regulating brain enzymes, altered by an iron or zinc deficiency, trigger specific cravings. Yet, the non- food items craved usually do not supply the minerals lacking in the person's body. Evidence supports the hypothesis that at least some pica is a response to dietary deficiency. Pregnant women, for example, have given up pica after they were treated for iron-deficiency anemia, a common condition among pregnant women with pica.

In Laura's case, her doctor suspected that she had a zinc deficiency. He suggested she try zinc supplements, which helped relieve her cravings for soap. One physiological theory to explain pica is that eating clay or dirt helps relieve nausea, control diarrhea, increase salivation, remove toxins, and alter odor or taste perception.

Some psychological theories explain pica as a behavioral response to stress, a habit disorder, or a manifestation of an oral fixation. Some people consume clay or dirt as part of a daily routine such as smoking.

Another explanation is that pica is a cultural feature of certain religious rituals, folk medicine, and magical beliefs. Some people believe that eating dirt will help them incorporate magical spirits into their bodies. Still others believe that consuming certain kinds of clay can suppress morning sickness.

Eating earth substances, such as clay or dirt, is a form of pica that can cause iron deficiency. Known as geophagia, this is a common practice among pregnant African-American women in the southern United States. Some women who have moved north have arranged for regular mailings of clay dug from some favorite area. In addition, some southern grocery stores have sold clay intended for human consumption.

Despite the wide variety of theories, not one of them explains all forms of pica. A doctor must treat every case individually to understand what may be causing the condition.

Does My Child Have Pica?
Young children are naturally curious about their environment, and they may, for instance, eat some dirt out of their sandbox. Yet children with pica go beyond this innocent exploration of their surroundings.

Look for these warning signs that your child may have pica:[list][*]repetitive consumption of a non-food item, despite efforts to restrict it, for a period of at least 1 month or longer [*]the behavior is considered inappropriate for your child's age or developmental stage [*]the behavior is not part of a cultural, ethnic, or religious practice [*]your child has another developmental problem[/list:u]Older people with pica may be reluctant to reveal their unusual cravings to their doctor, or they may not realize that their symptoms indicate some underlying problem. Therefore, doctors need to familiarize themselves with the symptoms of this disorder, many of which are common to other ailments, including fatigue, palpitations, lightheadedness, or shortness of breath.

If pica is suspected, your child may also display signs of iron deficiency, including pallor and thinned nails that are concave and have raised edges, known as spooning of the nails. The small elevations on your child's tongue may be flattened, and he may have superficial erosions and fissurings at the angles of the mouth, which frequently signals riboflavin deficiency.

What Does Pica Mean for My Child's Health?
If your child continues to consume non-food items, he may be at risk for potential health problems, including lead poisoning, bowel problems, intestinal obstruction or perforation, and parasitic infections.

If your child faces the risk of consuming toxic or potentially harmful substances, such as those contaminated by lead paint, seek medical attention immediately.

What Will the Doctor Do?
Your child's doctor plays an important role in helping you manage and prevent pica-related behaviors.

In cases such as Caleb's, your child's doctor will typically emphasize your responsibility to provide direct supervision of your child. "A child with pica needs a safe and secure family structure," Dr. Weinberg explains.

Your child's doctor will educate you on teaching your child about acceptable and non-acceptable food substances. The doctor also will work with you to prevent your child from obtaining the non-food items he wants. For example, with child-safety locks and high shelving, household chemicals and medications can (and should always) be kept out of reach of children.

Depending on your child's age and development stage, the doctor will work with your child to teach him ways to eat more appropriately. If your child also has a developmental disability, medication may be prescribed to help quell the behavior associated with pica.

If your child has been exposed to a contaminated substance such as lead, a health care provider will screen your child for lead poisoning.

If you can succeed in getting your child to stop consuming the non-food items he craves, future treatment may not be needed.

When to Call the Doctor
If a child, pregnant woman, or other person runs the risk of consuming toxic or potentially harmful substances, treatment should be sought immediately.

Medical emergencies and death can occur if the craved substance is toxic or contaminated with lead or mercury, or if the item forms an indigestible mass blocking the intestines. Pica involving lead-containing substances during pregnancy may be associated with an increase in both maternal and fetal lead levels.

Dental injury and phosphorus intoxication from match heads are other dangerous problems associated with pica. All of these cases require immediate medical attention.

Following treatment, if your child's pica behavior continues beyond several weeks, despite your attempts to intervene, contact your child's doctor again for additional treatment.