When you have young ones sometimes it is a constant battle of stopping them from ingesting nonfood items. Some parents have even ended up in the ER after a child ingested a potentially dangerous item or substance. This behavior is not out of the norm of child development, in fact children learn to explore the world around them by putting things in their mouths. So when does this become a problem, and when should parents worry? Normally after the age of two, children become aware of what is food and what is not and it is then that parents and caregivers need to pay attention to what they ingest or avoid and the frequency.

According to the DSM-5, feeding and eating disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. Although some of these disorders can affect adults as well, for example some pregnant women develop pica, they are more common in childhood and we are going to look at them from a child developmental perspective only.

What Is Pica?

Children with pica compulsively eat items that have no nutritional value and nonfood items. A person with pica might eat relatively harmless items, such as ice or they might eat potentially dangerous items, likes flakes of dried paint, pieces of metal, hair etc.

Although the prevalence of pica is more common in children with other developmental disorders, pica can still occur in otherwise normally developing children. For this behavior to warrant clinical attention, at least three of the below criteria should be met:

A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.

1. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.
2. The eating behavior is not part of a culturally supported or socially normative practice.
3. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder], autism spectrum disorder, schizophrenia) or a medical condition e.g. anemia, it is sufficiently severe to warrant additional clinical attention.

A minimum age of 2 years is suggested for a pica diagnosis to exclude developmentally normal mouthing of objects by infants that results in ingestion.

Typical substances ingested tend to vary with age and availability and might include paper, soap, cloth, hair, strings, wool, soil, chalk, talcum powder, paint, gum, metal, plastic, pebbles, crayons, charcoal or coal, feces, ash, clay, starch, or ice.

There is typically no aversion to food in general, which means they still eat proper food fairly well. Although deficiencies in vitamins or minerals (e.g., zinc, iron) have been reported in some instances, often no specific biological abnormalities are found. In some cases, pica comes to clinical attention only following general medical complications (e.g., mechanical bowel problems; intestinal obstruction, intestinal perforation, infections such as toxoplasmosis as a result of ingesting feces or dirt; poisoning, such as by ingestion of lead-based paint).

How is pica diagnosed?

There’s no specific test for pica. A doctor will diagnose this condition based on history and several other factors. The doctor may do some blood tests to see if a child has low levels of zinc or iron or any other deficiencies or underlying medical conditions that may contribute to the development of pica. Nutrient deficiencies may sometimes be related to pica.

What Are the Signs & Symptoms of Pica?

Pica signs and symptoms are normally related to the nonfood item that is being ingested. These may include but not limited to:

•  Stomach upset
•  Stomach cramps
•  Blood in the stool – which may be a sign of an ulcer(s) or irritation that has developed from eating nonfood items.

Bowel problems – such as constipation or diarrhea from eating things the body can’t digest like hair.
Intestinal infections – from eating soil or poop that has parasites or worms
Intestinal obstruction – from eating things that block the intestines
mouth or teeth injuries
Lead poisoning – from eating paint chips that contain lead.

Other underlying health problems that can lead to pica  Iron-deficiency anemia

Risk Factors for the Development of Pica

•  Psychosocial stressors – Neglect, lack of supervision, Posttraumatic Stress Disorder (PTSD), abuse etc.
•  Developmental delays can increase the risk for this condition e.g., speech delays
•  Mental disorders – e.g., Autism Spectrum Disorder, Intellectual disability etc. Pica can also be associated with trichotillomania (hair pulling disorder) and excoriation (skin-picking) disorder. In these comorbid presentations, the hair or skin is typically ingested.
•  Culture-Related Issues – In some populations, the eating of earth or other seemingly nonnutritive substances is believed to be of spiritual, medicinal, or other social value, or may be a culturally supported or socially normative practice. Such behavior does not warrant a diagnosis of pica (Criterion C above on what causes pica?).
•  Gender – Pica occurs equally in both males and females during childhood.
•  Malnutrition – in an environment where children do not get enough food whether due to poverty or any other reason, children can turn to nonfood items and it can become severe enough to warrant clinical attention.
•  Oral overstimulation – ingesting nonfood items can be a compensatory way of seeking oral sensation.
•  Maternal Pica – if a mother develops pica during pregnancy her offspring might develop pica as well.
•  Medications – Some medications can alter the absorption of nutrients and create a deficiency that might contribute to the development of pica.
•  Medical conditions – e.g. pediatric diabetes.

Treatment & Prevention

•  Psycho education and behavioral treatment approaches in pica that involve careful observational analysis and the application of consistent responses to help change the behavior have proven successful.
•  Iron supplementation has been seen to dramatically reverse pica in those patients whose clinical symptoms are more clearly coincident with iron deficiency from nutritional or covert medical causes.
•  Treatment for pica will also address other health problems caused by the ingesting of nonfood items. For example, the doctor will treat the child’s constipation, diarrhea, ulcer(s), intestinal tear, infection, or any other illnesses that may be present.
•  A doctor may also recommend other vitamin supplements and dietary recommendations just to make sure a child is getting all the required nutritional vitamins.

Another focus of treatment will have to address psychosocial stressors that could have contributed to the development of pica. Issues such as the child’s home environment, parental supervision, grief etc., will have to be addressed with a mental health expert.

Unfortunately pica cannot be prevented, however, the information that is out there and agreed upon by experts is that:

Proper nutrition may help some children from developing it.
Paying close attention to any changes in eating habits and changes in the child’s environment.
Supervising children who tend to put things into their mouths, you may be able to catch the disorder early, before complications can happen.
Administering vitamins to make sure that children are getting all the required nutrients for growth.
Rule out other developmental delays that might contribute to the development of pica and get intervention for that as well.

Talent Adamson Behaviour Therapist

BA (Health and Social Services) Applied Psychology, BA Hon (HSS) Psychological Counselling – (UNISA)