Jack Maypole, MD
Contributing Writer and Goddard School Educational Advisory Board Member
Infants and toddlers are like wobbly ninjas, focused maniacally on tasting and mouthing items from coins to blocks to the odd flotsam and jetsam that lives on living room floors. Parents know to beware, to police an area well…as you never know what they’ll pop in their mouth next. Infant and toddler oral fixation is considered developmentally appropriate (if not entirely healthy) behavior. Fortunately, most children outgrow this item-to-mouth impulse by the time they are closing in on their second birthday.
And then, there are those children with pica.
Pica, of course, refers to the old typewriting term of 12 points of line space equal to 1/6 of an inch. However, that has nothing to do with the more intriguing medical definition we’ll discuss here: Children with pica (estimated to be about 10-20% of kids at some point) demonstrate a persistent tendency to ingest or mouth non-food items for more than a month, at an age for which it is not considered developmentally appropriate.
What are we talking about here? The items children and adults with pica may consume range from the everyday (ice, fingernails, batting from stuffed animals, pebbles, and chips of wood), to the unusual (erasers, talcum powder, coins, cigarette butts) to off-putting or dangerous menu items (feces, pins, lightbulbs, batteries, and burnt matches).
In some cultures and communities, family members may promote eating non-food items for health, well-being, or enjoyment. For example, in Turkey and Rwanda, geophagia–the practice of eating soil–occurs in huge segments of the population. Dirt can be bought in marketplaces expressly for eating. In parts of the American South, particularly in African American communities, pregnant women may eat laundry starch, or bits of clay to allay the symptoms of morning sickness. Children or parents who consume these items report it works, and pass it on down the generations. But is it ok? More on that in a minute.
Even after documenting this phenomena for centuries, we don’t have a full explanation for pica, and the compulsion to consume non-food items in otherwise healthy individuals. The pre-eminent theory explains pica as a compensation for nutritional deficiencies–such as iron, zinc, or other minerals– in an individual’s or community’s diet. Ironically, the consumption of clay and starch block the body’s absorption of iron, and can create or exacerbate a low iron problem for a woman (not a good thing in pregnancy).
Even in a child who is progressing normally developmentally, pica may be associated with other complex factors. Children with histories of stress, economic hardship, trauma, depression, parental deprivation or frank hunger may consume non food items. Distraction? Boredom? Soothing? Perhaps. In other situations, pica strongly correlates (for reasons unclear) with certain mental disorders, such as schizophrenia, or developmental conditions, such as mental retardation or pervasive developmental delay (PDD ). This can be an important heads up for caretakers, and another challenge in managing these kids as they go through their day.
Pica behaviors in children and families may go on for years, undisclosed but in plain sight or in secret. For some children and families, shame or embarrassment may hinder discussion with their health care provider. Families may not perceive pica as a health issue, or consider the matter worth mentioning. For the primary care doc, if there is a suspicion or mention of pica, this is a matter best approached with awareness, sensitivity, and the right questions.
The medical problems from pica derive from what gets eaten. Kids with damaged or missing teeth from chewing or mouthing unusual materials may arouse suspicion and herald an unrecognized case of pica. Consumed items may exert poisoning effects when swallowed over days or weeks. Lead toxicity is most common, and may be subtle (anemia) or devastating (encephalopathy and brain damage). Pica behaviors around eating paint chips or contaminated soil may be the source, and observations by parents or astute history taking by health care providers may prove critical in helping manage the acute symptoms and preventing recurrences.
Other children and teens with pica may present with GI discomfort caused by items they’ve eaten. Constipation, ulcers, perforations, and bezoars (wads of undigestible items, such as hair, that are unable to pass out of the stomach) may require special imaging, ER visits, or surgical intervention.
The ingestion of soil or fecal matter in some individuals can also cause bacterial or parasitic infections. Toxoplasmosis, toxocariasis, and worm parasites like ascaris can occur, cause havoc, and require prompt treatment and evaluation. And, they are unpleasant.
Treatment of children and teens with pica requires a team effort. When the diagnosis is made, the first priority is to determine the health status of the child in question. Clinicians will perform complete physical and neurological examinations, with laboratory or imaging studies, or specialist consultation done as needed. Medical treatment for pica will be tailored to address any acute problems (infection, GI issues, or toxicity) and longer term, applying a comprehensive and collaborative approach to the family.
Primary care providers, social workers, and mental health experts need to partner with a family to understand their cultural attitudes and health beliefs around pica behaviors to develop trust, communication, and a workabole plan. Ideally, family members learn about the potential risks of pica, and to recognized potential symptoms of ingestion. With time, families can apply individualized strategies to redirect and distract from unhealthy mouthing or munching. In most cases, the prognosis is good: healthy children will often outgrow pica by school age, while children with mental or developmental disorders respond well to intervention, but may relapse into the behaviors into their adolescence, and beyond.
So then, while kids may gnaw on this or nibble on that, be mindful. If you are concerned, be careful. And if necessary, talk to your child’s primary doc.