Learning Objectives
By the end of this section, you will be able to:
- Discuss the etiology of pica
- Identify conditions that are associated with pica
- Summarize the treatment options for pica
- Describe nursing considerations for clients with pica
The eating disorder in which an individual repeatedly and compulsively consumes nonfood items that lack nutritional value is called pica (Stiegler, 2005). Items defined as nonfood are those that lack nutritional value. Common nonfood items consumed by people with pica include paint chips, clay, charcoal, metal, hair, soap, paper, chalk, metal, or small stones (APA, 2023a). Some individuals with pica have cravings for ice. A craving is an intense desire for something.
It is important to note that pica does not include culturally or socially accepted practices. It also is important to note that small children commonly place nonfood items in their mouth and that this is not considered pica. For these reasons, pica is not diagnosed in the presence of accepted social or cultural practices or in children under the age of two.
Etiology of Pica
Though the cause of pica is unknown, there are a few suspected etiologies. Studies have shown associations between pica and factors such as stress, child abuse/neglect, and vitamin/mineral deficiencies (Al Nasser et al., 2023). Iron deficiency anemia is a common proposed etiology; it is thought that the deficiency may modify enzymes in the brain and cause cravings for items such as clay, laundry starch, and ice. In the alternative, eating these items may alter the client’s experience of the deficiency (Advani et al., 2014). Evidence to support these etiologies varies, and more research is needed to explore the cause of pica.
Behavioral Factors Associated with Other Conditions
Behavioral factors have been associated with an increased risk of developing pica. Behavioral factors seen in individuals with autism and intellectual differences that can contribute to developing pica include sensory seeking behaviors, automatic reinforcement, and seeking attention from caregivers (Fields et al., 2021). Maladaptive eating behaviors are also commonly seen in clients with schizophrenia and are also associated with developing pica. Clients with schizophrenia may ingest nonfood items, including feces (Khosravi, 2021).
Acculturated Behaviors
There are relevant cultural factors associated with pica. In some cultures, consumption of nonfood items are socially accepted practices or social norms. For example, in parts of India, mud eating is culturally accepted and cravings for items like ash and dust are said to help predict the gender of an unborn child (Bhatia, 2014). Other examples are certain tribes in Peru who consume clay for health benefits and some cultures in Africa who eat soil during pregnancy and postpartum for health and spiritual benefits (Bhatia, 2014). The most common substances consumed by various cultures are soil and raw starches (Chung et al., 2019). These culturally accepted practices are not considered pica, so it is important to conduct a cultural assessment when evaluating clients who are suspected to have this disorder.
Learned/Reinforced Behaviors
Learned behaviors can play a role in the development of pica. For example, if a child grows up in a home where everyone eats ice or nonfood items, they may continue this learned behavior. Pica may also be a learned or reinforced behavior done in response to a stressor and used as a way to self-soothe (Liu et al., 2021).
Conditions Associated with Pica
Consumption of nonfood items can have sequelae, such as dental damage, toxicity, infection, parasites, or gastrointestinal blockage. Thorough medical and nursing assessment should identify client needs and focus the care. Problematic conditions may arise before determining that pica is the cause.
Nutritional Deficiencies
Pica has been associated with nutritional deficiencies. Deficiencies in minerals such as iron, zinc, and calcium are thought to cause cravings for nonfood items (Chung et al., 2019). The problem with consumption of certain nonfood items is that they can worsen these nutritional deficiencies. For example, consumption of clay and starch can bind to iron in the gastrointestinal tract and worsen iron deficiency anemia (Advani et al., 2014).
Medical/Pregnancy
Pica can develop during pregnancy. Though the prevalence is unknown, it estimated in a metanalysis to occur in approximately 28 percent of persons during pregnancy and the postpartum period (Liu et al., 2021). Pica is a great concern during pregnancy due to the risk that it poses to the fetus. Consumption of nonfood items like clay or paint chips can be toxic to the developing fetus. It can also lead to complications such as lead poisoning, which has been associated with chronic neurological complications and motor function delays in children (Al Nasser et al., 2023).
Iron deficiency anemia is associated with pica and is also seen in pregnant persons. Other people at risk for iron deficiency anemia include premenopausal menstruating persons, and frequent blood donors (Liu et al., 2021). Because these populations have a higher occurrence of iron deficiency anemia, the incidence of pica is also seen more in these groups. Individuals with iron deficiency anemia often consume large amounts of ice, known as pagophagia. Pagophagia is the most common form of pica in the United States and can lead to complications like dental injuries (Liu et al., 2021). It is important to note that pica is only diagnosed in pregnancy if the consumption of the nonfood item poses harm or risk. If there are no medical risks associated with the consumption of the nonfood item, the client may not require clinical care for this behavior (APA, 2023b).
Mental Health
There are several mental health conditions frequently seen with pica. Pica is commonly seen in individuals with intellectual disabilities and mental health disorders, such as schizophrenia, obsessive-compulsive disorder (OCD), and trichotillomania (Al Nasser et al., 2023). It can also be seen in individuals with autism and disorders like excoriation disorder (APA, 2023b). Pica has also been associated with other eating disorders like ARFID. Individuals with ARFID may have sensory sensitivities that can play a role in the development of pica (APA, 2023b).
Treatment of Pica
There are no medications to treat pica. Restoration of deficient minerals and nutrients is considered the first-line treatment for pica if there are deficiencies (NEDA, 2023b). If replacing minerals and nutrients is not effective, other methods like behavioral interventions may be effective. Behavioral interventions have shown promise in clients with mental disabilities and include redirection of compulsive eating of nonfood items to other activities (Al Nasser et al., 2023). It is also important to prevent continued consumption by removing the nonfood items or restricting access.
Behavior Modification
Behavior modification used in treating pica utilizes a technique called differential reinforcement, which is a strategy that redirects an unwanted behavior to more favorable activities (Al Nasser et al., 2023). For example, if a child consistently consumes clay or playdough during activity time, they can be redirected to choose a healthy snack such as baby carrots. Studies conducted on individuals with autism have shown that differential reinforcement is an effective strategy and can include rewarding favorable behaviors (NEDA, 2023b).
Emergency Care
Consumption of nonfood items can cause several medical complications that require emergency care. Complications that can occur include heavy metal toxicity, choking, sepsis, and intestinal blockages or perforation (Fields et al., 2021). Clients who consume items like paint chips are at risk for poisoning from high levels of toxic metals like lead (APA, 2023a). Choking can occur from nonfood items becoming lodged in the throat and causing airway blockages. Sepsis can develop from exposure to toxins in the nonfood items consumed, and intestinal blockages can occur from the buildup of the nonfood items in the gastrointestinal tract; that can also lead to perforation. These medical complications can lead to fatalities if they do not receive prompt medical intervention (Fields et al., 2021).
Nursing Considerations
Nurses are key players in helping manage individuals with pica. These individuals may seek care due to medical complications from ingesting nonfood items or they may seek care for routine examinations such as well-child or prenatal visits. These clients require compassionate, person-centered care to address their health needs. Nurses can help identify vulnerable clients who are at risk, such as pregnant individuals or children who reside in older homes that may contain lead paint, and educate clients on prevention strategies (Al Nasser et al., 2023).
Teaching
Client and family education regarding pica should focus on prevention and behavior modification. Individuals with pica need to learn strategies to limit their exposure to the substance or substances that they crave. This can be facilitated by decreasing access or substituting the nonfood item with a similarly textured item that is more appropriate (Al Nasser et al., 2023). Parents and caregivers play an essential role in managing pica in children. Preventative strategies that have been proven effective include making other caregivers aware of the pica behaviors, keeping a close watch on children, removing access to nonfood items, engaging childproof locks, and finding alternative activities to divert the child’s attention (Fields et al., 2021).
Family Support/Empowerment
Living with individuals with pica can be difficult for families. Because pica is commonly seen in children, parents, caregivers, and other family members are vital to include in the client’s plan of care. Empowering families to take an active role in the plan of care can help promote positive outcomes in individuals with pica.