Where to refer a patient with pica?

Referral Pathways for Patients with Pica

Patients with pica should be referred to a multidisciplinary team that includes specialists in psychiatry, psychology, and appropriate medical specialists based on the underlying etiology of the pica behavior.

Assessment and Referral Algorithm

Step 1: Determine Underlying Cause

First, identify the most likely etiology of pica, as this determines the primary referral pathway:

• Iron deficiency anemia

  • Check complete blood count, serum iron, ferritin levels 1
  • If confirmed, refer to hematology or internal medicine

• Developmental disorders

  • If associated with autism spectrum disorder (ASD) or intellectual disability
  • Refer to developmental pediatrics or neurodevelopmental specialists 2, 3

• Psychiatric conditions

  • If associated with obsessive-compulsive disorder (OCD) or other psychiatric disorders
  • Refer to psychiatry 4, 5

• Pregnancy-related pica

  • If occurring during pregnancy
  • Refer to obstetrics 4, 6

Step 2: Specialized Referrals Based on Presentation

For ASD/Developmental Disorder-Associated Pica:

Refer to a multidisciplinary team that includes:

• Psychologist
• Developmental pediatrician, neurologist, or pediatric psychiatrist
• Speech/language pathologist 2

This team should conduct comprehensive neurobehavioral evaluation including:

• Global ability assessment with verbal and nonverbal components
• Measures of sustained attention, working memory, and processing speed
• Receptive and expressive language evaluation 2

For Psychiatric Disorder-Associated Pica:

Refer to psychiatry services with expertise in:

• Obsessive-compulsive spectrum disorders
• Behavioral interventions
• Psychopharmacology 4, 5

For Medical Condition-Associated Pica:

• For iron deficiency: Hematology or internal medicine
• For pregnant patients: High-risk obstetrics
• For complications of pica (intestinal obstruction, toxicity): Appropriate surgical or medical specialty 1, 6

Treatment Considerations

Applied Behavior Analysis (ABA)

For patients with developmental disabilities, particularly autism:

• ABA has the most robust empirical support for treating pica 3
• Consider referral to centers specializing in ABA therapy

Medical Management

For patients with nutritional deficiencies:

• Iron supplementation for iron deficiency anemia
• Monitor response and continuation of pica behaviors 1

Psychiatric Interventions

For patients with psychiatric comorbidities:

• Consider serotonin reuptake inhibitors if OCD features are present
• Behavioral therapy approaches 4, 5

Special Considerations

Severity Assessment

Prioritize urgent referrals for patients with:

• History of surgical complications from pica
• Ingestion of potentially toxic substances
• Risk of aspiration or intestinal obstruction 5

Monitoring

Patients with severe pica may require:

• Abdominal imaging to detect ingested foreign bodies
• Regular monitoring for complications
• Institutional management in severe cases 5

Pitfalls to Avoid

• Overlooking pica: The condition is "common but commonly missed" 6
• Focusing only on behavioral aspects: Always rule out medical causes like iron deficiency 1, 6
• Single-discipline approach: Pica typically requires multidisciplinary management 2
• Cultural considerations: Some non-nutritive consumption may be cultural norms and not pathological 4

By following this structured referral approach based on the underlying etiology of pica, clinicians can ensure appropriate specialized care that addresses both the pica behavior and its root causes.