What is the treatment approach for pica in pediatric patients?

Treatment of Pica in Pediatric Patients

The treatment of pediatric pica should focus on screening for and treating iron deficiency anemia, implementing behavioral interventions, and addressing any underlying conditions, while ensuring appropriate supervision to prevent complications.

Assessment and Diagnosis

• Pica is defined as the persistent, compulsive craving and ingestion of non-nutritive substances for at least one month at an age where this behavior is developmentally inappropriate 1

• Common substances ingested include:

  • Clay and earth
  • Raw rice
  • Ice cubes (pagophagia)
  • Paint chips
  • Paper
  • Cloth
  • Hair

• Assess for risk factors:

  • Lower socioeconomic status
  • Mental/developmental disabilities
  • Emotional deprivation
  • Iron deficiency anemia

Treatment Algorithm

Step 1: Screen for and Treat Iron Deficiency

• Perform complete blood count, serum iron, ferritin, transferrin saturation, and iron-binding capacity 2
• Treat identified iron deficiency with appropriate iron replacement therapy
• Note: Pica often disappears within weeks after iron repletion, though biochemical evidence of deficiency may persist 2

Step 2: Screen for Lead Exposure and Toxicity

• Perform blood lead level testing, especially if:

  • Child has ingested paint chips
  • Home was built before 1960
  • Child has risk factors for lead exposure 3

• Management based on blood lead levels:

  • <5 μg/dL: Routine assessment of nutrition and development
  • 5-14 μg/dL: Retest within 1-3 months, provide nutritional counseling for calcium and iron, screen for iron deficiency
  • 15-44 μg/dL: Confirm with repeat test within 1-4 weeks, consider abdominal radiography for children with history of pica for paint chips

  • 44 μg/dL: Confirm within 48 hours, consider hospitalization or chelation therapy 3

Step 3: Implement Behavioral Interventions

• For children with normal intelligence:

  • Train to discriminate between edible and inedible items
  • Provide proper supervision
  • Implement positive reinforcement for appropriate eating behaviors
  • Redirect to safe alternatives when pica urges occur 1

• For children with developmental disabilities:

  • Applied Behavioral Analysis (ABA) therapy is recommended, particularly for children with autism spectrum disorders 4
  • Structured behavioral modification programs with consistent reinforcement

Step 4: Address Underlying Conditions

• Evaluate for and treat any associated conditions:

  • Developmental disorders
  • Autism spectrum disorder
  • Intellectual disability
  • Emotional or psychological stressors 5

• Consider psychiatric evaluation if:

  • Pica persists despite correction of nutritional deficiencies
  • There are signs of obsessive-compulsive behaviors
  • Auto- or hetero-aggressive behaviors are present 6

Step 5: Monitor for Complications

• Gastrointestinal:

  • Perform abdominal radiography if ingestion of foreign bodies is suspected
  • Monitor for signs of intestinal obstruction or perforation

• Infectious:

  • Screen for parasitic infections, especially with geophagia

• Nutritional:

  • Monitor iron status periodically
  • Assess for other micronutrient deficiencies

Special Considerations

• Pica in sickle cell disease: Common and not related to iron status; requires close monitoring and behavioral interventions 3

• Cultural context: Some non-nutritive consumption may be culturally normative and should not always be pathologized 4

• Pharmacological interventions have limited evidence in pediatric pica management 5

Prognosis

• Pica often self-remits in younger children with normal intelligence once proper supervision and training are provided 1

• In children with developmental disabilities, pica may persist into adulthood and require ongoing behavioral interventions 5

• The prognosis is generally good when iron deficiency is identified and treated promptly, though some cases may persist despite correction of deficiencies 2