What is the treatment approach for a patient with pica?

Treatment Approach for Pica

The treatment of pica should focus on identifying and addressing underlying causes, with iron supplementation as first-line therapy for suspected iron deficiency, behavioral interventions for persistent cases, and appropriate nutritional counseling.

Assessment and Diagnosis

• Pica is defined as the persistent ingestion of non-nutritive substances for more than 1 month at an age where this behavior is developmentally inappropriate 1
• Common substances ingested include paper, paint, soil, clay, and various non-food items 2, 3
• Assessment should include:
  • Evaluation for nutritional deficiencies, particularly iron deficiency anemia 3, 1
  • Screening for underlying psychiatric disorders (schizophrenia, obsessive-compulsive disorder, autism spectrum disorders) 4, 3
  • Assessment for developmental disabilities 2
  • Abdominal radiography for children with history of pica for paint chips or excessive mouthing behaviors 5

Treatment Algorithm

Step 1: Address Medical Complications and Urgent Issues

• For blood lead levels ≥15–44 μg/dL (150–440 ppb), confirm with repeat venous sample within 1-4 weeks 5
• For blood lead levels >44 μg/dL (>440 ppb), confirm with repeat venous level within 48 hours and consider hospitalization or chelation therapy 5
• Perform gut decontamination if leaded foreign bodies are visualized on radiography 5
• Consult with Poison Control Center or pediatric environmental health specialty unit for guidance 5

Step 2: Treat Underlying Nutritional Deficiencies

• Screen for iron deficiency with appropriate laboratory testing (complete blood count, ferritin, C-reactive protein) 5
• Provide iron supplementation if deficiency is detected 5
• Encourage consumption of iron-enriched foods (cereals, meats) 5
• Consider starting a multivitamin with iron 5
• Provide nutritional counseling related to calcium and other nutrients 5

Step 3: Implement Behavioral Interventions

• Applied Behavior Analysis (ABA) has the most robust empirical support for treating pica, particularly in patients with autism and intellectual disabilities 2
• Focus on positive behavioral procedures rather than aversive techniques 2
• Consider cognitive and behavioral therapies for patients with acquired behaviors 6
• Implement structured environmental modifications to limit access to non-food items 2, 1

Step 4: Address Psychiatric Comorbidities

• For pica associated with psychosis or schizophrenia, antipsychotic medications may be beneficial 4
• In the case study reported, paliperidone intramuscular injection and oral olanzapine led to improvement in psychosis and resolution of pica 4
• For pica with obsessive-compulsive features, consider serotonin reuptake inhibitors 6
• Limited evidence exists for pharmacological interventions specifically for pica in children 1

Special Considerations

• Pica in patients with developmental disabilities often requires long-term management strategies 2, 3
• A multidisciplinary approach involving physicians, psychiatrists, psychologists, and nutritionists yields the best outcomes 6, 1
• Cultural factors should be considered, as some variants of non-nutritive consumption are behavioral norms in certain cultures 3
• For patients with learning disabilities, pica may persist into adulthood and require ongoing intervention 1

Monitoring and Follow-up

• Retest venous blood lead concentration within 1–3 months for patients with elevated levels to verify that lead concentration is not rising 5
• Perform structured developmental screening evaluations at child health maintenance visits, as lead's effect on development may manifest over years 5
• Monitor for complications, particularly gastrointestinal, respiratory, and infectious complications 6
• Regularly reassess the effectiveness of behavioral interventions 2

Common Pitfalls to Avoid

• Failing to screen for iron deficiency, which is strongly associated with pica 3
• Overlooking psychiatric comorbidities that may be driving pica behavior 4, 6
• Relying solely on pharmacological interventions without implementing behavioral strategies 2, 1
• Not considering potential life-threatening complications from ingestion of harmful substances 6, 1
• Neglecting to involve a multidisciplinary team in complex cases 6