What is the treatment approach for pediatric patients with pica?

Treatment Approach for Pediatric Patients with Pica

The treatment of pediatric pica should focus on identifying and treating underlying iron deficiency, providing behavioral interventions, ensuring proper supervision, and addressing any potential complications. 1, 2

Assessment and Diagnosis

• Pica is defined as the persistent, compulsive craving for and ingestion of substances usually considered inedible for at least one month that is developmentally inappropriate 2
• Common substances ingested include clay, earth, paper, paint, raw rice, and ice cubes 2, 3
• Pica is more common in children from lower socioeconomic backgrounds, those with developmental disabilities, and those who are emotionally deprived 2
• Assess for risk factors including iron deficiency anemia, which has a strong association with pica 4, 2, 3

Treatment Algorithm

Step 1: Screen for and Treat Iron Deficiency

• Perform laboratory testing including complete blood count, serum ferritin, iron levels, and transferrin saturation 3
• If iron deficiency is identified, initiate iron replacement therapy, which often leads to resolution of pica behaviors within weeks 4, 3
• Note that pica is common in children with sickle cell disease but is not related to iron status in these patients; avoid iron supplementation unless biochemically proven deficient 1

Step 2: Behavioral Interventions

• For children with normal intelligence, provide training to discriminate between edible and inedible items 2
• For children with developmental disabilities or autism spectrum disorder, applied behavior analysis (ABA) has the most robust empirical support 5
• Behavioral techniques include:
  • Positive reinforcement for appropriate eating behaviors 5
  • Structured supervision during meals and play 2
  • Redirection when attempting to ingest non-food items 5

Step 3: Environmental Modifications

• Ensure proper supervision to prevent access to potentially harmful substances 2
• Remove dangerous items from the child's environment 2
• For children with lead exposure risk, follow CDC guidelines for lead screening and management 1
  • If blood lead levels are 5-14 μg/dL, provide nutritional counseling related to calcium and iron 1
  • If blood lead levels are 15-44 μg/dL, consider abdominal radiography for children with history of pica for paint chips 1

Step 4: Address Underlying Conditions

• Evaluate for developmental disorders, including autism spectrum disorder 6
• Assess for emotional deprivation or psychological stressors 2
• Consider referral to child psychiatrist if pica persists despite correction of nutritional deficiencies 4

Special Considerations

• In children with sickle cell disease, pica is common but not related to iron status; avoid iron supplementation unless biochemically proven deficient 1
• For adolescents, pica may be masked and should be specifically asked about when presenting with signs of iron deficiency 3
• Cultural factors should be considered, as some variants of non-nutritive consumption are prevalent behavioral norms in non-western cultures 6

Monitoring and Follow-up

• Monitor resolution of pica behaviors after iron therapy initiation 4, 3
• Screen for complications such as gastrointestinal obstruction and lead poisoning 2
• Follow up on developmental progress and nutritional status 1
• Continue behavioral interventions until pica behaviors have resolved 5

Prognosis

• Pica generally resolves in children of normal intelligence after appropriate training and supervision 2
• In cases associated with iron deficiency, pica typically disappears within weeks of starting iron therapy, although biochemical evidence of iron deficiency may persist 3
• Some cases may be resistant to treatment, particularly those associated with autism spectrum disorders or when underlying causes are not addressed 6, 5