Eating Large Amounts of Paper: Health Risks and Management
Paper eating (xylophagia) is a form of pica that requires immediate evaluation for iron deficiency anemia and underlying psychiatric conditions, with treatment focused on correcting nutritional deficiencies and behavioral interventions.
Understanding the Condition
Xylophagia represents a specific subtype of pica characterized by compulsive paper ingestion 1. This behavior is not benign—pica can lead to serious, sometimes life-threatening complications requiring surgical intervention 2. The condition affects individuals across all demographics without barriers of age, race, sex, or geographic region 3.
Immediate Medical Evaluation
Essential Laboratory Testing
- Screen for iron deficiency anemia using complete blood count, ferritin, and C-reactive protein, as iron deficiency is the most common reversible cause of pica 4, 5
- Evaluate for zinc deficiency, which has been associated with pica behaviors 5
- Assess nutritional status comprehensively, as depression and pica are associated with vitamin D, folate, and zinc deficiencies 4
Clinical Assessment Priorities
- Obtain focused history regarding the duration, frequency, and quantity of paper consumption 4
- Examine for abdominal complications including pain, distension, or signs of obstruction that may necessitate surgery 5
- Assess for developmental delays, intellectual disability, or autism, as pica occurs most commonly in these populations 2, 6
- Screen for other psychiatric comorbidities including severe mental impairment, autistic disorders, and schizophrenia, which are present in the majority of pica patients 6
Common Pitfalls to Avoid
Do not dismiss pica as benign—it is common in sickle cell disease and other conditions, but is not related to iron status in those contexts and will not improve with iron supplementation alone 4. However, in the general population, iron deficiency remains the primary treatable cause 5, 1.
Treatment Approach
First-Line: Address Nutritional Deficiencies
- Iron replacement therapy is the primary treatment when iron deficiency is documented, as xylophagia typically resolves after correcting the underlying deficiency 1
- Provide iron-enriched foods (cereals, meats) and consider multivitamin supplementation 4
- Monitor response to treatment, as pica secondary to iron deficiency is relatively common and remits after appropriate iron therapy 5
Behavioral Interventions
Applied behavior analysis (ABA) has the most robust empirical support for treating pica 2. Current clinical practice favors positive behavioral procedures over aversive techniques 2.
- Implement behavioral management strategies including reinforcement-based approaches rather than punishment 2
- Consider cognitive-behavioral therapy, as pica may represent an acquired behavior amenable to these interventions 6
- Evaluate for obsessive-compulsive features, as the compulsive nature of pica may benefit from treatments targeting obsessive-compulsive disorders, including serotonin reuptake inhibitors 6
Screen for Disordered Eating
- Use validated screening measures when evaluating unexplained behaviors, as pica can coexist with other eating disorders 4
- Assess whether the behavior represents true pica versus disrupted eating patterns related to physiologic disturbances 4
- Consider consultation with professionals trained in eating disorders and developmental disabilities 4
Monitoring for Complications
Gastrointestinal Risks
- Maintain high suspicion for intestinal obstruction or perforation, particularly with large volume consumption 5
- Consider abdominal radiography if there is history of excessive consumption or abdominal symptoms 4
- Be aware that surgical complications, particularly gastrointestinal, occur with high incidence in pica patients 6
Additional Complications
- Monitor for dental injury from paper consumption 5
- Screen for lead poisoning if paper sources include painted materials or newsprint 5
- Assess for respiratory complications from aspiration, especially in patients with concurrent gluttony or rapid consumption patterns 6
Long-Term Management
- Provide ongoing monitoring even after initial treatment, as pica often requires sustained intervention 2
- Address underlying psychiatric conditions with appropriate pharmacotherapy when indicated, though neuroleptic therapy typically provides only transient improvement 6
- Implement institutional support including compassionate care and restoration of self-confidence for patients with developmental disabilities 6
- Recognize that family involvement is crucial, particularly in pediatric cases, as parents must actively participate in treatment programs 4