Check serum lead levels in children who engage in geophagia since dirt may contain lead. Because ingestion of soil or clay is associated with soil-borne parasitic infections, also consider testing for ova and parasites if clinically indicated. Patients who eat paper may be exposed to mercury poisoning, so a serum mercury level is advisable.
Management: Prevention and behavior modification are key
Treatment for pica varies by patient and the specific behavior. Management approaches are primarily preventive, educational, and directed toward behavior modification.
Prevention. Residential facilities and primary care offices that care for people with developmental disabilities may screen for pica by means of prevalence surveys, direct observation, stool checks, review of medical history records, and interviews with caregivers.
Residential facilities can create a pica-safe environment by training staff in pica prevention, instituting regular on-site monitoring to ensure that no dangerous objects are available, and developing procedures to guide staff behavior, such as safe disposal of rubber gloves.22 Parents and caregivers of young children or children with developmental disabilities who don’t live in residential facilities should be aware of pica and monitor what their children are ingesting.
Behavior modification. Behavior-based approaches have proved effective for treating pica in developmentally disabled patients. Applied behavioral analysis “was found to have the most robust empirical support to treat this behavior.”39 Patients found to have pica may be referred for further assessment to a behavior specialist or a psychologist with experience in treating the condition.22,39
A review of 26 studies found that, in 25 studies, behavioral therapy reduced pica behavior by 80% or more.23 Behavioral treatments included reinforcement procedures alone, response reduction procedures alone, and combined reinforcement and response reduction procedures. Reinforcement shapes behavior by controlling the consequences of the behavior using a combination of rewards and punishments.23 Response reduction, or blocking, involves obstructing every attempt to eat inedible items.22
Treatments that combined reinforcement and response reduction showed good efficacy.23 An example of the combined approach would be to stop the patient from eating nonnutritive items while redirecting him to eat food instead.22
Supplementation. Iron supplementation has decreased or even reversed pica in patients whose clinical symptoms and behavior were associated with iron deficiency.35,40
Medications. Successful treatment with selective serotonin reuptake inhibitors (escitalopram), atypical neuroleptics (olanzapine), and attention-deficit/hyperactivity disorder medications (methylphenidate) has been reported in some patients, but case reports are few, and the evidence for the drugs’ efficacy is limited.41-43
Be alert for pica. Primary care physicians need to be aware of pica and proactively seek information about cravings or behaviors suggesting the condition from patients in high-risk populations—pregnant women, children, immigrants and refugees, people with developmental disabilities—or their caregivers. Once pica is identified, clinicians should undertake appropriate laboratory investigation and behavior modification attempts.
CORRESPONDENCE
Ranit Mishori, MD, MHS, Department of Family Medicine, Georgetown University School of Medicine, Pre-Clinical Building, GB-01D, 3900 Reservoir Road, NW, Washington, DC 20007; mishorir@georgetown.edu