Pica in Children: Evaluation Learning Tool

Clinical History Assessment

Systematic approach to history taking for a child presenting with pica (persistent eating of non-nutritive substances)

Physical Examination Guide

Systematic approach to examining a child with suspected pica

Diagnostic Approach

Initial Assessment

For a child presenting with pica, the initial assessment should include:

• Detailed history focusing on substances consumed, frequency, and duration
• Complete physical examination to identify complications
• Assessment of developmental and cognitive status
• Screening for nutritional deficiencies and environmental factors
• Evaluation of family and social dynamics

Diagnostic Criteria for Pica

DSM-5 diagnostic criteria for pica:

Criteria	Description	Key Features
Persistent eating	Persistent eating of non-nutritive, non-food substances	Must be inappropriate to developmental level (not normal mouthing behavior in young children)
Duration	Behavior persists for at least 1 month	Establishes chronicity rather than transient behavior
Not culturally supported	The eating behavior is not part of a culturally or socially normative practice	Some cultures practice geophagia or amylophagia which would not qualify as pica
Age consideration	If occurring in the context of another disorder, is severe enough to warrant additional clinical attention	Must be developmentally inappropriate (normal exploration excluded)
Exclusion criteria	Not exclusively during the course of another eating disorder	Not solely a manifestation of anorexia or bulimia nervosa

Differential Diagnosis

Category	Conditions	Distinguishing Features
Developmental	- Normal oral exploration (infants/toddlers) - Autism spectrum disorder - Intellectual disability - Attention deficit hyperactivity disorder	- Age-appropriate vs. persistent behavior - Presence of other developmental symptoms - Cognitive assessment results - Response to behavioral interventions
Nutritional	- Iron deficiency anemia - Zinc deficiency - Calcium deficiency - Malnutrition	- Laboratory evidence of deficiency - Response to supplementation - Associated physical findings - Dietary assessment results
Psychiatric	- Obsessive-compulsive disorder - Schizophrenia - Factitious disorder - Trauma-related disorders	- Presence of other psychiatric symptoms - Thought content/process - Motivations behind behavior - Response to psychiatric interventions
Medical	- Lead poisoning - Parasitic infections - Pregnancy - Celiac disease	- Confirmatory lab testing - Associated physical symptoms - Temporal relationship - Response to medical treatment
Cultural/Social	- Cultural practices (e.g., geophagia) - Family modeling - Neglect/poverty - Food insecurity	- Cultural context assessment - Family history of similar behavior - Social circumstances - Improvement with social interventions

Laboratory Studies

The following studies should be considered based on clinical presentation:

Investigation	Clinical Utility	When to Consider
Complete Blood Count	Assess for anemia, infection	All cases of confirmed pica
Iron Studies (Ferritin, TIBC, Serum Iron)	Evaluate iron status and stores	All cases, especially with clay or soil ingestion
Lead Level	Screen for lead poisoning	Ingestion of paint, soil, or exposure to older housing
Zinc Level	Assess for zinc deficiency	Chronic pica, poor growth, delayed healing
Electrolytes	Evaluate for electrolyte imbalances	History of chalk, soil ingestion or malnutrition
Stool Studies	Check for ova and parasites, occult blood	Soil ingestion, abdominal symptoms present

Advanced Studies

Consider these studies based on specific concerns:

Investigation	Clinical Utility	When to Consider
Abdominal X-ray	Identify radio-opaque foreign bodies, obstruction	Abdominal pain, suspected bezoar, metal ingestion
Heavy Metal Screen	Detect arsenic, mercury, cadmium exposure	Ingestion of substances with potential contamination
Cognitive/Developmental Testing	Assess developmental status, cognitive function	Concerns about developmental delay, intellectual disability
Endoscopy	Evaluate for bezoars, GI damage	Persistent abdominal symptoms, suspected obstruction
Psychiatric Assessment	Evaluate for underlying mental health conditions	Associated behavioral/emotional symptoms, older children

Diagnostic Algorithm

A stepwise approach to diagnosing pica:

1. Confirm diagnosis using DSM-5 criteria (persistent non-nutritive substance ingestion for ≥1 month)
2. Assess developmental appropriateness based on age and cognitive function
3. Conduct complete physical examination to identify complications
4. Screen for nutritional deficiencies (especially iron, zinc)
5. Evaluate for toxic exposures (lead, other heavy metals)
6. Assess for co-occurring conditions (developmental, psychiatric, medical)
7. Perform targeted laboratory testing based on substances consumed and symptoms
8. Screen for psychosocial factors (family dynamics, stressors, modeling)
9. Determine need for advanced studies based on clinical findings
10. Formulate comprehensive diagnosis addressing primary and secondary factors

Management Strategies

General Approach to Management

Key principles in managing pica in children:

• Address underlying causes: Treat nutritional deficiencies, developmental issues, or medical conditions
• Multimodal approach: Combine medical, behavioral, and environmental interventions
• Ensure safety: Reduce access to harmful substances and monitor ingestion behaviors
• Involve caregivers: Educate and engage family in management strategies
• Regular monitoring: Follow progress and adjust interventions as needed

Medical Interventions

Intervention	Description	Evidence Level
Iron Supplementation	- Oral iron supplementation for iron deficiency - Typical dose: 3-6 mg/kg/day elemental iron - Duration based on deficiency severity	High; multiple studies show resolution of pica with iron repletion in deficient patients
Zinc Supplementation	- For confirmed zinc deficiency - Pediatric dose: 1-2 mg/kg/day - Monitor for copper depletion with long-term use	Moderate; case reports and small studies support efficacy
Lead Chelation	- For elevated blood lead levels (typically >45 μg/dL) - Agent selection based on level and symptoms - Environmental remediation essential	High; standard of care for lead poisoning, but effect on pica behavior variable
Micronutrient Supplementation	- Multivitamin with minerals - Specific nutrient repletion based on deficiencies - Attention to calcium, magnesium if indicated	Low to moderate; empiric approach for at-risk populations
Treatment of Parasitic Infections	- Appropriate antiparasitic medication - Address source of infection - Follow-up testing to confirm resolution	Moderate; indicated when infection present, indirect effect on pica

Behavioral Interventions

Intervention	Approach	Evidence and Considerations
Differential Reinforcement	- Reinforce appropriate eating behaviors - Ignore or redirect pica behaviors - Consistent application across settings	- High evidence in developmental disabilities - Requires consistent implementation - Most effective with functional behavioral assessment - Parent training essential
Aversive Consequences	- Overcorrection procedures - Brief response interruption - Time-out from positive reinforcement	- Moderate evidence - Ethical considerations important - Best implemented by trained professionals - Less favored than positive approaches
Discrimination Training	- Teach to discriminate edible from non-edible items - Structured teaching sessions - Generalization across environments	- Moderate evidence - Particularly effective for developmental disabilities - Requires systematic instruction - Can be incorporated into daily routines
Sensory Substitution	- Provide appropriate oral stimulation - Chewable items with similar properties - Address sensory-seeking behaviors	- Low to moderate evidence - Particularly useful for sensory-motivated pica - Safe alternatives must be identified - Occupational therapy consultation helpful
Cognitive-Behavioral Therapy	- Self-monitoring techniques - Cognitive restructuring - Problem-solving skills	- Moderate evidence in older children - Appropriate for normal cognitive functioning - Address underlying anxiety or compulsions - Typically combined with other approaches

Environmental Interventions

Intervention	Considerations	Implementation Strategies
Environmental Safety Measures	- Remove access to dangerous substances - Secure household chemicals and medications - Monitor outdoor play areas	- Home safety assessment - Regular environmental checks - Childproofing high-risk areas - Lead hazard reduction when indicated
Increased Supervision	- Age-appropriate monitoring - Balance safety with independence - Consistent across caregivers	- Structured supervision schedule - Communication plan between caregivers - Gradual fading as behavior improves - Use of visual monitoring as appropriate
Dietary Management	- Regular meal and snack schedule - Balanced nutrition - Address food selectivity	- Nutritional consultation - Food diary monitoring - Attention to texture preferences - Addressing hunger as potential trigger
Environmental Enrichment	- Provide appropriate stimulation - Structured activities - Reduce boredom	- Activity schedule implementation - Sensory-rich environment - Engaging play materials - Physical activity opportunities

Management by Underlying Condition

Underlying Condition	Management Approach	Follow-up Recommendations
Iron Deficiency Anemia	- Iron supplementation - Dietary counseling - Address underlying cause of deficiency	- Recheck hemoglobin/ferritin in 4-6 weeks - Monitor pica behaviors - Continue iron for 3 months after normalization - Consider maintenance supplementation
Developmental Disabilities	- Behavioral intervention package - Environmental modifications - Speech/OT/PT as indicated - Special education services	- Regular developmental assessments - Behavior monitoring - Adjust interventions based on progress - Transition planning as child ages
Obsessive-Compulsive Disorder	- Cognitive-behavioral therapy - Consider SSRI medication - Family therapy - Exposure and response prevention	- Regular psychiatric follow-up - Monitor medication effects - Assess for symptom changes - Adjust therapy intensity as needed
Environmental/Psychosocial Factors	- Family support services - Parenting interventions - Address food insecurity - Social work involvement	- Regular home visits - Connect with community resources - Monitor family functioning - Assess for additional needs

Parent and Caregiver Support

• Education: Information about pica, its causes, risks, and management strategies
• Skills training: Techniques for environmental modification, supervision, and behavioral interventions
• Emotional support: Addressing frustration, guilt, or anxiety related to child's behavior
• Resources: Connecting to support groups, specialty providers, and community services
• Safety planning: Developing plans for high-risk situations and emergency response

When to Refer

• Gastroenterology: Suspected bezoar, GI obstruction, persistent GI symptoms
• Developmental Pediatrics: Co-occurring developmental disorders, complex presentations
• Psychiatry: Associated psychiatric conditions, severe or treatment-resistant pica
• Hematology: Severe iron deficiency, coagulopathy from lead poisoning
• Toxicology: Significant heavy metal exposure, complicated poisoning
• Behavioral Psychology: Design and implementation of behavioral intervention plans
• Neurology: Neurological symptoms, seizures, or movement disorders from toxicity
• Social Services: Concerns about safety, neglect, or inadequate supervision

Long-term Monitoring and Prognosis

• Monitoring frequency: Based on severity, typically every 1-3 months initially
• Duration of follow-up: Until sustained resolution for at least 3-6 months
• Prognostic factors:
  • Better: Nutritional etiology, normal development, good response to intervention
  • Worse: Multiple disabilities, severe developmental disorders, environmental toxin exposure
• Transition planning: For children with persistent pica into adolescence
• Complication surveillance: Regular screening for nutritional status, toxic effects