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19

Bubble Eater

PICA


Childhood is a precious thing. As children, we learn through play, through interacting with our environment and those within it. Nature itself, provides us with the most wondrous array of tastes and textures, a symphony of sounds and a smorgasbord of vibrant visuals. Naturally, as young children, we seek to explore the world as presented to us, through taste and touch, from babyhood forth. Innocent exploration of our surroundings invites discovery and feeds our imagination. Some of us may have lived close to or in a rainforest environment. For others, the ocean was our playground. For some, frozen winters and arctic conditions provided just as magnificent an array of experiences and discovery of taste and texture as any.


However, for some, tasting a slither of mudpie or partaking in a sand-wich, or an icy snow-cone, can be taken just a mite too far, entering the realms of what becomes for some, a serious disorder. The article(“Fluff and Stuff”) contained herein clearly illustrates the enormous impact upon a family , Pica can have. According to statistics, around 25% to 30% of children(and 20% of those seen in mental health clinics) have the eating disorder. The word itself is derived from the latin word for magpie, a bird known for its large and indiscriminate appetite. Pica is characterized by persistent and compulsive cravings (lasting one month or longer) and involves the eating of nonfood items. Research indicates that it is most common in people with developmental disabilities , including autism and ID, that it may surface in children or adults who’ve had a brain injury, and that it can also be a problem for some pregnant women, as well as people with epilepsy. It is said to occur in an equal number of boys and girls.

eating soil

Pica behaviour is also known to occur ritualistically in some cultures. Geophagia(clay ingestion) is the most common form of pica, occurring in tribe-oriented societies as well as in people living in the tropics. It was a common act in the 1800s in the southern United States, primarily among slaves. Geophagia(soil or clay ingestion) has been associated with soil-borne parasitic infections, such as toxoplasmosis and taxocariasis. Gastrointestinal (GI) tract complications, including mechanical bowel problems, constipation, ulcerations, perforations, and intestinal obstructions, have resulted from Pica. Pica has been practiced as part of religious ceremonies, magical beliefs, and attempts at healing. It occurs the world over. Pica is a widespread practice in western Kenya, southern Africa, and India. Pica has been reported in Australia, Canada, Israel, Iran, Uganda, Wales, Turkey, and Jamaica. In some countries, Uganda for example, soil is available for purchase for the purpose of ingestion. An article by Cynthia R Ellis states that Pica is reportedly problematic in 70% of the provinces in Turkey.


Let’s take a look at some of the non-food items being consumed:

  • dirt

  • clay

  • rust

  • paint chips

  • plaster

  • chalk

  • cornstarch

  • laundry starch

  • baking soda

  • coffee grounds

  • cigarette ashes

  • burnt match heads

  • cigarette butts

  • broken crockery

  • oyster shells

  • coins

  • faeces

  • ice

  • glue

  • hair

  • buttons

  • paper

  • sand

  • toothpaste

  • soap

  • shampoo
coins

Although consumption of some items may be harmless, pica is considered a serious eating disorder that can sometimes result in serious health problems such as lead poisoning and iron-deficiency anemia. There was an article in The Guardian way back in October, 2006 entitled “There’s nothing he wouldn’t eat” in regard a 61 year-old man from south Wales. And so it proceeds…”A recent inquest found that a man had died swallowing a screw, a pen top, some coins and a magnet. Emine Saner reports on pica syndrome – a rare but deadly condition.” To read on: http://lifeandhealth.guardian.co.uk/wellbeing/story/0,,1930043,00.html

In another case, in 2002, a French man went to hospital complaining of stomach pains. An x-ray showed he had swallowed 5kg of coins, necklaces and needles; his stomach was so heavy, it had been forced down between his hips. He subsequently died after an operation to remove the objects.


The following information comes courtesy of Kidshealth and was reviewed by Mary L. Gavin, MD in December, 2007.


So what are the signs and why does it occur?

You or your child may have Pica if you note:

repetitive consumption of nonfood items, despite efforts to restrict it, for a period of at least 1 month or longer

the behaviour is considered inappropriate for your child’s age or developmental stage (older than 18-24 months)

the behaviour is not part of a cultural, ethnic, or religious practice


The specific causes of Pica are unknown, but certain conditions and situations may increase likelihood:


nutritional deficiencies, such as iron or zinc, that may trigger specific cravings(however, the nonfood items craved usually don’t supply the minerals lacking in the person’s body)

  • dieting — people who diet may attempt to ease hunger by eating nonfood substances to get a feeling of fullness

  • malnutrition, especially in underdeveloped countries, where people with pica most commonly eat soil or clay

  • cultural factors — in families, religions, or groups in which eating nonfood substances is a learned practice

  • parental neglect, lack of supervision, or food deprivation — often seen in children living in poverty

  • developmental problems, such as intellectual deficit, autism, other developmental disabilities, or brain abnormalities

  • mental health conditions, such as obsessive-compulsive disorder (OCD) and schizophrenia

  • pregnancy, but it’s been suggested that pica during pregnancy occurs more frequently in women who exhibited similar practices during their childhood or before pregnancy or who have a history of pica in their family


Is a Doctor necessary?

If your child has consumed a harmful substance, seek medical care immediately. If you think your child has ingested something poisonous, call Poison Control at (800) 222-1222.

A child who continues to consume nonfood items may be at risk for serious health problems, including:

  • lead poisoning (from eating paint chips in older buildings with lead-based paint)

  • bowel problems (from consuming indigestible substances like hair, cloth, etc.)

  • intestinal obstruction or perforation (from eating objects that could get lodged in the intestines)

  • dental injury (from eating hard substances that could harm the teeth)

  • parasitic infections (from eating dirt or feces)

Medical emergencies and death can occur if the craved substance is toxic or contaminated with lead or mercury, or if the item forms an indigestible mass blocking the intestines. Pica involving lead-containing substances during pregnancy may be associated with an increase in both maternal and fetal lead levels.

What Will the Doctor Do?

Your doctor will play an important role in helping you manage and prevent pica-related behaviors. He or she will educate you on teaching your child about acceptable and unacceptable food substances. The doctor will also work with you ways to restrict the nonfood items your child craves (i.e., using child-safety locks and high shelving, and keeping household chemicals and medications out of reach). Some kids require behavioral intervention and families may need to work with a psychologist or other mental health professional.

Depending on a child’s age and developmental stage, doctors will work with kids to teach them ways to eat more appropriately. Medication may also be prescribed if pica is associated with significant behavioral problems not responding to behavioral treatments.

Your doctor may check for anemia or other nutritional deficiencies, if indicated. A child who has ingested a potentially harmful substance, such as lead, will be screened for lead and other toxic substances and might undergo stool testing for parasites. In some cases, X-rays or other imaging may be helpful to identify what was eaten or to look for bowel problems, such as an obstruction.

Fortunately, pica is usually a temporary condition that improves as kids get older or following pregnancy. But for individuals with developmental or mental health issues, pica can be a more prolonged concern.

Following treatment, if your child’s pica behavior continues beyond several weeks despite attempts to intervene, contact your doctor again for additional treatment. Remember that patience is key in treating pica because it can take time for some kids to stop wanting to eat nonfood items.

mud pie

The following article is provided courtesy of the NAS Communication magazine (Volume 40 Number 4 Winter 2006)

FLUFF AND STUFF

Vicky and Jonathon Foreman’s son Thomas has an overwhelming desire to eat fluff, along with soft furnishings, carpets, hair, soil, sand, grit, and much more. This consuming of non-food items is also known as ‘pica’. With the help of psychologist Emily Janes – and the odd glass of wine – the family has been finding ways to help Thomas satisfy his craving for sensory stimulation safely.

Our son Thomas is five years old. He has the face of an angel, topped with a mass of unruly blond hair. He is also severely autistic, has no language and suffers from severe sensory difficulties, particularly seeking oral stimulation.

He has an overwhelming desire to eat fluff. The list of things he will bite, pull and pluck is endless: almost any soft furnishing, carpets, his own hair, foam stuffing and the loose hairs he finds tangled up in hair or sweeping brushes. It includes fluff from other people’s jumpers (especially embarrassing if the person wearing that beautiful woolly jumper is a complete stranger who just happens to sit in front of him on the bus), soft toys – much to the sadness of his long-suffering sister, Ella – and cotton wool from Christmas displays; his class was the only one with a doily Santa instead of a cotton wool one. If he finds himself in a fluff-free environment, he has been known to eat the fluff balls that have collected on socks. Unfortunately, the person is usually still wearing them at the time.

Thomas also loves to eat gritty things. To satisfy this urge, he will eat soil, dust, sand, soot, rubber play park flooring and glitter, producing festive faeces at Christmas time. He will lick stones, sticks, logs, slides, swings, the soles of his shoes, pram wheels, and cars. Trips to the beach can be particularly tricky. Thomas spends his time scooping up handfuls of sand to eat, washed down with seawater, as we dash after him, brushing his hands down and vainly trying to distract him with tickles.

Thomas’ favourite pastime, however, has to be smearing. He likes to smear spit all over his hands, mouth, TV, books and windows, leaving a very wet and messy trail of devastation behind him. One particularly embarrassing incident involved him enjoying a soft play session. He began to spit into his hands and then, as his excitement levels rose, he started to flap. As we spotted a ball of spit fly out of his hands and disappear across the crowded room, we quickly left without waiting to find out who or what it landed on.

Occasionally, we get invited around to our very understanding friends and families’ homes. Thomas then embarks on a series of raids: to munch his way through their carpets and cushions, to ferret up chimneys for soot, to sneak into bedrooms for woolly, fleecy things to eat and to smear spit all over their TV and windows. We and our hosts spend what should be a lovely evening rearranging rooms and erecting temporary barriers in a vain effort to thwart a very determined and, in most cases, successful Thomas. Thank goodness for alcohol!” Vicky Foreman

As well as resorting to alcohol to get through the week, Vicky’s family has had ‘brilliant’ support from assistant psychologist Emily Janes. She has been involved with the family for over a year and comes round weekly to help tackle Thomas.

I will never forget the first time I was introduced to Thomas. As I entered the room, Thomas began flapping his arms and jumping up and down excitedly. He edged over to me and began patting my arms. I thought ‘Wow! What a friendly, sociable little boy.’ That is, until I realised he was in fact jumping up and down in glee at the lovely green fluffy poncho I was wearing and how best to eat me! That was the last time I wore anything fluffy on a Tuesday.

I have been working with Thomas and his family for the past year. Thomas was initially referred to our service, Community Team Learning Disability, for support and help regarding his fluff-eating. However, as is often the way with autism, fluff-eating was just the starting point. Thomas’ taste palate was becoming more sophistocated but, where you and I may broaden our tastes to enjoy olives, strong cheeses and coffee, his food list was expanding to include soil, sand and grit. Thomas’ pica had slowly begun to take over his day-to-day life, impacting hugely on his family.

The first approach we took was to try to find out what it was exactly that Thomas was getting from eating these items. We did some observations in our sessions and Vicky kept a record during the week, looking at what sorts of materials Thomas was seeking out, how he touched them and how he handled them in his mouth. This information told us that Thomas was not simply consuming these materials because of the taste: instead, he was obtaining sensory stimulation from the handling of the items – both oral and tactile. Therefore, if we were to stop Thomas from eating these substances completely, we would remove the danger of his ingestion of these items, but his need for this stimulation would still be there.

We began to look for alternatives to grit, sand, fluff and so on. We tried everything we could think of: lentils, liquorice, dried fruits, seeds, flour, icing sugar, gritty crackers: the list was endless. Eventually, we found a few alternatives with which Thomas seemed satisfied: seeds (similar to grit); flour (similar to soil); crusty bread (similar to fluff); and, strangely, mashed potato flakes (similarity unknown)! At controlled times of the day, Thomas was given these more appropriate items and happily played around with them. This did not stop his cravings for non-food items completely, but we found that it gave him some sort of ‘sensory fix’ that enabled him to attend to other activities for a short time.

We worked closely with Thomas’ school and passed on our findings to them. They began to incorporate controlled sensory sessions into their school day and found that Thomas was better able to concentrate on activities immediately following his ‘fix’. Thomas was also granted extra provision at school during holidays and this added stability in his routine, along with the sensory input, is helping him to slowly overcome his ‘addiction’ to non-food items, aiding his development in other areas, such as cognitive and social development.

Since then, we have looked at other areas in which Thomas is ‘sensory seeking’ and come up with lots of more appropriate alternatives. For example, the family recently bought a large exercise ball and Thomas spends his days jumping up and down on it, gaining proprioceptive (body awareness), tactile and vestibular (balance) stimulation, which acts to calm him down and enables him to simultaneously attend to other tasks.

Tackling Thomas has been a difficult journey, both for the family and other professionals involved. By discovering the route to Thomas’ behaviour, we were able to better understand his world, his wants and needs. Looking to the future, we hope this will help Thomas to remain the happy and special little boy his is. Emily Janes

pica on a plate

For further reading…

NAS Information Sheet “The sensory world of the autistic spectrum”:

http://www.nas.org.uk/nas/jsp/polopoly.jsp?d=299&a=3766

Articles, Recommended Reading and References:

Eating Disorder: Pica” Author: Cynthia R Ellis, MD

http://www.emedicine.com/ped/topic1798.htm

Cooper M. Pica. Springfield, Ill.: Charles C Thomas, 1957.

Crosby WH. Pica: a compulsion caused by iron deficiency. Br J Hematol. 1976; 34: 341–42. [PubMed]

Johnson BE, Stephens RL. Geomelophagia. An unusual pica in iron-deficiency anemia. Am J Med. 1982; 73: 931–32. [PubMed]

Lackey CJ. Pica during pregnancy. Bol Assoc Med Puerto Rico. 1984; 76: 405–7.

Reynolds RD, Binder HJ, Miller MB. et al. Pagophagia and iron deficiency anemia. Ann Intern Med. 1968; 69: 435–40. [PubMed]

Roselle HA. Association of laundry starch and clay ingestion with anemia in New York City. Arch Intern Med. 1970; 125: 57–61. [PubMed]

Vermeer DE, Frate DA. Geophagia in rural Mississippi: environmental and cultural contexts and nutritional implications. Am J Clin Nutr. 1979; 32: 2129–35. [PubMed]

VonBonsdorff B. Pica—a hypothesis. Br J Hematol. 1977; 35: 476–77.

Kirschner, Jeffrey. “Management of Pica: A Medical Enigma.” American Family Physician 63, no. 6 (March 15, 2001): 1169.

BOOKS

Heird, William C. “Food Insecurity, Hunger and Undernutrition.” In Nelson Textbook of Pediatrics. 17th ed. Ed. by Richard E. Behrman, et al., Philadelphia: Saunders, 2003, 167-172.

Matthews, Dawn D. Eating Disorders SourceBook Detroit, MI: Omnigraphics, Incorporated, 2001.

Walsh, B. Timothy. “Eating Disorders.” In Harrison’s Principles of Internal Medicine. 15th ed. Ed. by Eugene Braunwald et al., New York, McGraw Hill, 2001, 486-90.

West, Delia S. “Eating Disorders.” In Cecil Textbook of Medicine. 22nd ed. Ed. by Lee Goldman, et al. Philadelphia: Saunders, 2003, 1336–8.

PERIODICALS

Dreyer MJ, Chaushev PG, and Gledhill RF. “Biochemical investigations in geophagia.” Journal of the Royal Society of Medicine 97, no. 1 (2004): 48-53.

Kuhn DE and Matson JL. “Assessment of feeding and mealtime behavior problems in persons with mental retardation.” Behavior Modification 28, no. 5 (2004): 638–48.

Lavoie PM and Bailey B. “Lead poisoning from “lead-free” paint.” Canadian Medical Association Journal 170, no. 6 (2004): 956–8.

Moya J, Bearer CF, and Etzel RA. “Children’s behavior and physiology and how it affects exposure to environmental contaminants.” Pediatrics 113, no. 4 Supplement (2004): 996–1006.

ORGANIZATIONS

National Eating Disorders Organization (NEDO). 6655 South Yale Ave, Tulsa, OK 74136. (918) 481-4044. Hotline: (800) 931.2237. Web site: http://.

OTHER

“Children and Eating Disorders.” Vanderbilt University. Available online at http://.

“Eating Disorder: Pica.” eMedicine. Available online at http://.

“Eating Disorders.” Encyclopedia.Com. Available online at http://.

“Pica.” Web MD Health. Available online at .

  1. Fleming Fallon, Jr., MD, DrPH

Pica on Wikipedia:

http://en.wikipedia.org/wiki/Pica_(disorder)

In popular culture

eating kashiwa-mochi