A 2-year-old female came to clinic for her health maintenance examination. Her parents had no concerns except that she seemed to eat dirt more than other children. She would eat dirt and sand outdoors and dust balls and other particulates indoors. The parents reported no problems with abdominal pain or stool changes. She had a good general diet that included red meat, vegetables and dairy products. Her past medical history was non-contributory. The pertinent physical exam showed normal vital signs with growth parameters in the 33-75%. Her examination was negative including normal colored conjunctiva.
The diagnosis of a healthy female was made. Her parents were counseled that pica was normal in this age group but that they should monitor her closely. They also were reminded that items they did not want her to put into her mouth would need to be picked up if dropped inside the house. Her screening laboratory evaluation for possible iron deficiency anemia or lead toxicity were negative.
Oral behaviors are normal activities for infants and older children including exploration of toys and other environmental items by the mouth and thumb sucking. They could also be potentially more problematic such as nail biting, gum chewing or even tobacco smoking/chewing.
Pica is a disorder of ingestion of non-food items that is unusual in the type of item or the quantity. What is defined as food widely varies by region and ethnicity. The term pica is the medieval Latin name for the magpie bird which is known to eat food and non-food items. Many different animal species practice pica including several primate species. Pagophagia is a type of pica where one consumes an excessive amount of ice, snow or iced drinks. Geophagia is the more commonly thought of type of pica where one consumes earth including clay.
People ingest some dirt during the day (i.e. inadvertent exposure) through inhaled dust, dirty hands and contaminated food and water. Young children, especially those under age 4, intentionally eat dirt and other non-food items in larger quantities and more often that older children and adults. It is more common in boys than girls. It is also more common in patients that are disabled. For those disabled patients that are institutionalized it can be a self-injurious behavior that can be disastrous with a death rate of up to 11% in some studies. Geophagia is also more common with economic hardships which results in poverty, hunger and starvation. Geophagia is commonly practiced in famine settings.
Geophagia particularly of clays, is practiced in some ethnic groups to remove toxins, as medicines (ie kaolin clay for diarrhea), during pregnancy (for morning sickness) and as nutritional supplements (i.e. calcium). Some of these clays are often taken from specific areas (termite mounds in Africa which have high calcium and other mineral contents), subsurface (not contaminated by surface water and other soil debris) and some bake the clay before consumption (to reduce the risk of contamination). Some scientists believe soil alsos improve the immune system in a number of ways including as an evolutionary adaption to deal with bacteria in the world.
Some of the common problems associated with pica include gastrointestinal tract obstruction, lead toxicity, iron deficiency anemia, parasites (especially Toxocara canis and ascariasis) and industrial pollutant exposure.
Questions for Further Discussion
1. What potential patients in your practice setting may be at risk for pica?
2. What other minerals are found in subsoils that potentially are important for humans?
3. How would you behaviorally manage a patient with pica where the behavior is causing morbidity?
- Disease: Pica | Eating Disorders
- Symptom/Presentation: Behavior Problems
- Specialty: General Pediatrics | Psychiatry and Psychology
- Age: Toddler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Eating Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Callahan GN. Eating dirt. Emerg Infect Dis. 2003 Aug;9(8):1016-21.
Walker AR, Walker BF, Sookaria FI, Cannan RJ. Pica. J R Soc Health. 1997 Oct;117(5):280-4.
Williams DE, McAdam D. Assessment, behavioral treatment, and prevention of pica: clinical guidelines and recommendations for practitioners. Res Dev Disabil. 2012 Nov-Dec;33(6):2050-7.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital