A patient recently presented to our ED with abdominal pain and a history of pica. What should nurses know about this eating disorder?

Dita Adhikari, BSN, RN; Hyun-Anh Oh, BSN, RN; and Bridget Parsh, EdD, RN, CNS, CPN respond-Pica, an eating disorder, involves the intentional and persistent developmentally inappropriate eating of nonnutritive, nonfood substances for at least 1 month, unrelated to cultural or social practice.1 Examples of items consumed include gauze, hair, pebbles, paper, soap, shampoo, paper clips, screws, paste, laundry starch, chalk, ice, and dirt.1-4

When associated with another mental health disorder, such as schizophrenia or autism spectrum disorder, or a medical condition, including pregnancy, it is sufficiently severe to warrant independent clinical evaluation.1,2,4

The exact prevalence of pica is unknown as the behavior is often underreported and underdiagnosed.5 Risk factors for pica include stress, low socioeconomic status, nutritional deficiency, child neglect, pregnancy, and familial psychopathology.1,2,5,6

Clinical manifestations

Pica is clinically identified only after the patient presents with complications, such as mechanical bowel obstruction or intestinal perforation, manifestations of toxic ingestion, such as lead poisoning, or manifestations of infection or parasitic infestation, such as toxoplasmosis from soil or clay ingestion, and poisoning.1,2

The clinical presentation of patients with pica is highly variable and is associated with the specific nature of the resulting medical conditions and the ingested substances. However, the two most common clinical manifestations of pica are gastrointestinal (GI) distress and micronutrient deficiency.7 Additional GI signs and symptoms can include nausea, vomiting, anorexia weight loss, and abdominal pain or distension.1

Iron deficiency anemia can be both the cause and the result of pica. For example, iron deficiency may have prompted eating clay, or clay ingestion may have prevented iron absorption. Repeatedly ingesting nonfood, nonnutritive substances is of serious concern during pregnancy.1,2,7 Several case reports of maternal geophagy, or clay ingestion, have been associated with fetal toxicity and motor function delay.5

The consumption of paint or chalk puts children at risk for complications of lead poisoning, such as lethargy, seizures, encephalopathy, cranial nerve palsies, and papilledema.5

Treatment

Treatment of patients with pica can involve physiologic and psychologic interventions to address the eating disorder and treat complications secondary to the behavior.

The first-line treatment for pica involves correcting physiologic imbalances such as micronutrients and dietary deficiencies.2,3 If pica persists, treatment is tailored to behavioral interventions, including environmental enrichment (EE), noncontingent reinforcement (NCR), and differential reinforcement of alternative behavior (DRA) in combination with other procedures, such as overcorrection.8

The behavioral intervention of EE involves preventing the behavior by changing the environment, such as by rearranging daily routines or avoiding having pica items available.9 The treatment of NCR involves continuous verbal and physical attention.10 DRA, commonly used in patients with underlying behavioral health disorders, involves redirecting the person's attention away from the desired object and rewarding them for discarding or setting down the nonfood item.2,8

In overcorrection, the individual partaking in pica behaviors is forced to make an effortful correction for the behavior and substitute it with acceptable behavior. One of the most effective yet tentatively used interventions, overcorrection requires individuals to spit out a nonedible item, perform oral care, then engage in a positive practice.8 It can be physically demanding on the patient or an unavailable form of treatment due to varying state guidelines regarding aversive procedures.8 As of this writing, there is no gold standard for treating patients with pica.

Nursing interventions

The nursing assessment should include consideration of GI complications, poisoning, infection, nutritional deficiency, and cognitive deficiencies.1,11

During inpatient admission, specific nursing interventions include placing the patient under constant observation, removing potentially ingestible objects from the room, administering prescribed psychotropic medications when indicated, and utilizing individualized care plans to prevent reinforcement of the pica behavior.3

An interprofessional team of physicians, psychiatrists, advanced practice clinicians, nurses, behavioral therapists, social workers, and dietitians must work together to educate the patient on healthy eating habits.5 Children and pregnant women should be screened for lead paint or infectious agent exposure.5,6 Screening for risks, limiting exposures, and educating patients and caregivers are ways to not only address the possible complications due to pica but also to prevent the behavior.5,12

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