“My child does not eat” moaned the mother, “she refuses food.”
“Have you tried to figure out what she likes to eat?”
“I don’t think I can give her what she likes. I don’t think a diet of uncooked rice, mud and newspapers is healthy.”
Her logic cannot be faulted. Her daughter is a classical case of “pica,” the correct medical term for a perverted appetite, in which the person consumes non food items such as dirt, clay, raw rice, slate and chalk, paint, plaster, coffee grounds, cigarette ashes, cigarette butts, burnt match heads, rust, glue, hair, buttons, paper, sand, toothpaste, soap, sea shells, and even broken crockery. Pica is diagnosed if such items are eaten for a month or longer, after the age of two, by a mentally normal person unable to rationally control his or her behaviour.
Pica is not confined to India. It is an international phenomenon affecting 10-30 per cent of people of all ages and both sexes. It tends to be more common in the underprivileged, uneducated, mentally challenged and psychologically handicapped. It is aggravated by a lack of supervision.
In some areas, pica is culturally accepted. Consumption of clay and chalk is believed to protect against diseases such as jaundice, diarrhoea and morning sickness. Sometimes, it is believed to confer mystical powers, if eaten at the right time, like during a full moon. Another misconception is that it runs in families, with all members eating chalk or lime.
Many of these items are indigestible. Over a period of time they can get trapped inside the body, usually in the stomach or intestine, forming a hard lump called a bezoar. This has to eventually be surgically removed. Dirt and clay can lead to infection and parasitic infestation. Paint and newspapers can cause slow lead poisoning. Toothpaste damages intestinal villi. Even crunching ice and eating refrigerator frost damages teeth enamel. Lack of a nutritious diet can end in anaemia and malnutrition. Fatigue, palpitations, pallor, thinned out spooned concave nails, flattened tongue papillae, superficial erosions in the mucosa of the mouth and fissuring at the angles of the lips are the other effects.
Pica is different from bullemia nervosa, in which there are periodic intervals of binge eating. Unusually large amounts of a particular food item are consumed, with the feeling that the eating is out of control. The difference is that in bullemia edible items are consumed whereas in pica non-edible ones are eaten.
Children lack subtlety and openly exhibit their strange food preferences. They put everything into the mouth to feel its texture. This oral fixation is usually outgrown by the age of two but it can persists and metamorphise into adult pica.
Pregnancy has long been associated with accepted but peculiar food cravings, which unfortunately, is also accepted as the norm. Such cravings may be hidden from doctors, ignored by patients and condoned by family members.
Nutritional deficiency of iron, zinc or calcium may trigger appetite- regulating brain enzymes and specific cravings. The non-food items consumed in an effort to assuage this do not supply the deficient minerals, and the person is caught in a vicious cycle. The more they eat, the more they crave.
Geophagia (eating clay and mud) may become a habit, like having a cigarette in the morning. It may be an acquired behavioural response to unexpressed stress. It may be learned in childhood by watching other family members. It can in itself cause iron deficiency, aggravating the problem.
Emotional disturbances causing pica are more difficult to tackle, especially if the person is autistic, mentally challenged or has a psychiatric illness. Corporal punishment and ridicule only aggravates the problem, and is eventually self defeating.
Even though the cause is unproven, and varied, treatment is successful. Pica responds dramatically to iron, zinc, multivitamin and calcium supplements supported by regular deworming.
While administering these supplements, certain principles have to be kept in mind so that they are optimally absorbed. Zinc and iron compete for the same absorption sites in the intestine. They cannot be administered together as they “lock” the absorption site, and both are eventually not absorbed but eliminated. They need to be given separately on different days or at least 12 hours apart. Calcium precipitates with iron and zinc and prevents its absorption. It should be given separately. Manufacturers forget these principles and recommend the administration of a “hotchpotch” to patients, usually an elixir, tonic or capsule containing iron, zinc, calcium, vitamins and trace elements all mixed together. It offers little benefit.
After a satisfactory response to pica, no further treatment is required. However a close watch, for recurrence of the symptoms, may have to be kept on the individual for a couple of months by an involved and motivated caregiver.
Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at firstname.lastname@example.org