defines pica as eating nonnutritive, nonfood substances over a period of at least one

month. The term is derived from "pica pica," the Latin word for the magpie
bird, because of the bird's indiscriminate gathering and eating a variety of objects for
the sake of curiosity.
Definisi
Pica berasal dari bahasa Latin “pica pica” untuk burung magpie, burung tersebut
mengumpulkan dan memakan berbagai benda karena penasaran. Menurut The American
Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) mendefinisi pica sebagai makan makanan tidak bernutrisi, bukan makanan
selama satu bulan.

A variety of reasons make it challenging to estimate the exact prevalence of pica; for
example, studies use variable definitions of pica, under-reporting is common among
affected subjects, and a strong cultural and social influence adds further difficulty to
detection.[16] For the most part, the condition seems to affect women who are
pregnant and young children.[17] A German prevalence study of 804 children found that
99 children (12.3%) have engaged with a pica behavior at some point in their lives.[18] A
meta-analysis of studies of the prevalence of pica during pregnancy estimated
that 27.8% of pregnant women reported experiencing pica. The study also stated that
the sample was heterogeneous throughout the world, with a higher prevalence in Africa
compared to other continents.[19] A high prevalence of pica seems to be reported in
patients with mental retardation (approximately 10%); it correlates with the severity of
mental retardation

The act or habit of eating things that are not food is called pica in medical and
psychological textbooks. For children, who learn about the world by putting things into
their mouths, pica is really fairly common. Unfortunately, some children do not have
breakfast at home and they eat paper and other items just because they are hungry and
need to survive
anak-anak yang sedang mempelajari tentang dunia luar dengan memasukan benda kedalam
mulut, bisa dikatakan normal. Sedankan ada anak-anak yang tidak mendapat makanan
dirumah, makan kertas atau makanan lain karena lapar dan untuk bertahan hidup.
Many factors have been implicated in the etiology of pica; however, no direct causality
has been established. Studies of psychological factors have reported an association
between pica and stress, child neglect and abuse, and maternal deprivation.[3]. Iron
deficiency anemia has also been implicated.[4] Many population-based studies have
found a low level of serum iron/ferritin (and other micronutrients) among patients with
pica.[5][6][7].
Banyak faktor yang dapat mempengaruhi terjadinya pica, tidak ada yang secara langsung
menyebabkan pica. Pica dapat dipengaruhi oleh stres, kekerasan pada anak, sala asuhan
ibu. Anemia devisiensi besi uga dapat menyebabkan pica. Banya penelitian yang
menemukan kadar serum besi/feritin yang rendah diantara pasien dengan pica.
Despite this, studies conducted on substances consumed by pica patients failed to show
increased iron bioavailability among these substances. This suggests that the idea that
these cravings stem from a need for serum iron is an inadequate pathophysiological
explanation for this phenomenon.[8] Another proposed hypothesis that is gaining more
attention is that pica for non-nutritive substances offers protection from harmful toxins
during the most vulnerable stages of human cell replication and embryogenesis
(childhood and pregnancy).[9][10][11] The proposed mechanism of protection is binding
to toxins and decreasing its intestinal absorption.[12][13][14] In pagophagia, a Japanese
study hypothesized that when a patient with anemia chews ice, it increases perfusion
thus improving brain function. They contributed that to the activation of the dive reflex
which would lead to peripheral vasoconstriction and an increase in central perfusion.
Another explanation would be sympathetic activation which would also increase blood
flow to the brain.[15]

Developmentally, babies - more than elementary school kids - have a period of growth in which they
put just about everything they find into their mouths, even their own feet. They usually go on to
something more exciting that catches their attention and forget what they had in their mouths.
When a child that has passed this developmental point and is older, but who suddenly begins to eat
non-food items once again, there may be a problem of some kind. In this case, there is likely some
cause for it that can be found and eliminated
dalam masa pertumbuhan dan perkembangan anak memasukan ke dalam mulut semua yang
mereka temukan walaupun di kakinya. Jika ada hal yang lebih menyenangkan maka mereka akan
melupakan apa yang ada dalam mulutnya.

The other causes can be iron, zinc or calcium deficiency. Pica occurs variably in patients
with iron deficiency. The precise pathophysiology of the syndrome is unknown. Patients
consume unusual items, such as laundry starch, ice and soil clay. Both clay and starch
can bind iron in the gastrointestinal tract, exacerbating the deficiency.
Defisiensi zat besi, zinc dan kalsium dapat menyebabkan pica. Kejadian pica beragam
pada pasien dengan defisiensi zat besi dengan patofisologi yang tidak pasti. Beberapa
pasien pica mengkonsumsi seperti sabun cuci, es batu dan tana liat. Tanah liat dan sabun
sapat mengikat zat besi di traktus gastrointestinal, sehingga memperberat defisiensi.
Laboratory evaluation should be tailored according to the suspected substances
ingested. Iron studies in patients with pica should be performed, especially in women
who are pregnant and children. Lead (in pica for paint and chalk) and zinc levels should
be checked where appropriate.[25] A basic metabolic panel should be obtained,
especially in clay ingestion which can cause metabolic disturbances such as
hypokalemia.[26]
Evaluasi laboratorium harus dilauan berdasarkan substansi yang dicurigai ditelan. Ibu hamil dan
anak-anak harus diperiksa feritin serum. Presentase timah dan zinc harus diperiksa secara benar.
Hipokalemia dapat terjadi pada pica.
Pica is typically defined as persistent ingestion of nonnutritive substances for at least
1 month at an age for which this behavior is developmentally inappropriate. [1]The
definition is occasionally broadened to include the mouthing of nonnutritive
substances. Pica may be benign, or it may have life-threatening consequences.
Individuals who present with pica have been reported to mouth or ingest a wide
variety of nonfood substances, including, but not limited to, clay, dirt, sand, stones,
pebbles, hair, feces, lead, laundry starch, vinyl gloves, plastic, pencil erasers, ice,
fingernails, paper, paint chips, coal, chalk, wood, plaster, light bulbs, needles, string,
cigarette butts, wire, and burnt matches.
Although pica is observed most frequently in children, it is the most common eating
disorder in individuals with developmental disabilities. It has also been observed in
females during pregnancy. In some societies, pica is a culturally sanctioned practice
and is not considered pathologic.
Although pica can impair physical functioning, it rarely causes impairment of social
functioning, which is typically associated with comorbid disorders. The most common
of these disorders are autism spectrum disorder, intellectual disability, and, to a
lesser degree, schizophrenia and obsessive-compulsive disorder (OCD). When pica
coexists with trichotillomania or excoriation, the hair or skin is typically ingested. Pica
may also coexist with avoidant/restrictive food intake disorder, especially when there
is a strong sensory component to the presentation.
Diagnostic criteria (DSM-5)
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
classifies pica under feeding and eating disorders and notes that it may be present in
conjunction with other feeding and eating disorders. [1] DSM-5 criteria for pica are as
follows:
 Persistent eating of nonnutritive, nonfood substances over a period of at least 1
month
 The eating of such substances is inappropriate to the developmental level of
the individual
 The eating behavior is not part of a culturally supported or socially normative
practice
 If the behavior occurs within the context of another mental disorder or medical
condition (eg, schizophrenia, autism, or pregnancy), it is sufficiently severe to
warrant independent clinical attention
A minimum age of 2 years is suggested for the diagnosis. In children aged 18
months to 2 years, the ingestion and mouthing of nonnutritive substances is common
and is not considered pathologic.
Etiology
Although the etiology of pica is unknown, numerous hypotheses have been
advanced to explain the phenomenon, ranging from psychosocial causes to
causes of purely biochemical origin. Suggested causes include the
following:
 Nutritional deficiencies
 Cultural and familial factors
 Stress
 Low socioeconomic status
 Nondiscriminating oral behavior
 Learned behavior
 Underlying biochemical disorder
Although no firm empiric data support any of the nutritional etiologic
hypotheses, deficiencies in iron, calcium, zinc, and other nutrients (eg,
thiamine, niacin, and vitamins C and D) have been associated with pica. In
some patients with malnutrition who eat clay, iron deficiencies have been
diagnosed, but the direction of this causal association is unclear. Whether
the iron deficiency prompted the eating of clay or whether the inhibition of
iron absorption caused by the ingestion of clay produced the iron deficiency
is unknown.
Current methodologies for the physical, mineralogic, and chemical
characterization of pica substances, particularly clay and soil, may be
useful for determining the bioavailability of nutrients and other bioactive
components and for generating data to support or negate these nutritional
hypotheses. [2]
Ingestion of clay, soil, or starch may be regarded as culturally acceptable
by certain social groups. Clay eating and starch eating are seen in the
United States in some southern, rural, African American communities,
primarily among women and children. Starch eating, in particular, is
frequently started in pregnancy as a treatment for morning sickness and
may be continued into the postpartum period. Parents may proactively
teach their children to eat these and other substances. Pica behavior may
also be learned via modeling and reinforcement.
Maternal deprivation, parental separation, parental neglect, child abuse,
and insufficient amounts of parent-child interaction have been associated
with pica.
Ingestion of paint is most common in children from families of low
socioeconomic status and is associated with lack of parental supervision.
Malnutrition and hunger may also result in pica.
It has been suggested that in individuals with intellectual disability, pica
may result from an inability to discriminate between food and nonfood
items; however, the findings that individuals select pica items and that they
often search aggressively search for nonfood items of choice do not
support this theory.
In individuals with intellectual and developmental disabilities in particular,
the traditional view is that the occurrence of pica is a learned behavior
maintained by the consequences of that behavior.
The association of pica, iron deficiency, and a number of pathophysiologic states
with decreased activity of the dopamine system suggests the possibility of a
correlation between diminished dopaminergic neurotransmission and the expression
and maintenance of pica. [3] To date, however, no specific pathogenesis resulting
from any underlying biochemical disorders has been identified empirically.
Risk factors for pica include the following:
 Parent-child psychopathology
 Family disorganization
 Environmental deprivation
 Pregnancy
 Epilepsy
 Brain damage
 Intellectual disability
 Developmental disorders
Epidemiology
United States statistics
Because pica is often unrecognized and underreported, its true prevalence
is unknown. Although prevalence rates vary depending on the definition of
pica employed, the characteristics of the population sampled, and the
methods used for data collection, pica is reported most commonly in
children and in individuals with intellectual disability.
Children with intellectual disability and autism are affected more frequently
than children without these conditions. Among individuals with intellectual
disability, pica is the most common eating disorder. In this population, the
risk for and severity of pica increase as the severity of the disability
increases.
International statistics
Pica occurs throughout the world. Geophagia (deliberate consumption of
earth, soil or clay) is the most common form of pica in people who live in
poverty and people who live in the tropics and in tribe-oriented societies.
Pica is a widespread practice in western Kenya, southern Africa, and India.
It has been reported in Australia, Canada, Israel, Iran, Uganda, Wales,
Turkey, and Jamaica. In some countries (eg, Uganda) soil can be
purchased for the purpose of ingestion.
Age-, sex-, and race-related demographics
Pica is observed more commonly during the second and third years of life
and is considered developmentally inappropriate in children older than 18-
24 months. Research suggests that pica occurs in 25-33% of young
children and 20% of children seen in mental health clinics. A linear
decrease in pica occurs with increasing age. Pica occasionally extends into
adolescence but is rarely observed in adults who are not mentally disabled.
Among individuals with intellectual disability, pica occurs most often in
those aged 10-20 years. [4]
Infants and children commonly ingest paint, plaster, string, hair, and cloth.
Older children tend to ingest animal droppings, sand, insects, leaves,
pebbles, and cigarette butts. Adolescents and adults most often ingest clay
or soil.
In young pregnant women, the onset of pica frequently occurs during their
first pregnancy in late adolescence or early adulthood. Although the pica
usually remits at the end of the pregnancy, it may continue intermittently for
years. [5] Worldwide prevalence of pica during pregnancy and the
postpartum period has been estimated at 27.8%. [6]
Pica typically occurs with equal frequency in boys and girls; however, it is
rare in adolescent and adult males of average intelligence who live in
developed countries.
Although no specific data exist regarding the racial predilection of pica, the
practice is reported to be more common among certain cultural and
geographic populations. For example, geophagia is accepted culturally
among some families of African lineage and is reported to be problematic in
70% of the provinces in Turkey.
Pica often remits spontaneously in young children and pregnant women; however, it
may persist for years if untreated, especially in individuals with intellectual and
developmental disabilities.
Pica is a serious behavioral problem because it can result in significant medical
sequelae, which are determined by the nature and amount of the ingested
substance. Pica has been shown to be a predisposing factor in accidental ingestion
of poisons, particularly in lead poisoning. The ingestion of bizarre or unusual
substances has also resulted in other potentially life-threatening toxicities, such
as hyperkalemia after cautopyreiophagia (ingestion of burnt match heads).
Exposure to infectious agents via ingestion of contaminated substances is another
potential health hazard associated with pica, the nature of which varies with the
content of the ingested material. In particular, geophagia (soil or clay ingestion) has
been associated with soil-borne parasitic infections
(eg, toxoplasmosis and toxocariasis). Gastrointestinal (GI) tract complications (eg,
mechanical bowel problems, constipation, ulcerations, perforations, and intestinal
obstructions) have resulted from pica.

Patient Education
It is vital to educate patients regarding healthy nutritional practices. Failure
to inform patients of the dangers of eating nonnutritive substances is a
management pitfall to be avoided.
In some areas, homeowners and landlords are legally responsible for lead
hazard reduction in homes where hazardous lead-based paint conditions
have been discovered either after direct testing or after a child inhabitant is
found to have elevated blood lead levels. Remediation of the residence by
licensed lead abatement professionals will eliminate lead hazards by
removing, sealing, or enclosing lead-based paint with special materials.
Temporary relocation of the child may be required.

Clinical Presentation
History
The clinical presentation of pica is highly variable and is associated with the
specific nature of the resulting medical conditions and the ingested
substances. In poisoning or exposure to infectious agents, the reported
symptoms are extremely variable and are related to the type of toxin or
infectious agent ingested. Gastrointestinal (GI) tract symptoms may include
constipation, chronic or acute abdominal pain that may be diffuse or
focused, nausea and vomiting, abdominal distention, and loss of appetite.
Patients may withhold information regarding pica behavior and deny the
presence of pica when questioned. This secretiveness frequently interferes
with accurate diagnosis and effective treatment. The broad range of
complications arising from the various forms of pica and the delay in
accurate diagnosis may result in mild–to–life-threatening sequelae.
Physical Examination
The physical findings associated with pica are extremely variable and are
related directly to the materials ingested and the subsequent medical
consequences. These findings may include the following:
 Manifestations of toxic ingestion (eg, lead poisoning)
 Manifestations of infection or parasitic infestation
 GI manifestations
 Dental manifestations
Physical manifestations associated with lead poisoning (the most common
poisoning associated with pica) are nonspecific and subtle, and most
children with lead poisoning are asymptomatic. These manifestations can
include neurologic symptoms (eg, irritability, lethargy, ataxia,
incoordination, headache, cranial nerve paralysis, papilledema,
encephalopathy, seizures, coma, or death) and GI tract symptoms (eg,
constipation, abdominal pain, colic, vomiting, anorexia, or diarrhea).
Toxocariasis (including visceral larva migrans and ocular larva migrans)
and ascariasis are the most common soil-borne parasitic infections
associated with pica. Manifestations of toxocariasis are diverse and appear
to be related to the number of larvae ingested and the organs to which the
larvae migrate. Physical findings associated with visceral larva migrans
may include fever, hepatomegaly, malaise, coughing, myocarditis, and
encephalitis. Ocular larva migrans can result in retinal lesions and loss of
vision.
GI tract manifestations may be evident secondary to mechanical bowel
problems, constipation, ulcerations, perforations, and intestinal obstructions
caused by bezoar formation and the ingestion of indigestible materials into
the GI tract.
Dental abnormalities may be evident on physical examination, including
severe tooth abrasion, abfraction, and surface tooth loss. [7, 8]
Complications
Lead toxicity has neurologic, hematologic, endocrine, cardiovascular, and
renal effects. Lead encephalopathy is a potentially fatal complication of
severe lead poisoning, presenting with headache, vomiting, seizures,
coma, and respiratory arrest.
Ingestion of high doses of lead can cause significant intellectual impairment and
behavioral and learning problems. It has been demonstrated that neuropsychologic
dysfunction and deficits in neurologic development can result from very low lead
levels, even levels once considered safe. A hypochromic microcytic anemia
resembling iron deficiency anemia can also be seen with lead toxicity; lead interferes
with heme synthesis, beginning at blood lead concentrations of about 25 µg/dL.
GI tract complications associated with pica range from mild (eg, constipation) to life
threatening (eg, hemorrhages secondary to perforations or ulcerations).
Various infections and parasitic infestations, ranging from mild to severe, are
associated with the ingestion of infectious agents via contaminated substances, such
as feces or dirt. In particular, geophagia has been associated with soil-borne
parasitic infections, such as toxocariasis, toxoplasmosis, and trichuriasis.
Nutritional effects may also be evident. Theories regarding the direct nutritional
effects of pica are related to characteristics of specific ingested materials that either
displace normal dietary intake or interfere with the absorption of necessary nutritional
substances. Nutritional effects that have been linked to severe cases of pica include
iron and zinc deficiency syndromes; however, the data are only suggestive, and
there is no firm empiric evidence to support these theories. [9]
A meta-analysis of 43 studies including 6,407 individuals with pica behaviors and
10,277 controls found pica to be associated with 2.35 greater odds of anemia and
low hemoglobin (Hb), hematocrit (Hct), or plasma zinc (Zn) concentrations. [10]
Workup
Laboratory Studies
No specific laboratory studies are indicated in the evaluation of pica.
However, certain laboratory studies may be indicated to assess the
consequences of the condition, depending on the characteristics and
nature of the ingested materials and the resultant medical sequelae.
Universal screening of blood lead concentrations in all children aged 1-2
years is recommended in localities where at least 27% of houses were built
before 1950. Screening is also recommended in places where the
prevalence of elevated blood levels in children aged 1-2 years is 12% or
higher. Targeted screening for high-risk 1- and 2-year-old children is
otherwise recommended.
Radiography and Endoscopy
Various imaging studies may be used to identify ingested materials and aid
in the management of gastrointestinal (GI) tract complications of pica.
These may include the following:
 Abdominal radiography
 Upper and lower GI barium examinations
 Repeated imaging at regular intervals to track changes in location of
ingested materials
 Upper GI endoscopy to diagnosis bezoar formation, identify
associated lesions, or both
Treatment & Management
Approach Considerations
Although pica in children often remits spontaneously, a multidisciplinary
approach involving psychologists, social workers, and physicians is
recommended for effective treatment. [11]
pica pada anak-anak biasanya sembuh sendiri. pica diatasi secara efektif dibutuhkan multidisiplin meliputi dokter,
psikolog, dan lembaga sosial. tida ada panduan yang tetap untu mengatasi pica,
tetapi pendekatan personal
dan pemberian edukasi serta saran-saran yang baik mengenai nutrisi yang seimbang pada
pasien pica menjadi suatu hal penting untuk upaya mengurangi keinginan-keinginan
mengkonsumsi benda-benda yang aneh sehingga dapat tercipta keseimbangan nutrisi dalam
tubuh. Penatalaksanaan pasien pica dengan cara yang sama belum tentu mendapatkan hasil
yang sama, kesadaran dari praktisi kesehatan adalah hal yang paling penting dalam
manajemen pasien pica.
Development of the treatment plan must take into account the symptoms of
pica and any contributing factors, as well as the management of possible
complications of the disorder. Treatment of pica is conducted primarily on
an outpatient basis.
Assessment of nutritional beliefs may be relevant in the treatment of some
patients with pica. Any nutritional deficiencies that are identified should be
addressed. It must be kept in mind, however, that nutritional and dietary
approaches have successfully helped prevent pica in only a very limited
number of patients.
Consultation with a psychologist or psychiatrist is advisable. Consultation
with a social worker is also helpful.
A dentist may be consulted as well. Attention to oral health is important for
managing the detrimental effects pica may have on teeth from a young age
onward. [12]
Pharmacologic Therapy
No medical treatment is specific for pica. Few studies of pharmacologic
therapy for pica have been performed; however, the hypothesis that
diminished dopaminergic neurotransmission is associated with pica
suggests that drugs that enhance dopaminergic functioning may provide
treatment alternatives in individuals with pica that is refractory to behavioral
intervention. [3]
Pengobatan farmakologi tidak ada yang spesifik terhadap pica. Beberapa
penelitian telah dilakukan, dan menemukan hipotesis bahwa berkurangnya
neurotransmitter dopaminergic berhubungan dengan kejadian pica. Maka
bisa diberikan obat yang meningkatkan dopaminergik. Obat yang dapat
diberikan seperti olanzapin. Olanzapin merupakan obat antipsikotik yang
berperan penting memberi efek dopaminergik, serotoninergik, adernegik,
dan kolinergik.
In addition, a single case report found that olanzapine, an antipsychotic
agent with prominent dopaminergic, serotoninergic, adrenergic, and
cholinergic effects, reduced pica behaviors. [13] Medications used in the
management of severe behavioral problems may have a positive impact on
comorbid pica.
Psychosocial Interventions
Careful analysis of the function of pica behavior in individual patients is
critical for effective treatment. Currently, behavioral strategies are
considered the most effective in the treatment of pica. Such strategies
include the following:
 Antecedent manipulation
 Training in discrimination between edible and nonedible items
 Self-protection devices that prohibit placement of objects in the mouth
 Sensory reinforcement
 Differential reinforcement of other or incompatible behaviors, such as
screening (covering the eyes briefly), contingent aversive taste
sensation (eg, lemon), contingent aversive smell sensation (eg,
ammonia), contingent aversive physical sensation (eg, water mist),
and brief physical restraint
 Overcorrection (correct the environment, or practice appropriate
alternative responses)
In toddlers and young children, pica behavior may provide environmental or
sensory stimulation. Assistance in addressing these issues may prove
beneficial, along with help in managing economic problems or alleviating
deprivation and social isolation. Assessment of cultural beliefs and
traditions may reveal the need for education regarding the negative effects
of pica. Removal of toxic substances—especially lead-based paint—from
the environment is important.