What about pica?

About 5Y Linda R. Guild Curda, S.N.M..B.S DEFINITION OF PICA he term pica is a Latin word meaning magpie. Acrording to ancient authors ttls term became attached to the habit of seeking diverse, strange food subsrances since the magpie bj a bird who picks up a variety of things to satisfy its hunger or curiosity Some authors differentiate between craving and pica. Craving is defined as an insatiable desire for unusual but harmless foods such as pickles and ice cream. Pica is defined as a “perversion of appetite with persistent and purposeful ingestion of unsuitable substances seemingly of no nutrient v&e.“’ Within the definition of pica there are numerous categories which are defined according to the type of substance Ingested. For example: geophagia is the practice of eattng dirt or clay, amylophagia is the ingestion of

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Ms. Curda holds a BS. Nursing from the University land. After working at

degree m of Marythe

Public

Health Service Hospital in Bethel. Alaska. she is currently studymg nurse-midwifery at Johns Hopkins School of Hygiene and Public Health. JOURNAL OF NURSE-h:IDWIFERY

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hy do some pregnant wo men eat dirt. starch or chew ice? 1s this type of actlvltg really a symptom of a nutntlonal defl ciency or perhaps even a disease process? Throughout hlstory these and many similar questions have been asked. Nevertheless. few clear cut answers have been found to ex plain this intriguing condltlon known as pica. The practcce of pica has been um versally found It has occurred in men, women and children It has ex isted throughout various races. cul tures. religions and soc~~conom~ statuse,. Still the literaiure focuses on the pregnant woman as it seems “the habit is apparently commoner among aduit pregnant women than among other adults.“’ In a review of the pica literature of the last fifteen years, Ansell states that “pregnancy is an important consideration since the incidence (of pica) is so much greater in this condition.“’

Vd XXII, No. 1. Spring 1977

starch and pagophagia of ice ingestion. There

is the practice

are a!so trichophaglti or hair ingestion. lithophagia or stone and gravel ingestion. and alIctriophagia. the desire to e:lt decomposed material, urine or feces. Some unnamed forms of pica are I ?e eating (mnhnueaonpage4 7

of charcoal, sojip, ,ahes, soot, nlatches, plaster and paint.

burnt

HISTORICAL PERSPECTIVE hroughout the world, man utilizes various substances $3~ foe?. His practice may vary according to his erc*liro?ment, his individua: needs and his cultural sanetions and taboos. The acceptance. of a food substance by one culture may be considered an appetite perversion by another. For example, it is as naiu-

!3 e1 n 0 e a d

Argo laundry starch) like taking dooe.” The practice of pica Is not rest+ ted to Southern rural areas. Studies in Chicago and New York City show that people who migrate from one section of the country to another, but whose socioeconomic level remains the same, do not change their cultural patterns. Most reports of pica practice are among black and white women of the iower socioeconomic level. When members of a family move north they may have cla; mailed to them by relatlres who dig it from a favori:e clay pit. If clay is una

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vailable. parently

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ar ci tic m al 0

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1C

starch is used interchangeably.’

bv

some.

ap.

POSSIBLE EFFECTS OF PICA

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he deleterious effects seem to be related

of pica to both

the type and the amount ingested. Iron-deficiency anemia is the most frequently mentioned condition found in -association with pica. However, severe hwokalemia.. bilateral parotid enlarge&nt, intestinal ob. &uction, dy&nctional labor, hypertension, toxemia and a greater incidence of perina!al been reported.

mortality

have

THREE MOST COMMON FORMS OF PICA “Geophagia

-

dM or clay ingestion”

G

delivery. Starch.cating has also been reported as a form of “inexpamsive psychiatry.” In a Rme article elltttled “An Urge for Arg~“~ the first sentence quoted a black woman as saymg, “When l’m pregnant, it’s (eating

eophagia, the practice of eatmg dirt or clay. is more comm on among pregnant women in the southern United State-. White, brown, red and black varieties of clav are sold in the municipal markets there. Clay has been found very effective in blocking iron absorption for it acts as a cation exchange resin. The calcium and magnesium in clay s\Te replaced by iron which places the iron in a less absorbable form. However, this action varies with the mineral composition of the specific type of clay. The major question today is whether the irondeficiency anemia causes the pica or wiaether pica CXEIZS the iron-deficiency anemia. However, ciated with an increased

pica is assofrequency of

JOURNAL OF NURSE-MIDWIFERY. Vd. XXII, No. 1, SPriW 1977

both

iron

depletion

and

iron

deftci-

ency. “Amylophagia

-

starch

ingestion”

A

mylophagia is the ingestion of large quantities of starch either cornstarch or Arqo laundry starch. There seems to be-e, relationship between din eating dur. ing childhood and amylophagia during pregnancy. Ingestion of starch in significant amounts will produce ane. mia, for the calories supplied by starch replace those ordinarily obtained from foods. However, studies of the iron-binding capicity of starch are lacking to parallel the studies of the iron-binding capacity of clay. The

Whether there is u direct cause and ejfect between picq malnutrition and anemia is still controversial

diets of cornstarch-eaters have been found to be substantially low in calories and calcium and below recommended amounts in iron, thiamine and niacin. Pica patients are reported to have low serum albumin values and low urea/creatinine ratios. This may be a reflection of low protein in take and poor nutrition. The ingestion of clay and cornstarch does not appear to effect the birth weight, length, head or chest size, or period of gestation of infants studied, although a higher percentage of the cornstarch group infants were still-

born.’ -

ice ingestion”

agophagia, after the Greek “pago” for frost or ice, and “phagein” to eat, is defined as the purposeful ingestion of at least

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answel!s to be very mteresting and straightforward, e.g.: “1 used to eat clay when I was a little girl (West Virginia) but I don’t like it anymore;” ‘I know a lot of older women who eat starch. but I don’t like the taste of it;” ‘1 have a friend who is pregnant who eats laundry starch.” Although my sample size was small. every woman I interviewed had either hers& practiced pica or knew of someone who dki. Since pregnancy is a period of biochemical, physiological. and psychological adaptation, a successful pregnancy depends on the health status

MANAGEMENT

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“Pagophagta

one tray of ice dsily over a period in excess of two months ice-eating is the practice best shown to occur as a result of iron defichency. In articles on pagophagia. every oatient manifested an iron deficiency. Iron administration in doses which were insufficient to replenrsh iron stores still eliminated all cravings for ice. 1’ this situation heme-containing enzymes, such as buccal cytochrome oxidasas found in saliva, which are affected by Iron deficiency and are promptly replenished by iron, may provide a linking mechanism.

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or the nurse-midwife step m management aware that any of

the first IS tc be her pa

tients may practice pica in one or more of its forms A good nutritional history which tncluc;es food frequen cy. socral and dieta:y habits must be taken early in pregnancy to Identify a possible pica patrent. Thus IS especial ly important with low socroeconomic black women in or from the South However, the nurse midwlfe must remember that pica ‘:an not be ruled out with women ot other races. cul tures and SOCIO economrc back grounds, Approactl the subject of pica carefully smce some patients may not want to admit that they eat strange things. Questions abotbc clay. cornstarch, laundry starch and ice should be intermingled with those about foods The approach IS “how much” i.e.. potatoes. bread. Argo starch, rice, etc., does she eat. rather than whether or not she eats starch. clay, etc. Patients who don’t eat pica laugh, but those who do give a much more honest answer. To find out whether pica is a rele vant issue, I asked several women at the Johns Hopkins Hocpitat prenatal clinic about their dreta:s habits. After introducing myself as a nurse-mid wifery student conducting a nutnhon survey, I asked each patient where she was born and how long she has lived in Baltimore. Using the tech nique described above, 1 found the

JOURNAL OF NURSE-MIDWIFERY l Vol. XXII, No. 1, Splng 1977

67 Pica in pregnancy is a prevalent practice that has its roots in antiquity.

-9 of the woman prior to her pregnancy plus her health status during the pregnancy. Since the absorption and utilization of one nutrient is depen dent on several others, a nutrihona’ deficiency can not be considered alone. For example, a diet that pro vides an adequate amount of iron rich foods must include sufficienl quantities of amino acids and vitamin C to facilitate the absorption of die tary aon. Since diets deficient in iron are usually deficient in folic acid. the possibility of a deficiency of this sub stance should also be considered. I: ar any i:me during pregnancy woman states that she consumes excessive amount of ice, one can

a an in-

terpret this to be a symptom of iron deficiency and/or anemia. If she has a positive history of c!ay, dirt or starch ingestion an underlying iron (conhnwd on pags lOI 9

When confronted with a suspected or documented anemia in iater pregrancy, a nutritional history is again important. The grealest demani for ito? by thp fetus occ’i~s in the last trimester of pregnarlcy Unlers the iron c,?quirements of pregnancy are made ‘up by absorption of iron from rhe gastrointestina! tract, iron-deficipncy anemie develops. A decrease in the amount of matem,* iron affects the hemoglobin level, which m turn .dfects the amount of oxygen tia:15ported and trdldorred to the fetus The hemoglobi.: level determines the oxygm-carrying capacity oi the red

tice

of pica

Thorough

instruction

on

normal discomforts of pregnancy, anatomy and physiology of pregnancy, fetal growth and develop ment, and the mechanisms of labor should be given to each pica patient to dispel her specific fears and misconceptions. For some pica women, the practice of starch ur clay Ingestion is an “inexpensive form of psychiatry.” When a woman states she practices pica, first find out the reason and, if possible, try to change this habit. This may i.1. valve provision of emotional support. If her psychological needs and prob-

ica in pregnancy is a prevalent practice that has its roots in antiquity. The nlcrse-midwife needs to be aware that each patient she sees may practice pica. It is essential that she get a complete dietary and social history to screen for possible pica pati mts. Once the practice of pica is ii,ntified, the nursemidwife provides nutritional and educational counseling to meet the specific needs of her patient Commundy health programs should include a discussion of pica and its deleterious effects. With the proper education of adolescents the nursemidwife has the opportunity to break the cycle of pica. The nurse-midwife’s

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unique skill at establishing close patient relationships makes her the ap. propriate person to work with the pregnant

Snexpensive

form

of psychiatry’

lems are beyond your capabilities, psychological counseling may be indicated. The continuation of pica from childhood to adulthood and pregnancy raises the possibility that there is a “cominuum of a sublethal corn. ponent” that appears in the form of iron-deficiency anemia and/or perinata: casualties.’ With the aim of producing healthy mothers and in. fants. it is vital to breck the pica cycle Whe I the nurse-midwife is asked by her community to give maternal courses fqr young girls, her programs should include nutritional informa tion in whtch pica is discussed. Thi: guidance about the possiLle dangers of continued pica indulgence shoulc be emphasized in educational pro grams at the elementary and secon dary levels as well a5 in the prenata period of pregnancy.

pica patient.

BIBLIOGRAPHY

For some, pica is cn

1. Keith, L. Brown, B.FL and Rosenberg, C., Tka: Tbe Unfinished Story. Back. ground: Conelations with Anemia and Pregnancr).” Perspcctiues In Bloc ogy and Medicine. 626.631, Summer, 1970. 2. Ansell, J.E. and Wheby, MS.,-“Pica: Its Relation to Iron Defkiency. A Review of the Recent Literature.” VIP glnla Medlcel Mqnthfy. 99.951.954, 1972. 3. Dunston. Bevetl~ N.. “&a during Cuirunt Concep!s In F+egnancy.” Cllnkal Nuralng. 2:268-279.1969. 4. Aegeneta, cited by Cooper, M., PICU A survey of the Hla~orkal Mereture as Well as Reports From Ihe Fields c, Ve~etinary Medkke and Anthropology: The Present Study of Pica In Young Children and a Dlscuulon of lb Pedlatrk and Psychologkal fmpllcatlons. Page 6, Springfield, Ill.: Chales C. Tbomas, Publisher, 1957. 5. Cooper. op. cit. p. 24. 6. “An Urge for Argo,” Time. pp. &37. July 28, ?%7. 7. Edwards, C.H., et al. “Effects of Clay and Cornstarch Intake on Women and their Infants.” Journd of the American Dletetk Ass~clotlon. 44: 109.115,1964. 8. Dunaton. op. ck p. 278.

AIXRTIONAL REFERENCES Allan, ,J.D., and Woodruff, J. “Starch Gastrolith: reoort of a case of obstruction.” & E&land Journal of Medkin; 268:774.778,1%3.

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Bronstein, ES. and D&I, J. ‘ma in h+~~ancy.” Journd of the MedicalAs. smlatlonof Georgia.63~332.335,1974. Coltman,CA. “Pagophagta”.Society of Air Force i’hysfcfons; Annual Meeting, San Antonio,Texas,Febmary,1966. Coltman, C.A. “Pagophagia and Iron Lack.” Journal of the American Medical Associatfon.207~513.516,1969. Edwards, C.H. et al. “Clay and Corn. starch Eating Women.” Journal of the American DfeteNcAssociaNon.35810. 815.1959. Finch,C.A.“Diagnosticvalueof different methodsto detectiron defkiency:” Iron DeficiencyPathogenesls,Clinr Aspects, Therapy New York, Academic Press, 409.413,1970. Forti, T. NutritionSection,Confidentially Speaking. Louislana State Board oi Health,May,1965. Gusdon, J.P. and -‘unca, C. “Pica Mimicking Abruptb Placenta.”Obstetricsand Gynecology.43:197-199.1974. Ha&d, J.A. “Geophagia in Man: Its Nature and Nutritional Effects.” Amerlcon JournolofCl~n~~:olNutn’tion. 21:1384 -1393.1968. Holt, W.A. and Herdrkks, C.H. “Dys. functtonal Labor due to Fecal Impactlon.” Obstettiesand Gynecology.34:502 .504.1969. Keith, L. et al. “Amylophagia During Pregnancy.”Obstetrics end Gynecology. 32:415-418,1968. Lanzkowsky. P. “An Investigationinto the Aetlobgy and Treatment of Pica.” Archlues of Disease In Childhood. ?a: 140.148,1959. Laufer, B. Geophagy, Field Museum of Natural History, AnthropologicalSeries. Pub:katlon280,Chicago,1930. McDonald,R. and Marshall,S.R.“Value of Iron Therapy in Plea.”Pedlolrlcs.34: 558562.1964. Mengel,C.E. et al. “Geophagiawith Iron Deficiencyand Hypokalemla.” Archlues oflr ternalMedicine.114470.474.1964. Merkatz, I.R.“Parotid Enlargementfrom Excessive b-q&ion of Starch.” New EnglandJournd of Medlclne.2651304, 1961. Minnkh, \‘. et al. “Pica in Turkey: II Effeds of Cw upon Iron Absorption.” 4merkon JOUIt*d of Cllnlcd Nutrition. 21:78.86,1968. O’Rourke,DE. et al. “GeophagiaDurir.2 Pregnancy.”Obstetrics and Gynecology. 29581.584,1%7. Reynolds, R.D. et al. “Pagophagiaand Iron Defklency Anemia.” Annals of Internd Medklne.694354?0,1968. JOURNAL OF NURSE-MIDWIFERY a Vol. XXII, No. I, Spring 1977