Diagnostic features

• Persistent eating of nonfood items (e.g., soil, ice, paper, hair, clay, paint, stones) for ≥1 month.
• Behaviour is developmentally inappropriate (not part of normal exploration in toddlers) and not culturally or socially normative.
• Occurs with or without other mental disorders (intellectual disability, autism, schizophrenia) and may co‑exist with nutritional deficiencies.

Common subtypes & examples

• Geophagia: eating earth or clay.
• Pagophagia: compulsive eating of ice—often linked to iron deficiency anaemia.
• Trichophagia: hair eating (may lead to trichobezoar).
• Pica for paint, paper, or starch: ingestion of household items—risk of toxicity (lead) and GI obstruction.

Medical risks & complications

• Gastrointestinal: obstruction, perforation, constipation, bezoar formation.
• Toxicity: lead, mercury or other chemical exposure from ingested substances (paint chips, batteries).
• Infection: parasitic or bacterial contamination from soil or faecal matter.
• Nutritional problems: iron deficiency anaemia and other micronutrient imbalances (both cause and consequence).

Assessment checklist

1. History: onset, frequency, specific substances, context (stress, pregnancy), developmental level, and associated behaviours or psychiatric symptoms.
2. Medical exam: abdominal exam, signs of anaemia (pallor), growth parameters in children, oral/dental inspection and signs of toxicity or infection.
3. Investigations: CBC (look for iron deficiency), lead levels if paint ingestion suspected, abdominal X‑ray or ultrasound if obstruction or ingestion of radiopaque objects suspected, and specific toxicology as indicated.
4. Psychosocial assessment: family dynamics, neglect, food insecurity, cultural practices and access to items ingested; screen for comorbid developmental or psychiatric disorders.

Management principles

• Address medical complications first: treat obstructions, infections or toxicity urgently and correct nutritional deficiencies (iron supplementation for pagophagia linked to iron deficiency).
• Behavioural interventions: environmental modification to limit access, positive reinforcement for alternative behaviours, stimulus control, and habit reversal techniques adapted to developmental level.
• Family and caregiver education: safe storage of hazardous items, supervision strategies, and consistent responses to episodes to avoid inadvertent reinforcement.
• Treat comorbid conditions: manage autism/ID with tailored behavioural programs, treat OCD or psychosis when present, and involve social services if neglect suspected.

Behavioural strategies — practical tips

1. Remove or lock away hazardous items and replace with safe oral substitutes (e.g., chewing gum for pagophagia when appropriate).
2. Establish predictable routines, provide sensory alternatives for sensory‑seeking pica (safe textures/foods), and use token economies or reward charts for children.
3. Use redirection and brief, neutral corrective feedback rather than punishment; pair with positive reinforcement for safe behaviours.

When to involve specialists

• Lead or other heavy metal exposure, suspected GI obstruction/perforation, evidence of significant nutritional deficiency, or complex comorbidity — involve paediatrics, gastroenterology, toxicology and psychiatry.
• For individuals with intellectual disability or autism, involve specialist behaviour support teams, occupational therapy for sensory strategies, and community disability services.

Key takeaways

• Pica is a clinically significant behaviour with potentially serious medical consequences—identify specific substances ingested and assess for toxicity, obstruction and nutritional deficiencies.
• Correct medical problems first, then use environmental modification and developmentally appropriate behavioural strategies; involve specialists for toxicity, obstruction or complex comorbidity.
• Consider social determinants (food insecurity, neglect) and coordinate with community services when relevant.