Prevalence in primary school youth of pica and rumination behavior: The understudied feeding disorders

Analysis of feeding and eating disorders in 191 children according to psychiatric or gastroenterological recruitment: The PEDIAFED cohort study

OBJECTIVE

The DSM-5 classification introduced new Feeding and Eating Disorders (FED) diagnostic categories, notably Avoidant and Restrictive Food Intake Disorder (ARFID), which, like other FED, can present psychiatric and gastrointestinal symptoms. However, paediatric clinical research that focuses on children below the age of 12 years remains scarce. The aim of this study was first to investigate the clinical features of FED in a cohort of children, second to compare them according to their recruitment (gastroenterology or psychiatry unit).

METHOD

This non-interventional retrospective cohort study analysed 191 patients in a French paediatric tertiary care centre (gastroenterology n = 100, psychiatry n = 91). The main outcome variables were clinical data (type of FED, BMI, nutritional support, chronic diseases, psychiatric comorbidities, sensory, sleep, language disorders, gastrointestinal complaints, adverse life events, family history). The outcome was defined by a Clinical Global Impression of Change-score.

RESULTS

FED diagnoses were ARFID (n = 100), Unspecified FED (UFED, n = 57), anorexia nervosa (AN, n = 33) and one pica/rumination. Mean follow-up was 3.28 years (SD 1.91). ARFID was associated with selective and sensory disorders (p < 0.001); they had more anxiety disorders than patients with UFED (p < 0.001). Patients with UFED had more chewing difficulties, language disorder (p < 0.001), and more FED related to chronic disease (p < 0.05) than patients with ARFID and AN. Patients with AN were female, underweight, referred exclusively to the psychiatrist, and had more depression than patients with ARFID and UFED (p < 0.001). The gastroenterology cohort included more UFED, while the psychiatry cohort included more psychiatric comorbidities (p < 0.001). A worse clinical outcome was associated with ARFID, a younger age at onset (p < 0.001), selective/sensory disorders and nutritional support (p < 0.05).

CONCLUSION

ARFID and UFED children were diagnosed either by gastroenterologists or psychiatrists. Due to frequently associated somatic and psychiatric comorbidities, children with FED should benefit from a multidisciplinary assessment and care.

Serum Level of 25-Hydroxyvitamin D and Symptoms of Pica Among Adolescent School Children in Northern Sudan: A Cross-Sectional Study

Objectives. To assess levels of 25(OH)D among adolescents with symptoms of pica in northern Sudan. Methods. A cross-sectional study was conducted in North Sudan. Questionaries were used to collect adolescents' sociodemographics. The enzyme-linked immunosorbent assay was used to measure 25(OH)D level. Results. Of the 344 adolescents enrolled, 161 (46.8%) and 183 (53.2%) were male and female, respectively and 103 (29.9%) had symptoms of pica. The median (IQR) of 25(OH)D level was significantly lower in adolescents with symptoms of pica. Multiple linear regression analysis showed that while age (coefficient = 1.1, P = .023) was positively associated with 25(OH)D level, female sex (coefficient = -7.5, P < .001), and pica symptoms (coefficient = -3.5, P = .032) were negatively associated with 25(OH)D level. Conclusion. Adolescents with symptoms of pica had lower 25(OH)D levels. Adolescents with symptoms of pica have to be assessed for vitamin D status.

The prevalence of rumination syndrome and rumination disorder: A systematic review and meta-analysis

BACKGROUND

Rumination is characterized by the repeated regurgitation of food. Rumination syndrome is a disorder of gut-brain interaction diagnosed by Rome criteria, whereas rumination disorder is a feeding and eating disorder diagnosed by DSM-5 criteria. We aimed to determine the global prevalence of rumination according to these criteria across all age groups.

METHODS

We performed a systematic review and meta-analysis of studies reporting the prevalence of rumination syndrome according to Rome III and Rome IV and rumination disorder according to the following validated DSM-5 assessments: PARDI, EDA-5, EDY-Q, STEP, and STEP-CHILD. We searched MEDLINE, EMBASE, and PsychINFO (from January 1, 2006, to June 1, 2023) to identify studies reporting the prevalence of rumination in community settings in participants of any age. We did a meta-analysis to estimate the pooled prevalence and odds ratio (OR) of rumination according to diagnostic criteria, country, and characteristics such as age and sex.

KEY RESULTS

The search strategy generated 1243 studies, of which 147 studies appeared to be relevant. Thirty studies were included, with a total of 114,228 participants, of whom 61,534 of these were adults and 52,694 were children. The pooled prevalence of rumination syndrome in children of all ages according to Rome III criteria was 1.0% (95% CI 0.3-1.6; I2 91.1%), but no data were available for adults. According to Rome IV criteria, the pooled prevalence of rumination syndrome in children of all ages was 0.4% (95% CI 0.2-0.6; I2 56.4%) and 3.7% in adults (95% CI 2.3-5.1; I2 91.4%). The pooled prevalence of rumination disorder in children of all ages according to EDY-Q was 2.1% (95% CI 0.9-3.4; I2 = 78.1%), but only one study utilizing EDY-Q in adults was included (0.7% [95% CI 0.4-1.0]). No data were available for children or adults using any other validated DSM-5 assessments for rumination disorder. Irrespective of diagnostic criteria, the pooled prevalence of rumination was higher in adults compared to children and adolescents (3.0% [95% CI 1.4-4.7; I2 = 98.1%] vs. 0.8% [95% CI 0.4-1.3; I2 = 90.8%]), but higher in adolescents than in children (1.1% [95% CI 0.3-2.0; I2 = 92.8%] vs. 0.1% [95% CI 0.0-0.2; I2 = 24.5%]). In adults, factors independently associated with rumination were female gender (OR 1.4 [95% CI 1.0-2.0]), anxiety (OR 2.3 [95% CI 2.1-2.6]), and depression (OR 1.8 [95% CI 1.2-2.9]). No association between gender and rumination was seen in children.

CONCLUSIONS AND INFERENCES

The prevalence of rumination is more common in adults than in children. In adults, rumination is associated with female gender, anxiety, and depression. Future population studies should aim to better understand why this behavior is more common in adults and also compare validated DSM-5 assessments for rumination disorder with Rome criteria for rumination syndrome as prevalence may differ.

Prevalence and associated factors of symptoms of pica among adolescent schoolchildren in northern Sudan: a cross-sectional study

BACKGROUND

Pica, the craving for and purposive eating of non-food items, is a common worldwide problem, especially among children and pregnant women. There are few published data on pica among adolescents in sub-Saharan Africa, and no study has been carried- out in Sudan. This study was conducted to determine the prevalence and associated factors of symptoms of pica among adolescent schoolchildren in northern Sudan.

METHODS

A school‑based cross‑sectional study was conducted from July to September 2022 among adolescent students (aged 10-19 years) in four public primary and secondary schools in Almatamah locality in north Sudan. Sociodemographic information (age, sex, mother's education, mother's occupation, and father's education) was collected through a questionnaire. Weight and height were measured using a standard procedure, and the body mass index Z-score was computed using the World Health Organization's reference values. Logistic regression analysis was performed.

RESULTS

Of the 384 enrolled adolescents, 180 (46.9%) were male and 204 (53.1%) were female. Their median (interquartile range) age was 15.1 (13.1‒16.3) years. The prevalence of symptoms of pica was found to be 30.7%, accounting for 118 adolescents. The most common type of pica was geophagia (eating clay and sand; 102 adolescents, 86.4%), followed by pagophagia (eating ice; 14 adolescents, 11.8%) and flour (starch; two adolescents, 1.6%). In the logistic regression analysis, females (adjusted odds ratio = 3.52, 95% confidence interval (CI) = 2.15‒5.78) and a lower level of father's education (adjusted odds ratio = 2.05, 95% CI = 1.26‒3.34) were associated with symptoms of pica.

CONCLUSION

In Sudan, symptoms of pica are common among adolescents, especially females. Caregivers need to assess pica in adolescents. Further research is needed to develop guidelines, medical training, and practice.

Worldwide prevalence of DSM-5 eating disorders among young people

PURPOSE OF REVIEW

Eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, and other eating disorders) affect young people worldwide. This narrative review summarizes key studies conducted on the prevalence of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) eating disorders among young people in 2013-22.

RECENT FINDINGS

In Western settings, a substantial proportion of young people have reported an eating disorder. Overall, 5.5--17.9% of young women and 0.6-2.4% of young men have experienced a DSM-5 eating disorder by early adulthood. Lifetime DSM-5 anorexia nervosa was reported by 0.8-6.3% of women and 0.1-0.3% of men, bulimia nervosa by 0.8-2.6% of women and 0.1-0.2% of men, binge eating disorder by 0.6-6.1% of women and 0.3-0.7% of men, other specified feeding or eating disorders by 0.6-11.5% of women and 0.2-0.3% of men, and unspecified feeding or eating disorders 0.2-4.7% of women and 0-1.6% of men. Gender and sexual minorities were at particularly high risk. Emerging studies from Eastern Europe, Asia, and Latin America show similar high prevalences. During the COVID-19 pandemic, the incidence of eating disorders has still increased.

SUMMARY

Eating disorders are a global health concern among young people. Improved detection, management, and prevention methods are urgently needed.

Prevalence of pica and rumination behaviours in adults and associations with eating disorder and general psychopathology: findings form a population-based study

AIMS

Pica and rumination disorder are known as feeding disorder diagnoses in childhood, but little is known about their occurrence in adulthood. This study aimed to assess prevalence rates of one-time and recurrent pica and rumination behaviours (PB and RB) in adults, including sociodemographic subgroups, and to examine associations with other eating disorder and general psychopathology.

METHODS

The representative population sample (N = 2403) completed measures on PB and RB, symptoms of avoidant/restrictive food intake disorder (ARFID), body image and symptoms of depression and anxiety.

RESULTS

Any PB and RB were reported in 5.33 and 5.49%, respectively, while recurrent PB or RB occurred in 1.08 and 0.71%, respectively. Co-occurrence was high, with 35.29% of recurrent PB in RB, and 23.08% vice versa. Prevalence rates of recurrent PB or RB did not differ by gender, weight status, educational or migration history from those without recurrent behaviours. Adults with v. without recurrent PB and RB showed more symptoms of ARFID, general eating disorders depression and anxiety, and behavioural symptoms of eating disorders (with the exception of compensatory behaviours in recurrent PB), and less positive body image. However, there were no differences regarding age and body mass index.

CONCLUSIONS

Our findings highlight the clinical significance of PB and RB in adults regarding both prevalence and associations with other psychopathological symptoms. In particular, associations with body image need to be investigated further, as in contrast to other eating disorders, body image disturbance is not yet represented in the diagnostic criteria for pica and rumination disorder. In sum, the findings highlight the need for clinical attention for these disorders and related behaviours in adults.

Assessment of avoidant restrictive food intake disorder, pica and rumination disorder: interview and questionnaire measures

PURPOSE OF REVIEW

This article reviews available assessment instruments for three of the feeding and eating disorder diagnostic categories: avoidant restrictive food intake disorder (ARFID), pica, and rumination disorder (RD). It includes an overview of the current status of screening tools, questionnaire measures, and diagnostic instruments.

RECENT FINDINGS

Screening instruments are available for all three disorders; however, for pica and RD, these typically include single screening items only and do not cover any specific features of these presentations. Only one questionnaire suitable for clinical populations is included, covering ARFID only. Standardized diagnostic interviews are limited to two covering both pica and RD, only one of which provides further clinical information. Of the five diagnostic instruments for ARFID described here, two include diagnostic items as well as allowing more detailed assessment of clinical features.

SUMMARY

There are a limited number of assessment measures available for all three disorders, with instruments for ARFID being the greatest in number and widest in terms of scope. A commonly encountered difficulty is that many assessment instruments do not adequately cover diagnostic exclusion criteria, which raises the likelihood of false positive findings. All currently available measures require further study to determine their reliability and validity.

Rumination Syndrome in Children and Adolescents: A Mini Review

Introduction: Rumination syndrome involves recurrent regurgitation of food and is believed to be underdiagnosed with patients experiencing long delays in diagnosis. It can be associated with significant social consequences, high rates of school absenteeism, and medical complications such as weight loss. The primary aims of the current review are to assess the literature regarding prevalence, pathophysiology, and treatment outcomes with a focus on neurotypical children and adolescents. Results: Population studies in children/adolescents, 5 years of age or older, range from 0 to 5.1%. There are fewer studies in clinical settings, but the prevalence appears to be higher in patients with other gastrointestinal symptoms, particularly chronic vomiting. While physiologic changes that occur during a rumination episode are well-described, the underlying cause is less well-defined. In general, rumination appears to have similarities to other functional gastrointestinal disorders including dysmotility, possibly inflammation, and an interaction with psychologic function. While diaphragmatic breathing is considered the mainstay of treatment, pediatric data demonstrating efficacy is lacking, especially as an isolated treatment. Conclusion: Pediatric rumination syndrome remains greatly understudied, particularly regarding treatment. There is a need to better define prevalence in both the primary care and subspecialty clinical settings, especially in patients presenting with vomiting or apparent gastroesophageal reflux. There is a need to determine whether treatment of co-morbid conditions results in improvement of rumination. Diaphragmatic breathing needs to be studied and compared to other competing responses.

Demographic, clinical, and biochemical predictors of pica in a large cohort of blood donors

BACKGROUND

Pica is characterized as repeatedly eating or chewing a non-nutritious substance including, but not limited to ice, clay and dirt, starch, raw pasta, chalk, coal, paint, or paper. Pica symptoms can be intense and addiction-like and disrupt quality of life. It is strongly linked to iron deficiency. Since substantial iron loss occurs during blood donation, blood donors may be susceptible to development of pica behaviors.

METHODS

We investigated demographic, clinical, hematological, and biochemical factors associated with pica using univariable and multivariable logistic regression analysis in a cohort of 11,418 racially diverse blood donors. Pica was defined by questionnaire responses as consuming at least 8 oz of ice daily and/or consumption of non-ice substances regardless of the amount and frequency.

RESULTS

Pica was present in 2.2% of the donors. The sensitivity and specificity of pica in iron-deficient donors were 36% and 82%, respectively. Lower ferritin (p = .001), non-Asian race (p < .001), higher red cell distribution width (p < .001), younger age, and restless legs syndrome (p = .008) were independently associated with pica. Female sex is associated with iron deficiency but was not an independent predictor of pica suggesting that iron deficient males and females were equally susceptible to the development of pica behaviors. Donors with normal ferritin levels also reported pica, reinforcing the role of non-iron related factors in its presentation.

CONCLUSIONS

We have identified demographic, clinical, and biochemical predictors of pica that help identify those most at risk for developing pica behaviors, and thereby assist in its clinical diagnosis and treatment.

Estimated Prevalence and Care Pathway of Feeding and Eating Disorders in a French Pediatric Population

Feeding and Eating Disorders (FED) are mostly described in infants and adolescents but are less well-known in children. Information on the prevalence of FED in the general pediatric population is still limited. The aim of this study was to estimate the prevalence and the care pathway of FED in a population aged 0-18 years old, using the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 classification. Two physicians interviewed 401 families using a questionnaire including demographics, BMI, dietary behavior data, and age-appropriate screening tools. Qualitative and quantitative variables were compared using the Chi² test and Student's t-test, respectively. After a headcount adjustment based on the French population by age group, the estimated prevalence rate was 3% [95%CI (1.7-5.1)] for Avoidant and Restrictive Food Intake Disorder (ARFID), and 9.7% [95%CI (7.2-13.0)] for Unspecified FED (UFED), which included other restrictive and compulsive FED. The median age for ARFID was 4.8 years (0.8-9 years), and 7.5 years (0.6-17 years) for UFED. The interviews did not identify cases of anorexia, bulimia, binge eating disorder, other specified FED, pica or rumination. Only 15.2% of children with an FED were receiving medical care. The development of validated pediatric screening tools, as well as the training of health professionals in children FED is necessary.

Rumination syndrome: Critical review

Rumination syndrome is a functional disorder characterized by the involuntary regurgitation of recently swallowed food from the stomach into the mouth, from where it can be re-chewed or expelled. Clinically, it is characterized by repeated episodes of effortless food regurgitation. The most usual complaint is frequent vomiting. The physical mechanism that generates regurgitation events is dependent on an involuntary process that alters abdominal and thoracic pressures accompanied by a permissive oesophageal-gastric junction. The diagnosis of rumination syndrome is clinical, highlighting the importance of performing an exhaustive anamnesis on the characteristics of the symptoms. Complementary tests are used to corroborate the diagnosis or rule out organic pathology. Treatment is focused on behavioural therapies as the first line, reserving pharmacological and surgical therapies for refractory cases.

Rumination syndrome. A review article

Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation of ingested food into the mouth. An unperceived postprandial contraction of the abdominal wall could be a key mechanism. In those patients, retrograde flow of the ingested gastric content into the mouth is produced due to a simultaneous combination of elevated intra-abdominal pressure and negative intrathoracic pressure. The estimated prevalence is around 2% in the general adult population. The main clinical characteristics include: a) early postprandial regurgitation, b) the effortlessly regurgitated material is similar to the ingested food, c) the regurgitated material is spit out or swallowed again. The clinical diagnosis of rumination syndrome relies on the clinical criteria. High resolution esophageal manometry, ideally including impedance monitoring, can be an important adjunct for making the clinical diagnosis. Its management is based on instruction as to the nature of the pathology, education in postprandial diaphragmatic breathing, and the assessment of possible psychiatric comorbidity. Baclofen use is reserved for second-line treatment in patients with refractory symptoms.

Avoidant/restrictive food intake disorder symptoms are frequent in patients presenting for symptoms of gastroparesis

INTRODUCTION

Patients with symptoms of gastroparesis/dyspepsia often avoid foods or restrict eating for symptom management. There is growing interest in understanding risk for feeding/eating disorders (FEDs) like avoidant/restrictive food intake disorder (ARFID). Among patients presenting with gastroparesis/dyspepsia symptoms, we aimed to determine: (a) FED symptom frequency, and (b) relation of FED symptoms to gastrointestinal symptom severity and gastric retention abnormalities.

METHODS

Adult patients (N = 288; 78% female) referred for gastroparesis/dyspepsia symptoms at two academic medical centers from January 2018-February 2019 completed self-report surveys for gastrointestinal symptom severity and FED symptoms. Gastric retention data were available for 210 patients, using 4-hour EggBeater gastric emptying scintigraphy (GES).

RESULTS

Clinically significant FED symptoms were present in 158 patients (54.9%). Interestingly, 115 patients (39.9%) met conservative self-report cutoff for ARFID symptoms, with 67 (23.3%) patients having documented psychosocial/medical impairment. Of those with survey data for other FEDs (n = 239), only 28 patients (11.7%) had restrictive eating disorders (anorexia nervosa; unspecified FED). Likelihood of having FED symptoms was significantly associated with greater gastroparesis symptom severity (OR = 2.23, P < .001), but not GES. In addition, gastroparesis symptom severity was moderately and significantly associated with greater ARFID symptom severity (b = 0.45, P < .001), but neither GES nor other FED symptoms.

DISCUSSION

In patients presenting with gastroparesis/dyspepsia symptoms, FED symptoms were frequent (55%), particularly ARFID, and were associated with greater gastrointestinal symptom severity, but not gastric retention. Gastroparesis/dyspepsia symptoms may mimic FEDs, particularly ARFID. Clinicians should be cautious about diagnosing ARFID in gastroparesis/dyspepsia patients, and screening for ARFID could assist behavioral treatment referral.

Education, dissemination, and the science of eating disorders: Reflections on the 2019 International Conference on Eating Disorders: Editorial to accompany IJED Virtual Issue in honor of the 2019 International Conference on Eating Disorders

OBJECTIVE

This virtual issue of the International Journal of Eating Disorders highlights recently published research that aligns with the broad themes of the 2019 International Conference on Eating Disorders (ICED), held in New York, NY, USA.

METHODS AND RESULTS

We selected articles that were published between 2017 and 2019 that complement the content of the keynote and plenary sessions. We also curated additional articles from early career scholars, given that an important component of the annual ICED is to foster the development and training of the next generation of eating-disorder clinicians and researchers.

DISCUSSION

We hope that this virtual issue will spark more in-depth discussion and reflection on the topics, questions, and critical advances in the field of eating disorders that were presented at the 2019 ICED.

Diagnosis and Treatment of Rumination Syndrome: A Critical Review

Rumination syndrome (RS) is characterized by the repeated regurgitation of material during or soon after eating with the subsequent rechewing, reswallowing, or spitting out of the regurgitated material. Rumination syndrome is classified as both a "Functional Gastroduodenal Disorder" (by the Rome Foundation's Functional Gastrointestinal Disorders: Disorders of Gut-Brain Interaction, 4th edition) and a "Feeding and Eating Disorder" (by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition). Rumination syndrome is a disorder that is often inaccurately diagnosed or missed, resulting in patients experiencing protracted symptoms and not receiving treatment for long periods. There is a lack of clear consensus for RS diagnosis, mechanisms that maintain RS, and treatment. Guided by existing research and our clinical expertise, we synthesize available evidence and provide recommendations for clinical use. We present a case example and critically summarize the literature to date to (i) increase clinicians' understanding of heterogeneous clinical presentations, (ii) suggest assessment strategies to facilitate accurate diagnosis, and (iii) provide a schematic for intervention options. Overall, we recommend clinicians recognize the heterogeneous features of RS when considering diagnosis, assess for RS symptoms by clinical history, and treat RS with targeted diaphragmatic breathing while using other methods as augmented intervention or alternative treatment.

Development of the Pica, ARFID, and Rumination Disorder Interview, a multi-informant, semi-structured interview of feeding disorders across the lifespan: A pilot study for ages 10-22

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID), pica, and rumination disorder (RD) were added to the revised DSM-5 Feeding and Eating Disorders chapter in 2013. We developed a structured interview-the Pica, ARFID, and Rumination Disorder Interview (PARDI)-to assess the presence and severity of these diagnoses for evaluation and treatment planning in clinical and research settings. Here, we describe the development of the PARDI and provide a preliminary report on feasibility, acceptability, reliability, and validity in relation to ARFID.

METHOD

We created an initial item pool from existing measures of similar constructs and clinical experience. The PARDI includes items assessing the level of endorsement and overall severity of common ARFID features organized into profiles (i.e., sensory sensitivity, lack of interest in eating, and fear of aversive consequences) and algorithms for diagnosing ARFID, pica, and RD. We collected initial psychometric data from participants (10-22 years) with ARFID (n = 39), clinically significant avoidant/restrictive eating (n = 8), and healthy controls (n = 10).

RESULTS

On average, the PARDI took 39 min to complete and was acceptable to participants. All subscales achieved internal consistency greater ≥0.77, and inter-rater reliability for the ARFID diagnosis was moderate (κ = 0.75). Individuals with ARFID scored significantly higher than healthy controls on ARFID severity and ARFID profiles.

DISCUSSION

The PARDI appears acceptable to respondents and preliminary evidence of reliability and validity has been demonstrated in an initial sample. Larger-scale validation studies are currently underway. The PARDI is freely available to clinicians and researchers.

Pica: A Common Condition that is Commonly Missed - An Update Review

BACKGROUND

Pica is a common condition in childhood that is commonly missed.

OBJECTIVE

To familiarize physicians with the clinical evaluation and management of children with pica.

METHODS

A PubMed search was completed in Clinical Queries using the key term "pica" OR "dirteating". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Pica refers to the persistent, compulsive craving for and the ingestion of substances usually considered inedible and the behavior is discordant with cultural practices and continues beyond the normal developmental phase of occasional indiscriminate and experimental mouthing and swallowing over a period of at least one month. The condition is more common among children in lower socioeconomic classes and those who are mentally handicapped or emotionally deprived. Pica is a significant cause of anemia and lead poisoning. Pica generally resolves in children of normal intelligence after they have been trained to discriminate between edible and inedible items and proper supervision is provided. While relief of family economic and housing difficulties is an adjunct, attention to the individual's emotional needs and stresses is of paramount importance. Children with iron deficiency anemia should be treated with iron replacement therapy. Complications such as gastrointestinal obstruction and lead poisoning should be promptly recognized and treated.

CONCLUSION

Pica is often an overlooked phenomenon and its association with iron deficiency and lead poisoning has been known for centuries. The underlying cause and complications should be treated if possible. Primary care physicians should be aware of pica and proactively seek information about pica in patients that belong to the high-risk groups.