Pica is defined as the persistent eating of non-nutritive substances for at least 1 month. The word pica is derived from the Latin word for magpie, a bird once thought to eat anything.
The behavior must be inappropriate to the child’s developmental level (i.e., young infants tend to put almost anything into their mouths). In addition, the behavior must not be a part of a cultural practice (e.g., in some cultures, young women may eat clay or other non-nutritive substances). In reality, pica is a condition found in very different populations including toddlers ingesting lead in paint chips, developmentally disabled young adults who eat clothing, and even typically developing adults who eat unusual substances (tissues, pencil erasers).

In many respects, the most well-known example of pica is the eating of paint chips and lead poisoning. This behavior may be more common in less stimulating environments or with parental difficulties, both often co-occurring with poverty. In toddlers, it is typical for pica to begin from ages 1 to 3; the behavior may persist well into childhood, although it is frequently time limited. In persons with intellectual disability, the behavior may appear somewhat later but then may not diminish until middle age; in this population, a greater degree of cognitive impairment is more frequently associated with pica.

Substances ingested may include chalk, dirt, paper, soap, feces, and so forth. Some authorities also classify excessive eating of things that might, in small quantities, be thought of as food (e.g., starch, ice, flour, salt). Various terms for the different forms of pica exist, including coprophagia (consumption of feces) and geophagy (consumption of soil, clay, or chalk). Differential features of pica and other feeding disorders more frequent in young children are provided in Table 14.1.

Pica behavior is relatively common, occurring in as many as one-third of young children and from 10% to 25% of institutionalized adults with intellectual deficiency. The risk in intellectual deficiency increases in parallel with severity of the IQ deficit.

Intellectual disability is a risk factor for pica. There has been some speculation that iron deficiency may be associated with it, although this has not been clearly established (this connection is more firmly established in animals). Pica can be increased by various factors, including stress and anxiety, mood problems, and lack of stimulation.

Various medical problems can be associated with pica. As noted previously, lead exposure is a concern for infants and younger children. Other medical complications may include vitamin or mineral deficiency as well as ingestion of parasites. For some individuals, ingestion of nonfood substances can result in intestinal obstruction and require surgical correction. In some cases, cultural beliefs may be central. Thoughtful medical assessment is needed (e.g., to look for mineral deficiencies, anemia, and so forth).

The course of the disorder depends on the context. For individuals with intellectual disability, the behavior may diminish over time, particularly if an appropriate behavioral program is put into place and an appropriately stimulating environment is provided. In infants and toddlers with pica, the disorder is often very time limited.

Rumination disorder is defined in the DSM-IV-TR on the basis of repeated regurgitation and rechewing of food that occurs for a period of at least 1 month after some period of normal functioning. By definition, this cannot be attributable to an associated gastrointestinal (GI) or some other general medical condition. As with pica, rumination is seen in several rather different contexts. It can be observed in otherwise typically developing infants and very young children. It can also be observed in persons with intellectual deficiency, particularly more severe intellectual deficiency.

Information on clinical features is mostly derived from single case reports or small case series; thus, the available data are limited in important respects. The condition appears to be relatively rare. The issue of whether there is a gender predominance remains controversial. In infants
who are apparently typically developing, the onset is usually before age 1 year. In individuals with intellectual deficiency, the onset can be much later, including in adulthood. Rumination may be seen in association with other eating or feeding problems.

Several different mechanisms appear to be involved in the process of rumination (Woolston, 2007). To further complicate issues of diagnosis the presumption, in DSM-IV-TR, is that there be no underlying GI disease, although the boundaries and potential connections of gastroesophageal reflux (GER), rumination and operant vomiting have yet to be clarified. Several models have emerged from behavioral psychology that might account for rumination. There is some suggestion that rumination is more common in infants who experience an environment that is not appropriately stimulating.

As noted, the clinician should be alert to various factors (medical and psychosocial) that might contribute to rumination. The medical evaluation should include evaluation for possible GER and other gastroenterologic disorders.

The course of rumination disorder is highly variable. In some instances, the problem resolves fairly quickly. In other cases, medical complications (e.g., from aspiration or nutritional problems) may assume major significance. Dental problems are common in individuals with chronic rumination.

As a diagnostic concept, feeding disorder of infancy has its origins in work on failure to thrive (FTT) in infancy, a condition marked by decreased rate of weight gain and associated developmental problems (decelerated weight gain rather than head or linear growth changes was traditionally the major defining feature). The DSM-IV-TR diagnostic concept has the advantages and disadvantages associated with any novel diagnosis. On the one hand, 5 decades of work on FTT had resulted in a large but confused literature. On the other hand, the applicability of some aspects of this literature is put into question. Over the decades, a number of different terms had been used to refer to this concept. In addition to FTT, similar terms included psychosocial deprivation dwarfism, maternal deprivation syndrome, analytic depression, hospitalism, and organic and non-organic FTT. The various terms were used, often interchangeably, even though they were not precisely synonymous. They variably emphasize one or more of the features associated with feeding difficulties in infants. Some have the advantage or disadvantage of essentially specifying an etiology. Differences in definition can, not surprisingly, have major implications for research, so, for example, if a diagnosis of FTT is made based solely on decelerated weight gain, it is rather less frequent to find associated developmental difficulties in the child. Similarly, the various terms used reflect a continued debate of the relative contribution of social-emotional factors (e.g., maternal deprivations) on the one hand and malnutrition on the other. There are several potential difficulties with the definition used in the DSM-IV-TR. Clinical judgment is used to decide if failure to gain weight is significant, exclusionary rules are simplistic, and there are probably at least two subtypes or disorders (an early onset and later onset form that appear to differ in important ways). Some authorities (e.g., Chatoor et al, 1998a, 1998b) have suggested that three distinctive feeding disorders may well exist.

Although the DSM-IV-TR specifies that the onset must be before 6 years of age, the condition usually has its onset in the first years of life. In early-onset cases, attention to problems in caloric intake (or medical conditions accounting for slower growth) may result in rapid weight gain. When psychosocial problems are major components of the clinical picture, relapse can occur if these problems are not addressed. Later onset is much more likely to be associated with more obvious interactional difficulties.

Pediatric hospital admissions for FTT have been noted to account for 1% to 3% percent of all admissions (Woolston, 2007). Although most studies report equal sex ratios, there may be male predominance in later-onset cases. Risk factors include psychosocial adversity, parental psychopathology, and social isolation of the family. Some feeding problems clearly occur in the context of supportive families without obvious risk. In these cases, problems in the child or in the “fit” of the child and parents likely contribute.

Feeding disorder of infancy and early childhood clearly has both physical and behavioral and developmental components. Although inadequate caloric intake is a primary cause of slower than expected growth, other factors (e.g., poverty) may also be associated with developmental delays, and difficulties in the child can contribute to feeding problems in the parent-child dyad.

Medical evaluations should be guided by the clinical examination and history, although the yield from extensive laboratory and clinical studies is relatively low. Although the current DSM-IV-TR criteria “rule out” medical causes of feeding disorder, the reality is complex
because various medical issues can contribute to feeding problems and malnutrition. In the past, efforts were made to distinguish between “organic” and “non-organic” FTT, but this distinction proved somewhat arbitrary and cumbersome. Initial laboratory studies usually include a complete blood count and urinalysis as well as lead level and testing for cystic fibrosis. Premature infants may appear to have poor growth if gestational age is not considered; correction should be made for weight until 2 years of age. Children who are premature or small for gestational age can develop feeding problems, and such infants often already have significant clinical risk factors (e.g., maternal substance abuse, psychosocial adversity) and may have difficulties nursing. Observation of the infant in the act of nursing may help demonstrate difficulties with sucking (see Woolston and Hasbani, 2007).

The DSM-IV-TR feeding disorder concept is relatively new. The older literature on FTT suggests a highly variable outcome. Family functioning, psychosocial adversity, parental psychopathology, and parental education are all potential mediating variables. The prognosis is generally worse in the presence of chronic developmental delay and malnutrition.

Factors that impact outcome include age of onset, duration, degree of malnutrition and of growth problems, associated problems in the child (e.g., medical conditions, developmental delays), and risk factors in the parents and family. With infants younger than 1 year of age, absent associated medical conditions, the child either has not been given sufficient caloric intake or has such significant difficulties with feeding that the act of feeding becomes tremendously difficult. Infants are at higher risk for physical abuse and neglect.