Mrs. Nirmala
Jyothi
Professor, Department of Community Health Nursing,
NRI college of Nursing Mangalagiri, Guntur.
Corresponding Author Email:
ABSTRACT:
Pica
is the term used to describe the intense craving for and eating of non-food
items, such as soil, clay, laundry starch, ice, ashes, plaster, paint chips,
and coffee grounds. Pica which comes from the Latin word for magpie, a bird
known for eating almost anything is a worldwide phenomenon and seems to be more
common during pregnancy. No one knows what causes these unusual cravings, but a
combination of biochemical, psychological, and cultural factors may be at work.
In some studies, pica has been linked to iron deficiency, even though none of
the craved items contain a significant amount of iron. The Present case report
on Mrs. Gannga Bhavani has
a similar kind of pica i.e., eating of raw rice problem which was noticed in the
urban community setting in Guntur. The client and her family were taken to
study the case in detail. One the examination the client was noticed having
severe problem with associated complications. Client was counseled and referred
to NRI general hospital for further treatment.
KEYWORDS: Pica,
History, Pathophysiology, complications, treatment.
INTRODUCTION:
Nearly everyone had heard of the
strange food cravings and aversions pregnant women experience. But many people
are unfamiliar with pica, a disorder in which pregnant women feel the
insatiable usage to eat foods much more extraordinary and sometimes dangerous.
One reason that pica remains poorly understood is that neither its prevalence
nor social and biological correlates have been well characterized. Pica is
frequently either overlooked by researchers, concealed by consumers, or
both. It is of public health interest
because it is highly prevalent among the most biologically vulnerable
populations: pregnant women and children1. It is true that the
majority of women will experience cravings during pregnancy; however, most
of these cravings are for things like pickles and ice cream. Pica cravings
are most commonly seen in children and occur in approximately 25-30% of
all children; pica cravings in pregnant women are even less common2.
Pica, the craving and purposive consumption of non-food substances, is of
public health concern for its potential deleterious and salubrious health
consequences.
However, neither
its prevalence nor demographic correlates have been well characterized. However
it one of the important responsibilities of the physician and community health
nurses to identify such cases even during pregnancy itself and take preventive
measures2.
Client Profile
Mrs. Ganga Bhavani (name changed to
maintain anonymity) 28 year old female, resident of Israelpet
Guntur district had developed a strange practice of eating “Uncooked Raw Rice”
the consumption of raw starches during pregnancy. She delivered a healthy
female child in the year 2004. But the problem of pica had continued even after
the delivery and had become a habit. Even now after 9 years of child birth also
she is persisting with same problem of eating raw rice at least 200 grams per
day. She says that she is unable to get rid of this craving, tried however many
ways. She had developed many other side effects such as severe anemia, lose of
weight, glossitis, angular stomatitis,
lethargy and weakness in lower limbs. Since the problem and the related
complications have become so severe and most of the time she has been confined
to bed due to which husband had divorced. She and her family are suffering from
lot of family, social and financial crisis.
History of client:
Past history: There was no significant childhood illness
reported or no past history of any medical and surgical interventions. The
client was healthy and no relevant developmental disorders were noted.
Obstetrical history:
Mrs.
Ganga is
gravid1 and Para1. She has developed pica from the 3rd
month of pregnancy and persisting till date. Had complaint of maternal Birth
injury – due to which she has developed unstable gait, unable to walk, partial
paralysis of left lower limb and severe pain while walking and sitting.
Reported having developed postnatal psychosis by family members and underwent
treatment for the same but no significant positive results were found followed
by treatment. She was also diagnosed having hypokalemia
and on potassium supplements. Also having severe anemia and taking iron
supplements.
Present History:
On
10th September 2013 I found Mrs. Ganga Bhavani weeping and walking on the Israel pet street
heading towards railway track to attempt suicide. I have taken her back to her
house. While interacting with family members it was explored that there was
misunderstanding and quarrel between her, neighbors and parents which made her
to decide to end her life.
Chief complaints: The family members have reported
saying that the main problems with her are; consuming raw rice daily and
continuously, non compliance to treatments and medications, always confining to
bed and not doing any kind of ADL, depression and weeping.
Assessment Findings:
On
examination; weight 34 kgs, height 152 cm,
Temperature 98.60 C, BP 100/60 mmhg, PR
68/mt, RR 20/mt. Hb% 7.2 g/dl, eyes look pale, angular stomatitis,
unstable gait, irrelevant talk, aggressive behavior and suicidal tendency.
What is Pica?
Pica
was documented as early as 400 Bc by Hippocrates and
continues to be practiced today. Pica is generally considered to be a chronic
behavior (> 1 month). The word Pica is derived from the Latin for
magpie, a bird known for its curious eating habits. The Diagnostic and
Statistical Manual of Mental Disorders defines pica as, “The persistent
eating of non-nutritive substances for a period of at least one month, without
any association with an aversion to food.4”
Pica
in humans has many different subgroups, explains Stefanie B. N. Dugan, MS, in a
paper published in the Gale Encyclopedia of Medicine. Each of these
subgroups is defined by the substance ingested. Some of the most commonly
described types of pica are eating earth, soil, or clay (geophagia);
ice (pagophagia); and starch (amylophagia)4.
However, dozens of other substances, including cigarette butts and ashes, hair,
paint chips, and papers have also been reported. But in case of Mrs. Gnaga Bhavani a rare substance
raw rice (which may be grouped under raw starch (amylophagia)
has been recognized as a pica substance5, 6.
Pathophysiology:
There
is no clear unifying explanation of why pica occurs. Cultural beliefs,
micronutrient deficiency (especially iron and calcium), hunger, and medicinal
purpose may each play a role5. Although pica occurs in women all
over the world unfortunately the prevalence of pica is relatively unknown
because not only the disorder is frequently unrecognized but often women won’t
report these strange cravings due to embarrassment and fear of ridicule. There
are many theories as to why pica exists; major theories include: Eating nonfood
items to satisfy a psychological need (such as a response to stress or an oral
fixation); cultural influence or traditions that have been passed on for
religious, medicinal, or magical reasons; sensory relief to help with nausea,
hunger, or to appease the appetite when food is scarce; nutritional needs when
the body isn’t taking in adequate nutrients, such as iron (which pica items are
believed to contain); or for microbiological purposes (the belief that clay,
for instance, may promote a favorable pH for good micro flora in the
body). Dougan
suggests that one widely held theory points to iron deficiency as a major cause
of pica. Several reports describe pica in individuals with documented iron
deficiency, although it is uncertain in these cases whether iron deficiency was
a cause of pica or a result of it4, 5.
Possible causes:
Nutrient
deficiencies; especially Iron and Zinc, mental disorders like stress, OCD
(obsessive compulsive disorder) and developmental disorders.
Ø Inherent toxicity, including
direct toxic effects of substances such as lead or other heavy metals;
Ø Obstruction, such as may be seen
in trichophagia (hair eating);
Ø Excessive calorie intake,
generally related to amylophagia (starch eating)
Ø Nutritional deprivation, such as
eating clay instead of nutritive foods; and other, such as parasitic infections
and dental injury.
Treatment:
According
to Donatelli, “If pica is confirmed, medical care and
treatment must begin immediately. A multi-disciplinary approach is the best
course of action and must involve a psychologist, registered dietitians,
physicians, and possibly even social workers.” She continues, “There is no
specific treatment, or preventative measure for pica, but one must take into
account the specific symptoms … and address any nutrient deficiencies and
toxicities immediately3.”
Nursing Management and Interventions:
Ø Education about nutrition along
with iron therapy: is first wave of intervention. Advised the family members to
provide nutritious diet containing green leafy vegetables, dhal, egg, and other
vegetables, gaggiry containing foods to the client
along with iron and vitamin supplements.
Ø Psychological counseling or
behavior therapy: The client was counseled individually and along with parents.
The family members are taught about Behavioral interventions, such as
reinforcement for eating and mild punishment for engaging in pica.
Ø Advised and taught the client
simple ROM exercises of lower limbs.
Ø Parents were instructed to
provide closer supervision of the client for avoiding eating raw rice and
keeping away from reach of the client. Also watch client very closely for any
kind of suicidal attempts in order to prevent such attempts.
Ø Client is referred to NRI
General Hospital for appropriate treatments, which involves screening for
co-morbid conditions and complications and take necessary treatment.
Ø It was insisted family members
for Severe or disobedient case like Mrs. Ganga Bhavani requires referral to a mental health specialist and
taken immediately to NRI general hospital for psychological counseling.
Evaluation and Progress:
Initially
the client Mrs. Ganga bhavani
was very much determined to change her behavior and tried to reduce the intake
of raw rice. She has reduced from 200gm to 100gm. She came out of the thoughts
of suicidal attempts. But the client needs continuous reinforcement,
supervision on her behavior and constant guidance and support by the family
members and health personnel. During her course in the outpatient department,
the patient remained in stable condition with improvement in her behavior. She
was subsequently given instructions to discontinue her pica habit and follow
up with her primary care provider at UHC Israelpet.
1. http://www.babycenter.com/404_what-causes-pica-craving-and-consuming-non-food-items-during_1186643.bc
2. http://americanpregnancy.org/pregnancyhealth/unusualcravingspica.html
3. http://en.wikipedia.org/wiki/Pica_%28disorder%29
4. http://www.babyzone.com/pregnancy/prenatal-care/symptoms-treatments-pica_71176
5. Hong
K. Kim, MD, MPH, and Lewis S. Nelson, MD, FACEP, FACMT. Are You What You Eat?
Pica in Pregnancy:
emergency medicine, July 2012.
6. Young SL. Pica in pregnancy: new
ideas about an old condition. Annu Rev of Nutr. 2010;30:403-422.
Received on 26.08.2014 Modified on 15.09.2014
Accepted on 25.09.2014 © A&V Publication all right reserved
Asian J. Nur.
Edu. and Research 5(1): Jan.-March 2015; Page137-139
DOI: 10.5958/2349-2996.2015.00029.4