A comprehensive history should be pursued along with caregiver interviews. The details of the exposure should be sought, including the type of substance, amount, duration of exposure, settings where behavior usually happens, the source of the substance, any co-ingestions, and symptoms of toxicity.[21]

While, in most cases, the physical exam will be normal,[22] one should look for signs of poisoning or complications. Bezoar ingestion could lead to obstruction and, possibly, ulceration and perforation. Lead poisoning manifests with neurological signs such as lethargy, headache, seizure, encephalopathy, cranial nerve palsy, and papilledema. Infectious agents that could present in clay include Toxocara and Ascaris. Signs of such parasitic infections include fever, cough, myocarditis and encephalitis, hepatomegaly, and visual disturbance.[21][23][24]

Laboratory evaluation should be tailored according to the suspected substances ingested. Iron studies in patients with pica should be performed, especially in women who are pregnant, and children. Lead (in pica for paint and chalk) and zinc levels should be checked where appropriate.[25] A basic metabolic panel should be obtained, especially in clay ingestion which can cause metabolic disturbances such as hypokalemia.[26]

Imaging studies are usually required when patients have abdominal symptoms. This may include plain abdominal x-rays, barium studies, and endoscopy. In many cases, serial studies are needed to ensure that the substance has passed.

Primary prevention should be utilized to identify at-risk patients such as children who live in old homes with lead paint and woman who are pregnant. This could be achieved by screening for the condition among such populations.[27][28][29] Strategies should be utilized to decrease exposure to the craved substance, such as reducing access or providing an appropriate substitute with a similar texture.[30] Iron, zinc, and other nutrient supplementation should be provided when a deficiency is identified.[31][32][33] Behavioral and aversive treatment might be effective in patients with mental disabilities.[34] Differential reinforcement is a commonly used strategy to induce different patient responses to pica by redirecting the undesired behavior to other activities.[35]

There are no medications specifically for the treatment of pica. While there are anecdotal reports about antipsychotic use to reduce pica behaviors, these drugs also cause constipation and other adverse effects.

Besides the removal of the substance from the environment, it is important to assess the cultural traditions and beliefs that promote pica behavior.

Careful screening should be performed for mental health problems in the setting of pica. Several psychiatric illnesses should be considered in the differential diagnosis including other eating disorders, schizophrenia and psychosis, autism and developmental delay in children, substance abuse and addiction.[36][37]

Pica is usually a benign disorder if it is short term. In pregnant women and children, the condition spontaneously disappears without any sequelae. However, in individuals with intellectual impairment, it may persist for years. When Pica is long term it can result in bowel obstruction, bezoars, and even toxicity. Ingestion of dirt and paint can lead to infections and heavy metal toxicity. Many reports exist of people who have had to undergo surgery to relieve bowel obstruction, perforation, and ulcers.

The complications of pica can be categorized according to the type of substance ingested:

• Geophagia: Clay ingestion is a very common form of pica. It can lead to constipation, hypokalemia with myopathy, and nutritional deficiencies.[38][26][39] Clay can also be a source of many infectious agents such as parasites. Lead poisoning can be a serious complication with clay ingestion.
• Pagophagia: Ice ingestion could lead to iron deficiency, especially during pregnancy.[36] Other complications include tooth decay and sensitivity.[40]
• Amylophagia: Excessive starch consumption has been associated with iron deficiency. It also can cause high blood sugar and obesity due to its high carbohydrate content.[41]
• Other substances: Ingested materials can contain a wide variety of toxic contaminants such as lead, mercury, arsenic, fluoride, and many others. Exposure to such items can lead to a wide range of toxic effects such as lead poisoning.[42] Lead poisoning could have dire consequences, particularly among women who are pregnant, and high levels can result in seizures.[43] 

Fetal Toxicity

Pica during pregnancy can have dire consequences on the growing fetus. There are case reports of intrauterine toxicity due to maternal pica. Lead poisoning has been implicated in long-term neurological disability.[44] Maternal geophagy has been associated with childhood motor function delay.[45]

Treatment of patients with pica should utilize an interprofessional team approach. A team consisting of a physician, psychiatrist/psychologist, behavioral therapist, social worker, and dietitian. Patients should be treated in a nonjudgmental manner, with particular attention to their cultural and social background.[46]

Patient education is vital. Failure to educate patients on healthy eating habits is a common reason why pica can be prevalent in some populations. Parents need to be educated about the harms of ingesting nonnutritive substances by their children and the need for limiting such exposure. In some jurisdictions, landlords have to ensure that lead-based painting is removed. A dietary consult may benefit some families. Close follow up by the nurse practitioner may be required to ensure that the pica behavior is not continuing.

Clinicians should communicate with each other so that the same message is sent to the parent or caregiver.