What are the pharmacologic options for managing pica in pregnant women?

Background

According to the 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders, pica is a condition involving persistent eating of nonfood substances for over at least 1 month that is not part of cultural or social practice.¹ Pica occurs more frequently during pregnancy – close to 30% of pregnant or postpartum women experience pica worldwide, with the highest prevalence in Africa.^2-4 The prevalence numbers may be underreported because many pregnant women feel uncomfortable reporting the condition.³ Most common cravings consist of clay or dirt (geophagia), large amounts of ice (pagophagia), or raw starch (amylophagia). Cravings for substances such as cigarette ashes, burnt matches, stones, coffee grounds, paint chips, or sand may occur.

Although the causes of pica in pregnancy are unclear, certain risk factors predispose pregnant women to developing this condition.³ One theory suggests that deficiencies in minerals such as iron or zinc contribute to pica, while others propose that practicing pica interferes with micronutrient absorption and leads to these deficiencies.^3,5 A meta-analysis of 70 studies revealed that women with anemia are 1.6 times more likely to develop pica compared with women without anemia and that patients of African American ethnicity are 2.2 times more likely to have pica compared with other ethnicities.² Other risk factors for developing pica include lower educational status, residence in rural areas, and culture (eg, women in Kenya consume clay due to its perceived role in fertility and reproduction).^2,3

Complications of pica depend on the ingested substance and its amount.³ Ingestion of clay may cause nutritional deficiencies, constipation, and/or gastrointestinal obstruction or perforation. Ingestion of soil could lead to nutritional deficiencies and intestinal parasite infection, while ingestion of ice lacks notable complications. A meta-analysis of 43 studies revealed that pica contributes to developing anemia and lowering hemoglobin, hematocrit, and/or zinc levels.⁶ The effects of pica on the fetus remain unclear. A study revealed that head circumferences of infants born to women struggling with ingestion of large quantities of ice and/or freezer frost were smaller compared with infants born to women without pica.⁷ And a more recent study found that pica may affect birth weights of infants.⁸ On the contrary, another study showed a lack of pregnancy complications in women with pica.⁹

Treatment

Typical treatment for pica involves counseling and assessment for other psychiatric disorders, but some patients may require pharmacologic interventions.³ Women with iron deficiency anemia require iron supplementation as the evidence reveals a positive correlation between anemia and pica.¹⁰ Case reports explored additional pharmacological treatments for persisting pica.

Iron supplementation

Treatment of iron deficiency anemia can resolve pica. Two case reports described the effects of managing iron deficiency anemia in patients with pica that developed during pregnancy (Table 1). In 1 case, a patient developed pagophagia during pregnancy that continued for 4 years postpartum; the laboratory work-up revealed iron deficiency.¹¹ The patient, who was not pregnant at the time of treatment, received iron therapy leading to the resolution of pagophagia at 1 month. The case did not specify the formulation, dosing, or frequency of iron therapy. A more recent case report described administering 1 dose of intravenous iron dextran to a pregnant woman with iron deficiency and cravings for bar soap and laundry detergent.¹⁰ The cravings fully resolved at 36 h post-administration. This case illustrates that deficient iron stores may drive pica behavior. The authors urged to screen all pregnant women for pica and consider using parenteral iron formulation to rapidly replenish iron stores in pregnant women near term. Patients with malabsorption issues would also benefit from parenteral iron.

The 2008 American College of Obstetricians and Gynecologists guideline on anemia in pregnancy recommends screening all pregnant women for anemia.¹² Women with iron deficiency anemia should receive supplemental iron, preferably oral. Parenteral iron is reserved for patients with intolerance to oral iron, malabsorption syndrome, or severe iron deficiency anemia. The guidance notes that parenteral iron may improve hemoglobin levels faster compared with oral iron, but by day 40, both formulations correct hemoglobin to a similar level.

Pharmacologic treatments

The evidence for pharmacologic treatment of pica during pregnancy remains limited. One case report described a 26-year old female presenting with consumption of uncooked rice and wheat that started during her third pregnancy and continued postpartum.¹³ These symptoms presented during the last 2 pregnancies. After family history assessment, providers diagnosed the patient with obsessive-compulsive disorder presenting as pica. She was treated with fluoxetine 40 mg daily, and at 2 months, her eating habits improved (her case was eventually lost to follow-up).  Another case report described a 35-year old female who was not pregnant and ingested chalk during stressful situations responding to escitalopram 10 mg/day and clonazepam 0.25 mg/day by week 2.¹⁴

The rest of case reports primarily describe managing consequences of pica. A few case reports discussed administering intravenous and oral potassium supplementation to pregnant women who developed hypokalemia as a result of clay ingestion.^15,16 Some pregnant women required chelation therapy for lead poisoning as an aftermath of ingesting soil, clay, or pottery.¹⁷

Conclusion

Worldwide, pica affects up to 30% of pregnant and postpartum women, and this number may be underreported. Certain factors increase the risk for developing this condition during pregnancy – presence of anemia, African American ethnicity, lower educational status, residence in rural areas, and culture. The preferred treatment for pica during pregnancy consists of counseling. A positive correlation between iron deficiency anemia and pica exist, and thus, all pregnant women should be screened for anemia. Iron supplementation is necessary for women with iron deficiency anemia, and treating iron-deficiency anemia may resolve pica. Oral iron supplementation is preferred, but women with intolerance to oral iron, malabsorption issues, and being near term may require parenteral iron. The evidence for pharmacologic treatment of pica during pregnancy is limited to correcting electrolytes imbalances (eg, hypokalemia), treating potential poisonings (eg, lead poisoning), or using selective serotonin reuptake inhibitors (SSRIs) in situations where an additional psychiatric condition is suspected (eg, obsessive-compulsive disorder). Treatment with SSRIs is ideally initiated during the postpartum period. Paucity in high-quality evidence for treating severe pica during pregnancy exists, and further research is necessary to identify options for women struggling with this condition.

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.
2. Fawcett EJ, Fawcett JM, Mazmanian D. A meta-analysis of the worldwide prevalence of pica during pregnancy and the postpartum period. Int J Gynaecol Obstet. 2016;133(3):277-283. doi:10.1016/j.ijgo.2015.10.012
3. Zielinski R, Searing K, Deibel M. Gastrointestinal distress in pregnancy: prevalence, assessment, and treatment of 5 common minor discomforts. J Perinat Neonatal Nurs. 2015;29(1):23-31. doi:10.1097/jpn.0000000000000078
4. Prenatal care. In: Cunningham F, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, Spong CY. eds. Williams Obstetrics. 25th ed. McGraw-Hill; Accessed October 12, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1918§ionid=144148582
5. Young SL. Pica in pregnancy: new ideas about an old condition. Annu Rev Nutr. 2010;30:403-422. doi:10.1146/annurev.nutr.012809.104713
6. Miao D, Young SL, Golden CD. A meta-analysis of pica and micronutrient status. Am J Hum Biol. 2015;27(1):84-93. doi:10.1002/ajhb.22598
7. Edwards CH, Johnson AA, Knight EM, et al. Pica in an urban environment. J Nutr. 1994;124(6 Suppl):954s-962s. doi:10.1093/jn/124.suppl_6.954S
8. Sadeghi E, Yas A, Rabiepoor S, Sayyadi H. Are anemia, gastrointestinal disorders, and pregnancy outcome associated with pica behavior? J Neonatal Perinatal Med. 2020. doi:10.3233/npm-190257
9. Corbett RW, Ryan C, Weinrich SP. Pica in pregnancy: does it affect pregnancy outcomes? MCN Am J Matern Child Nurs. 2003;28(3):183-189; quiz 190-181. doi:10.1097/00005721-200305000-00009
10. Epler KE, Pierce A, Rappaport VJ. Pica in pregnancy: an unusual presentation. Obstet Gynecol. 2017;130(6):1377-1379. doi:10.1097/aog.0000000000002365
11. Osman YM, Wali YA, Osman OM. Craving for ice and iron-deficiency anemia: a case series from Oman. Pediatr Hematol Oncol. 2005;22(2):127-131. doi:10.1080/08880010590896486
12. ACOG Practice Bulletin No. 95: anemia in pregnancy. Obstet Gynecol. 2008;112(1):201-207. doi:10.1097/AOG.0b013e3181809c0d
13. Upadhyaya SK, Sharma A. Onset of obsessive compulsive disorder in pregnancy with pica as the sole manifestation. Indian J Psychol Med. 2012;34(3):276-278. doi:10.4103/0253-7176.106030
14. Bhatia MS, Gupta R. Pica responding to SSRI: an OCD spectrum disorder? World J Biol Psychiatry. 2009;10(4 Pt 3):936-938. doi:10.1080/15622970701308389
15. McKenna D. Myopathy, hypokalaemia and pica (geophagia) in pregnancy. Ulster Med J. 2006;75(2):159-160.
16. Ukaonu C, Hill DA, Christensen F. Hypokalemic myopathy in pregnancy caused by clay ingestion. Obstet Gynecol. 2003;102(5 Pt 2):1169-1171. doi:10.1016/s0029-7844(03)00705-1
17. Shannon M. Severe lead poisoning in pregnancy. Ambul Pediatr. 2003;3(1):37-39. doi:10.1367/1539-4409(2003)003<0037:slpip>2.0.co;2

Prepared by:
Janna Afanasjeva, PharmD, BCPS
Clinical Assistant Professor, Drug Information Specialist
University of Illinois At Chicago College of Pharmacy

November 2020

The information presented is current as of October 12, 2020. This information is intended as an educational piece and should not be used as the sole source for clinical decision-making.