Pica — কী?
Pica হলো এমন একটি feeding/eating disorder যেখানে একজন ব্যক্তি কমপক্ষে ১ মাস ধরে বারবার non-food / non-nutritive জিনিস খায়—যেমন মাটি/চক/দেয়ালের রং/কাগজ/চুল/বরফ/সাবান/কয়লা/স্টার্চ—যা বয়স, সংস্কৃতি বা সামাজিকভাবে স্বাভাবিক নয়। DSM-5/DSM-5-TR অনুযায়ী diagnosis মূলত clinical history-based; lab test পিকা “prove” করে না, বরং cause ও complication খুঁজে বের করে।
Core meaning: Pica নিজে একটি আচরণগত/psychiatric diagnosis, কিন্তু বেশিরভাগ practical case-এ এর পেছনে iron deficiency, zinc deficiency, pregnancy, worm infestation, lead exposure, ASD/ID, OCD/psychosis খুঁজতে হবে।
Etiology / Pathophysiology — কারণ
Common causes:
- Iron deficiency / iron-deficiency anemia — বিশেষ করে pagophagia, অর্থাৎ বরফ খাওয়ার craving। Pica রোগীর ক্ষেত্রে iron studies করা strongly justified; iron deficiency correction করলে অনেক ক্ষেত্রে pica কমে/বন্ধ হয়।
- Zinc deficiency — selected case-এ serum zinc check করা যায়; deficiency থাকলে supplement দিতে হয়।
- Pregnancy — iron/folate demand বাড়ে; WHO antenatal care-এ iron–folic acid supplementation recommend করে।
- Childhood / developmental disorders — Autism spectrum disorder, intellectual disability, developmental delay-তে pica বেশি দেখা যায়।
- Psychiatric comorbidity — OCD, schizophrenia/psychosis, trichotillomania/trichophagia, anxiety/stress।
- Environmental exposure — পুরনো বাড়ির lead paint, contaminated soil, chalk/paint ingestion → lead poisoning risk; WHO বলে lead-এর কোনো safe blood level নেই, আর CDC child blood lead reference value 3.5 µg/dL ব্যবহার করে action নিতে বলে।
- Soil eating / geophagia → hookworm/Ascaris/Toxocara, parasitic infection, hypokalemia, constipation/obstruction risk।
Symptoms / Clinical Features
Core symptom: non-food item খাওয়ার repeated urge/behavior ≥1 month.
Substance-specific examples
| Type | Meaning | Common risk |
| Geophagia | মাটি/কাদা/ক্লে খাওয়া | parasite, constipation, hypokalemia, lead |
| Pagophagia | বরফ খাওয়া | iron deficiency anemia |
| Amylophagia | raw starch খাওয়া | hyperglycemia/weight gain |
| Trichophagia | চুল খাওয়া | trichobezoar, obstruction |
| Plumbophagia risk | paint/chalk/old wall material | lead poisoning |
Associated symptoms: pallor, fatigue, dizziness, glossitis, koilonychia, restless leg, abdominal pain, constipation, vomiting, dental erosion, bad breath, worm symptoms, growth delay, behavioral dysregulation। Long-standing pica থেকে bezoar, bowel obstruction, perforation, toxicity পর্যন্ত হতে পারে।
Clinical Diagnosis — specific
DSM-based diagnosis checklist
Diagnosis হবে যদি:
- Non-food/non-nutritive substance খাওয়া ≥1 month
- বয়স অনুযায়ী inappropriate; সাধারণত <2 years শিশুর mouthing behavior pica নয়
- culturally/socially accepted practice নয়
- অন্য mental/developmental/medical condition থাকলেও behaviorটি আলাদা clinical attention দাবি করে
History নিতে হবে
- কী খায়: মাটি, chalk, paint, ice, hair, paper, soap, coal, starch?
- কতদিন, কতবার, কত পরিমাণ?
- গোপনে খায় নাকি impulsive urge?
- pregnancy, heavy menstruation, GI bleeding, malnutrition?
- ASD/ID/OCD/psychosis symptoms?
- old house/paint exposure?
- soil exposure, barefoot walking, worm history?
- abdominal pain, vomiting, constipation, blood stool?
- child neglect/abuse/stress?
Investigations — specific workup
Baseline for most patients
- CBC with RBC indices: Hb, MCV, MCH, RDW
- Peripheral blood film
- Serum ferritin, serum iron, TIBC, transferrin saturation
- CRP/ESR if inflammation suspected because ferritin acute-phase reactant
- RBS if starch ingestion/obesity
- Electrolytes, urea/creatinine, LFT
- Serum zinc if poor diet, chronic diarrhea, growth failure, skin/hair changes, resistant pica
- Urine pregnancy test/β-hCG in reproductive-age female
Exposure-based tests
- Blood lead level: paint/chalk/soil/old house exposure, neuro symptoms, abdominal colic, anemia। CDC/WHO guidance অনুযায়ী low-level lead exposure-ও harmful হতে পারে।
- Stool R/E + ova/parasite: soil eating, eosinophilia, abdominal symptoms
- Stool occult blood / GI evaluation: adult male, post-menopausal female, recurrent IDA
- Abdominal X-ray/USG/CT/endoscopy: abdominal pain, vomiting, suspected foreign body, bezoar, obstruction; pica evaluationে imaging symptom/substance-based।
- Developmental/psychiatric assessment: ASD, ID, OCD, psychosis, depression/anxiety
Differential Diagnosis
- Normal mouthing behavior in children <2 years
- Cultural clay/starch intake without clinical impairment
- Iron/zinc deficiency craving
- OCD-related compulsion
- Psychosis/schizophrenia-related bizarre ingestion
- Autism / intellectual disability sensory-seeking behavior
- Trichotillomania with trichophagia
- ARFID, anorexia nervosa, bulimia
- Dementia / frontal lobe syndrome / Klüver–Bucy syndrome
- Substance use disorder
- Factitious disorder / malingering in rare contexts
Management / Treatment — guideline-based
1) Emergency red flags — immediate referral
Immediate hospital/surgery/toxicology referral if:
- Battery, magnet, sharp object, glass, metal ingestion
- Severe abdominal pain, persistent vomiting, distension, constipation/obstruction
- Hematemesis/melena
- Seizure, encephalopathy, severe headache, papilledema → possible lead toxicity
- Severe anemia, syncope, pregnancy with toxicity risk
- Suicidal intent or psychosis-driven dangerous ingestion
2) Non-pharmacological management — first-line
- Remove access: chalk/paint/soil/hair/paper/soap/unsafe items locked away
- Safe substitute: crunchy safe food, ice alternative only if dental risk controlled, sensory toys for children
- Diet correction: iron-rich food—meat, liver, fish, egg, lentil, spinach; vitamin C with iron meal
- Behavioral therapy: functional behavior assessment, differential reinforcement, response interruption/redirection, caregiver training; applied behavior analysis has the best evidence in ASD/ID-related pica।
- CBT / habit reversal: OCD/anxiety-driven pica
- Family education: shame/blame না দিয়ে monitoring chart রাখতে হবে
Pharmacological Treatment — cause-specific
Important: Pica-এর জন্য আলাদা কোনো approved medicine নেই; medication দেওয়া হয় underlying cause অনুযায়ী—iron deficiency, zinc deficiency, worm infestation, OCD/psychosis/ASD-related severe behavior।
A) Iron deficiency / IDA থাকলে
Generic: Ferrous fumarate / ferrous sulfate / ferrous gluconate
Adult dose:
- Ferrous sulfate/fumarate/gluconate: 1 tablet once daily; intolerance হলে alternate-day বা lower dose। NICE/BSG initial oral iron হিসেবে once-daily ferrous salt recommend করে।
- Practical target: elemental iron 60–120 mg/day depending severity/tolerance। AAFP adult IDA treatmentে 120 mg elemental iron/day for 3 months উল্লেখ করে; response: Hb ~1 g/dL rise after 1 month।
Child dose:
- Elemental iron 3 mg/kg/day, max 60 mg/day; severe IDA হলে specialist protocol।
Duration:
- Hb normalize হওয়ার পরও আরও 3 মাস iron continue করে iron store replenish করা হয়।
Purpose: iron deficiency correct করলে pica craving, fatigue, pallor, restless leg, cognitive issues improve হতে পারে।
Side effects: nausea, epigastric pain, constipation/diarrhea, black stool, metallic taste, teeth staining with syrup.
Interactions / counselling:
- Tea/coffee/milk/calcium/antacid/PPI iron absorption কমায়
- Tetracycline, doxycycline, ciprofloxacin/levofloxacin, levothyroxine, bisphosphonate-এর সাথে 2–4 hour gap
- Vitamin C absorption বাড়াতে পারে
- Hemochromatosis/iron overloadে contraindicated
Bangladesh brand examples with strength
MedEx অনুযায়ী Bangladesh-এ ferrous sulfate syrup 200 mg/5 mL এবং ferrous fumarate + folic acid 200 mg combinations পাওয়া যায়।
- Ferrous sulfate syrup 200 mg/5 mL: Aristoferon, Ferroglobin, Ferigun S, Feglobin, G-Iron, Sinaferon, Hemobin
- Ferrous fumarate + folic acid 200 mg + 200/500 mcg: Femicap 200 mg+200 mcg, Femitab 200 mg+200 mcg, Ferigun 200 mg+500 mcg, Fero Plus 200 mg+400 mcg, Ferofol 200 mg+350 mcg, I-Fol 200 mg+200 mcg, Sinaferon 200 mg+200 mcg
B) Pregnancy-associated pica / IDA prevention
Generic: Iron + folic acid
WHO recommendation: pregnancy-তে daily 30–60 mg elemental iron + 400 mcg folic acid antenatal care-এর অংশ হিসেবে দেওয়া হয়।
Bangladesh brand examples: Ferigun 200 mg+500 mcg, Fero Plus 200 mg+400 mcg, Feroson-TR 200 mg+500 mcg, Zenifol Plus 200 mg+400 mcg, Aristofol Fe 308 mg+350 mcg।
C) Oral iron intolerance / severe IDA / malabsorption
Generic: Ferric carboxymaltose IV
Dose: total iron deficit অনুযায়ী; commonly 500–1000 mg IV, repeat after ≥1 week if needed; hospital setting.
Purpose: oral iron intolerance, poor response, malabsorption, rapid repletion needed। MedEx ferric carboxymaltose indication হিসেবে oral iron intolerance/unsatisfactory response ও non-dialysis CKD উল্লেখ করে।
Side effects: hypertension, flushing, nausea, headache, hypophosphatemia, hypersensitivity/anaphylaxis rare.
Interactions: same-day oral iron unnecessary; avoid iron overload.
BD brand examples: Ferinject 100 mg/2 mL, 500 mg/10 mL; Revofer 500 mg/10 mL, 1 g/20 mL; Maltofer 100 mg/2 mL, 500 mg/10 mL, 1 g/20 mL; Maxfer 500 mg/10 mL, 1 g/20 mL; Injefer 100 mg/2 mL, 500 mg/10 mL, 1 g/20 mL।
Generic: Iron sucrose IV
Dose: commonly 100–200 mg IV per session, repeated until total deficit corrected.
Purpose: rapid iron replacement, CKD/pregnancy-related selected cases, oral intolerance.
Side effects: hypotension, dizziness, nausea, injection-site reaction, hypersensitivity rare.
BD brand examples: Venofer 100 mg/5 mL, Anefer 100 mg/5 mL or 200 mg/10 mL, Ferimax 100 mg/5 mL or 200 mg/10 mL।
D) Zinc deficiency থাকলে
Generic: Zinc sulfate / zinc sulfate monohydrate
Dose:
- Adult confirmed deficiency: usually elemental zinc 25–50 mg/day for 2–3 months, then reassess.
- Child: weight/age-based; prolonged high-dose zinc specialist supervision ছাড়া না।
Purpose: zinc deficiency correction; pica directly cure করার drug নয়, deficiency থাকলে helpful।
Side effects: nausea, vomiting, abdominal pain, metallic taste.
Interactions: iron, calcium, tetracycline/quinolone antibiotics, penicillamine-এর সাথে absorption interaction; 2–4 hour gap. Long-term high-dose zinc → copper deficiency.
BD brand examples: MedEx-এ zinc sulfate monohydrate 20 mg tablet/DT ও 10 mg/5 mL syrup listed আছে।
- Tablet/DT 20 mg: Baby Zinc, Xinc, Zedex, Zesup, Ziflu, Zincoral DT, ZincTab, Zinga, G-Zinc
- Syrup 10 mg/5 mL: Xinc, Zedex DS, Zesup, Ziflu, Zincoral, Biozinc, Mazic, SMC Zinc
E) Soil eating / worm infestation risk থাকলে
Generic: Albendazole
Dose:
- Soil-transmitted helminth: Albendazole 400 mg single dose; CDC lists 400 mg orally once for common STH, and WHO recommends albendazole 400 mg or mebendazole 500 mg for deworming in endemic at-risk populations।
- Pinworm: single dose; repeat after 2 weeks often needed.
Purpose: hookworm/roundworm/pinworm/soil-transmitted helminth; geophagia + eosinophilia/stool positive/endemic exposure.
Side effects: abdominal pain, nausea, headache, transient LFT rise; rare leukopenia.
Interactions: cimetidine/dexamethasone/praziquantel may increase active metabolite; avoid 1st trimester unless specialist indication; monitor LFT for prolonged courses.
BD brand examples 400 mg: Almex 400 mg, Alphin DS 400 mg, Ben-A 400 mg, Estazol 400 mg, Exworm 400 mg, G-Albendazole 400 mg, Helben DS 400 mg, Krimizole DS 400 mg। MedEx lists many albendazole brands and strengths in Bangladesh।
Generic: Mebendazole
Dose:
- Pinworm: 100 mg single dose, repeat after 2 weeks if reinfection.
- Roundworm/hookworm/whipworm: 100 mg twice daily for 3 days or 500 mg single dose depending protocol. MedEx lists 100 mg single dose for threadworm and 100 mg twice daily for 3 days for whipworm/roundworm/hookworm।
Side effects: abdominal pain, diarrhea, rash, rare LFT rise/neutropenia with prolonged therapy.
Interaction: cimetidine may increase mebendazole level।
BD brand examples 100 mg / 100 mg/5 mL: Mebantrin 100 mg, Mebendox 100 mg, Mebrex 100 mg, Panamox 100 mg, Promex 100 mg, Helmox suspension 100 mg/5 mL, Mebantrin suspension 100 mg/5 mL।
F) OCD/anxiety-driven pica হলে — psychiatrist-guided
Generic: Sertraline
Dose:
- Adult OCD/anxiety: start 25–50 mg daily, titrate every 1–2 weeks; usual 50–200 mg/day. MedEx lists adult OCD starting dose 50 mg and range 50–200 mg।
- Pediatric OCD: specialist only; 6–12 years often 25 mg start, max 200 mg/day.
Purpose: OCD/anxiety compulsion কমানো; pica-specific drug নয়.
Side effects: nausea, diarrhea, insomnia/somnolence, sexual dysfunction, sweating, tremor, hyponatremia, bleeding risk, initial anxiety, suicidal ideation warning in young patients.
Interactions: MAOI/linezolid/methylene blue contraindicated; tramadol, triptan, lithium, St John’s wort → serotonin syndrome risk; NSAID/anticoagulant → bleeding risk.
BD brand examples: Chear 25/50/100 mg, Repose 25/50/100 mg, Seronex 25/50/100 mg, Sertal 25/50/100 mg, Setra 25/50/100 mg।
Generic: Fluoxetine
Dose:
- Adult OCD/depression/anxiety: 20 mg morning, titrate 40–60 mg/day if needed. MedEx notes 20 mg/day initial dose।
- Child/adolescent OCD: specialist dosing, often 10–20 mg start.
Side effects/interactions: sertraline-এর মতো; additionally long half-life, CYP2D6 inhibition; avoid MAOI within 5 weeks after stopping fluoxetine.
BD brand examples: Modipran 20 mg, Nodep 20 mg, Nodepress 20 mg, Oxetin 20 mg, Prolert 20 mg capsule / 20 mg/5 mL suspension।
G) Psychosis / severe ASD-ID related dangerous pica হলে — specialist only
Generic: Risperidone
Dose:
- Adult psychosis: usually start 1–2 mg/day, titrate; MedEx lists psychosis dosing starting 2 mg/day then 4 mg/day and usual 4–6 mg/day।
- ASD irritability/impulsivity: child/adolescent dosing must be weight-based psychiatrist-led.
Purpose: psychosis, severe aggression/impulsivity, ASD-related dangerous behavior; pica-specific drug নয়.
Side effects: sedation, weight gain, hyperprolactinemia, EPS, akathisia, QT prolongation, metabolic syndrome.
Interactions: alcohol/CNS depressants, fluoxetine/paroxetine increase risperidone level via CYP2D6, antihypertensives → hypotension.
BD brand examples: Sperid 1/2/4 mg tablet, Sperid ODT 1/2/3/4 mg, Sperid oral solution 1 mg/mL, Sperdal 1/2/4 mg or 1 mg/mL।
Generic: Olanzapine
Dose:
- Adult psychosis/mania: 5–10 mg once daily, range 5–20 mg/day; MedEx lists initial 5–10 mg once daily।
Purpose: psychosis/mania-related pica behavior only; routine pica treatment নয়.
Side effects: sedation, weight gain, increased appetite, dyslipidemia, hyperglycemia, orthostatic hypotension, constipation, dry mouth, LFT rise।
Interactions: alcohol/CNS depressants, smoking induces CYP1A2 and may lower level, fluvoxamine/ciprofloxacin may increase level.
BD brand examples: Deprex 5/10 mg, Lopez 5/10 mg, Olanor 5/10 mg, Olanza 5/10 mg, Oleanz 5/10 mg, Olixar 5/10/20 mg।
Prevention — কীভাবে করবেন
- High-risk screening: child, pregnant woman, IDA patient, ASD/ID patient—pica habit active question করে জিজ্ঞেস করুন।
- Iron deficiency prevent: balanced diet + pregnancy iron–folic acid supplementation।
- Lead prevention: পুরনো বাড়ির peeling paint, contaminated soil, battery/paint/chalk access কমানো; child with paint/soil pica হলে blood lead level।
- Deworming: endemic area/soil exposure থাকলে WHO/CDC-based deworming program।
- Behavior plan: caregiver observation chart, remove access, safe substitute, reinforcement.
- Follow-up: 2–4 weeksে craving frequency + Hb/ferritin response review; 8–12 weeksে iron store reassess.
Shortcut clinical algorithm
Pica suspected →
1 month + non-food eating? → yes →
Danger ingestion / obstruction / toxicity? → yes = emergency referral
→ no →
CBC + ferritin/iron profile + zinc if needed + lead if paint/chalk/soil + stool O&P if geophagia + pregnancy test
→
Deficiency/toxin/worm/comorbidity treat
→
Behavioral intervention + family education
→
2–4 week follow-up; persistent case = psychiatry/developmental pediatrics/gastro/toxicology depending cause
Overview / Summary
Pica হলো ≥1 মাস non-food substance খাওয়ার repeated behavior, যা বয়স/সংস্কৃতি অনুযায়ী inappropriate। Diagnosis clinical; investigations cause ও complication ধরার জন্য। সবচেয়ে গুরুত্বপূর্ণ causes হলো iron deficiency/IDA, pregnancy, zinc deficiency, worm infestation, lead exposure, ASD/ID, OCD/psychosis। Pica-এর নিজস্ব approved drug নেই; treatment হলো remove exposure + behavioral therapy + deficiency/complication/comorbidity-specific pharmacotherapy।
Actionable Plan / Steps
- Substance identify করুন: soil/chalk/paint/ice/hair/starch/soap/metal.
- CBC, ferritin, iron profile, CRP, electrolytes, LFT, serum zinc if indicated.
- Paint/chalk/soil ingestion হলে blood lead level.
- Soil eating হলে stool O&P ± deworming.
- IDA থাকলে oral iron 3 months after Hb correction; intolerance/severe হলে IV iron.
- OCD/psychosis/ASD-ID থাকলে psychiatry/developmental referral; SSRI/antipsychotic only indication-based.
- Access control + caregiver behavioral plan mandatory.
Reference List — Textbook + Guideline + DOI
Textbooks / diagnostic manuals
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, DSM-5-TR. APA Publishing, 2022.
- Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s Synopsis of Psychiatry, 12th ed. Wolters Kluwer. Feeding and eating disorders section.
- Jameson JL et al. Harrison’s Principles of Internal Medicine, 21st ed. McGraw Hill. Iron deficiency anemia / anemia evaluation sections.
- Ralston SH et al. Davidson’s Principles and Practice of Medicine, 24th ed. Elsevier. Hematology: iron deficiency anemia.
- Kliegman RM et al. Nelson Textbook of Pediatrics, 22nd ed. Elsevier. Feeding/eating disorders and anemia sections.
Guidelines / official sources
- WHO. Daily iron and folic acid supplementation during pregnancy, updated ELENA guidance, 2024.
- WHO. Preventive chemotherapy to control soil-transmitted helminth infections in at-risk population groups, 2017; WHO STH fact sheet, 2023.
- CDC. Recommended actions based on blood lead level, 2025; CDC blood lead reference value update, 2024.
- NICE CKS. Iron deficiency anaemia—management, current clinical knowledge summary.
- British Society of Gastroenterology. Guidelines for management of iron deficiency anaemia in adults, 2021.
Peer-reviewed DOI references
- Ganesan PR, Vasauskas AA. The association between pica and iron-deficiency anemia: a scoping review. Cureus. 2023;15:e37904. DOI: 10.7759/cureus.37904.
- Williams F, Gibbs S, Addo AS. The assessment and management of pica in people with intellectual disability. BJPsych Advances. 2022;28(6):383–392. DOI: 10.1192/bja.2022.24.
- Call NA, Simmons CA, Mevers JEL, Alvarez JP. Clinical outcomes of behavioral treatments for pica in children with developmental disabilities. J Autism Dev Disord. 2015;45:2105–2114. DOI: 10.1007/s10803-015-2375-z.
- Snook J et al. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut. 2021;70:2030–2051. DOI: 10.1136/gutjnl-2021-325210.
Md.Rafiqul Islam Lipu Date:-22-05-2026 Friday Time:-4-29-45 Pm