Pica for foam rubber in patients with sickle cell disease. (Case Report).

Abstract: We report three cases of pica for foam rubber among sickle cell disease patients. All three were African-American males, and at the times of initial presentation for the pica, two of them were 11 years of age and one was 15 years of age. In all cases, the pica reportedly had been occurring for at least several years. The foam rubber was most often obtained from furniture and mattresses, as well as from ironing-board pads, stereo speakers, and padded hair rollers. Reports from other researchers also suggest that this is not an uncommon type of pica. We discuss this problem from biologic, psychologic, and social perspectives.

Key Words: foam rubber, pica, sickle cell disease

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According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), (1) pica is defined as the "persistent eating of nonnutritive substances for a period of at least one month." Additional diagnostic criteria are that the ingestion of the substance is inappropriate to developmental level, is not part of a culturally sanctioned practice, and not merely symptomatic of another mental disorder (eg, pervasive developmental disorder, mental retardation, thought disorder).

Several researchers across the United States, including the present authors, have recently noted a high prevalence of pica in children with sickle cell syndromes. (2-4) More specifically, these reports have each noted pica for a particular substance--foam rubber. A review of the published literature indicated additional reference to childhood pica for foam rubber, (5) pica for paint chips among children with sickle cell disease, (6) and a general report of ingestion of foam rubber. (7) No published reports were found describing pica for foam rubber among children with sickle cell disease, however.

We present three cases of pica for foam rubber that came to our attention between June 1995 and August 1997. Each case fully meets DSM-IV diagnostic criteria for pica. All three are African-American males, and at times of initial contact for the pica, two of them were 11 years of age and one was 15 years old. In all cases, the pica reportedly had been occurring for at least several years. To our knowledge, the patients did not know one another.

Case Reports

Patient 1

The first case was an 11-year-old African-American male with hemoglobin S-O Arab disease living in rural Arkansas. His disease had been identified through a newborn screen, but he did not have his first painful crisis until he was 7 years of age. Until he was approximately 9 years old, he lived in a large urban area in California and received health care at a major medical center there.

The patient's pica was brought to our attention by his mother. She reported that since he was approximately 5 years old, she had known him to "eat foam [rubber] from furniture, out of a mattress pad, off of the front of stereo speakers, and from [padded] hair rollers." His mother said that she thought the patient had stopped this behavior, until she recently noticed a hole in the sofa where he had removed a large section of foam rubber. His mother also indicated that the patient's 3-year-old brother had recently begun to do the same.

The patient himself readily acknowledged his actions and voiced a desire to stop this eating behavior. With questioning, he reported enjoying the smell of the substance and also said that he sometimes had ingested sufficient quantities to feel full. He denied knowing anyone else who ingested foam rubber; however, his mother reported that the maternal grandmother routinely ate clay dirt as well as plain baking soda.

Not surprisingly, abdominal x-ray films taken after his mother's disclosure of the pica indicated changes consistent with constipation and ingestion of radiopaque foreign bodies. The patient's hemoglobin levels have ranged from 8.7 to 10.0 g/dl, and his hematocrit levels have ranged from 26.0 to 29.5 ml/dl. He has had one hospital admission for pericardial effusion, which was thought to be due to mycoplasmal infection.

Patient 2

The patient was an 11-year-old African-American male from a moderate-sized Arkansas city. He had sickle cell-hemoglobin C (hemoglobin SC) disease. His mother reported to the staff that "he has been eating the stuffing out of his mattress and out of my furniture." The mother stated that she had known about this for years, but no other specific details could be obtained from her. She indicated that she had firmly believed that the purchase of new furniture would help deter the patient's desire to ingest the foam rubber (ie, that he would not want to ruin new furniture and/or incur his mother's wrath for doing so). His mother had quickly seen that this would not be so, however.

The patient was reticent to discuss his pica; overall, he presented as very embarrassed and also angry with his mother for divulging this information. Still, he acknowledged ingesting pieces of foam rubber from furniture for years (again, a nonspecific time). He reported enjoying the smell of the substance. In addition, he indicated some perception (or perhaps hope) that foam rubber is high in calories (the patient was short in stature for his age). On the whole, he presented as minimally motivated to change what he saw as simply a habit, despite his mother's clear desire for change.

There was no history of significant medical problems other than tonsillar and adenoidal hypertrophy. The patient's hemoglobin levels have ranged from 9.8 to 11.3 g/dl, and hematocrit levels have ranged from 29.1 to 35.8 ml/dl.

Patient 3

The patient was a 15-year-old African-American male with hemoglobin SS disease, who was from a moderate- to large-sized Arkansas city. His disease was diagnosed when he was 2 years of age. His pica was brought to our attention by his aunt/guardian. She reported that he had been eating foam rubber from furniture, mattresses, and ironing-board pads for at least 4 years. Other family members had stated that the behavior began by the time he was 6 years of age.

The patient acknowledged the majority of these behaviors. He indicated primarily chewing (and holding in his mouth) the foam rubber, however, as opposed to always swallowing it. He stated that he had engaged in this behavior at least once per week for at least 4 to 5 years. He denied any particularly appealing aspects to the foam rubber that brought on this behavior. Although he was clearly embarrassed that we had been informed of the pica, the patient appeared desirous of assistance in decreasing and/or stopping it.

The patient also has a history of asthma (treated with albuterol and nedocromil sodium, with occasional use of steroid inhaler) and tonsillar adenoidal hypertrophy. His hemoglobin levels have ranged from 6.9 to 8.0 g/dl, and his hematocrit levels have ranged from 19.1 to 24.0 ml/dl. Review of other available medical records indicated that at age 13 years, he was diagnosed with attention-deficit/hyperactivity disorder, predominantly inattentive type, and also with a reading disorder. Neither of these diagnoses precludes the diagnosis of pica, however.

Discussion

Pica cases are often interesting, and the cases presented here certainly raise several questions. Perhaps the best way to conceptualize these cases is from a biopsychosocial perspective. From a biologic standpoint, we know of no clear etiology or any other medical factors related to repeated and long-term ingestion of this specific material. The question certainly arises, though, of whether this meets some biochemical need not previously characterized. Other anemic states, including iron deficiency and lead poisoning, have been associated with pica, although not for foam rubber. (8, 9) We speculate with regard to the roles of the smell of the substance (which is often distinctive), the stimulation of the chewing process, and whether patients truly believe on some level that foam rubber has nutritional value. What we do know, of course, is that there are potential hazards to ingesting foam rubber. (7, 10) The unknown hazards could be more concerning.

From a psychologic standpoint, we currently know little about this specific type of pica. Others have discussed pica within the context of obsessive-compulsive disorders in general. (5, 11) In addition, we can speculate that anxiety, boredom, and poor environmental stimulation could be salient factors. Yet, none of these three cases presented with symptoms or histories requisite to highlight any of those areas or to make any psychologic diagnoses other than pica (except as noted in Patient 3). Full psychologic evaluations would be necessary to further explore this area in these patients, but the costs could be prohibitive and would probably need to be completed within a funded research project. As for psychologic treatment, there is some evidence for the effectiveness of behavioral strategies (12,13) others have reported the use of pharmacologic agents. (5,11)

From a social standpoint, two issues readily come to mind. First, we wonder what impact familial ingestion of other nonfood items has on a patient's pica for other items, including foam rubber. In Patient 1, the patient's grandmother was reported to have a lengthy history of eating clay dirt as well as baking soda, and this was accepted within the family. We have also met other teenage patients with pica (not for foam rubber) with family members who routinely ingested a different set of substances; in each case, the family was still clearly disturbed by the patient's pica. Still, at what point does modeling for any pica simply beget a different pica? Second, we wonder whether patients with pica have a history of having little available food in the household, thus prompting them to ingest nonfood items. As far as we can determine, however, this was not the case for the three patients presented here.

Were it not that other clinicians have reported similar cases, (3,4) these might be less intriguing; however, the impression gained is that pica for foam rubber may not be that unusual in patients with sickle cell disease. Indeed, others have noted that foam rubber appears to be an item of choice for sickle cell disease patients with pica. (14) We hope that this report spurs further clinical and research interest in the area, specifically regarding prevalence/incidence, etiology, potential hazards of ingestion, and effective interventions.

Accepted December 3, 2001.

References

(1.) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, DC, American Psychiatric Press, 1994.

(2.) Hackworth SR, Williams LL, Pica and sickle cell disease: Unique pediatric cases. Presented at the annual meeting of the Southern Society for Pediatric Research, February 1997, New Orleans, LA.

(3.) Lemanek KL, Woods G, Parson P, et al. Pica in children with sickle cell disease. Presented at thc Twenty-first National Sickle Cell Meeting, March 1996, Mobile, AL.

(4.) Johnson CA, Boger D. Prevalence of pica in children with sickle cell syndrome. Presented at the Twenty-first National Sickle Cell Meeting, March 1996, Mobile, AL.

(5.) Schreier HA. OCD and tricyclics. J Am Acad Child Adolesc Psychiatry 1990;29-668-669.

(6.) Erenberg G, Rinsler SS, Fish BG. Lead neuropathy and sickle cell disease. Pediatrics 1974;54:438-441.

(7.) Weissberg D. Foreign bodies in the gastro-intestinal tract. S Afr J Surg 1991;29:150-153.

(8.) Callinan V, O'Hare JA. Cardboard chewing: Cause and effect of iron-deficiency anemia. Am J Med 1988;85:449.

(9.) Roselle HA. Association of laundry starch and clay ingestion with anemia in New York City. Arch Intern Med 1970;125:57-61.

(10.) Dooms-Goossens A, Loncke J, Michiels JL, Degreef H, Wahlberg J. Pustular reactions to hexafluorosilicate in foam rubber. Contact Dermatitis 1985;12:42-47.

(11.) Stein DJ, Bouwer C, van Heerden B. Pica and the obsessive-compulsive spectrum disorders. S Afr Med J 1996;86(12 Suppl): 1586-1588, 1591-1592.

(12.) Hackworth SR: Behavioral treatment of pica in a sickle cell patient. Presented at the annual meeting of the Southern Society for Pediatric Research, February 1998, New Orleans, LA.

(13.) Finney JW, Russo DC, Cataldo MF. Reduction of pica in young children with lead poisoning. J Pediatr Psychol 1982;7: 197-207.

(14.) Lemanek KL, Brown R, Armstrong FD, et al. Dysfunctional eating behaviors in children with sickle cell disease. Presented at the annual meeting of the American Psychological Association, August 1996, Toronto, ON, Canada.

RELATED ARTICLE: Key Points

* Reports from other researchers suggest that foam rubber pica is not an uncommon type of pica.

* We know of no clear etiology or any other medical factors related to repeated and long-term ingestion of foam rubber by patients with sickle cell disease.

* We speculate that anxiety, boredom, and poor environmental stimulation could be salient factors in the presentation of this type of pica.

* We also speculate that the familial ingestion of other nonfood items may have an impact on a patient's pica for other items, including foam rubber.

From the Section of Pediatric Psychology, Department of Pediatrics, University of Arkansas for Medical Sciences, and the Arkansas Children's Hospital, Little Rock, and the St. Vincent Family Clinic, Jacksonville, AR. Dr. Hackworth is now chief executive officer of AskaChildPsychologist.com and also in private practice in Austin, TX.

Reprint requests to Samuel R. Hackworth, PhD, Austin Psychotherapy Associates, 4601 Spicewood Springs Road, 4-200, Austin, TX 78759.

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9601-0081