AN UNUSUAL APPETITE
History
Amy is a 3-year-old girl brought to the GP by her mother. Her health visitor has discussed her previously in the surgery and has been trying to persuade Amy’s mother to attend. She is worried about Amy’s behaviour, although Amy’s mother laughs it off and thinks that it is just a phase she is going through. Amy has a long-standing habit of licking and chewing objects such as toys, and picking plaster and paint off walls and eating it. This will happen anywhere, including paint from shop windows. As a toddler she also used to eat mud and stones but this has recently reduced. Her mother reports some complaints of tummy ache and constipation but is otherwise not worried about her daughter.
Examination
Amy immediately starts exploring the surgery climbing onto the couch and windowsill before the GP stops her. She tips out the waste bin and starts to rummage through the contents and nibble paper towels. She also turns the taps on and off, splashing water over the floor. Her mother seems oblivious to all this and is seeking a letter about rehousing. From time to time during the consultation, Amy comes to the GP and reaches out to be picked up and sits on her knee for a while being cuddled. The GP notices that Amy’s fingers, nails and clothes are dirty and she has head lice. The health visitor has been monitoring her height and weight, and although her weight has been following the 2nd centile and her height is just above it, she is below the target range for her parents (25th–75th). On examination she is anaemic and looks thin but there are no other signs.
INVESTIGATIONS
Normal
Haemoglobin 9.3 g/dL 11.5–15.5 g/dL
White cell count 8.4 109/L 6.0–17.5 109/L
Platelets 365 109/L 150–400 109/L
Mean cell volume 56 fL 77–95 fL
Mean corpuscular haemoglobin 20 pg 24–30 pg
Blood film – microcytic, hypochromic, with basophilic stippling
Questions
• What is the diagnosis?
• What further information should you gather?
• What complications have arisen?
• What is the management?
Medicine
Amy has pica, the repeated or chronic ingestion of non-nutritive substances. This is almost universal in infants and toddlers but abnormal after the age of 2 years and needs investigation. It is very unusual for a child to spontaneously reach out to a relatively unknown adult for comfort. This behaviour should always raise the possibility of emotional and social neglect and these are known predisposing factors for pica. Others include autism and learning difficulties and the GP needs to ensure that there is no significant developmental delay. Her social behaviour is not typical of autism. The difficulty persuading the mother to attend, her indifference to the problem and her behaviour during the consultation all add to the concerns. Amy is also small for her family and thin. Emotional and physical neglect can lead to psychosocial dwarfism. A full social history should be gathered about the family and their circumstances. Who else is at home? Does the mother have a partner and is he the father of Amy? Is there a history of drug or alcohol abuse or domestic violence? Are there other children? Is this family known to Social Care? Anaemia and lead poisoning have developed. The microcytic, hypochromic anaemia is strongly indicative of iron deficiency, which is common in childhood and almost always dietary in origin. It is even more common in pica. Basophilic stippling is characteristic of lead poisoning, another known complication of pica. Sources include lead-containing paint from both buildings and imported painted toys. Symptoms range from colicky abdominal pain and constipation to headache, drowsiness, fits and coma in lead encephalopathy. Once in the intestine, lead competes with iron and calcium for binding sites, so if either or both of these are deficient, lead absorption is enhanced. Hyperactivity, as in this case, is frequently a manifestation of lead poisoning in pre-school and young school-aged children. The management of this child has two components, medical and psychosocial:
• Medical management
– urgent referral to hospital
– exclude other causes for poor growth and weight gain, e.g. coeliac disease
– measure blood lead and seek advice from the National Poisons Information Service about the need for chelating agents
– check blood ferritin and a haemoglobinopathy screen and give a 3-month course of iron
– measure bone biochemistry and vitamin D and consider treatment with vitamin D or a multivitamin preparation to minimize lead absorption
• Psychosocial management
– referral to Social Care for a multidisciplinary assessment of the whole family
– try to establish the source of lead and remove it or restrict access to it – involve the Health Protection Agency
– likely to need referral to Child and Family Therapy service for behaviour management.
KEY POINTS
• Exclude lead poisoning in any child with a history of pica.
• In lead poisoning, investigate and treat any coexisting calcium and iron deficiency to minimize lead absorption.
• Emotional and social neglect are known predisposing factors for pica.
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