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Year : 2013  |  Volume : 4  |  Issue : 2  |  Page : 122-123

Pica in children with tetralogy of Fallot: Report of two cases

Department of Pediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria

Date of Web Publication16-Sep-2013

Correspondence Address:
Aliyu Ibrahim
Department of Pediatrics, Aminu Kano Teaching Hospital, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-9727.118245

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Cyanotic congenital heart disease is a high iron-requiring illness; therefore affected children may be prone to iron deficiency if not actively sorted and treated. Among problems associated with iron deficiency is pica; the consumption of non-food substances for non-nutritive purposes. Children with pica are at risk of other health hazards like lead toxicity, Intestinal obstruction and parasitic infections from the contaminated substances consumed; however, this is often a forgotten problem in children with cyanotic heart disease; therefore two cases of pica in children with tetralogy of Fallot are reported.

Keywords: Cyanotic congenital heart disease, iron deficiency, pica, tetralogy of Fallot

How to cite this article:
Ibrahim A. Pica in children with tetralogy of Fallot: Report of two cases. Muller J Med Sci Res 2013;4:122-3

How to cite this URL:
Ibrahim A. Pica in children with tetralogy of Fallot: Report of two cases. Muller J Med Sci Res [serial online] 2013 [cited 2023 Mar 25];4:122-3. Available from: https://www.mjmsr.net/text.asp?2013/4/2/122/118245

  Introduction Top

Pica is defined as the consumption of non-food substances for non-nutritive purposes in an inappropriate age lasting for more than a month. [1] The exact cause of pica is not clear but it has been associated with mineral deficiencies like iron, zinc. [2],[3] It has also been reported in patients with emotional disorder, poor rearing, malnutrition, mentally retarded children, and in obsessive-compulsive disorder. [4] The exact prevalence of pica in Nigerian children is not known, but it has been reported to vary from one region to another among African countries, and it has been reported in about 25 % and 46% of Zambian adolescents and male children respectively; [5] furthermore it has been documented in 8.1% of pregnant African-American women in the United States, [6] in 8.8% of pregnant women in Saudi Arabia, [7] 63.7% [8] and 74.0% [9] respectively for two different African populations. However its prevalence in children with cyanotic congenital heart disease who are also at risk of iron deficiency disease is not known to the best of my knowledge. Therefore two cases of pica in children with tetralogy of Fallot are reported.

  Case Reports Top

Case 1

A six-year-old girl, known patient of the pediatric cardiology unit who was diagnosed with tetralogy of Fallot and recto-vestibular fistula at the age of one-year presented with complaint of increased frequency of hypercyanotic spells, she had three episodes within a span of two months, though she had been regular with clinic visits and also adherent to medication (oral propranolol). She was yet to have palliative or corrective surgery due to financial constraint. Upon evaluation, the blood film and red blood cell indices showed evidence of microcytic hypochromic anemia (MCV-69.0 fl; MCH-16.3 pg; MCHC-236 g/L; RDW-CV: 24.2%; RDW-SD: 55.4%; HGB-16.0 g/dl), with serum ferritin of 10 ng/ml. She had stool microscopy which was not remarkable, and a test for occult blood was also negative. Further review of her records gave a history of frequent consumption of dirt and sand for the past four months, no history of bleeding from any site. Her diet had been mainly maize and millet-based. She was then placed on oral iron supplement (6 mg/kg/day); she improved after the fourth week of therapy with cessation of pica and normalization of the RBC indices; similarly, the hypercyanotic spells subsequently subsided significantly following treatment for iron deficiency.

Case 2

A nine-year-old boy with tetralogy of Fallot at the age of 12 months and had being regular with clinic follow-up visits and also adherent to medication (oral propranolol) presented with RBC indices evidence of microcytic hypochromic anemia on routine check (MCV-67.0 fl; MCH-15.0 pg; MCHC-25 g/L; RDW-CV: 23.5%; RDW-SD: 53.5%; HGB- 15.0 g/dl); based on the experience from the first case, the history was revisited and it also revealed a history of consumption of dirt and sand for the past five-months. No similarly complaint in family member; there was no history of bleeding from any site, and he was not on NSAID prescription. The stool microscopy was not remarkable and was negative for occult blood. The serum ferritin was also low (9.5 ng/ml). Similarly, the pica and RBC indices improved with oral iron therapy.

  Discussion Top

Pica occurs worldwide but is commoner amongst children and women of African extraction; this may not be surprising because it is a commonly accepted practice especially among pregnant women in some African society. [9] Pica eating disorder has the risk of exposing affected children to health hazards like lead, mercury and other heavy metals toxicities, intestinal obstruction and parasitic infections. It is often classified based on the consumed substances such as: Pagophagia (ice), amylophagia (consumption of starch), coprophagia (consumption of feces), geophagia (consumption of soil, clay, or chalk), hyalophagia (consumption of glass), lithophagia (a subset of geophagia: Consumption of pebbles or rocks).

Patients with untreated congenital cyanotic heart disease are prone to a chronic hypoxic state which result in a high hematocrit; (polycythemia); therefore, there is a high demand for hematinics like iron. When the bodies need exceeds the supply, iron deficiency may set in. Congenital cyanotic heart disease with iron deficiency increases the risk of hypercyanotic spells as was witnessed in the first case, and they also have increased risk of stroke and cerebral abscess, which has been attributed to impaired deformability of iron deficient red blood cells; hypercyanotic spells often subsides following treatment for iron deficiency as was observed in the first case. [10] But, the relationship between pica and iron deficiency is still not completely understood; some authors believe that iron deficiency is the cause of pica rather than its effect. Though pagophagia is commonest among iron-deficient patients, other forms of pica like geophagia had been reported, as was observed in both cases. The resolution of pica following treatment for iron deficiency in these cases further substantiates this association. Therefore, clinicians should always ask for the history of pica in children with congenital cyanotic heart disease, because that history may not be readily volunteered by parents, especially in a society where it is culturally permissive and if not picked early, these children stand the risk of exposure to parasitic infections and toxic contaminants from materials consumed.

  Conclusion Top

Pica is an eating disorder associated with iron deficiency, and it may also occur in children with congenital cyanotic heart disease; therefore, it should be part of the routine evaluation to ask for history of pica when treating them in order to avoid its attendant complications.

  References Top

1.López LB, Ortega Soler CR, de Portela ML. [Pica during pregnancy: A frequently underestimated problem]. Arch Latinoam Nutr 2004;54:17-24.   Back to cited text no. 1
2.Kushner RF, Gleason B, Shanta-Retelny V. Reemergence of pica following gastric bypass surgery for obesity: A new presentation of an old problem. J Am Diet Assoc 2004;104:1393-7.  Back to cited text no. 2
3.Rose EA, Porcerelli JH, Neale AV. Pica: Common but commonly missed. J Am Board Fam Pract 2000;13:353-8.  Back to cited text no. 3
4.Hergüner S, Ozyildirim I, Tanidir C. Is pica an eating disorder or an obsessive-compulsive spectrum disorder? Prog Neuropsychopharmacol Biol Psychiatry 2008;32:2010-1.   Back to cited text no. 4
5.Golden CD, Rasolofoniaina BJ, Benjamin R, Young SL. Pica and amylophagy are common among Malagasy men, women and children. PLoS One 2012;7:e47129.   Back to cited text no. 5
6.Edwards CH, Johnson AA, Knight EM, Oyemade UJ, Cole OJ, Westney OE, et al. Pica in an urban environment. J Nutr 1994;124 Suppl 6:954S-62S.   Back to cited text no. 6
7.Al-Kanhal MA, Bani IA. Food habits during pregnancy among Saudi women. Int J Vitam Nutr Res 1995;65:206-10.   Back to cited text no. 7
8.Nyaruhucha CN. Food cravings, aversions and pica among pregnant women in Dar es Salaam, Tanzania. Tanzan J Health Res 2009;11:29-34.   Back to cited text no. 8
9.Ngozi PO. Pica practices of pregnant women in Nairobi, Kenya. East Afr Med J 2008;85:72-9.   Back to cited text no. 9
10.Bernstein D. Cyanotic congenital heart lesions: Lesions associated with decreased pulmonary blood flow. In: Kliegman RM, Stanton BF, Schor NF, St. Geme JW 3 rd , Behrman RE, editors. Nelson Textbook of Pediatrics. 19 th ed. Philadelphia: WB Saunders; 2011. p. 1573-85.  Back to cited text no. 10

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