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Pica in sickle cell disease: “She ate the headboard”
  1. Department of Haematology
  2. Central Middlesex Hospital
  3. London NW10 7NS
  4. marilyn_rae{at}

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Editor,—Within our sickle cell population, there are a small number of school aged children who eat sponge. Knowing that pica—the compulsive ingestion of non-nutritive substances—is more common in tropical countries where cultural and dietary factors play a role, it may not be a surprising finding. However geophagia (soil), pagophagia (ice), and trichophagia (hair) are the commonest substances eaten. We cannot explain the predilection for sponge amongst our patients.

Infants place everything in their mouth, and pica occurs in a variety of syndromes associated with brain damage and developmental delay. It is also more common in deprived and neglected children. Neurological complications are not uncommon in sickle cell disease (SCD) but none of our children had cognitive impairment.

There is a recognised association between iron deficiency and pica, leading to debate as to which is cause and which effect. Natural sponge contains various proteins and minerals, and is often fortified with silica or calcium salts, however, synthetic sponge consists of cellulose alone. We wondered whether a craving of an unidentified salt fuels the eating of sponge, or whether the texture of sponge is simply orally stimulating.

In one study of pregnant women, 33% with pica had a history of childhood pica and 56% had a positive family history. In our children, four have a positive family history. Therefore, pica can be a response to a nutritional deficit, it can be familial suggesting a learnt behaviour, or developmental and emotional issues may be involved. In America it is classified as an eating disorder, in the UK it is considered a behavioural disorder; it can also be an obsessive-compulsive disorder, or a manifestation of depression.

Our children could shed no light on their compulsion. In six cases the parents found the behaviour so unacceptable that they requested psychological intervention and in four, the behaviour has now stopped. Thus whilst we find this behaviour fascinating, we are no clearer in understanding the aetiology of pica for sponge in this small population of children with SCD.