Pica and rumination disorder — formative SAQs

SAQ 1 (10)

A 3-year-old living in housing built before 1970 is brought because of persistent paint-chip eating over four months. The child is irritable and has mild developmental regression. [2] [12]

1. Define pica and state why this presentation triggers the harm gate before a behavioural label is assigned. (3) [1] [2]
2. List five must-screen complications or drivers for this child. (3) [2] [12]
3. Outline your targeted investigations and first-step management principles (no invented drug doses). (4) [2] [12]

Model answer

Definition and harm gate. Pica is persistent eating of non-nutritive, non-food substances for at least one month that is not developmentally or culturally appropriate and is not better explained by another disorder. Irritability and developmental regression in a paint-chip eater trigger the harm gate because they suggest lead toxicity; the complication is assessed and treated before a behavioural label is fixed. [1] [2]

Must-screen items. Lead poisoning; iron or zinc deficiency; bezoar or obstruction; helminth infection (Toxocara or Baylisascaris with soil/geophagy); malnutrition or growth faltering; dental sequelae. (Any five.) [2] [12]

Investigations and management. Blood lead level, full blood count, iron studies, zinc level, electrolytes; growth and developmental assessment; abdominal imaging only if obstruction is suspected; dental review. First-step management: remove the lead source and involve public health; correct deficiency; begin behavioural intervention with supervision, response prevention, redirection and positive reinforcement; set review and explicit safety-net return criteria; escalate for encephalopathy or rising lead. [2] [12]

SAQ 2 (10)

A 14-year-old has three months of effortless regurgitation within minutes of meals, with re-chewing and weight loss. Endoscopy was normal. [6] [9]

1. Give a one-sentence problem representation and justify why this is rumination rather than reflux, cyclic vomiting or purging. (4) [9]
2. Which focused investigations support the diagnosis without over-investigation? (3) [9]
3. Outline stepwise management including the first-line behavioural technique and what to avoid. (3) [6] [7]

Model answer

Representation and discriminator. "Fourteen-year-old with three months of effortless, post-prandial regurgitation, re-chewing and weight loss with a normal endoscopy — rumination syndrome until proven otherwise." The effortless, non-nauseated, post-prandial quality without retching separates it from reflux (acid, variable timing), cyclic vomiting (episodic, retching, well between), and purging (induced, eating-disorder features). [9]

Focused investigations. Confirm growth failure and exclude structural obstruction; use high-resolution oesophageal impedance, pH monitoring or manometry where available to show the post-prandial, non-acidic pattern; avoid repeating normal endoscopies. [9]

Management. First-line behavioural technique is diaphragmatic breathing taught by a trained therapist, augmented by habit reversal and cognitive-behavioural therapy where needed, often within an intensive outpatient protocol. Treat reversible contributors such as constipation or reflux. Avoid endless repeat endoscopies and pharmacotherapy as a substitute for the behavioural plan. [6] [7]