Pica and rumination disorder — branching viva

Stem

The examiner will test whether you can run the harm gate before assigning a label, separate pica and rumination from their mimics, treat reversible drivers, replace the behaviour rather than restrain it, and keep safeguarding open when stress precedes the behaviour. [1] [2]

Branch 1 — Toddler with paint-chip eating in older housing

Examiner: A two-year-old living in housing built before 1970 is brought because of paint-chip eating over four months. The child is irritable and the parent reports the child seems to have forgotten some words. What is your first move, and why does the label wait? [2]

Strong answer: My first move is the harm gate, not the behavioural label. Irritability and loss of words in a paint-chip eater are red flags for lead toxicity, so I assess and treat the complication first. I check a venous blood lead level, a full blood count and iron studies, examine neurodevelopment, and identify the lead source with public health involvement. Pica is persistent eating of non-nutritive, non-food substances for at least one month that is not developmentally or culturally appropriate, and developmental mouthing under eighteen months is normal — but here the duration and the regression make this pathological and the complication is driving the encounter. The behavioural plan — supervision, response prevention, redirection, environmental enrichment, positive reinforcement — follows once the lead source is addressed and the deficiency corrected. I never reassure on age alone when growth, neurology or behaviour are regressing. [1] [2] [12]

Branch 2 — Adolescent girl with ice craving, heavy menses and fatigue

Examiner: A fifteen-year-old girl craves and eats ice through the day, has heavy periods, and is tired. What is the likely driver, what do you test, and what happens to the behaviour when you treat it? [1]

Strong answer: This is classic iron-deficiency pagophagia. I check a full blood count and iron studies, and a pregnancy test because pagophagia and iron deficiency also cluster in pregnancy. I address menstrual blood loss with adolescent gynaecology input and treat the iron deficiency with replacement. Iron and zinc deficiency are common, treatable drivers of pica, and the craving often settles as iron stores recover — so I re-assess the behaviour after correction rather than committing to a lifelong psychiatric label. I screen concurrently for lead exposure and food insecurity, because the drivers overlap. If the behaviour persists after the deficiency resolves, then I move to a behavioural plan with the multidisciplinary team. [1] [13]

Branch 3 — Adolescent with effortless post-prandial regurgitation and weight loss

Examiner: A fourteen-year-old has three months of food coming back up within minutes of meals. There is no nausea and no retching; she re-chews and re-swallows or spits it out. Endoscopy was normal and she has lost weight. What is the diagnosis, what is the mechanism, and what is the first-line treatment? [6]

Strong answer: This is rumination syndrome until proven otherwise, not treatment-resistant reflux. The effortless, post-prandial, non-nauseated quality without retching is the discriminator from reflux, cyclic vomiting, gastroparesis and eating-disorder purging. The mechanism is a somato-visceral reflex — an involuntary contraction of the abdominal wall raises intragastric pressure and pushes recently swallowed food back up, without structural obstruction; Rome V frames this as a paediatric disorder of gut–brain interaction. A normal endoscopy in this story should prompt rumination, not more tests. The first-line treatment is diaphragmatic breathing taught by a trained therapist — it interrupts the reflex by replacing it with a competing pattern, usually within weeks. Where breathing alone is insufficient, comprehensive cognitive-behavioural therapy and habit-reversal approaches augment it, and intensive outpatient protocols report good recovery in adolescents. I avoid endless repeat endoscopies and I do not substitute pharmacotherapy for the behavioural plan. [6] [7] [8] [9]

Branch 4 — Autistic child with persistent pica for non-food items

Examiner: A seven-year-old with autism chews and swallows foam, string and soil, and the family supervises closely. What is your management approach, and what rare complication must you keep on the differential? [4]

Strong answer: I use a function-first, sensory-aware approach. In autism and intellectual disability, sensory and ritualistic reinforcement sustain the behaviour, so the plan is built around hands-on supervision, environmental enrichment, response prevention, redirection, and positive reinforcement — never punitive restraint, which does not work and can harm. I screen for and treat iron and zinc deficiency, which coexist and amplify pica, and I coordinate occupational therapy, psychology, dietetics and school liaison around the family. The rare complication I keep open is Baylisascaris procyonis — raccoon roundworm — which causes devastating neurological infection in children with pica and raccoon or soil exposure, so I ask about environmental exposure and treat suspected infection aggressively. The behaviour often persists and demands long-term individualised support rather than a short fix, so I set review intervals and explicit safety-net return criteria. [4] [15]

Branch 5 — New rumination after family stress, in out-of-home care

Examiner: A ten-year-old in foster care has started effortlessly bringing food back up after meals since a placement move two months ago, with mild weight loss. How does your assessment change, and what is your team? [2]

Strong answer: I keep safeguarding, trauma and the gut open at the same time, without diagnostic overshadowing. New rumination after family stress, a placement move, or disclosure of abuse changes both the assessment and the team I mobilise. I confirm the effortless, post-prandial, non-nauseated pattern to separate it from reflux and vomiting, exclude structural obstruction, and check growth and weight trajectory. I assess trauma and safeguarding alongside the behaviour, and I mobilise psychology and social work with paediatrics. The rumination is treated behaviourally with diaphragmatic breathing and habit reversal, and the reflex often settles as the stressor is addressed — but I do not assume the behaviour is purely psychological before excluding medical harm. The team is multidisciplinary: paediatrics, psychology, social work, dietetics and school liaison, with a clear safety-net for weight loss or deterioration. [2] [7]

Branch 6 — Sickle-cell disease and pica for foam and starch

Examiner: A six-year-old with sickle-cell disease chews foam and eats starch through the day. The haematology team asks whether to investigate. What do you say? [13]

Strong answer: Pica is common in sickle-cell disease and tracks with chronic anaemia and healthcare use, so this is expected rather than exotic — but I still run the harm gate. I treat the anaemia and iron deficiency as the likely driver, monitor the behaviour over time, and coordinate with the haematology team. I check for iron and zinc deficiency, screen for lead exposure if there is paint or soil pica, and assess for bezoar if abdominal signs emerge. The behaviour is tracked longitudinally rather than dismissed, because pica in sickle-cell disease reflects the underlying deficiency and responds partly to correction. I give the family a safety-net for abdominal pain, distension, vomiting, constipation or regression. [13]

Examiner extras

• The single highest-yield move is running the harm gate before the label — lead, bezoar, helminth, malnutrition come first. [2] [12]
• Rumination is effortless, post-prandial, no nausea, no retching — say it aloud to separate it from reflux, cyclic vomiting and purging. [9]
• Iron and zinc deficiency are both driver and treatment of pica — correct them and re-assess. [1] [13]
• Diaphragmatic breathing replaces the rumination reflex; punitive restraint does not work for pica. [6]
• Most children are managed outpatient with the multidisciplinary team; admit only for active complications. [7]

Summary

Hold the harm gate open, treat reversible drivers, replace the behaviour with supervision and response prevention for pica or diaphragmatic breathing for rumination, and never use punitive restraint or forced re-feeding — a coordinated multidisciplinary plan with an explicit safety-net recovers most children in the community. [1] [6] [9]