Teaching Case: The Appearance of Pica in a 5 1/2‐Year‐Old Child With Short Bowel Syndrome

Abstract

W.M., a 5 1/2‐year‐old male with short bowel syndrome (SBS) secondary to an in utero midgut volvulus, had been dependent on total parenteral nutrition (TPN) in addition to gastrostomy tube (GT) feeds to maintain his nutritional status since birth. Bowel lengthening procedures performed at 15 and 30 months of age left W.M. with 82 centimeters of small bowel. Despite these procedures and what was presumed to be adequate nutrition, W.M.'s weight/age and height/age remained below the 5th percentile. With an observed improvement in oral intake at 5 1/2 years of age (2000 kcal/d), his GT was removed. TPN, which was continued for several months thereafter, was subsequently discontinued after a septic episode that resulted in severe neutropenia. However, family members soon began to report significant alterations in his behavior. An evaluation performed by a behavioral psychologist demonstrated no familial or developmental contributions to this new behavior pattern, which is termed pica in the psychological literature. Although a nutritional deficiency was suspected, serum levels of trace metals were found to be normal. With a reported increase in listlessness and lethargy at school, TPN was promptly reinstituted (approximately 6 months after it had been discontinued). The observed pica disappeared 1 week following the reinitiation of TPN therapy.