Pica and Other Unsafe Oral Behavior Introduction Stomach X-Ray Photograph: An X-ray shows the patient's stomach filled with coins, necklaces and needles. In 2002, a 62 year old man came to the emergency room complaining of stomach pain. He could not eat or move his bowels. After taking an x-ray of the patient, doctors found over $650 in coins in the man's stomach. The mass weighed over 12 pounds. They operated successfully, but the man died from complications 12 days later. The man had pica, a behavior that makes people crave non-food items. This, as well as other unsafe oral behavior, is common in people with developmental disabilities. Source: http://www.cnn.com/2004/HEALTH/02/18/ coin.eater.ap/index.html Our Mission At KNI, our mission is to support each person to have a meaningful life, which in part means to honor the lifestyle choices that people make. Balancing our need to protect people's ability to make personal choices is our need to protect people from harm, including unsafe oral behavior. What is Unsafe Oral Behavior? In 1990, a 27-year old female resident at a residential facility for people with disabilities was among a group listening to music in the back yard when she was observed eating a dead bird. After a struggle to have the resident relinquish the dead bird, the resident's hands and mouth were washed out with hydrogen peroxide solution. No observable injury was noted. Upon further search of the residence back yard, another dead bird was found. Source: http://www.paica.org/pubs/700201.htm Unsafe oral behavior includes the following: Mouthing Orally exploring objects that are not safe to eat. Often seen in people with cognitive disabilities/autism due to developmental delays Can lead to accidental swallowing or choking on items Eating excessive amounts of food Prader-Willi Syndrome Drinking excessive amounts of liquid Water intoxication or polydipsia Pica Appetite for non-foods Abnormal appetite for quasi-foods (for example, ice) In 1990, a 28-year old male resident at a residential facility for people with developmental disabilities died after ingesting caustic laundry detergent from a drinking cup that was left in the laundry room of the unit where he lived. Injuries included extensive facial burns, involving the eyes and cornea, all the way down to the larynx, trachea, and mid-portion of the esophagus. Cause of death was attributed to "acute chemical pneumonitis by corrosive substance." Source: http://www.paica.org/pubs/700201.htm Maintaining a safe environment is crucial to the well-being of the people we support. We must become aware of the unsafe oral behaviors affecting people who we support. We must enlist the cooperation of all staff in addressing environmental safety issues. We must address environmental safety issues pertinent to people we support. Names of Phagias (Unsafe Oral Behaviors) Acuphagia - sharp objects Amylophagia - laundry starch Coprophagia - feces Foliophagia - leaves, grass Geophagia - sand, clay, dirt Lithophagia - stones and pebbles Pagophagia - ice, freezer frost Tobaccophagia - cigarette butts Trichophagia - hair Guantophagia - latex gloves These are substances that are commonly ingested by those with pica behavior. Foliage Foil Crayons Coal Soil Chalk Washcloths Latex Gloves Adult Disposable Briefs Chux Feces Paper Plastic String Cloth Dirt Dust Hair Ties Cigarette Butts Hair Paint Metal Rocks Consequences of Pica Photograph: mass of hair removed from child's stomach Source: www.res.sd8.bc.ca/Digestive%20System.html The consequences of pica behavior can be devastating. - Malnutrition - Poisoning (eating 3 - 4 whole cigarettes can kill) - Parasitic infections - Oral and dental trauma - Intestinal obstructions and perforation - Death Exam Gloves Exam gloves pose special problems since they are used regularly by direct support and nursing staff as well as housekeeping and other staff. If ingested by someone they are: Difficult to remove when eaten glove material becomes rigid, sharp bezoars of foreign material in the stomach obstruction of airways and digestive system perforation of parts of the digestive system such as stomach or intestines inflammation ulceration Difficult to remove when inhaled exam gloves cling to mucous surfaces in the mouth and throat like sticky tape exam gloves are hard to eject with the Heimlich maneuver Special Problems of Exam Gloves In 1992, a 28-year old male resident at a residential facility for people with developmental disabilities died after choking on a rubber glove that he obtained from a housekeeping cart containing cleaning supplies and a bag of latex gloves. The resident was discovered by a housekeeper who observed him clutching his throat, walking down the hallway of the unit where he lived, and turning blue. The housekeeper reported that she had seen him roaming up and down the hallway as she was cleaning rooms. Source: http://www.paica.org/pubs/700201.htm The habit of eating clay, mud or dirt is known as geophagy, and is an accepted practice in some parts of the world. Photograph: Rena Bronson eats clay at her home in East Macon, Ga. Like many African-American women in the South, Bronson has for years found satisfaction from eating clay. (Nick Oza/The Telegraph) Source: http://abcnews.go.com/Health/ story?id=1167623page=1 Behavioral treatments of pica behavior are unlikely to be effective. Pica is "self-reinforcing." Self-reinforcing behaviors are very difficult to eliminate with behavioral plans. Staff have almost no control over the person's ability to produce pleasurable outcomes. The person will learn to do it secretly if consequences only occur when staff are around. Treatment of Pica Behavior Eliminate access to pica targets and replace with safe objects. Increase the available oral/taste stimulation by providing many healthy snacks, ice chips, or gum. Reinforce physically incompatable behavior with productive engagement involving use of hands. Medication is generally not effective. Prevention of Pica Photograph: Jennifer Lea Strange and her husband, William, are pictured with their children: Keegan Sims, 10, Ryland Strange, 3, and Jorie Strange, 11 months.  In 2007, a 28-year old mother named Jennifer Strange was found dead in her California home after drinking over two gallons of water as part of a radio contest. She was trying to win a Nintendo Wii for her children. The cause of death was water intoxication, where a person drinks so much water that it causes massive cell damage from a sodium imbalance in the body. Symptoms of water intoxication include nausea, altered mental state, vomiting, headaches, muscle weakness and convulsions. Left untreated, coma and death result. Source: waterintoxication.org - Become familiar with each individual you support. - Develop a safety plan for each person who is known to be at risk. - Include the safety plan in those persons' Protection from Harm guidelines. - Increase the general awareness of the issue with all people who work at your agency. - Store exam and rubber gloves in areas inaccessible to the people you support. - Dispose of exam and rubber gloves in inaccessible containers. - Police areas around the homes, dumpsters and vehicles frequently to ensure dangerous ingestible items are not present. - Every employee has responsibility to clean up items which pose a risk. Prevention of Pica Behavior Photograph: Brenden Fraser as Mad-eye Moody in "Harry Potter and the Goblet of Fire" Mad-eye Moody is a character in the Harry Potter novels. He is always on the lookout for evil witches and wizards. His catchphrase is "constant vigilance!" Source: moviejuice.com We must always be aware of the environment of the people we support. Some individuals prone to pica or other unsafe oral behaviors have been identified. However, anyone has the potential to engage in these behaviors. Mouthing is very common, and can lead to accidental swallowing or choking. Supervision and environmental protection are relevent to everyone we support. Constant Vigilance! Outcomes In order to provide a safe environment for the people we support, the following outcomes must be achieved. - People will dispose of special litter in appropriate places. - People will realize the impact pica has on specific individuals. - The culture will change to better protect people who may engage in unsafe oral behavior. Thank you for reading this important information about Pica and other unsafe oral behavior!