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Letters to the Editor Indian Pediatrics 2001; 38: 929-931 |
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Steroid Induced Pica? |
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A 3-year-old female child was admitted with complaints of swelling of face, trunk and extremities since 5 months, initially inter-mittent, later on persistent in the face. She was diagnosed to be a case of nephrotic syndrome by a practitioner and was on tablet predniso-lone since 5 months, apparently in usual doses. Past history, family history and history of birth and development were normal. There was no evidence of any stressful situation in the family that could trigger any emotional disturbance in the child. The child was well cared for by the parents and there was no dearth of love and affection. Pre-morbidly the child was healthy, active, playful and interactive and no specific behavior problem could be elicited. Although they belonged to low socio-economic strata and lived in a crowded locality, the father was in a private job and his income was sufficient to feed his small and unitary family consisting of the parents and two children. Pre-morbidly the child used to consume a diet of about 1000 Kcal per day. While exploring the diet it was found that she started eating wall paints, plasters and hair during the illness. She developed a special affinity for hair that was abundant in her crowded environment having many ladies around. As described by the parents, whenever some lady started combing, she would go there, pick up the hair falling on the ground and quickly eat these up. Parents also noticed marked increase in her appetite during this period. There was however no evidence of the child eating her own hair. We failed to get an answer from her regarding her fascination for hair. A consulta-tion for any psychiatric problem in the child or the family was also unrewarding. Examination revealed a child with marked steroid facies and having weight of 7 kg, head circumference of 48 cm, height of 74 cm and blood pressure of 110/80 mm, Hg (recorded on several occasions). Scalp had no alopecia. There was an ill-defined mass in the epi-gastrium, firm, non-tender, smooth and extending up to 3 cm below the costal margin. Other systems were normal. Investigations showed a normal hemogram with Hb of 12 g/dl, normal urinalysis with no proteinuria or glycosuria and normal routine examination of stool. LFT, KFT, X-ray chest, abdominal USG and Mantoux test were normal. Upper GI endoscopy revealed a mass conaining hair in the stomach suggestive of trichobezoar. A barium meal examination also showed findings suggestive of trichobezoar in the stomach extending up to duodenum. The child was finally diagnosed to have severe pica compli-cated with trichobezoar, with steroid toxicity and with probably nephrotic syndrome in remission. The child was discharged after surgical removal of the hairball. At 9 months of follow up she was doing well with no pica. Several heterogeneous entites like mental retardation(2), psychosocial stress in the form of maternal deprivation, parental neglect and abuse, martial discord and bad home environ-ment(3-6) and a variety of behavior dis-orders(5,6) have been speculated to be causatives of pica. Poor socioeconomic status, malnutrition and iron deficiency, so commonly associated with pica, have often been considered to have etiologic significance, however the cause and effect relationship has never been established clearly. Pica has been reported in apparently healthy children from higher socioeconomic class(7) and also iron deficiency has been shown to be ineffective in stopping this habit(8). We were wondering what could be the cause of pica in this particular child. Although anthropometrically she had malnutrition, which could, to some extent be due the current illness, the protracted steroid therapy and the effect of the trichobezoar, she did not have anemia or any other common associated deficiencies and nutritional factors thus do not appear to have primary role. Pre-morbidly the child was apparently healthy with normal neurodevelopment and normal behavior. Adverse environmental factors commonly associated with pica were also not there. The pica in this child developed during the current illness when she had received steroid all throughout with adverse side effects and also developed marked increase in appetite. Stimulation of appetite and elevation of mood are well known side effects of steroid therapy. It appears that the steroid therapy, through its effects on appetite and mood, was conducive to her adventure of eating hair, which was available in plenty around and ultimately ended up in development of a trichobezoar. Thus the pica in this child appears to have been induced by steroid through its effects on her psyche. B.
Talukdar,
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