Positive Approaches Journal, Volume 14, Issue 1

Volume 14 ► Issue 1 ►March 2025

Pica and Lead Exposure in Pennsylvania’s Children

Julia Kaya

Pennsylvania health care providers, especially pediatricians, should have an increased awareness of the potential interactions between pica and lead poisoning in the populations they serve. This awareness should increase vigilance in the care of young children with risk factors for either condition.

Pica is an eating disorder where people consume non-nutritious, non-food substances.1  While mouthing non-edible substances is considered normal to some degree in babies and toddlers, children with pica exhibit a persistent, compulsive urge to consume non-food substances.2 Pica affects approximately 3.5% of children in the United States, but is especially prevalent in children with autism spectrum disorder (23%) and is also associated with developmental and intellectual disabilities.3  Pica is most commonly seen in children between the ages of 1 and 6 years, a time when curiosity and oral exploration are part of normal development. This stage also marks a critical period for brain growth, making lead exposure especially dangerous.

Pica has historically been under-diagnosed, and its etiology is still poorly understood. The association between pica and iron deficiency is, however, well-known, with many researchers and clinicians believing that iron deficiency induces pica.4-5 Unfortunately, iron deficiency is also a known risk factor for lead poisoning, because individuals with iron deficiency absorb lead from the gut more efficiently.6 Even low-level exposure to lead can cause intellectual, behavioral, and academic deficits7, and intellectual disabilities are associated with pica.3 Because pica and childhood lead poisoning share many of the same risk factors, these conditions can create a self-sustaining cycle with permanent repercussions. 

According to data from the Centers for Disease Control and Prevention (CDC), Pennsylvania is one of the states with the highest percentages of children with blood lead levels above the reference level. This could be influenced by factors such as housing age, industrial history, and public health initiatives.8 Among homes built before 1940, 87% had some lead paint. Although lead paint was banned in the United States in 1978, 24% of homes built between 1960 and 1978 had some lead paint.9 Pennsylvania has the fifth most housing stock built before 1950 in the nation, meaning there are abundant opportunities for children to encounter lead paint.10 This is especially true for children in families with low socioeconomic status who are more likely to live in older homes.11  While lead paint is the supposed primary source of lead exposure in Pennsylvania, other sources of lead exposure include toys, ceramics, and drinking water when that water has flowed through older lead plumbing or pipes where lead solder has been used.10

Children with pica in Pennsylvania often eat paint chips from walls or windows, chew on ledges and windowsills, or consume soil from just outside their homes. All of these are potential sources of lead consumption. Peeling or chipping paint can either contain lead itself or pull lead from older layers of paint.12 Windowsills and frames are common sources of lead in older homes, as lead paint was once used primarily for high-contact areas. Lead paint outside the home can be leached into nearby soil by precipitation.13

The CDC uses a blood lead reference value of 3.5 micrograms per deciliter (µg/dL), to reflect the latest research on the health effects of lead exposure. Studies show that even blood lead levels below 5 µg/dL can cause harm, including reduced intelligence quotient (IQ), attention deficits, and behavioral problems in children. No safe level of lead exposure has been identified, particularly for children.14

The 2022 Pennsylvania Childhood Lead Surveillance Annual Report (the most recent year published at the time of writing) showed that non-Hispanic Black or African American children had both the highest screening rates and the highest rates of confirmed elevated blood lead levels (defined as one venous blood lead test ≥3.5 µg/dL or 2 capillary blood lead tests ≥3.5 µg/dL drawn within 12 weeks of each other).10 It is noteworthy that iron deficiency is also more prevalent in Black people than Caucasian people.15

Health care providers in Pennsylvania have a unique impetus to increase vigilance related to pica symptoms in their young patients, because their patients face higher risk than those in other geographic areas with younger housing stock. Pennsylvania’s pediatricians can go above and beyond national standards by making it a matter of practice to ask pica screening questions at regular intervals, as well as whenever a child’s blood lead result is above the reference value. Providers can also suggest additional blood level screenings when pica symptoms are observed. Addressing nutritional deficiencies in young children can help mitigate the effects of both pica and lead exposure, and additional awareness by providers of environmental exposures can help them to provide better patient care.

Blood lead level screening is currently recommended between 9 and 12 months and at 24 months of age.10 All providers in Pennsylvania should be invested in increasing the childhood blood lead screening rate to the best of their abilities, and especially in at-risk populations. This can be accomplished by empowering caregivers through education on potential lead hazards and the importance of participation in lead screening tests. Clear and frequent communication with local health departments can help foster collaboration on lead poisoning prevention.

References

1. Sigita Lesinskienė, Stonkutė G, Rokas Šambaras. Pica in childhood: Prevalence and developmental comorbidity. Frontiers in Child and Adolescent Psychiatry. 2023;2. doi:https://doi.org/10.3389/frcha.2023.1099527

2. Al Nasser Y, Muco E, Alsaad AJ. Pica. StatPearls. Treasure Island (FL): StatPearls Publishing; 2025. doi:https://www.ncbi.nlm.nih.gov/books/NBK532242/

3. ‌Fields VL, Soke GN, Reynolds A, et al. Pica, Autism, and Other Disabilities. Pediatrics. 2021;147(2):e20200462. doi:https://doi.org/10.1542/peds.2020-0462

4. ‌Federman DG, Kirsner RS, Federman GS. Pica: are you hungry for the facts?. Conn Med. 1997;61(4):207-209.

5. Ganesan PR, Vasauskas AA. The Association Between Pica and Iron-Deficiency Anemia: A Scoping Review. Cureus. 2023;15(4):e37904. Published 2023 Apr 20. doi:10.7759/cureus.37904

6. Kwong WT, Friello P, Semba RD. Interactions between iron deficiency and lead poisoning: epidemiology and pathogenesis. Sci Total Environ. 2004;330(1-3):21-37. doi:10.1016/j.scitotenv.2004.03.017

7. Gould E. Childhood Lead Poisoning: Conservative Estimates of the Social and Economic Benefits of Lead Hazard Control. Environmental Health Perspectives. 2009;117(7):1162-1167. doi:https://doi.org/10.1289/ehp.0800408

8. United States Environmental Protection Agency. How can I tell if my home contains lead-based paint? www.epa.gov. Published January 30, 2020. https://www.epa.gov/lead/how-can-i-tell-if-my-home-contains-lead-based-paint

9. CDC. Childhood Blood Lead Surveillance: National Data. Childhood Lead Poisoning Prevention. Published June 13, 2024. https://www.cdc.gov/lead-prevention/php/data/national-surveillance-data.html

10. Pennsylvania Department of Health. 2022 Childhood Lead Surveillance Annual Report. Published 2024. https://www.pa.gov/content/dam/copapwp-pagov/en/health/documents/topics/documents/environmentalhealth/2022%20Childhood%20Lead%20Surveillance%20Annual%20Report%20PDF.pdf

11. Neuwirth LS. Resurgent lead poisoning and renewed public attention towards environmental social justice issues: A review of current efforts and call to revitalize primary and secondary lead poisoning prevention for pregnant women, lactating mothers, and children within the U.S. Int J Occup Environ Health. 2018;24(3-4):86-100. doi:10.1080/10773525.2018.1507291

12. Lead Poisoning. Pa.gov. Published 2022. Accessed February 12, 2025. https://www.pa.gov/agencies/health/diseases-conditions/lead-poisoning.html

13. ‌National Center for Environmental Health (U.S.). Division of Environmental Health Science and Practice. (2022). ALL Children Can Be Exposed to Lead: Lead in Soil.

14. CDC. CDC Updates Blood Lead Reference Value. Childhood Lead Poisoning Prevention. Published April 25, 2024. https://www.cdc.gov/lead-prevention/php/news-features/updates-blood-lead-reference-value.html

15. Zakai NA, McClure LA, Prineas R, et al. Correlates of anemia in American blacks and whites: the REGARDS Renal Ancillary Study. Am J Epidemiol. 2009;169(3):355-364. doi:10.1093/aje/kwn355