Pica and rumination — medical risk, discrimination, and first-line treatment (MEQ)

(i) Diagnoses and differentials. Case 1: pica (paint chips and ice for more than 1 month, developmentally inappropriate, clinically significant) in the context of mild intellectual disability, with concurrent iron deficiency anaemia (pagophagia clue). Differentials: cultural practice (not fitting paint chips), psychosis (no evidence), ordinary ice preference without non-food paint ingestion. Case 2: rumination disorder / rumination syndrome — effortless meal-linked regurgitation with rechewing/reswallowing, no BN psychopathology, PPI non-response. Differentials: GORD, vomiting syndromes, gastroparesis, BN purging (excluded by history), achalasia (organic work-up if red flags).^[1][3][6]

(ii) Woman — medical assessment. Same-day safety: remove access to paint; inspect environment for other toxins. Full history of substances, frequency, abdominal symptoms, neurological symptoms. Exam: abdomen, dentition, neurology, nutrition. Labs: FBC (already anaemic), iron studies (ferritin low), blood lead level given paint chips, U&E, consider zinc. Imaging/surgical review if obstruction symptoms. Start iron repletion pathway while behavioural plan begins; involve haematology if parenteral iron needed; public health/toxicology if lead elevated.^[1][2][6]

(iii) Man — mechanism and first-line treatment. Postprandial abdominothoracic contraction raises gastric pressure with transient LES relaxation → effortless regurgitation (not reverse-peristalsis vomiting). First-line: education + diaphragmatic breathing as a competing response after meals, with practice and meal coaching; biofeedback if available for abdominothoracic control.^[3][4]

(iv) Baclofen. Consider for refractory rumination after behavioural first-line (or specialist concurrent use). RCT evidence: baclofen 10 mg orally three times daily reduced rumination episodes versus placebo in crossover design. Monitor sedation, dizziness, GI effects; avoid abrupt cessation after prolonged use; specialist supervision; not a substitute for breathing training.^[5]

(v) Pica in ID. Environmental enrichment and restricted access; functional analysis; differential reinforcement / PBS; carer training; treat iron deficiency; avoid purely punitive approaches; MDT with ID psychiatry and residential supports; capacity-informed least-restrictive safety measures.^[1][6]