Pica, rumination and avoidant/restrictive food intake disorder

Disorder

Three eating problems without worry about weight or shape: eating things that are not food, bringing food back up, and eating too little.

Updated Nov 13, 2026

Key points

Pica is seen in young children, pregnancy, intellectual disability and autism; check for iron or zinc deficiency, which can trigger cravings, and for lead exposure.
Complications of pica include lead poisoning, blockage of the stomach or bowel (for example by a hairball or other bezoar) and parasitic infection.
Rumination is regurgitation after meals without nausea or retching; behavioral treatment uses biofeedback-guided diaphragmatic breathing.
ARFID has three drivers: little interest in eating, avoidance of sensory features (texture, smell, color) and fear of consequences such as choking or vomiting.
ARFID differs from anorexia nervosa because there is no distorted body image or preoccupation with it, and from picky eating because growth, nutrition or psychosocial life suffer.
Medical causes come first: exclude gastrointestinal disorders such as reflux before diagnosing rumination, and general medical illness before diagnosing ARFID.

What it is

Pica is persistent eating of non-food substances for at least a month, at an age (over 2) and in a context where it is not developmentally or culturally normal. Rumination disorder is repeated regurgitation of eaten food, which may be rechewed, reswallowed or spat out, for at least a month and not due to nausea or involuntary retching. Avoidant/restrictive food intake disorder (ARFID) is eating so restricted that it causes weight loss or poor growth, nutritional deficiency, dependence on supplements or tube feeding, or disturbed psychosocial functioning, without the distorted body image of anorexia nervosa.

Key facts

Typical pica substances are clay, dirt, ice, paper, paint chips and hair; missing nutrients should be addressed first.
Pica is not diagnosed when the practice is culturally accepted, such as traditional clay eating in some communities.
Regurgitation happens after eating, usually daily; some patients cover their mouth, limit eating or avoid eating with others.
Patients who spit food out or limit intake may lose weight or develop nutritional deficiencies.
ARFID typically begins in childhood, most often at ages 11 to 13; autism and anxiety may contribute.
The nutritional deficiencies of ARFID can be life threatening.

Feeding and eating problems compared

Condition	What happens	Distinguishing point
Pica	Eats non-food items for a month or more	Check iron, lead and parasites
Rumination disorder	Regurgitation after meals; food rechewed, reswallowed or spat out	Not due to nausea or retching
Avoidant/restrictive food intake disorder	Eats too little or too narrow a range	No distorted body image or preoccupation with it
Anorexia nervosa	Restricts eating	Distorted body image or preoccupation with it
Gastroesophageal reflux disease	Regurgitation of stomach contents	Must be excluded before diagnosing rumination
Iron or zinc deficiency	Cravings for non-food items such as ice	Blood tests; correct the deficiency
Lead poisoning	May follow eating paint chips	Blood lead test
Failure to grow as expected	Poor weight gain or growth in a child	Can be part of ARFID; exclude medical illness

Clinical notes

Pica: blood tests for anemia and lead, stool tests for parasites and X-rays if a blockage is suspected; correct missing nutrients.
Rumination: once reflux and other gastrointestinal disorders are excluded, use behavioral treatment with biofeedback-guided diaphragmatic breathing.
ARFID: exclude general medical illness and check nutritional status; treatment is cognitive behavioral therapy or family-based treatment.
Pica treatment works on behavior, the environment and family education, for example mild aversion therapy followed by rewards for normal eating.

Test yourself

Think of the answer, then tap the question to see it.

Which deficiency should always be checked in a patient with pica?

Iron and zinc deficiency, which can trigger the cravings; lead exposure should also be checked.

How does rumination differ from vomiting?

Rumination is regurgitation of eaten food that is not due to nausea or involuntary retching; the food may be rechewed, reswallowed or spat out.

What is the behavioral treatment of choice for rumination disorder?

Diaphragmatic breathing guided by biofeedback.

A 10-year-old eats only a few foods since choking on meat, has lost weight and does not worry about his body. What is the likely diagnosis?

Avoidant/restrictive food intake disorder driven by fear of harmful consequences such as choking.

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Educational content on behavior and the clinical relationship; not a diagnostic or treatment guide and no substitute for assessment by a health professional. If you or someone near you is at risk, seek help now from an emergency service or a mental-health helpline.

Sources: Pica (MSD Manual Consumer Version, 2025); Rumination Disorder (MSD Manual Professional Edition, 2025); Avoidant/Restrictive Food Intake Disorder (ARFID) (MSD Manual Professional Edition, 2026); Pica (MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, 2026).

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