Rajiv Gandhi University of Health Sciences Karnataka



BRIEF RESUME OF THE INTENDED WORK

6. INTRODUCTION

Every child comes with the message that God is not yet discouraged of man.

~ Rabindranath Tagore

The child is the most precious possession of mankind, most loved and perfect in its innocent and a child is beautiful, a source of joy and happiness, a focus of love and care and a subject of dream for the future.

Children are one third of our population and all of our future. While we try to teach our children all about life, our children teach us what life is all about. Receive the children in reverence, educate them in love, and send them forth in freedom. Under five children focus on important segment of Indian population. They contribute to the vital human potential and impart strength to the national economy and development.

Under five children tend to establish eating habits during the first 2 to 3 years of life. During childhood, the eating preferences and attitudes related to food habits are established by family influences and culture. Unhealthy diets are common among lower income families, often because of the lack of nutritious fresh fruits and vegetables and adequate milk and protein intake. In addition, the lifestyles of homeless and migrant children place these populations at risk for inadequate food, causing nutrient deficiencies, developmental and growth delay, depression, hunger and behavior problem.1

Behavioral disorders are very common in childhood. Young people can have mental, emotional, and behavioral problems that are real, painful, and costly. These problems often called "disorders," are sources of stress for children and their families, schools, and communities. The number of young people and their families who are affected by mental, emotional, and behavioral disorders is significant. It is estimated that as many as one in five children and adolescents may have a behavioral disorder that can be identified and require treatment.2

It has been estimated that about 25% of children have behavioral problems and found to be more common in nuclear families. These are not considered as disease entities but as a symptom or group of symptoms because of faulty/disordered development of personality of the child due to environmental maladjustments.3

Eating disorder is one of the most common behavioral problem in children. The most common eating disorder in children are Pica, Anorexia/resistance to feeding, Obesity, vomiting, Rumination disorders. Of all eating disorders pica is commonest eating disorder.3

Many young kids put nonfood items in their mouths at one time or another. They are naturally curious about their environment and might, for instance, eat some dirt out of the sandbox. Kids with pica, however, go beyond this innocent exploration of their surroundings. Between 10% and 30% of kids ages of 1 to 6 years have the eating disorder pica, which is characterized by persistent and compulsive cravings (lasting 1 month or longer) to eat nonfood items.4

The word pica comes from the Latin word for magpie, a bird known for its large and indiscriminate appetite. Pica is an eating disorder typically defined as the persistent eating of non nutritive substances for a period of at least one month at an age in which the behavior is developed mentally in appropriate (>18-24 month). children with pica frequently crave and consume nonfood items such as: dirt, clay, sand(geophagy), paint chips, plaster, chalk, cornstarch, laundry starch(amylophagy), baking soda, coffee grounds, cigarette ashes, burnt match heads, cigarette butts, feces, ice (pagophagy), glue, hair, buttons, paper, sand, toothpaste, soap etc,4

Pica is most common in children with developmental disabilities, including autism and mental retardation between the ages of 2 and 3. Pica also may surface in children who have had a brain injury affecting their development. Pica may be due to parental neglect, poor attention of caregivers, inadequate love and affection, etc. In some societies, pica is culturally sanctioned practice and is not considered to be pathologic. Pica may be benign or it may have life threatening consequences.5

Children with pica may have associated problems of intestinal parasitosis, lead poisoning, vitamins and minerals deficiency. These children may have problems like trichotillomania and trichobezoar.6

The broad range of complications arising from the various forms of pica and the delay in accurate diagnosis may result in mild-to-life-threatening sequelae. Bezoar, infection, intestinal obstruction, ulcerations, perforations, malnutrition, inherent toxicity, lead poisoning, parasitic infections and dental injury.5

In most cases, pica disorder in not diagnosed until the child, adolescent, or adult are brought into the emergency room with severe to life threatening complications associated with non-food items. The main approach in such situations is identifying the health emergency (whether the person is poisoned, has an intestinal blockage or obstruction) and eliminating the problem in order to save the patient’s life and avoid other complications. Individuals with pica require close medical monitoring throughout their treatment and the medical team should include a physician (who evaluates and treat the physical problems associate with pica), social worker (responsible with probable socioeconomic issues), and mental health specialist (who will address the psychological issues associated with the disorder).7

The main goal of the treatment is to reduce and eliminate the habit of eating non-food items. Treatment of pica will often depend on the cause and type of pica. Medications may help reduce the abnormal eating behavior, if pica occurs as part of a developmental disorder such as mental retardation. 7

Management of pica involves behavioral, environmental, and family educational approaches. Other successful treatments include associating the pica behavior with bad consequences or punishment (mild aversion therapy) followed by positive reinforcement for eating the right foods.8

6.1 NEED FOR STUDY

Children always need special care to survive and thrive. Child health is greatly depending upon family health. Good health of these precious members of society should be ensured as prime importance in all countries. As said by Karl Meninger “what is done to children, they will do to the society.” Children are the wealth of tomorrow.

A child is the unique individual, he or she is not a miniature adult, not a little man or women. The child health care concerned with preventive, curative and rehabilitative care of children. Disease pattern and management of childhood illness are different than adult and they need special care to survive and thrive.6

In India about 35% of populations were children. They have a special place in the lives of the people, but a large number of children become a cause of sorrow because of illness and ultimate death. Pica is one of the Most Dangerous Eating Disorder especially among small children. Children eat certain ingredients like lead, it is very poisonous and can damage the stomach linings and may even kill. Other non-food items also contain harmful chemicals that may not only poison but also result in other very serious health conditions like intestinal obstruction,constipation, ulcerations, perforations, and iron and zinc-deficiency anemia, electrolyte metabolic disorders, tooth wear, hypokalemia.6

Researchers has estimated that 33% of children ingest more than 10 grams of soil 1 or 2 days a year. The soil ingestion rate reported by their parents was 3% for 6-month-old children, 30% for 12 month-old children, 31% for 18-month-old children.9

Pica occurs throughout the world. Pica is a widespread practice in western Kenya, southern Africa, and India. Pica has been reported in Australia, Canada, Israel, Iran, Uganda, Wales, Turkey, and Jamaica. In some countries, Uganda for example, soil is available for purchase for the purpose of ingestion. Pica is reported to be problematic in 70% of the provinces in Turkey.9

The true incidence of pica is not known but it is estimated to be 75% in infants, 15% in two-three year old toddlers and 10-33% among the institutionalized mentally retarded children.9

According to the Agency for Health care Research and Quality (AHRQ) finds that eating disorder called pica has sharply increased by 93% from 1999 to 2009. Hospital stays with a diagnosis of pica increased 41 percent from 1999–2000 to 2005–2006.9

In United states pica behavior is seen more often in young children than adults, between 10 and 32% of children (1-6yrs) have these behaviors. Worldwide Morbidity and Mortality rate is high due to pica behavior are related to the following types of ingestion: Ingestion of poisons, Exposure to infectious agents, gastrointestinal effects, direct nutritional effect, dental effects.9

The Nationwide the rate of pica is increased from 964 to 1,862 over the past ten years. Over 30% of child hospitalizations with pica in 2009 had autism spectrum disorders.9

A prospective study was undertaken at a pediatric clinic at Jammu. The main objective of the study was to observe the various aspects of clinical profile of pica among children. The study sample includes 200 children (18 months to 10 years) visiting pediatric clinic with history of pica. The study results show that 64% of children belonged to 2-4 years, 32% of mothers gave direct history of pica with presenting complaints were cough (30%), pain abdomen (34%), poor appetite (26%), increased pallor (19%), diarrhea (17%), vomiting (12%), abdominal fullness (11%), generalized weakness (8%), passage of stool (7%), family history for pica was positive in 44% children, 46% had poor nutritional status, intestinal parasites 63%. The study concluded that cough, pain abdomen, poor appetite, increasing pallor, abdominal fullness etc are the presenting features of pica in children.11

The study was conducted by Department of psychiatry,National Institute of Mental Health and Neurosciences, Banglore. The sample include 2064 children aged 0-16 years were selected by stratified random sampling from urban middle class, urban slum and rural areas at Banglore. The screening stage was followed by a detailed evaluation stage. The results indicated a prevalence rate of 12.5% among children aged 0-16 years. The morbidity among 0-3 year old children was 13.8% with the most common diagnosis being Pica and Behavior disorder.12

Some studies shows that pica has been associated with iron deficiency, zinc deficiency, geophagia, mental deficiency, develop mental delay & a family history of pica. Complications of pica includes abdominal problems (sometimes necessitating surgery) ,lead poisoning, hypokalemia, hyperkalemia, mercury poisoning, phosphorus, intoxication and dental injury. The study concluded that pica is an under diagnosed problem that can be cause by a variety of disorders and lead to, serious complications.13

The researcher during her experience has also found that mothers had lack of knowledge regarding prevention and management of pica. So the researcher felt the need to assess the knowledge among mothers of under five children and to impart planned teaching programme to improve the mothers knowledge.

6.2 REVIEW OF LITERATURE

A review of literature is essential aspect of scientific research. It involves the systematic identification, location, scrutinizing and summary of the written materials that contain information on research.

Review of literature is sectioned under following heading:

I. Studies related to general information about pica.

II. Studies related to complications of pica.

III. Studies related to prevention and management of pica.

IV. Studies related to structured teaching programme.

SECTION –A–STUDIES RELATED TO GENERAL INFORMATION ABOUT PICA:

A longitudinal study was conducted by Egerton University, Department of environmental Science, Egerton, Kenya. The main objective of this study was to investigate whether earth eating within the home environment by children is a risk factor for diarrhoeal disease. The study included that 350 households having children aged below 5 years. The result of the study shows that 37% of index children ingest earth less than handful and 12% ingest a lot. The study concluded that earth eating is a risk factor for diarrheoa in the home environment.14

A prospective study was undertaken at a pediatric clinic at Jammu. The main objective of the study was to observe the various aspects of clinical profile of pica among children. The study sample includes 200 children (18 months to 10 years) visiting pediatric clinic with history of pica. The study concluded that cough, pain abdomen, poor appetite, increasing pallor, abdominal fullness etc are the presenting features of pica in children.11

A study was conducted to determine the association between specific forms of pica and toxocariasis and elevated blood lead in children. The sample include 100 children aged 1-6 years in Allegheny country, Pennsylvania,US. The study results shows that significant associations were found between 1.feces, soil, or grass pica and toxocara infection; 2.paint or plaster pica and elevated blood lead, 3.dogowenership and toxocara infection. The study concluded that significant associations were found between specific forms of pica and toxocariasis and elevated blood lead in children.15

A study was conducted to analyse the association of pica with iron-defiency anemia among 2 year old children conducted by Dipartimentodi Pediatria, ospedale civile di Arzignano, Vicenza, India. The study concluded that a case of pica in Indian child, affected by a serious ferropenic anemia.16

A study was conducted regarding the frequency and riskfactors for intestinal parasitic infection in underfive children. A study sample includes 269 children underfives. The parasitic detection was confirmed by formalin ethyl acetate concentration method. Results of the study shows 185 (68.8%) children had parasitic infection. Majority of children 144(53.5%) were among 4-5 years of age. Only 40% children were not found to wash hands with soap after using the toilet, eating mud/pica was present 48%. The study concluded that frequency of intestinal parasitic infection was found to be high among children under 5 years, major contributory factors were pica and lack of hand washing.17

A retrospective observational study was conducted by Sickle cell center, children’s Hospital of Michigan.USA .the main objective of study is to determine the prevalence of pica and its characteristics among children with sickle cell disease. The sample includes 480 children who visited the center. The study results shows that 134(33.9%) of reported pica, ingested items included paper, foam and powders. The study concluded that prevalence of pica is high in children with sickle cell anemia.18

A study reveals that in India lead based paints were found in the homes of three children whose blood lead level were 40mcg/dl. In a study on dust lead levels in Delhi, homes had dust with lead level of 31%. Lead in house hold dust is dangerous to children who ingest lead from playing close to the ground and having frequent hand to mouth contact and who ingest soil . The study concluded that ingestion of soil leads to lead poisoning in children.19

SECTION –B– STUDIES RELATED TO COMPLICATIONS OF PICA:

A study was conducted in Turkey regarding assessment of heavy metal bioavailability in contaminated soil. Nine trace analytes (As,Ba,Cd,Cr,Cu,Mn,Ni,Pb and Zn) were determined. The results showed that high As,Ba,Pb,Zn,Cd concentrations were found in there soils. The amounts ingested by pica behavior of children at all rate of 10g/day. The study concluded that young children who ingest soil are at greater risk developing inherent toxicity.20

A study was performed on Low plasma zinc and iron in pica among children. The main objective of the study is to determine role of trace elements in causation of pica with specific reference to zinc and iron we studied plasma levels of iron (Fe), Zinc (Zn), calcium (Ca) and magnesium (Mg) and blood lead (Pb) levels by atomic absorption spectrophotometer. The sample includes 31 children with pica (pica group) and 60 controls matched for age, sex and nutrition (Control Group) in an observational case and control study in the settings of outpatient clinic of a tertiary care, teaching hospital. The study results shows that the plasma Fe level (mean ±SD) in children with pica (42.7 ±9.2) mg/dl) was about 20% lower than that in controls (51.5 ±10.0 mg/dl, p<0.001). Plasma Zn levels in the pica group (60 ±4.4 mg/dl) was about 45% lower than those in controls (110.2±8.5 mg/dl, p<0.001). Correlation of Zn and Fe levels with pica-related variables such as age at onset, duration and frequency and number of inedible objects ingested was not significant. The study concluded that hypozincemia with low iron levels may be the possible cause of pica and contradict the contention that low levels of plasma Zn and Fe could be an effect of pica.21

A descriptive study was conducted by Interdepartmental Medical Center Casanova. The main objective of this study is to evaluate pica's prevalence for hospitalized patients. Secondary objectives are to describe clinical characteristics, complications and outcome upon the different therapeutic approaches. The sample includes 943 hospitalized patients at a selected time period, 31 distinct substances have been identified in our study. The study results show a high incidence of surgical complications, essentially gastro-intestinal, Respiratory complication and infectious complications are seen most. The study concluded that Pica's evolution often implies severe complications, which are sometimes life threatening in spite of a well-conducted treatment.22

A study was conducted by Klinikum Remscheid Gmbh, Medizinishe klinik at central Europe and Germany regarding effects of amylophagia among young children. The sample includes children aged between 2-6 years having the habit of amylophagia. The result of the study shows that pica for starch associated with severe iron deficiency anemia in Germany. The study concluded that iron-deficiency anemia and less often potassium and zinc deficiency are the main complications of an excessive starch or clay ingestion, followed by gastrointestinal obstructions due to gastroliths or impaction.23

A study was conducted by Rhode Island Poison Control Center (RIPCC) Island. The main objective of the study is to characterize risk factors for outcomes associated with ingestion of cigarettes and cigarette butts among children. The sample includes 146 children aged < or = 6 years. According to Rhode Island Health Interview survey reports that ingestion of cigarettes and cigarettes butts by children occurred more frequently in households where smoking was permitted in the presence of children and where cigarettes and cigarette wastes were accessible to children. The study concluded that ingestion of cigarettes and cigarettes butts by children results in minor toxic effect.24

A study was conducted by Department of Pediatric Surgery, King`s College Hospital, Denmark hill, London, UK regarding pica and non –nutrient material. The study sample includes 9-year–old child with the history of persistent ingestion of Blu-tack (a common household putty-like adhesive). The case is reported with an extensive and complicated surgical history. The study concluded that ingestion of persistent blu- tack will leads to acute intestinal obstruction.25

A study reveals that lead can still be found in contaminated soil, household dust, drinking water, lead-glazed pottery and some metal jewelry. Eating food or swallowing or touching dirt that contains lead can cause many health problems. It can also make children irritable and affect their ability to concentrate and remember. Lead is especially dangerous for children. A child who swallows large amounts of leaded dust or soil or paint chips may develop anemia, severe stomachache, muscle weakness and brain damage. Even low levels of lead are linked to lower IQ score.26

A study was carried out on Acuphagia and Hyalophagia in India. In this case young female child is admitted to the emergency department with the history of acuphagia (consumption of sharp objects), hyalophagia (consumption of glass materials). On diagnosis the results shows that young female with impacted bunch of bangles in thestomach and few in the small and large bowel, who was completely asymptomatic, needed gastrotomy with enterotomy for complete and successful retrieval of glass bangles. The study concluded that acuphagia and hyalophagia may cause complication like impaction, leading to intestinal obstruction, ulceration, perforation and bleeding, thus needs surgical exploration.27

SECTION –C – STUDIES RELATED TO PREVENTION AND MANAGEMENT OF PICA.

A study was conducted regarding prevention of pica. The main objective of this study is to control pica by components of an over correction procedure among children. The study results that one of the components, oral hygiene, could eliminate pica by 2 retarded subjects when used alone. Although oral hygiene was the most effective component, each of other components, tidying and personal hygiene, did decrease pica. The study concluded that effective implementation of oral hygiene procedure will decrease pica among children.28

A descriptive and longitudinal study is presented detailing the development of an effective integrated approach to the treatment of pica. The subject was a mentally retarded male whose history of life-threatening pica resulted in 37 surgeries for the removal of foreign objects. Etiological explanations for the behavior are considered and their role in generating elements of treatment are described. Results indicated that pica was eliminated by: (a) directing the subject to engage in other behaviors, (b) encouraging developmental progress through environmental exploration and trusting relationships, and (c) analysis of and responsiveness to the subject's cues concerning the maladaptive behavior.29

In this study, behavior modification procedures were used to eliminate pica in three young children with lead poisoning. Three kinds of procedures were used: (1) discriminate training, in which the subject was taught to recognize that paint and several objects were not edible; (2) reinforcement for the absence of pica; and (3) overcorrection for the occurence of pica. The study concluded that Pica was eliminated in all three subjects.30

A comparative study was conducted regarding suppression of pica among mentally retarded children. In this study an alternating treatments design was used to measure the differential effects of over correction and physical restraint procedures in the treatment of pica. The study concluded that both procedures reduced the occurrence of pica and physical restraint was clinically more effective in terms of immediate response reduction.31

A study shows that intervention for children with pica typically involves parental education regarding the hazards of eating nonfood substances, increased social and environmental stimulation, closer supervision, & behavior therapy for persistent cases. The latter involves differential reinforcement (eg; food treats) for incompatible behaviors (eg; playing with toys) as well as overcorrection (eg; brushing the tongue & teeth with mouth wash contingent on eating nonfood substances).32

A study manipulated two parameters of response blocking to reduce pica: (a) the criteria for initiating the procedure (either earlier or later in the response chain) and (b) the distance from which the procedure was initiated. Results suggested that response blocking may be effective only when implemented early in the chain and with near-perfect consistency. Further, additional treatment components may be required to eliminate all pica attempts.33

A study is performed by Using Food Aversion to Decrease Severe Pica by a Child with Autism. The study sample include 4 –year –old boy with autism. The participant was suffering from digestive complications due to the ingestion of plastic from a variety of toys. The intervention was initially conducted in the child's preschool classroom during instructional periods and was systematically generalized to the entire preschool classroom, and eventually to both classrooms within the preschool and across 25 teachers. The study result shows that success of the intervention in decreasing pica was enhanced by its achievement in not reducing interactions with toys. The study concluded that food aversion was effective in reducing of plastic pica by a 4-year- old boy with autism.34

SECTION –D- STUDIES RELATED TO STRUCTURED TEACHING PROGRAMME

A study was conducted by Lehigh University, western Michigan university on developmental disabilities aged between (1-5) years. In this study the participants were aged between (1-5) years. In this study the participants were taught to exchange inedible items for edible in selected settings. Findings showed that the intervention resulted in reductions in pica for both participants. The study concluded that by teaching children to exchange inedible items for edible items will reduce pica in children.35

A study was conducted by Millican and Lourie, they suggested that educational intervention in which mothers of children with pica were adviced of the health hazards inherentin the disorder and encouraged to spend more time with their children & to discourage their ingestion of non food items. They also reported that the lessening of social & environmental deprivation in the lives of children with pica resulted in a diminishment of symtomatology & suggested psychotherapy for older children with persistent pica.36

STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of Planned Teaching Programme regarding prevention and management of Pica among the mothers of under five children in selected rural areas at Kolar Dist. Karnataka.”

6.3 OBJECTIVES OF THE STUDY:

1. To assess the existing level of knowledge of the mothers of under five children regarding prevention and management of pica.

2. To determine the effectiveness of planned teaching programme on prevention and management of pica.

3. To find association between pre-test knowledge scores with selected demographic variables.

4. OPERATIONAL DEFINITIONS:

1. ASSESS:

Refers to the process used to identify the level of knowledge regarding prevention and management of pica among mothers of under five children in rural areas.

2. EFFECTIVENESS:

In this study it refers to significant gain in knowledge scores among mothers of under five children regarding prevention and management of pica by comparing the pretest and post test scores.

3. KNOWLEDGE:

This study it refers to the awareness of mothers regarding prevention and management of pica among under five children which is elicited by using a planned knowledge questionnaire on pica.

4. PLANNED TEACHING PROGRAMME:

In this study, it refers to systematically developed instructional method and teaching aids designed to impact information regarding prevention and management of pica.

5. MOTHERS: Mothers who have under-five children.

6. UNDER FIVE CHILDREN: Children in the age group of 2 to 5 years.

7. PICA: Pica is the persistent craving and compulsive eating of nonfood substances such as dirt, clay, chalk, glue, ice, starch, hair, paint chips, plaster, cornstarch, laundry starch etc,

6.5 ASSUMPTIONS:

• The mother may have some basic knowledge regarding pica and its preventive measures.

• Planned teaching program may enhance knowledge regarding prevention of pica among the mothers of under five children.

6.6 HYPOTHESIS:

H1: There will be significant difference between pre-test and post test knowledge scores of mothers regarding prevention and management of pica.

H2: There will be significant association between post-test knowledge scores regarding prevention and management of pica among mothers of underfive children with their demographic variables.

6.7 VARIABLES:

• Dependent variable – knowledge of mothers of under five children regarding prevention and management of pica.

• Independent variable – Planned Teaching Programme regarding prevention and management of Pica among the mothers of under five children.

• Attributed variable – Age of mother, parity, education, occupation, monthly family income, religion, age of the child, source of health information.

7.0 MATERIALS & METHODS :

7.1 SOURCE OF DATA :

Data will be collected from mothers of under five children from selected rural areas of Kolar.

7.2 METHODOLOGY :

7.2.1 RESEARCH APPROACH: Evaluatory approach.

7.2.2 RESEARCH DESIGN:

Pre experimental design (one group pre test and post test design).

7.2.3 SETTING:

The study will be conducted in the rural areas that are Mudhuvathi, which is 6 Kms and Guluganji Gurki which is 10 Kms away from the Pavan College.

7.2.4 POPULATION: Mothers of under five children at kolar district.

7.2.5 SAMPLE:

Mothers of under five children in selected rural areas at Kolar District that is Mudhuvathi and Guluganji Gurki.

7.2.6 SAMPLE SIZE: 60 Mothers of under five children.

7.2.7 SAMPLING TECHNIQUE: Non probabality Convenient sampling technique.

7.2.8 SAMPLING CRITERIA

❖ INCLUSION CRITERIA

o Mothers who are permanent residence of the selected rural areas.

o Mothers who have under five children.

o Mothers who are willing to participate in the study.

o Mothers who can understand Kannada or English.

❖ EXCLUSION CRETERIA

o Mothers who are not available during the study.

o Mothers who are not willing to participate in the study.

o Mothers who are not able to understand Kannada or English.

9. DELIMITATIONS :

• The data collection period is de limited to 6 weeks.

• The study is delimited to 60 sample.

• The setting is limited to selected rural areas in Kolar.

10. TOOL:

A structured interview schedule will be used to assess the knowledge regarding prevention and management of pica among mothers of under five children.

DESCRIPTION OF TOOLS : It consists of 2 sections

SECTION A : DEMOGRAPHIC DATA

It consists of demographic variable like age of the mother, parity, education, occupation, monthly family income, religion, age of the child, source of health information.

SECTION B : It consists of structured knowledge questionnaire regarding prevention and management of pica among mothers of under five children.

7.2.11 METHOD OF DATA COLLECTION :

Planned interview schedule will be used to assess the knowledge among mothers of under five children regarding prevention and management pica.

7.2.12 DATA ANALYSIS & INTERPRETATION :

The researcher will use descriptive & inferential statistics such as frequency, percentage, standard deviation, paired “t” test, chi – square test, for data analysis & data will be interpreted in the forms of tables, diagrams and graphs.

7.3 DOES THE STUDY REQUIRES ANY INVESTIGATION OR INTERVINTION TO BE CONDUCTED FOR PATIENTS OR OTHER WOMEN OR ANIMALS IF SO BRIEFLY :

Yes, the study will be conducted among mothers of under five children In a selected rural areas of the Kolar district.

4. HAS ETHICAL CLEARENCE BEEN OBTAINED FROM CONCERNED AUTHORITIES

Prior to the study, the permission will be obtained from the concerned authorities to conduct the study in a selected rural areas at Kolar District & also from research committee of Pavan college of nursing. The purpose of the study will be explained to the mothers of under five children. In selected rural areas, scientific objectives of the study will be maintained with honesty & impartially.

8. LIST OF REFERENCES:

1. Wong’s. Essentials of pediatric nursing. 8th Edition. Mosby publications P, 2-3.

2.

3. Anil Kaushik.Behaviral Disorders in Childhood Current Medical Journal of India.October 2009. Volume 15. No 7. P, 15-18.

4. Cynthia R Ellis, MD; Cheifdi Caroly Pataki Eating Disorder, Pica June 4, 2009

5.

6. Parul Datta, Pediatric nursing. 2 nd Edition. Jaypee publications P1, 190

7. .../pica-disorder-introduction.html 7th sep2010

8. Wong`s Nursing care of infants & children 7th edition, Mosby publications P, 1422-1423.

9. atsdr.child /com.

10.Dr.B.T Basavanthappa, Text book of pediatric child nursing,New-Delhi, Ahuja book company pvt. Ltd; 1st Edition 2205. P.331

11. Ravinder K. Gupta, Ritu Gupta Clinical Profile of Pica in Childhood volume 7 No,2, April-June 2005

12.Srinath S, Girimaji SC, Gururaj G, Seshadri S, Subbakrishna DK, Bhola P, Kumar N Epidemiological study of child & adolescent psychiatric disorders in Bangalore, India Indian Journal 2005 July.

13. Federman DG, Kirsner RS, Federman GS Pica:are you hungry for the facts 2008 Apr;61(4):207-9.

14. Shivoga WA, Mothuri WN. Geophagia as a risk factor for diarrhea.2009 mar 1;3(2):94-8

15. Glickman LT, Chaudry IU, Costantino J,Clack FB, Cypess RH Pica patterns, toxocariasis, and elevated blood lead in children. 2008 Jan;30(1);77-80.

16. Vanin E, Urso L Meneghetti S,Mescoli G, Marcazzo L Pica and iron-deficiency anemia in a 2-year old Indian child.2007 Jan-feb;24(1):67-9

17. Mumtaz S,Siddiqui H,Ashfaq T. Frequency and factors for intestinal parasitic infection in children under five years age at a tertiary care hospital in Karachi.2007 Apr :59(4) :216

18. M.Roberts,Harewood,S C Davies Pica a complication of Sickle cell disease ,July 19,2008

19. Kumar A, Scott Clark c. Lead Loadings In Household Dust In Delhi, India. Pubmed. 2010. May.

20. Karadas C,Kara D.In vitro gasto-intestinal method for the assessment of heavy metal bioavailability in contaminated soils.2010 Oct 29.

21. Sunit Singhi S, Ravishanker R, Singhi P, Nath R. Low plasma zinc and iron in pica. Indian Journal Pediatrics 2003; volume70:139-143.

22. Haoui R, Gautie L, Puisset F. Pica: A descriptive study of patients in a speciality medical center. Encephale 2003;29:415-24

23. Klinikum Remscheid GmbH,Medizinische klinik Pica in Germany- amylophagia as etiology of iron deficiency anemia. 2006 Aug;36(8);635-40

24. McGee D, Brabson T, McCarthy J, Picciotti M Four-Year review of cigarette ingestions in children. 2008 feb;11(1):13-6.

25. Kliegman RM, Behrman RE, Jenson HB,Stanton BF,eds Nelson Textbook of Pediatrics. 18th edition.Philadelpia, Pa:Saunders Elsevier; 2007:chap 22

26. Moya, J., C. F. Bearer, and R. A. Etzel. "Children's Behavior and Physiology and How It Affects Exposure to Environmental Contaminants." Pediatrics 113 (April 2004): 996-1006.

27. P. L. Kariholu, R. Jakareddy, M. HemanthKumar, K. N. Parameshand N. P. Pavankumar Pica — a case of acuphagia or hyalophagia Indian journal of surgery, Volume 70, Number 3, 144-146

28. Linda Seligman and Lourie W. Reichenberg Selecting effective treatments 4th edition P, 84

29. Alison E. Stanley and Kathryn Glenn an integrated treatment approach to pica Journal of develoament and physical disabilities Volume 2, 155-165,

30. Nancy A. Modden,Dennisc,Russo &Michael, Treatment of Pica in Children, Child behavioral therapy volume 2, P 67-81 2008

31. Nirbhay N. Singh and Leon W. Bakker Suppresion of pica by overcorrection and physical restraint. Journal of Autism and Development Disorders Volume 14, Number3,331-341.

32. Carolyn S, Schoeder, Bettyl N.Gordon Assessment and treatment of childhood problems P, 85-86

33.McCord BE, Grosser JW, Iwata BA, Powers LJ,An analysis of response-blocking parameters in the prevention of pica J Appl Behav Anal. 2005 Fall;38(3):391-4

34. Summer J.Ferreri, Kristin G.Wier et.al Using food aversion to decrease severe pica by a child with autism, Behaviral Modification article, July 2006 volume 30, no 4, 456-471.

35. Lee Kern, K Starosta-Behavior modification Reducing Pica by Teaching Children to Exchange Inedible Items for Edibles 2006

36. Robert D, Lyman, Tonih, Henebre Kigin Mental health intervention with preschool children P, 74-76

| 9. |SIGNATURE OF THE CANDIDATE: | |

| 10. |REMARKS OF THE GUIDE: | |

| 11. |NAME AND DESIGNATION OF: | |

| |11.1 GUIDE: | |

| |11.2 SIGNATURE: | |

| |11.3 C0-GUIDE: | |

| |11.4 SIGNATURE: | |

| |11.5 HEAD OF THE DEPARTMENT: | |

| |11.6 SIGNATURE: | |

| |12.1 REMARKS OF THE PRINCIPAL: | |

|12. | | |

| |12.2 SIGNATURE: | |

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