A toddler with hair fascination

Joseph is a 24-months old boy referred by his pediatrician because of an "obsession" with pulling and eating hair. When Joseph was 14 months old, he enjoyed touching and twirling his mother's long hair. She observed that it seemed to provide comfort to him. At 18 months, he initiated pulling out and eating his own hair, twirling his mother's hair around his thumb and then sucking on it. Currently, he searches the carpet or a hard floor and looks for hair to eat. The identical behavior is observed at daycare. Joseph's teacher commented, "He pulled hair from a girl who has the longest hair of all the children. We try to distract him from this habit, but he is not distracted for long." Less frequently, Joseph has also eaten sand, chalk, and crayons at daycare. Joseph's mother describes him as a "happy and outgoing" child who interacts with his peers and has a best friend at the daycare. There have not been recent changes or stressful events in his life. Joseph separates from his mother with ease and he sleeps comfortably through the night in his own bed. There have been no episodes of nausea, vomiting, abdominal pain, or constipation. Strands of hair are occasionally seen in the stool. Prenatal and perinatal history was unremarkable. Joseph was breast-fed for 11 months, described as an "easy" baby, achieved motor, social, and language developmental milestones at the usual time, and has been in excellent health. He lives with his mother and maternal grandparents; the biological father has never been involved in his care. At 20 months, Joseph's pediatrician suggested cutting his hair. After several haircuts, Joseph stopped pulling his own hair. However, he continued to search the floor for hair. Hemoglobin and a blood lead level were normal. Joseph appeared pleasant and friendly with normal growth parameters and facial features. He was sitting comfortably on his mother's lap, sucking on his thumb. Social interactions with his mother were appropriate and reciprocal. He warmed up quickly to the examiner and engaged in play. He spoke in two to three word sentences and responded to questions with a speech pattern that was 50% intelligible. Physical and developmental examinations were normal. At the end of the examination, Joseph searched his mother's purse and located a piece of hair. He twirled the hair around his thumb and sucked on it. Initially, he refused to remove his thumb from his mouth. With gentle persuasion, he eventually removed his thumb and agreed to throw the hair in the trash. He did not appear distressed.