Thursday, February 9, 2017

Loss of Appetite (Anorexia) In Children

Loss of appetite (Anorexia) is a common symptom in children.

  • Acute illness in childhood is often associated with transient loss of appetite. 
  • Prolonged loss of appetite associated with poor weight gain or loss of weight usually signifies a serious chronic illness, either organic or psychogenic.
Pathophysiology: Th e mechanisms that regulate hunger and satiety are complex and redundant, remaining incompletely understood. Both appetite-stimulating and appetite-suppressing neuropeptides are secreted in the hypothalamus.Central control of appetite is influenced by anticipation of a pleasurable meal, visual and taste sensations, ambient temperature, and changes in blood levels of glucose or other nutrients, as well as by limbic signals from higher central nervous system (CNS) regions.

Each individual may have a set point for body fat content.
Cytokines are key mediators of the appetite suppression that occurs with acute and chronic illnesses.

Approach To A Child Presented With Loss Of Appetite: When considering anorexia, the physician must first separate complaints based on unrealistic parental dietary expectations from justified parental concern over a child’s diminished nutritional intake. In the former situation, the child is typically growing well and appropriately thriving.
  • Although significant GI disease commonly leads to poor appetite, anorexia may be the result of disease that is distant from the bowel.
  • In the newborn period, poor oral intake by an infant who is developmentally capable of feeding may be the first indication of a major disorder, such as sepsis, meningitis, urinary tract infection, congenital viral infection, a GI anomaly, CNS disease, renal failure, or an inborn error of metabolism.
  • An acute infectious disease is a common cause of transient anorexia in infants.
  • If no obvious explanation exists for poor feeding, then the pediatrician should always consider the possibility of an oral disease (eg, thrush).
  • Emotional deprivation is a common cause of failure to thrive and lack of interest in eating : a thorough social history is essential to the evaluation.
  • Generally, the best approach to anorexia is to treat the underlying condition.
List Of Causes of Decreased Appetite in Infants and Children: 

• Infections (acute or chronic)
• Neurologic causes
􀁻 Cerebral palsy
􀁻 Congenital degenerative disease (eg, neurodegenerative disorders, spinomuscular atrophy, muscular dystrophy)
􀁻 Hypothalamic lesion
􀁻 Increased intracranial pressure, including a brain tumor
􀁻 Static encephalopathy
• GI causes
􀁻 Oral or esophageal lesions (eg, thrush, herpes simplex, dental caries, ankyloglossia)
􀁻 Gastroesophageal refl ux
􀁻 Eosinophilic esophagitis
􀁻 Dietary protein intolerance
􀁻 Bowel obstruction (especially with gastric or intestinal distention)
􀁻 Inflammatory bowel disease
􀁻 Celiac disease
􀁻 Constipation
􀁻 Esophageal motility disorder (eg, cricopharyngeal dysfunction, achalasia, connective tissue disorder)
• Cardiac causes
􀁻 Congestive heart failure or cyanotic heart disease
• Metabolic causes
􀁻 Renal failure, renal tubular acidosis, or both
􀁻 Liver failure
􀁻 Inborn errors of metabolism
􀁻 Lead poisoning
• Nutritional causes
􀁻 Marasmus
􀁻 Iron deficiency
􀁻 Zinc deficiency
• Drugs
􀁻 Morphine
􀁻 Digitalis
􀁻 Antimetabolites
􀁻 Methylphenidate
􀁻 Amphetamines
􀁻 Topiramate
• Prolonged restriction of oral feedings, beginning in the neonatal period
• Tumor
• Chronic febrile conditions (eg, rheumatoid arthritis, rheumatic fever)

• Anxiety, fear, depression, mania.
• Avoidance of symptoms associated with meals (abdominal pain, nausea, diarrhea, bloating, urgency, dumping syndrome)
• Anorexia nervosa
• Excessive weight loss and food aversion in athletes, simulating anorexia nervosa.

  • In older children and adolescents, an adequate evaluation of nutritional intake requires careful calorie counts.
  • Separating children who have poor appetites from children who do not eat for fear of worsening their symptoms is important from the outset.
  • Enlisting the help of a dietitian to plan diets can be useful for maximizing nutritional intake in older children. 
  • Nutritional supplements may be indicated, either high-calorie milkshakes or commercial high-calorie supplements.
  • Several medications, including cyproheptadine and megestrol acetate, have been shown to stimulate appetite.
  • In some disorders, such as congenital heart disease, initial nasogastric or nasoduodenal infusion of nutrients may be necessary to promote growth
  • Parenteral nutrition may be indicated in specific situations. However, expertise with this modality and close supervision are required,
When to Refer
• Loss of appetite without an obvious explanation, especially in association with weight loss or failure to thrive
• Anorexia nervosa

When to Admit
• Weight loss or lack of weight gain that is unresponsive to outpatient management
• Requirement to initiate enteral or parenteral feeding because of inadequate oral intake

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