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Clinical Approach to Children with Low Appetite
Abstract
Appetite is a conscious desire for food and it is regulated mainly by the gastrointestinal system, pancreas and adrenal glands. Poor appetite is a common problem in childhood. For assessment, history of development, nutrition and family are important. Poor appetite may also be a symptom of feeding disorders. Even though the etiology of feeding disorders may be classified as organic or functional, it indeed reflects the complex interaction of biological, behavioral and social factors. Personal, familial, economic and sociocultural factors may affect appetite. In this review, approaches to a child with low appetite who presents a difficult problem for his/her family and doctor are discussed in the light of recent literature. © The Journal of Current Pediatrics, published by Galenos Publishing.
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To assess the subjective appetite responses to an imposed activity- and diet-induced energy deficit during a residential intervention programme for obese children.
A 6-week intervention of fixed, reduced dietary intake and 6 h/day of skill-based physical activity while resident in a weight loss camp.
Thirty-eight obese (mean body mass index (BMI)=34.9 kg m(-2)) boys and girls (mean age 13.9+/-1.57).
An electronic appetite rating system (EARS) was used to periodically measure subjective appetite sensations at the start (WK1) and at the end (WK6) of the camp. Subjective ratings of hunger and fullness were compared at the start and end of 6 weeks of an activity- and diet-induced-based weight loss intervention.
At the end of the 6 weeks, the children had lost 8.4 kg in body mass. The diurnal profiles of subjective appetite sensations demonstrated clear oscillations in hunger and fullness. There was a significant increase in hunger (P<0.0001) and decrease in fullness (P<0.005) at the end (WK6) of the medium-term energy deficit. In WK6, morning ratings of hunger were higher than in WK1 (P<0.005) and the fixed energy evening meal induced a lower suppression of hunger (P<0.02).
A programme of fixed, reduced-dietary intake combined with an activity and behavioural programme was successful at inducing a significant reduction in body mass in obese children. Subjective sensations of appetite were sensitive to a medium-term negative energy balance and weight loss. These data are essential as we continue to evolve methods of treatment for overweight and obese children.
The aim of the present study is to investigate possible alterations in ghrelin and other hormone levels related to appetite and somatic growth in children with iron deficiency anemia. Twenty-five patients and 25 healthy controls that were prepubertal and within normal limits regarding height and BMI standard deviation scores were recruited. Ghrelin, leptin, IGF-I, IGFBP-3, insulin, thyroid hormones and cortisol levels were studied. Ghrelin, insulin and IGF-I levels were significantly low in the study group (ghrelin 13.58 +/- 16.32 vs. 35.39 +/- 23.69 ng/ml, p<.001; insulin 3.41 +/- 2.42 vs. 5.67 +/- 1.09 mU/ml, p = .008 and IGF-I 126.94 +/- 92.82 vs. 203 +/- 105.1 ng/ml, p = .015). We concluded that low ghrelin and insulin levels might be causes of the appetite loss in iron deficiency and as a result of appetite loss and undernutrition as well as by direct effects they might be related with growth retardation, which could be also influenced by low IGF-I levels.
Appetite stimulants have been used to help overcome decreased appetite and malnutrition in children and adults with various chronic illnesses, including cystic fibrosis (CF). Stimulants have included megestrol acetate (MA), cyproheptadine hydrochloride (CH), cannabinoids, hydrazine sulfate, anabolic hormones, and growth hormone. Many of these, including MA, have substantial side effects and may not be suitable for prolonged use. We previously studied the effects of CH on weight gain in a short-term (12 week) trial in CF with good results compared to placebo. Side effects were few, and weight gain was significant. In this study, we sought to determine the effects of CH over a longer term in order to assess its suitability for prolonged use. Sixteen CF children and adults enrolled in the original short-term study subsequently entered this study, and 12 completed the 9-month trial. All patients receiving placebo in the original short-term study received CH 4 mg up to four times a day in the long-term study continuation, and those receiving CH in the short-term study continued on the drug. No pill counts were done, and patients were queried at quarterly visits as to their CH use. Anthropometrics and spirometry were also done quarterly, and antibiotic use was quantified. Subjects who had changed from placebo (CH2 group) gained weight significantly over 3–6 months, and those continuing on CH (CH1 group) generally maintained previously gained weight over the duration of the study. Select spirometric measures improved in both groups but not significantly, and side effects were mild. CH appears to be an effective appetite stimulant in CF, and generally maintains its effect over time with an acceptable side-effect profile. Pediatr Pulmonol. © 2005 Wiley-Liss, Inc.
Like other segments of the child's development, eating behavior follows a sequential pattern. To understand the infant's or child's feeding problems which can lead to failure to thrive or dwarfism we propose that a child's progression be studied through three stages of development: homeostasis, attachment and separation-individuation. Specific feeding problems can arise at each of these stages of development and consequently impede the child's weight gain. During the period of homeostasis the infant learns to regulate himself, to suck, to swallow and to time the onset and termination of feedings by giving signals of hunger and fullness. If he is unable to master these, he cannot be fed effectively. Failure to master these basic feeding skills interferes with the next developmental task of attachment and also impedes development of motor skills, language and affective engagement. During the period of attachment, the infant establishes distinct interactional patterns with his caretakers. Lack of engagement between mother and infant leads to lack of pleasure and lack of appetite or even to severe dysfunctional feeding patterns like vomiting and rumination. Feeding problems in the third developmental stage of separation and individuation can arise because of maladaption in the attachment phase or because of new difficulties which center around issues of autonomy vs. dependency. At this stage, the infant learns means-end differentiation and begins to understand that his actions elicit certain consequences. If the infant's struggle between autonomy and dependency gets caught in the feeding situation, the infant's emotional needs can dictate his eating behavior. The infant refuses to eat either to have his emotional hunger for mother's attention met or to assert his autonomy and to express his anger toward her. In order for the infant to learn to differentiate between his physiological feelings of hunger and his emotional need states, the caregiver needs to give contingent responses by offering food when the infant is hungry and comfort when the infant is distressed. Feeding problems which can create, co-exist with, or result from a growth problem must be considered within a developmental context. As the infant progresses through the developmental stages of homeostasis, attachment, and separation, he masters phase-appropriate feeding skills which help him to progress from reflex sucking to autonomous feeding. Early identification of maladaptive feeding behavior will assist the pediatrician in making timely interventions.
To identify whether differences exist between failure to thrive children and controls in either demographic characteristics or parental rating of their eating and other behaviour.
As part of an intervention study, 97 children with failure to thrive were identified by population screening and received a standardized assessment by their health visitor at a median age of 15.1 months. This included standard questions to parents concerning their perception of their child's feeding history and behaviour. Their responses were compared with the parents of 28 normally growing children aged 16-18 months, systematically sampled from the same district.
Cases had fallen through a mean of 1.69 weight standard deviation score and were markedly underweight for height. The case families had similar levels of deprivation, both to controls and city norms, and only four showed evidence of major neglect. Failure to thrive children had significantly more infancy feeding problems and were introduced to solids and finger foods later than controls; they were significantly more often described as variable eaters, undemanding and shy and less often as hungry. Cases liked most foods, but significantly less so than controls.
This suggests that the role of deprivation and neglect has been overstated and that undemanding behaviour, low appetite and poor feeding skills may contribute to the onset and persistence of failure to thrive.
Parents of short children born SGA often report that their children have a serious lack of appetite and a low food intake. In this study we investigated food intake, by using a standardized 7-day food questionnaire, in 88 short SGA children before start of GH treatment. The intake was compared with the recommended daily intake (RDI) of age-matched children. We also compared the food intake of GH-treated children (n=62) with randomized controls (n=26) after 1 year of GH treatment. In addition, we evaluated the effect of food intake and GH treatment on body composition and serum levels of IGF-I, IGFBP-3 and leptin. Our study shows that caloric intake, fat and carbohydrate intake of short SGA children aged 5.9 (1.6) years was significantly lower compared to the RDI for age-matched children. One year of GH treatment resulted in a significant increase of caloric, fat, carbohydrate and protein intake compared to baseline. Compared to randomized controls, caloric, carbohydrate and protein intake increased significantly after 1 year of GH treatment. Short SGA children had significantly lower SDS scores for LBM, fat mass, skinfold (SF) and BMI compared to age-matched references. They also had significantly lower serum IGF-I, IGFBP-3 and leptin levels. GH treatment resulted in a significant increase of height, LBM, BMI, IGF-I and IGFBP-3 SDS and a significant decrease of SF SDS and leptin SDS. In conclusion, our study shows that short SGA children have indeed a lower food intake than age-matched controls. During GH treatment the food intake increased significantly compared to baseline in contrast to the randomized control group.
To report the prevalence of dietary supplement use in a random sample of US infants 4 to 24 months of age, and to compare demographic characteristics, usual nutrient intakes, and food patterns of supplement users and nonusers.
Data from 24-hour recalls collected for the 2002 Feeding Infants and Toddlers Study were analyzed. Recalls included nutrient contributions from dietary supplements as well as all foods and beverages. We estimated usual energy and nutrient intakes of supplement users and nonusers, as well as the prevalence of nutrient adequacy and excess in the two groups. We also compared demographic characteristics and food patterns of supplement users and nonusers and, for supplement users, estimated the proportion of total intake provided by foods and the proportion provided by supplements.
A national random sample of 3,022 infants and toddlers age 4 to 24 months, including 430 vitamin and/or mineral supplement users and 2,592 nonusers.
We compared means, percentile distributions, and proportions by age and supplement subgroup, and applied the Dietary Reference Intakes to assess usual nutrient intakes. We conducted regression analysis to determine which population characteristics predict the use of dietary supplements in this population.
Overall, 8% of infants age 4 to 5 months received some type of dietary supplement. The prevalence of supplement use increased with age, to 19% among infants 6 to 11 months and 31% among toddlers 12 to 24 months. The vast majority of supplement users (97%) received only one type of supplement, most commonly a multivitamin and/or mineral supplement. Vitamin/mineral supplement use among infants and toddlers was associated with being a first-born child and being reported by the primary caretaker as being a picky eater. Characteristics that were independent predictors of supplement use were living in the Northeast, being male, and living in a household with fewer children. We found no significant differences between supplement users and nonusers in mean daily intakes of nutrients or nutrient density from foods alone, and few differences in food consumption. Overall, the prevalence of inadequate intakes was low (<1% to 2%). However, 65% of supplement nonusers and 9% of supplement users had vitamin E intakes less than the Estimated Average Requirement. Excessive intakes (ie, intakes above the Tolerable Upper Intake Level) were noted for both supplement users and nonusers for vitamin A (97% and 15% of toddlers) and zinc (60% and 59% of older infants and 68% and 38% of toddlers) as well as for folate among supplement users (18% of toddlers).
Generally, healthy infants and toddlers can achieve recommended levels of intake from food alone. Dietetics professionals should encourage caregivers to use foods rather than supplements as the primary source of nutrients in children's diets. Vitamin and mineral supplements can help infants and toddlers with special nutrient needs or marginal intakes achieve adequate intakes, but care must be taken to ensure that supplements do not lead to excessive intakes. This is especially important for nutrients that are widely used as food fortificants, including vitamin A, zinc, and folate.
Tumor growth leads to cancer anorexia that is ameliorated using omega-3 fatty acids (omega-3FA). We hypothesize that omega-3FA modulates up-regulation of hypothalamic orexigenic neuropeptide Y (NPY) and down-regulation of anorexigenic alpha melanocyte-stimulating hormone (alpha-MSH) and serotonin 1B receptors (5-HT(1B)-receptors) in tumor-bearing rats.
Twenty-eight tumor-bearing rats were fed either chow (TB-Control) or omega-3FA (TB-omega-3FA). When anorexia developed in TB-Control rats, they and a cohort of TB-omega-pi-3 rats were killed. The rest had their tumor resected (R-Control and R-omega-3FA), and when anorexic TB-Controls normalized their food intake, brains were removed for hypothalamic immunocytochemical study of NPY, alpha-MSH, and 5-HT(1B)-receptor antibodies concentrations. Comparison among slides were assessed by image analysis and analyzed by ANOVA and t test.
At anorexia, hypothalamic NPY in arcuate nucleus (ARC) increased by 38% in TB-omega3FA versus TB-Control, whereas alpha-MSH decreased 64% in ARC and 29% in paraventricular nucleus (PVN). Omega-3FA diet in anorexia (TB-omega-3FA vs R-omega-3FA) produced similar qualitative changes of NPY (22% increase) and alpha-MSH (31% decrease) in ARC, with concomitant decrease of 37% in 5-HT(1B)-receptors in PVN, confirming the influence of omega-3FA on the hypothalamic food intake modulators. However, after tumor resection (TB-Control vs R-Control) a 97% increase in NPY and a 62% decrease in alpha-MSH occurred that was significantly greater than in rats fed omega-3FA diet.
Tumor resection and omega-3FA modifies hypothalamic food intake activity, up-regulating NPY and down-regulating alpha-MSH and 5-HT(1B)-receptors. Tumor resection in anorexic rats on chow diet restored hypothalamic NPY, alpha-MSH, and food intake quantitatively more than in rats fed omega3FA diet.
The objective of this study was to examine the effects of television (TV) viewing on children's lunch and snack intake in one condition when the children watched a 22-minute cartoon video on TV (TV group), and in another without the TV (no TV group). Participants included 24 children and their parents, recruited from a university child-care center. Parents reported children's TV viewing habits at home. Overall, children ate significantly less snack and lunch in the TV condition compared with the no TV condition. However, children who reportedly watched more daily hours of TV and who had a higher frequency of meals eaten in front of the TV at home ate more lunch in the TV condition. TV viewing may either increase or reduce children's intake, depending on prior experience with eating during TV viewing.
This study sought to examine the association between the parent-reported appetite of a child and the child's weight status after 2 years. The design was a 2-year prospective study. A total of 531 Korean children aged 11 to 12 years were followed up for change in weight status (persistent overweight, persistent nonoverweight, recently overweight, recently nonoverweight) between 2001 and 2003 after the measurement of their appetite (low, moderate, and high) using a questionnaire administered to their parents in 2001. Weight status of each child was determined based on the criteria of body mass index (BMI) recommended by the International Obesity Task Force reference. The statistical analyses performed were multiple logistic regression analysis with adjustment for parental factors (parents' weight and height, education level, and income) and the child's characteristics (baseline BMI, physical activity, and television viewing). Main outcome measures were child's mean BMI and weight status, and the proportions of overweight children at the baseline and at the end of the follow-up were greater among those children whose parents reported that they had high appetites (P<0.001). Compared with the children with a low appetite, the odds ratio for overweight at the end of follow-up was 3.7 (95% confidence interval 1.2 to 11.7) in children with a high appetite. Subgroup analysis of overweight children at baseline showed that the risk of being persistently overweight over the 2-year follow-up was 5.5 times (95% confidence interval 1.1 to 27.5) higher in children with a high appetite than in those with a low appetite. There was a strong association between the parent-reported appetite of a child and being overweight after 2 years. Identifying children with higher appetites and targeting them for lifestyle modification may provide an effective way of reducing the incidence of childhood overweight.
Young children adjust their short-term intake in response to variations in energy density (ED; kcal/g) from preloads in laboratory studies. It remains unknown whether this compensation also occurs under free-living conditions.
The aims of the study were to test whether children aged 3-6 y regulate their habitual daily food (g) and energy (kcal) intakes in relation to ED and whether compensation differs for children born at different risk of obesity.
Participants were children born at high risk (n=22) or low risk (n=27) of obesity on the basis of maternal prepregnancy body mass index (BMI; in kg/m(2)). Daily ED, food intake, and energy intake were assessed from 3-d food records that either included or excluded beverages. Intake regulation was explored by relating children's daily food and energy intakes to ED and, more importantly, by examining residual scores derived by regressing daily food intake on ED.
For both risk groups, daily food intake was inversely correlated with ED (P < 0.05), whereas daily energy intake was not significantly correlated with ED at most ages (P>0.05). In analyses that excluded beverages, mean residual scores significantly increased from 3 to 6 y of age in high-risk children, which indicates relative overconsumption, but decreased in low-risk children, which indicates relative underconsumption (risk group x time interaction, P=0.005).
Children adjusted their daily food intake in relation to ED, which suggests caloric compensation under free-living conditions. Compensation ability may deteriorate with age in a manner that favors relative food overconsumption among obesity-prone children.