Appetite Interventions

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  Mealtime Structure/Schedule

Providing a consistent environment and a fixed daily schedule of meals and snacks.

Background Education for Providers

Children, similar to adults, often benefit from a fixed schedule of activities across the day. When meals are set at fixed times each day, children become accustom to the routine and are comforted by the predictability of the similar characteristics of each meal. Further, children will develop a predictable pattern of hunger that coincides with the schedule of meals and snacks, which in turn motivates the child to feed.

Families should also have a feeding environment which is free from distractions, which has appropriate seating for the child, and allows the adult caregiver the ability to monitor feeding for the duration of the meal. Children typically feed best when eating at a table with food placed in front of them for the duration of the meal. At minimum, the child should be supervised one–to-one throughout the meal by a responsible adult. Ideally, the adult supervising the feeding is also eating so that they are able to model appropriate feeding behaviors for the child. The feeding environment should be free of distractions (e.g., no toys or TV at the table) as this will help the child to focus on the task of eating as well as focus their attention on the adult supervising the meal. The child should be seated so that they are comfortable and secure (with safety strap as appropriate).

Children should only be offered foods and beverages at specified meal or snack times. However, water should be offered and encouraged throughout the day. Children should learn that meal times are finite and that opportunities to feed in a given day are limited to the fixed schedule. Studies have shown that children who adopt a grazing meal pattern (e.g., frequent intake of small portions of food and caloric beverages through the day) take in fewer nutrients in a 24 hour period when compared to children that eat on a fixed schedule. Specifically, grazing reduces appetite and intake secondary to disruption of the hunger and satiation cycle. Without intervention, the grazing child will chronically under meet his/her nutrition needs to support appropriate growth and development.

Finally, unstructured feeding patterns can result in ambiguity as to who controls the food selections. If a child is granted even occasional control of menu selections, this may result in periods of great conflict when the adult caregiver attempts to introduce new or non-preferred foods. Children may erroneously conclude that they are in control of food choices and that they are entitled to select whatever foods they wish. Unfortunately, caregivers that encounter significant resistance when selecting new or non-preferred foods may defer their authority over the meal to ensure that their child eats something.

Ultimately, the parent may lose all ability to control the mealtime environment (food selections, meal schedule, meal duration).

Potential negatives: Tantrums, begging, sneaking snacks.

Not every family is able to follow the same feeding schedule due to logistics, culture, or regular family practices.

Instructions for Providers

The use of schedule and environmental factors to increase the positive effects of mealtime include: promoting appetite improving intake, providing a mealtime environment that minimizes distractions, promoting parental control, and improving overall nutrient intake.

Before Meals

  • Avoid eating between scheduled meals and snacks. Do not allow children to graze on snacks or juice throughout the day.
  • Try to have meals and snacks around the same time every day. Keeping to a routine every day can be hard, but try to keep to routine on most days.
  • Make one meal for the family (with at least one item that your child enjoys) and expect that everyone eat what has been made (or they don’t eat at that meal). Do NOT act as a “short order cook!”

During Meals

  • Turn off the TV and put all toys and other distractions in a different area.
  • Eat all meals and snacks at a table with your child seated in a chair that fits him/her. Do not allow children to wander around the house with food /drink
  • Meals should last a maximum of 20 to 30 minutes. Younger children (under 5) may have 15 to 20 minute meals.
  • As often as possible, try to have family meals.
  • Offer solid food before liquids and oral feeding before tube feeding.

Ending Meals

  • Release your child from the table after the time is up (remember 20 to 30 minutes for kids over 5 and 15 to 20 minutes for kids under 5). Do not try to make a child sit at the table “until their plate is clean.”
  • Try to release your child from the table before he/she begins to whine, cry, or tantrum. It is best to end on a success!
  • Try to end meals on a positive note. An example could be your child taking one last bite or sip.

Supplemental Materials

  Elimination of Juice/Empty Calories

Eliminate the dietary practice of excess fruit juice.

Background Education for Providers

Typically, children will have an easier time drinking calories than eating them (e.g., whole milk, formula). Fruit juice or sugar sweetened beverages are often associated with obesity or excess weight gain in children. However, in the undernourished patient, most notably infants and toddlers, it can have an opposite effect. With an underweight patient the general goal is to maintain a healthy diet while increasing the calorie intake. Beverages such as fruit juice will increase caloric intake; however, many of these calories come from the added sugar. It is important to remember that the nutritional quality of the foods remains important.

Any caloric beverage provided between meals may decrease a child’s appetite at mealtimes. Providing high calorie beverages and fruit juices between mealtimes should be avoided in order to improve intake at mealtimes. Children should be given no more than 8 ounces of fruit juice per day, and other high calorie beverages should be made available for the child to drink with their meals. If children are thirsty between mealtimes, they should be encouraged to drink water. Often when children say they are hungry between mealtimes, it may often be a sign of thirst. Families may inquire about increasing fruit juice intake, which should be limited and could be avoided as this offers little nutritional benefit for the underweight or undernourished child.

Instructions for Provider

  • Prevent and control access to fruit juice. Prevent ad lib or grazing drinking patterns of juice or sugar sweetened beverages.
  • Only provide and encourage water to drink between scheduled meal and snack times.
  • Limit total fruit juice intake to less than 8 ounces per day.
  • Provide alternative choices for high calorie beverages that can be provided to children at mealtimes, such as PediaSure, formula, or whole milk.

Supplemental Materials

  Constipation Alleviation through Fluids/Fiber/Meds

Constipation is a common problem in childhood and is estimated to account for 3% of all general pediatric visits and 25% of all pediatric gastroenterology visits (Sonnenberg & Koch, 1989). Unfortunately, many children who experience constipation will have decreased interest in eating or may develop eating habits which result in a worsening of symptoms. Often, with medical management alone symptoms of constipation improve. However, some children will require a combination of behavioral and medical treatment.

  • Children generally have between 2 stools daily and 1 stool every other day. Stools should be soft and easily passed.
  • Foods which are high in fat may slow the motility of the gut and cause or worsen symptoms of constipation (e.g., concentrated dairy foods)
  • A higher fiber diet with adequate nutrition may help alleviate constipation. A good general rule to follow is to add five to a child’s age to estimate their daily grams of fiber and multiply that sum by 3 to estimate their hydration need. For example a 5 year old child would need about 10 grams of fiber each day and 30 or more oz of fluids.
  • If you suspect that a child has a constipation problem a medical evaluation should be recommended.

Supplemental Materials

  Appetite Stimulant

Background Education for Providers

Medications have been used to induce hunger (e.g., cyproheptadine) or to reduce anxiety that may cause a child to ignore hunger cues (e.g., clonidine), but unfortunately little data are available on the efficacy of these interventions. The children who are the most likely to benefit from these appetite stimulants are those with suboptimal nutrition who have intact oral skills but who are not responsive to internal hunger cues. Close consultation with a physician is strongly recommended if these medications are to be considered due to potential complications from these therapies.

Instructions for Provider

Careful consideration should be given to the underlying etiology of the feeding problem before appetite manipulation is used as a treatment strategy. For instance, there are a variety of medical conditions (e.g., feeding tube dependence, food allergies, cancer) and medical treatments (e.g., anti-seizure and stimulant medications) that predispose children to poor appetite. Appetite manipulation is also often difficult for caregivers to tolerate as they can become concerned about their child’s nutritional or hydration status. Therefore, careful selection criteria should be considered prior to implementing an appetite manipulation as a treatment strategy. Prior to attempting to manipulate the child’s appetite, the clinician should assess (1) medical conditions that prohibit periods of fasting; (2) the child’s hunger drive; (3) the child’s developmental and oral motor skills to ensure that foods presented are commensurate with the child’s feeding abilities; and (4) the caregiver acceptance of appetite manipulation so as not to cause undue stress on the family. Given the medical and nutritional concerns that frequently accompany this treatment strategy, appetite manipulation should only be conducted under close medical supervision. Often this intervention is best suited to inpatient care settings where medical supervision is consistently available.

Supplemental Materials

  Medical Evaluation

A variety of problems may impact upon the infant or child’s ability or desire to eat. These include medical disorders, developmental delays, and sensory processing problems. When physiological problems are suspected, medical evaluation is needed.

Background Education for Providers

Anatomic problems (e.g., cleft lip and palate, micrognathia, arthrogryposis), neuromuscular conditions (e.g., cerebral palsy, muscular dystrophies), sensory disorders (e.g. familial dysautonomia) and a variety of genetic disorders (e.g. Trisomy 21, velo-cardio-facial syndrome) all are associated with or cause feeding problems (Rudolph, 1994). These conditions may cause delays in or complete disruption of oral-motor skill development (Field, Garland, & Williams, 2003), limiting a child’s experience with oral feedings due to feeding safety concerns. In some instances, safety concerns prohibit oral experiences during critical/sensitive windows for the neurodevelopment of feeding skills such that later acquisition of these skills is challenging. Caregivers may also be reluctant to promote feeding out of concern that the child will experience hardship or that his or her nutritional status will be compromised. Patients presenting specifically with oral-motor problems require an evaluation by a pediatric speech and language pathologist trained in feeding and swallowing disorders to identify problems and to initiate an appropriate treatment program.

There are other medial conditions that also predispose a child to having a feeding problem. Although acute conditions (such as gastroenteritis, strep infection) may cause decreased appetite, fatigue, nausea, and abdominal pain, these conditions are likely to have only transient effects on nutritional status. Chronic conditions tend to be of greater concern, as they can have longer lasting effects, which can include poor appetite, and/or discomfort with feeding resulting in more serious nutritional compromise (Kirby & Noel, 2007; Needlman, Adair, & Bresnahan, 1998). Chronic medical problems presenting during infancy disrupt or delay the introduction of feeding can also cause the child to miss sensitive periods of feeding development. Conditions that require supplemental feeding (e.g., tube feeding) frequently disrupt the child’s association of oral feeding with satiation of hunger (Blackman & Nelson, 1985, 1987; Geertsma, Hyams, Pelletier, & Reiter, 1985).Of particular concern are prematurity (K.A. Burklow, McGrath, Valerius, & Rudolph, 2002), in utero growth retardation, and tracheostomy (Fowler, Simon, & Handler, 1985; L.T. Singer, Wood, & Lambert, 1985). Other medical conditions presenting as children develop that can cause negative associations to oral feeding include tooth decay, food allergies, esophagitis due to either eosinophilic esophagitis or gastroesophageal reflux, delayed gastric emptying, dumping syndrome, celiac disease, constipation, cardiac and respiratory disease, cystic fibrosis, and a variety of metabolic disorders.

A number of medicines have side effects that can contribute to feeding problems (Needlman et al., 1998). Common antibiotics can cause diarrhea and nausea. Medications used to treat gastroesophageal reflux, especially metoclopramide may cause tardive dyskinesia impinging upon feeding skills (Shaffer, Butterfield, Pamer, & Mackey, 2004). Over the counter dietary supplements frequently unwittingly used to treat feeding problems (e.g, vitamins) can cause nausea, constipation, or diarrhea. Cardiac medications can cause anorexia, nausea, dyspepsia, diarrhea, and electrolyte imbalance. Respiratory medications can cause nausea and vomiting. Psychotropic medications, including antidepressants and stimulants, can have unintended side effects that disrupt feeding including nausea, vomiting, and diarrhea. One of the most frequently encountered problems with psychotropic medication stems from the anorexic effects of stimulants used to treat Attention Deficit/Hyperactivity Disorder.

Feeding disorders are prevalent in developmentally disabled populations, with approximately one third of all disabled children having significant feeding problems (A. L. Gouge & S. W. Ekvall, 1975) and as many as 80% of children with severe or profound mental retardation having a feeding disorder (Manikam & Perman, 2000; Perske et al., 1977). These high prevalence rates are likely due to delay in development or deficiencies of oral motor skills and fine motor skills required for independent feeding with intake of a diet of varied textures. The prevalence rates of feeding problems secondary to medical and developmental problems are expected to rise as the survival rates of children with significant developmental disabilities due to prematurity or underlying medical conditions increases.

Instructions for Provider

  • Evaluate anthropomorphic of the child
  • Review medical history
  • Refer for additional medical evaluation as needed

Supplemental Materials

Contact Us

Email the Nutritional Disorders Telehealth Network Project Team

Please contact us if you are interested in using any of the project materials or if you would like more information regarding the project.