Growth issues in Children - saac.chu-sainte

LE RETARD
STATUROPONDÉRAL
CHEZ
L’ENFANT
Mallory Chavannes
Fellow en Gastroentérologie Pédiatrique
CHU Sainte Justine
Montréal, 23 Octobre 2015
OBJECTIFS
➤
Quiz sur quelques courbes de croissance
➤
Prise en charge médicamenteuse des mangeurs difficiles
➤
Recherche en cours
PREMIÈRE QUESTION!
➤
3 ans M, né à terme
➤
Diabète de grossesse
➤
Mère inquiète parce qu’il
semble plus petit que les autres.
➤
Appétit correct, peut-être pas
autant que son grand frère de 5
ans
➤
Pas d’autres plaintes à
l’anamnèse
➤
Aucune hospitalisation
PREMIÈRE QUESTION!
➤
Est-ce qu’il y a un problème?
1. Oui
2. Non
PREMIÈRE QUESTION!
➤
Est-ce qu’il y a un problème
1. Oui
2. Non
RETARD DE CROISSANCE CONSTITUTIONNEL
➤
Retours vers potentiel génétique
autours de 2-3ans
➤
Peut être exagéré chez enfants avec
un retards de croissance
constitutionnel.
➤
Généralement anamnèse negative
➤
Taille suit le poids
➤
Devrait reprendre une vélocité de
croissance normale
RETARD DE CROISSANCE CONSTITUTIONNEL
➤
Mais reste un diagnostique d’exclusion!!
➤
Investigation de base:
➤
Bonne histoire et examen physique
➤
FSC
➤
VS, CRP, Electrolytes, fct rénale, gazo
➤
Albumin
➤
Bilan martial
➤
Bilan hépatique
➤
Immunoglobuline, TSH, ATG
➤
Analyse d’urine
CPS: The toddler who is falling off the growth chart
DEUXIÈME QUESTION!
➤
26 mois F, né à terme
➤
Pas d’antécédents significatif
➤
Depuis 26 mois, elle à des
goûts plutôt restrains.
➤
Anamnèse révèle de la
constipation, avec trois
épisodes de sang dans les 6
derniers mois
➤
Histoire familiale négative
DEUXIÈME QUESTION!
➤
Quel est le problème?
1. Maladie Cœliaque
2. Manque d’apport
3. Fibrose Kystique
4. Maladie inflammatoire de l’intestin
DEUXIÈME QUESTION!
➤
Quel est le problème?
1. Maladie Cœliaque
2. Manque d’apport
3. Fibrose Kystique
4. Maladie inflammatoire de l’intestin
RETARD STATURO-PONDÉRAL
IMPORTANCE DE LA COURBE
PRISE EN CHARGE
➤
Réassurance
➤
Donner des portions adéquates
➤
Rajouter des calories
➤
Collations durant le jour, pas
autours des repas
➤
En faire une experience sociale
agréable
CPS: “The picky eater”: The toddler
or preschooler who does not eat
AVEZ-VOUS DÉJÀ UTILISER LA CYPROHEPTADINE?
➤
Oui
➤
Non
PRISE EN CHARGE MÉDICAMENTEUSE?
➤
La Cyproheptadine (Périactin)
➤
Antagoniste des récepteurs serotonin et
histamine
➤
Récepteurs de l’hypothalamus
ventromédial
➤
Possible influence sur l’axe d’hormone
de croissance et IGF-1
➤
Effet sur les dosages sériques de
Leptin
CYPROHEPTADINE (PERIACTIN)
❖
❖
Notons de manière concomitante une augmentation de
l’appétit chez des patients souffrants de l’asthme
❖
augmentation du poids et de l’appétit
❖
augmentation de l’apport calorique
Augmentation du poids durant premières semaines de
traitement
❖
Ralentissement de la vitesse du gain de poids
Drug Ther Bull. 1970 Aug 28;8(18):71-2.
CYPROHEPTADINE (PERIACTIN)
❖
Effets secondaires
❖
somnolence
❖
effets anticholinergiques
❖
❖
Plutôt à haute dose
Effet disparait après
quelques jours d’usage
Drug Ther Bull. 1970 Aug 28;8(18):71-2.
CYPROHEPTADINE (PERIACTIN)
off
2-4sem
2-4sem
on
on
2-4sem
2-4sem
off
Tachyphylaxie
CYPROHEPTADINE FAIT SES PREUVES
➤
Fibrose kystique
➤
Cancer
➤
Anorexie Nerveuse
➤
Étude en cours pour
enfants sur stimulants
➤
Petits mangeurs?
CHEZ LES MANGEURS DIFFICILES?
ORIGINAL ARTICLE: HEPATOLOGY
AND
NUTRITION
Use of Cyproheptadine in Young Children With Feeding
Difficulties and Poor Growth in a Pediatric
Feeding Program
!
Ana M.G.A. Sant’Anna, yPatricia S. Hammes, zMafalda Porporino, zChantal Martel,
z
Catherine Zygmuntowicz, and zMaria Ramsay
ABSTRACT
Objective: The aim of this study was to assess the efficacy and safety of
cyproheptadine (CY) use in infants and young children with poor growth
treated at our multidisciplinary pediatric feeding program, and to describe
changes in their weight and feeding behaviors.
Methods: A retrospective chart review of children treated with CY from
January 2007 to July 2011 was performed. Demographic data, medical
diagnosis, adverse effects of the drug, and changes in mealtime behaviors
P
arents of children with poor growth with or without underlying medical conditions often complain about their children
not having appetite. These children do not ask for food, eat small
quantities, and consume a limited variety of foods, resulting in
difficult mealtimes and poor growth (1). Despite efforts at improving mealtime behaviors, giving nutritional advice, and involvement
of occupational therapy, these children often remain poor feeders
and either do not gain weight (2) or gain some weight with extreme
ORIGINAL ARTICLE: HEPATOLOGY
AND
NUTRITION
Use of Cyproheptadine in Young Children With Feeding
Difficulties and Poor Growth in a Pediatric
Feeding Program
!
Ana M.G.A. Sant’Anna, yPatricia S. Hammes, zMafalda Porporino, zChantal Martel,
z
Catherine Zygmuntowicz, and zMaria Ramsay
ABSTRACT
Objective: The aim of this study was to assess the efficacy and safety of
cyproheptadine (CY) use in infants and young children with poor growth
treated at our multidisciplinary pediatric feeding program, and to describe
changes in their weight and feeding behaviors.
Methods: A retrospective chart review of children treated with CY from
January 2007 to July 2011 was performed. Demographic data, medical
diagnosis, adverse effects of the drug, and changes in mealtime behaviors
were extracted from the patients’ medical records. For each patient who
received the CY, weight-for-age z scores (WtZ) were calculated before and
during treatment. Repeated-measures mixed model was used to analyze the
pattern of change in WtZ over time and between groups. Differences in mean
WtZ were tested between patients regularly receiving CY and a naturally
conceived comparison group.
Results: Of the 127 patients in treatment owing to poor weight gain who
received the CY, 82 took the medication regularly as prescribed in
combination with our interventional program. For these patients, the
majority of the parents (96%) reported a positive change in mealtime
and feeding behaviors. A significant improvement in mean WtZ was
observed after starting CY when compared with the WtZ before
treatment for those patients regularly receiving the medication. This
effect was independent of patients’ age and/or presence of an underline
medical problem. No significant differences in mean WtZ were observed
over time within the comparison group.
Conclusions: In our experience, the use of CY in combination with a
specialized multidisciplinary interventional program is a safe and effective
therapy in infants and young children with low appetite and poor growth.
❖
Analyse rétrospective de 941 enfants
❖
Key Words: cyproheptadine, feeding behavior, poor growth, safety, weight
gain
❖
(JPGN 2014;59: 674–678)
P
arents of children with poor growth with or without underlying medical conditions often complain about their children
not having appetite. These children do not ask for food, eat small
quantities, and consume a limited variety of foods, resulting in
difficult mealtimes and poor growth (1). Despite efforts at improving mealtime behaviors, giving nutritional advice, and involvement
of occupational therapy, these children often remain poor feeders
and either do not gain weight (2) or gain some weight with extreme
maternal efforts. Cyproheptadine (CY), a known antiserotoninergic
and antihistaminergic agent (3,4), has been used as an appetite
stimulant (5,6) and in patients with gastrointestinal problems (7),
dyspepsia (8), anorexia nervosa (9), pulmonary consumptions (eg,
cystic fibrosis) (10–12), asthma (13), cancer and treatment-related
cachexia (13,14), and for stimulant-induced weight loss in children
with attention-deficit/hyperactivity disorder (15). The exact mechanism by which CY improves growth is not well understood; it may
affect appetite via receptors in the ventromedial hypothalamus
through its antihistamine and antiserotonin function (16), or it
may influence the growth hormone and insulin-like growth factor
axis (17). Several investigations have attempted to understand the
mechanisms of action of CY as an appetite stimulant (17,18).
Although the efficacy and safety of this medication have been
documented in the pediatric population, its use in poorly growing
children age "2 years and on specific feeding behaviors, has not
been investigated. Although rare, the most common adverse effects
reported are mild drowsiness and/or irritability that tend to wear off
after the first few days of use.
We hypothesized that the use of CY in young children with
poor growth is effective and safe and that this medication improves
feeding behaviors and weight gain. To test our hypothesis we
performed a retrospective analysis of all of the patients treated
with CY at the pediatric feeding program (PFP) at the Montreal
Children’s Hospital.
82 enfants retenus pour analyse (24 BS, 58
avec conditions médicales associées)
45 enfants utilisé comme groupe contrôle
METHODS
Résultats
Received August 14, 2013; accepted June 12, 2014.
From the !Division of Gastroenterology and Nutrition, and Feeding
Disorders Program, Montreal Children’s Hospital, McGill University,
the yFeeding Disorders Program, Montreal Children’s Hospital, and the
zDepartment of Psychology, Feeding Disorders Program, Montreal
Children’s Hospital, McGill University, Montreal, Canada.
Address correspondence and reprint requests to Ana M.G.A. Sant’Anna,
MD, 2300 Tupper St, Room D-562, Montreal, QC H3H 1P3, Canada
(e-mail: [email protected]).
The authors report no conflicts of interest.
Copyright # 2014 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000000467
❖
❖
Population and the PFP
From January 2007 to July 2011 the medical records of all of
the patients studied at the PFP with poor growth and treated with
CY were reviewed. This multidisciplinary clinic includes pediatric
psychologists, occupational therapists, dietitians, a behavioral
specialist, and a pediatric gastroenterologist. The PFP follows
patients with feeding disorders secondary to poor appetite (with
or without poor growth), difficulties with food textures and variety,
and patients with enteral feedings who require the discontinuation
of gavage. In this study, all tube-fed patients were excluded. The
program receives >200 new consults per year, with initial weekly
or biweekly follow-up by the psychologists. Behavioral and
96% Changement des habitudes alimentaires
674
JPGN # Volume 59, Number 5, November 2014
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
❖
Augmentation du poids statistiquement
significative du groupe expérimental
the available data of the group of children who did not use CY
regularly or never used the medication. We found that the experimental group had poorer WtZ than the comparison group at the time
the medication was received, but not at the pretreatment time point
(3–7 months before the treatment). This suggests that the group
ORIGINAL ARTICLE: HEPATOLOGY who
AND NUTRITION
took CY regularly—experimental group—was composed of
patients whose weight-for-age was severely declining with time.
Therefore, parental compliance to the treatment may be related to
Use of Cyproheptadine in Young the
Children
With
Feeding
severity
of the
WtZ at the time CY was prescribed.
Difficulties and Poor Growth in aThere
Pediatric
was no sex difference on the degree of weight gain in
Feeding Program
our study population of children of age <6 years. Twice as many
children
medical
conditions in our study, indicating that these
Ana M.G.A. Sant’Anna, Patricia S. Hammes, Mafalda
Porporino,had
Chantal
Martel,
Catherine Zygmuntowicz, and Maria
Ramsay are more likely to have comorbid feeding difficulties and
children
poor weight gain. Our results indicate that the youngest age group
ABSTRACT
the
lowest
rate
gain before
treatment
with CY,
arentshad
of children
withof
poor
growth with or
without of
under- weight
mber 5, November 2014
Use
Cyproheptadine
in Children
With Feeding
Difficulties
lying medical conditions often complain about their children
P
not havingsupporting
appetite. These children do
not ask
for food, eat small
the
notion
that when young children have diminished
quantities, and consume a limited variety of foods, resulting in
y
z
Mean WtZ
z
Objective: The aim of this study was to assess the efficacy and safety of
cyproheptadine (CY) use in infants and young children with poor growth
treated at our multidisciplinary pediatric feeding program, and to describe
changes in their weight and feeding behaviors.
Methods: A retrospective chart review of children treated with CY from
January 2007 to July 2011 was performed. Demographic data, medical
diagnosis, adverse effects of the drug, and changes in mealtime behaviors
–1.8
were extracted from the patients’ medical records. For each patient who
received the CY, weight-for-age z scores (WtZ) were calculated before and
during treatment. Repeated-measures mixed model was used to analyze the
pattern of change in WtZ over time and between groups. Differences in mean
–1.9
WtZ were tested between patients regularly receiving CY and a naturally
conceived comparison group.
Results: Of the 127 patients in treatment owing to poor weight gain who
received the CY, 82 took the medication regularly as prescribed in
–2
combination with our interventional program. For these patients, the
majority of the parents (96%) reported a positive change in mealtime
and feeding behaviors. A significant improvement in mean WtZ was
observed after starting CY when compared with the WtZ before
–2.1
treatment for those patients regularly receiving the medication. This
effect was independent of patients’ age and/or presence of an underline
medical problem. No significant differences in mean WtZ were observed
over time within the comparison group.
–2.2
Conclusions: In our experience, the use of CY in combination with a
specialized multidisciplinary interventional program is a safe and effective
therapy in infants and young children with low appetite and poor growth.
difficult mealtimes and poor growth (1). Despite efforts at improving mealtime behaviors, giving nutritional advice, and involvement
of occupational therapy, these children often remain poor feeders
and either do not gain weight (2) or gain some weight with extreme
maternal efforts. Cyproheptadine (CY), a known antiserotoninergic
and antihistaminergic agent (3,4), has been used as an appetite
stimulant (5,6) and in patients with gastrointestinal problems (7),
dyspepsia (8), anorexia nervosa (9), pulmonary consumptions (eg,
cystic fibrosis) (10–12), asthma (13), cancer and treatment-related
cachexia (13,14), and for stimulant-induced weight loss in children
with attention-deficit/hyperactivity disorder (15). The exact mechanism by which CY improves growth is not well understood; it may
affect appetite via receptors in the ventromedial hypothalamus
through its antihistamine and antiserotonin function (16), or it
may influence the growth hormone and insulin-like growth factor
axis (17). Several investigations have attempted to understand the
mechanisms of action of CY as an appetite stimulant (17,18).
Although the efficacy and safety of this medication have been
documented in the pediatric population, its use in poorly growing
children age "2 years and on specific feeding behaviors, hasComparison
not
been investigated. Although rare, the most common adverse effects
group
reported are mild drowsiness and/or irritability that tend to wear off
after the first few days of use.
Expermimental
We hypothesized that the use of CY in young children with
poor growth is effective and safe and that this medication improves
group
feeding behaviors and weight gain. To test our hypothesis we
performed a retrospective analysis of all of the patients treated
with CY at the pediatric feeding program (PFP) at the Montreal
Children’s Hospital.
–2.3
Key Words: cyproheptadine, feeding behavior, poor growth, safety, weight
gain
(JPGN 2014;59: 674–678)
–2.4
–1
–1.2
–1.4
–1.6
–1.8
7–18 mo
–2
19–30 mo
–2.2
31–80 mo
–2.4
METHODS
–2.5
Received August 14, 2013; accepted June 12, 2014.
From the !Division of Gastroenterology and Nutrition, and Feeding
Disorders Program, Montreal Children’s Hospital, McGill University,
the yFeeding Disorders Program, Montreal Children’s Hospital, and the
zDepartment of Psychology, Feeding Disorders Program, Montreal
–2.6
Children’s Hospital, McGill University, Montreal, Canada.
Address correspondence and reprint requests to Ana M.G.A. Sant’Anna,
MD, 2300 Tupper St, Room D-562, Montreal, QC H3H 1P3, Canada
(e-mail: [email protected]).
–2.7
The authors report no conflicts of interest.
2014 by
European
Society for Pediatric
Gastroenterology,
Copyright # 3–7
Beginning
of
mo
before
Hepatology, and Nutrition and North American Society for Pediatric
treatment
Gastroenterology,
Hepatology, and Nutrition treatment
DOI: 10.1097/MPG.0000000000000467
z
z
Mean WtZ
!
groups of children included some chil
of weight gain, relative to the minimu
(19,20). These children were included
of weight gain was the result of len
parental efforts at getting their child
not only did these older children resp
of CY in terms of weight gain but a
improved substantially. Based on thes
short questionnaire regarding patien
completed by the mothers during the
medication. The results of this quest
separate article.
In our routine practice we use
which is >0.1 mg/kg used by Maha
but <0.3 mg/kg used by Rerksuppap
The effect of our dosage was susta
Population and the PFP
From January 2007 to July 2011 the medical records of all of
the patients studied at the PFP with poor growth and treated with
CY were reviewed. This multidisciplinary clinic includes pediatric
psychologists, occupational therapists, dietitians, a behavioral
specialist, and a pediatric gastroenterologist. The PFP follows
patients with feeding disorders secondary to poor appetite (with
or without poor growth), difficulties with food textures and variety,
and patients with enteral feedings who require the discontinuation
First
time point Second time point
of gavage. In this study, all tube-fed patients were excluded. The
treatment
treatment
during
program
receives >200 during
new consults
per year, with initial weekly
or biweekly follow-up by the psychologists. Behavioral and
–2.6
–2.8
–3
3–7 mo before
treatment
Beginning of
treatment
First time point Second time point
during treatment during treatment
e experimental
and the comparison group at allFIGURE
4 time
points
of
measurement.
Significant
difference
in mean
WtZ at all 4 time points of measurement. Signific
# Volume2.
Mean
WtZ 2014
by age groups
for the
experimental
group
674
JPGN
59, Number
5, November
Copyright 2014
by ESPGHAN
and time
NASPGHAN.
Unauthorized
of started
this article
is
prohibited.
and comparison
groups
at the
treatment
started
(P <
There
was
no significant
difference
between
thesebetween 7- and 8-month-old and 31- and 80
thereproduction
time
CY0.05).
and
at the
first time point
during
treatment
of measurement. WtZ ¼ weight-for-age z scores.
Significant difference in mean WtZ at the second time point during treatment between the younger and the 2
CY ¼ cyproheptadine; WtZ ¼ weight-for-age z scores.
a quasicontrol group when we analyzed
appetite they refuse to eat regardless of parental efforts. The 2 older
ÉTUDE RANDOMISÉE EN DOUBLE
AVEUGLE
Dr. M Chavannes, Dr. V Marchand, Dr. V Groleau
CONCEPT ET DESIGN
➤
Étude randomisée, contrôlée à double insu, de type “chassécroisé”
➤
Enfants sans pathologie organique sous-jacente
➤
Recrutement en clinique gastro, pédiatrie et sensibilisation
auprès de l’équipe de nutrition
➤
Randomisation en bloc selon méthode chassé-croisé pas
équipe de pharmacie
➤
Placebo → Wash out → Cyproheptadine
➤
Cyproheptadine → Wash out → Placebo
ÉTUDE PRÉSENTEMENT À SAINTE-JUSTINE:
❖
Critères d’inclusion
❖
Enfants âgés de 2 à 4 ans
❖
Retard pondéral et/ou Statural
❖
❖
Décrochage de 2 corridors de la courbe pondérale et ou
plateau pondéral et ou perte de poids depuis au moins 3 mois
Critères d’exclusion
❖
Pathologie identifié lors de la première visite
❖
Médicament altérant l’appétit
❖
Prematuré <36 sem
❖
Atteinte neurologique
ANALYSES À FAIRE EN EXTERNE
TSH
Calcium, Phosphore
IgA/ ATG
Protéines totales,
Albumine
Hgb/Leucocytes/
Plaquettes
BUN, Créatinine
Glycémie, Na, K
Amylase
ALT, GGT
Élastase Fécale
Envoyez une consulte indiquant: Étude Périactin
Inclure bilan initial avec le fax si disponible
Dr. Mallory Chavannes, Dr. Valérie Marchand, Dr. Véronique Groleau
Fax: (514) 345-4741
Téléphone: (438) 395-1651
[email protected]