Clyde–
Great question!
We have long appreciated the use of cyproheptadine for several important off label uses in pediatrics.
If the FTT is due to lack of caloric intake, then cyproheptadine is a great option to try. We have been using this off label in peds for increasing oral intake for decades.
In short, a reminder for those who do not usually have to talk people into eating more (likely not as common an issue in adults as in peds)…….
Cyproheptadine (Periactin) is an old-fashioned anti-histamine which is no longer used for this affect, due to the fact that it usually makes people hungry, and therefore eat more and therefore gain weight. However, in peds we have used it regularly for decades in kids with ADHD, in whom the use of effective stimulants was limited by the appetite suppression of these meds (thereby causing weight/height/growth concerns). In these kids, if you gave them the stimulant WITH cyproheptadine in the morning…. they were often focused and would still eat lunch. (Side note here: in my experience, the effect lasts about the same amount of time for these two meds, and the stimulant suppresses more than cyproheptadine supports eating. But at least you could then talk the kids into eating).
The typical dose I use for it in these settings is 4mg Qam (at the same time as stimulant).
More and more now in the last few years (maybe the last 10 years) we have been using cyproheptadine in kids for a handful of other things:
-We enjoy the anticholinergic effects of cyproheptadine in it’s off label use for functional abdominal pain.
-We have been using it more and more lately for things like anorexia nervosa (here the dose is MUCH higher … like 8mg QID).
-It can be used to counteract serotonin syndrome if you overshoot with an SSRI (as it can be a potent serotonin antagonist as well).
And of course, to your question Clyde…. it can help make it easier for you to talk a reluctant kid into eating in general…. which is very helpful when you have a child failing to grow well (WHEN it is due to lack of caloric intake).
So if your child is not getting taller, because his BMI is too low, because he/she isn’t eating enough… then it is a great idea to do a trial of cyproheptadine. It is safe, and the only real side effect that you would need to watch out for (and warn them about), is that some kids (not many… maybe 5 kids ever for me in 25 years) have emotional side effects from the serotonin antagonism. In these kids, if you explain this is rare but warn them to watch out for it… if it is an issue for them they will say on day 1 or 2, “I hate that pill, it makes me feel crazy and I don’t want to take it”. These kids are not uncertain that they don’t like it, and that it isn’t right for them. Of course, listen to them. I suspect that if you didn’t warn them, they might just think they were having bad days building up until things got pretty bad. But if you warn them ahead of time, it is no problem just to stop after 1-2 days and then they feel fine again the next day. Side note; don’t try it again in these kids.
If you were going to try it… I would see them in clinic and give education, PLOT ht/wt/BMI on a appropriate peds growth chart an start them on 4mg Qam. I would also explain that the medication isn’t going to do the work for them, it will only make eating easier for these kids, not make them ravenous usually. THEY still have to do the job of eating.
I would have them call in 1 week with an update (just to make sure that they didn’t miss a mood issue), and then see them monthly to plot the ht/wt/BMI along the curve.
Success would be: increasing weight starting first month, then translated into increasing height as well, over the next few months (IF their height was being affected by their lack of intake).
Regardless, a kid with a BMI under the curve will not have enough energy in them to play, learn, and grow.. and they will not be making enough neurotransmitters, etc. So, if your patient has FTT with a BMI under the curve… even if you only bring his BMI onto the curve without significantly changing his/her height yet, you will see a big change in them academically, in play, in social settings, in mood, in behavior, etc.
It also goes without saying, that if what a patient has is short stature or is falling on the curve height wise, but NOT weight wise… then this is NOT due to lack of calories. And this is not the medication to help with that.
If you have a kid like the above with normal weight/BMI, but falling on the height curve then you need to go through the long list of possible medical causes for this (heart concerns like ASD, renal disease, celiac, etc all need to be checked off and ruled out before thinking about anything else).
Clearly I do not know how to answer questions succinctly…… there is just so much I want to say to make sure that your (and everyone’s) pediatric patients are helped and treated safely.
I could also continue to go on and on about the long list of reasons for a kid to have FTT or how to come at weight/height concerns, but at least for tonight I hope that I have given you enough info for you to help your patient be willing to eat more.
Warmly,
Cynthia
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