Using Periactin to Boost Appetite

This post is meant to be informational in nature and should not replace consultation with a medical provider. As with all medication, use is tailored to the individual needs of the child. Information was reviewed for accuracy by Dr. Paul Hyman, Pediatric Gastroenterology, New Orleans Children’s Hospital.

Using Periactin to Boost Appetite

Children who have feeding difficulty, food refusal, volume limiting, grazing, and poor weight gain often show decreased appetite and reduced hunger cues. Parents may report that their children rarely request food and never seem hungry. Using medicine to boost or stimulate appetite is becoming a frequent and successful strategy in the treatment of some children with feeding problems.

The most common medicine used to increase appetite is cyproheptadine, sold under the brand name Periactin. It is a first-generation antihistamine with additional anticholinergic, antiserotonergic, and local anesthetic properties. It is used to relieve allergy symptoms such as watery eyes, runny nose, itching eyes/nose, sneezing, hives, and itching. It works by blocking a natural substance (histamine) that your body makes during an allergic reaction.

Why is it used in the treatment of pediatric feeding difficulty?

In the treatment of poor feeding, Periactin is often used for one it’s side effect properties- to boost appetite. Clinically, we see that some children will have improved appetite and desire to eat when taking this medication. We have seen children double their intake, ask for food for the first time in their life, and transition into a routine of eating that is much easier and more comfortable for them resulting in weight gain and growth. Some children will also have reduced vomiting and improved gastric accommodation (or the ability to tolerate larger volumes of food/liquid in the stomach).

Other side effects include sleepiness, which may be desirable if the child has a pattern of poor sleeping which many of our children with feeding and reflux issues experience. In these cases, the provider may recommend that the medicine may be given at night. Some of our patients taking Periactin, have increased activity or hyperactivity, and the provider may be recommend that the medicine be given in the morning.  Of course, Periactin does not work for every child but the research summarized below does report promising results in the use of Periactin to boost appetite.

Anecdotally, we have the experience of trying the medication with some of our patients without results and then trying it again 6 months or a year later with improved appetite.

What ages can it be used for?

My experience is this will depend on the physician prescribing it.  We have used it off label in 6 months and above with some of our feeding patients. Many physicians feel more comfortable prescribing it in children over 1 and some wait until age 2.

When is the right time to use it?

This will be up to the medical provider and feeding team to decide if the child is ready for an appetite stimulant. Our GI providers often wait until reflux and constipation management are in place because they do not want to boost appetite in a child who is in pain or has discomfort. We find a successful strategy is to use Periactin when the child is stooling well, has reflux controlled and is in feeding therapy to assist with feeding refusal and oral aversion.

Length of time you can use periactin?

As far as I know, there are no studies looking at length of time to use this medication. We use it as long as needed. For many children, the hunger effect will wear off after a period of time of use. Parents will report that the medicine doesn’t seem to be working as well. At that point, the GI providers work with parents to cycle the medication. Some children take it for 5 days on /2 off, some take it for 3 weeks on/1 week off,. some children never cycle it. The schedule is tailored to the individual needs of the child.

What is the right dose?

Medication dosing information is beyond the scope of this blog due to the potential liability and possible misunderstanding of information. Please talk with your doctor about dosing which will vary depending on the child’s age and weight

Are their children who can’t or shouldn’t take Periactin? 

No.

Is it safe to use?

It is very safe.

 

Research Abstracts:

Madani S1, Cortes O, Thomas R.Cyproheptadine Use in Children With Functional Gastrointestinal Disorders.J Pediatr Gastroenterol Nutr. 2016 Mar;62(3):409-13.

The objective of this study was to evaluate clinical improvement and safety with use of cyproheptadine in functional gastrointestinal disorders (FGIDs) in children. Among 307 patients, 151 reported complete symptom improvement; 41 (27.2%) reported no or partial improvement. A total of 102/151 (68%) reported no adverse effects. Adverse effects shown were as sleepiness in 19/151 (13%) and weight gain in 15/151 (10%). Cyproheptadine was effective in improving symptoms of functional abdominal pain, functional dyspepsia. Patients in smaller numbers had significant improvement 13/18 (72%) abdominal migraine, 10/10 (100%) IBS, and 6/8 (75%) cyclic vomiting syndrome. This is the first time report of improvement in IBS. Lower body weight predicted no to partial improvement; the single best predictor of clinical improvement was body mass index. Cyproheptadine effectively improves symptoms of Rome III-defined FGIDs and has a good safety profile when used for these indications.

Merhar, S.L., Pentiuk, S. P.,Mukkada, V.A.,Meinzen-Derr, J., Kaul, A., Butler A.,  A retrospective review of cyproheptadine for feeding intolerance in children less than three years of age: effects and side effects . Acta Paediatr. 2016 Aug;105(8):967-70. doi: 10.1111/apa.13477. Epub 2016 Jun 10.

The medication had a positive effect, defined as resolution of vomiting, improved feeding or improved comfort with feeds in 67% of children. An additional 28% showed possible improvement, defined as some improvement in vomiting or improvement in vomiting or feeding tolerance in conjunction with other changes in addition to cyproheptadine.
In our experience, cyproheptadine appears to be safe and effective in decreasing vomiting and feeding intolerance in children less than three years of age. A trial of cyproheptadine could be considered before invasive testing in infants with feeding issues.

Najib K, Moghtaderi M, Karamizadeh Z, Fallahzadeh E. Beneficial effect of cyproheptadine on body mass index in undernourished children: a randomized controlled trial. Iran J Pediatr. 2014 Dec;24(6):753-8.

Cyproheptadine hydrochloride (CH) is a first-generation antihistamine which is used as an appetite stimulant. This study was designed to identify the role of CH therapy on weight gain, linear growth and body mass index in children with mild to moderate undernutrition. In our study, cyproheptadine promotes increase in body mass index in children with mild to moderate undernutrition after four weeks treatment.

Sant’Anna AM, Hammes PS, Porporino M, Martel C, Zygmuntowicz C, Ramsay M. Use of cyproheptadine in young children with feeding difficulties and poor growth in a pediatric feeding program. J Pediatr Gastroenterol Nutr. 2014 Nov;59(5):674-8. 

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. 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. 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. 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

Rodriguez L, Diaz J, Nurko S. Safety and efficacy of cyproheptadine for treating dyspeptic symptoms in children.J Pediatr. 2013 Jul;163(1):261-7. doi: 10.1016/j.jpeds.2012.12.096.

Cyproheptadine is safe and effective for treating dyspeptic symptoms in children, particularly in young children and those with early vomiting and retching after fundoplication.

Benjasuwantep B.Successful treatment in a child with feeding problems and growth failure. J Med Assoc Thai. 2009 Jun;92 Suppl 3:S60-4.

A 2-year-9-month-old boy presented with feeding disorder and poor growth. The clinical presentation was compatible with infantile anorexia. The author proposed that the main cause of poor food acceptance and growth failure in this child was poor appetite. Treatments were composed of behavioral interventions, rescheduling meals and foods enrichment. Alternative managements by prescribing cyproheptadine as an appetite stimulant resulted in improvement of feeding behaviors and weight gain.

Mahachoklertwattana P, Wanasuwankul S, Poomthavorn P, Choubtum L, Sriphrapradang A. Short-term cyproheptadine therapy in underweight children: effects on growth and serum insulin-like growth factor-I.

J Pediatr Endocrinol Metab. 2009 May;22(5):425-32.

Cyproheptadine therapy in underweight children increased caloric intake and serum IGF-I concentration and consequently enhanced growth velocity.

Homnick DN, Marks JH, Hare KL, Bonnema SK. Long-term trial of cyproheptadine as an appetite stimulant in cystic fibrosis.

Pediatr Pulmonol. 2005 Sep;40(3):251-6.

Leptin is a 167 amino acid protein encoded by the obesity gene that is synthesized in adipose tissue and interacts with receptors in the hypothalamus linked to the regulation of appetite and metabolism. It is known to suppress appetite and increase energy expenditure. Cyproheptadine is a piperidine antihistamine that increases appetite through its antiserotonergic effect on 5-HT2 receptors in the brain. Although both leptin and cyproheptadine are effective in controlling appetite, their interaction has not been addressed in clinical studies. This study evaluated serum leptin concentrations in patients who received cyproheptadine to treat a variety of disorders. Sixteen patients were given cyproheptadine 2 to 6 mg/day for a minimum of 7 days. Body weight was measured and blood samples were obtained at baseline and after 1 week of treatment. Serum leptin levels were determined by leptin radioimmunoassay. The mean body weight at baseline (52.59 kg) did not differ significantly from that at 1 week after treatment (52.84 kg; P > .05), but the mean leptin level after 1 week of treatment with cyproheptadine (3.14 ng/mL) was 14.2% higher than that at baseline (2.75 ng/mL; P < .05). This increase may suggest that both leptin and cyproheptadine may affect appetite via similar receptors and that cyproheptadine does not impair leptin activity through these receptors. Further study will be necessary to clarify this relationship.

Chinuck R, Dewar J, Baldwin DR, Hendron E. Appetite stimulants for people with cystic fibrosis. Cochrane Database Syst Rev. 2014 Jul 27;(7):CD008190.

In the short term (six months) in adults and children, appetite stimulants improved only two of the outcomes in this review – weight (or weight z score) and appetite; and side effects were insufficiently reported to determine the full extent of their impact. Whilst the data may suggest the potential use of appetite stimulants in treating anorexia in adults and children with cystic fibrosis, this is based upon moderate quality data from a small number of trials and so this therapy cannot be conclusively recommended based upon the findings in the review. Clinicians need to be aware of the potential adverse effects of appetite stimulants and actively monitor any patients prescribed these medications accordingly. Research is needed to determine meaningful surrogate measures for appetite and define what constitutes quality weight gain. Future trials of appetite stimulants should use a validated measure of symptoms including a disease-specific instrument for measuring poor appetite. This review highlights the need for multicentred, adequately powered and well-designed trials to evaluate agents to safely increase appetite in people with cystic fibrosis and to establish the optimal mode of treatment.

Epifanio M, Marostica PC, Mattiello R, Feix L, Nejedlo R, Fischer GB, Stein RT.

J Pediatr (Rio J). 2012  A randomized, double-blind, placebo-controlled trial of cyproheptadine for appetite stimulation in cystic fibrosis. Mar-Apr;88(2):155-60.

Use of cyproheptadine in cystic fibrosis patients was well tolerated, showing a weight gain and a significant increase in BMI after 12 weeks. A clinically relevant effect size for weight/age (z score) and body mass index for age (z score) was found. Such findings suggest that the prescription of cyproheptadine can be an alternative approach for patients who need nutritional support for a short period of time.

Couluris M, Mayer JL, Freyer DR, Sandler E, Xu P, Krischer JP. The effect of cyproheptadine hydrochloride (periactin) and megestrol acetate (megace) on weight in children with cancer/treatment-related cachexia.

J Pediatr Hematol Oncol. 2008 Nov;30(11):791-7. 

This study demonstrates that CH is a safe and effective way to promote weight gain in children with cancer/treatment-related cachexia.

Homnick DN, Homnick BD, Reeves AJ, Marks JH, Pimentel RS, Bonnema SK. Cyproheptadine is an effective appetite stimulant in cystic fibrosis.

Pediatr Pulmonol. 2004 Aug;38(2):129-34.

CH appears to be an effective appetite stimulant with minimal side effects in children and adults with CF.