A randomized, double-blind, placebo-controlled trial of cyproheptadine for appetite stimulation in cystic fibrosis

Challenges to Optimizing Nutrition in Children With Cystic Fibrosis

PURPOSE OF REVIEW

Cystic fibrosis is a chronic condition that has significant effects on the nutritional status of pediatric patients. Malnutrition is frequently encountered in this population and has been shown to contribute to poor pulmonary and overall disease outcomes. This article will provide an overview of the physiologic and psychosocial challenges toward attaining optimal nutrition in pediatric cystic fibrosis patients.

RECENT FINDINGS

Newer therapies such as CFTR modulators have played significant roles in improving the nutritional status of patients with cystic fibrosis. There is also a greater focus on becoming more aware of psychosocial and cultural barriers in the care of cystic fibrosis patients. Many challenges exist in optimizing nutritional support including but not limited to the patient's clinical manifestations and disease severity, caregiver ability, and access to care. Both gastrointestinal and non-gastrointestinal disorders lead to insufficient caloric intake, increased loss and metabolic needs, and micronutrient and macronutrient deficiency. Social factors including stressful patient and caregiver relationships and altered body image also contribute to poor nutritional status.

Impact of appetite stimulants on growth parameters in children with cystic fibrosis

OBJECTIVES

Malnutrition is prevalent among children with cystic fibrosis (CF), often resulting from frequent pulmonary exacerbations and intestinal malabsorption. In addition to providing sufficient calorie intake through enteral formulas, appetite stimulants may help address nutritional deficiencies and improve overall prognosis.

METHODS

This retrospective study included children who received cyproheptadine (CH) as an appetite stimulant for at least three consecutive months. Data on CH-related adverse effects, z-scores for weight, height, body mass index (BMI), and percentage of forced expiratory volume in 1 s (FEV1%) were collected from medical records. Z-scores of growth parameters were calculated at baseline (CH initiation), three months before baseline, and three and six months after treatment.

RESULTS

The study included 45 children with a mean age of 11 years. One patient was on modulator therapy, one was pancreatic sufficient, and another one had diabetes. Only one patient was using enteral supplementation simultaneously with CH. Significant improvements in weight and BMI z-scores were observed from baseline to three months of CH therapy (p = 0.004 and p = 0.006, respectively), with no significant changes noted in the three months before treatment. A modest increase in weight and BMI z-scores was seen from three to six months of therapy. Additionally, FEV1 z-scores significantly increased from baseline to three months of therapy, with no further improvement observed in the subsequent three months.

CONCLUSION

Six months of CH therapy was associated with significant improvements in weight and BMI z-scores, particularly within the first three months. No adverse effects were reported. Given the deceleration in the rate of increase in anthropometric z-scores from the third to sixth month, a three-month duration of CH therapy appears to be optimal and sufficient for children with CF.

Spectroscopic Screening of Dexamethasone and Cyproheptadine Adulteration in Weight Gaining Products Marketed in Aden, Yemen

Background

Weight-gaining (WG) products are either medicine or herbal products that have been used intensively by the young and adolescents in Yemen. These products may contain undeclared potentially toxic ingredients that can lead to several health problems and diseases on long-term usage. This study was intended to evaluate the presence of some undeclared pharmaceuticals, dexamethasone (DX) and cyproheptadine (CPR), in WG products in Aden, Yemen.

Methods

The detection of DX & CPR in WG products was evaluated using UV& Fourier transform infrared (FT-IR) spectroscopy. Also, phytochemical analysis was carried out for herbal products.

Findings

The study indicated the presence of CPR in Tab-II, honey mixture, and capsules in the range between 0.10%-102.6%. A lower percentage was detected in the honey mixture and a higher percentage in Tab-2. DX was only detected in Tab-I (102.87%).

Conclusion

It can be concluded that WG products may contain undeclared amounts of DX and CPR. Stricter regulations must be implemented for the usage and distribution of these products to avoid potential long-term adverse consequences.

Evaluation of the Use of Appetite Stimulants in Pediatric Patients with Cystic Fibrosis

OBJECTIVE

Poor nutrition in patients with cystic fibrosis (CF) has been associated with lower lung function and increased morbidity and mortality. Conversely, better nutritional status has been associated with improved pulmonary function and fewer CF-associated complications. There is no consensus regarding appetite stimulant therapy in patients with CF (pwCF). The primary objective of this study was to determine if the use of appetite stimulants was associated with weight changes in pediatric pwCF in the ambulatory care setting.

METHODS

This was a retrospective study that evaluated 62 pediatric pwCF who received cyproheptadine or mirtazapine for appetite stimulation for at least 6 consecutive months. Weight z scores were collected for each patient at baseline, 3, 6, and 12 months of therapy, if available.

RESULTS

Increase in weight z score after 3 months of therapy was statistically significant based on both univariable and multivariable models when evaluating the entire cohort. The adjusted mean difference for change in weight z score was 0.33 ( P < 0.001) from baseline to month 3. There was a statistically significant improvement in pulmonary function after 3 and 6 months of therapy.

CONCLUSIONS

Appetite stimulant therapy was associated with improvement in weight z score in the first 3 months of treatment. Appetite stimulant therapy was associated with improvement in pulmonary function in the first 3 months of therapy, which supports the relationship between weight gain and improved pulmonary function in pwCF. These findings suggest that appetite stimulants contribute to weight gain in pediatric pwCF, particularly within the first 3 months of therapy.

Appetite stimulants for people with cystic fibrosis

BACKGROUND

Chronic loss of appetite in cystic fibrosis concerns both individuals and families. Appetite stimulants have been used to help cystic fibrosis patients with chronic anorexia attain optimal body mass index (BMI) and nutritional status. However, these may have adverse effects on clinical status. This is an updated version of the original review.

OBJECTIVES

To systematically search for and evaluate the evidence on the beneficial effects of appetite stimulants in the management of cystic fibrosis-related anorexia and synthesise reports of any side effects.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and online trials registries; handsearched reference lists; and contacted local and international experts to identify relevant trials. Last search of the Cystic Fibrosis Trials Register: 23 May 2022. Last search of online trial registries: 10 May 2022.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of appetite stimulants compared to placebo, control, no treatment or different appetite stimulants, or to the same appetite stimulants at different doses or regimens for at least one month in adults and children with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Review authors independently extracted data and assessed risk of bias of the included trials. We used the GRADE approach to assess the certainty of the evidence and performed meta-analyses.

MAIN RESULTS

We included four trials (70 participants) comparing appetite stimulants (cyproheptadine hydrochloride and megestrol acetate) to placebo; the numbers of adults or children within each trial were not always reported. We assessed the certainty of evidence as low due to the small number of participants, incomplete or selective outcome reporting, and unclear risk of selection bias.  Regarding our primary outcomes, a meta-analysis of two trials (42 participants) showed that appetite stimulants may produce a larger increase in weight (kg) at three months (mean difference (MD) 1.25 kg, 95% confidence interval (Cl) 0.45 to 2.05), and one trial (17 participants) showed a similar result at six months (MD 3.80 kg, 95% CI 1.27 to 6.33) (both low-certainty evidence). Results also showed that weight z score may increase with appetite stimulants compared to placebo at three months (MD 0.61, 95% CI 0.29 to 0.93; 3 studies; 40 participants; P < 0.001) and at six months (MD 0.74, 95% CI 0.26 to 1.22; 1 trial; 17 participants). There was no evidence of a difference in effect between cyproheptadine hydrochloride and megestrol acetate for either outcome.   Only one trial (25 participants) reported analysable data for body composition (BMI), with results favouring cyproheptadine hydrochloride compared to placebo; a further trial (16 participants) narratively agreed with this result. All four trials reported on lung function at durations ranging from two to nine months. Considering analysable data, two trials (42 participants) found that appetite stimulants may make little or no difference in forced expiratory volume at one second (FEV1) % predicted at three months, and one trial (17 participants) found similar results at six months. Two further three-month trials narratively agreed with these results. Limited information was reported for secondary outcomes. Two trials (23 participants) reported results showing that appetite stimulants may increase appetite compared to placebo at three months (odds ratio 45.25, 95% CI 3.57 to 573.33; low-certainty evidence).  Only one study reported on quality of life, finding that cyproheptadine reduced fatigue in two participants compared with none with placebo. One study (25 participants) found no difference in energy intake between appetite stimulant or placebo at three months. Insufficient reporting of adverse effects prevented a full determination of their impact. Two studies (33 participants) narratively reported similar requirements for additional antibiotics between appetite stimulants and placebo at three months.  AUTHORS' CONCLUSIONS: At six months in adults and children, appetite stimulants improved only two of the outcomes of this review: weight (or weight z score) and subjectively reported appetite. Insufficient reporting of side effects prevented a full determination 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 low-certainty evidence from a small number of trials, therefore firm conclusions cannot be drawn. Clinicians need to be aware of the potential adverse effects of appetite stimulants and actively monitor any individuals prescribed these medications accordingly. Research is required to determine meaningful surrogate measures for appetite and to 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.

Efficacy and Tolerability of Cyproheptadine in Poor Appetite: A Multicenter, Randomized, Double-blind, Placebo-controlled Study

PURPOSE

Cyproheptadine, an antihistamine and antiserotonergic agent, is an appetite stimulant that is efficacious in promoting weight gain in children and adults with poor appetite. Despite numerous studies showing that cyproheptadine achieved positive outcomes, studies documenting its effectiveness on appetite are limited. This study evaluated the efficacy and tolerability of cyproheptadine in adults with poor appetite in South Korea.

METHODS

Patients aged 19 to 64 years with poor appetite were randomly assigned to receive either cyproheptadine or placebo for 8 weeks. The primary end point was the difference between the groups in change in appetite, as measured by the Korean version of the Edmonton Symptom Assessment System from the beginning to the end of the study period. The secondary end points included effects on weight, anthropometrics, body composition, Simplified Nutritional Appetite Questionnaire-measured appetite, and toxicities. A total of 375 patients were randomly assigned to the two groups (189 cyproheptadine, 186 placebo).

FINDINGS

The cyproheptadine group experienced a mean (SD) change in appetite score of -2.42 (0.12) compared with -2.03 (0.13) in the placebo arm, representing a statistically significant appetite gain in the cyproheptadine group (difference, +0.38 [0.18]; 95% CI, -0.73 to -0.04; P = 0.0307). Patients in the cyproheptadine group experienced significant increases in weight and body mass index. The most common adverse event was somnolence, as predicted. Cyproheptadine was well tolerated, with one serious adverse event (colitis) which was classified as a moderate adverse effect unlikely to be related to the study drug.

IMPLICATIONS

We present the largest randomized, double-blind, placebo-controlled clinical trial of cyproheptadine versus placebo in healthy adults with poor appetite using the lowest effective dosage of cyproheptadine. Cyproheptadine is a safe treatment option in patients with poor appetite. Our findings provide important information for the use of cyproheptadine to ameliorate poor appetite in adults. Further randomized studies focused on the effect of cyproheptadine in older populations are needed.

Cyproheptadine as an appetite stimulant in children with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is a multi-organ genetically inherited disease that leads to progressive lung disease and nutrient malabsorption. The aim of this study was to assess the effectiveness of cyproheptadine (CH) (Periactin®) as an appetite stimulant on improving the nutrition status of paediatric patients with CF.

METHODS

We conducted a retrospective study of 15 patients with a suboptimal nutrition status prescribed CH for ≥12 months from 2013 to 2018. Change in Body Mass Index (BMI) z-score and lung function before vs. after treatment with CH were measured as well as dose-response relationship.

RESULTS

The mean change in BMI z-score over 12 months of treatment with CH was +0.91 compared to -0.52 in the previous 12 months (p∗∗∗ = 0.0002). There was also a trend towards an improvement in lung function over the 12 months of CH treatment compared to the 12 months prior (+2.79 vs -6.2% (p = 0.07)). No dose-response relationship was observed.

CONCLUSION

These results suggest that CH is effective at improving the nutrition status of paediatric CF patients with suboptimal nutrition.

Safety of Cyproheptadine, an Orexigenic Drug. Analysis of the French National Pharmacovigilance Data-Base and Systematic Review

Objectives: Cyproheptadine is a first-generation H1-antihistamine drug first that was distributed in the 1960s. While its orexigenic effect was observed early, cyproheptadine is not yet authorized for this indication in all countries today. There is an increasing medical interest and demand for the orexigenic effect of cyproheptadine, especially in children with poor appetite. As cyproheptadine might be evaluated in future clinical trials, we wanted to assess its safety profile. Methods: Using the French national pharmacovigilance database, we retrospectively analyzed all pediatric and adult reports of adverse effects of cyproheptadine recorded since its first distribution in France. Next, we performed a systematic review of the literature of cyproheptadine adverse effects. Results: Since 1985, 93 adverse effects were reported in the French pharmacovigilance database (adults 81.7%, children 18.3%); these were mainly neurological symptoms (n = 38, adults 71%, children 28.9%), and hepatic complications (n = 15, adults 86.7%, children 13.3%). In the literature, the most frequent adverse effect reported was drowsiness in adults or children, and five case reports noted liver complications in adults. We estimated the frequency of hepatic adverse effects at 0.27 to 1.4/1000, regardless of age. Conclusion: Cyproheptadine can be considered a safe drug. Mild neurological effects appear to be frequent, and hepatotoxicity is uncommon to rare. Randomized controlled trials are needed to evaluate the safety and efficacy of cyproheptadine before authorization for appetite stimulation, especially in young children as studies at this age are lacking. Possible hepatic complications should be monitored, as very rare cases of liver failure have been reported.

Preventive effect of cyproheptadine on sleep and appetite disorders induced by methylphenidate: an exploratory randomised, double-blinded, placebo-controlled clinical trial

OBJECTIVES

Insomnia and loss of appetite are the most common side effects of methylphenidate in patients with attention deficit/hyperactivity disorder (ADHD). The adverse effects may limit optimal dosing and patients' compliance with treatment leading to the discontinuation of treatment. This research evaluates the preventive effects of cyproheptadine on sleeping and appetite disorders induced by methylphenidate in ADHD children.

METHODS

During this exploratory, randomised, double-blinded, placebo-controlled clinical trial, forty patients with ADHD diagnosis who had received methylphenidate randomly were assigned to participate in the cyproheptadine or the placebo group. Patients' weight and Pittsburgh Sleep Quality Index (PSQI) score were recorded at baseline, after four, six and eight weeks of treatment. The ADHD Parent Rating Scale-V score was also defined at the beginning and the end of study for each patient.

RESULTS

There was no significant difference between the cyproheptadine and the placebo groups regarding their weight, rate of growth and PSQI score in the monthly assessment. In addition, there was no significant difference in response to the therapy between the two groups.

CONCLUSIONS

Based on our findings, cyproheptadine does not have any considerable preventive effect on sleeping and appetite disorders induced by methylphenidate in ADHD children.

A novel treatment for height growth in patients with growth hormone insensitivity syndrome by cyproheptadine hydrochloride

BACKGROUND

Cyproheptadine HCl (CyproH) is an appetite-stimulating drug and while it was prescribed for a patient with growth hormone insensitivity syndrome (GHIS) for increasing appetite, his height growth was surprisingly increased. Therefore, the aim of this study was to investigate the effect of CyproH on growth parameters of the patients with GHIS.

PATIENTS AND DESIGN

Twenty patients were enrolled in two prospective cohorts at two different times. Fifteen cases were observed for 1.17 ± 1.3 years without treatment (observation period, OP). Then, CyproH was administered for 2.2 ± 2.7 years (treatment period, TP), and growth parameters were compared within these two periods. Five patients who did not receive any treatment for 1-8.24 years (4 ± 2.9) were the control group.

RESULTS

Height velocity (HV) increased from 1.88 ± 0.7 to 6.1 ± 0.8 cm/year and HV-SDS reached from -4.5 ± 0.74 to -0.21 ± 1.2 in OP and TP, respectively (P < .001), whereas HV and HV-SDS were 2.2 ± 1.1 cm/yr and -4.2 ± 1.2, respectively, in controls (P < .001). Height SDS was -7.0 ± 1.7 and increased to -6 ± 2.2 after treatment (P = .002). Gain in height was 2.3 ± 0.6 SDS in 5 patients who were treated for 5.4 ± 2.8 years. BMI-SDS was not significantly changed within two time periods and also in cases and controls.

CONCLUSION

CyproH caused height growth in the patients with GHIS, and therefore, this treatment can be considered as an alternative option to IGF-I injection.

Effect of Cyproheptadine on Weight and Growth Velocity in Children With Silver-Russell Syndrome

OBJECTIVES

Nutritional management of children with Silver-Russell syndrome (SRS) is crucial, especially before initiating growth hormone therapy. Since cyproheptadine (CYP) has been reported to be orexigenic, we retrospectively investigated the effects of CYP on changes in weight and height in patients with SRS.

METHODS

Anthropometric parameters (weight [W], length or height [H], weight on expected weight for height [W/H], and body mass index) were recorded for 34 children with SRS receiving CYP. We specifically analyzed the anthropometric parameters (expressed in median) in a group of 23 patients treated with CYP at baseline (M0-CYP) and every 3 months (M3 to M12-CYP) after the initiation of CYP treatment.

RESULTS

The 23 children with SRS treated by CYP only had weight stagnation during the months preceding the start of treatment. Anthropometric parameters, especially the weight, differed significantly between M0-CYP and all other times (M3, M6, M9, M12-CYP). After 1 year of treatment, a gain in overall length/height and weight was observed (W: +1.1 standard deviations from the mean [SDS]; H: +0.5 SDS). At M3, significant improvements in W/H (74.9% vs 79.3% [P = 0.01]) and body mass index (-3.4 vs -2.4 SDS [P = 0.001]) were also observed. Twenty-one patients (91%) improved their weight by at least +0.5 SDS, and 12 (52%) by at least +1 SDS.

CONCLUSIONS

Our results show that CYP can be effective in patients with SRS with significant improvements in growth velocity and nutritional status before initiation of growth hormone therapy. Further prospective studies are required to confirm these results.

Diagnosis and management of Silver-Russell syndrome: first international consensus statement

This Consensus Statement summarizes recommendations for clinical diagnosis, investigation and management of patients with Silver-Russell syndrome (SRS), an imprinting disorder that causes prenatal and postnatal growth retardation. Considerable overlap exists between the care of individuals born small for gestational age and those with SRS. However, many specific management issues exist and evidence from controlled trials remains limited. SRS is primarily a clinical diagnosis; however, molecular testing enables confirmation of the clinical diagnosis and defines the subtype. A 'normal' result from a molecular test does not exclude the diagnosis of SRS. The management of children with SRS requires an experienced, multidisciplinary approach. Specific issues include growth failure, severe feeding difficulties, gastrointestinal problems, hypoglycaemia, body asymmetry, scoliosis, motor and speech delay and psychosocial challenges. An early emphasis on adequate nutritional status is important, with awareness that rapid postnatal weight gain might lead to subsequent increased risk of metabolic disorders. The benefits of treating patients with SRS with growth hormone include improved body composition, motor development and appetite, reduced risk of hypoglycaemia and increased height. Clinicians should be aware of possible premature adrenarche, fairly early and rapid central puberty and insulin resistance. Treatment with gonadotropin-releasing hormone analogues can delay progression of central puberty and preserve adult height potential. Long-term follow up is essential to determine the natural history and optimal management in adulthood.

Quality of Reporting Nutritional Randomized Controlled Trials in Patients With Cystic Fibrosis

OBJECTIVE

Randomized controlled trials (RCTs) have a major role in the making of evidence-based guidelines. The aim of the present study was to critically appraise the RCTs that addressed nutritional interventions in patients with cystic fibrosis.

METHODS

Embase, PubMed, and the Cochrane Library were systematically searched until July 2015. Methodology and reporting of nutritional RCTs were evaluated by the Consolidated Standards of Reporting Trials (CONSORT) checklist and additional dimensions relevant to patients with CF.

RESULTS

Fifty-one RCTs were included. Full details on methods were provided in a minority of studies. The mean duration of intervention was <6 months. 56.9% of the RCTs did not define a primary outcome; 70.6% of studies did not provide details on sample size calculation; and only 31.4% reported on the subgroup or separated between important subgroups.

CONCLUSIONS

The examined RCTs were characterized by a weak methodology, a small number of patients with no sample size calculations, a relatively short intervention, and many times did not examine the outcomes that are important to the patient. Improvement over the years has been minor.

ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis

BACKGROUND

Malnutrition is both a frequent feature and a comorbidity of cystic fibrosis (CF), with nutritional status strongly associated with pulmonary function and survival. Nutritional management is therefore standard of care in CF patients. ESPEN, ESPGHAN and ECFS recommended guidelines to cover nutritional management of patients with CF.

METHODS

The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for determining grades of evidence and strength of recommendation. Statements were discussed, submitted to Delphi rounds, reviewed by ESPGHAN and ECFS and accepted in an online survey among ESPEN members.

RESULTS

The Working Group recommends that initiation of nutritional management should begin as early as possible after diagnosis, with subsequent regular follow up and patient/family education. Exclusive breast feeding is recommended but if not possible a regular formula is to be used. Energy intake should be adapted to achieve normal weight and height for age. When indicated, pancreatic enzyme and fat soluble vitamin treatment should be introduced early and monitored regularly. Pancreatic sufficient patients should have an annual assessment including fecal pancreatic elastase measurement. Sodium supplementation is recommended and a urinary sodium:creatinine ratio should be measured, corresponding to the fractional excretion of sodium. If iron deficiency is suspected, the underlying inflammation should be addressed. Glucose tolerance testing should be introduced at 10 years of age. Bone mineral density examination should be performed from age 8-10 years. Oral nutritional supplements followed by polymeric enteral tube feeding are recommended when growth or nutritional status is impaired. Zinc supplementation may be considered according to the clinical situation. Further studies are required before essential fatty acids, anti-osteoporotic agents, growth hormone, appetite stimulants and probiotics can be recommended.

CONCLUSION

Nutritional care and support should be an integral part of management of CF. Obtaining a normal growth pattern in children and maintaining an adequate nutritional status in adults are major goals of multidisciplinary cystic fibrosis centers.

The misuse of Cyproheptadine: a non-communicable disease risk behaviour in Kinshasa population, Democratic Republic of Congo

Background

Obesity is one of the main risk factors of non-communicable diseases (NCDs) worldwide, especially in sub-Saharan Africa. The use of Cyproheptadine increases body weight and the risk of becoming obese. The aim of this study is to determine the prevalence of Cyproheptadine misuse in the Kinshasa population and to describe its characteristics.

Methods

A cross-sectional study was conducted in two town sectors of Kinshasa, Democratic Republic of Congo (DRC), over a 4 month period (May 2011 to August 2011). Data from 499 participants, aged between 13 and 55 years were collected and analyzed. Mean and standard deviation were used for quantitative variables and frequency and percentage for categorical variables. In order to determine the relationship between socio-demographic status and Cyproheptadine use the Chi-square test was conducted. Student’s t-test was used to compare means age of Cyproheptadine users and non-users. Logistic regression was used to determine predictors of Cyproheptadine use. A p-value of <0.05 was considered statistically significant.

Results

Overall, 499 participants were enrolled (352 females, 147 males, mean age ± standard deviation 24.9 ± 9.7 years) in the study. The majority of the study participants (72.9 %) had used Cyproheptadine as an appetite stimulant. Females were 11 times more likely to use Cryproheptadine (OR = 11.9; 95 % CI: 7.1–20.1) than males. People aged between 36 and 55 were three times less likely to use Cryproheptadine (OR = 0.3; 95 % CI: 0.2–0.8) compared to teenagers. More than half of the participants (69.0 %) declared to take daily Cyproheptadine. Half of the study participants (50.0 %) used Cyproheptadine for more than a year and also declared to combine it with Dexamethasone (87.6 %).

Conclusion

This study shows that the Kinshasa population is significantly misusing Cyproheptadine and is highly exposed to its risk, including obesity.

Use of growth charts in Canada: A National Canadian Paediatric Surveillance Program survey

BACKGROUND

In 2010, the WHO Growth Charts for Canada were recommended for use in Canada, while the US Centers for Disease Control and Prevention (Georgia, USA) charts remained in active use.

OBJECTIVE

To assess the availability, utilization of and satisfaction with growth charts in clinical practice in Canada.

METHODS

In October 2012, a one-time survey was sent through the Canadian Paediatric Surveillance Program (CPSP) to 2544 paediatricians and 280 family physicians with a stated interest in paediatrics.

RESULTS

The response rate was 24% (63% general paediatricians, 36% subspecialists, 1% family physicians). Of these respondents, 68% preferred the WHO charts for infants and 49% for children and youth. Regarding the WHO charts, 49.7% of respondents reported concerns with their inability to assess weight for children >10 years of age, and many believed that there were too few percentile lines between the third and 97th percentiles for infant (24%) and for child and youth measures (19%). The addition of extreme percentiles (0.1 and 99.9), shading on charts and lack of availability with electronic medical record providers were other concerns mentioned by 10% to 13% of respondents.

CONCLUSION

There is support for the use of the WHO data for monitoring the growth of Canadian children. Concerns regarding the design of the charts were raised. These survey results lend support to the redesign of the WHO Growth Charts for Canada, as was recently completed in 2014.

Use of cyproheptadine in young children with feeding difficulties and poor growth in a pediatric feeding program

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.

Appetite stimulants for people with cystic fibrosis

BACKGROUND

Chronic loss of appetite in cystic fibrosis concerns both individuals and families. Appetite stimulants have been used to help cystic fibrosis patients with chronic anorexia attain optimal body mass index and nutritional status. However, these may have adverse effects on clinical status.

OBJECTIVES

The aim of this review is to systematically search for and evaluate evidence on the beneficial effects of appetite stimulants in the management of CF-related anorexia and synthesize reports of any side-effects.

SEARCH METHODS

Trials were identified by searching the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, MEDLINE, Embase, CINAHL, handsearching reference lists and contacting local and international experts.Last search of online databases: 01 April 2014.Last search of the Cystic Fibrosis Trials Register: 08 April 2014.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of appetite stimulants, compared to placebo or no treatment for at least one month in adults and children with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Authors independently extracted data and assessed the risk of bias within eligible trials. Meta-analyses were performed.

MAIN RESULTS

Three trials (total of 47 recruited patients) comparing appetite stimulants (cyproheptadine hydrochloride and megesterol acetate) to placebo were included; the numbers of adults or children within each trial were not always reported. The risk of bias of the included trials was graded as moderate.A meta-analysis of all three trials showed appetite stimulants produced a larger increase in weight z score at three months compared to placebo, mean difference 0.61 (95% confidence interval 0.29 to 0.93) (P < 0.001) (n = 40) with no evidence of a difference in effect between two different appetite stimulants. One of these trials also reported a significant weight increase with megesterol acetate compared to placebo at six months (n = 17). The three trials reported no significant differences in forced expiratory volume at one second (per cent predicted) between the appetite stimulant groups and placebo at follow up, with durations ranging from two to nine months. A meta-analysis of two trials showed a significantly higher proportion of patients reporting increased appetite, odds ratio 45.25 (95% confidence interval 3.57 to 573.33) (P = 0.003) (n = 23), but the frequency of reported side effects was undetermined.

AUTHORS' CONCLUSIONS

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.

Extending World Health Organization weight-for-age reference curves to older children

BACKGROUND

For ages 5-19 years, the World Health Organization (WHO) publishes reference charts based on 'core data' from the US National Center for Health Statistics (NCHS), collected from 1963-75 on 22,917 US children. To promote the use of body mass index in older children, weight-for-age was omitted after age 10. Health providers have subsequently expressed concerns about this omission and the selection of centiles. We therefore sought to extend weight-for-age reference curves from 10 to 19 years by applying WHO exclusion criteria and curve fitting methods to the core NCHS data and to revise the choice of displayed centiles.

METHODS

WHO analysts first excluded ~ 3% of their reference population in order to achieve a "non-obese sample with equal height". Based on these exclusion criteria, 314 girls and 304 boys were first omitted for 'unhealthy' weights-for-height. By applying WHO global deviance and information criteria, optimal Box-Cox power exponential models were used to fit smoothed weight-for-age centiles. Bootstrap resampling was used to assess the precision of centile estimates. For all charts, additional centiles were included in the healthy range (3 to 97%), and the more extreme WHO centiles 0.1 and 99.9% were dropped.

RESULTS

In addition to weight-for-age beyond 10 years, our charts provide more granularity in the centiles in the healthy range -2 to +2 SD (3-97%). For both weight and BMI, the bootstrap confidence intervals for the 99.9th centile were at least an order of magnitude wider than the corresponding 50th centile values.

CONCLUSIONS

These charts complement existing WHO charts by allowing weight-for-age to be plotted concurrently with height in older children. All modifications followed strict WHO methodology and utilized the same core data from the US NCHS. The additional centiles permit a more precise assessment of normal growth and earlier detection of aberrant growth as it crosses centiles. Elimination of extreme centiles reduces the risk of misclassification. A complete set of charts is available at the CPEG web site (http://cpeg-gcep.net).

Antisecretory effect of prescribed appetite stimulator drug cyproheptadine in rat intestine

Cyproheptadine (Cph) is an antiserotoninergic and antihistaminergic agent with alpha-blocking activity and central sedative effect. Cph has been found to be effective in stimulating appetite, but to our knowledge, its direct effects on the intestine have not been documented. We aimed to assess the antisecretory effects of Cph in rat proximal colon using Ussing chambers' technique. In basal and serotonin (5-HT)-stimulated conditions, Cph induced a dose-dependent reduction in short-circuit current (Isc). This effect was different in fed vs. fasted rats (EC50 = 1.9 × 10(-5 ) m and 4.9 × 10(-5 ) m, respectively). As expected, Cph induced a marked dose-dependent rightward shift of the concentration-response curve to 5-HT (pA2 = 5.4). The effect of Cph was found to be close to that of antisecretory agents in the following sequence: peptide YY > somatostatin > clonidine > Cph > C7-sorbin. To our knowledge, this is the first demonstration that Cph has a direct effect on the inhibition of electrogenic ionic secretion in intestinal epithelium in vitro. Our results indicate that Cph can modulate the intestinal transport of electrolytes and provide a new insight into the peripheral effects of this drug, which is frequently prescribed as appetite stimulator in developing countries.

Cyproheptadine for prevention of neuropsychiatric adverse effects of efavirenz: a randomized clinical trial

Cyproheptadine prevention of the neuropsychiatric adverse effects of an antiretroviral regimen including efavirenz has been evaluated in a randomized clinical trial. Twenty-five patients (16 males and 9 females with mean±SD ages of 36±9 years) in a cyproheptadine group, and 26 patients (17 males and 9 females with mean±SD ages of 34±7 years) in a control group completed the trial. Sexual contact and injection drug use were the main routs of HIV infection in both groups. The patients' neuropsychiatric adverse effects were evaluated based on the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Positive and Negative Syndrome Scale, Beck Depression Scale, Pittsburgh Sleep Quality Inventory, Positive and Negative Suicide Ideation, and Somatization Subscale of Symptom Checklist 90 at baseline and 4 weeks after treatment. Cyproheptadine significantly decreased the scores of Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Positive and Negative Syndrome Scale, Beck Depression Scale, Pittsburgh Sleep Quality Inventory, Positive and Negative Suicide Ideation of the patients after 4 weeks in comparison with control group. All of the scores increased in control group following antiretroviral therapy. Although short duration of the patients' follow-up was a major limitation of the study, the results of the study showed that cyprohepradine is effective in prevention of depression, anxiety, hallucination, aggressive behaviors, emotional withdrawal, poor rapport, poor impulse control, active social avoidance, suicidal ideation, and improved sleep quality of HIV-positive patients after initiation of antiretroviral therapy including efavirenz.