Decreased Appetite in Children
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Show notes:
Context is key for the pediatric patient with decreased appetite. Getting a sense of what is normal for the patient and their overall health goes a long way in deciding how to approach the visit. Doing this can be tricky if you’re not sure what to ask first or the big things that you don’t want to miss.
Diagnosing Decreased Appetite in Children
This week, let’s talk about where to start when you see these patients, and how to get the context that is so essential for these visits.
✅ What to know about the patient before you even walk into the exam room
✅ When to ask broad questions, when to ask targeted questions – and why
✅ Which body systems you must assess
✅ Considering the behavioral and social context
✅ The use of medication for children with decreased appetite
✅ Red flags and worst-case scenarios
Decreased appetite can seem like a scary chief complaint for a pediatric patient, but it doesn’t have to be. A good handle on what is normal, what is urgent, and when to send these patients to a specialist, will take a lot of the pressure off and increase your confidence in the visit.
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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In this week's episode, I'm going to be talking about decreased appetite in children.
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The most common scenario that happens is that a parent or a caregiver will bring in
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a child for a visit because they're really concerned about their weight.
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They're concerned that they're quote unquote too skinny or they're not gaining enough
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weight or they're losing weight or they're having these erratic eating behaviors that
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they're very concerned about.
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They also usually lead with, I need an appetite stimulant for my child.
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That's the general approach to this video, is that type of chief complaint.
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The disclaimer I want to add is that when you have younger children like infants or
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under two or three, you just want to tread lightly.
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You still want to think about these things.
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I mean, infants are a little bit of a totally unique situation because they're bottle
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feeding, et cetera, but generally, same rule applies, but I'm primarily talking
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about kind of more school-aged children.
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So if you have an infant or younger child that is having this difficulty, I just tread
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lightly the younger they are and I get more assistance the younger they are.
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That's my own personal comfort level.
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So I want to talk about decreased appetite in children, though.
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So the general approach that I'm taking is that number one, I want to assess is
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this like I want to get some more information.
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I want to look at the data.
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I want to look at their actual weight patterns over time.
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I want to ask about their behavioral eating patterns and physical symptoms that they
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are having.
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Like, is this an organic thing?
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Is this a behavioral thing?
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Or the other piece is that could it just be normal?
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So just spoiler alert, a lot of the time this happens to me in primary care,
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what we'll do is we'll look at the child's actual weight today and look at the
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And in fact, it's just normal for that kid.
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And their eating patterns and disclaimer, if you don't have any children in your
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life, there are eating days and not eating days.
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Like, this is such a pattern that I've seen in the children my life and also in
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just clinical practice is that some days they'll just like pick at food and have
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like little bits.
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And then the next day they'll eat like a ton.
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That's what we call it in my household is eating days and not eating days.
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But but that's a normal pattern.
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And so that's like majority of visits.
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We end up having that conversation about like, let's look at this.
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This is normal.
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Let's have a conversation about this.
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Right.
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But anyway, let's get into the assessment.
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So when you start those visits, you're always think I'm I always recommend
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starting with that red flag approach diagnosis of like, is there an again?
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Is there an organic process just in your mind?
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Right. Just thinking about that to start.
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Because if it looks if it appears that way, then you want to ask those
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questions. Right. But I'm going to I'm not going to approach that this episode
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that way. I'm going to start with like the general history questions and work
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through. Right. So what are the general history questions we want to ask?
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Obviously, we want to do that triage approach.
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Right. Just disclaimer there.
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If you have a, you know, a kid that's like having a hard time
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breathing and sweating and diaphoretic and all that stuff like, OK,
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that's a different route.
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But for the most part, we want to start with the general history of
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their eating.
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So we want to ask,
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we really like this is one of the pitfalls I had as a new nurse
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practitioner is that I would ask questions, but they were very general
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in their answers and it didn't really paint the full picture.
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I think because I was so concerned about the running of the visit
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and like the next steps of testing and evaluation that I was like,
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I just was too caught up.
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So I want to encourage you to be really specific in this.
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And I know it feels like it can take a lot of time.
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But when you ask specific questions and give options for answers,
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it really helps direct patients to like more smoothly
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get the information that you're looking for.
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So we want to ask just like, what's the picture?
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Like, tell me about your child's eating.
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How many times do they eat per day?
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What kinds of foods do they eat?
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Are they a picky eater?
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What foods do they not eat?
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Are there any foods that are specifically causing them to have symptoms
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aside from like the weight?
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What is like that pattern?
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Do they have that pattern of like picking a food all day one day
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and then eating a ton at every single meal the next?
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Are they watching TV when you are trying to feed them
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because they're so picky or just kind of like putting stuff
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in their mouth while they're watching TV
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versus you're all sitting together and it's like a calm thing?
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Is there like a power struggle happening?
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So the thing with kids is that they have very little control
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in their lives.
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So what they can control comes into their body
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and what comes out of their body, right?
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So they're going to hold onto their bowels,
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be constipated sometimes because that's a control thing
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versus they're not going to eat things
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because they have control over it, right?
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So we want to ask things about the portion sizes
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because there's a lot of education that comes in here too
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of like what is an appropriate portion size?
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It's a lot smaller than an adult's
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and it's a lot smaller than most of us will think.
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So that kind of ties into the behavior stuff.
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So we want to ask if there's like a,
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if there are in a non-judgmental way, right?
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Because it's hard being a caregiver.
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If you are not a caregiver yourself,
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just like imagine, just try to imagine what it would be like
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to take care of a little being
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and then multiply that potential perceived anxiety
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times like 10.
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I just think it was like way more intense
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than I ever expected now that I'm a parent.
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So just like, just always keep that
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in the front of your mind, right?
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But is there some sort of power struggle happening
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where they're like so worried,
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like this is typically what happens
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is that the parent is so worried
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that they're like forcing them to eat
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and then it creates this bigger backlash
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of they eat even less or they're more and more picky.
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And so there are some behavioral things
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that we can help parents with and caregivers rather,
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but just eliciting that information.
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That's like the general first kind of history
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to keep in mind, right?
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You get to change this order around.
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If you have somebody who has,
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who like on initial just physical view of the child,
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they look well, start with those questions.
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They look unwell,
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start with the organic questions, right?
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So that's the next part is asking,
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is there an organic etiology behind this weight?
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It's like one step back first, actually.
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The first thing you wanna kind of look at,
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even before I go in the room,
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I'm looking at their weight
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and I'm looking at the growth chart, right?
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Because right off the bat,
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if their growth chart is on the same path,
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it has not dropped off.
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And it's like, generally speaking, it's correlating.
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Way less to worry about.
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There's still something to worry about, right?
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If the parent's coming in,
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they're concerned and we have to lay that concern
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or intervene if we need to,
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but that's like your first assessment, right?
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So I probably should have said that first.
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But after you've assessed that,
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if they had that decline,
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we still wanna ask the initial history questions
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that I just mentioned,
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but we can kind of like maybe segue
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into those other organic questions first.
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Your choice, your choice, right?
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But so we're trying to figure out,
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is there an organic etiology?
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And there's a huge differential diagnosis list.
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I'm not gonna get into all of them,
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but I just wanna give you the general framework
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of what are the worst things that we're looking out for.
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So are we looking for some sort of increased
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metabolic demand?
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If there's actual true weight loss,
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like their growth chart is declining,
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do they have increased metabolic demands?
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Congenital cardiovascular disease, pulmonary disease,
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some congenital neurologic diseases?
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Are they having any difficulty
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with chewing, swallowing, talking?
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Do they need a speech, language,
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pathologist evaluation?
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Is there anything endocrine going on?
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Is there a risk for hyperthyroidism?
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Or signs of hyperthyroidism?
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Diabetes, type one diabetes,
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are they losing weight because of that?
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And then GI, of course.
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Those are kind of like the main general buckets.
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And GI can be a number of things.
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Whenever we have pediatrics,
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we've introduced the congenital,
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this applies to adults too,
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but we typically find the congenital diseases in kids
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more so than when we find them later in adults.
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So there's a whole host of congenital GI disturbances,
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celiac, some sort of food intolerance or allergy,
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things like that.
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So that's like the next place that you're gonna ask.
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And so keeping those general buckets in mind,
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you're going to pull out the ROS questions
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that are specific to those body systems, right?
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And that's like the initial kind of first pass, right?
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Cause it could be a pretty broad thing
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that is contributing to the child's weight loss.
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But in terms of primary care,
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especially if you're a family nurse practitioner
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and not in a pediatric specific office,
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let's just do like a triage assessment-based approach
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and then tag in our specialists as we need to.
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I don't know if this is national or regional.
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My impression is that with pediatrics specifically,
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like for example, with adults,
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when it comes to managing hypertension,
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I'm really gonna do my best
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to like do the full assessment,
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max out the medications and the doses
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before I send them to a specialist.
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However, for the most part in pediatrics
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throughout the clinics that I practiced in,
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there's a much sooner referral expectation for pediatrics.
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Right, so I mean, I'm jumbling topics here,
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but for example, like pediatric hypertension,
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most providers, pediatric or family,
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will refer those to a specialist
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and not manage them in-house.
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So that's just a thought.
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That might be regional though,
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that might be clinic dependent,
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but that seems to be the consensus with pediatrics
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is that we refer them to a specialist sooner.
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So yeah, we wanna ask all of those questions, right?
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So all the body systems, cardiovascular, pulmonary, GI,
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GU, whatever could potentially be contributing.
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If you're noted, I mean,
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I would ask those questions regardless,
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even if they're not presenting
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with those organic symptoms to start in the history
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because it's just thorough, it's just good practice.
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And once you've kind of figured those pieces out,
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you'll really have a place to go.
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Like is this, oh, sorry, I forgot to do,
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I forgot to mention,
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we always wanna assess in terms of like
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on that behavioral note and the power struggle potential,
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like what other psychosocial things could be going on,
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right, because is there,
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again, if a child wants to be in control,
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they're going to control what goes in their body
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or comes out of their body.
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And so if they can't control something at home,
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that might be contributing to the global picture,
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especially abdominal symptoms for kids.
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We always wanna be mindful of those other factors.
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We wanna be mindful of like, what are their resources?
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Does the family have enough resources to have,
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to provide food and healthy food options for the child?
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And then also that kind of ties in with behavioral stuff.
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Are there other behavioral components
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or psychological components
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that could be contributing to this eating pattern?
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And so that really, again,
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that just depends where you go from there.
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So if it's a GI,
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if you're leaning towards GI from your history,
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is there like a,
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there's usually a GI feeding team
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that's associated with children's hospitals.
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If you're in a rural setting,
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you may have to do some cold calling,
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especially if you're like three hours away
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from a major hospital, right?
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But, and that's what I've done.
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Even in a metropolitan area, major metropolitan area,
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I've placed phone calls to a GI feeding service
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because they have very long wait lists
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and it takes a long time to get in there.
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Are there other things I need to be looking at?
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And I also tag in my supervisor,
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collaborating physician, collaborating provider,
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when I need to,
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especially if it's like unclear.
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I really do, as a family nurse practitioner,
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I, personal philosophy of practice
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is that I really stick to the bread and butter
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of primary care pediatrics.
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And I get a little more expanded scope with the adults,
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but with the kids,
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I really stick with the bread and butter stuff.
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So yeah, so do you need to go to GI specialist,
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a pediatric feeding team,
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speech language pathology, nutrition, behavioral health,
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social worker for resources,
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any host of those things.
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And then there's, again,
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just reinforcement with the care givers,
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excuse me, with the caregivers and the patients.
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If nothing else is coming up in your assessment
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and it seems like it's a normal thing,
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education, reinforcement,
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you could even do a close follow-up.
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For patients that are either on the line
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or I'm not quite sure
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or the parents are really nervous,
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excuse me, caregivers,
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I keep saying parents, caregivers,
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you can check in with them in a month,
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every month for three months
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and chart their weight over time
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and then just see what happens.
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I guess I wanna add one other thing about the definition.
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So failure to thrive is a common term
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that was used before.
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It's not really used as much.
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There's kind of like a not really clear definition.
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It's just ambiguous.
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And even poor weight gain
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and trying to remember the other terms
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that I see more often now,
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those are a little bit ambiguous as well.
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And so if you have,
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it's just kind of like a general gist of your assessment
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and is their weight dropping off the chart, right?
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In terms of that growth line.
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And then the other area of potential concern
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is if their percentile is less than 2%
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on the growth chart.
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Those are patients you wanna be really concerned about
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and then the younger they are, the more concerned, right?
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So this is like a very triage-y kind of based video
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because it's very dependent
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on what you see in front of you.
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I guess one other disclaimer is that
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even if you have a patient
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with a low body mass percentile, weight percentile,
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I've had patients in the past
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where the entire family, they all come in
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and the entire family
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is probably in that same percentile too.
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So there aren't necessarily as hard and fast rules.
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Like I ended up doing some evaluations and some testing
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just thinking of a particular patient
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because I was like, I just wanna cross my T's
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and dot my I's because this child is like a little bit
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even lower on the percentile than the other family members
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because I took care of the whole family.
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But he was chilling.
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He was totally fine.
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I did my work up.
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I ended up referring him to GI just in case
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because there were some symptoms
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potentially going on with GI stuff.
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But he was chilling.
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So yeah, so hopefully this is a helpful video
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for assessing diagnostic approach
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to weight loss in children.
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I guess one thing I didn't address yet actually
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is about medications.
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So I basically never prescribe appetite stimulants.
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Personal philosophy of practice,
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not enough children in my practice
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and also my collaborating providers.
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Like culturally between all of the clinics
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that I've been at, like that is not like the norm.
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If you were in a pediatric practice,
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you may find that that is something that they do.
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So cyberheptadine for example,
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typically what we're doing is the same assessment,
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like complete full assessment.
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All of the questions that I've talked about,
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making sure there's absolutely no organic processes
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going on, there's no behavioral things going on.
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Potentially that is a short term intervention.
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But again, this is not something
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that I personally do in my practice
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in any of the clinics that I've worked in either.
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So again, I'm also a family of practice.
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So maybe that makes a difference.
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I don't know, maybe pediatrics are more comfortable.
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But yeah, hopefully this is a helpful video.
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If you have not already,
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00:16:02.610 --> 00:16:04.970
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00:16:12.770 --> 00:16:15.790
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00:16:15.890 --> 00:16:17.410
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00:16:17.630 --> 00:16:18.890
Hang in there and I'll see you soon.
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00:16:25.200 --> 00:16:26.800
That's our episode for today.
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00:16:26.920 --> 00:16:28.700
Thank you so much for listening.
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00:16:29.080 --> 00:16:31.420
Make sure you subscribe, leave a review
394
00:16:31.420 --> 00:16:33.320
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395
00:16:33.320 --> 00:16:36.280
so together we can help as many nurse practitioners
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00:16:36.280 --> 00:16:39.060
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00:16:39.060 --> 00:16:40.940
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398
00:16:40.940 --> 00:16:43.520
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00:16:50.680 --> 00:16:52.980
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00:16:53.180 --> 00:16:55.600
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404
00:16:55.600 --> 00:16:56.300
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405
00:16:56.720 --> 00:16:58.260
Thank you so much again for listening.
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00:16:58.480 --> 00:16:59.660
Take care and talk soon.
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