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Introduction 

Certain medications (especially stimulant medications for attention deficit hyperactivity disorder) can reduce appetite.

How Common is It?

About one-third of adult and pediatric patients report reduced appetite with stimulant medications. Typically, those taking stimulants in the morning have a low appetite during the daytime. Then as the medication wears off later in the day, their appetite returns.  In many people, this effect is temporary and/or is not very significant. In some cases, this may be a good thing. In other cases, the loss of appetite can be a problem that causes dehydration and weight loss. The good news is that there are things that can be done to deal with this.

Assessment / History for Healthcare Providers

Do relevant history in order to rule out other comorbid issues.

Comorbid / Differential Diagnoses (DDx) for Low Appetite

GI conditions such as

• Intolerances such as dairy, gluten, celiac or others.
• Irritable bowel syndrome (IBS).

Avoidant/restrictive food intake disorder (ARFID)

• Is the person’s low intake not due to fears of gaining weight but rather to problems with the actual physical act of eating or ingesting food?
• What are the symptoms or barriers that prevent the person from eating? E.g. feeling nauseous?
• Sensory issues such as problems with food textures? Sensitivity to smells?

“Picky eater”

• Is the person a “picky eater”? How picky?

Oromotor issues

• Do they have trouble with eating due to oromotor issues? Is there a tongue thrust or “reverse or immature swallow” where they push their tongue forward between upper and lower teeth when they swallow?

Eating disorder/ body image issues

• How does the person feel about their weight? Are they afraid of gaining weight?
• Do they feel that they are fat or overweight?

Management: Address Treatable Comorbid or Differential Diagnoses

Is there a dietary intolerance such as dairy, gluten, or celiac?

• Restrict dietary triggers from diet and see if there is an improvement.
• Refer to specialists such as gastroenterology.

Are there concerns about ARFID or picky eating?

• Options include
  • Clinics specializing in ARFID or “picky eating” in some areas, otherwise pediatrician or gastroenterologist.
  • Some speech/language pathologists (SLP) or occupational therapists (OT) have specialized expertise.

Are there concerns about oromotor issues?

• If so, consider SLP or OT.

Are there concerns about body image and eating disorders?

• Consider referral to mental health or eating disorders services.

Physical Exam

Physical exam can help rule out underlying medical causes of low appetite or significant sequelae of poor intake.

Investigations

Do a growth chart of height and weight to help monitor growth over time.

Vitals

Do postural vitals to rule out problems with dehydration or undernutrition, such as:

• Sitting BP and HR
• Standing BP and HR at 1-min, 5-min and 10-min.

Management

Are the problems mild?

• Is the ADHD medication felt to be helpful? It can be extremely difficult to find medications that work, and sometimes parents would prefer to continue the medication while trying other strategies to address the low appetite.

Is it possible to wait things out?

• Many patients report their appetite improves after they have been on their stimulant medication for at least a couple of months (Silver, 2019)

Start with guidance for parents and caregivers -- see next section.

Management: Guidance for Caregivers/Patients

Consider reviewing the following strategies with parents, which are summarized in this handout that can be given to families.

Food Advice: When to Eat?

Have regular meal times, such as 8 AM, 12 PM, 5 PM.

Have 2-3 snack times, such as between meals, such as 10 AM, 2-3 PM, 7-8 PM. In this way, your child can have something every 2-3 hrs. Avoid snacks right after an unfinished meal, as it encourages them to skip their meal and just have snacks.

Food Advice: What to Eat?

Offer foods that are high-calorie and healthy at the same time.

For an adult trying to lose weight, we might offer low-calorie foods (e.g. rice cakes, low-fat milk or yogurt) or high-fibre vegetables (e.g. celery sticks, etc.)

For a child trying to gain weight, we will instead want higher calorie foods (yet still healthy) such as whole-grain breads, high calorie vegetables such as sweet potatoes, etc. We can serve celery and carrots, but either serve them raw with a high-calorie dip such as mayonnaise or simply cook the celery and carrots in a soup to make them easier to digest.

Examples of healthy, high-calorie foods:

• Whole milk (rather than skim milk).
• High fat yogurt
• Cheese
• At snack time, consider salty snacks (e.g. salted nuts which are high calorie) which will make your child thirsty, then give them whole milk (as opposed to juice).

Do the classic culinary trick of adding butter, gravy, and grated cheese to food.

What about junk food and sweets?

• Do try to avoid junk food (e.g. chocolate bars, processed junk foods) as this runs the risk of setting up unhealthy dietary habits in the long run.

Food Advice: How to Eat?

At mealtimes, give your child food first and any drinks later. Drinks will fill up your child’s stomach but have less calories.

Serve food in a way that it is easier to handle.

• Are you serving a sandwich? Cut it up into “finger food” portions or “hors-d’oeuvres” sized pieces.
• Are you serving a carrot? Cut up the carrot to make it easier to eat while having it with dip.

Is your ADHD child hyperactive at the meal table? Do they have trouble sitting still at the table? Do they need to shake their legs?

• If so, consider giving the child opportunities to move (as opposed to telling them to sit still). Allow them to move or fidget. Consider the ‘mobility seating’ options such as wedge cushions. Let them stand at the table. Ask them to fetch things for people, or do other helpful things.

What about eating in front of the TV while distracted?

• On one hand, some people would argue against “mindless” eating. On the other hand, if you have tried other strategies and nothing else works, then consider it.

Don’t get into stressful conflicts about eating. Is your child getting upset or stressed out about eating?

• Try to give them time and space to calm down. Instead of giving them a command, “You have to eat”, try making a less pressuring comment, e.g. “Food is ready! It's always so much more delicious when its warm.”

Don’t punish by denying them food.

Sample Schedule / Meal Strategy for Child with Low Appetite from ADHD Medication

Morning		Breakfast (before medication) Examples: ● Eggs, bacon, sausage, potatoes. ● High-fat yogurt (rather than low fat yogurt). ● High calorie granola. Refusing to eat solid foods? ● Consider liquid breakfast (such as homemade smoothies; Breakfast Carnation Drink, Boost, etc.).
		Medication (after breakfast)
Snack		Healthy snack at school Yogurt, granola bar, etc.
Lunch		Serving a sandwich? Cut a standard sandwich bread into 4 pieces to make it seem smaller and less effort to eat. Ask the school to help monitor if lunch is being eaten, and encourage your child to eat before going out.
After school snack		Healthy snack after school
Dinnertime
After dinner snack		Does your child get hungry after the medication wears off later in the evening? Many parents report their child may have a “second supper” after the medication wears off. Accept that you may need to reheat dinner for them at this time; or simply eat like many Europeans do, with a later 7-8 PM dinner.

Management Strategies: Medication

Are the problems moderate to severe and have non-medication strategies already been tried?

Medication strategies

• Consider a drug holiday which is a period of time taking a break from the stimulant medication. Examples include;
• Not taking medications on weekends.
• Not taking medications during holiday periods, such as summer holidays.

Still struggling despite other interventions? Try the following:

• Switch from amphetamine to methylphenidate or vice versa (Dodson, 2005), or
• Add the antihistamine cyproheptadine, 4 mg, with morning and evening meals (Dodson, 2005), or
  
• Add mirtazapine, one-half of a 15-mg tablet at bedtime to stimulate appetite and initiate sleep (Dodson, 2005).
  

Are there severe behavioural problems or sleep problems?

• If so, consider antipsychotics that can increase appetite such as
  • Olanzapine
  • Risperidone

Where to Refer?

Are there still struggles with diet?

• Consider referral to a dietician.

Family Handout

Managing Medication Side Effects - Managing Low Appetite: Information for Caregivers

https://docs.google.com/document/d/1lxdg8Ft68Nkf7RZP3xZnEGfzsqz0q46iLqmj50NgCbk/edit#

References

Silver, L. 2019. Does ADHD Medication Make Every Meal a Power Struggle?, accessed Jan 5, 2020,

https://www.additudemag.com/does-adhd-medication-make-every-meal-a-power-struggle/

About this Document

Written by the health professionals at CHEO and the University of Ottawa.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from an accredited Continuing Medical Education (CME) provider.

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