Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – treatment of underlying conditions

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1st line – 

treatment of underlying conditions

If an organic cause is identified, appropriate treatment is needed. For example, if the child has a history of protracted vomiting, diarrhoea, or fever, the underlying illness should be treated; if there is a history of parental depression, anxiety, or other mental health problems, a referral to a mental health provider may be needed; if there is suspected child neglect, a referral to Child Protective Services must be considered.

Clinicians should keep in mind, however, that organic problems (e.g., nutrient deficiencies) can result from faltering growth with a non-organic origin, and parent-child conflicts over mealtime stress can result from faltering growth due to an organic origin.

Problems should be addressed stepwise depending on the severity of the condition.

Plus – multidisciplinary support for parents and families

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Plus – 

multidisciplinary support for parents and families

Treatment recommended for ALL patients in selected patient group

Feeding support should be given if there is concern about faltering growth in the first weeks of life. In infants, this begins with a lactation consult for breastfeeding infants and additional formula supplementation when indicated, with the aim of increasing feeding volume and caloric density of formula or breast milk if needed, while still considering free water requirements.[1]​ In older infants and children nutritional supplements and fortified foods can be useful when it is not possible to meet needs for one or more nutrients.[24] In older infants this can be through the addition of powdered formula or oil.

In toddlers and children, the focus should be on increasing calories using calorically dense foods such as avocado, heavy cream, and peanut butter, but while avoiding low nutritional value foods such as sweet and fried foods. Children receiving oral nutritional supplementation should be regularly assessed to decide if it should be continued.[1]

Children should be helped to transition to the family diet and age-appropriate mealtime behaviour. Early childhood is the time to help children develop health-promoting nutritional habits. Paediatric dietitian referral may also be appropriate and early referral for multidisciplinary support may help reduce the severity of malnutrition and feeding difficulties.[1]

Families should be counselled to provide a healthy and diverse diet; any nutritional supplements should be given after meals, not as meal replacements.

Consistent routines (in both times and places) are encouraged for family meals and snacks, eliminating grazing, minimising distractions, and engaging in pleasant conversation.

Children should be actively involved in meal preparation, if possible, and encouraged to touch and pick up food to increase appetite.

The goal of treatment is sustained expected velocity of weight gain for age without the need for prescribed supplements; therefore, children receiving oral nutritional supplementation should be regularly assessed to decide if it should be continued.[1] The following factors should be taken into account: weight change, linear growth, intake of other foods’ tolerance, adherence, the views of parents or carers.[36]

Consider – mealtime and nutritional support

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Consider – 

mealtime and nutritional support

Additional treatment recommended for SOME patients in selected patient group

​Nutritional supplements should be used in conjunction with helping children transition to the family diet and age-appropriate mealtime behaviour. Early childhood is the time to help children develop health-promoting nutritional habits. Paediatric dietitian referral may also be appropriate and early referral for multidisciplinary support may help reduce the severity of malnutrition and feeding difficulties.[1] 

Feeding support should be given if there is concern about faltering growth in the first weeks of life. In infants, this begins with a lactation consult for breastfeeding infants and additional formula supplementation when indicated, with the aim of increasing feeding volume and caloric density of formula or breast milk if needed, while still considering free water requirements.[1] In older infants and children, nutritional supplements and fortified foods can be useful when it is not possible to meet needs for one or more nutrients.[24] In older infants this can be through the addition of powdered formula or oil.

In toddlers and children, the focus should be on increasing calories using calorically dense foods such as avocado, heavy cream, and peanut butter, but while avoiding low nutritional value foods such as sweet and fried foods.

Consider – cyproheptadine

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Consider – 

cyproheptadine

Additional treatment recommended for SOME patients in selected patient group

Cyproheptadine (an antihistamine with antiserotonergic effects) has shown to be safe and effective in the short term (not studied long term) for improving oral intake, weight gain, and mealtime behaviour. There is some evidence which supports cyproheptadine as a pharmacological tool for weight gain in children.[1][42]​​ This is usually considered after non-pharmacological treatment and on a case-by-case basis.[1]

Primary options

cyproheptadine: consult specialist for guidance on dose

Consider – specialist referral

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Consider – 

specialist referral

Additional treatment recommended for SOME patients in selected patient group

Referral to a specialised growth and nutrition clinic may be valuable for interdisciplinary evaluation and treatment. Healthcare professionals should consider involving speech and language pathologists, dietitians, occupational therapists, and psychologists or other appropriate professionals. Referral to early intervention, a support programme such as Head Start, specialised services in public schools, and social work support may also help in supporting parents and families.[1]

Hospitalisation is rarely indicated; however, there are select circumstances in which it is recommended by the American Academy of Family Physicians (AAFP). These include: extreme parental impairment or anxiety; extremely poor parent-child interaction; need for precise documentation of nutritional intake; outpatient treatment failure; psychosocial factors that put the child’s safety at risk; serious underlying illness or medical problem; severe malnutrition or dehydration.[37] Additionally, it is also recommended to consider admission in suspected child abuse, a rare cause of faltering growth.[37] See Child abuse

Enteral tube feeding should only be considered when there are serious concerns about weight gain and only after an appropriate specialist multidisciplinary assessment has been completed. Additionally, the intervention should only be undertaken as a last resort, following the trial of other interventions with no improvement.[36]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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