Special diets and supplements: Do’s and don’ts for children

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

Educational resources for pediatricians and patients

Good nutrition is a key component of health. Along with regular physical activity, eating well is considered fundamental to maintaining good health and reducing the risk of chronic diseases. For children and adolescents, healthy nutrition may make all the difference for lifelong physical and mental health by providing key nutrients for neurodevelopment through early childhood.¹

Guidelines on what constitutes good nutrition for children and adolescents, as well as adults, are well established. Among these are 2 guidelines published in 2015, one for all Americans (adults and children)-Dietary Guidelines for Americans 2015-2020, 8th edition,² published by the US Department of Health and Human Services and US Department of Agriculture-and one published by the Academy of Nutrition and Dietetics specifically for children aged 2 to 11 years-Nutrition Guidance for Healthy Children Ages 2 to 11 Years.³ As shown in Tables 1 and 2, the foundation of both guidelines is a shift to more plant-based foods (vegetables, fruits, lean protein) and a reduction in saturated fats, sodium, and sugars.

For some children, however, medical conditions may mandate altering the diet to manage the condition. Examples include children with celiac disease for whom gluten is restricted; children with food allergies in whom specific foods related to the allergy are eliminated; overweight and obese children in whom overall caloric intake is reduced; and those with diabetes who need to avoid foods high in simple sugar. Table 3 lists a range of medically prescribed diets.⁴ Other conditions for which parents may place their children on a restricted diet, less supported by evidence but growing in popularity, may include attention-deficit/hyperactivity disorder (ADHD), non-celiac gluten sensitivity, and autism spectrum disorder.^5-6

Special diets are seen not only in children with medical conditions, however. Some children are placed on special diets because of family preferences or beliefs or because of limited resources. Parents against animal proteins may choose to eat a vegetarian diet, for example, offering the same diet to their children.⁷ Some children may lack adequate macronutrients needed for a healthy diet because they come from food-insecure households, which were estimated to account for 6.4 million households in 2015.¹

For all children, regardless of whether they receive a special diet or not, healthy nutrition is paramount for normal neurodevelopment growth and good lifelong habits of eating that nourish health and wellbeing.¹ For pediatricians, knowing the diet of a child is critical to ensure the physical and mental health of that child. Along with educating parents on what constitutes a healthy diet for their child, parents also need to know the potential adverse effects of special diets on their children. This ranges from inadequate intake of essential micronutrients that may lead to, for example, anemia, to the potential for increased cardiovascular risk in children consuming some gluten-free products that may be higher in sugar and fats (Table 3).^4,8,9

“Pediatricians are often unaware of the nutritional impact of various diets and do not know if a patient is receiving sufficient and balanced nutrition,” according to Diane L. Barsky, MD, a pediatric nutrition specialist in the Division of Pediatric Gastroenterology, Hepatology, and Nutrition at the Children’s Hospital of Philadelphia, Pennsylvania, who, with Maria Mascarenhas, MBBS, spoke about special diets in children at the recent American Academy of Pediatrics (AAP) National Conference and Exhibition in New Orleans, Louisiana. “Pediatric patients are also consuming vitamins and supplements that can have benefits, but parents may not be aware of potentially harmful effects from these substances.”

“It is the pediatrician’s responsibility to educate himself or herself, ask their patients about special diets and supplements, and educate/counsel families about these topics,” she says.

Special diets for children

VEGETARIAN DIET

Pediatricians may encounter children on a wide range of special diets. Among the most common are a group of diets that fall under the umbrella of vegetarianism. These are primarily plant-based diets that involve different degrees of restriction on animal products (Table 4).^7,10 Data from the early 2000s estimate that about 2% of US children and adolescents aged 6 to 17 years are vegetarian with about 0.5% described as vegan.¹⁰ This number may be higher based on more recent data showing that between 20% to 25% of US adults report some level of consuming a vegetarian diet.⁶

Although a well-balanced vegetarian diet for children and adolescents is supported by the evidence as well as associations such as the AAP,¹⁰ special attention is needed to make sure that children and adolescents on these diets are receiving the required nutrients and protein intake needed for growth and development during these formative years.^7,10 Of particular concern is the potential for deficiencies in key micronutrients needed for growth, bone mineral content, and neurodevelopment throughout childhood (Table 4).⁷

Table 5 provides some guidance on how to prevent micronutrient deficiencies in children who transition to a vegetarian diet.^1,7

GLUTEN-FREE DIET

Another special diet that has gained in popularity with the broadening availability of products is the gluten-free diet.¹¹ People on a gluten-free diet avoid food and beverages containing wheat and any wheat products (durum, einkorn, emmer, kamut, spelt, enriched flour, farina, graham flour, self-rising flour, semolina, and couscous), barley, rye, triticale, and sometimes oats. Evidence supports the use of gluten-free diets when appropriately used for children with celiac disease showing that it can help eliminate symptoms of celiac disease and improve quality of life.¹¹

However, the nutrient levels of gluten-free products vary significantly, and many may not contain key vitamins and nutrients, such as iron, calcium, fiber, thiamin, riboflavin, niacin, and folate. In addition, some gluten-free produces contain more fat and sugar than non–gluten-free products and may pose a risk of weight gain and obesity in children as well as potential cardiometabolic risk.⁹ As such, parents need to be aware of the quality of the gluten-free product their child is consuming to ensure proper nutrition. For most children without celiac disease, a gluten-free diet is not recommended.¹¹

ANTI-INFLAMMATORY DIET

A diet that has gained popularity for the entire family and is especially interesting given its well-established benefits with few if any downsides is the anti-inflammatory diet (Table 6).^12,13 Data from studies looking at an anti-inflammatory diet-a diet and lifestyle approach combining Mediterranean and Asian diets-suggest that daily adherence to an anti-inflammatory diet may lower a child’s risk of obesity, type 2 diabetes, heart disease, and other conditions linked to inflammation.^12,13

Much of the evidence to date on benefits of the anti-inflammatory diet come from studies on the Mediterranean diet, including a 2019 meta-analysis of over 2 million people showing a reduction in mortality (8% from any cause and 10% from cardiovascular or cerebrovascular disease) and 13% reduction in neurodegenerative diseases associated with a 2-point increase of adherence to the Mediterranean diet.¹⁴ Other benefits shown in children include a reduction in the severity of asthma and allergies as well as reduced recurrence of asthma and prevention of chronic asthma.¹³

Important to underscore is that the Mediterranean diet is not a specific diet but a pattern of eating habits that includes plant-based food, healthy fat sources, adequate water intake, and overall inclusion of a wide range of foods preferably eaten in season and locally grown. It is also seen as a lifestyle approach to eating that includes regular physical activity, adequate rest, and conviviality.¹⁵

Supplements

Although the AAP does not recommend multivitamins for children and adolescents who eat a healthy, well-balanced diet,¹⁶ many children receive dietary supplements. For some children this may be placing them at increased risk for getting too much of a certain vitamin. A 2012 national survey found that children taking multivitamins were at increased risk of getting too much iron, zinc, copper, selenium, folic acid, and vitamins A and C.¹⁷ However, the survey also found that children not on a healthy, well-balanced diet had low levels of vitamin D and E and calcium and therefore may need a multivitamin.¹⁷

Other supplements that children may be receiving include a variety of nonvitamin, nonmineral products. The 2012 national survey found that 5% of children in the United States used a dietary or herbal supplement. Fish oil/omega-3 fatty acids, melatonin, probiotics, echinacea, cranberry, ginseng, and garlic supplements were among the most commonly used.¹⁸

Pediatricians need to counsel patients and families that these products are not tested for safety nor effectiveness in children, and that many of the compounds and active ingredients in these products may be unknown and do not cohere to what is on the product’s label.¹⁸ Given the developing immune, digestive, and central nervous systems in children, especially infants and younger children, patients and families need to be aware of safety concerns. A particular concern is the combination of certain supplements with medications a child may be taking, which may result in unwanted adverse effects. For example, combining vitamin C with acetaminophen slows down the processing of acetaminophen; St. John’s wort may slow down interaction with antidepressants, birth control pills, seizure control drugs, and cancer medications; and melatonin may alter hormones in young children.¹⁸

Counsel patients and families

Asking patients and parents/caregivers what diet a child may be receiving is an important first step in evaluating if a patient is receiving adequate nutrition. Educating patients and families on the basics of good nutrition is important for all patients regardless of the diet they receive (see “Educational resources for pediatricians and patients,” for additional educational resources).

For children who are placed on a special diet, additional counseling is important to ensure caregivers are aware of potential nutritional deficiencies and ways to counter those deficiencies. An overall assessment of diet may be performed by the pediatrician, but referral to a registered dietitian is important for children on special diets.

Essential to note is that common to all healthiest diets is emphasis on more plant-based food with less reliance on animal-based and processed foods. The established nutritional guidelines as well as the special diets discussed here all deliver this main message.

References:

1. Schwarzenberg SJ, Georgieff MK; Committee on Nutrition. Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. Pediatrics. 2018;141(2):20173716. Available at: https://pediatrics.aappublications.org/content/pediatrics/141/2/e20173716.full.pdf. Accessed November 25, 2019.

2. US Department of Health and Human Services; US Department of Agriculture. Dietary Guidelines for Americans 2015–2020. 8th ed. Available at: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Published December 2015. Accessed November 25, 2019.

3. Ogata BN, Hayes D. Position of the Academy of Nutrition and Dietetics: nutrition guidance for healthy children ages 2 to 11 years. J Acad Nutr Diet. 2014;114(8):1257-1276. Available at: https://jandonline.org/article/S2212-2672(14)00604-2/fulltext. Accessed November 25, 2019.

4. Medically prescribed diets: Indications and nutritional risks. Courtesy of Maria Mascarenhas, MBBS; Children’s Hospital of Philadelphia (CHOP).

5. Sathe N, Andrews JC, McPheeters ML, Warren ZE. Nutritional and dietary interventions for autism spectrum disorder: a systematic review. Pediatrics. 2017;139(6):e20170346. Available at: https://pediatrics.aappublications.org/content/pediatrics/139/6/e20170346.full.pdf. Accessed November 25, 2019.

6. Cruchet S, Lucero Y, Cornejo V. Truths, myths and needs of special diets: attention-deficit/hyperactivity disorder, autism, non-celiac sensitivity, and vegetarianism. Ann Nutr Metab. 2016;68(suppl 1):43-50. Available at: https://www.karger.com/Article/Pdf/445393. Accessed November 25, 2019.

7. Di Genova T, Guyda H. Infants and children consuming atypical diets: vegetarianism and macrobiotics. Paediatr Child Health. 2007;12(3):185-188. Available at; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528709/pdf/pch12185.pdf. Accessed November 25, 2019.

8. Elliott C. The nutritional quality of gluten-free products for children. Pediatrics. 2018;142(2):e20180525. Available at: https://pediatrics.aappublications.org/content/pediatrics/142/2/e20180525.full.pdf. Accessed November 25, 2019.

9. Anania C, Pacifico L, Olivero F, Perla FM, Chiesa C. Cardiometabolic risk factors in children with celiac disease on a gluten-free diet. World J Clin Pediatr. 2017;6(3):143-148. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5547425/pdf/WJCP-6-143.pdf. Accessed November 25, 2019.

10. Amit M. Vegetarian diets in children and adolescents [article in English, French]. Paediatr Child Health. 2010;15:303-314. Available at: https://academic.oup.com/pch/article/15/5/303/2639457. Accessed November 25, 2019.

11. Rostami K, Bold J, Parr A, Johnson MW. Gluten-free diet indications, safety, quality, labels, and challenges. Nutrients. 2017;9(8):e846. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579639/pdf/nutrients-09-00846.pdf. Accessed November 25, 2019.

12. Katz DL, Meller S. Can we say what diet Is best for health? Annu Rev Public Health. 2014;35:83-103. Available at: https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-032013-182351. Accessed November 25, 2019.

13. Barsky DL. The anti-inflammatory diet’s surprising benefits in children. Medscape. Available at: https://www.medscape.com/viewarticle/894241#vp_2. Published April 3, 2018. Accessed November 25, 2019.

14. Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr. 2010;92(5):1189-1196. Available at: https://academic.oup.com/ajcn/article/92/5/1189/4597540. Accessed November 25, 2019.

15. Bach-Faig A. Berry EM, Lairon D, et al; Mediterranean Diet Foundation Expert Group. Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutr. 2011;14(12A):2274-2284. Available at: http://ciiscam.org/files/download/pubblicazioni/phn%20new%20md%20pyramid.pdf. Accessed November 25, 2019.

16. American Academy of Pediatrics (AAP). A vitamin a day. Healthychildren.org. Available at: https://www.healthychildren.org/English/ages-stages/preschool/nutrition-fitness/Pages/A-Vitamin-a-Day.aspx. Updated March 26, 2012. Accessed November 25, 2019.

17. National Center for Complementary and Integrative Health (NCCIH). 5 things to know about safety of dietary supplements for children and teens. Available at: https://nccih.nih.gov/health/tips/child-supplements. Modified October 9, 2019. Accessed November 25, 2019.

18. National Center for Complementary and Integrative Health (NCCIH). Use of natural products by children. NCCIH Clinical Digest. Available at: https://nccih.nih.gov/health/providers/digest/Children-and-Natural-Products. Modified July 18, 2018. Accessed November 25, 2019.