When Probiotics Are UN-Friendly

When Probiotics Are UN-Friendly

Everyone has heard about probiotics – but how do you know which are friendly and helpful, and which are UN-friendly and detrimental? Not all probiotics are all friendly, all the time. The microbes in probiotics vary in the sorts of tasks they do for us – so, depending on when, what, and how you’re using them, they can be a big help or a big fail.

Probiotics are bacteria or yeast supplements, in case you missed the memo, that you can buy and eat as a supplement. There are powders, capsules, chewables, probiotic foods and drinks… you  name it, it’s out there. The idea is to help populate your intestine with the types of bacteria that keep you healthy. Turns out we really need bacteria, viral exposures, and even some fungal (yeast) species to co-exist with us. These help our immune systems stay robust and direct traffic – especially at the gut wall lining, where our insides meet the outside world.

What’s in a human gut biome, and what species of microbes do what, is a burgoening area of study in medicine and health. While the old paradigm believed in a kill-all-germs and take-no-prisoners approach to immune health, the new paradigm has noticed that this doesn’t really work – because it makes people have more allergy, more inflammatory conditions, more autoimmune problems, and possibly, more susceptibility to serious conditions later in life, like cancer. A great example of this is how exposure to infections like measles and chickenpox in childhood protect us later on from certain cancers or shingles. But, now that we so enthusiastically use antibiotics, vaccines, and cleansers to keep germs at bay, we’ve really altered our human immune-scape!

Enter probiotics. Using these really can help many conditions, symptoms, and problems – from asthma and allergies to colitis or obesity.

But what if you use them and your child feels worse?

You may be using the wrong probiotic at the wrong time for the job.

One of the most-often misused strains I encounter in my pediatric nutrition practice is Saccharomyces boulardii. “Sacc B” for short, this is actually a strain of yeast (not bacteria) that has shown some action against tough infections like Clostridia difficile (“C diff”), which has become antibiotic-resistant. C diff has become so resistant to antibiotics that the FDA even approved use of fecal transplants to fight it, so any tools to fight it are worth exploring. Sacc B has been shown to reduce symptoms of irritable bowel, inflammatory bowel, and even Candida infection. Sounds great, right?

But it can make your child feel sick and may trigger symptoms like diarrhea, nausea, bloating, picky appetite or rashes if you use it for too long (more than a month). If your child has antibody reactions to Candida or other Saccharomyces species, then using Sacc B may fail – because the body may attack the Sacc B with an immune response. Cross reaction can occur here, as Candida and Saccharomyces – though they are different species and strains – are all in the fungal family. And that can make Sacc B backfire for your child.

Solution? Withdraw the Sacc B if your child is feeling worse on it; or, don’t use it at all until you screen for antibodies (IgG/M/A) to Saccharomcyes cerevisaie and Candida species. You can also run a stool test for microbiology of these species, which should not be found in excess on your child’s sample.

If you use Sacc B, use it in short bursts, say 3 weeks at a time. Look for improvement then rotate off the Sacc B to mixed Lactobacillus and Bifido strain product, or a spore probiotic with Bacillus species. If no improvement, get professional guidance.

Another frequent fail in supplementing probiotics is using them when your child has small intestine bacterial overgrowth (SIBO) or small intestine fungal overgrowth (SIFO). Symptoms of SIBO and SIFO are similar to symptoms of other GI problems – which leads many parents to give probiotics a try. But, these can make SIBO or SIFO symptoms worse, and fast. A healthy small intestine (which is the first part of the intestine after the stomach) contains a lot fewer bacteria and microbes than the large intestine or colon (further down the pipe). Too much microbial action in the upper part feels awful. This is why kids with SIBO or SIFO often don’t like eating, are very picky, struggle with the slightest variations in food textures, or are even averse to feeding themselves. They may claim to be full when they’ve eaten very little. Add some multistrain probiotics, and this can make it all feel worse.

Solution: If your child is old enough to tolerate a SIBO breath test, you may wish to do this – but, I generally don’t use this test, because it is a tough test for a child to endure, especially if they do have SIBO! Your GI doctor may offer it, and you can ask about how to get your child through the test. If positive, you will need to address this before advancing a probiotic regimen. SIBO and SIFO can be helped with herbal supports and may not necessarily need antibiotic treatment. Once you do eradicate the SIBO or SIFO, single strain products at lower potencies can be helpful, such as Lactobacillus rhamnosus or reuteri at 20 billion CFU per day or less.

Now and then I’ll encounter a child who is downright over-dosed on probiotics by a well meaning parent. Many of us have felt enthusiastic about fermented foods like kombucha, sauerkraut, or kimchee, but overdoing it can create symptoms you’re trying to correct, like gas, bloating, pain, or food refusal. If you’re using these daily for your kids but they aren’t thriving with comfortable appetites and eliminations, revisit this strategy. I like to use a GI MAP PCR DNA stool screen as well as a stool microbiology test to look at what is going on. Sometimes a less aggressive strategy is better, and you can start by simply withdrawing fermented foods or probiotic supplements for a week or so, then resume at smaller doses. You may find your child simply doesn’t need so much probiotic supplementation, from any source.

Lastly, don’t confuse probiotics with pre-biotics. Pre-biotics are starches that friendly bacteria can ferment for us. Some kids (especially with FPIES) don’t tolerate pre-biotic supplements very well, because they may be high in FODMAPs. If you’ve chosen a product that has ingredients like inulin, chicory, galactic-oligosaccharides, cellulose, or maltodextrin, or if the label says “prebiotics”, take note – this may not be the one for your child. You can buy probiotics that omit these ingredients from brands like GutPro or Custom Probiotics.

The choices are dizzying in the world of probiotics, but the good news is there is probably a product that can help your child with appetite, eliminations, and more. If you’d like help, work with me to look deeper into what your child’s solutions might be.

Camel Milk Infant Formula

Camel Milk Infant Formula

Can you make an infant formula out of camel milk? I’m often asked to find substitutes when commercial formula fails or when even breast milk is triggering a baby’s FPIES, allergy, or eczema. There are many good formula options from cow or goat milks on the market – but some babies still struggle, and need yet another option.

Camel milk has many health benefits – some of which I outline in my post on it here.

And yes, you can make an infant formula using it – as long as you know a few caveats up front. Most of all, you can’t use camel milk in its original form for infant formula. It must be modified first.

Camel milk is not the same as human milk, or milk from any other mammal like sheep, cows, or goats. It has to be modified to be safe as an infant formula, but it can be used to build a new formula (here are several links to research describing camel milk nutrition). Babies have very specific and very different needs than toddlers, children or adults when it comes to food and nutrition. If you miss the mark, your baby can pay the price with irreversible deficits in development or growth.

Camel milk has about half the fat of milks from cows or goats, and less than half the fat of your breast milk, especially early milk or colostrum. Babies need a lot of fat. It’s essential for all sorts of things, including brain growth, and for carrying critical path nutrients like vitamins A, D, E and K into tissues.

Camel milk also has more than twice as much protein than human breast milk – which might sound great at first. But human babies don’t need all this concentrated protein, and it can actually be harsh for their kidney tissue to eat too much of it too soon.

Lastly, camel milk has less carbohydrate in it that our own milk does. And babies need a lot of carbs too, because carbs become a primary fuel soon after birth – so protein and fats can do their own crucial jobs of building tissue, hormones, and carrying nutrients for us.

Less fat and less carb means camel milk has a lot fewer calories in it than human milk.

These macronutrient ratios – that is, the amounts of protein, carbs, fats, and calories in camel milk versus human milk – make it unsuitable as an infant formula on its own. Giving just camel milk in its original state will cause malnutrition in your baby (as will giving just milk from coconut, any nut milks, or any plant based milk substitutes).

So what to do? One popular recipe suggests adding cream (from cow’s milk), whey, lactose (that’s the carbohydrate), plus some oils and nutritional yeast to round it up to par for your baby. That’s a great recipe – for kids I’ve never met! If your baby can tolerate all the ingredients in that recipe, most likely, he or she can likely handle breast milk well too, or any of the European or American commercially available organic infant formulas that are made from goat milk.

You can use that camel milk recipe if you don’t mind mixing up your own and don’t like the organic commercial choices, or if your own milk has petered out and no donor milk is available. In that scenario, camel milk as mixed in the recipe above is a great option, and you can expect your baby to thrive with it. If you see funky stools, rashes, or crying, screaming, gas, bloating, or vomiting, then it isn’t a great option.

Not to despair! Even super sensitive babies can try a camel milk formula. It may even be a bonus for them as the immunoglobulins (immune proteins) in camel milk are legend for fighting enteroviruses and protecting immunity.

I work in that plan B zone. The babies I meet in my pediatric nutrition practice usually have severe feeding concerns, and/or are already in a growth regression or even growth failure. They can’t tolerate nutritional yeast because they already have fungal overgrowth in GI tract or an antibody reaction to it. For many of them, even this “healthy” yeast supplement triggers discomfort and pain. They can’t use cream because cream has some casein and whey in it from the cow’s milk it is made from, and they may be allergic or intolerant to those. They can’t use some of the oils in the recipe either because these may trigger their FPIES symptoms, which are terrifying – especially when a baby is vomiting violently until they pass out.

To use camel milk infant formula in these cases, you need to add about 6 grams of carbohydrate and 7 grams of fat for every 8 ounces of formula, while reducing the protein and mineral load. You also may need to remove the whole food sources of B vitamins and iron in the Healthy Home Econonmist’s recipe above, since kids with FPIES don’t do well with many whole foods until their gut/immune interface is improved.

That’s why in the recipe below, for B vitamins, I suggest using a commercially available multi vitamin supplement with iron. The brand chosen below has the least amount of flavors, whole food extracts (which can be poorly tolerated for sensitive babies), or other additives common in children’s liquid supplements. Sometimes, you have to pick your battles. For FPIES or highly allergic babies, it’s not worth the risk of using a whole food option like liver or nutritional yeast. These may be well tolerated later on. Either way, don’t omit the B vitamins, folate, and iron. Your baby needs these and camel milk doesn’t have enough of them.

For 12 (twelve) ounces of a camel milk infant formula that can be tried for sensitive babies or babies with FPIES:

  • 8 ounces whole camel milk (available shipped frozen from Desert Farms – request raw if available, flash pasteurized if not)
  • 4 ounces purified filtered water
  • 2 heaping teaspoons lactose powder
  • 1 teaspoon melted grass fed goat ghee or cow’s milk ghee (use goat source for more sensitive babies)
  • 1/4 teaspoon (20 drops) DHA fish oil 
  • 1 teaspoon any tolerated organic oils (olive oil, non GMO sunflower oil)
  • 1/4 teaspoon MCT oil
  • ~5 drops multivitamin for babies with iron (here’s an example) – don’t exceed 40 drops per day total

Warm camel milk and water gently in a stainless steel pot on low heat. Stir in lactose powder til dissolved. Add ghee, vegetable oils, and MCT oil but not DHA fish oil (heat quickly denatures this oil and makes it taste bad). Stir to melt/blend then transfer to a glass blender and blend on low speed for about 20 seconds. Add vitamin drops and DHA fish oil, and pulse to blend on low speed. If you’d like to add a probiotic, it can be added with vitamin and DHA, but not on stove top (heat kills the bacteria in the probiotic). Transfer to bottles to feed at wrist (warm) temperature.

A formula is a go when your baby can settle comfortably after feeding. Reflux can also often be resolved with the right formula, instead of depending on medicines like Prilosec or Nexium, which reduce your baby’s digestion and ability to absorb things like iron, zinc and B vitamins. If camel milk, goat milk, or products like Alimentum RTF or Nutramigen fail, your baby may  feel better with an elemental (amino acid based) formula. I’m happy to work with you to help you do that – make an appointment to get started any time.

If you’d like to try camel milk, you can purchase it here. I’ve personally used Desert Farms Camel Milk and was happy with this product!


What REALLY Heals Leaky Gut in Kids

What REALLY Heals Leaky Gut in Kids

Healing leaky gut is one of the most requested tasks in my pediatric nutrition practice. Many parents are surprised to hear me say that it is possible to repair leaky gut in children of all ages.

But what really works? There is a lot of buzz about dietary approaches, probiotics, and supplements, and less good research on leaky gut than we’d like, especially when it comes to infants, toddlers, kids, or teens. However, after twenty years in my clinical pediatric nutrition practice, I can tell you what nutrition supports I’ve seen consistently work, and what strategies often fail.

First, let’s get on the same page about what leaky gut is, and isn’t. It doesn’t mean there are actual ulcers or holes in your child’s intestine that are “leaking”. But it can mean that the intestinal wall has lost some integrity – and has become too permissive about the size of molecules that it lets pass into your bloodstream.

Another way you might hear leaky gut described is “intestinal permeability” or “hyper-permeability” – again, expressing a condition in which the intestine’s normally very selective, tight process for digesting and absorbing food has become, well, loose and sketchy!

Practitioners – myself included – might scrutinize zonulin, stool microbe studies (microbiology culture or PCR DNA methods), inflammatory markers like calprotectin, or immune markers like immunoglobulin A in a stool sample to gauge gut environment. Some doctors may order a lactulose-mannose test in which patients drink a concentrated solution made of those sugars. How these two sugars, which are different sizes, are excreted in urine can give a measure of how permeable the gut is. For more on intestinal permeability tests and their pros and cons, click here. Food allergy and non-IgE food reactions may also be measured, which requires a blood test.

Key To Restoring Leaky Gut Is….

Key to restoring a healthy gut is repairing “tight junctions” – these are the microscopic, traffic-cop structures of your gut. They form a tight seal between cells in the intestinal wall. When these junctions are injured, they break down – and larger-than-ideal molecules cross from the intestine into the bloodstream, triggering all sorts of reactions to stuff that your bloodstream and distant tissues were never meant to see in the first place. These might be anything from polypeptides (over-size fragments of food protein molecules that can masquerade as false hormones, false neurotransmitters, or invading antigens) to toxins, getting access your body from your gut, when they’re not supposed to. This permeability scenario is a catch-22, in that it can easily perpetuate itself, as more injury persists in the gut.

The intestine is our largest immune system interface with the world outside the body – so leaky gut can also wreak immune havoc, from autoimmune problems to frequent infections and illnesses.

What injures the gut? Lotsa stuff – and, making this harder is that leaky gut symptoms are often diffuse and insidious. They can evolve gradually, or with an abrupt onset that never quite resolves. Leaky gut can trigger symptoms in the GI tract of course, but also far from the gut, like headaches or joint aches, stiffness, pain, fatigue, or frequent colds and infections.

image courtesy Jill Carnahan MD

Here Are Usual Suspects for Triggering Leaky Gut

  • antibiotic use
  • intestinal Candida or other fungal species infections
  • undiagnosed food allergy or food sensitivity
  • intestinal flu or virus
  • food poisoning
  • non celiac gluten sensitivity
  • poorly tolerated routine vaccinations
  • chronic stress
  • traumatic brain injury or concussion
  • C section birth (baby misses exposure to helpful vaginal flora)
  • mom treated with antibiotics in pregnancy or at delivery for any reason
  • mastitis (mom needs antibiotics while breastfeeding)
  • radiation therapy
  • being underweight especially if you’re a baby, child, or teen

Most kids have had at least one of the items on this list. But that last one is key. In itself, underweight can cause intestinal permeability especially in children. You can address all the other triggers, but if your child is underweight – that is, more than fifteen percentile points off his or her expected pattern – your child’s gut can remain “leaky”. There simply isn’t enough raw material and energy on board for that tissue to repair itself, while your child is also trying to grow.

Here’s the rub: Generally, nobody scrutinizes your child’s growth pattern that closely (I will be honest and tell you that I even see gastroenterology work ups overlook this level of detail – and I routinely read my patients’ reports from their GI specialists nationwide). Without defining your child’s actual expected growth pattern – that is, where your child should be today given parental stature, pregnancy history, birth/delivery history, and growth history since birth – then you don’t know if your child is underweight or undernourished. You can learn more about that here.

I meet many children who are underweight. Sometimes it’s caused by families placing kids on diets that are too restrictive. Or some families have become so traumatized by frightening reactions to foods that they just don’t know how or what to feed their children – so, they don’t. Sometimes it’s caused by a well meaning practitioner who didn’t monitor growth and food intake, because they’re focused on lab tests and supplements instead, gave no guidance on what to actually eat, and encouraged a restrictive diet without effective replacements for foods taken out. I have also seen underweight caused by reflux medicines, which can diminish appetite and digestion when used for more than a few weeks or months. When it comes to picky eating, this too will drive growth status down in kids, injuring the gut too via underweight and poor diet.

The flip side of this coin is assessing what your child eats – how much and what – and the only way to discover if your child eats enough non-triggering, nourishing food is to assess a food diary  (part of every new patient intake I do), and then align it with the growth assessment. The food your child eats is the lumber that will be used to do the gut repair – so it has to be the right stuff, in the right amount. Supplements (including glutamine, which is a helpful amino acid but not an energy source), herbs, and probiotics don’t provide this raw building material. I meet a lot of kids who have been given a lot of supplements, lab tests, antifungals, special diets, and measures to repair leaky gut. But they’re still struggling – because this essential growth and feeding part gets lost in the shuffle. But put the right feeding plan with the right supplemental supports, and boom – now you’re talking!

Here’s What Works to Repair Leaky Gut In Kids

  • Balance gut microbe environment with herbal or prescription agents to directly address fungal burden, Clostridia burden (even commensal strains can be problematic if they far outnumber other helpful strains), Strep or Klebsiella, parasites, protozoans, and whatever comes up on testing. Combine this with probiotic supplementation that matches your child’s stool studies. My preferred tools for assessing this are GI MAP and Doctors Data Stool Microbiology.
  • Customize the special diet to your child. Skip dogmatic, one-size-fits-all approaches.
  • Give enough protein! Kids may need anywhere from 1 to 2 grams of protein per kilogram bodyweight per day depending on degree of growth impairment.
  • Give the right protein; assess first which proteins are triggering with lab studies. Replace trigger proteins with equal or better value non-trigger protein sources, and keep them varied.
  • Use free amino acids. Supplementing with amino acid mixes that give all 8 essential amino acids (and not just glutamine) has been a big bonus in my practice for kids who need deep gut repair. Formulas and powders are available. These give the gut direct access to building blocks for new tissue growth and repair. I use anywhere from 5 to 15 or even 30 grams daily of this protein source, depending on a child’s needs or status. Caveat: These won’t work well without an adequate total diet around them to support energy needs.
  • Give enough total food including “clean” (non sugary) carbohydrates, which are crucial for growth in children (carbs preserve protein for structure and function, and keep it from being burned for energy) and ample healthy fats and oils. Kids can need 4-6x more calories per pound than adults, depending on age and growth status. Don’t feed them like little adults – give energy-dense, nutrient-rich food.
  • Mastic gum, licorice root, zinc carnosine, glutathione, mineral-rich foods or products like Restore are just a tiny sliver of the thousands of products that can aid gut tissue repair. Work with a knowledgeable provider who has used these in children before. Using these tools is a routine part of my practice.
  • Correct sleep pattern so your child can sleep deeply and wake rested. Sleep is when our organs are busy with repair and clean up. Hint: Children who are underfed tend to sleep poorly and wake more often.
  • Minimize stress in your child’s world. Don’t discuss “leaky gut” with younger kids and don’t frame food or their bodies as problematic. Use positive language and emphasize the power to heal, which we all have.
  • Give it time (like, months), be chill, and remember that your child’s body is a miraculous thing with its own innate drive to grow, repair, and heal.

And Now For The Leaky Gut Fails…

  • Using rigid diet strategies for growing kids can be too restricting to support growth, gain, and gut repair. Yeast free diet, GAPS, ketogenic diet, AIP, SCD, Paleo, or Body Ecology all have merits (and devotees!), and I use components of all of them in my practice. But in themselves, none of these were created for use in children (except ketogenic diets for seizure control) and can fail when children are already struggling to gain or grow. If you’re not seeing good growth, gain, and progress in behavior or food reactions with one of these strategies within 2- 4 weeks, or if initial improvements lapse quickly, then it probably isn’t right for your child. Customize to your kid instead!
  • Needing your child to like any of this, including taking supplements, having blood draws, or accepting different foods. You’re the adult. They’re not going to make it easy for you – that’s a given. Hint: Picky appetites can improve with addressing these three steps – don’t assume your child “won’t eat that”.
  • Staying on reflux medicines for months at a time. These will work against your gut healing efforts by keeping pH in the stomach too weak to initiate good protein digestion. They will also cause your child to feel less hungry over time, to eat less, and to become more picky – thus leaving your child underfed and unreplenished for the task of gut repair. Learn more about the downside of reflux medicines here.
  • Using glutamine, vitamins, minerals, or lots of supplements before you situate the right feeding strategy for your child. Feeding strategy means knowing what foods to use, how much and which sources of protein, fats, and carbs, and for how long, to support your child’s expected weight and height.
  • Being aggressive with fermented foods, probiotics, or too much Saccharomyces boulardii. These can backfire if used for too long or at too high a dosage, and may even start to create their own dysbiosis or discomfort.
  • Leaving fungal, parasite, SIBO or SIFO, or other dysbiosis untreated or under-treated. This can interrupt appetite, digestion, and stooling and keep tight junctions from sealing up.
  • Giving up after 2-4 weeks. This is a restore and repair effort that may take months, depending on how long your child’s gut has been in the weeds.

Want help? This is a lot! Let me sort the best options for your child. Contact me today to set up a time to work with me remotely or in person. Or, peruse my options for books and on-line-course support.






Are Ketogenic Diets Good For Kids?

Are Ketogenic Diets Good For Kids?

I’m often asked if ketogenic diets are good for kids. Parents are trying this diet and having great results – why not put the whole family on a ketogenic diet?

It doesn’t take much searching to learn that ketogenic diets have been vetted for nearly a century, when they were first noted for their ability to control seizures. Even conventional training for dietitians has included training in ketogenic diets for decades – they’re not new.

The new part is using them for weight loss, fitness, and all sorts of chronic conditions, from cancer and autoimmune problems to Alzheimer’s, multiple sclerosis, or autism. You’ve probably seen experts – from Mark Hyman MD to David Perlmutter – singing the praises of ketogenic diets. But what about your kids? And, what about using a ketogenic diet for kids with autism?

Ketogenic diets use high amounts of fats and oils, lots of protein, and very little carbohydrate. Typically about 70% of all the food you eat on a ketogenic diet will come from fats and oils, with only about 5% coming from carbohydrates. By contrast, kids usually eat anywhere from 50-70% of their total diets as carbs, with 20-40% as fats – so this is a big switch.

Research is mounting to show that eating this way changes the bacteria that grow in your gut. By now, you’ve probably heard about how deeply we rely on gut bacteria for overall health. Gut bacteria are essential to our well being, in that they help us digest and absorb the nutrients we need. They also cut inflammation and protect us from invading pathogens – that is, if your gut bacteria profile is healthy.

This is critical in early infancy too, to avoid conditions like allergies and asthma later on. And gut bacteria play important roles in other conditions that have been regarded as exclusively psychiatric or neurological for decades, including autism – but for years, I have helped families reverse behavior and developmental concerns in their kids by restoring a healthy gut biome. Now research is finally mounting to show that this is indeed possible!

If you have a lousy gut bacteria profile (which you can acquire by eating a junky diet, or using antibiotics, reflux medicines, and steroid anti-inflammatories), chronic and systemic problems are likely going to ensue. It’s popping up all over the academic literature landscape, and I’ve seen it happen before my eyes in practice for years: Nasty gut flora = nasty kids, nasty poop, nasty behavior, poor eating habits, and chronic health problems!

Anytime you change your diet, you will change the bacteria in your gut, in about 2-3 weeks. Ketogenic diets change gut bacteria too, and it is through these changes that this diet can support renewed health. Ketogenic diets also change our body’s primary fuel from glucose, which is obtained by eating carbs, to ketones, which are obtained by eating mostly fats and oils. The brain, and all our organs and tissues, can run well on ketones. When the body is using ketones all the time, this is called being “in ketosis”, a goal that is closely monitored for people who use ketogenic diets to control seizures. Even tiny amounts of carbohydrate can trigger a seizure for some people with epilepsy. Being in ketosis is when seizure control can happen best, for people who fail on seizure medications.

But ketogenic diets for kids may have a cost. They may not grow as tall as they would if eating a diet with more carbohydrate in it. This was noted in this study in children using ketogenic diets. The children’s progress for linear growth (that is, height or stature) slowed down after 15 months on the diet.

This may be partly due to changes bone density. Effects on bone development were closely scrutinized in this study, which found reduced bone density with ketogenic diets for kids.

Effects like stunting from ketogenic diets for kids have been observed for many decades, and I have witnessed this myself in my pediatric nutrition practice. Kids who come to me already on a ketogenic diet follow what occurred in this study, that also saw slowed growth for height and weight in children using ketogenic diets. And in this study, the number of children who fell below tenth percentile for height more than doubled, from ten to twenty-three children, while using ketogenic diet. They also had more than expected kidney stones and bone fractures. Children also may gain weight more slowly on ketogenic diets, impairing their growth pattern for both weight and height.

Slowed growth is not just a physical issue. It can have cognitive, functional and behavioral impacts too – and this another often-seen issue in my pediatric nutrition care practice. Ketogenic diets for kids may thus create unwanted cognitive effects, as described in this study on developing rats. In my practice, one of the most common findings for school children with ADHD/ADD is that they are underfed – ironically, often because they have been using a stimulant medicine that suppresses appetite. Eating poorly, they fall in and out of ketosis during the school day and disintegrate behaviorally for focus. Their food intakes need improvement, but being in ketosis does not seem consistently helpful.

These impacts may not be a concern for adults on ketogenic diets. This very small study of only three individuals did not find changes in bone density after five years on a ketogenic diet. This study of sixty-five adults saw reduced bone density in groups using either very low carb or calorie restricted diets for weight loss, but it’s unclear if the subjects sustained ketosis or not, or if bone density dropped simply because subjects weighed less at the end of the trial.

The Up-Side of Carbs

Carbs have been demonized for sure, and not without cause. I have seen thousands of food diaries over my years in practice for infants, toddlers, kids and teens (thank you to all those parents who filled those out with dispassionate honesty!). Without question, many kids I encounter come in with carb-heavy, low quality diets that rely too much on processed grains, sugary yogurt, juices, or starchy crackers and snacks. Not good.

But there is an up-side when eat kids about a third to half their calories from clean carbs. Kids are growing. Adults aren’t. When we’re growing, carbohydrates from food we eat spare the protein and fat we eat, so that they can be used for other critical tasks – both metabolic and structural – that adults simply don’t have because they’re not growing.

A child needs a lot more energy per pound than an adult. Depending on a child’s age or growth status, they can need as much as five times more calories per pound than an adult! This could be the same as you or I eating ten thousand calories every day, just to maintain a normal healthy weight (imagine what would happen!). Strangely, even when kids use calorically adequate ketogenic diets, they can still experience stunting.

This might be related to the fact that kids’ brains use about double the amount of energy every day compared to an adult’s brain, in terms of the percentage of energy derived from the food you eat. This is true until about age four, when head growth slows down relative to the rest of the body.

Long short, adults aren’t growing, and thus don’t need a sparing effect from carbohydrates.

The big caveat here is that kids need clean carbs. When kids eat healthy, clean carb sources with good protein and ample varied fats, they grow well, and behave, sleep, and learn well too – I’ve seen this hundreds of times. “Clean carbs” are unprocessed, no-added-sugar, whole foods. Think vegetables, legumes, and tubers – parsnip, squashes (butternut, acorn, spaghetti squash, zucchini, pattypan), asparagus, cruciferous vegetables like Brussels sprouts, broccoli, or cauliflower, carrot, potato or sweet potato, greens, lentils, chick pea or beans, green and wax beans, taro, or manioc are all carbs to have on your menu rotation. They provide pre-biotics for your gut bacteria to work with for healthy fermentation in the gut and nutrient production, not to mention their bonus of minerals. Fresh unsugared fruit (not fruit juices) is helpful too. When it comes to grains, sprouted grains will be more digestible, but grains are by no means absolutely necessary in your child’s diet.

One not so great carb is yogurt – because yogurts for kids are generally loaded with added sugar or sugary fruit. Most yogurts on store shelves have far more sugar in them than fat or protein, so if your kid chugs drinkable yogurt tubes or even a non-dairy yogurt cup daily, switch to a no-added sugar option and use a drop or two of organic stevia to sweeten it if need be.

But Babies Are Born In Ketosis! So…Doesn’t That Prove Ketogenic Diets Are Good For Kids?

When babies are born, of course they’re in ketosis – they’re not eating anything yet at all, and need a fuel to carry them through what may be hours of labor. Ketones work great. A young baby (a month old or less) relies often on ketones to fuel the brain for its first few weeks. Ketones are preferentially allowed into the delicate new brain over glucose as an energy source in that first month too. This is when “early milk” or colostrum has more than twice as much fat in it than it does carbs. Does that mean ketogenic feeding is the next rage for babies and toddlers? I don’t see it. By the end of the first month, breast milk nutrient ratios shift, so that it’s nearly 40% carbohydrate, and this doesn’t change much even for moms eating ketogenic diets. In other words, after that early milk, we evolved to give our babies 30-40% of their calories as carbs in the first year; our bodies will preserve this ratio in our milk no matter what we eat.

For infants or kids with seizure disorders, ketogenic diets can be miraculous. They are definitely worth trying and definitely warrant professional guidance. They may work because they do change gut bacteria, and eating any carbs – even clean carbs – above 20-60 grams/day  (which is quite low) may trigger relapse of seizures. Follow your care team’s advice if this is your situation.

Ketogenic diets that are poorly monitored can be dangerous. I don’t recommend launching one for kids without professional guidance. If you have, watch for these warning signs of hyperketosis: Rapid, panting breathing; rapid heart rate; facial flushing; irritability; vomiting; or unusual lethargy. If you see those signs, call your doctor right away or go to your nearest emergency room.

For kids with autism or other conditions, there are options to tailor ketogenic diets to each child so that functioning improves dramatically, without compromising growth, bone health, or kidney health. This is one of my practice offerings, so contact me if you need help. And if you’re still laughing about that long list of veggies that your kid would never eat, let’s get in touch to work on that. Changing that gut bacteria profile can change your kids’ palate and appetite!


Grazing Versus Meals: What’s Best For Kids?

Grazing Versus Meals: What’s Best For Kids?

Which feeding strategy is healthier for kids – grazing as they please, or structured meals? I get asked this a lot. Here’s what I’ve experienced across some twenty years in clinical practice with all ages of kids, from young infants up to twenty-five year old young men who are finishing their last growth spurts. This question goes not only for meals, but breastfeeding too, especially when infants are wrapping up that first year or so, and becoming very interested in eating what they see you or their siblings eat.

But here’s the thing: The question you really need to start with is, what is best for you?

You may already know that supplying a steady stream of snacks and mini-meals isn’t nourishing for kids, and it’s a lot of work. Are you up for that? How about if you have three kids with different food allergies, not to mention different activities in different directions all day long? Or if your spouse doesn’t “believe” in all the effort you make to feed everybody, wants their own special favorites, and leaves it all on your shoulders? Mix in work schedules and budget constraints for special foods, and this becomes a fail, fast – one that I have witnessed many times in families reaching out for my help.

Usually, kids in these scenarios aren’t thriving. They’re often underweight, cranky, manipulative, poor sleepers, and picky eaters. And the chef-parent is at wits’ end. If you can’t keep up this workload, or if you plain just hate doing it, then it’s simple: Stop. Your happiness matters, period. And, happiness rubs off on your kids. And and, your kids will be healthier with discreet meal schedules, versus growing up on the non-stop graze.

As exhausting as feeding a grazer can be, it’s an easy trap to fall into. There are so many ready-to-eat packaged foods now for toddlers and children, that just handing over that pouch of organic veggie goo, paleo power bar, yogurt tube, or cup of snack crackers when you know your child probably isn’t eating enough is too tempting. But giving in to grazing has problems:

  • It may worsen small intestine bacterial overgrowth (SIBO) or small intestine fungal overgrowth (SIFO), a frequent cause of picky eating, weak appetite, and poor growth and gain for toddlers in my practice. Brief periods of day time fasting help keep this under control. Toddlers can manage two to three hour stretches between meals or snacks; school age kid, up to four hours or so.
  • Missing those short fasts throughout the day prevents an important thing called the “migrating motor complex“. This is what our GI tracts do between meals, when we’re on empty. It’s a housekeeping function that literally acts like a mini-cleanse broom, sweeping the intestine, and making it hard for lousy SIBO or SIFO microbial garbage to set up house.
  • When the body is fasted, the muscles in the small intestine make a wave of forward motion. This cleansing wave keeps intestinal contents from getting stuck – which is better for that constipation scenario you may be dealing with (read my blog on how to get off Miralax if that’s your kid). Eating too often abruptly ends this task.
  • Grazing can leave toddlers and kids hungry in the middle of the night, causing them to sleep poorly, wake up tired, or cry for a feeding when they’re old enough to sleep through – if they get the food they need during the day.

Some other points to consider

  • Eating is self-care. Kids learn good self care from parents who model health and happiness habits. If you’re miserable dealing with food and preparing meals, your kids will adopt a view of food as a burdensome annoyance too. Don’t expect them to lead the way here or make it easy for you – that’s your job.
  • Perhaps your toddlers (or kids) are good at grabbing what they want to eat, when they want. How independent is that, right? And maybe that makes your day easier. But, they’re toddlers. They are still dependent on adults to make wise decisions about what foods are good, and when. Left to their own devices, they’ll mostly eat what’s familiar, and not explore new foods that they may need, as they grow so rapidly.
  • Up until just a few years ago, there were none of these packaged foods parents now find so irresistible: The squeezable pouches of yogurt, fruit, and veggies; the packages full of crunchy snacks designed to be held by toddler hands; the endless variety of power bars, paleo bars, protein bars, and snack bars; the mini cups of chia pudding or vegan spreadable cheese or hummus; the gummy snacks that are fruit-like, sort of. All of this has been created for one reason: You buy it. It’s profitable. Kids definitely don’t need any of this stuff to be healthy, but if a bit of it in the mix makes life easier, enjoy – just don’t make it your only food strategy.
  • Learning to respond to hunger and fullness healthfully only happens when kids actually experience these things.

Avoid These Sure-To-Fail Scenarios

Recently a mom asked for my help with the breakfast routine for her three kids. One child especially did not want to eat in the morning, then went off to school semi-fed, where he proceeded to have meltdowns.

“Tell me the sequence of what happens; what is the first thing he does when he gets up?” I asked.

She explained that this one of her brood would get up, and immediately settle into Lego play before breakfast, which he would vehemently oppose leaving behind for food. He’d attempt some eating in this disintegrated state of mind, fail, and go off to school blunted for hunger but not well fed.

First step: Lose the Legos. Morning on school days is self care time, not play time. It’s get-ready-for-your-day. It’s fuel-up and settle-down for the tasks ahead. Toys should be nowhere in sight. This may sound hard, given the absurdly ubiquitous nature of branding for toys on everything from pillowcases to toothbrushes (not to mention snack food!). But it’s a self care routine that must be learned. Kids will not become good planners when toys, snacks, and whatever else they desire is within reach at any moment.

Another very common fail I encounter is prolonging breastfeeding. Don’t get me wrong: We all know how amazing breastmilk is. But, as infants age out toward their second year, they need some solid food too. I have met countless moms afraid to wean, for a variety of reasons. It’s  misguided to think that breast milk will continue to be the solution as their babies become toddlers. Their kids sip sip sip. They want feedings at midnight, 2 AM and 5 AM even though they’re 13 months old. Fail. This is a kid who needs to start eating food.

Continuing to breast feed is fine – but it should not be the only or primary source of sustenance at this age.

Even if your youngster is doing great at 14 months on just breast milk, I’ll bet you haven’t had a full night’s sleep in a long time. No good. You need sleep. Baby needs food. Solid foods needed for the baby’s higher demands get displaced with constant sipping on breastmilk, which can stop being adequate to meet all of a baby’s needs by about age 10-12 months. This can vary with circumstances for the baby, so finding the fit for you and your baby is key. It might be different from someone else.

If your child is fiercely picky for just breast milk, sleeping fitfully, waking for feedings, and failing to progress with introducing foods after age 15-18 months, it’s time for some intervention and redirection –  call me for an appointment.

Ok, one more: Just like toddlers, older kids need guidance and modeling for healthy self care habits when it comes to food. Teens who skip breakfast, breeze through lunch with a power bar, chow hard at dinner, then eat big again at midnight are setting themselves up for a bunch of challenges for mood, energy, attention/focus, and sleep. If they’re struggling, and combative about food, let’s talk. Most teens I’ve worked with are relieved to be offered options that lift this burden and give them strategies they feel better with quickly. The trick may be hearing it from someone other than mom or dad.

Need help? Work with me to sort out what food your kids need, when, and how!

Surprise! Your Child Is Underweight

Surprise! Your Child Is Underweight


Is your child underweight? Your doctor would have told you, right?

Maybe not. In fact, I am often the first person to capture this finding in a toddler, child or teen who has seen multiple providers, from the pediatrician to gastroenterologist to allergist and so on. But this is really important for kids. Why? Because once kids slide into growth impairments, it throws a lot of other stuff off kilter for them:

  • One, their immune systems don’t work as well. They can get sick more often, stay sick longer, and have more complications from infections than kids in healthy status.
  • Two, they struggle more to behave, learn, focus, or sleep, and will often experience more anxiety, less self regulation, and more mood swings.
  • Three, a lot of lab tests can wobble. Thyroid, creatinine, and liver function measures can begin to drift out of range, just from even mild but chronic growth impairments. I’ve seen this send specialist doctors on a goose chase for exotic problems that don’t exist – when kids might just need more food, better food, or different food.

This can happen even with mild or moderate growth impairments. In other words, kids don’t have to be severely underweight for this stuff to go wrong.

When kids finally hit bottom with that failure to thrive (FTT) status, this will create a leaky gut – something many parents ask me about – because there aren’t enough nutrients and energy from food for the child’s gut wall to maintain its integrity. And, the younger a child is, the more vulnerable they are, when dropping off channel.

Pediatric providers generally won’t intervene on or even mention a lagging growth pattern unless your child is really, really underweight, as in – heading for the very bottom of the growth chart. Why not? There are several reasons why this can be true:

  • Your insurance may not pay your doctor to intervene on any growth impairment other than failure to thrive (FTT),  a severe and entrenched problem in which a child has fallen to below the fifth percentile for weight for age.
  • Your doctor may not know that dropping just fifteen percentile points off expected growth pattern, for either weight or stature, actually means your child is underweight or undernourished.
  • Your pediatrician may not know how to calculate your child’s ideal body weight, expected weight, or expected height, or doesn’t have time to do it.
  • Your doctor doesn’t have time to scrutinize, integrate and explain all the growth data in that brief fifteen minute visit, including all the things that impact growth, from your kids’ food intakes to energy level to genetics.
  • Your doctor isn’t sure how to help you fix the problem, or why it’s happening in the first place, if they notice it.

Because I work with kids with problems like allergy, autism, severe picky eating, FPIES, inflammatory bowel conditions including Crohn’s disease, or all sorts of circumstances in which they don’t eat well, it’s common for me to find that a child is indeed underweight. Many parents who contact me have placed their kids on over-restricted special diets on their own, and don’t realize their kids are underfed and malnourished, even with all the best efforts at feeding well. But it can be a relief to know exactly what and how much food your child needs to grow, feel, and function better.

Usually, parents are downright surprised at what a difference something as simple as the right food intake makes for their kids.

This quote is straight out of clinic today from a mom regarding her fifth grader. Before nutrition intervention, he had severe attention and focus issues for which he’d been unsuccessfully medicated. He had accidents at school (smearing, pooping in his pants). He got sick often with colds. He was unhappy or frustrated often. After nutrition care, mom said this:

“Looks super healthy, I’ve never seen him this healthy. He seems more like a regular kid. He is thriving. He is growing like a weed. He is happy.”

This boy is off stimulant medication, using the bathroom independently and not having accidents, and has not had any infections for months, for the first time in his life.

What would your pediatrician do for these problems?

He would do what had been done for this child, and failed: Give methylphenidate (stimulants like Focalin, Ritalin, etc) for inattention and hyperactivity; Miralax for the constipation; antibiotics for the infections; and a “he seems fine” shrug for the moderate drop off of expected weight for age.

Nutrition care is not a replacement for medical care – and vice versa: Medical care is not nutrition care. They do different things, and require different skill sets. Strong nutrition in kids makes them healthy; prescription drugs mostly avert acute problems. Neither replaces the other, both are important for kids – but, unfortunately for kids all across the US, nutrition is not a big player in pediatrics nowadays.

Is your child underweight? Is it impacting their health? It’s easy to find out. There are well established criteria for determining things like expected growth pattern for a child, and how to restore it if lost. There are many tools at my disposal too, to sort out what foods would best serve your child, what foods you might really need to avoid, and what foods you really may not have to worry about. If you’re not sure, schedule an appointment and we can just find out!