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Pediatricians Have “Fragmented” Nutrition Knowledge

Do these guys know anything about nutrition?

“Ask your pediatrician.” That’s the mantra women hear over and over once we become moms. If you have questions on anything baby or child, it’s always “ask your pediatrician”.

Okay, here’s a twist… Just don’t ask about nutrition. It turns out that pediatricians may not know much more about nutrition – perhaps the single most powerful driver of your child’s health and well-being – than you do. It’s widely lamented that nutrition is marginalized in physicians’ training. The authors of Nutrition In Pediatrics (2008) wrote “the teaching of nutrition in medical schools is fragmented at best [and] appears to be entirely unsatisfactory”. A 2006 published report described efforts to encourage medical students to consider studying it. The solution touted in this report was a “ten hour workshop” (it was optional).  By comparison, my RD (registered dietitian) credential required 900 nutrition-specific hours of rotations in hospitals, clinics, and health departments, plus dozens of credit hours in undergraduate and graduate health and nutrition sciences.

But pediatricians must pick up this knowledge somewhere, right? Well… An older study (1975) found that “physicians learn about nutrition haphazardly”. Twenty years later, another study pegged pediatricians at about a C level (some as low as a D grade) for infant feeding knowledge. What about 2010? I checked the pediatric residency curriculum requirements for the Harvard-affiliated MassGeneral Hospital for Children, one of the world’s top training programs for pediatrics.

The word “nutrition” isn’t even on the page.

With deeper digging around their site, I unearthed a page for the Pediatric Gastroenterology and Nutrition Fellowship, an expertise that specialist physicians may pursue. But this is years’ of optional study and practice beyond what a general practice pediatrician gets – even though it covers basic topics like how to diagnose food allergies. In fact, nutrition is so absent from our pediatric health care landscape that it once triggered a peculiar phone call to me from a claims adjustor, on behalf of one of my patients. The call went like this:

Insurance Company: “Hello this is so and so insurance company calling in regard to your patient John Doe, age x.”

Me: “Yes.”

Insurance: “What are you?”

Me: “Beg your pardon?”

Insurance: “What type of provider are you?”

Me: “I’m a licensed registered dietitian.”

Insurance: “So what is that? What is the claim for? Is that physical therapy?”

Oy vey.

How nutrition – arguably the single most important thing to get right during pregnancy, infancy, and childhood – became an elective in an obscure pediatric specialty is a whole other blog topic.  But it remains a long established fact that healthy nutrition during pregnancy and early infancy lays the foundation for learning, growth, brain and whole body development, and IQ for years to come. For all babies and kids at any age, it affects sleep pattern, behavior, cognitive ability, attention, focus, and of course, growth again. It’s complex, and intertwined with every disease condition now saddling this generation of kids like never before. From asthma to autism, food allergies to ADHD, growth failure to obesity, diabetes to epilepsy, parents these days have a lot of nutrition questions that their pediatricians can’t answer.

That’s why registered dietitians specializing in children’s health are a resource you may want to know about. Here are a few examples of what a registered dietitian can do for you that a pediatrician doesn’t know how to do, doesn’t have time to do, or doesn’t want to do:

–        Help you collect and troubleshoot an accurate food intake on your child. What a child likes to eat, refuses to eat, or how strong his appetite is are all diagnostic clues for dietitians – clues that may save you time and money on lab tests or unnecessary specialist referrals.

–        Separate problems that are easily treated with nutrition tools from problems that need referral to an MD specialist.

–        Tap expertise on breastfeeding, preemie feeding, specialized infant formulas, food allergy or intolerance in infancy, or toddler feeding challenges.

–        Identify clinical signs and symptoms that signal nutrition problems, and tell you exactly how to fix them with the right nutrition intervention.

–        Discern whether or not your child is actually getting the right amount of food every day, growing as expected or not, or needing more of certain types of foods or nutrients.

–        Help you choose effective supplements and decide whether your child should use them.

–        Strategize with you on recipes, lunches, snacks, and meals that work for your household.

–        Connect you with special diet resources and practicalities of all sorts, from ketogenic diets for seizure control to diets for multiple food allergies (like GF CF diet, or diets that also omit egg, nuts, or soy) to strategies to either grow and gain more weight, or lose weight, that are safe and effective for kids.

It’s a matter of when, not if, nutrition expertise will infiltrate our pediatric health care system. Parents need it, seek it, and are very happy when they see their children thrive once it is applied. If your pediatrician is not answering your nutrition questions, find more expertise through your state dietetic association, which can refer you to dietitian experts in pediatric nutrition. You may also find help from naturopathic doctors, who study more nutrition in their training than MDs typically do. When working with a naturopath, check for long experience working with infants and children. Or, start with my books:

Special Needs Kids Eat Right: Strategies To Help Kids On The Autism Spectrum Focus, Learn, and Thrive

Special Needs Kids Go Pharm-Free: Nutrition-Focused Tools To Minimize Meds and Maximize Health and Well Being.

Using Supplements Effectively: What Works, What Doesn’t

When do kids need supplements?

If you’re reading this, then you have probably already discovered, hopefully with some guidance from your team of health care providers, that your child has a nutrition problem. Or maybe you’ve come to suspect there’s a deficit for some nutrients in your child. Should you fix it with a supplement? Does that work? What’s the best way to use those?

These are important questions for children with special needs like diabetes, food allergies, asthma and inflammatory conditions, developmental concerns like Down’s syndrome or autism spectrum disorders, inherited metabolic disorders, seizures, or growth and feeding problems. As many as 60% of children with special needs have nutrition problems that can potentially impair their functioning, learning, growth, or development (1). It has been known for decades that keeping children well nourished, whether they have special needs or not, helps them reach their functional potential, by supporting learning, growth, and development.

Supplements may fit into this, and part of my job as a pediatric dietitian is figuring out if, when, and how they do. This is something to discern based on individualized nutrition assessment. I take into account several pieces: Medical history, signs and symptoms, a food diary, a child’s growth history, circumstances of the child’s gestational period, delivery, and early infancy, and so on. The last piece to fill in the blanks would be lab data, because lab data alone can’t describe a child’s nutrition status. Here are some tips to help you use supplements more effectively. More tips are in my book Special Needs Kids Eat Right (2009, Penguin/Perigee) which you can pick up in most bookstores or libraries, or order via your favorite on line bookseller.

– Kids need food! In fact, they need much more food per pound than adults. If an adult were to eat what a toddler needs per pound, that adult would need 8,000-10,000 calories per day just to maintain normal weight. Giving lots of supplements without enough food means your child will probably not be able to use those supplements as intended. So, before buying supplements, do the footwork to give your child adequate and nutritious foods. How to do this for picky eaters with special needs is covered in Special Needs Kids Eat Right.
– Supplements don’t fix problems caused by inadequate food intake in kids. Anxiety, insomnia, irritability, rage/reactivity, behavior, low muscle tone, fatigue, cognitive difficulties, frequency of infections or illnesses, and school performance are all affected by total food intakes in children. Give a balance of healthy fats and oils, clean carbohydrates that aren’t too sugary, and easy to digest proteins every day.
– If you’ve been given a list of supplements to buy based on lab results, beware. Giving a pill for each lab finding out of reference range is a cumbersome, ineffective strategy, in my experience. For nutrition interventions to work well, children need the right amount of food, foods they can digest well, and good digestion and absorption. Your provider can help you assess whether your child needs to repair digestion and absorption before giving supplements.
– Rule out bowel infections in your child with your health care provider before beginning a complex supplement regimen. Remember, whatever you feed your child will be eaten by his resident bowel bacteria first. New research is emerging to describe how important this bowel flora can be – from helping us prevent inflammatory conditions (2), to encoding our own GI tracts with the skill to make digestive enzymes (3). Other research shows that unhealthy bowel bacteria can impact behavior or even seizures in children (4, 5) – making it all the more crucial to balance this piece before using supplements that might “fertilize” the wrong bowel flora.

Those are just a few reasons why supplements need to be worked into a total care plan for your child, rather than given without thoughtful strategy. Work with your health care providers to get it right; given in the right total context, the right supplements can work very well for children. If you need more help and information, contact me or schedule an appointment at NutritionCare.net.

Citations

1. Nutrition In The Prevention and Treatment of Disease, 2nd ed. Ann Coulston and Carol Boushey, Eds. Elsevier Academic Press. Burlington, MA and London, UK: 2008

2. Maslowski KM et al. Regulation of inflammatory responses by gut microbiota and chemoattractant receptor GPR43. Nature 2009 Oct 29;461(7268):1282-6.

3. Hehemann JH et al. Transfer of carbohydrate-active enzymes from marine bacteria to Japanese gut microbiota Nature 2010 April 8;464 (7269):908-912

4. MacFabe DF et al. Neurobiological effects of intraventricular propionic acid in rats: Possible role of short chain fatty acids on the pathogenesis and characteristics of autism spectrum disorders Behavioural Brain Research 2007;176:149–169

5. Herawati R et al. Colony count candida albicans of stool in autism spectrum disorders. Clinical Pathology and Medical Laboratory, Airlangga University E-Journal 13(1):November-2006

Orange Poop and Purple Crying: Halloween Colors Haunt Kids With Autism

Orange Poop and Purple Crying: Halloween Colors Haunt Kids With Autism

Orange and purple. Pumpkins, Frankenstein, cute goblins. It’s Halloween.  When I was a kid, October was my favorite month. Not only did it bring my birthday (still does), it felt like the most fun time of the year to me. Hurtling around outdoors with neighborhood friends on blustery, chilly fall days was my idea of heaven. We spent hours unsupervised and untracked, roaming woods and fields, and playing til our fingers were so cold it was just time to go in. New England’s blaze of colors was my backdrop. Leaf forts, leaf piles, leaf-filled scarecrows with my dad’s old clothes. Carving pumpkins, coloring decorations. Costumes, candy, staying out late to trick or treat.

It’s so different now, as kids spend less time outdoors with unstructured activities, and trick or treat traditions have faded out as we’ve become a more fearful society. Even less of this autumn joy might apply for kids with autism, sensory processing disorders, epilepsy and seizures – not to mention food allergies. It’s bad enough that this can be a traumatic week for kids on the autism spectrum and special needs. Routines and rules run amok (see Autism and Halloween: A Sometimes Scary Mix with Kim Stagliano). Behavior norms that parents work all year to teach their kids on the spectrum flip upside down. At Halloween, for some kids, confusion and anxiety mount as there are treats you can’t eat, and it’s loud, and random. But I’ve learned of news this week weirder than any Halloween trick, news that makes the autism journey at this time of year even stranger for me as a clinician.  It’s called Purple Crying.

The CDC and American Academy of Pediatrics are putting some spin together to convince new families, obstetrics nurses, and NICU staff nationwide that it’s normal to have a screaming, trembling newborn. And that colic is a “a normal developmental phase, not a medical condition”.  It actually says that on the Purple Crying website – yes, there is a Purple Crying Website.

Here we have a well funded effort afoot to systematically rework your thinking on this, right down to giving CDs about it to new parents, to take home with the new baby. The tag line on all this sends chills down my spine: “A new way to understand your baby’s crying”.

I did not understand my son’s crying as a neonate. Though the Purple Crying site does not intend to say purple babies are happy babies, my son’s crying turned him purple, and blue, and even left him unconscious for fleeting moments. It rocked his body into spasms. It kept him awake for as much as twenty straight hours, unhealthy and extremely costly for a newborn, who must eat and rest a lot, in order to survive. His limbs quivered, shook, and straightened. Yes, we called the doctor. Yes, we went to the emergency room. No, the physicians did not do anything. In fact, they were annoyed with us, because my son’s diagnostics were inconclusive. Once there were no clear test results, we went from being treated as proactive smart parents to being treated as nervous foolish parents. I should count my lucky stars: Nowadays, this scenario might land me in jail. I would be scrutinized for shaking him, in the absence of a clear cause for his symptoms. As it turned out, his symptoms were caused by an adverse event to newborn heptatitis B vaccine. But nobody told us that. We didn’t even know he’d been vaccinated in the nursery at birth. But that’s another story.

Prolonged, inconsolable screaming and crying is a serious sign of distress for an infant. It is a common feature of an adverse vaccine reaction. Is this what the purple crying public relations campaign is really about? CYA for the CDC? Like this: Your baby is suffering, maybe from a poorly tolerated vaccine we want you to use, so just ignore the crying, please.

Well, okay. Let’s acquiesce that babies can just plain cry their nuts off, boys and girls alike, for no particular reason, through the first three or five months of life, and it’s all right. Let’s make that leap of faith, and presume that we evolved to cry for no reason. We somehow got to the twenty first century, and never noticed this about human infants (but not other mammals?). Let’s presume screaming for hours on end is simply not related to a possible vaccine reaction (that may trigger lasting developmental effects, by the way), or any sort of painful inflammatory response to anything in shots or foods. Besides, the CDC reassures us that babies can look like they are in pain when they are screaming, but they’re not. Amazing creatures – they can do this for hours a day, and it’s fine. If you saw a newborn deer shrieking ceaselessly, would you think it was not in pain? Or that it was behaving “normally”?

I hate it when the CDC contradicts itself, and they’re doing it again. Here’s why this is not fine. First, obviously, it is not fine to tell parents to ignore possible signs of a vaccine adverse event. Second, for newborns, crying is exquisitely spendy. So is insomnia. It is not safe, normal, or healthy for young infants to spend hours awake and crying, week after week. Newborns are growing so fast, they need to eat two to three times more calories per pound than older kids and adults, just to stay alive. If you ate what a newborn needed, and you weighed 150 lbs, you would need to eat about 8500 calories/day just for baseline wellness. Add screaming all day and never sleeping to that, and, well, how long could you last? Just breathing inefficiently or suckling poorly can cost a newborn precious small gains in weight at the the start of life, if energy balance skews week after week into the red. This lowers nutrition status, and that in turn lowers disease resistance. Nutrition status directly correlates with immune function. Why is the CDC saying it’s okay for babies to endure something that threatens their ability to fight infection?

My next family arrives for consult in about thirty  minutes. Was their nine year old child one of the “purple criers”?  After taking nutrition histories on special needs children for eleven years, I have noticed that they usually are. They usually have more difficulty than their typical siblings did as infants, with screaming, crying, colic, and the orange part of this post: Explosive, copious, loose, orange-gold stools.  These often fill the baby’s diaper, pants, and shirt.  Stool to the neck and ankles, three or four, maybe even eight or nine times a day.  My pediatrician back in 1997 did not say it was normal for my son to have bowel movements like that. But he did tell me it was probably coming from my son’s diaper (no joke – see this memoir I published on this back in 2002). Here in my office, too many years later, pediatricians are still giving parents some peculiar feedback on this: Now it’s “toddler diarrhea”, and it’s “normal”.

No folks, purple crying and orange poop are not normal or benign.  My clinical observation is this: The more purple and orange there is in a child’s history from age 0-3, the more developmentally delayed, disabled, or challenged with inflammatory conditions the child is later on. These colors may haunt these kids for years, with lasting inflammation, developmental impacts, learning problems, or growth problems.

Colic is not a “developmental phase”.  Colic is often milk or soy protein intolerance, and it is painful. This pain is avoidable, much of the time. Food protein intolerance is not the only reason why an infant would cry, but it does account for a lot of colic in babies. It has been over-treated with reflux medications or drops to reduce gas. I give this topic a lot of ink in Special Needs Kids Go Pharm-Free, and in this blog too.  Please don’t start believing that in addition to regarding it as normal for your child to have crazy explosive poop several times a day, it’s normal for your baby to scream in pain for hours on end, months at a time.

When I was trained in public health nutrition and completing rotations as a dietitian, I never heard the phrase “toddler diarrhea”. It is now so common, no one blinks as children struggle through infancy and toddlerhood without potty training until they’re four years or older, stop growing as expected, or develop multiple food allergies and asthma. For kids with autism, it’s practically a rite of passage – often one that never ends: I have ten year olds with autism in my practice who can’t potty train, who struggle with impactions and constipation so bad they need regular hospital admissions for clean outs, and school aged kids with ADHD who can’t join sleepovers because they still wet the bed and have stooling accidents at school on a daily basis. Maybe the CDC will join up with the American Academy of Pediatrics to call this normal too. There will be a website, a CD from your pediatrician, a TV ad campaign. Followed by, no doubt, the drug of choice to fix it (mostly, it’s Miralax – another over-prescribed, non-FDA-approved-for-kids drug).

Here’s to young parents out there who are too smart to go there. Listen to your instincts and make safe choices around your child’s health care. Keep orange and purple for the fun parts of Halloween, not the horrors that can haunt your children for years.

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