Pediatrics: Diet Matters

SUMMARY POINTS

• The article focuses on evidence for use of specific diets in treatment of attention deficit hyperactivity disorder (ADHD), pediatric headaches, eczema, irritable bowel syndrome, celiac disease, and non-celiac gluten sensitivity.
• Diets include elimination diet for ADHD, eczema, and headaches; Mediterranean-type diet for headaches; low FODMAP for irritable bowel syndrome; and gluten-free diet for celiac disease and non-celiac gluten sensitivity.
• It's important to build a team that includes nutritionists and pediatric specialists, who can play especially important roles.

SYNOPSIS: Specific diets show evidence of efficacy in the treatment of several common pediatric disorders.

SOURCE: Erlichman J, Hall A, Dean A, et al. Integrative nutrition for pediatrics. Curr Probl Pediatr Adolesc Health Care 2016;46:165-171.

These ancient words from Hippocrates still ring true today. In many disorders of children and adolescents, there is evidence that what a child eats — and also what a child does not eat — makes a difference in the outcome and management of disease states. However, there are many non-evidence-based claims and popular trends touting specific diets for childhood disorders, making it confusing for parents to choose a rational way to proceed.¹ Knowing the medical evidence for specific diets allows the practitioners to guide parents and children through this decision. The importance of recommending well-studied and medically sound nutritional interventions when considering diet modification in children cannot be understated considering, among other factors, the potential to harm the developing brain via malnutrition. Recognizing this, Erlichman et al chose to undertake a comprehensive review of dietary interventions for several common disorders of children. They chose to focus specifically on diet and not nutritional supplements; thus, the interventions do not include reviews of nutraceuticals.

Table 1 summarizes dietary interventions for common childhood disorders. Each row is devoted to one of the specified diets, contains major features of each diet, and notes disorders for which these diets can be useful (often in conjunction with conventional medication and interventions). A more in-depth discussion of each reviewed childhood disorder and the potential role of nutritional intervention follows.

Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder thought to affect about 11% of U.S. children between the ages of 4 and 17 years. Psychostimulant medications remain the standard treatment, but an estimated 25% of parents look toward integrative therapies to provide non-pharmaceutical options. The most common interventions reside in the realm of nutrition, with either diet modification or the use of supplements (such as omega-3 fatty acids or vitamins).⁸

The Feingold Diet: Proposed in 1973 by pediatric allergist Ben Feingold, it is hypothesized that hyperactivity in children could be reduced by eliminating food additives and naturally occurring salicylates from food products. Although a large 1983 meta-analysis of 23 studies looking at this relationship was inconclusive,² research continues, and more recent studies have demonstrated a relationship between artificial food additives and hyperactivity.⁹

The Oligoantigenic Diet: Also known as the few-foods diet, this is an elimination diet in which common allergenic foods are removed (see Table 1) and then reintroduced in a challenge phase to see if/when symptoms re-emerge. Since 2007, several studies have demonstrated partial benefit in a subset of children with ADHD, particularly affecting specific symptoms, including sleep and hyperactivity. These effects do not appear to be IgG-mediated.³

There may be benefit to implementing a restrictive diet to improve symptoms of ADHD in children. The mechanism of action and likely responders still need to be identified. Erlichman et al recommended the assistance of a registered dietician if considering this as an option for intervention, given the need for “in-depth assessment, counseling, and support.”

For families interested in adopting nutritional guidelines without intensive intervention or assistance of a dietician, an integrative practitioner with expertise in nutrition may be able to provide guidance and monitoring. Online resources (such as printable handouts from www.fammed.wisc.edu/integrative) can be helpful in supporting efforts to address nutritional intervention in the primary care physician’s office.

PEDIATRIC HEADACHES

According to Erlichman et al, before recommending specific diets, most headache patients are advised about general dietary modifications that include avoiding fasting, preventing dehydration, limiting caffeine, and tracking and avoiding any specific food triggers through the use of a headache diary.

Oligoantigenic Diet (see above for details): Few studies have been conducted in children, but suggestive studies from adults look positive regarding efficacy of the IgG-based elimination diet (use IgG testing to determine which foods to avoid as opposed to non-IgG-mediated response in ADHD treatment).³

Ketogenic and Modified Atkins Diet: The ketogenic and modified Atkins diets are high-fat, low-protein, low-carbohydrate diets. The modified Atkins diet is less restrictive than the ketogenic diet.⁴ Both of these diets are used to treat intractable epilepsy in children and adults. There are limited studies in children regarding these diets for treatment of headaches, but at least one study with low numbers shows promise in teenagers. Specifically, a 2010 prospective trial enrolling eight teenagers with migraines showed promising results in terms of headache amelioration, but the numbers involved make results difficult to generalize. Additional large-scale studies are necessary before this intervention can be recommended.

Mediterranean-style Diet: The Mediterranean-style diet is becoming increasingly well-studied and shows promise in multiple areas of health and well-being.⁵ Characterized by plentiful fruits and vegetables, whole grains, nuts, seeds, fish, olive oil, and beans; moderate poultry, eggs, and dairy; and limited red meats and sweets, this diet can be adapted and followed under many conditions. Erlichman et al noted a promising study with 23 adolescents following a Mediterranean-style diet for headaches, and they said in general this heart-healthy diet can be recommended for dietary intervention in most children. If working with very young children (younger than 3-4 years of age), it is important to consider the American Academy of Pediatrics guidance to avoid nuts because of swallowing concerns and to provide whole milk up to 2 years of age.¹¹

Conclusion: A provider is safe to recommend avoidance of known triggers (or allergens) and a Mediterranean-style diet. If a family requests pursuit of a more restrictive dietary approach (such as ketogenic, modified Atkins diet, or oligoantigenic), providers should remember that evidence is limited for efficacy of these diets for headaches in children and should enlist the aid of a dietician to support and advise in more complicated cases.

ECZEMA

An estimated 9-18% of U.S. children younger than 17 years of age carry a diagnosis of eczema or atopic dermatitis; about one in three of these are considered moderate to severe in intensity.¹² There is evidence that food allergy and/or intolerance plays a role in development and severity of eczema. Erlichman et al noted there is heightened risk of food allergy when eczema occurs in infants younger than 6 months of age, in patients whose skin outbreaks cannot be controlled with standard topical therapies, and when parents report a food reaction (either immediate or delayed).

Under these conditions, Erlichman et al recommended an elimination diet with close observation after removal of the suspected food(s) for at least two weeks. If there is no remission of symptoms after two weeks, it is unlikely that the suspected food was a trigger. They also recommended a period of open challenge (under medical supervision in case of anaphylaxis) after the two-week elimination period to confirm the suspected relationship.

Conclusion: In specific cases, there is evidence that food allergies/intolerance contribute to pediatric eczema. A carefully conducted trial of an elimination diet followed by a challenge period can help confirm diagnosis. Consider enlisting the aid of a pediatric allergist if possible and if needed to manage or monitor the patient.

IRRITABLE BOWEL SYNDROME

Often presenting as recurrent abdominal discomfort or pain not associated with inflammation or other biological markers of disease state, irritable bowel syndrome (IBS) affects up to 20% of U.S. school-aged children.¹³ Many parents look for suspected food triggers, such as high-carbohydrate foods, milk, and fatty foods. However, the most promising studies regarding diet modification in children with IBS originate from adult trials.

Erlichman et al pointed to studies involving FODMAPs (fermentable oligosaccharides disaccharides monosaccharides and polyols); these are compounds (sugar alcohols and carbohydrates occurring naturally in or added to foods) that are poorly absorbed in the small intestine and fermented rapidly in the colon, producing gas and distention. Although medical evidence suggests use of a low-FODMAP diet in adults to lessen symptoms of IBS, studies involving children are less common. Two recent trials with school-aged children showed evidence of efficacy in this population, but long-term safety in terms of nutrient balance and efficacy has not yet been established.¹⁴

Conclusion: There is growing but incomplete evidence for use of a low-FODMAP diet in children and adolescents with IBS. If this course is desired, a registered dietician should assist with implementation. However, as with many of these disorders, an integrative practitioner with experience and knowledge in this area and age group also may be able to provide treatment.

Celiac Disease and Non-Celiac Gluten Sensitivity

Celiac Disease: Affecting up to 1% of the non-Hispanic white population in the United States, celiac disease is a chronic inflammatory disorder of the small bowel caused by a genetically determined autoimmune response to ingestion of gluten products. Among other symptoms, patients present with diarrhea, poor growth, abdominal pain, and/or bone and joint pain.¹⁵

A gluten-free diet with absolute avoidance of wheat, barley, and rye (gluten is a protein found in wheat, barley, and rye) is the sole treatment for celiac disease. Erlichman et al noted that because of malabsorption issues, patients should be tested for iron and vitamin deficiencies and supplemented if necessary.

Non-Celiac Gluten Sensitivity: Defined as a syndrome “characterized by intestinal and extra-intestinal symptoms related to the ingestion of gluten-containing food, in subjects that are not affected with either celiac disease or wheat allergy,” non-celiac gluten sensitivity originally was described in the 1980s. More recent research has investigated a link to neuropsychiatric disorders, and several interesting case reports involving children with autism and psychosis have been published.^16,17 At this point, additional research is needed before any conclusions can be drawn.

Conclusion: A gluten-free diet in children with celiac disease is essential to maintain health. There is less evidence of a relationship between a gluten-free diet and extra intestinal symptoms (including behavioral) in children with non-celiac gluten sensitivity.

SUMMARY

Overall, this review serves as a reminder of the importance of diet in healthcare and treatment of illness in the pediatric population. Additionally, the unique needs of children and the difficulty of conducting large-scale controlled studies makes dietary intervention challenging in this population.

It is worth stating that compliance with dietary changes can be difficult for any patient, but even more so for a young person who often is in the midst of a search for autonomy and independence. This drive (and many social factors) may make it difficult to take to heart dietary advice. Providers should remember the importance of a team approach — enlisting not only parents, a medical provider, and a dietician but also, and perhaps most importantly, making sure the young patient maintains a primary spot on the team.

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