Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Rachael Zimlich, RN, BSN

When thinking about protein in a diet, most people go straight to meat. But what they may not realize is there are plenty of plant products that are packed with proteins. In recent years, more and more Americans have begun to swap out animal proteins for those that are plant-based. Although this is generally seen as a good idea for adults, some may wonder if it’s appropriate for children. The big question: Can plant-based proteins give children all the nutrition they need?

Protein is an essential macronutrient in a person’s diet at any age. Across the globe, people—especially children—don’t get enough protein in their diets because of food availability or cost. Plant-based proteins are much leaner than animal proteins overall, making them more appealing as a protein “package.”

A protein package refers to all the things included in the protein source. So not only grams of protein, but also fat, sodium, and other substances. Animal protein packages typically include more fat and sodium along with the protein, whereas plant proteins have very little fat or sodium, and more benefits like fiber, according to the Harvard T.H. Chan School of Public Health.

Generally, getting proteins from plants is a healthier choice than getting this nutrient from meats, according to Harvard, but does this rule also apply to children?

Plant-based diets are suitable for children, according to guidance published by the American Academy of Pediatrics (AAP).

 Lisa Patel, MD, FAAP; and Amanda Millstein, MD, FAAP, both pediatricians serving on the AAP Council on Environmental Health, say parents are increasingly coming to their clinicians to ask about plant-based options. Patel and Millstein, who co-authored the guidance for the AAP, say there is less information on these diets for children than there are for adults, and it’s concerning because children have such unique nutrition needs.

“Parents worry whether a plant-based diet would, for example, provide enough protein for their child’s growth and development,” Patel says.

Patel and another colleague, Rebecca Philipsborn, MD, outlined guidance to help pediatricians discuss plant-based diets with parents.

“First, it’s important to realize that parents often don’t know how much protein their child needs and often aren’t aware that there are other foods that can meet protein needs beyond meat,” Philipsborn says. “To give a rough sense of how much protein a child needs, children between ages 1 and 3 years need about 13 grams of protein per day, from 4 to 8 years old they need 19 grams per day, and greater than 9 years old between 46 to 52 grams per day.”

Smaller amounts of protein may appear in other foods in a child’s diet such as oatmeal, wheat pasta, peas, broccoli, and potatoes.

“If you are following a plant-based diet where you continue to consume small amounts of eggs, meat, and dairy, your child will get all the necessary nutrients for growth,” Patel says, adding that there may be some supplementation needed if the plan is to cut out all animal products. “If switching to a vegan diet, where all animal products are eliminated, it is important to maximize sources of B12, calcium, zinc, vitamin D, and iron.”

Parents may want to feed their child more plant protein than animal for a number of reasons. Perhaps it’s already the way the parents eat, and they want the family to all eat the same foods. It can also be an environmental matter or a health decision.

“We know that the process of atherosclerosis likely starts in childhood, and parents want to know how vegetarian or vegan diets can improve health,” Patel says.

Outside of nutritional value, Patel and Philipsborn note that there are other safety concerns with meats. The World Health Organization has classified red meats as possible carcinogens, and processed meats as carcinogenic to humans.

“Parents are also beginning to understand that unless we as individuals make changes in our lives to protect our planet and mitigate climate change, the world they are leaving their children and grandchildren will pose many health threats and may be uninhabitable,” Patel says. “Reducing or eliminating our consumption of meat and dairy products is one way to decrease greenhouse gas emissions that are rapidly warming the planet.”

Finding information about plant-based diets for children is still a challenge, but Philipsborn and Patel say more guidance will be coming soon.

“The American Academy of Pediatrics is considering putting out formal guidance for pediatricians and parents given the importance both to the health of our children and the health of our planet to make the switch to a plant-based diet. Stay tuned for this,” Phillipsborn says.

Until then, they offer another resource from the Journal of the Academy of Nutrition and Dietetics

 that provides information for parents who are interested in offering their child more plant-based proteins.

1. Harvard T.H. Chan School of Public Health. The Nutrition Source – Protein. Accessed April 6, 2021.

 https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/protein/

2. Patel L, Millstein A. Plant-based diets: are they good for kids?. Updated June 2, 2020. Accessed April 6, 2021.

 https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Plant-Based-Diets.aspx

3. Melina V, Craig W, Levin S. Position of the academy of nutrition and dietetics: vegetarian diets. 

. 2016;116(12):1970-1980. doi:10.1016/j.jand.2016.09.025

Articles

Plant-based proteins may be healthier for our bodies and the environment, but there’s not much guidance on these types of diets for children.

Plant-based protein diets for children

Social media platforms have become an increasingly popular tool for information and communication during the coronavirus disease 2019 (COVID-19) pandemic. As parents were forced to keep their children home from school and avoid appointments of all kinds, social media became a lifeline for some to get advice and ideas to keep their children healthy and enriched at home.

The use of social media in the clinical environment poses unique problems, though, particularly when it comes to professionalism and ethical issues.

 from the American Academy of Pediatrics (AAP) aims to help pediatricians harness the benefits of social media use and avoid risky behaviors.

“Pediatricians need to recognize that social media can be an incredibly useful communication tool with their patients and families but there a number of potential professional, ethical, and legal pitfalls to avoid as well,” says Jonathan Fanaroff, MD, JD, a neonatologist, professor of pediatrics and director of the Rainbow Center for Pediatric Ethics at University Hospitals Rainbow Babies and Children’s Hospital and Case Western Reserve University in Cleveland, Ohio. “During the COVID pandemic when there was so much confusion and rapidly changing information social media was a very important to keep patients and families up to date.”

Fanaroff was one of the authors of the new guide, along with Robert Macauley, MD, FAAP, FAAHPM, a pediatrics professor and practitioner at Oregon Health & Science University in Portland.

“Social media offers many opportunities for pediatricians to promote the health of individuals and populations, and also experience greater fulfillment and a stronger sense of community. At the same time, there are also risks involved in terms of boundaries and professionalism,” Maccauley adds. “A thoughtful approach is necessary to take advantage of the opportunities while avoiding the pitfalls.”

, a number of recommendations are made to help pediatricians navigate the ethical and legal risks involved when it comes to using digital communication tools like social media networking sites. Social media can offer pediatricians a powerful tool for communicating important health information, advocacy, and education—as well as correcting misinformation spread by non-clinicians.

“The pandemic has definitely accelerated the implementation of ‘virtual visits.’ This doesn’t fall in the category of social media, but the shift away from in-person interactions has probably increased patients’ and parents’ expectations on being able to access information and guidance remotely,” Macauley says. “Questions about preventing COVID-19 transmission and—more recently—vaccine safety and availability are particularly important for pediatricians to address, given the prevalence of misinformation on the Internet.”

According to the report, more and more people are turning to the Internet for the bulk of their communication. A favorite digital tool for many age groups is social media, with 72% of Americans—including 90% of teenagers—engaged on some social media platform. As people increasingly use social media in their personal lives, the desire to use it to communicate with their health care providers has grown, too. According to the AAP, 54% of millennials and 42% of adults would like to connect with or follow their health care providers on social media channels. Even people who don’t use social media already would be willing to sign on to improve communication with their health care providers. This trend is only expected to grow as today’s children—dubbed digital natives due to their comfort in using digital communication—grow into adult patients.

The range of comfort in using social media varies among pediatricians, though, and reports of violations or complaints of unprofessionalism online have only increased hesitation to engage with patients online.

The question then becomes how can pediatricians navigate the pitfalls of social media without losing an important tool in education and advocacy? There are many loud voices on the Internet when it comes to issues affecting children, and pediatricians have to be a part of that discussion.

Some of the many benefits of a pediatric presence on social media include:

increased access to pediatricians by patients

better access to patients for pediatric research and trial recruitment

counseling opportunities for high-risk behaviors

more opportunity for information gathering

Still, the drawbacks that can come with social media use at a professional level can outweigh the benefits for some.

It can be very easy to cross the line of professionalism on social media, especially when some level of anonymity is falsely assumed. Even simple comments or photos can cause problems when taken out of context, or providing too self-disclosure about the pediatricians own political or personal habits.

“In terms of sharing important information, the most important things to avoid are inappropriate disclosure and failure to identify conflicts of interest,” Macauley explains. “Focusing on providing accurate health information—while separating one’s personal online presence from the professional—will address the first. In terms of the second, it is important to disclose any potential conflicts of interest, such as consultant fees or any other financial incentives, if promoting a relevant product or service.”

These risks aren’t only limited to what pediatricians themselves post, but also posts that they may be tagged in by others unknowingly. Too much self-disclosure or blurred boundaries can damage a professional reputation, compromise patient confidentiality, or create a conflict of interest.

“The clinical report recommends a number of ways to provide information in an ethical manner, including having separate personal and professional social media accounts, following state and federal privacy and confidentiality laws, and 'pausing before posting', meaning considering the impact of any particular post,” Fanaroff says.

Fanaroff explains the problematic nature of the Internet, and that postings can be forever. Any posting can be saved or a screen shot taken, meaning that it can be shared or reposted even after it has been deleted.

It’s important to draw a clear line between professional and personal beliefs, as well as boundaries with patients when it comes to privacy and relationships, adds Macauley.

“It is important to separate one’s personal from professional profile, to avoid inappropriate self-disclosure. Offering patient-specific health advice raises concerns both for Health Insurance Portability and Accountability Act (HIPAA) compliance, as well as potentially inadvertently entering into a physician-patient relationship,” Macauley warns. “Caution needs to be used in responding to ‘friend’ requests from current patients, which the AAP discourages. This also applies to parents of patients, if that is the sole basis of that person’s relationship with the pediatrician. Although not technically ‘social media,’ so-called ‘patient-targeted googling’ or seeking information about a patient without that patient’s knowledge is problematic, as such information may be unreliable and raises questions about how or whether to reveal knowledge of that information to the patient.”

Some recommendations for pediatricians who want to engage in social media professionally, but who also want to minimize their risk include:

create separate personal and professional social media pages

add privacy settings to personal social media pages

do not allow tagging on professional pages

pause before posting—even things that can be deleted may not disappear forever

follow state and federal health care information privacy laws in all postings

create social media policies for anyone who works in your practice

conflicts of interest should be clearly stated in any posting

use HIPAA-compliant sites that protect patient information

don’t use patient identifiers in any postings

be respectful, even when discussing unidentified patients

maintain professional boundaries at all time on social media

any search for patient information on the Internet or social media should have clear clinical relevance

monitor your online profile for inaccurate postings or negative comments

beware of providing specific medical advice and consider all state and local rules and liability

1. Macauley R, Elster N, Fanaroff JM, Committee on Bioethics, Committee on Medical Liability and Risk Management. Ethical considerations in pediatricians’ use of social media.

. 2021;147(3):e2020049685. doi:10.1542/peds.2020-049685

Social media can be a powerful tool for patient education and advocacy, but it can also lead to risky behavior and damage a professional reputation. New guidance from the American Academy of Pediatrics offers insight on how to ethically use it.

Social media: How to harness its power and avoid its traps

The answer to this is very individualized, says Megan Pesch, MD, MS, who specializes in congenital diseases and childhood obesity at the University of Michigan Institute for Healthcare Policy and Innovation in Ann Arbor. Pesch coauthored a study in 2020 exploring picky eating habits in children of low-income families.

“Is the child limited [regarding] the variety or amount they eat, or willingness to try new foods?” Pesch asks. “What crosses that threshold?”

This question varies by socioeconomic group and household, she notes. A family who relies on public assistance to purchase food may be happy their child finishes their plate and meets their calorie needs. Another family may want their child to try a new organic vegetable.

, concluded that all children are picky eaters at some point during childhood. It’s a means of demonstrating independence. For the study, mothers answered questions about their child’s baseline behavior and eating patterns, and investigators reviewed the child’s growth. The team looked for patterns in children who were judged as being more picky than others.

Children with higher emotional lability and lower self regulation were ranked among the pickiest eaters. Parents who were very strict or demanding in regard to their child’s eating habits also tended to have pickier eaters, the authors noted.

“Feeding is cultural,” Pesch explains. “There’s no right way to do things. Where picky eating is concerned, I think there is something inherent—maybe even evolutionary—in parents, especially mothers, that feels like an instinct to feed your child well.”

That very definition though, has evolved over time. Whereas at one point, feeding your child well simply meant providing them with food, today it means so much more.

“These days, there’s even more pressure on parents to make the Instagram-perfect meal for their child to eat.” she says. “The pressures on parents to feed their children to this high standard is real.”

When the research team investigated the eating and feeding behaviors of children aged 4 to 9 years in low-income groups, Pesch says the overall finding was that kids were “stably picky.” There were really only 5 children in the study group of 300 that ever “grew out” of their picky eating,

 and the team couldn’t find any reason. “There was no real reason. They just stopped,” Pesch says.

This may not be good news for parents looking to find an answer on how to change their child’s picky eating behaviors. However, Pesch notes that parents have to realize their own role in these behaviors, too. “The mother’s approach to feeding was also stable, but mothers of picky eaters tended to be more demanding.”

Demanding behavior by parents is really just a way to get their kids to eat, but these demands and rewards for eating come at a price, Pesch cautions. The children in the study who were less picky and gave in to parents’ demands had a higher risk of obesity than the children who were more picky,

 she says. She also noted that none of the children in the picky eating group were underweight. “Maybe picky eating in kids is what we’re trying to achieve when we try to be mindful eaters as adults,” she suggests.

“Maybe we should not stress so much about fixing picky eating. Maybe we need to just focus more on positive experiences with food that families deem to be healthy and that they usually eat.”

Parents will always worry whether their children are eating well enough, and sometimes there is cause for concern. There may be physical or mental problems that complicate feeding and impair growth and development. In most cases, however, children are not being harmed by their picky eating and it’s more of a frustration for both them and their parents.

“Parents can have permission to just not fight that battle if that’s not a priority for them,” Pesch says.

The main concern is that children are growing and developing. Most picky eaters don’t have macronutrient deficiencies, she adds.

“You don’t want to feed them nuggets for dinner every night, but there is a happy medium to work toward,” Pesch says. “The needle on picky eating moves so slowly. Things that backfire are forcing kids to eat and making it a power struggle.”

An exception to this is when picky eating turns into a more serious medical issue. Avoidant/restrictive food intake disorder is the term now used to describe “extreme picky eating.” This eating disorder affects thousands of people, mostly children, and involves a true fear of food, unlike other eating disorders. The person is scared knowing they must eat while also worrying about choking or becoming sick, or just having no interest at all in eating. These children may get full quickly or have physical problems eating or even sensory avoidance, Pesch says.

For problems of this nature, pediatricians should involve someone in child psychology who specializes in treating eating or feeding disorders. Dieticians and nutritionists may also be helpful, she adds. Close follow-up of these children is necessary to make sure they keep gaining weight or at least are not losing any.

“You have to treat it like an eating disorder,” Pesch says. “A child’s No. 1 job is to grow.”

 on behaviors of picky eaters, 20% to 50% of parents perceived their children as picky, yet the majority of these children were not deficient in terms of either growth or nutrition.

 However, telling parents there is nothing to be concerned about when discussing picky eating isn’t usually helpful.

Pediatricians need to look for feeding problems or other serious issues that could be causing picky eating or failure to absorb nutrients. Advice on helpful feeding practices and nutritional requirements based on age and size are helpful in terms of tempering parental anxieties and frustrations. “Picky eaters” can be tricky to define, but the issues that lead parents to this complaint usually involve low food consumption, a tendency to only eat certain foods­ refuse food, or be unwilling to eat certain foods or try new foods. Others have strong food and drink preferences. These behaviors are most common in children up to age 10 years, according to the 2014 paper. The biggest worry among parents is whether their children are getting the nutrition they need to meet their development needs.

A starting point for education from the pediatrician might focus on a discussion about normal growth benchmarks and nutrition requirements

For infants, a tripling of birth weight by 50% from birth weight in the first year of life.

In the second year, a growth in height of about 12 cm and an increase in weight of 2 to 3 kg is expected.

Beyond age 2 through puberty, average increases between 6 to 8 cm in height and 2 kg in weight are expected.

Pediatricians should also advise parents not to take these benchmarks too literally, and inform them that genetics play a big role in how a child’s height and weight develop. Parents should also keep in mind that children often refuse new foods at first, but increase acceptance with repeated exposure. The authors of the 2014 study note that it’s not a question of the food being offered, but rather the avoidance of new foods in general. The child’s personality, temperament, culture, and family dynamics also play a big role in feeding practices.

Additionally, the amount a child consumes at each meal can vary, sparking parents’ concern. Parents should be reminded to consider the entire day’s consumption when measuring their child’s intake.

1. Fernandez C, McCaffery H, Miller A, Kaciroti N, Lumeng J, Pesch M. Trajectories of picky eating in low-income US children. 

. 2020;145(6):e20192018. doi:10.1542/peds.2019-2018

2. Ong C, Phuah K, Salazar E, How C. Managing the ‘picky eater’ dilemma. 

Whether it’s getting a child to eat a certain vegetable, eat something other than chicken nuggets, most parents go through feeding struggles at some point. The question for pediatricians is knowing when to offer reassurance and support, and when to offer intervention.

Picky eating: When is the time to act?

Opioid misuse is a problem of epidemic proportion across the United States. Although significant efforts have been made in recent years to curb opioid prescribing in adult patients, similar efforts have been lacking in the pediatric population. A new report offers guidelines on how to tackle this problem.

, a multidisciplinary team of health care experts on opioid stewardship presented what is believed to be the first-ever set of guidelines on pediatric opioid use for postoperative pain management.

 The goal of the report was to review data on opioid use and risks in pediatric populations, and develop evidence-based opioid prescribing guidelines for children who need surgery.

Lead author of the report, Lorraine Kelley-Quon, MD, pediatric surgeon at Children’s Hospital Los Angeles in California, said pediatricians should encourage families to ask surgical teams about pain management both before and after any surgeries. They need to know what to expect, and how to treat pain effectively and safely.

“If a pediatrician is concerned about managing pain for a child that just had surgery, he or she should communicate both with the child’s surgical team and the family if there are concerns or questions,” Kelly-Quon said.

Historically, there have been previous guidelines for opioid prescribing in adults following surgery but no guidelines targeting the unique needs of children and families, she added.

Clinicians who care for children after surgery should be aware of the risks of using opioids in this population for pain management, and work to maximize non-opioid pain management strategies and educate families about these options. The expert panel that created the guidelines identified frequent opioid misuse in the adolescent population—especially when non-opioid options were found to be as effective.

In drafting the report, the team reviewed data from 1988 to 2019 and drafted 20 guidelines over a course of a 2-day summit. Misuse of opioids in the adolescent years is associated with opioid abuse problems later in life, as well as other high-risk behaviors. Extra opioids exist most often in a teenager’s home after surgery, the report notes, and new and ongoing use of opioids occurs in about 20% of children after surgery.

Many health care institutions have drafted opioid prescribing guidelines for adults in an effort to stem the ongoing opioid epidemic, yet similar guidance has been lacking for children. In developing this first-ever evidence-based opioid guideline for children, the panel sought to answer the following questions:

What are the risks of opioid use and possible long-term use of these medications in pediatric populations?

What are some non-opioid options for pain management?

What education should be provided to patients and families in regard to pain management after surgery?

The recommendations that were made based on these questions generally center on opioid avoidance in favor of non-opioid pain management, and dedicated education on managing pain for patients and families.

The guideline notes that a significant number of teenagers with access to opioids misuse them, and for many, access begins with a valid prescription. This misuse often is associated with a higher rate of heroin abuse and long-term opioid dependence, the report revealed. Teenagers who receive an opioid prescription have high rates of diverting these medications, as well, and are likely to receive additional opioid prescriptions in the years following initial use.

Clinicians have to be aware of these risks, the panel notes, and work to develop postoperative pain management regiments that control pain and also practice good opioid stewardship. In some cases, opioid-free recovery is feasible, according to the panel. Opioid-free recovery is recommended or possible for the following procedures:

If pain management after discharge is needed, non-opioid options should be the first-line choice, the panel recommends.

Ketorolac was one of the most studied opioid alternatives, according to the study, and was shown to be very effective in both perioperative and postoperative pain management. Intravenous acetaminophen is another option offered in the report, as well as dexamethasone. A number of studies cited in the report also suggested that combining some of these alternatives may help as well. Appropriate anesthesia during procedures, including nerve blocks and regional anesthesia, also help to reduce opioid use, the panel suggests.

Two alternatives that weren’t as favored were the use of codeine and tramadol in children aged younger than 18 years. Multiple warnings have been issued about the use of these medications in the pediatric population by the US Food and Drug Administration, particularly in terms of respiratory complications.

In terms of education, the report suggests that frequent education—both perioperatively and post-operatively—about pain and pain management is important for clinicians to offer to both patients and their families. This education should be specific to the situation and diagnosis of the patient, and a consistent message must be repeated throughout the care process from all team members to have the best impact. In this regard, the panel suggests that institutions work to create a consistent message to be shared across locations. When opioids must be prescribed, education should focus on safe storage and disposal of medications, as well as the possibility and seriousness of adverse effects that can occur with opioid use. The panel even recommends that health care centers may want to consider offering opioid disposal resources, as 30% of caregivers admitted to keeping excess opioids in the home because they didn’t get around to disposing of them, and 16% didn’t know where to take them.

“It is our hope that these guidelines will be used by health care providers to highlight the risks inherent in using prescription opioids; advocate for the use of non-opioid alternatives to minimize or eliminate the need for opioids; and that families will be engaged in education about appropriate use, storage, and disposal of opioids,” said Kelly-Quon.

1. Kelley-Quon L, Kirkpatrick M, Ricca R, et al. Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. 

. November 11, 2020. Epub ahead of print. doi:10.1001/jamasurg.2020.5045

Non-opioid pain management recommended in pediatrics when possible, according to new guideline.

Rachael Zimlich, RN, BSN

Articles

Plant-based protein diets for children

Social media: How to harness its power and avoid its traps

Picky eating: When is the time to act?

Expert panel warns against post-op opioid use in pediatrics