Good nutrition is a key component of health. Along with regular physical activity, eating well is considered fundamental to maintaining good health and reducing the risk of chronic diseases. For children and adolescents, healthy nutrition may make all the difference for lifelong physical and mental health by providing key nutrients for neurodevelopment through early childhood.1
Guidelines on what constitutes good nutrition for children and adolescents, as well as adults, are well established. Among these are 2 guidelines published in 2015, one for all Americans (adults and children)—Dietary Guidelines for Americans 2015-2020, 8th edition,2 published by the US Department of Health and Human Services and US Department of Agriculture—and one published by the Academy of Nutrition and Dietetics specifically for children aged 2 to 11 years—Nutrition Guidance for Healthy Children Ages 2 to 11 Years.3 As shown in Tables 1 and 2, the foundation of both guidelines is a shift to more plant-based foods (vegetables, fruits, lean protein) and a reduction in saturated fats, sodium, and sugars.
For some children, however, medical conditions may mandate altering the diet to manage the condition. Examples include children with celiac disease for whom gluten is restricted; children with food allergies in whom specific foods related to the allergy are eliminated; overweight and obese children in whom overall caloric intake is reduced; and those with diabetes who need to avoid foods high in simple sugar. Table 3 lists a range of medically prescribed diets.4 Other conditions for which parents may place their children on a restricted diet, less supported by evidence but growing in popularity, may include attention-deficit/hyperactivity disorder (ADHD), non-celiac gluten sensitivity, and autism spectrum disorder.5-6
Special diets are seen not only in children with medical conditions, however. Some children are placed on special diets because of family preferences or beliefs or because of limited resources. Parents against animal proteins may choose to eat a vegetarian diet, for example, offering the same diet to their children.7 Some children may lack adequate macronutrients needed for a healthy diet because they come from food-insecure households, which were estimated to account for 6.4 million households in 2015.1
For all children, regardless of whether they receive a special diet or not, healthy nutrition is paramount for normal neurodevelopment growth and good lifelong habits of eating that nourish health and wellbeing.1 For pediatricians, knowing the diet of a child is critical to ensure the physical and mental health of that child. Along with educating parents on what constitutes a healthy diet for their child, parents also need to know the potential adverse effects of special diets on their children. This ranges from inadequate intake of essential micronutrients that may lead to, for example, anemia, to the potential for increased cardiovascular risk in children consuming some gluten-free products that may be higher in sugar and fats (Table 3).4,8,9
“Pediatricians are often unaware of the nutritional impact of various diets and do not know if a patient is receiving sufficient and balanced nutrition,” according to Diane L. Barsky, MD, a pediatric nutrition specialist in the Division of Pediatric Gastroenterology, Hepatology, and Nutrition at the Children’s Hospital of Philadelphia, Pennsylvania, who, with Maria Mascarenhas, MBBS, spoke about special diets in children at the recent American Academy of Pediatrics (AAP) National Conference and Exhibition in New Orleans, Louisiana. “Pediatric patients are also consuming vitamins and supplements that can have benefits, but parents may not be aware of potentially harmful effects from these substances.”
“It is the pediatrician’s responsibility to educate himself or herself, ask their patients about special diets and supplements, and educate/counsel families about these topics,” she says.
Special diets for children
Pediatricians may encounter children on a wide range of special diets. Among the most common are a group of diets that fall under the umbrella of vegetarianism. These are primarily plant-based diets that involve different degrees of restriction on animal products (Table 4).7,10 Data from the early 2000s estimate that about 2% of US children and adolescents aged 6 to 17 years are vegetarian with about 0.5% described as vegan.10 This number may be higher based on more recent data showing that between 20% to 25% of US adults report some level of consuming a vegetarian diet.6
Although a well-balanced vegetarian diet for children and adolescents is supported by the evidence as well as associations such as the AAP,10 special attention is needed to make sure that children and adolescents on these diets are receiving the required nutrients and protein intake needed for growth and development during these formative years.7,10 Of particular concern is the potential for deficiencies in key micronutrients needed for growth, bone mineral content, and neurodevelopment throughout childhood (Table 4).7
Table 5 provides some guidance on how to prevent micronutrient deficiencies in children who transition to a vegetarian diet.1,7
Another special diet that has gained in popularity with the broadening availability of products is the gluten-free diet.11 People on a gluten-free diet avoid food and beverages containing wheat and any wheat products (durum, einkorn, emmer, kamut, spelt, enriched flour, farina, graham flour, self-rising flour, semolina, and couscous), barley, rye, triticale, and sometimes oats. Evidence supports the use of gluten-free diets when appropriately used for children with celiac disease showing that it can help eliminate symptoms of celiac disease and improve quality of life.11
1. Schwarzenberg SJ, Georgieff MK; Committee on Nutrition. Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. Pediatrics. 2018;141(2):20173716. Available at: https://pediatrics.aappublications.org/content/pediatrics/141/2/e20173716.full.pdf. Accessed November 25, 2019.
2. US Department of Health and Human Services; US Department of Agriculture. Dietary Guidelines for Americans 2015–2020. 8th ed. Available at: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Published December 2015. Accessed November 25, 2019.
3. Ogata BN, Hayes D. Position of the Academy of Nutrition and Dietetics: nutrition guidance for healthy children ages 2 to 11 years. J Acad Nutr Diet. 2014;114(8):1257-1276. Available at: https://jandonline.org/article/S2212-2672(14)00604-2/fulltext. Accessed November 25, 2019.
4. Medically prescribed diets: Indications and nutritional risks. Courtesy of Maria Mascarenhas, MBBS; Children’s Hospital of Philadelphia (CHOP).
5. Sathe N, Andrews JC, McPheeters ML, Warren ZE. Nutritional and dietary interventions for autism spectrum disorder: a systematic review. Pediatrics. 2017;139(6):e20170346. Available at: https://pediatrics.aappublications.org/content/pediatrics/139/6/e20170346.full.pdf. Accessed November 25, 2019.
6. Cruchet S, Lucero Y, Cornejo V. Truths, myths and needs of special diets: attention-deficit/hyperactivity disorder, autism, non-celiac sensitivity, and vegetarianism. Ann Nutr Metab. 2016;68(suppl 1):43-50. Available at: https://www.karger.com/Article/Pdf/445393. Accessed November 25, 2019.
7. Di Genova T, Guyda H. Infants and children consuming atypical diets: vegetarianism and macrobiotics. Paediatr Child Health. 2007;12(3):185-188. Available at; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528709/pdf/pch12185.pdf. Accessed November 25, 2019.
8. Elliott C. The nutritional quality of gluten-free products for children. Pediatrics. 2018;142(2):e20180525. Available at: https://pediatrics.aappublications.org/content/pediatrics/142/2/e20180525.full.pdf. Accessed November 25, 2019.
9. Anania C, Pacifico L, Olivero F, Perla FM, Chiesa C. Cardiometabolic risk factors in children with celiac disease on a gluten-free diet. World J Clin Pediatr. 2017;6(3):143-148. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5547425/pdf/WJCP-6-143.pdf. Accessed November 25, 2019.
10. Amit M. Vegetarian diets in children and adolescents [article in English, French]. Paediatr Child Health. 2010;15:303-314. Available at: https://academic.oup.com/pch/article/15/5/303/2639457. Accessed November 25, 2019.
11. Rostami K, Bold J, Parr A, Johnson MW. Gluten-free diet indications, safety, quality, labels, and challenges. Nutrients. 2017;9(8):e846. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579639/pdf/nutrients-09-00846.pdf. Accessed November 25, 2019.
12. Katz DL, Meller S. Can we say what diet Is best for health? Annu Rev Public Health. 2014;35:83-103. Available at: https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-032013-182351. Accessed November 25, 2019.
13. Barsky DL. The anti-inflammatory diet’s surprising benefits in children. Medscape. Available at: https://www.medscape.com/viewarticle/894241#vp_2. Published April 3, 2018. Accessed November 25, 2019.
14. Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr. 2010;92(5):1189-1196. Available at: https://academic.oup.com/ajcn/article/92/5/1189/4597540. Accessed November 25, 2019.
15. Bach-Faig A. Berry EM, Lairon D, et al; Mediterranean Diet Foundation Expert Group. Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutr. 2011;14(12A):2274-2284. Available at: http://ciiscam.org/files/download/pubblicazioni/phn%20new%20md%20pyramid.pdf. Accessed November 25, 2019.
16. American Academy of Pediatrics (AAP). A vitamin a day. Healthychildren.org. Available at: https://www.healthychildren.org/English/ages-stages/preschool/nutrition-fitness/Pages/A-Vitamin-a-Day.aspx. Updated March 26, 2012. Accessed November 25, 2019.
17. National Center for Complementary and Integrative Health (NCCIH). 5 things to know about safety of dietary supplements for children and teens. Available at: https://nccih.nih.gov/health/tips/child-supplements. Modified October 9, 2019. Accessed November 25, 2019.
18. National Center for Complementary and Integrative Health (NCCIH). Use of natural products by children. NCCIH Clinical Digest. Available at: https://nccih.nih.gov/health/providers/digest/Children-and-Natural-Products. Modified July 18, 2018. Accessed November 25, 2019.