Feeding Issues and Special Diets

David Berger, MD Medical Director -Wholistic Pediatrics Assistant Professor – USF College of Nursing Tampa, FL (813) 960-3415 www.wholisticpeds.com

Why won’t my kid eat?
Medical issues
Sensory Issues
Behavioral Issues
There could be a combination of these
Hunger is not always a motivator to eat.

Medical Reasons for Poor Eaters
Chronic congestion, making it difficult to breath and eat at same time
Motor problems coordinating the feeding activity
GERD
Gastritis/ulcers
Swallowing issues
Chronic abdominal discomfort
Colitis
Celiac Disease
Food sensitivities
Constipation
Refer to GI or allergy specialist if unable to evaluate or manage

Sensory Reasons for Poor Eaters
Does patient frequently gag?
Does patient have aversions to certain types of tastes, textures, temperatures or colors?
Does patient have other sensory issues?
Does the patient exhibit oral defensiveness…..not wanting to put anything in his/her mouth?
This can be very time consuming to properly manage, consider referring to sensory based OT

Behavioral Reasons for Poor Eaters
This (along with bowel habits) are one of the few things that kids have “real” control over in their lives.
Is it difficult to get child to attend to the meal?
Does the child get easily distracted at the table?
Does the child frequently get up from the table?
Does the child know that he will get his food choice eventually if he “holds out”?
Again, this can be time consuming to manage, consider referral to Behavioral Therapist

Is the Child Growing?
Closely monitor all growth parameters to make sure kids are not “falling off the curve”
Weight is usually the first curve to fall, then height, then Head Circumference.
Although “Failure To Thrive” from a medical perspective, is a term used for kids not growing, this can be a very difficult term for parents to come to grips with. I look at FTT as not just poor growth, but the possibility of behavior and development being affected because of inadequate nutrition.

Essential nutrients can easily be missed in kids on special diets
Calcium
Kids older than 1 and are pre-pubescent require 600-800mg of calcium a day
1000 (boys) -1200mg (girls) per day for children entering or in puberty
Magnesium
Usually 50% of the Calcium dose, for 2 to 1 ratio
Vitamin D3
if estimating, 1000IU per 25lbs of body weight
Check 25 OH vitamin D levels. I aim to get ALL people over 50ng/ml, but special needs individuals over 75ng/ml. 100ng/ml is the upper end of desirable, possibly toxicity over that.

Pediatric Caloric Needs
0-1 year 90-120 kcal/kg/day
1-7 years 75-90 kcal/kg/day
These are general requirements. Very active kids may need higher caloric intake.

Pediatric Protein Needs
Infants 1-12 months 2.5-3.0 gm/kg/day
children 1-12 years 1.5-2.5 gm/kg/day
adolescents 12-18 years 1.0-1.5 gm/kg/day

Pediatric Fiber Needs
The age of the patient, plus 5, in grams
Adults need 25-30gm
GFCF fiber supplements include
Pectin
Inulin (i.e. Metamucil Clear and Natural)
Psillium

www.nutritiondata.com 1 cup chopped

Seroussi/Lewis New Book

Special Diets
As a general rule of thumb, if a patient is consuming high amounts of foods that are to be avoided in a particular diet, that diet may actually be what is best for him/her.
Encourage the entire household to do the diet together.
Easier to prepare only one meal for everyone.
To be supportive of the person the diet is intended for.
Foods to avoid will not be seen by the patient.
High likelihood that someone else in house will have a medical benefit .

Theory: incomplete digestion of these protein leave a residual of opiate peptides that are then absorbed and have a physiological effect. Related to ineffective or inadequate DPP-IV enzyme.
Although this has been discussed to be relative to increased intestinal permeability, I question this because opiates(ie codeine, hydrocodone) are small enough molecules to be absorbed even with intact intestinal lining.
I have kids that after a few years of biomedical tx can eventually tolerate these foods, I believe it is because they are biochemically different than when they first needed the diet.
Casein, Gluten and Soy Free Diet

Gluten: not just in wheat, but also oat, spelt, barley
Dairy: I have encountered many parents who think that eggs are dairy, since they are in the dairy section of the supermarket.
Lactose itself as an ingredient does not automatically imply there is casein in the product, but it should be a warning sign.
Clarified Butter (ie ghee) if made properly is casein free.
Soy is in many products, but soybean oil and lecithin, unless contaminated, should not contain protein. Many soy sensitive patients can handle this. I restrict these at initiation of diet if possible, but do a trial early on to see if tolerated

Good Resources:
www.gfcfdiet.com
www.taca.org
Special Diets for Special Kids By Lisa Lewis

Specific Carbohydrate Diet
Theory:
When the body ingests complex carbohydrates (disaccharides, polysaccharides, or starches) these substances must be broken down before they can be absorbed.
In the body of a person who is not able to break these substances down efficiently, an increase in undigested material allows intestinal pathogens to flourish by providing nourishment.
Pathogen overgrowth is accordingly followed by a significant increase in the waste and other irritants they produce.
Irritation in the lining of the digestive tract results in the overproduction of mucus and injury to the digestive tract, which in turn causes malabsorption and makes it even more difficult to maintain proper digestion.
(modified from Breaking the Viscous Cycle , by Elaine Gottschall.)

Certain foods, such as commercial syrups and sugars, starchy vegetables, and dairy products are not allowed while on the diet. Other foods, such as fruits, greens, animal protein, and nuts are allowed.
Allows for non lactose containing dairy products

Recommended Foods
Meat, poultry, eggs, fish, oils, butter.
Homemade yogurt: Commercial yogurt is not allowed on the diet. Homemade yogurt made from milk fermented at 100-110 degrees Fahrenheit for 24-29 hours, rendering the yogurt virtually lactose-free, is permitted.
Most vegetables except potato, yam, parsnip, seaweed and canned vegetables.
Certain legumes are allowed including navy beans, lentils, split peas, lima beans, and string beans. Many other beans such as garbanzos, soybeans and mungbeans are to be avoided.
Cheese with a low content of lactose such as Swiss, cheddar, colby, havarti, dry curd cottage cheese.
Most fruits including apples, apricots, ripened bananas, cherries, dates, berries, grape, mango, papaya, citrus, peaches, pears.
Nuts such as almonds, Brazil nuts, pecans, walnuts, filberts, raw cashews, natural peanut butter.
Honey , stevia , and saccharin are the only permitted sweeteners.
Almond Flour is used as a substitute for grain flours.
Weak black coffee and tea is permitted.
(modified from Breaking the Vicious Cycle )

“ Special” Carbohydrate Diet
Elaine Gottschall encourage the use of this term if the diet needs to be modified to also be CF
In combination with GFCF, this is very similar to the GAPS ( Gut and Psychology Syndrome) Diet ( http://gapsdiet.com/ )

Good Resources
www.breakingtheviciouscycle.com
www.pecanbread.com
Breaking the Vicious Cycle , by Elaine Gottschall

Low Oxalate Diet
Theory
Oxalate is a very simple molecule found in many plant based foods that links up with calcium and then crystallizes under some conditions, including when it encounters damaged tissues. The crystals formed this way can be quite irritating and painful to tissues where they form, causing or increasing inflammation.
In human cells, when it is present in high amounts, it can lead to oxidative damage, depletion of glutathione, the igniting of the immune system's inflammatory cascade.
Ordinarily, the gut won't absorb much of the oxalate from the diet, and the oxalate will be metabolized by the flora or just leave the body with the stool. Under other conditions, a lot of the dietary oxalate is absorbed. Increased absorption is far more likely to occur when the tight junctions between the cells which line the gut open up and let molecules pass through between the cells in a condition called "leaky gut”.
(www.lowoxalate.info)

Low Oxalate Diet
There are quite a few pitfalls with this diet, and there are certain supplements that may aid the diet, while others may be detrimental. See article “Advice for Beginners on the LOD” on the medical topics section at www.wholisticpeds.com
Other resources:
www.lowoxalate.info
http://health.groups.yahoo.com/group/Trying_Low_Oxalates/
The Low Oxalate Cookbook, available at http://www.vulvarpainfoundation.org/vpfcookbook.htm

Elimination/Reintroduction Diets
I have found much success with the Gaby Elimination diet, which eliminates many of the most common foods that cause sensitivities.
After 2-3 weeks, foods are introduced every 4 days, if negative reaction occurs, stop the food and wait for symptoms to subside before trying the next food.
Full explanation and list of foods to avoid and what to eat, as well as how to reintroduce, can be found on the Medical Topics section at www.wholisticpeds.com

Fiengold Diet
Theory
A form of Elimination diet, as sensitivity to certain foods may cause neurobehavioral symptoms.
Synthetic coloring (are made from petroleum – crude oil)
Artificial flavoring (combinations of many natural and synthetic chemicals – eg imitation vanilla flavoring or “vanillin” might originate from the waste product of paper mills). There has been little research carried on these chemicals.
Artificial preservatives (BHA, BHT, and TBHQ, made from petroleum))
Artificial sweeteners (only aspartame is eliminated)
Other food additives considered undesirable (such as MSG, sodium benzoate, nitrites, sulfites) – these are not eliminated – but are “noted” in the food list.

Fiengold Diet
Salicylates
A group of chemicals related to aspirin, which are a naturally occurring pesticide found in particular plant based-foods, but also manufactured and used in many products including medicines, perfumes and solvents).
Only some are eliminated on the Feingold diet.
Almonds, Apples, Apricots, Aspirin, Berries, Cherries, Cloves, Coffee, Cucumbers, Currants, Grapes, Nectarines, Oil of wintergreen, Oranges, Peaches, Peppers (bell & chilli), Pickles, Plums, Prunes, Raisins, Rose hips, Tangelos, Tangerines, Tea, Tomatoes

Fiengold Diet
Resources
Why Your Child is Hyperactive, Ben Feingold, MD
www.feingold.org

Body Ecology Diet
Theory
Optimize the diet so the body can have a natural balance of flora, which maintains/restores intestinal health, and that a healthy intestine is critical for a healthy body.
This is accomplished by 3 principles:
the addition of cultured foods to the diet such as fermented vegetables, organic yogurt and kefir, which is a fermented drink, made from either organic milk or coconut water.
The second principle is to change the quality of fats in the diet, using ‘good’ fats such as flaxseed oil, extra virgin olive, and coconut oils.
The third principle involves dramatically reducing carbohydrate and sugar intake. Most forms of concentrated carbohydrates are eliminated on this diet such as grains, potato, sweets, and the majority of fruits. As dieters progress on the diet they may be allowed to carefully increase their intake of fruits, high carbohydrate vegetables, and specific grains.
Modified from http://www.everydiet.org/diet/body-ecology-diet

Resources
www.bodyecologydiet.com
http://tinyurl.com/BED-ANDI (Autism Network for dietary Intervention)
The Body Ecology Diet by Donna Gates
Body Ecology Diet

Feeding Issues and Special Diets

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