David Berger, MDMedical Director -Wholistic

PediatricsAssistant Professor – USF College of

NursingTampa, FL

(813) 960-3415www.wholisticpeds.com

Why won’t my kid eat?Medical issuesSensory IssuesBehavioral IssuesThere could be a combination of these

Hunger is not always a motivator to eat.

Medical Reasons for Poor EatersChronic congestion, making it difficult to breath and eat

at same timeMotor problems coordinating the feeding activityGERDGastritis/ulcersSwallowing issuesChronic abdominal discomfort

Colitis Celiac Disease Food sensitivities Constipation

Refer to GI or allergy specialist if unable to evaluate or manage

Sensory Reasons for Poor EatersDoes 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 EatersThis (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

CalciumKids older than 1 and are pre-pubescent require

600-800mg of calcium a day1000 (boys) -1200mg (girls) per day for children

entering or in pubertyMagnesium

Usually 50% of the Calcium dose, for 2 to 1 ratioVitamin D3

if estimating, 1000IU per 25lbs of body weightCheck 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/day1-7 years        75-90 kcal/kg/day7-12 years      60-75 kcal/kg/day12-18 years   30-60 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 NeedsThe age of the patient, plus 5, in gramsAdults need 25-30gm

GFCF fiber supplements includePectinInulin (i.e. Metamucil Clear and Natural)Psillium

www.nutritiondata.com

1 cup chopped

Seroussi/Lewis New Book

Special DietsAs 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, barleyDairy: 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

Casein, Gluten and Soy Free Diet

Casein, Gluten and Soy Free DietGood Resources:

www.gfcfdiet.comwww.taca.orgSpecial Diets for Special Kids By Lisa Lewis

Specific Carbohydrate DietTheory: 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.)

Specific Carbohydrate DietCertain 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

Specific Carbohydrate Diet 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 DietElaine 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/)

Specific Carbohydrate DietGood Resources

www.breakingtheviciouscycle.comwww.pecanbread.comBreaking the Vicious Cycle, by Elaine

Gottschall

Low Oxalate DietTheory

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 DietThere 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.infohttp://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 DietTheory

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 DietSalicylates

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 DietResources

Why Your Child is Hyperactive, Ben Feingold, MD

www.feingold.org

Body Ecology DietTheory

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:1. 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.

2. 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.

3. 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

Resourceswww.bodyecologydiet.comhttp://tinyurl.com/BED-ANDI (Autism Network

for dietary Intervention)The Body Ecology Diet by Donna Gates

Body Ecology Diet