Common Pediatric Nutrition Issues

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, we're going to talk about something that we haven't had much discussion about in the past, and that's some common pediatric nutritional issues. And today, I'm very pleased to welcome a new guest to our podcast. And that's Diana Schnee, who's a registered dietician in the Pediatric Gastroenterology, Hepatology, and Nutrition Department here at Cleveland Clinic Children's. Diana, welcome to Butts and Guts.

Diana Schnee: Thanks so much for having me.

Dr. Scott Steele: So, we always start out the same way. A little bit about your background. Tell me a little bit about yourself, where you're from, where'd you train, how'd it come to the point that you're here at the Cleveland Clinic?

Diana Schnee: Sure. So, I'm originally from Minnesota. I did my college training and my master's in nutritional sciences at Iowa State University. Came here for my clinical dietetic internship almost 10 years ago now. And since then, I got hired in the Department of Gastroenterology here at Children's, and I have been here ever since.

Dr. Scott Steele: Fantastic. And as a Wisconsiner, I can say my password when it says, "name the team you love to hate," it's always the Vikings, so not a big Minnesota Viking fan. So today, we're going to talk a little bit about common pediatric nutritional issues. So, to start, can you talk a little bit about what some of these, the more common nutritional issues are?

Diana Schnee: Yeah, absolutely. So, kind of big picture, what I'm looking at with the patients I work with, regardless of their medical condition, is that everything kind of boils down to getting the right nutrition to have them grow, develop, and have their GI tract function as normally as possible with the factors that we can control with the nutrition. So, I kind of divide these into three areas. So that would be growth issues, whether that's underweight or overweight, food allergies or intolerances, and then disease specific diets, which are kind of my favorite, cause they're most complex.

So, with growth issues, we're looking at kids who are both underweight and overweight. This can really be at any age. So, we're talking anywhere from infants to adolescents, anywhere in between. We even do work with some young adults. With infants, we are dealing with kids who might be failing to thrive. They might need extra nutrition through either formula or breast milk for whatever reason. And so, we're trying to make sure that we optimize those crucial times in the early in life to get them to grow. Slightly, older kids might also have growth issues, again, whether that's over or underweight, they might need some specialized oral supplements, vitamins or calorie boosters just to kind of help them catch up with growth.

With food allergies and intolerances, we do see things like this at any age, as well. Again, even in infants, we can have cow's milk protein allergy. These kids need to be on a specialized hypoallergenic formula or older kids who might have celiac disease or IBS, IBD, who might have specific foods that we need to remove from their diet, including lactose, fructose, gluten, things like that, to kind of help them feel well help their GI tracts function the best they can.

Dr. Scott Steele: So, you mentioned infants, but just how early can a nutrition issue present in a child?

Diana Schnee: Yeah. So, certainly birth is the earliest time. We have an amazing NICU team here who kind of does that hands-on right away when those kids come out if they need us, especially if those kids don't know how to suck, swallow, and breathe at the same time yet, that's when our team really helps intervene to get them the right nutrition.

Since I work primarily in the ambulatory setting, a lot of kids I see are just a little bit older, but I do take care of some kids who need me within the first few weeks of life. They might be showing signs of feeding difficulties, poor weight gain, or have some intolerance to any of the formulas or breast milk that they're on. So, especially for first time parents, this can be a really nerve-wracking time. But we do try to intervene quickly. Kids are really resilient, so we get them to turn around quite fast.

Dr. Scott Steele: So, day of life one is obviously pretty early, but let's turn that around and say who is more likely to develop a nutrition issue in childhood?

Diana Schnee: So, really any kid that's on a restricted diet for any reason probably has the highest risk. Most often, we see this with food allergies or intolerances, but also especially in the settings of complex medical conditions.

So, with allergies or intolerances, we often remove those foods as soon as we can from a kid's diet. For example, if they're dairy free, we want to make sure that they're getting adequate calcium, vitamin D, etc. But particularly with those kids with complex medical conditions, especially those with feeding tubes, they might be more at risk for nutrition abnormalities, particularly vitamins and minerals they might use a little bit differently if they have any underlying genetic issues. So, we make sure that we run labs to kind of evaluate their nutritional status and stay on top of that the best we can.

Dr. Scott Steele: Okay, so my mom said that I was a colicky baby and was throwing up all the time. So, what's a parent out there, a legal guardian, how do they know when to be on the lookout? This isn't just normal colic, it's actually something that is a nutritional issue. What do they look for?

Diana Schnee: Yeah, so I would say parent intuition. So, I probably would've told your mom, if you're feeling like something's wrong, something might be wrong. Talk to your primary care doctor. See your gastroenterologist, ask the questions. It's okay. Parenting is really hard, and I think some of us are just, we're learning as we go. But some of the obvious things we see are major growth changes. So, if a kid has some abnormal weight loss or abnormal weight gain, that's something we want to address as soon as we can. If your kid's been in the same size clothing for a while, their shoe size isn't changing, we want to look at that, address that, figure out why kid's not growing.

But even maybe prior to seeing poor weight gain or poor growth, if your kid's having any GI symptoms, such as chronic diarrhea, abdominal pain, poor appetite, these might be signs that your kid's not getting quite what they need from their diet. It could just be that they might need more fiber or fluids or some more fat in their diet, but this would be a time to get them evaluated. Also, food aversion or picky eating, especially if it's extreme in the sense where your child's eating less than 10 foods a day, they're very brand specific, those are some kind of red flags that your kid might be missing some key nutrition. So again, talk to your primary care doctor, ask to see a dietician, and we can always screen their intake and make sure we can adjust their intake to get what they need.

Dr. Scott Steele: So, "truth or myth?" Truth or myth: a nutrition issue in a child can impact their development if gone untreated.

Diana Schnee: This is a hundred percent absolutely true. Infancy and childhood are really key times to set those building blocks we need for kids to grow, learn, and develop. If a child goes for a prolonged period of time without their really good nutrition, that can certainly impact those things. So, while kids do bounce back very fast, and we do get them to do so, early intervention is always best. So, get in early, let's address those issues as early as we can.

Dr. Scott Steele: Okay, so I'm going to hold your feet to the fire here really quick. So, when really should treatment be sought for a child with a potential nutrition issue? I know that it's kind of maybe all over the map, but I throw up once, am I bringing them in to be able to see, or what are we talking about here?

Diana Schnee: Yeah, maybe not that soon. Definitely, I'd call your primary care doctor, go through triage there. But really if your kid's being seen by their primary care doctor, this is a great place to kind of screen for those prolonged issues. For sure once we see growth issues or any chronic GI upset or chronic issues that are kind of impacting that child's quality of life, I'd say, and/or the families, those are times that, let's get this addressed, let's figure this out and make sure that we can get it fixed.

Dr. Scott Steele: So, it might fall into a bunch of different bucket categories, but how does treatment work for a pediatric patient with maybe more of the common nutritional issues?

Diana Schnee: Yeah. So, on all of our visits, at the first nutrition visit, we do a full intake and assessment for malnutrition. People really freak out at the word malnutrition, but really it just means poor nutrition. So, we're looking at different factors like diet recall, feeding history. We kind of go through any medications or supplements the kid may be on. We actually also do a physical exam to assess the adequacy of fat and muscle stores. And then we work with the family to create a plan on how to address whatever their concern is. If it's picky eating, if it's overweight, underweight, food allergies, intolerances, etc. We kind of get that plan in place.

We also coordinate very, very, very closely with the medical team, the child's primary care doctor, and any specialist that might have referred the patient to us to make sure that we're all in the same place and getting a good plan in place to make sure that this kid is going to grow, develop, and be their best them. And then depending on their degree of malnutrition and their ongoing need for medical intervention, we'll continue to kind of schedule follow-ups as we need to monitor their progress.

Dr. Scott Steele: So, little kids become big kids become adolescents, and that's a transition time that's awful hard. So how does that care make that transition during that transformative period of years?

Diana Schnee: Yeah. So, we're still kind of focusing overall on growth and development, but as we get into those teenage years, now we're, as clinicians, we're kind of talking more with the patients and a little bit less focused on their parents. And that being because these kids or adolescents are really making their own food choices, right? They're out there deciding what they're going to eat, they're facing food choices on their own. And so, this independence and decision-making really kind of becomes a large factor in making any changes. So, we have to make sure that the kids are onboard, not just the parents, and that we kind of work with the child to make appropriate goals for them that they're willing to make changes with.

Dr. Scott Steele: So, conversely, this can be absolutely stressful for the parents or the legal guardians. So, do you have any advice for those parents or legal guardian of a child who's got a nutrition issue?

Diana Schnee: Yeah, absolutely. So, I'd say seek help early. It's really never a bad idea for a kid, even one who's growing appropriately to see a dietician. Again, even things like picky eating we can address. And I know a lot of parents are lost on how to feed their kids or how to go about getting them to change their diet. And sometimes even if a parent comes in and I tell a child the same thing a parent's been telling them, it comes from a different person. Maybe a different way of talking to them, and we're trained to do that. So, it can be helpful to have a third party involved there, and often it can feel like one more thing that you have to manage with these nutrition issues. But really, we do see when we feed these kids right, when we get them the right nutrition, they grow, develop, learn, and behave the best they can.

Dr. Scott Steele: So, are there any advancements on the horizon when it comes to diagnosing or treating nutritional issues in pediatric population?

Diana Schnee: Yeah, so I would probably say in any place in the world that there's medical advancements going on, there's also nutrition advancements. So, it's kind of hard for me to boil it down. But I would say, with regard to the world of malnutrition, right now in particular, we're looking at new ways to diagnose malnutrition as early as those premature babies that are in the NICU that we take care of. So, that's something that's coming down the hatch.

And then, in my particular area of focus with gastroenterology, we're looking at a lot of specialized diets to treat IBD or inflammatory bowel disease. And this has been a very hot topic and a cool place to intervene because we see that with just changing kids' diets, we're able to induce remission or keep kids in remission longer, even in conjunction with medical therapy or medicine. So, it's an awesome place where we can have control over kids' intake and their outcomes and that the kids and the families feel like they have a little bit more control, as well.

Dr. Scott Steele: So now it's time for our quick hitters, a chance to get to know you a little bit better. If I was to turn on your radio, iPod, Spotify, you name it, what would I be listening to?

Diana Schnee: Lots of country music.

Dr. Scott Steele: Fantastic. And so, what is your favorite food?

Diana Schnee: Oh, geez. I'd probably have to say peanut butter.

Dr. Scott Steele: What's your favorite sport to play?

Diana Schnee: Oh, this is a tough one. I don't know if people would call this a sport, but CrossFit is probably my go-to.

Dr. Scott Steele: I do not like thrusters. But other than that, it's very, very viable to do the work out of the day. And then finally, you're from Minnesota, went to Iowa back here in Cleveland Tell us something that you like about living here in Northeast Ohio.

Diana Schnee: Yeah. I love Metroparks. It's something I didn't really know much about until I moved here, and I think Cleveland gets a really bad rap, but there is a lot of nature tucked in here, so it's awesome to explore those.

Dr. Scott Steele: Absolutely. That's great. So, give us a final take home message regarding common pediatric nutrition issues.

Diana Schnee: Yeah, I would just add that a dietician can be a very crucial part of your child's medical team. I think, often, people just think I have all these doctors in a row, but a dietician looped in can be very helpful. We definitely monitor growth and development very closely. And again, even if your kid is healthy, we are here to help, here to figure out what we can do to optimize your kid's growth.

Dr. Scott Steele: Super advice. And so, to learn more about the Department of Gastroenterology, Hepatology, and Nutrition here at Cleveland Clinic Children's, visit ClevelandClinicchildrens.org/GI. Again, that's ClevelandClinicChildrens.org/GI. You can also call us at (216) 444-5437. That's (216) 444-5437. Diana, thanks so much for joining us on Butts and Guts.

Diana Schnee: Thanks for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.