Pediatric Nutrition: Key Insights for Parents from a Pediatric Gastroenterologist

Podcast Transcript

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

Hi, again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the president of Maine Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm pleased to welcome a first-time guest, Dr. Senthil Sankararaman, a pediatric gastroenterologist at Cleveland Clinic Children's, who's also the co-director of Intestinal Rehab and Pediatric Nutritional Support.

Senthil, thanks so much for joining us on Butts & Guts.

Dr. Senthil Sankararaman: Thank you so much for the invitation. Very excited to be here.

Dr. Scott Steele: We always like to start out with a little bit of background and tell us a little bit about yourself. Where'd you train and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Senthil Sankararaman: Wonderful. I grew up in India, in southern part of India. That's where I attended my med school. My first western exposure is to England. So I was there for a couple of years of my pediatric and neonatal training. Then I decided to come to United States. So I did my pediatric residency in Louisiana State University, Shreveport, and I came to Cleveland in 2014 for my fellowship at the Rainbow Babies and Children's Hospital. So after fellowship, I continued as attending gastroenterologist with focus and interest in pediatric nutrition for seven years and then I decided to come to Cleveland Clinic.

Dr. Scott Steele: We're glad to have you here. Today we're going to be talking about pediatric nutrition and the many questions and challenges that parents face when raising healthy kids. And so, to start, can you share a little bit more information about the nutritional issues you're seeing in your clinic?

Dr. Senthil Sankararaman: That's a really good question, Scott. In pediatric gastroenterology clinics, sometimes patients are referred to us to evaluate for issues such as not growing, weight loss, having difficulty in feeding the child, picky eating, things like that. Sometimes they are referred to us with abdominal or gastrointestinal symptoms such as excessive vomiting, excessive constipation or diarrhea or abdominal pain after eating, things like that. And after a careful evaluation, we do find that they have nutritional deficiencies as well.

Dr. Scott Steele: I know this may seem like a little bit of an obvious question, but how important is nutrition that early stages of a child's development?

Dr. Senthil Sankararaman: This is a very important question. So, as we all know, that nutrition is important for every one of us. It maintains the building blocks of our body such as protein, muscle development, bone development, and then also it provides fuel for all of us. So we know that that's important for all of us. But infants and children, especially the first couple of years, what we call first thousand days of life, from the time of pregnancy to second birthday is very, very crucial. And for various reasons.

Number one, they're rapidly growing. So you could imagine that when a baby was born, the birth weight doubles in five months, triples in a year. So like the growth is so fast. And then other important thing is the brain development. So the maximum brain development happens in the first couple of years of life. So any issues with nutrition, say a kid doesn't get enough nutrition at the time, it directly affects the development of the child with slowing down of the milestones. And also, this is the age that they are trying a lot of things first time in their lifetime, like developing swallow skills, trying new food, trying different textures. So there are a lot of rooms that where things can go wrong. So that also adds to the complexity of managing nutrition or evaluating nutritional deficiencies at the age. And it's very, very crucial.

As we all know that in a young child, because of the rapid growth, if they are malnourished, then they are prone for repeated infections or cessation of growth, which means growth faltering, and other consequences affecting their development as well.

Dr. Scott Steele: So what are some key nutrients that parents should ensure their children are getting enough of?

Dr. Senthil Sankararaman: That's a very good question. I'm going to divide broadly the nutrients into macronutrients, which means that the major proportions of our food, as we all know that fat, protein and carbs. So those are the macronutrients. And then there are micronutrients. So that's like vitamins, minerals, and also antioxidants, trace elements, things like that. Even though we require them in a very small quantity, they are very important for our health. So going back to macronutrients, fat and carbohydrates, they provide energy for us. And proteins are building block. So you have well-balanced diet will ensure that we get all of these together. But if we have issues, then we may run into nutritional deficiencies specifically.

Dr. Scott Steele: So Senthil, I remember my mom saying, "Oh, you were a picky eater when you were a kid and your sister was." And so how can parents differentiate between the "normal" picky eating in a more serious feeding issue?

Dr. Senthil Sankararaman: Scott, that's another excellent question. Picky eating is just part of your normal developmental thing in childhood. So when we introduce a new food, oftentimes it's very common that kids do not accept right away. Some of the experts say that at least it needs about eight to 15 times reintroduction again and again before a kid accepts their new food. So that's something just normal for most children. So we recommend in that instance, we look at the growth of the kid. If the growth is really good, we just offer recommendations to parents to just try again after at a later time, maybe near a different form, different texture or adding different ingredient, things like that in a different form so the acceptance will go up. And here, mosbefot of the time, our pediatricians will be able to help the parents and as I said, the growth will not be affected.

Then we have a subset of patients, very extreme form of picky eating with very restricted food. And also here, because of the restriction, because the number of food is so restricted, it definitely affects the growth. So which means that either they don't gain weight or they may even lose weight in extreme forms. Here, most often, there may be an underlying disorder, which makes the kid to restrict the diet, so then requires more evaluation by a gastroenterologist.

Dr. Scott Steele: So you mentioned a little bit about maybe not growing or gaining weight. Are there other signs that a child might not be getting enough nutrition that they need?

Dr. Senthil Sankararaman: That's another excellent question. Again, the caveat is in early stages we may not see much symptoms and signs. That's where the suspicion should be higher to evaluate, especially if parents are worried about the portion size or the varieties of food, things like that. And then, as I said, fat and carbohydrate are the energy sources. When the diet is so restricted, the kid doesn't grow as we discussed, but then micronutrients, some of the manifestations of nutrition deficiency include getting recurrent infections, recurrent in the sense again and again, so more prone for infections, and then feeling tired excessively, sleep issues, and then skin changes or hair changes. Those could come when the deficiencies are not treated at the right time.

Dr. Scott Steele: So truth or myth, children should avoid processed foods at all costs to maintain a healthy lifestyle.

Dr. Senthil Sankararaman: That's a tough question, Scott. So my answer, I will go with myth. In ideal circumstances it is true that less processed or less ultra processed, minimizing those is good. But then we live in a practical world, most of the food we consume are processed. Some of the foods we consume are ultra processed. So foods are processed for various reasons, either to increase their shell life or add some nutrient ingredients, add some preservative, things like that. The less is better, which gives... General idea is unprocessed include fruits, vegetables, whole grain foods, nuts and legumes. So maximizing that will help the kid to minimize the dependence on processed and ultra processed food. But in this life, in this era, it's just harder to completely avoid processed or ultra processed food.

Dr. Scott Steele: We know that food is much more than just food, and nutrition in fact can maybe play a role in managing chronic conditions like diabetes or cystic fibrosis in children. So can you talk a little bit about that and can a gastroenterologist help patients with chronic conditions?

Dr. Senthil Sankararaman: Yeah, that's another excellent question. I'm going to start with cystic fibrosis. It's one of the most common genetic disorder in the western world, and it's a multi-system disorder. Oftentimes patients with cystic fibrosis will come up with recurrent lung infections or what we call exacerbations, and they also have pancreatic insufficiency, which means that their pancreas doesn't work well. So they need to take pancreatic enzymes and they can also at risk of fat malabsorption and they sometimes could excrete fat in their poop or in the stools.

So as a gastroenterologist, we always involve and part of the multidisciplinary team managing CF patients, which also includes the pulmonologist, the dietician, social worker, and many other respiratory therapist and other professionals. So here the role of gastroenterologists to maximize all the ways we can provide nutrition to the patients, and that helps them to minimize their lung exacerbations or lung infections, as I mentioned, and also prolongs their life also. So a gastroenterologists play a very crucial role in the management of CF in the cystic fibrosis patients.

Similarly, diabetic patients, especially in the pediatric world where we see more type one diabetes mellitus where they will be on insulin. So these patients are prone for a condition called celiac disease, which is the inflammatory condition against gluten intake. So endocrinologists screen for this condition, and if someone gets positive for that, they refer to us for further confirmation and also managing the condition. So same way, other chronic conditions, just to mention a few, like kids with complex heart problems, kids with complex kidney problems or cancer, neurological impairment, so in all those clinics where patients have a lot of nutritional issues, we as gastroenterologists participate and help the other specialists and help the team members in optimizing nutrition.

Dr. Scott Steele: So how can parents navigate the challenges of feeding a child with special dietary needs?

Dr. Senthil Sankararaman: That's a good question. There are so much resources out there. It's not uncommon for parents to get frustrated or get overwhelmed with all the resources. I would say, for when we say special dietary requirement, depending upon, for example, someone may have celiac disease or allergy to milk or allergy to soy or something like that, the first point of contact should be the pediatrician who, depending upon what problem or what condition we are managing, could refer to a registered dietitian or to a gastroenterologist for further evaluation and further management. Cleveland Clinic, we have so many wonderful dietitians and very specialized in their own specialties and they could help. And also, as a gastroenterologist, once we find what the special dietary requirement is, we handhold up patients, provide them education, provide them resources, and help them in minimizing cross-contamination of the food. And our goal is to prevent further nutritional deficiencies and we help them.

Dr. Scott Steele: Are there any advancements on the horizon when it comes to pediatric nutrition?

Dr. Senthil Sankararaman: There are so many advances. The most popular one is the microbiome. That's a hot topic now. We know that the microbiome changes and the most important reason for the change is what we eat. We have good microbiome, we have undecided microbiome. So with the balanced food, healthy food, our microbiome gets better and better. So there are a lot of tools never before in the past. Now, there are a lot of tools to evaluate how we respond to the diet.

The things on the horizon are, when we say about microbiome, what are the diet which enrich our good microbiome and what supplements we can use, like probiotics. The other things I'll call prebiotics. We are getting more and more advanced. One of the other important area for further research is called personalized nutrition. So the food, even though it's a healthy food, one person may react a little differently than the other person. So in the future with all the precision, artificial intelligence, predictive models, a lot of work is being done to see which helps to which patient. For example, if two people are at the risk of developing type two diabetes mellitus, the one person may be more at risk than the other depending upon what we eat and what we metabolize, things like that. So it's an exciting time of the scientific advancements are upcoming, and it'll be available for all of us in the near future.

Dr. Scott Steele: So should parents be giving kids these multivitamins that are out there that stock the shelves on? Are those of any benefit at all over and above just good nutrition?

Dr. Senthil Sankararaman: That's here a tough question, I would say. So overall, if someone gets a good balanced diet, the role for supplementing multivitamins, as I would say, less are probably nil. But then if someone has a restrictive diet, then they definitely play a role in preventing vitamin deficiencies. And then, also, depending upon the age of the child, some micronutrients are more we are at risk of getting. For example, the common ones are vitamin D, especially in Cleveland, with less sunlight, not uncommon. And adolescents, they're at risk of iron deficiency, anemia, especially the vegans and restricting their meat intake, things like that. And then also calcium because during adolescent time, they have rapid bone growth, rapid height spurt. They can be at risk of deficiency of calcium. If they're drinking enough milk and good sources of calcium, then they don't need any extra supplements or vitamins. But if you have any issues with that, then I would say consulting a dietitian, evaluate their diet by a thorough history and then go with the recommendations will be the best way to go.

Dr. Scott Steele: Now it's time for our quick hitters, a chance to get to know our guests just a little bit better. So first of all, what was your favorite trip?

Dr. Senthil Sankararaman: I would say I went to a country in Southeast Asia called Laos. It's just mind-boggling. It's just complete, so different experience for me.

Dr. Scott Steele: And what was your first car?

Dr. Senthil Sankararaman: Honda Civic.

Dr. Scott Steele: Any particular color?

Dr. Senthil Sankararaman: It's silver gray, 2009 model.

Dr. Scott Steele: Nice, nice. And what's your favorite food?

Dr. Senthil Sankararaman: I would say Mexican is my favorite food.

Dr. Scott Steele: And then, finally, just tell us something you like about living here in northeast Ohio.

Dr. Senthil Sankararaman: Our summers are great. I feel like in the last 10 years I have been here, it's getting better and better. And then I love our Metroparks, so that's what we do except the three or four months of hardcore winter. We have tried almost all the metro parks and metro park trails. They're very well maintained. I feel like they don't get that much appreciation, but again, that's my favorite.

Dr. Scott Steele: Amen to that. So give us a final take-home message for our listeners regarding this whole pediatric nutrition.

Dr. Senthil Sankararaman: Yeah. Nutrition, as I said, important for everyone, more important for children. As I said, they're active growing, yet good balance to nutrition is the key, along with good exercise and then also a good sleep. And then, if there are any issues, especially in children, there are a lot of places where good nutrition intake can be jeopardized and we are here to help.

Dr. Scott Steele: That's fantastic. And so for more information about Cleveland Clinic Children's Gastroenterology, Hepatology and Nutrition Department, please visit clevelandclinicchildrens.org/gi. That's clevelandclinicchildrens.org/gi. You can also call us at 216.444.5437. That's 216.444.5437.

Senthil, thanks so much for joining us on Butts & Guts.

Dr. Senthil Sankararaman: Thank you so much for having me. I appreciate it.

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