Most pediatricians manage children and adolescents with mild to moderate nutritional deficiencies appropriately in the primary care setting. However, some of your patients with more complex clinical concerns can benefit from consultation with a subspecialty colleague.
It can be challenging to digest all the information, advice, and trends regarding vitamins and nutritional supplements, but staying up to date is important. This awareness will help you formulate an opinion before a patient or family member asks about a new "miracle" modality or "megadose" supplement cure.
Some supplementation advice for well children is old, well known, and time honored, such as vitamin K supplementation at birth and vitamin D supplementation for breastfeeding infants during their first 6 months of life.
The American Academy of Pediatrics is your best source of guidance on newer ideas and more recent developments. The academy also provides dependable guidance and thoughtful recommendations on overall nutritional supplementation. Stick with their evidence-based practice guidelines and policies whenever possible.
Also, consult their online publication resources often, as the academy updates their guidance frequently.
The Pediatric Nutrition Handbook is a useful offline reference. This wonderful resource has been prepared by the AAP Committee on Nutrition and is now in its sixth edition.
Patient and family counseling to optimize vitamin and supplement intake is important. Compared with prescription and over-the-counter medicines, vitamins and supplements are marketed with surprising freedom in the United States, although the Food and Drug Administration assumes some monitoring responsibilities once they are available to consumers. The agency’s involvement is surprisingly limited.
Your guidance, therefore, is crucial because vitamins, even the most familiar ones, are not harmless. Vitamins are sold openly in "health stores" and people assume they are safe. However, high doses of many vitamins can cause effects from discomfort to even life-threatening events. For example, too much vitamin A can damage the liver, and excess vitamin D can be toxic. Unfortunately, megadoses of most vitamins are not simply excreted in the urine, as is vitamin C.
Herbal supplements are even more mysterious, and there is simply not enough research to separate chaff from grain or to confidently advise patients on the benefits and harm.
There’s another issue: It does not occur to some families that supplements – especially the herbal ones – could be of interest to their medical doctor. They think of supplements in a domain that is separate from that of medical care, and forget or neglect to mention their use. In some cases, families will not disclose their use of herbal supplements because they fear your disapproval. This is a particular problem if anxiety about a child’s condition motivates parents to seek alternative therapies or unproven methods.
The best and perhaps only way of overcoming these hurdles is to ask the question about herbal supplements directly. Ideally, you already have a safe and trusting relationship with the family, one in which the family feels that you are interested and willing to listen with an open mind, and to research the subject on their behalf. If trust is established early on, before disagreements crop up, then the family knows everyone is on the same side – that is, on the child’s side – even if a disagreement does come up.
Although the issues surrounding supplementation can be complex, start with the basics. Diagnose and manage your patients who have nutritional issues by taking comprehensive histories and performing skillful physical examinations.
Signs and symptoms elicited by your evaluation drive your diagnostic work-up. No screening battery is specifically designed to catch undiagnosed nutritional deficiencies in the primary care of well children. Health maintenance guidelines support a complete blood count and comprehensive metabolic panel as being sufficient to screen healthy children. These panels also provide a good starting point to work up any nutritional deficiencies and growth problems.
Other children require special consideration, but the general rule is the same. Tailor any diagnostic work-up beyond established well-child primary care guidelines to your individual patient’s underlying condition, history, and physical examination.
Some of your patients will be at high risk for nutritional deficiency. Chronic kidney disease; growth issues related to failure to thrive; feeding challenges stemming from a neurodevelopmental disability; and deficiencies because of poverty or homelessness are examples. Because these conditions can inhibit the intake, absorption, or metabolism of nutrients, consider referral and comanagement of children with a subspecialist colleague.