Two years ago, we described what happened when well-meaning parents with serious health concerns restricted the diets of their very young children too severely. In most cases the goal was to prevent either obesity or atherosclerosis. In all instances, rigorous caloric restriction led to growth failure in children under 2.
Not all these children were followed over a long period of time, so the story is incomplete. But happily, among those parents who did receive nutrition counseling, the children began to grow.Now a new set of cases, this time involving older children, has been reported from the same medical facility, the Department of Pediatrics at North Shore University Hospital in Manhasset, N.Y. During 1986 and 1987, doctors saw 40 children who had been referred by their pediatricians some time after a routine blood test revealed the presence of elevated serum cholesterol.
Before they got to the medical center, however, many of the children had been following restrictive diets for varying lengths of time. Unfortunately, some of these regimens were too severe.
The children ranged in age from about 4 to almost 15 years. At the time of their first visit, 32 out of the 40 had normal growth patterns. That is, both their height and their weight were age-appropriate and were progressing normally.
For eight others, the picture was radically different. They were considered to have growth failure associated with dietary treatment for elevated blood cholesterol. Three showed nutritional dwarfism, meaning that their gain in length, which had been plotted since birth, did not continue on its established upward course and they stopped gaining weight. Five others either lost weight or failed to gain weight but showed no significant change in the rate at which they were growing taller. All were underweight.
Eight children may not seem like very many, but consider that it amounted to one out of every five of the group seen for elevated cholesterol.
Several differences were observed among the eight children who showed growth failure and those who grew normally. One, they tended to be older - in fact, the three who experienced nutritional dwarfism were the oldest patients seen. As a further complication, puberty was delayed in all three. A considerably longer period of time had elapsed between the initial finding of elevated cholesterol and the first visit to the Pediatric Department's Nutrition Center, an average of about 20 months, compared to just four months for those who were growing normally.
Additionally, children with growth problems tended to have more serious risk profiles for coronary heart disease. They were more likely to come from families where a close relative had experienced acute problems, particularly heart surgery and heart attack at a young age. Presumably, this previous family experience helped explain the severity of the diet.
And not surprisingly, the diets of the children with growth failure differed markedly from those who grew at a normal rate. They were consuming fewer calories; and their intakes of zinc, a trace element crucial for normal growth, were significantly lower. On average, they were consuming only two-thirds of the energy requirements and just 40 percent of the daily zinc requirements for their age and sex.
Diets of the three patients with nutritional dwarfism were considerably worse. They consumed less than 60 percent of their energy requirement, with only 20 percent of their calories coming from fat, 10 percent below the recommended level. Requirements for several nutrients fell below 50 percent of the Recommended Dietary Allowances (RDAs). In fact, they consumed Recommended Dietary Allowances for only two nutrients, vitamins E and C.
The message from these unfortunate findings is clear. A "prudent" cholesterol-lowering diet is appropriate for children who have elevated serum-cholesterol levels, and it can be perfectly safe. On the other hand, it is crucial that the diet also provide sufficient calories and a full measure of essential nutrients, particularly iron, zinc and other micro-nutrients they need in order to grow normally.
In commenting on the problem, Dr. Laurence Fineberg of the State University of New York Health Sciences Center observed that identifying children at risk seems sensible. So, too, does the use of a prudent diet.
Preventing potential problems had two components. First, this is a time when the services of a registered dietitian can be invaluable in helping the child and the family plan an appropriate diet. Second, careful monitoring of growth and pubertal development by the pediatrician is vital.
These cases bolster the argument against parents, however well-intentioned, undertaking the task of controlling fat and calories without professional guidance.