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Melanie Cole (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels.

Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And today we're talking about infant and child vitamin needs, vitamin D and iron supplementation in infants and children. Joining me in this panel today are my guests, Dr. Sherry Huang. She's the Site Medical Director for Pediatrics Lower Manhattan and an Assistant Professor of Clinical Pediatrics at Weill Cornell Medicine. And Alexis Fissinger. She's a Pediatric Dietician at New York Presbyterian Center for Advanced Digestive Care and New York Presbyterian Weill Cornell Medical Center's Ambulatory Care Network. Ladies, thank you so much for joining us today. And Dr. Huang, welcome back.

Can you tell us the difference between vitamins, minerals, herbals, botanicals, amino acids, enzymes. There's so many things that we see at that big wall at the pharmacy. Tell us a little bit about what we're looking at.

Sherry Huang, MD, FAAP (Guest): Thank you. Yes, it's a pleasure to be back Melanie. I am happy to explain the differences among these different often confusing terms. So vitamins are a number of unrelated organic substances, and they cannot be synthesized by the human body. So, they need to be ingested in the diet in small quantities for optimal health. They're divided into water-soluble and fat-soluble vitamins. And we'll talk about more about that later. Dietary minerals, these are elements that are required in small amounts for normal health and function, and they form only 5% of the typical human diet. They can be classified according to the amount that's required.

Macro minerals are minerals that are required in larger amounts, slightly larger amounts and more than 100 milligrams a day. Some examples of these are sodium, potassium, chloride, calcium, magnesium, and phosphorus. Then there are your trace minerals. These are defined as minerals that are required in amounts between one to a hundred milligrams per day by adults. These include iron, copper, fluoride, iodine, manganese and zinc. And then we have what we call the ultra trace elements that are required in really small amounts, less than one milligram per day by adults. And these are for example, chromium, selenium, as well as arsenic and boron. And then we have our herbs. Herbs are fresh or dried plants and botanicals are fresh or dried plant parts or chemical components that are distilled from plants and used for food, health and cosmetic purposes. We also have amino acids. These are molecules that are the building blocks for the proteins, hormones, and neurotransmitters that are essential to the body's function. The human body needs 20 amino acids to function properly, but we're unable to make nine of these amino acids.

So, they must be part of our diet. Foods are the main source of amino acids. Although some people take certain amino acids supplements in the hopes of boosting athletic performance or mood. And then finally we have enzymes. These are proteins that help speed up chemical reactions in our bodies. So our bodies have thousands of enzymes that are essential for digestion, liver function, nerve function, growth, and cell repair.

So having too little or too much of a certain enzyme can lead to health problems. In general, healthy people get all the enzymes they need from their diets. However, some people with chronic conditions may need to take enzyme supplements to help their bodies work as they should.

Host: Wow. That was an excellent comprehensive list. Dr. Huang, thank you so much. So Alexis, what are some of the common vitamin deficiencies that you see in infants and toddlers and tweens and really the prevalence of iron deficiency in our kiddos? I remember my son, when he was little, he had them. So, we had to do the Slo FE and ugh, with the constipation and everything like that. But what do you see most often?

Alexis Fissinger, MS, RD, CSP, CDN (Guest): So most often across all age groups, it's vitamin D and iron. Specifically, iron is important during those periods of more rapid growth like infancy and teen years. So that's when a supplement might be important. But to break it down into the age groups are infants, iron and vitamin D. They are at risk for these deficiencies. In children, vitamin D and iron a little bit. They are not growing as rapidly during their childhood as they are during infancy and teen years. So, their needs are not as high, but that common, quote unquote picky eating stage during childhood does put them at risk for iron deficiency. And then calcium as well becomes, something that we not necessarily see in the lab work as a deficiency, but more on my side when I'm asking about their diet, and insufficient diet of calcium. And then in teens, all three of these iron, calcium and vitamin D are very high risk for being deficient in these.

And for iron deficiency, is kind of common. In the US up to 15% of toddlers are iron deficient. And then, that risk kind of decreases until adolescence. And then adolescent girls are actually about 16% of them are iron deficient in our country.

Dr. Huang: I'd like to add that vitamin D deficiency and insufficiency is also similar in terms of the prevalence. So it's about 15% of children in the US and then we see very, very low vitamin D levels in about one to 2% of children in the US.

Host: Thank you both. So Alexis, there's a lot of confusion about vitamin supplementation for young children. What is the current thinking regarding that supplementation for kids? And is this something that we learn about from our pediatrician, do we bring our children to a dietician? Do we go to the pharmacy and start looking at that wall of stuff? What is going on right now as far as recommendations?

Alexis: Yeah, absolutely. Very, very confusing topic for many parents. But we do have certain standards, that your pediatrician can inform you of like when to give vitamin D, when to give iron, when to give a multivitamin, when it's just very unclear if they're getting enough. But in general, multivitamins, the supplementation of that is not necessary in young children who are healthy and eat foods from all food groups, as well as drinking milk. So if they eat fruit, vegetables, they eat some proteins and starches, they probably don't need a multivitamin, but in children who have severe picky eating, like they accept 20 foods or less, have feeding difficulties, refuse an entire food group, like no fruit, if they have food allergies, or a family food preferences, like a vegan household or gluten-free; these children most likely will need some sort of supplementation, whether that's a multivitamin or specific single nutrients. Now you can talk to your pediatrician about this and if they are uncertain, very unclear, then they can refer you to a dietician about more recommendations for what to supplement. I will say that as a pediatric dietician, no matter what a child is referred to me for, I'm always assessing these key nutrients that are commonly low in the diet, or commonly requiring high amounts depending on their growth period. So always iron calcium and vitamin D is in my mind. And those are the most likely vitamins to need supplementation.

Host: Well then Dr. Huang, are there signs and symptoms that would tell us our children are not getting enough nutrients? Are there some things parents would be able to identify? Or is it something that the pediatrician would notice at their well visit? Tell us a little bit about anything that might send up a red flag, letting us know that our kids have an issue.

Dr. Huang: So yes, vitamins and minerals play really varied roles in our bodies and they can essentially affect every organ system. But one way that we can tell if a child may lack vitamins and nutrients is by eliciting a thorough diet history during our visits. So, don't be afraid to tell the pediatrician everything that your child eats in a day or in a week, or, what they get in school with the nanny or the caretaker feeds them.

We also look carefully at the child's growth chart to make sure that their height, their weight, the heads circumference, these are increasing proportionally. And then we also make sure that the child is developmentally on track. So, we ask parents to track the skills that they acquire. There may be some physical signs in the hair, their teeth, or skin that we look at. We also look at certain bones in the body. So if there's a concern for vitamin D deficiency, we'll take a look at the bones in the legs. We ask parents to take a look at how their child is performing in school.

What their endurance is, if they're more fatigued than usual, this makes me, suspicious for iron deficiency. Then also sometimes on physical exam, we might hear a murmur, which indicates to me possible iron deficiency and anemia. We do regular blood checks for anemia in toddlers and in adolescents who are menstruating. And then we ask them about chronic diseases, chronic conditions, such as diarrhea or, malabsorption or, picky eating. These children are really at a high risk of vitamin deficiency.

Host: Such an important topic, really something that I think as a parent, and I remember when my kids were young, we worry so much that our kids are not getting enough of these important nutrients. So Alexis, what are the best ways? Obviously we would like them to get it in food. And you mentioned foods before and picky eaters, which in itself is its own podcast, but is there any difference in the delivery method for vitamins and supplements? How do we know how much to give, if our pediatrician isn't necessarily giving us a prescription, do we follow the bottle? Do you have a preference on chewables versus tablets versus liquids? Tell us a little bit about that.

Alexis: Yes, there are a lot of options. And, you had mentioned all of them, chewable, gummy, liquid, tablet. It can be quite confusing. They are slightly different. One is, how is the child's going to accept it? So I will say in my practice, chewable are not often the tastiest. Kids usually prefer the gummy or liquid, and that's okay if they need a vitamin, you know, it might have extra sugar in these gummies or liquids, but if they need one, you have to give them the one that they are going to accept.

My hesitation with things like gummies is that they're often like candy to the child. So, I would say most importantly, if you are going for a gummy, keep that vitamin somewhere where they can not access because an overdose of it is possible and can be dangerous. So, do follow the dosing instructions on the box of the vitamin. There are usually instructions for different age groups and that's the maximum I would recommend because we can remember, that your children are getting some vitamins and minerals from anything they eat. So, I would stick to the maximum dose for their child's age on the box. One important thing to note is that iron typically is not in your gummies.

It's more in the chewables. There are some liquid iron vitamins. So if your child specifically needs extra iron, then you will want to stick to a chewable or liquid. Also, calcium is not very common in multivitamins in general. So if your discussion with your pediatrician or dietician finds that the child needs calcium, primarily, you will want to look for a separate calcium instead of going for one of these vitamins.

Host: I think one of the very important questions that parents have, Dr. Huang, are these FDA regulated? How do we know if they're safe? I mean, obviously there are some brands that we'll see at our pharmacy that are sort of tried and true and we've seen them around for so many years that we know, but there's a lot of brands out there. Tell us a little bit just briefly about the regulation if they are, so we know that we can trust them.

Dr. Huang: So first the good news, and I wanted to just compare the different ways that the FDA is involved in these supplements. So the FDA does approve drugs and vaccines. The use strict criteria to make sure that they're safe and effective. The FDA does not approve infant formulas, but they're very, strictly regulated by the FDA. So, they must contain specific nutrition and labeling required. So all formulas that are sold in the US have standard levels of iron, calcium, vitamin D, et cetera. And then on the other hand, vitamins, minerals, herbs, amino acids, these things that we talked about before, they are considered dietary supplements and they're regulated as a food.

So therefore the FDA does not approve them like they do medications and manufacturers of these supplements are not really subject to strict FDA oversight. So, in this case, the manufacturers of dietary supplements are responsible for making sure that the products are safe before they go to market. And they're also responsible for determining that the labels are accurate. Dietary supplements, they're not reviewed by the government before they're marketed, but if the FDA has found that there are unsafe ingredients or toxic ingredients, then the FDA can take action to remove products, from the market. So, in light of this, I think it's a good idea to check the FDA website for any recalls or safety concerns, if you've decided to give supplements.

And then in terms of labeling, I would recommend, you know, in terms of looking at the brands, using a brand that has been tested by independent sources. So there are three that I can come up with the US Pharmacopia it's a USP seal. Consumer lab.com and NSF International. So the manufacturers of these supplements, they voluntarily submit and pay for their products to be independently evaluated by these organizations, to make sure that they have good manufacturing practices, accurate labeling of ingredients, and they don't have any harmful levels of contaminants. So I would look for brands that have been independently verified.

Host: Wow, what an informative show this is. I'd like to give you each a chance for a final thought. So Alexis starting with you, what are we looking for when we are looking at those labels? Now, Dr. Huang just really said a little bit for us, but I'd like you to just let parents know when they're standing there at the pharmacy, what they want to think about with their children. What they're looking for and really so that we can know that we're giving our children something quality. And even if they're not getting it in the food, and we know that that is more ideal, but kind of summarize your role of this for us.

Alexis: So if you have a child that does eat food from each food group, I would say the most important thing when you go for a multivitamin is to make sure that it has vitamin D in it. And also to make sure that whatever vitamin you choose, I would be wary of any that has a percentage that is above one or 200% of any sort of vitamin. If you do find one that does have that, I would discuss with your pediatrician or your dietician before starting something that has an excess of an amount of vitamin or mineral.

Host: And Dr. Huang last word to you. We didn't mention probiotics and fish oil. I used to call it bugs and oil for my kids when they were little. I'd like you to summarize this episode for us, but add in a little bit about probiotics and fish oil, because that's another thing that we're hearing a lot about and parents want to know.

Dr. Huang: Of course, yes. So probiotics are what many people call friendly bacteria. They live in the body and they help it work. They help your gut work well. And they defend the body from infections caused by other unfriendly bacteria. You generally can get probiotics in your diet from fermented foods.

So it's just kimchi, sauerkraut, yogurt and the research on whether supplemental probiotics and which specific strains, because there are so many strains, that can help reduce infant colic or help with constipation or diarrhea; that's still ongoing. So they're still considered a dietary supplement by the FDA and I would recommend not giving a supplemental probiotic before discussing it with your pediatrician.

Fish oil is a little bit different. Fish oil in the form of omega-3 fatty acids. So EPA and DHA, there have been studies that have shown that they have good cardiovascular and metabolic effects. So, they lower your blood pressure. They help lower triglyceride concentrations. They do come in a prescription drug, but also as a supplement.

But I would really just recommend two to three weekly servings of low mercury fish that are high in omega-3 fatty acids. That would be an optimal way of getting your fish oil. But, supplemental fish oil again is not so well-regulated. So again, I would choose a brand that has been verified to contain the amounts of EPA and DHA stated on the labels.

And then, my final, advice to parents is take pictures or bring in all the medications and supplements that your child takes. So, I can take a look at the ingredients and counsel parents effectively and try not to overlap on all the supplements because some supplements actually contain a hundred percent of a certain vitamin, like vitamin D, vitamin A and if you are taking multiple types, then you can overdose.

Host: Really great advice. Wow. We could go on for a long time about supplementation for kids, but what a great topic. Thank you both so much for joining us today. And Weill Cornell Medicine continues to see our patients in-person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download subscribe, rate, and review Kids Health Cast on apple podcasts, Spotify and Google podcast. And for more health tips, please visit weillcornell.org and search podcasts. And don't forget to check out Back to Health. I'm Melanie Cole.

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