Gastrointestinal complaints are extremely common in children, from mild bloating and discomfort to chronic constipation or diarrhoea, reflux and pain. The reasons behind these symptoms can be straightforward to diagnose and treat with dietary changes and sometimes with the use of medications. Most obvious to diagnose are symptoms which arise with a clear trigger, for example a child reacting to formula milk and not breast milk may have a cows milk protein allergy – or a child with constipation who drinks very little fluid could be mildly dehydrated. More severe conditions such as Crohn’s or coeliac disease can also be straightforward to diagnose, with visual changes to the gut on investigation and suggestive blood test results. Yes this is the same for adults, however what can make the diagnoses tricky is that young children are often unable to express exactly what hurts and how severely. For older children and teenagers communication may still be difficult (possibly more difficult) plus simple dietary changes may not be adhered to.
Irritable bowel syndrome is a very tricky condition to both diagnose and treat – with so many factors impacting on severity and limited diagnostic tools. The diagnosis of IBS is quite often only made after ruling out of other conditions after investigation, especially if there are any red flags. The Rome criteria is the international standard used to diagnose functional gastrointestinal disorders in adults such as irritable bowel syndrome. A decade after Rome III was released the Rome IV is shortly going to be available (www.romeonline.org) with more specific guidance for diagnosing IBS in children. The diagnosis of IBS in children is therefore unsurprisingly even more difficult and is often discovered following a long journey of suspected allergies/intolerances and dietary tweaking.
So once we have come to the point that IBS appears to be the cause of GI symptoms, which can be having a huge impact on a child/teens life; should we be using the low FODMAP diet?
The low FODMAP diet has been shown to alleviate IBS symptoms in approximately 50-80% of adults trying the diet, and is certainly very successful. The simple answer to this is yes we can use the diet with children, however the diet needs to be tackled with much more caution, support and guidance than may be necessary for a straightforward adult IBS case. This isn’t to say adults don’t need lots of guidance, however for children it is absolutely necessary to have health professionals; a paediatrician and appropriately trained paediatric dietitian, supporting this diet. There may be many factors that prevent a child from being able to follow the diet, especially as at that age you tend to have less control over the food you consume. However the low FODMAP diet may be a practical option for many and more research in this area is needed.
Until very recently there was no research which had provided data on the use of a low FODMAP diet in people under 18 years of age. The first ever published research study in children is found here: Randomised clinical trial: gut microbiome biomarkers are associated with clinical response to a low FODMAP diet in children with the irritable bowel syndrome by Chumpitazi et al 2015.
In this double blind RCT 33 children aged 7-17 with IBS completed a crossover trail where they were provided either a high FODMAP diet (up to 50g/day) or a low FODMAP diet (up to 9g/day) for 48 hours. Assessment of symptoms using a frequency and severity scale (0-10) revealed the children experienced less pain on the low FODMAP diet while overall gastrointestinal symptoms improved within 48 hours. Although this is promising work further controlled trails are needed. The use of dietary education rather than providing the food to ascertain if a child can follow the low FODMAP diet needs to be addressed in future research.
Despite the very limited evidence when it comes to children on the low FODMAP diet we can use the evidence found in the limited studies and adult trials along with our extensive knowledge of children’s dietary and social requirements through the ages to advise appropriately.
First line dietary IBS advise needs to be trialled initially which may involve manipulation of fibre, fluids, caffeine, rich foods and eating routines, before a low FODMAP diet is considered.
So why the extra caution? Plenty of people seem to be using the diet with support from the internet, apps and support groups successfully?
Nutrition from babies to teenagers is very complex, with rapidly changing requirements for macro and micro nutrients, plus their social and personal developmental changes. Any extreme change to the usual diet can have a significant impact on their overall energy intake and individual nutrients at a time where rapid and crucial growth processes are taking place, not to mention removing and adding foods at a time that a child is developing important lessons in taste preferences and eating behaviours.
Significant dietary changes can also have more impact than a parent or carer might think, as children may learn that certain foods are ‘not allowed’ or ‘bad for them’ if negative language is used around meal times and food choices. Complicated dietary changes can also be stressful for the parent or carer, which can be picked up by the child and may negativity impact a child with fussy tendencies.
One of the most crucial points to understand is that the low FODMAP diet is basically a diagnostic tool in itself; it is not a long term diet, and is simply for understanding which foods or fermentable sugar type an individual is reacting to. For adults it is generally recommended to follow the diet for 2-6 weeks. For children, I personally recommend only following the diet to the point of symptom resolution, with a maximum of around 4 weeks if followed accurately. This is to reduce the impact of strict dietary changes on a child’s intake and social development.
But it’s not all bad, the low FODMAP diet can be extremely effective for children and teenagers in reduction of GI symptoms which can have a huge impact on quality of life. This is if food reintroduction is then completed correctly, and a long term modified low FODMAP diet is followed. Eating out and finding low FODMAP meal options can be a problem on the diet. What The Fod? has produced a useful article with some practical tips on eating low FODMAP with kids (see here).
Please note these points before embarking on a low FODMAP diet for your child:
– You must see a paediatrician before starting a low FODMAP diet for your child. There may be investigations they want to do, or a much simpler explanation for your child’s symptoms. A diagnosis of IBS needs to be made and approved before starting the diet.
– If the diet is advised or agreed with your paediatrician, please ask for referral to a paediatric dietitian with knowledge of the diet (if possible) or seek private advice. Support from other parents can be very useful however you need to be careful following non professional advice given the complexity of the diet and individual requirements of children.
– The diet is not long term. Please only follow the diet for 2-4 weeks strictly or until symptom resolution before this time. Structured reintroduction should be done with guidance following this.
– Apps which are available with suitable vs not suitable amounts of food may not be applicable to children. Please be aware of this and discuss with your dietitian how to tackle this (for example ½ portion may be appropriate depending on the child’s age and size).
– If old enough, involve the child as much as possible explaining how the diet works and their role in the success of the process. This can be integral in ensuring the success of the diet. Try to keep communication open with teenagers, trying to inspire them to take the lead with the diet rather than it being something imposed on them.
– Inform those who need to know. Teachers and best friends parents for example so they are aware they may need to check with you about certain foods or if there is a reason your child is bringing their own food.
– Be aware of language being used about foods which are not suitable to be consumed. Try to avoid words like ‘bad foods’ or ‘not allowed’ to avoid any long term negative feelings about these foods, especially with young children.
– Try to give a very varied diet within the constraints, rather than sticking to a tried and tested pattern to help your child still receive a balanced diet full of variety (it is possible!) Preparation is the key…premade snacks, lunchbox plans and treats (there are so many ideas and recipes online).
– Don’t worry if a FODMAP containing food is eaten! Mistakes happen and remember we are eventually trying to find out the most suitable FODMAP load that can be tolerated. This is not an allergy with possible severe consequences.
– Avoid tricky times when commencing the diet such as holidays abroad, a time when lots of parties are planned (or their own birthday). Compliance is likely to be low which will drag out the process and not give a true understanding of how foods are affecting the child.
– Finally if you as a parent are following a low FODMAP diet, please don’t subject your children to the diet as well! They can eat the same meals plus the addition of some FODMAP containing vegetables or carbohydrates or fruit/pudding afterwards.
Research is being done which continues to help us understand the role of the low FODMAP diet for children and teenagers, which should give us some really interesting and useful information. Until then, we can successfully advise and use the diet for specific cases to help make a significant impact to young people with IBS.
Finally if you do not believe us then a useful overview of implementing the low FODMAP diet in children was discussed in a recent paper by the Monash FODMAP research team. Below is the table from the paper which we highly recommend you read, it is an excellent read (Peta Hill, Jane G. Muir, PhD, and Peter R. Gibson, MD. 2017. Controversies and Recent Developments of the low FODMAP diet)
Key points when considering the treatment of functional gastrointestinal disorders in children using the low FODMAP diet
Another interesting point this paper makes it that children under the age of 10 years have a reduced capacity to absorb fructose. Clearly therefore assessing if a child is consuming excessive amounts of fructose in fruit/fruit products and reducing intake or normalising intake of these would be an alternative option to a full restricted low FODMAP diet. Indeed combining this with a reduction in any excessive intakes of wheat/wheat products or dairy/dairy products may well be enough to reduce symptoms. Portion size and balance of a these of foods is still an important point to consider before starting a restrictive low FODMAP diet.
Good news! The first ever book dedicated to reintroducing FODMAPs is now available to purchase on Amazon. The book is titled ‘Re-challenging and Reintroducing FODMAPs – A self-help guide to the entire reintroduction phase of the low FODMAP diet’. Click on the logo for more details.
Want more information on the low FODMAP diet and IBS? Click here for the latest changes and important updates.
We recently travelled around the world and blogged about following a modified low FODMAP diet. See more on our low FODMAP diet travel section.