Scott Webb (Host): Many parents have questions and concerns about nutritional needs as they relate to growth and weight to help our kiddos get through puberty, and it's great to have my guest here today to answer these questions and more. I'm joined today by Rachel Devine. She's a Certified Pediatric Nurse Practitioner.

 Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. I'm Scott Webb

Rachel, it's nice to have you here today. We're essentially going to talk about children's nutritional needs, growth and weight, uh, as they go through puberty. So we got a lot to cover today. Uh, so let's start there. At what age do children generally start puberty?

Rachel Devine, APN, CPNP, CDCES: Thank you for having me. So we first break down puberty into boys and girls and boys will generally begin puberty somewhere between the ages of nine and 14 years old. They'll start puberty about two years later than the girls on average. We do see African American and Hispanic boys tend to enter puberty a little bit earlier.

 If a boy is showing signs of puberty before the age of nine, it's worth asking his pediatrician about these early changes. And similarly, if we see no signs of puberty by the age of 14 in a boy, it's worth discussing that with the pediatrician as well. For girls, we'll generally see puberty about two years earlier than boys, and puberty for girls usually will start somewhere between the age of 8 and 13 years old.

And again, African American and Hispanic girls tend to start puberty slightly earlier. And if girls are showing signs of puberty before the age of 8, it's important to discuss that with the pediatrician. And if a girl is not showing any signs of puberty by the age of 13, that should be discussed as well.

Host: Yeah. So the general age range is there. And obviously if it starts a little earlier or extends beyond 13, 14, just you know, boy, girl dependent, that makes sense, obviously, to reach out to a provider. Wondering if poor nutrition can delay puberty and what nutritional needs are needed for a child for puberty.

Rachel Devine, APN, CPNP, CDCES: Sure. So nutrition is one of the most important factors affecting pubertal development and consuming an adequate and balanced healthy diet during all the phases of growth, infancy, childhood, and puberty; it's necessary to get the proper nutrition for growth and normal development. Poor nutrition can either delay puberty, due to a child being underweight and poor nutrition can also cause obesity.

And that may in turn cause puberty to start a little ahead of time. Excessive eating with lots of processed foods and high fat foods may be the cause of this. And we do see that overweight and obese children are more likely to enter puberty a little bit earlier. So, puberty will trigger a growth spurt, which will increase a child's nutritional needs, and it's important at that point to increase your protein and iron and calcium and folate that is needed during this critical, rapid growth development.

If children are having malnutrition, whether it's due to an illness or through anorexia or bulimia, that can delay the onset and progression of puberty and cause more nutritional risks on their pubertal development. As a child is starting to enter puberty, having a healthy weight is very important to start the sexual maturation of things.

And if we restrict our calories during that time, it can delay the onset of our puberty.

Host: Yeah, I see what you're saying. I wanted to follow up, you know, if a family is a vegetarian, are there special considerations for a healthy puberty?

Rachel Devine, APN, CPNP, CDCES: Absolutely. So when we define vegetarian diet, there's obviously a lot of subsets of vegetarian diets, which has different restrictions. So it is important for that family and those children even to meet with a dietitian at some point, depending on what their restrictions are. Food groups that are really important to cover during puberty are, we make sure that children are getting enough calcium sources.

 Calcium is very important for bone growth and bone strength. And, cow's milk has the most amount of protein, but if they're not drinking cow's milk, we have to then be able to supplement their protein with other sources. As I said, protein is also important to help with our bone and muscle strength.

So getting other sources of protein, such as lentils and beans and eggs and nuts and soy and other tofu to help supplement the protein that may be lacking in those diets. Grains are very important. They provide a lot of vitamins and minerals and they give us a great source of energy. So getting grains that are whole grains, as much as possible and things such as brown rice and whole wheat pastas are important.

Vegetables are always a good source of vitamins and minerals and dietary fiber, and it helps, to make you feel full longer. So children should be getting two to three servings of vegetables a day, as well as fruits. Those, again, provide great sources of vitamins and minerals, and they should aim for getting two to three sources of vegetables and fruits each day. And we always have to make sure, especially for the children that are underweight, to get fats and oils into the diet. Healthy fats are important for a growing child, and they provide calories to help them grow. And sources of good fats are things such as olive oils, and nuts and nut butters and avocados are suggestions.

Host: I definitely should have eaten before we did this podcast, talking about all these yummy foods, making me hungry. I'm starting to drool a little bit. Wondering how you feel about vitamin supplements. Are those necessary?

Rachel Devine, APN, CPNP, CDCES: So if a child and adolescent has a well balanced diet; vitamin supplements are not necessary. There are certain supplements that are needed in order to make sure our bone growth is important. So we want to make sure that children and adolescents are getting enough calcium with vitamin D in their diet.

That is an important vitamin. And depending on the age of the child or adolescent, we have to vary that amount. So we generally say a child between the age of nine and 18,need about 12 to 1300 milligrams of calcium a day. The younger child between the age of four and eight needs about 800 to a thousand milligrams a day.

And the much smaller child, one to three years needs about 700 milligrams of calcium a day. Multivitamins are dependent on how your child's pediatrician may feel about that. Especially certain areas of the country have lacking fluoride in their water. And so a lot of these multivitamins will include fluoride as well.

Host: So we've talked about the links here between nutrition and puberty and the connections, if you will. Wondering if a child is not getting adequate nutrition, what can be the consequences?

Rachel Devine, APN, CPNP, CDCES: So nutritional deficiencies and poor eating habits during adolescence can have long-term consequences. As I had mentioned, children and adolescents that are severely underweight, it may delay their sexual maturation, whereas children and adolescents that are overweight, it may rapidly progress. When we worry about why that is an issue is it can cause loss of final adult height prediction.

It can cause osteoporosis, which is bone softening. It can cause menstrual irregularities in girls and it can weaken our immune system. So there are a lot of short and long term health consequences to not getting adequate nutrition.

Host: Yeah, I see what you mean. And both of my kids, my older one was an athlete and my 16 year old right now is an athlete playing multiple sports simultaneously. And maybe that's a different podcast. Wondering, do athletes have different considerations?

Rachel Devine, APN, CPNP, CDCES: Absolutely. And there is no one size fits all plan when it comes to nutrition and athletes. Obviously, depending on what their athletic sport is, it is going to require different nutritional needs. And that also has something to do with the age of the adolescent at that point. Most young athletes benefit from simple, healthy eating, with right balance of calories and proteins and carbohydrates and fats.

 They need carbohydrates to fuel their activities and their growing bodies through nutrient enriched foods. But instead of choosing foods that are high in fat and calories, they need to pick things that are more healthy in fruits and vegetables and whole grains and dairy products for sure. The more the intense the activity, the more hours you train, the higher your carbohydrate and overall calorie needs are.

 Generally speaking for young athletes to meet their daily protein, they need to make getting good sources of lean protein, such as eggs and milk and yogurt and nuts and nut butters, beans, chicken and fish. So those are all good sources of protein and their snacks need to be, choices that include protein in most of their snacks and whole grains as well.

Host: Let's talk about children with chronic conditions and any special considerations for them.

Rachel Devine, APN, CPNP, CDCES: Sure, children with chronic conditions, obviously there's a wide variety of those and they all need different dietary restrictions and so, any child with a chronic medical condition needs to meet with not only their specialist, potentially a registered dietitian to discuss what their needs are to help them grow and maintain a healthy weight.

Host: Yeah. Rachel, do you have any suggestions for adolescents with cognitive development needs to ensure that they get adequate intake as well?

Rachel Devine, APN, CPNP, CDCES: Sure, and again cognitive development needs can vary widely and so children that may be suffering with cognitive disabilities that are underweight; that parent really needs to work closely with their physician, and their dietician on supplementing their diets with correct nutritional drinks and foods to help them grow.

There's also many medical conditions that can cause children to become obese. And we do see those children really struggling with food choices and being picky eaters potentially. And parents, again, need to work with a dietician on making sure there are good food choices that are hopefully preventing the obesity.

Host: Yeah, I can really see the value of working with a dietitian. And this next question I have for you is maybe a bit of a third rail when it comes to parents and kids and talking about nutrition and their eating. But how can we do that? How can we talk about healthy eating without the risk for disordered eating?

Rachel Devine, APN, CPNP, CDCES: So when we talk to our children about healthy eating, that we really need to use those words healthy and not worrying about what our weight number is or our body size is. It's not the numbers or the way we may look, but instead what our lifestyle habits are and the way we pick our healthy foods. We really can't control what happens with the adolescents once they are outside with their friends.

Host: So true.

Rachel Devine, APN, CPNP, CDCES: So we really want to instill those good choices in our homes so that when they do leave, they make good choices. So I always want parents to make sure our refrigerator and our pantries are well stocked with healthy foods, limiting the sugar and processed foods options, and certainly trying to not keep sugar sweetened beverages in the house.

 We really encourage children to be drinking water and milk and not drinking those sugar sweetened beverages that we'll see many times outside the house. And make food convenient. Keep cut up fruits and vegetables in our refrigerator. Buy single serving portions of hummus and yogurt and peanut butter so when kids do come home from school and they're very hungry in that after school period of time, they can grab healthier options on the go.

Host: Sure.

Rachel Devine, APN, CPNP, CDCES: And also having our children involved in the kitchen in our food preparation and planning. If we are role models for our children for healthy eating habits and cooking and preparation, they will learn those sources from us. And the most important thing is getting exercise. Getting out and moving and letting kids be active. They don't need to be in organized sports, but getting them outside for a minimum of 60 minutes each day.

Moving our body produces lean strong muscles and sedentary lifestyles can promote fat cells which will cause obesity.

Host: Yeah, for sure. I want to switch gears just a little bit with you and kind of move into growth, if you will, because of your areas of expertise. If puberty is delayed, when should a parent be concerned?

Rachel Devine, APN, CPNP, CDCES: So delayed puberty is not harmful physically for the child. Significantly delayed puberty can affect adolescents more psychosocially. Since there are some medical causes of delayed puberty, they should be evaluated; but most of the time it's not a medical problem. When we have delayed puberty, as I mentioned, puberty in a boy after 14, if it hasn't occurred, or 13 for a girl, should be investigated.

But in the long aspect of things, delayed maturation of puberty is not a harmful effect and most cases will happen in time.

Host: In time, sure. Yeah, my son, our son, he was slow to grow and went through a bunch of testing and found that his HGH, the HGH in his body was, you know, 0.0, was doing absolutely nothing. And he was a good candidate for HGH and he had to give himself a shot, you know, for like four years. When he started high school, he was 4'9". Today, he's 5'10" so, so thankful that there was some help available for him.

 But just wondering in general, what can be done to increase or improve a child's growth?

Rachel Devine, APN, CPNP, CDCES: Improving growth if there is not an underlying medical issue can be done with proper nutrition, getting foods from all five food groups enriched with vitamins and nutrients, and avoiding high sugar intake and large amounts of processed foods. Adequate calcium and vitamin D intake, which can improve bone strength and growth potentially. And adequate sleep is necessary for our natural growth hormone to be produced. If your child doesn't get enough sleep, it can impact their physical, emotional, and cognitive health. If someone is consistently getting too little sleep, we call that sleep deprivation. Growth hormone is going to be suppressed.

For children ages 3 to 5, we recommend about 10 to 13 hours of sleep a night. A child who is age 6 to 13 generally should be getting about 9 to 11 hours of sleep. And the adolescents, 14 to 17 years, require about 8 to 10 hours of sleep. Our sleep routine is also very important and consistency is the key.

We want to try to maintain a regular sleep and wake schedule, including on the weekends, with having a relaxing bedtime routine. For the younger children, you really want to provide positive attention to them at bedtime, because it usually will reduce the resistance of any difficulty getting them into their beds.

Keep the bedrooms dark and cool and quiet, with no electronic equipment or TVs or cell phones. Avoid any type of drinks that may have some caffeine in it late in the afternoon or evening. And really encourage children to get to sleep in their own beds. It will help them fall asleep independently long term.

 If there is an underlying medical cause for the poor growth, then we need to look into that further.

Host: Yeah, you know, it's funny. Those are good tips for adults too, you know, don't have caffeine late in the day, you know, don't try to fall asleep with your phone in your hand. All good stuff, but certainly for kids. And I know I mentioned our son who was only four foot nine when he entered high school.

So it was pretty obvious that the kid wasn't growing, you know, when he was 14. Uh, in general though, what are some of the signs besides that maybe?

Rachel Devine, APN, CPNP, CDCES: Evaluating the child's growth curve is very important as it can show a trend. Pediatricians will plot a child's height and weight on a growth curve at each visit, and they use this to compare the child's height and weight against children of the same age and sex. Growth charts can help both the parent and the pediatrician follow the child as they grow and catch poor growth curves early on and then refer to the specialist if needed for evaluation and monitoring.

In general, a child should not be declining on their growth curve or having downward trends. There are those little dots we mark and look at on a growth curve each time. Also what's important is to see what percentile on the growth curve a child is growing and compared to their own parents. We call this the mid parental height, which is an important tool to use to compare a child's height percentiles in relation to their own parents height.

Growth curves for weight in an otherwise healthy child who is not overweight should be following a similar trend. Healthy children should not be losing weight unintentionally and should be gaining about four to seven pounds per year until puberty starts. Weight gain during adolescence varies much more widely.

Underweight children will not grow as well in general and that needs to be addressed by a pediatric gastroenterologist. If a parent has a concern in regards to their child's growth curve, they should speak with the pediatrician and possibly see a pediatric endocrinologist for further evaluation.

Host: So just wondering then when a child should be evaluated by a pediatric gastroenterologist due to their weight status versus an endocrinologist due to their growth status.

Rachel Devine, APN, CPNP, CDCES: That's a very good question. Growth charts are very important to be reviewed with the parent and their pediatrician. Generally speaking, if we have a child who is very thin, and so we may define on our BMI growth chart, under the fifth percentile would be considered underweight. They should be seen by the gastroenterologist. Generally underweight children who have poor eating habits or have any kind of difficulty with food consumption, early satiety, as we say, or any kind of abdominal issues, they need to be seen by the gastroenterologist for that. If a child is gaining weight appropriately but their growth has been very slow and on their growth curve they're seeing their growth be very slow through the years or they're dropping on the growth curve, that's when they should see the endocrinologist.

Host: Yeah, that's perfect. Well, I really appreciate your time and your expertise today. We covered a lot of ground here and hopefully it's really good information for parents, for children. Obviously, we want our kids to be happy, healthy, and to grow and be on the right part of the chart and all that good stuff. So thank you so much for your time and you stay well.

Rachel Devine, APN, CPNP, CDCES: Thank you very much.

Host: And for more information about pediatric care at Valley, please visit valleyhealth.com/children'shealth.

And if you found this podcast helpful, please share on your socials and check out our entire podcast library for topics of interest to you. And thanks for listening to Conversations Like No Other presented by Valley Health System in Ridgewood, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-291-6090 or email valleypodcast@valleyhealth.com. I'm Scott Webb. Stay well.