Dietary Fiber for Children: How Much?

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neutral sterols in healthy subjects. Cancer Res. 1989;49:4629-4635

46. Weisburger JH, Reddy BS, Rose D, Cohen U, Kendall ME, Wynder EU.

Protective mechanisms of dietary fibers in nutritional carcinogenesis. In: Bronzetti C, ed. Antimutagenesis and Anticarcinogenesis Mechaniasms III. New York: Plenum Press; 1993:45-63

47. Hardinge MG, Chambers AC, Crooks H, Stare FJ: Nutritional studies of vegetarians. III. Dietary levels of fiber. Am I Cliii Nutr. 1955;6:523-529 48. Sanders TAB, Purves R. An anthropometric and dietary assessment of

the nutritional status of preschool children. IHum Nutr. 1981 ;35:349-353 49. Dagnelie PC. Nutritional status of infants on a vegetarian diet. IAm Diet

Assoc. 1989;89:1661-1663

50. van Staveren WA, Dhuyvetter JHM, Zeelen M, Hautvast JGAJ. Food

consumption and height/weight status of Dutch preschool children on

alternative diets. IAm Diet Assoc. 1985;85:1579-1584

51. Williams CU, Bollella M, Wynder EL. A new recommendation for dietary fiber in childhood. Pediatrics. 1995;96:985-988

52. Center for Food Safety and Applied Nutrition. Physiologic Effects and

Health Consequences of Dietary Fiber. Washington, DC: US Department of

Health and Human Services; 1987;146

53. Anderson JW, Smith BM, Gustafson NJ. Health benefits and practical aspects of high fiber diets. Am J Clin Nutr. 1994;59:1242S-12475

54. Hendricks K, Walker A. Manual of Pediatric Nutrition. 2nd ed. Philadelphia: BC Decker; 1990

55. Feldman W, McGrath PJ, Hodgson C, Ritter H, Shipman RT. The use of dietary fiber in the management of simple childhood idiopathic recur-rent abdominal pain. Am IDis Child. 1985;139:1216-1218

Dietary

Fiber

for

Children:

How

Much?

Johanna

T. Dwyer,

DSc,

RD

ABSTRACT. Background. Dietary fiber intakes of most American children are lower than current American Academy of Pediatrics recommendations. Intakes of veg-etarian children come closer to these levels.

Results. We summarize dietary fiber recommendations for children based on existing evidence. The general public needs guidance on appropriate fiber intake levels for children and adolescents. It is important to ensure that energy intakes are adequate by monitoring child weight, growth, and size, especially when fiber intakes are very high. At levels of “age plus 5 g” there seem to be few problems.

Conclusions. Age plus 5 g is a reasonable recommen-dation and is easier to remember than others by weight or energy level, although it never exceeds them. Age plus

15 g is clearly

excessive;

there

is less

evidence

about

ill

effects arising with age plus 10 g. Delivery of dietary fiber in food rather than by supplements is suggested to ensure intakes of other nutrients and to avoid medical-izing dietary intake. In addition to dietary fiber recom-mendations for the general population of healthy chil-dren, individualized recommendations may be necessary for some high-risk groups. Practical steps to increase child fiber intakes from food sources are provided. The article concludes with suggestions for further research. Age plus 5 g is a reasonable minimum recommendation for dietary fiber intakes for children older than 3 years of age. Pediatrics 1995;96:1019-1022; dietary fiber, children, nutrition.

ABBREVIATIONS. USDA, US Department of Agriculture; AAP,

American Academy of Pediatrics.

This article focuses on recommendations and current

consump-tion patterns of dietary fiber in children. It discusses

consider-From the Department of Medicine (Nutrition) and Community Health and

the Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts

University Schools of Medicine and of Nutrition; and the Frances Stern Nutrition Center, New England Medical Center, Boston, MA.

The contents of this article do not necessarily reflect the views or policies of

the US Department of Agriculture, nor does mention of trade names,

commercial products, or organizations imply endorsement by the US

Government.

Acad-emy of Pediatrics.

ations in making recommendations for the population of healthy

children and strategies for groups at special risk. It concludes with

some practical measures and recommendations for future

research.

WHAT WE KNOW Intakes of Omnivorous Children

Compared with authoritative recommendations, dietary

fi-ber intakes of American children are low.’3 Other articles in this

supplement present detailed evidence that fiber intake among

most children living in this country is less than the amounts

that expert groups recommend. Additional evidence is also

available from the recent School Nutrition Dietary Assessment

Survey conducted for the US Department of Agriculture

(USDA).4

Low intakes of dietary fiber in childhood put some otherwise

healthy children at greater risk of constipation, which is an

ex-tremely common problem in pediatrics.5 Low fiber intakes also

possibly increase later risks of obesity, hyperlipidemia, and

adult-onset diabetes; these topics are reviewed elsewhere. Although

evidence on these latter disorders is not definitive at this time, it is

promising, and more research needs to be done. Existing

obser-vational studies in the literature are difficult to interpret, because

children in western countries who habitually eat very high (eg,

twice the usual) levels of fiber usually also differ from those who do not in other respects. They are usually vegetarians or members of ethnic minorities, such as those from the Indian Subcontinent

who eat very high amounts of fiber.

American children also have lower fiber intakes than children

in Western countries did in the past. After World War II in Europe, children grew well on diets that provided relatively large amounts of plant foods.6 Intakes are also lower than those of some children

from developing countries who recently have migrated to western

countries and who eat vegetarian or semivegetanan diets.7 For

example, Pakistani or Indian Gujarati children from the Indian

Subcontinent living in England had dietary fiber intakes nearly

one and one-half times and phytate intakes nearly double those of

native-born or West Indian children. This high level of fiber

was attributable to their high intakes of a variety of pulses

(lentils, grams, chick peas, and black-eyed beans) and

chappat-tis made from whole meal. Malabsorption of iron, zinc,

mag-nesium, and trace minerals with high-fiber diets is of theoretical

concern. However, such deficiencies have not developed in

long-term vegetarian adults who consumed an average of more

than SO g of fiber per day.8 Indices of iron nutrition such as

ferritin decreased among the older children in the Asian group,

but this seemed to be caused by a number of factors, including

their lower intakes of highly bioavailable heme iron from meat

and higher intakes of fiber, phytate, and tea, all of which reduce

iron absorption.9

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wean-1020 SUPPLEMENT

lings and very young children, dietary bulk from plant

staple-based diets is so high that the food intakes may be inadequate to

sustain good growth, especially if the children are only fed a few

times during the day.’#{176}The problem arises because some staple

cereals, such as corn (maize), swell when hydrated to very

high-volume, high-viscosity, low-energy density mixtures. The high

viscosity of these foods seems to inhibit gastric emptying,

partic-ularly with the gel fibers such as pectin and with maize-based

diets, which are very low in caloric density and high in volume,

thus possibly blunting the appetite even further.” These

observa-tions have led to the development of weaning foods that use

germination of cereals and legumes to produce higher-energy,

lower-nutrient density feeds.’2 However, there is little evidence

that most diets high in plant foods lead to poor health or growth

in older children, although it is known that among them

consti-pation is rarely a problem, and children usually pass three stools

a day compared with one in highly industrialized countries.’3

Vegetarian Children With Well-planned Diets

Most American omnivorous children have lower fiber intakes

than vegetarian children. The diets of Seventh Day Adventist

lacto-ovo-vegetanian children are higher in fiber than the

pro-posed “age plus S g” recommendations, and these diets are

nutri-tionally adequate in other respects. On such dietary patterns,

vegetarian children grow well, thrive, and exhibit excellent

health.’4’7

Vegan vegetarian children living in Tennessee who received

vitamin and mineral supplements generally had good growth,

although it was modestly less than that of reference populations

during ages I through 3 years.’8 A group of vegan vegetarian

school children living in England had dietary fiber intakes that are more than twice those of omnivores (5.2 vs 2.2 g/MJ), with intakes

of other nutrients that were adequate. Their growth was also

satisfactory, although weights for height were somewhat lighter

than those of reference children.’9

Vegetarian

Children

With

Nutritionally

Inadequate Diets

Macrobiotic vegetarians and some vegan children eat

nutrition-ally inadequate diets that are very high (two to four times higher

than current recommendations) in fiber and bulk. They sometimes

have growth and health problems. However, the dietary fiber

levels are not necessarily causes of the poor growth. Rather, the

growth stunting usually arises from dietary inadequacy in

essen-tial nutrients, low energy intakes, and other factors such as

dif-ferences in health care (eg, lack of immunizations and use of

conventional health services) by some parents. Growth is poor

among young infants and preschoolers weaned onto very bulky

high-fiber, low-caloric density diets that are also often deficient in nutrients such as vitamins D and B,2 and minerals such as calcium,

iron, and zinc.2#{176} The American Academy of Pediatrics (AAP)

recommendations are that as solids are introduced, and certainly

after 1 year of age, whole-grain cereals, breads, fruits, and

vege-tables should be introduced into toddlers’ diets, but diets that

emphasize high-fiber, low-calorie foods to the exclusion of other

food groups are not appropriate. Adherence to these

recommen-dations should avoid such problems. Disordered growth is

ob-served among infants and young children consuming inadequate

macrobiotic23’ and vegan diets.32’3 Catch-up growth usually

oc-curs in mid to late childhood among vegetarian and other children

who are fed inadequate diets, because by then the children have

more control over their food intakes, and they are able to satisfy

their appetites. Among some vegetarians puberty is slightly

de-layed compared with omnivorous populations.M Intelligence of

vegetarian children and adolescents is normal after adjusting for

other factors, such as parental education, that are known to affect it.37

RECOMMENDATIONS FOR CHILDREN’S FIBER INTAKES

Two kinds of recommendations must be considered. First are

public health recommendations for the general population of

healthy children. The age plus 5 g recommendations discussed

elsewhere in this supplement provide this kind of general

guidance.

Second, there is a need for more highly individualized,

med-ically oriented recommendations for children who are at high

risk of or already have diseases or conditions that may require

adjustments in dietary fiber intakes. Taken together, the

com-bination of these two approaches will cover the entire

popula-tion. A similar approach has been followed by the National

Cholesterol Education Program in its recommendations for

children and adolescents.39

General Population of Healthy Children

Daily fiber levels recommended by the AAP-0.S g/kg body

weight-are healthful for children and do not seem to pose

harm-ful effects.#{176} The problem is that such recommendations are

diffi-cult for many lay persons to remember, because the child’s weight

in kilograms is often not available. Also, if the 0.5-g/kg per day

recommendation were used without the additional caveat of not

exceeding an upper limit of 35 g/d, older (18-year-old) teenage

boys would be recommended very high levels (eg, 22 to 41 g/d) of

fiber. These levels would be higher than any standards currently

extant for adults and nearly two and one half times the current

intakes, which average IS g/d for boys and even less for girls.

Therefore, the age plus 5 g rule of thumb as guidance for families seems to be more practical.

Recommendations also can be expressed based on the energy

intakes of the child; using this AAP’s recommendation, this would

be 10 g of fiber per calorie. Such energy-linked recommendations

are important because they emphasize the need to ensure that

energy needs are met; this may become a problem with high-fiber,

high-bulk diets fed to very small infants and children. However, at

10 g/kcal, the recommended levels of dietary fiber intakes for

preschool children would be rather high.

The American Health Foundation’s proposal of dietary fiber

intakes that are at least age plus 5 g for healthy children therefore

seems to be sound and does not exceed the recommendations of

other expert groups, such as the AAP. The proposal has the

advantage of being easy to prescribe and easy to remember. It is

more moderate in preschool children than the energy-based

stan-dard and the gram per kg-based standard among older boys.

Recommendations for High-risk Groups

Some children fall into high-risk groups, because they have

diseases or other conditions that require very low or very high

fiber intakes; their needs are discussed elsewhere in this

supple-ment. Other conditions needing individualized guidance also

re-quire consideration. For example, children or adolescents with

colostomies and others who have exacerbations of irritable bowel

syndrome or who are being prepared for gastrointestinal surgery

might require very low fiber diets, at least temporarily. Children

with constipation, hyperlipidemia, or diabetes in childhood might

require very high amounts of dietary fiber as an adjunct to other

measures of treating their diseases. Other individuals who may be

at special risk are pediatric patients receiving long-term tube

feeding, who often do better when they receive tube feedings with

fiber in them.4143 Children and adolescents who have chronic

diarrhea, dysentery, or constipation are sometimes prescribed

is-abgol husk (Isphaghula) at doses of 2 tablespoons or about 25 g/d.

At these levels, fiber supplements did not have any adverse effects

on calcium, phosphorus, or iron nutrient balance in one study of

adolescents, although at higher levels ill effects may be observed.

However, zinc, copper, and manganese levels may have been

affected adversely.45 These children and others with special needs

should receive individualized guidance on fiber intakes from a

physician.

For high-risk older adolescents, adults, and those with other

special health problems, fiber supplements made from psyllium

seed provide about 3.5 g psyllium per teaspoon; usual dose levels

are 2 teaspoons/d. Other types of fiber supplements are also

available for those at high risk.

Other Considerations

Fiber Delivery by Food Versus Supplements

The Food and Nutrition Board recommends that desirable fiber

intake be achieved not by adding fiber concentrates to the diet, but

by consumption of foods that also provide minerals and vitamins

such as fruits, vegetables, legumes, and whole grains.

Epidemi-ologic evidence and most experience with the beneficial health

effects of increased fiber intakes are based on feeding varied diets

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with a mixture of dietary fibers. Also, a food-based approach is

preferable from the nutrition education standpoint in dealing with

children.

Ensuring Adequacy of Energy Intakes

Energy intakes always should suffice to maintain weights for

height and body fat levels that are appropriate. If children are

allowed to eat to appetite from a varied diet, energy intakes will

suffice to maintain adequate growth at levels of fiber suggested by

the age plus S g guidance. However, the admonition to monitor

child growth still applies.

Excessively High Intakes

The upper limit of dietary fiber intake in childhood needs

further study. At present age plus 15 g/d or more seems to be

clearly excessive. Intakes above age plus 10 g should be avoided

until better data are available.

PRACTICAL STEPS TO INCREASE CHILD FIBER INTAKES

Target Age Plus 5 g of Dietary Fiber Per Day

For the general child population, after 3 years of age, healthy

children should eat at least age plus S g of fiber per day from food sources. The age plus S g recommendations range from 8 g/d at

age 3 years up to approximately 23 g/d by age 18 years. These

never exceed the existing guidelines of the AAP or other expert

groups.

Five a Day-Six a Day Fiber-rich Food Eating Pattern

Practical steps for increasing children’s fiber consumption start

with increasing consumption of a variety of fresh fruits and

veg-etables and grain products, such as whole-grain and fortified

breads and cereals. The USDA Food Pyramid guide suggests five

servings of fruits and vegetables and six servings of breads,

cere-als, and grain products per day. Parents who feed their children

according to this five a day-six a day pattern for fiber-rich foods

and

other Pyramid-related guidance will achieve the age plus 5 g

of fiber target.

Parents can start by adding one or more servings of fiber-rich

fresh fruits (such as apples, blackberries, bananas, dried figs and

dates, pears, oranges, prunes, and berries), fresh or lightly

pro-cessed vegetables (such as broccoli, Brussels sprouts, carrots, corn,

peas, and potatoes with skins), or plenty of salads to meals each

day. The key to acceptance is a gradual increase, rather than

sudden and dramatic changes in fiber intake. Each serving of these

high-fiber fruits increases intakes by about 3 g/serving; other

fruits are lower in their content and more variable. The high-fiber

vegetables provide about 2.5 g/serving. Juices are low in fiber.

A changeover to whole-grain breads, cereals, and rice adds

fiber, about 2.5 g/serving, and is also in line with prudent dietary

recommendations for children.47 High-fiber cereals such as bran

are particularly good sources of fiber, providing as much as 8 to 10

g/serving. Other cereals increase intakes to a lesser degree. The

Nutrition Facts panel on the food label lists exact amounts. Older

children and adolescents may enjoy oat or wheat bran muffins and

cereals such as oat meal with oat or wheat bran added.

Another step is to introduce children to legumes and serve

them at least once a week. Pinto beans, lentils, chick peas, and

kidney beans are all good sources of fiber. Milk and milk products

and meat are low in fiber but are needed to meet other nutrient

needs.

As long as changes to higher-fiber intakes are gradual, and

plenty of water or other liquid is served (a glass of water for each additional serving of the drier sources of fiber), there is little risk of bloating, gas, or other complications at these levels of intake.

NEEDS FOR FURTHER INVESTIGATION

Research on several topics is required to answer the questions that remain about child fiber intake. First, the paucity of reliable

information on both the fiber composition of foods and current

child consumption patterns of fiber hampers efforts to put child

fiber intake targets on a sound scientific basis. Second, the

mech-anisms of action of both soluble and insoluble fibers are

incom-pletely understood.48 Third, the short- and long-term benefits and

risks to health associated with different doses and types of fibers

as they affect child growth, laxation, fatness levels, blood glucose,

blood pressure, and serum lipid levels need additional

documen-tation. Some studies have examined the benefits of a fiber-rich

diet, but our ability to recommend specific types of fiber is limited by lack of good evidence from carefully controlled clinical trials.

Do the effects of fiber differ in children and adults on these

parameters, and if so, how? Nutritional scientists suspect that

fiber intake levels may influence the risk of certain chronic

degenerative diseases in adulthood.49 Several articles in this

supplement explore the existing data on this issue. It is possible

that child dietary fiber intake patterns decrease risks by

incul-cating the habit of lifelong fiber intakes that are in line with

recommendations. Alterations in biochemical indices and

me-tabolism and/or changes in physiologic functions of the gut

with fiber intake probably begin during childhood and persist

as long as fiber intakes remain constant. However, these

changes seem to be temporary, not permanent, to depend on

continued fiber intakes, and to disappear when intakes decline.

More research is needed on these points and on the role of fiber

in reducing cardiovascular disease and cancer in di.tlth#{248}od.505’

Fourth, what levels of fiber intake are too high for children? Is

a rule of thumb such as age plus 15 g useful in defining excessively

high intakes? Are some children at particular risk on low-fiber

diets? Are others put at risk of failure to thrive and growth

stunting by very high-fiber diets, and if so, who are these

children?

CONCLUSIONS

Dietary fiber intakes of American children and adolescents

today fail to meet existing recommendations of expert groups.

Age plus five g is a reasonable standard for children older than 2

to 3 years. The health benefits of increased fiber intakes by

chil-dren are several and outweigh any potential risks.

Children, parents or care givers, and health professionals

should strive to increase their intakes by emphasizing five a

day-six a day fiber-rich food-eating patterns. The optimal way for

children to consume fiber is from a mixture of dietary sources, not

from

supplements

of isolated fibers. The USDA Pyramid Guide, especially the advice on five fruits (2 to 3 g/serving) and vegeta-bles (2 to 2.5 g/serving) a day (five a day) and at least six servings

of grain (2.5 g/serving) products (six a day) will ensure that

intakes are adequate.

Evidence is insufficient to make precise recommendations on

the type of fiber to be consumed or the safe upper limits; at

present, no more than age plus 10 g of dietary fiber per day should be exceeded. For children who are at high risk because of diseases

or other health problems that potentially might be affected by

fiber, the age plus 5 g recommendation may or may not be

suitable. Such children need to be referred to knowledgeable

ped iatricians, who can make individualized recommendations

and institute appropriate medical therapies.

In conclusion, age plus S g of fiber per day is a reasonable,

sensible guide for child fiber intakes that may be of practical help to parents and health professionals alike.

ACKNOWLEDGMENTS

This article was funded in part by federal funds from the US

Department of Agriculture, Agricultural Research Service, under contract 53-3K06-01 to Tufts University.

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