What are the initial evaluation steps, recommended laboratory screening, and first‑line lifestyle and supplement interventions in functional medicine for a pediatric patient?

Functional Medicine Pediatric Evaluation and Management

Initial Evaluation Framework

The initial evaluation of a pediatric patient in functional medicine should prioritize comprehensive nutritional assessment, growth monitoring, and lifestyle factor evaluation before proceeding to laboratory screening. 1

Core History Components

• Nutritional history must include detailed food and nutrition-related intake patterns, feeding difficulties, swallowing problems, and growth trajectory assessment 2
• Developmental assessment should document motor milestones, cognitive development, and adaptive functioning (daily living skills) 2
• Family history must identify relatives with developmental issues, chronic diseases, recurrent pregnancy loss, or infant death to uncover genetic etiologies 2
• Lifestyle factors require assessment of physical activity levels, screen time (should be <2 hours daily for non-academic use), sleep patterns, and stress management 2, 3
• Environmental exposures including toxin avoidance, accident prevention risks, and screen overuse must be documented 3

Physical Examination Priorities

• Anthropometric measurements using CDC or WHO growth curves: serial measurements of weight, length/height, head circumference, triceps skinfold thickness, and mid-arm circumference 2, 1
• Nutritional assessment examining for signs of malnutrition, vitamin deficiencies, drooling, poor weight gain suggesting oral motor weakness 2
• Neurologic examination including cranial nerves, muscle tone, strength assessment through functional observation, deep tendon reflexes, and primitive/protective reflexes 2
• Dysmorphic features or visceral anomalies that may suggest genetic conditions 2

Recommended Laboratory Screening

First-Line Laboratory Tests

• Complete blood count with differential to assess for anemia, immune dysfunction, or hematologic abnormalities 2
• Comprehensive metabolic panel including calcium, magnesium, creatinine to evaluate electrolyte balance and renal function 2
• Thyroid function studies (TSH and free T4) even without classic thyroid disease signs, as thyroid dysfunction can present with developmental delays 2
• Vitamin D level as part of endocrinological assessment 2
• Review state-mandated newborn screening results to exclude metabolic disorders and avoid unnecessary testing 2

Condition-Specific Screening

• Immunologic assessment (IgG, IgA, IgM levels after 6 months of age; T- and B-cell phenotyping if recurrent infections) 2
• Lipid screening for cardiovascular health assessment in at-risk populations 2
• Hemoglobin A1c or fasting glucose if obesity or family history of type 2 diabetes present 2

First-Line Lifestyle Interventions

Nutritional Interventions (Six Pillars Approach)

Preventive nutrition forms the foundation of pediatric functional medicine, emphasizing whole foods and adequate micronutrient intake. 3

• Caloric optimization: Children with chronic conditions may require 20-80% more calories than healthy peers; use medium-chain triglyceride-containing formulas in cholestatic conditions with normal protein intake 2
• Fat-soluble vitamin supplementation (A, D, E, K) with regular monitoring in cholestatic or malabsorptive conditions 2
• Avoid excessive dietary restrictions: Low-FODMAP, fructose-restricted, lactose-restricted, and gluten-free diets have no place in routine pediatric functional medicine practice and should only be considered for specific diagnosed conditions like IBS with documented benefit 4
• Mediterranean diet pattern shows promise for functional gastrointestinal disorders and should be emphasized over restrictive diets 4
• Sodium supplementation (1-4 mEq/kg/day) for infants with polyuric salt-wasting conditions to support growth and nitrogen retention 2

Physical Activity Prescription

• Age-appropriate daily physical activity to prevent obesity, improve mental health, and support metabolic health 3
• Structured exercise programs that increase peak oxygen uptake have been shown to improve vascular function in obese children 2
• Task-oriented physical therapy approaches for children with motor coordination difficulties 2, 5

Sleep Optimization

• Sleep hygiene recommendations including consistent bedtime routines and sleep environment optimization 2, 3
• Polysomnography evaluation if sleep-disordered breathing suspected, particularly pre- and post-surgical interventions 2

Stress Management and Social Connections

• Assessment for anxiety, depression, and behavioral challenges using standardized screening tools 2
• Promotion of positive social connections and family engagement as protective factors 3
• Neurocognitive testing to identify areas warranting early intervention and minimize later cognitive difficulties 2

Risk Prevention Strategies

• Screen time restriction to maximum 2 hours daily for non-academic use; remove screens from bedrooms 2
• Sun protection and radiation avoidance particularly in children with genetic instability disorders 2
• Toxin avoidance including environmental exposures and age-appropriate accident prevention 3

Supplement Interventions

Evidence-Based Supplementation

• Vitamin D supplementation to maintain adequate levels for bone health and immune function 2
• Omega-3 fatty acids (docosahexaenoic acid) may improve endothelial function, though benefits may not persist after discontinuation 2
• Folate supplementation in children with chronic renal disease improves endothelial function and reduces homocysteine 2
• Probiotics, prebiotics, and synbiotics may provide health benefits in specific conditions (NEC, diarrhea, irritable bowel syndrome, intestinal allergy) but should not be routinely prescribed without indication 6
• Avoid routine antioxidant supplementation (vitamins C and E) as evidence for benefit in general pediatric populations is lacking despite some condition-specific benefits 2

Referral Thresholds

Immediate Referral to Early Intervention

• All children with developmental delays should be referred immediately to early intervention programs regardless of whether definitive diagnosis is established 5
• Physical therapy for hypotonia and gross motor delays 5
• Occupational therapy for sensory integration and fine motor skills 5
• Speech-language pathology for oral-motor, articulation, and language assessment 2, 5

Subspecialist Consultation Triggers

• Elevated creatine kinase >3× normal: immediate pediatric neurology referral for suspected muscular dystrophy 5, 7
• Fasciculations or respiratory insufficiency: urgent evaluation for neuromuscular disorders with respiratory failure risk 5
• Loss of motor milestones: urgent neurology referral for suspected neurodegenerative process 5
• Failure to thrive with dysmorphic features: genetics consultation for chromosomal microarray testing 2

Common Pitfalls to Avoid

• Do not delay early intervention services while awaiting definitive diagnosis—therapy should begin immediately 5
• Do not implement restrictive diets (low-FODMAP, gluten-free, lactose-free) without documented medical indication, as they lack evidence in general pediatric populations 4
• Do not rely solely on weight for nutritional assessment in children with chronic conditions; use triceps skinfold and mid-arm circumference 2, 1
• Do not overlook treatable conditions: hypothyroidism, Pompe disease with enzyme therapy, and vitamin deficiencies are reversible 2, 5
• Do not restrict protein intake even in children with liver disease, as adequate protein supports growth 2