June 2018 Issue

Omega-3 Supplements and Children's Health
By Christen Cupples Cooper, EdD, RDN
Today's Dietitian
Vol. 20, No. 6, P. 22

While research is scant, some studies suggest supplementation may be associated with a variety of health benefits.

Omega-3 fatty acids seemingly have risen to royalty status in the nutrition community and among health-conscious consumers over the past several decades. These long-chain fatty acids have been touted for their health benefits, beginning with studies on northern Inuit populations that have had surprisingly low rates of heart disease despite a diet high in fatty fish. These findings have led scientists to research the benefits of omega-3s for not only the prevention of CVD but also the prevention and treatment of neurological and psychological conditions, asthma, cancer, and diabetes, and the promotion of brain and eye health. These results also have led researchers to explore the benefits of omega-3 (ie, fish oil) supplementation in adults and children.

According to the 2012 National Health Interview Survey, administered by the National Institutes of Health's National Center for Complementary and Integrative Health, about 7.8% of American adults (18.8 million) and 1.1% of children (664,000) aged 4 to 17 report taking a fish oil supplement within the past 30 days. As a result, RDs need to become well versed on the potential benefits and drawbacks of these supplements. Considerable research has been done on adults and omega-3 supplements, but much less so on children. Since children have different nutrient needs than adults and special requirements for growth and development, it's important to know how these supplements may impact children specifically. But while the research on omega-3 supplements in children is limited, there's some evidence supporting their use to augment therapies for some pediatric conditions.

Jessica Tosto, MS, RDN, CSP, CNSC, clinical coordinator of the Coordinated MS in Nutrition and Dietetics program at Pace University in Pleasantville, New York, says, "In light of growing evidence on the benefits of omega-3s and the fact that the typical Western diet is deficient in these fatty acids, there does seem to be increased interest in supplementation for children. In particular, parents are becoming interested in supplementation to help reduce symptoms of certain neurodevelopmental disorders such as autism spectrum disorder and ADHD." Today's Dietitian weighs in on the evidence for recommending omega-3 supplementation for children's health.

Effects of Maternal and Infant Supplementation
The earliest exposure to omega-3 supplementation in children comes from maternal intake. During the third trimester of pregnancy, 50 to 60 mg per day of a mother's DHA stores go to her fetus. The research to date on maternal supplementation with omega-3 fatty acids, particularly during the third trimester, suggests positive health outcomes in infants. According to a literature review by Riediger and colleagues on omega-3 fatty acid supplementation published in the April 2009 issue of the Journal of the Academy of Nutrition and Dietetics, several studies have shown that greater levels of DHA and omega-6 fatty acids in the womb and during lactation can improve visual acuity, vocabulary comprehension, and hand-eye coordination during the first year of life. Infants fed DHA and arachidonic acid-enhanced formula for 17 weeks had improved cognitive function.1 Study results are inconsistent, however, and more research must be done on the benefits of polyunsaturated fatty acid (PUFA) supplementation for this population.

According to a systematic review of the literature on omega-3s and atopy risk in children, studies suggest that fish oil supplementation during pregnancy and lactation or in the first few months of life can result in higher omega-3 serum levels in infants and children. The review, by Kremmyda and colleagues, published in the August 2011 issue of Clinical Review of Allergy and Immunology, also reported that maternal fish oil supplementation was associated with reduced sensitization of infants to food allergens and reduced risk of atopic dermatitis from birth to 12 months. In addition, fish oil supplementation in infants and children seems to lead to immunologic changes and may be associated with decreased risk of developing allergic disease, yet it's unclear whether such lowered risks can continue into later years.

The Agency for Healthcare Research and Quality published a report that summarized the impacts of omega-3 fatty acids on asthma risk. The authors concluded that there have been too few studies that are well powered and large enough to yield definitive answers about omega-3 supplementation in children and asthma risk, although asthma and other respiratory conditions are areas of interest for treatment with omega-3 fatty acid supplementation.2

Brain and Neurological Effects
As Riediger and colleagues summarize, phospholipids make up 25% of the dry weight of the human brain, and therefore PUFAs likely affect brain functioning, including the presence or absence of inflammation. PUFAs help keep membranes fluid, which aids in signal transduction and possibly the function of key neurotransmitters.1

Academic Performance
A study by Brew and colleagues, published in the August 2014 issue of the European Journal of Clinical Nutrition, followed a cohort of children with a history of asthma who were randomized to receive tuna fish oil (135 mg DHA, 32 mg EPA, and omega-6 fatty acids) or Sunola (low in omega-3s, but contains omega-6s) daily from age 6 months to 5 years. The National Assessment Program Literacy and Numeracy, or NAPLAN, test was administered in school every two years. Among 239 children who finished the study, there were no significant differences between groups in test scores. However, the children who consumed tuna fish oil appeared to have a significant increase in test scores per 1% absolute increase in plasma omega-3 fatty acids. Despite these results, the authors concluded their findings didn't support administering fatty acids to children in infancy and childhood to improve academic performance.

Developmental Coordination Disorder
Developmental coordination disorder (DCD), a deficit in motor function characterized by difficulties in learning, behavior, and psychosocial adjustment, affects around 5% of school-age children. For years, scientists believed that low levels of PUFAs may play a role in DCD. Richardson and colleagues conducted a randomized controlled trial of PUFA supplementation in children, published in the May 2005 issue of Pediatrics. The trial involved 117 children aged 5 to 12 who were randomized into parallel groups, with one group taking a supplement containing both omega-3s and omega-6s and the other group taking a placebo for three months. At the end of the three months, the placebo group began taking the supplement as well. The results showed that the supplements had no effect on motor skills, but all participants experienced significant improvements in reading, spelling, and behavior, with the children taking the supplement for the longest time having continuous improvements over six months. While the authors believe additional research is needed, they're encouraged that PUFA supplementation may help ameliorate educational and behavioral difficulties among children with DCD.

ADHD has been linked with low blood levels of DHA and high blood levels of omega-6s, as stated by Colter and colleagues in the February 2008 issue of Nutrition Journal. Fatty acid supplements represent a growing interest to those seeking a nonpharmacologic treatment for ADHD; however, the evidence is conflicting.

In a study by Stevens and colleagues, published in the October 2003 issue of Lipids, higher EPA levels were associated with reduced disruptive behavior in children with ADHD who received 480 mg per day of DHA and 80 mg per day of EPA for four months. As reported in the April 2004 issue of the European Journal of Clinical Nutrition, Hirayama and colleagues reported no change in behavior in children who were supplemented with 3.6 g per week of DHA for two months. In a study published in the August 2001 issue of the Journal of Pediatrics, Voigt and colleagues also found no improvement when children received 345 mg per day of DHA for four months.

Sinn and Bryan studied 106 children who presented with ADHD symptoms, but not necessarily an ADHD diagnosis, in a study published in the April 2007 issue of the Journal of Developmental and Behavioral Pediatrics. For 16 weeks they studied three groups: The first group took a multivitamin and mineral supplement plus a tablet containing 400 mg fish oil and 100 mg evening primrose oil (which is rich in omega-6), providing a total of 93 mg EPA, 29 mg DHA, 10 mg gamma-linolenic acid (GLA), and 1.8 mg vitamin E; the second group took only the tablet containing the EPA, DHA, GLA, and vitamin E; and the third took a placebo of palm oil. Children were required to take six active or six placebo capsules per day. The two groups that supplemented with omega-3s received significantly improved parent ratings in cognitive problems/inattention, restless-impulsive, inattentive, hyperactive-impulsive, and oppositional behavior subscales compared with the placebo group. The researchers found no additional benefit from the multivitamin. There were no significant results found in teacher ratings of the children's behavior.

A group of researchers from Sweden designed a study modeled after the Richardson study, which was a randomized, three-month, placebo-controlled, one-way crossover trial. Results were published in the March 2009 issue of the Journal of Attention Disorders. Their aim was to assess omega-3 and omega-6 fatty acid supplementation on 75 children aged 8 to 18 with ADHD. They found that most of the children didn't respond to the supplementation. However, 26% of participants experienced a 25% reduction in ADHD symptoms and a drop in Clinical Global Impression scores, which provide a summary of the severity of a condition and any change since the initiation of treatment. After six months of supplementation, all participants showed improvement.

A study published in March 2015 by Bos and colleagues in Neuropsychopharmacology matched 39 healthy boys aged 8 to 14 with 40 boys diagnosed with ADHD for a 16-week trial. Participants either consumed margarine fortified with 650 mg DHA and 650 mg EPA or a placebo (normal) margarine. Parent-rated attention scores increased for children in both the ADHD and non-ADHD groups after taking the omega-3 supplements. Magnetic resonance imaging showed no effect on task performance or brain activation. This trial was in line with previous findings that omega-3 supplements can improve attention by augmenting other therapies, but not necessarily improving more generalized ADHD symptoms.

As summarized by Kirby and colleagues in the October 2010 issue of British Educational Research Journal, more research is needed to determine whether omega-3 supplements can improve conditions such as ADHD. Kirby stated that in 2006, the Food Standards Agency in the United Kingdom completed a systematic review of omega-3 fish oil supplementation in school-aged children, concluding that findings were mixed and inconclusive, and therefore more research is needed to arrive at recommendations for children with various neurodevelopmental disorders.

Autism Spectrum Disorder
The impact of omega-3 supplementation on children with autism is another area that requires more research to support specific recommendations.

Ooi and colleagues studied 41 children and adolescents with autism between the ages of 7 and 18 (36 boys, 5 girls) for 12 weeks. All participants were given 15 mL of liquid Efamol Efalex, which consisted of 840 mg DHA, 192 mg EPA, and 1,278 mg pure evening primrose oil twice daily. The study was published in the March 2015 issue of the European Journal of Clinical Nutrition. Participants showed significant improvements on all scales of social responsiveness and social and attention problems. In addition, blood omega-3 fatty acid levels were significantly correlated with reductions in autistic symptoms. The authors believe that a larger sample size and longer-term study is warranted to advance knowledge about omega-3 fatty acids and their potential impact on children with autism.

Mankad and colleagues conducted a six-month, randomized, placebo-controlled trial of 38 children with autism aged 2 to 5 that was published in the March 2015 issue of Molecular Autism. Participants received either an olive oil placebo or a 1.5 g dose of NutraSea HP, a naturally derived fish oil that's extracted, isolated, and processed to contain EPA and DHA in a 3:1 ratio. The findings included no significant differences in autistic behaviors between the treatment and control groups in the first 24 weeks. Participants taking the omega-3 supplements actually had less favorable scores on a particular behavior assessment than those not taking supplements. This study demonstrates that more research is needed on the benefits of omega-3 supplementation in children with autism.

Tourette's Disorder
Tourette's disorder, a neurological condition characterized by repetitive, involuntary movements and vocalizations called tics, also has been studied. In the May 2012 issue of Pediatrics, Gabbay and colleagues tested omega-3 supplementation in children with the condition in a randomized, controlled trial. They assigned 33 children and adolescents aged 6 to 18 to an omega-3 group (combined EPA and DHA) or placebo group for 20 weeks. At the end of the study, the omega-3 group didn't have improvements in tics (as measured by the Yale Global Tic Severity Scale), but did show significant improvements in tic-related impairments. The researchers concluded that, again, more research is needed to determine whether omega-3 fatty acids are beneficial for children with Tourette's disorder.

Advice for RDs
Under the Dietary Supplement Health and Education Act of 1994, the FDA doesn't regulate dietary supplements. Supplement manufacturers are asked to sell products that are safe and effective, but they aren't required by law to provide evidence for this. In addition, there are no government recommendations for dosages of long-chain omega-3 fatty acids, given that research on many supplements, including EPA and DHA, is limited. According to the National Institutes of Health's National Center for Complementary and Integrative Health, there are no known adverse effects of omega-3 supplements except for minor gastrointestinal symptoms, such as belching, indigestion, or diarrhea. However, for individuals taking anticoagulants or NSAIDs, omega-3 supplementation may be contraindicated.

Furthermore, although omega-3s may offer health benefits, more research is necessary to identify benefits and drawbacks. Therefore, RDs have an important responsibility when guiding consumers who wish to take omega-3 supplements.

Barbara Quinn, MS, RDN, CDE, LMNT, author and columnist at Quinn-Essential Nutrition in Monterey County, California, believes there are instances in which omega-3 supplements can be beneficial. "However," she says, "I would encourage parents to first seek out food sources of omega-3s since we know without a doubt that a varied diet is the enduring key to optimal nutritional status."

For example, Quinn explains that one omega-3-enriched egg contains about 125 mg omega-3s, including DHA and EPA, which benefit brain development. One ounce of cooked salmon provides 400 mg. Other sources of omega-3s that easily could be integrated into a child-friendly diet include walnuts, soybeans, flaxseed and canola oils, omega-3-rich milk, and mayonnaise.

Tosto also believes that RDs have much to offer parents pondering the benefits of omega-3 supplements. "There are so many different products on the market that make various health claims, suggest different doses, etc," Tosto adds. "An RD can help make sense of what these supplements can truly do and how they can be included as part of a healthful diet. Even more importantly, RDs can help parents include natural food sources of omega-3s into their everyday meals in ways that are practical and cost-effective, and that kids will be willing and happy to eat."

While the jury is still out on omega-3 supplementation for children's health and disease treatment and prevention, parents are wise to offer omega-3-rich foods and try supplements for treatment augmentation under the supervision of a doctor and RD.

— Christen Cupples Cooper, EdD, RDN, is founding director and an assistant professor of nutrition and dietetics at Pace University in Pleasantville, New York.

1. Riediger ND, Othman RA, Suh M, Moghadasian MH. A systematic review of the roles of n-3 fatty acids in health and disease. J Acad Nutr Diet. 2009;109(4):668-679.

2. Newberry SJ, Chung M, Booth M, et al. Omega-3 Fatty Acids and Maternal and Child Health: An Updated Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality; 2016.