Toddler and Preschooler Nutrition

Definitions of the Life Cycle Stage

Toddlers -- 1-3 years • Stage of development is characterized by rapid increase in gross (major muscles) & fine (using hands) motor skills • Increased independence, exploration & language skills Preschool-age children -- 3-5 years • Characterized by increasing autonomy, broader social circumstances, increasing language skills & expanding self-control

Key Nutrition Concept #3

*Children have an innate ability to self-regulate food intake.* Parents and caretakers need to provide children nutritious foods and let children decide how much to eat.

Energy Needs - DRIs

Age 1-3 years: • *Girls: 992 kcal* • *Boys: 1046 kcal* • EER: (89 x kg - 100) + 20 (+20 = factor for growth) Age 4-8 years: • *Girls: 1642 kcal* • *Boys: 1742 kcal*

MyPlate meal preparation activities for young children

At 2 years: • Tear lettuce or greens • Rinse vegetables or fruits • Snap green beans At 3 years: • Mash potatoes • Squeeze citrus fruits • Stir pancake batter At 4 years: • Peel eggs and some fruits, such as oranges and bananas • Crack eggs • Help make sandwiches and tossed salads At 5 years: • Measure liquids • Cut soft fruits with a dull knife • Use an egg beater

Growth Charts

Charts are gender and age-specific -- 2 sets of charts: • birth to age 2 --> WHO growth charts • age 2 - 20 years --> CDC growth charts Plot & monitor: weight-for-age, HC-for-age, length- or stature-for-age, weight-for-length or -stature • BMI-for-age --> starting at age 2

Key Nutrition Concept #1

Children continue to grow and develop physically, cognitively, and emotionally during the toddler and preschool age years, adding many new skills rapidly with time

Protein Needs

DRI • *1-3 years: 1.1 g/kg/d or 13 g/day* • *4-8 years: 0.95 g/kg/d or 19 g/day*

Dietary Rxs

Dietary Guidelines for Americans • Designed for ages 2 and up • Offer a variety of foods, including WGs, F&Vs, and low-fat dairy products while limited foods high in sugar, saturated & trans fat, and sodium MyPlate • Children age 2-5 should play actively every day -- not official guidelines for these ages

DRI EER Prediction Equations

EER (kcal/day) = TEE + Energy Deposition Girls 3-8 years (within 5th-85th %ile for BMI): EER = 135.3 - (30.8 x age [yr]) + PA x [(10.0 x wt in kg) + (934 x ht in m)] + 20 • PA: 1 = sedentary, 1.16 = low active, 1.31 = active, 1.56 = very active Boys 3-8 years (within 5th-85th %ile for BMI): EER = 88.5 - (61.9 x age [yr]) + PA x [926.7 x wt in kg) + (903 x ht in m)] + 20 • PA: 1 = sedentary, 1.13 = low active, 1.26 = active, 1.42 = very active

Key Nutrition Concept #2

Learning to enjoy new foods and developing feeding skills are important components of this period of increasing independence and exploration -- great time to teach about food bc they're interested

Optimal Feeding Relationship

Parent or caretaker responsibilities: • "What" children are offered to eat • The environment in which food is served including "when" & "where" foods are offered Child's responsibilities: • "How much" they eat • "Whether" they eat a particular meal or snack

Key Nutrition Concept #4

Parents and caretakers have tremendous influence on children's development of appropriate eating, physical activity and other health behaviors and habits formed during the toddler and preschool years. These lessons are mainly transferred by example.

Food Safety

Young children vulnerable to food poisoning because they can become ill from smaller doses of organisms Food safety education program --> FightBAC • Clean: wash hands & surfaces often • Separate: don't cross-contaminate • Cook: cook to proper temperatures • Chill: refrigerate promptly

IDA

• 15.9% of 1-2 year olds are iron deficient • *Rapid growth rate plus inadequate intake places toddlers at the highest risk of deficiency* • May cause long-term delays in cognitive development & behavioral disturbances

Economic Issues in the US

• 23% of children age 0-5 years live in poverty (2015) -- more likely to be from African-American and Hispanic-American populations • Health disparities exist among races & ethnicities • In the setting of poverty and food insecurity, establishing health eating habits may not be high on a family's priority list

Overweight & Obesity

• 9.4% of children age 2-5 years are obese • BMI-for-age is the Rx tool for assessing pediatric overweight and obesity - Overweight = BMI-for-age ≥ 85th to 94th %ile - Obese = BMI-for-age ≥ 95th %ile • BMI rebound - normal gradual increase in BMI that occurs after ~age 4-6 (preparing for growth spurt) • Maintaining weight while gaining height is the Rx approach for obese children age 2-5 (vs. dramatic weight loss) • Goal is not promoting weight loss

Food Insecurity

• 9.4% of households with children were food insecure at times during the year -- households were unable to provide adequate, nutritious meals for their children • Food insecurity is more likely to exist in families with a single-parent, lower-income, and African American and Hispanic households • Young children are vulnerable because they must depend on caregivers for adequate access to food • Young children with food insecurity are more likely to exhibit behavioral, emotional & academic problems

Physiological & Cognitive Development: Toddlers

• A time of expanding physical & developmental skills • Most children begin to walk independently - 1st birthday Progress by month: • 15 - crawl upstairs • 18 - run swiftly • 24 - walk up stairs one step at a time • 30 - alternate feet going up stairs

Feeding Behaviors of Preschool-Age Children

• Appetite related to growth • Appetite increases prior to the "spurts" of growth • Therefore, appetite can be quite variable • Preschoolers want to be helpful and please their parents and caretakers making this a good time to teach children about food • Include child in meal selection & preparation

Development of Feeding Skills of Preschool-Age Children

• Can use a fork, spoon & cup well • Spills occur less frequently • Foods should be cut into bite-size pieces to avoid choking • Adult supervision still required

Dental Caries

• Caused by Streptococcus mutans -- acid produced by fermentation of CHO causes caries • Increased risk with: habitual use of a bottle or sippy cup with juice or milk at bedtime or throughout the day; consumption of sticky high CHO foods • Prevention: Fluoride - if water supply is not fluorinated, then supplementation is Rx (amounts vary by age & fluoride content of water supply)

Constipation

• Causes: "Stool holding" -- can lead to problems with peristalsis • Preventions: Adequate fiber & fluid -- WG breads & cereals, legumes, F&V Adequate intake of total fiber for children • *Age 1-3: 19 g/d* • *Age 4-8: 25 g/d*

Prevention of Iron Deficiency

• Children aged 1-5 years should drink no more than 24 oz/d (≤ 2-3 c/d) or milk d/t low iron content --> Ca and Fe compete for absorption in intestines • CDC Rx that children at high risk should be tested or deficiency at 9-12 months, 6 months later & annually from ages 2-5 • Children at risk --> low iron diet, consume >24 oz/d of milk, low income, chronic illness • AAP Rx universal screening at 12 months of age

Vegetarian Diets

• Children following vegan diets tend to have lower rates of growth but remain within normal ranges (often thinner) • Strict vegan diets may be deficient in vitamins B12 & D, zinc, Ca & omega-3 FAs unless fortified foods are consumed (educate on alternative food sources)

Appetite & Satiety

• Children have preferences for foods that are energy dense d/t high sugar and/or fat intake possibly d/t: association with pleasant feeling of satiety; positive association with special occasion (ex. birthday cake) • Severe restriction of palatable foods increases desirability for the foods

Innate Ability to Control Energy Intake

• Children have the innate ability to self-regulate food intake to meet caloric needs • Avoid encouraging child to "clean your plate" • Healthful eating habits must be learned

Child Care Nutrition Standards (USDA Guidelines)

• Children in party-day programs (4-7 hours/d) should receive 1 meal and 2 snacks or 2 meals and 1 snack • Full-day programs (≥ 8 hours/d) should provide 2 meals and 2 snacks or 1 meals and 3 snacks • Offer food at intervals not less than 2 hours & no more than 3 hours

Food Preference Development, Appetite & Satiety

• Children naturally prefer sweet & slightly salty tastes; generally reject sour & bitter foods • Tend to eat familiar foods and reject new foods but may learn to accept a new food with repeated exposure -- may need 8-10 exposures to new foods before acceptance • Children raised in an environment where family members consume a variety of foods are more likely to eat a variety of foods themselves (modeling)

Vitamin & Mineral Supplements

• Children who consume a variety of foods can meet nutrient needs without a vitamin or mineral supplement AAP Rx supplements for certain groups of children at high risk for deficiencies: • From deprived families, suffer from neglect • Chronic disease • Poor appetite or poor diet (chronically) • On a dietary program for weight management • Vegetarians without dairy products • FTT/malnourished

Cognitive Development of Toddlers

• Desire to explore their environment and exert their independence • Socially the toddler transitions from self-centered to more interactive • Social development involves imitating others • Vocabulary expands dramatically from 18-24 months: 10-15 words at 18 months; 100+ words at 2 years; 3 word sentences by 3 years • Temper tantrums common (the terrible two's) -- peak from ages 2-4; about exerting control

Importance of Nutrition Status

• During toddler and preschool years, adequate nutrition is required to achieve full growth & development potential • Undernutrition at this time impairs cognitive development (lower academic achievement later in life)

Cognitive Development of Preschool-Age Children

• Egocentric - cannot understand another's point of view • Increased social interactions with adults & peers • Learning how to limit behavior internally • Becomes more cooperative and moves toward more organized group play • Vocabulary expands to >2000 words • Begins using complete sentences • Exerting control is a central issue at this age (food battles)

Normal Growth & Development

• From birth to 1 year, average infant triples his/her birthweight, but growth velocity then slows until the adolescent growth spurt • *Toddlers gain on average 8 oz and grow 0.4 inches in height per month* • *Preschoolers gain 4.4 lb and grow 2.75 inches per year* • This decrease in growth velocity is accompanied by a reduced appetite and food intake in toddlers & preschoolers (because needs are decreasing from growth slowing down)

Development of Feeding Skills of Toddlers

• Gross & fine motor development improved • 12-14 months - usually completely weaned from bottle and drinking from a cup • 12-18 months - can move tongue laterally and learn to chew foods with rotary movements • Toddlers can handle chopped or soft table foods • 12 months- refined pincer to grasp small objects • 18-24 months - can handle meats, raw fruits & veg, and multiple food textures • Adult supervision vital to prevent choking (hard candy, whole grapes, popcorn, nuts & hot dogs should not be served to children under 2 years)

Rxs for Intake

• Iron - meats, fortified cereal, dried beans and peas • Fiber - fruits, vegetables, WGs • Calcium - dairy, green leafy vegetables, calcium-fortified beverages

Nutrition Intervention for IDA

• Iron supplementation: 3 mg/kg/d or iron drops • Counseling parents on dietary sources of iron -- increase consumption of lean meat, fish & poultry (+ fortified cereals); include sources of vitamin C at meal times to increase absorption of non-heme iron sources • Repeat screening in 4 weeks

Prevention of Overweight & Obesity

• Limit sugar-sweetened beverages • Encourage F&V • Limit TV & screen time to a max of 2 hours/d • Daily breakfast • Limit eating out - particularly fast foods • Appropriate portion sizes • Diets high in fiber • Follow the DRI for macronutrients • Promote moderate to vigorous physical activity for at least 60 mins/d • Limit energy-dense foods

Appetite & Food Intake of Preschool-Age Children

• May prefer familiar foods - may be comforting • Avoid battling over food • Serve child-sized portions • Make foods attractive • Young children often do not like foods to be mixed together or to touch each other -- casseroles are not a good idea • Strong-flavored or spicy foods may not be accepted • Control amount eaten between meals to ensure appetite at meals

Vitamins & Minerals

• Most toddlers & preschool age children have adequate vitamin and mineral consumption *except for iron, calcium & zinc* Age 1-3 DRIs: • Iron: 7 mg/d • Zinc: 3 mg/d • Calcium: 700 mg/d Age 4-8 DRIs: • Iron: 10 mg/d • Zinc: 5 mg/d • Calcium: 1,000 mg/d

Prevention of CVD

• Obese children & children with familial hyperlipidemia can have high LDL-cholesterol levels NHLBI Cardiovascular Health Integrated Lifestyle Diet (CHILD-1) for children at risk for CVD • Limit saturated fat to 8-10% of kcal needs • Avoid trans fats as much possible • Total fat: 30% (12-24 months) and 25-30% (2-10 years) of kcal needs • Transition to reduced fat (2%) in unflavored milk (age 12-24 months) and fat-free unflavored milk (ages 2-10 years) • Limit/avoid sugar-sweetened beverages

Parenting Skills & Child Feeding

• Parents should respond to children's hunger and satiety signals • Parents should focus on long term goal of developing healthy self-controls of eating; look beyond concerns of composition and quantity of foods children consume • Parents should not attempt to control intake • Parents should be cautioned against overly severe food restrictions • Parents should model a varied diet • Children need to be served appropriate child-sized portions • Children should never be forced to eat anything

Herbal Supplements

• Parents who take herbal supplements are likely to give them to their children • Few definitive studies exist on the effectiveness of herbal therapies for adults and much less in children • Advise parents of potential risks of herbal therapies & the need to closely monitor the child if given supplements -- do not Rx these to children

Growth Charts: BMI-For-Age

• Provides a guideline for assessing underweight and overweight in children • Is predictive of body fat for children over 2 years of age (goes up to age 20, but usually stop at 18) • BMI fluctuates during childhood - increases in infancy and decreases during preschool years with lowest level at 4-6 years (when child is leanest, appetite is low) • Must be tracked over time (looking at trends, not individual numbers)

Feeding Behaviors of Toddlers

• Rituals in feeding are common • May have strong preferences & dislikes • Food jags common: plan--> serve new foods with familiar foods & when child is hungry • Toddlers imitate parents & older siblings -- new foods are better accepted if child sees other family members eating the food; opportunity for parents to model healthy eating behaviors • Avoid battles over food or "force-feeding" (want eating environment to be positive & social, not a battleground)

Lead Posioning

• Seen in ~0.9% of children ages 1-5 • Major lead sources: airborne lead; lead chips & dust from paint -- ~25% of children live in housing with deteriorated lead-based paint • Young children at higher risk d/t tendency to put things in their mouth • Lead exposure linked to lower IQ, behavioral problems & decreased growth • Risk factors for exposure: older homes (built before 1978), living in poverty, IDA --> pica • Possible associations: adequate iron & calcium intake may decrease lead absorption; vitamin C may increase lead excretion • Prevent iron deficiency and provide a well-balanced diet with adequate vitamin C & calcium

Vegetarian Diet Guidelines for Young Children

• Several meals/day (3 meals, 2-3 snacks) • Include nutrient-dense foods (cheese, avocado, nut butters, hummus, tofu) • Provide an omega-3 FAs source - canola or soybean oil, walnuts • Ensure adequate intake of vitamin B12, vitamin D, calcium, zinc and iron -- supplement if needed (MVI + minerals)

Appetite and Food Intake of Toddlers

• Slowing growth results in decreased appetite • May have a decreased interest in food and be easily distracted • Toddlers should be allowed to control the amount of food eaten by hunger rather than parental pressure to eat more (able to self-regulate) • *Toddler-sized portions: 1 T of each food group per year of age* • Nutrient-dense snacks needed but avoid grazing on sugary foods that limit appetite for basic foods at meals • In general, toddlers age 12-24 months old should drink whole milk to help provide the dietary fats they need for normal growth & brain development -- after age 2, most children can switch to 1% reduced fat or nonfat milk • Starting at age 2, 1-2 servings/week of fish is recommended -- avoid those high in mercury (shark, swordfish, king mackerel, marlin, orange roughy, tilefish, bigeye tuna)

Temperament Differences

• Temperament - the behavioral style of the child • Affects feeding and meal-time behavior Temperaments: • "Easy" - adapts to regular schedules & accepts new foods • "Difficult" - slow to adapt and may be negative to new foods • "Slow-to-warm-up" - slow adaptability; negative to new foods but can learn to accept new foods • Caregivers need to be aware of child's temperament to avoid food conflicts • For a "difficult" or "slow-to-warm-up" child --> need to gradually expose her/him to new foods and not rush the child to accept them

Measuring Growth - Toddlers

• Those under age 2, weigh without clothes or just in a dry diaper • Measure recumbent length

Measuring Growth - Preschoolers

• Weighed & measured with light clothing and no shoes • Measure stature with a height board