Nutrition Chapter 10

Dietary guidelines for Americans 2010

Emphasize importance of maintaining appropriate calorie balance during each stage of life to manage weight and support principles of pediatric weight management Difficult to reduce weight at this young age because sufficient nutrients must be provided for kids to reach their full height potential and remain healthy

tracking toddler and preschooler health

% children living in poverty is a widely used indicator of child well being % of low income young children decreased from 48% in 2010 to 44% in 2016 49% children under 6 in families with a female householder were in poverty (compared to 9.5% for married couple families) Hispanics comprise the largest share of young kids living in low income families Black, Native American, and Hispanic children are disproportionately low income and poor

dental caries

1 in 3 kids 3-5 years old had decay in at least one primary or permanent tooth in 1999-2004 More prevalent in non while kids Untreated tooth decay was 2x as high for Hispanic and Non-Hispanic Black children compared to Non-Hispanic white kids in 2011-2012 Healthy People 2020 has the objective to reduce the % of kids who have dental caries experience and untreated dental decay Primary cause is habitual use of a bottle or non-spill training cup with milk or fruit juice at bedtime or throughout the day Prolonged exposure to these fluids can produce early childhood cares (ECC) Carbohydrates have direct effects on caries development because Streptococcus mutans (main bacteria that cause tooth decay) use carbs for food. Bacteria excrete acid that causes tooth decay. Grazing throughout the day exposes the teeth to carbs for longer periods and contributes to tooth decay Crunchy foods like apple slices and carrots are good choices because they are less likely to promote tooth decay

media influence

1/2 of food ads are directed towards children mostly for fast food restaurants and sweetened cereals fast food ads often focus on building brand recognition through the use of characters, logos, and slogans and do not even show food

Example ChooseMyPlat 4 year old boy who is physical active for at least 60 minutes a day

1600 total calories Less than 121 empty calories 5 oz grains 2 cups vegetables 1.5 cups fruit 2.5 cups dairy 5 oz protein 5 tsp oil

Child-care nutrition standards

23 million children in the US require care away from home while their parents work Standards exist for the amounts and types of foods included in meals and snacks and for the types of environments the foods are served in Standards for safety procedures too Children in part day programs (4-7 hours) receive food that provides 1/3 of their daily energy and nutrient needs in at least 1 meal and 2 snacks or 2 meals and 1 snack Full day program (8hrs)-- foods meet 1/2 to 2/3 child's needs based on the DRIs in at least 2 meals and 2 snacks or 3 snacks and 1 meal Offer food at intervals of not less than 2 hours and not more than 3 hours and should be consistent with the Dietary Guidelines for Americans

familial hyperlipidemia

A condition that runs in families and results in high levels of serum cholesterol and other lipids.

BMI rebound

A normal increase in body mass index that occurs after BMI declines and reaches its lowest point at 4 to 6 years of age.

Head Start and Early Head Start

Administered by US Department of Health and Human Services serve children from birth to 5 years, pregnant women, and their families Over 1 million kids participate in the program Goal is to increase the readiness for school of kids from economically disadvantaged families

prevention of overweight and obesity

All children should be targeted for prevention from birth by instituting lifestyle behaviors that are preventative Target behaviors - limit sugar sweetened beverages - encourage consumption of recommended amounts of fruits and vegetables - limit TV and other screen time by allowing a max of 2 hours per day and remove screens from bedrooms - eat breakfast every day - limit eating out - limit portion sizes - eat a diet rich in calcium - eat a diet high in fiber - eat a diet that follows the DRIs for macronutrients - promote moderate to vigorous physical activity for at least 60 minutes daily - limit energy dense foods Praise child's behavior without using food as a reward

Assessment of overweight and obesity

BMI-for-age percentile is used as a screening tool of assessment of pediatric overweight and obesity BMI-for-age percentile - 85th-94th-- overweight - 95th or over-- obesity No established normative BMIs for children under 2 years-- use weight-for-length percentile with greater than 95th percentile as overweight Decrease in BMI or weight-for-height during the preschool years is normal BMI reaches its lowest point at 4-6 years and then rebounds during the BMI rebound period Early BMI rebound increases the risk for adult obesity Evaluate child's medical risk, including parental obesity, family medical history, and evaluation of weight-related problems like sleep and respiratory problems Assess behavior risk, including dietary and physical activity behaviors Evaluate the child's or family's attitudes toward and capacity to change some behaviors

Healthy people 2020

Includes objectives that relate to toddlers and preschoolers in the topic areas of Food Safety, Nutrition and Weight Status (NWS), and Physical Activity (PA) NWS topic includes objectives for Healthier Food Access, Healthcare Settings, Weight Status, Food Insecurity, Food and Nutrient Consumption, and Iron Deficiency

Bright Futures: Nutrition

Bright Futures: Guidelines for Health Supervision - Resource that provides health care professionals with evidence based recommendations for pediatric health promotion, health supervision, and anticipatory guidance. - Mission is to promote and improve the health, education, and well-being of infants, children, adolescents, families, and communities. - Can be used to develop and implement programs and policies for the health and well being of infants, children, and adolescents. - Provides user-friendly materials and tools to assist in the implementation of the guidelines. - implementation guides have been published for oral health, general nutrition, physical activity, mental health, and families. Bright futures: nutrition, 3rd edition - focuses on health promotion and disease prevention for infants, children, adolescents, and families. - Provides positive attitudes toward nutrition and offers guidance on choosing healthy foods. - Family meals are emphasized because they are associated with better diets, build on family strengths, and promote unity, social bonds, and good communication. - Nutrition supervision guidelines, interview questions, screening, and assessment tips for anticipatory guidance are provided. - Address special issues and concerns related to pediatric nutrition, including oral health, vegetarian eating practices, iron deficiency anemia, pediatric undernutrition, and obesity. Bright futures: nutrition guidelines are a valuable resource for anyone who is interested in promoting healthy eating and physical activity behaviors in children.

Prevention of iron deficiency

Children 1-5 years old - drink no more than 24 oz cow's milk, goat's milk, or soy milk because they have low iron content. Large consumption of these may displace high iron foods. - high risk kids should be tested for deficiency between 9-12 months, 6 months later, and then annually from 2-5 years At risk - low iron diet - low income or migrant children - consume more than 24oz milk per day - limited access to food due to poverty or neglect - special care needs AAP recommends universal screening at 12 months and selective screening at any age in kids at increased risk

Innate ability to control energy intake

Children can self regulate food intake Eat as much as they need if allowed to decide when to eat and when to stop Innate ability to adjust caloric intake to meet energy needs Preschool age child's intake may fluctuate from meal to meal or day to day Stable intake over a week's time Parents who use food as a reward or make their children clean their plate are asking kids to overeat or under eat by messing with their self-regulation No inborn mechanisms to select a well-balanced diet Learn healthy eating habits Influenced by what they see their family members eat as well as what they see on TV

Dietary guidelines

Children should be offered a variety of foods, including grains (1/2 whole grains), vegetables (esp. dark green, red, and orange), whole fruits, and low fat dairy Reduce amount of sugar sweetened drinks and amount of added sugar Children age 2-8 years - drink 2 cups of fat free or low fat milk daily Keep total fat intake within 30-40% of calories for children 1-3 years of age and between 25-35% for children and adolescents age 4-18 years Fat- important source of calories, essential fatty acids, and fat soluble vitamins Fats should come from poly and mono unsaturated fatty acids (fish, nuts, vegetable oils) Choose fish with low mercury levels Tilefish from Gulf of Mexico, shark, swordfish, and king mackerel have high mercury levels Include beans, lean meats, and poultry as appropriate Foods high in solid fats and added sugar (SoFAS) like candy, cookies, and cakes should be limited in children's diets Parents should model a healthy diet No specific quantitative recommendation for physical activity for kids 2-5 years of age Young kids should play actively several times daily Parents should model a varied diet and regular physical activity Adequate intake of omega-3 fatty acids

appetite and satiety

Children's energy intake regulation has been studied by giving kids preloads of food or beverages of varying energy content followed by self-selected meals kids 3-5 years were given either a low energy preload beverage made with aspartame or high energy preload beverage made with sucrose. The fat and protein content of the preloads did not differ. Children were then allowed to self-select their lunches. Children who had the low calorie beverage before lunch consumed more calories at lunch while those who have a higher calorie beverage consume fewer calories. These results indicate that young children are able to adjust caloric intake based on caloric need. Similar studies were conducted in 2-5 year olds using foods with dietary fat or Olestra, which is a non energy fat substitute. Results indicate that children compensated for the lower level of calories in food when Olesta substituted for dietary fat. The preloading protocol was also used to study children's responsiveness to caloric content of foods and the presence or absence of common feeding advice from adults. In one group, teachers were trained to minimize their control over how much the children eat, and in another group, teachers were trained to focus the children on external factors to control their intake such as rewarding the children for finishing the portion served or encouraging them to eat because it was time to eat. Results of this investigation show that when the adults focus the children on external cues for eating, children lost their ability to regulate food intake based on calories. It appears that children's innate ability to regulate caloric intake can be altered by child feeding practices that focus on external cues rather than the child's own hunger and safety signals. The effects of portion size on intakes were compared between classes of three year old and five year old children. The children were served a small, medium, or large portion of macaroni and cheese along with standard amounts of other foods in their usual lunchtime setting. Analysis of the amount of food eaten showed that portion size did not affect the younger children's intakes; their intakes remained constant despite the amount of food served to them. The five year old children's intakes increased significantly with the larger portion sizes. The researchers concluded that by five years of age children are influenced by the size of the portion served. Doubling age appropriate portion size of an entree increased entree and total energy intake by 25% and 15%, respectively. These investigators raised the question of what effect large portion sizes have on overeating and on the development of childhood overweight, and the results point to the possible benefits of allowing children to self-select their portion sizes. 5 year old girls were given free access to snack foods such as ice cream, potato chips, fruit chew candy, and chocolate. The daughters of parents who reported restricting access to snack foods indicated to the investigators that they ate too much of the snack foods and also reported negative emotions about eating them. Parents' restriction of foods actually promoted the consumption of these foods by their young daughters, and of even more concern, the daughters reported feeling badly about eating these "forbidden" foods. A related study found a lower self-concept in 5 year old girls with high body weight. Daughters of parents who restricted access to food and expressed concern about their daughters' weight status tend to have negative self-evaluations. Mothers have more influence over their daughters' beliefs about food and dieting. In the optimal feeding relationship, parents are responsible for what children are offered to eat and the environment while the kids are responsible for how much they eat and whether they eat. This relationship can prevent feeding and weight problems. Late preschool age kids are responsive to external cues more than they are to their innate ability to sef-regulate.

Energy and nutrient needs

DRIs are available for males and females 0-6 months 6-12 months 1-3 years 4-8 years 9-13 years Updated based on new scientific findings

ChooseMyPlate

Developed by the US department of agriculture (USDA) Replaced the MyPyramid and MyPyramid for Kids Tool for consumers to employ the Dietary Guidelines for Americans Encourages consumption of foods from 5 food groups Website provides practical info for building healthier diets Make half the plate fruits and vegetables Make at least half of grains whole grains Switch to fat free or low fat milk Choose foods lower in sodium Drink water instead of sugary drinks Engage in age appropriate physical activity

Energy needs

Estimated energy requirements (EER) for kids 13-36 months--- (89x weight (kg) - 100) + 20(kcal for energy disposition) example: 24 month old girl who weighs 12kg would have an EER of (89x 12 -100)+20= 988kcal Beginning at 3 years, the DRI equations are based on gender, age, height, weight, and physical activity

Appetite and food intake of preschoolers

Familiar foods may be comforting Child may also ask for the same foods all the time because they are trying to exert control over this aspect of their life Avoid starting a battle over food selection between parent and kid Serve child sized portions in an attractive way Kids often do not like their food to touch or be mixed together like in casseroles and salads Often do not like strongly flavored vegetables and spicy foods Do not eat and drink indiscriminately between meals and snacks because this blunt appetite at mealtime Do not force the child to stay at the table until they have eaten a certain amount of food determined by the parent

fluoride

Fluoridated water and toothpaste are good sources Supplement is recommended if the water supply does not have an adequate amount 6 months- 3 years - 0.25mg fluoride daily if their water supply has less than 0.3 ppm 3-6 years - need 0.5mg daily if water has less than 0.3ppm - need 0.25mg if water has 0.3-0.6ppm Excess consumption can lead to fluorosis (permanent white or brownish staining of the enamel of teeth caused by excessive fluoride ingestion before teeth have erupted) Supplements are only available by prescription due to the risk of fluorosis

treatment of overweight and obesity expert committee: recommendations

Goal is improvement of long term physical health through permanent health lifestyle habits and behavior modification Improvement is measured by a decrease in BMI-for-age percentile (difficult to use in the short-term) Weight measurements on a regular basis can be used to measure progress in the short term Maintaining weight while gaining height can be the best treatment for obese children between 2-5 years-- allows them to grow into their weight and lower BMI Weight loss should not exceed 1 lb per month Expert committee recommends a staged approach Stage 1: Prevention Plus - Focuses on the behaviors identified in prevention section - Identify dietary and physical activity behaviors in the child and family that would be appropriate to target and use motivational interviewing techniques to assist the family in making changes - Targeted behaviors can be made in steps with the ultimate goal being improvement in BMI-for-age percentile - Involves frequent follow ups based on child's and family's needs Stage 2: Structured weight management (SWM) - more structured and requires frequent follow ups - planned diet or daily eating plan - reduce screen time further to less than 1 hour a day - planned supervised physical activity or active play for 60 minutes a day - monitor behavior using logs and planned reinforcement for achieving targeted behaviors - motivational interviewing - may need a counselor to address parenting skills or help resolve family issues that are barriers to healthy lifestyle behaviors - monthly visits with some as group sessions Stage 3: Comprehensive multidisciplinary intervention - increased intensity of behavior change - multidisciplinary team includes a registered dietitian, exercise specialist, behavioral counselor, and primary care provider - weekly visits for minimum of 8-12 weeks - structured program in behavior modification that includes food monitoring, short-term diet resulting in a negative energy balance, and physical activity goal setting - parents are involved in behavior modification for their children - parental training for improving the home environment - evaluate body measurements, diet, and physical activity at specified time intervals Stage 4: Tertiary care intervention - offered to severely obese adolescents who have failed other interventions - not appropriate for obese toddlers or preschoolers

Constipation

Hard and dry stools associated with painful bowel movements Common in young kids Stool holding may develop if the child does not completely empty the rectum, and this can lead to chronic overdistension so that the child is eventually retaining a large fecal mass. Bowel movements become painful, which leads to more stool holding. (Cycle) Adequate fiber and appropriate fluid intake can help prevent this Whole grain breads and cereals, legumes, fruits, and vegetables are good fiber sources Avoid too much fiber because kids can develop diarrhea from high fiber. Also, high fiber can displace other energy dense foods and decrease bioavailability of iron and calcium

Feeding behaviors of toddlers

Has a need for rituals which may be related to the development of food jags Many demonstrate strong preferences and dislikes May go through a long period of refusing a particular food or foods they previously liked Child's temperament affects how intense the refusal or negative attitude toward a particular food are Serve new foods with familiar foods to reduce food jags Kids accept new foods better when they are hungry or see another family member eating them (their natural curiosity will get the best of them, and they are great imitators) Mealtime is a great time to practice new language and social skills and develop a positive self image Do not force the toddler to eat or battle over eating because mealtime should be a time to model healthy eating behaviors for the young child Establish the habit of eating breakfast

Blood lead levels

Healthy People 2020 objective is to eliminate blood lead levels above 10mcg/dL in young children and reduce the mean blood lead levels in kids Sources are exposure to airborne lead (has decreased recently due to elimination of lead from gasoline and enforcement of industrial emissions standards) and leaded chips and dust from paint (particularly in houses built before 1978) At risk because they often put things in their mouths (some objects may have lots of lead) Lead is transported across the placenta, and so damage due to exposure can begin in pregnancy Blood levels peak around age 2 years Racial, ethnic, and socioeconomic disparities (higher rates in kids in poverty, minority groups, and recent immigrants) Affect brain, blood, and kidneys Decrease IQ Impair motor, behavioral, and physical abilities Decrease growth No safe level Enters food supply through lead soldered pipes, contaminated water, and canned goods from other countries that contain lead solder seals Dirt, lead weights, ceramic glazes, and pewter are non food contaminated sources Some parental occupations can be a source-- remove work clothing and wash them separately Federal policy requires lead screening in kids enrolled in Medicaid lead screening should be obtained at9-12 months and again around 24 months when levels epak

Food security

Healthy People 2020 objective to eliminate very low food security in children Higher prevalence of food insecurity in Black, Non-Hispanic households and Hispanic households Important for young kids since they have high nutrient needs for growth and development Vulnerable since they depend on parents/caregivers to supply them with access to food Children who are hungry and experience food insufficiency are more likely to exhibit behavioral, emotional, and academic problems

Nutrition and prevention of cardiovascular disease in toddlers and preschoolers

Heart disease- number one cause of death in the US Elevated levels of LDL cholesterol-- risk factor for cardiovascular disease Children with familial hyperlipidemias and obese children can have high levels of LDL cholesterol High intakes of saturated fat, trans fatty acids, and dietary cholesterol elevate LDL levels High triglyceride levels and high BMI are also risk factors Fatty streaks, which can be precursors to the buildup of fat deposits in blood vessels, have ben found in the arteries of young children. These streaks could represent the beginning of atherosclerosis and cardiovascular disease AHA has published guidelines for the primary prevention of atherosclerotic cardiovascular disease beginning in childhood AHA recommends that all children be screened for risk factors and that all kids have an overall healthy eating pattern while maintaining appropriate body weight, lipid profile, and blood pressure Avoid smoking Engage in physical activity daily AHA published dietary recommendations for kids, which have been endorsed by the AAP and which are consistent with the US Dietary Guidelines Recommended diet- fruits, vegetables, whole grain breads and cereals, nonfat or low-fat dairy, and two weekly servings of fish Use vegetable oils and soft margarines that are low in saturated fat and trans fatty acids instead of butter or most other animal fats Reduce intake of sugar sweetened beverages and foods Reduce salt intake For kids 2-3 years old, 30-35% of total energy from fat is recommended For kids 4 years of age or older, the recommendation is 25-35% from fat Intake less than 1% total calories from trans fat Dietary restrictions are safe and effective for reducing risk factors in childhood without negatively impacting growth Acceptable macronutrient distribution ranges (AMDRs) - for fat- 30-40% for children 1-3 years - for fat- 25-35% for children 4-18 years No specific recommendations for total fat per day in diets of young children Screen children for high lipid levels if they have a positive family history of dyslipidemia or premature cardiovascular disease Screen kids without unknown family history Screen kids with risk factors such as obesity, overweight, hypertension, diabetes Screening should take place after 2 years but before 10 years Children who are at risk of developing premature cardiovascular disease or who are found to have high lipid levels should have periodic screening for blood cholesterol levels. If LDL is high, they should restrict calories from saturated fat to less than 7% and restrict cholesterol to no more than 200mg

Physical activity

Helps maintain energy balance and strengthen muscles Outdoors - games in the yard or park - family walks after dinner - walking the dog - freestyle dance - playing catch - family bike rides on the weekend Indoors - follow the leader - play with dog - hide and seek - ring around the rosie - Simon says - walking around the mall or museum Toddlers under adult supervision should engage in activities like walking in the neighborhood, park, or zoo and free play outdoors Preschoolers can run, swim, tumble, throw, and catch no TV under 2 years Less than 2 hours screen time for other age groups Parents should be active to set an example

Normal values of biochemical parameters

Hematocrit- 39% Hemoglobin- 14g/dL Serum ferritin- more than 15ng/mL Serum total iron binding capacity- 350-400mcg/dL serum transferring saturation- more than 16% Serum transferrin- 170-250mg/dL Erythrocyte protoporphyrin- more than 70 mcg/dL Lead- less than 10mcg/dL Dyslipidemia screening - total cholesterol- less than 170mg/dL - LDL cholesterol- less than 110mg/dL

BMI

Index that correlates with total body fat content or percent body fat and is an acceptable measure of adiposity or body fatness in kids and adults Calculated by dividing weight in kg by the square of the height in m (kg/m2) Predictive of body fat for kids over 2 years of age No normative values available for kids less than 2 years old For kids over 2 years old, 85th to 94th percentile is considered overweight, and 95th percentile or above is considered obese (For kids less than 2 years old, weight for length greater than the 95th percentile is considered overweight) A weight for length or BMI for age percentile less than the 5th percentile indicates underweight in all categories Fluctuates throughout childhood Increases in infancy, decreases during preschool years (hits its lowest point between 4-6 years old), and increases into adulthood Due to the fluctuation, you can only tell if the BMI is in the normal range if you plot the BMI-for-age on the appropriate growth curve Goal is to strive for a BMI-for-age within the normal range and not for a specific value (same goal for adults) Healthy People 2020 has the objective to increase the proportion of primary care physicians who assess BMI regularly in children Growth charts provide visual aids for parents by demonstrating the expected slowing of growth velocity during toddler and preschool stage of development Weight-for-age and length- or stature-for-age continue to increase during the toddler and preschool age years, but the slope of the curve is not as steep as it is during the first year of life

Normal growth and development

Infant's birth weight triples in the first 12 months, but growth velocity slows after until the adolescent growth spurt Toddlers gain 8 oz (0.23kg) per month and 0.4 in (1cm) of height per month Preschoolers gain 4.4lb (2kg) and 2.75in (7cm) per year Decrease in growth rate is accompanied by reduced appetite and food intake Many parents complain that their kids have a lower appetite and interest in food than they did as infants, but parents need to be reassured that a decrease in appetite is part of normal growth and development for kids in this age group

nutritional considerations

Iron deficiency anemia is associated with pica, which is also a risk factor for lead ingestion Young age, poor nutrition, and low socioeconomic status are risk factors for iron deficiency anemia and elevated lead levels Adequate iron consumption may decrease lead absorption Vitamin C may increase lead excretion Calcium decreases lead absorption

Development of feeding skills in toddlers

Many begin to wean from breast or bottle around 9-10 months of age when their solid food intake increases and when they learn to use a cup Pay attention to cues for readiness for weaning like disinterest in breastfeeding or bottle feeding Weaning is easier for babies who adapt to change well Weaning is a sign of growing independence and is usually complete by 12-14 months of age AAP recommends that breastfeeding should continue for at least 12 months WHO recommends breastfeeding to continue up to 2 years of age or beyond if desired Gross and fine motor development enhances ability to chew foods of different textures and to self feed Between 12-18 months, they can move their tongue from side to side (laterally) and learn to chew with rotary movements Handle chopped or soft table foods 12 months- children have refined pincer grasp that enables them to pick up small objects like cooked peas and carrots and put them in their mouths—they can also use a spoon but not that well 18-24 months- use their tongue to clean the lips, have well developed rotary chewing movements, and can handle meats, raw fruit and vegetables, and multiple food textures Strong need for independence in self-feeding emerges Often become distracted while practicing their new skills Use cups and spoons more effectively as their fine motor and visual motor coordination skills increase Prefer to eat with their hands even though skill with spoon increases in the 2nd year Messy initial attempts to self-feed Limit distractions during mealtimes and allow the toddler to practice self-feeding skills and to experience new foods and textures High choking risk Should always be seated (high chair or booster seat with the family is best) and supervised Do not serve hard candy, popcorn, nuts, whole grapes, and hot dogs to kids under 2

fluids

Meet needs through beverages, foods, and sips throughout the day Needs increase with fever, vomiting, diarrhea, and hot/dry/humid environment Consumption of milk has decreased while consumption of carbonated soft drinks has increased by the same amount since the 1970s 50% children 2-5 years consume soft drinks Sugar sweetened drinks account for 10-15% total calorie intake 2 cups milk Less than 4-6oz fruit juice Offer water between meals and snacks

Tips for offering a variety of foods

Mix it up. Change your typical foods and try something new. Let your child choose a new vegetable to add to soup. Add different ingredients to your typical salads Vary the cereals, bread, and sandwich fillings Add fruit to breakfast by using it to top cereal Put rinsed and cut fruits and vegetables in a bag or bowl in the refrigerator where your child can see them

Vitamins and minerals

Most meet the targeted levels for consumption except for iron, calcium, and zinc Age 1-3 years - 7mg iron daily - 3mg zinc daily - 700mg calcium daily Age 4-8 years - 10mg iron - 5 mg zinc - 1000mg calcium

Calcium

Needed for peak bone mass High peak bone mass is protective against osteoporosis and fractures later DRIs - age 1-3 years-- 700mg/day - age 4-8 years-- 1000mg/day Dairy products, canned fish with soft bones (sardines), dark green leafy vegetables like kale and bok choy, tofu with calcium, and calcium fortified foods and drinks

Iron

Needed to prevent iron deficiency and iron deficiency anemia Ground or chop meats Fortified cereals and dried beans and peas Iron fortified commercial formulas are available, but healthy children who consume a variety of foods and whose milk intake is less than 24oz daily should be fine without these sorts of products

Overweight and Obesity in toddlers and preschoolers

Obesity rates are lowest in Asian children compared to Non-Hispanic white children, Non-Hispanic Black children, and Hispanic children Affects more low income children Prevention is the preferred approach because obesity is difficult to treat

Applications of child feeding research

Parents should respond to children's hinger and satiety signals. Focus on long term goal of developing healthy self-controls of eating in kids and look beyond their concerns regarding composition and quantity of foods children consume or fears that children may eat too much and become overweight Do not attempt to control kids' intake by attaching contingencies and coercive practices Do not restrict "junk" foods severely Develop food preferences and selection patterns in a way that is consistent with a healthy diet Model a varied diet Allow for repeated exposures of new foods Serve appropriate portion sizes Make the environment secure, happy, and positive Do not force them to eat anything

Prevention of nutrition related disorders

Prevalence of overweight and obesity is increasing in the US High energy and high fat diets and sedentary lifestyles contribute to increase in weight Cardiovascular disease is a major cause of morbidity and death Dietary habits, physical activity, and tobacco use can be acquired in childhood, and these behaviors affect health later American Heart Association (AHA) advocates that primary prevention of atherosclerotic disease begin in childhood

Fiber

Prevent constipation and provide long term disease prevention Ample fiber intake has been associated with the prevention of heart disease, some cancers, diabetes, and hypertension in adults Excessive fiber (defined as the child's age plus 15g) can be detrimental because high fiber diets have the potential of reducing energy density of the diet which could impact growth High fiber could also impact bioavailability of some minerals like iron and calcium Those who meet the recommendations tend to have lower intakes of fat and cholesterol and higher intakes of vitamin A, vitamin E, folate, magnesium, and iron (also higher intakes of bread, cereal, fruit, vegetables, legumes, nuts, and seeds) 1-3 years -- 19g/day 4-8 years-- 25g/day

Protein

RDAs are easily met with typical American diets and vegetarian diets With adequate energy intake, protein is spared and used instead for growth and repair Ingestion of high quality protein like milk and other animal products lowers the total amount needed in the diet to provide the essential AAs Age 1-3 years: 1.1g/kg/day (or 13g/day based on average weight) Age 4-8 years: 0.95g/kg/day (or average 19g/day)

Growth velocity

Rate of growth over time Growth during the toddler and preschool years is slower than in infancy but steady Decreased appetite Need adequate calories and nutrients to meet needs Eating and health habits established at this stage of life may impact food habits and subsequent health later Development of new skills and increasing independence marks the toddler and preschool stages Learn and accept new foods, develop feeding skills, and establish healthy food preferences and eating habits

iron deficiency anemia

Reduction below normal in the number of red blood cells per cubic mm in the quantity of hemoglobin or in the volume of packed red cells per 100 mL of blood Rapid growth rate coupled with inadequate iron intake places toddlers (especially 9-18 month olds) at the highest risk for deficiency More common in low income children and in African American and Mexican American children Causes long-term delays in cognitive development and behavioral disturbances Healthy People 2020 objective to reduce deficiency in young children Deficiency is defined as absent bone marrow iron stores, an increase in hemoglobin concentration of more than 1g/dL after treatment with iron, or other abnormal lab values such as serum ferritin concentration iron deficiency Anemia definition- less than the 5th percentile of the distribution of hemoglobin concentration or hematocrit in a healthy reference population NHANES III data are used for the age and sex specific cutoff values 1-2 years old - diagnosed with anemia if the hemoglobin concentration is less than 11 g/dL and hematocrit value is less than 32.9% 2-5 years - hemoglobin less than 11.1g/dL - hematocrit less than 33% Vitamin B12 deficiency, folate deficiency, chronic inflammation, or recent infection can also lead to forms of anemia

appetite and food intake of toddlers

Remember toddlers naturally have a decreased interest in food and decreased appetite because of their slowing growth Part of normal develop to be easily distracted at mealtime especially since they have so many new gross and fine motor skills to use and explore Need toddler sized portions. 1 tablespoon of food per year of age. Better to give a small portion and allow the child to ask for more. Parents often overestimate the amount of food needed and then label their kids as picky eaters. Snacks are vital to meet nutritional needs since they cannot eat a lot at one time. Do not allow them to graze throughout the day though on things like sweetened beverages and foods like cookies and chips since these foods can blunt their limited appetite for basic foods at meal and snack times. Establish regular but flexible meal and snack times with enough time in between for the toddler to get hungry Let the toddler control the amount of food they eat based on their hunger and not parental pressure

feeding behaviors of preschool age children

Remind parents that their growth rate is slow with relatively small appetite and food intake Growth occurs in spurts during childhood Appetite and food intake increase in advance of a growth spurt, causing kids to add some weight that will be used for the upcoming spurt in height Variable appetite Want to be helpful and please their parents-- this makes this stage a good time to teach kids about foods, food selection, and preparation by involving them in simple food related activities like taking them to the farmers' market Examples of activities 2 years old - tear lettuce or greens, rinse vegetables or fruits, snap green beans 3 years old - mash potatoes, squeeze citrus fruits, and stir batter 4 years old - peel eggs and fruits, crack eggs, and help make sandwiches and salads 5 years - measure liquids, cut soft fruits with dull knife, use eggbeater

WIC's Farmers' Market Nutrition Program

Seasonal program for WIC participants Provides vouchers for the purchase of locally grown produce at farmers' markets Helps low income families increase their consumption of fresh fruits and vegetables

Fat

Source of calories, essential FAs, and fat soluble vitamins Use foods high in fat sparingly Meet recommendations if you follow MyPlate Good sources of linoleic acid- peanut, canola, corn, safflower, and other vegetable oils alpha-linolenic acid- flaxseed, soy, and canola oil

Treatment for iron deficiency anemia

Supplement with iron drops at 3mg/kg/day Counsel parents about diets that prevent deficiency Repeat screening in 4 weeks Increase lean meat, fish, and poultry consumption with vitamin C An increase of more than 1g/dL in hemoglobin concentration or more than 3% in hematocrit within 4 weeks of treatment initiation confirm the diagnosis of deficiency Continue iron treatment for 2 months if the anemia responds to treatment and also continue dietary improvement Recheck 6 months alter If the levels do not increase after the 4 weeks, further tests are needed, and iron status will not improve with supplements if the cause of the anemia is not related to iron

vegetarian diets

The amount of food required to meet the nutrient needs may be more food than the child can eat children need some energy dense foods to reduce the total amount of food need to eat several times a day to meet energy needs because their stomachs cannot hold a lot Children with vegan diets and macrobiotic diets (falls between semivegetarian and vegan- includes brown rice, vegetables, fish, dried beans, spices, and fruits) tend to have lower rates of growth (still within the normal ranges though) during the first 5 years of life Strict vegans may be deficient in vitamins B12 and D, zinc, and omega 3 fatty acids and may be low in calcium Protein needs are usually met if the diet is adequate in energy and a variety of foods are consumed Vegan kids should receive B12 supplement or eat fortified cereal , textured soy protein, or fortified soy milk Monitor for vitamin B12 deficiency because it can cause anemia, leading to fatigue, pale skin, and shortness of breath Sun exposure, fortified soy milk, fortified breakfast cereal, fortified margarines for vitamin D Zinc can be found in legumes, nuts, and whole grains Include canola or soybean oil for omega 3 Unrefined cereals contain phytates, which may interfere with the absorption of calcium (may need more calcium in the diet) Fortified soy milk, fortified orange juice, fortified breads, tofu processed with calcium, blackstrap molasses, sesame seeds, tahini, almonds, broccoli, and kale are sources of calcium Calcium in spinach, Swiss chard, beet greens, and rhubarb is not well absorbed because insoluble calcium oxalate is formed Guidelines for vegetarian kids - provide 3 meals and 2-3 snacks each day - avoid serving bran and excessive intake of bulky foods like raw fruits and vegetables - encourage eating nutrient dense foods like cheese, avocado, soy cheese, hummus, nut butters, tahini, and tofu - provide omega 3 fatty acid like canola oil, soybean oil, tofu, soybeans, walnuts, and wheat germ - avoid excessive restriction of dietary fat - ensure adequate intake of calcium, zinc, iron, and vitamins B12 and D

WIC

The special supplemental nutrition program for women, infants, and children (WIC) is administered by the Food and Nutrition service of the USDA. Successful federally funded nutrition program in the US. Improves the growth, iron status, and quality of dietary intake of nutritionally at risk infants and children up to five years. Must live in low income household (185% or less of the federal poverty level) or be enrolled in Supplemental Nutrition Assistance Program (SNAP), or Medicaid, and be at nutrition risk to be eligible Nutrition risk means the child has a medical or dietary-based condition that places them at increased risk (underweight, iron-deficiency anemia, overweight, or chronic illness like cystic fibrosis, or consumption of an inadequate diet) Nutrition assistance, education, and follow up services Provide vouchers, checks, or electronic benefits transfer (EBT) that allow them to obtain specific types of food from participating stores at no charge

The WHO and CDC Growth Charts

Use the WHO growth charts for kids aged birth to younger than 2 years regardless of type of feeding Use the 2000 CDC growth charts for kids aged 2-20 years WHO charts were developed as growth standards which demonstrate how healthy children grow under optimal conditions CDC growth charts are based on data from cycles 2 and 3 of the National Health and Examination Survey (NHES) and the National Health and Nutrition Examination Survey (NHANES) I, II, and III, and they provide a reference for how kids in the US are growing Gender specific Plot and monitor weight for age, length or stature for age, head circumference for age, weight for length, weight for stature, and BMI for age Growth usually tracks within a steady percentile range Monitor growth over time and look for any deviations in growth The pattern of growth is what is important rather than the single measurement Weight measurement without length or stature measurement does not indicate whether the weight is appropriate Important to make measurements and use growth correctly because incorrect usages can lead to errors in health status assessment

development of feeding skills in preschool age children

Uses fork, spoon, and cup well Cutting and spreading with a knife need work still Sit comfortably at the table for all meals and snacks Eating is not as messy as during toddlerhood Spills are not intentional Modify foods that are easy to choke on to make them safer (cut grapes in half lengthwise and cut hot dogs in quarters lengthwise and then into little bites) Supervise at all times

Fat soluble vitamins

Vitamin A- whole eggs and dairy products Vitamin D- sun exposure and fortified milk (AAP recommended 400IU for all kids, but the recommendation was increased to 600IU for kids 1-8 years with the revision of the DRIs in 2010) Vitamin E- corn, soybean, safflower oils Vitamin K- widely distributed in animal and plant foods

food safety

Vulnerable to foodborne illnesses because they can become ill from smaller doses of organisms Campylobacter species and Salmonella species are key pathogens and are the most frequently reported foodborne illnesses in the US E. coli 0157:H7 is the most commonly identified Shiga toxin-producing E. Coli (STEC) in N America Campylobacter - highest rate of infections in children under 1 year - transmitted by handling raw poultry, eating undercooked poultry, drinking raw milk or nonchlorinated water, or handling infected animal or human feces Salmonella - undercooked or raw eggs E. coli - children under 10 years old account for a disproportionate percent of cases of e. coli related illness - serious and can cause bloody diarrhea and hemolytic uremic syndrome (HUS) - ingesting contaminated and undercooked hamburger meat, unpasteurized apple cider and juice, and unpasteurized milk FightBAC - food safety education program developed by Partnership for Food Safety Education, state and consumer organizations, CDC, and EPA - clean: wash hands and surfaces often - separate: do not cross contaminate - cook: cook to proper temp - chill: refrigerate promptly

measuring growth

Weigh toddlers less than 2 years old without clothing or diaper Measure the recumbent length of toddlers on a length board with a fixed head board and movable foot board (measurement of length while the child is lying down-- used for toddlers less than 24 months and those between 24-36 months who cannot stand unassisted)-- requires 2 adults to make sure the crown of the head is placed firmly against the head board and the legs are fully extended with foot board on the child's heels Measure and weight preschool age kids without shoes and in lightweight clothing using a calibrated scale and height board Measure stature- standing height Plot weight and height on the appropriate growth charts like the WHO and CDC growth charts

Recommended versus actual intake

What We Eat In America (WWEIA) is a joint project of the USDA and DHHS and is the dietary intake component of the NHANES Young children meet their energy needs and more than enough protein and fat 2-5 year olds have mean sodium intakes of 2331mg/ day for boys and 2283 mg/day for girls when the recommendation is 2300mg/day Mean intakes of zinc, folic acid, vitamin D, and vitamin E were consistently below the recommended levels Low zinc, vitamin E, and iron found in toddlers ages 12-18 months Diets of kids who ate fast foods-- high total energy, total fat, total carb, added sugars, and sugar sweetened beverages with less fiber, less milk, and fewer fruits and nonstarchy vegetables 11% 2-3years and 12% 4-5 years consumed more than 25% of total energy from added sugar Increased added sugar consumption is associated with decreased nutrient and food group intakes and increased % of children not meeting the DRIs Portion sizes of meat have decreased Children's portion sizes in general have stayed constant (this reinforces the hypothesis that young kids are capable of self-regulating energy intake)

Supplemental nutrition assistance program

administered by the USDA Helps adults in low income households buy food Improves food security and nutrition of participants Monetary amount of food vouchers provided to a household depends on the number of people in the house and the income of the house Average monthly benefits in 2015- $127.57 per individual Participation is associated with increased intake of nutrients and decrease in food insecurity

Early childhood caries (ECC)

aka nursing bottle caries or baby bottle tooth decay Upper front teeth are the most affected because that is where fluids pool when the toddler falls asleep while drinking from the bottle Increases the risk for caries in the permanent teeth since the conditions that lead to this often continue into childhood

Temperament differences

behavioral style of the child 3 clusters - the easy child (40%) - difficult child (10%) - slow-to-warm-up child (15%) the remaining children are intermediate-low or intermediate high and demonstrate a mixture of behaviors but gravitate toward one end of the spectrum Affect feeding and mealtime behavior Easy- regular in function, adapts easily to regular schedules, and tries and accepts new foods readily Difficult- irregularity in function and slow adaptability, reluctant to accept new foods and can be negative about them Slow to warm up- slow adaptability and negative responses to many new foods with mild intensity- can learn to accept new foods over time with limited complaining with repeated exposures

Preloads

beverages or foods such as yogurt in which the energy/macronutrient content has been varied by the use of carb and fat sources Given before a meal or snack and subsequent intake is monitored Employed by Birch and Fisher in studies of appetite, satiety, and food preferences in kids

Toddlers

children between 1-3 years Rapid increase in gross and fine motor skills with subsequent increases in independence, exploration of the environment, and language skills Gross motor skills- development and use of large muscle groups as exhibited by walking alone, running, walking upstairs, riding a tricycle, hopping, and skipping Fine motor skills- development and use of smaller muscle groups demonstrated by stacking objects, scribbling, and copying a circle or square

preschool age children

children between the ages of 3-5 years who are not yet attending kindergarten Increasing autonomy Experience broader social circumstances like attending preschool or staying with friends/relatives Increase language skills Expand ability to control behavior

Nutrition assessment

food/nutrition history Biochemical measurements anthropometric measurements like weight, height, BMI percentile, and medical history Identify nutrition diagnoses and design a nutrition intervention plan Plan monitoring and evaluation

Heart disease

leading cause of death and common cause of illness and disability in the US coronary heart disease is the principal form of heart disease and is caused by a buildup of cholesterol deposits in the coronary arteries that feed the heart

food preference development, appetite, and satiety

preferences determine what foods they consume Prefer sweet and slightly salty tastes Reject sour and bitter tastes Eat familiar foods Environment plays an important role in food preference development Reject new foods initially but learn to accept them with repeated exposure (may take 8-10 exposures) Children with family members that all eat a variety of foods are more likely to eat a variety of foods Preferences for foods that are energy dense due to high levels of sugar and fat (maybe because they associate them with the pleasure of satiety or because they are associated with special social occasions like parties) Context the food is offered in affects preference Foods served on a limited basis and as a reward are highly desirable Restricting access to a palatable food may promote desirability and intake of that food coercing or forcing kids to eat foods can have long term negative impact on their preference for them

Vitamin and mineral supplementation

recommended for children at risk for or with a deficiency Children at risk - anorexia or inadequate appetite - fad diets - chronic disease - from deprived families - suffer parental neglect or abuse - participate in dietary program for managing obesity - consume a vegetarian diet without adequate intake of dairy - with failure to thrive Young children are major users of supplements even though they should normally be able to get their nutrients from food Children are likely to use multivitamins and multiminerals Children most likely to receive supplements were underweight or at risk for underweight Families with greater income are more likely to give their kids supplements, but kids of families with greater incomes are less likely to be deficient If given, supplements should not exceed DRIs Vitamins A and D should be paid particular attention to make sure they are not given in excessive amounts Tolerable Upper Intake Levels serve as a guide for excessive nutrient intake from fortified foods and supplements

hemolytic uremic syndrome (HUS)

serious and sometimes fatal complication associated with illness causes by E. coli Primarily in kids under 10 years Renal failure, hemolytic anemia, and severe decrease in platelet count