6-promoting healthy nutrition

8/13/2019 6-Promoting Healthy Nutrition

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B R I G H T F U T U R E S G U I D E L I N E S F O R H E A L T H S U P E R V I S I O N O F I N F A N T S , C H I L D R E N , A N D A D O L E S C E N

Promoting Healthy Nutrition Theme5

INTRODUCTIONInfancy, childhood, and adolescence are marked by rapid physical growthand development, and every child’s and adolescent’s health and develop-ment depends on good nutrition. Any disruption in appropriate nutrientintake may have lasting effects on growth potential and developmentalachievement. Physical growth, developmental requirements, nutritionneeds, and feeding patterns vary significantly in each stage of growth anddevelopment.

The dramatic increase in pediatric over-weight and obesity in recent years hasincreased health care professionals’ and

parents’ attention to nutrition. Along withregular physical activity, a balanced and nutri-tious diet is essential to prevent pediatricoverweight conditions. Therefore, health careprofessionals are encouraged to review thisBright Futures theme in concert with thePromoting Physical Activity and Promoting

Healthy Weight themes.

Key Food and Nutrition ConsiderationsFood and nutrition behaviors are influencedby myriad environmental and cultural forces.Health care professionals should keep theseforces in mind as they work with patients andfamilies. Three issues of particular importanceare discussed here.

Culture and Food

All people belong to some kind of culturalgroup. Culture influences the way peoplelook at the world, how they interact withothers, and how they expect others tobehave. To meet the challenge of providingnutrition supervision to diverse populations,health care professionals must learn torespect and appreciate the variety of culturaltraditions related to food and the wide varia-

tion in food practices within and among cul-tural groups. They also need to understandhow their own cultures influence their atti-tudes and behaviors, and the resulting impli-cations for nutrition counseling. Sharing foodexperiences, asking questions, observing thefood choices people make, and working withthe community are important ways for healthcare professionals to learn about and appreci-ate the food and nutrition traditions of othercultures.1

Culture influences how people prepare

food, how they use seasonings, andhow often they eat certain foods.These behaviors can differ fromregion to region and family to fam-ily, though some traditions existacross cultures. For example, staple,



B R I G H T F U T U R E S G U I D E L I N E S F O R H E A L T H S U P E R V I S I O N O F I N F A N T S , C H I L D R E N , A N D A D O L E S C E N T S

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or core, foods form the foundation of thediet in all cultures. Staple foods, such as riceor beans, are typically bland, relatively inex-pensive, easy to prepare, an important sourceof calories, and an indispensable part of the

diet.Acculturation, which is the adoption of the

beliefs, values, attitudes, and behaviors of adominant, or mainstream, culture, can be asignificant influence on a person’s food choic-es. Acculturation may involve altering tradi-tional eating behaviors to make them similarto those of the dominant culture. Thesechanges can be grouped into 3 categories:(1) the addition of new foods, (2) the substi-tution of foods, and (3) the rejection offoods. People add new foods to their diets

for several reasons, including increased eco-nomic status and food availability (especiallyif the food is not readily available in the per-son’s homeland). Substitution may occurbecause new foods are more convenient toprepare, more affordable, or better liked thantraditional ones. Children and adolescents, inparticular, may reject traditional foodsbecause eating them makes them feel differ-ent from the mainstream.

Culture also influences nonnutritive aspects

of food practices, and any nutritional infor-mation and guidance should take these pref-erences and practices into account. Someethnic practices related to diet and nutritionmay focus more on the food’s texture,appearance, flavor, or aroma, or on beliefsrelated to the complementary nature of thefood items, rather than on specific nutritionalvalue. For many people, certain foods areclosely linked to strong feelings of beingcared for and nurtured by their families or area reflection of religious practices. People from

virtually all cultures use food during celebra-tions.

In many cultures, people believe that foodpromotes health, cures disease, or has othermedicinal qualities. In addition, many peoplebelieve that foods can help maintain a

balance in the body that is important tohealth. For example, many Chinese believethat health and disease are related to the ance between “yin” and “yang” forces inthe body. Diseases caused by yin forces are

treated with yang foods to restore balanceand vice versa. In Puerto Rico, foods are clasified as hot or cold (which may not reflectthe actual temperature or spiciness of foodand people believe that maintaining a bal-ance between these 2 types of foods isimportant to health.

Health care professionals can provideeffective nutrition guidance by being sensito cultural beliefs that categorize foods inways other than the Western scientificmodel, by exploring such beliefs, and by

incorporating them into their guidance.When discussing their food choices, patienand their parents may respond by sayingwhat they think the health care professionwants to hear. Health care professionals caencourage people to be more candid aboutheir food choices by asking open-ended,nonjudgmental questions that reflect theirknowledge of, and sensitivity to, these issu

Two issues illustrate the challenges of pviding nutrition supervision to people fromdiverse cultural backgrounds. The first, lac-tose intolerance, highlights the medicalaspects involved. The second, attitudestoward body weight, highlights the deep-seated emotional and attitudinal aspects tare often involved.

LACTOSE INTOLERANCE

Lactose intolerance is common in people onon-European ancestry. People who are latose intolerant may experience cramps anddiarrhea when they eat moderate to largeamounts of foods that contain lactose, suc

as milk and other dairy products. Childrenand adolescents may be able to avoid symtoms by consuming small servings of milkthroughout the day, by consuming lactosereduced milk, or by taking lactase tablets o

H E A L T H Y

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Health care profes-

sionals can provide

effective nutrition

guidance by being

sensitive to cultural

beliefs that categorize

foods in ways other

than the Western sci-

entific model, byexploring such beliefs,

and by incorporating

them into their guid-

ance.




drops with milk. Cheese and yogurt are oftenbetter tolerated than milk because they con-tain less lactose. For people who cannot tol-erate any milk or dairy products in their diet,health care professionals can suggest other

sources of calcium, such as dark green, leafyvegetables or canned salmon, and calcium-fortified foods, such as orange juice, tofu, orbread.

ATTITUDES ABOUT BODY WEIGHT

People from different cultures can view bodyweight differently. Keeping a child from beingunderweight can be very important to peoplefrom cultures in which poverty or insufficientfood supplies are common. Families may notrecognize that their child is overweight

according to body mass index (BMI) tables ormay view excess weight as healthy. In thesecases, the families may be offended if ahealth care professional refers to their child asoverweight or obese. (For more informationon this topic, see the Promoting HealthyWeight theme.)

Food Insecurity and Hunger

Hunger describes the personal sensation thatresults from a lack of food and is typically feltas unpleasant or painful. Involuntary hungerresults from not being able to obtain enoughfood and excludes hunger related to volun-tary dieting, religious fasting, or the personalchoice to skip a meal.

Food insecurity for a family means limitedor uncertain availability of nutritionally ade-quate and safe foods, or the uncertain abilityto acquire appropriate foods in sociallyacceptable ways. In contrast, food-securehouseholds have access to sufficient food fora healthy lifestyle at all times. Twelve percent

of American households were food insecurefor at least part of 2004.2 (The remainingfamilies were food secure throughout theentire year of 2004.) The prevalence of foodinsecurity has increased steadily since 1998.3

Food insecurity may occur with or withouthunger. In its most severe presentation, thisproblem is associated with hunger and is anindication of a serious nutritional problemand family predicament. Food insecurity with-

out hunger is associated with increased nutri-tional risk.

An important deleterious effect of foodinsecurity is that it forces people to buy andconsume less-expensive foods, which areoften less nutrient dense, but more caloricallydense and higher in fat than more expensivefoods. As a result, the nutritional quality ofthe diet declines. (For more information onthis topic, see the Promoting Healthy Weighttheme.)

The problems of food insecurity and

hunger may be difficult to detect in the pri-mary pediatric health care setting. If disordersof growth, both underweight and over-weight, are noted, health care professionalsshould ask about food security. Options forreferral and community support are availablefor each developmental stage. For example,local lactation specialists or other knowledge-able health care professionals, such as doulasor promotoras, can provide follow-up careafter a new mother is discharged from thehospital, and they can consult by phone orschedule visits to a hospital-based lactationclinic. Health maintenance organizations andcommunity hospitals also are a source ofinfant nutrition education. The US Departmentof Agriculture (USDA) Special SupplementalNutrition Program for Women, Infants, andChildren (WIC) offers a food package forwomen who are pregnant or postpartum,women who are breastfeeding their baby,and for infants and children up to 5 years ofage. Health departments offer educational

services through WIC and other programs inwhich public health nurses or nutritionistsvisit families at home.

Families also may qualify for programssuch as the USDA Food Stamp Program. Acommunity food shelf or pantry can provide

Twelve percent of

American households

were food insecure

for at least part of

2004… The preva-

lence of food insecuri-

ty has increased

steadily since 1998.




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additional food for needy families. Forschool-aged children and adolescents, com-munity services expand to include free schoolbreakfast and lunch programs and, ideally,nutritious and appealing school food services.

For adolescent parents, school programs canfocus on the importance of prenatal nutritionto ensure the quality of nutrition.

Partnerships With the Community

Partnerships among health care professionals,families, and communities are essential toensure that infants and children have goodnutrition and that parents receive guidanceon infant and child nutrition and feeding.(For more information on this topic, see the

Promoting Community Relationships andResources theme.) Health care professionalscan have a tremendous impact on decisionsabout feeding the family because they pro-vide an opportunity for parents to discuss,reflect on, and decide on options that bestsuit their circumstances. As part of their guid-ance, health care professionals also can iden-tify and contact community resources thathelp parents at each stage of their children’sdevelopment. As a result of considerablemedia attention to the problem of over-

weight and obesity, the public has becomeincreasingly aware of the importance ofhealthful eating and adequate physical activi-ty. Communities have responded by creatingeducational programs that provide nutritiousschool lunches, access to affordable nutritiousfoods, and safe neighborhood opportunitiesfor play and exercise. Health care profession-als can help families learn about and partici-pate in these opportunities. These resourcesare particularly important for families withlimited or no literacy skills and for those with

limited English proficiency.

Essential Components of NutritionThe following essential components of nuttion are useful constructs for discussing nution from birth to young adulthood:

• Nutrition for appropriate growth—Provide adequate energy and essentianutrients to ensure appropriate growand prevent overweight or obesity.

• Nutrition and development of feeing and eating skills—Choose feedings that provide all the essential nutents and support the development ofappropriate feeding and eating skills.

• Healthy feeding and eating habitEstablish a positive, nurturing environment and healthy patterns of feeding

and eating to promote healthy eatinghabits that are built on variety, balancand moderation.

• Healthy eating relationships—Promote healthy adult-child feedingrelationships and social and emotionadevelopment.

• Nutrition for children and youthwith special health care needs—Recognize special nutrient demands osupplemental needs for vitamins or merals related to a child’s specific and s

cial health condition and provide thesnutrition components in an effectiveand family-centered manner.

Promoting Nutritional Health:Preconception and the Prenatal PeriodIn deciding to become parents, a couple mexamine many issues of lifestyle and healtbecause they recognize that their nutritionand physical activity beliefs, habits, and prtices affect not only their own health but athe health of their family and children.

Obesity, smoking, alcohol, and substance uaffect the family as well. Pregnant womenand women who may become pregnantshould be encouraged to follow a nutritioudiet. Adequate intakes of certain nutrientssuch as folic acid, are important even befoconception.

H E A L T H Y

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Partnerships among

health care profes-

sionals, families, and

communities are

essential to ensure

that infants and chil-

dren have good nutri-

tion and that parents

receive guidance oninfant and child nutri-

tion and feeding.




Folic Acid

Neural tube defects are among the mostcommon birth defects contributing to infantmortality and serious disability. Women ofchildbearing age can substantially reducetheir risk of having babies with certain con-genital malformations, including spina bifida,by taking appropriate amounts of folic acidbefore and during early pregnancy. Currentguidelines suggest that all women of child-bearing age take a daily multivitamin ormultivitamin-mineral supplement containing400 µg of folic acid.4-7 Women who havegiven birth previously to a child with a neuraltube defect, or those who have a history ofinsulin-dependent diabetes or a seizure dis-

order and are taking antimetabolites or anti-epileptic drugs (eg, carbamazepine or valproicacid), require higher dosages of folate. Theappropriate folic acid dosages continue toevolve. The most current recommendationsare available from the Centers for DiseaseControl and Prevention (CDC).4

Promoting Nutritional Health: Infancy—Birth to 11 MonthsPhysical growth, developmental achieve-ments, nutrition needs, and feeding patternsvary significantly in each stage of infancy.

During the first 2 to 6 weeks of life, theinfant primarily feeds, sleeps, and grows. Themost rapid growth occurs in early infancy,between birth and 6 months of age. In mid-dle infancy, from 6 to 9 months of age, andlate infancy, from 9 to 12 months of age,rapid growth continues, but at a slower pace.By late infancy, mastery of purposeful activitycomplements physical maturity, and loss ofnewborn reflexes allows him to progress froma diet of breast milk or formula to feedingwith an increasingly wide variety of flavors,

textures, and foods.Feeding practices and routines serve as the

foundation for much of child and familydevelopment, as parents build many impor-tant skills. These skills include identifying,assessing, and responding to infant cues, pro-moting reciprocity, and building the infant’sfeeding and pre-speech skills. When feedingtheir infant, parents clarify and strengthentheir sense of what it means to be a parent.They gain a sense of responsibility by caringfor an infant, experience frustration whenthey cannot easily interpret their infant’s cues,and further develop their ability to negotiateand solve problems through their interactionswith the infant.

Nutrition for Growth

The infant’s diet must provide adequate ener-gy and essential nutrients for appropriategrowth. Conversely, growth is an importantindicator of nutritional adequacy. Althoughnewborns may lose up to 10% of their body

weight in the first week of life, they usuallyregain their birth weight by 7 days after birth.By the time they are 4 to 6 months old,infants typically have doubled their birthweight, gaining about 4 to 7 ounces per

Feeding practices and

routines serve as the

foundation for much

of child and family

development, as par-

ents build many

important skills.




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week. Infants typically triple their birth weightby 1 year of age, gaining about 3 to 5ounces per week from 6 to 12 months ofage.

Infants grow approximately 1 inch per

month from birth to age 6 months, but therate of growth slows from 6 to 12 months ofage when infants gain about one half inchper month. Infants usually increase theirlength by 50% in the first year.

Infants who are fed on demand usuallyconsume the amount they need to growwell. Growth of exclusively breastfed infantsduring the first 6 months exceeds that ofother infants, but formula-fed infants gainmore rapidly during the remainder of the firstyear.8-10 The significance of this difference to

future growth or risk of overweight is uncer-tain. Infants’ growth depends on nutrition,perinatal history, and genetic factors (such asparental height, genetic syndromes, or disor-ders), and other physical factors.

The growth of head circumference up to 2years of age is so closely related to growth inbody length that head circumference mea-surements do not yield more informationabout a child’s nutritional status than bodylength measures. After 2 years of age, head

circumference grows so slowly that it is apoor indicator of actual malnutrition.However, in an older child, head circumfer-ence may be a good indicator of malnutritionthat occurred during the first 2 years of life.Head circumference is not a good indicator ofnutritional status, but it remains important inscreening for microcephaly and macrocephalybecause these abnormalities are not nutrition-al in origin.

C A L OR I C NE E D S

To meet growth demands, all infants require

a high intake of calories and adequateintakes of fat, protein, vitamins, and minerals.Breast milk and formula provide 40% to50% of energy from fat to meet the infant’sgrowth and development demands. Fats

should not be restricted in the first 2 yearslife. Vitamin and mineral needs, with theexception of vitamin D, usually are suppliethe infant is breastfed or if the infant receian adequate volume of correctly prepared

formula. After 6 months of age, complemtary foods (solids) aid the development ofappropriate feeding and eating skills for alinfants and provide additional nutrients tomeet the dietary reference intakes (DRIs) fobreastfed infants.

VITAMIN AND MINERAL SUPPLEMENTS

A major concern in infancy is the adverseeffect of early iron deficiency on psychomodevelopment. Iron deficiency can result incognitive and motor deficits,11 some of wh

may be reversible with iron therapy.12

However, a recent Cochrane Review on thsubject concluded that there is no clear evdence that treating young children with anmia secondary to iron deficiency will impropsychomotor development.13 Thus, prevention is extraordinarily important. During thfirst year of life, the infants at highest risk iron deficiency are those born prematurelythose fed formula that is not iron fortified,and those who are exclusively breastfed wout iron supplements. Infants who receive

only breast milk are at risk for iron deficienby 6 months of age, and risk subsequentiron-deficiency anemia.14-15 It is judicious tobegin iron supplements of 1 mg/kg/d aftemonths of age if infants are not receivingiron-fortified complementary foods.16 Redmeat is a better source of iron than iron-fortified cereals for older infants. Infantswho receive at least 500 mL (17 oz) of ironfortified formula do not need additional irosupplementation.

The American Academy of Pediatrics (A

currently recommends vitamin D supplemetation (400 IU per day) for breastfed infantbeginning in the first few days of life.17

Breastfed infants whose mothers are vegaor vitamin B12 deficient need supplements vitamin B12.

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A major concern in

infancy is the adverse

effect of early iron

deficiency on psy-

chomotor develop-

ment. Iron deficiency

can result in cognitive

and motor deficits,

some of which maybe reversible with

iron therapy.




Fluoride supplementation is not indicateduntil after the eruption of teeth, which usual-ly occurs at approximately 6 months of age.At that time, the pediatric health care profes-sional or dentist will evaluate the need for

fluoride supplementation based on the child’srisk for of dental caries and total fluorideexposure. Adequate calcium intake is not anissue in infants who receive enough breastmilk or formula. (For more information onthis topic, see the Promoting Oral Healththeme.)

Developing Healthy Feeding and Eating Skills

Feedings should be planned to provide all theessential nutrients and support the develop-

ment of appropriate feeding and eating skills.BREASTFEEDING

Breastfeeding is recommended for infantsduring at least the first year of life because ofits benefits to infant nutrition, gastrointestinalfunction, host defense, neurodevelopment,and psychological well-being (Box 1).Breastfeeding, with a restricted maternal dietduring pregnancy and lactation, may reducethe incidence of atopic illness, such as allergyor eczema, in infants who have strong familyhistories of these illnesses. Immediately afterdelivery, early and frequent physical contact,rooming-in, and exclusion of commercialformula samples enhance the duration ofbreastfeeding. The AAP Section on Breast-feeding recommends exclusive breastfeedingfor about 6 months to maximize its benefits.18

However, after a review of all availableevidence, the AAP Committee on Nutritionrecommends exclusive breastfeeding for 4 to6 months.12

Because the decision to breastfeed is often

made before, or early in, pregnancy, the pre-natal visit offers an important opportunity topromote breastfeeding. Parents often areaware of the benefits of breastfeeding, butlack confidence in their ability to successfullybreastfeed their infant. They may have

questions about breastfeeding and its nutri-tional adequacy, their ability to know if theinfant is drinking enough milk, the mother’sability to produce enough milk to satisfy theinfant’s hunger, or whether the mother

should breastfeed if she smokes or has anunderlying health condition. Mothers alsoexpress concerns about their need to returnto work or school within 6 to 8 weeks afterthe baby’s birth, or the competing needs ofother children and family members. Prenataland postpartum counseling can addressthese issues and also prolong the durationof breastfeeding.19

Parents also may raise concerns aboutmaternal medication usage, or maternal orinfant illness, and the advisability of breast-

feeding. Decisions regarding the appropriate-ness of breastfeeding in these situations arebest made on an individual basis with ahealth care professional. Under most circum-stances, mothers can continue to breastfeedtheir infants or supply breast milk if the infantis unable to breastfeed directly, but a fewcontraindications to breastfeeding do exist.Medications taken by the mother should beindividually evaluated to determine whetherthey can be used safely when breastfeeding.Few prescription and nonprescription medica-tions are contraindicated for the mother whobreastfeeds her baby.20

Cultural factors may influence breastfeed-ing initiation and success. Parents needpractical support for breastfeeding, as well asculturally based information and guidance. Asolid knowledge of the parents’ culture andcommunity will help health care professionalsgive parents the support, appropriate educa-tion, and guidance they need to be successfulin breastfeeding their infant. (For more infor-

mation on this topic, see the PromotingCommunity Relationships and Resourcestheme.)

F OR M U L A F E E D I NG

For infants who are not breastfed, iron-fortified infant formula is the recommended

Breastfeeding is rec-

ommended for infants

during at least the

first year of life

because of its bene-

fits to infant nutrition,

gastrointestinal func-

tion, host defense,

neurodevelopment,and psychological

well-being.




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B O X 1

Benefits of Breastfeeding

Breast milk is uniquely suited to the needs of the newborn and growing infant and pro-

vides many benefits for general health, growth, and development.

Benefits to the infant

• Breastfeeding provides ideal nutrition and promotes the best possible growth and

development.

• Breastfeeding significantly decreases the incidence of diarrhea, lower respiratory trac

infection, otitis media, bacteremia, bacterial meningitis, botulism, and urinary tract

infection.

• Breastfeeding may be protective against Crohn’s disease, lymphoma, and certain

genotypes of type 1 diabetes mellitus, and delay the onset of certain allergies. 12

• Breastfeeding lowers the risk of obesity in some populations.

• Breastfeeding promotes healthy neurologic development.

• Breastfeeding can reduce the incidence of atopic illness, such as allergy or eczema.21

• Breastfeeding promotes close mother-infant connection.

Benefits to the mother

• Breastfeeding increases levels of oxytocin, which results in less postpartum bleeding

and more rapid uterine involution.

• Lactating women have an earlier return to pre-pregnancy weight, delayed resump-

tion of ovulation with increased child spacing, improved postpartum bone reminer-

alization, and reduced risk of ovarian cancer and premenopausal breast cancer.

• Lactational amenorrhea causes less menstrual blood loss over the months after

delivery.

Benefits to the family • Breastfeeding has no associated costs and requires no equipment or preparation.

• It is easy to travel with a breastfed baby because no special equipment or supplies

are necessary.

Benefits to the community

• Breastfeeding reduces health care costs and employee absenteeism because of

reduced childhood illness.

• Breastfeeding reduces parent absence from work and lost income.

Sources

American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics.

2005;115:496-506. 18

Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics, Committeeon Nutrition; 2004.12

Kramer M, Kakuma R. Optimal duration of exclusive breastfeeding (Cochrane Review). In: The Cochrane Library . Issue 2.

Oxford (UK): Software Update; 2002.22




substitute during the first year of life.12 Cow’smilk, goat’s milk, soy beverages (not soy for-

mula), and low-iron formulas should not beused during the first year. Reduced-fat (2%),low-fat (1%), fat-free (skim), and soy milk arenot recommended for infants during the first2 years.

Health care professionals should counselparents to avoid propping the bottle or lettingtheir infant feed alone. This precaution willminimize the risk of choking, ear infections,early childhood caries, insufficient intake, andthe missed opportunity for enhancing the par-ent-child relationship. To prevent early child-hood caries, parents should be instructed notto put the infant to bed with a bottle or sippycup that contains milk, juices, soda, or othersweetened liquids. (For more information onthis topic, see the Promoting Oral Healththeme.) Fruit juices are not needed in theinfant diet during the first 6 months, but, ifthey are given, they should be fed by cup, nota bottle. Cereal or other foods should not beadded to infant formula unless instructed by ahealth care professional.

A variety of specialized infant formulashave been developed for infants who cannottolerate milk protein or lactose (eg, soy for-mulas, protein hydrolysates, and amino acidformulas). Health care professionals shouldsupervise infants with milk intolerance.Intolerance to cow’s milk-based formulas,

manifested by loose stools, spitting up, orvomiting, may prompt a change to soy for-mula, but there is little evidence to supportthis practice. Soy formulas may be recom-mended for a vegetarian lifestyle, transient

lactase deficiency, and galactosemia. Soyformula should not be used for prematureinfants, cow’s milk protein-induced entero-colitis, or the prevention of colic or allergy.12

F R E QU E NC Y A ND A M OU NT OF F E E D I NGS

In the first months of life, breastfed infantsusually feed 8 to 12 times in 24 hours (ie,approximately every 2 to 3 hours). Parentsshould be taught to recognize and respondto early feeding cues. As infants grow older,they typically are satisfied by larger feedings

less frequently.No recommendations exist for maximum

volumes of formula at any one feeding, onlyfor meeting total energy and fluid needs.Parents should offer 2 ounces of infant for-mula every 2 to 3 hours in the first week oflife. If the infant still seems hungry, parentscan provide more until the infant indicatesthat he is full. As the infant grows, a largeramount of formula should be given, and theinfant should feed until he indicates that he isfull. Satiety cues include turning away fromthe nipple, falling asleep, and spitting upmilk. A newborn at the 50th percentile willconsume an average of 20 oz of formula perday; the amount of formula ranges from 16to 24 oz per day.

When he begins to sleep for longer peri-ods at night (4 to 5 hours at about 2 monthsof age), the formula-fed infant will still needto feed 6 to 8 times in 24 hours. A 4-month-old infant will consume an average of 31ounces of formula per day without comple-

mentary foods with a range of 26 to 36 ozper day. However, his intake fluctuates fromday to day and week to week. During growthspurts, intake volume increases but will fallback to lesser volumes.

In the first months of

life, breastfed infants

usually feed 8 to 12

times in 24 hours (ie,

approximately every 2

to 3 hours). Parents

should be taught to

recognize and

respond to early feed-ing cues.




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Infants 6 months and older generally con-sume 24 to 32 ounces per day, but largerinfants may take as much as 42 ounces offormula per day in addition to complementa-ry foods. Over time, the increasing volume of

complementary foods is accompanied by adecreasing volume of milk.

For the newborn, hunger cues includerooting, sucking, and hand movements. Inyoung infants, hunger cues may includehand-to-mouth movements and lip smacking.Smiling, cooing, or gazing at the parent dur-ing feeding can indicate that the infant wantsmore food. For older infants, hunger cuescan include crying, excited arm and legmovements, opening mouth and moving for-ward as the spoon approaches, and swiping

food toward the mouth. Crying is considereda late feeding cue and usually interferes withfeeding as the infant becomes distressed andis less likely to eat well.

Infants can signal that they are full bybecoming fussy during feeding, slowing thepace of eating, turning away, stopping suck-ing, or spitting out or refusing the nipple.Other satiety cues include refusing the spoon,batting the spoon away, and closing themouth as the spoon approaches. As with all

feeding interactions, parents should observethe infant’s verbal and nonverbal cues andrespond appropriately. If a food is rejected,parents should move on and try it again laterrather than forcing the infant to eat or finishfoods.

INTRODUCING COMPLEMENTARY FOODS

Complementary foods, commonly referred toas solids, include any foods or beveragesbesides human milk or formula. The AAPCommittee on Nutrition states that comple-

mentary foods can be introduced in infants’diets between 4 and 6 months of age andwhen the infant is developmentally ready.12

The AAP recommends exclusive breastfeedingfor a minimum of 4 months, but preferablyfor 6 months. During the second 6 months of

life, complementary foods are an addition not a replacement for, breast milk or infanformula.

Parents need practical guidance when tbegin to introduce complementary foods.

The health care professional should workwith each family to determine the best timto start this exciting new phase. Infants difin their readiness to accept complementaryfoods. Counseling parents on the normalprogression of the development of feedingand eating skills, and the infant’s related aty to safely eat, will help them succeed in enjoy the new experience.

Waiting until the infant is developmentaready to begin eating complementary foodmakes that process, and the later transitio

to table foods, easier. Signs that an infant ready to begin semisolids (pureed foods)include fading of the extrusion reflex (thetongue-thrust reflex that pushes food out the mouth) and elevating the tongue tomove pureed food forward and backwardmouth (which usually occurs between 4 an6 months of age). An increased demand fobreastfeeding that continues for a few dayis not affected by increased breastfeeding,and is unrelated to illness, teething, orchanges in routine also may be a sign ofreadiness for complementary foods. At thistage, the infant sits with arm support andhas good head and neck control. The infancan indicate his desire for food by openinghis mouth and leaning forward and can incate disinterest or satiety by leaning back aturning away.

When the infant is able to sit independely and tries to grasp foods with his palms, is ready to progress to thicker pureed foodand soft, mashed foods without lumps. He

also can begin to sip from a small cup. Whthe infant crawls and pulls to stand, he alsbegins to use his jaw and tongue to mashfood, plays with a spoon at mealtime (butdoes not use it for self-feeding yet), and trto hold a cup independently. At this stage

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The American

Academy of Pediatrics

recommends exclusive

breastfeeding for

a minimum of 4

months, but prefer-

ably for 6 months.




is able to progress to ground or soft, mashedfoods with small, soft, noticeable lumps (eg,finely chopped meat or poultry). At about 7to 9 months of age, the infant learns to putobjects in his mouth and will try to feed him-

self. At this age, the infant has developed apincer grasp (the ability to pick up objectsbetween thumb and forefinger). Any foodthe infant can pick up can be considered afinger food. Foods that dissolve easily, such ascrackers or dry cereal, are good choices, butfoods that can cause choking, such as pop-corn, grapes, raw carrots, nuts, hard candies,and hot dogs, should be avoided.

Evidence for introducing complementaryfoods in a specific sequence or at any specificrate is not available. The general recommen-

dation is that the first solid foods should besingle-ingredient foods and should be intro-duced one at a time at 2- to 7-day intervals.The order in which solid foods are introducedis not critical as long as essential nutrientsthat complement breast milk or formula areprovided. Pureed meats and iron-fortifiedcereals provide many of these nutrients forboth breastfed and formula-fed infants. Afterthe infant has accepted these new foods,parents can gradually introduce other pureedfoods or soft fruits and vegetables 2 to 3times per day and allow him to control howmuch he eats. Parents also can offer store-bought or home-prepared baby food andsoft table foods, such as mashed potatoesor bananas. Breastfed infants are exposed toa variety of flavors through their mother’sbreast milk; thus, dietary variety is importantnot just for infants, but for their mothers aswell. Mixing cereal with breast milk enhancesacceptance of cereal by the breastfed infant.23

Repeated exposures to foods enhances

acceptance by both breastfed and formula-fed infants.24

A nutritious and balanced diet for theolder infant includes appropriate amounts ofbreast milk or formula and complementary

foods to ensure intake of all essential nutri-ents and to foster appropriate growth. By theend of the first year, the infant should beintroduced to healthful foods, such as fruits,vegetables, whole grains, and lean meats.

Foods that are high in calories, fat, and sugar,and low in essential nutrients, such as sweet-ened drinks, sodas, chips, and french fries,should be avoided.

Because of their high sugar and caloriecontent and lack of nutrients, parents shouldavoid giving their infants and young childrencarbonated soda and fruit drinks. In addition,parents should allow no more than 4 to 6ounces of 100% fruit juice daily. Because100% fruit juice is considered nutritious,parents may not recognize the need to limit

consumption. However, fruit juice is high incalories and sugar. Consuming large quanti-ties can contribute to pediatric overweightand obesity, diarrhea, and early childhoodcaries.25

To establish habits of eating food in mod-eration, infants should be allowed to stopeating at the earliest sign of unwillingnessand not urged to consume more. Parentsshould allow the infant to control theamount of milk, formula, or complementaryfoods consumed based on his hunger andsatiety cues. Breastfeeding can aid in estab-lishing habits of eating in moderationbecause the breastfed infant has more con-trol over the amount consumed at a feeding.Parents who feed their infant formula shouldbe warned against encouraging the infant tofinish the bottle when satiety cues aredemonstrated.

Eating nutritious foods and avoiding foodsthat provide calories without nutrients helpestablish habits of eating in moderation.

Furthermore, establishing regular mealtimesand snack times and avoiding continuousfeeding, or “grazing,” will help prevent bothoverweight and underweight.

…fruit juice is high in

calories and sugar.

Consuming large

quantities can con-

tribute to pediatric

overweight and

obesity, diarrhea, and

early childhood caries.




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H A ND L I NG F E E D I NG A ND E AT I NG P R OB L E M S

Parents frequently have concerns and ques-tions about infant feeding and eating issues,and an important aspect of health supervi-sion during this developmental stage is help-

ing parents distinguish normal infant feedingbehaviors from feeding or eating problems.

Food Sensitivities and AllergiesFood allergy or hypersensitivity is a form offood intolerance characterized by repro-ducible symptoms with each exposure to theoffending food and an abnormal immunolog-ic reaction to the food. Symptoms anddisorders, such as irritability, hyperactivity,gastrointestinal discomfort, and asthma, havebeen attributed to food allergies, but true

food allergies are rare. Food hypersensitivityreactions occur in 2% to 8% of infants andchildren younger than 3 years. Food allergycan result in symptoms affecting thegastrointestinal tract (eg, vomiting, cramps,or diarrhea), skin (eg, eczema or hives), andrespiratory tract (eg, asthma), or it can resultin generalized, life-threatening allergic reac-tions (ie, anaphylaxis). Hyperactivity is notconsidered a manifestation of food allergy.

Approximately 2.5% of infants will experi-ence an allergic reaction to cow’s milk in the

first 3 years of life, 1.5% will have a reactionto eggs, and 0.6% will have a reaction topeanuts.12 The most common foods associat-ed with allergic reactions in young childrenare cow’s milk, eggs, peanuts, soy, andwheat. Tree nuts, fish, and shellfish becomemore common causes of food allergy in ado-lescents and adults.26 Infants who are exclu-sively breastfed may react to these or otherfood proteins that reach breast milk from themother’s diet.

Infants with a strong family history of food

allergy (ie, those whose parents or siblingshave or had significant allergies) may benefitfrom breastfeeding, particularly with regardto the development of cow’s milk allergy.27

However, another recent review concluded

that 4 months of exclusive breastfeeding dnot protect against food allergy at 1 year oage.22 Firm consclusions about the role ofbreastfeeding in either preventing or delaythe onset of specific food allergies are not

possible at this time. In addition, though sfoods should not be introduced before 4 tmonths of age, there is no convincing evi-dence that delaying their introduction beyothis period has a significant protective effeon the development of atopic disease,whether infants are fed cow’s milk proteinformulas or human milk.21 Single-ingrediennew foods should be introduced one at atime, and the infant should be watched foadverse reactions over several days to aweek. For infants who are not at risk of fo

allergies, no evidence indicates that restrictor avoidance of any food is necessary.

Regurgitation, Spitting Up, and Gastroesophageal Reflux DiseaseRegurgitation and spitting up are commonconcerns for parents. During the first year life, particularly in the first few months,infants typically have episodes of emesis(vomiting or “wet burps”) within the first to 2 hours after feeding. Emesis is related transient physiologic episodes of lowered

esophageal sphincter tone with efflux of gtric contents into the esophagus. Spitting often occurs because milk has been ingesttoo rapidly or as a reaction to overfeeding

H E A L T H Y

N U

T R I T I O N

Infants with a strong

family history of food

allergy (ie, those

whose parents or sib-

lings have or had sig-

nificant allergies) may

benefit from breast-

feeding, particularly

with regard to thedevelopment of cow’s

milk allergy




inadequate burping, or improper feedingtechniques (eg, bottle propped, bottle notadequately tipped up, or shaking formula toovigorously before feeding). Approximately halfof infants younger than 3 months spit up or

regurgitate one or 2 times a day, with theincidence peaking between the ages of 2 to4 months. The frequency may increase againwhen the baby starts solid foods. Spitting upresolves itself in most children by 12 to 24months of age.

Frequent spitting up or significant vomitingis classified as gastroesophageal reflux (GER)and usually is harmless in infants. The clinicalmanifestations of gastroesophageal reflux dis-ease (GERD) include vomiting and associatedpoor weight gain, apparent discomfort with

eating, esophagitis, and respiratory disor-ders.28 The health care professional will needto differentiate these symptoms from pyloricstenosis in some very young babies.

Providing a Nurturing and Healthy Feeding

Environment

Infants need a nurturing environment andpositive patterns of feeding and eating topromote healthy eating habits and build vari-ety, balance, and moderation. In early infancy,

feeding is crucial for developing a parent’sresponsiveness to an infant’s cues of hungerand satiation. The close physical contact dur-ing feeding facilitates healthy social and emo-tional development.

During the first year, feeding the hungryinfant helps him develop a sense of trust thathis needs will be met. For optimum develop-ment, newborns should be fed as soon aspossible when they express hunger. Childrenwith special health care needs often havesubtle cues that can be difficult for parentsto interpret. Parents must be careful observersof the infant’s behaviors, so that they canrespond to their infant’s needs. As infantsbecome more secure in their trust, theycan wait longer for feeding. Infants should

develop their feeding skills at their own rate.However, if significant delays occur in thedevelopment of these skills, or delays areanticipated (eg, as in the case of some chil-dren with special health care needs), a health

care professional should assess the infant.The suck-and-pause sequence in breast-

feeding or infant formula feeding andbehaviors such as eye contact, open mouth,turning to the parent, and even turning awayprovide the foundation for the first communi-cation between the infant and parents.Difficulties in early feeding create strongemotions for the parent and can undermineparenting confidence and sense of compe-tency. Thus, feeding difficulties must beaddressed in a timely manner.

Over time, parents become more skilled atinterpreting their infant’s cues and increasetheir repertoire of successful responses tothose cues. As they feed their infant, parentslearn how their actions comfort and satisfy.Physical contact during breastfeeding or for-mula feeding strengthens the psychologicalbond between the mother and infant andenhances communication because it providesthe infant with essential sensory stimulation,including skin and eye contact. A sense ofcaring and trust evolves, which lays thegroundwork for communication patternsthroughout life.

A healthy feeding relationship involves adivision of responsibility between the parentand the infant. The parent sets an appropri-ate, safe, and nurturing feeding environmentand provides appropriate, healthy foods. Theinfant decides when and how much to eat. Ina healthy infant-parent feeding relationship,responsive parenting involves:

• Responding early and appropriately to

hunger and satiety cues• Recognizing the infant’s developmental

abilities and feeding skills• Balancing the infant’s need for

assistance with encouragement of self-feeding

A healthy feeding

relationship involves a

division of responsi-

bility between the

parent and the infant.

The parent sets an

appropriate, safe, and

nurturing feeding

environment and pro-vides appropriate,

healthy foods.The

infant decides when

and how much to eat.




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• Allowing the infant to initiate and guidefeeding interactions

Nutrition for Infants With Special Health

Care Needs

Medical problems or other special health careneeds can place the infant at nutritional risk.Because this is a time of high caloric need,health care professionals should considerreferring the family for specialized medicaland nutrition consultation.

Not all infants are able to develop the skillsfor feeding and eating easily. Approximately25% of all children have some feeding prob-lems, and 80% of children with a develop-mental disability have some form of feeding

problem.29

Feeding difficulties can lead toproblems in the parent-child relationship, aswell as growth problems, inadequate nutri-tion, and significant feeding problems later inchildhood. Health care professionals shouldaddress the following common concernsexpressed by parents:

• Refusing food (infant cereal and purees)• Difficulty transitioning to textures• Gagging, choking, or vomiting with

feeding

• Poor or inadequate food volume• Poor or inadequate variety of foods,picky eating, or food jags

• Prolonged feeding time (more than 30minutes)

• Respiratory symptoms after feeding

Infants with special health care needs areat increased risk of feeding complications,including failure to thrive, aspiration of food,and GERD. Parents of infants with specialhealth care needs also may need extra emo-tional support and instruction about specialtechniques for positioning or specialequipment. These accommodations canhelp overcome feeding problems and preventsuboptimal nutrition, poor weight gain, andgrowth deficiency.

Parents often blame themselves for theiinfant’s feeding problem, yet the difficulty typically related to the infant’s oromotordevelopmental problem. Children with oromotor delay may retain primitive reflexes li

the extrusion reflex and the tonic bite refleThese behaviors can be mistakenly inter-preted as food refusals. Thus, health careprofessionals should try to identify feedingchallenges early and provide resources forevaluation, education, and support. Assessand treating physical or behavioral feedingdifficulties is best accomplished by an intedisciplinary team that may include a neurohavioral pediatrician, dietitian, occupationatherapist, speech pathologist, nurse or nurpractitioner, social worker, and psychologis

Parents should learn the different philoso-phies, intervention strategies, and approacof the different programs available, as weltheir costs and outcomes, before they makdecision on the best approach for their chiand family.

Low birth weight infants need additionairon after the first month of life (2 mg/kg/duntil they reach 1 year of age.12 They alsomay need special food (eg, preterm dischaformulas with enhanced nutrients). Infantswith sequelae of prematurity, chronic lungreactive airway disease, short bowel syn-drome, cholestasis, GERD, rickets, or chronheart, kidney, or liver disease have medicaand developmental factors that will affecttheir growth. They may require specializedfeedings with nutritional supplements, incing fortifiers, vitamins, and minerals.Medication usage also may alter nutritionarequirements.

Infants with special health care needsoften need increased calories, but may be

limited by feeding issues. Because theirimmune systems may be compromised, mof these infants benefit from breastfeeding(or being fed expressed breast milk). Parenmay need to modify breast milk or formuladapt their feeding techniques to ensure t

H E A L T H Y

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T R I T I O N

Infants with special

health care needs are

at increased risk of

feeding complica-

tions, including failure

to thrive, aspiration

of food, and gastro-

esophageal reflux

disease. Parents ofinfants with special

health care needs also

may need extra

emotional support

and instruction about

special techniques for

positioning or special

equipment.




infants with the following conditions achieveadequate caloric intakes:

• Prematurity and low birth weight• Chronic respiratory or congenital heart

disease• Gastrointestinal tract disease• Renal disease• Neurologic disorders• Syndromes and genetic disorders affect-

ing growth potential, such as cysticfibrosis

Promoting Nutritional Health: EarlyChildhood—1 to 4 YearsEnsuring adequate nutrition during earlychildhood focuses on promoting normal

growth by selecting appropriate amounts andkinds of foods and providing a supportiveenvironment that allows the child to self-regulate food intake. As in all other areas ofdevelopment, self-regulation of eating and itsaccompanying independence are majorachievements during the early childhoodyears. Children continue their exposure tonew tastes, textures, and eating experiencesdepending on their own developmental abili-ty, cultural and family practices, and individualnutrient needs.


Most infants triple their birth weight withinthe first year of life and experience a signifi-cantly slower rate of weight gain after thefirst year, which results in a dramatic decreasein appetite and diminished food intake. Thisdiminished intake is compensated for by eat-ing foods with increased caloric density (ie,foods with less water content). Health careprofessionals can alert parents to this change

when the child’s height and weight are mea-sured and plotted on the gender- andage-appropriate CDC growth and BMI-for-age charts (for children older than 2 years).

Monitoring growth measures by ageallows the health care professional to deter-mine how the child compares to others of

the same age and gender. These measurescan be used to signal abnormal growth pat-terns. Linear growth is used to detect long-term undernutrition. Using weight-for-lengthuntil age 2 years, and BMI growth charts

after that, allows the health care professionalto determine underweight and overweight orobesity and whether the child is maintainingher own growth trajectory. If the child hasmoved up or down 2 percentile lines on thegrowth chart since the previous visit, thehealth care professional should question par-ents in detail about portion sizes, types offood served, and feeding frequency. Skinfoldmeasurements for this age group are notused unless medically indicated and per-formed by an adequately trained technician.

As additional table foods are offered, tod-dlers consume foods similar to those of theentire family. Even in early childhood, dietarypreferences and patterns begin to be estab-lished, and, all too often, the reportedamount of milk consumed decreases signifi-cantly, while the intake of juices, fruit drinks,and carbonated sodas increases.30 The Infantand Toddler Study suggests that, in general,young children are getting sufficient intakesof calcium.31 However, the shift from milk to

juice and soda lowers calcium intake andmakes it more difficult for young children toattain the recommended calcium intake(Box 2). Fruit drinks and carbonated sodas are

Monitoring growth

measures by age

allows the health care

professional to deter-

mine how the child

compares to others

of the same age and

gender. These mea-

sures can be used tosignal abnormal

growth patterns.

B O X 2

Child Calcium Dietary Reference Intake

Children aged 1 to 3 years: 500 mg/d


Source: Institute of Medicine. Dietary reference intakes

for calcium, phosphorous, magnesium, vitamin D, and

fluoride. (1997). Washington, DC: National Academies

Press. 1997. Available at: http://www.iom.edu/file.asp?id

=21372. Accessed August 17, 2006.32,33




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discouraged, and 100% fruit juice is recom-mended at no more than 4 to 6 ouncesdaily.25 Overuse may lead to excess energyintake, diarrhea, and dental caries. (For moreinformation on this topic, see the Promoting

Healthy Weight and Promoting Oral Healththemes.)

A primary safety concern for preschoolersduring feeding is choking or inhalation offood. The following foods should be avoidedat this stage:

• Peanuts• Chewing gum• Popcorn• Chips• Round slices of hot dogs or sausages

• Carrot sticks• Whole grapes• Hard candy• Large pieces of raw vegetables or fruit• Tough meat

To limit the risk of choking, the toddlershould sit up while eating. Parents shouldavoid feeding a young child while in a carbecause, if the child should begin to choke,pulling over to the side of the road in trafficto dislodge the food is difficult.12 Further-

more, feeding children while driving contra-dicts the recommendation to feed children inappropriate locations.

Because few data were available on nutri-ent adequacy for toddlers and preschoolers,the Institute of Medicine (IOM)34 extrapolatedvalues from studies of infants and adults toestablish dietary reference intakes. Translatingthese nutrient intakes into specific foodchoices and portions for toddlers has notbeen clearly defined. However, guidelinessuggest offering appropriate nutritious foods

spaced into 3 meals, along with 2 or 3 snacksper day.12 For children older than 2 years, theDietary Guidelines for Americans are the pri-mary sources of dietary guidance.35

Other national health organizations alsohave developed nutrition policy statements to

promote optimal health and reduce risk fochronic disease, and these statements canused as well to guide food choices in child

older than 2 years.

36-39

These science-basednutrition guidelines recommend a diet thaincludes a variety of nutrient-dense foods beverages from the basic food groups andthat limits the intake of saturated and tranfats, cholesterol, added sugars, and salt. Abasic premise is that nutrient needs shouldmet primarily by consuming a variety of fothat have beneficial effects on health.Supplementation with vitamins and minerais not considered necessary when children consuming the recommended amounts of

healthful foods.40

However, health care professionals should not assume that all toddare getting the nutrients they need.41 A sigicant number of children in the United Stalive in households with insufficient food.

H E A L T H Y

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A basic premise is

that nutrient needs

should be met prima-

rily by consuming a

variety of foods that

have beneficial

effects on health.




Developing Healthy Feeding and Eating Skills

Young children often will eat sporadically overone day or several days. Over a period of aweek or so, their nutrient and energy intakesbalance out. Food jags (ie, favoring only oneor 2 foods) and picky eating (eg, refusing toeat certain foods or not wanting foods totouch) are normal behaviors in young chil-dren. For most children, these behaviors dis-appear before school age if parents patientlycontinue to expose them to a variety of newand familiar foods. As their manipulative skillsmature, preschoolers also can successfullyhelp in food preparation, which may helpthem accept new foods.

Unfortunately, some parents and caregivers

become discouraged and frustrated whentheir toddler seems to concentrate more onexploring food than eating it. This behaviorreflects the emerging curiosity and independ-ence associated with early childhood and isnormal. Parents and caregivers can foster thisnewly found, and often assertively expressed,independence while still ensuring adequatenutrition by offering a well-balanced selectionof foods and allowing children to choose thetypes and amounts of foods they want toeat. Parents and caregivers need to under-

stand that recognizing the child’s signals ofhunger and fullness supports the child’sinnate ability to self-regulate energy intakeand portion size. They also need to under-stand that a child does not have an innateability to select only appropriate foods. Foodchoice remains the responsibility of the care-giver.

Mealtime provides an opportunity for won-derful parent-child interactions. These oppor-tunities exist for the young toddler, who maybe fed before the family meal, as well as for

the older toddler and preschooler, who mayparticipate in the family routine and sit at thetable for a short time. Finger foods should beencouraged because they foster competence,mastery, and self-esteem. Even when the

parent or caregiver is doing the feeding,the child also should be given a spoon. The12- to 15-month-old toddler should beencouraged to use a spoon. When the childis finished eating, she should be allowed to

leave the table and be placed where she canbe supervised until the adults have finishedtheir meal.

Nutrition for Children With Special Health

Care Needs

Children with special health care needs gen-erally follow similar developmental pathwaysas children without these challenges whenthey begin the process of self-feeding.However, the pace of development and the

ultimate mastery of tasks will vary dependingon the physical, emotional, or cognitive chal-lenges facing the child. Health care profes-sionals should follow children with specialhealth care needs closely, paying particularattention to nutritional intake and physicalactivity.

The types of nutritional issues most com-mon for children with special health careneeds include feeding problems (eg, chewingand swallowing), slow growth, metabolic orgastrointestinal issues, and overweight or

obesity. Sometimes children with specialhealth care needs require special feedingtechniques, longer periods of time to feed, orspecial foods (both type and texture), formu-las, and feeding approaches (eg, restriction ofcertain foods). The health care professionalcan identify these issues and refer the family,as needed, to a registered dietitian or inter-disciplinary team for further assessment,intervention, and monitoring.

Food jags (ie, favoring

only one or 2 foods)

and picky eating (eg,

refusing to eat certain

foods or not wanting

foods to touch) are

normal behaviors in

young children.




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Promoting Nutritional Health: MiddleChildhood—5 to 10 YearsTo achieve optimal growth and development,children need a variety of nutritious foodsthat provide sufficient calories, protein, carbo-

hydrates, fat, vitamins, and minerals. By mid-dle childhood, a child needs 3 meals and 2 to3 healthy snacks per day. As the child’s abilityto feed himself improves, he can help withmeal planning and food preparation, and hecan perform tasks related to mealtime.Performing these tasks enables the child tocontribute to the family and can boost hisself-esteem. The USDA MyPyramid for Kids,which is based on the Dietary Guidelines for Americans, provides an easy reference onfood intake and physical activity recommen-

dations for children aged 6 to 11 years.42


Middle childhood is characterized by a slow,steady rate of physical growth. Plotting thechild’s BMI from 2 years of age into middlechildhood allows the health care professionalto note any increasing percentile changes andprovide early intervention as needed to pre-vent childhood obesity.

C A L C I U M

Calcium intake continues to be a concernduring middle childhood. Nutritional intakestudies indicate that few school-aged childrenreceive adequate calcium intake. Calcium is acritical nutrient for bone health, and a higherincidence of fractures is reported in childrenwho do not get adequate amounts of calci-um. Consumption of large amounts of juice,soft drinks, or sport drinks suggests inade-quate intake of milk. Children need 3 to 4servings of calcium-rich foods per day (Box 3).

One 8-ounce glass of milk provides approxi-mately 300 mg of calcium. Health careprofessionals should, therefore, encourageparents to provide water, low-fat milk, andno more than 4 to 6 ounces of 100% fruit

juice daily for their children to drink.

Developing Healthy Eating Habits

Parents and other family members continuto have the most influence on children’s eaing behaviors and attitudes toward foods.Parents need to make sure that nutritiousfoods are available and decide when to sethem; however, children should decide howmuch to eat. During this period, when chidren may be missing several teeth, it can bdifficult for them to chew certain foods (egmeat). Offering foods that are easy to eat alleviate this problem.

Health care professionals should try todetermine whether families have access toand can afford, nutritious foods. They alsoshould discuss families’ perceptions of whfoods are nutritious and their cultural belieabout foods. Families should eat together a pleasant environment (without the TV),allowing time for social interaction. Particiption in regular family meals is positively assciated with appropriate intakes of energy,protein, calcium, and many micronutrientsand can reinforce the development of heaeating patterns.43

During middle childhood, mealtimes takon social significance, and children becomincreasingly influenced by outside sources(eg, their peers and the media) regarding

H E A L T H Y

N U

T R I T I O N

Parents need to make

sure that nutritious

foods are available

and decide when to

serve them; however,

children should decide

how much to eat.

B O X 3

Child Calcium Dietary Reference Intake


Children aged 9 to 18 years: 1,300 mg/d

Source: Institute of Medicine. Dietary reference intakes

for calcium, phosphorous, magnesium, vitamin D, and

fluoride. (1997). Washington, DC: National Academies

Press. 1997. Available at: http://www.iom.edu/file.asp?id

=21372. Accessed August 17, 2006.32




eating behaviors and attitudes toward foods.In addition, they eat a growing number ofmeals away from home and may haveexpanding options for nonnutritious foods.Their eagerness to eat certain foods and to

participate in nutrition programs (eg, NationalSchool Lunch programs) may be based onwhat their friends are doing. However, somechildren can have difficulty in adapting toschool lunch programs. This difficulty can bebecause the foods are different from those athome, the foods may not conform to culturaland religious practices, they have less time toeat than they are accustomed to, or they mayhave difficulty serving their own plates.

Nutrition for Children With Special Health

Care Needs

Dietary needs of children with special healthcare concerns that can affect their ability tomaintain a healthy weight should beaddressed with the family. Health care profes-sionals should be aware of medications thatcan affect appetite, leading to weight loss orweight gain. The children may be makingfood choices at school, and parents may needhelp guiding them to make healthy choices,depending on their particular needs. Children

with special health care needs can have sig-nificant nutritional challenges, leading tounderweight or overweight. These challengescan be the result of behavioral disturbancesor because children may need assistance withfeeding. When weight gain is desired, nutri-tious high-calorie foods are preferred overcalorie-dense “junk food.” Some childrenmay require gastrostomy tubes and fundopli-cations. Overweight and obesity are riskswhen physical activity is limited by a specialhealth care need. Health care professionalsshould be aware of these challenges and beprepared to seek assistance in monitoring andfacilitating appropriate nutrition.

Promoting Nutritional Health:Adolescence—11 to 21 YearsAdolescence is one of the most dynamic peri-ods of human development. The increasedrate of growth that occurs during these years

is second only to that occurring in the firstyear of life. Nutrition and physical activity canaffect adolescents’ energy levels and influ-ence growth and body composition, and thechanges associated with puberty can influ-ence adolescents’ satisfaction with theirappearance. Health supervision visits providean opportunity for health care professionalsto discuss healthy eating and physical activitybehaviors with adolescents and their parents.(For more information on this topic, see thePromoting Physical Activity theme.)


As for the earlier stages of childhood, theadolescent’s diet should follow the Dietary Guidelines for Americans and the comple-mentary recommendations of other nationalhealth organizations.35,39 All of these recom-mendations emphasize a variety of nutrient-dense foods and beverages from the basicfood groups and moderation in saturatedand trans fats, cholesterol, added sugars, and

salt. They also emphasize meeting recom-mended intakes within energy needs andmaintaining a healthy body weight by balanc-ing calories from foods and beverages withcalories expended through physical activity.35

These recommendations direct that nutri-ent needs should be met primarily by con-suming a variety of healthful foods. In certaincases, fortified foods and dietary supplementsmay be useful sources of one or more nutri-ents that otherwise might not be consumedin the recommended amounts. However,

although they are recommended in somecases, dietary supplements cannot replace ahealthy diet.

For many adolescents, intake of certainvitamins (ie, folate, vitamin B6, and vitamin A)

Adolescence is one of

the most dynamic

periods of human

development. The

increased rate of

growth that occurs

during these years is

second only to that

occurring in the firstyear of life.




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B O X 4

Current Recommendations for Selected Nutrients

Folate

The Institute of Medicine recommends that, to reduce the risk of giving birth to an infant

with neural tube defects, female adolescents who are capable of becoming pregnantshould take 400 µg of folate per day from fortified foods, a supplement, or both, in addi-

tion to consuming folate-containing foods from a varied diet.34

Iron

The body’s need for iron increases dramatically during adolescence, primarily because of

rapid growth. Adolescent boys require increased amounts of iron to manufacture myoglo-

bin for expanding muscle mass, and hemoglobin for expansion of blood volume.

Although adolescent girls generally have less muscular development than adolescent boys,

they have a greater risk for iron-deficiency anemia because of blood lost through men-

struation. Iron-deficiency anemia in adolescents may be caused by inadequate dietary

intake of iron, which results from low-calorie and extremely restrictive diets, periods of accelerated iron demand, and increased iron losses. The current Dietary Reference Intakes

for iron are12:

• Females and males aged 9 to 13 years: 8 mg/d

• Females aged 14 to 18 years: 15 mg/d

• Males aged 14 to 18 years: 11 mg/d

Calcium

Adequate calcium intake is essential for peak bone mass development during adolescence,

a period when 45% of the total permanent adult skeleton is formed. Calcium require-

ments increase with the growth of lean body mass and the skeleton. Therefore, require-

ments are greater during puberty and adolescence than in childhood or adulthood. Thecurrent calcium DRIs for children and adolescents are32:

• Children and adolescents aged 9 to 18 years: 1,300 mg/d

• Adolescents aged 19 years and older: 1,000 mg of calcium per day

Sources: Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics,

Committee on Nutrition; 200412; Institute of Medicine. Dietary reference intakes for calcium, phosphorous, magnesium,

vitamin D, and fluoride. Washington, DC: National Academies Press; 199732; Institute of Medicine. Dietary reference intakes

for thiamin, riboflavin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Washington, DC: National

Academies Press. 1998;8:196-305.34 A summary table of the DRIs is available at: http://www.iom.edu/file.asp?id=21372.

Accessed August 17, 2006.32




and minerals (ie, iron, calcium, and zinc) isinadequate, particularly among adolescentsfrom families with low incomes and amongadolescent girls. Box 4 provides current rec-ommendations for several nutrients of partic-

ular concern for adolescents, including folate,iron, and calcium.

Dietary excess of total fat, saturated fat,cholesterol, sodium, and sugar is common inboth genders and in all income and racial andethnic groups. Other nutrition-related con-cerns for adolescents include low intakes offruits, vegetables, and calcium-rich foods, andhigh soft-drink consumption. Diets that arelow in fruits and vegetables and high in satu-rated fats constitute a significant risk factorfor obesity and other health problems.44 Only

21% of adolescents report eating 5 or moreservings of fruits and vegetables per day,45

and only 62% report eating a lower-fat dietwith no more than 2 daily servings of foodthat are typically high in fat content.Adolescent girls (71%) are significantly morelikely than adolescent boys (55%) to reporteating this lower-fat diet.46 Adolescents alsomay engage in unsafe weight-loss methods,and some experience iron-deficiency anemia(for girls), eating disorders, hyperlipidemia,or obesity. Hunger and insufficient foodresources are sometimes a concern amongadolescents from families with low incomes.In addition, nutritional problems can resultfrom pregnancy, disabilities, emotional trau-ma, chronic health conditions, or substanceabuse.

A S S E S SI NG T H E A D OL E S C E NT D I E T

Evaluating the dietary intake of an adolescentis a fundamental component of ongoinghealth supervision. It is, therefore, useful forthe health care professional to gather quanti-

tative and qualitative data about foods andbeverages consumed (both common andunusual), eating patterns, attitudes aboutfoods and eating, and other issues, such ascultural patterns and taboos associated withfood.

Although good eating behaviors are animportant component of a healthy lifestyle,the US Preventive Services Task Force has con-cluded that insufficient scientific evidenceexists to recommend for or against behavioral

counseling in primary care settings to pro-mote a healthy diet.47 Most intervention stud-ies of adolescents have focused on nonclinicalsettings (eg, schools) or have used physiologicoutcomes, such as cholesterol level or weight,rather than more comprehensive measures ofa healthy diet.47 However, because nutritionhas such an important impact on well-beingand longevity, nutritional counseling is includ-ed in preventive health care.

Developing Healthy Eating Habits

Developing an identity and becoming anindependent young adult are central to ado-lescence. Adolescents may use foods toestablish individuality and express identity.They usually are interested in new foods,including those from different cultures andethnic groups, and may adopt certain eatingbehaviors (eg, vegetarianism) to explore vari-ous lifestyles or to show concern for the envi-ronment. Parents can have a major influenceon adolescents’ eating behaviors by providing

a variety of nutritious foods at home and bymaking family mealtimes a priority.48 Parents

Developing an identi-

ty and becoming an

independent young

adult are central to

adolescence.

Adolescents may use

foods to establish

individuality and

express identity.




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also can be positive role models by practicinghealthy eating behaviors themselves.

As adolescents strive for independence,they begin to spend large amounts of timeoutside the home. Parents can encourage

adolescents to choose nutritious foods wheneating away from home.1 Many adolescentswalk or drive to neighborhood stores andfast-food restaurants and purchase foodswith their own money. This situation can beespecially problematic for adolescents fromfamilies with low incomes or adolescentswho live in neighborhoods with many fast-food restaurants and with no grocery storesor with stores that do not sell affordablenutritious foods.

Although eating together as a family is a

challenge for many adolescents and theirfamilies coping with school demands, after-school activities, and work schedules, the fre-quency of family meals has many positiveassociations. Having meals together ispositively associated with intake of fruits, veg-etables, grains, and calcium-rich foods, andnegatively associated with soft-drink con-sumption. Frequency of family meals also ispositively associated with more appropriateintake of energy, protein, iron, folate, fiber,

and vitamins A, C, E, and B6

.

43

Family mealsalso can promote the development of healthyeating patterns that may continue into adult-hood and can protect against the inadequatedietary intake reported by many adoles-cents.43,49

B OD Y I M A GE A ND E A TI NG D I S OR D E R S

The physical changes that are associated withpuberty can affect adolescents’ satisfactionwith their appearance. For some adolescentboys, the increased height, weight, and mus-cular development that come with physical

maturation can lead to a positive bodyimage. However, for many adolescent girls,puberty-related changes (in particular, thenormal increase in body fat) may result inweight concerns. The social pressure to be

thin and the stigma of being overweight clead to unhealthy eating behaviors and apoor body image.1 Adolescents may attemto lose weight or avoid gaining weight byeating smaller amounts of food, foods wit

fewer calories, or foods low in fat. They almay forego eating for many hours; engagexcessive physical activity; take diet pills, poders, or liquids without a physician’s adviceand vomit or take laxatives. Fad diets thatrecommend unusual and, sometimes, inadquate or unbalanced dietary patterns promthe loss of several pounds a week over ashort period of time. Virtually no evidenceavailable about their efficacy and safety inadolescents, making such regimens a poorchoice for adolescents who want to lose

weight and who may underestimate thehealth risks associated with them.12

Unhealthy eating behaviors and preoccupation with body size can lead to life-threatening eating disorders (eg, anorexianervosa or bulimia nervosa). Although eatdisorders are more prevalent among adolecent girls (prevalence is 1% to 2%) thanamong adolescent boys, they occur in botgenders across socioeconomic and racial aethnic groups and are now seen in childre(aged 10 to 12 years) as well. Major mediccomplications of eating disorders include cdiac arrhythmia, dehydration and electrolyimbalances, delayed growth and develop-ment, endocrine disturbances (eg, menstrudysfunction or hypothermia), gastrointestinproblems, oral health problems (eg, enamedemineralization or salivary dysfunction),osteopenia, osteoporosis, and protein andcalorie malnutrition and its consequences.Estimates of mortality that result fromanorexia nervosa vary considerably from th

average estimate of 5% to 8% to as high 20%.50 Death may be due to cardiac arrhymia (irregular heartbeat), acute cardiovascufailure, gastric hemorrhaging, or suicide.Bulimia nervosa can damage teeth and caenlargement of the parotid gland.

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Family meals also can

promote the develop-

ment of healthy eat-

ing patterns that may

continue into adult-

hood and can protect

against the inade-

quate dietary intake

reported by manyadolescents.




A T H LE T I C S A ND P E R F OR M A NC E- E NH A NC I NG

SUBSTANCES

Adolescents who engage in competitivesports can be vulnerable to nutrition misinfor-mation and unsafe practices that promise to

enhance performance. Inadequate nutritionalintake and unsafe weight control methodscan adversely affect performance andendurance, jeopardize health, and underminethe benefits of training. Health supervisionincludes the promotion of healthy eating andweight management strategies to enhanceperformance and endurance while ensuringoptimal growth and development.51,52

Nutrition for Youth With Special Health

Care Needs

As with earlier age groups, youth with specialhealth care needs are at increased risk fornutrition-related health problems for the fol-lowing reasons1: The energy and nutri-

ent requirements of

adolescents with spe-

cial health care needs

vary according to

their individual meta-

bolic rate, activity

level, and medical

status.

• Physical disorders or disabilities canaffect their capacity to consume, digest,or absorb nutrients.

• Biochemical imbalances can be causedby long-term medications or internal

metabolic disturbances.• Psychological stress that results from a

chronic condition or physical disordercan affect appetite and food intake.

• Environmental factors are often con-trolled by parents, who may influenceaccess to, and acceptance of, food.

The energy and nutrient requirements ofadolescents with special health care needsvary according to their individual metabolicrate, activity level, and medical status. Once a

desired energy level has been achieved, theadolescent should be routinely monitored toensure adequate nutrition for growth anddevelopment and to make adjustments forperiods of stress and illness.




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