Chapter 10Toddler and Preschooler Nutrition

Key Nutrition Concept #1

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

Key Nutrition Concept #2

• Learning to enjoy new foods and developing feeding skills are important components of this period of increasing independence and exploration.

Key Nutrition Concept #3

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

Key Nutrition Concept #4

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

Definitions of the Life Cycle Stage

• Toddlers—1-3 years– Characterized by rapid increase in gross & fine

motor skills

• Preschool-age children—3-5 years– Characterized by increasing autonomy, broader

social circumstances, increasing language skills, & expanding self-control

Importance of Nutrition Status

• During toddler and preschool years, adequate nutrition is required to achieve full growth & development

• Undernutrition impairs cognition & ability to explore environment

Tracking Toddler and Preschooler Health

• Economic & nutrition status of U.S. children– 18% live in poverty (2006)– 14% have no health insurance– 33% lived in single-parent families (make them

more likely to live in poverty)

Healthy People 2010

• Healthy People 2010 – objectives for the nation for improvements in health status by the year 2010

• Healthy People 2020 is under development (www.hhs.gov)

• Table 10.1 lists the objectives for toddlers and preschoolers with results to date

Normal Growth and Development

• From birth to 1 year, average infant triples his birthweight

• Toddlers gain 8 oz and grow 0.4 in per month

• Preschoolers gain 4.4 lb and grow 2.75 in per year

Monitoring Children’s Growth

• Use calibrated scales & height board

• Toddlers under age 2 years – Weighed without clothes or diaper – Determine recumbent length

• Children over age 2 years– Weighed with light clothing – Measure stature with no shoes

Recumbent Length

• The length of toddlers < 24 months are measured in the recumbent position

The 2000 CDC Growth Charts

• Charts are:– Gender specific - one set for girls & one for boys

– Age specific - a set for ages birth to 36 months and 2-20 years

• Monitor for:– Weight-for-age

– Length- or stature-for-age

– Weight-for-length or -stature

– BMI-for-age

The 2000 CDC Growth Charts

WHO Growth Standards

• WHO (World Health Organization) published growth standards for children from birth to 5 years.

• International growth standards regardless of ethnicity or socioeconomic status.

• See the “Resources” section at the end of the chapter or www.who.int/childgrowth

Common Problems with Measuring & Plotting Growth

Data

• Error in measuring may result in errors in health status assessment

• Use of calibrated equipment and plotting accuracy are vital

Appropriate Measuring Equipment for Young Children

Physiological and Cognitive Development: Toddlers

• A time of expanding physical and developmental skills• Walking begins as a “toddle,” improving in balance &

agility• Progress by month

– 15—crawl upstairs

– 18—run stiffly

– 24—walk up stairs one foot at a time

– 30—alternate feet going up stairs

– 36—ride a a tricycle

Cognitive Developmentof Toddlers

• Toddlers “orbit” around parents • Transitions from self-centered to more interactive• Vocabulary expands:

– 10-15 words at 18 months – 100 at 2 years– 3-word sentences by 3 years

• Temper tantrums common (the terrible two’s)

Development of Feeding Skills of Toddlers

• Gross & fine motor development improved

• 9-10 months—weaning bottle begins

• 12 to 14 months—completely weaned

• 12 months—refined pincer

• 18-24 months—able to use tongue to clean lips & has developed rotary chewing

• Adult supervision vital to prevent choking

Feeding Behaviors of Toddlers

• Rituals in feeding are common

• May have strong preferences & dislikes

• Food jags common

• Serve new foods with familiar foods & when child is hungry

• Toddlers imitate parents & older siblings

Appetite and Food Intake of Toddlers

• Slowing growth results in decreased appetite

• Toddler-sized portions average 1 tablespoon per year of age

• Nutrient-dense snacks needed but avoid grazing on sugary foods that limit appetite for basic foods at meals

Cognitive Development of Preschool-Age Children

• Egocentric—cannot accept another’s point of view

• Learning to set limits for himself

• Cooperative & organized group play

• Vocabulary expands to >2000 words

• Begins using complete sentences

Development of Feeding Skills of Preschool-Age Children

• Can use a fork, spoon, & cup

• Spills occur less frequently

• Foods should be cut into bite-size pieces

• Adult supervision still required

Feeding Behaviors of Preschool-Age Children

• Appetite related to growth

• Appetite increases prior to the “spurts” of growth

• Include child in meal selection & preparation

Meal-preparation Activities of Young Children

Innate Ability to Control Energy Intake & Preschool-Age Children• Children adjust caloric intake to meet

caloric needs

• Avoid encouraging child to “clean your plate”

• Healthful eating habits must be learned

Appetite and Food Intake of Preschool-Age Children

• May prefer familiar foods

• Serve child-sized portions

• Make foods attractive

• Strong-flavored or spicy foods may not be accepted

• Control amount eaten between meals to ensure appetite for basic foods

Temperament differences

• Temperament—the behavioral style of the children. Three main temperaments:– 40% “easy” temperaments– 10% “difficult” temperaments– 15% “slow-to-warm-up”– Remaining styles are “intermediate low” to

“intermediate high”

Temperament differences

• “Easy”—adapts to regular schedules & accepts new foods

• “Difficult”—slow to adapt and may be negative to new foods

• “Slow-to-warm-up”—slow adaptability, negative to new foods but can learn to accept new foods

• “Intermediate low” to “intermediate high” – a mixture of behaviors

Food Preference Development, Appetite, and Satiety

• Prefer sweet & slightly salty, reject sour & bitter foods

• Eat familiar foods

• May need 8–10 exposures to new foods before acceptance

• Food intake related to parent’s preferences

Appetite and Satiety

• Consumption of foods high in sugar and/or fat before meals decreases intake of basic foods

• Offering large portions increases food intake and may promote obesity

• Restriction of palatable foods increases preference for the foods

Feeding Relationship

• Parent or caretaker responsibilities:– “What” children are offered to eat– The environment in which food is served

including “when” & “where” foods are offered

• Child’s responsibilities:– “How much” they eat– “Whether” they eat a particular meal or snack

Feeding Relationship

Energy Needs

• Dietary Reference Intakes (DRIs) have been developed

• The reports present a comprehensive set of reference values for nutrient intakes of healthy individuals

• Table 10.4 gives the Estimated Energy Requirements for reference boys and girls

Nutrient Needs: Protein

Vitamins & Minerals

• Most toddlers and preschool-age children have adequate vitamin & mineral consumption except for iron, calcium and zinc

Common Nutrition Problems

• Iron-deficiency anemia

• Dental caries

• Constipation

• Lead poisoning

• Food security

• Food safety

Iron-deficiency Anemia

• Seen in 7% of toddlers• May cause delays in

cognitive development and behavioral disturbances

• Diagnosed by hematocrit and/or hemoglobin concentration

Iron-deficiency Anemia

• Preventing Iron Deficiency:– Nutrition-Limit milk consumption to 24 oz/d since

milk is a poor source of iron

– Infants at risk should be tested at 9 to 12 months, 6 months later, and annually from ages 2 to 5

• Intervention for Iron Deficiency – Iron supplements

– Counseling with parents

– Repeat screening

Dental Caries

• Prevalence: – 1 in 5 children ages 2 to 4

• Causes:– Bedtime bottle with juice or milk– Streptococcus mutans– Sticky carbohydrate foods

• Prevention:– Fluoride—supplemental amounts vary by age &

fluoride content of water supply

Constipation

• Definition: Hard, dry stools associated with painful bowel movements

• Causes: “Stool holding” and diet

• Prevention: Adequate fiber

Lead Poisoning

• Seen in ~2.2% of children ages 1-5

• Low levels of lead exposure linked to lower IQ & behavioral problems

• High blood lead levels may decrease growth

• Reduce lead poisoning by eliminating sources of lead

Food Security

• Defined as access at all times to sufficient supply of safe, nutritious foods

• Insecurity more common in minority populations

• A concern for growing children since food insecurity may hinder growth & development

Food Safety

• Young children vulnerable to food poisoning

• Food safety practices by FightBAC:– Clean: wash hands & surfaces often– Separate: don’t cross-contaminate– Cook: cook to proper temperature– Chill: refrigerate promptly

Prevention of Nutrition-Related Disorders

• Overweight and obesity

• Prevention and treatment of overweight and obesity

• Nutrition and prevention of cardiovascular disease

• Vitamin and mineral supplements

• Herbal supplements

Overweight and Obesity

• Of children ages 2-5:– 10.4% are overweight (BMI/age ≥95%)– 20.6% are at risk for becoming overweight

(BMI/age ≥ 85%-95%)• BMI is lowest from ages 4-6 years• Adiposity rebound—normal increase in BMI that

occurs after BMI declines • Best treatment is allowing child to “grow into his or

her height”

Prevention of Overweight & Obesity

• Limit sugar-sweet beverages

• Encourage fruits & vegetables

• Limit TV• Daily breakfast• Limit fast foods• Limit portions

• Calcium rich diets• Diets high in fiber• Follow the DRI for

carbs, pro & fat• Promote physical

activity• Limit energy-dense

foods

Nutrition and Prevention of Cardiovascular Disease

• Limit dietary saturated fats, trans fat & cholesterol

• Acceptable total fat intake ranges:– 2 to 3 years—30 to 35% of calories– 4 to 18 years—25 to 35% of calories

• For children at high risk of CVD limit saturated fat to < 7% of calories & cholesterol to < 200 mg

Vitamin and Mineral Supplements

• A varied diet provides all vitamins & minerals needed

• AAP recommends supplements for certain groups of children:– From deprived families– With anorexia, poor appetites or poor diets, or a

dietary program for wt mgmt– Who consume only a few types of foods– Vegetarians without dairy products

Herbal Supplements

• Parents who take herbs are likely to give them to their children

• Advise parents of potential risks of herbal therapies & the need to closely monitor the child if given supplements

Dietary and Physical Activity Recommendations

• Dietary guidelines– Offer a variety of foods, limiting foods high in

fat & sugar– 60 minutes of vigorous physical activity each

day

• MyPyramid developed by the USDA for young children

MyPyramid

MyPyramid

MyPyramid

Recommendations for Intake

• Iron- meats, fortified cereal, dried beans and peas

• Fiber- fruits, vegetables, whole grains

• Fat- follow food guide pyramid

• Calcium- dairy, canned fish with soft bones, green leafy vegetables, calcium-fortified beverages

• Fluids- beverages, foods and sips of water

Recommended vs. Actual Food Intake

• Dietary intake of children ages 2-5 – Energy exceeded by 31%– Consistently low “mean” intakes of zinc, folic

acid, Vit D and Vit E– Total fat is 31% of calories– Sodium intake is 2150-2400 mg (rec 2300 mg)– Table 10.10 shows the mean % of calories

Other Concerns

• Cross-cultural considerations– Build on cultural practices

• Reinforce positive practices

• Attempt change for more benefit

• Vegetarian diets– Vegan and macrobiotic diet children tend to

have lower growth rates but remain within normal ranges

Other Concerns

• Vegetarian diet guidelines– Several meals / day (3 meals, 2-3 snacks)– Avoid excessive bulky foods (i.e. bran)– Include energy dense foods (cheese / avocado)– Fat-30% with omega-3 fatty acids– Sources of Vitamin B12, Vitamin D and

Calcium should be included or supplemented

Other Concerns

• Child-care nutrition standards– Nearly half of preschool-age children attend a

child care program– Standards for child care vary by state– Offer food at intervals not less than 2 hours &

no more 3 hours

Other Concerns

• Physical activity recommendations– Children need at least 60 minutes of play

activity each day– Suggested activities

• Taking a nature walk

• Riding a tricycle or bicycle

• Walking, skipping, running

• Most important—have fun while being active!

Nutrition Intervention for Risk Reduction

• Model program– Bright Futures in Practice: Nutrition

• Public food and nutrition programs– WIC– WIC’s Farmers’ Market Nutrition Program– Head Start and Early Head Start– Supplemental Nutrition Assistance Program

(formerly Food Stamps)