Toddler and Preschooler Nutrition

Information from Judith E. Brown - Nutrition Through the Life Cycle-Cengage (2018)

Age Range For Toddlers

1 to 3 years

Age Range For Preschool Age

3 to 5 years

What % of toddlers and preschoolers live in poor and near poor families?

44%

What % of toddlers and preschoolers under the age of 6 in a family with a female householder were in poverty>

49.1%

Healthy People 2020 Objective: Increase Fruit

Baseline: 0.5 cup equivalents of fruits per 1000 calories

Target: 0.9 cup equivalents of fruits per 1000 calories

Healthy People 2020 Objective: Increase Veggies

Baseline: 0.8 cup equivalents of total vegetables per 1000 calories

Target: 1.1 cup equivalents per 1000 calories

Healthy People 2020 Objective: Increase Dark Green Veggies

Baseline: 0.1 cup equivalents of dark green or orange vegetables or legumes per 1000 calories

Target: 0.3 cup equivalents per 1000 calories

Healthy People 2020 Objective: Increase Whole Grain

Baseline: 0.3 oz equivalents of whole grains per 1000 calories

Target: 0.6 oz equivalents per 1000 calories

Healthy People 2020 Objective: Reduce Solid Fats

Baseline: 18.9% of total daily calorie intake

Target: 16.7%

Healthy People 2020 Objective: Reduce Added Sugars

Baseline: 15.7% of total daily calorie intake

Target: 10.8%

Healthy People 2020 Objective: Reduce Solid Fats and Added Sugars

Baseline: 34.6% of total daily calorie intake

Target: 29.8%

Healthy People 2020 Objective: Reduce Saturated Fat

Baseline: 11.3% of total daily calorie intake

Target: 9.5%

Healthy People 2020 Objective: Reduce Sodium

Baseline: 3641 mg

Target: 2300 mg

Healthy People 2020 Objective: Increase Calcium

Baseline: 1118 mg

Target: 1300 mg

Average gain in Toddler per month

8 oz (6 lb a year) and grow 0.4 inches (4.8 inches a year)

Average gain in preschoolers per month

4.4 lb a year and grow 2.75 inches per year

Measuring Growth

The length of toddlers <2 years of age is measured in the recumbent position

Body mass index (BMI) for age (kg/m²)

• <5^th percentile indicated underweight

• Between 85^th-95^th percentile indicated overweight

• ≥95^th percentile indicated obesity

severe obesity = BMI ≧120% of the 95^th percentile for age and sex

Expanding physical and developmental skills of toddlers

• 15 months: crawls upstairs

• 18 months: runs stiffly

• 24 months: walks up stairs one foot at a time and jumps in place

• 30 months: alternates feet going up stairs

• 36 months: rides a tricycle

Development of feeding skills of toddlers

• Nine to ten months: bottle weaning

• 12 to 14 months: completely weaned

• 12 months: refined pincer grasp

  • Pincer grasp wherein the pointer finger and the thumb squeeze to grasp an object.^[

• 18-24 months: able to use tongue to clean lips and has well-developed rotary chewing

• Adult supervision vital to prevent choking

Toddler-sized portions average

one tablespoon per year of age

Feeding Behaviors of Toddlers

• Rituals in feeding are common

• May have strong preferences and dislikes

• Food jags common

  • A food jag is defined as "when children prefer to eat the same food prepared the same way every day or at every meal."

• Serve new foods with familiar foods

• Toddlers imitate the eating behavior of others

Cognitive development of preschoolers

• Magical thinking and egocentrism

  • Egocentrism - the inability to differentiate between self and other

• Learning to set limits for himself

• Beginning of cooperative and organized play

• Expansion of vocabulary to over 2000 words

• Begins using complete sentences

Development of feeding skills of preschoolers

• Can use a fork, spoon, and cup

• Eating becomes less messy

• Spills occur less frequently

• Foods should be cut into bite-size pieces

• Adult supervision is imperative

Feeding behaviors of preschoolers

• Appetite is related to growth; increases prior to the “spurts”

• Involve child in meal selection and preparation

Appetite and Food Intake of Preschoolers

• May prefer familiar foods - comfort or control?

• Serve child-sized portions

• Make foods attractive

• Strong-flavored or spicy foods may not be accepted

• Control amount eaten between meals

• Young children often do not like their foods to touch or to be mixed together

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

How many exposure to new food until it is accepted?

8 to 10 exposures

EERs in kcal

DRI for Protein

DRI for Iron, Zinc, and Calcium

Common Nutrient Problems

• Iron-deficiency anemia

• Dental caries

• Constipation

• Elevated blood lead levels

• Food security

• Food safety

Normal values of biochemical nutritional parameters

How to prevent Iron deficiency

• Limit milk consumption to 24 ounces a day

  • Low-iron and may displace high-iron foods in the diet

• Infants at risk should be tested at nine to 12 months, six months later, and annually from ages two to five

Nutrition intervention

• Iron supplements

• Counseling with parents on proper dietary iron intake

  • Lean meat/fish/poultry with Vitamin C-containing foods

• Repeat screening

Pica

Eating disorder characterized by persistent consumption of non-nutritive substances (e.g. dirt, hair, paper).

Dental Carries

• Prevalence: one in three children ages three to five

• Causes: bedtime bottle with juice or milk, Streptococcus mutans, and sticky carbohydrate foods

• Prevention

  • Fluoride

  • Supplemental amounts vary by age and fluoride content of water supply

    • Excessive fluoride supplementation or water content can cause fluorosis

Streptococcus mutans

Bacterium responsible for dental cavities and tooth decay. Uses carbohydrates for food

Constipation

• Definition: hard and dry stools associated with painful bowel movements

• Causes: “stool holding” and diet

• Prevention: adequate fiber and fluid

  • Table 10.10 on pg 276: 1-3 years 19g/day; 4-8 years 25g/day

  • Sources: whole grain bread/cereals, legumes, fruits, and vegetables (age appropriate)

  • Excess fiber can lead to diarrhea, displace other energy-dense foods, and decrease bioavailability of iron & calcium

Food Security

Access at all times to sufficient supply of safe, nutritious foods

Fight-BAC food safety practices

• Clean: wash hands and surfaces often

• Separate: don’t cross-contaminate

• Cook: cook to proper temperatures

• Chill: refrigerate promptly

Key foodborne pathogens

Campylobacter (raw poultry, raw milk), salmonella (raw or undercooked eggs such as in raw cookie dough), E coli (undercooked beef, unpasteurized apple cider and juice, unpasteurized milk)

Adiposity (BMI) rebound

normal increase in BMI that occurs after BMI declines

Prevention of overweight and obesity (pg. 269-270)

• Limit sugar-sweet beverages

• Encourage fruits and vegetables

• Limit television and screen time (max 2 hrs/day)

• Eat a daily breakfast

• Limit restaurants and fast foods

• Limit portions

• Diet that is high fiber, calcium-rich, and follows DRI for macronutrients

• Moderate to vigorous physical activity for at least 60 min/day

• Limit energy dense Foods

Treatment of overweight and obesity expert committee: Recommendations

• Stage one: prevention plus

  • focuses on the behaviors identified in the prevention section

• Stage two: structured weight management (SWM)

  • Daily eating plan, further reduction of screen time, supervised physical activity/play for 60 min/day, meet with RD

  • more structured and requires more frequent follow-up

• Stage three: comprehensive multidisciplinary intervention

  • Food monitoring, negative energy balance, physical activity goals, evaluations at specific intervals

  • the intensity of behavior change is increased and a multidisciplinary team, including an RD, exercise specialist, behavioral counselor, and PCP is needed; weekly visits are recommended

• Stage four: tertiary care intervention

  • offered to severely obese adolescents who have failed other interventions; NOT appropriate for the obese toddler or preschool-age child

Nutrition and prevention of cardiovascular disease in toddlers and preschoolers

• Limit dietary saturated fats, trans fat, and cholesterol

• Avoid smoking, encourage daily physical activity, and reduce sedentary time, sugar-sweetened beverages, and salt

• Diet including fruits, vegetables, whole grains, non or lowfat dairy, and fish two times per week

• Acceptable macronutrient distribution ranges for fat

  • Two to three years: 30 to 35%

  • Four to 18 years: 25 to 35%

Recommendations for intake of iron

• Important to prevent iron deficiency

  • meats, fortified cereal, dried beans, and peas

  • less than 24oz milk daily

Recommendations for intake of fiber

• Important for prevention of constipation

  • fruits, vegetables, and whole grains (see slide 45)

Recommendations for intake of fat

• Follow Dietary Guidelines and MyPlate

  • needed for fat-soluble vitamins and essential fatty acids

Recommendations for intake of calcium

• Important for achieving peak bone mass

  • dairy, canned fish with soft bones, green leafy vegetables, calcium-fortified beverages, and tofu made with calcium

  • 1-3yrs = 700mg/day 

  • 4-8yrs = 1000mg/day

  • Calcium is low in general population and for children with special needs

Recommendations for intake of fluids

• Consumed through beverages, foods, and sips of water

  • Requirements increase with fever, vomiting, diarrhea, and hot/dry/humid environments

  • AAP recommends limiting juice to 4-6 oz. per day.

Children on Vegetarian Diets

• Children with vegan and macrobiotic diets tend to have lower growth rates but remain within normal ranges.

  • Amounts required to meet nutrient needs may be more than children can physically eat

  • Vitamin B12 and/or calcium supplements likely needed

Vegetarian diet guidelines (on pg 278)

• Provide three meals and two to three snacks per day

• Avoid excessive bulky foods (e.g., bran)

• Include energy dense foods (e.g., cheese)

• Provide an omega-3 fatty acid source (e.g., tofu)

• Ensure an adequate intake of calcium, zinc, iron, and vitamins B₁₂ and D

What % of children with disabilities have a nutrition problem?

90%

Eligibility for early intervention services

< 3 years

Chronic conditions generally associated with high and low energy needs

Diplegia

A type of paralysis that affects symmetrical body parts, such as both legs or both arms. It is typically caused by damage to the brain or spinal cord, resulting in muscle weakness or loss of control in the affected areas.

Prader-Willi Syndrome (PWS)

Genetic disorder causing insatiable appetite, obesity, intellectual disabilities, and low muscle tone. Also presents with short stature, hypogonadism, and behavioral issues.

Lower calories needed by children with slow growth or decreased muscles. Opposite for ADHD or ASD

Rett syndrome

Rett syndrome: A rare genetic disorder that affects brain development, primarily in girls. It leads to severe cognitive and physical impairments, including loss of purposeful hand skills, impaired speech, and repetitive hand movements. Symptoms usually appear between 6 and 18 months of age.

Feeding Problems

• Low interest in eating

• Long mealtimes (>30 minutes)

• Preferring liquids over solids

• Food refusals

Example of food choices for child with suspected developmental delay

Feeding problems w/ autism

Limited Food Selection/Strong Food Dislikes. Someone with autism may be sensitive to the taste, smell, color and/or texture foods. They may limit or totally avoid some foods and even whole groups of foods. Common dislikes include fruits, vegetables and slippery, soft foods.

Not Eating Enough Food. Kids with autism may have difficulty focusing on one task for an extended period of time. It may be hard for a child to sit down and eat a meal from start to finish.  The gluten free/casein free diet has not been found to be effective. However, some people report relief in symptoms after following a GFCF diet.

Feeding problems w/ adhd

ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for a child's age and development.  ADHD is a brain disorder caused by faulty connections between nerve cells that regulate attention. Diet alone probably isn't the driving force behind the multiple behavioral and cognitive symptoms that plague children with attention deficit hyperactivity disorder (ADHD). But several studies have renewed interest in whether certain foods and additives might affect particular symptoms in a subset of children with ADHD.

Diets for autism

• No specific diet is recommended for prevention or treatment

• Gluten-free and casein-free diets have been used by parents but not endorsed by professional societies

Excessive fluid intake

child would rather drink than eat

AAP recommendation for juice

4-6 fl oz/day for ages 1-6 years applies to ALL children

Pediatric Malnutrition - Formerly Failure to thrive (FTT)

Child’s weight for age falls below 5^th percentile on multiple occasions or declines to cross two or more growth percentiles lines on growth chart

Toddler Diarrhea

• Typically caused by sucrose and sorbitol content of fruit juices

• Limiting juice may be recommended

Celiac Disease

An autoimmune disorder affecting the small intestine due to gluten intolerance. It causes damage to the lining of the intestine, leading to malabsorption of nutrients. Symptoms include abdominal pain, diarrhea, weight loss, and fatigue. Treatment involves a strict gluten-free diet to manage symptoms and prevent complications.

Cerebral Palsy

Condition affecting movement and muscle control. Results from damage to the brain before or during birth, or in early childhood. Can cause difficulties with coordination, balance, and muscle strength. May also impact speech and fine motor skills. Treatment focuses on therapy, medication, and assistive devices to improve function and quality of life.

Spastic quadriplegia

• severe cerebral palsy

• compared to quadriplegia, spastic quadriplegia is defined by spasticity of the limbs as opposed to strict paralysis. It is distinguishable from other forms of cerebral palsy in that those afflicted with the condition display stiff, jerky movements stemming from hypertonia of the muscles. Spastic quadriplegia is generally caused by brain damage or disruptions in normal brain development preceding birth.

• No two individuals with cerebral palsy are alike; some individuals may be hypometabolic as a result of hypotonia, while others may be hypermetabolic related to increased muscle tone.

brochopulmonary dysplasia (BPD)

A chronic lung disease that affects premature infants. It occurs due to damage to the lungs from mechanical ventilation and oxygen therapy. Symptoms include difficulty breathing, wheezing, nd increased risk of respiratory infections. Treatment involves oxygen therapy, medications, and supportive care.

• Increase nutrient needs, lower interest in eating, and can slow growth

• Preterm infants at high risk of breathing difficulties

• Recommend small, frequent meals with concentrated energy that are easy to eat

Food Allergy

An adverse immune response to a specific food, causing symptoms like hives, swelling, difficulty breathing, or anaphylaxis.

Food Intolerance

an adverse reaction involving digestion or metabolism but not the immune system

Middle Childhood Age Range

5 to 10 years

Preadolescence Age Range

Girls: 9 to 10 years

Boys: 10 to 12 years

How is the growth rate during preadolescence?

Physical growth rate is steady but there is tremendous cognitive, emotional, and social development.

Nutrition Problems During Preadolescence

• Iron deficiency anemia

• Undernutrition

• Dental caries

• Weight issues at both ends of spectrum

Healthy People 2020 Objectives related to school-age children

	Healthy People 2020 Objective	Baseline	Target
NWS-2.1:	Increase the proportion of schools that do not sell or offer calorically sweetened beverages to students.	9.3%	21.3%
NWS-2.2:	Increase the proportion of school districts that require schools to make fruits or vegetables available whenever other food is offered or sold.	6.6%	18.6%
NWS-10.2:	Reduce the proportion of children (aged 6–11 years) who are considered obese.	17.4%	15.7%
NWS-11.2:	Prevent inappropriate weight gain in children aged 6–11 years (developmental).
PA-4:	Increase the proportion of the nation’s public and private schools that require daily physical education for all students. Elementary schools Middle and junior high schools	3.8% 7.9%	4.2% 8.6%

Healthy People 2020 Objectives related to school-age children

	Healthy People 2020 Objective	Baseline	Target
PA-6.2:	Increase the proportion of school districts that require regularly scheduled elementary school recess.	57.1%	62.8%
PA-8.2.2:	Increase the proportion of children and adolescents aged 6–14 years who view television, videos, or play video games for no more than 2 hours a day.	78.9%	86.8%
PA-8.3.2:	Increase the proportion of children and adolescents aged 6–14 years who use a computer or play computer games outside of school (for nonschool work) for no more than 2 hours a day.	93.3%	100%
PA-13.2:	Increase the proportion of trips to school of 1 mile or less made by walking by children and adolescents aged 5–15 years (developmental).
PA-14.2:	Increase the proportion of trips to school of 2 miles or less made by bicycling children and adolescents aged 5–15 years (developmental).

Height and weight gain during school age

•Average 7lbs (3-3.5kg) weight and 2.5in (6cm) height

When to use CDC and WHO growth charts

CDC: 2 to 20

WHO: >20

Physiological development for school age children

• Muscular strength, motor coordination, and stamina increase

• More complex pattern movements (dance/sports/gymnastics, etc.)

• Body fat reaches a minimum then increases in preparation for adolescent growth spurt (BMI rebound occurs on average at 6 years or age)

Cognitive development of school age children: Self efficacy

• Knowledge of what to do and ability to do it

• Changes from magical thinking and egocentrism to concrete operations

• Develops sense of self

• More independent and learning roles in family/school/community

• Peer relationships become important

DRI for Normal Growth

Age	Estimated Energy Requirements (kcal)
0-3 months	(89 x wt [kg] – 100) + 175
4-6 months	(89 x wt [kg] – 100 ) + 56
7-12 months	(89 x wt [kg] – 100) + 22
13-36 months	(89 x wt [kg] – 100) + 20
Boys 3-8 years	88.5 – (61.0 x age [y]) + PA x (26.7 x wt [kg] + 903 x ht [m]) + 20
Girls 3-8 years	135.3 – (30.8 x age [y]) + PA x (10 x wt [kg] + 934 x ht [m]) + 20
Boys 9-19 years	88.5 – (61.9 x age [y]) + PA x (26.7 x wt [kg] + 903 x ht [m]) + 25
Girls 9-19 years	135.3 – (30.8 x age [y]) + PA x (10 x wt [kg] + 934 x ht [m]) + 25

Physical activity coefficients

Physical activity coefficient (Boys)

• PA = 1 (sedentary)

• PA = 1.13 (low active)

• PA = 1.26 (active)

• PA = 1.42 (very active)

Physical activity coefficient (Girls)

• PA = 1 (sedentary)

• PA = 1.16 (low active)

• PA = 1.31 (active)

• PA = 1.56 (very active)

Low active – 30 to 60 minutes of moderate activity daily

Active – 60 minutes of moderate activity daily

Very active – 120 minutes moderate activity daily OR 60 minutes moderate + 60 minutes vigorous activity daily

Protein for school age

Recommended is 0.95 gram of protein per kg body weight per day for boys & girls ages 4-13yrs

Dietary Reference Intakes for key nutrients for  school-age children

Iron deficiency

•Less common in middle childhood than toddler age

•Treatment is oral iron trial for four weeks

•Dietary recommendations: eat iron-rich foods

•Meat, fish, poultry, and fortified cereals

Vitamin C rich foods to help absorption

Dental carries

• Seen in half of children aged six to nine

• Influenced by time teeth are exposed to carbohydrate

• Complex carbohydrates such as fruits, vegetables, and grains are better choices than simple sugars

• Regular meal and snack times are beneficial

• Continued need for fluoride supplementation

• Brush after eating!

% of school age children that are overweight between 2015 and 2016

• 32.8% of children ages 6 through 8 years and 35.6% age 9 to 11 years are overweight or obese (prevalence has increased over 30 years).  See Table 12.3 on pg. 307 for categories of overweight/obesity.

• Obesity prevalence differs by race/ethnicity

  • 38.2% Hispanic

    35.0% African American

    19.1% White

    12.1% Asian American

Characteristics of overweight school age children

• Taller

• Advanced bone ages (bone maturation)

• Earlier sexual maturity

• Look older

• Higher risk for health consequences of obesity

  • 30.5% increase in type 2 diabetes from 2001-2009

  • Effects of early onset obesity on adult morbidly and mortality is unclear

Predictors of childhood obesity

• Age at onset of BMI rebound

  • Normal increase in BMI after decline

  • Early BMI rebound results in higher BMIs in children

• Home environment - maternal and/or parental obesity is a predictor of childhood obesity

BMI Rebound

BMI rebound is the normal increase in BMI that occurs after BMI declines and reaches its lowest point, at about 4-6 years of age.  The age at which BMI rebound occurs may have a significant effect on the amount of body fat that the child will have during adolescence and into adulthood.  Early BMI rebound is defined as beginning before 5.5 years of age, while the average age of BMI rebound is 6 – 6.3 years of age.  BMI rebound after age 7 is considered to be late.  Studies have shown that adolescents and adults who had an early BMI rebound as children have higher BMI than those subjects who had an average or late BMI rebound. 

The connection between parental obesity and obesity in children is likely due to genetic as well as environmental factors.

AAP Recommendation for Screen Time

• AAP recommendations

  • No screen devices in bedrooms

  • Development of Family Media plan

  • No more than two hours each day of screen time

• Strong relationship between TV viewing and obesity (reduced energy expenditure, increased dietary intake, disruption of sleep patterns)

Treatment of overweight and obesity

Four stages

• Stage 1: Prevention Plus

• Stage 2: Structured Weight Management (SWM)

• Stage 3: Comprehensive Multidisciplinary Intervention (CMI)

• Stage 4: Tertiary Care Intervention (reserved for severely obese adolescents)

Obesity Percentiles

.  With his weight-for-age at the 95th percentile and his height-for-age at between the 75th and 90th percentiles, Timothy is large for his age as compared to other boys the same age. The most significant finding is a BMI-for-age greater than the 95th percentile. This places him in the “obese” category.

2.  Timothy’s parents should limit the amount of money they give him for extra food items school. They should provide healthier choices of foods, such as fruit and vegetables, in the home for after-school snacks. It would be good for the whole family to adopt healthier eating behaviors, especially since his mother is obese.

3.  (a) Timothy’s parents could talk to his PE teacher at school and make sure that he is being encouraged to be active during PE class. (b) His parents could look into the possibility of having Timothy participate in an after-school program where physical activity and active play would be encouraged. They could investigate available community programs and resources that would facilitate physical activity. (c) Eating in front of the TV should be discouraged. (d) The whole family could be engaged in a more active lifestyle.

4.  Having an obese parent does increase the likelihood that a child will have a weight problem. Having two obese parents further increases the risk of overweight. Researchers are realizing that pediatric overweight is a multifaceted problem, involving genetic as well as environmental factors. Lifestyle issues such as overeating and inactivity are also contributing factors.

Acceptable fat range

25 to 35% of energy for 4-18 years of age

Calcium and vitamin D

• Adequate intake at this time needed for peak bone mass

  • 4-8yrs = 1000mg/day  9-13yrs = 13oomg/day

• Dairy products and calcium-fortified foods

• Adequate vitamin D needed for calcium absorption

  • 4-18yrs = 600IU/day

• Vitamin D from exposure to sunlight and fortified foods

If needed, supplements for these nutrients can be given under the guidance of a physician or RD.

Types of Lactose intolerance

• Primary – lactase enzyme production decreases over time (falls sharply in adulthood)

• Secondary – decreased lactase enzyme production after an illness or injury

• Congenital – lack of lactase enzyme from birth