Nutrition in Toddlers

JEDDA RUPERT, Md, Nellis Air Force Base Family unit Medicine Residency Program, Nellis Air Force Base, Nevada

OLIVIA BOUCHER, Md, Eglin Air Strength Base Family Medicine Residency Program, Eglin Air Force Base, Florida

Am Fam Physician. 2018 Aug fifteen;98(4):227-233.

Patient information: Meet related handout on toddler diet.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

Article Sections

  • Abstract
  • Full general Principles
  • Food and Food Recommendations
  • Food Allergies
  • Mutual Challenges and Behavioral Recommendations
  • References

The establishment of eating practices that contribute to lifelong nutritional habits and overall wellness begins in toddlerhood. During this time, children acquire the motor skills needed to feed themselves and develop preferences that impact their food selections. Classifications for faltering weight (likewise chosen failure to thrive or growth faltering) and overweight are based on Earth Health Organization child growth standards (for children younger than two years) and Centers for Disease Control and Prevention growth charts (for children ii years and older). Breast milk or whole cow's milk should be offered every bit the primary beverage between ane and two years of historic period. Sugar-sweetened beverages should exist avoided in all toddlers, and h2o or milk should be offered instead. Allergenic foods such every bit peanuts should exist introduced early to infants at higher risk of allergies. Vitamin D and iron supplementation may be advisable in sure circumstances, only multivitamins and other micronutrient supplements are normally unnecessary in healthy children who have a balanced diet and normal growth. Optimal food choices for toddlers are fresh foods and minimally candy foods with piddling or no added sugar, salt, or fat (e.g., fruits, vegetables, lean protein, seeds, whole grains). Parents and caregivers are responsible for modeling healthy food choices and dietary practices, which shape children's food preferences and eating behaviors. Parents should avoid practices that lead to overeating in toddlers (eastward.g., feeding to soothe or to get children to sleep, providing excessive portions, pushing children to "clean their plates," punishing with food, force-feeding, allowing frequent snacks or grazing). In general, parents should use the approach of "the parent provides, the kid decides," in which the parent provides healthy food options, and the kid chooses which foods to eat and how much.

During the transition from a liquid-based infant nutrition to a diet more typical of older family members, toddlers have their starting time exposures to many food types and are experiencing rapid growth. This period marks the establishment of eating practices that contribute to lifelong nutritional habits and overall health. At this age, children learn the motor skills needed to feed themselves and develop preferences that affect their food selections.

WHAT IS NEW ON THIS TOPIC

Although the American Academy of Pediatrics supports the consideration of reduced-fatty milk instead of whole milk in toddlers who are at risk of obesity or cardiovascular affliction, early introduction of reduced-fat milk may ultimately increase the risk of obesity and should be avoided in most cases.

In a precipitous departure from previous recommendations, more recent guidelines recommend early introduction of potentially allergenic foods (e.m., peanuts) into the diets of some infants. Therefore, foods that were traditionally started in toddlerhood may at present be given earlier.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Show rating References

Children i to two years of age should drink whole milk rather than reduced-fat milk.

C

8, 16, 17

Children older than 12 months should exist offered primarily h2o and milk. 100% fruit juice should be limited to 4 oz per day in children ane to three years of age and served in an open cup. Sugary, nonnutritive beverages (due east.m., fruit drinks, sweetened bottled h2o, sports drinks, soda) should be avoided entirely.

C

23, 24

Fat intake should not be limited earlier 12 months of age just may be limited to thirty% to twoscore% of daily energy intake in one- to three-yr-olds. Trans fats should be avoided entirely.

C

3, 16, 26

Exclusively breastfed infants should receive vitamin D supplementation (400 IU per solar day) until they are consuming an acceptable corporeality of vitamin D in foods.

C

31, 32

The American Academy of Pediatrics recommends universal screening for iron deficiency anemia with hemoglobin at 12 months of age. According to the U.S. Preventive Services Task Forcefulness and American Academy of Family unit Physicians, there is insufficient evidence to brand a recommendation.

C

33, 35–37

Foods containing peanuts should be introduced at four to six months of age in infants at increased risk of food allergies.

C

thirteen, 40, 41

Parents and caregivers serve as the principal models for healthy eating and activeness patterns.

C

43

Picky eaters should receive frequent opportunities to attempt new foods to increase familiarity, and new foods should exist introduced with familiar foods. Children should non exist pressured to eat new foods because this tin can promote dislike of those foods.

C

46–49

Monitoring growth is a primary method of assessing over-and undernutrition. The World Wellness System child growth standards should be used for children younger than 2 years, and the Centers for Illness Control and Prevention growth charts should be used for children two years and older.1 Both are bachelor for free at http://world wide web.cdc.gov/growthcharts.

Standards for classification of overweight and obesity are relative to historic period and sexual activity. In children older than two years, trunk mass index in the 85th to 95th percentile is considered overweight, and a body mass index in the 95th percentile or greater is considered obese.

Although in that location is no clear consensus on its definition, faltering weight (as well called failure to thrive or growth unpleasing) may be defined as measuring less than the 2nd or 5th percentile and a pattern of growth over time that declines across two major percentile lines on standard growth charts. This topic was reviewed previously in American Family unit Doctor.2

General Principles

  • Abstruse
  • General Principles
  • Food and Food Recommendations
  • Food Allergies
  • Common Challenges and Behavioral Recommendations
  • References

The typical American diet that many young children are exposed to is dominated by calorie-dense, candy foods high in fatty, sodium, and simple sugars. The 2015–2020 Dietary Guidelines for Americans recommends that adults limit consumption of added sugars to less than x% of calories per twenty-four hour period, and instead encourages lean proteins, reduced-fatty dairy products, whole grains, fruits, vegetables, and seeds, with little or no added sugar, salt, or fatty.3 Whole foods from plants are expert sources of complex carbohydrates, fiber, vitamins, and minerals and allow children to feel full longer. Consumption of these foods during childhood has been correlated with a reduced chance of overweight and obesity later in life.4 Tabular array i provides examples of well-balanced meal plans appropriate for moderately agile children.iii,5,6

TABLE 1.

Sample Meal Plans and Nutritional Recommendations for Moderately Active Children

Recommended servings
Meal Ii-year-olds Four-year-olds

Breakfast

one/2 cup milk

1/2 cup milk

1/2 cup atomic number 26-fortified cereal

1/2 cup iron-fortified cereal

1/2 cup banana

i/2 cup assistant

1/2 slice whole wheat toast

1/ii tsp butter

Snack

one/two cup strawberries

ane/2 cup strawberries

1/ii cup water

1/2 cup milk

1/2 cup yogurt

Lunch

1/ii loving cup milk

1/ii cup milk

1/2 sandwich (ane slice whole wheat bread, one oz meat, slice of cheese, lettuce, tomato plant)

i sandwich (two slices whole wheat bread, 2 oz meat and cheese, lettuce, tomato)

3 carrot sticks

1/4 cup steamed broccoli

i small (1/2 oz) oatmeal cookie

Snack

1/2 cup milk

one stick of string cheese

one/2 apple tree, sliced

Dinner

one/2 cup milk

ane/2 cup milk

ii oz craven chest

2 oz chicken breast

1/iii loving cup whole wheat pasta

1/2 cup whole wheat pasta

1/eight cup steamed broccoli

i/iv cup steamed green beans
Recommended daily intake
Food Two-twelvemonth-olds Four-year-olds

Calcium (mg)

700

700

Calories

one,000

ane,400

Carbohydrates (% of kcal)

45 to 65

45 to 65

Fat (% of kcal)

30 to 40

25 to 35

Fiber (g)

xiv

16 to 20

Iron (mg)

seven

7

Protein (% of kcal)

five to 20

10 to 30

Vitamin D (IU)

600

600

Special diets for health promotion take become pop; however, they are non recommended in toddlers unless indicated for specific medical weather condition. For case, a gluten-gratis diet can be deficient in vitamins, iron, and dietary fiber because gluten-free grains are often not enriched. In that location is no prove that a gluten-gratuitous diet has any do good for those without celiac disease.7 Additionally, special diets may exist expensive and challenging to follow, making information technology hard to achieve adequate intake of nutrients.

Food and Nutrient Recommendations

  • Abstract
  • Full general Principles
  • Food and Food Recommendations
  • Nutrient Allergies
  • Common Challenges and Behavioral Recommendations
  • References

Figure 1 is a timeline for introducing key foods when transitioning from the liquid-based infant nutrition.viii–13

Figure 1.

Timeline for introducing key foods when transitioning from the liquid-based infant diet.

Information from references 8 through thirteen.

BREAST MILK/FORMULA

Exclusive breastfeeding is recommended for the first six months of life, and breastfeeding should be continued up to at to the lowest degree 12 months of age per the American Academy of Pediatrics (AAP) and American Academy of Family Physicians, or up to at least 24 months of age per the World Health System.nine–12 The addition of solid foods tin be considered betwixt 4 and vi months of historic period, as developmentally appropriate. The addition of formula, rather than milk or other beverages, is recommended if breastfeeding is decreased or discontinued before 12 months of age.12

MILK

Cow's milk provides key nutrients, such as protein, calcium, and vitamins A and D. Observational studies back up a recommendation of ii 8-oz servings of cow'south milk per day in toddlers to maintain adequate vitamin D and iron stores.14,fifteen Children one to two years of age should drink whole milk rather than reduced-fat milk.eight,xvi,17 Although the AAP supports considering reduced-fat milk for toddlers who are at risk of obesity or cardiovascular disease,17 early introduction of reduced-fat milk may ultimately increase the run a risk of obesity.18–twenty

If an alternative to cow'due south milk is preferred, fortified soy milk is most similar in limerick to cow's milk.three Other alternatives, including almond, rice, coconut, and hemp milks, tend to have less protein and fat compared with cow's milk, and have been associated with decreased adult acme and lower vitamin D levels.21,22

OTHER BEVERAGES

Daily intake of 100% fruit juice should exist limited to 4 oz between ane and three years of age and 4 to 6 oz between 4 and half dozen years of age.23 Juice should be offered only in an open loving cup, non a canteen or sippy cup. Saccharide-sweetened beverages (eastward.g., fruit drinks, sweetened bottled water, sports drinks, soda) are associated with obesity and dental caries, and should exist avoided entirely.24 Water is the best option for toddlers betwixt meals for hydration with no additional calories.

MACRONUTRIENTS

Fatty intake should not be limited before 12 months of historic period considering of its importance in neurologic development. Between one and three years of historic period, fatty can be safely limited to 30% to xl% of total daily energy intake. Polyunsaturated fatty acids and monounsaturated fatty acids are the preferred sources of fat. In that location is conflicting literature well-nigh restrictions on saturated fat and dietary cholesterol.3,sixteen,25 Trans fats should exist avoided entirely.3,16  Different dietary fat sources are listed in Table 2.3

Table 2.

Sources of Different Types of Dietary Fats

Type of fatty Sources

Monounsaturated fatty acids

Olive, canola, peanut, sunflower, safflower oils

Avocados

Virtually nuts

Fauna fats: chicken, pork, beef, wild game

Polyunsaturated fat acids

Sunflower, corn, soybean, cottonseed oils

Omega-three fatty acids: walnuts, flaxseed

Long-chain omega-3 fat acids (EPA, DHA): seafood

Saturated fat

Coconut, palm oils

Butter

Animal fats: craven, pork

Trans fats

Partially hydrogenated vegetable oils

Margarine

Diverse snack foods

Protein should incorporate 5% to 20% of daily energy intake from one to iii years of historic period.iii,26 Limited testify shows an association between a low-fat, loftier-protein diet and overweight and obesity later in life, suggesting the importance of balanced macronutrient composition in toddlerhood.27–29

Carbohydrates should contain the largest per centum of macronutrients, at 45% to 65% of daily energy intake, in children i to three years of age.three,26 Circuitous carbohydrates such equally vegetables, whole grains, beans, and lentils are preferred over simple or refined, processed carbohydrates. Added sugars should be avoided in children younger than ii years and limited in older children.24

Foods rich in dietary fiber tend to be nutrient-dense and contain fewer calories. Dietary cobweb from unprocessed or minimally processed foods is recommended because it has been associated with lower body fat limerick and better cardiometabolic wellness subsequently in babyhood.sixteen,30 The recommended corporeality of fiber intake for toddlers is 14 g per ane,000 kcal, or at least age plus five k per twenty-four hours.3,16

MICRONUTRIENTS

Vitamin D and calcium are essential for bone growth and os mass acquisition. The recommended daily intake of vitamin D for children one to three years of age is 600 IU.3,31 The AAP recommends vitamin D supplementation (400 IU daily) for exclusively breastfed infants until they are consuming an adequate amount of vitamin D in foods, with consideration for more if there is take chances of vitamin D deficiency (e.g., in those with chronic malabsorption).31,32 The recommended daily intake of calcium for children one to three years of age is 700 mg.3,31 There is 276 mg of calcium per eight oz of whole milk. Nondairy sources of calcium include green leafy vegetables, legumes, nuts, and fortified cereals.31

Iron deficiency and iron deficiency anemia in young children have potential neurodevelopmental implications. Infants between half-dozen and 12 months of age should consume 11 mg per twenty-four hour period of iron, and children i to 3 years of age should eat 7 mg per day.33 Take a chance factors for iron deficiency anemia include low socioeconomic status, lead exposure, prematurity, low birth weight, high intake of whole milk, and consuming depression-atomic number 26 foods.34

The AAP recommends iron supplementation (i mg per kg per twenty-four hours) starting at four months of age for exclusively breastfed infants until iron-rich foods are introduced; universal screening for anemia with hemoglobin at 12 months of historic period is also recommended.33 The U.S. Preventive Services Task Strength and American Academy of Family Physicians conclude that evidence is insufficient to recommend for or confronting routine screening for iron deficiency anemia in asymptomatic children six to 24 months of historic period.35–37 Prevention of fe deficiency in young children includes utilize of iron-fortified formula in formula-fed infants, consumption of atomic number 26-rich foods at the appropriate age, not introducing cow's milk before 12 months of age, and limiting cow's milk to 16 oz per day once it is introduced.34,38 Although sure loftier-run a risk groups take shown comeback in long-term outcomes from iron supplementation, it is not routinely recommended in low-risk infants and toddlers.35

Multivitamin supplementation is usually unnecessary in healthy toddlers and children who consume a balanced nutrition and accept normal growth, and information technology may increment the intake of nutrients to above the recommended maximal levels. Nutrition through the intake of foods is preferred, unless the child is at particular nutritional run a risk (e.k., those with chronic disease or faltering weight).3,39 Table 3 includes examples of nutrient-dense foods for toddlers.three

Table iii.

Examples of Food-Dense Foods for Toddlers

Nutrient Food sources

Calcium

Cheese

Cow's milk (whole, reduced fatty, or skim)

Plainly nonfat or low-fat yogurt

Soy milk

Dietary cobweb

Apples with skin

Black beans

Chickpeas

Loftier-cobweb bran cereal

Oranges or bananas

Quinoa

Shredded wheat cereal

Whole wheat bread

Whole wheat spaghetti

Atomic number 26

Beefiness, bottom circular

Chicken with skin

Fortified cereals

Spinach

White beans

Vitamin D

Moo-cow's milk (whole, reduced fat, or skim)

Salmon (sockeye or pink)

Soy milk

Yogurt

Food Allergies

  • Abstract
  • Full general Principles
  • Food and Food Recommendations
  • Food Allergies
  • Common Challenges and Behavioral Recommendations
  • References

In a sharp deviation from previous recommendations, more recent guidelines recommend early introduction of potentially allergenic foods into the diets of some infants. Therefore, foods that were traditionally started in toddlers may now be given earlier. For example, foods containing peanuts should be introduced between four and half-dozen months of age in infants with severe eczema or egg allergy (after serologic or skin prick testing) and at around six months for those with mild to moderate eczema. In children with no eczema or food allergies, peanuts can exist introduced as usual with other age-advisable foods.13 The new peanut recommendations were previously summarized in American Family unit Md.40

There is express evidence that allergen exposure through breastfeeding reduces future allergies.41 Even so, at that place is insufficient prove to make recommendations for maternal food preference or avoidance while breastfeeding or for the use of infant supplements such as probiotics to bear upon the run a risk of food allergies.42

Common Challenges and Behavioral Recommendations

  • Abstruse
  • General Principles
  • Food and Nutrient Recommendations
  • Food Allergies
  • Common Challenges and Behavioral Recommendations
  • References

Parents and caregivers serve as the primary models for good for you eating and activeness patterns, and are responsible for food selection and portion sizes, determining the timing and social context of meals, and influencing other associated behaviors such every bit screen fourth dimension, playtime, and sleep schedules.43 Some traditional feeding practices may negatively influence eating patterns, promote early on obesity, and foster picky eating. For example, parents and caregivers should avoid feeding to soothe or to become their children to sleep, providing excessive portions, pushing children to "clean their plates," punishing with food, force-feeding, or allowing frequent snacks or grazing.43,44

PICKY EATERS

Between 25% and 50% of normally developing children are picky eaters.45 Although toddlers' appetites and how much they eat may fluctuate considerably from day to twenty-four hour period (by up to 30%), they are able to self-regulate without significant detrimental effect on growth. Children may reject unfamiliar foods initially but accept them once they go more familiar. Providing frequent opportunities to try new foods, sometimes 20 to 30 offerings, is recommended to increase familiarity.46 However, forcing or pressuring children to eat new foods such as vegetables tin can promote dislike of those foods, especially if more than flavory foods are available.47 Flavor conditioning is recommended when introducing unfamiliar foods. This involves pairing new flavors with familiar flavors to promote associative learning. Similarly, food chaining includes presenting new foods along with previously accepted foods that are similar in taste, texture, or temperature.48 Selection of foods is too influenced past the choices of peers and developed models; children are more than likely to taste unfamiliar foods if they run across peers and caregivers eating those foods.44

The clinician should distinguish picky eating from a pediatric feeding disorder, which is defined every bit a pregnant impairment of oral intake lasting more than than two weeks that is non historic period-advisable and results in substantial medical, nutritional, and emotional consequences. Pediatric feeding disorder is most mutual in young children and affects an estimated three% to ten% of all children.49 If a pediatric feeding disorder is suspected, a multidisciplinary approach to the evaluation should be considered, including possible referral to a voice communication pathologist, registered dietitian, clinical social worker, behavioral psychologist, pediatric gastroenterologist, developmental pediatrician, or dedicated feeding team.49–51

OVEREATING

Self-feeding in toddlers should be encouraged to promote fine motor skills and regulation of food intake.46 The foods provided should be advisable to the toddler's developmental ability and cutting small plenty to avoid choking. Children should be encouraged to use child-sized cups and utensils. Overeating is worsened when inexpensive, high-calorie, palatable foods (i.e., junk foods) are available, and offering large portions of these foods has been correlated with greater consumption compared with offering smaller portions.52

The AAP offers guidance on toddler feeding and emphasizes the arroyo of "the parent provides, the child decides."53 In most instances, when a parent provides good for you foods at repast and snack times, the kid is able to appropriately cull how much and which foods to eat.53

This article updates a previous article on this topic by Allen and Myers.54

Data Sources: PubMed, Cochrane Database of Systematic Reviews, and Essential Evidence Plus were searched using terms such every bit toddler nutrition, preschool nutrition, and babyhood feeding. The search included randomized controlled trials, meta-analyses, clinical trials, and clinical reviews. Search dates: April and June 2017, and February 2018.

The authors presume full responsibility for the ideas and opinions expressed in this article, which should not be considered the opinions of the U.S. Air Forcefulness or the Department of Defence.

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The Authors

evidence all author info

LYRAD Yard. RILEY, MD, MPH, is a faculty physician at the St. Mary's Family unit Medicine Residency Programme, Grand Junction, Colo. When this article was written, Dr. Riley was a faculty physician at the Eglin Air Strength Base of operations Family Medicine Residency Program, Eglin Air Force Base of operations, Fla....

JEDDA RUPERT, MD, is a staff doctor at the Nellis Air Force Base Family Medicine Residency Program, Nellis Air Force Base, Nev.

OLIVIA BOUCHER, Md, is a third-twelvemonth resident at the Eglin Air Force Base of operations Family unit Medicine Residency Plan.

Address correspondence to Lyrad K. Riley, Physician, MPH, St. Mary's Family Medicine Residency Program, 2698 Patterson Rd., Grand Junction, CO 81506 (eastward-mail service: lyrad.riley@sclhs.net). Reprints are not bachelor from the authors.

Writer disclosure: No relevant financial affiliations.

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