1. Chapter 3: Normal Nutrition for Toddler through School Aged Children and the Role of Parents in Promoting Healthy Nutrition in Early Childhood Jennifer Sabo, RD, LDN, CNSD Barbara Robinson, MPH, RD, CNSD

2. Reader Objectives Understand the different nutritional factors that may affect growth and development in a toddler. Understand the use of vitamins and minerals in a toddler and how to provide them naturally. Identify the differences in portion sizes that are appropriate for toddlers verses adults.

3. Reader Objectives, cont. Understand the importance of “meal time” with toddlers. Identify reasons for excess weight gain in toddlers and how this can be prevented. Use the information obtained in the chapter to assess three problem toddlers and determine the solution.

4. Growth Expectations Age (in years) Average daily growth 1-310 gm/day 4-65-8 gm/day 7-105-12 gm/day

5. Growth Expectations, cont. Growth is measured and plotted on standard Center for Disease Control (CDC) growth charts based on age and sex. Head circumference and weight for height is measured and plotted until 36 months of age.

6. Growth Expectations, cont. Growth rates may vary considerably for each individual child. This is thought to be associated with a variety of factors, including parents’ growth history and patterns. It is essential for clinicians to note that approximately 25% of normal infants and toddlers in the first 2 years of life will drop to a lower growth percentile and subsequently remain on this new growth track.

7. Energy and Nutrient Needs Age (in years)Average monthly growth 1-30.7-1.1 cm/month 4-60.5-0.8 cm/month 7-100.4-0.6 cm/month

8. Energy and Nutrient Needs continued As a general rule, energy requirements are designed to promote an optimal rate of growth and adequate body composition. The overall energy requirements can be adjusted based on need for weight loss or gain, weight maintenance, or catch-up growth.

9. Protein Requirements Age (in years)Protein DRIs 1-313 gm/day 4-819 gm/day 9-1334 gm/day

10. Protein Requirements continued As a child grows and develops, protein is a crucial nutrient needed to provide optimal growth. Current recommendations state that protein intake should comprise approximately 10-20% of the child’s daily intake. This recommendation is designed to ensure that enough energy is provided to the body from all nutrients so that protein is spared for growth and development of tissues.

11. Fat Requirements Until age 3, dietary fat plays a large role in brain development. Fat comprises approximately sixty percent of the central and peripheral nervous system that essentially control, regulate, and integrate every body system, thus it is essential that growing toddlers obtain adequate fat from their diet. Fat content of the diet is known to be the crucial element in providing satiety. Therefore, low fat meals or snacks for children can lead to hunger and subsequent overeating between meals.

12. Fat Requirements, cont. After infancy, most children are able to meet their daily calorie and nutrient requirements for growth with a diet consisting of 30% of total calories from fat. If excess weight gain is a concern, often only minor changes in dietary choices are needed to help keep fat intake at or below 30% of daily calories to promote optimal growth

13. Vitamins and Minerals Calcium-the principal mineral required by the body for the process of bone mineralization. Toddlers and young children have an increased need for calcium in order to promote the rapid bone growth and skeletal development that takes place during these early years of life. Vitamin D-available to humans through the photochemical action of sunlight or UV light on 7-dehydrocholesterol in skin, and through dietary sources such as fish oils, fatty fish, as well as foods fortified with vitamin D including cow’s milk and infant or supplemental formulas.

14. Vitamins and Minerals continued Iron-requirements for iron intake are based on age and iron stores. During periods of rapid growth, the body’s need for iron increases. Iron can be classified as being derived from heme or non-heme sources. Heme sources include animal meats and products, such as beef and chicken, while non-heme sources include fortified grains, fruits, and vegetables. Fluoride-has been demonstrated to promote tooth formation and also inhibit the progression of dental caries. Children who begin to use fluoride toothpaste before age 2 are at higher risk for enamel fluorosis.

15. Foods at One Year Toddlers often eat 6 small meals each day, verses 3 larger meals. Suggested toddler serving sizes = ¼ to ½ that of adults. Some examples would be: grains (bread- ¼ to ½ slice, cereal/rice/pasta,cooked-4 tablespoons, dry cereal,- ¼ cup); cooked vegetables (1 tablespoon per year of age); fruit (cooked or canned- ¼ cup, fresh- ½ piece, 100% juice- ¼ to ½ cup); dairy (milk- ½ cup, cheese- ½ ounce, yogurt-1/3 cup); protein (chicken, turkey, beef, fish-1 ounce, ground meat-2 tablespoons).

16. Unsafe Finger Foods Foods that may promote choking: hot dog slices carrot rings whole grapes nuts popcorn hard candies large beans

17. Mealtime with Toddlers As toddlers continue to advance their feeding skills, it is crucial to provide a healthy feeding and eating environment. Structure at meals can have a significant influence on a child’s eating patterns. Suggestions to provide such a structured environment include the complete absence of television and other distractions. Introduce one food at a time in order to avoid confusion or overwhelming the child.

18. Other Food Issues Picky Eating- can be common in toddlers, and may continue throughout childhood. Grazing- may produce a constant feeling of fullness and cause the child to never eat an appropriate amount at meal, therefore not expanding the stomach size. Snacks-Toddlers and children have a comparatively small stomach size and cannot consume large amounts at meals, therefore snacks are able to provide needed servings of healthy foods.

19. Health Issues Failure to Thrive-is defined by inadequate physical growth diagnosed by observation of growth over time using a standard growth chart. This failure to maintain adequate growth can be caused by a multitude of factors (organic: inability to meet calorie needs due to medical conditions, malabsorption, increased metabolism with specific disease states, or inorganic: food shortage, incorrect mixing of formula, or neglect).

20. Health Issues continued Lactose Intolerance-stomach pain, flatulence, and loose stools in association with milk/products. Dental Health-introducing a toothbrush during the toddler years can initiate a good oral hygiene routine that continues through life.

21. Role of Parents in Promoting Healthy Nutrition in Early Childhood Parents are a child’s first teachers: modeling and self-regulation coercion and disordered eating Eating is a learned behavior of flavor and food preferences. Infants who gained weight rapidly by 4 months of age tended to be heavier in later childhood.

22. Best Practices Establishing a feeding routine Promote appropriate for age dietary variety Pleasant mealtimes Limit competing foods