January 2008
Nutrition
for Tots — Raising Healthy Eaters Through Balance and
Variety
By Sharon Palmer, RD
Today’s Dietitian
Vol. 10 No. 1 P. 32
Toddlers drinking soda and going gaga for
French fries—what’s wrong with this picture?
Children’s diets have become a nutritional nightmare.
But dietitians can intervene during the precious wonder years
and help shape lasting, healthy food habits.
Amid all the hoopla surrounding America’s
obese kids, the nutritional significance of the toddler years
seems to have been left behind. Yet, pediatric health experts
express concern that these years may be the most crucial when
it comes to encouraging healthy eating behaviors.
“The toddler years are formative and really
important. The first two years of life is when we can have the
most impact. It’s the time to reach parents,” says
Eileen Behan, RD, who works in family practice and authored
the upcoming Baby Food Bible: Complete Guide to
Feeding Your Children, From Infancy On.
As children journey from a milk-fed infancy
to an independent, omnivorous diet, it is important to ensure
that they are eating to adequately support growth and development,
as well as set up good eating behaviors for the future to prevent
obesity and its related mayhem. During this time, toddlers (frequently
defined as children aged 1 to 3) stake their independence by
developing self-feeding skills and increasing control over their
food choices. This period also sees children add to their repertoire
improved motor skills, awareness of table behavior, and increased
appreciation for tastes and food preferences to go along with
their increased energy and nutrient requirements.
But despite toddlers’ newfound independence,
feeding is still a source of parent-child attachment and reassurance.
Developing food preferences and eating patterns in childhood
is complex, involving issues such as parental modeling, food
availability, peer behavior, and rewards for food intake.1,2
Rating Toddlers’
Diets
What fills toddlers’ tummies today? Thanks to the landmark
2002 Feeding Infants and Toddlers Study (FITS), a collaboration
between researchers, statisticians, and the food industry that
included a national random sample of 3,022 infants and toddlers
with two days of dietary recall, we can better understand just
what toddlers are eating. Surprise, surprise—it’s
not enough of the good stuff. FITS found that 18% to 33% of
toddlers consumed no discrete servings of fruits or vegetables
on a given day. Instead, French fries, doughnuts, soda, and
candy were the standard fare.1-4
“In every age group, people are not getting
enough fruits and vegetables. The whole balance is off,”
says Elizabeth Ward, MS, RD, nutrition consultant and author
of The Complete Idiot’s Guide to Feeding Your
Baby and Toddler.
Young children appear to rely on a narrow arsenal
of foods. FITS discovered that during early childhood, only
10 foods provided 60% of the calories consumed. Milk and/or
formula provided 24% of energy during the toddler years, while
fruit-flavored drinks and juices provided an additional 11%
of energy, making them the second and third most significant
sources of energy for toddlers. Other foods that topped the
list for energy intake among toddlers were cheese, breads, poultry,
added fats, cereals, cookies, and processed meats. Only two
fruits and vegetables—bananas and white potatoes—were
among the top 25 sources of energy in young children’s
diets.2
Toddlers are typically fed a diet packed with
low–nutrient-density choices. Food items high in added
fats and sugars, including sweetened beverages and cereals,
butter/margarine, cookies, processed meats, and cakes/pies,
provided approximately 19% of the total energy in the diets
of toddlers, according to FITS. By the age of 2, more than 11%
of children were drinking carbonated sodas. For an afternoon
snack, 17% of toddlers consumed cookies, 13% consumed chips,
and 11% consumed candy. Sweetened fruit drinks were popular
beverage choices, with 14% of toddlers drinking them compared
with 15% who consumed whole milk.2
The portion size and frequency of toddlers’
eating sessions seem to be increasing as well. FITS indicated
that the average portions of milk, cereal, breads, fruits, and
vegetables were consistently larger than Child and Adult Care
Food Program (CACFP)-recommended portion sizes, and the per-eating-occasion
portion sizes of 50% to 90% of the infants and toddlers exceeded
the CACFP portion sizes.5 “People need to pay attention
to portion sizes. Most of us suffer from portion distortion.
Parents can educate themselves with the MyPyramid, which can
be used to build a healthy diet for everyone over the age of
2,” says Ward.
The FITS evaluation by age, ethnicity, and eating
occasion also noted that infants and toddlers were fed, on average,
seven times per day, and food frequently consumed at both meals
and snacks tended to be low in whole grains, vegetables, and
fruits.3 “Parents are fearful that their kids will get
hungry, which is why I think so many moms tote snacks with them.
But grazing all day may mean children are not interested in
meals, frustrating their parents to no end. It’s OK for
a child to feel hunger. Children need to be in touch with their
hunger and satiety so that they can regulate their food intake,”
says Ward, who encourages parents to consider snacks as mini-meals
with nutrient-dense foods such as 100% orange juice and whole
wheat crackers rather than highly refined processed foods such
as Goldfish crackers and a Capri Sun.
Mealtime locations for toddlers can also make
a difference, according to FITS findings. Lunches eaten at a
day care facility were significantly higher in calcium, phosphorus,
magnesium, vitamin D, potassium, and riboflavin compared with
those eaten at home or away. Trans fat intake was significantly
lower for lunches eaten at home compared with away from home.
For lunches eaten at away-from-home locations, the most frequently
consumed item was French fries (35% of toddlers). Carbonated
beverages were consumed at away-from-home lunches by 16% of
toddlers compared with 3% at home and none at day care.6
The FITS data highlight the possibility that
many toddlers’ diets may be inadequate in some vitamins
and minerals, yet high in added fats and sugars. “Every
time you feed something to a child, it’s an opportunity
for good nutrition,” says Ward, who uses the 90/10 rule:
90% of what they eat should be what is good for them and the
other 10% is for fun.1
Vulnerable Nutrient
Intakes for Toddlers
Pediatric experts are concerned about some specific shortfalls
in nutrients among toddlers. Iron is of particular concern because
deficiency can result in cognitive and motor deficiencies that
may not be reversible. Ward reports that she finds iron intake
is often overlooked in small children, noting that adequate
iron promotes peak cognition in kids. According to the National
Health and Nutrition Examination Survey III, 7% of children
under the age of 3 were iron deficient, and one third of these
were also anemic. Toddlers should have 7 milligrams of iron
each day.1
Vitamin D intake in toddlers is also an issue.
Young children who consume less than 2 cups of fortified cow’s
milk and do not get regular sunlight exposure should receive
a daily supplement with 200 international units of vitamin D,
according to the American Academy of Pediatrics (AAP).4 “Calcium
in toddlers is one of the biggest concerns for me,” adds
Kelly Vieira, MS, RD, CSP, clinical nutritionist at Children’s
Healthcare of Atlanta and public relations chair of the Pediatric
Nutrition Practice Group of the American Dietetic Association
(ADA). Toddlers should have 500 milligrams of calcium per day,
which is easily met if children get two servings of dairy foods
every day.4
Essential fatty acid intake in young children
is a growing worry. As children move from breast milk and formula
to cow’s milk, the amount of essential fatty acids—linoleic
acid and alpha-linolenic acid—is decreased. Cow’s
milk, especially skim and lower-fat milk, have very low levels
of these fatty acids. Surveys indicate low linoleic acid intakes
in toddlers who are fed cow’s milk. There is also a rising
interest in the intake of the long-chain polyunsaturated products
of these fatty acids, arachidonic acid (AHA) and docosahexaenoic
acids (DHA), in early childhood.1,4 “There is evidence
that DHA is very important in the first two years of life,”
notes Ward. Fat and cholesterol restriction should be avoided
in children younger than the age of 2. After this, fat should
account for 30% of total daily calories, with an emphasis on
polyunsaturated fats.1,4
Toddlers’ diets can also be low in fiber,
although some experts argue that the average recommendation
for fiber for children aged 1 to 3 may be difficult for most
to achieve. Since dietary fiber may play a role in reducing
the chances of heart disease and cancer later in life, it is
important to emphasize fruits, vegetables, whole grains, and
legumes in the diet, along with plenty of water to accompany
a higher fiber intake.1
Some parents are making up for uncertain diets
by pushing multivitamin/mineral supplements on their toddlers.
A reported 31% of toddlers use dietary supplements. Nutrient
supplements were the most significant source of vitamin E and
niacin in the diets of young children; the second highest source
of folate, thiamin, riboflavin, iron, and vitamins D and B12;
and the third highest source of vitamin C.7
“I think parents are more concerned about
issues like omega-3 fatty acids and flaxseed oil supplements.
I think parents are looking for other means of nutrition for
their children, [so] they run to supplements,” says Vieira.
Although vitamin D, calcium, and iron should be supplemented
in select toddlers, the routine use of multivitamins is not
considered necessary, according to the AAP. Supplements may
be appropriate for children at high risk of nutritional deficiencies.4
A Gold Star for
Good Eating Behavior
As any parent will tell you, toddlers aren’t always easy-to-please
little diners. They can be picky, unpredictable, and stormy
and get hungry at any time. Toddlers don’t come programmed
with an innate sense of what is “healthy,” and they
are prone to food jags, when they repeatedly demand the same
food.
So what’s a parent to do? Good nutritional
habits can be nurtured by encouraging toddlers to sit at the
table, turn off the television, and interact with others. Kids
can learn acceptable dining behavior, such as eating broccoli
before brownies and not tossing salad across the table. “Parents
are not willing to deal with picky toddlers’ eating; they
are not willing to deal with the problem, sit down with their
children, and turn off the TV. Kids are not eating vegetables,
and parents aren’t willing to deal with it,” says
Vieira.
“The public is concerned about picky eating,
and it’s true—children are picky eaters. But it’s
not to say we can’t influence them by getting into the
habit of offering fruits and vegetables at each meal. Research
shows if they experience it, they will eat it,” says Behan.
Parents should offer children a variety of foods and repeatedly
expose them to healthy foods at mealtime and snack time. Toddlers
will likely accept new foods after repeated exposure (at least
10 times).
Parents who are patient and foster independence
at the dining table may be rewarded with children who like to
eat. And parents who model healthy eating behavior by eating
the same foods they’d like their toddlers to eat may find
ultimate success. “Setting a good example early in life
so that children can pick up on your positive cues about eating
and regular physical activity is really important to their well-being
in the long run,” says Ward.
It’s also crucial for parents to remember
that toddlers often balance out their nutrient and calorie intake
over several days, and physicians monitor for normal growth
patterns. The key is for toddlers to eat balanced meals with
a variety of healthy foods from at least three of the four food
groups, with at least two of the four food groups for snacks.
“Toddlers need to learn to eat a variety
of foods, starting very early. If parents give in, they wind
up with a school-aged child [who] is very limited, and it’s
hard to eat out. Always have vegetables and fruits at the meal
and just encourage one or two bites,” says Vieira.1,4
Obesity in the
Making
“One of the biggest nutritional concerns for American
toddlers is the high rate of obesity in the 2- to 5-year-old
group. It is increasing at a rapid pace. In decades in the past,
you wouldn’t see that. Obesity is reaching down into the
toddler years. This is a relatively new trend,” reports
Ward.
It’s not a secret that the number of overweight
children has risen dramatically since the 1970s, becoming a
key talking point for many health organizations. But some may
find it surprising that even toddlers are included in these
alarming statistics. Among children aged 2 to 5, approximately
20% are overweight or at risk of being overweight. Obesity in
toddlers has not yet been proven as a direct risk factor of
obesity and its related conditions later in life, but overweight
toddlers may indeed grow into overweight school-aged children
who share the inherent risks of developing obesity-related issues.8
The pediatric obesity trend coincides with a
shift in food culture, including a decline in the consumption
of milk, vegetables, grains, and eggs, along with an increase
in the consumption of fruit juices, sweetened beverages, poultry,
and cheese. While the percentage of total fat and saturated
fat calories actually decreased, the total fat intake remained
constant because of a sheer increase in calories. Some studies
demonstrate a “substitution effect” of exchanging
milk for sweetened beverages, which can contribute to excessive
weight, poor intake, and dental caries. Parents should be encouraged
to meet the recommendations for two or three servings of milk
each day and offer plain water when their child is thirsty.
Juice should be limited to 4 to 6 ounces daily of 100% fruit
juice with no added sugars, with more emphasis on whole fruits
and vegetables.4
“It’s never too early to start promoting
healthy weight with children. To start, parents should examine
their own relationship with food because it may influence how
much they try to feed an infant or how much they think their
toddler should eat, for example,” says Ward.
The AAP recommends that physicians monitor growth
patterns and body mass index and make recommendations for healthy
eating and physical activity. It is important to balance the
fear of obesity and the concern about potential undernutrition
for toddlers. Obesity prevention in children is a challenge,
as parents must focus on providing a healthy diet without excessive
parental restriction, concern, or control.4
Nutritional Concerns
at Large
Along with the rigors of balancing nutrient intake for toddlers
comes a whole batch of new age nutritional issues that are causing
today’s parents gray hairs. One is the confusion about
appropriate foods for the toddler-aged group. “Parents
sometimes take an adult health message and apply it to toddlers,”
says Behan, who offers low-fat and low-calorie foods and sports
drinks as an example of foods often inappropriately offered
to toddlers.
Parents are also being sold on a growing number
of health claims found on food labels, as they are increasingly
on the lookout for better ways to nourish their children. “It’s
difficult to figure out the good from bad food with food labels
not being nutritionally clear. I tell people to be suspicious
and to look for real food that doesn’t need to make nutrition
claims to sell it,” says Behan. It doesn’t help
that people are on information overload when it comes to nutrition
and parenting. “Parents are overwhelmed with information
from the Internet. They don’t know what to believe anymore,”
says Behan, who reports that gluten-free foods and high fructose
corn syrup are on parents’ radar these days.
And, of course, who can forget one of today’s
biggest stumbling blocks when it comes to young children’s
diets: food allergies. An estimated one out of 25 children has
food allergies. Most childhood food allergies can be traced
back to five common foods: milk, eggs, peanuts, wheat, and soy.
Shellfish, citrus fruits, and strawberries are also common causes
of food allergy. A food allergy can further complicate delivering
a balanced nutritious diet to young children.1 “Food allergies
in toddlers is huge; it’s overwhelming. It’s not
always an immune response to food, but it can be a vague intolerance,”
says Vieira.
Help Is on the
Way
It seems that dietitians are in the perfect position to pick
up the mantle and help lead America’s young children to
better nutrition, if only they have a chance. “Dietitians
don’t get involved with this age group,” says Behan,
who would like to see dietitians working with parents at the
pediatrician’s level. “As a practicing dietitian,
we see 6-year-olds, but we don’t see toddlers. We need
to see them much sooner as the family forms food habits and
traditions.”
FITS data suggest there are plenty of ways for
healthcare professionals to intervene and improve the nutritional
status of young children. Key points in nutrition education
for expectant or new parents include the following:
• Encourage women to consume a variety
of foods during pregnancy, including fruits, vegetables, and
whole grains, not only to provide adequate nutrients for fetal
development but also to maximize fetal exposure to flavors of
a variety of nutritious foods and beverages.
• Promote breast-feeding to foster early
infancy exposure to a variety of food flavors.
• Teach parents and caregivers of young
children how to recognize the developmental milestones that
signal the appropriate time to introduce complementary foods
into the diets of infants and the appropriate order of complementary
food introduction.
• Emphasize the importance of repeated
exposures to novel foods and the need for diversity in the diets
of infants and toddlers.
• Encourage caregivers to purchase and
serve lower-fat and lower-sugar food selections to promote preferences
for more nutrient-dense foods and beverages.2
The Start Healthy Stay Healthy Feeding Guidelines
(www.eatright.org/ada/files/toddler.pdf) sponsored by the ADA
and Gerber Products Company offer parents and caregivers practical
information about feeding infants and toddlers that goes beyond
expert statements from authoritative bodies. And many dietitians
have taken matters into their own hands by publishing children’s
nutrition books offering practical tips for making the most
of nutrition during the toddler years.
With today’s landscape of numerous food
choices and nutrition-related diseases, it seems that dietitians
will have their work cut out for them in helping to cultivate
healthy toddler eating patterns.
— Sharon Palmer, RD, is a contributing
editor at Today’s Dietitian and a freelance
food and nutrition writer in southern California.
Toddler Nutrition
Sources
American Academy of Family Physicians:
www.aafp.org
American Medical Association:
www.ama-assn.org
Mayo Foundation:
www.mayo.edu
National Institute of Child Health & Human
Development:
www.nichd.nih.gov
Nemours Foundation:
www.nemours.org
Pediatric Nutrition Practice Group of the American
Dietetic Association:
www.pediatricnutrition.org
Women, Infants, and Children:
www.fns.usda.gov/wic
References
1. Butte N, Cobb K, Dwyer J, et al. The start healthy feeding
guidelines for infants and toddlers. J Am Diet Assoc.
2004;104(3,):442-454.
2. Ziegler P, Briefel R, Ponza M, et al. Nutrient
intakes and food patterns of toddlers’ lunches and snacks:
Influence of location. J Am Diet Assoc.
2006;106(1 Suppl):S124-S134.
3. Fox MK, Reidy K, Karwe V, et al. Average
portions of foods commonly eaten by infants and toddlers in
the United States. J Am Diet Assoc.
2006;106(1 Suppl):S66-S76.
4. Monsen E. New findings from the Feeding Infants
and Toddlers Study. J Am Diet Assoc.
2006;106(1):5-6.
5. Centers for Disease Control and Prevention.
Prevalence of overweight among US children and adolescents:
United States, 1992-2002. Reviewed January 11, 2007. Available
here.
6. Briefel R, Hanson C, Fox MK, et al. Feeding
Infants and Toddlers Study: Do vitamin and mineral supplements
contribute to nutrient adequacy or excess among US infants and
toddlers? J Am Diet Assoc. 2006;106(1
Suppl):S52-65.
7. Stang J. Improving the eating patterns of
infants and toddlers. J Am Diet Assoc.
2006;106(Suppl1):7-9.
8. Allen R, Myers AL. Nutrition in toddlers.
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