title sub title Toddler Nutrition

EXPERT MONOGRAPH ISSUE 38

Introduction

General practitioners are often the first port of call for parents concerned about their child’s nutrition and food intake. Parents often seek reassurance or referral; it can be challenging to assess what is normal and what

warrants further investigation.

The toddler years are a time of rapid learning, development and exploration. Children are developing a sense of independence which can be both rewarding and frustrating for their parents.

After the first year of life, growth slows down significantly. Concomitantly, appetite may also slow which can lead to erratic food intake, as less energy is required for growth.

Assessing Toddler Nutrition

Growth:

The best way to assess if a child is eating enough (in terms of total energy/quantity of food) is to check they are growing.

Take Home Messages

` Growth is the best way to assess toddler nutrition

` For toddlers it is common to reject new foods, but repeated exposure will improve familiarity and the chance of acceptance

` The variety of foods a child eats is more important than the amount eaten in ensuring adequate nutrition

` Force-feeding and conflict at mealtimes is counter-productive to promoting better eating habits in toddlers

` In toddlers, avoid using dessert or sweets as bribes and avoid over-consumption of milk

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KATIE MARKS B. Sc. (Nutr) (Hons), USyd

Katie is a paediatric dietitian working in gastroenterology, hepatology and nephrology. She has special interests in nutrition and assessment methods for patients undergoing liver transplant and in promoting a healthy lifestyle in patients and families post renal transplant. Katie has two children and has had first-hand experience with food allergies, feeding difficulties in infancy and managing toddler mealtimes!

This article provides a framework for assessing a child’s nutrition and intake, identifying if there are problems and practical strategies to help manage these.

FEBRUARY 13, 2019

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Hormonal Contraception Trouble-shooting Part One: The Overweight Woman

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Growth measurement needs to be accurate to make an informed assessment. Growth needs to be plotted on growth charts, with serial measures to assess growth velocity.1 A single measure indicates a child’s size at that time, but not their growth pattern, and rarely gives sufficient information to inform decision-making.2

Children less than two years: plot weight, length (supine) and head circumference on WHO charts2 (recommended from 20123). The child needs to be weighed bare between 0-12 months, and from then on in light clothing. Adjust for prematurity (85th centile is classified as overweight, >95th centile is classed as obese

If these issues are identified, patients can be referred to a dietitian to assess their intake both quantitatively and qualitatively. Additional investigations of abnormal growth may also be warranted. If

the growth issue is due to intake, a dietitian can also deliver individualised dietary advice tailored to the patient and their family.

Intake:

Parents of toddlers are often concerned about how much their child is eating. Young children’s appetites fluctuate from meal to meal and day to day. It can be easy for parents to focus on the ‘bad’ days instead of their child’s average intake over time. Studies have shown toddlers regulate energy intake very well when they are provided with regular meals and snacks and allowed to eat as much or as little as they like without pressure or restriction.7,8

A sufficient quantity of food, or total energy intake, can be assessed via serial growth measures. However, the quantity of food is not solely important in assessing a toddler’s nutrition. Quality is also vital during these years of rapid growth and development, and toddlers have unique nutrition requirements. For example, a toddler has the same iron requirements as a teenage boy (RDI for 7-12 months = 11mg, RDI for 14-18-year-old boy = 11mg9) which means they have high requirements per kilogram of body weight and need to be eating nutrient-dense, not just energy-dense foods.

The following is taken from the Australian Guide to Healthy Eating for toddlers aged 13-23 months.10 Remember, children will not eat all of this every day – some days they will eat more, and others, less. This can be useful for GPs as a rough checklist in assessing the amount and type of food toddlers eat in a typical day.

Toddlers are developing their eating skills. Usually, eating starts out as ‘practice’ – it can take a typically developing child two years to learn how to eat.11 Children become more independent in feeding themselves over time, with practice. Feeding can be very messy and inefficient (parents may need reassurance about this). It is normal for children to throw, squash and play with their food.12 They explore food and experiment with it in a similar way to exploring a toy, until the food becomes familiar and they are accustomed to eating it. Both mess and efficiency improve with time and consistent practice, and self-feeding can bring both the toddler and parents satisfaction in developing their independence.

Fussy Eating: A Common Challenge in the Toddler Years

Many parents are quick to label their child a ‘fussy eater’. To an extent, unpredictable eating patterns are normal in the toddler years. Choosing and refusing food is one way that children develop their independence.

Food neophobia is generally regarded as the reluctance to eat, or the avoidance of new foods.13 It is normal to reject new foods. It can take multiple exposures to a food (perhaps involving throwing, squashing, licking or mouthing the food, not actually eating it) before it becomes familiar and therefore accepted.12 Parents need

Toddler Nutrition

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to continue to offer foods their child refuses, and should not feel discouraged if their child does not eat a particular food. Studies have shown repeated exposure to foods in a positive context will encourage children to accept new foods.14,15

The variety of foods a child eats is more important than

the amount eaten in ensuring adequate nutrition

In contrast, fussy eaters are usually defined as children who consume an inadequate variety of foods through rejection of a substantial amount of foods that are familiar (as well as unfamiliar) to them.13

Toddlers are very busy little people, and often have better things to do than eat. Sometimes they are genuinely not hungry, they may be too tired to eat, or they may just not want the hassle of eating, especially if parents pressure them at mealtimes.

When assessing a toddler’s intake, concentrate on types of foods rather than how much is eaten. If all the food groups are represented in the child’s diet and they are growing well, then this child is not likely to be a ‘fussy eater’. Many parents are concerned that their child won’t eat certain vegetables or fruits, but if there is a range offered and accepted, this means they are not a fussy eater.

The division of responsibility, discussed by Ellyn Satter,12 gives a simple yet effective message for parents when discussing toddler eating habits. This can help to give parents realistic expectations and priorities.

Parents are responsible for WHAT, WHEN and WHERE the children eat. The toddler can decide HOW MUCH or IF they eat at all.

Remember, toddlers are very good at regulating what they eat over a period of a few days or weeks. If they have one small meal, or one ‘bad day’, they will usually make up for it later.8

Common Contributors to Fussy Eating, and Positive Strategies to Overcome Them

Contributor: force feeding – this is very unpleasant, the child will resist being fed in this way and can start to dread mealtimes. Food becomes associated with anxiety and children can develop oral aversions as a result.

Positive strategy: allow the child to self-feed at their own pace and help if they ask for it. Children who are allowed to regulate their own intake tend to do so very well.12,16

Contributor: pressuring the child to eat – studies have shown that pressuring children to eat results in lower BMI centiles17 and them consuming less than their peers.12,16 Children who are not pressured eat significantly more food.18

Positive strategy: keep mealtimes neutral, happy and relaxed14: the dinner table should not be a battleground! Talk as a family about things that happened during the day, rather than focusing on whether a child is or isn’t eating.

Contributor: asking the child what they want to eat or giving too much choice – open-ended questions like ‘what do you want to eat?’ can backfire with toddlers! (What if they ask for chocolate at every meal?) Too much choice can also be confusing and overwhelming.

Positive strategy: give a choice between two different, yet equal things, for example ‘would you like some apple or banana

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Toddler Nutrition

Food/group Serve size Serves per day Amount

Vegetables & legumes 75g 2-3 1-1 ½ cups

Fruit 150g ½ ½ a piece of fruit

Grain foods 40g 42 pieces of bread AND 2 x ½ cup serves rice/pasta/cereal

Lean meat, chicken, fish, eggs 65g 1 Approx. 2 x child’s palm size OR 1 egg

Milk, yoghurt, cheese 250g 1-1½ 1-1.5 metric cups milk OR 1.5 matchbox-sized pieces cheese OR 300g (1.5 tubs) yoghurt

Fats & oils 10g 1 2 teaspoons oil/margarine

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for morning tea?’. The toddler still has some say in what they are having (so feel like they have some independence) but the parent is still in control of WHAT is on offer.

Contributor: offering many alternative foods or preparing a special/separate meal if the child doesn’t eat – this shows the child they are in control of the mealtime, and not the parent. Children learn quickly that if they ‘hold out’ and refuse nutritious foods, they will get something they want later on. For example, many parents say things like ‘He won’t eat anything at dinner, but I know he’s hungry, so I give him some hot chips just so he eats something’. What child do you know who wouldn’t love hot chips for dinner instead of having to chew through some veggies and meat?

Positive strategy: offer one meal for everyone in the family. If the toddler refuses the meal, allow them to sit at the table until the meal is finished, cover their food and then offer it to them again if they say they are hungry later. This shows them that parents are in control of WHAT they eat. They still decide IF and HOW MUCH they eat.

For toddlers it is common to reject new foods, but repeated

exposure will improve familiarity and the chance of acceptance

Contributor: parents showing displeasure when eating – children copy what they see. Parents and siblings are the best role models for how children will learn to eat and develop their relationship with food.

Positive strategy: encourage parents to model the eating behaviour they would like to see in their child. Conversation should be kept neutral and about something apart from food. The more attention that is paid to food, the more children will start to manipulate the mealtime environment. Toddlers can be exposed to what the rest of the family eats – even if the family use spices or strong flavours. It should not be assumed that a child will not like a food. Studies have shown children exposed to new foods will accept more readily if the adult in the room is eating the same food.19 The texture may need some adaptation (they may need a piece of meat cut up into smaller, more manageable strips).

Eating family meals allows children to watch and learn from those around them. This also helps to develop their enjoyment of food and the social aspects of mealtimes.16,19

Contributor: using dessert and sweets as bribes – this sets up a discrepancy between the ‘value’ of foods, for example ‘if you eat your

vegetables, you can have some ice cream’, indicates that vegetables are an undesirable food, but ice cream is a desirable food.

Positive strategy: within reason, children can be given a small portion of nutritious ‘dessert’ regardless of how much of the main meal they eat.12 Examples may include yoghurt or custard with some fruit (tinned fruit, chopped banana, a small handful of berries). This is demonstrating that the foods have equal value, rather than one being a chore before being ‘rewarded’ with the other.

Contributor: grazing/eating all day – to an extent, grazing is normal as toddlers have small appetites and need to eat frequently. However, if they are allowed to snack constantly through the day, they are not really learning to feel properly hungry or full.

Contributor: free access to foods (and drinks) between meals – where the child has access to the fridge/pantry freely, it is likely they will select less nutritious options if they are available. This also does not allow a mealtime structure through the day and can also contribute to a grazing style eating pattern.

Positive strategy: offer meals and snacks at regular intervals through the day. The parent decides WHAT foods are offered.12,19,20 Aim to encourage intake from all the core food groups (including a variety of foods, textures and tastes) across the day. To maximise nutrient intake, processed and packaged foods should be limited. Have some times where food is available and food is not. This allows children to build up hunger and develop an appetite, and sets boundaries around WHEN they are eating.

Contributor: too much attention to the child and their eating – toddlers desire adult attention, whether it is positive or negative. If they are paid attention when they don’t eat, this can give positive reinforcement to their behaviour.

Positive strategy: pay the child attention for other positive behaviours, for example ‘you did a great job setting the table’ or ‘thank you for putting your plate away’. Telling a child they are ‘good’ for eating something or ‘bad’ for not eating can create a feeling of pressure, and again food/eating should be treated as neutrally as possible to avoid it becoming an issue.

Growth is the best way to assess toddler nutrition

Contributor: technology being used as a distraction, or having the TV on during meal times – children will not be focused on what they are eating and will either under- or over-eat.

Positive strategy: families should aim to have at least one meal per day together at the table without any devices being used this includes Mum and Dad on their phones!) Research shows that eating together is protective against many issues including obesity, eating disorders and builds kids’ confidence and family

Toddler Nutrition

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relationships. They are also learning about the social aspects of mealtimes.16,21,22

Contributor: child wandering around when eating, or parents chasing them with food – the child is not focused on the meal, they will likely get distracted, and being chased very soon becomes a game!

Positive strategy: toddler should be secured in high chair or booster seat where possible. Meals should be approx. 30 minutes long (this is when children eat the most food – any longer can be counter-productive as they can lose interest).23 If the child leaves the table, their meal should be put away so that they learn to sit at the table while eating, and to play after their meal. It can help to have a routine around mealtimes to signal the start and finish of a meal, for example wash hands before the meal, clean hands and face and pack away plates after the meal.

Contributor: overdoing milk – to meet calcium requirements,9 toddlers need only 400ml of milk per day (provided they are relying solely on milk for calcium, and not consuming other dairy products).10 Milk is easy to drink, comforting and can fill up small stomachs which displaces other nutrient-dense foods (it is common to see iron deficiency in children who are drinking excessive milk).

Positive strategy: water needs to be the main drink at mealtimes. Milk can be offered after or in between meals. Full cream milk is recommended up to two years of age. If the child is growing well, they can have reduced fat milk from two years of age.10

As a general rule, toddlers eat when they are hungry as long as a variety of nutritious food is offered at routine times.12 The above strategies apply to children who are growing well. Families of children who have poor growth should be referred to a dietitian for individual advice which may also include some of the below strategies.

When is fussy eating a problem? When should a child

be referred on?

` Change in growth rate or crossing centiles

` Avoiding entire food groups

` Restricting textures, avoiding certain textures or being ‘stuck’

on a texture (for example puree only)

` Poor oro-motor skills

` Less than 20 foods accepted

` Won’t re-introduce food after burnout

` stress/anxiety with new foods

` Oral aversions

Which groups are ‘at risk’?

Eating problems are more common with:

` Prematurity/small for dates

` Developmental (motor/language) delays

` Early feeding problems (including nasogastric feeding)

` History of frequent vomiting/GORD

` Chronic illness

` Social/family stressors, for example depression, parental

anxiety, financial issues, chaotic family life

Referring on allows appropriate multidisciplinary support for

the family.

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Toddler Nutrition

Video Resources

Infant Nutrition – Full Lecture A/Prof John Sinn – 2016

Infant Nutition – Interview Dr Rupert Hinds - 2018

Watch the full lectures on the Healthed website. Visit www.healthed.com.au/video

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Dietitians, Speech Pathologists, Occupational Therapists, Social Workers and Psychologists can all be utilised as members of the child’s health care team. These professionals can dedicate adequate time to the complexities of feeding – the reality is that GP consultations may not be long enough to address all issues. Organisations such as Tresillian or Karitane can also provide support. Most tertiary hospitals have feeding clinics for the assessment and management of complex feeding issues.

Each profession has unique contributions to make, and can provide complementary care to maximise patient outcomes.

References

1. World Health Organization (Department of Nutrition for Health and Development). Training Course on Child Growth Assessment. Geneva: World Health Organisation; 2008. 105 p.

2. The Royal Children’s Hospital Melbourne [Internet]. Melbourne VIC: The Royal Children’s Hospital Melbourne. Child growth e-learning resource; 2013 [cited 2018 Oct 20]. Available from: https://www.rch.org.au/childgrowth/Child_growth_e-learning/

3. National Health and Medical Research Council. Infant Feeding Guidelines: Information for Healthcare Workers. Canberra ACT: National Health and Medical Research Council; 2012 Dec. 160 p.

4. Centers for Disease Control and Prevention [Internet]. Atlanta GA: Centers for Disease Control and Prevention. Clinical Growth Charts; 2000 Oct 16 [cited 2018 Oct 20]. Available from: https://www.cdc.gov/growthcharts/clinical_charts.htm

5. Tanner JM, Goldstein H, Whitehouse RH. Standards for Children’s Height at Ages 2-9 Years Allowing for Height of Parents. Arch Dis Child 1970 Dec; 45(244): 755-62. DOI: 10.1136/adc.45.244.755

6. Wright CM, Cheetham TD. The strengths and limitations of parental heights as a predictor of attained height. Arch Dis Child 1999 Sep; 81(3): 257–60. DOI: 10.1136/adc.81.3.257

7. Fox MK, Reidy K, Karwe V, Ziegler PJ. Average portions of foods commonly eaten by infants and toddlers in the United States. J Am Diet Assoc. 2006 Jan; 106(1 Suppl 1): S66-76. DOI: 10.1016/j.jada.2005.09.042

8. Birch LL, Johnson SL, Andresen G, Peters JC, Schulte MC. The variability of young children’s energy intake. N Engl J Med. 1991; 324: 232-5. DOI: 10.1056/NEJM199101243240405

9. National Health and Medical Research Council. Nutrient Reference Values for Australia and New Zealand [Internet]. Canberra ACT: National Health and Medical Research Council; 2006 [updated 2018 Aug 23; cited 2018 Oct 24]. Available from: https://www.nrv.gov.au/nutrients

10. National Health and Medical Research Council. Eat for Health: Recommended number of serves for children, adolescents and toddlers [Internet]. Canberra ACT: National Health and Medical Research Council; 2012. [updated 2015 Jul 27; cited 2018 Oct 24]. Available from: https://www.eatforhealth.gov.au/food-essentials/how-much-do-we-need-each-day/recommended-number-serves-children-adolescents-and

11. Birch LL, Doub AE. Learning to eat: birth to age 2 y. Am J Clin Nutr. 2014 Mar; 99(3): 723S-8S. DOI: 10.3945/ajcn.113.069047

12. Ellyn Satter Institute. Ellyn Satter Institute [Internet]. Wichita KS: Ellyn Satter Institute; 2018 [cited 2018 Oct 29]. Available from: http://ellynsatterinstitute.org/

13. Dovey TM, Staples PA, Gibson EL, Halford JC. Food neophobia and ‘picky/fussy’ eating in children: a review. Appetite. 2008 Mar-May; 50(2-3): 181-93. DOI: 10.1016/j.appet.2007.09.009

14. Sullivan SA, Birch LL. Pass the sugar, pass the salt: Experience dictates preference. Dev Psych 1990 Jul; 26(4): 546-51. DOI: 10.1037/0012-1649.26.4.546

15. Birch LL. Development of food acceptance patterns in the first years of life. Proc Nutr Soc. 1998 Nov; 57(4): 617-24. DOI: 10.1079/PNS19980090

16. Berge JM, Rowley S, Trofholz A, Hanson C, Rueter M, Maclehose R, et. al. Childhood Obesity and Interpersonal Dynamics During Family Meals. Pediatrics. 2014 Nov; 134(5): 923-32. DOI: 10.1542/peds.2014-1936

17. Galloway AT, Fiorito LM, Francis LA, Birch LL. ‘Finish your soup’: counterproductive effects of pressuring children to eat on intake and affect. Appetite. 2006 May; 46(3): 318-23. DOI: 10.1016/j.appet.2006.01.019

18. Gahagan S. Development of eating behavior – biology and context. J Dev Behav Pediatr. 2012 Apr; 33(3): 261–71. DOI: 10.1097/DBP.0b013e31824a7baa

19. Addessi E, Galloway AT, Visalberghi E, Birch LL. Specific social influences on the acceptance of novel foods in 2-5-year-old children. Appetite. 2005 Dec; 45(3): 264-71. DOI: 10.1016/j.appet.2005.07.007

20. Rhee, KE. Childhood overweight and the relationship between parent behaviors, parenting style, and family functioning. Ann Am Acad Pol Soc Sci 2008; 615: 11-37. DOI: 10.1177/0002716207308400

21. Berge JM, Rowley S, Trofholz A, Hanson C, Rueter M, Maclehose R, et. al. Childhood Obesity and Interpersonal Dynamics During Family Meals. Pediatrics. 2014 Nov; 134(5): 923-32. DOI: 10.1542/peds.2014-1936

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https://www.rch.org.au/childgrowth/Child_growth_e-learning/https://www.cdc.gov/growthcharts/clinical_charts.htmhttps://doi.org/10.1136/adc.45.244.755http://dx.doi.org/10.1136/adc.81.3.257https://doi.org/10.1016/j.jada.2005.09.042https://doi.org/10.1056/NEJM199101243240405https://www.nrv.gov.au/nutrientshttps://www.eatforhealth.gov.au/food-essentials/how-much-do-we-need-each-day/recommended-number-serves-children-adolescents-andhttps://www.eatforhealth.gov.au/food-essentials/how-much-do-we-need-each-day/recommended-number-serves-children-adolescents-andhttps://www.eatforhealth.gov.au/food-essentials/how-much-do-we-need-each-day/recommended-number-serves-children-adolescents-andhttp://dx.doi.org/10.3945/ajcn.113.069047http://ellynsatterinstitute.org/https://doi.org/10.1016/j.appet.2007.09.009http://dx.doi.org/10.1037/0012-1649.26.4.546https://doi.org/10.1079/PNS19980090https://doi.org/10.1542/peds.2014-1936https://doi.org/10.1016/j.appet.2006.01.019https://doi.org/10.1097/DBP.0b013e31824a7baahttps://doi.org/10.1016/j.appet.2005.07.007https://doi.org/10.1016/j.appet.2005.07.007https://doi.org/10.1177/0002716207308400https://doi.org/10.1542/peds.2014-1936www.healthed.com.au

22. Gillman MW, Rifas-Shiman SL, Frazier AL, Rockett HR, Camargo CA Jr, Field AE, et. al. Family dinner and diet quality among older children and adolescents. Arch Fam Med. 2000 Mar; 9(3): 235-40. DOI: 10.1001/archfami.9.3.235

23. Black MM, Hurley KM. Helping Children Develop Healthy Eating Habits. In: Tremblay RE, Boivin M, Peters RDeV, editors. Faith MS, topic editor. Encyclopedia on Early Childhood Development [Internet]. Montreal, QC: Centre of Excellence for Early Childhood Development; 2013 [Updated 2013 Sep, cited 2018 Oct 29]. Available from: http://www.child-encyclopedia.com/child-nutrition/according-experts/helping-children-develop-healthy-eating-habits

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Editorial TeamMedical Editors: Dr Linda Calabresi, Dr Vivienne Miller Editorial Assistant: Neil Harris Commissioning Editor: Dr Ramesh Manocha

http://dx.doi.org/10.1001/archfami.9.3.235http://www.child-encyclopedia.com/child-nutrition/according-experts/helping-children-develop-healthy-eating-habitshttp://www.child-encyclopedia.com/child-nutrition/according-experts/helping-children-develop-healthy-eating-habitshttp://www.child-encyclopedia.com/child-nutrition/according-experts/helping-children-develop-healthy-eating-habitswww.healthed.com.au