Nutrition in Toddlers
Am Fam Physician. 2018 Aug 15;98(4):227-233.
Patient information: See related handout on toddler nutrition.
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The establishment of eating practices that contribute to lifelong nutritional habits and overall health begins in toddlerhood. During this time, children acquire the motor skills needed to feed themselves and develop preferences that affect their food selections. Classifications for faltering weight (also called failure to thrive or growth faltering) and overweight are based on World Health Organization child growth standards (for children younger than two years) and Centers for Disease Control and Prevention growth charts (for children two years and older). Breast milk or whole cow's milk should be offered as the primary beverage between one and two years of age. Sugar-sweetened beverages should be avoided in all toddlers, and water or milk should be offered instead. Allergenic foods such as peanuts should be introduced early to infants at higher risk of allergies. Vitamin D and iron supplementation may be advisable in certain circumstances, but multivitamins and other micronutrient supplements are usually unnecessary in healthy children who have a balanced diet and normal growth. Optimal food choices for toddlers are fresh foods and minimally processed foods with little 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 (e.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 child decides,” in which the parent provides healthy food options, and the child chooses which foods to eat and how much.
During the transition from a liquid-based infant diet to a diet more typical of older family members, toddlers have their first 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-fat milk instead of whole milk in toddlers who are at risk of obesity or cardiovascular disease, early introduction of reduced-fat milk may ultimately increase the risk of obesity and should be avoided in most cases.
In a sharp departure from previous recommendations, more recent guidelines recommend early introduction of potentially allergenic foods (e.g., peanuts) into the diets of some infants. Therefore, foods that were traditionally started in toddlerhood may now be given earlier.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
Children one to two years of age should drink whole milk rather than reduced-fat milk.
Children older than 12 months should be offered primarily water and milk. 100% fruit juice should be limited to 4 oz per day in children one to three years of age and served in an open cup. Sugary, nonnutritive beverages (e.g., fruit drinks, sweetened bottled water, sports drinks, soda) should be avoided entirely.
Fat intake should not be limited before 12 months of age but may be limited to 30% to 40% of daily energy intake in one- to three-year-olds. Trans fats should be avoided entirely.
Exclusively breastfed infants should receive vitamin D supplementation (400 IU per day) until they are consuming an adequate amount of vitamin D in foods.
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 Force and American Academy of Family Physicians, there is insufficient evidence to make a recommendation.
Foods containing peanuts should be introduced at four to six months of age in infants at increased risk of food allergies.
Parents and caregivers serve as the primary models for healthy eating and activity patterns.
Picky eaters should receive frequent opportunities to try new foods to increase familiarity, and new foods should be introduced with familiar foods. Children should not be pressured to eat new foods because this can promote dislike of those foods.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
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