Nutrition in Toddlers


Am Fam Physician. 2018 Aug 15;98(4):227-233.

  Patient information: See related handout on toddler nutrition.

Author disclosure: No relevant financial affiliations.

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.


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.

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Clinical recommendationEvidence ratingReferences

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


8, 16, 17

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.


23, 24

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.


3, 16, 26

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


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 Force and American Academy of Family Physicians, there is insufficient evidence to make a recommendation.


33, 3537

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


13, 40, 41

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


The Authors

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

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

OLIVIA BOUCHER, MD, is a third-year resident at the Eglin Air Force Base Family Medicine Residency Program.

Address correspondence to Lyrad K. Riley, MD, MPH, St. Mary's Family Medicine Residency Program, 2698 Patterson Rd., Grand Junction, CO 81506 (e-mail: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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1. Centers for Disease Control and Prevention. National Center for Health Statistics. Growth charts. Accessed June 2, 2017....

2. Cole SZ, Lanham JS. Failure to thrive: an update. Am Fam Physician. 2011;83(7):829–834.

3. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary guidelines for Americans 2015–2020. Eighth edition. Accessed June 20, 2017.

4. Bradlee ML, Singer MR, Qureshi MM, Moore LL. Food group intake and central obesity among children and adolescents in the Third National Health and Nutrition Examination Survey (NHANES III). Public Health Nutr. 2010;13(6):797–805.

5. Sample menu for a preschooler. Accessed June 20, 2017.

6. Sample menu for a two-year-old. Accessed June 20, 2017.

7. Nierengarten MB. Gluten-free diet: not for all children. June 1, 2016. Contemp Pediatr. Accessed February 12, 2018.

8. Holt KA, et al. Bright Futures: Nutrition, Edition Pocket Guide. 4th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2017.

9. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012;(8):CD003517.

10. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–e841.

11. American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). Accessed February 12, 2018.

12. The importance of infant and young child feeding and recommended practices. In: Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva, Switzerland: WHO Press; 2009:3–5.

13. Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel. Ann Allergy Asthma Immunol. 2017;118(2):166–173.e7.

14. Maguire JL, Lebovic G, Kandasamy S, et al.; TARGet Kids! Collaboration. The relationship between cow's milk and stores of vitamin D and iron in early childhood. Pediatrics. 2013;131(1):e144–e151.

15. Greenhill C. Nutrition: drinking cow's milk alters vitamin D and iron stores in young children. Nat Rev Endocrinol. 2013;9(3):126.

16. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213–S256.

17. Daniels SR, Hassink SG; Committee on Nutrition. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136(1):e275–e292.

18. Vanderhout SM, Birken CS, Parkin PC, et al.; TARGet Kids! Collaboration. Relation between milk-fat percentage, vitamin D, and BMI z score in early childhood. Am J Clin Nutr. 2016;104(6):1657–1664.

19. Beck AL, Heyman M, Chao C, Wojcicki J. Full fat milk consumption protects against severe childhood obesity in Latinos. Prev Med Rep. 2017;8:1–5.

20. Ludwig DS, Willett WC. Three daily servings of reduced-fat milk: an evidence-based recommendation? JAMA Pediatr. 2013;167(9):788–789.

21. Lee GJ, Birken CS, Parkin PC, et al.; TARGet Kids! Collaboration. Consumption of non-cow's milk beverages and serum vitamin D levels in early childhood. CMAJ. 2014;186(17):1287–1293.

22. Morency ME, Birken CS, Lebovic G, et al.; TARGet Kids! Collaboration. Association between noncow milk beverage consumption and childhood height. Am J Clin Nutr. 2017;106(2):597–602.

23. Heyman MB, Abrams SA; Section on Gastroenterology, Hepatology, and Nutrition; Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967.

24. Vos MB, Kaar JL, Welsh JA, et al. Added sugars and cardiovascular disease risk in children: a scientific statement from the American Heart Association. Circulation. 2017;135(19):e1017–e1034.

25. Lesser LI, Mazza MC, Lucan SC. Nutrition myths and healthy dietary advice in clinical practice. Am Fam Physician. 2015;91(9):634–638.

26. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2005.

27. Michaelsen KF, Greer FR. Protein needs early in life and long-term health. Am J Clin Nutr. 2014;99(3):718S–722S.

28. Rolland-Cachera MF, Maillot M, Deheeger M, Souberbielle JC, Péneau S, Hercberg S. Association of nutrition in early life with body fat and serum leptin at adult age. Int J Obes (Lond). 2013;37(8):1116–1122.

29. Rolland-Cachera MF, Akrout M, Péneau S. Nutrient intakes in early life and risk of obesity. Int J Environ Res Public Health. 2016;13(6):E564.

30. van Gijssel RM, Braun KV, Kiefte-de Jong JC, Jaddoe VW, Franco OH, Voortman T. Associations between dietary fiber intake in infancy and cardiometabolic health at school age: The Generation R Study. Nutrients. 2016;8(9):E531.

31. Golden NH, Abrams SA; Committee on Nutrition. Optimizing bone health in children and adolescents. Pediatrics. 2014;134(4):e1229–e1243.

32. Wagner CL, Greer FR; American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents [published correction appears in Pediatrics. 2009;123(1):197]. Pediatrics. 2008;122(5):1142–1152.

33. Baker RD, Greer FR; Committee on Nutrition American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics. 2010;126(5):1040–1050.

34. Domellöf M, Braegger C, Campoy C, et al.; ESPGHAN Committee on Nutrition. Iron requirements of infants and toddlers. J Pediatr Gastroenterol Nutr. 2014;58(1):119–129.

35. McDonagh MS, Blazina I, Dana T, Cantor A, Bougatsos C. Screening and routine supplementation for iron deficiency anemia: a systematic review. Pediatrics. 2015;135(4):723–733.

36. U.S. Preventive Services Task Force. Iron deficiency anemia in young children: screening. September 2015. Accessed February 12, 2018.

37. American Academy of Family Physicians. Clinical preventive service recommendation. Iron deficiency anemia. Accessed February 12, 2018.

38. Griebler U, Bruckmüller MU, Kien C, et al. Health effects of cow's milk consumption in infants up to 3 years of age: a systematic review and meta-analysis. Public Health Nutr. 2016;19(2):293–307.

39. Butte NF, Fox MK, Briefel RR, et al. Nutrient intakes of US infants, toddlers, and preschoolers meet or exceed dietary reference intakes. J Am Diet Assoc. 2010;110(12 suppl):S27–S37.

40. Hauk L. Peanut allergy prevention: guidelines from the NIAID. Am Fam Physician. 2017;96(2):130.

41. Pitt TJ, Becker AB, Chan-Yeung M, et al. Reduced risk of peanut sensitization following exposure through breast-feeding and early peanut introduction. J Allergy Clin Immunol. 2018;141(2):620–625.e1.

42. de Silva D, Geromi M, Panesar SS, et al.; EAACI Food Allergy and Anaphylaxis Guidelines Group. Acute and long-term management of food allergy: systematic review. Allergy. 2014;69(2):159–167.

43. Birch LL, Doub AE. Learning to eat: birth to age 2 y. Am J Clin Nutr. 2014;99(3):723S–728S.

44. Savage JS, Fisher JO, Birch LL. Parental influence on eating behavior: conception to adolescence. J Law Med Ethics. 2007;35(1):22–34.

45. Williams KE, Field DG, Seiverling L. Food refusal in children: a review of the literature. Res Dev Disabil. 2010;31(3):625–633.

46. Birch LL, Burns AC, Parker L, Burns A; Institute of Medicine. Early Childhood Obesity Prevention Policies. Washington, DC: National Academies Press; 2011.

47. Galloway AT, Fiorito LM, Francis LA, Birch LL. ‘Finish your soup’: counterproductive effects of pressuring children to eat on intake and affect. Appetite. 2006;46(3):318–323.

48. Anzman-Frasca S, Savage JS, Marini ME, Fisher JO, Birch LL. Repeated exposure and associative conditioning promote preschool children's liking of vegetables. Appetite. 2012;58(2):543–553.

49. Phalen JA. Managing feeding problems and feeding disorders [published correction appears in Pediatr Rev. 2014;35(11):496]. Pediatr Rev. 2013;34(12):549–557.

50. Silverman AH. Behavioral Management of Feeding Disorders of Childhood. Ann Nutr Metab. 2015;66(suppl 5):33–42.

51. Sharp WG, Volkert VM, Scahill L, McCracken CE, McElhanon B. A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: how standard is the standard of care? J Pediatr. 2017;181:116–124.e4.

52. Orlet Fisher J, Rolls BJ, Birch LL. Children's bite size and intake of an entrée are greater with large portions than with age-appropriate or self-selected portions. Am J Clin Nutr. 2003;77(5):1164–1170.

53. American Academy of Pediatrics. Toddler – food and feeding. Accessed February 12, 2018.

54. Allen RE, Myers AL. Nutrition in toddlers. Am Fam Physician. 2006;74(9):1527–1532.



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