Energy and Nutrient Intake of Infants and Toddlers: A Longitudinal View of Nutritional Adequacy. A thesis submitted to the.

Transcription

1

2 Energy and Nutrient Intake of Infants and Toddlers: A Longitudinal View of Nutritional Adequacy A thesis submitted to the Graduate School of the University of Cincinnati in partial fulfillment of the requirements for the degree of Master of Science in the Department of Nutritional Sciences of the College of Allied Health Sciences By Kaitlyn Paxton B.S. University of Dayton March 19, 2013 Committee Chair: Grace Falciglia, EdD, MPH, RD

3 ABSTRACT Background: The first 2 years of life are important for growth and development of children, but there is not much food and nutrient intake data available for this population. The purpose of this study is to assess energy and nutrient intake from food only, including breast milk and formula, in infants through toddlerhood, and identify deficiencies and excesses of nutrients when compared to the Institute of Medicine s Dietary Reference Intakes (DRIs). Methods: This longitudinal cohort study followed 60 infants over 18 months. Three-day food records were collected at six weeks, and six, 12, and 18 months of age and analyzed for energy and nutrient intakes. The mean, range of intake, and the percent of the recommendation met was calculated for both energy and macronutrients. The percentage of those who did not meet the Estimated Average Requirement (EAR) or Adequate Intake (AI) and the percentage with intakes above the Upper Intake Levels (UL), for specific vitamins and minerals, were also calculated. Results: Energy and macronutrient levels met or exceeded 100% of the recommendation at all time points with the exception of: carbohydrates at six weeks of age which met 91% and fiber at 18 months which met only 51% of the recommendation. More than 50% of the sample did not meet DRI recommendations for: magnesium, iron, zinc, vitamins D, E, C, and B6, thiamin and folate at six weeks; vitamin D at six months; vitamins D and E at 12 months and vitamins D, E, and K at 18 months. More than 50% of the sample exceeded UL recommendations for: zinc at six and 12 months; and phosphorus, magnesium, sodium, and niacin at 18 months. Conclusions and Implications: Healthcare professionals may want to monitor the diet of infants and toddlers more closely for nutritional adequacy. ii

4 iii

5 TABLE OF CONTENTS List of Tables v Introduction 6 Purpose 10 Methods Subjects 10 Measures 11 Data Analysis 11 Results Demographics 12 Energy and Macronutrients 12 Micronutrients 12 Summary 13 Discussion 17 Six Weeks 17 Six Months Months Months 19 Longitudinal Perspective 20 Summary 21 Implications 22 Limitations 22 Conclusion 23 References 24 iv

6 List of Tables Table 1 14 Table 2 15 Table 3 16 v

7 INTRODUCTION A healthy, nutritious start to life is an important aspect that can sometimes be unintentionally overlooked. Infants and toddlers rely entirely upon their parents and caregivers for this and ensuring a sufficient balance, of energy and nutrients, is paramount to giving babies this vital healthy beginning. Guidelines for Healthcare Professionals The Institute of Medicine provide the Dietary Reference Intakes (DRIs) (Institute of Medicine (IOM), 1997) as nutrient recommendation values that are intended to serve as a guide for good nutrition and provide the scientific basis for the development of food guidelines in the United States. For infants and children, the reference values are broken down into four age categories; infants zero to six months, infants six to 12 months, children one to three years and children four to eight years. The DRIs include values for Estimated Average Requirement (EAR), Recommended Dietary Allowance (RDA), Adequate Intake (AI), and Tolerable Upper Intake Levels (UL). The EAR is defined as the average daily level of intake that is estimated to meet the requirements of 50% of the individuals in a group while the RDA represents the average daily dietary intake level sufficient to meet the requirements of 97-98% of the individuals in a group. For clinical and research purposes, the EAR is used with groups and the RDA is used with individuals. The RDA is calculated from the EAR, however if there is not enough evidence to calculate the RDA an AI may be developed. The UL is the highest level of intake resulting in no observable toxicity effect among individuals in the general population. The American Academy of Pediatrics provides guidance on energy and nutrient balance and proper growth and development specifically for healthcare professionals (American Academy of Pediatrics (AAP), 2009). The current handbook provides the most up to date 6

8 science-based information summarized into clinical and practical applications. The handbook gives guidance on topics such as nutrient metabolism, and nutrition to support the appropriate growth and development of infants and children who are not only well but also children who have acute chronic illness or were born with congenital disorders of metabolism. Specifically, it provides insight into feeding infants and toddlers in terms of gastrointestinal development and function, breastfeeding, formula feeding, feeding full term versus preterm infants, complementary feeding, and feeding children and adolescents. Macro- and micronutrients are discussed in-depth and include current research findings as well as information from DRI references. Feeding Guidelines for Parents The Academy of Nutrition and Dietetics (formerly the American Dietetic Association) developed the Start Healthy Feeding Guidelines for Infants and Toddlers to provide parents and caregivers practical dietary and feeding guidance, for infants and toddlers (Butte et al, 2004). The guidelines are derived from the IOM DRIs and AAP recommendations and the methodology, results and complete references as well as the rationale used to develop the guidelines are described in detail elsewhere (Pac et al, 2004). The purpose of these practical guidelines is to help parents and caregivers ensure a balance of energy and nutrient intake to help babies grow and develop normally. The feeding guidelines recommend breastfeeding infants for as long as the mother is capable and preferably, until one year of age. Breastfeeding until one year of age may reduce the risk of obesity later in life, provide nutrients for optimal brain development and natural defenses against allergies as well as expose the baby to a variety of flavors from foods eaten by the mother to help increase acceptance of new foods later (Shevlov, 1998). The guidelines also recommend 7

9 introducing solid food around six months of age by starting with infant cereal at a very thin consistency and progressing to pureed foods. The guide also suggests introducing one new food every two to four days to monitor potential food sensitivities and allergies. Once the baby is acclimated to single-ingredient foods, then one can mix flavors and colors to create variety in the diet and ensure the recommended five servings of fruits and vegetables per day (Butte, 2004). In addition to breast milk or formula, toddlers should still receive the recommended five servings of fruits and vegetables per day in a variety of flavors, colors, and textures (Butte, 2004). They can begin to eat thicker, slightly lumpy pureed foods, ground or soft mashed foods and crunchy foods that will easily dissolve. Progression to more solid foods should be done as the baby development progresses. Toddler appropriate forms of protein and fiber can also be introduced at this time. Lastly, these guidelines delineate critical nutrients needed during infancy and toddlerhood. During infancy these nutrients include: iron, zinc, calcium and vitamin D. Iron and zinc, important for the baby s physical, mental and immune development, become limited in exclusively breastfeed infants. To ensure adequate intake of these nutrients, iron and zincfortified foods appropriate for infants are recommended after six months of age. Calcium is needed to help build strong bones and teeth, however, if the baby receives adequate formula or breast milk, then adequate calcium intake follows. Vitamin D is needed to support calcium absorption. Formed naturally from the sun, vitamin D would seem to be adequate. However, sunscreen and clothing used to mitigate risk of cancer also prevent vitamin D from forming. Therefore, vitamin D supplementation for babies exclusively breastfed or getting less than 16 ounces of formula per day is highly recommended (Gartner, 2003; Butte et al, 2004). 8

10 During toddlerhood critical nutrients include: iron, zinc, essential fats, and vitamin E. For iron and zinc, age-appropriate lean meats as well as iron-fortified cereals are recommended to ensure adequate nutrient intake. The guidelines also suggest serving iron rich foods alongside vitamin C rich foods to help enhance iron absorption. Essential fats and Vitamin E are found in many of the same foods, so they are easily provided together. However, they serve very different functions. Babies up to two years of age should obtain 30% to 40% of their total calories from fat to help with growth, brain development, and energy. Vitamin E is an antioxidant needed for healthy growth. To ensure adequate intake of both of these critical nutrients, once the switch from breast milk or formula to cow milk has occurred, whole milk should be drank until two years of age and foods should be prepared with one tablespoon of oil or salad dressing. (Butte et al, 2004) Current Research While there is much health and wellness data available on this population, not much of it focuses on food and nutrient intake. Most available nutritional and dietary data comes from national surveys such as the third National Health and Nutrition Examination Survey (NHANES III) (Center for Disease Control and Prevention (CDC) 1998), the 1994 to 1996 and 1998 Continuing Survey of Food Intake by Individuals (CSFII) (United States Department of Agriculture (USDA) 1998), which are both over 10 years old, and the 2002, 2004 and 2008 Feeding Infants and Toddlers Studies (FITS) (Pac et al, 2004). NHANES III is a program of studies that evaluate the health and nutritional status of adults and children in the United States. The survey studied 13,944 children and adolescents between two months and 16 years of age. Food and nutrient intake data was gathered using 24-hour dietary recall and a dietary food frequency Questionnaire. The CSFII, which was conducted by the U.S Department of 9

11 Agriculture, measures the types and amounts of foods eaten by individuals living in the U.S and their knowledge and attitude about diet and health. The CSFII surveyed 1551 children under the age of one year and 2191 children between one and two years old. Data was gathered using two food intake interviews. The most recent FITS publication is from 2010, and describes the food and nutrient intake of 3,273 infants, toddlers and preschoolers up to age four (47 months) using a 24-hour dietary recall (Briefel et al, 2010). Unlike other national surveys, FITS examines only infants, toddlers, and preschool aged children. Data from national surveys such as these, however, is limited as they only examine dietary intake at one particular time point. There is no longitudinal view of what infants and toddlers are eating nor is there an examination of the nutritional adequacy of their diets over time. PURPOSE The purpose of this study was to assess energy and nutrient intake from breast milk, formula and food only (without supplements), in six week old infants through 18 months of age. The goal was to identify deficiencies and/or excesses in the diet when compared to the calculated Estimated Energy Requirements (EER), EAR/AI and UL. METHODS Subjects A subsample of 60 six-week-old infants, participating with their mothers in a larger study on the prevention of childhood obesity, was followed until 18 months of age. Mothers and their infants were recruited from the Cincinnati metropolitan area using various strategies including; flyers and advertisements as well as physician referral. Inclusion criteria for the mothers were: 10

12 (1) a BMI >25, with no other co-morbidities, (2) mothers between 21 and 35 years of age, (3) have a single, full-term infant, (4) have a vegetable intake less than or equal to 1.5 servings, (5) have full medical clearance from a physician to participate, (6) are not on special diets, and (7) are not using alcohol (more than 5 ounces of wine, 12 ounces of beer daily and no liquor), illegal drugs, or tobacco. Once eligibility was determined, informed consent was obtained from the mother. This study was approved by the Institutional Review Board of the University of Cincinnati. Measures Three-day food records were collected at six weeks, and six, 12, and 18 months of age and analyzed for energy and nutrient content using the 2007 version of the Nutrition Data System for Research (NDSR) developed by the University of Minnesota. Mothers reported the dietary intake of their child at each data collection. Individually calculated EER as well as the DRI reference values: EAR, AI, and UL were used for comparison of each energy, macro- and micronutrient recommendation. Nutrients analyzed include: carbohydrate, protein, fat, fiber, calcium, phosphorus, magnesium, iron, zinc, sodium, potassium, Vitamins A, D, E, K, C, B6, B12, thiamin, riboflavin, niacin, pantothenic acid, and folate. Data Analysis Energy and nutrient intake, gathered from the three-day food records, were averaged at each time point for each child and then compared to the appropriate EER, EAR, AI, or UL. Energy and nutrient content was analyzed and compared to the appropriate recommendation using SPSS Statistics software Version 20 (IBM, 2011). For energy and macronutrients the groups mean, standard deviation, and range of the actual intake as well as the mean percent of 11

13 the recommendation met from intake was calculated and compared to the appropriate DRI. For each specific vitamin or mineral, the percentage of infants who did not meet the appropriate EAR or AI and the percentage that exceeded the UL were calculated for the group. RESULTS Demographic Data Table 1 summarizes the demographic data of the study sample and their mothers. Exactly half of children born were male with the majority of the sample being white, non-hispanic. Nearly half of children were the first born child and most had any breastfeeding at six weeks of age. Most mothers had completed some college, were employed and were married. Energy and Macronutrients Table 2 presents the actual intake (mean +SD and range), appropriate recommendations, and the percentage of that recommendation met by intake (mean +SD) for energy, carbohydrates, protein, fat, and fiber. All macronutrients exceeded 100% of their respective recommendations at all time points with the exception of: carbohydrates at six weeks (91%) and fiber at 18 months (51%). At 12 and 18 months, protein intake reached 322% and 338% of the recommendations, respectively. No other nutrients exceeded 150% of the recommendation. Micronutrients Table 3 shows the percentage of infants who did not meet the EAR/AI for specific vitamins and minerals as well as the percentage of infants who exceeded the UL for the vitamins and minerals. At six weeks, more than 50% of the sample did not meet the AI recommendations for: magnesium (61%), iron (50%), zinc (63%), vitamins D (98%), E (75%), C (55%), and B6 12

14 (51%), thiamin (63%) and folate (63%). At six months, 83% of infants studied did not meet the AI for vitamin D however there were no other nutrients with more than 50% of infants not meeting the AI. At 12 months, 93% did not meet the AI for vitamin D and 76% did not meet the AI for vitamin E. At 18 months, 95% did not meet the EAR for vitamin D, 81% did not meet the EAR for vitamin E, and 50% did not meet the AI for vitamin K. At six weeks, none of the infants exceeded the UL for any nutrient. More than 50% of the sample exceeded UL recommendations for zinc at both six (53%) and 12 (61%) months. At 18 months, 100% of the toddlers exceeded the UL for phosphorus, magnesium, and niacin with 50% exceeding the UL for sodium. Summary In summary, energy and macronutrients met or exceeded 100% of the recommendation at all time points except carbohydrates at 6 weeks of age and fiber at 18 months. More than 50% of the sample did not meet EAR/AI recommendations for: magnesium, iron, zinc, vitamins D, E, C, and B6, thiamin and folate at six weeks; vitamin D at six months; vitamins D and E at 12 months and vitamins D, E, and K at 18 months. More than 50% of the sample exceeded UL recommendations for: zinc at six and 12 months; and phosphorus, magnesium, sodium, and niacin at 18 months. 13

15 Table 1: Sample characteristics for child and mother. N=60 Characteristics % of Sample Gender Male 50 Female 50 First Born Child Yes 46.7 No 53.3 Feeding Method Breastfeeding (any breastfeeding at 6 wks of 73.3 age) Formula 26.7 Mother s Race White, non-hispanic 83.3 White, Hispanic 3.3 African American, non-hispanic 11.7 African American, Hispanic 0 Asian 1.7 Mother s Education 11 th grade or less 0 High School Diploma 1.7 Some College 11.7 Completed College 86.7 Mother s Occupational Status Employed 71.7 Not Employed 28.3 Mother s Marital Status Married 90.0 Single/Divorced

16 Table 2: Descriptive data for the group percentage of EER met from actual food intake. N=60 Age Actual Intake Mean + SD Actual Intake Range EER/EAR/AI Percent DRI Met by Intake (Mean +SD) Energy (kcal/d) 6 Weeks (89xweight[kg]) Months (89xweight[kg]) Months (89xweight[kg]) Months (89xweight[kg]) Carbohydrate (g/d) 6 Weeks Months Months Months Protein (g/d) 6 Weeks Months Months Months Fat (g/d) 6 Weeks Months Months Months Fiber (g/d) 6 weeks months months months

17 Table 3: Percentage of Infants who did not met EAR/AI and exceeded the UL. N=60 Nutrients 6 weeks 6 months 12 months 18 months EAR/AI %<EAR UL %>UL EAR/AI %<EAR UL %>UL EAR/AI %<EAR UL %>UL EAR/AI %<EAR UL %>UL Minerals Calcium(mg/d) Phosphorus(mg/d) Magnesium(mg/d) Iron(mg/d) Zinc(mg/d) Sodium(mg/d) Potassium(mg/d) Vitamins Vitamin A(µg/d) b Vitamin D(µg/d) Vitamin E(mg/d) c a 0.0 Vitamin K(µg/d) Vitamin C(mg/d) Thiamin(mg/d) Riboflavin(mg/d) Niacin(mg/d) d a Pant. Acid(mg/d) Vitamin B6(mg/d) Folate(µg/d) e a 26.7 Vitamin B12(µg/d) ND means Not determined a UL determined only for fortified foods, supplements or combination of the two b Total Vitamin A Activity, c Total Alpha-Tocopheral, d Niacin Equivalents, e Dietary Folate Equivalents 16

18 DISCUSSION Overall, infants and toddlers enrolled in this study either met or exceeded the energy and macronutrient recommendations (compared to the EARs and AIs). However, micronutrient consumption was inadequate, either too low or too high versus recommendation, for specific vitamins and minerals, at most time points examined. Six Weeks Energy and macronutrients. At six weeks of age, even though the average energy intake met the calculated EER, it was still lower than national averages reported by FITS (Butte et al, 2010). For each macronutrient examined, infant s average intake met or exceeded 100% of the respective recommendation(s) except mean carbohydrate intake which met 91% of recommendation. Mean protein and fat intake determined in the present study was comparable to the findings reported in FITS but the mean carbohydrate intake was lower than the average carbohydrate intake reported nationally. FITS reports a mean carbohydrate intake of 66g/d while infants in the present study exhibited a mean of 55g/d. While fiber intake was very low for both studies, FITS showed an average intake of 0.50g/d while this study determined a mean intake of only 0.07g/d (Butte et al, 2010). Micronutrients. Also for this age group, national data from FITS shows micronutrient inadequacy being low (Butte et al, 2010). However data from this study shows high percentages of infants with intakes of iron, zinc, magnesium, vitamins D, E, C, B6, thiamin and folate below the AI recommendation unlike FITS data which shows mean values well above the AI for all nutrients examined. At six weeks, infants are only receiving breast milk or formula, which should be enough to supply adequate nutrition. Upon further investigation, infants not meeting 17

19 the recommendations were only missing the mark by a few milligrams or micrograms. For example, of the 37 (63%) of infants who did not meet the 2mg/d recommendation for zinc intake 26 of those had an actual intake between 1.25mg/d and 1.99mg/d, coming very close to actually meeting the AI. Six Months Energy and macronutrients. At six months, mean energy intake meets the calculated EERs however it is still 225kcals below national averages reported by FITS (Butte et al, 2010). The mean intake for each macronutrient examined in this study met or exceeded recommendations but was considerably lower than those found by FITS. For example, an average intake of 73g/d of carbohydrates was found by this study compared to a mean of 114g/d reported by FITS (Butte et al, 2010). Micronutrients. For micronutrients, the high percentage of infants with low vitamin D intake was again not comparable to the adequate intake found in FITS. Interestingly, both studies showed high percentages of infants with zinc intake, from foods and beverages only that exceeded the UL, 53% of six month old infants from this study and 68% of the six to 11 month old FITS infants. A further look into the actual foods eaten by those who exceeded the UL showed a common infant formula being reported by mothers. The formula contains 1mg of zinc per five fluid ounces. Infants were eating between 25 and 35 ounces of formula per day giving them a zinc intake of between 5mg and 7mg/day. For this age group the UL recommendation is only 4mg/d causing them to easily reach and exceed the UL. 12 Months Energy and macronutrients. At 12 months, mean energy intake met 115% percent of calculated EER recommendation however it was still nearly 200kcals below national averages 18

20 found by FITS. Also, the average macronutrient intake met or exceeded recommendations however the average intake for each macronutrient was still lower than the average intakes found by FITS. Also, protein intake of infants in the current study exceeded 300% of the recommendation. Micronutrients. Most micronutrients showed low percentages of infants with intakes below the EAR/AI or above the UL except vitamins D and E, of which 93% and 76% of infants, respectively, did not meet the recommendation and zinc of which 61% exceeded the UL. The high percentage of infants with vitamin D intake below the AI value was again not comparable to the national data but the 76% of infants in this study with vitamin E intake below the AI was comparable to the 63% of FITS infants with vitamin E intake below the recommendation. Also, the high percentage of infants with intake above the UL for zinc, from foods and beverages only, was again seen in both studies however the percentage in FITS drops from 68% of six to 11 month olds to 4% of 12 to 23 months olds whereas the percentage increases from 53% of six months olds to 61% of 12 months olds in the current study. 18 Months Energy and macronutrients. At 18 months energy intake was 118% of calculated EER recommendations and the mean intake of 1089kcals is comparable to the national average of 1,113kcals reported by FITS (Butte et al, 2010). All average macronutrient intakes exceed 100% of recommendations except fiber which only meets 51% of the AI. Again, mean protein intake exceeded 300% of the recommendation. The mean intake for each macronutrient becomes very comparable to average intakes reported nationally. For the current study there was a mean intake of 138g/d of carbohydrates versus an average of 151g/d for FITS, a mean intake of 44g/d of 19

21 protein for both studies, and a mean of 41g/d and 42g/d of fat for each study, respectively. Both studies also found a mean intake of 9g/d of fiber. Micronutrients. For micronutrients the majority of infants met the EAR/AI for all nutrients except vitamins D, E and K. There were also several micronutrients with the majority of infants exceeding the UL; phosphorus, magnesium, sodium and niacin. The high percentage of infants with low vitamin K intake seen by the current study was not seen by FITS. Finally, of the nutrients that had more than 50% of the infants exceeding the UL at 18 months, only sodium was comparable to the 45% of infants in FITS. The high percentage of infants that exceeded the UL for niacin at 18 months is comparable to a on the dietary intake of three year old children (Weiner et al, 2009). Of the 372 three year olds in that study, 85% had intake exceeding the UL for niacin compared to the 100% of 18 month olds in the current study. Longitudinal Perspective From a longitudinal perspective, energy intake was relatively consistent throughout the time of the study. Energy intake also never exceeded 120% of the recommendation. Carbohydrate intake started out slightly low at the beginning, but increased throughout the rest of the study. Protein intake started out at appropriate levels, increased slightly and then more than doubled halfway through. Fat intake also started out at appropriate levels and then made a slight increase about halfway through the study. Fiber intake, which remains extremely low throughout the study, does increase as the study progresses. Interestingly, the percentage of the recommendation that was met by intake also increased as the child aged. While food and nutrient intake should increase as the child grows and gets older, the percentage of the recommendation being met by that intake should stay at or around 100%. However, in this study that percentage is also increasing. For example, protein intake reached 9.2g/d at six weeks and increased to 44.0g/d 20

22 by 18 months, with recommendations being 9.1g/d and13 g/d respectively. Therefore the percentages of those recommendations being met by intake are 101% at six weeks and 338% at 18 months. Children in this study showed a tendency towards disproportionate increases in intake with increases in their recommendations. Also, the larger increases approximately halfway through the study, at or between the 6 and 12 month time points, may be correlated with the introduction of or increase in the amount of solid or complementary foods eaten by the child. As for micronutrients, there was a tendency towards a decrease in the percentage of infants not meeting the EAR or AI for each vitamin or mineral. In other words, as the infants got older their vitamin and mineral intake increased. In fact, that increase in intake may have caused some nutrients to exceed the UL by 18 months. Summary Discrepancies between this data and those found nationally may in part be due to the fact that this study did not include supplementation in its analysis, whereas FITS did. However, there are a few nutrients, including zinc and sodium, that FITS compares the percentages of infants that exceed the UL from food, beverage and supplement intake to the percentages of the same infants who exceed the UL from food and beverage intake alone. For the purposes of this study, percentages discussed using food and beverage intake alone was considered in the comparison of the two studies. Aside from a few specific nutrients such as iron and vitamin D, infants and toddlers should be getting all the nutrients they need from breast milk, formula and foods, especially if parents and caregivers are following the guidelines set in place by experts. The high percentage of infants at six weeks of age who are not getting the nutrients they should be from an adequate 21

23 intake breast milk or formula may warrant further investigation. However, it is probable that mothers may have underreported amounts of breast milk or formula given to the child. Unlike other studies, such as FITS (2010) and the one done by Wiener (2009), this study showed an appropriate and acceptable energy and macronutrient intake with either inadequate or overly excessive intake of specific vitamins and minerals rather than excess energy intake with acceptable macro- and micronutrient intake. Implications Infancy and toddlerhood are critical periods in life when considering a diet. This is a time when lifelong eating habits are formed and a nutritional basis for adulthood begins. Therefore future research should look at the effects vitamin and mineral deficiency and excess during infancy and toddlerhood have on health later in life. Also, healthcare professionals, working with pregnant and lactating mothers should stress the benefits of and encourage breastfeeding past six months of age. Pediatricians also need to encourage this, as well as discuss limiting the intake of overly processed foods and focus on baby friendly, low energy, nutrient dense whole foods. Healthcare professionals should also be more aware of the child s diet to help ensure proper nutritional adequacy. Limitations One limitation of this study is that, at each time point, the three-day food records were self-reported by mothers. Unintentional misreporting may have occurred, especially in breastfed babies, as the mother may not remember or know the exact amounts of breast milk, formula or complementary foods given to the child. Another limitation of this study is that it has a homogenous sample. The participants are predominately white and come from well educated, two parent families. Generalizations to the entire population cannot be made. 22

24 CONCLUSION In general, it appears that energy and macronutrient intake for this sub-sample was adequate, even though micronutrient intake appeared to be inadequate for a few specific vitamins and minerals. Healthcare professionals may want to monitor the diets of infants and toddlers more closely for nutritional adequacy. 23

25 REFERENCES American Academy of Pediatrics. (2009). Pediatric Nutrition Handbook 6 th edition. Elk Grove Village, Illinois United States: Author. Briefel, R. R., Kalb, L. M., Condon, E., Deming D. M., Clusen N. A., & Fox M. K. (2010). The Feeding Infants and Toddlers Study 2008: Study Design and Methods. Journal of the American Dietetic Association (Supplement), 3, S16-S26. Butte, N., Cobb, K., Dwyer, J., Graney, L., Heird, W., Rickard, K. (2004). The Start Healthy Feeding Guidelines for Infants and Toddlers. Journal of the American Dietetic Association, 104(3): Butte, N. F., Fox, M. K., Briefel, R. R., Siega-Riz, A. M., Dwyer, J. T., & Deming, D. M. (2010). Nutrient Intakes of US Infants, Toddlers, and Preschoolers Meet or Exceed Dietary Reference Intakes. Journal of the American Dietetic Association (Supplement), 3, S27-S37. Continuing Survey of Food Intakes by Individuals Beltsville, MD: U.S. Department of Agriculture Gartner, L. M., Greer, F. R., & The Section on Breastfeeding and Committee on Nutrition. (2003). Prevention of rickets and Vitamin D deficiency: New guidelines for vitamin D intake. Peditatrics, 111: IBM SPSS Statistics (Version 20). (2011). [Computer Software]. Armink, NY: International Business Machines Corp. Institute of Medicine. Dietary Reference Intakes Tables and Application, 1997 [Tables]. Available from Institute of Medicine Web site, Tables.aspx Nutrition Data System for Research. (2007). [Computer Software]. University of Minnesota. 24

26 Pac, S., McMahon, K., Ripple M., Reidy, K., Ziegler, P., Myers, E. (2004). Development of the Start Healthy Feeding Guidelines for Infants and Toddlers, Journal of the American Dietetic Association, 104(3): Shevlov S. Feeding your baby: breast and bottle. In: American Academy of Pediatrics Caring for Your Baby and Young Child- Birth to Age 5. New York, NY: Bantam Books; 1998: The Third National Health and Nutrition Examination Survey (NHANES III). Hyattsville, MD: U.S. Center for Disease Control and Prevention Wiener, F. B., Schmidt, M., Munson, K., Khoury, P. R., Kalkwarf, H., & Daniels, S. R. (2009). Dietary intake of 3 year old children: Do they meet Recommended Intake?, Current Pediatric Reviews, 5,