Children s Hospital of Pittsburgh Continuity Clinic Curriculum Week of September 12, Revised by Debra Bogen, MD, July 2016

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1 Children s Hospital of Pittsburgh Continuity Clinic Curriculum Week of September 12, 2016 Revised by Debra Bogen, MD, July 2016 Topic: Nutrition through the Toddler and Preschool Years Learning Objectives: After reviewing these materials, viewers will be able to: 1. Provide appropriate anticipatory guidance to parents regarding toddler and preschool eating especially regarding food jags, sporadic appetites and the picky eater. 2. Incorporate AAP dietary guidelines regarding juice, milk, and fast food/snack food consumption into anticipatory guidance about preventing childhood obesity. 3. Describe the specific dietary recommendations to ensure adequate calcium, Vitamin D and iron intake in toddlers. Original module developed by K Hannibal MD August, 2004; revised by D Bogen MD July 2007; revised by D Bogen MD and E Reis MD July 2010; revised by D. Bogen June 2013, July 2016 Content copyright 2010, 2013 University of Pittsburgh Of the Commonwealth System of Higher Education. Created at the Division of General Academic Pediatrics, Children s Hospital of Pittsburgh of UPMC Permissions to reprint materials from other sources are received or pending. For educational purposes only. Do not copy and distribute Disclaimer: The University of Pittsburgh School of Medicine, The Children s Hospital of Pittsburgh of UPMC, authors, editors, producers and sponsors of this educational program do not guarantee the accuracy of the information contained herein and assume no liability for decisions made and actions taken based on this information. This information is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician or other health professional relative to diagnostic and treatment options of a specific patient s medical condition. The information provided is not intended to be allinclusive. The viewer should supplement this information with additional readings, other educational materials and discussion. No actual or implied endorsement or promotion of any specific reference(s) or product(s) is made or intended by the University of Pittsburgh School of Medicine, The Children s Hospital of Pittsburgh of UPMC, authors, editors, producers and sponsors of this material. By proceeding with this course, you are acknowledging this disclaimer. 1

2 Case 1: Toddler Nutrition During a well child care visit, Ms. Pfeiffer states that she is concerned about the eating habits of her 16-month old daughter, Sarah. Sarah is so picky. You obtain a more detailed dietary history. Sarah was formula-fed from birth. She started solids at 3 ½ months and by 7 months was introduced to some table food. By 11 months she was eating only table food and at 12 months was changed from formula to whole milk. She initially ate table foods well, trying most of what her mother offered her. Lately, she has been less and less interested in eating and she has become increasingly picky about the foods she does eat. She won t even eat foods she used to relish. When her mother tries to feed her with a spoon, Sarah turns her head away or pushes the spoon away. Question 1: Describe changes in growth rates from birth to 5 years and discuss how this relates to the Sarah s current eating habits. The growth rate slows down dramatically from birth to 5 years. Recall that an infant born weighing 3 kg will double birth weight by 4 months (3 kg gain in 4 months), triple by a year (3 kg gain in 8 months), quadruple by 2 years (3 kg gain in 12 months) and quintuple by 4 years (3 kg gain in 2 years) so growth rate is slowing exponentially. Accordingly, normal energy needs decrease over time, from a peak in early infancy. In response, the appetite decreases. Age kcal/kg/day Birth 6 months months years years 90 Adult Note that the recommended energy needs (kcal/kg/day) do not decrease as dramatically as the growth rate because children s energy expenditures increase with age (infants are sedentary while toddlers are always on the go). Question 2: How do language, cognitive and motor developmental changes from 9 to 24 months relate to changing toddler eating patterns and your anticipatory guidance? Language: Increasing language skills allows toddlers to verbalize their food preference and hunger needs. Cognitive: Toddlers begin to assert independence around 9-12 months starting with self-feeding. Few toddlers beyond 15 months will let anyone else feed them. 2

3 Remember - toddlers control their food selection and food quantity. They have short attention spans and are easily distracted - so offering frequent short meals work best. Motor: Improving fine motor skills allow toddlers to self-feed. Letting children selffeed encourages their self-regulation of energy intake and mastery of feeding skills. Question 3: What feeding safety advice do you have for parents of toddlers? Mobile toddlers may want to walk around and eat this can be a choking hazard, so should be discouraged Toddler should be sitting while eating ideally in a high-chair or booster seat Don t feed children in a moving car Introduction of new foods of various textures and sizes can be choking hazards so children should not be allowed to eat alone. Avoid small and hard foods (peanuts, raw carrots, etc) or food shaped like the airway (hotdogs, whole grapes) An adult should always supervise children while they eat. Case 1 Continued: Sarah s mother is concerned about her child s growth (see the attached growth curves). Sarah Growth Chart 1, Sarah Growth Chart 2. She asks whether Sarah needs any vitamins or other supplements to ensure optimal nutrition: Is there something I can give her so that she will EAT? She tells you that she is still offering Sarah a bottle just to get some calories into her. Sarah drinks up to 32 oz of whole milk a day and 8 to 12 ounces of juice per day from the bottle. Question 4: At what age do you recommend weaning to a cup and why? Cup drinking can be introduced as early as 6 months and is usually mastered between 9-15 months due to improving motor skills Reasons to wean the bottle: Dental caries: By 15 months, toddlers have teeth. Walking around with a bottle or sippy cup all day or taking one to bed greatly increases a child s risk of developing caries as this increases the frequency of the teeth s exposure to carbohydrates. Good advice is to offer only water in sippy cups between meals and snacks. Volume regulation: Drinking from a bottle allows large volumes to be consumed. 3

4 Most infants/toddlers will significantly decrease their intake of milk when weaned from the bottle. This can be problematic for infants weaned early because formula is their main source of calories until about 9 months of age. Question 5: How much and what types of milk are recommended for toddlers each day? Ages months: 12 to 24 ounces of breast milk, whole cow s milk or soy milk per day. Ages 2 to 5 year: same volume but can change to reduced fat (2%), or low fat (1%), depending on child s weight status and other dietary fat intake. There is some controversy around this decision (see article by Ludwig to read alternate viewpoint) Reduced fat milk has the same amount of calcium and vitamin D as whole milk (commonly labeled as Vitamin D milk) only the fat content is reduced. Whole milk has approximately 3.5% fat, not 100% as parents may think. Consequently, 2% milk is labeled reduced fat, not low fat. Whole milk is the single largest source of saturated fat in the American diet. Most all of the milks available now (dairy and nondairy) contain a substantial part of the calcium and Vitamin D needed for a toddler (see Table below for comparison of dairy and nondairy milks) Toddler RDA (recommended daily allowance) for Vit D is 600 IU/day - 16 oz milk gives ~200 IU/day so need to get the rest from other sources (dairy products, sun) Toddler RDA for Calcium is 700 mg/day 16 oz milk gives 600 mg/day Content of Milk per 8 ounces skim 1% 2% Whole Kcal Protein (g) CHO (g) Fat (g) Saturated fat (g) Cholesterol (mg) vitamin D (IU) Calcium (mg)

5 Comparison of dairy and non-dairy milks 1% Cow Milk Unsweetened soy Unsweetened Almond Unsweetened Rice Unsweetened Coconut Unsweetened Hemp Calories Protein (g) Fat (g) Vit D fort* Ca fort * Source: Cleveland Clinic website: * Different brands of nondairy milks contain different amounts of Ca and Vit D read labels Question 6: What are possible consequences of drinking too much milk per day? Milk is very filling (150 kcals/8oz whole milk) and can replace other nutritional foods. Excessive cow milk can contribute to obesity, especially if the milk is not replacing other foods but is being given in addition to other foods. Not only is cow milk low in iron, it also interferes with iron absorption from other foods. Question 7: What are the fruit juice recommendations for toddlers according to the AAP Committee on Nutrition? Summary of statement recommendations: Juice should not be introduced into the diet of infants before 6 months of age. Infants should not be given juice from bottles or easily transportable covered cups that allow them to consume juice easily throughout the day. Infants should not be given juice at bedtime. Intake of fruit juice should be limited to 4 to 6 oz/day for children 1 to 6 years old. Only pasteurized juice should be consumed. In the evaluation of children with malnutrition (over-nutrition and under-nutrition), the health care provider should determine the amount of juice being consumed. Pediatricians should routinely discuss the use of 100% fruit juice and fruit drinks and should educate parents about differences between the two. Question 8: Does Sarah need vitamins or supplements? No routine supplementation is necessary for healthy growing children who consume a varied diet. However, you can consider supplementation for toddlers whose diets do not meet the following nutritional recommendations: Iron: daily need about 7-8 mg/day 5

6 Dietary sources: meat, fish, fortified cereal, dark green leafy vegetables, beans Vitamin D: daily AAP recommendation 400 IU Dietary sources: liver, fish and fish oil, fortified dairy products and juice, egg yolk Calcium: recommendations vary by age (see recently updated recommendations in Table below) Dietary sources: dairy products (milk, cheese, and yogurt) mg/8 oz 2 cups/day gives most toddlers enough calcium dark green leafy vegetables (bok choy, broccoli, kale, collards, beet greens). Although vegetables are a good source of calcium, one needs to eat a lot to meet daily requirements alone Ca fortified foods (OJ, cereal, bread, soy beverages, and tofu products), nuts almonds. Some cereals (e.g., whole bran cereals) contain phytates, which reduce bioavailability Source: PEDIATRICS Volume 134, Number 4, October 2014 Children s chewable multivitamins for children vary in content (see below) so if recommend multivitamin make sure you tell parents to look for one that has enough D and Ca. Also please caution parents that if they give chewables before age 3, due to potential choking hazard, they should crush them and sprinkle onto food. Flintstones Complete: Vit D3 600 IU, Calcium 100 mg Solaray Children s Chewable: Vit D3 400 IU, Calcium 30 mg Centrum Children s Chewable: Vit D3 400 IU, Calcium 0 Question 9: How do you advise Ms. Pfeiffer s concern regarding Sarah s poor appetite? Does the growth curve help you here? Tell her it is normal reassure her! Show her the growth curve which reveals that her weight for height is 50 th -75 th percentile. 6

7 Recommend 4-6 small meals per day. Snacks should be considered mini-meals and planned to balance the total day s nutrient intake. Keep portion sizes small - parents often overestimate appropriate portion sizes for young children. Children will increase their intake as portion sizes increase but can be overwhelmed by too large a portion. For preschoolers, it may be best to initially offer 1 tablespoon per year of age with more food provided according to appetite. Case 2: Preschooler Nutrition Trey s mother brought him in today for a 3 year old checkup. He has been healthy since his last visit with you. When you ask Trey s mother about his diet, she says, He eats worse than any of my other 3 children; I think he lives on air. She describes that one day he may eat only grapes, the next day only hotdogs or chicken nuggets. He won t eat any vegetables; his only fruits are grapes and oranges. He even refuses milk unless it has Quik added to it. When asked what foods he does eat, his mother replies, of course, he eats pizza, noodles, chicken nuggets, American cheese, rice, sweetened cereals and macaroni and cheese. He asks for juice all the time, so his mother recently switched to Sunny D since she thinks it s healthier. Look how thin his arms and legs are getting. He used to be such a chubby baby! See Trey s growth curves. Trey Growth Chart 1, Trey Growth Chart 2, Trey Growth Chart 3. He has a normal physical exam including normal behavior and a normal developmental assessment in the office. Question 10: Are Trey s sporadic eating habits for his age developmentally appropriate? Yes - Trey s eating habits are typical for preschoolers and can be better understood with review of this developmental stage. Since they are in a period of slowed growth, preschoolers interest in eating is unpredictable with typical period of disinterest in food or appetite suppression. Their shorter attention span often limits the time spent at the table (10-15 minutes is a reasonable expectation). Most preschoolers have moved from feeding on demand to eating in an adult pattern (3 meals per day and snacks). Their intake from meal to meal may be erratic, but their total daily energy intake remains relatively constant if caregivers offer a variety of healthy, developmentally-appropriate foods. Between 2 and 5 years of age, children become predictably wary of trying new foods and sometimes the variety slips to 4 or 5 favorite foods. This stage of food neophobia is a normal stage of development. Parents need reassurance. Food jags, the preferential eating of limited foods, such as the toddler s/preschooler s white diet are normal. Note, however, that this white diet 7

8 (pasta, rice, milk, etc.) may lead to nutritional deficiencies (iron, fiber). Frequent fast food (pizza and chicken nuggets) consumption provides excess calories, salt and fat. Question 11: Interpret Trey s growth curves in light of the diet his mother described. He was growing well along the 50th percentile for weight until age 2 when his weight increased to the 75th and now nearly 90th percentile. His BMI is at the 90th percentile which demonstrates that he is overweight (defined as a BMI 85th-95th percentile for age and gender). Note that it is important to look at the BMI curve. As this case demonstrates, weight and height percentiles may fall in the normal range when considered independently, but when weight is considered in relation to height, as expressed in BMI (kg/m 2 ), a problem may be identified. He is taking in more calories than he is expending He eats foods high in fat and drinks lots of juice. Sunny Delight label information ( - accessed ) shows that this fruit drink contains primarily sugar water with very little fruit juice. 8

9 Question 12: Using Trey s growth curve to guide you, what advice do you give to Trey s mother to optimize his nutrition? Reassure her that Trey is growing well and is supposed to be leaner than when he was an infant. If anything, he is gaining weight too fast. You can show Trey s mother that he is gaining weight faster than he is gaining height, which is a concerning trend if it continues. Successful approaches to addressing overweight in children include: Don t force food or use food as a reward. Reduce fruit juice intake to 6 ounces per day and change to 100% fruit juice Switch to low fat or fat free milk Limit fast foods and fried foods Limit portion sizes of calorie-dense foods Behavior modification for the family as a whole rather than just for the targeted child including increased physical activity Consider a referral to Nutritionist for family nutritional education to supplement your advice Limit screen time (TV, videos, computer- and video games) to < 2 hours daily Frequent follow-up to assess growth and response to family-based changes Schedule a return visit in several months to assess weight gain, rather than waiting 1 year until next well visit. Other ideas to share with the parent: Use mealtime to model and encourage healthy eating habits. Preschoolers are aware of the social aspects of eating. By interacting with other children and adults at the table, they learn when and where eating takes place, what types of foods are consumed at certain times (e.g., desserts) how much of these foods are consumed at a meal (e.g., finish your vegetables ). Food acceptance in children can be improved with 1) repeated exposures (between 8-15) to new foods and 2) with opportunities to learn about food and eating (seeing where food is grown, helping with shopping for and preparing food, etc). 9

10 Take home points: AAP Yellow Book 7 th ed. (Chapter 7, page 154) states that caregivers and children should share responsibility for feeding Caregiver s responsibilities are to: Choose food Set mealtime routines Create positive mealtime environments that are free from distractions with positive physical components (chair, table, utensils, etc.) Use mealtime as a time of learning and mastery with respect to eating and social skills Model good eating behaviors Children s responsibilities are to: Participate in food selection Determine how much to eat at each occasion General comments to practitioners: Provide anticipatory guidance at well child visits to promote healthy eating habits. Make guidance relevant to children s individual development and growth patterns. Help parents anticipate and address developmental problematic feeding behaviors. General recommendations for feeding: Do not give cow s milk before the first birthday. Change to reduced fat milk after second birthday. Limit 100% fruit juice to 4 to 6 oz/day and do not start before 6 months of age. Do not give fruit drinks or pop/soda for children 1 to 6 years of age (8-12 for children 7-18 years) AAP Yellow Book, 6 th ed, p 164. Gradually increase the variety of vegetable and fruits on a daily basis-- emphasizing dark green, leafy, dark yellow and colorful fruits. Beginning at 6 months of age, plain pureed meats should be offered instead of commercially prepared dinners. Older children should be offered other meats that they can chew easily (chicken, turkey, fish and ground meat). Limit the frequency the child is offered sweets, desserts, sweetened beverages and salty snacks. Nutrient dense age-appropriate foods like fruit, cheese, yogurt and cereal are good alternatives. When new foods are introduced, tasting opportunities often need to occur approximately 10 times before the new food is accepted. 10

11 Do not use food as a reward. Recommended toddler feeding practices: Allow toddlers to eat the family meal rather than specially prepared foods that are bland and too familiar. Sharing meals as a family often helps the reluctant eater to model the feeding behaviors of her sibs/parents. Teach children to recognize hunger and satiety cues. Feed children when they are hungry. Do not force or bribe a child to eat, or use food as a reward. Stop the meal when the child indicates that he/she is full. Let toddlers get messy and play with foods as a way of experimenting with taste and texture. Providing more flavorful foods may help their acceptance (adding spices, dressings, or novel food presentations). Interestingly, breastfed babies are often more accepting of more variety of foods since they have been exposed to foods/tastes through their mother s breast milk. Engage toddlers and preschool children to help prepare foods as this also increases interest in new foods. 11

12 References: 1. Pediatric Basics: The Journal of Pediatric Nutrition and Development; 104:pp1-24, Spring Feeding Infants and Toddlers Study; Journal of the American Dietetic Association:104, Supplement 1, Jan Pediatric Nutrition Handbook, 7 th edition; American Academy Pediatrics 2013 (The Yellow Book). Chapter 7, pp American Academy of Pediatrics Committee on Nutrition: The Use and Misuse of Fruit Juice. Pediatrics 107 (5), May 2001, pp (reaffirmed October 2006). 5. Carol L. Wagner, MD, Frank R. Greer, MD, and the Section on Breastfeeding and Committee on Nutrition: Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents. Pediatrics 122 (5), Nov 1, 2008, pp Neville H. Golden, Steven A. Abrams, AAP Committee on Nutrition. Clinical Report: Optimizing Bone Health in Children and Adolescents. Pediatrics 134 (4). Oct IOM (Institute of Medicine) Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press. 8. Ludwig DS, Willett WC. Three daily servings of reduced-fat milk: an evidence-based recommendation? JAMA Pediatrics 2013 Sep;167(9):