The most recent representative large national sample

Continuing Education Feeding the Next Generation Nathalia Trees, MS, RD Johanna Dwyer, DSc, RD This review summarizes findings from the 2002 and 2008 Feeding Infants and Toddlers Studies on the dietary intakes of American children younger than 5 years old. It compares these findings to current dietary recommendations and concludes with recommendations and practical feeding guidelines for parents, health professionals, and community leaders. Nutr Today. 2012;47(6):281Y295 The most recent representative large national sample of the eating habits of infants and young children is the Feeding Infants and Toddlers Study (FITS 2002), a large national sample of infants and toddlers 4 to 24 months of age performed by Mathematica Policy Inc and sponsored by Gerber Products Company, now part of Nestlé. 1 Researchers of FITS 2002 collected data on the eating habits, food choices, portion sizes, and dietary intakes of 3022 infants and toddlers within the age parameters of the study. Nutrient intakes, food consumption patterns, eating habits, and food choices were compared with healthy-eating recommendations. The 2008 Feeding Infants and Toddlers Study (FITS 2008), also sponsored by Gerber, was an updated and expanded version of the prior study on the intakes of 3378 infants, toddlers, and preschoolers younger than 5 years. 2 It described the current feeding and consumption patterns of infants, toddlers, and preschoolers; identified any changes since 2002; and compared them with current recommendations. AREAS OF CONCERN Table 1 describes key characteristics of FITS 2002 and FITS 2008, progress, and room for improvement. The specific findings are described below. Nathalia Trees, MS, RD, is a clinical dietitian at Eating Recovery Center in Denver, Colorado. She received her bachelor s of science degree from the University of Colorado at Colorado Springs. She recently completed her master s of science degree at the Tufts University Friedman School of Nutrition Science and Policy and her dietetic internship at the Frances Stern Nutrition Center at Tufts Medical Center, Boston, Massachusetts. Johanna Dwyer, DSc, RD, is senior scientist at the Jean Mayer USDA Human Nutrition Research Center on Aging and a professor of medicine and nutrition at the Friedman School of Nutrition Science and Policy and the Tufts University Medical School, Boston, Massachusetts. She is also the director of the Frances Stern Nutrition Center at Tufts Medical Center, Boston, Massachusetts. This work was supported in part with resources from the US Department of Agriculture Research Science under agreement no. 58-1950-7-707. Any opinions, findings, conclusions, or recommendations expressed here are those of the authors and do not necessarily reflect the view of the US Department of Agriculture. Dr Tree has no conflicts of interest to disclose. Dr Dwyer is the Editor-in-Chief of Nutrition Today. Correspondence: Nathalia Trees, MS, RD, Frances Stern Nutrition Center, Box 783, Boston, MA 02111 (Nathalia.Trees@gmail.com). DOI: 10.1097/NT.0b013e3182761e6a Despite progress, infants and toddlers eating habits still need improvement. In FITS 2002, the infants and toddlers intakes were nutritionally adequate. However, some areas needed improvement. For example, toddlers 12 to 24 months had inadequate dietary intakes of iron, fiber, and vitamin E. Five percent of infants 9 to 11 months and 35% of older infants 19 to 24 months of age were given low-fat or reduced-fat milk. A surprising 27% of infants 7 to 11 months did not consume even a single serving of fruits or vegetables on a given day. Among 15- to 18-month-olds, French fries were the most commonly consumed vegetable. Also, the daily consumption of desserts, sweets, and sweetened beverages had increased significantly with age from 36% among infants 6 to 8 months to 91% among older toddlers 19 to 24 months. 3 In FITS 2008, there were several areas still in need of improvement. Fruit and vegetable consumption remained low. The proportion of infants and toddlers not consuming any vegetables changed very little from 2002, other than a lower consumption of French fries among 18- to 21- month-olds. Twenty-fiver percent of toddlers still did not consume a single serving of fruit on a given day, and 30% did not eat a single serving of vegetables. 4 Consumption of whole fruit and 100% fruit juice was also lower among toddlers 9 to 12 months of age than in 2002. Consumption of French fries was lower among older toddlers than in 2002, but fries continued to be the most popular vegetable among preschoolers with respect to excess. Also of concern was that fully 71% of toddlers and 84% of preschoolers consumed more sodium than recommended. IMPROVEMENTS Among the positive results in FITS 2008 were longer breastfeeding and more infants 4 to 6 months of age being breast-fed than in 2002. Fewer infants and toddlers 6 to 21 months of age were consuming sweets, desserts, candy, and sweetened beverages compared with the findings in 2002. Sweetened beverage consumption had also declined significantly among toddlers both in the 12- to 15- and 18-to 21-month age groups in 2008. PROBLEMS REMAINING The FITS telephone surveys were unable to determine rates of obesity among infants, toddlers, and preschoolers. Volume 47, Number 6, November/December 2012 Nutrition Today A 281

TABLE 1 Key Problems and Findings From Feeding Infants and Toddlers Study 1,2 2002 and 2008 Breast-feeding Some progress: Rates for infants ever breast-fed were high, but not significantly different over the 6 y (80% in 2008 vs 76% in 2002); rate of infants currently breast-feeding was significantly higher for infants 6Y9 mo (37% in 2008 vs 27% in 2002) and 9Y12 mo (37% in 2008 vs 21% in 2002) Iron intake No progress: Rates for iron intake among infants 6Y11 mo were not significantly different over the last 6 y; 12% in 2008 vs 7.5% in 2002 had inadequate iron intake Sodium intake No progress: Sodium intake increased; 71% of toddlers 12Y24 mo in 2008 exceeded both the adequate intake and maximum level of daily nutrient intake for sodium vs 64% of toddlers 12Y24 mo in 2002 Fat intake Some progress: Rates of consumed low-fat/skim milk improved for infants 9Y11 mo (5% in 2002 vs 17% in 2008); however, in 2008, 33% of toddlers 21Y24 mo consumed less than the recommended amount of total fat in their diet, and 75% of preschoolers 24Y36 mo consumed more than the recommended amount of saturated fat Sweets and sweetened beverage intake Some progress: Sweets and sweetened beverage consumption decreased slightly from 2002 to 2008; 36% vs 17% of infants 6Y8 mo, 59% vs 43% of infants 9Y11 mo, and 91% vs 60% of toddlers 12Y24 mo consumed sweets or sweetened beverages on a given day (continues) 282 Nutrition Today A Volume 47, Number 6, November/December 2012

TABLE 1 Key Problems and Findings From Feeding Infants and Toddlers Study 1,2 2002 and 2008, Continued Fruit intake No progress: Fruit intake declined among infants 6Y9 mo (25% in 2002 ate no fruit in a given day vs 35% in 2008) but improved among older infants 21Y24 mo (30% ate no fruit in a given day vs 25% in 2008) Vegetable intake No progress: No progress was made in vegetable consumption; 33% of infants 6Y9 mo and 20% of older infants 21Y24 mo ate no vegetables in a day vs 37% of infants 6Y9 mo and 30% of 21Y24 mo in 2008 Summarized from Devaney et al 1 and Briefel et al. 2 However, the National Health and Nutrition Examination Survey (NHANES), 5 monitors the national prevalence of overweight and obesity among children and adolescents and has produced such statistics. In the 2007Y2008 NHANES, obesity had increased 10.4% among children 2 to 5 years of age from 5.0% in 1971. Fully 9.5% of infants and toddlerswereatorabovethe95thpercentileoftheweight-forrecumbent-length growth charts. 5,6 Between 1999Y2000 and 2007Y2008 obesity rates appeared to stabilize, and no significant trends in the prevalence of obesity were evident for any age group, although they were still higher than desired. The 2002 and 2008 FITS survey data and other recent surveys suggest that some gaps exist between current dietary practices and recommended eating patterns for infants, toddlers, and preschoolers. These findings emphasize that food and beverage choices made by caregivers have an enormous impact, not only on the child s immediate nutrition, but also on the development of healthy-eating patterns as the child grows older. CURRENT FEEDING RECOMMENDATIONS Feeding recommendations have addressed issues such as breast-feeding duration; when to introduce complementary foods; poor iron status in some groups; low fruit and vegetable consumption; excessive intakes of sodium, saturated fat, and sweets and sweetened beverage; and increased obesity among infants and children. Current feeding recommendations for infants, toddlers, and preschoolers are detailed below. Dietary Reference Intakes of Macronutrients Table 2 presents the latest dietary references intakes for macronutrients for infants and children, as well as the most recent (2010) dietary references intakes for calcium and vitamin D and other micronutrients that were considered problems for infants and children in FITS 2002 and 2008. 7 With few exceptions, nutrient intakes in both FITS 2002 and 2008 were met. Exceptions included sodium, saturated fat, and energy intakes, which were excessive. In FITS 2008, sodium intakes were substantially higher than recommendations among toddlers and preschoolers, as 78% of preschoolers 24 to 72 months of age had exceeded the upper tolerable limit for sodium. Also, 76% of preschoolers had diets that exceeded 10% of energy as saturated fat, but were below the acceptable macronutrient distribution range for fat. Unfortunately, information on energy intakes of the infants, toddlers, and preschoolers surveyed in FITS 2008 could not be evaluated directly against the estimated energy requirements, because body weights and heights on the day of diet assessment were not available. However, the evidence from the 2007Y2008 NHANES reveals that a growing number of infants, toddlers, and preschoolers are becoming overweight and obese, suggesting that excessive energy intake remains a problem. Volume 47, Number 6, November/December 2012 Nutrition Today A 283

TABLE 2 Dietary Reference Intakes Acceptable Macronutrient Distribution Ranges for Children 7 Range (% of Energy) Macronutrient Children 1 3 y Children 4 8 y Fat 30%Y40% 25%Y35% n-6 polyunsaturated fatty acids (linoleic acid) 5%Y10% 5%Y10% n-3 polyunsaturated fatty acids (>-linolenic acid) 0.6%Y1.2% 0.6%Y1.2% Dietary cholesterol, trans-fatty acids, and saturated fatty acids As low as possible while consuming a nutritionally adequate diet Carbohydrate 45%Y65% 45%Y65% Added sugars Limit to no 925% Protein 5%Y20% 10%Y30% Dietary Reference Intakes (Micronutrients) 7 Nutrient Age Range RDA/AI a UL Sodium, mg/d Infants 0Y6 mo 120 ND 7Y12 mo 370 ND Children 1Y3 y 1000 1500 4Y8 y 1200 1900 Potassium, mg/d Infants 0Y6 mo 400 None 7Y12 mo 700 Children 1Y3 y 3000 4Y8 y 3800 Calcium, mg/d Infants 0Y6 mo 200 1000 7Y12 mo 260 1500 Children 1Y3y 700 2500 4Y8 y 1000 2500 Iron, mg/d Infants 0Y6 mo 0.27 40 7Y12 mo 11 40 Children 1Y3y 7 40 4Y8 y 10 40 Folate, Kg/d Infants 0Y6mo 65 ND 7Y12 mo 80 ND Children 1Y3y 150 300 4Y8 y 200 400 (continues) 284 Nutrition Today A Volume 47, Number 6, November/December 2012

TABLE 2 Dietary Reference Intakes, Continued Dietary Reference Intakes (Micronutrients) 7 Nutrient Age Range RDA/AI a UL Vitamin A, Kg/d Infants 0Y6 mo 400 600 7Y12 mo 500 600 Children 1Y3 y 300 600 4Y8 y 400 900 Vitamin D, IU/d Infants 0Y6 mo 400 1000 7Y12 mo 400 1500 Children 1Y3 y 600 2500 4Y8 y 600 3000 Vitamin E, mg/d Infants 0Y6 mo 4 ND 7Y12 mo 5 ND Children 1Y3 y 6 200 4Y8 y 7 300 Abbreviations: AI, adequate intakes; ND, not determinable because of lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts; RDA, recommended dietary allowance; UL, the maximum level of daily nutrient intake that is likely to pose no risk of adverse effects. Summarized from Institute of Medicine, Food and Nutrition Board, Dietary Reference Intakes. 7 a RDAs in bold type, AIs in ordinary type. Current child-feeding recommendations point the way forward. Dietary Guidelines for Americans Dietary guidelines for infants, toddlers, and preschoolers are established to help parents to initiate and sustain appropriate feeding patterns. Many of these recommendations for children younger than 5 years come from the 2005 and 2010 Dietary Guidelines, which aim to help translate scientific evidence into practical behaviors and practices that promote healthy living and prevent diet-related diseases for all Americans. 8,9 In contrast to the 2005 Dietary Guidelines, the 2010 Dietary Guidelines have singled out overweight and obesity for attention in young children 2 years or older. They also focus on a total diet approach, with an emphasis on energy balance and nutrient adequacy. Table 3 provides key messages for children 2 years or older from the 2010 Dietary Guidelines Advisory Report that includes topics such as solid fats, added sugars, and physical activity needs based on age. Healthy People Healthy People 2010 provided health promotion and disease prevention objectives for Americans to achieve by 2010. 10 The Healthy People 2020 nutrition objectives continue to focus on health promotion and disease prevention. Like the 2010 objectives, it also emphasizes that efforts to change eating habits and weight should address individual behaviors, along with policies and environments that support these behaviors in settings such as schools, work sites, healthcare organizations, and communities. 11 The 2 overarching goals of both the 2010 and 2020 objectives are to increase the quality and number of healthy years of life for Americans and to eliminate health disparities. Table 4 compares the objectives, baselines, and targets for children 5 years or younger for both Healthy People 2010 and 2020 and demonstrates that progress and backsliding have occurred since the previous decade. Recent American Academy of Pediatrics Statements The American Academy of Pediatrics offers recommendations for infants that address issues such as breast-feeding frequency and duration; formula preparation, frequency, Volume 47, Number 6, November/December 2012 Nutrition Today A 285

TABLE 3 Comparison of 2005 and 2010 Dietary Guidelines for Americans for Children Older Than 2 Years of Age 8,9 Weight gain/growth Dietary Guidelines 2005 Balance dietary calories with physical activity; infants and young children should not be overfed or forced to finish meals Dietary Guidelines 2010 (Updated 2011) Eat nutrient-dense foods such as fruits, vegetables, and low-fat dairy; use the MyPyramid tool to determine calorie needs Energy balance Carbohydrates Balance calories from foods and beverages with calories expended Reduce surplus energy intake from foods and beverages that contain added sugars, solid fats, and little else Eat a healthy breakfast and choose nutrient-dense, minimally processed snacks Refined grains Limit refined grains Limit consumption of refined grains Whole grains Make at least half the grains whole Whole grains: children 1Y3 y: 91.5 oz/d whole grains, children 4Y8y: 92-oz/d Fruits and vegetables Consume a variety of fruits and vegetables daily Children 1Y6 y: limit juice intake to 4Y6 oz/d Children aged Q2 y: limit juice intake to 4 oz of 100% juice/d % Calories from fat Children 2Y3 y of age: 30%Y35% of calories from fat Unchanged Children 4Y8 y of age: 25%Y35% of calories from fat % Saturated fatty acids G10% of total energy intake Lower; G7% of total energy intake % Monounsaturated and polyunsaturated fat Most fats should be monounsaturated and polyunsaturated fats Unchanged Cholesterol G300 mg/d Unchanged % trans-fatty acids Low as possible Limit to G0.5% of calories Meat, poultry, beans, and fish Should be lean, low-fat, or fat-free Increase consumption of omega-3 fatty acids; consumption of 3Y6 oz of seafood per week for children 2Y8 y Dairy products Children 2Y8 y:92 cups/d of fat-free or low-fat milk Children 2Y8 y:93 servings of low-fat dairy products Sodium Prepare foods with little salt Unchanged 1Y3 y of age 4Y8 y of age Potassium 1Y3 y of age 4Y8 y of age Consume approximately 1000 mg/d (AI) and G1500 mg/d (UL) Consume approximately 1200 mg/d (AI) and G1900 mg/d (UL) Consume potassium rich-foods, such as fruits and vegetables Consume 3000 mg/d (AI) Consume 3800 mg/d (AI) Unchanged (continues) 286 Nutrition Today A Volume 47, Number 6, November/December 2012

TABLE 3 Comparison of 2005 and 2010 Dietary Guidelines for Americans for Children Older Than 2 Years of Age 8,9, Continued Dietary Guidelines 2010 Dietary Guidelines 2005 (Updated 2011) Calcium Children 1Y3 y: 500 mg/d (RDA) Children 1Y3 y: 700 mg/d (RDA) Children 4Y8 y: 800 mg/d (RDA) Children 4Y8 y: 1000 mg/d (RDA) Vitamin D Children 0Y5 y: 200 IU/d (AI) Children 1Y8 y: 600 IU/d (AI) Vitamin D supplements are an alternative if food sources are not evident Fiber The recommended intake is 14 g per 1000 calories Children 1Y3 y: 14 g of fiber/d (AI) Children 4Y8 y Female: 17 g of fiber/d (AI) Males: 20 g of fiber/d (AI) Solid fats and added sugars Called discretionary calories in 2005 Solid fats and added sugars: G5%Y15% of total calories Children aged Q2 y currently consume 935% Abbreviations: AI, adequate intake; RDA, recommended dietary allowance; UL, tolerable upper limit. Summarized from Nutrition and Your Health: Dietary Guidelines for Americans, 2005 8 and Dietary Guidelines for Americans, 2010. 9 TABLE 4 Objectives, Baselines, and Targets for Healthy People 2010 and 2020 Weight gain/growth Healthy People 2010 Objectives 10 Healthy People 2020 Objectives 11 Reduce the proportion of children and adolescents who are overweight and obese Reduce the proportion of children 2Y5 y who are obese Baseline: 11% of children aged 6Y19 y are overweight or obese (unknown percentage of children 2Y5 y of age) Baseline: 10.7% of children aged 2Y5 y were overweight or obese in 2005Y2008 Unknown percentage of children 2Y5 years of age Target: 9.6% Target: 5% Evaluation: no progress Breast-feeding Increase the proportion of mothers who breast-feed their babies Ever Increase the percentage of infants who are breast-fed Ever Baseline: 64% Baseline: 74% Target: 75% Target: 82% At 6 mo At 6 mo Baseline: 29% Baseline: 43% Target: 50% Target: 61% (continues) Volume 47, Number 6, November/December 2012 Nutrition Today A 287

TABLE 4 Objectives, Baselines, and Targets for Healthy People 2010 and 2020, Continued Healthy People 2010 Objectives 10 Healthy People 2020 Objectives 11 At 1 y At 1 y Baseline: 16% Baseline: 23% Target: 25% Target: 34% Exclusively for 3 mo Exclusively through 3 mo Baseline: 31% Baseline: 33% Target: 40% Target: 44% Exclusively for 6 mo Exclusively through 6 mo Baseline: 11% Baseline: 14% Target: 17% Target: 24% Evaluation: progress observed, breast-feeding rates increased for immediate and 6 and 12 mo postpartum; still room for improvement Calcium Sodium Grains Fat Increase the proportion of persons aged Q2 y who meet dietary recommendations for calcium Baseline: 45% of persons 92 y were at or above mean calcium requirements Target: 74% Evaluation: No progress Increase the proportion of persons aged Q2 y who consume e2400 mg of sodium daily Baseline: 21% of persons aged Q2 y consumed e2400 mg of sodium/d Target: 65% Evaluation: backsliding, the average intake by persons aged 92 y remains well above 2400 mg/d Increase the proportion of persons aged Q2 y who consume at least 6 daily servings of grain products, with at least 3 being whole grains Baseline: 7% of children 92 y consumed at least 6 servings/d of grain products, with at least half being whole grains Target: 50% Evaluation: backsliding: whole-grain consumption decreased from 1.0 to 0.8 servings/d Increase the proportion of persons aged Q2 y who consume no more than 30% of calories from total fat Baseline: 33% consumed no more than 30% of daily calories from total fat Increase consumption of calcium aged Q2 y Baseline: mean total intakes of children 92 y 1120 mg of calcium Target: 1300 mg Reduce consumption of sodium in the population aged Q2 y Baseline: mean total intake of persons 92 y in 2003Y2006 was 3640 mg of sodium/d Target: 2300 mg/d Increase the contribution of whole grains to the diets of the population aged Q2 y Baseline: 0.3-oz equivalents of whole grains per 1000 calories were the mean daily intake by persons aged Q2 y Target: 0.6-oz equivalents per 1000 calories Reduce consumption of calories from solid fats and added sugars in aged Q2 y Baseline: 35% was the mean percentage of total daily calorie intake provided by solid fats and added sugars (continues) 288 Nutrition Today A Volume 47, Number 6, November/December 2012

TABLE 4 Objectives, Baselines, and Targets for Healthy People 2010 and 2020, Continued Healthy People 2010 Objectives 10 Healthy People 2020 Objectives 11 Target: 75% Target: 30% Evaluation: no progress Saturated fat Reduce the proportion of persons aged Q2 y who consume 9% of calories from saturated fat Baseline: 64% consumed 910% of daily calories from saturated fat Reduce consumption of saturated fat in the population aged Q2 y Baseline: 11% was the mean percentage of total daily calorie intake provided by saturated fat for the population aged Q2 y Target: 25% Target: 10% Evaluation: no progress was achieved in decreasing the consumption of saturated fat Fruit Vegetables Increase the proportion of persons aged Q2 y who consume at least 2 daily servings of fruit Baseline: 28% consumed at least 2 daily servings of fruit Target: 75% Evaluation: no progress Increase the proportion of persons aged Q2 y who consume at least 3 daily servings of vegetables, with at least one-third being dark green or orange vegetables Baseline: 3% consumed at least 3 daily servings of vegetables, with at least one-third of these servings being dark green or orange vegetables Target: 50% Increase the contribution of fruits to the diets of the population aged Q2 y Baseline: 0.5 cup equivalents of fruits per 1000 calories was the mean daily intake by persons aged Q2 y Target: 0.9 cup equivalents per 1000 calories Increase the variety and contribution of vegetables to the diets of the population aged Q2 y Baseline: 0.8 cup equivalents of total vegetables per 1000 calories was the mean daily intake by those aged Q2 y Target: 1.1 cup equivalents per 1000 calories Evaluation: backsliding: the vegetable consumption for children 92 y declined from 3.4 to 3.2 servings, with no noted change in the daily consumption of dark green or orange vegetables (0.3 servings) Summarized from Healthy People 2010 10 and Proposed Healthy People 2020 Objectives. 11 and amount; the introduction of complementary foods; iron supplementation; juice consumption; and physical activity, among others. 12Y14 For children older than 2 years, the American Academy of Pediatrics focuses on emphasizing family mealtimes, energy balance, portion control, and physical activity. Detailed recommendations are provided in Table 5. US Department of Agriculture s MyPyramid Table 6 describes dietary patterns for different energy intake levels for children 2 years or older. The US Department of Agriculture Food Guide Pyramid, now called MyPyramid, is designed to identify individual dietary patterns and to provide adequate nutrient intakes while meeting but not exceeding energy needs. 15 There are 5 food groups within the pyramid: grains, vegetables, fruits, dairy, and protein foods. The purpose of the pyramid is to educate consumers and to help translate the nutritional recommendations from the most recent Dietary Guidelines on the kinds and amounts of food an individual should consume in a given day. Physical Activity Physical activity helps to control weight and reduce obesity risk. For children, regular physical activity and exercise are especially important for building muscles, joints, and strong bones. According to the National Association of Sports and Physical Education, an organization of professionals supporting and assisting professionals involved Volume 47, Number 6, November/December 2012 Nutrition Today A 289

TABLE 5 Current Feeding Recommendations From the American Academy of Pediatrics Statements From 2005 to Present 12 14 Birth-2 y Breast-feeding Iron Recommendations Exclusively breast-feed a minimum of 4 mo, preferably 6 mo and maintain breast-feeding for 12 mo (breast-feeding should be 8Y12 times/d and every 2Y4 h or as needed; formula feedings should be 6Y8 times/d of 16Y24 oz, decreasing to 3Y4 feedings/d with the amount of formula increasing to 6-8 oz/feed) Premature infants need 2 mg/kg of oral iron/d until 1 y of age Breast-fed infants need 1 mg/kg/d of oral iron beginning at 4 mo of age until appropriate iron-containing complementary foods are introduced Infants 7Y12 mo need the RDA for iron (11 mg/d) Iron needs for formula-fed infants are met during the first 12 mo (iron content of formula: 12 mg/dl) Introduce iron-containing complementary foods after 4 to 6 mo of age Vitamin K Vitamin D Sodium All infants should receive 1.0 mg of vitamin K intramuscularly at birth All infants should receive 400 IU/d of oral vitamin D beginning in the first few days of life G1000 mg/d for 1Y3 y G1200 mg/d for 4Y8 y Solid food Introduce complementary foods rich in iron gradually near 6 mo of age Preterm and low-birth-weight infants may require iron supplementation before 6 mo of age Introduce new foods 6Y10 times to encourage acceptance Delay the introduction of cow s milk until 1 y of age. The milk should be whole cow s milk until 2 y of age Juice Physical activity 2Y6 y Mealtime Juice may be introduced in the diet after 6 mo; 100% juices should be used and limited to 4Y6oz/d. At least 30 min of structured playtime and 960 min of unstructured playtime should be encouraged for children up to 2 y of age (see Table 7 for more information) Recommendations Parents should be the ones to choose mealtimes, not children Have regular family meals to promote social interaction Avoid using food as a reward or punishment Energy balance and portion control Allow self-regulation of total caloric intake if the child has a normal body mass index or weight for height Limit snacking when child is sedentary or in response to boredom Restrict use of sweet/sweetened beverages as snacks (eg, juice, soda, sports drinks) Pay attention to portion size; serve portions appropriate for the child s size and age Fruit and vegetables Milk Provide a wide variety of nutrient-dense foods such as fruits and vegetables instead of high-energy-density/nutrient-poor foods Use nonfat or low-fat dairy products as sources of calcium and protein Physical activity Encourage 60 min of vigorous playtime and limit sedentary behaviors, with no more than 1Y2 h/d of video screen/television Abbreviation: RDA, recommended dietary allowance. Summarized from American Academy of Pediatrics, Committee on Nutrition, 12 American Academy of Pediatrics Section on Breastfeeding, 13 and Baker and Greer. 14 290 Nutrition Today A Volume 47, Number 6, November/December 2012

TABLE 6 MyPyramid Daily Food Intake for Different Calorie Levels for Children >2 Years From the US Department of Agriculture 15 Calorie Level Food group 1000 kcal 1200 kcal 1400 kcal 1600 kcal 1800 kcal 2000 kcal Fruits 1 cup 1 cup 1.5 cups 1.5 cups 1.5 cups 2 cups Vegetables 1 cup 1.5 cups 1.5 cups 2 cups 2.5 cups 2.5 cups Grains 3 oz 4 oz 5 oz 5 oz 6 oz 6 oz Meats and beans 2 oz 3 oz 4 oz 5 oz 5 oz 5.5 oz Milk 2 cups 2 cups 2 cups 3 cups 3 cups 3 cups Oils 3 tsp 4 tsp 4 tsp 5 tsp 5 tsp 6 tsp Discretionary calories 165 171 171 132 195 267 Summarized from MyPyramid Food Intake Patterns: US Department of Agriculture Web site. 15 in all specialties related to achieving a healthy and active lifestyle, children from birth to age 5 years should engage daily in physical activity that promotes movement skillfulness and foundations of health-related fitness. 16 Therefore, the National Association of Sports and Physical Education developed specific guidelines for the physical activity of children from birth to age 5 years. Table 7 provides a summary of those recommendations. More recently, First Lady Michelle Obama launched Let s MoveVAmerica s Move to Raise a Healthier Generation of Kids, a national campaign to curb the child obesity epidemic in the United States. 17 Through the Let s Move Web TABLE 7 Physical Activity Guidelines for Infants, Toddlers, and Preschoolers There are 5 guidelines for each age group, and they are intended to answer questions relative to the kind of physical activity, the environment, and the individuals responsible for facilitating the activity. 16 Infants (birth to 12 mo) Infants should interact with parents and/or caregivers in daily physical activities that are dedicated to promoting the exploration of their environment Infants should be placed in safe settings that facilitate physical activity and do not restrict movement for prolonged periods Infants physical activity should promote the development of movement skills Infants should have an environment that meets or exceeds recommended safety standards for performing large muscle activities Individuals responsible for the well-being of infants should be aware of the importance of physical activity and facilitate the child s movement skills Toddlers (12Y36 mo) Preschoolers (3Y5 y) Accumulate at least 30 min daily of structured physical activity and at least 60 min of unstructured physical activity daily Limit sedentary time to no more than 1 h at a time except when sleeping Accumulate at least 60 min of structured physical activity, and limit sedentary time to G1 h at a time Develop competence in movement skills that are building blocks for more complex movement tasks Develop movement skills that are building blocks for more complex movement tasks Summarized from National Association for Sport and Child s Movement Skills. 16 Have indoor and outdoor areas that meet or exceed recommended safety standards for performing large muscle activities Volume 47, Number 6, November/December 2012 Nutrition Today A 291

TABLE 8 Key Behaviors and Potential Strategies for Parents 18 20 Topic Area Key Parent Behaviors Potential Strategies for Parents Breast-feeding and complementary foods Encourage exclusive breast-feeding until 6 mo of age Introduce complementary foods when child is developmentally ready (4Y6 mo), signaled by holding head up, sitting well in highchair, making chewing motions, exhibiting significant weight gain (birth weight doubled), showing interest in food, teething and/or able to move food from front to back of mouth Incorporate new foods and meal variety Wean from the bottle to the cup before 12 mo of age Portion control and energy balance Ensure adequate portion sizes and energy balance Choose healthy options at snacks Offer new foods repeatedly (at least 6Y10 times) Allow infants to control mealtime and how much breast milk, formula, or solid foods will be consumed Avoid coaxing the child to eat more food or using food as a reward Infants and toddlers (12Y24 mo) usually consume 2 snacks per day equal to 100Y150 kcal; eg, 2 cup whole milk yogurt + 3 cup strawberries, 2 cup soft-cooked carrots + 1Y2 tbsp hummus, or 2 whole-wheat crackers + 2 oz cubed cheese Keep milk intake to 16Y24 oz/d (more may displace other nutrients or add excess energy) Avoid sugar-sweetened beverages such as soda; avoid snack foods such as French fries and potato chips Physical activity Limit screen time and sedentary behavior Avoid television in the infant s bedroom Give ample time for active play, with both structured and unstructured playtime The strategies presented in this table are not evidence-based recommendations. They are presented as helpful hints for parents based on the eating patterns for infants 6 to 24 months of age. Summarized from Barlow and the Expert Committee, 18 Krebs and Jacobson, 19 and the American Dietetic Association. 20 site, parents, educators, health professionals, and community leaders are able to easily access resources to help engage children in healthy lifestyle behaviors and fulfill the desired physical activity recommendations. PRACTICAL STEPS TO TAKE NEXT Although these professional associations provide much useful advice on feeding strategies, a renewed focus is needed if the recommendations are to be put into practice and lead to improved overall eating habits. Transition periods such as the 6- to 24-month-age period need more attention, as it is during this time that adding variety and healthier food choices in appropriate portion sizes should begin. Table 8 provides such guidance. Key points include exclusive breastfeeding until 6 months of age, introducing complementary foods during developmental milestones such as when the child can make chewing gestures or shows interest in food, weaning from the bottle, and limiting excessive milk and juice intake. 18Y20 Another challenge that parents and caregivers face is sustaining and enhancing these healthy-eating patterns throughout the preschool years. Recent reports indicate that the major contributors to excess energy intakes in 292 Nutrition Today A Volume 47, Number 6, November/December 2012

TABLE 9 Key Behaviors and Potential Strategies for Parents 18 20 Topic Area Key Behaviors Potential Strategies for Parents Calorie intake Ensure foods and drinks meet calorie needs Complete transition to a modified adult diet by age 3 y Encourage 3 meals per day at the table with other family members Role model mealtime and food behaviors Encourage family members to make healthy food choices and be good role models. Involve children in food purchasing and allow them to help select healthy foods Involve your child in the food preparation process (ie, washing vegetables, pouring and stirring ingredients) Present new foods in small quantities and encourage children to take a bites Ensure adequate portion sizes and energy balance Watch portion sizes: make certain diet is consistent with the recommendations of the Dietary Guidelines and MyPyramid Fruit and vegetables Increase fruit and vegetable intake and include more variety Encourage breakfast daily and snacks that are low in fat, sodium, and refined sugar Limit eating at fast food restaurants and emphasize family meals Consume at least 5 servings of fruits and vegetables each day; have them in a prominent location in the refrigerator Urge daycare and schools to serve fresh fruits and vegetables instead of chips and salty snacks Physical activity Limit screen time and sedentary behavior Limit television viewing to G2 h/d Make sure children have at least 60 min of physical activity/d The strategies presented in this table are not evidence-based recommendations. They are presented as helpful hints for parents based on the eating patterns for toddlers 2 years or older. Summarized from Barlow and the Expert Committee, 18 Krebs and Jacobson, 19 and the American Dietetic Association. 20 older toddlers 2 years or older are sugar-sweetened beverages, grain-based desserts, and foods high in solid fats. 21 Table 9 provides suggestions for toddlers 2 years or older on positive eating patterns and avoidance of excess calorie consumption. Key topics include meal consistency, food refusal, structured and unstructured playtime, food purchasing, meal preparation, and portion control. 18Y20 The most recent NHANES data indicate that the prevalence of infant and childhood obesity is no longer increasing, nor has it declined; it appears to be stable. 5 Although this stabilization may be due in part to the many efforts underway aimed at preventing childhood obesity, more time is needed before a decrease in fatness is evident. Table 10 summarizes those specific communitywide intervention strategies suggested by a committee of the Institute of Medicine, National Academy of Sciences, on ways to overcome the rising obesity rates among children. 22 The effectiveness of these recommendations has not yet been tested, but they represent the best thinking of experts at present. CONCLUSIONS The FITS 2008 survey suggested that parents were breastfeeding longer, delaying the introduction of complementary foods, and limiting fruit juice, sweetened beverages, and sweets in feeding young children. However, low intakes of iron-rich foods such as fortified infant cereal among Volume 47, Number 6, November/December 2012 Nutrition Today A 293

TABLE 10 Recommendations on Community Actions to Prevent Childhood Obesity 22 Improve access to and consumption of healthy, safe, and affordable foods. Increase community access to healthy foods through supermarkets, grocery stores, and convenience/corner stores. Improve the availability and identification of healthful foods in restaurants. Promote efforts to provide fruits and vegetables in a variety of settings, such as farmers markets, farm stands, mobile markets, community gardens, and youth-focused gardens. Ensure that publicly run entities such as after-school programs, child-care facilities, recreation centers, and local government work sites implement policies and practices to promote healthy foods and beverages and reduce or eliminate the availability of calorie-dense, nutrient-poor foods. Increase participation in federal, state, and local government nutrition assistance programs (eg, WIC, school breakfast and lunch, Child and Adult Care Food Program, Afterschool Snacks Program, and Supplemental Nutrition Assistance Program). Increase access to free, safe drinking water in public places to encourage water consumption in place of sugar-sweetened beverages. Reduce access to and consumption of calorie-dense, nutrient-poor foods. Implement fiscal policies and local ordinances to discourage the consumption of calorie-dense, nutrient-poor foods and beverages (eg, taxes, incentives, land use and zoning regulations). Raise awareness about the importance of healthy eating to prevent childhood obesity. Promote media and social marketing campaigns on healthy eating and childhood obesity prevention. Encourage physical activity. Encourage walking and bicycling for transportation and recreation through improvements in the built environment. Promote programs that support walking and bicycling for transportation. Promote other forms of recreational physical activity such as collaborating with school districts and other organizations to establish joint use of facilities agreements for allowing playing fields, playgrounds, and recreation centers to be used by community residents when schools are closed. Decrease sedentary behavior. Promote policies that reduce sedentary screen time. Abbreviation: WIC, The Special Supplemental Nutrition Program for Women, Infants, and Children. Summarized from Parker et al. 22 some infants 9 to 12 months of age, the use of cow s milk prior to 1 year of age, and low fruit and vegetable consumption among older infants 12 to 24 months of age continued to be of concern. Excessive sodium intake was common in both 2002 and 2008. The tolerable upper intake level for sodium was exceeded by a majority of toddlers and preschoolers and is likely related in part to salty snack intake and the increased use of canned and processed foods often given at this age, as reported by the findings in FITS 2008. Although use of reduced-fat milk in the second year of life is contraindicated, it is not clear if this has any adverse effects. Because children s diets largely reflect eating patterns within the household, nutrition professionals should use family-focused approaches to fostering the development of healthy-eating habits. Practitioners should encourage parents and caregivers to expose young children to a wide variety of fruits and vegetables and to limit consumption of low-nutrient, energy-dense foods and beverages, whether they are consumed as snacks or as part of meals. In the introduction of complementary foods, practitioners should reinforce the consumption of iron-fortified infant cereal followed by fruits and vegetables in appropriate portion sizes. A recent statement by the Committee of Nutrition of the American Academy of Pediatrics provides specific guidance for this period. After age 2 years, eating patterns should be consistent with the 2010 Dietary Guidelines for Americans, and the amounts of food in each meal should be based on the components provided by MyPyramid, specifying a wide variety of fruits and vegetables, at least half of grains to be in the form of whole grains, and monitoring 294 Nutrition Today A Volume 47, Number 6, November/December 2012

portion control. For preschoolers, caretakers are encouraged to provide alternatives to high-sodium finger foods such as French fries, crackers, and deli meats. To combat the ease of processed foods, caretakers should have quick, easy, and portable snacks that are nutrient-rich such as already peeled sweet potatoes or summer squash, low-fat cheese sticks, or whole fruits such as apples or grapes cut into bite-size portions. A focus on healthy eating should include everyone in the family, not just the children. Food preferences start early in life and are likely to last throughout adulthood. Therefore, educating caregivers to be good role models, implementing good dietary practices for the whole family, and delaying less desirable dietary practices are important goals for determining overall health. Although the findings in both FITS 2002 and 2008 indicate that caretakers have heard the messages about how to feed infants and are generally doing a good job, confusion remains regarding feeding transition periods, especially 6 to 24 months of age, and how to sustain these proper feeding behaviors among toddlers and preschoolers. More research is needed in these areas. REFERENCES 1. Devaney B, Ziegler P, Pac S, Karwe V, Barr S. Nutrient intakes of infants and toddlers. J Am Diet Assoc. 2004;104:S14YS21. 2. Briefel RR, Kalb LM, Condon E, et al. The Feeding Infants and Toddlers Study 2008: study design and methods. J Am Diet Assoc. 2010;110:S16YS26. 3. Dwyer JT, Suitor CW, Hendricks K. New insights and lessons learned. J Am Diet Assoc. 2004;104:S5YS9. 4. Butte NF, Fox MK, Briefel RR, et al. Nutrient intakes of US infants, toddlers, and preschoolers meet or exceed Dietary Reference Intakes. JAmDietAssoc. 2010;110:S27YS37. 5. NHANES Surveys (1976Y1980 and 2003Y2006): Centers for Disease Control and Prevention Web site. http://www.cdc.gov.ezproxy.library.tufts.edu/obesity/childhood/prevalence.html. Accessed February 16, 2011. 6. Ogden CL, Carroll MD, Flegal KM. High body mass index for age among U.S. children and adolescents, 2003Y2006. JAMA. 2008;299: 2401Y2405. 7. Institute of Medicine, Food and Nutrition Board: Dietary Reference Intakes. Applications in Dietary Assessment. Washington, DC: National Academies Press; (2000). 8. Nutrition and Your Health: Dietary Guidelines for Americans, 2005. Washington, DC: US Government Printing Office; 2005. 9. Dietary Guidelines for Americans 2010. Washington, DC: US Government Printing Office; 2010. 10. Healthy People 1020. Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office; 2000. 11. US Department of Health and Human Services. Proposed Healthy People 2020 Objectives. Washington, DC: USDHHS; 2009. 12. American Academy of Pediatrics Committee on Nutrition dietary recommendations for children and adolescents: a guide for Practitioners. Pediatrics. 2006;117:544Y559. 13. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115: 496Y506. 14. Baker RD, Greer FR. The Committee on Nutrition. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0Y3 years of age). Pediatrics. 2010;126: 1040Y1050. 15. MyPyramid Food Intake Patterns: US Department of Agriculture Web site. http://www.mypyramid.gov/downloads/mypyramid_ Food_Intake_Patterns.pdf. Accessed February 16, 2011. 16. National Association for Sport and Child s Movement Skills. Active Start: A Statement of Physical Activity Guidelines for Children Birth to Five Years. Reston, VA: NASPE; 2002:5Y11. www.aahperd.org/naspe. Accessed April 19, 2011. 17. Get Active Physical Activity 2010. http://www.letsmove.gov/get-active. Accessed April 12, 2011. 18. Barlow SE and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120:S164YS192. 19. Krebs NF, Jacobson MS. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112:424Y430. 20. American Dietetic Association. Childhood Overweight Evidence Analysis Project: updated 2006. www.adaevidencelibrary.com/ topic.cfm?cat_1046. Accessed November 29, 2010. 21. NHANES 2005Y2006. http://riskfactor.cancer.gov/diet/foodsources/. Accessed March 7, 2011. 22. Parker L, Burns AC, Sanchez E. Local Government Actions to Prevent Childhood Obesity. Washington, DC: National Academies Press; 2009. http://books.nap.edu/openbook.php?record_id= 12674&page=103. For more than 29 additional continuing education articles related to Nutrition topics, go to NursingCenter.com/CE. Volume 47, Number 6, November/December 2012 Nutrition Today A 295