Nutrition in Childhood

Growth Patterns

The rate of growth slows considerably after the first year of life. In contrast to the usual tripling of birth weight that occurs in the first 12 months, another year passes before the birth weight quadruples. Likewise, birth length increases by 50% in the first year but does not double until approximately the age of 4 years. Increments of change are small compared with those of infancy and adolescence; weight typically increases an average of 2 to 3 kg ( to  lb) per year until the child is 9 or 10 years old. Then the rate increases, signaling the approach of puberty. Height increase increments average 6 to 8 cm ( to inches) per year from 2 years of age until puberty.

Growth is generally steady and slow during the preschool and school age years, but it can be erratic in individual children, with periods of no growth followed by growth spurts. These patterns usually parallel similar changes in appetite and food intake. For parents, periods of slow growth and poor appetite can cause anxiety, leading to mealtime struggles.

Body proportions of young children change significantly after the first year. Head growth is minimal, trunk growth slows substantially, and limbs lengthen considerably, all of which create more mature body proportions. Walking and increased physical activity of the now erect child lead to the legs straightening and increased muscle strength in the abdomen and back.

The body composition of preschool and school age children remains relatively constant. Fat gradually decreases during the early childhood years, reaching a minimum between 4 and 6 years of age. Children then experience the adiposity rebound, or increase in body fatness in preparation for the pubertal growth spurt. Earlier adiposity rebound has been associated with increased adult body mass index (BMI) (Williams, 2009). A BMI at an “end” of the charts (e.g., less than 3rd or greater than 97th percentiles) requires careful evaluation to describe the degree of underweight or obesity (Flegal, 2009). Sex differences in body composition become increasingly apparent—boys have more lean body mass per centimeter of height than girls. Girls have a higher percentage of weight as fat than boys, even in the preschool years, but these differences in lean body mass and fat do not become significant until adolescence.

Assessing Growth

A complete nutritional assessment includes the collection of anthropometric data. This includes length or stature, weight, and weight-for-length or BMI, all of which are plotted on the Centers for Disease Control and Prevention (CDC) growth charts (see Appendixes 9 through 16). Other measurements that are less commonly used but that provide estimates of body composition include upper-arm circumference and triceps or subscapular skin folds. Care should be taken to use standardized equipment and techniques for obtaining and plotting growth measurements. Charts designed for birth to 36 months of age are based on length measurements and nude weights, whereas charts used for 2- to 20-year-olds are based on stature (standing height) and weight with light clothing and without shoes (see Chapter 6).

The proportion of weight to length or height is a critical element of growth assessment. This parameter is determined by plotting the weight-for-length on the WHO birth- to 24-month growth charts or calculating BMI and plotting it on the 2- to 20-year-old CDC growth charts. Growth measurements obtained at regular intervals provide information about an individual’s growth pattern. One-time measurements do not allow for interpretation of growth status. Growth channels are not well established until after 2 years of age. Children generally maintain their heights and weights in the same growth channels during the preschool and childhood years, although rates of growth can vary within a selected period.

Regular monitoring of growth enables problematic trends to be identified early and intervention initiated so that long-term growth is not compromised. Weight that increases rapidly and crosses growth channels suggests the development of obesity. Lack of weight gain or loss of weight over a period of months may be a result of undernutrition, an acute illness, an undiagnosed chronic disease, or significant emotional or family problems. However, many children are evaluated by health care professionals only when they are ill, so growth evaluation and development may not be a focus of care. Figure 18-1 demonstrates the changes that can occur in growth parameters.

Catch-Up Growth

A child who is recovering from an illness or undernutrition and whose growth has slowed or ceased experiences a greater than expected rate of recovery. This recovery is referred to as catch-up growth, a period during which the body strives to return to the child’s normal growth channel. The degree of growth suppression is influenced by the timing, severity, and duration of the precipitating cause, such as a severe illness or prolonged nutritional deprivation.

Initial studies supported the thesis that malnourished infants who did not experience immediate catch-up growth would have permanent growth retardation. However, studies of malnourished children from developing countries who subsequently received adequate nourishment, as well as reports of children who were malnourished because of chronic disease such as celiac disease or cystic fibrosis, have shown that these children caught up to their normal growth channels after the first year or two of life.

The nutritional requirements for catch-up growth depend on whether the child has overall stunted growth (both height and weight are proportionally low) and is chronically malnourished, or is primarily wasted, meaning that the weight deficit exceeds the height deficit. A chronically malnourished child may not be expected to gain more than 2-3 g/kg/day, whereas as a child who is primarily wasted may gain as much as 20 g/kg/day.

Nutrient requirements, especially for energy and protein, depend on the rate and stage of catch-up growth. For instance, more protein and energy are needed during the initial period of very rapid weight gain and for those in whom lean tissue is the major component of the weight gain. In addition to energy, other nutrients are important, including vitamin A, iron, and zinc.

Current growth parameters are used to evaluate the child’s weight in relation to age and stature, and to estimate a “desirable” or goal weight. Formulas are then used to estimate the minimum and maximum energy needed for catch-up growth. After a child who is wasted catches up in weight, dietary management must change to slow the weight gain velocity and avoid excessive gain. The catch-up in linear growth peaks approximately 1 to 3 months after treatment starts, whereas weight gain begins immediately.

Energy

The energy needs of healthy children are determined by basal metabolism, rate of growth, and energy expenditure of activity. Dietary energy must be sufficient to ensure growth and spare protein from being used for energy, but not allow excess weight gain. Suggested intake proportions of energy are 45% to 65% as carbohydrate, 30% to 40% as fat, and 5% to 20% as protein for 1- to 3-year-olds, with carbohydrates the same for 4- to 18-year-olds, 25% to 35% as fat, and 10% to 30% as protein (IOM, 2006).

The DRIs for estimated energy requirement (EER) are average energy requirements based on life-stage groupings for healthy individuals of normal weight. Toddlers 13 through 35 months are grouped together; for older children the EERs are divided by sex and age (3-8 years and 9-18 years.) The EER includes the total energy expenditure plus energy needed for growth (see Chapter 2). The DRIs are applied to child nutrition programs and other guidelines (IOM, 2006). See Box 18-1 for examples of determining EER for two children. On an individual basis, it can be useful to estimate energy requirements using kilocalories per kilogram of weight or per centimeter of height.

Protein

The need for protein decreases from approximately 1.1 g/kg in early childhood to 0.95 g/kg in late childhood (Table 18-1). Protein intake can range from 5% to 30% of total energy depending on age. Protein deficiency is uncommon in American children, partly because of the cultural emphasis on protein foods. National surveys show that less than 3% of children fail to meet the recommended dietary allowance (Moshfegh et al., 2005). Children who are most at risk for inadequate protein intake are those on strict vegan diets; those with multiple food allergies; or who have limited food selections because of fad diets, behavioral problems, or inadequate access to food.

Minerals and Vitamins

Minerals and vitamins are necessary for normal growth and development. Insufficient intake can cause impaired growth and result in deficiency diseases. See Chapter 3. The DRIs are listed inside the front cover.

Intake Patterns

Children are most likely to consume inadequate amounts of calcium, vitamin D, vitamin E, magnesium, and vitamin A (Moshfegh, 2009; Moshfegh et al., 2005). However, clinical signs of malnutrition in American children are rare.

Children’s food patterns have changed over the years. Although they drink less milk, more of it is low-fat or nonfat milk. The total fat as a percent of energy intake has decreased, but remains above recommendations. More energy comes from snacks, and portion sizes have increased. In addition, more food is consumed in environments other than the home (American Dietetic Association [ADA], 2008). Foods with low nutrient density (soft drinks, baked and dairy desserts, sweeteners, and salty snacks) often displace nutrient-dense foods (ADA, 2008). National food intake studies of children and adolescents indicate that most of their diets do not meet the national recommendations for food groups (ADA, 2008). Most children ages 2 to 3 years have high-quality diets; as they grow older, diet quality declines.

Like physical growth patterns, food intake patterns are not smooth and consistent. Although subjective, appetites usually follow the rate of growth and nutrient needs. By a child’s first birthday, milk consumption begins to decline. In the next year vegetable intake decreases; intakes of cereals, grain products, and sweets increase. Young children often prefer softer protein sources instead of meats that are harder to chew.

Changes in food consumption are reflected in nutrient intakes. The early preschool years show a decrease in calcium, phosphorus, riboflavin, iron, and vitamin A compared to infancy. Intakes of most other key nutrients remain relatively stable. During the early school years, a pattern of consistent and steadily increased intakes of most nutrients is seen until adolescence. In healthy children a wide variability of nutrient intake is seen at any age.

Factors Influencing Food Intake

Numerous influences, some obvious and others subtle, determine the food intake and habits of children. Habits, likes, and dislikes are established in the early years and carried through to adulthood. The major influences on food intake in the developing years include family environment, societal trends, the media, peer pressure, and illness or disease.

Feeding Preschool Children

From 1 to 6 years of age children experience vast developmental progress and acquisition of skills. One-year-old children primarily use fingers to eat and may need assistance with a cup. By 2 years of age, they can hold a cup in one hand and use a spoon well (see Figure 17-2, but may prefer to use their hands at times. Six-year-old children have refined skills and are beginning to use a knife for cutting and spreading.

As the growth rate slows after the first year of life, appetite decreases, which often concerns parents. Children have less interest in food and an increased interest in the world around them. They can develop food jags which can be periods when foods that were previously liked are refused, or there are repeated requests to eat the same food meal after meal. This behavior may be attributable to boredom with the usual foods or may be a means of asserting newly discovered independence. Parents may have concerns with their child’s seemingly irrational food behavior. Struggles over control of the eating situation are fruitless; no child can be forced to eat. This period is developmental and temporary.

A positive feeding relationship includes a division of responsibility between parents and children. Young children can choose a balanced nutritious diet if presented with nutritious foods. The parents and other adults provide safe, nutritious, developmentally appropriate food as regular meals and snacks; and the children decide how much, if any, they eat (Satter, 2000). Parents maintain control over what foods are offered and have the opportunity to set limits on inappropriate behaviors. Neither rigid control nor a laissez-faire approach is likely to succeed. Parents and other care providers should continue to offer a variety of foods, including the child’s favorites, and not make substitutions a routine.

With smaller stomach capacities and variable appetites, preschool children should be offered small servings of food four to six times a day. Snacks are as important as meals in contributing to the total daily nutrient intake. Carefully chosen snacks are those dense in nutrients and least likely to promote dental caries. A general rule of thumb is to offer 1 tablespoon of each food for every year of age and to serve more food according to the child’s appetite. Table 18-3 is a guide for food and portion size.

Senses other than taste play an important part in food acceptance by young children. They tend to avoid food with extreme temperatures, and some foods are rejected because of odor rather than taste. A sense of order in the food presentation is often required; many children will not accept foods that touch each other on the plate, and mixed dishes or casseroles with unidentifiable foods are not popular. Broken crackers may go uneaten or a sandwich may be refused because it is “cut the wrong way.”

The physical setting for meals is important. Children’s feet should be supported, and chair height should allow a comfortable reach to the table at chest height. Sturdy, child-size tables and chairs are ideal, or a high chair or booster seat should be used. Dishes and cups should be unbreakable and heavy enough to resist tipping. For very young children, a shallow bowl is often better than a plate for scooping. Thick, short-handled spoons and forks allow for an easier grasp.

Young children do not eat well if they are tired; this should be considered when meal and play times are scheduled. A quiet activity or rest immediately before eating is conducive to a relaxed, enjoyable meal. However, children also need active, large-motor activities and time in the fresh air to stimulate a good appetite.

Fruit juices and juice drinks are a common beverage for young children; they frequently replace water and milk in children’s diets. In addition to altering the diet’s nutrient content, excessive intake of fruit juice can result in carbohydrate malabsorption and chronic, nonspecific diarrhea (AAP, 2001). This suggests that juices, especially apple and pear, should be avoided when using liquids to treat acute diarrhea. For children with chronic diarrhea, a trial of restricting fruit juices may be warranted before more costly diagnostic tests are done.

When children aged 2 to 11 years consume 100% juice, their intakes have significantly higher intakes of energy, carbohydrates, vitamins C and B₆, potassium, riboflavin, magnesium, iron, and folate, and significantly lower intakes of total fat, saturated fatty acids, discretionary fat, and added sugar; this 100% juice intake does not correlate with overweight later (Nicklas et al., 2008). However, excess juice intake (12 to 30 oz/day) by young children may decrease a child’s appetite, resulting in decreased food intake and poor growth. Here, a reduction in juice intake results in improved growth (AAP, 2001). Fruit juice intake should be limited to 4-6 oz/day for children 1 through 6 years of age and 8-12 oz/day (in two servings) for older children and adolescents (AAP, 2009).

Large volumes of sweetened beverages, combined with other dietary and activity factors, may contribute to overweight in a child. High intake of fructose, especially from sucrose and high-fructose corn syrup in processed foods and beverages, may lead to increased plasma triglycerides and insulin resistance (Vos et al., 2008). In several studies, low calcium intake and obesity have been correlated with high intake of sugar-sweetened beverages in preschool children (Dubois et al., 2007; Keller et al., 2009; Lim et al., 2009). High milk and low sweetened-beverage intake is associated with improved nutrient intake, including calcium, potassium, magnesium, and vitamin A (O’Neil et al., 2009). Children should be offered milk, water, and healthy snacks throughout the day instead of sugar-sweetened choices.

Excess sodium is another concern. An increase in sodium or salt intake results in an increase in systolic blood pressure and diastolic blood pressure (ADA, 2010). A reduction in the use of processed foods may be warranted for children with elevated blood pressure. The Dietary Approaches to Stop Hypertension diet is useful for all age groups because it increases potassium, magnesium, and calcium in relation to sodium intake. See Chapter 34.

Meal time in group settings is an ideal opportunity for nutrition education programs focused on various learning activities around food (Figure 18-4). Experiencing new foods, participating in simple food preparation, and planting a garden are activities that develop and enhance positive food habits and attitudes.

Feeding School-Age Children

Growth from ages 6 to 12 years is slow but steady, paralleled by a constant increase in food intake. Children are in school a greater part of the day; and they begin to participate in clubs, organized sports, and recreational programs. The influence of peers and significant adults such as teachers, coaches, or sports idols increases. Except for severe issues, most behavioral problems connected with food have been resolved by this age, and children enjoy eating to alleviate hunger and obtain social satisfaction.

School-age children may participate in the school lunch program or bring a lunch from home. The National School Lunch Program, established in 1946, is administered by the USDA. Children from low-income families are eligible for free or reduced-price meals. In addition, the School Breakfast Program, begun in 1966, is offered in approximately 85% of the public schools that participate in the lunch program. The USDA also offers the Afterschool Snacks and Summer Food Service for organized programs, the Fresh Fruit and Vegetable Program in selected schools, and the Special Milk program for children not participating in school lunch (see Chapter 10).

More than 70% of schools met USDA standards for current target nutrients but less than one third of schools met standards for fat in lunch; levels of sodium remain high, whereas fiber is low relative to the DRI (Crepinsek, 2009). Of schools studied, 42% did not offer any fresh fruit or raw vegetables in the reimbursable school lunch on a daily basis (Gordon et al., 2007). New criteria for a broader number of specific nutrient targets and recommendations for menu planning using a food-based approach consistent with the DRI have been published (IOM, 2010). Efforts have been made to decrease food waste by altering menus to accommodate student preferences, allowing students to decline one or two menu items and offering salad bars. Efforts to increase participation in school lunch require consistent messages that support healthful eating.

School wellness policies were required by the school year 2006-2007 in institutions participating in school lunch and school breakfast programs. A survey indicated that many parents, although supportive of snack food restrictions and desirous of more physical education, were unaware of the required school wellness policies (Action for Healthy Kids, 2005). A survey of school food services directors revealed that 97% of school districts have policies that address nutrition standards for National School Lunch Program meals; in those districts, more than 92% have implemented activities including nutrition education, physical activity, and nutrition guidelines (School Nutrition Association, 2007). The school, including the administration, teachers, students, and food service personnel together with families and the community, are encouraged to work together to support nutrition integrity in the educational setting (ADA, 2006).

Consumption of school meals is also affected by the daily school schedule and the amount of time allotted for children to eat. When recess is scheduled before lunch rather than after, intake is better. A Montana “Recess Before Lunch” pilot study documented improvement in the mealtime atmosphere and students’ behavior. Discipline problems on the playground, in the lunchroom, and in the classroom decreased (Montana Office of Public Instruction, 2010).

Children who require a special diet because of certain medical conditions such as diabetes, hyperlipidemia, or documented food allergy are eligible for modified school meals. Children with developmental disabilities are eligible to attend public school from ages 3 to 21 years, and some of them need modified school meals (e.g., meals that are texture modified, or with increased or decreased energy density). To receive modified meals, families must submit written documentation by a medical professional of the diagnosis, meal modification, and rationale. For children receiving special education services, the documentation for meals and feeding can be incorporated as objectives in a child’s individual education plan (IEP) (see Chapter 45).

Studies of lunches packed at home indicate that they usually provide fewer nutrients but less fat than school lunch meals. Favorite foods tend to be packed, so children have less variety. Food choices are limited to those that travel well and require no heating or refrigeration. A typical well-balanced lunch brought from home could include a sandwich with whole-grain bread and a protein-rich filling; fresh vegetables, fruit, or both; low-fat milk; and possibly a cookie, a graham cracker, or another simple dessert. Food safety measures (e.g., keeping perishable foods well chilled) must be observed when packing lunches for school.

Today many school age children are responsible for preparing their own breakfasts. It is not uncommon for children to skip this meal altogether, even children in the primary grades. Children who skip breakfast tend to consume less calories and nutrients than those who eat breakfast (Wilson, 2006). Reviews of the effects of breakfast on cognition and school performance suggest that children who go to school without breakfast are more likely to experience performance deficits than those who eat breakfast (Rampersaud et al., 2005). See Focus On: Breakfast: Does It Affect Learning?

Snacks are commonly eaten by school age children, primarily after school and in the evening. As children grow older and have money to spend, they tend to consume more snacks from vending machines, fast-food restaurants, and neighborhood grocery stores. Families should continue to offer wholesome snacks at home and support nutrition education efforts in the school. In most cases, good eating habits established in the first few years help children through this period of decision making and responsibility. Developing and supporting programs and policies that ensure access to better-quality food, larger quantities of food, and better living conditions for low-income children help to reduce health disparities where present (Yoo et al., 2009).

Overweight and Obesity

The increasing prevalence of overweight children is a significant and alarming public health problem. The most recent NHANES reported an obesity (BMI higher than the 95th percentile) prevalence of 16.9% in children ages 2 to 19 years, and high BMI (BMI higher than the 85th percentile) prevalence of 31.7% (Ogden et al., 2010). For children 2 to 5 years of age, the prevalence is 10.4% for obese and 21.1% for high BMI (Ogden et al., 2010). This prevalence has remained relatively constant (except for an increase among the heaviest 6-19 year old boys) between 1999-2000 and 2007-2008.

Terminology for BMI categories related to overweight and obesity continues to change. The most recent Expert Committee report suggests the following terms to describe risk based on BMI: obesity as BMI at or above the 95th percentile and overweight as BMI between the 85th and 94th percentiles (Barlow et al., 2007). Determining whether growing children are obese is difficult. Some excess weight may be gained at either end of the childhood spectrum; the 1-year-old toddler and the prepubescent child may weigh more for developmental and physiologic reasons, but this extra weight is often not permanent. BMI, a useful clinical tool for screening for overweight, has limitations in determining obesity because of variability related to sex, race, body composition, and maturation stage.

The CDC growth charts allow tracking of BMI from age 2 into adulthood; thus children can be monitored periodically, and intervention provided when the rate of BMI change is excessive. The BMI charts show the adiposity rebound, which normally occurs in children between 4 and 6 years of age. Children whose adiposity rebound occurs before years of age are more likely to weigh more as adults than those whose adiposity rebound occurs after 7 years of age. The timing of the adiposity rebound and excess fatness in adolescence are two critical factors in the development of obesity in childhood, with the latter being the most predictive of adult obesity and related morbidity (Williams, 2009).

Although genetic predisposition is an important factor in obesity development, the increases in the prevalence of overweight children cannot be explained by genetics alone. Factors contributing to excess energy intake for the pediatric population include ready access to eating and food establishments, eating tied to sedentary leisure activities, children making more food and eating decisions, larger portion sizes, and decreased physical activity. In addition, American children snack three times a day, with chips, candy, and other low-nutrient foods providing more than 27% of their daily energy intake; this contributes 168 kcals/day (Piernas and Popkin, 2010).

Inactivity plays a major role in obesity development, whether it results from screen time, limited opportunities for physical activity, or safety concerns that prevent children from enjoying free play outdoors. Although increased television viewing and computer and handheld game use has been associated with childhood overweight, a review suggests that the greater risk of overweight is related to television viewing plus a low activity level (Ritchie et al., 2005). The need to use automobiles for short trips limits children’s opportunities to walk to local destinations, a phenomenon particularly relevant to children in the suburbs.

Obesity in childhood is not a benign condition, despite the popular belief that overweight children will outgrow their condition. The longer a child has been overweight, the more likely the child is to be overweight or obese during adolescence and adulthood. Consequences of overweight in childhood include psychosocial difficulties such as discrimination from others, a negative self-image, depression, and decreased socialization. Many overweight children have one or more cardiovascular risk factors such as hyperlipidemia, hypertension, or hyperinsulinemia (Daniels, 2009). An even more dramatic health consequence of overweight is the rapid increase in the incidence of type 2 diabetes in children and adolescents, which has a serious effect on adult health, development of other chronic diseases, and health care costs (see Chapter 31).

The AAP has developed guidelines for overweight screening and assessment for children from age 2 through adolescence (Barlow et al., 2007). In addition to growth parameters, other important information includes dietary intake and patterns, previous growth patterns, family history, physical activity, and family interactions. The U.S. Preventive Services Task Force (USPSTF) recommends obesity screening for 6- to 18-year olds and referral to treatment programs, if appropriate (USPSTF, 2010).

A 2010 paper described a lower prevalence of obesity among children who were exposed to the following routines: regularly eating the evening meal as a family, obtaining adequate night-time sleep, and having limited screen-viewing time (Anderson, 2010). Interventions for obesity in children have had limited effect on the childhood obesity problem, especially for black, Hispanic, and Native American populations. Success is most likely to result from programs that include comprehensive behavioral components such as family involvement, dietary modifications, nutrition information, physical activity, and behavioral strategies (Barlow et al., 2007). Incorporating behavioral intervention in obesity treatment improves outcomes and is most effective with a team approach. Depending on the child, goals for weight change may include a decrease in the rate of weight gain, maintenance of weight, or, in severe cases, gradual weight loss (see Chapter 22). An individualized approach should be tailored to each child, with minimum use of highly restrictive diets or medication, except if there are other significant diseases and no other options. (Barlow et al., 2007).

Intervention strategies require family involvement and support. Incorporating motivational interviewing and stages of change theory into the comprehensive program will likely be more successful (Kirk et al., 2005) (see Chapter 15). Changes to address overweight should include the child’s input, with choices and plans that modify the family’s food and activity environment, not just the child’s. Adequate energy and nutrients are needed to ensure maintenance of height velocity and nutrient stores. The hazards of treating overweight children too aggressively include alternate periods of undereating and overeating, feelings of failure in meeting external expectations, ignoring internal cues for appetite and satiation, feelings of deprivation and isolation, an increased risk for eating disorders, and a poor or an increasingly poor self-image.

Some children with special health care needs, such as those with Down syndrome, Prader-Willi syndrome, short stature, and limited mobility, are at increased risk for being overweight. Their size, level of activity, and developmental status need to be considered when estimating energy intake and providing dietary guidance to their families (see Chapter 45).

Prevention of childhood obesity is an important public health priority in the United States. The Institute of Medicine (IOM) has published recommendations that target families, health care professionals, industry, schools, and communities (IOM, 2005; Kirk et al., 2005). The recommendations include schools (improved nutritional quality of food sold and served, increased physical activity, wellness education), industry (improved nutrition information for consumers clear media messages), health care professionals (tracking BMI, providing counseling for children and families), and communities and government (better access to healthy foods, improved physical activity opportunities). Schools are a natural environment for obesity prevention, which can include nutrition and health curricula, opportunities for physical education and activity, and appropriate school meals. Recent efforts have resulted in school nutrition policies that limit the kinds of products sold in vending machines and food and beverages sold for fundraising. More research is also needed to develop effective prevention strategies that incorporate cultural competency for high-risk populations.

Families are essential for modeling food choices, healthy eating, and leisure activities for their children. Parents influence children’s environment by choosing nutrient-rich foods, having family meals (including breakfast), offering regular snacks, and spending time together in physical activity, all of which can be critical in overweight prevention. Reducing sedentary behaviors can increase energy expenditure and reduce prompts to eat; the AAP recommends limiting television and video time to no more than 2 hours per day (AAP, 2003; Epstein et al., 2008). Parents exerting too much control over their child’s food intake or promoting a restrictive diet may cause children to be less able to self-regulate and more likely to overeat when the opportunity is available (Ritchie et al., 2005). Health professionals should support positive parenting within the child’s developmental level (Satter, 2005).

Underweight and Failure to Thrive

Weight loss, lack of weight gain, or failure to thrive (FTT) can be caused by an acute or chronic illness, a restricted diet, a poor appetite (resulting from constipation, medication, or other issues), feeding problems, neglect, or a simple lack of food. Some experts prefer the terms pediatric undernutrition or growth deficiency. Infants and toddlers are most at risk for poor growth, often as a result of prematurity, medical conditions, developmental delays, inadequate parenting, or all of these. Dietary practices can also contribute to poor growth, including food restrictions in preschool children stemming from parents’ concerns about obesity, atherosclerosis, or other potential health problems.

A careful assessment is critical and must include the social and emotional environment of the child and any physical findings. If neglect is documented to be a contributing factor, health professionals are obligated to report the case to the local child protective services (Block and Krebs, 2005). Because of the complexity of growth failure, an interdisciplinary team is ideal for assessments and interventions.

The provision of adequate energy and nutrients and nutrition education should be one part of an overall interdisciplinary plan to assist children and their families. Attempts should be made to increase children’s appetites and modify the environment to ensure optimal intake. Frequent, small meals and snacks should be offered at regular times, using developmentally appropriate, nutrient-dense foods. This optimizes the smaller stomach capacity of the young child and provides structure and predictability for the eating environment. Families should receive support for positive parent-child interactions, with respect for the division of responsibility in feeding and avoidance of any pressure or coercion on the child’s eating. Severe malnutrition may require carefully planned interventions and close monitoring to prevent refeeding syndrome.

Chronic constipation can result in poor appetite, diminished intake, and FTT. Adding legumes and fruits (especially dried fruits), vegetables, high fiber breakfast cereals, bran muffins, or all of these to the diet can help relieve constipation, improve appetite, and eventually promote weight gain. Because the fiber intake of children is often low, especially in children who are picky eaters, fiber intake should always be addressed in the evaluation.

Iron Deficiency

Iron deficiency is one of the most common nutrient disorders of childhood. The highest prevalence of anemia in children occurs in those younger than 2 years of age. Iron deficiency is less of a problem among older preschool and school-age children.

Infants with iron deficiency, with or without anemia, tend to score lower on standardized tests of mental development and pay less attention to relevant information needed for problem solving. Poorer cognitive performance and delayed psychomotor development have been reported in infants and preschool children with iron deficiency. Deficiency can have long-term consequences, as demonstrated by poorer performance on developmental tests in late childhood and early adolescence (Lozoff, 2006, 2007). Iron intake should be considered during assessments of individual diets and in policy decisions intended to address the nutrition needs of low-income, high-risk children.

In addition to growth and the increased physiologic need for iron, dietary factors also play a role. For example, a 1-year-old child who continues to consume a large quantity of milk and excludes other foods may develop anemia. Many young preschool children do not like meat, so most of their iron is consumed in the nonheme form from fortified cereals, which is absorbed less efficiently (see Chapter 33).

Dental Caries

Nutrition and eating habits are important factors affecting oral health. An optimal nutrient intake is needed to produce strong teeth and healthy gums. The composition of the diet and an individual’s eating habits (e.g., dietary carbohydrate intake, eating frequency) are significant factors in the development of dental caries (see Chapter 26).

Allergies

Food allergies usually present during infancy and childhood and are more likely when a child has a family history of allergies. Allergic symptoms are most often seen as respiratory or gastrointestinal responses or involve the skin, but may include fatigue, lethargy, and behavior changes. Controversy exists over the definition of food allergy, food intolerance, and food sensitivity, and some tests for food allergies are unspecific and equivocal (see Chapter 27).

Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder is a clinical diagnosis based on specific criteria: excessive motor activity, impulsiveness, a short attention span, a low tolerance for frustration, and an onset before 7 years of age. Various dietary factors have been suggested as a cause of this disorder, including artificial flavors and colors, sugar, altered fatty acid metabolism, and allergies. Over the years, dietary treatments have been promoted such as the Feingold diet, the omission of sugar, allergy elimination diets, and supplements of vitamins and essential fatty acids (see Chapter 45).

Autism Spectrum Disorders (ASDs)

ASDs affect 1 in 110 children and are diagnosed by impairments in three behavioral categories: social interactions, verbal and nonverbal communication, and restricted or repetitive behaviors. These impairments can affect nutrient intake and eating behaviors if a child accepts only specific foods, refuses new or unfamiliar foods, or has increased hypersensitivities (e.g., to texture, temperature, color, and smell) or difficulty making transitions. Children with an ASD often refuse fruits and vegetables and may eat only a few foods from the other food groups. Although most children have normal growth parameters, their restricted diets make them at risk for marginal or inadequate nutrient intake. They are often very resistant to taking a vitamin-mineral supplement, even though they could benefit from one.

Popular nutrition advice for children with ASDs include elimination diets (e.g., gluten-free or casein-free), essential fatty acid supplements, large doses of vitamins, and other alternative therapies. Despite anecdotal reports of benefits, few well-designed controlled studies have been done to test the effectiveness of these interventions, and currently there is no strong evidence of benefits (Milward et al., 2008). Behavioral nutrition interventions may increase the types of food accepted at home and school. If families want to try alternative dietary therapies, nutrition professionals can help them ensure that the child’s diet is adequate and any supplements are safe (see Chapter 45).

Dietary Fat and Cardiovascular Health

Compared with their counterparts in many other countries, American children and adolescents have higher blood cholesterol levels and higher intakes of saturated fatty acids and cholesterol. Autopsy studies demonstrate that early coronary atherosclerosis begins in childhood and adolescence and is related to high serum total cholesterol, low-density lipoprotein (LDL) cholesterol, and very-low-density lipoprotein cholesterol levels, and low high-density lipoprotein levels (AAP, 2009).

The AAP recommendations for lipid screening and prevention of cardiovascular disease in children are similar to recommendations published for adults (Daniels, 2008; Lichtenstein, 2006). For children older than 2 years of age, nutrition recommendations are the same as those for adults: (1) no more than 30% of energy from fat (10% or less from saturated fat); and (2) 200-300 mg/day of cholesterol. Cholesterol screening is also recommended for children with risk factors—family history of dyslipidemia or premature cardiovascular disease (Daniels, 2008) (see Chapter 33).

Dietary trends have demonstrated a decrease in total fat, saturated fat, and percentage of energy from fat in children’s diets; but at the same time overweight has increased with increased risk of cardiovascular disease (Gidding et al., 2005). Recommendations include a balanced energy intake; sufficient physical activity to maintain a healthy weight; increased intake of fruits, vegetables, fish, and whole grains; and use of low-fat dairy products (Daniels, 2008). Reports have shown that from age 4 to adolescence, children can consume diets that comply with the NCEP guidelines without compromising energy or nutrient intake (Gidding et al., 2005). A long-term dietary intervention study demonstrated improved lipid levels and improved eating habits in children with elevated LDL cholesterol levels (Van Horn et al., 2005). Health practitioners should assess each child individually regarding total fat intake and excessive consumption of low-fat and nonfat foods especially by preschool children (see Chapter 33).

Calcium and Bone Health

Osteoporosis prevention begins early by maximizing calcium retention and bone density during childhood and adolescence, when bones are growing rapidly and are most sensitive to diet and physical activity (see Chapter 25). To reach the maximum calcium balance during puberty, children may need to consume more than the recommended amount. However, mean dietary intakes of calcium are lower than the AI, with 20% to 30% of pubertal girls having intakes less than 500 mg/day. Although calcium supplementation coupled with an average calcium dietary intake in pubertal children has been shown to increase bone mineral density significantly, it is less certain whether this benefit is long term (Matkovic et al., 2005). One longitudinal study of white children from infancy to 8 years of age found that bone mineral content was positively correlated with intake of protein and several minerals, suggesting that many nutrients are related to bone health in children (Bounds et al., 2005). Because food consumption surveys show that children are drinking more soft drinks and noncitrus juices and less milk, education is needed to encourage young people to consume an appropriate amount of calcium from food sources and possibly supplements.

Fiber

Education about dietary fiber and disease prevention has mainly been focused on adults, and only limited information is available on the dietary fiber intake of children. Dietary fiber is needed for health and normal laxation in children. National survey data indicate that preschool children consume a mean of 9.5 g/day of dietary fiber; school age children consume approximately 11.6 g/day (Moshfegh, 2005). This is lower than the DRI for children, which is based on the same 14 g/1000 kcal as adults because of lack of scientific evidence for the pediatric population (IOM, 2006). Generally, higher fiber intakes are associated with more nutrient-dense diets in young children (Kranz et al., 2005).

Physical Activity

A decreased level of physical activity in children has been noted for several decades. Participation in school physical education programs has declined over time and generally decreases with increasing age (ADA, 2008). Regular physical activity not only helps control excess weight gain, but also improves strength and endurance, enhances self-esteem, and reduces anxiety and stress. Activity, combined with an optimal calcium intake, is associated with increased bone mineral density in children and adolescents. Current physical activity recommendations for those ages 6 through 17 years of age are 60 minutes or more of physical activity every day with the majority at a moderate or vigorous aerobic intensity. Children and adolescents should do vigorous intensity activity on at least 3 days per week and include muscle-strengthening and bone-strengthening activity on at least 3 days per week. Information regarding activities that will meet these recommendations and are appropriate for children is available (U.S. Department of Health and Human Services, 2010). The Kid’s MyActivity Pyramid promotes substituting sedentary activities for more physically active choices (Figure 18-5). The Dietary Guidelines for Americans and MyPlate have also been applied to children and their parents (www.chooseMyPlate.gov/kids).

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Eat Well, Play Hard

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Nutrition and Physical Activity

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