NUTRITION ISSUES FOR TODDLERS AND OLDER CHILDREN

Cow’s milk ideally is not introduced until approximately 1 year of age to avoid occult intestinal blood loss. Low fat (2%) or whole milk is recommended until 2 years of age, after which fat free milk is recommended. Excessive milk (>24 oz/day) intake should be avoided in toddlers because larger intakes may reduce the intake of a good variety of nutritionally important solid foods and result in iron deficiency anemia; large intakes also may contribute to excessive caloric intake. Juice intake for toddlers and young children should be limited to 4 to 6 oz/day, and juice intake for children 7 to 18 years of age should be limited to 8 to 12 oz/day. By 1 year of age, infants should be eating meals with the family, have a regular schedule of meals and snacks, and be encouraged to self-feed with appropriate finger foods. The Food Guide Pyramid developed by the U.S. Department of Agriculture can provide parents with a general guideline for the types of foods to be offered on a regular basis. A general rule for the quantity of food to offer is 1 tablespoon of each food provided per meal, with more given if the toddler requests. Power struggles over eating are common between parents and toddlers. The parent’s role is to decide the what, when, and where of the meals. The child’s role is to decide if, what, and how much to eat. Breastfeeding of the older infant can continue as long as mutually desired, with care taken to ensure the infant is consuming a variety of other foods and is not depending excessively on breastfeeding for nutritional or comfort needs.

Iron intake may be inadequate in some children between 1 and 3 years of age in the United States. The incidence of iron deficiency anemia has decreased in young children in the United States. Significant iron deficiency and iron deficiency anemia exist in some high-risk minority or poor populations of young children. Toddlers with excessive milk intakes (> 32 oz/day) and/or those who consume little meat are at risk for iron deficiency.

Ten percent of 2- to 5-year-old children have weight-for-length or body mass index percentiles at or above the 95th percentile for age. The relatively high prevalence of underweight and overweight emphasizes the importance of surveillance of growth velocity in all young children to allow early detection of abnormal rates of weight gain relative to linear growth.

Learning healthy eating behaviors at an early age is an important preventive measure because of the association of diet with several chronic adult diseases, such as obesity, diabetes, and cardiovascular disease. Table 28-1 provides guidelines for a prudent diet appropriate for most children older than 2 years of age. After 2 years, it is recommended that the fat intake gradually be reduced to approximately 30% and not less than 20% of calories.

NUTRITION ISSUES FOR ADOLESCENTS

Adolescence can be a time when poor eating habits develop. Skipped meals (especially breakfast), binge eating with friends or alone, dieting, and consumption of nutrient-poor, calorically dense foods are common problems. Excessive consumption of sugar from soda, fruit drinks, and specialty coffee and tea drinks may contribute to excess weight gain and tooth decay and may displace other needed nutrients. Poor calcium intake during adolescence may predispose adults to osteoporotic hip fractures in later life. Osteoporosis (osteopenia) caused by poor dietary calcium or vitamin intake or poor absorption of ingested calcium in children and adolescents is becoming more clinically recognized and treated. Inadequate iron intake may result in symptoms of fatigue and iron deficiency anemia. Student athletes may be especially vulnerable to inadequate iron intakes, severely restrictive eating patterns, and use of inappropriate nutritional and vitamin supplements. Adolescents should be counseled on appropriate dietary recommendations (see Chapter 70).