Pediatric Annals

CME 

Strategies and Suggestions for a Healthy Toddler Diet

Sally Schwartz, RD, CSP, LDN; Irwin Benuck, MD, PhD

Abstract

CME Educational Objectives

1.Delineate what comprises a healthy toddler diet.

Discuss strategies for meal planning for toddlers.

Develop a clear understanding of the varying fat content of milk products.

Nutritional challenges for toddlers are common because their eating behaviors are inconsistent; they may eat more or less than requirements meal to meal and day to day. To help reduce parental stress, it’s essential to discuss with parents/caregivers their expectations on how and what they think their toddler should be eating. It is important to remember that toddlers are not little adults; portion sizes are often distorted (too large), and portions should reflect the individual child’s age and development. Parents/caregivers can help with new food acceptance by modeling good mealtime behaviors such as limiting high-energy, low-nutritional food and drinks, eating healthy foods along with their children together at the table with the television shut off, and eating appropriate portion sizes.

Pediatricians should inform concerned parents/caregivers that toddlers commonly do not accept new foods; foods may need to be introduced repeatedly, up to 10 to 15 times before a child will eat them. To adhere to National Heart, Lung, and Blood Institute (NHLBI) guidelines, parents and caregivers should focus on providing balanced meals that offer a variety of foods, with at least three to four food groups for meals and one to two food groups for snacks, always including familiar foods along with new foods.

It is important to reassure families that adherence to NHLBI guidelines for toddlers may be difficult at first, but with the proper education, planning ahead for meal/snack times, and education of all providers caring for the toddler (including nannies, daycares, and family members), it can be done successfully. Improving the nutrition and health of their young toddler will help prevent risk factors for the development of cardiovascular disease.

Abstract

CME Educational Objectives

1.Delineate what comprises a healthy toddler diet.

Discuss strategies for meal planning for toddlers.

Develop a clear understanding of the varying fat content of milk products.

Nutritional challenges for toddlers are common because their eating behaviors are inconsistent; they may eat more or less than requirements meal to meal and day to day. To help reduce parental stress, it’s essential to discuss with parents/caregivers their expectations on how and what they think their toddler should be eating. It is important to remember that toddlers are not little adults; portion sizes are often distorted (too large), and portions should reflect the individual child’s age and development. Parents/caregivers can help with new food acceptance by modeling good mealtime behaviors such as limiting high-energy, low-nutritional food and drinks, eating healthy foods along with their children together at the table with the television shut off, and eating appropriate portion sizes.

Pediatricians should inform concerned parents/caregivers that toddlers commonly do not accept new foods; foods may need to be introduced repeatedly, up to 10 to 15 times before a child will eat them. To adhere to National Heart, Lung, and Blood Institute (NHLBI) guidelines, parents and caregivers should focus on providing balanced meals that offer a variety of foods, with at least three to four food groups for meals and one to two food groups for snacks, always including familiar foods along with new foods.

It is important to reassure families that adherence to NHLBI guidelines for toddlers may be difficult at first, but with the proper education, planning ahead for meal/snack times, and education of all providers caring for the toddler (including nannies, daycares, and family members), it can be done successfully. Improving the nutrition and health of their young toddler will help prevent risk factors for the development of cardiovascular disease.

Q: What is the rationale for and what would a healthy diet look like for a child between 1 and 2 years of age, with examples of breakfast, lunch, and dinner?

The new National Heart, Lung, and Blood Institute (NHLBI) guidelines for cardiovascular risk in children and adolescents calls for lowering fat in their diets, increasing nutrient-rich foods, and reducing energy-rich, low-nutritional foods. In addition, the guidelines call for use of the lowest fat milk, which would be safe for a baby older than 1 year, as long as 30% of the diet is from fat and no more than 10% is from saturated fats.1

The transition to table food should include keeping the total fat to 30% of daily calories/estimated energy requirements (EER) for age, keeping saturated fat to 8% to 10% of daily calories/EER, and avoiding trans fats as much as possible. Monounsaturated and polyunsaturated fats should make up to 20% of the total daily calories/EER. The total cholesterol in the diet should be limited to 300 mg/d. Optimal intakes of total protein and total carbohydrates in children should make up the remaining 70% of total calories. A diet that follows the Diet Approach to Stop Hypertension (DASH), which is rich in whole grains, fruits, vegetables, lean proteins (including legumes), and healthy fats, helps meets the NHLBI guidelines. The guidelines recommend limiting or avoiding sugar-sweetened beverage intake and limiting 100% juice intake (juice without sugar added) to no more than 4 fl oz/d per the recommendations of the American Academy of Pediatrics.1,2

Consumption of Dairy

Cow’s milk is a significant component of a 1- to 2-year-old toddler’s diet because of its high-quality protein, calcium, and vitamins A and D. However, the fat content of milk is mostly saturated fat,3 which is atherosclerotic in nature and can lead to early-onset coronary artery disease. Two or three servings of milk per day are recommended to meet the requirements for age.4 The recommended daily allowance for calcium for a 1- to 2-year old is 700 mg/d.5 Research has compared 2% milk with whole milk consumption in children 12 to 24 months and found no difference in height, weight, and body fat percentage.6 In addition, the longitudinal Special Turku Coronary Risk Factor Intervention Project for Children studies conducted in Finland compared children with a diet low in fat with a group of children whose parents were not instructed on the use of low fat. Saturated fat intake among the intervention group was significantly less than the control subjects. Male subjects had long-term lower cholesterol levels, and female subjects weighed less. There were no harmful effects in terms of growth and cognitive development.7 Therefore, as young children transition from breast milk or formula, milk reduced in fat (ranging from 2% milk to fat-free milk) can be used based on the child’s growth, appetite, intake of other nutrient-dense foods, intake of other sources of fat, and risk for obesity and cardiovascular disease.1 Milk with reduced fat should be used only in the context of an overall diet that supplies 30% of calories from fat. Dietary intervention should be tailored to each specific child’s needs.

Consumption of Food

A sample menu for a young toddler that meets the NHLBI guidelines is presented in the Sidebar. The sample menu provides a typical toddler’s intake, but much care must be taken when monitoring the amount of saturated fat in the diet. Saturated fat often is found in several of the foods targeted toward children and young families as quick-and-easy/grab-and-go–type foods.


When counseling families to follow NHLBI guidelines, it is very important to provide practical resources that include the following: lists of healthy foods (including foods high in unsaturated fats), food preparation, and sample meals or websites that contain this information in easy-to-read language. If families need extra counseling, providing them with a registered dietitian familiar with the Cardiovascular Health Integrated Lifestyle Diet (CHILD 1) is essential for the family to adhere to the diet successfully.

Promotion of Good Habits

Nutritional challenges for toddlers are common because their eating behaviors are not consistent; they may eat more or less than requirements meal to meal and day to day. Discuss with parents/caregivers their expectations on how and what they think their toddler should be eating to help reduce parental stress. It is important to remember that toddlers are not little adults; portion sizes are often distorted (too large), and portions should reflect the individual child’s age and development.

It is important to teach parents/caregivers of the division of responsibility for feeding; it is the parents’ job to provide healthy foods and appropriate portion sizes, with structured meal times and locations. Toddlers are responsible for eating the food provided and determining how much they eat, which allows them to self-regulate. Parents should avoid force-feeding.8 Grazing, allowing a child to eat small snacks or drink from a cup (water is OK) all day long without structured meal times, reduces the child’s appetite for healthy meals and snacks and is not recommended.

Inform parents/caregivers that toddlers commonly do not accept new foods and that foods may need to be introduced repeatedly, up to 10 to 15 times before a child will eat them. Focus on balanced meals offering a variety of foods, with at least three to four food groups for meals and one to two food groups for snacks, always including familiar foods along with new foods. Parents/caregivers can help with new food acceptance by modeling good mealtime behaviors such as limiting high-energy drinks and foods, eating healthy foods along with their children together at the table with the television shut off, and eating appropriate portion sizes.

Conclusion

It is important to reassure families that adherence to NHLBI guidelines for toddlers may be difficult at first, but with the proper education, planning ahead for meal/snack times, and education of all providers caring for the toddler (including nannies, daycares, and family members), it can be done successfully. Improving the nutrition and health of their young toddler will help prevent risk factors for the development of cardiovascular disease.

References

  1. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Full report. 2011. Available at: www.nhlbi.nih.gov/guidelines/cvd_oed/index.htm. Accessed April 01, 2013.
  2. American Academy of Pediatricians Policy Statement. The use of fruit juice in the diets of young children. AAP News. 1991;7(2):11
  3. Duyff RL. American Dietetic Association Complete Food and Nutrition Guide [revised and updated]. 3rd ed. Hoboken, NJ: Wiley; 2006.
  4. Johnson RK, Panely C, Wang MQ. The association between noon beverage consumption and the diet quality of school age children. J Child Nutr Mgmt. 1998;22:95–100.
  5. Ross AC, Taylor CL, Yaktine AL, et al. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011:5.
  6. Wosje KS, Specker BL, Giddens J. No differences in growth or body composition from age 12 to 24 months between toddlers consuming 2% milk and toddlers consuming whole milk. J Am Diet Assoc. 2001;101:53–56. doi:10.1016/S0002-8223(01)00015-3 [CrossRef]
  7. Ninikoski H, Lagstrom H, Jokinen E, et al. Impact of repeated dietary counseling between infancy and 14 years of age on dietary intakes and serum lipids and lipoproteins: the STRIP study. Circulation. 2007;116(9):1032–1040. doi:10.1161/CIRCULATIONAHA.107.699447 [CrossRef]
  8. Satter EM. The feeding relationship. J Am Diet Assoc. 1986;86:352–356.


Authors

Sally Schwartz, RD, CSP, LDN, is Senior Clinical Nutritionist, Ann and Robert H. Lurie Children’s Hospital of Chicago. Irwin Benuck, MD, PhD, is Professor of Clinical Pediatrics, Feinberg School of Medicine, Northwestern University, and Attending Physician, Preventive Cardiology Program, Ann and Robert H. Lurie Children’s Hospital of Chicago.

Address correspondence to: Sally Schwartz, RD, CSP, LDN, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL 60611; email: sschwartz@luriechildrens.org.

Disclosure: The authors have no relevant financial relationship to disclose. 

10.3928/00904481-20130823-09

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