Nutrition in Children

Aka: Nutrition in Children, Fluid Intake in Children, Nutrition in Toddlers, Dietary Guideline for Young Children, Milk Intake in Young Children, Vitamin Supplementation in Young Children

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II. Approach

  1. Consider nutrition in perspective of Overweight or underweight status (see below)
  2. Childhood guidelines of Healthy Diet mirror those for adults
    1. See Nutrition Guidelines
    2. Limit added sugars
    3. Encourage lean Proteins, complex Carbohydrates (vegetables, fruits, whole grains)
  3. Avoid special diets (e.g. gluten free diet) unless medically indicated
    1. Risk of nutritional deficiencies (e.g. gluten-free grains may not contain B Vitamins, iron)
  4. Avoid feeding practices that may lead to difficult feeding behaviors or Overeating
    1. Avoid food to soothe or help children get back to sleep
    2. Avoid excessive portions or forcing children to finish all of the food on the plate
    3. Avoid food-related punishments
    4. Avoid forced feedings
    5. Limit snacks and discourage grazing (continuous snacking)
  5. Picky Eater approach
    1. Offer new foods multiple times (20-30 times)
    2. Avoid forcing children to eat a particular food
    3. Pair new foods with familiar flavors and with familiar foods
    4. Adults and peers with broad food choices may serve as good role models
    5. Precaution: Pediatric Feeding disorder
      1. Distinguish Picky Eating from pediatric feeding disorder (esp. in young children, up to 10%)
      2. Pediatric feeding disorder is age inappropriate decreased oral intake lasting >2 weeks
      3. Pediatric feeding disorder may result in medical and nutritional complications
  6. Overeating
    1. Allow toddlers to self-feed appropriate foods (non-Choke Hazards, healthy foods) at meals and snacks
    2. Use child sized cups and utensils
    3. Avoid high calorie junk foods
    4. Limit snacks (discretionary calories)
      1. Age 1 to 2 years: <=4 oz 100% juice per day (no sweetened drinks or soda)
      2. Age 2 to 9 years: <=130 to 280 kcals/day
      3. Age 9 to 13 years: <=50 to 350 kcals/day
      4. Age 14 to 18 years: <=140 to 580 kcals/day

III. Preparations: Milk

  1. Age birth to 12 months
    1. See Infant Nutrition
    2. Breast Milk is preferred until 12 months (WHO recommends Breast Feeding to 24 months)
    3. Alternatively, infant formula until age 12 months
  2. Age 1 to 2 years old: 1.5 to 2 cups/day
    1. Whole Milk is preferred
      1. Whole Milk is high in Protein, Calcium, Vitamin A, Vitamin D
        1. Whole milk 2 servings (8 ounces each) per day
    2. Reduced Fat Milk (2%) is not typically recommended
      1. Does not delay growth, but not generally recommended
      2. May be considered in obese toddlers (but paradoxically may risk adult Obesity)
      3. Wosje (2001) J Am Diet Assoc 101:53-6 [PubMed]
      4. Vanderhout (2016) Am J Clin Nutr 104(6): 1657-64 [PubMed]
    3. Non-Cow's Milk
      1. Unsweetend Fortified Soy Milk may be used as an equivalent to cow's milk
        1. Typically nutritionally similar to cow's milk (but may vary by brand)
      2. Other non-cow's milk (almond milk, rice milk, coconut milk, hemp milk) are not recommended
        1. Does not provide the same Vitamins, minerals and Protein as cow's milk
        2. Associated with decreased adult height and decreased Vitamin D
        3. Morency (2017) Am J Clin Nutr 106(2): 597-602 [PubMed]
        4. Lee (2014) CMAJ 186(17): 1287-93 [PubMed]
  3. Age 2 years and beyond
    1. Change to reduced fat cow's milk (or Unsweetend Fortified Soy Milk) at two 8-oz servings daily
    2. Other non-cow's milk (almond milk, rice milk, coconut milk, hemp milk) does not replace cow's milk (or soy milk)
      1. Non-cow's milk does not provide the same Vitamins, minerals and Protein as cow's milk
      2. However non-cow's milk may be used in place of other non-milk beverages (as listed below)
    3. Recommended dairy amounts by age
      1. Age 2 to 9 years: 2 to 2.5 cups/day
      2. Age 9 to 18 years: 3 cups/day
  4. References
    1. (2020) presc lett 27(2):10

IV. Preparations: Non-Milk Beverages

  1. Total Fluid Intake
    1. Age 1 to 3 years old: 4 cups per day
    2. Age 4 to 8 years old: 5 cups per day
    3. Age over 8 years old: 7 to 8 cups per day
  2. Water
    1. May be used between milk servings
    2. Assumes a minimum of 16 ounces of milk daily
  3. Juice
    1. Whole fruits and vegetables are preferred instead
    2. Age 1 to 3 years
      1. Limit to 4 ounces 100% juice with no added sugar
    3. Age 4 to 6 years
      1. Limit to 4 to 6 ounces 100% juice with no added sugar
  4. Other beverages
    1. Avoid sugar sweetened beverages (fruit drinks, sport drinks, soda) due to Obesity and Dental Caries risk
    2. Avoid unpasteurized dairy, cheese or juice

V. Preparations: Fat and Cholesterol

  1. Do not restrict fat or Cholesterol <1 year old (risk of neurologic development concerns)
  2. Fat, Cholesterol are critical for growth, development
    1. Important components for brain maturation
    2. Fat restriction may impede growth if <20% of calories
    3. Fat soluble Vitamin Deficiency risk if fat resricted
  3. Recommendations
    1. Fat is not restricted under age 12 months
    2. Fat reduction to 30-40% of daily calories is safe for ages 1 to 3 years old
    3. Polyunsaturated and monounsaturated fats are preferred
    4. Avoid trans-Fatty Acids and saturated fats
    5. USDA Recommended oils and fats per day
      1. Age 1 to 2 years: 9 to 13 g/day
      2. Age 2 to 9 years: 15 to 24 g/day
      3. Age 9 to 13 years: 17 to 34 g/day
      4. Age 14 to 18 years: 24 to 51 g/day

VI. Preparations: Protein, Carbohydrates and fiber

  1. Fiber
    1. Unprocessed or minimally processed Dietary Fiber sources are preferred
    2. Give 14 g fiber per 1000 kcals (or at least 5 g/day + 1 g/ageY)
  2. Protein
    1. Accounts 5-20% of daily Caloric Intake at ages 1 to 3 years old
    2. USDA Recommended Protein amounts per day
      1. Age 1 to 2 years: 2 oz/day
      2. Age 2 to 9 years: 2 to 5.5 oz/day
      3. Age 9 to 13 years: 4 to 6.5 oz/day
      4. Age 14 to 18 years: 5 to 7 oz/day
  3. Carbohydrates
    1. Accounts for 45-65% of daily Caloric Intake at ages 1 to 3 years old
    2. Avoid refined and processed Carbohydrates and added sugars
    3. Encourage complex Carbohydrates (vegetables, whole grains, beans)
    4. Vegetables (USDA recommendations 2020-2025)
      1. Age 1 to 2 years: 0.66 to 1 cup/day
      2. Age 2 to 9 years: 1 to 2.5 cups/day
      3. Age 9 to 13 years: 1.5 to 3.5 cups/day
      4. Age 14 to 18 years: 2.5 to 4 cups/day
    5. Fruits (USDA recommendations 2020-2025)
      1. Age 1 to 2 years: 0.5 to 1 cup/day
      2. Age 2 to 9 years: 1 to 2 cups/day
      3. Age 9 to 13 years: 1.5 to 2 cups/day
      4. Age 14 to 18 years: 1.5 to 2.5 cups/day
    6. Grains (USDA recommendations 2020-2025)
      1. Age 1 to 2 years: 1.75 to 3 oz/day
      2. Age 2 to 9 years: 3 to 6 oz/day
      3. Age 9 to 13 years: 5 to 9 oz/day
      4. Age 14 to 18 years: 6 to 10 oz/day

VII. Preparations: Vitamins and Supplements

  1. Routine supplements (e.g. Multivitamins) are not recommended in healthy children
    1. Varied diet contains all necessary Vitamins, minerals
    2. Supplements are deficient in Calcium and zinc
    3. Vitamins are Overdose/poison risk (Look like candy)
  2. General supplement indications (for micronutrients)
    1. Family with low-income and inadequate, inconsistent nutrition
    2. Cystic Fibrosis or other chronic disease state
    3. Vegetarians
    4. Failure to Thrive
  3. Vitamin D
    1. Age <1 year old
      1. Exclusively Breast fed infants: Vitamin D Supplement 400 IU daily (Rickets risk)
    2. Age 1 to 3 years
      1. Dietary Vitamin D 600 IU daily
      2. Consider Vitamin D Supplementation
        1. Toddler milk intake <16 ounces daily and no regular sunlight exposure
        2. Chronic malabsorption
  4. Calcium
    1. Dietary Calcium 700 mg daily at ages 1-3 years
      1. Two 8 oz glasses milk contain total of 550 mg alone
      2. Other sources (e.g. green vegetables, beans, nuts) are typically adequate for remainder of Calcium
  5. Iron
    1. Age <1 year
      1. Dietary Iron 11 mg/day at ages 6-12 months
      2. Iron Supplementation 1 mg/kg/day for exclusively Breast fed infants (until iron-rich foods)
      3. Do not introduce cow's milk until age 12 months
    2. Age 1-3 years
      1. Dietary Iron 7 mg/day

VIII. Evaluation: Weight

  1. See Childhood Obesity
  2. See Weight Measurement in Children
  3. Evaluate Body Mass Index over age 2 years for Overweight status
    1. Overweight
      1. BMI 85-95th percentile
    2. Obesity
      1. BMI >95th percentile
  4. Evaluate growth charts for underweight status (Failure to Thrive)
    1. Considered underweight if <2-5th percentile (or growth crosses 2 major percentile lines)
    2. WHO updated growth charts (predominantly Breast fed infants, data from 6 countries)
      1. http://www.who.int/childgrowth
    3. New CDC Growth Charts reflecting Body Mass Index (typically heavier than WHO cohorts)
      1. http://www.cdc.gov/growthcharts

IX. References

  1. Nicklas (2004) J Am Diet Assoc 104:660-77 [PubMed]
  2. Pierre (2022) Am Fam Physician 106(4): 427-38 [PubMed]
  3. Riley (2018) Am Fam Physician 98(4): 227-33 [PubMed]

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