NDD 10603

NDD 10603LECTURE 6:TODDLER AND PRESCHOOLER NUTRITION

DR. SHARIFAH WAJIHAH WAFA BTE SST WAFASchool of Nutrition and Dietetics

Faculty of Health [email protected]

KNOWLEDGE FOR THE BENEFIT OF HUMANITY

Key Nutrition Concepts

continue to grow and developPhysicallyCognitivelyEmotionallyNew skills rapidly

with time


innate ability to self-regulate food intake

Parents & caretakers provide nutritious foods

children decide if & how much to eat


Parents & caretakers tremendous influence

Toddlers

1-3 years (12-36 months)

Increase in fine motor skills

Rapid increases in gross motor skills

Preschool age

3-5 years of age (Begin Kindergarten) increasing autonomybroader social

circumstances increasing language

skillsexpanding self-

control of behavior

Physical growth

Decrease in rate Body proportions change – head growth is

minimal ; trunk & limbs lengthen Fat proportions decrease Catch-up growth can occur

Developmental connections to nutrition: toddlers

Initial neophobia reluctance to eat, or the avoidance of, new

foods. Exerting independenceimitation

Developmental connections: preschoolers

EgocentrismCooperation sociallyControl – languageStart to limit behavior internally

Importance of nutrition status

adequate energy & nutrientsUndernutritionFTT & cognitive impairment

SCHOOL OF NUTRITION AND DIETETICS . FACULTY OF HEALTH SCIENCES

Normal Growth and Development

Infants triple birth weight in first 12 months, but growth slows after that

Toddlers gain 0.2 kg and 1 cm per month

Preschoolers gain 2.0kg and 7cm per year

Decrease in growth rate accompanied by decrease in appetite and food intake


Monitoring Children’s Growth

Use calibrated scales & height board

Toddlers under age 2 years Weighed without clothes or

diaper Determine recumbent

length Children over age 2 years

Weighed with light clothing Measure stature with no

shoes


WHO Growth Standards

WHO (World Health Organization) published growth standards for children from birth to 5 years.

International growth standards regardless of ethnicity or socioeconomic status.


WHO Growth Standards

Gender-specific Health care professional can

plot and monitor: Length/height-for-age Weight-for-age Weight-for-length/height Body mass index-for-age

(BMI-for-age) Head circumference-for-age Arm circumference-for-age Subscapular skinfold-for-age Triceps skinfold-for-age

Interpreting the BMI

Underweight: BMI/age <5%tileNormal: BMI for age 5-85%tileAt risk of overweight: BMI for age 85-

95%tileOverweight: BMI for age>95%tile


Common Problems with Measuring & Plotting Growth Data

Error in measuring may result in errors in health status assessment

Use of calibrated equipment and plotting accuracy are vital

Recumbent length

Not my husband

Head Circumference

Not my baby

Physiological and Cognitive Development

Development of feeding skills

Feeding behaviors

Appetite and food intake

Growth


Physiological Development - Toddlers

A time of expanding physical and developmental skills

Walking begins as a “toddle,” improving in balance & agility

Progress by month 15—crawl upstairs 18—run stiffly 24—walk up stairs one foot

at a time 30—alternate feet going up

stairs 36—ride a tricycle


Cognitive Development- Toddlers

Toddlers “orbit” around parents

Transitions from self-centered to more interactive

Vocabulary expands: 10-15 words at 18 months 100 at 2 years 3-word sentences by 3

years Temper tantrums common

(the terrible two’s)


Cognitive Development -Preschooler

Egocentric—cannot accept another’s point of view

Learning to set limits for himself

Cooperative & organized group play

Vocabulary expands to >2000 words

Begins using complete sentences

Feeding skills: toddlers

Weaning Ability to chew and

self feed “I do it” Prefer to eat with

hands Can use cups and

spoons

Food jags: strong food preferences and dislikes

Food refusals Natural to have

decreased interest in food


“Food jags” – prolonged periods of refusing a particular food or foods they previously liked

To circumvent food jags: Serve new foods along

with familiar foods Serve new foods when

child is hungry Other family members

should eat the new foods in front of toddler

Feeding skills: toddlers

Feeding skills: Preschoolers

Skilled with fork, spoon, cup

Tolerates most textures of foods

Must be careful of choking hazards

Messy eating is not the norm

Growth variable….appetite and intake increase prior to growth spurt

Desire to help and please

May be picky – exerting control, comforted by familiar foods


Can use a fork, spoon, & cup

Spills occur less frequently

Foods should be cut into bite-size pieces

Adult supervision still required

Feeding skills: Preschoolers

Energy and Nutrient Needs

Energy needsProteinVitamins and minerals

Toddlers

Macronutrients:Estimated energy requirement (EER) is

kcal/day = (89 x weight(kg)-100)+20

DRI 992-1046 kcal30%-40% of total kcal from fat1.1 grams of protein per kg body weight130 g carbohydrates per day 14 grams fiber per 1,000 kcal/day

Toddlers

Micronutrients: fruits and vegetables

Vitamins A, C, E, calcium, iron, zinc

Iron deficient anemia

Toddlers

Fluid needs:1.3 liters per day

Supplements: fluoride via fluoridated waterSupplements ???

If giving supplements, should not exceed 100% RDA for any nutrient

Toddlers

Allergies:watch for food allergies introduce one new food at a time

Vegetarian families: including eggs and dairy can be a healthful

dietA vegan diet may lack essential vitamins and

minerals

Preschoolers

Macronutrients: Energy – 1642-2279 depending on gender

and ageTotal fat intake should gradually drop to a

level closer to adult fat intake25%-35% of total energy from fat

0.95 grams protein per kg body weight130 grams carbohydrate per day14 grams fiber per 1,000 kcal

Preschoolers

Micronutrients:Vitamins and minerals

fruits and vegetables continue to be a concern Vitamins A, C, E, calcium, iron, zinc

AI of calcium increases for toddlersRDAs for iron and zinc also increase

Preschoolers

Fluid:1.7 liters per day

Supplements:?????May be recommended when particular food

groups are not eaten regularlySupplements should be appropriate for the

child’s age

Vitamin and mineral supplements

Not strictly necessaryMay be beneficial when entire food

groups are not consumed with regularityShould be age specificMonitor ULAt risk children: abused or neglected;

anorexia; fad diets; vegan diet

How much food intake?

Toddlers – 1 T food per year of age

Caregivers tend to overestimate portion sizes

Important to establish regular (yet flexible) patterns

Avoid uncontrolled grazing

Serve child sized portions

Avoid mixing foods together

Again, regular but flexible patterns

Avoid uncontrolled grazing


Mealtime an opportunity for parents to model healthy eating behaviors, toddlers to practice language and social skills, develop positive self-image Not the time for

battles or “force feedings”

Mealtime

Other Factors

Temperament differences40% easy, 10% difficult, 15% slow-to-warm-

upFood preference development

Food Preference Development

a complex process Influences

Genetics Parents Media educators at school

*By age 3, the dislike for certain foods has already developed.*

Biological Influence Genetic pre-disposition

of tastes Food Neophobia Exposure After-meal results Self-Regulation Developmental

Landmarks Cognitive Development

Parental & Familial Influence

Economics & Geography

Nutrition Knowledge Foods Consumed

During Pregnancy Food Modeling Short-Order Cooking Restriction

Implications for Practice

1. Exposure2. Target Children’s Literature3. Learning across the curriculum4. Pregnancy Books5. Family Meals6. Proper Influence

Most common nutrition problems

Iron-deficiency anemiaDental caries

fluorideConstipationLead poisoningFood SecurityFood Safety

Iron-deficiency Anemia

Diagnostic levels

1-2 years of age: Hgb<11 g/dl; Hct <32.9%

2-5 years: Hgb <11.1 g/dl; Hct <33%

Prevention

7-10 mg iron/dayMilk intake – should meet calcium needs

but not replace iron rich foods.Max. 24 oz/day


Dental Caries

Prevalence: 1 in 5 children ages 2 to 4

Causes: Bedtime bottle with juice or milk Streptococcus mutans Sticky carbohydrate foods

Prevention: Fluoride—supplemental amounts vary by age &

fluoride content of water supply


Constipation

Definition: Hard, dry stools associated with painful bowel movements

Causes: “Stool holding” and dietPrevention: Adequate fiber

Lead

Exposure old paint, pieces of metal, lead pipes

leaching into water ;soil; imported canned foods; household dust;

5-10x higher rate of absorption Other nutrient deficiencies exacerbate

vitamin c, iron, calcium, Vitamin D, zinc3x more likely to have elevated lead levels

Lead

Seen in ~2.2% of children ages 1-5Low levels of lead exposure linked to

lower IQ & behavioral problemsHigh blood lead levels may decrease

growthReduce lead poisoning by eliminating

sources of lead

The signs and symptoms of lead poisoning in children are nonspecific and may include:

Irritability Loss of appetite Weight loss Sluggishness Abdominal pain Vomiting Constipation Pallor from anemia

Complications of lead contamination

Nervous system and kidney damage Learning disabilities Speech, language and behavior problems Poor muscle coordination Decreased muscle and bone growth Hearing damage

Treatment

Removal of sourcechelation


Dietary and Physical Activity Recommendations

Dietary guidelinesOffer a variety of foods, limiting foods high in

fat & sugar60 minutes of vigorous physical activity each

dayMyPyramid developed by the USDA for

young children

MyPyramid

Other Concerns

Food allergies and intoleranceDietary supplements and herbal

remediesSources of nutrition services

Food Allergies and Intolerance

True food allergies seen in ~2% to 8% of children

Common food allergies include: Milk Eggs Wheat Peanuts Walnuts Soy Shellfish

Dietary Supplements and Herbal Remedies

Parents should be cautioned about use of supplements and/or herbs to treat various conditions

Often unproven recommendations come from parent coalitions and advocacy groups

Sources of Nutrition Services

State programs Early intervention programs Early childhood education programs (IDEA) Head Start Early Head Start WIC Low birthweight follow up Child care feeding programs

Growth Assessment

Nutrition assessment should be first step to determine if nutrition services are needed

Assessment answers the following: Is child’s growth on track? Is child’s food and nutrient intake adequate? Are feeding or eating skills age appropriate? Does diagnosis affect nutritional needs?

Growth Assessment

Interpretation of growth charts should consider special health condition

Growth charts specific to some conditions include:LBW or VLBWSpecial head growth chart

Feeding Problems

Special health care needs cause feeding problems in young children combined with typical feeding issues of the average toddler or preschooler

Examples include:Low interest in eatingLong mealtimesPreferring liquids over solidsFood refusals

Behavioral Feeding Problems

Mealtime feeding problems are common with toddlers & preschoolers with behavioral & attention disorders

Behavioral disorders that affect nutritional statusAutism Spectrum Disorder (ASD)Attention deficit hyperactivity disorder

(ADHD)May be suspected in preschool years but usually

treated in the school years

Other Feeding Problems

Excessive fluid intakeChild would rather drink than eat

Feeding problems & food safetyMashed or pureed foods and tubing or

devices for feeding may be contaminated or spoilage may occur

Feeding problems from disabilities involving neuro-muscular control

Nutrition-Related Conditions

Failure to thrive (FTT)Toddler diarrhea & celiac diseaseAutism Spectrum DisordersMuscle coordination problems & cerebral

palsyPulmonary problemsDevelopmental delay & evaluations

Failure to Thrive (FTT)

Inadequate wt or ht gain with growth declines more than 2 growth percentiles

May result from:Digestive problemsAsthma or breathing problemsNeurological conditionsPediatric AIDS

Recovery can include catch-up growth

Toddler Diarrhea and Celiac Disease

“Toddler diarrhea” typically caused by sucrose & sorbitol content of fruit juicesLimiting juice may be recommended

Celiac disease results in diarrhea & caused by sensitivity to the protein gluten found in wheat & other grainsComplete restriction of any gluten-

containing foods

Autism Spectrum Disorders

No specific diet is recommended for prevention or treatment

Gluten-free & casein-free diets have been used by parents but not endorsed by professional societies

Muscle Coordination Problems & Cerebral Palsy

Cerebral palsy Group of disorders characterized by impaired

muscle activity & coordination present at birth or developed during early childhood

Spastic quadriplegia: a form of cerebral palsy Reduced dietary intake results from child easily

becoming tired while eating Meal pattern may be changed to provide small, frequent

meals, and snacks to prevent tiredness at meals Foods recommended are easy to chew and soft

Pulmonary Problems

Examples of pulmonary (breathing) problems are brochopulmonary dysplasia & asthma

Breathing problems increase nutrient needs, lower interest in eating & can slow growth

Preterm infants at high risk of breathing problems

Recommend small, frequent meals with concentrated energy

Developmental Delay & Evaluation

Developmental delay may be suspected when:Specific nutrients are inadequately or

excessively consumedMay result from iron deficiency or lead

toxicityPhysical growth may be impacted

NDD 10603

Health & Medicine

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