10 Nutrition

Good nutrition is the foundation for healthy growth and development. Without adequate nutrients, children’s physical and mental health can be severely compromised. Children’s ability to interact with their environment, to be active and curious, and to explore and learn can be limited. Good nutrition, combined with vigorous exercise, helps children grow and maintain a high level of health. For children with acute or chronic illness, appropriate nutrition can be essential to healing and/or successful management of their condition.

The pediatric primary health care providers’ goal is to ensure that children are well nourished. To accomplish this, providers must conduct thorough assessments, provide relevant education, develop clear and appropriate treatment plans, and refer the child and family to nutritional specialists as needed. Interventions aimed at helping children and families meet nutritional requirements and preventing problems related to poor nutrition are based on certain assumptions, including the following:

• Children’s nutritional needs vary as they grow.

• Children’s nutritional needs are influenced by their state of health.

• A wide range of food choices and feeding behaviors are used to meet nutritional needs.

• Parents and other caregivers are responsible for providing food choices that are nutritionally adequate and for establishing healthy eating patterns; to do so, they must be well informed.

• Family patterns of nutrition and eating are based on social, economic, cultural, and psychological dynamics. Patterns are not related to nutrients alone.

• The primary care provider is a source of information regarding nutrition, feeding patterns, and health.

• The primary care provider works with a network of specialists (e.g., registered dietitians) to manage children’s nutrition status.

This chapter looks at the nutritional requirements of children and the ways providers can use nutrition to help children be their healthiest. It begins with the nutritional standards for preventive care recommended by certain professional groups, followed by a review of the functions of specific nutrients in the body and the “recommended daily intakes” for these nutrients. It must be emphasized that these recommendations are just that—recommendations, not requirements—and the fact that they are often given as a range (e.g., 25% to 35% of energy intake in the form of fat) reinforces the concept that there is latitude in what can be considered healthy nutritional intake.

Approaches to general assessment, diagnosis, and management of nutritional status are then presented. Finally, sections on “normal” and “altered” patterns of nutrition conclude the chapter. The section on “normal” nutrition outlines development of eating habits and age-specific considerations related to food intake, including nutrition for the pregnant teenager and vegetarian diets. In the section on altered patterns of nutrition, several tables summarize nutritional considerations of specific conditions (e.g., diabetes mellitus). It would be impossible within the scope of a general text to discuss nutritional needs of all acute and chronic conditions, so general categories are outlined: conditions that require increased caloric intake, those that require decreased caloric intake, and so on. Obesity has become an epidemic in the United States and other developed countries. This eating problem (epidemiology, etiology, assessment, and management), as currently understood, is discussed.

Standards for Preventive Care

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding until 4 to 6 months old, and continued breastfeeding, supplemented with appropriate foods for infants, until at least 12 months old (AAP, 2005). The AAP also recommends giving 400 International Units of vitamin D to all breastfed infants until 1 year of age and to all children and adolescents with diets deficient in vitamin D (Wagner et al, 2008). The American Medical Association (AMA) supports breastfeeding as the best infant nutrition. It recommends that providers calculate body mass index (BMI) measures in children’s routine physical examinations, “recognizing ethnic sensitivities and its relation to stature.” The AMA school health advocacy agenda includes attention to healthy eating and exercise in schools and for school-age children (AMA, 2005). The Institute of Medicine (IOM) has published ways to ensure that school food programs meet current dietary recommendations (Committee on Nutrition Standards for National School Lunch and Breakfast Programs et al, 2010). Bright Futures in Practice: Nutrition (Holt and Wooldridge, 2011) presents nutritional guidelines, discusses issues and concerns related to pediatric nutrition, and outlines tools for providers to assess and manage nutrition in children. The U.S. Preventive Services Task Force (USPSTF) recommends that children ages 6 years and older be screened for obesity and that they be given, or referred for, comprehensive intensive behavioral interventions to improve weight (USPSTF, 2010). Nutrition standards for children emphasize that:

Nutritional Requirements and Recommended Daily Intake

The body requires energy, water and electrolytes, and macro- and micronutrients in order to survive. The amounts of these requirements vary greatly. The Food and Nutrition Board (FNB) of the National Academies of Science, IOM, lists dietary reference intakes (DRIs) based on diets consumed in the U.S. and Canada. Developed in 1997, DRIs include the estimated average requirement (EAR), the recommended dietary allowance (RDA), the adequate intake (AI), and the tolerable upper intake level (UL) of foods consumed. DRIs reference parameters of nutrient intake that will meet body needs and prevent adverse effects of excessive intake. They do not, however, set a standard below which the diet is judged inadequate to prevent pathology (basal requirement), or a standard that is sufficient for the body to maintain a healthy body reserve (normative requirement) (FNB, 2005). Based on extensive analysis of scientific evidence on diet and nutrition, and referencing the DRIs developed by the FNB, the U.S. Departments of Agriculture (USDA) and Health and Human Services (USDHHS) publish Dietary Guidelines for Americans every five years. These guidelines address questions of nutritional adequacy, energy balance, weight management, and food safety and technology, and make recommendations regarding intake of macro- and micronutrients, water, cholesterol, salt, and alcohol (USDA and USDHHS, 2010). They can assist families and providers to make healthful dietary decisions to meet the nutritional needs of individual children.

Energy

An individual’s basal metabolic rate and thermoregulation, growth, and activity are the three mechanisms requiring energy intake, measured in kilocalories. The body uses most of its energy for regulatory functions: respiration, digestion, temperature regulation, circulation, and so on. This activity is measured as the body’s basal metabolic rate (BMR), or resting energy expenditure (REE). Growth, greatest in infancy and adolescence, is a second source of energy consumption. Finally, activity, exercise, and other metabolic demands, including illness, increase the level of calories needed to support healing and sustain good health. The body meets these energy demands, or estimated energy requirement (EER), by using stored energy sources or calories consumed on a daily basis. EERs for healthy children can vary significantly by age, health status, and activity level. Tables providing a formula to calculate caloric needs of infants and toddlers and children age 2 to 18 years old can be found on the inside cover of this text.

Macronutrients (protein, carbohydrates, and fats) and alcohol are all sources of calories the body uses to meet its energy needs. The body makes no distinction as to the source of calories; it will use whichever calories are consumed. It is recommended, however, that caloric intake be distributed among the three macronutrients, with each providing a certain percentage of total daily caloric intake. These recommendations are given as an acceptable macronutrient distribution range (AMDR) and are presented in Table 10-1. They are based on age for children who are of average height, weight, and physical activity level (FNB, 2005; USDA and USDHHS, 2010). If more calories than are required for energy needs are consumed, they will be converted to fat and stored. In addition to energy needs, the body requires essential nutrients for growth and health. If the food a child eats is high in calories (calorie dense) but low in nutrients (nutrient poor, often referred to as “empty calories”), the child will gain excess weight and still be undernourished. Data from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2004 show that more than 90% of all children ages 2 years and older had intakes of empty calories that exceeded discretionary limits (Krebs-Smith et al, 2010), contributing to overweight and obesity.

TABLE 10-1 Recommended Daily Allowance or Adequate Intake^∗of Nutrient by Age for Children of Average Height, Weight, and Physical Activity Level

Water and Electrolytes

Macronutrients

Protein

Protein is a fundamental component of all body cells. Dietary protein is broken down into amino acids, which are required for the synthesis of body cell protein and nitrogen-containing compounds, some enzyme and hormone activity, cell transport, and tissue growth and development. Ten “indispensable” or essential amino acids are not synthesized by the body and must be provided in the diet (phenylalanine, leucine, methionine, lysine, isoleucine, valine, threonine, tryptophan, histidine, and arginine [arginine is required in diet for infants but not adults]). Depending on their age, children should receive approximately 5% to 30% of daily calories from proteins (see Table 10-1).

Protein and amino acid deficiencies rarely appear alone but follow other dietary deficits. Without sufficient carbohydrate intake, for example, dietary protein cannot be broken down for protein synthesis. Extreme stress and disease can deplete nitrogen, a process that contributes to tissue wasting and creates an increased demand for protein. Growth needs of the premature infant require higher levels of protein intake than those of infants born at term. The demand for protein is not generally increased with normal activity except with some illnesses or to build additional muscle tissue during body conditioning.

Carbohydrates

Carbohydrates are the body’s major dietary source of energy. More than half (45% to 65%) of children’s body energy requirements should be supplied by carbohydrates (FNB, 2005; USDA and USDHHS, 2010). There are two forms of carbohydrates: simple sugars (the monosaccharides and disaccharides of sucrose, fructose, and lactose found in fruits, vegetables, milk, and prepared sweets) or complex carbohydrates (starches found in cereal grains, potatoes, legumes, and other vegetables). Most dietary carbohydrates should be in the complex form. Refined food products (e.g., products made with white flour, white sugar, white rice, and high-fructose corn syrup) should be limited. Because carbohydrates are essential to facilitate protein synthesis, if carbohydrates are extremely limited or absent from the diet (e.g., with a ketogenic diet used to manage intractable seizures of epilepsy; see Chapter 27), the body utilizes stored triglycerides, oxidizes fatty acids, and breaks down dietary and tissue protein. This process contributes to accumulation of ketone bodies.

Fats

Lipids, fats, and fatty acids are used by the body to provide energy, to facilitate absorption of the fat-soluble vitamins (A, D, E, and K), and to maintain integrity of cell membranes and myelin. Two essential fatty acids are not produced by the body and must be included in the diet. These essential polyunsaturated fatty acids (PUFAs), linoleic acid (LA) and alpha-linoleic acid (ALA), are precursors of omega-6 and omega-3 fatty acids, respectively. LA is found in soy oil, corn oil, and sunflower, safflower, pumpkin, and sesame seeds. ALA is found in large quantities in flaxseed and flaxseed oil and in lesser quantities in walnuts, canola oil, and wheat germ. Adequate amounts of omega-3 and omega-6 fatty acids are produced in the body if there is adequate intake of these two essential fatty acids and the vitamins and minerals necessary to facilitate their conversion.

Micronutrients

Vitamins

Recommendations for daily intake of fat- and water-soluble vitamins are listed in Table 10-1. Table 10-2 identifies specific metabolic functions, dietary sources, and signs of deficient or excessive intake of these vitamins.

TABLE 10-2 Vitamins: Function, Dietary Sources, Interactions, Deficiency, and Excess

Fat-Soluble Vitamins

Several characteristics of fat-soluble vitamins (A, D, E, and K) have implications for dietary assessment and management:

• They can be stored for long periods of time in body tissues. As a result, temporary dietary deficiencies may not affect the body’s growth and development. If stores are depleted and nutritional intake is inadequate, signs of vitamin deficiency appear. If intake is excessive, as can occur when supplements are taken, toxic effects can appear.

• They are absorbed in the intestines along with fats and lipids in foods. Low-fat diets and increased intestinal motility or malabsorption syndromes may put individuals at risk for fat-soluble vitamin deficiency.

• They are fairly stable when heated, as in cooking. Food preparation does not destroy fat-soluble vitamins as readily as water-soluble vitamins.

• They require bile for absorption. Conditions that compromise the hepatobiliary system put the individual at risk for decreased vitamin absorption.

• They do not contain nitrogen and do not act as coenzymes in cellular metabolism of nutrients.

Water-Soluble Vitamins

In contrast to fat-soluble vitamins, water-soluble vitamins (C and B complexes) are stored in very small amounts in the body. If water-soluble vitamin intake is more than that needed by the body, absorption (primarily in the jejunum) decreases, and excess vitamins are excreted. As a result, daily intake of water-soluble vitamins is necessary, and there is little risk of toxicity from large doses. The B vitamins contain nitrogen and serve as essential coenzymes in the body’s metabolism of nutrients. Niacin (vitamin B₃) plays a significant role in increasing high-density lipoproteins (HDLs).

Minerals and Elements

Three major minerals—calcium, magnesium, and phosphorus—are present in the body in amounts greater than 5 g. DRIs have been set for boron, calcium, chromium, copper, fluoride, iodine, iron, magnesium, manganese, molybdenum, nickel, phosphorus, selenium, silicon, vanadium, and zinc (FNB, 2005). Table 10-1 identifies recommended allowances for calcium, fluoride, iron, and zinc.

Peak bone density is directly related to calcium intake during the years of bone mineralization, primarily before 20 years of age. Bone calcification continues for several years more, however, so to ensure maximum peak bone density, dietary calcium needs to remain high until about 25 years old. Breastfed infants or those who are fed an approved infant formula receive sufficient calcium and should not be given a supplement. Minerals and essential trace elements, their functions, dietary sources, and signs of deficit or excess are presented in Table 10-3. Foods rich in iron are listed in Table 10-4.

TABLE 10-3 Minerals and Trace Elements: Function, Dietary Sources, Interactions, Deficiency, and Excess^∗

TABLE 10-4 Iron-Rich Foods^∗

Use of Vitamin and Mineral Supplements

National surveys reveal that many U.S. children have suboptimal nutrient intakes, especially a deficit of fruits and vegetables that contain many vitamins and minerals. The NHANES data from 2001 to 2004 show that a majority of all Americans, including children, fail to meet federal dietary recommendations (Krebs-Smith et al, 2010). Project EAT (Eating Among Teens) data show a trend toward eating fewer fruits and vegetables as adolescence progresses (Larson et al, 2007), and school-age children are at high risk for vitamin and mineral deficits (Robinson-O’Brien et al, 2010).

In light of these data and when confronted with a “picky eater,” parents are justifiably concerned and often ask if they should be giving their child a vitamin and mineral supplement. Parents should be advised that supplements are not a substitute for food, but may be appropriate in some cases. A child’s intake should be assessed over a 3-day period (i.e., DRIs for all foods do not have to be met every day) and strategies to encourage the child to eat a healthful, varied diet put in place. If, after assessment, the provider concludes that the child is at risk for nutritional deficit, multivitamins can be given. Preterm or low-birth-weight babies and children with chronic illness may need supplements, and all pregnant teenagers should receive prenatal vitamins. The AAP recommends a vitamin D supplement in breastfed infants of 400 International Units per day. Children and adolescents whose diet does not include an equivalent amount should also be given a supplement of 400 International Units. The dosage is based on the amount used to treat rickets in children (Casey et al, 2010).

Assessment of Nutritional Status

Assessment of nutritional status is done to determine if there is deviation from normal growth and development, whether the child’s diet is adequate, and what variables may be influencing the child’s dietary intake. When doing nutritional assessment, it is important to remember that eating is a social, cultural, and economic activity; nutritional value of foods is not the only, or often the most important, variable in a child’s or family’s decisions about what, how, and when to eat.

Much data can be collected in the intake interview, or using a 3-day diet recall. Providers can also use the Healthy Eating Index-2005 (HEI-2005) to assess quality of nutrient intake (Table 10-5). The HEI-2005 is based on 2005 Dietary Guidelines for Americans and the formerly used MyPyramid model and is a revision of previous Healthy Eating Indices. It lists 12 nutrient categories and gives each a score of 5, 10, or 20, with a maximum score of 100. The HEI-2005 does not require calculation of energy requirements, but measures nutrient units per 1000 kcal, an easier concept for families and children to understand and apply. To analyze individual diets, long-term intake should be assessed; a simple 24-hour recall does not adequately reflect the usual diet and can give a biased HEI number. Ideally a mean daily intake is examined over a period of time, often as long as 1 year. In population studies, HEI scores typically settle around 50 to 60, indicating significant nutritional deficit (Freedman et al, 2010; Guenther et al, 2008a,b).

TABLE 10-5 Healthy Eating Index-2005: Components and Standards for Scoring¹

History

Questions to elicit a history of nutritional status can be grouped into several categories:

• Nutritional status of mother during pregnancy

• Food and fluid intake of child and of family:

Type of feeding method used during infancy: If not breastfed, formula name and preparation. Any problems? When weaned? When solids started? Any allergies or intolerances noted?

Current nutritional intake of child (if child is still an infant, ask more specifically about frequency and amounts of feedings in a 24-hour period)

Type of foods and fluids

Amounts eaten (may use 24-hour recall, 3-day diet history, or length of time and frequency that child is at breast)

Additional intake (e.g., vitamin, fluoride, or iron supplements)

Is child’s intake different from the rest of the family? How?

• Eating patterns:

Frequency of eating (nursing, meals, snacks)

Bottle feeding: Is bottle propped? Does child take bottle to bed at night or at naptime? Who feeds child?

Breastfeeding: On demand or scheduled? How flexible is mother to demands of infant? Is mother working? Is breast milk frozen and fed by someone other than the mother?

Feeding patterns or behaviors for both child and family

Describe mealtimes: Does family sit down together? Are meals prepared at home? Does child eat at school? How often are “fast foods” eaten? What amount of time is spent eating? How long does it take to feed child?

Does family eat out frequently? How many times per week?

• Reactions to and attitudes about foods:

Any reaction to particular foods (e.g., vomiting, diarrhea, rash)?

Food preferences or dislikes

Cultural factors: What beliefs or attitudes does family have about how and what child should eat or how family should eat?

What is child’s attitude about foods and eating?

Feeding abilities of child: For example, does child choke, gag, vomit, have suck or swallow difficulties, or refuse certain foods, perhaps because of texture or smell?

Parents’ and child’s knowledge of foods and nutritional needs

• Management of foods in the family:

Who plans, purchases, and prepares food and meals for family?

Economic and environmental factors that influence how food is managed: For example, are finances adequate to supply nutritious foods? Is there a refrigerator? Does family have a car to carry larger amounts of food from store? Is there a full-service grocery store in the neighborhood? What is the socioeconomic status of family? Is food shopping budgeted? Are food stamps or other supplemental programs used?

• Health status affected by nutrition:

Special considerations for children or family related to food: For example, does child have a chronic condition that requires a special diet, formula, or device for feeding? Are any medications being taken?

Elimination patterns

Dental status and care of teeth

Patterns of wound healing, infections, colds, and mild illnesses

Any change in hair, nails, skin, or mucous membranes?

Tolerance for hot or cold weather?

Growth, activity, and exercise pattern: For example, has child been growing as parent expects? Has there been a history of unusual weight gain or loss? Does child have energy to play? Is the child engaged in strenuous activity such as an athletic training program?

Family history: Hypertension, diabetes, hyperlipidemia, obesity, heart disease, allergies, eating disorders?

Physical Examination

The physical examination should include the following:

• Body temperature

• Height, weight, and head circumference measurements (see growth charts, Appendix B; also see table on inside cover of this text for average weight and height gains expected during childhood); arm circumference and triceps and subscapular skinfold caliper measurements for children at risk for obesity or malnutrition

• BMI

• Skin condition (clear, smooth, firm, with good turgor)

• Muscle tone, posture, skeletal development (body erect, tone good)

• Hair (smooth, full, shiny; no dryness, broken ends, bare patches, or discoloration)

• Mucous membranes, eyes (moist, shiny, no dark circles, conjunctiva pink)

• Teeth (eruption appropriate to age, gums healthy, no bleeding)

• Neck (thyroid, parotid glands of normal size)

• Abdomen (flat, soft)

• Cardiovascular (no pathologic murmur; normal heart size; skin warm, pink, less than 3-second capillary refill; peripheral pulses equal, strong)

• Neurologic and behavior (alert, active, reflexes present, no complaints of headache, neuritis)

Management Strategies for Optimal Nutrition

It is the parents’ responsibility to provide healthful food that is adequate to meet the child’s nutritional needs in an environment that makes eating enjoyable; it is the child’s responsibility to decide what and how much of these healthful foods to eat. Critical to this interaction is a parent who knows which foods are healthful and which are not, and who is aware of and responsive to the child’s cues around feeding. Also essential is the parents’ ability to provide healthful foods; this can be extremely difficult for some low-income families. Food insecurity, even in high-income countries, is common among low-income multiethnic groups, and contributes to health problems (Gorton et al, 2010; Park K et al, 2009). In the U.S., federal programs (e.g., food stamps; Women, Infants, and Children [WIC]) increase families’ access to foods.

It is the providers’ responsibility to help parents and children make good decisions about nutrition and to facilitate families’ access to healthful foods. Providers may know what nutrients are necessary for healthy growth and development, but translating that information into day-to-day diet intake can be complex and confusing. What advice should be given to families when there is such a wide range of “normal” intake? What does it mean, for example, that 35% or less of energy requirements should be in the form of fats? Will it be harmful if a 3-month-old is introduced to commercially prepared fruits and vegetables? What, if any, are the benefits to eating organic foods? Should children avoid sugar or flavored milk? The questions are endless, and often without a clear answer. But the basic message providers should give parents is simple (Pollan, 2007):

• Eat food (versus processed, edible food-products that contain additives, fats, and few nutrients)

• Less of it (i.e., eat appropriate portions, do not overeat)

• Mostly plants

• Exercise

Pediatric providers use nutritional education, counseling, anticipatory guidance, and appropriate referral to ensure that children have optimal dietary intake. MyPlate (formerly MyPyramid) and the HEI-2005 are two tools providers can use to help families identify dietary deficits and make recommendations for change. Cultural issues related to food should be considered in doing an assessment and in planning interventions. Providers may need to refer families to public health nurses for assistance to find adequate food sources and/or to pediatric dietitians for management of special needs diets.

Nutritional Education

Education about nutrition should include information about children’s age and developmental abilities and characteristics, nutritional requirements, foods that meet children’s nutritional needs, and strategies to facilitate the development of healthy eating behaviors. Providers should also explain the relationship between diet and health conditions, including obesity.

MyPlate and MyPlate for Kids

MyPlate is a useful tool for educating families and children of all ages about a healthful diet. Developed by the U.S. Department of Agriculture to implement DRI guidelines of the FNB and reflect the 2010 Dietary Guidelines for Americans, MyPlate allows individuals to calculate their personal nutrient needs based on age, gender, and activity level. It illustrates the proportions of a healthy diet, emphasizing a foundation of grains, fruits, vegetables, beans, peas, and lean meats, fish, and poultry.

These tools provide in-depth information, resources, and a wide variety of nutrition-related activities to engage individuals in assessing and planning healthy nutrition. School nutrition is also addressed.

Age-Specific Considerations

Healthy eating habits are essential to good nutrition. The role that food plays in the family, the meaning it has for family members, and the way it is incorporated into family dynamics (e.g., parents may use sweets to reward children for good behavior) must be considered as providers counsel families about nutrition. Healthy eating habits begin during gestation and continue throughout the life span. A healthy pregnancy most often leads to a healthy term newborn, ready to learn and master the skills of eating. The toddler and preschool years are critical to establishing lifelong patterns of eating. Many eating problems, including obesity, are in part due to poor eating habits learned in infancy and early childhood that are reinforced through the school-age and adolescent years. Special considerations related to developing healthy eating habits are presented for each of the age-specific sections that follow. Also covered in this section are specific nutritional needs for children in each age group.

Newborns and Infants

Energy

Rapid infant growth requires high caloric intake. The table found on the inside cover of this text can be used to calculate the energy needs of infants to meet demands of metabolism and growth. Adequate intake of breast milk or infant formula meets all energy needs for infants until 4 to 6 months old.

Fat

For proper myelinization to occur infants must have adequate fat intake. Children younger than 2 years can require more than 30% dietary fat for neural development. The lipids in breast milk and formulas meet infants’ dietary requirements. During the second year of life cow’s milk can be included in children’s diets. The AAP recommends whole milk for children between 12 and 24 months old, although reduced-fat, or 2% milk, is recommended if there is a concern of overweight or obesity, or a family history of obesity or cardiovascular disease (Daniels and Greer, 2008). As part of a varied diet, reduced-fat milk contributes to adequate fat intake and has no negative effect on growth or body composition (Wosje et al, 2001). Fat-free milk is not recommended for children younger than 2 years of age.

Vitamins

Vitamin supplements, except vitamin D, are usually not necessary for healthy term breastfed or formula-fed infants who eat a variety of cereal, fruits, vegetables, and proteins after 4 to 6 months old. Vitamin D supplement (400 International Units daily) is recommended for all breastfed infants and infants who receive an unfortified formula until they are 1 year old. Infants should have an adequate source of vitamin C after 4 to 6 months old. A multivitamin supplement is recommended for infants at nutritional risk.

Iron

Iron deficiency is the leading cause of anemia in children, and iron supplementation is appropriate in some cases. Term infants who are breastfed usually have adequate iron supplies until 4 to 6 months old. Premature or low-birth-weight infants, infants who are exclusively breastfed beyond 4 to 6 months old, and infants who are fed cow’s milk before they are 12 months old are at high risk for iron deficiency anemia. Iron-fortified cereals and iron-fortified formulas are excellent sources of dietary iron supplements for infants 6 to 12 months old. Earlier supplementation may be necessary for premature infants, especially those that are breastfed.

Fluoride

The American Dental Association (ADA) recommends fluoride treatment starting at 6 months old (ADA, 2005). (See Chapter 33 for recommended fluoride dosages.) The fluoride level of water used to mix formula should be measured to ensure that infants do not receive excess fluoride. If the water supply is fluoridated, formula-fed infants younger than 6 months old can be given ready-to-feed formula, or nonfluoridated bottled water can be used to prepare formula.

Infant Formulas

Breast milk is the ideal food for newborns and infants and should be promoted unless it is medically harmful to the infant. Most iron-fortified infant formulas provide adequate nutrition and, for some families, may be an appropriate alternative to breastfeeding. Box 10-1 outlines various types of commercial formulas available.

BOX 10-1 Categories of Infant Formulas ^∗

• Premature transitional formulas

Higher caloric content more nutrient dense than regular cow’s milk–based formulas; 24 kcal/oz

Protein source: nonfat cow’s milk, whey

• Cow’s milk–based formulas

Standard formula for healthy term infants; 20 kcal/oz

• Nutrient-dense cow’s milk–based formulas

• Hypoallergenic formulas

Partially hydrolyzed whey-based formulas

Soy-based formulas (protein source: soy protein isolate with L-methionine)

Extensively hydrolyzed casein–or whey-based formulas

Amino acid–based formulas (elemental)

• Formulas with long-chain polyunsaturated fatty acids

More closely approximates human milk with content of docosahexaenoic acid (DHA, an omega-3 fatty acid) and arachidonic acid (ARA, an omega-6 fatty acid)

May enhance visual and mental development, especially in preterm infants (Fleith and Clandinin, 2005)

• Formulas for feeding beyond 6 months of age (Step-2 formulas), usually calcium fortified, must be supplemented with solids

• Nutrient-dense formulas for older child

Caloric content up to 30 kcal/oz; other nutrients increased over regular infant formula

• Specialized formulas

Higher caloric content (24-30 kcal/oz); nutrient dense; free amino acid and peptide-based formulas; lactose-free

• Protein supplements

• Nitrogen-free calorie supplements

• Oral electrolyte solutions

^∗ For names of formulas, detailed description of formula content, and links to formula manufacturers for additional information, see Infant formulas: approximate composition of pediatric formulas. Available at http://depts.washington.edu/grow ing/Nourish/Ftable.htm (accessed Sept 24, 2010).

Occasionally infants demonstrate intolerance to formula, showing irritability, weight loss or slow gain, vomiting, diarrhea, constipation, other gastrointestinal problems, or atopic dermatitis. The provider must work closely with parents to identify a formula tolerated by the infant, being careful to allow sufficient time for the baby to respond to a new formula as it is introduced. This can be a time- and energy-consuming process in which parents need support, reassurance, and encouragement. Referral to a registered dietitian can be helpful.

Introduction of Solids

A number of variables converge at about 6 months that make this an appropriate time to introduce solids into the infant’s diet:

Solids can be introduced in whatever sequence the family desires, often based on cultural or family customs, though nonallergenic cereals are usually the first infant foods. Dense proteins should be introduced later to allow for maturation of the renal system. Home-prepared foods, such as grains, mashed bananas, applesauce, pureed squash, cooked vegetables, and blenderized meats, can meet all the child’s nutritional needs. Although not necessary, commercial baby foods can provide adequate nutrition, but labels should be examined to determine their content, especially for calories, fats, additives, salt, and sugar. Box 10-2 lists some principles to keep in mind when beginning solids.

BOX 10-2 Principles for the Introduction of Solids into the Infant’s Diet

Eating Habits

Whether infants are being exclusively breast- or formula-fed, parents need to be alert to cues of satiety. Feeding on demand in early infancy is important, and neonates should not be allowed to sleep for long periods of time without feeding. But feeding primarily to comfort a child should be discouraged; every time a child cries, he or she is not necessarily hungry. Bottle-fed infants, whether formula or breast milk is used in the bottle, can easily be overfed (e.g., the caregiver often urges the infant to take that extra half ounce just to empty the bottle). As a result, infants can learn to ignore feelings of satiety. Self-regulation of intake is evident in young infants, but by the early toddler years, children are influenced by social cues around feeding and can eat more than they need (Fox et al, 2006). Normal-weight term infants who rapidly gain weight in the first months of life are at higher risk for obesity as toddlers and preschoolers (Singhal, 2010). Bottle feeding beyond 12 months old appears to be a risk factor for overweight (Bonuck et al, 2010), and formula-fed infants introduced to solid foods before 4 months are six times as likely to be obese at age 3 (Hah et al, 2011).

Parents should be counseled to respond promptly to a child’s feeding cues and to allow the child to initiate and guide the feeding interaction. Do not encourage the child to overeat. A selection of varied, healthful foods gives the older infant a chance to explore textures, smells, colors, and taste. Feeding is also a time when older infants and toddlers learn physical skills of fine motor control, cognitive skills of relationships between action and consequence (the dog will eat whatever is dropped on the floor), and skills of social exchange among family members.

Toddlers and Preschoolers

Energy and Protein

The growth rate of toddlers and preschoolers is slower than that of infants, resulting in decreased energy needs per unit of body weight. But because of increased size and activity, these children require an increased number of total calories. Addition of muscle mass also demands a continued high protein intake.

Vitamin and Mineral Supplements

Vitamin supplements are usually not necessary for young children because many foods are fortified and, as noted, supplements should not be considered as a substitute for food. Findings from the Feeding Infants and Toddlers Study (FITS) show that most children who do not use supplements receive adequate amounts of vitamins, and adding a multivitamin supplement can actually place children at risk of excessive vitamin intake; 97% of children who received supplements had more than the tolerable UIL for vitamin A, 66% for zinc, and 20% for folate (Briefel et al, 2006; Fox et al, 2006). Evaluate a child’s intake over the course of a week. If children persist with extremely limited food choices or picky eating behavior, they might benefit from a children’s multivitamin plus mineral supplement.

Eating Habits

Toddlers become more skilled in managing eating, using utensils, joining the family for regular mealtimes, and demonstrating more distinctive food likes and dislikes. They learn how and what to eat by observing adults around them and by responding to the foods adults provide for them. Older infants and toddlers may show an initial aversion to new foods and may demonstrate “food jags,” eating only a few kinds of food. With time, guidance, and patience, toddlers will learn to eat a wide variety of foods (see Strategies to Develop Healthy Eating Behaviors). Parents should continue to be responsive to the child’s cues for hunger and satiety, providing age-appropriate portions and not insisting on the “clean-plate” approach to nutrition.

School-Age Children

Energy and Protein

Energy and protein needs of school-age children vary greatly, depending on body size, growth patterns, and activity and exercise levels. Protein needs increase in older children as they gain more muscle mass. Active boys from 10 to 18 years old generally need between 2200 and 3200 calories a day, whereas active girls require about 1800 to 2400 calories daily; older children require the higher intake of this range (see table on the inside cover of this text).

Vitamin and Mineral Supplements

Poor eating habits place school-age children at risk for deficiencies in iron, thiamine, vitamin A, and calcium. Teaching children about specific nutrient sources and encouraging healthy eating habits can prevent many problems; supplementation with a daily multivitamin is usually not necessary.

Eating Habits

Food likes and dislikes carry over from the preschool years. There is great variation in appetite and intake as a result of uneven growth and activity levels. School-age children have a tendency to skip meals and are more likely to snack as they become engrossed in activities. This tendency is exacerbated in families with hectic schedules, unstructured mealtimes, and reliance on fast foods. Parents and children can identify healthful fast foods that fit a busy school-age child’s schedule (e.g., homemade burritos, stir-fry chicken, peanut butter sandwiches, an apple, carrot sticks, string cheese, and a bagel on the way to soccer practice). High-fat, high-calorie, low-nutrient snacks, such as chips, soda, and pizza, should be a very small part of a child’s diet.

Adolescents

Energy and Protein

The growth rate of adolescents is remarkable (see table on the inside cover of this text), and the description by some parents that their children never seem to stop eating is apt. High levels of energy are needed to support adolescents’ rapid growth, and if children participate in sports or other exercise programs, additional caloric intake can be needed. Adequate protein intake is essential to produce muscle mass. The average intake of protein in the U.S. diet is significantly greater than the DRI, so additional supplementation is usually not necessary.

Vitamin and Mineral Supplements

Thiamine, riboflavin, niacin, folate, iron, zinc, and calcium needs increase during adolescence (see Table 10-1). Most adolescents who eat a well-balanced diet need no supplements, but their irregular eating habits put them at risk for deficits. Adolescent girls are at risk for iron deficit when menstruation begins, and children who eat a vegan diet will need vitamin B₁₂ supplements.

Eating Habits

Eating habits of adolescents are influenced by their increasing independence and social activity, perceptions of body image, and physical growth patterns. Adolescents often have erratic eating patterns; skip meals; eat high-fat, high-calorie, low-nutrient snack foods; and consume calories late in the day. Skipping breakfast has been associated with obesity in adolescents and young adults; missing this meal is more common among low-income youth, especially African-Americans, living in disadvantaged communities who have no parent at home at breakfast time (Merten et al, 2009). Teens who participate in sports and adolescents who eat a mainly vegetarian diet tend to have healthier eating habits than their nonsports-involved or meat-eating counterparts (Croll et al, 2006; Dunham and Kollar, 2006).

Pregnancy in Adolescence

Pregnancy presents added nutritional demands for growing adolescents. During the pubertal growth spurt, the teenager’s body will compete with the fetus for nutrients. This is particularly true of girls younger than 15 years. Infants born to teenage mothers are at higher risk for prematurity, low birthweight, chronic illness, disabilities, and death. Proper nutrition and early prenatal care can increase the chance of a successful pregnancy.

The nutrition needs of pregnant teenagers also are high at a time when the typical teen is likely to have irregular eating patterns that can contribute to poor nutritional status. Calcium; iron; zinc; vitamins A, D, E, and B₆; riboflavin; folic acid; and total calories—all essential to fetal growth—are often found to be inadequate in the diets of female adolescents (Moran, 2007).

When managing the pregnant teenager, providers should carefully assess dietary intake and counsel the adolescent to eat a varied and healthful diet. A prenatal multivitamin and mineral supplement, including iron, calcium, and folic acid, is essential. The pregnant teenager should strive for a total of 1300 to 1500 mg of calcium through diet and supplements each day (Chan et al, 2006). Daily folic acid intake of 0.4 mg is recommended for all girls capable of becoming pregnant, increased to 0.6 mg during pregnancy (FNB, 2005).

Gestational weight gain in adolescents should be carefully monitored using World Health Organization (WHO) growth charts. Adolescents should not gain more than a recommended healthy gestational weight, just because they are adolescents. Healthy teens who are still growing (i.e., less than 4 years after menarche) should gain the amount they would normally gain in 9 months if they were not pregnant plus a normal gestational weight gain. For adolescents who are 4 years past menarche, gestational weight gain should be similar to that of adult women (IOM and National Research Council, 2009). Extra gestational weight gain for normal-weight African-American teenagers has not been shown to be beneficial (Nielsen et al, 2006). Adolescents who begin pregnancy when overweight are at high risk for neonatal and perinatal morbidity (Sukalich et al, 2006). Gestational weight gains of 15 to 25 pounds in overweight and obese adult women and 15 pounds or less in morbidly obese women are associated with fewer adverse outcomes (Crane et al, 2009). There are no data on adolescents to match those of the study by Crane and associates, but weight gain should not be excessive, and all adolescents would benefit from comprehensive prenatal nutrition programs (Nielsen et al, 2006). For those adolescents who meet income guidelines, the federal supplemental food program, WIC, is a valuable resource. In addition to providing nutritious foods, the program offers nutrition education and counseling.

Strategies to Develop Healthy Eating Behaviors

As noted, basic eating patterns are established in the infant, toddler, and preschool years; these patterns tend to continue throughout the child’s life.

Parents Decide What Foods to Eat

Children learn eating behaviors by observation and instruction, and parents are the primary teachers in the process. Often that teaching is done without conscious reflection or planning on the part of parents. Studies indicate that children tend to eat what their parents do and that parents who exert overt pressure on their children to eat less fat or more fruits and vegetables—without changing their own habits—actually contribute to poor eating patterns (Spruijt-Metz et al, 2006). The responsibility of parents to provide healthful foods cannot be overemphasized. Parents may rationalize giving their child empty calories rather than nutrient-rich food by stating, “That’s all my child will eat, and I know she needs the energy,” or “But he cries and carries on if I don’t give it to him; I’m just doing it to make him happy.” Providers can remind parents that the parent—not the child—decides if an 18-month-old’s “treat” is french fries or fruits. Parents have a choice and a serious responsibility to their children’s long-term health. If children learn early that healthy, nutrient-filled foods are readily available and that Mom and Dad enjoy them, they might enjoy them as well.

High-fat, high-sugar, and high-salt foods should make up a very small part of the diet, but overly restricting them, especially in children, can contribute to unhealthy attitudes toward food. If these foods are occasionally available, children learn to make better choices about how to fit them into a healthful diet. Intervention by providers in the child’s first year of life to teach parents which foods are healthy and encourage them to provide those foods helps establish healthy eating patterns in older children (Vitolo et al, 2010).

Children Decide How Much of These Healthful Foods to Eat

Often parents will try to decide exactly how much their child should eat (e.g., they may make a child sit at the table to finish his vegetables). Appetite fluctuations and preferences are typical of children, and parents should be aware that children may appear to eat less than the parent thinks is sufficient or too much of one particular food to the neglect of others. If parents punish a child for not eating or force a child to eat, they have taken away the child’s responsibility to choose. As a result, the child may develop an aversion to certain foods, overeat, or act-out in other ways. Mealtimes can become contests of will between parents and children, creating feelings and patterns of interacting that extend far beyond the dinner table. Parents need to find out what healthy foods their children enjoy (it is perfectly all right to eat only carrots, peas, or broccoli for several weeks in a row!) and make those available. If provided a nutritious variety of foods they like, children tend to select those necessary for their healthy growth, in terms of both amount of calories and other nutrients. A general principle to keep in mind when considering portions is to serve 1 tablespoon of food per year of age. For children younger than 5 years old, one serving is about one fourth to one third of an adult serving; for older children, one fourth to one half of an adult serving. Children’s appetites vary, however, and parents should be alert to cues that the child wants more or less of any particular food.

Providers can help parents make the process more positive by having them examine their own values and patterns related to eating, identify and reinforce those they would like to foster in their children, and eliminate those they see as negative. Providers can educate parents about age differences and offer suggestions for effectively managing the eating experience.

Parents should be encouraged to provide the following:

• Positive examples of healthy intake; parents are the child’s role model

• An adequate supply of a wide variety of age-appropriate, nutritious foods and snacks

• Limits, but not prohibitions, on consumption of nonnutritious sugars and “sometimes” foods

• Food prepared in a form that stimulates children’s appetites

• Regular, structured mealtimes when the family sits down to eat together; this may occur only once a day

• A pleasant, relaxed environment for mealtimes

• Clear, developmentally appropriate expectations for children’s behavior at mealtimes

• Developmentally appropriate access to and instruction in the use of utensils

• Appropriate supervision during mealtimes

• Developmentally appropriate opportunities to participate in planning, preparing, and serving meals

• Adequate exercise, sleep, and rest to stimulate appetites

The introduction of new foods can create tension between parents and children, with children refusing to try or rejecting new tastes or textures. Parents should be informed that this is a normal reaction for many children. Children may reject a food up to 15 to 20 times before they become accustomed to it and enjoy eating it, and parents should not be too concerned if a child rejects a particular food. Rather than force the child to try the new food or give in to the child’s feeding demands, the food should be removed without comment, then offered again at another meal. With a well-balanced diet, not eating a vegetable prepared at one meal, for example, will not compromise the child’s health. However, parents should be encouraged to avoid becoming the child’s “short-order cook,” preparing a special dish if the child rejects what has been fixed for the family. If a child chooses not to eat much at a particular meal, he or she will be hungrier at the next. Between meals, children should be offered age-appropriate snacks, but snacks should not be a substitute for meals; “grazing” or eating whenever food is available tends to override the child’s natural sense of satiety and encourage overeating (Brazelton and Sparrow, 2004).

Strategies that can be used to increase the chances of children accepting a new food include the following:

Finally, remind parents that individuals do not need to eat all foods. The parent may not eat some foods because of a personal dislike (e.g., anchovies, sushi, or cilantro); children should be afforded the same courtesy if they have been offered the food numerous times and repeatedly demonstrate dislike. There are many food options for attaining the same nutrients. As children become older, parents can help them master the social skill of politely trying new foods in new situations (e.g., visiting friends or dining in public places).

Physical Activity

Physical activity is integrally related to healthy nutrition. It is recommended that children and adolescents engage in 60 minutes of physical activity every day, most of which is moderate- or vigorous-intensity aerobic (exercise that makes them breathe hard); they should do vigorous activity at least 3 days a week and muscle- and bone-strengthening activity at least 3 days a week (USDHHS, 2009). Increased activity creates a demand for more calories and nutrients; more sedentary behavior means the body needs fewer calories, and sedentary lifestyles combined with poor eating habits can contribute to obesity. Figure 10-1 presents an integration of the food guide pyramid with a physical activity pyramid and can be used by providers to proactively counsel children about the importance of being active (see Chapter 13 for suggestions of activities).

FIGURE 10-1 Physical activity pyramid.

(Data from Reinhardt WC, Brevard PB: Integrating the food guide pyramid and physical activity pyramid for positive dietary and physical activity behaviors in adolescents, J Am Diet Assoc 102(3 Suppl):S96-S99, 2002; University of Missouri Extension: MyActivity Pyramid for Kids, 2007, Columbia, MO. Adapted from USDA MyPyramid. Available at www.extension.missouri.edu/explorepdf/hesguide/foodnut/00386.pdf [accessed May 11, 2011]).

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