The goals of nutrition and physical activity for children are to promote optimal physical and cognitive development, a healthy weight, an enjoyment of food, and a decreased risk of chronic disease (Ogata & Hayes, 2014
). Actual nutrient requirements vary according to health status, activity pattern, and growth rate. The greater the rate of growth, the more intense the nutritional needs. Meeting needs is essential; also important is avoiding nutrient and calorie excesses.
The health trends of American children are mixed. Although deficiency diseases are rare and infant mortality has declined over recent decades, the prevalence of overweight and obesity are a public health concern. Today, nearly 1 out of 3 American children are overweight or obese, placing them at risk for chronic diseases that were once only diagnosed in adults, such as coronary artery disease, type 2 diabetes, hypertension, metabolic syndrome, and sleep apnea. Today’s children may experience shorter life expectancies related to young onset obesity.
This chapter presents nutrition from birth through adolescence, including calorie and nutrient needs and eating practices. Nutrition concerns during childhood—namely, poor diet quality and overweight and obesity—are discussed.
INFANCY (BIRTH TO 1 YEAR)
Excluding fetal growth, growth in the first year of life is more rapid than at any other time in the life cycle. Birth weight doubles by 4 to 6 months of age and triples by the first birthday. Length increases by approximately 10 in during the first year. From birth through 23 months of age, size and growth rate are monitored by tracking weight-for-length and weight-for-age on World Health Organization growth charts (www.cdc.gov/growthcharts/who_charts.htm#
). Adequate calories and nutrients are needed to support the unprecedented rate of growth.
Human milk has been the gold standard for estimating the nutritional needs of an infant even though the content is variable and the volume breastfed infants consume is impossible to measure (Stam, Sauer, & Boehm, 2013
). Still, recommendations for the amount of calories, macronutrients, vitamins, and minerals infants should consume are based on the estimated average intakes of healthy full-term newborns who are exclusively breastfed by well-nourished mothers. Although the total amount of calories and nutrients are generally far less than what adults need, the infant’s needs are much higher per kilogram of body weight. Proportionately, infants use large amounts of energy and nutrients to fuel their body processes and growth.
Because infants are born with low amounts of vitamin K stored in the body and a decreased ability to utilize vitamin K, infants are given a single intramuscular dose of vitamin K at birth to protect them from hemorrhagic disease of the newborn.
Breast milk is specifically designed to support optimal growth and development in the newborn, and its composition makes it uniquely superior for infant feeding (Box 12.1
) (American Academy of Pediatrics [AAP], 2012a
). Breastfeeding is credited with numerous potential health benefits for the infant, including lower risks of otitis media, upper respiratory tract infection, lower respiratory tract infection, asthma, atopic dermatitis, gastroenteritis, obesity, celiac disease, type 1 and type 2 diabetes, certain types of leukemia, and sudden infant death syndrome (AAP, 2012a). Although many of these benefits are linked to breastfeeding for 3 months or more, some benefits occur with any duration of breastfeeding, such as the reduced risk of obesity and type 2 diabetes.
The AAP contends that because of the short- and long-term medical and neurodevelopmental benefits of breastfeeding, infant nutrition should be considered a public health issue and not simply a lifestyle choice (AAP, 2012a).
The AAP (2014) recommends exclusive breastfeeding for the first 6 months of life, which, with one exception, is considered a complete source of nutrition adequate to meet the needs of healthy, full-term infants. The exception is vitamin D, which is given in supplemental form until the age of 1 year or until the infant consumes 1 quart of vitamin D-fortified formula per day. Even after solid foods are introduced, breastfeeding should continue for at least the first 12 months of age. What the breastfeeding mother needs to know appears in Box 12.2
The AAP (2014) also recommends breastfeeding for preterm infants, with the stipulation that infants who weigh less than 1500 g at birth receive human milk that is fortified with protein, minerals, and vitamins to ensure optimal nutrient intake.
Infant formulas may be used in place of breastfeeding, as an occasional supplement to breastfeeding, or when exclusively breastfed infants are weaned before 12 months of age. The Infant Formula Act regulates the levels of nutrients in formulas, specifying both minimum and maximum amounts of each essential nutrient. Almost all formula used in the United States is iron fortified, a practice that has greatly reduced the risk of iron deficiency in older infants. Because the minimum recommended amount of each nutrient is more than the amount provided in breast milk, nutrient supplements are unnecessary for the first 6 months of life.
Categories of Formula
features the categories of formulas for full-term and preterm infants. Full-term infant categories include “routine” cow’s milk protein based, soy protein based, hydrolyzed formulas for infants with cow’s milk protein allergy, and specialized formulas for infants with metabolic disorders. Within each of those categories there are a variety of formulas to choose. Currently, infant formula companies in the United States market directly to consumers and regularly release new formulas with or without slightly different compositions on a regular basis (Abrams, 2015
). For instance, lutein (a phytonutrient) is not an essential nutrient and is therefore not required in
formula, but a manufacturer is adding it to “support eye health.” Other optional but increasingly common formula features include the following:
The addition of docosahexaenoic acid (DHA) and arachidonic acid (ARA) to most formulas. Studies show these fatty acids promote eye and brain development.
The addition of prebiotics and probiotics. Several studies suggest probiotics may benefit infants with diarrhea.
Non-genetically modified organism (GMO) options
Table 12.1 General Parameters for Formula Feeding
Number of Feedings in 24 Hours
Amount per Feeding (oz)
Surprisingly, the U.S. Food and Drug Administration (FDA) does not “approve” new formulas but rather reviews the proposed formula composition and background information provided by the formula manufacturer. The FDA is more empowered to evaluate safety than efficacy of infant formulas (Abrams, 2015
The amount of formula provided per feeding and the frequency of feeding depend on the infant’s age and individual needs. General parameters are provided in Table 12.1
. Overfeeding is one of the biggest hazards of formula feeding. Caregivers should recognize that infants cry for reasons other than hunger and should not be fed every time they cry, nor should an infant be forced to finish his or her bottle. Feedings should always be supervised; bottles should never be propped for independent feeding. Nor should infant cereals be added to a bottle. To avoid nursing bottle caries, infants and children should not be put to bed with a bottle of formula, milk, juice, or other sweetened liquid (Fig. 12.1
). Teaching points for formula feeding are summarized in Box 12.4
Complementary Foods: Introducing Solids
The introduction of solids is dependent on the infant’s developmental readiness and nutrient needs.
Developmentally, most infants exhibit readiness to spoon-feed around 4 to 6 months of age as reflexes disappear, head control develops, and the infant is able to sit. Over time, control of the
head, neck, jaw, and tongue; hand-eye coordination; and the ability to sit, grasp, chew, drink, and self-feed evolve. The eruption of teeth indicates readiness to progress from strained to mashed to chopped fine to regular consistency foods. Guidelines for introducing solids on the basis of developmental readiness appear in Table 12.2
Figure 12.1 ▶ Nursing bottle caries. Notice the extensive decay in the upper teeth. (© K. L. Boyd, DDS/Custom Medical Stock Photo.)
Around 4 to 6 months of age, breast milk or formulas are not adequate as the sole source of nutrition and complementary foods become necessary, particularly for iron. Some experts recommend baby food meat as one of the first complementary foods because it provides iron and zinc, another important nutrient (AAP, 2012b). Traditionally, iron-fortified single-grain infant cereal has been the first solid food introduced, but there is no evidence to support any particular order for introducing solids. Formula-fed infants continue to need iron-fortified formula. The other nutrient of concern is fluoride. At 6 months of age, exclusively breastfed infants and infants who receive ready-to-use infant formula need supplemental fluoride. Infants who receive formula that has been prepared with local water need supplemental fluoride only if the water contains less than 0.3 ppm of fluoride.
To increase the likelihood of acceptance, parents are urged to give a small amount of formula or breast milk to take the edge off hunger before introducing the first solid. After the infant learns to accept the first solid food, new foods are introduced in plain and simple form one at a time for a period of at least 2 to 3 days so that allergic reactions, such as rashes, vomiting, or diarrhea, can be identified. After tolerance is established, another new food is added. Within a few months, the infant is eating texture-appropriate meats, cereal, fruits, and vegetables in addition to breast milk and/or formula. The notion that infants who are fed fruits before vegetables will develop a preference for sweets and reject vegetables is not supported by evidence.
Table 12.2 Sequence of Infant Development and Feeding Skills in Normal, Healthy, Full-Term Infants*
Baby’s Approximate Age
Hand and Body Skills
Feeding Skills or Abilities
Birth through 5 months
Tongue thrust reflex
Poor control of head, neck, trunk
Brings hands to mouth around 3 months
4 months through 6 months
Draws in upper or lower lip as spoon is removed from mouth
Up-and-down munching movement
Can transfer food from front to back of tongue to swallow
Tongue thrust and rooting reflexes begin to disappear
Gag reflex diminishes
Opens mouth when sees spoon approaching
Takes in a spoonful of pureed or strained food and swallows it without choking
Drinks small amounts from cup when held by another person, with spilling
5 months through 9 months
Begins to control the position of food in the mouth
Up-and-down munching movement
Positions food between jaws for chewing
Begins to eat mashed foods
Eats from a spoon easily
Drinks from a cup with some spilling
Begins to feed self with hands
8 months through 11 months
Moves food from side-to-side in mouth
Begins to curve lips around rim of cup
Begins to chew in rotary pattern (diagonal movement of the jaw as food is moved to the side or center of the mouth)
Begins to eat ground or finely chopped food and small pieces of soft food
Begins to experiment with spoon but prefers to feed self with hands
Drinks from a cup with less spilling
10 months through 12 months
*Developmental stages may vary with individual babies.
Source: U.S. Department of Agriculture, Food and Nutrition Service. (2016). Feeding infants: A guide for use in the child nutrition programs. Available at www.fns.usda.gov/sites/default/files/feeding_infants.pdf. Accessed 4/18/16.
Choice of Foods
Like a healthy eating pattern for adults, infants should consume foods that provide variety, balance, and moderation with the following considerations:
Fat intake should not be restricted because infants and young children need proportionately more fat than older children and adults.
Fruit juice can contribute to excessive calorie intake and displace the intake of more nutrient-dense foods. The AAP recommends fruit juice not be given to infants younger than 6 months of (AAP, 2015a). If it is given to infants between 6 and 12 months, the juice should be served in a cup, not a bottle.
Foods should be cooked without added salt or seasonings.
Foods that may cause choking in infants and small children are avoided (Box 12.5
Empty calorie foods should not be given. The high nutritional requirements for healthy growth and development leave little room for foods with low nutritional value (May & Dietz, 2010
Because honey may contain botulism spores, infants under the age of 1 year should not have honey in any form, cooked or raw.
Many pediatricians recommend against introducing eggs and fish before the age of 12 months, but there is no evidence that introducing these foods after 4 to 6 months affects the risk of allergy (AAP, 2012b). Similarly, the AAP advises health-care providers to recommend introducing peanut-containing products into the diets of high-risk infants between 4 and 11 months of age based on evidence that shows early introduction of peanuts into the diet of infants at high risk of peanut allergy can play a role in preventing peanut allergies (AAP, 2015b).
Infants differ in the amount of food they want or need at each feeding. The amount of solid food taken at a feeding may vary from 1 to 2 tsp initially to ¼ to ½ cup as the infant gets older. To avoid overfeeding, infants and children should be allowed to self-regulate the amount of food consumed.
Tips for creating a positive eating environment are listed in Box 12.6
NUTRITION FOR TODDLERS AND PRESCHOOLERS
Typically, every year from age 1 year until puberty, children typically grow 2 to 3 in taller and 5 to 6 pounds heavier. Beginning at age 2 years, Centers for Disease Control and Prevention (CDC) growth charts are used to monitor size and growth patterns by plotting body mass index (BMI) for age (Figs. 12.2
). Non-healthy weight status (Table 12.3
) and deviations in a child’s percentile channel warrant further attention.
Early parental influence is associated with the development of a child’s relationship with food later in life (Ogata & Hayes, 2014
). Young children are especially dependent on parents and caregivers as to which foods are available, the portion sizes offered, how often eating occurs, and the social context of eating. For instance, eating all food on the plate, dessert used as a reward, and eating regularly scheduled meals are behaviors young adults report their parents instilled in them during childhood (Vauthier, Lluch, Lecomte, Artur, & Herbeth, 1996
). Parents who offer large food portions (especially of calorie-dense, sweet, or salty foods), pressure their child to eat or
restrict the child’s eating, and model excessive eating undermine the child’s ability to self-regulate food intake (Ogata & Hayes, 2014
). Tips for getting children on the path to healthy eating appear in Figure 12.4
Figure 12.2 ▶ Body mass index-for-age percentiles for boys. (Source: Adapted from the Centers for Disease Control and Prevention [CDC] Growth Chart, New York State Department of Health.)
Figure 12.3 ▶ Body mass index-for-age percentiles for girls. (Source: Adapted from the Centers for Disease Control and Prevention [CDC] Growth Chart, New York State Department of Health.)
Table 12.3 Weight Status Based on Body Mass Index for Age Centers for Disease Control and Prevention Growth Charts
Weight Status Category
Normal or healthy weight
5th percentile to <85th percentile
85th percentile to <95th percentile
Source: Centers for Disease Control and Prevention. (2015). BMI for children and teens. Available at www.cdc.gov/obesity/childhood/defining.html. Accessed on 4/18/16.
▲ Healthy eating for preschoolers.
Get your child on the path to healthy eating. (Available at www.choosemyplate.gov.)
Calories and Nutrients
There is very little research on the best ways to achieve optimal nutritional intakes from 1 to 2 years of age, the transition period between infancy and childhood. The dramatic decrease in growth rate is reflected in a disinterest in food, a “physiologic anorexia” due to lower calorie needs per kilogram of body weight.
At age 2 years, three meals a day with two to three snacks providing a total of 1000 calories is appropriate. Estimated calorie needs per day for males and females ages 3 to 18 years are illustrated in Figure 12.5
The Dietary Guidelines for Americans
are intended for all healthy Americans age 2 years and older; thus, the key recommendations for healthy eating remain consistent from early childhood throughout the lifespan (Box 12.7
) (U.S. Department of Health and Human Services [USDHHS] & U.S. Department of Agriculture [USDA], 2015
). By focusing on variety, nutrient density, and appropriate amounts recommended within the appropriate calorie level eating pattern, it is assumed nutrient needs will be met within calorie limits. Figure 12.6
also illustrates eating pattern recommendations for 2- to 5-year-olds, with ranges reflecting gender and activity variations. Figure 12.7
features sample 1000-calorie and 1600-calorie meal patterns.
Figure 12.5 ▶ Estimated calorie needs per day for males and females ages 3 to 18 years.
Parents and caregivers determine what food is served, when food is served, and where it is served. Children should be allowed to decide whether they eat and how much they eat. Although the food children need is the same as adults, the portion sizes are not. A rule-of-thumb guideline to determine age-appropriate serving sizes is to provide 1 tbsp of food per year of age (e.g., the serving size for a 3-year-old is 3 tbsp). By ages 4 to 6 years, recommended serving sizes are similar to those for adults. Eating behaviors in young children that warrant further investigation are listed in Box 12.8
At age 1 year, the child should be drinking from a cup and eating many of the same foods as the rest of the family. Whole milk becomes a major source of nutrients, including fat; children between the ages of 1 and 2 years have a relatively higher need for fat to support rapid growth and development. However, milk intake should not exceed 2 to 3 cups per day because, in greater amounts, it may displace the intake of iron-rich foods from the diet and promote milk anemia
. Gradual introduction of 2% milk occurs after age 2 years and eventually progresses to nonfat milk. However, when there is concern about the risk of obesity based on family history, low-fat milk beginning at 12 months of age may be appropriate (Daniels & Hassink, 2015
Milk Anemia an iron deficiency anemia related to excessive milk intake, which displaces the intake of iron-rich foods from the diet.
New foods may take 15 to 20 exposures before they are accepted (Birch, 1999
). Beginning around 15 months of age, a child may develop food jags as a normal expression of autonomy as the child develops a sense of independence. By the end of the second year, children can completely self-feed and can seek food independently.
▲ Meal and snack pattern for 1000- and 1600-calorie eating patterns. (Available at www.choosemyplate.gov.)
Until the age of 4 years, young children are at risk for choking. To decrease the risk of choking, foods that are difficult to chew and swallow should be avoided (see Box 12.5
); meals and snacks should be supervised; foods should be prepared in forms that are easy to chew and swallow (e.g., cut grapes into small pieces and spread peanut butter thinly); and infants should not be allowed to eat or drink from a cup while lying down, playing, or strapped in a car seat.
NUTRITION FOR CHILDREN AND ADOLESCENTS
Childhood represents a more latent period of growth compared to infancy and adolescence. Although there are individual differences, usually a larger child eats more than a smaller one; an active child eats more than a quiet one; and a happy, content child eats more than an anxious one. School-age children maintain a relatively constant intake in relation to their age group; children who are considered big eaters in second grade are also big eaters in sixth grade.
The slow growth of childhood abruptly and dramatically increases with pubescence until the rate is nearly as rapid as that of early infancy. Adolescence is a period of physical, emotional, social, and sexual maturation. Approximately 15% to 20% of adult height and 50% of adult weight are gained during adolescence. Fat distribution shifts and sexual maturation occurs. Subsequently, calorie and nutrient needs increase, as does appetite, but exactly when those increases occur depends on the timing and duration of the growth spurt. Because there are wide variations in the timing of the growth spurt among individuals, chronological age is a poor indicator of physiologic maturity and nutritional needs.
Gender differences are obvious. For instance, girls generally experience increases in growth between 10 and 11 years of age and peak at 12 years. Because peak weight occurs before peak height, many girls and parents become concerned about what appears to be excess weight. In contrast, boys usually begin the growth spurt at about 12 years of age and peak at 14 years. Stature growth ceases at a median age of approximately 21 years. Nutritional needs increase later for boys than for girls.
Calories and Nutrients
Calorie range recommendations for males and females appear in Figure 12.5
. The lowest number within each range represents calorie estimates for a sedentary level of activity; for moderate activity, the number increases by 200 calories, and for an active individual, the increase is generally another 200 calories. Total calorie needs steadily increase during childhood, although calorie needs per kilogram of body weight progressively fall. The challenge in childhood is to meet nutrient requirements without exceeding calorie needs. Table 12.4
lists healthy U.S.-style eating patterns recommendations for calorie levels appropriate from childhood through adolescence. Generally, nutrient requirements are higher during adolescence than at any other time in the life cycles, with the exception of pregnancy and lactation.
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