Nutrition for Infants, Children, and Adolescents
Unfolding Case
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Luis Guzman
Luis is a 7-year-old boy who is 48 in tall and weighs 90 pounds. He is the only child of a single mother who worries that his weight is out of control. She admits she lets him eat whatever he wants, even though she knows he is eating inappropriately. His grandmother is his primary caregiver before school starts, and when school is not in session, and she also gives him whatever he wants, including fast food twice a week.
Check Your Knowledge
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Learning Objectives
Upon completion of this chapter, you will be able to
1 Compare breastfeeding to formula feeding.
2 Describe the process of introducing solid foods into the diet.
3 List eating behaviors of young children that may indicate nutrition risk.
4 Identify nutrients most likely to be under consumed by children and adolescents and the food groups that supply those nutrients.
5 Explain potential health risks of a poor quality eating pattern during childhood and adolescence.
6 Give examples of obesity prevention strategies for children and adolescents aimed at improving eating patterns, decreasing sedentary behaviors, increasing physical activity, and ensuring adequate sleep.
7 Evaluate an eating pattern based on MyPlate food intake recommendations.
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
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 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).
BOX 12.1 Composition of Breast Milk
The protein content of breast milk is adequate to support growth and development without contributing to an excessive renal solute load.
The majority of the protein is easy-to-digest whey.
Breast milk contains small amounts of amino acids that may be harmful in large amounts (e.g., phenylalanine) and high levels of amino acids that infants cannot synthesize well (e.g., taurine).
The fat in breast milk is easily digested because of fat-digesting enzymes contained in the milk.
The content of linoleic acid (an essential fatty acid) is high.
The high level of cholesterol is believed to help infants develop enzyme systems capable of handling cholesterol later in life.
Breast milk contains amylase (a starch-digesting enzyme), which may promote starch digestion in early infancy when pancreatic amylase is low or absent.
Breast milk contains enough minerals to support adequate growth and development but not excessive amounts that would burden immature kidneys with a high renal solute load.
The minerals are mostly protein bound and balanced to enhance bioavailability. For instance, the rate of iron absorption from breast milk is approximately 50% compared with about 4% for iron-fortified formulas. Zinc absorption is better from breast milk than from either cow’s milk or formula.
All vitamins needed for growth and health are supplied in breast milk, but the vitamin content of breast milk varies with the mother’s diet.
The renal solute load of breast milk is suited to the immature kidneys’ inability to concentrate urine.
Although they are more abundant in colostrum, antibodies and anti-infective factors are present in mature breast milk. Bifidus factor promotes the growth of normal gastrointestinal (GI) flora (e.g., Lactobacillus bifidus) that protect the infant against harmful GI bacteria.
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.
BOX 12.2 Teaching Points for Breastfeeding
The infant should be allowed to nurse for 5 minutes on each breast on the first day to achieve letdown and milk ejection. By the end of the first week, the infant should be nursing up to 15 minutes per breast.
In the first few weeks of breastfeeding, the infant may nurse 8 to 12 times every 24 hours. Mothers should offer the breast whenever the infant shows early signs of hunger, such as increased alertness, physical activity, mouthing, or rooting. After breastfeeding is well established, eight feedings every 24 hours may be appropriate.
The first breast offered should be alternated with every feeding so both breasts receive equal stimulation and draining.
Even though the infant will be able to virtually empty the breast within 5 to 10 minutes once the milk supply is established, the infant needs to nurse beyond that point to satisfy the need to suck and to receive emotional and physical comfort.
The supply of milk is equal to the demand—the more the infant sucks, the more milk is produced. Infants age 6 weeks or 12 weeks who suck more are probably experiencing a growth spurt and so need more milk.
Water and juice are unnecessary for breastfed infants in the first 6 months of life, even in hot climates.
Early substitution of formula or introduction of solid foods may decrease the chance of maintaining lactation.
Infants weaned before 12 months of age should be given iron-fortified formula, not cow’s milk.
Both feeding the infant more frequently and manually expressing milk will help to increase the milk supply.
Breast milk can be pumped, placed in a sanitary bottle, and immediately refrigerated or frozen for later use. Milk should be used within 24 hours if refrigerated or within 3 months if stored in the freezer compartment of the refrigerator.
Infant Formula
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
Box 12.3 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:
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.
Organic options
Non-genetically modified organism (GMO) options
BOX 12.3 Infant Formulas
Full-Term Formulas
Milk based (e.g., Similac Advance or Enfamil Infant)
For routine use; account for 80% of formula sold in the United States
Soy based (e.g., Isomil, ProSobee)
For infants with galactosemia; lactase deficiency; allergy to cow’s milk protein but not soy; vegan parents
Hydrolyzed
Vary from partially hydrolyzed (e.g., Carnation Good Start) to extensively hydrolyzed (e.g., Alimentum or Nutramigen) depending on the how small the protein molecules are broken down
Only extensively hydrolyzed formulas are hypoallergenic and suitable for infants with or at high risk of cow’s milk protein allergy
Specialized
For infants with inborn errors of metabolism, such as phenylketonuria (e.g., Phenyl-Free) or maple syrup urine disease (e.g., BCAD 1)
Are intentionally lacking or deficient in one or more nutrients, so they do not supply adequate nutrition for normal infants
Must be supplemented with small amounts of regular formula
For Infants Born Before Term
Preterm formulas (e.g., Enfamil Premature High Protein 24)
For infants born before 34 weeks of gestation
Designed to promote “catch-up” growth so are higher in calories, protein, calcium, magnesium, and phosphorus than routine formulas
Enriched formula (e.g., Enfamil EnfaCare, Similac NeoSure)
For infants 34 to 36 weeks of gestation
Provide more calories than term formula but less than preterm formula
Table 12.1 General Parameters for Formula Feeding | ||||||||||||
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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).
Formula Feeding
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.
Developmental Readiness
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.
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.) |
BOX 12.4 Teaching Points for Formula Feeding
Never force the infant to finish a bottle or to take more than he or she wants.
Signs that an infant is finished include biting the nipple, puckering the face, and turning away from the bottle.
Discourage the misconception that “a fat baby = a healthy baby = good parents.”
Each feeding should last 20 to 30 minutes.
Formula may be given at room temperature, slightly warmed, or directly from the refrigerator; however, always give formula at approximately the same temperature.
Spitting up of a small amount of formula during or after a feeding is normal. Feed the infant more slowly and burp more frequently to help alleviate spitting up.
Hold the infant closely and securely. Position the infant so that the head is higher than the rest of the body.
Avoid jiggling the bottle and making extra movements that could distract the infant from feeding.
Check the flow of formula by holding the bottle upside down. A steady drip from the nipple should be observed. If the flow is too rapid because of a too large nipple opening, the infant may overfeed and develop indigestion. If the flow rate is too slow because of a too small nipple opening, the infant may tire and fall asleep without taking enough formula. Discard any nipples with holes that are too large, and enlarge holes that are too small with a sterilized needle.
Reassure caregivers that there is no danger of “spoiling” an infant by feeding him or her when the infant cries for a feeding.
Burp the infant halfway through the feeding, at the end of the feeding, and more often if necessary to help get rid of air swallowed during feeding. Burping can be accomplished by gently rubbing or patting the infant’s back as he or she is held on the shoulder, lies on his or her stomach over the caregiver’s lap, or sits in an upright position.
After the teeth erupt, the baby should be given only plain water for a bedtime bottle-feeding. Never prop the bottle or put the infant to bed with a bottle.
Nutrient Needs
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.
Initiating Feeding
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* | ||||||||||||||||||||||||||||||||||||
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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.
BOX 12.5 Foods that May Cause Choking in Small Children
Hot dogs and sausages
Candy
Nuts and seeds (such as pumpkin or sunflower)
Grapes
Raw carrots
Tough meat
Watermelon with seeds
Celery
Popcorn
Raisins and other dried fruit
Chunks of cheese
Potato and corn chips and similar snack foods
Peanut butter and other nut or seed butters
Food Allergies
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).
Food Amounts
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.
BOX 12.6 Tips to Create a Positive Eating Environment
Eat with the child. Be a role model.
Eat at regular times. Offer three meals and up to three snacks at regular times each day.
Prepare one meal for the whole family.
Keep in mind that it is not important if a child refuses to eat a particular food (e.g., spinach), so long as the child has a reasonable intake from each major food group.
Offer a variety of foods, not just the ones you like. Repeated exposures—up to 15 to 20 times—may be needed before a child accepts a new food.
Fat and cholesterol should not be limited in the diets of very young children, who need fat and cholesterol for their developing brains and nervous systems.
Never force a child to eat; if a healthy child is hungry, he or she will eat.
Do not use food to reward, punish, bribe, or convey love.
Let toddlers explore and enjoy food, even if it means eating with their fingers.
Space meals further apart and limit snacking so the child will be hungry at mealtimes.
Keep mealtime relaxed, pleasant, and unhurried, allowing 20 to 30 minutes per meal. After 30 minutes, put the food away and let the child leave the table.
Children may refuse to eat because they are (1) too excited or distracted, (2) seeking attention, (3) expressing independence, (4) too tired, or (5) simply not hungry. When any of these instances occur, remove the child’s plate without comment. If the child wants a snack later, make it nutritious.
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 and 12.3). 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.
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 | ||||||||||||
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 Figure 12.4 ▲ 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. |
BOX 12.7 2015-2020 Dietary Guidelines for Americans Key Recommendations for Ages 2 Years and Older
Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level.
A healthy eating pattern includes:
A variety of vegetables from all of the subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other
Fruits, especially whole fruits
Grains, at least half of which are whole grains
Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages
A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products
Oils
A healthy eating pattern limits:
Saturated fats and trans fats, added sugars, and sodium
Key recommendations that are quantitative are provided for several components of the diet that should be limited. These components are of particular public health concern in the United States, and the specified limits can help individuals achieve healthy eating patterns within calorie limits:
Consume less than 10% of calories per day from added sugars
Consume less than 10% of calories per day from saturated fats
Consume less than 2300 mg/day of sodium
Source: U.S. Department of Health and Human Services & U.S. Department of Agriculture. 2015-2020 Dietary guidelines for Americans (8th ed.). Available at http://health.gov/dietaryguidelines/2015/guidelines/. Accessed on 4/18/16.
 Figure 12.6 ▲ Healthy eating for preschoolers daily food plan. (Available at www.choosemyplate.gov.) |
Eating Practices
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.
 Figure 12.7 ▲ 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.
BOX 12.8 Eating Behaviors in Young Children that May Indicate Nutrition Risk
Inadequate intake from any food group within the appropriate calorie level recommendations
Too few meals and snacks, for example, five to six eating times a day may be appropriate for a toddler based on their age, growth rate, appetite, and activity level
Frequent consumption of fast food
Consumption of sugar-sweetened beverages, artificially sweetened beverages, or beverages containing caffeine
Household food insecurity
Age-inappropriate eating behaviors, for example, uses a bottle
Poor appetite
Infrequently eats with family
Child is not allowed to decide how much to eat
Excessive TV watching, such as more than 2 hours a day after the age of 2 years
Distracted eating, for example, while watching TV or playing
Growth or weight concerns, for example, deviations in growth percentile or underweight (less than the 5th growth percentile) or overweight (≥85th percentile)
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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