Promoting dietary wellness in toddlers: Helping caregivers overcome barriers

Nutrition can have a positive or negative impact on health throughout the entire lifespan. Proper diet and nutrition is always essential, but it is especially important during the toddler years, ages 1 to 3. Toddlers with poor nutrition can develop significant diet-related issues such as iron deficiency anemia and obesity that will affect their health in the future. It’s imperative for caregivers and healthcare providers to have a clear understanding of the toddler’s nutritional requirements in order to avoid or prevent negative nutritional consequences during this period that can have effects throughout life. This article highlights the importance of dietary wellness among toddlers and discusses strategies that healthcare providers can use to educate parents and caregivers to promote a healthy diet in the toddler years.

Toddler growth and development

Several dietary changes that occur from ages 1 to 3 make the toddler population susceptible to diet-related issues. By the end of the first year of life, children are transitioning from dependent, milk-fed infancy to independent feeding. Toddlers are learning to chew and swallow foods, feed themselves, communicate verbally, walk and run independently, and are transitioning into the family diet and meal patterns.

Toddlerhood is a unique period when a child has newfound independence with quickly developing fine and gross motor skills, along with increasing communication skills. They are also developing cognitive and social skills such as autonomy, reasoning, fantasy thinking, and dramatic play. This developmental progression allows toddlers to become more mobile, feed themselves, and verbally express eating preferences and needs. Toddlers also develop the ability to observe their surroundings and practice cause-and-effect relationships.

Taste preferences begin developing from birth through the toddler years, and what the toddler is fed, including the amounts of sugar and sodium in food, can set future taste preferences. Feeding decisions made during the dietary transition in toddlerhood can shape what is familiar to the child and preferred, having lasting effects on the child’s eating habits.

Toddlers are making many transitions related to diet during this time, including weaning from bottle to sippy cup, learning to use eating utensils, and incorporating various new foods into their diet. Toddlers often have inconsistent eating patterns, with unpredictable appetites and interests from day to day. They are well known for their lack of new food acceptance, often becoming very selective during this period. Thus, the toddler stage can be stressful to caregivers as toddlers become more independent and have inconsistent eating habits.

It’s common and developmentally appropriate for the toddler to be selective with diet and wary of new foods. Their new sense of independence leads many toddlers to be resistant to trying new foods or choosing to eat only a handful of favorite foods. Many children who were once “good eaters” as infants develop into “picky eaters” as toddlers, causing parents to become concerned. Parents should be reassured that this is normal and typically only lasts a short time.


Providers should inform parents that foods may need to be introduced repeatedly, sometimes up to 10 times, before a child will eat them. An exposure to a wide variety of foods and flavors can expand the boundaries of what is familiar and preferred, and therefore increase the assortment of foods that are accepted by the toddler.

Consequences of poor diet in toddlers

Unhealthy dietary behaviors can increase the risk of several health issues such as obesity and deficiencies of vitamins and minerals (for example, iron deficiency).

Obesity

According to the Centers for Disease Control and Prevention (CDC), in the U.S. about one in every eight preschoolers is obese. Children who are overweight or obese as preschoolers are five times as likely as normal-weight children to be overweight or obese as adults. Obesity in children and adolescents is classified as a leading health indicator for the United States. A major goal of Healthy People 2020 is reducing the percentage of obese children ages 2 to 5 from 10.4% to 9.4%.

High intake of sweetened foods and beverages and having caregivers who offer little to no structure or guidance about the toddler’s dietary intake is associated with overweight and obesity among toddlers. Childhood obesity is associated with significant health concerns such as high cholesterol, high blood sugar, asthma, and mental health problems. Healthcare providers and caregivers must be equipped with a variety of strategies to promote dietary wellness in children to prevent negative outcomes related to poor dietary intake beginning in the toddler years.

Iron deficiency anemia

Poor dietary intake in toddlers can lead to iron deficiency and iron deficiency anemia. Iron deficiency is common in toddlers, affecting about 7% to 15% of U.S. toddlers (depending on socioeconomic status, race, and ethnicity), according to a 2010 report in Pediatrics. Iron deficiency anemia can be related to both a lack of iron-containing foods as well as excessive intake of cow’s milk. If not prevented or identified and treated, iron deficiency and iron deficiency anemia in infants and toddlers can have long-term adverse effects, and have been associated with developmental delays, behavioral delays, impaired growth and development, reduced attention span, decreased endurance, fatigue, and decreased immune response.

The recommended dietary allowance for iron for children ages 1 to 3 is 7 mg/day. Iron requirements can be met naturally through eating iron-rich foods (red meats, spinach and other leafy greens, lentils, beans, cereals fortified with iron, and fruits with Vitamin C, which increases the absorption of iron) rather than through supplementation.

Dietary guidelines

While dietary wellness involves a combination of several different factors such as healthy eating behaviors and patterns, the most important factor is the nutritional intake of the toddler. Young children need ample nutrients for growth and development, but have relatively modest energy requirements, ranging from 900 to 1400 kcal/day depending on age and activity level. Therefore, it is important that the toddler’s diet consists of mostly nutrient-dense food choices. A recent study by Fox and colleagues showed that toddlers are not receiving the recommended amount of fruits and vegetables, but are instead receiving sugar-sweetened beverages, desserts, and salty snacks. (See Daily dietary recommendation for toddlers.)

Children should eat balanced meals that include three to four food groups as well as balanced snacks throughout the day. Added sugars, trans and saturated fat, and high-sodium foods should be limited. Juice intake should be limited to 4 to 6 oz/day and should consist of juices that do not contain any added sugars.

Although parents are frequently interested in giving their child vitamin supplements, routine multivitamins supplementation aren’t needed for healthy growing children who consume a wide variety of foods. If the child is at nutritional risk because of chronic illness, neglect, special dietary needs, failure to thrive, or developmental disabilities, the need for vitamin supplementation can be assessed by the healthcare provider.

Behavioral considerations

While nutritional intake is a key component to dietary wellness, healthcare providers should also consider behaviors surrounding food intake. For example, toddlers tend to be on the move, wanting to eat while exploring and playing in their surroundings. Parents should be encouraged to sit as a family during mealtime, having the child sit in a highchair or booster seat at the table, with the television turned off. Grazing, or allowing the child to eat several small snacks or drinks throughout the day without structured meal or snack times, diminishes the child’s appetite for healthy meals or snacks.

Allowing the child to eat while walking, running, or riding in the car can increase the risk of choking and should be avoided. Healthy eating behaviors are essential to dietary wellness in toddlers, and should be encouraged by parents and caregivers. Offering appropriate food choices, along with offering several food groups at each meal, helps toddlers develop healthy eating behaviors and a balanced diet. Parents or caregivers are essential in providing an environment that fosters dietary wellness by developing appropriate eating patterns, modeling healthful eating practices, providing the proper setting for mealtimes, and responding appropriately to the toddler’s behavior.

Implications for nursing practice

Nurses who offer parents and caregivers appropriate guidance and education regarding dietary wellness in toddlers can help assure normal growth and development and lay a foundation for future healthy eating habits.

It’s essential to monitor the toddler’s growth patterns and weight gain with standardized growth charts. The AAP recommends using the World Health Organization growth charts for children younger than 24 months rather than the CDC growth charts. For ages 2 through 20, the CDC growth charts should be used. Identification of the overweight or obese toddler is imperative, and the nurse should educate the caregiver about possible interventions that can be initiated, such as include adding more fruits and vegetables to the diet, decreasing screen time and increasing activity level, reducing or eliminating sugar-sweetened beverages, and decreasing the amount of fast food eaten. More structured interventions include developing a planned daily meal and snack menu (including timing and content) or teaching self-monitoring through food journaling or tracking physical activity. (See Key strategies for healthcare providers to promote a healthy toddler diet.)

Universal screening for anemia should be performed at approximately 12 months of age, with additional screening at any time if risk factors are present, including inadequate dietary intake.

While nurses can provide education and guidance, the parent or caregiver is ultimately responsible for providing a nutritious diet and modeling healthy dietary behaviors. Feeding practices initiated by the parent, including what, when, and how the parent or caregiver feeds the toddler, play a significant role in a child’s food preferences and eating behaviors. Various strategies should be discussed with parents to aid their efforts in providing a healthy eating environment and nutritious diet. (See Key strategies for caregivers to use to promote a healthy diet for toddlers.)

 

Setting the stage for healthy eating habits

Toddlerhood is a distinctive period in which children are quickly developing physically, mentally, and socially. Healthcare providers need to discuss nutrition and eating habits frequently with parents and caregivers, teach them about dietary wellness, and reassure them that common nutritional challenges are normal. The healthcare provider should provide strategies that aid parents in providing a nutritious and healthy eating environment for toddlers. By encouraging and modeling healthy eating habits for toddlers, healthcare providers and caregivers will enable the child to continue these healthy habits into the future.

Selected references

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. Policy statement: Prevention of choking among children. Pediatrics. 2010;125(3):601-607.

American Heart Association Website. Dietary recommendations for healthy children. Updated September 2014.

Baker RD, Greer FR, the Committee on Nutrition. Clinical report: Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010;126(5):1040-1050.

Birch LL, Doub AE. Learning to eat: birth to age 2 y. Am J Clin Nutr. 2014:99(suppl):723S-728S.

Centers for Disease Control and Prevention Website. Vital signs. Progress on childhood obesity. August 6, 2013.

Chaidez V, McNiven S, Vosti SA, Kaiser LL. Sweetened food purchases and indulgent feeding are associated with increased toddler anthropometry. J Nutr Educ Behav. 2014;46(4):293-298.

Cogswell ME, Gunn JP, Yuan K, Park S, Merrit R. Sodium and sugar in complementary infant and toddler foods sold in the United States. Pediatrics. 2015;135(3):1-8.

Fox MK, Condon E, Briefel RR, Reidy KC, Deming DM. Food consumption patterns of young preschoolers: are they starting off on the right path? J Am Diet Assoc. 2010;110:S52-S59.

Healthy People 2020 Website. 2020 Leading health indicator topics. Updated March 25, 2016.

Holt K, Wooldridge N, Story N, Sofka D, eds. Bright Futures: Nutrition. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011.

Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014.

Paoletti G, Bogen DL, Ritchey, K. Severe iron-deficiency anemia still an issue in toddlers. Clin Pediatr. 2014;53(14):1352-1358.

Kylie Ross is a school-based clinic provider at the Shalom Health Care Center, Indianapolis, Indiana. Azza H. Ahmed is associate professor in the school of nursing, Purdue University, in West Lafayette, Indiana. Jennifer Coddington is clinical associate professor, director of the pediatric nurse practitioner master’s program, director of the doctor of nursing practice program, director of practice and outreach, and co-clinical director of the north central nursing clinics at Purdue University in West Lafayette, IN. Elizabeth A. Richards is assistant professor in the School of Nursing at Purdue University, West Lafayette, Indiana.

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One thought on “Promoting dietary wellness in toddlers: Helping caregivers overcome barriers”

  1. Nichole Duncan, RN-CCHC says:

    Dear Editor:

    I am writing in support of Promoting Dietary Wellness in Toddlers: Helping Caregivers Overcome Barriers in the June 2016 Vol. 11 No. 6 article (Ross, Ahmed, Coddington, & Richards, 2016). As a Child Care Health Consultant (CCHC) I support and will continue to implement educational strategies as a healthcare professional for the importance of modeling healthy eating habits in the child care and in-home settings of toddlers. In Caring for Our Children 3rd ed. (2011) it is recommended that learning about food promotes good nutritional habits for a lifetime, therefore, eating should be an enjoyable experience for children, childcare staff in their facilities and for children and parents/guardians at home (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education, 2011).

    As a CCHC I have observed poor nutrition modeling behavior in the child care setting from the child care staff. This is an important issue due to children spending many hours and consuming up to two meals and two snacks a day in the child care setting up to five days a week. The majority of the child care centers in my county do follow the nutritional guidelines set by our state’s child care rules which means the toddlers are given nutritious meals. However, in my experience when the teachers model poor eating habits in the presence of the toddlers, I often find that they struggle to eat their nutritious food. For example, I recently observed a teacher drinking a 1 L Pepsi and eating Chinese food while the one year old toddlers were served their planned nutritional meal. The visibility of the Pepsi bottle and the aroma of the Chinese food started unpleasant reactions from the majority of the class. The toddlers began to get up from their table, cry, and go to the teacher to request the teacher’s food and drink. This article provided more information and strategies that I can add to my current nursing practice of nutritional education to child care staff and parents/guardians on the importance on modeling healthy eating habits in the presence of toddlers.

    Education and coaching is key when working with caregivers of toddlers in the example referenced above. I plan on using the behavioral considerations such as providing proper settings for mealtimes referenced in the article to enhance teachable moments while I work in the child care setting as a health care professional. By doing this I believe I can continue to impact caregivers of toddlers to promote healthy eating habits and improve toddler health.

    Thank you,
    Nichole Duncan, RN-CCHC

    Reference
    American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. (2011). Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs (3rd ed.). Elk Grove, IL: American Academy of Pediatrics.

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