NUTRITION MANAGEMENT OF THE TODDLER AND PRESCHOOL CHILD

Description
The Regular Diet for the Toddler (1 to 3 years of age) and the Preschool Child (4 to 5 years of age) includes a wide variety of foods to promote optimal growth and development. The diet consists of foods of different textures, tastes, and colors provided throughout the day. Snacks are required to meet the nutrient needs, since the toddler and preschooler have small stomach capacities.

Indications
The diet is served when specific dietary modifications are not therapeutically required.

Nutritional Adequacy
The diet can be planned to meet the Dietary Reference Intakes (DRIs) for the specific age as outlined in the Statement on Nutritional Adequacy. Actual nutrient requirements may vary widely among children of the same age, depending on the rate of growth and stage of development.  Nutrients that may be of suboptimal intake at this age are protein and iron because children often refuse to eat an adequate quantity of protein sources. Adequate vitamin A intake may also be of concern because children often dislike vegetables. Most healthy children who eat a variety of foods do not need a vitamin and mineral supplement. However, supplementation may need to be discussed with the caregivers if dietary intake appears to be inadequate or sporadic (1,2).

How to Order the Diet
Order as “Pediatric Regular Diet” or “Regular Diet for Age ______.” The age of the patient will be taken into consideration in implementing the diet order. Any specific instructions should be indicated.

Planning the Diet
Energy needs vary with the growth rate, body size, and physical activity of the child. The average daily energy requirement for ages 1-3 years is 1046 kcal for males and 992 kcal for females (3).  The estimated daily energy needs for ages 4 to 5 years is 1742 kcal for males and 1642 kcal for females (3).  The Institute of Medicine’s Food and Nutrition Board have established acceptable macronutrient distribution ranges (ADMR) for children and include 45 to 65% of total calories from carbohydrates, 5 to 20% of total calories from protein for young children, and 30% to 40% of total calories from fat for 1 to 3 years and 25% to 35% of total calories from fat for 4 to 18 year olds (3,4).

    The recommended protein (RDA) intake is 13 g/day (or 1.1 g/kg) for 1- to 3-year-olds and 19 g/day (or 0.95 g/kg) for 4- or 5-year-olds (3). Adequate protein intake may be difficult to obtain if chewing skills are limited or milk intake is inadequate. Cheese, peanut butter, and yogurt may be considered to help promote adequate protein intake.  Dietary reference intakes that limit added sugars, defined as sugars and syrups that are added to food during processing or preparation, have been established (3,4). The daily intake of added sugars should be limited to 25% of the total energy consumed by a child (3). Twenty-five percent is a maximum limit; the recommended amount of added sugar in a healthy diet is 6% to 10% of total energy (3,4). Fruit juices can provide a substantial amount of sugar and energy in the diet of children.  Currently it is recommended that daily fruit juice consumption be limited to 4 to 6 ounces per day for children 1 to 6 years of age (5).

    The toddler and preschool child have distinct developmental and nutrition needs. After the first year of life, a time of rapid growth and development, the growth rate slows, but there is a steady increase in body size. Along with the decrease in growth rate, the appetite decreases. However, there is an increased need for protein and many vitamins and minerals (3-4,6). 

    The toddler and preschool child is striving for independence. Self-feeding is important, although the child may not physically be able to handle feeding utensils or have good hand-eye coordination. At this age, food likes and dislikes become prominent, and food acquires a greater social significance.

    Beginning at 2 years of age, recommendations from the Dietary Guidelines should be applied for healthy children (6-7). See Table E-3. Current guidelines recommend total fat intake between 30 to 35 percent of calories for children 2 to 3 years of age and between 25 to 35 percent of calories for children 4 years and older (7) .  Most fats should come from sources of polyunsaturated and monounsaturated fatty acids, such as fish, nuts, and vegetable oils (7) The DRIs have established an adequate intake (AI) of fiber which represents a higher than estimated requirements due to the known health benefits of fiber.   For children 1 to 3 years 19 g fiber/day is recommended and for ages 4 to 8 years 25 g/day of fiber is recommended (3).

Table E-3: Food Groups and Recommended Portion Sizes for Toddler and Preschool Child 

   
Children should be supervised during meals and snacks.  A child who is choking may not be able to make noise or to attract attention. Foods that may cause choking include hot dogs, chunks of meat, nuts, peanut butter, raw apples, jelly beans, hard candy, gum drops, popcorn, raw carrots, raisins, grapes, berries, and potato or corn chips.  By changing the form of some of these items, these foods are less likely to cause choking, such as serving peanut butter with jelly, not by the spoonful, or cutting hot dogs or grapes in small pieces (2).

References

1. Lucas B. Nutrition in Childhood. In: Mahan KL, Escott-Stump S, eds. Krause’s Food, Nutrition & Diet Therapy.  10th ed. Philadelphia, Pa: WB Saunders;2000:294.
2. Nutrition for the Preschool Child.  Pediatric Manual of Clinical Dietetics. 2nd ed. Chicago, Ill: American Dietetic Association; 2003.
3. Institute of Medicine’s Food and Nutrition Board.  Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (Macronutrients).  Washington, DC: National Academy of Science; 2002.
4. Position of the American Dietetic Association.  Dietary guidance for healthy children aged 2 to 11 years. J Am Diet Assoc. 2004;104:660-677.
5. Committee on Nutrition of the American Academy of Pediatrics.  Policy Statement:  the use and misuse of fruit juice in pediatrics.  Pediatrics.  2001;107:1210-1213.
6. Pipes PL, Trahms CM. Nutrition in Infancy and Childhood. 5th ed. St Louis, Mo: Mosby-Year Book; 1993.
7. Dietary Guidelines for Americans 2005.  Available at: www.healthierus.gov/dietaryguidelines on January 31, 2005.

Manual of Clinical Nutrition Management                                                     
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