Early Childhood Nutrition: Toddlers to Preschoolers 12–48 Months

Early Childhood Nutrition

The long-term health and vitality of entire nations depends on the wellbeing of its individual children.1

This powerful statement underscores the key point that investment in early childhood nutrition has far-reaching effects: early childhood nutrition protects health, boosts economic productivity and saves lives.1

Such a perspective brings an appropriate sense of urgency to understanding and supporting the young child's nutritional needs. Optimal nutrition in early childhood not only supports growth and development to the child's full potential, it can also initiate and reinforce healthy eating habits that contribute to overall health and well-being, and that may extend into later childhood and beyond.


Goals of optimal nutrition and healthy eating habits in early childhood: 12-48 months2-8

  • physical growth and development
  • visual and cognitive development
  • healthy immune system development
  • healthy body functions and organ systems, e.g., digestive, cardiovascular, neurological 
  • age-appropriate weight gain
  • achievement of expected physical and cognitive developmental milestones
  • enjoyment of healthy foods as a part of daily life. 

Nutritional Requirements by Developmental Stage: 12-48 Months

In the first year of life, breastmilk and/or formula is the infant's primary source of nutrition. Even as the infant's diet gradually starts to include developmentally appropriate complementary/solid foods, breastmilk and/or formula remain his main source of nutrition. 

12 to 24 months: A major transition in feeding capabilities and nutrition needs occurs as the child grows from infancy into toddlerhood. Energy and nutrient requirements can increasingly be met by a wide variety of nutritious foods from all food groups, with a whole new range of textures and flavors. Milk intake at 12 months should be winding down from 24 ounces (3 cups) per day to only 16 ounces (2 cups) per day in order to leave room for foods from other food groups. Breastfeeding may continue, a toddler-appropriate formula or milk-based beverage may be used, or the child may transition to whole cow's milk after the age of 12 months.7,8

The child's rate of growth is most rapid in the first year; in the second year, growth slows and the child may eat less than his parents expect. It is important to emphasize to parents that the rate of increase of calories their child needs may have slowed down compared to the first year, but the foods they eat must supply essential nutrients needed to support important developmental needs. In other words, there is very little room in their child's diet for foods of little nutritional value. This is why it is critical at this young age to help the child learn to enjoy the tastes of healthy foods, to establish positive food preferences, and to establish good eating habits, right from the start.7,8

24 to 48 months: Between the ages of 24 and 48 months, the toddler becomes a preschooler. Energy and nutrient requirements continue to change to meet the child's growth and developmental needs. Changes in developmental capabilities as they pertain to food - including improved motor skills, distinct but still changing preferences for different foods and tastes, and understanding of table behaviors - are leading the child toward a diet that is increasingly similar to that of older children and adults. During these impressionable years, guidance for healthy eating in both food selection and eating behaviors becomes even more important to developing skills and attitudes that support overall health, including maintenance of a healthy weight.7,8 

Professional Organizations with Guidelines and Resources for Meeting Nutrition Needs in Young Children

For young children, recommendations for food intake and for guiding early eating habits are valuable in daily practice, as these can provide important and practical guidance for parents. The following highlights are a selection of recent perspectives and guidelines from the American Academy of Pediatrics, the American Dietetic Association, the American Academy of Family Physicians, and the United States Department of Agriculture and Health and Human Services.

American Academy of Pediatrics (AAP)2

The following daily recommended intakes for children 12-48 months are adapted from the AAP endorsed policy statement, "Dietary Recommendations for Children and Adolescents: A Guide for Practitioners" (2006).2

Daily Estimate Calories and Recommended Servings for Children 12-48 Months:
Grains, Fruits, Vegetables and Milk/Dairy

12 Months 24-36 Months 48 Months Female 48 Months Male
Kilocaloriesa 900 1000* 1200 1400
Fat, % of total kcal 30-40  30-35 25-35   25-35
Milk/dairy, cupsb  2c  2  2  2
Lean meat/ beans, oz  1.5  2  3  4
Fruits, cups d  1  1  1.5  1.5
Grains, oz e  2  3  4  5

Adapted from American Academy of Pediatrics, 2006.2

* Calorie estimates for children 3 years and older are based on a sedentary lifestyle. Increased physical activity will require additional calories: by 0 to 200 kcal/day if moderately physically active and by 200 to 400 kcal/day if very physically active. 
a For youth 2 years and older; adopted from Tables 2 and 3 and Appendix A-2 in US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans. 6th ed. Washington, DC: US Government Printing Office; 2005; www.healthierus.gov/dietaryguidelines. Nutrient and energy contributions from each group are calculated according to the nutrient-dense forms of food in each group (e.g, lean meats and fat-free milk). 
b Milk listed is fat-free (except for children under the age of 2 years). If 1%, 2%, or whole-fat milk is substituted, this will utilize, for each cup, 19, 39, or 63 kcal of discretionary calories and add 2.6, 5.1, or 9.0 g of total fat, of which 1.3, 2.6, or 4.6 g are saturated fat. 
c For 1-year-old children, calculations are based on 2% fat milk. If 2 cups of whole milk are substituted, 48 kcal of discretionary calories will be utilized. The American Academy of Pediatrics recommends that low-fat/reduced-fat milk not be started before 2 years of age. 
d Serving sizes are 1/4 cup for 1 year of age, 1/3 cup for 2 to 3 years of age, and 1/2 cup for ≥4 years of age. A variety of vegetables should be selected from each subgroup over the week. 
e Half of all grains should be whole grains.

A Word About Fruit Juice

Fruit juice has been customarily regarded as a healthy beverage choice for children that supports hydration and may contribute to vitamin C, vitamin A or potassium intake. According to the AAP, by the age of 12 months, 90% of infants are consuming fruit juice.9In 2001, the AAP published a policy statement, The Use and Misuse of Fruit Juice in Pediatrics,10 which discusses excessive juice consumption as a contributing factor to childhood obesity, the development of dental caries, diarrhea, and other gastrointestinal problems, such as excessive gas, bloating and abdominal pain.9

For children 1 to 6 years old, the AAP recommends limiting intake of 100% fruit juice to 4-6 oz per day. Fruit "drinks", "beverages" or "cocktails" are not recommended, as these have less than 100% juice, and some have as low as 10% juice. Other specific recommendations from the AAP are as follows: 

  • Juice should not be considered an ‘equal' alternative to whole fruit.
  • Children should be encouraged to eat whole fruits to meet their fruit intake needs.
  • Children should not consume unpasteurized juice.9

According to the AAP, children are the single largest group of juice consumers. Physicians can provide valuable guidance for parents on limiting intake of 100% fruit juice for young children, while promoting the value of whole fruit. 

American Dietetic Association (ADA)3

The 2008 Position of the ADA on Nutrition Guidance for Healthy Children Ages 2 to 11 Years provides the following recommendations for macronutrient distribution and intake of sugars, fats and total fiber, based on the Institute of Medicine Dietary Reference Intakes (DRIs). The following information pertains to children ages 1-4 years. 

Carbohydrates: 

  • 45-65% of total calories
  • Adequate intake for total fiber:
  • children 1-3 years: 19 g total fiber/day
  • children 4 years: 25 g total fiber/day.
  • Maximum suggested intake for sugars: added sugars should not exceed 25% of total calories to ensure sufficient intake of essential micronutrients.

Fat: 

  • 30-40% of energy for 1 to 3 years, 25-35% of energy for 4 years and older
  • Consumption of saturated fat, trans-fatty acids and cholesterol should be as low as possible while maintaining a nutritionally adequate diet.

Protein:

  • 5-20% of total calories for young children and 10-30% for older children. 

Source: 2008 Position of the American Dietetic Association: Nutrition Guidance for Healthy Children Ages 2 to 11 Years. 

American Academy of Family Physicians (AAFP)7

The AAFP provides the following key nutritional recommendations for toddlers: 

  • A toddler's diet should include 2 or 3 servings of milk or other dairy products per day.
  • Fat and cholesterol should not be restricted in children younger than 2 years. Children older than 2 years should consume an average of 30% of total energy from fat.
  • Toddlers should not have more than 4 to 6 ounces of 100% fruit juice per day; whole fruits and vegetables should be offered instead.
  • Daily supplementation with 200 IU of vitamin D is recommended for toddlers who consume less than 2 cups of milk daily or do not get regular sunlight exposure
  • Good nutritional habits should be fostered by sitting at the table, turning off the television, and interacting socially.
  • Parents should offer children a variety of foods, expose them repeatedly to healthy foods, and model healthy eating behaviors.
  • To reassure parents and detect undernourished children, physicians should monitor growth patterns, including BMI.

Source: Nutrition in Toddlers. American Academy of Family Physicians, 2006.7

United States Department of Agriculture (USDA) and Health and Human Services (HHS)10
The USDA and HHS have jointly created The Dietary Guidelines for Americans10, which are the cornerstones of federal nutrition policy and nutrition education activities. The Dietary Guidelines have traditionally targeted the healthy general public older than 2 years of age, but as data continue to accumulate regarding the importance of dietary intake during gestation and from birth on, it also will become important to consider those younger than age 2 years in future Guidelines. These guidelines are updated every 5 years, and the 2010 Dietary Guidelines are currently being finalized. The full 2005 guidelines are available at dietaryguidelines.gov

Dietary Guidelines for Early Childhood Nutrition: As the infant grows into a toddler, the concept of ‘mealtime' starts to become more relevant, and the opportunity to start to learn healthy eating habits begins. The Dietary Guidelines provide the following guidance for early childhood nutrition: 

  • From the time solid foods are started, meals, snacks and beverages need to meet children's nutrition needs and provide them with healthy dietary patterns that can be maintained into adulthood. 
  • Ensure appropriate consumption of vegetables and fruits, both as a source of key nutrients, but also because diets that include a variety of vegetables and fruits tend to be lower in energy density and can help with maintaining a healthy weight. When consumed in moderation as part of a nutrient rich, energy-balanced diet, 100% juice can be a healthy part of a child's diet.
  • Consume the recommended servings of low-fat dairy products daily in order to meet recommended dietary intake levels for key nutrients, such as calcium and vitamin D. 
  • Children should also be encouraged to consume greater amounts and varieties of high-fiber foods in order to increase nutrient density, and promote healthy lipid profiles, glucose tolerance, and normal gastrointestinal function. 
  • Consumption of sugar-sweetened beverages in childhood should be discouraged because of the positive association with increased weight, and because these beverages can tend to replace nutrient-rich choices.10

USDA MyPyramid Food Guidance System11

The MyPyramid Food Guidance System translates nutritional recommendations into practical and easy to follow guidance on the kinds and amounts of food to eat each day. For children 2-5 years old, this system is expressed as MyPyramid for Preschoolers. A key emphasis for this age group is helping families to guide their children toward developing healthy eating habits for life. The MyPyramid website provides practical interactive tools to support families in planning meals to fit their child's nutrition needs. 

Achieving Balance: Today's Challenges in Early Childhood Nutrition
Feeding Infants and Toddlers Study (FITS)12

The Feeding Infants and Toddlers Study (FITS 2002, 2008), a dietary intake survey with large, representative, cross-sectional samples of parents or caregivers, has provided information on the diet and eating habits of U.S. infants, toddlers and preschoolers. As identified by FITS, some nutrients and dietary components are over-consumed by children, while others are under-consumed.12

FITS 2008 data shows some positive trends as compared with the 2002 results: 

  • the number of months that infants breastfeed is longer
  • on a given day fewer infants and toddlers are eating sweets and sweetened beverages. 

Other findings are less positive: 

  • on a given day, many toddlers and preschoolers aren't eating a single discrete serving of vegetables or fruit
  • French fries are still the most popular vegetable among toddlers and preschoolers
  • toddlers and preschoolers need more healthy fat in their diet
  • most preschoolers are eating too much saturated fat
  • sodium intake is high for the majority of preschoolers.12

Age-Appropriate Weight Gain

In the U.S., childhood obesity is a key health concern, and - along with healthy growth and development - is now a key factor in all of these nutrition recommendations. According to the 2005-2006 National Health and Nutrition Examination Survey, nearly half of all American children are either overweight or obese. Further, obesity is affecting children at steadily younger ages, with an increasing number of children under age 4 with an abnormally high BMI.13 The AAP notes that "Never before have the needs of children required such focus on nutrition, physical activity, and establishing a model for lifestyle change to promote healthy habits that can extend into the adult years."8

The identification of overweight in older children is often linked to excessive weight gain in infancy and toddlerhood.13 It is of critical importance that prevention and treatment strategies are put in place in order to curb early excessive weight gain. 

Early preventive approaches suggested by Harrington et al. include the following: 

  • Begin screening for excessive weight gain as early as possible as a key preventative measure. 
  • Employ preventative clinical strategies and measures; e.g., consider the crossing of 2 growth percentiles upward before age 2 as ‘at risk' of overweight or obesity. This view would be similar to the way falling downward 2 growth percentiles in children is viewed as at risk for failing to thrive. 
  • Consider the inclusion and utilization of such measures in the first year of life, but definitely by age 2.13

To best support age-appropriate weight gain, is it vital that healthy eating habits are a family goal. Young children are influenced by the eating habits of older siblings and parents. One of the key insights from the Feeding Infants and Toddlers Study 2008 is the particular need for dietary guidance for parents as their young child starts to make the transition to solid foods, and especially table foods: "More guidance and support is needed to help parents better transition from feeding baby to meeting the unique needs of a toddler or preschooler; their diets are mimicking the unhealthy eating patterns often seen in older children and adults."12 Positive approaches to achieving healthy, age-appropriate weight gain are far preferred to attempting to reverse less-than-desirable food intake and food choice patterns that may already be ingrained. 

The AAP advocates "anticipatory guidance" in approaches to promoting healthy nutrition and eating behaviors in early childhood, and this guidance includes discussion of healthy, age-appropriate weight.8 Prevention and early identification of weight issues are critical in order to address obesity in early childhood. 

Conclusion

Nutrition in early childhood involves accommodating transitioning nutrient needs to support healthy growth and development, coupled with important support and guidance to help the child build eating habits that will lead him toward a healthy adulthood. Evidence-based guidelines for feeding healthy infants and children are provided by a number of expert groups. 

Unfortunately, early childhood has become a time of potential nutrition challenges. The Feeding Infants and Toddlers Study in 2002 identified some significant nutrient gaps and issues in eating habits in infants and young children. While the 2008 FITS data has shown some progress in important areas, challenges continue in the goal of ensuring that children are eating a healthy, balanced diet that support optimal growth and development, including healthy weight gain. 

Partnering with parents to promote good nutrition and the development of healthy eating habits is a critical connection to make for pediatric healthcare professionals. For parents, understanding the child's nutrition and developmental needs right from infancy can open the way to establishing healthy eating habits early in life. Parents can benefit from nutrition guidance on: 

  • which food groups and nutrients are needed at each developmental stage, and why 
  • distinguishing nutritious foods and beverages from less healthy choices
  • the importance of establishing good eating habits early in life
  • fullness and hunger cues
  • developmentally appropriate food choices and preparation
  • feeding skills and how to feed.

Resources and Tools for Nutrition Guidance

USDA MyPyramid Food Guidance System
The MyPyramid Food Guidance System translates nutritional recommendations into practical and easy to follow guidance on the kinds and amounts of food to eat each day, for children 2-5 years; children 6-11 years; general population (age 12+); and pregnant and breastfeeding women. 

USDA MyPyramid for Preschoolers provides specific recommendations for children 2 to 5 years of age.

Gerber Website for Medical Professionals: Resources

Gerber Start Healthy, Stay Healthy™ Nutrition System
Planning Daily Nutrition by Developmental Stage, 12-48 Months
Drawing on extensive research in nutrition science and early childhood developmental needs, Nestlé has developed the Start Healthy, Stay Healthy™ Nutrition System to help guide healthcare professionals and families in determining optimal nutrition for healthy growth and development and the early establishment of healthy eating habits among young children 12-48 months of age. 
Start Healthy, Stay Healthy™ Nutrition System

Gerber Start Healthy, Stay Healthy™ Menu Planner
The Start Healthy, Stay Healthy™ Menu Planner has been developed to help parents provide customized, nutritionally balanced and developmentally appropriate menus for their child. The developmental stage-based interactive system allows parents to generate easy-to-follow menus based on food groups and nutrients required for infants and children from the time solid foods are started through to age 48 months. In the office, you can demonstrate use of the Menu Planner to parents, and can also print, share, and save menus for each child in your practice.
Start Healthy, Stay Healthy™ Menu Planner

Tools & Guides
Includes customizable practical parent handouts covering a wide range of nutritionally-based topics including the basics of a child's healthy diet and the unique nutritional needs of premature infants - to the role of probiotics and how parents can make the difference in childhood obesity.

References 
  1. de Pee S et al. How to ensure nutrition security in the global economic crisis to protect and enhance development of young children and our common future. J Nutr 2010;140:138S-142S.
  2. American Heart Association. Dietary Recommendations for Children and Adolescents: A Guide for Practitioners. American Academy of Pediatrics Endorsed Policy Statement. Pediatrics 2006;117(2):544-59.
  3. Nicklas TA, Hayes D. Position of the American Dietetic Association: Nutrition Guidance for Healthy Children Ages 2 to 11 Years. JADA 2008;108:1038-47.
  4. Healthy People 2010. Nutrition and Overweight.
    http://www.healthypeople.gov/Document/HTML/Volume2/19Nutrition.htm#_Toc490383123
  5. Barclay A, Weaver L. Feeding the normal infant, child and adolescent. Medicine 2006;34(12):551-6.
  6. Mayo Clinic.
    www.mayoclinic.com/health/healthy-diet/NU00190/NSECTIONGROUP=2
  7. Allen RE, Myers AL. Nutrition in Toddlers. Am Fam Physician 2006;74(9):1527-32.
  8. American Academy of Pediatrics Committee on Nutrition. Kleinman RE, ed. Pediatric Nutrition Handbook. 6th Edition. © 2009 American Academy of Pediatrics.
  9. American Academy of Pediatrics Committee on Nutrition. The Use and Misuse of Fruit Juice in Pediatrics. Pediatrics 2001;107(5):1210-3. A statement of reaffirmation for this policy was published in Pediatrics 2007;119:405.
  10. U.S. Department of Health and Human Services, U.S. Department of Agriculture. Dietary Guidelines for Americans 2005. www.healthierus.gov/dietaryguidelines 
  11. United States Department of Agriculture. MyPyramid for Preschoolers.
    www.mypyramid.gov/preschoolers/index.html
  12. Nestlé 2008 Feeding Infants and Toddlers Study (FITS) Preliminary Findings. What Are The Youngest American Children Eating? Presented at the American Dietetic Association Food & Nutrition Conference & Expo, Denver, CO. October 2009.
    medical.gerber.com/starthealthystayhealthy/FITSStudy.aspx
  13. Harrington JW et al. Identifying the "tipping point" age for overweight pediatric patients. Clin Pediatr OnlineFirst, February 11, 2010.
  14. National Health and Nutrition Examination Survey (NHANES) 2003-2004.
Nestle -- Good Food, Good Life

The content on this site is for educational purposes only and is intended solely for medical professionals in the United States only. If you are not a medical professional, please visit www.gerber.com.

All trademarks are owned by Société des Produits Nestlé S.A., Vevey, Switzerland or used with permission.

© 2016 Nestlé. All rights reserved.