In this age group, building positive eating habits is important for future health and relies on support from health care professionals, says dietititian and public health nutritionist Kathy Cowbrough


Kathy Cowbrough
RD RPHNutr Dietitian and Public Health Nutritionist

ABSTRACT 
feeding mainThe toddler stage from one to three years continues to be a period of rapid growth although not as rapid as in the first year. Energy needs are high as toddlers become more active, but stomachs are still small relative to nutrient needs so food provided for this age group needs to be nutrient dense. Toddlers are beginning to exert their independence in food choices and parents may be faced with a fussy eater who refuses food that they normally like and enjoy. Parents need to be encouraged to establish a routine of three meals and two snacks a day and not to allow the toddler to set the rules for eating. Making time to enjoy eating together as a family should be a priority to help toddlers establish good eating habits for the future. Journal of Family Health Care 2010; 20(2): 49-52

Introduction 
By the time infants reach the toddler stage, around 12 months, they should have moved to eating the foods and drinks the family eats and enjoys, and eating together with other family members.
This is a time when toddlers are beginning to form more strongly their food likes and dislikes, their eating habits and enjoyment of food for the future. Both the types of foods and drinks offered, and when and how they are eaten, will influence toddlers' eating habits. Since families vary considerably in their food choices and eating practices, depending on factors such as income, access to food, knowledge, experience and time available, a toddler's eating habits will develop in ways that have a positive or less positive influence on their future health. Some of the economic and social factors that influence a family's eating habits have changed over the last 50 years in the UK. For example:
_ Current adult eating habits are influenced by pressures of modern lifestyles. This affects the way in which young children are fed. For example, mothers may return to work soon after childbirth for economic reasons. Therefore, young children may eat a greater proportion of their meals with carers and often away from home. In addition, meals eaten at home are less likely than in the past to involve families eating together
_ There is a greater reliance on commercially produced ready-prepared meals1,2.feeding t1
The age group one to three years is a time when a toddler's food preferences are becoming established and they begin to have a decisive say in food selection, but they are dependent on their parents or other carers to provide a diet to meet their nutritional needs. As innate preferences are modified by children's experiences, parents and other carers play a major role in influencing the development of children's food preferences and eating patterns3. Health professionals may find that nutritional guidance for one to three year olds is not as clear as for infants in the first year. This Learning File considers current nutritional concerns for this age group, and guidance on diet to meet toddlers' nutrient requirements.

The toddler diet 
Data from the National Diet and Nutrition Survey 1995 found that the typical diets of children under five years in Britain were high in processed cereal foods (such as white bread, biscuits and cakes), soft drinks and snack foods, and low in vegetables and fruits, unprocessed meat, fish and eggs4,5,6. This can lead to nutrition and health issues for the toddler, as summarised in Table 1.

Iron deficiency anaemia 
The incidence of iron deficiency in UK toddlers from 1995 figures is 12% of one-and-a-half to two and- a-half year olds4, and between 20 and 29% of two year olds in immigrant populations8. Further examination of this data concluded that overdependence on cow's milk, where it displaces iron-rich or iron-enhancing foods, may put toddlers at increased risk of poor iron status. This is particularly relevant for households of lower socio-economic and employment status9. A healthy balanced diet as outlined in Table 2, and choosing moderate-to-high amounts of iron rich foods such as red meat, fortified breakfast cereals and iron-enhancing foods (fruit), can provide adequate iron. Follow-on formula or growing-up milks which have added iron can have a role in preventing iron deficiency if toddlers are eating poorly.

Obesity and overweight feeding t2
Data from the 2007 Health Survey for England found that around 14% of English toddlers aged two to three years were obese, with a body mass index (BMI) greater than or equal to the 95th centile. This has changed little over the last three years10. Obesity and overweight, especially in young children, are multifactorial issues. Obese children under five years of age do not need to lose weight but the family lifestyle will need to change so that weight gain slows down or stops for some time and the BMI decreases as the child grows taller. Changes should be made in line with the principles of healthy eating (see Table 2), but may require some discipline as preschool children prefer energy-dense foods, i.e. foods high in energy (calories) but with little other nutritional value, such as cakes, biscuits, chocolate, crisps, high-sugar drinks (lemonade or cola)11.

Nutrients for toddlers 
The nutritional requirements of children between one and four years of age differ markedly from those of infants, older children and adults. They have high energy needs and nutrient requirements relative to their size. Since their stomachs are small, a regular meal pattern of three small meals and two to three planned between-meal snacks is the best way to achieve the energy and nutrients they require.
This does not mean that toddlers need foods high in fat to meet their energy needs. The National Diet and Nutrition Survey found that fat intakes of four-and-a-half year olds were 36% of calories, similar to the adult recommendation4. Equally, although there is concern about overweight and obesity in young children, even in the toddler age group, this does not mean overuse of low-fat, highfibre foods as this could lead to insufficient energy intake and possibly faltering growth12.


What and when? 
There is increasing evidence linking infant and toddler eating and activity behaviour with health consequences later in life, such as obesity and related risks2,13. However, food and dietary guidance on how to provide the optimal diet for a toddler is not too specific, allowing for the fact that the amount toddlers eat will vary from toddler to toddler, day to day and meal to meal. Thus the general guidance is that toddlers should eat according to appetite rather than specific portion sizes.
The proportions of the Food Standards Agency Eatwell Plate (see Information for health care professionals at the end of the article) do not apply directly to children under five years14.
However, the menu for this age group should still include a combination of the five food groups to meet their nutrient requirements. Table 2 gives a guide to foods from these five food groups, the nutrients they provide and how foods and drinks can be planned into a toddler's menu.

Developing positive eating habits 
As parents work their way through different food and feeding issues of the toddler years, perhaps the best and simplest advice that health care professionals can give them is:
"Parents decide what and when food is served. Children decide whether and how much."Though this sounds simple and logical, parents will look for further support as their toddlers may develop a neophobic response to food18 - being wary of trying new foods - that sometimes leads to fussy eating and food refusal. Since the role of parents in developing children's food preferences and eating patterns should not be underestimated3, some practical strategies for both confident and not so- confident parents to refer to is provided in
Table 3.
Factsheets on Why Toddlers Refuse Food and How to Manage Simple Faddy Eating in Toddlers from the Infant and Toddler Forum offer additional practical suggestions. See Information for health care professionals at the end of this article.

Even with the pressures of family and work life, parents should make eating a positive experience by:
_ Making time to have a family meal together at least once a day if possible
_ Providing a daily routine of three meals and two snacks so toddlers do not become over hungry or tired.
_ Offering two small courses at meals, one savoury and one sweet
_ Avoiding other distractions like TV or toys and other children playing nearby
_ Allowing toddlers to help with meals when Possible
_ Inviting other small children to eat together.

Summary 
feeding t3The toddler age is a critical time for learning to like a wider variety of tastes and textures. The need for energy and nutrients is high, but appetites are small and eating habits can be fussy. Family foods provided can vary depending on resources (both money and skills); reliance on ready-prepared foods; cultural practices; and parental knowledge and confidence.Providing as wide a range of foods as possible from the five food groups, encouraging the child and family to be physically active, and developing strategies to cope with fussy eating can help to build healthy eating habits for the future. This relies on considerable support from health care professionals.

References 
1. Morgan J. The Formative Years. Network Health Dietitians 2007; 25: 15-16
2. Harris RJ. Nutrition in the 21st century: what is going wrong. Archives of Disease in Childhood 2004; 89(2):154-158. Review
3. Benton D. Role of parents in developing children's food preferences and eating patterns. Carbohydrate News 2006
4. Gregory JR, Collins DL, Davies PSW, Hughes JM, Clarke PC. National Diet and Nutrition Survey: Childhood Aged 11⁄2 to 41⁄2 Years, Volume 1. Report of Diet and Nutrition Survey. London: HMSO, 1995
5. Emmett P, Rogers I, Symes C. Food and nutrient intakes of a population sample of 3-year-old children in the south west of England in 1996. Public Health Nutrition 2002; 5(1): 55-64
6. Crawley H. Eating Well for Under-5s in Child Care. London: Caroline Walker Trust, 2006. Also available at www.cwt.org.uk (accessed 21 Jan 2010)
7. Shaw NJ, Pal BR. Vitamin D deficiency in UK Asian families: activating a new concern. Archives of Disease in Childhood 2002; 86(3): 147-149. Review
8. Lawson MS, Thomas M, Hardiman A. Iron status of Asian children aged 2 years living in England. Archives of Disease in Childhood 1998; 78(5): 420-426
9. Thane CW, Walmsley CM, Bates CJ, Prentice A, Cole TJ. Risk factors for poor iron status in British toddlers: further analysis of data from the National Diet and Nutrition Survey of children aged 1.5-4.5 years. Public Health Nutrition 2000; 3(4): 433-440
10. NHS Information Centre for Health and Social Care. Statistics on obesity, physical activity and diet. Health Survey for England 2007. England: NHS Information Centre, Lifestyles Statistics England, February 2009
11. Cooke L. The development and modification of children's eating habits. Nutrition Bulletin 2004; 29(1): 31-35
12. Thomas B, Bishop J (eds). Manual of Dietetic Practice. Oxford: Blackwell Publishing, 2007
13. NHS Information Centre for Health and Social Care. Health Survey for England 2007. England: The NHS Information Centre, Lifestyles Statistics England, February 2009
14. Food Standards Agency. Guidance for eating well for toddlers. Available at http://www.eatwell.gov.uk/agesandstages/children/yrtoddler/#elem218 427 (accessed 21 Jan 2010)
15. NHS Healthy Start website. All about milk. Available at http://www.healthystart.nhs.uk/en/fe/all_about_milk.html (accessed 21 Jan 2010)
16. Food Standards Agency. Peanut allergy. Available at http://www.eatwell.gov.uk/agesandstages/children/yrtoddler/ (accessed 22 Jan 2010)
17. Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment. Statement on the review of the 1998 COT Recommendations on Peanut Avoidance. December 2008. Available at http://cot.food.gov.uk/pdfs/cotstatement200807peanut.pdf (accessed 21 Jan 2010)
18. Addessi E, Galloway AT, Visalberghi E, Birch LL. Specific social influences on the acceptance of novel foods in 2-5-year-old children. Appetite 2005; 45(3): 264-271
19. British Columbia Ministry of Health. Helping your toddler to eat well: sharing the responsibility with your one to three-year-old. BC Health Files Child Nutrition. 2005, Series No. 69d. http://www.healthlinkbc.ca/healthfiles/hfile69d.stm (accessed 5 March 2010)
20. National Oral Health Promotion Group. Position Paper: The Use of No-spill Design Feeder/trainer Cups. April 2003. Reprinted Jan 2005. http://www.nohpg.org/positionpaper.asp (accessed 5 March 2010)
21. Gill DG, Vincent S, Segal DS. Follow-on formula in the prevention of iron deficiency: a multicentre study. Acta Paediatrica 1997; 86(7): 683 689
22. Daly A, MacDonald A, Aukett A et al. Prevention of anaemia in inner city toddlers by an iron supplemented cows' milk formula. Archives of Disease in Childhood 1996; 75(1): 9-16

Frequently Asked Questions1. Should I give my toddler commercially prepared food that is specifically for toddlers? 
If your toddler has to be left occasionally with a carer who is not providing meals, or when time is limited to prepare a meal for the family, these foods may be useful. It is still best to try to prepare foods for your family as often as possible and to include your toddler in the family meal, as toddler ready prepared meals, though nutritionally adequate, can taste different from what you prepare and should still be checked for salt content14. For family meals try to ensure you are providing foods that have a good amount of nutrients but are not high in salt or sugar.

2. How do I get my toddler to drink from a cup? 
Ideally help your baby take sips of water from a small unlidded cup (e.g. an egg cup) from six months as you begin introducing solid foods. The aim is to move infants from sucking to drinking from a cup by one year of age. If your toddler is still using a baby's bottle or any cups that require sucking, explain that these are for babies and that he or she will now be drinking the same way as an adult. Expect a mess but stay with the child as they drink. Don't worry if only small amounts are taken at first, but give water frequently so the child does not get dehydrated20.

3. I am concerned about the amount of sweets my toddler eats - what can I do? 
As you know, your toddler doesn't need sweets as they add no essential nutrients. Often parents, grandparents or other carers are the ones giving sweets to your child, so explain to anyone who cares for your toddler that you do not want your child to be eating them. This does not mean giving them up altogether, but does mean that they should only be offered very occasionally. They should be restricted to one or two after a meal, to avoid sweets taking the place of other foods and to limit the number of times sugar is consumed in order to reduce the risk of tooth decay.
This Learning File is supported by an educational grant from Aptamil. It represents the independent views of the author and has been independently peer reviewed by JFHC. The information was correct at the time of publication (March/April 2010). The next Learning File topic will be "Encouraging and Supporting Women through Breast-feeding" and will be published in the April/May issue of JFHC.

Further informationInformation for health care professionalsFood Standards Agency (FSA)   
See main website www.food.gov.uk or the FSA Eatwell website for consumers www.eatwell.gov.uk/agesandstages/children/yrtoddler/
Infant and Toddler Forum Resources for health professionals. Downloadable from www.infantandtoddlerforum.org. See:

Factsheet 1.1i Nutrients: Functions, Sources and Requirements
Factsheet 1.2 Combining Food for a Balanced Diet
Factsheet 2.1 Why Toddlers Refuse Food
Factsheet 2.2 How to Manage Simple Faddy Eating in Toddlers
Factsheet 3.3 Overweight and Obesity
Factsheet 4.1 Common Nutritional Problems in Toddlers
Little People's Plates   
Produced in conjunction with the Infant and Toddler Forum, Little People's Plates has food and nutrition materials for health professionals to use with parents, or for parents to access direct. See: Little People's Plates: Food and nutrition for the under threes. Available at http://www.littlepeoplesplates.co.uk  

The Caroline Walker Trust  

Eating Well for Under-5s in Child Care. (2nd edition, 2006.) Information to support better nutrition for this group of children. Materials include Practical and Nutritional Guidelines and Training materials and CD-rom. London: Caroline Walker Trust. The Caroline Walker Trust resources are now available online at www.cwt.org.uk as PDF files.

Booklets/leaflets for parentsFood Standards Agency (FSA)  

Feeding your toddler. Available free from FSA publications. Tel 0845 606 0667, e-mail foodstandards@ecgroup.co.uk or download from http://www.food.gov.uk/aboutus/publications/nutritionpublications/  

British Dietetic Association (BDA)  

See the BDA's Food Fact sheets: Healthy Eating for Children. Downloadable from http://www.bda.uk.com/foodfacts/070830HealthyEatingChildren.pdf Vitamin Supplements for Babies and Children. Downloadable from http://www.bda.uk.com/foodfacts/081014BabyChildVitamins.pdf Diet, Behaviour and Learning in Children. Downloadable from http://www.bda.uk.com/foodfacts/081014BabyChildVitamins.pdf See also the following leaflets for parents produced by the Paediatric Group of the BDA (June 2009): Food for the growing years Help my child won't eat My child still won't eat Feeding the vegetarian child Sample copies are available to preview and order via the Scottish Nutrition and Diet Resources Initiative (SNDRi). http://www.gcal.ac.uk/sndri/index.html