Promoting Healthy Nutrition

Promoting Healthy Nutrition
Infancy, childhood, and adolescence are marked balanced and nutritious diet offered in a supportive
by rapid physical growth and development, and feeding environment is essential to prevent pediat-
every child’s and adolescent’s health and develop- ric overweight. Therefore, health care professionals
ment depends on good nutrition. Any disruption are encouraged to review this Bright Futures theme
in appropriate nutrient intake may have lasting in concert with the Promoting Physical Activity and
effects on growth potential and developmental Promoting Healthy Weight themes.
achievement. Physical growth, developmental
requirements, nutrition needs, and feeding pat- Key Food and Nutrition Considerations
terns vary significantly during each stage of
Food and nutrition behaviors are influenced by
growth and development.
myriad environmental and cultural forces. Health
The dramatic rise in pediatric overweight and care professionals should keep these forces in mind
obesity in recent years has increased health care as they work with patients and families. Four issues
professionals’ and parents’ level of attention to of particular importance are discussed here.
nutrition. Along with regular physical activity, a
The Feeding Environment
The feeding and eating experience strongly affects
an infant’s, child’s, and adolescent’s physical, social,
emotional, and cognitive development. The expe-

rience includes the foods selected and the environ-
ment within which food is offered. The relationship
between the caregiver and the child reflects a
dynamic process that is initiated during infancy
and extends into adolescence.
In principle, the infant or child provides cues
(expressing hunger) to the parent to begin the
process. The caregiver responds by selecting and
providing age-appropriate food. They continue to
interact throughout the process until the infant or
child provides satiety cues to the caregiver.
In reality, multiple issues affect the relationship. A
host of psychosocial, economic, and other factors
influence a parent’s choice of foods and the style
used to feed. Factors include how the caregiver was
fed as a child and his or her current knowledge,
skills, and attitudes. Caregivers have limited con-
trol over foods eaten away from home or prepared
elsewhere to be consumed at home, among other
167
BFG 4TH ED.indb 167 1/20/17 2:46 PM

Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents
things. Adult interactions can be helpful or harm- Culture influences which foods people select to eat,
ful as children try new foods, learn to self-regulate how people prepare food, how they use seasonings,
food intake, develop self-help skills, and fine-tune and how often they eat certain foods. These behav-
internal self-control over how much food to eat. iors can differ from region to region and family to
Recent evidence suggests decreasing quality in a family, although some traditions exist across cul-
child’s diet with advancing age. Children aged 2 to tures. For example, staple, or core, foods form the
5 years are more likely to consume 3 meals a day, foundation of the diet in all cultures. Staple foods,
beginning with breakfast, while adolescent girls, such as rice or beans, are typically bland, relatively
young adult men, and those with lower incomes inexpensive, easy to prepare, an important source
are least likely to have breakfast or consume of calories, and an indispensable part of the diet.
3 daily meals. Many young children consume rec- Acculturation, which is the adoption of the beliefs,
ommended amounts of fruit and dairy, but that values, attitudes, and behaviors of a dominant, or
intake drops as they reach school age and beyond.1 mainstream, culture, can be a significant influ-
The reasons for this decline in diet quality are ence on a person’s food choices. Acculturation
subjects for future study, but clinicians note that may involve altering traditional eating behaviors
when children are young, parents and caregivers to make them similar to those of the dominant
are highly motivated to provide healthy food and culture. These changes can be grouped into 3 cat-
have significant control over what their children egories: (1) the addition of new foods, (2) the sub-
consume. With advancing age, however, children stitution of foods, and (3) the rejection of foods.
and adolescents increasingly make their own People add new foods for various reasons, includ-
food choices and are influenced by the outside ing improved economic status and food availability
food environment. (especially if the food is not readily available in
the person’s homeland). Substitution may occur

Culture and Food because new foods are more convenient to prepare,
All people belong to some kind of cultural group. more affordable, or better liked than traditional
Culture influences the way people look at the ones. Children and adolescents, in particular, may
world, how they interact with others, and how reject traditional foods because eating them makes
they expect others to behave. To meet the chal- them feel different from the mainstream.
lenge of providing nutrition supervision to diverse
Culture also influences nonnutritive aspects of
populations, health care professionals must learn
food practices, and any nutritional information
to respect and appreciate the variety of cultural
and guidance should take these preferences and
traditions related to food and the wide variation
practices into account. Some ethnic practices
in food practices within, among, and across cul-
related to diet and nutrition may focus more on
tural groups. Health care professionals also need
the food’s texture, appearance, flavor, or aroma or
to understand how their own cultures influence
on beliefs related to the complementary nature of
their attitudes and behaviors and the resulting
the food items, rather than on specific nutritional
implications for nutrition counseling. Sharing food
value. Cultural flavor preferences may be adopted
experiences, asking questions, observing the food
in utero as well as through breastfeeding and influ-
choices people make, and working with the com-
ence the dietary preferences for complementary
munity are important ways for health care profes-
foods when they are added at around 6 months
sionals to learn about and appreciate the food and
of age.3 For many people, certain foods are closely
nutrition traditions of other cultures.2
linked to strong feelings of being cared for and
168
BFG 4TH ED.indb 168 1/20/17 2:46 PM

nurtured by their families or are a reflection of intolerant. People who are lactose intolerant may
religious practices. People from virtually all cul- experience cramps and diarrhea when they eat
tures use food during celebrations. moderate to large amounts of foods that contain
In many cultures, people believe that food pro- lactose, such as milk and other dairy products.
motes health, cures disease, or has other medicinal Children and adolescents may be able to avoid
qualities. In addition, many people believe foods symptoms by consuming small servings of milk
can help maintain a balance in the body that is throughout the day, by consuming lactose-reduced
important to health. For example, many Chinese milk, or by taking lactase tablets or drops with
persons believe that health and disease are related milk. Cheese and yogurt are often better toler-
to the balance between yin and yang forces in the ated than milk because they contain less lactose.
body. Diseases caused by yin forces are treated For people who cannot tolerate any milk or dairy
with yang foods to restore balance, and vice versa. products, health care professionals can suggest a
In Puerto Rico, foods are classified as hot or cold combination of other sources of calcium. A vita-
(which may not reflect the actual temperature or min D supplement also may be needed.
spiciness of foods), and people believe that main- Attitudes About Body Weight
taining a balance between these two types of foods People from different cultures can view body
is important to health. weight differently. Keeping a child from having
Health care professionals can provide effective underweight can be very important to people
nutrition guidance by being sensitive to cultural from cultures in which poverty or insufficient food
beliefs that categorize foods in ways other than the supplies are common. Families may not recognize
Western scientific model, by exploring such beliefs, that their child has overweight according to body
and by incorporating them into their guidance. mass index (BMI) tables or may view excess weight

When discussing their food choices, patients and as healthy. In these cases, the families may be
their parents may respond by saying what they offended if a health care professional refers to their
think the health care professional wants to hear. child as having overweight or obesity. (For more
Health care professionals can encourage people to information on this topic, see the Promoting Healthy
be more candid about their food choices by asking Weight theme.)
open-ended, nonjudgmental questions that reflect
their knowledge of and sensitivity to these issues.
Food Insecurity and Hunger
Hunger describes the personal sensation that
Two issues illustrate the challenges of providing results from a lack of food and is typically felt as
nutrition supervision to people from diverse cul- unpleasant or painful. Involuntary hunger results
tural backgrounds. The first, lactose intolerance, from not being able to obtain enough food and
highlights the medical aspects involved. The sec- excludes hunger related to voluntary dieting, reli-
ond, attitudes about body weight, highlights the gious fasting, or the personal choice to skip a meal.
deep-seated emotional and attitudinal aspects
Food insecurity for a family means limited or
that are often involved.
uncertain availability of nutritionally adequate and
Lactose Intolerance safe foods or uncertain ability to acquire appropriate
Lactose intolerance is common in people of foods in socially acceptable ways. In 2014, 19.2% of
non-European ancestry. When discussing cal- households with infants, children, and adolescents
cium intake, health care professionals need to be younger than 18 years were food insecure.4
sensitive to the fact that people may be lactose
169
BFG 4TH ED.indb 169 1/20/17 2:46 PM

Food insecurity may occur with or without hunger. and families on nutrition, cooking, and healthy
At its most extreme, this problem is associated with eating habits.
hunger and is an indication of a serious nutritional Another source of support for families experienc-
problem and family predicament. Food insecu- ing food insecurity is programs such as the USDA
rity without hunger is associated with increased Supplemental Nutrition Assistance Program (the
nutritional risk. An important deleterious effect program formerly known as Food Stamps).8 A
of food insecurity is that it forces people to buy community food bank or pantry can provide
and consume less expensive foods, which are often additional food for families needing assistance.
lower in nutritional value but more calorically For young children, some child care settings are
dense than more expensive foods. As a result, the eligible for reimbursement from the USDA Child
nutritional quality of the diet declines.5 (For more and Adult Care Food Program.9 For school-aged
information on this topic, see the Promoting Healthy children and for adolescents, community services
Weight theme.) expand to include free and reduced-cost school
The problems of food insecurity and hunger may breakfast and lunch programs and, ideally, school
be difficult to detect in the primary pediatric food services that offer healthy and appealing food
health care setting. Living with adult smokers choices. For adolescents, some school programs
is an independent risk factor for frequency and focus on the importance of pre-conceptual nutri-
severity of food insecurity.6 If disorders of growth, tion to ensure good nutrition.
either underweight and overweight, are noted,
health care professionals should consider food Partnerships With the Community
insecurity. Options for referral and community Partnerships among health care professionals,
support are available for each developmental stage. families, and communities are essential to ensure
that infants and children have good nutrition and
For example, local lactation specialists or other

knowledgeable health care professionals, such as that parents receive guidance on infant and child
doulas, promotoras, or home visitors, can provide nutrition and feeding. (For more information on
follow-up care after a new mother is discharged this topic, see the Promoting Lifelong Health for
from the hospital, and they can consult by phone Families and Communities theme.) Health care
or schedule visits to a hospital-based lactation professionals can have a tremendous effect on
clinic. Health care facilities, community health decisions about feeding the family because they
teams, and community hospitals also are sources provide an opportunity for parents to discuss,
of infant nutrition education. The US Department reflect on, and decide on options that best suit their
of Agriculture (USDA) Special Supplemental circumstances. As part of their guidance, health
Nutrition Program for Women, Infants, and care professionals also can identify and refer par-
Children (WIC)7 offers a food package for women ents to community resources that help at each stage
who are pregnant or postpartum, women who are of a child’s development. Because of considerable
breastfeeding their infant, and infants and children media attention to the problem of overweight and
up to 5 years of age. Health departments offer edu- obesity, the public has become increasingly aware
cational services through WIC and other programs of the importance of healthy eating and regular
in which public health nurses or nutritionists visit physical activity. Communities have responded
families at home. Additionally, early care and edu- by creating educational programs that provide
cation programs, which include home visiting and nutritious school lunches, access to affordable
child care, create opportunities to educate parents nutritious foods, and safe neighborhood
170
BFG 4TH ED.indb 170 1/20/17 2:46 PM

opportunities for play and exercise. Health care consumption, and substance use affect the family
professionals can help families learn about and as well as the individual. Women who are pregnant
take advantage of these opportunities. These or who may become pregnant should be encour-
resources are particularly important for families aged to follow a nutritious diet, abstain from
with limited or no literacy skills and for those alcohol, and take a daily prenatal vitamin and iron
with limited English proficiency. supplement to help ensure their health and that
of a developing fetus. They also are encouraged
Essential Components of Nutrition to quit smoking during and after pregnancy and
avoid all secondhand smoke exposure. Both active
The following essential components of nutrition
and maternal smoking and maternal secondhand
are useful constructs for discussing nutrition from
tobacco smoke exposure have been shown to
birth through young adulthood:
reduce birth weight. Many health care profes-
■■ Nutrition for appropriate growth. Provide sionals recommend the continued use of prenatal
adequate energy and essential nutrients to vitamin supplements during lactation. Adequate
ensure appropriate growth and prevent over- intakes of certain nutrients, such as folic acid,
weight or obesity. omega-3 fatty acids, and choline, are important
■■ Nutrition and development of feeding and before conception as well as during lactation.
eating skills. Choose foods that provide essen-
tial nutrients and support the development of Folic Acid
age-appropriate feeding and eating skills. Neural tube defects are among the most common
■■ Healthy feeding and eating habits. Establish birth defects contributing to infant mortality and
a positive, nurturing environment and healthy serious disability. Women capable of becoming
patterns of feeding and eating to promote eating pregnant can substantially reduce the risk of

habits that are built on variety, balance, and having an infant with certain congenital malfor-
moderation. mations, including spina bifida, by taking appro-
■■ Healthy eating relationships. Promote healthy priate amounts of folic acid before and during
adult-child feeding relationships and social and early pregnancy. Current guidelines indicate that
emotional development. all females capable of becoming pregnant take a
■■ Nutrition for children and youth with special daily multivitamin or multivitamin-mineral sup-
health care needs. Recognize specific nutrient plement containing 400 µg of synthetic folic acid
demands or supplemental needs for vitamins or (from fortified food or supplements) in addition
minerals related to a child’s special health condi- to consuming foods rich in folate.10-13 Women
tion and provide these nutritional components. who have given birth previously to a child with a
neural tube defect or women who have a history
Promoting Nutritional Health: of insulin-dependent diabetes or a seizure disor-
Preconception and the Prenatal Period der and are taking antimetabolites or antiepileptic
drugs (eg, carbamazepine) require higher dosages
In deciding to become parents, a couple may
of folate. Knowledge about appropriate folic acid
examine many issues of lifestyle and health because
dosages continues to evolve. Current recommen-
they recognize that their nutrition and physical
dations are available from the Centers for Disease
activity beliefs, habits, and practices not only affect
Control and Prevention (CDC).12
their own health but will now also affect the health
of their family and child. Obesity, smoking, alcohol
171
BFG 4TH ED.indb 171 1/20/17 2:46 PM

Omega-3 Fatty Acids and Choline include identifying, assessing, and responding to
To guarantee a sufficient concentration of pre- infant cues, promoting reciprocity, and building
formed docosahexaenoic acid (DHA) in her breast the infant’s feeding and pre-speech skills. When
milk, the mother’s diet should include an aver- feeding their infant, parents clarify and strengthen
age daily intake of 200 to 300 mg of the omega-3 their sense of what it means to be a parent. They
long-chain polyunsaturated fatty acid (PUFA) gain a sense of responsibility by caring for an
DHA.14 One or two 3-oz servings of fish weekly infant, experience frustration when they cannot
will provide the necessary omega-3 long-chain easily interpret their infant’s cues, and further
PUFAs. The possible risk from intake of excessive develop their ability to negotiate and solve prob-
mercury or other contaminants in fish is offset by lems through their interactions with the infant.
the neurobehavioral benefits of adequate DHA
intake. Predatory fish (eg, shark, king mackerel, Nutrition for Growth
tile fish, swordfish) are to be avoided, as they The infant’s diet must provide adequate energy and
carry the highest heavy metal contamination risk. essential nutrients for appropriate growth. Con-
Salmon, herring, canned white tuna, and trout are versely, growth is an important indicator of nutri-
recommended as very low-risk.15 Additionally, the tional adequacy. Although newborns may lose up
mother’s diet should include 550 mg/day of choline to 10% of their body weight in the first week of life,
because human milk is rich in choline and breast- they usually regain their birth weight by 14 days
feeding depletes the mother’s tissue stores. Eggs, after birth.17 By the time they are 4 to 6 months of
milk, chicken, beef, and pork are the biggest con- age, infants typically have doubled their birth weight,
tributors of choline.16 gaining about 4 to 7 oz per week. Infants typically
triple their birth weight by 1 year of age, gaining
about 2 to 3 oz per week (breastfed) and 3 to 5 oz
Promoting Nutritional Health: per week (formula fed from 6 –12 months of age).18
Infancy—Birth Through 11 Months
Infants grow approximately 1 in per month from
Physical growth, developmental achievements, birth to 6 months of age, but the rate of growth
nutrition needs, and feeding patterns vary signifi- slows from 6 to 12 months of age when infants gain
cantly in each stage of infancy. During the first 2 about a half an inch per month. Infants usually
to 6 weeks of life, the infant primarily feeds, sleeps, increase their length by 50% in the first year of life.
and grows. The most rapid growth occurs in early Infant growth is properly assessed using the World
infancy, between birth and 6 months of age. In Health Organization (WHO) Growth Charts for 0
middle infancy, from 6 to 9 months of age, and late to 2 years (Appendix A), as recommended by the
infancy, from 9 to 12 months of age, rapid growth American Academy of Pediatrics (AAP) and the
continues but at a slower pace. By late infancy, CDC. The WHO charts are derived from a popu-
mastery of purposeful activity complements phys- lation of healthy breastfed infants.18 They are con-
ical maturity, and loss of newborn reflexes allows ceptually prescriptive and prospective for desired
the infant to progress from a diet of human milk or growth, unlike the CDC birth to 2 charts, which
infant formula to feeding with an increasingly wide are observational and often based on overweight
variety of flavors, textures, and foods. populations and include a large number of
Feeding practices and routines serve as the founda- formula-fed infants.
tion for much of a child’s and family’s development, Infants who are fed on demand usually consume
as parents build many important skills. These skills the amount they need to grow well. Breastfeeding
172
BFG 4TH ED.indb 172 1/20/17 2:46 PM

initiation and duration are associated with a reduc- on the subject concluded there is no clear evidence
tion in excess weight gain by age 3 years compared that treating young children with anemia second-
to formula feeding.19 The significance of this dif- ary to iron deficiency will improve psychomotor
ference to future growth or risk of overweight is development within 30 days of therapy, but the
uncertain. Infants’ growth depends on nutrition, effects of longer-term iron supplementation are
perinatal history, epigenetic and genetic factors not yet known.22 Thus, prevention is extraordi-
(eg, parental height, genetic syndromes, disorders), narily important. During the first year of life,
and other physical factors. infants at highest risk of iron deficiency are those
Growth in head circumference up to 2 years of age born prematurely, those fed infant formula that is
is so closely related to growth in body length that not iron fortified, and those who are exclusively
head circumference measurements do not yield breastfed for more than 4 months without iron
more information about an infant’s nutritional supplements. Term, healthy infants have enough
status than do body length measures. After 2 years iron stores for at least 4 months of life. Because
of age, head circumference grows so slowly that it human milk contains little iron, infants who
is a poor indicator of nutritional status. However, receive only human milk are at an increasing
in an older child, small head circumference may risk for iron deficiency after 4 months of age.15
be a good indicator of malnutrition that occurred Therefore, the AAP Committee on Nutrition
during the first 2 years. Head circumference, recommends that oral iron drops (1 mg/kg/day)
however, remains important in screening for begin at 4 months of age and continue until iron-
microcephaly and macrocephaly because these and zinc-rich complementary foods (baby meats
abnormalities are not nutritional in origin. and iron-fortified cereals) are introduced.23
Energy (Caloric) Needs

To meet growth demands, all infants require a
high intake of calories and adequate intakes of fat,
protein, carbohydrates, vitamins,
and minerals. Human milk and
infant formula provide 40% to
50% of energy from fat to meet the
infant’s growth and development demands.
Fats should not be restricted in the first 2 years of
life. Vitamin and mineral needs, with the exception
of vitamin D, usually are supplied if the term infant
is breastfed or if the infant receives an adequate
volume of correctly prepared infant formula.
Vitamin and Mineral Supplements

A major concern in infancy is the adverse effect of
early iron deficiency on psychomotor develop-
ment. Iron deficiency can result in cognitive and
motor deficits,20 some of which may be prevented
with iron supplementation.21 A Cochrane Review
173
BFG 4TH ED.indb 173 1/20/17 2:46 PM

It may take a month or two following introduction Immediately after delivery, early and frequent
of these foods for infants to consume sufficient physical contact, rooming-in, and exclusion of
iron from complementary foods alone. Red meat commercial infant formula samples enhance the
is a better source of iron than are iron-fortified duration of breastfeeding. The AAP Section on
cereals for older infants because a higher percen- Breastfeeding recommends exclusive breastfeeding
tage of the iron in red meat is absorbed. Infants for about 6 months to maximize its benefits.15,26
who receive at least 500 mL (17 oz) of iron-fortified Because the decision about whether to breastfeed
infant formula per day do not need additional is often made before or early in pregnancy, the
iron supplementation. Prenatal Visit offers an important opportunity to
Vitamin D deficiency or insufficiency is now more promote exclusive breastfeeding. Women may
prevalent in infants because of the decreased expo- have questions about breastfeeding and its nutri-
sure to sunlight secondary to changes in lifestyle and tional adequacy, their ability to know if the infant
use of topical sunscreens. The AAP recommends that is drinking enough human milk, the mother’s
all breastfed infants receive vitamin D supplementa- ability to produce enough human milk to satisfy
tion (400 IU per day) beginning in the 2 months after the infant’s hunger, or whether the mother should
birth.24 Breastfed infants whose mothers are vegans breastfeed if she smokes or has an underlying
or vitamin B12 deficient need supplements of vitamin health condition. Women also express concerns
B12. Calcium intake is sufficient in infants who about their need to return to work or school within
receive enough human milk or infant formula. 6 to 8 weeks after the infant’s birth, or the compet-
Fluoride supplementation is not indicated until ing needs of other children and family members.
after the eruption of teeth, which usually occurs To promote continued breastfeeding, health care
at approximately 6 months of age. Beginning at 6 professionals can inform women about breast
months, fluoride supplementation is recommended pumping and proper storage and handling of
for infants and children who do not drink flurori- human milk as an option for women returning to
dated water.25 (For more information on this topic, work and school. Prenatal and postpartum coun-
see the Promoting Oral Health theme.) seling can address these issues and also prolong
the duration of breastfeeding.27
Developing Healthy Feeding and Parents also may raise concerns about maternal
Eating Skills medication usage or maternal or infant illness and
Feedings should be planned to provide all known the advisability of breastfeeding. Decisions about
essential nutrients and to support the development the appropriateness of breastfeeding in these sit-
of appropriate feeding and eating skills. uations are best made on an individual basis with
a health care professional. Under most circum-
Breastfeeding stances, mothers can continue to breastfeed their
Breastfeeding is recommended for at least the first infants or supply human milk if the infant is unable
year of life because of its benefits to newborn and to feed directly at the breast, but a few contraindi-
infant nutrition, gastrointestinal function, host cations to breastfeeding exist. Medications taken
defense, neurodevelopment, and psychological by the mother should be individually evaluated to
well-being (Box 1). Maternal avoidance of highly determine whether they can be used safely when
allergenic foods during lactation is not recom- breastfeeding.28 Few prescription and nonpre-
mended because it provides no proven benefit scription medications are contraindicated for the
to the infants and children. mother who breastfeeds her infant.
174
BFG 4TH ED.indb 174 1/20/17 2:46 PM

Box 1
Benefits of Breastfeeding
Human milk is uniquely suited to the needs of the newborn and growing infant and provides many benefits
for general health, growth, and development.26
Breastfeeding15
•• Provides ideal nutrition and promotes the best possible growth and development
•• Significantly decreases the incidence of diarrhea, lower respiratory tract infection, otitis media, bacteremia,
bacterial meningitis, botulism, and urinary tract infection
•• May be protective against inflammatory bowel disease, leukemias, and certain genotypes of type 1
diabetes mellitus
•• Lowers the risk of obesity in some populations
•• Promotes healthy neurologic development
•• May reduce the incidence of atopic illness, such as allergy or eczema, in children at genetic risk29
•• Promotes close mother-infant connection
Benefits to the Mother

•• Breastfeeding increases levels of oxytocin, which results in less postpartum bleeding and more rapid
uterine involution.
•• Lactating women have an earlier return to prepregnancy weight, delayed resumption of ovulation with
increased child spacing, improved postpartum bone remineralization, and reduced risk of ovarian cancer
and premenopausal breast cancer.
•• Lactation amenorrhea promotes the recovery of maternal iron stores depleted during pregnancy.
•• Breastfeeding lowers the risk for maternal chronic diseases such as hypertension, type 2 diabetes,
coronary artery disease, and some cancers.30,31

Benefits to the Family
•• Breastfeeding has no associated costs and requires no equipment or preparation.
•• It is easy to travel with a breastfed infant because no special equipment or supplies are necessary.
Benefits to the Community

•• Breastfeeding reduces health care costs and employee absenteeism by reducing childhood illness.
Cultural factors may influence breastfeeding initia- Formula Feeding

tion and success. Parents need practical support for For infants who are not breastfed, iron-fortified
breastfeeding as well as culturally based informa- infant formula is the recommended nutrition
tion and guidance. A solid knowledge of the par- substitute during the first year of life. Cow’s milk,
ents’ culture and community will help health care goat’s milk, soy beverages (not soy infant formula),
professionals give parents the support, appropriate and low-iron infant formulas should not be used
education, and guidance they need to be successful during the first year of life. Reduced-fat (2%),
in breastfeeding their infant. low-fat (1%), fat-free (skim), and soy milk are not
recommended for infants and children during the
first 2 years of life.
175
BFG 4TH ED.indb 175 1/20/17 2:46 PM

Health care professionals should counsel parents movements, opening mouth and moving forward
to avoid propping the bottle or letting their infant as the spoon approaches, and swiping food toward
self-feed. This precaution will minimize the risk the mouth. Crying is considered a late feeding cue
for choking, ear infections, early childhood caries, and usually interferes with feeding as the infant
insufficient intake, and the missed opportunities becomes distressed and is less likely to eat well.
for enhancing the parent-child relationship. To Infants can signal that they are full by becoming
prevent dental caries, parents should be instructed fussy during feeding, slowing the pace of eating,
not to put the infant to bed with a bottle or sippy turning away, stopping sucking, or spitting out
cup that contains milk, infant formula, juices, or refusing the nipple. Other satiety cues include
soda, or other sweetened beverages. (For more refusing the spoon, batting the spoon away, and
information on this topic, see the Promoting Oral closing the mouth as the spoon approaches. As
Health theme.) Fruit juices are not needed during with all feeding interactions, parents should
the first 6 months of life, but if they are given after observe the infant’s verbal and nonverbal cues and
6 months, they should be given by cup, not a bottle. respond appropriately. If a food is rejected, parents
Caregivers should not add cereal or other foods should move on and try it again later rather than
to infant formula unless a health care professional forcing the infant to eat or finish foods. It may take
has instructed them to do so. multiple exposures to a food before an infant is
Soy, protein hydrolysates, and amino acid infant willing to recognize a new taste as part of her diet.
formulas have been developed for infants who In the first months of life, breastfed infants must
cannot tolerate milk protein or lactose. It is rec- be fed a minimum of 8 to 12 times in 24 hours
ommended that parents manage their infant’s (ie, approximately every 2–3 hours). Parents
milk intolerance with guidance from their health should be taught to recognize and respond to early
care professional. Intolerance to cow’s milk–based feeding cues. As infants grow older, they typically
infant formulas, manifested by loose stools, spitting are satisfied by less frequent, larger feedings.
up, or vomiting, may prompt a change to soy infant
formula, but little evidence supports this practice. No recommendations exist for maximum volumes
Soy infant formulas may be recommended for a of infant formula at any one feeding, only for
vegetarian lifestyle, transient lactase deficiency, meeting total energy and fluid needs. Parents
and galactosemia. Soy infant formula should not should offer 2 oz of infant formula every 2 to
be used for premature infants, cow’s milk protein– 3 hours in the first week of life. If the newborn
induced enterocolitis, or the prevention of colic still seems hungry, parents can provide more until
or allergy.32 the newborn indicates that she is full. As the new-
born grows, a larger amount of infant formula is
Frequency and Amount of Feedings needed, and the newborn should feed until she
Hunger cues for the newborn include rooting, indicates that she is full. Satiety cues in formula-fed
sucking, and hand movements. In young infants, newborns include turning away from the nipple,
hunger cues may include hand-to-mouth move- falling asleep, and spitting up milk. A newborn
ments and lip smacking. Smiling, cooing, or gazing at the 50th percentile for weight will consume
at the parent during feeding can indicate that the an average of 20 oz of infant formula per day;
infant wants more food. For older infants, hun- the amount of infant formula ranges from 16 to
ger cues can include crying, excited arm and leg 24 oz per day.
176
BFG 4TH ED.indb 176 1/20/17 2:46 PM

When she begins to sleep for longer periods at food out of the mouth) and elevating the tongue
night (4 –5 hours at about 2 months of age), the to move pureed food forward and backward in
formula-fed infant will still need to feed 6 to 8 the mouth (which usually occurs between 4 and
times in 24 hours. A 4-month-old will consume 6 months of age). An increased demand for breast-
an average of 31 oz of infant formula per day with- feeding that continues for a few days, is not affected
out complementary foods with a range of 26 to by increased breastfeeding, and is unrelated to ill-
36 oz per day. However, her intake will fluctuate ness, teething, or changes in routine also may be a
from day to day and week to week. During growth sign of readiness for complementary foods. At this
spurts, intake volume increases but will fall back stage, the infant sits self-supported by her arms and
to lesser volumes when the growth spurt ends. has good head and neck control. The infant can
Infants 6 months and older generally consume indicate her desire for food by opening her mouth
24 to 32 oz per day in addition to complementary and leaning forward and can indicate disinterest
foods. Over time, the increasing volume of com- or satiety by leaning back and turning away.
plementary foods is accompanied by a decreasing When the infant is able to sit independently and
volume of infant formula. tries to grasp foods with her palms, she is ready to
progress to thicker pureed foods and soft, mashed
Introducing Complementary Foods foods without lumps. She also can begin to sip from
Complementary foods, commonly referred to as a small cup. When the infant crawls and pulls to
solids, include any foods or beverages besides a standing position, she also begins to use her jaw
human milk or infant formula. The AAP Com- and tongue to mash food, plays with a spoon at
mittee on Nutrition states that complementary mealtime (but does not use it for self-feeding yet),
foods can be introduced in infants’ diets at about and tries to hold a cup independently. At this stage,

6 months of age and when the infant is develop- she is able to progress to ground or soft, mashed
mentally ready.33 During the second 6 months of foods with small, soft, noticeable lumps (eg, finely
life, complementary foods are an addition to, not chopped meat or poultry). At about 7 to 9 months
a replacement for, human milk or infant formula. of age, the infant learns to put objects in her mouth
Parents need practical guidance when they begin and will try to feed herself. At this age, the infant
to introduce complementary foods, as they seek to has developed a pincer grasp (the ability to pick
determine the best time to start this exciting new up objects between thumb and forefinger). Any
phase. Infants differ in their readiness to accept food the infant can pick up can be considered
complementary foods. Counseling parents on the a finger food. Foods that dissolve easily, such as
normal progression of development of feeding crackers or dry cereal, are good choices, but foods
and eating skills and the infant’s related ability to that can cause choking, such as popcorn, grapes,
safely eat will help them succeed in and enjoy the raw carrots, nuts, hard candies, and hot dogs,
new experience. should be avoided.
Waiting until the infant is developmentally ready Evidence for introducing complementary foods
to begin eating complementary foods makes that in a specific sequence or at any specific rate is not
process and the later transition to table foods available. The general recommendation is that
easier. Signs that an infant is ready to begin semi- the first solid foods should be single-ingredient
solid (pureed) foods include fading of the extru- foods and should be introduced one at a time
sion reflex (the tongue-thrust reflex that pushes and no more frequently than every 3 days. The
order in which solid foods are introduced is not
177
BFG 4TH ED.indb 177 1/20/17 2:46 PM

critical as long as essential nutrients that comple- appropriate growth. By the end of the first year
ment human milk or infant formula are provided. of life, the infant should be introduced to healthy
Pureed meats and iron-fortified cereals provide foods, such as vegetables, fruits, and whole grains,
many of these nutrients for both breastfed and as well as poultry, fish, and lean meats. Foods that
formula-fed infants. After the infant has accepted are high in calories, saturated fats, and added sug-
these new foods, parents can gradually introduce ars and low in essential nutrients, such as sweet-
other pureed foods or soft fruits and vegetables ened drinks, soda, chips, and french fries, should
2 to 3 times per day and allow her to control be avoided.
how much she eats. Parents also can offer store- Parents should not give their infants soda and
bought or home-prepared baby food and soft fruit drinks because of their high added sugar and
table foods, such as mashed potatoes, bananas, calorie content and lack of nutrients. In addition,
or avocados. Breastfed infants are exposed to a parents should give no more than 4 to 6 oz of
variety of flavors through their mother’s breast 100% fruit juice daily to infants 6 months or older
milk; thus, dietary variety is important not just who can drink from a cup. Because many parents
for infants but for their mothers as well. Mixing consider 100% fruit juice to be nutritious, they
cereal with human milk enhances acceptance of may not recognize the need to limit consumption.
cereal by the breastfed infant.34 Repeated exposures However, fruit juice is high in calories and sugar.
to foods enhances acceptance by both breastfed Consuming large quantities can contribute to early
and formula-fed infants.35 childhood caries, pediatric overweight and obesity,
A nutritious and balanced diet for the older infant and diarrhea. Fruit juice could be used as part of
includes appropriate amounts of human milk a meal; it should not be diluted with water and
or infant formula and complementary foods to sipped throughout the day as a means to pacify
ensure intake of all essential nutrients and to foster an unhappy child.36

To establish habits of eating in moderation, infants
should be allowed to stop eating at the earliest
sign of unwillingness and not urged to consume
more. Parents should allow the infant to control
the amount of milk, infant formula, or comple-
mentary foods consumed according to her hunger
and satiety cues. Breastfeeding can aid in estab-
lishing habits of eating in moderation because the
breastfed infant has more control over the amount
consumed at a feeding.37 Parents who feed their
infant using infant formula or human milk by
bottle should be warned against encouraging the
infant to finish the bottle when satiety cues
are demonstrated.
Eating nutritious foods and avoiding
foods that provide calories without
nutrients help establish habits of eat-
ing in moderation. Furthermore,
178
BFG 4TH ED.indb 178 1/20/17 2:46 PM

e stablishing regular mealtimes and snack times allergic disease through nutrition interventions.
and avoiding continuous feeding, or grazing, They endorse exclusive breastfeeding for at least
will help prevent overweight and underweight. 4 months and up to 6 months of age to reduce the
incidence of atopic dermatitis, wheezing before
Handling Feeding and Eating Problems 4 years of age, and cow’s milk allergy but not food
Parents frequently have concerns and questions allergy in general.39
about infant feeding and eating issues, and an
Additionally, the AAAAI endorses the intro-
important aspect of health supervision during this
duction of complementary foods between 4 and
developmental stage is helping parents distinguish
6 months of age, with recommendations for how
normal infant feeding behaviors from feeding or
and when to introduce the main allergenic foods
eating problems.
(cow’s milk, egg, soy, wheat, peanuts, tree nuts,
Food Sensitivities and Allergies fish, and shellfish). Importantly, they concluded
Food allergy and hypersensitivity are forms of that delayed introduction of solid foods, especially
food intolerance characterized by reproducible the highly allergenic foods, may increase the risk
symptoms with each exposure to the offending of food allergy or eczema.39,40
food and an abnormal immunologic reaction to Once a few typical complementary foods
the food. Symptoms and disorders such as irrita- (eg, pureed meat, infant cereal, yellow or orange
bility, hyperactivity, gastrointestinal discomfort, vegetables [eg, sweet potato, carrots], fruits
and asthma have been attributed to food aller- [eg, pears, bananas], green vegetables) are toler-
gies, but true food allergies are not common. Food ated, foods considered to be potentially allergenic
hypersensitivity reactions occur in 2% to 8% of (eg, wheat, egg, fish, cow’s milk in small amounts)
infants and children younger than 3 years. Food may be introduced as complementary foods.

allergy can result in symptoms affecting the gastro- The infant should be given an initial taste of one
intestinal tract (eg, vomiting, cramps, or diarrhea), of these foods at home rather than at day care or
skin (eg, eczema or hives), and respiratory tract at a restaurant. Most reactions occur within a day
(eg, asthma) or in generalized, life-threatening or two in response to what is believed to be the
allergic reactions (ie, anaphylaxis). Hyperactivity initial ingestion. If there is no apparent reaction,
is not a manifestation of food allergy. the food can be introduced in gradually increasing
The most common foods associated with allergic amounts. Introduction of other new foods should
reactions in young children are cow’s milk, eggs, continue if no adverse reactions occur.
peanuts, soy, and wheat. Approximately 2.5% of
infants and children will experience an allergic Regurgitation, Spitting Up, and
reaction to cow’s milk in the first 3 years of life, Gastroesophageal Reflux Disease
1.3% will have a reaction to eggs, and 0.8% will Regurgitation and spitting up are common con-
have a reaction to peanuts. Tree nuts, fish, and cerns for parents. During the first year of life, par-
shellfish become more common causes of food ticularly in the first few months, infants typically
allergy in adolescence and adulthood.38 have episodes of vomiting or “wet burps” within
the first 1 to 2 hours after feeding. Vomiting or wet
The American Academy of Allergy, Asthma & burps are related to transient physiologic episodes
Immunology (AAAAI) has developed recom- of lowered esophageal sphincter tone with efflux
mendations, based on current evidence and of gastric contents into the esophagus. Spitting up
expert opinion, for the primary prevention of often occurs because milk has been ingested too
179
BFG 4TH ED.indb 179 1/20/17 2:46 PM

rapidly or as a reaction to overfeeding, inadequate occur in the development of these skills or if delays
burping, or improper feeding techniques (eg, bot- are anticipated (eg, as in the case of some children
tle propped, bottle not adequately tipped up, or with special health care needs), a health care pro-
shaking infant formula too vigorously before feed- fessional should assess the infant.
ing). Approximately half of infants younger than The suck-and-pause sequence in breastfeeding
3 months spit up or regurgitate 1 or 2 times a day, or infant formula feeding and behaviors such as
with the incidence peaking between 2 to 4 months eye contact, open mouth, turning to the parent,
of age. The frequency may increase again when the and even turning away provide the foundation for
infant starts solid foods. Spitting up resolves itself the first communication between the infant and
in most children by 12 to 24 months of age. parents. Difficulties in early feeding elicit strong
Frequent spitting up or significant vomiting is emotions in parents and can undermine parenting
classified as gastroesophageal reflux and usually is confidence and sense of competency. Thus, feeding
harmless in infants. The clinical manifestations of difficulties must be addressed in a timely manner.
gastroesophageal reflux disease (GERD) include Over time, parents become more skilled at inter-
vomiting and associated poor weight gain, appar- preting their infant’s cues and increase their reper-
ent discomfort with eating, esophagitis, and respi- toire of successful responses to those cues. As they
ratory disorders.41 The health care professional will feed their infant, parents learn how their actions
need to differentiate these symptoms from pyloric comfort and satisfy. Physical contact during breast-
stenosis in some young infants. feeding or infant formula feeding strengthens the
psychological bond between the parent and infant
Providing a Nurturing and Healthy
and enhances communication because it provides
Feeding Environment
the infant with essential sensory stimulation,
Infants need a nurturing environment and positive

including skin and eye contact. A sense of caring
patterns of feeding and eating to promote healthy
and trust evolves, which lays the groundwork for
eating habits and build variety, balance, and mod-
communication patterns throughout life.
eration. In early infancy, feeding is crucial for
developing a parent’s responsiveness to an infant’s A healthy feeding relationship involves a division
cues of hunger and satiation. The close physical of responsibility between the parent and the infant.
contact during feeding facilitates healthy social The parent sets an appropriate, safe, and nurturing
and emotional development. feeding environment and provides appropriate,
healthy foods. The infant decides when and how
During the first year, feeding the hungry infant
much to eat. In a healthy infant-parent feeding
helps her develop a sense of trust that her needs
relationship, responsive parenting involves
will be met. For optimum development, new-
borns should be fed as soon as possible when they ■■ Responding early and appropriately to hunger
express hunger. Children with special health care and satiety cues
needs often have subtle cues that can be difficult ■■ Recognizing the infant’s developmental abilities
for parents to interpret. Parents must be careful and feeding skills
observers of the infant’s behaviors, so they can ■■ Balancing the infant’s need for assistance with
respond to their infant’s needs. As infants become encouragement of self-feeding
more secure in their trust, they can wait longer for ■■ Allowing the infant to initiate and guide
feeding. Infants should develop their feeding skills feeding interactions
at their own rate. However, if significant delays
180
BFG 4TH ED.indb 180 1/20/17 2:46 PM

Nutrition for Infants With Special Health retain primitive reflexes like the extrusion reflex
Care Needs and the tonic bite reflex. These behaviors can be
Medical problems or other special health care needs mistakenly interpreted as food refusals. Thus,
can place the infant at nutritional risk. Because health care professionals should try to identify
this is a time of high caloric need, health care pro- feeding challenges early and provide resources for
fessionals should consider referring the family for evaluation, education, and support. Assessing and
specialized medical and nutrition consultation. treating physical or behavioral feeding difficulties
is best accomplished by an interdisciplinary team
Not all infants are able to easily develop the skills
that may include a developmental and behavioral
for feeding and eating. Approximately 25% of all
pediatrician, a dietitian, an occupational therapist,
children have some form of feeding problem, and
a speech pathologist, a nurse or nurse practitioner,
80% of children with a developmental disability
a social worker, and a psychologist. Parents should
have some form of feeding problem.42 Feeding dif-
learn the different philosophies, intervention strat-
ficulties can lead to problems in the parent-child
egies, and approaches of the different programs
relationship, as well as growth problems, inade-
available, as well as their costs and outcomes,
quate nutrition, and significant feeding problems
before they make a decision on the best approach
later in childhood. It is recommended that health
for their child and family.
care professionals address the following common
concerns expressed by parents: Low-birth-weight infants need additional iron after
the first month of life (2 mg/kg/day) until they
■■ Refusing infant cereal and purees
reach 1 year of age.43 They also may need special
■■ Difficulty transitioning to textures
food (eg, preterm discharge infant formulas with
■■ Gagging, choking, or vomiting with feeding
enhanced nutrients). Infants with sequelae of pre-
Poor or inadequate food volume

■■
maturity, chronic lung or reactive airway disease,
■■ Poor or inadequate variety of foods, picky eating
short bowel syndrome, cholestasis, GERD, rickets,
(eg, refusing to eat certain foods), or food jags
or chronic heart, kidney, or liver disease have
(ie, favoring only 1 or 2 foods)
medical and developmental factors that will affect
■■ Prolonged feeding time (>30 minutes)
their growth. They may require specialized feed-
■■ Respiratory symptoms after feeding
ings with nutritional supplements, including forti-
Infants with special health care needs are at fiers, vitamins, and minerals. Medication use also
increased risk of feeding complications, including may alter nutritional requirements.
failure to thrive, aspiration of food, and GERD.
Infants with special health care needs often need
Parents of infants with special health care needs
increased calories but may be limited by feeding
also may need extra emotional support and
issues. Because their immune systems may be
instruction about special techniques for posi-
compromised, most of these infants benefit from
tioning or special equipment. These accommo-
breastfeeding (or being fed expressed human
dations can help overcome feeding problems and
milk). Parents may need to modify human milk
prevent suboptimal nutrition, poor weight gain,
or infant formula or adapt their feeding techniques
and growth deficiency.
to ensure that infants with the following conditions
Parents often blame themselves for their infant’s achieve adequate caloric intake:
feeding problem, yet the difficulty is typically
■■ Prematurity and low birth weight
related to the infant’s oromotor developmental
■■ Chronic respiratory or congenital heart disease
problem. Children with oromotor delay may
181
BFG 4TH ED.indb 181 1/20/17 2:46 PM

■■ Gastrointestinal tract disease can alert parents to this change while plotting the
■■ Kidney disease child’s height, weight, and BMI on the sex- and
■■ Neurologic disorders age-appropriate WHO or CDC Growth Charts
■■ Syndromes and genetic disorders affecting (Appendixes A and B) to demonstrate expectations
growth potential, such as cystic fibrosis for healthy growth.
Monitoring growth measures by age also allows the
Promoting Nutritional Health: health care professional to determine how the child
Early Childhood—1 Through 4 Years compares with others of the same age and sex.
Ensuring adequate nutrition during early child- These measures can be used to signal abnormal
hood focuses on promoting normal growth growth patterns. Linear growth is used to detect
by selecting appropriate amounts and kinds of long-term undernutrition. Using weight-for-length
foods and providing a supportive environment until age 2 years, along with BMI growth charts
that allows the child to self-regulate food intake. after that, allows the health care professional to
Self-regulation of eating and its accompanying determine underweight and overweight or obesity
independence are major achievements during the and whether the child is maintaining his own
early childhood years. Children continue their growth trajectory. If the child has moved up or
exposure to new tastes, textures, and eating expe- down 2 percentile lines on the growth chart since
riences depending on their own developmental the previous visit, it is recommended that the
ability, cultural and family practices, and individual health care professional question parents in detail
nutrient needs. about portion sizes, types of food served, and feed-
ing frequency. Skinfold measurements for this age
Nutrition for Growth group are not used unless medically indicated and
Most infants triple their birth weight within the performed by an adequately trained technician.
first year of life and experience a significantly Early childhood is the time to establish lifelong
slower rate of weight gain after the first year, which eating habits. Healthy eating includes 3 meals
results in a dramatic decrease in appetite and daily, beginning with breakfast, and 2 to 3 snacks.
diminished food intake (Box 2). This diminished Because most children, adolescents, and adults
intake is compensated for by eating foods with in the United States consume too few vegetables,
increased caloric density. Health care professionals fruits, and whole grains and too little dairy, early
Box 2
Changes in Appetite in Early Childhood
The anticipated but sudden reduction in appetite is a common source of concern and anxiety to parents of
infants soon after the first birthday. This parental concern affords a unique opportunity to educate parents
about changing dietary needs.
Health care professionals can use this opportunity to emphasize that
•• Reduced intake is normal.
•• Picky eating more often reflects lack of hunger than a change in taste preferences.
•• Encouraging a child to eat when he is not hungry leads to consumption of excess calories, an undesired
outcome because obesity is a major nutrition problem.
•• Offering multiple alternatives to a child who is not hungry is unnecessary and it rewards picky eating,
potentially contributing to lifelong food biases.
182
BFG 4TH ED.indb 182 1/20/17 2:46 PM

childhood is the proper time to establish tastes Box 3

and preferences, as well as healthy eating patterns. Dietary Reference Intakes for Calcium and
Refined grains, saturated fat, added sugars, and Vitamin D45
sodium are overconsumed throughout the age Birth at Term Until 1 Year
range, so care should be taken with introducing
•• 200 mg calcium per day, birth–6 months
foods and beverages that are high in these compo- •• 260 mg calcium per day, 7–12 months
nents. Many young children do consume recom- •• 400 IU vitamin D per day
mended amounts of fruit and dairy, a habit to be
supported and maintained. Children Aged 1–3
•• 500 mg calcium per day
As additional table foods are offered, young chil- •• 400 IU of vitamin D per day
dren consume foods similar to those of the entire
family. The Feeding Infant and Toddler Study sug- Children Aged 4–8
gests that, in general, young children are getting •• 800 mg calcium per day
sufficient intakes of calcium.44 Children in this age •• 600 IU vitamin D per day
group using cow’s milk or soy as a primary protein
Children, Adolescents, and Young Adults Aged
and calcium source should be encouraged to drink
9–18
16 to 32 oz (480–960 mL) of cow’s milk or soy milk
•• 1,300 mg calcium per day
per day to receive adequate levels of these nutrients.
•• 600 IU vitamin D per day
Other products sold as “milk” (eg, almond milk,
hemp milk) are generally lower in protein and have Data derived from Ross AC, Taylor CL, Yaktine AL, Del Valle HB;
Institute of Medicine Committee to Review Dietary Reference
not been studied sufficiently to promote their use. Intakes for Vitamin D, Calcium, Food and Nutrition Board. Dietary
Reference Intakes for Calcium and Vitamin D. Washington DC:
Even in early childhood, however, dietary prefer- National Academies Press; 2011.

ences and patterns begin to be established, and, all
too often, the reported amount of milk consumed ■■ Chips
decreases significantly, while the intake of juices, ■■ Round slices of hot dogs or sausages
fruit drinks, and soda increases. The shift from ■■ Raw carrot sticks
milk to juice and soda lowers calcium intake and ■■ Whole grapes and cherries
makes it more difficult for young children to attain ■■ Large pieces of raw vegetables or fruit
the recommended calcium intake (Box 3). Fruit ■■ Whole cherry or grape tomatoes
drinks and sodas are discouraged, and 100% fruit ■■ Tough meat
juice is recommended at no more than 4 to 6 oz ■■ Hard candy
daily.36 Overuse may lead to excess energy intake,
To limit the risk of choking, children should sit up
diarrhea, and dental caries. (For more information
while eating. Infants and children younger than
on this topic, see the Promoting Healthy Weight and
3 years should not eat without direct adult supervi-
Promoting Oral Health themes.)
sion, even if they are able to feed themselves. Parents
A primary safety concern for young children should avoid feeding a young child while in a car
during feeding is choking or inhalation of food. because, if the child should begin to choke, pulling
The following foods should be avoided at this age: over to the side of the road in traffic to dislodge the
■■ Peanuts and other whole nuts food is difficult. Furthermore, feeding young chil-
■■ Chewing gum dren while driving contradicts the recommenda-
■■ Popcorn tion to feed children in appropriate locations.46
183
BFG 4TH ED.indb 183 1/20/17 2:46 PM

Because few data are available on nutrient As their manipulative skills mature, preschoolers
adequacy for young children, the Institute of also can successfully help in food preparation,
Medicine46 extrapolated values from studies of which may help them accept new foods.
infants and adults to establish Dietary Reference Unfortunately, some parents and other caregivers
Intakes.1,2 A clear translation of these nutrient become discouraged and frustrated when their
intakes into specific food choices and portions child seems to concentrate more on exploring food
for young children is not yet available. However, than eating it. This behavior reflects the emerging
guidelines suggest offering appropriate nutritious curiosity and independence associated with early
foods spaced into 3 meals, along with 2 or 3 snacks childhood and is normal. Parents and caregivers
per day.2,21 For children older than 2 years, the can foster this newly found and often assertively
Dietary Guidelines for Americans are the primary expressed independence while still ensuring
source of dietary guidance.1 Other national health adequate nutrition by offering a well-balanced
organizations also have developed nutrition policy selection of foods and allowing children to choose
statements to promote optimal health and reduce the types and amounts of foods they want to eat.
risk for obesity and chronic disease, and these Parents and caregivers should encourage young
statements can be used to guide food choices in children to explore food tastes and textures by
children older than 2 years.47–50 repeating exposure to foods. Health care profes-
All of these science-based nutrition guidelines sionals can empower caregivers by letting them
recommend a diet that includes a variety of know that children will often begin to accept
nutrient-dense foods and beverages from the foods after 10 or more exposures to certain foods.
major food groups and limits the intake of satu- Preparing a familiar-looking food in different ways
rated and trans fats, added sugars, and salt. A basic can also increase acceptance of foods. Parents and
premise is that nutrient needs should be met pri- other caregivers need to understand that recog-
marily by consuming a variety of foods that have nizing the child’s signals of hunger and fullness
beneficial effects on health. Supplementation with supports the child’s innate ability to self-regulate
vitamins and minerals is not considered necessary energy intake and portion size. They also need to
when children are consuming the recommended understand that a child does not have an innate
amounts of healthy foods.51 However, health care ability to select only appropriate foods. Food
professionals should not assume that all young choice remains the responsibility of the caregiver.
children are getting the nutrients they need.52 A Parents and other caregivers can be positive
significant number of children in the United States role models by practicing healthy eating behav-
live in households with insufficient healthy food. iors themselves.
Mealtime provides opportunities for wonderful
Developing Healthy Feeding and parent-child interactions. These opportunities exist
Eating Skills for the toddler, who may be fed before the family
Young children often eat sporadically over one day meal, as well as for young children, who may par-
or several days. Over a period of a week or so, their ticipate in the family routine and sit at the table for
nutrient and energy intakes balance out. Food jags a short time. Finger foods should be encouraged
and picky eating are normal behaviors in young because they foster competence, mastery, and
children. For most young children, these behaviors self-esteem. Even when the parent is doing the
disappear before school age if parents continue to feeding, the child also should be given a spoon.
expose them to a variety of new and familiar foods. The 12- to 15-month-old should be encouraged to
184
BFG 4TH ED.indb 184 1/20/17 2:46 PM

use a spoon. When the toddler is finished consume recommended amounts of fruit and dairy,
eating, he should be allowed to leave the table the quality of dietary patterns drops in middle
and be placed where he can be supervised until childhood and adolescence.1 Even into middle
the adults have finished their meal. childhood, a child needs 3 meals and 2 to 3 healthy
snacks per day. As the child’s ability to feed her-
Nutrition for Children With Special Health self improves, she can help with meal planning and
Care Needs food preparation, and she can perform tasks related
Children with special health care needs generally to mealtime. Performing these tasks enables the
follow similar developmental pathways as children child to contribute to the family and can boost her
without these challenges when they begin the pro- self-esteem. The USDA MyPlate, which is based on
cess of self-feeding. However, the pace of develop- the Dietary Guidelines for Americans, provides an
ment and the ultimate mastery of tasks will vary easy reference on food intake and physical activity
depending on the physical, emotional, or cognitive recommendations for children and adolescents
challenges facing the child. Attention to nutritional 6 to 11 years.54
intake and physical activity is important.
The types of nutritional issues most common for Nutrition for Growth
children with special health care needs include Middle childhood is characterized by a slow, steady
feeding problems (eg, chewing and swallowing), rate of physical growth. Plotting the child’s BMI
slow growth, metabolic or gastrointestinal issues, allows the health care professional to note any per-
and overweight or obesity. By age 15 months, centile changes and provide early intervention as
children with autism spectrum disorder (ASD) needed to prevent childhood underweight or over-
demonstrate greater food selectivity compared to weight. During middle childhood, children gain an
average of 7 lb in weight and 2½ in in height per

typically developing peers and demonstrate more
challenging food-related behaviors as toddlers, year. The BMI gradually increases from its lowest
even before diagnosis of ASD.53 Sometimes, chil- point at 5 to 6 years of age. Additionally, during
dren with special health care needs require special middle childhood, a child’s body fat increases in
feeding techniques, longer periods of time to feed, preparation for the growth spurt. On average, the
or special foods (both type and texture), infant growth spurt and puberty begins for girls at ages
formulas, and feeding approaches (eg, restriction 9 to 11 years (Tanner stages 2–3) and for boys at
of certain foods). The health care professional ages 10 to 12 years (Tanner stages 3–4). Children
can identify these issues and refer the family, as may become concerned about their appearance
needed, to a registered dietitian or interdisciplin- and body image and may eat less or go on diets
ary team for further assessment, intervention, for weight loss.
and monitoring. The health care professional can reassure the fam-
ily about normal growth patterns while addressing
Promoting Nutritional Health: the child’s or family’s weight concerns. Common
Middle Childhood—5 Though 10 Years nutrition concerns in middle childhood include
To achieve optimal growth and development, chil- ■■ Decreased consumption of milk and milk
dren need a variety of nutritious foods that provide products
sufficient—but not excessive—calories, protein, ■■ Increased consumption of beverages high in
carbohydrates, fat, vitamins, and minerals. Recent added sugars
data suggest that while many young children Limited intake of fruit and vegetables
185
■■
BFG 4TH ED.indb 185 1/20/17 2:46 PM

■■ High consumption of foods high in saturated and breads), and soy milk foods and beverages
fat, added sugars, refined grains, and sodium that are similar to milk and dairy products in their
(primarily from snack foods) content of calcium and vitamin D. Parents should
■■ Rise of overweight and obesity be alert to the nutritional content of other products
■■ Increase in body image concerns sold as “milk” (eg, almond milk, hemp milk) that
■■ Effect of the media and advertising on may not provide equivalent calcium, vitamin D, or
nutritional intake protein. A dietary supplement containing calcium
and vitamin D may be recommended for children
Calcium and Vitamin D
who do not consume enough of either through
Calcium and vitamin D intake is a concern during
their diets.
middle childhood. These nutrients are critical for
bone health, and a higher incidence of fractures Developing Healthy Eating Habits
is reported in children who do not get adequate Parents and other family members continue to have
amounts. Studies indicate that few children con- the most influence on children’s eating behaviors
sume enough of either nutrient. Consumption of and attitudes toward foods. They can be positive
juice, soft drinks, or sports drinks often leads to role models by practicing healthy eating behaviors
reduced milk intake. Decreased outdoor activity, themselves. The 2015–2020 Dietary Guidelines
along with sunscreen use, also has resulted in for Americans explain that contemporary nutri-
reduced vitamin D absorption. ent consumption patterns are of potential public
Nutrition recommendations for calcium change health concern.1
during middle childhood from 800 mg per day for ■■ Vitamin D, calcium, potassium, and fiber are
children aged 4 to 8 years to 1,300 mg per day for under-consumed.
children, adolescents, and young adults aged 9 to Iron is under-consumed in adolescent girls.
■■
18.45 Health care professionals should encourage ■■ Sodium is overconsumed by people of all ages.
parents to provide several servings of low-fat or ■■ Saturated fats, added sugars, and refined grains
fat-free milk daily. One 8-oz are overconsumed.
glass of milk provides
Parents need to make sure that nutritious foods
approximately 300 mg
are available and decide when to serve them;
of calcium and 120 IU
however, children should decide how much
of vitamin D. For chil-
of these foods to eat. During this period, when
dren who are unable
children may be missing several teeth, it can
to consume milk
be difficult for them to chew certain foods
or dairy products,
(eg, meat). Offering foods that are easy to
health care profes-
chew can alleviate this problem. Responsive
sionals can recommend
feeding remains important during middle
the consumption of other
childhood as a means of
calcium-rich foods,
reinforcing awareness of
calcium-fortified
hunger and satiety cues.
products (eg, some
orange juices Health care profession-
als should try to deter-
mine whether families
have access to and can
186
BFG 4TH ED.indb 186 1/20/17 2:46 PM

afford nutritious foods. They also should discuss when physical activity is limited by a special health
families’ perceptions of which foods are nutritious care need. In addition, children may be making food
and their cultural beliefs about foods. Families choices at school, and parents may need help in guid-
should eat together in a pleasant environment ing them to make healthy choices, depending on
(without the television and other media distractions), their particular needs. Health care professionals
allowing time for social interaction. Participation should be aware of these challenges and be prepared
in regular family meals is positively associated with to seek assistance in monitoring and facilitating
appropriate intakes of energy, protein, calcium, and appropriate nutrition. When a child has a special
many micronutrients and can reinforce the develop- dietary need, it should be shared with school person-
ment of healthy eating patterns.55 nel and included on her Individualized Education
During middle childhood, mealtimes take on social Program, if one is in effect. This will allow the school
significance, and children become increasingly to provide any special foods that may be needed.
influenced by outside sources (eg, their peers and
the media) regarding eating behaviors and attitudes Promoting Nutritional Health:
toward foods. In addition, they eat a growing number Adolescence—11 Through 21 Years
of meals away from home and may have expanding Adolescence is one of the most dynamic periods of
options for consuming nonnutritious foods. Their human development. The increased rate of growth
willingness to eat certain foods and to participate in that occurs during these years is second only to
nutrition programs (eg, School Breakfast Program that occurring in the first year of life. Nutrition and
and National School Lunch Program) may be based physical activity can affect adolescents’ energy levels
on what their friends are doing. However, some chil- and influence growth and body composition, and
dren can have difficulty adapting to school meals. the changes associated with puberty can influence

This difficulty can result from the foods being dif- adolescents’ satisfaction with their appearance.
ferent from those at home, the foods not conform- Health supervision visits provide an opportunity for
ing to cultural and religious practices, or children health care professionals to discuss healthy eating
having less time to eat than they are accustomed to, and physical activity behaviors with adolescents and
eating at different times than accustomed, or having their parents. (For more information on this topic,
difficulty serving their own food. see the Promoting Healthy Weight and the Promoting
Physical Activity themes.)
Nutrition for Children With Special Health
Care Needs Nutrition for Growth
Children with special health care needs can have
The adolescent’s diet should follow the 2015–2020
significant nutritional challenges that can lead to
Dietary Guidelines for Americans1 and comple
underweight or overweight. These challenges can be
mentary recommendations from national health
the result of behavioral disturbances or of children
organizations.49,54 These recommendations empha-
needing assistance with feeding. Some children
size eating healthy foods such as vegetables, fruits,
may require gastrostomy tubes and fundoplications.
whole-grain products (eg, cereals, bread, or crackers),
Medications also can affect appetite, leading to
low-fat or nonfat milk and dairy products (eg, cheese,
weight loss or weight gain. When weight gain is
cottage cheese, and unsweetened yogurt), and lean
desired, nutritious high-calorie foods should be
meats, fish, chicken, eggs, beans, and nuts and limit-
served rather than calorie-dense foods with little
ing or avoiding foods high in saturated fat, added
nutritional value. Overweight and obesity are risks
sugars, sodium, and refined grains. They also
187
BFG 4TH ED.indb 187 1/20/17 2:46 PM

emphasize balancing calories consumed from foods recommendations for folate, iron, and calcium,
and beverages with calories expended in normal which are nutrients of particular concern for ado-
body functions and through physical activity.49 lescents because they are often under-consumed.33
Nutrient needs should be met by consuming a Adolescents of both sexes and all income and racial
variety of healthy foods. In certain cases, fortified and ethnic groups often consume excess amounts of
foods and dietary supplements may be useful sources total fat, saturated fat, and added sugars. Other
of one or more nutrients that otherwise might not nutrition-related concerns for adolescents include
be consumed in the adequate amounts. However, low intakes of vegetables, fruits, whole-grain prod-
although they are recommended in some cases, ucts, and low-fat and nonfat milk and other dairy
dietary supplements cannot replace a healthy diet. products.56 These dietary patterns constitute a signif-
For many adolescents, particularly girls and those icant risk factor for obesity and other health condi-
from families with low incomes, intake of certain tions.2,56 Reducing the consumption of high-fat
vitamins (ie, folate and vitamins A, B6, and E) foods as well as beverages and foods with added
and minerals (ie, iron, calcium, magnesium, and sugars will lower the caloric content of the diet
zinc) is inadequate. Box 4 provides current without compromising its nutrient adequacy.1
Box 4
Current Recommendations for Selected Nutrients33
Folate
The IOM recommends that, to reduce the risk of giving birth to an infant with neural tube defects, female
adolescents who are capable of becoming pregnant should take 400 µg of synthetic folic acid per day from
fortified foods, a supplement, or both in addition to consuming foods rich in folate.1,46
Iron
The body’s need for iron increases dramatically during adolescence, primarily because of rapid growth.
Adolescent boys require increased amounts of iron to manufacture myoglobin for expanding muscle mass
and hemoglobin for expansion of blood volume. Although adolescent girls generally have less muscular
development than adolescent boys, they have a greater risk for iron-deficiency anemia because of blood lost
through menstruation. Iron-deficiency anemia in adolescents may be caused by inadequate dietary intake of
iron, which results from low-calorie and extremely restrictive diets, periods of accelerated iron demand, and
increased iron losses. The DRIs for iron are2
•• Girls and boys 9–13 years of age: 8 mg iron per day
•• Females 14 –18 years: 15 mg iron per day
•• Women 19–21 years: 18 mg iron per day
•• Males 14 –18 years: 11 mg iron per day
•• Men 19 and 21 years: 8 mg iron per day
Calcium
Adequate calcium intake is essential for peak bone mass development during adolescence, a period when 45%
of the total permanent adult skeleton is formed. Calcium requirements increase with the growth of lean body
mass and the skeleton. Therefore, requirements are greater during puberty and adolescence than in childhood
or adulthood. The current calcium DRIs for children and adolescents are1
•• Children, adolescents, and young adults 9 –18 years of age: 1,300 mg calcium per day
•• Young adults 19 –21 years: 1,000 mg calcium per day
188 Abbreviations: DRI, Dietary Reference Intake; IOM, Institute of Medicine.
BFG 4TH ED.indb 188 1/20/17 2:46 PM

Only 22% of adolescents report eating fruit 3 or more As adolescents strive for independence, they begin
times per day, only 15% report eating vegetables 3 or to spend large amounts of time outside the home.
more times per day, and only 15% report drinking 3 Parents can encourage adolescents to choose nutri-
or more glasses of milk per day. In addition, 11% of tious foods when eating away from home.59 Many
adolescents report drinking soda 3 or more times a adolescents walk or drive to neighborhood stores
day, only 37% report eating breakfast every day, 29% and fast-food restaurants and purchase foods with
describe themselves as having slight or substantial their own money. This situation can be especially
overweight, 46% report trying to lose weight, and problematic for adolescents from families with low
12% report not eating for 24 hours or more to lose incomes or adolescents who live in neighborhoods
weight or to keep from gaining weight.57 Common with many fast-food restaurants and no grocery or
nutrition concerns during adolescence include other stores that sell affordable, nutritious foods.
■■ Increase in overweight and obesity Although eating together as a family is a challenge
■■ Increase in eating disorders and body for many adolescents and their families who are
image concerns coping with school demands, after-school activities,
■■ Prevalence of iron-deficiency anemia in girls and work schedules, having frequent family meals
■■ Prevalence of hyperlipidemia and type 2 diabetes can promote the development of healthy eating pat-
■■ Food insecurity among adolescents from terns that may continue into adulthood and can pro-
families with low incomes2 tect against the inadequate dietary intake reported
by many adolescents.56,58,60 Having meals together is
Assessing the Adolescent Diet
positively associated with intake of vegetables, fruits,
Evaluating the dietary intake of an adolescent is a
grains, and milk and dairy products rich in calcium
fundamental component of health supervision. It is
and negatively associated with soda consumption.
useful for health care professionals to gather quan-

Frequency of family meals also is positively associ-
titative and qualitative data about foods and bever-
ated with more appropriate intake of energy, protein,
ages consumed (both common and unusual), eating
iron, folate, fiber, and vitamins A, C, E, and B6.60
patterns, attitudes about foods and eating, and
other issues, such as cultural and religious patterns Body Image and Eating Disorders
and taboos associated with food. The physical changes that are associated with
puberty can affect adolescents’ satisfaction with
Developing Healthy Eating Habits their appearance. For some adolescent boys, the
Developing an identity and becoming an indepen- increased height, weight, and muscular develop-
dent young adult are central to adolescence. Adoles- ment that come with physical maturation can lead
cents may use foods to establish individuality and to to a positive body image. However, for many
express their identity. They usually are interested in adolescents, puberty-related changes (in adolescent
new foods, including those from different cultures girls in particular, the normal increase in body fat)
and ethnic groups, and may adopt certain eating may result in weight concerns. The social pressure
behaviors (eg, vegetarianism) to explore various to be thin and the stigma of having overweight can
lifestyles or to show concern for the environment. lead to unhealthy eating behaviors and a poor body
Parents can have a major influence on adolescents’ image.61 Adolescents may attempt to lose weight
eating behaviors by providing a variety of healthy or avoid gaining weight by eating smaller amounts
foods at home and by making family mealtimes a of food, foods with fewer calories, or foods low in
priority.58 Parents also can be positive role models fat. They also may forego eating for many hours;
by practicing healthy eating behaviors themselves. engage in excessive physical activity; take diet pills,
189
BFG 4TH ED.indb 189 1/20/17 2:46 PM

powders, or liquids without a physician’s advice; includes the promotion of healthy eating and
use illegal “street” drugs (eg, methamphetamines); weight management strategies to enhance per-
and vomit or take laxatives. Fad diets that rec- formance and endurance while ensuring optimal
ommend unusual and, sometimes, inadequate or growth and development.
unbalanced dietary patterns promise the loss of The AAP recommends against the use of
several pounds in a short period of time. In addi- performance-enhancing substances (eg, supple-
tion, the lack of evidence about their efficacy and ments, ergogenic aids [eg, amphetamines, creatine,
safety in adolescents make such regimens a poor and steroids]) for athletic or other purposes.65
choice for adolescents who want to lose weight Performance-enhancing substances may pose a
and who may underestimate the health risks asso- significant health risk to adolescents. Supplements
ciated with them.62 and amphetamines do not contribute positively to
Unhealthy eating behaviors and preoccupation athletic performance. Health care professionals can
with body image can lead to life-threatening eating stress the importance of seeking accurate informa-
disorders (eg, anorexia nervosa, bulimia nervosa, tion so young athletes and their parents can make
binge-eating disorder). Although eating disorders informed choices.
are more prevalent among adolescent girls (prev-
alence is 1% –2%) than among adolescent boys, Nutrition for Adolescents With Special
they occur in both sexes across socioeconomic Health Care Needs
and racial and ethnic groups and are even seen in As with younger age groups, adolescents with
children and young adolescents (10 –12 years of special health care needs are at increased risk for
age).63 Major medical complications of eating dis- nutrition-related health problems.66
orders include cardiac arrhythmia, dehydration and ■■ Physical disabilities can affect their capacity to
electrolyte imbalances, delayed growth and devel- consume, digest, or absorb nutrients.
opment, endocrine disturbances (eg, menstrual ■■ Long-term medications or metabolic distur-
dysfunction or hypothermia), gastrointestinal bances can lead to biochemical imbalances.

problems, oral health problems (eg, enamel demin- ■■ Psychological stress that results from a chronic
eralization or salivary dysfunction), osteopenia, condition or physical disorder can affect appe-
osteoporosis, and protein and calorie malnutrition tite and food intake.
and its consequences. In 2009, the mortality rate ■■ Environmental factors, often controlled by par-
for anorexia nervosa was 4.0%; for bulimia, 3.9%; ents or other caregivers, may influence access to
and for eating disorders not otherwise specified, and acceptance of food.
5.2%.64 Death may be caused by cardiac arrhyth- The energy and nutrient requirements of adoles-
mia, acute cardiovascular failure, gastric hemor- cents with special health care needs have been
rhaging, or suicide. Bulimia nervosa can damage reviewed.2 The adolescent’s diagnosis, medical
teeth and cause enlargement of the parotid gland. status, individual metabolic rate, and activity level
are used to determine a desired energy level to be
Athletics and Performance-Enhancing
established and achieved. The adolescent is subse-
Substances
quently monitored to (1) ensure adequate nutrition
Inadequate nutritional intake and unsafe weight
for growth, development, and health and (2) make
control methods can adversely affect performance
adjustments for periods of stress and illness.
and endurance, jeopardize health, and under-
mine the benefits of training. Health supervision
190
BFG 4TH ED.indb 190 1/20/17 2:46 PM

References
1. US Department of Health and Human Services, US Depart- 18. WHO Multicentre Growth Reference Study Group. WHO Child
ment of Agriculture. 2015-2020 Dietary Guidelines for Amer- Growth Standards: Growth Velocity Based on Weight, Length,
icans. 8th ed. 2015. http://health.gov/dietaryguidelines/2015/ and Head Circumference: Methods and Development. Geneva,
guidelines. Accessed September 15, 2016 Switzerland: World Health Organization; 2009. http://www.
2. Holt K, Wooldridge N, Story N, Sofka D. Bright Futures: who.int/childgrowth/standards/velocity/technical_report/en.
Nutrition. 3rd ed. Elk Grove Village, IL: American Academy Accessed September 17, 2016
of Pediatrics; 2011 19. Griffiths LJ, Smeeth L, Hawkins SS, Cole TJ, Dezateux C. Effects
3. Mennella JA. Ontogeny of taste preferences: basic biology and of infant feeding practice on weight gain from birth to 3 years.
implications for health. Am J Clin Nutr. 2014;99(3):704S-711S Arch Dis Child. 2009;94(8):577-582
4. Coleman-Jensen A, Rabbitt MP, Gregory C, Singh A. Household 20. Lozoff B, Jimenez E, Hagen J, Mollen E, Wolf AW. Poorer
Food Security in the United States in 2014. Washington, DC: US behavioral and developmental outcome more than 10 years
Department of Agriculture, Economic Research Service; 2015. after treatment for iron deficiency in infancy. Pediatrics.
Publication ERR-194. http://www.ers.usda.gov/media/1896841/ 2000;105(4):E51
err194.pdf. Accessed September 17, 2016 21. American Academy of Pediatrics Committe on Nutrition. Iron.
5. Widome R, Neumark-Sztainer D, Hannan PJ, Haines J, Story In: Kleinman RE, Greer FR, eds. Pediatric Nutrition: Policy of the
M. Eating when there is not enough to eat: eating behaviors and American Academy of Pediatrics. 7th ed. Elk Grove Village, IL:
perceptions of food among food-insecure youths. Am J Public American Academy of Pediatrics; 2014:449-466
Health. 2009;99(5):822-828 22. Wang B, Zhan S, Gong T, Lee L. Iron therapy for improving
6. Cutler-Triggs C, Fryer GE, Miyoshi TJ, Weitzman M. psychomotor development and cognitive function in children
Increased rates and severity of child and adult food insecurity under the age of three with iron deficiency anaemia. Cochrane
in households with adult smokers. Arch Pediatr Adolesc Med. Database Syst Rev. 2013;(6):CD001444
2008;162(11):1056-1062 23. Baker RD, Greer FR; American Academy of Pediatrics
7. US Department of Agriculture, Food Nutrition Service. Women, Committee on Nutrition. Diagnosis and prevention of iron
Infants, and Children (WIC) Web site. http://www.fns.usda.gov/ deficiency and iron-deficiency anemia in infants and young
wic/women-infants-and-children-wic. Accessed September 17, children (0-3 years of age). Pediatrics. 2010;126(5):1040-1050
2016 24. Wagner CL, Greer FR; American Academy of Pediatrics Section
8. US Department of Agriculture, Food and Nutrition Service. on Breastfeeding, Committee on Nutrition. Prevention of rickets
Supplemental Nutrtion Assistant Program (SNAP) Web and vitamin D deficiency in infants, children, and adolescents.
site. http://www.fns.usda.gov/snap/supplemental-nutrition- Pediatrics. 2008;122(5):1142-1152
assistance-program-snap. Accessed September 17, 2016 25. Clark MB, Slayton RL; American Academy of Pediatrics Section

9. US Department of Agriculture, Food and Nutrition Service. on Oral Health. Fluoride use in caries prevention in the primary
Child and Adult Care Food Program (CACFP): Child Day Care care setting. Pediatrics. 2014;134(3):626-633
Centers. http://www.fns.usda.gov/cacfp/child-day-care-centers. 26. Kramer MS, Kakuma R. Optimal duration of exclusive
Updated January 27, 2014. Accessed September 17, 2016 breastfeeding. Cochrane Database Syst Rev. 2012;(8):CD003517
10. Bailey LB, Rampersaud GC, Kauwell GP. Folic acid supplements 27. Overfield ML, Ryan CA, Spangler A, Tully MR. Clinical
and fortification affect the risk for neural tube defects, vascular Guidelines for the Establishment of Exclusive Breastfeeding.
disease and cancer: evolving science. J Nutr. 2003;133(6): Raleigh, NC: International Lactation Consultant Association;
1961S-1968S 2005. http://www.breastcrawl.org/pdf/ilca-clinical-
11. Centers for Disease Control and Prevention. Recommendations guidelines-2005.pdf. Accessed September 17, 2016
for the use of folic acid to reduce the number of cases of spina 28. Hale TW, Rowe HE. Medications and Mothers’ Milk 2014.
bifida and other neural tube defects. MMWR Recomm Rep. 16th ed. Plano, TX: Hale Publishing; 2014
1992;41(RR-14):1-7 29. Greer FR, Sicherer SH, Burks AW; American Academy of
12. Facts about folic acid. Centers for Disease Control and Pediatrics Committee on Nutrition, Section on Allergy and
Prevention Web site. http://www.cdc.gov/ncbddd/folicacid/ Immunology. Effects of early nutritional interventions on
about.html. Updated December 24, 2014. Accessed September the development of atopic disease in infants and children:
17, 2016 the role of maternal dietary restriction, breastfeeding, timing
13. Lumley J, Watson L, Watson M, Bower C. Periconceptional of introduction of complementary foods, and hydrolyzed
supplementation with folate and/or multivitamins for formulas. Pediatrics. 2008;121(1):183-191
preventing neural tube defects. Cochrane Database Syst Rev. 30. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation
2001;(3):CD001056 and risk factors for maternal cardiovascular disease. Obstet
14. Carlson SE. Docosahexaenoic acid supplementation in Gynecol. 2009;113(5):974-982
pregnancy and lactation. Am J Clin Nutr. 2009;89(2):678S-684S 31. Collaborative Group on Hormonal Factors in Breast Cancer.
15. American Academy of Pediatrics Section on Breastfeeding. Breast cancer and breastfeeding: collaborative reanalysis of
Breastfeeding and the use of human milk. Pediatrics. 2012; individual data from 47 epidemiological studies in 30 countries,
129(3):e827-e841 including 50302 women with breast cancer and 96973 women
16. Zeisel SH, da Costa KA. Choline: an essential nutrient for public without the disease. Lancet. 2002;360(9328):187-195
health. Nutr Rev. 2009;67(11):615-623 32. Bhatia J, Greer F; American Academy of Pediatrics Committee
17. Crossland DS, Richmond S, Hudson M, Smith K, Abu-Harb M. on Nutrition. Use of soy protein-based formulas in infant
Weight change in the term baby in the first 2 weeks of life. Acta feeding. Pediatrics. 2008;121(5):1062-1068
Pædiatr. 2008;97(4):425-429
191
BFG 4TH ED.indb 191 1/20/17 2:46 PM

33. Kleinman RE, Greer FR; American Academy of Pediatrics 51. Fox MK, Reidy K, Novak T, Ziegler P. Sources of energy and
Committe on Nutrition. Pediatric Nutrition: Policy of the nutrients in the diets of infants and toddlers. J Am Diet Assoc.
American Academy of Pediatrics. 7th ed. Elk Grove Village, IL: 2006;106(1 suppl 1):S28-S42
American Academy of Pediatrics; 2014 52. Fox MK, Pac S, Devaney B, Jankowski L. Feeding infants and
34. Mennella JA, Beauchamp GK. Mothers’ milk enhances the toddlers study: what foods are infants and toddlers eating? J Am
acceptance of cereal during weaning. Pediatr Res. 1997;41(2): Diet Assoc. 2004;104(1 suppl 1):S22-S30
188-192 53. Emond A, Emmett P, Steer C, Golding J. Feeding symptoms,
35. Forestell CA, Mennella JA. Early determinants of fruit and dietary patterns, and growth in young children with autism
vegetable acceptance. Pediatrics. 2007;120(6):1247-1254 spectrum disorders. Pediatrics. 2010:126(2):e337-e342
36. American Academy of Pediatrics Committee on Nutrition. 54. US Department of Agriculture. ChooseMyPlate.gov Web site.
The use and misuse of fruit juice in pediatrics. Pediatrics. 2001; http://www.choosemyplate.gov. Accessed September 17, 2016
107(5):1210-1213 55. Neumark-Sztainer D, Hannan PJ, Story M, Croll J, Perry C.
37. Li R, Fein SB, Grummer-Strawn LM. Do infants fed from bottles Family meal patterns: associations with sociodemographic
lack self-regulation of milk intake compared with directly characteristics and improved dietary intake among adolescents.
breastfed infants? Pediatrics. 2010;125(6):e1386-e1393 J Am Diet Assoc. 2003;103(3):317-322
38. Sampson HA. Update on food allergy. J Allergy Clin Immunol. 56. Munoz KA, Krebs-Smith SM, Ballard-Barbash R, Cleveland LE.
2004;113(5):805-820 Food intakes of US children and adolescents compared with
39. Fleischer DM, Spergel JM, Assa’ad AH, Pongracic JA. Primary recommendations [published correction appears in Pediatrics.
prevention of allergic disease through nutritional interventions. 1998;101(5):952-953]. Pediatrics. 1997;100(3 pt 1):323-329
J Allergy Clin Immunol Pract. 2013;1(1):29-36 57. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior
40. Boyce JA, Assa’ad A, Burks AW, et al. Guidelines for the surveillance—United States, 2011. MMWR Surveill Summ.
Diagnosis and Management of Food Allergy in the United 2012;61(4):1-162
States: summary of the NIAID-sponsored expert panel report. 58. Neumark-Sztainer D, Story M, Perry C, Casey MA. Factors
J Am Diet Assoc. 2011;111(1):17-27 influencing food choices of adolescents: findings from
41. Rerksuppaphol S, Barnes G. Guidelines for evaluation and focus-group discussions with adolescents. J Am Diet Assoc.
treatment of gastroesophageal reflux in infants and children: 1999;99(8):929-937
recommendations of the North American Society for Pediatric 59. Savage JS, Fisher JO, Birch LL. Parental influence on eating
Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. behavior: conception to adolescence. J Law Med Ethics.
2002;35(4):583 2007;35(1):22-34
42. Manikam R, Perman JA. Pediatric feeding disorders. J Clin 60. Larson NI, Neumark-Sztainer D, Hannan PJ, Story M. Family
Gastroenterol. 2000;30(1):34-46 meals during adolescence are associated with higher diet quality
43. Mills RJ, Davies MW. Enteral iron supplementation in preterm and healthful meal patterns during young adulthood. J Am Diet
and low birth weight infants. Cochrane Database Syst Rev. Assoc. 2007;107(9):1502-1510
2012;(3):CD005095 61. Kleinman RE, Greer FR; American Academy of Pediatrics

44. Devaney B, Ziegler P, Pac S, Karwe V, Barr SI. Nutrient intakes Committe on Nutrition. Fast foods, organic foods, fad diets, and
of infants and toddlers. J Am Diet Assoc. 2004;104(1 suppl 1): herbs, herbals, and botanicals. In: Kleinman RE, Greer FR, eds.
s14-s21 Pediatric Nutrition: Policy of the American Academy of Pediatrics.
45. Ross AC, Taylor CL, Yaktine AL, Del Valle HB; Institute of 7th ed. Elk Grove Village, IL: American Academy of Pediatrics;
Medicine Committee to Review Dietary Reference Intakes 2014:299-356
for Vitamin D, Calcium, Food and Nutrition Board. Dietary 62. Neumark-Sztainer D. Preventing obesity and eating disorders in
Reference Intakes for Calcium and Vitamin D. Washington DC: adolescents: what can health care providers do? J Adolesc Health.
National Academies Press; 2011 2009;44(3):206-213
46. Institute of Medicine Standing Committee on the Scientific 63. Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas
Evaluation of Dietary Reference Intakes. Dietary Reference KR. Prevalence and correlates of eating disorders in adolescents.
Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Results from the national comorbidity survey replication
Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714-723
DC: National Academy Press; 1998 64. Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality
47. Gidding SS, Dennison BA, Birch LL, et al. Dietary recommen in bulimia nervosa and other eating disorders. Am J Psychiatry.
dations for children and adolescents: a guide for practitioners: 2009;166(12):1342-1346
consensus statement from the American Heart Association. 65. Gomez J; American Academy of Pediatrics Committee on
Circulation. 2005;112(13):2061-2075 Sports Medicine and Fitness. Use of performance-enhancing
48. Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children substances. Pediatrics. 2005;115(4):1103-1106
and adolescents: pathophysiology, consequences, prevention, 66. Kleinman RE, Greer FR; American Academy of Pediatrics
and treatment. Circulation. 2005;111(15):1999-2012 Committe on Nutrition. Nutritional support for children with
49. Krebs NF, Jacobson MS; American Academy of Pediatrics developmental disabilities. In: Kleinman RE, Greer FR, eds.
Committee on Nutrition. Prevention of pediatric overweight Pediatric Nutrition: Policy of the American Academy of Pediatrics.
and obesity. Pediatrics. 2003;112(2):424-430 7th ed. Elk Grove Village, IL: American Academy of Pediatrics;
50. Slawson DL, Fitzgerald N, Morgan KT. Position of the Academy 2014:883-906
of Nutrition and Dietetics: the role of nutrition in health
promotion and chronic disease prevention. J Acad Nutr Diet.
2013;113(7):972-979
192
BFG 4TH ED.indb 192 1/20/17 2:46 PM

Promoting Healthy Nutrition

Uploaded by

Copyright:

Available Formats

Promoting Healthy Nutrition

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Promoting Healthy Nutrition

Uploaded by

Copyright:

Available Formats

Promoting Healthy Nutrition