Nutrition for toodler

and pre school children

Mei Neni Sitaresmi
 Outline of lecture
Development of feeding
Dietary recommendation
Feeding guidness
Growth and nutrition assessment
Nutrition problem:
Feeding difficulties
Failure to thrive
malnutrition
Iron def. Anemia
 Development of feeding

Achieving independence and mastery

of feeding skills is an important
developmental task of early
childhood:
Promote self feeding and self regulation
 3 important developmental tasks
in the first 3 years of life
The regulation of eating, sleeping,
emotional
3 stages:
stage of regulation (0-2 months)
dynamic reciprocity (2-6 months)
Transition to self-feeding and regulation of
emotion (6 months 3 years)
continues dynamic interaction between
the child and the experience provided
by his or her family and social context
 1. Achieving Stage of regulation
(0-2 months)
Establish rhythms of sleep and weakness;
feeding (hunger and fullness) and elimination
Communicate to caregiver through crying:
hunger, pain, fear or tiredness caregiver
must learn to differentiate between
different type of crying
Caregiver: Sensitive and responsive
Achieve a state of calm alertness
fail: feeding disorder of state regulation
too irritable, Infantile colic
Conclusions: Persistence of crying beyond the first 6
months heralded a higher prevalence of eating or sleeping
difficulties in children with excessive crying than
in children without excessive crying. These parents
should be offered support and counseling over a broader
spectrum of features related to multiple regulatory
problems.

Arch Pediatr Adolesc Med. 2006;160:508-511

Excessive crying and eating difficulties - poor sleeping

Von Kries R, Kalies H, Papouek M. Exessive crying beyond 3 months may herald other
features of multiple regulatory problems. Arch Pediatr Adolesc Med 2006;160:508-11.
2. Achieving dynamic reciprocity (2-6
months)
Mature parents and child interaction:
mutual eye contact, reciprocal
vocalization, physical closeness express
through touching
If infant and caregiver are not
successfully engaged feeding
problem FTT, impair the infants
emotional and cognitive development
non organic failure to thrive
3. Transition to self-feeding and regulation of
emotion (6 months 3 years)
Dependency autonomy
Infant learn to differentiate between
hunger/ full and emotional experiences
(anger, frustration)
Parents should respond differentially:
Offering food when infant hunger, if the
child satiated do not insisting infant keeps
eating until the plate is empty
calming trough the tactile sensation
anorexia infantile
 Feeding development in the
second year
the progressive acquisition of motor skills and
eruption of the full complement of deciduous
teeth learn to feed independently and
make the transition to a modified adult diet
Skill:
Drinking from a cup
Self feeding: grasp food with their hands,
between the thumb and first finger; use their lips
to remove food from a spoon.
 Drinking from a cup
should be completely transitioned from the bottle
to the cup
should not sleep with a bottle: predisposes to
dental caries
large volumes of caloric beverages in a bottle may
lead either to overfeeding or to decreased solid
food intake and undernutrition
 Feeding behaviors at second year
Playing with food
Exploratory behaviors (touching, smelling, putting
the food in the mouth and spitting it out) may
precede acceptance or willingness to taste or
swallow new foods
Decrease in dietary variety
resistant to trying new foods offer new foods
several times (as many as 8 to 10) before
concluding that the child will not accept them
Initiating adult food risk of chooking
 3 year old
Influence by environment:
Structure and routine for all eating occasions are
important
The meal environment should be free from
distractions
Limited attention span exploring the
enviroment
 more effective communication Language is
important.
Sitting with the family during meals provides
an opportunity for caregivers to model healthy
eating behaviors and choices
Peers become increasingly important. Most
preschoolers enjoy sharing food with friends
 Caregiver responsibilities
Providing a variety of nutritious foods
Defining the structure and timing of meals
Creating a mealtime environment that
facilitates eating and social exchange (eg, free
of distractions)
Recognizing and responding to the child's
signals of hunger and fullness
Modeling healthy eating behaviors (eg,
consuming a varied diet)
encourage physical activity and Limit TV time
 Key issues for toddlers and
preschool children
the transition to cup and utensil feeding
fluctuations in appetite
achieving adequate iron and zinc intake
avoiding overconsumption of juice and
sweetened beverages
developing routines for healthy eating and
activity
 appetite
fluctuating from day to day: depending on
their rate of growth and level of physical
activity.
Children are able to decide how much food
they need if allowed to eat to appetite,
encourage parents to allow this.
Many parents find their children eat better at
certain times of the day.
 Children commonly eat small amounts of
foods, frequently, due to their small stomach
capacity.
Forcing children to clean the plate or giving
sweets as rewards may lead to problems of
overeating later on.
Dietary recommendation
 Key recommendation
Start with healthy eating for infants
Offer a wide variety of foods
Offer suitable sized portions
Offer healthy food choices and tooth-friendly drinks
Accommodate special food needs of individual
children
Plan healthy, varied meals and snacks
Help children learn to eat
Foster good dental health
Prepare food in a clean and safe way
 Offer a wide variety of food

Foods and beverages should contain or be prepared with little

added salt, sugar, or caloric sweeteners.
 Fat and cholesterol:
1 to 2 years: are not restricted.
2 to 3 years: 30 to 35% of total energy intake;
saturated fats <10% , <300 mg/day; trans fats
should be as low as possible.
Meat/protein
Select and prepare meat, poultry, fish, and dried
beans with as little fat as possible.
 Fruits and vegetables

A colorful variety of fruits and vegetables

should be offered each day.
Whole fruit is preferred to fruit juice, but one-
half of the recommended daily servings can be
provided in the form of 100 percent fruit juice.
Consumption of 100 percent fruit juice should
be limited to 4 to 6 ounces in children aged 1
to 6 years and 8 to 13 ounces in children older
than 7 years.
 Grains
At least one-half of total grains consumed should
be whole grains.
Cow's milk
1 to 2 years: 1 to 2 cups of whole milk per day (or
equivalent products).
2 to 8 years: 2.5 to 3 cups of fat-free or low-fat
milk per day (or equivalent products).
 Snacks and beverages
Healthy Snacks are an essential component of
the young child's diet. Healthy snacks should
be planned
fresh fruit, cheese, whole-grain crackers, bread
products, milk, raw vegetables, sandwiches,
peanut butter, and yogurt
 beverages
soft drinks and other sweetened beverages
should be discouraged a major source of
added sugar in the diet. Their consumption is
associated with lower intake of key nutrients
(particularly calcium) because they generally
are consumed instead of milk
 Frequency of feeding
toodler should be fed four to 6 times per day:
3 meals and 2-3 snack
Planed-healthy snacks are an essential
component of the young child's diet total
energy
Tips for safe food handling to avoid
food poisoning
Purchase:
Do not buy canned goods that are dented, cracked
or have a bulging lid
Make sure meat and poultry products are
refrigerated when purchased.
Use plastic bags to keep drippings from packages
of meat and fish from contact with other foods
Store perishable items in the refrigerator within
one hour of purchase
 Storage

home refrigerator 0 and 4C and freezer -

18C
Freeze meat and poultry that will not be cooked
within 48 hours.
Freeze tuna, bluefish and mahi-mahi that will not
be cooked within 24 hours; other fish can be
stored in the refrigerator for 48 hours.
Do not store eggs on the refrigerator door
(warmest part of the refrigerator).
 Refrigerate cooked foods within two hours of
preparation.
Divide leftovers into small portions and store
in shallow containers.
Reheat leftovers to 74C
 Preparation
Wash hands with soap and water before food
preparation and after handling raw meat,
poultry, fish, and uncooked eggs.
Thaw frozen meats and fish in the refrigerator
or microwave, not at room temperature.
keep foods in the refrigerator, not at room
temperature.
Avoid contact of cooked foods with
contaminated plates, or food preparation
surfaces.
 Wash plates and cutting surfaces with soap
and water after contact with raw meat,
poultry, fish or eggs.
Avoid contact of juices from uncooked meat,
poultry, or fish with cooked foods or foods
that will be eaten raw.
Thoroughly wash all fresh fruits and
vegetables.
Avoid recipes using raw eggs
 Cooking

cook beef and lamb to an internal

temperature of 63C, pork and ground beef
to 160F (71C), and poultry 77 to 82C).
Cook eggs until the yolk begins to harden.
 Serving

Serve cooked products on clean plates with

clean utensils.
Keep hot foods at 60C and cold foods below
4C.
Never leave foods at room temperature longer
than two hours (one hour if the ambient
temperature is 32C
Use coolers and ice packs to transport
perishable foods away from home
 Feeding guidess:
Help children learn to eat
 Feeding guideline for parents
1. How to facilitate the awareness of hunger:
Feed the child at regular times and space meals
and snacks 3-4 hours apart to allow the child to
feel hungry
Do not allow the child to have snack, juice or milk
between regular times
 Feeding guideline for parents
2. How to facilitate the awareness of fullness
serving small portion and allowing to ask the
second, third and forth helpings
Teach the child to sit at table until the other
family are full
 Feeding guideline for parents
3. How to help child to differentiate
physiological feeling of hunger from emotional
experience
Dont use food as present/ reward for comfort
or as an expression of affection
later they will eat those food for emotional
reasons
 Feeding guideline for parents
4. Meal should no longer than 20- 30 minutes
even if the child has eaten very little or
nothing
5. Praise the child for self-feeding skill
6. Make mealtimes fun, make food look
interesting - colours, taste and textures are
very important
7. Dont force a child to eat or to clear their
plate of food.
 Feeding guideline for parents
Dont allow distractions (toys, TV)
during meals when distracted child
dont pay attention to their inner signals
of hunger and fullness
Discourage the child from playing the
food instead of eating during mealtime
have a special playtime outside of
mealtime
 Foster good dental health
Reduce the frequency and the amount of
contact that sugary foods and drinks have with
teeth and offer with meals - not between
meals
Encourage calcium rich foods, for example,
milk, cheese and yogurt. These foods will
protect and help to build strong teeth.
Give milk and water as between meal drinks,
these are the most tooth-friendly drinks
Encourage a feeding cup bottle-feeding
should be stopped from the age of 12 months
 Investigate:
History:
emphasize on feeding behavior and food intake
including parents feeding behaviour
prematurity, SMK
Examination:
organic etiology
genetic syndrome
sign of abuse and neglected
Observation: Child-parent interaction
Development: gross- fine motoric, personal-social,
language, cognitive
 Anthropometric:

WHO 2006
Weight for age; height for age; weight for height;
BMI for age; head circumference for age
Mid-parental height calculation:
Growth : FTT?
 MIDPARENTAL HEIGHT
(Target height/ Tinggi potensi genetik)

boys =
parental height + (maternal height + 13)
2
girls =
(parental height - 13) + maternal height
2
+ secular trends (+ 3-5 cm)
7,5 cm
 Masing-masing organ
memiliki
pertumbuhan yang
berbeda: 4 pola
pertumbuhan:
pertumbuhan umum
Pertumbuhan organ
limfoid
Pertumbuhan otak
dan kepala
Pertumbuhan organ
reproduksi
Grafik anak laki-laki 0-24 bln Grafik anak perempuan 0-24bln
Linear growth
 INTERPRETING GROWTH INDICATORS

Notes:
1. A child in this range is very tall. Tanness is rarely a problem, unless it is so excessive that it may indicate endocrine such as a growth-
hormone-producing tumor. Refer a child in this range for assessment if you suspect an endocrine disorder (e.g. If perents of normal height
have a child who is excessively tall fot his or her age)
2. A Child whose weight-for-age falls in this range may have a growth problem, but this is better assessed from weight-length/heoght or BMI-
for Age.
3. A plotted point above 1 shows possible risk. A trent toward the 2 z-score line show definite risk
4. It is possibke for a stunded or severely stunded child to become overweight
 Approach of Management
Focus on educating parents about
appropriate expectations for feeding,
growth, and nutrition
basic feeding principles and underscore the
importance of applying these principles
consistently.
Nutritional supplement may be offered
to reduce coercive or forceful feeding
practices
Management: infantile anorexia
Explain childs temperament
Increase feeling of hunger and fullness:
Feed the child at regular 3-4 hour intervals
and not to offer any snack, milk or juice in
between
Offer very small portion and allow her to
ask for 2nd, 3rd, 4th helping
Keep the child in the high chair until
parents is full
Meal should last no longer than 20-30
minutes
 The feeding guidelines for
parents
DO not offer more than 3 different
food at one meal
Praise the child for self feding skill, but
keep a neutral attitude of the child
food intake. The parents should not praise or
critie the child for how much or little the child is
eating
During feeding, there should not any
toys or TV to distract the child
The child should be refocused when they engage in
distracing conversation during mealtimes
 Feeding guideline for parents
If the child gets up from the chair or
throws food or misbehaves

give her only one warning.

If she does not stop the behaviour give

her time-out
 Time out procedure
Should not be a punishment
To help the child to:
Learn calm himself
Self regulate emotions and behaviour
develop inner controls
Before the procedure, the caregiver
should explain to the child what will
happen during the time-out
 The child should be put in time-out in a
safe place, where the child is alone and
does not see the parents
The time-out begins only after the child
has calmed herself:
If the child cries, wait until he has calmed.
Dont interact with the child while he is
crying or talking
 After he has calmed, go in and tell the child
that you:
understand that it was very difficult for
him, and you are proud of him
Want him to stay calm and think about what
he did wrong
Then set the alarm (about 1 minute for each
age).
After the alarm has gone off, praise the
child, ask he to correct the behaviour
 If the child is still angry and misbehaves
again, repeat the procedure until the child
complies.
Dont take the child from the time-out when
is crying
Dont stop the procedure until the child
complies
 Systematic introduction of new food items

Serve minimal quantities, one food

Expose the child to the food repeatedly
(10 to 15 times), possibly first on the
parents plate.
Try leaving the food within reach
without necessarily offering it.
 Systematic introduction of new food items

Parents model the consumption with obvious

pleasure and without offering the food until
the childs fear abates and he or she
expresses an interest in the food.
If exposure causes gagging or vomiting,
withdraw the food and try something that
more closely resembles a preferred food.
Mix very small amounts of the new food with
the accepted food and gradually shift the
ratio.
Parents must also remain neutral and relaxed
about the childs intake.
 Approach to management
Desensitize the relatively mild cases by taking
advantage of the childs propensity to feed when half
asleep and relaxed and avoiding the need to feed
while the patient is awake and stressed at the sight
of food.
If the child fears the bottle, offer a sippy cup or
spoon instead.
Ensure that feedings are not threatening or coercive.
Tube-dependent children may benefit from a
multidisciplinary feeding disorders team approach
designed to enhance oral motor skills while
systematically cutting back on enteral tube feedings.