Since 1995, children’s nutrition has received much attention. There are ongoing efforts to improve the quality of food and beverages offered in schools and there are some restrictions on advertising ‘junk food’ to young people. But have healthy-eating messages had any impact on toddlers’ diets? By the time you read this article, the first findings should be available from the new NDNS rolling programme,² which will give indications of toddlers’ eating habits. Sadly, however, it is unlikely that the new NDNS findings will demonstrate marked improvements in the nutritional quality of toddlers’ diets.

Toddlerhood marks an important phase when children move onto the full family diet and eating habits and preferences – both of which have considerable impact on both short- and long term health – are established.^3,4 This article reviews current knowledge about toddlers’ diets, outlines common nutrition-related problems and suggests ways that parents can increase the nutritional quality of meals and improve the overall health of their toddlers.

Issues and potential problems

Between 1 and 3 years, children continue to grow rapidly, therefore good nutrition remains essential for healthy physiological and mental development. During toddlerhood, personalities and food preferences come to the fore: what – and how – toddlers are fed impacts on many aspects of their future life and health.

Sadly, nutritional deficiencies appear to be widespread among toddlers. Several studies^1,5,6 show that essential micronutrient levels frequently fall below the daily recommended nutritional intake (RNI) (Table 1).⁷ Rates of conditions such as iron deficiency anaemia,⁵ rickets⁷ and obesity are increasing,¹ and poor diets put toddlers at considerable risk of long-term health problems.¹

A recent survey conducted by the Infant and Toddler Forum, involving 1000 mothers of children aged 9 months to 3 years,⁶ gave insight into nutritional knowledge and feeding patterns. Some of the findings were reassuring; others could be considered alarming (See Practical Advice and Insight box).⁶

Weaning and the family diet
One could be forgiven for being surprised that toddlers’ diets are so nutritionally inadequate, because the 2005 Infant Feeding survey reported notable improvements in weaning practices, compared with previous surveys.¹⁰ Fewer babies were given solids before 17 weeks, more babies received home-prepared foods, and more parents avoided salt, honey and potential allergens until the appropriate ages.¹⁰ Parents generally followed government guidelines and introduced a wide range of tastes and flavours during the early weaning stages, which should help to establish good eating patterns for later life.

However, the good work undertaken in the early weaning phase appears to stall in many households, when the older baby moves onto the family diet. Food diaries frequently indicate that a 1-year-old’s diet is nutritionally inferior to that consumed previously:¹¹ vegetable mashes, carrot sticks and commercially-made nutritionally balanced baby foods are replaced with oven chips, baked beans and ready-made pies. Fewer fruits, but more cakes, are consumed. Parents could argue that they are only following governmental guidance, by weaning their child onto family foods. The issue is that these foods are not always nutritious or healthy enough for the growing toddler. Some indications of what toddlers should (and shouldn’t) eat are given in the table below.

What the toddler should (and shouldn’t) be eating Family foods: Texture should be comparable to adult foods, but toddlers (and children) are not mini adults! Salt should never be added, and sugar should be used in moderation. Commercial toddler foods (e.g. those made by Cow&Gate) are specifically tailored to provide the child with nutritionally balanced meals. Discourage parents from relying on other commercially prepared foods (including sauces, gravy, soups and ready-meals), primarily because of the high salt content. Encourage the family to eat at least some meals with the toddler, ideally at a table, so that they develop social eating skills and focus on their food. Watch out for: foods marketed at families. Strict guidelines cover foods specifically developed for children under 36 months old. These guidelines do not cover ‘family’ foods such as breakfast cereals, dairy desserts and snack foods, which may contain ingredients that would be restricted in foods produced for children under 36 months old. Drinks: Encourage water rather than soft drinks (especially sugary drinks, which provide unnecessary calories). Discourage large volumes of drinks, which can curb appetite. To increase absorption of non-haem iron, offer unsweetened, diluted fruit juice with meals (1 full glass of fruit juice contributes to one of a child’s 5-a-day). Milk/dairy foods: Between 350 and 600 ml milk (or 3 servings of dairy produce) per day. Breastfeeding may continue. Growing-up milks have a better nutritional profile than unmodified cows’ milk and are particularly useful for toddlers who do not regularly consume a wide variety of foods, especially if they are at risk of iron, Vitamin D or other micronutrient deficiency. Watch out for: unmodified cows’ milk, which should not be consumed in excessive quantities because it restricts the appetite, may contribute to obesity and is of limited nutritional value. Protein: Consume a minimum of 1 portion per day from animal/fish source and 2 portions from vegetable sources. Because of its high iron content, regular consumption of lean meat, especially red meat, should be encouraged (unless there are cultural reasons for its omission). Oily fish (chopped texture) and pulses are also important for toddlers. Carbohydrate (starch): One serving at each meal. Encourage boiled foods (e.g. potato, whole-grain pasta, rice) and bread (especially whole-grain bread). Watch out for: pastry, crisps and savoury snacks, and fried carbohydrates. Discourage grazing on carbohydrate snacks. Instead, offer fruit or protein-based snacks (e.g dairy or hummus) between meals. Fruits/vegetables: 5 portions per day (a portion equals a child’s handful). Mix the colours, chop larger foods, include raw foods. Peel fruits/vegetables where necessary. Fibre: Children over 2 years of age should consume a minimum quantity of fibre equivalent to age plus 5g per day, not exceeding age plus 10g/day; in other words, a 2-year old should consume between 7 and 12g fibre per day. As a guide, a slice of wholemeal bread contains approximately 1.6g fibre. Watch out for: whole-grain and bran-based fibre or brown rice, which may reduce absorption of key micronutrients (especially iron, in children under 2 years old). Prebiotics: For optimum gut health and immune-system function, prebiotic supplementation through breast milk or infant formula are necessary for the first 6 months of life.12 Although the long-term health benefits of prebiotic supplementation are not clear, regular consumption beyond the first 6 months appears to help maintain a healthy balance of gut bacteria, which may offer protection against acute infection, food allergy and long-term inflammatory-mediated diseases.13

Why a good diet is important for life
There is unequivocal evidence that the quantity and quality of the diet in the early years affects the life-time risk of diseases such as asthma, diabetes, metabolic syndrome, atherosclerosis, and cancer.^14–18 The concept of ‘nutritional programming’ indicates that the pattern of future diet (and therefore health) is set before weaning, and that precursors of disease are found in children on suboptimal diets many years before clinical symptoms emerge.¹⁵ However very early nutrition is only one part of the process. Even those who receive optimal nutrition in their first year could still become obese (and risk poor long-term health) if diet and lifestyle become less healthy during toddlerhood.^19,20

Food, exercise, obesity and health
Obesity is increasingly reported in toddlers^1,5 but it is important to remember that toddler growth occurs in a cyclical fashion of fattening, growing in height, and slimming, with rapid weight gain being normal in the second year of life.³ Obesity, like any growth-related issue, may require more than one or two measurements of height and weight, because there are proven ethnic differences between body size, composition and fat distribution.²¹ The proportions of body fat and muscle change as the toddler becomes a more active child and develops new motor skills.³

Obesity is caused by many different genetic, environmental and social factors. For example:

• When one or both parents is obese, their children are at increased risk of becoming obese;^19,20
• Modern, predominantly ‘indoor’, urban living might predispose toddlers and children to a more sedentary lifestyle.^22,23

Although experts argue whether the link between sedentary behaviour and obesity is proven, one-fifth of all 2 to 5-year-olds in the UK is obese,²⁴ with most of the excess weight gained during the pre-school years.²⁵ The number of overweight or obese toddlers is expected to continue to rise,²² particularly as the new UK-WHO growth charts will reclassify up to 15% more young children into these categories.²⁶

On paper, the solutions to obesity are relatively simple: eat the right balance of foods and exercise regularly.²² Table 4 suggests a number of dietary tactics to try if a toddler is confirmed as obese.²⁷ Giving good advice on diet and lifestyle for children between 7 months and 10 years also reduces the long-term risk of obesity.²⁸ A pilot project called Fighting Fit Tots,²⁹ which is based on the MEND programme,³⁰ was devised to tackle parent and toddler health and nutrition, but needs wider testing.²⁹ Clearly, this is an area where health care professionals could make an impact, by developing free or subsidised services that encourage healthy eating and physical activity.²⁹

Other dietary problems in toddlers
Obesity is such a hot topic that other problems associated with poor diet and nutrition can easily be overlooked. Key areas are summarised below.

Sugar intake and dental caries
Dental caries continues to be a major nutrition-related problem in young children: rates of tooth decay increase from 4% in toddlers to 30% in 4-year-olds. Eighty per cent of children aged between 1.5 and 4.5 years obtain more than the recommended 10% of daily energy from non-milk sugar and added sugars,¹ although this survey demonstrated that dental caries have a stronger association with lower social class than with sugar consumption or tooth brushing.¹

The following factors have some association with higher rates of dental caries in toddlers:

• Grazing and snacking on high-sugar foods
• Consuming beverages that have a high sugar content
• Drinking from a bottle rather than a trainer cup.²²

Sugary foods have less impact when consumed with foods that reduce the risk of dental caries: for example, the rate of tooth decay does not increase when sugary breakfast cereals are eaten with milk.²²



Constipation
Toddlers commonly develop constipation because they have become fearful of defecation; lack of dietary fibre or low fluid intakes are secondary causes.²² Toddlers can usually consume sufficient dietary fibre from eating their 5-a-day fruits and vegetables, wholemeal bread, dried fruits, wholewheat cereals or porridge; high fibre diets are unnecessary, but it is important that they drink adequate fluids (at least six cups per day).²²

Faddy eaters and under-nourishment
Table 5 gives some simple techniques to try in fussy eaters, to help them achieve the correct nutritional intake. Faddiness may indicate an underlying health problem, therefore if simple measures fail, ensure that these children undergo thorough physiological and dietetic assessment so that signs of under-nourishment or illness can be identified and addressed. Tools are available for assessing undernourishment in children, such as the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP). Other resources such as Open Book on Growth develop professionals skills in child growth measurement and monitoring, so that they are better equipped to identify problems early.³³

Eating patterns and modern lifestyles
Perhaps the quality of the toddler diet has been hampered by changes that have altered the eating habits of many people in our society. Cooking from scratch is no longer the norm. Convenience foods are frequently the mainstay of home-prepared meals, perhaps because both parents need to work outside the home, many adults lack culinary skills and there is a widespread reliance on microwaves, freezers and take-away food outlets. In addition the nutritional balance of our diet has changed. In the mid 20^th century, for example, the average diet was considered to be nutritionally balanced, but the daily calorific intake was slightly higher, with greater quantities of animal products and starchy carbohydrates.^34,35 However, obesity rates were probably lower because daily life was more physically active, for many people. Since the late 20^th century, the modern ‘western’ family has become more reliant on labour-saving services at home, at work and when travelling, which reduces daily physical activity. In addition, the consumption of foods that are high in sugar and low in vitamins and minerals has increased.^1,36

Also, family eating patterns are affected by the pressures of modern life. Mealtimes rarely involve the whole family, grazing is more common than taking three meals per day, more meals are consumed in front of the television rather than at the dining table, more toddler meals are provided out of the home environment (e.g. at child-care facilities or restaurants), and some toddlers remain vulnerable to suboptimal eating patterns due to poor socio-economic conditions, poverty and parents’ lack of nutritional knowledge.^3,5

Lack of clear guidance
The Child Health Promotion Programme calls for health care professionals to give ‘advice and information on nutrition and physical activity for the family, and on healthy eating, portion size and mealtime routines.³⁷ However, few professionals receive adequate training to discuss child nutrition with parents, and there are no clear dietary guidelines for the under-3s. Several publications and websites such as EatWell³⁸ emphasize the importance of a healthy toddler diet, but give no information on what constitutes good nutrition and very little advice on portion size.^37–40 The Caroline Walker Trust has produced information about toddler nutrition, but this is not easy for professionals to interpret, let alone parents.⁴¹ For under-5s in day-care, there are no national standards to define nutritional intake (although there are advisory guidelines in Scotland). Obesity guidance from the National Institute for Health and Clinical Excellence provide some broad information that may be applied to children between 1 and 2 years of age, but again there is nothing to cover the transitory phase between weaning and family foods.⁴²

The Department of Health considers the publication Birth to Five as an excellent source of advice and it certainly gives guideline daily requirements for toddler meals.⁴³ However, research printed in a discussion document, Food and nutrition for the under threes, found that only 6% of parents were still using this publication: copies had often been lost.⁶


Summary and Conclusion

The toddlers’ diet requires special attention, from both parents and health care professionals. Parents may think they are acting correctly by offering family foods, but an over-reliance on processed or pre-prepared meals is unlikely to be nutritionally appropriate for toddlers, unless they have been manufactured specifically for children under 36 months of age.

Faddy eating and over-reliance on cows’ milk can often lead parents into dietary corners where alternative foods are refused and the child’s nutrient intake becomes compromised. Health care professionals can help by educating parents and involving dietetic, speech and language or psychology services if children do not respond to simple measures.

Perhaps we are missing the opportunity to educate, motivate and support parents to change their own eating habits during pregnancy and the weaning phase. What can we do to encourage more mums to turn half that batch of sweet potato and parsnip puree into a soup for their own lunch? How can we show parents that their children are far more likely to develop a life-long taste for broccoli if they eat it regularly as part of the family’s diet, not just as a finger food while they are weaning? The answers are not clear-cut, but unless parents look at what’s on their own plate, it will always be challenging for them to make sustained improvements to their children’s diets.

For more information visit (click each link to access)

DH Infant Feeding Recommendations
Infant & Toddler Forum

Cow & Gate Weaning Foods

For parents - for practical advice and information and advice on preterm babies and suitable products, visit the Cow & Gate website using this link:

Cow & Gate parents website – information about Cow & Gate products
References
1. Gregory J et al. (eds). National Diet and Nutrition Survey: Children aged 11⁄2 to 41⁄2 years. London: HMSO, 1995.
2. National Diet and Nutrition Survey. Will be available via
http://www.natcen.ac.uk/study/national-diet-and-nutrition-survey
3. Morgan J. Nutrition for toddlers: the foundation for good health. 1. Toddlers’ nutritional needs: what are they and are they being met? J Fam Health Care 2005; 15: 56–59.
4. Turnbull B et al. Toddler diets in the UK: deficiencies and imbalances. 1. Risk of micronutrient deficiencies. J Fam Health Care 2007; 17: 167–170.
5. Cowin I et al. Diet in a group of 18-month-old children in South West England, and comparison with the results of a national survey. J Hum Nutr Dietetics 2000;13: 87-100.
6. Food and nutrition for the under threes. A discussion document from the Infant & Toddler Forum 2009 http://www.littlepeoplesplates.co.uk/objects/pdf/food-and-nutrition-under3.pdf
7. Department of Health. Dietary Reference Values for Energy and Nutrients for the United Kingdom. Report on Health and Social Subjects No. 45. London: HMSO: 1991.
8. Scientific Advisory Committee on Nutrition. Update on Vitamin D Position statement by the Scientific Advisory Committee on Nutrition 2007 http://www.sacn.gov.uk/pdfs/sacn_position_vitamin_d_2007_05_07.pdf. Accessed 04 September 2009.
9. Department of Health. Weaning and the weaning diet. Report on health and social subjects no. 45. London: HMSO, 1994.
10. Infant feeding survey 2005. A commentary on infant feeding practices in the UK. http://www.sacn.gov.uk/pdfs/sacn_ifs_paper_2008.pdf. Accessed 05 September 2009.
11. Harris G, Grimshaw K. What you need to know about weaning. Family Health Care Bulletin. J Fam Health Care 2009; 19 (1): 1–4.
12. Arslanoglu S et al. Early supplementation of prebiotic oligosaccharides protects formula-fed infants against infections during the first 6 months of life J Nutr 2007;137:2420-2424.
13. Waligora-Dupriet AJ et al. Effect of oligofructose supplementation on gut microflora and well-being in young children attending a day care centre. Int J Food Microbiol. 2007; 113: 108-113.
14. Battista M et al. Use of the metabolic syndrome in pediatrics: a blessing and a curse. Semin Pediatr Surg 2009; 18: 136-143.
15. Singhal A. The early origins of atherosclerosis. Adv Exp Med Biol 2009; 646: 51-58.
16. Litonjua AA, Gold DR. Asthma and obesity: common early-life influences in the inception of disease. J Allergy Clin Immunol 2008; 121:1075-1084.
17. McMillen IC et al. The early origins of later obesity: pathways and mechanisms. Adv Exp Med Biol 2009; 646: 71-81.
18. Brawer R et al. Obesity and cancer. Prim Care 2009; 36:509-31.
19. Fuiano N et al. Prevalence and risk factors for overweight and obesity in a population of Italian schoolchildren: a longitudinal study. J Endocrinol Invest. 2008; 31: 979-984.
20. Butte NF. Impact of infant feeding practices on childhood obesity. J Nutr. 2009;139:412S-416S.
21. Deurenberg P et al. Differences in body composition between Singapore Chinese, Beijing Chinese and Dutch children. Eur J Clin Nutr. 2003; 57: 405–409.
22. Lanigan J et al. Toddler diets in the UK: deficiencies and imbalances. 2 Relationship of toddler diet to later health. J Fam Health Care 2007; 17: 197–200.
23. Healthcare Georgia Foundation. Progress in preventing childhood obesity: focus on communities. Available at: http://www.nap.edu/catalog.php?record_id=11580. Accessed 25 September 2009.
24. Cross Government Obesity Unit. Department of Health and Department for Children, Schools and Families. Healthy Weight, Healthy Lives: A cross-government strategy for England. London: COI, 2008.
25. Foresight Programme. Tackling obesities: Future choices - summary of key messages. London: HMSO, 2007.
26. Edmondson L. National Seminars and Workshops on the New UK-WHO Growth Standards. J Fam Health Care 2009, in press.
27. Poskitt EM. Nutrition in childhood. In: Morgan JB, Dickerson JWT (eds). Nutrition in early life. Chichester: John Wiley & Sons Ltd, 2003; p 305.
28. Hakanen M et al. Development of overweight in an atherosclerosis prevention trial starting in early childhood. The STRIP study, Int J Obesity (London) 2006; 30 (4) 618–26.
29. Wolman J et al. Tackling toddler obesity through a pilot community-based family intervention. Community Pract 2008; 81: 28-31.
30. Sacher PM et al. Assessing the acceptability and feasibility of the MEND Programme in a small group of obese 7-11-year-old children. J Hum Nutr Diet 2005; 18: 3-5.
31. Gibson EL, Wardle J. Energy density predicts preferences for fruit and vegetables in 4-year-old children. Appetite 2003; 41: 97-98.
32. Coulthard H et al. Delayed introduction of lumpy foods to children during the complementary feeding period affects child’s food acceptance and feeding at 7 years of age. Maternal and Child Nutrition 2009; 5: 75-85.
33. More J. Don’t forget the undernourished children in our midst. J Fam Health Care 2008; 18: 159-160.
34. Welch RW, Mitchell PC. Food processing: a century of change. Br Med Bull 2000; 56:1-17.
35. No author listed. Britain`s Post-war Diet Br Med J. 1954; 2: 1410-1411.
36. Zhou BF et al. Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: the INTERMAP study. J Hum Hypertens. 2003; 17: 623-30.
37. Shribman S, Billingham K. The Child Health Promotion Programme Guide. London: Department of Health, 2008.
38. http://www.eatwell.gov.uk/healthydiet/nutritionessentials/vitaminsandminerals. Accessed 05 September 2009.
39. Cross Government Obesity Unit. Department of Health and Department for Children, Schools and Families. Healthy Weight, Healthy Lives: A cross-government strategy for England. London: COI, 2008.
40. Department of Health, Department for Children, Schools and Families. Healthy lives, brighter futures – The strategy for children and young people’s health. London: COI, 2009.
41. Crawley H. Eating well for the under-5s in childcare. Practical and nutritional. 2nd Ed. St Austell: The Caroline Walker Trust, 2006.
42. National Institute of Health and Clinical Excellence. Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. London: NICE, 2006.
43. Department of Health. Birth to Five. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074924. Accessed 04 September 2009.