INTRODUCTION — The feeding development, nutritional requirements, and dietary guidelines for toddlers (12 to 24 months), preschool, and school-age children will be discussed here. Nutritional needs of infants are discussed separately. (See "Introducing solid foods and vitamin and mineral supplementation during infancy".)
FEEDING DEVELOPMENT — Achieving independence and mastery of feeding skills is an important developmental task of early childhood [1,2]. Allowing the child to self-feed promotes and reinforces self-regulation of intake.
Toddlers — During the second year of life, most children acquire sufficient motor skills and a full complement of deciduous teeth, which allow them to feed themselves independently and make the transition to a modified adult diet [2]. As dietary preferences and patterns continue to be established, it is important to ensure adequate intake of iron and zinc [1].
The growth rate and appetite decrease after the first birthday. Toddlers may eat variable quantities at any given meal. they also may choose from a small variety of foods [3,4]. These behaviors are to be expected [2,3].
Feeding development — Feeding development during the second year includes acquisition of the following skills [1,5]:
●Drinking from a cup – The use of a training cup can begin as soon as the child is able to drink from a training cup (usually before 12 months of age). By 15 months of age, children can manage a cup by themselves but will continue to spill; by 18 to 24 months of age, cup manipulation is improved, and spills occur less frequently.
Toddlers should be completely transitioned from the bottle to the cup by two years of age (ideally by 15 to 18 months). Infants and toddlers should not sleep with a bottle. Drinking from a bottle predisposes to dental caries, particularly if the bottle is taken to bed or sipped throughout the day. (See "Preventive dental care and counseling for infants and young children", section on 'Dietary habits'.)
In addition, supplying large volumes of caloric beverages in a bottle may lead either to overfeeding or to decreased solid food intake and undernutrition. Continuing to use a bottle at two years was associated with obesity at 5.5 years in a longitudinal cohort study [6]. Prolonged bottle feeding has also been associated with iron deficiency anemia due to excessive intake of cow milk and/or reduced intake of iron-rich foods [7,8].
●Self-feeding – During the second half of the first year, infants learn to grasp food with their hands (palmar grasp) and then between the thumb and first finger (pincer grasp); they can use their lips to remove food from a spoon. By 16 to 17 months of age, they can use their hands to transfer food from a bowl to their mouth, because of improved wrist rotation.
●By 24 months of age, most children are ready to consume an adult diet (with modifications to prevent choking). (See 'Choking' below.)
Children who have developmental delays may not master feeding skills at the same pace as typically developing children; prolonged use of a bottle or persistent finger feeding may be necessary to ensure adequate dietary energy and nutrient intake.
Feeding behaviors — The acquisition of healthy feeding behaviors is dependent upon the interaction of several factors. These include child-specific elements, such as developmental maturation, temperament, personal experiences, and medical needs, as well as environmental considerations, like family dynamics, ethnic dietary practices, and food accessibility. A feeding problem can result from any of these factors [9].
Normal toddler feeding behaviors include [1,2]:
●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 [10].
●Decrease in dietary variety (feeding "jags") – Beginning at approximately two years of age, toddlers may become resistant to trying new foods; they may choose to eat only a small number of well-accepted favorites [3,4]. It may be necessary to offer new foods several times (as many as 8 to 10) before concluding that the child will not accept them [2,11,12].
Young children generally can self-regulate energy intake [3,13]. However, self-regulation may be overridden if eating behaviors are driven by factors other than hunger and fullness (eg, coercive feeding, restriction of intake, environmental cues to eat) [14,15].
Preschool children — By three to four years of age, children can handle utensils and cups efficiently and can sit at the table for meals [2]. They are better able to protect their airways and can safely consume the small, round, hard foods that previously posed a choking hazard. (See 'Choking' below.)
Preschool children are more aware of the feeding environment than younger children, and environmental cues affect their food selection and intake patterns [2]. Environmental cues include time of day, portion size, restriction of food or pressure to eat, the preferences and eating behaviors of others, and packaging (eg, the presence of licensed characters on the package) [16,17]. (See 'Eating environment' below.)
Preschool children may have unpredictable interest in eating [2]. Their ability to sit at the table may be limited by their attention span. However, they should be encouraged to sit with the family for a reasonable period of time (eg, 15 to 20 minutes) during meals, even if they choose not to eat. Sitting with the family during meals provides an opportunity for caregivers to model healthy eating behaviors and choices.
School-age children — School-age children can understand basic nutrition concepts [2]. They can help with meal planning, food preparation, and mealtime chores (eg, setting the table) [1].
School-age children have more freedom over their food choices; many eat at least one meal per day away from home. Allowing them to participate in food choices at home and providing positive reinforcement when they make healthy choices may help them to make healthy choices away from home.
School-age children also are more aware of their body weight and shape than when they were younger. The food attitudes and choices of school-age children may be influenced (positively or negatively) by family members, friends, nonfamily members, and/or the media [18-20]. Body image concerns and societal attitudes may affect the energy intake and nutritional status of older children. Caregivers may need to balance potentially negative influences by increasing positive influences in the home (eg, by making healthy choices themselves during family meals, increasing reinforcement when the child makes healthy choices, and setting an example).
EATING ENVIRONMENT — The eating environment is a critical factor in the development of healthy eating behaviors [2]. Structure and routine for all eating occasions are particularly important. The meal environment should be free from distractions. Eating should occur in a designated area, and the child should have a developmentally appropriate chair.
Family meals provide an opportunity for children to learn healthy eating habits and begin to appreciate the social aspects of eating. In a 2011 meta-analysis of observational studies, children and adolescents who shared meals with their family ≥3 times per week were more likely to be of normal weight and have healthy dietary and eating patterns, and less likely to engage in disordered eating than those who shared <3 family meals per week [21]. In a subsequent prospective study, family meals of any frequency were associated with decreased risk of overweight and obesity in young adulthood [22].
The responsibility for establishing a healthy eating environment is divided between the child and the caregivers. The division of responsibility is based upon the child's ability to regulate intake and inability to choose a well-balanced diet [2,13,23].
Caregiver responsibilities include [1,2]:
●Providing a variety of nutritious foods (see 'Dietary framework' below)
●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)
The child's responsibilities include choosing what and how much of the foods offered by the caregiver to consume.
Caregivers should understand that resistance to trying new foods and eating only a small number of favorite foods are normal stages of child development [2]. Attempts to control the child's eating (eg, by pressuring them to eat specific foods or clean their plate, bribing, restricting foods) may make the child less sensitive to physiologic cues of satiety and hunger and contribute to overeating [2,24-26]. (See 'Toddlers' above.)
DIETARY FRAMEWORK
Energy and macronutrient balance — Energy and nutrient requirements for children vary depending upon age, sex, and activity level (table 1). MyPlate is an interactive website that provides individual dietary guidance according to these parameters. (See 'Resources' below.)
●Energy – Energy is provided through three primary macronutrients: protein, fat, and carbohydrates. Energy intake is influenced by the number of meals and snacks that are eaten during the day, the energy density of foods consumed, and portion size.
●Macronutrient balance
•Protein – Recommended protein intake varies with age [27,28] (see 'Meat and protein-containing foods' below)
-Age 1 to 3 years – Protein should constitute 5 to 20 percent of total energy intake
-Age 4 to 18 years – Protein should constitute 10 to 30 percent of total energy intake
•Fat – Fat should constitute at least 20 percent of total energy intake. The recommended intake of fat and cholesterol varies with age [2,28-30]:
-Age 1 to 2 years – Dietary fat is not restricted
-Age 2 to 3 years – 30 to 40 percent of total energy intake
-Age 4 to 18 years – 25 to 35 percent of total energy intake
Essential fatty acid intake, primarily as linoleic and linolenic acid, should be 3 percent of total daily energy intake.
•Carbohydrates – Carbohydrates are an important source of energy and support the transport of vitamins, minerals, and trace elements. Adequate carbohydrate intake contributes to sufficient intake of dietary fiber, iron, thiamine, niacin, riboflavin, and folic acid. Carbohydrates should constitute 45 to 65 percent of total energy intake [27,28,31]. Added sugars are discussed below. (See 'Added sugars' below.)
Micronutrients — Micronutrients include vitamins, minerals, and trace elements. Dietary Reference Intakes for micronutrients are available through the United States Department of Agriculture National Agricultural Library [32]. (See "Dietary history and recommended dietary intake in children", section on 'Dietary reference intakes'.)
Frequency of feeding — Most young children should be fed four to seven times per day [2]. Snacks are an essential component of the young child's diet. (See 'Snacks' below.)
●Toddlers eat an average of seven times per day, with snacks accounting for approximately one-fourth of daily energy intake [33].
●Preschool children generally eat three meals and several small snacks per day.
●School-age children typically eat fewer meals and snacks per day than younger children, although they may continue to have a snack after school [2]. Children who skip breakfast tend to consume less energy and fewer nutrients than those who eat breakfast [34,35].
Portion size — The appropriate portion size varies with the child's age and the particular food (table 2 and table 3).
Serving children portions that are larger than recommended for their age may contribute to excessive energy intake and weight gain. In a crossover study, preschool children who were repeatedly exposed to large portions (two times the size of an age-appropriate portion) during a series of lunches increased their total energy intake at lunch by 15 percent and their entrée intake by 25 percent [36]. When permitted to select their own portion size, they consumed 25 percent less of the entrée than when served the large portion.
DIETARY COMPOSITION
General guidance — General guidance regarding dietary composition is provided in the table (table 4).
Young children have the innate ability to adjust their energy intake to the energy density of their diet but not to choose a well-balanced diet [3,4,24,37]. They depend upon caregivers to offer them a variety of nutritious, developmentally appropriate foods to meet the recommended number of servings per day (table 2) [23]. Similarly, caregivers should offer older children a variety of nutrient-dense foods from the basic food groups each day (table 3). Foods and beverages should contain or be prepared with little added salt, sugar, or caloric sweeteners [2,29,30,38].
Meat and protein-containing foods — When choosing and preparing meat, poultry, and other high-protein foods, make choices that are lean, low-fat, or fat-free.
An estimated 65 to 70 percent of protein intake should come from sources of high biologic value, typically animal products, which contain a full complement of essential amino acids. Animal products are not necessary to provide optimal protein, but most alternative sources from plants (eg, legumes, grains, nuts, seeds, and vegetables) do not contain a full complement of essential amino acids, and therefore greater dietary planning is required for diets without meat. (See "Vegetarian diets for children", section on 'Protein'.)
The AHA recommends two servings of fish/shellfish per week, not including commercially prepared fried fish/shellfish, since these products may be high in trans fats and relatively low in omega-3 fatty acids [38,39]. The US Food and Drug Administration (FDA) and the Environmental Protection Agency recommend that children eat one to two servings of fish/shellfish per week [40]. The serving size is measured before cooking and should be appropriate for the child's age and energy needs:
●2 through 3 years – Approximately 1 ounce (28 g) per serving
●4 through 7 years – Approximately 2 ounces (57 g) per serving
●8 through 10 years – Approximately 3 ounces (85 g) per serving
●≥11 years – Approximately 4 ounces (113 g) per serving
The fish should be low in mercury (eg, shrimp, canned light tuna, salmon, pollock, tilapia, crab, haddock, lobster, catfish, and cod) [38,40]. Consumption of fish with higher levels of mercury (eg, shark, marlin, swordfish, king mackerel, bigeye tuna, and Gulf of Mexico tilefish [sometimes called golden bass or golden snapper]) should be avoided (table 5) [38,40].
Many sources of protein are also common allergens (eg, milk, eggs, soy, fish, shellfish, peanuts, and tree nuts). Insuring adequate protein intake in children with food allergies is discussed separately. (See "Management of food allergy: Nutritional issues", section on 'Protein'.)
Fat and cholesterol-containing foods — Dietary fat is an important source of energy, supports the transport of fat-soluble vitamins, and provides the two essential fatty acids, alpha-linolenic acid (ALA, omega-3 group) and linoleic acid (LA, omega-6 group).
Most fats should come from polyunsaturated and monounsaturated fatty acids rather than trans or saturated fatty acids (table 6) [29,30,41]. For children older than two years, saturated fats should make up less than 10 percent of total energy intake, and the intake of trans fats should be as low as possible. A diet in which saturated fats make up less than 10 percent of total energy intake will also be low in cholesterol.
The types of dietary fat are discussed separately. (See "Dietary fat".)
Fruits, vegetables, and fruit juice — A colorful variety of fruits and vegetables should be offered each day (table 2 and table 3). Strategies that caregivers can use to increase fruit and vegetable consumption include [42]:
●Provide "hands on" experience with fruits and vegetables through gardening, grocery shopping, and cooking
●Involve children in the selection and preparation of fruits and vegetables
●Cut fruits and vegetables into shapes that the child can dip
●Expose children to a variety of fruits and vegetables
●Be a role model by eating fruits and vegetables for snacks and during meals
●Make fruits and vegetables more accessible
●Add vegetables to sandwiches, pasta, chili, soups, casseroles, and pizza
●Add fruit to cereal or pancakes
●Provide fruits and vegetables as snacks
●Provide repeated exposure and tell the child what the food does for the body (eg, "this will help you grow big and strong") [43]
Low-quality evidence from randomized trials and observational studies suggests that child-feeding practices (eg, repeated exposure, provision of rewards, serving methods) and multicomponent interventions may have a small effect on child fruit and vegetable consumption [44,45].
We encourage consumption of whole fruit rather than fruit juice [46]. No more than one-half of the recommended daily servings of fruit should be provided in the form of fruit juice [47]. Age-appropriate limits for 100 percent fruit juice are as follows:
●One through 3 years – 4 ounces (120 mL)
●Four through 6 years – 4 to 6 ounces (120 to 180 mL)
●≥7 years – 8 ounces (240 mL)
Fruit juice that is offered to children should be 100 percent fruit juice rather than "fruit drinks" [47]. It should also be pasteurized; unpasteurized fruit juice may contain pathogens (eg, Escherichia coli O157:H7). Fruit juice should be offered as part of a meal or snack and not sipped throughout the day; it should not be consumed at bedtime or in bed. (See "Preventive dental care and counseling for infants and young children", section on 'Dietary habits' and "Causes of acute infectious diarrhea and other foodborne illnesses in resource-rich settings".)
Whole fruit is preferred to fruit juice because fruit juice generally lacks the fiber of whole fruit and provides no nutritional advantage [47]. Although calcium-fortified juices provide a bioavailable source of calcium, they lack other nutrients present in cow milk and fortified plant-based milks (eg, protein, magnesium). Overconsumption of fruit juice may be associated with dental caries, diarrhea, bloating, excessive flatulence, abdominal distension, undernutrition, and overnutrition [48-53]. However, consumption of 100 percent fruit juice within the recommended limits does not appear to be associated with weight gain. In a meta-analysis of eight prospective cohort studies including 34,470 children older than one year, one daily serving of 100 percent fruit juice was not associated with clinically significant weight gain [54].
Grains — At least one-half of total grains consumed should be whole grains. Whole grains contain the bran, germ, and endosperm. Examples of whole grains include whole or cracked wheat, oats or oatmeal, rye, barley, corn, brown or wild rice, and quinoa. Whole grains are an excellent source of fiber, plus several B vitamins, iron, magnesium, and selenium.
Fiber — The optimum intake of dietary fiber for infants and children younger than two years of age is not known. Studies of weaning diets with the gradual introduction of solid foods, including increased fiber, suggest that an intake of 5 g per day is beneficial provided the children ingest adequate calories, vitamins, and minerals [55,56].
For children older than two years, a safe range of fiber intake equals the age (in years) plus 5 to 10 g per day (maximum 30 g per day) [31,57,58]. This goal is best met by eating a variety of fiber-rich fruits, vegetables, cereals, and whole-grain products (table 7) [28]. One-half cup (approximately 120 mL) of vegetables or one piece of fruit provides approximately 3 g of fiber. Fiber helps prevent constipation. High-fiber diets are associated with lower visceral fat mass in adolescents and beneficial gastrointestinal microbiota [59,60].
Dairy products — Dairy products include milk and milk products that come from animals, most often cows and goats. Nondairy milk alternatives (ie, plant-based milks) are not "milk" per se, but extracts derived from plant sources. They are discussed below. (See 'Beverages' below.)
●Milk
•12 to 24 months – Children between 12 and 24 months of age generally should drink whole unflavored cow milk (rather than skim milk, 1 percent milk, or 2 percent milk, or toddler formulas) unless they have cow milk allergy or intolerance [46]. However, if the child's overall diet supplies 30 percent of energy intake from fat, a decision to use reduced-fat milk for children between 12 and 24 months of age may be made on a case-by-case basis by the caregivers and pediatric health care provider, as recommended by the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents [28]. Factors to be considered in the decision include the child's growth, appetite, intake of other nutrient-dense foods, intake of other fat sources, and potential risk for obesity and cardiovascular disease.
Children between 12 and 24 months of age should consume at least 2 cups (each cup equals 8 ounces [approximately 240 mL] and contains approximately 300 mg of calcium) per day and eat foods rich in calcium to meet their daily calcium requirement (700 mg/day). Excessive milk intake can displace the desire for foods that fulfill nutritional requirements (eg, iron). (See "Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis".)
•≥24 months – Children older than two years should consume fat-free (skim) or low-fat cow milk (1 percent milk, 2 percent milk), calcium- and vitamin D-fortified soy milk, or equivalent cow milk or fortified soy milk products (eg, yogurt, cheese). However, switching from whole milk to fat-free or low-fat milk is not sufficient to prevent obesity or lower body mass index if total daily energy intake exceeds metabolic needs [61-65].
Children between two and eight years should consume at least 2 to 3 cups (approximately 480 to 720 mL) per day and eat foods rich in calcium to meet their daily calcium requirement (700 mg/day for children one to three years and 1000 mg/day for children four to eight years) [66].
Children and adolescents 9 to 18 years should consume at least 3 cups (approximately 720 mL) per day and eat foods rich in calcium to meet their daily calcium requirement (1300 mg/day) [66].
●Yogurt – When substituting yogurt for cow milk, caregivers should review the nutrition label to make sure that it contains an equivalent amount of calcium, vitamin D, and other nutrients, without too much added sugar. The nutrient profile of yogurt has changed over time. A variety of yogurt products are available, including products with low fat or no fat; reduced sodium or sugar; protein or calcium fortification; "mix-ins" (eg, fruit, nuts, granola, candy), etc [67]. Many of the available products contain only one-half to two-thirds of the calcium in an equivalent volume of milk; some are not fortified with vitamin D. Flavored yogurts may contain two to three times the amount of natural sugars in plain yogurt.
Snacks — Snacks are an essential component of the young child's diet. Healthy snacks should be planned so they contribute to the day's total nutrient intake (table 1) [2].
Healthy snacks include fresh fruit, cheese, whole-grain crackers or bread products, milk, raw vegetables, sandwiches, peanut butter, and yogurt, and may include a limited quantity of 100 percent fruit juice [2].
Added sugars — Added sugars include sugars and syrups that are consumed directly (eg, candy, cookies) or added during preparation and processing (eg, high fructose corn syrup) or before consumption of food and beverages (eg, sugar, honey, maple syrup, agave nectar, malt syrup) [68,69]. Added sugars have been associated with increased risk factors for cardiovascular disease (eg, increased adiposity and dyslipidemia) and dental caries [70,71].
The AHA recommends that [38,70]:
●Children <2 years of age avoid added consumption of sugars
●Children ≥2 years of age limit consumption of added sugars to ≤25 g (approximately 100 kilocalories or 6 teaspoons)
This limit is based upon the recommendation in the 2005 Dietary Guidelines for Americans to limit discretionary kilocalories (ie, those available for consumption as added sugars or solid fats after essential daily nutrient requirements are met) to 6 to 10 percent of total daily energy intake [72]. The 2020 Dietary Guidelines suggests that added sugars be limited to <10 percent of total daily energy intake [30].
The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition provides similar recommendations [73]. Studies evaluating added sugars in children are limited [70]. Pending additional information, these consensus guidelines seem reasonable.
Beverages
●Plain water – In addition to unflavored cow milk, plain (unflavored, unsweetened, uncarbonated) fluoridated water is the preferred beverage for children, particularly when fluids are consumed outside of meals and snacks [46].
●Cow milk – Recommendations for cow milk consumption are provided above. (See 'Dairy products' above.)
●Plant-based milks – Plant-based milks generally are not recommended for children <5 years of age unless they have cow milk allergy or intolerance [46]. If cow milk alternatives are used for children as part of a vegan diet, other foods must be chosen wisely to provide the nutrients missing from alternative milk sources. Plant-based milks also may be deficient in calcium and protein. Consultation with a dietitian to review the overall dietary nutrient intake may be warranted for children in whom plant-based milks are a dietary staple.
Common plant-based milks include soy, almond, rice, coconut, and hemp milks; newer alternative milks include quinoa, oat, potato, and mixed grain milks. Among the plant-based milks, soy milk has a nutrient profile that is most similar to cow milk (although it contains less protein) and usually is fortified with calcium and vitamin D. Other plant-based milks generally are lower in protein, calcium, vitamin D, and calories; they also may be lacking in other vitamins, minerals, and fatty acids that are found in dairy milk. (See "Vegetarian diets for children", section on 'Plant-based formulas and beverages'.)
Children who drink non-cow milk or nonfortified soy milk (eg, goat milk or plant-based milks such as rice, almond, coconut, etc) may require supplemental vitamin D. Commercially available cow milk is fortified with vitamin D; fortification of non-cow milk is voluntary. In a cross-sectional study of 2831 children (one to six years of age), 10 percent of children drank non-cow milk [74]. Drinking only non-cow milk was associated with decreased levels of vitamin D [74]. Vitamin D requirements and recommendations for meeting the recommended daily intake of vitamin D are discussed separately. (See "Vitamin D insufficiency and deficiency in children and adolescents".)
●Fruit juice – Fruit juice consumption is discussed above. (See 'Fruits, vegetables, and fruit juice' above.)
●Soft drinks and sweetened beverages – The consumption of soft drinks and other sweetened beverages (eg, fruit drinks, flavored water) should be discouraged [1,31,73,75-77]. An expert panel consensus recommends that children <5 years avoid consumption of these beverages [46]. For older children, consumption should be limited to ≤8 ounces (approximately 240 mL) per week [38,70].
Sweetened beverages (eg, sugar-sweetened soda, fruit drinks, sweetened tea and coffee) are a major source of added sugar in the diet and an important contributor to the development of obesity [69,73]. Sweetened beverage consumption also is associated with lower intake of key nutrients (particularly calcium) because sweetened beverages generally are consumed instead of milk. (See "Definition, epidemiology, and etiology of obesity in children and adolescents", section on 'Sugar-sweetened beverages'.)
●Low-calorie sweetened beverages – Low-calorie sweetened beverages are sweetened with low-calorie or no-calorie sweeteners (eg, saccharin, aspartame, sucralose, stevia). Consumption of low-calorie sweetened beverages should be limited in children and adolescents [46,78,79]. There is no evidence that these beverages have benefits over plain water. Evaluation of adverse effects of low-calorie beverages is an active area of research; potential adverse effects include decreased intake of healthier beverages (eg, cow milk), development of a taste preference for sweetened beverages, and altered sensations of fullness and hunger [78,80,81].
●Caffeinated beverages – Caffeinated beverages are not recommended for children <5 years of age [46]. There is little information about safe levels of consumption or the short- and long-term effects on health for young children or adolescents [82,83].
Health Canada suggests the following limits for caffeine consumption in children and adolescents [84]:
•Age 4 to 6 years – ≤45 mg/day
•Age 7 to 9 years – ≤62.5 mg/day
•Age 10 to 12 years – ≤85 gm/day
•Age ≥13 years – ≤2.5 mg/kg of body weight per day
The caffeine content of various beverages is available in the table (table 8).
VITAMIN AND MINERAL SUPPLEMENTS — Routine supplementation of vitamins and minerals is not necessary for healthy children who are growing normally, consume a varied diet, and have adequate dairy intake and exposure to sunlight [1,2,85,86]. In surveys of children in the United States, use of vitamin and mineral supplements was associated with excessive intake of vitamin A, vitamin C, folate, zinc, and other minerals [85,86].
If caregivers wish to give their children supplements, a standard pediatric multivitamin generally poses no risk. However, interactions with medications may occur [87]. Megadose vitamins and doses of any nutrient in excess of the recommended daily allowance should be discouraged because of the potential toxic effects. Vitamin and mineral supplements, particularly those designed to appeal to children (eg, vitamin gum), should be kept out of reach of children.
Vitamin and mineral supplements may be indicated for children at nutritional risk, including those [2]:
●From neglected or deprived environments.
●With anorexia or inadequate appetite.
●With lead poisoning. (See "Childhood lead poisoning: Management", section on 'Approach'.)
●With poor weight gain. (See "Poor weight gain in children older than two years in resource-abundant countries", section on 'Dietary intervention' and "Poor weight gain in children younger than two years in resource-abundant countries: Management", section on 'Vitamin and mineral supplementation'.)
●Who do not get regular sunlight exposure and/or do not have adequate vitamin D intake (eg, those who drink only non-cow milk products that are not fortified with vitamin D). (See "Vitamin D insufficiency and deficiency in children and adolescents", section on 'Pathogenesis and risk factors'.)
●With chronic diseases that may affect absorption and utilization of nutrients. As examples, children with chronic liver disease or fat malabsorption (eg, cystic fibrosis) need supplementation of the fat-soluble vitamins A, D, E, and K; children with hemolytic anemia (eg, sickle cell anemia) may need folic acid supplementation; and children with inflammatory bowel disease may need supplementation with iron, vitamin B12, folic acid, fat-soluble vitamins, and zinc.
●Who are trying to lose weight or are consuming fad or restrictive diets. As an example, children who consume strict vegan diets (avoidance of all animal products, including eggs, milk, and milk products) may need supplementation of vitamin B12, iron, or vitamin D. (See "Vegetarian diets for children" and "Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis", section on 'Dietary recommendations'.)
FOOD SAFETY — There are two major safety considerations when feeding children: choking and foodborne infection.
Choking — To limit the risk of choking, children younger than three to four years of age should not be given small, round, hard foods (eg, hot dogs, nuts [particularly peanuts], grapes, raisins, raw carrots, popcorn, round candies). In addition [1,2]:
●Toddlers should always be supervised while eating
●Children should be seated upright during eating; they should not eat while reclining, walking, or running
●Children should not eat while riding in a car, because the caregiver may not be able to intervene if the child chokes
Foodborne infection — To minimize the risk of foodborne infection, children should not be fed [2,88]:
●Raw (unpasteurized) milk or juice
●Raw or partially cooked eggs or foods containing raw eggs
●Raw or undercooked meat, poultry, fish, or shellfish
●Raw sprouts
Virtually all international and national advisory and regulatory committees endorse the consumption of only pasteurized milk and milk products. Ingestion of raw milk has been associated with various bacterial infections, including Campylobacter, Brucella, Listeria monocytogenes, Salmonella, and E. coli and associated hemolytic uremic syndrome [89-95]. The FDA mandates pasteurization in final package form for all milk and milk products for direct human consumption that are shipped for interstate sale [90,96]. However, individual states regulate milk shipped within the state, and some states permit raw milk to be sold in some form to the public. In December 2013, the Committee on Infectious Diseases and Committee on Nutrition of the AAP published a policy statement on the consumption of raw or unpasteurized milk and milk products by pregnant women and children that endorses a ban on the sale of such food items. This recommendation is based on the multiplicity of data regarding the burden of illness, as well as the strong scientific evidence that the nutritional value of milk is not altered by the pasteurization process [88].
Additional steps to prevent foodborne infection are outlined in the table (table 9).
INDICATIONS THAT MAY WARRANT CONSULTATION WITH A DIETITIAN — Indications that may warrant consultation with a dietitian include:
●Developmental delay
●Chewing and swallowing dysfunction (see "Aspiration due to swallowing dysfunction in children", section on 'Modified feeding')
●Cerebral palsy (see "Cerebral palsy: Overview of management and prognosis", section on 'Growth and nutrition')
●Consumption of plant-based milks (other than soy milks fortified with calcium and vitamin D) as a dietary staple (see 'Dairy products' above and "Vegetarian diets for children", section on 'Plant-based formulas and beverages')
●Poor weight gain (see "Poor weight gain in children younger than two years in resource-abundant countries: Management", section on 'Nutritional therapy' and "Poor weight gain in children older than two years in resource-abundant countries", section on 'Dietary intervention')
●Obesity (see "Prevention and management of childhood obesity in the primary care setting", section on 'Stage 1: Prevention plus')
●Diabetes mellitus (see "Overview of the management of type 1 diabetes mellitus in children and adolescents", section on 'Nutrition' and "Management of type 2 diabetes mellitus in children and adolescents", section on 'Dietary prescription')
●Dyslipidemia (see "Dyslipidemia in children and adolescents: Management", section on 'Dietary modification')
●Food allergy (see "Management of food allergy: Nutritional issues")
●Celiac disease (see "Management of celiac disease in children", section on 'Dietary management')
●Cystic fibrosis (see "Cystic fibrosis: Nutritional issues")
●Vegetarian diets (see "Vegetarian diets for children" and "Vegetarian diets for children", section on 'Vitamins and minerals')
RESOURCES
●MyPlate Plan is an interactive website that provides individual dietary guidance according to age, sex, and activity level based upon the United States Departments of Agriculture and Health and Human Services (USDA/HHS) Dietary Guidelines for Americans (older than one year)
●The USDA/HHS Dietary Guidelines for Americans
●The Eatwell Guide (Public Health England) defines recommendations on eating healthily and achieving a balanced diet
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Healthy diet in children and adolescents".)
SUMMARY AND RECOMMENDATIONS
●Feeding development and behaviors
•Toddlers – During the second year of life, children learn to feed themselves independently and make the transition to a modified adult diet. Achieving independence and mastery of feeding skills is an important developmental task of early childhood. It is normal for toddlers to eat variable quantities at any given meal, to become resistant to trying new foods, and to choose to eat a small number of favorite foods. (See 'Toddlers' above.)
•Preschool children – The feeding choices and behaviors of preschool children are largely influenced by environmental cues. It is important for preschool children to sit with the family during meal times (even if the child chooses not to eat) so that they can observe the eating behaviors and choices of family members. Children and adolescents who share meals with their family have better health outcomes. (See 'Preschool children' above.)
•School-age children – The feeding choices and behaviors of school-age children may be influenced (positively or negatively) by friends, family members, nonfamily members, and/or the media. Caregivers may need to balance these potentially negative influences by increasing positive influences in the home. (See 'School-age children' above.)
●Dietary framework
•Energy and nutrient requirements for toddlers, preschool, and school-age children vary depending upon age, sex, and activity level (table 1). (See 'Energy and macronutrient balance' above.)
•Most young children should be fed four to seven times per day. Snacks are an essential component of the young child's diet. (See 'Frequency of feeding' above and 'Snacks' above.)
•The appropriate portion size varies with the child's age and the particular food (table 2 and table 3). Serving children portions that are larger than recommended for their age may contribute to overeating. (See 'Portion size' above.)
●Dietary composition – Young children can regulate their energy intake but rely on adults to offer them a variety of nutritious, developmentally appropriate foods for a well-balanced diet (table 2). Similarly, caregivers should offer older children a variety of nutrient-dense foods from the basic food groups each day (table 3). (See 'General guidance' above.)
●Vitamin and mineral supplements – Routine supplementation of vitamins and minerals is not necessary for healthy growing children who consume a varied diet and have adequate exposure to sunlight. Children who drink little or no cow milk or drink plant-based "milks" (eg, goat milk or plant-based milks such as soy, rice, almond, coconut, etc) may require supplemental vitamin D. (See 'Vitamin and mineral supplements' above.)
●Eating environment – In the establishment of a healthy eating environment, the caregiver is responsible for providing a variety of nutritious foods; defining the structure and timing of meals; creating a mealtime environment that facilitates eating and social exchange; and recognizing and responding to the child's signals of hunger and fullness. The child is responsible for participating in food selection and determining how much is consumed at each eating occasion. (See 'Eating environment' above.)
