Planes, trains, and automobiles—these are all tricks that parents and caregivers use to get food into their children's mouths. These methods may work for awhile, but once a child reaches the toddler age, he craves the independence to do it himself, learning, exploring and deciding on his own what he will or will not eat. Of course, this can create special mealtime challenges, the most difficult being: How do I help maintain my child's healthy diet when he doesn't want to eat his vegetables?
The Feeding Infants and Toddlers Study™ (FITS) recently reviewed the transition to table foods, and showed that during this pivotal developmental time, children go from several fruits and vegetables a day to almost none.* This finding was echoed in the Continuing Survey of Food Intakes of Individuals, in which 63% of children age 2-9 years weren't consuming the recommended number of fruits, and 78% weren't consuming the recommended number of vegetables.1 (Lack of availability, "finicky" eating, or the perceived taste of vegetables could be possible causes.) Highlighted nutritional concerns included calcium, fiber, fruit and vegetable intake; portions; and the alarming number of high-calorie, low-nutrient-density foods that enter the diet at this time.
Overall, despite the efforts of food organizations, healthcare professionals and the media, there remains little change in the dangerous trend of children consuming unhealthy diets. As more of our toddlers transition away from fruits and vegetables and toward fatty, salty and sugary snacks and meals, more are ending up obese or with a higher risk profile for many diseases. Now more than ever, we must increase our efforts to get the message through to parents: establishing healthy eating habits at the toddler age is absolutely critical to future development. To present regular and consistent solutions, consider the following areas of concern: environment, education, portion sizes, and development.
Parents Must Create a Positive Eating Environment
A positive and consistent eating environment can go a long way toward encouraging children to eat healthy. Minimizing distractions, turning off media devices, and modeling positive interaction all make mealtimes pleasant and rewarding experiences for children.
There is some discussion in the literature regarding grazing for toddlers vs. established meal and snack times. The American Academy of Pediatrics recommends establishing a pattern for mealtimes, naps and bedtimes, as this provides consistent expectations for the child.2 In today's busy world, it's understood that no schedule is set in stone, but preparing for such occasions and having healthy options when the parent or caregiver is on the go is very important for the child.
Parents need to encourage three meals and 2-3 snacks per day in order to pace the child's intake and prevent over-hunger. Food should be provided no more then 2-3 hours apart during the active part of a child's day, due to her small stomach capacity and high level of activity.3 It is equally important to allow sufficient time in between meals and snacks, to allow the child to become hungry. A hungry child is more likely to eat the foods presented to her, rather than demand cookies or candy. Eating should occur at the table, to discourage snacking while walking or playing. Finally, remind parents that snacks are a great opportunity to meet nutritional goals by complementing meals, not replacing them.
Should parents bribe their child to eat? Birch and Fischer showed that rewards were not a means to an end.(4) Children who were rewarded with a trip to the playground after trying a new juice were less likely to try the juice again compared with children who simply were allowed to experiment and taste the juice. Researchers concluded that what helped with food acceptance was allowing children to make use of their internal cues.
The most important thing for parents to remember is not to exert too much control. Restricting a child's access to a food can actually enhance liking and increase intake of that food.5 Conversely, what starts out as a well-intentioned practice to encourage a child to consume a particular food may in fact increase the child's dislike for that food. When parents impose child-feeding practices that provide children with few opportunities for self-control, they often meet with resistance. Birch showed that attempts to restrict and control children's eating and weight to prevent obesity may be producing the very problem intended to avoid fostering problems of energy balance. Instead, it's best if parents try to allow the child's physical needs and hunger cues to dictate her intake, rather than relying on environmental cues, such as being told to "clean her plate" and/or "take three more bites."6
Ellyn Satter recommends that instead of force, parents take on a leadership role.7 This includes being responsible for choosing and preparing the food, providing regular sit-down meals, making eating time a pleasant time, and showing the child what to eat.
Meals Away from Home
Parents Must Regulate Portion Sizes
The increase of dual-income and single-parent families have led to more children eating up to three meals out of the home, with someone other than their parent as their role model and food-experience provider. Based on the 2001 National Household Education Survey, 74% of children age 3-6 are in some form of non-parental care, and 56% are in a center-based child-care program.8 Often up to 50-100% of the toddlers' recommended dietary allowances are obtained in child-care settings. Thus, non-family members have a strong influence on the toddlers' nutritional behaviors.9 Encouraging parents to be nutrition advocates at their child's day care is pivotal.
Several issues arise when faced with feeding a toddler. How much is enough? How do we not overwhelm them? Should we limit the amount of food items?
There is resounding research showing that this age group has an innate ability to self-regulate the amount of food they consume.10 Yet research and experience show that many people are unaware of what a true ‘portion' or ‘serving' size is for them. Therefore, they don't notice portion variations. Dietitians, pediatricians, and health educators need to provide guidance to parents and caregivers about reasonable portion sizes for infants and toddlers.11 (See Table, "Serving and Portion Sizes for Toddlers.")
A recent study showed that children as young as 5 years of age eat more food when offered larger portions than when offered "normal" portions.12 Yet portions didn't influence the intakes of 3-year-olds—they ate the same amount of food no matter what portion they were provided. No encouragement was given to eat more, and no bribes were offered to finish what was available. Most parents, on the other hand, likely employ such tactics at the table. Therefore, it's important to realize that as a child develops, his food intake is increasingly affected by a variety of social, cultural, and environmental factors. By providing the toddler with appropriate amounts of foods to start with, we allow them to self-regulate their caloric intake. If they want more, then it can be provided.
How many servings of different types of foods should be given in a day? A general guideline includes the following: 6 or more servings of grains (half of those being whole grains), 4 servings of milk, 3 servings of vegetables, 2 servings of fruit, and 2 servings of meat.13 Adequate fats are important for this age group for a number of reasons, including caloric needs, small stomach capacity, and need for brain growth and development. Unfortunately, 29% of toddlers are consuming less than the Acceptable Macronutrient Distribution Range (AMDR).†
Parents Must Educate
Children About Healthy Foods
As children grow, they learn about food choices from their parents and other caregivers. Therefore, it's critical that parents use mealtimes, snacks, and other food occasions as teaching times. Providing nutritious food alternatives in fun varieties, limiting empty-calorie or low-nutrition items, and modeling healthy eating behavior are all excellent ways to educate children about a proper diet.
Limit Sweetened Beverages
When a toddler transitions to table food, they decrease their intake of breast milk or formula and increase their intake of solid foods. Yet drinks continue to be very important in their nutrition. Two cups of milk per day will provide the child with adequate calcium (600 mg). Milk is also a good source of vitamin D, potassium, protein, and carbohydrates. Whole cow's milk is recommended, but if there are allergies or lactose intolerance, calcium-fortified full-fat soymilk and lactose-free whole milk are appropriate.
One-hundred percent fruit juices are allowed but should be limited to no more than 4-6 ounces per day.14 (This counts as one fruit serving.) Children often attempt to quench their thirst with juice, thereby drinking large amounts, but all those calories often leave them full and not wanting to eat much at the next meal or snack. Parents and caregivers often believe that fruit juice is healthy, so why not just use it as the drink of choice all the time? Juice (100%) is healthy in limited quantities, but water should be used to quench thirst. Easy-to-eat fruits can be served to satisfy the sweet taste the child desires, while delivering important nutrients and fiber.
Children of all ages like carbonated and other sweetened beverages. However, these should be discouraged for toddlers. The FITS study examined how much of these types of beverages were consumed starting at one year of age. The amounts steadily increased to 30-40% of total daily beverage intake for fruit drinks and up to 10% for carbonated beverages. These beverages have a negative impact on the toddler's nutrition, as they provide only empty calories. In addition, total calcium decreased as intake of these sweetened beverages increased.
Model Healthy Behavior
Parents are role models for their children. It is important that they provide not only healthy foods, but also model healthy-eating behaviors. Perhaps the best advice is to lead by example.15 According to the American Academy of Pediatrics, during the toddler's second year of cognitive development, he utilizes imitation as a big part of his learning process.16In fact, the parent, caregiver, and older peers serve as role models who can powerfully impact what the child will eat.17 The parent cannot simply insist that the child consume fruits, vegetables and drink his milk, when the parent does not consume these items or even place them on the table. It's vital that parents analyze their own diet and fitness behaviors and adjust them. For parents and caregivers, leading by example is crucial.
Social context also plays a major role in eating behaviors.18 When Sam, a preschool child, observes other children choosing and eating vegetables that he doesn't like, he'll be more likely to try those vegetables again. Even more promising is the finding by Harper and Sanders that toddlers were more likely to put foods into their mouths when their mothers, rather than strangers, were the examples.19
Provide a Variety of Fun Foods
Toddlers thrive on fun, new experiences. Parents can encourage healthy eating by providing foods in a variety of colors, textures and shapes. Encourage finger feeding so the child can practice independence, but always serve foods the rest of the family is eating, as this encourages experimentation. It also helps to serve some items warm rather than hot; moist rather than dry. Offer foods separately, and avoid sauces, spices, gravies and mixed foods. Sauces and spices can change the flavor of the food just when your child is getting to like it. For example, she may like green beans, but not green beans with bacon. Keep it simple—as they age, they can explore the "extras."
Snack time is also the perfect opportunity to make eating fun. Parents can provide a variety of snacks that are nutrient-rich including fruits, vegetables, dairy, and whole grains, but can also use their imaginations to create fun combinations or even make faces.
Parents Must Work with a
Child's Developmental Needs
During the second year of life, there is a sharp drop in the toddler's appetite. From birth, weight triples during the first year, but then increases by only 25% in the second year. As the growth rate declines, a child's appetite decreases and the amount of food that she consumes may become unpredictable. In addition to the physiological changes, children are predisposed to reject new foods.20 They like sweet and salty tastes and reject sour and bitter tastes, preferring high-energy sources. It will take time for them to explore new foods, learn associations between foods and flavor, and react to the fullness they feel after eating.
Parents need to be prepared for the transition in their toddler's autonomy. The child wants to feed himself and will say "no" to mom, not because he doesn't want to eat the foods but because he wants to do it on his own. The toddler's need for autonomy is part of his natural development. The unpredictability can alarm parents; the child may eat a lot one day and very little the next. But there typically is no reason for worry. Research shows that a child's changes in appetite over time will lead him to eat a variety of food and maintain a nutritionally adequate diet. It is the child's intake over time that matters.21
Still, many parents worry about how their child won't eat or try new foods.22 The child may play with his food or delay eating as long as possible. Research shows that a mother's typical response to this behavior is to provide foods and plan meals based on what her child will eat. If the child refuses to eat what is offered, she provides alternatives, becoming, in essence, a "short-order-cook," making a separate meal that she knows the child will eat. If this happens repeatedly over a long period of time, the child will have a limited variety and exposure to new foods. Instead, parents need to set limits while providing healthy options. This establishes structure for the child while allowing her the comfort of exploring and getting used to new foods. Pairing a new, strange or disliked food with something desired will help the child get used to it.23 The resounding advice is not to force the child to eat anything, but to continue to expose her to new foods.
Findings suggest that inviting a toddler to taste a small amount of a rejected or disliked food, without great emphasis on how much he eats, is a good strategy for promoting liking. Wardle et al. state, "The element of repetition may be particularly crucial since the process of adaptation may be slower than parents expect, leaving some parents to give up before the exposure has had a chance to work."24 According to Dr. Leanne Birch, parents and caregivers need to offer new foods to the toddler at least 8 and up to 15 times.25 In the FITS study, as many as 25% of caregivers offered new foods only one-two times before they decided the toddler disliked it. Health care professionals need to encourage caregivers to provide up to 15 tasting opportunities before giving up.26
According to research (FITS), both picky and non-picky eaters met or exceeded RDAs or DRIs on a given day. The survey showed that picky eating increased with age. Fifty percent of the families surveyed reported that by age 18 months, their toddler was a "picky eater." But are they truly picky? We must consider the developmental stage of the toddler to fully appreciate "picky eating." Ellyn Satter points out that we must see it from the toddler's viewpoint: she is skeptical, but not rejecting. She may say "no" simply because she's becoming more independent. Often she will eventually eat the item, having made the decision on her own. If picky eating is chronic, there may be cause for concern. In such cases, the dietitian should review intake for nutrient adequacy, assess growth and suggest ways to improve food acceptance.
Solutions for the Busy Family
The FITS study shows that once children move from "baby foods" to "table foods," the risk for adopting unhealthy eating habits rises significantly. To avoid this pitfall, parents must show and provide opportunities for their toddlers to make healthy choices. Instead of asking, "Are you going to eat a vegetable?", ask, "Which veggie are you going to eat?" The child still has a choice, but it's a choice among healthy options.
Of course, implementing healthy diets can be easier said than done. When two parents are working full-time jobs, they can meet with some tough challenges. "If I only had time, I could prepare better meals," some parents say. "I don't want to fight with them when I haven't seen them all day," others complain, referring to the upsetting quarrels that can occur over what the child will eat. "I don't want a temper tantrum when my time is so limited."
These are very real concerns, but they don't doom a family to fast food and unhealthy meals. Instead, parents can be on the lookout for fast, convenient ways to prepare healthy foods, and most importantly, shop carefully so that the refrigerator is always full of nutritious options. Some ideas include: Pre-wash, chop, and store fruits and veggies in baggies that are easy to grab and go. Whole-grain crackers, cereal, and pretzels also work great this way. For the toddler, keeping his dinner like the family dinner will help him eat a greater variety of foods. Heat up either fresh, canned, or frozen vegetables, or cook the meat minus the gravies and sauces. (Keep these on the side and the child can always dip it in later.) Remember, children are still exploring and experimenting with tastes, so it's best not to overwhelm them.
With a little inventive effort, parents can encourage healthy eating and provide healthy options, but they need to start early and stay consistent to help promote the long-term health of their child.
Marilyn Tanner-Blasiar, MHS, RD, LD, is a clinical pediatric dietitian at St. Louis Children's Hospital and Washington University School of Medicine in St. Louis. She is the study coordinator of an international investigation of nutritional prevention of type 1 diabetes, which is being conducted at the university's Patient Oriented Research Unit. Tanner-Blasiar teaches dietetic interns and speaks frequently to groups including parents, physicians and other health professionals on children's nutrition and obesity. She was named the Missouri Dietetic Association's 1997 Recognized Young Dietitian of the Year and the 2004 Missouri Outstanding Dietitian of the Year.
* The FITS study is a cross-sectional survey of households with 3,022 infants and toddlers (ages 4-24 months). From: Fox MK, Pac S, Devaney B, Jankowski L. J Am Diet Assoc. 2004 Jan; 104(1 Suppl 1):s22-30.
† Devaney et al. J Am Diet Assoc. 2004:104:s14-21.
- Position paper of the American Dietetic Association—Dietary guidance for healthy children aged 2-11 years. J Am Diet Assoc 2004; 104:660-667.
- Steven P. Shelov, MD, FAAP Editor in Chief, Robert E. Hannenmann MD FAAP, Associate Medical Editor. The American Academy of Pediatrics. The complete and Authoritative Guide: Caring for Your Baby and Young Child Birth to Age 5. Bantam June 1998 "Stimulating Child Brain Growth: Second Year," p 272.
- Position of the American Dietetic Association: Benchmark for Nutrition Programs in Child Care Settings. J Am Diet Assoc. 2005; 105:979-986. Also, Kleinman RE, American Academy of Pediatrics committee on Nutrition Pediatric Nutrition Handbook,Elk Grove Village, IL: American Academy of Pediatrics; 2003.
- Birch LL, Fischer JO. Development of eating behaviors among children and adolescents. Pediatrics Vol 101 No. 3. Supplement March 1998; pp 539-549.
- Briefel RR, Reidy K, Karewe V, Jankowski L, Hendricks K. Toddlers' Transition to Table Foods: Impact on Nutrient Intakes and Food Patterns. JADA 2004; 104: S38-S44.
- Satter EM. The feeding relationship. J Am Diet Assoc. 1986; 86:352-1986.
- Ammerman AS, Ward DS, Benjamin SE, Ball SC, Sommers JK, Molloy M, et al. An intervention to promote healthy weight: Nutrition and physical activity self-assessment for child care NAP-SACC theory and design. Prev Chronic Disease [serial online] 2007 Jul 13. Available from: http://www.cdc.gov/pcd/issues/2007/jul/06_0115.htm.
- Wardle J, Cooke L, Gibson EL, Sapochnik M, Sheiham A, Lawson M. Increasing children's acceptance of vegetables; a randomized trial of parent-led exposure. Appetite 2003; 40(2):155-62.
- Rolls B, Engell D, Birch LL. Serving portion size influences 5-year-old but not 3-year-old children's food intakes. Journal of the Amer. Diet Assoc Feb 2000; 100 (2): 232-234.
- Fox MK, Reidy K, Karwe V, Ziegler P. Average portions of foods commonly eaten by infants and toddlers in the United States. J Am Diet Assoc. 2006 Jan; 106 (1Suppl1):S66-76.
- Rolls B, Engell D, Birch LL. Serving portion size influences 5-year-old but not 3-year-old children's food intakes. Journal of the Amer. Diet Assoc Feb 2000; 100 (2): 232-234.
- Combined from: CACFP guidelines (Child and Adult Care Food Program Guidelines), USDA Mypyramid, Cooperative Extension, WIC guidelines, American Academy of Pediatrics, (VIT) Variety Index for Toddlers (Cox DR, Skinner JD, Carruth BR, Moran J, Houck KS "A Variety Index for Toddlers [VIT]: Development and application. J Am Diet Assoc. 1997;97:1382-1386) and Fox MK, Reidy K, Vatsala K, Ziegler P. Average portions of foods commonly eaten by infants and toddlers in the United States. J Am Diet Assoc. 2006; 106:S66-S76.
- American Academy of Pediatrics, Committee on Nutrition. The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107:1210-1213.
- Wardle J, Carnell S, Cooke L. Parental control over feeding and children's fruit and vegetable intake: how are they related? J Am Diet Assoc. 2005;105:227-232.
- Steven P. Shelov, MD, FAAP Editor in Chief, Robert E. Hannenmann MD FAAP, Associate Medical Editor. The American Academy of Pediatrics. The complete and Authoritative Guide: Caring for Your Baby and Young Child Birth to Age 5. Bantam June 1998.
- Birch LL, Fischer JO. Development of eating behaviors among children and adolescents. Pediatrics Vol 101 No. 3. Supplement March 1998; 539-549.
- Birch LL. Effects of peer models' food choices and eating behaviors on preschoolers' food preferences. Child Development 1980; 51:489-496.
- Harper LV, Sanders KM. The effect of adults' eating on young children's acceptance of unfamiliar foods. J Exp Child Psychol. 1975;20:206-214.
- Birch LL, Johnson SL, Fisher JO. Children's eating: The development of food acceptance patterns. Young Children 1995;50(2):71-78.
- Birch LL, Johnson SL, Andresen G, Peters JC, Schulte MC. The variability of young children's energy intake. New England Journal of Medicine 1991;3244:232-235.
- Skinner JK, Carruth BR, Houch K, et al. Mealtime communication patterns of infants from 2-24 months of age. Journal of Nutrition Education 1998;30:8-16.
- Satter EM. Child of Mine: Feeding With Love and Good Sense. Palo Alto: Bull Publishing; 2000. p 307.
- Wardle J, Herrera M-L, Cooke L, and Gibson EL. Modifying children's food preferences: the effects of exposure and reward on acceptance of an unfamiliar vegetable. European Journal of Clinical Nutrition February 2003; 57(2):341-348.
- Birch LL, McPhee L, Steinberg L, Sullivan S. Conditioned flavor preferences in young children. Physiology and Behavior 1990;47:501-505.
- Betty Ruth Carruth, Paula J Ziegler, Anne Gordon and Susan I Barr. Prevalence of picky eaters among infants and toddlers and their caregivers' decisions about offering a new food. JADA Jan 2004; 104 (1,S1):57-64.