Toddler Nutrition: First 1000 Days

    Toddler nutrition during the first 1,000 days

    Help ensure toddlers are getting the nutrition they may need

    Picky eating is a common concern for parents of toddlers. Many factors can contribute to “dinnertime battles,” such as resistance to unfamiliar foods, aversion to certain textures and desire to only consume favorite foods1.

    Toddlerhood represents an important time in social development, especially in the toddler’s sense of self. Their picky eating may result from desiring to select and feed their own foods, or from modeling the eating habits of family members or their peers2.

    Picky eating habits could lead to missing out on key nutrients

    The Feeding Infants and Toddlers Study (FITS) found that toddlers generally under-consume foods such as dairy products, lean red meats, leafy greens like spinach and kale, dark red and yellow vegetables, cantaloupe, salmon, and eggs, all of which provide essential nutrients3.

    A recent analysis of data from the National Health and Nutrition Examination Survey (NHANES) found that many toddlers consumed less than the recommended amount for nutrients like vitamin D and DHA4.

    Read the full abstract here:

    See Abstract

    Nutritional gaps in toddlers

    Toddler nutrition webcast

    Watch Dr. Corey Hébert address the key nutrients that support infant and toddler growth and development during the first 1,000 days of life.

    Learning objectives:

    • Consider common toddler dietary concerns and the impact of complementary feeding.
    • Review how complementary foods support nutritional and developmental milestones.
    • Describe appropriate introduction of complementary foods into a toddler’s diet to help achieve optimal nutrition.
    • Discuss a case study to illustrate benefits of optimal toddler nutrition and examine how to manage common challenges with complementary feeding and picky eating.

    Iron

    Adequate iron intake in the first 1,000 days is important for brain development and helps deliver adequate oxygen to organs and muscles. Severe and unmitigated iron deficiency during the first year of life can have irreversible impacts.

    Iron deficiency in children in the U.S. may have a negative impact on brain development. Studies have found that by age 5, children who were iron deficient exhibited cognitive and socioemotional developmental impairments5,6.

    Learn more about the importance of iron in the first 1,000 days in PNCE’s webcast series:

    View Iron Webcast

    Vitamin D

    Vitamin D deficiency may be difficult to detect in routine clinical practice, as a child’s vitamin D status is not typically evaluated as part of routine care7.

    One study has found significant predictors of vitamin D insufficiency include breastfeeding without supplementation among infants and lower milk intake among toddlers7.

    Learn more about the importance of vitamin D in the first 1,000 days in PNCE’s webcast series:

    View Vitamin D Webcast

    Nearly 1 out of 8 healthy infants and toddlers* were found to be vitamin D deficient7,†.

    * Healthy infants and toddlers (N=365) in a cross-sectional sample in an urban primary care clinic.

    † Defined as serum 25-hydroxyvitamin D (25OHD) concentrations <20 ng/mL (50 nmol/L).

    DHA

    DHA is a naturally occurring long-chain polyunsaturated fatty acid found in breast milk, and many infant formulas are fortified with it. However, the transition from infant formula or breast milk to cow’s milk can lead to an 80% drop in DHA consumption, making it important to provide good nutrition, as it sets the foundation for optimal development‡.

    DHA is important, as brain myelination occurs throughout childhood and adolescence9. Global experts including EFSA and AFSSA recommend that toddlers have 70-100 mg/day of DHA.

    Learn more about the importance of DHA in the first 1,000 days in PNCE’s webcast series:

    View DHA Webcast

    ‡ DHA intake calculated for 6-month-old infants exclusively fed a 20 kcal/fl oz formula that has DHA at 17 mg/100 kcal. Formula intake volume per day (~32 fl oz) is based on WHO average age daily energy requirements for 6-month-old boys and girls. DHA intake calculation for exclusively breastfed infants at 6 months of age assumes breast milk daily intake volume of 32 fl oz (based on WHO average daily energy requirements) and the DHA worldwide average breast milk level of 0.32% of total fatty acids (17 mg/100 kcal).

    Bridging the nutrient gap

    Studies have shown that proper nutritional supplementation along with psychosocial stimulation results in greater improvements in child development, rather than one of these approaches alone10.

    Iron supplementation

    Iron deficiency is the most common nutritional insufficiency in the world11. The AAP recommends the below iron supplementation12:

    AGE IRON AMOUNT NOTES
    4-6 months (partially/fully breastfed) 1 mg/kg/d Supplementation until appropriate iron-containing complementary foods are introduced
    0-12 months (formula fed) 10-12 mg/L Supplementation until appropriate iron-containing complementary foods are introduced
    6-12 months 11 mg/d Liquid iron supplements are appropriate if iron needs are not being met by the intake of formula and complementary foods
    1-3 years 7 mg/d Liquid iron supplements are appropriate if iron needs are not being met by the intake of formula and complementary foods

    Vitamin D supplementation

    To prevent vitamin D deficiency in healthy infants and toddlers, a vitamin D intake of at least 400 IU/day is recommended. The AAP recommends the below vitamin D supplementation13:

    AGE NOTES
    Breastfed/partially breastfed infants Supplementation should begin in the first few days of life and be continued unless the infant is weaned to at least 1 L/day or 1 qt/day of vitamin D–fortified formula or whole milk
    Nonbreastfed infants and weaned older children Other dietary sources of vitamin D, such as fortified foods, may be included in the daily intake
    Children with increased risk of vitamin D deficiency At-risk children include those with chronic fat malabsorption and those chronically taking antiseizure medications; these children may require higher doses of vitamin D supplementation

    DHA supplementation

    Global experts including EFSA and AFSSA recommend that toddlers have 70-100 mg/day of DHA; however, most U.S. children do not meet expert recommendations for DHA intake14. The FAO/WHO recommends the following dietary intake for DHA15:

    AGE NOTES
    0-6 months >0.2-0.36% total fatty acids
    6-24 months 10-12 mg/kg body weight
    2-3 years 70 mg/day

    Supplementing with nutritional drinks

    Nutritional drinks made with real milk and fortified with key nutrients can complement the toddler diet to help close nutritional gaps. Studies have demonstrated that drinking toddler milks (also known as growing-up milks) can help toddlers meet daily nutrient recommendations16-18.

    Provide parents with the nutritional strategies their toddler may need:

    See Toddler Options

    References

    1. Van der Horst K, Deming DM, Lesniauskas R, et al. Picky Eating: Associations with Child Eating Characteristics and Food Intake. Appetite. 2016;103:286-293.
    2. Leung AKC, Marchand V, Sauve RS, et al. The ‘Picky Eater’: The Toddler or Preschooler Who Does Not Eat. Pediatr Child Health. 2012:17(8):455-457.
    3. Roess AA, Jacquier EF, Catellier DJ, et al. Food Consumption Patterns of Infants and Toddlers: Findings from the Feeding Infants and Toddlers Study (FITS) 2016. J Nutr. 2018;148(Suppl 3):1525S-1535S.
    4. Bailey A, Fulgoni V, Patterson A, et al. Examining Nutrient Adequacy, Iron Deficiency, and Anemia in US Children 1-3 Years of Age Using Data from NHANES 2001-2016. Curr Dev Nutr. 2020;4(Suppl 2):507. doi: https://doi.org/10.1093/cdn/nzaa046_007
    5. Lozoff B, Jimenez E, Wolf AF. Long-Term Developmental Outcomes of Infants with Iron Deficiency. N Eng J Med. 1991;325:687-694.
    6. Tamura T, Goldenberg RL, Hou J, et al. Cord Serum Ferritin Concentrations and Mental and Psychomotor Development in Children at Five Years of Age. J Pediatr. 2002;140(2):165-170.
    7. Gordon CM, Feldman HA, Sinclair L, et al. Prevalence of Vitamin D Deficiency Among Healthy Infants and Toddlers. Arch Pediatr Adolesc Med. 2008;162(6):505-512.
    8. Walsh KR, Ye Q, Piekarz A. Dietary Intake of Omega-3 Long-Chain Polyunsaturated Fatty Acids (n-3 LCPUFA) by US Toddlers. FASEB J. 2012;26(Suppl 1):811.6. doi: https://faseb.onlinelibrary.wiley.com/doi/10.1096/fasebj.26.1_supplement.811.6
    9. Kuratko CN, Barrett EC, Nelson EB, et al. The Relationship of Docosahexaenoic Acid (DHA) with Learning and Behavior in Healthy Children: A Review. Nutrients. 2013;5(7):2777-2810.
    10. Prado EL and Dewey KG. Nutrition and Brain Development in Early Life. Nutr Rev. 2014;72(4):267-284.
    11. Looker AC, Dallman PR, Carroll MD, et al. Prevalence of Iron Deficiency in the United States. JAMA. 1997;277(12):973-976.
    12. Baker RD, Greer FR and the Committee on Nutrition. Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age). Pediatrics. 2010;126(5):1040-1050.
    13. Wagner CL, Greer FR, Section on Breastfeeding and Committee on Nutrition. Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents. Pediatrics. 2008;122(5):1142-1152.
    14. Thompson M, Hein N, Hanson C, et al. Omega-3 Fatty Acid Intake by Age, Gender, and Pregnancy Status in the United States: National Health and Nutrition Examination Survey 2003-2014. Nutrients. 2019;11(1):177. doi: https://doi.org/10.3390/nu11010177
    15. Food and Agriculture Organization of the United Nations (2010). Fats and fatty acids in human nutrition: Report of an expert consultation. FAO Food and Nutrition Paper 91. Rome. Available online at: http://www.fao.org/docrep/013/i1953e/i1953e00.pdf
    16. Walton J and Flynn A. Nutritional Adequacy of Diets Containing Growing Up Milks or Unfortified Cow’s Milk in Irish Children (Aged 12-24 Months). Food Nut Res. 2013;57:1. doi: https://doi.org/10.3402/fnr.v57i0.21836
    17. Ghisolfi J, Fantino M, Turck D, et al. Nutrient Intakes of Children Aged 1-2 Years as a Function of Milk Consumption, Cows’ Milk or Growing-Up Milk. Public Health Nutr. 2013;16(3):524-534.
    18. Lovell AL, Davies PSW, Hill RJ, et al. Compared with Cow Milk, a Growing-Up Milk Increases Vitamin D and Iron Status in Healthy Children at 2 Years of Age: The Growing-Up Milk-Lite (GUMLi) Randomized Controlled Trial. J Nutr. 2018;148(10):1570-1579.