AN EVIDENCE-BASED GUIDE TO TODDLER NUTRITION FOR HEALTHCARE PROFESSIONALS
Healthcare Professionals are vital in helping parents of toddlers (1-3 years) foster healthy eating habits, based on an understanding of their toddler’s needs.
- Smaller capacity, greater need. Toddlers have a smaller stomach capacity than adults, but need a nutrient-rich diet to promote their rapid growth and development1. Many parents are conscious of the importance of nutritious food.
- Eating behaviour can be affected by the experience of mealtimes as well as the food. If parents gently encourage positive eating behaviours at the table, their toddler should eat enough.
- Providing self-directed choice. Since every toddler has the ability to regulate their own appetite, parents should create an environment in which a toddler can choose the amount of food they eat. Comparing the amount of food different toddlers eat during this time of rapid development is unhelpful.
FACTORS COMMONLY AFFECTING A TODDLER’S APPETITE
- Excessive fluid intake1
- Unstructured meals1,3
- Pressure to eat1,2
- Insufficient sleep4
- EXCESSIVE FLUID INTAKE
As toddlers have a smaller stomach capacity, offering excessive volumes of fluid or providing fluid at inappropriate times throughout the day will affect their food intake. Toddlers should consume between 1200-1500mls of fluid each day, including milk1. Toddlers should consume at least 300mls (10oz) milk, but should not drink more than 600mls (20oz) of milk, in 24 hours1. The remaining volume of fluid consumed should be water. All fluids given to toddlers should be:
- Served in a lidless beaker1,5. A lidless beaker moderates fluid intake. It is easier for a toddler to drink excessive amounts of fluid if their cup has a lid.
- Spread evenly throughout the day1. Offer about six beakers containing 150mls (5oz) water and two or three beakers of 150mls (5oz) milk throughout the day.
- Not offered for about 30 minutes before a meal1. Toddlers can easily fill up on fluids and not feel hungry in time for their meal or snack.
- Included with meals once half of the meal is eaten1. To encourage a toddler to prioritise their food first, fluids should be offered once half a meal is eaten. Then, a lidless beaker with 150mls (5oz) of milk or water can accompany the remainder of the meal.
- UNSTRUCTURED MEALS OR ‘GRAZING’ ON FOOD
Toddlers should have a regular routine of three main meals and two or three snacks at similar times each day. This helps to prime a toddler to feel hunger in time for a meal or snack, which should reduce grazing between feeding times2. Such a pattern means they are eating roughly every two hours, and so should not be hungry between these times.
QUICK TIP FOR PARENTS
If your toddler wants food between feeding times, offer a piece of fruit only. If they refuse, they’re probably bored rather than hungry, so distract them with an activity!
- PRESSURE TO EAT AT MEALTIMES
If a toddler feels pressured to eat at mealtimes, they can become anxious close to mealtimes. This nervousness can cause a loss of appetite and reduce food intake2. Pressure to eat does not have to be heavy-handed. Even mild pressure or unnecessary prompting to eat can be stressful for some toddlers, and should be avoided.
Parents should set appropriate expectations for their toddler’s behaviour at meals and snacks6. When a toddler knows what behaviour is expected from them at mealtimes, they should feel more relaxed. The behaviours that parents encourage should be ones which make their toddler feel that they are fully included during mealtimes. Parents should encourage their toddler’s involvement in all steps of a meal. Reasonable behaviours parents should encourage at meals include6,7:
- Before the meal. Help with a simple part of food preparation. Set their place at the table.
- At the table. Toddlers should come to the table promptly when asked, without any screens or toys in tow. They should try to serve and feed themselves, and then stay at the table until they are finished eating (remind parents not to allow them to keep leaving the table and coming back to eat over the course of a meal). They should be taught to always show good manners at the table.
- After the meal. Toddlers should be taught to help with the clean-up after eating, by doing simple tasks such as taking their dishes to the sink.
Explain to parents that none of these behaviours involve asking a toddler to eat. They encourage toddlers to enjoy taking part in mealtimes. Remind parents to encourage these behaviours consistently and set a good eating example themselves.
QUICK TIP FOR PARENTS
When your toddler has acquired good eating habits,they can properly regulate their own appetite and will eat enough to meet their needs2.
If a toddler is not consuming enough fibre-containing foods or enough fluid, or is drinking excessive amounts of cows’ milk, they can become constipated. Constipation in a toddler can result in a reduced appetite1.
- To include enough fibre in a toddler’s diet, parents should aim to1:
- Provide a high-fibre cereal for breakfast each morning, e.g. one wheat biscuit or a small bowl of porridge or bran flakes
- Offer some wholemeal bread each day
- Provide 2-4 portions of fruits and vegetables each day
To include enough fluid in a toddler’s diet, parents should aim to1,4:
- Offer about six beakers containing 150mls (5oz) water everyday
- Offer two or three beakers of 150mls (5oz) milk everyday
- Limit juices to no more than one glass per day and ensure they are well diluted with water.
To avoid excessive cows’ milk consumption, parents should remember to1,2:
- Use a lidless beaker
- Plan their toddler’s fluid consumption so that fluids are spread out evenly over the day
- Keep meal and snack times regular
- Offer no more than 600mls (20oz) of cows’ milk every 24 hours
When dealing with a constipated toddler, remind parents that: Constipation is a common problem in toddlers and is not a cause for concern in most cases. While toddlers do not have to have a bowel motion every day, there are symptoms of chronic constipation which parents can be aware of. These include:
- Having fewer than 3 bowel motions a week
- Toddler straining when having a bowel motion
- Toddler distress or anxiety around passing a bowel motion
- Behaviour indicating a toddler is withholding stools
- Episodes of soiling clothes
- POOR SLEEPING PATTERNS
Insufficient sleep can result in an irritable toddler who is less interested in eating or who is less sensitive to their satiety cues. The amount of sleep needed varies by age, but the approximate allocated hours for sleep each day4 are:
HOW MUCH FOOD SHOULD BE PROVIDED AT MEAL AND SNACK TIMES?
Toddlers grow at different rates and have different levels of physical activity, and so have different-sized appetites. Every toddler has the ability to regulate their own appetite, so parents should create an environment in which a toddler can choose the amount of food they eat.
Since toddlers vary in their rate of development, portion sizes for this age group7 are not exact. This is why the positive approach to feeding a toddler is so important. Parents should help toddlers to serve themselves, but should also avoid over-filling plates with food1,2. If a smaller second serving is needed, that’s okay. These guidelines can give parents an idea of the approximate amount of food a toddler might need at a meal or snack. Bigger and more active toddlers might need a little more, and smaller less active toddlers may need a little less.
PARENTS SHOULDN’T MAKE ALL THE EATING DECISIONS
When feeding a toddler, a parent’s job is to decide on the what, when and where of eating. A toddler’s job at meals is to decide on the whether and how much6. This means that once a parent has prepared a meal and provided it on schedule at a table, they should not interfere in the decisions a toddler makes on whether, and how much, they eat. Instead, they should sit down, pay attention to their own meal and focus on creating a relaxed and enjoyable eating environment in which their toddler will want to participate without any prompting7.
Some toddlers find it difficult to eat similar amounts of food each day. Instead, they have some days where they eat particularly well, and some where they eat what appears to be quite little. This is generally due to a food regulation pattern which is week-by-week, rather than day-by-day2. There is often no particular reason2 why some toddlers regulate their food intake this way. Parents should try to avoid labelling the toddler as fussy or picky, and should simply continue to provide nutritious meals and snacks at regular intervals. If a toddler is sleeping well, growing normally, alert throughout the day, and is not constipated, there is generally no cause for concern when food is consumed in this pattern6.
QUICK TIP FOR PARENTS
Learn the signs your toddler has eaten enough. When you can tell that they’re full, give them permission to leave the table.
SIGNS A TODDLER IS EATING ENOUGH
It’s important that parents can recognise the signs that their toddler has eaten enough. Signals of satiety1,2,3 include:
- Spending a long time chewing a mouthful of food.
- Holding food in their mouth for extended periods, without chewing.
- Playing with the food on their plate.
- Trying to leave their chair.
- Saying no and becoming more vocal about wanting to do another activity.
Once a toddler expresses these signals, they should be given permission to leave the table. Parents should not distort a feeding routine by omitting meals or snacks to make a toddler hungrier2. Instead, an unfinished plate should be removed without comment, and the next meal or snack should be offered at the usual time. Doing this positively benefits the regulation of food intake and weight.
Rather than always focusing on the quantity of food eaten, it can be helpful to encourage parents to step back and look at the overall health of their toddler.
Checklist for Parents!
Your toddler is eating enough, if they are:
- Growing normally.
- Meeting developmental milestones.
- Active and energetic throughout the day.
- Alert and interested.
- Not constipated.
- Sleeping regularly and well.
No-one, whether they are a toddler, child, teenager or adult, has a perfect diet. There will always be aspects of a toddler’s diet which can be improved upon, but if a toddler is showing the signs of healthy eating as listed above, parents need not worry. Parents should continue to provide a warm, relaxed and inclusive feeding environment for the entire family, and to trust that with such a healthy environment available, their toddler will reap the benefits of it.
Suitable articles for parents on this topic are available at www.toddlebox.ie/nutrition