Helping toddlers eat right


Many toddlers are deficient in iron and on their way to becoming obese. Pediatricians can help these little ones establish healthy eating habits by educating their parents.

Helping toddlers eat right

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Choose article section...Many reasons for iron deficiencyObesity on the increaseAnticipatory guidance the keyThe time is rightGUIDE FOR PARENTS: Feeding your toddlerGetting enough calcium and iron

By Alvin N. Eden, MD

Many toddlers are deficient in iron and on their way tobecoming obese. Pediatricians can help these little ones establish healthyeating habits by educating their parents.

Infants tend to have a nutritious diet during their first year of lifebecause parents usually scrupulously follow their pediatrician's adviceabout feeding. In addition, many of these young children are being breastfed,and iron-fortified formulas and iron-enriched and nutritious baby food lowin salt and sugar are in common use. The marked decline in the prevalenceof iron-deficiency anemia during the first year of life, one of the importantrecent success stories in pediatrics, is a marker of how infant diet hasimproved in recent years.1

The picture changes when the infant becomes a toddler. Because of laxand faulty feeding practices, many 1- to 3-year-olds develop two major nutrition-relatedproblems--iron deficiency and obesity. Both of these conditions are easyto prevent.

Many reasons for iron deficiency

The Third Report on Nutrition Monitoring in the US reported anemia in15% of 1- to 3-year-old children tested between 1988 and 1991.2Prevalence of anemia was 19% in the 1996 Pediatric Nutrition SurveillanceSystem Report of 50,000 1- to 2-year-olds.3 In a recent studyof 500 healthy inner-city 1- to 3-year-olds, 20% were iron deficient and11% had iron-deficiency anemia.4 These findings may reflect less-than-adequateintake of iron during the first year of life, the too-early introductionof cow's milk, or the use of formulas that are not fortified with iron.Of greater importance, however, is the scenario that often unfolds afterthe baby's first birthday:

  • A switch from breast milk or an iron-fortified formula to regular cow's milk, which contains practically no iron
  • Use of cereals for adults, which are not fortified with iron, rather than iron-fortified infant cereals
  • The toddler's decreased appetite for solid foods and increased intake of milk and juice.

In 1994, the Third Nutritional Health and Nutrition Survey confirmedthat the daily iron intake in 1- to 3-year-old children is lower than inany other age group of children or adults.5 These findings andthose in the studies cited above are disturbing since the association ofiron deficiency and impaired psychomotor and mental development during thefirst two years of life is now firmly established. Two large-scale, well-controlled,prospective follow-up studies showed that these deficits are long lastingand perhaps irreversible, despite adequate treatment to correct the irondeficiency.6,7 This strongly suggests that iron-deficiency anemiaduring the second year of life is just as dangerous as iron-deficiency anemiaduring the first year of life.

Iron-deficiency anemia is prevented when the toddler eats iron-rich foodssuch as poultry, fish, red meats, iron-fortified cereals, iron-fortifiedgrain products, green vegetables, and dried fruits (see table on page 198).Eating citrus fruits and juices along with iron-rich foods increases ironabsorption, which is enhanced by vitamin C. Many toddlers are picky andfinicky eaters, however, so it's a good idea to routinely recommend dailysupplemental iron during the second year of life. (You may want to makean exception for the occasional toddler who has a good appetite and eatsa well-balanced diet containing iron-rich foods.) Supplements are availableas iron drops, iron-fortified vitamins, or an iron-fortified nutritionaldrink. It is easier and safer to prevent iron deficiency with these supplementsthan to screen for it and treat youngsters found to be anemic.

Obesity on the increase

Childhood obesity in the United States has risen dramatically in thelast 20 years.8 Obesity often starts when the child is a toddler.Increasing numbers of toddlers drink enormous quantities of milk and juice,especially apple juice. Many 1- to 3-year-olds also are offered foods highin sugar and fat, both at home and in fast-food establishments during familyoutings. These faulty eating habits and too many hours spent sitting infront of the television set can lead to excessive weight gain.

Anticipatory guidance the key

In our practice, we try to head off the bad eating habits that lead toiron deficiency and obesity by offering anticipatory guidance about nutritionat the one-year visit. We explain to parents the dangers of iron deficiencyand of obesity and point out the importance of prevention while the childis still a toddler.Parents learn to monitor and, if necessary, restrictmilk and juice intake and to offer their child a variety of foods from eachof the major food groups. We also encourage participating in physical activitiesas a family.

We give parents three nutrition-related handouts we have developed withthe Committee on Nutrition of our district chapter of the American Academyof Pediatrics. They contain guidelines similar to those in the Parent Guidewith this article.

The time is right

Pediatricians can help toddlers establish healthy eating habits thatwill serve them well the rest of their lives. The key to teaching toddlersto eat as they should is to convince their parents that it is worthwhile
to dedicate time and energy to the task. Anticipatory guidance reinforcedby handouts is the best way to motivate parents to offer their toddlersa healthy diet.


1.Oski FA: Iron deficiency in infancy and childhood: N Engl J Med 1993;329:190

2.Third Report on Nutrition Monitoring in US. Bethesda, MD, Federationof American Societies for Experimental Biology, Life Sciences Research Office,1995

3. Committee on Nutrition, American Academy of Pediatrics: Personal communication,1998

4. Eden AN, Mir MA: Iron deficiency in 1- to 3-year-old children: A pediatricfailure? Arch Pediatr Adolesc Med 1997;151:986

5. McDowell MA, Briefel RB, Alaimo K, et al: Energy andMacronutrientIntakes of Persons Ages Two Months and Overin US: Third Nutritional Healthand Nutrition Survey, Phase1, 1988­91. Atlanta, GA, US Department ofHealth and Human Services, 1994. Centers for Disease Control and PreventionAdvance Data No. 258

6. Lozoff B, Jimenez E, Wolf AW: Long-term developmental outcomeof infantswith iron deficiency. N Engl J Med 1991;325:687

7.Walter T, DeAndraca I, Chadud MT, et al: Iron-deficiency anemia: Adverseeffects on infant psychomotor development. Pediatrics 1989;84:7

8.Troiano RP, Flegal KM, Kuczmarski RJ, et al: Overweightprevalence andtrends for children and adolescents. Arch Pediatr Adolesc Med 1995;149:1085

GUIDE FOR PARENTS: Feeding your toddler

Once your baby is eating table food and has made the switch from breastmilk or formula to cow's milk, you need to make a special effort to seethat he or she eats the right foods. Toddlerhood is the ideal time to establishgood eating habits that will ensure the best possible physical growth andmental development and prevent disease later in life.

Offer a variety of foods from each of the following food groups, butdon't worry if your child doesn't have a serving from each group every day:

  • Vegetables
  • Fruits
  • Dairy products (milk, cheese, yogurt)
  • Meat, poultry, fish, eggs, andbeans (for example, chick peas)
  • Breads, cereals, pastas, and rice

Getting enough calcium and iron

Milk is the main source of calcium in your toddler's diet. Provide wholemilk from 1 year of age until 2, then gradually get the child used to drinkinglow-fat milk. Your child should drink no more than two or three cups ofmilk a day. Cheese and yogurt are also excellent sources of calcium, asare green leafy vegetables, soy beans, and calcium-supplemented juices.Don't let your child drink more than two cups of juice a day, however; ifhe is thirsty, offer water instead. Do not use sweetened juices, fruit drinks,or soda. These beverages are high in sugar and calories but have littlenutritional value.

It also is important that your child eat foods that are high in iron.Excellent sources are meats, such as pork, lean steak, hamburger, and lamb,as well as chicken, tuna fish, sardines, salmon, and white fish. Non-animalsources of iron are dried fruits, baked beans, baked potatoes with skin,almonds, lima beans, enriched macaroni, spaghetti, and white bread, peanutbutter, eggs, enriched and fortified breakfast cereals, broccoli, and peas.You can enhance the absorption of iron in these foods by offering your childcitrus fruits and juices to eat or drink along with them.

Snacks can be an important part of a nutritious diet--just don't offerthem to your child too close to mealtime. Crackers with cheese or peanutbutter, pretzels that are not overly salty, bread sticks, yogurt, and custardor pudding are nutritious snacks. Other possibilities are hard-boiled eggs,frozen juice pops, graham crackers, cut-up raw vegetables, leftover "fingerfoods," such as small pieces of chicken or meatloaf, cut-up fresh fruit,and cereal with milk and fruit.

Don't give your toddler salty snacks, like potato chips, and limit otherhighly salted foods and condiments, such as catsup and pickles. Also keepthe salt shaker off the table. Because salt intake and high blood pressureare related in some people, you don't want your child to acquire a tastefor highly salted foods.

THE AUTHOR is Chairman, Department of Pediatrics, Wyckoff Heights MedicalCenter, Brooklyn, NY, and Associate Clinical Professor of Pediatrics, NewYork Hospital­Cornell Medical Center, New York, NY.

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