TODDLERS : THE FUSSY EATER

Afiza Azmee

OVERVIEW

-What’s Toddler (range of age)

-The needs of a Toddler

-What is the normal diet for Toddlers.

-The Fussy Eating

-Management of The Fussy Eater

-Iron Deficiency in infant and young Children.

Toddler-hood

A child with the age of approximately 1-2 years. Time for change in behaviour and development Starting to achieve self-control of thinking, behaviour and social

interaction. Gain self-feeding skill and control over choice of food and

appreciation for taste and preference.THE SIGNIFICANCE OF TODDLER-HOOD Perfect opportunity to lay the groundwork for future normal

eating. Forcing food on an already satisfied child OR withhold food

from a hungry child, even if done with good intentions, can confuse the child about her own feelings of hunger leading to abnormal eating habits.

Normal Nutrition Requirement For Toddlers

Four Common Toddler Eating Behaviour

Small Quantity Eating Inconsistent Eating Patterns Food Jags Food neophobia

Normal To Be Fussy… But…

Normal for toddlers to be fussy Responsibility for food intake should be shared

between parent and child force-feeding not recommended. We start worry if:

– When it results in an inadequate intake of some nutrients.– If it’s a Sx of certain medical condition– Aggravated by dietary Mx of a specific medical condition

Why Do Parents Worry?

Lack of solid food intake. Perceived lack of growth; height and weight

of toddler check whether the parents have realistic expectation regarding this.

Child refuses ‘good’ food or the intake is nutritionally imbalanced.

Assessing Diet.

Take a brief diet history Usual pattern of breakfast, lunch, dinner and

snacks Take note about any medical condition the

toddler might have.

Assessing Diet: 1)Routine

Is there a lack of routine or is family eating chaotic?– Does the child sit down to 3 meals a day

OR– Does the child snack all day?

Suggestions to make:– Introduce routine of 3 meals/day and 3 snacks– Make sure snacks are healthy; mainly fruit, bread,

sandwiches, plain biscuits, yoghurts, cheese

Assessing Diet2)Nutritional balance

Is the diet nutritionally imbalanced?– Is there a high intake of crisps, lollies and takeaways?

Make sure snacks are healthy.– Does the child frequently demand breast or bottle feeds

Limit number of feeds; offer food first If bottle fed, change to a cup. Reduce milk intake to 600 ml/day

– How much juice, soft drink or cordial does the child drink? Reduce juice intake to 200 ml/day Offer water freely but limit cordial and juice to the occasional

– Do parents restrict the child’s usual intake in any way (eg; vegetarian, or weight conscious etc)

Investigate further or reassure.

Assessing Diet3)The type of food the child can eat

Are there problems with the type of food the child can eat.

– Is the child on a special diet Confer with the parents and the medical and dietetic team on

what is negotiable and not negotiable about the diet. Look for ways to modify the diet so that it’s more manageable

– Does the toddler still eat pureed food Assess as to cause Investigate and problems with swallowing etc. Introduce finger foods and lumps if appropiate.

Assessing Diet4)Child’s behaviour at mealtime

Is mealtime a war zone?

– How does the child behave during meals and how does the parent respond.

Let the child decide how much to eat Allow the child to self-feed Don’t force feed Keep meals and snacks short Change the venue

Asesseing Diet5)Parental Expectations

Are there unrealistic parental expectations?

How long does the typical meal last? – Advise parents to stay calm. – Give no snacks or drinks just before meals.

Guidelines For Parents of Toddlers

Over a week, your Toddler’s food intake should average out to the following quantities of food per day.

More is fine; as long as the intake of one particular type of food does not reduce the intake of others:

– 500 mL full cream milk or soy substitute– 2 small serves of meat, fish, chicken, egg, peanut butter,

lentils or bakes beans.– 3 to 6 serves of fruit and vegetable (no more than 200 ml of

juice/day)– 3 to 5 slices of bread or small serves of breakfast, pasta or

rice.

Managing The Fussy Eater:Tips for parents of fussy eaters

Set a good example – eat a range of foods yourself Have a routine of 3 meals plus snacks. Don’t fill them up with juice/milk/snack

just before meals. Provide a small serve; offer seconds if wanted. For slow eaters, serve food that is easy to eat (mince or casserole instead of

steak, cooked vegetables instead of salad) Allow some decision making by the child that doesn’t impact on food quality.

But don’t offer too many choices – ask the child to choose between two choices.

Limit the less desirable foods in the house. Bribery doesn’t work or work only in short term. Continue to offer refused foods without fuss or comment Be creative – eg add vegetables to spaghetti sauce, offer cheese and yoghurt if

your child don’t drink milk. Make eating a fun and happy experience ; picnics, meals in the gard,

When To Refer To A Paediatric Dietition

Dental caries

Irregular bowel habit

Anaemia and low iron stores

Chronic illness

Illness treated by diet

IRON DEFICIENCY IN INFANTS AND YOUNG CHILDREN

Anaemia In Toddlers; a brief overview.

Iron deficiency is a common nutrient deficiency in young children.

Anaemia is defined as an Hb level below the normal range:– Neonate: Hb<14g/dL– 1-12 months : Hb< 10g/dL– 1-12 years: Hb<11 g/dL

Physiology Iron Absorption; Very Briefly.

Depends on types of iron and its bioavailability.

Depends on body iron status The presence of promoters and inhibitors of

iron absorption.

Iron requirements in infants and children

3-4 months of life – need only low level of exogenous iron as they reuse fetal Hb.

After the first 6 months - need dietary source of iron because rapid growth will have depleted their iron stores.

– 9 mg/day By 1 year – their growth rate has slowed down, so

their iron requirement is reduced until adolescent. Adolescence – rapid growth of adolescence requires

increased iron in diet.

Iron in Milk

Breast milk : low iron content but 50% of the iron is absorbed

Infant Formula: supplemented with adequate amounts of iron

Cow’s milk: higher iron content than breast milk but only 10% is absorbed

Recommended dietary intake

AGE Iron (mg/d)

0-6 months (breastfed) 0.5

0-6 months (formula fed) 3

7-12 months 9

1-11 years 6-8

12-18 years 10-13

Dietery Sources of Iron

Common causes in children

Nutritional – a low dietary intake of iron especially in its bioavailable form.

Low birth-weight babies Cow’s milk protein enteropathy Haemangiomas Rare cause; iron malabsorption due to

coeliac disease.

Clinical Features

Iron deficiency without anaemia – aSx In the presence anaemia, usually associated

with:– Impaired psychomotor development– Lethargy, pallor– Decreased physical and mental performance– Occasionally, pica

Making The Dx…

Usually on clinical suspicion Laboratory Dx:

– Decreased Hb– Decreased hematocrit– Decreased mean cell vol– Decreased serum ferritin– Decreased serum iron level– Microcytosis and hypochromia on blood film– Increased reticulocyte count within 7-10 days of starting iron

supplements.

Management

Iron supplement – for a minimum of 3 months. Failure to respond to iron supplementation should prompt Ix for non-dietary causes.

Modify the diet– Encourage continuation of breastfeeding (the iron in human milk is more

bioavailable than cow’s milk). Now, formula milks are fortified with iron and supplemented with vitamin C to increase bioavailability.

– Introduce iron-fortified manufactured infant cereals, fruits, vegetables and diary products at around 6 months of age

– Use of an iron enriched cereal can be mixed with a Vitamin C rich food at the same meal

– Avoid tea and coffee – they will decrease iron absorption– Meat is a good source of iron – Vegetarians could include food like legumes (pea and bean group) and

grains. Include vitamin C rich food to improve bioavailability.

Thank You