THIRD EDITION

POCKET GUIDE

Bright Futures Nutrition THIRD EDITION

POCKET GUIDE

Katrina Holt, MPH, MS, RD Editor

Published by American Academy of Pediatrics American Academy of Pediatrics Department of Marketing and Publications Staff Maureen DeRosa, MPA Director, Department of Marketing and Publications Mark Grimes Director, Division of Product Development Sandi King, MS Director, Division of Publishing and Production Services Maryjo Reynolds Product Manager, Bright Futures Peg Mulcahy Manager, Graphic Design and Production Kate Larson Manager, Editorial Services Kevin Tuley Director, Division of Marketing and Sales Bright Futures: Nutrition, 3rd Edition Pocket Guide Library of Congress Control Number: 2010917945 ISBN: 978-1-58110-555-1 Product Code: BF0038 The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of care. Variations, taking into account individual ­circumstances, may be appropriate. Every effort has been made to ensure that the drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of the publication. It is the responsibility of the health care provider to check the package insert of each drug for any change in indications or dosage and for added warnings and precautions. The mention of product names in this publication is for informational purposes only and does not imply endorsement by the American Academy of Pediatrics. Copyright © 2011 American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission from the publisher. Printed in United States of America This publication has been produced by the American Academy of Pediatrics under its cooperative agreement (U04MC07853) with the US Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). 1 2 3 4 5 6 7 8 9 10 Fe Ba T S Key Nutritio Ado Midd E I Nutritio A B Building Bright Futures: Nutrition Bright Futures:Nutritio Table ofCon nfancy (Prenatal–Agenfancy 11Months) tra right Futures: Nutrition Vision and ar ips f bout Bright Futures: Nutrition deral Nutritionderal Assistance Programs sics for ly Childhood (Ages 1–4) ly Childhood tegies for lescence (Ageslescence 11–21) I ndicators of Nutrition le Childhood (Ages 5–10) le Childhood or Fostering aPositive Body n n H

an T S ools upervisio H dling Food ea lth Professionals to Promote t en t n s S ...... a R . fely ...... n is k for Children and Adolescents ...... I ...... ma G oa ge Among Children and Adolescents ...... ls ...... H ea lthy E at ing Behaviors ...... 55 ...... 64 ...... 70 ...... viii vii 71 45 37 25 74 ix 3 iii Bright FUTURES

Bright Futures: Nutrition v Bright FUTURES

dence between the parent the dence between and infant, the child, or adolescent; balance ofminerals diet; the inthe and dependence indepen- ­bal I 2. ceptu ­crit Balance is centralBalance nutrition to good and the health: good child care facilities, schoolsystem, the and community. the and adolescents requires effort in manysettings:the home, ence infants, children’s, and adolescents’ eating behaviors. pressuressocial created those (eg, byinflu- all the media) availability,food family and cultural customs, and external of dailyaspects life. Bright Futures: Nutrition weaves nutrition principles into all 3. 1. B B nteg uilding BrightFutures:Nutritio g ance of protein, calories, fat, carbohydrates, ical principlesical consistent with Bright the Futures con An elem ­childr Nut well-being. promotion. This comprehensive based guideon3 is right Futures: Nutrition is offeredthe in spirit of health rating nutrition good into lives the of infants, children, ood n ood al frameworkal rition must integrated be into lives the of infants, en, adolescents, and families. utrition requires balance. ent of joy enhances nutrition, and health, I t incor porates aclear understanding that ­vit n amins, and ­ of healthy nutrition into people’s lives. The ofA sense joy of is fundamental to effective the integration for balanced can health. be good Futures: Nutrition ways and food inwhich describes nutrition and balanceof the cultural norms trends. and Bright secular the livesthe of infants, children, adolescents, and families. their sis on nutritional integration, balance, and improve joy will andchildhood, adolescence. We hope that guide’s the empha- nutrition during supervision infancy, early middle childhood, Bright Futures: Nutrition provides athorough of overview munity at clam the bake. mother’s breast, family the at dinner the table, and the com- as happy events that bring people together—the infant at the Nutrition planning and preparing and sharing are food seen in infants, children, adolescents, families, and communities. Bright Futures: Nutrition of value sense the wonder and joy ­cont ributors to vii Bright FUTURES viii Bright FUTURES Th and Bright Futures:Nutritio ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ e vision and goals of Bright Futures: Nutrition are to ado b I withinnutrition community. the services roles the ofDescribe professionals health indelivering status of infants, children, and adolescents. ­fami E n S r I I dentify opportunitiesdentify for coordination and collaboration desireddentify and health nutrition outcomes that mprove nutrition the status of infants, children, and esult from positive nutrition status. et guidelines to help professionals health promote the etween health professionalsetween health and community. the utrition status of infants, children, and adolescents. ncourage partnerships among professionals, health lescents. G lies, and communities to promote nutrition the oals n Vision need toneed practicehealthy eating behaviors. for own their and health to help develop them they skills the childrentheir and adolescents to become more responsible and adolescence, it is important for parents to encourage of and infancy childhood middle early During childhood. bined with flexibility, is essential for handlingthe challenges lies with consistent nutrition messages. Consistency, com- providing infants, children, adolescents, and fami- their tive attitudes toward and food healthy eating behaviors by The contextual approach emphasizesthe promotion posi- of healthy eating behaviors. and adolescents’ attitudes toward and food for encouraging for is critical understanding period, tal infants, children’s, and psychologicalsocial characteristics of eachdevelopmen- The developmental approach, whichthebased unique on is eating behaviors. develop positive attitudes toward and food practicehealthy textual approach for helping infants, children, and adolescents Bright Futures: Nutrition represents adevelopmental and con- A Dev A bou elopmental and Contextual Approach t BrightFutures:Nutritio n tion status of infants, children, and adolescents. families, and communities can make adifferencethe in nutri- Bright Futures: Nutrition is that, together, professionals, health adolescents is ashared responsibility. E and Communities Partnerships Among Health Professionals, Families, communication.good on family strengths and promote unity, bonds, and social of Family food. are meals emphasized help they because build and creating an environment that encourages enjoyment the lescents involves recognizing multiple the meanings of food and healthy eating behaviors ininfants, children, and ado- and celebration. Promoting positive attitudes toward food Food is connected with nurturing, family, culture, tradition, merable symbolic, emotional, and meanings. personal social, provides more than just and energy sustenance. health-enhancing as both viewed be and pleasurable. Food Bright Futures: Nutrition recommends that and food eating nco uraging healthy eating behaviors in infants, children, and O ne o f the principlesf the of I t hold s innu- ix Bright FUTURES x Bright FUTURES or guardian. legal an couldthis person be aunt, uncle, grandparent, custodian, care of infant, the child, or adolescent. “ Throughoutthe nutritionpocket guide, the term we use are applied to children and adolescents. orderstood misinterpreted, adult when especially guidelines tion information. recommendations Dietary misun- can be guidance; however, are they with contradictory faced nutri- infants’, children’s, and adolescents’ and health are looking for Parents want to know how can contribute they to their healthy eating behaviors. The familythis influence exerts by and adolescents’ attitudes toward and food adoption their of The familythe is predominant influence on infants’, children’s, tailored to need be gies to family’s the individual needs. and snacks into busy their lives. fessionals can help families how learn to fit nutritious meals a T ■ ■ ■ ­pa nd home life andschedules. with dealing hectic oday many families challenges facethe of balancing work ■ ■ ■ s E w T Providing food rent” to refer to adult the or adults responsible for the hared ransmitting attitudes, preferences, and values about food, stablishing environment social the is food inwhich hich affect lifetimeeating behaviors T o be m o be I n so ost effective, strate- me situations H ea lth pro- current generation and of generations to come. strive as to they ties ensure and health the well-being of the to professionals, health useful can be families, and communi- of infants, children, and adolescents. Bright Futures: Nutrition There are many opportunities to promotethe nutrition status Where We From Go Here in communicating positive nutrition messages. healthy, affordable, and enjoyablecanbe instrumental foods Communityties). settings and events that provide avarietyof child care centers, hospitals, schools, colleges and universi- in avarietyof community settings clinics, (eg, and health healthy eating behaviors. Bright Futures: Nutrition used can be adolescents develop positive attitudes about and food practice The communitycanbe invaluable in helping children and Nutrition Supervision 1 Bright FUTURES

them tothem eat varietyof awider foods. slows, but infants’ maturation activity allow and purposeful (ages 9–12months).Late infancy stage this During growth slows but rapid. is still (ages 6–9months). infancy stage this During Middle growth during stage. this occur (birth–age 6months). infancy Early The most rapid changes significantlyeach.vary in mental achievements, nutrition and needs, feeding patterns I Ov ■ ■ ■ nfanc ■ ■ ■ bir second half. during first the half the of year but less rapidly theduring fe G of year. the ye I triple weight birth their by age 1. I ■■ nfants usually regain weight birth their by 7days after nfants usually increase length their by first 50%inthe er rowth rates of exclusively breastfed infants and formula- d infants differ. Breastfed infantsgrow more rapidly ar, but rate the of increase slows during second the half th, doubleth, weight birth their by age 4to 6months, and INFAN y is into divided 3stages. Physical growth, develop- v iew C Y ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ which they acquire they which is them different. acquire motor same inthe order, skills but at speed the Development is an individual process. crawling, standing, and eventually walking. more physical activity, including sitting up, rolling over, trol over movements. their With increasing control comes ing. At first, infants mostspend timetheir of sleeping eat-and engages inchange dramatically during infancy. The amount andtype of physicalthat activity an infant development. during feeding facilitates and healthy emotional social physicalClose contact infant the between and aparent early and infancy. middle different textures,than they were able to consume during tothem eat including varietyfoods, awider with foods I I more volume at one and time require fewer feedings. quent feedings, whereas older infants are able to consume and varietyof increases. Newborns food fre- small, need As infants grow, ability their to consume agreater volume pur drin n late infancy, infants’ physical maturation, of mastery nfants tolearn chew and swallow, manipulate finger foods, poseful activity,poseful and reflexes loss ofallow newborn k from acup, and ultimately themselves. feed O ver th e next few months, infants slowly gain con- I nfants t ypically

3 Bright FUTURES Infancy 4 Infancy Bright FUTURES Common ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ sense ofsense competency. ents and can undermine parenting confidence parents’and in earlyDifficulties feeding evoke strong emotions in par- apy inan early intervention program. c I help overcome feeding problems. techniquesspecial for positioning, equipment or special to mayneeds emotional extra need support, instruction about Breastfeeding mothers of infants care health with special rupted for any reason. returns to work or breastfeeding when inter- to needs be visits, and help managing breastfeeding mother the when to provide follow-up care, phone consultation, follow-up ing guidance and referrals to lactation support services hospital,the breastfeeding mothers may breastfeed- need Afterthe mother new theand infant are dischargedfrom ormilk infant formula. Parents are often unsurewhethertheir infant to feed breast activity and motor development. skills with, and environments their influence all their physical The ways infants are held and handled,the toys they play nfants care health with may special needs have feeding hallenges that addressed of can as part be nutrition ther- N u t ri t ion Con c erns Interview Questions Interview age-specificvisits. provided firstpocketthe guide, in followed by information on Nutrition to entire the pertaining developmental is period H visitstion supervision or of visits. as part supervision health A N ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ n infant’s nutrition status should evaluated be during nutri- ea u H H H D H and from infant to infant. R and assessment and providing anticipatory guidance. parents before visit. the Continue by conducting screening questionsview or by aquestionnaire reviewing out filled by nutritionBegin by supervision selectively asking inter- into foods solid infant’s the diet. Parents may help need indetermining to when introduce m t lth professionals can following: dothe ecognize that questions,ecognize interview screening and assess- ow often do you yourfeed baby? ow doy ow your does baby letyou know she when is hungry? o you have any questions about feeding your baby? ow doyou feeding is going think for you and your baby? ent, and anticipatory from visit vary guidance to will visit ri t ion ou know she when has had enough to eat? S u p er v ision Screening and Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ fortable, distant, anxious). a O Assess infant the for age-appropriate development. gum E may normal or be may indicate anutrition problem. growthfrom patterns expected should evaluated. be This ence, and plot on them astandard growth chart. Deviation Measure infant’s the length, weight, and circumfer- head youDo bottled or use processed water? What is source the of your and drinking cooking water? buy food? Are you concerned about having enough money to H or infant formula? yourDoes baby receive anything breast besides else milk nd infants’ responses to one another (affectionate, com- valuate appearance the of infant’s the skin,hair, teeth, ow doyou feel about way the your baby is growing? bserve the parent-infant the bserve interaction, and assess parents’ s, tongue, and eyes. Food Feeding D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss ­con breast or milk open containers of ready-to-feed or Following safety food practicesfor storage of expressed f S and swiping toward food mouth. the include moving forward head the to reach spoon the For older infant (ages 4–6months), signs of hunger and grimaces, fussing. facial pre-cry include putting hand the to mouth, the sucking, rooting, For younger infant (up to age 3months), signs of hunger Feeding infant their until he is full. (cow’s, goat’s, soy), evenininfant cereal. iron-fortified infant formula and avoiding low-iron milk Feeding infant, their until age 12months, breast or milk 4 months, but preferably for 6months.) [only breast is recommended milk] for aminimum of growth and physical development. ( Breast provides milk nutrition ideal and supports optimal eeding iseeding normal. pitting up alittle breast or milk formula at each S centrated formula. afety P W ractices ith Parents of A ll I nfants E xc lusive breastfeeding

5 Bright FUTURES Infancy 6 Infancy Bright FUTURES S ( ■ ■ ■ ■ ■ ■ S upplements ■ ■ ■ ■ ■ ■ ee B ee 12 months.) Cow’s should milk not given be to infants younger than dayper of vitamin D–fortified formula whole or milk. is weaned and is consuming at day least 1Lper or 1qt life. ( min Ds G of illness. food-borne Following safety food practicesto reduce infant’s their risk of meat). sticky or tough such foods, as peanut butter, large chunks difficult-to-chew suchfoods, as popcorn, raw carrots, nuts; suchfoods, as hard candy, and whole grapes, hot dogs;dry Avoiding that foods may cause choking or (small slippery lukewarm; warm, down iftoo cool and test again). wa T or placing inabowlof them hot water for afew minutes. Warming bottles by holding under them hot water running incontainersfood or jars microwave. inthe Dangers of warming expressed breast formula, milk, or esting warmed fluids to make surethat they aren’t too iving breastfed breastfed and partially infants avita- rm byrm sprinkling drops on fluid (the wrist should feel asics for S up upplement during beginning first the days few of plementation should continue infant unless the H an dling Food S a fely.) O ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ral supplements). the motherthe is vitamin B products], is undernourished, not does vitamin take B fluoridated toothpaste and flossing once a day]). oralticing hygiene good [brushing aday twice teeth with larly, limiting and foods insugar, beverages high and prac- Maintaining oral personal (visiting health dentist the regu- sippy cup containing insugar). beverages high allowing frequent and prolonged bottle-feedings or of use a infant to with sleep a bottle or sipper-type [“sippy”] cup or Avoiding habits to infant’s harmful their (putting teeth the infant’stheir mouth). a b H breakfast and before bed). and asmear of fluoridated toothpasteday a twice (after Brushing infant’s their with soft asmall, teeth toothbrush G ment during beginning first the days few of life. d G ay of vitamin D–fortified formulavitamin a D supple- iving breastfed infants vitamin B iving infants ingesting less day than 1Lper or 1qt per olding infant their feeding, and while never propping H ottle (using pillows or other to objects hold abottle in ealth 12 deficient (vegan [eats no 12 before age 6months if ­anim 12

al al Feeding D P ■ ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ ■ iscuss and prevent breasts the from getting full.) too growth. (Frequent feedings help establish supply milk the Feeding infant their more often periods of rapidduring day per 12 times thereafter. day per 12 times for months, next the several and 6to dayto per 12 times during weeks initial the of life, 8to Feeding infant their she when is hungry, typically 10 feedings). between adequatevides intake and allows mother the rest time offeringthe other breast (20–45minutesper feeding pro- Allowing infant their to finish feeding at one breastbefore mother’sthe makes). body process longer (the infant the sucks, more the breast milk Feeding infant their on demand stimulates lactation the mother and child wish to continue. Continuing breastfeeding for 12months or as long as the act Discouraging television and viewing encouraging inter ive and (talking activities reading together). P W ractices ith Parents of B reastfed I nfants ­ S Maternal ■ ■ ■ ■ ■ ■ upport ■ ■ ■ ■ ■ ■ ing tional nutrition counseling, and help extra at home. Mothers breastfeeding multiples require more addi- food, infant;the helping with burping, diapering, and bathing). E daysumed per [less for women].) small 8 oz wine, 12oz beer, or 2oz hard liquor should con- be ( Avoiding alcoholic beverages 2hours before breastfeeding. per day.(coffee, servings softdrinks) to2 tea, Limiting consumption the of beverages containing caffeine of aglass drinking water at eachfeeding. beverages suchDrinking or as milk juice thirsty and when E h I ealthy and helps infant the grow. ncouraging father the to help care for infant their (bring- ating avarietyof healthy helps foods mother the stay f th the the infant to the mother at breastfeeding time; cuddling e mother alcoholic drinks beverages, no more than E ating Behaviors

7 Bright FUTURES Infancy 8 Infancy Bright FUTURES Feeding D ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss infa S formula come out faster. Not enlarging hole the bottle inthe nipple to make infant feeding environment). firm too or hole too unheeded big, hunger cues, distracting ing position, formula prepared incorrectly, bottle nipple (uncomfortable time the usual orall hungry seems feed- Checking for causes infant iftheir more is crying than (infan O ­ap Preparing and offering more formulatheir infant’sas arefoods added. to 4hours in24hours) (6–8times until complementary Feeding infant their he when is hungry, 3 typically every p H eeking consultation with professional ahealth iftheir osition. olding infant their feeding, when inasemi-upright close fferingtheir infant water on hotdays between feedings petite increases. nt is not feeding enough. ts don’t water). usually need P W ractices ith Parents of F ormula- F ed I nfants F In P ( Food ■ ■ ■ ■ ■ ■ S or Pregnant ■ ■ ■ ■ ■ ■ RENA ee B ee terview Questions terview you gained at point? this did you gain inprior pregnancies? What was your pre-pregnancy weight? S orfeed concentrated formula. Covering and refrigerating open containers of ready-to- started. been infant has finishedeating; not reusingbottle athat has Discarding infant formulabottlethetheirwhen leftin Not adding cereal or other to foods infant formula. before opening). washing topeach use; and of drying formula container ­disinf cleaning area where formula is prepared; cleaning and procedures (washing hands before preparing formula; Preparing formula as and instructed, following toring powdered formula at room temperature. S asics for afety T ecting reusableecting bottles, caps, and nipples before AL H W an omen dling Food S a fely.) H ow m H ow m uch weight have uch weight ­sa nitary nitary F ■ ■ ■ ■ ■ ■ ■ ■ ■ or ■ ■ ■ ■ ■ ■ ■ ■ ■ to get help from as them you are learning to breastfeed? of your family or breastfeed? friends Would you able be youDo know anyone breastfeeds who her baby? Didany H body)? privacy, having enough breast changes milk, inyour youDo have any worries about breastfeeding (your diet, andgain, allergies sensitivities, food or any other reason? of appetite, aversions, food vegan or vegetarian diet,weight Are you restricting any inyour foods of dietbecause lack about breastfeeding? you heard about breastfeeding? you Do have questions What are your plans for feeding your baby? What have supplements? Are you using any or or (legal other illegal) drugs youwhen that learned you were pregnant? I youDo alcohol teas drink or or any take special herbs? t H Are you other taking vitamins or minerals? Are you or taking doyou plan to prenatal take vitamins? n o improve your since health you have pregnant? been s th urse yoururse baby? W ave you any used or traditional special remedies health ave you to any been classes that taught you how to omen Planningto ere anything that you were but taking stopped using H av e you had any breast surgery? B r eastfeed D Anticipatory Guidance F ■ ■ ■ ■ ■ ■ ■ or Parents Planningto ■ ■ ■ ■ ■ ■ ■ iscuss alcohol adversely affects development. fetal Avoiding consumption of alcoholic beverages, because most ready-to-eat breakfast cereals). Consumingwith fortified foods folic acid (grain products, and beans). kidney broccoli, brussels sprouts), and legumes (black, pinto, navy, ­(sp avocados), dark-greenstrawberries, leafy Consuming containingfoods folate, such as (oranges,fruits ­gi f O y H infant formula? Are you worried about having enough money to buy any questions about formula-feeding? ­fo What have you read or heard about different infant olic acid, or amixture of to both risk of minimizethe ou heard about formula safety? ving to birth an infant with tube aneural defect. ow doyou plan to prepare formula? the What have btain 600 dietary folatebtain 600dietary equivalents day per of folate, food rmulas (iron-fortified,soy, Do youlactose-free)? have inach, turnip greens), some other vegetables (asparagus, W ith Pregnant W F omen ormula- F eed ­veg etables

9 Bright FUTURES Infancy 10 Infancy Bright FUTURES D D ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss iscuss ­su p G first and more formulathe infant if seems hungry). 24 hours (2oz of infant 2–3 hours formula at every Feeding infant their on average 20oz of formula in and nipples. ­po Preparing infant formula (directions differ among c S 12 months.) Cow’s should milk not given be to infants younger than dayper of vitamin D–fortified formula whole or milk. is weaned and is consuming at day least 1Lper or 1qt life. ( min Ds G ­su t H o infants (many teas contain herbal ephedra and other hanges informula. electing infantelecting formula and discussing any proposed er day of vitamin D–fortified formulavitamin a D iving infants ingesting less day than 1Lper or 1qt iving breastfed breastfed and partially infants avita- erbal orerbal traditional remedies health may harmful be pplement first inthe beginning days few of life. bstances that may harmful). be wdered formulas), and heating and cleaning bottles S up W W upplement first inthe beginning days few of plementation should continue infant unlessthe ith Parents Planningto ith W omen Planningto F B ormula- r eastfeed F eed F F In NEWBORN ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ terview Questions terview (t Are you restricting any inyour foods diet? H breastfeed? D H when he is hungry? H e H H rooting, still look, anxious? H b H generally take? H ach day? ack, is irritable or calm? enderness, swelling, pain)? o you hear himmake swallowing sounds you when ow your does baby attach to your breast and suck? ow often do you yourfeed baby? ow many wet diapers and stools your does baby have ow your does baby behave after feedings? ow he behave does during afeeding?away, Pulls arches ow often your does baby feed? ave you had any problems with your breasts or nipples as your baby received any other fluidsfrom bottle? a B A reastfed ll I nfants I nfants H ow lo H ow doy ng does afeedingng does S ou know a tisfied baby tisfied Screening and Assessment F ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess administration of vitamin K. Perform metabolic screening as indicated by state. the infant formula? Are you worried about having enough money to buy H baby has finished feeding? What doyou dowith formula the bottle inthe after your H H (brands, cost, preparation, amount)? What questions doyou have about infant formula attake afeeding? H iron-fortified? What formula are you planning to use? street drugs)? youDo any use (prescription, drugs over counter, the youDo any drink teas or any take special herbs? youDo wine, beer, drink or other alcoholic beverages? to take? What vitamin or supplements mineral doyou or take plan ow your does baby like held to you when be her? feed ow doyou clean bottles, nipples, and other equipment? ow doyou store infant the formula after you make it? ow often do you yourfeed baby? I s yo ur baby receiving vitamin Dsupplements? F ormula- F ed I nfants H ow m I s th uch does sheuch does e formula D D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss iscuss ( well established; at occurs this around age 4to 6weeks. ments indicated) (unlessmedically until breastfeeding is Avoiding nipples artificial (pacifiers, bottles) and supple- ­gainin diapers and 3or 4stools in24hours and infant the is Their infant is gettingthere if enough milk are 6 to 8 wet to 3hours, about 8to 12feedings in24hours. Feeding infant their she when is hungry, 2 usually every room. delivery the Feeding infant their immediately after preferablybirth, in with fewer distractions (lights, noise). s H than 4hours. Waking infant their for feeding infant ifthe more sleeps ­(cry S s S troking, or swaddling infant the or feeding inaroom ucking, and rooting, grimaces, fussing facial pre-cry igns of hunger include putting hand the to mouth, the elping infant their on focus feeding by rocking, patting, om ing is alate hunger). sign e infants pacifiers neverbottles.) use or g weight as expected. W W ith Parents of ith Parents of B A reastfed ll I nfants I nfants

11 Bright FUTURES Infancy 12 Infancy Bright FUTURES F In 3 T D ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss terview Questions terview H rooting, still look, anxious? H b H to eat? Are you comfortable that your baby is getting enough H fortake afeeding? H H first and more formulathe infant if seems hungry). 24 hours (2oz of infant 2–3hours formula at every Feeding infant their on average 20oz of formula in ­br ­int Waiting until breastfeeding is well established before O ack, is irritable, or calm? ow your does baby behave after feedings? ow he behave does during afeeding?away, Pulls arches ow your does baby like held to you when be him? feed ow often your does baby feed? ow are you feeding your baby? as he received any other fluidsfrom bottle? a eastfeeding and formula-feeding). roducing infant formula (for mothers combining 5 DA W ith Parents of YS A ll I nfants F ormula- H ow lo F ed ng does itng does generally I nfants S a tisfied baby tisfied F F ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and storing it safely? What questions doyou have about preparing formula (brands, cost, preparation, amount)? What questions doyou have about infant formula hold bottle? the H take at afeeding? H H ir What formula are you feeding your baby? H H (tingling sensation and astrong surge of milk)? youDo “let-down” feel agood or “milk-ejection” reflex breastfeed inarhythm? yourDoes baby suck she well? latch Does on well and I H What is longest the he time has slept at one time? H s your baby receiving avitamin Dsupplement? on-fortified? ow doyou hold your baby feeding? while ow often do you yourfeed baby? ow are you preparing formula? the ow often does yourbaby feed? ow is breastfeeding going for you and your baby? ow many wet diapers and stools he have does eachday? ave you noticed changes inyour milk? F B ormula- reastfed F ed I nfants I nfants H ow H ow m long do feedings last? I uch does heuch does s it H ow doy ou D Anticipatory Guidance Screening and Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss more than 4hours. Waking infant their for feeding infant ifthe for sleeps ­fu m S to suck. distractions environment, inthe and infant’s the ability with infant, the parent’s the and infant’s the responses to parent the between and infant, the parent’s the parentthe with feeding seems infant, the eyecontact ­pa I and age-appropriate elimination patterns. Assess infant the for intake, milk hydration, jaundice, Perform metabolic screening as indicated by state. the infant formula? Are you worried about having enough money to buy f possible, observe the mother the f possible,breastfeeding observe or either igns of hunger include infant putting hand the in the outh, sucking, and rooting, grimaces, facial pre-cry ssing (crying is alatessing hunger). (crying sign rent bottle-feeding infant. the Assess how W ith Parents of A ll I nfants ­comf ­int ortable eraction D D ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss iscuss more formula infant ifthe hungry). seems 24 hours (2oz of 2–3hours formula at every first and Feeding infant their on average 20oz of formula in ( is well established; around occurs this age 4to 6weeks. ments indicated) (unlessmedically until breastfeeding Avoiding nipples artificial (pacifiers, bottles) and supple- days.)quently several as every feeding afterstoolsor every as infre- [typically loose] about 6to 8wet diapers in24hours. ( Afterthe mother’s comes milk in,infants should have total of 10 to 12feedings in24hours. at night, with 4-to 5-hour stretches feedings; between 2to 3hoursof every 3hours daytime inthe and every Their infantsettling intotypical breastfeeding routine with fewer distractions (lights, noise). s H S troking, or swaddling infant the or feeding inaroom elping infant their on focus feeding by rocking, patting, om e infants pacifiers neverbottles.) use or W W ith Parents of ith Parents of F B ormula- reastfed F I nfan ed I nfants I ts may have nfants

13 Bright FUTURES Infancy 14 Infancy Bright FUTURES F F In BY ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ terview Questions terview him eachtime? H you feeding your baby? Are you breastfeeding exclusively? vitamins? Are you giving your baby any supplements, herbs, or What is longest the your time baby has slept? e H H you do? v H know ifyour baby has had enough food? H D H 1 ach day? ery fast to and want seemed ery to eatWhat time? the all did uring night? the ow often do you yourfeed baby? ow many wet diapers and stools your does baby have ow your does easily baby burp during or after a feeding? ow doyou know ifyour baby is hungry? ow often are you feeding yourbaby theday?during ave growing to shebe when times there seemed been MON T H B A reastfed ll I nfants I nfants I H f no ow lo t, what are else ng doyou feed H ow doy ou F ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ f infant formula? Are you worried about having enough money to buy (cost, preparation, nutrient content)? What concerns doyou have about infant formula H H at afeeding? H What formula doyou use? with abottle? bed youDo everprop abottle to your feed baby or put her to H you pumping your breast milk? Are you planning to return to work or school? H Are you breastfeeding more often or for longerperiods? ormula? ow long it does to take your feed baby? ow often your does baby feed? ow lo ow can you tell ifyour baby is satisfied the at breast? ave you given your baby anything other than infant ng doyou keep it? F ormula- F I ed s th I e formula iron-fortified? nfants H H ow doy ow m uch does sheuch take does ou store it? I f so , are D Anticipatory Guidance Screening and Assessment ■ ■ ■ ■ ■ ■ ■ ■ iscuss ­su coordinated swallowing and infant the is sitting with 4–6 months, sucking the when reflex changes allowto until infant their is developmentally ready (at about age Forgoing other foods than breast or milk infant formula agesbetween 6and 8weeks. Their infant’s increasing appetite growthduring spurts, infant the whether is receiving vitamin Dsupplementation. For breastfed breastfed and partially infants, determine ity to suck. to distractions environment, inthe and infant’s the abil- tion with infant, the parent’s the and infant’s the responses parent the between and infant, the parent’s the interac- able parent the with feeding seems infant, the eyecontact ­pa I f possible, observe the mother the f possible,breastfeeding observe or either pport and and head has good neck control). rent bottle-feeding infant. the Assess how comfort- W ith Parents of A ll I nfants D D ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss iscuss ( infantthe may consume 20to 31oz of formula in24hours. Feeding infant their on average 24to 27oz of formula, but ­bo nor andhungry allowing full infant the to explore the than mother the infant their when is neither extremely When appropriate, introducing abottle by someone other ing weight as expected. diapers and 3or 4stools in24hours and infant the is gain- Their infant is gettingthere if enough milk are 6 to 8 wet recommend short, frequent feedings.) I with fewer distractions (lights, noise). s H a ndications inconsolably of colic (crying for hours several I troking, or swaddling infant the or feeding inaroom nd passing alot of gas). ( nfan elping infant their on focus feeding by rocking, patting, ttle’s nipple and put it inhis mouth. t needs to feed every 3–4hours.) tot needs every feed W W ith Parents of ith Parents of I F B f th ormula- reastfed e mother is breastfeeding, F ed I nfants I nfants

15 Bright FUTURES Infancy 16 Infancy Bright FUTURES F F In 2 ■ ■ ■ ■ ■ ■ ■ or Parents of or Parents of ■ ■ ■ ■ ■ ■ ■ terview Questions terview MON H pump your inprivacy? milk yourDoes schoolor workplace have aplace where you can you pump your breast milk? Are you planning to return to work or school? breast milk? yourDoes baby receive other or foods fluidsbesides or for longer periods? like it your seem Does baby is breastfeeding more often her eachtime? H did you do? v H T ery fast to and want seemed ery to eatWhat time? the all ell meell about you foods the all are offering yourbaby. ow lo ow often do you yourfeed baby? ave growing to be he when times seemed there been T ng will young will keep it? HS B A reastfed ll I nfants I nfants H ow w H ill youill store your milk? ow lo ng doyou feed I f so , will , will Screening and Assessment F ■ ■ ■ ■ ■ ■ ■ or Parents of ■ ■ ■ ■ ■ ■ ■ receiving vitamin Dsupplementation. For breastfed infants, infant the determine whether is to suck. ­dis with the infant, parent’s the and infant’s the responses to parent between tact and infant, parent’s the interaction able parent the with feeding seems infant, the eyecon- ­pa I h O infant formula? Are you worried about having enough money to buy with a bottle? youDo everprop abottle to or feed put your baby to bed anything other than formula? About how long afeeding last? does at afeeding? H f possible, observe the mother the f possible,breastfeeding observe or either olding, comforting). cuddling, ow often your does baby feed? bserve parent/infantbserve interaction smiling, (gazing, talking, rent bottle-feeding infant. the Assess how comfort- tractions environment, inthe and infant’s the ability F ormula- F ed I nfants H ow m H av uch does he drink heuch drink does e you offered him D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss a gr E help develop and head neck control and motor skills. withobjects his eyes)to stimulate system nervous the and Playing with infant their (encouraging infant the to follow throughsleep night. the Adding cereal to infant’s their not dietwill help infant the ­su coordinated swallowing and infant the is sitting with 4–6 months, sucking the when reflex changes allowto until infant their is developmentally ready (at about age Forgoing other foods than breast or milk infant formula recommend short, frequent feedings.) I (lights, noise, other people). stroking) or feeding inaroom with fewer distractions and gentle, need repetitive stimulation (rocking, patting, G ndications inconsolably of colic (crying for hours several nd passing alot of gas). ( ncouraging “tummy time” to promote control head and rowing infants are more during distracted easily oss motor development. pport and and head has good neck control). W ith Parents of I A f th ll e mother is breastfeeding, I nfants ­fe eding F In 4 D D ■ ■ ■ ■ ■ ■ ■ or Parents of ■ ■ ■ ■ ■ ■ ■ iscuss iscuss terview Questions terview MON b H or formula? Are you feeding your baby any breast besides foods milk are you feeding her? T night of up to 5or 6hours feedings). between 3–4hours,(infants with one every feed longer stretch at infantthe may consume up to 32oz of formula in24hours Feeding infant their on average 26to 28oz of formula, but S night feedings. between but may they have one longer stretch of 4to 5hours at By age 3months, feeding 2to infant their 3hours, every feeding more frequently during growth spurts. Breastfeeding infant their 8to in24hours, 12times and tools may as infrequent be 3days. as once every aby solids? ell meell about what you are feeding your baby. ave you thought about to give you when begin your will T W W HS ith Parents of ith Parents of A ll I nfants F B ormula- reastfed F ed I nfants I nfants H ow o ften

17 Bright FUTURES Infancy 18 Infancy Bright FUTURES F F ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ y (c H H H H What formula are you using? pumped breast milk? you pumping your breast milk? Are you planning to return to work or school? Are you giving your baby any supplements (vitamin D,H iron)? H p I I I ones?which H yourDoes baby interested seem inyour food? f ormula? s your baby breastfeeding more often or for longer n what ways is breastfeeding different nowfrom when n addition to feeding her at home, where is else she fed ou were last here? eriods? ow m ow often your does baby feed? ow can you tellhe is whether satisfied the at breast? as he received breast or milk other fluidsfrom bottle? a ave you offeredfrom her the familyfoods meal? ave you offered yourbaby anything than other infant as your baby to put begun her hands around bottle? the hild care,hild relative’s home)? uch in24hours? F B ormula- reastfed H ow lo F ed I nfants ng doyou keep it? I s th I nfants H H ow a e formula iron-fortified? ow m re you storing uch at afeeding? I f so I , are f so , D Anticipatory Guidance Screening and Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss allergic reactions. I ­su coordinated swallowing and infant the is sitting with 4–6 months, sucking the when reflex changes allowto until infant the is developmentally ready (at about age Forgoing other foods than breast or milk infant formula (leaningfullness back and turning away from food). R infant is receiving iron-rich or foods iron supplementation. receiving vitamin Dsupplementation and the whether For breastfed infants, infant the determine whether is infant formula? Are you worried about having enough money to buy a (m ntroducing one single-ingredient at food atime, nd observing the infant the nd for observing 3to 5days for possible esponding to infant’s their feedingindicating cues hunger pport and and head has good neck control). oving forward head the to reach bottle the or or spoon) W ith Parents of A ll I nfants D D ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss iscuss v t in 24 hours. but the infant may consume up to 26to 36oz of formula Feeding infant their on average 30to 32oz of formula, iron-rich foods. weight/day) infant ifthe not does consume sufficient Providing an iron supplement (1mg/kg of body Providing avitamin Dsupplement (400 the infant is ready for foods. solid ­te increased breastfeeding; and is unrelated to illness, demand continues for afew days; is not affected by related to infant’s their growth spurt. A demand for more frequent breastfeeding is anced dietand helps promote healthy eating behaviors.) variety of flavors, foods, and textures contributes bal- to a I an reaction. allergic I he first supplementalbecause it is least likelyfood causeto ntroducing avarietyof pureed or soft meats,fruits, and ntroducing iron-fortified, single-grain infantrice cereal as egetables after cereals. gradual (The introduction ofa ething, orething, changes inroutine, it may that asign be W W ith Parents of ith Parents of F B ormula- reastfed I F f an in ed I nfants IU I /day). nfants creased creased ­us ually ually F F In 6 ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ terview Questions terview MON b What are your plans for continuing to breastfeed? for longer periods? like it your seem Does baby is breastfeeding more often or o H What of types fluids is yourbaby gettingbottle ina cup?or which ones? H cer H H What are you feeding your baby at time? this formula appropriate for growth. ­con Vitamin supplements are not infant iftheir needed is n eachbreast? aby solids? ow often are you breastfeeding yourbaby? For how long ow are you planning to introduce such foods, solid as as he eaten any from foods family the meal? ave you thought about to give you when begin your will eal, fruits, vegetables, fruits, eal, meats, and other foods? suming an adequate amount of iron-fortified infant T HS B A reastfed ll I nfants I nfants I f so ,

19 Bright FUTURES Infancy 20 Infancy Bright FUTURES Screening and Assessment F ■ ■ ■ ■ ■ ■ ■ or Parents of ■ ■ ■ ■ ■ ■ ■ need for iron supplementation. receiving vitamin Dsupplementation, and assess the For breastfed infants, infant the determine whether is has had a dental caries(tooth decay). infant the whether Determine Assess eating behaviors to determine infant’s the risk for night feedings? m H u H ir I I b H s your baby receiving an iron supplement and/or s your baby receiving vitamin Dsupplements? ottle or cup? sing now? on-rich foods? ow often your does baby in24 hours,feed and how ow is formula-feeding going? What formula are you as your baby received breast or milk other fluidsfrom a uch does sheuch at take does afeeding? Day feedings versus ­dent al visit. F ormula- F ed I nfants D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss to sit with family the during mealtime. Placing infant their chair in ahigh (using asafety belt) o S food.) accepts aparticular not like it. ( Not forcing infant their to infant eatifthe food anew does I cause an reaction. allergic I allergic reactions. I and neck control). and infant the is sitting with support and head has good ­suc men I v a a ntroducing avarietyof pureed or soft meats,fruits, and ntroducing iron-fortified, single-grain infantrice cereal ntroducing one single-ingredient at food atime, ntroducing infant their when foods solid is develop nd observing their infant their nd for observing 3to 5days for possible s the firsts the supplementalbecause it food, is least likely to egetables after cereals. erving only juice 100%fruit inacup of as erving part ameal r snack, and limiting juice to 4to day. 6oz per king reflex changes allowto coordinated swallowing tally readytally (at about age 4–6months, the when W ith Parents of I t ma y take 10–15 attemptsy take before an infant A ll I nfants ­ D D ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss iscuss in formula appropriate for growth. ­con Vitamin supplements are not infant ifthe needed is 5 to 6 in24hours. times Feeding infant their infant the when is hungry, usually iron-rich foods. weight/day) infant ifthe not does consume sufficient Providing an iron supplement (1mg/kg of body Providing avitamin Dsupplement (400 of t E I de T nfantsfrom benefit playingwith toys for stacking, shak- alking with infant their alking during feedings. (As infants ncouraging mother the to breastfeed for first the year g, pushing,g, or dropping and from playing with others. velop, increasingly they respond interaction.) to social he infant’s life. suming an adequate amount of iron-fortified infant W W ith Parents of ith Parents of B F ormula- reastfed F ed I nfants IU I /day). nfants F F In 9 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or Parents of or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ terview Questions terview MON H her each time? o What are your plans for continuing to breastfeed? home (at child care)? youDo know what your baby eats he when is away from What your does baby he dowhen has had enough to eat? I a cup? What your does baby eat with his fingers? ­fe I I H When your does baby have something to eat or drink? Who feeds your baby? do y H s your baby interested you food inthe eat? s your What baby interested is he infeeding himself? s your baby less breast drinking or milk infant formula? ften does ftenyour does baby breastfeed? eding himself? ow is your supply? milk ow m ow going? has feeding been What questions or concerns ou have? T HS uch does heuch eat does or at drink a time? B A reastfed ll I nfants I nfants H ow lo ng doyou feed H as h e used e used H ow

21 Bright FUTURES Infancy 22 Infancy Bright FUTURES a G I Screening and Assessment F ■ ■ ■ ■ ■ ■ ■ ■ ■ ron-Deficiency Anemia nd Centers the for Control Disease and Prevention (CDC): or Parents of ■ ■ ■ ■ ■ ■ ■ ■ ■ uidelines from American the Academy of Pediatrics (AAP) infant formula? Are you worried about having enough money to buy from the bottle? youDo have any questions about weaning your baby waterDoes the contain fluoride? What kindof water to prepare is used formula? the H night feedings? m H What formula are you using now? ir I s H I s your baby receiving an iron supplement and/or s your baby receiving vitamin Dsupplementation? oy milk? on-rich foods? ow are you preparing infant formula for your baby? ow often your does baby in24 hours?feed as your baby had infant formula or cow’s, goat’s, or uch does he atuch take does afeeding? Day feedings versus F ormula- F ed I nfants H ow L ■ ■ ■ ead ■ ■ ■ S 15–18 months). (CDC) at ages 9to 12months and again 6months later (ages S S — — creen infant the for exposure. lead creen infants at risk or with known high those risk creen infants at about age 12months. (AAP) — — E ▶ ▶ ▶ ▶ ▶ ▶ ▶ ▶ I I a a nfants have who known risk factors for iron-deficiency nfants considered at risk for high iron-deficiency xposure nemia include nemia include ▶ ▶ ▶ ▶ ▶ ▶ ▶ ▶ 4 months I I I I I I (W Nutrition Program for Women, I I ade m nfants are who breastfed and donot who receive nfants fed cow’s before milk age 12months nfants fed non–iron-fortified infant formula for nfants preterm born or with low weight birth nfants and children are who Mexican American nfants are who migrants or recently arrived refugees nfants are who eligible for nfants from families with low incomes ore than 2months I quate iron from supplemental after foods age C) S pe cial cial I nfan S up ts, and Children plemental ­fact ors D Anticipatory Guidance V O ■ ■ ■ ■ ■ ■ ■ ■ itamin Dand iscuss ral of life. breast infant milk, formula, or through both first the year ing or bottle-feeding. Nevertheless, infants should receive in f U 10–15 attempts before an infant food.) accepts aparticular textures,certain refusing to chew, or vomiting. ( de G need for iron supplementation. receiving vitamin Dsupplementation, and assess the For breastfed infants, infant the determine whether is has had adental visit. dental caries(tooth decay). infant the whether Determine Assess eating behaviors to determine infant’s the risk for nderstanding that infants become more will interested radually introducing infant their to textures solid to crease risk of the feeding problems, such as rejecting H ood their parents their ood eat and less interested inbreastfeed- ealth W ith Parents of I r on A ll I nfants I t ma y take y take D ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss th iron-rich foods. weight/day) infant if the not does consume sufficient Providing an iron supplement (1mg/kg of body Providing vitamin Dsupplement (400 E dinner.) same eating breakfast, schedule lunch, as family: the and noon, and evening. inthe (Most 9-month-olds are on the Providing infant their snacks midmorning, after- inthe and drinks. fruit sodas Avoiding feeding infant their sweetened beverages, such as sn S sit with family the during mealtime. Placing infant their chair inahigh (using asafety belt) to mo O fr O erving only juice 100%fruit inacup of as orerving part ameal ncouraging mother the to breastfeed for first the year of om gumming to chewing foods. ffering small softpieces their infantof as foods gains fferingsoft, moisttheir infant as foods gradually moves e infant’s life. ack, and limiting juice to 4to day. 6oz per re control over picking up and holding food. W ith Parents of B reastfed IU I nfants /day).

23 Bright FUTURES Infancy 24 Infancy Bright FUTURES D ■ ■ ■ ■ iscuss formula appropriate for growth. ­con Vitamin supplements are not infant ifthe needed is in24hours.6 times Feeding infant the infant the when is hungry, usually 5to suming an adequate amount of iron-fortified infant W ith Parents of F ormula- F ed I nfants in ing more interested and foods new participating intrying handstheir rather than using utensils. They arebecom- ­com Young (ages 3–4).Young child children are increasingly motor eating so skills, is often messy. and refusing to eatThey are foods. certain developing fine ofsense independence and sometimesover by struggles food Toddler (ages 1–2). is into divided period 2stages. and emotionalsocial, development are tightly linked. The E Ov ■ ■ ■ ■ ■ ■ ■ ■ ar ­fami soft eatingpieces to of with food morefoods texture. As toddlers’ eating develop, skills progress they from eating may become unpredictable. appetites decrease, and amount the consume of they food As growth rates decline during early children’s childhood, 6.5 lbs and grow 2.5to 3.5inches year. per ages 2andBetween 5,children gain an average of 4.5 to Children quadruple weight birth their by age 2. ■■ ly childhood is a period during physical, which is aperiod ly childhood cognitive, er petent at self-feeding,but prefer still they eating with EARLY v ly meals. iew C HILDHOOD T odd lers are characterized by agrowing ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ appropriate during early childhood. catching) and simple games ( Physical jumping, (running, activities climbing, throwing, control of their large muscles but have still time to just play. Parents to need plan that so activities children can master that last alifetime. will E they were as toddlers. are more comfortable eating inunfamiliar places than bowls and plates and to passothers. food Young children can followthemselves from can instructions.serve They As young children grow, become less impulsive they and reluctant foods. new to try werethan they may asstill although toddlers, they be Most young children become more curious about food from acup. ontofood pick aspoon, up with afork, food and drink By age 3or 4,children are able fingers to their use to push day little and next. the very o T smell, and taste many them before times accept they them. e T m at tolook They need them. the and at new foods touch, ne day and dislike next. the may them They eat alot one oddlers areoddlers unpredictable. may They like certain foods of and foods new may tend leery oddlers refuse to to be arly is akeyfor time childhood promoting develop- the ent of motor and habits skills good for physical activity S imo n S a ys, chase, are tag)

25 Bright FUTURES Childhood Early 26 Early Childhood Bright FUTURES Common ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ in c elimination problems, and metabolic disorders. inadequate or excessive intake, food developmental delays, tion concerns, including growth, poor eating poor skills, care health Children with may special needs have nutri- on growth and development. incomes. I disease. vascular diabetes mellitus, hypertension, dyslipidemia, and cardio- ciated with many chronic conditions, health including with increasing risk of persistent obesity. andhood, degrees higher of excess weight are associated Children are who often obese remain into obese adult- a O a healthy weight. physicallyBeing active helps ensure that children maintain and balance. require which sports, acuity, visual control, cooperation, Young children are not ready for organized, competitive ron and deficiency iron-deficiency anemia are common mong children ages 2to 5. besity prevalence from has risen 5%to more than 12% hildren, especially childrenhildren, from especially families with low I ro N u n-deficiency anemia n-deficiency may have adverse effects t ri t ion Con c erns O besi ty isty asso- Interview Questions Interview age-specificvisits. provided firstpocketthe guide, in followed by information on Nutrition to entire the pertaining developmental is period H visitstion supervision or of visits. as part supervision health A c N Adolescents.) ( ■ ■ ■ ■ S ■ ■ ■ ■ ea u ee Keyee w H behaviors or growth? What concerns doyou have about your child’s eating and from child to child. R and assessment and providing anticipatory guidance. parents before visit. the Continue by conducting screening questionsview or by aquestionnaire reviewing out filled by nutritionBegin by supervision selectively asking inter- m hild’s nutrition status should evaluated be during nutri- t lth professionals can following: dothe ecognize that questions,ecognize interview screening and assess- hen she is full? ow your does child letyou know she when and is hungry ent, and anticipatory from visit vary guidance to will visit ri t ion I ndicators of Nutrition S u p er v ision R is k for Children and G Screening and Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ rowth andDevelopment f wh gum E dividing weight by square of height (kg/m using mass body index (BM child’s the Determine nutrition status and overall health normal or may indicate anutrition problem. growth patternsexpected should evaluated. be This maybe and plot it on astandard growth chart. Deviation from Measure child’s the length or height and child’s the weight, buy food? Are you concerned about having enough money to shewhen is away from home? youDo have any to concerns her about served food the and spoons,chair, ahigh seat)? abooster youDo have equipment for feeding your child (cups, forks What doyou doifyour child doesn’t food? like a particular do you do? what yourDescribe during child does mealtimes. What or-age growth chart to determine BM valuate appearance the of child’s the skin,hair, teeth, eel oreel calculator. Plot child’s the BM s, tongue, and eyes. I ). C alculate child’s the BM I I p a ercentile. nd age on aBM 2 ), or aBM use I b I I

y - Children AgesChildren 12to 18Months a G I ■ ■ ron-Deficiency Anemia nd Centers the for Control Disease and Prevention (CDC): ■ ■ uidelines from American the Academy of Pediatrics (AAP) (ages 15–18months). (CDC) ­fact S 18 m S — creen children at risk or with known high those risk creen children at about age 12months and about age — ▶ ▶ ▶ ▶ deficienc Children considered at to be risk for high iron- ors at ages 9to 12months and again 6months later ▶ ▶ ▶ ▶ onths. (AAP) Children are who Mexican American refugees Children are who migrants or recently arrived I S Children are who eligible for the Children from families with low incomes nfan up plemental Nutrition Program for Women, ts, and Children (W y anemia include I C) S pe cial cial ­

27 Bright FUTURES Childhood Early 28 Early Childhood Bright FUTURES Children AgesChildren 2to 5 ■ ■ p S — — — — creen children annually following ifthe risk factors are resent (AAP): — — — — ▶ ▶ ▶ ▶ ▶ ▶ Vegetarian diet Diet low iniron S deficienc Children have who known risk factors for iron- ▶ ▶ ▶ ▶ ▶ ▶ pecial health care health needs pecial a wound, an accident, or surgery. or or those with chronic infection; inflammatory dis (eg, antacids, calcium, phosphorus, magnesium) ­me care health Children use with who special needs day milk per Children consume who more than 24oz of cow’s 4 months adequate iron from supplemental after foods age Children are who breastfed and donot receive Children fed cow’s before milk age 12months more than 2months Children fed non–iron-fortified infant formula for Children preterm born or with low weight birth ders; restricted diets;or extensive loss from blood dications that interfere with iron absorption y anemia include ­ ­ P O ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ ral television during mealtimes. puter, games). child watches the video whether Determine ­te howDetermine much child spends the time watching in weekly. howDetermine much physical child activityengages the for dental caries(tooth decay). and insugar) beverages high to determine child’s the risk Assess eating behaviors of (frequency consuming foods child has the whether regularDetermine dental visits. p S — — — — — — — — creen children annually following ifthe risk factors are resent (CDC): levision and engaging inother (com- activities media — — — — — — — — H Migrant or recently arrived refugee E Low income S Limited of access because to food poverty or neglect Diet low iniron Limited access to food Low status socioeconomic ealth pecial health care health needs pecial ligible for W I C Meals and P D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ar ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss Being positiveBeing role models by eating foods. new b S food at one time. as snacks children because ofteneat small amounts of an O at a O much. Allowing to child to their whether eat decide and how r H (p H snac O Purchasing and preparing nutritious food. ent-Child Feeding esponding to internal of cues hunger and fullness. haring and meals snacks with child. their (Children eat etter an when adult is nearby.) elping to child learn their self-regulate intake food by elping child develop their skills eating and self-serving ffering nutritious (whole-grain crackers,foods milk ffering healthy choices food at meals and snacksserved ffering developmentally appropriate, healthy meals and rogressing from using hands for eating to using utensils). d milk products,d milk vegetables, fruits, meat or poultry) bout same the eachday. time ks at inapleasant times scheduled environment. W ith Parents S nacks R elationship E ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ating ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ (t S (s S ofhistory obesity, dyslipidemia, or cardiovascular disease). fa S fa H toModifying foods make for easier them child to their eat. 14 months. Weaning child from their bottle the by age 12to of am O comfort,to calm, or entertain her. Not using to foods reward, bribe, or punish child or their O herself. orfeed serve patientBeing and understanding as child learns their to ­dis Making family mealtimes apriority, and getting of rid erving children ages of erving 2and milk older 2servings children older thanerving age 2low-fat (1%) or fat-free reduced- children ageserving 1to(serving 2whole milk wo 8-oz day. cups) per kim) milk. kim) t [2%] milk ifobesity is oft [2%]milk concern or if there is afamily t intake. elping children ages 2to their 5gradually decrease ffering dessert (custard,ffering dessert part fruits, as pudding, yogurt) portionsffering small (1 tablespoons)or 2 of new foods. tractions (television). eal.

29 Bright FUTURES Childhood Early 30 Early Childhood Bright FUTURES ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ E in sugar. high drinks) drinks, soft ­limit Maintaining child’s their appetite for healthy by foods soft drinks). drinks, beveragesened (fruit unlimitedchild to amounts drink of juices fruit or sweet- t R 4 t S eggs [yolks]). ing) and vitamin (fortified cereals, D–fortified foods through vitamin (100 D–fortified milk chi Providing avitamin Dsupplement of 400 bread; 2–3oz of cooked lean meat, poultry, or fish). vegetables; ¾cup of juice; 100%fruit 1slice of whole-grain t S ­po as children ages 4andservings older, but with smaller Providing children ages 2to 3with same the number of meat, poultry, fish, and other protein-rich foods. f S ruits; vegetables; and products; milk milk and beans, lean ions, stools and and loose diarrhea by not allowing their hose eatenhose by older family members (½cup of or fruits erving 100% fruit juice 100%fruit inacup; limiting consumptionerving to children ageserving 4and older portionsizessimilar to children grain products,erving whole grains; especially ncouraging water child to their drink throughout day. educing risk of dental caries(tooth decay), minor infec- o 6 oz per day.o 6oz per rtions (about two-thirds of aserving). ldren donot who obtain 400 ing (candy, foods and cookies) beverages (fruit IU p er day of vitamin D IU p IU er 8-oz serv- per day per for ( Food ■ ■ ■ ■ ■ S ■ ■ ■ ■ ■ ee B ee in spreading peanut butter on thinly nuts finely, chopping rawcarrots finely or into thinstrips, pieces, cutting whole grapes lengthwise, inhalf chopping (cutting hot dogs in quarters lengthwise and then into small forModifying foods young their child to make safer them Following precautions to prevent child from their choking. care needs. m U H of illnesses. food-borne Following safety food practicesto reduce child’s their risk — — — — — sing techniques for positioning equipment or special or aving child sit their chair inahigh or seat dur- booster g feeding. odifying utensilsodifying for feeding childrenhealth with special — — — — — S dried fruits, whole grapes). fruits, dried chunks of meat, hot dogs,raw carrots, raisins and other chips, of spoonfuls peanut butter, nuts, large seeds, (hard candy, mini-marshmallows, pretzels, popcorn, Avoiding that foods may cause to choke toddler their Keeping mealtimes and snack calm. times Not allowing child to their eat car. inthe H S asics for taying eating. with child while their afety aving child siteating. their while H an dling Food S a fely.) ­crack ers or bread). O T ■ ■ ■ ■ ■ ■ ■ ■ ■ eaching Children AboutFood ■ ■ ■ ■ ■ ■ ■ ■ ■ ral Drinking waterDrinking thirsty. when effectively.)teeth shoelaces], typically by age 7or can brush 8,they their (After children acquire fine motor skills [ability their tie to y T before bed). fluoridated toothpasteday a twice (after breakfast and with soft asmall, toothbrush amountpea-sized and a of For children ages 2and older, brushing child’s the teeth paste aday twice (after breakfast beforeand bed). softsmall, toothbrush and asmear of fluoridatedtooth- For children ages 1to 2,brushing child’s the with a teeth I R dairy farm). et T O O nvolving shopping child infood their and preparation. oung children cannot clean without teeth their help. oothbrushing requires fine motor good control, and eaching child how are foods grown (planting aveg- eading books andeading books singing songs about foods. able garden) and where come foods from (visiting a ffering foods fromffering foods cultures. other ffering avariety of healthy foods. H ealth P ■ ■ ■ ■ ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ ■ ■ ■ ■ re no more than 1to 2hours of quality programming aday. (watching television, playing computer or games) video to Limiting child’s their total entertainment time media E h T ­fami physical which Letting child decide their the activities physically active. Planning family eachweek activities to encourage being have apositive impact on child’s their play experiences.) (Parents’ involvement and enthusiasm inphysical activity Playing with child and their physically being active. (child moves inany way he likes) play. Promoting structured (following both and leader) the free in sugar. high soft drinks) drinks, Limiting (candy, foods and cookies) beverages (juice, juice of approximately 0.8–1.0mg/L [ppm].) recommend abrand with fluoride added at aconcentration wa U aking part incommunity part aking projects as afamily (neighbor- ood cleanupood days, community gardens, drives). food ncouraging interactive (playing, activities singing, and sing community fluoridated watersafe, as a effective ading together). s to reduce dental caries.( ly will do (walking, hiking, playing hiking, do(walking, ly will tag). I f bo ttled waterttled is preferred,

31 Bright FUTURES Childhood Early 32 Early Childhood Bright FUTURES Screening and Assessment In 1 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ terview Questions terview Y M E S he eatDoes with family? the pieces of soft food? What textures your of does food he child eat? eat Does ing him from bottle? the bottle now and then? your from from heDoes drink child drink a acup? Does What of type infant formula or doyou milk him? feed Are you breastfeeding your child? — — — — — — — creen child for the exposure. lead ear valuate child’s the progress indeveloping eating skills. ake sure child the — — — — — — — Can drink fromCan drink acup apincerCan use grasp to pick up pieces small of food motion usingCan chew food an up-and-down or rotary swallow) Can retain mouth inthe food (doesn’t immediately H Can put mouth inthe food Can bite off small pieces of food as an adequate gag reflex I f so , what are your plans for wean- D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss cer together). playing,active (talking, activities singing, and reading Discouraging television and viewing encouraging inter- child eats.the I H ca O dr S andfoods feeding at afamily table. (c G E b in mposing limits on child’s their unacceptable mealtime erving beverages inacup.erving (Children may help need ehaviors without controlling amount the or of types foods valuate child’s the interest inactive play (bouncing, crawl- iving child opportunities their to develop eating skills andling child’s their limit-testing behaviors (asking for ffering their child food every 2 to 3 hours.every (Children’sffering their child food hewing, swallowing)hewing, by offering avariety of healthy g, climbing).g, pacity to eat at any one is time limited.) inking frominking acup.) tain foods andtain foods throwing tantrums refused). when W ith Parents In Screening and Assessment 15 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ terview Questions terview parent daily. s E What concerns doyou have about your child’s weight? What kinds of physical your does activities child enjoy? how do you handle them? yourDoes child throw tantrums over food? I she ask andDoes for meals between snacks? food the family? your child’sDescribe she eat mealtimes. Does with shefoods doesn’t like? Which your does foods child like to eat? Are there any juice juice? 100%fruit When them? she drink does (f H H ­bo Are you breastfeeding your child? Are you giving her f so kills. Children should activelykills. be playing with a M valuate child’s the progress indeveloping large motor ruit drinks, soft drinks) does your does soft drinks) drink? ruit drinks, child ow much juice fruit or how many sweetened drinks ow m ttles? inacup? Milk What she kindof drink? does milk on , how doyou handle this? uch? t hs I f so , I s th e D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss re ­int Discouraging television and viewing encouraging time.) takes foods new snacks. (Children should not trying rushed, because be Providing arelaxed atmosphere during and meals increases.foods patientBeing as child’s their at skill eating avarietyof cups, and dishes with steep sides(bowls). Making eating for easier child by their using spoons, developed until about age 8.) and(Chewing swallowing functions are not completely pie O eating at afamily table. (c G ca O iving child opportunities their to develop eating skills ffering age-appropriate into (cut food foods small 2 to 3 hours.every (Children’sffering their child food hewing, swallowing)hewing, by offering avariety of and foods ading together). pacity to eat at any one is time limited.) eractive activities (talking, playing,eractive (talking, activities singing, and ces) and continuing to monitor sizeof the foods. W ith Parents ­

33 Bright FUTURES Childhood Early 34 Early Childhood Bright FUTURES In Screening and Assessment 18 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ terview Questions terview parent daily. s E S do you handle them? yourDoes child throw tantrums over food? how do you handle this? he ask and for meals Does between snacks? food family?the your child’sDescribe he eat mealtimes. with Does meals he doesn’tfoods like? Which your does foods child like to eat? Are there any juice juice? 100%fruit Whenthem? he drink does (f H H bottles? inacup? Milk What he drink? kindof does milk Are you breastfeeding your child? Are you giving him kills. Children should activelykills. be playing with a M creen child for the exposure. lead valuate child’s the progress indeveloping large motor ruit drinks, soft drinks) does your does soft drinks) drink? ruit drinks, child ow much juice fruit or how many sweetened drinks ow m on uch? t hs I f so , how I I s th f so e , I 2 D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ nterview Questions nterview ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss Y foods shefoods doesn’t like? Which your does foods child like to eat? Are there any juice juice? 100%fruit When them? she drink does (f H What she kindof drink? does milk H playing, singing, and reading together). than age 2,and encouraging interactive (talking, activities Discouraging television for viewing children younger T and to than easier use utensils for designed adults). Providing forks and spoons for designed children (smaller eating at afamily table. (c G ca O ears urning offthe television during mealtimes. ruit drinks, soft drinks) does your does soft drinks) drink? ruit drinks, child iving child opportunities their to develop eating skills ow much juice fruit or how many sweetened drinks as your weaned from child been bottle? the ffering their child food every 2 to 3 hours.every (Children’sffering their child food hewing, swallowing)hewing, by offering avariety of and foods pacity to eat at any one is time limited.) W ith Parents H ow m uch? I s th e D A Screening and Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ nticipatory Guidance iscuss T other healthy foods. ­pa H with self-help practicethis mastered.) can be skill himself from bowls and plates. (This is messy at first, but Allowing child to their self-regulate intake food by serving eating at afamily table. (c G E Assess child’s the risk for hyperlipidemia. familial S she eatDoes same as the rest the foods of family? the or platter onto her plate. a bucket? Can your child shovel sand into or apail pour water from with family? the your child’sDescribe mealtimes. creen child for the exposure. lead urning offthe television during mealtimes. valuate the child’s progress in developing large motor skills. iving child opportunities their to develop eating skills andling child’s their jags (wanting food to eat only a hewing, swallowing)hewing, by offering avariety of and foods rticular food) by serving the favorite the by food) serving alongrticular food with W ith Parents I f sh e can, let her try to serve foods from foods abowl to serve e can, lether try H ow o ften does eatftenshe does Screening and Assessment I 3 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ nterview Questions nterview ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ t ing Assess child’s the risk for hyperlipidemia. familial O S y H he eat with family? Does the himselfmeals foods? serve what yourDescribe during he child does mealtimes. Does What concerns doyou have about your child’s weight? he doesn’tfoods like? Which your does foods child like to eat? Are there any juice juice? 100%fruit Whenthem? he drink does (f H What your kindof does milk child drink? E 1 to 2hours of quality programming aday. vi Limiting total entertainment (watching time media tele o 4 ou serve? creen child for the exposure. lead ncouraging interactive playing, (talking, activities sing- ruit drinks, soft drinks) does your does soft drinks) drink? ruit drinks, child sion, playing computer or games) video to no more than ow often snacks? do youserve What do types of foods ow much juice fruit or how many sweetened drinks btain child’s the pressure. blood , and reading together). Y ears H ow m I uch? s th e ­

35 Bright FUTURES Childhood Early 36 Early Childhood Bright FUTURES D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ iscuss s ing E 1 to 2hours of quality programming aday. vi Limiting total entertainment (watching time media tele T en H f S in T enjoying them. I in how to improve large and muscle small movements. ways to move around bodies their and through and objects marching, and galloping. Adults can direct children in ent daily. By age, this many children can master running, s E ood to helpood child become their familiar with them. ncreasing child’s their awareness of by foods new making ure the child sees family members and friends trying and familyure members child sees the and trying friends kills. Children should activelykills. be playing with apar- haring stories, drawing pictures, and singing songs about eaching child about their by foods new growing, prepar- urning offthe television during mealtimes. valuate child’s the progress indeveloping large motor ncouraging interactive playing, (talking, activities sing- sion, playing computer or games) video to no more than elping child become their more fit (stability, agility, g, and aboutg, talking them. durance, and coordination). , and reading together). W ith Parents ­ E G developmentand social at occur arapid pace. slow, steady physical growth. M Ov ■ ■ ■ ■ ■ ■ ating ■ ■ ■ ■ ■ ■ rowth andDevelopment iddle childhood, ages 5 to 10, is a period characterized ages by childhood, 5toiddle 10, is a period know why are they healthy. Children may that foods identify are healthy but may not and don’t like. shape, and quantity and as ones foods like classify they according foods to describe Children begin to color, plus3 meals 1or 2snacksday. per toChildren need eat avarietyof healthy They need foods. relatively constant. compositionBody and shape body remain intake of during decrease slower periods growth. f G in weight and 2½inches inheight year. per gain an childhood averageChildren inmiddle of 7lbs ■■ ood intake,ood are common. Conversely, appetite and food er rowth spurts, accompanied by increased appetite and MIDDLE v iew C HILDHOOD H ow ever, cognitive, emotional, Body ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ pr ­ha (weight lifting) do not build muscle mass andcanbe muscle-building childhood, middle During activities size and strength. mayBoys concerned be about stature their and muscle not permanent. p G a G ­ph Children may become overly concerned about their parentstheir eat. Children’s intake food is strongly associated with what over children’s attitudes toward eating behaviors and food. to more exert sources begin media) the (peers, influence Mealtimes on take more significance, and social outside to mealtime. can help with simple preparation food and tasks related Children’s ability to themselves feed improves, and they positive effect growthon and health. to realize thatChildren begin eating healthy has a food nd may to eat begin less or diet. art ofart normal growth and development and probably is irls need to be reassuredirls to need be that fat increased body is irls worried mayabout especially be overweight being iate physical activities. rmful; musclermful; strength improved can be with appro ysical appearance.ysical I mage ­

37 Bright FUTURES Childhood Middle 38 Middle Childhood Bright FUTURES P O ■ ■ ■ ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ ■ ■ ■ ral ac T increases child’s their activity level. Parents’ encouragement physically to be active significantly activity is fun. participatethey with child and their show that physical Parents influence a child’s level of physicalwhen activity activities. ing feeling fun, competent, and engaging inavarietyof Children are motivated physically to be active by hav- activities. cal movements, allowing to them engage inavarietyof physi- Children acquire motor the required skills for complex increase. Children’s muscle strength, motor and skills, stamina thatfoods are to easier eat. undergoing orthodontic treatment, and may they require as raw vegetables or meat, are ifthey missing or teeth Children may have suchfoods, difficulty certain chewing to erupt.begin and teeth, permanent primary to lose Children begin teeth eachers and children’s influence friends a child’s physical tivity level. H ealth H visitstion supervision or of visits. as part supervision health A c N Adolescents.) Common ( ■ ■ ■ ■ ■ ■ ■ ■ S ■ ■ ■ ■ ■ ■ ■ ■ ea u ee K ee and assessment and providing anticipatory guidance. parents before visit. the Continue by conducting screening questionsview or by aquestionnaire reviewing out filled by nutritionBegin by supervision selectively asking inter- I R fa H Limited intake of and fruits vegetables. I inconsumptionDecrease of and milk products. other milk tolearn cooperate with others. Participating inphysical activity programs helps children ci hild’s nutrition status should evaluated be during nutri- ncrease in body imagencrease inbody concerns. ncrease inconsumption of sweetened beverages, espe- t lth professionals can following: dothe ise inoverweightise and obesity. ally softally drinks. t, especially saturatedt, especially and trans fats. igher consumptionigher than recommended in of high foods ri ey ey t ion I ndic N ators of Nutrition S u u t p ri er t ion Con v ision R c is erns k for Children and F E Questions Interview ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or theChild ating BehaviorsandFoodChoices ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ m or drink yesterday? What and fruits vegetables, including juices, didyou eat What doyou with your usually drink With meals? snacks? Are there any you foods won’t eat? What is your favorite food? What snacks doyou usually eat? Between meals? Around noon? What doyou usually eat and inthe drink friend’s house? Where didyou eat yesterday? At school?At home? At a H m Which doyou meals usually eat eachday? E S visit and from child to child. R ee ee at ecognize that questions,ecognize interview screening and assess- ow often your does familyeat together?meals ent, and anticipatory from visit vary guidance to will any snacks? ing Behaviors. S trategies for I n th H ea e afternoon? lth Professionals to Promote I n th I f so e evening? , which ones?, which ­mo H ow rning? H ea lthy F Weight andBody F Food F ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or the or theChildPar or theParent ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ H or not enough money to buy food? Are there there when times is not to enough eat food prepares it? Who usually buys for food the your family? Who soft drinks)? drinks, What water, (milk, he usually drink does juice, fruit fruit At after-schoolcare? friend’sAt a house? Where your does child eat snacks? At home? At school? What he usually eat does for snacks? H why not? youDo your think child eats healthy Why foods? or or behaviors (getting enough himto milk)? drink youDo have any concerns about your child’s eating habits H ow doyou feel about your weight? ow often your does eat child breakfast? ow often your does familyeat together?meals R esources Y ounger Child I mage ent

39 Bright FUTURES Childhood Middle 40 Middle Childhood Bright FUTURES F F P F F ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or theParent or theChild hysical Activity or theParent or the ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Does yourDoes child have atelevision inhis bedroom? t H H What of types physical your activity does child engage in? What doyou you think can more doto be active? sio H H What doyou physically doto be active? H Are to change you trying your weight? H H elevision or playing computer or games? video ow much your does time child spendeach day watching ow o ow much doyou time spendeachday watching televi- ow much doyou time active spendbeing inaweek? ow doyou feel about your child’s weight? ow much would you like to weigh? ow doyou feel about your weight? n and playing computer or games? video O ften? lder Child I f so H ow o , how? ften? S G Screening and Assessment ■ ■ ■ ■ ■ ■ ■ tunting ■ ■ ■ ■ ■ ■ ■ rowth and a BM BM the result of stunted growth. Low height-for-age is usuallyresult the of genetics, not of other underlying problems. child mayfrom benefit improved nutrition treatmentor I Assess child’s the risk for hyperlipidemia. familial O E b using mass body index (BM child’s the Determine nutrition status and overall health indicate anutrition problem. patterns should evaluated. be This maybe normal or may standard growth chart. Deviation growth from expected Measure child’s the height and weight, and plot on them a t gum o determine whether growtho determine whether is stunted and the whether f height-for-age is below third the percentile, evaluate y dividing weight by square of height (kg/m valuate appearance the of child’s the skin,hair, teeth, btain child’s the pressure. blood I s, tongue, and eyes. w I -f heel or calculator. Plot child’s the BM or-age growth chart to determine BM P hysical Development I ). C alculate child’s the BM I a 2 ), or a use I p nd age on ercentile. I

a G I O U ■ ■ ■ ■ ■ ■ ron-Deficiency Anemia nd Centers the for Control Disease and Prevention (CDC): ■ ■ ■ ■ ■ ■ nderweight uidelines from American the Academy of Pediatrics (AAP) verweight and ous diagnosis of iron-deficiency anemia). (CDC) a S ir S s at or above percentile, 95th the child is the con- andsidered assessment. in-depth obese needs medical and 85th percentiles, the 94th s between child the I is considered overweight screening. and further needs I a chronic disease. resources,food restrictive dieting,anutritional deficit, or be t percentile,s below fifth the assess for organic dis- Children with alow BM andease eating disorders. I f BM f BM f BM nemia (low iron intake, care health previ- special needs, creen children with known risk factors for iron-deficiency creen children consuming vegetarian astrict dietwithout on supplementation. (AAP) hin as aresult of inadequate intake, energy inadequate I I I i i i O besity I may naturally thin be or may G D Anticipatory Guidance P O ■ ■ ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ ■ ■ r iscuss ral owth and U Variation inonset of among puberty children. b E during mealtimes. games). child watches the whether Determine television television and on other (computer, activities media video howDetermine much child spends the time watching assessment). national standards (school’s standardized physical fitness in weekly. Compare child’s the physical fitness levelwith howDetermine much physical child activityengages the for dental caries(tooth decay). and insugar) beverages high to determine child’s the risk Assess eating behaviors of (frequency consuming foods child has the whether regularDetermine dental visits. oys at about age 12). xpected acceleratedxpected growth (for girls at ages 9–11,for pcoming physical changes and concerns. specific H ealth W ith Parents, theChild,or P hysical Development B oth

41 Bright FUTURES Childhood Middle 42 Middle Childhood Bright FUTURES ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ o f and nutrients for growth and development.) losing weight, children to need consume sufficientcalories with BM more than week 2lbs may per appropriate be for children b month1 lb per may appropriate be for children with BM th Weight loss should inchildren not with occur BM E are, regardless of sizeand their shape. Assuring children that are they loved and accepted as they and Adolescents.) shapes, within arange of healthy weights.) body ( Positive image. body (People come inunique sizesand a H g H or Fostering aPositive Body nd shape ratherweight. ideal defined than on socially rowth chart. r maintain ahealthy weight. etween the 95th and 95th percentiles.etween the 99th Aweight loss of no ating healthy and foods physically being active to achieve ealthy weight on body geneticallysize determined based ow child compares the to others on astandard e 95th percentile;e 95th weight gradual loss of no more than I a bove percentile. 99th the (But, are even ifthey I ma ge Among Children S I ee ee below T ips I

E ■ ■ ■ ■ ■ ■ ■ ating BehaviorsandFoodChoices ■ ■ ■ ■ ■ ■ ■ act E eggs [yolks]). ­ser D through vitamin (100 D–fortified milk Providing avitamin Dsupplement of 400 alent from products. other milk (1%) or day fat-free per or (skim)milk consume equiv- the Children ages 9and 3cups older toof need drink low-fat from products other milk (cheese, yogurt). or day fat-free per or (skim)milk consume equivalent the Children ages 2cups 2toof 8need drink low-fat (1%) E andbeans, eggs, nuts). cheese, and yogurt]; [milk, leanucts meats, poultry, fish, whole grain]; low-fat [1%]and fat-free prod- [skim]milk for Americans vegetables, (fruits, grain products [especially Making healthy choices foods on Dietary based Guidelines I chi wa ncreasing varietyof the child eats the foods and finding nergy requirementsnergy are influenced growth,by physical ating and 3meals 1to 2snacksday. per ys to incorporate into foods new child’s the diet. ivity level, and composition. body ving) and vitamin (fortified cereals, D–fortified foods ldren donot who obtain 400 IU p er day of IU IU p per day per for ­vi er 8-oz tamin O ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ral Drinking waterDrinking thirsty. when (after breakfast beforeand bed). Brushing with fluoridated teeth toothpasteday a twice effectively.) teeth their typicallytheir shoelaces], by age 7or can brush 8,they (After children acquire fine motor skills [ability tie to y T if ne E in sugar. high softand drinks) drinks, beverages (fruit trans fats (chips, and french (candy, foods fries), cookies) insaturated infat,Limiting high high foods especially and and incalories Limiting high low foods innutrients. ofrid distractions (television). Providing arelaxed atmosphere for mealtimes and getting Making family mealtimes apriority. and vegetables).fruits ­com healthyChoosing for foods and meals snacks richin oung children cannot clean without teeth their help. oothbrushing requires fine motor good control, and nrolling child inschoolbreakfast and lunch programs, H ealth plex carbohydrates (whole-grain products, fresh eded. ( eded. S ee F ee ederal Nutritionederal Assistance Programs.) P ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ mouth guards, physically when goggles) active. Wearing appropriate safety equipment (helmets, pads, of medical or physical conditions). physical activity for cardiovascular fitness (within limits For care childrenhealth with engaging special needs, in E in sugar. high softjuice drinks) drinks, Limiting (candy, foods and cookies) beverages (juice, of approximately 0.8–1.0mg/L [ppm].) recommend abrand with fluoride added at aconcentration wa U — — — ngaging in60or more minutes of daily physical activity. sing community fluoridated watersafe, as a effective — — — y to reduce dental caries.( ing) o ­pl (weight-bearing) physical activity (jumping rope, Bone-strengthening: a week. physical activity (climbing trees, sit-ups) at least 3days Muscle-strengthening: physical activity at least 3days aweek. physical activity daily, and include vigorous-intensity Aerobic: aying at basketball) least 3days aweek. r vigorous-intensity bicycling) (running, aerobic E ither moderate-intensity skateboard- (hiking, I nc I nc lude bone-strengthening I f bo lude muscle-strengthening ttled waterttled is preferred,

43 Bright FUTURES Childhood Middle 44 Middle Childhood Bright FUTURES S ■ ■ ■ ■ ■ ■ ubstance ■ ■ ■ ■ ■ ■ ­(pr Dangers of using performance-enhancing products Dangers of using alcohol, tobacco, and other drugs. child is overweight. pl R than 1to 2hours of quality programming aday. vi Limiting total entertainment (watching time media tele Not having atelevision child’s inthe bedroom. glands are not developed.) fully increased risk for heat-related sweat their because illness waterDrinking physically when active. (Children are at educing sedentary behaviorseducing sedentary (watching television, sion, playing computer or games) video to no more aying computer or ifthe games), video especially otein supplements, anabolic steroids). U se ­ ­ G reason and logically solve problems. tant and personal vocational decisions and refined abilities to (ages 18–21).This Late adolescence stagetime is a of impor- andthinking, problem-solving abilities. byterized independence, experimentation, future-oriented (ages 15–17).Adolescents adolescence Middle are charac- thought, although concrete and oriented toward present. the by changesized pubertal and agrowing capacity for abstract (ages 11–14).Adolescents adolescence Early are character- into 3stages. and emotional changes. This developmental is divided period Ado Ov ■ ■ ■ ■ ■ ■ rowth andDevelopment 3–4 in males). growth maturity (sexual rating [ Nutrient are needs greatest of periods during peak Adolescents accumulate up to 40%of skeletal their mass. height and gain 50%of adult their weight. Adolescents achieve 15% final the to 20% their adultof ■■ er lescence is a period of dramatic is aperiod lescence physical, cognitive, social, ADOLES v iew C EN C E S M R ] 2–3infem ales, ales, E ■ ■ ■ ■ ■ ■ ■ ■ ■ ating ■ ■ ■ ■ ■ ■ ■ ■ ■ restaurants and purchase with own their food money. were younger. Many adolescents go to stores and fast-food more and meals snacks away from home than they when Adolescents spendmore away time from home and eat I ­concer as vegetarianism) to explore various lifestyles or to show Adolescents may adopt eating certain behaviors (such tothem establish individuality and express identity. their Foods can have symbolic meanings. Adolescents may use young adult are central to adolescence. Developing an identity and becoming an independent adolescence. Cognitive capacities increase dramatically during muscle mass during adolescence. middle Males major experience growth spurts and increases in about puberty Males begin 2years later than females. menarche. Mean age of menarche is 12.5years. Females complete most physical growth about 2years after tur nterest including foods, innew from those differentcul- es and groups, ethnic is common during adolescence. n for environment. the

45 Bright FUTURES Adolescence 46 Adolescence Bright FUTURES P Body ■ ■ ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ ■ ■ ­influen ­adoles Physical in group activity usually occurs settings, and physical activity. increase, providing more opportunities for engaging in As adolescents grow and develop, motor their skills ­as Adolescents fad dietsand mayunderestimate try the during adolescence. le S ­con fact For females, physical maturation may to lead dissatis body image. come with physical maturation usually improve their For increased sizeand males, muscle development that satisfaction with appearance. their Changes associated can with affect puberty adolescents’ ocial pressureocial and thin to of stigma the be obesity can ad to unhealthy eating behaviors image and body apoor sociated health risks.sociated health I cerns and dieting. ion with their bodies, which may which ion with bodies, their result inweight mage cents’ engagement inphysical activity may be ced byced peers. ­ Adolescents.) ( Common ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ S ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ee K ee low incomes. amongFood insecurity adolescents from families with Prevalence of hyperlipidemia. Prevalence of iron-deficiency anemia (in females). ­dietin I Low levels of physical activity. R and sodium. in fa H I ­esp I inconsumptionDecrease of and milk products. other milk increases adolescents’ activity levels. Parents’ encouragement physically to be active significantly physical activity is fun. participate they when with adolescent the and show that Parents influence an adolescent’s physical activity level ncrease ineating disorders, image body concerns, nsufficient fruitsintake of and vegetables. ncrease inconsumption of insugar, beverages high ise inoverweightise and obesity. igher consumptionigher than recommended of high foods ecially soft drinks softand drinks drinks. ecially sports ey ey t, especially saturatedt, especially and trans fats, cholesterol, g, and unsafe weight-loss methods. I ndic N ators of Nutrition u t ri t ion Con R c is erns k for Children and F E Questions Interview E ( visits. nutrition visits supervision or of as part supervision health A N ■ ■ ■ ■ S or the ating BehaviorsandFoodChoices ■ ■ ■ ■ at n adolescent’s nutrition status should evaluated be during u ee ee m H Lunch? Dinner? snacks? Which doyou meals usually eat eachday? and from adolescent to adolescent. R anticipatory guidance. by conducting screening and assessment and providing ­pa questions or by aquestionnaire reviewing out filled by nutritionBegin by supervision selectively asking ing Behaviors.) t ecognize that questions,ecognize interview screening and assess- ow often your does familyeat together?meals S ent, and anticipatory from visit vary guidance to will visit ri rents and/or adolescent the before visit. the Continue tra H t ea tegies for ion A lth professionals can following: dothe H dolescent ow m S u p any aweek times doyou eat breakfast? H er ea lth Professionals to Promote v ision H ow m H ­int any ea erview erview lthy F ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or theParent ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ why not? youDo your think teenager eats healthy Why foods? or behaviors? youDo have any concerns about your teenager’s eating H What changes would you like to make way inthe you eat? s H yesterday?drink What and fruits vegetables, including juices, didyou eat or What[skim] milk)? products other milk doyou like to eat? dr H Are there any you foods won’t eat? What snacks doyou usually eat? Between meals? ing? Around noon? What doyou usually eat andmorn- inthe drink ports drinks? ports ow often your does familyeat together?meals ow oftendrinks, or dosoft energy drinks, you drink ow often do you milk? What drink kind do youof milk ink (whole milk, reduced-fat (whole milk, ink [2%],low-fat [1%],fat-free I n th e afternoon? I f th I n th ere are, ones? which e evening?

47 Bright FUTURES Adolescence 48 Adolescence Bright FUTURES F F Weight andBody F Food ■ ■ ■ ■ ■ ■ ■ ■ ■ or the or the or theParent ■ ■ ■ ■ ■ ■ ■ ■ ■ H Are you about teased your weight? H Are to change you trying your weight? H Are just right the weight? Why? youDo that think you little? weigh too Weigh much? too H not enough money to buy food? Are there there when times is not to enough eat food or prepares it? Who usually buys for food the your family? Who ow doyou feel about your teenager’s weight and height? ow much would you like to weigh? ow doyou feel about your weight and height? ow doyou feel about way the you look? R esources A A dolescent dolescent orPar I mage ent I f so , how? F F P ■ ■ ■ ■ ■ ■ ■ ■ or theParent or the hysical Activity ■ ■ ■ ■ ■ ■ ■ ■ Does yourDoes teenager have atelevision in his bedroom? in H in? What of type physical your activity does teenager engage What doyou you think can more doto be active? vi H not doing now? What physical activity would you like to dothat you are H What doyou dofor physical activity? sion and playing computer or games? video ow much your does time teenager spendeachday watch- ow much doyou time spendeachday watching tele ow much doyou time active spendbeing inaweek? g television or playing computer or games? video H ow o A dolescent ften? H ow c an you make for time it? H ow o ften? ­ S G Screening and Assessment ■ ■ ■ ■ ■ ■ ■ tunting ■ ■ ■ ■ ■ ■ ■ rowth and to determine BM ­adoles the result of stunted growth. Low height-for-age is usuallyresult the of genetics, not ment of other underlying problems. ­adoles t I Assess adolescent’s the risk for hyperlipidemia. familial O gum E (kg/m ­adoles usingmasshealth body index (BM adolescent’s the Determine nutrition status and or may indicate anutrition problem. growth patterns should evaluated. be This maybe normal on astandard growth chart. Deviation from expected Measure adolescent’s the height and weight, and plot them o determine whether growtho determine whether is stunted and the whether f height-for-age is below third the percentile, evaluate valuate appearance of adolescent’s the skin,hair, teeth, btain adolescent’s the pressure. blood s, tongue, and eyes. 2 cent’s BM cent mayfrom benefit improved nutrition treat-or cent’s BM ), or aBM use P hysical Development I I a b I p nd age on aBM y dividing weight by square of height ercentile. I wheel or wheel calculator. Plot the I I -f ). C or-age growth chart alculate the ­ov erall erall a G I O U ■ ■ ■ ■ ■ ron-Deficiency Anemia nd Centers the for Control Disease and Prevention (CDC): ■ ■ ■ ■ ■ nderweight uidelines from American the Academy of Pediatrics (AAP) verweight and exa S s at or above percentile, 95th the adolescent the is considered and assessment. in-depth obese needs medical I and 85th percentiles, the 94th s between further screening. adolescentthe is considered overweight and needs I tional deficit, or a chronic disease. ­inade ma s below percentile, 5th the assess for organic Adolescents with alow BM ­dis I f BM f BM f BM creen females ages 12to 21during routine physical eases andeases eating disorders. y be thin as aresult thin y be of inadequate intake, energy ms. (AAP) quate resources, food restrictive dieting,anutri- I I I i i i O besity I may naturally thin be or

49 Bright FUTURES Adolescence 50 Adolescence Bright FUTURES P O ■ ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ ■ ral physical fitness assessment). ­fit engages inweekly. Compare adolescent’s the physical howDetermine much physical adolescent activity the risk for dental caries(tooth decay). and insugar) beverages high to determine adolescent’s the Assess eating behaviors of (frequency consuming foods adolescent the whether Determine has regular dental visits. anemia). (CDC) carehealth previous needs, diagnosis of iron-deficiency f S p S ­ph 5to 10yearsrisk factors, during screenevery routine deficienc loss, lowblood iron intake, previous diagnosis of iron- ir S or iron-deficiency anemia (low iron intake, special creen ages males 12to 18with known risk factors creen ages males growth 12to 18during peak their creen females ages 12to 21with known risk factors for eriod during routineeriod physical examinations. (AAP) on-deficiency anemia (extensive menstrual or other ness level with national standards (school’s standardized H ysical examinations.ysical (CDC) ealth y anemia) annually. For with no known those ­ G D Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ r iscuss owth and by age and growththeir is normal. ( For late-maturing ages males, 15to 17,reassurance that (by age 18,about 15%–18%of weight). body the growth spurt, and an fat increase inbody after puberty ages(between fat 9and inbody 13),adecrease during For aslight males, weight gain before agrowth spurt of puberty.) of weight body before to 20%–25%at puberty end the and buttocks. (Fat accumulation ranges from 15%–18% For females, normal accumulation of fat inhips, thighs, U g H vi games). adolescent the whether Determine watches tele television and on other (computer, activities media video howDetermine much adolescent the time spends watching rowth chart. pcoming physical changes and concerns. specific sion during mealtimes. ow adolescent the compares with others on standard the W ith P S M hysical Development A R dolescent, Parents, or t o ease concerns.)o ease U se c se harts that plot height velocity B oth ­ E ■ ■ ■ ■ ■ ■ ating BehaviorsandFoodChoices ■ ■ ■ ■ ■ ■ Programs.) gra E in sugar. high softand drinks) drinks, beverages (fruit trans fats (chips, and french (candy, foods fries), cookies) insaturated infat,Limiting high high foods especially and E eggs [yolk]). and vitamin (fortified cereals, D–fortified serving) foods min Dthrough vitamin (100 D–fortified milk ­adoles T (cheese, yogurt). day or consuming equivalent the from products other milk 3cups ofDrinking low-fat (1%)or fat-free per (skim)milk andbeans, eggs, nuts). cheese, and yogurt]; [milk, leanucts meats, poultry, fish, whole grain]; low-fat [1%]and fat-free prod- [skim]milk for Americans vegetables, (fruits, grain products [especially Making healthy choices foods on Dietary based Guidelines aking avitaminaking Dsupplement of 400 nrolling adolescent inschoolbreakfast and lunch pro- ating and 3meals day. snacks, per as needed, ms, ( ifneeded. cents donot who obtain 400 S ee F ee ederal Nutritionederal Assistance IU p IU er day of vita- p er day for IU p er 8-oz Weight andBody O ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ral healthy lifestyle. Discouraging dieting; instead, emphasizing sedentary behaviors). ages; engaging inregular reducing physical activity; ­limit healthy weight (practicing healthy eating behaviors; S a H in sugar. high softjuice drinks) drinks, Limiting (candy, foods and cookies) beverages (juice, of approximately 0.8–1.0mg/L [ppm].) recommend abrand with fluoride added at aconcentration wa U waterDrinking thirsty. when (after breakfast beforeand bed). Brushing with fluoridated teeth toothpasteday a twice nd shape ratherweight. ideal defined than on socially afe and healthy ways for achieving and sing community fluoridated watersafe, as a effective ealthy weight on body geneticallysize determined based H y to reduce dental caries.( ealth ing low-nutrient high-calorie, and foods bever- I mage I f bo ttled waterttled is preferred, ­ma intaining

51 Bright FUTURES Adolescence 52 Adolescence Bright FUTURES P ■ ■ ■ ■ ■ hysical Activity ■ ■ ■ ■ ■ f of or medical physical conditions). in physical activity for cardiovascular fitness (within limits For adolescents care health with engaging special needs, and friends). p I E are,they regardless of sizeand their shape. Assuring adolescents that are they loved and accepted as and Adolescents.) shapes, within arange of healthy weights.) body ( Positive image. body (People come inunique sizesand — — — or Fostering aPositive Body ncorporating physical activity into daily life (through hysical education at schooland with activities family ngaging in60or more minutes of daily physical activity. — — — ­pl (weight-bearing) physical activity (jumping rope, Bone-strengthening: a week. physical activity (climbing trees, sit-ups) at least 3days Muscle-strengthening: physical activity at least 3days aweek. physical activity daily, and include vigorous-intensity ing) o Aerobic: aying at basketball) least 3days aweek. r vigorous-intensity bicycling) (running, aerobic E ither moderate-intensity skateboard- (hiking, I nc I nc lude bone-strengthening I lude muscle-strengthening ma ge Among Children S ee ee T ips S ■ ■ ■ ■ ■ ■ ■ ■ ■ ubstance ■ ■ ■ ■ ■ ■ ■ ■ ■ ­(pr Dangers of using performance-enhancing products Dangers of using alcohol, tobacco, and other drugs. coffee,drinks). (soft drinks, energy Consuming excessive quantities of caffeinatedbeverages is overweight. R 1 to 2hours of quality programming aday. vi Limiting total entertainment (watching time media tele Not having atelevision adolescent’s inthe bedroom. waterDrinking physically when active. Finding safe settings for physical activity. mouth guards, physically when goggles) active. Wearing appropriate safety equipment (helmets, pads, in educing sedentary behaviorseducing sedentary (watching television, play- sion, playing computer or games) video to no more than g computer or adolescent ifthe games, video especially otein supplements, anabolic steroids). U se ­ Nutrition Tools 53 Bright FUTURES

Consumes <3servingsof Consumes <2servingsof Consumes <3servingsof Consumes <6servingsof Food Choices vegetables per day. fruits perday. whole grainsperday. per day. pasta, rice,orotherpasta cereal, bread,crackers, ■■ Key N I ndi u t ri c I ndi a t ion t ors of c R is a k t ors of Fruits andvegetablesprovidevitamins Grain productsprovidecomplex (such asAandC),minerals,fiber colon cancer. with constipationandincreasedriskof fiber. Lowintakeoffiberisassociated carbohydrates, vitamins,minerals,and many types ofcancer. is associatedwithanincreasedriskof Low intakeoffruitsandvegetables N u t ri t ion R ele v R an is c k e forChildrenand . Assess thechildoradolescentwhohas Assess thechildoradolescentwhois Assess thechildoradolescentwhois Assess thechildoradolescentwhois Assess thechildoradolescentwhois recent historyofconstipation. other grainsperday. cereal, bread,crackers,rice,pasta,or consuming <3servingsofwhole-grain per day. crackers, rice,pasta,orothergrains consuming <6servingsofcereal,bread, per day. consuming <2servingsofvegetables consuming <1servingoffruitper day. Cri t eria for and A A doles F ssessmen ur t her c Sc en t reening t s

55 Bright FUTURES Tools Nutrition 56 Nutrition Tools Bright FUTURES For children<9:Consumes For children≥9and Food Choices,continued milk productsperday <2 servingsofmilkand milk productsperday. <3 servingsofmilkand adolescents: Consumes ■■ c Key N on I ndi u t ri t c I ndi a t inued ion t ors of c R is a k t . ors of Milk andmilkproductsareagoodsource of osteoporosis. peak bonemassandincreasetherisk milk andproductsmayreduce and otherminerals.Lowintakeof of protein,vitamins,andcalcium N u t ri t ion R ele v R an is c k e forChildrenand Assess thechildoradolescentwhois Assess thechildoradolescentwhohasa Assess thechild(≥9)oradolescentwhois Assess thechild(<9)whoisconsuming consuming >2softdrinksper day. milk allergyorislactoseintolerant. products per day. consuming <2servingsofmilkand per day. <1 servingofmilkandproducts Cri t eria for and A A doles F ssessmen ur t her c Sc en t reening t s, Consumes <2servingsof For children≥5:Consumes seeds) perday. (eg, beans,eggs,nuts, meat oralternatives excessive amountoffat. ■■ c Key N on I ndi u t ri t c I ndi a t inued ion t ors of c R is a k t ors of Protein-rich foods(eg,meats,meat Excessive intakeofdietaryfatcontributes vegetarian diet. to childrenandadolescentswhofollowa home. Specialattentionshouldbepaid inadequate availabilityofthesefoodsat or meatalternativesmayindicate sexual maturation.Lowintakeofmeat anemia andofdelayedgrowth and increasetheriskofiron-deficiency protein-rich foodsmayimpairgrowth vitamins, iron,andzinc.Lowintakeof alternatives) aregoodsourcesofB some cancers. and obesityisassociatedwith to theriskofcardiovasculardisease N u t ri t ion R ele v R an is c k e forChildrenand Assess thechildoradolescentwhois Assess thechildoradolescentifbody mass Assess thechildoradolescentwho alternatives perday consuming <1servingofmeator index (BMI)is≥85thpercentile. cardiovascular disease. has afamilyhistoryofpremature Cri t eria for and A A doles F ssessmen ur . t her c Sc en t reening t s,

57 Bright FUTURES Tools Nutrition 58 Nutrition Tools Bright FUTURES Exhibits poorappetite. Consumes foodfromfast- E ating Behaviors per week. food restaurants≥3times ■■ c Key N on I ndi u t ri t c I ndi a t inued ion t ors of c R is a k t ors of Excessive consumptionofconvenience A poorappetitemaybedevelopmentally intake ofcertainvitaminsandminerals. calorie, andsodiumintake,aswell low restaurants isassociatedwithhighfat, foods andfromfast-food stress, or a chronic disease. indicate depressionorotheremotional older childrenandadolescentsitmay appropriate foryoungchildren,butin N u t ri t ion R ele v R an is c k e forChildrenand Assess thechildoradolescentwho Assess thechildoradolescentfororganic Assess thechildoradolescentifirregular Assess thechildoradolescentifBMIis dietary fat. other conditionsrequiringreduction in diabetes mellitus,hyperlipidemia,or is overweightorobesewhohas and psychiatricdisease. ≥3 months. menses oramenorrheahasoccurredfor occurred. <15th percentileorifweightlosshas Cri t eria for and A A doles F ssessmen ur t her c Sc en t reening t s, Has inadequatefinancial Has foodjags—eatsone Skips breakfast,lunch,or Food cooking facilities. food, orlackofaccessto insufficient accessto resources tobuyfood, particular foodonly. per week. dinner orsupper≥3times ■■ c Key R N on I esour ndi u t ri t c I ndi a t ces inued ion t ors of c R is a k t ors of Poverty canresultinhungerand Food jags,whichlimitthevarietyoffood Meal-skipping isassociatedwithalow interferes withlearning. status. Inadequatedietaryintake compromised foodqualityandnutrition adequacy ofthediet. consumed, decreasethenutritional nutritional adequacyofthediet. Repeatedly skippingmealsdecreasesthe compromise growthanddevelopment. and, ifitisaregularpractice,could intake ofenergyandessentialnutrients N u t ri t ion R ele v R an is c k e forChildrenand Assess thechildoradolescentwhois from Assess thechild’ Assess thechildoradolescenttoensure is arunaway. a familywithlowincome,ishomeless, or weight-loss practices. inadequate foodresourcesorunhealthy that meal-skippingisnotdueto intake overseveraldays. Cri t eria for and A s oradolescent’s dietary A doles F ssessmen ur t her c Sc en t reening t s,

59 Bright FUTURES Tools Nutrition 60 Nutrition Tools Bright FUTURES Is excessivelyconcerned Practices unhealthy Weight andBody about bodysizeorshape. or dietpillstoloseweight). using laxatives,diuretics, dieting, vomiting;and behaviors (eg,chronic ■■ c Key N on I ndi u t ri t c I ndi a t inued ion t ors of c I R mage is a k t ors of Eating disordersareassociatedwith signi Chronic dietingisassociatedwithmany complications. is associatedwithseriousmedical use, suicidalbehaviors).Purging compromising behaviors(eg,substance purging isassociatedwithhealth- Frequent dietingincombinationwith binge) andcanleadtoeatingdisorders. growth andsexualmaturation,irrita health concerns(eg,fatigue,impaired their long-termprognosis. earlier adolescentsaretreated,the better disorders beginduringadolescence. The Eighty-five percentofallcaseseating ficant healthandpsychosocialmorbidity. bi ­lity, poorconcentration,impulseto N u t ri t ion R ele v R an is c k e forChildrenand ­ ­ Assess thechildoradolescentfororganic Assess thechildoradolescentforeating Assess thechildoradolescentfordistorted and psychiatricdisease. disorders. is <85thpercentile. adolescent wantstoloseweightbut BMI behaviors, especiallyifthechildor body imageanddysfunctionaleating Cri t eria for and A A doles F ssessmen ur t her c Sc en t reening t s, a M 5hpretl.Thinnessmayindicateaneatingdisorderor Has BMI<5thpercentile. a M 8t ecnie Overweightchildren andadolescentsare Has BMI>85thpercentile. Exhibits significantweight G change inpast6months. ■■ r owth c Key N on I ndi u t ri t c I ndi a t inued ion t ors of c R is a k t ors of Significant weightchangeduringthepast type 2diabetesmellitus. risk factorforcardiovascular diseaseand blood pressure. Obesity is an independent elevated cholesterollevelsand as adults.Obesityisassociatedwith are atincreasedriskforhealthproblems more likelytobeoverweightadults and poor nutrition. organic disease,oraneatingdisorder. 6 monthsmayindicatestress,depression, N u t ri t ion R ele v R an is c k e forChildrenand Assess thechildoradolescentwhois at Assess thechildoradolescentfor Assess thechildoradolescentfororganic Assess thechildoradolescentforeating Assess risk foroverweight. inadequate foodresources. or psychiatricdisease. disorders. disorder). poor appetite,meal-skipping,eating (eg, limitedortoomuchaccesstofood, the causeofweightlossorgain Cri t the child or adolescent to determine eria for and A A doles F ssessmen ur t her c Sc en t reening t s,

61 Bright FUTURES Tools Nutrition 62 Nutrition Tools Bright FUTURES Is physicallyinactive: P hysical Activity activity <5daysper week. participates inphysical ■■ c Key N on I ndi u t ri t c I ndi a t inued ion t ors of c R is a k t ors of Lack ofphysicalactivityisassociatedwith overweight andobesity throughout life. reduction andweightmaintenance and well-being;facilitatesweight contributes topsychologicalhealth joint structure,andfunction; maintaining normalmusclestrength, Regular physicalactivityisnecessary for skeletal developmentduringchildhood. physical activityisessentialfornormal hyper reduces theriskofcardiovasculardisease, the longterm.Regularphysicalactivity a greaterriskofcardiovasculardiseasein poor muscletoneintheshorttermand 2 diabetesmellitus.W N u ­tension, coloncancer, andtype t ri t ion R ele v R an eight-bearing is , fatigue,and c k e forChildrenand Assess thechild’s oradolescent’s definition Assess howmuchtimethechildor of physicalactivity. or DVDs andplayingcomputergames. adolescent spendswatchingtelevision Cri t eria for and A A doles F ssessmen ur t her c Sc en t reening t s, ssdeaysplmns Dietarysupplements(eg,vitaminand Uses dietarysupplements. Engages inheavyalcohol, Participates inexcessive L ifestyle drug use. tobacco, andother physical activity. ■■ c Key N on I ndi u t ri t c I ndi a t inued ion t ors of c R is a k t ors of Alcohol, tobacco,andotherdrugusecan Intense physicalactivitynearlyeveryday anabolic steroids. may betemptedtoexperimentwith who usesupplementsto“bulkup” can haveserioussideeffects. Adolescents deficiency anemia;however, highdoses adolescents withahistoryofiron- additions toadietforchildrenor mineral preparations)canbehealthy nutrition status. adversely af loss, andmalnutrition. menstrual irregularity, excessiveweight unhealthy andmaybeassociatedwith sometimes morethanonceaday, canbe N u t ri t fect nutrientintakeand ion R ele v R an is c k e forChildrenand , Assess adolescent’s useofanabolicsteroids Assess thechildoradolescentfortype Assess thechildoradolescentfurtherfor Assess thechildoradolescentfor and megadosesofothersupplements. of supplementsusedanddosage. alcohol, tobacco,andotherdruguse. eating disorders. Cri t eria for and A A doles F ssessmen ur t her c Sc en t reening t s,

63 Bright FUTURES Tools Nutrition 64 Nutrition Tools Bright FUTURES Use simpleterminology. Understand andrespectthechild’s oradolescent’s cultural Focus ontheshort-termbenefitsofhealthyeating Provide concretelearningsituations. Encourage thechild’s oradolescent’s activeparticipation Promote positive,nonjudgmentalstrategiestohelpthe Communication Factors eating behaviors. behaviors. in changing eatingbehaviors. child oradolescentadopthealthyeatingbehaviors. ■■ E St a ra t ing t egies for B eha St v ra iors t egies H eal t h Professionals Avoid usingtheterm “diet” withthechildoradolescent Help thechildoradolescentintegrate culturaleating Emphasize thathealthyeatingbehaviorswillmakethe Use charts,foodmodels,andvideotapestoreinforceverbal Help thechildoradolescentidentifybarriersthatmakeit Reinforce positiveaspectsofthechild’ may beconfusing. because ittendstobeassociatedwith weightlossand behaviors withdietaryrecommendations. child oradolescentfeelgoodandhavemoreenergy. information andinstructions. of actionforadoptingnewbehaviors. difficult tochangeeatingbehaviors,anddevelopaplan eating behaviors. t o Promo App li c a t t e ions/Ques H eal t t s oradolescent’s hy ions Use simpleterminology. Understand andrespectthechild’s oradolescent’s cultural Facilitate behaviorchangewithcounseling strategies Identify thechild’ R Focus ontheshort-termbenefitsofhealthyeating Provide concretelearningsituations. Encourage healthprofessionalsandstaff tobecomerole Communicate developmentallyappropriate Encourage thechild’s oradolescent’s activeparticipation Create anoffice orclinicenvironmentorientedtochildren Promote positive,nonjudgmentalstrategiestohelpthe E Communication Factors nvir eadiness toChange eating behaviors. manual). of Change model(Tool FinBrightFutures:Nutrition tailored tothechildoradolescentbased ontheStages model (Tool FinBrightFutures:Nutrition manual). and readinesstochangebasedontheStagesofChange behaviors. models forhealthyeatingbehaviors. health messages. in changing eatingbehaviors. or adolescents. child oradolescentadopthealthyeatingbehaviors. ■■ E St onmental Factors a ra t ing t egies for B s oradolescent’s stageof behavior change eha St St v ra ra iors, t t egies egies H eal c on t h Professionals t inued Avoid usingtheterm “diet” withthechildoradolescent Help thechildoradolescentintegrate culturaleating Develop aplanthat incorporatesincrementalstepsfor Prioritize behaviorstobechanged,set goals,andidentify Provide asupportiveenvironment,basic information, “Are youtryingtokeepeatingtheway youhavebeen?” “Are youchangingthewayeat?” “Are youreadytochangetheway eat?” “Are youthinkingaboutchangingthewayeat?” “Do youwanttochangethewayeat?” Emphasize thathealthyeatingbehaviorswillmakethe Use charts,foodmodels,andvideotapestoreinforceverbal Have healthprofessionalsandstaff modelhealthy Use postersandmaterialsthathighlighttheimportance Help thechildoradolescentidentifybarriersthatmakeit Use postersandmaterialswrittenforchildrenor Reinforce positiveaspectsofthechild’ may beconfusing. because ittendstobeassociatedwith weightlossand behaviors withdietaryrecommendations. making changes,support, andreinforcement. barriers tochange. and assessment. child oradolescentfeelgoodandhavemoreenergy. information andinstructions. eating behaviors. of actionforadoptingnewbehaviors. of healthy eatingbehaviors. difficult tochangeeatingbehaviors,anddevelopaplan eating behaviors. adolescents. t o Promo App App li li c c a a t t t e ions/Ques ions/Ques H eal t t t s oradolescent’s hy ions ions

65 Bright FUTURES Tools Nutrition 66 Nutrition Tools Bright FUTURES Identify andaddressbarrierstobehavior change;help Set realistic,achievablegoalsthatare supportedbythe dniyadpirtz eaircagst emd.Suggestchangesthatwillhaveameasurableimpactonthe Identify andprioritizebehaviorchangestobemade. Provide task-orientedcounselingforthechildoradolescent Provide counselingforthechildoradolescentwhoisin Action reduce barrierswhenpossible. child’s oradolescent’s family. who isreadytochangeeatingbehaviors. to change. the earlystagesofbehaviorchangeorwhoisunwilling ■■ E St a P ra t lans ing t egies for B eha St v ra iors, t egies H eal c on t h Professionals t inued “What couldmakeithardforyouto makethischange— “How andwhenwillyouchange, whowillhelpyou?” “What goalisrealisticrightnow?” “What willyouchange?” Support andfollowupwiththechildoradolescentwho Encourage afewsmall,concretechangesfirst,andbuild Encourage thechildoradolescenttomakebehavior Increase thechild’ this?” money, friends,orfamily?”“Howcanyou getaround child’s oradolescent’s mostseriousnutritionissues. has changedbehavior. on those. changes. knowledge ofeatingbehaviors. t o Promo App s oradolescent’s awareness and li c a t t e ions/Ques H eal t t hy ions Help thechildoradolescentobtain family and Give thechildoradolescentresponsibilityforchanging Encourage thechildoradolescenttocommitbehavior Establish incrementalstepstohelpthechildoradolescent Make surethatthebehaviorchangesarecompatiblewith peer support. and monitoring eatingbehaviors. changes withcontracts. change eatingbehaviors. the child’ ■■ E St a ra t ing s oradolescent’s lifestyle. t egies for B eha St v ra iors, t egies H eal c on t h Professionals t inued Meet withparentstoclarifygoalsand actionplans; Discuss howthechildoradolescent can encourageparents Make record-keepingsimple,andreview theplanwith Stress theimportanceofplanninghowchildor Discuss nonfoodrewards(incentives)tohelpthechildor For example,havethechildoradolescentreducefat Don’t expectthechildoradolescenttoconformrigid education orcounseling toparents,asappropriate. determine howtheycanhelp.Provide nutrition and peerstohelp. child oradolescent. behavior. adolescent willmakeandtrackchangesineating adolescent focusonchangingeatingbehaviors. (skim) milk. from reduced-fat(2%),tolow-fat(1%),fat-free consumption bychangingthetypeofmilkconsumed, realistic goals. eating behaviors.Keepinmindcurrentbehaviorsand t o Promo App li c a t t e ions/Ques H eal t t hy ions

67 Bright FUTURES Tools Nutrition 68 Nutrition Tools Bright FUTURES Discuss howtomakehealthyfoodchoices inavarietyof Provide counselingthatintegratesrealistic behaviorchange Focus on“howto”insteadof“why” information. Build onpositiveaspectsofthechild’s oradolescent’s Emphasize tothechildoradolescentconsumptionof Ask thechildoradolescentaboutchangesineating G Of eneral settings. into thechild’s oradolescent’s lifestyle. eating behaviors. foods ratherthannutrients. behaviors ateveryvisit. ■■ fer feedbackandreinforcesuccesses. E St a ra t S trategies ing t egies for B eha St v ra iors, t egies H eal c on t h Professionals t inued Talk abouthowtochoosefoodsinvarious settingssuch “I understandthatyourfriendseat lunch atfast-food Share behaviorallyorientedinformation (eg,what,how “It’s greatthatyou’reeating breakfast.Would yoube Show interesttoencouragecontinuedbehaviorchange. For example,say “How areyoudoinginchangingthewayeat?” vending machines, andfriends’homes. as fast-foodandother restaurants,conveniencestores, healthier foodchoicesattheserestaurants?” restaurants. Would ithelpyoutolearnhowmake than focusingonwhytheinformation isimportant. much, andwhentoeathow prepare food)rather and doughnuts 4daysaweek?” willing totrycereal,fruit,andtoastinsteadofbacon and yogurt”ratherthan“youneedmorecalcium.” t o Promo App , “drinkmoremilk,andeatcheese, li c a t t e ions/Ques H eal t t hy ions When assessingfoodintake,keepin mindthatachild’s Make surethatyouandthechildor adolescentdefine Make surethatthechildoradolescenthearswhatyouare Make recordkeepingeasy, andtellthechildoradolescent Introduce theconceptofachievingbalanceandenjoying Provide thechildoradolescentwithlearningexperiences standard servingsize. or adolescent’s portionsizemaynotbethesameasa terms inthesamewaytoavoidconfusion. saying. behaviors tobeperfect. that youdonotexpectspelling,handwriting,andeating all foodsinmoderation. and skillspractice. ■■ E St a ra t ing t egies for B eha St v ra iors, t egies H eal c on t h Professionals t inued Use foodmodelsorhouseholdcups and bowlstoclarify Discuss thedefinitionofwordsthat maycauseconfusion, “What areyouplanningtoworkonbeforeyournext “Be asaccurateandhonestyoucanrecordyour “Y Practice problem-solvingandrole-playing(eg,having serving sizes. such as“fat,”“calories,”“meal,”and “snack.” appointment?” how youeat.” food intake.Thisrecordisatooltohelpyouthinkabout throughout the day.” That’s a goodwaytobalance yourfoodintake pizza for lunchyesterday, youatealighterdinner. the mayonnaise). the childoradolescentaskfoodservertohold our foodrecordshowsthatafterhavingpepperoni t o Promo App li c a t t e ions/Ques H eal t t hy ions

69 Bright FUTURES Tools Nutrition 70 Nutrition Tools Bright FUTURES If youhavequestionsaboutyour Realize thateveryonehasa If youareoverweightandwant Look atmagazineswitha Think aboutyourpositive Say somethingnicetoyour Look inthemirrorandfocuson professional. size orweight,ask ahealth unique sizeandshape. gradual change. your expectations,andaimfor to loseweight,berealisticin look thewaytheydo. designers dotomakemodels photographers andgraphic critical eye,andfindoutwhat appearance. traits thatarenotrelatedto friends abouthowtheylook. negative ones. your positivefeatures,not ■■ Child or and Ti p s for A doles A doles F os c t c en ering aPosi en t t s Share withahealthprofessional If yourchildoradolescentis Show thatyouloveyourchildor Analyze mediamessageswithyour Praise yourchildoradolescentfor Focus onnon–appearance-related Model healthyeatingandphysical behaviors orbody image. your child’s oradolescent’s eating any concernsyouhaveabout instead. appearance—offer support overweight, don’ weighs. adolescent regardlessofwhathe child oradolescent. academic andothersuccesses. and others. traits whendiscussingyourself activity behaviors. extreme eatingandphysical activity behaviors,andavoid t Paren i v e t criticizeher B t ody s I mage Refer children,adolescents,andparents with Take extratimewithanoverweightchild or Emphasize thepositivecharacteristics Educate parents,physicaleducationinstructors, Discuss normalvariationinbodysizesand Discuss howthemedianegativelyaffects If achildoradolescenthasdistortedbody Assess weightconcernsandbodyimage. Discuss changesthatoccurduringadolescence. or otherhealthprofessional. weight-control issues toaregistereddietitian and weightcontroloptions. adolescent todiscusspsychosocialconcerns you see. appearance) ofchildrenandadolescents (related toappearanceandnotrelated to body weights. and coachesaboutrealistichealthy shapes amongchildrenandadolescents. body image. consequences. image, explorecausesanddiscusspotential A mong Children H eal t h Professional Storage Shopping bacteria thatmaycauseillness.Ineverystepoffoodpreparation,follow 4guidelinestokeepfoodsafe: Safe foodhandling,cooking,andstorageareessentialtopreventfoodborneillness.You can’t see,smell,ortasteharmful ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ condition andhas beenkeptinacool,clean,anddry place. Discardcansthataredented, leaking,bulging,orrusted. low-acid foodssuch asmeat,poultry, fish,andmostvegetables canbestoredfor2to5years ifthecanremainsingood In general, canned high-acid foods such as tomatoes, grapefruit, and pineapple can be stored for 12 to 18 months. Canned wrap thatisrecommendedforthefreezer. To maintainqualitywhenfreezingmeat andpoultryinitsoriginalpackage,wrapthepackageagainwithfoil orplastic from comingintocontactwithother food. Make sureperishablefoodsuchasmeat andpoultryiswrappedsecurelytomaintainqualityprevent meatjuices beef, veal,lamb,orporkwithin3to 5days. Cook orfreezefreshpoultry, fish,ground meat,andvarietymeat(eg,calf’s tongue)within2days;cookorfreezeother 40°F orbelowandthefreezerat0°F orbelow. Check thetemperaturesofyourrefrigeratorandfreezerwithanappliance thermometer. Therefrigerator shouldbeat Always refrigerateperishablefoodwithin2hours(1hourwhenthetemperature isabove90°F). Never buyfoodafter“sell-by,” “use-by,” orotherexpirationdates. Never buymeatorpoultryinpackagingthatistornleaking. Buy refrigeratedorfrozenitemsafterselectingnon-perishablefood. Chill—Refrigerate promptly. Cook—Cook topropertemperatures. Separate—Don’t cross-contaminate. Clean—Wash handsandsurfacesoften. ■■ B asi c s for H andling F ood S afely a

71 Bright FUTURES Tools Nutrition 72 Nutrition Tools Bright FUTURES Cooking (Minimal Internal Temperature) Thawing Preparation ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Poultry cookedto 165°F. Ground beef,veal,andlambcooked to160°F. All cutsofporkcookedto160°F. Beef, veal,andlambsteaks;roasts; chopscookedto145°F. Cook meat, poultry, eggcasseroles,and fishimmediatelyaftermicrowavethawing. microwave andcoverwithalidormicrowave-safe plasticwraptoholdinmoistureandprovidesafe,evenheating. Microwave: Forfastestthawing,usethemicrowave.Placefoodincookware thatismanufacturedforuseinthe Change the waterevery30minutes.Cookimmediatelyafterthawing. Cold water:Forfasterthawing,placefoodinaleak-proofplasticbag,and submergethebagincoldtapwater. onto other food. Refrigerator: Therefrigeratorallowsslow, safethawing.Makesurethawingmeatandpoultryjuicesdonotdrip Marinate meatandpoultryinacovereddishtherefrigerator. 1 gallonofwater. Sanitize cuttingboards,utensils,andcountertopswithasolutionof1tablespoon ofunscented,liquidchlorinebleachin wash thecuttingboard,utensils,andcountertopswithhot,soapywater. Don’t cross-contaminate.Keeprawmeat,poultry, fish,andtheirjuicesawayfromotherfood.After cuttingrawmeat, Always washyourhandswithwarmwaterandsoapfor20secondsbefore andafterhandlingfood. ■■ B asi c s for H andling F ood S afely, c on t inued a Refreezing Leftovers Serving ■ ■ ■ ■ ■ ■ ■ ■ Washington, DC.USDepartmentofAgriculture, FoodSafetyandInspectionService; 2006. Adapted fromUS Department ofAgriculture,FoodSafety andInspectionService.BasicsforHandling FoodSafely  ■ ■ ■ ■ ■ ■ ■ ■ methods, cookbeforerefreezing. Meat andpoultrydefrostedintherefrigerator mayberefrozenbeforeoraftercooking.Formeatthawed by other Use cookedleftoverswithin4days. Place perishablefoodinshallowcontainersandimmediatelyputitthe refrigeratororfreezerforrapidcooling. Discard anyperishablefoodkeptatroomtemperatureformorethan2 hours(1hourifthetemperaturewasabove90°F). above 90°F). Perishable foodshouldnotbekeptatroomtemperatureformorethan 2hours(1hourwhenthetemperatureis bowls ofice. At buffets, keepfoodhotwithchafingdishes,slowcookers,andwarmingtrays.Keepcold bynestingdishesin Cold foodshouldbeheldat40°Forcolder. Hot foodshouldbeheldat140°Forwarmer. ■■ B asi c s for H andling F ood S afely, c on t inued .

73 Bright FUTURES Tools Nutrition 74 Nutrition Tools Bright FUTURES Commodity Child andAdult and S Food (C Car P ■■ A upplemental r Programs ogram (CACF S F ssis F e Food ederal P F N ) P ood u r t ogram t an ri t c ion e P ) N Food Reduced-price or u snacks free mealsand t S er ri B v enefi t i c ion es and t s A ssis Infants andchildrenuptoage Children andadolescentsupto t poverty level at or<185%ofthefederal 6 fromfamilieswithincomes institution, childcarefacility by thestate)enrolledinan with adisability(asdefined and childrenadolescents residents ofemergencyshelters; adolescents uptoage18whoare migrant workers;childrenand up toage15fromfamiliesof age 12;childrenandadolescents emergency shelter an c W e Programs ho Qualifies , or A State agency USDA State education US Department F dm (eg, health) agencies (USDA) of Agriculture unding and A inis gen t c ra ies t i v e Local public Child care agencies private and nonprofit shelters emergency programs, and school care “at-risk” after- care homes, centers, day Pro S er v v iders i c e T E E and he xpanded Food arly P Food Assistance and and Nutrition P E ■■ A r r ducation Programs ogram ( ogram ( F E ssis mergency H ederal H F N ead ood ead u t t an ri S TE E S tart FN t tart c F ion e A EP P ) ) N Food Nutrition education Nutrition services u Breakfast Program) and the School Lunch Program the National School snacks (through and m t S er ri B v enefi t i eals and c ion es and t s A ssis V Infants andchildrenuptoage5 Children andadolescentsfrom t aries bystate with disabilities available forinfantsandchildren least 10%oftotalenrollment of thefederalpovertylevel;at assistance orwithincomes<100% and theirfamiliesreceivingpublic families withlimitedresources an c W e Programs, ho Qualifies c on A State agency USDA DHHS regional Department of State landgrant USDA t F dm offices (DHHS) Human Services Health and Service offices Extension Cooperative universities and unding and inued A inis gen t c ra ies t i v e Local public Local public Local Cooperative agencies and for-profit nonprofit and private soup kitchens) food pantries, food banks, agencies (eg, private and nonprofit Service offices Extension Pro S er v v iders i c e

75 Bright FUTURES Tools Nutrition 76 Nutrition Tools Bright FUTURES Food Distribution National and (FD (N on L R P ■■ A unch r eservations Programs ograms SLP F ssis I PIR ndian ederal F N ) ood u ) P S t r t an chool ogram ri t c ion e N Reduced-price or Food u afternoon snacks free lunchesand t S er ri B v enefi t i c ion es and t s A ssis Children andadolescentsattending Children andadolescentsfrom t of federalpoverty level available ifincome isator<130% level; freelunches andsnacksare and 185%offederalpoverty family income isbetween130% and snacksareavailableif school: reduced-pricelunches standards based onincomeandresource recognized tribe;eligibility who belongstoafederally Oklahoma withafamilymember reservations andinthestateof in designatedareasnear American familiesresiding and adolescentsfromNative reservations andchildren families livingonIndian an c W e Programs, ho Qualifies c on A State education USDA Indian tribal USDA t F dm agencies of and Nutrition and USDA,Food organizations unding and inued A fice inis gen t c ra ies t i v e Public and Indian tribes care institutions residential child schools and nonprofit private organizations and tribal Pro S er v v iders i c e S Nutrition S and pecial Milk chool Br P for Assistance P P ■■ A r r r Programs ogram ( ogram ogram (NA F ssis P ederal F N uerto ood u t eakfast t an ri S R M t c ico ion P P e ) ) N Reduced-price or Reduced-price or Cash topurchase u free milk free breakfasts food t S er ri B v enefi t i c ion es and t s A ssis Children andadolescentsattending Children andadolescentsattending Children andadolescentsfrom t criteria asNSLP service programs;sameeligibility participate inotherfederalmeal- and summercampsthatdonot child careprograms,schools, as NSLP school; sameeligibilitycriteria Puerto Rico one personage≥60)livingin (≤$3,000 ifhouseholdhasatleast (aside fromincome)of≤$2,000 families withhouseholdresources an c W e Programs, ho Qualifies c on A State education USDA State education USDA USDA t F dm agency agencies unding and inued A inis gen t c ra ies t i v e Child care Public and Puerto Rico summer camps schools, and programs, care institutions residential child schools and nonprofit private Pro S er v v iders i c e

77 Bright FUTURES Tools Nutrition 78 Nutrition Tools Bright FUTURES S S and pecial upplemental P S Nutrition (W Women, and Childr Assistance Nutrition P ■■ A r upplemental r Programs ogram for ogram ( F ssis I C) ederal F N ood u t t an I ri nfants S en NA t c ion e P ) N Food, vouchersfor Benefits topurchase u and socialservices referral tohealth education, and food, nutrition food t S er ri B v enefi t i c ion es and t s A ssis Infants andchildrenuptoage5at Children andadolescentsfrom t poverty level incomes ator<185%offederal nutrition riskfromfamilieswith one personage≥60) (≤$3,000 ifhouseholdhasatleast (aside fromincome)of≤$2,000 families withhouseholdresources an c W e Programs, ho Qualifies c on A State agency(eg, USDA State agency(eg, USDA t F dm health) human services) services, and welfare, social unding and inued A inis gen t c ra ies t i v e Health, social Public assistance agencies community services, and departments public health networks, and nutrition extension cooperative agencies, services and social Pro S er v v iders i c e S and ummer Food ( S ■■ S A ervice Programs F F ssis SP ederal F N ) ood u t P t an r ri ogram t c ion e N Reduced-price or u snacks free mealsand t S er ri B v enefi t i c ion es and t s A ssis Children andadolescentsattending t eligibility criteriaasNSLP a summeractivityprogram;same an c W e Programs, ho Qualifies c on A State education USDA t F dm agency unding and inued A inis gen t c ra ies t i v e Public and camps and summer governments; county municipal, local, institutions; nonresidential schools and nonprofit private Pro S er v v iders i c e

79 Bright FUTURES Tools Nutrition