Bright Futures: Nutrition Supervision

Home , Birth weight, Infant, Infant nutrition

Supervision Nutrition BRIGHT FUTURES: BRIGHT

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Infancy

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BRIGHT FUTURES: Infancy formula, or acombination of provide both 40%to 50%of from calories fat and are thus of fat, protein, vitamins, and first the minerals. During year of life, breast infant milk, To growth meet demands, infants require intake ahigh of and calories adequate intakes parental height, genetic syndromes, disorders), and other physical factors. first year. more rapidly during first the 6 months of life but less rapidly theduring remainder the of Growth rates of exclusively breastfed and formula-fed infants differ. Breastfed infantsgrow 12 months, gain about they inch ahalf amonth. tobirth age 6months, infants gain approximately 1inch amonth, and from ages 6to first year of life, butthe rate of increase slows secondtheduring half the of year. From week fromper ages 6 to 18months. Infants usually increase length their by 50% inthe age 1. Onaverage, infants gain 4to week 7oz first inthe per 4 to 6 months and 3 to 5 oz 7 days. Typically, infants double weight birth their by age 4to 6months and triple it by fluid loss someand breakdown tissue.of They usually regain their weight birth within Immediately after infants birth, lose approximately 10% body theirweight becauseof of ents. Conversely, growth poor is an important indicator of nutritional inadequacy. For infants to grow at appropriate rates, adequate need they and calories essential nutri with infant. the expandtheiralso They abilitiestheir infant’s to meet needs. andcues, develop ability the to negotiate and solve problems through interactions their ofa sense responsibility, cannot frustration they when experience interpret infant’s the building infant’s the feeding and pre-speech When skills. feeding infant, their parents gain parents, and siblings and parents’, grandparents’, and siblings’ responses to infant); the and and responding to infant promoting cues; reciprocity (infant’s responses to parents, grand responding appropriately to one another’s include These skills cues). identifying, assessing, members of family—parents, the grandparents, siblings, and infant—develop the in skills as foundation the Feeding practicesserve for many of family aspects development (ie, all emotional bonding parents between and infants. beyond supporting purposes growth. their serves Feeding provides also opportunities for ment. But feeding infants is more than simply offering they whenare food hungry, and it first the During year of life, good nutrition is to infants’key vitality and healthy develop slows but remains still rapid. infancy, from ages 6to 9months, and inlate infancy, from ages 9to 12months, growth most rapid changes inearly infancy, occur and birth between age 6months. In middle terms of growth, developmental achievements, nutrition and needs, feeding patterns. The throughoutenced life. Infancy is into divided stages, eachof several is which unique in markedInfancy by is aperiod most the rapid growth and physical development experi GROWTH CONTEXT 1–3 Infants’ growth on depends nutrition, history, perinatal genetic factors (eg,

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PHYSICAL Infancy

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NUTRITION 6 months. for aminimum of 4months, but preferably for Ideally, mothers should exclusively breastfeed and given inadequate volume, provides sufficient be restricted duringbe first the year of life. acids, and fat-soluble vitamins. Fats should not important sources of essential calories, fatty digest breast infant designed or milk specifically Newborns’ digestive systems can effectively ume at one and time require fewer feedings. older infants are able to consume more vol- frequent small, borns need feedings, whereas volume and variety of increases. Thus food - new As infants grow, ability their to consume agreater and middle infancy. werethan they able to consume during early includingfoods, with different foods textures, reflexesborn allow them eat to wider a activity, ofmastery purposeful and loss of- new In late infancy, infants’ physical maturation, fromdrink acup, and ultimately themselves. feed to chew and swallow, manipulate finger foods, next the few months, Over foods. learn they tary and head good neck control) to eat complemen- lowing, can sit they with support, and have they has changed to allow more coordinated- swal out of mouth] the is fading, sucking their reflex (ie, tongue the when reflex thrust [pushing food 4 to 6months, infants are developmentally ready to receive and At colostrum milk. then about age mother’s breast, latch onto nipple, the and suck way infants feed. Newborns are able to locate the firstthe year of life have a profound effect the on Significant developmental changesthat in occur the Dietary Reference Intakes for breastfed infants. infants and provide additional nutrients to meet of appropriate feeding and eating for skills all 6 months, aid foods solid development inthe infantthe is developmentally ready. After age introduced ages between 4and 6months when minerals. Complementary can foods be (solid) amounts of nutrients, all including iron supplement at beginning age 4months. byciency age 6months and should receive an iron, breastfed infants are at risk of iron defi- However, since breast contains milk little very have sufficient iron stores for 4 to6 months. 6 months. Infants are who at born term with exception the of vitamin D, during first the mother offers enoughvitamins and minerals, term infants, breast from milk awell- 6 Formula, correctly when prepared 7 vi tamins and no var 4 us urished For full- ually ually iety iety 5

age-appropriate development. ing, crawling, and are walking, then nurturing that play with infants, their encouraging roll- ity and motor development. skills Families ronments influence all their physical- activ handled, toys the play they with, and envi their - isthem different. The ways infants are held and acquire with they same,which the speed the infantswhich acquire motor is typically skills aftertheir first birthday. Although the order in early as age 9months, and others months walk infants sit earlier than others. as Some walk Development is an individual process. Some crawling, standing, and eventually walking. physical activity, including sitting up, rolling over, movements. With increasing control comes more pear, and infants slowly gain control over their next the few months,Over reflexes these disap- mouth toward breast the or bottle and suckle. rootingthe reflexcauses the infant to his turn that promote infant’s the For survival. example, sleeping and eating. Activity with reflexes begins ically. At first, infants mostspend timetheir of activity that an infant engages inchanges dramat- infancy,During amount the and of type physical have evenifthey food their front teeth. infants process infants because food, usually gum firstThese teeth, however, do not change how fromceeding front the of mouth the to back. the upper the ing between and lower jaws, and pro- months, usually inright andpairs left alternat - at around age 6months. Teeth few erupt every For most infants, first the tooth appearsprimary tion of more complex foods. system has matured enough to allow absorp the - formula. By age 3months, an infant’s digestive or infant-formula feeding and behaviors such The suck-and-pausesequence in breastfeeding of infant’s the behavior, that can so respond. they express hunger. Parents must careful observers be should fed as as possible soon be they when met. Forbe optimal development, newborns infant helps that to him learn trust his will needs first the During year of life, the feeding andfoods, to learn eat inmoderation. ing habits, to learn eat dietof abalanced varied tive feeding patterns to promote healthy eat- Infants anurturing need environment and- posi DEVELOPMENTAL

ISSUES hun gry gry of infant’s their development. munity resources that help parents at eachstage professionals can and identify also contact com- stances. As of part guidanceoffer, the they health and on decide options that suit best circum their - parents with opportunities to reflect discuss, on, sions tremendously can provide they because Health professionals can impact feeding- deci receive guidance on infant nutrition and feeding. that infants are well nourished and that parents lies, and communities are essential for ensuring Partnerships among professionals, health fami- ■ ■ ■ ■ ing relationship, responsive parenting involves how much to eat. In ahealthy infant-parent- feed ate, healthy The infant foods. when decides and ing feeding environment and provides appropri- infant.parent The establishessafe a and nurtur sion of responsibility parent the between and the A healthy feeding relationship involves adivi- for communication patterns throughout life. and evolves, trust lays which groundwork the and emotional development. of Asense caring parent during feeding facilitates healthy social physicalClose contact infant the between and a howlearn actions their comfort and satisfy. As infant, their feed cues. to they those parents increase repertoire their of responses successful atskilled interpreting infant’s their and cues timely manner. time, parents Over become more Thus difficultiesfeeding beaddressed ina must confidence parents’and sense of competency. tions inparents and can undermine parenting in earlyDifficulties feeding evoke strong emo- at own their rate. for feeding. Infants should develop feeding skills more can wait they trust, intheir secure longer munication with her parents. As infants become turning to parent the are an infant’s first com- as making eyecontact, opening mouth, the and ■ ■ ■ ■ BUILDING ing interactions Allowing infant the to initiate and- guidefeed encouragement of self-feeding Balancing infant’s the for need assistance with andties feeding skills infant’s the Recognizing developmental abili - infant’s hunger and satiety cues Responding early and appropriately to the

PARTNERSHIPS - severe bacterial and viral diseases, including and diseases, viral severe bacterial infants, breastfed infants have fewer and less- and supplies. food Compared with formula-fed sanitationwith poor and contaminated water inareasvariety of particularly infectious diseases, infantsvides with significant protection against a to promote and support breastfeeding Hospital Initiative, are following the taking steps Organization and UNICEF the Baby-Friendly requirements the meet of World the Health Many hospitals, including striving to those feeding and instruction support. professionals’ awareness of for need the breast- and maintenance of breastfeeding, and health hospital climate that is conducive to initiation the on professionals’ health supportive attitudes, a Breastfeeding success is inlarge dependent part and for how long to breastfeed infant. their ents to make informed choices about whether breastfeeding during prenatal care enables par benefits are significant. benefits the Discussing of breastfed for only afew weeks or months, the necrotizing enterocolitis. infections,monia, tract and botulism, urinary meningitis, gastroenteritis, otitis pneu media, longer breaks and aprivate setting for pumping of breastfeeding women. employers Certain offer Some workplaces are adapting to needs the meet ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ feeding whenever possible. forfood infants and should encourage breast- should emphasize that breast is ideal the milk towhether breastfeed. Health professionals to influence womentheir decisions in about Health professionals are uniquely positioned ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Fostering breastfeeding support groups Limiting of use the pacifiers infantstheir on demand Supporting mothers that can so breastfeed they Having stay newborns mother’s inthe room other than breast milk Limiting of use the any or foods beverages maintain lactation Educating mothers on how to breastfeed and Initiating breastfeeding early and management of breastfeeding Educating pregnant women about benefits the have to implement skills the policy the Training staff members to ensurethat they communicating it care health to all staff Developing awritten breastfeeding and policy 6 Even infant ifthe is 6 Breastfeeding pro- 8 : BRIGHT FUTURES: BRIGHT -

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NUTRITION as breast pumps, nipples, special and bottles. assistance equipment, inprocuring special such human breast Families banks. milk may need also In someinfants cases, mayfrom benefit access to can provide additional for food families in need. Programs.) A community shelf food or pantry ments. Tool (See K:Federal Nutrition Assistance stantial of part achild’s daily nutrition require- nutrition assistance programs can provide asub - from families with low incomes. Federally funded women and for infants and children up to age 5 age for pregnant, postpartum, and breastfeeding adequately nourished. WIC offerspack - a food resources to families to ensure that infants are The community may also supply financial offer infant nutritioneducation. organizations and community hospitals may also ists visit families at home. Health maintenance communityin which nurses health or nutrition - Infants and Children (WIC) and other programs Supplemental Nutrition Program for Women, through Special ilar the educational services nutrition Health needs. departments offer sim- value and benefits of breastfeeding, and infants’ on importance the of prenatal nutrition, the community.the For parents, programs can focus nutritionOther resources may available be in breastfeed infants their during workday. the andmilk, on-site child care that so mothers can breast refrigeration milk, to safely store breast can be successfully breastfed,can be although mothers Infants care health services. with special needs feeding and provide referrals to lactation support professionals can help to barriers identify breast- breastfeeding or bottle feeding Health is best. nutrients she but needs, don’t they know whether that certain infantbe their is receiving the all breast or milk infant formula. want They to fessional to indeciding infant whether their feed Many parents guidance need from pro ahealth - COMMON

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CONCERNS Health Care Needs chapter.) Children the and Adolescents(See With Special tion therapy inan early intervention program. tion problems may addressed of as part be nutri - For infants with developmental disabilities, nutri- support for parents of infants with such needs. Resources are available to provide education and feeding challenges that raise concerns for parents. Infants care health with may special needs have with differenttastestry foods and textures. to cups use andger begin utensils; foods; and chewing, swallowing, and manipulation of fin- ages 6andBetween 12months, infants master to ages eat between 4and foods solid 6months. abilities.tal Infants are developmentally ready to infant’s the nutrition and needs developmen- professionals can provide information related introduce into foods solid infant’s the diet.Health Parents may help need also determining to when Nutrition Resources.) availablebe community. inthe Tool (See J: support groups, may League, Leche such as La or infant or for other reasons. Breastfeeding rupted of because severe mother inthe illness to work or breastfeeding when inter to needs be lies manage breastfeeding mothers when return visits. Moreover, lactation help specialists fami- professionalshealth for during use follow-up lactation also clinic. offer They suggestions to schedule follow-up visits inahospital-based hospital, consult with mother the by phone, and motherthe and infant are discharged from the tation provide specialists follow-up care after referralsvide as appropriate. In many- lac cases, mothers have who breastfed before, and pro- benefitsthe even of forusingthese specialists, availablespecialists area; inthe tell parents about Health professionals should aware be of problems. Breastfeeding the (See chapter.) or tion about techniques special for positioning, may emotional extra need support,- instruc special equipmentspecial to help overcome feeding lac tation - visit and from infant to infant. as appropriateused from visit andvary to will assessment, and anticipatory guidance should be visits. specific questions,Interview screening and provided first, followed by information for age- (Nutrition SupervisionThroughout Infancy) is tains to entire the developmental infancy period Nutrition information supervision that per Healthy Eating Behaviors.) Strategies for Health Professionals to Promote tion of healthy eating behaviors. Tool (See G: developmental and to period, foster promo the - of what as infant the to expect enters next the infant’s nutrition status, to make parents aware guidance to parents to offer information the on ily. Health professionals provide anticipatory followed by screening and assessment to iden- These methods providepoint starting a useful Awareness inNutrition chapter.) Services and among cultural groups. Cultural the (See and variation wide the practiceswithin infood varietyofthe cultural traditions related to food lations, professionals health to need appreciate providing nutrition to diverse supervision popu- Infants.) Additionally, to challenge the meet of Tool visit.the (See A: Nutrition Questionnaire for ing aquestionnaire out filled parentsby before information accomplished be can also by- review professional’s communication style. Gathering Questions to match modified can be the health from visitvary to visit and from family to family. and build partnerships. Use of questions the may infant’sthe nutrition status, to invite discussion by selectively questions asking interview about Health professionals nutrition begin supervision Suggested Reading chapter.) inthis Infants, Children, and Adolescents, listed under Futures: Guidelines for Health Supervision of information Bright on see supervision, health of visits.part supervision health (For more ated during nutrition visits supervision or as An infant’s nutrition status should- evalu be concerns for infant that particular and fam to address family’s the questions and nutrition panying anticipatory guidance should geared be an infant’stify nutrition concerns. The accom Nutrition Supervision - - ■ ■ ■ ■ ■ ■ Interview Questions ■ Growth and Development FOR PARENTS OFALLINFANTS Anticipatory Guidance ■ ■ ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ body fatbody increases as much twice as muscle; money to buy food? Are you concerned about having enough is growing? How doyou feel about way the your baby breast or milk infant formula? yourDoes baby receive anything besides else How often do you yourfeed baby? enough to eat? Howhungry? doyou know she when has had How your does baby letyou know she when is feeding your baby? your baby? you Do have any questions about How doyou feeding is going think for you and year of life. infant’srestrict the fat intake during first the growth and and energy that should they not Inform parents that infant the fat needs for distant, anxious). one another affectionate, (eg, comfortable, assess parents’ and infants’ responses to parent-infant the Observe interaction, and development. Assess infant the for age-appropriate hair, gums, teeth, tongue, and eyes. Evaluate appearance the of infant’s the skin, feeding(eg, or eating difficulties, overfeeding). normal or may indicate anutrition problem chart)the should evaluated. be This maybe amajor(eg, change ingrowth percentiles on growthDeviation from pattern expected the and plot on these astandard growth chart. length, weight, and circumference, head Assess infant’s the growth. Measure infant’s the processed water? cooking water? you Do bottled or use What is source the of your and drinking ■ THROUGHOUT INFANCY NUTRITION 4 Between ages 2and Between 6months,

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NUTRITION ■ ■ ■ ■ ■ Feeding Practices ■ ■ ■ ■ ■ ■ ■ of chubbiness. cle and less fat, reducing appearance the 12 months, however, infants gain more mus- age of fat ages than boys.6and Between 6 months. Girls deposit agreater percent- therefore, many infants chubby seem at age spoon andspoon swiping toward food the her mouth. include moving her forward head to reach the older infant (ages 4–6months), signs of hunger and grimaces, fussing. facial pre-cry For the ting his hand to his mouth, sucking, rooting, to age 3months), signs of hunger include put - arefoods added. For younger the infant (up day) per (6–8 times until complementary she is hungry, 3to 4hours typically every parents to formula-fed the feed infant when and day 6to per 12times thereafter. Instruct day per 12 times for months, next the several dayper during weeks initial the of life, 8to hewhen is hungry, typically 10to 12times Instruct parents to breastfed the feed infant for 6 months. for aminimum of 4months, but preferably tions offered the infant)to is recommended ing (only breast and milk - prescribed medica for food ideal infants. Exclusive breastfeed- Emphasize to parents that breast is the milk eyes during feeding. distress. Parents should into look infant’s the infant’s of cues hunger, comfort, fullness, and upright position, that so parents can assess the hold the infant feeding, when inasemi- close Explain to parents that it is important to in infant cereal. cow’s,(eg, goat’s, soy) should not even used, be formula is recommended, and low-iron milk 12 months, breast or milk iron-fortified infant Inform parents that until infant the is age and development. of because needs rapid their dietary growth Tell parents that infants have special ents for toassessment. aspecialist further developmentin the of feedingrefer skills, par and textures. If infant the has significant delays readybe before introduced being to foods new ing at skills own their rates. The infant must Reassure parents that infants develop- feed 6 4 - ■ ■ ■ ■ ■ Food Safety ■ ■ ■ ■ ■ ■ ■ ■ ■ or may eating be other soon. too foods receiving formula that is prepared incorrectly, enough breast or milk infant formula, may be are with difficulty) passed may be gettingnot stipated (ie, have who hard, stools that dry Explain to parents that infants are who con- a sitting position on lap. their shoulder and chest orsupporting while himin infant’s holding back while himagainst their after a feeding by gentlyrubbing pattingor the feeding midway (eg, through feeding) the or ents to infant burp the at natural breaks during aftersoon a feeding may help. Encouragepar ing afeeding and avoiding excessive movement feeding. Burping infant the dur times several to spit up alittle breast or milk formula at each Reassure parents that it is normal for infants from food. the includefullness leaning back and turning away olderthe infant (ages 4–6months), signs of other than eating, and closing her mouth. For from nipple, the showing interest inthings signs of include fullness turning her away head full. For the younger infant (age up to 3 months), Tell parents to infant the feed until he seems used within 24hours.used in bottlesplaced should refrigerated be and Formula that is prepared from powder and and immediately refrigerator. inthe placed keptbe up to 48hours, iftightly covered to-feed or concentrated infant formula can Tell parents that an open container of ready- 12 months. and inachest or upright for freezer deep 6to erator with separate doors for 3to 6months, weeks, compartment inafreezer of- refrig the compartmentfreezer of arefrigerator for 2 24 hours, refrigerator inthe for 5days, inthe storedcan be inan insulated bagfor cooler Instruct parents that expressed breast milk per day. instead of abottle and limit it to 4to 6oz 6 months, provide juice 100%fruit inacup to infants younger than 6months. After age Tell parents that juice should not given be infant from bottle the by age 12to 14months. ing at about age 6months and to wean their Instruct parents to introduce acup for- drink 9 10 11 4 - - ■ ■ Supplements ■ ■ ■ ■ ■ ■ ■ ■ beginning in the first inthe beginning days few of life. receive avitamin Dsupplement of 400IU/day 1 qt/day of vitamin D-fortified formula should infants are who ingesting less than 1L/day or Explain to parents that non-breastfed all younger than 12 months. Cow’s should milk not given be to infants of and is consuming at least 1L/day or 1qt/day should continue infant unlessthe is weaned firstin the days few of life. Supplementation min Dsupplement of 400IU/day beginning breastfedtially infants should receive avita- Explain to parents that breastfed and par Handling Food Safely.) Toolfood-safety practices.(See for H:Basics parents illness, food-borne to need follow not developed. To fully reduce risk for the immune and gastrointestinal systems are for many their because illnesses food-borne Inform parents that infants are at risk high priate for infants. choking hazards, are foods these not appro get throat. inthe lodged In addition to being peanut(eg, butter, large chunks of meat) can Foods that are sticky or tough to break apart cult to raw popcorn, chew (eg, carrots, nuts). hot dogs)and that foods and are diffi- dry hardor (eg, slippery candy, whole grapes, that infants can choke on that foods are small low properly. foods Parents aware to need be have enough muscle control to chew and- swal a problem for infants may they because not Emphasize to parents that choking can be can wait for it to down cool and test it again. (it should feel lukewarm). If parents can afew drops sprinkle on their wrist To make sure that fluid the isn’t warm, too refrigerator,in the or inawarm-water bath. thawedbe slowly either at room temperature, for afew minutes. Frozen breast should milk water or placing inabowlof them hot water warmed be by holding them under hot running ing milk’s the Bottles can qualities. beneficial microwaving), burning infant the and destroy - heat unevenly of (because hotspots caused by in amicrowave can overheat easily or may or jars inamicrowave. Breast warmed milk infantmilk, formula, or any in food Instruct parents not to warm expressed breast vitamin D–fortified formula whole or milk. 6 12 ne cessary, they con 12 tainers - ■ ■ Oral Health ■ ■ Physical Activity ■ ■ ■ ■ ■ ■ ■ ■ if the motherif the is vitamin B infant’s mouth). or any other to object hold bottle the inthe and to never prop abottle (that pillows is, use Tell parents to hold infant the feeding while Health chapter.) (after breakfast the Oral before and (See bed). usually around age 6to 10 months, aday twice toothpaste as first as the soon erupts,tooth day. Brush infant’s the with fluoridated teeth fordesigned infants, and plain water a twice toothbrush head, withpreferably asmall one with aclean, moist washcloth or asoft-bristled Instruct parents to clean infant’s the gums vitamin B is rare,deficiency a breastfed infant may need Inform parents that although vitamin B opment, such and as talking playing together. tive that activities promote proper brain devel- younger than 2, and encourage more interac- Discourage television for viewing children once aday). day with fluoridated toothpaste and flossing oral hygiene (ie, brushing a twice teeth their and insugar, beverages high and practicegood parents to visit dentist the regularly, limit foods to infant. their bacteria It is important for parentsbecause can transmit caries- has an impact on infant’s their oral health with parentsDiscuss that own their oral health dental caries(tooth decay). can which teeth, increase infant’s the risk for prevent fluidsfrom sugary pooling aroundthe ormilk, formula during day the or at night to fruit juice), soft drinks, breast drinks, fruit (eg, a sippy cup containing insugar beverages high quent and prolonged bottle feedings or of use or sipper-type (“sippy”) cup or allowed fre- infant should not put be to with sleep abottle drate-rich Explain foods. to parents that their feedings or snacking or on carbohy sugary - decay) may result from frequent or prolonged Explain to parents that dental caries(tooth B she is undernourished and not does take she is avegan [eats no animal products], if 12 supplements). 12 supplements before age 6months 13 4 12 deficient if (eg, 13 pr omoting 12 BRIGHT FUTURES: BRIGHT

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NUTRITION Feeding Practices FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ erably 6months provides nutrition ideal without breastfeeding. not allowed be to more sleep than 4hours Inbegin. first the 2 to 4 infantsweeks, should requiresally calmingbefore breastfeeding can breastfeeding; infantgood crying the usu- late of sign hunger that often interfereswith ing early the weeks is of a lactation. Crying fedto 10to be in24hours 12times dur Inform mothers that infants typically need totime rest feedings. between adequate intake and allows mother the some 45 minutes feeding generally per provides ings should not restricted, although be 20to otherthe breast is offered. The length- offeed allowed to finish feeding at one breastbefore Emphasize to parents that infant the should be milk supply. recommended to increase or maintain the mother the when is away from her infant is expressing breast or milk using abreast pump way best the to stimulate lactation. Manually make.will Feeding infant the on demand is sucks, more the breast mother’s the milk body Explain to parents that longer the an infant infant.the comfortable andnurturing experience the for to breastfeed. Theposition feeding shouldbe more relaxing mother ifthe has aquiet place Explain to parents that breastfeeding can be child wish to continue. for 12months or as long as mother the and Inform parents that breastfeeding can continue physical development. and exclusively for at least 4months but pref Tell parents that breastfeeding an infant Breastfeeding the well-being. (See chapter.) defense, neurodevelopment, and psychological infant nutrition, gastrointestinal host function, year of life of because its benefits related to ommended for infants during at leastfirst the Explain to parents that breastfeeding is rec- supports possible best the growth and 6 6 - - ■ Maternal Eating Behaviors ■ ■ ■ ■ ■ ■ Support ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Physical Activity chapter.) infantthe grow. Healthy the (See Eating and Eating well helps mother the stay healthy and Tell mothers to eat avarietyof healthy foods. cow’s milk. iron-fortified infant formula ratherthan from breast before milk age 12months needs Emphasize to parents that an infant weaned infantthe with additional iron. agesduced between 4and 6months to provide turkey) complementary when are foods intro- are richiniron pork, lean chicken, (eg, beef, Instruct parents to introduce pureed meats that the breasts from getting full. too ings help establish supply milk and prevent to adjust to infant’s the Frequent needs. - feed give mother’s the production milk achance to more them feed may necessary be often to grow fast. they Atwhen very it times, these Explain to parents that infants have periods have help extra at home. receive additional nutrition counseling, and more than one infant may to need eat more, Emphasize that mothers are who breastfeeding orpering, bathing. infant the cuddle and help with burping,- dia infant is finished breastfeeding,the father can mother it when is to time breastfeed. When the infants. The fathercan the bring infant the to Encourage fathers to help care for breastfed consultants, and educational materials. family, breastfeeding support groups, lactation breastfeeding information include and friends Explain to mothers that additional sources of feeding is delayed then for 2hours. of beer, or 2oz of hard liquor is safe ifbreast- Explain to mothers that 8oz of wine, 12oz day.per servings to 2 soft drinks) containingdrinks caffeine coffee, (eg, tea, Tell mothers to limit consumption the of of aglass waterdrink feeding. at every or aremilk juice they when thirsty and to Encourage mothers liquids to drink such as 6 4 15 15 ■ ■ Food Safety ■ ■ ■ ■ ■ ■ ■ ■ Feeding Practices FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ should not to added infant be formula. Emphasize to parents that cereal or other foods — — — — procedures. mula and as instructed to follow sanitary these Tell parents to carefully prepare infant for should consult with professional. ahealth If infant the is not feeding enough, parents formula come out faster. nipple to make expressed breast or milk infant Tell parents not to enlarge hole the bottle inthe — — — — want to eat time: the all infant more is crying than usualor to seems Instruct parents to check following the ifthe ings air the when temperature is high. water, but water offered can be - between feed Inform parents that infants donot usually need infant’s appetite increases. prepare and offer more infant formulathe as with parentsDiscuss to need that will they infant’s eyes. parentThe shouldbe able intoto look the in asemi-upright position, during feeding. Encourage parents to hold infant the close, infant intolerance. with documented lactose include an infant fed avegetarian dietor an life. Indications for of use formula soy-based or low-iron formulas during first the year of infanttheir cow’s goat’s milk, soy milk, milk, Explain to parents that should they not feed during first the year of life. breast for milk infant feeding full-term the formula is recommended the substitute for Explain to parents that iron-fortified infant — — — — — — — — tainer before opening. Wash top the of and formula the dry con- and nipples use. before every andClean disinfectreusable bottles, caps, with anontoxic biodegradable cleaner. area the Clean where formula is prepared Wash hands before preparing formula. Is feeding the environment distracting? too ger cues? Are parents responding to infant’s the hun- water added? been Is formula the prepared correctly? Has extra able position for feeding? Is infant the comfort inasemi-erect, placed - 11 4 4 4 - 4 ■ FOR PREGNANTWOMEN Interview Questions ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and family? should know about to better care for your baby Are there any family concerns health that I NUTRITION storedcan be at room temperature. Inform parents that powdered infant formula coveredbe and refrigerated. to-feed or concentrated infant formula should Inform parents that open containers of readybe reused. ing. Abottle that should started has not been bottle infantthe the when has finishedeat - Tell parents to discard any formula leftin that you were pregnant? buttaking stopped using you when learned any herbs? Is there anything that you were youDo alcohol teas, drink or or take special have pregnant? been remedies to improve your since health you Have you any used or traditional special health have you any taken past? inthe counter medications or pain relievers now, or Are you any taking prescribed or over-the- or minerals? vitamins?tal Are you other taking vitamins Are you or taking doyou plan to prena take - your baby? would help you afford careto for yourself and Would you interested be inresources that and child care? have enough money for clothing, food, diapers, baby? you Do have insurance? health you Do baby? you Do feel comfortable caring for your youDo have what you to need care for your youDo have appliances that work? have enough heat, hot water, and electricity? Tell me about your living situation. you Do until now? cies? How much weight have you gained much weight didyou gain inprior pregnan- What was your pre-pregnancy weight? How ■ PRENATAL 11

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Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 30 Bright FUTURES

NUTRITION ■ ■ ■ ■ ■ ■ FOR PARENTS PLANNINGTOFORMULA-FEED ■ ■ ■ ■ ■ FOR WOMENPLANNINGTOBREASTFEED ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or supplements? Are you using any or (legal other illegal) drugs will helpwill you your feed baby? youDo have family members or who friends What have you heard about formula safety? How doyou plan to prepare formula? the to buy infant formula? Are you worried about having enough money your baby? Would you like help choosing formula for about formula feeding? you Do havelactose-free)? any questions infant formulas iron-fortified, (eg, soy, What have you read or heard about different or lactation consultants? youDo know how to contact support groups as you are learning to breastfeed? Wouldfeed? you able be to get help from them baby? Didany of your family or breast friends - youDo know anyone breastfeeds who her how to nurse your baby? Have you to any been classes that taught you any breast surgery? changesmilk, inyour Have body)? you had your(eg, diet,privacy, having enough breast youDo have any worries about breastfeeding How did that go? Did you breastfeed your other children? waterthe you contain drink fluoride? youDo have problems with your Does teeth? your plan for feeding? What your does or partner familyabout think or intolerance? allergy food anyoneDoes inyour family have of ahistory andallergies sensitivities, or any other reason? vegan or vegetarian diets,weight gain, food ofbecause lack of appetite, aversions, food Are you restricting any inyour foods diet children? Your siblings? ing babies? With your own children? Other What kinds of have experiences you had- feed Do you have questions about breastfeeding? What have you heard about breastfeeding? What are your plans for feeding your baby? ■ ■ ■ Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ products, most ready-to-eat breakfast cereals). from fortified products grainfood (eg, fortified and beans). Folic kidney obtained acidcan be sprouts); and legumes black, (eg, pinto, navy, vegetables asparagus, (eg, broccoli, brussels bles spinach, (eg, turnip greens); some other avocados); vegeta dark-greenberries, - leafy folatefood include oranges, (eg, fruits straw- Inform women that concentrated sources of of folate, food folic acid, or amixture of both. folateintake is 600dietary equivalents day per Once pregnancy is confirmed, recommended suming avarietyof that foods contain folate. and/orfoods supplements inaddition to con- synthetic(the form of folate) from fortified should consume day 400µgper of folic acid ter of pregnancy. Before pregnancy, females before pregnancy and during first the - trimes women to consume folic acid, particularly infant with tube aneural encourage defect, To risk for minimizethe giving to birth an andfoods gaining right the amount of weight. physical activity, as well as by eating healthy ments, getting enough sleep, and getting ing by health going prenatal to all care appoint- Explain to women importance the of maintain- caloric intake,caloric level of physical activity, or both. gradually bynancy should occur adjusting Explain to women that weight loss after preg- level.to increase energy their swimming), as as possible soon after delivery activity, such as gentle aerobics walking, (eg, Recommend to women moderate physical Health Oral the chapter.)(See hygiene and obtain oral care health ifneeded. Encourage women to maintain oral good development.fetal beverages alcohol because adversely affects are pregnant to avoid consumption of alcoholic Advise women planning for conception or who Nutrition Assistance Programs.) Program, can help. Tool (See K:Federal and Supplemental the Nutrition Assistance Commodity Supplementalthe Food Program nutritionfunded assistance programs, such as or other assistance programs. federally Several may They them. be eligible for food, nutrition, Tell women that resources are available to help 16 ■ ■ ■ ■ FOR PARENTS PLANNINGTOFORMULA-FEED ■ ■ ■ ■ ■ ■ FOR PARENTS PLANNINGTOBREASTFEED ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ provide more infant ifthe hungry. seems still 2toformula 3hours at every first and then to day.per Tell parents to prepare 2 oz of infant are formula-fed average 20oz of formula Explain to parents infants that newborn who and nipples. mula, including heating and cleaning bottles information about how to safely prepare for among powdered formulas. Provide written read directions. the Mixing directions differ formula, and reinforce to need carefully the with parentsReview steps the for preparing changes informula. formula plan they to and use any proposed Encourage parents of totype infant the discuss Encourage parents to attend prenatal classes. and concerns. monitor breastfeeding, and address questions check infant’s the feeding and weight status, 48 hours of discharge from hospital the to visitborn with professional ahealth within Emphasize to parents for need the - anew few days of life. vitamin Dsupplement first inthe beginning breastfeedpartially that infant the a need will Inform mothers plan who to breastfeed or ing can help. breastfeeding consultation and monitor close challenging may breastfed be still and that a with conditions that make breastfeeding successfully breastfeed. Explain that infants Assure women that most mothers are able to orherbal traditional products that she is using. cian or another professional health about any Encourage mothers to consult with an obstetri- stances that may to infant. harmful the be teas containherbal ephedra and other sub- traditional remedies. health Explain that many known effects on pregnant women of herbal or Share information with women about the assist with breastfeeding. consultants and nurses are who available to In addition, many communities have lactation Encourage parents to attend prenatal classes. 12 - - ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFALLINFANTS Interview Questions age-specific informationthat follows. Throughout (pagesInfancy 25–29), as the well as information Nutrition section inthe Supervision ■ ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS Health professionals should general the use ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ one How time? much rest are you getting? What is longest the your time baby has slept at Is anyone helping you your feed baby? each day? How many wet diapers and stools he have does Has she received any other fluidsfrom bottle? a Satisfiedbaby look, rooting,still anxious? How your does baby behave after feedings? away, arches back, is irritable or calm? How he behave does during afeeding? Pulls itdoes generally for take afeeding? How often your does baby feed? How long mula brands, (eg, cost, preparation, amount)? What questions doyou have about infant for she at take does afeeding? How often do you yourfeed baby? How much iron-fortified? What formula are you using? Is formula the counter,the street drugs)? youDo any use prescription, (eg, drugs over anytake herbs? youbeverages? Do any drink teas or special youDo wine, beer, drink or other alcoholic vitamin Dsupplements? ortake plan to Is take? your baby receiving What vitamin or supplements mineral doyou Are you restricting any inyour foods diet? or nipples tenderness, (eg, swelling, pain)? Have you had any problems with your breasts sounds you when breastfeed? and suck? you Do hear her make swallowing How your does baby attach to your breast you know he when is hungry? How often do you yourfeed baby? How do youDo any need help with breastfeeding? your baby? How is breastfeeding going for you and ■ NEWBORN BRIGHT FUTURES: BRIGHT -

NUTRITION 31

Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 32 Bright FUTURES

NUTRITION ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ FOR PARENTS OFALLINFANTS Anticipatory Guidance ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Breastfeeding chapter.) you make it? How doyou store infant the formula after and night). 12 feedings in24hours (throughout day the 2to 3hours and every requiregry about 8to Newborn infantscan begin. usually are hun- usually requires calmingbefore breastfeeding breastfeeding; infantwith good crying the is alate of sign hunger that often interferes not to wait until infant their Crying is crying. or activity, mouthing, rooting). Tell women shows signs of hunger increased alertness (eg, Instruct women to breastfeed infant their when preferably room. delivery inthe asas possible soon afterthe infant born, is Encourage women breastfeeding to begin room with less light and noise. infants may or swaddled fed to ina need be ting, or stroking, is usually most helpful. Some repetitive movements such as rocking, pat- on gentle feeding. Acalm, approach, using by lights and noise and may help need to focus Inform parents that infants may distracted be duringtime first the 2 weeks. for feeding ifshe more sleeps than 4hours at a Instruct cues. parentstle to awaken infant the by respondingcrying to infant’s the more sub - and grimaces, fussing.facial Parents can avoid hand to her mouth, sucking, rooting, pre-cry infant’s hunger include which cues, putting her Instruct parents on how to recognize an Assess administration of vitamin K. state.the Perform metabolic screening as indicated by to buy infant formula? Are you worried about having enough money him? feed How your does baby like held to you when be after yourbaby has finishedfeeding? What doyou dowith formula the bottle inthe other equipment? How doyou clean bottles, nipples, and 6 6 (See the the (See ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFALLINFANTS Interview Questions age-specific informationthat follows. Throughout (pagesInfancy 25–29), as the well as information Nutrition section inthe Supervision Health professionals should general the use ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ still seems hungry. first and then to provide morethe infant if 2 oz of infant 2to formula 3hours at every of formula day. per Tell parents to are formula-fed consume an average of 20oz Explain to parents infants that newborn who infant formula. ( to wait until lactation is well established combining breastfeeding and formula- Encourage women are who considering around age 4to 6weeks. well established. For most infants, occurs this indicated)medically until breastfeeding is bottles)(pacifiers, and supplements (unless Tell parents to avoid using any nipples artificial are gaining weight at appropriate the rate. 8 wet diapers and 3or 4stools day per and getting have ifthey enough milk about 6to Reassure parents that breastfed infants are one time? What is longest the he time has slept at have each day? How many wet diapers and stools he does Is anyone helping you your feed baby? Has she received any other fluidsfrom bottle? a Satisfiedbaby look, rooting,still anxious? How your does baby behave after feedings? away, arches back, is irritable, or calm? How she behave does during afeeding? Pulls enough to eat? Are you comfortable that your baby is getting her?feed How your does baby like held to you when be itdoes generally for take afeeding? How often your does baby feed? How long How are you feeding your baby? concerns doyou have? How is feeding going? What questions or ■ usually at age 2–4weeks) before introducing 3

DAYS pr epare fe eding ■ ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and infant’s the ability to suck. responses to distractions environment, inthe tion with infant, the parent’s the and infant’s the the with feeding infant, the eye contact between Assess how comfortable parent the seems ing or either parent bottle-feeding infant. the If mother the possible,breastfeed observe - patterns. jaundice, and age-appropriate elimination Assess infant the for intake, milk hydration, state.the Perform metabolic screening as indicated by to buy infant formula? Are you worried about having enough money formula and storing it safely? What questions doyou have about preparing mula brands, (eg, cost, preparation, amount)? What questions doyou have about infant for enough to eat? How does she letyou know she has had How doyou know ifyour baby is How doyou hold bottle? the How doyou hold your baby feeding? while she at take does afeeding? How often do you yourfeed baby? How much How are you preparing formula? the Is it iron-fortified? What formula are you using for your baby? medications are you taking? What over-the-counter or prescription a bottle? Are you offering yourbaby breast in milk the breast? How can you tellhe is whether satisfied at do feedings last? How often your does baby nurse? How long Have you noticed changes inyour milk? strong surge of milk)? ejection” reflexsensation (tingling and a youDo “let-down” feel agood or “milk- well and breastfeed inarhythm? yourDoes baby suck he latch well? Does on supplement? Is your baby receiving avitamin D your baby? How is breastfeeding going for you and parent and infant, the parent’s the interac hun gry? gry? - - ■ ■ FOR PARENTS OFALLINFANTS Anticipatory Guidance ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ room with less light and noise. infants may or swaddled fed to ina need be ting, or stroking, is usually most helpful. Some repetitive movements such as rocking, pat- on gentle feeding. Acalm, approach, using by lights and noise and may help need to focus Inform parents that infants may distracted be hunger cues. by make it will to easier recognize early the first 2 Explain weeks. that keeping her close moresleeps than 4hours at during atime the parents to awaken infant the for feeding ifshe ing to infant’s the more subtle Instruct cues. Parentsbegin. can avoid by respond crying - requiresally calmingbefore breastfeeding can breastfeeding; infantgood crying the usu- late of sign hunger that often interfereswith is a and grimaces, fussing. facial Crying cry her hand to her mouth, sucking, rooting, pre- infant’s hunger include which cues, putting Instruct parents on how to recognize an more infant ifthe hungry. seems still 2to 3hours atevery first and then to provide Tell parents to prepare 2oz of infant formula mula-fed average 20oz of formula day. per Explain to parents that infants are who for pacifiers bottles.use or around age 4to 6weeks. Some infants never well established. For most infants, occurs this indicated)medically until breastfeeding is bottles)(pacifiers, and supplements (unless Tell parents to avoid using any nipples artificial not diarrhea. infants’ stools are This is normal loose. and is go for days several without astool. Breastfed stools as frequently as one feeding or per may mother’sthe comes milk in.Infants may have have about 6to 8wet diapers in24hours after Inform parents that breastfed infants should of 10to 12feedings in24hours. to 5-hour stretch feedings, for between atotal 3hoursand at every night, with one longer 4- ing routine 2to 3hours of daytime inthe every should into settle amore typical breastfeed- Tell parents that at about age 1week, infant the BRIGHT FUTURES: BRIGHT -

NUTRITION 33

Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 34 Bright FUTURES

NUTRITION ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFALLINFANTS Interview Questions age-specific informationthat follows. Throughout (pagesInfancy 25–29), as the well as information Nutrition section inthe Supervision Health professionals should general the use ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ do you store it? How long doyou keep it? If so, are you pumping your breast How milk? Are you planning to return to work or school? fluidsfrom bottle? a Has your baby received breast or milk other the breast? How can you tell ifyour baby is satisfied at from you when were last here? In what ways is breastfeeding different now feeding more often or for longerperiods? as it though your seem Does baby is breast- do you himeachtime? feed How often do you yourfeed baby? How long what else is he getting? Are you breastfeeding exclusively? If not, youDo any need help with breastfeeding? your baby? How is breastfeeding going for you and herbs, or vitamins? Are you giving your baby any supplements, What is longest the your time baby has slept? baby have eachday? How many wet diapers and stools your does a feeding? How your does easily baby burp during or after Is anyone helping you him? feed What time? the didyou do? growing fast to and want very seemed to eat all Have to be he when times seemed there been infant formula? Have you given your baby anything other than know ifhe has had enough? How doyou know ifheHow is hungry? doyou night? the During How often are you him feeding theday?during What are you feeding your baby at time? this cerns doyou have? How is feeding going? What questions or con- ■ BY

MONTH ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ FOR PARENTS OFALLINFANTS Anticipatory Guidance ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ to buy infant formula? Are you worried about having enough money after he has finished eating? What doyoubottlethe leftin dowith milk cost,(eg, preparation, nutrient content)? What concerns doyou have about formula the than formula? Have you given your baby anything other How long it does to take your feed baby? he at take does afeeding? How often your does baby feed? How much How doyou prepare formula? the iron-fortified? What formula doyou Is use? formula the your baby? How is formula feeding going for you and with abottle?to bed youDo everprop abottle to or feed put him How do you hold your baby when you feed her? appetite increases. offer more infant formulathe infant’sas fed infants, parents to need prepare will and intakemilk during that time. For formula- 8 weeks and significantly increasetheir through growth ages spurts between 6and Explain to parents that infants often go infant is receiving For breastfed infants, the determine whether swallowing.difficulty ences delays inlearning feedingor skills, has to exhibit oral reflexes such as - rooting, experi infantif the stiffens during continuesfeeding, iors. Assess for need the neurologic infantthe develop feeding successful behav- infant’s ability to suck. Help parents the and to distractions environment, inthe and the infant,the parent’s the and infant’s responses ent and infant, the parent’s the interaction with feeding infant,the eye contact parthe between Assess how comfortable parent the with seems ing or either parent bottle-feeding infant. the If mother the possible,breastfeed observe - vi tamin Dsupplements. eva luation - ■ FOR PARENTS OF FORMULA-FEDINFANTS ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Infants need 3to 4hours. to every feed 24 hours, but may consume 20to 31oz. usually consume 24to 27oz of formula in Explain to parents that 1-month-old infants and it take inhis mouth. to allow infant the to explore bottle’s the nipple mother offerthe infant bottle.the parents Tell nor Suggest full. that someone other than the infant the when is neither extremely hungry bottle to infant, their should they pick atime Tell parents that wish to ifthey introduce a few days of life. a vitamin Dsupplement first inthe beginning Explain to parents that breastfed infants need days. every 3 infants may have stools as infrequently as may and, decrease by age 6weeks, at appropriate the rate. The number of stools and 3or 4stools day per and is gaining weight ifheenough has milk about 6to 8wet diapers Inform parents that infant their is getting control and motor skills. and helps infants develop and head neck eyes. Playing stimulates nervous the encouraging her to follow with objects her Suggest that parents play with infant, the recommended. breastfeeding, short, frequent feedings are lot of gas, he may have colic. If infant the is ably for hours several eachday and a passes Tell parents that infant ifthe inconsol cries - infantthe and parent. the opportunityful interaction for social between light and noise. Feeding offer times a wonder infants may fed to inaroom need be with less ting, or stroking, is usually most helpful. Some repetitive movements such as rocking, pat- on gentle feeding. Acalm, approach, using by lights and noise and may help need to focus Inform parents that infants may distracted be have and head good neck control). canswallowing, sit they with support, and they reflex has changed allowto more coordinated outfood of mouth] the is fading, sucking their (ie, tongue the when reflex thrust [pushing formula are until they developmentally ready offeredbe than other food breast milk or infant Emphasize to parents that infants should not 12 br syst eastfed em - ■ ■ ■ ■ ■ ■ FOR PARENTS OFALLINFANTS Interview Questions age-specific informationthat follows. Throughout (pagesInfancy 25–29), as the well as information Nutrition section inthe Supervision Health professionals should general the use ■ ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ after a feeding? How your does easily baby burp during or What time? all the didyou do? growing fast to and want very seemed to eat Have to shebe when times there seemed been What is longest the your time baby has slept? Is anyone helping you her? feed your baby. Tell me about you foods the all are offering tions or concerns doyou have? How is your baby’s feeding going? What ques- fortified withfortified iron? What formula doyou Is use? formula the How are you preparing formula? the your baby? How is formula-feeding going for you and you keep it? How you will store your How milk? long will where you can pump your inprivacy? milk yourDoes schoolor workplace have aplace If so, you will pump your breast milk? Are you planning to return to work or school? fluidsfrom bottle? a Has your baby received breast or milk other the breast? How can you tell ifyour baby is satisfied at from you when were last here? In what ways is breastfeeding different now more often or for longerperiods? like it your seem Does baby is breastfeeding do you himeachtime? feed How often do you yourfeed baby? How long breastbesides milk? yourDoes baby receive other or foods fluids (eg, vitamin D)? Are you giving your baby any supplements youDo any need help with breastfeeding? your baby? How is breastfeeding going for you and ■ 2

MONTHS BRIGHT FUTURES: BRIGHT

NUTRITION 35

Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 36 Bright FUTURES

NUTRITION ■ ■ ■ ■ FOR PARENTS OFALLINFANTS Anticipatory Guidance ■ ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ does she drink at she drink does afeeding? How often your does baby feed? How much they have and head good neck control). canswallowing, sit they with support, and ing reflex has changed allowto coordinated (ie, at about age 4–6months, suck their when - formula are until they developmentally ready offeredbe than other food breast milk or infant Emphasize to parents that infants should not are recommended. is breastfeeding, short, frequent feedings a lot of gas, he may have colic. If infant the ably for hours several eachday and passes Tell parents that infant ifthe inconsol cries - infant the action between and parent. the offer a wonderful opportunity inter forsocial without other people present. Feeding times environment, perhaps with low lighting and patting, stroking). Infants may aquiet need gentle,need repetitive stimulation rocking, (eg, more during distracted easily feeding and may Explain to parents that as infants grow, are they infant is receiving For breastfed infants, the determine whether develop feeding successful behaviors. ity to suck. Help parents the and infant the tions environment, inthe and infant’s the abil- parent’sthe and infant’s responses to distrac- infant, parent’s the interaction with infant, the infant, eyecontact parent the between and the fortable parent the with feeding seems the or bottle-feeding infant. the Assess how com- If mother the possible,breastfeeding observe ing affection). smiling, holding, comforting, cuddling, show- infant are to eachother gazing, (eg, talking, how responsiveObserve parents the and the to buy infant formula? Are you worried about having enough money after yourbaby has finished eating? What doyou dowith formulabottlethe leftin with abottle?her to bed youDo everprop abottle to her feed or put feed him? How doyou hold your baby you when offered her anything than other formula? About how long afeeding last? does Have you vi tamin Dsupplements. - ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ FOR PARENTS OFALLINFANTS Interview Questions age-specific informationthat follows. Throughout (pagesInfancy 25–29), as the well as information Nutrition section inthe Supervision Health professionals should general the use ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ stretch of 4 to 5 hours at night between feedfeedings. every 2 to 3 hours but may have one spurts.longer By age 3 months, breastfed infantsmore generally frequently when they go through growth(throughout the day and night). They may continuefeed to need 8 to 12 feedings in 24 hoursEmphasize to parents that breastfed infantsto breastfeed! Congratulate mother the for continuing and appropriate gross motor development. encouraged it because promotes control head trol and motor Tummy skills. should time be and helps infants develop and head neck con- eyes. Playing stimulates system nervous the encouraging himto follow with objects his Suggest that parents play with infant, the through night. the infant’s not dietwill help infant the sleep Explain to parents that adding cereal to the to give your baby solids? Have you thought about you when begin will or formula? ing your baby any breast besides foods milk how long afeeding last? does Are you- feed How much she at take does a feeding? About How often are you him? feeding Tell me about what you are feeding your baby. cerns doyou have? How is feeding going? What questions or con- between feedings. longer stretch at night of up to 5or 6hours Infants 3to 4hours, with every feed one 24 hours, but may they consume 21to 32 oz. usually consume 26to 28oz of formula in Explain to parents that 2-month-old infants quently 3days. as every 6 weeks and older may have stools as infre- Reassure parents that breastfed infants ages ■ 4

MONTHS ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ containing or supplements. foods and infant is the whether receiving any iron- infant is For breastfed infants, the determine whether to buy infant formula? Are you worried about having enough money than infant formula? Have you offered yourbaby anything other bottle he when has finished feeding? What doyou dowith infant formulathe leftin Are you holding still your baby for feedings? bottle?the Has your baby to put begun his hands around a feeding? How much in24hours? How often your does baby feed? How much at How are you preparing formula? the other formulas?tried Is formula the with fortified iron? Have you using now? How is feeding going? What formula are you do you keep it? are you storing pumped breast How milk? long If so, are you pumping your breast How milk? Are you planning to return to work or school? (eg, iron, vitamin D)? Are you giving your baby any supplements from abottle? Has she received breast or milk other fluids the breast? How can you tellshe whether is satisfied at longer periods? Is your baby breastfeeding more often or for how long afeeding last? does How often your does baby breastfeed? About from you when were last here? In what ways is breastfeeding different now your baby? How is breastfeeding going for you and she fed (eg, at child care, at a relative’s home)? In addition to feeding her at home, where else is Ifmeal? so, ones? which Have you offeredfrom him the familyfoods yourDoes baby interested seem inyour food? receiving vi tamin Dsupplements ■ ■ ■ FOR PARENTS OFALLINFANTS Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ tion of avarietyof flavors, foods, and textures improper balanceof nutrients) to doing so. there may disadvantages be overfeeding, (eg, infant is developmentally ready. However, tages to introducing before foods solid the Tell parents that there are no nutritional advan neck control). sit with support, and have they and head good allow more coordinated can swallowing, they is fading, sucking their reflex has changed to reflexthrust [pushing outfood the of mouth] ages(ie, between 4–6months, tongue the when formula are until they developmentally ready offeredbe than other food breast milk or infant Emphasize to parents that infants should not can(which cause spitting up) or underfeeding. behaviors for feeding to avoid overfeeding Itfood). is important to respond to infant’s the (byfull leaning back and turning away from forwardhead to reach bottle the or or spoon) show are they when (by hungry moving the Explain to parents that infants can now clearly respond interaction. to social feedings. As infants develop, increasingly they Encourage parents to infant the to talk during vegetables after cereals. gradual The introduc variety of pureed or soft meats,fruits, and Encourage parents to gradually introduce a asthma and ininfancy early childhood. of atopic dermatitis, cow’s allergy, milk and formulas may prevent or delay occurrence the sively for at least 4months or using hydrolyzed Breastfeedingling) disease. with allergic exclu- least one first-degree relative (parent or sib- risk for developing are allergies with at those Explain to parents that infants are who at high least likelyfoods to cause an reaction. allergic infant cereal appears rice one to be of solid the for possiblereactions. allergic Iron-fortified for foods new 3to infant the 5days to observe at food new and atime not to introduce other Instruct parents one to begin single-ingredient mote healthy eating behaviors. contributes to diet and abalanced helps pro- (See the Food Allergy chapter.) Food Allergy the (See 4 17 BRIGHT FUTURES: BRIGHT 4 - 4 18

NUTRITION 37

Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 38 Bright FUTURES

NUTRITION ■ ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ from cereal. the such enhances which as fruits, iron absorption infantthe is fed richinvitamin with foods C, infant’s daily iron requirement, if particularly One ounce (30g)of infant cereal provides an dated toothpaste, flossing onceday). a brushing aday twice teeth their with fluori- in sugar, and oral hygiene practicegood (ie, to visit dentist the regularly, limit high foods to infant. their ria It is important for parents parents can transmit caries-promoting- bacte an impact on infant’s their oral because health with parentsDiscuss that oral their has health iron-deficiency anemia. mentary foods have been introduced to prevent 4 months and continued until iron-rich comple (1 mg/kg of body weight/day) beginning at age feeding from breastmilk) need iron supplement (who receive more than one-half of their daily Explain to parents that partially breastfed infants duced to prevent iron-deficiency anemia. iron-rich complementary foods have been intro beginning at age 4 months and continued until infants need iron (1 mg/kg of body weight/day) Explain to parents that exclusively breastfed byents needed breastfed especially infants. ample sources of iron, zinc, and protein, nutri- red meats, as first the solid They food. provide cereal) and(eg, rice pureed meats, especially as iron-fortified, single-grain infant cereals ready,tally offersources good of iron such plementation and infant ifthe is developmen- Instruct parents to continue vitamin Dsup- thata sign infant the is ready for foods. solid ness, teething, or changes inroutine, it may be increased breastfeeding; and is unrelated- to ill continues for afew days; is not affected by breast supply. milk If an increased demand growth spurt and is nature’s way of increasing breastfeeding is usually related to infant’s the Explain to parents that demand for more frequent to breastfeed! Congratulate mother the for continuing to themselves. feed begin they when helps infants later use will develop they skills mouth, and sucking and gumming them plastic toys), moving from them hand to appropriate toys rattles, (eg, stuffed animals, age physical activity. Playing with safe, age- Inform parents that infant toys encour 5 13 - 5 4,19,20 - -

■ FOR PARENTS OFALLINFANTS Interview Questions age-specific informationthat follows. Throughout (pagesInfancy 25–29), as the well as information Nutrition section inthe Supervision Health professionals should general the use ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ cerns doyou have? How is feeding going? What questions or con- of infant formula for appropriate growth. infantthe is consuming an adequate volume not formula ifthe needed is iron-fortified and Inform parents that vitamin supplements are 24 hours, but may they consume 26to 36oz. consume 30to 32oz of infant formula in Tell parents that 4-month-old infants the breast? How can you tell ifyour baby is satisfied at more often or for longerperiods? like it your seem Does baby is breastfeeding For how long on each breast? How often are you breastfeeding yourbaby? from you when were last here? In what ways is breastfeeding different now How is breastfeeding going? is away from home at (eg, child care)? youDo know what your baby is fed she when bottle or cup? What of types fluids is yourbaby getting ina yourDoes baby have any favorite foods? Has your baby fed himself anything? If so, ones? which Has she eaten any from foods family the meal? food? likes acertain How your does baby letyou know he when other foods? such as cereal,vegetables, fruits, meats, and How are you planning to introduce foods, solid to give your baby solids? Have you thought about you when begin will long dofeedings last? How much she eat does or About drink? how How often do you yourfeed baby? breastbesides or milk formula? Are you feeding her any (liquid food or solid) What are you feeding your baby at time? this ■ 6

MONTHS us ually ually ■ ■ FOR PARENTS OFALLINFANTS Anticipatory Guidance ■ ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ head andhead neck control). ing, he can sit with support, and he has good changed to allow more coordinated swallow- mouth]the is fading, his sucking reflex has tonguethe reflex thrust [pushing outfood of infantthe is developmentally ready (ie, when Instruct parents to introduce when foods solid back and turning away. that he’s or doesn’t full want by food leaning towarding food the his mouth. He can indicate his forward head to reach and spoon the swip- is hungry. An infant shows hunger by moving Encourage parents to infant the feed he when Health Oral chapter.)(See the infant’s risk for dental caries(tooth decay). Assess eating behaviors to determine the Ask infant the whether has had adental visit. for ironassess need the supplementation. infant is receiving For breastfed infants, the determine whether to buy infant formula? Are you worried about having enough money How are you preparing your formula? formula? water the Does contain fluoride? What kindof water to prepare is used the cost,(eg, preparation, or nutrient content)? youDo have any concerns about formula the feedings versus night feedings? and how much he at take does afeeding? Day How often your does baby in24 hours,feed ofthinking using other formulas? Have you other formulas, tried or are you are you using now? How is formula-feeding going? What formula or iron-rich foods? Is your baby receiving an iron supplement and/ Is your baby receiving vitamin Dsupplements? cow’s, goat’s, or soy milk? than breast such milk, as infant formula or Have you given your baby any fluids other fluidsfrom bottle a cup?or Has your baby received breast or milk other breastfeed? What are your plans for continuing to vi tamin Dsupplements, and ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Allergy chapter.)Allergy of flavors, foods, and textures etables.gradual The introduction of a other pureed or soft meats,fruits, and veg- Encourage parents to gradually introduce then least likelyfoods to cause an reaction. allergic infant cereal appears rice one to be of solid the for possiblereactions. allergic Iron-fortified for foods new 3to infant the 5days to observe at food new and atime not to introduce other Instruct parents one to begin single-ingredient asthma inearly childhood. of atopic dermatitis, cow’s allergy, milk and formulas may prevent or delay occurrence the sively for at least 4months or using hydrolyzed Breastfeedingling) disease. with allergic exclu- least one first-degree relative (parent or sib- risk for developing are allergies with at those Explain to parents that infants are who at high 0.8 to 1.0mg/L (ppm) is recommended. atis added aconcentration of approximately prefer bottled water, abrand fluoride inwhich fluoridatedlies to drink water; forthat families with parentsDiscuss that it for is best fami- respond interaction. to social feedings. As infants develop, increasingly they Encourage parents to infant the to talk during secure him. mealtime, but asafety belt to should used be infantthe of part to family the be circle at Explain to parents that chair ahigh allows and limit it to 4to day. 6oz per juice of inacup, orpart ameal snack. Serve Tell parents only juice 100%fruit as to serve pureed foods. can themselves feed do softnot foods need and home-prepared baby but food, infants who Inform parents that can offer they store-bought spices, or sugar to food. added their Tell parents that infants donot salt, need food. accepts aparticular It may 10to take 15attempts before an infant to eat it.canbe The offeredfood ata later time. not she likefood, anew should not forced be Emphasize to parents that infant ifthe does infantthe food. anew Instruct parents offering towhen aspoon use (See the Food Allergy chapter.) Food Allergy the (See eating behaviors. to dietand abalanced helps promote healthy 4 21,22 17 (See the Food the (See 18 contributes 9 var 13 BRIGHT FUTURES: BRIGHT iety iety 4

NUTRITION 39

Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 40 Bright FUTURES

NUTRITION ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ iron absorption from cereal. the in vitamin C,such enhances which as fruits, infant ifthe particularly is fed rich with foods provides an infant’s daily iron requirement, Encourage parents to include infant the in or dropping and from playing with others. ing with toys for stacking, shaking, pushing, active andfrom benefitbecome very play- Inform parents that by age 6months, infants foods havefoods introduced. been day) until beginning iron-rich complementary iron supplement (1mg/kg of weight/ body dailytheir feeding from breast need milk) infants receive (who more than one-half of Explain to parents breastfed that partially anemia. deficiency havefoods introduced been to prevent iron- weight/day) until iron-rich complementary infants iron need supplement (1mg/kg of body Explain to parents that exclusively breastfed anemia. deficiency to(1 mg/kg/d) prevent used can be iron- sources after age 6 months, elemental iron unable to consume sufficient iron from dietary Explain to parents that ifabreastfed infant is infants. tein, nutrients by needed breastfed especially provide ample sources of iron, zinc, and pro- redcially meats, as first the solid They foods. cereal) and rice (eg, als pureed meats,- espe such as iron-fortified, single-grain infant cere- mentation and to offersources good of iron Instruct parents to continue vitamin Dsupple- wish to continue. and for as long thereafter as she theand child breastfeed for first the year the infant’sof life infants. Encourage mother the to continue to remains the source best of nutrition for breast (together milk with foods) solid Emphasize to parents that at age 6months, to breastfeed! Congratulate mother the for continuing family play. 4,19,20 One ounce (30g)of infant cereal 5 5 5 ■ ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ FOR PARENTS OFALLINFANTS Interview Questions age-specific informationthat follows. Throughout (pagesInfancy 25–29), as the well as information Nutrition section inthe Supervision Health professionals should general the use ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ community fluoride levels. departmenthealth for information about Encourage parents to check with local their tation. (<0.3 ppm) may require fluoride supplemen with water that is severely deficient in andfluoride older who receive infant formula prepared (tooth decay) ininfants. Infants ages 6 months nificantly riskreducethe for dentalcaries fluoridationsafe is a and effective way tosig Explain to parents that community water of formula for appropriate growth. infantthe is consuming an adequate volume not formula ifthe needed is iron-fortified and Inform parents that vitamin supplements are in24hours.6 times shewhen shows signs of hunger, usually 5to Instruct parents to continue to infant the feed is away from home at (eg, child care)? youDo know what your baby eats he when enough to eat? What your does baby she dowhen has had Is your baby interested you food in the eat? Has he acup? used What your does baby eat with his fingers? What is she feeding herself? Is your baby interested in feeding herself? infant formula? Is your baby less breast drinking or milk a time? or How drink? much she eat does or at drink When your does baby have something to eat Who feeds your baby? or concerns doyou have? How going? has feeding been What questions ■ 9

MONTHS 13 (See the Oral Health Oral the (See ch apter.) ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ — — — — anemia includedeficiency Infants considered at risk for high iron- 9 to 12months. risk factors for iron-deficiency anemia at ages iron-deficiency anemiawith known those or recommends screening infants at risk for high anemia at about age 12months, infants during first the year of life. The AAP recommendand CDC screening Iron-Deficiency the (See Anemia chapter.) for Control Disease and Prevention (CDC). Academy of Pediatrics (AAP) and Centers the screening have put been forth by American the Recommendations for iron-deficiency anemia to buy infant formula? Are you worried about having enough money your baby from bottle? the youDo have any questions about weaning formula? water the Does contain fluoride? What kindof water to prepare is used the your baby? How are you preparing infant formula for feedings versus night feedings? How much he at take does afeeding? Day How often your does baby in24 hours?feed are you using now? How is formula-feeding going? What formula and/or iron richfoods? Is your baby receiving an iron supplement goat’s, or soy milk? Has your baby had infant formula or cow’s, supplementation? Is your baby receiving vitamin D How is your supply? milk How long doyou her feed eachtime? Howfeed? often your does baby breastfeed? What are your plans for continuing to breast- infants for iron and deficiency iron-deficiency AAP recommends universal screening for all — — — — Mexican-American Infants and children are who arrived refugees Infants are who migrants or recently Infants are who eligible for WIC Infants from families with low incomes 23 5 23 5 the CDC CDC the 5,23 While the ■ FOR PARENTS OFALLINFANTS Anticipatory Guidance ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ tures during may time this risk the decrease infant the Exposing gradually to tex solid - is for asensitive learning period to chew. introduction of and foods solid age 9months Explain to parents that the between time the iron supplementation. min Dsupplements, and for assess need the infant the determine whether is receiving vita- For breastfed breastfed and partially infants, E: Screening forLevels.) Lead Elevated Blood infant the Screen for Tool exposure. lead (See — — — — anemia includedeficiency Infants have who known risk factors for iron- that infant the stayson food. focused Encourage parents to remove distractions so learns to himself. feed standing as infant the and foods new tries Encourage parents patient to be and under ofcanbe soft offered.foods over picking up and holding pieces small food, Explain that as infant the gains more control chewing foods. infantthe gradually moves from gumming to vegetables, spaghetti with sauce, rice,tuna) as (eg, mashed potatoes and other soft cooked Instruct parents to offersoft, moist foods mula, or through both first the year of life. infants should receive breast infant milk, for breastfeeding or bottle-feeding. Nevertheless, parents their food the eat and less interest in to 9 months, infants show more interest in Explain to parents that at beginning age 6 ing how much to eat. andfoods, infant the is responsible for- decid responsible for providing avarietyof nutritious independent infeeding herself, parents are Tell parents that as infant their becomes more food. a particular 10totake 15attempts before an infant accepts textures, refusing to chew, or vomiting. It may for — — — — age 4 months adequate iron from supplemental after foods Infants are who breastfed and donot receive Infants fed cow’s before milk age 12months for more than 2months Infants fed non–iron-fortified infant formula Infants born preterm or with low birth weight feeding problems, such as certain rejecting 5 21 23 BRIGHT FUTURES: BRIGHT 24,25 -

NUTRITION 41

Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 42 Bright FUTURES

NUTRITION ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ secure her. mealtime, but asafety belt to should used be infantthe of part to family the be circle at Explain to parents that chair ahigh allows cardiovascular disease. family of history obesity, dyslipidemia, or whom obesity is aconcern or have who a is recommended for children ages 1to 2for atwhole milk age 1.Reduced-fat (2%) milk Explain to parents feeding child the to begin explores her newfound strength and agility. physically support infant the as she plays and risk for severe injuryor death. Parents can to put infant the of because inawalker the holding onto furniture. Warn parents never ing by age 9months and may by to walk begin Explain to parents that some infants are crawl- 0.8 to 1.0mg/L (ppm) is recommended. atis added aconcentration of approximately prefer bottled water, abrand fluoride inwhich fluoridatedlies to drink water; forthat families with parentsDiscuss that it for is best fami - from home. much their infant isthe infant fed while is away Instruct parents aware to be of what and how afternoon, evening.theand in to give infant the snacks midmorning, inthe breakfast, lunch, and dinner. Instruct parents are on same the eating schedule as family: the Explain to parents that most 9-month-olds no nutrients. beverages These containcalories but few or beverages,ened and such drinks. fruit as sodas Tell parents to avoid feeding infant the sweet- and limit it to 4to day. 6oz per juice of inacup, orpart ameal snack. Serve Tell parents only juice 100%fruit as to serve from a cup with assistance. Encourage parents to infant letthe drink 26 9 13 ■ FOR PARENTS OFFORMULA-FEDINFANTS ■ ■ ■ FOR PARENTS OFBREASTFEDINFANTS ■ ■ ■ ■ ■ ■ ■ ■ 6 times in24hours.6 times shewhen shows signs of hunger, usually 5to Instruct parents to continue to infant the feed anemia. deficiency havefoods introduced been to prevent iron- day) until beginning iron-rich complementary iron supplement (1mg/kg of weight/ body dailytheir feeding from breast need milk) infants receive (who more than one-half of Explain to parents breastfed that partially mother and child wish the to continue. first year the infant’sof life, or for as longthe as mother to continue breastfeeding through the infant’s source best of nutrition. Encourage the (along continues with foods) solid the to be Tell parents that, at age 9months, breast milk to breastfeed! Congratulate mother the for continuing community fluoride levels. departmenthealth for information about Encourage parents to check with local their mentation. (<0.3 ppm) may require fluoride supple- with water that is severely deficient in and older receive who infant formula (tooth decay) ininfants. Infants ages 6 months sig fluoridationsafe is a and effective way to Explain to parents that community water of formula for appropriate growth. infantthe is consuming an adequate volume not formula ifthe needed is iron-fortified and Inform parents that vitamin supplements are nificantly riskreducethe for dentalcaries 13 (See the Oral Health Oral the (See 5 ch apter.) pr fluo epared ride ride professionals inpromoting optimal nutrition. The desired outcomes forthe infant theand role the familyof outlined in Tablecan 1 assist health Desired Role ofthe Infant for the Outcomes Family TABLE

1. Understands the Enjoys eating Bonds withparents Has asenseoftrust Acquires asenseof Understands theinfant’s Enjoys feedingtheinfant Bonds withtheinfant

DESIRED Educational/Attitudinal long-term health promote short-termand physical activity, to behaviors andregular including healthy eating healthy lifestyle, importance ofa the infant’s needs competence inmeet nutrition needs

OUTCOMES ing

FOR Seeks helpwhenproblems Uses nutritionprograms Provides apleasantfeeding Talks totheinfantduring Holds theinfantwhen Responds totheinfant’s Meets theinfant’s nutrition Consumes supplemental Bottle-feeds successfullyif Breastfeeds successfully

THE occur needed and foodresourcesif environment feeding eye contact feeding, andmaintains breastfeeding orbottle- hunger andfullnesscues needs development appropriate growthand foods tosupport not breastfeeding

INFANT, Behavioral

AND

THE

ROLE Maintains goodhealth Develops normal Develops fineand Grows anddevelopsat Maintains goodhealth

OF swallowing reflexes rooting, sucking,and gross motorskills an appropriaterate

THE Health

FAMILY BRIGHT FUTURES: BRIGHT

NUTRITION 43

Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 44 Bright FUTURES

NUTRITION 12. 11. 10. 14. 13. 1. 9. 8. 7. 6. 5. 4. 3. 2. REFERENCES

position. Pediatrics.2000;106(6):1355–1366 Infant feeding affectsearly mode growth combody and - Butte NF, Wong WW, Hopkinson JM,Smith EO, KJ. Ellis Pediatrics. 2001;107(2):423–426 Education. Children, adolescents and television. American Academy of Pediatrics Committee on Public Therapeutics. ed. Chicago, 5th IL:ADA Publishing; 2009 American Dental Association. 2008;122(5):1142–1152 ininfants,ciency children, and adolescents. Pediatrics. Nutrition. Prevention of rickets and vitamin Ddefi- Pediatrics on Breastfeeding, Section Committee on Wagner CL,Greer FR;American Academy of Institute for Care Child Health Consultants; 2007 Child Care Programs. Chapel Hill, NC: National Training Performance Standards—Guidelines for Out-of-Home Children: How to Meet the National Health and Safety Benjamin SE, ed. Making Food Healthy and Safe for Medicine; 2004 Term Infants. Rochester, NJ:Academy of Breastfeeding Storage Information for Home Use for Healthy Full- Academy of Breastfeeding Medicine. Human Milk Pediatrics.rics. 2001;107(5):1210–1213 Nutrition. The use and misuse fruit pediatof juice in - American Academy of Pediatrics Committee on Health Organization; 1998 Successful Breastfeeding. Switzerland; Geneva, World and Development. Evidence for the Ten Steps to World Health Organization, Division of Health Child Childhood. ed. New 6th York, NY: McGraw-Hill; 1997 Trahms CM,Pipes PL. Nutrition in Infancy and Pediatrics.milk. 2005;115(2):496–506 Breastfeeding. Breastfeeding and of use the human American Academy of Pediatrics on Section 2010;126(5):1040–1050 infants and young children (0to 3years). Pediatrics. tion of iron and deficiency iron in deficiency anemia Committee on Nutrition. Diagnosis and preven- RD,Baker Greer FR;American Academy of Pediatrics Pediatrics; 2008 Grove ed. Elk 6th Village, IL:American Academy of Kleinman RE,ed. Pediatric Nutrition Handbook. 2000 growth charts. JNutr. 2007;137(1):144–148 son of WHO the child growth standards and CDC the de Onis M,Garza C,Onyango AW, E.Compari Borghi Growth. Pediatrics.1995;96(3 pt 1):495–503 World Health Organization Working Group on Infant analysispooled of US,Canadian, and European data sets. breast-fed infants deviates from current reference data: a KG,Dewey Peerson JM,Brown KH,etal. Growth of ADA/PDR Guide to Dental 19. 18. 17. 16. 15. 26. 25. 24. 23. 22. 21. 20.

2006;42(2):207–214 zinc intake and status. JPediatr Gastroenterol Nutr. forfood breastfed infants: feasibility and impact on M, Hambidge KM.Meat as afirst complementary Krebs NF, Westcott JE,Butler N,Robinson C,Bell 1997;41(2):188–192 acceptancethe of cereal during weaning. Pediatr Res. Mennella JA, Beauchamp GK.Mothers’ enhances milk Pediatrics. 2008;121(1):183–191 of restriction, breastfeeding, timing of introduction in infants and children: role the of maternal dietary interventions on development the of atopic disease and Immunology.Allergy Effects earlyof nutritional of Pediatrics Committee on Nutrition, on Section Greer Sicher FR, SH, Burks AW; American Academy Academies Press; 1998 Acid, Biotin, and Choline. Washington, National DC: Niacin, Vitamin B6,Folate, Vitamin B12,Pantothenic Dietary Reference Intakes for Thiamin, Riboflavin, Institute of Medicine, Food and Nutrition Board. Academy Press; 1991 Nutrition During Lactation. Washington, National DC: Institute of Medicine, Food and Nutrition Board. 2008;122(1):198–208 ing and cardiovascular Pediatrics. inchildhood. health Pediatrics Committee on Nutrition. Lipid screen- Daniels Greer SR, FR;American Academy of 6 and 15months. JHum Nutr Diet. 2001;14(1):43–54 solids on eaten foods and reported feeding difficulties at The effect of Childhood. age of introduction to lumpy Team. Avon Longitudinal Study of Pregnancy and Northstone K,Emmett P, Nethersole F; ALSPAC Study infants and children. JPediatr. 1964;65:839–848 referencewith special feeding to certain problems in RS,Lister J.Illingworth Thesensitive critical or period, 1998;47(RR-3):1–29 United inthe ciency States. MMWRRecomm Rep. Recommendations to prevent and control iron defi- Centers for Control Disease and Prevention. of Appetite. similar foods. 1998;30(3):283–295 Infants’ consumption enhances of food acceptance anew Birch LL,Gunder L,Grimm-ThomasDG. Laing K, acceptance of Pediatrics. foods. solid 1994;93(2):271–277 Sullivan SA,Birch LL.Infant and experience dietary sition. Am JClin Nutr. 2007;85(2):S639–S645 clinically relevant factors affectingtiming and compo Krebs NF, Hambidge KM.Complementary feeding: complementary and foods, hydrolyzed formulas. Hagan JF, Shaw JS,Duncan Bright PM,eds. Futures: Edelstein S.Nutrition in Public Health: AHandbook for Casamassimo P, Holt Bright K,eds. Futures in Practice: Oral Casamassimo P, ed. Bright Futures in Practice: Oral Health. Brown JE,Isaacs J, Wooldridge N,Krinke B, Murtaugh M. Academy of Pediatrics; 2007 and Adolescents. 3rd Grove ed. Elk Village, IL:American Guidelines for Health Supervision of Infants, Children, Jones &Barlett Publishers; 2010 Developing Programs and 3rd ed. Boston, MA: Services. Healthand Oral Child 2004 Resource Center; Health—Pocket Guide. Washington, National DC: Maternal and Health; Child 1996 Arlington, VA: National Center for Education inMaternal Wadsworth Publishing; 2008 Nutrition Through the Life Cycle. 3rd ed. Belmont, CA: SUGGESTED

READING Stang J, TaftBayerl C,Flatt MM; Association Dietetic Patrick K,Spear B, Holt K,Sofka eds. BrightD, Futures in Kaiser LH;American Dietetic L,Allen Association. Position James R;American Dietetic Association. Lessen DCS, Diet Assoc. 2010;110(5):701–799 child and adolescent and food nutrition programs. JAm Association. Position of Americanthe Dietetic Association: for Education inMaternal and Health; Child 2001 Practice: Physical Activity. Arlington, VA: National Center 2008;108(3):553–561 forstyle ahealthy pregnancy outcome. JAm Diet Assoc. of American the Dietetic Association: nutrition and life- 2009;109(11):1926–1942 moting and supporting breastfeeding. JAm Diet Assoc. Position of American the Dietetic Association: pro- BRIGHT FUTURES: BRIGHT

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Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 46 Bright FUTURES

NUTRITION in his mouth. motion or aspoon when is object placed no longer exhibits the “tongue thrust” and he brings to them his mouth. He thatobjects are within placed his reach, forth movements. He is able to grasp of early to infancy stronger, back-and- weaker, up-and-down movements pattern has changed from the no assistance. His suckingting position with and can maintain a sit head and neck control that John has good dietitian confirmed foods to his diet. The to addsome solid rightwould all be wonders whether it time,the and she want to breast J that her son seems to the registered dietitian, mother tells Liz Roberts, At clinic, health the John’s of allergies. John’s family not does have any history his appetite appears to have increased. since he wastiles 2months old. Lately, and 75th percen the - 90th between been his length and13 oz. Both weight have He is 27.5inches long and weighs 19lbs who has been fed only haswho been breast milk. ohn Matthews is a6-month-old infant Successfully Introducing fe ed all lit

tle ortle

to 5days or more to make and John to observe for 3 sure he doesnot have an new foods one foods new at atime Solid Foods

adverse reaction. is carefulis to offer

John’s mother i i John continues to breastfeed on demand. nothe does have an adverse reaction. John for 3to 5days or more to make sure one foods new at and atime to observe bles into John’s diet.She is careful to offer When John’s mother first him feeds and slightly hungry. he cerealhim the when is well rested mends that John’s feeding mother try ing it to John on She aspoon. recom- with expressed breast and milk offer amount of iron-fortifiedrice cereal mixing advises asmall Ms Roberts pureed orfruits soft and vegeta- the rice cereal, rice the he sur looks duce pureed meats and then prised butprised swallows it. He gradually begins togradually begins intro- accepts asecond- spoon weeks, John’s mother ful, then turns then ful, his Over the next the few Over head away.head The next day, John’s mother several tablespoons.several offersthe cereal him amount of cereal to mixture again, and slowly increases the spoonfuls. Shespoonfuls. he eagerly eats 4

- - ■ ■ ■ ■ ■ ■ What shouldIfeedmybaby? About Nutrition in Infancy Frequently Asked Questions ■ ■ ■ ■ ■ ■ ciency (rare).ciency defi- or lactase hereditary with galactosemia preference for avegetarian dietor an infant mula instead ifcow’s formula milk include a birthday. Indications for of use for soy-based recommended until after yourbaby’s first Cow’s goat’s milk, and milk, are soy milk not should not evenininfant used, be cereal. old. Low-iron cow’s, (eg, milk goat’s, soy) recommended until your baby is 12months Breast or milk iron-fortified infant formula is infant formula. tions about feeding and preparation the of right kindof formula and answer your ques- professionala health can help you the choose If you to decide your feed baby infant formula, arefriends sources also of support. you come up with solutions. Your family and can They answer your questions and help oring specialist, breastfeeding support group. to professional, ahealth talk milk, breastfeed- worried about not producing enough breast or you have condition) amedical or ifyou are you(eg, have conflictsschoolwith or work, If you you think may not able be to breastfeed a few months or weeks is beneficial. 4 to 6months, but breastfeeding evenfor just Exclusive breastfeeding is recommended for andallergies, other illnesses. helpsalso babies resist colds, ear infections, mothers and babies bonds form and special mothers and babies. Breastfeeding helps breastfeeding offers manybenefits to both forBreast food is ideal babies, the milk and - ■ ■ ■ baby enoughbreast milk? How doIknowifamfeedingmy ■ ■ or manageit? What iscolic?HowcanIprevent ■ ■ ■ ■ ■ birth weightbirth by age 4to 6months. gain 4to week 7oz and per should double her Your gaining baby be weight. will She should 7 days old. and 3or 4stools day per by she time the is 5to Your baby usually have will 5to 8wet diapers She may show by she is asleep. full falling closing her mouth, or looking for nipple. the putting her hands inher mouth, opening and Your baby may show she by is hungry sucking, — — — — — outgrow it. help manage colic as you wait for your baby to There cureis no for colic. Here aresome tips to appears by age 3or 4months. develops ages between 2and 6weeks and dis- parentingpoor not does cause it. usually Colic babies. No one knows what causes colic, but may have inalmost 10%of occurs colic. Colic son for hours several on aregular basis, he When your baby without cries apparent rea- — — — — — caring for your baby. Get helpGet you so can off time from take Darken room the or play soft music. pressure to stomach. the Swaddle your baby, or apply firm but gentle crying bouts. Cuddle and rock your baby during have colic. Breastfeeding not does cause your baby to breastfeed through first the year of life. If you are breastfeeding, continue to BRIGHT FUTURES: BRIGHT

NUTRITION 47

Bright FUTURES Infancy Infancy BRIGHT FUTURES: BRIGHT 48 Bright FUTURES

NUTRITION solid foods? When andhowshouldIintroduce ■ ■ and howmuch? When shouldIintroduce juice, ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and diarrhea. andfoods increase risk for the stools loose may your decrease baby’s appetite for other day).oz per Too much juice day) (>6oz per Offer 100% juice insmall amounts 4–6 (eg, a cup. At age 6months or later, introduce juice in nurser kits.” notDo addcereal to bottles or “baby food to chew later. rejectionthe of textures certain and refusal duced through age 10months) may decrease ing to chew (from solids time are the intro - textures during for sensitive the - learn period to chewingexposure Agradual foods. to solid progressestally ineating from skills gumming and soft lumps) as yourbaby developmen- pureed,(eg, blended, mashed, finely chopped, Give your baby textures of foods varying the foods. make yourwill baby more likely to accept Repeated exposure to(10–15tries) foods accept the cereal. makemula your will baby more likely to Mixing cereal with breast or milk infant for are least likely to cause an reaction. allergic protein, and other nutrients. These foods fed infant, provide they because iron, zinc, choices for for first especially the foods, breast- cereal) and rice (eg, pureed meats are good Iron-fortified, single-grain infant cereals beforefood introducing nextfood. the new 5 days how to see your baby tolerates new the spoons) of one at food new atime. Wait 3to control. Offer asmall amount 1 (eg, or 2- tea with support, and she and head has good neck coordinated swallowing, your baby can sit the sucking reflex has changed allowto more (pushing out food of mouth) the is fading, 6 months and tongue the when reflex thrust Introduce ages between solids4and foods - ■ from toothdecay? How canIprotect mybaby’s teeth ■ to feedherself? How canItellifmybabyisready ■ ■ cow’s milk? When shouldIgivemybaby ■ ■ from thebottle? When shouldIweanmybaby ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ — — — in your baby’s mouth by Minimize exposure to natural or refined sugars of table food. mash it, she is ready to herself feed soft pieces If your baby can pick up and food chew or her cow’s goat’s milk, or milk, soy milk. After yourbaby’s first birthday, you canfeed of life. iron-fortified infant formula forthe first year Continue to your feed baby breast or milk from acup. By age 12to 14months, most babies can drink from abottle. months), you to wean can begin himgradually and from drink acup (at about age 9–10 As your baby to begins eat more foods solid day.6 oz per amounts,in small no more than about 4to your baby juiceServe 100%fruit inacup 10 months, aday. twice first erupts,tooth usually around age 6 to Brush your baby’s as as the soon teeth for designed head small babies. feeding. Use asoft-bristled toothbrushwith a cloth or toothbrush and plain water aftereach yourClean baby’s gums with aclean damp — — — — — other sweetened liquid. bottle that contains formula, milk, juice, or Not allowing your baby asleep with to a fall can bathe insugar her teeth for long periods. cup, not inabottle, juice because inabottle formula inabottle. Give your baby juice ina Breastfeeding or feeding your baby infant baby’s mouth). or any other to object hold abottle inyour propping abottle donot (eg, pillows use Holding your baby feeding and while never liquid, sugars, or syrups. Avoiding dipping pacifiers in any sweetened ■ ■ At about age 3to 4months, your baby will ■ ■ From birth to about age 1month, your baby will as shegrows? What canIexpectmybabytodo ■ ■ ■ ■ ■ ■ ■ too much? How doIavoidfeedingmybaby ■ Should Igivemybabysweets? ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Put his hand inhis mouth alot. Drool more. Wake up and asleep easily. fall sucking. to develop ability the Begin to and start stop avoid continuous feeding or “grazing.” and meals snacks atServe regular and times, candy, cake). ents chips, french sweetened (eg, drinks, fries, thathim foods provide without calories nutri - fortified infant formula), and avoid feeding meats, whole grains with breast or milk iron- nutritious vegetables, fruits, (eg, foods lean When your baby is eating him feed foods, solid to eat. feeding her at earliest the of sign unwillingness force her tobottle finish a or other Stopfoods. 20 minutes for your baby to Don’t feel full. Feed your baby until It he is full. about takes fort as he gets older. may as teach asource himto food use of com- feeding him.Using to comfort food your baby rocking,cuddling, and him—not walking by Comfort your baby by to himand talking by your baby to eat more than he needs. notDo addcereal to bottle; the may this cause infant formula come out faster. bottle nipple to make expressed breast or milk baby slowly. not Do enlarge hole the inthe himonlyfeed he when is hungry. Feed your howLearn your baby shows he is hungry, and each feeding. have more control over how much eat they at Breastfeed, ifpossible, breastfed because babies and development. eat healthy (nutrient-rich) for foods growth ing first the year of life. Yourbaby to needs candy, drinks, ened cake, or dur cookies, notDo give your baby sweets, such as sweet- - Satter E.Your Child’s Weight: Helping Without Harming: Birth Nestle M.What to Eat: An Aisle-by-Aisle Guide to Food Savvy Nader Zive MM.You PR, Can LoseYour Baby Fat: New Rules Murkoff HE, Hathaway SE, Eisenberg SE. What tothe Expect Murkoff HE, Mazel S.What toEating Expect: Well When Murkoff HE, Mazel S.What toWhen Expect You’re Expecting, Mohrbacher N,StockBreastfeeding League. Leche J;LA American Academy of Pediatrics. Caring for Your Baby and ■ ■ ■ At about age 9to 11months, your baby will ■ ■ At about age 7to 9months, your baby will ■ ■ ■ At about age 4to 6months, your baby will ■ ■ ■ ■ ■ ■ ■ ■ Through Adolescence. Madison, WI:Kelcy Press; 2005 Press; 2006 Choices and Good Eating. New York, NY: North Point Society. San Diego, CA:PhilNader Publications; 2008 Others Who Care About Children and the Future of Our to Protect Kids from Obesity—For Parents, Providers, and Company; 2003 First Year. 2nd ed. New York, NY: Workman Publishing Company; 2005 You’re Expecting. New York, NY: Workman Publishing 4th ed. New York, NY: Workman Publishing Company; 2008 International; 2003 Answer Book. Schaumburg, League Leche IL:La Hannemann New RE,eds. York, NY: Bantam2009 Books; Young Child—Birth to Age 5.Shelov SP, Altmann TR, RESOURCES Pick up and chew soft pieces of food. Try to hold acup. her thumbbetween and forefinger. forReach pieces of and food pick up them Move from food one hand to other. the toward his palm. teething biscuits, fingers with all themand pull Try to such grasp foods, as toast, crackers, and Explore with her foods mouth. infant cereals. meats, and fruits, vegetables, and iron-fortified to eat such foods, solid asBegin pureed or soft Bring to objects her mouth.

FOR

FAMILIES BRIGHT FUTURES: BRIGHT

NUTRITION 49

Bright FUTURES Infancy

Early Childhood

Bright

FUTURES 51 NUTRITION

BRIGHT FUTURES: Early Childhood Early

Practicing healthy eating behaviors during is essential early for childhood become more interested and enjoy foods, new they participating intrying infamily meals. and eat what take. they intake. food their When children are themselves, tend allowed they to less to take serve fromfood bowls and plates—an important self-help that skill allows to them self-regulate can shovelif they sand or pour water from taught themselves can apail, be they to serve dren donot yet have muscle the control toor cut food neatly. their eat foods all However, to push onto food pick aspoon, up with afork, food and from drink acup. Young chil of towith more foods food texture. By age 3 or 4,children are able fingers to their use tongues to swallow. As toddlers’ eating develop, skills progress they from eating soft pieces early childrenDuring childhood, predominantly cheeks their use rather than their should offered be scheduledfoods at daily)mealtimes (3 and snacktimesdaily). (2–3 may become unpredictable. during early achild’s childhood, appetite and decreases, amount the of consumed food age of 4.5to year 6.5lb per and grow 2.5to 3.5inches year. per As growth the rate declines A child’s weight birth quadruples by ages age 2and 2.Between 5,children gain an aver ■ ■ ■ themselvesand and accordingly. fullness serve using utensils. and toddlers young Both children can recognize internal of cues hunger werethan they as however, toddlers; prefer still they eating with hands their rather than often messy. By age 3, young children usually are more competent at themselves feeding eat In foods. certain addition, are toddlers developing still fine motoreatingso skills, is ofa sense independence. Toddlers with parents may their struggle over refusing food, to child stage (ages 3 and 4). The stage cantoddler be stressful forparents as developtoddlers is into divided Early childhood 2stages: stage toddler the (ages 1and 2)and young the supportive environment, children can thrive. others community. inthe The child’s physical, cognitive, andsocial, emotional develop early achild’sDuring childhood, world expands to include schoolmates, friends, and but emotional their also When health. offered developmentally appropriate ina food ment are tightly linked. For example, nutrition affects not only children’s physical health ■ ■ ■ CONTEXT GROWTH forms of cancer, osteoporosis) 2diabetes(eg, cardiovascular mellitus, type disease, obesity, hypertension, some Laying foundation the for lifelong and health reducing risk for the chronic diseases vitamin Ddeficiency, overweight or obesity, dentalcaries [tooth decay]) Preventing immediate problems health iron-deficiency (eg, anemia, undernutrition, Promoting optimal growth, development, and health Early Childhood

AND

PHYSICAL 1 2 To promote optimal growth and development, children

DEVELOPMENT 1 As get older, they many young children - - - BRIGHT FUTURES: BRIGHT

NUTRITION 53

Bright FUTURES Early Childhood Early Early Childhood BRIGHT FUTURES: BRIGHT 54 Bright FUTURES

NUTRITION can pool aroundcan pool teeth. their for prolonged beverages these because periods, juice), or milk, formula during day the or night fruit ing insugar beveragesdrinks, high fruit (eg, on abottle or sipper-type (“sippy”) cup contain- decay increases ifchildren are allowed to suck about age 12to 14months.risk The for tooth from bottle the and encouraged to acup use at Children are who bottle-fed should weaned be grow them. and allow child to their prepare and perhaps overcomecan be ifparents about talk foods new reluctant Thisbe foods. new reluctance to try more curious about may still although food, they Around age 3or 4,most young children become and cups. height and using appropriate-sized utensils providing chair ahigh or seat at booster table should include infamily by toddler their meals role models by eating avarietyof Parents foods. but pleasant mealtime environment as and serve behaviors, parents to need provide astructured To encourage to toddlers establish healthy beforetimes accept they them. andfoods touch, smell, feel, and taste many them refuse to eat tolook They need them. the at new Toddlers of and foods new may tend leery to be ■ ■ and snacks. developmentallyserve appropriate healthy meals sume avariety of if parents foods continue to Despite changes, these usually toddlers con- childhood; therefore, their energy needs decrease. Toddlers’ growth rates during decrease early eating behaviors change or radically abruptly. Parents oftenwhenbecome alarmed toddlers’ usually eatthey only 1or at 2foods ameal. one day little and next. the Unlike very adults, day and dislike next. the may them They eat alot unpredictable. may They likeone certain foods DEVELOPMENT ■ ■ THE THE

TODDLER: YOUNG

CHILD:

ISSUES

AGES

3,4 1 Toddlers are

3 2

TO ea

4 ting

fats such as salmon, trout, and albacore tuna), poultry,that those contain fish (especially special other and calcium-rich foods; beans, lean meat, vegetables;fruits; low-fat products milk and to need eatthey more whole-grain products; todren consume begin fewer from calories fat, a healthy weight. active helpscally ensure that children maintain control, cooperation, and physi balance. Being - competitive require which sports, acuity, visual motor are they skills, not ready for organized, children to need develop large their and small sideways,space (eg, backwards). most Because Dancing can help children to learn move in and are tag appropriate during early childhood. aged. Simple games such as Simon Says, chase, ing, throwing, catching) should encour be Physical jumping, running, (eg, activities climb- to just play. control of large their muscles but have still time toneed plan that so activities children can master movesbody inspace, or play and explore. Parents nity to master large motor how learn skills, their safety concerns, may they not have opportu the - Most children are active but, of because space or its for physical activity that last alifetime. will developmentthe of motor and hab skills good - is akeyfor time Early childhood promoting and other protein-rich foods. 35% of total their daily as calories fat. thatso by age are 5they eating 25%and between ofconsumeber they calories from high-fat foods, age 2,children should gradually reduce num the - andgiven meals in3small 2to 3snacks. After a varietyof healthy throughout foods day, the to parents is thatto need offer they their child The most important nutrition message to impart plates.their of healthy foods—not simply to eat what is on The is foods. goal for children to accept a Young children shouldnew encouraged be to try places were than they as toddlers. dren are more comfortable eating inunfamiliar and plates, and to passothers. food Young chil- themselvesduring from mealtimes, serve bowls are they when calm hungry, join inconversation sive and can followcan instructions. They stay As young children grow, become less impul they - HEALTHY

LIFESTYLES 5 As chil- var - iety iety 6

centers) and safe places for children to play. programs at (eg, child care facilities, recreation Communities to need provide physical activity provide food.also nity groups, and faith-basedorganizations can Programs.) Food shelves and pantries, commu- Tool(See K:Federal Nutrition Assistance of part daily their nutrienttial requirements. programs help provide children with asubstan program.the Federally food funded of healthy that foods children about in learn and child care a facilities should serve ofshould part education the be curriculum, in apleasant environment. Nutrition avarietyofChildren need healthy served foods enjoying to be seem peers them. more andthem foods new may readily try iftheir in community programs introduced can be to for promoting healthy eating behaviors. Children school programs, provide which opportunities viders or participate inHead Start or other pre- Many children with spendtime child care pro- their children. communitytact resources to help parents feed about children their and can and identify con- tunity to nutrition discuss issues and concerns Health professionals can give parents oppor the eating, and promote regular physical activity. encourage positive attitudes toward and food to teach children about healthy eating behaviors, professionals,health families, and communities providesEarly childhood an opportunity for BUILDING

PARTNERSHIPS as ed var sistance ucation iety iety - anemia may have adverse effects growthon and Anemia chapter.)Deficiency Iron-deficiency from families with low Iron- incomes. the (See are common children inchildren, especially Iron and deficiency iron-deficiency anemia Obesity chapter.) with many chronic conditions, health includ- idemia, andidemia, cardiovascular disease. ing risk of persistent obesity. excess weight are associated with increasing intoobese adulthood, and degrees higher of Childrenarecosmetic. who often obese remain consequences of epidemic this are not 5% to 12.4% among children ages 2to 5. 2003–2006), obesity prevalence from has risen Nutrition Examination (1976–1980and Survey on dataBased from National the Health and Needs chapter.) and Adolescents With Health Special Care grams communities. intheir Children the (See may referral need to also early intervention pro - caremay from specialized need adietitian; they lems, and metabolic disorders. These children intake, developmental delays, elimination prob- eatingpoor inadequate skills, or excessive food have nutrition concerns, including growth, poor care health Children with may special needs ■ ■ ■ anemia can reducedbe by doing the following development. The prevalence of iron- ■ ■ ■ COMMON enhances iron absorption tain vitamin vegetables), fruits, C(eg, which meat,that(eg, and poultry) fish,foods con - Encouraging consumption of iron-rich foods daily milk Offering children no morethan 16 oz of cow’s before feeding cow’s them milk Waiting until children are 12months old diabetes mellitus, hypertension, dyslip

NUTRITION 8 Obesity is Obesity associated

CONCERNS 9 (See the the (See deficienc simp 7 The - BRIGHT FUTURES: BRIGHT ly 10,11 y :

NUTRITION 55

Bright FUTURES Early Childhood Early Early Childhood BRIGHT FUTURES: BRIGHT 56 Bright FUTURES

NUTRITION Nutrition Supervision Eating Behaviors.) for Health Professionals to Promote Healthy healthy eating behaviors. Tool (See G:Strategies andmental to period, foster promotion the of as child enters the to expect next the develop- nutrition status, to make parents aware of what ance to parents to offer information the on child’s Health professionals provide anticipatory guid- concerns for child thatand family. particular to address family’s the questions and nutrition nying anticipatory guidance should geared be achild’stify nutrition concerns. The accompa- followed by screening and assessment to iden- These methods providepoint, starting a useful nutrition concerns. starting pointa useful for identifying achild’s chapter.) Asking questions interview provides Cultural the (See Awareness inNutrition Services practiceswithin andfood among cultural groups. tions related and to variation food wide the in toneed appreciate varietyof the cultural- tradi sion to diverse populations, professionals health challengethe of providing nutrition- supervi for Children Ages 1to 10)Additionally, to meet Tool visit.the (See B:Nutrition Questionnaire ing aquestionnaire out filled parentsby before information accomplished be can also by- review professional’s communication style. Gathering Questions to match modified can be the health from visitvary to visit and from family to family. and build partnerships. Use of questions the may child’sthe nutrition status to invite discussion by selectively questions asking interview about Health professionals nutrition begin supervision visit and from child to child. as appropriateused from visit andvary to will and tions, vision, includes which ques asking- interview important to remember that nutrition super under Suggested chapter.) inthis Reading It is Children, and Adolescents, 3rd Edition, listed Guide Brighton see supervision, health Futures: visits. supervision health (For more during nutrition visits supervision or of as part A child’s nutrition status should evaluated be providing anticipatory guidance, should be lines for Health Supervision of Infants, conducting screening and assessment, info rmation - ■ ■ Interview Questions from visitvary to visit and from child to child. guidance as appropriate should used be and will tions, screening and assessment, and anticipatory mation for age-specificvisits. ques- Interview is providedChildhood) first, followed by infor (Nutritionperiod SupervisionThroughoutEarly to entire the developmental early childhood Nutrition information supervision that ■ Growth and Development Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ problem difficulties (eg, with eating). may normal or be may indicate anutrition ontiles chart) the should evaluated. be This is hungry andis hungry she when is full? How your does child letyou know she when eating behaviors or growth? What concerns doyou have about your child’s THROUGHOUT NUTRITION pattern amajor (eg, change ingrowth percen chart. growth Deviation from expected the weight, and plot on these astandard growth Measure child’s the length or height and money to buy food? Are you concerned about having enough processed water? cooking water? you Do bottled or use What is source the of your and drinking to her she when is awayserved from home? youDo have any concerns about food the utensils, ahighchair, seat)? abooster feeding your child (for example, cups, eating youDo have appropriate equipment for with her? youDo enjoy sharing and meals snacks food? particular What doyou doifyour child doesn’t like a Whattimes. doyou do? what yourDescribe during- child does meal child’s weight? What concerns doyou have about your

SUPERVISION

EARLY

CHILDHOOD per tains - - ■ ■ 12to 18MonthsChildren ■ Iron-Deficiency Anemia ■ ■ ■ ■ ■ ■ ■ ■ ■ determine child’s the BMI-for-age percentile. BMI on aBMI-for-age and growth sex chart to by referring to aBMIchart. Plot child’s the — — 6 months later (ages 15–18months). anemia at ages 9to 12months and again with known risk factors for iron-deficiency risk forhigh iron-deficiency anemia those or recommendsThe CDC screening children at and about age 18months. anemia deficiency at about age 12 months for children all for iron and deficiency iron- The AAP recommends universalscreening Iron-Deficiency the (See Anemia chapter.) for Control Disease and Prevention (CDC). Academy of Pediatrics (AAP) and Centers the screening have put been forth by American the Recommendations for iron-deficiency anemia hair, gums, teeth, tongue, and eyes. Evaluate appearance the of child’s the skin, ing weight by square the of height (kg/m child’s the Calculate health. all BMIby divid- tool to determine nutrition status and over mass as indexascreening (BMI)is used Body tive nutrition or problems. health Low height-for-age reflects long-term,cumula - cators of nutrition status and overall health. term nutrient intake as general indi- and serve status. Changes inweight reflect a child’s short- to indicate used can be nutrition and growth orLength height and weight measurements — — • • • iron-deficiency anemia include Children have who known risk factors for • • • • anemia includedeficiency Children considered at risk for high iron-

12 months Children fed cow’s before milk age formula for more than 2months Children fed non–iron-fortified infant birth weight Children preterm born or with low Children are who Mexican American arrived refugees Children are who migrants or recently Women, Infants and Children (WIC) Supplemental Nutrition Program for Children are who eligible for Special the Children from families with low incomes 10 11 11 11 2 ) or 10 - ■ Ages 2toChildren 5 ■ ■ Physical Activity ■ ■ Oral Health ■ ■ ■ ■ ■ ■ ■ — — — following risk factors are present iron-deficiency anemia annually, if any the of The AAP recommendsscreening children for during mealtimes. Ask child watches the whether television suchactivities, as computer or games. video watching television and on other media forScreen amount the of child spends the time doing on aweekly basis. Ask how much physical child activityis the Health Oral the decay). chapter.) (See mine child’s the risk for dental caries(tooth andfoods in sugar) beverages high to deter Assess eating behaviors of frequency (eg, eating Ask child has the whether regular dental visits. — — — — — — are present annually, ifany of following the risk factors recommendsThe CDC screening of children — — — — — — — — — — — — — Children consume who avegetarian diet Children consume who adietlow iniron care health Children with special needs • • • arrived refugees Children are who migrants or recently Children are who eligible for WIC Children from families with low incomes care health Children with special needs of poverty or neglect Children with limited access because to food Children consume who adietlow iniron to food Children infamilies with limited access Children from low socioeconomoic status

from awound, an accident, or surgery restricted diets,or extensive loss blood chronic infection, inflammatory disorders, phosphorus, magnesium), or with those iron absorption antacids, (eg, calcium, medications use who that interfere with care health Children with special needs of cow’s day per milk Children consume who more than 24oz afterfoods age 4 months receive adequate iron from supplemental Children are who breastfed and donot 11 : 3 : BRIGHT FUTURES: BRIGHT -

NUTRITION 57

Bright FUTURES Early Childhood Early Early Childhood BRIGHT FUTURES: BRIGHT 58 Bright FUTURES

NUTRITION Anticipatory Guidance ■ ■ ■ ■ Eating Behaviors ■ ■ Parent-Child Feeding Relationship to Promote Healthy Eating Behaviors.) and Tool G:Strategies for Health Professionals of Change—A Model for Nutrition Counseling (For additional information, see Tool F: Stages behaviors, choices, food and physical activity. and child entersthe next the developmental period; child and parents aware of whatas to expect tion on child’s the nutrition status; make the tion, professionals health should offer informa - child’s and parents’ nutrition concerns. In addi- Anticipatory guidance should address the ■ ■ ■ ■ ■ ■ oatmeal cookie. or and withyogurt peaches, sliced milk an whole-wheat crackers with string cheese, plain low-nutrient snacks. Some examples include erate amounts of sweets and high-calorie, in complex carbohydrates and only- mod Tell parents to provide healthy snacks rich foreasier child to their eat. Instruct parents to foods make them to modify to nutrition their meet needs. parents that children usually eat enough food and to meal meal from day to day. Reassure amountsthe eat, and of they from types foods Tell parents that children are unpredictable in tional balance. throughout day the to help achieve them nutri - healthy and meals snacks at times scheduled Emphasize to parents that children need todeciding whether eat and how much. Tell parents that children are responsible for — — — — — met, parents to need ensure that child’s their nutrition are needs what, and when, where child eats. their To Inform parents that are they responsible for — — — — — promote apositive attitude toward eating hunger and fullness. intake by responding to internal of cues Help to child learn their self-regulate food his hands for eating to using utensils). progresses (eg, skills from usingself-serving Make sure child develops their eating and Make mealtimes and snack pleasant. times healthy foods. offering developmentally appropriate and mealtimesSchedule and snack times, Purchase and prepare nutritious food. 13 12 12 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ obesity is aconcern or have who afamily mended for children ages 1to 2for whom mended. low-fat (1%)or fat-free is recom (skim)milk - diets.Forin their children older than age 2, increase proportionually the of low-fat foods Afterwhole milk. age 2, children shouldgrad- Instruct parents children ages to 1to serve 2 an older child would eat. about for two-thirds of eachserving aserving younger children may portions— smaller need number as children ages of 4to servings 6,but ents that children ages same 2tothe 3 need 35% of daily their by calories age 5.Tell par reducedgradually be to no more than 25%to Inform parents that children’s fat intake should recommended for rest the of population. the intake infants to lower need the fat intake dren make transition the from fat higher the Explain to parents that from ages 2to 5,chil- grain breads and cereals. Encourage parents to offerwhole-their child consumption of juice to 4to day. 6oz per cup instead of abottle and to limit child’s the Instruct parents juice 100%fruit ina to serve the bottle by age 12to 14months. Encourage parents to wean child from their 2 to 3oz of cooked lean meat, poultry, or fish). juice;100% fruit 1slice of whole-grain bread; fruits 1/2 (eg, cup of or vegetables; 3/4 cup of eatensimilar to those by older family are 4years sizes old, can eat they serving Explain to parents that by children time the supplement of 400IU/day. [yolk]) eggs als, should receive avitamin D vitamin cere (eg, D–fortified fortified - foods and serving) per 8-oz (100IU fortified milk 400 IU/day of vitamin Dthrough vitamin D– D deficiency, childrenwho do not obtain Tell parents that to prevent rickets and 8-oz day cups) per to children ages 2to 6. Tell parents (two to offerof milk servings 2 and other protein-rich foods. products; and beans, lean meat, poultry, fish, grains; vegetables; fruits; low-fat and milk milk to eat more grain products, whole especially consume fewer from calories fat, need they Explain to parents that as childrento begin disease. vascular ofhistory obesity, dyslipidemia, or cardio appetite for other foods. Excessive intake milk can reduce child’s the 14 Reduced-fat (2%)is recom milk - 15 14 16 mem vi tamin 14 bers bers

- ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Mealtimes ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ hunger and cues. fullness Parents can help child respond their to internal eat or foods to certain eat more than she wants. Caution parents not to pressure child to their andeasier safer for child to their eat. Instruct parents to foods make them to modify oneswhich to eat. healthy and foods, allow child to the choose Instruct parents to offertheir avariety child of themselves. foods ing these offer they theirwhen to child new foods eatby - Encourage parents positive to be role models herself food. the child to serve perhaps 1or 2tablespoons—and allowing the to eat by foods new offeringportions— small Tell parents that can encourage they child their herself.learns to or feed serve standing child makes iftheir she amess while Encourage parents patient to be and under herself atchild totable. the serve or pour water from a pail, parents can teach the Tell parents that once achild can shovel sand adult shares or meal the snack with them. anwhen adult is nearby, the when particularly Emphasize to parents that children eat better andtimes snack pleasant. times should turn offthe television and - make meal important for times children. social Parents Explain to parents that and meals snacks are food choices. to teach used childrenbe to make healthy preschool, child care, and other places can samethe eachday. time Mealtimes at home, choices atfood atapproximately served meals Encourage parents to offer children healthy plentydrinks of water throughout day. the Encourage parents to make sure child their rather foods these than eat healthy foods. insugar high aredrinks) likely to fill up on soft andcookies) drinks, beverages fruit (eg, sume unlimited amounts of candy, (eg, foods Emphasize to parents that children con who - stools and loose diarrhea. experience (tooth decay) and minor infections and may aredrinks) at increased risk for dental caries soft sweetened drinks, beverages fruit (eg, unlimited amounts of juices 100%fruit or Explain to parents that children drink who - ■ Food Safety ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Handling Food Safely.) Tool safetyfood practices.(See for H:Basics parents illnesses, foodborne to need follow not developed. To fully reduce risk for the immune and gastrointestinal systems are for many their because illnesses foodborne Inform parents that children are at risk high vegetables,fruits, meat as snacks. or poultry) whole-grain crackers, and products, milk milk should offeredthey be nutritious (eg, foods ofteneat small amounts of food at time,one Explain to parents that young because children healthy contribution to meal. the custard,(eg, pudding, makes yogurt) a fruit, of desserts certain serving Asmall meal. the Encourage parents to offer part as of dessert ments and are patient and understanding. parentswhen praise for them accomplish their - Emphasize to parents that children benefit entertain her. or punish child or their comfort, to calm, or Tell parents not to to foods reward, use bribe, — — — — — tions to prevent child from their choking Instruct parents to following the take precau- care health ing child with their special needs. equipment,cial or modified utensils for- feed about techniques special for positioning,- spe Provide parents with instructions, as needed, feedingwhen child. their Tell parents chair to ahigh use or seat booster — — — — — and whole grapes). fruits, other dried chunks of meat, hot dogs,raw carrots, raisins ofspoonfuls peanut butter, nuts, large seeds, marshmallows, pretzels, popcorn, chips, should avoided be hard (eg, candy, mini- For that foods toddlers, may cause children to choke. Overexcitement eating while may cause Keep mealtimes and snack calm. times able to help ifchoking occurs. the parent is driving, he or not she will be notDo allow children to eat car. inthe If orwalking may running cause choking. Have children siteating. while Eating while Stay are with children they while eating. ch 13 oking BRIGHT FUTURES: BRIGHT 17 :

NUTRITION 59

Bright FUTURES Early Childhood Early Early Childhood BRIGHT FUTURES: BRIGHT 60 Bright FUTURES

NUTRITION ■ ■ ■ ■ ■ Oral Health ■ ■ ■ ■ ■ Teaching Children About Food ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ make safer them cutting (eg, hot dogsinquar may are ifthey eat foods to modified these Explain to parents that children ages 3to 5 can help prevent dental caries(tooth decay). in sugar high soft drinks) ages drinks, fruit (eg, tion of candy, (eg, foods and cookies) bever Tell parents that limiting their child’s consump tively by but aparent. should supervised be by age 7or can clean effec 8,they - teeth their ability the (eg, shoelaces),typically to their tie help. After children acquire fine motor skills dren cannot clean without teeth their parental fine motorgood control thatand young - chil Explain to parents that toothbrushing requires before bed). toothpaste aday twice (after breakfast and soft toothbrush amountpea-sized and a of older to brush child’s their using teeth asmall, Instruct parents with children ages 2and before bed). toothpaste aday twice (after breakfast and soft toothbrush and asmear of fluoridated to brush child’s their with asmall, teeth Instruct parents with children ages 1to 2 shopping and preparation. Encourage parents to involve child infood the werethey children. about child andtheir talk what ate they when Suggest that parents about read books to foods farm). visiting adairy garden) and where come foods from by (eg, arefoods grown by (eg, planting avegetable Encourage parents to teach child how their fromfoods other cultures. about from foods other cultures by offering Tell parents that can help they child learn their variety of healthy foods. Encourage parents to offertheirwide a child ablebe to help child. the car. If parent the is driving, he or not she will Caution parents not to child eat lettheir inthe crackers or bread). strips,thin spreading peanut butter on thinly nuts finely, chopping rawcarrots finely or into ting whole grapes lengthwise, inhalf chopping ters lengthwise and into then pieces, small cut - 17 - - - ■ ■ Physical Activity ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ the child canthe move inany way he likes. toleader master hopping), whereas play, infree opmental physical following (eg, purpose the is involved adevel inan- activity that serves way. ness develop inaprogressive, sequential that large their motor and skills spatial aware- engage structured and inboth play free so Explain to parents that children to need of activity followed by of short rest. periods Tell parents that children’s bursts need bodies to 1.0mg/L (ppm) is recommended. atadded aconcentration of approximately 0.8 fer bottled water, abrand fluoride inwhich is Health Oral the chapter.) For families that pre- reduce the risk for tooth decay in children. (See water is asafe and effective way to significantly Explain to parents that fluoridated drinking 1 to 2hours of quality programming aday. ing computer or games) video to no more than ment watching (eg, time media television, play- discouraged. Limit child’s the total entertain- or playing computer or games, video should be activity,sedentary such as watching television For children ages 2and older, of long periods and reading together. development, playing, such as talking, singing, active that activities promote proper brain younger than age 2,and encourage more inter Discourage television for viewing children active together. for entire the family physically to be gardens, drives) food provide neighborhoodcleanup(eg, days, community Point out to parents that community projects swimming, playing tag). skating, hiking, to walking, (eg, the activity together but to match child’s the abilities physicalwhich do family the activities will Encourage parents to child decide lettheir active.cally to encourage family all members physi to be - Suggest that parents plan eachweek activities child’s play experiences. enthusiasm have apositive impact on their active themselves. Parents’ involvement and playing with child and their physically being Encourage parents role good to be models by 19 Structured play child the when occurs op portunities 18 20 - ■ ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ Interview Questions well as age-specific the informationthat follows. Throughout (pages 56–60) Earlyas Childhood information Nutrition section inthe Supervision Health professionals should general the use ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ing are age-appropriate activities. parent daily. Bouncing,crawling, and climb Children should actively be playing with a Evaluate child’s the interest inactive play. — — — — — — — eating Make skills. sure child the Evaluate child’s the progress indeveloping Screening forLevels.) Lead Elevated Blood child for the Screen Tool exposure. lead (See E: child’s weight? What concerns doyou have about your he eat Does times. with family? the what yourDescribe during- child does meal he eatDoes pieces of soft food? What textures your of does food child eat? the bottle? what are your plans for weaning himfrom fromhe drink abottle now and If then? so, your from Does child drink acup? Does juice? Whenthem? he drink does yourdoes Is child drink? juice the 100%fruit (fordrinks example, soft drinks) drinks, fruit How much juice fruit or how many sweetened him? feed What of type infant formula or doyou milk or cup? giving himinfant formula or inabottle milk Are you breastfeeding your child? Are you What is your child’s feeding routine? NUTRITION ■ — — — — — — — Can drink fromCan drink acup. pieces of food. a“pincerCan use grasp” to pick up small rotary motion. inanCan chew food up-and-down or immediately swallow). Can retain mouth inthe food (ie, doesn’t Has an adequate gag reflex. Can put mouth. inthe food Can bite off small pieces of food. 1

YEAR

SUPERVISION

VISIT - ■ ■ ■ ■ ■ Anticipatory Guidance ■ ■ Interview Questions well as age-specific the informationthat follows. Throughout (pages 56–60), Earlyas Childhood information Nutrition section inthe Supervision Health professionals should general the use ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ meals andmeals snacks. at any one to is time limited.schedule Begin 2 to 3hours, children’s because capacity to eat Instruct parents to offerevery their child food toenough nutrition their meet food needs. day. Reassure parents that children usually eat eatthey from and to meal meal from day to dictable amount inthe and of types foods Explain to parents that children are unpre- of soft foods. Encourage parents child avariety their to serve sipper-type (“sippy”) cup by themselves. from acup; however, may they able be to a use in acup. Children may help need drinking Instruct parents child beverages their to serve of and foods to herself feed at family the table. chewing and swallowing) by offering avariety tunities to develop her eating (including skills Encourage parents to give child oppor their juice? When them? he drink does yourdoes Is child drink? juice the 100%fruit (fordrinks example, soft drinks) drinks, fruit How much juice fruit or how many sweetened How he drink? of does milk much? giving himbottles? inacup? Milk What kind Are you breastfeeding your child? Are you and reading together. development, playing, such as talking, singing, active that activities promote will proper brain younger than age 2,and encourage more inter Discourage television for viewing children to turn offthe television during mealtimes. vision andEncourage viewing. media them Explain to parents about effects the of tele- shefoods eats. iors without controlling amount the orof types on child’s their unacceptable mealtime behav- Reassure parents that can impose limits they throwing tantrums refused. when its by asking for and foods certain perhaps by Explain to parents that children test lim- will ■ 15

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NUTRITION ■ ■ ■ ■ ■ ■ ■ Anticipatory Guidance ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ there any he doesn’t foods like? Which your does foods child like to eat? Are and reading together. development, playing, such as talking, singing, active that activities promote will proper brain younger than age 2,and encourage more inter Discourage television for viewing children to turn offthe television during mealtimes. vision andEncourage viewing. media them Explain to parents about effects the of tele- time. takes foods new trying snacks. Children should not rushed, because be from arelaxed atmosphere during and meals Emphasize to parents that children benefit increasingly at skilled eating avarietyof foods. Reassure parents that children become will eating for easier child. the dishes with steep bowls) sides(eg, to make Instruct parents to spoons, use cups, and untiloped about age 8. swallowing functions are not completely devel- monitor sizeof the offered. foods Chewing and cut into foods (eg, pieces). small Continue to as parents are offering age-appropriate foods that family the is eating at mealtimes, as long child shouldthe able be to eat healthy foods Explain to parents that by age 15to 18months, at any one is time limited. 2 to 3hours, children’s because capacity to eat Instruct parents to offerevery their child food playing with aparent daily. large motor Children should skills. actively be Evaluate child’s the progress indeveloping child’s weight? What concerns doyou have about your child enjoy? What kinds of physical your does activities If so, how doyou handle them? yourDoes child throw tantrums over food? snacks? If so, how doyou handle this? he ask and for meals Does between food with family? the your child’sDescribe he eat mealtimes. Does 20 - ■ ■ ■ ■ ■ Interview Questions well as age-specific the informationthat follows. Throughout (pages 56–60), Earlyas Childhood information Nutrition section inthe Supervision Health professionals should general the use ■ ■ ■ ■ Anticipatory Guidance ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ snacks? If so, how doyou handle this? he ask and for meals Does between food with family? the meals your child’sDescribe he eat mealtimes. Does there any he doesn’t foods like? Which your does foods child like to eat? Are juice? Whenthem? he drink does yourdoes Is child drink? juice the 100%fruit (fordrinks example, soft drinks) drinks, fruit How much juice fruit or how many sweetened How he drink? of does milk much? giving himbottles? inacup? Milk What kind Are you breastfeeding your child? Are you talking, playing, singing, and reading together. will promote proper brain development, such as and encourage more interactive that activities television viewing for children younger than age televisionthe during2, mealtimes. Discourage and media viewing. Encourage them to turn off Explain to parents about the effects of television that are and smaller to easier use). spoons that are for designed (ie, them those Explain to parents that children forks need and of and foods to herself feed at family the table. chewing and swallowing) by offering avariety tunities to develop her eating (including skills Encourage parents to give child oppor their at any one is time limited. 2 to 3hours, children’s because capacity to eat Instruct parents to offerevery their child food playing with aparent daily. large motor Children should skills. actively be Evaluate child’s the progress indeveloping Screening forLevels.) Lead Elevated Blood child for the Screen Tool exposure. lead (See E: child’s weight? What concerns doyou have about your If so, how doyou handle them? yourDoes child throw tantrums over food? ■ 18

MONTHS - 20

■ ■ Anticipatory Guidance ■ ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ ■ ■ ■ Interview Questions well as age-specific the informationthat follows. Throughout (pages 56–60), Earlyas Childhood information Nutrition section inthe Supervision Health professionals should general the use ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ practice, self-help this mastered. can be skill bowls and plates. This is messy at first, but with regulate intake himself from food by serving Encourage parents to allow child to their self- of foods. chewing and swallowing) by offering avariety tunities to develop her eating (including skills Encourage parents to give child oppor their playing with aparent daily. large motor Children should skills. actively be Evaluate child’s the progress indeveloping Hyperlipidemia the (See emia. chapter.) Assess child’s the risk for hyperlipid familial - Screening forLevels.) Lead Elevated Blood child for the Screen Tool exposure. lead (See E: child’s weight? What concerns doyou have about your particular food? not want to eat or only wants to eat a What doyou your dowhen child does the family? she eatDoes same as the rest the foods of her plate. from foods abowlor platterto serve onto water from abucket? If she can, let her try Can your child shovel sand into or apail pour she eatdoes with family? the your child’sDescribe mealtimes. How often there any she foods doesn’t like? Which your does foods child like to eat? Are juice? When them? she drink does yourdoes Is child drink? juice the 100%fruit (fordrinks example, soft drinks) drinks, fruit How much juice fruit or how many sweetened What How she kindof drink? does milk much? Has your weaned from child been bottle? the ■ 2

YEARS - Health professionals should general the use ■ ■ ■ ■ ■ Screening andAssessment ■ ■ ■ ■ ■ ■ Interview Questions well as age-specific the informationthat follows. Throughout (pages 58–62), Earlyas Childhood information Nutrition section inthe Supervision ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and reading together. development, playing, such as talking, singing, active that activities promote will proper brain ity programming aday. Encourage more inter games) to no more than 1to 2hours of qual- watching television, playing computer or video child’sthe total entertainment (eg, time media turn offthe television duringLimit mealtimes. sion andEncourage viewing. media to them Explain to parents about effects the - of televi healthy foods. tofoods ensure that child eats the avarietyof favored offered can be food along with other arelar food) of common. the servings Smaller children(when only want to- eat aparticu Reassure parents that jags inchildren food emia. (See the Hyperlipidemia the (See emia. chapter.) Assess child’s the risk for hyperlipid familial - Hypertension chapter.) Obtain child’s the pressure. blood the (See Screening forLevels.) Lead Elevated Blood child for the Screen Tool exposure. lead (See E: of foods doyou serve? How often snacks? do youserve What types eat with family? the meals he Does himself foods? he serve Does times. what yourDescribe during- child does meal child’s weight? What concerns doyou have about your there any he doesn’t foods like? Which your does foods child like to eat? Are juice? Whenthem? he drink does yourdoes Is child drink? juice the 100%fruit (fordrinks example, soft drinks) drinks, fruit How much juice fruit or how many sweetened How much? What your kindof does milk child drink? ■ 3

YEARS 20 BRIGHT FUTURES: BRIGHT -

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NUTRITION ■ promoting optimal nutrition. The desired outcomes forthe child theand role the familyof can assist health professionals in ■ ■ Anticipatory Guidance Desired Role ofthe ■ ■ ■ muscle movements. andobjects inhow to improve large and small to move around bodies their and through galloping. Adults can direct children inways children can master marching, running, and playing with aparent daily. By age, this many large motor Children should skills. actively be Evaluate child’s the progress indeveloping help children become familiar with foods. the ing pictures, and singing songs related to foods Suggest to parents that sharing stories, draw - eating, and enjoyingtrying, them. byfoods family seeing members and friends Explain that children become aware of new Child for the Outcomes Family TABLE

1. Understands theimportance Understands theimportance Encourages the child to recog Enjoys beingactive Enjoys avarietyofhealthy Tries newfoods Encourages thechildtotrya Understands thenutrition Has apositiveattitude Understands thateachchild’s being physically activity eating healthy foods and of a healthy lifestyle, including and saferto eat child tomakethemeasier of modifyingfoodsforthe of hunger and fullness nize and listen to internal cues foods variety ofhealthyfoods and snacks scheduled healthy meals and theimportanceof needs ofthegrowingchild toward food are unique growth anddevelopment Educational andAttitudinal Educational andAttitudinal

DESIRED

OUTCOMES

FOR

THE Provides safeopportunities Uses nutritionprograms Provides positiverole Eats mealstogether Encourages childtoserve Offers avarietyoffoods Schedules healthymeals Offers developmentally Masters increasingly Participates inactiveplay Eats healthyfoods Gradually increasesvariety playtimes for structured and active needed and foodresourcesif physically activity healthy foodsandbeing models byeating communication to facilitatefamily optimal nutritionand regularly toensure bowls and platters herself foods from common and snacks appropriate foods motor skills complex largeandsmall of foodseaten

CHILD, ■ ■ ■ ■ and reading together. development, playing, such as talking, singing, active that activities promote will proper brain ity programming aday. Encourage more inter games) to no more than 1to 2hours of qual- watching television, playing computer or video child’sthe total entertainment (eg, time media turn offthe television duringLimit mealtimes. sion andEncourage viewing. media to them Explain to parents about effects the - of televi endurance, and coordination). to improve her fitness levels (stability, agility, Tell parents thatto child need guidetheir they growing, preparing, and about talking them. Children enjoy learning about by foods new Behavioral Behavioral

AND

THE

ROLE 20

OF Maintains good Improves Grows and Maintains good

THE health muscle tone endurance, and agility, stability, coordination, motor skills, appropriate rate develops atan health

FAMILY Health Health - 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES

2008;122(1):198–208 cardio Committee on Nutrition. Lipid screening and Daniels Greer SR, FR;American Academy of Pediatrics Agriculture; 2005 Health and Human and USDepartment of Services Americans 2005.Washington, USDepartment of DC: Department of Agriculture. Dietary Guidelines for US Department of Health and Human US Services, Diet Assoc. 2008;108(6):1038–1044,1046–1047 guidance for healthy children ages 2to 11years. JAm Position of American the Dietetic Association: nutrition Nicklas TA, Hayes D;American Dietetic Association. MI: Kelcy Press; 1998 Satter EM.Secrets of Feeding aHealthy Eater. Chelsea, 1998;47(RR-3):1–29 United inthe ciency States. MMWRRecomm Rep. Recommendations to prevent and control iron defi- Centers for Control Disease and Prevention. 2010;126(5):1040–1050 infants and young children (0to 3years). Pediatrics. of iron and deficiency iron in deficiency anemia Committee on Nutrition. Diagnosis and RD,Baker Greer FR;American Academy of Pediatrics Disord. 1999;23(suppl 2):S2–S11 and adolescenthood obesity. Int JObes Relat Metab Must A,Strauss RS.Risks and consequences of child - 1997;337(13):869–873 andfrom parental childhood obesity. NEngl JMed. Dietz WH.Predicting obesity inyoung adulthood Whitaker RC, Wright JA, Pepe KD, MS,Seidel 2003–2006. JAMA. 2008;299(20):2401–2405 index for age among USchildren and adolescents, Ogden CL,Carroll MD, mass KM.High Flegal body Academies Press; 2007 Balancing Benefits and Risks. Washington, National DC: Nesheim, MC, Yaktine, Seafood AL,eds. Choices: and Prevention Circulation. Science). 2008;118:428–464 Prevention (formerly Panel Expert the on Population and Prevention, Interdisciplinary Committee for American Heart Association on Council Epidemiology activity, and balance:ascientific statement energy from comprehensive promotion ofeating, healthful physical Population-based prevention for need the of obesity: Prevention, Interdisciplinary Committee for Prevention. Heart Association on Council Epidemiology and Kumanyika SK, Obarzanek E,Stettler American N,etal; ventions. JPediatr. 1990;117(2,pt 2):S181–S189 Satter E.The feeding relationship: problems and inter Pediatrics; 2008 Grove ed. Elk 6th Village, IL:American Academy of Kleinman RE,ed. Pediatric Nutrition Handbook. children. Birch LL,Fisher JA. Appetite and eating behavior in Nutr. 2003;77(5):1164–1170 with age-appropriate portions. or Am self-selected JClin intake of an entrée are greater with large portionthan Orlet Fisher J, Rolls BJ, Birch LL.Children’s bite sizeand vascular health in childhood. in childhood. health vascular Pediatr Clin North Am. 1995;42(4):931–953 Pediatrics. pr evention - Gidding SS,Lichtenstein AH,Faith MS,etal. Implementing Gidding SS,Dennison BA, Birch American LL,etal; Heart Freedman B. The validity DS,Sherry of BMI as an indica- Edelstein S,ed. Nutrition in Public Health: AHandbook for Davis MM,Gance-Cleveland B, Hassink S,Johnson R, Daniels setting. The SR. theuse Pediatrics.of BMIin clinical Casamassimo P, Holt Bright K,eds. Futures in Practice: Oral Brown JE,Isaacs J, Wooldridge N,Krinke B, Murtaugh M. Benjamin SE, ed. Making Food Healthy and Safe for Children: 20. 19. 18. 17. 16. Pressure Research. Circulation. 2009;119(8):1161–1175 Epidemiology and Prevention, and for Council High Blood onCouncil Cardiovascular Nursing, on Council Arteriosclerosis, Thrombosis and Biology,Vascular on CardiovascularYoung, inthe Disease on Council on Nutrition, Physical Activity and Metabolism, Council Heart Association Nutrition Committee of Council the tion guidelines: ascientific statementfrom the American American Heart Association and pediatric adult nutri- Heart Association. Circulation. 2005;112(13):2061–2075 practitioners—consensus statement from American the ommendations for children and adolescents: aguidefor Association; American Academy of Pediatrics. rec- Dietary 2009;124(suppl 1):S23–S34 tor of fatness body and risk among children. Pediatrics. Jones and Publishers; Bartlett 2010 Developing Programs and 3rd ed. Boston, MA: Services, S229–S253 obesity.of childhood Pediatrics. 2007;120(suppl 4): Paradis G,Resnicow K.Recommendations for prevention 2009;124(suppl 1):S35–S41 Healthand Oral Child 2004 Resource Center; Health—Pocket Guide. Washington, National DC: Maternal Wadsworth Publishing; 2008 Nutrition Through the Life Cycle, 3rd ed. Belmont, CA: CareChild Health Consultants; 2007 Programs. Chapel Hill, NC: National Training Institute for Standards—Guidelines for Out-of-Home Child Care How to Meet the National Health and Safety Performance SUGGESTED

Pediatrics. 2001;107(2):423–426 Public Education. Children, adolescents and television. American Academy of Pediatrics, Committee on Children; 2002 NationalDC: Association for Education of Young Movement Programs for Young Children. Washington, Sanders SW. Active for Life: Developmentally Appropriate Company; 2009 Dental Therapeutics. American Dental Association. ADA/PDR Guide to Safety Care; inChild 2007 Aurora, National CO: Resource Center for Health and Care. Healthy Kids, Healthy Care: Meals and Snacks. National Resource Center for Health and Safety inChild 2008;122(5):1142–1152 ininfants,ciency children, and adolescents. Pediatrics. Nutrition. Prevention of rickets and vitamin Ddefi- Pediatrics on Breastfeeding, Section Committee on Wagner CL,Greer FR;American Academy of

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NUTRITION Rhee K. Childhood overweight and relationship the K.Childhood Rhee between Patrick K,Spear B, Holt K,Sofka eds. BrightD, Futures in Nicklas TA, Hayes D;American Dietetic Association. Position Himes JH.Challenges of accurately measuring and using Hagan JF, Shaw JS,Duncan PM,eds. Ann Am Acad Pol 2008;615(1):11–37 Sci. Soc parent behaviors, parenting style, and family functioning. for Education inMaternal and Health; Child 2001 Practice: Physical Activity. Arlington, VA: National Center 2008;108(6):1038–1044, 1046–1047 for healthy children ages 2to 11years. JAm Diet Assoc. of American the Dietetic Association: nutrition guidance 2009;124(suppl 1):S3–S22 BMI and other indicators of obesity inchildren. Pediatrics. Academy of Pediatrics; 2008 and Adolescents, 3rd Grove ed. Elk Village, IL:American Guidelines for Health Supervision of Infants, Children, Bright Futures: Stang J, TaftBayerl C; American Dietetic Association. Spear BA, BarlowC,etal. Recommendations SE, Ervin for US Department of Health and Human Office Services, US Department of Agriculture, USDepartment of Health adolescent and food nutrition programs. Position of American the Dietetic Association: child and Pediatrics. 2007;120(suppl 4):S254–S288 treatment of child and adolescent overweight and obesity. Surgeon 2010 General; Department of Health and Human Office the of Services, for aHealthy and Fit Nation 2010.Washington, DC: of Surgeon the The General. SurgeonGeneral’s Vision Office; 2010 ed. Washington,2010, 7th USGovernment DC: Printing and Human Dietary Guidelines Services. for Americans 2010;110(5):791–799

J Am Diet Assoc. and interest in eating. visit, their During maywhich affecting be Tyler’s appetite differentfrom the environment at home, environment at child care may very be children.the She says that mealtime the Ms Eisenberg’s home she when feeds Ms Hill suggests that Tyler’s parents visit dietitian, for guidance. iors at home. Sandycall They a Hill, any changes inhis eating behav- parents have not noticed eat anything at Tyler’s all. sometimes refuses to and foods new to try that Tyler refuses to eat and his meal table long enough not sit down at the says that Tyler will ing. MsEisenberg about Tyler’s eat- with them speak Eisenberg, asks to care provider, Fran Tyler’s when prised child Tyler’s parents are thus sur own to willingness eat that food. 2 bites by of food anew modeling their 1or ingetting successful been himto try appetite,has agood and his parents have However,sive foods. new about trying he other children his age, Tyler is apprehen- his parentsweek while work. many Like T in ahome child care facility 5days a Mikkelsen, a22-month-old,yler is Reducing Distractions During Mealtime Tyler and the other children in hercare are eating better as aresultas of the changes, - and enjoying mealtimes tells Tyler’s parents that Ms Eisenberg together. i i to his food. watching cartoons the to pay attention parents notice that Tyler isbusy too watch eat. cartoons they Tyler’s while vision kitchen inthe children the so can children. MsEisenberg turns on tele the - notdoes sit down to eat with the meals Tyler’s parentsthat find MsEisenberg mealtimes together. her care are eating better and enjoying changes, Tyler and other the children in Tyler’s parents that as aresult of the improve. Two weeks later, she tells Tyler’s whether to see eating changes the Ms Eisenberg agrees to try turned off. also suggestthat They the be television Tyler’s parents with meet Ms vide afamily-likevide atmosphere. Eisenberg to the discuss dren at mealtime to pro- mealtime environment. Eisenberg join chil- the parents suggest that Ms thatThey tell her they distracts Tyler.distracts Tyler’s always eat at the table with Tyler to times because it because times sion during- meal help himeat and to turn on- televi the encourage himto plate. do They not on eachfood his try be haviors BRIGHT FUTURES: BRIGHT

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NUTRITION Early Childhood About Nutrition in Frequently Asked Questions ■ ■ ■ ■ ■ enjoyable? How canImakemealtimes ■ ■ ■ ■ ■ ■ ■ eating behaviors? How canIteachmychildhealthy ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Talk with your child at mealtimes. television).the Create arelaxed setting for turn (eg, off meals eating utensils. Use your child’s favorite plate, bowl, cup, and but times, scheduled allow for flexibility. Offer healthy forfoods meals and snacks at isthis normal. makes she amess learns while to herself— feed patientBe and understanding your when child physical activity. eating behaviors, and engage inregular apositive roleBe healthy model—practice your child. not toDo reward, food use bribe, or punish preparation. yourLet child help shopping with food and differentyour child to try ones. Offer avariety of healthy and encouragefoods, that helps also to regulate intake. food and plates). This is an importantself-help skill taught themselvesbe from food tobowls serve shovel sand or pour water from can apail, they and platters, once she is able to (ifchildren can Allow herself your from bowls child to serve with food. such as throwing or food utensils and playing tant are cues ones that demand your attention, or stop eating. subtle Less but impor equally eating begin moreare will they slowly full, havefocusing difficulty task. ona they When are hungry, may they irritable be or tired or hungernal When and cues. fullness children Help your to child learn recognize inter Eat together meals as afamily. - - ■ ■ changed. ShouldIbeworried? My 2-year-old’s appetitehas ■ ■ ■ ■ ■ picky eater? What canIdoaboutmy ■ ■ ■ What shouldmychildeat? ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ cheese orcheese and yogurt; cooked lean meat, cereals, and or pasta, fruits vegetables; rice; family is eating whole-grain (eg, breads and eating enough. child is energetic and growing, he is probably to day and even from to If meal. meal your Children’s appetites change alot from day children do. usually have bigger appetites than young than during first the 12 months of life. Infants Children grow more slowly from ages 1to 5 your child. not toDo reward, food use bribe, or punish and preparation. yourLet child participate shopping infood it.rejected evenifyourContinue afood child has to serve differentyour child to try ones. Offer avariety of healthy and encouragefoods, growing, he is probably eating enough. than at If eachmeal. your child is energetic and atLook your child’s eating over rather time ormeal snack. 2 to 3 Offerhours every your for child food a hungry.is still spoons), and letyour child ask for more ifshe portions.portions Offer 1 small (eg, tableor 2 - Children younger than age 2usually eat small poultry, fish, or eggs). At mealtimes, offerwhat the rest of your

■ ■ What shouldmychilddrink? ■ ■ ■ ■ ■ ■ new foods? How canIgetmychildtotry ■ ■ ■ I do? butter sandwiches.Whatshould My childwantstoeatonlypeanut ■ ■ during meals.WhatcanIdo? My childsometimesdawdles ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ growth and development. fat extra the child needs for inwhole milk Until your Your age child whole milk. 2,serve healthy foods. can reduce your child’s appetite for other day.oz) of per milk more Drinking than this Your child should about drink 2cups (16 your child in shopping and preparing food. the appealing foods new Make by involving trying tastes good. and texture, but don’t about talk it whether Talk about food’s the color, shape, aroma, Introduce inaneutral manner. food anew yourself. apositive roleBe model—eat foods new ifher favoritesnew foods are on her plate. She foods. new may more be to willing try your child’sServe favorite along foods with before times several take she accepts food. the evenifyourfood child has it. rejected It may don’t force her to eat it. Continue a to serve Encourage but food, anew your child to try for more. 1 or 2tablespoons—and letyour child ask portionsOffer small of new foods—perhaps probably eating enough. If your child is energetic and growing, he is Jags rarely last long enough harmful. to be child eats avarietyof foods. along with other to foods, ensure that your the favoredof servings Offer smaller food, children. are food) commona particular inyoung Food children jags (when want to eat only andmeals snacks. Routines are important to children. Schedule andmeals snacks. distractions turn (eg, offthe television) during They easilyare distracted. also to reduce Try activity, including eating, after a shorttime. It is normal for children interest to lose inan ■ ■ enough calcium? How canIhelpmychildget ■ ■ ■ ■ ■ ■ and mineralsupplement? Should Igivemychildavitamin ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ dings, milkshakes, soups, and casseroles. Use products milk inrecipes, such as inpud- turnip greens. calcium sulfate, broccoli, and collard and cheese, tofu yogurt, as milk, processed with that foods are richincalcium,Serve such and snacks. throughout day, the meals between especially thirsty. Make sure plenty he drinks of water Your child may not tell you he when is to tooth decay. sugar for of long and time periods contribute in abottle can cover your child’s with teeth juice inacup,Serve not abottle. Juice served 4 to day. 6oz per fruitOffer 100% juice insmall amounts, about fat-free is recommended. (skim)milk For children older than age 2,low-fat (1%)or mineral supplement. sidering giving your child avitamin and Talk to professional ahealth ifyou are con- supplement.mineral healthy not he does avitamin foods, need and If your child is growing and eats avarietyof calcium supplement. professionalhealth about giving your child a If suggestions these donot work, ask a — — — — — these suggestions tities of and milk products), other milk try digestive system cannot handle larger quan- If your intolerant child is lactose (that is, her yogurt. Serve — — — — — and cereal products. have calcium), such added as orange juice that (foods calcium-fortified foods Serve productsmilk containing lactose. Give tablets your before child lactase she eats tose. Add drops lactase to your child’s milk. Swiss, and Parmesan, are which low- inlac aged hard such cheeses, as cheddar, Colby, products, milk and yogurt, lactose-free Serve products. along foods with these non-milk Serve out day. the portions through small of foods - these Serve BRIGHT FUTURES: BRIGHT

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NUTRITION ■ ■ ■ ■ ■ ■ ■ ■ ■ overweight? What shouldIdoifmychildis ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ oride supplement. sician may recommend giving your child aflu- your child’s water, drinking dentist the or phy - tooth decay and known the level of fluoride in onDepending your child’s risk for developing (eg, hiking, biking,(eg, hiking, swimming). Plan family that activities enjoys everyone instead of singling out of those child. the ing behaviors and physical activity practices on gradually changing entire the family’s eat- or engage inenough physical activity, focus If your not child does eat enough healthy food physical activity. eating behaviors, and engage inregular arole healthyBe model—practice child’s other attributes. or shape, redirect comments their to your If others comment on your child’s size, weight, weight, or shape. as she is. Never criticize your child’s size, many sizes and shapes and that you love her yourLet child know that people come in or utensils and playing with food. demand your attention, such as throwing food buttle important equally are cues ones that eating more slowly or stop eating. sub Less - on begin atask. When are will they they full, irritablebe or tired or havefocusing difficulty ness When cues. children are hungry, may they her to learn recognize internal hunger- and full Allow herself yourand food, help child to serve problems.health to makeyour certain not child does have any Have your child’s professional health check professional. child’s weight, with your talk child’s health However, ifyou have any concerns about your aboutto worry she whether is overweight. and is physically active, you do not need If your child is growing, eats healthy foods, many at once harmful. can be andlook taste like candy, and consuming too bottle out of his reach. The supplements may If your asupplement, take child does keep the ■ body? How canIhelpmychildlikeher ■ ■ ■ ■ ■ ■ ■ choking? How canIprevent mychildfrom ■ ■ ■ ■ foods? Should mychildeatlow-fat ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ own sizeor shape or that of others. apositive roleBe model—don’t criticize your for reasons it. medical and supervises professionalunless ahealth recommends one Never place your child on weight, adietto lose regular basis. low-nutrient inlarge foods quantities or on a your child to eat. Avoid buying high-calorie, Bring into house the only that foods you want in moderation. notDo forbid them sweets andServe desserts. and meals scheduled snacks. Serve remove it. in your child’s bedroom; ifone is already there, ity programming day. per Don’t put atelevision puter or games) video to 1to 2hours of qual - watching (eg, time television, playing com- Limit your child’s total entertainment media may choke. Iftimes. your child becomes overexcited, he Keep at things calm mealtimes and snack orwalking may running cause himto choke. Have your child siteating. while Eating while mayneeds higher. be active or having agrowth spurt, energy their tocalories grow well. When children are very It is important for children to consume enough tuna, are important for young children to eat. Fatty fish, suchsalmon, as trout, albacoreand tein foods. fat-free lean meats, milk, and other high-pro- and and cereals, fruits vegetables, low-fat or fat, children more need whole-grain breads to consumeAs begin they fewer from calories proportionthe of low-fat diets. intheir foods After age 2, children shouldgradually increase children fat need for growth and development. younger than age infants 2,because and young are(skim) milk not recommended for children Reduced-fat (2%),low-fat (1%),and fat-free to yourtalking child. Focus on traits other than appearance when ■ ■ shopping withmychild pleasant? What canIdotomakegrocery ■ ■ ■ ■ ■ ■ ■ ■ be more physicallyactive? How canIencouragemychildto ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ shopping. Make alist inadvance to save while time is hungry. shoppingGo neither when you nor your child playgrounds, parks, community centers). and walking activity (eg, bikingical paths, your child has safe places for engaging inphys- Work with community leadersto ensure that hike, abike eachweek. ride) Plan at least physical one special a activity (eg, leaves, dog). the walking Involve your child infamily chores raking (eg, activity or stretch break. encourage her to a10-minute take physical vision, or plays computer or games, video For hour your every child reads, watches tele- there, remove it. vision inyour child’s bedroom; ifone is already of quality programming aday. Don’t put atele- or games) video to no more than 1to 2hours watching (eg, time television, playing computer Limit your child’s total entertainment media your child. It’skick aball). agreat way to with spendtime Play together dance, (eg, play hideand seek, ing, dancing, tossing bag). abean Find acceptable indoor march (eg, activities - jumping,(eg, hopping, skipping). Encourage active, spur-of-the-moment play nut butter on thinly crackers or bread). carrots finely or intothin strips, spreading- pea lengthwise, chopping nuts finely, chopping raw into pieces, small cutting whole grapes inhalf ting hot dogsinquarters lengthwise and then arethey saferto themmake modified cut (eg, - Children ages 3to 5may if eat foods these and whole grapes). fruits, other dried chunks of meat, hot dogs,raw carrots, raisins ofspoonfuls peanut butter, nuts, large seeds, marshmallows, pretzels, popcorn, chips, that may cause choking hard (eg, candy, mini- For children younger than age 3,avoid foods able to help him. chokes you while are driving, you not will be notDo letyour child eat inamoving car. If he ■ ■ At ages 12–18months, your child will master at skills the ages the indicated. development disabilities—may not able be to children, with some those children—especially Although listed skills the are attainable for most as hegrows? What canIexpectmychildtodo ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ At ages 4–5,your child will ■ ■ ■ ■ ■ ■ ■ At age 3–4,your child will ■ ■ ■ ■ At ages 2–3,your child will ■ ■ ■ ■ At ages 18–24months, your child will ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Grasp and releasewith his foods fingers. love to around look and what discuss see. they If possible, donot your rush child. Children Talk to your child about what you are buying. Ask your child to help you for look items. food your child for following rules. the out of no cart, asking the for candy), and praise for clear rules Set behavior no (eg, climbing Bring toys to keep your child busy. shopping cart. Use asafety belt your when ina child rides Be moreBe interested than ineating. intalking to foods herself. able toBe serve able toBe himself. feed able to acupBe use well. able to aknifeBe use and fork. influenced Be by television. toLike imitate cook. the invarious foods Like shapes and colors. Request favorite foods. able toBe pour liquids from pitcher. asmall able toBe hold acup by its handle. able to afork.Be use Have definite likes and dislikes. able toBe chew more foods. to on place foods ownBegin plate. able toBe hold acup. easily. distracted Get Have favorite foods. toLike eat with his hands. and older. Eat less than infants and than children ages 2 Want that foods others are eating. ting go of it). able to acupBe use (but have will let- difficulty well). ituse very able toBe hold (but aspoon not able will be to BRIGHT FUTURES: BRIGHT

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NUTRITION ■ Satter E. Your Child’s Weight: Helping Without Harming: Birth Nemours Foundation. KidsHealth. http://kidshealth.org Nestle M.What to Eat: An Aisle-by-Aisle Guide to Food Savvy National Institutes of Health, National Heart Lung, and Blood Nader Zive MM.You PR, Can LoseYour Baby Fat: New Rules International Food Information Council. Kidnetic. http:// Centers for Control Disease and Prevention. Eat a Centers for Control Disease and Prevention. Division of ■ ■ ■ ■ ■ ■ ■ wants to food). eat aparticular Continue to have he jags (when only food Through Adolescence. Madison, WI:Kelcy Press; 2005 Press; 2006 Choices and Good Eating. New York, NY: North Point obesity/wecan Nutrition. http://www.nhlbi.nih.gov/health/public/heart/ Institute. We Can! Ways to Enhance Children’s Activity & Society. San Diego, CA:PhilNader Publications; 2008 Others Who Care About Children and the Future of Our to Protect Kids from Obesity—For Parents, Providers, and www.kidnetic.com www.fruitsandveggiesmatter.gov Variety of Fruits &Vegetables Every Day. http:// gov/nccdphp/dnpa Nutrition, Physical Activity and Obesity. http://www.cdc. RESOURCES moreBe influenced peers. by his interestedBe inwhere comes food from. toLike help prepare food.

FOR

FAMILIES Warner P. Preschoolers Play and Learn: 150Games and Virgilio SJ. Active Start for Healthy Kids: Activities, Exercises, US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition US Department of Agriculture. MyPyramid for Preschoolers. Minnetonka, MN:Meadowbrook Press; 2000 Learning Activities for Children Aged Three to Six. Publishers; 2005 and Nutritional Tips. Champaign, IL:Human Kinetics Agriculture, Food and Nutrition 2009 Service; The Two Bite Club. Washington, USDepartment of DC: Nutrition 2008 Service; Washington, USDepartment of DC: Agriculture, Food and Nibbles for Health: Newsletter for Parents of Young Children. nal.usda.gov/cgi-bin/dexpldcgi?qry1355492943;1 Loving Your Family, Feeding Their Future. http://desearch. Agriculture, Food and Nutrition 2010 Service; and Vegetables. Washington, USDepartment of DC: GrowService. It, Try It, Like It! Preschool Fun with Fruits Resources/eatsmartmaterials.html Eat Smart. Play Hard. http://teamnutrition.usda.gov/ Agriculture, Food and Nutrition Information 2009 Center; Preschoolers. MD:USDepartment of Beltsville, Information Center. Food and Nutrition Fun for http://www.mypyramid.gov/preschoolers

Middle Childhood

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lean body mass inchlean body per of height than girls do. ofis part normal growth and development. boys have childhood, middle During more cence or early (but adolescence, boys) girls inparticular may also appear “chunky,” but this lescence. In girls,amount the of increase the is greater than inboys. preadoles During fatbody percentage increases inpreparation for growth the spurt that during occurs ado preadolescenceDuring ingirls (ages 9–11)and early adolescence inboys (ages 10–12), compositionBody and shape body remain relatively constant during childhood. middle 5–6), may associated with be obesity inadulthood. growth children. that inall However, occurs an early BMIrebound before (occurring ages andthe is reflectedBMI-for-age in and Thisgrowthgender isa curves. normal pattern of increase inBMIthat after occurs it reaches its lowestpoint is referred to as BMI rebound increase thatual is sustained through adolescence and into adulthood. The rebound or reaches its lowest point at around ages 5to 6.Subsequently, BMI-for-age agrad begins for-age to begins decline, and it continues to during decrease preschool the years until it mass index (BMI)changesBody substantially After during childhood. age middle 2,BMI- of slower growth. tite and intake. food Conversely, achild’s appetite and intake food during decrease periods year.per have They growth which spurts, are accompaniedusually by an increase in appe gain an average of 7lbs inweight, 2 or inlateoccurs early children childhood middle adolescence. childhood, middle During Middle childhood’s slow, steady rate of growth continues until onset the of puberty, which ■ ■ ■ essential for Children benefitgreatly from practicing healthyeating behaviors. behaviors These are day,per 3 meals They need plus 1 or 2snacks. thatfoods provide sufficient energy, protein, carbohydrates, fat, vitamins, and minerals. To achieve optimal growth and development, children to need eat avarietyof healthy of achild’s period this life. However, cognitive, emotional, development and social at occur atremendous rate during (ages 5–10)isMiddle characterized childhood by aslow, steady rate of physical growth. ■ ■ ■ CONTEXT GROWTH cancer, osteoporosis) 2diabetes(eg, cardiovascular mellitus, type disease, hypertension, some forms of Laying foundation the for lifelong and health reducing risk for the chronic diseases obesity, undernutrition, eating disorders, dental caries[tooth decay]) Preventing immediate problems health iron-deficiency (eg, anemia, overweight and Promoting optimal growth, development, and health Middle Childhood

AND

PHYSICAL

DEVELOPMENT 1/2 inches inheight, and 1inch circumference inhead 1 - - - - BRIGHT FUTURES: BRIGHT

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NUTRITION strength. Parents and children should aware be aboutcerned stature their and muscle sizeand a permanent change. may Boys become con- growth and development and is probably not fat of is part duringnormal childhood middle can reassure child that their an increase inbody should aware be of possibility this that so they weight and may to eat begin less or diet.Parents Girls may that are especially worry they over overly concerned about appearance. their children childhood, may middle During become more away meals from home at (eg, child care behaviors and In food. addition, children eat ence over children’s attitudes toward eating to more exert begin media) the (eg, peers, influ- more significance, and social outsidesources mealtimes on take childhood, middle During their self-esteem. to contribute to family, the thereby boosting time. Performing tasks enables these children and can performtasks related they - to meal help planning with meal and preparation, food ability to themselves feed improves, can they family, at school, and community. inthe Their ofa sense and self to roles their learn inthe to develop begin childhood Children inmiddle growth and health. that eating healthy has apositive food effect on healthy. As children mature, to realize begin they that are healthy but may not know why are they and don’t like. may They be able to identify foods and quantity and as ones foods like classify they according foods dren describe to color, shape, In early the stages chil- of childhood, middle are able to eat ahealthy diet. and softercan helpfoods ensurethat children suchfoods, as meat. Offering chopped meats ment, it may difficult be them for to certain chew or teeth eral are undergoing orthodontic treat - to erupt.begin When children are missing- sev andduring childhood, permanent middle teeth Most teeth primary their childrento lose begin activity, can improve they muscle their strength. adolescence although, with appropriate physical unable to increase muscle their mass until middle ing) that DEVELOPMENT muscle-building weightlift (eg, activities during this period can be harmful. Boys are harmful. Boys can be during period this

ISSUES - - children approach adolescence. eating as afamily becomes more challenging as families with age decreases the of child, the and proportion of children that eat dinner with their als, and decreased soft drink consumption. andals, soft drink decreased vegetables, products, milk vitamins, and miner quality diet,including greater intake of fruits, eatwho dinner with families their have ahigher- involved Children activities. inextracurricular can become more difficult as children get more interactionsocial and family togetherness. This in apleasant environment, allowing for time It is important for families to eat together meals strongly associated with what parents their eat. behaviors themselves. Children’s intake food is positive role models by practicing healthy eating calorie, low-nutrient Parents foods. should be able at home and to limit availability the of high- Parentsfood. to need make healthy avail foods - children’s eating behaviors and attitudes toward Parents continue to have most the influence on aretheir friends doing. Lunch Program) may influenced be whatby in nutrition programs National the (eg, School towilling eatand foods certain to participate and relatives). The degreewhichthey are to facilities, at school, and at homes the of friends and during puberty. in bone during mass years the occur just before important for children greatest the because gains bone-strengthening remain activities especially strengthening, or bone strengthening). Even so, or mix specific the (aerobic,of activities muscle component (frequency, intensity, or duration) tant for achieving benefits health than any one total amount of physical activity is more impor bone-strengthening It activities. appears that the activity as well as age-appropriate muscle- and or more eachday. This should include aerobic sity efits by doing moderate- andvigorous-inten - Children can achieve substantial- ben health away from home. ance to help children make healthy choices food owntheir money. Parents to need provide guid- restaurantsfast-food and purchase with food Many children to neighborhoodstores walk and HEALTHY physical activity for atotal of 60minutes

LIFESTYLES 3 2 2 The - - their children. communitytact resources to help parents feed about children their and can and identify con- tunity to nutrition discuss issues and concerns Health professionals can give parents oppor the ing, and promote regular physical activity. encourage positive attitudes toward and food eat- to teach children about healthy eating behaviors, professionals,health families, and communities providesMiddle childhood an opportunity for products and alcohol. drinking begin discouraging children from using tobacco is an appropriateMiddle childhood to time cooperate with others. activity programsical helps children to learn are friends their engaging. Participating inphys- may more be interested inwhich inactivities ence achild’s level of physical activity. Children offered.be Teachers and children’sfriends influ - day, every vided and enjoyable should activities Physical education at schoolshould pro be - significantly increase. active,cally children’s physical activity levels When parents encourage children physi to be - show child that their physical fun. activity can be importancethe of regular physical activity and with child, their parentsor baseball) emphasize activebiking, (eg, playingcally hiking, basketball dren’s physical activity levels. By physi being - Parents play amajor role indetermining chil - in avarietyof activities. by having feeling fun, competent, and engaging Children are motivated physically to be active to engage inavarietyof physical activities. perform complex movements, allowing them Children acquire motor the to necessary skills strength, motor and skills, stamina increase. children’s childhood, middle During muscle ■ ■ ■ ■ Children are who physically active ■ ■ ■ ■ BUILDING and depression May have reduced symptoms of anxiety Have stronger bones Typically have fat less body and stronger muscles Have levels higher of cardiorespiratory fitness

PARTNERSHIPS 4 - tion of advertising and education). or brand character) or “advercation” (acombina- (online games that feature acompany’s product keting forms, innew such as “advergames” Internet the use who are subjected mar to food childhood includechildhood following: the Common nutrition concerns during middle ation centers) and safe places for children to play. grams at (eg, child care facilities, schools, recre- Communities need to provide physical activity pro- provide food.also nity groups, and faith-basedorganizations can Programs.) Food shelves and pantries, commu - ments. Tool (See K:Federal Nutrition Assistance a substantial of part daily their nutrient require- programsschool meal help provide children with aboutlearn classroom. inthe Federally funded avarietyof healthy thatserve foods children lum, and child care facilities and schools should tion of should part education the - be curricu in apleasant environment. Nutrition educa- avarietyofChildren need healthy served foods or added sugars or low innutrients. focusing on that foods are infat, high sodium, on with food, 9out of 10of commercials these showed that almost 50%of commercials focus television programming on Saturday morning A study of commercials aired during children’s messagesmedia encourage children to eat them. saturated and trans fats, are readily available, and are insugar high and in high fat, those especially to need stay they foods healthy.the Foods that may poverty orexperience neglect lack access to live inunsafe neighborhoods. Children who opportunities physically to be active, and some physically active. Some children donot have children from eating healthy and foods being There are manythatbarriers may prevent ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ COMMON Increase image inbody concerns inoverweightRise and obesity trans fats infat, saturated high foods especially and Higher consumption than recommended of Limited intake of and fruits vegetables softages, drinks especially Increase inconsumption of sweetened bever products inconsumptionDecrease of and milk milk

NUTRITION

CONCERNS 6 5 Children BRIGHT FUTURES: BRIGHT - -

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NUTRITION there that is evidence achild is at risk for poor Nutrition Risk for Children and Adolescents. If nutrition status, Tool see D:Key Indicators of For alist of risk factors that canto lead poor ■ ■ FOR THECHILD Eating Behaviors and Food Choices Interview Questions nutrition concerns. starting pointa useful for identifying achild’s chapter.) Asking questions interview provides Cultural the (See Awareness inNutrition Services practiceswithin andfood among cultural groups. tions related and to variation food wide the in toneed appreciate varietyof the cultural- tradi sion to diverse populations, professionals health challengethe of providing nutrition- supervi for Children Ages 1to 10.)Additionally, to meet Tool visit.the (See B:Nutrition Questionnaire ing aquestionnaire out filled parentsby before information accomplished be can also by- review professional’s communication style. Gathering Questions to match modified can be the health from visitvary to visit and from family to family. and build partnerships. Use of questions the may child’sthe nutrition status, to invite discussion by selectively questions asking interview about Health professionals nutrition begin supervision from child to child. appropriate from visit andvary to will visit and viding anticipatory guidance, as should used be conducting screening and assessment, and pro- sion, includes which questions, asking interview important to remember that nutrition- supervi under Suggested chapter.) inthis Reading It is Children, and Adolescents, ThirdEdition, listed Guidelines for Health Supervision of Infants, Brighttion on see supervision, health Futures: visits. supervision health (For more informa- during nutrition visits supervision or of as part A child’s nutrition status should evaluated be Nutrition Supervision ■ ■ together? How often your does familyeat meals How many snacks? Which doyou meals usually eat eachday? ■ ■ ■ ■ ■ ■ or both. ing anutritional assessment, laboratory tests, nutrition, assessment further includ is needed, - ■ FOR THEYOUNGERCHILD Weight and Body Image ■ ■ FOR THECHILDORPARENT Food Resources ■ ■ ■ ■ ■ ■ ■ FOR THEPARENT ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ With snacks? What doyou with your usually drink meals? which ones? Are there any you foods won’t eat? If so, What is your favorite food? What snacks doyou usually eat? In the meals? evening? Between morning? Around noon? In afternoon? the What doyou usually eat and inthe drink At home? At afriend’s house? Where didyou eat yesterday? At school? How doyou feel about your weight? to eat or not enough money to buy food? Are there there when times is not enough food Who prepares it? Who usually buys for food the your family? soft juice, drinks)? fruit drinks, fruit What water, milk, (eg, he usually drink does At afriend’s house? At home? At school?At after-schoolcare? Where your does child eat snacks? What he usually eat does for snacks? How often your does eat child breakfast? Why or why not? youDo your think child eats healthy foods? enough milk)? drink eating habits or behaviors getting (eg, her to youDo have any concerns about your child’s together? How often your does familyeat meals did you eat or yesterday? drink What and fruits vegetables, including juices, ■ Growth and Physical Development Screening andAssessment ■ ■ ■ FOR THEPARENT ■ ■ ■ ■ FOR THECHILD Physical Activity ■ FOR THEPARENT ■ ■ ■ FOR THEOLDERCHILD ■ ■ ■ Sources: World HealthOrganization, Obesity Overweight Healthy weight Underweight Stunting Indicator ■ ■ ■ ■ ■ ■ ■ ■ ■ ties with eating).ties may indicate anutrition problem- difficul (eg, should evaluated. be This maybe normal or change ingrowth percentiles on chart) the growthfrom pattern expected the amajor (eg, onthese astandard growth chart. Deviation Measure child’s the height and weight, and plot Does your child have a television in his bedroom? or video games? day watching television or playing computer How much your does time child spendeach engage in?How often? What of types physical your activity does child What do you think you can do to be more active? video games? watching television and playing computer or How much doyou time spendeachday a week? How much doyou time active spendbeing in How often? What do you do to be physically active? How doyou feel about your child’s weight? If so, how? Are to change you trying your weight? How much would you like to weigh? How doyou feel about your weight? TABLE

INDICATORS BMI-for-age BMI-for-age BMI-for-age BMI-for-age Height-for-age Anthropometric Variable 7 Barlowetal, 8 andKrebsetal.

HEIGHT ■ ■ ■ as a only as a screening tool and should not used be ment mass index mayserves Body needed. be healthythe weight range, amore in-depth assess- height and weight status. When a child is outside Table 1provides of an indicators overview of ■ ■ ■ ■ ■ ■ ■ ■ ■ chart to determine child’s the BMIpercentile. child’s BMIand age on aBMI-for-age growth orwheel calculator. To interpret BMI,plot the excess fat body inchildren. percentile95th on growth charts) can confirm frame size. An elevated skinfold (ie, above the ing from physical activity, muscularity, or of because alarge,tile mass lean body result- Some children may have BMIpercen- ahigh by square the of height (kg/m child’s the Calculate BMIby dividing weight determine nutrition status and overall health. mass as indexascreening is used toolBody to tive nutrition or problems. health height-for-age may reflect long-term,cumula - tors of nutrition status and overall Low health. nutrient intake as general indica- and serve Changes inweight reflect a child’s short-term to indicateused nutrition and growth status. Height and weight measurements can be emia. (See the Hyperlipidemia the (See emia. chapter.) Assess child’s the risk for hyperlipid familial - Hypertension chapter.) Obtain child’s the pressure. blood the (See hair, gums, teeth, tongue, and eyes. Evaluate appearance the of child’s the skin, 9 diagnostic tool.

AND

WEIGHT ≥95th percentile ≥85th–94th percentiles ≥5th–84th percentiles <5th percentile <3rd percentile Cut-Off Values

STATUS 2 ) or using aBMI BRIGHT FUTURES: BRIGHT

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NUTRITION Obesity ■ Stunting ■ ■ Overweight ■ Underweight ■ ■ ■ ■ Obesity chapter.) Survey data. Survey National Health and Nutrition Examination on percentile 99th the cutpoints based from committeedren. The expert suggested using sus on adefinition severeof obesity in - chil excessive weight. However, there is no consen- highest risk for comorbidities associated with a BMIat or above percentile 99th the are at quate intake,energy inadequate resources,food rally, or may as aresult they thin be of inade- result of nutrition poor or health. poor reflects afailure to reach optimum height as a third percentile should evaluated. be Stunting height-for-ageChildren whose is below the in-depth medical assessment.in-depth medical percentile are considered and an obese need Children with aBMIat or above 95th the weight screening. and further need and percentiles 94th are considered over 85th the Children with aBMIbetween chronic disease. restrictive dieting,anutritional eating disorders. Children may natu thin be for should assessed tile be organic and disease Children percen with aBMIbelow- fifth the hormone or thyroid deficiency. outnologist to rule may growth necessary be potential to achieve. Areferral to- an endocri children reach height the that have they the interventions should implemented be to help of factorsAll these should and assessed, be malabsorption syndrome, or other conditions. eating problems, an altered metabolic rate, for-age of because agenetic disorder, chronic care health mayspecial needs have low height- of other underlying problems. Children with frombenefit improved nutrition treatmentor dren growth whose is stunted and may who or chronic The is illnesses. - to identify goal chil dren with severely inadequate intakes energy is stunted. Stunting reported inchil has- been a result of genetics, not growth their because children with low height-for-age are short as 10 These cutpoints These maybe 9 Children with deficit, o 8 (See the the (See 7 Most - r a - ■ Iron-Deficiency Anemia ■ ■ ■ Physical Activity ■ ■ Oral Health ■ ■ ■ ■ ■ ■ — — Iron-Deficiency the (See Anemia chapter.) for Control Disease and Prevention (CDC). Academy of Pediatrics (AAP)and Centers the screening have put been forth by American the Recommendations for iron-deficiency anemia chapter.) Obesity the (See range,mal and therefore intervention is urgent. compared with children with BMIs nor inthe levelthis are at risk for higher comorbidities imprecise, but children with aBMIat or above during mealtimes. Ask child watches the whether television suchactivities, as computer or games. video spends watching television and on other media forScreen amount the of child the time laboratory tests, or both. conducted, including anutrition assessment, of nutrition assessment risk, further should be Children and Adolescents. If there is evidence Toolsee D:Key Indicators of Nutrition Risk for with of an nutrition, increased likelihood poor For physical activity characteristics associated — — — Assess child’s the level of physical fitness by Health Oral the (tooth decay). chapter.) (See to determine child’s the risk for dental caries suming and foods insugar) beverages high Assess eating behaviors of frequency (eg, con- Ask child has the whether regular dental visits. — — — — — deficiency anemia). deficiency care previous needs, diagnosis of iron- anemia low (eg, iron intake, health special with known risk factors for iron-deficiency recommendsThe CDC screening children without iron supplementation. arewho consuming vegetarian astrict diet The AAP recommendsscreening children priateness of physical (Table activities 2) Evaluating child’s the motor and skills appro- physical fitness assessment) child didonthe school’s the standardized compares to national standards how (eg, well Evaluating how child’s the physical fitness engages inon aweekly basis Asking how much physical child activity the 12 11 - ■ ■ ■ Growth and Physical Development to Promote Healthy Eating Behaviors.) and Tool G:Strategies for Health Professionals Change—A Model for Nutrition Counseling, additional information, Tool see F: Stages of iors, choices, food and physical activity. (For mote apositive attitude about eating behav- enters next the developmental and pro period; - and parents aware of whatas child the to expect on child’s the nutrition status; make child the professionalshealth should offer information and parents’ nutrition concerns. In addition, Anticipatory guidance should address child’s the Anticipatory Guidance Source: Patricketal. 10–11 7–9 5–6 Ages ■ ■ ■ people come inunique sizesand shapes, weight is. Help child understand the that Tell child and the parents what ahealthy Children and Adolescents.) for Fostering aPositive Image Body Among defined weight. (See socially ideal, I: Tool Tips sizeanddetermined shape rather than on an healthy weight on body isagenetically based compares to others his age. Emphasize that a child and parents, and how discuss child the Explain standard the growth chart to the boys, it may at occur ages 10to 12. For may girls, this at occur ages 9to 11;for accelerated should they when expect growth. and parents, including approximate the times physicalDiscuss development with child the TABLE Transitional complex(eg, Fundamental transitional Fundamental (eg,running, Motor Skills playing basketball) throwing foraccuracy) (eg, throwingfordistance, throwing, catching,kicking) hopping, skipping, galloping, jumping,

MOTOR 13

SKILLS

DEVELOPMENT

Continue toemphasizemotorskilldevelopmentbut Require entry-levelcomplexmotorandcognitiveskills Focus onhavingfunanddevelopingmotorskill Do notrequirecomplexmotorandcognitiveskills Require littleinstruction Have flexiblerules Focus onhavingfunanddevelopingmotorskill Are repetitiveanddonotrequirecomplexmotor Are simpleactivitiesthatrequirelittleinstruction Focus onhavingfunanddevelopingmotorskill Recommended PhysicalActivities teamwork begin toincorporateinstructiononstrategyand rather thanoncompetition (eg, entry-levelbaseball,soccer) rather thanoncompetition throwing andcatchingaball) cognitive skills(eg,running,swimming,tumbling, rather thanoncompetition

AND ■ Eating Behaviors and Food Choices ■ ■ ■ ■ ■ ■ ■ ■ ■ porating into foods new child’s their diet. she eats and guidance to parents on incor onthe child increasing varietyof the foods tance of healthy eating. Provide guidance to with child and the Discuss parents impor the for growth and development. to consume sufficientcalories and nutrients areeven ifthey losing weight, children need mum of 2lbs aweek may appropriate. be But, with aBMIabove percentile, 99th the amaxi- and 95th percentiles.the 99th For children appropriate for children with a BMI between loss of no more than 1lb amonth may be below percentile, 95th the but weight agradual loss should inchildren not with occur aBMI Explain to child and the parents that weight healthy weight. physically active to achieve or maintain a importance of eating healthy and foods being Emphasize to child and the parents the nearin the future, as well concerns. as specific changes that to experience child can the expect with child and the Discuss parents physical the but that are they normal. still may earlier puberty or start later do, than they Explain to children that some of peers their less of sizeand their shape. accepted by are, families their as they regard- children to need know are they loved and within arange of healthy weights. body All

APPROPRIATE

PHYSICAL 8

ACTIVITY BRIGHT FUTURES: BRIGHT -

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NUTRITION ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Americans choices on Dietary the based Guidelines for Encourage child to the make healthy food fruits andfruits vegetables). carbohydrates whole-grain (eg, products, fresh children healthy choose snacks richincomplex ensure that are they eating ahealthy diet. Help andtime therefore 1to need 2snacks daily to cannot consume large amounts of at food one Tell parents that children childhood inmiddle importance of having regular family meals. regular healthy and meals snacks. the Discuss Emphasize to parents that children to need eat ment of 400IU/day. [yolk])eggs should receive avitamin Dsupple - vitamin cereals, (eg, D–fortified fortified foods and serving) per 8-oz (100IU fortified milk 400 IU/day of vitamin Dthrough vitamin D– min Ddeficiency, childrenwho do not obtain Tell parents that to prevent rickets and vita- day to calcium their meet needs. productsother milk per cheese) yogurt, (eg, or(skim) milk consume equivalent the from 3cups toofneed drink low-fat (1%)or fat-free Tell parents that children ages 9and older later inlife. helps prevent osteoporosis and bone fractures and cheese, to attain maximum bone density provide enough calcium, such yogurt, as milk, calcium Eating their meet needs. that foods products daymilk per cheese) yogurt, to (eg, ormilk consume equivalent the from other 2cups ofdrink low-fat (1%)or fat-free (skim) Tell parents that children ages 2to 8need children are who less active. are activewho require very more than calories requirements on activity levels. based Children Reference IntakesDietary provide energy growth increase. spurts, needs calorie when day per calories until of beginning the their approximatelygirls need same the number of activity level, and composition. body and Boys and arehood influenced growth,by physical remain fairly constant during child- middle Explain to parents that requirements energy fish, beans,fish, eggs, and nuts. cheese, lean yogurt), meats,(eg, milk, poultry, grain), low-fat and fat-free products milk vegetables, grain products whole (especially For example, encourage child to the eat fruits, Healthy Eating and Physical Activity chapter.) 14 and on MyPyramid. 18 16,17 15 (See the the (See ■ ■ ■ ■ ■ ■ ■ ■ Oral Health ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ may make evenmore them stubborn. learning independent. to be Fighting over food stubborn about eating, it is oftentheir way of pleasant environment. When children are andmeals snacks should offered be ina tions such as television. the Well-balanced sphere for mealtimes and to get of rid distrac- Encourage parents to provide arelaxed atmo - food choices. to teach used childrencan be to make healthy at home, school, restaurants, and other places offered healthy choices at meals. Mealtimes with parentsDiscuss that children should be juice and sweetened beverages. child is their thirstywhen and to limit intake of Encourage parents to promote water drinking insugar. high drinks) soft andcookies) drinks, beverages fruit (eg, chips,(eg, and french candy, (eg, foods fries), insaturated high those especially and trans fats Encourage parents to infat, limit high foods is recommended. tration of approximately 0.8to 1.0mg/L (ppm) brand fluoride inwhich is added at aconcen - ter.) For families that prefer bottled water, a Healthdecay) Oral the inchildren. chap (See - cantly reduce risk for the dental caries(tooth water is asafe and effective way - to signifi Explain to parents that fluoridated drinking (tooth decay). in sugar canhigh help prevent dental caries soft drinks) drinks, beverages fruit (eg, sumption of candy, (eg, foods and cookies) Tell parents that limiting child’s their con breakfast and before bed). with fluoridated toothpasteday a twice (after Encourage child to the brush his or her teeth teeth effectively. typically by age 7or can clean 8,they their ability the (eg, skills shoelaces), to their tie help.tal After children acquire fine motor dren cannot clean without teeth their paren- fine motorgood control thatand young - chil Explain to parents that toothbrushing requires Assistance Programs.) Toolif needed. (See K:Federal Nutrition in schoolbreakfast and lunch programs Encourage parents to enroll child their 19 ■ ■ ■ ■ ■ Physical Activity ■ ■ ■ ■ ■ present to cushion afall. gravel,pea sand, fine rubber or shreddedare to ensure that materials such as mulch chips, check under surfaces playground equipment physically active. Also, suggest that parent the mouthpads, guards, child is the when goggles) tance of wearing safety equipment helmets, (eg, Emphasize to child and the parents impor the into adulthood. daily life. activities These tendbe continued to he enjoysties and can incorporate into his Encourage child to the find physical- activi physical activity tends to decline. child to stay active during adolescence, when tance of physical activity. Encourage older the Emphasize to child and the parents impor the HealthSpecial Care Needs chapter.) Children the and Adolescents (See needs. With foractivities care health child with the special physical therapist can help appropriate identify physical education is often helpful thatand a or physical conditions). Explain that adaptive fitnessthe (within limits the of child’s medical in regular physical activity for cardiovascular carehealth to needs allow child to their engage Encourage parents of children with special — — — following child the the guidelines: minutes of daily physical activity. Explain to Encourage child to the engage in60or more — — — least 3days a week. (eg, jumping rope, playing at basketball) bone-strengthening physical activity physical activity, children should include ofpart 60or their more minutes of daily Bone-strengthening (weight-bearing): As at least 3days aweek. physical climbing activity (eg, trees, sit-ups) dren should include muscle-strengthening more minutes of daily physical activity, chil- Muscle-strengthening: As of part 60or the 3 days aweek. vigorous-intensity physical activity at least aerobic physical activity and should include vigorous-intensity bicycling) running, (eg, intensity skateboarding) hiking, (eg, or or more aday should either be moderate- Aerobic: Most of 60or the more minutes 3 - - ■ ■ ■ ■ ■ Substance Use ■ ■ ■ ■ ■ ■ ■ ■ ■ Activity chapter.) the fluids. (See HealthyEating and Physical make sure that adequate child drinks their lescents or adults can. Encourage parents to cannotthey themselves cool as well as ado- sweattheir glands are not developed, and fully increased risk for heat-related because illness important. Before puberty, children are at organized adequate sports, fluid intake is very Tell parents that for children engage who in as suggestions for improvement. child’s fitness testing to discuss results as well Encourage parents to bring results the of their ing children when are childhood. inmiddle programs usually conduct physical fitness test - and that schoolphysicalcurricula education schools include physical education intheir Explain to parents that most elementary find settings other for physical activity. is aconcern, helphood parents and child the If safety the of environment the or neighbor tein supplements, anabolic steroids). of performance-enhancing products pro (eg, - Warn parents and child about the dangers the of alcohol, tobacco, and other drugs. Warn parents and child about the dangers the weight or to obese, reducebehaviors. sedentary Encourage ifshe child,is the over especially of quality programming aday. or games) video to no more than 1to 2hours (eg, watchingtime television, playing computer Limit child’s the total entertainment media not have atelevision child’s inthe bedroom. turn offthe television during mealtimes and sion andEncourage viewing. media to them Explain to parents about effects the - of televi 20 BRIGHT FUTURES: BRIGHT - -

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NUTRITION professionals inpromoting optimal nutrition. The desired outcomes forthe child theand role the familyof outlined in Tablecan 3 assist health Desired Role Child for the Outcomes Family of the TABLE

Understands thatpeople Understands thephysical, Understands theimportance Understands theimportance Understands that healthy Educational/Attitudinal Understands thedangersof Understands thatpeople Understands theimportance Understands theimportance Understands children’s Understands therelationship Understands physicalchanges 3. of healthybody weights and shapes,withina range come inuniquebodysizes physical activity level and howtoincrease benefits ofphysicalactivity emotional, andsocial 2 snacksasneeded of 3mealsper dayand1to of ahealthydietconsisting to increase food variety healthy foodsandhow of eatingavariety health growth, development, and physical activity are crucial to eating behaviors and regular healthy weight achieve andmaintaina and knowssafewaysto unsafe weight-lossmethods of healthybody weights and shapes,withinarange come in uniquebodysizes of familymeals snacks as needed of 3 mealsperdayand of ahealthydietconsisting healthy foodstheyeat to increasethevarietyof eating behaviorsandhow short- andlong-termhealth between nutritionand development that occurwithgrowthand

DESIRED

OUTCOME

FOR

THE Watches televisionor Engages in regular physical Uses nutrition programs and Provides opportunitiesfor Eats mealstogetherregu Engages inatleast60 Makes healthyfood Consumes avarietyof Provides avarietyof Provides a positive role programming aday 1 to2hoursofquality games nomorethan plays computerorvideo the week preferably all,daysof activity onmost,and min activity with the child food resources if needed food preparation in mealplanningand the childtoparticipate family communication nutrition andfacilitate larly toensureoptimal from home choices atandaway healthy foods and transfats those highinsaturated fat foods,especially of high-sugarandhigh- and limits the availability healthy foodsathome, body image and promotes a positive in regular physical activity, eating behaviors, engages model: practices healthy

CHILD, utes ofphysical Behavioral

AND

THE

ROLE

OF Helps thechild Provides Maintains optimal Achieves nutritional Achieves and Provides develop

and develop necessary modifies themif healthy foodsand appropriate, men weight maintain ahealthy achieve and physical activity child toengagein safe placesforthe opportunities and promote growth nutrition to related problems or othernutrition- caries (tooth decay), disorders, dental obesity, eating undernutrition, deficiency anemia, signs ofiron- being, without and physicalwell- body image weight and positive healthy body maintains a THE

tally FAMILY Health ment 16. 15. 13. 12. 10. 14. 11. 9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES

Washington, National DC: Academies Press; 2002 Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Scientific the EvaluationReference of Dietary Intakes. Reference Intakes,Dietary Standing Committee on ofLevels Nutrients and Interpretation and Uses of on Macronutrients, Subcommittees on Upper Reference Institute of Medicine, Food and Nutrition Board, Panel USDepartment ofDC: Agriculture; 2005 US Department of Agriculture. MyPyramid. Washington, Office; 2010 2010. and Human Services. US Depart Center for Education inMaternal and Health; Child 2001 in Practice: Physical Activity. Arlington, VA: National Patrick K,Spear B, Holt K,Sofka eds. BrightD, Futures United States. MMWRRecomm Rep. 1998;47(RR-3):1–29 dations to prevent and control ironthe in deficiency Centers for Control Disease and Prevention. Recommen Grove Village, IL: American Academy of Pediatrics; 2008 Kleinman RE, ed. HeartBogalusa Study. JPediatr. 2007;150(1):12–17.e2 posity among overweight children and adolescents: the Dietz WH.Cardiovascular risk factors and excess adi- Freedman DS,Mei Z,Srinivasan Berenson SR, GS, and obesity. Pediatrics. 2007;120(suppl 4):S193–S228 Styne D. Assessment of child and adolescent overweight Krebs NF, Himes JH,Jacobson D, Nicklas TA, Guilday P, summary report. treatment of child and adolescent overweight and obesity: mendations regarding prevention, the assessment, and Barlow Committee. committee SE; Expert Expert recom 1995;854:1–452 Committee.Expert World Health Organ Tech Rep Ser. and interpretation of anthropometry. of Report aWHO World Health Organization. Physical status: use the Foundation; 2006 Children. Menlo Park, J. CA:Henry Kaiser Family Advergaming and the Online Marketing of Food to Moore ES;Kaiser Family Foundation. It’s Child’s Play: Diet Assoc. 2008;108(4):673–678 in fat, or sodium, sugars, added or low innutrients. JAm ing children’s television programming are for high foods advertisements10 food shown during Saturday morn- MD,Batada A,Seitz Wootan MG, Story M.Nine out of 1998;101(3 pt 2):549–554 ity behaviors among children and adolescents. Pediatrics. Kohl HWIII,Hobbs KE.Development of physical- activ DC: US Department of Health and Human Services; 2008 Physical Activity Guidelines for Americans. Washington, US Department of Health and Human 2008 Services. cents. Arch Fam Med. 2000;9(3):235–240 dinner and dietquality among older children and adoles- Gillman MW, Rifas-Shiman SL, Frazier AL,etal. Family sity. Pediatrics. 1998;101(3):e5 WH. Early adiposity rebound and risk of the adult- obe Whitaker RC, Pepe MS,Wright JA, KD, Seidel Dietz 7th ed. Washington, DC: US Government Printing ment of Agriculture; US Department of Health Pediatrics. Pediatric Nutrition Handbook. Dietary Guidelines for Americans 2007;120(suppl 4):S164–S192 6th ed. Elk

Gidding SS,Dennison BA, Birch recom- LL,etal. Dietary Freedman B. The validity DS,Sherry of BMI as an indica - Edelstein S.Nutrition in Public Health: AHandbook for Davis MM,Gance-Cleveland B, Hassink S,Johnson Paradis R, Daniels Greer SR, FR;American Academy of Pediatrics Daniels setting. The SR. theuse Pediatrics.of BMIin clinical Casamassimo P, Holt Bright K,eds. Futures in Practice: Oral Brown JE,Isaacs J, Wooldridge N,Krinke B, Murtaugh M. Nicklas TA, Hayes D;American Dietetic Association. Position Himes JH.Challenges of accurately measuring and using Hagan JFJr, Shaw JS,Duncan Bright PM,eds. Futures: Gidding SS,Lichtenstein AH,Faith MS,etal. Implementing 20. 19. 18. 17. mendations for children and adolescents: aguidefor 2009;124(suppl 1):S23–S34 tor of fatness body and risk among children. Pediatrics. Jones and Publishers; Bartlett 2010 Developing Programs and 3rd ed. Boston, MA: Services. hood obesity. G, Resnicow K. Recommendations for prevention of child Pediatrics.lar inchildhood. health 2008;122(1):198–208 Committee on Nutrition. Lipid screening and cardiovascu- 2009;124(suppl 1):S35–S41 Healthand Oral Child 2004 Resource Center; Health—Pocket Guide. Washington, National DC: Maternal Wadsworth Publishing; 2008 Nutrition Through the Life Cycle. 3rd ed. Belmont, CA: SUGGESTED 2008;108(6):1038–1044, 1046–1047 for healthy children ages 2to 11years. JAm Diet Assoc. of American the Dietetic Association: nutrition guidance 2009;124(suppl 1):S3–S22 BMI and other indicators of obesity inchildren. Pediatrics. Academy of Pediatrics; 2007 and Adolescents. 3rd Grove ed. Elk Village, IL:American Guidelines for Health Supervision of Infants, Children, Pressure Research. Circulation. 2009;119(8):1161–1175 Epidemiology and Prevention, and for Council High Blood onCouncil Cardiovascular Nursing, on Council Arteriosclerosis, Thrombosis and Biology,Vascular on CardiovascularYoung, inthe Disease on Council on Nutrition, Physical Activity and Metabolism, Council Heart Association Nutrition Committee of Council the tion guidelines: ascientific statementfrom the American American Heart Association and pediatric adult nutri- Heart Association. Circulation. 2005;112(13):2061–2075 practitioners—consensus statement from American the

Pediatrics. 2001;107(2):423–426 Education. Children, adolescents and television. American Academy of Pediatrics Committee on Public Company; 2009 Dental Therapeutics. American Dental Association. ADA/PDR Guide to 2008;122(5):1142–1152 in infants, children, and adolescents. Pediatrics. Prevention of rickets and vitamin D on BreastfeedingSection and Committee on Nutrition. Wagner CL,Greer FR;American Academy of Pediatrics Center. kidsnutrition.org Research Service’s Children’s Nutrition Research Baylor of College Medicine; USDA, Agricultural Pediatrics.

READING 5th ed. Chicago,5th IL: ADA Publishing 2007;120(suppl 4):S229–S253 deficienc y BRIGHT FUTURES: BRIGHT -

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NUTRITION Stang J, TaftBayerl C,Flatt MM; American Dietetic Spear BA, BarlowC,etal. Recommendations SE, Ervin for overweight and relationship the K.Childhood Rhee between Diet Assoc. 2010;110(5):791–799 child and adolescent and food nutrition programs. J Am Association. Position of Americanthe Dietetic Association: Pediatrics. 2007;120(suppl 4):S254–S288 treatment of child and adolescent overweight and obesity. Ann Am Acad Pol 2008;615(1):11–37 Sci. Soc parent behaviors, parenting style, and family functioning. US Department of Health and Human Office of Services, General; 2010 General; of Health and Human Office the Surgeon of Services, Healthy and Fit Nation 2010. Surgeonthe The General. SurgeonGeneral’s Vision for a Washington, Department DC: in the schoollunchin the program at eats breakfast at home and participates snack at 3:00pm. Melanie didn’t to seem 9:30 am, lunch at 11:30am, and another ing breakfast at home, asnack at ity. At she time the was eat- week at achild care- facil and spent 3afternoons a ing kindergarten class attended amorn- yearLast Melanie cranky. hungry, tired, and 3:30 pm, she is school at around gets home from Melanie time the afternoon.in the By larly snack scheduled notdoes have aregu- at 11:00am.school The she eats day lunch every her elemen M has just first started grade. She elanie Walker is a6-year-old who tary school, where tary The Importance of Healthy Snacks result, the school authorizes a concerns with theconcerns teacher and the principal. As a regular afternoon snack for children who eat Walker share their Mr and Mrs lunch early. i i of afternoon the as she is now. as hungry,be tired, or cranky at end the children eat who lunch early. Melanie’s parents with anutri talk - rizes aregularrizes afternoon snack for tionist suggests who that they As aresult, schoolautho the - meet withmeet teacher the and snacks inchildren’s diets. the principalthe to discuss importance of healthy adding an afternoon information on the snack. Mr and Mrs nutritionist shares Walker and par the meeting, andmeeting, the ents of other chil- ing an after-school dren inMelanie’s the principalthe dur the teacherthe and concerns with class share their

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NUTRITION Frequently Asked Questions ■ ■ ■ ■ ■ ■ so busy? meals togetherwhenweare How canourfamilyeathealthy ■ ■ ■ ■ ■ ■ ■ eat healthyfoods? How canIencouragemychildto Childhood About Nutrition in Middle ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ a week. (breakfast,4 meals lunch, or dinner) together Try to prioritize family and meals, strive to eat vision off, and don’t answerthe telephone. Avoidto socialize. distractions. Turn tele the When your family eats together, time the use or healthy take-out from foods arestaurant. Buy healthy, ready-to-eat from foods store the sandwiches). Make simple soups, salads, (eg, meals dinner next. the eat breakfast together one day and lunch or Eat different together.meals For example, able family activity. Make preparation food and cooking an enjoy- Plant agarden. and trans fats. sugarhigh in and fat, saturated especially andcookies) beverages soft (eg, drinks) Limit availability the of candy, (eg, foods Keep avarietyof healthy house. inthe foods Avoid of using as part food areward system. not prepare separate for foods him. Don’t fight with over yourfood child, and do eating behaviors yourself. apositive roleBe healthy model—practice Shop for and foods together. cook and foods new regional and foods. ethnic Serve ■ ■ ■ eat breakfast? How canIgetmychildto ■ ■ ■ ■ ■ ■ ■ ■ ■ more fruitsandvegetables? How canIgetmychildtoeat ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ time totime eat morning. inthe Help your child get organized that so she has overs such as chicken or pasta). sandwiches, (eg, foods potatoes, baked left- other foods than usualbreakfast the Serve juicefruit [limit to day], 6–8oz per yogurt). (eg, bagels, low-fat granola bars, 100% fruit, Provide that foods are fast and convenient vegetables yourself. role agood model—eatBe more and fruits Plant agarden. to eat them. andmeals snacks, but don’t force your child Offer avariety fruits of and vegetables at to eat at school. Pack and fruits vegetables inyour child’s bag and casseroles. Use plenty of vegetables insoups, sauces, with achoice of low-fat dressing. ing at least one asalad your child likes. Serve 2or moreServe vegetables with dinner, includ- andthe fruits vegetables easily. seen can be fat dip Use or salsa. aclear container that so keep refrigerator inthe them along with low- Wash and cut up and fruits vegetables, and youwhen know your hungry. teenager be will Put cut-up and fruits vegetables on counter the Keep avarietyof and fruits vegetables at home. ifyourSee schooloffers a breakfast program. oras fruit mixto trail eat at school. If your child is inahurry, offer suchher foods Make breakfast night the before. ■ ■ ■ ■ ■ Should Ibeconcerned? My childhasbecomeavegetarian. ■ ■ ■ ■ enough calcium? How canIhelpmychildget ■ ■ ■ ■ ■ ■ ■ ■ ■ you plan healthy meals. Ask aregistered dietitian or nutritionist to help ian for meals whole the family. formeals your child, occasionally fix vegetar Instead of always preparing separate vegetarian provided by fortified and foods supplements. cium, vitamin B oreggs, fish. They additionalneed maycal- any animal products, including foods, dairy Vegans are vegetarians strict don’t who eat iron supplement. ents; however, your child may to an need take anducts usually provides eggs adequate nutri- A vegetarian dietthat includes prod milk - nutritional needs. healthycan be and can children’s meet With careful planning, avegetarian diet calcium supplement. professional about giving your child a If donot ideas these work, ask ahealth — — — — — intolerant), suggestions. these try and products milk milk dle (ie, he is lactose If your child’s digestive system cannot han- soups, casseroles). recipes inpuddings, (eg, milkshakes, Use low-fat or fat-free products milk in collard and turnip greens. processed with calcium sulfate, broccoli, and cheese, cottage milk, (eg, cheese, tofu yogurt), low-fat (1%)or fat-free products (skim)milk that foods are richincalcium,Serve such as — — — — — added calcium (calcium-fortified).added day)6–8 oz per and cereal products, with such foods, as 100%juice (limit toServe eats milk products containing lactose. Give tablets your before child lactase she your child’s milk. are low Add inlactose. drops lactose to cheddar,(eg, Colby, Swiss, Parmesan) that anding milk and yogurt, aged hard cheeses products, milk includ lactose-free - Serve products. along foods with these non-milk Serve throughout day. the portions small of foods these Serve 12 , and vitamin D, can which be - ■ ■ ■ ■ ■ from home? make healthyfoodchoicesaway How canIteachmychildto ■ ■ ■ ■ ■ ■ candy. WhatshouldIdo? My childsnacksonchipsand ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ “hold mayonnaise.” the healthier,foods to such as asking server the Teach your child to ask for changes to make ting an order of with frenchafriend). fries or by size(eg, foods to split reduce serving the - Encourage your child to avoid eating fried or meats. baked dressing,calorie vegetables, fruits, and broiled Encourage your child to eat with low- salads in fat, sugar, and calories. appropriate portions. that Find foods are low child, and healthy discuss choices food and schooland restaurantReview menus with your and restaurants, and from vending machines. choices purchasing when at food school, stores, Encourage your child to make healthy food and restaurants, and from vending machines. choices purchasing when at food school, stores, Encourage your child to make healthy food Keep abowlof on fruit table the or counter. opens the fridge. arethey when firsthe the sees thingthe child Keepor salsa. at them your child’s eyelevel so ily) refrigerator, inthe along with low-fat dip in a clear container- eas seen can be they (so Wash and cut up vegetables, and keep them day], applesauce, fruit, vegetables, yogurt). products, juice 100%fruit [limit to 6–8oz per whole-grain (eg, low-fat foods healthier Serve onfoods hand. Keep avarietyof easy-to-prepare and healthy soft drinks). drinks, fruit (eg, sugar, such as candy and sweetened beverages such as potato chips that are and in high fried, Limit inyour foods home that are infat, high BRIGHT FUTURES: BRIGHT

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NUTRITION more active? How canIhelpmychildbe ■ ■ ■ ■ ■ ■ is overweight? What shouldIdoifmychild ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 6 oz per day).6 oz per water,milk, and juice 100%fruit (limited to Limit most beverages to low-fat or fat-free soft drinks). drinks, (eg, fruit such as candy and sweetened beverages potato chips, and that foods are insugar, high Limit that foods are infat, high such as fried buttimes, allow for flexibility. healthy and meals snacksServe at scheduled eating and physical activity behaviors. Focus on gradually changing entire the family’s for reasons it. medical and supervises professionalunless ahealth recommends one Never place your child on weight, adietto lose child’s BMI. professional, and request an evaluation of your bring to this attention the of your child’s health If you are concerned about your child’s weight, physical activity yourself. role agood model—engageBe inregular ahike,(eg, abike eachweek. ride) Plan at least physical one special activity family members and can dotogether. friends Take physical turns selecting that activities withspend time your child. dancing,ing ball, skating). It’s agreat way to physicallyBe active together, biking, (eg, play- dancing). arts, swimming, martial (eg, Enroll your child inplanned physical activities a bike instead of riding inacar. antaking elevator or escalator, and or walk ride daily life. For example, stairs the use instead of Make physical of activity apart your child’s leaves, dog). the walking Involve your child infamily chores raking (eg, activity break. encourage her to a10-minute take physical vision, or plays computer or games, video For hour your every child reads, watches tele- there, remove it. vision inyour child’s bedroom; ifone is already of quality programming aday. Don’t put atele- or games) video to no more than 1to 2hours watching (eg, time television, playing computer Limit your child’s total entertainment media dancingactivity (eg, to music). Encourage spur-of-the-moment physical ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ her body? How canIhelpmychildlike ■ ■ ■ ■ child gainweight? How canIhelpmyunderweight ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ family members. weight or allow teasing about weight by other notDo make negative comments about their grounds, parks). andactive walking (eg, biking paths, play- your child has safe places for physically being Work with your community to make sure that of moderate to vigorous activity eachday. ity yourself. at Children need least 60minutes behaviors and engage inregular physical- activ role agood healthy model—practice Be eating computer or games. video yourtime child watches television and plays Limit to 1to 2hours day per amount the of biking,(eg, hiking, swimming). Plan family that activities enjoys everyone appropriate portions. and healthy discuss choices food and atLook schoolmenus with your child, in moderation. notDo forbid them sweets andServe desserts. low-fatServe or fat-free products. milk size or shape or that of others. role agood model—don’tBe criticize your own image.his body Talk to your child about how affects media the to yourtalking child. Focus on traits other than appearance when not criticize your child about his sizeor shape. Children are sensitive about how Do look. they have offeredtimes. been several more likely to after accept foods they these has refused to eat before. them Your child is Continue to offereven if yourfoods child food preparation. Involve your planning child inmeal and ifsnackingtimes is affecting his appetite. school, ifpossible. Limit snacks- to close meal age your child to eat amidmorning snack at an after-schoolServe snack, and encour being affected. ifhis appetite meals between drinks is Limit quantity the of beverages your child - ■ ■ ■ ■ ■ ■ ■ ■ BULIMIA NERVOSA ■ ■ ■ ■ ■ ■ ■ ANOREXIA NERVOSA about yourconcerns. talk toahealthprofessional If you notice any of these symptoms, ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ (eg, to(eg, induce vomiting) Disappearance into bathroom for long periods Vomiting or laxative use Binge-eating with no noticeable weight gain Binge-eating Depression Obsession with exercise Eating insecret ment of unusual eating rituals Unusual interest and foods incertain develop - Depression Obsession with exercise Eating insecret development of unusual eating rituals Unusual interest and foods, incertain is fatbody eventhough extremely thin Dissatisfaction with appearance; that belief Continuation of dieting although thin Excessive weight loss inashort period US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture. MyPyramid for Kids. http:// Satter E. Your Child’s Weight: Helping Without Harming: Birth Nemours Foundation. KidsHealth. http://www.KidsHealth.org National Institutes of Health, National Heart Lung, and Blood Nader Zive MM.You PR, Can LoseYour Baby Fat: New Rules Ludwig D, S.Ending Rostler the Food Fight: Guide Your Child International Food Information Council. Kidnetic. http:// Centers for Control Disease and Prevention. Eat aVariety Centers for Control Disease and Prevention. Division of Team Nutrition. http://www.fns.usda.gov/tn id=6322&level4_id=0 level=3&tax_subject=261&topic_id=1941&level3_ usda.gov/nal_display/index.php?info_center=15&tax_ Loving Your Family, Feeding Their Future. http://snap.nal. http://healthymeals.nal.usda.gov/hsmrs/EY Empowering Youth with Nutrition and Physical Activity. Resources/eatsmartmaterials.html Eat Smart. Play Hard. http://teamnutrition.usda.gov/ www.mypyramid.gov/kids Through Adolescence. Madison, WI:Kelcy Press; 2005 NY: North Point Press; 2006 Guide Eating. toFood Choices New Savvy and York, Good obesity/wecNestle M.What to Eat: An Aisle-by-Aisle Nutrition. http://www.nhlbi.nih.gov/health/public/heart/ Institute. We Can! Ways to Enhance Children’s Activity & Society. San Diego, CA:PhilNader Publications; 2008 Others Who Care About Children and the Future of Our to Protect Kids from Obesity—For Parents, Providers, and York, NY: Houghton Mifflin Company; 2007 to aHealthy Weight in aFast Food/Fake Food World. New www.kidnetic.com fruitsandveggiesmatter.gov of Fruits &Vegetables Every Day. http://www. gov/nccdphp/dnpa Nutrition, Physical Activity and Obesity. http://www.cdc. RESOURCES

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FUTURES 93 NUTRITION

BRIGHT FUTURES: Adolescence

ual maturation,ual slow or stop linear growth, and compromise bone mass. Practicing peak ments and influencegrowth composition.body and Inadequate nutritioncan delaysex Nutrition and physical activity are major determinants of adolescents’ require energy cle mass during adolescence. middle than females,major their and typically experience they growth spurt and increase inmus arche. (The mean age of menarche is age about 12.5.) begin puberty 2 Males yearslater For3–4 inmales). females, most physical growth is completed by about 2years after men of growth maturity period ring (sexual during peak the rating [SMR] 2–3infemales and etal mass.etal gain about 50%of adult their weight, body and accumulate up to 40%of adult their skel adolescents period, achievecycle. 15% this final During the to 20% their adultof height, ents. Total nutrition are needs greater during adolescence than at any other life inthe time duringoccurs first the year of life body’sand increasesthe demand for and energy nutri The phenomenalgrowth that occurs duringsecond adolescence is onlygrowth the to that healthy eating behaviors and physically be active. as aframework forserve providing adolescents with information the to need practice they understanding adolescents’ eating behaviors and image body issues. The stages can also important and personal vocational decisions. These stages provide context a useful for andpendence experimentation. late During adolescence, ages 18to 21,adolescents make andtal cognitive changes. Middle adolescence, ages 15to 17,is of atime increased inde Adolescence is into divided 3stages. Early adolescence, ages 11to 14,includes puber ■ ■ ■ healthy eating behaviors during adolescence is essential for Rapid physical growth creates an increased demand for and energy nutrients. Practicing nutrition status. acceptance, and active lifestyles, can significantly their affect behaviors,eating weight, and cents’ growing independence, search for identity, concern with appearance, for need peer physical, cognitive, and emotional social, changes. These changes,along with adoles most of dynamic human periods development. Adolescence is characterized by dramatic Adolescence (ages transition 11–21),the and adulthood, childhood is one between of the ■ ■ ■ CONTEXT GROWTH cancer, osteoporosis) cardiovascular 2diabetes(eg, mellitus, type disease, hypertension, some forms of Laying foundation the for lifelong and health reducing risk for the chronic diseases obesity, eating disorders, dental caries[tooth decay]) Preventing immediate problems health iron-deficiency (eg, anemia, undernutrition, Promoting optimal growth, development, weight, and health 1 Nutrient rate the parallel needs of growth, with greatest the demands occur

AND Adolescence

PHYSICAL

DEVELOPMENT - - -

- - - - - BRIGHT FUTURES: BRIGHT - -

NUTRITION 95

Bright FUTURES Adolescence Adolescence BRIGHT FUTURES: BRIGHT 96 Bright FUTURES

NUTRITION middle adolescence, they become adolescence, moremiddle they capa- crete and oriented toward present. the During thought, but tends still con to thinking their be - adolescents have agrowing capacity for abstract during adolescence. early During adolescence, The changes canassociated with affect puberty thereby reducing risk for their obesity. weightnormal body and composition, body lar physical activity can help adolescents achieve healthy eating behaviors and engaging inregu- lish indivi meanings, can foods havelescence. Because symbolic independent young adult are central to ado- Developing an identity and becoming an behavior and understand its consequences. adolescents are to beginning reflect their on eating and regular physical activity, because during adolescenceoccur can facilitate healthy and solve problems. The cognitive changesthat continue to refinetheir ability to reason logically oriented late During thinking. adolescence, they ble of problem-solving and abstract and future- Cognitive capacities increase dramatically ory, test and grades, schoolattendance. may improve cognitive related function to mem- school performance. Conversely, eating breakfast ment, affects which learning, concentration, and Undernutrition compromises cognitive develop- and apositive image. body healthy eating behaviors, regular physical activity, a key opportunity toimportance the discuss of presents period this professionals health with interested own intheir growth and development, a ated and with puberty help adolescents develop lescents and parents their for changes- associ Anticipatory guidance can help prepare ado- weight concerns and dieting. may which isfaction with bodies, their result in maturation among females may to lead dissat- improve image. body their However, physical ment that come with physical maturation For increased the males, size and muscle develop- adolescents’ satisfaction with their positive image. adolescents body Because are DEVELOPMENT duality and express identities. their adoles cents may to them estab use

ISSUES ap pearance. 2 us

ually ually - away from home. to help adolescents make healthy choices food professionalshealth can provide guidance behaviors themselves. In addition, parents and positive role models by practicing healthy eating consumption should limited. be Parents can be fat, incalories, high can be and sugar, and their with own their money. Snacks and fast foods Many adolescents go to stores and fast-food sweetened beverages and snacks. salty ity of low-nutrient high-calorie, such foods, as bles, are available at home and limit availabil the - sure that healthy such foods, and as fruits vegeta- are they when away from home, can make they parents cannot control what adolescents their eat andmeals snacks away from home. Although more away time from home and thus eat more strive for to spend begin independence, they as aform of group identification. As adolescents mity are important. may They eat certain foods influence andfriends, peer groupand confor Adolescents spendalot of with time their Children and Adolescents.) for Fostering aPositive Image Body Among iors image. Tool and body a poor (See I:Tips of obesity canto lead unhealthy eating behav- pressuresocial The thin be the and to stigma andfoods cooking skills. learn and includingfoods, from those differentcultures ment. Adolescents are usually interested innew lifestyles or to show concern for environ the - behaviors vegetarianism) (eg, to explore various risks. Adolescents may adopt eating certain diets and underestimate associated the health ing adolescence. middle Adolescents fad may try Experimentation and are idealism common dur ing benefits health than any one component of physical activity is more important for- achiev ening It activities. appears that total the amount bic, muscle-strengthening, and bone-strength- aerobic activity as well as age-appropriate aero- minutes or more eachday. This should include efits by doing physical activity for a total of 60 Adolescents can achieve substantial- ben health restaurants on own their and purchase foods HEALTHY ethnic groups. This can be a time to try new groups. ethnic new time Thiscanbeatry to

LIFESTYLES -

- cents. Nutrition education should integrated be ing healthy eating behaviors among adoles- canSchools play asignificant role in promot- activity programs. to developinggral nutrition and physical fessionals, families, and communities are inte- weight status. Partnerships among pro health - activity promotecal adolescents’ nutrition and Healthy eating behaviors and regular physi- offered.be day, and avarietyof enjoyable should activities education at schoolshould provided be every activity maycal influenced be peers. Physicalby group settings, adolescents’ engagement inphysi- muchBecause of physical their in activity occurs ficantly increase. active, adolescents’ physical activity levels signi parents encourage adolescents physically to be importance of regular physical activity. When with adolescent, their parents emphasize the activebiking, (eg, playingcally hiking, baseball) for engaging inphysical activity. By physi being - increase,skills giving more them opportunities As adolescents grow and develop, motor their ■ ■ ■ ■ Adolescents are who physically active obtained by end the of adolescence. puberty. In addition, bone mass most is peak during years the occur just before and during lescents greatest the because gains inbone mass remainactivities important especially for ado- ing, or bone strengthening). Bone-strengthening mix of (aerobic, activities muscle-strengthen- (frequency, intensity, or duration) or specific the ■ ■ ■ ■ BUILDING and depression May have reduced symptoms of anxiety Have stronger bones Typically have fat less body fitness and stronger muscles Have levels higher of cardiorespiratory

PARTNERSHIPS 4 3 ■ ■ include following: the Common nutrition concerns during adolescence providealso food. nity groups, and faith-basedorganizations can Programs.) Food shelves and pantries, commu - ments. Tool (See K:Federal Nutrition Assistance substantial of part daily their nutrition require- programsmeal help provide adolescents with a ing) should healthy. be Federally school funded ing machines, at events, sports for fundrais- healthy Foods at sold foods. invend school(eg, - what is taught classroom inthe by providing program for adolescents. can Schools reinforce within acomprehensive education schoolhealth tests, or both. including anutritional assessment, laboratory nutrition,poor assessment further is needed, there that is evidence an adolescent is at risk for Nutrition Risk for Children and Adolescents. If nutrition status, Tool see D:Key Indicators of For alist of risk factors that canto lead poor ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ages, especially soft drinks softages,and drinks sports especially Increase inconsumption of sweetened bever productsmilk inconsumptionDecrease of and milk other COMMON families with low incomes amongFood insecurity adolescents from Prevalence of hyperlipidemia females) Prevalence of iron-deficiency anemia (in dieting, and unsafe weight-loss methods Increase in eating disorders, body image Low levels of physical activity inoverweightRise and obesity trans fats, cholesterol, and sodium infat, saturated high foods especially and Higher consumption than recommended of Insufficient fruitsintake of and vegetables

NUTRITION

CONCERNS co ncerns, BRIGHT FUTURES: BRIGHT -

NUTRITION 97

Bright FUTURES Adolescence Adolescence BRIGHT FUTURES: BRIGHT 98 Bright FUTURES

NUTRITION Nutrition Supervision ■ ■ ■ ■ FOR THEADOLESCENT Eating Behaviors and Food Choices Interview Questions nutrition concerns. starting pointful for identifying an adolescent’s ter.) Asking questions interview provides- ause Cultural Awareness inNutrition chap- Services within and among cultural groups. the (See and variationfood wide the practices infood varietyofthe cultural traditions related to lations, professionals health to need providing nutrition to diverse supervision popu 11 to 21.)Additionally, to challenge the meet of C: Nutrition Questionnaire for Adolescents Ages and/or adolescent the before Tool visit. the (See by aquestionnaire reviewing out filled parentsby Gathering information accomplished be can also professional’s health the communication style. to family. Questions to match modified can be tions may from visit vary to visit and from family cussion and build partnerships. Use of ques the - adolescent’sthe nutrition status, to invite dis - by selectively questions asking interview about Health professionals nutrition begin supervision visit to visit and from adolescent to adolescent. as appropriateshould used be from andvary will assessment, and providing anticipatory guidance, questions,interview conducting screening and nutrition includes which supervision, asking chapter.)in this It is important to remember that ThirdEdition, listed under SuggestedReading Supervision of Infants, Children, and Adolescents, Brightvision, see Futures: Guidelines for Health visits. (For more information on super health vision visits or of as part supervision health should evaluated be during nutrition super An adolescent’s nutrition and weight status ■ ■ ■ ■ What snacks doyou usually eat? In meals? evening? the Between morning? Around noon? In afternoon? the What doyou usually eat and inthe drink How often does your family eat meals together? do you eat breakfast? Lunch? Dinner? How many snacks? How many aweek times Which doyou meals usually eat eachday? ap preciate - - - ■ ■ FOR THEPARENT ■ ■ ■ ■ ■ ■ FOR THEPARENT ■ ■ ■ ■ ■ ■ FOR THEADOLESCENT Weight and Body Image ■ ■ FOR THEADOLESCENTORPARENT Food Resources ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Do youDo have any concerns about your together? How often your does familyeat meals way you eat? What changes would you like to make inthe or drinks? drinks, sports How often dosoft energy drinks, you drink did you eat or yesterday? drink What and fruits vegetables, including juices, What products other milk doyou like to eat? [2%], low-fat [1%],fat-free milk [skimmilk])? reduced doyou whole (eg, milk, milk fat drink How often do you milk? What drink kind of ones?which Are there any you foods won’t eat? If there are, and height? How doyou feel about your teenager’s weight Are you about teased your weight? How much would you like to weigh? Are you trying to change your weight? If so, how? How doyou feel about your weight and height? much?too Are just right the weight? Why? youDo that think you little? weigh too Weigh How doyou feel about way the you look? to eat or not enough money to buy food? Are there there when times is not enough food Who prepares it? Who usually buys for food the your family? Why or why not? youDo your think teenager eats healthy foods? teenager’s eating behaviors? ■ ■ Growth and Physical Development Screening andAssessment ■ ■ ■ FOR THEPARENT ■ ■ ■ ■ ■ FOR THEADOLESCENT Physical Activity ■ ■ Sources: World HealthOrganization, Obesity Overweight Healthy weight Underweight Stunting Indicator ■ ■ ■ ■ ■ ■ ■ ■ cumulative nutrition or problems. health Low height-for-age may reflect long-term, cators of nutrition status and overall health. term nutrient intake as general indi - and serve Changes inweight reflect an adolescent’s short- to indicateused nutrition and growth status. Height and weight measurements can be difficulties (eg, with eating). normal or may indicate anutrition problem chart)the should evaluated. be This maybe amajor(eg, change ingrowth percentiles on growthDeviation from pattern expected the and plot on these astandard growth chart. Measure adolescent’s the height and weight, bedroom? yourDoes teenager have atelevision inhis games?video day watching television or playing computer or How much your does time teenager spendeach ager engage in? How often? What of type physical your activity does teen - What do you think you can do to be more active? games?video watching television and playing computer or How much doyou time spendeachday make for time it? that you are not doing now? How can you What physical activity would you like to do a week? How much doyou time active spendbeing in How often? What do you do to be physically active? TABLE

1. BMI-for-age BMI-for-age BMI-for-age BMI-for-age Height-for-age Anthropometric Variable

INDICATORS 5 Barlowetal, 6 andKrebsetal.

HEIGHT index serves only as ascreeningindex tool serves and should depth assessment mass may Body needed. be is outside healthy the weight range, amore inheight and weight status. When an adolescent Table 1provides of an indicators overview of ■ ■ ■ ■ ■ ■ Stunting as a not used be ■ ■ ■ ■ ■ ■ excess fat body inadolescents. Prevention growth [CDC] charts) can confirm centile on Centers for Control Disease and lipidemia. Hyperlipidemia the (See chapter.) Assess adolescent’s the risk for hyper familial Hypertensionthe chapter.) Obtain adolescent’s the pressure. blood (See skin, hair, gums, teeth, tongue, and eyes. Evaluate appearance the of adolescent’s the An physical activity, muscularity, or frame size. of a large, mass lean body resulting from Some adolescents have BMIbecause ahigh dividing weight by square the of height (kg/m adolescent’s the Calculate health. all BMIby tool to determine nutrition status and over mass as indexascreening (BMI)is used Body improved nutrition or treatment of other growth is stunted and may who from benefit The is adolescentsto identify goal whose inadequate intake energy or chronic illnesses. reported inadolescentsbeen with severely growth their because is stunted. Stunting has for-age are short as aresult of as aresult of nutrition poor or health. poor reflects afailure to reach optimum height third percentile should evaluated. be Stunting Adolescents height-for-age whose is below the However, most adolescents with low height- adolescent’s BMIpercentile. a BMI-for-age growth chart to determine the pret BMI,plot adolescent’s the BMIand age on or using or aBMIwheel calculator. To inter 7

AND elevated skinfold (ie, above per 95th the

WEIGHT dia ≥95th percentile ≥85th–94th percentiles ≥5th–84th percentiles <5th percentile <3rd percentile Cut-Off Values gnostic tool.gnostic

STATUS gen etics, notetics, BRIGHT FUTURES: BRIGHT - 5 - -

- 2 )

NUTRITION 99

Bright FUTURES Adolescence Adolescence BRIGHT FUTURES: BRIGHT 100 Bright FUTURES

NUTRITION Obesity Iron-Deficiency Anemia Underweight ■ ■ ■ Overweight ■ ■ ■ ■ ■ Obesity chapter.) Survey data. Survey National Health and Nutrition Examination on percentile 99th the cutpoints based from cents. committee The expert suggested using sus on adefinition severeof obesity inadoles- excessive weight. However, there is no consen- highest risk for comorbidities associated with with a BMIabove percentile 99th the are at urgent. chapter.) Obesity the (See normal range, and therefore intervention is compared with adolescents with BMIs inthe levelthis are at risk for higher comorbidities cise, but adolescents with aBMIat or above hormone or thyroid deficiency. outnologist to rule may growth necessary be potential to achieve. Areferral to- an endocri lescents reach height the that have they the ventions should implemented be to help ado- of factors these should and assessed, be inter sorption syndrome, or other conditions. All problems, an altered metabolic rate, malab- ofbecause agenetic disorder, chronic eating carehealth may needs have low height-for-age underlying problems. Adolescents with special the Iron-Deficiencythe Anemia chapter.) Academy of Pediatrics (See (AAP)and CDC. screening have put been forth by American the Recommendations for iron-deficiency anemia assessment.in-depth medical percentile are considered and an obese need Adolescents with aBMIat or above 95th the weight screening. and further need and percentiles 94th are considered over Adolescents 85th the with aBMIbetween deficit, or a chronic disease. resources, restrictive dieting,anutritional inadequate intake, energy inadequate food naturally, or may as aresult they thin be of and eating disorders. Adolescents may thin be centile for should assessed be organic Adolescents per with aBMIbelow fifth the 8 These cutpoints These maybe impre - 7 Adolescents 6 (See the the (See dis - ease ease - - ■ ■ FOR ADOLESCENTMALESAGES12TO18 ■ ■ FOR ADOLESCENTFEMALESAGES12TO21 ■ ■ ■ Physical Activity ■ ■ Oral Health ■ ■ ■ ■ ■ ■ ■ ■ ■ dental visits. special health care previousspecial health needs, diagnosis lowanemia (eg, deficiency iron intake, withmales known risk factors for iron- recommendsThe CDC screening routine physical examination. during growth duringmales period peak their The AAP recommendsscreening adolescent during routine physical examinations. recommends 5to 10years screening every For with no known those risk factors, CDC the previous diagnosis of iron-deficiency anemia). or loss, other lowstrual blood iron intake, a for iron-deficiency extensiveanemia (eg, men- adolescent females with known risk factors recommendsThe CDC annuallyscreening females during all routine physical examinations. The AAP recommends screening during mealtimes. Ask adolescent the whether watches television suchactivities, as computer or games. video spends watching television and on other media forScreen amount the of adolescent the time ratory tests. including anutritional assessment and/or- labo of nutrition assessment risk, further is needed, Children and Adolescents. If there is evidence Toolsee D:Key Indicators of Nutrition Risk for with of an nutrition, increased likelihood poor For physical activity characteristics associated — — fitness by Assess adolescent’s the level of physical Health Oral the (tooth decay). chapter.) (See determine adolescent’s the risk for dental caries suming and foods insugar) beverages high to Assess eating behaviors of frequency (eg, con- Ask adolescent the whether has regular of iron-deficiency anemia). — — standardized physical fitness assessment) how well adolescent the didon school’s the fitness compareswith national standards (eg, Evaluating how adolescent’s the physical adolescent engages inon aweekly basis Asking how much physical activity the 10 9 ad adoles olescent 10

cent 9 Growth and Physical Development Eating Behaviors.) for Health Professionals to Promote Healthy Nutrition Counseling, and Tool G:Strategies Tooltion, see F: Stages of Change—A Model for attitude about eating behaviors, choices, food developmental and promote period; apositive what as adolescent the to enters expect next the tus; make adolescent the and parents aware of information on adolescent’s the nutrition- sta In addition, professionals health should offer ■ FOR EARLY ADOLESCENCE:AGES11 TO 14 ■ ■ and adolescent’s and parents’ nutrition concerns. Anticipatory guidance should address the Anticipatory Guidance ■ ■ ■ 20%–25% at end the of puberty). 15%–18% of weight body before to puberty buttocks is normal during adolescence (from that fat accumulation hips, inthe and thighs, faction with appearance. their Reassure them growth and development may to lead dissatis- thatDiscuss adolescent females’ physical weight, and growth rates among adolescents). large the bodies; in their variation inheight, widening of females’ hips and fat accumulation physicalmal changes weight (eg, changes; the Help adolescents understand and accept nor Children and Adolescents.) for Fostering aPositive Image Body Among and watching Tool portionsizes.(See I:Tips Explain importance the ofbalance energy being softand(eg, drinks), physically active. iors, limiting intake of insugar beverages high achieved by practicing healthy eating behav- defined weight. A healthy body weight canbe size and shape rather than on an socially ideal, weight on isagenetically determined based cific concerns. Emphasizethat a healthy body upcomingDiscuss physical changes and- spe comparethey to other adolescents age. their cents and parents, their and show how them Explain standard the growth chart to adoles- physical activity. (For additional informa 1

- - Eating Behaviors and Food Choices ■ FOR LATE ADOLESCENCE:AGES18TO 21 ■ FOR MIDDLEADOLESCENCE:AGES15TO17 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Physical Activity chapter.) lescents their age. Discuss any specific concerns. and show them how they compare to other ado Explain the standard growth chart to adolescents, velocity by age and SMR concerns. their to ease arethey normal. Use charts that plot height Reassure late-maturing adolescent that males during upcoming the growth spurt. gain is normal andprobably will level off adolescent and males parents their that fat 15% to weight. 18% of body their Reassure centage increases, and by age 18,it is about (SMR 3–4).After puberty, fatbody theirper centage during decreases growth their spurt ages 9and 13.In addition, fat body their per (ie, increase inheight), between occurs which a slight weight gain before growth their spurt thatDiscuss adolescent may males experience ment of 400IU/day. [yolk])eggs should receive avitamin Dsupple- vitamin cereals, (eg, D–fortified fortified foods and serving) per 8-oz (100 IU fortified milk 400 IU/day of vitamin Dthrough vitamin D– D deficiency, adolescentswho do not obtain Tell parents that to prevent rickets and vitamin later inlife. helps prevent osteoporosis and bone fractures and cheese, to attain maximum bone density provide enough calcium, such yogurt, as milk, young 20s).Eating (the adulthood that foods bone because needs, density increases well into day per cheese) yogurt, to calcium their meet equivalentthe from products other milk (eg, fat (1%)or fat-free or (skim)milk consume Encourage adolescents 3cups to of drink low- level, and composition body (Table 2). influenced growthby status, physical activity increase greatly during adolescence and are Explain that requirements (calorie) energy on Dietary the based Guidelines for Americans ping Encourage meals. healthy choices food achieve and them, importance the of not skip- healthyDiscuss eating behaviors, ways to and MyPyramid. 12 (See the Healthy the (See Eating and 13 1 BRIGHT FUTURES: BRIGHT - - - 11

NUTRITION 101

Bright FUTURES Adolescence Adolescence BRIGHT FUTURES: BRIGHT 102 Bright FUTURES

NUTRITION ■ ■ Oral Health ■ ■ ■ ■ Male Gender c b a Female ■ ■ ■ ■ ■ ■ Active meansalifestylethatincludesphysicalactivityequivalenttowalkingmorethan3milesperdayat4 Sedentary meansalifestylethatincludesonlythelightphysicalactivityassociatedwithtypicalday-to-daylife. Moderately activemeansalifestylethatincludesphysicalactivityequivalenttowalkingabout1.53milesperday (after breakfast beforeand bed). with fluoridatedteeth toothpasteday a twice Encourage adolescent the to brush his or her in sugar juice, (eg, soft juice drinks). drinks, thirsty and to limit intake of beverages high Encourage adolescent the water to drink when a healthy weight. body safe and healthy ways to achieve and maintain unhealthyuse weight-loss practices.Discuss cent females are more also likely to diet and mature who those later. adoles- Overweight more likely to dietshortly afterthan puberty onset of puberty. Early-maturing females are Many adolescent to dietafter females begin the at home and eating when away from home. Encourage adolescents healthy to choose foods in sugar. high soft drinks) candy, and cookies) drinks, beverages fruit (eg, fats chips, (eg, and french (eg, foods fries) insaturated high fat, those especially and trans Encourage adolescents to in limit high foods promote communication. nity to healthy model eating behaviors and to togethermeals provides parents an opportu- family mealtimes apriority. Eating of low-nutrient high-calorie, and foods; make healthy at foods home; limit availability the Encourage parents to provide avarietyof pendent and make own their choices. food adolescents because lescence are more inde- oftenfromthrough decreases ado- childhood Explain to parents that quality the of diet the per hour, inadditiontothelightphysicalactivityassociatedwithtypicalday-to-daylife. at 3to4milesperhour, inadditiontothelightphysicalactivityassociatedwithtypicalday-to-daylife. TABLE EACH 19–30 14–18 9–13 19–30 14–18 Age (years) 9–13

2. GENDER

ESTIMATED

AND

AGE CALORIE 2,400 2,200 1,800 2,000 1,800 Sedentary 1,600 fami

GROUP ly

REQUIREMENTS a

■ ■ ■ ■ ■ Weight and Body Image ■ 3 ■ ■ ■ ■ ■ ■

(tooth decay). in sugar can help prevent dental caries ages juice, (eg, high soft juice drinks) drinks, tion of candy, (eg, foods and cookies) bever Tell adolescents that limiting consump their - Image Among Children and Adolescents.) Tool I:Tips for Fostering aPositive Body are, regardless of sizeand their shape. (See know that are they loved and accepted as they healthy weights. body Adolescents to need unique sizesand shapes, within arange of image by explaining that people come in Help adolescent the build apositive body behaviors).ing sedentary engaging inregular reduc physical- activity; low-nutrienthigh-calorie, and foods beverages; by practicing healthy eating behaviors; limiting to achieve and maintain ahealthy weight (eg, healthyDiscuss and safe ways for adolescents balance and watching portionsizes. active. Explain importance the of energy being softand drinks), drinks, physically intake of insugar beverages high fruit (eg, practicing healthy eating behaviors, A healthy weight body achieved by can be rather defined than onweight. an socially ideal, on ageneticallysizeand determined shape Emphasize that ahealthy weight body is based 0.8 to 1.0mg/L (ppm) is recommended. atis added aconcentration of approximately prefer bottled water, abrand fluoride inwhich Healththe Oral Chapter.) For families that risk forthe tooth decay inadolescents. (See safe and effective way to significantlyreduce Explain that fluoridated drinking water is a instead, emphasize a healthy lifestyle. LEVELS 2,600–2,800 2,400–2,800 1,800–2,200 2,000–2,200 2,000 1,600–2,000 Moderately Active

OF (IN

PHYSICAL

KILOCALORIES) b

ACTIVITY 15 Discourage dieting; 3,000 2,800–3,200 2,000–2,600 2,400 2,400 1,800–2,200 Active

FOR c 11 limit . 14 ing - ■ ■ ■ ■ ■ Physical Activity ■ ■ ■ ■ ■ ities with family and friends). through physical education at school and- activ lar physical activity into daily their lives (eg, in females. Help adolescents incorporate regu - matically during early adolescence, especially Engagement inphysical activity declines dra- settings for physical activity. is aconcern, helphood adolescents find other If safety the of environment the or neighbor goggles) when the adolescent is physically active. equipment helmets, (eg, mouth pads, guards, Emphasize importance the of wearing safety Care Needs chapter.) Children and Adolescents With Health Special can help appropriate identify the (See activities. is often helpful thatand a physicaltherapist tions). Explain that adaptive physical education of adolescent’s the or medical physical condi- ity for cardiovascular fitnessthe (within limits care to needs engage inregular physical- activ Encourage adolescents health with special — — — to adolescent the following the guidelines: more minutes of daily physical activity. Explain Encourage adolescent the to engage in60or — — — a week. ing rope, playing at basketball) least 3days strengthening physical activity (eg, jump activity, adolescents should include bone- of their 60 or more minutes of daily physical Bone-strengthening (weight-bearing): As part sit-ups) at least 3days aweek. ening physical climbing activity (eg, trees, lescents should include muscle-strength- more minutes of daily physical activity, ado- Muscle-strengthening: As of part 60or the sity physical activity at least 3days aweek. activity and should include vigorous-intensity bicycling) running, (eg, aerobic physical skateboarding)hiking, or vigorous-inten- day should either be moderate-intensity (eg, Aerobic: Most of 60or the more minutes a - 3 - ■ Substance Use ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ drinks, coffee, drinks). drinks, energy sive quantities of caffeinatedbeveragessoft (eg, Discourage adolescents from consuming exces- games).video watching(eg, television, playing computer or are overweight, to reduce behaviors sedentary Encourage who adolescents, those especially ming aday. no more than 1to 2hours of quality program - vision, playing computer or games) video to entertainment watching (eg, time media tele- room. Tell parents to limit adolescent’s the total not to have atelevision adolescent’s inthe - bed turn offthe television during mealtimes and sion andEncourage viewing. media to them Explain to parents about effects the - of televi are they when physically active. Encourage adolescents plenty to drink of water supplements, anabolic steroids). performance-enhancing products protein (eg, Warn adolescents about dangers the of using alcohol, tobacco, and other drugs. Warn adolescents about dangers the of using 16 BRIGHT FUTURES: BRIGHT

NUTRITION 103

Bright FUTURES Adolescence Adolescence BRIGHT FUTURES: BRIGHT 104 Bright FUTURES

NUTRITION professionals in promoting optimal nutrition. The desired outcomes for the adolescent and the role the familyof outlined in Tablecan 3 assist health Role ofthe Desired Family Adolescent for the Outcomes TABLE

DESIRED Understands safewaysto Understands thatpeople Educational/Attitudinal Understands thedangers Understands thatpeople Understands the importance Understands the Understands physical Understands thenutrition Understands the physical, Understands the importance Understands the importance Understands that healthy weight-gain methods of unsafeweight-lossand recognizes thedangers healthy bodyweight,and achieve andmaintaina of healthybodyweights and shapes, within a range come inuniquebodysizes physical activity level activity and how to increase benefits of regular physi maintain ahealthyweight safe waystoachieveand methods, andknows of unsafeweight-loss of healthybodyweights and shapes, within a range come inuniquebodysizes snacks as needed of 3 meals per day and of a healthy diet consisting long-term health nutrition andshort- relationship between growth anddevelopment changes thatoccurwith adolescent needs ofthegrowing emotional, and social of family meals appropriate serving sizes of healthy foods and of eating a variety weight, and health to growth, development, physical activity are crucial eating behaviors and regular

OUTCOMES

FOR

THE ca l

ADOLESCENT, Does nothaveatelevision Watches televisionor Engages inphysical Seldom skipsmeals, Makes healthyfood Limits intakeofhigh- Consumes avarietyof Uses communitynutrition Engages in regular physi Provides opportunitiesfor Eats mealstogether Provides avarietyof Provides a positive role in hisbedroom programming aday 1 to2hoursofquality games nomorethan plays computerorvideo all, daysoftheweek activity onmost,ifnot eating behaviors restrictive ordisordered and doesnotpractice from home choices atandaway foods andbeverages calorie, low-nutrient healthy foods resources ifneeded programs andfood and foodpreparation cipate inmealplanning theadolescenttoparti activity with the adolescent communication to facilitatefamily optimal nutritionand regularly toensure sugar foods of high-fatandhigh- limiting theavailability healthy foodsathome, body image and promotes a positive in regular physical activity, eating behaviors, engages model: practices healthy Behavioral

AND

THE ca

ROLE l

Provides Helps theadolescent Maintains optimal Achieves nutritional Achieves and Provides develop weight tain ahealthy achieve andmain necessary fies themif foods, andmodi priate, healthy men physically active adolescent tobe safe placesforthe opportunities and and development promote growth nutrition to problems nutrition-related caries, orother disorders, dental obesity, eating undernutrition, deficiency anemia, signs ofiron- being, without and physicalwell- image positive body body weightand maintains a healthy

tally appro THE Health

FAMILY 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES

Pediatrics. 2001;107(2):423–426 Education. Children, adolescents and television. American Academy of Pediatrics Committee on Public obesity. Pediatrics. 2007;120(suppl 4):S254–S288 for treatment of child and adolescent overweight and Spear BA, BarlowC,etal. Recommendations SE, Ervin Company; 2009 Dental Therapeutics. American Dental Association. ADA/PDR Guide to 2008;122(5):1142–1152 ininfants,ciency children, and adolescents. Pediatrics. Nutrition. Prevention of rickets and vitamin Ddefi- Pediatrics on Breastfeeding, Section Committee on Wagner CL,Greer FR;American Academy of USDepartment ofDC: Agriculture; 2005 US Department of Agriculture. MyPyramid. Washington, Office; 2010 ed. Washington,2010. 7th USGovernment DC: Printing and Human Dietary Guidelines Services. for Americans US Department of Agriculture; US Department of Health 1998;47(RR-3):1–29 United inthe ciency States. MMWRRecomm Rep. Recommendations to prevent and control iron defi- Centers for Control Disease and Prevention. 2008 GroveElk Village, IL:American Academy of Pediatrics; Kleinman RE,ed. Pediatric Nutrition Handbook. ed. 6th HeartBogalusa Study. JPediatr. 2007;150(1):12–17.e2 posity among overweight children and adolescents: the Dietz WH.Cardiovascular risk factors and excess adi- Freedman DS,Mei Z,Srinivasan Berenson SR, GS, and obesity. Pediatrics. 2007;120(suppl 4):S193–S228 Styne D. Assessment of child and adolescent overweight Krebs NF, Himes JH,Jacobson D, Nicklas TA, Guilday P, Pediatrics. 2007;120(suppl 4):S164–S192 and adolescent report. overweight summary and obesity: ing prevention, the assessment, and treatment of child Committee. committee Expert recommendations regard- Barlow SE; American Academy of Pediatrics Expert 1995;854:1–452 committee.expert World Health Organ Tech Rep Ser. and interpretation of anthropometry. of Report aWHO World Health Organization. Physical status: use the 1998;101(3 pt 2):549–554 ity behaviors among children and adolescents. Pediatrics. Kohl HWIII,Hobbs KE.Development of physical- activ DC: US Department of Health and Human Services; 2008 Physical Activity Guidelines for Americans. Washington, US Department of Health and Human 2008 Services. Diet Assoc. 1005;105(5)743–760 performanceacademic inchildren and adolescents. JAm JD. Breakfast habits, nutritional status, weight, body and Rampersaud GC,Pereira MA,Girard BL, Adams J, Metzl W.B. Saunders; 1992:75–84 Textbookeds. of Adolescent Medicine. Philadelphia, PA: In: McAnarney Kreipe ER, DE, RE,Orr Comerci GD, Story M.Nutritional requirements during adolescence. 5th ed. Chicago,5th IL: ADA Publishing Rhee K. Childhood overweight and relationship the K.Childhood Rhee between Patrick K,Spear B, Holt K,Sofka eds. BrightD, Futures in Nicklas TA, Hayes D;American Dietetic Association. Position Himes JH.Challenges of accurately measuring and using Hagan JF, Shaw JS,Duncan Bright PM,eds. Futures: Gidding SS,Lichtenstein AH,Faith MS,etal. Implementing Gidding SS,Dennison BA, Birch recom- LL,etal. Dietary Freedman B. The validity DS,Sherry of BMI as an indica - Edelstein S,ed. Nutrition in Public Health: AHandbook for Davis MM,Gance-Cleveland B, Hassink S,Johnson R, Daniels Greer SR, FR;American Academy of Pediatrics Daniels setting. The SR. theuse Pediatrics.of BMIin clinical Casamassimo P, Holt Bright K,eds. Futures in Practice: Oral Casamassimo P, ed. Bright Futures in Practice: Oral Health. Brown JE,Isaacs J, Wooldridge N,Krinke B, Murtaugh M. American Dietetic Association. Position of American the Ann Am Acad Pol 2008;615(1):11–37 Sci. Soc parent behaviors, parenting style, and family functioning. for Education inMaternal and Health; Child 2001 Practice: Physical Activity. 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Circulation. 2005;112(13):2061–2075 titioners: consensus statement from American the Heart mendations for children and adolescents: aguidefor prac- 2009;124(suppl 1):S23–S34 tor of fatness body and risk among children. Pediatrics. Jones and Publishers; Bartlett 2010 Developing Programs and 3rd ed. Boston, MA: Services. 4):S229–S253 tion obesity. of childhood Pediatrics. 2007;120(suppl Paradis G,Resnicow K.Recommendations for preven- Pediatrics.lar inchildhood. health 2008;122(1):198–208 Committee on Nutrition. Lipid screening and cardiovascu- 2009;124(suppl 1):S35–S41 Healthand Oral Child 2004 Resource Center; Health—Pocket Guide. Washington, National DC: Maternal and Health; Child 1996 Arlington, VA: National Center for Education inMaternal Wadsworth Publishing; 2008 Nutrition Through the Life Cycle. 3rd ed. Belmont, CA: ments. JAm Dietetic Assoc. 2005;105(8):1300–1311 Dietetic Association: fortification and nutritional supple- SUGGESTED

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NUTRITION Stang J, TaftBayerl C,Flatt MM; American Dietetic Samour PQ, King K,eds. Dietetic Assoc. 2010;110(5):791–799 child and adolescent and food nutrition programs. JAm Association. Position of Americanthe Dietetic Association: ed. Boston, MA:Jones and Publishers; Bartlett 2005 Handbook of Pediatric Nutrition. 3rd US Department of Health and Human Office of Services, Surgeon 2010 General; Department of Health and Human Office the of Services, a Healthy and Fit Nation 2010.Washington, US DC: Surgeonthe The General. SurgeonGeneral’s Vision for her age. He asks Katherine also about height are within normal the range for Mrs Gomez that Katherine’s weight and BMI. He assures Katherine and height and determines her Katherine’s weight and Dr Meyer measures Katherine. Meyer, for adietfor physician,their Dr Mrs Gomez asks making team. the to have achance of down ifshe is going ably to need slim that prob she will - “chunky” and thinks Katherine appears is concerned that Katherine’s mother out fortry team. the seventh-grader, she can M dance team, and now, as a has dreamed of on being her school’s ing lessons since she was 5.Katherine loves to dance- and tak has been Katherineiddle-schooler Gomez A Dancer’s Dream additional information and guidance on anti realizes that Katherine nutrition needs during physical changes and and hermother need adolescence. Dr MeyerDr i i ing her next visit. height, weight, diet,and intake food dur nutritious snacks she when is hungry. Katherine to eat aday 3meals and to eat arethey appropriate. DrMeyer advises her eating behaviors and determines that in Katherine’s chart to evaluate her cipa He suggests that she eat awide low-up. He makes a note also ted variety of and foods choose them tothem adietitian for fol- fruits, vegetables,fruits, and low- adolescence. He refers fat and fat-free milk nutrition during needs products as snacks physical changes and rather than chips, ance on anticipated candy, and soft mation and guid- drinks. additional infor her mother need that Katherine and Dr Meyer realizes BRIGHT FUTURES: BRIGHT - -

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NUTRITION About Nutrition in Adolescence Frequently Asked Questions ■ ■ ■ ■ breakfast? How canIgetmyteenagertoeat ■ ■ ■ ■ ■ ■ so busy? meals togetherwhenweare How canourfamilyeathealthy ■ ■ ■ ■ ■ ■ to eathealthyfoods? How canIencouragemyteenager ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Make breakfast night the before. has to time eat morning. inthe Help your teenager get organized that so she overs such as chicken or pasta). sandwiches, (eg, foods potatoes, baked left- other foods than usualbreakfast the Serve juicefruit [limit to day], 6–8oz per yogurt). bagels,(eg, low-fat granola bars, 100% fruits, Provide that foods are fast and convenient, a week. (breakfast,4 meals lunch, or dinner) together Try to prioritize family and meals strive to eat sion off, and don’t answerthe telephone. Avoidto socialize. distractions. Turn- televi the When your family eats together, time the use or healthy take-out from foods arestaurant. Buy healthy ready-to-eat from foods store the next.the breakfast together one day and lunch or dinner Eat different together.meals For example,eat Make simple meals (eg, salads, soups, sandwiches).able family activity. Make preparation food and cooking an enjoy- Plant agarden. trans fats. in sugar and fat, saturated especially and andcookies) high beverages soft (eg, drinks) Limit availability the of candy, (eg, foods Keep avarietyof healthy house. inthe foods do not prepare separate for foods him. Don’t fight with over yourfood teenager, and eating behaviors yourself. apositive roleBe healthy model—practice Shop for and foods together. cook and foods new regional and foods. ethnic Serve ■ ■ ■ more fruitsandvegetables? How canIgetmyteenagertoeat ■ ■ ■ ■ ■ enough calcium? How canIhelpmyteenagerget ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and vegetables easily. seen can be Useor salsa. aclear container that so fruits the refrigerator, inthe them along with low-fat dip Wash and cut up and fruits vegetables and keep youwhen know your hungry. teenager be will Put cut-up and fruits vegetables on counter the Keep avarietyof and fruits vegetables at home. ifyourSee schooloffers a breakfast program. such or as fruits mixto trail eat at school. If your teenager is inahurry, offer her foods — — intolerant), suggestions these try handle and products milk milk (ie, he is lactose If your teenager’s digestive system cannot casseroles). recipes inpuddings, (eg, milkshakes, soups, Use low-fat or fat-free products milk in collard and turnip greens. processed with calcium sulfate, broccoli, and cheese, cottage milk, (eg, cheese, tofu yogurt), low-fat (1%)or fat-free products (skim)milk that foods are richincalcium,Serve such as vegetables yourself. role agood model—eatBe more and fruits Plant agarden. to eat them. meals and snacks, but don’t force your teenager Offer avariety fruits of and vegetables at bag to eat at school. Pack and fruits vegetables inyour teenager’s and casseroles. Use plenty of vegetables insoups, sauces, with achoicesalad of low-fat dressing. ing at least one your a teenager likes. Serve 2or moreServe vegetables with dinner, includ- — — products. along foods with these non-milk Serve out day. the portions through small of foods - these Serve ■ ■ ■ ■ ■ from home? make healthyfoodchoicesaway How canIteachmyteenagerto ■ ■ ■ ■ ■ vegetarian. Should I be concerned? My teenager has become a ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ vided byvided fortified and foods supplements. “hold mayonnaise.” the healthier,foods to such as asking server the Teach your teenager to ask for changes to make an order of with frenchafriend). fries or byfoods sizes (eg, to reduce splitting serving Encourage your teenager to avoid eating fried broiled or meats. baked low-calorie dressings, vegetables, fruits, and Encourage your teenager to eat with salads in fat, sugar, and calories. appropriate portions. that Find foods are low teenager, and healthy discuss choices food and schooland restaurantReview menus with your and restaurants, and from vending machines. choices purchasing when at food school, stores, Encourage your teenager to make healthy food you plan healthy meals. Ask aregistered dietitian or nutritionist to help fortarian meals whole the family. formeals your teenager, occasionally fix vege - Instead of always preparing separate vegetarian vitamin B and fish. They additionalneed maycalcium, animal products, including eggs, foods, dairy Vegans are vegetarians strict don’t who eat any iron supplement. however, your teenager may to an need take and usually provides eggs adequate nutrients; A vegetarian dietthat includes products milk nutritional needs. healthy canstyle be and teenagers’ meet With careful planning, avegetarian life- calcium supplement. professional about giving your teenager a If donot ideas these work, to ahealth talk products, with added calcium (calcium-fortified). such foods, juice as 100%fruit and cereal Serve eats products milk containing lactose. Give your tablets teenager before lactase he teenager’s milk. are low Add inlactose. drops lactose to your cheddar,(eg, Colby, Swiss, Parmesan) that anding milk and yogurt, aged hard cheeses products, milk includ lactose-free - Serve 12 , and vitamin D, pro can which be -

■ ■ ■ ■ ■ ■ candy. WhatshouldIdo? My teenagersnacksonchipsand ■ ■ ■ ■ ■ ■ ■ ■ more active? How canIhelpmyteenagerbe ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and restaurants, and from vending machines. choices purchasing when at food school, stores, Encourage your teenager to make healthy food or counter. Keep abowlof on fruit kitchen the table opens the fridge. arewhenso they first the thinghe sees he Keepor salsa. at them your teenager’s eyelevel ily) refrigerator, inthe along with low-fat dip in a clear container- eas seen can be they (so Wash and cut up vegetables, and keep them day], applesauce, fruit, vegetables, yogurt). products, juice 100%fruit [limit to 6–8oz per whole-grain (eg, low-fat foods healthier Serve onfoods hand. Keep avarietyof easy-to-prepare and healthy beveragessoftened juice (eg, drinks). drinks, that are insugar, high such as candy and sweet - such as potato chips that are and foods fried, Limit inyour foods home that are infat, high family members and can dotogether. friends Take physical turns selecting that activities withspend time your teenager. dancing,ing ball, skating). It’s agreat way to physicallyBe active together biking, (eg, play- orarts, dancing. physical such activities, as swimming, martial Encourage your teenager to enroll in planned a bike instead of riding inacar. antaking elevator or escalator, and or walk ride daily life. For example, stairs the use instead of Make physical of activity apart your teenager’s leaves,raking dog). the walking Involve your teenager infamily chores (eg, activity break. encourage her to a10-minute take physical television, or plays computer or games, video For hour your every teenager reads, watches room; ifone is already there, remove it. Don’t put atelevision inyour teenager’s- bed 1 to 2 hours of quality programming aday. computer or games) video to no more than watching (eg, time media television, playing Limit your teenager’s total entertainment dancingactivity (eg, to music). Encourage spur-of-the-moment physical BRIGHT FUTURES: BRIGHT

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NUTRITION ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ overweight? What shouldIdoifmyteenageris ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ hike, abike eachweek. ride) Plan at least physical one special a activity (eg, bers to tease the teenager to the bers tease about weight. teenager’s weight or allow other family mem- notDo make negative comments about your playgrounds, parks). and activewalking (eg, cally biking paths, your teenager has safe places for physi being - Work with your community to make sure that to vigorous activity each day. Teenagers at need least 60minutes of moderate ing behaviors and physically be active yourself. role agood healthy model—practice Be eat- computer games. yourtime teenager watches television and plays Limit to 1to 2hours day per amount the of biking, hiking, (eg, swimming). Plan family that activities enjoys everyone appropriate portions. and healthy discuss choices food and atLook schoolmenus with your in moderation. notDo forbid them sweets andServe desserts. low-fatServe or non-fat products. milk (limited to day). 6oz per fat water, (skim)milk, and juice 100%fruit Limit most beverages to low-fat (1%)or non- low-nutrienthigh-calorie, snacks. in sugar high soft juice(eg, drinks) and drinks, candy,Limit (eg, foods and cookies) beverages buttimes, allow for flexibility. healthy and meals snacksServe at scheduled eating and physical activity behaviors. Focus on gradually changing entire the family’s supervises it. ommends one for reasons medical and weight professional unlessahealth rec- Never place your teenager on adietto lose evaluation of your teenager’s BMI. teenager’s professional, health and request an weight, bring to this attention the of your If you are concerned about your teenager’s yourself. role agood physically model—be Be activity te enager, ■ her body? How canIhelpmyteenagerlike ■ ■ ■ ■ teenager gainweight? How canIhelpmyunderweight ■ ■ ■ ■ BULIMIA NERVOSA ■ ■ ■ ■ ■ ■ ■ ■ ANOREXIA NERVOSA professional aboutyour concerns. symptoms, talktoahealth If younoticeanyofthese ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ size or shape. not Do look. criticize your teenager about her Teenagers are sensitive very about how they have offeredtimes. been several is more likely to after accept foods they these has to refused eat before. them Your teenager Continue to offereven if yourfoods teenager and preparation. food Have your teenager help planning with meal if snacking is affecting his appetite. school snack. Limit snacks to close mealtimes ing snack at school, ifpossible, and an after- Encourage your teenager to eat amidmorn- affected. ifhis appetite meals between drinks is being Limit quantity the of beverages your teenager Obsession with exercise Eating insecret ment of unusual eating rituals Unusual interest and foods in certain develop- ofLoss period menstrual Depression Obsession with exercise Eating insecret ment of unusual eating rituals Unusual interest and foods incertain develop- ofLoss period menstrual is fatbody eventhough extremely thin Dissatisfaction with appearance; that belief Continuation of dieting although thin Excessive weight loss inashort period size or shape or that of others. role agood model—don’tBe criticize your own image.affectsbody his Talk to your teenager about how media the to yourtalking teenager. Focus on traits other than appearance when Nader Zive MM.You PR, Can LoseYour Baby Fat: New Rules Ludwig D, S.Ending Rostler the Food Fight: Guide Your Child J,Lock Grange Le D. Help Your Teenager Beat an Eating Fletcher AM.Weight Loss Confidential Journal: Week-by- Fletcher AM.Weight Loss Confidential: How TeensLose International Food Information Council. Kidnetic. http:// Centers for Control Disease and Prevention. Eat a Centers for Control Disease and Prevention. Division of ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Society. San Diego, CA:PhilNader Publications; 2008 Others Who Care About Children and the Future of Our to Protect Kids from Obesity—For Parents, Providers, and York, NY: Houghton Mifflin Company; 2007 to aHealthy Weight in aFast Food/Fake Food World. New Disorder. New York, NY: The Guilford Press; 2005 Houghton Mifflin Company; 2007 Week Success Strategies for Teens from Teens. Knew. New York, NY: Houghton Mifflin Company; 2006 Weight and Keep It Off—And What TheyWish Parents www.kidnetic.com fruitsandveggiesmatter.gov Variety of Fruits &Vegetables Every Day. http://www. gov/nccdphp/dnpa Nutrition, Physical Activity and Obesity. http://www.cdc. RESOURCES Alcohol or abuse drug to(eg, induce vomiting) Disappearance into bathroom for long periods Vomiting or laxative use Binge-eating with no noticeable weight gain Binge-eating Depression

FOR

FAMILIES New York, NY: US Department of Health and Human Food and Service, US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture, Food and Nutrition Service. US Department of Agriculture. MyPyramid.gov. http://www. Satter E.Your Child’s Weight: Helping Without Harming: Birth Neumark-Sztainer D. “I’m, Like, Fat!”: So Helping Your Teen Nemours Foundation. KidsHealth. http://www.KidsHealth.org National Institutes of Health, National Heart Lung, and Blood of Agriculture, Food and Nutrition 2008 Service; Food and Administration; Drug Services, USDepartment Washington, USDepartment of DC: Health and Human Helping Youth Make Healthy Eating and Fitness Decisions. Food and Nutrition The Power Service. of Choice: Administration;Drug USDepartment of Agriculture, Team Nutrition. http://www.fns.usda.gov/tn id=6322&level4_id=0 level=3&tax_subject=261&topic_id=1941&level3_ usda.gov/nal_display/index.php?info_center=15&tax_ Loving Your Family, Feeding Their Future. http://snap.nal. http://healthymeals.nal.usda.gov/hsmrs/EY Empowering Youth with Nutrition and Physical Activity. mypyramid.gov Through Adolescence. Madison, WI:Kelcy Press; 2005 Press; 2005 Weight–Obsessed World. New York, NY: The Guilford Make Healthy Choices About Eating and in Exercise a NY: North Point Press; 2006 Guide to Food Savvy Choices and Good Eating. New York, obesity/wecanNestle M.What to Eat: An Aisle-by-Aisle Nutrition. http://www.nhlbi.nih.gov/health/public/heart/ Institute. We Can! Ways to Enhance Children’s Activity & BRIGHT FUTURES: BRIGHT

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