Dietary Recommendations For Toddlers, Preschool, and School-Age Children

10/11/2017 Dietary recommendations for toddlers, preschool, and school-age children - UpToDate
Official reprint from UpToDate®

www.uptodate.com ©2017 UpToDate®
Dietary recommendations for toddlers, preschool, and school-age children
Author: Teresa K Duryea, MD

Section Editors: Jan E Drutz, MD, Kathleen J Motil, MD, PhD
Deputy Editor: Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2017. | This topic last updated: Jul 11, 2017.
INTRODUCTION — The nutritional requirements, feeding development, and dietary guidelines for toddlers
(12 to 24 months), preschool, and school-age children will be discussed here. Nutritional needs of infants are
discussed separately. (See "Introducing solid foods and vitamin and mineral supplementation during
infancy".)
FEEDING DEVELOPMENT — Achieving independence and mastery of feeding skills is an important

developmental task of early childhood [1,2]. Allowing the child to feed him or herself promotes and reinforces
self-regulation of intake.
Key issues for toddlers and preschool children include making the transition to cup and utensil feeding,
fluctuations in appetite, achieving adequate iron and zinc intake, avoiding overconsumption of juice and
sweetened beverages, and developing routines for healthy eating and activity [1,3,4]. Key issues for school-
age children include adequate intake of fruits, vegetables, calcium, vitamin D, and fiber; avoidance of energy-
rich/nutrient-poor snacks (eg, salty snacks, cookies, sweetened beverages) and overconsumption of sugar-
sweetened foods and beverages; and development of a healthy body image [1,5].
Children who have developmental delays may not master feeding skills in a timely fashion. Parents should
understand that the prolonged use of a bottle or the persistence of finger feeding may be necessary to insure
adequate dietary energy and nutrient intake.
Toddlers — During the second year of life, through the progressive acquisition of motor skills and eruption of
the full complement of deciduous teeth, children learn to feed themselves independently and make the
transition to a modified adult diet [1]. Dietary preferences and patterns continue to be established [2].
The growth rate and appetite decrease after the first birthday. Toddlers may eat variable quantities at any
given meal. They also may choose from a small variety of foods [6,7]. These behaviors are to be expected
[1,6].
Feeding development — Feeding development during the second year includes acquisition of the
following skills [1,2]:
● Drinking from a cup. Weaning from the bottle should begin at 12 to 15 months of age. By 15 months of
age, children can manage a cup by themselves but will continue to spill; by 18 to 24 months of age, cup
manipulation is improved, and spills occur less frequently.
Toddlers should be completely transitioned from the bottle to the cup by two years of age (ideally by 15
to 18 months), and they should not sleep with a bottle. Drinking from a bottle predisposes to dental
caries, particularly if the bottle is taken to bed or sipped throughout the day. (See "Preventive dental care
and counseling for infants and young children", section on 'Dietary habits'.)
In addition, supplying large volumes of caloric beverages in a bottle may lead either to overfeeding or to
decreased solid food intake and undernutrition. Continuing to use a bottle at two years was associated
with obesity at 5.5 years in a longitudinal cohort study [8].
https://ezproxy.usm.my:4243/contents/dietary-recommendations-for-toddlers-preschool-and-school-age-children/print?source=see_link&section… 1/25
● Self-feeding. During the second half of the first year, infants learn to grasp food with their hands and then
between the thumb and first finger; they can use their lips to remove food from a spoon. By 16 to 17
months of age, improved wrist rotation permits the transfer of food from a bowl to the mouth.
● By 24 months of age, most children are ready to consume an adult diet (with modifications to prevent
choking). (See 'Choking' below.)
Feeding behaviors — The acquisition of healthy feeding behaviors is dependent upon the interaction of
several factors. These include child-specific elements, such as developmental maturation, temperament,
personal experiences, and medical needs, as well as environmental considerations, like family dynamics,
ethnic dietary practices, and food accessibility. A feeding problem can result from any of these factors [9].
Normal toddler feeding behaviors include [1,2]:
● Playing with food. Exploratory behaviors (touching, smelling, putting the food in the mouth and spitting it
out) may precede acceptance or willingness to taste or swallow new foods [10].
● Decrease in dietary variety (feeding "jags"). Beginning at about two years of age, toddlers may become
resistant to trying new foods; they may choose to eat only a small number of well-accepted favorites
[6,7]. It may be necessary to offer new foods several times (as many as 8 to 10) before concluding that
the child will not accept them [1,11,12].
Preschool children — By three to four years of age, children are better able to protect their airways and can
safely consume the small, round, hard foods that previously posed a choking hazard. They can handle
utensils and cups efficiently and can sit at the table for meals [1].
Preschool children are more aware of the feeding environment than younger children, and environmental
cues affect their food selection and intake patterns [1]. Environmental cues include time of day, portion size,
restriction of food or pressure to eat, the preferences and eating behaviors of others, and packaging (eg, the
presence of licensed characters on the package) [13,14].
Preschool children may have unpredictable interest in eating [1]. Their ability to sit at the table may be limited
by their attention span. However, they should be encouraged to sit with the family for a reasonable period of
time (eg, 15 to 20 minutes) during meals, even if they choose not to eat. Sitting with the family during meals
provides an opportunity for caregivers to model healthy eating behaviors and choices.
School-age children — School-age children can understand basic nutrition concepts [1]. They can help with
meal planning, food preparation, and mealtime chores (eg, setting the table) [2].
School-age children have more freedom over their food choices; many eat at least one meal per day away
from home. Allowing them to participate in food choices at home and providing positive reinforcement when
they make healthy choices may help them to make healthy choices away from home.
School-age children also are more aware of their body weight and shape than when they were younger. The
food attitudes and choices of school-age children may be influenced (positively or negatively) by friends,
nonfamily members, and/or the media [15-17]. Parents may need to balance potentially negative influences
by increasing positive influences in the home (eg, by making healthy choices themselves during family meals,
increasing reinforcement when the child makes healthy choices, and setting an example).
NUTRITIONAL REQUIREMENTS — Energy and nutrient requirements for children vary depending upon
age, sex, and activity level (table 1). ChooseMyPlate is an interactive website that provides individual dietary
guidance according to these parameters. (See 'Resources' below.)
Energy intake is influenced by the number of meals and snacks that are eaten during the day, the energy
density of foods consumed, and portion size. Children generally can self-regulate energy intake [6,18].
However, self-regulation may be overridden if eating behaviors are driven by factors other than hunger and
fullness (eg, coercive feeding, restriction of intake, environmental cues to eat) [19,20]. Parents should provide
a range of nutritious foods for meals and snacks, but children should be allowed to decide how much, if any,
they eat [21]. Parents must be cognizant that peers and others outside the family greatly influence food
choices of school-age children and adolescents. Body image concerns and societal attitudes may affect the
energy intake and nutritional status of older children. (See 'Eating environment' below.)
Energy — Energy is provided through three primary macronutrients: protein, fat, and carbohydrates.
Protein — Protein should constitute 5 to 20 percent of total energy intake for children one to three years
of age, and 10 to 30 percent of total energy intake for children 4 to 18 years of age [22,23].
Fat — Dietary fat is an important source of energy, supports the transport of fat-soluble vitamins, and
provides the two essential fatty acids, alpha-linolenic acid (ALA, omega-3 group) and linoleic acid (LA,
omega-6 group). Total fat intake should be between 30 and 35 percent of energy intake for children two to
three years of age; total fat intake should be between 25 and 35 percent of energy intake for children 4 to 18
years of age [23]. Essential fatty acid intake, primarily as linoleic acid, should be 3 percent of total daily
energy intake.
Carbohydrate — Carbohydrates are an important source of energy and support the transport of vitamins,
minerals, and trace elements. Adequate carbohydrate intake contributes to sufficient intake of dietary fiber,
iron, thiamine, niacin, riboflavin, and folic acid. Carbohydrates should constitute 45 to 65 percent of total
energy intake [22-24].
Added sugars should be avoided in children <2 years and limited to <5 percent of total energy intake in
children ≥2 years (approximately 25 g, 100 kilocalories, or 6 teaspoons) [24,25]. (See 'Added sugars and
sweetened beverages' below.)
Micronutrients — Micronutrients include vitamins, minerals, and trace elements. Dietary Reference Intakes
(DRI) for micronutrients are available through the United States Department of Agriculture Food and Nutrition
Information Center [26]. (See "Dietary history and recommended dietary intake in children", section on
'Dietary Reference Intakes (DRIs)'.)
DIETARY GUIDELINES — Fostering the development of healthy eating behaviors is an important goal of
early childhood nutrition [1]. Several national health organizations have issued dietary guidelines for children
and adolescents. These groups include the American Academy of Pediatrics (AAP), the American Heart
Association (AHA), the American Dietetic Association, and the United States Departments of Agriculture and
Health and Human Services (USDA/HHS) [1,5,27,28]. The recommendations from the various organizations
are relatively consistent and are summarized below (table 2).
The USDA/HHS devised ChooseMyPlate, an interactive Web site, to facilitate implementation of the
USDA/HHS dietary guidelines for individuals older than two years. ChooseMyPlate provides individual dietary
guidance based upon age, sex, and physical activity.
Dietary composition — Young children have the innate ability to adjust their energy intake to the energy
density of their diet, but not to choose a well-balanced diet [6,7,29,30]. They depend upon adults to offer
them a variety of nutritious, developmentally appropriate foods to meet the recommended number of servings
per day (table 3 and table 4) [21].
Overview — A variety of nutrient-dense foods from the basic food groups should be offered each day
(table 3 and table 4). Foods and beverages should contain or be prepared with little added salt, sugar, or
caloric sweeteners [1,5,28].
Fat and cholesterol — The recommended intake of fat and cholesterol varies depending on age
[1,23,28].
● Fat and cholesterol intake are not restricted for children younger than two years.
● Total fat intake should be between 30 and 40 percent of energy intake for children two to three years of
age; total fat intake should be between 25 and 35 percent of energy intake for children 4 to 18 years of
age. Fat intake should not be restricted below 20 percent of total energy intake.
Most fats should come from polyunsaturated and monounsaturated fatty acids (table 5) [31]. For children
older than two years, saturated fats should make up less than 10 percent of total energy intake and the intake
of trans fats should be as low as possible. A diet in which saturated fats make up less than 10 percent of total
energy intake will also be low in cholesterol.
The types of dietary fat are discussed separately. (See "Dietary fat".)
Meat and protein — When choosing and preparing meat, poultry, and other high-protein foods, make
choices that are lean, low fat, or fat free.
An estimated 65 to 70 percent of protein intake should come from sources of high biologic value, typically
animal products, which contain a full complement of essential amino acids. Animal products are not
necessary to provide optimal protein, but most alternative sources from plants (eg, legumes, grains, nuts,
seeds, and vegetables) do not contain a full complement of essential amino acids, and therefore greater
dietary planning is required for diets without meat. (See "Vegetarian diets for children", section on 'Protein'.)
The American Heart Association (AHA) recommends two servings of fish/shellfish per week, not including
commercially prepared fried fish/shellfish, since these products may be high in trans fats and relatively low in
omega-3 fatty acids [5,32]. The US Food and Drug Administration (FDA) and the Environmental Protection
Agency recommend that children eat one to two servings of fish/shellfish per week [33]. The serving size is
measured before cooking and should be appropriate for the child's age and energy needs:
● 2 through 3 years – Approximately 1 ounce (28 g) per serving

● 4 through 7 years – Approximately 2 ounces (57 g) per serving
● 8 through 10 years – Approximately 3 ounces (85 g) per serving
● ≥11 years – Approximately 4 ounces (113 g) per serving
The fish should be low in mercury (eg, shrimp, canned light tuna, salmon, pollock, tilapia, crab, haddock,
lobster, catfish, and cod) [5,33]. Consumption of fish with higher levels of mercury (eg, shark, marlin,
swordfish, king mackerel, bigeye tuna, and Gulf of Mexico tilefish [sometimes called golden bass or golden
snapper]) should be avoided [5,33]. (See "Fish oil and marine omega-3 fatty acids".)
Many sources of protein are also common allergens (eg, milk, eggs, soy, fish, shellfish, peanuts, and tree
nuts). Insuring adequate protein intake in children with food allergies is discussed separately. (See
"Management of food allergy: Nutritional issues", section on 'Protein'.)
Fruits, vegetables, and fruit juice — A colorful variety of fruits and vegetables should be offered each
day (table 3 and table 4). Strategies that parents can use to increase fruit and vegetable consumption include
[34]:
● Provide "hands on" experience with fruits and vegetables through gardening and cooking
● Involve children in the selection and preparation of fruits and vegetables
● Cut fruits and vegetables into shapes that the child can dip
● Expose children to a variety of fruits and vegetables
● Being a role model by eating fruits and vegetables for snacks and during meals
● Making fruits and vegetables more accessible
● Add vegetables to sandwiches, pasta, chili, soups, casseroles, and pizza
● Add fruit to cereal or pancakes
● Provide fruits and vegetables as snacks
We encourage consumption of whole fruit rather than fruit juice. No more than one-half of the recommended
daily servings of fruit should be provided in the form of 100 percent fruit juice (rather than "fruit drinks") [4].
Age-appropriate limits for 100 percent fruit juice are as follows:
● One through 3 years – 4 ounces (120 mL)

● Four through 6 years – 4 to 6 ounces (120 to 180 mL)
● ≥7 years – 8 ounces (240 mL)
Fruit juice that is offered to children should be pasteurized; unpasteurized fruit juice may contain pathogens
(eg, Escherichia coli O157:H7). Fruit juice should be offered as part of a meal or snack and not sipped
throughout the day; it should not be consumed at bedtime or in bed. (See "Differential diagnosis of microbial
foodborne disease" and "Preventive dental care and counseling for infants and young children", section on
'Dietary habits'.)
Fruit juice generally lacks the fiber of whole fruit and provides no nutritional advantage [4]. Although calcium-
fortified juices provide a bioavailable source of calcium, they lack other nutrients present in cow's milk and
fortified plant-based milks (eg, protein, magnesium). Overconsumption of fruit juice may be associated with
dental caries, diarrhea, bloating, excessive flatulence, abdominal distension, undernutrition, and overnutrition
[35-40]. However, consumption of 100 percent fruit juice within the recommended limits does not appear to
be associated with weight gain. In a meta-analysis of eight prospective cohort studies including 34,470
children older than one year, one daily serving of 100 percent fruit juice was not associated with clinically
significant weight gain [41].
Grains — At least one-half of total grains consumed should be whole grains. Whole grains contain the
bran, germ, and endosperm. Examples of whole grains include whole or cracked wheat, oats or oatmeal, rye,
barley, corn, brown or wild rice, and quinoa. Whole grains are an excellent source of fiber, plus several B
vitamins, iron, magnesium, and selenium.
Fiber — The optimum intake of dietary fiber for infants and children younger than two years of age is not
known. Studies of weaning diets with the gradual introduction of solid foods, including increased fiber,
suggest that an intake of 5 grams per day is beneficial provided the children ingest adequate calories,
vitamins, and minerals [42,43].
For children older than two years, a safe range of fiber intake equals the age (in years) plus 5 to 10 g per day
(maximum 30 g per day) [24,44,45]. This goal is best met by eating a variety of fiber-rich fruits, vegetables,
cereals, and whole-grain products [23]. One-half cup (approximately 120 mL) of vegetables or one piece of
fruit provides approximately 3 g of fiber.
Dairy products
● Milk
• 12 to 24 months – Children between 12 and 24 months of age generally should drink whole cow's
milk (rather than skim milk, 1 percent milk, or 2 percent milk) [1]. However, the Expert Panel on
Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents
recommends that the decision to use whole or reduced-fat milk for children between 12 and 24
months of age be made on a case-by-case basis by the parents and pediatric healthcare provider
[23]. Factors to be considered in the decision include the child's growth, appetite, intake of other
nutrient-dense foods, intake of other fat sources, and potential risk for obesity and cardiovascular
disease. Consumption of skim or low-fat milk should only be undertaken if the child's overall diet
supplies 30 percent of energy intake from fat.
Children between 12 and 24 months of age should consume at least 2 cups (each cup equals 8
ounces (approximately 240 mL) and contains approximately 300 mg of calcium) per day and eat
foods rich in calcium to meet their daily calcium requirement (700 mg/day). Excessive milk intake
can displace the desire for foods that fulfill nutritional requirements (eg, iron). (See "Iron deficiency
in infants and young children: Screening, prevention, clinical manifestations, and diagnosis".)
• ≥24 months – Children older than two years should consume fat-free (skim) or low-fat cow's milk (1
percent milk, 2 percent milk), calcium- and vitamin D-fortified soy milk, or equivalent cow's milk or
fortified soy milk products (eg, yogurt, cheese). However, switching from whole milk to fat-free or
low-fat milk should not, in and of itself, be expected to prevent obesity or lower body mass index
(BMI) if total daily energy intake exceeds metabolic needs [46,47].
Children between two and eight years should consume at least 2 to 3 cups (approximately 480 to
720 mL) per day and eat foods rich in calcium to meet their daily calcium requirement (700 mg/day
for children 1 to 3 years, and 1000 mg/day for children 4 to 8 years) [48].
Children and adolescents 9 to 18 years should consume at least 3 cups (approximately 720 mL) per
day and eat foods rich in calcium to meet their daily calcium requirement (1300 mg/day) [48].
Dairy milk comes from animals, most often cows and goats. Nondairy milk alternatives are not "milk" per
se, but extracts derived from plant sources. Common alternative milks include soy, almond, rice,
coconut, and hemp milks; newer alternative milks include quinoa, oat, potato, and mixed grain milks.
Among the plant-based milks, soy milk has a nutrient profile that is most similar to cow's milk and usually
is fortified with calcium and vitamin D. Other plant-based milks generally are lower in protein, calcium,
vitamin D, and calories; they also may be lacking in other vitamins, minerals, and fatty acids that are
found in dairy milk.
Children who drink non-cow's milk or nonfortified soy milk (eg, goat's milk or plant-based milks such as
rice, almond, coconut, etc) may require supplemental vitamin D. Commercially available cow's milk is
fortified with vitamin D; fortification of non-cow's milk is voluntary. In a cross-sectional study of 2831
children (one to six years of age), 10 percent of children drank non-cow's milk [49]. Drinking only non-
cow's milk was associated with decreased levels of vitamin D [49]. Vitamin D requirements and
recommendations for meeting the recommended daily intake of vitamin D are discussed separately. (See
"Vitamin D insufficiency and deficiency in children and adolescents", section on 'Targets for vitamin D
intake'.)
If cow's milk alternatives are used for children, other foods must be chosen wisely to provide the
nutrients missing from alternative milk sources. Plant-based milks also may be deficient in calcium and
protein. Consultation with a dietitian to review the overall dietary nutrient intake may be warranted for
children in whom plant-based milks are a dietary staple.
● Yogurt – When substituting yogurt for cow's milk, caregivers should review the nutrition label to make
sure that it contains an equivalent amount of calcium, vitamin D, and other nutrients, without too much
added sugar. The nutrient profile of yogurt has changed over time. A variety of yogurt products are
available including products with low fat or no fat; reduced sodium or sugar; protein or calcium
fortification; "mix-ins" (eg, fruit, nuts, granola, candy), etc [50]. Many of the available products contain
only one-half to two-thirds of the calcium in an equivalent volume of milk; some are not fortified with
vitamin D. Flavored yogurts may contain two to three times the amount of natural sugars in plain yogurt.
Snacks — Snacks are an essential component of the young child's diet. Healthy snacks should be
planned so they contribute to the day's total nutrient intake (table 1) [1].
Healthy snacks include fresh fruit, cheese, whole-grain crackers or bread products, milk, raw vegetables, 100
percent fruit juices, sandwiches, peanut butter, and yogurt [1].
Added sugars and sweetened beverages — Added sugars have been associated with increased risk
factors for cardiovascular disease (eg, increased adiposity and dyslipidemia) [25].
Added sugars include sugars and syrups that are consumed directly (eg, candy, cookies) or added during
preparation and processing (eg, high fructose corn syrup) or before consumption of food and beverages (eg,
sugar, honey, maple syrup, agave nectar, malt syrup) [51].
Sweetened beverages are a major source of added sugar in the diet and an important contributor to the
development of obesity. Sweetened beverage consumption also is associated with lower intake of key
nutrients (particularly calcium) because sweetened beverages generally are consumed instead of milk. (See
"Definition; epidemiology; and etiology of obesity in children and adolescents", section on 'Sugar-sweetened
beverages'.)
The consumption of soft drinks and other sweetened beverages (eg, fruit drinks, flavored water) should be
discouraged [1,2,24,52-54]. Plain, unflavored water is the preferred beverage for children, particularly when
fluids are consumed outside of meals and snacks [1].
The American Academy of Pediatrics and the American Heart Association recommend that consumption of
[5,25]:
● Added sugars be avoided in children <2 years of age
● Added sugars be limited to ≤25 g (approximately 100 kilocalories or 6 teaspoons) in children ≥2 years of
age
This limit is based upon the recommendation in the 2005 Dietary Guidelines for Americans to limit
discretionary kilocalories (ie, those available for consumption as added sugars or solid fats after
essential daily nutrient requirements are met) to 6 to 10 percent of total daily energy intake [55]; the 2015
Dietary Guidelines suggest limiting added sugars to <10 percent of total daily energy intake [28].
● Sugar sweetened beverages be limited to ≤8 ounces (~240 mL) per week in children ≥2 years of age.
Studies evaluating added sugars in children are limited [25]. Pending additional information, these consensus
guidelines seem reasonable.
Frequency of feeding — Most young children should be fed four to six times per day [1]. Snacks are an
essential component of the young child's diet. (See 'Snacks' above.)
Toddlers eat an average of seven times per day, with snacks accounting for approximately one-fourth of daily
energy intake [56]. Preschool children generally eat three meals and several small snacks per day. School-
age children typically eat fewer meals and snacks per day than younger children, although they may continue
to have a snack after school [1]. Children who skip breakfast tend to consume less energy and fewer
nutrients than those who eat breakfast [57,58].
Portion size — The appropriate portion size varies depending upon the child's age and the particular food
(table 3 and table 4). Serving children portions that are larger than recommended for their age may contribute
to overeating. In a crossover study, preschool children who were repeatedly exposed to large portions (two
times the size of an age-appropriate portion) during a series of lunches increased their total energy intake at
lunch by 15 percent and their entree intake by 25 percent [59]. When permitted to select their own portion
size, they consumed 25 percent less of the entree than when served the large portion.
Vitamin and mineral supplements — Routine supplementation of vitamins and minerals is not necessary
for healthy children who are growing normally, consume a varied diet, and have adequate exposure to
sunlight [1,2,60,61]. In a survey of the dietary habits of toddlers and preschool children in the United States,
more children who received supplements had excessive intake of vitamin A, zinc, and folate than those who
did not [61]. In another national survey, supplement use contributed to excessive intake of vitamin A, vitamin
C, iron, zinc, copper, selenium, and folic acid among children 2 through 18 years of age [60].
If parents wish to give their children supplements, a standard pediatric multivitamin generally poses no risk.
However, interactions with medications may occur [62]. Megadose vitamins and doses of any nutrient in
excess of the recommended daily allowance should be discouraged because of the potential toxic effects.
Vitamin and mineral supplements, particularly those designed to appeal to children (eg, vitamin gum), should
be kept out of reach of children.
Vitamin and mineral supplements may be indicated for children at nutritional risk, including those [1]:
● From neglected or deprived environments.
● With anorexia or inadequate appetite.
● With lead poisoning. (See "Childhood lead poisoning: Management", section on 'Approach'.)
● With failure to thrive. (See "Poor weight gain in children older than two years of age", section on 'Dietary
intervention' and "Failure to thrive (undernutrition) in children younger than two years: Management",
section on 'Vitamin and mineral supplementation'.)
● Who do not get regular sunlight exposure and/or do not have adequate vitamin D intake. (See "Vitamin D
insufficiency and deficiency in children and adolescents", section on 'Prevention'.)
● Who drink only non-cow's milk products that are not fortified with vitamin D.
● With chronic diseases that may affect absorption and utilization of nutrients. As examples, children with
chronic liver disease or fat malabsorption (eg, cystic fibrosis) need supplementation of the fat-soluble
vitamins A, D, E, and K, and children with hemolytic anemia (eg, sickle cell anemia) may need folic acid
supplementation.
● Who are trying to lose weight or are consuming fad or restrictive diets. As an example, children who
consume strict vegan diets (avoidance of all animal products, including eggs, milk, and milk products)
may need supplementation of vitamin B12, iron, or vitamin D. (See "Vegetarian diets for children" and
"Iron deficiency in infants and young children: Screening, prevention, clinical manifestations, and
diagnosis", section on 'Dietary recommendations'.)
Food safety — There are two major safety considerations when feeding children: choking and foodborne
infection.
Choking — To limit the risk of choking, children younger than three to four years of age should not be
given small, round, hard foods (eg, hot dogs, nuts [particularly peanuts], grapes, raisins, raw carrots,
popcorn, round candies). In addition [1,2]:
● Toddlers should always be supervised while eating

● Children should be seated upright during eating; they should not eat while reclining, walking, or running
● Children should not eat while riding in a car, because the parent may not be able to intervene if the child
chokes
Foodborne infection — To minimize the risk of foodborne infection, children should not be fed [1,28,63]:
● Raw (unpasteurized) milk or juice

● Raw or partially cooked eggs or foods containing raw eggs
● Raw or undercooked meat, poultry, fish, or shellfish
● Raw sprouts
Virtually all international and national advisory and regulatory committees endorse the consumption of only
pasteurized milk and milk products. Ingestion of raw milk has been associated with various bacterial
infections, including Campylobacter, Brucella, Listeria monocytogenes, Salmonella, and E. coli and
associated hemolytic uremic syndrome [64-69]. The FDA mandates pasteurization in final package form for
all milk and milk products for direct human consumption that are shipped for interstate sale [65,70]. However,
individual states regulate milk shipped within the state, and some states permit raw milk to be sold in some
form to the public. In December 2013, the Committee on Infectious Diseases and Committee on Nutrition of
the AAP published a policy statement on the consumption of raw or unpasteurized milk and milk products by
pregnant women and children that endorses a ban on the sale of such food items. This recommendation is
based on the multiplicity of data regarding the burden of illness, as well as the strong scientific evidence that
the nutritional value of milk is not altered by the pasteurization process [63].
Additional steps to prevent foodborne infection are outlined in the table (table 6).
EATING ENVIRONMENT — The eating environment is a critical factor in the development of healthy eating
behaviors [1]. Structure and routine for all eating occasions are particularly important.
The meal environment should be free from distractions. Eating should occur in a designated area, and the
child should have a developmentally appropriate chair. Family meals provide an opportunity for children to
learn healthy eating habits and begin to appreciate the social aspects of eating. In a 2011 meta-analysis of
observational studies, children and adolescents who shared meals with their family ≥3 times per week were
more likely to be of normal weight and have healthy dietary and eating patterns, and less likely to engage in
disordered eating than those who shared <3 family meals per week [71]. In a subsequent prospective study,
family meals of any frequency were associated with decreased risk of overweight and obesity in young
adulthood [72].
The responsibility for establishing a healthy eating environment is divided between the child and the
caregivers. The division of responsibility is based upon the child's ability to regulate intake and inability to
choose a well-balanced diet [1,18,21].
Caregiver responsibilities include [1,2]:
● Providing a variety of nutritious foods

● Defining the structure and timing of meals
● Creating a mealtime environment that facilitates eating and social exchange (eg, free of distractions)
● Recognizing and responding to the child's signals of hunger and fullness
● Modeling healthy eating behaviors (eg, consuming a varied diet)
The child's responsibilities include choosing what and how much of the foods offered by the caregiver to
consume.
Caregivers should understand that failure to accept new foods and "eating jags" are normal stages of child
development [1]. Attempts to control the child's eating (eg, by pressuring them to eat specific foods or clean
their plate, bribing, restricting foods) may make the child less sensitive to physiologic cues of satiety and
hunger and contribute to overeating [1,29,73,74]. (See 'Toddlers' above.)
INDICATIONS THAT MAY WARRANT CONSULTATION WITH A DIETITIAN — Indications that may warrant
consultation with a dietitian include:
● Developmental delay
● Chewing and swallowing dysfunction (see "Aspiration due to swallowing dysfunction in infants and
children", section on 'Feeding decisions')
● Cerebral palsy (see "Management and prognosis of cerebral palsy", section on 'Feeding and nutrition')
● Consumption of plant-based milks (other than soy milks fortified with calcium and vitamin D) as a dietary
staple (see 'Dairy products' above)
● Poor weight gain (see "Failure to thrive (undernutrition) in children younger than two years:
Management", section on 'Nutritional therapy' and "Poor weight gain in children older than two years of
age", section on 'Dietary intervention')
● Obesity (see "Management of childhood obesity in the primary care setting", section on 'Diet')
● Diabetes mellitus (see "Management of type 1 diabetes mellitus in children and adolescents", section on
'Nutrition' and "Management of type 2 diabetes mellitus in children and adolescents", section on 'Dietary
prescription')
● Dyslipidemia (see "Dyslipidemia in children: Management", section on 'Dietary modification')
● Food allergy (see "Management of food allergy: Nutritional issues")
● Celiac disease (see "Management of celiac disease in children", section on 'Nutritional considerations')
● Cystic fibrosis (see "Cystic fibrosis: Nutritional issues")
● Vegetarian diets (see "Vegetarian diets for children" and "Vegetarian diets for children", section on
'Nutritional considerations')
DIETARY PATTERNS IN THE UNITED STATES — Cross-sectional surveys of the daily intakes of toddlers
(12 through 23 months) and preschoolers (24 through 47 months) in the United States indicate that most
such children meet their nutritional needs [61,75-78]. However, recommendations regarding dietary
composition and avoidance of trans fat, added sugar, and sweetened beverages are poorly followed, as
illustrated by the following observations [61,75-78]:
● Approximately 20 to 25 percent of toddlers consumed no discrete servings of fruit on any given day
● About one-third of toddlers and preschool children consumed no discrete servings of vegetables on any
given day
● After 12 months of age, french fries and other fried potatoes were the most common vegetable
consumed by toddlers and preschool children
● About one-third of preschoolers were still consuming whole milk
● Between 60 and 90 percent of toddlers and approximately 85 percent of preschoolers consumed some
type of sweetened beverage, dessert, sweet, or salty snack on any given day
RESOURCES
● ChooseMyPlate is an interactive website that provides individual dietary guidance according to age, sex,
and activity level based upon the United States Departments of Agriculture and Health and Human
Services (USDA/HHS) Dietary Guidelines for Americans (older than two years)
● The USDA/HHS Dietary Guidelines for Americans
● The Eatwell Guide (Public Health England) defines recommendations on eating healthily and achieving a
balanced diet
SUMMARY AND RECOMMENDATIONS
● Energy and nutrient requirements for toddlers, preschool, and school-age children vary depending upon
age, sex, and activity level (table 1). (See 'Nutritional requirements' above.)
● During the second year of life, children learn to feed themselves independently and make the transition
to a modified adult diet. Achieving independence and mastery of feeding skills is an important
developmental task of early childhood. It is normal for toddlers to eat variable quantities at any given
meal, to become resistant to trying new foods, and to choose to eat a small number of favorite foods.
(See 'Toddlers' above.)
● The feeding choices and behaviors of preschool children are largely influenced by environmental cues. It
is important for preschool children to sit with the family during meal times (even if the child chooses not
to eat) so that they can observe the eating behaviors and choices of family members. Children and
adolescents who share meals with their family have better health outcomes. (See 'Preschool children'
above.)
● The feeding choices and behaviors of school-age children may be influenced (positively or negatively) by
friends, nonfamily members, and/or the media. Parents may need to balance these potentially negative
influences by increasing positive influences in the home. (See 'School-age children' above.)
● Young children can regulate their energy intake but rely on adults to offer them a variety of nutritious,
developmentally appropriate foods for a well-balanced diet (table 3 and table 4). (See 'Dietary guidelines'
above.)
● Dietary guidelines for children are summarized in the table (table 2). (See 'Dietary guidelines' above.)
● Most young children should be fed four to six times per day. Snacks are an essential component of the
young child's diet. (See 'Frequency of feeding' above and 'Snacks' above.)
● Appropriate portion sizes vary depending upon the child's age and the particular food (table 3 and table
4). Serving children portions that are larger than recommended for their age may contribute to
overeating. (See 'Portion size' above.)
● Routine supplementation of vitamins and minerals is not necessary for healthy growing children who
consume a varied diet and have adequate exposure to sunlight. Children who drink non-cow's milk (eg,
goat's milk or plant-based milks such as soy, rice, almond, coconut, etc) may require supplemental
vitamin D. (See 'Vitamin and mineral supplements' above.)
● In the establishment of a healthy eating environment, the caregiver is responsible for providing a variety
of nutritious foods; defining the structure and timing of meals; creating a mealtime environment that
facilitates eating and social exchange; and recognizing and responding to the child's signals of hunger
and fullness. The child is responsible for participating in food selection and determining how much is
consumed at each eating occasion. (See 'Eating environment' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. American Academy of Pediatrics Committee on Nutrition. Feeding the child. In: Pediatric Nutrition, 7th e
d, Kleinman RE, Greer FR (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2014. p.143.
2. Promoting healthy nutrition. In: Bright Futures: Guidelines for Health Supervision of Infants, Children, an
d Adolescents, 4th ed, Hagan JF, Shaw JS, Duncan PM (Eds), American Academy of Pediatrics, Elk Gr
ove Village, IL 2017. p.167.
3. Picciano MF, Smiciklas-Wright H, Birch LL, et al. Nutritional guidance is needed during dietary transition
in early childhood. Pediatrics 2000; 106:109.
4. Heyman MB, Abrams SA, SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION,
COMMITTEE ON NUTRITION. Fruit Juice in Infants, Children, and Adolescents: Current
Recommendations. Pediatrics 2017; 139.
5. Gidding SS, Dennison BA, Birch LL, et al. Dietary recommendations for children and adolescents: a
guide for practitioners: consensus statement from the American Heart Association. Circulation 2005;
112:2061.
6. Nicklaus S, Chabanet C, Boggio V, Issanchou S. Food choices at lunch during the third year of life:
increase in energy intake but decrease in variety. Acta Paediatr 2005; 94:1023.
7. Nicklaus S, Boggio V, Issanchou S. Food choices at lunch during the third year of life: high selection of
animal and starchy foods but avoidance of vegetables. Acta Paediatr 2005; 94:943.
8. Gooze RA, Anderson SE, Whitaker RC. Prolonged bottle use and obesity at 5.5 years of age in US
children. J Pediatr 2011; 159:431.
9. Phalen JA. Managing feeding problems and feeding disorders. Pediatr Rev 2013; 34:549.
10. Johnson SL, Bellows L, Beckstrom L, Anderson J. Evaluation of a social marketing campaign targeting
preschool children. Am J Health Behav 2007; 31:44.
11. Wardle J, Herrera ML, Cooke L, Gibson EL. Modifying children's food preferences: the effects of
exposure and reward on acceptance of an unfamiliar vegetable. Eur J Clin Nutr 2003; 57:341.
12. Wardle J, Cooke LJ, Gibson EL, et al. Increasing children's acceptance of vegetables; a randomized
trial of parent-led exposure. Appetite 2003; 40:155.
13. Roberto CA, Baik J, Harris JL, Brownell KD. Influence of licensed characters on children's taste and
snack preferences. Pediatrics 2010; 126:88.
14. Lapierre MA, Vaala SE, Linebarger DL. Influence of licensed spokescharacters and health cues on
children's ratings of cereal taste. Arch Pediatr Adolesc Med 2011; 165:229.
15. Muñoz KA, Krebs-Smith SM, Ballard-Barbash R, Cleveland LE. Food intakes of US children and
adolescents compared with recommendations. Pediatrics 1997; 100:323.
16. Kant AK. Reported consumption of low-nutrient-density foods by American children and adolescents:
nutritional and health correlates, NHANES III, 1988 to 1994. Arch Pediatr Adolesc Med 2003; 157:789.
17. Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary sources of nutrients among US children, 1989-
1991. Pediatrics 1998; 102:913.
18. Birch LL, Johnson SL, Andresen G, et al. The variability of young children's energy intake. N Engl J
Med 1991; 324:232.
19. Fox MK, Devaney B, Reidy K, et al. Relationship between portion size and energy intake among infants
and toddlers: evidence of self-regulation. J Am Diet Assoc 2006; 106:S77.
20. Fomon SJ. Taste acquisition and appetite control. Pediatrics 2000; 106:1278.
21. Satter EM. The feeding relationship. J Am Diet Assoc 1986; 86:352.
22. Trumbo P, Schlicker S, Yates AA, et al. Dietary reference intakes for energy, carbohydrate, fiber, fat,
fatty acids, cholesterol, protein and amino acids. J Am Diet Assoc 2002; 102:1621.
23. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and
Adolescents, National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for
cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics 2011;
128 Suppl 5:S213.
24. Pyne V, Macdonald IA. Update on carbohydrates and health: the relevance of the Scientific Advisory
Committee on Nutrition report for children. Arch Dis Child 2016; 101:876.
25. Vos MB, Kaar JL, Welsh JA, et al. Added Sugars and Cardiovascular Disease Risk in Children: A
Scientific Statement From the American Heart Association. Circulation 2017; 135:e1017.
26. USDA Dietary Reference Intakes (DRIs) fnic.nal.usda.gov/nal_display/index.php?tax_level=1&info_cent
er=4&tax_subject=256html (Accessed on September 13, 2011).
27. Hampl JS, Anderson JV, Mullis R, American Dietetic Association. Position of the American Dietetic
Association: the role of dietetics professionals in health promotion and disease prevention. J Am Diet
Assoc 2002; 102:1680.
28. US Department of Health and Human Services. Dietary Guidelines for Americans, 2015. www.health.go
v/dietaryguidelines/ (Accessed on January 08, 2016).
29. Johnson SL, Birch LL. Parents' and children's adiposity and eating style. Pediatrics 1994; 94:653.
30. Birch LL, Deysher M. Conditioned and unconditioned caloric compensation: evidence for self-regulation
of food intake by young children. Learn Motiv 1985; 16:341.
31. Sacks FM, Lichtenstein AH, Wu JHY, et al. Dietary Fats and Cardiovascular Disease: A Presidential
Advisory From the American Heart Association. Circulation 2017; 136:e1.
32. Kris-Etherton PM, Harris WS, Appel LJ, American Heart Association. Nutrition Committee. Fish
consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation 2002; 106:2747.
33. US Food and Drug Administration. United States Environmental Protection Agency. Eating fish: What pr
egnant women and parents should know. http://www.fda.gov/Food/FoodborneIllnessContaminants/Meta
ls/ucm393070.htm (Accessed on January 19, 2017).
34. Kim SA, Grimm KA, May AL, et al. Strategies for pediatric practitioners to increase fruit and vegetable
consumption in children. Pediatr Clin North Am 2011; 58:1439.
35. Hyams JS, Etienne NL, Leichtner AM, Theuer RC. Carbohydrate malabsorption following fruit juice
ingestion in young children. Pediatrics 1988; 82:64.
36. Dennison BA. Fruit juice consumption by infants and children: a review. J Am Coll Nutr 1996; 15:4S.
37. Lifschitz CH. Carbohydrate absorption from fruit juices in infants. Pediatrics 2000; 105:e4.
38. Smith MM, Lifshitz F. Excess fruit juice consumption as a contributing factor in nonorganic failure to
thrive. Pediatrics 1994; 93:438.
39. König KG, Navia JM. Nutritional role of sugars in oral health. Am J Clin Nutr 1995; 62:275S.
40. Gibson SA. Non-milk extrinsic sugars in the diets of pre-school children: association with intakes of
micronutrients, energy, fat and NSP. Br J Nutr 1997; 78:367.
41. Auerbach BJ, Wolf FM, Hikida A, et al. Fruit Juice and Change in BMI: A Meta-analysis. Pediatrics
2017.
42. Agostoni C, Riva E, Giovannini M. Dietary fiber in weaning foods of young children. Pediatrics 1995;
96:1002.
43. Davidsson L, Mackenzie J, Kastenmayer P, et al. Dietary fiber in weaning cereals: a study of the effect
on stool characteristics and absorption of energy, nitrogen, and minerals in healthy infants. J Pediatr
Gastroenterol Nutr 1996; 22:167.
44. Williams CL, Bollella M, Wynder EL. A new recommendation for dietary fiber in childhood. Pediatrics
1995; 96:985.
45. Kranz S, Mitchell DC, Siega-Riz AM, Smiciklas-Wright H. Dietary fiber intake by American preschoolers
is associated with more nutrient-dense diets. J Am Diet Assoc 2005; 105:221.
46. Scharf RJ, Demmer RT, DeBoer MD. Longitudinal evaluation of milk type consumed and weight status
in preschoolers. Arch Dis Child 2013; 98:335.
47. Huh SY, Rifas-Shiman SL, Rich-Edwards JW, et al. Prospective association between milk intake and
adiposity in preschool-aged children. J Am Diet Assoc 2010; 110:563.
48. Moore LL, Bradlee ML, Gao D, Singer MR. Effects of average childhood dairy intake on adolescent
bone health. J Pediatr 2008; 153:667.
49. Lee GJ, Birken CS, Parkin PC, et al. Consumption of non-cow's milk beverages and serum vitamin D
levels in early childhood. CMAJ 2014; 186:1287.
50. Hasemann A. Yogurt: Nutritious food or sugary treat. Pract Gastroenterol 2014; 38:37.
51. Dietary carbohydrates: Sugars and starches. In: Dietary Reference Intakes: The Essential Guide to Nutr
ient Requirements, Otten JJ, Hellwig JP, Meyers LD (Eds), National Academies Press, Washington, DC
2006. p.103.
52. Johnson RK, Appel LJ, Brands M, et al. Dietary sugars intake and cardiovascular health: a scientific
statement from the American Heart Association. Circulation 2009; 120:1011.
53. DeBoer MD, Scharf RJ, Demmer RT. Sugar-sweetened beverages and weight gain in 2- to 5-year-old
children. Pediatrics 2013; 132:413.
54. Council on School Health, Committee on Nutrition. Snacks, sweetened beverages, added sugars, and
schools. Pediatrics 2015; 135:575.
55. US Department of Health and Human Services. The Report of the Dietary Guidelines Advisory Committ
ee on Dietary Guidelines for Americans, 2005. https://health.gov/dietaryguidelines/dga2005/report/ (Acc
essed on September 08, 2016).
56. Ziegler P, Hanson C, Ponza M, et al. Feeding Infants and Toddlers Study: meal and snack intakes of
Hispanic and non-Hispanic infants and toddlers. J Am Diet Assoc 2006; 106:S107.
57. Morgan KJ, Zabik ME, Leveille GA. The role of breakfast in nutrient intake of 5- to 12-year-old children.
Am J Clin Nutr 1981; 34:1418.
58. Preziosi P, Galan P, Deheeger M, et al. Breakfast type, daily nutrient intakes and vitamin and mineral
status of French children, adolescents, and adults. J Am Coll Nutr 1999; 18:171.
59. Orlet Fisher J, Rolls BJ, Birch LL. Children's bite size and intake of an entrée are greater with large
portions than with age-appropriate or self-selected portions. Am J Clin Nutr 2003; 77:1164.
60. Bailey RL, Fulgoni VL 3rd, Keast DR, et al. Do dietary supplements improve micronutrient sufficiency in
children and adolescents? J Pediatr 2012; 161:837.
61. Butte NF, Fox MK, Briefel RR, et al. Nutrient intakes of US infants, toddlers, and preschoolers meet or
exceed dietary reference intakes. J Am Diet Assoc 2010; 110:S27.
62. Goldman RD, Vohra S, Rogovik AL. Potential vitamin-drug interactions in children: at a pediatric
emergency department. Paediatr Drugs 2009; 11:251.
63. Committee on Infectious Diseases, Committee on Nutrition, American Academy of Pediatrics.
Consumption of raw or unpasteurized milk and milk products by pregnant women and children.
Pediatrics 2014; 133:175.
64. Rangel JM, Sparling PH, Crowe C, et al. Epidemiology of Escherichia coli O157:H7 outbreaks, United
States, 1982-2002. Emerg Infect Dis 2005; 11:603.
65. Centers for Disease Control and Prevention (CDC). Escherichia coli 0157:H7 infections in children
associated with raw milk and raw colostrum from cows--California, 2006. MMWR Morb Mortal Wkly Rep
2008; 57:625.
66. US Food and Drug Administration. Questions &Answers: Raw Milk. www.fda.gov/food/foodsafety/produ
ct-specificinformation/milksafety/ucm122062.htm (Accessed on September 13, 2011).
67. Robinson TJ, Scheftel JM, Smith KE. Raw milk consumption among patients with non-outbreak-related
enteric infections, Minnesota, USA, 2001-2010. Emerg Infect Dis 2014; 20:38.
68. Centers for Disease Control and Prevention. Food Safety and Raw Milk. www.cdc.gov/foodsafety/rawmi
lk/raw-milk-index.html (Accessed on July 08, 2014).
69. Costard S, Espejo L, Groenendaal H, Zagmutt FJ. Outbreak-Related Disease Burden Associated with
Consumption of Unpasteurized Cow's Milk and Cheese, United States, 2009-2014. Emerg Infect Dis
2017; 23:957.
70. Food and Drug Administration. Grade "A" pasteurized milk ordinance: 2003 revision. US Department of
Health and Human Services Rockville, MD 2004. www.cfsan.fda.gov/~ear/pmo03toc.html (Accessed on
September 13, 2011).
71. Hammons AJ, Fiese BH. Is frequency of shared family meals related to the nutritional health of children
and adolescents? Pediatrics 2011; 127:e1565.
72. Berge JM, Wall M, Hsueh TF, et al. The protective role of family meals for youth obesity: 10-year
longitudinal associations. J Pediatr 2015; 166:296.
73. Fisher JO, Birch LL. Restricting access to palatable foods affects children's behavioral response, food
selection, and intake. Am J Clin Nutr 1999; 69:1264.
74. Faith MS, Berkowitz RI, Stallings VA, et al. Parental feeding attitudes and styles and child body mass
index: prospective analysis of a gene-environment interaction. Pediatrics 2004; 114:e429.
75. Briefel RR, Kalb LM, Condon E, et al. The Feeding Infants and Toddlers Study 2008: study design and
methods. J Am Diet Assoc 2010; 110:S16.
76. Siega-Riz AM, Deming DM, Reidy KC, et al. Food consumption patterns of infants and toddlers: where
are we now? J Am Diet Assoc 2010; 110:S38.
77. Fox MK, Condon E, Briefel RR, et al. Food consumption patterns of young preschoolers: are they
starting off on the right path? J Am Diet Assoc 2010; 110:S52.
78. Miles G, Siega-Riz AM. Trends in Food and Beverage Consumption Among Infants and Toddlers: 2005-
2012. Pediatrics 2017; 139.
Topic 2866 Version 37.0
GRAPHICS
Estimated energy requirements (low activity) and recommended dietary

allowance (RDA) of selected nutrients for infants, children, and adolescents
Energy Protein Total fat Iron Calcium Zinc

Age
(kcal/day) (g/day) (g/day) (mg/day) (mg/day) (mg/day)
1-3 years
Boys 850-1300 13 30-40 7 700 3
Girls 750-1250 13 30-40 7 700 3
4-8 years
Boys 1400-1700 19 25-35 10 1000 5
Girls 1300-1600 19 25-35 10 1000 5
9-13 years
Boys 1800-2300 34 25-35 8 1300 8
Girls 1700-2000 34 25-35 8 1300 8
14-18 years
Boys 2500-2800 52 25-35 11 1300 11
Girls 2000 46 25-35 15 1300 9
Adapted from:
1. The Dietary Reference Intakes, National Academy of Sciences, Washington, DC, 2002.
2. National Academies Press. Dietary Reference Intakes for Calcium and Vitamin D (2010). Available at
http://books.nap.edu/openbook.php?record_id=13050&page=291. Accessed on December 13, 2010.
Graphic 78274 Version 12.0
Dietary guidelines for children older than one year
General guidelines
A variety of nutrient-dense foods from the basic food groups (cow's milk/milk products or fortified soy products,
meat/protein, grains, fruits/vegetables) should be offered each day.
Foods and beverages should contain or be prepared with little added salt, sugar, or caloric sweeteners.
Fat
1 to 2 years: Fat and cholesterol intake are not restricted.
2 to 3 years: Fat should comprise 30 to 40 percent of total energy intake; saturated fats should be limited to <10
percent of total energy intake; intake of trans fats should be as low as possible.
4 to 18 years: Fat should comprise 25 to 35 percent of total energy intake; fat intake should not be restricted to
<20 percent of total energy intake; saturated fats should be limited to <10 percent of total energy intake; intake of
trans fats should be as low as possible.
Meat/protein
Select and prepare meat, poultry, fish, and dried beans with as little fat as possible.
Fruits, vegetables, and fruit juice

A colorful variety of fruits and vegetables should be offered each day.
Whole fruit is preferred to fruit juice, but one-half of the recommended daily servings can be provided in the form of
100 percent fruit juice.
Consumption of 100 percent fruit juice should be limited to 4 ounces (120 mL) in children aged 1 through 3 years, 4
to 6 ounces (120 to 180 mL) in children aged 4 through 6 years, and 8 ounces (240 mL) in children older than 7
years.
Grains
At least one-half of total grains consumed should be whole grains. When reading the label, "whole grain" should be
the first ingredient.
Cow's milk or fortified soy milk

1 to 2 years: At least 2 cups (~480 mL) of whole cow's milk per day (or equivalent products).
2 to 8 years: At least 2 to 3 cups (~480 to 720 mL) of fat-free or low-fat milk per day (or equivalent products).
≥9 years: At least 3 cups (~720 mL) of fat-free or low-fat milk per day (or equivalent products).
Beverages
Plain, unflavored water is the preferred beverage for children, particularly when fluids are consumed outside of
meals and snacks.
Data from:
1. Committee on Nutrition American Academy of Pediatrics. Feeding the Child. In: Pediatric Nutrition Handbook, 6 th
ed, Kleinman RE (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2009. p.145.
2. US Department of Health and Human Services. Dietary Guidelines for Americans, 2015.
www.health.gov/dietaryguidelines/ (Accessed on January 08, 2016).
3. Gidding SS, Dennison BA, Birch LL, et al. Dietary recommendations for children and adolescents: A guide for
practitioners: Consensus statement from the American Heart Association. Circulation 2005; 112:2061.
4. National Academies of Sciences, Engineering, and Medicine. Dietary reference intakes for calcium and vitamin D.
Available at: http://www.nationalacademies.org/hmd/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-
Vitamin-D/DRI-Values.aspx (Accessed on August 18, 2016).
5. Heyman MB, Abrams SA, AAP Section on Gastroenterology, Hepatology, and Nutrition, Committee on Nutrition.
Fruit juice in infants, children, and adolescents: Current recommendations. Pediatrics 2017; 139:e20170967.
Dietary recommendations for toddlers to early-school-age children
Age 12 to Age 2 to 3 Age 4 to 8

Food groups and number of daily servings
23 months years years
Milk and milk products*
Low-fat or fat-free milk or milk products. 2 cups/day 2 to 2.5 2.5 to 3 cups/day

(whole milk or cups/day
milk products)
1 cup equivalent =
1 cup of milk or yogurt, 1½ ounces of natural cheese, 2
ounces of processed cheese, 1/3 cup of shredded
cheese
Meat and other protein foods
Includes beef, chicken, pork, poultry, fish, eggs, 1½ ounces/day 2 ounces/day 3 to 4

peanut butter, and legumes. ounces/day
1 ounce equivalent =
1 ounce of beef, poultry, or fish, ¼ cup cooked beans, 1
egg, 1 tablespoon peanut butter ¶, ½ ounce of nuts ¶
Breads, cereals and starches
Includes whole-grain breads, infant and cooked 2 ounces/day 3 ounces/day 4 to 5

cereals, rice, pasta, ready-to-eat cereals. Half of all ounces/day
starches should be whole grains.
1 slice whole-grain bread, ½ cup cooked cereal, rice or
pasta, 1 cup dry cereal
Fruits
Includes one source of vitamin C daily (citrus fruits 1 cup/day 1 cup/day 1 to 1½ cups/day
and juices, strawberries) and one source of vitamin A
1 cup equivalent =
every other day (dark green and yellow fruits,
melons). 1 cup of fruit or 100 percent fruit juice Δ, ½ cup of dried
fruit
Vegetables
Includes one source of vitamin C daily (broccoli and ¾ cup/day 1 cup/day 1½ cups/day
tomatoes) and one source of vitamin A every other
1 cup equivalent =
day (spinach, sweet potatoes, corn, squash).
1 cup of raw or cooked vegetables or vegetable juice, 2
cups of raw leafy greens
Fats and oils
Includes margarine, butter, oils. Do not limit* 3 teaspoons/day 4 teaspoons/day
1 teaspoon equivalent =
1 teaspoon oil, margarine, butter or mayonnaise, 1
tablespoon salad dressing, sour cream or light
mayonnaise
Miscellaneous
Desserts, sweets, soft drinks, candy, jams and jelly. Limit to small amount, use sparingly
Limit intake 100 100 discretionary

discretionary kilocalories ◊
kilocalories ◊
NOTE: For more details, go to www.choosemyplate.gov.
* Low fat products are not recommended for children under the age of 2.
¶ May be a choking hazard for children under the age of 3.
Δ Children should be encouraged to consume whole fruits. Recommend limiting fruit juice to 4 to 6 ounces (120 to 180
mL) for children 4 through 6 years of age. Recommend limiting fruit juice to 8 ounces (240 mL) for children 7 to 18 years
of age.
◊ Discretionary kilocalories are those available for consumption as added sugars or solid fats after essential daily nutrient
requirements are met.
Adapted with permission from: Texas Children's Hospital Pediatric Nutrition Reference Guide 2010, 9 th ed, Bunting KD,
Mills J, Phillips S, et al (Eds). Copyright © 2010 Texas Children's Hospital. All rights reserved.
Additional data from:
1. Vos MB, Kaar JL, Welsh JA, et al. Added sugars and cardiovascular disease risk in children: A scientific statement
from the American Heart Association. Circulation 2016.
Dietary recommendations for school-age children to adolescents
Age 14 to 18
Food groups and number of servings Age 9 to 13 years
years
Milk and milk products
Low-fat or fat-free milk or milk products 3 cups/day 3 cups/day
1 cup equivalent =
1 cup of milk or yogurt, 1½ ounces of a natural
cheese, 2 ounces of processed cheese, 1/3 cup of
shredded cheese
Meat and other protein foods
Includes beef, chicken, pork, poultry, fish, eggs, peanut 5 ounces/day 5 to 6 ounces/day
butter, and legumes
1 ounce of beef, poultry or fish, ¼ cup cooked
beans, 1 egg, 1 tablespoon peanut butter, ½ ounce
of nuts
Breads, cereals, and starches
Includes whole-grain breads, infant and cooked cereals, 5 to 6 ounces/day 6 to 7 ounces/day

rice, pasta, ready to eat cereals. Half of all starches
should be whole grains.
1 slice whole-grain bread, ½ cup cooked cereal, rice,
or pasta, 1 cup dry cereal
Fruits
Includes one source of vitamin C daily (citrus fruits and 1½ cups/day 1½ to 2 cups/day
juices, strawberries) and one source of vitamin A every
1 cup equivalent =
other day (dark green and yellow fruits, melons)
1 cup of fruit or 100 percent fruit juice*, ½ cup of
dried fruit
Vegetables
Includes one source of vitamin C daily (broccoli and 2 to 2½ cups/day 2½ to 3 cups/day

tomatoes) and one source of vitamin A every other day
1 cup equivalent =
(spinach, sweet potatoes, corn, squash)
1 cup of raw or cooked vegetables or vegetable
juice, 2 cups of raw leafy greens
Fats and oils
Includes margarine, butter, oils 5 teaspoons/day 5 to 6 teaspoons/day
1 teaspoon equivalent =
1 teaspoon oil, margarine, butter or mayonnaise, 1
tablespoon salad dressing, sour cream or light
mayonnaise
Miscellaneous
Desserts, sweets, soft drinks, candy, jams and jelly Limit to small amount, use sparingly
Discretionary kilocalories ¶
100 kilocalories 100 kilocalories

(approximately 25 g or 6 (approximately 25 g or 6
teaspoons of added teaspoons of added
sugars) sugars)
NOTE: For more details, go to www.choosemyplate.gov.
* Children should be encouraged to consume whole fruits. Recommend limiting fruit juice to 8 ounces (240 mL) for
children 7 to 18 years of age.
¶ Discretionary kilocalories are those that are available for consumption as added sugars and solid fats after essential
daily nutrient requirements are met.
Reproduced with permission from: Texas Children's Hospital Pediatric Nutrition Reference Guide 2010, 9 th ed, Bunting
KD, Mills J, Phillips S et al (Eds). Copyright © 2010 Texas Children's Hospital. All rights reserved.
Additional data from:

1. Vos MB, Kaar JL, Welsh JA, et al. Added sugars and cardiovascular disease risk in children: A scientific statement
from the American Heart Association. Circulation 2016.
Sources of dietary fat
Type of fat Food sources
Monounsaturated fatty Vegetable oils (canola, olive, sunflower, safflower), peanut, tree nuts, seeds, avocado
acids
Polyunsaturated fatty ALA - Vegetable oils (canola, soybean, walnut), flax/linseed/hemp/chia seed, wheat
acids; n-3 or omega-3 germ; also vegetables of the cabbage family and some fortified eggs
EPA and DHA - Seafood (especially fatty fish); some infant formulas and fortified eggs
Polyunsaturated fatty LA - Vegetable oils (soybean, corn, cottonseed), peanut, tree nuts, seeds, other
acids; n-6 or omega-6 vegetable sources, poultry
Saturated fatty acids Full-fat or fat-reduced dairy products, meat, poultry, vegetable oils (coconut, palm
kernel, palm)
Trans fatty acids Partially hydrogenated vegetable oils (stick and full-fat margarine, commercial baked
goods, deep fried foods)
ALA: alpha-linolenic acid; EPA: eicosapentaenoic acid; DHA: docosahexaenoic acid; LA: linoleic acid.
Tips for safe food handling to avoid microbial food-borne illness (food poisoning)
Purchase
Do not buy precooked food that is stored adjacent to raw food, even if stored on ice.
Do not buy canned goods that are dented, cracked, or have a bulging lid.
Storage
Make sure meat and poultry products are refrigerated when purchased.
Use plastic bags to keep drippings from packages of meat and fish from contact with other foods.
Store perishable items in the refrigerator within one hour of purchase.
Maintain home refrigerator temperature between 32 and 40°F (0 and 4°C) and freezer temperature at ≤0°F
(-18°C).
Freeze meat and poultry that will not be cooked within 48 hours.
Freeze tuna, bluefish, and mahi-mahi that will not be cooked within 24 hours; other fish can be stored in the
refrigerator for 48 hours.
Do not store eggs on the refrigerator door (warmest part of the refrigerator).
Refrigerate cooked foods within two hours of preparation.
Divide leftovers into small portions and store in shallow containers.
Reheat leftovers to 165°F (74°C).
Preparation
Wash hands with soap and water before food preparation and after handling raw meat, poultry, fish, and uncooked
eggs.
Thaw frozen meats and fish in the refrigerator or microwave, not at room temperature.
Marinate foods in the refrigerator, not at room temperature.
Avoid contact of cooked foods with contaminated utensils, plates, or food preparation surfaces.
Wash utensils, plates, and cutting surfaces with soap and water after contact with raw meat, poultry, fish, or eggs.
Avoid contact of juices from uncooked meat, poultry, or fish with cooked foods or foods that will be eaten raw.
Thoroughly wash all fresh fruits and vegetables.
Avoid recipes using raw eggs.
Cooking
Use a meat thermometer to monitor internal cooking temperatures:
Cook fresh beef, veal, and lamb (eg, steaks, roasts, or chops) to an internal temperature of 145°F (63°C) and
rest for 3 minutes
Cook ground beef, pork, veal, and lamb to 160°F (71°C)
Cook ground poultry to 165°F (74°C)
Cook poultry to 165°F (74°C)
Cook fresh pork (eg, roasts, chops, raw ham) to 145°F (63°C) and rest for 3 minutes
Cook precooked ham to 140°F (60°C)
Cook fin fish until 145°F (63°C) or until flesh is opaque and separates easily with a fork
Cook shrimp, lobster, and crabs until flesh is pearly and opaque
Cook unshucked clams, oysters, and mussels until shells open during cooking; discard the ones that do not open
Cook shucked oysters, clams, and mussels until they are opaque and firm
Cook scallops until flesh is milky white or opaque and firm
Cook eggs until the yolk and white are firm.
Boil marinade from raw meat or fish before using it on cooked food.
Serving
Serve cooked products on clean plates with clean utensils.
Keep hot foods at 140°F (60°C) and cold foods below 40°F (4°C).
Never leave foods at room temperature longer than two hours (one hour if the ambient temperature is >90°F
(32°C)).
Use coolers and ice packs to transport perishable foods away from home.
United States Department of Agriculture. Food Safety. Safe minimum cooking temperatures. Available at:
www.foodsafety.gov/keep/charts/mintemp.html (Accessed on January 11, 2016).
Contributor Disclosures
Teresa K Duryea, MD Nothing to disclose Jan E Drutz, MD Nothing to disclose Kathleen J Motil, MD,
PhD Nothing to disclose Mary M Torchia, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

Dietary Recommendations For Toddlers, Preschool, and School-Age Children - UpToDate

Uploaded by

Copyright:

Available Formats

You might also like

Dietary Recommendations For Toddlers, Preschool, and School-Age Children - UpToDate

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Dietary Recommendations For Toddlers, Preschool, and School-Age Children - UpToDate

Uploaded by

Copyright:

Available Formats

10/11/2017 Dietary recommendations for toddlers, preschool, and school-age children - UpToDate

Official reprint from UpToDate®

Author: Teresa K Duryea, MD

FEEDING DEVELOPMENT — Achieving independence and mastery of feeding skills is an important

Normal toddler feeding behaviors include [1,2]:

● 2 through 3 years – Approximately 1 ounce (28 g) per serving

● One through 3 years – 4 ounces (120 mL)

● Added sugars be avoided in children <2 years of age

● From neglected or deprived environments.

● With anorexia or inadequate appetite.

● Toddlers should always be supervised while eating

● Raw (unpasteurized) milk or juice

Caregiver responsibilities include [1,2]:

● Providing a variety of nutritious foods

● Dyslipidemia (see "Dyslipidemia in children: Management", section on 'Dietary modification')

● Food allergy (see "Management of food allergy: Nutritional issues")

● Cystic fibrosis (see "Cystic fibrosis: Nutritional issues")

● About one-third of preschoolers were still consuming whole milk

● The USDA/HHS Dietary Guidelines for Americans

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 2866 Version 37.0

Estimated energy requirements (low activity) and recommended dietary

Energy Protein Total fat Iron Calcium Zinc

Boys 850-1300 13 30-40 7 700 3

Girls 750-1250 13 30-40 7 700 3

Boys 1400-1700 19 25-35 10 1000 5

Girls 1300-1600 19 25-35 10 1000 5

Boys 1800-2300 34 25-35 8 1300 8

Girls 1700-2000 34 25-35 8 1300 8

Boys 2500-2800 52 25-35 11 1300 11

Girls 2000 46 25-35 15 1300 9

Graphic 78274 Version 12.0

Dietary guidelines for children older than one year

Fruits, vegetables, and fruit juice

Cow's milk or fortified soy milk

Graphic 79084 Version 11.0

Dietary recommendations for toddlers to early-school-age children

Age 12 to Age 2 to 3 Age 4 to 8

Milk and milk products*

Low-fat or fat-free milk or milk products. 2 cups/day 2 to 2.5 2.5 to 3 cups/day

Meat and other protein foods

Includes beef, chicken, pork, poultry, fish, eggs, 1½ ounces/day 2 ounces/day 3 to 4

Breads, cereals and starches

Includes whole-grain breads, infant and cooked 2 ounces/day 3 ounces/day 4 to 5

Fats and oils

Includes margarine, butter, oils. Do not limit* 3 teaspoons/day 4 teaspoons/day

Limit intake 100 100 discretionary

NOTE: For more details, go to www.choosemyplate.gov.

Graphic 60734 Version 16.0

Dietary recommendations for school-age children to adolescents

Milk and milk products

Low-fat or fat-free milk or milk products 3 cups/day 3 cups/day

Meat and other protein foods

Breads, cereals, and starches

Includes whole-grain breads, infant and cooked cereals, 5 to 6 ounces/day 6 to 7 ounces/day

Includes one source of vitamin C daily (broccoli and 2 to 2½ cups/day 2½ to 3 cups/day