This article was published in the November 2018 edition of NHD Magazine.

Toddlerhood (between one and three years old) is a time of rapid growth and development.

Malnutrition during these early years can lead to stunted growth, and problems with behavioural development and learning¹.

Following the exposure to new tastes and feeding experiences during infancy, toddlers are continuing on their journey of food discovery. Development of biting and chewing skills also continues at this age. For example, between 18 – 24 months toddlers will begin to chew with their lips closed².

Nutrient Intake

The results of the most recent National Diet and Nutrition Survey (NDNS) from 2014 – 2016 are outlined in table one, along with an explanation of what role these nutrients play in a toddler’s diet^3-8.

Table one: Results of NDNS survey of children aged 1.5 – 3 years*

* Table devised using references 3 – 12

Sugar intake for those who were 18 months to three years old was found to be more than double the recommended limit

Only 13% of toddlers achieved a sugar intake which was below or equal to 5% of total energy. The main source of free sugar intake in this age group was found to be ‘cereal and cereal products’, with the second highest source being fruit juice and soft drinks, followed by ‘sugar, preserves and confectionery’.

One of the risks associated with excess sugar intake in children is dental caries, and 28% of 5 year olds in England are already found to have tooth decay^7,13.

Fibre intake was found to be 5g below the daily recommended amount for toddlers

‘Cereals and cereal products’ being the main source of fibre, followed by ‘vegetables and potatoes’ and then fruit.

After the age of two, wholegrain foods can be gradually introduced to a toddler’s diet¹⁴. Before this, the high fibre content of wholegrains can make a toddler feel full before they have consumed enough calories and nutrients.

Although protein is an important nutrient for toddlers to consume, the overall protein intake from the NDNS appears to be very high in this group. This is worrying as this can effect bone health, kidney health and increase the risk of obesity in later life.

Another notable results of the NDNS was that iron intake was slightly low and vitamin D intake was very low in toddlers, even when intake from supplements was included.

Toddlers in the UK tend to have a good intake of iodine, however those who avoid cow’s milk are at a higher risk of deficiency as this is the main source of iodine in the UK¹⁵.

The amount of salt in a toddler’s diet should also be limited, especially as the average intake in the age group in the UK was found to be 2.3g of salt per day, which is above the recommended limit of 2g per day¹⁶.

Intake From Food Groups

The recommended portion sizes and distribution of food groups is outlined in the ‘5532-a-day’ image from the British Nutrition Foundation below¹⁷.

When the data for daily energy intake from various food groups from the most recent NDNS are compared with this, it seems that intake of starchy foods, dairy foods and protein are close to the recommended amount.

But toddlers seem to have a low intake of fruit and vegetables.

And although these are not necessary in most toddlers’ diet, they also appear to be having a regular intake of: sugary drinks, sugary snacks, and savoury snacks.

Image source: https://www.nutrition.org.uk/healthyliving/toddlers/5532aday.html

Breastfeeding Advice

The World Health Organisation (WHO) advise that babies should be breastfed exclusively for the first six months of life, and “thereafter infants should receive complementary foods with continued breastfeeding up to 2 years of age or beyond”¹⁸

This advice to continue breastfeeding beyond twelve months is because breast milk continues to provide energy, hydration and key nutrients.

However, it is rare in the UK to breastfeed beyond 12 months¹⁹

In developing countries continued breastfeeding is linked with improved growth and a lower risk of infant mortality²⁰.

There is not much research which has examined the effect of breastfeeding past infancy in developed countries. A relatively small study from America in 2016 found that the mothers’ breast milk in the second year of lactating had a significant increase in total protein, prebiotics (oligosaccharides) and proteins which boost immunity, as compared with mothers in the first year of lactating²¹. This study also found that zinc and calcium levels reduced in breastmilk in the second year of lactating, and no changes were found in lactose, fat, iron or potassium levels.

An older study also found that 448ml of breastmilk in the second year of lactation provides:²²

• 29% of energy requirements
• 43% of protein requirements
• 36% of calcium requirements
• 75% of vitamin A requirements
• 60% of vitamin C requirements
• 76% of folate requirements
• 94% of vitamin B12 requirements

A systematic review by Victora et al. (2016) identified an increase in tooth decay in children who were breastfed for more than 12 months. However this study also highlighted that “this should not lead to discontinuation of breastfeeding, but rather to improved oral hygiene”²³.

Nutritional Supplements

In the UK, all children from the age of one to five are advised have a daily age-appropriate supplement which contains vitamin A, vitamin C and 10 microgram of vitamin D^24-25.  

These can be bought in a pharmacy or supermarket, or they can be obtained on the ‘Healthy Start Scheme’ for those who are eligible.

Advice About Drinks

Water is the best drink for toddlers.

Baby bottles should be stopped by age of one, as this can become a comfort and can cause tooth decay²⁶. Instead, drinks should be given from a beaker with a free-flow lid, and when a toddler is ready they should be encouraged to drink from an open cup²⁶.

Milk can be given to toddlers, and it is an important source of calcium. However, toddlers should ideally have no more than two or three glasses of milk per day, depending on how many other dairy foods they eat¹⁴. This is because drinking too much milk is associated with increasing the risk of anaemia and providing excess protein²⁷.

Full fat milk should be given until a toddler is two years old, but from the age of two the fat content of most toddler’s diet can be reduced; as long as they are growing well and have a balanced and varied diet². Semi-skimmed milk can be given from two years old, but skimmed milk should not be offered until they are five years old². Rice milk should not be given to children under five years, as it can contain traces of arsenic²⁶.

Fruit juice is a good source of vitamin C, but to reduce the risk of tooth decay it needs to be diluted with one part juice to 10 parts of water for toddlers²⁶.

Squash, ‘juice drinks’, fizzy drinks, flavoured milk, diet or reduced sugar drinks, or ‘baby drinks’ should not be offered to toddlers.

Tea and coffee are also not recommended for this age group, as these drinks can reduce the amount of iron which is absorbed from meals²⁶.  

Fussy Eating

Infants usually start to become hesitant about trying new foods at around 18 months, this is called ‘food neophobia’².

This is a stage where fussy eating behaviour can start to emerge and become reinforced.

To avoid fussy eating becoming a long-term problem it is best to:²⁸

• Establish eating routines
• Eat together as a family to model good eating habits
• Provide varied and balanced meals of appropriate portion sizes
• Encourage self-feeding and messy play
• Give praise when a new food is tried
• Try to remain calm when food is refused

It is also important that everybody involved in taking care of the toddler (including both parents, other family members and nursery staff) are consistent in handling food refusal in an appropriate way.

References:

1. Huffman & Schofield (2011) “Consequences of malnutrition in early life and strategies to improve maternal and child diets through targeted fortified products” [accessed August 2018 via: http://fsnnetwork.org/sites/default/files/consequencs_of_maternal_and_child_nutritution.pdf]
2. Manual of Dietetic Practice. edited by Joan Gandy in conjunction with The British Dietetic Association (5th Edition, 2014).
3. Results of the National Diet and Nutrition Survey (NDNS) rolling programme for 2014 to 2015 and 2015 to 2016 [accessed August 2018 via: https://www.gov.uk/government/statistics/ndns-results-from-years-7-and-8-combined].
4. Department of Health. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. London. HMSO,1991.
5. Great Ormond Street Hospital for Children (2015) “Nutritional Requirements (6th Edition)”.
6. SACN (2016) “Vitamin D and Health” [accessed August 2018 via: https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report]
7. SACN (2015) “Carbohydrates and Health” [accessed August 2018 via: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_Carbohydrates_and_Health.pdf].
8. Manual of Dietetic Practice. edited by Joan Gandy in conjunction with The British Dietetic Association (5th Edition, 2014). Table A.2.1 p. 923.
9. NIH (2012) “Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents” [accessed August 2018 via: https://www.nhlbi.nih.gov/files/docs/peds_guidelines_sum.pdf]
10. SACN (2017) “Draft Feeding in the First Year of Life Report”  [accessed August 2018 via: https://www.gov.uk/government/publications/feeding-in-the-first-year-of-life-sacn-report]
11. Lozoff & Georgieff (2006) “Iron deficiency and brain development” [accessed August 2018 via: https://www.ncbi.nlm.nih.gov/pubmed/17101454]
12. Pearce (2014) “Iodine deficiency in children” [accessed August: https://www.ncbi.nlm.nih.gov/pubmed/25231449]  
13. National Dental Epidemiology Programme for England: oral health survey of five-year-old children 2015
14. NHS Choices (2016) “What to Feed Young Children” [available August 2018 via: https://www.nhs.uk/conditions/pregnancy-and-baby/understanding-food-groups/]
15. BDA Food Fact Sheet ‘Iodine’ [accessed August 2018 via:  https://www.bda.uk.com/foodfacts/Iodine.pdf]
16. Gibson & Sidnell (2014) “Nutrient adequacy and imbalance among young children aged 1–3 years in the UK” [available August 2018 via: https://onlinelibrary.wiley.com/doi/abs/10.1111/nbu.12087]
17. BNF (2014) “5532-a-day resource” [available August 2018 via: https://www.nutrition.org.uk/healthyliving/toddlers/5532aday.html]
18. WHO Website “Breastfeeding” [available August 2018 via: http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/]
19. NCT (2010) “Key Baby Feeding Statistics
    from the 2005 UK Infant Feeding Survey” [available August 2018 via: https://www.nct.org.uk/sites/default/files/KeyBabyFeedingStatistics.pdf]
20. WHO Website “Continued breastfeeding for healthy growth and development of children” [available August 2018 via: http://www.who.int/elena/titles/continued_breastfeeding/en/]
21. Agarwal & Fulgoni (2016) “Assessment of the Infant and Toddler Nutrition Status in the US: A Recent Literature Review”
22. Dewey (2001) “Nutrition, growth, and complementary feeding of the breastfed infant” [available August 2018 via: https://www.ncbi.nlm.nih.gov/pubmed/11236735]
23. Victora et al. (2016) “Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect” [available August 2018 via: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/abstract]
24. SACN (2016) “Vitamin D and Health” [accessed August 2018 via: https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report]
25. NHS Choices (2018) “Vitamins for Children” [accessed August 2018 via: https://www.nhs.uk/conditions/pregnancy-and-baby/vitamins-for-children/]
26. NHS Choices (2015) “Drinks and cups for babies and toddlers” [accessed August 2018 via: (https://www.nhs.uk/conditions/pregnancy-and-baby/drinks-and-cups-children/)
27. Ziegler (2011) “Consumption of cow’s milk as a cause of iron deficiency in infants and toddlers” [accessed August 2018 via: https://www.ncbi.nlm.nih.gov/pubmed/22043881]
28. GOSH Website “Fussy eaters” [accessed August 2018 via: https://www.gosh.nhs.uk/medical-information/general-health-advice/food-and-diet/fussy-eaters]