Major physiological changes continue into the toddler years. Unlike in infancy, the limbs grow much faster than the trunk, which gives the body a more proportionate appearance. By the end of the third year, a toddler is taller and more slender than an infant, with a more erect posture. As the child grows, bone density increases and bone tissue gradually replaces cartilage. This process known as ossification is not completed until puberty.^[1]

Developmental milestones include running, drawing, toilet training, and self-feeding. How a toddler acts, speaks, learns, and eats offers important clues about their development. By the age of two, children have advanced from infancy and are on their way to becoming school-aged children. Their physical growth and motor development slows compared to the progress they made as infants. However, toddlers experience enormous intellectual, emotional, and social changes. Of course, food and nutrition continue to play an important role in a child’s development. During this stage, the diet completely shifts from breastfeeding or bottle-feeding to solid foods along with healthy juices and other liquids. Parents of toddlers also need to be mindful of certain nutrition-related issues that may crop up during this stage of the human life cycle. For example, fluid requirements relative to body size are higher in toddlers than in adults because children are at greater risk of dehydration.

The toddler years pose interesting challenges for parents or other caregivers, as children learn how to eat on their own and begin to develop personal preferences. However, with the proper diet and guidance, toddlers can continue to grow and develop at a healthy rate.

Nutritional Requirements

MyPlate may be used as a guide for the toddler’s diet (http://www.choosemyplate.gov/preschoolers.html). A toddler’s serving sizes should be approximately one-quarter that of an adult’s. One way to estimate serving sizes for young children is one tablespoon for each year of life. For example, a two-year-old child would be served 2 tablespoons of fruits or vegetables at a meal, while a four-year-old would be given 4 tablespoons, or a quarter cup. Here is an example of a toddler-sized meal:

• 1 ounce of meat or chicken, or 2 to 3 tablespoons of beans
• One-quarter slice of whole-grain bread
• 1 to 2 tablespoons of cooked vegetable
• 1 to 2 tablespoons of fruit

Energy

The energy requirements for ages two to three are about 1,000 to 1,400 calories a day. In general, a toddler needs to consume about 40 calories for every inch of height. For example, a young child who measures 32 inches should take in an average of 1,300 calories a day. However, the recommended caloric intake varies with each child’s level of activity. Toddlers require small, frequent, nutritious snacks and meals to satisfy energy requirements. The amount of food a toddler needs from each food group depends on daily calorie needs. See Table 13.6 “Serving Sizes for Toddlers” for some examples.

Table 13.6 Serving Sizes for Toddlers

Source: Hayes, D. (2018, February 20). It‘s about eating right: Size-wise nutrition for toddlers. Academy of Nutrition and Dietetics. https://www.eatright.org/food/nutrition/dietary-guidelines-and-myplate/what-and-how-much-should-my-preschooler-be-eating

Macronutrients

For carbohydrate intake, the Acceptable Macronutrient Distribution Range (AMDR) is 45 to 65 percent of daily calories (113 to 163 grams for 1,000 daily calories). Toddlers’ needs increase to support their body and brain development. The RDA of protein is 5 to 20 percent of daily calories (13 to 50 grams for 1,000 daily calories). The AMDR for fat for toddlers is 30 to 40 percent of daily calories (33 to 44 grams for 1,000 daily calories). Essential fatty acids are vital for the development of the eyes, along with nerve and other types of tissue. However, toddlers should not consume foods with high amounts of trans fats and saturated fats. Instead, young children require the equivalent of 3 teaspoons of healthy oils, such as canola oil, each day.

Micronutrients

As a child grows bigger, the demands for micronutrients increase. These needs for vitamins and minerals can be met with a balanced diet, with a few exceptions. According to the American Academy of Pediatrics, toddlers and children of all ages need 600 international units of vitamin D per day. Vitamin D-fortified milk and cereals can help to meet this need. However, toddlers who do not get enough of this micronutrient should receive a supplement. Pediatricians may also prescribe a fluoride supplement for toddlers who live in areas with fluoride-poor water. Iron deficiency is also a major concern for children between the ages of two and three. You will learn about iron-deficiency anemia later in this section.

Learning How to Handle Food

As children grow older, they enjoy taking care of themselves, which includes self-feeding. During this phase, it is important to offer children foods that they can handle on their own and that help them avoid choking and other hazards. Examples include fresh fruits that have been sliced into pieces, orange or grapefruit sections, peas or potatoes that have been mashed for safety, a cup of yogurt, and whole-grain bread or bagels cut into pieces. Even with careful preparation and training, the learning process can be messy. As a result, parents and other caregivers can help children learn how to feed themselves by providing the following:

• small utensils that fit a young child’s hand
• small cups that will not tip over easily
• plates with edges to prevent food from falling off
• small servings on a plate
• high chairs, booster seats, or cushions to reach a table

Feeding Problems in the Toddler Years

During the toddler years, parents may face a number of problems related to food and nutrition. Possible obstacles include difficulty helping a young child overcome a fear of new foods, or fights over messy habits at the dinner table. Even in the face of problems and confrontations, parents and other caregivers must make sure their preschooler has nutritious choices at every meal. For example, even if a child stubbornly resists eating vegetables, parents should continue to provide them. Before long, the child may change their mind, and develop a taste for foods once abhorred. It is important to remember this is the time to establish or reinforce healthy habits.

Nutritionist Ellyn Satter states that feeding is a responsibility that is split between parent and child. According to Satter, parents are responsible for what their infants eat, while infants are responsible for how much they eat. In the toddler years and beyond, parents are responsible for what they offer their children to eat, when they eat, and where they eat, while children are responsible for how much food they eat and whether they eat. Satter states that the role of a parent or a caregiver in feeding includes the following:

• selecting and preparing food
• providing regular meals and snacks
• making mealtimes pleasant
• showing children what they must learn about mealtime behavior
• avoiding letting children eat in between meal- or snack-times^[2]

Picky Eaters

The parents of toddlers are likely to notice a sharp drop in their child’s appetite. Children at this stage are often picky about what they want to eat because they just aren’t as hungry. They may turn their heads away after eating just a few bites. Or, they may resist coming to the table at mealtimes. They also can be unpredictable about what they want to consume for specific meals or at particular times of the day. Although it may seem as if toddlers should increase their food intake to match their level of activity, there is a good reason for picky eating. A child’s growth rate slows after infancy, and toddlers ages two and three do not require as much food.

One way to encourage a picky eater to try healthy foods is to get them involved in age-appropriate tasks in meal preparation. Even small toddlers can tear up lettuce leaves for a salad, or arrange fruit and cheese slices on a plate. Keiki Can Cook! is an online Hawai‘i cookbook with healthy recipes for children that highlights tasks for young children. It can be found at: https://health.hawaii.gov/wic/files/2019/03/Cookbook-Keiki-Can-Cook.pdf.

Toddler Obesity

Another potential problem during the early childhood years is toddler obesity. According to the US Department of Health and Human Services, in the past thirty years, obesity rates have more than doubled for all children, including infants and toddlers.^[3] Almost 10 percent of infants and toddlers weigh more than they should considering their length, and slightly more than 20 percent of children ages two to five are overweight or have obesity.^[4]

Some minority group children, such as Filipinos, Native Hawaiians, and Other Pacific Islanders, in Hawai‘i have higher rates of overweight and obesity. In 2012, 12.8% of Hawai‘i WIC (low-income) participants ages two to four years were overweight and 10.2% had obesity.^[5][6][7] One study that investigated 2000-2010 data for children ages two to eight years in 51 communities in 11 United States Affiliated Pacific (USAP) jurisdictions found that 14.4% of the study population was overweight and 14% had obesity.^[8]

Obesity during early childhood tends to linger as a child matures and cause health problems later in life. There are a number of reasons for this growing problem. One is a lack of time. Parents and other caregivers who are constantly on the go may find it difficult to fit home-cooked meals into a busy schedule and may turn to fast food and other conveniences that are quick and easy, but not nutritionally sound. Another contributing factor is a lack of access to fresh fruits and vegetables. This is a problem particularly in low-income neighborhoods where local stores and markets may not stock fresh produce or may have limited options. Physical inactivity is also a factor, as toddlers who live a sedentary lifestyle are more likely to be overweight or obese. Another contributor is a lack of breastfeeding support. Children who were breastfed as infants have lower rates of obesity than children who were bottle-fed.

To prevent or address toddler obesity parents and caregivers can do the following:

• Eat at the kitchen table instead of in front of a television to monitor what and how much a child eats.
• Offer a child healthy portions. The size of a toddler’s fist is an appropriate serving size.
• Plan time for physical activity, about sixty minutes or more per day. Toddlers should have no more than sixty minutes of sedentary activity, such as watching television, per day.

Early Childhood Caries

Early childhood caries remain a potential problem during the toddler years. The risk of early childhood caries continues as children begin to consume more foods with a high sugar content. According to the National Health and Nutrition Examination Survey, children between ages of two and five consume about 200 calories of added sugar per day.^[9] Therefore, parents with toddlers should avoid processed foods, such as snacks from vending machines, and sugary beverages, such as soda. Parents also need to instruct a child on brushing their teeth at this time to help a toddler develop healthy habits and avoid tooth decay. Generally, children need help brushing their teeth until they are 5 years old.

Iron-Deficiency Anemia

An infant who switches to solid foods, but does not eat enough iron-rich foods, can develop iron-deficiency anemia. This condition occurs when an iron-deprived body cannot produce enough hemoglobin, a protein in red blood cells that transports oxygen throughout the body. The inadequate supply of hemoglobin for new blood cells results in anemia. Iron-deficiency anemia causes a number of problems including weakness, pale skin, shortness of breath, and irritability. It can also result in intellectual, behavioral, or motor problems. In infants and toddlers, iron-deficiency anemia can occur as young children are weaned from iron-rich foods, such as breast milk and iron-fortified formula. They begin to eat solid foods that may not provide enough of this nutrient. As a result, their iron stores become diminished at a time when this nutrient is critical for brain growth and development.

There are steps that parents and caregivers can take to prevent iron-deficiency anemia, such as adding more iron-rich foods to a child’s diet, including lean meats, fish, poultry, eggs, legumes, and iron-enriched whole-grain breads and cereals. A toddler’s diet should provide 7 to 10 milligrams of iron daily. Although milk is critical for the bone-building calcium that it provides, intake should not exceed the RDA to avoid displacing foods rich with iron. Children may also be given a daily supplement, using infant vitamin drops with iron or ferrous sulfate drops. If iron-deficiency anemia does occur, treatment includes a dosage of 3 milligrams per kilogram once daily before breakfast, usually in the form of a ferrous sulfate syrup. Consuming vitamin C, such as orange juice, can also help to improve iron absorption.^[10]