- Toddlers and pre-school children are growing rapidly and are active so their energy requirements are high relative to their body size.
- An adequate intake of protein, calcium, iron and vitamins A and D is important during this time.
- While pre-school children can start to adopt some of the principles of the eatwell plate, a diet which is low in fat and high in fibre may not supply enough energy for a young child.
- An eating pattern based on small meals and snacks selected from the four main food groups should be encouraged.
- A healthy family approach to diet and lifestyle should be encouraged, as food preferences are often established during this early stage of life.
Toddlers and pre-school children
The dietary requirements of toddlers and pre-school children differ from those of older children. Pre-school children are growing rapidly and are active so their energy requirements are high relative to their body size. They require foods that combine high energy and nutrient density (particularly in relation to protein, vitamin and mineral content), which should be eaten as part of small and frequent meals.
Whilst it is recommended that the diets of children over the age of 5 years follow the eatwell plate model, healthy eating guidelines are not intended to apply in full to pre-school children. A diet which is low in fat and high in fibre may be too bulky and not supply enough energy for a young child. It is recommended, however, that pre-school children start to adopt some of the principles of the eatwell model and a healthy family approach to diet and lifestyle should be encouraged, as food preferences are often established during this early stage of life.
A good supply of protein, calcium, iron and vitamins A and D is important during this time. An eating pattern based on small meals and snacks selected from the four main food groups should be encouraged.
Bread, rice, potatoes, pasta and other starchy foods
These foods provide energy, which is important for growth and activity, and a variety of essential nutrients. Children of this age should be encouraged to consume at least 4 servings of starchy foods per day (at least one serving at each mealtime). It is important to encourage toddlers to try lots of different varieties of starchy foods. Wholemeal varieties can be given now and again, but should not be given too often as they are more bulky and filling and therefore make it harder for young children to meet their energy needs.
Fruit and vegetables
Toddlers should be encouraged to eat a variety of different fruit and vegetables, gradually working up to five portions a day. There are no specific guidelines for portion sizes of fruit and vegetables for young children, but portions will be smaller than for adults.
Milk and dairy foods
Toddlers should be encouraged to consume milk and dairy products such as cheese, yogurt and fromage frais as these are particularly good sources of bio-available calcium, which is important for bone development, as well as providing a range of other nutrients.
It is recommended that children aged 1-3 years consume at least 300ml (1/2 pint) of milk or 2 servings of dairy foods daily (Department of Health, 1994). It is better to give whole milk and full fat dairy products to children under the age of 5.
Some parents may choose to give their toddlers reduced fat milk. However, government advice indicates that skimmed or 1% fat milk should not be given to a child under age 5, and that semi-skimmed milk should not be given to a child under age 2.
Meat, fish, eggs, beans and other non-dairy sources of protein
It is important for toddlers and pre-school children to get enough food from this food group to ensure they have an adequate intake of protein, iron, zinc, vitamin D and B vitamins.
Vegetarian food sources of iron should be served with a food or drink that is rich in vitamin C, such as fruit and vegetables, to help with iron absorption (e.g. fortified breakfast cereal with fruit or fruit juice).
Foods high in fat and/or sugar
Pre-school children require plenty of high energy, nutrient dense foods to help them meet their nutritional requirements. Whole milk and full fat dairy foods should therefore be given at this age. However, foods such as chips, some crisps, cakes, biscuits and fried foods which are also high in fat should not be given too often, to help encourage good eating habits from an early age.
Most toddlers enjoy sweet foods and drinks and a small amount of sugar at mealtimes is fine. However, it is also better not to offer foods and drinks containing sugar in-between meals, as this is more likely to cause tooth decay. Dried fruit and fruit juice can also cause decay if consumed too frequently, so these are also best kept to mealtimes.
Foods, particularly sweet foods should not be used as a reward. This encourages children to think of sweet foods in a more positive way (and conversely to see other foods more negatively) and is likely to lead to an increased liking for sweet foods.
The daily recommended maximum salt intake for children aged 1-3 years is 2g per day (3g per day for children aged 4-6 years). Too much salt in the diet can lead to health problems, such as high blood pressure, in later life. Most of the salt in our diets comes from manufactured or processed foods. Foods such as crisps, bacon, ham, sausages and other meat products, ready meals and ready prepared sauces are particularly high in salt.
Tips for reducing children’s salt intake:
- Limit intake of salty snacks, such as crisps, which encourage an increased liking for salty foods.
- Try to avoid giving processed foods too often and look out for low salt or reduced salt alternatives (e.g. reduced salt bread, baked beans and ready meals).
- Try to buy tinned vegetables and pulses labelled ‘no added salt’ and tuna canned in water, rather than brine.
- Avoid adding salt to foods during cooking, or at the table.
Children aged 1-3 should be given at least ½ pint of milk daily (either breast milk or cows’ milk or a combination of both). They can also be given tap water or still mineral water to drink.
Whole cows’ milk is recommended for children over the age of one year as a main drink as it is a rich source of a number of nutrients. Semi-skimmed milk can be introduced gradually after the age of two, as long as the child is consuming sufficient energy and nutrients and growth is satisfactory. Skimmed milk or 1% milk is not suitable for children under five years of age, as it does not provide enough energy and vitamin A for the growing child.
Drinks containing sugar e.g. fruit squashes, fruit juices, fizzy drinks and flavoured milks can cause decay of first teeth if consumed too frequently. Diluted, unsweetened fruit juice is the best choice, but should be limited to meal times only to help protect teeth from dental erosion. Fruit juice should be diluted with 1 part fruit juice to 10 parts water for young children. It is best not to give diet drinks as these contain artificial sweeteners, such as saccharin.
The use of a bottle for milk feeds should be discontinued after the age of one year as otherwise this can become a difficult habit to break. Milk and other drinks should be given from a beaker or cup instead.
It is recommended that children aged 6 months to 5 years are given supplements providing vitamins A, C and D (in the form of liquid drops), this is particularly important if they do not eat a very varied diet.
Some parents are eligible to receive free vitamin supplements as part of the Healthy Start scheme. See http://www.healthystart.nhs.uk/index.asp for further details.
Foods to avoid
Avoid giving the following to children of pre-school age:
- Salt – children aged 1-3 years should have no more than 2g of salt (0.8g sodium) per day to help minimise any health problems related to salt in later life. See also salt.
- Raw eggs – eggs should be cooked until the white and yolk are solid. Foods containing raw or partially cooked eggs should be avoided to reduce the risk of salmonella poisoning.
- Shark, marlin and swordfish should not be given to toddlers because of the high levels of mercury they can contain.
- Whole or chopped nuts should not be given to children under age 5 because of the risk of choking.
Current dietary intakes
The most recent National Diet and Nutrition Survey in young children (aged 1½ to 4½ years) was published in 1995. According to this survey, intakes of most nutrients were found to be adequate. However, energy intakes were found to be below recommended levels. Intake of non-milk extrinsic sugars (NMES) (sometimes known as added sugars) was 19% of total food intake which exceeds the recommended 11% of food energy. Salt intake was also higher than target recommendations in this age group.
Intakes of most vitamins and minerals were found to be adequate, with the exception of vitamins A and D, zinc, copper and iron. The survey found 50% of children had average daily intakes of vitamin A below the RNI, while 72% of children under 4 years had zinc intakes below the RNI and 84% had iron intakes below the recommended level. Furthermore, only 5% of children aged under 4 years met the RNI for vitamin D of 7µg/day (there is no RNI for older children and adults as it is assumed that most vitamin D comes from summer sunlight).The survey also found evidence of low vegetable intakes in this age group, with only 39% of children consuming leafy green vegetables and less that 24% consuming raw vegetables and salad during the survey period. Oily fish was only eaten by 16% of children in the survey.
According to the 2003 Children’s Dental Health Survey, over 43% of children in the UK showed signs of obvious decay experience by the age of 5 years. The survey found 40% of 5 year-olds had at least one primary tooth with decay into dentine and 12% had at least one filled primary tooth.
Tooth decay occurs when the bacteria on the tooth surface convert sugar into acid - the acid produced attacks the tooth surface. Children are more prone to tooth decay because newly formed teeth are more vulnerable to acid. Frequent consumption of sugar-containing foods is associated with tooth decay, so it is best to keep these foods to mealtimes, when other foods eaten at the meal will buffer the impact on teeth of any acid produced by fermentation of the sugar. Dentists recommend that children should have sugar containing foods and drinks no more than 4 times a day, as it is the frequency of consumption rather than the amount consumed that is most important from a dental health perspective.
It is best to give toddlers water or milk to drink. Drinks containing sugar e.g. fruit squashes, fruit juices, fizzy drinks and flavoured milks are best kept to meal times. They may also be quite acidic and this can damage the protective enamel on teeth. Fruit juices should be diluted for young children (1 part fruit juice to 10 parts water). Dried fruit can also be damaging to teeth so it is best to keep this to mealtimes.
Thorough brushing for two minutes, twice a day, particularly last thing at night, will help to prevent tooth decay.
Common diet-related problems
Iron deficiency anaemia
Iron deficiency anaemia is common in certain groups of young children such as those who are not receiving a good supply of iron from solid foods and who are given cow’s milk as a main drink too early (i.e. before 12 months of age). Iron deficiency anaemia is associated with frequent infections, poor weight gain and delay in development.
Red meat is the best source of easily absorbable iron and can be offered to children from 6 months of age. Iron rich foods, such as liver and red meat, may not be popular with young children, so other ways of providing this nutrient must be found, e.g. mildly flavoured liver pate (for children aged over one year) or minced meat hamburgers (paying attention to the salt content). Children who are vegetarian need alternative sources of iron, such as green vegetables and pulses (e.g. beans, lentils, chick peas). Other useful sources include bread and fortified breakfast cereals. Iron from plant sources is less well absorbed than iron from animal sources but can be improved by consuming vitamin C rich foods or drinks (such as fruit or fruit juice) with a meal.
Constipation and diarrhoea
Constipation is quite a common problem in young children and can usually be dealt with by gradually increasing the amount of fibre in the child’s diet. Parents should try increasing the amount of vegetables and wholegrain bread in the diet plus other fibre-rich foods that are popular with children, such as baked beans and high fibre white bread. Constipation can also result from too low a fluid intake so children should be encouraged to drink more water.
Toddler diarrhoea is also quite common and may arise because the gut isn’t fully developed. It may also be linked with allowing children to have too many sugary drinks and fruit juice, particularly in between meals. It also appears to be more common in children who eat a low fat diet. Toddler's diarrhoea is not serious and will go as the child becomes older. In many cases, the diarrhoea should stop with some dietary changes:
- Encourage an eating pattern based on small meals and snacks selected from the four main food groups.
- Do not give children too much fruit juice or squash
- Give whole milk and full fat dairy foods (rather than low fat dairy foods)
- Make sure the child has enough fibre (e.g. from wholemeal bread, fruit and vegetables), although too much fibre is not suitable for young children as it can fill them up too quickly.