TODDLERS : THE FUSSY EATER

1. TODDLERS : THE FUSSY EATER Afiza Azmee

2. OVERVIEW -What’s Toddler (range of age) -The needs of a Toddler -What is the normal diet for Toddlers. -The Fussy Eating -Management of The Fussy Eater -Iron Deficiency in infant and young Children.

3. Toddler-hood • A child with the age of approximately 1-2 years. • Time for change in behaviour and development • Starting to achieve self-control of thinking, behaviour and social interaction. • Gain self-feeding skill and control over choice of food and appreciation for taste and preference. THE SIGNIFICANCE OF TODDLER-HOOD • Perfect opportunity to lay the groundwork for future normal eating. • Forcing food on an already satisfied child OR withhold food from a hungry child, even if done with good intentions, can confuse the child about her own feelings of hunger leading to abnormal eating habits.

4. Normal Nutrition Requirement For Toddlers

5. Four Common Toddler Eating Behaviour • Small Quantity Eating • Inconsistent Eating Patterns • Food Jags • Food neophobia

6. Normal To Be Fussy… But… • Normal for toddlers to be fussy • Responsibility for food intake should be shared between parent and child • force-feeding not recommended. • We start worry if: • When it results in an inadequate intake of some nutrients. • If it’s a Sx of certain medical condition • Aggravated by dietary Mx of a specific medical condition

7. Why Do Parents Worry? • Lack of solid food intake. • Perceived lack of growth; height and weight of toddler  check whether the parents have realistic expectation regarding this. • Child refuses ‘good’ food or the intake is nutritionally imbalanced.

9. Assessing Diet. • Take a brief diet history • Usual pattern of breakfast, lunch, dinner and snacks • Take note about any medical condition the toddler might have.

10. Assessing Diet: 1)Routine • Is there a lack of routine or is family eating chaotic? • Does the child sit down to 3 meals a day OR • Does the child snack all day? • Suggestions to make: • Introduce routine of 3 meals/day and 3 snacks • Make sure snacks are healthy; mainly fruit, bread, sandwiches, plain biscuits, yoghurts, cheese

11. Assessing Diet2)Nutritional balance • Is the diet nutritionally imbalanced? • Is there a high intake of crisps, lollies and takeaways? • Make sure snacks are healthy. • Does the child frequently demand breast or bottle feeds • Limit number of feeds; offer food first • If bottle fed, change to a cup. • Reduce milk intake to 600 ml/day • How much juice, soft drink or cordial does the child drink? • Reduce juice intake to 200 ml/day • Offer water freely but limit cordial and juice to the occasional • Do parents restrict the child’s usual intake in any way (eg; vegetarian, or weight conscious etc) • Investigate further or reassure.

12. Assessing Diet3)The type of food the child can eat • Are there problems with the type of food the child can eat. • Is the child on a special diet • Confer with the parents and the medical and dietetic team on what is negotiable and not negotiable about the diet. • Look for ways to modify the diet so that it’s more manageable • Does the toddler still eat pureed food • Assess as to cause • Investigate and problems with swallowing etc. • Introduce finger foods and lumps if appropiate.

13. Assessing Diet4)Child’s behaviour at mealtime • Is mealtime a war zone? • How does the child behave during meals and how does the parent respond. • Let the child decide how much to eat • Allow the child to self-feed • Don’t force feed • Keep meals and snacks short • Change the venue

14. Asesseing Diet5)Parental Expectations • Are there unrealistic parental expectations? • How long does the typical meal last? • Advise parents to stay calm. • Give no snacks or drinks just before meals.

15. Guidelines For Parents of Toddlers • Over a week, your Toddler’s food intake should average out to the following quantities of food per day. • More is fine; as long as the intake of one particular type of food does not reduce the intake of others: • 500 mL full cream milk or soy substitute • 2 small serves of meat, fish, chicken, egg, peanut butter, lentils or bakes beans. • 3 to 6 serves of fruit and vegetable (no more than 200 ml of juice/day) • 3 to 5 slices of bread or small serves of breakfast, pasta or rice.

16. Managing The Fussy Eater:Tips for parents of fussy eaters • Set a good example – eat a range of foods yourself • Have a routine of 3 meals plus snacks. Don’t fill them up with juice/milk/snack just before meals. • Provide a small serve; offer seconds if wanted. • For slow eaters, serve food that is easy to eat (mince or casserole instead of steak, cooked vegetables instead of salad) • Allow some decision making by the child that doesn’t impact on food quality. But don’t offer too many choices – ask the child to choose between two choices. • Limit the less desirable foods in the house. • Bribery doesn’t work or work only in short term. • Continue to offer refused foods without fuss or comment • Be creative – eg add vegetables to spaghetti sauce, offer cheese and yoghurt if your child don’t drink milk. • Make eating a fun and happy experience ; picnics, meals in the gard,

17. When To Refer To A Paediatric Dietition • Dental caries • Irregular bowel habit • Anaemia and low iron stores • Chronic illness • Illness treated by diet

18. IRON DEFICIENCY IN INFANTS AND YOUNG CHILDREN

19. Anaemia In Toddlers; a brief overview. • Iron deficiency is a common nutrient deficiency in young children. • Anaemia is defined as an Hb level below the normal range: • Neonate: Hb<14g/dL • 1-12 months : Hb< 10g/dL • 1-12 years: Hb<11 g/dL

20. Physiology Iron Absorption; Very Briefly. • Depends on types of iron and its bioavailability. • Depends on body iron status • The presence of promoters and inhibitors of iron absorption.

21. Iron requirements in infants and children • 3-4 months of life – need only low level of exogenous iron as they reuse fetal Hb. • After the first 6 months - need dietary source of iron because rapid growth will have depleted their iron stores. • 9 mg/day • By 1 year – their growth rate has slowed down, so their iron requirement is reduced until adolescent. • Adolescence – rapid growth of adolescence requires increased iron in diet.

22. Iron in Milk • Breast milk : low iron content but 50% of the iron is absorbed • Infant Formula: supplemented with adequate amounts of iron • Cow’s milk: higher iron content than breast milk but only 10% is absorbed

23. Recommended dietary intake

24. Dietery Sources of Iron

25. Common causes in children • Nutritional – a low dietary intake of iron especially in its bioavailable form. • Low birth-weight babies • Cow’s milk protein enteropathy • Haemangiomas • Rare cause; iron malabsorption due to coeliac disease.

26. Clinical Features • Iron deficiency without anaemia – aSx • In the presence anaemia, usually associated with: • Impaired psychomotor development • Lethargy, pallor • Decreased physical and mental performance • Occasionally, pica

27. Making The Dx… • Usually on clinical suspicion • Laboratory Dx: • Decreased Hb • Decreased hematocrit • Decreased mean cell vol • Decreased serum ferritin • Decreased serum iron level • Microcytosis and hypochromia on blood film • Increased reticulocyte count within 7-10 days of starting iron supplements.

28. Management • Iron supplement – for a minimum of 3 months. Failure to respond to iron supplementation should prompt Ix for non-dietary causes. • Modify the diet • Encourage continuation of breastfeeding (the iron in human milk is more bioavailable than cow’s milk). Now, formula milks are fortified with iron and supplemented with vitamin C to increase bioavailability. • Introduce iron-fortified manufactured infant cereals, fruits, vegetables and diary products at around 6 months of age • Use of an iron enriched cereal can be mixed with a Vitamin C rich food at the same meal • Avoid tea and coffee – they will decrease iron absorption • Meat is a good source of iron • Vegetarians could include food like legumes (pea and bean group) and grains. Include vitamin C rich food to improve bioavailability.

29. Thank You