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POCKET GUIDE
Bright Futures
Nutrition
THIRD EDITION
POCKET GUIDE
Katrina Holt, MPH, MS, RD
Editor
Published by
American Academy of Pediatrics
American Academy of Pediatrics Department of Marketing and Publications Staff
Maureen DeRosa, MPA
Director, Department of Marketing and Publications
Mark Grimes
Director, Division of Product Development
Sandi King, MS
Director, Division of Publishing and Production Services
Maryjo Reynolds
Product Manager, Bright Futures
Peg Mulcahy
Manager, Graphic Design and Production
Kate Larson
Manager, Editorial Services
Kevin Tuley
Director, Division of Marketing and Sales
Bright Futures: Nutrition, 3rd Edition Pocket Guide
Library of Congress Control Number: 2010917945
ISBN: 978-1-58110-555-1
Product Code: BF0038
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of care. Variations, taking into account individual
circumstances, may be appropriate.
Every effort has been made to ensure that the drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the
time of the publication. It is the responsibility of the health care provider to check the package insert of each drug for any change in indications or dosage and for added
warnings and precautions.
The mention of product names in this publication is for informational purposes only and does not imply endorsement by the American Academy of Pediatrics.
Copyright © 2011 American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission from the publisher. Printed in United States of America
This publication has been produced by the American Academy of Pediatrics under its cooperative agreement (U04MC07853) with the US Department of Health
and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB).
1 2 3 4 5 6 7 8 9 10
Table of Contents
Nutrition Supervision
Infancy (Prenatal–Age 11 Months).................................................................................................................................................................3
Early Childhood (Ages 1–4)......................................................................................................................................................................... 25
Middle Childhood (Ages 5–10).................................................................................................................................................................... 37
Adolescence (Ages 11–21)............................................................................................................................................................................ 45
Nutrition Tools
Key Indicators of Nutrition Risk for Children and Adolescents.............................................................................................................. 55
Strategies for Health Professionals to Promote Healthy Eating Behaviors............................................................................................. 64
Tips for Fostering a Positive Body Image Among Children and Adolescents....................................................................................... 70 iii
Basics for Handling Food Safely................................................................................................................................................................... 71
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Federal Nutrition Assistance Programs....................................................................................................................................................... 74
Bright Futures: Nutrition
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Building Bright Futures: Nutrition
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minerals in the diet; the balance of dependence and indepen-
dence between the parent and the infant, child, or adolescent;
Bright Futures: Nutrition Vision
and Goals
The vision and goals of Bright Futures: Nutrition are to
■■ Improve the nutrition status of infants, children, and
adolescents.
■■ Identify desired health and nutrition outcomes that
result from positive nutrition status.
■■ Set guidelines to help health professionals promote the
nutrition status of infants, children, and adolescents.
■■ Encourage partnerships among health professionals,
families, and communities to promote the nutrition
status of infants, children, and adolescents.
■■ Describe the roles of health professionals in delivering
nutrition services within the community.
■■ Identify opportunities for coordination and collaboration
between health professionals and the community.
viii
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About Bright Futures: Nutrition
A Developmental and Contextual Approach Bright Futures: Nutrition recommends that food and eating
be viewed as both health-enhancing and pleasurable. Food
Bright Futures: Nutrition represents a developmental and con- provides more than just energy and sustenance. It holds innu-
textual approach for helping infants, children, and adolescents merable symbolic, emotional, social, and personal meanings.
develop positive attitudes toward food and practice healthy Food is connected with nurturing, family, culture, tradition,
eating behaviors. and celebration. Promoting positive attitudes toward food
The developmental approach, which is based on the unique and healthy eating behaviors in infants, children, and ado-
social and psychological characteristics of each developmen- lescents involves recognizing the multiple meanings of food
tal period, is critical for understanding infants, children’s, and creating an environment that encourages the enjoyment
and adolescents’ attitudes toward food and for encouraging of food. Family meals are emphasized because they help build
healthy eating behaviors. on family strengths and promote unity, social bonds, and
The contextual approach emphasizes the promotion of posi- good communication.
tive attitudes toward food and healthy eating behaviors by Partnerships Among Health Professionals, Families,
providing infants, children, adolescents, and their fami- and Communities
lies with consistent nutrition messages. Consistency, com-
bined with flexibility, is essential for handling the challenges Encouraging healthy eating behaviors in infants, children, and
of infancy and early childhood. During middle childhood adolescents is a shared responsibility. One of the principles of
and adolescence, it is important for parents to encourage Bright Futures: Nutrition is that, together, health professionals, ix
their children and adolescents to become more responsible families, and communities can make a difference in the nutri-
for their own health and to help them develop the skills they tion status of infants, children, and adolescents.
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need to practice healthy eating behaviors.
Today many families face the challenges of balancing work The community can be invaluable in helping children and
and home life and dealing with hectic schedules. Health pro- adolescents develop positive attitudes about food and practice
fessionals can help families learn how to fit nutritious meals healthy eating behaviors. Bright Futures: Nutrition can be used
and snacks into their busy lives. To be most effective, strate- in a variety of community settings (eg, clinics, health and
gies need to be tailored to the family’s individual needs. child care centers, hospitals, schools, colleges and universi-
The family is the predominant influence on infants’, children’s, ties). Community settings and events that provide a variety of
and adolescents’ attitudes toward food and their adoption of healthy, affordable, and enjoyable foods can be instrumental
healthy eating behaviors. The family exerts this influence by in communicating positive nutrition messages.
■■ Providing food
Where We Go From Here
■■ Transmitting attitudes, preferences, and values about food,
which affect lifetime eating behaviors There are many opportunities to promote the nutrition status
■■ Establishing the social environment in which food is of infants, children, and adolescents. Bright Futures: Nutrition
shared can be useful to health professionals, families, and communi-
ties as they strive to ensure the health and well-being of the
Parents want to know how they can contribute to their
current generation and of generations to come.
infants’, children’s, and adolescents’ health and are looking for
guidance; however, they are faced with contradictory nutri-
tion information. Dietary recommendations can be misun-
derstood or misinterpreted, especially when adult guidelines
are applied to children and adolescents.
x
Throughout the nutrition pocket guide, we use the term
“parent” to refer to the adult or adults responsible for the
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As infants grow, their ability to consume a greater volume
■■ INFANCY ■■
and variety of food increases. Newborns need small, fre-
quent feedings, whereas older infants are able to consume
Overview more volume at one time and require fewer feedings.
Infancy is divided into 3 stages. Physical growth, develop- ■■ Infants learn to chew and swallow, manipulate finger foods,
mental achievements, nutrition needs, and feeding patterns drink from a cup, and ultimately feed themselves.
Infancy
vary significantly in each. ■■ In late infancy, infants’ physical maturation, mastery of
Early infancy (birth–age 6 months). The most rapid changes purposeful activity, and loss of newborn reflexes allow
occur during this stage. them to eat a wider variety foods, including foods with
different textures, than they were able to consume during
Middle infancy (ages 6–9 months). During this stage growth
early and middle infancy.
slows but is still rapid. ■■ Close physical contact between the infant and a parent
Late infancy (ages 9–12 months). During this stage growth during feeding facilitates healthy social and emotional
slows, but infants’ maturation and purposeful activity allow development.
them to eat a wider variety of foods. ■■ The amount and type of physical activity that an infant
■■ Infants usually regain their birth weight by 7 days after engages in change dramatically during infancy.
birth, double their birth weight by age 4 to 6 months, and ■■ At first, infants spend most of their time sleeping and eat-
triple their birth weight by age 1. ing. Over the next few months, infants slowly gain con-
■■ Infants usually increase their length by 50% in the first trol over their movements. With increasing control comes
year, but the rate of increase slows during the second half more physical activity, including sitting up, rolling over, 3
of the year. crawling, standing, and eventually walking.
■■ Growth rates of exclusively breastfed infants and formula- Development is an individual process. Infants typically
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■■
fed infants differ. Breastfed infants grow more rapidly acquire motor skills in the same order, but the speed at
during the first half of the year but less rapidly during the which they acquire them is different.
second half.
■■ The ways infants are held and handled, the toys they play ■■ Parents may need help in determining when to introduce
with, and their environments all influence their physical solid foods into the infant’s diet.
activity and motor skills development.
Nutrition Supervision
Common Nutrition Concerns An infant’s nutrition status should be evaluated during nutri-
■■ Parents are often unsure whether to feed their infant breast tion supervision visits or as part of health supervision visits.
Infancy
■■ Difficulties in early feeding evoke strong emotions in par- ■■ How does your baby let you know when she is hungry?
ents and can undermine parenting confidence and parents’ How do you know when she has had enough to eat?
sense of competency. ■■ How often do you feed your baby?
■■ Does your baby receive anything else besides breast milk Anticipatory Guidance
or infant formula?
■■ How do you feel about the way your baby is growing? Discuss With Parents of All Infants
■■ Are you concerned about having enough money to Feeding Practices
buy food?
■■ Breast milk provides ideal nutrition and supports optimal
■■ What is the source of your drinking and cooking water?
growth and physical development. (Exclusive breastfeeding
Infancy
Do you use bottled or processed water?
[only breast milk] is recommended for a minimum of
Screening and Assessment 4 months, but preferably for 6 months.)
■■ Measure the infant’s length, weight, and head circumfer- ■■ Feeding their infant, until age 12 months, breast milk or
ence, and plot them on a standard growth chart. Deviation iron-fortified infant formula and avoiding low-iron milk
from expected growth patterns should be evaluated. This (cow’s, goat’s, soy), even in infant cereal.
may be normal or may indicate a nutrition problem. ■■ Feeding their infant until he is full.
■■ Evaluate the appearance of the infant’s skin, hair, teeth, ■■ For younger infant (up to age 3 months), signs of hunger
gums, tongue, and eyes. include putting the hand to the mouth, sucking, rooting,
■■ Assess the infant for age-appropriate development. pre-cry facial grimaces, and fussing.
■■ Observe the parent-infant interaction, and assess parents’ ■■ For older infant (ages 4–6 months), signs of hunger
and infants’ responses to one another (affectionate, com- include moving the head forward to reach the spoon
fortable, distant, anxious). and swiping food toward the mouth.
■■ Spitting up a little breast milk or formula at each
5
feeding is normal.
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Food Safety
■■ Following food safety practices for storage of expressed
breast milk or open containers of ready-to-feed or
concentrated formula.
■■ Dangers of warming expressed breast milk, formula, or ■■ Giving infants ingesting less than 1 L per day or 1 qt per
food in containers or jars in the microwave. day of vitamin D–fortified formula a vitamin D supple-
■■ Warming bottles by holding them under hot running water ment beginning during the first few days of life.
or placing them in a bowl of hot water for a few minutes. ■■ Giving breastfed infants vitamin B before age 6 months if
12
■■ Testing warmed fluids to make sure that they aren’t too the mother is vitamin B deficient (vegan [eats no animal
12
warm by sprinkling drops on wrist (the fluid should feel products], is undernourished, does not take vitamin B 12
Infancy
Infancy
■■ Continuing breastfeeding for 12 months or as long as the (coffee, tea, soft drinks) to 2 servings per day.
mother and child wish to continue. ■■ Avoiding alcoholic beverages 2 hours before breastfeeding.
■■ Feeding their infant on demand stimulates the lactation (If the mother drinks alcoholic beverages, no more than
process (the longer the infant sucks, the more breast milk 8 oz wine, 12 oz beer, or 2 oz hard liquor should be con-
the mother’s body makes). sumed per day [less for small women].)
■■ Allowing their infant to finish feeding at one breast before Support
offering the other breast (20–45 minutes per feeding pro- ■■ Encouraging the father to help care for their infant (bring-
vides adequate intake and allows the mother rest time
ing the infant to the mother at breastfeeding time; cuddling
between feedings).
the infant; helping with burping, diapering, and bathing).
■■ Feeding their infant when she is hungry, typically 10 ■■ Mothers breastfeeding multiples require more food, addi-
to 12 times per day during the initial weeks of life, 8 to
tional nutrition counseling, and extra help at home.
12 times per day for the next several months, and 6 to
12 times per day thereafter.
■■ Feeding their infant more often during periods of rapid 7
growth. (Frequent feedings help establish the milk supply
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and prevent the breasts from getting too full.)
Discuss With Parents of Formula-Fed Infants Food Safety
Feeding Practices
■■ Preparing formula as instructed, and following sanitary
procedures (washing hands before preparing formula;
■■ Holding their infant close when feeding, in a semi-upright
cleaning area where formula is prepared; cleaning and
position.
disinfecting reusable bottles, caps, and nipples before
■■ Feeding their infant when he is hungry, typically every 3
each use; washing and drying top of formula container
to 4 hours (6–8 times in 24 hours) until complementary
Infancy
before opening).
foods are added. ■■ Not adding cereal or other foods to infant formula.
■■ Preparing and offering more formula as their infant’s ■■ Discarding infant formula left in the bottle when their
appetite increases.
infant has finished eating; not reusing a bottle that has
■■ Offering their infant water on hot days between feedings
been started.
(infants don’t usually need water). ■■ Covering and refrigerating open containers of ready-to-
■■ Checking for causes if their infant is crying more than
feed or concentrated formula.
usual or seems hungry all the time (uncomfortable feed- ■■ Storing powdered formula at room temperature.
ing position, formula prepared incorrectly, bottle nipple
too firm or hole too big, unheeded hunger cues, distracting (See Basics for Handling Food Safely.)
feeding environment).
PRENATAL
■■ Not enlarging the hole in the bottle nipple to make infant
formula come out faster. Interview Questions
■■ Seeking consultation with a health professional if their
8
infant is not feeding enough. For Pregnant Women
What was your pre-pregnancy weight? How much weight
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■■
did you gain in prior pregnancies? How much weight have
you gained at this point?
■■ Are you taking or do you plan to take prenatal vitamins? For Parents Planning to Formula-Feed
Are you taking other vitamins or minerals? ■■ What have you read or heard about different infant
■■ Have you used any special or traditional health remedies formulas (iron-fortified, soy, lactose-free)? Do you have
to improve your health since you have been pregnant? any questions about formula-feeding?
■■ Do you drink alcohol or special teas or take any herbs? ■■ Are you worried about having enough money to buy
Is there anything that you were taking but stopped using infant formula?
Infancy
when you learned that you were pregnant? ■■ How do you plan to prepare the formula? What have
■■ Are you using any other drugs (legal or illegal) or you heard about formula safety?
supplements?
■■ What are your plans for feeding your baby? What have Anticipatory Guidance
you heard about breastfeeding? Do you have questions
about breastfeeding? Discuss With Pregnant Women
■■ Are you restricting any foods in your diet because of lack ■■ Obtain 600 dietary folate equivalents per day of food folate,
of appetite, food aversions, vegan or vegetarian diet, weight folic acid, or a mixture of both to minimize the risk of
gain, food allergies and sensitivities, or any other reason? giving birth to an infant with a neural tube defect.
■■ Consuming foods containing folate, such as fruits (oranges,
For Women Planning to Breastfeed strawberries, avocados), dark-green leafy vegetables
■■ Do you have any worries about breastfeeding (your diet, (spinach, turnip greens), some other vegetables (asparagus,
privacy, having enough breast milk, changes in your broccoli, brussels sprouts), and legumes (black, pinto, navy,
body)? Have you had any breast surgery? and kidney beans). 9
■■ Have you been to any classes that taught you how to ■■ Consuming foods fortified with folic acid (grain products,
nurse your baby? most ready-to-eat breakfast cereals).
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■■ Do you know anyone who breastfeeds her baby? Did any ■■ Avoiding consumption of alcoholic beverages, because
of your family or friends breastfeed? Would you be able alcohol adversely affects fetal development.
to get help from them as you are learning to breastfeed?
Discuss With Women Planning to Breastfeed NEWBORN
■■ Herbal or traditional health remedies may be harmful
Interview Questions
to infants (many herbal teas contain ephedra and other
substances that may be harmful). For Parents of All Infants
■■ Giving breastfed and partially breastfed infants a vita-
■■ How often does your baby feed? How long does a feeding
min D supplement beginning in the first few days of
generally take?
Infancy
■■
(tenderness, swelling, pain)?
per day of vitamin D–fortified formula a vitamin D
■■ Are you restricting any foods in your diet?
supplement beginning in the first few days of life.
■■ What vitamin or mineral supplements do you take or plan Anticipatory Guidance
to take? Is your baby receiving vitamin D supplements?
■■ Do you drink wine, beer, or other alcoholic beverages? Discuss With Parents of All Infants
Do you drink any special teas or take any herbs? ■■ Signs of hunger include putting the hand to the mouth,
■■ Do you use any drugs (prescription, over the counter, sucking, rooting, pre-cry facial grimaces, and fussing
street drugs)? (crying is a late sign hunger).
Infancy
■■ Waking their infant for feeding if the infant sleeps more
For Parents of Formula-Fed Infants
than 4 hours.
■■ What formula are you planning to use? Is the formula ■■ Helping their infant focus on feeding by rocking, patting,
iron-fortified? stroking, or swaddling the infant or feeding in a room
■■ How often do you feed your baby? How much does she with fewer distractions (lights, noise).
take at a feeding?
■■ What questions do you have about infant formula Discuss With Parents of Breastfed Infants
(brands, cost, preparation, amount)? ■■ Feeding their infant immediately after birth, preferably in
■■ How do you store the infant formula after you make it? the delivery room.
■■ How do you clean bottles, nipples, and other equipment? ■■ Feeding their infant when she is hungry, usually every 2
■■ What do you do with the formula in the bottle after your to 3 hours, about 8 to 12 feedings in 24 hours.
baby has finished feeding? ■■ Their infant is getting enough milk if there are 6 to 8 wet
■■ How does your baby like to be held when you feed her? diapers and 3 or 4 stools in 24 hours and the infant is
■■ Are you worried about having enough money to buy gaining weight as expected. 11
infant formula? ■■ Avoiding artificial nipples (pacifiers, bottles) and supple-
ments (unless medically indicated) until breastfeeding is
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Screening and Assessment
well established; this occurs at around age 4 to 6 weeks.
■■ Perform metabolic screening as indicated by the state. (Some infants never use pacifiers or bottles.)
■■ Assess administration of vitamin K.
■■ Waiting until breastfeeding is well established before ■■ How many wet diapers and stools does he have each day?
introducing infant formula (for mothers combining ■■ What is the longest time he has slept at one time?
breastfeeding and formula-feeding).
For Parents of Breastfed Infants
Discuss With Parents of Formula-Fed Infants ■■ How is breastfeeding going for you and your baby?
■■ Feeding their infant on average 20 oz of formula in ■■ Is your baby receiving a vitamin D supplement?
Infancy
24 hours (2 oz of infant formula every 2–3 hours at ■■ Does your baby suck well? Does she latch on well and
first and more formula if the infant seems hungry). breastfeed in a rhythm?
■■ Do you feel a good “let-down” or “milk-ejection” reflex
3 TO 5 DAYS (tingling sensation and a strong surge of milk)?
■■ Have you noticed changes in your milk?
Interview Questions
■■ How often does your baby feed? How long do feedings last?
For Parents of All Infants For Parents of Formula-Fed Infants
■■ How are you feeding your baby? ■■ What formula are you feeding your baby? Is it
■■ How often does your baby feed? How long does it generally iron-fortified?
take for a feeding? ■■ How are you preparing the formula?
■■ How does your baby like to be held when you feed him? ■■ How often do you feed your baby? How much does he
■■ Are you comfortable that your baby is getting enough take at a feeding?
to eat? ■■ How do you hold your baby while feeding? How do you
12 ■■ How does he behave during a feeding? Pulls away, arches hold the bottle?
back, is irritable, or calm? ■■ What questions do you have about infant formula
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■■ How does your baby behave after feedings? Satisfied baby (brands, cost, preparation, amount)?
look, still rooting, anxious? ■■ What questions do you have about preparing formula
■■ Has he received any other fluids from a bottle? and storing it safely?
■■ Are you worried about having enough money to buy ■■ Helping their infant focus on feeding by rocking, patting,
infant formula? stroking, or swaddling the infant or feeding in a room
with fewer distractions (lights, noise).
Screening and Assessment
■■ Perform metabolic screening as indicated by the state. Discuss With Parents of Breastfed Infants
■■ Assess the infant for milk intake, hydration, jaundice, ■■ Their infant settling into typical breastfeeding routine
Infancy
and age-appropriate elimination patterns. of every 2 to 3 hours in the daytime and every 3 hours
■■ If possible, observe the mother breastfeeding or either at night, with 4- to 5-hour stretches between feedings;
parent bottle-feeding the infant. Assess how comfortable total of 10 to 12 feedings in 24 hours.
the parent seems with feeding the infant, eye contact ■■ After the mother’s milk comes in, infants should have
between the parent and the infant, the parent’s interaction about 6 to 8 wet diapers in 24 hours. (Infants may have
with the infant, the parent’s and the infant’s responses to stools [typically loose] after every feeding or as infre-
distractions in the environment, and the infant’s ability quently as every several days.)
to suck. ■■ Avoiding artificial nipples (pacifiers, bottles) and supple-
ments (unless medically indicated) until breastfeeding
Anticipatory Guidance is well established; this occurs around age 4 to 6 weeks.
(Some infants never use pacifiers or bottles.)
Discuss With Parents of All Infants
■■ Signs of hunger include infant putting the hand in the Discuss With Parents of Formula-Fed Infants
mouth, sucking, rooting, pre-cry facial grimaces, and ■■ Feeding their infant on average 20 oz of formula in
13
fussing (crying is a late sign hunger). 24 hours (2 oz of formula every 2–3 hours at first and
■■ Waking their infant for feeding if the infant sleeps for more formula if the infant seems hungry).
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more than 4 hours.
BY 1 MONTH ■■ Are you breastfeeding more often or for longer periods?
■■ How can you tell if your baby is satisfied at the breast?
Interview Questions ■■ Are you planning to return to work or school? If so, are
you pumping your breast milk? How do you store it?
For Parents of All Infants
How long do you keep it?
■■ How often are you feeding your baby during the day?
During the night? For Parents of Formula-Fed Infants
Infancy
■■ How do you know if your baby is hungry? How do you ■■ Do you ever prop a bottle to feed your baby or put her to
know if your baby has had enough food? bed with a bottle?
■■ Have there been times when she seemed to be growing ■■ What formula do you use? Is the formula iron-fortified?
very fast and seemed to want to eat all the time? What did ■■ How often does your baby feed? How much does she take
you do? at a feeding?
■■ How easily does your baby burp during or after a feeding? ■■ How long does it take to feed your baby?
■■ How many wet diapers and stools does your baby have ■■ Have you given your baby anything other than infant
each day? formula?
■■ What is the longest time your baby has slept? ■■ What concerns do you have about infant formula
■■ Are you giving your baby any supplements, herbs, or (cost, preparation, nutrient content)?
vitamins? ■■ Are you worried about having enough money to buy
infant formula?
For Parents of Breastfed Infants
14 ■■ Are you breastfeeding exclusively? If not, what else are
you feeding your baby?
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■■ How often do you feed your baby? How long do you feed
him each time?
Screening and Assessment ■■ Helping their infant focus on feeding by rocking, patting,
■■ If possible, observe the mother breastfeeding or either stroking, or swaddling the infant or feeding in a room
parent bottle-feeding the infant. Assess how comfort- with fewer distractions (lights, noise).
able the parent seems with feeding the infant, eye contact ■■ Indications of colic (crying inconsolably for several hours
between the parent and the infant, the parent’s interac- and passing a lot of gas). (If the mother is breastfeeding,
tion with the infant, the parent’s and the infant’s responses recommend short, frequent feedings.)
Infancy
to distractions in the environment, and the infant’s abil- Discuss With Parents of Breastfed Infants
ity to suck.
■■ Their infant is getting enough milk if there are 6 to 8 wet
■■ For breastfed and partially breastfed infants, determine
diapers and 3 or 4 stools in 24 hours and the infant is gain-
whether the infant is receiving vitamin D supplementation.
ing weight as expected.
Anticipatory Guidance ■■ When appropriate, introducing a bottle by someone other
than the mother when their infant is neither extremely
Discuss With Parents of All Infants hungry nor full and allowing the infant to explore the
■■ Their infant’s increasing appetite during growth spurts, bottle’s nipple and put it in his mouth.
between ages 6 and 8 weeks.
Discuss With Parents of Formula-Fed Infants
■■ Forgoing foods other than breast milk or infant formula
until their infant is developmentally ready (at about age
■■ Feeding their infant on average 24 to 27 oz of formula, but
4–6 months, when the sucking reflex changes to allow the infant may consume 20 to 31 oz of formula in 24 hours.
coordinated swallowing and the infant is sitting with (Infant needs to feed every 3–4 hours.)
15
support and has good head and neck control).
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2 MONTHS For Parents of Formula-Fed Infants
■■ How often does your baby feed? How much does he drink
Interview Questions
at a feeding?
For Parents of All Infants
■■ About how long does a feeding last? Have you offered him
anything other than formula?
■■ Tell me about all the foods you are offering your baby. ■■ Do you ever prop a bottle to feed or put your baby to bed
Have there been times when he seemed to be growing
Infancy
■■
with a bottle?
very fast and seemed to want to eat all the time? What ■■ Are you worried about having enough money to buy
did you do?
infant formula?
For Parents of Breastfed Infants
Screening and Assessment
■■ How often do you feed your baby? How long do you feed
■■ Observe parent/infant interaction (gazing, talking, smiling,
her each time?
holding, cuddling, comforting).
■■ Does it seem like your baby is breastfeeding more often
■■ If possible, observe the mother breastfeeding or either
or for longer periods?
parent bottle-feeding the infant. Assess how comfort-
■■ Does your baby receive other foods or fluids besides
able the parent seems with feeding the infant, eye con-
breast milk?
tact between parent and infant, the parent’s interaction
■■ Are you planning to return to work or school? If so, will
with the infant, the parent’s and the infant’s responses to
you pump your breast milk?
distractions in the environment, and the infant’s ability
■■ Does your school or workplace have a place where you can
16 to suck.
pump your milk in privacy? How will you store your milk?
■■ For breastfed infants, determine whether the infant is
How long will you keep it?
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Infancy
(lights, noise, other people). ■■ Stools may be as infrequent as once every 3 days.
■■ Indications of colic (crying inconsolably for several hours
and passing a lot of gas). (If the mother is breastfeeding, Discuss With Parents of Formula-Fed Infants
recommend short, frequent feedings.) ■■ Feeding their infant on average 26 to 28 oz of formula, but
■■ Forgoing foods other than breast milk or infant formula the infant may consume up to 32 oz of formula in 24 hours
until their infant is developmentally ready (at about age (infants feed every 3–4 hours, with one longer stretch at
4–6 months, when the sucking reflex changes to allow night of up to 5 or 6 hours between feedings).
coordinated swallowing and the infant is sitting with
support and has good head and neck control). 4 MONTHS
■■ Adding cereal to their infant’s diet will not help the infant Interview Questions
sleep through the night.
■■ Playing with their infant (encouraging the infant to follow For Parents of All Infants
objects with his eyes) to stimulate the nervous system and ■■ Tell me about what you are feeding your baby. How often
help develop head and neck control and motor skills. are you feeding her? 17
■■ Encouraging “tummy time” to promote head control and ■■ Are you feeding your baby any foods besides breast milk
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gross motor development. or formula?
■■ Have you thought about when you will begin to give your
baby solids?
■■ Does your baby seem interested in your food? ■■ Are you worried about having enough money to buy
■■ Have you offered her foods from the family meal? If so, infant formula?
which ones?
Screening and Assessment
■■ In addition to feeding her at home, where else is she fed
(child care, relative’s home)? ■■ For breastfed infants, determine whether the infant is
receiving vitamin D supplementation and whether the
For Parents of Breastfed Infants
Infancy
■■ Has your baby begun to put her hands around the bottle?
■■ Have you offered your baby anything other than infant
formula?
■■ Introducing iron-fortified, single-grain infant rice cereal as ■■ Vitamin supplements are not needed if their infant is
the first supplemental food because it is least likely to cause consuming an adequate amount of iron-fortified infant
an allergic reaction. formula appropriate for growth.
■■ Introducing a variety of pureed or soft meats, fruits, and
vegetables after cereals. (The gradual introduction of a 6 MONTHS
variety of foods, flavors, and textures contributes to a bal- Interview Questions
Infancy
anced diet and helps promote healthy eating behaviors.)
Bright FUTURES
but the infant may consume up to 26 to 36 oz of formula for longer periods?
in 24 hours. ■■ What are your plans for continuing to breastfeed?
■■ Has your baby received breast milk or other fluids from a Anticipatory Guidance
bottle or cup?
■■ Is your baby receiving vitamin D supplements? Discuss With Parents of All Infants
■■ Is your baby receiving an iron supplement and/or ■■ Introducing solid foods when their infant is develop
iron-rich foods? mentally ready (at about age 4–6 months, when the
sucking reflex changes to allow coordinated swallowing
For Parents of Formula-Fed Infants
Infancy
and the infant is sitting with support and has good head
■■ How is formula-feeding going? What formula are you and neck control).
using now? ■■ Introducing one single-ingredient food at a time,
■■ How often does your baby feed in 24 hours, and how and observing their infant for 3 to 5 days for possible
much does she take at a feeding? Day feedings versus allergic reactions.
night feedings? ■■ Introducing iron-fortified, single-grain infant rice cereal
Screening and Assessment as the first supplemental food, because it is least likely to
cause an allergic reaction.
■■ Assess eating behaviors to determine the infant’s risk for ■■ Introducing a variety of pureed or soft meats, fruits, and
dental caries (tooth decay). Determine whether the infant vegetables after cereals.
has had a dental visit. ■■ Not forcing their infant to eat a new food if the infant does
■■ For breastfed infants, determine whether the infant is not like it. (It may take 10–15 attempts before an infant
receiving vitamin D supplementation, and assess the accepts a particular food.)
need for iron supplementation.
20 ■■ Serving only 100% fruit juice in a cup as part of a meal
or snack, and limiting juice to 4 to 6 oz per day.
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Infancy
■■ Encouraging the mother to breastfeed for the first year
of the infant’s life. ■■ Who feeds your baby?
■■ Providing a vitamin D supplement (400 IU/day). ■■ When does your baby have something to eat or drink?
■■ Providing an iron supplement (1 mg/kg of body How much does he eat or drink at a time?
weight/day) if the infant does not consume sufficient ■■ Is your baby drinking less breast milk or infant formula?
iron-rich foods. ■■ Is your baby interested in feeding himself? What is he
feeding himself?
Discuss With Parents of Formula-Fed Infants ■■ What does your baby eat with his fingers? Has he used
■■ Feeding their infant when the infant is hungry, usually a cup?
5 to 6 times in 24 hours. ■■ Is your baby interested in the food you eat?
■■ Vitamin supplements are not needed if the infant is ■■ What does your baby do when he has had enough to eat?
consuming an adequate amount of iron-fortified infant ■■ Do you know what your baby eats when he is away from
formula appropriate for growth. home (at child care)?
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often does your baby breastfeed? How long do you feed
her each time?
■■ How is your milk supply?
■■ Is your baby receiving vitamin D supplementation? ■■ Screen infants at about age 12 months. (AAP)
■■ Has your baby had infant formula or cow’s, goat’s, or ■■ Screen infants at high risk or those with known risk factors
soy milk? at ages 9 to 12 months and again 6 months later (ages
■■ Is your baby receiving an iron supplement and/or 15–18 months). (CDC)
iron-rich foods? —— Infants considered at high risk for iron-deficiency
anemia include
For Parents of Formula-Fed Infants
Infancy
Infancy
■■ For breastfed infants, determine whether the infant is ■■ Serving only 100% fruit juice in a cup as part of a meal or
receiving vitamin D supplementation, and assess the snack, and limiting juice to 4 to 6 oz per day.
need for iron supplementation. ■■ Avoiding feeding their infant sweetened beverages, such as
sodas and fruit drinks.
Anticipatory Guidance ■■ Providing their infant snacks midmorning, in the after-
noon, and in the evening. (Most 9-month-olds are on the
Discuss With Parents of All Infants
same eating schedule as the family: breakfast, lunch, and
■■ Gradually introducing their infant to solid textures to dinner.)
decrease the risk of feeding problems, such as rejecting
certain textures, refusing to chew, or vomiting. (It may take Discuss With Parents of Breastfed Infants
10–15 attempts before an infant accepts a particular food.) ■■ Encouraging the mother to breastfeed for the first year of
■■ Understanding that infants will become more interested the infant’s life.
in food their parents eat and less interested in breastfeed- ■■ Providing vitamin D supplement (400 IU/day).
ing or bottle-feeding. Nevertheless, infants should receive ■■ Providing an iron supplement (1 mg/kg of body 23
breast milk, infant formula, or both through the first year weight/day) if the infant does not consume sufficient
of life. iron-rich foods.
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Discuss With Parents of Formula-Fed Infants
■■ Feeding the infant when the infant is hungry, usually 5 to
6 times in 24 hours.
■■ Vitamin supplements are not needed if the infant is
consuming an adequate amount of iron-fortified infant
formula appropriate for growth.
Infancy
24
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Toddlers tend to be leery of new foods and may refuse to
■■ EARLY CHILDHOOD ■■
eat them. They need to look at the new foods and touch,
smell, and taste them many times before they accept them.
Overview ■■ Toddlers are unpredictable. They may like certain foods
Early childhood is a period during which physical, cognitive, one day and dislike them the next. They may eat a lot one
Early Childhood
social, and emotional development are tightly linked. The day and very little the next.
period is divided into 2 stages. ■■ By age 3 or 4, children are able to use their fingers to push
Toddler (ages 1–2). Toddlers are characterized by a growing food onto a spoon, pick up food with a fork, and drink
sense of independence and sometimes by struggles over food from a cup.
and refusing to eat certain foods. They are developing fine ■■ Most young children become more curious about food
motor skills, so eating is often messy. than they were as toddlers, although they still may be
reluctant to try new foods.
Young child (ages 3–4). Young children are increasingly ■■ As young children grow, they become less impulsive and
competent at self-feeding, but they still prefer eating with
can follow instructions. They can serve themselves from
their hands rather than using utensils. They are becom-
bowls and plates and pass food to others. Young children
ing more interested in trying new foods and participating
are more comfortable eating in unfamiliar places than
in family meals.
they were as toddlers.
■■ Children quadruple their birth weight by age 2. ■■ Early childhood is a key time for promoting the develop-
■■ Between ages 2 and 5, children gain an average of 4.5 to ment of motor skills and good habits for physical activity
6.5 lbs and grow 2.5 to 3.5 inches per year. that will last a lifetime. 25
■■ As growth rates decline during early childhood, children’s ■■ Parents need to plan activities so that children can master
appetites decrease, and the amount of food they consume control of their large muscles but still have time to just play.
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may become unpredictable. ■■ Physical activities (running, jumping, climbing, throwing,
■■ As toddlers’ eating skills develop, they progress from eating catching) and simple games (Simon Says, chase, tag) are
soft pieces of food to eating foods with more texture. appropriate during early childhood.
■■ Young children are not ready for organized, competitive (See Key Indicators of Nutrition Risk for Children and
sports, which require visual acuity, control, cooperation, Adolescents.)
and balance.
■■ Being physically active helps ensure that children maintain Nutrition Supervision
a healthy weight. A child’s nutrition status should be evaluated during nutri-
Early Childhood
inadequate or excessive food intake, developmental delays, ■■ How does your child let you know when she is hungry and
elimination problems, and metabolic disorders. when she is full?
■■ Describe what your child does during mealtimes. What Iron-Deficiency Anemia
do you do?
Guidelines from the American Academy of Pediatrics (AAP)
■■ What do you do if your child doesn’t like a particular food?
and the Centers for Disease Control and Prevention (CDC):
■■ Do you have equipment for feeding your child (cups, forks
and spoons, a high chair, a booster seat)? Children Ages 12 to 18 Months
Early Childhood
■■ Do you have any concerns about the food served to her ■■ Screen children at about age 12 months and about age
when she is away from home? 18 months. (AAP)
■■ Are you concerned about having enough money to ■■ Screen children at high risk or those with known risk
buy food? factors at ages 9 to 12 months and again 6 months later
(ages 15–18 months). (CDC)
Screening and Assessment —— Children considered to be at high risk for iron-
deficiency anemia include
Growth and Development
▶▶ Children from families with low incomes
■■ Measure the child’s length or height and the child’s weight, ▶▶ Children who are eligible for the Special
and plot it on a standard growth chart. Deviation from Supplemental Nutrition Program for Women,
expected growth patterns should be evaluated. This may be Infants, and Children (WIC)
normal or may indicate a nutrition problem. ▶▶ Children who are migrants or recently arrived
■■ Determine the child’s nutrition status and overall health refugees
using body mass index (BMI). Calculate the child’s BMI by ▶▶ Children who are Mexican American
dividing weight by square of height (kg/m ), or use a BMI
2
27
wheel or calculator. Plot the child’s BMI and age on a BMI-
for-age growth chart to determine BMI percentile.
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■■ Evaluate the appearance of the child’s skin, hair, teeth,
gums, tongue, and eyes.
—— Children who have known risk factors for iron- —— Low socioeconomic status
deficiency anemia include —— Limited access to food
▶▶ Children born preterm or with low birth weight ■■ Screen children annually if the following risk factors are
▶▶ Children fed non–iron-fortified infant formula for present (CDC):
more than 2 months —— Diet low in iron
Early Childhood
▶▶ Children fed cow’s milk before age 12 months —— Limited access to food because of poverty or neglect
▶▶ Children who are breastfed and do not receive —— Special health care needs
adequate iron from supplemental foods after age —— Low income
4 months —— Eligible for WIC
▶▶ Children who consume more than 24 oz of cow’s —— Migrant or recently arrived refugee
milk per day
▶▶ Children with special health care needs who use Oral Health
medications that interfere with iron absorption ■■ Determine whether the child has regular dental visits.
(eg, antacids, calcium, phosphorus, magnesium) ■■ Assess eating behaviors (frequency of consuming foods
or those with chronic infection; inflammatory dis and beverages high in sugar) to determine the child’s risk
orders; restricted diets; or extensive blood loss from for dental caries (tooth decay).
a wound, an accident, or surgery. Physical Activity
Children Ages 2 to 5 ■■ Determine how much physical activity the child engages
■■ Screen children annually if the following risk factors are in weekly.
28 present (AAP): ■■ Determine how much time the child spends watching
—— Special health care needs television and engaging in other media activities (com-
Bright FUTURES
—— Diet low in iron puter, video games). Determine whether the child watches
—— Vegetarian diet television during mealtimes.
Anticipatory Guidance ■■ Making family mealtimes a priority, and getting rid of
distractions (television).
Discuss With Parents ■■ Being patient and understanding as their child learns to
feed or serve herself.
Parent-Child Feeding Relationship
■■ Offering small portions (1 or 2 tablespoons) of new foods.
Early Childhood
■■ Purchasing and preparing nutritious food. ■■ Not using foods to reward, bribe, or punish their child or
■■ Offering developmentally appropriate, healthy meals and to calm, comfort, or entertain her.
snacks at scheduled times in a pleasant environment. ■■ Offering dessert (custard, pudding, fruits, yogurt) as part
■■ Helping their child develop eating and self-serving skills of a meal.
(progressing from using hands for eating to using utensils).
■■ Helping their child learn to self-regulate food intake by Eating
responding to internal cues of hunger and fullness. ■■ Weaning their child from the bottle by age 12 to
■■ Allowing their child to decide whether to eat and how 14 months.
much. ■■ Modifying foods to make them easier for their child to eat.
■■ Helping children ages 2 to 5 gradually decrease their
Meals and Snacks
fat intake.
■■ Offering healthy food choices at meals and snacks served ■■ Serving children ages 1 to 2 whole milk (serving reduced-
at about the same time each day. fat [2%] milk if obesity is of concern or if there is a family
■■ Offering nutritious foods (whole-grain crackers, milk history of obesity, dyslipidemia, or cardiovascular disease).
and milk products, fruits, vegetables, meat or poultry) ■■ Serving children older than age 2 low-fat (1%) or fat-free 29
as snacks because children often eat small amounts of (skim) milk.
food at one time. ■■ Serving children ages 2 and older 2 servings of milk
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■■ Sharing meals and snacks with their child. (Children eat (two 8-oz cups) per day.
better when an adult is nearby.)
■■ Being positive role models by eating new foods.
■■ Serving children grain products, especially whole grains; Food Safety
fruits; vegetables; milk and milk products; and beans, lean ■■ Following food safety practices to reduce their child’s risk
meat, poultry, fish, and other protein-rich foods. of food-borne illnesses.
■■ Providing children ages 2 to 3 with the same number of ■■ Having their child sit in a high chair or booster seat dur-
servings as children ages 4 and older, but with smaller ing feeding.
Early Childhood
portions (about two-thirds of a serving). ■■ Using techniques for positioning or special equipment or
■■ Serving children ages 4 and older portion sizes similar to modifying utensils for feeding children with special health
those eaten by older family members (½ cup of fruits or care needs.
vegetables; ¾ cup of 100% fruit juice; 1 slice of whole-grain ■■ Following precautions to prevent their child from choking.
bread; 2–3 oz of cooked lean meat, poultry, or fish). —— Staying with their child while eating.
■■ Providing a vitamin D supplement of 400 IU per day for —— Having their child sit while eating.
children who do not obtain 400 IU per day of vitamin D —— Not allowing their child to eat in the car.
through vitamin D–fortified milk (100 IU per 8-oz serv- —— Keeping mealtimes and snack times calm.
ing) and vitamin D–fortified foods (fortified cereals, —— Avoiding foods that may cause their toddler to choke
eggs [yolks]). (hard candy, mini-marshmallows, popcorn, pretzels,
■■ Serving 100% fruit juice in a cup; limiting consumption to chips, spoonfuls of peanut butter, nuts, seeds, large
4 to 6 oz per day. chunks of meat, hot dogs, raw carrots, raisins and other
■■ Reducing risk of dental caries (tooth decay), minor infec- dried fruits, whole grapes).
tions, and loose stools and diarrhea by not allowing their ■■ Modifying foods for their young child to make them safer
30 child to drink unlimited amounts of fruit juices or sweet- (cutting hot dogs in quarters lengthwise and then into small
ened beverages (fruit drinks, soft drinks). pieces, cutting whole grapes in half lengthwise, chopping
Maintaining their child’s appetite for healthy foods by
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Early Childhood
dairy farm). drinks, soft drinks) high in sugar.
■■ Reading books and singing songs about foods.
Physical Activity
■■ Involving their child in food shopping and preparation.
■■ Promoting both structured (following the leader) and free
Oral Health (child moves in any way he likes) play.
■■ For children ages 1 to 2, brushing the child’s teeth with a ■■ Playing with their child and being physically active.
small, soft toothbrush and a smear of fluoridated tooth- (Parents’ involvement and enthusiasm in physical activity
paste twice a day (after breakfast and before bed). have a positive impact on their child’s play experiences.)
■■ For children ages 2 and older, brushing the child’s teeth ■■ Planning family activities each week to encourage being
with a small, soft toothbrush and a pea-sized amount of physically active.
fluoridated toothpaste twice a day (after breakfast and ■■ Letting their child decide which physical activities the
before bed). family will do (walking, hiking, playing tag).
■■ Toothbrushing requires good fine motor control, and ■■ Taking part in community projects as a family (neighbor-
young children cannot clean their teeth without help. hood cleanup days, community gardens, food drives).
(After children acquire fine motor skills [ability to tie their ■■ Encouraging interactive activities (playing, singing, and 31
shoelaces], typically by age 7 or 8, they can brush their reading together).
teeth effectively.) ■■ Limiting their child’s total entertainment media time
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■■ Drinking water when thirsty. (watching television, playing computer or video games) to
no more than 1 to 2 hours of quality programming a day.
1 Year ■■ Evaluate the child’s interest in active play (bouncing, crawl-
ing, climbing).
Interview Questions
Anticipatory Guidance
■■ Are you breastfeeding your child?
Early Childhood
■■ What type of infant formula or milk do you feed him? Discuss With Parents
■■ Does your child drink from a cup? Does he drink from a ■■ Giving their child opportunities to develop eating skills
bottle now and then? If so, what are your plans for wean-
(chewing, swallowing) by offering a variety of healthy
ing him from the bottle?
foods and feeding at a family table.
■■ What textures of food does your child eat? Does he eat ■■ Serving beverages in a cup. (Children may need help
pieces of soft food?
drinking from a cup.)
■■ Does he eat with the family? ■■ Offering their child food every 2 to 3 hours. (Children’s
Screening and Assessment capacity to eat at any one time is limited.)
■■ Handling their child’s limit-testing behaviors (asking for
■■ Screen the child for lead exposure.
certain foods and throwing tantrums when refused).
■■ Evaluate the child’s progress in developing eating skills.
■■ Imposing limits on their child’s unacceptable mealtime
Make sure the child
—— Can bite off small pieces of food
behaviors without controlling the amount or types of foods
—— Can put food in the mouth
the child eats.
—— Has an adequate gag reflex
■■ Discouraging television viewing and encouraging inter-
—— Can retain food in the mouth (doesn’t immediately
active activities (talking, playing, singing, and reading
32
together).
swallow)
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Early Childhood
bottles? Milk in a cup? What kind of milk does she drink?
How much? ■■ Giving their child opportunities to develop eating skills
■■ How much fruit juice or how many sweetened drinks (chewing, swallowing) by offering a variety of foods and
(fruit drinks, soft drinks) does your child drink? Is the eating at a family table.
juice 100% fruit juice? When does she drink them? ■■ Offering age-appropriate foods (cut food into small
■■ Which foods does your child like to eat? Are there any pieces) and continuing to monitor the size of foods.
foods she doesn’t like? (Chewing and swallowing functions are not completely
■■ Describe your child’s mealtimes. Does she eat with developed until about age 8.)
the family? ■■ Making eating easier for their child by using spoons,
■■ Does she ask for food between meals and snacks? cups, and dishes with steep sides (bowls).
If so, how do you handle this? ■■ Being patient as their child’s skill at eating a variety of
■■ Does your child throw tantrums over food? If so, foods increases.
how do you handle them? ■■ Providing a relaxed atmosphere during meals and
■■ What kinds of physical activities does your child enjoy? snacks. (Children should not be rushed, because trying
■■ What concerns do you have about your child’s weight? new foods takes time.)
■■ Discouraging television viewing and encouraging 33
Screening and Assessment interactive activities (talking, playing, singing, and
Bright FUTURES
■■ Evaluate the child’s progress in developing large motor reading together).
skills. Children should be actively playing with a
parent daily.
18 Months Anticipatory Guidance
skills. Children should be actively playing with a juice 100% fruit juice? When does she drink them?
parent daily. ■■ Which foods does your child like to eat? Are there any
foods she doesn’t like?
■■ Describe your child’s mealtimes. How often does she eat ■■ Limiting total entertainment media time (watching tele
with the family? vision, playing computer or video games) to no more than
■■ Can your child shovel sand into a pail or pour water from 1 to 2 hours of quality programming a day.
a bucket? If she can, let her try to serve foods from a bowl ■■ Encouraging interactive activities (talking, playing, sing-
or platter onto her plate. ing, and reading together).
Early Childhood
■■ Does she eat the same foods as the rest of the family?
3 to 4 Years
Screening and Assessment
Interview Questions
■■ Screen the child for lead exposure.
■■ Assess the child’s risk for familial hyperlipidemia. ■■ What kind of milk does your child drink? How much?
■■ Evaluate the child’s progress in developing large motor skills. ■■ How much fruit juice or how many sweetened drinks
(fruit drinks, soft drinks) does your child drink? Is the
Anticipatory Guidance juice 100% fruit juice? When does he drink them?
■■ Which foods does your child like to eat? Are there any
Discuss With Parents foods he doesn’t like?
■■ Giving their child opportunities to develop eating skills ■■ What concerns do you have about your child’s weight?
(chewing, swallowing) by offering a variety of foods and ■■ Describe what your child does during mealtimes. Does he
eating at a family table. serve himself foods? Does he eat meals with the family?
■■ Allowing their child to self-regulate food intake by serving ■■ How often do you serve snacks? What types of foods do
himself from bowls and plates. (This is messy at first, but you serve?
35
with practice this self-help skill can be mastered.)
■■ Handling their child’s food jags (wanting to eat only a Screening and Assessment
Bright FUTURES
particular food) by serving the favorite food along with ■■ Screen the child for lead exposure.
other healthy foods. ■■ Obtain the child’s blood pressure.
■■ Turning off the television during mealtimes. ■■ Assess the child’s risk for familial hyperlipidemia.
■■ Evaluate the child’s progress in developing large motor
skills. Children should be actively playing with a par-
ent daily. By this age, many children can master running,
marching, and galloping. Adults can direct children in
ways to move their bodies around and through objects and
Early Childhood
Anticipatory Guidance
Middle Childhood
Middle childhood, ages 5 to 10, is a period characterized by to mealtime.
slow, steady physical growth. However, cognitive, emotional, ■■ Mealtimes take on more social significance, and outside
and social development occur at a rapid pace. sources (peers, the media) begin to exert more influence
over children’s attitudes toward eating behaviors and food.
Growth and Development ■■ Children’s food intake is strongly associated with what
■■ Children in middle childhood gain an average of 7 lbs their parents eat.
in weight and 2½ inches in height per year.
■■ Growth spurts, accompanied by increased appetite and Body Image
food intake, are common. Conversely, appetite and food ■■ Children may become overly concerned about their
intake decrease during periods of slower growth. physical appearance.
■■ Body composition and body shape remain ■■ Girls may be especially worried about being overweight
relatively constant. and may begin to eat less or diet.
■■ Girls need to be reassured that increased body fat is
Eating
part of normal growth and development and probably is
■■ Children need to eat a variety of healthy foods. They need not permanent.
3 meals plus 1 or 2 snacks per day. ■■ Boys may be concerned about their stature and muscle 37
■■ Children begin to describe foods according to color, size and strength.
shape, and quantity and classify foods as ones they like ■■ During middle childhood, muscle-building activities
Bright FUTURES
and don’t like. (weight lifting) do not build muscle mass and can be
■■ Children may identify foods that are healthy but may not harmful; muscle strength can be improved with appro
know why they are healthy. priate physical activities.
Oral Health ■■ Participating in physical activity programs helps children
■■ Children begin to lose primary teeth, and permanent teeth learn to cooperate with others.
begin to erupt.
■■ Children may have difficulty chewing certain foods, such Common Nutrition Concerns
■■ Decrease in consumption of milk and other milk products.
Middle Childhood
movements, allowing them to engage in a variety of physi- (See Key Indicators of Nutrition Risk for Children and
cal activities. Adolescents.)
■■ Children are motivated to be physically active by hav-
ing fun, feeling competent, and engaging in a variety of Nutrition Supervision
activities. A child’s nutrition status should be evaluated during nutri-
■■ Parents influence a child’s level of physical activity when tion supervision visits or as part of health supervision visits.
they participate with their child and show that physical Health professionals can do the following:
38 activity is fun. ■■ Begin nutrition supervision by selectively asking inter-
■■ Parents’ encouragement to be physically active significantly view questions or by reviewing a questionnaire filled out by
increases their child’s activity level.
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Middle Childhood
Eating Behaviors. ■■ Do you think your child eats healthy foods? Why or
why not?
Interview Questions
■■ How often does your child eat breakfast?
Eating Behaviors and Food Choices
■■ What does he usually eat for snacks?
■■ Where does your child eat snacks? At home? At school?
For the Child At after-school care? At a friend’s house?
■■ Which meals do you usually eat each day? How
■■ What does he usually drink (milk, water, fruit juice, fruit
many snacks? drinks, soft drinks)?
■■ How often does your family eat meals together? Food Resources
■■ Where did you eat yesterday? At school? At home? At a
friend’s house? For the Child or Parent
■■ What do you usually eat and drink in the morning? ■■ Who usually buys the food for your family? Who
Around noon? In the afternoon? In the evening? prepares it?
Between meals? ■■ Are there times when there is not enough food to eat
■■ What snacks do you usually eat? or not enough money to buy food?
■■ What is your favorite food? 39
■■ Are there any foods you won’t eat? If so, which ones? Weight and Body Image
Bright FUTURES
■■ What do you usually drink with your meals? With snacks?
■■ What fruits and vegetables, including juices, did you eat For the Younger Child
or drink yesterday? ■■ How do you feel about your weight?
For the Older Child Screening and Assessment
■■ How do you feel about your weight?
■■ How much would you like to weigh? Growth and Physical Development
■■ Are you trying to change your weight? If so, how? ■■ Measure the child’s height and weight, and plot them on a
Middle Childhood
Middle Childhood
be thin as a result of inadequate energy intake, inadequate for dental caries (tooth decay).
food resources, restrictive dieting, a nutritional deficit, or
Physical Activity
a chronic disease.
■■ Determine how much physical activity the child engages
Overweight and Obesity in weekly. Compare the child’s physical fitness level with
■■ If BMI is between the 85th and 94th percentiles, the child national standards (school’s standardized physical fitness
is considered overweight and needs further screening. assessment).
■■ If BMI is at or above the 95th percentile, the child is con- ■■ Determine how much time the child spends watching
sidered obese and needs in-depth medical assessment. television and on other media activities (computer, video
games). Determine whether the child watches television
Iron-Deficiency Anemia
during mealtimes.
Guidelines from the American Academy of Pediatrics (AAP)
Anticipatory Guidance
and the Centers for Disease Control and Prevention (CDC):
■■ Screen children consuming a strict vegetarian diet without
Discuss With Parents, the Child, or Both
iron supplementation. (AAP)
■■ Screen children with known risk factors for iron-deficiency 41
Growth and Physical Development
anemia (low iron intake, special health care needs, previ- ■■ Expected accelerated growth (for girls at ages 9–11, for
Bright FUTURES
ous diagnosis of iron-deficiency anemia). (CDC) boys at about age 12).
■■ Variation in onset of puberty among children.
■■ Upcoming physical changes and specific concerns.
■■ How the child compares to others on a standard Eating Behaviors and Food Choices
growth chart. ■■ Increasing the variety of foods the child eats and finding
■■ Healthy body weight based on genetically determined size ways to incorporate new foods into the child’s diet.
and shape rather than on socially defined ideal weight. ■■ Making healthy foods choices based on Dietary Guidelines
Middle Childhood
■■ Positive body image. (People come in unique sizes and for Americans (fruits, vegetables, grain products [especially
shapes, within a range of healthy body weights.) (See Tips whole grain]; low-fat [1%] and fat-free [skim] milk prod-
for Fostering a Positive Body Image Among Children ucts [milk, cheese, yogurt]; and lean meats, poultry, fish,
and Adolescents.) beans, eggs, and nuts).
■■ Assuring children that they are loved and accepted as they ■■ Energy requirements are influenced by growth, physical
are, regardless of their size and shape. activity level, and body composition.
■■ Eating healthy foods and being physically active to achieve ■■ Children ages 2 to 8 need to drink 2 cups of low-fat (1%)
or maintain a healthy weight. or fat-free (skim) milk per day or consume the equivalent
■■ Weight loss should not occur in children with BMI below from other milk products (cheese, yogurt).
the 95th percentile; gradual weight loss of no more than ■■ Children ages 9 and older need to drink 3 cups of low-fat
1 lb per month may be appropriate for children with BMI (1%) or fat-free (skim) milk per day or consume the equiv-
between the 95th and 99th percentiles. A weight loss of no alent from other milk products.
more than 2 lbs per week may be appropriate for children ■■ Providing a vitamin D supplement of 400 IU per day for
with BMI above the 99th percentile. (But, even if they are children who do not obtain 400 IU per day of vitamin
losing weight, children need to consume sufficient calories D through vitamin D–fortified milk (100 IU per 8-oz
42 and nutrients for growth and development.) serving) and vitamin D–fortified foods (fortified cereals,
eggs [yolks]).
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Middle Childhood
■■ Providing a relaxed atmosphere for mealtimes and getting ■■ Limiting foods (candy, cookies) and beverages (juice,
rid of distractions (television). juice drinks, soft drinks) high in sugar.
■■ Limiting foods high in calories and low in nutrients.
Physical Activity
■■ Limiting foods high in fat, especially high in saturated and
trans fats (chips, french fries), and foods (candy, cookies) ■■ Engaging in 60 or more minutes of daily physical activity.
—— Aerobic: Either moderate-intensity (hiking, skateboard-
and beverages (fruit drinks, soft drinks) high in sugar.
■■ Enrolling child in school breakfast and lunch programs, ing) or vigorous-intensity (running, bicycling) aerobic
if needed. (See Federal Nutrition Assistance Programs.) physical activity daily, and include vigorous-intensity
physical activity at least 3 days a week.
Oral Health —— Muscle-strengthening: Include muscle-strengthening
■■ Toothbrushing requires good fine motor control, and physical activity (climbing trees, sit-ups) at least 3 days
young children cannot clean their teeth without help. a week.
(After children acquire fine motor skills [ability to tie —— Bone-strengthening: Include bone-strengthening
their shoelaces], typically by age 7 or 8, they can brush (weight-bearing) physical activity (jumping rope,
their teeth effectively.) playing basketball) at least 3 days a week.
■■ Brushing teeth with fluoridated toothpaste twice a day ■■ For children with special health care needs, engaging in 43
(after breakfast and before bed). physical activity for cardiovascular fitness (within limits
■■ Drinking water when thirsty. of medical or physical conditions).
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■■ Wearing appropriate safety equipment (helmets, pads,
mouth guards, goggles) when physically active.
■■ Drinking water when physically active. (Children are at
increased risk for heat-related illness because their sweat
glands are not fully developed.)
■■ Not having a television in the child’s bedroom.
Middle Childhood
Substance Use
■■ Dangers of using alcohol, tobacco, and other drugs.
■■ Dangers of using performance-enhancing products
(protein supplements, anabolic steroids).
44
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Females complete most physical growth about 2 years after
■■ ADOLESCENCE ■■
menarche. Mean age of menarche is 12.5 years.
■■ Males begin puberty about 2 years later than females.
Overview ■■ Males experience major growth spurts and increases in
Adolescence is a period of dramatic physical, cognitive, social, muscle mass during middle adolescence.
Adolescence
and emotional changes. This developmental period is divided ■■ Cognitive capacities increase dramatically during
into 3 stages. adolescence.
Early adolescence (ages 11–14). Adolescents are character- ■■ Developing an identity and becoming an independent
ized by pubertal changes and a growing capacity for abstract young adult are central to adolescence.
thought, although concrete and oriented toward the present. Eating
Middle adolescence (ages 15–17). Adolescents are charac- ■■ Foods can have symbolic meanings. Adolescents may use
terized by independence, experimentation, future-oriented them to establish individuality and express their identity.
thinking, and problem-solving abilities. ■■ Adolescents may adopt certain eating behaviors (such
Late adolescence (ages 18–21). This stage is a time of impor- as vegetarianism) to explore various lifestyles or to show
tant personal and vocational decisions and refined abilities to concern for the environment.
reason logically and solve problems. ■■ Interest in new foods, including those from different cul-
tures and ethnic groups, is common during adolescence.
Growth and Development ■■ Adolescents spend more time away from home and eat
■■ Adolescents achieve the final 15% to 20% of their adult more meals and snacks away from home than when they 45
height and gain 50% of their adult weight. were younger. Many adolescents go to stores and fast-food
■■ Adolescents accumulate up to 40% of their skeletal mass. restaurants and purchase food with their own money.
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■■ Nutrient needs are greatest during peak periods of
growth (sexual maturity rating [SMR] 2–3 in females,
3–4 in males).
Body Image ■■ Parents influence an adolescent’s physical activity level
■■ Changes associated with puberty can affect adolescents’ when they participate with the adolescent and show that
satisfaction with their appearance. physical activity is fun.
■■ For males, increased size and muscle development that ■■ Parents’ encouragement to be physically active significantly
come with physical maturation usually improve their increases adolescents’ activity levels.
Adolescence
body image.
■■ For females, physical maturation may lead to dissatis Common Nutrition Concerns
faction with their bodies, which may result in weight ■■ Decrease in consumption of milk and other milk products.
concerns and dieting. ■■ Increase in consumption of beverages high in sugar,
■■ Social pressure to be thin and the stigma of obesity can especially soft drinks and sports drinks.
lead to unhealthy eating behaviors and a poor body image ■■ Insufficient intake of fruits and vegetables.
during adolescence. ■■ Higher consumption than recommended of foods high
■■ Adolescents may try fad diets and underestimate the in fat, especially saturated and trans fats, cholesterol,
associated health risks. and sodium.
■■ Rise in overweight and obesity.
Physical Activity ■■ Low levels of physical activity.
■■ As adolescents grow and develop, their motor skills ■■ Increase in eating disorders, body image concerns,
increase, providing more opportunities for engaging in dieting, and unsafe weight-loss methods.
physical activity. ■■ Prevalence of iron-deficiency anemia (in females).
46 ■■ Physical activity usually occurs in group settings, and ■■ Prevalence of hyperlipidemia.
adolescents’ engagement in physical activity may be ■■ Food insecurity among adolescents from families with
influenced by peers.
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low incomes.
(See Key Indicators of Nutrition Risk for Children and
Adolescents.)
Nutrition Supervision ■■ What do you usually eat and drink in the morn-
An adolescent’s nutrition status should be evaluated during ing? Around noon? In the afternoon? In the evening?
nutrition supervision visits or as part of health supervision Between meals?
visits. Health professionals can do the following:
■■ What snacks do you usually eat?
■■ Begin nutrition supervision by selectively asking interview
■■ Are there any foods you won’t eat? If there are, which ones?
Adolescence
questions or by reviewing a questionnaire filled out by
■■ How often do you drink milk? What kind of milk do you
parents and/or the adolescent before the visit. Continue drink (whole milk, reduced-fat [2%], low-fat [1%], fat-free
by conducting screening and assessment and providing [skim] milk)? What other milk products do you like to eat?
anticipatory guidance.
■■ What fruits and vegetables, including juices, did you eat or
■■ Recognize that interview questions, screening and assess- drink yesterday?
ment, and anticipatory guidance will vary from visit to visit
■■ How often do you drink soft drinks, energy drinks, or
and from adolescent to adolescent. sports drinks?
■■ What changes would you like to make in the way you eat?
(See Strategies for Health Professionals to Promote Healthy
Eating Behaviors.) For the Parent
■■ How often does your family eat meals together?
Interview Questions
■■ Do you have any concerns about your teenager’s eating
Eating Behaviors and Food Choices behaviors?
■■ Do you think your teenager eats healthy foods? Why or
For the Adolescent why not? 47
■■ Which meals do you usually eat each day? How many
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snacks? How many times a week do you eat breakfast?
Lunch? Dinner?
■■ How often does your family eat meals together?
Food Resources Physical Activity
■■ Are there times when there is not enough food to eat or ■■ What physical activity would you like to do that you are
not enough money to buy food? not doing now? How can you make time for it?
■■ How much time do you spend each day watching tele
Weight and Body Image
vision and playing computer or video games?
■■ What do you think you can do to be more active?
For the Adolescent
■■ How do you feel about the way you look? For the Parent
■■ Do you think that you weigh too little? Weigh too much? ■■ What type of physical activity does your teenager engage
Are just the right weight? Why? in? How often?
■■ How do you feel about your weight and height? ■■ How much time does your teenager spend each day watch-
■■ Are you trying to change your weight? If so, how? ing television or playing computer or video games?
■■ How much would you like to weigh? ■■ Does your teenager have a television in his bedroom?
■■ Are you teased about your weight?
Adolescence
growth patterns should be evaluated. This may be normal inadequate food resources, restrictive dieting, a nutri-
or may indicate a nutrition problem. tional deficit, or a chronic disease.
■■ Determine the adolescent’s nutrition status and overall
health using body mass index (BMI). Calculate the Overweight and Obesity
adolescent’s BMI by dividing weight by square of height ■■ If BMI is between the 85th and 94th percentiles,
(kg/m ), or use a BMI wheel or calculator. Plot the
2 the adolescent is considered overweight and needs
adolescent’s BMI and age on a BMI-for-age growth chart further screening.
to determine BMI percentile. ■■ If BMI is at or above the 95th percentile, the adolescent is
■■ Evaluate appearance of the adolescent’s skin, hair, teeth, considered obese and needs in-depth medical assessment.
gums, tongue, and eyes.
Iron-Deficiency Anemia
■■ Obtain the adolescent’s blood pressure.
■■ Assess the adolescent’s risk for familial hyperlipidemia. Guidelines from the American Academy of Pediatrics (AAP)
and the Centers for Disease Control and Prevention (CDC):
Stunting ■■ Screen females ages 12 to 21 during routine physical
■■ If height-for-age is below the third percentile, evaluate exams. (AAP) 49
to determine whether growth is stunted and whether the
adolescent may benefit from improved nutrition or treat-
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ment of other underlying problems.
■■ Low height-for-age is usually the result of genetics, not
the result of stunted growth.
■■ Screen females ages 12 to 21 with known risk factors for ■■ Determine how much time the adolescent spends watching
iron-deficiency anemia (extensive menstrual or other television and on other media activities (computer, video
blood loss, low iron intake, previous diagnosis of iron- games). Determine whether the adolescent watches tele
deficiency anemia) annually. For those with no known vision during mealtimes.
risk factors, screen every 5 to 10 years during routine
Anticipatory Guidance
Adolescence
fitness level with national standards (school’s standardized their growth is normal. (Use charts that plot height velocity
physical fitness assessment). by age and SMR to ease concerns.)
Eating Behaviors and Food Choices Oral Health
■■ Making healthy foods choices based on Dietary Guidelines ■■ Brushing teeth with fluoridated toothpaste twice a day
for Americans (fruits, vegetables, grain products [especially (after breakfast and before bed).
whole grain]; low-fat [1%] and fat-free [skim] milk prod- ■■ Drinking water when thirsty.
ucts [milk, cheese, yogurt]; and lean meats, poultry, fish, ■■ Using community fluoridated water as a safe, effective
Adolescence
beans, eggs, and nuts). way to reduce dental caries. (If bottled water is preferred,
■■ Drinking 3 cups of low-fat (1%) or fat-free (skim) milk per recommend a brand with fluoride added at a concentration
day or consuming the equivalent from other milk products of approximately 0.8–1.0 mg/L [ppm].)
(cheese, yogurt). ■■ Limiting foods (candy, cookies) and beverages (juice,
■■ Taking a vitamin D supplement of 400 IU per day for juice drinks, soft drinks) high in sugar.
adolescents who do not obtain 400 IU per day of vita-
Weight and Body Image
min D through vitamin D–fortified milk (100 IU per 8-oz
serving) and vitamin D–fortified foods (fortified cereals, ■■ Healthy body weight based on genetically determined size
eggs [yolk]). and shape rather than on socially defined ideal weight.
■■ Eating 3 meals and snacks, as needed, per day. ■■ Safe and healthy ways for achieving and maintaining
■■ Limiting foods high in fat, especially high in saturated and healthy weight (practicing healthy eating behaviors;
trans fats (chips, french fries), and foods (candy, cookies) limiting high-calorie, low-nutrient foods and bever-
and beverages (fruit drinks, soft drinks) high in sugar. ages; engaging in regular physical activity; reducing
■■ Enrolling adolescent in school breakfast and lunch pro- sedentary behaviors).
grams, if needed. (See Federal Nutrition Assistance ■■ Discouraging dieting; instead, emphasizing 51
Programs.) healthy lifestyle.
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■■ Positive body image. (People come in unique sizes and ■■ Wearing appropriate safety equipment (helmets, pads,
shapes, within a range of healthy body weights.) (See Tips mouth guards, goggles) when physically active.
for Fostering a Positive Body Image Among Children ■■ Finding safe settings for physical activity.
and Adolescents.) ■■ Drinking water when physically active.
■■ Assuring adolescents that they are loved and accepted as ■■ Not having a television in the adolescent’s bedroom.
Adolescence
they are, regardless of their size and shape. ■■ Limiting total entertainment media time (watching tele
vision, playing computer or video games) to no more than
Physical Activity
1 to 2 hours of quality programming a day.
■■ Engaging in 60 or more minutes of daily physical activity. ■■ Reducing sedentary behaviors (watching television, play-
—— Aerobic: Either moderate-intensity (hiking, skateboard- ing computer or video games, especially if the adolescent
ing) or vigorous-intensity (running, bicycling) aerobic is overweight.
physical activity daily, and include vigorous-intensity
physical activity at least 3 days a week. Substance Use
—— Muscle-strengthening: Include muscle-strengthening ■■ Consuming excessive quantities of caffeinated beverages
physical activity (climbing trees, sit-ups) at least 3 days (soft drinks, coffee, energy drinks).
a week. ■■ Dangers of using alcohol, tobacco, and other drugs.
—— Bone-strengthening: Include bone-strengthening ■■ Dangers of using performance-enhancing products
(weight-bearing) physical activity (jumping rope, (protein supplements, anabolic steroids).
playing basketball) at least 3 days a week.
52
■■ Incorporating physical activity into daily life (through
physical education at school and activities with family
and friends).
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53
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■■ Key Indicators of Nutrition Risk for Children and Adolescents
Indicators of Criteria for Further Screening
Nutrition Risk Relevance and Assessment
Nutrition Tools
Food Choices
Consumes <2 servings of Fruits and vegetables provide vitamins Assess the child or adolescent who is
fruits per day. (such as A and C), minerals, and fiber. consuming <1 serving of fruit per day.
Consumes <3 servings of Low intake of fruits and vegetables Assess the child or adolescent who is
vegetables per day. is associated with an increased risk of consuming <2 servings of vegetables
many types of cancer. per day.
Consumes <6 servings of Grain products provide complex Assess the child or adolescent who is
cereal, bread, crackers, carbohydrates, vitamins, minerals, and consuming <6 servings of cereal, bread,
pasta, rice, or other pasta fiber. Low intake of fiber is associated crackers, rice, pasta, or other grains
per day. with constipation and increased risk of per day.
Consumes <3 servings of colon cancer. Assess the child or adolescent who is
whole grains per day. consuming <3 servings of whole-grain
cereal, bread, crackers, rice, pasta, or
other grains per day.
Assess the child or adolescent who has
55
recent history of constipation.
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■■ Key Indicators of Nutrition Risk for Children and Adolescents,
continued
Indicators of Criteria for Further Screening
Nutrition Tools
56
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■■ Key Indicators of Nutrition Risk for Children and Adolescents,
continued
Indicators of Criteria for Further Screening
Nutrition Tools
Nutrition Risk Relevance and Assessment
Consumes <2 servings of Protein-rich foods (eg, meats, meat Assess the child or adolescent who is
meat or meat alternatives alternatives) are good sources of B consuming <1 serving of meat or meat
(eg, beans, eggs, nuts, vitamins, iron, and zinc. Low intake of alternatives per day.
seeds) per day. protein-rich foods may impair growth
and increase the risk of iron-deficiency
anemia and of delayed growth and
sexual maturation. Low intake of meat
or meat alternatives may indicate
inadequate availability of these foods at
home. Special attention should be paid
to children and adolescents who follow a
vegetarian diet.
For children ≥5: Consumes Excessive intake of dietary fat contributes Assess the child or adolescent who
excessive amount of fat. to the risk of cardiovascular disease has a family history of premature
and obesity and is associated with cardiovascular disease. 57
some cancers. Assess the child or adolescent if body mass
index (BMI) is ≥85th percentile.
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■■ Key Indicators of Nutrition Risk for Children and Adolescents,
continued
Indicators of Criteria for Further Screening
Nutrition Tools
Nutrition Tools
Nutrition Risk Relevance and Assessment
Skips breakfast, lunch, or Meal-skipping is associated with a low Assess the child or adolescent to ensure
dinner or supper ≥3 times intake of energy and essential nutrients that meal-skipping is not due to
per week. and, if it is a regular practice, could inadequate food resources or unhealthy
compromise growth and development. weight-loss practices.
Repeatedly skipping meals decreases the
nutritional adequacy of the diet.
Has food jags—eats one Food jags, which limit the variety of food Assess the child’s or adolescent’s dietary
particular food only. consumed, decrease the nutritional intake over several days.
adequacy of the diet.
Food Resources
Has inadequate financial Poverty can result in hunger and Assess the child or adolescent who is from
resources to buy food, compromised food quality and nutrition a family with low income, is homeless, or
insufficient access to status. Inadequate dietary intake is a runaway.
food, or lack of access to interferes with learning.
59
cooking facilities.
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■■ Key Indicators of Nutrition Risk for Children and Adolescents,
continued
Indicators of Criteria for Further Screening
Nutrition Tools
Nutrition Tools
Exhibits significant weight Significant weight change during the past Assess the child or adolescent to determine
change in past 6 months. 6 months may indicate stress, depression, the cause of weight loss or weight gain
organic disease, or an eating disorder. (eg, limited or too much access to food,
poor appetite, meal-skipping, eating
disorder).
Growth
Has BMI <5th percentile. Thinness may indicate an eating disorder or Assess the child or adolescent for eating
poor nutrition. disorders.
Assess the child or adolescent for organic
or psychiatric disease.
Assess the child or adolescent for
inadequate food resources.
Has BMI >85th percentile. Overweight children and adolescents are Assess the child or adolescent who is at
more likely to be overweight adults and risk for overweight.
61
are at increased risk for health problems
as adults. Obesity is associated with
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elevated cholesterol levels and elevated
blood pressure. Obesity is an independent
risk factor for cardiovascular disease and
type 2 diabetes mellitus.
■■ Key Indicators of Nutrition Risk for Children and Adolescents,
continued
Indicators of Criteria for Further Screening
Nutrition Tools
throughout life.
■■ Key Indicators of Nutrition Risk for Children and Adolescents,
continued
Indicators of Criteria for Further Screening
Nutrition Tools
Nutrition Risk Relevance and Assessment
Participates in excessive Intense physical activity nearly every day, Assess the child or adolescent for
physical activity. sometimes more than once a day, can be eating disorders.
unhealthy and may be associated with
menstrual irregularity, excessive weight
loss, and malnutrition.
Lifestyle
Engages in heavy alcohol, Alcohol, tobacco, and other drug use can Assess the child or adolescent further for
tobacco, and other adversely affect nutrient intake and alcohol, tobacco, and other drug use.
drug use. nutrition status.
Uses dietary supplements. Dietary supplements (eg, vitamin and Assess the child or adolescent for the type
mineral preparations) can be healthy of supplements used and dosage.
additions to a diet for children or Assess adolescent’s use of anabolic steroids
adolescents with a history of iron- and mega doses of other supplements.
deficiency anemia; however, high doses 63
can have serious side effects. Adolescents
who use supplements to “bulk up”
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may be tempted to experiment with
anabolic steroids.
■■ Strategies for Health Professionals to Promote Healthy
Eating Behaviors
Strategies Applications/Questions
Nutrition Tools
Communication Factors
Promote positive, nonjudgmental strategies to help the Reinforce positive aspects of the child’s or adolescent’s
child or adolescent adopt healthy eating behaviors. eating behaviors.
Encourage the child’s or adolescent’s active participation Help the child or adolescent identify barriers that make it
in changing eating behaviors. difficult to change eating behaviors, and develop a plan
of action for adopting new behaviors.
Provide concrete learning situations. Use charts, food models, and videotapes to reinforce verbal
information and instructions.
Focus on the short-term benefits of healthy eating Emphasize that healthy eating behaviors will make the
behaviors. child or adolescent feel good and have more energy.
Understand and respect the child’s or adolescent’s cultural Help the child or adolescent integrate cultural eating
eating behaviors. behaviors with dietary recommendations.
Use simple terminology. Avoid using the term “diet” with the child or adolescent
because it tends to be associated with weight loss and
64 may be confusing.
Bright FUTURES
■■ Strategies for Health Professionals to Promote Healthy
Eating Behaviors, continued
Strategies
Strategies Applications/Questions
Applications/Questions
Nutrition Tools
Communication Factors
Environmental Factors
Promote
Create anpositive,
office ornonjudgmental strategies
clinic environment to help
oriented the
to children Reinforce positive
Use posters aspects written
and materials of the child’s or adolescent’s
for children or
child or adolescent adopt healthy eating behaviors.
or adolescents. eating behaviors.
adolescents.
Encourage thedevelopmentally
Communicate child’s or adolescent’s active participation
appropriate Helpposters
Use the child
andormaterials
adolescent identify
that barriers
highlight that make it
the importance
in changing eating behaviors.
health messages. difficult
of healthyto eating
changebehaviors.
eating behaviors, and develop a plan
of action for adopting new behaviors.
Encourage health professionals and staff to become role Have health professionals and staff model healthy
Provide
modelsconcrete learning
for healthy situations.
eating behaviors. Use charts, food models, and videotapes to reinforce verbal
eating behaviors.
information and instructions.
Readiness to Change
Focus on the short-term benefits of healthy eating Emphasize that healthy eating behaviors will make the
Identify the child’s or adolescent’s stage of behavior change
behaviors. “Do you
child orwant to change
adolescent feel the
good way you
and eat?”
have more energy.
and readiness to change based on the Stages of Change “Are you thinking about changing the way you eat?”
Understand
model (Tooland respect
F in Brightthe child’sNutrition
Futures: or adolescent’s cultural
manual). Help
“Are the
you child
readyortoadolescent
change the integrate
way youcultural
eat?” eating
eating behaviors. behaviors
“Are with dietary
you changing recommendations.
the way you eat?”
Use simple terminology. “Are you
Avoid trying
using the to keep
term eating
“diet” the
with way
the youorhave
child been?”
adolescent
Facilitate behavior change with counseling strategies because
Provide it tends to environment,
a supportive be associated basic
with weight loss and
information,
may be confusing. 65
tailored to the child or adolescent based on the Stages and assessment.
of Change model (Tool F in Bright Futures: Nutrition Prioritize behaviors to be changed, set goals, and identify
Bright FUTURES
manual). barriers to change.
Develop a plan that incorporates incremental steps for
making changes, support, and reinforcement.
■■ Strategies for Health Professionals to Promote Healthy
Eating Behaviors, continued
Strategies Applications/Questions
Nutrition Tools
Action Plans
Provide counseling for the child or adolescent who is in Increase the child’s or adolescent’s awareness and
the early stages of behavior change or who is unwilling knowledge of eating behaviors.
to change. Encourage the child or adolescent to make behavior
changes.
Provide task-oriented counseling for the child or adolescent Encourage a few small, concrete changes first, and build
who is ready to change eating behaviors. on those.
Support and follow up with the child or adolescent who
has changed behavior.
Identify and prioritize behavior changes to be made. Suggest changes that will have a measurable impact on the
child’s or adolescent’s most serious nutrition issues.
Set realistic, achievable goals that are supported by the “What will you change?”
child’s or adolescent’s family. “What goal is realistic right now?”
66 “How and when will you change, and who will help you?”
Identify and address barriers to behavior change; help “What could make it hard for you to make this change—
Bright FUTURES
reduce barriers when possible. money, friends, or family?” “How can you get around
this?”
■■ Strategies for Health Professionals to Promote Healthy
Eating Behaviors, continued
Strategies Applications/Questions
Nutrition Tools
Make sure that the behavior changes are compatible with Don’t expect the child or adolescent to conform to rigid
the child’s or adolescent’s lifestyle. eating behaviors. Keep in mind current behaviors and
realistic goals.
Establish incremental steps to help the child or adolescent For example, have the child or adolescent reduce fat
change eating behaviors. consumption by changing the type of milk consumed,
from reduced-fat (2%), to low-fat (1%), to fat-free
(skim) milk.
Encourage the child or adolescent to commit to behavior Discuss nonfood rewards (incentives) to help the child or
changes with contracts. adolescent focus on changing eating behaviors.
Give the child or adolescent responsibility for changing Stress the importance of planning how the child or
and monitoring eating behaviors. adolescent will make and track changes in eating
behavior.
Make record-keeping simple, and review the plan with the
child or adolescent.
Help the child or adolescent obtain family and Discuss how the child or adolescent can encourage parents 67
peer support. and peers to help.
Meet with parents to clarify goals and action plans;
Bright FUTURES
determine how they can help. Provide nutrition
education or counseling to parents, as appropriate.
■■ Strategies for Health Professionals to Promote Healthy
Eating Behaviors, continued
Strategies Applications/Questions
Nutrition Tools
Offer feedback and reinforce successes. Show interest to encourage continued behavior change.
General Strategies
Ask the child or adolescent about changes in eating “How are you doing in changing the way you eat?”
behaviors at every visit.
Emphasize to the child or adolescent the consumption of For example, say, “drink more milk, and eat more cheese,
foods rather than nutrients. and yogurt” rather than “you need more calcium.”
Build on positive aspects of the child’s or adolescent’s “It’s great that you’re eating breakfast. Would you be
eating behaviors. willing to try cereal, fruit, and toast instead of bacon
and doughnuts 4 days a week?”
Focus on “how to” instead of “why” information. Share behaviorally oriented information (eg, what, how
much, and when to eat and how to prepare food) rather
than focusing on why the information is important.
Provide counseling that integrates realistic behavior change “I understand that your friends eat lunch at fast-food
68
into the child’s or adolescent’s lifestyle. restaurants. Would it help you to learn how to make
healthier food choices at these restaurants?”
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Discuss how to make healthy food choices in a variety of Talk about how to choose foods in various settings such
settings. as fast-food and other restaurants, convenience stores,
vending machines, and friends’ homes.
■■ Strategies for Health Professionals to Promote Healthy
Eating Behaviors, continued
Strategies Applications/Questions
Nutrition Tools
Provide the child or adolescent with learning experiences Practice problem-solving and role-playing (eg, having
and skills practice. the child or adolescent ask the food server to hold
the mayonnaise).
Introduce the concept of achieving balance and enjoying “Your food record shows that after having pepperoni
all foods in moderation. pizza for lunch yesterday, you ate a lighter dinner.
That’s a good way to balance your food intake
throughout the day.”
Make recordkeeping easy, and tell the child or adolescent “Be as accurate and honest as you can as you record your
that you do not expect spelling, handwriting, and eating food intake. This record is a tool to help you think about
behaviors to be perfect. how you eat.”
Make sure that the child or adolescent hears what you are “What are you planning to work on before your next
saying. appointment?”
Make sure that you and the child or adolescent define Discuss the definition of words that may cause confusion,
terms in the same way to avoid confusion. such as “fat,” “calories,” “meal,” and “snack.”
69
When assessing food intake, keep in mind that a child’s Use food models or household cups and bowls to clarify
or adolescent’s portion size may not be the same as a serving sizes.
Bright FUTURES
standard serving size.
■■ Tips for Fostering a Positive Body Image Among Children
and Adolescents
Child or Adolescent Parents Health Professional
Nutrition Tools
Look in the mirror and focus on Model healthy eating and physical Discuss changes that occur during adolescence.
your positive features, not your activity behaviors, and avoid Assess weight concerns and body image.
negative ones. extreme eating and physical If a child or adolescent has a distorted body
Say something nice to your activity behaviors. image, explore causes and discuss potential
friends about how they look. Focus on non–appearance-related consequences.
Think about your positive traits when discussing yourself Discuss how the media negatively affects
traits that are not related to and others. body image.
appearance. Praise your child or adolescent for Discuss normal variation in body sizes and
Look at magazines with a academic and other successes. shapes among children and adolescents.
critical eye, and find out what Analyze media messages with your Educate parents, physical education instructors,
photographers and graphic child or adolescent. and coaches about realistic and healthy
designers do to make models Show that you love your child or body weights.
look the way they do. adolescent regardless of what he Emphasize the positive characteristics
If you are overweight and want weighs. (related to appearance and not related to
to lose weight, be realistic in If your child or adolescent is appearance) of children and adolescents
your expectations, and aim for overweight, don’t criticize her you see.
70 gradual change. appearance—offer support Take extra time with an overweight child or
Realize that everyone has a instead. adolescent to discuss psychosocial concerns
unique size and shape. Share with a health professional and weight control options.
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If you have questions about your any concerns you have about Refer children, adolescents, and parents with
size or weight, ask a health your child’s or adolescent’s eating weight-control issues to a registered dietitian
professional. behaviors or body image. or other health professional.
■■ Basics for Handling Food Safely a
Safe food handling, cooking, and storage are essential to prevent foodborne illness. You can’t see, smell, or taste harmful
bacteria that may cause illness. In every step of food preparation, follow 4 guidelines to keep food safe:
■■ Clean—Wash hands and surfaces often.
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■■ Separate—Don’t cross-contaminate.
■■ Cook—Cook to proper temperatures.
■■ Chill—Refrigerate promptly.
Shopping
■■ Buy refrigerated or frozen items after selecting non-perishable food.
■■ Never buy meat or poultry in packaging that is torn or leaking.
■■ Never buy food after “sell-by,” “use-by,” or other expiration dates.
Storage
■■ Always refrigerate perishable food within 2 hours (1 hour when the temperature is above 90° F).
■■ Check the temperatures of your refrigerator and freezer with an appliance thermometer. The refrigerator should be at
40°F or below and the freezer at 0°F or below.
■■ Cook or freeze fresh poultry, fish, ground meat, and variety meat (eg, calf’s tongue) within 2 days; cook or freeze other
beef, veal, lamb, or pork within 3 to 5 days.
■■ Make sure perishable food such as meat and poultry is wrapped securely to maintain quality and to prevent meat juices
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from coming into contact with other food.
■■ To maintain quality when freezing meat and poultry in its original package, wrap the package again with foil or plastic
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wrap that is recommended for the freezer.
■■ In general, canned high-acid foods such as tomatoes, grapefruit, and pineapple can be stored for 12 to 18 months. Canned
low-acid foods such as meat, poultry, fish, and most vegetables can be stored for 2 to 5 years if the can remains in good
condition and has been kept in a cool, clean, and dry place. Discard cans that are dented, leaking, bulging, or rusted.
■■ Basics for Handling Food Safely, continued
Preparation
■■ Always wash your hands with warm water and soap for 20 seconds before and after handling food.
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■■ Don’t cross-contaminate. Keep raw meat, poultry, fish, and their juices away from other food. After cutting raw meat,
wash the cutting board, utensils, and countertops with hot, soapy water.
■■ Sanitize cutting boards, utensils, and countertops with a solution of 1 tablespoon of unscented, liquid chlorine bleach in
1 gallon of water.
■■ Marinate meat and poultry in a covered dish in the refrigerator.
Thawing
■■ Refrigerator: The refrigerator allows slow, safe thawing. Make sure thawing meat and poultry juices do not drip
onto other food.
■■ Cold water: For faster thawing, place food in a leak-proof plastic bag, and submerge the bag in cold tap water.
Change the water every 30 minutes. Cook immediately after thawing.
■■ Microwave: For fastest thawing, use the microwave. Place food in cookware that is manufactured for use in the
microwave and cover with a lid or microwave-safe plastic wrap to hold in moisture and provide safe, even heating.
Cook meat, poultry, egg casseroles, and fish immediately after microwave thawing.
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■■ Cold food should be held at 40°F or colder.
■■ At buffets, keep food hot with chafing dishes, slow cookers, and warming trays. Keep food cold by nesting dishes in
bowls of ice.
■■ Perishable food should not be kept at room temperature for more than 2 hours (1 hour when the temperature is
above 90°F).
Leftovers
■■ Discard any perishable food kept at room temperature for more than 2 hours (1 hour if the temperature was above 90°F).
■■ Place perishable food in shallow containers and immediately put it in the refrigerator or freezer for rapid cooling.
■■ Use cooked leftovers within 4 days.
Refreezing
■■ Meat and poultry defrosted in the refrigerator may be refrozen before or after cooking. For meat thawed by other
methods, cook before refreezing.
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a
Adapted from US Department of Agriculture, Food Safety and Inspection Service. Basics for Handling Food Safely.
Washington, DC. US Department of Agriculture, Food Safety and Inspection Service; 2006.
■■ Federal Nutrition Assistance Programs
Food
Assistance Funding and
and Nutrition Services and Administrative Service
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Programs Benefits Who Qualifies Agencies Providers
Early Head Start Nutrition services Infants and children up to age 5 Department of Local public
and Head Start and meals and and their families receiving public Health and and private
snacks (through assistance or with incomes <100% Human Services nonprofit
the National School of the federal poverty level; at (DHHS) and for-profit
Lunch Program least 10% of total enrollment DHHS regional agencies
and the School available for infants and children offices
Breakfast Program) with disabilities
The Emergency Food Varies by state USDA Local public
Food Assistance State agency and nonprofit
Program (TEFAP) private
agencies (eg,
food banks,
food pantries,
soup kitchens)
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Expanded Food Nutrition education Children and adolescents from USDA Local Cooperative
and Nutrition families with limited resources State land grant Extension
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Education universities and Service offices
Program (EFNEP) Cooperative
Extension
Service offices
■■ Federal Nutrition Assistance Programs, continued
Food
Assistance Funding and
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Nutrition Tools
and Nutrition Services and Administrative Service
Programs Benefits Who Qualifies Agencies Providers
Nutrition Cash to purchase Children and adolescents from USDA Puerto Rico
Assistance food families with household resources
Program (NAP) (aside from income) of ≤$2,000
for Puerto Rico (≤$3,000 if household has at least
one person age ≥60) living in
Puerto Rico
School Breakfast Reduced-price or Children and adolescents attending USDA Public and
Program free breakfasts school; same eligibility criteria State education private
as NSLP agencies nonprofit
schools and
residential child
care institutions
Special Milk Reduced-price or Children and adolescents attending USDA Child care
Program (SMP) free milk child care programs, schools, State education programs, 77
and summer camps that do not agency schools, and
participate in other federal meal- summer camps
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service programs; same eligibility
criteria as NSLP
■■ Federal Nutrition Assistance Programs, continued
Food
Assistance Funding and
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(WIC)
■■ Federal Nutrition Assistance Programs, continued
Food
Assistance Funding and
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and Nutrition Services and Administrative Service
Programs Benefits Who Qualifies Agencies Providers
Summer Food Reduced-price or Children and adolescents attending USDA Public and
Service Program free meals and a summer activity program; same State education private
(SFSP) snacks eligibility criteria as NSLP agency nonprofit
schools and
nonresidential
institutions;
local,
municipal,
county
governments;
and summer
camps
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