INFANT NUTRITION HUMAN NUT CHAPTER 17

1. Because learning changes everything.®
Chapter 17
Infants, Children, and
Adolescents
Lecture Outline
HUMAN NUTRITION
Science for Healthy Living
Third Edition
Tammy J. Stephenson, Megan R.
Sanctuary, Caroline W. Passerrello
© 2022 McGraw Hill, LLC. All rights reserved. Authorized only for instructor use in the classroom.
No reproduction or further distribution permitted without the prior written consent of McGraw Hill, LLC.

2. © McGraw Hill, LLC
17.1 Infancy: Birth to 12 Months
Learning Outcomes
1. Compare the nutrient compositions of human breast milk
and infant formula.
2. Discuss the nutrient needs of healthy infants.
3. Identify the physiological milestones that indicate an
infant is ready to eat solid foods.
4. Discuss nutrition-related problems that are common
among infants.
2

3. © McGraw Hill, LLC
Infancy
Infancy - the period from birth to 12 months of age
Newborn - an infant during its first 4 weeks of life
Meconium - the first stool passed by a newborn shortly after
birth
It is typical for infants to lose 5% of their birth weight during
the first few days after birth
• Any weight loss is usually regained within the first 7 to 10
days of life
3

4. © McGraw Hill, LLC
Growth in Infancy
An average healthy infants:
• Double their birth weight by 4 to 6 months
• Triple their birth weight by first birthday
• Increases in length by 50% in first year
Brain growth occurs at a very rapid rate
• Healthcare providers can estimate brain growth by
monitoring changes in head circumference
• If undernutrition occurs, brain size may be adversely affected and
can result in impaired cognitive (intellectual skills) development
4

5. © McGraw Hill, LLC
From Birth to 1 Year of Age
Courtesy of Megan Sanctuary
5

6. © McGraw Hill, LLC
Reflexes
Reflexes are involuntary muscular reactions that occur in
response to a stimulus
Healthy newborns typically exhibit three nutrition-related
reflexes:
• Suck reflex - enables an infant to draw milk and
coordinate swallowing and breathing during feedings
• Rooting reflex - the child turns and opens its mouth as
the cheek is stroked
• Extrusion reflex - the infant’s tongue thrusts forward to
remove small objects from the mouth
These reflexes disappear by the age of 4 to 6 months
6

7. © McGraw Hill, LLC
Major Nutrition-Related Developmental Milestones from
Birth to 12 Months
Approximate Age in
Months When Skills
Are Acquired Milestones
1–2 Briefly follows objects with eyes
Holds head up without support
3–4 Grasps objects with palms of hands
Begins to lose extrusion and rooting reflexes
5–6 Sits upright with back support
7–8 Has the strength and coordination to self-feed with a bottle
Sits without support
First teeth emerge
Moves tongue from side to side and closes lips over spoon
8–10 Self-feeds finger foods
Begins to drink from cup
11–12 Uses spoon to self-feed and drinks liquids from a cup
Has several teeth and good control over chewing ability
7

8. © McGraw Hill, LLC
Nutrition During Infancy1
Human breast milk is a unique biological fluid
• Has evolved over millions of years to provide human
infants with highly digestible and bioavailable nutrients
• These promote optimal health and growth through various stages of
development
• Contains several factors that uniquely promote the health
of infants
The 2020–2025 Dietary Guidelines for Americans emphasize
the importance of exclusive breastfeeding for infants for the
first 6 months of life
8

9. © McGraw Hill, LLC
Nutrition During Infancy2
The guidelines also suggest:
• Use of donor human milk if the mother is not able to
provide her own
• Should acquire donor milk from an accredited human milk bank to
ensure its safety
Although breast milk is preferred, certain barriers to
breastfeeding may necessitate feeding an infant formula
• Can provide nourishment
• Has been developed to match human breast milk as closely as
possible
9

10. © McGraw Hill, LLC
Nutrient Requirements During Infancy1
During the first 3 months, infants need about 108 kcal/kg
body weight daily
Protein is a critical nutrient for an infant’s growth and
development
• The AI for protein during the first 6 months is 1.52 g/kg
body weight
• Growth slows after 6 months of age
• The RDA for protein decreases to 1.2 g/kg body weight
10

11. © McGraw Hill, LLC
Nutrient Requirements During Infancy2
There are no recommendations for total lipid intake, but both
breast milk and infant formulas provide about 55% of calories
from fat
• Ensures a concentrated source of energy
• Provides the essential fatty acids
Breast milk naturally provides arachidonic acid (AA) and
docosahexaenoic acid (DHA)
• They are added to most commercially prepared infant
formulas
11

12. © McGraw Hill, LLC
Nutrient Requirements During Infancy3
Lactose is the main carbohydrate
Cereals or other starchy foods are not appropriate for infants
under 4 months
• Such young infants lack adequate amount of the enzyme
amylase, required for starch digestion
12

13. © McGraw Hill, LLC
Nutrient Requirements During Infancy4
Micronutrient recommendations for infants are often based
on levels found in breast milk
• They set a standard for breastfed and formula-fed infants
• Maternal dietary intake and nutritional status impacts the
nutrient content of breast milk
• More research needed to determine if current suggested intakes
are appropriate
13

14. © McGraw Hill, LLC
Adequate Intake Values for Micronutrients During
Infancy1
Infant Age in Months
Nutrient, Unit 0-6 7-12
Thiamin, mg 0.2 0.3
Riboflavin, mg 0.3 0.4
Niacin, mg 2.0 4.0
Vitamin B-6, mg 0.1 0.3
Vitamin B-12, μg 0.4 0.5
Folate, μg DFE 65 80
Vitamin C, mg 40 50
Vitamin A, μg RAE 400 500
Vitamin D, IU 400 400
Vitamin E, mg 4 4.0 5.0
Vitamin K, μg 2.0 2.5
14

15. © McGraw Hill, LLC
Adequate Intake Values for Micronutrients During
Infancy2
Infant Age in Months
Nutrient, Unit 0-6 7-12
Calcium, mg 200 260
Copper, μg 200 220
Iodine, μg 110 130
Iron, mg 0.3 11 (RDA)
Magnesium, mg 30 75
Selenium, μg 15 15
Zinc, mg 2.0 3.0 (RDA)
15

16. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk1
The nutrient composition of breast milk is dynamic
• It changes within a single feeding and over the weeks and
months of nursing period
• The changes are adaptations that reflect the dynamic nutritional
needs of the growing infant
• This property is unique to breast milk and cannot be replicated with
infant formula
16

17. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk2
Carbohydrates: Lactose and oligosaccharides
• Human milk oligosaccharides (HMOs)
• Complex, chemically unique sugar molecules with bioactive
properties
• Antibacterial activity: Prevents pathogen colonization
• Natural prebiotics: Promote the growth of beneficial bacteria in the large
intestine
• Reduce intestinal infections
• Promote immune tolerance to help prevent allergies
• Improve the overall function of the developing GI tract
17

18. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk3
Lipids: Delivered in a unique package, similar in structure to
lipoproteins:
• Milk fat globule (MFG) delivers in highly bioavailable form:
• Triglycerides
• Phospholipids
• Cholesterol
• Fat-soluble vitamins
18

19. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk4
The fat content of breast milk:
• Varies, depending in part on the diet of the mother
• Changes during each feeding
• At the beginning of the session it is called foremilk, and is low in fat
• Fat content gradually increases as infant nurses
• The hindmilk is produced at the end of a feeding, and has higher fat
content, which may make the baby feel satisfied and discontinue
feeding
• Mothers should make sure the baby drains one breast before moving to
the second
19

20. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk5
Protein: Content is not affected by maternal diet
• Whey is milk protein that is water-soluble and quickly
digested
• Casein is milk protein that is water-insoluble and slowly
digested
Colostrum contains about 21 g/L of protein
• About 90% whey and 10% casein
Mature milk contains about 11 g/L of protein
• About 60% whey and 40% casein
20

21. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk6
Whey proteins
• Often are immune factors, nutrient transporters,
hormones, and digestive enzymes
• Remain active in the infant intestines
• Often digested more quickly than casein proteins
Casein proteins
• Clump together, or curdle, in the infant stomach
• Take longer to digest
• Carry certain minerals, calcium and phosphorus,
increasing their absorption
21

22. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk7
Vitamins and Minerals: The content is generally adequate
for most vitamins and minerals
• Levels of vitamins D and K can be inadequate
Vitamin D
• Infants can receive adequate vitamin D from carefully
monitored sun exposure
• Mothers may be able to increase levels in their breast milk
through supplementation
• The Academy of Pediatrics recommends supplementation
with 400 IUs of vitamin D per day for exclusively breastfed
infants
22

23. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk8
Vitamin K
• Not effectively transported across the placenta
• Levels in breast milk are low
• It is recommended that newborn infants receive vitamin K
supplementation immediately after birth to prevent
hemorrhagic disease
23

24. © McGraw Hill, LLC
Nutritional Qualities of Human Breast Milk9
Minerals and Other Vitamins
• Levels in breast milk are dependent on maternal intake
for:
• Certain B vitamins (thiamin, riboflavin, vitamin B-6, and vitamin B-
12)
• Vitamin A
• Vitamin C
• Calcium, iodine, and selenium
• Mothers on exclusively plant-based diets often have low
levels of certain B vitamins and require supplementation
24

25. © McGraw Hill, LLC
Did You Know? – Early Infant Formulas Were Home-
Made
In the early 1900s, many infants were bottle fed formulas
prepared at home
• Made with canned evaporated cow’s milk, corn syrup, and
water
• To prevent scurvy and rickets, babies were given orange
juice and cod liver oil to supply vitamins C and D
In the 1940s, commercially prepared infant formulas made
from cow’s milk with added micronutrients became more
widely available in the United States
25

26. © McGraw Hill, LLC
Immunological Qualities of Human Breast Milk1
Colostrum is a rich source of
• Antibodies
• Other immunological proteins
Mothers who plan to formula-feed should be encouraged to
nurse their newborns for at least the first few days of life
26

27. © McGraw Hill, LLC
Immunological Qualities of Human Breast Milk2
Compared to formula-fed infants, breastfed infants:
• Have a lower risk of gastrointestinal, respiratory, and ear
infections
• Are at a lower risk for sudden infant death syndrome
(SIDS)
• Are less likely to develop childhood asthma, allergies,
leukemia, obesity, and type 1 diabetes
27

28. © McGraw Hill, LLC
Nutritional Qualities of Infant Formula1
Recently, infant formula has been reformulated to more
closely match the composition of breast milk.
• May help improve the health outcomes of formula-fed
infants
• Modifications include:
• Adjustment of the whey:casein ratio
• Addition of several ingredients, including taurine, DHA and AA, and
prebiotics (fructo- or galacto-oligosaccharides)
28

29. © McGraw Hill, LLC
Comparing Compositions
The nutrient contents of human
milk and commercially prepared
infant formulas are similar, but
breast milk has several beneficial
components that are not duplicated
in formulas:
• Antibodies
• Hormones
• Immune factors
• Growth factors
• Enzymes
Access the text alternative for slide images.
29

30. © McGraw Hill, LLC
Nutritional Qualities of Infant Formula2
Infant formula is manufactured to serve as a sole source of
nutrients for infants
• Manufacturers must meet stringent criteria for growth
promotion and protein quality
• Compared to breast milk, infant formula contains more protein to
compensate for reduced digestibility
• Cow’s milk serves as the base of most infant formulas,
with added vegetable oil, vitamins, and minerals
30

31. © McGraw Hill, LLC
Classes of Infant Formula1
There are three main classes of commercial infant formulas
available:
• Cow’s milk–based
• Soy-based
• Specialized formulas
They vary in their nutrient composition, calorie content, taste,
digestibility, and cost
31

32. © McGraw Hill, LLC
Classes of Infant Formula2
There are three main classes of commercial infant formulas
available:
• Cow’s milk–based, the most similar to breast milk
• Soy-based
• May be options for infants with an allergy to cow’s milk or with
hereditary galactosemia or lactase deficiencies
• Specialized formulas
• Available for infants with an allergy to cow’s milk
32

33. © McGraw Hill, LLC
Specialized Infant Formulas
Hypoallergenic formulas - a class of infant formula
containing predigested protein that has been hydrolyzed to
polypeptides and free amino acids
• An alternative to soy-based formulas for allergic infants
Amino acid formulas - a class of infant formula containing
protein that has been hydrolyzed completely to free amino
acids
• An option for infants with severe allergies or who refuse
hydrolyzed formulas due to poor taste
33

34. © McGraw Hill, LLC
Benefits of Breastfeeding for Infant Health 1
Compared to breast-fed infants, formula-fed infants:
• Show different growth patterns
• Tend to accumulate more body fat
• Have different nutritional status
• May be more susceptible later in life to:
• Type 1 and type 2 diabetes
• Obesity
• Cardiovascular disease (CVD)
34

35. © McGraw Hill, LLC
Benefits of Breastfeeding for Infant Health 2
Despite addition of oligosaccharide prebiotics to infant
formula:
• The gut microbiota of breastfed infants is significantly
different from that of formula-fed infants
• May affect health status
• The amino acid composition of formula is different from
that of breast milk
• May contribute to lower levels of insulin, amino acids, and blood
urea nitrogen in breastfed infants
35

36. © McGraw Hill, LLC
Benefits of Breastfeeding for Infant Health 3
Vitamins and minerals supplied in breast milk are present in
highly bioavailable forms
• Most infants not consuming an iron-fortified formula should
receive a supplemental dose of 8-10 mg of iron/day
Formulas do not have the many beneficial biological
substances present in breast milk
According to the American Academy of Pediatrics (AAP):
“Breastfeeding and the use of human milk confer unique
nutritional and non-nutritional benefits to the infant and the
mother”
36

37. © McGraw Hill, LLC
COVID-19 and Breastfeeding
The CDC provides guidance for mothers breastfeeding their
infants during the COVID-19 pandemic
• Experts do not believe that mothers with COVID-19 can
transmit the virus to their child through breast milk
• However, breastfeeding mothers with suspected or
confirmed COVID-19 are advised to:
• Wash her hands well before touching her infant
• Thoroughly clean any bottles or breast pump parts
• Adhere to health department and healthcare provider
recommendations for home isolation
37

38. © McGraw Hill, LLC
Complementary Foods1
Complementary foods are the first foods fed to infants
during weaning
Weaning is the gradual process of shifting from a liquid to a
solid food diet in infants
Complementary foods should be introduced when the infant
is 4 to 6 months
• The “Fresh Tips” box provides good indicators that an
infant is ready to eat solid foods
38

39. © McGraw Hill, LLC
Fresh Tips – Introduction of Complementary Foods
The following signs indicate that an infant is ready for
complementary foods. The child:
• Can sit with some back support
• Has lost the extrusion reflex
• Can hold their head up steady and straight
• Shows interest in consuming foods that adult caregivers
and older children eat
• Open their mouth when they see food
39

40. © McGraw Hill, LLC
Complementary Foods2
Foods fed during weaning should:
• Be energy dense
• Contain high-quality protein
• Be good sources of bioavailable vitamins and minerals
• Contain limited amounts of antinutritional factors, such as
mineral-binding proteins and enzyme inhibitors
40

41. © McGraw Hill, LLC
Complementary Foods3
Iron is the primary limiting nutrient in breast milk requiring
addition of complementary foods
• Iron needs increase from 0.3 mg/day during 0-6 months of
age to 11 mg/day during 6-12 months of age
• The most common iron-containing first foods are infant
cereals
• Whole-grain cereals are recommended over those made from
refined grains, with rice and oat cereals being easiest to digest
• Soaking, sprouting, and cooking of cereal grains increases
digestibility and reduces levels of antinutritional factors
41

42. © McGraw Hill, LLC
Complementary Foods4
Fiber should be slowly introduced into the diet
• Large increases can bulk the stool, increase flatulence,
and decrease appetite
The WHO recommends that complementary foods be varied
and include sufficient amounts of:
• Meat, poultry, eggs, fish, and fruits and vegetables
containing zinc, choline, vitamin A, and long chain
polyunsaturated fats daily
• If unavailable, consumption of fortified foods and micronutrient
supplements may be necessary
42

43. © McGraw Hill, LLC
Complementary Foods5
Assuming average intake of breast milk, complementary
foods should provide an additional:
• 200 kcal/day for infants 6 to 8 months of age
• 300 kcal/day for infants 8 to 11 months of age
• 500 kcal/day for children 12 to 23 months of age
43

44. © McGraw Hill, LLC
Food Allergy Prevention in Complementary Feeding1
Experts with the American Academy of Allergy, Asthma &
Immunology (AAAAI) recommend gradual introduction of
new foods
• Adding just one new food for a period of time (3-5 days)
can help identify adverse responses that may indicate
allergies to the particular food
• Wheezing
• Vomiting
• Itchy skin
44

45. © McGraw Hill, LLC
Food Allergy Prevention in Complementary Feeding2
The updated 2020-2025 Dietary Guidelines for Americans
recommend early introduction of potential food allergens (For
example peanuts, egg whites, fish, sesame, and wheat
protein-containing foods) may reduce the child’s risk of food
allergies
• May induce oral tolerance, preventing allergic sensitization
Other possible considerations for prevention of childhood
food allergies include:
• Ensuring adequate vitamin D status
• Improving the health of the gut microbiota
45

46. © McGraw Hill, LLC
Did You Know? – Infants and Sleep
Many caregivers think adding complementary foods to
infants’ diets before 4 months of age helps them sleep
through the night
• There is no scientific evidence to support this practice
As an infant’s nervous system matures:
• It stays awake more often during the day
• Sleeps for longer periods at night
Staying asleep between midnight and 5 a.m. is a
developmental milestone
• Reached by most healthy babies at 3 months of age,
regardless of what they are eating
46

47. © McGraw Hill, LLC
Did You Know? – Infantile GER
Infantile gastroesophageal reflux (GER) occurs when
stomach contents flow back into the esophagus after a
feeding
• Baby often vomits a small amount of food (“spits up”)
• About 50% of babies experience GER during first 3
months of life; to reduce its likelihood:
• Infant should be kept upright for 30 minutes after eating
• Pause each feeding session a few times to “burp” the baby by
sitting the infant upright and gently rubbing or patting its back
• If a baby forcibly vomits (“projectile vomits”) or fails to gain
weight, caregivers should contact a healthcare provider
47

48. © McGraw Hill, LLC
Physiological Readiness for Weaning1
Healthy infants are usually physiologically ready for weaning
when they reach 6 months of age
• A significant nutrition-related milestone is the emergence
of the first primary tooth
Gross motor skills - control of the large muscles
Fine motor skills - control of the small muscles, particularly
thumb and fingers
Pincer grasp - use of the thumb and forefinger to pick up
small objects
48

49. © McGraw Hill, LLC
Pincer Grasp
Older infants use their
pincer grasp to pick up
foods and feed
themselves
49

50. © McGraw Hill, LLC
Physiological Readiness for Weaning2
As muscular coordination improves, beverages like water can be
offered from a cup at meal times
• Sugar-sweetened, caffeinated, carbonated, or artificially-
sweetened beverages are not appropriate
• Added sugars promote dental caries
• Caffeine interferes with sleep
• The consequences of carbonated beverage and artificial sweetener
consumption are unknown
• According to the AAP recommendations, babies should not be
given fruit juice before they are 12 months of age
• The 2020-2025 Dietary Guidelines for Americans recommend:
• Complete avoidance of added sugar in the diet until the child is 2 years old
• After 1 year of age, whole fruit consumption is preferable
50

51. © McGraw Hill, LLC
Self-feeding
Babies learning to feed
themselves is a messy
process!
51

52. © McGraw Hill, LLC
Foods to Avoid During Infancy
The following foods and beverages are not recommended for
infants:
• Honey may contain spores of Clostridium botulinum
• Regular cow’s or goat’s milks and plant-based milk
alternatives should not replace human milk or formula
• Nonfat foods are often high in refined carbohydrates and
poor sources of healthy fats critical for development
• Processed foods can lead to deficiencies and increase
the risk of chronic disease in adulthood
• Small pieces of hard or coarse foods can cause
choking
52

53. © McGraw Hill, LLC
Assess Your Progress 17.1
1. Discuss the reflexes that are present at birth and the role
of each in infant feeding.
2. James is a healthy newborn who weighs 6.5 pounds and
is 18 inches in length. What weight and length would his
caregivers expect him to be when he is 12 months of
age?
3. What are the advantages of feeding meat and other
animal foods before infant cereals during the weaning
process?
4. List at least three foods that should not be fed to infants.
53

54. © McGraw Hill, LLC
Sustainability and Your Diet1
Ensuring that complementary foods are produced from
sustainable farming practices is important for promoting
optimal nutrition in weaning diets
• Historically, chickens, turkeys, and other poultry were
raised in free-range environments, resulting in nutrient-rich
eggs and meat
• The commercialization of poultry production has resulted
in unsustainable farming practices with negative effects
on:
• Animal welfare
• Antibacterial resistance
• The nutrient profiles of poultry products
54

55. © McGraw Hill, LLC
Sustainability and Your Diet2
Factory-farmed poultry production systems rely on
agricultural commodity grain crops for feed
• Large-scale poultry feed production is estimated to be
responsible for 10% of greenhouse-gas emissions
• The use of alternative feedstuffs may reduce emissions,
decrease competition between humans and poultry for
feed, and increase the nutritional value of poultry products
• Sustainable poultry production systems require
collaboration among researchers, farmers, and consumers
• Can be costly, which may be reflected in product prices
55

56. © McGraw Hill, LLC
17.2 Toddlers and Preschool-Age Children
Learning Outcomes
1. Describe normal growth patterns of children who are
between 1 and 5 years of age.
2. Discuss the energy and nutrient needs of young children.
3. List micronutrients that are most likely to be low in the
diets of young children.
56

57. © McGraw Hill, LLC
Toddlers and Preschool-Age Children
Toddler - child who is 1 to 3
years of age
Preschool-age - child who is
3 to 5 years of age
57

58. © McGraw Hill, LLC
Growth and Development of Toddlers and Preschool-Age
Children1
• From 1 to 2 years, a healthy child gains about 6 pounds
• During the preschool years, the child gains 4 to 5
pounds/year
• Increases in body length average 2 ½ to 3 inches/year
58

59. © McGraw Hill, LLC
Growth and Development of Toddlers and Preschool-Age
Children2
• Most 2-year-old children have a full set of teeth
• By the age of 3, most children can eat with a fork or spoon
• Toddlers are beginning to develop autonomy
• Autonomy refers to independence from caregivers and
the ability to make decisions
59

60. © McGraw Hill, LLC
Nutrition for Toddlers and Preschoolers 1
Energy: The number of calories needed varies by:
• Body size
• Gender
• Physical activity level
The Institute of Medicine created a formula to calculate the
Estimated Energy Requirement (EER) for toddlers:
EER = ([89 kcal/kg/day] × [body weight in kg]) - 80
60

61. © McGraw Hill, LLC
Nutrition for Toddlers and Preschoolers 2
Macronutrients
The RDA for protein is:
• 13 g/day for toddlers
• 19 g/day for preschool-age children
Preschool-age children typically do not eat recommended
amounts of fruits and vegetables
61

62. © McGraw Hill, LLC
Nutrition for Toddlers and Preschoolers 3
The AI for fiber is:
• 19 g/day for children 1 to 3 years
• 25 g/day for children 4 to 8 years
Toddlers should consume between 30 to 40% of total kcal
from fat
• According to the 2020-2025 Dietary Guidelines for
Americans, children under 2 years of age should consume
full-fat milk
Older children should consume between 25 to 30% of total
kcal from fat
62

63. © McGraw Hill, LLC
Nutrition for Toddlers and Preschoolers 4
Vitamins and Minerals: Adequate amounts of vitamin D,
calcium, and iron are very important
• Dairy products, bone-in fish, and cooked, leafy greens are
sources of calcium
• Meat, poultry, eggs, and fish are sources of iron
• Cow’s milk is a poor source of iron: A diet with over two
glasses per day increases iron deficiency risk
• Moderate sun exposure is a good source of vitamin D
• Fortified milk and orange juice can also provide vitamin D
63

64. © McGraw Hill, LLC
Diet-Related Concerns for Toddlers and Preschool-Age
Children
Diets of toddlers and preschoolers tend to be:
• Inadequate in potassium, fiber, and vitamins E & D
• High in sodium and sugar
• Low in fruit, vegetables, and whole-grains
• High in baked goods, processed meats, and sugar-
sweetened beverages
Added sugar consumption contributes to tooth decay
64

65. © McGraw Hill, LLC
Fresh Tips – Reducing Intake of Added Sugars
Adults can use the following tips to reduce children’s intake
of added sugars:
• Replace sugar-sweetened beverages and fruit drinks with
fruit-infused water
• Replace chocolate or other flavored milks with plain milk
• Serve dried fruit and nuts as snacks instead of sugary
treats
• Serve fresh fruit for dessert
65

66. © McGraw Hill, LLC
MyPlate for Preschool-Age Children
U.S. Department of Agriculture, Center for Nutrition Policy and Promotion
Access the text alternative for slide images.
66

67. © McGraw Hill, LLC
Special Supplemental Nutrition Assistance Program for
Women, Infants and Children1
Special Supplemental Nutrition Assistance Program for
Women, Infants, and Children (WIC) - federal program that
provides funds to state governments so that they can help
specific populations obtain certain supplemental foods, basic
health care services, and nutrition education
• People with low-incomes
• Nutritionally at-risk pregnant women
• Women who have recently given birth and are
breastfeeding or formula-feeding their infants
• Children under 5 years of age who are considered at
“nutritional risk”
67

68. © McGraw Hill, LLC
Special Supplemental Nutrition Assistance Program for
Women, Infants and Children2
WIC-eligible foods are those that rich in iron, calcium,
vitamins A and C, and protein, including:
• Iron-fortified infant and adult cereals
• Eggs, milk, cheese, peanut butter, dried beans and peas,
canned fish
• Certain fruit and vegetable juices
• Soy beverages, tofu, baby foods, whole-wheat breads and
grain options
• Fresh fruits and vegetables
68

69. © McGraw Hill, LLC
Special Supplemental Nutrition Assistance Program for
Women, Infants and Children3
Studies indicate that participation in the WIC program
provides important public health benefits, including:
• Reduced incidence of fetal death, low birth weight, and
infant mortality
• Improved growth of nutritionally at-risk infants and children
• Decreased incidence of iron deficiency anemia in young
children
• Improved intellectual development
69

70. © McGraw Hill, LLC
Did You Know? – Food Jags
Food jags are periods in which a young child refuses to eat a
food that they liked in the past or will only eat certain foods
• They usually begin in the toddler years and may continue
throughout the preschool period
• Adults should continue to offer a variety of nutrient-dense
foods, such as yogurt with fresh fruit, celery sticks with
peanut butter and raisins, or trail mix with nuts and dried
fruit
• After a while, the child will begin to incorporate new foods
into their diet
70

71. © McGraw Hill, LLC
Assess Your Progress 17.2
5. Calculate the energy needs of a toddler who weighs 19
pounds.
6. What steps can caregivers take to reduce the risk of
nutritional deficiencies among young children?
7. List three nutrient-dense snacks that would be
appropriate for toddlers.
71

72. © McGraw Hill, LLC
17.3 School-Age Children
Learning Outcomes
1. Discuss major diet-related concerns of school-age
children.
2. Identify nutrients that tend to be excessive and those that
are inadequate in the diets of school-age children.
3. Describe factors that influence the food choices of school-
age children, including school lunches.
72

73. © McGraw Hill, LLC
School-Age Children
School-age refers to a child who is 6 to 11 years of age
Healthy children gain about 5 pounds and grow 2 to 3 inches
in length annually during this period
Many school-age children have inadequate diets
• Often skip breakfast
• Compared to younger children, they consume:
• More foods away from home, more fried items and sugar-
sweetened beverages
• Less fruits, vegetables (especially greens and beans), and whole
grains
• More empty calories, sodium, and refined grains
73

74. © McGraw Hill, LLC
Planning Nutritionally Adequate Meals and Snacks
School-age children’s appetites fluctuate according to their
growth rates and activity levels
Adults can help control factors that affect children’s diets,
which can be:
• Positive, such as serving high-quality meat and eggs,
fresh vegetables, and fresh fruit with meals and snacks
• Negative, such as viewing advertisements for sugary fruit
drinks and carbonated beverages
74

75. © McGraw Hill, LLC
School Lunches
Pixtal/AGE fotostock
The National School Lunch
Program is a federally assisted
school meal program
• The program provides
nutritionally balanced, low-cost
or free lunches to children
75

76. © McGraw Hill, LLC
COVID-19 and School Lunches1
Millions of American children consume nutritionally-
balanced, low-cost or free breakfast and lunch each school
day through the National School Lunch Program
• In March 2020, the COVID-19 pandemic lead to many
schools moving abruptly to a virtual learning option for the
remainder of the school year
• Many schools continued in this virtual or hybrid format
through the 2020–2021 school year
• This impacted the ability of eligible children to receive a
healthy breakfast and lunch at school each day
76

77. © McGraw Hill, LLC
COVID-19 and School Lunches2
On October 9, 2020, the United States Department of
Agriculture (USDA) announced an extension of flexibilities to
allow free meals to continue to be available to children
through June 30, 2021
• The USDA waivers permit breakfast and lunch meals to be
served in all areas and at no cost
• The meals can be served outside of the typical school
setting and parents or guardians can pick up meals for
their child/children
77

78. © McGraw Hill, LLC
Assess Your Progress 17.3
8. How does a child’s diet often change when they reach
school age?
9. Which foods are generally consumed by school-age
children in amounts that are lower than recommended?
Higher than recommended?
10. What factors influence a school-age child’s food
choices?
11. Describe the National Lunch Program.
78

79. © McGraw Hill, LLC
17.4 Adolescence
Learning Outcomes
1. Describe physiological changes that normally occur
during the adolescent growth spurt.
2. Compare the typical growth pattern of females to that of
males during adolescence.
3. Identify nutrients that tend to be low in diets of
adolescents.
79

80. © McGraw Hill, LLC
Adolescence
• Adolescence - period of life that begins at puberty and
ends at adulthood
• Puberty - time at which a child matures physically and
sexually into an adult
• This textbook refers to children who are 12 to 19 years of
age as adolescents
80

81. © McGraw Hill, LLC
Growth and Development of Adolescents 1
Adolescence is the second most rapid period of physiological
growth that occurs after birth
A growth spurt is a period characterized by a rapid increase
in growth
During the adolescent growth spurt:
• Female ovaries secrete high levels of estrogen
• Male testes secrete high levels of testosterone
• This increase in hormone secretion increases the rate of
bone growth
81

82. © McGraw Hill, LLC
Growth of Long Bones
• The long bones in arms and legs increase in length by
cellular activity in the epiphyseal plates
• A person reaches their adult height when the epiphyseal
plates close
82

83. © McGraw Hill, LLC
Growth and Development of Adolescents 2
In females:
• The adolescent growth spurt typically begins around the
ages of 10 to 13 years
• There is usually an increase in weight about 6 months
before their stature growth spurt occurs
• Skeletal growth is almost complete about 2 years after a
female’s first menstrual period
• Adult height is generally reached during the middle of
adolescence
83

84. © McGraw Hill, LLC
Growth and Development of Adolescents 3
In males:
• The adolescent growth spurt occurs a year or two later
than females
• For most males, this growth begins between 12 and 15 years of age
• Adult height is reached later than females
The timing of puberty and growth spurts can vary widely
among adolescents, primarily as a result of interactions
among genetic, environmental, and nutritional factors
84

85. © McGraw Hill, LLC
Estimated Energy (kcal) Needs per Day Based on Age,
Sex, and Activity Level
Males
Age (Years) Sedentary Active Active
12–13 1,800–2,000 2,200 2,400–2,600
14–18 2,000–2,400 2,400–2,800 2,800–3,200
19–20 2,600 2,800 3,000
Females
Age (Years) Sedentary Active Active
12–13 1,600 2,000 2,200
14–18 1,800 2,000 2,400
19–20 2,000 2,200 2,400
85

86. © McGraw Hill, LLC
Nutrition During Adolescence 1
Energy: If energy needs are not met over extended periods
of time, adolescents may become underweight
• Defined as having a BMI under 18.5
Underweight in adolescence may be a sign of disordered
eating or an eating disorder
• Adolescence is the life stage when eating disorders are
most likely to develop
86

87. © McGraw Hill, LLC
Nutrition During Adolescence 2
Macronutrients: Most adolescents consume amounts of
protein, carbohydrate, and fat that are within the AMDR
• Average saturated fat intake is about 12% of total energy
• Higher than the recommended 10% or less)
• Average carbohydrate intake is 51% of total calories for
females and 50% of total calories for males
• Average fiber intake is 15.7 g/day for males and 13.5
g/day for females
• Well under the recommended of 30 g for males and 25 g for
females
87

88. © McGraw Hill, LLC
Nutrition During Adolescence 3
Micronutrients
The DRIs for all vitamins increase during adolescents,
especially for those involved in:
• New cell synthesis (folate, vitamin B‒12)
• Collagen formation (vitamin C)
• Protein metabolism (vitamin B‒6)
• Bone development (vitamins A, D, and K)
• In the US, average intakes of vitamins A, D, and E by adolescents
are lower than the DRIs
88

89. © McGraw Hill, LLC
Nutrition During Adolescence 4
RDAs for most minerals are higher than for school-age
children
• On average, adolescents do not meet the RDA for calcium
(1,300 mg/day)
• Low calcium intakes during adolescence puts teenagers at
increased risk of developing osteoporosis later in life
• The RDA for iron increases to 15 mg/day for females who
are 14 to 18 years of age due to losses that occur during
menstrual bleeding
• Females between 12 and 19 years of age consume, on average,
about 12 mg/iron/day
89

90. © McGraw Hill, LLC
Nutrition-Related Concerns of Adolescents 1
Poor diet quality in adolescence has been linked with:
• Early puberty
• Numerous adverse health conditions, including high blood
pressure and central obesity
• These conditions increase the likelihood of cancer, diabetes, and
CVD in adulthood
The diets of adolescents are often lower in fruit, whole
grains, and dairy than those of younger children
90

91. © McGraw Hill, LLC
Nutrition-Related Concerns of Adolescents 2
Adolescent females who have poor eating habits and
nutritionally inadequate diets are a concern of public health
experts
• A pregnant teenager may lack adequate nutrient stores to
support the pregnancy
• Could lead to serious pregnancy complications and poor pregnancy
outcomes
• May continue to make unhealthy food choices into
adulthood
91

92. © McGraw Hill, LLC
Assess Your Progress 17.4
12. Compare the typical growth pattern of a healthy
adolescent girl to that of a healthy male of the the same
age.
13. Which vitamins and minerals are often low in adolescent
diets?
92

93. © McGraw Hill, LLC
17.5 Overweight and Obesity in Children
Learning Outcomes
1. Provide definitions for overweight and obesity in
childhood.
2. Discuss the factors that contribute to childhood obesity.
3. Identify health problems associated with obesity in
childhood.
4. List strategies for preventing and treating obesity in
children and adolescents.
93

94. © McGraw Hill, LLC
Prevalence of Obesity among Children and Adolescents
The prevalence of obesity among American children and
adolescents (“childhood obesity”) has increased dramatically
since 1994
• About 19% of American children who are between the
ages of 2 and 19 years have obesity
• The prevalence tends to increase with age
• Nearly 42% of children between the ages of 16 and 19 have obesity
• The trend continues to rise, especially in children between
the ages of 2 and 5
94

95. © McGraw Hill, LLC
Prevalence of Childhood Obesity from 1988-1994 to
2015-2016 (United States)
National Center for Health Statistics, 2017. https://www.cdc.gov/nchs/data/.databriefs/db288.pdf. Accessed October 20, 2020.
Access the text alternative for slide images.
95

96. © McGraw Hill, LLC
Defining Obesity in Children
Healthcare professionals use BMI-for-age charts from the
CDC to determine the weight status of children and
adolescents
• The BMI for children is calculated in the same way as for
adults
• But BMIs for children are plotted on sex-specific growth charts that
define BMI-for-age percentiles for each weight classification
96

97. © McGraw Hill, LLC
Weight Status Classifications: Children and Adolescents
(Ages 2 to 19)
Classification BMI-for-Age Percentile
Underweight < 5th
Normal Weight ≥ 5th to < 85th
Overweight ≥ 85th to < 95th
Obese > 95th
97

98. © McGraw Hill, LLC
Health Problems Associated with Childhood Obesity
Children and adolescents with obesity are more likely to
have elevated:
• Blood pressure
• Cholesterol levels
• Glucose levels
Many children and adolescents with obesity carry excess
body fat into adulthood
98

99. © McGraw Hill, LLC
Chronic Health Problems Associated with Childhood
Obesity
• Impaired glucose tolerance, insulin resistance, metabolic
syndrome, and type 2 diabetes
• Breathing problems, including sleep apnea and asthma
• Musculoskeletal problems, including joint discomfort
• Fatty liver disease, gallstones, and gastroesophageal
reflux (heartburn)
• Social and psychological problems, such as poor self
esteem, anxiety, and depression
• Cardiovascular problems including elevated blood lipids
and hypertension
99

100. © McGraw Hill, LLC
Childhood Obesity: Contributing Factors
Researchers have identified multiple factors that contribute to
childhood obesity:
• Genetic
• Biological
• Environmental
100

101. © McGraw Hill, LLC
Genetic and Physiological Factors in Childhood Obesity
Genetic and other physiological factors in the development of
childhood obesity include:
• Family history of overweight and obesity
• Maternal overweight/obesity and diabetes during
pregnancy
• Maternal undernutrition
• Tobacco exposure during pregnancy
• Presence of an endocrine disorder
101

102. © McGraw Hill, LLC
Environmental Factors That Contribute to Childhood
Obesity1
• Easy access to processed foods and drinks that are high
in added sugars and empty calories at or near schools
• Limited access to healthy and affordable foods,
particularly in areas with many convenience stores and
fast-food restaurants
• Advertising of processed foods that are sources of added
sugars, refined carbohydrates, and empty calories that
targets youth
102

103. © McGraw Hill, LLC
Environmental Factors That Contribute to Childhood
Obesity2
• Lack of established periods for daily physical activity in
schools and safe places to be active in many communities
• Large portion sizes of foods sold from vending machines
and in restaurants and grocery stores
• Excess exposure to digital media as such sedentary
activities can reduce the time children spend being
physically active
103

104. © McGraw Hill, LLC
Dietary Factors in Childhood Obesity1
Poor diets at a young age greatly increase the chances of
becoming overweight and obese
• It is likely that poor diet quality drives excess consumption
• May be due to low nutrient availability or absence of
satiety elements
• Overweight children and adults tend to have more nutrient
deficiencies
• They may be overfed but undernourished
104

105. © McGraw Hill, LLC
Dietary Factors in Childhood Obesity2
Consumption of processed foods has been shown to impact
the gut microbiota
• Gut microbial dysbiosis is an important factor in adult
overweight and obesity
Overconsumption of added sugars and refined
carbohydrates at an early age may affect the developing
insulin system
• The insulin response to dietary intake affects fat tissue
growth and metabolism
105

106. © McGraw Hill, LLC
Lifestyle Factors in Childhood Obesity
Besides diet, lifestyle factors that play a role in obesity
development in children include:
• Maladaptive eating behavior
• Low levels of physical activity
• Poor sleep habits
• Early disruption of the gut microbiota
Caregiver influence at home and in schools plays a large role
in diet and lifestyle factors
106

107. © McGraw Hill, LLC
Did You Know? – Disabilities and Obesity
Adolescents with disabilities have higher rates of overweight
and obesity than typically developing youth
• It is necessary to develop more mobile applications (apps)
specific to the needs of adolescents with disabilities
• As part of the app development process, experts
recommend engaging a range of stakeholders, including
the adolescents, their caregivers, and healthcare
professionals
107

108. © McGraw Hill, LLC
Childhood Obesity: Prevention1
Strategies to prevent childhood obesity:
• Breastfeed babies exclusively for first 6 months of life
• Continue breastfeeding while introducing complementary foods
after 6 months
• Should provide high levels of bioavailable nutrients
• Diet should be low in processed foods that are high in sugars and
empty calories
• Encourage consumption of prebiotic and probiotic foods to
promote proper colonization of a child’s gut
• Fruits, vegetables, and fermented foods
108

109. © McGraw Hill, LLC
Childhood Obesity: Prevention2
Provide opportunities for children to be physically active
throughout the day
Use of electronic devices should be monitored
• When used in an academic setting, allow numerous break
periods that encourage movement
Model proper eating behaviors and physical activity to
encourage healthy lifestyle habits from an early age
109

110. © McGraw Hill, LLC
Childhood Obesity: Treatment 1
The treatment goal for managing overweight and obese
young children and adolescents is to slow the rate of weight
gain without interfering with normal growth and physical
development
• Rather than using a calorie-restricted diet, focus should be
on improving the overall quality of the diet
• Dietary interventions for weight loss are often necessary in
cases of severe obesity and co-occurring medical
conditions (co-morbidities)
110

111. © McGraw Hill, LLC
Childhood Obesity: Treatment 2
Recent studies have found that children can lose weight
using various dietary strategies, including:
• Low-carbohydrate diets
• Low-glycemic-index diets
• Low-fat diets
• High-protein diets
• Intermittent fasting
111

112. © McGraw Hill, LLC
Bariatric Surgery for Teens with Severe Obesity
Bariatric surgery may be an option for obese teens with other
chronic health conditions, such as:
• Diabetes
• CVD
• Sleep apnea
• Nonalcoholic fatty liver disease
Compared to adults that undergo the surgery, teens are more
likely to:
• Have low vitamin D and iron status
• Need additional surgeries, such as gallbladder removal
112

113. © McGraw Hill, LLC
Assess Your Progress 17.5
14. Define overweight and obesity in children as defined by
the Centers for Disease Control and Prevention.
15. List genetic, physiological, dietary, and other factors that
contribute to cases of childhood and adolescent obesity.
16. List at least three practical steps caregivers can take to
help children achieve and maintain healthy weights.
113

114. © McGraw Hill, LLC
Case Study1
Complementary foods during weaning
Tanya is preparing to begin weaning her daughter, Felicity,
who is 6 months old. Felicity is exclusively breastfed, and
Tanya would like to start introducing some solid foods to
supplement the child’s diet.
114

115. © McGraw Hill, LLC
Case Study2
Tanya decides to consult with her daughter’s pediatrician to
get more information about appropriate complementary foods
for infants. The doctor informs her that there are many
options for first foods that Tanya can introduce when Felicity
shows signs that she is ready to wean.
115

116. © McGraw Hill, LLC
Case Study3
1. Describe some of the developmental milestones that
Felicity needs to accomplish before Tanya should begin
feeding her solid foods.
2. Discuss the nutritional considerations for complementary
foods for infants, including the role of nutrient digestibility
and bioavailability. Suggest food items that would be
good first foods for Tanya to feed Felicity.
116

117. Because learning changes everything.®
www.mheducation.com
© 2022 McGraw Hill, LLC. All rights reserved. Authorized only for instructor use in the classroom.
No reproduction or further distribution permitted without the prior written consent of McGraw Hill, LLC.

118. © McGraw Hill, LLC
Accessibility Content: Text Alternatives for Images

119. © McGraw Hill, LLC
Comparing Compositions - Text Alternative
Return to parent-slide containing images.
The benefits of breast milk are antibodies, hormones, immune factors,
growth factors, enzymes, vitamins, inron and calcium, fat and cholesterol,
carbohydrates, protein, water. The benefits of infant formula are vitamins,
iron and calcium, fat and cholesterol, carbohydrates, protein and water.
Return to parent-slide containing images.
119

120. © McGraw Hill, LLC
MyPlate for Preschool-Age Children - Text Alternative
Return to parent-slide containing images.
The poster has the heading of healthy eating for preshoolers. The plate is
divided into fruits, grains, protein, and vegetables and another smaller
plate is labeled dairy. The website choosemyplate dot gov is given below.
The text beside reads, get your child on the path to healthy eating. Focus
on the meal and each other: your child learns by watching you, childrens
are likely to copy your table manners, your likes and dislikes and your
willingness to try new foods. Offer a variety of healthy foods: let your child
choose how much to eat, children are more likely to enjoy a food when
eating it is their own choice. Be patient with your child: sometimes new
food take time, give children a taste at first and be patient with them, offer
new foods many times. Let your children sever themselves: teach your
children to take small amount at first, let them know they can get more if
they are still hungry. Cook together. Eat together. Talk together. Make
meal time family time.
Return to parent-slide containing images.
120

121. © McGraw Hill, LLC
Prevalence of Childhood Obesity from 1988-1994 to
2015-2016 (United States) - Text Alternative
Return to parent-slide containing images.
The horizontal axis represents the years. The vertical axis represents the
percentage of American children in each age group who were obese
ranging from 0 to 25 in increments of 5. The data represented are as
follows: 1988-1994: 2-5 years old, 7.5; 6-11 years old, 11.5; 12-19 years
old, 10.3. 2003-2004: 2-5 years old, 14; 6-11 years old, 19; 12-19 years
old, 18. 2015-2016: 2-5 years old, 14; 6-11 years old, 18.5; 12-19 years
old, 19.5.
Return to parent-slide containing images.
121