Dietary Recommendations For Toddlers, Preschool, and School-Age Children - UpToDate

05/10/2021 Dietary recommendations for toddlers, preschool, and school-age children - UpToDate
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Dietary recommendations for toddlers, preschool, and

school-age children
Author: Teresa K Duryea, MD
Section Editors: Kathleen J Motil, MD, PhD, Sanghamitra M Misra, MD
Deputy Editor: Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2021. | This topic last updated: Aug 04, 2020.
INTRODUCTION
The feeding development, nutritional requirements, and dietary guidelines for toddlers (12
to 24 months), preschool, and school-age children will be discussed here. Nutritional needs
of infants are discussed separately. (See "Introducing solid foods and vitamin and mineral
supplementation during infancy".)
FEEDING DEVELOPMENT
Achieving independence and mastery of feeding skills is an important developmental task of

early childhood [1,2]. Allowing the child to feed him or herself promotes and reinforces self-
regulation of intake.
Key issues for toddlers and preschool children include [2-4]:
● Making the transition to cup and utensil feeding

● Fluctuations in appetite
● Achieving adequate iron and zinc intake
● Avoiding overconsumption of juice and sweetened beverages
● Developing routines for healthy eating and activity
Children who have developmental delays may not master feeding skills in a timely fashion.
Parents should understand that the prolonged use of a bottle or the persistence of finger
feeding may be necessary to insure adequate dietary energy and nutrient intake.
Key issues for school-age children include [2,5]:
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● Adequate intake of fruits, vegetables, calcium, vitamin D, and fiber

● Avoiding energy-rich/nutrient-poor snacks (eg, salty snacks, cookies, sweetened
beverages)
● Avoiding overconsumption of sugar-sweetened foods and beverages
● Development of a healthy body image
Toddlers — During the second year of life, through the progressive acquisition of motor
skills and eruption of the full complement of deciduous teeth, children learn to feed
themselves independently and make the transition to a modified adult diet [2]. Dietary
preferences and patterns continue to be established [1].
The growth rate and appetite decrease after the first birthday. Toddlers may eat variable
quantities at any given meal. They also may choose from a small variety of foods [6,7]. These
behaviors are to be expected [2,6].
Feeding development — Feeding development during the second year includes

acquisition of the following skills [1,8]:
● Drinking from a cup – Weaning from the bottle should begin at 12 to 15 months of age.
By 15 months of age, children can manage a cup by themselves but will continue to spill;
by 18 to 24 months of age, cup manipulation is improved, and spills occur less
frequently.
Toddlers should be completely transitioned from the bottle to the cup by two years of
age (ideally by 15 to 18 months), and they should not sleep with a bottle. Drinking from a
bottle predisposes to dental caries, particularly if the bottle is taken to bed or sipped
throughout the day. (See "Preventive dental care and counseling for infants and young
children", section on 'Dietary habits'.)
In addition, supplying large volumes of caloric beverages in a bottle may lead either to
overfeeding or to decreased solid food intake and undernutrition. Continuing to use a
bottle at two years was associated with obesity at 5.5 years in a longitudinal cohort study
[9]. Prolonged bottle feeding has also been associated with iron deficiency anemia
[10,11].
● Self-feeding – During the second half of the first year, infants learn to grasp food with
their hands (palmar grasp) and then between the thumb and first finger (pincer grasp);
they can use their lips to remove food from a spoon. By 16 to 17 months of age,
improved wrist rotation permits the transfer of food from a bowl to the mouth.
● By 24 months of age, most children are ready to consume an adult diet (with
modifications to prevent choking). (See 'Choking' below.)
Feeding behaviors — The acquisition of healthy feeding behaviors is dependent upon the

interaction of several factors. These include child-specific elements, such as developmental
maturation, temperament, personal experiences, and medical needs, as well as
environmental considerations, like family dynamics, ethnic dietary practices, and food
accessibility. A feeding problem can result from any of these factors [12].
Normal toddler feeding behaviors include [1,2]:
● Playing with food – Exploratory behaviors (touching, smelling, putting the food in the
mouth and spitting it out) may precede acceptance or willingness to taste or swallow
new foods [13].
● Decrease in dietary variety (feeding "jags") – Beginning at approximately two years of

age, toddlers may become resistant to trying new foods; they may choose to eat only a
small number of well-accepted favorites [6,7]. It may be necessary to offer new foods
several times (as many as 8 to 10) before concluding that the child will not accept them
[2,14,15].
Preschool children — By three to four years of age, children are better able to protect their
airways and can safely consume the small, round, hard foods that previously posed a
choking hazard. They can handle utensils and cups efficiently and can sit at the table for
meals [2].
Preschool children are more aware of the feeding environment than younger children, and
environmental cues affect their food selection and intake patterns [2]. Environmental cues
include time of day, portion size, restriction of food or pressure to eat, the preferences and
eating behaviors of others, and packaging (eg, the presence of licensed characters on the
package) [16,17].
Preschool children may have unpredictable interest in eating [2]. Their ability to sit at the
table may be limited by their attention span. However, they should be encouraged to sit with
the family for a reasonable period of time (eg, 15 to 20 minutes) during meals, even if they
choose not to eat. Sitting with the family during meals provides an opportunity for caregivers
to model healthy eating behaviors and choices.
School-age children — School-age children can understand basic nutrition concepts [2].

They can help with meal planning, food preparation, and mealtime chores (eg, setting the
table) [1].
School-age children have more freedom over their food choices; many eat at least one meal
per day away from home. Allowing them to participate in food choices at home and
providing positive reinforcement when they make healthy choices may help them to make
healthy choices away from home.
School-age children also are more aware of their body weight and shape than when they
were younger. The food attitudes and choices of school-age children may be influenced
(positively or negatively) by family members, friends, nonfamily members, and/or the media
[18-20]. Parents may need to balance potentially negative influences by increasing positive
influences in the home (eg, by making healthy choices themselves during family meals,
increasing reinforcement when the child makes healthy choices, and setting an example).
NUTRITIONAL REQUIREMENTS
Energy and nutrient requirements for children vary depending upon age, sex, and activity
level ( table 1). MyPlate is an interactive website that provides individual dietary guidance
according to these parameters. (See 'Resources' below.)
Energy intake is influenced by the number of meals and snacks that are eaten during the
day, the energy density of foods consumed, and portion size. Children generally can self-
regulate energy intake [6,21]. However, self-regulation may be overridden if eating behaviors
are driven by factors other than hunger and fullness (eg, coercive feeding, restriction of
intake, environmental cues to eat) [22,23]. Parents should provide a range of nutritious foods
for meals and snacks, but children should be allowed to decide how much, if any, they eat
[24]. Parents must be cognizant that peers and others outside the family greatly influence
food choices of school-age children and adolescents. Body image concerns and societal
attitudes may affect the energy intake and nutritional status of older children. (See 'Eating
environment' below.)
Energy — Energy is provided through three primary macronutrients: protein, fat, and

carbohydrates.
Protein — Protein should constitute 5 to 20 percent of total energy intake for children one
to three years of age and 10 to 30 percent of total energy intake for children 4 to 18 years of
age [25,26].
Fat — Dietary fat is an important source of energy, supports the transport of fat-soluble

vitamins, and provides the two essential fatty acids, alpha-linolenic acid (ALA, omega-3
group) and linoleic acid (LA, omega-6 group). Total fat intake should be between 30 and 35
percent of energy intake for children two to three years of age; total fat intake should be
between 25 and 35 percent of energy intake for children 4 to 18 years of age [26]. Essential
fatty acid intake, primarily as linoleic and linolenic acid, should be 3 percent of total daily
energy intake.
Carbohydrate — Carbohydrates are an important source of energy and support the

transport of vitamins, minerals, and trace elements. Adequate carbohydrate intake
contributes to sufficient intake of dietary fiber, iron, thiamine, niacin, riboflavin, and folic
acid. Carbohydrates should constitute 45 to 65 percent of total energy intake [25-27].
Added sugars should be avoided in children <2 years and limited to <5 percent of total
energy intake in children ≥2 years (approximately 25 g, 100 kilocalories, or 6 teaspoons)
[27,28]. (See 'Added sugars' below.)
Micronutrients — Micronutrients include vitamins, minerals, and trace elements. Dietary

Reference Intakes (DRI) for micronutrients are available through the United States
Department of Agriculture Food and Nutrition Information Center [29]. (See "Dietary history
and recommended dietary intake in children", section on 'Dietary reference intakes'.)
DIETARY GUIDELINES
Fostering the development of healthy eating behaviors is an important goal of early

childhood nutrition [2]. Several national health organizations have issued dietary guidelines
for children and adolescents. These groups include the American Academy of Pediatrics
(AAP), the American Heart Association (AHA), the American Dietetic Association, and the
United States Departments of Agriculture and Health and Human Services (USDA/HHS)
[2,5,30-32]. The recommendations from the various organizations are relatively consistent
and are summarized below ( table 2).
The USDA/HHS devised MyPlate Plan, an interactive website, to facilitate implementation of

the USDA/HHS dietary guidelines for individuals older than one year. MyPlate provides
individual dietary guidance based upon age, sex, and physical activity.
Dietary composition — Young children have the innate ability to adjust their energy intake
to the energy density of their diet but not to choose a well-balanced diet [6,7,33,34]. They
depend upon adults to offer them a variety of nutritious, developmentally appropriate foods
to meet the recommended number of servings per day ( table 3 and table 4) [24].
Overview — A variety of nutrient-dense foods from the basic food groups should be
offered each day ( table 3 and table 4). Foods and beverages should contain or be
prepared with little added salt, sugar, or caloric sweeteners [2,5,31,32].
Fat and cholesterol — The recommended intake of fat and cholesterol varies depending
on age [2,26,31,32].
● Fat and cholesterol intake are not restricted for children younger than two years.
● Total fat intake should be between 30 and 40 percent of energy intake for children two to
three years of age; total fat intake should be between 25 and 35 percent of energy intake
for children 4 to 18 years of age. Fat intake should not be restricted below 20 percent of
total energy intake.
Most fats should come from polyunsaturated and monounsaturated fatty acids rather than
trans or saturated fatty acids ( table 5) [31,32,35]. For children older than two years,
saturated fats should make up less than 10 percent of total energy intake and the intake of
trans fats should be as low as possible. A diet in which saturated fats make up less than 10
percent of total energy intake will also be low in cholesterol.
The types of dietary fat are discussed separately. (See "Dietary fat".)
Meat and protein — When choosing and preparing meat, poultry, and other high-protein
foods, make choices that are lean, low-fat, or fat-free.
An estimated 65 to 70 percent of protein intake should come from sources of high biologic
value, typically animal products, which contain a full complement of essential amino acids.
Animal products are not necessary to provide optimal protein, but most alternative sources
from plants (eg, legumes, grains, nuts, seeds, and vegetables) do not contain a full
complement of essential amino acids, and therefore greater dietary planning is required for
diets without meat. (See "Vegetarian diets for children", section on 'Protein'.)
The AHA recommends two servings of fish/shellfish per week, not including commercially
prepared fried fish/shellfish, since these products may be high in trans fats and relatively low
in omega-3 fatty acids [5,36]. The US Food and Drug Administration (FDA) and the
Environmental Protection Agency recommend that children eat one to two servings of
fish/shellfish per week [37]. The serving size is measured before cooking and should be
appropriate for the child's age and energy needs:
● 2 through 3 years – Approximately 1 ounce (28 g) per serving

● 4 through 7 years – Approximately 2 ounces (57 g) per serving
● 8 through 10 years – Approximately 3 ounces (85 g) per serving
● ≥11 years – Approximately 4 ounces (113 g) per serving
The fish should be low in mercury (eg, shrimp, canned light tuna, salmon, pollock, tilapia,
crab, haddock, lobster, catfish, and cod) [5,37]. Consumption of fish with higher levels of
mercury (eg, shark, marlin, swordfish, king mackerel, bigeye tuna, and Gulf of Mexico tilefish
[sometimes called golden bass or golden snapper]) should be avoided [5,37].
Many sources of protein are also common allergens (eg, milk, eggs, soy, fish, shellfish,
peanuts, and tree nuts). Insuring adequate protein intake in children with food allergies is
discussed separately. (See "Management of food allergy: Nutritional issues", section on
'Protein'.)
Fruits, vegetables, and fruit juice — A colorful variety of fruits and vegetables should be
offered each day ( table 3 and table 4). Strategies that parents can use to increase fruit
and vegetable consumption include [38]:
● Provide "hands on" experience with fruits and vegetables through gardening, grocery
shopping, and cooking
● Involve children in the selection and preparation of fruits and vegetables
● Cut fruits and vegetables into shapes that the child can dip
● Expose children to a variety of fruits and vegetables
● Be a role model by eating fruits and vegetables for snacks and during meals
● Make fruits and vegetables more accessible
● Add vegetables to sandwiches, pasta, chili, soups, casseroles, and pizza
● Add fruit to cereal or pancakes
● Provide fruits and vegetables as snacks
● Provide repeated exposure and tell the child what the food does for the body (eg, "this
will help you grow big and strong") [39]
Low quality evidence from randomized trials and observational studies suggests that child-
feeding practices (eg, repeated exposure, provision of rewards, serving methods) and
multicomponent interventions may have a small effect on child fruit and vegetable
consumption [40,41].
We encourage consumption of whole fruit rather than fruit juice [42]. No more than one-half
of the recommended daily servings of fruit should be provided in the form of 100 percent
fruit juice; "fruit drinks" are not recommended [4]. Age-appropriate limits for 100 percent
fruit juice are as follows:
● One through 3 years – 4 ounces (120 mL)

● Four through 6 years – 4 to 6 ounces (120 to 180 mL)
● ≥7 years – 8 ounces (240 mL)
Fruit juice that is offered to children should be pasteurized; unpasteurized fruit juice may
contain pathogens (eg, Escherichia coli O157:H7). Fruit juice should be offered as part of a
meal or snack and not sipped throughout the day; it should not be consumed at bedtime or
in bed. (See "Preventive dental care and counseling for infants and young children", section
on 'Dietary habits' and "Causes of acute infectious diarrhea and other foodborne illnesses in
resource-rich settings".)
Fruit juice generally lacks the fiber of whole fruit and provides no nutritional advantage [4].
Although calcium-fortified juices provide a bioavailable source of calcium, they lack other
nutrients present in cow milk and fortified plant-based milks (eg, protein, magnesium).
Overconsumption of fruit juice may be associated with dental caries, diarrhea, bloating,
excessive flatulence, abdominal distension, undernutrition, and overnutrition [43-48].
However, consumption of 100 percent fruit juice within the recommended limits does not
appear to be associated with weight gain. In a meta-analysis of eight prospective cohort
studies including 34,470 children older than one year, one daily serving of 100 percent fruit
juice was not associated with clinically significant weight gain [49].
Grains — At least one-half of total grains consumed should be whole grains. Whole grains
contain the bran, germ, and endosperm. Examples of whole grains include whole or cracked
wheat, oats or oatmeal, rye, barley, corn, brown or wild rice, and quinoa. Whole grains are an
excellent source of fiber, plus several B vitamins, iron, magnesium, and selenium.
Fiber — The optimum intake of dietary fiber for infants and children younger than two
years of age is not known. Studies of weaning diets with the gradual introduction of solid
foods, including increased fiber, suggest that an intake of 5 g per day is beneficial provided
the children ingest adequate calories, vitamins, and minerals [50,51].
For children older than two years, a safe range of fiber intake equals the age (in years) plus 5
to 10 g per day (maximum 30 g per day) [27,52,53]. This goal is best met by eating a variety
of fiber-rich fruits, vegetables, cereals, and whole-grain products [26]. One-half cup
(approximately 120 mL) of vegetables or one piece of fruit provides approximately 3 g of
fiber.
Dairy products — Dairy products include milk and milk products that come from animals,
most often cows and goats. Nondairy milk alternatives are not "milk" per se, but extracts
derived from plant sources. They are discussed below. (See 'Beverages' below.)
● Milk
• 12 to 24 months – Children between 12 and 24 months of age generally should

drink whole unflavored cow milk (rather than skim milk, 1 percent milk, or 2 percent
milk, or toddler formulas) unless they have cow milk allergy or intolerance [42].
However, if the child's overall diet supplies 30 percent of energy intake from fat, the
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction
in Children and Adolescents recommends that the decision to use whole or reduced-
fat milk for children between 12 and 24 months of age be made on a case-by-case
basis by the parents and pediatric health care provider [26]. Factors to be considered
in the decision include the child's growth, appetite, intake of other nutrient-dense
foods, intake of other fat sources, and potential risk for obesity and cardiovascular
disease.
Children between 12 and 24 months of age should consume at least 2 cups (each
cup equals 8 ounces [approximately 240 mL] and contains approximately 300 mg of
calcium) per day and eat foods rich in calcium to meet their daily calcium
requirement (700 mg/day). Excessive milk intake can displace the desire for foods
that fulfill nutritional requirements (eg, iron). (See "Iron deficiency in infants and
children <12 years: Screening, prevention, clinical manifestations, and diagnosis".)
• ≥24 months – Children older than two years should consume fat-free (skim) or low-
fat cow milk (1 percent milk, 2 percent milk), calcium- and vitamin D-fortified soy
milk, or equivalent cow milk or fortified soy milk products (eg, yogurt, cheese).
However, switching from whole milk to fat-free or low-fat milk should not, in and of
itself, be expected to prevent obesity or lower body mass index if total daily energy
intake exceeds metabolic needs [54-58].
Children between two and eight years should consume at least 2 to 3 cups
(approximately 480 to 720 mL) per day and eat foods rich in calcium to meet their
daily calcium requirement (700 mg/day for children one to three years and 1000
mg/day for children four to eight years) [59].
Children and adolescents 9 to 18 years should consume at least 3 cups

(approximately 720 mL) per day and eat foods rich in calcium to meet their daily
calcium requirement (1300 mg/day) [59].
● Yogurt – When substituting yogurt for cow milk, caregivers should review the nutrition
label to make sure that it contains an equivalent amount of calcium, vitamin D, and other
nutrients, without too much added sugar. The nutrient profile of yogurt has changed
over time. A variety of yogurt products are available, including products with low fat or
no fat; reduced sodium or sugar; protein or calcium fortification; "mix-ins" (eg, fruit,
nuts, granola, candy), etc [60]. Many of the available products contain only one-half to
two-thirds of the calcium in an equivalent volume of milk; some are not fortified with
vitamin D. Flavored yogurts may contain two to three times the amount of natural
sugars in plain yogurt.
Snacks — Snacks are an essential component of the young child's diet. Healthy snacks
should be planned so they contribute to the day's total nutrient intake ( table 1) [2].
Healthy snacks include fresh fruit, cheese, whole-grain crackers or bread products, milk, raw
vegetables, 100 percent fruit juices, sandwiches, peanut butter, and yogurt [2].
Added sugars — Added sugars include sugars and syrups that are consumed directly (eg,
candy, cookies) or added during preparation and processing (eg, high fructose corn syrup) or
before consumption of food and beverages (eg, sugar, honey, maple syrup, agave nectar,
malt syrup) [61,62]. Added sugars have been associated with increased risk factors for
cardiovascular disease (eg, increased adiposity and dyslipidemia) and dental caries [28,63].
The AHA recommends that consumption of [5,28]:
● Added sugars be avoided in children <2 years of age
● Added sugars be limited to ≤25 g (approximately 100 kilocalories or 6 teaspoons) in

children ≥2 years of age
This limit is based upon the recommendation in the 2005 Dietary Guidelines for
Americans to limit discretionary kilocalories (ie, those available for consumption as
added sugars or solid fats after essential daily nutrient requirements are met) to 6 to 10
percent of total daily energy intake [64]; the 2020 Dietary Guidelines Advisory Committee
suggests that added sugars be limited to ≤6 percent of total daily energy intake [31].
The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition

Committee on Nutrition provides similar recommendations [65]. Studies evaluating
added sugars in children are limited [28]. Pending additional information, these
consensus guidelines seem reasonable.
Beverages
● Plain water – In addition to unflavored cow milk, plain (unflavored, unsweetened,

uncarbonated) fluoridated water is the preferred beverage for children, particularly
when fluids are consumed outside of meals and snacks [42].
● Cow milk – Recommendations for cow milk consumption are provided above. (See 'Dairy
products' above.)
● Plant-based milks – Plant-based milks generally are not recommended for children <5
years of age unless they have cow milk allergy or intolerance [42].
Common plant-based milks include soy, almond, rice, coconut, and hemp milks; newer
alternative milks include quinoa, oat, potato, and mixed grain milks. Among the plant-
based milks, soy milk has a nutrient profile that is most similar to cow milk and usually is
fortified with calcium and vitamin D. Other plant-based milks generally are lower in
protein, calcium, vitamin D, and calories; they also may be lacking in other vitamins,
minerals, and fatty acids that are found in dairy milk.
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Children who drink non-cow milk or nonfortified soy milk (eg, goat milk or plant-based
milks such as rice, almond, coconut, etc) may require supplemental vitamin D.
Commercially available cow milk is fortified with vitamin D; fortification of non-cow milk
is voluntary. In a cross-sectional study of 2831 children (one to six years of age), 10
percent of children drank non-cow milk [66]. Drinking only non-cow milk was associated
with decreased levels of vitamin D [66]. Vitamin D requirements and recommendations
for meeting the recommended daily intake of vitamin D are discussed separately. (See
"Vitamin D insufficiency and deficiency in children and adolescents".)
If cow milk alternatives are used for children, other foods must be chosen wisely to
provide the nutrients missing from alternative milk sources. Plant-based milks also may
be deficient in calcium and protein. Consultation with a dietitian to review the overall
dietary nutrient intake may be warranted for children in whom plant-based milks are a
dietary staple.
● Fruit juice – Fruit juice consumption is discussed above. (See 'Fruits, vegetables, and
fruit juice' above.)
● Soft drinks and sweetened beverages – The consumption of soft drinks and other
sweetened beverages (eg, fruit drinks, flavored water) should be discouraged
[1,27,65,67-69]. An expert panel consensus recommends that children <5 years avoid
consumption of these beverages [42]. For older children, consumption should be limited
to ≤8 ounces (approximately 240 mL) per week [5,28].
Sweetened beverages (eg, regular soda, fruit drinks, sweetened tea and coffee) are a
major source of added sugar in the diet and an important contributor to the
development of obesity [62,65]. Sweetened beverage consumption also is associated
with lower intake of key nutrients (particularly calcium) because sweetened beverages
generally are consumed instead of milk. (See "Definition, epidemiology, and etiology of
obesity in children and adolescents", section on 'Sugar-sweetened beverages'.)
● Low-calorie sweetened beverages – Low-calorie sweetened beverages are sweetened

with low-calorie or no-calorie sweeteners (eg, saccharin, aspartame, sucralose, stevia).
Consumption of low-calorie sweetened beverages should be limited in children and
adolescents [42,70,71]. There is no evidence that these beverages have benefits over
plain water. Evaluation of adverse effects of low-calorie beverages is an active area of
research; potential adverse effects include decreased intake of healthier beverages (eg,
cow milk), development of a taste preference for sweetened beverages, and altered
sensations of fullness and hunger [70,72,73].
● Caffeinated beverages – Caffeinated beverages are not recommended for children <5
years of age [42]. There is little information about safe levels of consumption or the
short- and long-term effects on health for young children or adolescents [74,75].
Health Canada suggests the following limits for caffeine consumption in children and
adolescents [76]:
• Age 4 to 6 years – ≤45 mg/day

• Age 7 to 9 years – ≤62.5 mg/day
• Age 10 to 12 years – ≤85 gm/day
• Age ≥13 years – ≤2.5 mg/kg of body weight per day
The caffeine content of various beverages is available in the table ( table 6).
Frequency of feeding — Most young children should be fed four to six times per day [2].
Snacks are an essential component of the young child's diet. (See 'Snacks' above.)
Toddlers eat an average of seven times per day, with snacks accounting for approximately
one-fourth of daily energy intake [77]. Preschool children generally eat three meals and
several small snacks per day. School-age children typically eat fewer meals and snacks per
day than younger children, although they may continue to have a snack after school [2].
Children who skip breakfast tend to consume less energy and fewer nutrients than those
who eat breakfast [78,79].
Portion size — The appropriate portion size varies depending upon the child's age and the
particular food ( table 3 and table 4). Serving children portions that are larger than
recommended for their age may contribute to overeating. In a crossover study, preschool
children who were repeatedly exposed to large portions (two times the size of an age-
appropriate portion) during a series of lunches increased their total energy intake at lunch by
15 percent and their entree intake by 25 percent [80]. When permitted to select their own
portion size, they consumed 25 percent less of the entree than when served the large
portion.
Vitamin and mineral supplements — Routine supplementation of vitamins and minerals is

not necessary for healthy children who are growing normally, consume a varied diet, and
have adequate exposure to sunlight [1,2,81,82]. In a survey of the dietary habits of toddlers
and preschool children in the United States, more children who received supplements had
excessive intake of vitamin A, zinc, and folate than those who did not [82]. In another
national survey, supplement use contributed to excessive intake of vitamin A, vitamin C, iron,
zinc, copper, selenium, and folic acid among children 2 through 18 years of age [81].
If parents wish to give their children supplements, a standard pediatric multivitamin

generally poses no risk. However, interactions with medications may occur [83]. Megadose
vitamins and doses of any nutrient in excess of the recommended daily allowance should be
discouraged because of the potential toxic effects. Vitamin and mineral supplements,
particularly those designed to appeal to children (eg, vitamin gum), should be kept out of
reach of children.
Vitamin and mineral supplements may be indicated for children at nutritional risk, including
those [2]:
● From neglected or deprived environments.
● With anorexia or inadequate appetite.
● With lead poisoning. (See "Childhood lead poisoning: Management", section on

'Approach'.)
● With poor weight gain. (See "Poor weight gain in children older than two years in
resource-abundant countries", section on 'Dietary intervention' and "Poor weight gain in
children younger than two years in resource-abundant countries: Management", section
on 'Vitamin and mineral supplementation'.)
● Who do not get regular sunlight exposure and/or do not have adequate vitamin D
intake.
● Who drink only non-cow milk products that are not fortified with vitamin D.
● With chronic diseases that may affect absorption and utilization of nutrients. As
examples, children with chronic liver disease or fat malabsorption (eg, cystic fibrosis)
need supplementation of the fat-soluble vitamins A, D, E, and K; children with hemolytic
anemia (eg, sickle cell anemia) may need folic acid supplementation; and children with
inflammatory bowel disease may need supplementation with iron, vitamin B12, folic
acid, fat-soluble vitamins, and zinc.
● Who are trying to lose weight or are consuming fad or restrictive diets. As an example,
children who consume strict vegan diets (avoidance of all animal products, including
eggs, milk, and milk products) may need supplementation of vitamin B12, iron, or
vitamin D. (See "Vegetarian diets for children" and "Iron deficiency in infants and children
<12 years: Screening, prevention, clinical manifestations, and diagnosis", section on
'Dietary recommendations'.)
Food safety — There are two major safety considerations when feeding children: choking
and foodborne infection.
Choking — To limit the risk of choking, children younger than three to four years of age
should not be given small, round, hard foods (eg, hot dogs, nuts [particularly peanuts],
grapes, raisins, raw carrots, popcorn, round candies). In addition [1,2]:
● Toddlers should always be supervised while eating

● Children should be seated upright during eating; they should not eat while reclining,
walking, or running
● Children should not eat while riding in a car, because the parent may not be able to
intervene if the child chokes
Foodborne infection — To minimize the risk of foodborne infection, children should not
be fed [2,84]:
● Raw (unpasteurized) milk or juice

● Raw or partially cooked eggs or foods containing raw eggs
● Raw or undercooked meat, poultry, fish, or shellfish
● Raw sprouts
Virtually all international and national advisory and regulatory committees endorse the
consumption of only pasteurized milk and milk products. Ingestion of raw milk has been
associated with various bacterial infections, including Campylobacter, Brucella, Listeria
monocytogenes, Salmonella, and E. coli and associated hemolytic uremic syndrome [85-91].
The FDA mandates pasteurization in final package form for all milk and milk products for
direct human consumption that are shipped for interstate sale [86,92]. However, individual
states regulate milk shipped within the state, and some states permit raw milk to be sold in
some form to the public. In December 2013, the Committee on Infectious Diseases and
Committee on Nutrition of the AAP published a policy statement on the consumption of raw
or unpasteurized milk and milk products by pregnant women and children that endorses a
ban on the sale of such food items. This recommendation is based on the multiplicity of data
regarding the burden of illness, as well as the strong scientific evidence that the nutritional
value of milk is not altered by the pasteurization process [84].
Additional steps to prevent foodborne infection are outlined in the table ( table 7).
EATING ENVIRONMENT
The eating environment is a critical factor in the development of healthy eating behaviors [2].
Structure and routine for all eating occasions are particularly important.
The meal environment should be free from distractions. Eating should occur in a designated
area, and the child should have a developmentally appropriate chair. Family meals provide an
opportunity for children to learn healthy eating habits and begin to appreciate the social
aspects of eating. In a 2011 meta-analysis of observational studies, children and adolescents
who shared meals with their family ≥3 times per week were more likely to be of normal
weight and have healthy dietary and eating patterns, and less likely to engage in disordered
eating than those who shared <3 family meals per week [93]. In a subsequent prospective
study, family meals of any frequency were associated with decreased risk of overweight and
obesity in young adulthood [94].The responsibility for establishing a healthy eating
environment is divided between the child and the caregivers. The division of responsibility is
based upon the child's ability to regulate intake and inability to choose a well-balanced diet
[2,21,24].
Caregiver responsibilities include [1,2]:
● Providing a variety of nutritious foods

● Defining the structure and timing of meals
● Creating a mealtime environment that facilitates eating and social exchange (eg, free of
distractions)
● Recognizing and responding to the child's signals of hunger and fullness
● Modeling healthy eating behaviors (eg, consuming a varied diet)
The child's responsibilities include choosing what and how much of the foods offered by the
caregiver to consume.
Caregivers should understand that failure to accept new foods and "eating jags" are normal
stages of child development [2]. Attempts to control the child's eating (eg, by pressuring
them to eat specific foods or clean their plate, bribing, restricting foods) may make the child
less sensitive to physiologic cues of satiety and hunger and contribute to overeating
[2,33,95,96]. (See 'Toddlers' above.)
INDICATIONS THAT MAY WARRANT CONSULTATION WITH A DIETITIAN
Indications that may warrant consultation with a dietitian include:
● Developmental delay
● Chewing and swallowing dysfunction (see "Aspiration due to swallowing dysfunction in

children", section on 'Modified feeding')
● Cerebral palsy (see "Cerebral palsy: Overview of management and prognosis", section on
'Growth and nutrition')
● Consumption of plant-based milks (other than soy milks fortified with calcium and
vitamin D) as a dietary staple (see 'Dairy products' above)
● Poor weight gain (see "Poor weight gain in children younger than two years in resource-
abundant countries: Management", section on 'Nutritional therapy' and "Poor weight
gain in children older than two years in resource-abundant countries", section on

'Dietary intervention')
● Obesity (see "Prevention and management of childhood obesity in the primary care
setting", section on 'Stage 1: Prevention plus')
● Diabetes mellitus (see "Overview of the management of type 1 diabetes mellitus in

children and adolescents", section on 'Nutrition' and "Management of type 2 diabetes
mellitus in children and adolescents", section on 'Dietary prescription')
● Dyslipidemia (see "Dyslipidemia in children and adolescents: Management", section on

'Dietary modification')
● Food allergy (see "Management of food allergy: Nutritional issues")
● Celiac disease (see "Management of celiac disease in children", section on 'Nutritional

considerations')
● Cystic fibrosis (see "Cystic fibrosis: Nutritional issues")
● Vegetarian diets (see "Vegetarian diets for children" and "Vegetarian diets for children",
section on 'Vitamins and minerals')
DIETARY PATTERNS IN THE UNITED STATES
Data from the National Health and Nutrition Examination Surveys in the United States from
1999 to 2016 indicate that diet quality among children (age 2 to 19 years) has improved over
time, with increased consumption of whole grains, whole fruits, and vegetables and
decreased consumption of sugar-sweetened beverages, added sugar, and 100 percent fruit
juice [97]. Nonetheless, during the 2015-2016 cycle, more than one-half of children
consumed a poor-quality diet as defined by the American Heart Association, and <1 percent
had ideal diet quality in the 2015-2016 cycle.
RESOURCES
● MyPlate Plan is an interactive website that provides individual dietary guidance

according to age, sex, and activity level based upon the United States Departments of
Agriculture and Health and Human Services (USDA/HHS) Dietary Guidelines for
Americans (older than one year)
● The USDA/HHS Dietary Guidelines for Americans
● The Eatwell Guide (Public Health England) defines recommendations on eating healthily
and achieving a balanced diet
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Healthy diet in
children".)
SUMMARY AND RECOMMENDATIONS
● Energy and nutrient requirements for toddlers, preschool, and school-age children vary
depending upon age, sex, and activity level ( table 1). (See 'Nutritional requirements'
above.)
● During the second year of life, children learn to feed themselves independently and
make the transition to a modified adult diet. Achieving independence and mastery of
feeding skills is an important developmental task of early childhood. It is normal for
toddlers to eat variable quantities at any given meal, to become resistant to trying new
foods, and to choose to eat a small number of favorite foods. (See 'Toddlers' above.)
● The feeding choices and behaviors of preschool children are largely influenced by
environmental cues. It is important for preschool children to sit with the family during
meal times (even if the child chooses not to eat) so that they can observe the eating
behaviors and choices of family members. Children and adolescents who share meals
with their family have better health outcomes. (See 'Preschool children' above.)
● The feeding choices and behaviors of school-age children may be influenced (positively
or negatively) by friends, family members, nonfamily members, and/or the media.
Parents may need to balance these potentially negative influences by increasing positive
influences in the home. (See 'School-age children' above.)
● Young children can regulate their energy intake but rely on adults to offer them a variety
of nutritious, developmentally appropriate foods for a well-balanced diet ( table 3 and
table 4). (See 'Dietary guidelines' above.)
● Dietary guidelines for children are summarized in the table ( table 2). (See 'Dietary
guidelines' above.)
● Most young children should be fed four to six times per day. Snacks are an essential
component of the young child's diet. (See 'Frequency of feeding' above and 'Snacks'
above.)
● Appropriate portion sizes vary depending upon the child's age and the particular food (
table 3 and table 4). Serving children portions that are larger than recommended
for their age may contribute to overeating. (See 'Portion size' above.)
● Routine supplementation of vitamins and minerals is not necessary for healthy growing
children who consume a varied diet and have adequate exposure to sunlight. Children
who drink non-cow milk (eg, goat milk or plant-based milks such as soy, rice, almond,
coconut, etc) may require supplemental vitamin D. (See 'Vitamin and mineral
supplements' above.)
● In the establishment of a healthy eating environment, the caregiver is responsible for

providing a variety of nutritious foods; defining the structure and timing of meals;
creating a mealtime environment that facilitates eating and social exchange; and
recognizing and responding to the child's signals of hunger and fullness. The child is
responsible for participating in food selection and determining how much is consumed
at each eating occasion. (See 'Eating environment' above.)
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Topic 2866 Version 55.0
GRAPHICS
Estimated energy requirements (low to moderate activity) and recommended

dietary allowance of selected nutrients for infants, children, and adolescents
Energy
Protein
Total fat
Iron
Calcium
Zinc
Age
(kcal/day) (g/day) (g/day) (mg/day) (mg/day) (mg/day)
1 to 3 years
Males 850 to 1400 13 30 to 40 7 700 3
Females 800 to 1400 13 30 to 40 7 700 3
4 to 8 years
Males 1400 to 1900 19 25 to 35 10 1000 5
Females 1300 to 1800 19 25 to 35 10 1000 5
9 to 13 years
Males 1800 to 2600 34 25 to 35 8 1300 8
Females 1600 to 2200 34 25 to 35 8 1300 8
14 to 18 years
Males 2400 to 3200 52 25 to 35 11 1300 11
Females 2000 to 2300 46 25 to 35 15 1300 9
Adapted from:
1. The Dietary Reference Intakes, National Academy of Sciences, Washington, DC, 2002.
2. National Academies Press. Dietary Reference Intakes for Calcium and Vitamin D (2010). Available at:
books.nap.edu/openbook.php?record_id=13050&page=291. (Accessed on December 13, 2010.)
Graphic 78274 Version 16.0
Dietary guidelines for children older than one year
General guidelines
A variety of nutrient-dense foods from the basic food groups (cow milk/milk products or fortified soy
products, meat/protein, grains, fruits/vegetables) should be offered each day.
Foods and beverages should contain or be prepared with little added salt, sugar, or caloric sweeteners.
Fat
1 to 2 years: Fat and cholesterol intake are not restricted.
2 to 3 years: Fat should comprise 30 to 40% of total energy intake; saturated fats should be limited to
<10% of total energy intake; intake of trans fats should be as low as possible.
4 to 18 years: Fat should comprise 25 to 35% of total energy intake; fat intake should not be restricted
to <20% of total energy intake; saturated fats should be limited to <10% of total energy intake; intake of
trans fats should be as low as possible.
Meat/protein
Select and prepare meat, poultry, fish, and dried beans with as little fat as possible.
Fruits, vegetables, and fruit juice

A colorful variety of fruits and vegetables should be offered each day.
Whole fruit is preferred to fruit juice, but one-half of the recommended daily servings can be provided
in the form of 100% fruit juice.
Consumption of 100% fruit juice should be limited to 4 ounces (120 mL) in children aged 1 through 3
years, 4 to 6 ounces (120 to 180 mL) in children aged 4 through 6 years, and 8 ounces (240 mL) in
children older than 7 years.
Grains
At least one-half of total grains consumed should be whole grains. When reading the label, "whole
grain" should be the first ingredient.
Cow milk or fortified soy milk

1 to 2 years: At least 2 cups (approximately 480 mL) of whole cow milk per day (or equivalent products).
2 to 8 years: At least 2 to 3 cups (approximately 480 to 720 mL) of fat-free or low-fat milk per day (or
equivalent products).
≥9 years: At least 3 cups (approximately 720 mL) of fat-free or low-fat milk per day (or equivalent
products).
Beverages
Plain, unflavored water is the preferred beverage for children, particularly when fluids are consumed
outside of meals and snacks.
Data from:
1. American Academy of Pediatrics Committee on Nutrition. Feeding the child. In: Pediatric Nutrition, 8th ed, Kleinman RE,
Greer FR (Eds), American Academy of Pediatrics, Itasca, IL 2019. p.189.
2. USDA Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of
Agriculture and the Secretary of Health and Human Services. Available at: www.dietaryguidelines.gov/2020-advisory-
committee-report (Accessed on August 03, 2020).
3. Gidding SS, Dennison BA, Birch LL, et al. Dietary recommendations for children and adolescents: A guide for
practitioners: Consensus statement from the American Heart Association. Circulation 2005; 112:2061.
4. National Academies of Sciences, Engineering, and Medicine. Dietary reference intakes for calcium and vitamin D.
Available at: http://www.nationalacademies.org/hmd/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-
Vitamin-D.aspx (Accessed on December 12, 2019).
5. Heyman MB, Abrams SA, AAP Section on Gastroenterology, Hepatology, and Nutrition, Committee on Nutrition. Fruit
juice in infants, children, and adolescents: Current recommendations. Pediatrics 2017; 139:e20170967.
6. Lott M, Callahan E, Welker Duffy E, et al. Healthy beverage consumption in early childhood: Recommendations from key
national health and nutrition organizations. Technical Scientific Report. Healthy Eating Research, Durham, NC 2019.
Available at: https://healthydrinkshealthykids.org/professionals/ (Accessed on October 09, 2019).
Dietary recommendations for toddlers to early school-age children[1]
Food groups and

number of daily Age 1 to 2 years Age 2 to 3 years Age 4 to 8 years
servings
Dairy
2 cups/day*
2 to 2½ cups/day 2½ to 3 cups/day
Includes all fluid milk (whole milk or milk
products such as milk, products)
yogurt, and cheese, and
1 cup equivalent =
calcium-fortified soy
1 cup milk or yogurt, 1½ ounces natural cheese, 2 ounces processed cheese,
beverage.
⅓ cup shredded cheese
Protein foods
2 ounces/day 2 to 3 ounces/day 3 to 5 ounces/day
Includes meat, poultry,
1 ounce equivalent =
seafood, beans, peas,

1 ounce cooked meat, poultry, or fish, ¼ cup cooked beans, 1 egg, 1 tbsp nut
eggs, nuts, seeds,
butter¶ , ½ ounce nuts¶
processed soy.
Grains
2 ounces/day 3 to 4 ounces/day 4 to 5 ounces/day
Includes any food made
from wheat, rice, oats,
cornmeal, barley, or
1 slice whole grain bread, 1 6-inch tortilla, ½ cup cooked cereal, rice, or pasta,
other cereal grain
1 cup dry cereal
product. Half of all
starches should be whole
grains.
Fruits
1 cup/day 1 cup/day 1 to 1½ cups/day
Includes any fruit or
1 cup equivalent =
100% fruit juice.

Limit fruit juiceΔ , ½ cup dried fruit, 1 small whole fruit, or ½ large whole fruit
Vegetables
1 cup/day 1 to 1½ cup/day 1½ to 2 cups/day
Includes any vegetable
1 cup equivalent =
or 100% vegetable juice.

1 cup raw or cooked vegetables or vegetable juice, 2 cups raw leafy greens
Oils
Do not limit* 3 teaspoons/day 4 teaspoons/day
Includes oils, avocado,
olives, nuts, seeds, soft 1 tsp equivalent =
margarine, and 1 tsp oil, margarine, mayonnaise, or nut butter, 1 tbsp dressing
dressings.
Calories for other Limit to small amount, use sparingly

uses
Desserts, sweets, soft Use sparingly 100 to 150 100 to 130 calories
drinks, candy, jams, and discretionary calories
jelly.
NOTE: For more details, go to www.myplate.gov.
tbsp: tablespoon; tsp: teaspoon.
* Low fat products are not recommended for children under the age of 2.
¶ May be a choking hazard for children under the age of 3.
Δ Recommend to limit fruit juice to: no more than 4 ounces for children 1 to 3 years of age; 4 to 6
ounces for children 4 to 6 years of age; 8 ounces for children 7 to 18 years of age.
Adapted from:
1. The United States Department of Agriculture.
From: Texas Children's Hospital Pediatric Nutrition Reference Guide, 12th ed, Beaver B, Carvalho-Salemi J, Hastings E, et al
(Eds). Copyright © 2019, Texas Children's Hospital. Reproduced with permission.
Dietary recommendations for school-age children to adolescents[1]
Food groups and number Age 9 to 13 years

Age 14 to 18 years
of servings (1600 to 1800 calories) (1800 to 2200 calories)

Dairy
3 to 4 cups/day 3 to 4 cups/day
Includes all fluid milk products
1 cup equivalent =
such as milk, yogurt, and cheese,

1 cup milk or yogurt, 1½ ounces natural cheese, 2 ounces processed
and calcium-fortified soy
cheese, ⅓ cup shredded cheese
beverage.
Protein foods
5 ounces/day 5 to 6 ounces/day
Includes meat, poultry, seafood,
beans, peas, eggs, nuts, seeds,

1 ounce meat, poultry, or fish, ¼ cup cooked beans, 1 egg, 1 tbsp
processed soy.
nut butter, ½ ounce nuts
Grains
5 to 6 ounces/day 6 to 7 ounces/day
Includes any food made from
wheat, rice, oats, cornmeal, 1 ounce equivalent =
barley, or other cereal grain 1 slice whole grain bread, 1 6-inch tortilla, ½ cup cooked cereal, rice,
product. Half of all starches or pasta, 1 cup dry cereal
should be whole grains.
Fruits
1½ cup/day 1½ to 2 cups/day
Includes any fruit or 100% fruit
1 cup equivalent =
juice.
Limit fruit juice*, ½ cup dried fruit, 1 piece small whole fruit, or ½
large whole fruit
Vegetables
2 to 2½ cups/day 2½ to 3 cups/day
Includes any vegetable or 100%
1 cup equivalent =
vegetable juice.
1 cup raw or cooked vegetables or vegetable juice, 2 cups raw leafy
greens
Oils
5 teaspoons/day 5 to 6 teaspoons/day
Includes oils, avocado, olives,
1 tsp equivalent =
nuts, seeds, soft margarine, and

1 tsp oil, margarine, mayonnaise, nut butter, 1 tbsp dressing
dressings.
Calories for other uses

Limit to small amount, use sparingly
Desserts, sweets, soft drinks,
130 to 170 calories
candy, jams, and jelly.
3 cups/day 3 cups/day
NOTE: For more details, go to www.myplate.gov.
tbsp: tablespoon; tsp: teaspoon.
* Recommended to limit fruit juice to 8 ounces for children 7 to 18 years of age.
Adapted from:
1. The United States Department of Agriculture.
From: Texas Children's Hospital Pediatric Nutrition Reference Guide, 12th ed, Beaver B, Carvalho-Salemi J, Hastings E, et al
(Eds). Copyright © 2019, Texas Children's Hospital. Reproduced with permission.
Sources of dietary fatty acids
Type of fat Food sources

Monounsaturated Vegetable oils (canola, olive, sunflower, safflower), peanut, tree nuts, seeds,
fatty acids avocado
Polyunsaturated fatty ALA - Vegetable oils (canola, soybean, walnut), flax/linseed/hemp/chia seed,
acids; n-3 or omega-3 wheat germ; also vegetables of the cabbage family and some fortified eggs
EPA and DHA - Seafood (especially fatty fish); some infant formulas and
fortified eggs
Polyunsaturated fatty LA - Vegetable oils (soybean, corn, cottonseed), peanut, tree nuts, seeds, other
acids; n-6 or omega-6 vegetable sources, poultry
Saturated fatty acids Full-fat or fat-reduced dairy products, meat, poultry, vegetable oils (coconut,
palm kernel, palm)
Trans fatty acids Partially hydrogenated vegetable oils (stick and full-fat margarine, commercial
baked goods, deep fried foods)
ALA: alpha-linolenic acid; EPA: eicosapentaenoic acid; DHA: docosahexaenoic acid; LA: linoleic acid.
Caffeine content in foods and beverages
Coffees Serving size, oz (mL) Caffeine, mg
Coffee, brewed 8 (235) 133 (range: 102 to

200)
Coffee, generic instant 8 (235) 93 (range: 27 to 173)
Coffee, generic decaffeinated 8 (235) 5 (range: 3 to 12)
Espresso 1 (30) 40 (range: 30 to 90)
Espresso decaffeinated 1 (30) 4
Teas Serving size, oz (mL) Caffeine, mg

Tea, brewed 8 (235) 53 (range: 40 to 120)
Arizona Iced Tea, black 16 (470) 32
Arizona Iced Tea, green 16 (470) 15
Nestea 12 (355) 26
Snapple, Just Plain Unsweetened 16 (470) 18
Snapple, Kiwi Teawi 16 (470) 10
Snapple, Lemon, Peach, or Raspberry 16 (470) 42
Starbucks Tazo Chai Tea Latte (Grande) 16 (470) 100
Soft drinks Serving size, oz (mL) Caffeine, mg
FDA official limit for cola and pepper soft 12 (355) 71

drinks
7-Up, regular or diet 12 (355) 0
Barq's Diet Root Beer 12 (355) 0
Barq's Root Beer 12 (355) 22
Coke, regular or diet 12 (355) 35 to 47
Dr. Pepper, regular or diet 12 (355) 42 to 44
Fanta, all flavors 12 (355) 0
Fresca, all flavors 12 (355) 0
Jolt Cola 12 (355) 72
Mellow Yellow 12 (355) 53
Mountain Dew, regular or diet 12 (355) 54 (20 oz = 90)
Mountain Dew MDX, regular or diet 12 (355) 71 (20 oz = 118)
Mug Root Beer, regular or diet 12 (355) 0
Pepsi, regular or diet 12 (355) 36 to 38
Sierra Mist, regular or free 12 (355) 0
Sprite, regular or diet 12 (355) 0
TAB 12 (355) 46.5
Energy drinks Serving size, oz (mL) Caffeine, mg
5-hour ENERGY 2 (60) 215*
Amp 8.4 (250) 74
Cocaine 8.4 (250) 288
Enviga 12 (355) 100
Full Throttle 16 (470) 144
Glaceau Vitamin Water Energy Citrus 20 (590) 50
Monster Energy 16 (470) 160
Red Bull 8.3 (245) 80
Red Bull Sugarfree 8.3 (245) 80
Rip It, all varieties 8 (235) 100
Rockstar Energy Drink 8 (235) 80
SoBe Adrenaline Rush 8.3 (245) 79
SoBe Essential Energy, Berry or Orange 8 (235) 48
SoBe No Fear 8 (235) 83
Spike Shooter 8.4 (250) 300
Tab Energy 10.5 (310) 95
Frozen desserts Serving size, oz (mL) Caffeine, mg
Ben & Jerry's Coffee Ice Cream 8 (235) 68 to 84
Häagen-Dazs Coffee Ice Cream or Yogurt 8 (235) 58
Starbucks Coffee Ice Cream 8 (235) 50 to 60
Chocolates/candies/other Serving size, various Caffeine, mg

units
Hershey's Chocolate Bar 1.55 oz (45 g) 9
Hershey's Kisses 41 g (9 pieces) 9
Hershey's Special Dark Chocolate Bar 1.45 oz (41 g) 31
Hot cocoa 8 oz (235 mL) 3 to 13
Powdered caffeine 1/16 tsp 200
FDA: US Food and Drug Administration; oz: ounce.
* Reported by Consumer Reports.
References:
1. Harland BF. Caffeine and nutrition. Nutrition 2000; 16:522.
2. Juliano LM, Griffiths RR. Caffeine. In: Substance Abuse: A Comprehensive Textbook, Fourth Edition, Lowinson JH, Ruiz P,
Millman RB, Langrod JG (Eds), Baltimore: Lippincott Williams, & Wilkins, 2005.
3. Center for Science in the Public Interest. Caffeine Content of Food and Drugs.
Tips for safe food handling to avoid microbial foodborne illness (food
poisoning)
Purchase
Do not buy precooked food that is stored adjacent to raw food, even if stored on ice.
Do not buy canned goods that are dented, cracked, or have a bulging lid.
Storage
Make sure meat and poultry products are refrigerated when purchased.
Use plastic bags to keep drippings from packages of meat and fish from contact with other foods.
Store perishable items in the refrigerator within 1 hour of purchase.
Maintain home refrigerator temperature between 32 and 40°F (0 and 4°C) and freezer temperature
at ≤0°F (–18°C).
Freeze meat and poultry that will not be cooked within 48 hours.
Freeze tuna, bluefish, and mahi-mahi that will not be cooked within 24 hours; other fish can be
stored in the refrigerator for 48 hours.
Do not store eggs on the refrigerator door (warmest part of the refrigerator).
Refrigerate cooked foods within 2 hours of preparation.
Divide leftovers into small portions and store in shallow containers.
Reheat leftovers to 165°F (74°C).
Preparation
Wash hands with soap and water before food preparation and after handling raw meat, poultry, fish,
and uncooked eggs.
Thaw frozen meats and fish in the refrigerator or microwave, not at room temperature.
Marinate foods in the refrigerator, not at room temperature.
Avoid contact of cooked foods with contaminated utensils, plates, or food preparation surfaces.
Wash utensils, plates, and cutting surfaces with soap and water after contact with raw meat, poultry,
fish, or eggs.
Avoid contact of juices from uncooked meat, poultry, or fish with cooked foods or foods that will be
eaten raw.
Thoroughly wash all fresh fruits and vegetables.
Avoid recipes using raw eggs.
Cooking[1]
Use a meat thermometer to monitor internal cooking temperatures:
Cook fresh beef, veal, and lamb (eg, steaks, roasts, or chops) to an internal temperature of
145°F (63°C) and rest for 3 minutes
Cook ground beef, pork, veal, and lamb to 160°F (71°C)
Cook ground poultry to 165°F (74°C)

Cook poultry to 165°F (74°C)
Cook fresh pork (eg, roasts, chops, raw ham) to 145°F (63°C) and rest for 3 minutes
Cook precooked ham packaged in USDA-inspected plants to 140°F (60°C); otherwise cook to
165°F (74°C)
Cook fin fish until 145°F (63°C) or until flesh is opaque and separates easily with a fork
Cook shrimp, lobster, and crabs until flesh is pearly and opaque
Cook unshucked clams, oysters, and mussels until shells open during cooking; discard the
ones that do not open
Cook shucked oysters, clams, and mussels until they are opaque and firm
Cook scallops until flesh is milky white or opaque and firm
Cook eggs until the yolk and white are firm.
Boil marinade from raw meat or fish before using it on cooked food.
Serving
Serve cooked products on clean plates with clean utensils.
Keep hot foods at 140°F (60°C) and cold foods below 40°F (4°C).
Never leave foods at room temperature longer than 2 hours (1 hour if the ambient temperature is
>90°F [32°C]).
Use coolers and ice packs to transport perishable foods away from home.
USDA: United States Department of Agriculture.
Reference:
1. United States Department of Agriculture. Food Safety. Safe minimum cooking temperatures. Available at:
www.foodsafety.gov/food-safety-charts/safe-minimum-cooking-temperature (Accessed on December 12, 2019).
Contributor Disclosures
Teresa K Duryea, MD Nothing to disclose Kathleen J Motil, MD, PhD Consultant/Advisory Boards:
Acadia. Sanghamitra M Misra, MD Nothing to disclose Mary M Torchia, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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Dietary recommendations for toddlers, preschool, and

Achieving independence and mastery of feeding skills is an important developmental task of

Key issues for toddlers and preschool children include [2-4]:

● Making the transition to cup and utensil feeding

Key issues for school-age children include [2,5]:

● Adequate intake of fruits, vegetables, calcium, vitamin D, and fiber

Feeding development — Feeding development during the second year includes

Feeding behaviors — The acquisition of healthy feeding behaviors is dependent upon the

Normal toddler feeding behaviors include [1,2]:

● Decrease in dietary variety (feeding "jags") – Beginning at approximately two years of

School-age children — School-age children can understand basic nutrition concepts [2].

Energy — Energy is provided through three primary macronutrients: protein, fat, and

Fat — Dietary fat is an important source of energy, supports the transport of fat-soluble

Carbohydrate — Carbohydrates are an important source of energy and support the

Micronutrients — Micronutrients include vitamins, minerals, and trace elements. Dietary

Fostering the development of healthy eating behaviors is an important goal of early

The USDA/HHS devised MyPlate Plan, an interactive website, to facilitate implementation of

● 2 through 3 years – Approximately 1 ounce (28 g) per serving

● Involve children in the selection and preparation of fruits and vegetables

● Expose children to a variety of fruits and vegetables

● Make fruits and vegetables more accessible

● Add vegetables to sandwiches, pasta, chili, soups, casseroles, and pizza

● Add fruit to cereal or pancakes

● Provide fruits and vegetables as snacks

● One through 3 years – 4 ounces (120 mL)

• 12 to 24 months – Children between 12 and 24 months of age generally should

Children and adolescents 9 to 18 years should consume at least 3 cups

The AHA recommends that consumption of [5,28]:

● Added sugars be avoided in children <2 years of age

● Added sugars be limited to ≤25 g (approximately 100 kilocalories or 6 teaspoons) in

The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition

● Plain water – In addition to unflavored cow milk, plain (unflavored, unsweetened,

● Low-calorie sweetened beverages – Low-calorie sweetened beverages are sweetened

• Age 4 to 6 years – ≤45 mg/day

Vitamin and mineral supplements — Routine supplementation of vitamins and minerals is

If parents wish to give their children supplements, a standard pediatric multivitamin

● From neglected or deprived environments.

● With anorexia or inadequate appetite.

● With lead poisoning. (See "Childhood lead poisoning: Management", section on

● Toddlers should always be supervised while eating

● Raw (unpasteurized) milk or juice

Caregiver responsibilities include [1,2]:

● Providing a variety of nutritious foods

INDICATIONS THAT MAY WARRANT CONSULTATION WITH A DIETITIAN

Indications that may warrant consultation with a dietitian include:

● Chewing and swallowing dysfunction (see "Aspiration due to swallowing dysfunction in

gain in children older than two years in resource-abundant countries", section on

● Diabetes mellitus (see "Overview of the management of type 1 diabetes mellitus in

● Dyslipidemia (see "Dyslipidemia in children and adolescents: Management", section on

● Food allergy (see "Management of food allergy: Nutritional issues")

● Celiac disease (see "Management of celiac disease in children", section on 'Nutritional

● Cystic fibrosis (see "Cystic fibrosis: Nutritional issues")

DIETARY PATTERNS IN THE UNITED STATES

● MyPlate Plan is an interactive website that provides individual dietary guidance

● The USDA/HHS Dietary Guidelines for Americans

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● In the establishment of a healthy eating environment, the caregiver is responsible for

Use of UpToDate is subject to the Subscription and License Agreement.

13. Johnson SL, Bellows L, Beckstrom L, Anderson J. Evaluation of a social marketing

borneIllnessContaminants/Metals/ucm393070.htm (Accessed on January 19, 2017).