Introduction

Good nutrition is a sufficient intake of a well-balanced diet to support body dietary and energy requirements.¹ A rich, nutritional diet adopted during early childhood ensures normal growth and development. This, in turn, contributes to overall positive physical and mental health. Research has indicated children in the United States may be suffering from malnutrition associated with unmet nutritional needs, which is reflected in the proportion of young children overweight as well as the increasing rates of chronic diseases in childhood: 8% of infants are overweight, whereas 14% of toddlers aged two to five are obese. Rapid weight gain during a child’s first two years of life is associated with a risk of the child becoming overweight or obese in later life.² A poor diet in children is associated with an increased risk of impaired neurodevelopment and restricted academic achievement.² A good, healthy diet may help reduce such poor health patterns. It is crucial to establish a nourishing dietary pattern during infancy and throughout preschool age to prevent negative health effects from developing.²           

The American 2020–2025 Dietary Guidelines and the American Academy of Pediatrics provide nutrition recommendations from birth to two years. Breastfeeding is recommended exclusively for six months and continued to the infant’s first birthday or mutually desired by the mother or infant. It is recommended that solids should only be introduced at six months of age and should include a variety of healthy foods rich in texture. Avoiding juices and sweetened beverages is advised. In addition, the Dietary Guidelines emphasise that toddlers and preschool-aged children should adopt a healthy eating pattern of foods and beverages that are limited in added sugars, saturated fat, and sodium.²          

Understanding nutritional needs

A balanced diet is defined by the diversity of varied food groups, frequency and consumption over time. The World Health Organisation has designed a minimum dietary diversity score to focus on eight food groups. These include human milk, grains, vegetables, nuts, dairy products, meat, eggs and fruits and vegetables.²

There is an association between high dietary diversity within the first year of life and a lower risk of developing food allergies over the first decade due to allergens being introduced into the diet early on. The early introduction of allergenic foods such as cow’s milk, cooked egg, fish, wheat, sesame, and peanuts could play a part in effectively preventing allergies.² 

Haines and colleagues have discussed how unhealthy diets, components of which include saturated fats and trans-fatty acids, sugar, and salt, can lead to an increased risk of certain medical ailments. These include hypertension (high blood pressure), diabetes, cardiovascular diseases, certain cancers, and various atopic (allergic) disorders.¹

The consumption of fish oil and omega-3 fatty acid (such as DHA) supplementation in infancy contains potential positive benefits. In addition to possibly preventing childhood food allergies, consuming these supplements in the first three years of life is advisable.²   

Components of balanced toddler meals

Fruits and vegetables

Dr Frankie Phillips has provided recommendations in the BBC Good Food Guide on the important components of balanced meals for toddlers.³ Five hand-sized portions of fruit per day and vegetables are suggested, which can be fresh, dried, or frozen canned. Dr Frankie Phillips has advised to include a rainbow of different colours to ensure a variety of foods. For example, frozen fruit skewers would be a great source of micronutrients, including vitamin C, providing a colourful and appealing snack or dessert. It is recommended to create familiarity in developing food preferences, such as having a bowl of colourful fruit and vegetables on show to encourage a toddler to try new foods.³     

Proteins

Two portions of protein are required daily as part of a toddler’s diet. This includes meat, eggs, fish, nuts and pulses. These foods provide protein and essential micronutrients, including minerals such as zinc and iron.   

Whole grains

It is recommended that a toddler consumes five portions per day of either bread, rice, cereal, pasta, or potatoes. These foods will provide energy and vitamin B (where fortified). Carbohydrates rich in fibre and other extra nutrients should be introduced gradually, such as wholegrain cereals and brown rice.   

Dairy or dairy alternatives

A toddler’s diet should consist of calcium-rich options, such as cheese, yoghurt, and milk. Three servings per day are ideal as calcium plays an essential role in bone development. Full-fat milk is preferred for toddlers, however, from the age of two, semi-skimmed milk can be introduced if the toddler’s diet is varied and wholesome. Dairy alternatives such as oat milk may be used for toddlers who cannot consume dairy (such as those with cow’s milk protein allergy or lactose intolerance), however, alternatives should be unsweetened, contain no added salt, and fortified with calcium where possible.⁵ 

Healthy fats

The body requires healthy fats to provide energy help absorb vitamins and produce hormones. Healthy fats are categorised into monounsaturated and polyunsaturated fats. It is crucial for toddlers and children to consume the right types and amounts of fats to maintain a balanced diet. Healthy fats can provide a source of nourishment for toddlers, particularly aiding brain and eye development during the first six months of life. Monounsaturated fats can be found in avocados, lean meat, almonds, cashews, peanuts, and seeds. Polyunsaturated fats can be found in walnuts, flax seeds, chia seeds, tuna, salmon, and mackerel.⁴ 

Tips for maintaining balanced meals

Children across the globe acquire eating habits and social behaviour from those around them, such as parents, grandparents, siblings and peers. The home environment, school and the community are the initial sources of learning and education. This, in turn, shapes eating patterns from birth, through childhood, and ultimately into adolescence. Developing and maintaining good eating habits is complex and is influenced by parents’ beliefs and attitudes, emotional, and cultural relations with foods. For example, there is a correlation between parental feeding behaviours and children’s body mass index.1

Haines and colleagues have reviewed evidence that suggests family meals positively impact eating habits and dietary intake. However, over the past decade, family organisation, traditions, and lifestyle have profoundly affected eating habits. Advances in food technology have increased the availability of foods high in energy and nutritionally low in content, such as crisps and sweetened beverages. Changes in the home environment have influenced food availability, parental engagement, parents’ behaviour, and child-regulated eating.¹      

Parents should generally adopt a healthy and motivating healthy eating practices, behaviours, values and beliefs which are accepted by immediate family and culture; a process known as ‘socialisation’. This will encourage children to adopt goals and values that are hoped to help them make appropriate food choices as they grow older.¹  

Addressing common challenges

Families may face challenges of the modern world, such as busy parents struggling to balance work and family life. This problem may be particularly apparent within single-parent families. This has resulted in parents having less time to purchase groceries and prepare traditional home-cooked food, as well as having less time to create meals and share quality moments with family. Children from migrant families, as well as from single-parent families, are more likely to experience food insecurity, be overweight, and adopt unhealthy eating habits.      

Parents are the primary source of influence during socialisation, although due to the structure of modern society, many infants spend more time outside of the home (for example, in nurseries, kindergartens, and childminders’). It is crucial that toddlers and preschool children are guided on appropriate eating practices, self-regulation of food intake, and identifying food preferences. As children grow and gain independence, they encounter different eating environments, greater choices of foods, and eating companions, such as friends and peers at school. The parental environment remains essential, but the key influences in socialisation change. Parental control diminishes as children age and peer group influence becomes dominant. However, parents at this stage hope their children have adopted family goals and values to guide their food choices and eating behaviours. Socialisation strategies are categorised by how a parent shapes a child’s eating habits. Feeding practices are goal-oriented and individual behaviours that parents use to encourage children to do or not do something. This could be eating more fruits and vegetables and not eating cookies and sweets. Feeding styles are associated with the emotional climate a parent creates with their child at meal times influencing the child’s eating behaviour.¹

Parents’ feeding styles can be characterised into four categories, which involve the level of control a parent exerts on their child’s eating behaviour and the level of sensitivity with which a parent expresses their demands.

1. Authoritative: parents have reasonable nutritional demands and sensitivity towards their child’s needs
2. Authoritarian: parents are highly controlling, with little sensitivity to the child
3. Indulgent: parents who are highly responsive and provide little structure
4. Uninvolved: parents are not concerned about their children’s eating habits, and/or those that do cannot provide structure

Authoritative parents create healthy foods and encourage healthy eating, whereas authoritarian parents create healthy foods but expect children to consume the food that is placed in front of them. On the contrary, more lenient parents (indulgent and involved) are noted to have low expectations in relation to child eating behaviours. Indulgent parents want to see their children happy; hence, they provide the foods they know will be eaten by their child, prioritising their child’s food preferences over nutritional content. Uninvolved parents only provide the foods that are convenient for themselves and do not consider nutritional value or child preference. According to research, approximately 17% of parents in the USA are classified as authoritative, 34% as authoritarian, 34% as indulgent, and 17% as uninvolved.¹

Healthy eating patterns and good self-regulation are most reported in children of authoritative parents with better diet quality. Children of authoritarian parents have a lower intake of low-nutrient energy-dose foods, a higher intake of fruit and vegetables, with a higher nutritionally valued intake during the child’s main meal.  The nutritional value of a meal can be measured by the Healthy Eating Index, a measure of how closely individuals meet the dietary guidelines. Children of indulgent parents are reported to have poorer nutritional habits: this is due to larger self-selected portion sizes, lower intakes of fruit, vegetables, dairy products and whole grains, but a higher intake of low nutritional value energy-dense foods.¹       

Involving caregivers in meal maintenance

Some cooking and feeding practices worldwide use the sensory properties associated with food to promote the pleasure of eating healthy foods. For example, parents may utilise food's appearance, taste, flavour, or texture to entice their children. Healthy recipes and certain cooking techniques may be used that their children enjoy. Parents may use fresh fruits to sweeten foods and include different flavours and textures in recipes to make food more appealing to children, as well as adopt cooking techniques to increase the energy density of low-energy foods, such as adding small amounts of healthy fats over food. One example would be drizzling olive oil onto vegetables or using a thickener in soups. This technique may be used by parents to create rich energy foods to maintain a balanced diet in children.  Adding seasoning may make the taste of foods more acceptable, however, it is unclear whether this could change the long-term acceptance of foods.  

Involving parents to establish healthy eating patterns in children is crucial. However, many parents struggle due to pressures in their modern lives. Similarly, healthcare providers often do not have the time or the information to provide guidance to empower parents to establish healthy eating practices. Danone Institute International conducted epidemiologic and intervention research and identified four key themes that would encourage and support healthy eating among children:

1. Positive parental feeding - explores parenting practices and styles that influence children’s dietary intake. For example, avoiding food restriction and encouraging children to self-limit portion sizes and to make their own food choices
2. Eating as a family - emphasises the importance of a healthy diet and the link between socialisation and regular family meals
3. A healthy food environment explores the effect of family resources, food availability and accessibility, and parent modelling on healthy eating practices 
4. The pleasure of eating - associates children’s eating patterns with pleasure through repeated exposure to healthy foods, enjoyable social meals and enhanced cognitive qualities of healthy foods             

There is a sensory dimension associated with food; this can affect how pleasure is experienced before and after consuming food. There is an association with the characteristics of food, which can be modified by the rewarding properties of the food, such as the ability to satisfy energy needs. Sensory pleasure is the development of liking particular food tastes, which is thought to be innate and learnt in the first few years of life. Haines and colleagues reviewed research that suggests infants favour the tastes and textures of foods that they are exposed to in-utero and during breast/formula feeding. Infants then continue to taste and smell the elements found in foods that they are exposed to after birth, developing the ability to process foods with different textures. However, learning to like new foods relies on repeated exposure; this varies according to each child and their own individual characteristics.¹        

Summary

To ensure good growth and development, toddlers must receive healthy, nourishing meals. This can impact physical and mental health. Early diet and nutritional status can play a role in determining health in later life.³ 

On the whole, parents can encourage their children to learn to prefer healthy foods by providing an opportunity to learn different tastes through repeated exposure to such healthy foods. This may have different levels of success in different children, depending on the child’s individual eating behaviour and attitude toward foods. Children may require more food exposure before learning to like a certain food.¹