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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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20Nutrition

Proper nutrition during childhood is essential for normal growth and development. Inadequate intake of nutrients is reflected in slow growth rates, inadequate mineralization of bones, and low body reserves of micronutrients. The nutrients most commonly deficient in children's diets are iron and calcium. Excessive caloric intake is a greater problem for children in United States than is inadequate caloric intake. Many children are substantially overweight, physically inactive, and have high dietary intakes of total fat and saturated fat. These factors may lead to obesity and poor nutritional habits as adults, resulting in an increased risk of heart disease, type 2 diabetes, high blood pressure, certain types of cancer, and other chronic diseases. Primary care clinicians face the challenge of helping children develop dietary habits that promote growth and development and reduce the risk of chronic diseases later in life.

Recommendations of Major Authorities

  • Most major authorities, including the American Academy of Family Physicians, American Academy of Pediatrics, American Dietetic Association, American Medical Association, Bright Futures, and US Preventive Services Task Force (USPSTF) --
  • Primary care providers should counsel children and adolescents and their parents about proper nutrition. The USPSTF has reported that there is insufficient evidence that nutritional counseling by physicians has an advantage over dietitian counseling or community interventions in changing the dietary habits of patients.
  • American Academy of Family Physicians --
  • Counseling should be provided to promote breast-feeding through at least 6 months of age.
  • American Academy of Pediatrics, American Medical Association, Bright Futures, Canadian Task Force on the Periodic Health Examination, and US Preventive Services Task Force --
  • Parents should be counseled about the benefits and techniques of breast-feeding for infants.
  • American College of Obstetricians and Gynecologists, US Preventive Services Task Force, and Canadian Task Force on the Periodic Health Examination --
  • Women of childbearing age who are capable of becoming pregnant should consume 0.4 mg of folic acid per day.

Basics of Nutrition Counseling

Younger than 2 Years of Age

1.

Breast milk is the best choice for feeding almost all infants. Encourage mothers to breast-feed for 6 to 12 months, if possible, but even a few weeks is desirable. Breast-feeding is contraindicated in a few situations, such as certain maternal infections or use of certain drugs or medications by the mother. Educate parents about the benefits of breast-feeding and techniques for successfully initiating and maintaining breast-feeding.

2.

Counsel parents to begin introducing single-ingredient foods when infants are developmentally ready, usually at 4 to 6 months of age. A child should be able to sit up with some help, maintain good head and neck control, and accept soft food from a spoon. Infant cereal mixed with breast milk or formula is often a good first choice. Introduce new foods one at a time, at 3- to 5-day intervals, to permit detection of food intolerances.

3.

Encourage use of iron-rich foods, such as iron-fortified infant formula and iron-fortified cereal. Infants who are exclusively breast-fed may need iron supplementation beginning at 6 months of age. Many authorities recommend hemoglobin/hematocrit testing to detect iron deficiency anemia before 1 year of age ( chapter 1).

4.

Advise parents not to feed cow's milk to children younger than 1 year of age, because its nutrient composition is inadequate to meet the needs of younger children. Do not use reduced-fat milk until the child is at least 2 years of age.

5.

Advise parents not to limit fat in children's diets during the first 2 years of life.

6.

Counsel parents not to feed honey to infants during the first year of life because of the risk of infant botulism.

7.

Counsel parents that vitamin supplements have not been proven to be necessary in healthy children who have balanced diets that include a variety of foods. Infants who are exclusively breast-fed, particularly if they are dark-skinned or are not regularly exposed to sunlight, may need vitamin D supplementation.

8.

Children 6 months of age and older who live in areas with low fluoride content in the drinking water may need fluoride supplementation for prevention of dental caries ( chapter 19).

Over 2 Years of Age

1.

Counsel parents that children, like adults, need a balanced diet that includes a wide variety of foods. The US Departments of Agriculture and Health and Human Services have published the Dietary Guidelines for Americans and the Food Guide Pyramid (Figure 56.1) to assist the public in planning a healthful diet.

2.

Help parents and children choose a diet that is low in total fat (30% or less of total calories), saturated fat (less than 10% of total calories), and cholesterol. Encourage inclusion of poultry (without skin), fish, lean meat, low-fat and skim milk products, cooked dry peas and beans, whole-grain breads and cereals, and fruits and vegetables.

3.

Encourage parents and children to use sugar and salt only in moderation and to choose foods with low or reduced sugar and salt content.

4.

Advise children, particularly adolescent girls, and their families to eat foods rich in calcium (such as milk and milk products) and iron (such as lean meats, dry legumes, fortified cereals, and whole-grain products).

5.

Counsel parents and children about the importance of maintaining a healthy weight. A child's weight should be related to height, age, body build, and other factors that may influence weight. The limits of "healthy" weight are not well defined for children. As a rule of thumb, however, weight-for-height values from the 5th through the 95th percentiles (chapter 3) can be considered "healthy." However, for individuals with a family history of obesity-related diseases or conditions, such as high blood pressure or abnormal lipid patterns, a weight lower than the 85th percentile is desirable.

6.

Weight reduction through dieting or other means is not advisable for children and adolescents, because they are still growing. Counsel overweight children and their parents to strive to maintain the child's weight at a constant level as the child continues to grow, while increasing physical activity to improve fitness and to avoid gaining weight. Ask patients about their dietary habits and determine if they try to limit their food intake for any reason. Pay special attention to individuals who participate in sports requiring stringent weight standards or those who perceive their weight to be too high.

7.

Discuss the use of dietary supplements. Advise patients that vitamin supplements have not been proven to be necessary in normal children and adolescents with balanced diets. Those who live in areas with low fluoride content in the drinking water may need fluoride supplements to prevent dental caries until approximately 16 years of age (chapter 19).

8.

Advise adolescent females of the following options for comsuming adequate amounts of folic acid:

  • Consumption of a diet consistent with the Dietary Guidelines for Americans (chapter 56) and the Food Guide Pyramid (Figure 56.1) is likely to provide the proper amount of folic acid. Dry beans, leafy green vegetables, and citrus fruits are good sources of folic acid.
  • Consumption of fortified foods, such as breakfast cereals, may help patients consume enough folic acid.
  • Folic acid supplement pills and multivitamin preparations containing 0.4 mg folic acid are available.
  • Caution patients against consuming more than 1 mg of folic acid daily, because the effects of excess folic acid are not well known. Such effects may include a delay in the detection of vitamin B12 deficiency, thus allowing neurologic damage to progress. However, women who have had a previous neural tube defect-affected pregnancy should consult with their clinicians several months before they plan to become pregnant about consuming a higher dose of folic acid. Public health measures to fortify the US food supply with folic acid are currently being implemented.

Figure 56.1. Food Guide Pyramid: A Guide to Daily Food Choices.

Figure

Figure 56.1. Food Guide Pyramid: A Guide to Daily Food Choices. From: Human Nutrition Information Service. Food Guide Pyramid: A Guide to Daily Food Choices. Washington, DC: US Department of Agriculture; 1992. (Leaflet No (more...)

Patient Resources

  • The Gift of Love; Feeding Kids Right Isn't Always Easy: Tips for Preventing Food Hassles; Growing Up Healthy: Fat, Cholesterol and More; Right from the Start: ABC's of Good Nutrition for YoungChildren; What's to Eat? Healthy Foods for Hungry Children. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org
  • Nutrition and Sports Performance: A Guide for High School Athletes. American College of Sports Medicine, PO Box 1440, Indianapolis, IN 46202-1440; (317)634-7817.
  • Nutrition and Your Health: Dietary Guidelines for Americans; The Food Guide Pyramid. These booklets are available through the Cooperative Extension System, or contact the Superintendent of Documents, US Government Printing Office, Washington, DC 20402; (202)783-3238.
  • The Food Guide Pyramid: Beyond the Basic 4. Food Marketing Institute, 800 Connecticut Ave NW, Washington, DC 20006.

Provider Resources:

  • Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American Academy of Pediatrics, Committee on Nutrition. Pediatric Nutrition Handbook.3rd ed. Elk Grove Village, Ill: American Academyof Pediatrics; 1993.
  3. American Academy of Pediatrics, Committee on Nutrition. The promotion of breast-feeding: [recommendations of the Councils of the Society for Pediatric Research (SPR) and American Pediatric Society (APS), and of the American Academy of Pediatrics (AAP)] Pediatrics. . 1982; 69:654–661. [PubMed: 7078995]
  4. American Academy of Pediatrics, Committee on Nutrition. The use of whole cow's milk in infancy. Pediatrics. . 1992; 89:1105–1109. [PubMed: 1594357]
  5. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS). Chicago, Ill: American Medical Association; 1992.
  6. Canadian Task Force on the Periodic Health Examination. The periodic health examination: 2. 1984 update. Can Med Assoc J. . 1984; 130:1278–1285. [PMC free article: PMC1483525] [PubMed: 6722691]
  7. Cunningham AS. Morbidity in breast-fed and artificially fed infants. J Pediatr. . 1977; 90:–. [PubMed: 856961]
  8. Freed GL, Landers S, Schanler RJ. A practical guide to successful breast-feeding management. Am J Dis Child. . 1991; 145:917–921. [PubMed: 1858730]
  9. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health; 1994.
  10. Mallick MJ. Health hazards of obesity and weight control in children: a review of the literature. Am J Public Health. . 1983; 73:78–82. [PMC free article: PMC1650445] [PubMed: 6336638]
  11. American Academy of Pediatrics. National Cholesterol Education Program: Report of the Expert Panel on Blood Cholesterol Levels for Children and Adolescents. Pediatrics. . 1992; 89(suppl 3):525–584. [PubMed: 1538956]
  12. US Department of Agriculture, US Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. Washington, DC: US Goverment Printing Office; 1995. Home and Garden Bulletin 232.
  13. US Preventive Services Task Force. Counseling to promote a healthy diet.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 56.
  14. US Public Health Service. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR. . 1992; 41:1–7. [PubMed: 1522835]
  15. US Public Health Service. The Surgeon General's Report on Nutrition and Health. Washington DC: US Department of Health and Human Services; 1988. DHHSPHS publication 88-50210.
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