Newborns, Infants, and Toddlers (age 0 to 2 years old)

PILLAR ONE: Exercise

Daily exercise is key to preventing childhood obesity and should begin at an early age. Regular activity also helps infants and toddlers reach developmental milestones like crawling, sitting up, and standing.

Inquire about how much time the child spends every day in active play. Research shows that children ages 1 to 2 should have at least 30 minutes of structured activity and an hour or longer of unstructured playtime each day.

Family routines and regular interactions with parents can impact a child’s amount of daily activity and playtime. Educate parents about the importance of proper movement and ways they can increase their child's activity time and limit their sedentary time.

For example, during daily interactions, parents should encourage various types of movements, such as:

• Reaching
• Kicking
• Grabbing
• Rolling
• Tummy time

Wellness tip: Watch TV Time

A TV that is always on can disrupt play and activity time and encourage sedentary behavior. Parents should keep the daily TV and other screen time to two hours or less (and no TV exposure for infants). Make sure to turn off all electronics during active play, or change the TV to pleasant background music.

To help increase activity and play, limit your child's time spent in positions that restrict movements, such as car seats, strollers, and bouncy seats.

Newborns, Infants, and Toddlers (age 0 to 2 years old)

PILLAR TWO: Nutrition

The American Academy of Pediatrics (AAP) and the World Health Organization both recommend breastfeeding for the first six months of life. The health gains from breastfeeding can lower the risk of obesity later in life.

Promoting and supporting breastfeeding should be the standard of care for all prenatal and routine pediatrician visits.

The AAP notes that breastfeeding cessation often occurs during the transition from hospital to home, at ages 6 to 8 weeks, and when the mother returns to work.

When breastfeeding is not feasible, the alternative is bottle-feeding infant formula. At 2 months of age, an infant will consume 4 to 5 ounces per feeding, every three to four hours, for a total of about six feedings within 24 hours.

This amount of formula volume per feeding gradually increases while the number of meals per day decreases until a peak at 6 months of age. Here, the infant will consume 7 to 8 ounces of formula per feeding, every four to five hours during the day, with no nighttime feedings.

Complementary foods should be introduced at 6 months of age and not before. Introducing solids before 4 months of age is associated with excessive weight gain in infancy as well as childhood obesity.

The initial foods should be high in iron and zinc. Pureed meats and iron-fortified infant cereals best meet the nutritional needs at this age.

Share with parents the Infant Feed Chart, which shows the types and amounts of solid foods required in the first year of life.

Why excessive weight gain occurs

Discuss with the parents the possible reasons for excessive weight gain and how to avoid it:

• Introducing complementary foods too early (it should begin after six months).
• Formula feeding greater than 45 ounces a day if there are no solid foods or 32 ounces a day with solid foods. (Suggest they limit formula to 24 ounces a day if the infant is higher than 85 percentile weight for length and takes solid foods.)
• Review with parents the appropriate intake of complementary foods after 6 months of age, including food selections and portion sizes. (Also, stress the need to maintain regular vegetable and fruit intake and encourage adding a fruit or vegetable to at least one daily snack.)
• Share the handouts, Introduction to Solids and Spoon Feeding and How to Start Feeding Solids.

PARENT EDUCATION

Evidence shows that overfeeding is the most common factor for excessive infant weight gain. Parents need to recognize the signs of hunger and satiety. These include:

Wellness tip: Healthier bottle-feeding

Make sure parents follow these healthy bottle-feeding habits:

• Only use expressed breast milk or formula
• Do not give juice or sweetened beverages like soda or sports drinks
• Do not prop the bottle during feedings and let babies feed alone (this takes away from parent-baby bonding and may increase the risk of choking) Additionally, propping the bottle may lead to overfeeding.
• Do not add cereal or other foods to the bottle
• Learn their infant’s hunger and satiety signs to avoid overfeeding

Transition to Toddlerhood

Parents should introduce a variety of foods by the end of the child's first year, which can teach the child healthful food habits and reduce the risk of obesity later in life. Here are some strategies to help parents make a successful food transition.

• As an infant moves from puree foods to more textured table foods, a lower intake of vegetables and fruit is common. Parents should make sure to offer softer, chopped vegetables and fruits to the infant’s diet.
• By 9 months of age, an infant should have two snacks a day and can include easy-to-eat finger foods, such as cereal, crackers, and cookies.
• If the infant/toddler refuses food, try again. It can take 10 to 20 attempts before food is accepted. Also, offer new meals prepared in different ways. For example, vegetables can be served fresh, steamed, roasted, or mashed.
• Share the handout Infant Feed Chart for portion sizes and recommended daily servings.

PARENT EDUCATION

The AAP recommends no fruit juice for children younger than 1 year old because it does not provide the necessary nutrients like breast milk, formula, or fruits and vegetables. Excessive juice intake also may contribute to weight gain. Juice can be introduced after 1 year of age but should be limited to no more than four ounces a day. Parents should also avoid sodas, sports drinks, and sugar-sweetened beverages like lemonade, fruit punch, sweet tea, and portable kids drinks, such as Sunny D and Capri Sun.

Other practices also are associated with increased weight gain among infants. Parents should NEVER do the following:

• Offer food as a reward. Instead offer age-appropriate non-food related treats, such as reading a favorite book together, visiting the park, or taking a walk.
• Force feed. Never force a child to eat during designated mealtimes. Allow the child to self-regulate when he or she is hungry and full.
• Insist on finishing the plate. Again, let the child eat until he or she feels full and not until the dish is clean. Serving appropriate portion sizes can help.

Wellness Tip: Reduce excessive caloric intake

Here are some other tips to share with parents about managing their child’s calories:

• Create a structured daily meal and snack times, such as three meals and one to two snacks a day. This approach encourages regulation of appetite.
• Provide meals and snacks at the table or in a highchair versus eating on the go.
• Use smaller, age-appropriate plate sizes.
• Avoid feeding during non-meal and snack times; for example, waiting for appointments, in the grocery store, and when driving.
• Introduce a spoon at 8 to 9 months of age, and transition to a cup by 1 year of age. A spoon promotes self-feeding behavior. Also, share the handout Transitions to Cup and Table Food.

Newborns, Infants, and Toddlers (age 0 to 2 years old)

PILLAR THREE: Behavioral Health

Developmental disabilities and autism can have a significant impact on an infant's eating habits. Identifying early signs of behavioral issues can help improve a child's nutrition, physical activity, and sleep. Additionally, it can allow infants to receive early intervention.

Inquire if the child experiences any of the following signs, which may warrant further evaluation by a psychologist or team of behavioral experts:

• Trouble relating to others, or not having any interest in people
• Not looking at objects when another person points at them
• Avoiding eye contact and wanting to be alone
• Preferring not to be held or cuddled
• Repeating or echoing words said to him or her in place of regular language
• Engaging in repetitive behaviors
• Problems adapting to routine changes
• Unusual reactions to the way food or objects smell, taste, look, feel, or sound.

PARENT EDUCATION

Effective parenting practices

Every family's approach to parenting is different, but here are some standard methods that can help improve a child's emotional, behavioral, cognitive, and social functioning:

• Show warmth and sensitivity
• Predictably respond to infants when they cry; for example, use a calm tone and react in a consistent amount of time.
• Establish routines and household rules
• Read books to infants and read to toddlers daily
• Talk, play music, and sing with infants and toddlers
• Teach safety behaviors; for instance, show toddlers how to ask for help and identify hazardous objects.
• Distract infants with toys and move them to safe areas when they move and touch objects they should not
• Use appropriate discipline without harshness
• Offer praise and loving attention
• Spend time cuddling and holding
• Encourage a toddler’s curiosity and ability to recognize objects by taking him or her to the park or store
• Play matching games and simple puzzles.

Wellness Tip: Self-Care for parents

Parenting is a constant challenge. Remind parents to take care of their physical and emotional health, too. Here are some self-care tips they can try:

Physical Care

• Aim for seven to nine hours of sleep. Also, try to take a nap whenever the child sleeps. If you have a partner, take turns with nighttime awakenings.
• Exercise and stay active. Join a gym or YMCA center that provides childcare. You can also adopt at-home workouts, such as bodyweight exercises, yoga, and cardio on a treadmill or stationary bike.
• Stay hydrated with water. Buy a fun water bottle and keep it with you throughout the day. Use a mobile app to help track your water intake.
• Spend time outside and get some fresh air. Take your child for a stroller walk, or visit a playground. If you have a partner, take turns watching the child and enjoy a short walk or some quiet time on the porch.
• Eat nutritious meals. Make sure each meal and snack includes a protein, and eat at least five servings of fruits and vegetables throughout the day. Do your best to avoid processed foods and don’t skip meals even when busy. Another option is to use a meal prep service that delivers healthy meals to your home.

Emotional Care

• Spend time with your significant other; for instance, hire a sitter and have a date night
• Spend time with friends, like a casual lunch or coffee
• Talk about and express your feelings with your spouse, a friend, or family member, so you don’t keep anything bottled up.
• Engage in an enjoyable activity every day (even if it’s only for10 minutes)
• Say no to extra responsibility
• Take a break from your phone and social media
• Attend a local place of worship, spirituality, or meditation

Newborns, Infants, and Toddlers (age 0 to 2 years old)

PILLAR FOUR: SLEEP

Setting proper sleep habits at an early age can help prevent childhood obesity. Newborns, infants, and toddlers undergo a robust period of maturational changes in their brains and bodies, and adequate sleep is an essential part of their growth. Of course, both the child and parent face many sleep challenges during this period.

GUIDELINES

The National Sleep Foundation (NSF) notes that the evidence behind specific sleep recommendations for newborns, infants, and toddlers is weaker than other age groups. Still, the NSF suggests the following sleep guidelines:

• Newborns (ages 0 to 3 months): 14 to 17 hours each day (although 11 to 18 hours may be permissible)
• Infants (ages 4 to 11 months): 12 to 15 hours each day (although as few as 10 hours and as many as 18 hours may be appropriate)
• Toddlers (ages 1 to 2 years): 11 to 14 hours each day (although as few as nine and as many as 16 hours may be appropriate).

IDENTIFYING PROBLEMS

If a child in this age group has sleep problems, review his or her sleep routine with the parents, and focus on the following common causes of sleep disruptions.

Nighttime Waking.
Nighttime waking is typical among infants and toddlers because they have shorter sleep cycles than older children and adults.

• Introduce bedtime routines by 2 months of age.
• Studies have shown that infants and toddlers often wake up two to four times a night. It is unusual if an infant or toddler sleeps without any disruption for extended periods during the day or night.
• By 6 months of age, infants have a more regular sleep cycle and become better able to self soothe when they awaken. However, about 50% of all 1-year-olds still require parental soothing to fall back asleep.

Transition From Overnight Feedings.
Overnight feeding is regular during infancy and especially for breastfed infants. Most formula-fed infants do not require overnight feedings by 4 months of age, and can sometimes occur as early as 2 months of age, but often no later than 6 months of age.

• If formula-fed infants older than 6 months wake up to feed, this is often not a sign of a problem.
• Parents should not use formula feedings as a soothing strategy.
• Breaking this habit can help the child learn to self-regulate their emotions.
• It is important to counsel parents not to add solids to the child’s bottle before bedtime to promote better sleep.

Trained Night Crying.
This occurs when infants and toddlers weaned off of overnight feeding still need parental soothing to fall back asleep after waking up.

• Placing the child in the crib after he or she falls asleep is a common cause. Upon waking, the child becomes disoriented and needs soothing.
• The solution is for infants and toddlers to learn to fall asleep on their own in the crib, which teaches them how to self soothe.
• Parents can help the process by waiting longer to check in after the child wakes up. Although it can be stressful for parents to hear prolonged crying, this gives the child the chance to fall back asleep on his or her own.

PARENT EDUCATION

Parents need to understand these common sleep disturbances and know how to address them. Additional areas for troubleshooting with parents include:

• sleep duration
• frequency of naps
• snoring
• amount of juice and other fluids consumed each day
• amount of daily screen time exposure (the American Academy of Pediatrics [AAP] recommends zero screen time for children under 18 months of age aside from video chatting).

SAFETY TIP

Protect Against SIDS

Adopting safe sleep habits can reduce the incidence of sudden infant death syndrome (SIDS), according to recommendations from the AAP Task Force on SIDS. For example, infants should be placed on their backs to sleep and on a firm surface without any soft objects or materials. They should be tightly swaddled in a thin blanket until they are mobile enough to push out. After that, use a warm onesie. Also, under no circumstance, it is safe for a parent and infant to sleep in the same bed. Parents can learn other sleep safety tips from Safe Kids Worldwide.