Preschool: Ages 2-4

PILLAR ONE: Exercise

Research suggests that increased levels of physical activity in children younger than age 6 is associated with a reduced risk of excessive body weight and obesity.

Daily active play and movement also help children develop their motor skills and increase body awareness and coordination. Other health benefits include improved muscle strength, better mood and cognition, and stronger bones.

Children ages 2 to 5 should engage in at least one hour of structured play and two hours or longer of unstructured physical activity per day. Parents often need coaching and support to help keep preschool-aged children active. Here are some suggestions:

• Children should be encouraged to walk more during family outings and not use strollers as much.
• Parents should limit screen time, discourage eating in front of screens, and avoid placing TVs in children’s rooms.
• Parents should persuade children to play more outside.
• Parents should organize regular family activities (spending time being active together as a family makes everyone healthier).

There also are many types of activities, games, and toys that can help increase movement for preschool-age children. Here are some ideas to share with parents:

• Offer different kinds of balls and bean bags that are easy to grasp, hold, throw, and catch.
• Make tunnels from old boxes that children can crawl through.
• Buy a tricycle or other riding toys and push-pull toys like wagons, doll buggies, and lawnmowers.
• Schedule regular time at playgrounds with climbing equipment.
• Do a "movement parade" where you march around the room or outside with your child and then call out different movements he or she has to do, such as twirl, leap, hop, and jump.
• Play simple singing games that involve movement, such as “Hokey-Pokey,” “Head, Shoulders, Knees, and Toes,” and “If You're Happy and You Know It!”
• Incorporate outdoor running games like “Tag,” “Red Light-Green Light,” and “Freeze Tag.”

All-around health

Parents should ensure their children participate in different kinds of activities to improve their overall wellness. Here is a summary of everyday activities and their specific health benefits:

Wellness Tips

Another way for parents to increase a child’s daily activity is to involve him or her in household tasks, such as setting the table, sorting laundry, folding clothes, putting away toys, cleaning the house, packing for a trip, or doing yard work. Make the activity a game so it will not feel like a chore.

Preschool: Ages 2-4

PILLAR TWO: Nutrition

The most common nutrition-related causes of obesity among preschool-age children are drinking too much juice and sugar-sweetened beverages, eating large portions, and consuming high-calorie, low-nutrient processed junk food.

The parents’ responsibility is to offer the right foods, drinks, and portions while the child should learn to regulate their appetite. (See the “Parenting and Creating an Environment to Promote Healthy Meal Patterns” handout for more information.)

Preschool-age children should eat three healthy meals and two snacks a day at structured times. It is essential to focus on age-appropriate portion sizes with no sugar-sweetened beverages. The American Academy of Pediatrics (AAP) also recommends no more than 4 ounces of juice per day. Healthier drink options are low-fat milk and water.

Advise parents that meals should consist of healthy foods from the five food groups (fruits, vegetables, grains, protein, and dairy) instead of prepackaged, low-nutrient foods. Snacks are an opportunity to provide additional nutrients and should include at least two food groups (fruit or vegetable and protein). Picking eating is frequent in this age group, so parents need to be careful not to offer only favorite foods.

Here is a breakdown of the recommended daily intake and portion sizes for preschool-age children:

Daily Intake:

• 3 ounces protein
• 2 to 2½ cups dairy
• ¾ cup to 1½ cups non-starchy vegetables
• 1 cup whole fruit
• 1 cup whole grains

Portion Sizes for Meals and Snacks:

Protein - 1 Ounce

Fruit - ¼ cup

Vegetable - ¼-½ cup

Dairy - ½ cup

Grains - ¼ cup

See the “Toddler meal plans” handout for more examples of healthy meals and snacks.

Watch the carbohydrates

When a preschooler has a body mass index (BMI) greater than 95th percentile, the child’s diet should limit carbohydrates and focus on low glycemic index foods. See the “Go-Slow-Whoa Plan” handout for more details.

Wellness Tips

Encourage parents to adopt the following healthy eating habits for their children:

• Limit high sugar desserts to special occasions to meet the American Heart Association’s recommendation of only 3 teaspoons of sugar per day for young children.
• Limit fast foods
• Have children try new foods, which can expand their healthy food choices. (See the “Fruits & Veggies for Toddlers” handout for ideas.)
• Don’t tell children to “finish their plate,” which can cause overeating. Instead, let them say when they are full.
• Eat structured meals as a family whenever possible. Avoid distractions at the table, like watching TV or electronic devices.
• Never use food as a reward or to soothe an emotional outburst.

Preschool: Ages 2-4

PILLAR THREE: Behavioral Health

During early childhood, 13 to 22 percent of children are considered picky eaters where they only eat certain foods, don't always eat during meals, or refuse to try new foods (especially healthy ones). Picky eating can be a challenging phase for parents and turn mealtime from relaxing family time into a tense battle.

It is important to intervene early in children who are picky eaters. This ensures they expand their diet to include the variety of foods they need to help combat obesity and improve health outcomes.

Parents often need support and guidance during picky eating moments. Here are some strategies that may help:

• Offer new foods first. Encourage children to try at least three to five bites of a new food before allowing them to eat their preferred food. Research suggests that it takes from 10 to 20 bites for a child to adjust to different food, Allowing children to touch or lick their food also can be helpful.
• Demonstrate eating new foods. Parents should set a good example and try new foods with their children
• Do not force feed. While it is frustrating when children will not eat, never force them, which can make children even more reluctant to eat. Instead, parents should be patient and wait it out. Eventually, the child will get hungry enough.
• Avoid guilt and use positive statements. Do not guilt children into eating by comparing them to other children, or reminding them of how fortunate they are to have food. Guilt only intensifies negative feelings about eating. Instead, offer words of praise and encourage, especially after every bite, like “I know you can do this! You’re really trying!”

PARENT EDUCATION

Taming tantrums

Tantrums are normal for toddlers and preschool-age children and often show up during bouts of picky eating. Many of these episodes can be managed, shortened, and even avoided by following these guidelines:

• Do not engage during a tantrum. For safety reasons, you should stay near younger children and monitor their behavior, but do not engage them by touching or talking unless they pose a safety risk. Parental interaction often can make the tantrum last longer or become more intense.
• Adopt a personal coping statement. A child’s tantrums can make parents feel frustrated or helpless. To minimize these feelings, take a few deep breaths and silently repeat to yourself a positive coping statement or mantra. For example, “This will be over soon” or “They are just frustrated.”
• Avoid piling on. In an attempt to end a tantrum, parents may threaten their child with punishment or take away privileges. However, this often results in both the child and the parent becoming more upset.
• Return to the planned activity. If the child’s tantrum occurred during or right before an activity, pick up where you left off and praise the child for any positive engagement. If the outburst was because the child wasn't allowed to do an activity, stick to your parental rules, and do not give in.
• Label the child’s feelings. Never tell a child he or she is “bad” based on behavior. Instead, after the tantrum use simple, age-appropriate labels for the child’s feelings, like “You were really upset. Why do you think felt that way?" These kinds of labels can help the child better understand why he or she had a tantrum. Also, parents should teach their child appropriate ways to express negative emotions, which can help prevent future tantrums; for example, taking deep breaths and then calmly talking about how he or she feels and what made them upset.

Preschool: Ages 2-4

PILLAR FOUR: SLEEP

The National Sleep Foundation recommends that preschool-age children get 10 to 13 hours of sleep each night; however, as few as eight hours and as many as 14 hours may be appropriate.

Preschool age is when children learn bedtime routines. Offer guidelines that can help parents make the transition to sleep less of a challenge for both them and their child. For example:

• Parents should establish consistent routines, such as dinnertime, bath time, brushing teeth, and reading books.
• Parents should resist protests from a crying child no matter how difficult.
• Parents might consider minimizing the duration of the bedtime routine.
• Parents can use comforting objects like blankets and stuffed animals when putting the child to bed.

Parents also need guidance with the following bedtime issues:

Prolonged bedtime routines. These occur when the routine extends longer than usual because the child attempts to delay bedtime because they fear separation. Parents often exacerbated the situation by feeling guilty about leaving a fearful or crying child. Parents need to understand that allowing this period to draw out makes exiting the child's bedroom even more difficult.

Nightmares. Children can experience dreaming as young as 1 year old. However, nightmares occur in children by ages 3 to 6. Nightmares often happen during rapid eye movement (REM) sleep early in the mornings. Children still have a clear recollection of their bad dream when they wake up and feel anxious and frightened. They are often hesitant to return to sleep after a nightmare but respond well to consoling.

Night terrors. These can occur in toddlers but are more common in preschool-age children. There is often a family history of night terrors, or other sleep-related issues, like sleepwalking or talking in one's sleep. Night terrors are characterized by arousals (not awakenings) and often happen after an hour to an hour and a half of sleep. Common traits include extreme fear and panic, along with screaming and shrieking, sweating, and heart racing. Children should NOT be forced awake in these situations, but instead protected from any potential bodily injury. Parents should allow the terror to run its course (most last about 10 minutes), and the child should subsequently be allowed to fall back asleep. Children do not recall the events, as they occur during deeper sleep stages.

PARENT EDUCATION

Soothing an awakened child

Parents should always console their child in his or her bedroom. This reinforces the room as a place of safety and warmth. Avoid removing the child or allowing him or her to sleep in the parents' bed, which can be detrimental to the regular sleeping routine.

Look out for Obstructive Sleep Apnea (OSA)

OSA is a disorder in which a sleeping person experiences either partial upper airway obstruction for prolonged periods or complete upper airway obstruction intermittently. Among children, OSA is most common in children ages 2 to 6 as this is when tonsils and adenoids are largest relative to the size of the oropharynx.

Children with OSA frequently snore with periodic pauses or gasps in their breathing. Snoring can disrupt their sleep and cause problems with attention, concentration, and daytime sleepiness.

Always screen children for snoring during wellness checks. Refer any child who snores three or more nights per week and has any OSA symptoms to a sleep medicine physician/sleep lab, or a pediatric ear, nose, and throat physician. A polysomnography—a test used to diagnose sleep disorders—can diagnose OSA.