Chapter 4: Provide young child nutrition

Maternal, infant, and young child nutrition is a cornerstone of public health nutrition in Kenya. Ensuring optimal nutrition during early childhood underpins healthy growth, cognitive development, and long-term wellbeing. Professionals in nutrition and dietetics must be adept at assessing and addressing the unique nutritional needs of young children to reduce undernutrition and its associated risks. This chapter delves into the nutritional requirements for young children, the significance of adequate nutrition during this period, and methods for assessing their nutritional status effectively.

4.1 Nutritional needs for young child

A young child, in this unit, is a child from 12 months to under five years of age, covering the toddler years from one to three and the preschool years from three to five. These are years of steady growth, rapid brain development, growing independence and changing taste, so the nutritional needs change from year to year. A dietitian who understands those needs can judge whether a child's diet is adequate, assess the child's nutritional status and plan feeding that prevents stunting, wasting and micronutrient deficiencies. Example: a mother brings a two-year-old who refuses most meals, and the dietitian can only judge whether this is a problem after comparing the child's weight, diet and clinical signs with what a child of that age needs.

4.1.1 Introduction to nutrition needs for young child

After the first year, growth is slower than in infancy but is still fast compared with later childhood, and the child must obtain enough energy and nutrients from a small stomach. This means that meals have to be nutrient-dense and frequent, usually three meals and one or two snacks each day, in portions the child can finish. The child moves from mashed foods to the family pot, begins to feed without help and develops strong likes and dislikes, all of which affect intake. Example: a child of 18 months who eats half a cup of porridge may need an enriched porridge and a snack to reach the energy that a larger portion would have given.

Needs fall into several groups that are assessed separately later in this topic: energy, the macronutrients, and the vitamins, minerals and water that support growth, immunity and brain development. Breastfeeding remains important beyond the first birthday.

Importance of continued breastfeeding

The World Health Organization recommends that breastfeeding continues to two years of age or beyond, together with other foods. Breast milk goes on supplying energy, fat and protein in a form that the child digests easily, together with antibodies that lower the risk of diarrhoea and other infections. It does not replace family foods, because by itself it no longer provides enough iron and zinc, so the child is breastfed after or between meals rather than in place of them. A mother who is still breastfeeding a 16-month-old is encouraged to continue and to offer the family foods first at meal times.

4.1.2 Importance of nutrition in young child

The first five years, and especially the first two, are a window when food shapes growth, brain development and defence against disease. Damage to growth and learning that happens in this period is hard to reverse later, so good feeding at this age pays back across the whole of life. Dietitians and nutritionists advocate for adequate feeding to address undernutrition and the rising problem of overweight. Example: a child who is fed well between the ages of one and three is more likely to reach a normal height than one who goes through repeated spells of poor feeding and infection.

Impact on physical growth

Adequate energy and protein support linear growth and weight gain, and they allow the body to build muscle and bone. Chronic shortage of food or nutrients slows growth in height, which is called stunting, and a stunted child often has less muscle strength and falls ill more easily. Height lost in the early years is difficult to regain later, which is why growth is checked at every health visit.

Cognitive development and learning ability

The brain grows fastest in early life, and iron, iodine, zinc, fats and enough energy are needed to build it. A child with iron deficiency, for example, may be tired, inattentive and slow to talk. Good feeding together with play and talk from caregivers gives the child a better start with learning when formal learning begins.

Immunity and disease resistance

A well-fed child has stronger defences, so infections such as diarrhoea and pneumonia are less frequent and less severe. Malnutrition weakens immunity and increases the risk of severe infection, and repeated infection in turn reduces appetite and wastes nutrients, creating a cycle that is hard to break.

Long-term health consequences

Poor feeding in early childhood can lead to a small adult body and to reduced strength and work capacity. An unhealthy pattern in early life, such as many sweet drinks and snacks, is linked with overweight and a higher risk of diabetes and heart disease in adulthood. Good habits set at this age often stay with the child, so early guidance has lasting effect.

Socioeconomic implications

Malnourished children need more treatment, miss opportunities to learn and grow into adults who earn less, which strains household budgets and the health services. Investing in young child nutrition benefits the family, the community and the country, because healthy children become productive adults.

4.1.3 Assessment of nutritional needs in young children

Assessment collects information about the child's growth, health and diet and compares it with standards, so that needs and problems can be identified. It combines four sets of information: anthropometric measurements, biochemical tests, clinical signs and dietary intake. No single set is enough, because for example a child with a normal weight may still have low iron stores. Example: a nutrition clinic weighs and measures a child, looks for pallor, asks the caregiver what the child ate the day before and, if anaemia is suspected, refers the child for a haemoglobin test.

4.1.3.1 Anthropometry

Anthropometry is the measurement of the child's body size and is the basic tool for judging growth. The measurements are compared with the World Health Organization child growth standards and expressed as z-scores, which show how far a measurement lies from the median for children of the same age and sex. Example: a 30-month-old girl with a height-for-age z-score of −2.4 is stunted, because the value is below −2.

Measurements and indicators:

• Weight: taken on a scale that has been zeroed, with the child wearing little clothing, and plotted as weight-for-age.
• Length or height: a child under two years is measured lying on a length board, and from two years standing against a stadiometer.
• Weight-for-height or length: shows thinness, with a z-score below −2 indicating wasting and below −3 severe wasting.
• Height-for-age: shows past, long-term undernutrition, and a z-score below −2 is stunting.
• Weight-for-age: combines both aspects, and a z-score below −2 is underweight.
• Mid-upper arm circumference (MUAC): measured on the left arm for children aged 6 to 59 months, with 12.5 cm or more normal, 11.5 to less than 12.5 cm moderate acute malnutrition and below 11.5 cm severe acute malnutrition.
• Overweight: a weight-for-height z-score above +2 indicates overweight and above +3 obesity.
• Bilateral oedema: swelling of both feet by pitting is recorded, because it indicates severe acute malnutrition regardless of the other measurements.

Routine growth monitoring plots the child's weight on the growth chart at each visit, so that a flat or falling line is noticed early, and caregivers are counselled on what to do. This growth promotion is what turns measurement into action.

4.1.3.2 Biochemical assessments

Biochemical assessment uses laboratory tests on blood, urine or stool to find deficiencies and infections that cannot be seen on examination. The clinician orders the tests, and the dietitian interprets them together with the child's diet and signs. Example: a pale 22-month-old has a finger-prick haemoglobin of 9.4 g/dL, which is below the cut-off of 10.5 g/dL for children aged 6 to 23 months and falls in the moderate band, so the child is referred for treatment.

Common tests:

• Haemoglobin: anaemia is present below 10.5 g/dL at 6 to 23 months and below 11.0 g/dL from 24 to 59 months (WHO, 2024). At 6 to 23 months mild anaemia is 9.5 to 10.4, moderate 7.0 to 9.4 and severe below 7.0 g/dL. From 24 months mild is 10.0 to 10.9, moderate 7.0 to 9.9 and severe below 7.0 g/dL.
• Serum ferritin: reflects iron stores, and a value below 12 µg/L in a well child indicates depleted stores, although infection can raise ferritin and hide a deficiency.
• Serum retinol: measures vitamin A status, and a value below 0.70 µmol/L indicates deficiency.
• Stool examination: looks for worm eggs and parasites that cause blood loss and poor absorption.
• Blood film or rapid test for malaria: done in a child with fever, because malaria causes anaemia.
• Urinary iodine: used in surveys to judge the iodine status of a population rather than of one child.

Finger-prick samples are taken with a single-use lancet that is placed in a sharps container immediately after use and is never reused.

4.1.3.3 Clinical monitoring

Clinical assessment is a careful look at the child for physical signs that suggest nutrient deficiency or excess, together with a short history of illness and appetite. The dietitian examines the child from head to foot in a good light and records what is seen so that changes can be followed. Signs suggest a problem, but they do not prove it, so each finding is read together with measurements and diet. Example: a child with pale inner eyelids and palms, brittle nails and tiredness is likely to have anaemia and is sent for a haemoglobin test.

Signs to look for:

• General appearance: whether the child is active and alert or lethargic, and thin, wasted or overweight.
• Hair: thin, sparse or easily pulled out hair, or loss of normal colour, which may reflect protein and energy deficiency.
• Skin: dry, flaking or peeling skin, and small sores, which may reflect lack of protein, zinc or essential fats.
• Eyes: pale inner eyelids, dry eyes or spots on the white of the eye, which may indicate anaemia or vitamin A deficiency.
• Mouth and teeth: cracks at the mouth corners, a swollen or pale tongue, bleeding gums and decayed teeth.
• Legs and bones: swollen feet, and bowed legs or wide wrists that may indicate rickets.
• Neck: a swelling at the front of the neck that may indicate goitre from iodine deficiency.

4.1.3.4 Dietary assessments

Dietary assessment establishes what the child eats and sets it against what the child needs. It shows gaps in energy and nutrients that measurements alone do not, and it points to the advice the caregiver needs. The sub-sections that follow give the needs and food sources for each nutrient that is assessed. Example: a recall shows that a three-year-old eats ugali and tea with milk and sugar and rarely any beans, fish or vegetables, which suggests low iron, protein and vitamin A before any test is done.

Methods of dietary assessment:

• 24-hour recall: the caregiver describes everything the child ate and drank in the previous day, including portions, using household measures such as cups, spoons and handfuls.
• Food frequency questionnaire: lists foods and asks how often the child eats each over a week or month, which shows usual patterns.
• Food record: the caregiver writes down every food and drink for two or three days, which suits literate caregivers.
• Dietary diversity score: counts the food groups eaten in a day, as a quick measure of diet quality.
• Direct observation: the assessor watches a meal to see the amount eaten, how the child is fed and the hygiene during feeding.

Each method has limits. A recall depends on the caregiver's memory and on estimating portions, one day may not show the usual diet, a food frequency questionnaire does not give amounts, and a food record needs a caregiver who can write and may change what the child is fed while it is kept.

Steps in a 24-hour recall:

1. Greet the caregiver and explain that you want to hear about the child's food and drinks over the last day and night.
2. Ask her to list every food and drink the child had, from waking up until the next morning, without interrupting.
3. Prompt for forgotten items, such as snacks, sweets, drinks between meals and breast milk.
4. Ask the time, the place and who gave each item.
5. Estimate each portion with household measures, using a cup or spoon that you have shown her.
6. Read back the list to confirm it, and thank her.

The result is compared with the child's needs for each nutrient. Example: a two-year-old whose needs are estimated at 1,100 kcal and whose recall adds up to 825 kcal has an intake of 825 ÷ 1,100 × 100 = 75% of the need.

4.1.3.4.1 Energy needs

Energy is needed for the body's basic functions, for activity and for growth. Needs rise with age and with activity, and they are higher during and after illness. An approximate guide is about 800 to 1,000 kcal a day at one year, about 1,400 kcal at three years and 1,200 to 1,600 kcal a day at four to five years, depending on size, sex and activity. After the first year, breast milk still contributes a share of energy in a breastfed child, and family foods supply the rest. Example: a recall that gives a child only 70% of the estimated energy need, with a flat growth line, suggests that portions or meal frequency must increase.

Ways to raise the energy density of a young child's food:

• Add fat: a little oil, margarine, avocado or groundnut paste stirred into porridge or vegetables adds energy without adding bulk.
• Thicken porridge: use more flour and less water so that each spoonful carries more energy.
• Offer snacks: add one or two nutritious snacks, such as boiled egg, bananas or roasted groundnuts that are mashed or ground for young children.
• Add milk: mix milk or yoghurt into porridge instead of water.
• Avoid sweet drinks: they fill the stomach and give little besides sugar.

4.1.3.4.2 Macronutrient needs

Macronutrients are protein, fat and carbohydrate, and they supply the energy and building material for growth. Protein builds and repairs tissue, fat gives concentrated energy and supports brain growth, and carbohydrate is the main fuel. Reference intakes for protein are about 13 g a day at 1 to 3 years and 19 g at 4 to 8 years, with 30 to 40% of energy from fat at 1 to 3 years and 45 to 65% of energy from carbohydrate. Example: a child who eats mostly maize meal with little beans, egg or fish may take enough energy but not enough protein.

Good sources and balance:

• Protein: eggs, fish, meat, beans, lentils, milk, yoghurt and groundnut paste supply protein, and combining cereals with legumes improves the protein quality.
• Fat: milk, eggs, groundnuts, avocado, fish, and cooking oil provide fat for energy and for absorbing vitamins A and D.
• Carbohydrate: maize, millet, sorghum, rice, potatoes, sweet potatoes, cassava, arrowroot and bananas provide the energy base of meals.
• Fatty fish and groundnuts: supply essential fatty acids that the brain needs.
• Balance: an adequate diet includes all three at each main meal, and a diet too low in fat leaves a small child short of energy.

4.1.3.4.3 Vitamin A

Vitamin A supports vision, the immune system, healthy skin and growth. Reference intakes are about 300 µg retinol activity equivalents a day at 1 to 3 years and 400 µg at 4 to 8 years. A diet low in vitamin A increases the risk of severe infection and of eye damage. Example: a child who eats ugali with a few tomatoes and almost no leafy vegetables, liver, eggs or orange fruits has a low vitamin A intake.

Food sources:

• Liver: a small amount provides much more vitamin A than other foods.
• Eggs and whole milk: supply vitamin A in a form that is easy to absorb.
• Orange-fleshed sweet potato, pumpkin and carrots: supply beta-carotene, which the body turns into vitamin A.
• Dark green leafy vegetables: kale, spinach and amaranth leaves also supply beta-carotene.
• Ripe mangoes and pawpaw: are fruit sources, and a little fat in the same meal helps absorption.

The routine vitamin A supplement given to young children is a separate matter, covered under supplementation in the nutrition intervention plan.

4.1.3.4.4 Vitamin D

Vitamin D helps the body absorb calcium and build bone. The reference intake for children aged 1 to 18 years is about 15 µg (600 IU) a day. The skin makes vitamin D when it is exposed to sunlight, which is an important source for most children, but few foods contain much, so dietary intake matters most when sun exposure is limited. Example: a child who is kept indoors or wrapped in clothing for most of the day depends more on food sources of vitamin D.

Sources:

• Sunlight: short, regular exposure of the face, arms and legs to daylight lets the skin make vitamin D, and the child is kept out of the harshest midday sun.
• Oily fish: such as sardines and mackerel supply small amounts.
• Eggs: the yolk contains some vitamin D.
• Fortified foods: some milks and fats are fortified, and the label states this.
• Liver: contains a small amount.

Dietary assessment asks about outdoor play and clothing as well as foods, and bowed legs or delayed walking may suggest too little vitamin D.

4.1.3.4.5 Vitamin C

Vitamin C forms collagen for skin, gums and blood vessels, supports the immune system and helps the body absorb iron from plant foods. Reference intakes are about 15 mg a day at 1 to 3 years and 25 mg at 4 to 8 years. It is easily destroyed by long cooking, so fresh fruit and lightly cooked vegetables are the best sources. Example: serving a few slices of orange or guava with a bean and sweet potato meal increases the iron absorbed from the beans.

Sources:

• Citrus fruit: oranges, tangerines and lemons.
• Guava: among the fruits that carry a high amount of vitamin C.
• Mango, pawpaw and passion fruit: also contain vitamin C.
• Tomatoes and green peppers: can be eaten raw or lightly cooked.
• Dark green leafy vegetables: retain more vitamin C when cooked briefly.

4.1.3.4.6 B vitamins

The B vitamins, including thiamine, riboflavin, niacin, vitamin B6, folate and vitamin B12, help the body release energy from food and make blood cells and nerve tissue. A diet low in these vitamins can cause tiredness, sore mouth corners and anaemia, and the needs are small but rise with age. Example: a child who eats refined white flour and little else is likely to have a low intake of thiamine and riboflavin.

Sources:

• Whole grains and fortified flour: supply thiamine, riboflavin and niacin.
• Beans, lentils and groundnuts: supply thiamine and folate.
• Dark green leafy vegetables: supply folate.
• Milk and eggs: supply riboflavin and vitamin B12.
• Meat, fish and liver: supply vitamin B12, which is found naturally only in foods from animals.

A child who is fed no animal-source foods at all may need advice from a clinician on vitamin B12.

4.1.3.4.7 Calcium

Calcium builds bones and teeth and is needed for muscle and nerve function. The World Health Organization and Food and Agriculture Organization reference intake is about 500 mg a day at 1 to 3 years and 600 mg at 4 to 6 years. Example: a child who drinks no milk and eats no small fish with bones must get calcium from finger millet and leafy vegetables, which supply less per serving.

Sources:

• Milk, yoghurt and fermented milk: supply well-absorbed calcium in a small serving.
• Small fish eaten whole: such as omena, supply calcium from the bones.
• Finger millet: porridge from finger millet flour is a good cereal source.
• Dark green leafy vegetables: kale and amaranth contribute calcium, though less is absorbed from some leaves.
• Beans: contribute smaller amounts.

4.1.3.4.8 Iron

Iron makes haemoglobin, which carries oxygen in the blood, and supports brain development and immunity. Reference intakes are about 7 mg a day at 1 to 3 years and 10 mg at 4 to 8 years. Iron from meat, fish and liver is absorbed far better than iron from plant foods. Example: a toddler who drinks large amounts of milk and eats little else may be too full to eat iron-rich foods, and milk is a poor source of iron.

Sources and absorption:

• Liver, red meat and chicken: supply well-absorbed iron.
• Small fish such as omena: supply iron and calcium together.
• Beans, lentils and dark green leaves: supply iron that is less well absorbed.
• Vitamin C with meals: fruit or tomato eaten with beans or leaves increases absorption.
• Tea with meals: tea reduces iron absorption, so it is kept away from main meals and is not a good drink for young children.

4.1.3.4.9 Zinc

Zinc supports growth, wound healing, appetite and the immune system. Reference intakes are about 3 mg a day at 1 to 3 years and 5 mg at 4 to 8 years. A diet low in zinc may be linked with slow growth and frequent infections, and plant foods such as unrefined cereals and legumes contain compounds that reduce zinc absorption. Example: a child on a maize and bean diet with no animal foods has a lower intake and absorption of zinc than a child who eats meat or eggs.

Sources:

• Meat and liver: supply well-absorbed zinc.
• Eggs and milk: supply smaller amounts.
• Small fish: supply zinc along with calcium.
• Beans, groundnuts and seeds: provide zinc, though absorption is lower.
• Processed cereals and legumes: soaking, fermenting or germinating the grain before cooking reduces the compounds that block zinc absorption.

4.1.3.4.10 Fibre

Fibre helps bowel movement and gives a feeling of fullness. A guide for children is about 19 g a day at 1 to 3 years and 25 g at 4 to 8 years, but very bulky foods should not crowd out energy-rich foods in a small child. Example: a child fed mainly on watery vegetable soup and whole grain porridge feels full early and may take too little energy.

Sources:

• Whole grain cereals: whole maize meal, millet and sorghum.
• Beans, lentils and peas: such as githeri, also provide protein.
• Fruits: eaten with the skin where suitable, for example ripe pears and guavas without hard seeds.
• Vegetables: green leaves, carrots and pumpkin.
• Root crops: sweet potatoes and cassava.

4.1.3.4.11 Water

Water carries nutrients, regulates body temperature and is needed for digestion and removing waste. The reference total intake, including water from food and milk, is about 1.3 litres a day at 1 to 3 years and 1.7 litres at 4 to 8 years. Young children lose water quickly in hot weather and with diarrhoea or fever, and the water offered must be safe. Example: a child playing outside on a hot day is offered small cups of boiled and cooled water throughout the day.

Guidelines for the dietary assessment of water:

• Ask about drinks: record the amount of water, milk, juice, tea and other drinks, as well as the soups and fruits that supply water.
• Check the source: ask whether water is boiled or treated and stored in a covered container.
• Limit sweet drinks: juice and sugary drinks reduce appetite and add sugar, so water and milk are better choices.
• Watch for signs of dehydration: dry mouth, no tears, sunken eyes and passing little urine need prompt action.
• Increase fluids when ill: a child with fever or diarrhoea needs extra fluids.

Iodine in the young child's diet

Iodine is needed to make thyroid hormones that control growth and brain development. Iodised salt used in small amounts in cooking, fish and milk supply it, and a swelling at the front of the neck is a sign of deficiency. Dietary assessment asks whether the household uses iodised salt.

Chapter Summary

This chapter provides a comprehensive overview of young child nutrition, beginning with an explanation of their unique nutritional needs and the importance of adequate nutrition for growth and development. It details various methods for assessing these needs, including anthropometry, biochemical assessments, clinical monitoring, and dietary evaluations. The chapter then explores common nutrition-related complications in young children such as malnutrition, micronutrient deficiencies, overnutrition, food allergies, infections, developmental delays, and dental issues. It proceeds to outline the process of developing an effective nutrition intervention plan, covering different types of interventions like formula feeding, complementary feeding, supplementation, breastfeeding promotion, emergency nutrition strategies, and dehydration management. The implementation phase is discussed with steps and the necessary tools and resources for carrying out these interventions. Finally, the chapter emphasizes the importance of monitoring and evaluating nutrition interventions, describing the steps involved, tools used for tracking progress, indicators of success, and the challenges faced in ensuring effective nutritional outcomes for young children.