Chapter 4: Provide young child nutrition

Providing optimal nutrition to young children is a critical responsibility for Nutrition and Dietetics professionals in Kenya. The early years of life, particularly from birth to five years, represent a period of rapid growth and development that is highly sensitive to nutritional status. This chapter focuses on understanding the nutritional needs of young children, the importance of meeting these needs for their overall health, and the methods used to assess nutritional status effectively. Accurate assessment and tailored interventions can reduce the burden of malnutrition and support healthy development in Kenyan communities.

4.1 Nutritional needs for young child

A young child, in this chapter, is a child from the first birthday to the fifth. Growth is slower than in infancy but still steady, activity rises sharply as the child learns to walk, run and play, and the child moves from a diet built on breast milk and special foods to the foods the family eats. A dietitian must know what a child at this age needs, why it matters, and how to assess whether the child is getting it. Feeding of children between six and twelve months is taught in the chapter on infant nutrition, and this chapter continues from there.

4.1.1 Introduction to nutrition needs for young child

Nutrition needs for a young child are the amounts of energy, protein, fat, carbohydrate, vitamins, minerals and fluid that support growth, activity, immunity and brain development. They are small in total but large for body size. A young child has a stomach that holds little, so the food has to be rich in energy and nutrients and given often.

In Kenya, many young children eat the family's staple, such as ugali, rice or boiled bananas, which is low in protein, iron, zinc and vitamin A. Frequent infections such as diarrhoea and malaria add to the demand and reduce appetite. A dietitian therefore looks at the child's age, size, activity, health and diet together.

Why young children's needs differ from adults

Young children have a higher metabolic rate for their size, a small stomach capacity, rapid brain growth and a high need for protein, iron, zinc and calcium per kilogram. Their immune system is still developing, and they depend on adults to choose and prepare their food. For these reasons, an adult's portion or an adult's diet of the same kind is not suitable.

Feeding frequency and portions

Because of the small stomach, young children need frequent meals and snacks. For breastfed children aged 9 to 23 months, the World Health Organization advises three to four meals plus one or two nutritious snacks a day. A child of two years and older usually takes three meals and one or two snacks a day. Portions are small and grow with age: for a child of 12 to 23 months, three-quarters to one full cup of 250 mL is a typical amount for a meal.

Staple-heavy diets

Carbohydrate staples such as maize, rice and cassava give energy at low cost but are not enough on their own. Diets are improved by adding pulses, eggs, fish, milk, groundnut paste, vegetables and fruits, and a little oil, so that energy density and protein quality rise. This is a main task of dietitians who plan feeding for young children.

4.1.2 Importance of nutrition in young child

Nutrition in early childhood affects health, development and survival, and the effects reach into adult life. Proper feeding lowers illness and death among young children and gives them a good chance to grow and learn.

Supports physical growth

Adequate food lets a child reach his or her growth potential. Stunting, which is low height for age, results from long-term undernutrition and repeated infection and is linked with more frequent infection and delayed motor development.

Enhances cognitive development

Iron, iodine, zinc, essential fatty acids and adequate energy are needed for brain development. Undernutrition during the years of rapid brain growth can impair attention, language and learning, and these effects can limit a child's progress at school age and productivity as an adult.

Strengthens immune function

Adequate nutrition supports the body's defences, so well-nourished children have a lower risk of severe infections such as diarrhoea and pneumonia, and recover better when they fall ill. Poorly nourished children get sick more often and for longer.

Reduces risk of chronic diseases

Early nutrition affects how the body handles energy and blood pressure later in life. Promoting balanced diets in childhood helps reduce the risk of overweight, diabetes and high blood pressure.

Improves survival

The World Health Organization estimates that undernutrition is linked with about 45 per cent of deaths in children under five. Adequate feeding, together with treatment of illness, protects children from death.

4.1.3 Assessment of nutritional needs in young children

Assessing the nutritional needs of a young child means finding out whether the child is growing, healthy and eating adequately, and why not if the answer is no. A dietitian combines body measurements, laboratory tests, clinical signs and diet information. The mother or caregiver is the main source of information, so the dietitian uses open questions and explains each step.

Findings are recorded on the child health booklet and compared with the World Health Organization Child Growth Standards for children under five years.

4.1.3.1 Anthropometry

Anthropometry is measurement of the body to judge growth and nutritional status. It is done at each child health visit and when a child is unwell or has a feeding problem.

• Weight: taken with a scale that reads to the nearest 100 g, with the child in light clothing and no shoes.
• Length or height: length is measured lying down for children under two years, and height is measured standing for children of two years and older. If a child of two or more is measured lying, 0.7 cm is subtracted to give height, and if a child under two is measured standing, 0.7 cm is added to give length.
• Mid-upper arm circumference: measured on the left arm for children from 6 to 59 months. Below 11.5 cm is severe acute malnutrition, 11.5 to below 12.5 cm is moderate acute malnutrition, and 12.5 cm or more is normal.
• Bilateral pitting oedema: swelling of both feet that holds a pit when pressed for three seconds is a sign of severe acute malnutrition.
• Body mass index: weight in kg divided by height in metres squared, read against the World Health Organization body mass index for age chart.

The measurements are compared with the growth standards. Weight-for-age below minus 2 z-scores is underweight, height-for-age below minus 2 is stunting, and weight-for-height below minus 2 is wasting; below minus 3 is severe. Weight-for-age cannot tell stunting from wasting, so the other indices are used with it.

Worked example: a child aged three years weighs 14.5 kg and is 94.0 cm tall, which is 0.94 m. Body mass index is 14.5 ÷ (0.94 × 0.94) = 14.5 ÷ 0.8836 = 16.4 kg/m². The dietitian plots 16.4 on the chart for the child's sex and age and reads the z-score line from the chart.

4.1.3.2 Biochemical assessments

Biochemical assessments are laboratory tests on blood, urine or stool that measure nutrients or their effects. They confirm what the other methods suggest. They are requested by the clinician or by the dietitian within the facility protocol, and they are not routine for every child.

• Haemoglobin: the World Health Organization (2024) sets the anaemia cut-off at a haemoglobin below 10.5 g/dL at 6 to 23 months and below 11.0 g/dL at 24 to 59 months. At 6 to 23 months mild is 9.5 to 10.4, moderate 7.0 to 9.4 and severe below 7.0 g/dL. At 24 to 59 months mild is 10.0 to 10.9, moderate 7.0 to 9.9 and severe below 7.0 g/dL.
• Serum ferritin: shows iron stores, and is read with an infection marker because infection raises it.
• Serum retinol: a level below 0.70 micromoles per litre shows vitamin A deficiency.
• Blood glucose: checked with a glucometer in a sick or severely malnourished child.
• Stool and urine tests: look for worms, blood and infection.

Worked example: a child aged 30 months has a haemoglobin of 8.1 g/dL. This is below 11.0 and within the band of 7.0 to 9.9, so the child has moderate anaemia. The dietitian reviews the diet for iron, asks about worms and malaria, and sends the child to the clinician.

Blood sampling follows the facility's infection prevention protocol, with a new lancet for each child and disposal in a sharps container.

4.1.3.3 Clinical monitoring

Clinical monitoring is the examination of the child's body and behaviour for signs of poor nutrition and illness. The dietitian observes the child's alertness, activity, skin, hair, eyes, mouth, teeth, abdomen and legs, and checks development and immunisation.

The dietitian also checks milestones for the age, such as walking, speaking words and sentences, and playing with other children. Delay is referred to the clinician. A child who cannot drink, vomits everything, has convulsions or is unusually sleepy is a danger case and goes for urgent care.

4.1.3.4 Dietary assessments

Dietary assessment finds out what the child eats and drinks and how well this meets his or her needs. It uses information from the caregiver and, for the youngest, direct observation.

• 24-hour recall: the caregiver lists everything the child ate and drank in the last day and night, with amounts in household measures. It shows recent intake and not the usual diet.
• Food frequency questionnaire: how often the child eats listed foods in a week or a month. It shows the usual pattern of intake.
• Food diary: the caregiver records foods for several days.
• Observation: the dietitian watches a meal to see the amounts, textures and feeding behaviour.
• Feeding history: breastfeeding, age at which complementary foods began, use of milk and formula, appetite and any food refusals.

For children aged 6 to 23 months, the World Health Organization indicators of minimum dietary diversity (at least five of eight food groups) and minimum meal frequency can be used.

Worked example: a food frequency questionnaire for a 2-year-old shows milk daily, beans five times a week, eggs once a week and liver or meat not at all. The dietitian sees that iron-rich animal foods are rarely eaten, so the diet is likely to be low in absorbable iron and zinc.

The nutrients below are checked against reference intakes. The table gives the Dietary Reference Intakes of the Institute of Medicine of the United States and Canada for children aged 1 to 3 years, which are widely used in training. Where a national table is available, it is used at work.

4.1.3.4.1 Energy needs

Energy is needed for growth, activity, body warmth and body processes. A child of two years needs about 1,000 kcal a day, and the need rises with age, size and activity. Energy density of food matters as much as quantity, because the child's stomach is small.

The Institute of Medicine equation for children aged 13 to 35 months is (89 × weight in kg − 100) + 20 kcal a day.

Worked example: a child of 2 years weighs 12 kg. The energy need is 89 × 12 = 1,068, then 1,068 − 100 = 968, then 968 + 20 = 988 kcal a day. This is about 1,000 kcal, and the child's activity and illness may raise it.

Inadequate energy leads to weight loss and stunting. The dietitian checks meal frequency, portion size, the thickness of porridge, and whether oil, groundnut paste or milk is added.

4.1.3.4.2 Macronutrient needs

Macronutrients are protein, fat and carbohydrate. Protein builds tissue, and the reference intake is about 13 g a day at 1 to 3 years. Fat gives concentrated energy and supports brain development, and 30 to 40 per cent of energy should come from fat. Carbohydrate is the main energy source and the reference is 130 g a day.

Sources of protein are milk, eggs, fish, meat, beans, lentils, peas and groundnuts. Fat comes from oil, groundnut paste, milk, avocado and fish. Carbohydrate comes from ugali, rice, bananas, cassava, sweet potato and bread. The dietitian looks for a diet that is mostly staple with little protein or fat, and advises adding the missing ones. Low-fat diets are not suitable for young children.

4.1.3.4.3 Vitamin A

A child needs vitamin A to see in dim light, keep the skin and gut lining intact and fight infection. The reference intake at 1 to 3 years is 300 µg RAE a day. Sources include liver, egg yolk, whole milk, orange-fleshed sweet potato, pumpkin, carrots, mango, pawpaw, dark green leafy vegetables and fortified cooking oil.

Deficiency causes night blindness, dry eyes and increased risk of severe infection and death. In assessment, the dietitian asks how often vitamin A-rich foods are eaten, checks the child health booklet for vitamin A doses given at the clinic, and looks for eye signs.

4.1.3.4.4 Vitamin D

Strong bones in a growing child depend on vitamin D, which lets the gut absorb calcium. The skin makes it when exposed to sunlight, and small amounts come from oily fish, egg yolk and fortified foods. The reference intake at 1 to 3 years is 15 µg a day.

A child who is kept indoors, heavily covered, or lives with a limited diet is at risk of rickets. In assessment, the dietitian asks about outdoor play, clothing and diet, looks for bowing of the legs and widened wrists, and refers when signs are present. Supplements are prescribed by the clinician.

4.1.3.4.5 Vitamin C

Wound healing, firm gums and sound blood vessels rely on vitamin C, which also helps the body take up iron from plant foods. The reference intake at 1 to 3 years is 15 mg a day. Sources include guava, oranges, mango, pawpaw, tomatoes and fresh green leafy vegetables.

Vitamin C is lost with long cooking and storage, so fruit is eaten fresh when it is safe to do so and vegetables are cooked briefly. In assessment, the dietitian asks whether fruit or vegetables are eaten with iron-rich meals and looks for bleeding gums.

4.1.3.4.6 B vitamins

The B vitamins include thiamin, riboflavin, niacin, vitamin B6, folate and vitamin B12. They help release energy from food, support the nervous system and blood formation. Reference intakes at 1 to 3 years include thiamin 0.5 mg, riboflavin 0.5 mg, niacin 6 mg, vitamin B6 0.5 mg, folate 150 µg and vitamin B12 0.9 µg a day.

Whole grains, fortified flour, pulses, eggs, milk, fish and meat supply them. Folate comes from green leafy vegetables and pulses, and vitamin B12 comes from animal foods such as milk, eggs, fish and meat. Cracks at the mouth corners suggest riboflavin shortage, and pallor with a sore tongue may suggest folate or B12 deficiency. In assessment, the dietitian checks the variety of foods and the use of fortified flour.

4.1.3.4.7 Calcium

Bones and teeth are built from calcium, which also supports muscles and nerves. The reference intake at 1 to 3 years is 700 mg a day. Milk, yoghurt and fermented milk are good sources, and so are small fish eaten with bones, such as omena, and green leafy vegetables.

Children who take little milk or no fish with bones may fall short. A child who takes a great deal of milk may eat too little iron-rich food, so the dietitian checks the balance. Calcium needs vitamin D to be used well, so both are assessed together.

4.1.3.4.8 Iron

A child uses iron to make haemoglobin and to support the brain, and a shortage lowers learning ability and resistance to infection. The reference intake at 1 to 3 years is 7 mg a day. Iron from liver, meat, fish and eggs is absorbed better than iron from beans and green leafy vegetables, and vitamin C taken with the meal improves absorption from plant foods.

Tea and coffee reduce iron absorption, and large amounts of cow's milk displace iron-rich foods. Iron deficiency anaemia remains a public health problem in Kenya, and malaria and worms add to the loss. In assessment, the dietitian asks how often iron-rich foods are served, looks for pallor, and refers for a haemoglobin test.

4.1.3.4.9 Zinc

Zinc supports growth, immune function, appetite and wound healing. The reference intake at 1 to 3 years is 3 mg a day. Sources include meat, liver, eggs, fish, milk, groundnuts and pulses.

Plant foods contain phytates that reduce zinc absorption, so a diet based on plain cereals leaves a child at risk. Deficiency causes poor growth, frequent infections and prolonged diarrhoea. In assessment, the dietitian asks about animal-source foods, appetite and diarrhoea.

4.1.3.4.10 Fibre

Plant foods contain fibre, the part the body does not digest. It helps the bowel to work and may help prevent constipation. The reference intake at 1 to 3 years is 19 g a day.

Whole grains, pulses, vegetables and fruit, preferably with the skin when it is clean and soft, are sources. Too much fibre fills the stomach with bulk that has few nutrients and can reduce absorption of iron and zinc. In assessment, the dietitian asks about stool pattern and checks that the child is not filling up on bulky, watery foods.

4.1.3.4.11 Water

Water makes up much of the child's body and is needed for temperature control, digestion and removal of wastes. The total water reference at 1 to 3 years is 1.3 L a day from drinks and foods, of which about 0.9 L is from drinks, which is about four cups of 250 mL.

Clean, safe water is offered between meals, and in hot weather or illness the amount is increased. Sugary drinks, sodas and tea are not suitable as drinks for young children. Diarrhoea, vomiting and fever raise the risk of dehydration, which is treated with oral rehydration solution. In assessment, the dietitian asks about the type and amount of drinks and the safety of the water.

Socioeconomic and environmental factors

The child's nutrition also depends on the household. The dietitian asks about household food security, caregiver knowledge, who feeds the child, the family's income, and access to clean water, sanitation and health care. Addressing these factors is needed for lasting improvement in the child's nutrition.

Chapter Summary

This chapter explored the nutritional needs of young children, emphasizing the critical role of proper nutrition in supporting growth and development. It detailed various methods for assessing these needs, including anthropometric measurements, biochemical tests, clinical monitoring, and dietary evaluations. The chapter then examined common nutrition-related complications faced by young children, such as malnutrition, micronutrient deficiencies, overnutrition, food allergies, infections, developmental delays, and dental problems. Approaches to nutrition intervention were outlined, covering the development of tailored nutrition plans and different intervention types like formula feeding, complementary feeding, supplementation, breastfeeding promotion, emergency nutrition, and dehydration management. The process of carrying out nutrition interventions was described with attention to practical steps and necessary tools and resources. Finally, the chapter highlighted the importance of monitoring and evaluating nutrition interventions, discussing methods, indicators of success, and challenges encountered to ensure effective nutritional outcomes for young children.