How Much Milk Is Too Much?

A Case Study of an Obese Toddler

Barbara Gray, PhD, RN, CPNP; Maria C. Reyes, MS, FNP-C, APRN; Lori L. Conners, RN, BSN; Jo Ann Serota, DNP, RN, CPNP; Beverly Giordano, MS, RN, ARNP, PMHS; Donna Hallas, PhD, PNP-BC, CPNP


J Pediatr Health Care. 2013;27(2):148-154. 

In This Article

Case Study Answers

1. How is Overweight and Obesity Assessed in Children?

The terms "overweight" and "obese" have been used interchangeably and ambiguously defined. One definition of overweight is measurement of body weight over a weight standard as compared with obesity, which is the measurement of body fat over a body fat standard (Flegal & Ogden, 2011). In recent years, the calculation of BMI has become the standard for the assessment of overweight and obesity for adults and children over the age of two years. BMI is measured in a weight for height ratio that has a strong correlation with body fat percentage (Flegal & Ogden, 2011; Krebs et al., 2007).

The American Academy of Pediatrics (AAP) Expert Committee (Barlow & Expert Committee, 2007) defines overweight as having a BMI for age and gender between the 85th and 94th percentiles. The term "obese" applies to children and adolescents having a BMI at or above the 95th percentile for age and gender (Barlow & Expert Committee, 2007). It is recommended that BMI measurement be assessed at least annually beginning at 2 years of age and every 3 to 6 months if the child meets the criteria for overweight or obesity (The National Initiative for Children's Healthcare Quality [NIHCQ], 2007). The child in this case study has a BMI of 22.1, placing him above the 95th percentile and in the "obese" category.

Assessment of the overweight and obese child includes a thorough medical history to elicit any health problems, a family history, dietary and physical activity assessment (Krebs et al., 2007). Particular attention should be focused on the amounts and types of foods consumed, as well as family behaviors and practices that can contribute to an unhealthy life style, leading to obesity. For example, in this case study, the child is still drinking from a baby bottle throughout the day and at night at the age of two years, eating foods with low nutritional value, and has little opportunity for physical activity and exercise. Additionally, there is a positive family history of type 2 diabetes and hypertension.

A thorough physical examination should be conducted, including assessment of pulse and blood pressure, skin assessment for acanthosis nigricans which can occur with insulin resistance, and assessment for hepatomegaly, which is associated with fatty liver disease (Rao, 2008). Signs of other diseases known to be associated with obesity should be noted, such as striae (Cushing's syndrome), and coarse dry skin, slowing of linear growth, and constipation (thyroid disease; Krebs et al., 2007). Interestingly, one study found that obesity in children may change the structure and function of the thyroid gland resulting in a lowered metabolism and weight gain (Radetti et al., 2008). This concept of obesity causing thyroid problems rather than thyroid dysfunction causing obesity supports a different physiological mechanism for overweight and requires further research.

Laboratory screening tests in the assessment of obese children may include fasting glucose, insulin and lipid profile, hemoglobin A1C, complete blood count, and comprehensive metabolic panel. Other laboratory tests would be considered if the history and physical exam indicated another health problem, such as thyroid tests if there were a concern about thyroid disease (Krebs et al., 2007; Rao, 2008).

2. What are Some Risk Factors that Can Lead to Obesity in Children?

A number of risk factors clearly put children at risk for overweight and obesity, including genetics, race, ethnicity, culture, and socioeconomic status. Childhood obesity exists among all races and ethnic groups, but occurs more frequently in non-White populations (Caprio et al., 2008). Hispanics, Native Americans, and African Americans are disproportionally represented in children with obesity, and consequently also in the development of type 2 diabetes (Caprio). Obesity is more common in children of lower socioeconomic status than those who live in families with higher income levels; however, most obese children are not classified as low income (Centers for Disease Control and Prevention [CDC], 2010). One study of low-income Hispanic children found that although their typical diet may contain the most essential nutrients, it did not meet the U.S. dietary guidelines for cholesterol, fat, added sugar, fiber, and sodium, putting them at risk for obesity and long-term health complications (Wilson, Adolf, & Butte, 2009). Clearly, the child in this case study did not eat a nutritious diet, with a large amount of complex carbohydrates, fats, and increased portions sizes and calories.

Cultural beliefs may contribute to obesity; research has shown that Latina mothers hold different beliefs and perceptions about their children's weight than health care practitioners, rejecting the label of overweight, and may prefer a heavier weight for their children (Berkowitz & Borchard, 2009). One study noted that minority mothers of children enrolled in Head Start Centers perceived their children to be thinner than their actual body size (Killion, Hughes, Wendt, & Nicklas, 2006).

A child who has an overweight parent is more likely to be overweight (Binns & Ariza, 2004). Obese mothers tend to have large-for-gestational-age infants, and are less likely to breastfeed their infants or to continue breastfeeding once initiated when compared with mothers who are not obese (Rasmussen & Kjolhede, 2007). Breastfed infants tend to gain weight more slowly than formula-fed infants, and prolonged bottle use has been associated with obesity in early childhood (Gooze, Anderson, & Whitaker, 2011; Spiotta & Luma, 2008). Infants who experience rapid weight gain in the first year of life are at higher risk for overweight and obesity as toddlers and preschoolers (Goodell, Wakefield, & Ferris, 2009).

Lack of physical activity is a known risk factor for childhood obesity (CDC, 2011). Sedentary behaviors, such as television viewing, have been related to overweight and obesity in children (Jordan, 2010). One factor that influences whether or not children will get activity and eat nutritionally sound foods is referred to as the "built environment," or the spaces that occupy the lives of children and their families (Razani, 2010). Is there access to parks and community centers where children can run and play? Is it safe to get to there? Are there grocery stores in the neighborhood, and do they have healthy and affordable food choices?

Biologic factors may affect one's susceptibility to obesity. Leptin is a hormone produced by adipose tissues that normally serves to control satiety. It appears to trigger signals in the ventromedial hypothalamus and the sympathetic nervous system to reduce energy intake and increase energy expenditure (Lustig, 2006). Insufficient leptin, whether resulting from low levels as occurs in starvation or leptin resistance as occurs in obesity, stimulates food seeking and promotes reduced energy use, thereby contributing to the body's inability to register satiety and subsequent overeating (Crocker & Yanovski, 2011; Lustig, 2006).

The obese individual may be resistant to leptin, so the normal processes of stimulating the sympathetic nervous system do not occur, even though there is a high level of leptin in the blood. Instead, the body believes itself to be in a perpetual state of starvation, spontaneous activity decreases, and calories are used more sparingly (Lusting, 2006). The result is further storage of energy in the form of adipose tissue, so the obese individual will gain more weight even if an effort is made to reduce caloric intake (Lustig, 2006).

Chronic hyperinsulinemia may be the source of this leptin resistance. Insulin and leptin share the same "signaling cascade" in the hypothalamus; therefore, if insulin levels are high, leptin is prevented from signaling its message that the body has adequate energy stores (Lustig, 2006, p. 902). Hyperinsulinemia in children may be due to genetics and environmental factors. Increased stress leads to increased cortisol production, which can lead to insulin resistance. A decrease in physical activity contributes to insulin resistance, and a diet with high levels of fructose and decreased fiber leads to excess insulin secretion. Restoring the body's leptin feedback system to its normal function is a key to increasing energy expenditure and reducing weight (Cornier, 2011). This can be done by decreasing insulin production through diet change and increased exercise (Lusting, 2006).

3. What Role Does Self-regulation Play in Childhood Obesity?

Feeding behaviors may increase a child's risk to become obese. A developmental characteristic of infancy is that of self-regulation for food intake (Vaughn & Waldrop, 2007). Children who are able to self-regulate while eating can follow their cues of hunger or feeling satisfied or full. These children are less likely to be overweight than those children who cannot self-regulate (Tan & Holub, 2010). Parents who do not respond to their children's feeding cues and exhibit controlling feeding practices can interfere with their child's ability to self-regulate (Gross et al., 2010; Vaughn & Waldrop, 2007). An example of a controlling feeding practice is pressuring the child to eat more, even when an infant is pushing the bottle away, or offering rewards to encourage a child to eat when it is obvious that the child is not hungry (Gross et al., 2010).

Toddlers develop the ability to feed themselves while they are learning feeding behaviors that are expected of them by their family and society (Allen & Myers, 2006). Self-feeding is important because it will help the child develop fine motor skills and will assist them in self-regulating their food intake. Toddlers tend to eat on demand and require snacks during the day; these snacks should be healthy, rather than high-calorie foods that are quickly absorbed, such as juices or juice drinks with sugar (Allen & Myers, 2006).

4. What is the Recommended Dietary Intake for Young Children?

How much milk is too much? The toddler in this case study was drinking one gallon of whole milk per day. The American Heart Association ([AHA], 2011) recommends that children from 1 to 3 years get 2 cups of milk or dairy products per day. Milk is an important source of protein, calcium, and vitamins A and D; however, milk is low in iron content and the iron that is present is not well absorbed (Allen & Myers, 2006; Kazal, 2002). Additionally, a high milk intake interferes with the absorption of iron from other foods and increases the risk of iron deficiency anemia (Kazal, 2002).

Research has found that children who have a higher milk intake have higher BMI measurements than those with a lower milk intake (Wiley, 2010). Dietary recommendations for milk intake in toddlers have traditionally included whole milk until the age of two years, when a transition can be made to reduced fat milk. However, the AAP noted in 2008 that it is appropriate to use reduced fat milk in children between the ages of 12 months and 2 years if there is a concern about overweight and obesity or if there is a family history of obesity, dyslipidemia, and cardiovascular disease (Daniels, Greer, and the Committee on Nutrition, 2008).

The AHA recommends that children get a variety of fruits and vegetables each day, and juice should be limited (AHA, 2011). Toddlers need 1.5 to 2 ounces of lean meat/beans per day and 2 to 3 ounces of grains (the smaller amount for 1-year-olds and the larger amount for 2- to 3-year-olds), half of which should be whole grains. The recommended amount of fruit per day is 1 cup, and three-quarter cup to 1 cup of vegetables per day; a serving size is one-quarter cup for a 1-year-old, and one-third cup for children ages 2 to 3 years (AHA, 2011).

The U.S. Department of Agriculture (USDA) recently introduced a new system to help parents determine the types and amounts of healthy foods to serve their children beginning at 2 years of age (USDA, 2011). MyPlate has replaced the Food Guide Pyramid that had been used for many years. MyPlate uses a visual representation of a dinner plate divided into colorful sections for fruits, vegetables, grains, and protein (USDA, 2011). Specific serving sizes on the plate are not addressed on the diagram, but it is easy to see that fruits and vegetables should fill half of the child's plate. The goal is for parents to use the plate as a guide when planning and serving meals so that children get a variety of food groups at each meal (The Nemours Foundation/Kid's Health, 2011; USDA, 2011).

Health care providers should help caregivers understand that they are responsible for providing nutritious foods to their children. Children will eat the foods available to them; if they do not have access to foods with low nutritional value they will not eat those foods. Parents may express concern that their child is a "picky eater" or will only eat two or three foods to the exclusion of all others. These "food jags" are common in young children and usually disappear as they get older. Generally, children tend to balance their food intake and energy expenditure over a period of time (Hagan, Shaw, & Duncan, 2008). Parents should be encouraged to be patient and continue to offer a variety of nutritious foods.

5. What are Some Treatment and Evidence-based Interventions that Can be Used for Obese Children and Their Families?

The best approach to childhood obesity is to prevent it in the first place, as treatment for children who are already obese is challenging and can be difficult (McTernan & Meiri, 2011). Research has shown, however, that caregivers are receptive to measures that can help change problem behaviors contributing to obesity (Hesketh & Campbell, 2010). Patterns of eating, physical activity, and sleep develop during early childhood, so it is important to create healthy environments at this time in order to promote healthy development and decrease the risk of obesity (Institute of Medicine [IOM], 2011; McTernan & Meiri, 2011).

For those children who are already overweight and obese, a staged management approach is recommended (Barlow & the Expert Committee, 2007). The first stage of this approach, Prevention Plus, is focused on a variety of areas, such as careful tracking of growth during childhood, promoting healthy eating, increasing physical activity, limiting screen time, and promoting healthy sleep patterns (IOM, 2011; NICHQ, 2007; Seal & Broome, 2011).

Healthy eating consists of such measures as consuming the recommended dietary intake for fruits and vegetables and significantly decreasing (or preferably eliminating) sugary drinks (Barlow & Expert Committee, 2007). One way to promote healthy eating for the child in this case study is to provide guidance for removing the infant feeding bottles that are inappropriate for a child of his age. Strategies such as offering water rather than milk, trying different types of cups, and developing a special nighttime routine focused on activities other than drinking from a bottle (bedtime bath, reading a book, playing with a special toy) can be planned with parents to help them achieve the goal of discontinuing the bottle. Guidance should also be provided on dealing with children's behavior issues such as temper tantrums, which may occur during this time of frustration for the toddler.

The toddler in this case study was mostly sedentary and the parents needed guidance about ways to increase physical activity. Opportunities should be provided for physical activity for at least 15 minutes per hour (IOM, 2011). Children this age should have playtime with other children, and have appropriate structured and unstructured play activities (IOM, 2011). Preschools and other childcare settings can utilize such strategies as increasing outdoor free-play time, teaching about healthy foods, and scheduling daily activity sessions that consist of warm-up activities, jumping, hopping, skipping, and cool-down activities (McTernan & Meiri, 2011). The IOM recommends provision of a safe outdoor environment with some shade and natural elements.

Children are bombarded by all forms of media–television, digital media, electronic and video games, and the Internet. The IOM (2011) and the AAP (2001) recommends that screen time be limited. Children from 2 to 5 years of age should have no more than 2 hours of screen time per day, including television or digital media for because of its potential for contributing to childhood obesity (IOM, 2011). Additionally, there should be no screen media in rooms where children sleep in order to promote a restful sleeping environment (IOM).

Progression to the second stage, Structured Weight Management, is indicated when there is a need for more structure in the plan to help children achieve more normal, healthy weights (Barlow & Expert Committee, 2007; NICHQ, 2007). The same aspects of stage one are addressed, but an additional measure utilized is close follow-up by a health care professional who has had training in weight management and behavioral counseling. Motivational interviewing is one tool that may be helpful in counseling a family with an obese child (NICHQ, 2007). This is an interviewing style in which a rapport is developed between the health care provider and the patient or family that will facilitate movement toward healthy outcomes (Shinitzky & Kub, 2001).

The remaining stages, Comprehensive Multidisciplinary Intervention and Tertiary Care Intervention, require interventions beyond the scope of a typical general pediatric primary care setting (Barlow & Expert Committee, 2007). At these levels of treatment, specialists are utilized to provide an intensely structured program to address nutrition, activity, and behavioral modification.