Healthy From the Start—Lifestyle Interventions in Early Childhood

Introduction

Lifestyle medicine can change the trajectory of lives when lifestyle changes are implemented in early childhood starting from birth. The opportunity to enact positive lifestyle measures early can prevent chronic diseases leading to improved well-being and decreased future healthcare costs. As we seek to promote these changes, each of the six pillars of lifestyle medicine should be applied to the family’s life such that the child is automatically introduced to a healthy lifestyle. This includes high levels of healthy nutritious foods via a whole-food, plant-based (WFPB) or plant-predominant diet, daily physical activity, especially in the form of play, positive family and peer social connections, avoidance of risky substances for caregivers, optimal sleep habits, and stress management and mindfulness for all family members. These habits can be established from the start of life through the introduction of key concepts during clinical encounters, in schools, through community organizations, and in all places where a child spends time throughout each day. Advocacy becomes a key role for lifestyle medicine practitioners to encourage these changes to facilitate the seamless integration of lifestyle practices into children’s daily lives.

The six pillars of lifestyle medicine mentioned above deserve attention in the early years to provide the healthiest start for a lifetime of wellness.

Nutrition and Feeding Practices

One of the six pillars of lifestyle medicine is nutrition. Understanding the components of a WFPB diet for the family is important for its successful implementation in the early childhood years and can help support parents in providing an optimal diet for their children. Food is fuel and can provide children and their families with vital macronutrients and micronutrients. However, in the United States, children are currently deriving nearly 70% of their calories from ultra-processed foods. ¹ Many parents know that eating more whole foods, particularly vegetables and fruits, is a healthy goal, but many barriers exist to creating healthy eating habits in families. Chronic disease rates are rising in children, and many parents feel stressed and confused about what and how to feed their children.

As lifestyle medicine (LM) providers, we understand the importance of nutrition, but how do we equip our families with this information and help them incorporate behaviors that will lead to health-promoting habits?

We must first recognize that nutrition is vital in all stages of the life cycle. Maternal diet during pregnancy and breastfeeding will affect the health and food preferences of the baby. Better nutrition has been linked to improved health at all ages, less chronic disease, and improved longevity. One study found that the quality of a mother’s diet during pregnancy predicted diet quality of her offspring at age 14. ² Incredibly, fatty streaks have been detected in fetuses of mothers with high cholesterol. ³ But what is potentially even more powerful is that fetuses develop taste as early as 18 weeks’ gestation, ⁴ presenting an opportunity for mothers to create a long-lasting effect on the taste preferences of babies before they are even born. Although it is never too late to implement changes in behavior and create health-promoting habits, it is also never too early. Assisting pregnant mothers with adopting healthier diets has a strong and predictable impact on the future health of her child. The dietary habits that mothers maintain during pregnancy persist even after the baby is born and what mothers eat highly influences what the child will eat.

Breastfeeding confers the opportunity to influence a baby’s future taste preferences via the absorbed flavors present in breast milk. Mothers that eat a more diverse diet filled with a variety of vegetables and fruits have offspring that will be more receptive to these foods when they start eating solids. It is thought that these flavor experiences during breastfeeding may serve as a “bridge” to the introduction of complementary foods. Breast-fed babies are less likely to be picky eaters as they have already been exposed to a wide variety of flavors. ⁵

One study found that when it comes to predicting what foods children will eat, the length of nursing and whether their mother consumed those foods were among the 3 strongest predictors. The other predictor was whether the child liked the food. However, liking a food can only be influenced through exposure. ⁶

The introduction of complementary foods in babies can be seen as another opportunity to expose them to a variety of flavors. It can also encourage oral motor and fine motor development through the process of chewing and self-feeding, respectively; intake of key nutrients such as iron; and be a fun and pleasurable part of social development. Complementary foods should not be introduced until babies are developmentally ready. Signs of readiness include sitting up supported, seeming interested or reaching for food, and opening their mouth for a spoon. Although babies should not be offered complementary foods before 4 months of age, there is some evidence that introducing flavors to them between 4 and 7 months of age may provide benefits in the receptivity of flavors. ⁷ During this time frame, babies may be less likely to reject strong and bitter flavors and less exposures may be needed for food acceptance. Before 1 year of age, babies will acquire the majority of their calories from breast milk or formula. However, taking advantage of this time to offer diverse plant foods can be very beneficial. It can take upwards of 15 exposures to a food before a child will accept it and subsequently like it. ⁸ However, the younger a child is, the lower the number of exposures is needed to create a liking. Unfortunately, parents may decide quickly that a child does not like a food and stop offering it. Most parents stop after just 3 attempts at a particular food. The only way for any human to learn to like a food is through repeated and consistent exposure. What foods to offer babies at the beginning of their feeding journey might be just as important as what not to offer them. Added sugar, salt, and fried foods should be avoided.

What do we offer our children? Overall, our emphasis should be on whole plants: fruits, vegetables, whole grains, beans, and nuts and seeds. Many parents wonder whether an exclusively plant-based diet is safe or appropriate for children, and when planned well, a WFPB diet is appropriate. Choosing a plant-predominant diet is just as beneficial. It does not have to be all or nothing: there is plenty of room to add more plant-based whole foods to children’s diets at all ages.

Whole plant foods are beneficial and necessary because they provide an excellent source of fiber, phytonutrients, and antioxidants; are lower in calorie density; and contain less added sugar, salt, and additives. These components help support a healthy gut microbiome and lead to increased satiety which can help regulate appropriate calorie intake.

Fiber has many health advantages, but with children under 3 years of age, we should be cautious to balance low calorie-density foods such as raw vegetables and fruits with calorie-dense foods. Younger children especially should be offered foods such as nut and seed butters or avocado to ensure adequate calorie intake.

Children are often quite skilled at responding to their hunger and satiety and regulate their intake accordingly. However, parents fear that their children do not eat enough. Research studies have found that 85% of parents try to get their children to eat more at mealtimes. ⁹ Parents utilize different strategies to accomplish this, but with this strategy, they are encouraging a child to eat a greater quantity of food than the child desires or needs, leading children to consume less fruits and vegetables overall.

“Intuitive Eating” is a concept created by dietitians Evelyn Tribole and Elyse Resch in the early 90s. It is defined by ten principles and was intended to support people in taking a non-diet approach to eating. Among those ten principles is the idea that humans have the innate ability to recognize their hunger and satiety and can use this intrinsic feedback rather than rely on external measures to determine appropriate intake of food. ¹⁰ Understanding that children innately know how to regulate their intake is important to teach parents to prevent attempts to externally regulate their intake.

Another helpful concept to teach parents is Ellyn Satter’s Division of Responsibilities. ¹¹ In this concept, the parent and the child have different roles, or “jobs,” pertaining to feeding and eating. It is the job of the parent to decide what food is to be served, when it will be served, and where it will be served, and the child’s responsibility is then to determine if and how much they would like to eat. The parent does not impose upon the child’s autonomy but allows them free rein of their eating experience once the food has been served. This may be initially anxiety-provoking for parents, but over time, it decreases stress and anxiety at mealtimes.

A flexible feeding structure can complement these concepts. Having a flexible schedule for the timing of breakfast, lunch, dinner, and snacks can help reinforce these behaviors and reassure parents that their children are eating sufficient quantities of food. Most toddlers and preschoolers need to eat every 2–3 hours. Sitting down for these eating opportunities with minimal distractions can help children focus on the eating task as parents practice the Division of Responsibilities. Sharing family meals as often as possible also allows for parents to model healthy behaviors and has many other benefits for children and families.

Including children early in the growing, selecting, and preparation of food can also increase their intake of those foods. Letting babies and toddlers explore and play with their food, although messy, is a great way for them to fully experience the differences in flavors and textures. In addition, getting toddlers involved in the kitchen with safe tasks and tools gets them excited about food preparation. Taking children along for grocery shopping and letting them pick a fruit and vegetable they would like to taste is another strategy that can be integrated into the family routine. Growing a garden together can lead to the awe and fascination of watching plants grow. Even growing herbs on the windowsill can be exciting for young children. As children get older, they can help choose recipes and become even more involved in the kitchen.

It may seem complicated, but we can help parents see that feeding children can be a fun and joyful journey. In the process, parents often come to appreciate and be mindful of their own eating habits. As this occurs, the child and family can begin to focus on eating well with increased plant-based foods such as fruits and vegetables, minimally processed foods, whole grains, nuts, and spices leading to long-term health benefits for the entire family.

Sleep

Restorative sleep plays an important role in the mental and physical health of both parents and children in their early lives. The ability to create an environment for restorative sleep takes planning but can benefit everyone in the family. Healthy sleep patterns impact a child’s learning, development, attention, mood, behavior, and even metabolism. Children may be at risk for higher BMI if sleep is inadequate. ¹² Decreased total sleep and interrupted sleep can also negatively affect the physical and mental health of both parents. For example, sleep deprivation is associated with an increased risk of maternal postpartum depression particularly in women with pre-existing depression. ¹³

Sleep patterns can vary greatly in the first year, particularly in the first 4 months of life. Newborns split their sleep approximately 50/50 between day and night sleep with a general trend of decreasing daytime sleep as they age. According to the American Academy of Pediatrics, 4- to 12-month-olds require 12 to 16 hours of total sleep, 1- to 2-year-olds require 11–14 hours, and 3- to 5-year-olds need about 10 to 13 hrs.

Anticipatory guidance about sleep can serve as a mindset shift for parents who often approach early parenthood with an expectation of poor sleep. LM practitioners can prepare parents by teaching them sleep is a learned behavior and position them as their child’s teachers of good sleep habits. Three strategies may help parents establish consistent sleep habits: entraining the infant’s circadian rhythm, promoting self-soothing skills, and setting up family sleep routines.

Circadian rhythm becomes stable around 3–6 months of age. ¹⁴ Entraining circadian rhythms involves using daylight and darkness to establish sleep patterns. A bright daytime environment promotes wakefulness, while dim light and darkening the room will foster sleep at bedtime. ¹⁵

Teaching sleep to infants also can be done early by teaching self-calming techniques. Infants who are put to bed in a bassinet or crib when awake have a greater chance of learning to self-soothe than infants who are put to bed already asleep. Being attuned to their baby’s signs of sleepiness will help parents know when to put the baby in the crib. Signs of sleepiness may include less movement, becoming more quiet, glazed eyes, rubbing eyes, yawning, and fussing. Whereas self-calming may help infants gain independence in sleep initiation, infants who require parental assistance to fall asleep such as rocking tend to need parental assistance when they wake up in the middle of the night. ¹⁶ LM practitioners can encourage parents to put their baby to bed awake by reframing this process as allowing their baby to learn an important life skill. It can also help to set reasonable expectations since it may take time for a baby to learn this skill.

These strategies for promoting restorative sleep can begin in early infancy as opposed to formal sleep training with graduated extinction which may occur later in infancy. ¹⁷ LM practitioners can help and encourage parents to pursue whichever philosophy fits their parenting style best. Both styles are equally effective although some parents feel sleep training through graduated extinction is more stressful than sleep teaching through circadian rhythm entraining, teaching self-soothing, or even controlled crying. ¹⁸

Family sleep routines are additional habits which help parents and children sleep well. A consistent bedtime routine for everyone occurring at the same time each night is one tool parents can use for entraining a child’s (and their own) sleep pattern. Parent can focus on sleep in early infancy by ensuring caregivers can work as a team to divide overnight feeding responsibilities once breastfeeding is well established. This can serve to minimize interrupted sleep for all caregivers. As infants grow older, building good sleep habits may involve repetitive routines. One example of this is the concept of “Brush, Book, Bed” serves as a reminder to brush teeth, read a book, and go to bed and can be taught to reinforce a bedtime routine for children. ¹⁹ Another important habit is to make bedrooms a screen-free zone and to remind parents to turn off screens 1–2 hours before the desired bedtime as blue light exposure inhibits melatonin release which can affect a child getting to sleep at the desired time.

LM practitioners can support parents within the framework of their own parenting philosophies, helping troubleshoot challenges, and assisting with devising a sleep plan that supports sleep for the entire family unit while promoting sleep for their children and them.

Physical Activity

Physical activity benefits young children by increasing bone and muscle strength and contributing to brain development. It also plays a role in sleep quality, behavior, attention, and mood. Physical literacy competency (the movement skills children learn) predicts likelihood for future physical activity levels as an adult which impacts cardiovascular health and risk for obesity. ²⁰

Infants under 1 should be active several times a day with floor time. Their environment should be conducive to helping them roll, crawl, and walk. Children ages 1–4 should be active 60 minutes to several hours with unstructured play and at least 30 minutes being structured play led by an adult. During this age, they will be mastering basic gross motor skills such as walking, marching, galloping, hopping, running, moving around obstacles, and skipping. Children ages 5 and older should be active 60 minutes daily with moderate-to-vigorous exercise. This should include 3 days of vigorous activity, 3 days of bone-strengthening activity, and 3 days of muscle-strengthening activity. ²⁰ During this time, they will continue to build on their skills which will foster a sense of enjoyment and mastery of movement.

LM practitioners can support parents by addressing any barriers they may face in keeping children active. For time barriers, suggest playing “clean up,” having family dance parties, or going for family walks. For space barriers, brainstorm activities that can be done at home. For disinterest barriers, play pretend and make it fun in multiple short sessions throughout the day.

Another strategy that can be used is providing parents with a “playscription.” Play is an important way by which physical activity can be incorporated into daily lives. A playscription (Figure 1) offers an opportunity for the healthcare provider to make specific suggestions of how to add preferred activities into daily lives.

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Figure 1.

Sample playscription. Source: American College of Lifestyle Medicine (ACLM) pediatric and adolescent medicine interest group.

Stress Management

LM practitioners can begin the conversation of mindfulness in the first year of life. Babies are born mindful but may lose this ability over time from environments filled with constant stimuli such as that which comes from electronics. Playing with traditional toys as opposed to video toys has also been shown to improve language skills. ²¹

LM practitioners can impact a parent’s choice of entertainment for their child by counseling on the benefits of traditional play on development, creativity, and mindfulness. It can also be helpful to teach parents that there is a benefit to allowing children to be bored. Boredom builds imagination, creativity, and the ability to self-regulate. It is important to be sensitive to why a parent may choose to use screens and address their specific barriers.

Parents can teach self-regulation skills to toddlers and older children using the mnemonic “ABC.” A stands for awareness of emotions, B stands for breathing, and C stands for calming. The first step is to identify their feelings on an emotions chart. Consider placing a chart within the home or showing them through your own facial expressions how to name various emotions. This can help them identify emotions verbally which helps them to create a trained response to various emotions. For example, they can learn to do some simple breathing techniques when they identify the feeling of anger. Breathing skills to stay calm can be taught through blowing bubbles or a pinwheel or through breathing techniques such as 5-finger breathing ²² and square box breathing (Figure 2). ²³

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Figure 2.

Square box breathing.

Finally, children can learn to do a calming activity such as coloring, free play, or spending time in nature as a routine part of their day so that mindfulness becomes an ingrained habit. Older children can be taught the 5 senses grounding tool to promote mindfulness (Figure 3).

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Figure 3.

Five-sense grounding tool for mindfulness.

Setting up a “calm corner” at home with comforting toys, books, and stuffed animals for a child to go to when they are upset can additionally help with self-regulation. This is different from the traditional idea of a time-out corner as it encourages self-soothing and mindfulness.

Avoidance of Risky Substances

The impact of a caregiver’s own lifestyle choices on their infant is most pronounced when it comes to the realm of risky substance use. Substances such as alcohol, tobacco, and recreational drugs such as cannabis are well-known toxic substances for our bodies. From the prenatal stage and beyond, physical, mental, and behavioral problems are potential consequences of parental substance use. Counseling parents-to-be from the preconception phase is imperative to prepare them for crucial lifestyle changes such as abstaining from substance use or pledging to continue to live a drug-free life. Supporting parents’ efforts in sobriety is challenging; however, in the face of addiction, both motivation and readiness to quit at the individual level are needed to proceed. A strategic plan through collaboration between their healthcare provider, community, support groups, family, and friends is often needed along with close clinical follow-up to facilitate this change and encourage its maintenance. While the list of risky substances is long, we focus here on alcohol, tobacco, and cannabis.

Use of alcohol can inhibit a caregiver’s alertness and ability to be present and maintain normal executive function, potentially endangering the child’s life. As a central nervous system depressant, alcohol inhibits one’s natural reflexes and reduces the caregiver’s alertness. If a mother chooses to breastfeed, alcohol can directly impact the infant as it readily passes through the breast milk. Peak alcohol level in breast milk is approximately 30–60 minutes after ingestion, although it may be delayed by eating food. Short-term effects include sleep disturbances, increased crying, heightened startle reflex, and impaired mother–infant interactions. Studies show long-term effects include decreased motor function development, lower verbal IQ, and impaired growth. ²⁴ If a mother chooses to drink, then breastfeeding should happen prior to consumption. Caregivers dealing with alcohol addiction should speak to healthcare providers and acquire resources such as Alcoholics' Anonymous for support.

Environmental, or secondhand, tobacco smoke puts infants at risk for multiple preventable illnesses. There are over 5000 toxic compounds in tobacco smoke, including upwards of 70 carcinogens. While smoking during pregnancy has significant morbidity and mortality for the growing fetus including preterm birth, low birth weight, birth defects, and increased risk of sudden infant death syndrome (SIDS), the risk continues after birth by environmental exposure and through breast milk. Nicotine is present in breast milk at levels that are 3 times higher than that of maternal plasma and affects the infant’s heart rate variability. Breast milk volume may be reduced and lactation itself curtailed. ²⁵ Children exposed to tobacco smoke suffer from increased oxidative stress, more mucosal inflammation, and higher levels of inflammatory markers that places them at greater risk of both upper and lower respiratory illnesses, ear infections, and asthma, and allergic diseases. ²⁶ Caregivers must be encouraged to stop using nicotine-containing substances. Both nicotine replacement therapy (NRT) and non-nicotine replacement therapy (NNRT) are pharmacological options to facilitate tobacco cessation. Cognitive behavioral therapy with counseling is an important treatment adjunct to consider. E-cigarettes are not considered a safe alternative to smoking. While it is most important to have the mother, and partner if applicable, quit tobacco prior to pregnancy, the addictive nature of tobacco mandates LM practitioners to revisit this topic at each appointment and identify potential setbacks.

Cannabis use is prevalent in the US population as legalization and medicinal use of this drug in many states has made it more accessible and socially acceptable. Increasingly, women are using cannabis to self-medicate their symptoms of nausea during pregnancy. In utero exposure, however, has a negative impact on fetal growth and important infant safety reflexes such as the startle. ²⁷ The main psychoactive ingredient, Δ-9-tetrahydrocannabinol, or Δ9–THC, can cross the placenta to the fetus and in a newborn. In infancy and early childhood, executive function deficits may emerge related to memory, verbal reasoning, concentration, and attention. Normal developmental milestones may lag. Hyperactivity, impulsivity, and aggression are potential behavioral changes that may present. ²⁸ From a safety standpoint, caregivers that use cannabis risk cognitive impairment, mood disorders, and sleep disturbances that can impact their ability to care for their children.

Beyond alcohol, tobacco, and cannabis, caregivers should be mindful of safety with all drugs, including prescriptions. Prescriptions for opioids and anxiolytics are common and are of immediate risk to young children by accidental ingestion, secondarily by impact on caregiver’s health and behavior, and finally by example. From early years, children are influenced by the actions of their caregivers. Setting an example of a healthy lifestyle, and prudence and safety regarding medications is key to fostering healthy habits in youngsters. Resources available to caregivers and families to assist in quitting should be provided (Figure 4). ²⁹

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Figure 4.

Community resources for addiction services.

Importance of Positive Social Connections

The early years are an important time for infants and children to connect to other human beings including family and friends. With the pandemic in progress, social connections have been altered such that families are spending more time connecting through electronic means such as by cell phones or video chats. This is still a powerful way for young infants to begin to connect to the outside world and see and respond to facial expressions of others. As infants grow older, playgroups may be a good way to connect others. It is also important for young parents to have positive social connections to support them when they have questions or feel overwhelmed.

Conclusion

Through understanding of the six pillars of lifestyle medicine, families can begin to incorporate improved habits from the start. To assist LM practitioners in disseminating this information, the American College of Lifestyle Medicine (ACLM) Pediatric and Adolescent Medicine Interest Group has created a Healthy from the Start toolkit which offers various tools and resources to easily begin these important conversations early in interactions with families. These tools include handouts regarding Infant Food Introduction, How to Stay Healthy While Breastfeeding, Promoting Physical Activity in Young Children, a Playscription, Sleep in Young Children, Managing Stress in the Early Childhood Years, a Calm Space Handout, and a Family Guide to Avoiding Risky Substances. This may assist LM practitioners in delivering information to families. LM practitioners can also help instill health through advocating for all the lifestyle interventions in the environment of the child including in schools and the community. Such advocacy may include ensuring healthful meals at daycare and schools or encouraging ample opportunities for physical activity through building sidewalks and play areas in communities. Lifestyle changes must be feasible and practical to ensure they can be implemented.

Introducing lifestyle medicine in early infancy is crucial in the establishment of lifelong, healthy practices. Just as this conversation can only happen with the parents and family as a proxy for these youngest members of our society, successful change in fact begins with an understanding of family practices and the family’s stage of change. With motivational interviewing, we can meet families where they are at and provide both the information and support they need to move from precontemplation to eventual action. Specific information about the six pillars of lifestyle medicine and how to incorporate change intentionally, albeit in small steps, will set up families for lifelong success in establishing a healthy lifestyle for babies and all members of the family unit.