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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Page R8
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
×
Page R9
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Page R10
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Page R11
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance. Washington, DC: The National Academies Press. doi: 10.17226/25747.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance Kathryn Dewey and Meghan Harrison, Editors Committee on Scoping Existing Guidelines for Feeding Recommendations for Infants and Young Children Under Age 2 Food and Nutrition Board Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention (200-2011-38807/75D30120F00082), the Office of Dietary Supplements at the National Institutes of Health (HHSN263201800029I/75N98019F00857), and by the Kellogg Endowment Fund of the National Academies of Sciences, Engineering, and Medicine’s Health and Medicine Division. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25747 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Feeding infants and children from birth to 24 months: Summarizing existing guidance. Washington, DC: The National Academies Press. https://doi.org/10.17226/25747. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

COMMITTEE ON SCOPING EXISTING GUIDELINES FOR FEEDING RECOMMENDATIONS FOR INFANTS AND YOUNG CHILDREN UNDER AGE 2 KATHRYN DEWEY (Chair), Distinguished Professor Emerita, Department of Nutrition, University of California, Davis STEPHANIE A. ATKINSON, Professor, Pediatrics, McMaster University, Hamilton, Ontario, Canada SUSAN BAKER, Professor, Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo-SUNY, NY SARA BENJAMIN-NEELON, Associate Professor, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD LISA BODNAR, Professor, Department of Epidemiology, University of Pittsburgh, PA RONETTE BRIEFEL, Senior Fellow, Mathematica, Washington, DC FRANK GREER, Emeritus Professor of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI DEBRA HAIRE-JOSHU, Joyce Wood Professor of Public Health and Medicine, Director of Center for Diabetes Translation Research; Center for Obesity Prevention and Policy Research; and Brown School, Washington University in St. Louis, MO RAFAEL PEREZ-ESCAMILLA, Professor and Director, Office of Public Health Practice, Global Health Concentration, Yale School of Public Health, New Haven, CT CHARLENE RUSSELL-TUCKER, Deputy Commissioner, Connecticut State Department of Education, Hartford, CT ELIZABETH YAKES JIMENEZ, Research Associate Professor, Department of Pediatrics and Internal Medicine and College of Population Health, University of New Mexico Health Sciences Center, Albuquerque, NM Study Staff MEGHAN HARRISON, Study Director ALICE VOROSMARTI, Associate Program Officer ZARIA FYFFE, Senior Program Assistant REBECCA MORGAN, Senior Librarian ANN YAKTINE, Director, Food and Nutrition Board PREPUBLICATION COPY: UNCORRECTED PROOFS v

REVIEWERS This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: STEVEN ABRAMS, Dell Medical School at The University of Texas at Austin STEPHEN DANIELS, University of Colorado School of Medicine TANIS FENTON, University of Calgary VALERIE FLAHERMAN, University of California, San Francisco EDWARD FRONGILLO, University of South Carolina NANCY KREBS, University of Colorado Anschutz Medical Campus NATHAN NICKEL, University of Manitoba MYRA PARKER, University of Washington RUTH M. PARKER, Emory University School of Medicine SELENA A. RAMKEESOON, American University and DualStar LLC MADELEINE SIGMAN-GRANT, University of Nevada, Reno (retired) PATRICK STOVER, Agriculture and Life Sciences, Texas A&M AgriLife Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by DIANE BIRT, Iowa State University, and BARBARA ABRAMS, University of California, Berkeley. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

CONTENTS SUMMARY S-1 1 INTRODUCTION 1-1 Importance of Feeding Practices for Children Under 2 Years of Age Challenges of Understanding What and How to Feed Infants and Young Children Recent Efforts and Work on Feeding Guidance from Birth to 24 Months The Committee’s Task and Approach Organization of the Report 2 METHODOLOGY 2-1 Searches for Guideline Documents Eligibility Criteria Abstracted Information Identifying the Span of Topics Covered and Consistency of Recommendations Capturing Guidance on Communication and Dissemination Summary 3 CHARACTERISTICS OF INCLUDED GUIDELINE DOCUMENTS 3-1 Type of Guideline Documents Level of Collaboration Scope of Topics Covered Target Country or Region Target Audiences Guideline Document Methodologies Declaration of Conflicts of Interest Statements of Recommendation Evidence Mapping to Each Recommendation Inclusion of Guidance on Communication and Dissemination Inclusion of Research Recommendations Summary 4 EXISTING RECOMMENDATIONS ON WHAT TO FEED 4-1 Exclusive Breastfeeding Continuation of Breastfeeding Supplementary Formula Feeding of Breastfed Infants Duration of Infant Formula Use Type of Infant Formula Toddler Milks and Follow-On Formulas Milk and Milk-Based Products Fluids: Water, Juice, Sugar-Sweetened Beverages, and Other Nonmilk Beverages Substances to Avoid or Limit PREPUBLICATION COPY: UNCORRECTED PROOFS ix

Variety and Healthy, Nutritious Foods Fruits and Vegetables Vegetarian and Vegan Diets Foods Associated with Food Allergy and Celiac Disease Iron Vitamin D Iodine Other Nutritional Supplements Dietary Fat Summary 5 EXISTING RECOMMENDATIONS ON HOW TO FEED 5-1 Bottle Use and Propping Cup Use Safety of Foods and Feeding Practices Introduction of Complementary Foods Food Consistency and Texture Meal Frequency Hunger and Satiety Cues Responsive Feeding Summary 6 COMMUNICATION AND DISSEMINATION 6-1 Defining Terminology Identified Communication and Dissemination Strategies for Various Target Audiences Considerations for Communication and Dissemination Strategies Summary 7 CONCLUSIONS AND FUTURE DIRECTIONS 7-1 Consistency Among Existing Feeding Recommendations and Types of Evidence Used Harmonizing the Development of Future Feeding Guidelines Evidence Gaps Closing Remarks REFERENCES R-1 APPENDIXES A EXCLUDED GUIDELINE DOCUMENTS A-1 B ABSTRACTED RECOMMENDATIONS B-1 C COMMITTEE MEMBER BIOGRAPHICAL SKETCHES C-1 PREPUBLICATION COPY: UNCORRECTED PROOFS x

BOXES, FIGURES, AND TABLES BOXES 1-1 Statement of Task, 4-1 Committee’s Terminology Related to Consistency of Recommendations, 5-1 Committee’s Terminology Related to Consistency of Recommendations, 6-1 Definitions of Key Terms, 7-1 Examples of Inconsistencies Across Feeding Recommendations, 7-2 Steps for Incorporating Dissemination and Implementation (D&I) Science into the Guideline Development Process, FIGURES 2-1 Flow diagram of guideline document search and screening process, 2-2 Flow diagram of how the Food and Agriculture Organization of the United Nations catalog of national food-based guidelines was used to identify potentially relevant guideline documents, TABLES 2-1 Summary of Database Searches, 2-2 Guideline Document Eligibility Criteria, 2-3 Recommendation-Level Eligibility Criteria, 3-1 Characteristics of Included Guideline Documents, 4-1 Aspects of Dietary Variety or Diversity Mentioned in Recommendations from Eligible Guideline Documents, 4-2 Key Nutrients Included in Recommendations Related to Nutrient Adequacy of Vegetarian or Vegan Diets, 4-3 Summary of the Consistency of Recommendations on What to Feed Infants and Young Children, by Topic Area, 5-1 Examples of Specific Foods Identified as Potential Choking Hazards for Young Children in Abstracted Feeding Recommendations, 5-2 Summary of the Consistency of Recommendations on How to Feed Infants and Young Children, by Topic Area, 6-1 Summary of Eligible Guideline Documents That Included Information About Communication and Dissemination, PREPUBLICATION COPY: UNCORRECTED PROOFS xi

B-1 Recommendations Related to Exclusive Breastfeeding, B-2 Recommendations Related to Continuation of Breastfeeding, B-3 Recommendations Related to Supplementary Formula Feeding of Breastfed Infants, B-4 Recommendations Related to Duration of Infant Formula Use, B-5 Recommendations Related to Type of Infant Formula, B-6 Recommendations Related to Toddler Milks and Follow-On Formulas, B-7 Recommendations Related to Milk and Milk-Based Products, B-8 Recommendations Related to Fluids: Water, Juice, Sugar-Sweetened Beverages, and Other Nonmilk Beverages, B-9 Recommendations Related to Substances to Avoid or Limit, B-10 Recommendations Related to Variety and Healthy, Nutritious Foods, B-11 Recommendations Related to Fruits and Vegetables, B-12 Recommendations Related to Vegetarian and Vegan Diets, B-13 Recommendations Related to Foods Associated with Food Allergy and Celiac Disease, B-14 Recommendations Related to Iron and Iron-Fortified Formula, B-15 Recommendations Related to Vitamin D, B-16 Recommendations Related to Iodine, B-17 Recommendations Related to Supplementation, B-18 Recommendations Related to Dietary Fat, B-19 Recommendations Related to Bottle Use and Propping, B-20 Recommendations Related to Cup Use, B-21 Recommendations Related to Safety of Foods and Feeding Practices, B-22 Recommendations Related to Introduction of Complementary Foods (CFs), B-23 Recommendations Related to Food Consistency and Texture, B-24 Recommendations Related to Meal Frequency, B-25 Recommendations Related to Hunger and Satiety Cues, B-26 Recommendations Related to Responsive Feeding Practices, PREPUBLICATION COPY: UNCORRECTED PROOFS xii

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Recommendations for feeding infants and young children have changed substantially over time owing to scientific advances, cultural influences, societal trends, and other factors. At the same time, stronger approaches to reviewing and synthesizing scientific evidence have evolved, such that there are now established protocols for developing evidence-based health recommendations. However, not all authoritative bodies have used such approaches for developing infant feeding guidance, and for many feeding questions there is little or no sound evidence available to guide best practices, despite the fact that research on infant and young child feeding has expanded in recent decades. Summarizing the current landscape of feeding recommendations for infants and young children can reveal the level of consistency of existing guidance, shed light on the types of evidence that underpin each recommendation, and provide insight into the feasibility of harmonizing guidelines.

Feeding Infants and Children from Birth to 24 Months collects, compares, and summarizes existing recommendations on what and how to feed infants and young children from birth to 24 months of age. This report makes recommendations to stakeholders on strategies for communicating and disseminating feeding recommendations.

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