4

Existing Recommendations on What to Feed

This chapter reviews the recommendations related to what to feed infants and young children that were included in the guideline documents that met the committee’s inclusion criteria (see Chapter 2). Numerous topics related to what to feed infants and young children did not appear in the eligible guideline documents. Thus, although this chapter is a comprehensive summary of the identified recommendations, it is not an exhaustive summary of all topics that are of interest to various stakeholders. Eligible recommendations were found in all 43 guideline documents. The recommendations have been grouped into 18 topic areas; within those topic areas, recommendations are discussed thematically. Throughout this chapter, the following terminology is used:

• Organization refers to the agency, organization, or group that directly participated in the guideline development. Throughout, there is reference to different organizations, which refers to the number of unique entities that participated in one or multiple guideline documents.
• Guideline document refers to the overall resource (e.g., journal article, report, webpage) from the organization that contains the recommendation(s).
• Recommendation refers to a statement on one or multiple topic areas that the committee abstracted from the guideline documents. Each abstracted recommendation is provided in Appendix B.
• Consistency refers to the committee’s comparison of existing recommendations on a given theme. Box 4-1 presents the terminology the committee uses throughout this chapter to describe the levels of consistency.

EXCLUSIVE BREASTFEEDING

Fifteen guideline documents included recommendations related to exclusive breastfeeding (see Appendix B, Table B-1). Four of the guideline documents were collaborative efforts between two or more organizations (Health Canada et al., 2015; New Zealand Dental Association, 2008; PAHO/WHO, 2003; SACN and COT, 2018). The identified guideline documents reflect 17 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with the Pan American Health Organization (PAHO) and the World Health Organization (WHO).¹

Defining What Constitutes Exclusive

The identified recommendations largely did not define or specify what constituted exclusive breastfeeding. One recommendation stated “most babies only need breast milk (or formula)” (Pérez-Escamilla et al., 2017 [RWJF-HER]). Some of the guideline documents included additional recommendations advising against routine supplementary formula feedings among breastfed infants or providing any other liquids (AAFP, 2014; NHMRC, 2012; RCPCH, 2019) (for additional information, see the “Supplementary Formula Feeding of Breastfed Infants” section below and Appendix B, Table B-3). The committee notes that definitions of exclusivity may have been included in the narrative text of the guideline documents, rather than the statements of recommendation.

Duration of Exclusive Breastfeeding

Fifteen guideline documents included recommendations related to duration of exclusive breastfeeding. Thirteen of the guideline documents recommended exclusive breastfeeding for the first 6 months of age. There was slight variation in the specific wording, using phrases such as “for about 6 months,” “around 6 months,” “up to 6 months,” or “the first 6 months.” One guideline document from the Robert Wood Johnson Foundation-Healthy Eating Research (RWJF-HER) stated that the recommendation was “[f]or the first 6 months (or until the introduction of solid food) most babies only need breast milk (or formula),” clarifying that the breastfeeding recommendation was tied to the complementary feeding recommendation (Pérez-Escamilla et al., 2017). Two guideline documents included recom-

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¹ Organizations reflected in the guideline documents include AAFP, AAP, AHA, Breastfeeding Committee for Canada, COT, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, PAHO, RCPCH, RWJF-HER, SACN, and WHO.

mendations that specified an age range. One guideline document from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommended “exclusive or full breastfeeding … for at least 4 months (17 weeks, beginning of the 5th month of life) and exclusive or predominant breastfeeding for approximately 6 months is considered a desirable goal” (Fewtrell et al., 2017). The other guideline document, from the American Heart Association (AHA), recommended “Maintain breastfeeding as the exclusive source of nutrition for the first 4–6 months of life” (Gidding et al., 2005).

Consistency

The guideline documents were generally consistent in recommending exclusive breastfeeding for up to, about, or around 6 months of age. However, two recommended 4–6 months, one of which emphasized aiming for 6 months.

Evidence Base

Across the 15 guideline documents, the committee identified 16 statements of recommendation. A guideline document from the Australian government (NHMRC, 2012) included two statements of recommendation related to exclusive breastfeeding, pertaining to different contexts; one of the recommendations mapped to a systematic review, whereas the other mapped to previous Australian guidelines. A recommendation from the American Academy of Family Physicians (AAFP) (2014) mapped to a systematic review. One recommendation from an ESPGHAN guideline document (Fewtrell et al., 2017) mapped to a systematic literature search. The recommendations from the Scientific Advisory Committee on Nutrition (SACN) and the Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment (COT) (2018) and the New Zealand Dental Association (2008) mapped to earlier documents from their organization or other authoritative organizations. Portions of one recommendation from the American Academy of Pediatrics (AAP) (AAP Section on Breastfeeding, 2012) were based on a narrative review, and the rest of the recommendation could not be mapped to its evidence. The rest of the recommendations mapped to narrative reviews and/or technical documents.

CONTINUATION OF BREASTFEEDING

Eighteen guideline documents included recommendations on the continuation of breastfeeding (see Appendix B, Table B-2). Four of the guideline documents were collaborative efforts between two or more organizations

(AAPD, 2016; Health Canada et al., 2014; New Zealand Dental Association, 2008; PAHO/WHO, 2003). The identified guideline documents reflect 18 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with PAHO and WHO.²

How Long Breastfeeding Should Continue

Eighteen guideline documents included recommendations related to how long breastfeeding should continue. Fourteen guideline documents recommended continued breastfeeding to at least 12 months of age. Four guideline documents recommended continued breastfeeding to at least 2 years of age (Abrams et al., 2019 [CPS]; Grueger et al., 2013 [CPS]; Health Canada et al., 2014; PAHO/WHO, 2003). Frequently these recommendations included supportive statements of longer durations (e.g., “at least to [age],” “or beyond”) and qualifiers (e.g., “as long as mutually desired,” “as long as the mother and child desire”). Three guideline documents did not specify a specific duration (AAPD, 2016; Fewtrell et al., 2017 [ESPGHAN]; NICE, 2008). One other document recommended breastfeeding beyond 6 months of age and stated that “mothers should be supported to continue breastfeeding for as long as they wish,” but it cited a lack of evidence to support a specific duration of breastfeeding (RCPCH, 2019). Date of publication of the guideline document did not appear to be related to whether the recommended continuation of breastfeeding was to 12 months or 2 years of age.

Four guideline documents related continuation of breastfeeding to benefits. One guideline document, from the Australian government, recommended breastfeeding for the first 6–12 months and beyond, but also stated, “any breastfeeding is beneficial to the infant and the mother” (NHMRC, 2012).³ Similarly, a guideline document from SACN (2018) noted that exclusive breastfeeding for the first 6 months and continuation for at least the first year “makes an important contribution to infant and maternal health.” A guideline document from AAFP that recommended continuing breastfeeding through at least the first year stated, “Health outcomes for mothers and babies are best when breastfeeding continues for at least 2 years” (AAFP, 2014). A guideline document from the American Academy of Pediatric Dentistry (AAPD) (2017) noted that breastfeeding for the first

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² Organizations reflected in the guideline documents include AAFP, AAP, AAPD, AHA, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, NICE, PAHO, RCPCH, RWJF-HER, SACN, and WHO.

³NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).

12 months of life “ensure[s] the best possible health and developmental and psychosocial outcomes for infant.”

Five documents explicitly recommended that breastfeeding continue during the introduction and feeding of complementary foods (AAFP, 2014; Fewtrell et al., 2017 [ESPGHAN]), solid foods (NHMRC, 2012; RCPCH, 2019), or dietary carbohydrates (AAPD, 2016). Among these, one stated continuing breastfeeding “until 12 months of age and beyond” (NHMRC, 2012),⁴ one stated “through at least the first year” (AAFP, 2014), one stated “beyond 6 months” (RCPCH, 2019), and two did not specify an age (AAPD, 2016; Fewtrell et al., 2017 [ESPGHAN]).

Consistency

The guideline documents were generally consistent in promoting and supporting continued breastfeeding after complementary foods were introduced and until at least 12 months of age, but they were not consistent in terms of the specific age to which breastfeeding should be continued.

Evidence Base

Across the 18 guideline documents, the committee identified 23 statements of recommendation. One of the recommendations that did not specify an age mapped to a systematic literature search (Fewtrell et al., 2017 [ESPGHAN]). A portion of one recommendation from AAP (AAP Section on Breastfeeding, 2012) mapped to a narrative review, and the rest of the recommendation could not be mapped to its evidence. A recommendation from the National Institute for Health and Care Excellence (NICE) (2008) mapped to both a UK Department of Health report (Department of Health, 1994) and a rapid review.⁵ Six recommendations from guideline documents by AAFP (2014), AAPD (2017), the Australian government (NHMRC, 2012), and the New Zealand Dental Association (2008) mapped to earlier documents from the issuing organization or other authoritative organizations. One recommendation from ESPGHAN (Hojsak et al., 2018) could not be mapped to its evidence. The remaining recommendations mapped to narrative reviews and/or technical documents, alone or in combination with other resources.

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⁴NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).

⁵ A rapid review is a literature review process that has simplified or omitted some of the components of the systematic review process. A rapid review has been described as a “streamlined approach to synthesizing evidence—typically for informing emergent decisions faced by decision makers in health care settings” (Khangura et al., 2012).

SUPPLEMENTARY FORMULA FEEDING OF BREASTFED INFANTS

Four guideline documents included recommendations related to supplementary formula feeding of breastfed infants (see Appendix B, Table B-3). The identified guideline documents reflect four different organizations from Australia, New Zealand, the United Kingdom, and the United States.⁶

Routine Supplementary Formula Feedings

Four guideline documents included recommendations related to supplementary formula feedings. All discouraged routine supplementary formula feeding of breastfed infants (AAFP, 2014; Ministry of Health, 2012; NHMRC, 2012; RCPCH, 2019). Medical indication or advice was suggested as the basis for introduction of infant formula to breastfed infants (AAFP, 2014; NHMRC, 2012). One of the recommendations discouraged giving other liquids, in addition to infant formula, to breastfed infants (Ministry of Health, 2012); this topic is explored in greater detail in other sections of this chapter (see “Milk and Milk-Based Products” and “Fluids: Water, Juice, Sugar-Sweetened Beverages, and Other Nonmilk Beverages”).

Consistency

The guideline documents were consistent in recommending that breastfed infants should not be routinely given supplementary formula feedings.

Evidence Base

Across the four guideline documents, the committee identified four statements of recommendation. One recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review. Two recommendations—one each from the New Zealand Ministry of Health (2012) and the Royal College of Paediatrics and Child Health (RCPCH) (2019)—mapped to narrative reviews. One recommendation from AAFP (2014) mapped to a WHO/UNICEF document.

DURATION OF INFANT FORMULA USE

Five guideline documents provided recommendations related to the duration of formula use for infants or young children who are formula fed (see Appendix B, Table B-4). One of the guideline documents was a collab-

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⁶ Organizations reflected in the guideline documents include AAFP, New Zealand Ministry of Health, NHMRC, and RCPCH.

orative effort among four organizations (Health Canada et al., 2014); one of the collaborating organizations (Canadian Paediatric Society [CPS]) also had its own guidelines that included a separate recommendation related to duration of formula use. The identified guideline documents reflect seven different organizations from Australia, Canada, New Zealand, and the United States.⁷

How Long Infant Formula Should Be Used

Five guideline documents included recommendations related to how long infant formula should be used. Four of the guideline documents recommended that, for formula-fed infants, commercial infant formula should be used until 12 months of age (Ministry of Health, 2012; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]; Unger et al., 2019 [CPS]). One guideline document recommended “commercial infant formula until nine to 12 months of age” (Health Canada et al., 2014).⁸ Two documents explicitly stated that formulas are not needed beyond 12 months of age (Health Canada et al., 2014; Unger et al., 2019 [CPS]). One guideline document from the New Zealand Ministry of Health (Ministry of Health, 2012) recommended that vegan infants who are partially breastfed or not breastfed use “a commercial soy-based infant formula during the first 2 years of life”; recommendations related to vegetarian and vegan diets are explored in detail later in this chapter (see “Vegetarian and Vegan Diets”).

Consistency

The guideline documents were generally consistent in recommending that, for formula-fed infants, commercial infant formula should be used until 12 months of age, and infant formula is not needed beyond 12 months of age. Only one of the guideline documents indicated an age range, indicating that infant formula should be used until 9–12 months of age (Health Canada et al., 2014). The recommendation on formula use for 9–12 months is internally consistent with another recommendation in that document to delay cow milk until 9–12 months to reduce iron deficiency (Health Canada et al., 2014).

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⁷ Organizations reflected in the guideline documents include Breastfeeding Committee for Canada, CPS, Dietitians of Canada, Health Canada, New Zealand Ministry of Health, NHMRC, and RWJF-HER.

⁸ © All rights reserved. Nutrition for healthy term infants: Recommendations from six to 24 months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.

Evidence Base

Across the five guideline documents, the committee identified seven statements of recommendation. Most recommendations mapped to narrative reviews. One of the recommendations from the Australian government (NHMRC, 2012) mapped to a systematic review. One recommendation from Health Canada et al. (2014) could not be mapped to its evidence.

TYPE OF INFANT FORMULA

Seven guideline documents included recommendations on the type of formula for infants receiving formula (see Appendix B, Table B-5). One of the guideline documents was a collaborative effort between multiple organizations (Health Canada et al., 2015), and CPS and AAP each contributed to two guideline documents. Accordingly, the identified guidelines documents reflect eight different organizations from Australia, Canada, New Zealand, and the United States.⁹ Discussion of iron-fortified infant formulas is found under the “Iron” section later in this chapter.

Cow Milk–Based Infant Formulas

Six guideline documents included recommendations related to cow milk–based infant formula. All recommended that cow milk–based infant formula be used for infants receiving formula (Bhatia et al., 2008 [AAP]; Health Canada et al., 2015; Ministry of Health, 2012; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]; Unger et al., 2019 [CPS]). Three guideline documents recommended use of cow milk formula for 12 months or 1 year of age (Ministry of Health, 2012; NHRMC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]), while one guideline document recommended use of iron-fortified cow milk formula for the first 9–12 months (Unger et al., 2019 [CPS]).

Consistency

The guideline documents were consistent in recommending cow milk–based infant formula for formula-fed infants.

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⁹ Organizations reflected in the guideline documents include AAP, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, Health Canada, New Zealand Ministry of Health, NHMRC, and RWJF-HER.

Evidence Base

Across the six guideline documents, the committee identified six statements of recommendation. One recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review. The rest of the recommendations mapped to narrative reviews.

Soy-Based Infant Formulas

Five guideline documents included recommendations related to the use of soy-based formulas. Soy-based formula was only recommended in special circumstances, such as for infants with a confirmed pathology or specific medical, religious, or cultural needs (Bhatia et al., 2008 [AAP]; Health Canada et al., 2015; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]). Two guideline documents indicated the use of soy formula only under medical supervision (NHMRC 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]). The New Zealand Ministry of Health noted that vegan infants who are not breastfed or who are partially breastfed should receive commercial soy-based infant formula for the first 2 years of life (Ministry of Health, 2012).

Consistency

The guideline documents were consistent in their position on limiting the use of soy-based formula to special circumstances.

Evidence Base

Across the five guideline documents, the committee identified nine statements of recommendation. One recommendation from the Australian government mapped to a systematic review (NHMRC, 2012). The remaining eight recommendations, four of which came from a single guideline document (Bhatia et al., 2008), mapped to narrative reviews.

Hydrolyzed and Hypoallergenic Infant Formula

Three guideline documents included statements related to hydrolyzed or hypoallergenic infant formula. One guideline advised consultation with the child’s doctor before use (Pérez-Escamilla et al., 2017 [RWJF-HER]), while another suggested use under medical supervision (NHMRC, 2012). A guideline document from AAP noted evidence that partially or extensively hydrolyzed formula prevented atopic disease was lacking (Greer et al.,

2019 [AAP]); this topic is further explored in detail later in this chapter (see “Foods Associated with Food Allergy and Celiac Disease”).

Other Types of Infant Formulas

Four guideline documents included recommendations addressing other types of infant formula not described above. Two guideline documents commented on goat milk infant formula. One from RWJF-HER indicated it was a suitable alternative to breast milk (Pérez-Escamilla et al., 2017), while another guideline document from the Australian government indicated it was not a suitable alternative to cow milk–based formula and should only be used under medical supervision (NHMRC, 2012). The Australian government guideline document (NHMRC, 2012) also made recommendations for the use of specialty formulas with the advice of health professionals for formula-fed infants with confirmed pathology who cannot tolerate cow milk formula. Similarly, the New Zealand Ministry of Health (2012) advised that a health care practitioner be consulted before switching to an alternative formula not based on cow milk. One guideline document noted that homemade, evaporated milk formula should not be used (Health Canada et al., 2015).

Consistency

The two guideline documents that addressed the use of goat milk infant formula were not consistent.

Evidence Base

Across the four guideline documents, the committee identified five statements of recommendation. One of the recommendation from an Australian guideline document (NHMRC, 2012) mapped to a systematic review, while another from the same document mapped to a 2009 WHO report. The rest of the recommendations mapped to narrative reviews.

TODDLER MILKS AND FOLLOW-ON FORMULAS

Six guideline documents included recommendations regarding toddler milks and follow-on formulas (see Appendix B, Table B-6).¹⁰ One of the guideline documents was an RWJF-HER consensus statement that included

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¹⁰ Considered breast milk substitutes, these are products that are “specifically marketed for feeding infants and young children up to the age of 3 years” (WHO Secretariat, 2016). They are also known as growing-up milk, growing-up formula, or formulated milk.

participants representing four organizations (Lott et al., 2019), and two of the guideline documents were from ESPGHAN (Domellöf et al., 2014; Hojsak et al., 2018). The identified guideline documents, therefore, reflect nine different organizations from Australia, Canada, Europe, New Zealand, and the United States.¹¹

Use of Toddler Milks or Follow-On Formulas

Six guideline documents included recommendations related to the use of toddler milks or follow-on formulas. The RWJF-HER consensus document recommended against provision of transition or weaning formulas in the first year of life, stating that human milk or standard infant formula are the preferred choices (Lott et al., 2019). One guideline document from ESPGHAN indicated that follow-on formulas should be iron fortified, without recommending a specific iron concentration (Domellöf et al., 2014).

Five of the guideline documents stated that toddler milks are not indicated, with the recommendation statements ranging from recommending against the use of toddler milk (Lott et al., 2019 [RWJF-HER]) to stating that toddler milks are not required or necessary (Ministry of Health, 2012; NHMRC, 2012; Unger et al., 2019 [CPS]) or routinely needed (Hojsak et al., 2018 [ESPGHAN]). Appropriate drink options for toddlers were identified as whole cow milk (Ministry of Health, 2012; Unger et al., 2019 [CPS]) or a “suitable alternative” (Ministry of Health, 2012), with one recommendation from an RWJF-HER consensus statement noting that toddler nutrient needs should be met through “nutritionally adequate dietary patterns” (Lott et al., 2019). In one guideline document from ESPGHAN (Hojsak et al., 2018), the statement that toddler milk is not needed was qualified with the caveat that toddler milk or follow-on formula can potentially be used to increase intake of iron, vitamin D, and n-3 polyunsaturated fatty acids and to decrease intake of protein relative to unfortified cow milk. Three of the guideline documents indicated that the recommendation against the general use of toddler milk applied after 12 months (Ministry of Health, 2012; NHMRC, 2012; Unger et al., 2019 [CPS]), with two documents giving more specific age ranges of 1–3 years (Hojsak et al., 2018) and 1–5 years (Lott et al., 2019).

Consistency

The guideline documents were consistent in recommending against the general use of toddler milks, with some variability in the exact language

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¹¹ Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, CPS, ESPGHAN, New Zealand Ministry of Health, NHMRC, and RWJF-HER.

used. The guideline documents were generally consistent in indicating that the recommendations were applicable to children 12 months of age and older, although the specific age range varied. A single organization (ESPGHAN) mentioned that follow-on formula and toddler milk could potentially be used to change child intake of specific nutrients relative to intakes from cow milk (Domellöf et al., 2014; Hojsak et al., 2018). As only one guideline document commented on iron fortification of follow-on formulas (Domellöf et al., 2014), no comment on consistency can be made. The recommendation against provision of follow-on formulas in the first year of life was made in only one guideline document (Lott et al., 2019 [RWJF-HER]), but this reflected a consensus of the collaborating organizations.

Evidence Base

Across the six guideline documents, the committee identified seven statements of recommendation. The RWJF-HER (Lott et al., 2019) recommendation against provision of follow-on formulas in the first year of life mapped to a narrative review. Of the five recommendations related to use of toddler milks, one mapped to a systematic literature review (Hojsak et al., 2018 [ESPGHAN]), three mapped to narrative reviews (Lott et al., 2019 [RWJF-HER]; Ministry of Health, 2012; Unger et al., 2019 [CPS]), and one recommendation could not be mapped to its evidence (NHMRC, 2012). The ESPGHAN (Domellöf et al., 2014) recommendation related to iron fortification of follow-on formulas mapped to a narrative review.

MILK AND MILK-BASED PRODUCTS¹²

Fourteen guideline documents included recommendations regarding milk and milk-based products apart from infant formula (see Appendix B, Table B-7). Three guideline documents reflected collaborations across multiple organizations (Health Canada et al., 2014; Lott et al., 2019 [RWJF-HER]; New Zealand Dental Association, 2008); five organizations participated in multiple guideline documents. The identified guideline documents reflect 15 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with WHO.¹³

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¹² This section does not include milk-based infant formulas or human milk.

¹³ Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, RWJF-HER, SACN, and WHO.

Milk and Milk-Based Products for Infants 0–12 Months of Age

Thirteen guideline documents provided recommendations related to the use of milk and milk-based products, apart from infant formula, for infants 0–12 months of age. The majority stated that cow milk should not be introduced until 12 months of age (Baker et al., 2010 [AAP]; Lott et al., 2019 [RWJF-HER]; Ministry of Health, 2012; New Zealand Dental Association, 2008; Pérez-Escamilla et al., 2017 [RWJF-HER]; SACN, 2018; Unger et al., 2019 [CPS]). One guideline document from AAP indicated that human milk and infant formula were sufficient to meet the fluid needs of infants, and water and milk were sufficient for older children, but it did not specify age groups within the recommendation (Heyman et al., 2017).¹⁴ Three guideline documents—two from ESPGHAN and the other from the Australian government—stated that cow milk should not be the main beverage before 12 months (Domellöf et al., 2014 [ESPGHAN]; Fewtrell et al., 2017 [ESPGHAN]; NHMRC, 2012). Two of these guideline documents went on to indicate that small volumes could be added to complementary foods (Fewtrell et al., 2017 [ESPGHAN]; NHMRC, 2012). A collaborative Canadian guideline document noted that cow milk could be introduced at 9–12 months, and that intake of pasteurized homogenized (3.25 percent milk fat) cow milk should be no more than 750 mL per day (Health Canada et al., 2014). A guideline document from WHO noted that for nonbreastfed infants 6–24 months of age, “full-cream animal milk (cow, goat, buffalo, sheep, camel), ultrahigh temperature milk, reconstituted evaporated (but not condensed) milk, and fermented milk or yogurt” are acceptable (WHO, 2005)¹⁵; recommended amounts of milk depended on the amount of other animal-source foods. An Australian government guideline document stated that full-fat yogurt, cheese, or custards are acceptable before 12 months of age (NHMRC, 2012).

Consistency

The guideline documents were generally consistent in recommending against any cow milk before 9 months, but statements regarding intake at 9–12 months and whether milk can be added to complementary foods before 12 months of age were not consistent. Only two guidelines discussed the introduction of milk-based products (e.g., yogurt, cheese); both indicated that such foods could be introduced to older infants.

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¹⁴ Another AAP guideline document stated that donor milk is an alternative to mother’s breast milk, in the context of exclusive breastfeeding (AAP Section on Breastfeeding, 2012).

¹⁵ Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Nutrient Content of Foods, p. 12, Copyright (2005).

Evidence Base

Across the 13 guideline documents, the committee identified 18 statements of recommendation. Three recommendations from one guideline document from the Australian government (NHMRC, 2012) mapped to systematic reviews; one of these recommendations also mapped to a narrative review. A recommendation from an ESPGHAN guideline document (Fewtrell et al., 2017) mapped to a systematic literature search. Two recommendations from an RWJF-HER consensus statement (Lott et al., 2019) mapped to previous reports and federal nutrition standards. One recommendation from the New Zealand Dental Association (2008) could not be mapped to its evidence. The remaining recommendations mapped to narrative reviews, alone or in combination with other documents.

Appropriate Fat Content of Milk for Children 12–24 Months of Age

Ten guideline documents included recommendations related to the appropriate fat content of milk for children 12–24 months of age. Nine guideline documents recommended intake of whole cow milk for children 12–24 months of age (Baker et al., 2010 [AAP]; Health Canada et al., 2014; Lott et al., 2019 [RWJF-HER]; Ministry of Health, 2012; New Zealand Dental Association, 2008; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]; Unger et al., 2019 [CPS]; WHO, 2005). Two of these guideline documents (both of which were from RWJF-HER), however, stated that reduced- or low-fat milk could be consumed under consultation with a pediatrician (Lott et al., 2019; Pérez-Escamilla et al., 2017). An AAP guideline document indicated that water and low-fat/nonfat milk were sufficient for older children, but it did not specify age groups within the recommendation itself (Heyman et al., 2017). Two guideline documents—one from Canada, the other from Australia—explicitly stated that skim milk is not suitable for the first 2 years of life (Health Canada et al., 2014; NHMRC, 2012).

Consistency

The guideline documents were generally consistent in recommending that whole milk should be provided to children in the age range of 12–24 months. Two guidelines specified circumstances under which reduced-fat milk could be provided (Lott et al., 2019 [RWJF-HER]; Pérez-Escamilla et al., 2017 [RWJF-HER]). Only one guideline document suggested that reduced-fat or nonfat milk was appropriate for “older children,” but it did not specify the applicable age range (Heyman et al., 2017 [AAP]).

Evidence Base

Across the 10 guideline documents, the committee identified 14 statements of recommendation. Most of the recommendations mapped to narrative reviews, alone or in combination with other documents. Two recommendations from an RWJF-HER consensus statement (Lott et al., 2019) mapped to previous reports and federal nutrition standards. One recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review, a narrative review, and a WHO European region report. Another recommendation from the Australian government guideline document (NHMRC, 2012) and two recommendations from the New Zealand Dental Association (2008) could not be mapped to their evidence.

Amount of Milk and Milk-Based Products for Children 12–24 Months

Six guideline documents provided quantitative recommendations for milk intake for children 12–24 months of age. Guideline documents from ESPGHAN, the New Zealand Ministry of Health, and RWJF-HER advised limiting cow milk intake to approximately 500 mL per day (Domellöf et al., 2014; Ministry of Health, 2012; Pérez-Escamilla et al., 2017). A separate collaborative consensus statement from RWJF-HER advised to limit milk intake to approximately 500–700 mL per day (Lott et al., 2019). Another guideline document recommended offering 500 mL of milk per day, but limiting it to no more than 750 mL per day (Health Canada et al., 2014). One recommendation for nonbreastfed children from WHO encouraged 200–400 mL milk per day (from any animal source) if animal-source foods are regularly consumed and 300–500 mL milk per day if not (WHO, 2005). One guideline document from RWJF-HER indicated that half to three-quarters of a cup of plain yogurt without excessive total sugars could be given in place of milk (Pérez-Escamilla et al., 2017).¹⁶

Consistency

There were some inconsistencies in the recommended limit for the amount of cow milk consumed by children 12–24 months of age, from approximately 500 to 750 mL per day.

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¹⁶ Terminology related to sugar and sugars varies in the field. Whereas some may use the singular to refer specifically to the disaccharide sucrose, it is often used to describe sweeteners broadly. As much as possible, the committee uses verbatim language related to sugars from each recommendation.

Evidence Base

Across the six guideline documents, the committee identified eight statements of recommendation. Most of the recommendations mapped to narrative reviews, either alone or in combination with other resources. One of the recommendations from the RWJF-HER consensus guideline document (Lott et al., 2019) mapped to previous reports and federal nutrition standards.

Flavored Milk

Three of the guideline documents included recommendations related to flavored milk (Fidler Mis et al., 2017 [ESPGHAN]; Lott et al., 2019 [RWJF-HER]; Pérez-Escamilla et al., 2017 [RWJF-HER]). The two RWJF-HER guideline documents indicated that only plain, unflavored milk without added sugars should be offered when milk is provided (Lott et al., 2019; Pérez-Escamilla et al., 2017). The ESPGHAN guideline document recommended limiting the intake of sweetened milk drinks such as smoothies or condensed milk and replacing sweetened milk products with water (Fidler Mis et al., 2017). Age groups were not specified in either ESPGHAN recommendation.

Consistency

The three guideline documents were consistent in recommending limiting or not providing flavored milk to infants and young children.

Evidence Base

Across the three guideline documents, the committee identified six statements of recommendation. The three recommendations that came from a single guideline document (Lott et al., 2019 [RWJF-HER]) mapped to previous reports and federal nutrition standards. Two recommendations from an ESPGHAN guideline document (Fidler Mis et al., 2017) mapped to a systematic literature search. The remaining recommendation from Pérez-Escamilla et al. (2017 [RWJF-HER]) mapped to a narrative review.

FLUIDS: WATER, JUICE, SUGAR-SWEETENED BEVERAGES, AND OTHER NONMILK BEVERAGES¹⁷

Seventeen guideline documents included recommendations regarding water, juice, sugar-sweetened beverages, and other nonmilk beverages (see

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¹⁷ This section does not include recommendations related to infant formulas. One recommendation on beverages containing low-calorie sweetener has been omitted from this section, but it is discussed in the “Substances to Avoid or Limit” section later in this chapter.

Appendix B, Table B-8). Six guideline documents were collaborative efforts between two or more organizations (AAPD, 2016; Health Canada et al., 2014, 2015; Lott et al., 2019; New Zealand Dental Association, 2008; PAHO/WHO, 2003). Eleven organizations participated in multiple guideline documents. Accordingly, the identified guideline documents reflect 17 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with PAHO and WHO.¹⁸

Water and Fluid Needs

Ten guideline documents included recommendations related to water and fluid needs. Recommendations varied by age of the infants and young children. For children younger than 6 months, two guideline documents made explicit recommendations related to water. A collaborative consensus statement from RWJF-HER specified that no additional water is needed (Lott et al., 2019); the other guideline document, from the New Zealand Ministry of Health, made a recommendation that strongly discouraged providing breastfed infants with water before 6 months (Ministry of Health, 2012). Three guideline documents—one each from AAP, the Australian government, and the New Zealand Ministry of Health—indicated that infants in this age range only need breast milk or infant formula, implying that water and other fluids are not necessary (Heyman et al., 2017; Ministry of Health, 2012; NHMRC, 2012).

A WHO guideline document recommended that nonbreastfed infants and young children receive “at least 400–600 mL/day of extra fluids (in addition to the 200–700 mL/day of water that is estimated to come from milk and other foods) in temperate climates and 800–1200 mL/day in hot climates” (WHO, 2005).¹⁹ Similarly, a guideline document from the New Zealand Ministry of Health suggested that additional fluids may be required for formula-fed infants when they are unwell or the weather is hot (Ministry of Health, 2012).

Two guideline documents from RWJF-HER and one guideline document from SACN indicated that water was appropriate for infants 6–12 months of age (Lott et al., 2019; Pérez-Escamilla et al., 2017; SACN, 2018). The two guideline documents from RWJF-HER recommended half to 1 cup of plain water daily (Lott et al., 2019; Pérez-Escamilla et al., 2017).

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¹⁸ Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, NICE, PAHO, RWJF-HER, SACN, and WHO.

¹⁹ Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Fluid Needs, p. 20, Copyright (2005).

Six guideline documents recommended that water be offered to children older than 1 year of age (Health Canada et al., 2014; Lott et al., 2019 [RWJF-HER]; Ministry of Health, 2012; New Zealand Dental Association, 2008; NICE, 2008; Pérez-Escamilla et al., 2017 [RWJF-HER]). Recommendations from RWJF-HER guideline documents slightly varied: one stated that 2 cups of water per day should be provided (Pérez-Escamilla et al., 2017), while the other recommended 1–4 cups of water per day, depending on the intake of other fluids (Lott et al., 2019).

Consistency

The guideline documents were consistent in discouraging the provision of water to infants 0–6 months of age; two guideline documents made exceptions for nonbreastfed infants related to climate. Fewer guideline documents made recommendations related to water intake of infants 6–12 months of age, but those that did were consistent. The guideline documents were consistent regarding the provision of water to children older than 1 year of age, although the recommended quantity varied.

Evidence Base

Across the 10 guideline documents, the committee identified 17 statements of recommendation. The majority of the recommendations mapped to narrative reviews, alone or in combination with other resources. One recommendation (NICE, 2008) was based on a UK Department of Health report (Department of Health, 1994) and a rapid review. One recommendation from the New Zealand Dental Association (2008) could not be mapped to its evidence.

Juice

Fifteen guideline documents included recommendations related to juice. Five guideline documents made specific recommendations for juice, eight guideline documents made recommendations for the combined topics of juice and sugar-sweetened beverages, and two guideline documents made recommendations both specific to juice and for the combination of juice and sugar-sweetened beverages. Eight of the corresponding recommendations referred to “fruit juice,” 11 recommendations referred to just “juice” or “juices,” 3 recommendations referred to “100% juice,” and 1 recommendation referred to “baby juices.” None of the recommendations mentioned vegetable juices.

Of the recommendations specific to infants 0–12 months, the most stringent said that “fruit juice is not necessary or recommended”

(NHMRC, 2012),²⁰ that juice “should be avoided” (Fewtrell et al., 2017 [ESPGHAN]), or that juice is “not recommended” (Lott et al., 2019 [RWJF-HER]). A 2005 guideline document from AHA stated that 100% juice should be delayed “until at least 6 months of age” and limited to no more than 4–6 ounces from a cup (Gidding et al., 2005). One guideline document from AAP indicated that juice should not be introduced until after 12 months of age “unless clinically indicated” (Heyman et al., 2017).

Four guideline documents included recommendations specific to toddlers. A guideline document from the New Zealand Ministry of Health stated that juice is not recommended for toddlers (Ministry of Health, 2012). In contrast, three guideline documents, one from AAP and two from RWJF-HER, recommended that juice intake should not exceed 4 ounces per day for children 1–3 years of age (Heyman et al., 2017; Lott et al., 2019; Pérez-Escamilla et al., 2017). Two of the guideline documents specified that juice should not be given in a bottle (Heyman et al., 2017; Pérez-Escamilla et al., 2017), and one specified that juice should not be provided at bedtime (Heyman et al., 2017).

Of the recommendations relevant to both infants and young children collectively, the more restrictive ones said to “avoid” juice (NHMRC, 2012), “do not give” juice (NHMRC, 2012), or that juice is “not recommended” (Ministry of Health, 2012). Other guideline documents used language such as “advise limiting” (Health Canada et al., 2014)²¹ and “advise parents that juice … [is] not recommended” (New Zealand Dental Association, 2008). Other guideline documents suggested restricting the amount of juice. One guideline document from AAPD recommended that frequent consumption of juice in a baby bottle or no-spill cup should be avoided (AAPD, 2016); two other guideline documents advised limiting the amount of juice provided “to avoid displacing more nutrient-rich foods” (PAHO/WHO, 2003; WHO, 2005).^22,23 A guideline document from ESPGHAN recommended that sugar-containing beverages, including juice, be replaced with water (Fidler Mis et al., 2017). A NICE guideline document stated that parents and caregivers should not offer “baby juices” at bedtime and that diluted fruit juice (1 part juice to 10 parts water) can be

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²⁰NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).

²¹ © All rights reserved. Nutrition for healthy term infants: Recommendations from six to 24 months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.

²² Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Nutrient Content of Complementary Foods, p. 22, Copyright (2003).

²³ Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Nutrient Content of Foods, p. 13, Copyright (2005).

provided with meals (NICE, 2008). An AAP guideline document indicated that “pediatricians should advocate for a reduction in fruit juice in the diets of young children and the elimination of fruit juice in children with abnormal (poor or excessive) weight gain” (Heyman et al., 2017). An AAPD guideline document did not offer its own recommendations (AAPD, 2017); rather, the organization supported the recommendations put forth by the AAP in a recent publication (Heyman et al., 2017).

Consistency

The language used to describe what type of juice was included in the recommendations varied across guideline documents. The guideline documents were generally consistent in stating that juice should not be provided in the first 12 months of life, although one guideline document suggested delaying introduction until at least 6 months of age (Gidding et al., 2005 [AHA]). Similarly, the recommendations specific to toddlers were generally consistent, indicating that juice intake should not exceed 4 ounces per day, although one guideline document stated that juice was not recommended (Ministry of Health, 2012). Broader recommendations that were applicable to both infants and toddlers had some inconsistencies, with some recommendations stating that juice should not be given, while other recommendations indicated that juice intake should be limited.

Evidence Base

Across the 15 guideline documents, the committee identified 23 statements of recommendation. Twelve of the recommendations mapped to narrative reviews or technical documents, either alone or in combination with other resources. One recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review, whereas two recommendations from ESPGHAN (Fewtrell et al., 2017; Fidler Mis et al., 2017) mapped to systematic literature searches. Two recommendations from NICE (2008) mapped to a UK Department of Health report (Department of Health, 1994) and rapid reviews. The three recommendations that came from a single guideline document (Lott et al., 2019 [RWJF-HER]) mapped to a previous AAP report (Heyman et al., 2017) and the Dietary Guidelines for Americans (DGA). One guideline document (AAPD, 2017) supported a previous AAP report (Heyman et al., 2017). Two recommendations from two guideline documents (Giddings et al., 2005; New Zealand Dental Association, 2008) could not be mapped to their evidence.

Sugar-Sweetened Beverages

Twelve guideline documents included recommendations related to sugar-sweetened beverages. All but two of these documents also made recommendations for the combined topics of fruit juice and sugar-sweetened beverages. Recommendations used different terms to describe sugar-sweetened beverages, although most refer to either “sugar-sweetened beverages,” “sugar sweetened drinks,” “sugar-containing beverages,” “sweet drinks,” or “sweetened beverages.” Some guideline documents used slightly different terms, including “soft drinks” and “cordials” (New Zealand Dental Association, 2008; NHMRC, 2012) and “sugary soft drinks” or “sugary drinks such as soda” (PAHO/WHO, 2003; WHO, 2005).^24,25 Six guideline documents provided examples of sugar-sweetened beverages (e.g., sports drinks, sweetened teas, sodas, sweetened milk drinks) (AAPD, 2016; Fidler Mis et al., 2017 [ESPGHAN]; Lott et al., 2019 [RWJF-HER]; New Zealand Dental Association, 2008; PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]).

Some of the recommendations relevant to infants indicated that sugar-sweetened beverages are drinks to “avoid” (Fewtrell et al., 2017 [ESPGHAN]; NHMRC, 2012) or “not offer” (NHMRC, 2012; Pérez-Escamilla et al., 2017); one guideline document stated that sugar-sweetened beverages are not recommended (Ministry of Health, 2012). A guideline document from ESPGHAN recommended replacing “sugar-containing beverages” with water; however, no age range was provided (Fidler Mis et al., 2017 [ESPGHAN]). One RWJF-HER guideline document stated that “[i]t is strongly recommended to offer no sugar-sweetened beverages” to infants (Pérez-Escamilla et al., 2017). A guideline document from AAPD stated that frequent consumption of sugar-sweetened beverages and other liquids containing sugar should be avoided (AAPD, 2016).

One recommendation in a collaborative guideline document from New Zealand indicated that sweet drinks are not recommended for toddlers (New Zealand Dental Association, 2008). Five additional guideline documents provided recommendations relevant to both infants and young children. Generally, they stated that sugar-sweetened beverages were “not recommended” (Lott et al., 2019 [RWJF-HER]; Ministry of Health, 2012) or should not be given (Ministry of Health, 2012; PAHO/WHO, 2003; WHO 2005). However, a recommendation in one collaborative guideline document from Canada was to “advise limiting” sweetened beverages (Health Canada et al., 2014). A NICE guideline document discouraged parents from offering sugary drinks at bedtime (NICE, 2008).

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²⁴ Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Nutrient Content of Complementary Foods, p. 22, Copyright (2003).

²⁵ Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Nutrient Content of Foods, p. 13, Copyright (2005).

Consistency

The guideline documents were consistent in recommending against providing infants and young children with sugar-sweetened beverages, although one used slightly softer language (“advise limiting”) (Health Canada et al., 2014).

Evidence Base

Across the 12 guideline documents, the committee identified 15 statements of recommendation. Most of the recommendations mapped to narrative reviews and/or technical background documents, either alone or in combination with other resources. One recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review, whereas two recommendations from ESPGHAN guideline documents (Fewtrell et al., 2017; Fidler Mis et al., 2017) mapped to systematic literature searches. A recommendation from NICE (2008) mapped to a UK Department of Health report (Department of Health, 1994) and a rapid review. One recommendation from the New Zealand Dental Association (2008) could not be mapped to its evidence.

Coffee and Tea

Five guideline documents included recommendations that referred to coffee and tea. Two guideline documents stated that coffee and tea “are not recommended” (Lott et al., 2019 [RWJF-HER]; Ministry of Health, 2012). Four guideline documents said to “not offer” (NHMRC, 2012), “not give” (Ministry of Health, 2012), or “avoid giving” (PAHO/WHO 2003; WHO, 2005) coffee and tea. All but one included a reason that these beverages should not be offered. The reasons offered were that the beverages are “sweetened” (Lott et al., 2019 [RWJF-HER]), “caffeine-containing” or “containing caffeine” (Ministry of Health, 2012), or of “low nutrient value” (PAHO/WHO, 2003; WHO, 2005).^26,27 One recommendation described “tea, herbal teas, [and] coffee” as beverages that should not be offered (NHMRC, 2012), but it provided no further rationale. Notably, two guideline documents included “herbal teas” in their lists of beverages not to offer (Ministry of Health, 2012; NHMRC, 2012).

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²⁶ Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Nutrient Content of Complementary Foods, p. 22, Copyright (2003).

²⁷ Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Nutrient Content of Foods, p. 13, Copyright (2005).

Consistency

The guideline documents were consistent in recommending that coffee and tea should not be given to infants and young children.

Evidence Base

Across the five guideline documents, the committee identified six statements of recommendation. The recommendations mapped to narrative reviews, technical consultations, and/or a technical background document.

Caffeinated Beverages

Two guideline documents included recommendations that specifically referenced beverages that are “caffeinated” (Lott et al., 2019 [RWJF-HER]), “caffeine-containing” (Ministry of Health, 2012), or “containing caffeine” (Ministry of Health, 2012). The guideline document from the New Zealand Ministry of Health contained two recommendations indicating that caffeinated beverages are “not recommended” and caffeinated beverages should not be given to infants and toddlers (Ministry of Health, 2012). The other guideline document similarly stated that children 0–5 years of age should not consume caffeinated beverages (Lott et al., 2019 [RWJF-HER]).

Consistency

The two guideline documents that specifically referred to caffeinated beverages were consistent with each other, advising against the provision of such beverages to infants and young children.

Evidence Base

Across the two guideline documents, the committee identified three statements of recommendation that all mapped to narrative reviews.

Beverages of Low Nutrient Value

Two guideline documents included recommendations that referred to drinks with “low nutrient value” (PAHO/WHO, 2003; WHO, 2005).^28,29

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²⁸ Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Nutrient Content of Complementary Foods, p. 22, Copyright (2003).

²⁹ Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Nutrient Content of Foods, p. 13, Copyright (2005).

In both, the recommendation was to “[a]void giving drinks with low nutrient value.”

Consistency

The two guideline documents were consistent in the wording of their recommendation for infants and young children to avoid beverages with low nutrient value. However, one of the guideline documents was specific to nonbreastfed children 6–24 months of age (WHO, 2005) and the other was written for breastfed children (PAHO/WHO, 2003). Notably, both guideline documents were relevant to a global audience.

Evidence Base

Across the two guideline documents, the committee identified two statements of recommendation. One mapped to a technical background document and narrative review (WHO, 2005), and the other mapped to technical consultations and documents (PAHO/WHO, 2003).

Plant-Based Beverages

Six guideline documents included recommendations on plant-based beverages (Health Canada et al., 2014, 2015; Lott et al., 2019; Ministry of Health, 2012; NHMRC, 2012; Pérez-Escamilla et al., 2017). The guideline documents recommended against the use of plant-based beverages for infants except when specifically indicated and when a commercially prepared infant formula is available (e.g., soy-based formula). Plant-based beverages were not recommended for children older than 12 months, except in two instances. One guideline document, from the New Zealand Ministry of Health, stated: “For vegetarian and vegan toddlers, provide plenty of liquids each day as water, breast milk, cow milk, or plant-based milks only” (Ministry of Health, 2012).³⁰ The other, from the Australian government, recommended:

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³⁰Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).

Consistency

The guideline documents were generally consistent in recommending that plant-based beverages should not be given to infants. Although several of the guideline documents had a similar position for children older than 12 months of age, two guideline documents identified circumstances under which such beverages could be provided (Ministry of Health, 2012; NHMRC, 2012).

Evidence Base

Across the six guideline documents, the committee identified nine statements of recommendation. Most of the recommendations mapped to narrative reviews.³¹ Two recommendations from an RWJF-HER consensus guideline document (Lott et al., 2019) mapped to the DGA. One recommendation from the Australian government (NHRMC, 2012) could not be mapped to its evidence.

SUBSTANCES TO AVOID OR LIMIT³²

Fourteen guideline documents included recommendations related to substances to avoid or limit (see Appendix B, Table B-9). Four guideline documents were collaborations between two or more organizations (AAPD, 2016; Health Canada et al., 2014; Lott et al., 2019; New Zealand Dental Association, 2008); six organizations participated in multiple guidelines. The identified guideline documents reflect 15 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States.³³

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³¹ Although Table B-8 in Appendix B notes that a recommendation from the Australian government (NHMRC, 2012) maps to both a systematic and narrative review, the portion related to plant-based milks only mapped to a narrative review.

³² With the exception of the recommendation related to beverages containing low-calorie sweeteners, this section has not summarized recommendations related to beverages. Recommendations related to beverages are summarized in “Milk and Milk-Based Products” and “Fluids: Water, Juice, Sugar-Sweetened Beverages, and Other Nonmilk Beverages” sections earlier in this chapter. Furthermore, the committee considered recommendations related to avoiding honey in the first year of life due to the risk of botulism as a safety issue. Recommendations related to this topic are summarized in Chapter 5, “Safety of Foods and Feeding Practices.”

³³ Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, NICE, RWJF-HER, and SACN.

Consuming Nonnutritive Sweeteners

Two guideline documents included recommendations related to nonnutritive sweeteners. One, a consensus statement from RWJF-HER, advised against providing beverages with low-calorie sweeteners to children 0–5 years of age (Lott et al., 2019). The other, an AAP guideline document, stated that there was inadequate evidence to make a recommendation regarding consumption of nonnutritive sweeteners by children under the age of 2 years (Baker-Smith et al., 2019).

Consistency

The guideline documents were not consistent in their recommendations related to nonnutritive sweeteners. However, in the rationale justifying the RWJF-HER recommendation, the guideline document noted that there is a dearth of evidence regarding health effects of beverages with low-calorie sweeteners in young children (Lott et al., 2019). A precautionary approach was taken based on expert opinion, resulting in a recommendation against consumption. Thus, the inconsistency in the recommendations appears to stem from different approaches to handling situations where there is inadequate evidence to make a recommendation.

Evidence Base

Across the two guideline documents, the committee identified two statements of recommendation. Both mapped to narrative reviews. In one case, the recommendation explicitly stated there was a lack of evidence (Baker-Smith et al., 2019 [AAP]), and in the other case, the lack of evidence for young children was mentioned in the rationale and the recommendation was based on expert opinion (Lott et al., 2019 [RWJF-HER]).

Limiting Consumption of Sugars

Two guideline documents included recommendations related to limiting consumption of sugars. One guideline document from AAPD recommended reducing sugar intake below 5–10 percent of children’s total energy intake, with the lower bound recommended to prevent weight gain and dental caries (AAPD, 2017). Similarly, a guideline document from ESPGHAN recommended that intakes of free sugars for children younger than 2 years of age should be lower than the recommendation for older children, who are recommended to consume less than 5 percent of energy intakes from free sugars (Fidler Mis et al., 2017). The ESPGHAN guideline document also emphasized the importance of avoiding or limiting intakes of free sugars by infants.

Consistency

The two guideline documents were consistent in recommending that intake of sugars should be at most a small portion of total energy intake, but they provided slightly different targets. The recommendation from ESPGHAN was specific to infants and children under age 2; AAPD did not provide specific age ranges. AAPD noted that it was endorsing the recommendation of “national and international organizations.”

Evidence Base

Across the two guideline documents, the committee identified two statements of recommendation. One recommendation from AAPD (2017) mapped to guidance from the DGA, WHO, and AHA; the other recommendation from ESPGHAN (Fidler Mis et al., 2017) mapped to a systematic literature search.

Preparing Foods Without Added Sugars

Seven guideline documents included recommendations related to not adding sugar to foods being prepared for infants (Fewtrell et al., 2017 [ESPGHAN]; Fidler Mis et al., 2017 [ESPGHAN]; Ministry of Health, 2012; NHMRC, 2012; NICE, 2008; Pérez-Escamilla et al., 2017 [RWJF-HER]) or toddlers or young children (Health Canada et al., 2014; Ministry of Health, 2012; NICE, 2008). Three guideline documents also mentioned not adding honey (Ministry of Health, 2012; NHMRC, 2012; NICE, 2008) or other sweeteners (Ministry of Health, 2012). Some guideline documents emphasized adding no sugar, particularly for infants (Fewtrell et al., 2017 [ESPGHAN]; Ministry of Health, 2012; NHMRC, 2012; NICE, 2008; Pérez-Escamilla et al., 2017 [RWJF-HER]). Recommendations for toddlers mentioned “little added sugar” (Ministry of Health, 2012) or “little or no added … sugar” (Health Canada et al., 2014)³⁴ or “without adding sugar” (NICE, 2008). One guideline document recommended discouraging parents from adding sugar to bottle feeds (NICE, 2008).

Consistency

The guideline documents were consistent in recommending that foods for infants and young children be prepared without added sugars, with an

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³⁴ © All rights reserved. Nutrition for healthy term infants: Recommendations from six to 24 months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.

emphasis on no added sugar for infants and little to no added sugar for toddlers.

Evidence Base

Across the seven guideline documents, the committee identified 10 statements of recommendation. One recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review, while two recommendations from ESPGHAN (Fewtrell et al., 2017; Fidler Mis et al., 2017) mapped to systematic literature searches. Three recommendations from NICE (2008) mapped to both a UK Department of Health report (Department of Health, 1994) and rapid reviews. The rest of the recommendations mapped to narrative reviews, either alone or in combination with other resources.

Offering Pre-Prepared Foods and Snacks with No or Limited Added or Total Sugars

Seven guideline documents included recommendations related to offering pre-prepared foods and snacks with no or limited added or total sugar to young children. The exact language for these recommendations was variable. For example, an RWJF-HER guideline document recommended choosing pre-prepared baby food “without (or with limited amounts of) added sugars,” avoiding offering sweets or foods or snacks high in added sugars during the transition to family food, limiting toddler consumption of snacks with added sugars, and serving toddlers only plain yogurt or yogurt with no more than 23 grams of sugar per 6 ounces (Pérez-Escamilla et al., 2017). Similarly, a guideline document from the New Zealand Ministry of Health recommended selection of pre-prepared complementary foods with no added sugar, honey, or other sweeteners, and selection of foods and snacks that have little added sugar for toddlers (Ministry of Health, 2012). Others indicated the following:

• Frequent consumption of foods containing sugar should be avoided in early childhood (AAPD, 2016).
• Intake of all foods with added sugars should be limited and intake of “nutrient-poor discretionary foods” with high levels of added sugars should be avoided during the complementary feeding period (NHMRC, 2012).
• Foods low in sugar should be selected for 12–24-month-olds (New Zealand Dental Association, 2008).
• Giving young children sweets as treats should be avoided (NICE, 2008).

One organization (SACN, 2018) stated that it is necessary to reemphasize the risks associated with free sugars in complementary foods and to monitor reported intakes.

Consistency

Three guideline documents were consistent in recommending that pre-prepared foods and snacks offered to young children should contain no or limited added or total sugars, with some variability in the exact language used.

Evidence Base

Across the seven guideline documents, the committee identified 12 statements of recommendation. Most of the recommendations mapped to narrative reviews. Two recommendations from the Australian government (NHMRC, 2012) mapped to systematic reviews, while one from NICE (2008) mapped to both a UK Department of Health report (Department of Health, 1994) and to a rapid review.

Consuming Foods with Sugars at Mealtimes Instead of Snacks

Four guideline documents included recommendations related to timing of consumption of foods with sugars, if consumed. Three guideline documents recommended that if sugary foods are consumed, they should be eaten at meals instead of snacks (Fidler Mis et al., 2017 [ESPGHAN]; New Zealand Dental Association, 2008; NICE, 2008). One guideline document recommended that foods free of added sugar, such as fruits and vegetables, be encouraged between meals (NICE, 2008). Another guideline document specifically recommended that dried fruit not be given as a snack, however, because it is cariogenic (Ministry of Health, 2012).

Consistency

The guideline documents were consistent in recommending that if foods with sugars are consumed, they should be eaten at mealtimes instead of snacks. Fruits and vegetables were recommended as appropriate snacks, with the New Zealand Ministry of Health (2012) specifically identifying dried fruit as an exception.

Evidence Base

Across the four guideline documents, the committee identified five statements of recommendation. The recommendation from ESPGHAN

(Fidler Mis et al., 2017) mapped to a systematic literature search. Two recommendations from NICE (2008) mapped to both a UK Department of Health report (Department of Health, 1994) and rapid reviews. The recommendation from the New Zealand Ministry of Health (2012) mapped to the New Zealand Dental Association (2008) guideline document recommendation, which in turn mapped to a 2005 NHS Scotland guideline.

Dipping Pacifiers or Bottle Teats in Sugary Substances

Three guideline documents advised against dipping pacifiers or bottle teats in sugary substances, specifically mentioning sugar (Ministry of Health, 2012; New Zealand Dental Association, 2008; NHMRC, 2012), honey (Ministry of Health, 2012; New Zealand Dental Association, 2008; NHMRC, 2012), jam (NHMRC, 2012), and sweetened drinks (New Zealand Dental Association, 2008).

Consistency

The three guideline documents that had recommendations related to dipping pacifiers or bottle teats in sugary substances consistently recommended against the practice, with “sugar” and “honey” most frequently mentioned as specific examples.

Evidence Base

Across the three guideline documents, the committee identified three statements of recommendation. The recommendation from the New Zealand Ministry of Health (2012) mapped to the New Zealand Dental Association (2008) guideline document recommendation, which in turn mapped to an earlier 2008 New Zealand Ministry of Health guideline. The recommendation from the Australian government (NHMRC, 2012) could not be mapped to its evidence.

Preparing Foods Without Added Salt

Six guideline documents recommended not adding salt to foods being prepared for infants (Fewtrell et al., 2017 [ESPGHAN]; Ministry of Health, 2012; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]) and toddlers and young children (Health Canada et al., 2014; Ministry of Health, 2012; NICE, 2008). Some organizations emphasized adding no salt (Fewtrell et al., 2017 [ESPGHAN]; Ministry of Health, 2012; NICE, 2008; Pérez-Escamilla et al., 2017 [RWJF-HER]), particularly for infants, with one guideline document specifying the rationale that immature infant

kidneys cannot excrete excess salt (NHMRC, 2012). Recommendations for toddlers mentioned food prepared with “little or no added salt” (Health Canada et al., 2014)³⁵ or “low in salt” (Ministry of Health, 2012). One guideline document from the New Zealand Ministry of Health specified that if salt is used in food preparation, it should be iodized salt (Ministry of Health, 2012). One additional guideline document from SACN (2018) stated that it is necessary to reemphasize the risks associated with added salt in complementary foods, and to monitor reported intakes.

Consistency

The guideline documents were consistent in recommending that foods for infants and young children be prepared without adding salt, with an emphasis on no added salt for infants and little to no added salt for toddlers.

Evidence Base

Across the six guideline documents, the committee identified seven statements of recommendation. The recommendation from the ESPGHAN guideline document (Fewtrell et al., 2107) mapped to a systematic literature search. The recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review, although the supporting rationale for the recommendation (related to infant’s inability to excrete excess salt) could not be mapped to its evidence. The NICE (2008) recommendation mapped to both a UK Department of Health report (Department of Health, 1994) and a rapid review. The remaining recommendations mapped to narrative reviews, either alone or in combination with other resources. The additional recommendation related to emphasizing the risk of sodium intake during the complementary feeding period (SACN, 2018) also mapped to a narrative review.

Offering Pre-Prepared Foods and Snacks with No or Limited Salt

Four guideline documents recommended offering pre-prepared foods and snacks with no or limited salt to young children. The exact language for these recommendations was somewhat variable. For example, an RWJF-HER guideline document recommended to choose pre-prepared baby food “without (or with limited amounts of) added salt,” to avoid offering foods or snacks high

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³⁵ © All rights reserved. Nutrition for healthy term infants: Recommendations from six to 24 months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.

in salt during the transition to family food, to limit toddler consumption of snacks high in sodium, and to avoid feeding toddlers foods that are high in sodium, with specific mention of processed meats, lunch meats, and packaged, breaded chicken and fish (Pérez-Escamilla et al., 2017). Other guideline documents recommended selection of pre-prepared complementary foods with no added salt (Ministry of Health, 2012), avoiding “nutrient-poor discretionary foods” with high levels of added salt during the complementary feeding period (NHMRC, 2012), and selection of foods and snacks that are low in salt for toddlers (Ministry of Health, 2012). A NICE guideline document recommended that foods free of salt, such as fruits and vegetables, be encouraged between meals (NICE, 2008).

Consistency

The guideline documents were consistent in recommending that pre-prepared foods and snacks offered to young children should have no or limited salt, with some variability in the exact language used.

Evidence Base

Across the four guideline documents, the committee identified nine statements of recommendation. The recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review. The recommendation from the NICE (2008) guideline document mapped to both a UK Department of Health report (Department of Health, 1994) and a rapid review. The rest of the recommendations mapped to narrative reviews.

VARIETY AND HEALTHY, NUTRITIOUS FOODS

Ten guideline documents included recommendations related to healthy eating patterns, encompassing eating a variety of healthy, nutrient-dense foods within and across food groups (see Appendix B, Table B-10). Three of the guidelines were collaborative efforts between multiple organizations (Alvisi et al., 2015 [SIAIP and SIGENP]; Health Canada et al., 2014; PAHO/WHO, 2003); WHO contributed to two different guideline documents (PAHO/WHO, 2003; WHO, 2005). The identified guideline documents reflect 14 different organizations from Canada, Europe, Italy, New Zealand, the United Kingdom, and the United States, along with PAHO and WHO.³⁶

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³⁶ Organizations reflected in the guideline documents include AHA, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Ministry of Health, NICE, PAHO, RWJF-HER, SACN, SIAIP, SIGENP, and WHO.

Variety of Complementary Foods

Ten guideline documents included recommendations related to offering a variety of complementary foods. A number of aspects of dietary variety or diversity were addressed across the recommendations (see Table 4-1).

For recommendations on variety in foods, some guideline documents called attention to vegetables (Fewtrell et al., 2017 [ESPGHAN]; Ministry of Health, 2012; PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; WHO, 2005). For instance, one guideline document from the New Zealand Ministry of Health recommended offering a “wide variety of vegetables and fruit including dark-green leafy vegetables … and yellow, red, and orange vegetables” (Ministry of Health, 2012).³⁷ Another guideline document, from ESPGHAN, suggested “including foods with different flavours and textures including bitter-tasting green vegetables” (Fewtrell et al., 2017).

Four documents made statements about the frequency of eating different food groups, including offering “healthy foods from the different food groups (fruits, vegetables, grains, proteins, dairy) at each meal” (Pérez-Escamilla et al., 2017 [RWJF-HER]); “meat, poultry, fish or eggs should be eaten daily, or as often as possible” (PAHO/WHO, 2003; WHO, 2005)^38,39; and “daily consumption of fruits and vegetables” (Alvisi et al., 2015 [SIAIP and SIGENP]).⁴⁰

Some guideline documents also recommended increasing variety to meet the nutritional needs of infants and toddlers. These include general statements about specific types of foods that contain fat (WHO, 2005), and specific statements on B vitamins or vitamin B12 (Ministry of Health, 2012; WHO, 2005), calcium (WHO, 2005), iron (Ministry of Health, 2012; WHO, 2005), vitamin A (PAHO/WHO, 2003; WHO, 2005), vitamin C (Ministry of Health, 2012; WHO, 2005), and zinc (Ministry of Health, 2012; WHO, 2005). In addition, one guideline document from the New Zealand Ministry of Health stated that “variety should be increased to ensure an additional intake of nutrients, especially energy, protein, iron, calcium, and vitamin B12” for vegetarian and vegan infants (Ministry of Health, 2012). Other documents describe nutritious foods as sources of specific nutrients. One collaborative guideline document stated “nutritious, higher-fat foods are an important source of energy for young children” (Health Canada et al., 2014).⁴¹ Other relevant statements include “nutritious food that provides an adequate amount of protein (such as eggs, fish, meat) and energy” (Pérez-Escamilla et al., 2017 [RWJF-HER]), and “do

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³⁷Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).

³⁸ Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Nutrient Content of Complementary Foods, p. 22, Copyright (2003).

³⁹ Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Nutrient Content of Foods, p. 12, Copyright (2005).

⁴⁰Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).

⁴¹ © All rights reserved. Nutrition for healthy term infants: Recommendations from six to 24 months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.

not introduce foods without overall nutritional value simply to provide calories” (Gidding et al., 2005 [AHA]).

Some of the guideline documents made general statements about encouraging a variety of nutritious foods (NICE, 2008) or to “introduce healthy foods and continue offering if initially refused” (Gidding et al., 2005 [AHA]). One guideline document from SACN recommended taking the infant’s developmental attainment and nutritional requirements into consideration (SACN, 2018). In four guideline documents, recommendations on what nutritious or healthy foods should be provided are combined with cautionary statements about foods to avoid, such as sugar-sweetened beverages, sweets, salty food and snacks, and fried food and snacks (Gidding et al., 2005 [AHA]; PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; WHO, 2005).⁴²

Consistency

The guideline documents were consistent in recommending a variety of nutritious foods and food groups, textures, and flavors, which can help meet nutritional requirements. There was variability in the level of specificity about foods, food groups, and nutrients across the recommendations.

Evidence Base

Across the 10 guideline documents, the committee identified 30 statements of recommendation. The majority of recommendations mapped to narrative reviews, background documents, and/or technical documents, either alone or in combination with other resources. A recommendation from ESPGHAN (Fewtrell et al., 2017) mapped to a systematic literature search. One recommendation from the NICE (2008) guideline document mapped to both a UK Department of Health report (Department of Health, 1994) and a rapid review.

FRUITS AND VEGETABLES

Eight guideline documents included recommendations related to feeding fruits and vegetables (see Appendix B, Table B-11). Two of the guideline documents were collaborative efforts between two organizations (Alvisi et al., 2015 [SIAIP and SIGENP]; PAHO/WHO, 2003); two guideline documents were from AAP (Baker et al., 2010; Heyman et al., 2017). Accordingly, the identified guidelines documents reflect nine different organizations

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⁴² Detailed summaries of recommendations on these related topics are found in “Fluids: Water, Juice, Sugar-Sweetened Beverages, and Other Nonmilk Beverages” and “Substances to Avoid or Limit.”

from Europe, Italy, New Zealand, the United Kingdom, and the United States, along with PAHO and WHO.⁴³

Variety, Frequency, and Types of Fruits and Vegetables

Eight guideline documents that included statements on variety, frequency, or types of fruits and vegetables varied in their specificity. Two guideline documents stated that children should be fed a variety of fruits and vegetables, and emphasized that children should eat dark-green leafy vegetables (Ministry of Health, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]). Guideline documents from AAP noted that children should be fed whole fruit (Heyman et al., 2017) and that children should eat foods rich in vitamin C to improve iron absorption (Baker et al., 2010). One guideline document from ESPGHAN recommended offering infants a varied diet that included bitter-tasting green vegetables (Fewtrell et al., 2017). A guideline document from PAHO/WHO stated that children should eat vitamin A–rich fruits and vegetables (PAHO/WHO, 2003).

Three guideline documents addressed the amount or frequency of consumption of fruits and vegetables. One guideline document stated that children should eat plenty of fruits and vegetables (Pérez-Escamilla et al., 2017 [RWJF-HER]). A guideline document from Italian pediatric societies recommended daily consumption of fruits and vegetables (Alvisi et al., 2015 [SIAIP and SIGENP]), whereas a guideline document from AAP recommended daily consumption of fruit (Heyman et al., 2010). A NICE (2008) guideline document recommended offering fruits and vegetables as snacks. The New Zealand Ministry of Health stated that dried fruits should not be offered as snacks because they can be cariogenic (Ministry of Health, 2012).

Consistency

The guideline documents were consistent in recommending consumption of a variety of fruits and vegetables, especially dark-green vegetables and orange- and red-colored fruits and vegetables. Guideline documents were consistent in recommending frequent or abundant fruit and vegetable consumption, but they varied with respect to the daily amount specified in the recommendation.

Evidence Base

Across the eight guideline documents, the committee identified 11 statements of recommendation. Most of the recommendations mapped

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⁴³ Organizations reflected in the guideline documents include AAP, ESPGHAN, New Zealand Ministry of Health, NICE, PAHO, RWJF-HER, SIAIP, SIGENP, and WHO.

to narrative reviews or technical documents. The recommendation from ESPGHAN (Fewtrell et al., 2017) mapped to a systematic literature search. The recommendation on dried fruit in the New Zealand Ministry of Health (Ministry of Health, 2012) guideline document mapped to a 2008 New Zealand Dental Association guide. The recommendation from AAP (Baker et al., 2010) mapped to the Dietary Reference Intakes (DRIs) for iron. The recommendation from NICE (2008) mapped to both a UK Department of Health report (Department of Health, 1994) and a rapid review.

Acceptance of Vegetables

An RWJF-HER guideline document included statements on ways to help children accept vegetables (Pérez-Escamilla et al., 2017). Recommendations stated the importance of early introduction (once complementary feeding is started), repeated exposure, and mixing new vegetables with familiar foods.

Consistency

As only one guideline discussed acceptance of vegetables, no comment on consistency can be made.

Evidence Base

Within the RWJF-HER guideline document (Pérez-Escamilla et al., 2017), the committee identified three statements of recommendation. All recommendations mapped to a narrative review.

VEGETARIAN AND VEGAN DIETS

Nine guideline documents include recommendations related to vegetarian or vegan diets for infants and children under 2 years of age (see Appendix B, Table B-12). One of the guideline documents was an RWJF-HER consensus statement that included participants representing four organizations (Lott et al., 2019), two of which also provided their own guideline documents on the topic; one guideline document was a joint PAHO/WHO effort (PAHO/WHO, 2003). The identified guideline documents reflect 11 different organizations from Australia, Canada, Europe, New Zealand, and the United States, along with PAHO and WHO.⁴⁴

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⁴⁴ Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, CPS, ESPGHAN, New Zealand Ministry of Health, NHMRC, PAHO, RWJF-HER, and WHO.

Nutrient Adequacy of Vegetarian or Vegan Diets

Seven guideline documents included recommendations related to nutrient adequacy of vegetarian or vegan diets. Guideline documents from the Academy of Nutrition and Dietetics (AND) and CPS stated that an “appropriately planned” or “well-balanced” vegetarian diet is acceptable (Amit et al., 2010 [CPS]; AND, 2016), though both stipulated the need for attention to specific nutrients either in the recommendations themselves (Amit et al., 2010 [CPS]) or in the rest of the guideline document (AND, 2016). Four guideline documents made explicit cautionary statements about vegetarian or vegan diets. A guideline document from ESPGHAN cautioned against vegan diets, stating that they “should only be used under appropriate medical or dietetic supervision” and that “parents should understand the serious consequences of failing to follow advice regarding supplementation of the diet” (Fewtrell et al., 2017). Similarly, a guideline document from CPS commented on the need for fortified foods or supplements for infants on vegan diets (e.g., to meet calcium and vitamin B12 needs) (Amit et al., 2010). For nonbreastfed infants, a WHO guideline document stated that “diets that do not contain animal-source foods (meat, poultry, fish, or eggs, plus milk products) cannot meet all nutrient needs at this age unless fortified products or nutrient supplements are used” (WHO, 2005).⁴⁵ For breastfed infants, a PAHO/WHO guideline document stated that “vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used” (PAHO/WHO, 2003).⁴⁶

Four guideline documents mentioned specific nutrients of concern for vegetarian infants and young children in the recommendations (Amit et al., 2010 [CPS]; Fewtrell et al., 2017 [ESPGHAN]; Ministry of Health, 2012; NHMRC, 2012), and another mentioned key nutrients elsewhere in its guideline document (AND, 2016). In all four documents, iron was mentioned as a key nutrient. For instance, the statement from the Australian government guideline document said that “care needs to be taken particularly with a plant-based diet to ensure that supplies of iron are adequate” (NHMRC, 2012).⁴⁷ Other key nutrients mentioned in these recommendations are outlined in Table 4-2. Two guideline documents—one from CPS, the other from the New Zealand Ministry of Health—also provided recommendations about specific types of foods to include in vegetarian or vegan diets (Amit et al., 2010; Ministry of Health, 2012).

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⁴⁵ Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Nutrient Content of Foods, p. 12, Copyright (2005).

⁴⁶ Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Nutrient Content of Complementary Foods, p. 22, Copyright (2003).

⁴⁷NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).

TABLE 4-2 Key Nutrients Included in Recommendations Related to Nutrient Adequacy of Vegetarian or Vegan Diets

NOTE: ALA = alpha-linolenic acid; CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; LCPUFA = long-chain polyunsaturated fatty acids; NHMRC = National Health and Medical Research Council; Vit. = vitamin; WHO = World Health Organization.

Consistency

The guideline documents were consistent in stipulating the need for a carefully planned diet to meet requirements for several key nutrients, and somewhat inconsistent in whether they explicitly mentioned a need for fortified products or nutrient supplements for vegans.

Evidence Base

Across the seven guideline documents, the committee identified 20 statements of recommendation. Most recommendations mapped to narrative reviews, background documents, or technical documents. The recommendation from ESPGHAN (Fewtrell et al., 2017) mapped to a systematic literature search.

Use of Soy-Based Formulas for Nonbreastfed Infants When a Vegetarian or Vegan Diet Is Selected⁴⁸

Two guideline documents—one from AAP and one from the New Zealand Ministry of Health—stated that for infants who are not breastfed or are partially breastfed, soy-based formulas are recommended when a

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⁴⁸ Recommendations related to soy-based infant formula use are more broadly reviewed in the “Type of Infant Formula” section earlier in this chapter.

vegetarian or vegan diet is selected (Bhatia et al., 2008; Ministry of Health, 2012).

Consistency

The guideline documents were consistent in stating that soy-based formula is an appropriate choice for nonbreastfed infants whose caregivers choose a vegetarian diet.

Evidence Base

Across the two guideline documents, the committee identified three statements of recommendation that all mapped to narrative reviews.

Use of Plant-Based Beverages When a Vegetarian or Vegan Diet Is Selected⁴⁹

Two guideline documents mentioned plant-based beverages for young children when a vegetarian or vegan diet is selected, one explicitly (Lott et al., 2019 [RWJF-HER]) and one implicitly (Ministry of Health, 2012). The recommendation from a collaborative consensus statement from RWJF-HER said that children 1–5 years of age should consume such beverages “only when medically indicated or to meet specific dietary preferences” (Lott et al., 2019). The recommendation from the New Zealand Ministry of Health stated that “for toddlers who do not have cow milk or milk products, calcium-fortified milk alternatives can provide calcium” (Ministry of Health, 2012).⁵⁰

Consistency

The guideline documents were generally consistent in mentioning plant-based beverages as an option for toddlers in the context of specific dietary preferences, though with more cautionary language from the collaborative consensus statement from RWJF-HER (Lott et al., 2019).

Evidence Base

Across the two guideline documents, the committee identified three statements of recommendation. The New Zealand Ministry of Health (2012)

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⁴⁹ Recommendations related to plant-based beverages are more broadly reviewed in the “Fluids and Nonmilk Beverages” section earlier in this chapter.

⁵⁰Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).

recommendations mapped to narrative reviews. The collaborative consensus statement from RWJF-HER (Lott et al., 2019) mapped to the DGA.

FOODS ASSOCIATED WITH FOOD ALLERGY AND CELIAC DISEASE

Ten guideline documents included recommendations regarding the consumption of foods associated with food allergy and celiac disease (see Appendix B, Table B-13). Two of the guidelines were collaborative efforts among two organizations (Alvisi et al., 2015 [SIAIP and SIGENP]; SACN and COT, 2018). Two relevant guideline documents were identified for both ESPGHAN (Fewtrell et al., 2017; Szajewska et al., 2016) and SACN (SACN, 2018; SACN and COT, 2018). Accordingly, the identified guideline documents reflect 10 different organizations from Canada, Europe, Italy, the United Kingdom, and the United States.⁵¹

Allergenic Foods in General and Relationship to Food Allergy

Six guideline documents made a general recommendation that the introduction of allergenic complementary foods should not be delayed in order to prevent food allergy (atopic disease). There were slight variations in the recommended age of introduction across the guideline documents. An ESPGHAN guideline document recommended introduction any time “after 4 months (17 weeks)” (Fewtrell et al., 2017). An RWJF-HER guideline document recommended that common allergenic foods could be introduced when the infant “is ready to eat solid food (usually between 4 and 6 months of age)” (Pérez-Escamilla et al., 2017). Similarly, the AAP guideline document recommended not delaying introduction beyond 4–6 months of age (Greer et al., 2019). Both a CPS guideline document and a SACN and COT guideline document recommended introduction at about 6 months of age (Abrams et al., 2019; SACN and COT, 2018). A collaborative guideline document from Italian pediatric societies recommended not to delay introducing potentially allergenic foods, but it did not specify age of introduction (Alvisi et al., 2015).

Some of the guideline documents included guidance on how to introduce potentially allergenic foods. A guideline document from CPS recommended introducing allergenic foods one at a time and continuing these several times per week if they were tolerated (Abrams et al., 2019). Both

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⁵¹ Organizations reflected in the guideline documents include AAP, COT, CPS, ESPGHAN, NIH/NIAID, RCPCH, RWJF-HER, SACN, SIAIP, and SIGENP. The committee notes that one of the references (Togias et al., 2017) had a coordinating committee with members representing 25 professional organizations, along with a 26-member expert panel.

the SACN and COT (2018) guideline document and an RWJF-HER (Pérez-Escamilla et al., 2017) guideline document recommended consulting a physician regarding timing of introduction of allergenic foods if there were a family history of food allergy. The RWJF-HER guideline document also recommended introducing allergenic foods after other solids foods were tolerated (Pérez-Escamilla et al., 2017).

Consistency

The guideline documents were consistent in recommending that the introduction of allergenic foods as complementary foods not be delayed, although there was some variation in the recommended timing of introduction.

Evidence Base

Across the six guideline documents, the committee identified 12 statements of recommendation. Two recommendations from the SACN and COT (2018) guideline document mapped to a systematic review, whereas one recommendation from an ESPGHAN (Fewtrell et al., 2017) guideline document mapped to a systematic literature search. Three recommendations from the RWJF-HER guideline document (Pérez-Escamilla et al., 2017) mapped to the American Academy of Allergy, Asthma & Immunology (AAAAI) (2015) and the Australasian Society of Clinical Immunology and Allergy (ASCIA) (2016). One recommendation from the AAP guideline document (Greer et al., 2019) and one recommendation from the Italian pediatric societies (Alvisi et al., 2015) mapped to narrative reviews. One of the recommendations from the CPS guideline document (Abrams et al., 2019) mapped to a narrative review; however, three statements of recommendation in that guideline document could not be mapped to evidence.

Peanut-Containing Food and Peanut Allergy

Five guideline documents included specific recommendations about timing of introduction of peanut-containing foods and peanut allergy. All of the recommendations referred to the Learning Early About Peanut Allergy (LEAP) trial (Du Toit et al., 2015). One of these guideline documents, a National Institute of Allergy and Infectious Diseases (NIAID)-sponsored expert panel report (Togias et al., 2017), made specific recommendations for timing of introduction of peanuts based on three levels of risk. For the highest-risk infants (infants with severe eczema and/or egg allergy), the NIAID-sponsored expert panel recommended that peanuts should be introduced between 4 and 6 months of age. For infants with mild to

moderate eczema, the NIAID-sponsored expert panel recommended that peanut-containing foods should be introduced at around 6 months of age. Infants at low risk for peanut allergy (no eczema or food allergy) could have peanut-containing foods “freely introduced in the diet together with other solid foods and in accordance with family preferences and cultural practices” (Togias et al., 2017). In its 2019 guideline document, AAP (Greer et al., 2019) directly endorsed the NIAID recommendations (Togias et al., 2017). An ESPGHAN guideline document recommended that for infants at high risk for peanut allergy (defined by the LEAP trial), peanuts should be introduced between 4 and 11 months (Fewtrell et al., 2017). Two of the guideline documents recommended introduction of peanuts at 6 months of age without regard to risks (SACN, 2018; SACN and COT, 2018); both also stated that delaying the introduction of peanuts beyond 6–12 months may increase the risk of peanut allergy.

Consistency

The guideline documents were not consistent in recommending when and how to introduce peanuts based on the infant’s risk for peanut allergy. There was consistency among the recommendations from NIAID (Togias et al. 2017), AAP (Greer et al., 2019), and ESPGHAN (Fewtrell et al., 2017). The recommendations from SACN (2018) and SACN and COT (2018) guideline documents were consistent with each other, but not with the other three guideline documents, particularly with respect to timing of introducing peanuts based on the risk of peanut allergy.

Evidence Base

Across the five guideline documents, the committee identified eight statements of recommendation. The NIAID recommendations (Togias et al., 2017), which were endorsed by AAP (Greer et al., 2019), were based on the LEAP trial for the highest-risk infants and evidence from the LEAP trial and the Enquiring About Tolerance trial (Perkin et al., 2016) and expert opinion for moderate- and low-risk infants. Two recommendations from the SACN and COT guideline document (2018) mapped to systematic reviews, whereas one recommendation from the ESPGHAN guideline document (Fewtrell et al., 2017) mapped to a systematic literature search. The SACN (2018) recommendation mapped to a narrative review.

Eggs and Egg Allergy

Three guideline documents included specific recommendations related to the introduction of eggs and egg allergy. Though AAP recommended earlier

rather than later introduction of eggs, it stated that the evidence for preventing atopic disease (food allergy) was less clear compared to evidence for introducing peanuts (Greer et al., 2019). Both the SACN (2018) and SACN and COT (2018) guideline documents recommended introduction of eggs “around 6 months of age.” Both guideline documents also noted that the deliberate exclusion of eggs beyond 6–12 months of age may increase the risk of egg allergy.

Consistency

The guideline documents were generally consistent in recommending that introduction of eggs not be delayed, although the specific recommended age of introduction varied slightly.

Evidence Base

Across the three guideline documents, the committee identified five statements of recommendation. The two recommendations from the SACN and COT (2018) guideline document mapped to a systematic review. The recommendations from the AAP (Greer et al., 2019) and SACN (2018) guideline documents mapped to narrative reviews.

Other Specific Allergenic Foods⁵² and Food Allergies

Two guideline documents included specific recommendations about the consumption of allergenic foods, other than eggs or peanuts. The RWJF-HER guideline document stated that dairy products (e.g., yogurt, cow milk protein formula), soy, wheat, fish, and shellfish can be introduced between 4 and 6 months of age (Pérez-Escamilla et al., 2017). An AAP guideline document stated that there was no evidence to delay the introduction of fish beyond 4–6 months of age to prevent atopic disease (food allergy) (Greer et al., 2019).

Consistency

The guideline documents were consistent with respect to their recommendations related to the introduction of fish between 4 and 6 months of age and food allergy. The RWJF-HER document, however, had a more extensive list of other potential allergenic foods.

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⁵² Other than eggs or peanuts.

Evidence Base

Across the two guideline documents, the committee identified two statements of recommendation. The recommendation from the RWJF-HER guideline document (Pérez-Escamilla et al., 2017) was cited as coming from AAAAI (2015) and ASCIA (2016). The recommendation from AAP (Greer et al., 2019) mapped to a narrative review.

Gluten-Containing Foods and Celiac Disease

Three guideline documents included recommendations related to the introduction of gluten-containing foods and celiac disease. A guideline document from Italian pediatric societies stated that “there is no ideal timing for gluten introduction in relation with the onset of celiac disease” (Alvisi et al., 2015).⁵³ Two ESPGHAN guideline documents stated that gluten-containing foods can be introduced between 4 and 12 months of age but to avoid large amounts of gluten during the first weeks or months after gluten introduction and during infancy (Fewtrell et al., 2017; Szajewska et al., 2016). The 2016 ESPGHAN guideline document, which was specific for gluten-containing foods and the relationship to celiac disease or celiac disease autoimmunity, also stated that introduction of gluten while breastfeeding does not reduce the risk of celiac disease and recommendations for breastfeeding should not be modified based on the prevention of celiac disease (Szajewska et al., 2016).

Consistency

The guideline documents were generally consistent regarding the introduction of gluten-containing foods and risk of celiac disease. The recommendations either indicated that there was no ideal timing or offered a broad range of ages (4–12 months) for introduction of gluten.

Evidence Base

Across the three guideline documents, the committee identified six statements of recommendation. The four recommendations from Szajewska et al. (2016 [ESPGHAN]) mapped to a systematic review, whereas one recommendation from Fewtrell et al. (2017 [ESPGHAN]) mapped to a systematic literature search. The recommendation from the Italian pediatric societies guideline document (Alvisi et al., 2015) mapped to a narrative review.

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⁵³Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).

Foods That May Prevent Food Allergy

Two guideline documents included recommendations as to whether breastfeeding or the use of hydrolyzed formulas influences risk of food allergy (Greer et al., 2019; Pérez-Escamilla et al., 2017 [RWJF-HER]). The AAP guideline document stated that “no conclusions can be made about the role of any duration of breastfeeding in either preventing or delaying the onset of specific food allergies” (Greer et al., 2019). Both the AAP and RWJF-HER guideline documents stated that the feeding of either partially or extensively hydrolyzed formulas will not prevent food allergy.

Consistency

Only one guideline document addressed the relationship between breastfeeding and prevention of food allergies. As such, no statement about consistency can be made. Two guideline documents were consistent in stating that partially or extensively hydrolyzed formulas would not prevent food allergies.

Evidence Base

Across the two guideline documents, the committee identified four statements of recommendations. The recommendation from the RWJF-HER guideline document (Pérez-Escamilla et al., 2017) was cited as coming from AAAAI (2015) and ASCIA (2016). The three recommendations from the AAP guideline document (Greer et al., 2019) mapped to a narrative review.

IRON

Seventeen guideline documents included recommendations regarding iron intake in the first 2 years of life (see Appendix B, Table B-14). One of the guideline documents was a collaborative effort among four organizations (Health Canada et al., 2015). Three organizations participated in multiple guideline documents: AAP (AAP Section on Breastfeeding, 2012; Baker et al., 2010), CPS (Amit et al., 2010; Grueger et al., 2013; Health Canada et al., 2015; Unger et al., 2019), and ESPGHAN (Domellöf et al., 2014; Fewtrell et al., 2017; Hojsak et al., 2018). The identified guideline documents reflect 14 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with WHO.⁵⁴

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⁵⁴ Organizations reflected in the guideline documents include AAFP, AAP, ABM, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, EFSA, ESPGHAN, Health Canada, New Zealand Ministry of Health, NHMRC, RWJF-HER, SACN, and WHO.

Iron-Rich Complementary Foods

Fourteen guideline documents included recommendations related to iron-rich complementary foods. Seven guideline documents from six organizations recommended introducing iron-rich foods at 6 months of age (AAP Section on Breastfeeding, 2012; Baker et al., 2010 [AAP]; Domellöf et al., 2014 [ESPGHAN]; SACN, 2018; Taylor and ABM, 2018; Unger et al., 2019 [CPS]; WHO, 2005). A guideline document from RWJF-HER recommended introducing iron-rich complementary foods at 4–6 months (Pérez-Escamilla et al., 2017).

Two of the guideline documents related the timing of introducing iron-rich foods to an infant’s risk for iron deficiency or depletion. A CPS guideline document recommended that the introduction of iron-rich complementary foods between 4 and 6 months could be considered when there is high risk for iron deficiency anemia and the infant is developmentally ready (Unger et al., 2019). Similarly, a European Food Safety Authority (EFSA) guideline document suggested introduction of complementary foods as a source of iron before 6 months of age in infants at risk for iron depletion, including “exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping (less than 1 minute after birth)” (EFSA Panel on Nutrition et al., 2019).

Some guideline documents were less specific about the timing of introducing iron-rich complementary foods. Recommendations in guideline documents from ESPGHAN (Fewtrell et al., 2017), a collaborative effort among four Canadian organizations (Health Canada et al., 2015), AAFP (2014), CPS (Grueger et al., 2013), and the Australian government (NHMRC, 2012) did not specify an age for introducing iron-rich complementary foods. Only two guideline documents specifically recommended iron-rich foods for toddlers 12–24 months (Baker et al., 2010 [AAP]; WHO, 2005).

Consistency

The guideline documents were consistent in acknowledging the need to introduce iron-rich complementary foods, but they were not consistent in the recommended age of introduction. Most of the guideline documents recommended introducing iron-rich foods at 6 months. The RWJF-HER guideline document recommended the introduction of iron-rich foods at 4–6 months of age dependent on when the infant was developmentally ready for complementary food (Pérez-Escamilla et al., 2017). Two guideline documents recommended introduction before 6 months for infants at risk for iron depletion. Several of the recommendations underscored the importance of iron-rich complementary foods but did not specify timing of introduction. Only two guideline documents noted the importance of iron-rich foods for children older than 1 year of age.

Evidence Base

Across the 14 guideline documents, the committee identified 19 statements of recommendation. The majority of the recommendations mapped to narrative reviews and background documents. For one recommendation from ABM (Taylor and ABM, 2018), the type of literature review supporting the guidance was unclear. One recommendation from the EFSA guideline document (EFSA Panel on Nutrition et al., 2019) and two recommendations from the Australian government (NHMRC, 2012) mapped to systematic reviews, either alone or in combination with other resources. One recommendation from an ESPGHAN guideline document (Fewtrell et al., 2017) mapped to a systematic literature search. One recommendation from the AAFP (2014) guideline document mapped to an AAP statement. Three recommendations from two AAP guideline documents (AAP Section on Breastfeeding, 2012; Baker et al., 2010) could not be mapped to their evidence.

Iron-Fortified Formulas

Six guideline documents included recommendations related to iron-fortified formulas. Five guideline documents included recommendations supporting the use of iron-fortified infant formula for formula-fed infants, versus formula not fortified with iron, though the recommended duration of use varied. Recommendations from RWJF-HER (Pérez-Escamilla et al., 2017), NHMRC (2012), and AAP (Baker et al., 2010) encouraged the use of iron-fortified formulas until 12 months of age. In contrast, a CPS guideline document recommended use “for the first 9 to 12 months” (Unger et al., 2019), and an ESPGHAN guideline document recommended use “until up to 6 months” (Domellöf et al., 2014). Domellöf et al. (2014) further noted that after 6 months of age, formula-fed infants should receive additional iron in the formula, but that the high amounts currently used in European standard infant formulas (up to 8.5 mg/L) cannot be justified for use in the second 6 months of life compared to the lower amounts typically found in follow-on formulas.

Three organizations specified the suggested iron concentration for infant formulas. A CPS guideline document recommended that formulas contain 6.5–13 mg/L (Unger et al., 2019). An ESPGHAN guideline document recommended that formulas contain 4–8 mg/L of iron (Domellöf et al., 2014), and AAP recommended 10–12 mg/L (Baker et al., 2010). One guideline document recommended against the use of low-iron formulas, defined as those with iron content less than 6.7 mg/L (Pérez-Escamilla et al., 2017 [RWJF-HER]).

One guideline document from ESPGHAN stated that iron-fortified formula (rather than a formula not fortified with iron) for children 1–3 years

of age can be used to increase iron intake but there is no necessity for these young children formulas (Hojsak et al., 2018). An earlier ESPGHAN statement noted that follow-on formulas should be iron fortified, but that the optimal iron concentration could not be determined (Domellöf et al., 2014).

Consistency

The guideline documents were consistent in recommending iron-fortified formula (as compared to unfortified formula) for formula-fed infants. There were some inconsistencies in the specified age range to which this applied (once formula is introduced), ranging from the first 6 months of age to the first 12 months of age. There were also some inconsistencies among the three guideline documents that made recommendations for the iron content of infant formula, with suggested content varying from 4 to 13 mg/L. One guideline document recommended against the use of low-iron formula (Pérez-Escamilla et al., 2017 [RWJF-HER]).

Evidence Base

Across the six guideline documents, the committee identified eight statements of recommendation. Most of the recommendations mapped to narrative reviews. One recommendation from the Australian government (NHMRC, 2012) mapped to a systematic review, whereas one recommendation from an ESPGHAN guideline document (Hojsak et al., 2018) mapped to a systematic literature review.

Medicinal Iron Supplements

Seven guideline documents included recommendations regarding the use of medicinal iron supplements. A guideline document from AAP (Baker et al., 2010) recommended general use of an iron supplement (1 mg/kg/day) for all exclusively breastfed and partially breastfed infants beginning at 4 months of age and continuing until age-appropriate iron-containing complementary foods are introduced in the diet. Two other recommendations from the AAP guideline document (Baker et al., 2010) recommended targeted iron supplements for infants between 6 and 12 months and children between 1 and 3 years of age with inadequate iron intake. An ABM guideline document recommended that if iron supplementation is given before 6 months of age, 1 mg/kg/day should be given until iron-fortified cereals or other iron-rich foods are introduced into the diet (Taylor and ABM, 2018). For nonbreastfed children, WHO (2005) recommended use of fortified foods or vitamin mineral supplements that contain iron (8–10 mg/day at 6–12 months), as needed.

Four guideline documents did not recommend general use of iron supplements: CPS (Unger et al., 2019), ESPGHAN (Domellöf et al., 2014), New Zealand Ministry of Health (Ministry of Health, 2012), and SACN (2018); however, all included qualifications that may account for some of the inconsistency with the earlier 2010 AAP recommendation (Baker et al., 2010). For instance, the 2012 guideline document from the New Zealand Ministry of Health recommended iron supplements for infants and toddlers if there is a diagnosis of iron deficiency or if there has been exclusive breastfeeding for a prolonged period (Ministry of Health, 2012). An ESPGHAN guideline document recommended no general iron supplementation for healthy European infants and toddlers of normal birthweight, but it also recommended that delayed cord clamping be considered for all infants (Domellöf et al., 2014). This narrative summary also noted that iron supplementation may be provided to infants “from high-risk groups (low socioeconomic status or living in areas with high prevalence of [iron deficiency anemia]) if the infant has a low intake of iron-rich complementary foods” (Domellöf et al., 2014). The SACN guideline document recommended delayed cord clamping for all infants (SACN, 2018), and the narrative review also noted the importance of normal maternal iron status and adequate fetal iron stores. The most recent CPS guideline document recommended no iron supplementation for healthy term infants with no risk factors who are exclusively breastfed for 6 months, but it promoted delayed cord clamping in the narrative review to reduce iron deficiency (Unger et al., 2019).

Two organizations made recommendations for iron supplements for toddlers 12–24 months of age. For nonbreastfed children, WHO (2005) recommended use of fortified foods or vitamin mineral supplements, 5–7 mg/day at 12–24 months, as needed. An AAP guideline document recommended that for toddlers (12–36 months) not receiving an intake of 7 mg/day of iron from foods, liquid supplements could be used (Baker et al., 2010).

Consistency

The guideline documents were generally consistent in recommending against general iron supplementation of infants, with qualifications for infants with potential risks for iron deficiency. The one exception, a 2010 AAP recommendation for general iron supplements starting at 4 months of age for exclusively breastfed infants (Baker et al., 2010), was written before delayed cord clamping was recommended in the United States and was a general recommendation without regard for risks. AAP (Baker et al., 2010) and WHO (WHO, 2005) were the only organizations that addressed the potential need for iron supplements for children 12–24 months of age, and these were consistent.

Evidence Base

Across the seven guideline documents, the committee identified nine statements of recommendation. The majority of recommendations mapped to narrative reviews, alone or in combination with other resources. The AAP recommendation (Baker et al., 2010) regarding general supplementation starting at 4 months for exclusively breastfed infants mapped to a citation for a double-blind, randomized controlled trial on iron supplementation (Friel et al., 2003), whereas the recommendation for partially breastfed infants mapped to a narrative review. The other two recommendations in Baker et al. (2010) regarding targeted use of iron supplements for those whose dietary intake is low mapped to the iron DRIs. For one recommendation from ABM (Taylor and ABM, 2018), the type of literature review supporting the guidance was unclear.

Iron Intake of Vegetarian or Vegan Infants⁵⁵

Five guideline documents noted the importance of adequate intake of (bioavailable) iron for vegetarian and vegan infants (Amit et al., 2010 [CPS]; Fewtrell et al., 2017 [ESPGHAN]; Ministry of Health, 2012; NHMRC, 2012; WHO, 2005). The ESPGHAN recommendation did not provide guidance on the source of the iron (Fewtrell et al., 2017), whereas guideline documents from the Australian government (NHMRC, 2012), CPS (Amit et al., 2010), the New Zealand Ministry of Health (Ministry of Health, 2012), and WHO (2005) indicated that iron-rich foods or iron supplements may be used. The New Zealand Ministry of Health also recommended that a source of vitamin C should be added to the diet to improve iron absorption (Ministry of Health, 2012).

Consistency

The guideline documents were consistent in underscoring the importance of adequate iron intake among vegetarian and vegan infants, although not all of them described the recommended sources of iron. Only one guideline document included a recommendation that emphasized vitamin C intake to enhance iron absorption (Ministry of Health, 2012).

Evidence Base

Across the five guideline documents, the committee identified six statements of recommendation. All recommendations mapped to narrative reviews,

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⁵⁵ For a more in-depth exploration of related recommendations, see the “Vegetarian and Vegan Diets” section earlier in this chapter.

alone or in combination with other resources, except one from ESPGHAN (Fewtrell et al., 2017), which mapped to a systematic literature search.

VITAMIN D

Twelve guideline documents included recommendations related to vitamin D (see Appendix B, Table B-15). Two of the guideline documents were collaborative efforts among the same four organizations (Health Canada et al., 2014, 2015). Furthermore, CPS and the New Zealand Ministry of Health provided multiple guideline documents that contained vitamin D–related recommendations. The identified guideline documents reflect 10 different organizations from Canada, Europe, New Zealand, the United Kingdom, and the United States.⁵⁶

Vitamin D Supplementation for Breastfed Infants

Nine guideline documents included vitamin D–related recommendations for breastfed infants. The levels of vitamin D supplementation recommended were 340–400 IU/day (SACN, 2018), 400 IU/day (Golden et al., 2014; Health Canada et al., 2014, 2015; Pérez-Escamilla et al., 2017), or 400–800 IU/day (Taylor and ABM, 2018). Although a CPS guideline document recommended vitamin D supplementation, no specific dose was given (Grueger et al., 2013). In contrast, a 2013 New Zealand Ministry of Health guideline document recommended vitamin D supplementation (400 IU/day) for breastfed or partially breastfed infants (who receive less than 500 mL of formula/day) only if they are at high risk for vitamin D deficiency (Ministry of Health, 2013); the recommendation further noted that if supplementation is used, it should not be used until breastfeeding is established (Ministry of Health, 2013). A 2012 New Zealand Ministry of Health guideline document stated that it did not support the use of routine vitamin D supplements for breastfed infants, except for infants and toddlers at risk for vitamin D deficiency (Ministry of Health, 2012). An AAP guideline document stated

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⁵⁶ Organizations reflected in the guideline documents include AAP, ABM, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Ministry of Health, RWJF-HER, and SACN.

Consistency

The guideline documents were generally consistent in recommending vitamin D supplementation for breastfed infants. When provided, the suggested dose was generally consistent, at ~400 IU/day, although there was some variation in range. The New Zealand Ministry of Health (2012, 2013) was the only organization that recommended against supplementation of exclusively or partially breastfed infants and toddlers, unless they were at high risk for vitamin D deficiency.

Evidence Base

Across the nine guideline documents, the committee identified 10 statements of recommendation. Most recommendations mapped to narrative reviews. One recommendation from an AAP guideline document (Golden et al., 2014) mapped to the vitamin D DRIs. For one recommendation from ABM (Taylor and ABM, 2018), the type of literature review supporting the guidance was unclear.

Vitamin D Supplementation and Formula-Fed Infants

Two guideline documents included recommendations specifically for formula-fed infants. The guideline document from SACN (2018) recommended vitamin D supplements (without specifying a dose) if infants are receiving less than 500 mL/day of formula. A guideline document from RWJF-HER noted that a doctor may advise vitamin D supplementation for formula-fed infants receiving less than 1,000 mL/day of formula (Pérez-Escamilla et al., 2017).

Consistency

The guideline documents were consistent in relating the need for vitamin D supplementation to the total amount of daily infant formula intake. However, the guideline documents were not consistent regarding the amount of infant formula intake that necessitated vitamin D supplementation.

Evidence Base

Across the two guideline documents, the committee identified two statements of recommendation. Both mapped to narrative reviews.

Vitamin D Supplementation Independent of Breastfeeding Status

Three guideline documents included recommendations related to vitamin D for infants 0–12 months without regard to their breastfeeding status.

Universal supplementation of infants with 400 IU/day of vitamin D was recommended in ESPGHAN and CPS guideline documents (Braegger et al., 2013; Godel et al., 2007). The New Zealand Ministry of Health recommended vitamin D supplementation for infants at high risk for vitamin D deficiency (Ministry of Health, 2012). The CPS guideline also specified a higher dose (800 IU/day) “between October and April north of the 55th parallel (approximate latitude of Edmonton) and between the 40th and 55th parallel in individuals with risk factors for vitamin D deficiency other than latitude alone” (Godel et al., 2007).

Consistency

The guideline documents that provided vitamin D recommendations for infants independent of breastfeeding status were not consistent for either universal supplementation or supplementation for infants at risk for vitamin D deficiency.

Evidence Base

Across the three guideline documents, the committee identified three statements of recommendation that all mapped to narrative reviews.

Vitamin D Supplementation for Children 12–24 Months of Age

Four guideline documents included recommendations related to vitamin D supplementation for children 12–24 months of age. An ESPGHAN guideline document recommended supplementation only for high-risk children (Braegger et al., 2013). Similarly, the New Zealand Ministry of Health recommended supplementation for toddlers at risk for vitamin D deficiency (Ministry of Health, 2012). Neither recommended a vitamin D dose. A guideline document from CPS stipulated 400 IU/day of vitamin D as a supplement for infants, children, and adolescents taking in less than 500 mL of vitamin D–fortified milk and 800 IU/day for children with a high-risk profile for vitamin D deficiency (Amit et al., 2010). One guideline document recommended 400 IU/day of vitamin D for breastfed children 12–24 months of age (Health Canada et al., 2014).

Consistency

The guideline documents were consistent in recommending vitamin D supplementation for children 12–24 months of age based on the child’s vitamin D risk status. How high risk for vitamin D deficiency was defined varied by recommendation. Both Health Canada and CPS recommended a

supplemental dose of 400 IU/day of vitamin D for at-risk children between 12 and 24 months of age (Amit et al., 2010; Health Canada et al., 2014).

Evidence Base

Across the four guidelines, the committee identified five statements of recommendation that all mapped to narrative reviews.

IODINE

Two guideline documents included recommendations related to iodine (see Appendix B, Table B-16). The guideline documents were from the New Zealand Ministry of Health (2012) and WHO (WHO Secretariat et al., 2007).

Iodine Supplementation

The two guideline documents included recommendations regarding iodine supplementation. Both recommended against the use of iodine supplements (Ministry of Health 2012; WHO Secretariat et al., 2007); the New Zealand Ministry of Health (2012) stated that medical supervision was necessary if iodine supplements were to be provided.

Consistency

The guidelines were consistent in indicating that iodine supplementation is generally not required for infants and young children.

Evidence Base

Across the two guideline documents, the committee identified two statements of recommendation. The recommendation from the New Zealand Ministry of Health (2012) guideline document mapped to a narrative review. The recommendation from the WHO guideline document (WHO Secretariat et al., 2007) could not be mapped to its evidence.

Iodine Consumption from Foods

The New Zealand Ministry of Health (2012) guideline document recommended using iodized salt, if salt is used in the food provided to toddlers, and to “gradually introduce foods containing iodine.” The guideline document also included a list of specific foods containing iodine, and suggested that these foods be prioritized for exclusively breastfed infants.

Consistency

Only one guideline document included recommendations related to iodine intake from foods. As such, no comment on consistency could be made.

Evidence Base

The four statements of recommendation from the New Zealand Ministry of Health (2012) mapped to narrative reviews.

OTHER NUTRIENT SUPPLEMENTS

Seven guideline documents included recommendations related to other nutrient supplements, beyond iron, vitamin D, and iodine (recommendations related to supplementation of these nutrients are described in the preceding sections) (see Appendix B, Table B-17). One of the guideline documents was a collaborative effort among two organizations (PAHO/WHO, 2003). WHO participated in two of the guideline documents (PAHO/WHO, 2003; WHO, 2005). The guideline documents reflect seven organizations from Australia, New Zealand, and the United States, along with PAHO and WHO.⁵⁷

Nutrient Supplements, Generally

Five guideline documents included general recommendations related to nutrient supplements. The recommendations generally stated that nutrient supplements are not needed if the infant or child is consuming a healthy, nutritious diet. Guideline documents noted nutrients that did not require supplementation, including zinc (even for breastfed infants) (Taylor and ABM, 2018) and selenium (Ministry of Health, 2012). Both an RWJF-HER guideline document (Pérez-Escamilla et al., 2017) and the New Zealand Ministry of Health (2012) noted that supplements and multivitamins are not necessary if a healthy diet is being consumed.

When nutrient supplements were recommended, the dose required was not always stated. In the WHO (2005) and PAHO/WHO (2003) guideline documents, use of fortified foods or supplements was recommended “as needed.” Such scenarios included recommending fortified foods or supplements containing several micronutrients (including iron, zinc, calcium, and vitamin B12) when the diet did not contain adequate amounts of animal-source foods.

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⁵⁷ Organizations reflected in the guideline documents include ABM, New Zealand Ministry of Health, NHMRC, PAHO, RWJF-HER, USPSTF, and WHO.

Consistency

The guideline documents were generally consistent in indicating that infants and toddlers with healthy, varied diets typically do not need nutrient supplements. The guideline documents varied with respect to which nutrients were specifically discussed and whether conditions under which nutrient supplementation would be warranted were explicitly specified.

Evidence Base

Across the five guideline documents, the committee identified seven statements of recommendation. Most recommendations mapped to narrative reviews, technical documents, or background documents. For the one recommendation from ABM (Taylor and ABM, 2018), the type of literature review supporting the guidance was unclear.

Fluoride Supplementation

Two guideline documents made recommendations related to fluoride supplementation. The U.S. Preventive Services Task Force (USPSTF) recommended “that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride” (Moyer, 2014). The Australian government did not recommend fluoride supplementation for infants and stated that, in nonfluoridated water areas, a dentist should be consulted regarding fluoride supplementation (NHMRC, 2012).

Consistency

The guideline documents were consistent in recommending that fluoride supplementation for infants and young children be contingent on the fluoride status of the water supply. There were some inconsistencies in the language describing the extent to which supplementation should be provided in areas with fluoride-deficient water supplies. The USPSTF guideline document (Moyer, 2014) indicated that health care providers should prescribe fluoride supplements in such areas, whereas the Australian government guideline document (NHMRC, 2012) indicated supplementation should be based on a dental consultation.

Evidence Base

Across the two guideline documents, the committee identified two statements of recommendation. The USPSTF recommendation was based on a systematic review; the recommendation was graded B, meaning “There

is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial” (Moyer, 2014). The Australian government recommendation mapped to a Centers for Disease Control and Prevention recommendation (CDC, 2001).

DIETARY FAT

Seven guideline documents included recommendations related to dietary fat (see Appendix B, Table B-18). One of the guideline documents was a collaborative effort among four organizations (Health Canada et al., 2014), one of which also provided a separate guideline document (Amit et al., 2010 [CPS]). Another guideline document was a collaborative effort among two organizations (PAHO/WHO, 2003), one of which also provided a separate guideline document (WHO, 2005). The identified guideline documents reflect nine different organizations from Australia, Canada, New Zealand, and the United States, along with PAHO and WHO.⁵⁸

Dietary Fat Intake, Generally

Three guideline documents included recommendations broadly focused on fat intake. A collaborative guideline document from Canada highlighted the importance of intake of nutritious higher-fat foods (Health Canada et al., 2014). A WHO guideline document recommended amounts of fats to be added to the diet of nonbreastfed infants based on whether or not animal-source foods were eaten (WHO, 2005). A guideline document from PAHO/WHO (2003) recommended that the diets of breastfed children contain “adequate fat content.”⁵⁹

Consistency

The guideline documents were consistent in noting the importance of young children having diets with adequate fat content.

Evidence Base

Across the three guideline documents, the committee identified three statements of recommendation. All recommendations mapped to narrative reviews, background documents, or technical documents.

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⁵⁸ Organizations reflected in the guideline documents include Breastfeeding Committee for Canada, CPS, Dietitians of Canada, Health Canada, New Zealand Ministry of Health, NHMRC, PAHO, RWJF-HER, and WHO.

⁵⁹ Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Nutrient Content of Complementary Foods, p. 22, Copyright (2003).

Type of Fat

Four guideline documents included recommendations on types of fat. Two guideline documents recommended avoiding foods with high levels of saturated fat and/or trans fat (NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]). Other guideline documents encouraged intake of essential fatty acids for strict vegans (Amit et al., 2010 [CPS]) or consumption of polyunsaturated fatty acids from plant oils in spreads and margarines (Ministry of Health, 2012). The guideline document from RWJF-HER recommended offering deboned fish to toddlers because it is a good source of healthy fat (omega-3s) and recommended choosing healthy oils such as “olive, canola, corn, or sunflower oil” when preparing foods for toddlers (Pérez-Escamilla et al., 2017).

Consistency

Two guideline documents, one from the Australian government (NHMRC, 2012) and one from RWJF-HER (Pérez-Escamilla et al., 2017), were consistent in recommending against foods high in saturated or trans fats. Guideline documents from RWJF-HER (Pérez-Escamilla et al., 2017) and the New Zealand Ministry of Health (2012) were consistent in recommending plant oils.

Evidence Base

Across the four guideline documents, the committee identified seven statements of recommendation. Most of the recommendations mapped to narrative reviews. The saturated fat recommendation from the Australian government (NHMRC, 2012) was embedded in a broader recommendation; the portion specifically related to saturated fat could not be mapped to its evidence.

SUMMARY

Guideline documents from government agencies and authoritative organizations provide a wide range of recommendations related to what to feed infants and young children. Guideline documents that commented on similar topics were mostly consistent in concept, although nuanced details often varied. The vast majority of recommendations were mapped to narrative reviews. A summary of the committee’s findings regarding consistency of recommendations is provided in Table 4-3.

TABLE 4-3 Summary of the Consistency of Recommendations on What to Feed Infants and Young Children, by Topic Area

TABLE 4-3

TABLE 4-3

NOTE: The committee uses the following phrases to describe consistency of recommendations:

• Consistent indicates alignment across the recommendations.
• Generally consistent indicates that the recommendations tended to provide similar guidance, although there were some differences in details or wording.
• Some inconsistencies indicates mixed recommendations, some of which align.
• Not consistent indicates recommendations provided different guidance on a topic.

^a This statement pertains to general use of plant-based beverages. A caveat is noted in the “Vegetarian and vegan diet” section.

^b Recommendations regarding foods to avoid or limit based on food safety considerations (e.g., unpasteurized beverages, honey due to the risk of botulism) are summarized in Chapter 5, “Safety of Foods and Feeding Practices,” and Table 5-2.

^c A recommendation in a 2010 guideline document predated the acceptance of delayed cord clamping in the United States, which changed iron supplementation recommendations for infants. The statement of consistency reflects only the more recent guideline documents.

^d This statement pertains to nutrient supplements generally. Consistency of recommendations related to supplementing specific nutrients are noted elsewhere in the table.

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