5
Existing Recommendations on How to Feed
This chapter reviews the recommendations related to how 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 how to feed infants and young children did not appear in the eligible guideline documents. Thus, although this chapter is a comprehen-
sive summary of the identified recommendations, it is not an exhaustive summary of all topics that are of interest to various stakeholders. Approximately one-third of the abstracted recommendations provided guidance related to how to feed infants and young children from birth to 24 months. Eligible recommendations were found in 23 of the 43 guideline documents. The recommendations have been grouped into eight 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 5-1 presents the terminology the committee uses throughout this chapter to describe the levels of consistency.
BOTTLE USE AND PROPPING
Ten guideline documents included recommendations related to bottle use or propping (see Appendix B, Table B-19). Four of the guideline documents were collaborative efforts between two or more organizations (AAPD, 2016; Health Canada et al., 2014, 2015; New Zealand Dental
Association, 2008); the American Academy of Pediatrics (AAP) and the New Zealand Ministry of Health each participated in two different guideline documents. Accordingly, the identified guideline documents reflect 12 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States.1
Foods and Fluids to Provide or Avoid in Bottle Use
Six guideline documents included recommendations on foods and fluids to provide or avoid in bottle use. Two guideline documents indicated that a bottle should be used for breast milk or infant formula (New Zealand Dental Association, 2008; NICE, 2008); the National Institute for Health and Care Excellence (NICE) guideline document also specified that a bottle could be used for water. A guideline document from the New Zealand Ministry of Health stated, “Avoid … long-term use of bottles containing liquids other than water” (Ministry of Health, 2012).2 Guideline documents from AAP (Heyman et al., 2017) and the American Academy of Pediatric Dentistry (AAPD) (2016) stated that juice or sugar-sweetened beverages should not be provided in a bottle. A NICE (2008) guideline document discouraged the addition of sugar and solid foods to bottles.3 A guideline document from the Robert Wood Johnson Foundation-Healthy Eating Research (RWJF-HER) recommended against the mixing of cereal with formula or breast milk in a bottle (Pérez-Escamilla et al., 2017).
Consistency
The guideline documents were generally consistent in recommending that certain foods and fluids should be avoided in bottle use, including sugar-sweetened beverages and juice (AAPD, 2016; Heyman et al., 2017 [AAP]), sugar and solid foods (NICE, 2008), and cereal mixed with formula or breast milk (Pérez-Escamilla et al., 2017 [RWJF-HER]). One guideline document advised against prolonged use of bottles with fluids besides water (Ministry of Health, 2012).
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1 Organizations reflected in the guideline documents include AAP, AAPD, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, NICE, and RWJF-HER.
2Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
3 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 seven statements of recommendation. Three of the recommendations—from AAP (Heyman et al., 2017), AAPD (2016), and RWJF-HER (Pérez-Escamilla et al., 2017)—mapped to narrative reviews. Two recommendations from the NICE (2008) guideline document mapped to a UK Department of Health report (Department of Health, 1994) and a rapid review.4 The New Zealand Ministry of Health (2012) recommendation mapped to a New Zealand Dental Association guideline document (New Zealand Dental Association, 2008). One recommendation from the New Zealand Dental Association (2008) could not be mapped to its evidence.
Age Restriction for Bottle Use
Four guideline documents included recommendations on age restrictions for bottle use. A European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guideline document indicated “by 12 months infants should mainly drink from a cup rather than a bottle” (Fewtrell et al., 2017). Similarly, an RWJF-HER guideline document and a NICE guideline document both discouraged bottle use after 12 months of age (NICE, 2008; Pérez-Escamilla et al., 2017). An AAPD (2016) guideline document recommended avoiding baby bottle use after 12–18 months.
Consistency
The guideline documents were generally consistent in recommending that bottle use should be discontinued at 12 months, with one guideline document recommending bottle use be discontinued during the 12–18-month age range (AAPD, 2016).
Evidence Base
Across the four guideline documents, the committee identified four statements of recommendation. The ESPGHAN recommendation from Fewtrell et al. (2017) mapped to a systematic literature search, the AAPD (2016) and RWJF-HER (Pérez-Escamilla et al., 2017) recommendations mapped to narrative reviews, and the NICE (2008) recommendation mapped to a UK Department of Health report (Department of Health, 1994) and a rapid review.
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4 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).
Going to Bed or Sleeping Without a Bottle
Five guideline documents included recommendations related to going to bed or sleeping without a bottle. Four of the recommendations specifically stated that an infant or toddler should not be put to sleep or go to bed with a bottle (Ministry of Health, 2012; New Zealand Dental Association, 2008; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]). Two of the guideline documents recommended avoiding giving bottles at night (Health Canada et al., 2014; Ministry of Health, 2012), with the collaborative guideline document from Canada indicating that the recommendation specifically applied to “an older infant or young child who is not breastfed or receiving breastmilk.”5
Consistency
The guideline documents were generally consistent in recommending putting a child to bed and sleeping without a bottle. Two guideline documents had related statements regarding avoidance of nighttime bottle feeding, although not specifically linked to putting a child to bed or sleeping with a bottle.
Evidence Base
Across the five guideline documents, the committee identified eight statements of recommendation. Recommendations from RWJF-HER (Pérez-Escamilla et al., 2017) and a collaborative Canadian guideline document (Health Canada et al., 2014) mapped to narrative reviews. Recommendations in the New Zealand Dental Association (2008) guideline document and the Australian government guideline document (NHMRC, 2012) could not be mapped to their evidence. The New Zealand Ministry of Health (2012) guideline document, in turn, cited the New Zealand Dental Association’s 2008 guideline document as evidence for its recommendation.
Type of Bottle and Bottle-Feeding Behaviors
Four guideline documents included recommendations related to bottle-feeding behaviors. An RWJF-HER guideline document discouraged behaviors such as using a bottle or food as a reward and forcing or encouraging the baby to finish the bottle (Pérez-Escamilla et al., 2017); the guideline document also specifically noted that the size of the bottle could contribute
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5 © 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.
to consuming more than needed (Pérez-Escamilla et al., 2017). A guideline document from the Australian government advised bottle feeding according to the infant’s needs (NHMRC, 2012). The New Zealand Dental Association (2008) advised holding the baby while bottle feeding. Finally, the New Zealand Ministry of Health recommended a fully ventilated bottle when bottle feeding, and cautioned against leaving the infant unattended and feeding from a bottle (Ministry of Health, 2012).
Consistency
Recommendations that addressed the type of bottle and bottle-feeding behaviors were diverse, with little overlap in the type of guidance provided. As such, no comment can be made on the consistency of the recommendations.
Evidence Base
Across the four guideline documents, the committee identified eight statements of recommendation. Recommendations from RWJF-HER (Pérez-Escamilla et al., 2017) and the New Zealand Ministry of Health (2012) mapped to narrative reviews. Recommendations from the Australian government (NHMRC, 2012) and the New Zealand Dental Association (2008) could not be mapped to their evidence.
Bottle Propping
Three guideline documents included recommendations on bottle propping (Health Canada et al., 2015; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]). All advised against bottle propping.
Consistency
The guideline documents were consistent in advising against bottle propping.
Evidence Base
Across the three guideline documents, the committee identified four statements of recommendation. Recommendations from RWJF-HER (Pérez-Escamilla et al., 2017) and a collaborative Canadian guideline document (Health Canada et al., 2015) mapped to narrative reviews. Two statements of recommendation from the Australian government (NHMRC, 2012) could not be mapped to their evidence.
CUP USE
Eleven guideline documents included recommendations related to cup use (see Appendix B, Table B-20). Four of the guideline documents were collaborative efforts across multiple organizations (AAPD, 2016; Health Canada et al., 2014; Lott et al., 2019 [RWJF-HER]; New Zealand Dental Association, 2008); four of the organizations that participated in collaborative guideline documents also had independent guideline documents that included recommendations related to cup use. Accordingly, the identified guideline documents reflect 14 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States.6
Age for Cup Use
Six guideline documents included recommendations on the age for cup use. All indicated that the appropriate age range for introducing cup use was between 6 and 12 months. Three of the guideline documents specifically stated the age range as “6–12 months” (Lott et al., 2019; NICE, 2008; Pérez-Escamilla et al., 2017 [RWJF-HER]). An ESPGHAN guideline document indicated the appropriate age was “by 12 months” (Fewtrell et al., 2017). Two guideline documents—one from the American Heart Association (AHA) (Gidding et al., 2005) and one from the Australian government (NHMRC, 2012)—said cups can be introduced at “at least” or “around” 6 months.
Consistency
The guideline documents were generally consistent in recommending that the age for transitioning infants to cup use should be 6–12 months, although two guideline documents used the phrase “around 6 months” (Gidding et al., 2005 [AHA]; NHMRC, 2012). One possible reason for the variation could be that the AHA recommendation refers to delaying the introduction of 100% juice until at least 6 months of age, and if given it should be given in a cup (Gidding et al., 2005), whereas the statement by the Australian government addressed the need to teach sipping skills (NHMRC, 2012).
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6 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, and RWJF-HER.
Evidence Base
Across the six guideline documents, the committee identified six statements of recommendation. The recommendation from the ESPGHAN guideline document (Fewtrell et al., 2017) mapped to a systematic literature search. Recommendations from the two RWJF-HER guideline documents (Lott et al., 2019; Pérez-Escamilla et al., 2017) and the Australian government guideline document (NHMRC, 2012) mapped to narrative reviews. The NICE (2008) guideline document mapped to a UK Department of Health report (Department of Health, 1994) and a rapid review. The recommendation from the AHA guideline document (Gidding et al., 2005) could not be mapped to its evidence.
Fluids to Provide or Avoid in Cup Use
Eight guideline documents included recommendations that addressed the fluids to provide or avoid when feeding from a cup. Two guideline documents from RWJF-HER advised providing drinking water (4–8 ounces) from a cup (in one case, fluoridated water) to infants 6–12 months or once solid foods are introduced (Lott et al., 2019; Pérez-Escamilla et al., 2017). One of the RWJF-HER guideline documents (Pérez-Escamilla et al., 2017) also specified that toddlers should be offered water in a cup. Four guideline documents mentioned using a cup for cow milk (Pérez-Escamilla et al., 2017 [RWJF-HER]), milk and other drinks (NHMRC, 2012), or expressed breast milk and formula (Ministry of Health, 2012; New Zealand Dental Association, 2008). Four guideline documents addressed limiting or avoiding juice (and sugar-sweetened beverages) fed by cup (AAPD, 2016; Gidding et al., 2005 [AHA]; Heyman et al., 2017; Pérez-Escamilla et al., 2017 [RWJF-HER]).
Consistency
The guideline documents were generally consistent in recommending that milk (cow milk, breast milk) should be served to toddlers in a cup (Ministry of Health, 2012; New Zealand Dental Association, 2008; NHMRC, 2012; Pérez-Escamilla et al., 2017). Although some guidelines referenced water being provided in a cup and the avoidance or limitation of serving juice in a cup, these were not stated across all documents.
Evidence Base
Across the eight guideline documents, the committee identified 12 statements of recommendation. Most of the recommendations mapped to
narrative reviews. Two recommendations from the New Zealand Dental Association (2008) and one from the AHA guideline document (Gidding et al., 2005) could not be mapped to their evidence.
General Considerations for Cup Use
Two guideline documents included recommendations related to general cup use. A collaborative guideline document from Canada encouraged the use of an open cup, with assistance (Health Canada et al., 2014). A recommendation from an RWJF-HER guideline document advised not putting a toddler to sleep with a sippy cup (Pérez-Escamilla et al., 2017).
Consistency
Recommendations that addressed general considerations related to cup use were diverse, with little overlap in the type of guidance provided. As such, no comment can be made on the consistency of the recommendations.
Evidence Base
Across the two guidelines, the committee identified two statements of recommendation. Both recommendations mapped to narrative reviews.
SAFETY OF FOODS AND FEEDING PRACTICES
Fourteen guideline documents included recommendations related to food safety and safe feeding practices (see Appendix B, Table B-21). Six guideline documents represented a collaboration between multiple organizations (Health Canada et al., 2014, 2015; Lott et al., 2019; New Zealand Dental Association, 2008; PAHO/WHO, 2005; SACN and COT, 2018). Five of the collaborating organizations also had a separate guideline document that included related recommendations. The identified guideline documents therefore reflect 17 different organizations from Australia, Canada, New Zealand, the United Kingdom, and the United States, along with the Pan American Health Organization (PAHO) and the World Health Organization (WHO).7
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7 Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, Breastfeeding Committee for Canada, COT, CPS, Dietitians of Canada, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, NICE, PAHO, RWJF-HER, SACN, and WHO.
Pasteurized Juice, Milk, and Dairy Products
Five guideline documents included recommendations related to the pasteurization of juice, milk, and dairy products. Guideline documents from the Australian government (NHMRC, 2012) and an RWJF-HER consensus statement (Lott et al., 2019) specified that milk provided to children should be pasteurized. Several guideline documents recommended against providing children unpasteurized juice (Health Canada et al., 2014; Heyman et al., 2017 [AAP]; Pérez-Escamilla et al., 2017 [RWJF-HER]), milk (Health Canada et al., 2014; NHMRC, 2012; Pérez-Escamilla et al., 2017), or dairy products (Health Canada et al., 2014; Pérez-Escamilla et al., 2017). These guideline documents indicated that such products should not be offered or used (NHMRC, 2012; Pérez-Escamilla et al., 2017), should be “strongly discouraged” (Heyman et al., 2017 [AAP]), and should be avoided (Health Canada et al., 2014).
Consistency
The guideline documents were consistent in recommending that pasteurized milk be provided and that giving children unpasteurized juice, milk, or milk products should be avoided.
Evidence Base
Across the five guideline documents, the committee identified seven statements of recommendation. Recommendations from AAP (Heyman et al., 2017) and a collaborative guideline document from Canada (Health Canada et al., 2014) mapped to narrative reviews. A guideline document from the Australian government (NHMRC, 2012) included two recommendations, one of which mapped to both a systematic review and a narrative review, with the other mapping to a systematic review, a narrative review, and a WHO report (Michaelsen et al., 2003). Recommendations from an RWJF-HER consensus statement (Lott et al., 2019) mapped to resources from the government (Dietary Guidelines for Americans, Child and Adult Care Food Program federal standards), AAP, and other RWJF-HER expert panels. Finally, the recommendation from the other RWJF-HER guideline document mapped to FoodSafety.gov.
Safety of Honey Consumption8
Three guideline documents included recommendations related to the safety of honey consumption. All recommended that honey not be given to
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8 Recommendations related to avoiding or limiting honey as a sugary substance that are not related to the risk of botulism (e.g., general recommendations, recommendations related to dental caries) are presented in Chapter 4, “Substances to Avoid or Limit.”
infants under 12 months of age because of the risk of botulism (Health Canada et al., 2014; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]).
Consistency
The guideline documents were consistent in recommending that giving honey to infants under 1 year of age should be avoided owing to risk of botulism.
Evidence Base
Across the three guideline documents, the committee identified three statements of recommendation. The recommendation from the Australian government guideline document (NHMRC, 2012) mapped to a single journal article (Brook, 2007). The other recommendations mapped to narrative reviews.
Consumption of Raw or Undercooked Foods
Five guideline documents included recommendations related to infant and young child consumption of raw or undercooked foods. One guideline document recommended avoiding raw or undercooked meat, poultry, and fish (Health Canada et al., 2014). Another guideline document included undercooked meats, poultry, or seafood as foods to avoid (Pérez-Escamilla et al., 2017 [RWJF-HER]). All of the guideline documents included recommendations related to preparation of eggs and consumption of raw or undercooked eggs. The Australian government guideline documents recommended cooking all eggs thoroughly, “until the white is completely set and the yolk begins to thicken” (NHMRC, 2012).9 Similarly, a guideline document from RWJF-HER recommended that undercooked eggs (e.g., “runny eggs”) should not be offered (Pérez-Escamilla et al., 2017 [RWJF-HER]). A collaborative guideline document from Canada recommended avoiding raw or undercooked products containing raw eggs (Health Canada et al., 2014). Two guideline documents from advisory committees to the UK government, which were published in the same year, had slightly different recommendations (SACN, 2018; SACN and COT, 2018). Both guideline documents indicated that duck, goose, and quail eggs should always be cooked thoroughly (SACN, 2018; SACN and COT, 2018), with one document also including hen eggs from outside the United Kingdom (SACN, 2018). One, however, specified that infants and children “can safely eat raw or lightly cooked eggs that are produced under the British Lion Code of Practice” (SACN, 2018). The other mentioned that the recommendation related
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9NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
to consuming raw and undercooked hen eggs was under review because of another United Kingdom government committee’s recent conclusions regarding microbiological risk from shell eggs (SACN and COT, 2018).
Consistency
The guideline documents were generally consistent in recommending that infants and young children avoid consumption of raw or undercooked eggs. The one exception from the Scientific Advisory Committee on Nutrition (SACN) (2018) mentioned was hen eggs produced under the British Lion Code of Practice, as eggs produced under this code are considered to pose very low microbiological risk (ACMSF, 2016). This exception appeared to be differentially identified between two guideline documents from the advisory committees to the UK government in the same year because the assessment of risk from microbial contamination was evolving. A guideline document from RWJF-HER (Pérez-Escamilla et al., 2017) and a collaborative guideline document from Canada (Health Canada et al., 2014) were consistent in recommending that infants and young children avoid eating raw or undercooked meat, poultry, fish, and seafood.
Evidence Base
Across the five guideline documents, the committee identified five statements of recommendation. The recommendation from the SACN and the Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment (COT) (2018) guideline document was embedded in a broader recommendation that mapped to a systematic review; the portion specifically related to raw eggs, however, was noted as being under review as a result of a recent publication (ACMSF, 2016). Recommendations from the collaborative Canadian guideline document (Health Canada et al., 2014), RWJF-HER (Pérez-Escamilla et al., 2017), and the SACN (2018) guideline document each mapped to narrative reviews. The recommendation from the Australian government (NHMRC, 2012) could not be mapped to its evidence.
Prevention of Choking
Eleven guideline documents included recommendations related to the prevention of choking. Several recommendations advise not offering food items that are a choking hazard to infants and young children. Some of the guideline documents specified general characteristics related to shape, size, texture, and consistency, such as hard, small, round, or sticky foods (Abrams et al., 2019 [CPS]; Health Canada et al., 2014; Ministry of Health, 2012; New Zealand Dental Association, 2008; NHMRC, 2012). Some guideline documents provided specific examples of foods that are potential choking hazards (see Table 5-1).
| Organization | Citation | Hard Candy | Hot Dogs | Grapes | Large Seeds | Nuts | Popcorn | Raw Carrots | Boned Fish |
|---|---|---|---|---|---|---|---|---|---|
| Australian government | NHMRC, 2012 | X | |||||||
| New Zealand Dental Association | New Zealand Dental Association, 2008 | X | |||||||
| New Zealand Ministry of Health | Ministry of Health, 2012a | X | X | X | X | X | X | X | |
| PAHO/WHO | PAHO/WHO, 2003 | X | X | X | |||||
| RWJF-HER | Pérez-Escamilla et al., 2017 | X | X | X | X | X | X | ||
| SACN | SACN, 2018 | X | |||||||
| SACN and COT | SACN and COT, 2018 | X | |||||||
| WHO | WHO, 2005 | X | X | X |
NOTE: COT = Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment; NHMRC = National Health and Medical Research Council; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; WHO = World Health Organization.
a The recommendations from this guideline document refers the reader to a more comprehensive list of potential choking hazards. Foods included in the comprehensive list, but not in the abstracted recommendations, are noted in the table. Potential choking hazards not reflected in the table, but identified by the Ministry of Health (2012) guideline document include
- Foods that are difficult to bite or chew (e.g., raw apple, raw celery, hard dried fruit, corn chips, rice crackers),
- Small round foods (e.g., berries, cherry tomatoes, raisins/sultanas, peas, watermelon seeds), foods with skins or leaves (e.g., sausage, chicken, lettuce, spinach, cabbage, stone fruits),
- Compressible foods (e.g., sausage, pieces of cooked meat, marshmallow, chewing or bubble gum),
- Thick pastes (e.g., chocolate spreads, thick peanut butter), and
- Fibrous or stringy foods (e.g., raw pineapple, rhubarb).
Four guideline documents recommended not offering foods that are a choking hazard until after 5 years of age, mentioning whole nuts as a specific example (Ministry of Health, 2012; New Zealand Dental Association, 2008; SACN, 2018; SACN and COT, 2018). Two guideline documents provided specific guidance related to bottle feeding, citing the practices of adding cereal to formula or breast milk in bottles (Pérez-Escamilla et al., 2017 [RWJF-HER]) and leaving infants alone while feeding and bottle propping (Health Canada et al., 2015) as choking hazards.
Some guideline documents provided specific examples for ways in which food shape, size, texture, and consistency can be altered to reduce choking risk. A guideline document from the New Zealand Dental Association (2008) cited general food preparation techniques, such as grating, cooking, mashing, or puréeing foods. A guideline document from the Canadian Paediatric Society (CPS) provided a specific example, suggesting diluting smooth peanut butter with water or breast milk or offering a peanut puff product (Abrams et al., 2019). A recommendation in the New Zealand Ministry of Health (2012) guideline document referred the reader to additional resources, which advised that altering food texture (“grate, cook, finely chop, or mash the food”) and removing potentially problematic portions of the food (“peel off the skin or remove the strong fibers”) can reduce choking risk.
Consistency
The guideline documents were consistent in recommendations to prevent choking, with some differences in the examples of choking hazards that were provided and on specifically indicating the age at which foods that are choking hazards can be safely offered. Most recommendations focused on food types and feeding practices to avoid, while a few provided examples of how to modify foods to reduce the risk of choking.
Evidence Base
Across the 11 guideline documents, the committee identified 15 statements of recommendation. Most recommendations mapped to narrative reviews, background documents, or technical documents. A recommendation from the SACN and COT (2018) guideline document was embedded in a broader recommendation that mapped to a systematic review; the portion specifically related to choking hazards, however, could not be mapped to its evidence. The Australian government guideline document (NHMRC, 2012) contained two recommendations; one recommendation mapped to recommendations from the UK Food Standards, while the other recommendation could not be mapped to its evidence. The recommendation from the
New Zealand Dental Association (2008) guideline document could not be mapped to its evidence.
Supervision During Eating
Eight guideline documents included recommendations related to supervision of infants and young children while they are eating. Some guideline documents recommended that infants and young children never be left unattended while they are eating (NICE, 2008; SACN, 2018; SACN and COT, 2018), in some cases specifically mentioning that infants should not be left alone feeding from a bottle, and particularly from a propped bottle (Health Canada et al., 2015; Ministry of Health, 2012; NHMRC, 2012). Other guideline documents specified that infants and young children should be supervised while they are eating (Health Canada et al., 2014; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]).
Consistency
The guideline documents were consistent in recommending that infants and young children be supervised or that they never be left alone while they are eating.
Evidence Base
Across the eight guideline documents, the committee identified nine statements of recommendation. Most recommendations mapped to narrative reviews. One recommendation from the SACN and COT (2018) guideline document was embedded in a broader recommendation that mapped to a systematic review; the portion specifically related to supervision, however, could not be mapped to its evidence. The recommendation from NICE (2008) mapped to a UK Department of Health report (Department of Health, 1994) and a rapid review. Two recommendations from the Australian government guideline document (NHMRC, 2012) could not be mapped to their evidence.
INTRODUCTION OF COMPLEMENTARY FOODS
Seventeen guideline documents included recommendations related to introduction of complementary foods (see Appendix B, Table B-22). Five of the guideline documents were collaborative efforts between two or more organizations (Alvisi et al., 2015; Health Canada et al., 2014, 2015; PAHO/WHO, 2003; SACN and COT, 2018). Four organizations—AAP, CPS, SACN, and WHO—each participated on two or more guideline docu-
ments. Accordingly, the identified guideline documents reflect 17 different organizations from Australia, Canada, Europe, Italy, New Zealand, the United Kingdom, and the United States, along with PAHO and WHO.10
Age of Introduction
Twelve guideline documents included recommendations on age of introduction. Six guideline documents stated that complementary foods should be introduced at “about” or “around” 6 months (AAP Section on Breastfeeding, 2012; Abrams et al., 2019 [CPS]; Ministry of Health, 2012; NHMRC, 2012; SACN, 2018; SACN and COT, 2018). Similarly, a guideline document from PAHO/WHO specified 6 months (PAHO/WHO, 2003). Three guideline documents recommended an age range of 4–6 months (Alvisi et al., 2015 [SIAIP and SIGENP]; Fewtrell et al., 2017 [ESPGHAN]; Pérez-Escamilla et al., 2017 [RWJF-HER]). One guideline document implied an age range, but the actual recommendation is unclear, stating, “All infants require solid foods from 6 months for adequate nutrition. Solid food should never be introduced before 4 months” (RCPCH, 2019). A guideline document from the European Food Safety Authority (EFSA) (2019) stated that a specific age cannot be defined; the guideline went on to say, “for nutritional reasons, the majority of infants need complementary foods from around 6 months of age,” but it also noted that “the appropriate age range depends on the individual’s characteristics and development, even more so if the infant was born preterm.”
Consistency
The guideline documents were generally consistent in recommending that complementary foods should not be introduced before 4 months and should be introduced by or around 6 months of age. The guideline documents were inconsistent as to whether the recommended age of introduction is an age range (4–6 months) or is focused on (approximately) 6 months, with the latter being more common.
One possible reason for the inconsistency is whether the recommendation was intended to be applied at the population level or at the individual level. The PAHO/WHO (2003) guiding principles were aimed at the population level (WHO, 2001), recognizing that there may need to be adapta-
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10 Organizations reflected in the guideline documents include AAP, Breastfeeding Committee for Canada, COT, CPS, Dietitians of Canada, EFSA, ESPGHAN, Health Canada, New Zealand Ministry of Health, NHMRC, PAHO, RCPCH, RWJF-HER, SACN, SIAIP, SIGENP, and WHO.
tion at the individual level. Another reason for the inconsistency is that the potential risks of introducing complementary foods before 6 months may differ between high-income and low-income populations, such as exposure to pathogens from complementary foods (PAHO/WHO, 2003). Lastly, several organizations aligned the recommendation for introduction of complementary foods with the recommendation for exclusive breastfeeding for 6 months.
Evidence Base
Across the 12 guideline documents, the committee identified 20 statements of recommendation. Most of the recommendations mapped to narrative reviews and technical background documents. Four statements of recommendation from an EFSA (2019) guideline document and one recommendation each from an Australian government guideline document (NHMRC, 2012) and an ESPGHAN guideline document (Fewtrell et al., 2017) mapped to systematic reviews or systematic literature searches. A recommendation from SACN and COT (2018) mapped to a WHO report (WHO, 2001). Recommendations from a CPS guideline document (Abrams et al., 2019) and an AAP guideline document (AAP Section on Breastfeeding, 2012) could not be mapped to their evidence.
Recommended Foods to Introduce First
Ten guideline documents included recommendations about which foods to introduce first. All mentioned iron-rich foods (such as puréed or mashed meats) or iron-fortified foods (AAP Section on Breastfeeding, 2012; Baker et al., 2010 [AAP]; EFSA Panel on Nutrition et al., 2019; Grueger et al., 2013 [CPS]; Health Canada et al., 2014, 2015; Ministry of Health, 2012; NHMRC, 2012; Pérez-Escamilla et al., 2017; SACN, 2018). Some guideline documents also stated that first foods should be rich in “other micronutrients” (AAP Section on Breastfeeding, 2012) or mentioned zinc specifically (Pérez-Escamilla et al., 2017). A guideline document from RWJF-HER recommended that vegetables be introduced early (mixed with familiar foods) to foster acceptance (Pérez-Escamilla et al., 2017). A guideline document from the New Zealand Ministry of Health stated, “as sources of carbohydrate and dietary fiber, start infant with white or wholemeal bread” (Ministry of Health, 2012).11
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11Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
Consistency
The guideline documents were consistent in recommending that the foods introduced first should be iron rich or iron fortified.
Evidence Base
Across the 10 guideline documents, the committee identified 15 statements of recommendation. Most of the recommendations mapped to narrative reviews. Two recommendations from the Australian government guideline document (NHMRC, 2012) and one recommendation from an EFSA guideline document (EFSA Panel on Nutrition et al., 2019) mapped to systematic reviews, either alone or in combination with a narrative review. One recommendation from AAP (Baker et al., 2010) cited the Dietary Reference Intakes for iron. The recommendation from the AAP guideline document (AAP Section on Breastfeeding, 2012) could not be mapped to its evidence.
Gradual Introduction of New Foods and Order of Introduction
Seven guideline documents included recommendations on the gradual introduction of new foods and order of introduction. Five recommended that diversification of the diet and introduction of new foods should occur gradually (Grueger et al., 2013; Ministry of Health, 2012; PAHO/WHO, 2003; SACN, 2018; WHO, 2005). One guideline document recommended that foods be introduced “one at a time to allow the detection of reactions to individual components of foods” (Ministry of Health, 2012).12 Two guideline documents stated that no particular order is advised for introduction of new foods (after starting with iron-rich foods) (NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]).
Consistency
The guideline documents were consistent in advising gradual introduction of new foods. Two guideline documents were consistent in indicating no restrictions on the order in which complementary foods are introduced; the other three guideline documents did not mention order of introduction.
Evidence Base
Across the seven guideline documents, the committee identified 10 statements of recommendation. Most of the recommendations mapped to
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12Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
narrative reviews or technical background documents. Two recommendations from the Australian government (NHMRC, 2012) mapped to systematic reviews, either alone or in combination with a narrative review.
FOOD CONSISTENCY AND TEXTURE
Ten guideline documents included recommendations on food consistency and texture during infancy and early childhood (see Appendix B, Table B-23). Three of the guideline documents were collaborative efforts between two or more organizations (Alvisi et al., 2015; Health Canada et al., 2014; PAHO/WHO, 2003); both CPS and WHO participated in two of the guideline documents. Accordingly, the identified documents reflect 13 different organizations from Australia, Canada, Europe, Italy, New Zealand, the United Kingdom, and the United States, along with PAHO and WHO.13
Appropriate Consistency and Texture
Ten guideline documents included recommendation on the appropriate consistency and texture of foods. All stated or implied that food consistency or texture needs to incrementally change from puréed to more solid consistencies as a function of the developmental stage of the child (Abrams et al., 2019 [CPS]; Alvisi et al., 2015 [SIAIP and SIGENP]; Fewtrell et al., 2017 [ESPGHAN]; Health Canada et al., 2014; Ministry of Health, 2012; NHMRC, 2012; PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; SACN, 2018; WHO, 2005). One guideline document from ESPGHAN specifically discouraged the prolonged use of puréed foods (Fewtrell et al., 2017). Two guideline documents stated that most infants can eat finger foods by 8 months (PAHO/WHO, 2003; WHO, 2005). A collaborative guideline document from Canada recommended that lumpy textures be offered no later than 9 months (Health Canada et al., 2014). One collaborative guideline document from Italian pediatric societies specifically recommended to wait until the child demonstrates the needed body and oral motor skills to introduce ground, chopped, or finger foods (Alvisi et al., 2015).
Consistency
The guideline documents were consistent in recommending that the food consistency or texture be tailored to the developmental needs of the
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13 Organizations reflected in the guideline documents include Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Ministry of Health, NHMRC, PAHO, RWJF-HER, SACN, SIAIP, SIGENP, and WHO.
child. The guideline documents were also consistent in recommending that the consistencies or textures should change as a child ages.
Evidence Base
Across the 10 guideline documents, the committee identified 11 statements of recommendation. The majority of recommendations mapped to narrative reviews, background documents, and/or technical documents. One recommendation from the ESPGHAN guideline document (Fewtrell et al., 2017) mapped to a systematic literature search.
MEAL FREQUENCY
Five guideline documents included recommendations related to meal frequency (see Appendix B, Table B-24). Two of the guideline documents were collaborative efforts between two or more organizations (Health Canada et al., 2014; PAHO/WHO, 2003). One of the collaborating organizations also had a separate relevant guideline document. As such, the identified guideline documents reflect eight organizations from Canada and the United States, along with PAHO and WHO.14
Consistent Meal Schedule During the Complementary Feeding Period
Four guideline documents included recommendations on meal schedule and complementary foods. Three guideline documents recommended that a regular meal schedule be established (Gidding et al., 2005 [AHA]; Health Canada et al., 2014; Pérez-Escamilla et al., 2017 [RWJF-HER]). Two of the guideline documents recommended increasing the number of times per day that complementary foods are offered as an infant ages (Health Canada et al., 2014; PAHO/WHO, 2003). One guideline put forth the concept that it is the caregiver’s responsibility to determine when and what food is eaten (Gidding et al., 2005 [AHA]).
Consistency
The guideline documents were generally consistent in recommending that a regular meal schedule should be established.
Evidence Base
Across the four guideline documents, the committee identified six statements of recommendation. All of the recommendations mapped to
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14 Organizations reflected in the guideline documents include AHA, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, Health Canada, PAHO, RWJF-HER, and WHO.
narrative reviews or technical background documents, either alone or in combination with another resource.
Age and Number of Eating Occasions
Three guideline documents included recommendations on age and number of eating occasions. A guideline document from RWJF-HER recommended three meals and two to three snacks daily once the child reaches 1 year of age (Pérez-Escamilla et al., 2017). A guideline document from WHO stated that for nonbreastfed infants, “meals should be provided 4–5 times per day with additional nutritious snacks offered 1–2 times per day as desired” (WHO, 2005);15 this recommendation includes breast milk substitutes, if used. A guideline document from PAHO/WHO stated,
For the average healthy breastfed infant, meals of complementary foods should be provided 2–3 times per day at 6–8 months of age and 3–4 times per day at 9–11 and 12–24 months of age. Additional nutritious snacks may be offered 1–2 times per day, as desired. (PAHO/WHO, 2003)16
Consistency
The guideline documents were generally consistent in recommending that infants and young children need several eating occasions over the course of the day, including both meals and snacks. However, the recommended number of meals and snacks slightly varied across the recommendations. One reason for this inconsistency is that one of the recommendations only pertained to the provision of complementary foods to breastfed children (PAHO/WHO, 2003), while another recommendation pertained to eating events for the nonbreastfed child, inclusive of the provision of breast milk substitutes (WHO, 2005).
Evidence Base
Across the three guideline documents, the committee identified three statements of recommendation. Two of the recommendations mapped to narrative reviews or background documents (PAHO/WHO, 2003; Pérez-Escamilla et al., 2017). The other recommendation was “based on theoreti-
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15 Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Meal Frequency and Energy Density, p. 10, Copyright (2005).
16 Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Meal Frequency and Energy Density, p. 21, Copyright (2003).
cal estimates of the number of feedings required, calculated from energy requirements and gastric capacity” (WHO, 2005).17
Number of Feedings and Energy Density
Two guideline documents included recommendations relating the minimum number of feedings to the energy density of the diet. Both stated that the “number of feedings depends on the energy density and the usual amounts consumed at each feeding” (PAHO/WHO, 2003; WHO, 2005)18,19 and also noted that if energy density is low, more frequent meals may be needed.
Consistency
The two guideline documents were consistent in recommending that the minimum number of feedings should be based on the energy density of the diet. The same verbatim language was used in both guideline documents.
Evidence Base
Across the two guideline documents, the committee identified two statements of recommendation. The recommendation from PAHO/WHO (2003) mapped to a background document. The recommendation from WHO (2005) mapped to “theoretical estimates of the number of feedings required, calculated from energy requirements and gastric capacity.”20
HUNGER AND SATIETY CUES
Seven guideline documents included recommendations related to hunger and satiety cues (see Appendix B, Table B-25). Three of the guideline documents were joint efforts (Alvisi et al., 2015; Health Canada et al., 2014; PAHO/WHO, 2003); WHO participated in two of the guideline documents. The identified guideline documents therefore reflect 11 differ-
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17 Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Meal Frequency and Energy Density, p. 10, Copyright (2005).
18 Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Meal Frequency and Energy Density, p. 21, Copyright (2003).
19 Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Meal Frequency and Energy Density, p. 10, Copyright (2005).
20 Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Meal Frequency and Energy Density, p. 10, Copyright (2005).
ent organizations from Canada, Europe, Italy, and the United States, along with PAHO and WHO.21
Using Hunger and Satiety Cues to Guide Infant and Child Feeding
Seven guideline documents included recommendations related to hunger and satiety cues. Of these, six advised that infant or child satiety cues or hunger signs should guide feeding (Fewtrell et al., 2017 [ESPGHAN]; Gidding et al., 2005 [AHA]; Health Canada et al., 2014; PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; WHO, 2005). Recommendations from two guideline documents specifically underscored the importance of child self-regulation of intake (Alvisi et al., 2015 [SIAIP and SIGENP]; Gidding et al., 2005 [AHA]), while another guideline document described the natural ability for appetite control (Pérez-Escamilla et al., 2017 [RWJF-HER]). Three guideline documents encouraged responsive feeding practices (Health Canada et al., 2014; PAHO/WHO, 2003; WHO, 2005), with PAHO/WHO (2003) and WHO (2005) describing strategies such as talking during feeding, eye contact, minimizing distractions, and strategies for managing food refusal. Four guideline documents warned against forced or pressured feeding (Gidding et al., 2005 [AHA]; PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; WHO, 2005); two guideline documents warned against using food as a reward (Fewtrell et al., 2017 [ESPGHAN]; Pérez-Escamilla et al., 2017 [RWJF-HER]).
The recommendations covered a variety of different age groups. Recommendations from the collaborative guideline document from Canada specified older infants (6–12 months) and young children (12–24 months) (Health Canada et al., 2014). The RWJF-HER recommendations pertained to three different age groups: up to 6 months, 6–12 months, and 12–24 months (Pérez-Escamilla et al., 2017). The WHO (2005) guideline document focused on nonbreastfed children 6–24 months of age, while the PAHO/WHO (2003) recommendations pertained to breastfed children 6–24 months of age. The AHA (Gidding et al., 2005) and ESPGHAN (Fewtrell et al., 2017) guideline documents did not specify an age group for their recommendations.
Consistency
The guideline documents were generally consistent in emphasizing the importance of hunger and satiety cues in infant and child feeding. There was also consistency across organizations in support of the importance of
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21 Organizations reflected in the guideline documents include AHA, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, PAHO, RWJF-HER, SIAIP, SIGENP, and WHO.
responsive parenting or feeding practices in addressing hunger and satiety cues among infants and children.
Evidence Base
Across the seven guideline documents, the committee identified 10 statements of recommendation. The majority of recommendations mapped to narrative reviews, background documents, and technical documents. The recommendation from the ESPGHAN guideline document (Fewtrell et al., 2017) mapped to a systematic literature search.
RESPONSIVE FEEDING
Nine guideline documents included recommendations related to responsive feeding (see Appendix B, Table B-26). Three of the guideline documents were collaborative efforts from two or more organizations (Alvisi et al., 2015; Health Canada et al., 2014; PAHO/WHO, 2003); WHO participated in two of the guideline documents. As such, the identified guideline documents reflect 13 different organizations from Australia, Canada, Italy, the United Kingdom, and the United States, along with PAHO and WHO.22
Feeding Environment
Seven guideline documents included recommendations related to the feeding environment. Three stated the need for a pleasant feeding environment (PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; WHO, 2005). Four guideline documents recommended that caregivers and other family members be role models through their own eating practices (Alvisi et al. 2015 [SIAIP and SIGENP]; Gidding et al., 2005 [AHA]; Health Canada et al., 2014; NICE, 2008).
Recommendations from six of the guideline documents discussed the need for nurturing verbalization (PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; WHO, 2005), for eye-to-eye contact between caregiver and child (PAHO/WHO, 2003; WHO, 2005), to not force the child to eat (PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; WHO, 2005), to avoid distractions during feeding (Pérez-Escamilla et al., 2017), and for eating together as a family (Alvisi et al., 2015 [SIAIP and SIGENP]; Gidding et al., 2005 [AHA]; NICE, 2008).
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22 Organizations reflected in the guideline documents include AHA, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, Health Canada, NHMRC, NICE, PAHO, RWJF-HER, SACN, SIAIP, SIGENP, and WHO.
Consistency
The guideline documents were generally consistent in recommending that the feeding environment should be pleasant and that caregivers should implement nurturing behaviors including verbalization, eye-to-eye contact, and not forcing the child to eat.
Evidence Base
Across the seven guideline documents, the committee identified 13 statements of recommendation. The majority mapped to narrative reviews, background documents, and technical documents, alone or in combination with other resources. The recommendation from the NICE (2008) guideline document mapped to a UK Department of Health report (Department of Health, 1994) and a rapid review.
Repeated Exposure
Five guideline documents included recommendations related to repeated exposure. All stated the importance of repeated exposure to help children accept new foods (Gidding et al., 2005 [AHA]; PAHO/WHO, 2005; Pérez-Escamilla et al., 2017 [RWJF-HER]; SACN, 2018; WHO, 2005). Of these, one stated that acceptance of vegetables takes more tries than is the case for fruits (Pérez-Escamilla et al., 2017).
Consistency
The guideline documents were consistent in recommending that repeated exposure is needed for children to accept new foods.
Evidence Base
Across the five guideline documents, the committee identified six statements of recommendation. All statements mapped to narrative reviews.
Self-Feeding and Self-Regulation
Six guideline documents included recommendations related to self-feeding and self-regulation. All emphasized the importance of encouraging self-feeding and self-regulation (Alvisi et al., 2015 [SIAIP and SIGENP]; Health Canada et al., 2014; NHMRC, 2012; PAHO/WHO, 2003; Pérez-Escamilla et al., 2017 [RWJF-HER]; WHO, 2005). Recommendations stated that the infant should decide how much to eat (Pérez-Escamilla et al., 2017),
including new foods that are introduced (Alvisi et al., 2015). One guideline document recommended feeding infant formula based on need rather than the quantity stated in infant formula packaging (NHMRC, 2012).
Consistency
The guideline documents were generally consistent in recommending that self-feeding and self-regulation should be encouraged in infants and toddlers.
Evidence Base
Across the six guideline documents, the committee identified eight statements of recommendation. Most mapped to narrative reviews, background documents, and technical documents. One recommendation from an Australian Government guideline document (NHMRC, 2012) could not be mapped to its evidence.
SUMMARY
Guideline documents from government agencies and authoritative organizations provide a variety of recommendations related to how to feed infants and young children. Recommendations on the same topic areas were often conceptually consistent, but slightly differed from each other in the details. 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 5-2.
| Topic Area | Summary of Consistency Across Recommendations |
|---|---|
| Bottle use and propping |
|
| Cup use |
|
TABLE 5-2
| Topic Area | Summary of Consistency Across Recommendations |
|---|---|
| Safety of foods and feeding practices |
|
| Introduction of complementary foods |
|
| Food consistency and texture |
|
| Meal frequency |
|
| Hunger and satiety cues |
|
| Responsive feeding |
|
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 providing different guidance on a topic.
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