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Introduction

Every day, people make decisions about what and how to feed infants and young children. To inform these decisions, parents, health care providers, and others have a wide array of advice publicly available to them, ranging from social media posts to position statements by authoritative groups. Even when guidance comes from authoritative groups, including government, professional, and nonprofit organizations and agencies, there can be inconsistencies in advice owing to differences in approaches taken to develop feeding recommendations. Little information exists on the breadth and consistency of current guidelines for feeding children under 2 years of age, as well as the type of evidence that is used to support specific recommendations. The aim of this report is to compare and summarize existing feeding recommendations for this age group, document the type of evidence used to support each recommendation, and examine if and how existing guideline documents describe approaches to communication and dissemination of the feeding recommendations.

IMPORTANCE OF FEEDING PRACTICES FOR CHILDREN UNDER 2 YEARS OF AGE

Infant feeding practices have important short- and long-term consequences. Breastfeeding practices are associated with the health and development of the young child (Koletzko et al., 2019), may alter the risk for chronic disease later in life (Gungor et al., 2019; Horta et al., 2015), and influence maternal health outcomes such as breast cancer and type 2 diabetes (Chowdhury et al., 2015). The timing of introduction and the types and amounts of

solid foods and beverages provided to the infant, including infant formula, may also influence child growth, development, and various health outcomes (English et al., 2019; Obbagy et al., 2019). In addition, the way in which infants and young children are fed, such as responsive feeding practices that are sensitive to hunger and satiety cues (Hohman et al., 2016; Hurley et al., 2011; Spill et al., 2019), can influence child weight status and the development of healthy eating behaviors. Children establish food preferences early in life, which may have a significant effect on dietary intake in childhood as well as later in life. There is growing evidence that the first 1,000 days, from conception to 2 years of age, influence long-term health and development (Darling et al., 2020); optimal nutrition of infants and young children is an essential component of building this foundation for a healthy and productive life.

CHALLENGES OF UNDERSTANDING WHAT AND HOW TO FEED INFANTS AND YOUNG CHILDREN

Recommendations for feeding infants and young children have changed substantially in the United States in the past century because of scientific advances, cultural influences, societal trends, and other factors. More recently, more robust approaches to reviewing and synthesizing scientific evidence have evolved, such that there are now established protocols with which to develop evidence-based recommendations and guidelines (IOM, 2011; Kredo et al., 2016; Qaseem et al., 2012; Schünemann et al., 2014; WHO, 2012). To date, however, not all authoritative organizations have used such approaches for developing feeding guidance. In addition, although scientific research on feeding infants and toddlers has expanded during this period, for many feeding questions there is little or no evidence available to guide best practices, meaning that guideline developers must rely instead on expert or consensus opinion. As a result, currently available recommendations on early-life feeding can vary, leading to mixed messaging and making it more difficult for parents and health care providers to make well-informed choices on feeding children under 2 years of age.

RECENT EFFORTS AND WORK ON FEEDING GUIDANCE FROM BIRTH TO 24 MONTHS

Within the past decade, several countries, including the United States, have expanded efforts to develop scientifically based guidance for feeding infants and young children under 2 years of age. In the United States, the Dietary Guidelines for Americans (DGA) for 2020–2025 will, for the first time, include guidelines for this age group. Several steps were taken in preparation for this. In 2012, the U.S. Department of Agriculture and the U.S. Department of Health and Human Services initiated the B-24 Project, which

subsequently expanded in 2014 to also include pregnant women and was renamed the Pregnancy and Birth to 24 Months Project, or the P/B-24 Project. That project was designed to examine diet-related topics of public health importance for pregnant women and infants and toddlers from birth to 24 months of age and to conduct a number of systematic reviews. Those reviews were published in 2019 (Stoody et al., 2019), and have been incorporated into the work of the 2020 Dietary Guidelines Advisory Committee (DGAC) (DGA, 2020).

It should be noted that, owing to time constraints, the topics addressed by the 2020 DGAC focus mostly on what to feed rather than how to feed. In addition to the DGA process, other organizations in the United States have been working to update and expand guidance on feeding children from birth to 24 months. For example, the American Academy of Pediatrics published updated guidance in a revised version of Pediatric Nutrition in 2019 (AAP Committee on Nutrition, 2019), and the Robert Wood Johnson Foundation recently published two relevant reports (Lott et al., 2019; Pérez-Escamilla et al., 2017). In several other high-income countries, including Australia, Canada, New Zealand, and the United Kingdom, comprehensive guidance on infant and young child feeding has been developed within the past few years. At the global level, the World Health Organization is currently implementing a process to update guiding principles on complementary feeding (WHO, 2019).

THE COMMITTEE’S TASK AND APPROACH

This report seeks to describe the consistency of existing feeding recommendations for infants and young children, to document the type of evidence for existing recommendations, and to provide recommendations about strategies to communicate and disseminate such guidance.

As directed by the Statement of Task, the committee reviewed and assessed publicly available guidance on feeding practices for infants and children up to 2 years of age (see Box 1-1). To meet this task, the committee identified and collected guidance documents on what to feed and how to feed from government agencies and from authoritative domestic and international organizations, including governmental and nongovernmental sources. The committee then evaluated each included guidance document and compiled a comprehensive list of the topics that were addressed and the recommendations made on those topics across organizations. The committee summarized the level of agreement or consistency of the recommended practices across the documents. The committee also documented the type of evidence that was used as the basis for each of the recommendations on infant and young child feeding. The guideline documents were examined for descriptions of strategies to support the communication and dissemination of the recommended infant and young child feeding guidance.

Intended Audience

The primary intended audiences for this report are governmental and nongovernmental agencies, organizations, and groups who develop or are planning to develop feeding recommendations for infants and young children. Findings related to the consistency of existing guidance may shed light on the potential for harmonization of recommendations across different entities. Similarly, the descriptions of the types of evidence used to support each recommendation provide insight into the methods used to develop existing guidelines and the state of the science on what and how to feed infants and young children. This information, in turn, may highlight evidence gaps and inform research agendas. Additionally, approaches to communicating and disseminating feeding recommendations are explored, and

may provide insight for those who develop and test strategies to enhance reach and effectiveness of guideline documents.

This report may also be of value to the broader community of stakeholders who are invested in the health, well-being, and development of infants and young children. These groups may include, but are not limited to, health care providers (e.g., physicians, nurse practitioners, nurses, dentists, registered dietitian nutritionists, and other nutrition professionals), parents and guardians, early care and education providers, program administrators, and policy makers.

Scope of the Report

Countless websites, videos, magazines, handouts, reports, forums, social media platforms, and other resources provide advice about what and how to feed infants and young children. The vast and ever-changing landscape of where and what information can be accessed makes cataloging the totality of guidance that exists on these topics an insurmountable task. The aim of this report is not to be exhaustive in its search, but rather to identify and compare guidelines from authoritative domestic and international government, professional, and nonprofit organizations and agencies. The recommendations summarized are applicable to infants and young children from birth to 24 months of age. The phrases birth to 24 months, infants and children under 2 years, and infants and children up to age 2 years are used interchangeably throughout.

Recognizing that differences in the applicable population for guideline documents could lead to apparent inconsistencies across recommendations, the committee limited its search for international sources to broad, global guidance and to guideline documents from high-income countries. The health, food safety, and resource issues in lower-income countries differ substantially from those in high-income countries, which has implications for feeding recommendations. The committee interpreted the Statement of Task concept of “public-facing” as meaning the resources for the general public that are readily accessible online. Searches, screening, and selection of guideline documents focused on those that provided recommendations for healthy mother–infant dyads. The committee acknowledges that there are a host of topics and population groups (e.g., middle- and low-income countries, premature infants) that are of interest to the field that could not be addressed in this scoping study, and it views this report as providing a foundation for future scoping reviews of other types of feeding guidelines.

With respect to the review of best practices and implementation strategies for communication and dissemination, the committee interpreted its task as being focused on information provided within the guideline documents it reviewed. A comprehensive evaluation and exploration of models,

theories, and examples of communication and dissemination strategies beyond the information provided in the guideline documents would be valuable but was considered outside of the committee’s charge.

ORGANIZATION OF THE REPORT

This introductory chapter describes the importance of feeding practices and the challenges of understanding what and how to feed children under 2 years of age, the committee’s task and approach, and the aim of the report. The methodology that the committee used to identify and compare guideline documents is detailed in Chapter 2. Chapter 3 presents the characteristics of the guideline documents that met the eligibility criteria described in Chapter 2. The next two chapters provide the committee’s review of the recommendations related to what (Chapter 4) and how (Chapter 5) to feed infants and young children from the included guideline documents. Each of these chapters contains a summary table on the consistency of the recommendations. Chapter 6 discusses the communication and dissemination of feeding recommendations. Chapter 7 summarizes the consistency of existing feeding recommendations and offers suggestions for the development of future guidelines. Appendix A is a collection of the guideline documents that were excluded from the review based on the eligibility criteria. Appendix B is a series of tables that provide all of the recommendations that were abstracted from the included guideline documents. Biographical sketches of the committee members are found in Appendix C.