Appendix B
Abstracted Recommendations
Recommendations were abstracted from each of the guideline documents and resources that were found eligible after screening. Recommendations were organized into 26 topic areas, presented in the tables that follow.1 Within each table, recommendations are presented chronologically, beginning with the most recent. Consistency of recommendations on a given topic is summarized in Chapters 4 and 5. Citations included in the tables are found in the references list.
- TABLE B-1 Recommendations Related to Exclusive Breastfeeding
- TABLE B-2 Recommendations Related to Continuation of Breastfeeding
- TABLE B-3 Recommendations Related to Supplementary Formula Feeding of Breastfed Infants
- TABLE B-4 Recommendations Related to Duration of Infant Formula Use
- TABLE B-5 Recommendations Related to Type of Infant Formula
- TABLE B-6 Recommendations Related to Toddler Milks and Follow-On Formulas
- TABLE B-7 Recommendations Related to Milk and Milk-Based Products
- TABLE B-8 Recommendations Related to Fluids: Water, Juice, Sugar-Sweetened Beverages, and Other Nonmilk Beverages
___________________
1 The tables in this appendix contain recommendations directly from the provided citation. Recommendations have been edited for style, which did not affect their content.
- TABLE B-9 Recommendations Related to Substances to Avoid or Limit
- TABLE B-10 Recommendations Related to Variety and Healthy, Nutritious Foods
- TABLE B-11 Recommendations Related to Fruits and Vegetables
- TABLE B-12 Recommendations Related to Vegetarian and Vegan Diets
- TABLE B-13 Recommendations Related to Foods Associated with Food Allergy and Celiac Disease
- TABLE B-14 Recommendations Related to Iron and Iron-Fortified Formula
- TABLE B-15 Recommendations Related to Vitamin D
- TABLE B-16 Recommendations Related to Iodine
- TABLE B-17 Recommendations Related to Supplementation
- TABLE B-18 Recommendations Related to Dietary Fat
- TABLE B-19 Recommendations Related to Bottle Use and Propping
- TABLE B-20 Recommendations Related to Cup Use
- TABLE B-21 Recommendations Related to Safety of Foods and Feeding Practices
- TABLE B-22 Recommendations Related to Introduction of Complementary Foods (CFs)
- TABLE B-23 Recommendations Related to Food Consistency and Texture
- TABLE B-24 Recommendations Related to Meal Frequency
- TABLE B-25 Recommendations Related to Hunger and Satiety Cues
- TABLE B-26 Recommendations Related to Responsive Feeding Practices
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TABLE B-1 Recommendations Related to Exclusive Breastfeeding
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| CPS | Unger et al., 2019 | Exclusive breastfeeding is recommended for the first 6 months. | Narrative review |
| RCPCH | RCPCH, 2019 | Key messages for health professionals: Mothers should be supported to breastfeed their healthy term infant exclusively for up to 6 months. | Narrative review |
| SACN | SACN, 2018 | The totality of the evidence reviewed for this report supports current guidance to breastfeed exclusively for around the first 6 months of an infant’s life and to continue breastfeeding for at least the first year of life. Each makes an important contribution to infant and maternal health. | Narrative review |
| SACN; COT | SACN and COT, 2018 | The government should continue to recommend exclusive breastfeeding for around the first 6 months of life. | WHO reporta |
| ESPGHAN | Fewtrell et al., 2017 | Exclusive or full breastfeeding should be promoted 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.b | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | For the first 6 months (or until the introduction of solid food), most babies only need breast milk (or formula). Breast milk provides nearly all the nutrients needed for optimal growth and strengthens the infant’s immune system. The composition of breast milk changes as your baby grows to match her or his individual nutritional needs. Breastfeeding is recommended to continue until your baby is at least 1 year old. | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Recommend exclusive breastfeeding for the first 6 months.c | Narrative review |
| AAFP | AAFP, 2014 | Almost all babies should be breastfed or receive human milk exclusively for approximately 6 months. | A Cochrane reviewd |
| CPS | Grueger et al., 2013 (reaffirmed 2018) | Support exclusive breastfeeding, with vitamin D supplementation, for the first 6 months of life. | Narrative review |
| AAP | AAP Section on Breastfeeding, 2012 | Exclusive breastfeeding for about 6 months. Breastfeeding preferred; alternatively, expressed mother’s milk or donor milk.e | Narrative review; Could not be mappedf |
| New Zealand Ministry of Health | Ministry of Health, 2012g | Give only breast milk until the infant is ready for and needs extra food; this will be at around 6 months of age. | Narrative review |
| NHMRC (Australian government) | NHMRC, 2012h | Encourage exclusive breastfeeding for around 6 months. | Systematic reviewi,j |
| Encourage, support, and promote exclusive breastfeeding to around 6 months of age. | Previous Australian guidelines | ||
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Encourage mothers to exclusively breastfeed infants until around 6 months of age and to continue to breastfeed until at least 1 year of age, or beyond. | 2008 New Zealand Ministry of Health’s Food and Nutrition Guidelines for Healthy Infants and Toddlersk |
| AHA | Gidding et al., 2005 | Maintain breastfeeding as the exclusive source of nutrition for the first 4–6 months of life. | Narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed.l | Technical consultations and documents |
TABLE B-1
NOTE: AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; AHA = American Heart Association; COT = Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment; CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HC = Health Canada; NHMRC = National Health and Medical Research Council; PAHO = Pan American Health Organization; RCPCH = Royal College of Paediatrics and Child Health; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; WHO = World Health Organization.
b Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
c © All rights reserved. Nutrition for healthy term infants: Recommendations from birth to six months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.
e This recommendation contained additional guidance unrelated to exclusive breastfeeding that has been omitted from this table.
f The first sentence mapped to a narrative review; the second sentence could not be mapped to its evidence.
g Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
h NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
i Although it is not stated in this excerpt, this recommendation pertains to food allergies.
j Using the NHMRC system, the strength-of-evidence ratings related to this recommendation were as follows: Grade C (for breastfeeding and asthma and atopy) and Grade D (introduction of solid foods and allergy). Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application. Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution.
l Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Duration of Exclusive Breastfeeding and Age of Introduction of Complementary Foods, p. 10, Copyright (2003).
TABLE B-2 Recommendations Related to Continuation of Breastfeeding
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| CPS | Abrams et al., 2019 | Breastfeeding should be protected, promoted, and supported for up to 2 years and beyond.a | Narrative review |
| RCPCH | RCPCH, 2019 | Key messages for health professionals: Mothers should be supported to continue breastfeeding for as long as they wish; in countries such as the United Kingdom, evidence is lacking to recommend any particular duration of breastfeeding. | Narrative review |
| Key messages for health professionals: We recommend that mothers should be encouraged to breastfeed beyond 6 months, alongside giving solid food. | Narrative review | ||
| ESPGHAN | Hojsak et al., 2018 | Breastfeeding should be recommended as part of a healthy diet after the first year of life if mutually desired by mother and child. | Could not be mapped |
| SACN | SACN, 2018 | The totality of the evidence reviewed for this report supports current guidance to breastfeed exclusively for around the first 6 months of an infant’s life and to continue breastfeeding for at least the first year of life. Each makes an important contribution to infant and maternal health. | Narrative review |
| AAPD | AAPD, 2017 | AAPD supports breastfeeding of infants prior to 12 months of age to ensure the best possible health and developmental and psychosocial outcomes for infants. | An AAP statementb |
| ESPGHAN | Fewtrell et al., 2017 | Continued breastfeeding is recommended along with the introduction of complementary foods.c | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | It is fine to continue breastfeeding beyond 1 year if desired by parent and child. | Narrative review |
TABLE B-2
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| AAP; AAPD | AAPD, 2016 | To decrease the risk of developing early childhood caries, AAPD encourages professional and at-home preventive measures that include avoiding frequent consumption of liquids and/or solid foods containing sugar, in particular, and ad libitum breastfeeding after the first primary tooth begins to erupt and other dietary carbohydrates are introduced.d | Narrative review |
| AAFP | AAFP, 2014 | Breastfeeding with appropriate complementary foods, including iron-rich foods, should continue through at least the first year. | An AAP statementb |
| Health outcomes for mothers and babies are best when breastfeeding continues for at least 2 years. Breastfeeding should continue as long as mutually desired by mother and child. | Innocenti Declaratione | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Encourage continued breastfeeding, or offering 500 mL per day of homogenized (3.25% milk fat) cow milk. f,g | Narrative review; 2007 Eating Well with Canada’s Food Guideh |
| Support breastfeeding for up to 2 years or beyond, as long as mother and child want to continue.f | Narrative review | ||
| AAP | AAP Section on Breastfeeding, 2012 | Exclusive breastfeeding for about 6 months, to continue for at least the first year and beyond for as long as mutually desired by mother and child.d | Narrative review; Could not be mappedi |
| NHMRC (Australian government) | NHMRC, 2012j | Continue breastfeeding while introducing appropriate solid foods until 12 months of age and beyond, for as long as the mother and child desire. | Other national and international statements on infant feeding |
| While breastfeeding is recommended for the first 6–12 months and beyond, any breastfeeding is beneficial to the infant and mother. | Other national and international statements on infant feeding |
| CPS | Grueger et al., 2013 (reaffirmed 2018) | Encourage continued breastfeeding for up to 2 years and beyond while providing appropriate nutritional guidance. | Narrative review |
| New Zealand Ministry of Health | Ministry of Health, 2012k | Breastfeed until at least 1 year of age, or beyond. | Narrative review |
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Encourage mothers to exclusively breastfeed infants until around 6 months of age, and to continue to breastfeed until at least 1 year of age, or beyond. | 2008 New Zealand Ministry of Health’s Food and Nutrition Guidelines for Healthy Infants and Toddlersl |
| NICE | NICE, 2008 | Child health promotion: Health visitors and the CHPP team should support mothers to continue breastfeeding for as long as they choose. | Rapid review,m UK Department of Health reportn |
| AHA | Gidding et al., 2005 | Choose breastfeeding for first nutrition; try to maintain for 12 months. | Narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Continue frequent, on-demand breastfeeding until 2 years of age or beyond.o | Technical consultations and documents |
NOTE: AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; AAPD = American Academy of Pediatric Dentistry; AHA = American Heart Association; CHPP = Child Health Promotion Programme; CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HC = Health Canada; NHMRC = National Health and Medical Research Council; NICE = National Institute for Health and Care Excellence; PAHO = Pan American Health Organization; RCPCH = Royal College of Paediatrics and Child Health; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; WHO = World Health Organization.
a Although not stated in this excerpt, this recommendation is intended for infants considered to be at high risk for allergic disease, having either a personal history of atopy or a first-degree relative with atopy.
b AAP Section on Breastfeeding, 2012.
c Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
d This recommendation contained additional guidance unrelated to continuation of breastfeeding that has been omitted from this table.
TABLE B-2
e UNICEF, 1990. This is the reference for the first sentence of the recommendation. The second sentence did not contain a citation.
f © 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.
g Recommendation is applicable to older infants (6–12 months) and young children (12–24 months).
i The first half of the statement mapped to a narrative review, whereas the second half could not be mapped to its evidence.
j NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
k Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
m Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There is no overall statement on the strength of the evidence for each recommendation.
o Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Maintenance of Breastfeeding, p. 12, Copyright (2003).
TABLE B-3 Recommendations Related to Supplementary Formula Feeding of Breastfed Infants
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RCPCH | RCPCH, 2019 | Key messages for health professionals: Mothers should be advised that the use of infant formula “supplements” or combined breast and formula feeding may make it more difficult to establish exclusive breastfeeding. | Narrative review |
| AAFP | AAFP, 2014 | Formula supplementation of breastfed babies should occur only when medically indicated. Family physicians should not undermine breastfeeding by providing formula samples or coupons to breastfeeding mothers. | WHO/UNICEF document;a a primary research articleb |
| NHMRC (Australian government) | NHMRC, 2012c | If supplementary feeding is needed in hospital, it should only be given for specific medical indications and with the mother’s agreement. | Systematic reviewd |
| New Zealand Ministry of Health | Ministry of Health, 2012e | Strongly discourage the supplementing of breastfeeding with formula, water, herbal teas, milks, or any other liquids. A breastfeeding mother who is considering supplementing breast milk with infant formula to settle an infant should be given advice on settling the infant in other ways. This should include advice on increasing the mother’s supply of breast milk or introducing appropriate complementary foods if the infant is developmentally ready. | Narrative review |
NOTE: AAFP = American Academy of Family Physicians; NHMRC = National Health and Medical Research Council; RCPCH = Royal College of Paediatrics and Child Health; UNICEF = United Nations Children’s Fund; WHO = World Health Organization.
a WHO/UNICEF, 2009. Citation for the first sentence of the recommendation.
b Howard et al., 2000. Citation for the second sentence of the recommendation.
c NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
d Using the NHMRC system, the strength of evidence supporting this recommendation was Grade C (impact of prelacteal feeds on breastfeeding outcomes). Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application.
e Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
TABLE B-4 Recommendations Related to Duration of Infant Formula Use
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| CPS | Unger et al., 2019 | For well infants, formula feeding is not required beyond 12 months of age, when whole cow milk can be introduced. Formulas designed for toddlers beyond 12 months are not necessary. | Narrative review |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Infant formula (based on either cow or goat milk) is the only suitable alternative to breast milk for babies who are under 12 months old. | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | For an older infant or young child who is not breastfed or receiving breast milk: Advise that, for most healthy young children, there is no indication for the use of commercial formulas beyond one year of age.a | Narrative review |
| For an older infant or young child who is not breastfed or receiving breast milk: Recommend commercial infant formula until 9–12 months of age.a | Could not be mapped | ||
| New Zealand Ministry of Health | Ministry of Health, 2012b | If the infant is not breastfed, then an infant formula should be used until the infant is 1 year of age. For vegan infants who are not breastfed or are partially breastfed, the use of a commercial soy-based infant formula during the first 2 years of life is recommended. | Narrative review |
| If the infant is not breastfed, then use an infant formula as the milk source until the infant is 1 year of age. | Narrative review | ||
| NHMRC (Australian government) | NHMRC, 2012c | Use cow milk–based formulas until 12 months of age. (Note: All infant formulas available in Australia are iron fortified.) | Systematic review |
NOTE: CPS = Canadian Paediatric Society; HC = Health Canada; NHMRC = National Health and Medical Research Council; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research
a © 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.
b Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
c NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
TABLE B-5 Recommendations Related to Type of Infant Formula
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| AAP | Greer et al., 2019 | There is lack of evidence that partially or extensively hydrolyzed formula prevents atopic disease in infants and children, even in those at high risk for allergic disease. | Narrative review |
| CPS | Unger et al., 2019 | If normal birth weight infants are not breastfed, they should receive formula containing 6.5 mg/L to 13 mg/L of iron (which is the typical concentration in standard cow milk–based formulas in Canada) for the first 9–12 months. | Narrative review |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Ask your child’s doctor if you are considering using hydrolyzed or “hypoallergenic” infant formulas, as these formulas have not been found to help prevent food allergies in infants. | Adapted from American Academy of Allergy, Asthma & Immunology (2015)a and Australasian Society of Clinical Immunology and Allergy (2016)b |
| Infant formula (based on either cow or goat milk) is the only suitable alternative to breast milk for babies who are under 12 months old. The use of soya-based formula should only be on medical advice, and the possible health effects of soya-based formula should be kept under review. | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Discourage the use of homemade, evaporated milk formula. Cow milk, goat milk, soy beverage, rice beverage, or any other beverages should not be given to young infants.c | Narrative review |
| Recommend cow milk–based, commercial infant formula for an infant who is not exclusively fed breast milk. Soy-based infant formula is indicated only for those infants who have galactosemia or who cannot consume dairy-based products for cultural or religious reasons.c | Narrative review |
TABLE B-5
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| NHMRC (Australian government) | NHMRC, 2012d | Use cow milk–based formulas until 12 months of age. (Note: all infant formulas available in Australia are iron fortified.) Special formulas such as extensively hydrolyzed or soy milk–based formulas may be used under medical supervision for infants who cannot take cow milk–based products or because of specific medical, cultural, or religious reasons. (Note: Goat milk–based formula is not a suitable alternative for infants with allergies to cow milk–based formulas.) | Systematic review |
| Specialty formulas are indicated only for infants with confirmed pathology; health care professionals should advise parents accordingly. | 2009 WHO reporte | ||
| New Zealand Ministry of Health | Ministry of Health, 2012f | If the infant is not breastfed, then an infant formula should be used until the infant is 1 year of age. For vegan infants who are not breastfed or are partially breastfed, the use of a commercial soy-based infant formula during the first 2 years of life is recommended. | Narrative review |
| Use cow milk formula. If concerns arise, consult a health practitioner rather than switch to an alternative. | Narrative review | ||
| AAP | Bhatia et al., 2008 (reaffirmed 2016) | In term infants, although isolated soy protein–based formulas may be used to provide nutrition for normal growth and development, there are few indications for their use in place of cow milk–based formula. These indications include (a) for infants with galactosemia and hereditary lactase deficiency (rare), and (b) in situations in which a vegetarian diet is preferred. | Narrative reviewg |
| The routine use of isolated soy protein–based formula has no proven value in the prevention of atopic disease in healthy or high-risk infants. | Narrative review |
| The routine use of isolated soy protein–based formula has no proven value in the prevention or management of infantile colic or fussiness. | Narrative review | ||
| Isolated soy protein–based formula has no advantage over cow milk protein–based formula as a supplement for the breastfed infant, unless the infant has one of the indications noted previously—(a) for infants with galactosemia and hereditary lactase deficiency (rare), and (b) in situations in which a vegetarian diet is preferred). | Narrative review |
NOTE: AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; CPS = Canadian Paediatric Society; HC = Health Canada; NHMRC = National Health and Medical Research Council; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; WHO = World Health Organization.
c © All rights reserved. Nutrition for healthy term infants: Recommendations from birth to six months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.
d NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
f Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
g Guideline document included references related to soy protein–based formulas and infant growth and development. No references were provided for the portion of the recommendation related to galactosemia or vegetarian diets.
TABLE B-6 Recommendations Related to Toddler Milks and Follow-On Formulas
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| CPS | Unger et al., 2019 | For well infants, formula feeding is not required beyond 12 months of age, when whole cow milk can be introduced. Formulas designed for toddlers beyond 12 months are not necessary. | Narrative review |
| RWJF-HER | Lott et al., 2019a | 0–12 months: Avoid supplementation with transition or weaning formulas; nutrient needs should be met primarily through human milk and/or infant formula. | Narrative review |
| 1–5 years (12–60 months): Toddler milk is not recommended; nutrient needs should be met primarily through nutritionally adequate dietary patterns. | Narrative review | ||
| ESPGHAN | Hojsak et al., 2018 | Based on available evidence there is no necessity for the routine use of [young child formula] in children from 1 to 3 years of life, but they can be used as part of a strategy to increase the intake of iron, vitamin D, and n-3 PUFAs and decrease the intake of protein compared to unfortified cow milk. Follow-on formula can be used for the same purpose. | Systematic literature review |
| Domellöf et al., 2014 | Follow-on formulas should be iron fortified; however, there is not enough evidence to determine the optimal iron concentration in follow-on formula.b | Narrative review | |
| NHMRC (Australian government) | NHMRC, 2012c | Toddler milks and special and/or supplementary foods for toddlers are not required for healthy children. | Could not be mapped |
| New Zealand Ministry of Health | Ministry of Health, 2012d | Whole cow milk or a suitable alternative is recommended for toddlers. Fortified cow milk, such as toddler milk, is generally not necessary. | Narrative review |
NOTE: CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; NHMRC = National Health and Medical Research Council; PUFA = polyunsaturated fatty acid; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research.
a Lott et al. (2019) was an expert panel report with representation from the Academy of Nutrition and Dietetics, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association.
b Recommendation noted as being valid for Europe and other regions with a low general prevalence of iron deficiency anemia.
c NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
d Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
TABLE B-7 Recommendations Related to Milk and Milk-Based Productsa
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| Infants 0–12 Months of Age | |||
| CPS | Unger et al., 2019 | For well infants, formula feeding is not required beyond 12 months of age, when whole cow milk can be introduced. | Narrative review |
| RWJF-HER | Lott et al., 2019b | 0–12 months: Children under 12 months should not consume milk. | DGA, AAP, and a prior RWJF-HER expert panel on infant and toddler feeding guidelines |
| 0–12 months: Do not consume milk (flavored or plain). | Federal CACFP nutrition standards, and the National Academies recommendation that only unflavored milk be permitted in the WIC food package | ||
| SACN | SACN, 2018 | Unmodified cow milk should not be given as a main drink to infants under 12 months of age. | Narrative review |
| AAP | Heyman et al., 2017 | Families should be educated that, to satisfy fluid requirements, human milk and/or infant formula is sufficient for infants and low-fat/nonfat milk and water are sufficient for older children. | Narrative review |
| ESPGHAN | Fewtrell et al., 2017 | Cow milk is a poor iron source and provides excess protein, fat, and energy when used in large amounts. It should not be used as the main drink before 12 months of age, although small volumes may be added to complementary foods.c | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Cow milk should not be offered before the child turns 1 year old because it may cause intestinal bleeding. | Narrative review |
TABLE B-7
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| ESPGHAN | Domellöf et al., 2014 | Unmodified cow milk should not be fed as the main milk drink to infants before the age of 12 months and intake should be limited to < 500 mL daily in toddlers.d | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Encourage continued breastfeeding, or offering 500 mL per day of homogenized (3.25% milk fat) cow milk.e | Narrative review; 2007 Eating Well with Canada’s Food Guidef |
| For an older infant or young child who is not breastfed or receiving breast milk: Advise pasteurized homogenized (3.25% milk fat) cow milk be introduced at 9–12 months of age. Skim milk is not appropriate in the first 2 years.e | Narrative review | ||
| If parents and caregivers are introducing cow milk, advise them to delay until 9–12 months of age. Recommend limiting cow milk intake to no more than 750 mL per day.e | Narrative review | ||
| NHMRC (Australian government) | NHMRC, 2012g | Any unmodified milk from nonhuman species, for example, cow, goat, and sheep milk is not suitable for human infants, and should not be given as a main drink before 12 months. | Systematic reviewh |
| Cow milk should not be given as the main drink to infants under 12 months; however, small amounts may be used in the preparation of solid foods. | Systematic reviewi | ||
| Foods can be introduced in any order provided iron-rich nutritious foods are included and the texture is suitable for the infant’s stage of development. Cow milk products including full-fat yogurt, cheese and custard may be given, but not cow milk as a main drink before 12 months. | Systematic review; narrative reviewj | ||
| Low-fat and reduced-fat milks (skim milk and milk with 2–2.5% fat) are not recommended in the first 2 years of life. | Could not be mapped | ||
| Pasteurized full cream milk may be introduced to a child’s diet as a drink at around 12 months of age and be continued throughout the second year of life, and beyond. It is an excellent source of protein, calcium, and other nutrients. Do not use unpasteurized cow or goat milk. | Systematic review; narrative review; 2003 WHO European region reportk |
| New Zealand Ministry of Health | Ministry of Health, 2012l | After 1 year, cow milk may be introduced. | Narrative review |
| AAP | Baker et al., 2010 | Whole milk should not be used before 12 completed months of age. | Narrative review |
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Discuss healthy eating and remind parents to choose nutritious and tooth-friendly snacks.… Cow milk should not be given before a child is 12 months old. Whole milk is recommended for children aged 1 to 2 years. Reduced-fat and low-fat milks can be introduced from 2 years of age.m | Could not be mapped |
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. If adequate amounts of other animal-source foods are consumed regularly, the amount of milk needed is ~200–400 mL/day; otherwise, the amount of milk needed is ~300–500 mL/day. Acceptable milk sources include full-cream animal milk (cow, goat, buffalo, sheep, camel), ultrahigh temperature (UHT) milk, reconstituted evaporated (but not condensed) milk, fermented milk or yogurt, and expressed breast milk (heat treated if the mother is HIV positive).n | A background document and narrative review |
| Children 12–24 Months of Age | |||
| CPS | Unger et al., 2019 | For well infants, formula feeding is not required beyond 12 months of age, when whole cow milk can be introduced. Formulas designed for toddlers beyond 12 months are not necessary. | Narrative review |
TABLE B-7
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Lott et al., 2019b | 12–24 months: At 12 months of age, plain, pasteurized whole milk may be introduced; 2 to 3 cups per day (16–24 oz) whole milk is recommended until 2 years of age.* *For 12- to 24-month-olds, individual needs will depend on the amount of solid food consumed. As toddlers transition from getting most of their daily calories and nutrient needs from liquids (e.g., breast milk, formula, cow milk) to eating more solid foods, less milk is needed to meet daily calcium and caloric needs. However, milk remains an important dietary source of protein, calcium, and vitamin D for young children during this time. |
DGA, AAP, and a prior RWJF-HER expert panel on infant and toddler feeding guidelines |
| 12–24 months: Reduced-fat (2%) or low-fat (1%) milk may be considered, in consultation with a pediatrician, especially in the presence of excessive weight gain or family history of obesity, dyslipidemia, or other cardiovascular diseases. | DGA, AAP, and a prior RWJF-HER expert panel on infant and toddler feeding guidelines | ||
| 1–5 years (12–60 months): Consume only plain, pasteurized milk; flavored milk is not recommended. | Federal CACFP nutrition standards, and the National Academies recommendation that only unflavored milk be permitted in the WIC food package | ||
| AAP | Heyman et al., 2017 | Families should be educated that, to satisfy fluid requirements, human milk and/or infant formula is sufficient for infants and low-fat/nonfat milk and water are sufficient for older children. | Narrative review |
| RWJF-HER | Pérez-Escamilla et al., 2017 | At each meal, or as part of a snack, offer your toddler 1/2 cup (4 oz) of milk. | Narrative review |
| Give your toddler cow milk in a cup instead of a bottle. | Narrative review | ||
| The American Academy of Pediatrics recommends giving pasteurized whole cow milk to 1- to 2-year-olds. However, your health care provider may recommend pasteurized reduced-fat milk (2%) instead if there is a family history of obesity or heart problems. | Narrative review | ||
| Too much milk may decrease your toddler’s appetite for other food needed to meet nutritional needs. Keep your child’s total milk consumption to no more than 2 cups (16 fluid oz) per day while offering a variety of healthy food. | Narrative review | ||
| You can offer 1/2 to 3/4 cup of yogurt in place of milk during meal or snack times, but serve only plain yogurt or yogurt without excessive total sugars (no more than 23 g per 6 oz). | Narrative review | ||
| ESPGHAN | Domellöf et al., 2014 | Unmodified cow milk should not be fed as the main milk drink to infants before the age of 12 months, and intake should be limited to < 500 mL daily in toddlers.d | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Encourage continued breastfeeding, or offering 500 mL per day of homogenized (3.25% milk fat) cow milk.e | Narrative review; 2007 Eating Well with Canada’s Food Guidef |
| For an older infant or young child who is not breastfed or receiving breast milk: Advise pasteurized homogenized (3.25% milk fat) cow milk be introduced at 9–12 months of age. Skim milk is not appropriate in the first 2 years.e | Narrative review | ||
| If parents and caregivers are introducing cow milk, advise them to delay until 9–12 months of age. Recommend limiting cow milk intake to no more than 750 mL per day.e | Narrative review |
TABLE B-7
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| NHMRC (Australian government) | NHMRC, 2012g | Low-fat and reduced-fat milks (skim milk and milk with 2–2.5% fat) are not recommended in the first 2 years of life. | Could not be mapped |
| Pasteurized full cream milk may be introduced to a child’s diet as a drink at around 12 months of age and be continued throughout the second year of life, and beyond. It is an excellent source of protein, calcium, and other nutrients. Do not use unpasteurized cow or goat milk. | Systematic review; narrative review; WHO European region reportk | ||
| New Zealand Ministry of Health | Ministry of Health, 2012l | If the infant is not breastfed, then use an infant formula as the milk source until the infant is 1 year of age. After 1 year, cow milk may be introduced. | Narrative review |
| It is recommended that toddlers consume no more than 500 mL of cow milk each day. | Narrative review | ||
| Whole cow milk or a suitable alternative is recommended for toddlers. Fortified cow milk, such as toddler milk, is generally not necessary. | Narrative review | ||
| AAP | Baker et al., 2010 | Whole milk should not be used before 12 completed months of age. | Narrative review |
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Discuss healthy eating and remind parents to choose nutritious and tooth-friendly snacks.… Cow milk should not be given before a child is 12 months old. Whole milk is recommended for children aged 1 to 2 years. Reduced-fat and low-fat milks can be introduced from 2 years of age.m | Could not be mapped |
| Emphasize water/full-fat cow milk as drinks of choice. | Could not be mapped | ||
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. If adequate amounts of other animal-source foods are consumed regularly, the amount of milk needed is ~200–400 mL/day; otherwise, the amount of milk needed is ~300–500 mL/day. Acceptable milk sources include full-cream animal milk (cow, goat, buffalo, sheep, camel), ultrahigh temperature (UHT) milk, reconstituted evaporated (but not condensed) milk, fermented milk or yogurt, and expressed breast milk (heat treated if the mother is HIV positive).n | A background document and narrative review |
| Flavored Milk | |||
| RWJF-HER | Lott et al., 2019b | 0–12 months: Do not consume milk (flavored or plain). | Federal CACFP nutrition standards, and the National Academies recommendation that only unflavored milk be permitted in the WIC food package |
| 12–24 months: At 12 months of age, plain, pasteurized whole milk may be introduced; 2 to 3 cups per day (16–24 oz) whole milk is recommended until 2 years of age.* *For 12- to 24-month-olds, individual needs will depend on the amount of solid food consumed. As toddlers transition from getting most of their daily calories and nutrient needs from liquids (e.g., breast milk, formula, cow milk) to eating more solid foods, less milk is needed to meet daily calcium and caloric needs. However, milk remains an important dietary source of protein, calcium, and vitamin D for young children during this time. |
DGA, AAP, and a prior RWJF-HER expert panel on infant and toddler feeding guidelines | ||
| 1–5 years (12–60 months): Consume only plain, pasteurized milk; flavored milk is not recommended. | Federal CACFP nutrition standards, and the National Academies recommendation that only unflavored milk be permitted in the WIC food package | ||
| RWJF-HER | Pérez-Escamilla et al., 2017 | Offer cow milk with no added sugars (e.g., no flavored milks). | Narrative review |
TABLE B-7
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| ESPGHAN | Fidler Mis et al., 2017 | Smoothies and sweetened milk drinks/products (i.e., milk products containing a higher concentration of sugars than unprocessed human, cow, or goat milk, such as chocolate milks, condensed milks, fruit yogurts) are not specifically mentioned in the WHO definition; however, they are an important source of free sugars and their intake should be limited.o | Systematic literature search |
| Sugar-containing beverages and foods (SSBs, fruit juices, fruit-based smoothies, and sweetened milk drinks/products) should be replaced by water or, in the latter case, with unsweetened milk drinks/products with lactose up to the amount naturally present in milk and unsweetened milk products.o | Systematic literature search |
NOTE: AAP = American Academy of Pediatrics; CACFP = Child and Adult Care Food Program; CPS = Canadian Paediatric Society; DGA = Dietary Guidelines for Americans; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HC = Health Canada; NHMRC = National Health and Medical Research Council; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; SSB = sugar-sweetened beverage; WHO = World Health Organization; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
a This table does not include milk-based infant formulas or human milk.
b Lott et al. (2019) was an expert panel report with representation from the Academy of Nutrition and Dietetics, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association.
c Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
d Recommendation noted as being valid for Europe and other regions with a low general prevalence of iron deficiency anemia.
e © 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.
g NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
h For cow milk and goat milk only; no literature was presented for sheep milk.
i Using the NHMRC system, the strength-of-evidence rating related to this recommendation was a draft Grade D (for risks associated with feeding unmodified cow milk to infants less than 12 months of age). Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution.
j Portions of this recommendation could be mapped to a systematic review prepared for this guideline document; other portions appeared to be related to a narrative review of the evidence. Using the NHMRC system, the strength-of-evidence rating related to this recommendation was Grade D (risk associated with cow milk). Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution.
k Portions of this recommendation could be mapped to a systematic review prepared for this guideline document; other portions appeared to be related to a narrative review of the evidence and a WHO report (Michaelsen et al., 2003). Using the NHMRC system, the strength-of-evidence rating related to this recommendation was Grade D (risk associated with cow milk). Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution. There was insufficient evidence to provide an evidence statement on unpasteurized cow or goat milk.
l Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
m This recommendation contained additional guidance unrelated to milk or milk-based products that has been omitted from this table.
n 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).
o Recommendation did not specify an age group. The guideline document is aimed at infants, children, and adolescents.
TABLE B-8 Recommendations Related to Fluids: Water, Juice, Sugar-Sweetened Beverages, and Other Nonmilk Beveragesa,b
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| Water and Fluid Needs | |||
| RWJF-HER | Lott et al., 2019c | 0–6 months: No supplemental drinking water needed. | Narrative review |
| 6–12 months: Offer a total of 1/2 to 1 cup (4–8 oz) per day of plain, fluoridated drinking water in a cup during mealtimes. | Narrative review | ||
| 1–3 years (12–36 months): 1–4 cups (8–32 oz) per day of plain, fluoridated drinking water.* *The specific amount of plain water consumed between 1 and 5 years is determined for each child based on the total amount of milk consumed per day. For example, if a 3-year-old does not consume any milk in a given day, all fluid needs should be met via plain water, and thus 4 cups of plain water would be advised. However, if the same 3-year-old drank 2 cups of milk in a given day, approximately 2 cups of plain water per day would suffice to meet total fluid needs. |
Narrative review | ||
| If 100% juice is consumed, this additional fluid should also be factored into the amount of plain drinking water to consume. If plain drinking water is the only fluid consumed to meet total fluid needs, careful dietary planning is essential to promote adequate nutrient intake from foods. | |||
| SACN | SACN, 2018 | Breast milk, infant formula, and water should be the only drinks offered after 6 months of age. | Narrative review |
| AAP | Heyman et al., 2017 | Families should be educated that, to satisfy fluid requirements, human milk and/or infant formula is sufficient for infants and low-fat/nonfat milk and water are sufficient for older children. | Narrative review |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Once your baby starts solid food, it is recommended to offer a total of 4–8 oz per day of plain drinking water in a cup. | Narrative review |
| Your toddler needs about 2 cups of water per day to cover her or his fluids needs. Use a cup to offer water. | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Advise limiting fruit juice and sweetened beverages. Encourage offering water to satisfy thirst.d,e | Narrative review; 2007 Eating Well with Canada’s Food Guidef |
| NHMRC (Australian government) | NHMRC, 2012g | Exclusively breastfed infants do not require additional fluids up to 6 months of age. | Narrative review |
| New Zealand Ministry of Health | Ministry of Health, 2012h | Additional breastfeeds or fluids (in formula-fed infants) may be required if the infant or toddler is unwell or the weather is hot. | Narrative review |
| For toddlers, provide plenty of liquids each day such as water, breast milk, or cow milk (although no more than 500 mL per day of cow milk). | Narrative review | ||
| Fruit juices or sweet drinks are not recommended for infants and toddlers. Infants need only milk (breast milk or infant formula) to drink. Toddlers need only breast milk, cow milk, and water to drink. | Narrative review | ||
| For vegetarian and vegan toddlers, provide plenty of liquids each day, as water, breast milk, cow milk, or plant-based milks only (and no more than 500 mL of milk per day). | Narrative review | ||
| Strongly discourage the supplementing of breastfeeding with formula, water, herbal teas, milks, or any other liquids. | Narrative review | ||
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Emphasize water/full-fat cow milk as drinks of choice. | Could not be mapped |
TABLE B-8
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| NICE | NICE, 2008 | Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to provide milk and water to drink between meals (diluted fruit juice can be provided with meals—1 part juice to 10 parts water). | Rapid review,i UK Department of Health reportj |
| WHO | WHO, 2005 | Nonbreastfed infants and young children need 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 a temperate climate, and 800–1,200 mL/day in a hot climate. Plain, clean (boiled, if necessary) water should be offered several times per day to ensure that the infant’s thirst is satisfied.k | A background document and narrative review |
| Juicel | |||
| RWJF-HER | Lott et al., 2019c | 0–6 months: Juice is not recommended. | 2015 DGA and 2017 AAP recommendations for 100% fruit juice consumption |
| 6–12 months: Juice is not recommended. | 2015 DGA and 2017 AAP recommendations for 100% fruit juice consumption | ||
| 1–3 years (12–36 months): No more than 4 oz of 100% juice per day. | 2015 DGA and 2017 AAP recommendations for 100% fruit juice consumption | ||
| AAP | Heyman et al., 2017 | Juice should not be introduced into the diet of infants before 12 months of age unless clinically indicated. The intake of juice should be limited to, at most, 4 oz/day in toddlers 1 through 3 years of age, and 4–6 oz/day for children 4–6 years of age. | Narrative review |
| 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. | Narrative review | ||
| Toddlers should not be given juice from bottles or easily transportable covered cups that allow them to consume juice easily throughout the day. Toddlers should not be given juice at bedtime. | Narrative review | ||
| AAPD | AAPD, 2017 | AAPD supports the AAP recommendations on fruit juice in infants, children, and adolescents. | 2017 AAP recommendations on fruit juicem |
| ESPGHAN | Fewtrell et al., 2017 | No sugar or salt should be added to complementary foods, and fruit juices or sugar-sweetened beverages should be avoided.n | Systematic literature search |
| Fidler Mis et al., 2017 | Sugar-containing beverages and foods (SSBs, fruit juices, fruit-based smoothies, and sweetened milk drinks/products) should be replaced by water or, in the latter case, with unsweetened milk drinks/products with lactose up to the amount naturally present in milk and unsweetened milk products.o | Systematic literature search | |
| RWJF-HER | Pérez-Escamilla et al., 2017 | If you decide to offer 100% fruit juice to your toddler, limit intake to no more than 4 oz per day and offer it with a cup, not a bottle. | Narrative review |
| AAP; AAPD | AAPD, 2016 | To decrease the risk of developing early childhood caries, AAPD encourages professional and at-home preventive measures that include avoiding frequent consumption of liquids and/or solid foods containing sugar, in particular … sugar-sweetened beverages (e.g., juices, soft drinks, sports drinks, sweetened tea) in a baby bottle or no-spill training cup.p | Narrative review |
TABLE B-8
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Advise limiting fruit juice and sweetened beverages. Encourage offering water to satisfy thirst.d | Narrative review; based on the 2007 Eating Well with Canada’s Food Guidef |
| NHMRC (Australian government) | NHMRC, 2012g | Fruit juice is not necessary or recommended for infants. Consumption may interfere with their intake of breast milk or infant formula. | Narrative review |
| Avoid juices and sugar-sweetened drinks. Limit intake of all foods with added sugars. | Systematic reviewq | ||
| Do not offer tea, herbal teas, coffee, soft drinks, cordials, or other beverages. | Narrative review | ||
| New Zealand Ministry of Health | Ministry of Health, 2012h | Fruit juices or sweet drinks are not recommended for infants and toddlers. Infants need only milk (breast milk or infant formula) to drink. Toddlers need only breast milk, cow milk, and water to drink. | Narrative review |
| NICE | NICE, 2008 | Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to provide milk and water to drink between meals (diluted fruit juice can be provided with meals—1 part juice to 10 parts water). | Rapid review,i UK Department of Health reportj |
| Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should discourage parents and carers from offering baby juices or sugary drinks at bedtime. | Rapid review,i UK Department of Health reportj |
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Advise parents that fruit drinks and juice, cordials, and other sweetened drinks (including soft drinks and sports drinks) are not recommended.r | Narrative review |
| Discuss healthy eating and remind parents to choose nutritious and tooth-friendly snacks. Sweet drinks, such as fruit drinks and juice, cordials, and soft drinks, are not recommended.p | Could not be mapped | ||
| AHA | Gidding et al., 2005 | Improving nutritional quality after weaning: Delay the introduction of 100% juice until at least 6 months of age and limit to no more than 4–6 oz/day; juice should only be fed from a cup. | Could not be mapped |
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary soft drinks. Limit the amount of juice offered, to avoid displacing more nutrient-rich foods.s | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Feed a variety of foods to ensure that nutrient needs are met…. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.t | Technical consultations and documents |
| Sugar-Sweetened Beverages | |||
| RWJF-HER | Lott et al., 2019c | 0–5 years: SSBs are not recommended, including, but not limited to, soft drinks/soda, fruit drinks, fruit-flavored drinks, fruitades, sports drinks, energy drinks, sweetened waters, and sweetened coffee and tea beverages. | Narrative review |
| ESPGHAN | Fewtrell et al., 2017 | No sugar or salt should be added to complementary foods and fruit juices or SSBs should be avoided.n | Systematic literature search |
| Fidler Mis et al., 2017 | Sugar-containing beverages and foods (SSBs, fruit juices, fruit-based smoothies, and sweetened milk drinks/products) should be replaced by water or, in the latter case, with unsweetened milk drinks/products with lactose up to the amount naturally present in milk and unsweetened milk products.o | Systematic literature search | |
TABLE B-8
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Pérez-Escamilla et al., 2017 | It is strongly recommended to offer no SSBs such as flavored drinks, including Kool-Aid, fruit drinks, sodas, horchata (sweetened rice water), sports drinks, sweetened teas, or any other SSBs, to your baby during the first year of life. Doing so could reinforce your baby’s strong preference for sugary food and beverages and make it more difficult for her or him to learn to like healthy food such as vegetables, fruits, and plain water. | Narrative review |
| AAP; AAPD | AAPD, 2016 | To decrease the risk of developing early childhood caries, AAPD encourages professional and at-home preventive measures that include avoiding frequent consumption of liquids and/or solid foods containing sugar, in particular … SSBs (e.g., juices, soft drinks, sports drinks, sweetened tea) in a baby bottle or no-spill training cup.u | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Advise limiting fruit juice and sweetened beverages. Encourage offering water to satisfy thirst. | Narrative review; based on the 2007 Eating Well with Canada’s Food Guidef |
| NHMRC (Australian government) | NHMRC, 2012g | Avoid juices and sugar-sweetened drinks. Limit intake of all foods with added sugars. | Systematic reviewq |
| Do not offer tea, herbal teas, coffee, soft drinks, cordials, or other beverages. | Narrative review | ||
| New Zealand Ministry of Health | Ministry of Health, 2012h | Fruit juices or sweet drinks are not recommended for infants and toddlers. Infants need only milk (breast milk or infant formula) to drink. Toddlers need only breast milk, cow milk, and water to drink. | Narrative review |
| NICE | NICE, 2008 | Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should discourage parents and carers from offering baby juices or sugary drinks at bedtime. | Rapid review,i UK Department of Health reportj |
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Advise parents that fruit drinks and juice, cordials, and other sweetened drinks (including soft drinks and sports drinks) are not recommended.r | Narrative review |
| Discuss healthy eating and remind parents to choose nutritious and tooth-friendly snacks.… Sweet drinks such as fruit drinks and juice, cordials, and soft drinks, are not recommended.u | Could not be mapped | ||
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary soft drinks. Limit the amount of juice offered, to avoid displacing more nutrient-rich foods.s | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Feed a variety of foods to ensure that nutrient needs are met…. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.t | Technical consultations and documents |
| Coffee and Tea | |||
| RWJF-HER | Lott et al., 2019c | 0–5 years: SSBs are not recommended, including, but not limited to, soft drinks/soda, fruit drinks, fruit-flavored drinks, fruitades, sports drinks, energy drinks, sweetened waters, and sweetened coffee and tea beverages. | Narrative review |
| NHMRC (Australian government) | NHMRC, 2012g | Do not offer tea, herbal teas, coffee, soft drinks, cordials, or other beverages. | Narrative review |
| New Zealand Ministry of Health | Ministry of Health, 2012h | Coffee, tea, herbal teas, caffeine-containing beverages, smart or energy drinks, carbonated beverages, and alcohol are not recommended for infants and toddlers. | Narrative review |
| Do not give infants and toddlers alcohol, coffee, cordials, juice, soft drinks, tea (including herbal teas), and other drinks containing caffeine. | Narrative review | ||
TABLE B-8
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary soft drinks. Limit the amount of juice offered, to avoid displacing more nutrient-rich foods.s | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Feed a variety of foods to ensure that nutrient needs are met…. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.t | Technical consultations and documents |
| Caffeinated Beverages | |||
| RWJF-HER | Lott et al., 2019c | 0–5 years: Do not consume caffeinated beverages. | Narrative review |
| New Zealand Ministry of Health | Ministry of Health, 2012h | Coffee, tea, herbal teas, caffeine-containing beverages, smart or energy drinks, carbonated beverages, and alcohol are not recommended for infants and toddlers. | Narrative review |
| Do not give infants and toddlers alcohol, coffee, cordials, juice, soft drinks, tea (including herbal teas), and other drinks containing caffeine. | Narrative review | ||
| Beverages of Low Nutrient Value | |||
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary soft drinks. Limit the amount of juice offered, to avoid displacing more nutrient-rich foods.s | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Feed a variety of foods to ensure that nutrient needs are met…. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.t | Technical consultations and documents |
| Plant-Based Beverages | |||
| RWJF-HER | Lott et al., 2019c | 0–12 months: Plant milks/nondairy beverages are not recommended. | DGAs |
| 1–5 years (12–60 months): Plant milks/nondairy beverages are not recommended for exclusive consumption in place of dairy milk (with the exception of soy milk); consume only when medically indicated or to meet specific dietary preferences. | DGAs | ||
| Pérez-Escamilla et al., 2017 | Plant-based beverages (e.g., soy, rice, almond milks) are not recommended for your child in place of breast milk or formula, unless prescribed by your pediatrician (e.g., commercially prepared soy-based infant formula). These beverages are not designed to meet the nutritional needs of your child to the same extent as breast milk or infant formula. | Narrative review | |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Discourage the use of homemade, evaporated milk formula. Cow milk, goat milk, soy beverage, rice beverage, or any other beverages should not be given to young infants.v,w | Narrative review |
| Health Canada et al., 2014 | For an older infant or young child who is not breastfed or receiving breast milk: Advise that soy, rice, or other plant-based beverages, whether or not they are fortified, are inappropriate alternatives to cow milk in the first 2 years.d | Narrative review | |
| New Zealand Ministry of Health | Ministry of Health, 2012h | For vegetarian and vegan toddlers, provide plenty of liquids each day, as water, breast milk, cow milk, or plant-based milks only (and no more than 500 mL of milk per day). | Narrative review |
| For toddlers who do not have cow milk or milk products, calcium-fortified milk alternatives can provide calcium. | Narrative review | ||
TABLE B-8
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| NHMRC (Australian government) | NHMRC, 2012g | Rice and oat milk can be used after 12 months, as long as a full-fat, fortified variety (at least 100 mg of calcium per 100 mL) is used and alternative forms of protein and vitamin B12 are included in the diet. These products are suitable when used under health professional supervision. | Could not be mapped |
| Soy (except fortified soy products and soy formula where specifically indicated), and other nutritionally incomplete alternate milks or milk substitutes (e.g., goat milk, sheep milk, coconut milk, almond milk) are inappropriate alternatives to breast milk, formula, or pasteurized whole cow milk in the first 2 years of life. | Systematic review;x narrative review |
NOTE: AAP = American Academy of Pediatrics; AAPD = American Academy of Pediatric Dentistry; AHA = American Heart Association; CPS = Canadian Paediatric Society; DGA = Dietary Guidelines for Americans; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; GP = general practitioner; HC = Health Canada; mg = milligrams; mL = milliliters; NHMRC = National Health and Medical Research Council; NICE = National Institute for Health and Care Excellence; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; SSB = sugar-sweetened beverage; UK = United Kingdom; WHO = World Health Organization.
a This table does not include recommendations related to infant formulas. Recommendations are duplicated in this table if they address multiple subtopics (italicized text).
b One recommendation on beverages containing low-calorie sweetener has been omitted from this table, but it is found in Table B-9, Recommendations Related to Substances to Avoid or Limit.
c Lott et al. (2019) was an expert panel report with representation from the Academy of Nutrition and Dietetics, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association.
d © 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.
e This recommendation pertains to children 12–24 months of age.
g NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
h Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
i Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There is no overall statement on the strength of the evidence for each recommendation.
k Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Fluid Needs, p. 20, Copyright (2005).
l Recommendations listed in this section include those focused specifically on juice and those in which juice is one of multiple beverages listed.
n Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
o Recommendation did not specify an age group. The guideline document is aimed at infants, children, and adolescents.
p This recommendation contained additional guidance unrelated to juice that has been omitted from this table.
q Using the NHMRC system, the strength-of-evidence rating related to this recommendation was Grade C (for intake of sugar and risk of dental disease). Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application.
r Recommendation was given for both infants 6–12 months of age and toddlers 12–24 months of age.
s 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).
t 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).
u This recommendation contained additional guidance unrelated to sugar-sweetened beverages that has been omitted from this table.
v © All rights reserved. Nutrition for healthy term infants: Recommendations from birth to six months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.
w Recommendation is applicable to infants from birth to 6 months of age.
x Portions of this recommendation could be mapped to a systematic review prepared for this guideline document; other portions appeared to be related to a narrative review of the evidence. There was insufficient evidence to provide an evidence statement on unpasteurized cow or goat milk.
TABLE B-9 Recommendations Related to Substances to Avoid or Limita
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| AAP | Baker-Smith et al., 2019 | No advice can be provided on the use of nonnutritive sweeteners in children younger than 2 years old given the absence of data on this age group. | Lack of evidenceb |
| RWJF-HER | Lott et al., 2019c | 0–5 years: Beverages with low-calorie sweeteners are not recommended. | Narrative reviewd |
| SACN | SACN, 2018 | In view of the high intakes of salt (sodium chloride) and free sugars in this age group, there is a need to reemphasize the risks associated with added salt and free sugars in foods given to infants during the complementary feeding period and to keep reported intakes under review. | Narrative review |
| AAPD | AAPD, 2017 | AAPD supports the recommendation of national and international organizations to reduce the consumption of sugar to less than 10% of total energy intake and, to reduce children’s risk of weight gain and dental caries, sugar intake should be less than 5% of total energy intake (less than 16 g of sugar for children aged 4–8).e | DGA, WHO, and AHA |
| ESPGHAN | Fewtrell et al., 2017 | No sugar or salt should be added to complementary foods, and fruit juices or SSBs should be avoided.f | Systematic literature search |
| Fidler Mis et al., 2017 | Intakes of free sugars should be reduced and minimized with a desirable upper limit of < 5% energy intake in children and adolescents aged ≥ 2–18 years. This represents: 15–28 g of free sugars (3.5–7 teaspoons) for girls; 16–37 g (4–9 teaspoons) for boys, according to age. Intakes should be even lower in infants and toddlers < 2 years. | Systematic literature search | |
| Sugars should preferably be consumed in a natural form such as human milk, milk, unsweetened dairy products, fresh fruits, rather than as SSBs, fruit juices, smoothies, and/or sweetened milk drinks/products, and as a part of a main meal, not as snacks.g | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Avoid feeding your toddler food that is high in sodium (salt) such as processed meats like ham, lunch meats, and packaged breaded chicken and fish. | Narrative review |
| During the transition to family food, continue to expose your baby to healthy food including plenty of vegetables and fruits, and avoid offering unhealthy food such as SSBs, sweets, salty food/snacks, and fried food/snacks that are high in added sugars, calories, and/or salt. | Narrative review | ||
| Limit your toddler’s consumption of snacks high in sodium and with added sugars. | Narrative review | ||
| Offer healthy meals and snacks to the entire family, and do not have unhealthy food around her or him, including SSBs, sweets, salty snacks, and fried food/snacks. | Narrative review | ||
| When preparing food for your infant, do not add salt or sugar. Likewise, when choosing baby food that is already prepared, choose options without (or with limited amounts of) added salt or sugars. | Narrative review | ||
| You can offer 1/2 to 3/4 cup of yogurt in place of milk during meal or snack times, but serve only plain yogurt or yogurt without excessive total sugars (no more than 23 g per 6 oz). | Narrative review | ||
| AAP; AAPD | AAPD, 2016 |
To decrease the risk of developing early childhood caries, AAPD encourages professional and at-home preventive measures that include avoiding frequent consumption of liquids and/or solid foods containing sugar, in particular:
|
Narrative review |
TABLE B-9
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Recommend foods prepared with little or no added salt or sugar.h | Narrative review; 2007 Eating Well with Canada’s Food Guidei |
| NHMRC (Australian government) | NHMRC, 2012j | Avoid juices and sugar-sweetened drinks. Limit intake of all foods with added sugars. | Systematic reviewk |
| Consumption of nutrient-poor discretionary foods with high levels of saturated fat, added sugars, and/or added salt (e.g., cakes, biscuits and potato chips) should be avoided. | Systematic reviewsl | ||
| Do not add salt to foods for infants. This is an important safety issue as infant kidneys are immature and unable to excrete excess salt. | Systematic reviewm | ||
| Do not add sugar or honey to infant foods as this increases the risk of dental caries. | Systematic reviewk | ||
| Do not dip pacifiers or bottle teats in sugar, jam, honey, or any other sugary substance. | Could not be mapped | ||
| New Zealand Ministry of Health | Ministry of Health, 2012n | Do not dip pacifiers or bottle teats in sugar or honey. | 2008 New Zealand Dental Association guideo |
| Dried fruit is not recommended as a snack between meals because it sticks to teeth and is cariogenic. | 2008 New Zealand Dental Association guideo | ||
| For infants, prepare or choose pre-prepared complementary foods with no added fat, salt, sugar, honey, or other sweeteners. | Narrative review | ||
| For toddlers, prepare foods or choose pre-prepared foods, drinks, and snacks that are low in salt, but if using salt, use iodized salt, and that have little added sugar (and limit the toddler’s intake of high-sugar foods). | Narrative review |
| Liver and pâté are excellent sources of vitamin A. However, infants should not be offered liver or pâté more than once per week, and no more than 10 g per serving. | Narrative review | ||
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | If a pacifier is used, advise parents not to dip the pacifier in sugar, honey, or any other sweetened drinks. | 2008 New Zealand Ministry of Health guidelinesp |
| Remind parents that if sugar foods are eaten they should be taken at mealtimes instead of as snacks. | 2005 NHS Scotland guidelineq | ||
| Remind parents to choose foods and drinks low in sugar. | Narrative review | ||
| NICE | NICE, 2008 | Child health promotion. Health visitors and the CHPP team should encourage and support parents and carers to make home-prepared foods for infants and young children without adding salt, sugar, or honey. | Rapid review,r UK Department of Health reports |
| Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should discourage parents and carers from adding sugar or any solid food to bottle feeds. | Rapid review,r UK Department of Health reports | ||
| Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should discourage parents and carers from adding sugar or honey to weaning (solid) foods. | Rapid review,r UK Department of Health reports | ||
| Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to avoid giving biscuits or sweets as treats. | Rapid review,r UK Department of Health reports |
TABLE B-9
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| NICE | NICE, 2008 | Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to encourage snacks free of salt and added sugar (such as vegetables and fruit) between meals. | Rapid review,r UK Department of Health reports |
| Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to limit sugary foods to mealtimes only. | Rapid review,r UK Department of Health reports | ||
| AHA | Gidding et al., 2005 | Improving nutritional quality after weaning: Introduce healthy foods and continue offering if initially refused; do not introduce foods without overall nutritional value simply to provide calories. | Narrative review |
NOTE: AAP = American Academy of Pediatrics; AAPD = American Academy of Pediatric Dentistry; AHA = American Heart Association; CHPP = Child Health Promotion Programme; CPS = Canadian Paediatric Society; DGA = Dietary Guidelines for Americans; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; g = grams; GP = general practitioner; HC = Health Canada; NHMRC = National Health and Medical Research Council; NHS = National Health Service (United Kingdom); NICE = National Institute for Health and Care Excellence; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SSB = sugar-sweetened beverage; UK = United Kingdom; WHO = World Health Organization.
a With the exception of the recommendation related to beverages containing low-calorie sweeteners, this section has omitted recommendations that only address beverages. Recommendations specifically related to beverages are found in Table B-8. Recommendations related to the risk of botulism with honey intake are found in Table B-21.
b The guideline, which was based on narrative review, notes that there is a lack of evidence on this topic; accordingly, no evidence was cited.
c Lott et al. (2019) was an expert panel report with representation from the Academy of Nutrition and Dietetics, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association.
d The guideline, which was based on narrative review, notes that there is a lack of evidence for young children; accordingly, the recommendation was based on expert opinion.
e It is unclear if this statement is relevant to children from birth to 24 months.
f Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
g Recommendation did not specify an age group. The guideline document is aimed at infants, children, and adolescents.
h © 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.
j NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
k Using the NHMRC system, the strength-of-evidence rating related to this recommendation was Grade C (for sugar’s effect on risk of dental disease). Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application.
l The systematic reviews were only related to sugar and salt. Using the NHMRC system, the strength-of-evidence ratings related to this recommendation were as follows: Grade A (for salt or sodium having an effect on blood pressure in children and adolescents) and Grade C (for sugar’s effect on risk of dental disease). Grade A (convincing association) indicates that the body of evidence can be trusted to guide practice. Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application.
m Using the NHMRC system, the strength-of-evidence rating related to this recommendation was Grade A (for salt or sodium having an effect on blood pressure in children and adolescents). Grade A (convincing association) indicates that the body of evidence can be trusted to guide practice. The rationale related to infant kidney immaturity could not be mapped to its evidence.
n Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
o New Zealand Dental Association, 2008.
r Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There is no overall statement on the strength of the evidence for each recommendation.
TABLE B-10 Recommendations Related to Variety and Healthy, Nutritious Foods
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| SACN | SACN, 2018 | Dietary, flavor, and texture diversification should proceed incrementally throughout the complementary feeding period, taking into account the variability between infants in developmental attainment and the need to satisfy nutritional requirements. When introducing new foods it should be recognized that they may need to be presented to infants on many occasions before they are accepted, particularly as infants get older. | Narrative review |
| ESPGHAN | Fewtrell et al., 2017 | Recommendations on specific types of complementary foods should take into consideration traditions and feeding patterns in the population. Infants should be offered a varied diet including foods with different flavors and textures including bitter-tasting green vegetables.a | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | During the transition to family food, continue to expose your baby to healthy food including plenty of vegetables and fruits, and avoid offering unhealthy food such as sugar-sweetened beverages, sweets, salty food/snacks, and fried food/snacks that are high in added sugars, calories, and/or salt. | Narrative review |
| Feed your baby only healthy food that provides plenty of vitamins, minerals, and fiber, including fresh vegetables, fruits, and age-appropriate whole grain products. Also, make sure to feed your baby nutritious food that provides an adequate amount of protein (such as eggs, fish, meat) and energy.b | Narrative review | ||
| Offer your child the recommended portion of healthy food from the different food groups (fruits, vegetables, grains, proteins, dairy) at each meal, and let her or him decide how much to eat.c | Narrative review | ||
| Provide healthy, tasty food that is appropriate for your child’s age at regular times and in a pleasant environment, and let your baby decide how much she or he wants to eat.b | Narrative review |
| Remember that it may take more tries for your baby to learn to like vegetables than other healthy food like fruits. Continue offering a variety of vegetables and other healthy food, and let your child decide when she or he is ready. | Narrative review | ||
| SIGENP; SIAIP | Alvisi et al., 2015d | The child’s diet will be better inasmuch as the family will follow a correct and balanced diet, mindful of the caloric and protein intake. It is therefore of paramount importance to provide parents with the right information about a nutritionally balanced diet, and encourage them to recognize and respect every child’s self-regulatory capacity. It is also important to promote the daily consumption of fruits and vegetables. | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Explain to parents and caregivers that nutritious, higher-fat foods are an important source of energy for young children.e | Narrative review; 2007 Eating Well with Canada’s Food Guidef |
| Ensure that lumpy textures are offered no later than 9 months. Encourage progress toward a variety of textures, modified from family foods, by 1 year of age.e | Narrative review | ||
| Recommend a regular schedule of meals and snacks, offering a variety of foods from the four food groups.e | Narrative review; 2007 Eating Well with Canada’s Food Guidef | ||
| Recommend iron-rich meat, meat alternatives, and iron-fortified cereal as the first complementary foods. Encourage parents and caregivers to progress to introduce a variety of nutritious foods from the family meals.e | Narrative review |
TABLE B-10
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| New Zealand Ministry of Health | Ministry of Health, 2012g | The variety of complementary foods should be increased to ensure an additional intake of nutrients, especially zinc. At around 6 months of age, meat or chicken purées can be added. As chewing skills develop, finely chopped meats can be introduced. Infants should be eating family foods by around 1 year of age. | Narrative review |
| (For vegetarian and vegan infants and toddlers): Toddlers should be offered a variety of nutritious foods from each of the major food groups each day. The food groups are vegetables and fruit; breads and cereals, preferably wholemeal; milk and milk products or suitable alternatives; vegetarian protein foods, such as pulses (peas, beans, lentils, soy), grains (wheat, oats, rice, barley, buckwheat, millet, pasta, bread), nuts (not whole), meat substitutes, eggs, and nut butters. | Narrative review | ||
| (For vegetarian and vegan infants and toddlers): Once an infant has started complementary foods, the variety should be increased to ensure an additional intake of nutrients, especially energy, protein, iron, calcium, and vitamin B12. | Narrative review | ||
| Increase the texture, variety, flavor, and amount of food offered so the infant receives an additional intake of nutrients, especially iron and vitamin C, and is eating some family foods by around 1 year of age. | Narrative review | ||
| Infants and toddlers should be offered a wide variety of vegetables and fruit, including dark-green leafy vegetables (spinach, silverbeet, or pūhā) and yellow, red, and orange-colored vegetables and fruit (carrots, pumpkin, kūmara, tomatoes, apricots, tamarillos). | Narrative review | ||
| Maintain healthy growth and development of the infant and toddler by providing them with appropriate food and physical activity opportunities every day. | Narrative review |
| Offer toddlers a variety of nutritious foods from each of the major food groups each day. The food groups are vegetables and fruit; breads and cereals, including wholemeal; milk and milk products or suitable alternatives; lean meat, poultry, seafood, eggs, legumes, nuts, and seeds.* *Do not give small hard foods like whole nuts and large seeds until children are at least 5 years old. |
Narrative review | ||
| The variety of complementary foods should be increased to ensure an additional intake of nutrients, especially iron. Iron-fortified infant cereals are suitable starter foods, and absorption can be enhanced if the infant is also given foods containing vitamin C. Once the infant is around 6 months of age, meat or chicken purées can be added to their feeds, and as they develop chewing skills finely chopped meats can be introduced. Infants should be eating some family foods by around 1 year of age. | Narrative review | ||
| NICE | NICE, 2008 | Child health promotion: Health visitors and the CHPP team should provide mothers and other family members with support to introduce a variety of nutritious foods (in addition to milk) to ensure the child is offered a progressively varied diet from 6 months. | Rapid review,h UK Department of Health reporti |
| AHA | Gidding et al., 2005 | Improving nutritional quality after weaning: Introduce healthy foods and continue offering if initially refused; do not introduce foods without overall nutritional value simply to provide calories. | Narrative review |
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. Avoid giving drinks with low nutrient value, such as tea, coffee and sugary soft drinks. Limit the amount of juice offered, to avoid displacing more nutrient-rich foods.j | A background document and narrative review |
TABLE B-10
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. Dairy products are the richest sources of calcium. If dairy products are not consumed in adequate amounts, other foods that contain relatively large amounts of calcium, such as small fish that include the bones (dried or fresh, with the bones crushed or otherwise processed so that they are safe to eat) and lime-treated maize tortillas, can fill the gap. Other foods such as soybeans, cabbage, carrots, squash, papaya, dark green leafy vegetables, guava, and pumpkin are useful additional sources of calcium.j | A background document and narrative review |
| Feed a variety of foods to ensure that nutrient needs are met. If adequate amounts of other animal-source foods are consumed regularly, the amount of milk needed is ~200–400 mL/day; otherwise, the amount of milk needed is ~300–500 mL/day. Acceptable milk sources include full-cream animal milk (cow, goat, buffalo, sheep, camel), ultrahigh temperature (UHT) milk, reconstituted evaporated (but not condensed) milk, fermented milk or yogurt, and expressed breast milk (heat treated if the mother is HIV positive).j | A background document and narrative review | ||
| Feed a variety of foods to ensure that nutrient needs are met. If milk and other animal-source foods are not eaten in adequate amounts, both grains and legumes should be consumed daily, if possible within the same meal, to ensure adequate protein quality.j | A background document and narrative review | ||
| Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish, or eggs should be eaten daily, or as often as possible, because they are rich sources of many key nutrients such as iron and zinc. Milk products are rich sources of calcium and several other nutrients. 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.j | A background document and narrative review |
| Feed a variety of foods to ensure that nutrient needs are met. Provide diets with adequate fat content. If animal source foods are not consumed regularly, 10–20 g of added fats or oils are needed unless a fat-rich food is given (such as foods or pastes made from groundnuts, other nuts, and seeds). If animal-source foods are consumed, up to 5 g of additional fats or oils may be needed.j | A background document and narrative review | ||
| Feed a variety of foods to ensure that nutrient needs are met. The daily diet should include vitamin A–rich foods (e.g., dark colored fruits and vegetables, red palm oil, vitamin A–fortified oil or foods); vitamin C–rich foods (e.g., many fruits, vegetables, and potatoes) consumed with meals to enhance iron absorption; and foods rich in the B vitamins including riboflavin (e.g., liver, egg, dairy products, green leafy vegetables, soybeans), vitamin B6 (e.g., meat, poultry, fish, banana, green leafy vegetables, potato and other tubers, peanuts), and folate (e.g., legumes, green leafy vegetables, orange juice).j | A background document and narrative review | ||
| PAHO/WHO | PAHO/WHO, 2003 | Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish, or eggs should be eaten daily, or as often as possible. Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used.… Vitamin A–rich fruits and vegetables should be eaten daily. Provide diets with adequate fat content.… Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.k | Technical consultations and documents |
NOTE: AHA = American Heart Association; CHPP = Child Health Promotion Programme; CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HC = Health Canada; NICE = National Institute for Health and Care Excellence; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; SIAIP = Italian Society of Pediatric Allergology and Immunology; SIGENP = Italian Society of Gastroenterology, Hepatology and Pediatric Nutrition; UK = United Kingdom; WHO = World Health Organization.
a Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
b Recommendation is applicable to infants 6–12 months of age.
TABLE B-10
c Recommendation is applicable to children 12–24 months of age.
d Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).
e © 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.
g Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
h Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There was no overall statement on the strength of the evidence for each recommendation.
j Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Nutrient Content of Foods, pp. 12–13, Copyright (2005).
k 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).
TABLE B-11 Recommendations Related to Fruits and Vegetables
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| AAP | Heyman et al., 2017 | Children should be encouraged to eat whole fruit to meet their recommended daily fruit intake and should be educated regarding the benefit of fiber intake and the longer time to consume the same kilocalories when consuming whole fruit compared with fruit juice. | Narrative review |
| ESPGHAN | Fewtrell et al., 2017 | Recommendations on specific types of complementary foods should take into consideration traditions and feeding patterns in the population. Infants should be offered a varied diet including foods with different flavors and textures including bitter-tasting green vegetables.a | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | During the transition to family food, continue to expose your baby to healthy food including plenty of vegetables and fruits, and avoid offering unhealthy food such as sugar-sweetened beverages, sweets, salty food/snacks, and fried food/snacks that are high in added sugars, calories, and/or salt. | Narrative review |
| Feed your baby only healthy food that provides plenty of vitamins, minerals, and fiber, including fresh vegetables, fruits, and age-appropriate whole grain products. Also, make sure to feed your baby nutritious food that provides an adequate amount of protein (such as eggs, fish, meat) and energy. | Narrative review | ||
| Include a variety of vegetables, especially dark green, red, and orange types. These vegetables are rich in many nutrients that are difficult to get in adequate amounts from other food. | Narrative review | ||
| Remember that it may take more tries for your baby to learn to like vegetables than other healthy food like fruits. Continue offering a variety of vegetables and other healthy food, and let your child decide when she or he is ready. | Narrative review |
TABLE B-11
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Pérez-Escamilla et al., 2017 | When introducing a new vegetable, it is recommended to mix it first with a familiar food such as breast milk, formula, or cereal. Combining new food items that are more difficult to accept by babies, such as some vegetables, with food they are already familiar with can help your baby accept and learn to like vegetables more readily. | Narrative review |
| Whenever possible, offer fresh fruit instead of 100% fruit juice to your toddler since whole fruit provides less sugar and more fiber than juice. | Narrative review | ||
| After introducing iron- and zinc-fortified baby cereals or mashed meats, there is no particular order to follow for introducing solid food. At this point, your baby is able to digest and absorb the nutrients from healthy food belonging to different food groups. However, it is important to keep in mind that the earlier vegetables are introduced (once your baby is ready to consume solid food), the more she or he is likely to easily accept them. | Narrative review | ||
| SIGENP; SIAIP | Alvisi et al., 2015b | The child’s diet will be better inasmuch as the family will follow a correct and balanced diet, mindful of the caloric and protein intake. It is therefore of paramount importance to provide parents with the right information about a nutritionally balanced diet, and encourage them to recognize and respect every child’s self-regulatory capacity. It is also important to promote the daily consumption of fruits and vegetables. | Narrative review |
| New Zealand Ministry of Health | Ministry of Health, 2012c | Dried fruit is not recommended as a snack between meals because it sticks to teeth and is cariogenic. | 2008 New Zealand Dental Association guided |
| Infants and toddlers should be offered a wide variety of vegetables and fruit, including dark-green leafy vegetables (spinach, silverbeet or pūhā) and yellow, red, and orange-colored vegetables and fruit (carrots, pumpkin, kūmara, tomatoes, apricots, tamarillos). | Narrative review |
| AAP | Baker et al., 2010 | Toddlers 1 through 3 years of age should have an iron intake of 7 mg/day. This would be best delivered by eating red meats, cereals fortified with iron, vegetables that contain iron, and fruits with vitamin C, which augments the absorption of iron. For toddlers not receiving this iron intake, liquid supplements are suitable for children 12–36 months of age, and chewable multivitamins can be used for children 3 years and older. | Iron DRIse |
| NICE | NICE, 2008 | Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to encourage snacks free of salt and added sugar (such as vegetables and fruit) between meals. | Rapid review,f UK Department of Health reportg |
| PAHO/WHO | PAHO/WHO, 2003 | Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish, or eggs should be eaten daily, or as often as possible. Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used.… Vitamin A–rich fruits and vegetables should be eaten daily. Provide diets with adequate fat content.… Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.h | Technical consultations and documents |
NOTE: AAP = American Academy of Pediatrics; DRI = Dietary Reference Intake; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; GP = general practitioner; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SIAIP = Italian Society of Pediatric Allergology and Immunology; SIGENP = Italian Society of Gastroenterology, Hepatology and Pediatric Nutrition; UK = United Kingdom; WHO = World Health Organization.
a Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
b Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).
c Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
d New Zealand Dental Association, 2008.
e Citation pertains to the first sentence. Evidence could not be mapped for the remainder of the recommendation.
f Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There is no overall statement on the strength of the evidence for each recommendation.
h 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).
TABLE B-12 Recommendations Related to Vegetarian and Vegan Diets
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Lott et al., 2019a | 1–5 years (12–60 months): Plant milks/nondairy beverages are not recommended for exclusive consumption in place of dairy milk (with the exception of soy milk); consume only when medically indicated or to meet specific dietary preferences. | DGA |
| ESPGHAN | Fewtrell et al., 2017 | Vegan diets should only be used under appropriate medical or dietetic supervision to ensure that the infant receives a sufficient supply of vitamin B12, vitamin D, iron, zinc, folate, n-3 LCPUFA, protein, and calcium, and that the diet is sufficiently nutrient and energy dense. Parents should understand the serious consequences of failing to follow advice regarding supplementation of the diet.b | Systematic literature search |
| AND | AND, 2016 | It is the position of the Academy of Nutrition and Dietetics that appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes. | Narrative review |
| NHMRC (Australian government) | NHMRC, 2012c | To prevent iron deficiency, iron-containing nutritious foods are recommended to be the first foods. Iron-containing foods include iron-fortified cereals, as well as puréed meat and poultry dishes. Cooked plain tofu and legumes/beans are also sources of iron. Care needs to be taken particularly with a plant-based diet to ensure that supplies of iron are adequate. This is an important issue because of the neurocognitive development implications. | Narrative review |
| New Zealand Ministry of Health | Ministry of Health, 2012d | Dark-green leafy vegetables, puréed or mashed lentils, chickpeas, and peas are suitable alternatives for vegetarian infants, although the iron is less well absorbed and should be eaten with a source of vitamin C. | Narrative review |
| (For vegetarian and vegan infants and toddlers): Toddlers should be offered a variety of nutritious foods from each of the major food groups each day. The food groups are vegetables and fruit; breads and cereals, preferably wholemeal; milk and milk products or suitable alternatives; vegetarian protein foods, such as pulses (peas, beans, lentils, soy), grains (wheat, oats, rice, barley, buckwheat, millet, pasta, bread), nuts (not whole), meat substitutes, eggs, and nut butters. | Narrative review | ||
| (For vegetarian and vegan infants and toddlers): Once an infant has started complementary foods, the variety should be increased to ensure an additional intake of nutrients, especially energy, protein, iron, calcium, and vitamin B12. | Narrative review | ||
| Dark-green leafy vegetables, sieved lentils, chickpeas, and peas are suitable alternatives to increase zinc intake for vegetarian infants. | Narrative review | ||
| For vegetarian and vegan toddlers, provide plenty of liquids each day, as water, breast milk, cow milk, or plant-based milks only (and no more than 500 mL of milk per day). | Narrative review | ||
| If the infant is not breastfed, then an infant formula should be used until the infant is 1 year of age. For vegan infants who are not breastfed or are partially breastfed, the use of a commercial soy-based infant formula during the first 2 years of life is recommended. | Narrative review | ||
| For toddlers who do not have cow milk or milk products, calcium-fortified milk alternatives can provide calcium. Foods that can be used include mashed canned fish with bones (e.g., sardines and salmon), tofu, nut pastes, green vegetables (e.g., broccoli, leeks, cabbage and spinach), and cooked dried beans. | Narrative review |
TABLE B-12
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| CPS | Amit et al., 2010 (reaffirmed in 2018) | A well-balanced vegetarian diet as a healthy lifestyle choice is an acceptable option to provide for the needs of growth and development in the young. | Narrative reviewe |
| Both lacto-ovo-vegetarian and vegan diets have increased iron needs (1.8-fold) compared with omnivores, and caregivers will require sound knowledge of food sources that are iron fortified or rich in iron. Iron supplementation may be required during periods of rapid growth. | Narrative reviewe | ||
| Calcium intake in strict vegans needs careful attention to assure recommended consumption of fortified foods or supplements. | Narrative reviewe | ||
| Energy needs in strict vegans may require intake of calorie-dense foods to provide for adequate growth. Growth should be monitored closely. | Narrative reviewf | ||
| Foods containing the precursor of the essential fatty acid linolenic acid should be included in strict vegan diets (flaxseed, canola, nut oils, and soya products). | Narrative reviewg | ||
| Infants, children, and adolescents on vegan diets should ensure adequate intake of vitamin B12–fortified food or be provided with 5 µg to 10 µg of daily supplement. | Narrative reviewh | ||
| Lacto-ovo-vegetarian diets should be adequate to meet all nutrient needs comparable with omnivores (standard recommendations regarding supplementation). | Narrative reviewe |
| CPS | Amit et al., 2010 (reaffirmed in 2018) | Protein requirements in strict vegans will need to be increased to account for the lower digestibility of plant protein. | Narrative reviewi |
| Vitamin D recommendations for infants in Canada are standard. Children and adolescents who consume less than 500 mL of vitamin D–fortified milk product per day should be supplemented with 400 U daily. For children younger than 2 years of age living above a northern latitude of 55°, those with dark skin, and those avoiding sunlight, 800 U of vitamin D per day should be provided in the winter months. | Narrative reviewe | ||
| Zinc needs for breastfed infants of vegan mothers will require fortified foods after 7 months of age. Strict vegans will need to consume 50% more zinc to account for bioavailability. | Narrative reviewe | ||
| AAP | Bhatia et al., 2008 | In term infants, although isolated soy protein–based formulas may be used to provide nutrition for normal growth and development, there are few indications for their use in place of cow milk–based formula. These indications include (a) for infants with galactosemia and hereditary lactase deficiency (rare), and (b) in situations in which a vegetarian diet is preferred. | Narrative reviewj |
| Isolated soy protein–based formula has no advantage over cow milk protein-based formula as a supplement for the breastfed infant, unless the infant has one of the indications noted previously—(a) for infants with galactosemia and hereditary lactase deficiency (rare), and (b) in situations in which a vegetarian diet is preferred). | Narrative reviewj |
TABLE B-12
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish, or eggs should be eaten daily, or as often as possible, because they are rich sources of many key nutrients such as iron and zinc. Milk products are rich sources of calcium and several other nutrients. 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.k | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish, or eggs should be eaten daily, or as often as possible. Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used.… Vitamin A–rich fruits and vegetables should be eaten daily. Provide diets with adequate fat content…. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.l | Technical consultations and documents |
NOTE: µg = microgram; AAP = American Academy of Pediatrics; AND = Academy of Nutrition and Dietetics; CPS = Canadian Paediatric Society; DGA = Dietary Guidelines for Americans; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; n-3 LCPUFA = omega-3 long-chain polyunsaturated fatty acid; NHMRC = National Health and Medical Research Council; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; WHO = World Health Organization.
a Lott et al. (2019) was an expert panel report with representation from the Academy of Nutrition and Dietetics, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association.
b Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
c NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
d Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
e Using the Canadian Task Force on Preventive Health Care system, the strength-of-evidence rating related to this recommendation was BII. A rating with the letter B indicates “fair evidence from well-designed case controlled and cohort studies.”
f Using the Canadian Task Force on Preventive Health Care system, the strength-of-evidence rating related to this recommendation was CII. A rating with the letter C indicates “existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.”
g Using the Canadian Task Force on Preventive Health Care system, the strength-of-evidence rating related to this recommendation was BIII. A rating with the letter B indicates “fair evidence from well-designed case controlled and cohort studies.”
h No rating was given for this recommendation.
i Using the Canadian Task Force on Preventive Health Care system, the strength-of-evidence rating related to this recommendation was CIII. A rating with the letter C indicates “existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.”
j Guideline document included references related to soy protein–based formulas and infant growth and development. No references were provided for the portion of the recommendation related to galactosemia or vegetarian diets.
k 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).
l 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).
TABLE B-13 Recommendations Related to Foods Associated with Food Allergy and Celiac Disease
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| AAP | Greer et al., 2019 | No conclusions can be made about the role of any duration of breastfeeding in either preventing or delaying the onset of specific food allergies. | Narrative review |
| The new recommendations for the prevention of peanut allergy are based largely on the LEAP trial and are endorsed by AAP. An expert panel has advised peanut introduction as early as 4–6 months of age for infants at high risk for peanut allergy (presence of severe eczema and/or egg allergy). The recommendations contain details of implementation for high-risk infants, including appropriate use of testing (specific IgE measurement, skin-prick test, and oral food challenges) and introduction of peanut-containing foods in the health care provider’s office versus the home setting, as well as amount and frequency. For infants with mild to moderate eczema, the panel recommended introduction of peanut-containing foods at around 6 months of age, and for infants at low risk for peanut allergy (no eczema or any food allergy), the panel recommended introduction of peanut-containing food when age appropriate and depending on family preferences and cultural practices (i.e., after 6 months of age if exclusively breastfeeding). | Togias et al., 2017 | ||
| There are no short- or long-term advantages for exclusive breastfeeding beyond 3–4 months for prevention of atopic disease. | Narrative review | ||
| There is lack of evidence that partially or extensively hydrolyzed formula prevents atopic disease in infants and children, even in those at high risk for allergic disease. | Narrative review | ||
| There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4–6 months prevents atopic disease. | Narrative review | ||
| There is now evidence that the early introduction of infant-safe forms of peanuts reduces the risk for peanut allergies. Data are less clear for timing of introduction of eggs. | Narrative review |
| CPS | Abrams et al., 2019 | Allergenic foods should be introduced one at a time, to gauge reaction, without unnecessary delay between each new food. | Could not be mapped |
| For high-risk infants, and based on developmental readiness, consider introducing common allergenic solids at around 6 months of age, but not before an infant is 4 months of age. | Narrative review | ||
| For infants at no or low risk for food allergy, introducing complementary foods at about 6 months is recommended. | Could not be mapped | ||
| If an infant appears to be tolerating a common allergenic food, advise parents to offer it a few times per week to maintain tolerance. If an adverse reaction is observed, advise parents to consult with a primary care provider about next steps. | Could not be mapped | ||
| RCPCH | RCPCH, 2019 | Key messages for health professionals: All infants require solid foods from 6 months for adequate nutrition. Solid food should never be introduced before 4 months (17 weeks) as this is associated with increased short-term risk of infection and later risk of obesity, allergy, and CD. | Narrative review |
| SACN | SACN, 2018 | Advice on complementary feeding should state that foods containing peanut and hen egg can be introduced from around 6 months of age and need not be differentiated from other solid foods. The deliberate exclusion of peanut or hen egg beyond 6–12 months of age may increase the risk of allergy to the same foods. Once introduced, and where tolerated, these foods should be part of an infant’s usual diet, to suit both the individual child and family. If initial exposure is not continued as part of an infant’s usual diet, then this may increase the risk of sensitization and subsequent food allergy. Families of infants with a history of early-onset eczema or suspected food allergy may wish to seek medical advice before introducing these foods. | Narrative review |
TABLE B-13
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| SACN; COT | SACN and COT, 2018 | Advice on complementary feeding should state that foods containing peanut and hen egg need not be differentiated from other complementary foods. Complementary foods should be introduced in age-appropriate form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. | Systematic review;a BRAFO methodology |
| Families of infants with a history of early-onset eczema or suspected food allergy may wish to seek medical advice before introducing these foods. | Systematic review;a BRAFO methodology | ||
| The deliberate exclusion of peanut or hen egg beyond 6–12 months of age may increase the risk of allergy to the same foods. Once introduced, and where tolerated, these foods should be part of the infant’s usual diet, to suit both the individual child and family. If initial exposure is not continued as part of the infant’s usual diet, then this may increase the risk of sensitization and subsequent food allergy. | Systematic review;a BRAFO methodology | ||
| ESPGHAN | Fewtrell et al., 2017 | Allergenic foods may be introduced when complementary food is commenced any time after 4 months (17 weeks).b | Systematic literature search |
| Gluten may be introduced between 4 and 12 months of age. Consumption of large quantities of gluten should be avoided during the first weeks after gluten introduction and also during infancy.b | Systematic literature search | ||
| Infants at high risk of peanut allergy (those with severe eczema, egg allergy, or both as defined in the LEAP study) should have peanut introduced (e.g., as smooth peanut butter) between 4 and 11 months, following evaluation by an appropriately trained professional.b | Systematic literature search |
| NIH/NIAIDc | Togias et al., 2017 | The [Expert Panel] recommends that infants with severe eczema, egg allergy, or both have introduction of age-appropriate peanut-containing food as early as 4–6 months of age to reduce the risk of peanut allergy. Other solid foods should be introduced before peanut-containing foods to show that the infant is developmentally ready. The [Expert Panel] recommends that evaluation with peanut-specific IgE (peanut sIgE) measurement, SPTs, or both be strongly considered before introduction of peanut to determine if peanut should be introduced and, if so, the preferred method of introduction. | Balance of benefits and harms; LEAP Trial;a expert opinion |
| The [Expert Panel] suggests that infants with mild-to-moderate eczema should have introduction of age-appropriate peanut-containing food around 6 months of age, in accordance with family preferences and cultural practices, to reduce the risk of peanut allergy. Other solid foods should be introduced before peanut-containing foods to show that the infant is developmentally ready. The [Expert Panel] recommends that infants in this category may have dietary peanut introduced at home without an in-office evaluation. However, the [Expert Panel] recognizes that some caregivers and health care providers may desire an in-office supervised feeding, evaluation, or both. | LEAP Trial;d balance of benefits and harms; expert opinion; Enquiring About Tolerance Triale | ||
| The [Expert Panel] suggests that infants without eczema or any food allergy have age-appropriate peanut-containing foods freely introduced in the diet together with other solid foods and in accordance with family preferences and cultural practices. | Balance of benefits and harms; expert opiniond |
TABLE B-13
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Pérez-Escamilla et al., 2017 | Ask your child’s doctor if you are considering using hydrolyzed or “hypoallergenic” infant formulas as these formulas have not been found to help prevent food allergies in infants. | American Academy of Allergy, Asthma & Immunology (2015)f and Australasian Society of Clinical Immunology and Allergy (2016)g |
| If the biological parent has allergies to any food items, talk to your child’s doctor about any precautions you need to take regarding the introduction of common allergenic food items (such as products with peanuts, eggs, dairy, or wheat) to your infant. | |||
| Introduce common allergenic food items to your baby after other solid food has been fed and tolerated, and with the first taste being at home. If no reaction occurs, then you can gradually increase the amount at a rate of one new food every 3 to 5 days. | |||
| You can introduce common allergenic food items to your baby when she or he is ready to eat solid food (usually between 4 and 6 months of age). These food items include dairy products such as yogurt or cow milk protein formula, eggs, soy, wheat, peanut butter, fish, and shellfish. | |||
| ESPGHAN | Szajewska et al., 2016 | Gluten can be introduced into the infant’s diet between the ages of 4 and 12 completed months. The age of gluten introduction in infants in this age range does not seem to influence the absolute risk of developing CDA or CD during childhood. | Systematic reviewh |
| Introducing gluten while the infant is being breastfed cannot be recommended as a means of reducing the risk of developing CD. Breastfeeding should, however, be promoted for its other well-established health benefits. | Systematic reviewh | ||
| Neither the optimal amounts of gluten to be introduced at weaning nor the effects of different wheat preparations on the risks of developing CD and CDA have been established. Despite the limited evidence regarding the exact amounts and with no RCTs to support it, ESPGHAN suggests that consumption of large amounts of gluten should be discouraged during the first months after gluten introduction. | Systematic reviewh |
| No recommendation can be made regarding the type of gluten to be used at introduction. | Systematic reviewh | ||
| No recommendation was made on gluten introduction in children from families with first-degree relatives with CD. | Systematic review | ||
| Recommendations on breastfeeding should not be modified because of considerations regarding prevention of CD. | Systematic reviewh | ||
| SIGENP; SIAIP | Alvisi et al., 2015i | It is not advisable to delay the introduction of potentially allergenic foods, nor of gluten with the purpose of preventing the development of allergic diseases; there is no ideal timing for gluten introduction in relation with the onset of CD and T1DM. | Narrative review |
NOTE: AAP = American Academy of Pediatrics; BRAFO = Benefit-Risk Analysis for Foods; CD = celiac disease; CDA = celiac disease autoimmunity; COT = Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment; CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; IgE = immunoglobulin E; LEAP = Learning Early About Peanut Allergy; NIAID = National Institute of Allergy and Infectious Diseases; NIH = National Institutes of Health; RCPCH = Royal College of Paediatrics and Child Health; RCT = randomized controlled trial; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory-Committee on Nutrition; SIAIP = Italian Society of Pediatric Allergology and Immunology; SIGENP = Italian Society of Gastroenterology, Hepatology and Pediatric Nutrition; SPT = skin prick test; T1DM = type 1 diabetes mellitus.
a Using GRADE, the strength of the evidence for the recommendation was rated as Moderate (“further research is likely to have an effect on the quality of the body of evidence and may cthe hange the recommendation”).
b Recommendation was noted as being relevant to European infants, “typically in relatively affluent populations with access to clean water and good healthcare.”
c For Togias et al. (2017), the National Institute of Allergy and Infectious Diseases convened a coordinating committee with members representing 25 professional organization, along with a 26-member expert panel.
d Using GRADE, the strength of the evidence for the recommendation was rated as Low (“further research is very likely to have an important effect on the body of evidence and is likely to change the recommendation”).
h Using GRADE, this was rated as a “conditional recommendation.” The strength of a recommendation was graded as strong when the evidence showed that the benefit of the intervention clearly outweighed the undesirable effects. The strength of a recommendation was graded as conditional when the trade-offs were less certain.
i Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).
TABLE B-14 Recommendations Related to Iron and Iron-Fortified Formula
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| CPS | Unger et al., 2019 | For the healthy term infant, iron-rich complementary foods, such as meat, meat alternatives, and iron-fortified infant cereals, should be introduced at about 6 months. Access to traditional iron-rich foods should be encouraged and facilitated in indigenous communities. In populations with higher risk for IDA, case-selecting infants for testing may be one approach to assess the benefit from receiving supplementation with oral iron drops before 6 months. If an infant is developmentally ready, introducing iron-rich complementary foods between 4 and 6 months could also be considered when there is high risk for IDA. | Narrative review |
| If normal birth weight infants are not breastfed, they should receive formula containing 6.5 mg/L to 13 mg/L of iron (which is the typical concentration in standard cow milk–based formulas in Canada) for the first 9–12 months. Formula-fed infants who may be at higher risk for iron deficiency (e.g., owing to low socioeconomic status; maternal anemia; low intake of iron-rich complementary foods; or living in an indigenous community that may be challenged by poverty, food insecurity, high consumption of evaporated milk or cow milk, and a high burden of H. pylori infection) should receive formula with a higher iron content (13 mg/L of iron).a | Narrative review | ||
| There is insufficient evidence to recommend routine iron supplementation or laboratory screening for iron deficiency in healthy term infants with no risk factors who are exclusively breastfed for 6 months. | Narrative review | ||
| EFSA | EFSA Panel on Nutrition et al., 2019 | Infants at risk of iron depletion (exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping [< 1 min after birth], or born preterm, or born small for gestational age or with high growth velocity) may benefit from introduction of complementary foods that are a source of iron before 6 months of age.b | Systematic review |
| ABM | Taylor and ABM, 2018 | Iron supplementation to the 4-month-old, full-term, exclusively breastfed infant is associated with improved hematological indices. However, the long-term benefit of improved hematologic indices at 4–6 months is not known. If iron supplementation is given before 6 months, it should be given as a 1 mg/kg/day distinct iron supplement until iron-fortified cereals (7–7.5 mg ferrous sulfate/day) or other iron-rich foods such as meat, tofu, beans, and others are initiated at 6 months of age with other complementary foods. | Review of evidencec,d |
| ESPGHAN | Hojsak et al., 2018 | Based on available evidence there is no necessity for the routine use of [young child formula] in children from 1 to 3 years of life, but they can be used as part of a strategy to increase the intake of iron, vitamin D, and n-3 PUFAs and decrease the intake of protein compared to unfortified cow milk. Follow-on formula can be used for the same purpose. | Systematic literature review |
| SACN | SACN, 2018 | A wide range of solid foods, including iron-containing foods, should be introduced in an age-appropriate form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. | Narrative review |
| Healthy infants do not require iron supplements. To optimize iron status throughout the first year of life, SACN and NICE recommendations on delayed cord clamping should be implemented and monitored. | Narrative review | ||
| ESPGHAN | Fewtrell et al., 2017 | All infants should receive iron-rich complementary foods including meat products and/or iron-fortified foods. The strategy used will depend on the population, cultural factors, and available foods but can include iron-fortified foods or infant formulas, foods naturally rich in iron such as meat, or iron supplements.e | Systematic literature search |
| Vegan diets should only be used under appropriate medical or dietetic supervision to ensure that the infant receives a sufficient supply of vitamin B12, vitamin D, iron, zinc, folate, n-3 LCPUFA, protein, and calcium, and that the diet is sufficiently nutrient and energy dense. Parents should understand the serious consequences of failing to follow advice regarding supplementation of the diet.e | Systematic literature search |
TABLE B-14
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Pérez-Escamilla et al., 2017 | After introducing iron- and zinc-fortified baby cereals or mashed meats, there is no particular order to follow for introducing solid food. At this point, your baby is able to digest and absorb the nutrients from healthy food belonging to different food groups. However, it is important to keep in mind that the earlier vegetables are introduced (once your baby is ready to consume solid food), the more she or he is likely to easily accept them. | Narrative review |
| Exclusively breastfed babies need to get started on solid foods that are rich in iron and zinc sometime between 4 and 6 months, because by that time breast milk does not provide enough of these nutrients. Iron-zinc fortified baby cereals or puréed/mashed meats are recommended as first solid foods for exclusively breastfed babies. | Narrative review | ||
| If you are not feeding your baby breast milk, iron-fortified formula is the next best choice to satisfy your baby’s nutritional needs during the first 6 months of life. Do not feed low-iron formulas (those that have less than 6.7 milligrams of iron per liter) to your baby. | Narrative review | ||
| (For 6–12 months): If you choose to formula feed, it is recommended that you give your baby formula fortified with iron and zinc. | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Recommend meat, meat alternatives, and iron-fortified cereal as an infant’s first complementary foods.f | Narrative review |
| Continue to recommend a variety of iron-rich foods. Ensure that foods such as meat and meat alternatives and iron-fortified cereal are offered a few times each day.f | Narrative review | ||
| Recommend iron-rich meat, meat alternatives, and iron-fortified cereal as the first complementary foods. Encourage parents and caregivers to progress to introduce a variety of nutritious foods from the family meals.f | Narrative review | ||
| AAFP | AAFP, 2014 | Breastfeeding with appropriate complementary foods, including iron-rich foods, should continue through at least the first year. | An AAP statementg |
| ESPGHAN | Domellöf et al., 2014 | Follow-on formulas should be iron fortified; however, there is not enough evidence to determine the optimal iron concentration in follow-on formula.h | Narrative review |
| Formula-fed infants up to 6 months of age should receive iron-fortified infant formula, with an iron content of 4 to 8 mg/L.h | Narrative review | ||
| From the age of 6 months, all infants and toddlers should receive iron-rich (complementary) foods, including meat products and/or iron-fortified foods.h | Narrative review | ||
| There is no need for general iron supplementation of healthy European infants and toddlers of normal birth weight.h | Narrative review | ||
| CPS | Grueger et al., 2013 (reaffirmed 2018) | Advise mothers to introduce iron-fortified foods in the form of meat, fish, or iron-fortified cereals as first foods, to avoid iron deficiency. | Narrative review |
| AAP | AAP Section on Breastfeeding, 2012 | Complementary foods rich in iron and other micronutrients should be introduced at about 6 months of age. | Could not be mapped |
| NHMRC (Australian government) | NHMRC, 2012i | Encourage exclusive breastfeeding for around 6 months. There is no particular order that is advised for the introduction of solid foods or rate that new foods can be introduced, other than first foods should be nutritious and iron rich. | Systematic reviewj |
| Foods can be introduced in any order provided iron-rich nutritious foods are included and the texture is suitable for the infant’s stage of development. Cow milk products including full-fat yogurt, cheese, and custard may be given, but not cow milk as a main drink before 12 months. | Systematic review; narrative reviewk | ||
| To prevent iron deficiency, iron-containing nutritious foods are recommended to be the first foods. Iron-containing foods include iron-fortified cereals, puréed meat, and poultry dishes. Cooked plain tofu and legumes/beans are also sources of iron. Care needs to be taken particularly with a plant-based diet to ensure that supplies of iron are adequate. This is an important issue because of the neurocognitive development implications. | Narrative review | ||
| Use cow milk–based formulas until 12 months of age. (Note: All infant formulas available in Australia are iron fortified.) | Systematic review |
TABLE B-14
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| New Zealand Ministry of Health | Ministry of Health, 2012l | Dark-green leafy vegetables, puréed or mashed lentils, chickpeas, and peas are suitable alternatives for vegetarian infants, although the iron is less well absorbed and should be eaten with a source of vitamin C. | Narrative review |
| (For vegetarian and vegan infants and toddlers): Once an infant has started complementary foods, the variety should be increased to ensure an additional intake of nutrients, especially energy, protein, iron, calcium, and vitamin B12. | Narrative review | ||
| Increase the texture, variety, flavor, and amount of food offered so the infant receives an additional intake of nutrients, especially iron and vitamin C, and is eating some family foods by around 1 year of age. | Narrative review | ||
| Infants and toddlers may need iron supplements under certain circumstances, for example, if an infant is diagnosed with iron deficiency or has been exclusively breastfed for a prolonged period. | Narrative review | ||
| The variety of complementary foods should be increased to ensure an additional intake of nutrients, especially iron. Iron-fortified infant cereals are suitable starter foods, and absorption can be enhanced if the infant is also given foods containing vitamin C. Once the infant is around 6 months of age, meat or chicken purées can be added to their feeds, and as they develop chewing skills finely chopped meats can be introduced. Infants should be eating some family foods by around 1 year of age. | Narrative review | ||
| AAP | Baker et al., 2010 | Exclusively breastfed infants are at increasing risk of iron deficiency after 4 completed months of age. Therefore, at 4 months of age, breastfed infants should be supplemented with 1 mg/kg per day of oral iron beginning at 4 months of age until appropriate iron-containing complementary foods (including iron-fortified cereals) are introduced in the diet. | Friel et al., 2003 |
| For formula-fed infants, the iron needs for the first 12 months of life can be met by a standard infant formula (iron content: 10–12 mg/L) and the introduction of iron-containing complementary foods after 4–6 months of age, including iron-fortified cereals. Whole milk should not be used before 12 completed months of age. | Narrative review | ||
| For partially breastfed infants, the proportion of human milk versus formula is uncertain; therefore, beginning at 4 months of age, partially breastfed infants (more than half of their daily feedings as human milk) who are not receiving iron-containing complementary foods should also receive 1 mg/kg per day of supplemental iron. | Narrative review | ||
| The iron intake between 6 and 12 months of age should be 11 mg/day. When infants are given complementary foods, red meat and vegetables with higher iron content should be introduced early. To augment the iron supply, liquid iron supplements are appropriate if iron needs are not being met by the intake of formula and complementary foods. | Iron DRIsm | ||
| Toddlers 1 through 3 years of age should have an iron intake of 7 mg/day. This would be best delivered by eating red meats, cereals fortified with iron, vegetables that contain iron, and fruits with vitamin C, which augments the absorption of iron. For toddlers not receiving this iron intake, liquid supplements are suitable for children 12 through 36 months of age, and chewable multivitamins can be used for children 3 years and older. | Iron DRIsm | ||
| CPS | Amit et al., 2010 (reaffirmed in 2018) | Both lacto-ovo-vegetarian and vegan diets have increased iron needs (1.8-fold) compared with omnivores, and caregivers will require sound knowledge of food sources that are iron fortified or rich in iron. Iron supplementation may be required during periods of rapid growth. | Narrative reviewn |
TABLE B-14
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| WHO | WHO, 2005 | As needed, use fortified foods or vitamin-mineral supplements (preferably mixed with or fed with food) that contain iron (8–10 mg/d at 6–12 months, 5–7 mg/d at 12–24 months). If adequate amounts of animal-source foods are not consumed, these fortified foods or supplements should also contain other micronutrients, particularly zinc, calcium, and vitamin B12.o | A background document and narrative review |
| Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish, or eggs should be eaten daily, or as often as possible, because they are rich sources of many key nutrients such as iron and zinc. Milk products are rich sources of calcium and several other nutrients. 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.p | A background document and narrative review |
NOTE: AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; ABM = Academy of Breastfeeding Medicine; CPS = Canadian Paediatric Society; DRI = Dietary Reference Intake; EFSA = European Food Safety Authority; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HC = Health Canada; IDA = iron deficiency anemia; mg/d = milligrams per day; mg/kg = milligrams per kilogram; mg/L = milligrams per liter; n-3 LCPUFA = omega-3 long-chain polyunsaturated fatty acid; n-3 PUFA = omega-3 polyunsaturated fatty acid; NHMRC = National Health and Medical Research Council; NICE = National Institute for Health and Care Excellence; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; WHO = World Health Organization.
a All dosage recommendations were noted as referring to elemental iron.
b Document includes a strength-of-evidence rating for each question related to introduction of complementary foods and health outcomes (e.g., age of introduction of fish and odds of developing asthma-like symptom); the conclusion statements were not accompanied by a rating of strength.
c Using the National Guideline Clearinghouse system, the level-of-evidence rating related to this recommendation was IB (“evidence from at least one randomized controlled trial”).
d Statements of the evidence are accompanied by a level-of-evidence rating. It is unclear, however, if it is based on a systematic or narrative review.
e Recommendations were noted as being relevant to European infants, “typically in relatively affluent populations with access to clean water and good healthcare.”
f © All rights reserved. Nutrition for healthy term infants: Recommendations from birth to six months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.
g AAP Section on Breastfeeding, 2012.
h Recommendations were noted as being relevant to Europe and other regions with a low general prevalence of iron deficiency anemia.
i NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
j Using the NHMRC system, the strength-of-evidence ratings related to this recommendation were as follows: Grade C (for breastfeeding and asthma and atopy) and Grade D (introduction of solid foods and allergy). No grade could be mapped to the portion of the recommendation related to iron. Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application. Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution.
k Portions of this recommendation could be mapped to a systematic review prepared for this guideline document; other portions appeared to be related to a narrative review of the evidence. Using the NHMRC system, the strength-of-evidence rating related to this recommendation was Grade D (risk associated with cow milk). No grade could be mapped to the portion of the recommendation related to iron. Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution.
l Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
m Citation pertains to the first sentence. Evidence could not be mapped for the remainder of the recommendation.
n Using the Canadian Task Force on Preventive Health Care system, the strength-of-evidence rating related to this recommendation was BII. A rating with the letter B indicates “fair evidence from well-designed case controlled and cohort studies.”
o Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Use of Vitamin-Mineral Supplements or Fortified Products, p. 18, Copyright (2005).
p 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).
TABLE B-15 Recommendations Related to Vitamin D
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| ABM | Taylor and ABM, 2018 | The breastfeeding infant should receive vitamin D supplementation shortly after birth in doses of 10–20 µg/day (400–800 IU/day). The breastfeeding infant should receive vitamin D supplementation shortly after birth…. This supplement should be cholecalciferol, vitamin D3, because of superior absorption unless a vegetable source such as ergocaliferol vitamin D2, is desired. | Review of evidencea,b Review of evidenceb,c |
| SACN | SACN, 2018 | All infants from birth to 1 year of age who are being exclusively or partially breastfed should be given a daily supplement containing 8.5 to 10 µg of vitamin D (340–400 IU/d). Infants who are fed infant formula should not be given a vitamin D supplement unless they are consuming less than 500 mL (about 1 pint) of infant formula per day, as infant formula is fortified with vitamin D. | Narrative review |
| RWJF-HER | Pérez-Escamilla et al., 2017 | It is recommended that exclusively breastfed infants receive a daily supplement of vitamin D (400 IU), because this vitamin is low in breast milk. Infant formulas are fortified with vitamin D. However, if your baby consumes less than 1 liter per day of formula, your doctor may advise a vitamin D supplement for your baby. | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Recommend a daily vitamin D supplement of 10 µg (400 IU) for breastfed infants.d,e | Narrative review |
| Health Canada et al., 2014 | Recommend a daily vitamin D supplement of 10 µg (400 IU) for infants and young children who are breastfed or receiving breast milk.f,g | Narrative review | |
| AAP | Golden et al., 2014 | Because human milk contains inadequate amounts of vitamin D (unless the lactating mother is taking supplements of approximately 6,000 IU/d), breastfed and partially breastfed infants should be supplemented with 400 IU of vitamin D per day beginning in the first few days of life and continued until the infant has been weaned and is drinking at least 1 L/day of vitamin D–fortified infant formula or cow milk. | Vitamin D DRIs |
| ESPGHAN | Braegger et al., 2013 | All infants should receive an oral supplementation of 400 IU/day of vitamin D. The implementation should be ensured and supervised by pediatricians and other health care professionals. | Narrative review |
| For children in risk groups identified above, oral supplementation of vitamin D must be considered beyond 1 year of age.h | Narrative review | ||
| CPS | Grueger et al., 2013 (reaffirmed 2018) | Support exclusive breastfeeding, with vitamin D supplementation, for the first 6 months of life. | Narrative review |
| New Zealand Ministry of Health | Ministry of Health, 2013 | Infants who are exclusively or partially breastfed (who receive less than 500 mL of formula per day, based on current NRVs; NHMRC 2006) and have one or more of the risk factors above may benefit from vitamin D supplementation.i | Narrative review |
| It would be reasonable to wait until breastfeeding is well established in full-term, high-risk infants, such as until 6 weeks of age, before introducing vitamin D supplementation. | Narrative review | ||
| Ministry of Health, 2012j | Evidence does not support the routine use of vitamin D supplements for breastfed infants in New Zealand. However, pregnant or breastfeeding women, and infants and toddlers at risk for vitamin D deficiency, may need a vitamin D supplement taken with the supervision of a health practitioner. | Narrative review | |
| Vitamin D supplements may be required by infants of vitamin D–deficient mothers and toddlers at risk of vitamin D deficiency. | Narrative review | ||
| CPS | Amit et al., 2010 (reaffirmed in 2018) | Vitamin D recommendations for infants in Canada are standard. Children and adolescents who consume less than 500 mL of a vitamin D–fortified milk product per day should be supplemented with 400 U daily. For children younger than 2 years of age living above a northern latitude of 55°, those with dark skin and those avoiding sunlight, 800 U of vitamin D per day should be provided in the winter months. | Narrative reviewk |
| Godel et al., 2007 (reaffirmed in 2017) | Subsequent vitamin D dosage should be 400 IU/day for all infants during the first year, with an increase to 800 IU/day from all sources 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. | Narrative reviewl |
TABLE B-15
NOTE: µg = micrograms; AAP = American Academy of Pediatrics; ABM = Academy of Breastfeeding Medicine; CPS = Canadian Paediatric Society; HC = Health Canada; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; IU = international units; L/d = liters per day; mL = milliliter; NHMRC = National Health and Medical Research Council; NRV = nutrient reference value; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition.
a Using the National Guideline Clearinghouse system, the level-of-evidence rating related to this recommendation was IB (“evidence from at least one randomised controlled trial”).
b Statements of the evidence are accompanied by a level-of-evidence rating. It is unclear, however, if it is based on a systematic or narrative review.
c Using the National Guideline Clearinghouse system, the level-of-evidence rating related to this recommendation was IIA (“evidence from at least one controlled study without randomization”).
d © All rights reserved. Nutrition for healthy term infants: Recommendations from birth to six Months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.
e Recommendation is applicable to infants birth to 6 months of age.
f © 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.
g Recommendation is applicable to infants 6–12 months and young children 12–24 months.
h The risk groups were identified as breastfed infants not adhering to the present recommendation of vitamin D supplementation, children and adolescents with dark skin living in northern countries, children and adolescents without adequate sun exposure (excessive use of sunscreen with high SPF, staying indoors for much of the day, wearing clothes covering most of the skin, living in northern latitudes during wintertime), and obese children.
i Infants at higher risk of vitamin D deficiency were identified as breastfed infants with one or more of the following: a naturally dark skin, a sibling diagnosed with rickets or hypocalcaemic seizures, a mother who is deficient in vitamin D or is at a higher risk of becoming deficient, all preterm infants with a body weight less than 2.5 kilograms, and infants who are breastfed over winter months in New Zealand.
j Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
k Using the Canadian Task Force on Preventive Health Care system, the strength-of-evidence rating related to this recommendation was BII. A rating with the letter B indicates “fair evidence from well-designed case controlled and cohort studies.”
l Using the Canadian Task Force on Preventive Health Care system, the strength-of-evidence rating related to this recommendation was Grade B. A rating with the letter B indicates “fair evidence from well-designed case controlled and cohort studies.”
TABLE B-16 Recommendations Related to Iodine
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| New Zealand Ministry of Health | Ministry of Health, 2012a | For toddlers, prepare foods or choose pre-prepared foods, drinks and snacks that … are low in salt, but if using salt, use iodized salt.b | Narrative review |
| Gradually introduce foods containing iodine. In September 2009 mandatory iodine fortification of bread, will over time, help to address the suboptimal iodine status of New Zealanders, including pregnant and breastfeeding mothers. | Narrative review | ||
| If required, iodine supplementation for infants and toddlers should be managed by a medical practitioner. Kelp tablets are not recommended. | Narrative review | ||
| If salt is added when family food is cooked, use small amounts of iodized salt. Rock salt and sea salt have negligible levels of iodine, so unless iodized they are not recommended. | Narrative review | ||
| Introduce foods containing iodine, such as fish and seafood, meat and poultry, eggs, milk and milk products, seameal custard, and bread gradually into infants’ and toddlers’ diets. Prioritize these foods for infants who are exclusively breastfed. | Narrative review | ||
| WHO | WHO Secretariat et al., 2007 | Pregnant and lactating women have no need for iodine supplements, nor do children aged 0–24 months require them. Indeed, the amount of iodine stored in the thyroid of a child at birth, when added to the iodine intake from the mother’s breast milk, is likely to be sufficient to meet a child’s need for iodine for the first 6 months of life and even up to 24 months of age. | Could not be mapped |
NOTE: WHO = World Health Organization.
a Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
b This recommendation contained additional guidance unrelated to iodine that has been omitted from this table.
TABLE B-17 Recommendations Related to Supplementationa
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| ABM | Taylor and ABM, 2018 | Zinc supplementation, above dietary intake, to the lactating mother or breastfeeding infant is not associated with improved outcomes and, therefore, is not recommended. | Review of evidenceb,c |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Multivitamins are not needed if your child is eating a healthy nutritious diet. If your doctor or health care provider recommends giving multivitamins to your child, choose brands that are low in sugar. | Narrative review |
| USPSTF | Moyer, 2014d | USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. | Systematic reviewe |
| NHMRC (Australian government) | NHMRC, 2012f | Fluoride supplementation is not recommended. | CDC recommendationg |
| New Zealand Ministry of Health | Ministry of Health, 2012h | Infants and toddlers generally do not require supplements. A healthy well-balanced diet is the best way to provide nutrients for the body. | Narrative review |
| Selenium supplements are recommended only under specialized nutritional and medical advice. | Narrative review | ||
| WHO | WHO, 2005 | As needed, use fortified foods or vitamin-mineral supplements (preferably mixed with or fed with food) that contain iron (8–10 mg/day at 6–12 months, 5–7 mg/day at 12–24 months). If adequate amounts of animal-source foods are not consumed, these fortified foods or supplements should also contain other micronutrients, particularly zinc, calcium, and vitamin B12.i | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used.j | Technical consultations and documents |
| Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed.k | Technical consultations and documents |
NOTE: ABM = Academy of Breastfeeding Medicine; CDC = Centers for Disease Control and Prevention; mg/d = milligrams per day; NHMRC = National Health and Medical Research Council; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; USPSTF = U.S. Preventive Services Task Force; WHO = World Health Organization.
a This table omits recommendations that only pertain to iron, iodine, or vitamin D supplementation. Those recommendations are found in their respective tables above. This table also omits recommendations specific to vegetarian or vegan diets. Those recommendations are found in Table B-12, Recommendations Related to Vegetarian and Vegan Diets.
b Using the National Guideline Clearinghouse system, the level-of-evidence rating related to this recommendation was IB (“evidence from at least one randomised controlled trial”).
c Statements of the evidence are accompanied by a level-of-evidence rating. It is unclear, however, if it is based on a systematic or narrative review.
d At the time of abstraction, this guideline was in the process of being updated.
e Using the USPSTF grading system, this recommendation was graded as B, meaning “The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.”
f NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativcommons.org.au).
h Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
i Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Use of Vitamin-Mineral Supplements or Fortified Products, p. 18, Copyright (2005).
j 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).
k Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Use of Vitamin-Mineral Supplements or Fortified Products for Infant and Mother, p. 25, Copyright (2003).
TABLE B-18 Recommendations Related to Dietary Fata
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Pérez-Escamilla et al., 2017 | Offering a variety of vegetables and fruits and avoiding food of limited nutritional value, such as those high in calories, sugar, salt, and fat (e.g., french fries, sugary cereals, cookies) helps your child gain a healthy amount of weight. | Narrative review |
| It is important to introduce your baby to a large variety of vegetables and fruits prepared in different healthy ways and textures before she or he turns 1 year old. This will expose your baby to an array of flavors and textures that will make it easier for her or him to accept and learn to like healthy food from all the food groups (fruits, vegetables, whole grains, dairy, and protein). Your baby will also learn to self-control the desire for unhealthy food that has excessive amounts of added sugars, sodium (salt), saturated fat, and calories. | Narrative review | ||
| Offer your toddler deboned fish such as salmon, white tuna, and trout. Fish is a good source of healthy fats known as omega-3s that are very important for brain development. | Narrative review | ||
| Choose food for your toddler prepared with healthy oils, such as olive, canola, corn, or sunflower oil. | Narrative review | ||
| Read food labels and the list of ingredients when choosing already prepared food for your toddler. Avoid food that has high amounts of any type of added sugars, including high-fructose corn syrup (e.g., SSBs like Kool-Aid, sodas, sports drinks) or sodium (e.g., packaged macaroni and cheese) or that contains any amount of trans fats (e.g., french fries). | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Explain to parents and caregivers that nutritious, higher-fat foods are an important source of energy for young children.b | Narrative review |
| NHMRC (Australian government) | NHMRC, 2012c | Consumption of nutrient-poor discretionary foods with high levels of saturated fat, added sugars, and/or added salt (e.g., cakes, biscuits, and potato chips) should be avoided. | Systematic reviewsd |
| New Zealand Ministry of Health CPS | Ministry of Health, 2012e | Use margarine derived from polyunsaturated plant oils as a spread, and margarine and reduced-fat milk in baking. | Narrative review |
| Amit et al., 2010 (reaffirmed in 2018) | Foods containing the precursor of the essential fatty acid linolenic acid should be included in strict vegan diets (flaxseed, canola, nut oils, and soya products). | Narrative reviewf | |
| WHO | WHO, 2005 | Feed a variety of foods to ensure that nutrient needs are met. Provide diets with adequate fat content. If animal-source foods are not consumed regularly, 10–20 g of added fats or oils are needed unless a fat-rich food is given (such as foods or pastes made from groundnuts, other nuts, and seeds). If animal-source foods are consumed, up to 5 g of additional fats or oils may be needed.g | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Provide diets with adequate fat content.h | Technical consultations and documents |
NOTE: CPS = Canadian Paediatric Society; HC = Health Canada; NHMRC = National Health and Medical Research Council; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SSB = sugar-sweetened beverage; WHO = World Health Organization.
a This table omits recommendations related to milk fat. Those recommendations are found in Table B-7, Recommendations Related to Milk and Milk-Based Products.
b © 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.
c NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
d The systematic reviews were only related to sugar and salt. Using the NHMRC system, the strength-of-evidence ratings related to this recommendation were as follows: Grade A (for salt or sodium having an effect on blood pressure in children and adolescents) and Grade C (for sugar’s effect on risk of dental disease). Grade A (convincing association) indicates that the body of evidence can be trusted to guide practice. Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application.
e Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
f Using the Canadian Task Force on Preventive Health Care system, the strength-of-evidence rating related to this recommendation was BIII. A rating with the letter B indicates “fair evidence from well-designed case controlled and cohort studies.”
g 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).
h 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).
TABLE B-19 Recommendations Related to Bottle Use and Propping
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| AAP | Heyman et al., 2017 | Toddlers should not be given juice from bottles or easily transportable covered cups that allow them to consume juice easily throughout the day. Toddlers should not be given juice at bedtime. | Narrative review |
| ESPGHAN | Fewtrell et al., 2017 | By 12 months, infants should drink mainly from a cup or training cup rather than a bottle.a | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Be cautious about the volume of formula or expressed breast milk given at each feed. Studies have shown that bottle size matters. The bigger the bottle used, the more likely the baby will be to consume more than needed. | Narrative review |
| Bottle feeding is strongly discouraged after 12 months. Try to wean your child from the bottle by the time she or he is 1 year old. Doing so will reduce the risk of dental cavities and other dental problems later on. | Narrative review | ||
| Do not give a bottle or food to your baby as a reward for behaving the way you want. Only offer food in response to your baby’s hunger signals. | Narrative review | ||
| Do not force your baby to finish the bottle or continue eating from your breast, since this will interfere with the baby’s natural ability for appetite control down the road. | Narrative review | ||
| Do not put your toddler to sleep with a bottle or sippy cup. This can cause dental cavities and other oral health problems. | Narrative review | ||
| It is not recommended to mix cereal with formula or breast milk in a bottle. There is no evidence that this helps babies sleep longer, and it could be a choking hazard. | Narrative review | ||
| You should not put your baby to bed with a bottle. This practice can affect the health of the baby’s teeth and is an example of nonresponsive feeding. | Narrative review |
| Do not practice bottle propping (leaning the bottle against a pillow or other support at the stage when babies cannot hold the bottle on their own). | Narrative review | ||
| AAP; AAPD | AAPD, 2016 | To decrease the risk of developing early childhood caries, AAPD encourages professional and at-home preventive measures that include avoiding frequent consumption of liquids and/or solid foods containing sugar, in particular … SSBs (e.g., juices, soft drinks, sports drinks, sweetened tea) in a baby bottle or no-spill training cup … baby bottle use after 12–18 months.b | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Warn of the risk of choking if infants are left alone while feeding. Explain the dangers of propping a bottle.c | Narrative review |
| Health Canada et al., 2014 | For an older infant or young child who is not breastfed or receiving breast milk: Recommend avoiding prolonged bottle feeding and giving bottles at night.d | Narrative review | |
| NHMRC (Australian government) | NHMRC, 2012e | As with breastfeeding, bottle feeding according to need is appropriate. It is important for parents to be aware that information on formula packages recommending certain amounts for various ages is a guide only and does not necessarily suit every infant. | Could not be mapped |
| Put an infant to bed without a bottle or take the bottle away when the infant has finished feeding or before they fall asleep; do not let the infant keep sucking on the bottle. | Could not be mapped | ||
| Avoid feeding an infant using a “propped” bottle. | Could not be mapped | ||
| Avoid leaving an infant unattended with a bottle containing liquids (i.e., no bottle propping). | Could not be mapped |
TABLE B-19
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| New Zealand Ministry of Health | Ministry of Health, 2012f | Avoid leaving a feeding bottle in the mouth of a sleeping infant or using one as a pacifier. | 2008 New Zealand Dental Association guideg |
| Avoid nighttime and long-term use of infant bottles containing liquids other than water. | 2008 New Zealand Dental Association guideg | ||
| Fully ventilated bottles should be used when bottle feeding. | Narrative review | ||
| Never leave an infant unattended and feeding from a bottle. | Narrative review | ||
| NICE | NICE, 2008 | Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should discourage parents and carers from adding sugar or any solid food to bottle feeds. | Rapid review,h UK Department of Health reporti |
| Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to discourage feeding from a bottle from 1 year onward. | Rapid review,h UK Department of Health reporti | ||
| Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to use a bottle for expressed breast milk, infant formula, or cooled boiled water only. | Rapid review,h UK Department of Health reporti | ||
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Advise parents to hold the baby while bottle feeding and not to put baby to bed with a bottle. | Could not be mapped |
| If bottle feeding, advise parents to use only expressed breast milk or infant formula. | Could not be mapped | ||
| Reinforce the message to hold the baby while bottle feeding and not to put the baby to bed with a bottle. | Could not be mapped |
NOTE: AAP = American Academy of Pediatrics; AAPD = American Academy of Pediatric Dentistry; CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; GP = general practitioner; HC = Health Canada; NHMRC = National Health and Medical Research Council; NICE = National Institute for Health and Care Excellence; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SSB = sugar-sweetened beverage; UK = United Kingdom.
a Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
b This recommendation contained additional guidance unrelated to bottle use or bottle propping that has been omitted from this table.
c © All rights reserved. Nutrition for healthy term infants: Recommendations from birth to six months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.
d © 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.
e NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
f Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
g New Zealand Dental Association, 2008.
h Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There was no overall statement on the strength of the evidence for each recommendation.
TABLE B-20 Recommendations Related to Cup Use
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Lott et al., 2019a | 6–12 months: Offer a total of 1/2 to 1 cup (4–8 oz) per day of plain, fluoridated drinking water in a cup during mealtimes. | Narrative review |
| AAP | Heyman et al., 2017 | Toddlers should not be given juice from bottles or easily transportable covered cups that allow them to consume juice easily throughout the day. | Narrative review |
| ESPGHAN | Fewtrell et al., 2017 | By 12 months, infants should drink mainly from a cup or training cup rather than a bottle.b | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Between 6 and 12 months, it is recommended to transition infants from using a bottle to a cup. | Narrative review |
| Do not put your toddler to sleep with a bottle or sippy cup. This can cause dental cavities and other oral health problems.c | Narrative review | ||
| Give your toddler cow milk in a cup instead of a bottle. | Narrative review | ||
| If you decide to offer 100% fruit juice to your toddler, limit intake to no more than 4 oz per day and offer it with a cup, not a bottle. | Narrative review | ||
| Once your baby starts solid food, it is recommended to offer a total of 4–8 oz per day of plain drinking water in a cup. This will help your baby get familiar with the taste and to learn to like plain water. | Narrative review | ||
| Your toddler needs about 2 cups of water per day to cover her or his fluids needs. Use a cup to offer water.c | Narrative review | ||
| AAP; AAPD | AAPD, 2016 | To decrease the risk of developing early childhood caries, AAPD encourages professional and at-home preventive measures that include avoiding frequent consumption of liquids and/or solid foods containing sugar, in particular … sugar-sweetened beverages (e.g., juices, soft drinks, sports drinks, sweetened tea) in a baby bottle or no-spill training cup.d | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Encourage use of an open cup, initially with help.e | Narrative review |
| NHMRC (Australian government) | NHMRC, 2012f | A cup can be introduced at around 6 months, to teach infants the skill of sipping from a cup. | Narrative review |
| Milk and other drinks should be offered in a cup rather than a feeding bottle. | Narrative review | ||
| New Zealand Ministry of Health | Ministry of Health, 2012g | If the mother is feeding expressed breast milk, suggest she tries using a cup and seeks advice from a health practitioner if she has questions about this method. | Narrative review |
| NICE | NICE, 2008 | Oral Health. Health visitors, GPs, dentists, dental hygienists/assistants, community and day care nursery nurses, home-based child carers, and others who work with young children should encourage parents and carers to offer drinks in a nonvalved, free-flowing cup from age 6 months to 1 year. | Rapid review,h UK Department of Health reporti |
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | If not breastfeeding, expressed breast milk or formula can also be provided by cup feeding.j | Could not be mapped |
| If a mother is temporarily unable to breastfeed, expressed breast milk can be given to the infant by cup feeding. | Could not be mapped | ||
| AHA | Gidding et al., 2005 | Improving nutritional quality after weaning: Delay the introduction of 100% juice until at least 6 months of age and limit to no more than 4–6 oz/day; juice should only be fed from a cup. | Could not be mapped |
NOTE: AAP = American Academy of Pediatrics; AAPD = American Academy of Pediatric Dentistry; AHA = American Heart Association; CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; GP = general practitioner; HC = Health Canada; NHMRC = National Health and Medical Research Council; NICE = National Institute for Health and Care Excellence; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; UK = United Kingdom.
a Lott et al. (2019) was an expert panel report with representation from Academy of Nutrition and Dietetics, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association.
TABLE B-20
b Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
c Recommendation was noted as being applicable to children in the second year of life.
d This recommendation contained additional guidance unrelated to cup use that has been omitted from this table.
e © 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.
f NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
g Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
h Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There is no overall statement on the strength of the evidence for each recommendation.
j Recommendation applicable to infants 6–12 months.
TABLE B-21 Recommendations Related to Safety of Foods and Feeding Practices
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| Pasteurized Juice, Milk, and Dairy Products | |||
| RWJF-HER | Lott et al., 2019a | 12–24 months: At 12 months of age, plain, pasteurized whole milk may be introduced. 2 to 3 cups per day (16–24 oz) whole milk is recommended until 2 years of age. | DGA, AAP, and a prior RWJF-HER expert panel |
| 1–5 years (12–60 months): Consume only plain, pasteurized milk; flavored milk is not recommended. | Federal CACFP nutrition standards, and the National Academies recommendation that only unflavored milk be permitted in the WIC food package | ||
| AAP | Heyman et al., 2017 | Consumption of unpasteurized juice products should be strongly discouraged in infants, children, and adolescents. | Narrative review |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Do not offer your child unpasteurized juice, milk, or dairy products. | FoodSafety.gov |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Promote safe food preparation and storage to prevent foodborne illness. Recommend avoiding products that contain raw or undercooked meat, eggs, poultry, or fish; unpasteurized milk or milk products; unpasteurized juice; and cross-contamination between cooked and uncooked foods.b | Narrative review |
TABLE B-21
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| NHMRC (Australian government) | NHMRC, 2012c | Pasteurized full-cream milk may be introduced to a child’s diet as a drink at around 12 months of age and be continued throughout the second year of life, and beyond. It is an excellent source of protein, calcium, and other nutrients. Do not use unpasteurized cow or goat milk. | Systematic review; narrative review; WHO European region reportd |
| Soy (except fortified soy products and soy formula where specifically indicated), and other nutritionally incomplete alternate milks or milk substitutes (e.g., goat milk, sheep milk, coconut milk, almond milk) are inappropriate alternatives to breast milk, formula, or pasteurized whole cow milk in the first 2 years of life. | Systematic review; narrative reviewe | ||
| Honeyf | |||
| RWJF-HER | Pérez-Escamilla et al., 2017 | Honey should not be given to children under 12 months old because it may cause a serious condition known as botulism. | Narrative review |
| NHMRC (Australian government) | NHMRC, 2012c | To prevent botulism, do not feed honey to infants aged under 12 months. | Single journal articleg |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Advise parents and caregivers not to give honey to a child under 1 year of age. This helps to prevent infant botulism.b | Narrative review |
| Consumption of Raw or Undercooked Foods | |||
| SACN | SACN, 2018 | A wide range of solid foods, including iron-containing foods, should be introduced in an age-appropriate form* from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. *Infants and young children should never be left alone while they are eating. Children under 5 years old must not be given whole nuts, as they can choke on them. |
Narrative review |
| Infants, children, pregnant women, and elderly people can safely eat raw or lightly cooked eggs that are produced under the British Lion Code of Practice. The revised advice (updated October 2017), based on the latest scientific evidence, means that people vulnerable to infection or who are likely to suffer serious symptoms from food poisoning (such as infants, children, pregnant women, and elderly people) can now safely eat raw or lightly cooked hen eggs or foods containing them. The existing advice on UK non-Lion eggs has not changed; nonhen eggs and eggs from outside the United Kingdom should always be cooked thoroughly for vulnerable groups. Eggs from other birds, such as duck, goose, and quail eggs, should always be cooked thoroughly. |
|||
| SACN; COT | SACN and COT, 2018 | Advice on complementary feeding should state that foods containing peanut and hen egg need not be differentiated from other complementary foods. Complementary foods should be introduced in age-appropriate* form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. *Infants and young children should never be left alone while they are eating. Children under 5 years old must not be given whole nuts, as they can choke on them. Currently it is advised that infants and young children should not eat raw eggs, eggs with runny yolks, or any food that contains raw eggs and is uncooked or only lightly cooked. These can cause food poisoning and serious illness although this advice is currently under review as a result of the ACMSF recommendations (ACMSF, 2016). Eggs from other birds such as duck, goose, and quail eggs should always be cooked thoroughly, and this will not change following the current review. |
Systematic review;h BRAFO methodology |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Do not offer your child undercooked meats, poultry, eggs (e.g., runny eggs), or seafood. | Narrative review |
TABLE B-21
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Promote safe food preparation and storage to prevent foodborne illness. Recommend avoiding products that contain raw or undercooked meat, eggs, poultry, or fish; unpasteurized milk or milk products; unpasteurized juice; and cross-contamination between cooked and uncooked foods.b | Narrative review |
| NHMRC (Australian government) | NHMRC, 2012c | To prevent salmonella poisoning, cook all eggs thoroughly (i.e., until the white is completely set and yolk begins to thicken) and do not use uncooked products containing raw eggs such as homemade ice cream or mayonnaise. | Could not be mapped |
| Choking | |||
| CPS | Abrams et al., 2019 | The texture or size of any complementary food should be age appropriate to prevent choking. For young infants, smooth peanut butter can be diluted with water or mixed with a previously tolerated puréed fruit or vegetable, or with breast milk (HealthLinkBC, 2017; Togias et al., 2017). For older infants, smooth peanut butter can be spread lightly on a piece of thin toast crust, or a peanut puff product could be offered (Togias et al., 2017). | Narrative review |
| SACN | SACN, 2018 | A wide range of solid foods, including iron-containing foods, should be introduced in an age-appropriate form* from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. *Infants and young children should never be left alone while they are eating. Children under 5 years old must not be given whole nuts, as they can choke on them.i |
Narrative review |
| SACN; COT | SACN and COT, 2018 | Advice on complementary feeding should state that foods containing peanut and hen egg need not be differentiated from other complementary foods. Complementary foods should be introduced in age-appropriate* form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. | Systematic review;h BRAFO methodology |
| *Infants and young children should never be left alone while they are eating. Children under 5 years old must not be given whole nuts, as they can choke on them.i | |||
| RWJF-HER | Pérez-Escamilla et al., 2017 | It is not recommended to mix cereal with formula or breast milk in a bottle. There is no evidence that this helps babies sleep longer, and it could be a choking hazard. | Narrative review |
| Supervise your child during feeding time, and avoid offering food items that are a choking hazard such as nuts, grapes, popcorn, hot dogs, and hard candies. | Narrative review | ||
| If you offer fish to your toddler, which is strongly recommended, make sure it is completely deboned. | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Warn of the risk of choking if infants are left alone while feeding. Explain the dangers of propping up a bottle.j | Narrative review |
| Health Canada et al., 2014 | Recommend parents and caregivers avoid offering hard, small, and round, or smooth and sticky, solid foods. These may cause aspiration and choking.b | Narrative review | |
| NHMRC (Australian government) | NHMRC, 2012 | Avoid whole nuts and other hard foods to reduce the risk of choking. | UK Food Standards recommendations |
| Hard, small, round, and/or sticky solid foods are not recommended because they can cause choking and aspiration. | Could not be mapped | ||
| New Zealand Ministry of Health | Ministry of Health, 2012k | Be aware of foods that are more likely to cause choking.l | Narrative review |
| Offer toddlers a variety of nutritious foods from each of the major food groups each day. The food groups are vegetables and fruit; breads and cereals, including wholemeal; milk and milk products or suitable alternatives; lean meat, poultry, seafood, eggs, legumes, nuts, and seeds.* *Do not give small, hard foods like whole nuts and large seeds until children are at least 5 years old. |
Narrative review | ||
| New Zealand Dental Association; New Zealand Ministry of Health | New Zealand Dental Association, 2008 | Discuss healthy eating and remind parents to choose nutritious and tooth-friendly snacks.* *Any whole pieces of food can cause children to choke. Do not give small, hard foods such as whole nuts until children are at least 5 years old. Altering food texture may be helpful, such as grating, cooking, mashing, or puréeing foods.i |
Could not be mapped |
TABLE B-21
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| WHO | WHO, 2005 | Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities. Infants can eat puréed, mashed, and semisolid foods beginning at 6 months. By 8 months most infants can also eat finger foods (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods). Avoid foods in a form that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as whole nuts, whole grapes, or raw carrots, whole or in pieces).m | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities. Infants can eat puréed, mashed, and semisolid foods beginning at 6 months. By 8 months most infants can also eat finger foods (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods). Avoid foods that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as nuts, grapes, and raw carrots).n | Technical consultations and documents |
| Supervision | |||
| SACN | SACN, 2018 | A wide range of solid foods, including iron-containing foods, should be introduced in an age-appropriate form* from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. *Infants and young children should never be left alone while they are eating. Children under 5 years old must not be given whole nuts, as they can choke on them.o |
Narrative review |
| SACN; COT | SACN and COT, 2018 | Advice on complementary feeding should state that foods containing peanut and hen egg need not be differentiated from other complementary foods. Complementary foods should be introduced in age-appropriate* form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. *Infants and young children should never be left alone while they are eating. Children under 5 years old must not be given whole nuts, as they can choke on them.o |
Systematic review;g BRAFO methodology |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Supervise your child during feeding time, and avoid offering food items that are a choking hazard such as nuts, grapes, popcorn, hot dogs, and hard candies. | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Warn of the risk of choking if infants are left alone while feeding. Explain the dangers of propping a bottle.j | Narrative review |
| Health Canada et al., 2014 | Recommend infants and young children always be supervised during feeding.b | Narrative review | |
| NHMRC (Australian government) | NHMRC, 2012 | Avoid leaving an infant unattended with a bottle containing liquids (i.e., no bottle propping). | Could not be mapped |
| Ensure that infants and toddlers are always supervised during feeding. | Could not be mapped | ||
| New Zealand Ministry of Health | Ministry of Health, 2012k | Never leave an infant unattended and feeding from a bottle. | Narrative review |
| NICE | NICE, 2008 | Child Health Promotion: Health visitors and the CHPP team should advise parents and carers not to leave infants alone when they are eating or drinking. | Rapid review,p UK Department of Health reportq |
NOTE: AAP = American Academy of Pediatrics; BRAFO = Benefit-Risk Analysis for Foods; CACFP = Child and Adult Care Food Program; CHPP = Child Health Promotion Programme; COT = Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment; CPS = Canadian Paediatric Society; DGA = Dietary Guidelines for Americans; HC = Health Canada; NHMRC = National Health and Medical Research Council; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; UK = United Kingdom; WHO = World Health Organization; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
TABLE B-21
a Lott et al. (2019) was an expert panel report with representation from Academy of Nutrition and Dietetics, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association.
b © 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.
c NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
d Portions of this recommendation could be mapped to a systematic review prepared for this guideline document; other portions appeared to be related to a narrative review of the evidence and a WHO report (Michaelsen et al., 2003). Using the NHMRC system, the strength-of-evidence rating related to this recommendation was Grade D (risk associated with cow milk). Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution. There was insufficient evidence to provide an evidence statement on unpasteurized cow or goat milk.
e Portions of this recommendation could be mapped to a systematic review prepared for this guideline document; other portions appeared to be related to a narrative review of the evidence. There was insufficient evidence to provide an evidence statement on unpasteurized cow or goat milk.
f Recommendations related to avoiding or limiting honey generally or related to dental caries are presented in Table B-9, Recommendations Related to Substances to Limit or Avoid.
g Brook, 2007. The cited article is a narrative review on infant botulism.
h Using GRADE, the strength of the evidence for the recommendation was rated as Moderate (“further research is likely to have an effect on the quality of the body of evidence and may change the recommendation”).
i Portions of this recommendation not related to the prevention of choking have been omitted.
j © All rights reserved. Nutrition for healthy term infants: Recommendations from birth to six months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.
k Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
l A list of such foods is provided in the guideline document.
m Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Food Consistency, p. 9, Copyright (2005).
n Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Food Consistency, p. 20, Copyright (2003).
o Portions of this recommendation not related to supervision have been omitted.
p Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There is no overall statement on the strength of the evidence for each recommendation.
TABLE B-22 Recommendations Related to Introduction of Complementary Foods (CFs)
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| CPS | Abrams et al., 2019 | For infants at no or low risk for food allergy, introducing complementary foods at about 6 months is recommended. | Could not be mapped |
| EFSA | EFSA Panel on Nutrition et al., 2019 | As long as the foods are given in an age-appropriate texture, are nutritionally appropriate, and prepared according to good hygiene practices, there is no convincing evidence that the introduction of CFs is associated with either adverse or beneficial health effects (except for infants at risk of iron depletion) at any age investigated in the included studies (< 1 months to < 6 months for earlier introduction). | Systematic reviewa |
| For nutritional reasons, the majority of infants need CFs from around 6 months of age. | Systematic reviewa | ||
| Infants at risk of iron depletion (exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping [< 1 min after birth], or born preterm, or born small for gestational age or with high growth velocity) may benefit from introduction of CFs that are a source of iron before 6 months of age. | Systematic reviewa | ||
| The available data do not allow the determination of a single age for the introduction of CFs for infants living in Europe. The appropriate age range depends on the individual’s characteristics and development, even more so if the infant were born preterm. | Systematic reviewa | ||
| The fact that an infant may be ready from a neurodevelopmental point of view to progress from a liquid to a more diversified diet before 6 months of age does not imply that there is a need to introduce CFs. | Systematic reviewa | ||
| RCPCH | RCPCH, 2019 | Key messages for health professionals: All infants require solid foods from 6 months on for adequate nutrition. Solid food should never be introduced before 4 months (17 weeks) as this is associated with increased short-term risk of infection and later risk of obesity, allergy, and celiac disease. | Narrative review |
TABLE B-22
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| SACN | SACN, 2018 | A wide range of solid foods, including iron-containing foods, should be introduced in an age-appropriate form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. | Narrative review |
| Current advice on the age of introduction of complementary feeding should remain unchanged. That is, most infants should not start solid foods until around the age of 6 months, having achieved developmental readiness. | Narrative review | ||
| Dietary, flavor, and texture diversification should proceed incrementally throughout the complementary feeding period, taking into account the variability between infants in developmental attainment and the need to satisfy nutritional requirements. When introducing new foods it should be recognized that they may need to be presented to infants on many occasions before they are accepted, particularly as infants get older. | Narrative review | ||
| SACN; COT | SACN and COT, 2018 | Complementary foods should be introduced in age-appropriate form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. | WHO reportb |
| ESPGHAN | Fewtrell et al., 2017 | Complementary foods (i.e., solid foods and liquids other than breast milk or infant formula) should not be introduced before 4 months but should not be delayed beyond 6 months.c | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | After introducing iron- and zinc-fortified baby cereals or mashed meats, there is no particular order to follow for introducing solid food. At this point, your baby is able to digest and absorb the nutrients from healthy food belonging to different food groups. However, it is important to keep in mind that the earlier vegetables are introduced (once your baby is ready to consume solid food), the more she or he is likely to easily accept them. | Narrative review |
| Exclusively breastfed babies need to get started on solid foods that are rich in iron and zinc sometime between 4 and 6 months, because by that time breast milk does not provide enough of these nutrients. Iron-zinc fortified baby cereals or puréed/mashed meats are recommended as first solid foods for exclusively breastfed babies. | Narrative review | ||
| Infants should be fed only breast milk and/or formula for about 6 months. However, babies may be ready to be introduced to solid food between 4 and 6 months if they are able to sit with good head control and showing other signs of readiness. | Narrative review | ||
| It is not recommended to introduce solid food before baby is 4 months old as the baby’s body is not ready and this adds unnecessary calories to her or his diet. | Narrative review | ||
| When introducing a new vegetable, it is recommended to mix it first with a familiar food such as breast milk, formula, or cereal. Combining new food items that are more difficult to accept by babies, such as some vegetables, with food they are already familiar with can help your baby accept and learn to like vegetables more readily. | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2015 | Recommend meat, meat alternatives, and iron-fortified cereal as an infant’s first complementary foods.d | Narrative review |
TABLE B-22
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| SIGENP; SIAIP | Alvisi et al., 2015e | Solid introduction should privilege family, ethnic, and regional habits, considering the nutritional needs of every child. | Narrative review |
| The age of introduction of solid foods should be defined individually, based on the competences acquired and on the interest of the infant towards food (to be assessed together with parents). The beginning of the introduction of solid foods at 6 months of age remains a desirable goal also in Western societies and for exclusively breastfed infants, although it would be advisable to introduce solid foods together with breast milk before such age. We would however suggest to introduce complementary foods not before 4 months of age and not after 6 months of age. | Narrative review | ||
| A synthesis of baby-led weaning and traditional solid introduction, probably spontaneously adopted by many families, allows the child to benefit both from the positive implications of meal sharing and from a nutritionally adequate meal, with attention placed on the moment when the infant expresses her or his desire to experiment with new foods. | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Recommend iron-rich meat, meat alternatives, and iron-fortified cereal as the first complementary foods. Encourage parents and caregivers to progress to introduce a variety of nutritious foods from the family meals.f | Narrative review |
| CPS | Grueger et al., 2013 (reaffirmed in 2018) | Advise slow, progressive, natural weaning whenever possible. | Narrative review |
| Advise mothers to introduce iron-fortified foods in the form of meat, fish, or iron-fortified cereals as first foods, to avoid iron deficiency. | Narrative review | ||
| AAP | AAP Section on Breastfeeding, 2012 | Complementary foods rich in iron and other micronutrients should be introduced at about 6 months of age. | Could not be mapped |
| NHMRC (Australian government) | NHMRC, 2012g | Encourage exclusive breastfeeding for around 6 months. There is no particular order that is advised for the introduction of solid foods or rate that new foods can be introduced, other than first foods should be nutritious and iron rich. | Systematic reviewh |
| Foods can be introduced in any order provided iron-rich nutritious foods are the first foods and the texture is suitable for the infant’s stage of development. Cow milk products including full-fat yogurt, cheese, and custard may be given, but not cow milk as a main drink before 12 months. | Systematic review; narrative reviewi | ||
| Introduce solid foods at around 6 months to meet the infant’s increasing nutritional and developmental needs. | Systematic reviewj | ||
| New Zealand Ministry of Health | Ministry of Health, 2012k | Give only breast milk until the infant is ready for and needs extra food; this will be at around 6 months of age. | Narrative review |
| After an infant is 6 months of age, the contribution of energy from complementary food increases. However, in the first year of life, most infants and toddlers still obtain most of their energy from breast milk (or infant formula if breast milk is unavailable). | Narrative review | ||
| Increase the texture, variety, flavor, and amount of food offered so the infant receives an additional intake of nutrients, especially iron and vitamin C, and is eating some family foods by around 1 year of age. | Narrative review | ||
| Introduce infants to new foods one at a time to allow the detection of reactions to individual components of foods. At first, a new food should be added only every 2 to 4 days. | Narrative review | ||
| The variety of complementary foods should be increased to ensure an additional intake of nutrients, especially iron. Iron-fortified infant cereals are suitable starter foods, and absorption can be enhanced if the infant is also given foods containing vitamin C. Once the infant is around 6 months of age, meat or chicken purées can be added to their feeds, and as they develop chewing skills finely chopped meats can be introduced. Infants should be eating some family foods by around 1 year of age. | Narrative review | ||
| As sources of carbohydrate and dietary fiber, start infant with white or wholemeal bread. | Narrative review |
TABLE B-22
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| AAP | Baker et al., 2010 | The iron intake between 6 and 12 months of age should be 11 mg/day. When infants are given complementary foods, red meat and vegetables with higher iron content should be introduced early. To augment the iron supply, liquid iron supplements are appropriate if iron needs are not being met by the intake of formula and complementary foods. | Iron DRIsl |
| WHO | WHO, 2005 | Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities. Infants can eat puréed, mashed, and semisolid foods beginning at 6 months. By 8 months most infants can also eat finger foods (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods). Avoid foods in a form that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as whole nuts, whole grapes, or raw carrots, whole or in pieces).m | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities. Infants can eat puréed, mashed, and semisolid foods beginning at 6 months. By 8 months most infants can also eat finger foods (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods). Avoid foods that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as nuts, grapes, and raw carrots).n | Technical consultations and documents |
| Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed.o | Technical consultations and documents | ||
| Start at 6 months of age with small amounts of food, and increase the quantity as the child gets older, while maintaining frequent breastfeeding.p | Technical consultations and documents |
NOTE: AAP = American Academy of Pediatrics; BRAFO = Benefit-Risk Analysis for Foods; CF = complementary food; COT = Committee on Toxicity of Chemicals in Food, Consumer Products, and the Environment; CPS = Canadian Paediatric Society; EFSA = European Food Safety Authority; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HC = Health Canada; NHMRC = National Health and Medical Research Council; PAHO = Pan American Health Organization; RCPCH = Royal College of Paediatrics and Child Health; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; SIAIP = Italian Society of Pediatric Allergology and Immunology; SIGENP = Italian Society of Gastroenterology, Hepatology and Pediatric Nutrition; WHO = World Health Organization.
a Document includes strength-of-evidence rating for each question related to introduction of complementary foods and health outcomes (e.g., age of introduction of fish and odds of developing asthma-like symptom); the conclusion statements were not accompanied by a rating of strength.
c Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
d © All rights reserved. Nutrition for healthy term infants: Recommendations from birth to six Months. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2020.
e Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).
f © 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.
g NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
h Using the NHMRC system, the strength-of-evidence ratings related to this recommendation were as follows: Grade C (for breastfeeding and asthma and atopy) and Grade D (introduction of solid foods and allergy). Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application. Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution.
i Portions of this recommendation could be mapped to a systematic review prepared for this guideline document; other portions appeared to be related to a narrative review of the evidence. Using the NHMRC system, the strength-of-evidence rating related to this recommendation was Grade D (risk associated with cow milk). Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution.
TABLE B-22
j Using the NHMRC system, the strength-of-evidence ratings related to this recommendation were as follows: Grade C (for overweight outcomes) and Grade D (introduction of solid foods and allergy). Grade C (suggestive association) indicates that the body of evidence provides some support for the recommendations but care should be taken in its application. Grade D indicates that the body of evidence is weak and any recommendation must be applied with caution.
k Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
l Citation pertains to the first sentence. Evidence could not be mapped for the remainder of the recommendation.
m Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Food Consistency, p. 9, Copyright (2005).
n Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Food Consistency, p. 20, Copyright (2003).
o Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Duration of Exclusive Breastfeeding and Age of Introduction of Complementary Foods, p. 10, Copyright (2003).
p Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Amount of Complementary Food Needed, p. 18, Copyright (2003).
TABLE B-23 Recommendations Related to Food Consistency and Texture
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| CPS | Abrams et al., 2019 | The texture or size of any complementary food should be age-appropriate to prevent choking. For young infants, smooth peanut butter can be diluted with water or mixed with a previously tolerated puréed fruit or vegetable, or with breast milk (HealthLinkBC, 2017; Togias et al., 2017). For older infants, smooth peanut butter can be spread lightly on a piece of thin toast crust, or a peanut puff product could be offered (Togias et al., 2017). | Narrative review |
| SACN | SACN, 2018 | Dietary, flavor, and texture diversification should proceed incrementally throughout the complementary feeding period, taking into account the variability between infants in developmental attainment and the need to satisfy nutritional requirements. When introducing new foods it should be recognized that they may need to be presented to infants on many occasions before they are accepted, particularly as infants get older. | Narrative review |
| ESPGHAN | Fewtrell et al., 2017 | Foods should be of an appropriate texture and consistency for the infant’s developmental stage, ensuring timely progression to finger foods and self-feeding. Prolonged use of puréed foods should be discouraged, and infants should be eating lumpy foods by 8–10 months at the latest. By 12 months, infants should drink mainly from a cup or training cup rather than a bottle.a | Systematic literature search |
| Recommendations on specific types of complementary foods should take into consideration traditions and feeding patterns in the population. Infants should be offered a varied diet including foods with different flavors and textures including bitter-tasting green vegetables.a | Systematic literature search | ||
| RWJF-HER | Pérez-Escamilla et al., 2017 | From around 6–12 months, your baby will progress from assisted feeding to self-feeding. During this time offer your baby food of different flavors and textures. | Narrative review |
TABLE B-23
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Pérez-Escamilla et al., 2017 | Eating habits are established early in life, so it is important that parents only offer healthy food to their babies. Offer your baby a variety of soft/cooked vegetables, fruits, and other healthy food with different flavors and textures so that she or he learns to like them. | Narrative review |
| SIGENP; SIAIP | Alvisi et al., 2015b | Offer ground, chopped, or finger food only once the child has developed the necessary postural and oral motor skills. | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Ensure that lumpy textures are offered no later than 9 months. Encourage progress towards a variety of textures, modified from family foods, by 1 year of age.c | Narrative review |
| Promote offering finger foods to encourage self-feeding.c | Narrative review | ||
| Recommend iron-rich meat, meat alternatives, and iron-fortified cereal as the first complementary foods. Encourage parents and caregivers to progress to introduce a variety of nutritious foods from the family meals.c | Narrative review | ||
| NHMRC (Australian government) | NHMRC, 2012d | Ensure that solid foods are of appropriate texture. The texture of foods that are introduced should be suited to an infant’s developmental stages, moving from puréed to lumpy to normal textures during the 6–12 month period. | Narrative review |
| From 12 months of age and beyond, toddlers should be consuming family foods consistent with the Australian Dietary Guidelines. | Could not be mapped |
| New Zealand Ministry of Health | Ministry of Health, 2012e | The variety of complementary foods should be increased to ensure an additional intake of nutrients, especially zinc. At around 6 months of age, meat or chicken purées can be added. As chewing skills develop, finely chopped meats can be introduced. Infants should be eating family foods by around 1 year of age. | Narrative review |
| Increase the texture, variety, flavor, and amount of food offered so the infant receives an additional intake of nutrients, especially iron and vitamin C, and is eating some family foods by around 1 year of age. | Narrative review | ||
| WHO | WHO, 2005 | Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities. Infants can eat puréed, mashed, and semisolid foods beginning at 6 months. By 8 months most infants can also eat finger foods (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods). Avoid foods in a form that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as whole nuts, whole grapes, or raw carrots, whole or in pieces).f | A background document and narrative review |
| Practice responsive feeding, applying the principles of psychosocial care. Specifically (a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; (b) feed slowly and patiently, and encourage children to eat, but do not force them; (c) if children refuse many foods, experiment with different food combinations, tastes, textures, and methods of encouragement; (d) minimize distractions during meals if the child loses interest easily; (e) remember that feeding times are periods of learning and love—talk to children during feeding, with eye-to-eye contact.g | A background document and narrative review |
TABLE B-23
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| PAHO/WHO | PAHO/WHO, 2003 | Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities. Infants can eat puréed, mashed, and semisolid foods beginning at 6 months. By 8 months most infants can also eat finger foods (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods). Avoid foods that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as nuts, grapes, and raw carrots).h | Technical consultations and documents |
| Practice responsive feeding, applying the principles of psychosocial care (Engle et al., 2000; Pelto et al., 2003). Specifically (a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; (b) feed slowly and patiently, and encourage children to eat, but do not force them; (c) if children refuse many foods, experiment with different food combinations, tastes, textures, and methods of encouragement; (d) minimize distractions during meals if the child loses interest easily; (e) remember that feeding times are periods of learning and love—talk to children during feeding, with eye-to-eye contact.i | Technical consultations and documents |
NOTE: CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HC = Health Canada; 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; SIAIP = Italian Society of Pediatric Allergology and Immunology; SIGENP = Italian Society of Gastroenterology, Hepatology and Pediatric Nutrition; WHO = World Health Organization.
a Recommendation was noted as being relevant to European infants, “typically in relatively affluent populations with access to clean water and good healthcare.”
b Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).
c © 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.
d NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
e Ministry of Health, 2012, is licensed under CC BY 4.0 International (http://creativecommons.org/licenses/by/4.0).
f Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Food Consistency, p. 9, Copyright (2005).
g Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Responsive Feeding, p. 22, Copyright (2005).
h Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Food Consistency, p. 20, Copyright (2003).
i Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Responsive Feeding, p. 14, Copyright (2003).
TABLE B-24 Recommendations Related to Meal Frequency
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| RWJF-HER | Pérez-Escamilla et al., 2017 | Establish a consistent regular schedule for your baby’s meals, snacks, and sleep times. | Narrative review |
| Once your child is 1 year old, structure eating occasions—she or he needs to eat three meals and two to three healthy snacks at about the same time every day. Following a regular schedule will help your child learn when and what to expect to eat during the day. | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Recommend a regular schedule of meals and snacks, offering a variety of foods from the four food groups.a | Narrative review; 2007 Eating Well with Canada’s Food Guideb |
| Recommend gradually increasing the number of times per day that complementary foods are offered while continuing to breastfeed.a | Narrative review | ||
| AHA | Gidding et al., 2005 | Parent, guardian, and caregiver responsibilities for children’s nutrition: Control when food is available and when it can be eaten (nutrient quality, portion size, snacking, regular meals). | Narrative review |
| WHO | WHO, 2005 | For the average healthy infant, meals should be provided 4–5 times per day, with additional nutritious snacks (such as pieces of fruit or bread or chapatti with nut paste) offered 1–2 times per day, as desired. The appropriate number of feedings depends on the energy density of the local foods and the usual amounts consumed at each feeding. If energy density or amount of food per meal is low, more frequent meals may be required.c | Based on theoretical estimates of the number of feedings required, calculated from energy requirements |
| PAHO/WHO | PAHO/WHO, 2003 | Increase the number of times that the child is fed complementary foods as she or he gets older. The appropriate number of feedings depends on the energy density of the local foods and the usual amounts consumed at each feeding. 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 (such as a piece of fruit or bread or chapatti with nut paste) may be offered 1–2 times per day, as desired. Snacks are defined as foods eaten between meals—usually self-fed, convenient, and easy to prepare. If energy density or amount of food per meal is low, or the child is no longer breastfed, more frequent meals may be required.d | Technical consultations and documents |
NOTE: AHA = American Heart Association; CPS = Canadian Paediatric Society; HC = Health Canada; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; WHO = World Health Organization.
a © 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.
c 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).
d 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).
TABLE B-25 Recommendations Related to Hunger and Satiety Cues
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| ESPGHAN | Fewtrell et al., 2017 | Parents should be encouraged to respond to their infant’s hunger and satiety queues and to avoid feeding to comfort or as a reward.a | Systematic literature search |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Do not give a bottle or food to your baby as a reward for behaving the way you want. Only offer food in response to your baby’s hunger signals. | Narrative review |
| Do not force your baby to finish the bottle or continue eating from your breast, because this will interfere with the baby’s natural ability for appetite control later in life. | Narrative review | ||
| Do not pressure your toddler to finish her or his plate. | Narrative review | ||
| During night awakenings, first give your baby an opportunity to self-soothe back to sleep before picking her or him up. If this does not work, before feeding try using other soothing strategies that work for your baby. | Narrative review | ||
| SIGENP; SIAIP | Alvisi et al., 2015b | The child’s diet will be better inasmuch as the family will follow a correct and balanced diet, mindful of the caloric and protein intake. It is therefore of paramount importance to provide parents with the right information about a nutritionally balanced diet, and encourage them to recognize and respect every child’s self-regulatory capacity. It is also important to promote the daily consumption of fruits and vegetables. | Narrative review |
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Encourage responsive feeding based on the child’s hunger and satiety cues.c | Narrative review |
| AHA | Gidding et al., 2005 | Improving nutritional quality after weaning: Respond to satiety clues and do not overfeed; infants and young children can usually self-regulate total caloric intake; do not force children to finish meals if not hungry as they often vary caloric intake from meal to meal. | Narrative review |
| WHO | WHO, 2005 | Practice responsive feeding, applying the principles of psychosocial care. Specifically (a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; (b) feed slowly and patiently, and encourage children to eat, but do not force them; (c) if children refuse many foods, experiment with different food combinations, tastes, textures, and methods of encouragement; (d) minimize distractions during meals if the child loses interest easily; (e) remember that feeding times are periods of learning and love—talk to children during feeding, with eye-to-eye contact.d | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Practice responsive feeding, applying the principles of psychosocial care (Engle et al., 2000; Pelto et al., 2003). Specifically (a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; (b) feed slowly and patiently, and encourage children to eat, but do not force them; (c) if children refuse many foods, experiment with different food combinations, tastes, textures, and methods of encouragement; (d) minimize distractions during meals if the child loses interest easily; (e) remember that feeding times are periods of learning and love—talk to children during feeding, with eye-to-eye contact.e | Technical consultations and documents |
TABLE B-25
NOTE: AHA = American Heart Association; CPS = Canadian Paediatric Society; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; HC = Health Canada; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SIAIP = Italian Society of Pediatric Allergology and Immunology; SIGENP = Italian Society of Gastroenterology, Hepatology and Pediatric Nutrition; WHO = World Health Organization.
a Recommendation was noted as being relevant to European infants, typically in relatively affluent populations with access to clean water and good health care.
b Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).
c © 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.
d Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Responsive Feeding, p. 22, Copyright (2005).
e Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Responsive Feeding, p. 14, Copyright (2003).
TABLE B-26 Recommendations Related to Responsive Feeding Practices
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| SACN | SACN, 2018 | Dietary, flavor, and texture diversification should proceed incrementally throughout the complementary feeding period, taking into account the variability between infants in developmental attainment and the need to satisfy nutritional requirements. When introducing new foods it should be recognized that they may need to be presented to infants on many occasions before they are accepted, particularly as infants get older. | Narrative review |
| RWJF-HER | Pérez-Escamilla et al., 2017 | Actively engage in conversations with your baby while feeding her or him and as you change routines throughout the day. | Narrative review |
| Avoid distractions while feeding your baby, including using your smartphone. | Narrative review | ||
| Do not give up if your baby does not accept the food the first time you offer it. Try again during a different eating occasion. It may take as many as 15 to 20 tries before your baby learns to like a new food. | Narrative review | ||
| Provide healthy, tasty food that is appropriate for your child’s age at regular times and in a pleasant environment, and let your baby decide how much she or he wants to eat. | Narrative review | ||
| Remember that it may take more tries for your baby to learn to like vegetables than other healthy food like fruits. Continue offering a variety of vegetables and other healthy food, and let your child decide when she or he is ready. | Narrative review | ||
| SIGENP; SIAIP | Alvisi et al., 2015a | A synthesis of baby-led weaning and “traditional” solid introduction, probably spontaneously adopted by many families, allows the child to benefit both from the positive implications of meal sharing and from a nutritionally adequate meal, with attention placed on the moment when the infant expresses their desire to experiment new foods. | Narrative review |
TABLE B-26
| Organization | Citation | Recommendation | Evidence Mapped to Recommendation |
|---|---|---|---|
| SIGENP; SIAIP | Alvisi et al., 2015a | It is recommended to encourage the sharing of mealtimes and the satisfaction of the infant’s curiosity and requests with small tastings of food. | Narrative review |
| Offer ground, chopped, or finger food only once the child has developed the necessary postural and oral motor skills. | Narrative review | ||
| The child’s diet will be better inasmuch as the family will follow a correct and balanced diet, mindful of the caloric and protein intake. It is therefore of paramount importance to provide parents with the right information about a nutritionally balanced diet, and encourage them to recognize and respect every child’s self-regulatory capacity. It is also important to promote the daily consumption of fruits and vegetables. | Narrative review | ||
| Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC | Health Canada et al., 2014 | Encourage parents and caregivers to be role models and instill lifelong healthy eating habits.b | Narrative review; 2007 Eating Well with Canada’s Food Guidec |
| Promote offering finger foods to encourage self-feeding.b | Narrative review | ||
| NHMRC (Australian government) | NHMRC, 2012d | As with breastfeeding, bottle feeding according to need is appropriate. It is important for parents to be aware that information on formula packages recommending certain amounts for various ages is a guide only and does not necessarily suit every infant. | Could not be mapped |
| NICE | NICE, 2008 | Child health promotion: Health visitors and the CHPP team should encourage families to eat together and encourage parents and carers to set a good example by the food choices they make for themselves. | Rapid review,e UK Department of Health reportf |
| AHA | Gidding et al., 2005 | Parent, guardian, and caregiver responsibilities for children’s nutrition: Control when food is available and when it can be eaten (nutrient quality, portion size, snacking, regular meals). | Narrative review |
| Parent, guardian, and caregiver responsibilities for children’s nutrition: Serve as role models and lead by example; do as I do rather than do as I say. | Narrative review | ||
| Provide social context for eating behavior (family meals, role of food in social intercourse). | Narrative review | ||
| Improving nutritional quality after weaning: Introduce healthy foods and continue offering if initially refused; do not introduce foods without overall nutritional value simply to provide calories. | Narrative review | ||
| WHO | WHO, 2005 | Practice responsive feeding, applying the principles of psychosocial care. Specifically (a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; (b) feed slowly and patiently, and encourage children to eat, but do not force them; (c) if children refuse many foods, experiment with different food combinations, tastes, textures, and methods of encouragement; (d) minimize distractions during meals if the child loses interest easily; (e) remember that feeding times are periods of learning and love—talk to children during feeding, with eye-to-eye contact.g | A background document and narrative review |
| PAHO/WHO | PAHO/WHO, 2003 | Practice responsive feeding, applying the principles of psychosocial care (Engle et al., 2000; Pelto et al., 2003). Specifically (a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; (b) feed slowly and patiently, and encourage children to eat, but do not force them; (c) if children refuse many foods, experiment with different food combinations, tastes, textures, and methods of encouragement; (d) minimize distractions during meals if the child loses interest easily; (e) remember that feeding times are periods of learning and love—talk to children during feeding, with eye-to-eye contact.h | Technical consultations and documents |
TABLE B-26
NOTE: AHA = American Heart Association; CHPP = Child Health Promotion Programme; CPS = Canadian Paediatric Society; HC = Health Canada; NHMRC = National Health and Medical Research Council; NICE = National Institute for Health and Care Excellence; PAHO = Pan American Health Organization; RWJF-HER = Robert Wood Johnson Foundation-Healthy Eating Research; SACN = Scientific Advisory Committee on Nutrition; SIAIP = Italian Society of Pediatric Allergology and Immunology; SIGENP = Italian Society of Gastroenterology, Hepatology and Pediatric Nutrition; UK = United Kingdom; WHO = World Health Organization.
a Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).
b © 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.
d NHMRC, 2012, is licensed under CC BY 4.0 Australia (https://creativecommons.org.au).
e Each recommendation was associated with multiple evidence statements. Each evidence statement was taken from a review of effectiveness. Some of the evidence statements give a strength-of-evidence rating (++, +, –). There is no overall statement on the strength of the evidence for each recommendation.
g Reprinted from Guiding principles for feeding non-breastfed children 6–24 months of age, World Health Organization, Responsive Feeding, p. 22, Copyright (2005).
h Reprinted from Guiding principles for complementary feeding of the breastfed child, Pan American Health Organization/World Health Organization, Responsive Feeding, p. 14, Copyright (2003).
