3

Characteristics of Included Guideline Documents

The committee identified a wide range of potentially relevant documents, webpages, and resources through its multipronged search (see Chapter 2). Of the 156 potentially relevant resources the committee screened using its eligibility criteria, 43 guideline documents were ultimately included. For its review, the committee began by abstracting information about each of the

guideline documents, summarized in Table 3-1. This chapter discusses the characteristics of the guideline documents reviewed and implications for the interpretation of the recommendation summaries presented in Chapters 4 and 5. The list of excluded documents and rationale for exclusion are provided in Appendix A.

TABLE 3-1

TABLE 3-1

TABLE 3-1

TABLE 3-1

TABLE 3-1

NOTES: The phrase “health care provider” encompasses a range of practitioners, including but not limited to physicians, nurse practitioners, nurses, dentists, registered dietitian nutritionists, and other nutrition professionals. AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; AAPD = American Academy of Pediatric Dentistry; ABM = Academy of Breastfeeding Medicine; AHA = American Heart Association; AND = Academy of Nutrition and Dietetics; 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; GRADE = Grading of Recommendations Assessment, Development and Evaluation; HC = Health Canada; NIAID = National Institute of Allergy and Infectious Diseases; NICE = National Institute for Health and Care Excellence; NIH = National Institutes of Health; PAHO = Pan American Health Organization; RCPCH = Royal College of Paediatrics and Child Health; Recs. = recommendations; 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; SINPE = Italian Society for Parenteral and Enteral Nutrition; UK = United Kingdom; U.S. = United States; USPSTF = U.S. Preventive Services Task Force; WHO = World Health Organization.

^a Methodologies presented in this column summarize what was presented in the guideline document. As a result, some of the terminology varies. Documents and resources that did not explicitly describe their methodology are listed as “Not specified.” Such documents may have included a narrative literature review but did not explain how evidence was identified and/or used to develop the feeding recommendations. The designation in this column may differ from the category assigned to specific recommendations in Chapters 4 and 5 and Appendix B.

^b This includes a statement of any length providing guidance related to changing knowledge, attitudes, and/or behaviors, and the channels by which to spread feeding guidance.

^c Document also noted that it was reviewed by relevant AAP sections and committees and by the Centers for Disease Control and Prevention, the U.S. Department of Agriculture, and the U.S. Food and Drug Administration.

^d Endorsed by AAP.

^e This document included a section called “Implementation of Dietary Recommendations Including Considerations for Specific Age Groups.” However, this section contains the feeding recommendations the committee abstracted and does not contain additional guidance on the communication or dissemination of the recommendations.

^f No date was provided for this resource. Year in citation reflects year the webpage was last updated. The text of the resource indicates it preceded Health Canada et al., 2014.

^g Reaffirmed in 2018.

^h Reaffirmed in 2017.

ⁱ This guideline document was developed using a coordinating committee representing 25 professional organizations and a 26-member expert panel.

^j Date reflects year the webpage was last modified. The post date is listed as 2017.

^k Lott et al. (2019) was a consensus document that included participation from AAP, AAPD, AHA, and AND.

^l The guideline includes a section on implementation, but the information does not pertain to the recommendation related to what or how to feed infants and young children.

^m Recommendations were provided by regions defined by salt iodization and iodine intake status.

TYPES OF GUIDELINE DOCUMENTS

Guidance about what and how to feed young children appears in a variety of document types, both within and between organizations. Professional organizations often provide different forms of guidance to the membership versus the stakeholder communities. The American Academy of Pediatrics (AAP), for instance, publishes policy statements that provide the organization’s position and recommendations on an advocacy or public health topic (AAP IHCW, 2020). AAP clinical reports, in contrast, provide pediatricians with practical guidance (AAP IHCW, 2020). The Academy of Nutrition and Dietetics (AND) publishes different types of guidance for its members and stakeholders based on the level of available evidence and practice considerations. When a topic covered by a systematic review is “controversial, confusing, important for policy, or requires clarification,” AND publishes a position statement if the systematic review has Grade I or II evidence and a consensus statement if the systematic review has Grade III evidence (Handu et al., 2018, p. 1743). AND position statements were previously based on narrative reviews; in the past few years, the process has changed to base the position statements on systematic reviews. Position and consensus statements are separate from the AND Evidence-Based Nutrition Practice Guidelines, which are created from the systematic review if the topic is complex and merits the creation of formal practice recommendations (Handu et al., 2018).

The World Health Organization has included recommendations in a variety of publications, including guideline documents (e.g., WHO, 2001), descriptions of guiding principles (e.g., PAHO/WHO, 2003; WHO, 2005), and journal articles (e.g., WHO Secretariat et al., 2007). Recommendations from national governments can also take various forms. Health Canada, for instance, participated in a collaborative effort that included three health professional groups to develop nutrition recommendations for healthy, term infants from birth to 6 months and 6–24 months (Health Canada et al., 2014, 2015); the guidance, along with the scientific rationale, is posted on Canadian government-hosted webpages. The New Zealand Ministry of Health prepared an extensive background document for the food and nutrition guidelines (Ministry of Health, 2012), which served as the policy basis for educational resources for the public.

Challenges Related to Summarizing Recommendations from Different Types of Guideline Documents

The types of documents that contain feeding recommendations vary both within and between organizations, and have changed over time within an organization, which makes comparisons challenging. For some organi-

zations, policy statements offer a position on a particular topic, but the practitioner-oriented publications often provide specific guidance on what or how to feed infants and young children. Similarly, both nongovernmental organizations and governmental agencies offer a range of reports that contain feeding guidance. As a goal of this report was to explore the scope of topics that have been covered in existing guideline documents, the committee was broadly inclusive and uses the term guideline document to describe the wide range of resources, websites, and materials that screened eligible based on the committee’s inclusion criteria. The committee acknowledges that, in some cases, the included documents are not formally considered guidelines by the identified organizations, and that the heterogeneity likely contributes to some of the differences observed across recommendations described in Chapters 4 and 5.

LEVEL OF COLLABORATION

Most of the eligible guideline documents were prepared by a single organization. A subset, however, reflected collaborative efforts between multiple agencies, organizations, or groups. The eligible guideline documents reflect the contributions of 26 different organizations.¹

The types of collaboration between organizations varied. For instance, the Breastfeeding Committee for Canada, the Canadian Paediatric Society (CPS), Dietitians of Canada, and Health Canada worked together on two guideline documents related to nutrition in the first 2 years of life (Health Canada et al., 2014, 2015). For a 2019 Robert Wood Johnson Foundation-Healthy Eating Research (RWJF-HER) guideline document, a consensus panel was convened with representatives from AND, the American Academy of Pediatric Dentistry (AAPD), AAP, and the American Heart Association (AHA) (Lott et al., 2019). The guideline document by Alvisi et al. (2015) was a collaboration between the Italian Society of Gastroenterology, Hepatology and Pediatric Nutrition (SIGENP) and the Italian Society of Pediatric Allergology and Immunology (SIAIP); the document also acknowledged “support of nutrition experts from the Italian Society for Parenteral and Enteral Nutrition (SINPE) and the European Society [for] Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)” (Alvisi et al., 2015, p. 1).² Some of the eligible guideline documents were endorsed by other groups. For example, an AAP clinical report about bone health (Golden et al., 2014) stated that it was endorsed

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¹ This value takes into account the caveats decisions described in the section “Challenges Related to Discerning Collaborators.”

²Alvisi et al., 2015, is licensed under CC BY 4.0 (http://creativecommons.org/licenses/by/4.0).

by the organization American Bone Health. Similarly, a guideline document from AHA stated that it was endorsed by AAP (Gidding et al., 2005). Some collaborations were between different advisory committees reporting to a government. For example, two independent scientific advisory committees to the UK government collaborated on a joint statement (SACN and COT, 2018).

Challenges Related to Discerning Collaborators

One of the challenges the committee encountered was that some of the organizations that collaborated on guideline documents also had their own, separate guideline document that provided recommendations on the same topic. In some cases, it was unclear if the newer recommendation (be it the stand-alone or collaborative guideline document) superseded the previously published recommendations. For instance, CPS participated in a collaborative guideline document in which a recommendation advised that pasteurized homogenized cow milk could be introduced at 9–12 months (Health Canada et al., 2014). In a later stand-alone CPS guideline document, the recommendation indicates that cow milk should be introduced at 12 months of age (Unger et al., 2019).

Another challenge the committee encountered was characterizing organizations when they were described as something other than a direct collaborator. For instance, the guideline document by Alvisi et al. (2015) stated that support was provided by members from SINPE and ESPGHAN. The extent to which these two organizations were officially involved, as opposed to members of these organizations participating in the process, was not clear. In this case, the committee counted only the two clearly identified collaborators (SIAIP and SIGENP) as the contributing organizations for this particular guideline document. For Togias et al. (2017), the National Institute of Allergy and Infectious Diseases convened a coordinating committee with members representing 25 professional organizations, along with a 26-member expert panel. For this guideline document, the committee did not count the individual organizations separately, but reference to the number of organizations involved in Togias et al. (2017) is accompanied by an explanatory footnote throughout the rest of the report. For Lott et al. (2019), the committee counted RWJF-HER along with the four organizations that participated in the consensus statement development. Organizations noted within a guideline document as endorsing the recommendations were not counted as contributors; however, when an organization had its own publication stating that they endorsed another organization’s recommendation, it was counted as a separate guideline document and contributing organization.

SCOPE OF TOPICS COVERED

The eligible guideline documents ranged in the scope of topics covered. Some of the guideline documents provided broad explorations of many different topics related to feeding infants and young children (e.g., Gidding et al., 2005; Ministry of Health, 2012; NHMRC, 2012; NICE, 2008; Pérez-Escamilla et al., 2017; SACN, 2018). Others focused on providing guidance for just early infancy (e.g., Health Canada et al., 2015) or the complementary feeding period (e.g., Alvisi et al., 2015; Fewtrell et al., 2017; Health Canada et al., 2014; PAHO/WHO, 2003; WHO, 2005). Some were conceptually broad, but proved to be narrower in scope because of the guideline’s target audience. For example, a 2017 guideline document from AAPD titled “Policy on Dietary Recommendations for Infants, Children, and Adolescents” focused its review and recommendations only on dietary practices for the promotion of dental health (AAPD, 2017). In contrast, most of the included guideline documents focused on a specific topic area (e.g., breastfeeding, fruit juice consumption, supplementation, vegetarian and vegan diets, iron requirements). These types of documents tended to provide multiple detailed recommendations on the singular topic.

Challenges Related to Scope of Topics Covered

The guideline documents that broadly covered a range of topic areas about feeding during the first 2 years of life are repeatedly represented throughout the committee’s summaries in Chapters 4 and 5. A guideline document with a more specific focus inherently appears less frequently throughout. Nevertheless, both broad and narrowly focused guideline documents serve important roles in informing health care providers, parents and guardians, policy makers, early care and education providers, and other target audiences. As such, the committee captured the range of recommendations that met its eligibility criteria.

The original intent of the committee was to include only the most recent recommendation on a given topic area from each organization. However, looking across the collection of eligible guideline documents, the committee recognized that publication date could not completely drive its decision making. In situations where an organization had multiple publications with recommendations on a particular topic area, the guideline documents typically differed in scope. For instance, CPS participated in two collaborative guideline documents (Health Canada et al., 2014, 2015) and published three separate guideline documents (Amit et al., 2010; Godel et al., 2007; Grueger et al., 2013), each of which included one or more recommendations related to vitamin D. The collaborative guideline documents

were broad in scope, and covered infant and young child feeding from birth to 24 months. The three separate guideline documents from CPS focused on different topics including vegetarian diets in children (Amit et al., 2010), “weaning from the breast” (Grueger et al., 2013), and vitamin D supplementation (Godel et al., 2007), with each providing recommendations on vitamin D. In such instances, rather than attempting to judge whether any of the recommendations were superseded, the committee opted to include all statements of recommendation from an organization on a given topic when the scope of the guideline documents differed.

TARGET COUNTRY OR REGION

The included guideline documents reflected the contributions of agencies, organizations, or groups from Australia, Canada, Europe, Italy, New Zealand, the United Kingdom, and the United States, along with global guidance from the World Health Organization.

TARGET AUDIENCES

Most of the eligible guideline documents targeted health care providers, including but not limited to physicians, nurse practitioners, nurses, dentists, registered dietitian nutritionists, and other nutrition professionals. Across the collection of eligible guidelines, additional target audiences were identified, but were not as common: advocates, community leaders, early care and education providers, program administrators, parents, and policy makers.

Challenges Related to Recommendations for Different Target Audiences

The structure and wording of some of the recommendations intended to inform health care providers were prefaced with the action the health care provider should take (e.g., “Pediatricians should advocate for…”; “Parents should be encouraged to…”; “Explain to parents and caregivers that…”). In such cases, the committee focused on the portion of the recommendation that pertained specifically to what or how to feed the infant or young child, rather than the action of the health care provider.

GUIDELINE DOCUMENT METHODOLOGIES

During document-level abstraction, the committee noted whether the identified guideline document included a description of the overall methodology used. Many of the eligible guideline documents did not specify how the literature cited throughout the document was identified and assessed.

Guideline documents that included an overall methodology tended to describe narrative review literature searches. Few guideline documents conducted systematic reviews and/or integrated a commissioned systematic review (see Table 3-1). Of these, some reported using evidence grading methodology (e.g., Grading of Recommendations Assessment, Development and Evaluation; Canadian Task Force on Prevention Health Care; National Guideline Clearinghouse), while others did not.

Challenges Related to Assessing Guideline Document Methodologies

The extent to which methodologies were described varied across guideline documents. In some cases, even when the general methodology used to identify the evidence was included, recommendations could not be mapped to the evidence cited. Even in guideline documents that described using a systematic review, individual recommendations could not always be directly mapped to a systematic review question. Stated document methodologies were not always consistent. For instance, some guideline documents stated using a “systematic review,” whereas others described their methodology as “systematic literature search” or “systematic literature review.” As the committee focused on the information provided within the guideline documents themselves, it was unable to discern if these differences in terminology reflected true methodological differences.

As described above, guideline documents varied in scope. Some topic areas, such as those for which randomized controlled trial data are available (e.g., micronutrient supplementation), may lend themselves to using formal evidence assessment techniques. For many topic areas related to infant and young child feeding, the nature of the available evidence may be well understood to those making the recommendations, and this could be one reason why many of the guideline documents used a less formal narrative literature review approach.

Few guideline documents formally graded the evidence to support recommendations, and even fewer systematically indicated additional considerations related to the recommendations, such as potential benefits versus harms, side effects, or risks. Of the guidelines that graded the evidence to support recommendations, the grading system used varied. For instance, two guidelines from the Canadian Paediatric Society used the Canadian Task Force on Preventive Health Care grading system to rate the strength of the recommendation (Amit et al., 2010; Godel et al., 2007). In other cases, such as the Australian government’s literature review to support its infant feeding guidelines (NHMRC, 2012), a system was used to describe the state of the evidence for specific questions (e.g., “What are the risks associated with feeding unmodified cow’s milk to infants less than 12 months of

age?”³) that then inform broader recommendations. In some instances, ratings were provided within a guideline document without a clear description of their meaning. The committee noted evidence rating systems as they were reported in the guideline documents. Recommendations that are accompanied by a rating are footnoted throughout Appendix B.

Although the stated methodology can provide initial insight into the process as described, caution against overinterpretation is warranted. Some high-quality narrative reviews also follow structured and thorough protocols. Furthermore, not all systematic reviews follow best-practice procedures. The committee did not assess or determine the quality or fidelity of the stated approaches. Given this, the stated methodologies summarized in Table 3-1 can serve as only a general indicator of guideline development approaches, without reflecting a judgment of quality.

DECLARATION OF CONFLICTS OF INTEREST

As a check on reporting best practices, the committee recorded which guideline documents included a statement about the guideline authors’ conflicts of interest. Seventeen of the 43 guideline documents included such statements.

STATEMENTS OF RECOMMENDATION

The committee broadly interpreted the concept of feeding recommendations as concluding or summary statements that provided specific guidance related to what or how to feed infants or young children. For many guideline documents, these statements were found in a section labeled “Recommendations.” Other guideline documents, however, presented guidance under headings such as “Summary,” “Policy Statement,” “Conclusions,” “Key Points,” and “Anticipatory Guidance,” or simply noted it as being “guidance for practice.” In addition to how recommendations were labeled, their presentation varied across the guideline documents. In many cases, recommendations were provided at the end of the guideline document, chapter, or section in narrative form or as bulleted lists; some were found in boxes or in tables. The committee captured the verbatim statements of recommendation as presented in the guideline documents. In some instances, this meant capturing several sentences that the guideline document had grouped together in a single bullet point as the statement of recommendation. Often, the concepts reflected in these complex statements of recommendation crossed several topic areas. Many of the recommendations intertwined context for the particular action. For example, a recom-

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

mendation from the New Zealand Ministry of Health (Ministry of Health, 2012, p. 118) stated, “Dried fruit is not recommended as a snack between meals because it sticks to teeth and is cariogenic.” This recommendation includes both the action (not giving dried fruit as a snack between meals) and the rationale for the action (due to its cariogenic properties).

Challenges Related to Recommendation Statements

In strategizing how to summarize the state of recommendations on feeding infants and young children, the committee had initially envisioned being able to quantify the number of recommendations on a particular topic area. As the committee reviewed the format of recommendations in the eligible guideline documents, however, it became rapidly apparent that a more qualitative approach was needed.

Some guideline documents, particularly those that broadly described feeding recommendations from birth to 24 months, often presented recommendations multiple times (e.g., across age groups), and in slightly different ways. As the committee’s approach was to capture verbatim statements of recommendation, this posed a challenge. If one of the repetitive recommendations provided slightly more information than an alternative version in the guideline document, the more comprehensive version was abstracted. One guideline document in which this was particularly difficult to navigate was a 2017 RWJF-HER document (Pérez-Escamilla et al., 2017). The guideline document included eight appendixes of guidance on what and how to feed infants and young children; the statements were presented as several pages of bullet points, thematically grouped into tables and presented by age groups. Some of the statements provided rationale or context, rather than a feeding recommendation (e.g., “Parents may feel overwhelmed when their babies cry or seem fussy.”). Within the document, tables of different themes often repeated or slightly reworded the recommendations presented elsewhere. The committee attempted to consolidate the recommendations and select the most comprehensive option available. It is possible that not all of the concepts presented in Pérez-Escamilla et al. (2017) have been fully captured through the committee’s consolidation and abstraction process. Given these considerations, caution is warranted in interpreting the number of recommendations described in Chapters 4 and 5 as strict quantification; rather, the numbers describe the number of recommendation units abstracted, which in turn was used to map the evidence. The number of guideline documents that commented on a particular topic area may serve as a more informative metric.

Another challenge the committee faced related to summarizing the abstracted recommendations was the level of detail provided in each statement. As described above, both the type and scope of the guideline documents influenced the information provided in the recommendation. Some

of the policy statement documents made general statements, whereas more detailed-oriented recommendations appeared in focused or clinically oriented guideline documents. The primary focus of the committee’s summary of recommendations was the abstracted statements. However, there were instances in which the committee sought and added clarifying details from a guideline document, in addition to the clearly labeled statements of recommendation within the document, when there were apparent discrepancies across recommendations on the same topic that were likely attributable to the level of detail incorporated directly into the statement of recommendation by guideline authors. In these cases, it was difficult to judge whether or not the guideline authors intended those details to be part of the formal recommendation, but consultation with the guideline document authors to determine this was beyond the committee’s scope of work.

In a unique situation, the committee was aware of key guidance that did not exist in the format that could be abstracted using the standard approach. In its search for eligible guideline documents, the committee identified an AAP clinical report on vitamin D (Wagner et al., 2008). The guideline, however, had since been retired; in 2012, AAP released a statement of endorsement for the updated Dietary Reference Intakes (DRIs) for vitamin D and calcium (AAP, 2012). As the committee did not abstract DRI values or endorsements of DRIs, AAP appeared absent from the vitamin D recommendation topic area, as none of the other identified guideline documents from AAP contained the level of detail that had existed in the 2008 clinical report. However, a more recent AAP clinical report (Golden et al., 2014) included a statement about vitamin D supplementation of breastfed and partially breastfed infants, although it was presented in the narrative text of the guideline document, rather than the summary recommendation portion. Ultimately, the committee determined that the supplementation guidance included in Golden et al. (2014) should be included in its summaries, as it reflected AAP’s best practice recommendations for health care providers. This example demonstrates that, despite efforts to be comprehensive in its searches, the committee may not have captured all current recommendations from relevant sources.

In its efforts to summarize existing feeding recommendations, the committee grouped recommendations into topic areas, which were then categorized as being broadly related to either what to feed or how to feed. Identified themes within a topic area, however, did not always precisely match the what or how to feed categorization. For instance, there were several recommendations related to intake of sugars.⁴ Most of the recommen-

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⁴ Terminology related to sugar and sugars varies in the field. Whereas some may use the singular to refer specifically to the disaccharide sucrose, it is often used to describe sweeteners broadly. As much as possible, the committee uses verbatim language related to sugars from each recommendation.

dations discussed limiting intake and providing foods with no or limited added or total sugars, which clearly fell within the concept of what to feed. However, there were some recommendations that advised against dipping pacifiers or bottle teats in sugary substances (e.g., sugar, honey, jam, sweetened drinks), which is more of a how to feed concept. Another example is the guidance related to safety of foods and feeding practices, which the committee grouped into a single topic area. Recommendations related to the prevention of choking clearly fell under the how to feed concept, but recommendations related to consumption of pasteurized juice, milk, and dairy products; honey; and raw or undercooked foods fell more within the concepts of what to feed. In these instances, the committee decided that it was more important to keep recommendations on a particular topic area together than to strictly categorize each recommendation based on whether it fit best within what or how to feed. Therefore, some of the themes discussed in Chapter 4 relate to how to feed concepts, and some of the themes discussed in Chapter 5 relate to what to feed concepts.

EVIDENCE MAPPING TO EACH RECOMMENDATION

In addition to capturing the overall methodology described in each guideline document, the committee noted what type of evidence mapped to each recommendation. This documentation was performed at the recommendation level, as different types of evidence could potentially support different recommendations within the same guideline document. The committee considered investigation of citations within the guideline documents to be beyond its Statement of Task. Thus, the documentation of the type of evidence that mapped to each recommendation was based only on the information provided within the guideline document itself, except in the few instances in which a source document of related material was made available to support the guideline document.

Given the diversity in document types and formats, the committee used broad groupings to characterize the evidence that mapped to each recommendation. A designation of “systematic review” meant an entire systematic review was contained within the guideline document or a systematic review was specifically prepared to be used to develop the guideline document. The designation of “narrative review,” in contrast, broadly captured a wide range of approaches. This option was selected when two or more references were cited as evidence in the narrative that mapped to the recommendation. One important caveat to this designation is that any type of document or resource could be cited; this includes citing previously published systematic reviews that were not prepared for the purposes of that specific guideline document. Other types of evidence, such as single research studies or web resources, were also noted. One additional option was available to char-

acterize the evidence that mapped to each recommendation—“could not be mapped.” This option was selected when the committee was unable to discern which portions of the guideline document were used to justify or support the recommendation.

Challenges Related to Evidence Mapping to Each Recommendation

Despite using broad categories, the committee found that discerning which type of evidence mapped to each recommendation was one of the most challenging portions of its task. Few of the eligible guideline documents were structured in a way that clearly presented the evidence and rationale for each individual statement of recommendation. Instead, a common format used across many guideline documents was to present a narrative discussion, followed by all recommendations presented together. The committee attempted to disaggregate such presentations, and looked in the narrative sections for portions that specifically related to each stated recommendation. This approach to documenting the type of evidence used is subjective and is contingent on being able to locate portions of a guideline document relevant to each statement of recommendation. As discussed earlier in this chapter, assessing the fidelity of the procedures and quality of the materials used to support each recommendation was considered beyond the scope of the committee’s task. Consequently, the committee’s categorization of the types of evidence used should be regarded as a qualitative description of how evidence is presented in guideline documents, rather than being viewed as a statement about the strength and quality of evidence that supports each recommendation. The committee also notes that the inability to map a recommendation to its evidence, or use of a narrative review as opposed to a systematic review, should not be viewed as diminishing the importance or usefulness of important practical guidance.

INCLUSION OF GUIDANCE ON COMMUNICATION AND DISSEMINATION

The committee noted when a guideline document included guidance on communicating or disseminating the feeding recommendations. Across the 43 guideline documents, 25 included such a statement or section. This topic is further explored in Chapter 6.

INCLUSION OF RESEARCH RECOMMENDATIONS

As a check on reporting best practices, the committee recorded which guideline documents included explicit research recommendations. Fourteen of the 43 guideline documents included such statements.

SUMMARY

Existing feeding recommendations summarized in this report are from a diverse collection of guideline documents that met the committee’s eligibility criteria. The guideline documents varied with respect to the document type (e.g., position statement, clinical practice reports), level of collaboration, scope of topics covered, target audiences, stated methodologies, presentation of recommendations, and mapping of evidence to each recommendation. Each of these variables affected the committee’s ability to summarize the current state of feeding recommendations for infants and young children. The committee notes that, although some aspects have been quantified in Chapters 4 and 5 for descriptive purposes, the committee’s summaries are intended to be qualitative in nature.

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