Summary1
Recommendations for feeding infants and young children have changed substantially over time owing to scientific advances, cultural influences, societal trends, and other factors. At the same time, stronger approaches to reviewing and synthesizing scientific evidence have evolved, such that there are now established protocols for developing evidence-based health recommendations. However, not all authoritative bodies have used such approaches for developing infant feeding guidance, and for many feeding questions there is little or no sound evidence available to guide best practices, despite the fact that research on infant and young child feeding has expanded in recent decades. Summarizing the current landscape of feeding recommendations for infants and young children can reveal the level of consistency of existing guidance, shed light on the types of evidence that underpin each recommendation, and provide insight into the feasibility of harmonizing guidelines.
THE COMMITTEE’S TASK AND APPROACH
With support from the Centers for Disease Control and Prevention and from the National Institutes of Health, the National Academies of Sciences, Engineering, and Medicine convened an ad hoc consensus committee that was asked to collect, compare, and summarize existing recommendations on what and how to feed infants and young children from birth to
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1 This summary does not include references. Citations to support the text herein are provided in the body of the report.
24 months of age (see Box S-1). The committee was also asked to make recommendations to stakeholders on strategies for communicating and disseminating feeding recommendations.
The committee’s search for guideline documents that included recommendations on what and/or how to feed infants and children from birth to 24 months focused on resources from government agencies and from authoritative domestic and international organizations. Guideline documents were found by performing targeted website searches, further supplemented by using the Food and Agriculture Organization of the United Nations’ catalog of food-based dietary guidelines, by leveraging expert input, and by searching databases (e.g., ECRI Institute Guideline Trust, CPG Infobase: Clinical Practice Guidelines, PubMed).
The identified documents and resources varied in span and scope, and they required a screening process to determine whether the guideline document contained feeding recommendations and, if so, which of the recommendations addressed the concepts of what or how to feed infants and young children. To that end, the committee established guideline document-level and recommendation-level eligibility criteria (see Table S-1).
TABLE S-1 Guideline Document- and Recommendation-Level Eligibility Criteria
| Level | Inclusion Criteria | Exclusion Criteria |
|---|---|---|
| Guideline document-level eligibility criteria |
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TABLE S-1
| Level | Inclusion Criteria | Exclusion Criteria |
|---|---|---|
| Recommendation-level eligibility criteria |
|
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NOTE: LEAP = Learning Early About Peanut Allergy.
a Summaries of the state of science in an attempt to make recommendations, but which found inadequate evidence to do so, were considered eligible.
b Countries’ income levels classified using the fiscal year 2020 World Bank classification (https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups; accessed November 8, 2019).
c Recommendations may include the primary prevention of food allergies and other common conditions (e.g., diarrhea, constipation, dental caries). However, recommendations on the treatment of a condition were excluded.
d Recommendations were excluded if they were about preterm infants; clinical treatment of a specific disease or condition; clinical management of lactation; the benefits of breastfeeding; methods for preparing and storing foods, including breastmilk and formula; malnutrition or emergency situations; intake of breastfeeding mothers; or infant formula composition.
e Many agencies, organizations, and groups used the LEAP trial to update feeding guidelines related to the primary prevention of peanut allergy. Inclusion of peanut allergy–related recommendations predating the release of the LEAP trial results would unnecessarily introduce inconsistency and those earlier recommendations were therefore excluded.
The committee abstracted each eligible recommendation verbatim, along with the type of evidence that directly mapped to the recommendation and the associated strength-of-evidence rating, if available. Abstracted recommendations were sorted by topic area and thematically grouped within each topic. Within each theme, the committee reviewed the guidance provided in the verbatim recommendations to describe the level of consistency across guideline documents. The committee also summarized the type of evidence that mapped to each recommendation within a given theme.
For each guideline document, the committee noted any information that the organization included about communicating or disseminating the feeding recommendations. As the available guidance was limited in scope, the committee performed exploratory scans for examples of communication and dissemination materials from the resources and websites reviewed in its guideline document search.
CONSISTENCY OF EXISTING FEEDING RECOMMENDATIONS
The committee identified 156 potentially relevant documents, webpages, and resources through its various search strategies. After applying the eligibility criteria, 43 guideline documents remained to be reviewed in more detail. Included guideline documents reflected the contributions of 26 different 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. Nine of the guideline documents were collaborative efforts between two or more organizations.
The included guideline documents varied with respect to the document type (e.g., position statement, clinical practice reports), level of collaboration across organizations, scope of topics covered, target audiences, overall methodologies, presentation of recommendations, and mapping of evidence to each recommendation. Few guideline documents graded the evidence, and those that did often used different rating systems. This heterogeneity likely contributed to some of the noted inconsistencies found across recommendations.
Comparison of Guidance on What to Feed
The majority of abstracted recommendations provided guidance on what to feed (as opposed to how to feed) infants and young children from birth to 24 months. Eligible recommendations were found in all 43 guideline documents. The committee grouped the recommendations into 18 topic areas, with most topic areas having multiple themes. The committee’s comparison of recommendations on what to feed children from birth to 24 months of age is presented in Table S-2. The type of evidence mapping to each recommendation was varied. Most recommendations mapped to narrative reviews, with fewer mapping to systematic reviews. Some recommendations mapped to other types of evidence (e.g., government reports and websites, single scientific publication) and some could not be mapped to any specific evidence.
Comparison of Guidance on How to Feed
Approximately one-third of the abstracted recommendations provided guidance related to how to feed infants and young children from birth to 24 months of age. Eligible recommendations were found in 23 of the guideline documents. The committee grouped the recommendations into eight topic areas, with most topic areas having multiple themes. The committee’s comparison of recommendations on how to feed children from
TABLE S-2 Summary of the Consistency of Recommendations on What to Feed Infants and Young Children, by Topic Area
| Topic Area | Summary of Consistency Across Recommendations |
|---|---|
| Exclusive breastfeeding |
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| Continuation of breastfeeding |
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| Supplementary formula feedings |
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| Duration of formula use |
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| Type of infant formula |
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| Toddler milks and follow-on formulas |
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| Milk and milk-based products |
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| Fluids: Water, juice, sugar-sweetened beverages, and other nonmilk beverages |
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TABLE S-2
| Topic Area | Summary of Consistency Across Recommendations |
|---|---|
| Fluids: Water, juice, sugar-sweetened beverages, and other nonmilk beverages |
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| Substances to avoid or limitb |
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| Variety and healthy, nutritious foods |
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| Fruits and vegetables |
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| Vegetarian and vegan diet |
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| Foods associated with food allergy and celiac disease |
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| Iron |
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TABLE S-2
| Topic Area | Summary of Consistency Across Recommendations |
|---|---|
| Iron |
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| Vitamin D |
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| Iodine |
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| Other nutrient supplements |
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| Dietary fat |
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NOTE: The committee uses the following phrases to describe consistency of recommendations:
- Consistent indicates alignment across the recommendations.
- Generally consistent indicates that the recommendations tended to provide similar guidance, although there were some differences in details or wording.
- Some inconsistencies indicates mixed recommendations, some of which align.
- Not consistent indicates recommendations provided different guidance on a topic.
a This statement pertains to general use of plant-based beverages. A caveat is noted in the “Vegetarian and vegan diet” section.
b Recommendations regarding foods to avoid or limit based on food safety considerations (e.g., unpasteurized beverages, honey due to the risk of botulism) are summarized in Table S-3 in the “Safety of foods and feeding practices” section.
c A recommendation in a 2010 guideline document predated the acceptance of delayed cord clamping in the United States, which changed iron supplementation recommendations for infants. The statement of consistency reflects only the more recent guideline documents.
d This statement pertains to nutrient supplements generally. Consistency of recommendations related to supplementing specific nutrients are noted elsewhere in the table.
birth to 24 months of age is presented in Table S-3. As was the case with recommendations on what to feed infants and young children, the type of evidence mapping to each recommendation varied, but the recommendations predominantly mapped to narrative reviews.
TABLE S-3 Summary of the Consistency of Recommendations on How to Feed Infants and Young Children, by Topic Area
| Topic Area | Summary of Consistency Across Recommendations |
|---|---|
| Bottle use and propping |
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| Cup use |
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| Safety of foods and feeding practices |
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| Introduction of complementary foods |
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| Food consistency and texture |
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| Meal frequency |
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TABLE S-3
| Topic Area | Summary of Consistency Across Recommendations |
|---|---|
| Hunger and satiety cues |
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| Responsive feeding |
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NOTE: The committee uses the following phrases to describe consistency of recommendations:
- Consistent indicates alignment across the recommendations.
- Generally consistent indicates that the recommendations tended to provide similar guidance, although there were some differences in details or wording.
- Some inconsistencies indicates mixed recommendations, some of which align.
- Not consistent indicates recommendations providing different guidance on a topic.
COMMUNICATION AND DISSEMINATION OF FEEDING RECOMMENDATIONS
The feeding guideline documents reviewed by the committee generally did not describe complex, multisector implementation strategies. Accordingly, the committee focused on information contained within the guideline documents related to changing knowledge, attitudes, and/or behaviors, and the channels by which to spread feeding guidance. Of the 43 eligible guideline documents the committee reviewed, 25 included a statement or section related to communicating or disseminating the feeding recommendations. Most of the guideline documents the committee reviewed were specifically developed for one or more target audiences, with a large majority aimed at health care providers (e.g., physicians, nurse practitioners, nurses, dentists, registered dietitian nutritionists, and other nutrition professionals). Other target audiences included parents and guardians, early care and education providers, program administrators, and policy makers. Communication and dissemination approaches were varied across these different target audiences:
- Health care providers: The guideline documents primarily focused on the health care provider as a critical nexus for guiding caregiver practices. The guideline documents encouraged practitioners to promote awareness, changes in attitudes and knowledge, and adoption of recommendations, and to engage in advocacy.
- Parents and guardians: Although the importance of providing parents and guardians with specific feeding guidance was acknowl-
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edged, these groups were infrequently the target audience for the guideline documents reviewed. A host of online resources is available to parents and guardians, but these materials are sometimes inconsistent in directly mapping back to a guideline document.
- Early care and education providers: Despite being integral players in infant and young child feeding, early care and education providers were often not the target audience of the guideline documents the committee reviewed. The committee notes that, in the United States, this stakeholder group has a key publication that provides national health and safety performance standards, referred to as Caring for Our Children. One of the standards included relates to nutrition and draws on feeding recommendations from authoritative organizations.
- Program administrators: Program administrators were also not a primary target audience for most of the included guideline documents. The Child and Adult Care Food Program and the Special Supplemental Nutrition Program for Women, Infants, and Children are two key federal programs in the United States that integrate feeding recommendations into practice. Although the committee did not find an eligible guideline document from or for these programs, it did identify recent key resources that translated feeding recommendations, national policy, and federal regulations into programmatic guidance.
- Policy makers: Some of the guideline documents reviewed included recommendations targeting policy makers. The level of detail provided for this target audience varied. For instance, one organization expressed strong support for national policies and legislation related to the feeding recommendations, whereas another guideline document provided explicit guidance to the government.
The guideline documents the committee reviewed were limited in their descriptions of best practices or approaches to communication and dissemination of the feeding recommendations. There is a need to better understand effective communication and dissemination techniques for each of the target audiences, with special consideration of issues of equity, especially in light of an increasing recognition of the association between social determinants of health and persistently observed health disparities, the changing landscape of mobile health devices and applications, and the role of social networks in influencing knowledge, attitudes, and behaviors.
CONCLUSIONS AND FUTURE DIRECTIONS
Across the 26 topic areas related to what to feed and how to feed infants and young children, the committee found that many of the recommendations from the various organizations were consistent or generally consistent. When there was inconsistency, it often related to the specific ages or age ranges stated in the recommendation. Although the committee found considerable variability in the wording of recommendations, in many cases, the differences in wording were subtle.
Overall, recommendations often mapped to narrative reviews. Within most of the themes, at least one of the recommendations for that theme mapped to a systematic review. For some themes, the committee was unable to map a few of the recommendations to the evidence, and for others, the guideline document indicated that there was little or no evidence to support a recommendation. In almost all cases, the body of evidence for a given recommendation was not formally graded.
As many organizations had recommendations on the same topics, and many recommendations were generally consistent, there is substantial potential for harmonization using a collaborative approach. Collaboration on feeding guidelines, starting at the development phase and continuing through the dissemination phase, is likely to facilitate the harmonization of guidance. Harmonization of the process for developing feeding guidelines does not necessarily imply that the specific feeding recommendations need to be exactly the same across countries, communities, and professional organizations. In fact, the need to customize guidance for particular target audiences and contexts means that some of the wording of recommendations may vary, especially in the dissemination and communication products.
Harmonizing the Development of Future Feeding Guidelines
Across the collection of guideline documents reviewed, the committee identified a range of methodological approaches taken to develop feeding recommendations. This heterogeneity has implications for the consistency and quality of guideline documents, and it underscores the need to consider ways to harmonize the process. Based on its review and comparison of feeding recommendations, along with its collective expertise, the committee offers insight to help align and improve future guidelines.
Preparing to Develop the Guidelines
When developing feeding guidelines, there are several potential advantages of using a collaborative approach that involves multiple organizations
from the start of the process. If a formal systematic review of the evidence is to be conducted, this process can be centralized so that all of the organizations or a consortium of organizations make use of the resulting review, potentially enhancing both quality and efficiency. Collaboration between organizations can also facilitate development of uniform standards for quality guidelines, avoid duplication of effort in generating recommendations, and establish consensus across organizations. Including key stakeholders, communication experts, and representatives of the target audience at the beginning stages can help to ensure that the final product is appropriately designed and disseminated.
Developing the Guidelines
Published criteria on developing high-quality guidelines stipulate that a range of best practices related to the guideline development process, review, and dissemination be consistently considered during each step and specified in the guideline document. Within the guideline document, recommendations need to be identifiable, specific, unambiguous, and explicitly linked to supporting evidence.
Planning for Dissemination and Implementation of Guidelines
Timely and effective dissemination of evidence-based recommendations is critical to bridge the practice chasm and improve feeding practices and health and developmental outcomes for infants and young children. Effective strategies are needed to support communication and dissemination of feeding guidance, and to promote the systematic uptake of guidelines.
Incorporating principles of dissemination and implementation (D&I) science may speed up the translation and application of recommendations. By identifying key influences on the adoption, implementation, and sustainability of interventions, D&I science provides vital information about how, when, by whom, and under what circumstances evidence spreads, both within or by organizations, and affects the intended population. Documenting any adaptations that are made in response to the local context and target audience can guide future D&I efforts for feeding guidelines, taking equity principles into account.
Thus, the committee recommends that agencies, organizations, and groups developing guideline documents related to feeding infants and young children should consider the principles of dissemination and implementation science as a means to enhance the reach and impact of the feeding recommendations that are developed.
CONCLUDING REMARKS
In spite of all of the differences in the ways that guideline documents were developed, it is encouraging that there was consistency for the majority of recommendations across a variety of authoritative organizations. For the future, it is important to harmonize the process across organizations and to use more rigorous methods for developing, communicating, and disseminating recommendations for feeding infants and children from birth to 24 months of age.
