Feeding Infants and Children from Birth to 24 Months Summarizing Existing Guidance (2020) / Chapter Skim
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4 Existing Recommendations on What to Feed
4 Existing Recommendations on What to Feed
Pages 63-126
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From page 63... ...
• Differences were identified in some topic areas, particularly re lated to the age or age range specified in the recommendation, including ° Age to which breastfeeding should be continued, ° The suitability of cow milk for infants 9–12 months of age, ° When and how to introduce peanuts based on infant's risk for peanut allergy, and ° Age of introduction of iron-rich complementary foods. • Most recommendations mapped to narrative reviews.
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From page 64... ...
. Numerous topics related to what to feed infants and young children did not appear in the eligible guideline documents.
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From page 65... ...
. Two guideline documents included recom 1 Organizations reflected in the guideline documents include AAFP, AAP, AHA, Breastfeeding Committee for Canada, COT, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, PAHO, RCPCH, RWJF-HER, SACN, and WHO.
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From page 66... ...
The rest of the recommendations mapped to narrative reviews and/or technical documents. CONTINUATION OF BREASTFEEDING Eighteen guideline documents included recommendations on the continuation of breastfeeding (see Appendix B, Table B-2)
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From page 67... ...
. The identified guideline documents reflect 18 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with PAHO and WHO.2 How Long Breastfeeding Should Continue Eighteen guideline documents included recommendations related to how long breastfeeding should continue.
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Evidence Base Across the 18 guideline documents, the committee identified 23 statements of recommendation. One of the recommendations that did not specify an age mapped to a systematic literature search (Fewtrell et al., 2017 [ESPGHAN]
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From page 69... ...
. The identified guideline documents reflect four different organizations from Australia, New Zealand, the United Kingdom, and the United States.6 Routine Supplementary Formula Feedings Four guideline documents included recommendations related to supplementary formula feedings.
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From page 70... ...
The identified guideline documents reflect seven different organizations from Australia, Canada, New Zealand, and the United States.7 How Long Infant Formula Should Be Used Five guideline documents included recommendations related to how long infant formula should be used. Four of the guideline documents recommended that, for formula-fed infants, commercial infant formula should be used until 12 months of age (Ministry of Health, 2012; NHMRC, 2012; Pérez-Escamilla et al., 2017 [RWJF-HER]
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From page 71... ...
Cow Milk–Based Infant Formulas Six guideline documents included recommendations related to cow milk–based infant formula. All recommended that cow milk–based infant formula be used for infants receiving formula (Bhatia et al., 2008 [AAP]
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From page 72... ...
Soy-Based Infant Formulas Five guideline documents included recommendations related to the use of soy-based formulas. Soy-based formula was only recommended in special circumstances, such as for infants with a confirmed pathology or specific medical, religious, or cultural needs (Bhatia et al., 2008 [AAP]
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From page 73... ...
TODDLER MILKS AND FOLLOW-ON FORMULAS Six guideline documents included recommendations regarding toddler milks and follow-on formulas (see Appendix B, Table B-6) .10 One of the guideline documents was an RWJF-HER consensus statement that included 10 Considered breast milk substitutes, these are products that are "specifically marketed for feeding infants and young children up to the age of 3 years" (WHO Secretariat, 2016)
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From page 74... ...
. The identified guideline documents, therefore, reflect nine different organizations from Australia, Canada, Europe, New Zealand, and the United States.11 Use of Toddler Milks or Follow-On Formulas Six guideline documents included recommendations related to the use of toddler milks or follow-on formulas.
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From page 75... ...
The identified guideline documents reflect 15 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with WHO.13 12 This section does not include milk-based infant formulas or human milk. 13 Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, RWJF-HER, SACN, and WHO.
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14 Another AAP guideline document stated that donor milk is an alternative to mother's breast milk, in the context of exclusive breastfeeding (AAP Section on Breastfeeding, 2012)
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Appropriate Fat Content of Milk for Children 12–24 Months of Age Ten guideline documents included recommendations related to the appropriate fat content of milk for children 12–24 months of age. Nine guideline documents recommended intake of whole cow milk for children 12–24 months of age (Baker et al., 2010 [AAP]
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From page 78... ...
. Another guideline document recommended offering 500 mL of milk per day, but limiting it to no more than 750 mL per day (Health Canada et al., 2014)
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FLUIDS: WATER, JUICE, SUGAR-SWEETENED BEVERAGES, AND OTHER NONMILK BEVERAGES17 Seventeen guideline documents included recommendations regarding water, juice, sugar-sweetened beverages, and other nonmilk beverages (see 17 This section does not include recommendations related to infant formulas. One recom mendation on beverages containing low-calorie sweetener has been omitted from this section, but it is discussed in the "Substances to Avoid or Limit" section later in this chapter.
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From page 80... ...
Accordingly, the identified guideline documents reflect 17 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with PAHO and WHO.18 Water and Fluid Needs Ten guideline documents included recommendations related to water and fluid needs. Recommendations varied by age of the infants and young children.
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From page 81... ...
could not be mapped to its evidence. Juice Fifteen guideline documents included recommendations related to juice.
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. Four guideline documents included recommendations specific to toddlers.
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Evidence Base Across the 15 guideline documents, the committee identified 23 statements of recommendation. Twelve of the recommendations mapped to narrative reviews or technical documents, either alone or in combination with other resources.
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. However, a recommendation in one collaborative guideline document from Canada was to "advise limiting" sweetened beverages (Health Canada et al., 2014)
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could not be mapped to its evidence. Coffee and Tea Five guideline documents included recommendations that referred to coffee and tea.
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From page 86... ...
The recommendations mapped to narrative reviews, technical consultations, and/or a technical background document. Caffeinated Beverages Two guideline documents included recommendations that specifically referenced beverages that are "caffeinated" (Lott et al., 2019 [RWJF-HER]
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From page 87... ...
. Plant-Based Beverages Six guideline documents included recommendations on plant-based beverages (Health Canada et al., 2014, 2015; Lott et al., 2019; Ministry of Health, 2012; NHMRC, 2012; Pérez-Escamilla et al., 2017)
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From page 88... ...
Recommendations related to this topic are summarized in Chapter 5, "Safety of Foods and Feeding Practices." 33 Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, Breastfeeding Committee for Canada, CPS, Dietitians of Canada, ESPGHAN, Health Canada, New Zealand Dental Association, New Zealand Ministry of Health, NHMRC, NICE, RWJF-HER, and SACN.
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From page 89... ...
. Limiting Consumption of Sugars Two guideline documents included recommendations related to limiting consumption of sugars.
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Preparing Foods Without Added Sugars Seven guideline documents included recommendations related to not adding sugar to foods being prepared for infants (Fewtrell et al., 2017 [ESPGHAN] ; Fidler Mis et al., 2017 [ESPGHAN]
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The rest of the recommendations mapped to narrative reviews, either alone or in combination with other resources. Offering Pre-Prepared Foods and Snacks with No or Limited Added or Total Sugars Seven guideline documents included recommendations related to offering pre-prepared foods and snacks with no or limited added or total sugar to young children.
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and to a rapid review. Consuming Foods with Sugars at Mealtimes Instead of Snacks Four guideline documents included recommendations related to timing of consumption of foods with sugars, if consumed.
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mapped to the New Zealand Dental Association (2008) guideline document recommendation, which in turn mapped to an earlier 2008 New Zealand Ministry of Health guideline.
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Evidence Base Across the six guideline documents, the committee identified seven statements of recommendation. The recommendation from the ESPGHAN guideline document (Fewtrell et al., 2107)
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The rest of the recommendations mapped to narrative reviews. VARIETY AND HEALTHY, NUTRITIOUS FOODS Ten guideline documents included recommendations related to healthy eating patterns, encompassing eating a variety of healthy, nutrient-dense foods within and across food groups (see Appendix B, Table B-10)
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. TABLE 4-1 Aspects of Dietary Variety or Diversity Mentioned in Recommendations from Eligible Guideline Documents Foods Variety and Frequency in Food of Food Nutritious Amounts Organization(s)
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. For instance, one guideline document from the New Zealand Ministry of Health recommended offering a "wide variety of vegetables and fruit including dark-green leafy vegetables … and yellow, red, and orange vegetables" (Ministry of Health, 2012)
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FRUITS AND VEGETABLES Eight guideline documents included recommendations related to feeding fruits and vegetables (see Appendix B, Table B-11)
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Most of the recommendations mapped 43 Organizations reflected in the guideline documents include AAP, ESPGHAN, New Zea land Ministry of Health, NICE, PAHO, RWJF-HER, SIAIP, SIGENP, and WHO.
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From page 100... ...
. The identified guideline documents reflect 11 different organizations from Australia, Canada, Europe, New Zealand, and the United States, along with PAHO and WHO.44 44 Organizations reflected in the guideline documents include AAP, AAPD, AHA, AND, CPS, ESPGHAN, New Zealand Ministry of Health, NHMRC, PAHO, RWJF-HER, and WHO.
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From page 101... ...
Two guideline documents -- one from CPS, the other from the New Zealand Ministry of Health -- also provided recommendations about specific types of foods to include in vegetarian or vegan diets (Amit et al., 2010; Ministry of Health, 2012)
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From page 102... ...
Use of Soy-Based Formulas for Nonbreastfed Infants When a Vegetarian or Vegan Diet Is Selected48 Two guideline documents -- one from AAP and one from the New Zealand Ministry of Health -- stated that for infants who are not breastfed or are partially breastfed, soy-based formulas are recommended when a 48 Recommendations related to soy-based infant formula use are more broadly reviewed in the "Type of Infant Formula" section earlier in this chapter.
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Evidence Base Across the two guideline documents, the committee identified three statements of recommendation that all mapped to narrative reviews. Use of Plant-Based Beverages When a Vegetarian or Vegan Diet Is Selected49 Two guideline documents mentioned plant-based beverages for young children when a vegetarian or vegan diet is selected, one explicitly (Lott et al., 2019 [RWJF-HER]
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mapped to the DGA. FOODS ASSOCIATED WITH FOOD ALLERGY AND CELIAC DISEASE Ten guideline documents included recommendations regarding the consumption of foods associated with food allergy and celiac disease (see Appendix B, Table B-13)
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Peanut-Containing Food and Peanut Allergy Five guideline documents included specific recommendations about timing of introduction of peanut-containing foods and peanut allergy. All of the recommendations referred to the Learning Early About Peanut Allergy (LEAP)
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Eggs and Egg Allergy Three guideline documents included specific recommendations related to the introduction of eggs and egg allergy. Though AAP recommended earlier
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Other Specific Allergenic Foods52 and Food Allergies Two guideline documents included specific recommendations about the consumption of allergenic foods, other than eggs or peanuts. The RWJF-HER guideline document stated that dairy products (e.g., yogurt, cow milk protein formula)
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mapped to a narrative review. Gluten-Containing Foods and Celiac Disease Three guideline documents included recommendations related to the introduction of gluten-containing foods and celiac disease.
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. The identified guideline documents reflect 14 different organizations from Australia, Canada, Europe, New Zealand, the United Kingdom, and the United States, along with WHO.54 54 Organizations reflected in the guideline documents include AAFP, AAP, ABM, Breastfeed ing Committee for Canada, CPS, Dietitians of Canada, EFSA, ESPGHAN, Health Canada, New Zealand Ministry of Health, NHMRC, RWJF-HER, SACN, and WHO.
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A CPS guideline document recommended that the introduction of iron-rich complementary foods between 4 and 6 months could be considered when there is high risk for iron deficiency anemia and the infant is developmentally ready (Unger et al., 2019)
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could not be mapped to their evidence. Iron-Fortified Formulas Six guideline documents included recommendations related to ironfortified formulas.
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Medicinal Iron Supplements Seven guideline documents included recommendations regarding the use of medicinal iron supplements. A guideline document from AAP (Baker et al., 2010)
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, and the narrative review also noted the importance of normal maternal iron status and adequate fetal iron stores. The most recent CPS guideline document recommended no iron supplementation for healthy term infants with no risk factors who are exclusively breastfed for 6 months, but it promoted delayed cord clamping in the narrative review to reduce iron deficiency (Unger et al., 2019)
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. Evidence Base Across the five guideline documents, the committee identified six statements of recommendation.
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VITAMIN D Twelve guideline documents included recommendations related to vitamin D (see Appendix B, Table B-15)
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Both mapped to narrative reviews. Vitamin D Supplementation Independent of Breastfeeding Status Three guideline documents included recommendations related to vitamin D for infants 0–12 months without regard to their breastfeeding status.
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Evidence Base Across the three guideline documents, the committee identified three statements of recommendation that all mapped to narrative reviews. Vitamin D Supplementation for Children 12–24 Months of Age Four guideline documents included recommendations related to vitamin D supplementation for children 12–24 months of age.
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IODINE Two guideline documents included recommendations related to iodine (see Appendix B, Table B-16)
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OTHER NUTRIENT SUPPLEMENTS Seven guideline documents included recommendations related to other nutrient supplements, beyond iron, vitamin D, and iodine (recommendations related to supplementation of these nutrients are described in the preceding sections) (see Appendix B, Table B-17)
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Evidence Base Across the five guideline documents, the committee identified seven statements of recommendation. Most recommendations mapped to narrative reviews, technical documents, or background documents.
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All recommendations mapped to narrative reviews, background documents, or technical documents. 58 Organizations reflected in the guideline documents include Breastfeeding Committee for Canada, CPS, Dietitians of Canada, Health Canada, New Zealand Ministry of Health, NHMRC, PAHO, RWJF-HER, and WHO.
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From page 122... ...
was embedded in a broader recommendation; the portion specifically related to saturated fat could not be mapped to its evidence. SUMMARY Guideline documents from government agencies and authoritative organizations provide a wide range of recommendations related to what to feed infants and young children.
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From page 123... ...
EXISTING RECOMMENDATIONS ON WHAT TO FEED 123 TABLE 4-3 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 • Generally consistent in terms of recommending exclusive breastfeeding breastfeeding for up to, about, or around 6 months of age Continuation of • Generally consistent in being in support of continuing breastfeeding breastfeeding for at least 12 months • Not consistent in terms of the specific age to which breastfeeding should be continued Supplementary • Consistent in indicating that breastfed infants should not be routinely formula feedings given supplementary formula feedings Duration of • Generally consistent in recommending that, for formula-fed infants, formula use commercial infant formula should be used until 12 months of age • Consistent in indicating that infant formula is not needed beyond 12 months of age Type of infant • Consistent in recommending cow milk–based infant formulas for formula formula-fed infants • Consistent in recommending that the use of soy-based formula be limited to special circumstances Toddler milks • Consistent in recommending against the general use of toddler milks and follow-on formulas Milk and milk- • Generally consistent in recommending against cow milk before 9 based products months of age • Not consistent regarding suitability of cow milk for infants 9–12 months of age • Not consistent in whether milk can be added to complementary foods before 12 months of age • Generally consistent in indicating that whole milk should be provided to children in the age range of 12–24 months • Consistent in indicating that the amount of cow milk should be limited for children 12–24 months of age • Some inconsistencies in the recommended limit for the amount of cow milk for children 12–24 months of age • Consistent in recommending against providing flavored milk to infants and young children Fluids: Water, • Consistent in discouraging the provision of water to breastfed infants juice, sugar- 0–6 months of age sweetened • Consistent in recommending provision of water to infants 6–12 beverages, and months of age and children older than 1 year other nonmilk • Generally consistent in stating that juice should not be provided in the beverages first 12 months of life continued
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From page 124... ...
124 FEEDING INFANTS AND CHILDREN FROM BIRTH TO 24 MONTHS TABLE 4-3 Continued Topic Area Summary of Consistency Across Recommendations Fluids: Water, • Generally consistent in recommending that juice intake for toddlers juice, sugar- not exceed 4 ounces per day sweetened • Consistent in recommending against providing infants and young beverages, and children with sugar-sweetened beverages other nonmilk • Consistent in recommending against providing coffee, tea, and beverages caffeinated beverages to infants and young children (continued) • Generally consistent in recommending against providing plant-based beverages to infants or young childrena Substances to • Consistent in recommending that foods for infants and young children avoid or limitb should be prepared without added sugars • Consistent in recommending that if pre-prepared foods and snacks are offered to young children, they should contain no or limited added or total sugars • Consistent in recommending that if foods with sugars are consumed, they should be consumed at mealtimes instead of as snacks • Consistent in advising against dipping pacifiers or bottle teats in substances with sugars • Consistent in recommending that foods for infants and young children be prepared without adding salt • Consistent in recommending that if pre-prepared foods and snacks are offered to young children, they should contain no or limited salt Variety and • Consistent in recommending that a variety of foods and food groups, healthy, nutritious textures, and flavors can help meet nutritional requirements foods Fruits and • Consistent in recommending consumption of a variety of fruits and vegetables vegetables Vegetarian and • Consistent in stipulating the need for a carefully planned diet to meet vegan diet requirements for several key nutrients • Some inconsistencies in explicitly mentioning a need for fortified products or nutrient supplements for vegans • Generally consistent in mentioning plant-based beverages as an option for toddlers in the context of specific dietary preferences Foods associated • Consistent in recommending that introduction of potentially allergenic with food allergy foods should not be delayed and celiac disease • Not consistent in recommending when and how to introduce peanuts based on the infant's risk for peanut allergy • Generally consistent in recommending not delaying introduction of allergenic food beyond 6 months of age, including eggs Iron • Consistent in acknowledging the importance of iron-rich complementary foods • Not consistent in recommended age of introduction of iron-rich complementary foods • Consistent in recommending that formula-fed infants be given iron fortified infant formulas until at least 6 months of age
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From page 125... ...
are summarized in Chapter 5, "Safety of Foods and Feeding Practices," and Table 5-2. 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.
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