Report highlights ‘substantial opportunity to harmonize’ development of feeding guidelines for infant and children up to 2-years-old
The report, Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance, was sponsored by several organizations including the Centers for Disease Control and Prevention, the National Institutes of Health, and the National Academy of Sciences’ W.K. Kellogg Foundation Fund.
Sorting through nutritional guidance on what to feed infants and young children can be confusing for parents, especially as recommendations have changed substantially from decade to decade due to scientific advances, cultural influences, societal trends, and other factors, the report notes.
“Even when guidance comes from authoritative groups, including government, professional, and nonprofit organizations and agencies, there can be inconsistencies in advice owing to differences in approaches taken to develop feeding recommendations,” argue the report authors.
The report is meant to be separate from the forthcoming 2020-2025 Dietary Guidelines for Americas, which will for the first time include feeding guidelines for infants and children under two-years-old, noted Dr. Elizabeth Yates Jimenez, a research associate professor at the University of New Mexico’s health sciences center in the departments of pediatrics and internal medicine and one of number of committee members involved in compiling the report.
However, she told FoodNavigator-USA, “It might be helpful for the federal agencies that are developing the dietary guidelines for Americans’ policy documents to understand the breadth of topics that they might want to consider, but there is no expectation that this report is going to influence the final Dietary Guidelines for Americans.”
The report reviewed 43 guideline documents from 29 different domestic and international authoritative groups to examine how feeding guidelines compare.
Dr. Jimenez emphasized that the report is not seeking to rule which feeding practices are best for a child under two-years-old, but instead aims to compare and summarize existing feeding recommendations for this age group, document the type of evidence used to support each recommendation, and examine if and how existing guideline documents describe approaches to communication and dissemination of the feeding recommendations.
Addressing inconsistencies in guidelines
The report reviewed 26 topics related to feeding children under two-years-old, from exclusive breastfeeding and infant formula use to toddler milks and vegetarian and vegan diets.
While the committee found generally consistent recommendations across the topics, the report did highlight some inconsistencies on specific ages or age ranges stated in some of the recommendations.
For example, when it came to infant formula consumption, the recommendations varied and inconsistencies related to specific age ranges were prominent, the report noted.
Most recommendations stated that infant formula should not be substituted for breastmilk until 12 months of age, while one guideline allowed for introduction of formula beginning at nine months. Similarly, some recommended delaying any cow’s milk until after 12 months, while others stated that cow milk could be introduced at 9–12 months or even as early as 6 months.
Authors commented that research would be useful to evaluate the consequences of replacing infant formula with cow milk at 9 months versus 12 months among formula-fed infants and partially breastfed infants
In the US specifically, duration of the need for iron-fortified formulas advised until 6 months, 9 months, or 12 months differed.
“Research on this issue would need to take into account the relatively large amounts of iron currently added to infant formula in the United States, and the role of iron-fortified complementary foods,” the report stated.
Introducing peanuts
When it came to peanut-containing foods and peanut allergies, the committee reviewed five guideline documents, which all referred to the Learning Early About Peanut Allergy (LEAP) trial, and identified eight statements of recommendations.
“The guideline documents were not consistent in recommending when and how to introduce peanuts based on the infant’s risk for peanut allergy,” the report stated, noting inconsistencies in regards to what age to begin introducing peanut-containing foods and in what format (e.g. paste, powder, snack puff), the report noted.
“Some organizations made recommendations about the timing of introduction of peanuts based on the infant’s risk of peanut allergy, while others did not differentiate on that basis,” noted the authors.
Seeking harmonization in development, dissemination, and implementation process of guidelines
“There’s really an opportunity to harmonize the development of future guidelines which would maximize available resources and effort,” Dr. Jimenez said.
Organizations involved in developing feeding guidelines should employ the principles of dissemination and implementation (D&I) science – an emerging area – into the guidance development process to maximize the uptake of these guidelines, noted Dr. Jimenez.
“There’s a lot of work that goes into the development of recommendations, but if the resources are not invested in the dissemination and implementation pieces, they won’t have the impact that everyone is likely hoping for,” said Dr. Jimenez.
She also clarified that harmonization does not necessarily imply feeding recommendations should be exactly the same across communities and audiences for the guidelines.
“Harmonizing the process for developing guidelines doesn’t necessarily mean that every organization’s feeding recommendations need to have the exact same wording. We definitely recognize that recommendations need to be tailored for a particular audiences and local context,” said Dr. Jimenez.
“There needs to be tailoring of the recommendations, particularly in the communication and dissemination phase.”
Authors of the report advocated for a “collaborative approach” that involves multiple organizations from the start of the process to facilitate development of uniform standards for quality guidelines, avoid duplicative efforts, and establish consensus across organizations.
Authors of the report added, “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.”
To learn more about the report's findings and recommendations from the committee, register for the National Academies of Sciences, Engineering, and Medicine's Report Release Webinar at 11 a.m. EST TODAY, July 8, 2020.
