Sep 1, 2019 — pdf. 44 American Academy of Pediatrics, Committee on Nutrition. Feeding the child. In: Kleinman RE, Greer F, eds.
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Healthy Beverage Consumption in Early Childhood | September 2019 1INTRODUCTIONEstablishing healthy dietary patterns in early childhood (0˜to 5 years) is important to help prevent future diet-related chronic diseases, as well as to support optimal physical and cognitive growth and development and overall health. 1-4 Healthy beverage intake is critical in early childhood as beverages can make a signi˚cant contribution to dietary intake during this period,5 and thus may serve as important sources of essential nutrients. However, many beverages also contain added sugars and saturated fats, which can be harmful when consumed in excess. 6 Overconsumption of unhealthy beverages along with inadequate consumption of healthy beverages in early childhood can contribute to risk of diet-related chronic diseases, such as obesity, type 2 diabetes, or dental caries. 7 ˛is makes beverages a critical target for improving the health and well-being of infants and young children. Despite the importance of healthy beverages in early childhood, many young children™s beverage intakes diverge from evidence- based recommendations. For example, many infants consume milk and 100% juice before their ˚rst birthday, which can increase their risk for nutrient de˚ciencies, such as anemia. 6 Among 2 to 5-year-olds, close to half (44%) consume a sugar- sweetened beverage (SSB) daily, 8 and the prevalence of SSB consumption increases throughout childhood. 5 ˛ere are also signi˚cant di˝erences in beverage intake by race/ethnicity and income groups in early childhood that need to be addressed. 9,10BACKGROUNDMany authoritative bodies have issued guidance and recommendations for healthy beverage intake, 5,11,12 but important gaps exist as these recommendations have not been comprehensive in the age groups covered or in the types of beverages discussed. ˛ere also are inconsistencies in certain aspects of existing recommendations, such as suggested consumption amounts or recommended ages for introduction, potentially contributing to misunderstanding among health care providers, parents, and caregivers. Given the importance of beverage consumption in early childhood and the need for comprehensive and consistent evidence-based recommendations, Healthy Eating Research (HER), a national program of the Robert Wood Johnson Foundation (RWJF), convened an expert panel representing 4 key national health and nutrition organizations to develop comprehensive recommendations for beverage consumption consistent with a healthy diet for children from birth to age˜5. ˛e 4 organizations represented on the expert panel are (in alphabetical order) the Academy of Nutrition and Dietetics (AND), the American Academy of Pediatric Dentistry (AAPD), the American Academy of Pediatrics (AAP), and the American Heart Association (AHA). ˛e resulting recommendations focus exclusively on beverage consumption among 0 to 5-year-olds and support a life course approach to the development of healthy dietary patterns and prevention of chronic disease. ˛e expert panel did not address breast milk or infant formula as recommendations in these areas vary by the infant™s age, weight, and developmental milestones, and are generally well understood and widely accepted. For detailed recommendations on these topics, please refer to Pediatric Nutrition from the American Academy of Pediatrics and HER™s Feeding Guidelines for Infants and Young˜Toddlers .12,13Healthy Eating Research September 2019 CONSENSUS STATEMENT Healthy Beverage Consumption in Early ChildhoodRecommendations from Key National Health and Nutrition Organizations

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Healthy Beverage Consumption in Early Childhood | September 2019 2DEFINITIONS100% Juice Beverage made from the extraction or pressing of the natural liquid found in fruits or vegetables; 100% juice means that everything in the container came from a fruit or vegetable with no added sugars or arti˚cial ingredients. Beverages with Low-Calorie Sweeteners (LCS) Beverages with no- or reduced-calorie sweeteners. ˛e term LCS includes the six high-intensity sweeteners currently approved by the U.S. Food and Drug Administration as food additives (saccharin, aspartame, acesulfame-K, sucralose, neotame, and advantame) and 2 additional high- intensity sweeteners permitted for use in the food supply (steviol glycosides and monk fruit). Other terms for LCS include non-nutritive sweeteners, arti˚cial sweeteners, and sugar substitutes. 14Ca˜einated Beverages Drink that contains ca˝eine, a legal stimulant that is mildly addictive. Common ca˝einated beverages include co˝ee, tea, soft drinks, and energy drinks.Flavored Milk Cow™s milk to which caloric sweeteners have been added for the main purpose of improving palatability. Common examples include chocolate milk or strawberry milk. ˛ese products have also been referred to as sweetened˜milk. Plain Drinking Water Un˙avored, unsweetened, uncarbonated, ˙uoridated drinking water. Plain, Pasteurized Milk Cow™s milk that has been heated to a speci˚ed temperature and for a speci˚c length of time to kill pathogens that may be found in raw milk, and to which no caloric sweeteners, arti˚cial sweeteners, or ˙avorings have been added. Common varieties include whole milk (also known as Vitamin D milk), reduced fat (2%), low-fat (1%), and skim˜(fat-free). Plant Milks/Non-Dairy Beverages Non-dairy, alternative milk beverages that are derived from plant-based ingredients (e.g., rice, nuts/seeds, coconut, oats, peas, or blends of these ingredients) and often forti˚ed with nutrients found in dairy milk. Many plant milks come in both sweetened and unsweetened varieties; sweetened varieties generally contain added sugars. Sugar-Sweetened Beverages (SSB) Liquids to which any forms of sugar are added. ˛is category does not include beverages sweetened with low-calorie sweeteners (see de˚nition for fiBeverages with LCSfl), 100% juice, or ˙avored dairy and/or plant-based milks.Toddler Milk Milk drink supplemented with nutrients and often contains added sugars.15 ˛ese products are marketed as appropriate for children ages 9 to 36 months, and may be marketed as fitransition formulas,fl fifollow-on formulas,fl or fiweaning formulasfl for children 9 to 24 months and fitoddler˜milk,” figrowing-up milk,fl or fiyoung˜child˜milkfl for children ages 12˜to˜36˜months.16Whole Fruit Fresh, frozen, canned, and dried forms of fruit that do not have added caloric or low-calorie˜sweeteners. 5

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Healthy Beverage Consumption in Early Childhood | September 2019 3METHODOLOGYHER used a multi-step process to develop the evidence-based recommendations detailed below: ^ Convening an expert panel of representatives from 4 national health and nutrition organizations, as well as a scienti˚c advisory committee; _ Conducting an extensive review of approximately 50 existing source documents and reports from domestic and international authoritative bodies on recommendations and guidance for beverage consumption during early childhood; ` Conducting structured narrative scienti˚c literature reviews for beverages where there was a lack of existing recommendations or where recommendations were incomplete or inconsistent; a Hosting in-person and virtual expert panel meetings to discuss preliminary consensus recommendations based on available evidence gathered in steps 2 and 3; and b Developing and reviewing ˚nal consensus recommendations by expert panelists and scienti˚c advisory committee members.˛e expert panel was comprised of 2 representatives from each of the 4 national health and nutrition organizations, a chair, and a research consultant. Panelists were experts in pediatrics, nutrition, and dentistry. HER also recruited a scienti˚c advisory committee of 6 individuals with extensive expertise in establishing dietary guidance, early childhood nutrition, and nutrition science. ˛e scienti˚c advisory committee provided input on the background research strategy and protocols, identi˚ed important resources or papers to be included in the technical report and consensus statement, and reviewed the ˚nal consensus recommendations for scienti˚c rigor and accuracy. ˛e expert panel met approximately 1-2 times per month over a 6-month period, and also held an in-person meeting to review the evidence, discuss gaps, conduct literature reviews, agree on research terms and content, and develop the ˚nal consensus˜recommendations. For additional details on the consensus process and methodology, technical-scienti˚c-report-healthy-beverage-consumption-in- early-childhood-recommendations-from-key-national-health-and- nutrition-organizations/.SUMMARY OF KEY PANEL FINDINGS AND RECOMMENDATIONS 0-6 months6-12 months12-24 months2-3 years4-5 yearsPlain drinking waternot needed0.5-1 cups/day1-4 cups/day1-4 cups/day1.5-5 cups/dayPlain, pasteurized milknot recommended 2-3 cups/day whole milk skim or low-fat milk skim or low-fat milk100% juicenot recommended Plant milks/Non-dairy˜beveragesnot recommended medical indication/dietary reasons only Flavored milk not recommended Toddler milk not recommended Sugar-sweetened beverages (SSB)not recommended Beverages with low-calorie sweeteners (LCS)not recommended Caffeinated beverages not recommended Full key panel ˚ndings and recommendations listed in Appendix A on page 14.

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Healthy Beverage Consumption in Early Childhood | September 2019 4Plain Drinking Water and Overall Hydration Expert Panel Recommendations 0-6 months: No supplemental drinking water needed. 6-12 months: O˝er a total of ½ to 1 cup (4-8 ounces) per day of plain, ˙uoridated drinking water in a cup during meal times. 1-3 years (12-36 months): 1 to 4 cups (8-32 ounces) per day of plain, ˙uoridated drinking water*. 4-5 years (37-60 months): 1.5 to 5 cups (12-40 ounces) per day of plain, ˙uoridated drinking water*. *˛e speci˚c 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 ˙uid 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 suˆce to meet total ˙uid needs.If 100% juice is consumed, this additional ˙uid should also be factored into the amount of plain drinking water to consume. If plain drinking water is the only ˙uid consumed to meet total ˙uid needs, careful dietary planning is essential to promote adequate nutrient intake from foods. Rationale Water is essential for life, yet there is no single daily requirement of total water or ˙uid for a given person. Individual ˙uid needs vary on a day-to-day basis because of di˝erences in physical activity, climate, and other foods and beverages consumed. 17 Furthermore, the human body is generally able to compensate for some degree of over- and under-hydration in the short term, and thus, normal hydration can be maintained over a range of water intakes.Due to this variation in an individual™s total water needs, the expert panel proposed ranges of plain water intake that are dependent on the amount of other recommended beverages consumed throughout the day. Infants younger than 6 months of age need only breast milk or infant formula to maintain adequate ˙uid intake. 11 For˜6 to 12-month-olds, o˝ering a small amount of plain water (4-8 ounces total per day) in an open, sippy, or strawed cup is recommended. 12 ˛is drinking water is not intended to replace any amount of breast milk or infant formula, and practically speaking, it is unlikely that much of this drinking water will be ingested as many infants 6 to 12-months-old are still developing cup-drinking skills. ˛is practice is suggested to help familiarize the infant with plain water. ˛e proportion of total daily water intake that is consumed via foods is approximately 30% for children ages 1˜to 3 years and 4 to 8 years. 17 ˛erefore, the expert panel used only 70% of the reference value for recommended total water intakes (based on the Dietary Reference Intakes for water) to calculate the recommended ranges for plain drinking water. It is important to note that individual requirements will be determined based on amounts of other beverages a child consumes (e.g., milk or 100% juice) in a given day. BEVERAGES RECOMMENDED AS PART OF A HEALTHY DIET IN EARLY CHILDHOOD

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Healthy Beverage Consumption in Early Childhood | September 2019 5Plain, Pasteurized Milk Expert Panel Recommendations 0-12 months: Children under 12 months should not consume milk. 12-24 months:Ł At 12 months of age, plain, pasteurized whole milk may be introduced. 2 to 3 cups per day (16-24 ounces) whole milk is recommended until 2 years of age*. Ł 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 (CVD). 2-5 years: Ł At 2 years of age (24 months), children should transition to plain, pasteurized fat-free (skim) or low-fat˜(1%)˜milk. Ł Total daily milk intake may be up to 2 cups per day (16 ounces) for children ages 2 to 3 years and up to 2.5 cups per day (20 ounces) for children ages 4 to 5 years. *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™s 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.Rationale ˛ese recommendations are in alignment with recommendations from the Dietary Guidelines for Americans (DGAs), the˜AAP, and a prior HER expert panel on infant and toddler feeding guidelines. ˛e dairy food group is an important source of calcium, phosphorous, vitamins A and D, B vitamins, and protein. Milk is the number one source of energy, calcium, vitamin A, vitamin D, and zinc for infants and young children, making it a critical component of a healthy diet. 6˛e expert panel recognizes that there has been recent research and discussion regarding the role of dairy fat in healthy dietary patterns; however, in the absence of clear evidence justifying a departure from current recommendations, the panel chose to remain consistent with current guidance recommending whole milk for most children ages 12 to 24 months and fat-free (skim) or low-fat (1%) milk for children ages 2 years and older.

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Healthy Beverage Consumption in Early Childhood | September 2019 7Plant Milks/Non-Dairy Beverages Expert Panel Recommendations 0-12 months: Plant milks/non-dairy beverages are not recommended. 1-5 years (12-60 months): Plant milks/non-dairy 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 speci˚c dietary preferences. Rationale Plant-based milks are growing in popularity, but it is important to note that they are not nutritionally equivalent to cow™s milk. ˛ey have varying nutritional pro˚les based on their plant source and many often contain added sugars. With the exception of soy milk, the DGAs do not include these beverages as part of the dairy group because their overall nutritional content is not similar to dairy foods. ˛e expert panel identi˚ed published analyses of the nutritional composition of plant milks compared to cow™s milk. 22,23 Although plant milks may be forti˚ed to attain similar nutrient levels as cow™s milk, it is not known whether the bioavailability of these added nutrients is comparable to that of their naturally-occurring counterparts in cow™s milk. ˛ese studies concluded that cow™s milk should not be removed from the diets of young children unless there is a medical indication or speci˚c dietary preference, and that non-dairy milk beverages should not be considered adequate nutritional substitutes for cow™s milk until nutrient quality and bioavailability are established. ˛us, the expert panel agrees with the DGAs that plant milks are not generally a good substitute for meeting daily serving recommendations from the dairy food group. For 0 to 12-month-olds, plant milks/non-dairy beverages should not be used as a substitute for breast milk or infant formula. Use of alternative beverages as a major component of the diet during this period has been associated with malnutrition.11 For children 1 to 5 years of age, plant milks may be useful for those with allergies or intolerances to cow™s milk. For those children, the choice to consume plant milk should be undertaken in consultation with a health care provider, such as a pediatrician and/or registered dietitian nutritionist, so that intake of nutrients commonly obtained from dairy milk can be considered in dietary planning. Flavored Milk Expert Panel Recommendations 0-12 months: Do not consume milk (˙avored or plain). 1-5 years (12-60 months): Consume only plain, pasteurized milk*; ˙avored milk is not recommended. *See section on plain milk for amounts and types of plain milk recommended for 1 to 5-year-olds. Rationale Flavored milk contains caloric sweeteners, and the expert panel concurs with the American Heart Association™s recommendation to avoid added sugars for children younger than 2 years old. 24 For older children (ages 2 to BEVERAGES NOT RECOMMENDED AS PART OF A HEALTHY DIET IN EARLY CHILDHOOD

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Healthy Beverage Consumption in Early Childhood | September 2019 85˜years), the expert panel considered it appropriate to recommend avoiding ˙avored milk in order to minimize intake of added sugars and avoid contributing to early establishment of a preference for sweet taste as well as potential negative impacts on nutrient intake and diet quality. ˛e expert panel™s recommendations on ˙avored milk are consistent with the federal Child and Adult Care Food Program (CACFP) nutrition standards, as well as the National Academies of Sciences, Engineering and Medicine recommendation that only un˙avored milk be permitted in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package. 25,26˛e expert panel reviewed literature on the impact of ˙avored milk consumption in early childhood on diet quality, taste preference development, bone density, type 2 diabetes, CVD, and body weight. ˛ere was limited evidence surrounding the health e˝ects of ˙avored milk consumption in 0 to 5-year-olds, and the evidence related to weight and dietary intake was inconsistent. 27-30Toddler Milk Expert Panel Recommendations 0-12 months: Avoid supplementation with fitransitionfl or fiweaningfl formulas; nutrient needs should be met primarily through human milk and/or infant formula. 1-5 years (12-60 months): Toddler milk is not recommended; nutrient needs should be met primarily through nutritionally adequate dietary patterns. Rationale ˛e World Health Organization has called toddler milks or transition formulas unnecessary and unsuitable as a breast milk substitute, and suggests that they undermine sustained breastfeeding up to 2 years and beyond. 31,32 ˛e AAP has noted that follow-up or weaning formulas o˝er no clear advantage for infants consuming suˆcient amounts of iron- and vitamin-containing solid food. 33 Moreover, some toddler milks or transition formulas have added caloric sweeteners. ˛e expert panel did not identify any longitudinal studies on consumption of these beverages in early childhood and their impact on health outcomes. Although there is not currently evidence to indicate that these products are harmful, the expert panel concluded that they o˝er no unique nutritional value beyond what could be obtained with healthy foods; furthermore, they may contribute added sugars to the diet. ˛erefore, they are not recommended as part of a healthy diet in early childhood. If nutrient-rich food intake appears to be inadequate, other strategies to increase food acceptance should be tried ˚rst, such as repeated exposures to healthy foods. Toddler milk and transition formulas are also more expensive than an equivalent volume of cow™s milk. Sugar-Sweetened Beverages (SSB) Expert Panel Recommendations 0-5 years: SSB are not recommended, including, but not limited to, soft drinks/soda, fruit drinks, fruit-˙avored drinks, fruitades, sports drinks, energy drinks, sweetened waters, and sweetened co˝ee and tea˜beverages. 5Rationale Consumption of SSB in early childhood has a negative impact on overall dietary intake and health outcomes, such as dental caries, overweight and obesity, and type 2 diabetes. 7 ˛us, it is prudent to limit children™s

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Healthy Beverage Consumption in Early Childhood | September 2019 9exposure to added sugars in early childhood, and SSB are the largest source of added sugars in young children™s diets.34 Fruit-˙avored drinks (e.g., fruitades, fruit cocktails, fruit punch) are the most commonly consumed SSB in young children. ˛erefore, additional attention should be paid to reducing consumption of these beverages to limit children™s exposure to added sugars in early childhood, including through policy strategies. 35No research has been conducted to examine the impact of SSB consumption in early childhood on the development of ˙avor preferences. However, children™s innate preference for sweetness is well-documented, and it is plausible that early and consistent introduction of SSB could lead to increased preference for sweet foods and beverages and poor diet quality later in life. 7Beverages with Low-Calorie Sweeteners (LCS) Expert Panel Recommendations 0-5 years: Beverages with LCS are not recommended. Rationale ˛e use of LCS in the food supply has increased in recent years alongside demand for lower-sugar products. In 2018, the AHA released a science advisory cautioning against children™s prolonged consumption of LCS beverages, stating fi–there is a dearth of evidence on the potential adverse e˝ects of LCS beverages relative to health bene˚ts.fl 36 ˛e expert panel likewise identi˚ed little evidence regarding the short and long-term health impacts of beverages with LCS, particularly among young children, 37-41 and therefore, concluded that a precautionary approach was prudent. Given that early childhood is a critical developmental period in children™s lives with rapid physical, brain, cognitive, and social growth and development, along with the lack of evidence regarding the short- and long-term health impacts of beverages with LCS in young children, it is this panel™s expert opinion that beverages with LCS should be avoided between the ages of 0 to 5 years. Moreover, it is plausible that given children™s innate preference for the taste of sweetness, frequent early life exposure to and familiarization with highly sweet substances may contribute to their vulnerability to poor dietary habits as they age. Ca˜einated Beverages Expert Panel Recommendations 0-5 years: Do not consume ca˝einated beverages. Rationale Compared to adults, there is less certainty about the safe level of ca˝eine intake in children and adolescents. ˛ere are currently no speci˚c recommendations for ca˝eine intake, and ca˝eine content is not required to be disclosed on nutrition labels, making it diˆcult to gauge intake.Average ca˝eine intakes for children are typically low; however, it is the opinion of this expert panel that ca˝einated beverages should not be consumed among 0 to 5-year-olds due to potential for adverse e˝ects. 42-44

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Healthy Beverage Consumption in Early Childhood | September 2019 10CONCLUSIONSAdequate intake of healthy beverages in early childhood is critical to meeting the nutritional needs of infants and young children and supporting healthy development. Despite e˝orts in recent years to improve beverage intake patterns among children, many children are still not meeting recommendations and disparities in intake persist. ˛e beverage recommendations put forward by this expert panel are based on the best available evidence and provide consistent messages that can be used by health care providers, public health practitioners, and parents and caregivers to improve the beverage intake patterns of infants and young children. ˛is expert panel uncovered many areas requiring additional rigorous research in order to inform future dietary guidance for 0 to 5-year-olds. Researchers should focus future e˝orts on longitudinal studies of the impact of consumption of beverages, such as ˙avored milk, plant milks/non-dairy beverages, and beverages with LCS in early childhood and diet-related disease˜outcomes.˛ese consensus recommendations are a strong basis for practitioners, providers, and advocates to develop tailored materials for a wide variety of stakeholders, such as parents, health care providers, policymakers, and industry representatives. ˛e level of collaboration and consistency among major national health and nutrition organizations represented in these recommendations is unprecedented and has the capacity to make meaningful change and improve the health and well-being of infants and young children throughout the˜United˜States. ACKNOWLEDGEMENTS˛e expert panel was supported by Healthy Eating Research, a˜national program of the Robert Wood Johnson Foundation. We would like to express our gratitude and appreciation to our panel chair (Stephen R. Daniels, MD, PhD), lead research consultant (Emily A. Callahan, MPH, RDN), and to each of the four organizations engaged in this project (in alphabetical order): the Academy of Nutrition and Dietetics (AND), the American Academy of Pediatric Dentistry (AAPD), the American Academy of Pediatrics (AAP), and the American Heart Association (AHA). In addition to appointing two representatives to serve on the expert panel, each organization provided engagement from multiple constituents throughout the project, including: CEOs/Directors, Organizational Presidents, and sta˝ with both content and communications˜expertise. We would also like to thank our Scienti˚c Advisory Committee Members who observed the guidelines™ development process, reviewed and provided input to our methodology, and responded promptly and eˆciently to queries made from the panel. Finally, we would also like to thank Tina Kauh, PhD (Robert Wood Johnson Foundation) and Jennie Day-Burget (Robert Wood Johnson Foundation) for their guidance and counsel throughout the expert panel process. Expert Panel MembersStephen R. Daniels, MD, PhD Chairman of the Department of Pediatrics University of Colorado School of Medicine Expert Panel MembersAcademy of Nutrition and Dietetics Lori J. Bechard, PhD, MEd, RDN Alison Steiber, PhD, RDN American Academy of Pediatrics David Krol, MD, MPH, FAAP Natalie Muth, MD, MPH, RDN, FAAP, FACSM American Academy of Pediatric Dentistry Paul Casamassimo, DDS, MS Jenny Ison Stigers, DMD, FAAPD American Heart Association Marie-Pierre St-Onge, PhD, FAHA, CCSH Laurie Whitsel, PhD, FAHA

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