Consultation outcome

Summary of draft report: Feeding young children aged 1 to 5 years

Updated 4 July 2023

Introduction

Between 1974 and 1994, the Committee on Medical Aspects of Food and Nutrition Policy (COMA) published a series of reports on infant feeding practices in the UK and made recommendations for infant and young child feeding. The last of these reports, Weaning and the weaning diet was published in 1994 and has been the basis for much of the advice on feeding young children in the UK.

Subsequent recommendations made by the Scientific Advisory Committee on Nutrition (SACN) and by international expert committees have carried implications for current infant feeding policy. These include the adoption of World Health Organization (WHO) Growth Standards (SACN/RCPCH, 2007; WHO MGRS, 2006a; WHO MGRS, 2006b) and revisions to energy requirements (FAO, 2004; SACN, 2011a).

Accordingly, SACN requested its Subgroup on Maternal and Child Nutrition (SMCN) to review recent developments in this area. To complement this work, the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) was asked by the Department of Health and Social Care (DHSC) to conduct a review of the risks of toxicity from chemicals in the diets of infants and young children, and to examine the evidence relating to the influence of the infant diet on development of allergic and autoimmune disease.

This draft report covers the period from 12 to 60 months of age (1 to 5 years). It forms part of a wider piece of work considering the scientific basis of current recommendations for feeding children up to 5 years of age, of which the first part, Feeding in the first year of life, was published in 2018.

In keeping with SACN’s terms of reference, this draft report is restricted to risk assessment and only evidence in young children in health has been considered. The draft report considers evidence identified on:

• young child energy, macronutrient and micronutrient requirements
• eating and feeding behaviours
• dietary patterns and consumption of individual foods
• weight status
• oral health
• risks of chemical toxicity arising from the young child diet

In line with the SACN Framework for the Evaluation of Evidence (SACN, 2012; SACN, 2020), the draft report does not provide advice on how recommendations are taken forward for policy, that is, risk management. The role of government, the health service, and non-governmental organisations in protecting, promoting and supporting breastfeeding fall under risk management and are not in the scope of this draft report.

This draft report was developed using SACN process and was signed off by SACN.

Terms of reference

The terms of reference for this review are defined below:

• to review the scientific basis of current recommendations for complementary and young child feeding up to 5 years (60 months) of age.^{[footnote 1]} This draft report covers young children aged 1 to 5 years of age^{[footnote 2]}
• to consider evidence on developmental stages and other factors that influence eating behaviour and diversification of the diet in the early years
• to review the nutritional basis for current dietary recommendations applying to breastfeeding mothers (where relevant to the health of the infant)^{[footnote 3]}
• to make recommendations for policy, practice and research

As noted above, this draft report is the second part of SACN’s review of the scientific basis of recommendations for feeding young children under 5 years, the first part of which considered feeding in the first year of life (SACN, 2018).

The decision to split the review into 2 age groups covering infants aged 0 to 12 months and young children aged 1 to 5 years was largely pragmatic. SACN recognises that this boundary does not reflect the underlying biology which is a continuum feeding in the first year of life will impact on nutritional status and health outcomes in the second year of life and beyond.

The key dietary factors considered in this draft report are:

• energy requirements
• macronutrients
• micronutrients (focus on vitamins A and D,^{[footnote 4]} iron and zinc)
• dietary patterns (including consideration of vegetarian and vegan diets, and consumption of different food groups)
• chemical contaminants (or the risk of chemical toxicity)
• the latest available nutritional intakes and status of children aged 1 to 5 years (12 to 60 months) in the UK

Health outcomes considered

The health outcomes considered in this draft report are divided into those relating to childhood health and those relating to future health.

Childhood health outcomes are:

• growth and body composition:
  • linear growth
  • body composition (lean mass, adiposity, body mass index)
  • underweight or overweight or obesity
  • neurological outcomes, including cognitive outcomes
  • bone or skeletal health outcomes
• oral health
• development of eating habits and feeding behaviours
• morbidities (including respiratory diseases)

Future health outcomes are:

• obesity or body composition
• cancer
• cardiovascular outcomes (coronary heart disease, diabetes)

SACN considers evidence for the general population and does not make recommendations related to clinical assessment or management of children with clinical conditions requiring specialist care.

Methodology

This draft report is based primarily on evidence provided by systematic reviews (SRs) and/or meta-analyses (MAs) of prospective cohort studies (PCS) and randomised controlled trials (RCTs). SRs and MAs reduce the potential for biased study selection or overlooking relevant studies since they are systematic and provide a comprehensive and quantitative analysis of the research in a particular field.

SACN’s Framework for the Evaluation of Evidence) was used as the basis for assessing the evidence. The Framework is based on an evidence hierarchy which ranks the certainty of the evidence according to study design.

More weight is placed on evidence from RCTs since well-conducted RCTs minimise the potential for selection bias and confounding.

Less weight is placed on observational studies because such studies are potentially subject to bias, confounding and reverse causality.

However, in the absence of RCTs, evidence from non-randomised intervention studies (NRSI) and prospective studies is considered stronger than that from other study designs (case-control, cross-sectional and case reports).

Evidence review process

Inclusion criteria

The following types of studies were included: SRs and MAs of RCTs, NRSI and PCS.

Additional eligibility criteria included:

• English language publications, conducted in populations in health and directly relevant to the UK, and published in peer-reviewed scientific or medical journals from January 1990
• evidence from studies conducted in high-income countries (HIC). Evidence from studies conducted in low and middle income countries (LIC and MIC) (using the World Bank classification) that was potentially relevant to the UK context was also considered

The following types of studies were excluded: primary studies, reviews that included only case-control studies, and narrative reviews.

Additional exclusion criteria were:

• reviews published in grey literature, such as dissertations, conference proceedings, magazine articles, books or book chapters, opinion pieces, information from websites, and other non-peer reviewed articles
• studies in hospitalised or malnourished patients and those in children with a disease, including infectious disease
• interventions to reduce obesity prevalence, unless they had a dietary or feeding style component of interest
• childcare setting intervention, unless they had a dietary or feeding style component of interest
• weight management interventions

Overall summary and conclusions

Background

This draft report considers the scientific basis of current recommendations for feeding young children aged 1 to 5 years. This report forms part of a wider piece of work considering the evidence underpinning recommendations for feeding children up to 5 years of age, of which the first part, ‘Feeding in the first year of life’, was published in 2018. Existing recommendations for feeding children aged 1 to 5 years are provided in Table 11.1 (below).

The draft report does not include a review of the evidence informing the Dietary Reference Values (DRVs) for children under 5 years of age. The existing DRVs have been used to assess the adequacy of the diets of children aged 1 to 5 years in the UK.

The draft report considers evidence obtained through literature searches for systematic reviews (SRs) and meta-analyses (MAs) examining the relationship between the diet of young children and later health outcomes. Most of the evidence identified was from observational or non-randomised intervention studies.

In addition, food and nutrient intake and status data were obtained from the National Diet and Nutrition Survey (NDNS) and the Diet and Nutrition Survey of Infants and Young Children (DNSIYC). Data from the National Child Measurement Programme (NCMP) were also considered in relation to the prevalence of overweight and obesity among children aged 4 and 5 years. Data from national dental health surveys were considered in relation to the prevalence of dental caries in children up to 5 years of age.

The section below summarises findings from the surveys and evidence from SRs that was graded adequate, moderate, limited or inconsistent. For evidence graded insufficient see Annex 9, Table A9.29. The approach taken to grade the evidence is described in chapter 2.

Throughout this summary section, data are interpreted against the UK Dietary Reference Values (DRVs). DRVs describe the distribution of nutrient and energy requirements of different groups of people within the UK population – they are not recommendations for individuals. They comprise:

• estimated average requirement (EAR): estimated average requirement of a group of people for energy or protein or a vitamin or mineral. About half of a defined population will usually need more than the EAR, and half less
• reference nutrient intake (RNI): the average daily intake of a nutrient sufficient to meet the needs of almost all members (97.5%) of a healthy population. Values set may vary according to age, gender and physiological state
• lower reference nutrient intake (LRNI): The estimated average daily intake of a nutrient which can be expected to meet the needs of only 2.5% of a healthy population. Values set may vary according to age, gender and physiological state

Overall summary of survey data and assessment of systematic review evidence

Energy and macronutrients

Energy

Data from DNSIYC and NDNS indicated that 90% of children aged 12 to 24 months and 70% of children aged 24 to 35 months had reported energy intakes above the EAR for dietary energy. By age 36 to 47 months approximately half of children had reported intakes above the EAR. By age 48 to 60 months less than half of children had reported intakes above the EAR.

There is moderate evidence from SRs that increasing portion sizes (in grams or energy intake) of snacks and meals in preschool settings increases children’s food and energy intake in the short term (interventions lasting for up to 3 months).

Carbohydrates

The current government recommendation for total carbohydrate intake is that it should contribute approximately 50% of total dietary energy. Data from DNSIYC and NDNS indicated that, on average, this was achieved in most age groups. Mean total carbohydrate intake contributed on average 49% of total dietary energy intake (TDEI) in children aged 12 to 47 months and 51% in children aged 48 to 60 months.

The recommendation for intake of free sugars is that their contribution to TDEI should not exceed 5%. This recommendation currently applies from age 2 years and above. Data from NDNS indicated that mean intake of free sugars was double the maximum recommendation for children aged 18 to 47 months (10% of TDEI) and children aged 48 to 60 months (12% of TDEI). Eighty-five per cent and 97% of children in these age groups, respectively, had intakes above the recommendation of 5% of TDEI.

The DRV for dietary fibre for children aged 2 years and older is 15g a day. Data from NDNS indicated that mean dietary fibre intake was lower than recommended at 10g a day for children aged 18 to 47 months and 13g a day for children aged 48 to 60 months. Eighty-eight per cent of children aged 18 to 47 months and 72% of children aged 48 to 60 months had dietary fibre intakes below the DRV.

There is adequate evidence from SRs that higher intake of free sugars (from food and drinks) in children aged 1 to 5 years is associated with increased dental caries (increment, incidence or prevalence) in later childhood.

There is adequate evidence from SRs that higher consumption of sugars-sweetened beverages (SSBs) in children aged 1 to 5 years is associated with an increased odds of overweight or obesity in later childhood, adjusted for total dietary energy intake (TDEI).

There is moderate evidence that higher SSBs consumption in children aged 1 to 5 years is associated with a greater increase in body mass index (BMI) (or BMI z-score/weight-for-height z-score) in later childhood, unadjusted for TDEI (see chapter 3, paragraph 3.45).

Dietary fat

The DRV for total dietary fat intake is that it should contribute no more than 33% of TDEI. The DRV applies from age 5 years onwards, while a flexible approach is currently recommended to the timing and extent of dietary change for individual children between the ages of 2 and 5 years. Data from DNSIYC and NDNS indicated that the mean intake of total dietary fat as a percentage of TDEI was 35% in children aged 12 to 47 months and 33% in children aged 48 to 60 months. Fifty-three per cent of children aged 4 to 5 years (48 to 60 months) had intakes above the DRV.

The DRV for saturated fat intake is that it should contribute no more than 10% TDEI. The DRV applies from 5 years of age onwards, while a flexible approach is currently recommended to the timing and extent of dietary change for individual children between 2 and 5 years. Data from DNSIYC and NDNS indicated that mean saturated fat intake was 16% of TDEI in children aged 12 to 18 months and 14% in children aged 48 to 60 months where 91% of children had intakes above the DRV.

There is limited evidence from SRs of no association between total fat intake in children aged 1 to 5 years and change in BMI or body weight in the shorter-term (1 to 3 years). The role of TDEI is uncertain in this relationship (see chapter 3 paragraph 3.166.

No additional evidence from SRs was identified on saturated fat intake and health outcomes since the SACN report ‘Saturated Fats and Health’ (SACN, 2019). The SR evidence in children included in the ‘Saturated Fats and Health’ report identified only 1 RCT that included children aged 1 to 5 years and findings from this study could not be disaggregated from those in older children.

Protein

The reference nutrient intake (RNI) for protein is 14.5g a day for children aged 1 to 3 years and 19.7g a day for children aged 4 and 5 years. Data from DNSIYC and NDNS indicated that mean protein intake in children aged 12 to 18 months was 38g a day, more than twice the RNI, rising to 41g a day in children aged 18 to 47 months, which is close to 3 times the RNI for this age group. Children aged 48 to 60 months had a mean protein intake of 46g a day, more than twice the RNI for this age group.

There is moderate evidence from SRs that higher total protein intake in children aged 1 to 5 years is associated with increased BMI in later childhood. The role of TDEI is uncertain in this relationship (see chapter 3 paragraph 3.262).

There is limited evidence from SRs that higher animal protein intake in children aged 1 to 5 years is associated with earlier measures of puberty timing, menarche in girls or voice break in boys.

Micronutrients

The RNI for iron is 6.9mg a day for children aged 1 to 3 years and 6.1mg a day for children aged 4 to 6 years. The RNI for zinc is 5.0mg a day for children aged 7 months to 3 years and 6.5mg a day for children aged 4 to 6 years. The RNI for vitamin A is 400 µg (retinol equivalents) a day for children aged 1 to 6 years.

Data from NDNS indicated that while mean intakes of iron, zinc and vitamin A were above the RNI for these micronutrients in almost all age groups, between 8% and 11% of children aged 18 to 47 months had intakes below the LRNI for iron, zinc and vitamin A and 20% of children aged 48 to 60 months had intakes below the LRNI for zinc. These findings should be interpreted with caution as there was evidence to suggest underreporting in children with intakes below the LRNI for these micronutrients.

Analyses of data from NDNS (years 2008 to 2009 to 2018 to 2019 of the rolling programme) indicated that inadequate intakes of iron, zinc, vitamin A or vitamin D may be more prevalent among children from lower socioeconomic status households and certain ethnic minority groups. Children with intakes below the LRNI did not obtain any vitamin A from dietary supplements. Current government advice is that all children aged 6 months to 5 years should be given a vitamin supplement containing vitamin A.

Despite NDNS data indicating that mean intake of vitamin A are above the RNI in all age groups, the potential risks from intakes at these levels are unlikely to be a cause for concern (see chapter 4, paragraphs 4.170 and 4.171).

Data from DNSIYC and NDNS indicated that although 11% of children aged 12 to 18 months and over 24% of children aged 18 to 60 months had iron deficiency, less than 4% of children in all age groups had iron deficiency anaemia. It should be noted there are uncertainties in the iron DRVs for children.

Data from NDNS indicated that 7% of children aged 18 to 47 months had plasma retinol concentrations between 0.35 µmol/L and 0.70 µmol/L, the range associated with mild vitamin A deficiency in adults.^{[footnote 5]}

The RNI for vitamin D for children aged 1 to 5 years is 10µg a day. Data from DNSIYC and NDNS indicated that the mean vitamin D intake of children aged 12 to 18 months was 55% of the RNI and around 40% in children aged 18 to 60 months.

Analysis of data from NDNS (years 2012 to 2013 to 2016 to 2017) for children aged 18 to 36 months indicated that vitamin D intakes decreased with increasing deprivation (as measured by equivalised household income). Moreover, although the sample size was too small to draw firm conclusions, data from NDNS (years 2008 to 2009 to 2018 to 2019) indicate that, compared with white children, young children from ethnic minorities are likely to be at higher risk of vitamin D deficiency.

Data from NDNS indicated that 9% of children aged 18 to 47 months had serum 25(OH)D concentrations below 25nmols/l which is the threshold for increased risk of rickets and osteomalacia. Analysis of data from NDNS (years 2012 to 2013 to 2016 to 2017) for children aged 18 to 36 months indicated that serum 25(OH)D concentrations decreased with increasing deprivation (as measured by equivalised household income).

The RNI for vitamin C for children aged 1 to 5 years is 30mg a day. Data from DNSIYC and NDNS indicated that vitamin C intakes in children aged 12 to 60 months are adequate with no children with intakes below the LRNI.

There is limited evidence from SRs that fortification with iron and other micronutrients (including zinc, vitamin A and vitamin C) of milk or micronutrient sprinkles reduces the prevalence of anaemia in children aged 6 to 36 months.

There is limited evidence from SRs that vitamin D fortification of milk or formula improves vitamin D status or decreases the risk of vitamin D deficiency in children aged 1 to 5 years.

Foods, dietary components and dietary patterns

There are currently no UK government recommendations on portion sizes for vegetables and fruit for young children. However, it is recommended that from about 6 months of age, gradual diversification of the diet to provide increasing amounts of vegetables and fruit is encouraged. Data from DNSIYC and NDNS indicated that children aged 12 to 18 months consumed, on average, 170g a day of vegetables (excluding potatoes) and fruit (excluding fruit juice). For children aged 18 to 47 months, and aged 48 to 60 months, consumption was, on average, 178g a day and 217g a day, respectively. In all age groups fruit made a greater contribution to intakes than vegetables.

Data from NDNS indicated that total milk consumption (all types of cows’ milk and other dairy milk) contributed 16% to TDEI for children aged 18 to 47 months, falling to 10% for children aged 48 to 60 months. The contribution of total dairy intake to TDEI was 22% and 15% for the 2 age groups, respectively.

Substitution modelling using data from DNSIYC indicated that replacing whole cows’ milk with semi-skimmed cows’ milk for children aged 12 to 18 months would be unlikely to have a detrimental effect on nutrient intakes at the population level. By contrast, replacing whole milk with skimmed or 1% cows’ milk may result in a greater risk of inadequate intakes of vitamin A in young children.

Data from NDNS indicated that foods rich in starchy carbohydrates contributed 21% and 20% to TDEI in children aged 18 to 47 months, and aged 48 to 60 months, respectively.

Data from NDNS indicated that non-dairy sources of protein contributed 9% to TDEI in children aged 18 to 60 months, with unprocessed meat making the largest contribution (8% of TDEI).

Data from NDNS indicated that foods high in (total) fat, salt and free sugars contributed 27% of TDEI for children aged 18 to 47 months. This increased to 34% of TDEI for children aged 48 to 60 months.

There is limited evidence from SRs that higher fruit juice consumption is associated with increased BMI when unadjusted for TDEI, and limited evidence that fruit juice consumption is not associated with BMI following adjustment for TDEI (see chapter 5, paragraph 5.34).

There is moderate evidence from SRs of no association between total milk intake in children aged 1 to 5 years and BMI in later childhood.

There is limited evidence from SRs that dietary patterns classified as ‘unhealthy’ are associated with higher body fat measures in children aged 1 to 5 years.

Eating and feeding behaviours

There is moderate evidence from SRs that feeding practices (including repeated exposure and pairing vegetables with positive stimuli) can increase children’s vegetable consumption in the short term (up to 8 months).

There is moderate evidence from SRs that repeated taste exposure (around 8 to 10 times) is the most effective feeding practice at increasing vegetable consumption in children aged up to 5 years in the short term (less than 8 months).

There is moderate evidence from SRs that repeated taste exposure to vegetables paired with liked foods or additional flavours or energy increases vegetable consumption, although this strategy may be less effective in increasing vegetable consumption than repeated taste exposure to vegetables in their plain form.

There is inconsistent evidence from SRs on the effect of adult modelling of food consumption (including vegetables and fruit) on children’s food acceptance or consumption in the short term.

Excess weight and obesity

Data from NCMP shows that the combined prevalence of overweight and obesity (85th and 95th centiles, respectively) for children living in England in reception year (aged 4 to 5 years) was fairly stable at around 22% to 23% from the collection years 2006 to 2007 to the collection year preceding the coronavirus (COVID-19) pandemic (2019 to 2020). In the latest collection year 2020 to 2021, the combined prevalence of overweight and obesity increased substantially to approximately 28%.

In addition, there were large increases in the proportion of children aged 4 to 5 years categorised as obese (including severely obese) (from 10% to 14%) and severely obese (from 3% to 5%). The prevalence of obesity was highest for children categorised as black African (23.5%) and black other (22.7%).

The gap in obesity prevalence between children living in the most and least deprived areas also increased from 5.3% in 2006 to 2007 to 7.3% in 2019 to 2020, and this gap increased further during the first year of the COVID-19 pandemic to 12.4% (2020 to 2021).

The overall increase in prevalence of overweight and obesity may in part be explained by the reported decrease in physical activity levels leading up to and during the first national lockdown in the UK due to the pandemic.

In Scotland, the latest available survey data from 2019 showed that the combined prevalence of overweight and obesity (85th and 95th centiles, respectively) for children aged 2 to 6 years was 30%. The 85th and 95th centiles used are intended for population monitoring use only, and do not provide the number or percentage of individual children clinically defined as overweight or obese.

There is limited evidence from SRs that adiposity rebound occurring before the age of 5 years is associated with a higher risk of obesity in adulthood.

There is adequate evidence from SRs that higher BMI or weight status in children aged 1 to 5 years is associated with higher adult BMI or risk of adult overweight or obesity.

There is moderate evidence from SRs of no association between BMI at age 6 years and under and adult coronary heart disease.

There is moderate evidence from SRs of no association between BMI at age 6 years and under and adult stroke.

Oral health

Dental caries in children remains a major public health problem despite reductions in prevalence of dental caries since the 1970s. National dental health surveys showed that 40% of children aged 5 years in Northern Ireland (2013), 34% in Wales (2015 to 2016), 27% in Scotland (2020), and 23% in England (2019) had tooth decay.

There is adequate evidence from SRs that higher intake of free sugars in children aged 1 to 5 years is associated with increased dental caries (increment, incidence or prevalence) in later childhood.

There is moderate evidence from SRs that breastfeeding beyond 12 months protects against the development of malocclusion.

Table 10.1 Exposure-outcomes relationships graded moderate or adequate

Exposure (children aged 1 to 5 years)	Outcome (mostly aged over 5 years through to adolescence)	Direction of effect or association	Certainty of evidence
Portion sizes	Food and energy intake (short term, up to 3 months) in preschool settings	Increase	Moderate
Sugars-sweetened beverages	Odds of overweight BMI/body weight	Increase	Adequate Moderate
Total protein intake	BMI	Increase	Moderate
Total milk intake (often unspecified, presumed cow’s milk)	BMI	Null	Moderate
Feeding practices	Vegetable consumption (short term, up to 8 months)	Increase	Moderate
Repeated taste exposure	Vegetable consumption (short term, less than 8 months)	Increase	Moderate
Child BMI or overweight or obesity	Adult BMI or risk of adult overweight or obesity	Increase	Adequate
Child BMI (children aged under 6 years)	Adult coronary heart disease	Null	Moderate
Child BMI (children aged under 6 years)	Adult stroke	Null	Moderate
Breastfeeding beyond 12 months	Malocclusion	Inverse	Moderate
Free sugars intake	Dental carries	Increase	Adequate

Overall conclusions

In 1994, the Committee on Medical Aspects of Food and Nutrition Policy (COMA) published its report ‘Weaning and the weaning diet’ and, since then, has been the basis for much of the advice on feeding young children in the UK.

The current diet of young children in the UK, as captured in both the Diet and Nutrition Survey in Infants and Young Children (DNSIYC) and the National Diet and Nutrition Survey (NDNS), while acceptable in many respects, does not meet current dietary recommendations for several nutrients.

Energy and macronutrients

Evidence from DNSIYC and NDNS indicated that:

• mean intakes of energy for children aged 12 to 35 months are above the estimated average requirement (EAR) for dietary energy
• the percentage above the EAR decreases with increasing age and is less than half by age 5 years
• mean intakes of protein exceed the RNI
• mean intakes of free sugars for children aged 18 to 60 months exceed current recommendations of no more than 5% of TDEI
• mean intakes of saturated fats exceed the population recommendation of no more than 10% TDEI (it should be noted that this recommendation currently does not apply in full until age 5 years)
• foods high in (total) fat, salt and free sugars provide over a quarter of TDEI in children aged 18 to 47 months and over a third of TDEI in children aged 48 to 60 months
• mean intakes of dietary fibre for children aged 18 to 60 months are below the recommended intake of 15g a day

Evidence identified from SRs indicates that:

• increasing portion sizes in preschool settings increases food and energy intakes in the short term (interventions lasting for up to 3 months)
• higher total protein intake in children aged 1 to 5 years is associated with increased BMI in later childhood
• higher childhood BMI is associated with adult overweight or obesity

Evidence from SRs also indicates that a higher intake of free sugars (from food and drinks) in children aged 1 to 5 years is associated with dental caries development in later childhood.

These findings are of concern in relation to wider evidence on:

• the high and recent increasing prevalence of overweight and obesity in childhood particularly in lower socioeconomic groups and in some ethnic minority groups
• the high prevalence of dental caries in children in the UK

Micronutrients

Certain groups of children, including children from lower socioeconomic status households (as measured by the Index of Multiple Deprivation) and ethnic minority groups, may be at risk of inadequate intakes of iron, zinc and vitamin A, and inadequate dietary vitamin D intakes and vitamin D status. There is evidence of low uptake of government advice that children aged up to 5 years should be given vitamin supplements.

Current intakes of vitamin C exceeded the RNI across all age groups.

Vegetables and fruit

Currently there are no UK government recommendations on portion sizes for vegetables and fruit for young children. Findings from NDNS indicate that in all age groups fruit made a greater contribution to intakes than vegetables. Vegetables and fruit consumption appears to decrease with increasing deprivation. Maintaining consumption of vegetables as children grow up and develop more independence around food is important to ensure diet quality and adherence to population dietary guidelines.

Evidence identified from SRs indicates that repeated taste exposure to a vegetable (around 8 to 10 times) can increase consumption of that vegetable in the short term (less than 8 months). No SR evidence was identified on the efficacy of this feeding practice in increasing vegetable consumption in the longer term.

Drinks

The available evidence indicates that continued breastfeeding beyond the age of 1 year is protective against malocclusion.

Substitution modelling using data from DNSIYC indicates that replacing whole cows’ milk with semi-skimmed cows’ milk for children aged 12 to 18 months would be unlikely to have a detrimental effect on nutrient intakes at the population level. By contrast, replacing whole milk with skimmed or 1% milk may result in a greater risk of inadequate intakes of vitamin A in young children.

Evidence identified from SRs indicates that higher sugars-sweetened beverage (SSB) consumption in children aged 1 to 5 years is associated with greater odds of overweight or obesity in later childhood.

Risks of chemical toxicity

COT assessed toxicity issues from the infant and young child diet for a number of nutrients, substances and contaminants in breast milk, infant formula and solid foods. They concluded there were unlikely to be concerns over toxicity in the diet of young children for substances considered at current levels of exposure. Issues where COT has identified that there is potential concern are described in chapter 9.

General limitations in the evidence base

Several limitations were identified in the evidence base including:

• there was no or insufficient systematic review evidence for a number of health outcomes of interest for this risk assessment, including paediatric cancers, allergy and autoimmune diseases, and bone or skeletal health
• most of the evidence identified from SRs that was specific to children aged 1 to 5 years was observational (from prospective cohort studies) or from non-randomised intervention studies and may therefore have been subject to confounding and selection bias
• many of the identified SRs had a broad search strategy that included population groups outside the age group of interest for this draft report (children aged 1 to 5 years) and it was difficult to determine whether their search strategy for the target age group was comprehensive
• risk of publication bias was not formally assessed in many of the identified SRs
• the evidence base for most topic areas was highly heterogeneous in terms of exposures, dietary assessment methods, outcome measures, populations, settings, and study designs, which prevented the pooling of results by MA
• few primary studies that were conducted in high income countries considered ethnic minorities – the majority were conducted in white participants only
• the majority of primary studies had short follow-up periods limiting the ability to draw conclusions about the longer-term health effects of nutrient or dietary intake
• SRs (without MAs) reported findings from primary studies with varying levels of detail. Several SRs did not report quantitative results making it difficult to assess effect sizes and the certainty of findings
• the number of children that provided blood samples for status measures in NDNS was small and extrapolation to the wider population should be done with caution
• there was evidence of underreporting of dietary intakes in NDNS

Recommendations

SACN supports the existing dietary recommendations for young children (which are presented in Table 11.1). In addition, SACN has made the following new recommendations outlined below.

It is recommended that government:

• gives consideration to strategies that support parents who choose to breastfeed to continue for as long as they and their child want, including into the second year of life
• gives consideration to strategies to help improve uptake of advice on feeding children aged 1 to 5 years an appropriate and diverse diet
• gives consideration to strategies to help ensure the uptake of advice on micronutrient supplements in children aged 1 to 5 years, especially in at-risk groups such as children from lower socioeconomic status households and some ethnic minority groups
• continues to monitor the prevalence of both overweight and obesity and the extent of overfeeding in children aged 1 to 5 years

The following recommendations are suitable for children who are able to consume a varied diet and are growing appropriately for their age.

Diversification of the diet

Current population dietary guidelines apply from age 5 years. It is recommended that government considers advising that these should be applied from age 2 years.

Between 1 to 2 years of age, children’s diets should be diversified in relation to foods, dietary flavours and textures. Diversification should proceed incrementally, taking into account the variability between young children in developmental attainment and the need to satisfy nutritional requirements.

Vegetables should be presented on multiple occasions to children. This may require frequent presentation (as many as 8 to 10 times for each vegetable) before acceptance. Pairing vegetables with liked foods or additional flavours or energy may also increase acceptance.

It is recommended that government considers:

• developing and communicating age-appropriate portion sizes for food and drinks, including for vegetables and fruit, for children aged 1 to 5 years
• strengthening advice on limiting the consumption of high energy density foods and drinks, particularly discretionary or snack foods and SSBs for children aged 1 to 5 years

Macronutrients

Current population guidelines on average intake of free sugars apply from age 2 years. It is recommended that government considers advising these should be applied from age 1 year.

It is recommended that government consider approaches to:

• reducing excess protein intakes towards the Dietary Reference Values (DRVs) for children aged 1 to 5 years
• support children aged 1 to 5 years to consume a diet that does not exceed energy requirements

Drinks

From 1 year of age, semi-skimmed cows’ milk can be given as a main drink. As currently recommended, skimmed and 1% cows’ milk should not be given as a main drink until 5 years of age.

SSBs should not be given to children aged 1 to 5 years.

Advice on the consumption of plant-based drinks (soya, oat and almond) placeholder (pending COT or SACN findings)

Risks of chemical toxicity

Government should keep the risk from acrylamide and arsenic under review. Efforts to reduce the levels of inorganic arsenic in food and water, and levels of acrylamide in commercially produced and home-cooked foods should continue.

Additional compounds of potential concern identified included:

• excess retinol consumption, percholroate and chlorate
• monochloropropanediol, its fatty acid, and glycidol
• furan and methylfurans, aflatoxin
• citrinin and polybrominated diphenyl ethers

Table 11.1 Existing dietary recommendations for young children

Recommendation area	Recommendation wording	Source or reference
Breastfeeding	It is recommended that infants are breastfed exclusively for around the first 6 months of their life and, alongside appropriate complementary foods, and continue to be breastfed for at least the first year of life. Each period makes an important contribution to infant and maternal health.	Breastfeeding: World Health Organization Feeding in the first year of life: SACN report (2018)
Diversification of the diet	From around 6 months of age, children should be offered a variety of fruit and vegetables (including those with bitter flavours).	Feeding in the first year of life: SACN report (2018)
Diversification of the diet	From around 1 year of age, children should eat the same (appropriately prepared) foods, as the rest of the family.	Start for Life What to feed young children: NHS
Diversification of the diet	Once your child is 2, you can gradually introduce lower-fat dairy products and cut down on fat in other foods – provided your child is a good eater and growing well.	What to feed young children: NHS
Diversification of the diet	From about 6 months of age, gradual diversification of the diet to provide increasing amounts of whole grains, pulses, fruits and vegetables is encouraged.	SACN carbohydrates and health report (2015)
Carbohydrates and fibre	For children aged 2 years and older: - total carbohydrate intake should be maintained at a population average of approximately 50% of total dietary energy - the population average intake of free sugars should not exceed 5% of total dietary energy - the average population intake of dietary fibre for children aged 2 to 5 years should be approximately 15 grams per day	SACN carbohydrates and health report (2015)
Saturated fat	It is recommended that the dietary reference value for saturated fats remains unchanged: the (population) average contribution of saturated fatty acids to (total) dietary energy be reduced to no more than about 10%. This recommendation applies to adults and children aged 5 years and older.	Saturated fats and health: SACN report (2019)
Protein	Young children need protein and iron to grow and develop. Try to give your toddler 1 or 2 portions from this group (beans, pulses, fish, eggs, meat and other proteins) each day.	What to feed young children: NHS
Fish	Boys should eat no more than 4 portions of oily fish per week and girls no more than 2 portions of oily fish per week	What to feed young children: NHS
Fish	Children under 16 should avoid eating shark, marlin and swordfish.	Fish and shellfish: NHS COT statement on potential risks from methylmercury in the diet of infants aged 0 to 12 months and children aged 1 to 5 years, (PDF, 509KB)
Dietary fat	Advice to reduce fat intake does not apply to children under age 2 years. It applies in full from 5 years of age.	COMA Weaning and the weaning diet report (1994)
Fibre, including wholegrain	You can give your child wholegrain foods, such as wholemeal bread, pasta and brown rice. But it’s not a good idea to only give wholegrain starchy foods to under 2s. Wholegrain foods can be high in fibre and they may fill your child up before they have taken in the calories and nutrients they need. After age 2 you can gradually introduce more wholegrain foods.	What to feed young children: NHS
Vegetables and fruit	Try to make sure vegetables and fruit are included in every meal. Dried fruit should be given to your toddler with meals, rather than as a snack in between, as the sugar they contain can cause tooth decay.	What to feed young children: NHS
Drinks	Feeding from a bottle is discouraged from 1 year. From the age of 6 months babies should be encouraged to drink from a free-flow cup (rather than one with a valve which requires a child to suck).	COMA Weaning and the weaning diet report (1994)
Drinks	Beyond 1 year, infant and follow-on formula are not needed, and toddler milks, growing-up milks, goodnight milks, comfort milks and specialised formula, for example hypoallergenic formulas for the management of cows’ milk protein allergy (if not prescribed by a clinician) are also unnecessary as nutrient requirements can be met through consuming a healthy, balanced, and varied diet.	Drinks and cups for babies and young children: NHS
Drinks	Large volumes of milk (more than 600ml per day) should be discouraged as these will stop appetite for other foods.	COMA Weaning and the weaning diet report (1994)
Drinks	Whole cows’ milk can be given as a main drink from the age of 1 year.	COMA Weaning and the weaning diet report (1994)
Drinks	Skimmed and 1% milk should not be given as a drink until 5 years of age. Skimmed or 1% fat milk can be used in cooking from the age of 1 year.	COMA Weaning and the weaning diet report (1994)
Drinks	Young children should limit consumption of 100% fruit and vegetable juices or smoothies to no more than a combined total of 150ml per day.	Drinks and cups for babies and young children: NHS
Drinks	Children aged 1 to 5 years should not be given rice drinks as they may contain too much arsenic.	COT Statement on potential risks from arsenic in the diet of infants aged 0 to 12 months and children aged 1 to 5 years, (PDF, 658KB) COT editorial update on the conclusions on arsenic, (PDF, 75KB)
Drinks	Milk (including breast milk) or water should constitute the majority of drinks given.	COMA Weaning and the weaning diet report (1994)
Drinks	Squashes, flavoured milk and juice drinks, diet drinks and no added sugar drinks, tea and coffee and fizzy drinks should not be given to babies and young children.	Drinks and cups for babies and young children: NHS
Micronutrients	All infants from birth to 1 year of age who are being exclusively or partially breastfed should be given a daily supplement containing 8.5 to 10µg of vitamin D (340-400IU/d). Infants who are fed infant formula should not be given a vitamin D supplement unless they are consuming less than 500ml (about one pint) of infant formula a day, as infant formula is fortified with vitamin D. Children aged 1 to 4 years should be given a daily supplement containing 10μg (400 IU) of vitamin D.	SACN vitamin D and health report (2016)
Micronutrients	It’s recommended that all children aged 6 months to 5 years are given vitamin supplements containing vitamins A, C and D every day. Babies who are having more than 500ml (about a pint) of infant formula a day should not be given vitamin supplements. This is because formula is fortified with vitamins A, C and D and other nutrients.	Vitamins for children: NHS
Micronutrients	A wide range of iron-containing foods should be introduced in an age-appropriate form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child. Healthy infants and young children do not require iron supplements unless advised by their health professional.	Feeding in the first year of life: SACN report (2018)
Oral health	For oral health, in addition to reiterating breastfeeding recommendations: - infants should be introduced to drinking from a free-flow cup from the age of 6 months while feeding from a bottle should be discouraged from the age of 1 year - sugars should not be added to foods or drinks - minimise amount and frequency of consumption of sugars-containing foods and drinks - avoid sugars-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost	Delivering better oral health: an evidence-based toolkit for prevention, chapter 2: Summary guidance tables for dental teams
Salt	Children aged 1 to 3 years should eat no more than 2g salt a day (0.8g sodium) and children aged 4 to 6 years should eat no more than 3g salt a day (1.2g sodium).	SACN salt and health report: recommendations on salt in diet (2003)

1. To note that this should be understood as 5 completed years of age. ↩

2. The original terms of reference specified in the age group months (12 to 60 months) but SACN considered that designating the age group in years would make this report more accessible. ↩

3. As this report covers the 1 to 5 age group, it was not considered relevant to address this term of reference. ↩

4. For vitamin D it was agreed that only data published since the SACN report ‘Vitamin D and health’ (2016) cut-off date for inclusion of evidence would be included. ↩

5. There is no equivalent threshold in children. ↩