Independent report

Feeding young children aged 1 to 5 years - summary report

Published 4 July 2023

Background

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 (DH, 1994b).

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 to conduct a review of the risks of toxicity from chemicals in the diets of infants and young children. COT was also asked to examine the evidence relating to the influence of the infant diet on development of allergic and autoimmune disease.

This report covers the period from 1 to 5 years of age (12 to 60 months) and accompanies the ‘Feeding in the first year of life’ report, which was published in 2018 (SACN, 2018).

Terms of reference

The terms of reference as they apply to this report are to:

• review the scientific basis of current recommendations for feeding children aged 1 to 5 years (12 to 60 months)
• consider evidence on developmental stages and other factors that influence eating behaviour and diversification of the diet in the early years
• make recommendations for policy, practice and research

The key dietary factors considered in this report are:

• energy requirements
• macronutrients
• micronutrients (focussing on vitamins A, C and D, iron and zinc)
• foods, food components and dietary patterns (including consideration of vegetarian and vegan diets, and consumption of different food groups)
• drinks
• eating and feeding behaviours
• chemical contaminants (or the risk of chemical toxicity)

The key child and adolescent health outcomes considered in this report are:

• growth and body composition
  • linear growth
  • body composition (body mass index, adiposity)
  • excess weight (overweight and obesity)
• neurodevelopment and cognitive development
• bone or skeletal health outcomes
• oral health
• morbidities, including respiratory diseases

The key adult health outcomes considered in this report are:

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

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.

Methods

SACN’s Framework for the Evaluation of Evidence (SACN, 2012) was used as the basis for considering appropriate evidence for inclusion in the review. An updated version of this framework has since been published in 2023.

Consideration of the evidence was primarily focused on systematic reviews (SRs) and meta-analyses of randomised controlled trials, prospective cohort studies and non-randomised studies of interventions.

SACN also considered evidence on young child feeding from large national surveys. The report includes data on food and drink consumption, and nutrient intakes and status in young children living in the UK from the 2011 Diet and nutrition survey of infants and young children (DNSIYC) for children aged 12 to 18 months (Lennox et al, 2013) and the National Diet and Nutrition Survey rolling programme (mainly from years 2016 to 2019) (NDNS) for children aged 18 to 60 months (Bates et al, 2020).

The report also includes data on the prevalence of overweight and obesity in children entering primary school (aged 4 to 5 years) from the National Child Measurement Programme (for England), the Child Health Surveillance Programme School system (for Scotland) and the Child Measurement Programme for Wales (there are currently no comparable data in children aged under 5 years for Northern Ireland).

In parallel with SACN, COT considered the risks of toxicity from chemicals in the diet of young children aged 1 to 5 years and whether current government advice should be revised.

Assessment of the systematic review evidence

The methodological quality of individual SRs was assessed using SACN’s Framework for the Evaluation of Evidence (SACN, 2012) and the quality assessment tool, AMSTAR 2 (AMSTAR, 2021).

The certainty of evidence from SRs was assessed using modified methods based on those outlined in the SACN reports ‘Carbohydrates and health’ (SACN, 2015) and ‘Saturated fats and health’ (SACN, 2019).

The certainty of the evidence was graded ‘adequate’, ‘moderate’, ‘limited’, ‘inconsistent’ or ‘insufficient’.

Evidence that was graded ‘adequate’ or ‘moderate’ was used to inform conclusions and recommendations of this report (alongside findings from national dietary surveys). These are summarised in Table S1.

Table S1: systematic review evidence in children aged 1 to 5 years graded ‘moderate’ or ‘adequate’

Topic area	Systematic review finding	Certainty of evidence
Energy	Larger portion sizes of snacks and meals provided in preschool settings are associated with higher food and energy intakes (in the short term, less than 6 months)	Moderate
Macronutrients	Higher total protein intake in children aged 1 to 5 years is associated with higher body mass index (BMI) in childhood	Moderate
Macronutrients	Higher free sugars intake is associated with increased development of dental caries in childhood and adolescence	Adequate
Drinks	Higher sugar-sweetened beverage (SSB) consumption in children aged 1 to 5 years is associated with greater odds of overweight or obesity in childhood	Adequate
Drinks	Higher SSB consumption in children aged 1 to 5 years is associated with a greater increase in BMI in childhood and adolescence	Moderate
Eating and feeding behaviours	Feeding practices (including repeated taste exposure, pairing with positive stimuli such as liked foods, modelling of vegetable consumption and offering the child non-food rewards) increase vegetable consumption in children aged 1 to 5 years (in the short term, up to 8 months)	Moderate
Eating and feeding behaviours	Repeated taste exposure to vegetables increases vegetable consumption in children aged 1 to 5 years (in the short term, up to 8 months)	Moderate
Excess weight and obesity	Higher child BMI or weight status at age 1 to 5 years is associated with higher adult BMI or risk of overweight or obesity	Adequate
Excess weight and obesity	Child BMI at age 6 years and under is not associated with incidence of coronary heart disease in adulthood	Moderate
Excess weight and obesity	Child BMI at age 6 years and under is not associated with incidence of stroke in adulthood	Moderate
Oral health	Breastfeeding beyond 12 months is associated with lower odds of malocclusion (teeth that are not aligned correctly)	Moderate

Limitations of the evidence base

A range of limitations was identified in the evidence base provided by SRs and dietary surveys. These are summarised below.

General limitations of the systematic review evidence

There was either no or insufficient SR evidence for a number of dietary exposures (including saturated fat and dietary fibre) and health outcomes (including paediatric cancers, allergy and autoimmune diseases, and bone and skeletal health) that were included in the scope and literature search for this risk assessment.

Many of the SRs identified for this report had a broad search strategy that included population groups outside the age range of interest for this report (children aged 1 to 5 years) and it was difficult to determine whether their search strategy for the target population was comprehensive.

Most of the SR evidence that was specific to children aged 1 to 5 years was observational (from prospective cohort studies) or from non-randomised studies of interventions, and may have been subject to confounding and selection bias.

The evidence base on many 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 meta-analysis or other methods of quantitative synthesis.

Due to the lack of quantitative syntheses in the included SRs, risk of publication bias was seldom formally assessed.

The SR evidence identified on micronutrients was drawn almost exclusively from supplementation and food fortification trials designed for populations in low income, lower-middle or upper-middle income countries (defined according to the World Bank classification system) and therefore may not be generalisable to children living in the UK.

Primary studies, particularly those conducted in high-income countries, seldom considered whether the impact of dietary exposures on nutritional status (for example, vitamin D) or health outcomes differed among different ethnic groups.

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 in children aged 1 to 5 years.

General limitations of the evidence from dietary surveys

DNSIYC was conducted in 2011. Dietary patterns may have changed significantly in the period since the data were collected.

The number of children that provided blood samples for status measures in NDNS was small and may not be representative of the wider population. Children who gave a blood sample were more likely to come from higher socioeconomic status households.

Misreporting of food consumption, specifically underreporting, and therefore underestimation of total dietary energy intake (TDEI) in self-reported dietary methods is a well documented source of bias and is an important consideration when interpreting survey data.

Conclusions

The current diet of young children in the UK, as captured in both DNSIYC and NDNS, does not meet current dietary recommendations for several nutrients.

The following conclusions are informed by the main findings from DNSIYC and NDNS together with SR evidence that was graded ‘adequate’ and ‘moderate’ (see Table S1 above).

Energy and macronutrients

Evidence from DNSIYC and NDNS indicated that:

• mean intakes of TDEI for children aged 1 to 3 years were above the estimated average requirement
• mean intakes of free sugars for children aged 1.5 to 5 years were above the current recommendation of no more than 5% TDEI
• mean intakes of dietary fibre for children aged 1.5 to 5 years were below the recommended intake of 15g a day
• mean intakes of saturated fats were above the current recommendation of no more than 10% TDEI (which applies in full from age 5 years)
• mean intakes of protein were above the reference nutrient intake (RNI)

Evidence identified from SRs indicated that:

• larger portion sizes of snacks and meals provided in preschool settings are associated with higher food and energy intakes in the short term (less than 6 months)
• higher free sugars intake in children aged 1 to 5 years is associated with increased dental caries (increment, incidence or prevalence) in childhood and adolescence
• higher total protein intake in children aged 1 to 5 years is associated with higher BMI in childhood
• higher child BMI or weight status is associated with higher risk of adult overweight or obesity

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

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

Micronutrients

Evidence from DNSIYC and NDNS indicated that mean salt intake was above the target average salt intake in children aged 1.5 to 4 years, where 76% of children in this age group had intakes above the target salt intake.

Evidence from DNSIYC and NDNS indicated that certain groups of children, including children from lower socioeconomic status households (measured by the Index of Multiple Deprivation) and some ethnic groups, may be at risk of inadequate intakes of iron, zinc, vitamin A and vitamin D, and low vitamin D status. Conversely, intakes of vitamin C exceeded the RNI across all age groups.

Evidence from NDNS indicated that use of vitamin D supplements in the general population of children aged 1 to 5 years was low (no comparable data were available for supplements containing vitamin A or C), while the latest available data indicated variable uptake of Healthy Start vitamins (containing vitamins A, C and D).

Foods

Currently, there are no UK government recommendations on portion sizes for vegetables and fruit for young children. Evidence from NDNS indicated that children ate more fruit than vegetables. Consumption of total vegetables and fruit decreased with increasing deprivation. Encouraging consumption of vegetables as children grow and develop more independence around food is important to support children to meet population dietary recommendations.

Evidence identified from SRs indicated 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).

Evidence from DNSIYC indicated that the food group (sugar-sweetened) ‘yoghurts, fromage frais and dairy desserts’ was among the top contributors to free sugars intake in children aged 1 to 1.5 years, providing approximately 18% of free sugars intake.

Evidence from NDNS indicated that foods that are energy dense and high in saturated fat, salt or free sugars contributed approximately 16% TDEI, 24% TDEI and 30% TDEI in children aged 1 to 1.5 years, 1.5 to 4 years and 4 to 5 years, respectively. Of these, biscuits, buns, cakes and pastries were the largest contributor to TDEI.

Evidence from DNSIYC indicated that, among children aged 12 to 18 months who consumed commercially manufactured foods and drinks marketed specifically for infants and young children (65% of this age group), these products provided approximately 20% of free sugars intakes.

A Public Health England (PHE) evidence review (PHE, 2019) found that the nutrient composition of many of these products was inconsistent with UK dietary recommendations for this age group, particularly for sugar and salt. The PHE review highlighted that commercially manufactured finger foods have been the main driver in the growth of the infant food market in recent years.

Drinks

Evidence from DNSIYC and NDNS indicated that:

• formula milks (mainly follow-on formula and milks marketed for children over the age of 1 year, also known as ‘toddler milks’ and ‘growing-up milks’) were consumed by 36% of children aged 1 to 1.5 years and contributed 50% of free sugars intake in consumers (18% of free sugars intake at a population level)
• fruit juice (100% fruit juice and smoothies) contributed nearly 11% to free sugars intake in children aged 1.5 to 4 years, and less than 10% in the other age groups at a population level

Substitution analysis using data from DNSIYC indicated that replacing whole cows’ milk with semi-skimmed cows’ milk for children aged 1 to 1.5 years 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 indicated that higher SSB consumption in children aged 1 to 5 years is associated with a greater odds of overweight or obesity in childhood.

Evidence identified from SRs indicated that continued breastfeeding beyond the age of 1 year is protective against malocclusion (teeth that are not correctly aligned).

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. It 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 there may be potential concerns are described in chapter ‘10. Risks of chemical toxicity’ of the full report.

Nutritional and toxicological aspects associated with the consumption of plant-based drinks by children aged 1 to 5 years are being considered in a joint benefit:risk assessment being undertaken by SACN and COT. Findings are expected to be published in 2024 and will include recommendations on plant-based drink consumption. View more information on the work of the joint SACN-COT working group.

SACN’s ‘Feeding in the first year of life report’ (SACN, 2018) considered findings from a benefit:risk assessment on timing of the introduction of peanut and hen’s egg into the infant diet, and the risk of developing allergy to these foods. The available evidence indicated that the deliberate exclusion or delayed introduction of peanut or hen’s egg beyond 6 to 12 months of age may increase the risk of allergy to the same foods. These findings will have a bearing on children in the older age group (1 to 5 years).

Recommendations

The following recommendations are suitable for children aged 1 to 5 years who are able to consume a varied diet and are growing appropriately for their age.

Between 1 to 2 years of age, children’s diets should continue to be gradually diversified in relation to foods, dietary flavours and textures. A flexible approach is recommended to the timing and extent of dietary diversification, taking into account the variability between young children in developmental attainment and the need to satisfy their individual nutritional requirements (SACN, 2023; SACN 2018).

Current UK dietary recommendations as depicted in the Eatwell Guide should apply from around age 2 years (SACN, 2023), with the following exceptions:

• UK dietary recommendations on average intake of free sugars (that free sugars intake should not exceed 5% of total dietary energy intake) should apply from age 1 year (SACN, 2023)
• milk or water, in addition to breast milk, should constitute the majority of drinks given to children aged 1 to 5 years (SACN, 2023)
• pasteurised whole and semi-skimmed cows’ milk can be given as a main drink from age 1 year (SACN, 2023), as can goats’ and sheep’s milks (SACN, 2023; COMA, 1994)
• pasteurised skimmed and 1% cows’ milk should not be given as a main drink until 5 years of age. These lower-fat milks can be used in cooking (SACN, 2023; COMA, 1994)
• children aged 1 to 5 years should not be given rice drinks as they may contain too much arsenic (SACN, 2023 endorses COT, 2016 and 2021)
• children aged 1 to 5 years should not be given sugar-sweetened beverages (SACN, 2023)
• dairy products (such as yoghurts and fromage frais) given to children aged 1 to 5 years should ideally be unsweetened (SACN, 2023; COMA 1994)

Formula milks (including infant formula, follow-on formula, ‘growing-up’ or other ‘toddler’ milks) are not required by children aged 1 to 5 years (SACN, 2023 endorses WHO, 2013). Specialised formula, including low-allergy formula, are also usually not required after the first year of life (SACN, 2023).

Foods (including snacks) that are energy dense and high in saturated fat, salt or free sugars should be limited in children aged 1 to 5 years in line with current UK dietary recommendations (SACN, 2023).

Commercially manufactured foods and drinks marketed specifically for infants and young children are not needed to meet nutritional requirements (SACN, 2023).

Salt should not be added to foods given to children aged 1 to 5 years. Children aged 1 to 3 years should, on average, aim to have no more than 2g of salt a day. The figure for children aged 4 to 6 years is 3g a day (SACN, 2023; SACN, 2003).

Children aged 1 to 5 years should be presented with unfamiliar vegetables on multiple occasions (as many as 8 to 10 times or more for each vegetable) to help develop and support their regular consumption (SACN, 2023).

Deliberate exclusion of peanut or hen’s egg (and foods containing these) beyond 12 months of age may increase the risk of allergy to the same foods. Importantly, once introduced, these foods should continue to be consumed as part of the child’s usual diet in order to minimise the risk of allergy to peanut or hen’s egg developing after initial exposure (SACN,2023; SACN-COT, 2018).

Children aged 1 to 5 years should continue to be offered a wide range of foods that are good sources of iron. They do not require iron supplements unless advised by a health professional (SACN, 2023; SACN, 2018).

Children aged 1 to 5 years should be given a daily supplement of 10μg (400 IU) vitamin D and 233μg vitamin A unless, contrary to recommendations, they are consuming more than 500ml of formula milk a day (SACN, 2023; SACN, 2016; COMA, 1994),

Vitamin C supplements are not necessary for the general population. However, there is no evidence that taking vitamin C supplements at the current recommended level of supplementation has any adverse effects (SACN, 2023),

It is recommended that government considers a range of strategies and actions to improve the diets of children aged 1 to 5 years, and continues to monitor dietary intakes, and the nutritional, weight and oral health status of young children as outlined below.

Consider strategies to support and promote:

• continuation of breastfeeding into the second year of life (SACN, 2023)
• current UK dietary recommendations to children aged 1 to 5 years (SACN, 2023)
• feeding of an appropriate and diverse diet to children aged 1 to 5 years that meets nutritional requirements but does not exceed energy requirements (SACN, 2023)
• awareness and uptake of current advice on vitamins D and A supplements at the current recommended levels in children aged 1 to 5 years, particularly in at-risk groups such as children from some ethnic groups and lower socioeconomic status households (SACN, 2023)
• good oral health in children aged 1 to 5 years (SACN, 2023)

Consider strategies to reduce consumption of:

• free sugars and excess protein in children aged 1 to 5 years (SACN, 2023)
• foods (including snacks) that are energy dense and high in saturated fat, salt or free sugars in children aged 1 to 5 years, while encouraging uptake of healthier snacks (SACN, 2023)
• sugar-sweetened beverages in children aged 1 to 5 years (SACN, 2023)

Actions for consideration:

• develop and communicate age-appropriate portion sizes for food and drinks, including for vegetables, fruit, fruit juice and milk, for children aged 1 to 5 years (SACN, 2023)
• review advice on the need for vitamin C supplements for children aged 1 to 5 years (SACN, 2023)
• support parents or caregivers of children aged 1 to 5 years following vegetarian, vegan and plant-based diets to ensure the nutritional requirements (including for iron, iodine, calcium and vitamin B12) of their children are met (SACN, 2023)

Monitoring of children aged 1 to 5 years for consideration:

• collect detailed, nationally representative data on nutrient intakes and status (SACN, 2023)
• collect detailed data on nutrient intake and status of population subgroups, including ethnically diverse populations and socially disadvantaged groups (SACN, 2023)
• monitor the nutritional impact of a population shift towards adopting vegetarian, vegan and plant-based diets (SACN, 2023)
• continue to monitor the prevalence of both overweight and obesity, and the extent of excess energy intakes (SACN, 2023)
• continue to monitor oral health (SACN, 2023)
• monitor intakes of low and non-caloric sweeteners (SACN, 2023)

Research recommendations

Throughout the development of this report, SACN identified a number of significant gaps in the evidence relating to infant and complementary feeding, as well as limitations in the study design for some of the available research.

The committee has therefore made a number of recommendations for research, which are described in chapter ‘13. Research recommendations’ of the full report.