THE COMMITTEE'S TASK AND APPROACH

With support from the Centers for Disease Control and Prevention and from the National Institutes of Health, the National Academies of Sciences, Engineering, and Medicine convened an ad hoc consensus committee that was asked to collect, compare, and summarize existing recommendations on what and how to feed infants and young children from birth to 24 months of age (see Box S-1). The committee was also asked to make recommendations to stakeholders on strategies for communicating and disseminating feeding recommendations.

BOX S-1

Statement of Task.

The committee's search for guideline documents that included recommendations on what and/or how to feed infants and children from birth to 24 months focused on resources from government agencies and from authoritative domestic and international organizations. Guideline documents were found by performing targeted website searches, further supplemented by using the Food and Agriculture Organization of the United Nations' catalog of food-based dietary guidelines, by leveraging expert input, and by searching databases (e.g., ECRI Institute Guideline Trust, CPG Infobase: Clinical Practice Guidelines, PubMed).

The identified documents and resources varied in span and scope, and they required a screening process to determine whether the guideline document contained feeding recommendations and, if so, which of the recommendations addressed the concepts of what or how to feed infants and young children. To that end, the committee established guideline document-level and recommendation-level eligibility criteria (see Table S-1).

The committee abstracted each eligible recommendation verbatim, along with the type of evidence that directly mapped to the recommendation and the associated strength-of-evidence rating, if available. Abstracted recommendations were sorted by topic area and thematically grouped within each topic. Within each theme, the committee reviewed the guidance provided in the verbatim recommendations to describe the level of consistency across guideline documents. The committee also summarized the type of evidence that mapped to each recommendation within a given theme.

For each guideline document, the committee noted any information that the organization included about communicating or disseminating the feeding recommendations. As the available guidance was limited in scope, the committee performed exploratory scans for examples of communication and dissemination materials from the resources and websites reviewed in its guideline document search.

CONSISTENCY OF EXISTING FEEDING RECOMMENDATIONS

The committee identified 156 potentially relevant documents, webpages, and resources through its various search strategies. After applying the eligibility criteria, 43 guideline documents remained to be reviewed in more detail. Included guideline documents reflected the contributions of 26 different agencies, organizations, or groups from Australia, Canada, Europe, Italy, New Zealand, the United Kingdom, and the United States, along with global guidance from the World Health Organization. Nine of the guideline documents were collaborative efforts between two or more organizations.

The included guideline documents varied with respect to the document type (e.g., position statement, clinical practice reports), level of collaboration across organizations, scope of topics covered, target audiences, overall methodologies, presentation of recommendations, and mapping of evidence to each recommendation. Few guideline documents graded the evidence, and those that did often used different rating systems. This heterogeneity likely contributed to some of the noted inconsistencies found across recommendations.

COMMUNICATION AND DISSEMINATION OF FEEDING RECOMMENDATIONS

The feeding guideline documents reviewed by the committee generally did not describe complex, multisector implementation strategies. Accordingly, the committee focused on information contained within the guideline documents related to changing knowledge, attitudes, and/or behaviors, and the channels by which to spread feeding guidance. Of the 43 eligible guideline documents the committee reviewed, 25 included a statement or section related to communicating or disseminating the feeding recommendations. Most of the guideline documents the committee reviewed were specifically developed for one or more target audiences, with a large majority aimed at health care providers (e.g., physicians, nurse practitioners, nurses, dentists, registered dietitian nutritionists, and other nutrition professionals). Other target audiences included parents and guardians, early care and education providers, program administrators, and policy makers. Communication and dissemination approaches were varied across these different target audiences:

• Health care providers: The guideline documents primarily focused on the health care provider as a critical nexus for guiding caregiver practices. The guideline documents encouraged practitioners to promote awareness, changes in attitudes and knowledge, and adoption of recommendations, and to engage in advocacy.
• Parents and guardians: Although the importance of providing parents and guardians with specific feeding guidance was acknowledged, these groups were infrequently the target audience for the guideline documents reviewed. A host of online resources is available to parents and guardians, but these materials are sometimes inconsistent in directly mapping back to a guideline document.
• Early care and education providers: Despite being integral players in infant and young child feeding, early care and education providers were often not the target audience of the guideline documents the committee reviewed. The committee notes that, in the United States, this stakeholder group has a key publication that provides national health and safety performance standards, referred to as Caring for Our Children. One of the standards included relates to nutrition and draws on feeding recommendations from authoritative organizations.
• Program administrators: Program administrators were also not a primary target audience for most of the included guideline documents. The Child and Adult Care Food Program and the Special Supplemental Nutrition Program for Women, Infants, and Children are two key federal programs in the United States that integrate feeding recommendations into practice. Although the committee did not find an eligible guideline document from or for these programs, it did identify recent key resources that translated feeding recommendations, national policy, and federal regulations into programmatic guidance.
• Policy makers: Some of the guideline documents reviewed included recommendations targeting policy makers. The level of detail provided for this target audience varied. For instance, one organization expressed strong support for national policies and legislation related to the feeding recommendations, whereas another guideline document provided explicit guidance to the government.

The guideline documents the committee reviewed were limited in their descriptions of best practices or approaches to communication and dissemination of the feeding recommendations. There is a need to better understand effective communication and dissemination techniques for each of the target audiences, with special consideration of issues of equity, especially in light of an increasing recognition of the association between social determinants of health and persistently observed health disparities, the changing landscape of mobile health devices and applications, and the role of social networks in influencing knowledge, attitudes, and behaviors.

CONCLUSIONS AND FUTURE DIRECTIONS

Across the 26 topic areas related to what to feed and how to feed infants and young children, the committee found that many of the recommendations from the various organizations were consistent or generally consistent. When there was inconsistency, it often related to the specific ages or age ranges stated in the recommendation. Although the committee found considerable variability in the wording of recommendations, in many cases, the differences in wording were subtle.

Overall, recommendations often mapped to narrative reviews. Within most of the themes, at least one of the recommendations for that theme mapped to a systematic review. For some themes, the committee was unable to map a few of the recommendations to the evidence, and for others, the guideline document indicated that there was little or no evidence to support a recommendation. In almost all cases, the body of evidence for a given recommendation was not formally graded.

As many organizations had recommendations on the same topics, and many recommendations were generally consistent, there is substantial potential for harmonization using a collaborative approach. Collaboration on feeding guidelines, starting at the development phase and continuing through the dissemination phase, is likely to facilitate the harmonization of guidance. Harmonization of the process for developing feeding guidelines does not necessarily imply that the specific feeding recommendations need to be exactly the same across countries, communities, and professional organizations. In fact, the need to customize guidance for particular target audiences and contexts means that some of the wording of recommendations may vary, especially in the dissemination and communication products.

CONCLUDING REMARKS

In spite of all of the differences in the ways that guideline documents were developed, it is encouraging that there was consistency for the majority of recommendations across a variety of authoritative organizations. For the future, it is important to harmonize the process across organizations and to use more rigorous methods for developing, communicating, and disseminating recommendations for feeding infants and children from birth to 24 months of age.