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ENDORSEMENTS: HEALTHY BEVERAGES
Healthy Beeae C t Ealy Chlh
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Endorsed by the American Academy How to Cite: Ae
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2019 ey atal health a tt aat S ay al
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The American Academy of Pediatric Dentistry (AAPD), in its olds, close to half (45 percent) consume a sugar-sweetened
efforts to promote optimal health for children, supports the beverage (SSB) daily, and the prevalence of SSB consumption
2019 technical report and consensus statement on beverage increases throughout childhood. Significant differences in
consumption by young children (ages 0-5 years). These guide- beverage intake by race/ethnicity and income groups in early
lines were developed as part of a collaboration of the Academy childhood have been noted.
of Nutrition and Dietetics (AND), the AAPD, the American Leading medical and nutrition organizations recommend
Academy of Pediatrics (AAP), and the American Heart Asso- breast milk, infant formula, water, and plain milk as part of
ciation (AHA). This cooperative effort transpired under the beverage guidelines for children under age five. They caution
leadership of Healthy Eating Research (HER), a leading nutri- against beverages that are sources of added sugars in young
tion research organization, through funding from the Robert children’s diets, including flavored milks (e.g., chocolate,
Wood Johnson Foundation. strawberry) and sugary and low-calorie sweetened beverages.
To develop the technical report and recommendations, HER In addition, they advise against a wide variety of new beverages
conducted a review of scientific literature, gathering existing on the market targeted to children, such as toddler formulas,
guidelines from national and international bodies and reports caffeinated beverages, and plant-based/non-dairy milks (e.g.,
on early childhood beverage consumption. It also convened almond, rice, oat) that provide no unique nutritional value.
an expert panel of representatives from the AND, AAPD, AAP, The recommendations outlined on the next pages by age
AHA, and a scientific advisory committee. This policy brief are intended for healthy children in the United States and do
is intended to summarize key findings, especially as related to not address medical situations in which specific nutrition
oral health considerations. guidance is needed to manage a health condition.
Establishing healthy dietary patterns in early childhood is Summary of considerations related to oral health:
important to help prevent future diet-related chronic diseases The overconsumption of unhealthy beverages coupled
and support optimal growth and development and overall with the underconsumption of healthy beverages during
health. Healthy beverage intake is critical in early childhood early childhood can lead to the development of chronic
because beverages can make a significant contribution to die- diet-related diseases including diabetes, obesity, and
tary intake during this period and, thus, may serve as important dental caries.
sources of essential nutrients. However, many beverages con- Establishing healthy beverage patterns in the first five
tain added sugars and saturated fats, which can be harmful years can promote adequate intake of healthy nutrients
when consumed in excess. Overconsumption of unhealthy while reducing excess consumption of sugars and
beverages along with inadequate consumption of healthy saturated fats.
beverages in early childhood can contribute to chronic diseases,
including dental caries.
Despite the importance of healthy beverages in early ABBREVIATION
childhood, the beverage intake of many young children AAPD: Ae
a A
aey Peat
Detty AAP: Ae
a
diverges from evidence-based recommendations. For example, A
aey Peat
AHA: Ae
a Heat A
at AND:
many infants consume cow’s milk and 100 percent juice before A
aey N tt a Detet
HER: Healthy Eat Reea
h
their first birthday, which can increase their risk for such LCS: L
ale eetee SSB: S aeetee eeae
nutrient deficiencies as anemia. Among two- and three-year
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 565
ENDORSEMENTS: HEALTHY BEVERAGES
Early life is an important period for the development of uncarbonated, fluoridated drinking water), particularly
flavor and food preferences. Thus, minimizing children’s for beverages consumed outside of meals and snacks.
exposure to sweet-tasting beverages during their early Fluoridated drinking water is a beneficial and inexpensive
years may help reduce their preference for sweetened strategy for reducing dental caries. The vast majority of
food and beverages at older ages. bottled waters do not contain optimal levels of fluoride,
Strong evidence demonstrates the adverse health effects and some do not contain any fluoride.
of SSBs, which include, but are not limited to, soft Between one and five years of age, plant milks may be
drinks/soda, fruit drinks, fruit-flavored drinks, sports particularly useful for children with allergies or intoler-
drinks, energy drinks, sweetened waters, and sweetened ances to cow’s milk (about 2.5 percent of children under
coffee and tea beverages. Children from birth to five years three years old are allergic to milk) or to accommodate
old should not consume sugar-sweetened beverages. vegan or certain vegetarian dietary preferences. Children
For children ages six to 12 months who are eating solid should consume only unsweetened varieties in order to
foods, a small amount (e.g., approximately four to eight avoid additional added sugar in the diet.
ounces total per day) of plain drinking water may be Little research has examined low-calorie sweeteners (LCS)
offered in an open, sippy, or strawed cup to help famil- intake and sweet taste preferences among young children.
iarize the infant with plain water. The early introduction Given that early childhood is a critical developmental
of water may help children become accustomed to its period and that there is a lack of evidence regarding the
taste. long-term health impact of LCS consumption in young
Children ages one to five years are encouraged to con- children, children from birth to five years old should not
sume plain drinking water (i.e., unflavored, unsweetened, consume beverages with LCS.
Table. Summary of Beverage Recommendaton for Cldren Age yeara
mont mont mont year Note
year year
er No Approximately 1-4 cups 1-4 cups 1.5-5 cups Where an individual child falls
t
a supplemental 0.5-1.0 cups (8-32 oz.) (8-32 oz.) (12-40 oz.) within these ranges for 12
g drinking (4-8 oz.)/day per day per day per day months to 5 years will depend
water in a cup. Begin on the amounts of other bever-
needed offering during ages consumed during the day.
meals once
an drn
n solid foods are
l introduced.
P
Not Not 2-3 cups Up to 2 cups Up to 2.5 cups For 12-24 months, reduced-fat
l
recommended recommended (16-24 oz.) (16 oz.) (20 oz.) (2%) or low-fat (1%) milk may
per day per day per day be considered in consultation
ed m whole milk skim (fat-free) skim (fat-free) with a pediatrician, especially if
or or weight gain is excessive or
ur low-fat low-fat family history is positive for
er
t (1%) milk (1%) milk obesity, dyslipidemia, or other
a cardiovascular disease; the total
an amount of milk consumed dur-
l ing this age will depend on how
P
much solid food is being eaten.
Not Not Whole fruit Whole fruit Whole fruit Amounts listed for ages 12
e recommended recommended preferred. preferred. preferred. months to 5 years are upper
c limits (not minimum require-
No more than No more than No more than ments) that may be consumed
u 0.5 cup (4 oz.) 0.5 cup 0.5-0.75 cup only if fruit intake recommen-
per day (4 oz.) per day (4-6 oz.) per day dations cannot be met with
100% juice. 100% juice. 100% juice. whole fruit.
a
The 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.
566 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
ENDORSEMENTS: HEALTHY BEVERAGES
Table. Contnued
mont mont mont year Note
Not Not Not recommended Consume only when Consumption of these beverages
y recommended recommended for exclusive con- medically indicated as a full replacement for dairy milk
ar sumption in place of (e.g., allergy or intol- should be undertaken in consulta-
d dairy milk; consume erance) or to meet tion with a health care provider
n
o ge only when medically specific dietary pre- so that adequate intake of key
N a
l
er indicated (e.g., cow’s ferences (e.g., vegan) nutrients commonly obtained from
v
t mbe milk allergy or in- dairy milk can be considered in
an tolerance) or to meet dietary planning.
l
P specific dietary pre-
ferences (e.g., vegan)
Not Not Not Not Added sugars intake should be
l
recommended recommended recommended recommended avoided in children <2 years old
and minimized in children 2-5
ed m years old to avoid contributing to
r early establishment of a prefer-
o
v
a
l ence for sweet taste as well as
potential negative impacts on
nutrient intake and diet quality.
l
Not Not Not Not These products offer no unique
recommended recommended recommended recommended nutritional value beyond what a
nutritionally adequate diet pro-
oddler m vides and may contribute added
T sugars to the diet and undermine
sustained breastfeeding.
Not Not Not Not Strong evidence demonstrates
B recommended recommended recommended recommended the adverse health effects of SSB,
enedSS which include, but are not limited
eet to, soft drinks/soda, fruit drinks,
ge fruit-flavored drinks, fruitades,
a
ar er sports drinks, energy drinks, sweet-
g v
uS be ened waters, and sweetened coffee
and tea beverages.
S Not Not Not Not This recommendation is based
LC recommended recommended recommended recommended on expert opinion given that early
re childhood is a critical develop-
to
ge al mental period, and there is a lack
a cener of evidence regarding the long-
er o
v l eet
e term health impact(s) of LCS
B
consumption in young children.
ed Not Not Not Not Caffeinated beverages are not
t ge
a a recommended recommended recommended recommended appropriate for young children.
ener
affv
C be
Notes: All amounts listed are per day, unless otherwise noted; 1 cup fluid ounces.
It is ideal for young children to achieve fruit intake goals. The recommendations for juice consumption are
recommendations primarily by eating whole fruits with- considered upper limits for daily servings, not minimum
out added sugars or low-calorie sweeteners. However, a requirements. If consumed, 100 percent juice should be
combination of fruit plus 100 percent fruit juice is pre- part of a meal or snack, not sipped throughout the day.
ferred to the alternative of falling short of fruit intake
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 56
ENDORSEMENTS: HEALTHY BEVERAGES
Frequent consumption of between-meal snacks and Bleich SN, Vercammen KA. The negative impact of sugar-
beverages containing sugars, whether added or naturally- sweetened beverages on children’s health: An update of the
occurring, increases the risk for dental caries due to literature. BMC Obesity 2018;5(6):1-27. Available at: “https:
prolonged contact between sugars in the consumed food //bmcobes.biomedcentral.com/track/pdf/10.1186/s40608-
or liquid and cariogenic bacteria on the teeth. To reduce 017-0178-9”. Accessed September 28, 2019.
the risk of caries: Gordon-Larsen P, The NS, Adair LS. Longitudinal trends in
– Avoid consumption of sugar sweetened beverages obesity in the United States from adolescence to the third
from a sippy cup or other training cup. decade of life. Obesity 2009;18(9):1801-4.
– Wean young children from a bottle by age one.
– Do not put children to bed with a bottle containing Kay M, Welker E, Jacquier E, Story M. Beverage consumption
anything but water. patterns among infants and young children (0–47.9 Months):
Data from the feeding infants and toddlers study, 2016.
For the complete consensus statement, visit: Nutrients 2018;10(7):825.
– https://healthyeatingresearch.org/wp-content/uploads/2019/ Marshall TA, Levy SM, Broffitt B, et al. Dental caries and
09/HER-HealthyBeverage-ConsensusStatement.pdf beverage consumption in young children. Pediatrics 2003;112
For the complete technical report, visit: (3 Pt 1):e184-91. Available at: “https://pediatrics.aappublica
– https://healthyeatingresearch.org/research/technical-scientific- tions.org/content/pediatrics/112/3/e184.full.pdf”. Accessed
report-healthy-beverage-consumption-in-early-childhood- September 28, 2019.
recommendations-from-key-national-health-and-nutrition- Okubo H, Crozier SR, Harvey NC, et al. Diet quality across
organizations/ early childhood and adiposity at 6 years: The Southampton
Bblogray Women’s Survey. Int J Obes 2015;39(10):1456-62.
American Academy of Pediatrics. Maintaining and improving Skinner JD, Carruth BR, Wendy B, Ziegler PJ. Children’s
the oral health of young children. Pediatrics 2014;134(6): food preferences: A longitudinal analysis. J Am Diet Assoc
1224-9. Available at: “https://pediatrics.aappublications. 2002;102(11):1638-47.
org/content/pediatrics/134/6/1224.full.pdf”. Accessed U.S. Department of Health and Human Services. Dietary
September 28, 2019. Guidelines for Americans 2015-2020. 8th ed. 2015. Available
American Dental Association. The facts about bottled water. at: “https://health.gov/dietaryguidelines/2015/resources/2015
J Am Dent Assoc 2003;134(9):1287. Available at: “https:// -2020_Dietary_Guidelines.pdf”. Accessed September 28,
jada.ada.org/article/S0002-8177(14)65095-9/pdf”. Accessed 2019.
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Birch LL, Doub AE. Learning to eat: Birth to age 2 y. Am J
Clin Nutr 2014;99(3):723S-8S. Available at: “https://
academic.oup.com/ajcn/article/99/3/723S/4577491”. Accessed
September 28, 2019.
56 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
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