There are 2 important yet different types of standards for describing the nutritional needs (dietary guidelines) for populations of healthy individuals of varying ages.1 One of the standards is described as the recommended dietary allowance (RDA) while the other is generally referred to as the nutrition recommendations. The two standards fulfill different functions. RDAs are designed to define a comprehensive set of reference values for dietary nutrient intakes for healthy populations. Nutrition recommendations define appropriate nutritional and feeding standards for different age and gender groups. Two recent examples in each category will exemplify the difference between the 2 standards. The Dietary Reference Intake (DRI) Committee has recently defined the calcium and vitamin D needs of Canadians and Americans from birth to old age of both genders.2 DRIs have direct applications in planning or formulating foods for special diets and situations for individuals or groups; for estimating the total needs of the population for energy and nutrients; in setting standards eg, for institutional feeding; and in food and nutrition monitoring.3 The report on calcium and related nutrients was the first in a series of reports that presented dietary reference values for the intake of nutrients for healthy Americans and Canadians. The overall project is a comprehensive effort undertaken by the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes by the Food and Nutrition Board, Institute of Medicine, National Academy of Sciences with the involvement of Health Canada.
Nutrition recommendations have recently been published in Canada for infants from birth to age 2 years.4 The Canadian Paediatric Society, the Canadian Dietetic Society (Dietitians of Canada), and the federal ministry of health (Health Canada) collaborated on the preparation of this statement on infant nutrition for healthy term infants from birth to 24 months of age. These 3 organizations, who are most responsible for the development of policy on nutrition, were equal partners in the development of these feeding guidelines. The recommendations were intended to be used by health care professionals. They provide information that is basic to communicating consistent messages about infant nutrition to parents and caregivers across Canada. It is not designed, however, to be an all-encompassing practical guide to infant feeding. First, a summary of the nutrition recommendations for healthy term infants from birth to 24 months of age was presented. Then 4 major topics related to nutrition in the first year of life are discussed: breastfeeding, formulas and alternate milks, other fluids, and transition to solid foods. Nutrition in the second year of life is presented next, followed by safety issues around feeding. The last section covers other issues in infant nutrition: allergies, colic, constipation, dietary fat modifications, nursing bottle syndrome, fluoride supplementation, gastroenteritis, infants genetically at risk for diabetes, iron supplementation, and vegetarian diets.
Wherever possible, the recommendations in this statement were based on available scientific evidence. However, many studies on infant nutrition are not based on randomized trials because it is neither possible nor ethical in many circumstances (eg, it is not possible to randomize potentially breastfed infants into a non-breastfed control group). Similarly, it is often not possible to randomize infants into feeding practices that are rational from a nutritional perspective, but culturally unacceptable. In the absence of solid science, accepted practice and its rationale were presented. Throughout this document, the authors attempted to clearly distinguish those recommendations based on science versus those based on common practice. As new clinical studies and meta-analyses are published in this area, recommendations may be altered accordingly.
One of the most significant changes in the provision of health care in the last decade has been the shift to managed care using evidence-based clinical guidelines. Evidence-based medicine has been defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”5 The practice of evidence-based medicine means integrating individual clinical expertise with a critical appraisal of the best available external clinical evidence from systematic research.6 Conscientious means evidence is relevant and is applied consistently; judicious means evidence is combined with clinical expertise to obtain a balance of risk and benefit for the patient, client, or customer; and current best evidence means evidence is up-to-date.7
To date, there have been no attempts to use the evidence-based approach for the development of nutrition policy on the feeding of complementary foods to infants. Two recent publications have emphasized the need for an evidence-based approach within the field of nutrition.7,8 In preparation for this International Meeting on Complementary Foods, it became apparent that there were no international equivalents to either the DRIs for infants or nutrition recommendations for infants. To achieve the degree of international consensus that would be necessary to develop and accept international DRIs and nutrition recommendations for the use of complementary foods, the following questions would have to be answered.
Is it possible to develop a methodology for the systematic and comprehensive review of the literature within the framework of evidence-based science that would be applicable to guidelines for nutrition recommendations?
Is it possible to develop a grading system for assessing the value of studies (other than randomized, controlled trials) as would be found in a literature review on infants feeding?
Can a single set of set of international nutrition recommendations targeted to complementary foods be developed?
Premature or poorly substantiated recommendations to the public can lead to confusion, especially if the public is faced with a reversal of advice, as more evidence becomes available. Availability of guidelines for the introduction of complementary foods based on an evidence-based approach would go a long way to diminish the apparent confusion in this area.
- Truswell AS. Dietary goals and guidelines: national and international perspectives. In: Shils ME, Olson JA, Shike M, eds. Modern Nutrition in Health and Disease. Baltimore, MD: Williams & Wilkins; 1994
- Standing Committee on the Scientific Evaluation of Dietary Reference Intakes: Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1997
- Beaton GH. Dimensions of Nutrient Requirements. National Institute of Nutrition. Ottawa, Canada: Rapport; 1995:7–8
- Nutrition for Healthy Term Infants: Statement of the Joint Working Group: Canadian Paediatric Society, Dietitians of Canada and Health Canada. Ottawa, Canada: Minister of Public Works and Government Services; 1998
- Sackett D,
- Rosenberg W,
- Gray J,
- Richardson W
- Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine. New York, NY: Churchill Livingstone; 1997
- Copyright © 2000 American Academy of Pediatrics