New Kids' Guidelines: Drink Milk, Water, Avoid Plant-Based 'Milk'

Ricki Lewis, PhD

September 23, 2019

A new campaign, "Healthy Drinks, Healthy Kids," addresses the importance of healthful drink choices for children under age 5, enforcing the standards of drinking breast milk and formula, milk, and water, while limiting juice and avoiding most plant-based/non-dairy "milks."

The brainchild of a panel of experts representing four organizations — the Academy of Nutrition and Dietetics, the American Academy of Pediatric Dentistry, the American Academy of Pediatrics, and the American Heart Association — the recommendations advise drinking mostly milk and water, with limited juices and avoidance of most plant-based "milks."

The Robert Wood Johnson Foundation funded Healthy Eating Research, which convened the expert panel. The recommendations are published in a technical 62-page report online as part of a website for parents and caregivers.

"These recommendations were made to address the confusion people have on what is appropriate for children to drink and what age-specific drinks should be introduced. Almost half of 2-to-5-year old children consume sugary drinks every day," said American Academy of Pediatric Dentistry President Kevin Donly, DDS, who is chair of the department of developmental dentistry at University of Texas Health San Antonio.

The guidelines are intended to help physicians, parents, and caregivers navigate the world of colorful cartoon images festooning juice boxes and slogans that may misrepresent the nutritional value of beverages pitched to children.

"Since its creation, (brand name) has reminded us of cheerful childhoods full of energy and fun," proclaims the packaging of a chocolaty drink that's been popular for decades. The energy, of course, comes from the high fructose corn syrup, the second ingredient following water.

"Beverage companies have one goal — to sell their product. They know that kids love sugary tastes and that parents want to offer their children healthy options, so they make sure their products taste sweet but market them so that parents think that they are healthy," said Natalie Muth, MD, MPH, an expert panel member who is a pediatrician at Children's Primary Care Medical Group in Carlsbad, CA, and spokesperson for the American Academy of Pediatrics.

Age-Based Chart

The panel developed an age-based chart to guide parents, recommending that all kids under 5 should not drink flavored milks, toddler formulas (also known as "weaning" or "transition" formulas), most plant-based "milks," and beverages containing caffeine, added sugar, or sugar substitutes.

The age-based recommendations are:

• Under 6 months of age, babies should drink only breast milk or formula.

• Babies 6 to 12 months can sip water at mealtime once they begin solid foods, but should avoid juice.

• At 12 to 24 months, children can drink whole milk and water. A small volume of 100% fruit juice is okay.

• At 2 to 5 years, "milk and water are the go-to beverages," stressing milk that is low-fat or skim. A small serving of 100% fruit juice is okay.

Angela Lemond, RDN, CSP, LD, national spokesperson for the Academy of Nutrition and Dietetics, fleshes out the recommendations. "We encourage parents to [feed their children] cut-up whole fruit over juice. If a child under 5 years old has juice, make it 100% fruit juice, without added sugar, and keep the intake below one-half to three-quarters of a cup, depending on age.

"Children of 1 to 3 years may have up to 4 oz of 100% juice and children of 4 to 5 years may have up to three-quarters of a cup of 100% juice. Adding water to 100% fruit juice can make a little bit go a long way."

Plant-Based "Milks"

Plant-based "milks" pose a challenge. Data show increased sales for milk-like drinks made from almond, rice, coconut, soy, cashews, or hazelnuts, but not consumption by age group.

These products aren't necessarily dangerous, but they're not nutritionally equivalent to cow's milk, with the exception of soy, said Muth. "The concern is that these drinks will displace milk and that subsequently children will not get enough of important nutrients that they need like calcium, vitamin D, and protein."

Phytates in seeds, which are often mashed to yield a "milk," bind zinc, magnesium, and iron. Lemond added that a child's growing body cannot properly absorb vitamins added to plant-based "milks."

For children with a dairy allergy, "we recommend working with a registered dietitian nutritionist that specializes in children. It's important that the entire diet is looked at to make sure that the child gets individualized guidance to ensure proper accommodations," said Lemond.

About 2.5% of children under age 3 are allergic or intolerant to cow's milk, according to the report. "For children with lactose intolerance, fortified soy milk is recommended," Donly said.

For families that wish to use plant "milks" as part of a vegetarian or vegan diet to either fully or partially replace cow's milk, the recommendations state that "careful attention should be given to the selection of other dietary choices in order to provide the nutrients that would otherwise be consumed through cow's milk."

For help, parents should consult a healthcare provider, such as a pediatrician and/or registered dietitian nutritionist, the panel advises. If plant-based beverages are part of a child's diet, stick to unsweetened varieties.

Sweet Milk

Chocolate milk may be an obstacle in some families, especially when parents have fond memories of a chocolate milk carton at the epicenter of a long-ago school cafeteria lunch tray, or recall the enticing brown river of Willy Wonka and the Chocolate Factory. How can they deny the treat to their own youngsters?

Alas, science suggests ditching the chocolaty drinks.

"While milk is nutritious for children, chocolate milk contains a lot of added sugars. They increase a child's risk for type 2 diabetes, heart disease, fatty liver disease, cavities, and childhood obesity. It is much better to offer young children plain milk when they are young so they will continue to like and drink plain milk when they are older," said Muth.

Although taste preferences are typically well formed by the time a child starts school, with repeated exposures even older kids can learn to like new tastes, she added.

Donly weighed in on chocolate milk too. "Similar to other carbohydrated drinks, chocolate milk has sugar added for flavor. Chocolate milk also has calcium, which is good; so chocolate milk is better than soda."

"Make It the Norm"

Muth suggested taking a straightforward approach to following the guidelines. "Only keep water and milk in the home and make it the norm for these beverages to be the go-to default for young kids. These are the best drinks for the rest of the family as well."

Lemond advised taking the direct approach in restaurants too. " 'Would you like water or milk to drink?' Those are two acceptable options and the child may choose."

The new guidelines may provide a defense for a parent standing in the juice aisle of a grocery store with a wailing, pleading child. For example, the juice box label that boldly states its goal "to provide your family with pure, healthy juices that taste as good as they are good for you and your kids" isn't consistent with the recommendations, and may have to soon amend its message.

Early signs suggest this change may be on the way, with more packages adding bright labels proclaiming "1/2 the sugar."

The new recommendations should catalyze that trend in the right direction. "Food and beverage preferences are formed very early," said Lemond. "It is never too early to start feeding our children well so they are set on a proper path of health."

The commenters have disclosed no relevant financial relationships.

Healthy Eating Research. Healthy Beverage Consumption in Early Childhood: Recommendations from Key National Health and Nutrition Organizations. Technical Scientific Report

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