Content uploaded by Nathali Lehmann Hirsch
All content in this area was uploaded by Nathali Lehmann Hirsch on May 14, 2020
Content may be subject to copyright.
Downloaded from https://journals.lww.com/jpgn by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3YeLEAQtdJ83me5LpHBRACYSdrGG6RolD8LFuI5vMdbcoAgJy4TVseA== on 05/14/2020
Downloadedfromhttps://journals.lww.com/jpgn by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3YeLEAQtdJ83me5LpHBRACYSdrGG6RolD8LFuI5vMdbcoAgJy4TVseA== on 05/14/2020
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
Pureed Fruit Pouches for Babies: Child Health
Nathali Lehmann Hirsch,
Jo M. Jewell,
Joao Rodrigues Da Silva Breda, and
Breast-feeding is the optimal form of infant feeding, with
numerous benefits for maternal and child health (1 –3). From
an age of about 6 month onwards ‘‘breast milk alone is no longer
sufficient to meet the nutritional requirements of infants’’ (1), and
complementary feeding should be introduced to provide additional
energy and critical nutrients such as iron, zinc, iodine, or long-chain
polyunsaturated fatty acids for supporting continued healthy growth
and development (3,4). In addition to the widely used homemade
complementary foods, many commercial food products for infants
and young children are available. WHO has provided guidance on
ending the inappropriate promotion of such foods for infants and
young children (5).
In recent years, a rapidly increasing number and variety of a
new type of commercial complementary foods has been offered,
that is, pureed, semiliquid foods for infants, and young children
packed in squeezable plastic pouches usually equipped with a spout
and screw cap (Fig. 1). These pureed pouch products promise added
convenience to families: after unscrewing the lid, the contents can
be directly squeezed into an infant’s mouth, or infants can suck out
the contents directly from the spout, thereby enabling fast feeding
on the go. This new method of infant feeding has proved very
popular; even reusable pouches are now sold for feeding infants
with homemade pureed baby food from a squeezable bag.
What might appear as a great idea for adding convenience
and reducing parents’ time spent with infant feeding raises some
serious concerns. The complementary feeding period is not only
about provision of nutrients, but it is also is the period of learning
the transition from exclusive milk feeding to the varied family diet
consumed in early childhood, with rapid advancement of oropha-
ryngeal motor learning and development, and of acquiring feeding
and eating behavior skills (4). If infants are fed predominantly by
sucking from a pouch, this may delay and impair learning to eat
from a spoon; exploring foods with tongue; lips, and hands; and
chewing. Some observations point to a critical time window for the
introduction of lumpy solid foods. Delayed introduction of lumpy
foods after the age of about 9 to 10 months was linked to increased
feeding difficulties and low intakes of eating vegetables and fruits at
later ages (6). Therefore, it is not advisable to provide complemen-
tary feeding mostly by sucking—similar to milk feeding.
Feeding infants a variety of food textures and lumpy foods by
spoon feeding and finger foods provides great opportunities for
intensive reciprocal interaction between parent and infant, for
listening and talking, and for learning to sense each other’s signals
(responsive feeding) (7,8), which may be missed if infants are left
on their own to suck from a pouch.
Major concerns arise also from the typical composition of
baby foods in pouches. Manufacturers tend to stress the natural and
often organic nature of these foods, and the absence of artificial
additions, gluten, lactose, or other components often considered by
the public as less desirable. These products, however, often have a
high energy density, high sugar content, and a very sweet taste. This
adds to the already unbalanced composition of commercial com-
plementary feeds, where two thirds of marketed products were
reported to be sweet foods (9). Many of the pouch products for
infants and young children provide pureed fruit. Although some
pureed foods in pouches are offered with grains and vegetables,
even they tend to have a very sweet taste and to be high in sugar
content, and they also need to be liquid or semiliquid to be delivered
through the spout.
Whole meals provided by fruit only are not usually recom-
mended as part of complementary feeding, because they do not
supply appreciable amounts of those nutrients which need to be
provided in addition to continued breast-feeding, in particular iron,
zinc, iodine, and long-chain polyunsaturated fatty acids . Therefore,
fruits are usually recommended only as an addition to a cereal or as
a small portion to accustom infants to a variety of flavors and
textures, provided after a mixed meal based on vegetables, meat, or
Parents may consider a fruit pouch equivalent to offering a
piece of fresh cut fruit to their baby, which is not the case. The
composition of 10 such products with high sugar contents found in
retail stores in Denmark (Table 1) indicates an energy density of 45
to 95 kcal/100 g, which often is much higher than the typical energy
density of fresh fruit (eg, 54 kcal/100 g apple), presumably due to
removal of water or fiber during the production process, and/or the
preferential use of fruits with high sugar contents. The combination
of a high energy density with an easy consumption by sucking, as
opposed to having to chew and swallow pieces of fruit, can lead to a
high intake of energy and sugar in the form of fructose during a
short time period. Therefore, regular infant feeding with pureed
Received April 27, 2018; accepted June 5, 2018.
From the LMU-Ludwg-Maximilians-Universita¨t Mu
¨nchen, Dr. von
Hauner Children’s Hospital, University of Munich Medical Center,
¨nchen, Germany, the yWHO Regional Ofﬁce for Europe, Copenha-
gen, Denmark, the zWHO European Ofﬁce for Prevention and Control of
Noncommunicable Diseases, Moscow, Russian Federation, and the
§European Childhood Obesity Group, Francavilla Fontana, Italy.
Address correspondence and reprint requests to Berthold Koletzko, MD,
PhD, Dres hc, LMU-Ludwig-Maximilians-Universita¨t Mu
von Hauner Children’s Hospital, Lindwurmstr 4, 80337 Mu
Germany (e-mail: ofﬁce.firstname.lastname@example.org).
The work of B.K. is ﬁnancially supported in part by the Commission of the
European Communities, Projects Early Nutrition (FP7-289346), DYNA-
HEALTH (H2020-633595), and LIFECYCLE (H2020-SC1-2016-RTD),
the European Research Council Advanced Grant META-GROWTH
(ERC-2012-AdG 322605), the Erasmus Plus programme ‘‘Early Nutri-
tion eAcademy Southeast Asia—573651-EPP-1-2016-1-DE-EPPKA2-
CBHE-JP,’’ and the EU Interreg Programme ‘‘Focus in CD-CE111.’’
Travel support to attend meetings at the WHO regional Ofﬁce for Europe
was provided by the European Society for Paediatric Gastroenterology,
Hepatology and Nutrition (www.espghan.org). J.R.B., J.M.J., and
M.W are WHO staff members. The opinions expressed are theirs and
do not necessarily reﬂect the views and policies of the World Health
The authors report no conﬂicts of interest.
Copyright #2018 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
JPGN Volume 67, Number 5, November 2018 561
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
fruit from pouches may bear the risk to induce overfeeding and an
excessive infant weight gain, which has been associated with a
markedly increased risk of later obesity (10,11). Many such pro-
ducts have extremely high sugar contents ranging from 84% to 98%
of total energy content (Table 1), which seems inadequate for a meal
provided to babies. Apparently most if not all of the sugar content is
composed of sugars found naturally in fruits, and not of ‘‘added
sugars’’ supplemented during processing of the foods. Although the
term ‘‘added sugar’’ is useful for regulatory and policy purposes,
we do not consider it to describe the quality and suitability of
complementary foods because any content of sugars, be it
from prepared fruits and other ingredients or from added isolated
sugars, has similar untoward metabolic, dental, and other health
A pureed food with high sugar content is more likely to stick
on dental surfaces than chewed foods with abrasive qualities, and
thereby may pose an increased risk for the development of dental
caries. Also, the repeated exposure to the very sweet taste of such
products may induce potential programming effects on later taste
and food choices. Early dietary experience of sweet tasting foods
and drinks was linked to a stronger preference of sweet foods later
(13), which is undesirable because of the associated risk increase for
dental caries, obesity, and associated diseases (14).
The very high sugar intake with feeding a whole comple-
mentary feeding meal based on pureed fruits must be expected to
increase blood glucose and insulin levels to an even greater extent
than occurring with eating an equal amount of intact fruit, because
the preserved matrix of natural fruits tends to slow down absorption,
as compared to absorption from mushed foods. For example the
glycemic index of mashed potatoes is 83 and thus far higher than the
glycemic index of boiled potatoes with only 49 (5). A high glycemic
load stimulates high infant insulin secretion that can induce an
undesirable high infant weight gain velocity and increased later
obesity risk (15). High habitual dietary sugar intake over lifetime
has also been associated with an increased adiposity-related cancer
risk (16). In the project VIVA birth cohort study, maternal sugar
intake in pregnancy and offspring sugar intake in early childhood
were inversely associated with child cognition (17). Different fruits
vary in the composition of sugars, but fruits are generally rich in
fructose, along with variable contents of glucose and sucrose (18). It
appears likely that the high fructose intake with pureed fruit
pouches has greater adverse metabolic effects than similar intakes
of other carbohydrates, because fructose appears to promote de
novo lipogenesis, hepatic steatosis, and nonalcoholic fatty liver
disease (19–21), and also a fructose-induced increase in asthma risk
has been reported (22). Although further work is needed to define
and fully understand the health impact of dietary sugars (23), based
on the currently available data a limited dietary sugar intake is
strongly recommended (14).
We conclude that infants and young children should not
regularly suck pureed foods from a plastic pouch, but rather be
given the opportunity to explore a variety of foods given by
spoon feeding or as finger foods, supported by a reciprocal,
responsive relationship between parent and infant. We recom-
mend the use of well-prepared home-made complementary foods
with limited amounts of sugar but high contents of nutrients that
are of critical importance for the age, and that offer diverse
flavor and texture experiences. If commercial complementary
foods are used, they should be selected based on the same
TABLE 1. Energy density (kcal/100 g) and sugar contents (percentage of energy) in 10 fruit puree pouch products with high natural sugar contents
sold in retail stores in Denmark in May 2017
Declared Main Ingredients Promoted From Age, mo Energy, kcal/100 g Sugar, g/100 g Sugar (percentage of kcal)
Banana 4 95 23.2 98
Apple, banana, and mango smoothie 6 64 14.0 88
Strawberry and apple 4 45 9.8 87
Apple and plums 4 58 12.6 87
Apple and banana smoothie 6 65 14.0 86
Banana and apple 4 76 16.3 86
Prunes 4 45 9.6 85
Banana, mango, apricot, apple 6 72 15.2 84
Apple and mango smoothie 6 57 12.0 84
Apple and strawberry 6 57 12.0 84
Data represent the declarations on the package.
FIGURE 1. Example of a pureed fruit pouch offered for infants and
Editorial JPGN Volume 67, Number 5, November 2018
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
guiding principles. Readymade pureed fruits should usually not
substitute for a whole meal, but only be used as an addition to a
meal, for example, as an addition to a cereal, and they should be
fed by a spoon and not by sucking out of a pouch. Implementa-
tion of regulatory standards for these types of products may be
required to protect child health.
1. World Health Organisation. Complementary Feeding Report of the
Global Consultation. Geneva, 10– 13 December 2001. Summary of
Guiding Principles. Geneva: World Health Organisaton; 2002.
2. ESPGHAN Committee on NutritionAgostoni C, Braegger C, Decsi T,
et al. Breast-feeding: a commentary by the ESPGHAN Committee on
Nutrition. J Pediatr Gastroenterol Nutr 2009;49:112–25.
3. Prell C, Koletzko B. Breastfeeding and complementary feeding—
recommendations on infant nutrition. Dtsch Arztebl Int 2016;113:
4. ESPGHAN Committee on NutritionFewtrell M, Bronsky J, Campoy C,
et al. Complementary feeding: a position paper by the European Society
for Paediatric Gastroenterology, Hepatology, and Nutrition (ESP-
GHAN) Committee on Nutrition. J Pediatr Gastroenterol Nutr
5. World Health Organisation. Guidance on Ending the Inappropriate
Promotion of Foods for Infants and Young Children. Report to the
69th World Health Assembly. Geneva: World Health Organisation; 2016
6. Coulthard H, Harris G, Emmett P. Delayed introduction of lumpy foods to
children during the complementary feeding period affects child’s food
acceptance and feeding at 7 years of age. Matern Child Nutr 2009;5:75–85.
7. Hetherington MM. Understanding infant eating behaviour—lessons
learned from observation. Physiol Behav 2017;176:117– 24.
8. Silva GA, Costa KA, Giugliani ER. Infant feeding: beyond the nutri-
tional aspects. J Pediatr (Rio J) 2016;92(3 suppl 1):S2– 7.
9. Garcia AL, Raza S, Parrett A, et al. Nutritional content of infant
commercial weaning foods in the UK. Arch Dis Child 2013;98:793–7.
10. Rzehak P, Oddy WH, Mearin ML, et al. Infant feeding and growth
trajectory patterns in childhood and body composition in young adult-
hood. Am J Clin Nutr 2017;106:568– 80.
11. Oddy WH, Mori TA, Huang RC, et al. Early infant feeding and adiposity
risk: from infancy to adulthood. Ann Nutr Metab 2014;6:215–23.
12. ESPGHAN Committee on NutritionFidler Mis N, Braegger C, Bronsky
J, et al. Sugar in infants, children and adolescents: a position paper of
the European Society for Paediatric Gastroenterology, Hepatology and
Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr
13. Beauchamp GK, Moran M. Dietary experience and sweet taste pre-
ference in human infants. Appetite 1982;3:139– 52.
14. World Health Organisation. Sugars Intake for Adults and Children.
Geneva: World Health Organisation; 2015.
15. Socha P, Hellmuth C, Gruszfeld D, et al. Endocrine and metabolic
biomarkers predicting early childhood obesity risk. Nestle Nutr Inst
Workshop Ser 2016;85:81–8.
16. Makarem N, Bandera EV, Lin Y, et al. Consumption of sugars, sugary
foods, and sugary beverages in relation to adiposity-related cancer risk
in the Framingham Offspring Cohort (1991– 2013). Cancer Prev Res
(Phila) 2018;11:347– 58.
17. Cohen JFW, Rifas-Shiman SL, Young J, et al. Associations of prenatal
and child sugar intake with child, cognition. Am J Prev Med 2018;54:
18. Ma C, Sun Z, Chen C, et al. Simultaneous separation and determination
of fructose, sorbitol, glucose and sucrose in fruits by HPLC-ELSD. Food
Chem 2014;145:784– 8.
19. Schwarz JM, Noworolski SM, Erkin-Cakmak A, et al. Effects of dietary
fructose restriction on liver fat, de novo lipogenesis, and insulin kinetics
in children with obesity. Gastroenterology 2017;153:743–52.
20. Sekkarie A, Welsh JA, Vos MB. Carbohydrates and diet patterns in
nonalcoholic fatty liver disease in children and adolescents. Curr Opin
Clin Nutr Metab Care 2018;21:283– 8.
21. Tappy L. Fructose metabolism and noncommunicable diseases: recent
ﬁndings and new research perspectives. Curr Opin Clin Nutr Metab
Care 2018;21:214– 22.
22. DeChristopher LR, Tucker KL. Excess free fructose, high-fructose corn
syrup and adult asthma: the Framingham Offspring Cohort. Br J Nutr
23. Herman MA, Samuel VT. The sweet path to metabolic demise: fructose
and lipid synthesis. Trends Endocrinol Metab 2016;27:719– 30.
JPGN Volume 67, Number 5, November 2018 Editorial