Consensus of the Brazilian Association of Nutrology on Milky Feeding of Children Aged 1–5 Years Old

Abstract

Objective To publish a consensus on the milky feeding of children aged between 1 and 5 years old, in the face of the nonuniformity of indication and the lack of standardization, in Brazil, on the nomenclature and classification of milky products produced for this stage.
Methods Literature review and members discussion.
Results The review showed the nutrition deficiencies among Brazilian children and the position of different medical societies.
Conclusions Recommendations of milky feeding are proposed for government area, industry and health care professionals.

Full text

Consensus of the Brazilian Association of Nutrology
on Milky Feeding of Children Aged 1–5 Years Old
Consenso da Associação Brasileira de Nutrologia sobre a
alimentação láctea da criança com idades entre 1 e 5 anos
Carlos Alberto Nogueira-de-Almeida1MarioCiceroFalcão
2Durval Ribas-Filho3
Renato Augusto Zorzo1Tulio Konstantyner4Raquel Ricci5Nathalia Gioia5Mauro Fisberg5
1Department of Medicine, Universidade Federal de São Carlos,
Ribeirao Preto, SP, Brazil
2Department of Pediatrics, Faculdadede Medicina da Universidade de
São Paulo, São Paulo, SP, Brazil
3Department of Nutrology, Universidade Fundação Padre Albino,
Brazil
4Department of Pediatrics, Universidade Federal de São Paulo,
São Paulo, SP, Brazil
5Centro de Dificuldades Alimentares do Instituto de Pesquisa em
Saúde Infantil (PENSI), Rio de Janeiro, RJ, Brazil
Int J Nutrol 2020;13:2–16.
Address for correspondence Carlos Alberto Nogueira-de-Almeida,
MD,MSc,PhD,DepartamentodeMedicina,UniversidadeFederalde
São Carlos - UFSCAR, Rua Eugenio Ferrante, 170, Ribeirao Preto,
SP, 14027-150, Brazil (e-mail: dr.nogueira@ufscar.br).
Keywords
►consensus
►child
►diet
►milk
Abstract Objective To publish a consensus on the milky feeding of children aged between 1
and 5 years old, in the face of the nonuniformity of indication and the lack of
standardization, in Brazil, on the nomenclature and classification of milky products
produced for this stage.
Methods Literature review and members discussion.
Results The review showed the nutrition deficiencies among Brazilian children and
the position of different medical societies.
Conclusions Recommendations of milky feeding are proposed for government area,
industry and health care professionals.
Palavras-chave
►consenso
►crianças
►dieta
►leite
Resumo Objetivo Publicar um consenso sobre a alimentação láctea de crianças com idades
entre 1 a 5 anos, diante da não uniformidade da indicação e da falta de padronização,
no Brasil, sobre a nomenclatura e classificação dos produtos lácteos produzidos para
esta etapa.
Métodos Revisão de literatura e discussão entre os autores.
Resultados Arevisãomostrouasdeficiências nutricionais em crianças brasileiras e a
posição de diferentes sociedades médicas.
Conclusões Recomendações de alimentação láctea são propostas para as áreas
governamental, da indústria e dos profissionais de saúde.
received
May 6, 2020
accepted
June 4, 2020
DOI https://doi.org/
10.1055/s-0040-1714136.
ISSN 1984-3011.
Copyright © 2020 by Thieme Revinter
Publicações Ltda, Rio de Janeiro, Brazil
Original Article | Artigo Original
THIEME
2
Published online: 2020-07-31

Introduction
During the first years of life, children need relatively larger
amounts of macro and micronutrients to process the rapid
growth and development of organs, including the brain. There
is the global recommendation, endorsed by the World Health
Organization(WHO), of exclusivebreastfeedingup to 6months
of age, and breast milk and adequate complementary feeding
up to 2 years old or more.1After the 1
st
year of life, children
show significant progress in their development, a fact that is
also reflected in eating behavior. As the growth rate decreases
during childhood, appetite and food intake also decrease.2
The main goal of child nutrition is, since an early age, to
ensure the current and future health of the child, through the
development of healthy eating habits . The period between 12
and 60 months of life is critical, as it comprises the transition
from breastfeeding an d complementary feeding to the family
diet. In this period, family habits that will influence the
health of the individual will be established, especially from
the metabolic point of view.3
Eating patterns in early childhood are characterized by
independence in physical ability, as well as in language
acquisition, allowing their verbal expression in food prefer-
ences, so much s o that at 15 months old they are alrea dy able
to eat and dr ink with little help. Between the 1
st
and 2
nd
years
of life, children evolve from basic motor activities to thinner
motor ones also in their diet, that is, of holding the spoon to
sticking the spoon into the plate, putting food and taking it to
the mouth. These interactions are part of children’s learning
about patterns of cultural and family behavior.4Thus, it is
considered that the environment at mealtime should be free
from distractions such as television, music, computer, etc.
These bad practices can lead to future eating disorders.
In early childhood, some concerns regarding food are
common: limited variety of food ingested, waste of mealtime,
distraction, limitedconsumption of legumes, vegetables, fruits
and meats and thedesire for sweetsand other goodies. Helping
parents focus on children’s positive eating behaviors, rather
than refusals, keeps mealtime pleasant and productive. An
early orientation for parents is fundamental for the prevention
of eating problems, thus avoiding the deficit of macronu-
trients.5The preference for sweet taste is common in this
age group. This creates some problems, as these foods, in
addition to having high caloric density, are usually poor in
micronutrients. The acceptance of foods with other flavors is
usually not immediate, and some children only begin to accept
them after eight to ten exposures in a noncoercive manner.
Touching, smelling, playing, putting in the mouth and spitting
new foods are normalexploratory behaviors that precede the
acceptance of this new food.4These facts should be informedto
the family, emphasizing that the failure of children to accept
new foods is part of a development stage and, although
frustrating, especially for the mother, should be experienced
with knowledge, consistency and patience.
Thus, children in the first years of life may have inadequate
intake, both for more and less, of various nutrients, which will
negatively influence their growth, neuropsychomotor devel-
opment, immunity, in addition to metabolic imprinting.6–8
In summary, it can be observed that the feeding of
children in the first years of life has three topics that deserve
special attention:5,7,8
•Imbalance (for more or for less) of energy and protein
supply;
•Intake of various micronutrients below the recommen-
dations: vitamins A, D, B12, C and folic acid; iodine; iron
and zinc;
•Low intake of omega 3 chain fatty acids, mainly Docosa-
hexaenoic acid (DHA), with important consequences, not
only for childhood, but throughout life, affecting growth,
neurodevelopment, immunity and metabolic imprinting.
Based on the three topics described above, special foods
have been designed for this pediatric age group. These
products have existed in many countries for about 2 decades
and have been called Growing Up Milk (GUM), Young Child
Formula (YCF) and “growth formula.”Adopting the term
“milk”is not appropriate, since in some compounds the
protein source is vegetable and not cow’s milk protein. In
Brazil, this food is called a milky compound, which causes
remarkable confusion, since this category encompasses
many products with quite different profiles.
The current legislation9defines milky compound as:
“powdered product resulting from the mixture of milk and
milky or non-milky product(s) or food substances(s), or
both, added or not of milky or non-milky product(s) or food
substances(s) or both permitted in this Regulation, suitable
for human feeding, by means of technologically appropriate
process. Milky ingredients must represent at least 51%
(fifty-one percent) mass/mass (m/m) of the total ingre-
dients (mandatory or raw material) of the product”
Given the difficulty of naming and the fact that “milky
compound”does not exactly character ize the type of product
that this consensus addresses, only for the purpose of
standardization, in the present document, this type of for-
mulation will be called by the name currently more accepted
in English: Young Child Formula.
In a 2011 publication, the Nutrition Committee of the
French Pediatric Society recommended the use of YCF for all
children of this age group, instead of cow’s milk, based on a
cross-sectional nutritional survey conducted with 3-day
food recalls.10,11 In this survey, children who did not con-
sume YCF, but only cow’s milk or other milky products (at
least 250 ml/day) had 3 to 4 times more protein intake than
recommended and the intake of essential fatty acids (linoleic
and linolenic acids), iron, zinc, vitamins C, D and E below
daily recommendation s. In contrast, children who consumed
at least 250 ml/day of YCF had intake within the recommen-
dation, except for vitamin D.10,11
In 2013, the European Food Safety Authority (EFSA)
considered that YCFs are one of the ways to modulate critical
nutrient intake in early childhood, but should not be the only
one to reverse nutrient excess or shortages.
Not all pediatric nutrition societies recommend replacing
cow’s milk with YCF for children as of 1 year old. The
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Consensus of the Brazilian Association of Nutrology on Milky Nogueira-de-Almeida et al. 3

Nutrition Committee of the German Society of Pediatrics
states that these formulas would not be a need as long as the
child’s diet is adequate, both in quantity and quality.12 This
committee also considers that YCF based on cow’s milk
should preserve the beneficial properties of milk in relation
to calcium, vitamins B2 and A, and have a reduction in
protein and lipid content. Fat quality should be modified,
since the deposition of Aracdonic acid (ARA) and DHA within
the central nervous system (CNS) continues to be high after
the 1
st
year of life and the addition of these fatty acids, at
least DHA, would be interesting, especially in children who
do not ingest foods which are sources of omega 3 fatty acids
(Eicosapentaenoic acid [EPA] and DHA), such as cold water
fish. In addition, micronutrients should be supplemented in
these formulas, so that the recommendations are met.12
In the face of the nonuniformity of indication of the YCF and
the lack of standardization, in Brazil, on the nomenclature and
classification of milky products produced for children, the
Brazilian Association of Nutrology brought together a group of
experts to write a consensus on the milky feeding of children
aged between 1 and 5 years old, based on the epidemiology of
nutritional deficiencies of the Brazilian child in this age group
and on studies published on the use of YCF versus raw cow
milk.
TheDoubleImpactofMalnutritionintheChildhood
Nutritional problems have been historically studied and
evaluated in two ways separately, considering that they
affected distinct populations and with opposite and con-
trasting risk factors. The first is characterized by chronic
malnutrition, food insecurity, extremes of poverty, infec-
tions and micronutrient deficiency. The second is defined
by overweight, sedentary lifestyle and inadequate energy
consumption. However, as a result of social, economic and
demographic changes that have occurred globally in the last
3 decades, the two extremes of malnutrition have been
related to common triggers and re-contextualized in a single
spectrum.13
Throughout their lives, a growing proportion of individuals
will be exposed to the rapidly expanding obesogenic environ-
ment and causes of malnutrition that still persist. Studies with
representative samples of the Brazilian population demon-
strate the unequal distribution of the magnitude of complica-
tions related to nutritional problems in childhood and reveal
worrying trends for the future. Although overweight has
exceeded the frequency of nutritional deficits, childhood
malnutrition remains a public health problem in Brazil.14
The gestational period and the first 2 years of life –the
“first 1000 days”- constitute a critical and sensitive period to
nutritional and metabolic changes. When they occur at this
stage, both malnutrition and overweight can cause long-
term harmful effects, and the occurrence of one implies a
higher risk of occurrence of t he other in the future. A relevant
point regarding the prevalence of obesity in childhood refers
to the earliness with which complications may arise,15–21
such as chronic noncommunicable diseases (NCDs), in addi-
tion to the relationships existing between childhood obesity
and its persistence until adulthood.22 On the other hand,
malnutrition jeopardizes the neuropsychomotor develop-
ment of the child and reduces their chances of reaching
the maximum potential in adulthood. In addition, the “first
1000 days”are a crucial period for establishing children’s
eating habits and behaviors that will influence growth and
development at all stages of childhood. Therefore, the evalu-
ation of the diet composition and the consumption profile of
infants and preschoolers has become an important point,
considering that eating habits and nutritional status in this
age group can prevent or predispose to diseases resulting
from eating deficiencies or excesses. Similarly, interventions
aimed at reducing the double impact of malnutrition in
Brazil can contribute to the reduction of the frequency and
severity of diseases that, to date, are understood as NCDs.
Encompassingalltheseaspects,the mappingofthe Brazilian
child nutritional status allows the understanding of one of the
main triggers for changes in nutritional status in the country:
nutritional transition. The current nutritional situation in
Brazil reflects the fact that the most recent economic, cultural
and demographic changes have not affected the population
equally, resulting in scenarios where malnutrition and over-
weight coexist; micronutrient deficiency is present in both
conditions.
Nutritional Transition in Developing Countries
The paradox of nutritional status in children <5 years old in
Brazil reflects changes in lifestyle, eating habits, consump-
tion patterns an d physical activity pract ice at global, national
and individual levels. This transformation process occurs
unevenly throughout the country and is characterized by
the inversion of the distribution patterns of the nutritional
diseases, called Nutritional Transition. The children most
vulnerable to this condition during early childhood are those
living in situations of poverty and extreme poverty, such as
those from indigenous and quilombola communities or
beneficiaries of income concession programs. The inequality
that marks the distribution of resources in the countr y is also
imprinted on the evolution of the nutritional status of the
Brazilian child.23,24
Throughout Latin America, social (urbanization, women’s
education, greater access to health services, increased work-
load and importance of women in the labor market) and
contextual (increase in per capita income, national income
distribution programs) changes have affected the availability,
accessibility and demand for certain foods, under the strong
influence of advertising and marketing. The nutritional tran-
sition results in a diet rich in fat, sugar and low in nutrients,
which is associated with increased risk of infections, impaired
immune system and growth deficits.25 Paradoxically, the risk
factors that contributed to the reduction of malnutrition from
1996 to 2006 support the increasing incidence of overweight
in childhood today.26
The Main Risk and Protective Factors for Changes in
the Nutritional Status of Children in Brazil
Obesity has been recognized by the WHO as the largest
public health epidemic and is associated with chronic non-
communicable diseases of high morbidity and mortality,
International Journal of Nutrology Vol. 13 No. 1/2020
Consensus of the Brazilian Association of Nutrology on Milky Nogueira-de-Almeida et al.4

which affect children and adolescents earlier and earlier23.
Regardless of age group and gender, inadequate energy
intake and sedentary lifestyle are crucial risk factors for
the alarming increase in the prevalence of obesity in devel-
oping countries. However, there is little evidence on the
importance of these risk factors in children and adolescents
living in these regions27.
A relevant point regarding its presence in the pediatric
population refers to the amplification of the predisposition to
harmful effects throughout life because changes in the nutri-
tional status before 5 years old increasethe riskof evolution to
the spectra of malnutrition and overweight in adulthood. The
combination of weight deficit and growth in early stages of
life, with subsequent progression to overweight, is an example
resulting from the nutritional transition that contributes to
the increased risk of developing NCD in adulthood. The
consequences that high metabolic burden determines on an
organism with impairedhomeostasis capacitycanbeexplained
by the concept of Metabolic Programming,13 which conspires
with genetic factors for the adjustment that affects the body
weight and health of the individual throughout life.28
Development and growth occur due to a succession of
critical periods and great plasticity known as “windows”
when the phenotype is particularly sensitive to exposoma
stimuli. Physiological mechanisms such as formation, differ-
entiation and organization of tissues, organs and systems,
occur in these periods, as well as the constitution of the
microbiotaand theregulationofhormonaland immunological
signaling pathways. These mechanisms respond both to the
excess and lack of nutrients in the diet at the beginning of life,
programming according to the nutritional context and con-
tributing to long-term and intergenerational effects of both
ends of malnutrition. Some of these opportunity windows
close at early periods of life and development: preconception,
gestational, perinatal, breastfeeding phase or in the first years
of life. Thus, the incidence of risk factors for changes in
nutritional status in early stages of life may change the
functioning of the organism permanently.13
Fisberg et al have evaluated the r isk factors that determine
the establishment of exogenous obesity in childhood: early
weaning, introduction of inappropriate complementary
foods, inadequate consumption and preparation of milky
formulas, eating behavior disorders and misfits of family
relationships. The same study has pointed out other contex-
tual risk factors, such as the difficult access to areas for the
practice of physical activities and active leisure in urban
cities, the universalization of access to industrialized restau-
rants and foods, t he inadequacies of the school infr astructure
and the poor quality of school meals.28
Population-based studies have also evaluated the indepen-
dent variables associated with higher risk for overweight
before 5 years old in Brazil: residence in the South and
Southeast regions, mean socioeconomic class (C1 and C2),
maternal education >6 years, maternal body mass index
(BMI) >30Kg/m
2
, being an only child or having up to 1 sibling,
birthweight 3,900 Kg, consumption of soft drinks or fried
foods or artificial juice 4 days/week. The National Survey
Children and Women Demography and Health (PNDS, in the
Portuguese acronym) (2006) has associated this condition to
the early introduction of complementary feeding, consump-
tion of inadequate food and sedentary lifestyle.29
In a recent publication, the WHO has emphasized the
importance of food in the beginning of life to avoid excessive
weight gain.30 One of the most studied strategies to achieve this
purpose is the reductionof protein burden. In fact, a cohort that
has been monitored since birth by an European group of
researchers31 has demonstrated that, at 6 years of age, differ-
ences in BMI can be observed that are higher in children who
during the first 6 months of life have received protein-content
formulas located at the upper limits of the Codex as compared
with those receiving breast milk or protein-content formulas
located at the lower limit. Even after 6 months of life, excessive
protein consumption, especially those of animal origin, should
be considered a risk factor for future obesity.32 It has also been
observed that this excess is due to adiposity33 and that it can
lead to other health risks.32,34 This effect is believed to be
mediated by the lower circulation of insulin-like growth factor
1 (IGF-1) and by the reduced presence of insulinogenic amino
acids observed when protein supply is lower.35 Rauschertet al36
statethat the high proteinintake in childhood is associated with
higher blood concentrations of branched chain amino acids
(BCAA)(valine, leucine and isoleucine), higher earlygrowth and
obesity.
According to the Household Budget Survey (HBS) 2008–-
2009, the foods who se consumption were most related to the
moderate risk of overweight in childhood were: soft drinks,
butter or margarine, fried foods, coffee, pasta and artificial
juices. The consumption of sugar-rich foods (milky products,
cookies, cakes and pies, sausages, breads and chocolate
products) was higher than the daily recommendations and
showed a strong association with the risk of overweight in
childhood. Considering these results, the child obesity
depends not only on income, but also on the eating habits
of the family, education level of the parents, availability of
caregiver time to prepare meals, among others.37
The same risk factors related to the incidence of obesity in
childhood increase the risk of incidence of nutritional deficien-
cies. Currently, malnutrition can be understood by anthropo-
metric parameters (low birthweight, short stature, low weight
gain) or by states of depletion of nutrients and micronutrients,
which reflect inadequate nutrition.13 Analyses of socioeconomic
profile and family income indicate that the risk of child malnu-
trition is strongly determined by family income.24 On the other
hand, infants are an important risk group for the double impact
of malnutrition because they are susceptible to complementary
feedingrichinfatanddeficient in micronutrients.13
Institutionalization in day care centers can be a protective
factor for nutri tional status changes in childhood but can a lso
contribute to obesity. Full-time day care centers directly
interfere with the nutritional status and growth of children,
as they offer alm ost all meals of the child’s day and cons titute
the ideal environment for the implementation of strategies
for health promotion and education.24 The school can be a
facilitator to the quality of food consumption of Brazilian
children when well assisted. The National School Feeding
Program (PNAE, in the Portuguese acronym) (one of the most
International Journal of Nutrology Vol. 13 No. 1/2020
Consensus of the Brazilian Association of Nutrology on Milky Nogueira-de-Almeida et al. 5

important food policy programs in Brazil, benefiting almost
45 million people ), coordinated by the Ministry of Education,
establishes that children who stay full time in the teaching
institution must receive at least 70% of the daily energy and
nutrients recommendation. This determination certainly
protects many children from malnutrition, but, on the other
hand, causes those in b etter socioeconomic conditions to end
up receiving a large daily caloric amount, when meals at
home and in the institution are added and combined with
the fact that, in general, there is limited space for the practice
of physical activity.38
Mapping of The Brazilian Children Nutritional Status
up to 5 Years old
The WHO estimates suggest that overweight affects 5
million children <5 years old worldwide.39 According to a
review of 6 Brazilian studies of population bases conducted
between 1974 and 1975 and 2008 and 2009, the following
changes in the nutritional status of infants and preschoolers
have occurred in the past 35 years26:
1. The incidence of malnutrition and short stature in chil-
dren has decreased significantly, especially in the last
decades;
2. The incidence of overweight in children <5yearsold
remained constant, while a significant increase occurred
in children from 6 to 11 years old.
The 2008–2009 HBS37 showed an important increase in the
number of obese children in Brazil, with a prevalence of 32.8%
of overweight and of 16.2% of obesity in children <5 years old.
The increasing trends of overfeeding, overweight and obesity
indicate that the prevention of these outcomes is a priority for
the prevention of complications and NCDs in adulthood.
Currently, >20% (42.5 million) of Latin American children
aged between 0 and 19 years old are overweight (overweight
or obese).39
The most recent information on the pediatric age group in
different regions of the country is of municipal coverage, small
communities and isolated studies conducted in different cities,
indicating the prevalence of overweight ranging from 10.8% to
33.8%. The results of the 2008–2009 HBS confirm the positive
evolution of the nutritional status of Brazilian children. The
prevalence of overweight and obesity among Brazilian
preschoolers increased dramatically between 1989 and 2006,
mainly between 1996 and 2006.23
The secular trends of overweight among Brazilian pre-
school children <5 years old were studied in 3 surveys of
national population bases conducted between 1989 and
2006 that suggest29:
1. Increased obesity prevalence by 9.4% per year: in 1989,
the prevalence of overweight in this age group was 3%
(95% confidence interval [CI]: 2.2–3.9), remaining at 3.4%
in 1996 (95%CI: 2.5–4.3%) and with an increase of 129%
(7.8%; 95% CI: 6.3–9.5) in 2006.
2. The Southern region of the country appears in all studies
as the one with the highest prevalence of obesity in
preschoolers. However, the increase that occurred in the
Northeast region exceeds all regions, with a record in-
crease of 20.6% per year from 1989 to 2006.
Associated with the increased prevalence of overweight,
there is an increase in the frequency of chronic NCDs and the
precocity with which they affect pediatric age groups. The set
of diseases called metabolic syndrome involves conditions
such as high blood pressure, type 2 diabetes mellitus and
dyslipidemia, and is a strong determinant of the risk of NCD,
reduced quality of life and increased morbidity and mortality.
At a lower rate, the prevalence of malnutrition decreased
by >60% from 1996 to 2007.14 In Latin America, low growth
(Length/Age <Z score - 2) is the most frequent nutritional
deficiency in children <5 years old. In Brazil, the prevalence
of short stature i n children <5 years old was 7.1% (2007). Th e
coexistence of high prevalence of short stature with high
prevalence of overweight increases the risk o f double impact
of malnutrition at the home level, which occurs in the
binomial “children with short stature”and “overweight
mothers”; whose prevalence in 2006 and 2007 was of 2.7%.25
Despite the unquestionable importance of national stud-
ies, they do not discriminate specific population groups and
variations of prevalence in different epidemiological con-
texts. In an attempt to encompass the complexity of the
distribution of child nutritional problems in the country, a
systematic review included 33 articles published from 2006
to 2014, conducted with preschool children and children <5
years old. As described, despite the reduction in the preva-
lence of nutritional deficits in children <5 years old, its
prevalence still represents a public health problem associat-
ed with social inequality:24
1. Samples from day care centers: 9 articles with samples
from 189 to 676 children, from 6 months to 7 years old
(states of SP, MG, PA, PE, PB). Prevalence of growth deficit:
3.3 to 20.5%; prevalence of overweight/obesity: 2.3 to
7.5%. Mean prevalence of growth deficit by sample size:
9.11%; overweight: 5.37%.
2. Samples of primary care services: 4 articles with samples
from 155 to 443 children from 6 months to 7 years old
(states of SP and MG). Prevalence of growth deficit: 6.3 to
9.7%; prevalence of overweight/obesity: 5.2 to 17.9%.
Mean prevalence of growth deficit by sample size:
7.25%; overweight: 10.97%.
3. Samples in at-risk populations: 5 articles with samples
from 99 to 973 children from 6 months to 5 years old
incomplete. Prevalence of growth deficit: 11.5 to 45.3%;
prevalence of overweight/obesity (weight/height [W/H]):
2.1 to 7.1% (W/H) and 5.9% to 6.4% (BMI/I).
4. Samples in studiesby Brazilian cities, regions, and states: 15
articles with samples from 164 to 6,397 children from
6 months to 5 years old. Prevalence of growth deficit: 5 to
16.5%;prevalence of overweight/obesity:3.2to12.5%(W/H)
and 6.3 to 11.2% (BMI/I). Mean prevalence of growth deficit
by sample size: 10.2%; 10.18% (W/H) and 7.70% (BMI/I).
According to the same survey, the highest growth deficit
rates are found in populations living in hazardous conditions
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(21.42%); the risk of malnutrition is up to 2.38 times higher in
these groups compared with population-based sampling.
The risk of malnutrition in children assisted in public prima-
ry care services is also 2.37 times higher compared with
population-based studies (p¼0.01). Samples of children
attending day care centers are not at increased risk. On the
other hand, obesit y and overweight are equally distributed i n
the population of Brazilian children, with no significant
differences between the results of population-based studies
and studies with specificgroups.
24
The Consumption Profile of Children Under 5 Years Old
in Brazil
One of the key aspects for assessing the child’s nutritional
status is the knowledge of their eating habit, which, when
properly established in the first years, can have a positive
impact on the state of health and nutrition throughout life.
Because it is an accelerated development and growth phase,
with the possibilit yof preventing metabolic diseases directly
related to the quality of food, the knowledge of the consump-
tion profile at early ages reflects a fundamental indicator of
health and economy.40
In Brazil, introduction of complementary foods before
6 months old and of inadequate foods to children <2 years
oldarefrequent.41Data from 2015fromthe Food and Nutrition
Surveillance System (SISVAN, in the Portuguese acronym)
reflect this reality, in which 41.1% of the children evaluated
under6monthsand 98.7% of thoseaged6to 23 months old had
inadequate food consumption, based on the recommendations
of the “Ten steps towards healthy eating.”Among the factors
associated with this inadequacy are primiparity, inadequate
health care without support to the mother and previous
education, maternal age, return to work, child’s low weight
gain, popular practices and habits such as offering tea in the
presenceof colic, use of pacifier and low adherencetoexclusive
breastfeeding.42 Vieira et al showed a lower incidence ofearly
supply of water, tea, juice, fruit porridge, vegetable porridge
and family meal in infants who were breastfed than those not
breastfed,43 where the chance was 8.2 times higher of offering
family meal to infants aged 4 months old and nonbreastfed.
From 6 months, the inclusion of adequatefoods is necessary
to ensure caloric and protein complement and adequacy of
micronutrients important for the development and growth of
the child, no longer being sufficiently affected only with breast
milk and/or infant formula.44 The familyplays a decisive rolein
the formation of new habits, in responsiveness to food intake
and in the formation of a pattern of eating behavior.
The food introduction of Brazilian children consists of
mashed fruit, beaten soup and milky preparations in the
form of porridge (addition of cereal or thickener –corn starch),
and therefore, the insufficiency of iron, vitamin A and zinc
consumption through complementary feeding is frequent.
Saldiva et al40 in a study conducted in 136 municipalities of
São Paulo, totaling 24,448 children, have identified a dietary
pattern ofchildren with 6 months, of fruit (87%), soup (liquid or
pasty meal and salt, 78%), porridge (63%), beans (58%), pot food
(solid salty meal that contains whole pieces of food and
resembles adult food, 64%) and soup or food with meat, that
is, iron source, lower than the other items (36%), and the
probability of the child consuming meals based only on milk
and porridge was 82%.
The late introduction of beef was also observed in other
studies, reinforcing the increased risk for inadequate iron
consumption.45,46 However, as a positive evaluation, the
average fruit supply at the time of food introduction is
high, evidencing that fruit is the second most consumed
food, after milk.40
The food profile as of the introduction of food and propa-
gated until 2 years old reflects, primarily, family eating habits,
nutritional knowledge of the caregiver, time of maternal study
and urbanization with direct access to food.40,47,48 From 1974
to 2003, the food intake of the Brazilian population was
characterized by consumption of fruits and vegetables below
the recommendation and surplus sugar and fat. This profile is
consistent with evaluations of the dietary pattern of children
aged 2 to 5 years old throughout Brazil, as shown in the 2006
National Survey of Demography and Health, in which 53.2% of
the children evaluated (n¼3,086) had not consumed vegeta-
bles in the 7 days prior to the interview, 25.3% had not
consumed legumes and 11.5% fruits.49 On the other hand,
foods such as fried foods, soft drinks and cookies were part of
the diet of 50.1%, 73.7% and 91.3% of the children in at least
1day,respectively.
Studies from north to south of the country evaluated their
regions separately with similar patterns –inadequate con-
sumption of food sources of fiber and micronutrients and
excessive consumption of foods rich in fat, sugar, salt and low
fiber, directly corroborating the current anthropometric pat-
terns in the Brazilian infant population. Foods such as breads,
cookies, cakes, sweet pies, milky products, chocolate products
and sausages are strongly related to overweight. Despite the
still significant daily consumption of rice or pasta (77%; 95%CI:
75–79.5), beans or lentils (66.2%; 95%CI: 63.5–68.8), meat
(beef or pork), chicken or fish (32.2% 95% CI) and fruit
(44.6%; 95%CI 41.5–47.8) in the food repertoire of Brazilian
children aged 6 to 59 months old,49 the high consumption of
foods with highercaloric density (fried foods, candies, cookies,
snacks and softdrinks), added tothe inadequate consumption
of vegetables and legumes, have a substantial impact on the
prevalence of overweight, in addition to other associated
chronic diseases, and nutritional deficiencies due to inade-
quateconsumptionof vitaminsand minerals.39,45,47 According
to de Carvalho et al, when conducting a review study on food
intake and nutritional adequacy in Brazilian children, with
data from 2003 to 2013, the authorsshowed that consumption
adjustments have ranged from 0.4% to 65% for iron, 20% to
59.5% for vitamin A, 20% to 99.4% for zinc, 12.6% to 48.9% for
calcium and from 9.6% to 96.6% for vitamin C.45
Better eating patterns, with consumption of beans, veg-
etables and legumes, are prevalent among female children,
among children living in the urban area and among children
with mothers who have 12 years of education. Inversely
proportional are the markers of unhealthy feeding, with
higher prevalence of the consumption of fried foods, biscuits
or cookies and snacks among children with mothers aged 
20 years old, children whose mothers have 9 to 11 years of
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education and w hose mothers were between 20 and 29 years
old, respectively. Regarding the frequent consumption of
sugary drinks (soft drinks and artificial juices), data are
associated to children with mothers who have 5 to 8 years
of education.50
As of the age of 2 years old, school, social relationships
outside the family environment and food preferences interfere
positively and/or negativelyin the repertoire and eating habits
in a more marked way.49,51 Bueno et al52 in a multi-year study
conductedwith 85 schools (public[63.5%] and private[36.5%]),
covering 3,058 children between 2 and 6 years old from 9
Brazilian cities, evaluated the adequacyof nutrient intake from
a qualitative and quantitative analysis of children’s feeding for
one day, from weighing and diet calculation. The results
reinforce the need for constant attention and improvements
in the profile of food supply and consumption of Brazilian
school-age children, where despite the low prevalence of
inadequate intake of vitamins essential to health (B1, B2, B3,
B6, folate, phosphorus, magnesium, iron, copper, zinc and
selenium), 30% of the sample consumed more saturated
fat than recommended, 15 to 29% had inadequate vitamin
E, >90% had inadequate vitamin D intake, 45% of children >4
years old did not reach the calcium recommendation, and
sodium intake was higher than recommended for >90% of
children <4 years old and for 73% of children >4 years old.
On the other hand, the school can be an ally in the
construction of appropriate eating practices, by promoting
the interaction of consumption with other children, planning a
nutritionally appropriate menu, according to age, schedule of
nutritional education activities and control in the quality of
snacks brought by children and those sold in canteens.Accord-
ing to the dietary recommendations of the Manual of Healthy
Snackof the Brazilian Society of Pediatrics,53 for the snack tobe
considered healthy it should be composed of three food
groups: one source of carbohydrate (breads, cakes and whole
cookies, corn, popcorn), one source of protein (almost always
milk) and a source of vitamins and minerals (fruit or vegeta-
bles, avoiding juice). Often, what is observed in studies evalu-
ating the quality of intermediate snacks in preschoolers and
schoolchildren is a high presence of industrialized foods,
although eventually they follow the recommendation of
food groups. Foods such as snacks, cereal, cereal bar, stuffed
biscuit, biscuit without filling, artificial juices like nectar,
industrialized cake, milk drink, yogurt with added sugar,
processed cheese and candies are common in children’s
snacks,54 and reflect inadequate practices that reinforce the
maintenance of the nutritional status profile of children today.
Complications Associated with Changes in Nutritional
Status in Childhood
Despite the higher availability of food in recent decades,
there is still a high prevalence of nutritional deficiencies in
the Brazilian population. First, because access to food is not
egalitarian to all and, second, because food choices will not
necessarily meet physiological nutritional demands accord-
ing to age, gender, health condition and nutritional status.51
This is a reality considering the inadequate profile of food
consumption in recent years presented in the previous topic;
although it seems that over time children are better fed, due
to the reduction of malnutrition throughout Brazil, children
may suffer from “hidden hunger,”which consists of adequate
or even increased caloric intake, but without achieving
micronutrient recommendations, to the detriment of inade-
quate food choices; high caloric density foods, high in sugar
and low quality fat, and insufficient consumption of fruits,
vegetables, legumes and meat (HBS 2002–2003). The condi-
tion of a child’s n utritional status is st rongly evaluated by the
presence or absence of deficienc y diseases, the most frequent
being iron deficiency anemia, zinc and calcium deficiency,
hypovitaminosis A, D, B9 and B12; micronutrients directly
related to linear growth and healthy development.
Iron Deficiency Anemia
According to a systematic review conducted in 2014 on the
prevalence of anemia in Latin American countries, Brazil has
a moderate prevalence of anemia among children aged
6 months to 5 years old, ranging from 20.1% to 37.3%. The
most recent Brazilian data on this problem are from the
National Health Survey (2006–2007), which indicates that 1
in 4 Brazilian children <5 years old have anemia (18.6–-
24.9%). In the same period, the prevalence of short stature
and malnutrition was 7.1% (5.8–8.7%) and 7.3% (6.0–8.6%),
respectively. In children <5 years old, overweight is associ-
ated with growth deficit, but there is no association with
anemia. There was no association between anemia and other
anthropometric markers in children <5 years old.55,56
The highest prevalence of anemia occurs in preschool
children (47.4%), followed by pregnant women (41.8%) and
women of childbearing potential (30.2%).57 It is known that, in
addition to the determining factors of this serious situation,
the most worrying systemic manifestation of iron deficiency
anemia and iron deficiency are, however, the impairment in
cognitive, behavioral development, and in motor coordination
not only due to the smallest level of clinical suspicion but also
due to the diagnostic difficulty, severity and late onset.58
The clinical trial National Study of Home Fortification of
Complementary Feeding (ENFAC, in the Portuguese acronym)
was conducted in 4 Brazilian cities (Rio Branco, Olinda, Goiânia
and Porto Alegre) to evaluate the impact of micronutrient
fortificationonthehealthofchildrenwhoattendedprimary
health care services. A total of 1,213 children were evaluated
between June 2012 and January 2013. One arm of the study
aimedtostudytheprevalenceofanemiainthesamplestudied.A
total of 520 children aged between 11 and 15 months old were
evaluated. Anemia was defined by hemoglobin concen-
trations <110 g/L (WHO) and iron deficiency by plasma ferritin
concentration <12 mcg/L or transferrin saturation >8.3mg/L.
Theprevalenceofanemia,irondeficiency, and iron deficiency
anemia was: 23.1%, 37.4% and 10.3%, respectively. The preva-
lence of short stature was 5%. The risk factors that were
significantly related to the occurrence of anemia in the sample
studied were: >1child<5 years old in thehouse, introduction
of fruits and vegetables after 8 months of life, short stature,
previous hospitalization, and low serum folate concentrations.
The prevalencefound in this cohort was lower than the results of
a systematic review of studies published between 1996 and
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2006, which revealed a prevalence of 55.6 to 65.4% in
children <12 months old and 55.1% and 89.1% in children
aged 12 to 24 months old. Other studies in different regions of
Brazil indicated a prevalence of 37.2 to 76%, evidencing regional
variations and unequal distribution of this condition in the
country.59
According to a study by Vellozo et al, fortification is widely
considered to be the most practical approach and the one
with the best cost-effectiveness ratio in the medium and long
term. Since 2002, with the approval of the Ministry of Health
Technical Regulation, through Resolution RDC no. 344 of the
National Health Surveillance Agency (Anvisa, in the Portu-
guese acronym), the fortification of wheat and corn flours
with iron and folic acid has become mandatory. This manda-
tory measure, since June 2004, establishes that each 100 g of
the product must contain at least 4.2 mg of iron, which
represents 30% of the adult Dietary Reference Intakes
(DRI), and 150 mcg of folic acid, which corresponds to 37%
of the adult DRI.60
Hypovitaminosis A
Since the introduction of food, there has been a low presence,
mainly of vegetables and meat, in the diet of children <1year
old, a more critical immunologic period. Associated with this,
foods low in micronutrients, including vitamin A, such as
cookies, breads, cereals, pasta, rice, candies, among others, are
inserted more frequently. The survey of the National Demogra-
phy and Health Survey (PNDS, in the Portuguese acronym)
(2006), shows a prevalence of 17.4% of hypovitaminosis A in
Brazilian children <5 years old; classified as amoderate public
health problem (prevalence of 10 to 20%).39,45,47
Other Nutritional Deficiencies
All other vitamin deficiencies may result from the typical
eating pattern of Brazilian children aged 0 to 5 years old (HBS
2002–2003) and reinforce the food inadequacy due to low
consumption of the recommended portions, according to
Guides and Manuals of the Ministry of Health and of the
Brazilian Society of Pediatrics, and frequency of irregular
consumption to the point of lacking essential elements for
good growth and development.
Sangalli et al61 showed that there was a low prevalence of
micronutrient inadequacy (evaluation by Estimated Average
Requirement [EAR]) important for the growth and development
of the child (zinc [0%], iron [1.2%], vitamin C [4.7%], vitamin A
[5.2%], calcium [11.4%] and folate [15.2%]), due to the high
consumption of fortified products in the analyzed infant popu-
lation (88.1% of the 466 children, contributing between 11.3 and
38.3% in micronutrient intake). Thus, in addition to addressing
the quality of food processing, it is currently important to
evaluate whether the food consumed, such as milky products,
cookies and farinaceous, is fortified or not, because even if there
is no consumption of naturally source food, the diet may be
adequate in the evaluation of certain micronutrients.
►Table 1 summarizes the source foods, the prevalence of
serum inadequacy and the expected consequences of low
consumption of vitamins and minerals, in addition to iron
and vitamin A, on the child’shealth.
Food Difficulties and Nutritional Risk in Childhood
Eating problems such as selectivity, refusal to eat, neophobia
or aversion are heterogeneously identified among children
and adolescents.62 During the first years of life, family eating
habits and biopsychosocial factors are particularly relevant
in the genesis of nutritional problems and malnutrition.63
The inclusion of all food groups in the main meals, the
variety of the supply of fruits in natura, legumes and vege-
tables, and the restriction of the consumption of flavor
enhancers, sugar and saturated fats, contribute to the estab-
lishment of preferences, choi ces and habits that confer health
benefits.64 The choices and behaviors that go to the family
table directly reflect on the quality of the food of the child,
who mirrors their parents.
Often, the fragility ofthe mother-baby dyad bond results in
problems with eating and nutritional problems in childhood,
which can negatively influence healthy growth and develop-
ment and, mainly, be a determining risk factor for the worsen-
ing of several clinical conditions –in this case overweight and/
or obesity –or even some other initial process –such as
difficulties and eating disorders. Paradoxically, most inappro-
priate parental practices result from the concern of the parents
about their children’sweight.
63 Responsive or authoritative
caregivers are those who sufficiently correspond to the child’s
demands, encouraging the exercise of their autonomy and
valuing the signs of hunger and satiety to determine the
beginning and end of the meal. On the other hand, authoritari-
an, indulgent or negligent caregivers, impair the normal devel-
opment of the diet. In nonresponsive practices, the caregiver or
the child has excessive control over the diet and there is no
division of responsibilities. Practices of restriction, coercion,
bargaining, blackmail or punishment originate obesogenic
eating behaviors, characterized by monotonous diets, rich in
energy, sugar, fats, and poor in micronutrients. Randomized
controlled trials have shown evidence that providing guidance
on responsive practices for mothers to recognize signs and
adequately respond to their children’s hunger and satiety can
lead to “normal”weight gain and “normal”nutritional status in
children aged 0 to 24 months old, compared with mothers who
did not receive guidance. On the other hand, restrictive and
coercive practices are associated with excess and weight gain
and nutritional deficits and low weight, respectively.63
Even in cases of greater severity, the occurrence of eating
difficulties in childhood does not determine anthropometric
changes in most cases. However, the risk of nutritional
problems and micronutrient deficiency results from the
consumption of foods of high energy value, rich in fat and
sugar, and of low nutritional value. Therefore, evaluation and
approach of infants and preschoolers with eating difficulties
should precede changes in nutritional status.
Studies on the Use of Young Child Formula
and its Results in Different Populations
A recent study, published by Eldridge et al65 has evaluated
the patterns of milk and dairy products consumption in
Australia, Russia and the United States, using nationwide
data. The authors verified that milk and dairy products
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determine an important contribution to adequate nutrient
intake in children, so t hat this practice should be encouraged.
Within this reality, the use of YCFs in children has been the
object of study in different populations, seeking to under-
stand whether such segment would fit as essential, optional
or expendable. Basically, these studies were designed to
compare the adequacy of consu mption and nutritiona l status
before and after interventions.
Evaluating the studies of the last 5 years related to this
consensus (2016–2020) indexed on the PubMed and Scielo
platforms, some relevant datacan be highlighted, as described
below.
Two studiesused data fromthe UK Diet andNutrition Survey
of Infants and Young Children to assess the adequacy of various
micronutrient consumption in >1,000 children aged between
12 and 18 months old. A group of childrenwho often consumed
an YCF was compared with a group that did not. Verger et al
observed better scores of consumption of short-chain fatty
acids, long-chain polyunsaturated fatty acids (LC-PUFAs), vita-
min D, zinc, iron and copper in the group that consumed anYCF.
The study does not mention the amount of YCF consumed by
the children and characterized as “routine use”any consump-
tion other than zero.66 Vieux et al67 have observed that the
group using YCF and/or nutritional supplement has reached
with greater proportion the nutritional adjustments proposed
by the EFSA. The nutrients with improved consumption related
to the useof YCF were carbohydrates, fiber, LC-PUFAs, thiamine,
niacin, biotin, folate, vitamin D, vitamin E, retinol, sodium,
potassium, calcium and phosphorus. There was no anthropo-
metric difference between the groups resulting from the
intervention.
Several other studies on the impact of YCFs consumption
on the nutritional adequacy of micronutrients have been
conducted in several populations, all of which have reached
Table 1 Source foods, the prevalence of serum inadequacy and the expected consequences of low consumption of vitamins and
minerals, in addition to iron and vitamin A, on the child’s health
Food Sources (I) Daily consumption
recommend ation (I)
Prevalence of serum
inadequacy in
children under
5yearsofage
Symptoms of vitamin
deficiency
Consequences
of severe dis ability
VITAMIN D D2 (ergocalciferol),
obtained by ultraviolet
irradiationofvegetable
ergosterol (vegetables,
fungi, yeasts) and in
commercial products.
D3 (cholecalciferol),
result of the non-enzy-
matic transformation of
the precursor 7-dehy-
drocholesterol existing
intheskinofmammals,
by the action of ultravi-
olet rays. 7-dehydro-
cholesterol is also found
in cod liver oil, tuna,
dogfish, sardines, egg
yolk, but ter and fat ty
fish (herring).
400 IU - 0 to 12 months
600 IU - 1 t o 3 year s
600 IU - 4 t o 8 year s
68.2%
(2019) - 468 children
aged 11 to 15 months
old (II)
Fatigu e
Muscle weakness
Pain in joints, muscles
and bones
Growth retardation
Autoimmune diseases
Cancers
Fractures Develop-
ment of osteoporosis
in adulthood
FOLATE - B9 Beans, viscera, dark
green leaves (broccoli,
spinach), potatoes,
wheat and yeasts and,
to a lesser extent, milk,
eggs and fruits.
65 μg - 0 to 6 months
80 μg-7to12months
150 μg - 1 to 3 years
200 μg- 4 to 8 years
0.8% - 460 children
from 11 to 15 months
(IV)
Diarrhea
Weakness
Vertigo
Dyspnea
Anemia
CYANOCO-
BALAMIN - B12
Animal tissues, beef,
pork, poultry and fish,
viscera, mainly liver,
kidneys and heart, egg
yolk, seafood and beer
yeast and, to a lesser
extent, milk and dairy
products.
0.4 μg-0to6months
0.5 μg-7to12months
0.9 μg - 1 to 3 year s
1.2 μg- 4 to 8 years
15% - 460 children
from 11 to 15 months
(IV)
Fatigue, shor tness of
breath, numbness,
lack of balance and
memory problems.
Pernicious anemia
Neuropathy
CALCIUM Milk and derivatives,
fruits, fish, meats,
greenery, beans.
210 mg/day - 0 to 6 m onths
270 mg/day - 7 to 12 months
500 mg/day - 1 to 2 yea rs
800 mg/day - 3 to 8 yea rs
50% and 93% - children
from 1 to 3 years
(N¼45) and 4 years
(N¼19), respectively
(study 2019) (V)
Cramps, muscle
weakness or muscle
spasms, fatigue,
irritability or tingling
sensation
Growth delay
Fractures
Cardiovascular
diseases
Development of oste-
oporosis in adulthood
ZINC Beef, chicken, fish,
legumes, whole grains,
nuts.
2 mg/day - 0 to 6 months
3mg/day-7to12months
3 mg/day - 1 to 2 years
5 mg/day - 3 to 8 years
13.8% and 16.2%
(2016 review study,
children attending day
care centers) (III)
Drop of immunity Short stature
Loss of taste
References of ►Table 1:(I),
23 (II),95 (III),51 (IV),96 (V).97
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very similar obser vations. Li et al,68 for example, in a Chinese
study conducted in five large c ities, have shown that YCFs can
contribute to reducing the risk of insufficient intake of
several key micronutrients. The design of the studies below
was also quite similar: the comparison of a group using one
YCF with another using cow’s milk.
Lovell et al69 conducted a study in two sites: Auckland
(New Zealand) and Brisbane (Australia). A total of 160
children have been evaluated and monitored from 12 to
24 months old, divided into 2 groups: 1 in consumption of
at least 300mL/day of YCF and the other in consumption of a
similar amount of cow’s milk. The children in the interven-
tion group had lower protein intake and higher in take of iron,
vitamin D, vitamin C and zinc. At the end of the 12 months of
intervention, the children in the study group showed im-
provement in serum levels of vitamin D, hemoglobin and
ferritin when compared with baseline, with statistical sig-
nificance when compared with the control group under
control consumption.70 Another interesting outcome was
the difference in body composition in favor of the study
group, which presented lower mean body fat percentage in
the 12
th
month of intervention.71
In Germany, Hower et al showed that the daily intake of
350mL of YCF enriched with 2.85 mcg/100mL of vitamin D
protected children aged between 2 and 6 years old against
hypovitaminosis D in the winter period of that country.72
Ghisolfiet al, in 2013,11 compared the consumption of
various micronutrients in French children aged between 1
and 2 years old in consumption of YCF or cow’s milk, and
concluded that the control group did not reach the recom-
mended amounts of vitamin D, vitamin C, iron, α-linolenic
acid and linoleic acid, unlike the study group that reached
them without difficulties.
Chouraqui et al, 2019,73 conducted a controlled multicen-
ter study with almost 1,000 children aged between 1 and
3 years old. Children <2 years old using YCF consumed lower
amounts of protein and sodium than those who consumed
cow’s milk. For all ages, the consumption of 240mL/day of
YCF was shown to be a sufficient st rategy for the adequacy of
vitamin A, vitamin C, vitamin D, vitamin E, B complex (except
vitamin B12), iron and LC-PUFAs, with statistical significance.
In the United Kingdom, a group of >500 children aged
between 12 and 18 months old were compared by Eussen
et al74 regarding the adequacy of vitamin D, iron and lipid
intake. Children who received YCF had lower consumption of
saturated fats and higher intake of LC-PUFAs, vitamin D and
iron, which was interpreted by the authors as a better
nutritional adequacy.
Akkermans et al75 showed that children aged between 1
and 3 years old from three European sites who received YCF
daily for 20 weeks improved their serum levels of ferritin,
hemoglobin and vitamin D, unlike the group that received
cow’s milk in the same period.
In Ireland, two studies have also shown advantages in the
use of YCF. In one of them, Walton et al76 observed that
children aged between 1 and 3 years old who received
300mL/day of an YCF had consumption of lower amounts
of protein, saturated fat and vitamin B12 and higher of
carbohydrates, fiber, zinc, iron, vitamin C and vitamin D. In
another study, by Kehoe et al,77 a four-day recall was used
with parents of 500 children aged between 1 and 3 years old,
and concluded that the inta ke of 1 YCF enriched with 3.1 mcg/
100mL of vitamin D and 1.2mg/100mL of iron had an
important impact on the adequacy of daily intake of these
2 micronutrients. In the case of vitamin D, the intake of the
group receiving YCF was higher when compared with anoth-
er group that received supplementation alone of this nutri-
ent. It was observed in the groups that the 2 main nutritional
sources of iron were YCF and red meat (12 and 11% of the iron
consumed, respectively), and this strategy proved to be more
effective than the fortification of cow’s milk with iron salts.
Two studies had as object the impact of the association of
prebiotics in YCFs. Chatchatee et al78 followed 2 groups of
children aged between 11 and 29 months old. The study
group received between 400–750mL/day from 1 YCF
enriched with 1.2 g/100mL of galactooligosaccharide (GOS)
mixture with fructo-oligosaccharides (FOS), in the ratio of
9:1, plus 19.2mg/100mL of mixture of EPA with DHA in the
proportion of 4:6. The control group received the same YCF
but without galactooligosaccharides (GOS), Fructooligosac-
charides (FOS) and omega-3. The authors observed a 6%
reduction in the risk of viral infections in the period of
52 weeks of observation, a result that, although apparently
small, presented statistical significance by the 95%CI. Also,
the effect of adding pre- and probiotics on the intestinal
microbiota was tested by Kosuwon et al,79 using a group of
129 Thai children between 1 and 3 years old. The proposed
intervention was the consumption of 500–650mL/day for
12 weeks of one YCF enriched with a mixture of 1.2 g/100mL
of GOS and FOS in the ratio 9:1, in addition to the probiotic
Bifidobacterium breve M-16V. The results observed in the
intervention group were increased proportion of intestinal
microbiota components belonging to the gender Bifidobac-
terium, reduction of fecal pH by an average of 7.05 to 6.79 and
presence of softer feces.
Another Consensus on the Subject
The European Society for Paediatric Gastroenterology Hep-
atology and Nutrition (ESPGHAN)80 defines YCF as milky
compounds or vegetable drinks designed to partially meet
the nutritional needs of children aged between 1 and 3 years
old. The understanding of this society is that there is insuffi-
cient evidence for the drink to be indicated as a routine in
children of the aforementioned age, although it can be used
as a strategy to improve the nutritional intake of iron,
vitamin D and LC-PUFAs and to reduce excessive protein
intake. It is also highlighted that infant continuation formu-
las could be used for this same purpose.
The EFSA81 defines YCF as a formula designed specifically
for young children (1 to 3 years old). The document mentions
that there is no specific legislation that serves as a guideline
for the composition of this drink and raises nutritional
requirements for children up to 36 months old. The posi-
tioning of the society, similar to that of ESPGHAN, is that the
use of GUM should not be indicated as a routine for
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children >1 year old, because a balanced diet would be able
to provide the necessary nut rients for adequate physiological
growth. However, it can be a useful tool for the adequacy of
vitamin D, iron, iodine and LC-PUFAs consumption.
Positioning of other Countries and other
Societies
There is a Belgian consensus on the indication of YCFs for
children aged between 1 and 3 years old, published by
Vandenplas et al. According to this document, and in a way
very similar to the previous positions, YCF is not an indis-
pensable product for the child’s diet to be balanced, but can
be used as a tool to improve the consumption of nutrients
such as vitamin D, fiber and LC-PUFAs in children with
inadequate eating habits.82
In 2019, a document published by a panel of American
experts83 with participation of The American Academy of
Pediatrics (AAP) stated that milky products specific to chil-
dren between 1 and 5 years old are not recommended
because nutritional needs must be met primarily through
nutritionally appropriate dietary patterns. According to this
panel, although there is no evidence to indicate that YCF is
harmful, these products do not offer an unique nutritional
value, beyond that that could be achieved through a healthy
diet; in additi on, they could contribute to sugars adde d to the
diet, as well as being more expensive than an equivalent
volume of cow’s milk. The recommendation endorsed by the
AAP is for chil dren >1 year old to use unmodified cow’smilk.
Przyrembel et al84 published a position on the theme, also
against the above: although YCF is not a necessity in children
aged between 1 and 3 years old, it can be used as a tool for
nutritional adequac y of some essential nutr ients and prevent
excessive protein intake. Turck85 has also published posi-
tioning similar to that of Przyrembel et al.84
Tounian,86 on behalf of “The multidisciplinary working
group of the French Pediatric Society on iron”, expressly
recommends that between 1 and 6 years old, children should
drink at least 300 ml per day of YCF until they can consume
100 to 150 g per day of meat products.
Discussion on Literature Data and the
Brazilian Reality
While the use of new technologies in the production of healthy
foods is often a cause for concern, the potential for and an
innovative food technology that allows to produce a wide
variety of foods with enhanced flavor and texture and confers
various benefits to consumer health is promising. Thus, the use
of modified foods and products in all age groups has been
increasinglyproposedand studiedinscientific investigations.87
Specifically, YCFs, which are drinks or infant formulas
based on milk or vegetable proteins, specially developed to
partially meet the nutritional requirements of children >1
year old, have aroused the interest of the food industry and
researchers in the child health field.80
Since there is no single international definition or compo-
sition criteria for YCF80 and its composition is not fully
regulated, the industry has launched and made available
different milk-based products with varying nutritional com-
position on the market in recent years. In addition, it has
performed aggressive marketing of “baby milks”(sugary milk-
based drinks for babies), declaring health benefits of the
product, often with a focused and not comprehensive look.82
These products oftenhave unclear labeling information, which
creates confusion with infant formulas.88
Consequently, YCF has been increasingly introduced into
the diets of young children, leading to increased consump-
tion in the last 2 decades. Market studies estimate associa-
tions between marketing (television advertising spending,
product price, number of retail views) and sales volume of
milks by brand and category. In a recent publication, Ameri-
can researchers analyzed products sold by 8 brands from
2006 to 2015. During this period, advertising spending on
“baby milks”increased 4-fold and sales volume increased 2.6
times.89
This scenario has raised concerns about the consumption
of these food by young children, which has motivated child-
ren’s health researchers, government agencies and industry
to seek scientifically bas ed answers about the contribution of
these products to children’s health.90 From the science side,
there has been substantial growth in the number of
researches related to this topic in recent years. As an exam-
ple, 236 scientific papers assigned to the terms growing up
milk or young child formulas have been identified in the
virtual PubMed database of the National Library of Medicine
in February 2020, and more than half of them have been
published in the last 7 years (►Fig. 1).
Literature reviews point out that although they are not a
need for adequate nutrition for the age group for which they
are intended, YCFs can be useful and compensate the nutri-
tional deficiencies that may occur in the phase of transition
from child nutrition to family nutrition, especially in situa-
tions in which the eating pattern of the family is insufficient
to meet nutritional requirements.82,84
Expert groups have been formed to determine the appro-
priate nutritional composition of these products aimed at
children from 1 to 6 years old, which aim at the development
of guidelines with practical implications in their manufac-
ture.90 Although there are efforts for public-private dialogue,
there is still a considerable difference between the strength
of marketing and scientific evid ence on the health benefits of
GUM.
A study based on the Delphi method with Portuguese
pediatricians specialized in infant nutrition identified that
there was no consensus on the nutritional benefits of using
YCF in the 2
nd
year of life, although the panel agrees that
these formulas have some advantages over integral cow’s
milk.91 Another study concluded that GUM consumption
reduced the risk of iron and vitamin D inadequacies, two
nutrients often absent in the diets of young children who
consume only enriched cow’smilk.
76
Concisely, it seems acceptable to understand that the
composition of an YCF potentially contributes to (1) decreas-
ing the overall protein intake, which tends to be higher than
the reference values for this age, (2) increase the content of
International Journal of Nutrology Vol. 13 No. 1/2020
Consensus of the Brazilian Association of Nutrology on Milky Nogueira-de-Almeida et al.12

essential fatty acids with the addition of long-chain polyun-
saturated fatty acids (docosahexaenoic and arachidonic
acids) and (3) ensure the supply of some minerals (such as
iron, calcium and phosphorus), vitamins (D, B2 and B12) and
fibers/prebiotics.84
In Brazil, the growth in the consumption of these com-
pounds is recent. The feeding of Brazilian children evaluated
in 2 national sur veys (1996 and 2006), showed that, among 4
eating patterns, the least present among children in the 2
nd
year of life, was one that included dietary formulas.92
Another retrospective study with 164 mothers from 11
Brazilian cities with children aged 13 to 24 months old,
conducted in 2009 and 2010, identified that 32.9% of the
children consumed breast milk, 98.7% whole cow’s milk, and
only 10.9% “grow up milk,”at the time of the interview.93
The Brazilian Society of Pediatrics recognizes the possi-
bility of using YCF to minimize any nutritional deficiencies
that may occur du e to food selectivity. However, it s tates that
it is recommended that these compounds do not present
sucrose and fructose addition and, besides, reduce sodium
and saturated fat.23
In this context, the results presented here suggest that, in
general, the evidence on the health effects of YCF is still
limited.80 In some specific situations of clinical practice, this
product presents as an alternative to improve the quantity
and quality of ingested nutrients which, once lacking, jeop-
ardize the maintenance of metabolic functions and normal
physical growth. However, it seems clear that YCF should not
be pointed out as a mandatory nutritional need for young
children.84 Traditional foods in a balanced diet potentially
provide all the nutrients necessary to ensure adequate
nutritional status, especially when breastfeeding is provided
exclusively until the 6
th
month and continued with comple-
mentary feeding until 2 years old.94
Conclusions
Considering that:
1. Current Brazilian recommendations suggest the con-
sumption of 3 portions of milky products per day for
children aged between 1 and 3 years old a nd 2 portions for
preschoolers and recognize the importance of these foods
for nutritional health;
2. There is no specific regulation in Brazil for milky products
specifically formulated for children between 1 and 6 years
old;
3. The prevalence of obesity is high and increasing in the
preschool age group;
4. Excessive protein consumption is one of the obesogenic
factors in young children;
5. Different surveys demonstrate the presence of multiple
deficiencies of vitami ns, minerals and essential fat ty acids
omega 3 in the feeding of Brazilian children, configuring a
high prevalence of hidden hunger;
6. In Brazil, the usual infant diet, as of the introduction of
complementary feeding, is generally inadequate, with
excessive calories and proteins, contributing to the high
prevalence of obesity;
7. There is a need for an institutional positioning based on
scientific evidence on YCF that directs the practice of
professionals who care for children in this age group.
Fig. 1 Number of scientific articles related to the terms “GrowingUpMilk”or “Young Child Formulas”that were pu blished in journals indexed in
the PubMed database of the National Library of Medicine in February 2020.
International Journal of Nutrology Vol. 13 No. 1/2020
Consensus of the Brazilian Association of Nutrology on Milky Nogueira-de-Almeida et al. 13

The Brazilian Association of Nutrology Recommends
that:
1. FOR THE GOVERNMENT AREA
(a) Start an evidence-based discussion to create the YCF
category, separately from the general category of
infant formulas and milky compounds;
(b) Be created regulations on the composition of YCF so
that this product is aligned with the nutritional needs
of the age group and the Brazilian reality;
(c) The marketing of YCF is regulated to avoid misleading
advertising and confusion with infant formulas, pre-
serving policies to protect breastfeeding.
2. FOR THE INDUSTRY
(a) Young Child Formula is produced with composition
aligned with the nutritional needs of the Brazilian
child;
(b) The YCF should also meet the recommendations of the
country’s public policies, especially with regard to the
levels of calories, sugar, salt and saturated fats;
(c) Young Child Formula is disseminated in such a way as
not to lead to consumer confusion when comparing
these products with food aimed at children <1year
old;
(d) The YCF have, in the context of their divulgation, the
clear information that it is not a product for routine
use and, even less, mandatory.
3. FOR HEALTHCARE PROFESSION ALS
(a) Young Child Formula may be prescribed for chil-
dren >1 year old, within the recommendation of the
intake of milky products, in substitution or in parallel
to unmodified cow’s milk, especially in case of need to
adjust the supply of macro and micronutrients;
(b) Consider YCF as a strategy to provide the recognized
benefits of unmodified cow’s milk, with the advantage
of having lower protein content and being a food
fortification vehicle to ensure adequate intake of
essential vitamins, minerals and fatty acids;
(c) Assess the economic impact that YCF will bring to the
family and take these data into consideration in the
prescribing decision;
(d) Make it clear to the family that YCF is not a product for
routine use, even less, mandator y, but rather an option
with recognized benefits;
(e) Preferably, children who demonstrate nutritional risk
during the clinical evaluation should receive the pre-
scription of the YCF;
(f) Stimulate the consumption of traditional foods with
high nutritional value for the composition of a quan-
titative and qualitatively balanced diet;
(g) Promote breastfeeding, which is the most effective
way to prevent infant morbidity and mortality
worldwide.
Conflicts of Interest
The Brazilian Association of Nutrology has received finan-
cial support from the company Danone Nutricia to enable
this consensus to be achieved by supporting the expenses
inherent to the execution of the project.
The authors expressly state that there was no interference
by the company Danone Nutricia in the content of the
material and all the information contained in the consen-
sus represents exclusively the views of the authors and of
the Brazilian Association of Nutrology, based on the
bibliographic review used for its execution.
Acknowledgments
The Brazilian Association of Nutrology thanks the compa-
ny Danone Nutricia for the financial support that allowed
this consensus to be reached.
References
1Section on Breastfeeding. Breastfeeding and the use of human
milk. Pediatrics 2012;129(03):e827–e841
2Miller AL, Miller SE, Clark KM. Child, Caregiver, Family, and Social-
Contextual Factors to Consider when Implementing Parent-Focused
Child Feeding Interventions. Curr Nutr Rep 2018;7(04):303–309
3Finn S, Culligan EP, Snelling WJ, Sleator RD. Early life nutrition. Sci
Prog 2018;101(04):332–359
4Campoy C, Campos D, Cerdó T, Diéguez E, García-Santos JA. Com-
plementary Feeding in Developed Countries: The 3 Ws (When,
What, and Why?) Ann Nutr Metab 2018;73(Suppl 1):27–36
5Were FN, Lifschitz C. Complementary Feeding: Beyond Nutrition.
Ann Nutr Metab 2018;73(Suppl 1):20–25
6Campoy C, Escolano-Margarit MV, Anjos T, Szajewska H, Uauy R.
Omega 3 fatty acids on child growth, visual acuity and neuro-
development. Br J Nutr 2012;107(Suppl 2):S85–S106
7Szajewska H, Makrides M. Is early nutrition related to short-term
health and long-term outcome? Ann Nutr Metab 2011;58
(Suppl 1):38–48
8Suthutvoravut U, Abiodun PO, Chomtho S, et al. Composition of
Follow-Up Formula for Young Children Aged 12-36 Months:
Recommendations of an International Expert Group Coordinated
by the Nutrition Association of Thailand and the Early Nutrition
Academy. Ann Nutr Metab 2015;67(02):119–132
9Regulamento técnico para fixação de identidade e qualidade de
composto lácteo, Instrução Normativa n° 28 de 12/06/2007 (2007)
10 GhisolfiJ, Vidailhet M, Fantino M, et al; Comité de nutrition de
Société française de pédiatrie. [Cows’milk or growing-up milk:
what should we recommend for children between 1 and 3 years of
age?] Arch Pediatr 2011;18(04):355–358
11 GhisolfiJ, Fantino M, Turck D, de Courcy GP, Vidailhet M. Nutrient
intakes of children aged 1-2 years as a function of milk consump-
tion, cows’milk or growing-up milk. Public Health Nutr 2013;16
(03):524–534
12 Böhles HJ, Fusch C, Genzel-Boroviczény O, et al. Zusammenset-
zung und Gebrauch von Milchgetränken für Kleinkinder. Mon-
atsschr Kinderheilkd 2011;159:981–984
13 Wells JC, Sawaya AL, Wibaek R, et al. The double burden of
malnutrition: aetiolo gical pathways and consequences for health.
Lancet 2020;395(10217):75–88
14 Flores LS, Gaya AR, Petersen RD, Gaya A. Trends of underweight,
overweight, and obesity in Brazilian children and adolescents. J
Pediatr (Rio J) 2013;89(05):456–461
15 Garcia J, Benedeti ACGS, Caixe SH, Mauad F, Nogueira-de-Almeida
CA. Ultrasonographic evaluation of the common carotid intima-
media complex in healthy and overweight/obese children. J Vasc
Bras 2019;18:e20190003
16 Nogueira-de-Almeida CA, Mello ED. Correlation of body mass index
Z-scores with glucose and lipid profiles among overweight and obese
children and adolescents. J Pediatr (Rio J) 2018;94(03):308–312
International Journal of Nutrology Vol. 13 No. 1/2020
Consensus of the Brazilian Association of Nutrology on Milky Nogueira-de-Almeida et al.14

17 Nogueira-de-Almeida CA, Garcia J, Caixe SH, Benedeti ACGS. Ultra-
sonographic Assessment of the Common Carotid Intima-Media
Complex in Normal Weight Children and in Overweight/Obese
Children. FASEB J 2016;30:1165.3
18 Nogueira-de-Almeida CA, Caixe SH, Benedeti ACGS, Garcia J.
Echocardiography Evaluation as a Marker of Cardiovascular Risk
on Obese Children and Adolescents. FASEB J 2016;30:126.1
19 Nogueira-de-Almeida CA, Benedeti ACGS, Garcia J, Caixe SH. Corre-
lation Between Ultrasonographic Measures of the Abdominal Adi-
posity and Indicators of Obesity in Normal and Overweight/Obesity
Children. FASEB J 2016;30:1165.4
20 Nogueira De Almeida CA. We Need To Look At the Comorbidities
of Obesity during Chil dhood and Adolescence. Biomedical Journal
of Scientific & Techinical Research. 2017;1:2
21 Costa KCM, Ciampo LAD, Silva PS, Lima JC, Martins WP, Nogueira-
de-Almeida CA. Ultrasonographic Markers of Cardiovascular Dis-
ease Risk in Obese Children. Rev Paul Pediatr. 20180
22 Pediatria SBd. Obesidade na infância e adolescência: manual de
orientação. 2a. ed. Sociedade Brasileira de Pediatria, Departa-
mento de Nutrologia São Paulo Rio ….2012
23 Manual de Alimentação SBP. orientações para alimentação do
lactente ao adolescente, na escola, na gestante, na prevenção de
doenças e segurança alimentar. São Paulo: SBP; 2018:172
24 Sousa CP, Olinda RA, Pedraza DF. Prevalence of stunting and
overweight/obesity among Brazilian children according to differ-
ent epidemiological scenarios: systematic review and meta-an al-
ysis. Sao Paulo Med J 2016;134(03):251–262
25 Corvalán C, Garmen dia ML, Jones-Smith J, et al. Nutrition stat us of
children in Latin America. Obes Rev 2017;18(Suppl 2):7–18
26 Conde WL, Monteiro CA. Nutrition transition and double burden
of undernutrition and excess of weight in Brazil. Am J Clin Nutr
2014;100(06):1617S–1622S
27 Popkin BM, Corvalan C, Grummer-Strawn LM. Dynamics of the
double burden of maln utrition and the changing nutr ition reality.
Lancet 2020;395(10217):65–74
28 Fisberg M,Baur L, Chen W, et al; Latin AmericanSociety for Pediatric
Gastroenterology, Hepatology, and Nutrition. Obesity in children
and adolescents: Working Group report of the second World
Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.
J Pediatr Gastroenterol Nutr 2004;39(Suppl 2):S678–S687
29 Silveira JA, Colugnati FA, Cocetti M, Taddei JA. Secular trends and
factors associated with overweight among Brazilian preschool
children: PNSN-1989, PNDS-1996, and 2006/07. J Pediatr (Rio J)
2014;90(03):258–266
30 WHO. Report of the commission on ending childhood obesity.
2016
31 Weber M, Grote V, Closa-Monasterolo R, et al; European Child-
hood Obesity Trial Study Group. Lower protein content in infant
formula reduces BMI an d obesity risk at school age: follow-up of a
randomized trial. Am J Clin Nutr 2014;99(05):1041–1051
32 Voortman T, Braun KV, Kiefte-de Jong JC, Jaddoe VW, Franco OH,
van den Hooven EH. Protein intake in early childhood and body
composition at the age of 6 years: The Generation R Study. Int J
Obes 2016;40(06):1018–1025
33 Gruszfeld D, Weber M, Gradowska K, et al; European Childhood
Obesity Study Group. Association of early protein intake and pr e-
peritoneal fat at five years of age: Follow-up of a randomized
clinical trial. Nutr Metab Cardiovasc Dis 2016;26(09):824–832
34 Voortman T, van den Hooven EH, Tielemans MJ, et al. Protein
intake in early childhood and cardiometabolic health at school
age: the Generation R Study. Eur J Nutr 2016;55(06):2117–2127
35 Socha P, Grote V, Gruszfeld D, et al; European Childhood Obesity
Trial Study Group. Milk protein intake, the metabolic-endocrine
response, and growth in infancy: data from a randomized clinical
trial. Am J Clin Nutr 2011;94(6, Suppl)1776S–1784S
36 Rauschert S, Kirchberg FF, Marchioro L, Koletzko B, Hellmuth C, Uhl
O. Early programming of obesity throughout the life course: a
metabolomics perspective. Ann Nutr Metab 2017;70(03):201–209
37 Estatística IBdGe, Estatística IBdGe. Pesquisa de orçamentos
familiares 2008–2009: análise do consumo alimentar pessoal
no Brasil. IBGE Rio de Janeiro; 2011
38 Pretto ADB, Dutra GF, Spessato BC, Valentini NC. Prevalência de
excesso de peso e obesidade em crianças frequentadoras de uma
creche no Município de Por to Alegre e sua relação com a atividade
física e o consumo alimentar. RBONE-Revista Brasileira de Obe-
sidade, Nutrição e Emagrecimento 2014:8
39 de Araujo AM, Brandão SAdSM, Araújo MAdM, Frota KdMG,
Moreira-Araujo RSdR. Overweight and obesity in preschoolers:
Prevalence and relation to food consumption. Rev Assoc Me d Bras
(1992) 2017;63(02):124–133
40 Saldiva SR, Escuder MM, Mondini L, Levy RB, Venancio SI. Feeding
habits of children aged 6 to 12 months and associated maternal
factors. J Pediatr (Rio J) 2007;83(01):53–58
41 Coelho LdeC, Asakura L, Sachs A, Erbert I, Novaes CdosR, Gimeno
SG. Food and Nutrition Surveillance System/SISVAN: getting to
know the feeding habits of infants under 24 months of age. Cien
Saude Colet 2015;20(03):727–738
42 Sotero AM, Cabral PC, da Silva GA. Fatores socioeconômicos,
culturais e demográficos maternos associados ao padrão alimen-
tar de lactentes. Rev Paul Pediatr 2015;33(04):445–452
43 Vieira GO, Silva LR, Vieira TdeO, Almeida JA, Cabral VA. [Feeding
habits of breastfed and non-breastfed children up to 1 year old]. J
Pediatr (Rio J) 2004;80(05):411–416
44 Dias MCAP, Freire LMS. Franceschini SdCC. Recomendações para
alimentação complementar de crianças menores de dois anos.
Rev Nutr 2010;23:475–486
45 de Carvalho CA, Fonsêca PCdA, Priore SE, Franceschini SdCC,
Novaes JFd. Consumo alimentar e adequação nutricional em
crianças brasileiras: revisão sistemática. Rev Paul Pediatr 2015;
33(02):211–221
46 Souza RdLVd, Madruga SW, Gigante DP, Santos IS, Barros AJD,
Assunção MCF. Padrões alimentares e fatores associados entre
crianças de um a seis anos de um município do Sul do Brasil. Cad
Saude Publica 2013;29:2416–2426
47 Leal KK, Schneider BC, França GVA, Gigante DP, dos Santos I,
Assunção MCF. Qualidade da dieta de pré‐escolares de 2 a 5 anos
residentes na área urbana da cidade de Pelotas, RS. Rev Paul
Pediatr 2015;33:310–317
48 Nobre LN, Lamounier JA, Franceschini SCC. Preschool children
dietary patterns and associated factors. J Pediatr (Rio J) 2012;88
(02):129–136
49 Bortolini GA, Gubert MB, Santos LMP. Consumo alimentar entre
crianças brasileiras com idade de 6 a 59 meses. Cad Saude Publica
2012;28(09):1759–1771
50 Alves MN, Muniz LC, Vieira MdeF. Consumo alimentar entre
crianças brasileiras de dois a cinco anos de idade: Pesquisa
Nacional de Demografia e Saúde (PNDS), 2006. Cien Saude Colet
2013;18(11):3369–3377
51 Pedraza DF, Rocha ACD. Deficiências de micronutrientes em
crianças brasileiras assistidas em creches: revisão da literatura.
Cien Saude Colet 2016;21(05):1525–1544
52 Bueno MB, Fisberg RM, Maximino P, Rodrigues GdeP, Fisberg M.
Nutritional risk among Brazilian children 2 to 6 years old: a
multicenter study. Nutrition 2013;29(02):405–410
53 Wefort V. Lanche Saudável-Manual de Orientação. Sociedade
Brasileira de Pediatria Departamento Científico de NutrologiaSão
Paulo2011
54 Matuk TT, Stancari PCS, Bueno MB, Zaccarelli EM. Composição de
lancheiras de alunos de escolas par ticulares de São Paulo. Rev Paul
Pediatr 2011;29:157–163
55 Almeida CA, Ricco RG, Ciampo LA, Souza AM, Pinho AP, Oliveira JE.
Factors associated with iron deficiency anemia in Brazilian pre-
school children. J Pediatr (Rio J) 2004;80(03):229–234
56 Fisberg M, Mello AVd, Ferrari GLM, et al. Is it possible to modify
the obesogenic environment? - Brazil case. Child and Adolescent
Obesity. 2019;2:40–46
International Journal of Nutrology Vol. 13 No. 1/2020
Consensus of the Brazilian Association of Nutrology on Milky Nogueira-de-Almeida et al. 15

57 Fisberg M, Tosatti AM. Enrichment of iron and folic acid: the real
need and the dangers of this in itiative. RevB ras Hematol Hemoter
2011;33(02):94–95
58 Coutinho GGPL, Goloni-Bertollo EM, Bertelli ÉCP. Iron deficiency
anemia in children: a challenge for public health and for society.
Sao Paulo Med J 2005;123(02):88–92
59 da Silva LLS, Fawzi WW, Cardoso MA, Group EW; ENFAC Working
Group. Factors associated with anemia i nyoung child ren in Brazil.
PLoS One 2018;13(09):e0204504
60 Vellozo EP, Fisberg M. A contribu ição dos alimentos fortificados na
prevenção da anemia ferropriva. Rev Bras Hematol Hemoter
2010;32:140–147
61 Sangalli CN, Rauber F, Vitolo MR. Low prevalence of inadequate
micronutrient intake in young children in the south of Brazil: a
new perspective. Br J Nutr 2016;116(05):890–896
62 Maximino P, Machado RHV, Junqueira P, et al. How to monitor
children with feeding difficulties in a multidisciplinary scope?
Multidisciplinary care protocol for children and adolescents –
pilot study. J Hum Growth Dev 2016;•••:2
63 Spill MK, Callahan EH, Shapiro MJ, et al. Caregiver feeding
practices and child weight outcomes: a systematic review. Am J
Clin Nutr 2019;109(Suppl 7):990S–1002S
64 SPSP. Enfrentando a obesidade infantil. Pediatra Atualize-se.
2019;4:11
65 Eldridge A, Semenova I, Bryantseva S, et al. Milk and Dairy Foods
Improve Nutrient Intakes Among Children in Austra lia, Russia and
the US (P18–097–19). Curr Dev Nutr 2019;•••:3
66 Verger EO, Eussen S, Holmes BA. Evaluation of a nutrient-based
diet quality index in UK young children and investigation into the
diet quality of consumers of formula and infant foods. Public
Health Nutr 2016;19(10):1785–1794
67 Vieux F, Brouzes CM, Maillot M, et al. Role of Young Child
Formulae and Supplements to Ensure Nutritional Adequacy
in U.K. Young Children. Nutrients 2016;8(09):8
68 Li T, You J, Pean J, et al. The contribution of milks and formulae to
micronutrient intake in 1-3 years old children in urban China: a
simulation study. Asia Pac J Clin Nutr 2019;28(03):558–566
69 Lovell AL, Davies PSW, Hill RJ, et al. A comparison of the effect of a
Growing Up Milk - Lite (GUMLi) v. cows’milk on longitudinal
dietary patterns and nutrient intakes in children aged 12-23
months: the GUMLi randomised controlled trial. Br J Nutr
2019;121(06):678–687
70 Lovell AL, Davies PSW, Hill RJ, et al. Compared with Cow Milk, a
Growing-Up Milk Increases Vitamin D and Iron Status in Healthy
Children at 2 Years of Age: The Growing-Up Milk-Lite (GUMLi)
Randomized Controlled Trial. J Nutr 2018;148(10):1570–1579
71 Wall CR, Hill RJ, Lovell AL, et al. A multicenter, double-blind,
randomized, placebo-controlled trial to evaluate the effect of
consuming Growing Up Milk “Lite”on body composition in
children aged 12-23 mo. Am J Clin Nutr 2019;109(03):576–585
72 Hower J, Knoll A, Ritzenthaler KL, Steiner C, Berwind R. Vitamin D
fortification of growing up milk prevents decrease of serum 25-
hydroxyvitamin D concentrations during winter: a clinical inter-
vention study in Germany. Eur J Pediat r 2013;172(12):1597–1605
73 Chouraqui JP, Turck D, Tavoularis G, Ferr y C, Dupont C. The Role of
Young Child Formula in Ensuring a Balanced Diet in Young
Children (1-3 Years Old). Nutrients 2019;11(09):11
74 Eussen SR, Pean J, Olivier L, Delaere F, Lluch A. Theoretical Impact
of Replacing Whole Cow’s Milk by Young-Child Formula on
Nutrient Intakes of UK Young Children: Results of a Simulation
Study. Ann Nutr Metab 2015;67(04):247–256
75 Akkermans MD, Eussen SR BM, van der Horst-Graat JM, van Elburg
RM, van Goudoever JB, Brus F. A micronutrient-fortified young-
child formula improves the iron and vitamin D status of healthy
young European children: a randomized, double-blind controlled
trial. Am J Clin Nutr 2017;105(02):391–399
76 Walton J, Flynn A. Nutritional adequacy of diets containing
growing up milks or unfortified cow’s milk in Irish children
(aged 12-24 months). Food Nutr Res 2013;57:57
77 Kehoe L, Walton J, McNulty BA, Nugent AP, Flynn A. Dietary
strategies for achieving adequate vitamin D and iron intakes in
young children in Ireland. J Hum Nutr Diet 2017;30(04):405–416
78 Chatchatee P, Lee WS, Carrilho E, et al. Effects of growing-up milk
supplemented with prebiotics and LCPUFAs on infections in young
children. J Pediatr Gastroenterol Nutr 2014;58(04):428–437
79 Kosuwon P, Lao-Araya M, Uthaisangsook S, et al. A synbiotic
mixture of scGOS/lcFOS and Bifidobacterium breve M-16V
increases faecal Bifidobacterium in healthy young children. Benef
Microbes 2018;9(04):541–552
80 Hojsak I, Bronsky J, Campoy C, et al; ESPGHAN Committee on
Nutrition. Young Child Formula: A Po sition Paper by the ESPGHAN
Committee on Nutrition. J Pediatr Gastroenterol Nutr 2018;66
(01):177–185
81 EFSA. Scientific Opinion on nutrient requirements and dietary
intakes of infants an d young children in the European Union. EFSA
J 2013:11
82 Vandenplas Y, De Ronne N, Van De Sompel A, et al. A Belgian
consensus-statement on growing-up milks for children 12-36
months old. Eur J Pediatr 2014;173(10):1365–1371
83 Lott M, Callahan E, Duf fy EW, Story M, Daniels S. Healthy Beverage
Consumption in Early Childhood: Recommendations from Key
National Health and Nutrition Organizations. 2019
84 Przyrembel H, Agostoni C. Growing-up milk: a necessity or
marketing? World Rev Nutr Diet 2013;108:49–55
85 Turck D. Quelle place pour les laits « Croissance »? Arch Pediatr
2015;22(05, Suppl 1):85–86
86 Tounian P, Chouraqui JP. [Iron in nutrition]. Arch Pediatr 2017;24
(5S):S23, S31
87 Hsieh YH, Ofori JA. Innovations i n food technology for health. Asia
Pac J Clin Nutr 2007;16(Suppl 1):65–73
88 Pereira C, Ford R, Feeley AB, Sweet L, Badham J, Zehner E. Cross-
sectional survey shows that follow-up formula and growing-up
milks are labelled similarly to infantformula in four lowand middle
income countries. Matern Child Nutr 2016;12(Suppl 2):91–105
89 Choi YY, Ludwig A, Harris JL. US toddler milk sales and associa-
tions with marketing pract ices. Public Hea lth Nutrition. 20201–9.
90 Lippman HE, Desjeux J-F, Ding Z-Y, et al. Nutrient Recommenda-
tions for Growing-up Milk: A Report of an Expert Panel. Crit Rev
Food Sci Nutr 2016;56(01):141–145
91 Rêgo C, Pereira-da-Silva L, Ferreira R. CoFI - Consenso Sobre
Fórmulas Infantis: A Opinião de Peritos Portugueses sobre a
Sua Composição e Indicações. Acta Med Port 2018:31
92 Rinaldi AEM, Conde WL. Secular trends in dietary patterns of
young children in Brazil from 1996 to 2006. Public Health Nutr
2017;20(16):2937–2945
93 Morais MBd, Cardoso AL, Lazarini T, Mosquera EMB, Mallozi MC.
HÁBITOS E ATITUDES DE MÃES DE LACTENTES EM RELAÇÃO AO
ALEITAMENTO NATURAL E ARTIFICIAL EM 11 CIDADES BRASI-
LEIRAS. Rev Paul Pediatr 2017;35(01):39–45
94 Brady JP. Marketing breast milk substitutes: problems and perils
throughout the world. Arch Dis Child 2012;97(06):529–532
95 Lourenço BH, Silva LLS, Fawzi WW, Cardoso MA. Vitamin D
sufficiency in young Brazilian children: associated factors and
relationship with vitamin A corrected for inflammatory status.
Public Health Nutrition. 1–10
96 Silva LLS, Fawzi WW, Cardoso MA; ENFAC Working Group. Serum
folate and vitamin B12 status in young Brazilian children. Public
Health Nutr 2019;22(07):1223–1231
97 Leroux IN, Ferreira APSDS, Paniz FP, et al. Brazilian preschool
children attending day care centers show an inadequate micro-
nutrient intake through 24-h dup licate diet. J Trace Elem Med Biol
2019;54:175–182
International Journal of Nutrology Vol. 13 No. 1/2020
Consensus of the Brazilian Association of Nutrology on Milky Nogueira-de-Almeida et al.16