Organizational Principles to Guide and Define the Child Health Care System

POLICY STATEMENT and/or Improve the Health of all Children

Advocacy for Improving

Nutrition in the First 1000
Days To Support Childhood
Development and Adult Health
Sarah Jane Schwarzenberg, MD, FAAP, Michael K. Georgieff, MD, FAAP, COMMITTEE ON NUTRITION

Maternal prenatal nutrition and the child's nutrition in the first 2 years of life abstract
(1000 days) are crucial factors in a child’s neurodevelopment and lifelong
mental health. Child and adult health risks, including obesity, hypertension,
and diabetes, may be programmed by nutritional status during this
University of Minnesota Masonic Children’s Hospital, Minneapolis,
period. Calories are essential for growth of both fetus and child but are Minnesota
not sufficient for normal brain development. Although all nutrients are Drs Schwarzenberg and Georgieff both contributed to the writing and
necessary for brain growth, key nutrients that support neurodevelopment editing of this policy statement and approved the final manuscript as
submitted.
include protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12;
This document is copyrighted and is property of the American
and long-chain polyunsaturated fatty acids. Failure to provide key nutrients Academy of Pediatrics and its Board of Directors. All authors have
during this critical period of brain development may result in lifelong deficits filed conflict of interest statements with the American Academy
of Pediatrics. Any conflicts have been resolved through a process
in brain function despite subsequent nutrient repletion. Understanding the approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
complex interplay of micro- and macronutrients and neurodevelopment involvement in the development of the content of this publication.
is key to moving beyond simply recommending a “good diet” to optimizing
Policy statements from the American Academy of Pediatrics benefit
nutrient delivery for the developing child. Leaders in pediatric health and from expertise and resources of liaisons and internal (AAP) and
external reviewers. However, policy statements from the American
policy makers must be aware of this research given its implications for Academy of Pediatrics may not reflect the views of the liaisons or the
public policy at the federal and state level. Pediatricians should refer to organizations or government agencies that they represent.

existing services for nutrition support for pregnant and breastfeeding The guidance in this statement does not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking
women, infants, and toddlers. Finally, all providers caring for children can into account individual circumstances, may be appropriate.
advocate for healthy diets for mothers, infants, and young children in the
All policy statements from the American Academy of Pediatrics
first 1000 days. Prioritizing public policies that ensure the provision of automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
adequate nutrients and healthy eating during this crucial time would ensure
that all children have an early foundation for optimal neurodevelopment, a 1,​000 Days® is a trademark of 1,​000 Days, a 501(c)(3) nonprofit
organization. The 1,​000 Days mark is used with permission from 1,​
key factor in long-term health. 000 Days.

DOI: https://​doi.​org/​10.​1542/​peds.​2017-​3716

To cite: Schwarzenberg SJ, Georgieff MK, AAP COMMITTEE

Introduction ON NUTRITION. Advocacy for Improving Nutrition in the First
1000 Days To Support Childhood Development and Adult
Healthy, normal neurodevelopment is a complex process involving
Health. Pediatrics. 2018;141(2):e20173716
cellular and structural changes in the brain that proceed in a specified

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PEDIATRICS Volume 141, number 2, February 2018:e20173716 From the American Academy of Pediatrics
sequence.‍1,​2‍ Changes that are too occur during this period will not be inadequate or excessive amounts
rapid or too slow in one part of able to occur in later life. both place the individual at risk.
the brain may result in the failure Each of these 2 forms of malnutrition
The period of fetal life and the first
of crucial pathway connections to affects neurodevelopment, and they
2 years postpartum may be seen as
other parts of the brain. Timing may coexist in an individual.‍10
a time of tremendous opportunity
is crucial; once a particular
for neurodevelopment and a time In this Policy Statement, we seek
developmental sequence fails, it
of great vulnerability.‍5 Healthy to inform pediatricians and other
may not be possible to retrieve
neurodevelopment is dependent on health care providers of the key role
all the lost function. Moreover,
socioeconomic, interpersonal and/or of nutrition in brain development in
neurodevelopment proceeds by a
family, and nutritional factors.‍6 the first 1000 days of life (conception
scaffolding process in which the
In the presence of a supportive to 2 years of age). It is not meant as
development of increasingly complex
environment, an attached primary a comprehensive review of the data
neural circuits (and the behaviors
caregiver, and a healthy diet, the on brain-nutrient interaction (for
they support) relies on successful
brain typically thrives. In infants this, see Rao and Georgieff‍11). With
completion of previous stages of
and children, toxic stress, emotional this policy statement, we intend
development. Thus, optimal, healthy
deprivation, and infection or to support pediatricians and other
neurobehavioral development
inflammation have been shown to be health care providers in promoting
requires that all necessary factors be
associated with less optimal brain healthy nutrition and advocating
present at their biologically defined
development, and a deficient diet for for the expansion of programs that
time points and that no inhibitory
the child can worsen this. The effects affect early life nutrition as a means
factors be present.
of early adverse experiences may be of providing scaffolding for later
a lifetime of medical and psychosocial nutritional programs and preventing
The most active period of
problems, lost academic achievement early developmental loss. In this
neurologic development occurs
and productivity, and possible way, offered in this policy is an
in the first 1000 days of life, the
effects on the next generation.‍7–9
‍ opportunity to improve each child’s
period beginning at conception
These long-term issues are the true chance for the healthiest and most
and ending at the start of the third
cost to society, a cost that exceeds productive life possible.
postnatal year.‍3 Rapid change
that of preventing them, and we
occurs from the first development Macronutrient (protein, fat,
again emphasize the importance
of a structure recognizable as the glucose) sufficiency is essential for
of recognizing the developmental
brain (postconception day 18) to normal brain development. Early
origins of adult health and disease.
age 2 years.‍4 Important primary macronutrient undernutrition is
structures and processes that For the purposes of this discussion, associated with lower IQ scores,
support fundamental behaviors our focus is on the nutritional reduced school success, and
and provide scaffolds for later- environment of the fetus, infant, and more behavioral dysregulation.‍12
developing structures form during toddler. The nutritional environment Intervention in early nutritional
this time period. These structures has an effect on whether brain deficiency can be effective, and the
and processes include the sensory growth and differentiation proceed full effects may be felt for many
systems (especially auditory and normally or abnormally. Both years.‍13 In a study unlikely to be
visual), the hippocampus (declarative adequate overall nutrition (ie, replicated, investigators in rural
learning and memory), myelination absence of malnutrition) and Guatemala between 1969 and
(speed of processing), and the provision of adequate amounts of 1989 provided protein-calorie
monoamine neurotransmitter key macro- and micronutrients at supplementation of different degrees
systems (affect, reward). Even critical periods in development to different rural villages. Two
the prefrontal cortex (planning, are necessary for normal brain villages received a high-calorie,
attention, inhibition, multitasking) development. Importantly, the high-protein supplement, and 2
and brain circuits involved in social definition of malnutrition includes villages received a low-calorie
development have the onset of both undernutrition (provision of supplement without protein. Both
rapid development in the first 1000 inadequate amounts of macro- and/or supplements contained vitamins
days. Although neurodevelopment micronutrients) and also obesity and minerals. The supplements
continues throughout the life of a (provision of excessive calories, were provided for pregnant and
healthy person, by age 2 years the often at the expense of other lactating women and children up
brain has undergone tremendous crucial nutrients). It is important to to age 7 years. The investigators
restructuring. Many of the recognize that many nutrients exhibit measured locally relevant outcomes
developmental changes expected to a U-shaped risk curve, whereby over a period longer than 10 years,

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2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
assessing children between 13 and 2015, children were reported to be TABLE 1 Nutrients That Particularly Affect Early
19 years of age. Children who had hungry, to have skipped a meal, or to Brain Development and Demonstrate
received high-calorie, high-protein have not eaten all day as a result of a Critical or Sensitive Period
supplementation before age 2 years the severity of the food insecurity.‍14 Macronutrients
scored higher on tests of knowledge, The researchers who conducted Proteina
numeracy, reading, and vocabulary studies in Guatemala demonstrated Specific fats (eg, LC-PUFAs)a
and had faster reaction times in the potential long-term efficacy (in Glucose
Micronutrients
information-processing tasks terms of school performance) of
Zinca
than age-matched children who targeting these households with Coppera
received the low-calorie supplement. low or very low food security for Iodinea
In villages receiving the high- supplementation. Irona
calorie, high-protein supplement, Selenium
Vitamins and cofactors
there were no differences in test The failure to provide
B vitamins (B6, B12)
scores between children of high adequate macronutrients or Vitamin A
and low socioeconomic status, key micronutrients at critical Vitamin K
but in villages receiving the low- periods in brain development Folatea
calorie supplements, children can have lifelong effects on a Cholinea
in the higher socioeconomic child. In addition to generalized LC-PUFA, long-chain polyunsaturated fatty acid. Reprinted
with permission from Georgieff MK, Brunette KE, Tran PV.
group had higher test scores. In macronutrient undernutrition, Early life nutrition and neural plasticity. Dev Psychopathol.
summary, early supplementation deficiencies of individual nutrients 2015;27(2):415.
of nutrients to children at risk for may have a substantial effect on a Nutrients that meet the principles for demonstrating a

critical or sensitive period during development.

macronutrient deficiency improved neurodevelopment (‍Table 1).
neurodevelopmental outcomes over Prenatal and early infancy iron
an extended period of life, beyond the deficiency is associated with long- associated with reduced performance
period of supplementation. term neurobehavioral damage that on IQ tests.‍1 Women living in iodine-
may not be reversible, even with deficient areas of the world require
There are populations in the United iron treatment.‍15 Severe maternal attention to supplementation
States that, similar to the villages in iron deficiency, limited maternal- during pregnancy.‍16 Long-chain
Guatemala, have inadequate access fetal iron transport (associated, for polyunsaturated fatty acids, which
to macronutrients or only access to example, with cigarette smoking include docosahexaenoic acid and
low-quality macronutrients. A food- or maternal hypertension), or arachidonic acid, are important
insecure household, as defined by conditions that increase fetal for normal development of vision
the US Department of Agriculture iron demand (such as maternal and may also affect neurocognitive
(USDA), is one in which “access to diabetes) may lead to newborn iron development.‍17 Importantly in,
adequate food is limited by a lack deficiency and associated long-term some studies of supplementation
of money and other resources.”‍14 cognitive deficits.‍5 Adolescent iron of these fatty acids in early life,
In 2015, among US households deficiency is also associated with researchers did not demonstrate an
with children, 16.6% (or 6.4 million neurocognitive impairment but effect on development until 6 years
households) were food insecure is reversible with iron treatment, after supplementation. Traditions in
at some time during the year.‍14 suggesting differential effects of complementary feeding or restricted
Of households with children with timing on brain function.‍15 The diets because of poverty or neglect
incomes below 185% of the poverty earlier the timing of the deficiency, may reduce infant intake of many key
line, 36.8% were food insecure.‍14 the more likely long-term effects factors in normal neurodevelopment,
Impoverished households are at will occur, probably because including zinc, protein, and iron.‍18
increased risk of food insecurity, but structure and regulation of genes
sudden social changes (for example, involved in neural plasticity have As the normative infant feeding,
divorce, loss of job) can introduce been significantly altered.5 Iodine human milk and breastfeeding play
food insecurity into households that is essential for synthesis of thyroid a crucial role in neurodevelopment.
are not impoverished. Although hormone, which is in turn crucial Although randomized trials are
parents shield children from the in neurodevelopment. Deficiency of not feasible, improved cognitive
worst effects of food insecurity, in iodine in pregnant women leads to function in term and preterm infants
approximately half of these food- cretinism in the child, with attendant who are fed human milk compared
insecure households, children severe, irreversible developmental with those who are fed formula is
were food insecure. In ∼274 000 delays. Mild to moderate postnatal supported by the weight of evidence
households in the United States in chronic iodine deficiency is on this topic.‍19–‍ 21
‍ Despite ongoing

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PEDIATRICS Volume 141, number 2, February 2018 3
attempts to mimic human milk childhood.‍30 In emerging but still Meeting the Nutritional
with infant formula, human milk limited evidence, it is suggested Needs of Young Children for
may contain nutrients, growth that childhood obesity may impact Neurodevelopment
factors, and cells important for brain neurodevelopment.‍10 If this is true, Opportunities to improve early child
development that formula lacks.‍21 improving infant feeding patterns, nutrition, and thus neurodevelopment,
A role for the intestinal microbiome including breastfeeding duration, age are currently focused in 2 areas: first
in brain development and behavior of complementary food introduction, and foremost, programs directed
is supported by increasing evidence, and types of foods introduced, at supporting breastfeeding and
and human milk and breastfeeding may protect neurodevelopment by provision of nutritious food to young
produce a microbiome with reducing the risk of obesity in young children; and second, guidelines that
increased beneficial microbial children.‍31–33
‍ Although further inform providers of the best practices
communities.22 Some micronutrient studies will be important, obesity in early childhood nutrition. It should
supplementation is needed in the of mother or child appears to be be noted that programs that serve the
breastfeeding infant (eg, zinc, iron, a form of malnutrition affecting nutritional needs of children after the
and vitamin D), and breastfeeding neurodevelopment in the first first 1000 days form a crucial link from
mothers need information about 1000 days. this early period to adulthood and
optimal nutrition.‍23 are most effective when building on a
In summary, nutrition is 1 of scaffolding of optimal early nutrition.
several factors affecting early
Obesity neurodevelopment and is a factor
Programs
that pediatricians and other health Special Supplemental Nutrition
Although there is evidence that Program for Women, Infants, and
care providers have the capacity
obesity in children and adolescents Children
to improve by application of well-
is associated with poorer educational
described, well-piloted, effective The Special Supplemental Nutrition
success, studies are often
interventions.‍5 Improved nutrition Program for Women, Infants, and
complicated by small sample size,
in the prenatal period, broad Children (WIC) serves pregnant
failure to control for confounding
support for breastfeeding, and women, breastfeeding women
factors, and other aspects of study
improved transitional and toddler (up to the child’s first birthday),
design.‍24 In children born preterm
nutrition all contribute to optimal nonbreastfeeding postpartum
with very low birth weights, body
neurocognitive development in the women (up to 6 months postpartum),
composition is correlated with
first 1000 days. Failure to provide infants (up to their first birthday),
neurodevelopment, and infants
adequate essential nutrients during and children up to their fifth
with greater fat-free mass (as
the first 1000 days of life may birthday. As such, it is the most
opposed to fat mass) show improved
result in increased expenditures important program providing
neurodevelopment at 1 year of
later in the form of medical care, nutritional support in the first 1000
age. Weight gain alone, particularly
psychiatric and psychological care, days. In the United States, 53%
when excessive weight is gained,
remedial education, loss of wages, of all infants younger than 1 year
may not achieve the desired goal of
and management of behavior.‍26,​34 ‍ are served by WIC. WIC supports
preserving brain development in
Conversely, the positive effects of breastfeeding prenatally through
the very low birth weight preterm
improved early nutrition may not education and postpartum by
infant.‍25 Obesity of the expectant
be apparent in short-term studies; helping mothers breastfeed, and
mother affects her offspring’s health
indeed, because neurodevelopment they perform screening for anemia
throughout the life span, including
is a biologic process across the life in women and children receiving
an increased risk for diabetes and
span in which changes are built on services through the program.
obesity as well as an increased risk
of adverse neurodevelopment.‍26 previous changes, the positive effects Published evidence supports the
Maternal obesity is also associated of an intervention may be seen after impact of WIC on the health of
with decreased breastfeeding many years and may continue for children: prenatal WIC participation
initiation rates, delayed onset of full many years. Thus, early nutritional has been consistently associated
milk production, and insufficient intervention provides enormous with higher birth weight and longer
milk supply, resulting in a shortened potential advantages across the life gestation, particularly among
duration of breastfeeding.‍27–29
‍ The span and, if nutritional needs are mothers at highest risk,​‍35 and WIC
introduction of complementary unmet in this period, developmental participation has been linked to
foods before 4 months of age may losses occur that are difficult to better infant health and less infant
increase the risk of obesity in later recover. overweight and underweight.‍36

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4 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Despite the impact of WIC, children The USDA, in partnership with states, not specifically aimed at nutrition,
in many families who do not qualify has supported the use of bonus the services include education on
under current guidelines would benefit incentives within SNAP, such as the parenting and health.
from the nutrients and educational use of “bonus dollars” in the form of
support of this program. Children tokens or paper coupons, for purchases Baby-Friendly Hospital Initiative
whose families are on the margin made with SNAP benefits at farmer’s The Baby-Friendly Hospital Initiative
of qualification for WIC may, for markets.‍38 Nutrition education or was developed by the United Nations
economic reasons, subsist on cheaper, incentive programs that are specifically Children’s Fund and the World
less nutritionally replete diets. Many targeted to families with infants and Health Organization in 1991 to
families fail to take advantage of young children would be valuable. In increase hospital and/or birthing
the program after the first year of addition, many families receiving SNAP centers’ attention to initiation of
life, in part because of the challenge live in areas with limited grocery store breastfeeding. Centers who qualify for
of access. Keeping families in the options (“food deserts”), making it this designation have implemented the
program longer (for example, through difficult to use their benefit optimally. “Ten Steps to Successful Breastfeeding”
the elimination of the requirement to and adhere to the International Code
recertify eligibility at 1 year of age and Child and Adult Care Food Program
of Marketing Breast-Milk Substitutes.‍41
extending eligibility for WIC through 6 The Child and Adult Care Food In a meta-analysis of programs
years of age) will make supplemental Program (CACFP) is administered by created to improve many aspects
food available to the growing toddler. the USDA and, among other things, of breastfeeding, Baby-Friendly
WIC is a crucial program in providing provides money to assist child care Hospital support interventions had
food and education to support institutions and family or group day the greatest effect on promoting any
neurodevelopment. care homes in providing nutritious breastfeeding.‍42
foods that contribute to the wellness,
Supplemental Nutrition Assistance Guidelines
healthy growth, and development of
Program
children. In fiscal year 2013, CACFP National Guidelines
The Supplemental Nutrition Assistance served more than 3 million children.
The USDA and Department of Health
Program (SNAP, formerly “Food Completion of the revision of CACFP
and Human Services are responsible
Stamps”) is a food and nutrition meal requirements to make them
for developing and maintaining
program of the USDA. It provides a more consistent with the Dietary
evidence-based guidelines for good
modest benefit (just $1.35 on average Guidelines for Americans (DGA)‍39
nutrition, the DGA.‍39 These guidelines
per person per meal for households should improve the nutritional quality
focus on children 2 years and older. In
with children) to all who qualify. of these meals for young children.
2014, the Birth to 24 Months project
Seventy-two percent of households
Food Pantries and Soup Kitchens was started to develop guidelines
served are families with children. In
for children in that age group.‍43
addition to the antipoverty effects Food pantries and soup kitchens
This process is an evidence-based
of the SNAP benefit (SNAP kept are generally community-supported
review of the existing literature on
∼10.3 million people out of poverty programs that serve as a safety net
feeding children from birth to age 24
in 2012, including nearly 4.9 million for children and families struggling
months. It begins with the formulation
children), SNAP Nutrition Education, with inadequate food. However,
of questions, systematic reviews
a partnership between the USDA and many charitable food providers are
through the Nutrition Evidence
states, is intended to provide SNAP not consistently able to provide
Library at the USDA, and the grading
participants or eligible nonparticipants healthful food in general, nutritional
of evidence on the basis of study
with the skills and knowledge to make items appropriate for infants and
quality, consistency of findings,
healthy choices within a limited budget toddlers, or amounts adequate to
number of studies and subjects, impact
and choose active lifestyles consistent protect children from inadequate
of outcome, and generalizability of
with federal dietary guidance. In nutrition for more than a few days.
findings.‍44 Pediatricians with expertise
fiscal year 2016, the USDA Food and
Maternal, Infant, and Early Childhood in nutrition in these age groups are
Nutrition Service authorized $408
Home Visiting Program members of the committees currently
million to all 50 states, the District
doing this work. The final report and
of Columbia, Guam, and the Virgin Congress established the Maternal,
incorporation of these guidelines into
Islands to provide nutrition education Infant, and Early Childhood Home
the overall DGA is expected in 2020.
and obesity prevention services using Visiting Program in 2010 to provide
interventions that include direct funds for states and tribes providing Because these guidelines are the
education, social marketing, and policy, voluntary, evidence-based home reference point for state and federal
systems, and environmental changes.‍37 visiting to at-risk families.‍40 Although policies and programs, pediatricians

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PEDIATRICS Volume 141, number 2, February 2018 5
TABLE 2 Resources To Help Pediatricians Optimize Nutrition in the First 1000 Days
Resource Crucial Period Major Points
The American College of Obstetrics and Gynecologists. Prenatal, immediate postnatal Breastfeeding toolkit, obesity toolkit
Available at: http://​www.​acog.​org
Guidelines for Perinatal Care. 8th ed. American Academy Prenatal, immediate postnatal Chapters on prenatal and postnatal care
of Pediatrics and American College of Obstetrics and
Gynecologists; 2017
Kleinman RE and Greer FR, eds. Pediatric Nutrition. 7th ed. From birth Chapters that make recommendations on
American Academy of Pediatrics; 2014 breastfeeding, complementary feeding,
feeding the child, and macro- and
micronutrients
Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: From birth Chapters on healthy wt and healthy nutrition
Guidelines for Health Supervision of Infants, Children
and Adolescents. 4th ed. American Academy of
Pediatrics; 2017
Schanler RJ, Krebs NF, Mass SB, eds. Breastfeeding From birth Guide to rationale for breastfeeding,
Handbook for Physicians. 2nd ed. American Academy of implementation, and maintenance
Pediatrics and The American College of Obstetrics and
Gynecologists; 2013
Policy statement: breastfeeding and the use of human From birth AAP policy on breastfeeding
milk. Section on breastfeeding. Pediatrics. 2012;129(3).
Available at: www.​pediatrics.​org/​cgi/​content/​full/​129/​
3/​e827
Baker RD, Greer FR, and the Committee on Nutrition. Birth to 3 y of age AAP policy on iron supplementation
Clinical report: diagnosis and prevention of iron
deficiency and iron-deficiency anemia in infants
and young children (0–3 y of age). Pediatrics.
2010;126(5):1–11

should be aware of the importance of health care providers need federal levels to preserve and
these guidelines. The 2015 DGA saw to be knowledgeable about strengthen nutrition programs
an organized and concerted effort breastfeeding to educate with a focus on maternal,
by special interest groups to subvert pregnant women about fetal, and neonatal nutrition.
or dilute the results of the guideline breastfeeding and be prepared Interventions to ensure normal
process and the process itself. It is to help breastfeeding mothers neurodevelopment include
important that pediatricians, who are and their infants when problems programs to minimize adverse
familiar with using evidence-based occur. The AAP recommends environmental influences and
clinical guidelines, advocate for the exclusive breastfeeding for programs to mitigate the effects
scientific foundations of this process approximately the first 6 of adverse environmental
and support implementation of the months of life and continuation influences. These interventions
guidelines. after complementary foods have begin with nutritional health for
been introduced for at least the the pregnant woman, including
American Academy of Pediatrics
first year of life and beyond, adequate protein-energy intake,
The American Academy of Pediatrics as long as mutually desired appropriate gestational weight
(AAP) provides substantial by mother and child. Several gain, and iron sufficiency.
information on the nutritional needs organizations have reviewed To some degree, the placenta
and support of children from birth to interventions to support protects the fetus in terms
age 2 years, including information and breastfeeding.‍48,​49
‍ Despite the of prioritization of nutrients
guidance on breastfeeding‍45 and on known advantages of human from the mother. After birth,
feeding infants and toddlers.‍46 AAP milk in early life, estimates are human milk provides optimal
policies on breastfeeding‍21 and iron that 19% of children receive no neurodevelopmental nutrition
supplementation‍47 directly address human milk in infancy and only for at least the first 6 months.‍21
key issues in nutrition and cognition. 22% breastfeed exclusively for After 6 months, pediatricians and
the recommended 6 months;‍50 other health care providers can
2. Pediatricians, family physicians, support policies that advocate
Recommendations
obstetricians, and other child for optimal protein-calorie and
1. Pediatricians, family physicians, health care providers can micronutrient administration
obstetricians, and other child advocate at the local, state, and to infants and young children

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6 FROM THE AMERICAN ACADEMY OF PEDIATRICS
TABLE 3 Organizations Focused on Hunger
Name Web Site Focus Comments
Bread for the World www.​bread.​org Nonpartisan policy analysis and strategies Yearly report on key issues in hunger, often
to end hunger in the United States focused on the United States. Offers
and the world. Provides education for strategies for engaging churches and
opinion leaders, policy makers, and the communities in advocacy. Faith-based,
public on hunger Christian organization
Feeding America http://​www.​feedingamerica.​org/​ Nationwide network of food banks; E-mail newsletter, annual report. Volunteer
develops and stocks food banks and opportunities locally at many levels
other emergency food distribution
systems
Mazon http://​mazon.​org Policy change, strategy, and education to Works to improve nutritious food choices
end hunger in food banks, provides food for seniors,
and impacts hunger in rural areas.
Places a high priority on the support of
child nutrition programs. Faith-based,
Jewish organization
Community for Zero http://​www.​zerohungercommuni​ty.​org Supports UN Zero Hunger Challenge; High-level policy oriented
Hunger focused on world hunger
Share Our Strength https://​www.​nokidhungry.​org Runs the No Kid Hungry Campaign; Guides volunteers to hunger-based
teaches cooking to low-income families, opportunities in their communities
supports and teaches MyPlate
Food and Research http://​frac.​org National nonprofit organization that works Maintains a list of state antihunger
Action Center on policy and research with hundreds organizations, which can be found at:
of national, state, and local nonprofit http://​frac.​org/​about/​1303-​2
organizations, public agencies,
corporations, and labor organizations
to address hunger, food insecurity, and
their root cause: poverty
1,​000 Days www.​thousanddays.​org Focuses on nutrition and all forms of 1,​000 Days is “high-level policy oriented” in
malnutrition in the first 1000 d of life. both the global and domestic contexts,
Works in the United States and globally and the organization has a large
to promote action and investment grassroots constituency of advocates
in maternal, infant, and young child (primarily mothers) in the United States
nutrition
UN, United Nations.

(eg, AAP iron policy‍47) as well dietary recommendations. into existing nutritional advice
as programs that provide high- As the infant’s nutritional an actionable guide to healthy
quality nutrition to infants and intake moves from the relative eating as a positive choice
young children (eg, WIC); protection of breastfeeding to rather than an avoidance of
dependence on choices made by unhealthy foods. This would
3. Pediatricians and other child
his or her parents, pediatrician give pediatricians and families
health care providers can
guidance for informed food more prescriptive advice as
become conversant about food
choices becomes increasingly to optimal dietary choices.
sources that supply the critical
important. Moreover, knowing Additionally, it is important that
nutrients necessary for brain
which nutrients are at risk in the families understand that no 1
development during particularly
breastfed infant after 6 months food is alone adequate to ensure
important times. Although most
(eg, zinc, iron, vitamin D) will optimal neurodevelopment and
pediatricians are aware that
guide dietary recommendations health (ie, a “superfood”);
exclusive breastfeeding is the best
in the clinic or practice. Guidance
source of nutrition for the first 6 5. Pediatricians and other child
for pediatricians is provided in
months, dietary advice thereafter health care providers can focus
existing documents (‍Tables 1
is less robust. Awareness of which the attention of existing programs
and 2‍) but over a spectrum of
foods are “healthy,​” not just on improving micro- and
resources and chapters, and it is
as alternatives to unhealthy or macronutrient offerings for infants
often without clear prescriptive
junk food but as positive factors and young children. For example,
recommendations;
targeting optimal development, providing information to existing
would allow pediatricians 4. Leaders in childhood nutrition food pantries and soup kitchens
to make more appropriate can advocate for incorporating to create food packages and meals

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PEDIATRICS Volume 141, number 2, February 2018 7
 that target the specific needs of anticipate neurodevelopmental Committee on Nutrition, 2016–2017
pregnant women, breastfeeding concerns in children with early Stephen Daniels, MD, PhD, FAAP, Chairperson
women, and children in the first 2 nutrient deficiency. Pediatricians Mark Corkins, MD, FAAP
years of life; can educate themselves as to Neville H. Golden, MD, FAAP
which nutrients are at risk Jae H. Kim, MD, PhD, FAAP
6. Pediatricians and other child for deficiency and at what age C. Wesley Lindsey, MD, FAAP
health care providers can Sheela N. Magge, MD, MSCE, FAAP
as well as about appropriate Sarah Jane Schwarzenberg, MD, FAAP
encourage families to take screening for children at high
advantage of programs providing risk. For example, the risk of Past Committee Members
early childhood nutrition and iron deficiency is not equal Steven Abrams, MD, FAAP
advocate for eliminating barriers throughout the pediatric life Sarah de Ferranti, MD, FAAP
that families face to enrolling span. Pediatricians can be aware
and remaining enrolled in such that the newborn, the toddler, Liaisons
programs. Many families do not and the adolescent are at highest Carrie L. Assar, PharmD, MS – Food and Drug
take advantage of WIC services risk and should be aware of Administration
after the first year of life. factors that increase those risks; Janet de Jesus, MS, RD – National Institutes of
Encouraging the use of services Health
and benefits for which the Cria Perrine, PhD – Centers for Disease Control
9. Pediatricians and other child
and Prevention
family is eligible and eliminating health care providers can Valery Soto, MS, RD, LD – USDA
the requirement to recertify partner with obstetricians and
eligibility for young children at family physicians to encourage Staff
1 year of age can improve early improvements in maternal Debra Burrowes, MHA
life nutrition for children; diet and attention to clinical Madeline Curtis
situations that may limit Tamar Magarik Haro
7. Pediatricians and other child the fetus’s access to crucial
health care providers can oppose micronutrients; and
changes in eligibility or financing
structures that would adversely 10. Pediatricians and other child
affect key programs providing health care providers can
Abbreviations
early childhood nutrition. Such become advocates in the
changes include changing funding “Hunger Community.” Many AAP: American Academy of
to block grants or delinking organizations work to reduce Pediatrics
nutrition and health assistance hunger at the local level, CACFP: Child and Adult Care
programs, such as the adjunctive across the United States, and Food Program
eligibility between WIC and in the global community. As DGA: Dietary Guidelines for
Medicaid. Federal nutrition pediatricians consider their Americans
programs such as SNAP are personal contribution to social SNAP: Supplemental Nutrition
successful because of eligibility action, involvement in 1 of these Assistance Program
rules and a funding structure organizations is an excellent USDA: US Department of
that makes benefits available to option (see ‍Table 3). Agriculture
children in almost all families with WIC: Special Supplemental
little income and few resources; Nutrition Program for
Lead Authors
Women, Infants, and
8. Pediatricians and other child Sarah Jane Schwarzenberg, MD, FAAP Children
health care providers can Michael K. Georgieff, MD, FAAP

Address correspondence to Sarah Jane Schwarzenberg, MD, FAAP. E-mail: schwa005@umn.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2018 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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8 FROM THE AMERICAN ACADEMY OF PEDIATRICS
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10 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood
Development and Adult Health
Sarah Jane Schwarzenberg, Michael K. Georgieff and COMMITTEE ON
NUTRITION
Pediatrics 2018;141;
DOI: 10.1542/peds.2017-3716 originally published online January 22, 2018;

Updated Information & including high resolution figures, can be found at:
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Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood
Development and Adult Health
Sarah Jane Schwarzenberg, Michael K. Georgieff and COMMITTEE ON
NUTRITION
Pediatrics 2018;141;
DOI: 10.1542/peds.2017-3716 originally published online January 22, 2018;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/141/2/e20173716

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