Public health recommendations published today that children 5 years to 18 years old should “mostly drink water and plain pasteurized milk” may feel overly restrictive to beverage manufacturers, but according to one expert there is room for innovation, renovation, new packaging and enhanced communication, which could give companies a competitive edge.
The recommendations, which were developed in collaboration with experts form the Academy of Nutrition and Dietetics, American Academy of Pediatric Dentistry, American Academy of Pediatrics and American Heart Association under the leadership of Healthy Eating Research with funding from the Robert Wood Johnson Foundation, build on a similar guidance published by the same organizations in 2019 for children younger than 5 years old.
“There has been so many new beverages that have emerged in the marketplace in the past five to 10 years, a lot of which we are seeing grow in terms of consumption among school aged children, especially adolescents, and it drove home the point that we needed updated recommendations because so many beverage categories were not covered in existing ones,” said Megan Elsener Lott, deputy editor of Healthy Eating Research.
She added that in promoting the recommendations from 2019 for children under 5 years old, many parents asked what their older children should and should not be drinking for optimal health.
“There was a lot of confusion and so we decided to embark on a similar effort for school aged children,” she added.
“These recommendations really do reflect the latest science and pull in the latest evidence. At times when evidence was lacking, expert opinion based on evidence we have for adults was used,” Lott explained.
Plain water recommendation reveals need for flavors that will not impact pH levels
When considering children’s health, Lott noted “it is probably no surprise that the top two recommended beverages are water and milk,” given the importance of water for overall hydration and milk as a “nutrition powerhouse when it comes to providing essential vitamins and minerals that young children and developing adolescents really need.”
She explained that “plain water” is just that – unflavored, flat water. And while she acknowledged the plain sparkling water could also fit the bill, she warned that flavored waters – even if unsweetened – could harm children’s health.
“This recommendation has a lot to do with oral health. Many of the flavorings in flavored water are often acid-based, which changes the pH level of the water,” she said. “Water has a natural pH of 7, which is neutral, and anything in the 5 to 7 range has not been shown to have negative impacts on oral health. So, plain sparkling water falls in there. It has a pH of 5 or 6. But when you add the flavoring” it changes the pH level down to 3 or 4, “which starts to lead to dental erosion and increased risk of cavities – especially in younger children. And so those are not recommended.”
Lott noted another area ripe for innovation could be creating flavors that will not lower the pH level of beverages.
Recommendation to limit 100% juice reveals innovation opportunity
The guidance also recommends children younger than 18 years limit 100% juice, plant-based milk alternatives and flavored milk.
“From a science perspective, the reason most of these are in this category is really around limiting added sugar and unnecessary calories,” Lott said.
She explained that 100% juice “still provides essential vitamins and minerals to some kids, but we would really rather have kids meet the daily fruit group recommendations by consuming whole fruit. And studies show when kids drink too much juice, it just replaces the fruit and vegetable intake.”
The guidelines recommend children 5 to 8 years old consume less than 4 to 6 fluid ounces of juice per day, children 9 to 13 years old consume less than 6 to 8 fluid ounces per day and children 14 to 18 years old consume less than 8 ounces per day.
To help children and caregivers follow these guidelines, Lott suggested beverage manufacturers could innovate around packaging – offering sizes that align with the recommended caps per age group.
“Adjusting package sizes to meet those serving sizes would be wonderful. For an 18-year-old, they can have up to a cup of juice per day, but it is really hard to find an 8-ounce serving container of juice. Most of them are smaller juice boxes, which are 4 to 6 ounces and great for elementary school aged kids and middle schoolers. But then you jump to a 16-ounce individual container serving. So that could be an area for product innovation – selling that 8-ounce size that meets that recommended size,” Lott said.
She also encouraged manufacturers to clearly and consistently label in the same place when products are 100% juice and explain what that recommendation means.
Evidence is ‘pretty strong’ that plant-based milk is not nutritionally equivalent to cow’s milk
The recommendations also encourage caregivers to limit plant-based milk alternatives as a replacement for cow’s milk for children unless they are selected based on specific medical reasons or dietary needs.
“The one exception here would be the Dietary Guidelines support fortified soy milk, and we definitely encourage that as the top recommendation” when cow’s milk is not an option for dietary or medical reasons, Lott said.
“It is not that plant-based milks are harmful to kids. It is that we found a lot of families are using them as a cow’s milk substituted and not realizing they are not getting the nutrition their kids need from the beverage the way they thought they were,” said Lott.
When children refuse to drink cow’s milk, many may turn to flavored milk – but the recommendations advise against this, saying this category should also be limited due to added sugar.
“Flavored milk should be an absolute last resort. If your kid won’t drink plain milk, for example, you should offer unsweetened yogurt or cheese instead to meet the dairy group recommendation,” Lott said.
She added that some flavored milk, like chocolate, can have as much added sugar as a can of regular soda and more than a sports drink.
“A lot of families really don’t realize how much added sugar can be in those flavored milks, and the ones with lower sugar often have non-sugar sweeteners added, which are not recommended by this panel for consumption by children either,” she said.
Lott explained the panel eschewed non-sugar sweeteners in part because there is a lack of nutrition research on the impacts of them on children.
But, she added, “emerging evidence on adults shows that non-sugar sweeteners are not actually helping with weight maintenance or weight gain prevention, as originally thought, and that increased consumption among adults has been documented to lead to increased prevalence of type 2 diabetes and adverse cardiac events, which is really concerning to the panel.”
As such, she said, “the expert panel felt really strongly that we should not be giving these to our kids until we know more.”
Beverages to avoid: Sweetened and caffeinated options
Finally, the recommendations urge caregivers to avoid giving children under 18 years old beverages with caffeine and other stimulants, sugar-sweetened beverages and beverages with non-sugar sweeteners.
Lott explained that these were made to reduce unnecessary calories and potential negative side-effects.
For example, she said, “even small amounts of caffeine can have impacts on kids’ health, like delayed sleep onset and poor sleep quality, increased blood pressure, depressive moods and anxiety.”
Research also suggested consumption of caffeinated beverages “provided a gateway towards increased alcohol and tobacco consumption as well as other negative food habits, like increased amount of foods high in added fat, sugar and salt,” said Lott.