Weighing in on fruit juice: AAP now says no juice before age 1

One of the most common questions parents ask pediatricians is how much 100% fruit juice they should give their children. A new AAP policy recommends some children should be consuming less juice than previously advised.

An AAP policy statement published in 2001 and reaffirmed in 2006 recommended no juice for children younger than 6 months of age, 4-6 ounces daily for children ages 1-6 years and 8-12 ounces for children 7 and older. Since then, however, considerable concern has been expressed about increasing obesity rates and risks for dental caries.

Lower daily intakes

The Academy’s new policy Fruit Juice in Infants, Children and Adolescents: Current Recommendations builds on the original but considers the evidence released since then. The new advice indicates that fruit juice should not be provided to children younger than 1 year of age unless there is a strong clinical basis for it in the management of constipation. For older children, maximum daily intakes of 100% juice products should be 4 ounces for children ages 1-3 years, 4-6 ounces for children ages 4-6 years and 8 ounces for those 7 and older.

The policy, from the AAP Section on Gastroenterology, Hepatology and Nutrition and the Committee on Nutrition, is available at https://doi.org/10.1542/peds.2017-0967 and will be published in the June issue of Pediatrics.

Importance of whole fruits, other advice

Further recommendations emphasize the importance of fresh fruit in children’s diets. Fruit generally contains additional fiber compared to juices. Consistent with recent AAP recommendations, water and cow’s milk are preferred as primary fluid sources for children after weaning.

Families of small children with dental caries should have a discussion with their pediatrician about the child’s fruit juice intake and its possible contribution to the caries.

The literature regarding the contribution of 100% juice to obesity development remains uncertain with recent studies failing to identify a clear connection, especially in children over age 6. The Academy, therefore, recommends eliminating 100% fruit juice from the diets of children with excessive weight gain but not necessarily from the diets of all children.

In addition, the Academy strongly recommends that whole fruit be provided and encouraged for children participating in the Special Supplemental Nutrition Program for Women, Infants and Children. The policy also strongly discourages consumption of unpasteurized juice.

These recommendations, taken together, represent a policy goal of decreasing juice consumption, especially in small children, while ensuring an adequate intake of whole fruits. It balances the role of a small amount of 100% fruit juice in meeting these intake goals while limiting the exposure to juice and emphasizing the key roles of water and milk in a healthy diet. It recognizes that juice may provide some vitamins — such as vitamin C in orange juice and calcium and vitamin D in some fortified juice products — but lacks the fiber and protein critical for the growth of children.

More caveats

The policy clarifies that there is virtually no role for juice during the first year of life and that expensive juice products designed specifically for infants are not of value. When juice is served to older toddlers, it is important that it not be sipped throughout the day or used to calm an upset child. It is not useful for the management of diarrheal illnesses and may predispose infants or young children to the development of hyponatremia.

In summary, pediatricians should caution families that there is minimal nutritional value to fruit juice, and it should be limited to small amounts and generally avoided in infancy.

Recommendations

• Juice should not be introduced to infants before 1 year unless clinically indicated. Daily intake should be limited to 4 ounces in toddlers ages 1-3 years, 4-6 ounces for those 4-6 years. For those 7-18 years, limit juice intake to 8 ounces or 1 cup of the recommended 2-2½ cups of fruit servings/day.
• Toddlers should not be given juice from bottles or easily transportable covered cups that make it easy to consume throughout the day, nor should they be given juice at bedtime.
• Children should be encouraged to eat whole fruits and educated on the benefit of fiber intake.
• Families should be educated that human milk and/or infant formula is sufficient to satisfy fluid requirements for infants, and low-fat/nonfat milk and water are sufficient for older children.
• Consumption of unpasteurized juice products should be strongly discouraged.
• Grapefruit juice should be avoided in those taking certain medications (see policy).
• When evaluating children with malnutrition — as well as chronic diarrhea, excessive flatulence, abdominal pain and bloating — pediatricians should determine the amount of juice being consumed.
• In evaluating risk for dental caries, discuss the relationship between fruit juice and dental decay, and inquire about the amount and means of juice consumption.
• Routinely discuss the use of fruit juice vs. fruit drinks, and educate older children and parents about the differences.

Dr. Abrams is a co-author of the policy statement and incoming chair of the AAP Committee on Nutrition.