The first stage of infancy is one of the most dynamic, critical periods in child development, establishing the basis for the child’s future wellbeing, learning, participation1. Malnutrition during the first years of life can cause irreversible physical, cognitive alterations, increasing the probability of later suffering from undernutrition, overweight, obesity, noncommunicable chronic diseases, learning difficulties2–4. Cumulative evidence underlines the relevance of the first 1000 days of life of an individual for programming later diseases, during which nutrition is fundamental5. The microbiota is known to play an essential role in the mediation between nutrition, the programming of chronic diseases, so its adequate establishment, which stabilizes in the first 1500 days of life, is important6. However, nutritional problems are those that most affect Latin American children under5, years of age, the most frequent are chronic undernutrition, micronutrient deficiency7. Feeding practices vary from region to region, they are adapted to the sociocultural characteristics of each zone. Nevertheless, there are international guidelines that have been endorsed by different international societies, the acting authorities on the subject8–10.

Given the vast importance of this topic, the Early Nutrition Group of the Latin American Society of Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) set forth the goal of identifying the main feeding practices in the first 1500 days of life that are recommended by health professionals in Latin America.

A descriptive, observational, cross-sectional study, utilizing a survey, was conducted. At the time of this study’s conception, there was only one publication of an 8-item survey on nutrition in infants under one year of age, but it was insufficient for the aims we wished to evaluate11. Thus, we decided to carry out a survey, named the E-1500 survey, that encompassed more aspects of infant and young child nutrition. It was conceived and developed by two of the researchers (LLM, RVF). Ninety-four questions were initially formulated. The questionnaire was reviewed by the other colleagues, also experts on the topic (CBM, EOO), and at a virtual meeting, the questions were discussed, producing the final questionnaire made up of 68 items. The survey was then applied to a small sample of 10 healthcare professionals, to ensure that the questions were clear, and to identify any differences in terminology among regions. The first 7 items refer to sociodemographic aspects, including place of origin, age, sex, and profession, and the rest of the items refer to aspects of infant and young child nutrition within the first 1500 days of life, concerning general concepts (3 items); weight gain during pregnancy (2 items); maternal breastfeeding (6 items); complementary feeding (33 items), including time of introduction to foods considered potentially allergenic, additional components (sugar, salt), vitamin and mineral supplements, feeding method and focus, drinks during infancy; and feeding in children up to 3 years of age (16 items). The majority of those 61 questions were multiple choice, albeit many of them had the option of “other”, for filling in the blank. There was only one open-ended question, in which the participants were asked to give the name of the first food they recommended for starting complementary feeding. Forty-six of the questions had the option “I don’t know”, to minimize arbitrary responses to the other options presented. The survey can be viewed in the Supplementary Material.

The survey was published on the official website of the LASPGHAN. An additional link was also created, and an open invitation to Latin American healthcare professionals was extended, to answer the questionnaire online and anonymously. Emphasis was placed on the participants’ answering the questions in accordance with their usual behavior, regardless of international guideline recommendations. The questionnaires answered by persons that were not healthcare professionals, or by healthcare professionals not residing in Latin America, were excluded. The data were downloaded from the online survey system employed, to carry out the descriptive statistics. Proportions were determined for the qualitative variables and mean with standard deviation or median with interquartile range were determined for the quantitative variables. The study protocol was accepted by the Ethics Committee of the Universidad El Bosque in Bogotá, Colombia. Due to the fact that the study was an online survey answered by healthcare professionals, informed consent to take part in it was not requested from the participants. No experiments were performed on animals and/or humans. The authors declare that the present article contains no personal information that could identify any patient.

At present, this is the first survey that examines the recommendations made by healthcare professionals from different Latin American countries, with respect to feeding within the first 1500 days of life. Questions about nutrition have evolved over the last two decades, breaking paradigms and changing certain practices professionals were taught during their years of training that were based more on tradition than on evidence-based nutrition9. Current knowledge about early programming has resulted in the appearance of the concept of “the first 1000 days of life”, which spans the period from conception to 2 years of age. That is the period when the programming of many physiologic processes mainly occurs and when there can be an increased risk for various chronic pathologic conditions in the child, including metabolic syndrome, cognitive dysfunction, immunologic dysfunction, and growth abnormalities, among others12,13. Likewise, the first 1500 days of life are also spoken of, which is the period from conception to 3 and a half years of age, and corresponds to the time in which the gut microbiota stabilizes and acquires characteristics similar to those observed in the adult6. Given that diet is the main factor that affects the gut microbiota, or better said, the main way in which the gut microbiota is modified, the Early Nutrition Group of the LASPGHAN decided to adopt that concept of nutrition in the first 1500 days of life because it directly impacts the gut microbiota (said impact was not evaluated in the present study). Despite the importance of those concepts, a considerable number of the survey participants were unaware of them.

Excessive weight gain during pregnancy is associated with greater weight of the child at birth and greater susceptibility to his/her later weight gain14,15. Recommended weight gain during the pregnancy of adolescents with a normal pre-pregnancy BMI should be 12.5–17.5 kg16. The US National Institutes of Health recommends a weight gain of 11.5−16 kg for adult pregnant women with a normal pre-pregnancy BMI17. The results of our survey show the low level of knowledge about the ideal weight of women during pregnancy, signaling the need for establishing strategies to make the healthcare personnel aware of those data so they can guide the pregnant woman and her immediate family.

It is perfectly well known that the best way to begin feeding all infants, save a few exceptions, is with the milk each of the mothers produces, and should ideally be provided exclusively in the infant’s first 6 months of age and continued at least up to 2 years of age18,19. Close to 5% of the participants surveyed did not recommend exclusive breastfeeding during the first 6 months of life. This is important to point out, because a similar percentage was found in a recent survey conducted in Mexico that showed that 91% of healthcare professionals recommended exclusive breastfeeding up to 6 months. Nine percent did not recommend it, despite the fact that it is well established that breast milk sufficiently covers the energy and nutrient requirements the infant requires, during the first 6 months18,20. An important number of the healthcare professionals surveyed in the present study did not recognize the different immunologic components of breast milk; many of them identified immunoglobulins as defense components, but the large majority did not identify oligosaccharides as having immunomodulatory and immunoprotective effects21. It is alarming that only one-fourth of those surveyed were aware of breast milk storage time. Once the breast milk is expressed, it can be kept at room temperature for 4–6 h, after which its composition changes. It can be stored in a cooler for up to 12 h, and in a freezer for up to 15 days22. There is still an important lack of knowledge, with respect to breast milk, and so medical, pediatric, and nutritional training programs should be restructured for more efficient acquisition of that awareness.

One of the aspects of infant and young child nutrition that has recently evolved the most is that of complementary feeding. The introduction time has not changed, and according to the Pan American Health Organization, it is 6 months of age23. However, other international societies, such as the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), state that in some countries, introducing complementary feeding between 4 and 6 months can be recommended7. That was reflected in the results of our survey. Even though the majority of healthcare professionals answered that it should be started at 6 months, at least one-third responded that it could be started between 4 and 6 months of age. A recent survey conducted in Colombia showed that close to 97% of those surveyed also answered that the introduction age should be between 4 and 6 months of age24. Currently, the introduction time of complementary feeding is considered to be the same in breastfed children and formula-fed children7. Nevertheless, the Early Nutrition Group of the LASPGHAN considers that the nutritional gaps in complementary feeding differ between breast-fed children and formula-fed children, and therefore, the introduction time of complementary feeding should be different.

With respect to the first food or food group to be introduced in complementary feeding, the healthcare professionals surveyed considered any of them appropriate, but the traditionally recommended choice of fruits or vegetables was very frequent, results that were similar to those from other surveys conducted in Mexico and Colombia10,24. Indeed, there is no contraindication for starting with a fruit or vegetable, but that should not be exclusively maintained for a prolonged period; instead, the introduction of the second, third, and fourth foods should be continued, to achieve a diet that is as diverse as possible8. Juices are not a source of fiber or protein, and thus may lead to inadequate weight gain, and because of their usually sweet flavor, they are innately accepted by children. Therefore, it is better to offer children whole fruit25. Despite the fact that, more than a decade ago, the former practices of food introduction in complementary feeding were shown to lack a scientific basis, the delay in introducing foods considered allergenic is still deeply ingrained. That was apparent in our survey, given that a significant number of healthcare professionals continue to delay the introduction of those foods until after one year of age, which was also true in the previously described surveys10,24. The risk for an egg allergy decreases, when eggs are introduced between 4 and 6 months of age, whereas its risk increases, if the introduction of eggs is delayed7,26. However, in our survey results, one-fourth of the participants still recommend delaying the introduction of eggs until after one year of age, and similar results (33%) were found by Dadán et al.24 The same thing occurred with other foods, but to a lesser degree. One study conducted on 1612 children that evaluated exposure to different foods at 3, 6, 9, 15, and 24 months of age, and whose aim was to measure the development of wheat allergy, showed that introducing wheat after 6 months of age resulted in a greater risk for allergy in the children, compared with its introduction before 6 months of age, more specifically, between 4 and 6 months of age27. There is evidence that the introduction of fish between 6 and 12 months of age reduces the appearance of allergic rhinitis, whereas its introduction between 6 and 9 months of age, reduces the sensitization of the infant28,29. Nevertheless, more than one-third of our survey participants continue to recommend delaying the introduction of fish, as did 63% of the Colombian participants in the study by Dadán et al.24 The introduction of beef and pork is recommended from 6 months of age, because they are an important source of iron, starting at that age. Chicken, as well as other meat products, can also be introduced from 6 months of age30.

Infant cereals, preferably those fortified with iron and zinc, can be part of complementary feeding. They should be introduced in the form of simple grains, such as rice or corn, and should be prepared in breast milk or formula. Infant cereals reconstituted with water are not recommended because they can result in reduced protein and calcium intake31.

The addition of sugar is not recommended during the first 2 years of age because it contributes to the appearance of dental caries32. Salt should not be added to foods, either, given that their intrinsic sodium content is sufficient for covering the daily requirements7. Supplemental iron is recommended in premature or low birthweight neonates between 2 and 6 months of age or in children with iron deficiency anemia, under the recommendation and supervision of a physician7.

Some publications report that a vegetarian diet in children has diverse, long-term benefits, such as a low BMI in adulthood and low mortality from ischemic heart disease, which are related to a high consumption of vegetables, whole grains, legumes, and fruits. Other studies show that a vegetarian diet has no negative impact on the growth and development of children, compared with children that consume meats. Nevertheless, particular care should be taken in that context. A vegetarian diet is feasible, as long as it is carried out under the strict supervision of an experienced nutriologist/nutritionist that specializes in vegetarian nutrition7,33. A vegan diet can be implemented under strict medical and nutritional supervision by experienced healthcare professionals trained in plant-based nutrition, to ensure that the child receives adequate supplements of vitamin B12, vitamin D, iron, zinc, folate, proteins, and calcium, i.e., to ensure that the diet contains the nutrients and calories the child needs7.

There has recently been an increased demand by parents for baby-led weaning, or rather, baby-led complementary feeding, which is based on the child feeding himself/herself, from 6 months of age, instead of being spoon-fed by the parents34–36. It is postulated that this method enables the child to achieve self-regulation in food consumption, and as a result, in calories, thus potentially preventing the risk for overfeeding and consequent overweight or obesity. However, the only controlled clinical trial on that method, called the Baby-Led Introduction to SolidS (BLISS) study, showed no reduction in the risk for overweight or obesity36.

Very importantly, adequate feeding during the first months of life has implications on neurodevelopment. A protein and iron supply deficiency in the early stages of life can produce alterations in the development of the brain, modifying the normal anatomy of the neurons and their chemical processes, affecting communication and the entire neurotransmission system. Iron is one of the main substrates that contributes to the development of the brain, participating in multiple metabolic processes, including myelinization and the regulation and conduction of neurotransmitters, such as dopamine, serotonin, and GABA. The alteration of their transport due to iron deficiency can compromise the affective response, cognitive functioning, movement coordination, and memory in children37–40.

From one year of age, the child can consume the same foods as the rest of the family23. Nevertheless, the fact that the period of complementary feeding is up to 2 years of age should be recognized, making 2 years the age that the child should be completely integrated into the family diet. In general, no multivitamins are recommended, if the child is receiving an adequate diet. The use of nutritional supplements/complements is only recommended in children that need them, for example, in children at a moderate or high risk for undernutrition. They are usually used in situations of insufficient nutrient intake, when there are increased energy requirements, or in cases of metabolic alterations that hinder correct nutrient utilization41.

Our study sample was very heterogeneous, regarding the level of experience and knowledge, and so generalizations regarding all the healthcare professionals could not be made. Given the study design, an important limitation was the fact that there was not an adequately balanced representation of all the Latin American countries, which also impeded making generalizations that would be true for each of the countries. Another limitation was the social desirability of the participants to provide the best answers and not be perceived as having insufficient knowledge, which could have been reduced if the representatives of the different areas of healthcare had been interviewed.

Based on the results of the present study conducted on a group of Latin American healthcare professionals, their knowledge about nutrition in the first 1000–1500 days of life of an individual is still incomplete and insufficient. An important percentage of the healthcare professionals surveyed still adhere to traditional complementary feeding practices, despite new evidence. The present survey results give us an idea of the awareness of healthcare professionals, with respect to infant nutrition in the first 1500 days of life, revealing the need for their continued training on those topics. Continuous medical education programs are a feasible option and can even be integrated into healthcare career programs. In turn, having a Latin American consensus on maternal, infant, and young child nutrition, based on the healthcare needs and situations of the region, is essential.

No financial support was received in relation to the present article.

LLM: has received honoraria for conferences given at Abbott®, Mead Johnson®, Nestlé, and Nestlé Nutrition Institute®.

RVF: has received honoraria for conferences given at Abbott®, Nestlé®, and Nestlé Nutrition Institute®.

ALMP: has no conflict of interest.

MCBM: has received honoraria for conferences given at Abbott® and Danone®.

EOO: has received honoraria for conferences given at Danone®.

VPGMB: has no conflict of interest.