nutrients

Article
Many Infants and Young Children Are Not Compliant
with Mexican and International Complementary
Feeding Recommendations for Milk and
Other Beverages
Myriam C. Afeiche 1 , Salvador Villalpando-Carrión 2 , Kathleen C. Reidy 3 , Lisa R. Fries 4 ID

and Alison L. Eldridge 1, *

1 Institute of Nutritional Science, Nestlé Research Center, Route du Jorat 57, 1000 Lausanne, Switzerland;
Myriam.AfeicheZehil@rd.nestle.com
2 Hospital Infantil de Mexico, Gastroenterology and Nutrition, Mexico City and Nestlé Infant Nutrition,
Av. Ejercito Nacional 453, Delegacion Miguel Hidalgo, Col. Granada, Mexico City 11520, Mexico;
Salvador.Villalpando@MX.nestle.com
3 Nestlé Nutrition Global R&D, 12 Vreeland Road, Florham Park, NJ 07932, USA;
Kathleen.Reidy@rd.nestle.com
4 Consumer Science and Applied Nutrition, Institute of Material Science, Nestlé Research Center,
Route du Jorat 57, 1000 Lausanne, Switzerland; Lisa.Fries@rdls.nestle.com
* Correspondence: alison.eldridge@rdls.nestle.com; Tel.: +41-21-785-8365




Received: 27 February 2018; Accepted: 5 April 2018; Published: 10 April 2018


Abstract: Mexican and international authorities provide guidelines for milk and beverage
consumption for young children. This study classifies beverages as appropriate or inappropriate
by age (0–5.9, 6–11.9, and 12–23.9 months) and details consumption patterns, amounts consumed,
and the associated socio-demographic characteristics. Analysis of the Mexican National Nutrition
and Health Survey (ENSANUT 2012) was conducted (n = 949). Among 0–5.9 month olds, 66.7%
consumed either breast milk, infant formula, or a combination with no other beverages, whereas 29.3%
consumed breast milk and/or infant formula with water (mean = 58 g/day) and/or other beverages
(mean = 115 g/day), such as 100% fruit juice, milk, and sugar-sweetened beverages (SSBs). For infants
6–11.9 months, appropriate beverages include breast milk, infant formula, and water; only 40.2% met
these recommendations. Many 6–11.9 month olds consumed age-inappropriate beverages, including
milk (31%) and SSBs (35%). After 12 months of age, appropriate beverages include water, milk, and a
limited amount of 100% fruit juice and SSBs; 32.4% complied fully, 18.3% consumed appropriate and
inappropriate beverages, and 49.3% consumed only inappropriate beverages. Among 12–23.9 month
olds, 58% consumed milk, 18% juice, and 42% water while 63% consumed SSBs. Many infants and
young children are not compliant with Mexican and international breastfeeding and complementary
feeding guidelines for beverages. Communication and guidance about age-appropriate beverages
should be improved.

Keywords: ENSANUT 2012; infant diet; young child diet; milk intake; beverages intake

1. Introduction
Human milk is the ideal nutrition source for infants. The World Health Organization
recommends exclusive breastfeeding for the first six months of life and continuing frequent, on-demand
breastfeeding until 2 years of age or beyond [1]. The Mexican Norm on Nutrition 043 is consistent
with these recommendations, including gradual and progressive introduction of complementary foods

Nutrients 2018, 10, 466; doi:10.3390/nu10040466 www.mdpi.com/journal/nutrients

Nutrients 2018, 10, 466 2 of 14

from 6 months of age [2]. If a mother cannot or chooses not to breastfeed, fortified infant formula is an
appropriate alternative [1].
While clear recommendations about infant feeding and complementary feeding exist [3], there is
growing evidence that infants in Mexico are not fed according to recommendations. Breastfeeding
rates in Mexico have declined in the last 10 years. According to the 2012 Mexican National Health and
Nutrition Survey (ENSANUT, Encuesta Nacional de Salud y Nutrición), only 14.4% of Mexican babies are
exclusively breastfed by 6 months of age [4].
Usual energy intakes of Mexican infants and toddlers (6–23.9 months) exceed estimated energy
requirements in 14–32% of the population [5]. The extra energy has been linked to consumption of
energy-dense foods low in micronutrients, including foods and beverages with added sugar and
various maize-based preparations [6]. Sweetened tea and other sweetened beverages, including
traditional non-milk beverages, are frequently consumed among infants and young children in
Mexico [6,7] and may contribute to these excess energy intakes.
Approximately one-third of Mexican infants less than 1 year of age consume cow’s milk [6,7].
Cow’s milk is considered an inappropriate milk for children under 1 year, as early feeding of cow’s
milk is associated with an increased risk of developing iron-deficiency anemia [8]. The reason behind
this includes its low iron content, poor iron availability, and the associated occult intestinal blood
loss [9].
Despite these various reports, no one has systematically compared intakes of milk and other
beverages among infants and young children in Mexico to feeding guidelines and recommendations.
The objective of this study is to evaluate recommendations for milk and other beverages by age, and
examine consumption of age-appropriate milks and other beverages among Mexican infants and
young children. We also explore socio-demographic associations among children adhering to beverage
recommendations and those who do not to better understand the role that these beverages play in the
diets of infants and young children in Mexico.

2. Methods

2.1. Study Population

The 2012 Mexican National Health and Nutrition Survey, ENSANUT, is a cross-sectional,
probabilistic, population-based survey designed to characterize the health and nutritional status
of the Mexican population. ENSANUT 2012 is a nationally representative study that used a
multi-stage stratified sampling system drawn to be representative of four geographic regions in
Mexico (North, Center, Mexico City, and South), by rural, urban, and socioeconomic strata [10].
Household demographic data were collected from the adult respondent and included education level,
employment, marital status, socioeconomic status, and whether the child benefited from any type
of food assistance program. The data were collected during October 2011 through May 2012 from
50,528 Mexican households with a household response rate of 87%. Dietary intake data were collected
from a stratified, nationally representative subsample of participating households. We have included
data from the 949 infants and young children up to two years of age for whom dietary intake data
were available.
The survey protocol and data collection instruments were approved by the Ethics Committee of
the Mexican National Institute of Public Health. Informed consent was obtained from each child’s
parent/guardian for participation in the study [10].

2.2. Dietary Assessment

A single 24-h dietary recall was collected for each child by trained interviewers during a
face-to-face interview with the parent or primary caregiver. Parents or caregivers reported detailed
descriptions of all foods and beverages and the amounts consumed by the child for the previous
24-h period. To improve dietary recall data, ENSANUT 2012 implemented an automated five-step
Nutrients 2018, 10, 466 3 of 14

multiple-pass method [11,12] adapted to the Mexican context [13]. One 24-h dietary recall was
completed for each of the participating children and could occur on either a weekday or a weekend day.
A small subset completed a second 24-h recall [5]. The adaptations included translation to the Spanish
language as well as modifications to reflect unique characteristics of food intake and preparation
methods used in Mexico. The 24-h dietary recall data were also linked, for the first time, to a food and
beverage composition table based on a compilation of the nutrient composition analyses conducted in
Mexico and Central America (67% of foods), and the food composition tables from the USDA Nutrient
Database for Dietary Studies [14] and the USDA National Nutrient Database for Standard Reference,
release 26 [15] (33% of foods) [16]. Data on breastfeeding practices in children ages 0–35.9 months
were based on an infant feeding practices questionnaire implemented on the day of the 24-h dietary
recall, and breastfeeding amounts were estimated based on the child’s age and the total amounts
of other milks consumed [5]. The total daily volume of breast milk was estimated to be 0.78 L/day
for infants 0–5.9 months and 0.60 L/day for infants 6–11.9 months of age. If the child was partially
breastfed, the volume of infant formula was subtracted from the estimated daily breast milk total.
For those continuing to breast feed after 12 months, the volume assigned per feeding was 88.72 mL
(3 fluid ounces) for children 12–17.9 months, and 59.15 mL (2 fluid ounces) for children 18–23.9 months
old [5,17].

2.3. Beverage Groups

All milks and other beverages reported in the 24-h recalls were assigned to beverage groups.
The list of beverage groups was based on the grouping system used in the U.S. Feeding Infants and
Toddlers Study (FITS) [17,18]. Two trained Mexican dietary research specialists and a nutrition scientist
at Nestlé modified these food groups and created additional groups to reflect the beverages commonly
consumed by children in Mexico. Several Mexican beverage groups were added, including traditional
beverages, such as atoles (hot beverages prepared with corn flour, milk, or water, sugar, and flavorings),
aguas frescas (sweetened beverages prepared with fruit and water), licuados (smoothie-type drinks
prepared with milk, fruit, and ice); and sweetened probiotic dairy drinks, such as Yakult® [7].
Once the reported milks and other beverages were assigned to a beverage group, the groups were
classified into seven mutually exclusive categories for analysis: breast milk, infant formula, water,
100% fruit juice, milk, sugar-sweetened beverages (SSBs), and artificially sweetened beverages [19].
Each category was then evaluated according to Mexican and international guidelines, and determined
to be appropriate or inappropriate by age (Table 1).
Breast milk and infant formula are the only recommended milks for infants 0–5.9 months
old [1–3,20]. From the age of 6 months, water is also allowed [2,20,21]. Beginning at the age of
12 months, 100% fruit juice [22] and whole cow’s milk [3,23] can be introduced. We considered that
sweetened beverages should be limited due to the potential to over-consume and displace more
healthful choices [3,23,24]. For the purposes of this research, sweetened beverages include both
energy-dense, nutrient-poor beverages (such as sodas) as well as sweetened traditional beverages,
such as atoles and aguas frescas, that may be made with milk or fruit juices.
 Nutrients
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Table 1. Classification Table

of
Table Classification
milk1.1.and
Table 1. Classification ofbeverages
milk andof
Classification of
as milkand
andas
beverages beverages
recommended
milk asrecommended
recommended recommended
or inappropriate
beverages as orinappropriate
inappropriate
or inappropriate
for Mexican
or for Mexican
infants andfor Mexican
infants
for and
toddlers
Mexican infants
toddlers
byinfants and
age. and toddlers
bytoddlers
age. by age.
by age.

Milks and Beverages

Milks and Beverages Milksand
Milks 0–5.9 Months0–5.9 Months
andBeverages
Beverages 0–5.9
0–5.9Months
Months 6–11.9 Months 6–11.9 Months 6–11.9 Months
6–11.9 Months 12–23.9 Months 12–23.9 Months 12–23.9 Months
12–23.9 Months
The WHO,
The WHO, Mexican Norm Mexican
onWHO,
The Norm onTheNorm
Mexican WHOon The
and WHO and
Mexican TheMexican
Norm Norm
on Nutrition
WHO and on
043Nutrition
Mexican Norm on 043Nutrition 043
The WHO and Mexican Norm on Nutrition 043 The WHO and Mexican Norm on Nutrition 043
Breast milk Breast milk Breast Nutrition
milk 043, Nutrition The
and the 043, WHO,
Mexicanand theMexican
Nutrition Mexican
043, and Norm
recommend on Nutrition
the Mexican recommend
continued 043, and
continued
frequent,
recommend frequent,
on-demand
continued on-demand Thefrequent,
frequent, WHO and
on-demand The WHO and
Mexican TheMexican
Norm Norm
on Nutrition
WHO and on
043Nutrition
Mexican recommend
Norm on 043Nutrition
recommend 043 recommend
recommend continued on-demand recommend continued frequent, on-demand
Breast
Consensus Consensusthe
milk recommend Mexican Consensus
recommend
exclusive
Consensus exclusive
recommend recommend
breastfeeding until
exclusive exclusive
breastfeeding
at least until at least
2 years of age
breastfeeding 2 [1,2];
years
until
breastfeeding of age
atuntil
least [1,2];
2continued
at years continued
frequent,
least 2ofyears
age frequent,
of ageon-demand
[1,2]; on-demand
frequent, breastfeeding
the breastfeeding
continued
[1,2]; breastfeeding until
on-demand
until2 years until 2 years
of of age
breastfeeding
2 years of 2 years
until
or beyond [1,2]; of
breastfeeding
breastfeedingbreastfeeding
until 6 months until
[1–3];
breastfeedingtheuntil
6 monthsuntil6 months
[1–3];
the 6 AAP
months [1–3];
the the
the recommends
AAP
[1–3]; AAP
the recommends
breastfeeding
the AAP breastfeeding
in
recommends in age
breastfeedingor beyond
in age or
[1,2]; beyond
AAP [1,2];
recommends
age or AAP
beyond recommends
continued
[1,2]; AAP continued
recommends continued
AAP recommends breastfeeding in combination AAP recommends continued breastfeeding after
Infant
AAPformula recommends
AAP recommends ‘exclusive
‘exclusive breastfeeding forintroduction
about
recommends ‘exclusive
AAP recommends ‘exclusive combination
combination with the with the
combinationintroduction
withofthe
with of breastfeeding
the introduction
introduction of breastfeeding
of complementary after 12foods
months afterfor12as
breastfeeding
until months
12 long asfor
after
months as
mutually
12for long
months
as asformutually
desired
long asas long desired
mutually as mutually
desired bydesired
mother
Infant formulaInfant formulaInfant formula the first six months of a baby's life’ [20].
breastfeedingbreastfeeding
for about the for about
first six thefor
breastfeeding first six the first
complementary
about complementary
foods until
six atfoods
least until atfoods
12 months
at least
complementary 12 leastofuntil
months 12 of
months
byage
at of12 and
mother
[20].
least by baby
months mother
of[20].and
by baby
mother [20].
and
andbabybaby[20].
[20].
monthslife’
months of a baby's of a[20].
baby's
monthslife’of a[20].
baby'sagelife’ [20]. age [20].
[20]. age [20].
Mexican Norm on Nutrition 043 [2], AAP [20] and
Mexican Norm Mexican Norm
on Nutrition on
043Nutrition
[2], AAP 043
[20][2], AAP [20]can Reference values for water intake include water from all
Water Mexican Norm
EFSA on
[21] Nutrition
indicate water 043 [2], be
AAP [20]
introduced at
Reference values Reference values
for water for water
intake
Reference include
values
sources:intake
water
for
foods,include
from
water water
all
intake
beverages, from
include all
and foodswater[21].from all
Water Water Water and EFSA [21] and EFSA [21]
indicate water
andindicate
can
EFSA water
be[21] can bewater
introduced
6 months. indicate introduced
can be introduced
sources: foods, sources: foods,
beverages, beverages,
and
sources: foodsfoods, and
[21]. foods [21].
beverages, and foods [21].
at 6 months. at 6 months. at 6 months. 100% fruit juice can be a healthy part of the diet of
100% fruit juice 100% fruit juice 100% canfruit
be ajuice
healthy
100% canfruit
be
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healthy diet
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1 year of children
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as part of a
100% fruit juice
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than 1consumed
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older thanwell-balanced
as1consumed
part
yearof diet
asconsumed
a well-balanced
when of a bwell-balanced
part[22]. as part of a well-balanced
diet [22]. b diet [22]. b diet [22]. bFull-fat cow's milk can be introduced at 1 year of age;
Full-fat cow'sFull-fat
milk can cow's milk can
beFull-fat
introduced cow'sbeatintroduced
reduced fat
1 year
milk can milk
ofbe atintroduced
age; 1reduced
can year
be usedof age; 1 reduced
atafter 2 years
year of reduced
of age; age [23], or
fat milk can be fat used
milk after
can be used
milk after
2 years
fat of
canafter
age 2 12
be months
years
[23],
used or
afterage2if years
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[23],
12 weight
orof
months after gain
12
age [23], orisafter
months excessive. Other
12 months
Milk if child weight if child
gain isweight gain Other
excessive.
if child is animal
excessive.
weight milks
animal
gain Other
is are animal
milks acceptable,
are Other
excessive. milksbut aremilkmilks
animal substitutes
are
Milk Milk Milk (including plant milks) are not nutritionally
acceptable, but acceptable, but
milk substitutes milk(including
acceptable, substitutes
but milk (including
plant milks)
substitutes plant
are notmilks)
(including are not
plant milks)equivalent
are not
nutritionallynutritionally
equivalent to equivalent
animal milk
to to
animal
animal
and
milk
aremilk
not
and andareare
notnot recommended as a major
nutritionally equivalent to animal milk and are not
food source [23].
recommended recommended as asource
as a majorrecommended
food major [23].food
as asource
major [23].food source [23].
Excessive consumption
Excessive consumption SSBs canExcessive
ofExcessive of SSBs can
contribute
consumption consumption
tocontribute
energy
of SSBs can oftoSSBs
energy can contribute
contribute to energyto energy
Sugar-sweetened imbalance [3,23,24]; traditional beverages are often high
Sugar-sweetened
Sugar-sweetened Sugar-sweetened a imbalance imbalance
[3,23,24]; [3,23,24];
traditional traditional
beverages arebeverages
often high arein often
imbalance [3,23,24]; traditional beverages are often high in high in
beverages (SSBs) in sugar and should be limited as they can displace
beverages
beverages (SSBs) a (SSBs) a
beverages (SSBs) a sugar and should sugarbe and should
limited
sugar asbethey
and limited asbethey
can displace
should can
other
limited displace
as they can other displace other
other healthier choices [3].
healthier choices healthier
[3]. choices [3]. choices [3].
healthier
Artificially sweetened
sweetened Mexican Consensus discourages artificially sweetened
Artificially sweetened
Artificially sweetened Artificially Mexican Consensus Mexicandiscourages
Consensus discourages
Mexicanartificially
Consensus artificially sweetened
sweetened
discourages artificially sweetened
beverages beverages for children under 2 years of age [3].
beverages beverages beverages beverages forbeverages forbeverages
children under children
2 yearsunder age2 [3].
yearsunder
of children
for of age2 years
[3]. of age [3].
White Recommended
White indicates indicates
White
White Recommended
beverages;
indicates
indicates beverages;
Recommended
Recommended beverages; Dark
Darkbeverages;
greyDark grey
indicates
grey indicates
greyinappropriate
inappropriate beverages
Darkinappropriate
indicates indicates beverages
by age
inappropriate
beverages by age by
group; age group;
beverages
group; Lightagegrey
bygrey
Light Light
group;
indicates greyLight
indicates indicates
beverages
beverages grey
to limit duebeverages
to
indicates to a Includes
beverages
to sugar content. to
fruit-flavored b
limit
limit due to duecontent.
sugar to sugar
limit to drinks,
content.
a Includes
due sugara carbonated
Includes
fruit-flavoreda sodas, sweetened
content. fruit-flavored
drinks,
Includes tea and
drinks,
carbonated
fruit-flavored coffee
carbonated
sodas, (including
sweetened
drinks, herbal
sodas,
carbonatedtea infusions),
sweetened tea
and coffee
sodas, and
andMexican
teatraditional
coffee
(including
sweetened (including
herbal
and sweetened
herbalbeverages.
infusions),
coffee infusions),
andherbal
(including Limited
Mexican to at most
andtraditional
Mexican
infusions), 4Mexican
ounces (approximately
andtraditional traditional
120 mL) perbday for children ages 1–3 years of age. WHO = World Health Organization; AAP = American Academy of Pediatrics.
sweetened sweetened beverages.
beverages. sweetened
b Limited
most 4toounces
Limited tobeverages.
at b at most
Limited 4toounces (approximately
(approximately
at most 120 mL)
4 ounces per120
daymL)
for per
(approximately day
children
120 for
mL) children
ages
per1–3 ages
dayyears
for of1–3 years
age.
children agesof1–3
WHO =age. WHO
World
years = World
Health
of age. Health
Organization;
WHO Organization;
= World AAP
Health AAP =
= Organization; AAP =
American Academy
American Academy ofAmerican of Pediatrics.
Pediatrics.Academy of Pediatrics.
Nutrients 2018, 10, 466 5 of 14

2.4. Statistical Analysis

Analyses were based on the single 24-h dietary recall completed for all children. Consumers
of the different beverages were defined as those who reported any consumption during the day of
the recall, regardless of the amounts consumed. Stata version 14 (StataCorp, College Station, TX,
USA) was used to create data files, assign individual beverages to beverage groups, and estimate the
percentages of children who consumed beverages. For each beverage type, amount (g) per consumer
and per capita were calculated. Daily energy (kcal) and amounts consumed from appropriate and
inappropriate beverages were compared. ANOVA was used to compare demographic characteristics
for the most commonly consumed inappropriate beverages by age and included water (0–5.9 months),
SSBs and cow’s milk (6–11.9 months), and SSBs (12–23.9 months). A Bonferroni correction was applied
for multiple comparisons. All estimates applied stratum-specific probability weights provided by
ENSANUT to account for the complex survey design, resulting in nationally representative samples.

3. Results
Adherence to beverage recommendations are summarized in Figure 1 and Table 2. Overall,
approximately two-thirds of infants 0–5.9 months of age consumed only age-appropriate beverages,
breast milk, or infant formula. Approximately 30% consumed breast milk or infant formula in addition
to other age-inappropriate beverages, whereas 4% consumed only inappropriate beverages (no breast
milk or infant formula) on the day of the survey. At 6–11.9 months of age, 40.2% consumed only
appropriate beverages: breast milk, infant formula, or water. Approximately one-third consumed these
appropriate beverages in addition to other age-inappropriate beverages, and one-quarter consumed
only inappropriate beverages. From 12 months of age, only 32.4% consumed age-appropriate beverages
while nearly half were consuming only sweetened beverages and no age-appropriate beverages at
all. The amounts and energy contribution from appropriate beverages decreased with age, while
inappropriate beverage consumption increased from 56 kcal/day among infants 0–5.9 months to
approximately 200 kcal/d beginning at the age of 6 months (Table 2).
The consumption of appropriate and age-inappropriate beverages can be found in Table 3. The
most commonly consumed inappropriate beverage among infants 0–5.9 months was water. However,
among the few infants who consumed other inappropriate beverages, consumption was relatively
high, ranging from 120 mL for juice to 500 mL for supplement drinks and 727 mL for sweetened
milks. At 6 months, water becomes an appropriate beverage, and 35% of older infants reported
water consumption. Inappropriate beverages for this age were most often milk (31%) and SSBs (35%).
Average inappropriate milk consumption among consumers was 466 mL, close to two cups, and
more than twice the amount of water consumed. In toddlers 12–23.9 months, appropriate beverages
included water, 100% juice, and cow’s milk, which were consumed by 42%, 18%, and 58%, respectively.
More children (63%) consumed SSBs than any other type of beverage, most commonly sweetened teas,
infusions or coffee (23%), and traditional beverages (30%).
We selected the most commonly consumed inappropriate beverages by age, and compared various
sociodemographic characteristics among those who consumed them and those who consumed only
appropriate beverages (Table 4). Infants 0–5.9 months who consumed water tended to be older than
four months and were more likely to consume breast milk compared to those who consumed only
appropriate beverages. They were also less likely to come from the North of Mexico and more likely to
be of normal weight. Older infants aged 6–11.9 months who consumed SSBs were more likely to be
from households where the primary caregiver had less education. Inappropriate milk consumption in
this age group was associated with lower consumption of breast milk or infant formula and occurred
more frequently among urban dwellers. Inappropriate beverage consumption was also significantly
higher among infants whose parent or caregiver was not employed. Among toddlers 12–23.9 months,
SSB consumption was pervasive and did not differ in any meaningful way from those consuming
appropriate beverages.
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Table 2. Amounts (g) and energy (kcal) per capita provided by appropriate and inappropriate milk and beverages among Mexican infants and toddlers from
ENSANUT
Table 2012.energy
Table 2. Table
Amounts (g) and2.energy
2. Amounts Amounts
(g) and (g)per
(kcal) and energy
(kcal) per
capita (kcal) provided
capita
provided per
by capita provided
by and by appropriate
appropriate
appropriate and and
inappropriate
and inappropriate
inappropriate milk milk milk andMexican
and beverages
beverages among beverages
among among
Mexican
infants Mexican
infants
and andinfants
toddlers from andfrom
toddlers toddlers from
ENSANUT
ENSANUT 2012. ENSANUT
2012. 2012.
Appropriate Beverage Consumption Only Appropriate with Inappropriate Beverage Consumption
AppropriateAppropriate Appropriate
Beverage
Beverage Consumption
0–5.9 Months Beverage6–11.9
Consumption
Only Consumption
Only MonthsOnly 12–23.9 Months
Appropriate Appropriate
with Appropriate
with
Inappropriate
0–5.9 Months withConsumption
Inappropriate
Beverage
6–11.9 Inappropriate Beverage
Beverage Consumption
Months Consumption
12–23.9 Months
0–5.9 Months 0–5.9 Months
0–5.9 Months 6–11.9 6–11.9 Months6–11.9
Months Months
12–23.9 12–23.9
12–23.9 Months
Months 0–5.9Months
Months0–5.9 Months 0–5.9 Months
6–11.9 6–11.9 Months6–11.9
Months Months
12–23.9 12–23.9 Months
Months 12–23.9 Months
n
n 118
118 98179
98 17964
179 6464 130 130 359
359 359
n n 118 118 98 98 179 64 130 130 359
% consuming 66.7 40.2 32.4 33.3 59.8 59.8 67.6
% consuming% consuming % consuming 66.7 66.7 66.7
40.2 40.2 40.2
32.4 32.4 32.4
33.3 33.3 33.359.8 59.8 67.6 67.6 67.6
Appropriate beverages, g 1061 788 694 680 574 555
AppropriateAppropriate Appropriate
beverages, gbeverages, g beverages,
1061g 1061 1061
788 788 788694 694 694680 680 680 574 574 555 555 555
(kcal) (648) (476) (329) (444) 574 (220) (225)
(kcal) (kcal) (kcal) (648) (648) (648)
(476) (476) (476)
(329) (329) (329)
(444) (444) (444)
(220) (220) (220) (225) (225) (225)
Water, g NA 76 134 58 102 178
Water, g Water, g Water, g NA NA NA 76 76134 134 13458 58 58 102 102 178 178 178
Inappropriate beverages, g 76 115 102 393 316
Inappropriate Inappropriate
Inappropriate beverages, gbeverages, g beverages, g NA NA NA
115 115 115 393 393 393 316 316 316
NA NA
(kcal) NA
NA NA NA NA NA NA (56) (227) (193)
(kcal) (kcal) (kcal) (56) (56) (56)(227) (227) (227) (193) (193) (193)
NAnot
indicates NA indicates not applicable.
not applicable.
NA indicates
NA indicates applicable.
not applicable.

Table
Table
Table 3. Consumption
Table 3. Consumption Consumption
3.3.Consumption ofappropriate
of
of appropriate
of appropriate appropriate andand
and inappropriate
inappropriate
and inappropriate
and inappropriate milk milk milk and
milk and
and beverages
beverages among beverages
beverages
among
Mexican among
among
Mexican
infants Mexican
Mexican
infants
and toddlers infants
andinfants
toddlers
in and
andin toddlers
the ENSANUT the ENSANUT
in the
the ENSANUT
2012. 2012. 2012.

0–5.9 Months 0–5.9 182) 0–5.9

(n =Months Months (n6–11.9
(n = 182) = 182) Months 6–11.9 229) 6–11.9
(n =Months Months
(n = 229) (n = 229)
12–23.9 Months 12–23.9 538) 12–23.9
(n =Months Months (n = 538)
(n = 538)
0–5.9 Months (n = 182) 6–11.9 Months (n = 229) 12–23.9 Months (n = 538)
g/Consumer g/Consumer g/Consumer
g/Capita g/Capita g/Capita
g/Consume g/Consume
g/Capita g/Consume
g/Capita g/Capita
g/Consume g/Consume
g/Capita g/Consume
g/Capita g/Capita
%a %a %a %±a SE Mean %a %a %±a±SE %a %a
Mean ± SE Mean%±Mean aSE ±g/Consumer
Mean
SE Mean± SE g/Capita
r Mean ±± SE
SEr MeanMean± SE r Mean
% a ± SE
g/Consumer
Mean Mean
SEr Mean ±g/Capita
± rSE
SE Mean ± SE± SE
Mean r Mean
%a
Mean±±SE g/Consumer
SE Mean ± SE g/Capita
Breast milk Breast
b milk b Breast milk 75
b
75 ± 28
669 66975 Mean
± 28502 ± 35 ±47
669 ±502
28 ±SE
35 Mean 47±±±
502
536 35SE 536 ±254
18 4718 ± 26 536 Mean
254 ±1418
± 26± SE286254
14±Mean ± SE
22± 26 286 14
22 ± 7 28640± 22
± 40 ± 7 Mean ±40SE± 7 Mean ± SE
Infant Formula
Infant FormulaBreast milk Infant
b Formula
51 51
844 ± 201 844 51
± 201 844 ± 201
429
75429 ± 110669 ± 28 ± 110
34 429
81234 ±
502 ±±167 11035 812 ± 34
167
27347± 65 812 ±
273
536167
± 65 273
18 ± 65 571 ± 18
66
18 ± 18 571 ± 66254 ± 26101 ± 18 14 571
101 ± 66
± 18 286 ± 22± 18
101 40 ± 7
Water Water
Infant Formula Water 19 19 ± 23
100 10019 ±51 100 ±±19
2319 ± 6 844 23201
±6
35 19
35±±±40
223
429 6
110 223 ±35
77 34± 19 22377
40 812±42
±4019
± 1672914277 ±273
± 21 19 ± 291 42
65±123
21 ± 12 18 291
123 ± 21
± 12 571 ±123
66± 12 101 ± 18
100%
100% fruit juiceWaterfruit juice 100% fruit 6 juice 120 6 ± 15 120 6±19 15 8 ± 3 120
100±±158 23
±133 8±
13
116
19 ±± 19
36 116 ±13 35± 4 11615
19
15 ±1819
223 ± 4± 40 1811815
± 14±774 ±181 18
19± 33
14 ± 6 42 18133± 14
± 6 291 ± 3321± 6 123 ± 12
100% fruitMilk 6 ± 168 456 ±66 25 ± 12456
120±25168 25
831±±± 8412 3184
13± 30 466 ±5884 ± 19 432143
58± 23± 15
30 ± 58 432 ± 23
± 18 181 ±248
14± 18
c
Milk c Milk c
juice 6 456 168 ± ±3112
15 466 3 466 ±143 143
116 ± 30 4324 ±248
23 ± 18 18 248 33 ± 6
Unsweetened c
Unsweetened
Milk
d Unsweetened
d
5
d
5 ± 171 450 ±56
450 17124 ± 12450
456±± 171
24 ±3012
168 24
30±
470
25 ±± 88
12
12 470 ±139 3088
31± 30 470 139 ±5388
466 ± 84 418139
± 30 53± 22±143
30 ±418 53
30±221
22 ± 18 58 418
221 ± 22
± 18 432 ±221
23± 18 248 ± 18
Sweetened eSweetened
Unsweetened
e Sweetened
d0 e
0 ±0
727 7270±50 1 ± 1 450 727 ±±10171
±21 2412±±± 65
217 112 217 ±265 430± 1 217470
4±8±651± 88 3688±483 ±139
1 ± 368 8 ± 7 53
30± 28
83 36828± 83
± 7 418 ± 2822± 7 221 ± 18
Sugar-sweetened
Sugar-sweetened beverages
Sweetened Sugar-sweetened
e
beverages
8 beverages
8 ± 41
99 99 ±8041 8 ± 4 99 727± 41
8 ±35
± 04 8±
135
187 ±± 27
41 187 ±35
66272± 12 18766 ±63
217 ±2712 66
± 65 28263 ± 12
± 26 4 ±282 63
1 ±178
26 ± 19 8 282
178 ± 26
± 19 368 ±178
83± 19 28 ± 7
Fruit-flavored
Fruit-flavoredSugar-sweetened
drinks f Fruit-flavored
drinks f
1beverages drinks
1 ± 26
81
f
81 ±1826 1 ± 1 81 99±±26141±91 819±±± 73
226 14 226 ±92035± 9 22620
73 ±1573
187 ± 9± 27 2661520
± 48±669 ±26612±4015
48± 11 63 266
40±±4811 282 ±40 26± 11 178 ± 19
CarbonatedCarbonated
sodas Carbonated
sodas
Fruit-flavored 0
drinks sodas
f 0 ± 71
79 79 ±0171 0 ± 0 79 81±±71026±70 107±
96 ±±18 01 96 ± 718
69± 3 96 226
±61718
± 3± 73 8517 ±610± 320 ±859± 10 17 ± 2 15
14 8514± 10
± 2 266 ± 1448± 2 40 ± 11
Sweetened tea, coffee g tea,Sweetened
Sweetened
Carbonated coffee4 g tea, coffee
sodas 4 ± 17g
64 64 ±4017 2 ± 1 64 79±±17271±101 2±
010
131 ±± 27
10 131 ±1027
13 7 ± 4 1311396 ±2327
±± 4 18 2002313
± 22± 46 ±200 23
3 ± 46
22 ± 7 17 20046± 22
± 7 85 ± 1046 ± 7 14 ± 2
Traditional Traditional
Sweetened
beverages Traditional
h beverages
tea,2coffeeh beverages
g 2 ± 5h
37 37 2±45 1 ± 1 64 37 ±±5117±171 1±
217
138 ±± 35
11 138 ±17 10± 6 13823
35
23 ±3035
131 ± 6± 27 2503023
± 35± 13
6 ± 250 30
4 ±75
35± 15 23 250
75±±3515 200 ±75 22± 15 46 ± 7
SupplementSupplement
drinks i
Traditional Supplement
drinks 1i
beverages drinks
h 500 1 i± 0 5001±20 4 ± 4 500 37 ±±405±24 142±±± 55
178 41 178 ±255
417± 2 178138
4±1±552± 35 3391±485 ± 223 ± 339 14 ± 2 30
6 ± 85 3394±±852 250 ± 35 4±2 75 ± 15
Artificially Artificially
sweetened drinkssweetened
i
Artificially sweetened
Supplement
0 j 00 ± 0 0 ±01 0 0 ± 0 500 0 ± 0±
0 ±000 4±4
800 ±± 00 80 ±0002± 0 0±3±00± 55 2283±044
80178 ± 04 ±228 2 ± 4436 ± 2 12286±±442 339 ± 85 6±2 4±2
Artificiallybeverages
beverages j beverages j
sweetened beverages j 0 0±0 0±0 0 80 ± 0 0±0 3 228 ± 44 6±2
White indicates
White indicates White
appropriate
White indicates
appropriate
indicates beverages;appropriate
appropriate beverages;
beverages; beverages;
Dark grey Dark
Dark grey
indicates
grey Dark
indicatesgreyinappropriate
inappropriate
indicates indicates
beverages
inappropriate inappropriate
beverages
beverages by by
ageage beverages
by
group; age group;
group; by age
Light
Light group;
greygreyLight grey
indicates
indicates Light
beverages grey
indicates
beverages
to limitindicates
beverages
to
duelimit beverages
to
to sugar content. to
limit limit
a Percent

consuming (weighted); ba Breast milk amounts were estimated band based on child age. c Includes cow’s milk and other milks (e.g., soy cmilk and other animal milks); % consuming other
due to sugardue to
content.sugar content.
a Percent Percent
consuming consuming
(weighted); (weighted);
b Breast milk Breast
amounts milk amounts
were estimatedwere estimated
and
due to sugar content. Percent consuming (weighted); Breast milk amounts were estimated and based on child age. Includes cow’s milk and other milks (e.g.,
a b based and
on based
child
c on
age. c child
Includesage. Includes
cow’s milk cow’s
and milk
other and
milks other
(e.g., milks (e.g.,
milks was 0 for 0–5.9 months, 1.8% for 6–11.9 months, and 1.8% for 12–23 month olds. d Includes plain unsweetened cow's milk and all other unsweetened milks. e Includes all sweetened
soy milk soyandmilk
otherandsoy
animalmilkmilks);
other and other
animal animal
%milks);
consuming milks);
other %
% consuming consuming
other
milks wasmilks
0 forother
was0–5.9milks
0 for was 01.8%
0–5.9
months, for 0–5.9
months, for 1.8% months,
6–11.9 1.8% and
formonths,
6–11.9 for 6–11.9
months,
1.8%and months,
for 1.8%
12–23for and 1.8%
12–23
month for 12–23
month
olds. d olds.month
Includes d olds. plain
Includes
plain d Includes plain
cow’s milk and sweetened other milks (e.g., soy milk and other animal milks). f Fruit-flavored drinks containing <100% fruit juice and added sugar. g Sweetened tea, herbal infusions, and
unsweetenedunsweetened unsweetened
cow's milk cow's
andh milk
all cow's
and
other milk
all other and
unsweetened all other
unsweetened
milks. unsweetened
milks.
e Includes all milks.
e Includes
sweetened e Includes
all sweetened
cow’s all
milk sweetened
cow’sand milk cow’s
and
sweetened milk and
sweetened
other sweetened
other
milks milks
(e.g.,
® soy
i other
(e.g.,
milk milks
soy
and (e.g.,
milk
other
coffee. Traditional sweetened beverages, including atoles, licuados, aguas frescas, and other beverages, such as Yakult . Fortified milks, such as Progresa , and rehydration drinks, andsoy milk
other
animal and
animal
milks).® other animal
f milks). f milks). f
Fruit-flavored
Fruit-flavored drinksFruit-flavored
such drinks
as Gatorade
containing drinks
<100% containing
® and Suero
containing <100%
fruit ® (all
juicefruitof<100%
and juice
which
added fruit
and
contain juice
added
sugar. g and
or are sugar.added
served
Sweetened withsugar.
g Sweetened
sugar).
tea, g
herbalj Sweetened
tea,infusions,
Artificially tea,
herbalsweetened
andherbal
infusions, infusions,
and
beverages
coffee. wereand
coffee.
h Traditional coffee.
h Traditional
included
sweetened h
in theTraditional
sweetened
total
beverages, sweetened
beverages,
for SSBs as there were
including beverages,
very few including
including consumers.
atoles, SE =aguas
atoles,
licuados, standard
licuados, error.
frescas,aguas
and frescas,
other and other
beverages, beverages,
such as Yakultsuch ®. as Yakult
i Fortified ®.milks,
i Fortified
such milks,
as such
Progresa as Progresa
®, and ®, and rehydration
rehydration drinks, such drinks,
as such
Gatorade as Gatorade
® and Suero ®®and
(all Suero
of ® (all of
atoles, licuados, aguas frescas, and other beverages, such as Yakult . Fortified milks, such as Progresa , and rehydration drinks, such as Gatorade and Suero (all of
® i ® ® ®

whichor
which contain arewhich
containserved contain
or are served
with or are
withserved
sugar). j sugar).with
j
Artificially sugar). Artificially
Artificially
sweetened j sweetened
beverages sweetened
beverages beverages
were
were included in thewere
included inincluded
total the totalin
for SSBs asthe
for total
SSBs
there asfor SSBs
there
were very wereas there
few very wereconsumers.
few
consumers. very
SE =few consumers.
SE = standard
standard SE = standard
error. error. error.
Nutrients 2018, 10, 466 7 of 14

Table 4. Appropriate and inappropriate milk and beverage consumption among Mexican infants and toddlers by age and socio-demographic characteristics
(ENSANUT 2012).

0–5.9 Months (n = 182) 6–11.9 Months (n = 229) 12–23.9 Months (n = 538)

Appropriate Beverages Inappropriate Appropriate Inappropriate Appropriate Inappropriate Appropriate Inappropriate
Sociodemographic Characteristic (No Water) % (Water) a % Beverages (No SSBs) (SSBs) b % Beverages (no Cow (Cow’s Milk) c Beverages (No SSBs) (SSBs) d %
Consuming Consuming % Consuming Consuming Milk) % Consuming % Consuming % Consuming Consuming
n 144 38 152 77 177 52 203 328
Mean child age (months) 3.3 4.2 9.0 9.9 9.1 10.0 18.2 18.2
Age <4 m 63 37 *
Age ≥4 m 37 63 *
Child sex
Male 55 59 48 37 48 36 54 54
Female 45 41 52 63 52 64 46 46
Feeding mode
Breast milk not infant formula 37 78 * 42 33 42 33 12 12
Infant formula not breast milk 24 9 32 13 * 36 0* 23 13
Breast milk and infant formula 35 6* 7 11 11 1* 1 2
No breast milk/ infant formula 8 43 65 * 64 73
Region
North 27 10 * 24 20 26 12 21 17
Central 35 29 31 40 32 41 34 27
South 33 33 32 37 40 19 * 30 37
Mexico City 6 28 13 3 2 28 15 19
Urbanicity
Rural 29 22 24 29 30 16 * 31 31
Urban 71 78 76 71 70 84 * 69 69
Body weight
Overweight/obese 18 2* 8 22 11 17 6 9
Underweight/normal weight 82 98 * 92 78 89 83 94 91
Socio-economic status
Lowest tertile 38 38 40 37 37 44 28 40
Middle tertile 30 44 33 41 38 30 48 28 *
Highest tertile 32 19 28 23 26 26 24 32
Dietary recall on weekday
No 10 7 20 25 22 23 24 22
Yes 90 93 80 75 78 77 76 78
Child beneficiary of assistance program
Food 7 16 5 5 4 6 4 7
Money 8 29 6 8 8 3 8 12
Medical 0 0 3 0 2 0 3 3
None 85 55 87 87 86 90 85 78
Education of primary caregiver
Less than elementary 4 13 3 0* 2 3 4 4
Elementary-secondary 86 82 86 98 * 90 91 84 84
More than high school 10 5 11 2* 9 6 12 12
Primary caregiver employed
Nutrients 2018, 10, 466 8 of 14

Table 4. Cont.

0–5.9 Months (n = 182) 6–11.9 Months (n = 229) 12–23.9 Months (n = 538)

Nutrients 2018, 10, x FOR PEER REVIEW Appropriate Beverages Inappropriate Appropriate Inappropriate Appropriate Inappropriate Appropriate 8 of 14
Inappropriate
Sociodemographic Characteristic (No Water) % (Water) a % Beverages (No SSBs) (SSBs) b % Beverages (no Cow (Cow’s Milk) c Beverages (No SSBs) (SSBs) d %
No Consuming
68 Consuming
79 %78Consuming 71Consuming Milk)
70 % Consuming %*Consuming
89 %
67 Consuming 69Consuming
No Yes 32 68 21 79 22 78 29 71 30 70 11 * 89 * 33 67 31 69
Yes Marital status of primary caregiver 32 21 22 29 30 11 * 33 31
Separated
Marital status or divorced,
of primary widowed,
caregiver
21 30 16 23 16 24 16 12
not married
Separated or divorced, widowed, not married 21 30 16 23 16 24 16 12
Married, partners
Married, living together
partners living together 79 79 70 70 84 84 77 77 84 84 76 76 84 84 88 88
a beverages represented by water consumption (21% consuming); b Inappropriate
a Inappropriate beverages represented by water consumption (21% consuming);
Inappropriate beverages represented by SSB consumption (34% consuming); c Inappropriate
b Inappropriate beverages represented by SSB consumption (34% consuming); beverages
represented by cow’s milk consumption (23% consuming); d Inappropriate beverages represented by SSB consumption
c Inappropriate beverages represented by cow’s milk consumption (23% consuming); Inappropriate
d beverages(62% consuming);
represented * Significantly
by SSB consumption different from appropriate
(62% consuming);
beverages group, p < 0.05; Bonferroni adjustment applied for multiple comparisons.
* Significantly different from appropriate beverages group, p < 0.05; Bonferroni adjustment applied for multiple comparisons.

100 4.0
90 25.7
80 29.3
49.3
Percent Consuming

70
60 34.1
50
40 18.3
30 66.7
20 40.2
32.4
10
0
0-5.9 months 6-11.9 months 12-23.9 months
Child Age

Appropriate Both Only inappropriate

Figure 1. Percent of Mexican infants and toddlers consuming appropriate and inappropriate milk and beverages by age.
Figure 1. Percent of Mexican infants and toddlers consuming appropriate and inappropriate milk and beverages by age.
Nutrients 2018, 10, 466 9 of 14

4. Discussion
This research provides a detailed picture of the consumption of breast milk, infant formula, water,
and other beverages in the diets of infants and toddlers in Mexico. We compared consumption to
Mexican and international policy and guidance documents to evaluate the proportions of these young
children complying with recommendations or not and to characterize consumption of appropriate and
inappropriate beverages by age.
In line with recommendations, 75% of infants from birth to 5.9 months of age consumed breast
milk. More than half consumed infant formula alone or in combination with breast milk. However,
only 67% of these young infants consumed only these appropriate beverages. A small study in the U.S.
reported 53.1% of Latino infants at 4–6 weeks of age consuming infant formula, usually in combination
with breast milk [25]. The rates of breastfeeding and infant formula consumption are also similar to that
reported from the non-quantitative Infant and Young Child Feeding Practices questionnaire (IYCFP), a
part of the ENSANUT 2012 [26], but whereas 19% of young infants were reported to consume water in
our analysis of 24-h recall data, the IYCFP reported water consumption in infants less than 6 months at
51%. The study in Latino infants in the U.S. also confirmed a high percentage of infants consuming
water at 4–6 weeks of age (56.3%) [25]. The differences may be due to the way data were collected,
such as if water was separately coded from powdered infant formula or provided as a supplement.
The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation Water supplies
indicates that 96.1% of Mexican households have access to “improved” water supplies [27], but this
does not ensure microbiologically safe water [28]. For that reason, water used in the preparation of
infant formula should be boiled for at least one minute and cooled before use [2,29]. Nevertheless,
infants below the age of 6 months generally do not need water in addition to breast milk or properly
prepared infant formula, even in warm climates [29,30]. It is for this reason that we classified water as
an inappropriate beverage for young infants, but in practice, this should be evaluated on a case-by-case
basis with the infant’s physician.
Other beverages were also consumed by young infants. We found that infants 0–5.9 months were
consuming 100% juice (6%), milk (6%), and sugar-sweetened beverages or supplement drinks (8%)
for a total of 20%, somewhat less than the 25.7% reported in the IYCFP [26]. Among those receiving
milk and supplement drinks, the quantity (450–500 mL/day) would indicate that these were replacing
age-appropriate breast milk or infant formula. Smaller amounts were consumed by infants reporting
100% juice, sweetened teas, herbal infusions or coffee, traditional beverages, and fruit-flavored drinks.
Even so, these beverages replace necessary nutrition from breast milk or infant formula, potentially
reducing the infant’s intake of micronutrients.
Breastfeeding was reported in 47% of older infants 6–11.9 months, comparable to 48% reported
in IYCFP [26]. Fruit juice is not recommended for this age [22], but 13% consumed 100% fruit juice
(116 mL/d), equivalent to about 0.5 cup (4 ounces) among consumers. Milk and SSBs are inappropriate
at this age, but were consumed by 31% and 35%, respectively. As with younger infants, the amount of
inappropriate milk consumed among consumers (about 470 mL; close to 2 cups per day), indicates
that it was displacing breast milk and infant formula in this age group. One such milk was Liconsa,
a fortified filled milk product provided at a reduced price through a federal program for families in
need [31]. While we did not estimate intakes of Liconsa milk separately from other milks, the IYCFP
reported 7% of infants 6–11.9 months were consuming this age-inappropriate milk [26]. Cow’s milk is
inappropriate for infants as it increases risk for iron deficiency anemia in this vulnerable age group [8],
and others have cautioned against the higher protein content of cow’s milk, increasing renal solute
load and potentially increasing the risk for dehydration [32].
Consumption of SSBs was 63% in toddlers 12–23.9 months, an increase from 35% in older infants,
consistent with that reported by Rodríguez-Ramírez et al. [6] but less than the 69.9% reported for
non-nutritive liquids in IYCFP [26]. SSBs are not recommended at all for infants, and should be
consumed with caution for toddlers as they provide excess energy and very few nutrients. Longitudinal
studies in the U.S. and Portugal have shown that consumption of SSBs is associated with higher odds
Nutrients 2018, 10, 466 10 of 14

of obesity [33] and that consumption of energy-dense foods at age 2 years predicts consumption at age
4 years [34]. In Mexico, children in the highest tertile of cumulative consumption of SSBs from infancy
to school-age were almost 3 times as likely to be obese at age 8–14 years [35].
Almost half of the SSBs consumed by toddlers are traditional Mexican beverages, and nearly
one-quarter consume sweetened teas, herbal infusions, or coffee. Consumption is widely accepted,
and many of the beverages are perceived to provide health benefits [3,36]. Parents may remember
consuming these beverages themselves as children and consider them to be comfort foods. The
Mexican Consensus on complementary feeding calls upon physicians and health professionals to
educate themselves and guide parents away from frequent consumption of these beverages [3], largely
because they provide excess calories with little nutritive value, increase dental caries risk, and for some
beverages, provide caffeine.
We have found few other reports identifying demographic characteristics associated with
adherence to feeding recommendations for milk and other beverages in infants and young children.
National survey data on breastfeeding in the U.S. are not typically reported by ethnic subgroup [37].
However, U.S. breastfeeding rates were 49.5% in 2013 [38], similar to the 47% we observed for
6–11.9 month olds in the 2012 ENSANUT. In a study among 4–6 week old Latino infants in the
U.S., 25.4% were fed water or teas, but early feeding of water and teas was not related to any maternal
demographic characteristics [25]. We found that 20.9% of 0–5.9 month olds consumed water and that
consumption was higher among breastfed children, while Wojcicki et al [25] found that tea and water
consumption was higher among those consuming infant formula. This discrepancy could be due to
the differences in age classifications, considering we also observed that water consumption was higher
among infants older than 4 months.
A child’s perception of taste develops over infancy [39] and taste preferences are shaped over
the first years of life. Although infants show an innate preference for sweet taste [40], early in
complementary feeding, they will accept many foods and beverages, including very bland ones. One
study found that 5–7 month-old infants showed positive reactions to 88% of foods tried [41]. Even
foods and beverages that are not initially liked will often come to be accepted after the child tastes it
repeatedly [42–45]. Although some have hypothesized that adding sweetness or energy to food could
facilitate that process (flavor-flavor learning and flavor-nutrient learning, respectively), recent studies
suggest that simple repeated exposure to the food, as-is, is just as effective [46,47].
Children’s preferences are shaped by the foods and beverages which they are offered in infancy.
That is to say, children who are accustomed to consuming sweeter beverages will come to prefer
them. One study showed that infants whose parents fed them sweetened water (e.g., with sugar or
honey) at home consumed more sweetened water in the lab than infants who had not been exposed
to sweetened water at home [48]; infants who had not received sweetened water at home consumed
more plain water than sweetened. This can have long-term implications on later food preferences.
Infants who had initially been fed with hydrolyzed or soy infant formulas, which tend to be more sour
and bitter than standard milk-based infant formulas, showed better acceptance of broccoli at 4–5 years
old [49]. For this reason, infant and young children’s early exposure to very sweet beverages could
have long-term implications for their dietary preferences.
Our study is not without limitations. The ENSANUT 2012 is a cross-sectional survey, and while
it comprehensively covers the country and provides national estimates of the population’s intakes,
only one day of intake was reported. Habitual intakes may differ from this snap-shot view. The fact
that breast milk volumes were estimated is also a limitation of this and other intake surveys of infants
and young children [17,18,50]. We combined data from underweight and normal weight infants and
young children in our analysis due to the small sample size for underweight children, but this does not
necessarily mean that beverage consumption patterns would be the same. Another limitation is that
taxes on sugar-sweetened beverages were introduced in Mexico in 2014, and this may have influenced
purchase of SSBs, reducing intakes and increasing consumption of water [51]. We look forward to
Nutrients 2018, 10, 466 11 of 14

evaluating the longer-term effects of this policy change using data from the next Mexican national
nutrition survey.

5. Conclusions
Breastfeeding rates of Mexican infants need to be improved to meet Mexican and international
recommendations. Many infants and young children are not compliant with complementary feeding
recommendations. Early consumption of cow’s milk before the age of 12 months may put some
infants at risk for iron deficiency anemia. Even more problematic is the pervasive consumption of
sugar-sweetened beverages, beginning in infancy and increasing to be the most frequently consumed
beverages among toddlers. The Mexican consensus on infant feeding practices and other national
and international recommendations are available to guide care-givers and parents on the proper
feeding and timing of introduction of beverages complementary to breast milk and infant formula,
but additional educational efforts are needed to improve feeding practices of infants and toddlers
in Mexico.

Acknowledgments: The ENSANUT survey was sponsored by the Mexico National Institute of Public Health
(INSP: Instituto Nacional de Salud Pública). The research presented here is from secondary data analyses of
ENSANUT and was sponsored by the Nestlé Research Center (Nestec, Ltd.), Lausanne, Swizterland. The authors
also wish to thank the Carolina Population Center, University of North Carolina at Chapel Hill, for data analysis.
Author Contributions: M.C.A. and A.L.E. designed the research, and along with S.V.-C. and K.C.R., defined the
beverage categories and age groups used in the study. M.C.A., S.V.-C., K.C.R., L.R.F., and A.L.E. contributed to
writing the manuscript. A.L.E. was primarily responsible for final content. All authors have read and approved
the final manuscript.
Conflicts of Interest: M.C.A., L.R.F., and A.L.E. are employed by the Nestlé Research Center, sponsors of these
analyses. K.C.R. is employed by Nestlé Nutrition in Florham Park, NJ, USA. S.V.-C. has a joint appointment at
Hospital Infantil de Mexico, Gastroenterology and Nutrition, and Nestlé Infant Nutrition in Mexico City, Mexico.

Abbreviations
AAP American Academy of Pediatrics
ENSANUT Encuesta Nacional de Salud y Nutrición, the Mexican National Health and Nutrition Survey
IYCFP Infant and Young Child Feeding Practices questionnaire
SSB sugar-sweetened beverage
USDA United States Department of Agriculture

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