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Human Milk, Infant Formula, and Other Milks Fed to Infants and Toddlers in the United States, NHANES 2007-2018

Open AccessPublished:November 01, 2022DOI:https://doi.org/10.1016/j.jand.2022.10.017

      Abstract

      Background

      For the first time, the 2020-2025 Dietary Guidelines for Americans provide specific guidance regarding the types of foods and beverages that should be offered in the first 2 years of life. Milk, in various forms (eg, human milk, infant formula, and cow’s milk) contributes a large proportion of key nutrients to the diets of infants and toddlers in the United States.

      Objective

      The aim of this study was to determine the types of milk (human milk, infant formula, and other milk) fed to US infants and toddlers in the past 12 years and to describe trends over time.

      Design

      This was a cross-sectional analysis of 2-day, 24-hour dietary recalls.

      Participants/setting

      Data from the 2007-2018 National Health and Nutrition Examination Survey were used for these analyses. Infants and toddlers aged 0 through 23.9 months with 2 days of dietary recall data (n = 3,079) were included.

      Main outcome measures

      The main outcome was proportion of infants and toddlers fed different milk types.

      Statistical analyses performed

      Survey-adjusted weighted percentages were used to report sociodemographic characteristics and the proportion of subjects fed each milk type category by age group and survey cycles. Binary and multinomial logistic regressions were used to assess differences in subject characteristics by age groups.

      Results

      Sociodemographic characteristics did not differ by age group. The proportion of infants aged 0 to <6 months fed infant formula only was 60.2% in 2007-2012 and 44.8% in 2013-2018. The proportion of infants aged 6 to <12 months fed partially hydrolyzed infant formula only was 7.3% in 2007-2012 and 13.1% in 2013-2018. In toddlers (>12 months old), cow’s milk was the predominant milk type in both 2007-2012 and 2013-2018.

      Conclusions

      The percentage of infants fed any human milk increased over the past decade. Unsweetened cow’s milk was the most predominate milk type consumed among toddlers.

      Keywords

      Research Question: What are the types and prevalence of milk fed to infants and toddlers in the first 2 years of life in the United States?
      Key Findings: The proportion of infants fed human milk only in the first year of life increased over the past decade. Among formula-fed infants, the types of formulas fed have changed, with a higher proportion of infants fed infant formulas containing partially hydrolyzed proteins. In the second year of life, most toddlers were fed unsweetened cow’s milk, consistent with the 2020-2025 Dietary Guidelines for Americans.
      Infants start the first year of life consuming a liquid diet typically consisting of human milk and/or infant formula. In the second year of life (12 through 23.9 months) these sources of milk are replaced with other types of milk. Human milk is considered the gold standard for infant nutrition, as recognized by the 2020-2025 Dietary Guidelines for Americans (DGA),
      Dietary Guidelines for Americans, 2020-2025
      9th ed. US Department of Agriculture, US Department of Health and Human Services.
      Academy of Nutrition and Dietetics,
      • Lessen R.
      • Kavanagh K.
      Position of the Academy of Nutrition and Dietetics: Promoting and supporting breastfeeding.
      American Academy of Pediatrics,
      American Academy of Pediatrics, Committee on Nutrition
      Feeding the infant.
      World Health Organization,
      Infant and Young Child Feeding. World Health Organization.
      and European Society for Paediatric Gastrointestinal Health and Nutrition.
      • Agostoni C.
      • Braegger C.
      • et al.
      ESPGHAN Committee on Nutrition
      Breastfeeding: A commentary by the ESPGHAN Committee on Nutrition.
      When human milk cannot be fed as an exclusive or partial source of nutrition, infant formula is considered the nutritionally suitable feeding alternative.
      Dietary Guidelines for Americans, 2020-2025
      9th ed. US Department of Agriculture, US Department of Health and Human Services.
      • Lessen R.
      • Kavanagh K.
      Position of the Academy of Nutrition and Dietetics: Promoting and supporting breastfeeding.
      American Academy of Pediatrics, Committee on Nutrition
      Feeding the infant.
      ,
      • Agostoni C.
      • Braegger C.
      • et al.
      ESPGHAN Committee on Nutrition
      Breastfeeding: A commentary by the ESPGHAN Committee on Nutrition.
      Data from the 2020 Centers for Disease Control and Prevention Breastfeeding Report Card indicate that 46.9% of 3-month-old infants and 25.6% of 6-month-old infants in the United States were fed human milk exclusively.
      Breastfeeding Report Card
      Centers for Disease Control and Prevention.
      The 2020 Breastfeeding Report Card also indicated that as early as 3 months of age, many infants (53%) were fed infant formula as a supplement to human milk or as a sole source of nutrition.
      Breastfeeding Report Card
      Centers for Disease Control and Prevention.
      Infant formulas, according to the US Food and Drug Administration (FDA) Code of Federal Regulations, are defined as “a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk” and are intended for infants <12 months of age.
      Code of Federal Regulations Title 21
      21CFR106.3. US Food and Drug Administration, Department of Health and Human Services. Subchapter B - Food for Human Consumption.
      Infant formulas marketed in the United States differ in nutrient composition to some extent, however, all must meet minimum and maximum nutrient composition requirements for protein, carbohydrates, fats, vitamins, and minerals, as set forth by the FDA,
      Code of Federal Regulations Title 21
      21CFR106.3. US Food and Drug Administration, Department of Health and Human Services. Subchapter B - Food for Human Consumption.
      as well as all requirements of the Infant Formula Act
      Code of Federal Regulations Title 21
      21CFR106.3. US Food and Drug Administration, Department of Health and Human Services. Subchapter B - Food for Human Consumption.
      and other pertinent FDA regulations.
      Code of Federal Regulations Title 21
      21CFR106.3. US Food and Drug Administration, Department of Health and Human Services. Subchapter B - Food for Human Consumption.
      To date, the FDA does not distinguish between infant formulas designed for younger vs older infants; however, the product market does include transition formulas, which are formulas marketed for use by infants 9 months and older.
      • Pomeranz J.L.
      • Romo Palafox M.J.
      • Harris J.L.
      Toddler drinks, formulas, and milks: Labeling practices and policy implications.
      ,
      • Harris J.L.
      • Fleming-Milici F.
      • Frazier W.
      • et al.
      Baby Food Facts 2016.
      Because transition formulas include an age range that begins with <12 months, these products must also meet the FDA requirements set forth for infant formulas.
      Some attributes by which the composition of infant formulas differ are the source and form of protein, carbohydrate, and fat. Specific to the form of protein, some studies have found that replacing milk ingredients in standard infant formula, such as nonfat milk, which mainly contains intact proteins,
      • Ventura A.K.
      • San Gabriel A.
      • Hirota M.
      • Mennella J.A.
      Free amino acid content in infant formulas.
      with partial protein hydrolysate ingredients, which contain primarily smaller-sized proteins (molecular weight <5,000 Daltons
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on Nutrition, Section on Allergy and Immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      ), may be beneficial for infants with fussiness, gas, or regurgitation.
      • Berseth C.L.
      • Mitmesser S.H.
      • Ziegler E.E.
      • Marunycz J.D.
      • Vanderhoof J.
      Tolerance of a standard intact protein formula versus a partially hydrolyzed formula in healthy, term infants.
      ,
      • Vandenplas Y.
      • Latiff A.H.A.
      • Fleischer D.M.
      • et al.
      Partially hydrolyzed formula in non-exclusively breastfed infants: A systematic review and expert consensus.
      Formulas composed of extensive protein hydrolysates, which are primarily free amino acids and peptides (molecular weight <3,000 Daltons
      • Agostoni C.
      • Braegger C.
      • et al.
      ESPGHAN Committee on Nutrition
      Breastfeeding: A commentary by the ESPGHAN Committee on Nutrition.
      ,
      • Ventura A.K.
      • San Gabriel A.
      • Hirota M.
      • Mennella J.A.
      Free amino acid content in infant formulas.
      ,
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on Nutrition, Section on Allergy and Immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      ,
      • Hays T.
      • Wood R.A.
      A systematic review of the role of hydrolyzed infant formulas in allergy prevention.
      ), are used for infants with allergies to intact protein (eg, cow’s milk and soy).
      • Hays T.
      • Wood R.A.
      A systematic review of the role of hydrolyzed infant formulas in allergy prevention.
      ,
      • Canani R.B.
      • Nocerino R.
      • Frediani T.
      • et al.
      Amino acid-based formula in cow's milk allergy: Long-term effects on body growth and protein metabolism.
      Amino acid–based formulas (ie, only free amino acids
      • Greer F.R.
      • Sicherer S.H.
      • Burks A.W.
      Committee on Nutrition, Section on Allergy and Immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods.
      ) are also hypoallergenic and intended for infants with severe protein allergies and other protein maldigestion disorders.
      • Hill D.J.
      • Murch S.H.
      • Rafferty K.
      • Wallis P.
      • Green C.J.
      The efficacy of amino acid-based formulas in relieving the symptoms of cow's milk allergy: A systematic review.
      ,
      • Joeckel R.J.
      • Phillips S.K.
      Overview of infant and pediatric formulas.
      Beyond the first year of life, infant formula and human milk consumption decreases, and consumption of cow’s milk or cow’s milk substitutes (also referred to as “other milks” or “milk alternatives”) increases.
      • Grimes C.A.
      • Szymlek-Gay E.A.
      • Nicklas T.A.
      Beverage consumption among U.S. children aged 0-24 months: National Health and Nutrition Examination Survey (NHANES).
      ,
      Results: Breastfeeding and Infant Feeding Practices
      Centers for Disease Control and Prevention.
      Cow’s milk and cow’s milk substitutes generally provide substantive amounts of key required nutrients in early childhood (eg, protein, carbohydrates, vitamin A, vitamin D, potassium, magnesium, and zinc).
      • Grimes C.A.
      • Szymlek-Gay E.A.
      • Campbell K.J.
      • Nicklas T.A.
      Food sources of total energy and nutrients among U.S. infants and toddlers: National Health and Nutrition Examination Survey 2005-2012.
      The market of different types of infant formulas and milk products has changed
      • Wargo W.F.
      The history of infant formula: Quality, safety, and standard methods.
      and, as such, the purpose of this study was to determine the types of milk (human milk, infant formula, and other milk) fed to US infants and toddlers in the past 12 years and to assess trends over time.

      Methods

      Study Design and Participants

      Data from the National Health and Nutrition Examination Survey (NHANES), a cross-sectional and nationally representative survey of noninstitutionalized civilians in the United States conducted by the National Center for Health Statistics, were used for these analyses.
      NHANES Questionnaires, Datasets, and Related Documentation
      Centers for Disease Control and Prevention.
      The National Center for Health Statistics Research Ethics Review Board approved the NHANES protocols. The sample (n = 3,079; Figure 1) consists of infants (0 to 11.9 months) and toddlers (12 to 23.9 months) within survey cycles from 2007-2008 through 2017-2018, with two 24-hour dietary recalls. In addition, secondary analyses were conducted in all infants and toddlers 0 to 23.9 months of age using only day one 24-hour dietary recall data (n = 3,597). To assess temporal trends over time, and for stability in estimates, cycles were combined into 2 intervals; 2007-2012 (n = 1,666) and 2013-2018 (n = 1,413).
      Figure thumbnail gr1
      Figure 1Flow diagram of cohort and analytical sample of infants and toddlers from the National Health and Nutrition Examination Survey (NHANES) 2007-2018, less than 24 months of age.

      Dietary Data

      In brief, child proxies, of whom 89.6% were mothers (data not shown), were interviewed by trained examiners to obtain detailed information regarding the types and amounts of foods and beverages their infant or toddler was fed in the 24-hour period before the interview, using computer-assisted, multiple-pass dietary interview system.
      • Zipf G.
      • Chiappa M.
      • Porter K.S.
      • et al.
      National Health and Nutrition Examination Survey: Plan and operations, 1999-2010. National Center for Health Statistics.
      The first dietary recall was collected in the mobile examination center and the second dietary recall was collected via telephone 3 to 10 days after the participant’s visit at the mobile examination center.
      • Zipf G.
      • Chiappa M.
      • Porter K.S.
      • et al.
      National Health and Nutrition Examination Survey: Plan and operations, 1999-2010. National Center for Health Statistics.
      Milks fed to infants and toddlers were obtained from the NHANES individual food files (DR1IFF and DR2IFF). These files contain the 8-digit codes from the US Department of Agriculture’s Food and Nutrient Database for Dietary Studies
      Food and Nutrient Database for Dietary Studies (FNDDS)
      US Department of Agriculture.
      for each food and beverage consumed. Each Food and Nutrient Database for Dietary Studies code is linked to a What We Eat in America major and sub-major food category.
      What We Eat in America Food Categories 2017-2018. US Department of Agriculture, Agricultural Research Service
      Milks consumed were classified into a primary, secondary, and/or tertiary category, as applicable. In general, the primary milk type categories were constructed based on What We Eat in America sub-major food categories, the secondary milk type categories were classified according to product characteristics, and the tertiary milk type categories were constructed based on protein form (Figure 2). Two researchers (J.D., J.T.) independently assigned each milk reported to the applicable primary, secondary, and tertiary milk type category. Any discrepancies were discussed until consensus was reached.
      Figure thumbnail gr2
      Figure 2Composition of primary, secondary, and tertiary milk type categories used to quantitatively and qualitatively describe milks fed to infants and toddlers less than 24 months of age from the National Health and Nutrition Examination Survey 2007-2018.
      More specifically, the primary milk type categories included “human milk,” “infant formulas,” “cow’s milks and flavored cow’s milks,” and “cow’s milk substitutes” (also described as “other milks” or “milk alternatives”). The What We Eat in America
      What We Eat in America Food Categories 2017-2018. US Department of Agriculture, Agricultural Research Service
      category dairy drinks and substitutes was limited to cow’s milk substitutes only because dairy drinks (eg, milk shakes) are more aligned nutritionally with dairy desserts. Because toddler milks are marketed for use by toddlers 12 months and older and are not subject to the requirements set forth by the FDA
      • Pomeranz J.L.
      • Harris J.L.
      Federal regulation of infant and toddler food and drink marketing and labeling.
      for infant formulas, they were not categorized as infant formulas and, instead, a fourth primary milk type category, “toddler milks,” was created for these products. A fifth category, “>1 primary milk type,” was created to characterize infants and toddlers fed more than 1 primary milk type category (eg, human milk and infant formula, within a day or over the 2 days).
      The secondary milk type category describes product characteristics based on information found on the product label and/or manufacturers’ websites, resulting in the following categories: “preterm infant formula,” “term infant formula,” “transition formula,” “store brand or infant formula not specified,” “unsweetened cow’s milk,” “sweetened cow’s milk,” “unsweetened cow’s milk substitutes,” “sweetened cow’s milk substitutes,” and “>1 secondary milk type.” Preterm formula included those formulated for premature and/or low-birth-weight infants. Term formula included those designated for full-term infants aged 0 to 12 months. Transition formula included those formulated for infants aged 9 months and older. Infant formula “not specified” or “store brand” included those that were reported without the details to categorize as preterm, term, or transition infant formula. Sweetened cow’s milk and sweetened cow’s milk substitutes were defined as containing >0 g of added sugar, as identified by the US Department of Agriculture’s Food Patterns Equivalence Database.
      Food Patterns Equivalence Database
      US Department of Agriculture.
      Infants and toddlers fed more than 1 secondary milk type category within the respective primary milk type category were classified as “>1 secondary milk type.”
      The tertiary milk type category was based on protein form (ie, degree of protein hydrolysis). Using information found on the product label and/or manufacturer’s websites, infant formulas were assigned to the following categories: “nonhydrolyzed protein,” “partially hydrolyzed protein,” “extensively hydrolyzed protein,” “amino acid-based,” “>1 tertiary milk type,” and “not specified or store brand.” Nonhydrolyzed formula included those formulated with intact protein sources, such as nonfat milk, milk protein isolate, and/or soy protein isolate. Partially hydrolyzed formula included those composed of partially hydrolyzed nonfat milk, enzymatically hydrolyzed whey protein concentrate, and/or enzymatically hydrolyzed soy protein isolate. Extensively hydrolyzed formula included those formulated with extensively hydrolyzed protein, often labeled as hypoallergenic, such as casein hydrolysate. Amino acid–based formula included those composed of free amino acids only. Similar to the primary and secondary milk type categories, a combination category was created if infants were fed products with different protein forms. Not specified or store brand included those that were reported as only infant formula without the details needed to categorize the tertiary milk type.
      Examination of data found that some participants consumed 1 type of primary milk on day 1 (eg, infant formula) and a different type of primary milk on day 2 (eg, human milk), therefore, 2 days of recall were selected as the primary analyses to account for intra-individual variability in milk type and increase the accuracy of infant milk type categorization. Secondary analyses were repeated in all infants and toddlers using only day 1 of dietary recall.

      Statistical Analysis

      The primary analyses included those with two 24-hour dietary recalls and, therefore, the WTDR2D variable
      NHANES Survey Methods and Analytic Guidelines
      Centers for Disease Control and Prevention.
      for each survey cycle was used, along with strata and primary sampling units, to account for the complex survey design, nonresponse, and post-stratification adjustments to replicate US Census Bureau population counts.
      NHANES Tutorials
      Centers for Disease Control and Prevention.
      Secondary (sensitivity) analyses included all infants and toddlers using only the day one 24-hour dietary recall and used the WTDR1D variable
      NHANES Survey Methods and Analytic Guidelines
      Centers for Disease Control and Prevention.
      instead. Preliminary descriptive analyses of primary milk type frequencies were conducted on all subjects regardless of the number of days of dietary recall compared with only subjects with 2 days of dietary recall. Weighted cumulative percentages were used to report sociodemographic characteristics and the proportion of subjects fed each milk type category by age group (0 to <6 months, 6 to <12 months, 12 to <18 months, and 18 to <24 months) and by survey cycle intervals (eg, 2007-2012 and 2013-2018). Differences in subject characteristics by age group were assessed using binary or multinomial logistic regression. All estimates were examined for stability on the basis of guidance from National Center for Health Statistics Data Presentations for Proportions.
      • Parker J.D.
      • Talih M.
      • Malec D.J.
      • et al.
      National Center for Health Statistics data presentation standards for proportions. National Center for Health Statistics.
      Estimates identified as unreliable due to nominal or effective sample size or relative CI width were identified.
      • Parker J.D.
      • Talih M.
      • Malec D.J.
      • et al.
      National Center for Health Statistics data presentation standards for proportions. National Center for Health Statistics.
      All analyses were performed using Stata IC, version 15.1
      using α = .05.

      Results

      A total of 3,597 infants and toddlers younger than 24 months had either 1 or 2 days of dietary intake data. Preliminary descriptive data review (n = 3,597) revealed that some participants were fed more than 1 primary milk type category within the same day and/or across 2 days. With respect to the latter, because subjects could be characterized differently based on day 1 or day 2 of dietary intake data, only those participants with 2 days of dietary intake data (n = 3,079) were included in these analyses. Sociodemographic characteristics by age group for subjects with 2 days of dietary intake are provided in Table 1. Secondary analyses of sociodemographic characteristics by age group for all subjects with 1 day of diet recall are provided in Table 2 (available at jandonline.org). There were no differences in sociodemographic characteristics by age group.
      Table 1Sociodemographic characteristics of infants and toddlers aged <24 months with 2 days of dietary recall (n = 3,079) from the National Health and Nutrition Examination Survey (2007-2018), by age group


      Characteristic
      Age GroupsP value
      Differences in subject characteristics by age group were assessed using binary or multinomial logistic regression.
      0 to <6 mo (n = 933)6 to <12 mo (n = 963)12 to <18 mo (n = 652)18 to <24 mo (n = 531)
      ←————————————%————————————→
      Weighted
      Two-day dietary recall weights (WTDR2D)28 for each survey cycle were used to account for the complex survey design, nonresponse, and post-stratification adjustments to replicate US Census Bureau population counts.29
      25.527.125.422.0
      Infant sex.1355
      Male51.249.755.352.7
      Female48.850.344.747.3
      Infant race/ethnicity.6657
      Non-Hispanic White51.553.649.447.6
      Non-Hispanic Black13.913.113.313.7
      Mexican American19.518.319.018.3
      Other Hispanic6.98.07.911.3
      Other race and/or multiracial8.37.110.59.2
      Head of household education
      Percentages do not include participants with missing data, n = 514 missing.
      .2062
      Less than high school22.319.820.023.6
      High school/GED
      GED = General Educational Development test.
      /some college
      50.147.857.450.0
      College graduate27.732.422.826.4
      Head of household marital status
      Percentages do not include participants with missing data, n = 553 missing.
      .5194
      Married/living with partner81.583.779.581.6
      Widowed/divorced/separated9.46.810.810.1
      Never married9.19.59.68.3
      Annual household income
      Percentages do not include participants with missing data, n = 117 missing and n = 89 with reported income more than $20,000 and could not be categorized).
      .8508
      <$35,00038.940.039.938.5
      $35,000–$75,00031.528.131.429.7
      >$75,00029.631.928.731.9
      a Differences in subject characteristics by age group were assessed using binary or multinomial logistic regression.
      b Two-day dietary recall weights (WTDR2D)
      NHANES Survey Methods and Analytic Guidelines
      Centers for Disease Control and Prevention.
      for each survey cycle were used to account for the complex survey design, nonresponse, and post-stratification adjustments to replicate US Census Bureau population counts.
      NHANES Tutorials
      Centers for Disease Control and Prevention.
      c Percentages do not include participants with missing data, n = 514 missing.
      d GED = General Educational Development test.
      e Percentages do not include participants with missing data, n = 553 missing.
      f Percentages do not include participants with missing data, n = 117 missing and n = 89 with reported income more than $20,000 and could not be categorized).
      The proportion of infants fed each milk type category (primary, secondary, and tertiary) by age group and by survey cycle intervals are provided in Table 3. Secondary analyses of milk type categories by survey cycle intervals for all subjects with 1 day of diet recall are provided in Table 4 (available at jandonline.org). As shown in Table 3, the percentage of infants aged 0 to <6 months fed human milk only was 23.8% in 2007-2012 and 35.3% in 2013-2018. Among infants aged 6 to <12 months, 10.8% and 22.4% were fed human milk only in 2007-2012 and 2013-2018, respectively. Among infants aged 0 to <6 months in 2007-2012 and 2013-2018, 60.2% and 44.8% were fed “infant formula only,” respectively. Similarly, 63.3% of infants aged 6 to <12 months in 2007-2012 and 54.0% in 2013-2018 were fed “infant formula only.” Among infants aged 0 to <6 months in 2007-2012 and 2013-2018, 42.7% and 25.9% were fed a nonhydrolyzed protein formula and 9.2% and 11.0% were fed a partially hydrolyzed protein formula, respectively.
      Table 3The proportion of infants aged <12 months with 2 days of dietary recall (n = 1,896) from the National Health and Nutrition Examination Survey (2007-2018), fed each primary, secondary, and tertiary milk type category, by age group and survey cycle


      Milk type category fed
      Primary milk type categories were constructed based on What We Eat in America sub-major food categories,25 secondary milk type categories were classified according to product characteristics, and tertiary milk type categories were constructed based on protein form. See Methods section for details. Primary milk type categories sum to 100% within each age group (column). Secondary milk type categories further describe each primary milk type category and sum to the primary milk type category within each age group (column). Tertiary milk type categories further describe each secondary milk type category and sum to the secondary milk type category within age group (column).
      Age Groups
      0 to <6 mo6 to <12 mo
      2007-2012 (n = 495)2013-2018 (n = 438)2007-2012 (n = 523)2013-2018 (n = 440)
      ←————————————% (95% CI)
      Cumulative percent within each column may not add to 100% due to rounding.
      —————————————→
      Human milk only23.8 (18-29.6)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      35.3 (28.5-42.2)10.8 (6.8-14.9)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      22.4 (16.8-28.0)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      Infant formulas only60.2 (53.6-66.8)44.8 (39.2-50.4)63.3 (57-69.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      54.0 (48.6-59.4)
      Premature infant formulas only1.3 (0.3-5.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.7 (0.7-4.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0 (0-0.3)0.3 (0-1.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Term infant formulas only55.6 (49.9-61.4)41.4 (36.1-46.7)55.1 (48.5-61.7)44.6 (37.6-51.6)
       Nonhydrolyzed protein42.7 (35.2-50.5)25.9 (21.5-30.8)44.5 (38.1-51.1)28.2 (22.7-34.4)
       Partially hydrolyzed protein9.2 (5.4-15.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      11.0 (7.5-15.9)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      7.3 (4.3-12.2)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      13.1 (8.0-20.7)
       Extensively hydrolyzed protein0.3 (0-1.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.6 (1.6-7.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.2 (0.5-2.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.1 (1.1-4.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
       Amino acid–based protein0.5 (0-3.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reported0.2 (0-0.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
       Tertiary milk type, combination2.9 (1.5-5.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.0 (0.4-2.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.1 (0.9-4.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.9 (0.4-2.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Transition infant formulas only0.2 (0-1.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reported0.6 (0-0.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Store brand or infant formulas not specified1.8 (0.3-3.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.3 (0.1-2.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      5.6 (1.5-9.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      4.3 (1.5-7.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Secondary milk type, combination1.3 (0-2.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.4 (0-0.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.6 (0.2-0.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      4.2 (1.1-7.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Cow’s milk and flavored cow’s milk onlyNone reportedNone reported3.9 (1.4-6.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.0 (0.5-3.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Unsweetened cow’s milkNone reportedNone reported3.7 (1.3-6.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.0 (0.5-3.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Sweetened cow’s milkNone reportedNone reportedNone reportedNone reported
      Secondary milk type, combinationNone reportedNone reported0.2 (0-1.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
      Cow’s milk substitute onlyNone reportedNone reportedNone reported0.1 (0-0.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Unsweetened cow’s milk substituteNone reportedNone reportedNone reportedNone reported
      Sweetened cow’s milk substituteNone reportedNone reportedNone reported0.1 (0-0.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Secondary milk type, combinationNone reportedNone reportedNone reportedNone reported
      Primary milk type, combination16.0 (11.8-20.2)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      19.8 (13.4-26.3)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      21.3 (17-25.7)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      21.6 (16.7-26.4)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      a Primary milk type categories were constructed based on What We Eat in America sub-major food categories,
      What We Eat in America Food Categories 2017-2018. US Department of Agriculture, Agricultural Research Service
      secondary milk type categories were classified according to product characteristics, and tertiary milk type categories were constructed based on protein form. See Methods section for details. Primary milk type categories sum to 100% within each age group (column). Secondary milk type categories further describe each primary milk type category and sum to the primary milk type category within each age group (column). Tertiary milk type categories further describe each secondary milk type category and sum to the secondary milk type category within age group (column).
      b Cumulative percent within each column may not add to 100% due to rounding.
      c Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      d Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      The proportions of toddlers fed each milk type category (primary, secondary, and tertiary) by age group and by survey cycle intervals are provided in Table 5. Results of secondary analyses of milk type categories by survey cycle intervals for all subjects with 1 day of diet recall are provided in Table 6 (available at jandonline.org). As shown in Table 5, 77.6% and 66.7% of toddlers aged 12 to <18 months were fed “cow’s milk and flavored cow’s milk” only in 2007-2012 and 2013-2018, respectively. Within cow’s milk and flavored cow’s milk, 74.1% and 62.6% of toddlers aged 12 to <18 months were fed unsweetened cow’s milk in 2007-2012 and 2013-2018, respectively. Similarly, 75.1% and 70.5% of toddlers aged 18 to <24 months were fed unsweetened cow’s milk in 2007-2012 and 2013-2018, respectively.
      Table 5The proportion of toddlers aged 12 to <24 months with 2 days of dietary recall (n = 1,183) from the National Health and Nutrition Examination Survey (2007-2018), fed each primary, secondary, and tertiary milk type category, by age group and survey cycle


      Milk type category fed
      Primary milk type categories were constructed based on What We Eat in America25 sub-major food categories, secondary milk type categories were classified according to product characteristics, and tertiary milk type categories were constructed based on protein form. See Methods section for details. Primary milk type categories sum to 100% within each age group (column). Secondary milk type categories further describe each primary milk type category and sum to the primary milk type category within each age group (column). Tertiary milk type categories further describe each secondary milk type category and sum to the secondary milk type category within age group (column).
      Age Groups
      12 to <18 mo18 to <24 mo
      2007-2012 (n = 353)2013-2018 (n = 299)2007-2012 (n = 295)2013-2018 (n = 236)
      ←————————————% (95% CI)
      Cumulative percent within each column may not add to 100% due to rounding.
      —————————————→
      Human milk only3.1 (1.1-8.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.7 (1.4-5.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.6 (0.1-2.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.0 (0.9-7.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Infant formulas only2.5 (1.3-4.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      4.6 (2.0-10.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.1 (0.8-11.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
      Premature infant formulas onlyNone reportedNone reportedNone reportedNone reported
      Term infant formulas only1.7 (0.8-3.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      4.2 (1.6-9.8)1.3 (0.2-7.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
       Nonhydrolyzed protein1.3 (0.5-3.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.1 (0.8-5.0)0 (0-0.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
       Partially hydrolyzed protein0.2 (0-1.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.2 (0-0.7)None reportedNone reported
       Extensively hydrolyzed proteinNone reported1.8 (0.3-10.4)1.2 (0.2-8.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
       Amino acid-based proteinNone reportedNone reportedNone reportedNone reported
       Tertiary milk type, combination0.2 (0-1.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0 (0-0.7)None reportedNone reported
      Transition infant formulas only0.5 (0-3.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reportedNone reported
      Store brand or infant formulas not specified0.2 (0-1.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.2 (0-1.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.8 (0.3-11.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
      Secondary milk type, combination0.1 (0-0.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.3 (0-2.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reported
      Cow’s milk and flavored cow’s milks only77.6 (71.9-82.4)66.7 (58.3-74.2)83.0 (76.6-87.9)76.7 (68.4-83.4)
      Unsweetened cow’s milk74.1 (68.9-78.8)62.6 (54.6-69.9)75.1 (68.6-80.7)70.5 (61.8-77.9)
      Sweetened cow’s milk0.4 (0-2.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.7 (0-4.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.1 (0.3-3.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.0 (0.2-3.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Secondary milk type, combination3.1 (1.9-5.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.5 (1.3-8.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      6.8 (3.9-11.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      5.2 (2.6-10.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Cow’s milk substitutes only2.9 (1.0-8.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.8 (0.4-7.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.7 (0.5-5.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      6.7 (3.2-13.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Unsweetened cow’s milk substituteNone reported0.2 (0-0.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.9 (0.1-6.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.3 (0-1.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Sweetened cow’s milk substitute2.9 (1.0-8.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.6 (0.4-6.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.8 (0.3-3.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.9 (1.4-10.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Secondary milk type, combinationNone reportedNone reportedNone reported2.6 (1.0-6.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Primary milk type, combination12.1 (8.0-17.9)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      23.0 (16.1-31.9)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      8.5 (5.5-12.9)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      7.2 (5.3-12.0)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      No milk reported1.8 (0.6-5.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.9 (0.3-3.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.1 (1.5-6.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      5.1 (3.0-9.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      a Primary milk type categories were constructed based on What We Eat in America
      What We Eat in America Food Categories 2017-2018. US Department of Agriculture, Agricultural Research Service
      sub-major food categories, secondary milk type categories were classified according to product characteristics, and tertiary milk type categories were constructed based on protein form. See Methods section for details. Primary milk type categories sum to 100% within each age group (column). Secondary milk type categories further describe each primary milk type category and sum to the primary milk type category within each age group (column). Tertiary milk type categories further describe each secondary milk type category and sum to the secondary milk type category within age group (column).
      b Cumulative percent within each column may not add to 100% due to rounding.
      c Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      d Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.

      Discussion

      The percentage of infants fed human milk only was higher in 2013-2018 compared with 2007-2012. These data are in line with guidance from the DGA, underscoring the importance of human milk feeding as the preferred source of nutrition
      Dietary Guidelines for Americans, 2020-2025
      9th ed. US Department of Agriculture, US Department of Health and Human Services.
      and consistent with the Centers for Disease Control and Prevention Breastfeeding Report Card, which showed the percentage of US infants exclusively breastfed at 6 months has increased from 11.3% in the 2007 Breastfeeding Report Card
      Breastfeeding Report Card
      Centers for Disease Control and Prevention.
      to 25.6% in the 2020 report.
      Breastfeeding Report Card
      Centers for Disease Control and Prevention.
      Similarly, the percentage of infants fed any human milk at 6 months has increased from 41.5% in the 2007 Breastfeeding Report Card to 58.3% in the 2020 Breastfeeding Report Card.
      Breastfeeding Report Card
      Centers for Disease Control and Prevention.
      With respect to the tertiary milk types of infant formulas, although nonhydrolyzed protein formulas continue to be fed to most infants, the percentage of infants in these analyses and in previous NHANES analyses (2003-2010)
      • Rossen L.M.
      • Simon A.E.
      • Herrick K.A.
      Types of infant formulas consumed in the United States.
      suggest that the percentage of infants fed partially hydrolyzed protein formula increased from 2007-2012 to 2013-2018 in infants younger than 12 months. These data suggest that the types of infant formulas (ie, form of protein) fed to US infants is changing and partial protein hydrolysate formula use may be increasing. Infant formulas containing partially hydrolyzed protein ingredients have been proposed to reduce fussiness,
      • Berseth C.L.
      • Mitmesser S.H.
      • Ziegler E.E.
      • Marunycz J.D.
      • Vanderhoof J.
      Tolerance of a standard intact protein formula versus a partially hydrolyzed formula in healthy, term infants.
      ,
      • Vivatvakin B.
      • Estorninos E.
      • Lien R.
      • et al.
      Clinical response to two formulas in infants with parent-reported signs of formula intolerance: A multi-country, double-blind, randomized trial.
      gas, vomiting, spitting up, and nighttime awakening
      • Vivatvakin B.
      • Estorninos E.
      • Lien R.
      • et al.
      Clinical response to two formulas in infants with parent-reported signs of formula intolerance: A multi-country, double-blind, randomized trial.
      ; however, not all studies are consistent
      • Vandenplas Y.
      • Latiff A.H.A.
      • Fleischer D.M.
      • et al.
      Partially hydrolyzed formula in non-exclusively breastfed infants: A systematic review and expert consensus.
      and additional research is needed to determine the clinical benefits of feeding partially hydrolyzed formulas, as well as caregiver motivation for selecting these formulas. Differences in degree of protein hydrolyzation between products, as evidenced by different concentrations of free amino acids,
      • Ventura A.K.
      • San Gabriel A.
      • Hirota M.
      • Mennella J.A.
      Free amino acid content in infant formulas.
      ,
      • Agostoni C.
      • Carratu B.
      • Boniglia C.
      • Riva E.
      • Sanzini E.
      Free amino acid content in standard infant formulas: Comparison with human milk.
      may be a factor in the inconsistent clinical outcomes.
      Furthermore, it appears that a small proportion of infants aged 6 to <12 months were introduced to milks other than human milk or infant formula (ie, cow’s milk and flavored cow’s milk). By 6 to <12 months of age, although more than two-thirds of infants were fed infant formula only or human milk only as the primary milk type, the introduction of cow’s milk and flavored cow’s milk was present. These data are consistent with a recent report that 20% to 22% of US infants aged 6 to 11 months were fed any cow’s milk or toddler milk.
      • Romo-Palafox M.J.
      • Harris J.L.
      Caregiver's provision of non-recommended commercially prepared milk-based drinks to infants and toddlers.
      This is of concern, given that the American Academy of Pediatrics,
      American Academy of Pediatrics, Committee on Nutrition
      Complementary feeding.
      the Healthy Eating Research Expert Panel,
      • Lott M.
      • Callahan E.
      • Welker Duffy E.
      • Story M.
      • Daniels S.
      Healthy Beverage Consumption in Early Childhood: Recommendations from Key National Health and Nutrition Organizations. Healthy Eating Research.
      and the most recent DGA
      Dietary Guidelines for Americans, 2020-2025
      9th ed. US Department of Agriculture, US Department of Health and Human Services.
      all discourage the introduction of milks other than human milk or infant formula before a child’s first birthday,
      Dietary Guidelines for Americans, 2020-2025
      9th ed. US Department of Agriculture, US Department of Health and Human Services.
      as cow’s milk and cow’s milk substitutes fail to provide appropriate amounts of key nutrients required for infants aged 0 to <12 months. One possible explanation is that the marketing of toddler milks often uses branding, packaging, and labeling that make it difficult for caregivers to distinguish toddler milks from infant formulas,
      • Harris J.L.
      • Pomeranz J.L.
      Infant formula and toddler milk marketing: Opportunities to address harmful practices and improve young children's diets.
      and some caregivers may be unintentionally providing toddler products to infants.
      Focusing on milks beyond the first year of life, only a small percentage of toddlers continued to be fed human milk only or infant formula only, and a small percentage were fed cow’s milk substitutes only. A recent report found that per-capita consumption of dairy milk as a beverage in US households has declined steadily since 1975.
      • Wolf C.A.
      • Malone T.
      • McFadden B.R.
      Beverage milk consumption patterns in the United States: Who is substituting from dairy to plant-based beverages?.
      Furthermore, although more than three-quarters of US households reported regularly consuming dairy milk, 38% report consuming only plant-based beverages and 16% report consuming plant-based and other dairy alternatives.
      • Wolf C.A.
      • Malone T.
      • McFadden B.R.
      Beverage milk consumption patterns in the United States: Who is substituting from dairy to plant-based beverages?.
      However, research on milk consumption in infants and toddlers is limited, and future research should focus on cow’s milk substitute consumption in younger age groups.
      The American Academy of Pediatrics and DGA recognize plain cow’s milk and unsweetened milk alternatives (eg, soy milk and almond milk) as acceptable components of the toddler diet
      Dietary Guidelines for Americans, 2020-2025
      9th ed. US Department of Agriculture, US Department of Health and Human Services.
      ,
      American Academy of Pediatrics, Committee on Nutrition
      Feeding the infant.
      and, consistent with these recommendations, unsweetened cow’s milk was the only milk fed to nearly three-quarters of toddlers aged 12 to <18 months and 18 to <24 months. The DGA
      Dietary Guidelines for Americans, 2020-2025
      9th ed. US Department of Agriculture, US Department of Health and Human Services.
      and the American Heart Association
      • Vos M.B.
      • Kaar J.L.
      • Welsh J.A.
      • et al.
      Added sugars and cardiovascular disease risk in children: A scientific statement from the American Heart Association.
      recommend that added sugars should not be introduced before 2 years of age, yet flavored cow’s milk and cow’s milk substitutes have been reported to be among the top 8 sources of added sugars in the diets of US infants and toddlers from 2011 to 2016.
      • Herrick K.A.
      • Fryar C.D.
      • Hamner H.C.
      • Park S.
      • Ogden C.L.
      Added sugars intake among US infants and toddlers.
      Avoiding milks that contain added sugars (eg, toddler milks, flavored cow’s milks, and sweetened cow’s milk substitutes) is important in the first 2 years of life, as this is a sensitive period in flavor development and preference,
      • Mennella J.A.
      • Griffin C.E.
      • Beauchamp G.K.
      Flavor programming during infancy.
      • Mennella J.A.
      • Ventura A.K.
      Early feeding: Setting the stage for healthy eating habits.
      • Mennella J.A.
      • Castor S.M.
      Sensitive period in flavor learning: Effects of duration of exposure to formula flavors on food likes during infancy.
      and may contribute to setting the palate for a preference for sweetness and other poor health outcomes related to diet later in life.
      • Zalewski B.M.
      • Patro B.
      • Veldhorst M.
      • et al.
      Nutrition of infants and young children (one to three years) and its effect on later health: A systematic review of current recommendations (Early Nutrition Project).
      A strength of this study is the use of a nationally representative data set in which sample weights were applied, resulting in findings that are generalizable to the US infant and toddler population. However, this study is not without limitations. Due to the small sample size, many estimates were not stable, however, the CIs provide context for the estimate. Because infants and toddlers are unable to complete dietary recalls independently, researchers are dependent on caregivers to serve as a proxy, and research in younger pediatric populations has found that adults are suitable proxies.
      • Bornhorst C.
      • Bel-Serrat S.
      • Pigeot I.
      • et al.
      Validity of 24-h recalls in (pre-) school aged children: Comparison of proxy-reported energy intakes with measured energy expenditure.
      Research has found that the 24-hour dietary recall is an appropriate method of measuring dietary intake in infants
      • Davies P.S.
      • Coward W.A.
      • Gregory J.
      • White A.
      • Mills A.
      Total energy expenditure and energy intake in the pre-school a child: A comparison.
      ; however, this study is limited to the fact that there are only 2 days of dietary data available in NHANES data. Because these analyses focus on the occurrence of milk types in the diet (ie, presence or absence) as opposed to amounts of each milk type, this reduces potential error. Another limitation is the lack of specific information on some reported formula types (eg, store brand, infant formula not specified). This led to the creation of a separate category for these reported formulas and thus other categories may be underestimated. It should be noted that store brand and infant formula not specified contributed to 2.4%, on average, of formulas reported.

      Conclusions

      In summary, the milk-based diet of infancy and early toddlerhood transitions from primarily human milk and infant formulas, eventually to cow’s milk and flavored cow’s milks, cow’s milk substitutes, and toddler milks. These data demonstrate shifts in the proportion of infants fed human milk and infant formula, as well as transitions in the types of infant formulas fed. In the second year of life, most toddlers were fed unsweetened cow’s milk. One unexpected finding from these data was the proportion of infants and toddlers receiving different combinations of primary milk types in both infancy and toddlerhood. Future research should qualitatively describe these combinations in milk types.

      Supplementary Materials

      Table 2Sociodemographic characteristics of infants and toddlers aged <24 months with day 1 of dietary recall (n = 3,597) from the National Health and Nutrition Examination Survey (2007-2018), by age group


      Characteristic
      Age GroupsP value
      Differences in subject characteristics by age group were assessed using binary or multinomial logistic regression.
      0 to <6 mo (n = 1,034)6 to <12 mo (n = 1,127)12 to <18 mo (n = 760)18 to <24 mo (n = 676)
      ←—————————————%—————————————→
      Weighted
      Two-day dietary recall weights (WTDR2D)28 for each survey cycle were used to account for the complex survey design, nonresponse, and post-stratification adjustments to replicate US Census Bureau population counts.29
      24.327.025.223.6
      Infant sex.7083
      Male51.150.753.052.4
      Female48.949.347.047.6
      Infant race/ethnicity.5433
      Non-Hispanic White51.454.050.049.3
      Non-Hispanic Black13.913.012.712.6
      Mexican American19.417.617.818.2
      Other Hispanic6.47.78.610.7
      Other race and/ or multiracial8.97.611.09.2
      Head of household education
      Percentages do not include participants with missing data, n = 597 missing.
      .4419
      Less than high school21.919.920.221.3
      High school/GED
      GED = General Educational Development test.
      /some college
      50.749.456.550.4
      College graduate27.430.723.328.3
      Head of household marital status
      Percentages do not include participants with missing data, n = 632 missing.
      .0342
      Married/living with partner81.683.579.282.0
      Widowed/divorced/separated9.36.411.610.4
      Never married9.210.19.27.7
      Annual household income
      Percentages do not include participants with missing data, n = 148 missing and n = 111 with reported income >$20,000 and could not be categorized).
      .8779
      <$35,00039.040.338.438.8
      $35,000–$75,00030.627.631.928.9
      >$75,00030.432.129.632.3
      a Differences in subject characteristics by age group were assessed using binary or multinomial logistic regression.
      b Two-day dietary recall weights (WTDR2D)
      NHANES Survey Methods and Analytic Guidelines
      Centers for Disease Control and Prevention.
      for each survey cycle were used to account for the complex survey design, nonresponse, and post-stratification adjustments to replicate US Census Bureau population counts.
      NHANES Tutorials
      Centers for Disease Control and Prevention.
      c Percentages do not include participants with missing data, n = 597 missing.
      d GED = General Educational Development test.
      e Percentages do not include participants with missing data, n = 632 missing.
      f Percentages do not include participants with missing data, n = 148 missing and n = 111 with reported income >$20,000 and could not be categorized).
      Table 4The proportion of infants aged <12 months with day 1 of dietary recall (n = 2,161) from the National Health and Nutrition Examination Survey (2007-2018), fed each primary, secondary, and tertiary milk type category, by age group and survey cycle


      Milk type category fed
      Primary milk type categories were constructed based on What We Eat in America sub-major food categories,25 secondary milk type categories were classified according to product characteristics, and tertiary milk type categories were constructed based on protein form. See Methods section for details. Primary milk type categories sum to 100% within each age group (column). Secondary milk type categories further describe each primary milk type category and sum to the primary milk type category within each age group (column). Tertiary milk type categories further describe each secondary milk type category and sum to the secondary milk type category within age group (column).
      Age Group
      0 to <6 mo6 to <12 mo
      2007-2012 (n = 551)2013-2018 (n = 483)2007-2012 (n = 606)2013-2018 (n = 521)
      ←—————————————% (95% CI)
      Cumulative percent within each column may not add to 100% due to rounding.
      ————————————→
      Human milk only24.4 (18.7-30.0)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      32.5 (26.7-38.3)11.5 (7.6-15.5)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      22.5 (17.6-27.4)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      Infant formulas only59.3 (52.9-65.8)46.5 (40.4-52.5)63.2 (57.3-69.2)56.3 (51.3-61.2)
      Premature infant formulas only1.8 (0-3.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.4 (0.2-2.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.1 (0-0.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.3 (0-0.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Term infant formulas only54.0 (48.6-59.3)42.3 (37.2-47.3)56.8 (50.6-62.9)48.5 (41.8-55.1)
       Nonhydrolyzed protein42.2 (34.8-49.7)27.8 (23.4-32.2)45.0 (39.2-50.8)29.5 (23.4-35.7)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
       Partially hydrolyzed protein8.1 (3.8-12.5)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      11.5 (7.8-15.1)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      7.8 (3.7-11.9)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      14.5 (8.7-20.4)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
       Extensively hydrolyzed protein0.6 (0-1.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.2 (0.6-3.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.2 (1.0-3.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.2 (1.2-5.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
       Amino acid–based protein0.5 (0-1.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reported0.2 (0-0.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
       Tertiary milk type, combination2.5 (0.7-4.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.9 (0-1.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.8 (0.2-3.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.0 (0.3-1.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Transition infant formulas only0.1 (0-0.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.2 (0-0.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.1 (0-0.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.8 (0-1.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Store brand or infant formulas not specified1.9 (0.6-3.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.2 (0.5-3.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      4.6 (1.5-7.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      4.0 (1.4-6.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Secondary milk type, combination1.5 (0.1-2.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.5 (0-1.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.8 (0.4-3.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.8 (1.1-4.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Cow’s milk and flavored cow milks onlyNone reported0.1 (0-0.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.8 (1.7-5.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.7 (0.6-2.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Unsweetened cow’s milkNone reported0.1 (0-0.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.7 (1.7-5.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.7 (0.6-2.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Sweetened cow’s milkNone reportedNone reportedNone reportedNone reported
      Secondary milk type, combinationNone reportedNone reported0.1 (0-0.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
      Cow’s milk substitutes onlyNone reportedNone reportedNone reported0.1 (0-0.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Unsweetened cow’s milk substituteNone reportedNone reportedNone reportedNone reported
      Sweetened cow’s milk substituteNone reportedNone reportedNone reported0.1 (0-0.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Secondary milk type, combinationNone reportedNone reportedNone reportedNone reported
      Primary milk type, combination16.3 (12.4-20.2)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      20.9 (14.7-27.2)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      21.1 (17.1-25.2)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      19.4 (15.1-23.7)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      a Primary milk type categories were constructed based on What We Eat in America sub-major food categories,
      What We Eat in America Food Categories 2017-2018. US Department of Agriculture, Agricultural Research Service
      secondary milk type categories were classified according to product characteristics, and tertiary milk type categories were constructed based on protein form. See Methods section for details. Primary milk type categories sum to 100% within each age group (column). Secondary milk type categories further describe each primary milk type category and sum to the primary milk type category within each age group (column). Tertiary milk type categories further describe each secondary milk type category and sum to the secondary milk type category within age group (column).
      b Cumulative percent within each column may not add to 100% due to rounding.
      c Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      d Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Table 6The proportion of toddlers aged 12 to <24 months with day 1 of dietary recall (n = 1,436) from the National Health and Nutrition Examination Survey (2007-2018), fed each primary, secondary, and tertiary milk type category, by age group and survey cycle


      Milk type category fed
      Primary milk type categories were constructed based on What We Eat in America sub-major food categories,25 secondary milk type categories were classified according to product characteristics, and tertiary milk type categories were constructed based on protein form. See Methods section for details. Primary milk type categories sum to 100% within each age group (column). Secondary milk type categories further describe each primary milk type category and sum to the primary milk type category within each age group (column). Tertiary milk type categories further describe each secondary milk type category and sum to the secondary milk type category within age group (column).
      Age Group
      12 to <18 mo18 to <24 mo
      2007-2012

      (n = 415)
      2013-2018

      (n = 345)
      2007-2012

      (n = 389)
      2013-2018

      (n = 287)
      ←—————————————% (95% CI)
      Cumulative percent within each column may not add to 100% due to rounding.
      ———————————→
      Human milk only3.2 (0.1-6.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.6 (0.7-4.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.5 (0-1.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.1 (0.1-4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Infant formulas only3.8 (1.8-5.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.9 (1.8-6.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.3 (0-5.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
      Premature infant formulas onlyNone reportedNone reportedNone reportedNone reported
      Term infant formulas only2.9 (1.2-4.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.7 (1.3-4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.0 (0-2.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
       Nonhydrolyzed protein2.6 (0.9-4.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.9 (0.7-3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.1 (0-0.2)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
       Partially hydrolyzed protein0.2 (0-0.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.2 (0-0.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reported
       Extensively hydrolyzed proteinNone reported0.5 (0-1.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.9 (0-2.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
       Amino acid-based proteinNone reportedNone reportedNone reportedNone reported
       Tertiary milk type, combination0.1 (0-0.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.1 (0-0.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reported
      Transition infant formulas only0.4 (0-1.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reportedNone reported
      Store brand or infant formulas not specified0.4 (0-1.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.8 (0-1.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.3 (0-3.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reported
      Secondary milk type, combination0.1 (0-0.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.4 (0-1.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      None reportedNone reported
      Cow’s milk and flavored cow’s milks only77.0 (70.7-83.2)66.2 (59.2-73.2)82.7 (77.9-87.4)76.5 (70.2-82.8)
      Unsweetened cow’s milk72.0 (65.9-78.2)62.9 (55.9-69.9)75.8 (70.6-81.1)71.2 (65.2-77.3)
      Sweetened cow’s milk0.7 (0-1.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.5 (0-1.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.3 (0-2.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.7 (0-1.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Secondary milk type, combination4.2 (1.6-6.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      2.7 (0-5.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      5.5 (2.5-8.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      4.5 (1.3-7.7)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Cow’s milk substitutes only2.2 (0.9-3.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.5 (0-3.5)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.6 (0-3.3)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      6.4 (1.8-11.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Unsweetened cow’s milk substitute2.2 (0.9-3.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.2 (0-0.6)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.3 (0-1.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.3 (0-1.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Sweetened cow’s milk substituteNone reported1.3 (0-3.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      1.2 (0-2.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      3.6 (0-7.4)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Secondary milk type, combinationNone reportedNone reportedNone reported2.5 (0-4.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      Primary milk type, combination12.3 (7.0-17.6)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      24.8 (18.2-31.4)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      8 (4.7-11.3)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      8.6 (5.0-12.3)
      Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.
      No milk reported1.5 (0-2.9)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      0.9 (0-2.0)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      5 (2.9-7.1)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      4.9 (1.9-7.8)
      Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      a Primary milk type categories were constructed based on What We Eat in America sub-major food categories,
      What We Eat in America Food Categories 2017-2018. US Department of Agriculture, Agricultural Research Service
      secondary milk type categories were classified according to product characteristics, and tertiary milk type categories were constructed based on protein form. See Methods section for details. Primary milk type categories sum to 100% within each age group (column). Secondary milk type categories further describe each primary milk type category and sum to the primary milk type category within each age group (column). Tertiary milk type categories further describe each secondary milk type category and sum to the secondary milk type category within age group (column).
      b Cumulative percent within each column may not add to 100% due to rounding.
      c Estimate may be statistically unreliable because the nominal or effective sample size is <30.
      d Estimate may be statistically unreliable because the relative CI width is >130% of the proportion.

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      Biography

      J. E. Decker is a doctoral candidate, Department of Behavioral Health and Nutrition, University of Delaware, Newark.
      M. T. Delahanty is a research associate, Department of Behavioral Health and Nutrition, University of Delaware, Newark.
      A. Davey is a professor, Department of Behavioral Health and Nutrition, University of Delaware, Newark.
      S. M. Robson is an associate professor, Department of Behavioral Health and Nutrition, University of Delaware, Newark.
      J. C. Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, University of Delaware, Newark.