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The Use of Nonnutritive Sweeteners in Children Carissa M

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The Use of Nonnutritive Sweeteners in Children Carissa M POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children The Use of Nonnutritive Sweeteners in Children Carissa M. Baker-Smith, MD, MPH, FAAP,a Sarah D. de Ferranti, MD, MPH, FAAP,b William J. Cochran, MD, FAAP,c COMMITTEE ON NUTRITION, SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION The prevalence of nonnutritive sweeteners (NNSs) in the food supply has abstract increased over time. Not only are more children and adolescents consuming NNSs, but they are also consuming a larger quantity of NNSs in the absence of strong scientific evidence to refute or support the safety of these agents. This aSchool of Medicine, University of Maryland, Baltimore, Maryland; bBoston Children’s Hospital, Boston, Massachusetts; and cGeisinger policy statement from the American Academy of Pediatrics is intended to Medical Center, Danville, Pennsylvania provide the pediatric provider with a review of (1) previous steps taken for Dr Baker-Smith is the primary author and drafted this policy approved use of NNSs, (2) existing data regarding the safety of NNS use in the statement, conducted the literature search and literature review, general pediatric population, (3) what is known regarding the potential created the evidence table used to support the content of this policy statement, and assisted with final revisions and review of the benefits and/or adverse effects of NNS use in children and adolescents, (4) document; Dr de Ferranti reviewed the literature, assisted with the identified gaps in existing knowledge and potential areas of future research, drafting and editing of the policy statement, and conducted final revisions and review; Dr Cochran assisted with literature review, and (5) suggested talking points that pediatricians may use when discussing contributed to the creation of the evidence table used to support the content of this policy statement, and assisted with the final review of NNS use with families the document; and all authors approved the final version of the manuscript as submitted. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and INTRODUCTION external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the Nonnutritive sweeteners (NNSs), also known as noncaloric artificial organizations or government agencies that they represent. sweeteners or high-intensity sweeteners, were first introduced into the This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed food supply in the late 1800s (eg, saccharin) and were first approved for conflict of interest statements with the American Academy of use as a food additive under the Food Additives Amendment of the Federal Pediatrics. Any conflicts have been resolved through a process 1,2 approved by the Board of Directors. The American Academy of Food, Drug, and Cosmetic Act of 1958. NNSs increase the palatability of Pediatrics has neither solicited nor accepted any commercial food and beverages without increasing caloric content. It has been involvement in the development of the content of this publication. proposed that the lack of caloric content of the sweeteners may contribute The guidance in this statement does not indicate an exclusive course to weight loss. To date, however, there has been no consistent or of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. conclusive evidence that NNS use lends to a reduction in total caloric 3–8 All policy statements from the American Academy of Pediatrics intake and thereby to weight loss in humans or in animal physiology automatically expire 5 years after publication unless reaffirmed, 9 models. Questions regarding the long-term safety of these agents also revised, or retired at or before that time. 3 remain. Most NNSs, including saccharin, aspartame, acesulfame DOI: https://doi.org/10.1542/peds.2019-2765 potassium, sucralose, and neotame, have been approved by the US Food and Drug Administration (FDA) for use as food additives and, as such, To cite: Baker-Smith CM, de Ferranti SD, Cochran WJ, AAP have undergone premarket review and approval (https://www.fda.gov/ COMMITTEE ON NUTRITION, SECTION ON GASTROENTEROLOGY, food/food-ingredients-packaging/overview-food-ingredients-additives- HEPATOLOGY, AND NUTRITION. The Use of Nonnutritive colors). Other agents such as stevia and luo han guo have been approved Sweeteners in Children. Pediatrics. 2019;144(5):e20192765 Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 144, number 5, November 2019:e20192765 FROM THE AMERICAN ACADEMY OF PEDIATRICS by the FDA under the “generally conclusively demonstrating the long- who do not believe that they have recognized as safe” (GRAS) term safety and efficacy of NNS been exposed to NNSs have distinction, a distinction that has been agents are lacking.3,26 Also lacking is detectable levels of NNS in their determined to be insufficient for published evidence of parental urine.32,33 ensuring the safety of food additives confidence in the safety of NNSs. Estimates of consumption are largely without specific protections against Despite FDA assurances, published based on dietary recall12,29,30,34,35; conflict of interest and without data reveal that parents continue to however, such studies are fraught mechanisms to ensure ongoing have questions about the safety of with inaccuracies and thus may result acquisition of safety data.10,11 NNSs. For instance, in a single-site in underestimates of true intake.29 study, only 16% of parents responded Ideally, intake of NNS remains within Concerns regarding the safety of in the affirmative to the statement, the ADI level. Studies from the late NNSs were initially related to their “Nonnutritive sweeteners (ie, 1990s and early 2000s, including potential carcinogenic effects. Splenda, Sweet‘N Low, and Equal) are fi studies in children, had suggested Cyclamate, rst approved for use in safe for my child to use.”27 Knowledge 1958, was later removed from the list that intake of intense sweeteners was of how to identify products – substantially below the ADI.34 36 of approved food additives in 1969 containing NNSs remains poor Contemporary data addressing total because of concerns regarding an because only 23% of parents were daily intake of NNS in adults and association between cyclamate use able to correctly identify food children are limited. According to and the development of bladder products that contain NNSs. In fact, 1,2,10,12 select studies, intake of particular cancer. The relationship 53% of parents stated they seek NNSs (eg, acesulfame potassium or between cyclamate and cancer was items labeled “reduced sugar,” but cyclamate) may exceed the ADI.37 later refuted on the basis of most did not recognize that the sweet fi Historically, carbonated beverages additional scienti c data in rats, mice, taste was instead being provided by have contributed the greatest dogs, hamsters, and monkeys. an NNS,27 and only one-quarter of milligram dosage to total daily intake youth were able to distinguish the Cyclamate was not the only NNS of NNS (eg, saccharin).12,38 However, taste of NNS from sucrose.28 initially suspected of an associated there is a growing and widening cancer risk. Beginning in the 1970s Estimating total content of NNS in variety of food, drink, and consumer and 1980s, animal studies suggested manufactured products has been products that contain NNSs (eg, an association between saccharin challenging. Manufactured products chewing gum, oral rehydration intake and the development of 10 containing NNSs are not required to solutions, mouthwash, etc; Table 1). bladder cancer in rodents.3,13,14 This specify the content of NNS in Therefore, estimates of intake would association was later refuted because fi a product. However, the consumption be dif cult to capture given current it was determined that the “cancer- methods of reporting. of NNSs among children has causing mechanisms in rodents are increased.29,30 The long-term safety not applicable to humans.”3,14 Ongoing questions also exist or potential benefit of the growing fi Furthermore, human studies regarding the bene ts of NNSs. Added prevalence of NNS use in children has evaluating the relationship between sugars are known to have detrimental not been systematically reviewed.31 39,40 saccharin intake and stomach, effects, including an association One barrier to better understanding pancreatic, and endometrial cancer between sugar intake and increased the health effects of NNS is the have not identified a relationship body mass, dyslipidemia, and blood difficulty inherent in measuring the 40 between the consumption of pressure. Recommendations to saccharin and cancer.2,3,15,16 Overall, amount of NNS consumed at the promote cardiovascular health in it appears that science does not individual and population levels. The children include limiting the total support a potential carcinogenic FDA designation of a food item as an intake of sugar-sweetened beverages effect of cyclamate, saccharin, or additive or GRAS means that although (SSBs) to 4 to 6 oz per day in children sucralose in humans.3,17–19 The manufacturers must report that 1 to 6 years of age and limiting the a particular product contains total intake of SSBs to 8 to 12 oz per relationship between aspartame and 41 the development of attention-deficit a sweetener, there is no obligation to day in children 7 to 18 years of age. state the amount of sweetener NNSs have been considered for use disorders, birth defects, diabetes, and 1 lupus has also been refuted.3 a product contains, making it among those aiming to reduce their difficult to estimate how much NNS total SSB intake while still preserving A number of health organizations the average American consumes per the sweet taste.
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