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Excessive Fruit Juice Consumption Alone in Two Year-Old Children Is Not Proven To Cause Failure to Thrive

Question

  • Children with failure to thrive are occasionally found to be drinking excessive quantities of fruit juice.  Does excessive fruit juice consumption in normally growing two year-olds cause poor growth?

Clinical Bottom Lines

  1. Failure to thrive in the pediatric population is unusual.
  2. The body of literature addressing fruit juice consumption and children's growth consists of three articles, none of which are randomized controlled trials.
  3. In two year-old children who drink greater than 12 ounces per day of 100% fruit juice compared to those who drink less than this amount per day, there is no significant difference in body mass index (BMI) or ponderal index (PI).
  4. In children with failure to thrive, asking about fruit juice consumption may be a simple screen for aberrant dietary habits, suggesting a nutritional component to the failure to thrive.
  5. In children without failure to thrive, excessive fruit juice consumption does not appear to have a dramatically adverse effect on growth; therefore efforts surrounding nutrition during the limited time provided for a well-child check may be better focused on another aspect of diet. 


Summary of Key Evidence

  1. In the first study, feeding histories, weight, length, head circumference, and anthropometric measurements of 8 children ages 14 to 27 months referred for FTT with negative H & P and lab work-up, all of whom consumed more than 12 ounces per day of juice, were gathered.  Growth parameters were followed before and after juice intake was restricted.  Follow-up data was available for 7 of the 8 patients. Mean weight gain increased from 0.08 +/- 0.05 kg/month before intervention to 0.36 +/- 0.16 kg/month after restricting juice (p< .05).1
  2. The second study was a cohort study in which dietary records, height, weight, BMI, and ponderal indexes of 94 two year-olds presenting for well child checks were gathered.  The children who drank greater than 12 oz/day of juice more often had height < 20th percentile for age (47% v. 14%) and were significantly shorter  (86.5 +/- 0.9 cm v. 89.3 +/- 0.4 cm (p < 0.003). There was no statistical difference in the BMI's 17.1 +/- 0.3 kg/m2 v. 16.7 +/- 0.1 kg/m2.  The ponderal indexes had a borderline significant difference (19.9 +/- 0.5 kg/m3 v. 18.7 +/- 0.2 kg/m3) (p < 0.02).2
  3. The relative risk for greater than 12 oz/day juice intake causing a height < 20th percentile is 3.35.  This is an absolute risk of 33%.  The number needed to harm is 3.  In other words, 3 children would have to drink more than 12 oz per day of juice for one child to have a height less than the 20th percentile.  However, statistically 1 in 5 children would be expected to fall in this range.
  4. The last study was a cohort study, and gathered data on 105 children, ages 24 to 36 months, who were interviewed for diet history, height, weight, BMI, and ponderal index.  There was no significant difference in any of the above growth parameters between the children who drank more than 12 oz/day of juice and those who drank less.3

Additional Comments

  • Neither of the large studies assessed growth velocity (i.e., growth rate over time).  Both studies defined poor growth as a height less than the 20th percentile.  This is not an accurate measure of poor growth, and therefore it is difficult to assess the results from either study.

  • All of the studies provided extensive dietary counseling which was not limited to only fruit juice intake.  It is therefore difficult to assess the pure impact of limiting fruit juice on growth.

  • The studies do not satisfy the "diagnostic tests for causation."  Specifically, it is unclear that the "poor growth" did not precede the onset of excessive juice intake.  There is no evidence from a dechallenge - rechallenge study.  It is unclear if there is a dose-response gradient.  The findings in the studies do not always make biological sense.  Also, the results are not consistent from study to study.

Citation

  1. Smith MM and Lifshitz F.  Excess fruit juice consumption as a contributing factor in nonorganic failure to thrive.  Pediatrics 1994; 93(3):438-43.
  2. Dennison BA, et al.  Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity.  Pediatrics 1997; 99(1): 15-22.
  3.  Skinner JD, et al. Fruit juice intake is not related to children’s growth.  Pediatrics 1999; 103(1):58-64.

CAT Author: Julie Lumeng, MD

CAT Appraisers: John Frohna, MD

Date appraised: October 19, 1999

Last updated June 15, 2003
Department of Pediatrics and Communicable Diseases
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