Front-of-Package Nutrition Labelling for Child-Targeted Foods: A Systematic Review of Caregiver-Mediated Decision Outcomes and Evidence Certainty

Introduction: Front-of-package nutrition labelling (FOPL) aims to support healthier food choices, but its effectiveness for foods and beverages marketed to children remains uncertain because purchasing and feeding decisions are largely caregiver-mediated.

Methods: This systematic review followed PRISMA 2020 and a registered protocol (PROSPERO CRD420251117263). Five databases and BASE were searched to 31 July 2025. Eligible studies assessed interpretive or non-interpretive FOPL for packaged foods/beverages marketed to or selected for children aged 0-12 years and/or caregivers. Risk of bias was appraised with JBI tools; certainty was assessed using GRADE and GRADE-CERQual. Because of heterogeneity, findings were synthesized narratively and by direction of effect.

Results and Discussion: Thirty-nine studies were included: 18 RCTs, 5 quasi-experimental, 6 cross-sectional and 10 qualitative studies. Evidence was most consistent for perceived healthfulness and intention-related outcomes. In FOPL versus no-label comparisons, all classifiable effects favoured FOPL for product purchase (6/6), product selection (11/11), perceived healthfulness (14/14), purchase intention (4/4), intention to serve/consume (5/5), label attention (2/2) and comprehension (1/1), whereas nutritional-profile outcomes were less consistent (7/9). Warning labels showed the clearest pattern, particularly for discouraging selection or intended purchase of less healthy products. Comparisons between label formats suggested advantages for more interpretive or warning-based formats, but heterogeneity limited claims of universal superiority. Educational components tended to favour FOPL conditions, although certainty was very low. Qualitative evidence indicated that FOPL can act as a simple heuristic for caregivers but is shaped by comprehension, price, time constraints and marketing cues.

Conclusions: FOPL may support early stages of caregiver-mediated food-choice pathways, especially healthfulness judgement and purchase intention, but sustained nutritional impact remains uncertain. Child-relevant labelling policies should prioritize interpretive clarity, contextual fit and real-world longitudinal evaluation.

Acknowledgments: This work was supported by IJUP Empresas and SONAE MC (BABY-SCORE, IJUP-SONAE MC-1-2) and by FCT/MECI national funds (UID/50006/2025; 10.54499/UID/50006/2025). RC acknowledges FCT support (2022.00965.CEECIND). FS acknowledges funding from FODMAPS (COMPETE2030-FEDER-0901300; 15338 (SGO).