[2][3] Outside of Italy, cream is sometimes used to thicken the sauce, and ingredients such as chicken, shrimp, salmon or broccoli may also be added when it is served as a main course.

[2] In Italy, the combination of pasta with butter and cheese dates to at least the 15th century, when it was mentioned by Martino da Como, a northern Italian cook active in Rome;[13] this recipe for "Roman macaroni" (Italian: maccaroni romaneschi) calls for cooking pasta in broth or water and adding butter, "good cheese" (the variety is not specified) and "sweet spices".

Et dapoi caccia fore il bastone, et tagliala la pasta larga un dito piccolo, et resterà in modo de bindelle, overo stringhe.

According to family lore, in 1892 Alfredo began to work in a restaurant located in Piazza Rosa that was run by his mother Angelina.

[23][18][1][2] Di Lelio's fame and success grew (he was knighted by the King of Italy, making him a Cavaliere dell'Ordine della Corona d'Italia) until war rationing made it increasingly difficult to obtain flour, eggs, and butter.

[27][3] He vigorously promoted the restaurant by creating a celebrity wall of fettuccine themed photographs showing himself (in humorous poses, with his pasta and gold cutlery) serving dignitaries, politicians, famous musicians and film stars such as James Stewart, Bob Hope, Anthony Quinn, Bing Crosby, Gary Cooper, Jack Lemmon, Ava Gardner, Tyrone Power, Sophia Loren, Cantinflas, and many others.

[The] owner mixes the pasta and lifts it high to serve it, the white threads of cheese gilded with butter and the bright yellow of the ribbons of egg pasta offering an eyeful for the customer; at the end of the ceremony, the guest of honor is presented the golden cutlery and the serving dish, where the blond fettuccine roll around in the pale gold of the seasonings.

The owner, son of old Alfredo and looking exactly like him [...] bends over the great skein of fettuccine, fixes it intensely, his eyes half-closed, and dives into mixing it, waving the golden cutlery with grand gestures, like an orchestra conductor, with his sinister upwards-pointing twirled moustache dancing up and down, pinkies in the air, a rapt gaze, flailing elbows.

As a violinist plays inspiring music, Alfredo performs the sacred ceremony with a fork and spoon of solid gold.

A 1925 Italian guidebook and its English translation uses "fettuccine al burro";[35][36] however, a 1927 article by Alice Rohe mentions "noodles Alfredo".

[45][46][47] The two largest full-service Italian-American restaurant chains, Olive Garden and Carrabba's Italian Grill, both serve and advertise the dish widely.

[48] A smaller chain, Il Fornaio, which says that its goal is, to "provide our guests with the most authentic Italian experience outside of Italy", does not serve fettuccine Alfredo.

Writing in Bon Appétit, the Italian-American chef Carla Lalli Music notes that "American cooks added heavy cream or half-and-half to thicken and enrich the sauce.

[29] On the other hand, the food writer Gillian Riley says that the fettuccine of Rome "hardly need Alfredo's gross sauce of butter, cream [sic], and cheese".

[53] In the United States, shelf-stable Alfredo sauce is sold by brands such as Ragú, Trader Joe's, Whole Foods Market, Bertolli, Kroger, Classico, Prego, Rao's, Newman's Own, Signature Select, and Saclà in glass jars for home cooks.

Sold in glass jars and promoted as using only the highest quality ingredients, the sauce contains Parmesan (43%), water, butter, rice flour, and sunflower seed oil—but no cream.