Vegan and Vegetarian Children
By Whitney English Tabaie, MS, RDN
Today’s Dietitian
Vol. 24 No. 8 P. 34
Expert Strategies for Meeting Their Needs
As concerns increase about climate change, chronic disease risk, and the growing global population, more people are choosing to follow plant-based diets.1 A 2022 survey found that the number of US adults following vegan or vegetarian diets has risen to about 10% of the population, double the estimated percentage from 2017.2,3 This increase appears to be primarily driven by young adults. A survey of US consumers found that millennials were more than twice as likely to follow a vegan or vegetarian diet compared with older adults.4 While data in the United States is sparse, it’s likely that adults choosing plant-based diets also will choose to raise their children the same way.
“More health professionals and people have become aware of the benefits of exclusively and mainly plant-based diets for all ages and stages of life,” says James Marin, RD, EN, an integrative dietitian and environmental nutritionist who specializes in using whole plant foods as a form of MNT, and cofounder of Married to Health, an integrative dietetics practice in Newport Beach, California. “This has led to an increase in parents being curious about, and experimenting with, vegan and vegetarian diets for their little ones.”
A 2010 poll from the Vegetarian Resource Group found that about 3% of US youth aged 8 to 18 were vegetarian, and about 2% considered themselves vegan, which paralleled rates in adults the same year.5 A more recent study in Italy found that 9.2% of families were feeding their infants a vegan or vegetarian diet.6
The trend toward plant-based eating patterns has a few core drivers: human health, planetary health, and animal welfare. A 2022 position paper from the American Academy of Pediatrics (AAP) addresses the connection between the first two factors, stating that “promoting consumption of plant-based proteins helps reduce carbon emissions and promotes health.”7 Similarly, a recent report from the World Health Organization states, “Plant-based diets have the potential not only to improve human health but also to reduce the environmental impacts associated with high consumption of animal-sourced foods. … Plant foods, such as fruits and vegetables, grains, legumes, and nuts and seeds, produce lower greenhouse gas emissions than that of animal foods.”8
Unlike the terms vegan (a diet excluding all meat, poultry, seafood, and animal products) and vegetarian (excluding meat, poultry, and seafood but may include dairy or eggs), plant-based has no universal definition. Some use it interchangeably with the term vegan, while others use it more liberally to refer to any diet rooted in plants. In this article, the term plant-based is used to refer to vegan and vegetarian diets.
Support for Plant-Based Children’s Diets
Numerous global health organizations, including the AAP, the Academy of Nutrition and Dietetics (the Academy), and the Canadian Paediatric Society, support plant-based diets for children.9-11 A 2016 position paper from the Academy on vegetarian diets states: “Appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits for the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle.” For the first time, the 2020–2025 Dietary Guidelines for Americans included a vegetarian eating pattern for children aged 12 to 23 months in their recommendations.12 Still, there’s been debate on whether children who eat vegan and vegetarian diets grow and develop as healthfully as omnivores. Due to a lower content of some vitamins and minerals, concerns have been raised about the nutritional adequacy of these eating patterns, especially during periods of rapid growth such as pregnancy, lactation, and early childhood.13 One study reported that 77.4% of vegetarian and vegan parents met opposition from their pediatricians, and 45.2% felt their pediatricians couldn’t provide adequate nutrition information during the weaning period.14 Fortunately, data suggest that with proper planning, plant-based diets are safe and potentially beneficial for children.
Children’s Growth
Recent studies looking at the anthropometrics of children following plant-based diets show they achieve normal growth, though typically weigh slightly less on average compared with omnivores.15 The recent VeChi Diet Study of 430 vegan, vegetarian, and omnivorous children aged 1 to 3 showed that median weight-for-height, height-forage, and weight-for-age didn’t differ significantly among the diet groups. All groups fell in the normal range for growth though a higher percentage of omnivores were classified as overweight or at possible risk of being overweight (23% vs 18%), and stunting occurred only in vegan and vegetarian children (4% and 2%).15
Nutrient Status of Plant-Based Kids
Children who eat plant-based diets typically meet or exceed the recommended intake for many nutrients, with a few exceptions that can be avoided with proper supplementation. Similar to omnivores, most children following plant-based diets exceed daily protein requirements. In the VeChi Diet Study, both vegan and vegetarian children consumed more than twice the German reference value for protein.15 Similarly, the 2021 VeChi Youth Study of vegan and vegetarian children and adolescents aged 6 to 18 found that protein intake exceeded recommendations for all dietary groups.16
Fat intake has been shown to be adequate in well-planned plant-based diets and described as advantageous due to a high intake of mono- and polyunsaturated fats and a low intake of saturated fat and cholesterol.15,17,19 This may translate to a more favorable cardiometabolic profile, as seen in one recent study of children aged 5 to 10. In this cross-sectional study, vegan children were found to have lower total cholesterol, LDL cholesterol, and hs-CRP compared with omnivores. However, their HDL cholesterol also was found to be lower.17 One exception is intake of the long-chain omega-3 fatty acids EPA and DHA, which are critical for early development; EPA and DHA have been shown to be low in children following plant-based diets. While humans can convert the essential fatty acid alphalinolenic acid (ALA) to EPA and DHA, the conversion rate is low. Studies estimate only about 5% to 10% of ALA is converted to EPA, and 2% to 5% is converted to DHA.35 Since these fatty acids are present only in animal-based foods, supplementation is recommended for pregnant and lactating women and should be considered for children eating plant-based diets.
Furthermore, children who eat plant-based diets typically consume a larger portion of calories from carbohydrates and also have an increased intake of dietary fiber.15,17,18,19 Since 95% of children are failing to meet fiber recommendations, plant-based diets can be viewed as a benefit.18
Regarding other nutrients, children following plant-based diets typically meet their needs and have a higher intake of vitamin C, vitamin E, vitamin B1, folate, zinc, iron, and magnesium, compared with omnivorous children. Without supplementation and fortified food consumption, children on plant-based diets typically have a lower intake of iodine, calcium, vitamin B2, vitamin B12, and vitamin D, as these nutrients are found mainly or exclusively in animal foods.19
Nutrients of Concern
While macronutrient needs generally are easy to meet for children following plant-based diets, a few micronutrients require special attention, such as vitamin B12, vitamin D, iodine, iron and zinc, and calcium, depending on fortified-food intake and sun exposure, says Alexandra Caspero, MS, RD, author of The Plant-Based Baby & Toddler: Your Complete Feeding Guide for the First 3 Years.
B12
B12 is made exclusively by bacteria and can be reliably obtained only from animal-based and fortified foods. Plants neither use nor store B12.20 Plant-based eaters who don’t supplement with B12 are at an increased risk of deficiency.22 However, with supplementation, plant-based children can meet their needs. In the VeChi Diet Study, 97% of vegan children aged 1 to 3 received B12 supplements, and this group exceeded both the RDA and the intake of omnivores.20
While vegetarians and semivegetarians consume B12-containing foods, such as milk and eggs, often it’s not sufficient to meet needs. One review found that deficiency rates among vegans and vegetarians ranged from 17% to 39% for pregnant women, 45% for infants, and 0% to 33% for children and adolescents.21 Because fortification practices are inconsistent and intake varies from day to day, it’s recommended that all plant-based eaters supplement with B12.
B12 absorption decreases with increasing doses, and amounts higher than the RDA are required to absorb enough B12 from a single daily dose.22 B12 can be added as a liquid drop to children’s water or milk or consumed as part of a daily multivitamin.
Some sources claim that plants such as seaweed, algae, and fermented foods contain B12; however, these foods contain inactive analogs of the vitamin that aren’t biologically active in the human body.23
Vitamin D
Primary sources of vitamin D include fortified cow’s milk, fatty fish, and sunlight. While some studies have shown higher rates of suboptimal vitamin D intake in plant-based children, vitamin D status is a concern for all children. According to a study from the AAP, cases of suboptimal intake have risen 15-fold in children from 2008 to 2014.24
Per AAP guidelines, all breastfed babies should receive 400 IU of vitamin D daily starting shortly after birth until they’re consuming enough through dietary sources. The RDA for children 1 year and older is 600 IU per day. Children eating plant-based diets can ensure continued adequate intake through fortified foods, including fortified plant milk (or cow’s milk for vegetarians), and supplements. Vitamin D3, sourced from lichen, is recommended for plant-based diets as it may have higher bioavailability compared with D2.25
Iodine
Iodine is essential for the functioning of the brain and thyroid, and deficiency is the most common cause of acquired hypothyroidism and mental impairment in infants.26
The main dietary sources of iodine are dairy, seafood, and iodized salt. Due to increased use of non-iodized salt and its low content in plant foods, vegan and vegetarian children may be at a higher risk of suboptimal intake.27
Sea vegetables contain iodine; however, the amount varies widely depending on the species and country of origin, and some species, such as kombu, may exceed the upper tolerable intake level for children.28
While vegetarian children may be able to meet iodine needs through dairy and eggs, it’s recommended that vegan children supplement. The use of iodized salt in home cooking can provide an additional source.
Iron and Zinc
Iron and zinc intake tend to be adequate in children on plant-based diets. However, the bioavailability of these nutrients from plant foods is lower than that of animal products, and some research has shown an increased risk of iron deficiency in children who eat plant-based diets.29,30 “Vegans tend to consume the same or more iron than their omnivorous peers, but may have a lower iron status because of the difference in bioavailability of heme vs non heme sources,” Caspero says. However, with a little planning and strategies to maximize absorption, children who eat plant-based diets can meet their iron and zinc requirements.
Iron and zinc are found in similar plant foods, including whole grains, legumes, nuts, and seeds. Individuals can increase absorption of these nutrients through preparation methods such as sprouting, soaking, and fermentation.31 For example, beans and seeds can be soaked before cooking, and grains can be sprouted to improve bioavailability. Though these techniques may be too labor-intensive for most parents, many sprouted or fermented store-bought products are available. In addition, iron absorption is increased three to six times with the addition of vitamin C. Practitioners should remind parents to pair these nutrients together. Easy, natural food pairings may include oatmeal and strawberries, beans and bell peppers, or tofu and marinara sauce.
Moreover, iron-fortified foods such as oat-based baby cereal should be recommended for all breast-fed children during weaning (6 to 12 months) to meet high demands during this period.32 Such foods can be paired with vitamin-C-rich fruits or fruit puree to maximize iron absorption.
Calcium
Dairy is the main source of calcium for most children, but a common concern is whether kids who eat plant-based diets can meet their needs without it. Many studies have found that children following plant-based diets, particularly vegans, have suboptimal calcium intake.32
Fortunately, many plants are excellent sources of calcium and have a high bioavailability. Calcium from cruciferous vegetables such as broccoli and Brussels sprouts is absorbed at about twice the rate of cow’s milk, and calcium from fortified foods is absorbed at the same rate.33
Fortified products such as plant milks are a good option for meeting needs, especially for young children who may not regularly consume the richest whole foods sources. Providing calcium-rich plant foods along with two to three servings of fortified soy or pea milk daily can help children meet their needs.
Recommendations for RDs
As mentioned, many health practitioners aren’t well versed in the needs of children following vegan and vegetarian dietary patterns. Therefore, dietitians play an essential role in ensuring that children receive appropriately planned diets. “Educating parents on food synergy, label reading, and the importance of energy-sustaining, appropriate whole plant foods helps set the foundation for well-nourished vegan and vegetarian kids,” Marin says.
Dietitians can help ensure nutritional adequacy by educating families on how to properly balance the plate by including sources of fat, protein, and fiber at all meals and snacks. “Give examples for each nutrient to parents to help them see the application of how to obtain them,” says Amy Kimberlain, RDN, CDCES, media spokesperson for the Academy. Beans and soy often are considered the best sources of plant-based protein, but grains, nuts, and seeds also contain large amounts. Varying protein sources will ensure that requirements for individual amino acids are met, though specifically pairing protein sources at meals is unnecessary when overall caloric and protein needs are satisfied.35 Since plants typically are lower in fat than animal foods, dietitians can help ensure proper intake by educating clients on sources and how to include them, such as cooking foods in oils and regularly including nuts, seeds, nut butters, and avocado in addition to dairy and eggs for vegetarian families.
Combating misinformation within the plant-based community also may be necessary. Whole foods and low-fat diets, which are popular among adults, aren’t appropriate for children whose fat needs range from 30% to 40% of calories from ages 1 to 3 and 25% to 35% from ages 4 to 18. Moreover, some groups minimize the need for fortified foods and supplements. Dietitians should inform parents that they’re a necessity to meet dietary needs.
Finally, it’s important that dietitians understand a family’s reasons for their dietary choices, including cultural or ethical considerations, and assess any barriers. Some families follow plant-based diets for religious reasons, whereas health may be the primary concern for other families. If, for example, the diet needs to be liberalized in the case of food allergies, these differences in dietary drivers may dictate what foods the family will agree to include. “Always ask questions when counseling,” Kimberlain says. “I never assume I know how something is made. I ask the questions to make sure I’m speaking to their customs, traditions, and cultural foods.”
Despite the low cost of plant foods, access and availability may be a barrier to properly implementing plant-based diets for some families. Dietitians can provide tips to minimize costs, such as making use of bulk bins for staple items such as grains, legumes, nuts, and seeds and making homemade versions of more high-cost specialty items such as plant-based cream cheese or alternative meats. RDs also should be aware of the plant-based options government assistance programs offer. “The WIC program provides plant-based options like dry legumes, whole grains, nut butters, plant milks, fruits, and vegetables,” Marin says. It also can be helpful to remind parents that all produce is beneficial. “All forms of fruits and vegetables count, and frozen fruit and vegetables can be more economical than fresh,” Caspero says.
— Whitney English Tabaie, MS, RDN, is an author, educator, and nutrition advocate. She’s the co-owner of Plant-Based Juniors, a media company dedicated to helping families get more plants on the plate, and creator of the website and social media channels, Whitney E RD. She’s also the coauthor of the bestselling book, The Plant-Based Baby & Toddler.
References
1. EAT-Lancet Commission summary report. EAT Forum website. https://eatforum.org/eat-lancet-commission/eat-lancet-commission-summary-report/
2. Meat Demand Monitor – January 2022. AgManager website. https://agmanager.info/livestock-meat/meat-demand/monthly-meat-demand-monitor-survey-data/meat-demand-monitor-january-2022. Published January 2022.
3. Lusk JL, Norwood FB. Some vegetarians spend less money on food, others don’t. Ecological Economics. 2016;130:232-242.
4. Share of consumers who consider themselves vegan or vegetarian in the United States as of June 2018, by age group. Statista website. https://www.statista.com/statistics/738851/vegan-vegetarian-consumers-us/. Published January 27, 2022.
5. How many youth are vegetarian? The Vegetarian Resource Group website. https://www.vrg.org/press/youth_poll_2010.php. Published February 24, 2010.
6. Baldassarre ME, Panza R, Farella I, et al. Vegetarian and vegan weaning of the infant: how common and how evidence-based? A population-based survey and narrative review. Int J Environ Res and Public Health. 2020;17(13):4835.
7. Paulson JA, Ahdoot S, Baum CR, et al. Global climate change and children’s health. Pediatrics. 2015;136(5):992-997.
8. World Health Organization. Plant-based diets and their impact on health, sustainability and the environment: a review of the evidence. https://apps.who.int/iris/bitstream/handle/10665/349086/WHO-EURO-2021-4007-43766-61591-eng.pdf?sequence=1&isAllowed=y. Published 2021.
9. Plant-based diets: are they good for kids? Healthy Children website. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Plant-Based-Diets.aspx. Updated June 2, 2020.
10. Vegetarian diets for children and teens. Caring for Kids website. https://caringforkids.cps.ca/handouts/healthy-living/vegetarian_diets_for_children_and_teens. Updated January 2017.
11. Melina V, Craig W, Levin S. Position of the Academy of Nutrition and Dietetics: vegetarian diets. J Acad Nutr Diet. 2016;116(12):1970–1980
12. U.S. Department of Agriculture; U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf. Accessed July 13, 2022.
13. Schürmann S, Kersting M, Alexy U. Vegetarian diets in children: a systematic review. Eur J Nutr. 2017;56(5):1797-1817.
14. Baldassarre ME, Panza R, Farella I, et al. Vegetarian and vegan weaning of the infant: how common and how evidence-based? A population-based survey and narrative review. Int J Environ Res Public Health. 2020;17(13):4835.
15. Weder S, Hoffmann M, Becker K, Alexy U, Keller M. Energy, macronutrient intake, and anthropometrics of vegetarian, vegan, and omnivorous children (1-3 years) in Germany (VeChi Diet Study). Nutrients. 2019;11(4):832.
16. Alexy U, Fischer M, Weder S, Längler A, Michalsen A, Keller M. Food group intake of children and adolescents (6-18 years) on a vegetarian, vegan, or omnivore diet: results of the VeChi Youth Study. Br J Nutr. 2021;1-12.
17. Desmond MA, Sobiecki JG, Jaworski M, et al. Growth, body composition, and cardiovascular and nutritional risk of 5- to 10-y-old children consuming vegetarian, vegan, or omnivore diets. Am J Clin Nutr. 2021;113(6):1565-1577.
18. US Department of Agriculture; Agricultural Research Service. What We Eat in America: Nutrient intakes from food by gender and age. National Health and Nutrition Examination Survey (NHANES) 2009-2010. http://www.ars.usda.gov/Sp2userfiles/Place/12355000/Pdf/0910/Table_1_Nin_ Gen_09.Pdf. Accessed July 18, 2022.
19. Weder S, Keller M, Fischer M, Becker K, Alexy U. Intake of micronutrients and fatty acids of vegetarian, vegan, and omnivorous children (1–3 years) in Germany (VeChi Diet Study). Eur J Nutr. 2022;61(3):1507-1520.
20. Kennedy KJ, Taga ME. Cobamides. Curr Biol. 2020;30(2):R55-R56.
21. Pawlak R, Lester SE, Babatunde T. The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature. Eur J Clin Nutr. 2014;68(5):541-548.
22. Baroni L, Goggi S, Battaglino R, et al. Vegan nutrition for mothers and children: practical tools for healthcare providers. Nutrients. 2018;11(1):5.
23. Watanabe F. Vitamin B12 sources and bioavailability. Exp Biol Med (Maywood). 2007;232(10):1266-1274.
24. Basatemur E, Horsfall L, Marston L, Rait G, Sutcliffe A. Trends in the diagnosis of vitamin D deficiency. Pediatrics. 2017;139(3):e20162748.
25. Cardwell G, Bornman JF, James AP, Black LJ. A review of mushrooms as a potential source of dietary vitamin D. Nutrients. 2018;10(10):1498.
26. World Health Organization. Nutrition: effects of iodine deficiency. https://www.who.int/news-room/questions-and-answers/item/nutrition-effects-of-iodine-deficiency. Published May 24, 2013.
27. Yeliosof O, Silverman LA. Veganism as a cause of iodine deficient hypothyroidism. J Pediatr Endocrinol Metab. 2018;31(1):91-94.
28. Yeh TS, Hung NH, Lin TC. Analysis of iodine content in seaweed by GC-ECD and estimation of iodine intake. Journal of Food and Drug Analysis. 2014;22(2):189-196.
29. Monsen ER. Iron nutrition and absorption: dietary factors which impact iron bioavailability. J Am Diet Assoc. 1988;88(7):786-790.
30. Pawlak R, Bell K. Iron status of vegetarian children: a review of literature. Ann Nutr Metab. 2017;70(2):88-99.
31. Luo Y, Xie W. Effect of soaking and sprouting on iron and zinc availability in green and white faba bean (Vicia faba L.). J Food Sci Technol. 2014;51(12):3970-3976.
32. Müller P. Vegan diet in young children. Nestle Nutr Inst Workshop Ser. 2020;93:103-110.
33. Overview of calcium. In: Ross AC, Taylor CL, Yaktine AL, Del Valle HB, eds. Dietary Reference Intakes for Calcium and Vitamin D. Washington, D.C.: National Academies Press; 2011:35-74. https://www.nap.edu/read/13050/chapter/4.
34. Young VR, Pellett PL. Plant proteins in relation to human protein and amino acid nutrition. Am J Clin Nutr. 1994;59(5 Suppl):1203S-1212S.
35. Davis BC, Kris-Etherton PM. Achieving optimal essential fatty acid status in vegetarians: current knowledge and practical implications. Am J Clin Nutr. 2003;78(3 Suppl):640S-646S.