In her recent post about vegan diets for babies, vegan dietitian Ginny Messina wrote, “Both the Academy of Nutrition and Dietetics and the American Academy of Pediatrics say that appropriate vegan diets are safe for babies. (And in case you’re wondering, omnivore diets for babies need to be appropriate as well.)” I’m used to vegans citing the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) to establish that there’s a mainstream nutritional organization that is okay with veganism, but this is the first time I’ve seen the American Academy of Pediatrics (AAP) used in the same way. That inspired me to look into what the AAP has said about vegan diets for babies.
I emailed Debra Burrowes, who is the Manager of the Division of Technical & Medical Services for the AAP, and asked her if the AAP states that appropriate vegan diets are safe for babies. She responded, “The AAP does not have a specific policy statement on the vegan diet; however AAP’s Pediatric Nutrition Handbook, 7th edition, includes a chapter on the nutritional aspects of vegetarian diets. Some information regarding vegan diets is included within the chapter.”
Here are some excerpts from that chapter, called “Nutritional Aspects of Vegetarian Diets”. I left in the source numbers of sources that I’ll refer to:
Vegetarianism is a way of life for many individuals for various reasons. However, there can be potentially serious implications for the growing pediatric and adolescent population as a result of self-imposed or misguided limitations of the vegetarian diet. Therefore, pediatricians should proactively ask and assess the nutritional status of their vegetarian patients to ensure optimal health and growth, as well as provide anticipatory guidance to prevent any potential deficits. …
As with any dietary pattern, the degree of adherence to vegetarian patterns varies, and thus, overall nutrient intake differs from one vegetarian to the next. Most dietary patterns can be accommodated while fulfilling nutrient needs with appropriate dietary planning based on scientific principles of sound nutrition. Most vegetarian parents welcome such advice. However, when goals are zealously pursued and nutrition principles are ignored, the health consequences can be unfortunate, especially for infants and young children. Overall, it is possible to provide a balanced diet to vegetarians and vegans13. …
Position papers of the American Dietetic Association and Canadian Paediatric Society state that appropriately planned vegetarian diets are healthful, nutritionally adequate and provide health benefits in the prevention and treatment of certain diseases14,15. A vegetarian, including a vegan, diet can also meet current recommended daily requirements for protein, iron, zinc, calcium, vitamin D, riboflavin, vitamin B12, vitamin A, n-3 omega fatty acids and iodine. In some cases, use of fortified foods or supplements can be helpful in meeting recommendations for individual nutrients. Well planned vegan and other types of vegetarian diets are appropriate for all stages of the life cycle including pregnancy, lactation, infancy, childhood and adolescence. Vegetarian diets in general have lower levels of saturated fat, cholesterol and higher levels of complex carbohydrates, fiber, magnesium, Vitamin C and E14 carotenoids and phytochemicals16.
There have been concerns that vegetarians, and in particular vegans, have lower than adequate intakes of vitamin B12, vitamin D, calcium, zinc and riboflavin. A Polish study suggested that prepubertal vegetarian children had lower levels of leptin, a polypeptide which plays a role in bone growth, maturation and weight regulation, in comparison to their omnivore counterparts, which may contribute towards reduced bone growth and development in childhood. A vegan diet may also put children at risk for vitamin A deficiency and subsequent keratomalacia, anemia, protein and zinc deficiency if a proper evaluation of the diet isn’t performed and the family isn’t given appropriate information of the potential dietary deficiencies relevant to the vegetarian diet. However the overall belief that individuals following vegan or vegetarian diets suffer from nutritional deficiencies may be exaggerated, as reports of specific malnutrition in these populations are rare.
The study they cite for the line, “Overall, it is possible to provide a balanced diet to vegetarians and vegans” is C Jacobs’ and Johanna Dwyer’s 1988 paper, “Vegetarian children: appropriate and inappropriate diets” (Am J Clin Nutr, 1988; 48:811-818). Dwyer and Jacobs are friendlier toward vegetarian than vegan diets in the study, concluding:
An appropriate vegetarian diet can adequately provide for each phase of growth in the child. The nutritional needs at each stage vary. In general, it is difficult to achieve normal growth following a vegan-like diet unless care is taken to ensure that the diet is sufficient in calories, protein, vitamin B-12, vitamin D, and Fe. Well-planned lactoovo- and lactovegetarian diets for children, on the other hand, can provide adequate nutrition. Further, they may help establish healthful patterns that will continue through all the stages of life.
The third paragraph I excerpted from the AAP’s “Nutritional Aspects of Vegetarian Diets” chapter appears to be a paraphrasing of two main sources, one of them being the most recent Academy of Nutrition and Dietetics (formerly American Dietetic Association) position paper on a vegetarian diet from 2009 (source 14). The authors of that position paper are Reed Mangels, who is vegan for ethical reasons, and Winston J. Craig, a Seventh-day Adventist vegetarian who believes that God told the Seventh-day Adventist prophet Ellen G. White that a vegetarian diet was the only appropriate diet for humankind. I bring this up because vegans often cite the Academy of Nutrition and Dietetics position paper on a vegetarian diet as proof that a mainstream organization agrees with them, and I’ve never seen them mention that it’s vegans and vegetarians who write these position papers. I’ve even seen vegan dietitians cite one of these position papers to establish mainstream cred for veganism without admitting that they were one of the authors on that specific paper, or of a similar one from a previous year.
The other main source for that third paragraph I quoted from “Nutritional Aspects of Vegetarian Diets” is “Vegetarian diets in children and adolescents” by Minoli Amit of the Canadian Paediatric Society (source 15). The introduction of Amit’s paper states:
The concept that a well-balanced vegetarian diet can provide for the needs of a growing child and adolescent is supported by Canada’s Food Guide, the American Dietetic Association and Dietitians of Canada, and the American Academy of Pediatrics. There is sufficient evidence from well-developed studies to conclude that children and adolescents grow and thrive well on vegetarian diets that are well designed and supplemented appropriately.
However, certain components of these diets and some required nutrients may be in short supply and need specific attention. This is particularly true in the case of strictly vegan diets and other very restrictive diets in which significant medical consequences could result from inattention to nutrient needs. The present statement highlights some of these areas and recommends appropriate interventions.
By referencing this paper, the American Academy of Pediatrics is using the Canadian Paediatric Society as support for the claim that a well-balanced vegetarian diet can be safe – and in return, the Canadian Paediatric Society references the American Academy of Pediatrics as support for the claim that a well-balanced vegetarian diet can be safe.
The Canadian Paediatric Society paper goes on to list some concerns they have with a vegan diet, which includes that younger vegan children are at risk of not getting enough calories if they eat too many foods that have low energy density and a lot of fiber. It says that parents of vegan children need to pay special attention to DHA, B12, calcium, and Vitamin D.
The paper concludes:
Well-planned vegetarian and vegan diets with appropriate attention to specific nutrient components can provide a healthy alternative lifestyle at all stages of fetal, infant, child and adolescent growth (7,8,22). Appropriate education of the family and follow-up over time are essential. There are many useful tools and excellent guides to assist families and professionals.
The cited papers there — 7, 8 and 12 — are: the 2003 vegetarian position paper by the American Dietetic Association, which Ginny Messina, Reed Mangles, and vegan dietitian Vesanto Melina co-authored; the 6th edition of the AAP’s Pediatric Nutrition Handbook; and a paper called “Considerations in planning vegetarian diets: Children,” by Ginny Messina and Reed Mangles (J Am Diet Assoc. 2001;101:661–9).
For the most part, the rest of “Nutritional Aspects of Vegetarian Diets” looks at the various pluses and minuses of vegetarian and vegan diets as far as obtaining particular nutrients. The AAP doesn’t seem to be worried about vegan children getting enough calories, protein, fat, fiber, vitamin A, riboflavin or folic acid. They are more concerned about vegan children getting enough B12, vitamin D, calcium, iodine, zinc, iron and DHA, but they don’t think it’s impossible for vegans to get these things. They also mention carnitine and taurine commonly being low in vegetarians and vegans, but they aren’t bothered about this because they don’t know of any adverse effects this could have.
My impression from reading this chapter is that the AAP certainly wouldn’t suggest a vegan diet to anyone who doesn’t see ethical or religious reasons to be vegan, but that they also don’t believe that it’s unworkable. “Overall, it is possible to provide a balanced diet to vegetarians and vegans” seems to sum up their attitude.
However, just like not everyone at the Academy of Nutrition and Dietetics seems very accepting of a vegan diet, not everyone at the AAP appears to think that a vegan diet is a decent option for children. On page 303 of the AAP’s Caring for Your Baby and Young Child: Birth to Age Five by American Academy Of Pediatrics (Fifth edition, 2009, edited by Steven P. Shelov and Tanya Remer Altmann), it says:
For some children, however, supplementation may be important. Your child may need some vitamin and/or mineral supplementation if your family’s dietary practices limit the food groups available to her. For example, if your household is strictly vegetarian, with no eggs or dairy products (which is not a diet recommended for children), she may need supplements of vitamin B12 and D as well as riboflavin and calcium.
A post on Jack Norris RD’s blog in 2011 noted that the AAP was thinking of promoting red meat as the best first solid food to introduce to infants, quoting AAP Committee on Nutrition member Frank Greer as saying, “Red meat is the nutrient-rich food that biologically may be best as the first complementary feeding for infants.” The link Norris used is broken now, but I found a story about Greer making a similar claim in 2009, called “Rice Cereal Can Wait, Let Them Eat Meat First”.
According to the AAP paper titled “Use of Soy Protein-Based Formulas in Infant Feeding” by Jatinder Bhatia and Frank Greer, there is one definite instance in which they feel a vegan infancy may not be workable: when a prematurely born infant doesn’t have access to breast milk. They wrote,
On the other hand, soy protein-based formulas are not recommended for preterm infants. Serum phosphorus concentrations are lower, and alkaline phosphatase concentrations are higher in preterm infants fed soy protein-based formula than they are in preterm infants fed cow milk-based formula. As anticipated from these observations, the degree of osteopenia is increased in infants with low birth weight receiving soy protein-based formulas. Even with supplemental calcium and vitamin D, radiographic evidence of significant osteopenia was present in 32% of 125 preterm infants fed soy protein-based formula. The cow milk protein-based formulas designed for preterm infants are clearly superior to soy protein-based formula for preterm infants.
As Messina pointed out to me in a comment on her blog, soy protein based formula isn’t vegan either, because it contains vitamin D3 that is derived from animals. But she implied that this was a better option for vegans than cow-milk based formula, which is even less vegan.
Overall, though, “it’s not ideal, but we’ll work with it” seems to be the AAP’s unofficial implied motto in regards to vegan diets. That’s the sense I get from an article called “Vegetarian Diets for Children” on the AAP website Healthychildren.org:
If your child is following a vegetarian diet, you need to guard against nutritional deficiencies. There are various degrees of vegetarianism, and the strictness of the diet will determine whether your youngster is vulnerable to nutritional shortcomings. …
Children can be well nourished on all three types of vegetarian diet, but nutritional balance is very difficult to achieve if dairy products and eggs are completely eliminated. Vegetarians sometimes consume insufficient amounts of calcium and vitamin D if they remove milk products from their diet.
Also, because of the lack of meat products, vegetarians sometimes have an inadequate iron intake. They may also consume insufficient amounts of vitamin B-12, zinc, and other minerals. If their caloric intake is also extremely low, this could cause a delay in normal growth and weight gain.
Vegetarians may also lack adequate protein sources. As a result, you need to ensure that your child receives a good balance of essential amino acids. As a general guideline, his protein intake should come from more than one source, combining cereal products (wheat, rice) with legumes (dry beans, soybeans, peas), for example; when eaten together, they provide a higher quality mixture of amino acids than if either is consumed alone.
Other planning may be necessary. To ensure adequate levels of vitamin B-12, you might serve your child commercially prepared foods fortified with this vitamin. While calcium is present in some vegetables, your child may still need a calcium supplement if he does not consume milk and other dairy products. Alternative sources of vitamin D might also be advisable if there is no milk in the diet. Your pediatrician may recommend iron supplements, too, although your child can improve his absorption of the iron in vegetables by drinking citrus juice at mealtime.
A Zen macrobiotic diet usually presents many more problems than a vegetarian diet. With a macrobiotic program, important foods (animal products, vegetables, and fruit) are severely restricted in stages. This diet is generally not recommended for children. Youngsters who adhere to it may experience serious nutritional deficiencies that can impair growth and lead to anemia and other severe complications.
Given all this, does Ginny Messina’s claim that the AAP says “that appropriate vegan diets are safe for babies” hold up?
I think it holds up well enough, with the exception of premature infants who don’t have access to breast milk. The AAP may surround much of their talk of vegan diets for babies with negative words like “difficult,” but that’s not the same as saying “unsafe.”
Even when Caring for Your Baby and Young Child: Birth to Age Five says, “For example, if your household is strictly vegetarian, with no eggs or dairy products (which is not a diet recommended for children)…” it’s not clearly stating that vegan diets are unsafe for children. They seem to be suggesting that a vegan diet is riskier for babies, maybe, or more challenging, or just not the first recommendation they would make. But that’s not exactly the same as saying “unsafe.”
I doubt that very many people at the AAP are crazy about vegan diets, but I don’t see anyone from the AAP overtly calling them dangerous.