A “plant-based diet” has become increasingly popular, particularly as we learn more about the benefits for heart-health and energy for adults. Increasingly, more parents are choosing to raise their children as vegetarians. Sometimes this is for religious reasons or ethical reasons (e.g. animal rights). However, just like in adults, it is crucial to ensure that your child still obtains all of the nutrients he/she needs for their developing brains and body. Of note, veganism is not discussed here as there are a number of drawbacks to this diet in children (and there are insufficient studies to show that growth and development is not compromised low caloric density (http://www.cps.ca/documents/position/vegetarian-diets) and it might be best to discuss this further with a dietician/nutritionist as well as your child’s physician. Ideally, all children should have a dietary history taken by their dietician/nutritionist and physician, and this is particularly important in children that have specific diets (for personal or medical reasons).
Here I discuss some things to think about if your child consumes a vegetarian diet, as described by the Dieticians of Canada (PEN guidelines) as well as the Canadian Pediatric Society (http://www.cps.ca/documents/position/vegetarian-diets) and American Academy of Pediatrics (AAP).
1.What does it mean to be a “vegetarian?”
While no two vegetarians (or people!) are alike, there are two main “categories” of vegetarians [http://www.cps.ca/documents/position/vegetarian-diets]. The first is termed “lacto-ovo-vegetarian,” which means a diet that is meat-free but includes eggs and dairy products such as cheese, milk, and yogurt. The second type is termed “lacto-vegetarian,” which omits eggs, but includes dairy.
2.Non-meat sources of protein
As described by the AAP [https://www.healthychildren.org/English/ages-stages/gradeschool/nutrition/Pages/Vegetartian-Diet-for-Children.aspx], intake of essential amino acids is key, and particularly important to ensure in a vegetarian diet. A combination of cereal products (e.g. rice, quinoa) with legumes (dry beans, soybeans) can provide a complete protein if eaten together. Legumes (lentils or beans for instance), cereals such as quinoa, nuts, seeds, nut and seed butters (e.g. almond butter, pumpkin seed butter) are also great sources of protein, as are cheese and yogurt.
If you use seed butter, choose a “smooth” version, as whole seeds can pose a choking hazard (https://www.pennutrition.com/index.aspx). Tofu and other soy products may be considered in moderation, though some experts recommend limiting these products all together, as many of these products tend to be heavily processed. Some research, albeit controversial, suggests a pro-estrogenic effect of these foods when consumed frequently (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1480510/).
4.Fats are Important!
We are thankfully moving away from non-fat options in dairy (e.g.skim milk and nonfat milk substitutes) which often substitute processed carbohydrates (sugar) for in place of fat for palatability and caloric reasons. In dairy, look for homogenized options for children starting between 9-12 months (http://www.caringforkids.cps.ca/handouts/feeding_your_baby_in_the_first_year).
Toddlers may benefit most from whole milk, as it that provides the calories needed for growth and development. Limit milk to a maximum of 3 standard cups per day, in order to ensure a balanced diet and reduce the risk of iron-deficiency anemia [http://www.aafp.org/afp/2011/0301/p624.html]. Almond milk may be an option but the fat content may be lower. Avocados, nut/seed butters, pasteurized cheeses, are all good options to encourage the intake of healthy fats. Omega-3 Fats (DHA and EPA) which are essential for brain development, are often found in fatty fish (e.g. wild salmon, sardines, and mackerel), but vegetarians can obtain limited quantities of these fats in flax seeds/oil, walnuts, tofu, and in fortified eggs (https://www.healthychildren.org/English/ages-stages/gradeschool/nutrition/Pages/Vegetartian-Diet-for-Children.aspx).
3.Specific Micronutrient Requirements
Vitamin B12: This nutrient is found in animal products such as meat, eggs, milk and butter. It is crucial for brain development, memory, and red blood cell formation (http://www.cps.ca/documents/position/vegetarian-diets). Sheep and goat milk are lower in B12 compared to cows milk, so if the former is chosen, supplementation may be required, in consultation with your physician and dietician/nutritionist.
Iron: Iron deficiency is the most common nutritional deficiency in children globally, and supplements may be required in some children. Lacto-ovo-vegetarians require almost twice as much iron due to the differences in bioavailability compared to heme-iron found in red meat (http://www.cps.ca/documents/position/vegetarian-diets). We usually think of iron as found predominantly in red meat, but it can also be found in green leafy vegetables. Your child’s physician may be able to determine if iron deficiency is an issue on physical exam and laboratory testing if appropriate. If an iron supplement is recommend, taking vitamin C (either through citrus fruits, kiwi, or sweet potato or a supplement) may help improve bioavailability.
Zinc: Usually total body zinc may not be an issue, but bioavailable zinc may be lower in vegetarians. Vegetarians tend to have higher levels of plant-based substances called “phytates” which can attach to zinc molecules, preventing its use by the body (http://www.cps.ca/documents/position/vegetarian-diets). As such, they may require a higher intake of zinc is needed. Zinc is most often found in nuts, sprouted grains, and legumes.
Vitamin D: This nutrient is special as it is both a micronutrient as well as a hormone. It is found in fortified milk (it will be listed as an ingredient). In Canada most of us are Vitamin D deficient in the Winter, so it may be good idea to take a supplement of 400IU-800IU (depending on where you live) daily in consultation with your child’s physician and dietician/nutritionist. In the summer, 10-15minutes of exposure in direct sunlight on both the upper and lower limbs is usually sufficient, but needs to balanced with the risks associated with sunburn and there are no clear recommendations that balance both of these issues (http://pediatrics.aappublications.org/content/early/2011/02/28/peds.2010-3501.short).
Calcium: Dairy is a great source of calcium, but this powerful nutrient can also be found in almonds and certain greens such as kale and bok choy (http://www.cps.ca/documents/position/vegetarian-diets). It is rare for children to require calcium supplementation, unless they have a specific condition or consume a diet that is low in calcium (e.g. low consumption of dairy or leafy greens). If you are concerned about your child’s calcium intake, be sure to discuss this with your child’s physician who can determine clinically and sometimes with laboratory testing whether a supplement is required.
Regardless of whether your child is vegetarian, it is recommended that we limit refined foods such as fruit juice, sugar, and white bread. These food items, while suitable as an occasional treat, may provide empty calories, encourage cravings and perhaps affect attention, behavior, and concentration. Most dieticians and nutritionists recommend that we all “consume a rainbow” of colorful fruits and vegetables, followed by high quality plant-based proteins and whole grains. As food security is a huge issue that we must address when choosing healthy food options, discuss with your dietician/nutritionist and physician about ways to obtain essential nutrients in a cost-effective way. I really like the Environmental Working Group’s resources on this issue: http://www.ewg.org/goodfood/. Above all, please do not hesitate to discuss your child’s nutrition and eating habits with his/her health care providers so that together you can formulate a framework to help your child choose nutritious options throughout their life.
Article contributed by: Amitha Kalaichandran, MD and pediatrics resident, Twitter (@DrAmithaK).