Do babies need cows milk after weaning from breast milk or formula? Is raising an infant vegan safe and healthy? We dig into the challenges and offer tips to do it right.
Nutrition is complicated and most often and not, CONTROVERSIAL. While scientists are still trying to understand the role of nutrition in human physiology, there is research out there to help guide policies and professional recommendations. Recently, Dietitians of Canada and the Canadian Paediatric Society released a statement about the rise in plant-based beverages for children as an alternative to cows milk for babies. While the article does provide sound, research-informed recommendations, controversy ensued. In fact, people from both sides were going back and forth on many news comment forums. Now, I understand that nutrition is a touchy subject, and everyone has the right to their opinion, however, as a Dietitian, it’s important for me to put on my research hat and go through the facts.
So, I decided to speak with a fellow colleague, Sarah Remmer, RD, who’s an Alberta-based Registered Dietitian that specializes in child and family nutrition. This kind of stuff is right up her alley, and she provided a wealth of information about about plant-based food and beverages, whether or not babies need cows milk, and how to do vegetarianism or veganism the right and healthy way.
Let’s dive in!
Dietitians of Canada and Canadian Paediatric Society Position Statements
The statement was released mainly because of the rise in plant-based beverages touted online and in social media. As well, there has been an increase in nutrition deficiencies, and even a death. Becky Blair, a spokesperson for Dietitians of Canada, stated “The challenge for parents is conflicting messages. They read that these drinks are considered ‘healthier’ on social media or hear misinformation about cows milk or fortified soy beverage…The reason children can become malnourished is that these beverages contain very little protein and are very low in fat and calories.” And yes, this is true. Besides fortified soy beverages, plant-based beverages such as almond, coconut, hemp, rice, and potato milk are very low in protein.
Catherine Pound, a paediatrician and spokesperson for the Canadian Paediatric Society, stated “What parents often don’t realize is that some plant-based beverages are not fortified with any minerals or vitamins; these drinks are low in all nutrients except carbohydrate, in fact sugar is often the second ingredient after water…in the case of allergies, or other concerns, I recommend that parents speak with a dietitian to ensure all nutrient needs, including protein, fat and calories are being met with an age-appropriate diet.” This is also true. Unless the package explicitly states, “fortified with ‘xyz’ vitamin” then chances are the beverage is low in nutrients. As well, many plant-based beverages are flavoured to make the drink more appetizing. These flavourings tend to have a lot of sugar.
For example, let’s check out the nutrition facts table of an almond beverage found at your local grocery store:
If we look at the nutrition facts table, you can see that there is only 1 gram of protein. This is well below the recommended amount of 6-8 grams of protein per 1 cup of a milk-alternative beverage. As well, 1 cup of vanilla almond milk contains 16 grams of sugar, which is about 4 teaspoons. If we take a look at the ingredients, sugar (in the form of cane sugar) is the second ingredient, meaning it’s one of the main ingredients, next to “almond base” (a mixture of water and almonds).
INGREDIENTS: ALMONDMILK (FILTERED WATER, ALMONDS), CANE SUGAR, CONTAINS LESS THAN 2% OF: VITAMIN & MINERAL BLEND (CALCIUM CARBONATE, VITAMIN E ACETATE, VITAMIN A PALMITATE, VITAMIN D2), SEA SALT, NATURAL FLAVOR, LOCUST BEAN GUM, GELLAN GUM, ASCORBIC ACID (TO PROTECT FRESHNESS).
As well, the reason why the protein is so low is because of the first ingredient: filtered water and almonds. During processing, most of the nutrients in the almonds are strained out, leaving mainly water and a little bit of the leftover bit of almond. Since one almond has about 0.25 grams of protein, this is why the statement alludes to the fact that for one cup of almond milk, you get 4 almonds.
Okay, so those statements are correct. Then why is there so much controversy? Well, for those who want their child to avoid animal products, cows milk won’t work. Also, many argue that plant-based diets are healthier. Another topic of concern is the belief that us health professionals are in bed with the meat and dairy industry (we’re not!). So, I want to go through each point of concern and see what the research says on whether babies need cows milk to thrive.
Nutrition Basics for Baby
First, let’s start out by understanding what a growing child needs. According to a systematic review on vegetarian and vegan diets in children, vegetarians and vegans (in particular) need to pay attention to important nutrients such as protein, iron, vitamin B12, calcium, vitamin D, omega-3 fatty acids, and iodine. Because infants, children, and adolescents have higher calorie and nutrient needs based on their size, they are particularly vulnerable to nutritional inadequacies.
Protein is important for the development of basically everything in our body, from muscles and enzymes to even the tiniest of cells. Amino-acids, the “building blocks” of protein, are chained together to make different protein structures in the body. There are 20 amino acids, 11 of which our body can make (called “nonessential” amino acids) and 9 our body cannot make (called “essential” amino acids). While animal-based proteins have a complete amino-acid profile, the amino-acid profile in plant-based proteins is generally not complete, except for soy, hemp, quinoa, and buckwheat. As long as you eat a diet with a lot of variety, you should have no problems getting all the amino-acids you need.
Iron is important for the development of the central nervous system, especially in the first few years of life because of its role in brain and spine development, such as myelination (a coating around nerve cells to help with delivering signals). As well, iron is important for the development of red blood cells, which carry oxygen throughout our bodies. This delivery of oxygen is important for brain health. Some studies reported that vegetarian and vegan children consumed more iron than the control groups. However, the authors noted that it is important to understand that iron from plant sources have lower bioavailability of iron and therefore would need to consume more than those who eat meat. Therefore, this does not mean that they have better iron stores. In fact, studies showed that over half of vegetarians had low iron stores. Health Canada recommends feeding your child iron-rich sources of food, such as iron-fortified cereals and meat/meat-alternatives (e.g., legumes) a few times a day starting at 6 months, since an infant’s iron stores become depleted around this time.
Vitamin D and calcium are important for bone health. The authors noted that those on vegetarian and vegan diets are at risk of low vitamin D and calcium and some studies reported that children on these diets had lower osteocalcin levels. However, vitamin D is hard to obtain through food alone and most people rely on the sun for vitamin D synthesis. The authors recommend supplementation for those who live in Northern areas or are of darker pigment. It is important to note that there are two types of vitamin D available via supplements: vitamin D2 and D3. If you choose to refrain from animal products, vitamin D2 would be your choice. Evidence is still limited as to whether vitamin D2 is as effective as vitamin D3. Health Canada recommends a vitamin D supplement (400 IU) for young children that are receiving breastmilk.
Vitamin B12 is important for human metabolism, and deficiencies can lead to issues with blood and brain development. For infants and toddlers, deficiency can result in failure to thrive (insufficient growth), movement disorders, and developmental delays. Studies from the systematic review showed that most children were provided supplements to help with vitamin B12 intake since this vitamin primarily comes from animal products. The authors stressed that if the child is not supplemented, then serious developmental consequences could arise. Therefore, children should be screened for B12 deficiencies if vegetarian or vegan.
Iodine plays an important role in thyroid hormone production and can therefore have an impact on mental and physical development. In Canada, table salt must have iodine added to it. Therefore, this should not be an issue unless you strictly avoid all foods with added salt and use non-iodized salt.
Long-chain polyunsaturated fatty acids (PUFA) are important for visual and cognitive development, blood pressure, and the immune system. The two most well-known PUFAs are omega-3 and omega-6. Most people get plenty of omega-6 in their diet, but omega-3 can be a little trickier. There are 3 types of omega-3’s: ALA, EPA, and DHA. ALA is found in nuts and seeds (try grinding them up first to increase absorption), legumes, and animal products. This omega-3 is used to create EPA and DHA, which are found to have the most beneficial effect on our health. However, this conversion of ALA to EPA and DHA is limited, therefore it is important to get these in your diet as well. EPA and DHA are mainly found in fish sources, which can be an issue for those avoiding animal products. If you choose to eat fish, then try to get at least 2 servings a week. If you avoid this, speak with a Registered Dietitian or doctor to discuss other ways to get these important nutrients.
The authors noted that vegetarian diets (in particular) and vegan diets can provide an array of benefits. These groups tend to consume more vegetables and fruit which can provide antioxidants, fibre, and more monounsaturated and polyunsaturated fatty acids.
Nutritional Content of Cow’s Milk vs. Plant-based Beverages
Based on the position statement, cow’s milk is recommended after the age of 9-12 months of age. Before this, infants should be consuming solely breast milk until 6 months of age and then slowly introduced to solid foods. The reason cow’s milk is the “go-to” drink is because of its nutritional composition. Per cup, cow’s milk (3.25% milk fat, recommended for children under 2) contains about 8 grams of protein, 300 mg of calcium, and half the RDA of vitamin B12. It also is a good source of magnesium, vitamin A, riboflavin, vitamin B6, and iodine.
Okay, what about the other beverages?
Fortified soy beverage is your next best option in terms of protein. In one cup of unflavoured fortified soy beverage, you get about 7.4 grams of protein, half the RDA of vitamin B12, and 319 mg of calcium. It also has similar nutrients to cow’s milk and is fortified with vitamin D. So, why isn’t it recommended in the position statement? Well, for adults, this is definitely a great alternative to milk to meet your protein needs. However, children need fat! Sarah Remmer, RD stated “The problem here is that, because it’s high in protein, it fills precious space in a toddler’s stomach (which is really small), and without having the fat, depending on how much a toddler is drinking, it could maybe contribute to that toddler not getting enough fat overall. One of the benefits to whole cow’s milk is the fat content, which growing toddlers need. I would say, instead, to continue with a soy-based, vegan infant or toddler formula vs. soy milk until two years and offer [it] via a cup with meals, just like you would milk.” By using this formula, you are still providing your child with the important healthy fats they need for proper growth and development.
For one cup of an enriched almond beverage, you get about 1 gram of protein, 312 mg of calcium, a little less than half the RDA of B12, and a good amount of vitamin D. Now, the issue here is that manufacturers are not required to enrich or fortify their beverages. So, you’re not guaranteed to get nutrients in this amount. Rice, coconut, potato, and hemp beverages are similar to almond beverage but have slightly less protein and calcium, with the exception of hemp beverages having 2-3 grams of protein per cup.
So is Raising an Infant Vegan Safe and Healthy?
Unless extremely diligent with your child’s vegan diet, nutritional deficiencies can easily occur and lead to an array of health issues. Recently, a Belgian couple were sentenced to a 6-month suspended jail sentence for feeding their child an “alternative” milk diet which led to the unfortunate death of their child. While it was clear that the parents had good intentions, alternative diets can be life-threatening if not handled correctly.
Another example is a case study from Spain, where an 11-month-old was brought to hospital and diagnosed with scurvy from low vitamin C as well as low vitamin D. The child had osteopenia, cortical thinning, Wimberger ring, Frankel line, fracture, and periosteal reaction, which are all issues with bone development. An x-ray also showed there were vertebral fractures and wide intervertebral spaces, meaning his spine was weak.
Vitamin C is an important antioxidant and also plays a crucial role in collagen synthesis. In the processing of plant-based beverages, like almond milk, the biological activity of vitamin C is gone. The authors suggest that complementary feeding of fruits (e.g., orange, peppers, kiwi) with the plant-based beverage would have helped avoid this. They also noted that intake of vitamin C and D, calcium, zinc, and iron were much lower than the recommended amounts for this age. The infant was immediately switched off of the almond-milk infant formula. Eventually, his nutrient deficiencies improved and there was improvement in his leg pain. After 8 weeks, he was able to start walking. There is no information about neurological impacts, however.
While in both cases, the parents had good intentions, it is always important to speak with a Registered Dietitian and/or doctor to ensure your child is getting the proper nutrition they need. Breast milk should be the first choice of food for a baby. If there is a reason the child cannot have breast milk, then an infant formula could be used. In Canada, there are rigid guidelines that must be followed. All infant formulas must be compositionally similar to human breast milk.
So Do Babies NEED Cows Milk?
When asked if veganism fits into an infants diet, Sarah Remmer, RD suggested, “It can, although it can be very challenging. Parents need to be extremely vigilant in making sure that the important nutrients that kids would be otherwise getting largely from animal sources (protein, iron, calcium, B12, etc.) are met through plant sources. Because more selective eating (picky eating) typically happens between the ages of 2 and 7, it can be very challenging to ensure that all nutrient requirements (and energy requirements) are met, with a strict vegan diet.”
If the child is under 1 year, “it would be very important that the baby was still receiving breastmilk or formula until the age of one. This will be where the baby would be getting the majority of his/her nutrition. I would then focus on plant-based nutrient-dense foods such as beans, lentils, nut and seed butters, avocado, fruits, veggies and whole grains. If vegetarian, eggs and dairy provide a lot of nutrition too.” If nut allergies are of concern for your child, she suggests seed butters.
We asked Sarah if she thought there were any nutritional concerns with feeding a child a vegan or vegetarian diet. Her response: “Unless a parent was extremely careful about ensuring that their baby was meeting all nutrient requirements through plant-based foods (and supplements), it’s challenging (vegan). Vegetarian is a lot easier, especially if both eggs and dairy are included.”
To make sure you’re providing your child (over 6 months) with adequate nutrition while consuming a vegetarian or vegan diet, be sure you’re able to check off everything on this list:
- My child continues to breastfeed OR is taking a soy-based, vegan infant or toddler formula OR 3.25% milk
- My child is trying different vegetables and fruit
- My child is getting a variety of whole grains (e.g., whole grain bread, rice, quinoa, buckwheat)
- My child eats various plant-based proteins, such as legumes, tofu, and nut/seed butters. If vegetarian, my child also eats dairy products (e.g., cheese, yogurt) and eggs, unless there is an allergy.
- I provide my child with different sources of omega-3’s such as ground chia, hemp seeds, oil, ground nuts/nut butters, and fortified products (e.g., eggs, margarine)
- If my child is breastfeeding, he/she is getting 400 IU of vitamin D through vitamin D drops
- My child eats protein-rich foods (e.g., beans or lentils, fortified cereals, tofu, eggs) with a source of vitamin C (e.g., red peppers, oranges, kiwi) to increase absorption
- A Registered Dietitian and/or doctor continues to monitor my child’s growth and development and screens for any deficiencies
So are dietitians in bed with the meat and dairy industry?
No. As a regulated health professional, Registered Dietitians must disclose any conflicts of interest, such as being sponsored by a company or industry. In this case, we cannot say ‘This product is better than that product’ and must give balanced, evidence-informed advice. So, for example, for vitamin D, we cannot say “buy X-company’s products instead of Y-company’s products” if they both provide equivalent nutrition. We must also abide to a code of ethics that refrains us from misusing scientific research to benefit a cause. This means that we must review scientific evidence and use our professional opinion in a non-biased manner in order to protect you and the public. If you have any questions, please visit College of Dietitians.
Bottom line on whether babies need cows milk and whether infants can thrive while vegan
Everyone has a right to eat what they choose and we need to stop diet shaming. At the same time, we want to make sure that children get the proper nutrition they need to grow properly. As Sarah Remmer, RD mentioned, a vegetarian or vegan diet can fit, but it takes a lot of work – especially for vegan diets. My recommendation is to always consult with a Registered Dietitian and/or doctor who is trained to deal with special diets such as this and will not judge you for your decision to feed your child according to your values and beliefs. At the end of the day, we want to children to thrive and grow up to be healthy, long-living adults.
Contribution by RD2B Katey Davidson