Alternatives to animal-based milks: Protecting infant and young child health when families choose plant-based diets
Plant-based diets, where foods and drinks based on or containing animal derived ingredients are avoided, have become increasingly popular.
Helen Crawley, First Steps Nutrition Trust, UK
Plant-based diets, where foods and drinks based on or containing animal derived ingredients are avoided, have become increasingly popular. Families choosing a plant-based diet may do so for ethical, environmental or health reasons, or a combination of these. Families who want to avoid the exploitation of animals for ethical reasons may be most likely to ensure products that they offer infants and young children are plant-based. There are currently no plant-based breastmilk alternatives available in the UK that can be used without medical supervision, and infants in the first year of life should only have breastmilk or a suitable infant formula as their main milk drink. Plant-based milks can be used in food preparation from six months of age and as the main milk drink for children over one year, but great care is needed to ensure their diet has sufficient energy and nutrients and that it is diverse in the non-animal foods provided.
Keywords: plant-based, milk alternative, vegan, infant, young child
Animal-based milks have traditionally been an important part of the diet of infants and young children in many parts of the world. Infants in most developed countries are given human milk and/or infant formula made from cows’ or goats’ milk in the first year of life and after one year of age, either remain on human milk or transition to an animal milk, primarily cows’ milk. Historically, most information on complementary feeding and feeding children in the first two years of life recommended whole cows’ milk as an important source of protein and calcium. Welfare food schemes such as Healthy Start and the Nursery Milk Scheme have encouraged milk consumption through the provision of free supplies to all children in child care settings or to eligible low income families. In recent years, however, there has been an increase in interest in plant-based diets, driven primarily by concerns over the environment, health and animal welfare. Whilst those who choose a completely plant-based or vegan diet may still be small in number (the Vegan Society estimate that there are around 600,000 vegans in the UK) the number of people choosing plant-based foods has risen enormously, and it is predicted that by 2025, vegetarians and vegans may make up a quarter of the population and that half the population will be ‘flexitarians’ – increasing the amount of plant-based foods in their omnivorous diet (National Farmers’ Union, NFU, 2017).
Marketing information suggests that there has been a substantial rise in the purchase of plant-based milk alternatives, which in 2019 represented 4% of the total milk market in the UK, although 23% of people used them in the first three months of 2019 (MINTEL, Global Market Research, 2019). Sales are highest in younger consumers who are choosing these products for health reasons and because they believe dairy farming is not good for the environment. Little data is available on how many families with infants and young children are choosing a plant-based diet in the UK, but it is likely that this number will rise as a younger generation habituated to plant- based foods and drinks enter parenthood, and as environmental concerns increase.
Feeding infants in the first year of life
Global recommendations are that all infants should be exclusively breastfed for the first six months of life and that breastfeeding should continue in the second six months of life alongside complementary foods. Where infants are not breastfed or are partially breastfed then infant formula is the only recommended alternative, but there are currently no plant-based infant formulas on the UK market that are recommended for use without medical supervision. Soya based infant formula (which still contains animal sourced Vitamin D) is not recommended in the UK as there are concerns over the potential role of phyto-oestrogens on a baby’s reproductive system (NHS, 2020a). Despite clarity in public health recommendations, the manufacturer of the one soya based infant formula available in the UK advertises their product as suitable for those choosing a vegetarian diet.
Caregivers who choose a plant-based diet for themselves and who are not exclusively breastfeeding their babies in the first year of life therefore have to make a decision as to which infant formula they will use. Practitioners should encourage caregivers to consider the rights of their infant to the safest breastmilk alternative available for the first year, whilst being supportive that they can, with care, move to a plant-based diet with their child once over the age of one. This may bring up ethical issues for caregivers which they need support in discussing. Families may also want to discuss informal use of donor milk or milk sharing. Health workers should, however, advise caregivers that they should not attempt to make home-made plant-based infant formula as this is unlikely to be safe.
Infants have the right to safe breastmilk alternatives in the first year of life
From six months of age, when complementary food is added to the diet, plant-based milk alternatives can be used in cooking and food preparation, providing that the main milk drink remains breastmilk or an appropriate infant formula.
What plant-based milk alternatives are on the market? How do they compare nutritionally to animal milk?
A ‘milk alternative’ can be made from any number of plants including soya beans, peas, rice, quinoa, oats, nuts (e.g. almond and hazelnut), coconut or hemp. Most milk alternatives are primarily water, with varying amounts of added solids from the plant base (e.g. soya milk generally contains less than 10% soya; nut milks contain about 2-3% nuts), and these can be both sweetened or unsweetened and may or may not be fortified with additional vitamins and minerals. Despite many of the ingredients used being relatively low cost, all milk alternatives marketed are more expensive than cows’ milk. Table 1 compares some of the unsweetened and fortified plant-based milk alternatives commonly on sale in the UK.
Dairy products currently provide a significant amount of energy and nutrients to the diets of young children in the UK. Data from the National Diet and Nutrition Survey 2014-2016 reported that for children aged 1.5 to 3 years, 31% of protein, 38% of vitamin A, 53% of riboflavin, 57% of calcium, 62% of iodine and 34% of zinc came from milk and milk products (Food Standards Agency, FSA, and Public Health England, PHE, 2018). We currently have no dietary survey data which can tell us about how plant-based diets for young children may be adapted to ensure they are nutritionally adequate, and much of the concern about a shift to plant-based milk alternatives and other products is driven by doubt that they may not be an adequate replacement. It is possible to provide an adequate diet that is plant-based for infants and young children, but this requires great care and some supplementation as well as a varied source of plant-based foods to replace those of animal origin.
No data exists on how plant-based diets are being adapted for young children
The most commonly used milk alternative is soya drink which has been widely available for many years and remains the most cost-effective of the milk alternatives on the market. The European Union has ruled, however, that the name ‘soya milk’ cannot be used for this product and that plant-based milk alternatives cannot use the word milk, with the exception of coconut milk and almond milk. Products may use similar names such as ‘mylk’ to get around this regulation. Many other products made from soya can be used as animal sourced food replacements: for example, soya cheese alternative, tofu, soya-based mince, soya yoghurt alternatives etc. The use of high amounts of soya-based products in the diets of infants and young children is currently under consideration by the Committee on Toxicity (COT) as there is concern that such diets might impact on health. Regarding the use of soya formula and soya drinks in the diets of infants and young children, current advice from the UK Government (NHS, 2020b) remains that:
• Soya based infant formula should only be used in the first year of life under medical supervision;
• Unsweetened calcium-fortified milk alternatives, such as soya, almond and oat drinks can be given from the age of one.
The main concern relating to the consumption of soya formula or soya drinks by infants and young children is related to the phyto-oestrogens present, and the potential impact these might have on the developing reproductive system. The COT report in 2013 concluded that whilst there is limited evidence for impacts on human health from epidemiological studies, animal studies suggest some risk. The Committee concluded that:
There is no scientific basis for a change in the current government advice that there is no substantive medical need for, nor health benefit arising from the use of soya-based infant formula and it should only be used in exceptional circumstances to ensure adequate nutrition. (COT, 2013)
COT has also considered the role of almond milk in the diet of infants and young children in a recent discussion paper (COT, 2020). Most milks marketed as almond milks contain a small percentage of almonds (typically 2.5%) but there are known contaminants in almonds such as aflatoxins, cyanide and cyanogenic glycosides. COT concluded that there was little available data on contaminants in almond based drinks and that intakes of contaminants were likely to be within safe levels; however, very high intakes of products with higher levels of some contaminants have been referred to the Scientific Advisory Committee on Nutrition (SACN) for consideration.
Rice milk is not recommended for young children owing to its arsenic content
Currently the only milk alternative drink that is clearly not recommended for consumption by young children is rice milk. COT’s most recent statement outlining the potential risks of arsenic poisoning from the consumption of rice milk was produced in 2016, and concluded that the advice that rice milk should be avoided by children aged 1 to 4.5 years should remain, with the proviso that up to 50ml/day in the diet of children aged 1 to 5 years was not an appreciable risk (COT, 2016). The NHS position, however, remains that:
• Toddlers and young children under the age of 5 shouldn’t have rice drinks because of the levels of arsenic they contain. (NHS, 2020b)
Many of the commonly available unsweetened fortified milk alternatives are considerably lower in energy and protein than whole animal milk, and not all products are fortified with the nutrients that are associated with animal milk. However, new products are being put on to the market all the time; for example, a new higher energy oat milk alternative that contains 57kcal/100ml has been launched as well as an enriched version with 22.5µg iodine/100ml. Care is needed when selecting products to ensure they are unsweetened and fortified and it may be prudent if young children are having a large number of soya based alternatives to animal sourced food in their diet to use a variety of appropriate milk alternatives.
What about plant-based toddler milk?
Soya-based fortified toddler milks are not recommended for use as these are sweetened. The milk offered should be unsweetened and fortified. The most commonly available soya based ‘growing up milk’ contains maltodextrin, raw cane sugar and fructose as sweeteners.
Managing a plant-based diet for young children
It is important to remember that continued breastfeeding is recommended in the second year of life (and beyond for as long as the mother wishes to do so) and that this should be supported. Children over one year of age can move to whole animal milk as their main milk drink or, as reported earlier, a milk alternative can be used (providing care is taken that the overall diet is sufficient in energy and nutrients). In the UK, SACN are currently reviewing recommendations on the diets of children aged one to four years and there is increasing concern about plant-based dietary adequacy both here and globally. In Ireland in 2020, the Food Safety Authority (2020) made the following dietary recommendation for children aged 1 to 5 years:
• Plant-based milk replacement beverages (e.g. soya ‘milk’) can be used to replace cow’s milk, provided they are fortified with the same level of nutrients, particularly calcium. Use of plant-based milk replacement beverages such as almond ‘milk’, coconut ‘milk’ and rice ‘milk’, is not recommended, as they are nutritionally inadequate.
This is slightly confusing as many of the plant-based milk replacements are fortified and the reason to avoid rice milk alternative is based on the arsenic content rather than its nutritional profile. In other parts of the world, it has been recommended that plant-based milk alternatives should not be used for children under two years as their main milk drink (e.g. Alberta Health Services, 2016) or that only soya milk should be used (e.g. New Zealand Ministry of Health, 2012, and American Academy of Pediatrics, American Heart Association, Academy of Nutrition and Dietetics, and the American Academy of Pediatric Dentistry: see Lott et al., 2019). Global recommendations from the World Health Organisation on complementary feeding for children aged six to 23 months are also under review, but WHO does not currently recommend a diet free of animal sourced foods (WHO, 2014). Concerns about the use of plant-based milk alternatives primarily focus on their nutritional differences to animal milk. A few tragic cases of infant and young child deaths where caregivers have given inadequate plant-based milk alternatives and diets have made the headlines, and health workers may be alarmed if they work with families who choose a plant-based diet. It is particularly important that caregivers are not alienated but are supported and guided to the appropriate information about the energy and nutrient needs of infants and young children on a plant-based diet including the need for supplementation.
Parents should receive information on supplementation of plant-based diets for children
When young children are given a plant-based diet, care also needs to be taken that they don’t fill up on higher volumes of low-energy milk alternatives and have less appetite for nutritious foods at mealtimes. Figure 1 compares the volumes of different milk alternatives needed to get the same calories as in whole cows’ milk.
If caregivers who want to cut down on the use of dairy based foods for whatever reason, use a plant-based milk alternative for a child who has an otherwise omnivorous diet containing animal sourced foods, negative implications for nutritional health are likely to be low providing a good range of other foods is offered and eaten. Where a child is offered plant-based milk alternatives in a diet that is completely plant-based then caregivers should be encouraged to:
• Offer a wide variety of plant-based foods including vegetables, cereals, pulses, soya products, nuts, seeds and fruit.
• Think about the energy and nutritional density of the diet: a lot of very bulky foods with low energy density may fill up a small child before they meet their energy and nutrient needs. Energy and nutrient dense foods include oils and fats, ground nuts and seeds, pulses and foods such as tofu.
• All young children aged one to four years in the UK are encouraged to have daily vitamin drops containing vitamins A, C and D; children on plant-based diets are also likely to need additional Vitamin B12, riboflavin and iodine.
• All young children need to have adequate amounts of iron and zinc in their diet, and caregivers are recommended to find out about good sources of these nutrients and ensure they are regularly included in the diet.
Practical advice on how to manage a plant-based diet for infants and young children can be found in: ‘Eating well: vegan infants and under 5s’ at www.firststepsnutrition.org/eating-well-resources
Information on all infant milks available on the UK market can be found at: www.infantmilkinfo.org
Alberta Health Services (Canada) (2016) Nutrition guideline: Healthy infants and young children – plant based beverages. Available at: https://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-ng-healthy-infants-other-milks-fluid-plant-based-beverages.pdf <accessed 17 August, 2020>
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