Strict vegan and vegetarian diets, a challenge for providers

Strict vegan and vegetarian diets, a challenge for providers | Image Credit: © mallinka1 - © mallinka1 - stock.adobe.com.

Pregnant persons who follow vegan and vegetarian diets throughout pregnancy, and for their infants and young children, need guidance from their pediatricians to assure that the nutritional needs of both the pregnant person and their children are met, states Rachel Zimlich, BSN, RN, in her article, “Pediatricians must play a role in early plant-based diets.”

Likewise, pediatric nurse practitioners (PNPs), and all pediatric focused advanced practice registered nurses (APRNs), and midwives must be prepared to discuss with parents, the risks of following a strict vegan or vegetarian diet especially during the critical times when brain growth, both during the pregnancy and in the first 3-years of life, can be adversely affected by inadequate dietary intake. In addition, normal patterns of growth and developmental may also be affected by nutritional intake.

Earlier in my career as a registered nurse (RN), I encountered a mother who followed a strict vegan diet, and when the infant was born prematurely, she and her husband insisted that their infant only be fed the mother’s breastmilk. This became a complicated case, with significant ethical considerations, as the premature infant struggled to gain weight. After many meetings between the parents and the medical/nursing care team, the parents permitted their premature infant to receive routine premature nutritional support care including supplementation and the mother’s breastmilk.

As a PNP, I have had several families in which the parents were adamant about their infants and children maintaining a strict vegan diet and refused to follow the nutritional guidance offered at each office visit. I have seen outcomes for some preschool-age children who were limited to a strict vegan diet from birth presented with height and weight measurements at–3 Standard Deviations (SDs) on growth charts. Developmentally, the preschoolers were often evaluated as delayed. Even when appropriate interventions and referrals are made, the question remains, what shared decision making strategies may work best for parents who only want to follow strict vegan diets for the entire family?

Nutrients lacking in vegan and vegetarian diets

As pediatric providers, we must be knowledgeable about nutritional counseling for parents whose infants and children are following a vegan and/or vegetarian diet. Pregnant persons are managed by their obstetricians or midwives throughout the pregnancy. If a pregnant person has a child in the pediatric practice, questions can be asked about their diet and they can be advised about the resources available on the Centers for Disease Control (CDC) website that identifies the nutrients that are deficient in a strict vegan and/or vegetarian diets.^1,2 Parents can also be referred to the CDCs infant and toddler nutrition website that contains detailed information for parents.³ We can advise breastfeeding parents, per the CDC recommendations, that nutrients such as iodine and choline increase while breastfeeding and diet alone may not meet the infants/toddlers nutritional needs.¹

Dairy products, eggs, seafood, and iodized salt all contain iodine.¹ Choline is found in dairy and protein food groups including eggs, meats, beans, peas, and lentils.¹ Individuals who follow a strict vegan diet, will not consume any of these foods, except perhaps use iodized salt. These individuals, most likely need nutritional supplements. While we as pediatric providers, do not prescribe for the parent, we can refer them to their obstetrician/midwife or to their primary provider for possible vitamin supplementation while breastfeeding. Some parents may prefer to continue breastfeeding through the toddler years, thus, adequate nutrition for the parent and child must be a priority. At each visit, pediatric providers must take the time to query the parent about their eating behaviors and the way the parent is feeding the infant and toddler.

Vitamin B12 lacking in vegan and vegetarian diets

Another concern for brain development is the vitamin B12 level in infants who either are breastfed by a mother who is on a vegan or vegetarian diet. Vitamin B12 is found in foods from animals.2 Foods that contain adequate amounts of vitamin B12 include milk and milk products, eggs, meat, and fish.2 Mothers who follow a strict vegan or vegetarian diet and breastfeed their infant need to have their vitamin B12 levels measured. If the mother has a vitamin B12 deficiency, the infant is more likely to be vitamin B12 deficient.2 In addition, parents who provide only a vegan or vegetarian diet for their infants, also place the infant at risk for vitamin B12 deficiency. As pediatric providers, we can ask the mother if she knows her vitamin B12 level. We can advise the mother of potential risks and ask the mother to have their primary care provider, obstetrician, or midwife obtain the vitamin B12 level and notify us of the results so that the infant status can be assessed.

Obtaining a careful nutritional history

As pediatric providers, we ask about diet and nutritional intake at every visit. Considering the risks for infants and toddlers who are fed a strict vegan or vegetarian diet, it is essential to obtain a detailed nutritional history for both the breastfeeding person, and the infant/toddler. Diet recall in the office is sometimes difficult for parents. Parents can be encouraged to participate in shared decision making by having their diets and the infant/toddler diets evaluated. Ask the parents to make a quick note, either written or verbal, on their smart phone for a 24-hour period of all foods and drinks that are consumed by themselves, if breastfeeding, and for the infant or toddler. They can send this information to the office, and it can be reviewed by the provider. After review of this information, dietary recommendations can be made by the provider, or a referral can be made to a dietician, if needed. The goal of shared decision making is to provide a healthy diet for the infant and toddler to optimize brain development and normal growth and development patterns.

For more from the June issue of Contemporary Pediatrics®, click here.

References:

1. Maternal Diet: Diet Considerations for Breastfeeding Mothers. Centers for Disease Control and Prevention. May 17, 2022.Accessed June 25, 2023. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/maternal-diet.html 

2. Vitamin B12. Centers for Disease Control and Prevention. April 4, 2023. Accessed June 25, 2023. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/vitamin-b12.html

3. Infant and Toddler Nutrition. Centers for Disease Control and Prevention. June 3, 2022. Accessed June 25, 2023. https://www.cdc.gov/nutrition/infantandtoddlernutrition/