Research Overview:

When assessing evidence on nutritional adequacy of dairy-free diets in children, one interesting approach is to look into the evidence of children following “plant-based diets” without dairy, such as “strictly vegetarian” diets or “vegan diets”.

It should be noted, though, that a strictly vegetarian diet may be very different to a dairy-free diet in which other animal foods are included (such as meats, fish or eggs). For example, a strictly vegetarian diet usually prioritizes beans intake on daily basis to replace meats as protein sources, and this could on itself provide different nutrients and health effects that go beyond the exclusion of dairy from the diet. On the contrary, a dairy-free omnivore diet could be adopted when there is a need or preference of excluding only dairy in the diet, and could for instance not include a frequent beans intake.

In this analysis, we will review the nutritional adequacy and status of children following dairy-free plant-based diets, based on the current evidence. We will be able to have a better view of what a healthy plant-based diet looks like, and have straight-forward recommendations for both children following a dairy-free diet and a strictly vegetarian diet.

The following review comes mainly from 3 important studies on vegetarian and vegan children:

• The VeChi Study (Germany) (Weder S et al, 2019) (Alex U et al, 2021). It is one of the biggest studies that assessed nutrient intakes and status in children following ovo-lacto vegetarian diet (OLV) and strict vegetarian diets (VG) and comparing them with children following an omnivore diet (OM).
• Neufingerl systematic review, assessing and comparing nutrient intakes and status of children and adolescents following plant-based diets with meat-eating counterparts, including 30 published studies of children and/or adolescents (Neufingerl N et al, 2023)
• Desmond systematic review, looking at the available data on health outcomes of children on vegetarian and vegan diets from 14 cross-sectional and longitudinal studies published between 2013-2023, plus 24 studies published before in a previous systematic review (Desmond MA et al, 2024)

When a “vegetarian” diet is mentioned, it should be noted that it refers to a diet that is meat-free but includes eggs and/or dairy. Whereas a strictly vegetarian or a vegan diet does not include any animal foods.

Cardiometabolic health

It has been well established that diets that are plant-based, including vegetarian and vegan diets, have a significant positive cardiometabolic effect in different adult cohorts that have been studied, and there is growing evidence in children too.

On the German VeChi Study (Weder S et al, 2019 & Alex U et al , 2021), it was observed that the vegetarian and vegan groups of children were less overweight and obese than the omnivore children, associated with a higher intake of fiber and lower intake of fats and sugars, especially in the vegan group. Similar results were seen in a more recent meta-analysis (Desmond MA et al, 2024), where vegan children had lower measures of weight and fat mass.

Vegan children have a more favorable lipid profile than omnivore children, particularly lower total cholesterol, non-HDL cholesterol, and LDL cholesterol compared to omnivores (Desmond MA et al, 2024), and follow diets that are higher in fiber and also in other important nutrients such as poly-unsaturated fatty acids, vitamin C, vitamin E and folate, when compared with diets that include meat (Neufingerl N et al, 2023). On the contrary, saturated fatty acids are more highly consumed amongst meat-eaters; in fact, their intake of saturated fats measured on Neufingerl study, found they had an intake higher on average than the upper limit recommended of 10% daily intake (Neufingerl N et al, 2023). These differences in intakes of key nutrients can explain the better lipid profiles and cardiometabolic health of vegan children and adults.

Nutrient intakes and nutritional markers

Total energy intake was measured in the VeChi study and did not vary between omnivores, vegetarian and vegan children. Protein intake was higher in omnivores, but all groups had higher intakes than the reference values.

There tends to be a significant higher intake of total fats, added sugars and saturated fatty acids amongst omnivores compared to vegan children, which can be expected given that the main dietary sources of saturated fats in western diets are animal foods (meats and dairy).

Regarding fiber intake, the differences are also significant; vegan children have a higher intake of fiber than omnivores. Together with the above, this can explain at least in part why vegan children have a more favorable lipid profile that can lead to better cardiometabolic outcomes.

Nutrients that appear to be higher in the vegan children’s diet according to the evidence include vitamin E, Magnesium, Iron, Vitamin C and Folate equivalents. These are all nutrients that in a vegan diet are not of concern, and can explain some of its positive health outcomes.

On the other hand, calcium vitamin B2, Iodine, DHA and Vitamin B12 can be of concern, because intakes seem to be lower in vegan children than in omnivores in most studies; and Iron and Zinc can have a lower bioavailability in a plant-based diet. Vitamin D can also be deficient in  a vegan diet, but in these studies, there was a significant prevalence of Vitamin D deficiency in all diet groups.

Vitamin B12 deficiency can be prevented through supplementation of people following vegetarian and vegan diets, but not everyone seems to be supplementing: in Desmond MA systematic review, it was found that overall a 30% of vegetarian and vegan children were not supplemented with this nutrient, being vegan children more usually supplemented than vegetarian children.

Ferritin levels have found to be usually lower in vegan children than in omnivores, however, other iron metabolism markers – including Hemoglobin – are usually similar or slightly lower, showing no clear difference in the prevalence of iron deficiency anaemia between vegan and omnivore children.

Anthropometric measures

According to the VeChi study, anthropometric measures for normal growth were not significantly different between each dietary group (including height for age z-score), and height did not significantly differ either. However, more vegan and vegetarian toddlers were classified as stunted or wasted than omnivores.

In this study, the children classified as stunted, 3 had low reported energy intakes associated with an exclusively breastfed for more than 6 months. 4 of the stunted children had parents with a lower body height than the german average, another stunted child was categorized as small gestational age.

In Desmond MA systematic review, it was found that overall anthropometric measures were comparable or slightly lower in vegetarians than in omnivores, with vegan children tending to have lower values for height, weight and fat mass. These results are based mainly on young infants and toddlers, that have not yet accomplished their adult-height, so it does not necessarily mean that height is different between adults that have been raised on a plant-based diet compared to an omnivore diet.

These results were associated with a lower bone mineral content and bone mineral density values, that were attenuated after adjustment but remained significant for vegan children compared to omnivores.

An important nutrient for bone health and density is calcium, and we know its intake can be insufficient in vegan diets, as stated before.

Conclusions and important data for the health of children on plant-based diets

Overall, studies confirm the position of the American Academy of Nutrition and Dietetics on vegetarian diets that “plant-based diets, including vegan diets, can be adequate in all stages of life and can have certain benefits in overall health, considering some of their advantages in diet quality”, but some nutrients may be insufficient and should be given a bigger attention in these diets.

It is important to notice that a well planned plant-based diet is one that includes a high and varied intake of whole-plant foods such as beans, whole-grains, fruits, vegetables, nuts and seeds. Wether a child is having dairy or not is just one piece of the puzzle, and for the positive health outcomes seen for plant-based diets it is appropriate to recommend a daily intake of all groups of whole-plant foods, and to put emphasis on energy-dense healthy foods such as unsaturated fats sources is key to prevent undernutrition in this stage.

On the other hand, evidence shows that all dietary patters can have nutritional inadequacies that can be different, and should be addressed accordingly.

To support children on dairy-free diets, consider the following strategies:

• Fortified alternatives of dairy: Incorporate plant-based milks and other dairy substitutes fortified with calcium, vitamin D and vitamin B₁₂ on daily basis
• Calcium-rich foods: Include plant-based sources of calcium such as leafy green vegetables (e.g., kale, bok choy, broccoli), tofu, almonds, dried figs, chickpeas, and calcium-rich mineral water (≥400 mg/L) several times a day.
• Energy-dense foods: healthy energy can come from vegetable fats, which are mainly unsaturated, and a higher concentration of them in a child that is growing is important to cover their high energy needs. Include foods like nut butters, milled seeds, avocado and vegetable oils on daily basis and without restriction
• Include all whole-food plant-based groups on daily basis: fruits, vegetables, legumes, whole-grains, nuts and seeds should always be on the menu. These are the main sources of all important nutrients for growth and long-term health, and a higher intake of them is recommended for children following any dietary pattern.
• Increase bioavailability of key nutrients in foods: soak and cook legumes and whole-grains, and consider further processing such as grinding for a better bioavailability of iron and zinc, especially for small seeds such as chia, flaxseeds, poppy and sesame seeds.
• Supplementation: Consider vitamin B₁₂ supplements, especially for vegetarian and vegan children, to prevent deficiencies according to supplement recommendations. Vitamin D and omega-3 supplements may be also necessary for any dietary pattern, according to age, risk assessment and status.
• Physical activity: bone health in the long term is highly dependent on physical activity on the first stages of life, including childhood and adolescence. It is important to support your patient’s bone development and health by recommending physical activity throughout the lifespan, especially early in life, for both endurance and resistance type of exercises.
• Professional guidance: Consult with healthcare providers or dietitians to ensure the diet meets all nutritional requirements.

In conclusion, while dairy-free diets can be nutritionally adequate for children, but they should be adequately planned and monitored by health professionals, like other dietary patterns. With appropriate substitutions and professional guidance, children can thrive on dairy-free diets.