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Plant-based Beverages Are Not a Good Alternative for Young Children

Posted: 2019-10-31

 

Plant-based beverages continue to grow in popularity. There is a misconception that these beverages are healthy and nutritionally equivalent to cow’s milk but this is not the case (1). A comparison of the nutritional value of plant-based beverages in Canada, was covered recently in a televised news segment on the CTV Network.

The nutrient composition of plant-based beverages can become a problem for young children. With the exception of fortified soy beverages, if plant-based beverages displace breastmilk, formula or cow’s milk, young children can be at the risk of malnutrition. Plant-based beverages, excluding soy (soy-fortified beverages have a similar nutrient profile to cow’s milk), are very low in protein, calories and fat (1,2). There are currently 21 reports and case series published in the literature of severe malnutrition and nutritional disease in children who consumed rice and nut beverages instead of breastmilk, formula or cow’s milk (3-23). This number is up from seven reports noted in 2016 (2). While many plant-based beverages are fortified with vitamins and minerals, the amounts vary widely, and it is not known if the bioavailability of the minerals and protein is the same as cow’s milk (1,3,24).

A recently released technical scientific report, from a panel of experts representing key national health and nutrition organizations in the U.S., recommended for young children that “Consumption of [plant milks] as a full replacement for dairy milk should be undertaken in consultation with a health care provider so that adequate intake of key nutrients commonly obtained from dairy milk can be considered in dietary planning” (1).

For country-specific (Australia, Canada, New Zealand, U.K.) recommendations for consuming plant-based beverages, see the PEN Practice Question: What are recommendations for the use of plant-based beverages (e.g. soy, rice, almond, coconut and oat milk/beverage) during the complementary feeding period in infants?

For more information on the potential health implications of plant-based beverages in young children, see the PEN Trending Topic: Plant-based Beverages – Are They Really Healthier for Young Children, and the Dietitians of Canada News Release: Dietitians, paediatricians advise parents to exercise caution with plant-based beverages.

For information and practical tips for providing children with healthy drinks see the website: https://healthydrinkshealthykids.org (Note: this is a U.S. website and recommendations are based on the technical scientific report noted above (1). These recommendations may be different from other country recommendations, particularly around juice consumption.

References

1. Lott M, Callahan E, Welker Duffy E, Story M, Daniels S. Healthy beverage consumption in early childhood: recommendations from key national health and nutrition organizations. Technical Scientific Report. Durham, NC: Healthy Eating Research; 2019. Available from: http://healthyeatingresearch.org
2. Dietitians of Canada. What are the recommendations for the use of plant-based beverages (e.g. soy, rice, almond, coconut and oat milk/beverage) during the complementary feeding period in infants? In: Practice-based Evidence in Nutrition [PEN]. 2016 Apr 14 [cited 2019 Oct 29]. Available from: https://www.pennutrition.com/KnowledgePathway.aspx?kpid=2503&pqcatid=146&pqid=19553&kppid=19554&book=Evidence&num=1#Evidence. Access by subscription only. 
3. Vitoria I. The nutritional limitations of plant-based beverages in infancy and childhood. Nutr Hosp. 2017;34(5):1205-214. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/29130721
4. Ellis D, Lieb J. Hyperoxaluria and genitourinary disorders in children ingesting almond milk products. J Pediatr. 2015 Nov;167(5):1155-8. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/26382627
5. Diamanti A, Pedicelli S, D'Argenio P, Panetta F, Alterio A, Torre G. Iatrogenic kwashiorkor in three infants on a diet of rice beverages. Pediatr Allergy Immunol. 2011. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/22122793
6. Barreto-Chang OL, Barreto-Chang O, Pearson D, Shepard WE, Longhurst CA, Longhurst C, et al. Vitamin D -deficient rickets in a child with cow's milk allergy. Nutr Clin Pract. 2010 Aug;25(4):394-8. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/20702845
7. Mesa Medina O, González JL, García Nieto V, Romero Ramírez S, Marrero Pérez C. Infant metabolic alkalosis of dietetic origin. An Pediatr (Barc). 2009 Apr;70(4):370-3. Spanish. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/19303829
8. Kuhl J, Davis MD, Kalaaji AN, Kamath PS, Hand JL, Peine CJ. Skin signs as the presenting manifestation of severe nutritional deficiency: report of 2 cases. Arch Dermatol. 2004 May;140(5):521-4. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15148094
9. Novembre E, Leo G, Cianferoni A, Bernardini R, Pucci N, Vierucci A. Severe hypoproteinemia in infant with AD. Allergy. 2003 Jan;58(1):88-9. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/12580819
10. Doron D, Hershkop K, Granot E. Nutritional deficits resulting from an almond-based infant diet. Clin Nutr. 2001 Jun;20(3):259-61. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11407873
11. Massa G, Vanoppen A, Gillis P, Aerssens P, Alliet P, Raes M. Protein malnutrition due to replacement of milk by rice drink. Eur J Pediatr. 2001 Jun;160(6):382-4. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11421421
12. Kanaka C, Schütz B, Zuppinger KA. Risks of alternative nutrition in infancy: a case report of severe iodine and carnitine deficiency. Eur J Pediatr. 1992 Oct;151(10):786-8. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/1425805
13. Vitoria I, López B, Gómez J, Torres C, Guasp M, Calvo I, Dalmau J. Improper use of a plant-based vitamin C-deficient beverage causes scurvy in an infant. Pediatrics. 2016 Feb;137(2):e20152781. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/26783325
14. Mori F, Serranti D, Barni S, Pucci N, Rossi ME, de Martino M, et al. A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis. Nutr J. 2015 Aug 21;14:83. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/26293684
15. Le Louer B, Lemale J, Garcette K, Orzechowski C, Chalvon A, Girardet JP, et al. Severe nutritional deficiencies in young infants with inappropriate plant milk consumption. Arch Pediatr. 2014 May;21(5):483-8. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/24726668
16. Alvares M, Kao L, Mittal V, Wuu A, Clark A, Bird JA. Misdiagnosed food allergy resulting in severe malnutrition in an infant. Pediatrics. 2013 Jul;132(1):e229-32. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/23733797
17. Katz KA, Mahlberg BA, Honig PJ, Yan AC. Rice nightmare: kwashiorkor in 2 Philadelphia-area infants fed Rice Dream beverage. J Am Acad Dermatol. 2005 May;52(5 Suppl 1):S69-72. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15858513
18. Carvalho NF, Kenney RD, Carrington PH, Hall DE. Severe nutritional deficiencies in toddlers resulting from health food milk alternatives. Pediatrics. 2001 Apr:107(4):e46. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11335767
19. Keller MD, Shuker M, Heimall J, Cianferoni A. Severe malnutrition resulting from use of rice milk in food elimination diets for atopic dermatitis. Isr Med Assoc J. 2012 Jan;14(1):40-2. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/22624441
20. Fourreau D, Peretti N, Hengy B, Gillet Y, Courtil-Teyssedre S, Hess L, et al. [Pediatric nutrition: severe deficiency complications by using vegetable beverages, four cases report]. Presse Med. 2013 Feb;42(2):e37-43. [French]. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/23021957
21. Tierney EP, Sage RJ, Shwayder T. Kwashiorkor from a severe dietary restriction in an 8-month infant in suburban Detroit, Michigan: case report and review of the literature. Int J Dermatol. 2010 May;49(5):500-6. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/20534082
22. Liu T, Howard RM, Mancini AJ, Weston WL, Paller AS, Drolet BA, et al. Kwashiorkor in the United States: fad diets, perceived and true milk allergy, and nutritional ignorance. Arch Dermatol. 2001 May;137(5):630-6. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11346341
23. Imataka G, Mikami T, Yamanouchi H, Kano K, Eguchi M. Vitamin D deficiency rickets due to soybean milk. J Paediatr Child Health. 2004 Mar;40(3):154-5. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15009584
24. Singhal S, Baker RD, Baker SS. A comparison of the nutritional value of cow's milk and nondairy beverages. J Pediatr Gastroenterol Nutr. 2017 May;64(5):799-805. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/27540708