Pregnancy, Infants, and Children

Contents

• Introduction
• Pregnancy
• Vitamin B12 Levels During Pregnancy
• More information on Pregnancy and Vegan Diets
• Birth Defects
• Nursing
• Infants
  • Safety of Soy Formulas
• Children
  • Germany (2019 and 2021)
  • Poland (2021)
  • Fiber and Children
  • More Information on Feeding Vegan Children
• References

Introduction

This page features information about specific details about vegan diets for pregnancy, breastfeeding, and children that are not typically addressed elsewhere. For general information, see Vegan Nutrition in Pregnancy and Childhood by Reed Mangels, PhD, RD and Katie Kavanagh-Prochaska, RD. Nutrition Tips for Vegans contains recommendations.

In their 5th Edition (2004) of the Pediatric Nutrition Handbook, the American Academy of Pediatrics says:

Children exhibit good growth and thrive on most lacto-ovo vegetarian and vegan diets when they are well planned and supplemented appropriately. (Chapter 12: Nutrition Aspects of Vegetarian Diets, p. 194)

In their 2016 Position Paper, Vegetarian Diets, the Academy of Nutrition and Dietetics says:

It is the position of the Academy of Nutrition and Dietetics that appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes

[Update December 2022: The Academy of Nutrition and Dietetics 2016 Position Paper on vegetarian diets has expired. To our knowledge there are no plans to replace it.]

See Real Vegan Children for examples of vegan kids whose mothers had a vegan pregnancy.

Pregnancy

Pregnant vegans should make sure they have a reliable supply of vitamin B12, iodine, and choline.

Deva Nutrition has a Vegan Prenatal Multivitamin.

A systematic review of vegan and vegetarian pregnancies published in 2015 concluded that “vegan [and] vegetarian diets may be considered safe in pregnancy, provided that attention is paid to vitamin and trace element requirements [mainly vitamin B12 and iron].” The authors acknowledged that there were a limited number of studies of vegan and vegetarian pregnancy. They focused on vegan and vegetarian diets that were chosen freely and not linked with limited access to food or with poverty (Piccoli, 2015).

Two of six studies of vegetarian mothers showed an increased risk of having a boy with hypospadias. You can read more about that research in the article Hypospadias and Vegetarian Diets.

Two studies (Avnon, 2020; Kesary, 2020) from Israel examined vegan diets in pregnancy and found:

• Vegan women had a slightly lower BMI prior to pregnancy than did omnivores. The second study reported that significantly more vegan women than omnivores were categorized as underweight prior to pregnancy (12.7% vs. 7.8%).
• Vegan women gained less weight during pregnancy than did omnivores (average of 25.5 lbs. vs. 31.5 lbs. in the first study; 26.8 lbs. vs 30.4 lbs. in the second study).
• Infants of vegan women weighed less at birth than did infants of omnivores (average of 6 lb. 10 oz. vs. 7 lb. 5 oz. in one study; birth weights were only specified as percentiles in the other study).

Significantly more infants whose mothers were vegan were classified as being small for gestational age compared to infants whose mothers were omnivores. Babies that are classified as small for gestational age are smaller than 90% of babies of the same gestational age and have a higher risk of problems like low blood sugar and difficulty maintaining body temperature after birth.

Many factors can result in having a small for gestational age infant including the parents being smaller; the mother having conditions such as diabetes, high blood pressure, or an infection; problems with the placenta; and birth defects. We don’t know what caused the higher incidence of small for gestational age infants in these studies; we do know that starting a pregnancy underweight and gaining less than the recommended amount of weight in pregnancy are associated with delivering a small baby. You can see current weight gain recommendations in the Center for Disease Control and Prevention’s article Weight Gain During Pregnancy.

Vitamin B12 Levels During Pregnancy

Some people who monitor their B12 levels on a regular basis might want to know what to expect during pregnancy.

We found no comparisons of B12 levels before pregnancy to during pregnancy, and so were unable to determine if there is a significant change upon becoming pregnant. Three studies have compared B12 levels at different times during pregnancy among apparently healthy omnivores.

Two studies from Denmark found that serum B12 decreases over the course of pregnancy while holotranscobalamin, a marker of B12 delivery to cells, stays steady (Greibe, 2011; Morkbak, 2007). The prevalence of B12 supplementation among the women studied wasn’t stated.

A study from Canada found that both serum B12 and holotranscobalamin decreased slightly from the 1st to 2nd trimester in a population in which B12 supplementation was common (Schroder, 2019).

We’ve summarized the data from these studies in our spreadsheet, B12 Levels in Pregnancy.

More information on Pregnancy and Vegan Diets

• Pregnancy and the Vegan Diet by Reed Mangels, PhD, RD
• Your Complete Vegan Pregnancy (2019) by Reed Mangels, PhD, RD
• Gestational Diabetes on VeganHealth.org

Birth Defects

Folic acid supplementation in the weeks before and after conception has been shown to decrease the risk of neural tube defects (NTDs), such as spina bifida, in more than 10 studies (USPSTF, 2017). While the focus has been primarily on folic acid, vitamin B12’s role has also been studied:

• Five case-control studies found that women with low B12 status were significantly more likely to have a baby born with NTDs; five studies found significantly lower B12 in the amniotic fluid of babies with NTDs. Women who began pregnancy with blood vitamin B12 levels below about 250 pmol/l were at the highest risk for having an infant with a NTD (Molloy, 2018).
• A case-control study from the UK of 135 women, 27 of whom had a baby with a NTD, found that women who had children with NTDs had B12 levels an average of 28 pmol/l lower in the first trimester than controls. However, after adjusting for folate levels, there was no independent association for B12 and NTDs (Wald, 1996). Other, more recent case-control studies have found an association of B12 independent of folic acid (Zhang, 2009; Ray, 2007).
• A case-control study from Turkey of 194 infants, in which 92 had NTDs, found significantly lower plasma B12 in infants with NTDs and their mothers (Peker, 2016).
• A case-control study from France of 14 unborn fetuses with NTDs and 16 unborn fetuses without NTDs found those with NTD had significantly lower amounts of stored B12 in their livers (Fofou-Caillierez, 2019).

Vegans should ensure adequate B12 and folic acid intake in the weeks before and after conception to reduce the risk of NTDs. See Vitamin B12 for our recommendations for pregnancy. Use of a folic acid supplement and/or foods fortified with folic acid providing at least 400 μg/d of folic acid is recommended for all women able to become pregnant, and should be continued through the first 2 to 3 months of pregnancy (CDC, 1992; USPSTF, 2017; WHO, 2019).

Nursing

Vegans who are breastfeeding should make sure they have a reliable supply of vitamin B12, omega-3 fats, and iodine.

Some women continue to use a prenatal vitamin-mineral supplement during lactation.

A systematic review of vegan and vegetarian lactation published in 2020 concluded that the breast milk of vegan and vegetarian women who are meeting nutrition requirements (presumably the Dietary Reference Intakes) was nutritionally equivalent to the breast milk of well-nourished nonvegetarian women. The fat composition of breast milk tended to reflect the women’s diets. Breast milk from nonvegetarians was higher in saturated fat and breast milk from vegetarians was higher in unsaturated fat (Karcz, 2020).

More information:

• Lactation and the Vegan Diet—Reed Mangels, PhD, RD

Infants

The Academy of Nutrition and Dietetics and the American Academy of Pediatrics agree that well-planned vegan diets can satisfy the nutrient needs and normal growth of infants (Mangels, 2001).

It’s important for child development that the mothers of exclusively breast-fed infants ensure they’re getting a reliable supply of vitamin B12.

Vegan parents should not try to make their own infant formulas as this often leads to poor child development. Although more research is desirable, it appears that soy infant formulas are safe. See below for information regarding soy formulas.

Breast milk is usually low in vitamin D. Because of this, the American Academy of Pediatrics recommends that breastfed infants be given a vitamin D supplement providing 400 IU/day beginning soon after birth (Wagner, 2008.). One study found that lactating women who took a vitamin D supplement containing 6,400 IU of vitamin D3 had breast milk that contained enough vitamin D to meet their infants’ needs (Hollis, 2015). This could be an alternative to giving the infant a vitamin D supplement.

In 2008, the American Academy of Pediatrics raised its recommendations for infants from 5 µg (200 IU) of vitamin D per day to 10 µg (400 IU). They stated, “It is now recommended that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth (Wagner, 2008.).”

More information:

• Vegetarian Infants (PDF)—Vegetarian Nutrition Dietetic Practice Group
• Feeding Vegan Kids—Reed Mangels, PhD, RD
• Vitamin A and Breastfed Babies—Reed Mangels, PhD, RD

Food writer, Nina Planck, occasionally writes articles to dissuade parents from feeding their infants and children a vegan diet. Here are two responses to her articles from experts on vegan nutrition for infants and children:

• Vegan Children: Response to NYT Op-Ed—Reed Mangels, PhD, RD
• The New York Times, Nina Planck, and Safety of Vegan Diets—Ginny Messina, MPH, RD

Safety of Soy Formulas

The short answer is that soy formula is just as safe as cow’s milk formula, but it’s not intended for pre-term infants.

For a review of the research on the safety of soy formulas, see Soy Part 2—Research.

Children

There aren’t many published studies of vegan children and most of the available studies are old and have a small number of subjects. When we think about how much more information is now available to vegan parents than was available 30 or more years ago and about the proliferation of fortified foods, it’s possible that studies of vegan children from 1990 or earlier may not be relevant today. There are two more recent studies, from Germany and Poland, summarized below.

Germany (2019 and 2021)

Two recent studies from Germany examined the diet and growth of vegan children.

One compared 139 vegan children to 127 vegetarian and 164 nonvegetarian children age 1-3 years. There was no significant difference in weight-for-age, height-for-age, or weight-for-height scores between the groups, suggesting that the children in all groups were growing normally (Weder, 2019).

Vegan children had the highest intakes of carbohydrate (median 53.8% of calories for vegans; 53.6% for vegetarians; 53.1% for nonvegetarians) and fiber while nonvegetarian children had the highest intakes of protein, fat, and added sugars. On average, all groups had protein intakes that were more than adequate and all groups met the German recommendations for protein, fat, and carbohydrates.

The World Health Organization (WHO) defines “stunting” as when a child’s height for their age is considerably below what would be expected. In some cases, stunting can be explained by a child’s parents being very short—chances are their child will also be short. In other cases, stunting can indicate poor nutrition.

The researchers in the German study reported that 3.6% of the vegan children, 2.4% of the vegetarian children, and 0% of the nonvegetarian children were classified as stunted based on their height for their age. Of the 8 children (5 vegans, 3 vegetarians) classified as stunted, stunting could be explained by factors not related to a vegan or vegetarian diet:

• Two had a very low caloric intake and were exclusively breastfed beyond the age when complementary foods are usually introduced, and one of those was small for gestational age (SGA) which increases the risk for stunting.
• Three had parents who were short.
• One was SGA.
• One was exclusively breastfed beyond the age when complementary foods are usually introduced and had short parents.
• One was exclusively breastfed beyond the age when complementary foods are usually introduced.

Exclusive breastfeeding is recommended for the first 6 months after birth with the introduction of complementary foods at around 6 months. After a certain age, breast milk alone cannot meet a child’s needs for calories and nutrients. Most vegan children are not SGA (Piccoli, 2015).

Overall, this study indicates that a vegan diet supports normal growth in childhood.

The second study was of older children and adolescents (6-18 years old) and compared 115 vegans to 149 vegetarians and 137 nonvegetarians (Alexy, 2021). There was no significant difference in height, weight, or BMI among the groups. Most vegans (88%) used a vitamin B12 supplement and more than half of the vegans used a vitamin D supplement. Median protein intake of all groups was above the German reference value of 0.9 g/kg/day. The vegan children had low calcium intakes; the median calcium intake was less than half of the recommended intake. Approximately 8% of the vegans were categorized as likely deficient in vitamin B12 compared to 13% of vegetarians and 4% of nonvegetarians.

Poland (2021)

A study from Poland examined growth, body composition, and nutritional status in 52 vegan children compared to 63 vegetarian and 72 nonvegetarian children age 5–10 years (Desmond, 2021).

The average height of both vegetarians and vegans was less than that of the nonvegetarians, averaging 1.25 inches shorter for vegans and 0.75 inches shorter for vegetarians; the difference between vegetarians and nonvegetarians wasn’t statistically significant. Vegans also had a lower mean body mass index.

The vegan children had a lower average bone density even after adjusting for their smaller body size. The average intake of all diet groups was below the RDA for calcium and vitamin D despite about one-third using a vitamin D supplement; the vegan children’s intake of these nutrients was significantly less than that of the nonvegetarians possibly contributing to their lower bone density. Vegan children using vitamin D supplements had higher serum vitamin D concentrations than did nonvegetarians.

The vegan children had lower average serum cholesterol, LDL cholesterol, and HDL cholesterol. They also had lower hemoglobin, hematocrit, and ferritin. About 2% of vegans had a moderate iron-deficiency anemia; none had severe iron deficiency anemia.

About 70% of the vegan children used a vitamin B12 supplement, vitamin B12-fortified foods, or both. Based on blood levels, about 13% of vegan children were deficient in vitamin B12; those receiving both vitamin B12 supplements and fortified foods were least likely to be deficient.

The results of this study support the need for vegan children to have adequate intakes of vitamin B12, calcium, and vitamin D.

Fiber and Children

Fiber recommendations for children vary depending on their age.

Fiber Recommendations

Age	Fiber (g/day)
1-3 years	19
4-8 years	25
Boys, 9-13 years	31
Girls, 9-13 years	26
Boys, 14-18 years	38
Girls, 14-18 years	26
Source: FNB, 2002

Vegan children often get this much, or even more fiber. There is no official upper limit on fiber; however, sometimes young children whose stomach capacity is small, can fill up on high fiber foods and not get enough calories. Very high fiber diets can interfere with absorption of minerals like iron and zinc.

If a child’s growth is within the normal limits and he or she is eating a variety of foods, it’s not likely that excess fiber is something to be concerned about. If a health care provider is concerned about the child’s growth being lower than expected and the child is eating a lot of high fiber foods—whole grains, beans, fruits, and vegetables—it may be helpful to reduce fiber somewhat.

For example, having the child eat some low-fiber foods such as refined grains, peeled fruits and vegetables, and added oils could help (Messina, 2001). Nuts and nut butters can also increase children’s calorie and protein intake. For younger children, be sure to chop or grind nuts well enough to prevent choking.

Most children don’t need high fiber supplements—check with the child’s health care provider before using these.

Vegan children who do not eat much because they get full easily can benefit from eating some low-fiber foods such as refined grains, peeled fruits and vegetables, and added oils (Messina, 2001). Nuts and nut butters can also increase their calorie and protein intake. For younger children, be sure to chop or grind nuts well enough to prevent choking.

More Information on Feeding Vegan Children

• Iodine and Young Children—Reed Mangels, PhD, RD
• Feeding Vegan Kids—Reed Mangels, PhD, RD
• Raising Vegetarian Children (2002)—Joanne Stepaniak, MS ED and Vesanto Melina, MS, RD
• Vegetarian Resource Group’s Facebook group for parents of vegetarian or vegan children

References

Last updated June 2021

Alexy U, Fischer M, Weder S, et al. Nutrient intake and status of German children and adolescents consuming vegetarian, vegan or omnivore diets: Results of the VeChi Youth Study. Nutrients. 2021;13(5):1707.

Avnon T, Paz Dubinsky E, Lavie I, Ben-Mayor Bashi T, Anbar R, Yogev Y. The impact of a vegan diet on pregnancy outcomes [published online ahead of print, 2020a Sep 1]. J Perinatol. 2020;10.1038/s41372-020-00804-x. 

Centers for Disease Control. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR Recomm Rep. 1992;41(RR-14):1-7.

Desmond MA, Sobiecki JG, Jaworski M, et al. Growth, body composition, and cardiovascular and nutritional risk of 5- to 10-y-old children consuming vegetarian, vegan, or omnivore diets . Am J Clin Nutr. 2021;113(6):1565-1577.

Finkelstein JL, Layden AJ, Stover PJ. Vitamin B-12 and Perinatal Health. Adv Nutr. 2015;6(5):552-563. [Reviewed]

Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, D.C.:National Academies Press; 2002.

Fofou-Caillierez MB, Guéant-Rodriguez RM, Alberto JM, et al. Vitamin B-12 and liver activity and expression of methionine synthase are decreased in fetuses with neural tube defects. Am J Clin Nutr. 2019;109(3):674-683.

Greibe E, Andreasen BH, Lildballe DL, Morkbak AL, Hvas AM, Nexo E. Uptake of cobalamin and markers of cobalamin status: a longitudinal study of healthy pregnant women. Clin Chem Lab Med. 2011 Nov;49(11):1877-82.

Gu Q, Li Y, Cui ZL, Luo XP. Homocysteine, folate, vitamin B12 and B6 in mothers of children with neural tube defects in Xinjiang, China. Acta Paediatr. 2012;101(11):e486-e490. Not cited.

Hollis BW, Wagner CL, Howard CR, et al. 2015. Maternal versus infant vitamin D supplementation during lactation: A randomized controlled trial. Pediatrics 136(4):625–34.

Hovinen T, Korkalo L, Freese R, Skaffari E, Isohanni P, Niemi M, Nevalainen J, Gylling H, Zamboni N, Erkkola M, Suomalainen A. Vegan diet in young children remodels metabolism and challenges the statuses of essential nutrients. EMBO Mol Med. 2021 Feb 5;13(2):e13492. Not cited; only 6 vegans.

Karcz K, Królak-Olejnik B. Vegan or vegetarian diet and breast milk composition – a systematic review. Crit Rev Food Sci Nutr. 2020 Apr 22:1-18. doi: 10.1080/10408398.2020.1753650. [Epub ahead of print]

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Molloy AM. Should vitamin B12 status be considered in assessing risk of neural tube defects Ann N Y Acad Sci. 2018;1414(1):109-125.

Morkbak AL, Hvas AM, Milman N, Nexo E. Holotranscobalamin remains unchanged during pregnancy. Longitudinal changes of cobalamins and their binding proteins during pregnancy and postpartum. Haematologica. 2007 Dec;92(12):1711-2.

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Schroder TH, Tan A, Mattman A, Sinclair G, Barr SI, Vallance HD, Lamers Y. Reference intervals for serum total vitamin B12 and holotranscobalamin concentrations and their change points with methylmalonic acid concentration to assess vitamin B12 status during early and mid-pregnancy. Clin Chem Lab Med. 2019 Oct 25;57(11):1790-1798.

US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Folic Acid Supplementation for the Prevention of Neural Tube Defects: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(2):183-189.

Wagner CL, Greer FR, and the Section on Breastfeeding and Committee on Nutrition. Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents. Pediatrics 2008;122:1142-1152. (PDF)

Wald NJ, Hackshaw AD, Stone R, Sourial NA. Blood folic acid and vitamin B12 in relation to neural tube defects. Br J Obstet Gynaecol. 1996 Apr;103(4):319-24.

Weder S, Hoffmann M, Becker K, Alexy U, Keller M. Energy, macronutrient intake, and anthropometrics of vegetarian, vegan, and omnivorous children (1-3 Years) in Germany (VeChi Diet Study). Nutrients. 2019 Apr 12;11(4).

World Health Organization. Periconceptional folic acid supplementation to prevent neural tube defects. WHO—e-Library of Evidence for Nutrition Actions (eLENA); Updated February 11, 2019.

Yang M, Li W, Wan Z, Du Y. Elevated homocysteine levels in mothers with neural tube defects: a systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2017;30(17):2051-2057. [Reviewed]

Zhang T, Xin R, Gu X, et al. Maternal serum vitamin B12, folate and homocysteine and the risk of neural tube defects in the offspring in a high-risk area of China. Public Health Nutr. 2009;12(5):680-686.