- Infancy: A Critical Time
- B12 in Breast Milk of Vegans
- Infants of Vegan Mothers Who Do Not Use B12 Supplements
- Black Hebrews
- Correction of B12 Deficiency in Infants
- Vegan Infants Taking B12 Supplements
Infants breastfed by vegan mothers who supplement their diets with B12, or infants who receive B12 through fortified foods or supplements, develop normally. Infants breastfed by vegan mothers who do not supplement with B12 and do not receive B12 fortified foods or supplements often develop severe B12 deficiency and nerve-related disorders.
During pregnancy, B12 is actively transported by the placenta to the fetus, which can reduce the mother’s stores of B12 if she has none in her diet (1).
Infancy: A Critical Time
Weaning may be a critical time to ensure that vegan infants have plenty of B12, as low B12 levels at weaning were correlated to retarded growth in one study of vegan, macrobiotic children (2).
In contrast to the adult’s normal storage of 2-3,000 µg B12, newborn infants (of mothers with normal B12 stores) have body stores of only 25 µg. B12 stores in infants at birth are normally adequate to last the first several weeks of life (1), after which they must get it from breast milk or other sources. Studies have shown that colostrum and/or milk during the first week of life contains larger amounts of B12 (as much as 2421 pg/ml) than later milk (3). The B12 in mother’s milk is more related to current B12 intake than to mother’s B12 stores (4). Serum B12 levels of healthy, nonvegetarian infants decrease progressively until 6 months (5), after which they start to increase again.
If the mother is B12 deficient during pregnancy, the baby may have low B12 levels and some have developed clinical signs of deficiency as young as 2 weeks of age (6). At birth, these newborns typically have higher B12 levels than their mothers and usually show no deficiency symptoms (5).
Minet et al (7). (2000, Switzerland) found that among apparently healthy infants, low serum B12 (and serum folate) was correlated with increased homocysteine levels; many infants in the lower range of normal serum B12 had elevated homocysteine levels. Breastfed infants had significantly lower B12 levels and significantly higher homocysteine levels than infants using a formula fortified with B12. This does not mean that mothers should choose formula over breast milk, as there are many advantages to breastfeeding. Rather, it indicates that even among the non-vegetarian population, B12 can be a problem in infants, and breastfeeding mothers should consider a B12 supplement for themselves and/or their infants.
In rare cases, some infants cannot convert cyanocobalamin to an active form of vitamin B12 and thus cannot rely on cyanocobalamin supplements (7). These infants require medical treatment.
B12 in Breast Milk of Vegans
In a small cross-sectional study of vegan, vegetarian, and non-vegetarian breastfeeding women in the U.S., there was no significant difference in breast milk vitamin B12 concentrations between the three groups (18). Of the 26 vegan women in the study, 24 were taking supplements containing B12. For more information see Vitamin B12 Levels in Breast Milk of Vegan Women.
Infants of Vegan Mothers Who Do Not Use B12 Supplements
Since 1980, and excluding the Black Hebrews described below, there have been at least 30 reports of very serious B12 deficiency in vegan mothers’ infants whose main or only food was breast milk. This happened only when the mother did not supplement her own or the baby’s diet with B12. In many cases, the mother belongs to a subculture which does not believe in supplementation. Lack of B12 in the mother’s diet during pregnancy has been shown to cause a severe lack of myelin in nerve tissue (8).
B12 Deficiency Cases in Vegan Infants and Toddlers lists the cases since 1981 in which infants of vegan mothers have suffered from B12 deficiency. In all cases, the infants are healthy until about 1-12 months of age after which they fail to thrive and show developmental regression. They are lethargic, lose their ability to use their muscles adequately, and sometimes cannot sense properly. They normally have macrocytic anemia, which is unusual in childhood and normally due to nutritional deficiency rather than to congenital disease (9).
Zmora et al. (10) (1979, Israel) reported severe nutritional deficiencies in 4 infants from a vegan religious community, the Black Hebrews. The Black Hebrews originated in the USA. The infants received breast milk until the age of 3 months; thereafter, breast milk was supplemented with, or replaced by, extremely low caloric preparations. All of the infants had profound protein-calorie malnutrition, severe rickets, osteoporosis, and B12 and other deficiencies. One infant died, while 3 others recovered after treatment.
After discharge of the infants from the hospital, the community responded well to a modification of the infants’ diet which did not violate their vegetarian philosophy. However, they refused to give their infants B12 on a regular basis.
Shinwell & Gorodischer (11) (1982, Israel) also reported on a Black Hebrew religious community. Infants were breast-fed for 3 months and then fed mainly a dilute, homemade soymilk from 3 months to 1 year. 25 infants showed evidence of protein-calorie malnutrition, iron and B12-deficient anemia, rickets, zinc deficiency, and multiple recurrent infections. 3 of the infants were dead on arrival to a hospital. 5 more died within a few hours of admission despite treatment. Serum B12 levels were low in 9 of 15 cases (undetectable in 3).
Shinwell & Gorodischer said, “In spite of tactful but perseverant contact with the community health leaders during this time, no change in feeding habits of infants was achieved.”
The reason the Black Hebrew leaders gave for withholding vitamin supplements:
If the organism of the cow subsists by eating plant foods only, why should the human organism need artificial vitamins, animal foods, and drugs?
Correction of B12 Deficiency in Infants
Although B12 supplementation has been shown to result in rapid lab value improvements in these infants, concern has been raised about their long-term development.
von Schenck (12) (1997) reviewed 25 reports of infant B12 deficiency which had appeared in the scientific literature. Among the 25 cases, vegan mothers were associated with 13 (9 of which occurred since 1980 and are included in B12 Deficiency Cases in Vegan Infants and Toddlers. Of the 7 vegans that were followed, 5 had abnormal neurological development at their final follow-up (26 months, 26 months, 2 years, 5 years, and 12 years after diagnosis). 2 were normal at their respective final follow-up (13 months and 2 years).
von Schenck says, “Efforts should be directed therefore to preventing deficiency in pregnant and breastfeeding women on vegan diets and their infants?. If dietary changes are not acceptable to parents, vitamin B12 supplements are essential.”
Grattan-Smith et al. (13) (1997, Australia) reports the cases of 3 infants of vegan mothers who developed muscle twitching and/or seizure-like symptoms upon treatment with B12 in doses of 500 µg or more. Other infants have developed tremors at doses of 300 µg. Grattan-Smith et al. state that in the cases of dietary deficiency in infants, it seems unnecessary to give such high doses of B12.
Interestingly, Goraya (14) (1998, India) reported that in India, many infants have “infantile tremor syndrome.” This occurs in exclusively breastfed infants from low socioeconomic conditions. Documented B12 deficiency, megaloblastic anemia, and response to B12 therapy was observed in some but not all patients.
Vegan Infants and Children Receiving Dietary B12
In stark contrast, Sanders (15) (1988, UK) studied the growth and development of 37 vegan children. All were breastfed for their first 6 months and in most cases well into their second year. The majority of these children grew and developed normally. They tended to be smaller in stature and lighter in weight than the general population. Energy, calcium, and vitamin D intakes were usually below the recommended amounts. Their diets were generally adequate with a few children having low intakes of riboflavin and B12. Most parents knew to supplement the diet with B12.
Sanders concludes that provided sufficient care is taken, a vegan diet can support normal growth and development. In another paper (16), Sanders points out that many potential hazards of vegan diets can be avoided by the use of soymilks fortified with calcium and B12 in the post-weaning period.
Fulton et al. (17) (1980, USA) studied 48 preschool children between 2-5 years old, who had followed a vegan diet since birth. They lived at The Farm, a vegan commune in Tennessee, where soymilk was fortified with B12 at a rate of 6.25 µg per 8 oz of milk. They also supplemented with nutritional yeast containing 2.0 µg B12 per tablespoon, which they used as a flavoring agent in many foods. B12 status was not assessed, but there were no cases of overt B12 deficiency reported.
2. Schneede J, Dagnelie PC, van Staveren WA, Vollset SE, Refsum H, Ueland PM. Methylmalonic acid and homocysteine in plasma as indicators of functional cobalamin deficiency in infants on macrobiotic diets. Pediatr Res. 1994 Aug;36(2):194-201.
3. Specker BL, Black A, Allen L, Morrow F. Vitamin B-12: low milk concentrations are related to low serum concentrations in vegetarian women and to methylmalonic aciduria in their infants. Am J Clin Nutr. 1990 Dec;52(6):1073-6.
4. Food and Nutrition Board, Institute of Medicine.Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 2000.
6. Drogari E, Liakopoulou-Tsitsipi T, Xypolyta-Zachariadi A, Papadellis F, Kattamis C. Transient methylmalonic aciduria in four breast fed neonates of strict vegetarian mothers in Greece. Journal of Inherited Metabolic Disease. 1996 19S:A84. (Abstract)
7. Minet JC, Bisse E, Aebischer CP, Beil A, Wieland H, Lutschg J. Assessment of vitamin B-12, folate, and vitamin B-6 status and relation to sulfur amino acid metabolism in neonates. Am J Clin Nutr. 2000 Sep;72(3):751-7.
13. Grattan-Smith PJ, Wilcken B, Procopis PG, Wise GA. The neurological syndrome of infantile cobalamin deficiency: developmental regression and involuntary movements. Mov Disord. 1997 Jan;12(1):39-46.
18. Pawlak R, Vos P, Shahab-Ferdows S, Hampel D, Allen L, Perrin M. Vitamin B-12 content in breast milk of vegan, vegetarian, and nonvegetarian lactating women in the United States. Am J Clin Nutr. 2018 June; 146(5): 1125–1131. doi: 10.3945/jn.115.228189.