General approach to families who follow a vegetarian or vegan diet: - Review parental knowledge on preparation of foods and their access to a variety of foods.
- Consider referral to dietitian for evaluation of 3-day food diary and detailed counseling (especially if diet is vegan).
- Emphasize that infants and toddlers should not be given homemade infant formulas, including those made from a recipe that the parent might perceive to be healthy. Homemade formulas are usually deficient in key nutrients and this can have severe health effects.
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| Lactating mother | Infant |
| Breastfed | Formula fed |
Vitamin B12: - Consume vitamin B12-fortified foods (cereals, alternative milk, meat analogs, and nutritional yeast), and
- If mother is lacto-vegetarian (or consumes meat or fish less than once weekly), either supplement with vitamin B12 (50 mcg/day) or check serum B12 level/urinary methylmalonic acid and supplement if needed.
- If mother is vegan, supplement empirically with vitamin B12 (50 mcg/day).
| Vitamin B12: - If mother follows a lacto-vegetarian or vegan diet and does not take a vitamin B12 supplement, supplement the infant with vitamin B12.
- The RDA is 0.4 mcg for infants 0 to 6 months and 0.5 mcg for those >6 months.
| Vitamin B12: - Commercial infant formulas (either cow's milk-based or soy-based) are typically adequate in vitamin B12, proteins, calcium, iron, zinc, iodine, and DHA (if the formula is DHA enriched).
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Vitamin D: - If mother declines to give the infant a vitamin D supplement, the lactating mother should take a vitamin D supplement:
- 100 to 160 mcg (4000 to 6400 int. units) daily, or
- 1250 mcg (50,000 int. units) once weekly or once every 2 weeks.
- A vitamin D2 supplement derived from fungi is suitable for vegetarian or vegan diets.
| Vitamin D: - For all breastfed infants, supplement with vitamin D:
- 10 mcg (400 int. units) daily, beginning within the first few days of life.
- Continue supplement until the infant is weaned to at least 1 L/day of vitamin D-fortified formula or whole milk.
- Commercial infant vitamin D drops are derived from sheep's wool (lanolin) and thus are suitable for vegetarians but not vegans.
| Vitamin D: - If infant consumes less than 32 oz/day formula, supplement with vitamin D: 10 mcg (400 int. units) daily.
- Do not use a homemade infant formula (which is likely to be deficient in vitamin D and other nutrients).
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Protein: - Consume a nutrient-rich balanced diet comprised of a variety of vegetables, cereals, and appropriate sources of protein.
| Protein: - Human milk provides the appropriate macronutrient balance for the infant, including protein.
| Protein: - Appropriate macronutrient balance: cow's milk-based or soy-based infant formulas.
- Plant-based beverages that are not suitable substitutes for infant formula (even if calcium enriched)[4]:
- Rice milk
- Non-adapted soy milk
- Almond milk
- Formulas/beverages made from grains or nuts
- Vegetable juice
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Complementary feeding*: - May introduce pureed legumes or tofu beginning at 4 to 6 months to provide additional protein.
- Ensure sufficient caloric density of meals by adding oil rich in linolenic acid (flaxseed, canola, rapeseed, or nut oil).
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Calcium: - The RDA for calcium during lactation is 1000 mg daily (or 1300 mg daily for lactating adolescents). Many mothers will need a calcium supplement to meet this goal, depending on other food sources.
| Calcium: - Human milk will supply appropriate amounts of calcium to the infant, regardless of maternal calcium intake¶.
| Calcium: - Commercial infant formulas supply appropriate amounts of calcium to the formula-fed infant. After complementary foods are introduced, a formula intake of at least 400 mL/day will supply adequate amounts of calcium.
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Iron: - Consume iron-rich plant-based foods together with vitamin C-rich fruit to promote iron absorption.
- Specific preparation methods (grinding, soaking, germination) can increase iron bioavailability.
- The RDA for iron during lactation is 9 mg daily (or 10 mg daily for lactating adolescents)Δ. Mothers with low iron stores may require additional supplementation.
| Iron: - Supplement with elemental iron 1 mg/kg/day until iron-containing pureed foods are introduced at 4 to 6 months of age.
- If serum ferritin is low (indicating iron deficiency, add iron supplement (elemental iron 2 to 3 mg/kg/day)◊.
| Iron: - Use an iron-fortified formula (elemental iron 0.8 to 1.2 mg/100 mL) from birth through the entire first year of life
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Complementary feeding*: - When complementary foods are introduced, include iron-rich foods such as iron-fortified infant cereals. Feed simultaneously with foods with vitamin C (eg, pureed fruits) to enhance iron absorption.
- The RDA for iron is 11 mg daily for infants >6 months.
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Zinc: - Consume plants rich in zinc (Brassicaceae), including nuts and lentils, and/or zinc-fortified foods such as breakfast cereal.
- Specific preparation methods (grinding, soaking, germination) can increase zinc bioavailability.
- The RDA for zinc during lactation is 12 mg daily (or 13 mg daily for lactating adolescents)§.
| Zinc: - Human milk provides adequate quantities of zinc independent of the mother's zinc status§. Infant formula also provides adequate quantities of zinc.
- When complementary foods are introduced, include foods rich in zinc (eg, fortified infant cereal, chickpeas, eggs). Infants who do not consume meats or fortified infant cereal may require a zinc supplement (elemental zinc 0.3 mg/kg/day).
- The RDA/AI for zinc is 2 mg/day for infants 0 to 6 months and 3 mg/day for infants >6 months.
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Iodine: - The RDA for iodine during lactation is 290 mcg/day. This amount of iodine is provided in approximately 3/4 teaspoon of iodized table salt.
| Iodine: - No added iodized salt up to 12 months of life.
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DHA and ALA: - Consume DHA-fortified foods and ALA-rich foods (flaxseeds, chia seeds, walnuts).
- Microalgae also supply these nutrients and are suitable for vegans.
- AI of ALA is 1300 mg/day[5].
- For DHA, an RDA/AI has not been established, but some authorities recommend intake of 200 to 300 mg daily for lactating mothers[6,7].
| DHA: - The concentration of DHA in human milk varies with the maternal diet.
- AI for omega-3 fatty acids (as ALA, DHA, and EPA) is 500 mg/day[5].
| DHA: - If the infant formula is not DHA enriched, supplement with microalgae.
- AI for omega-3 fatty acids (as ALA, DHA, and EPA) is 500 mg/day[5].
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