The role of plant-based drinks in children's diets - an extensive review

This study conducted a comprehensive review of the scientific literature and recommendations from national and paediatric organizations worldwide regarding the suitability of plant-based formula feeds (PBFF) and regular plant-based drinks (PBD) in the diets of young children, including infants.(1)

The review covers a wide range of topics concerning infants and children over 12 months, including special conditions such as cow's milk protein allergy (CMPA), a comparison of nutritional profiles to cow's milk, dietary preferences (usually influenced by parents), dyslipidemia, diabetes, and weight management.

Some key findings from the paper are as follows:

The review focuses on two specific types of plant-based milk alternatives:

PBFF: These are specialized infant formulas that, by law, must offer a complete nutritional profile for infants, matching their cow milk-based infant formulas.

PBD: These are standard drinks available in supermarkets alongside dairy products. They are made by mixing ground plant bases with water before being heat treated. PBD can be based on soya, pea, rice, nuts, oats, and other plants. This review specifically examines soya, rice, oat, and almond PBD. Except for soya PBD, protein levels are generally low, and the presence of micronutrients depends on the degree of fortification, which is not mandatory. The reviewed PBD commonly included added calcium, vitamins D, B12, and B2. Energy levels vary depending on the presence of added sugars, and fat levels were lower compared to dairy.

The authors emphasize the importance of understanding the role and recommendations of plant-based milk alternatives within the dietary patterns of children, given the growth of this sector. They express particular concern about many consumers perceiving PBD as nutritionally comparable to dairy milk while being unaware of the differences in micronutrient provision, which solely depends on the degree of fortification.

Recommendations for children 0-12 months

Formulas intended for infants under 12 months of age are subject to strict regulations and must provide a complete nutritional profile, regardless of whether they are plant-based or cow's milk-based. The review found consistent recommendations across different countries and organizations. Primary recommenations are for mothers to breastfeed for a long as possible and up to two years of age. Only if breastfeeding is not possible or insufficient to meet an infant's should infant formulas be considered. In such instances, most paediatric health organizations prioritize the use of cow milk formulas, while PBFF are more commonly recommended to accommodate parental preferences. In the case of cow's milk protein allergy (CMPA), specialised hydrolysed cow's milk formulas are recommended as the first-line treatment by most organizations. Soya and rice-based PBFF may be advised as second-line treatments for CMPA, with a preference for rice-based formulas due to potential cross-reactivity with soya.

Recommendations for children over 12 months

Most countries and paediatric organizations recommend the introduction of fortified PBD into a child's diet after the age of 12 months, provided that they contain essential micronutrients (primarily calcium). However, there is discord regarding which type of PBD and the age at which it can be used as a main drink and in substitute for cow's milk.

There are significant differences between countries in terms of recommended age. In general, global guidelines suggest that fortified PBD can be part of a child's balanced diet from either 1 or 2 years of age. Some countries prefer soya PBD due to its protein similarity to cow's milk, especially in the early years. Some countries only recommend PBD in special circumstances until the age of 5 years, while others recommend any type of fortified PBD from the age of 1 year. Rice-based PBD are often not recommended until 5 years of age due to naturally occurring arsenic levels.

The review also cites studies that question the necessity or reliance on milk for children over 1 year of age and research demonstrating that the introduction of fortified PBD from the age of 1 year does not compromise nutritional status.

Regarding CMPA, many paediatric guidelines recommend the continued use of specialised hydrolysed cow's milk formula or PBFF to ensure adequate nutritional intake. On the other hand, research suggests that plant-based drinks can be used as alternatives to cow's milk for 1-5 year-olds. For lactose intolerance, soya PBD is preferred due to its protein content.

Conclusion

The recommendations for infants under 12 months of age are consistent, but for children over 12 months, there is variation in the advice given. Since the nutritional composition of PBD differs from cow's milk, it is crucial to tailor the choices based on the specific needs of each child and in the context of a diverse diet. Moreover, it is important to improve labelling and provide consumer education to emphasise that not all PBDs are fortified. This awareness is necessary to ensure that caregivers can make informed choices. Based on the scientific literature, introduction of fortified PBD to the diets of healthy children from the age of 1 year does not compromise nutritional status, as long as the child is meeting their energy and protein requirements and following a balanced and nutritious diet.

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