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Planning Well-Balanced Vegetarian Diets in Infants, Children, and Adolescents: The VegPlate Junior

Open AccessPublished:August 31, 2018DOI:https://doi.org/10.1016/j.jand.2018.06.008
      Vegetarian diets, defined as being devoid of flesh foods (such as meat, poultry, wild game, seafood, and their products), are followed by a growing number of people worldwide because of ethical, health, and environmental reasons.
      • Leitzmann C.
      Vegetarian nutrition: #Past, present, future.
      Vegetarian diets include a variety of plant-based foods such as grains, legumes, nuts and seeds, fruits, and vegetables, and may or may not include dairy products and eggs. Vegan diets exclude all animal foods.
      Although for over 30 years we have known that well-planned vegetarian diets, including vegan, are nutritionally adequate and promote regular growth from the early years of human development on,
      American Academy of Pediatrics
      Committee on Nutrition. Nutritional aspects of vegetarianism, health foods, and fad diets.
      • Melina V.
      • Craig W.
      • Levin S.
      Position of the Academy of Nutrition and Dietetics: Vegetarian diets.
      • Agnoli C.
      • Baroni L.
      • Bertini I.
      • et al.
      Position paper on vegetarian diets from the working group of the Italian Society of Human Nutrition.
      some researchers still discourage parents from raising vegetarian children.
      Complementary feeding: A position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition.
      • Richter M.
      • Boeing H.
      • Grünewald-Funk D.
      • et al.
      Vegan diet: Position of the German Nutrition Society (DGE).
      This may be at least partially accounted for by the fact that children following very restrictive vegetarian patterns, which limit food choices and calorie intake, have been described.
      • Schürmann S.
      • Kersting M.
      • Alexy U.
      Vegetarian diets in children: A systematic review.
      These dietary patterns do not meet the criteria to be defined as well planned,
      • Baroni L.
      Vegetarianism in food-based dietary guidelines.
      and therefore no conclusions about the growth of children following them should be made.
      In Italy, 7.1% of the population follows a vegetarian diet (6.2% a lacto-ovo-vegetarian and 0.9% a vegan diet), a percentage that has nearly doubled in the last 5 years. The exact number of vegetarian children is not known, but likely vegetarian parents would raise children following the same dietary pattern.
      Various Vegetarian Food Guides have been proposed for adult vegetarians since 1997,
      • Baroni L.
      Vegetarianism in food-based dietary guidelines.
      but so far none specifically for vegetarians aged 6 months to 17 years. Therefore, we designed the VegPlate Junior (VPJ), a Vegetarian Food Guide specific for dietary planning in infancy, childhood, and adolescence, and conceived to meet the Italian, as well as US, Dietary Reference Intakes (DRIs).

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      National Institute of Health. Office of Dietary Supplements. Nutrient recommendations: Dietary Reference Intakes (DRI). https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx. Accessed May 28, 2018.

      Diets obtained with the VPJ method meet all the criteria defining a vegetarian diet as “well-planned”
      • Baroni L.
      Vegetarianism in food-based dietary guidelines.
      and are therefore suitable for promoting thriving and regular growth.
      These criteria are:
      • Including a wide variety of plant foods, such as grains, legumes and their derivatives, nuts and seeds, vegetables, and fruit. Dairy products and eggs are considered optional.
      • Carefully choosing vegetable fats, consuming good sources of n-3 fatty acids, such as flaxseeds, chia seeds, and walnuts.
      • Including reliable sources of calcium and paying attention to the status of both vitamin B-12 and vitamin D.
      The aim of the VPJ is to help health care professionals in advising vegetarian parents, because parental education plays a central role in achieving optimal dietary patterns in vegetarian children.
      • Northstone K.
      • Smith A.D.
      • Cribb V.L.
      • Emmett P.M.
      Dietary patterns in UK adolescents obtained from a dual-source FFQ and their associations with socio-economic position, nutrient intake and modes of eating.

      Food Selection

      The VPJ is based on six food groups, plus two cross-sectional groups of calcium-rich foods and n-3-rich foods. Methods for food selection and serving size calculation have been described in detail in the VegPlate for adults.
      • Baroni L.
      • Goggi S.
      • Battino M.
      VegPlate: A Mediterranean-based food guide for Italian adult, pregnant, and lactating vegetarians.
      For each food group, we selected the most representative plant foods from the Mediterranean tradition. Serving sizes for each item were calculated so that within the same group they would all be isocaloric, and they are the same as those in the VegPlate for adults.
      • Baroni L.
      • Goggi S.
      • Battino M.
      VegPlate: A Mediterranean-based food guide for Italian adult, pregnant, and lactating vegetarians.
      The average nutritional composition of one serving from each group was then calculated and used to determine the daily number of servings to consume from each group to satisfy the Italian DRIs

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      from 1 to 17 years of age, for calorie requirements ranging from 800 to 3,600 kcal.
      Other foods listed, such as dairy products, eggs, or meat analogs, are proposed as possible foods to consume but were not included in the calculations, and they can be consumed according to personal preference. For the different calorie requirements, from 1 to 17 years of age, the number of servings in each group necessary to reach nutritional adequacy is listed in Table 1.
      Table 1Number of servings in the VegPlate Junior for children and adolescents (from 1 to 17 years of age)
      kcal
      Energy requirements according to the Italian Dietary Reference Intakes10:1-3 y: 800-1,500 kcal4-6 y: 1,200-1,800 kcal7-10 y: 1,500-2,500 kcal11-14 y: 2,100-3,200 kcal15-17 y: 2,400 kcal-3,600 kcal.
      GrainsProtein-rich foodsVegetablesFruitsNuts and seedsFatsCalcium-rich foods
      This total number of servings must be consumed as calcium-rich foods from the other food groups.
      n-3–rich foods
      Of which at least one serving is flaxseed oil.
      The number of servings of the n-3–rich foods must be included in the total number of servings of nuts and seeds or fats.
      Essential caloriesDiscretionary calories
      8003.51.01.01.01.03.0328020
      9003.51.01.01.51.04.03287921
      1,0004.51.01.51.51.04.03298614
      1,1005.51.01.51.51.04.0321,08119
      1,2006.01.03.01.51.04.0421,16238
      1,3006.01.03.02.01.54.0421,27228
      1,4006.02.03.02.01.54.0421,36436
      1,5006.52.04.02.01.55.0521,48020
      1,6007.52.04.02.01.55.0521,57525
      1,7007.52.04.02.52.05.0521,68515
      1,8008.02.05.02.52.05.0521,75545
      1,9009.02.05.02.52.05.0521,85050
      2,0009.03.06.02.52.05.0521,96535
      2,1009.53.06.03.02.06.0522,09010
      2,2009.53.06.03.02.56.0522,16733
      2,30010.53.06.03.02.56.0522,26337
      2,40010.53.06.03.53.06.0522,37228
      2,50011.53.06.03.53.06.0522,46832
      2,60011.53.06.04.03.07.0522,54555
      2,70012.53.06.04.03.07.0522,64060
      2,80013.53.06.04.03.07.0522,73565
      2,90014.03.06.04.53.07.0522,81585
      3,00015.03.06.04.53.07.022,91090
      3,10015.53.06.04.53.08.023,00397
      3,20016.03.06.05.03.08.023,083117
      3,30016.53.06.05.03.09.023,175125
      3,40017.03.06.05.03.010.023,268132
      3,50017.03.06.05.53.510.023,378122
      3,60017.03.06.05.54.010.023,455145
      a Energy requirements according to the Italian Dietary Reference Intakes

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      :
      • 1-3 y: 800-1,500 kcal
      • 4-6 y: 1,200-1,800 kcal
      • 7-10 y: 1,500-2,500 kcal
      • 11-14 y: 2,100-3,200 kcal
      • 15-17 y: 2,400 kcal-3,600 kcal.
      b This total number of servings must be consumed as calcium-rich foods from the other food groups.
      c Of which at least one serving is flaxseed oil.
      d The number of servings of the n-3–rich foods must be included in the total number of servings of nuts and seeds or fats.

      Graphics of the VPJ

      The VPJ (Figure, A) is based on six food groups: grains, protein-rich foods, vegetables, fruits, nuts and seeds, and fats. The graphic draws attention to nutrients considered critical in vegetarian diets during all life stages: vitamin B-12 and vitamin D, located in the center of the plate, and calcium and n-3 fatty acids, whose food sources are represented as two cross-sectional groups. The basic graphic structure of the VPJ is the same as for adults,
      • Baroni L.
      • Goggi S.
      • Battino M.
      VegPlate: A Mediterranean-based food guide for Italian adult, pregnant, and lactating vegetarians.
      given that the only adjustments performed were in the number of servings for each calorie range.
      We also developed an adaptation of the VPJ for infants (Figure, B), to be used during complementary feeding (from approximately 6 months of age). The VPJ for infants recommends including the seventh food group of breastmilk (or infant formula) during complementary feeding.

      Use of the VPJ

      Infants

      The VPJ adaptation for infants is meant to help vegetarian dietary planning from the beginning of complementary feeding. During this period of life, children experience extremely rapid growth,

      Center for Disease Control and Prevention. Growth charts. https://www.cdc.gov/growthcharts/index.htm. Accessed May 28, 2018.

      for which a good nutritional status is essential. Because breast milk of vegetarian mothers is similar in composition to that of nonvegetarian mothers and thus nutritionally adequate,
      • Melina V.
      • Craig W.
      • Levin S.
      Position of the Academy of Nutrition and Dietetics: Vegetarian diets.
      • Agnoli C.
      • Baroni L.
      • Bertini I.
      • et al.
      Position paper on vegetarian diets from the working group of the Italian Society of Human Nutrition.
      the timing of the introduction of solid foods should not differ from that of nonvegetarian children, that is, between 17 and 26 weeks.
      Complementary feeding: A position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition.
      Breast or formula milk should be continued until at least 1 year of age, because it provides a large amount of the daily requirements of energy, calcium, and n-3 fatty acids.
      Section on Breastfeeding
      Breastfeeding and the use of human milk.
      In the first year of life, if the mother is not breastfeeding, the only alternatives are cow’s milk infant formula and soy or rice formulas for vegan infants.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      Nonformula soy and rice beverages lack important nutrients and should not be offered as breast or formula milk substitutes until at least 12 months of age.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      During complementary feeding, all solid foods from the VPJ are introduced in forms that do not constitute choking hazards (ie, nut butters instead of nuts),
      Complementary feeding: A position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition.
      with no particular rigid rule regarding the order of introduction.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      • Agostoni C.
      • Laicini E.
      Early exposure to allergens: A new window of opportunity for non-communicable disease prevention in complementary feeding?.
      To avoid early satiety, nutrient malabsorption, and poor growth, all of the offered foods to should be as low-fiber and as energy- and nutrient-dense as possible.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      Main meals should be based on refined infant cereals, peeled beans, and nut and seed butters, and strained fruits and vegetables should be preferred.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      Fruit should be offered as a snack, along with more nutritious foods such as breast milk or infant formula, cereals, yogurt, and nut and seed butters.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      Dairy products and eggs from the protein-rich food group are considered optional, and they should be included in the diet according to parents’ choices and beliefs. These recommendations apply also to meals or snacks offered to infants undergoing baby-led weaning.
      • D’Auria E.
      • Bergamini M.
      • Staiano A.
      • et al.
      Baby-led weaning: What a systematic review of the literature adds on.
      Cow’s milk should not be introduced before 12 months of age because of its high protein and low iron content.
      • Domellöf M.
      • Braegger C.
      • Campoy C.
      • et al.
      ESPGHAN Committee on Nutrition. Iron requirements of infants and toddlers.
      Fats are the primary source of energy for all infants and help vegetarian babies to easily reach their calorie requirements. Because fats play an important role in brain development, they should not be limited but carefully chosen to maintain an optimal n-3/n-6 ratio.
      • Uauy R.
      • Dangour A.D.
      Fat and fatty acid requirements and recommendations for infants of 0-2 years and children of 2-18 years.
      • Masters C.
      Omega-3 fatty acids and the peroxisome.
      • Harnack K.
      • Andersen G.
      • Somoza V.
      Quantitation of alpha-linolenic acid elongation to eicosapentaenoic and docosahexaenoic acid as affected by the ratio of n6/n3 fatty acids.
      For infants, the VPJ does not indicate the number of servings from each group to offer.
      Breast or formula milk should continue on demand as usual until at least 1 year of age, and food from all groups should be offered daily at each meal or snack in the amount shown in Table 2.
      Table 2Amount of food to offer to vegetarian infants at each main meal or snack
      6 mo8 mo12 mo
      Instant infant cereal, refined grains or pasta20 g20-30 g30 g
      Beans (dry weight)10 g15 g20 g
      Tofu10-20 g10-20 g20 g
      Flaxseed oil/olive oil5-10 g5-10 g5-10 g
      Nuts and seeds butter0-10 g10 g10 g
      Fresh fruit0-100 g0-100 g0-100 g
      Plant-milks
      Plant-milks should not replace breast or formula milk for infants up to 12 months of age but can be used as a liquid in food preparation.
      0-200 mL0-250 mL0-250 mL
      Cheese20 g20 g
      Egg½ yolk½ yolk
      a Plant-milks should not replace breast or formula milk for infants up to 12 months of age but can be used as a liquid in food preparation.

      Children and Adolescents

      From 1 year of age, the growth rate slightly decreases, although it is still quite rapid until 24 months of age. After that, weight and height increase steadily until puberty, when a spike in growth velocity takes place.

      Center for Disease Control and Prevention. Growth charts. https://www.cdc.gov/growthcharts/index.htm. Accessed May 28, 2018.

      The VPJ satisfies nutrient needs from 1 year to 17 years of age, as established by the Italian and US DRIs.

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      National Institute of Health. Office of Dietary Supplements. Nutrient recommendations: Dietary Reference Intakes (DRI). https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx. Accessed May 28, 2018.

      For different calorie requirements in the various age groups, the VPJ suggests the number of daily servings to consume for each group, as shown in Table 1. The nutritional composition of diets obtained with the VPJ method is shown in Table 3.
      Table 3Energy content and nutrient composition of diets obtained with the VegPlate Junior for children and adolescents (from 1 to 17 years of age), compared with the Italian and the US Dietary Reference Intakes (DRIs)
      Calories from carbohydrates, protein, and fat, respectively, expressed as a percentage of total energy.
      kcal

      Unit of measure
      Carbohydrates (g)Carbohydrates
      Calories from carbohydrates, protein, and fat, respectively, expressed as a percentage of total energy.
      (%)
      Protein (g)Protein
      Calories from carbohydrates, protein, and fat, respectively, expressed as a percentage of total energy.
      (%)
      Fat (g)Fat
      Calories from carbohydrates, protein, and fat, respectively, expressed as a percentage of total energy.
      (%)
      Calcium
      Calcium content is underestimated, because it does not account for calcium in water and the recommended number of servings of calcium-rich foods.
      (mg)
      Iron (mg)Zinc (mg)Thiamin (mg)Riboflavin (mg)Vitamin B-3
      Niacin synthesized endogenously from tryptophan must be added to this value.
      (mg)
      Fiber (g)
      80099502814%3540315860.90.58.122
      900107472913%4040332961.00.68.423
      1,000128513213%42373901071.10.710.427
      1,100148543513%42354191171.30.712.029
      1,200163544013%43335181381.51.014.134
      1,300171534313%51355561591.61.014.538
      1,400181525215%533463617101.71.215.341
      1,500194525515%593570618111.91.316.945
      1,600214545815%593373619112.01.418.547
      1,700222526215%673577420122.11.419.051
      1,800236526515%683484422132.21.62155
      1,900256546814%683287423142.41.62257
      2,000269547916%71321,01026152.61.92462
      2,100286558115%77331,04127162.72.02565
      2,200287528415%84341,06228162.82.02568
      2,300307538715%85331,09228172.92.12770
      2,400315529015%92341,13029183.02.12774
      2,500335549315%93331,16030193.22.12977
      2,600342539414%98341,17731193.22.22978
      2,700362549714%99331,20631193.32.23180
      2,800382559914%100321,23632203.52.33282
      2,9004005510114%100311,26833213.62.33385
      3,0004205610414%101301,29734213.82.33587
      3,1004305510614%107311,31234213.82.43688
      3,2004475610813%108301,34435223.92.43791
      3,3004575510913%113311,35935224.02.43892
      3,4004675511013%118311,37436224.12.53893
      3,5004755411413%126321,41237244.22.53997
      3,6004765311713%133331,43338244.22.539100
      Italian DRIs 1-3 y45-601435-40700850.40.5712.6-16.7
      For each 1,000 kcal consumed.
      US DRIs 1-3 y13045-65135 - 20ND30-40700730.50.5619
      Italian DRIs 4-17 y40-6019-6220-351,00011-186-120.5-1.20.6-1.68-1812.6-16.7
      For each 1,000 kcal consumed.
      US DRIs 4-17 y13045-6519-5210 - 30ND25-351,30010-153-110.6-1.20.6-1.38-1625-38
      abc Calories from carbohydrates, protein, and fat, respectively, expressed as a percentage of total energy.
      d Calcium content is underestimated, because it does not account for calcium in water and the recommended number of servings of calcium-rich foods.
      e Niacin synthesized endogenously from tryptophan must be added to this value.
      f For each 1,000 kcal consumed.
      For corresponding levels of energy, the daily number of servings differs from the VegPlate for adults,
      • Baroni L.
      • Goggi S.
      • Battino M.
      VegPlate: A Mediterranean-based food guide for Italian adult, pregnant, and lactating vegetarians.
      because the nutritional needs of children and adolescence are particular.

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      National Institute of Health. Office of Dietary Supplements. Nutrient recommendations: Dietary Reference Intakes (DRI). https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx. Accessed May 28, 2018.

      Although discretionary calories do not contribute to attaining nutritional adequacy and can be consumed according to individual preference, children and adolescents should be discouraged from choosing sweetened beverages or processed foods.
      • Malik V.S.
      • Schulze M.B.
      • Hu F.B.
      Intake of sugar-sweetened beverages and weight gain: A systematic review.

      Nutrients of Concern: Specific Recommendations

      Calcium and Vitamin D

      Calcium, an essential mineral during growth when bone mass is expanding, can be a critical nutrient in those vegetarian children who do not consume dairy products.
      • Agnoli C.
      • Baroni L.
      • Bertini I.
      • et al.
      Position paper on vegetarian diets from the working group of the Italian Society of Human Nutrition.
      • Larsson C.L.
      • Johansson G.K.
      Dietary intake and nutritional status of young vegans and omnivores in Sweden.
      For the calculations in the VPJ, only plant foods and no dairy products were taken into account. Calcium needs were met by including 3 to 5 servings daily of calcium-rich foods. Calcium-rich foods are the same as for the VegPlate for adults,
      • Baroni L.
      • Goggi S.
      • Battino M.
      VegPlate: A Mediterranean-based food guide for Italian adult, pregnant, and lactating vegetarians.
      one serving providing approximately 125 mg calcium. Because variety within the same food group must be ensured, even lacto-ovo-vegetarians should derive most of their dietary calcium from plant foods.
      Tap and mineral water are also reliable sources of highly bioavailable calcium (absorption fraction from 23.6% to 47.5%).
      • Heaney R.P.
      Absorbability and utility of calcium in mineral waters.
      When the calorie requirements are above 3,000 kcal, counting calcium-rich foods servings is unnecessary, because the variety of the diet provides the required amount of calcium. Although calcium content of breast milk is little affected by maternal calcium intakes,
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      breastfeeding vegetarian women are encouraged to meet their calcium requirements.
      • Baroni L.
      • Goggi S.
      • Battino M.
      VegPlate: A Mediterranean-based food guide for Italian adult, pregnant, and lactating vegetarians.
      Because vitamin D status mainly depends on sun exposure, all children living at high latitudes, regardless of the type of diet, are at risk for deficiency.
      • Kaganov B.
      • Caroli M.
      • Mazur A.
      • Singhal A.
      • Vania A.
      Suboptimal micronutrient intake among children in Europe.
      Both breastfed and formula-fed infants up to 1 year of age should be supplemented daily with 400 UI vitamin D.
      • Wagner C.L.
      • Greer F.R.
      American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents.
      From 1 year of age, if sun exposure is not adequate, the VPJ suggests meeting the DRI for vitamin D (600 UI)

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      National Institute of Health. Office of Dietary Supplements. Nutrient recommendations: Dietary Reference Intakes (DRI). https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx. Accessed May 28, 2018.

      through supplementation.
      • Wacker M.
      • Holick M.F.
      Sunlight and vitamin D: A global perspective for health.

      n-3 Fatty Acids

      From weaning on, n-3 fatty acids should represent 0.5% to 2% of total energy and provide 250 mg of eicosapentaenoic-docosaexaenoic acid daily.

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      The consumption of two servings of n-3–rich foods recommended in the VPJ provides on average 5.0 g alpha-linolenic acid and satisfies the above-mentioned conditions for all of the calorie ranges. The avoidance of n-6–rich oils (ie, sunflower oil, corn oil) and tropical oils maximizes the conversion of alpha-linolenic acid to eicosapentaenoic-docosaexaenoic acid, because it minimizes the n-6:n-3 ratio,
      • Masters C.
      Omega-3 fatty acids and the peroxisome.
      • Harnack K.
      • Andersen G.
      • Somoza V.
      Quantitation of alpha-linolenic acid elongation to eicosapentaenoic and docosahexaenoic acid as affected by the ratio of n6/n3 fatty acids.
      • Abedi E.
      • Sahari M.A.
      Long-chain polyunsaturated fatty acid sources and evaluation of their nutritional and functional properties.
      which ranges from 2.79 to 3.08 in the VPJ.
      During complementary feeding, infants can generally meet their n-3 fatty acid requirements through breast or formula milk and the suggested servings of fats.
      • Abedi E.
      • Sahari M.A.
      Long-chain polyunsaturated fatty acid sources and evaluation of their nutritional and functional properties.
      Breastfeeding women should heed the recommendation to include a DHA source in their diet.
      • Baroni L.
      • Goggi S.
      • Battino M.
      VegPlate: A Mediterranean-based food guide for Italian adult, pregnant, and lactating vegetarians.
      According to the Italian DRIs, all children from 6 months up to 3 years of age should additionally consume a 100 mg/d of DHA, regardless of the type of diet.

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      Vitamin B-12

      All vegetarians, including those who consume dairy products and eggs, are at risk of developing B-12 deficiency.
      • Rizzo G.
      • Laganà A.S.
      • Rapisarda A.M.
      • et al.
      Vitamin B12 among vegetarians: Status, assessment and supplementation.
      Failure to meet requirements for vitamin B-12 can result in life-threatening conditions in children whose B-12 stores can be low.
      • Hartmann H.
      • Das A.M.
      • Lücke T.
      • et al.
      Clinical presentation and metabolic consequences in 40 breastfed infants with nutritional vitamin B12 deficiency: What have we learned?.
      Mothers should check their B-12 levels before conceiving and supplement vitamin B-12 throughout pregnancy and breastfeeding to guarantee an adequate intake to the infant.
      • Agnoli C.
      • Baroni L.
      • Bertini I.
      • et al.
      Position paper on vegetarian diets from the working group of the Italian Society of Human Nutrition.
      • Snow D.
      Vegetarian diet during pregnancy: Making sure vitamin B12 intake is adequate.
      After the beginning of weaning, because the amount of breast or formula milk can be variable, B-12 should be supplemented in all vegetarian infants.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      Because of the high variability of absorption attributable to different frequencies of intakes, to satisfy the DRIs by supplementation, the Italian Society of Human Nutrition suggests B-12 daily single doses from 5 μg in infants to 50 μg in adolescents.
      • Agnoli C.
      • Baroni L.
      • Bertini I.
      • et al.
      Position paper on vegetarian diets from the working group of the Italian Society of Human Nutrition.
      These recommendations satisfy both the Italian and US DRIs.

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      National Institute of Health. Office of Dietary Supplements. Nutrient recommendations: Dietary Reference Intakes (DRI). https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx. Accessed May 28, 2018.

      Other Nutrients

      Fiber

      Vegetarian children show a higher intake of fiber compared with nonvegetarian peers and may in some cases exceed recommendations.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      • Messina V.
      • Mangels A.R.
      Considerations in planning vegan diets: Children.
      Excessive amounts of fiber trigger early satiety, may cause constipation, and may interfere with nutrient absorption (especially iron, calcium, and fats).
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      Choosing refined grains, peeling beans, and straining fruits and vegetables are practices that effectively reduce the fiber content of the diet and should be pursued from 6 to 24 months of age, a period of rapid growth.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.

      Protein

      Plants provide all of the essential amino acids, and protein requirements are usually met and even exceeded on a vegetarian diet providing sufficient energy from a variety of plant foods.
      • Melina V.
      • Craig W.
      • Levin S.
      Position of the Academy of Nutrition and Dietetics: Vegetarian diets.
      Animal-derived products are not necessary to attain protein requirements, and their consumption depends on the family habits. Because of the lower digestibility of plant proteins, some authors suggest increasing protein DRIs of vegetarian children by 10% to 15%,
      • Agnoli C.
      • Baroni L.
      • Bertini I.
      • et al.
      Position paper on vegetarian diets from the working group of the Italian Society of Human Nutrition.
      a percentage that the VPJ surpasses for all age ranges (Table 3).
      Combining complementary sources of protein at each meal is not necessary, but an advantage in consuming complementary proteins at intervals of less than 6 hours was shown in children younger than 2 years of age.
      • Messina V.
      • Mangels A.R.
      Considerations in planning vegan diets: Children.
      In everyday practice, young children eat often throughout the day, so combining protein sources is not necessary when the variety of plant foods in the diet is assured.

      Iron

      Iron deficiency is highly prevalent among all children, regardless of the type of diet.
      • Borgna-Pignatti C.
      • Marsella M.
      Iron deficiency in infancy and childhood.
      Vegetarian, and especially vegan, children show iron intakes above recommended levels, as much as twice the intakes of nonvegetarian peers,
      • Sanders T.A.
      Growth and development of British vegan children.
      and have normal iron stores.
      • Laskowska-Klita T.
      • Chelchowska M.
      • Amroszkiewicz J.
      • Gajewska J.
      • Klemarczyk W.
      The effect of vegetarian diet on selected essential nutrients in children.
      In vegetarian diets, all iron is in the non-heme form, which has lower bioavailability than the heme iron found in meat and fish products (1%-34% compared with 15%-35%), because of differences in absorption and the fiber and phytate content of plant foods.
      • Collings R.
      • Harvey L.J.
      • Hooper L.
      • et al.
      The absorption of iron from whole diets: A systematic review.
      • Hurrell R.
      • Egli I.
      Iron bioavailability and dietary reference values.
      Vitamin C, beta-carotene, and organic acids positively influence non-heme iron absorption, as well as some cooking practices that reduce the phytate content of foods (ie, soaking, sprouting, grinding, sour leavening, fermentation).
      • Mangels R.
      • Messina V.
      • Messina M.
      The Dietitian’s guide to vegetarian diets.
      • Collings R.
      • Harvey L.J.
      • Hooper L.
      • et al.
      The absorption of iron from whole diets: A systematic review.
      • Hurrell R.
      • Egli I.
      Iron bioavailability and dietary reference values.
      Vegetarian parents should be aware of the iron-rich foods in vegetarian diets, such as whole grains, legumes, soy products, green leafy vegetables, and nuts and seeds, and of the practices enhancing its bioavailability. Iron-fortified infant cereals may be useful for maximizing the iron content of the diet in the first 2 years of life, when whole grains should be limited.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.

      Zinc

      Zinc requirements are met in all diets obtained with the VPJ, but the overall diet bioavailability of zinc may be lower when compared with nonvegetarian diets because of the high content of fiber and phytate in vegetarian diets.
      • Foster M.
      • Samman S.
      Vegetarian diets across the lifecycle: Impact on zinc intake and status.
      The previously mentioned practices that decrease the phytate content of the diet also enhance zinc absorption, and the daily inclusion of zinc-rich foods, such as legumes, nuts and seeds, and cheese for lacto-ovo-vegetarian children, maximizes zinc intakes.

      Iodine

      Vegetarian children and adolescents should not rely on seaweed to meet iodine requirements, because its high content might exceed recommendations and impair thyroid function,
      • Teas J.
      • Pino S.
      • Critchley A.
      • Braverman L.E.
      Variability of iodine content in common commercially available edible seaweeds.
      along with possible arsenic contamination.
      • Taylor V.F.
      • Li Z.
      • Sayarath V.
      • et al.
      Distinct arsenic metabolites following seaweed consumption in humans.
      Iodine requirements

      Società Italiana di Nutrizione Umana. Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. http://www.sinu.it/html/pag/tabelle_larn_2014_rev.asp. Accessed May 28, 2018.

      National Institute of Health. Office of Dietary Supplements. Nutrient recommendations: Dietary Reference Intakes (DRI). https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx. Accessed May 28, 2018.

      are met by using iodized salt or algal source supplements. Because the amount of iodine per gram of iodized salt varies among countries, a daily consumption of approximately 3.3 to 5 g for Italian children and adolescents (providing 100 to 150 μg of iodine)
      • Baroni L.
      • Goggi S.
      • Battino M.
      VegPlate: A Mediterranean-based food guide for Italian adult, pregnant, and lactating vegetarians.
      and approximately 2 to 3.33 g for US children and adolescents (providing 95 to 155 mg of iodine)

      National Institute of Health. Office of dietary supplements. Iodine. Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/Iodine-HealthProfessional. Accessed May 28, 2018.

      is suggested. Infants from 6 to 12 months of age meet their iodine requirements through breast and formula milk, and no salt should be added to infants’ food.
      • Mangels A.R.
      • Messina V.
      Considerations in planning vegan diets: Infants.

      Summary

      Well-balanced vegetarian diets planned with the VPJ, which include a wide variety of plant foods and reliable sources of vitamin B-12 and vitamin D, are an adequate option for infants, children, and adolescents. Vegetarian diets, because of their favorable content of fiber and essential nutrients, have been shown to be protective against childhood and adolescence obesity,
      • Sabaté J.
      • Wien M.
      Vegetarian diets and childhood obesity prevention.
      as well as obesity-related diseases that may occur later in life.
      American Academy of Pediatrics
      Committee on Nutrition. Nutritional aspects of vegetarianism, health foods, and fad diets.
      • Melina V.
      • Craig W.
      • Levin S.
      Position of the Academy of Nutrition and Dietetics: Vegetarian diets.
      Exposing children to a great variety of plant foods may promote healthful eating habits later in life.
      In Italy, one of three children is either overweight or obese,

      Epicentro. Istituto Superiore di Sanità. OKkio alla Salute. http://www.epicentro.iss.it/okkioallasalute. Accessed May 28, 2018.

      and Europe and the United States show similar percentages.
      NCD Risk Factor Collaboration (NCD-RisC)
      Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults.
      In this scenario, the VPJ can serve as a foundation for planning omnivorous diets rich in plant foods and protective against childhood obesity, simply by introducing some servings per week of nonvegetarian foods.

      Acknowledgements

      Authors wish to thank Ilaria Fasan, RD, for the thoughtful inputs, Paul Foster Griffith, MD, for the careful revision of the language, and the anonymous reviewers whose suggestions have led to an improvement of the contents.

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      Linked Article

      • Corrigendum
        Journal of the Academy of Nutrition and DieteticsVol. 120Issue 7
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          In the article “Planning Well-Balanced Vegetarian Diets in Infants, Children, and Adolescents: The VegPlate Junior” by Baroni, Goggi, and Battino, published in the July 2019 issue (pp 1067-1074) of the Journal of the Academy of Nutrition and Dietetics, the authors would like to make the following corrections and points of clarity:
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