Archives of Disease in Childhood, 1988, 63, 1286-1292

Special report

Vegetarian weaningNUTRITION STANDING COMMITTEE OF THE BRITISH PAEDIATRIC ASSOCIATION

1 Introduction

1.1 BACKGROUND1.1.1 The proportion of the British populationfollowing a vegetarian diet today may be larger thanever before. Immigration, particularly from theIndian subcontinent, has introduced to Britain manyfamilies who follow vegetarian diets for religiousand cultural reasons. In addition widespread interestin conservation and environmental issues, concernabout food additives, and attempts to achievepurpose in life through combinations of physical andspiritual disciplines have stimulated enthusiasms forvegetarianism among indigenous Britons.

1.1.2 With many vegetarian diets the provision ofadequate nutrition for infants and children is notdifficult. Some regimens may even have healthbenefits for older children and adults as they areusually high in fibre and low in cholesterol andsaturated fatty acids. Traditional practices whichinclude well established and successful dietary pat-terns provide guidance and support for familiestrying to achieve adequate and balanced diets onmany of these vegetarian regimens. Otherwise somenutritional knowledge or dietetic advice is necessaryto ensure adequate nutrition over the weaningperiod.

1.1.3 The whole population is at risk from dietswhich severely restrict the variety of foods eaten.Weanlings are, however, at particular risk becauseof the problems inherent in: (1) changing from fluidto mixed diet; (2) high nutrient needs for rapidgrowth; and (3) susceptibility to infection whichitself may adversely affect nutrition.Where mothers have been receiving nutritionally

inadequate vegetarian diets, breast fed infants arelikely to suffer the same nutritional deficiencies astheir mothers, particularly vitamin and mineraldeficiencies. By the age of 4 to 6 months (if notbefore) these deficiencies of intake may havereached critical levels. Thus the need for excellentnutrition at weaning may be even greater for the

infants of vegetarian mothers than for the infants ofthose on normal mixed diets.

1.2 TERMS OF REFERENCEThe purpose of this paper is to outline vegetarianregimens and the hazards associated with them andto provide guidelines to the doctors and othersconcerned with advising on weaning diets forvegetarian children.

2 Terms of vegetarian diets

2.1 Vegetarian is not a specific term. It covers awide variety of diets with very differentrestrictions,' but with partial or complete absten-tion from animal foods, eggs, and dairy products.Some vegetarian disciplines are outlined below.

2.2.1 SEMIVEGETARIANSThese eat some meat (for example, fish and chick-en) but not red meat. Often the diet is followed forpersonal preference and varies between individuals.

2.2.2 LACTO-OVO VEGETARIANSThese eat no meat but eat dairy products and eggs.Yogic vegetarians are lacto-ovo vegetarians whostress the importance of natural and unprocessedfoods in the diet.

2.2.3 LACTOVEGETARIANSThese eat dairy products but neither eggs nor meat.

2.2.4 TOTAL VEGETARIANSThese eat no dairy products, no eggs, and no meatand thus consume no animal foods. Vegans are agroup of total vegetarians who are not only unitedby dietary disciplines but by 'the desire to rememberman's responsibilities to the earth and its resourcesand seek to bring about a healthy soil and plantkingdom and a proper use of the materials of theearth.'4 Vegans accept the need for vitamin B12 andD supplements to their diets.

Fruitarians follow a total vegetarian diet but alsoexclude cereals and pulses as well as animalproducts.5

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2.2.5 FOOD ADDITIVE AVOIDANCEThose following diets which avoid food additivesmay pursue vegetarian diets in some form and inaddition may concentrate on so called natural plantfoods. The diets are often self prescribed and maybe bizarre. When the natural food is raw unpasteu-rised cow, goat, or sheep milk, there is real risk ofbacterial infection due to contamination of the milk.

3 Religious and cultural dietary restrictions leadingto vegetarianism

There is great variety in the vigour with whichfollowers adhere to religious and cultural dietaryrestrictions. The table outlines the restrictionsaffecting the diets of some groups.

3.1.1 JEWSAs avoiding pork, fish without fins, shellfish, andfoods which have not been prepared by koshermethods are the only dietary exclusions, Jewishdiets are neither vegetarian nor particularly likely toput weanlings at nutritional risk. Strict orthodoxJewish dietary practices, however, define foodswhich can, or cannot be, prepared and eatentogether. Meat and milk, for example, must beprepared separately and not eaten after one anotherunless several hours have elapsed. The extra labourinvolved in food preparation may impose stresses onthe mothers of young children which, together with.difficulty in some non-Jewish areas of obtainingkosher foods, could present problems for weanlings.Because of the difficulty ensuring that bought foodsare correct, some Jewish families adopt lacto-ovovegetarian diets.

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3.1.2 HINDUSHindu dietary practices vary according to the branchof Hinduism followed and individual strictness ofadherence. The practice of non-violence againstliving things means that some Hindus eat no animalmeat or fish. Strict Hindus do not eat eggs. Westerncheese may also be forbidden as it contains animalrennet or gelatine. Other Hindus eat meat buttraditionally avoid the meat of the cow (beef, veal,sausages, beef extracts) as the cow is a sacredanimal, and of the pig because it is consideredunclean. Milk and ghee are sacred foods and dairyproducts are an important part of the diet.

Jains are members of a non-Brahminical Hindusect with dietary restrictions similar to those ofBuddists. They are strict vegetarians and fastfrequently as well. Many avoid 'hot' foods whichinclude eggs, fish, tea, honey, brown sugar, lentils,carrots, onions as well as the foods most Europeanswould regard as hot: ginger and chilli.

3.1.3 MUSLIMSAgain there is tremendous variety both in therigidity of adherence to, and the interpretation of,rules by different sects. Pig meat and the blood of allanimals must be avoided. Animals should beslaughtered after the 'halal' ritual. Fasting fromsunrise to sunset occurs during the lunar month ofRamadan but young children do not usually fast.

3.1.4 SIKHSAlthough Sikhs follow a separate religion, theirdietary customs overlap with those of Hindus andMuslims. Some are vegetarians but many eat eggsand meat, although animals should be killed with

Table Guide to foods avoided by certain religious practices

Pork Beef Other Non-scaly Eggs Milk Cannedmeat fish, foods

shellfish

Religion:Jewish* x xHindu* x x ?Jain x x x xSikh* xMuslim* xBuddhist x x x x x ?Bahai ? ? ? ? ? ?Seventh Day

Adventist x x x xRastafarian x x x x x ? xMacrobiotic (Zen) x x x x x x xHare Krishna x x x x x x

*Dietary restrictions may be greater if foods not prepared in acceptable way.xFoods generally avoided.?Denotes considerable vanation within religion over consumption of these foods.

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1288 Nutrition Standing Committee of the British Paediatric Association

one blow (khakka). Some eat port but not beef. Inpractice their diet is largely meat free.

3.1.5 BUDDHISTSBuddhists avoid killing any living thing. StrictBuddhists avoid eggs and milk.

3.1.6 The traditional diets of Hindus, Sikhs, Mus-lims, Buddhists, particularly for less strict adhe-rents, can achieve nutritional adequacy for wean-lings fairly easily.6 Problems may arise when tryingto provide an adequate diet for children in Britaindue to difficulty in obtaining foods preparedaccording to religious laws and to uncertainty overwhether food bought ready made or in jars or tinshas been handled inappropriately or containsforbidden foods. Commercial infant foodswhich are recognised as correct may be limited totinned fruits which are commonly of lower energydensity then some of the savoury meals and cerealproducts.

Religious practices other than dietary restrictionmay influence nutrition. Eating in the home may beby hand and right hand only-not easy for smallchildren. Fasting does not normally involve youngchildren but a mother who is herself fasting mayhave little energy and interest in preparing meals forher young children. Where meals are traditionallyonly twice a day and one meal late at night,problems may also arise from the volume of foodyoung children have to consume at each meal andbecause the children are too tired or too hungry toeat.

3.2. The religious practices described above havelong traditions. Customs and recipes have de-veloped to avoid some of the more likely nutritionaldeficiencies. Dietary practices developing in associa-tion with more recent religions and cults may notalways have the same secure nutritional basis. Thedietary regimens associated with some of these areoutlined.

3.2.1 SEVENTH DAY ADVENTISTSThe moral importance of a meatless and stimulantfree diet is part of the belief of this movement. Tea,coffee, chocolate, and many food flavourings arenot allowed. Milk is acceptable. The first commer-cial breakfast cereals (cornflakes) evolved from thesearch for a tasty acceptable food which fulfilled theAdventists' dietary strictures.7

3.2.2 BAHAISVegetarianism is not at present obligatory on Bahaisalthough Bahai writings state that the diet of thefuture will be fruits and grains. Many Bahai do

follow vegetarian (often total vegetarian) regimensnow. Fasting at specific times is obligatory on Bahaisbetween the ages of 15 and 70, although pregnantand lactating women are exempt.

3.2.3 RASTAFARIANSThe advent of this movement in Britain is relativelyrecent but the concepts on which it is based dateback to the 17th century.8 The extent to whichfollowers adhere to particular dietary practicesvaries. Orthodox Rastafarians avoid all animalproducts, eggs, alcohol, salt, and canned foods.Diets concentrate on chemical free, organic foods.Some Rastafarians drink milk.Foods acceptable to strict Rastafarians are foods

which are 'total' or in their natural state: 'I-tal'foods. Animal foods are dead foods and thusunhealthy as are inorganic and chemical foods.Tablets and medicines may be included in the lattercategory. Strict Rastafarian diets present problemsfor weanlings as nutritional knowledge and traditionare not well established within this community andpoverty and adherence to expensive West Indianfoods may restrict the diet excessively.

3.2.4 ZEN MACROBIOTICHere the Taoist philosphy of contrasting Yin andYang foods is mixed with strict adherence to organicforms and 10 dietary regimens (-3 to +7) ofincreasingly restrictive stages. All concentrate onnaturally grown foods. Meat is allowed in the loweststages. With increasing stages foods are graduallywithdrawn so that in the final stage the diet isthe most elemental and natural-entirely wholegrains. White sugar and sugar-containing items areavoided. Exotic foods tend to be prominent. Liquidsare used very sparingly. Macrobiotic foods areencouraged for young infants instead of milk but thetraditional infant formula derived from grains andseeds is grossly energy deficient and infant nutritionmay be compromised before the weaning age isreached.

3.2.5 HARE KRISHNASThese are lactovegetarians who again stress naturaland unprocessed foods.

3.2.6 These last three relatively recently developeddietary cults, if followed strictly, can lead to majornutritional problems for weanlings. Unfortunatelycult followers have often opted out of society andout of formal medical practices. Thus dietary helpand advice from traditional sources-communitydietician, general practitioner, health visitor-maybe unacceptable. Nutrition education for groupleaders may be important.

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4 How to ensure a satisfactory vegetarian diet forweanlings

4.1 The basic principles of weaning as outlined inPresent Day Practice in Infant Feeding9 apply tovegetarian weaning as much as to weaning on tounrestricted diets.

4.1.1 Weaning diet should occur between 3 and 6months in most cases and the introduction of non-milk, non-formula foods should be a gradual process.

4.1.2 Children's vitamin drops (vitamin A, 200 rig;vitamin C, 20 mg; vitamin D, 7 ig in five drops)should be given daily from 1 month until at least 2years.

4.1.3 Breast milk or infant formula (cow or soyprotein based) but not unmodified cow milk shouldbe continued with the weaning diet in children under1 year.

4.1.4 Growth of weanlings should continue to bemonitored and plotted on standard centile charts as

part of health surveillance and mothers advisedappropriately if growth deviates from the expected.

4.1.5 Families should be encouraged to seek adviceon vegetarian weaning diets from community dieti-cians, suitably trained health visitors or groups suchas the Vegan Society (33/35 George Street, OxfordOX1 2AY).

4.2 ENERGYAt weaning the infant's main need is for a source ofenergy. If the energy intake is adequate, proteinutilisation will be more efficient and essential aminoacids and nitrogen will be conserved. Withoutadequate energy, amino acids must be metabolisedto provide essential energy and nitrogen is lost fromthe body.

Provided infants continue to take about 500ml/day of breast milk or infant formula, the needsfor other protein will be relatively small. The energy

density of many vegetarian foods is low, however,due to low fat and high fibre content. Small infantsmay have difficulty consuming the necessary volumeof diet to achieve adequate energy intake. Thissituation can usually be avoided by:

4.2.1 Feeding infants frequently: weanlings shouldbe fed at least four times a day.

4.2.2 Including energy dense weaning foods at eachmeal. Home prepared, but strained or homoge-nised, meals are often more energy dense than tins

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and jars of commercial weaning food. Cereals andpulses are usually more energy dense than fruits butripe bananas have 15-20% carbohydrate and avoca-dos are rich in fat (22 g/100 g) and thus good sourcesof energy (0-93 MJ (223 kcal)/100 g).

4.2.3 Controlling or increasing the energy density offoods by serving cereals as thick, rather than thin,porridge and/or adding fats to cereal meals. Fatsadded to cooked cereals prevent them solidifyingquite so much on cooling. ° Margarine and peanutbutter (avoid crunchy peanut butter as this can causeinhalation of nut fragments) improve the energydensity of bread. Oils mixed with flour in prepara-tion of traditional breads improve energy density.

4.2.4 Preventing infants filling themselves withjuice or milk formula before taking the main part ofthe meal.

4.3 PROTEINMany vegetable proteins are deficient in one ormore essential amino acids. The total protein invegetable foods is also low compared with animalprotein sources. Legumes have the highest propor-tion of protein (over 20%). Soya beans are a veryrich source achieving about 36% protein. Thedifficulties of achieving adequate protein nutritionof weanlings on vegetarian diets can be reduced bycontinuing a moderate intake of breast milk or cows'milk or soya protein based formula. A pint-orabout 500 ml-per day breast milk or formulaprovides a quarter to a third of the year old infant'sprotein requirements as first class protein. Mixingmilk or formula intake with vegetable protein foodsenhances the amino acid composition of the mealand improves net protein utilisation.'1(}12 Wherebreast milk intakes have fallen to low levels orwhere mothers wish to stop breast feeding, infantsshould be changed to standard infant formula (notcows' milk, which does not have added vitamins andiron) or to a totally animal product free soya proteinisolate infant formula.Not all soy protein infant formulas are free in

animal fat but appropriate formulas are Formula S(Cow and Gate); Prosobee (Mead Johnson) andIsomil (Ross-Abbott). Soya formulas suitable foradults and obtainable from health food shops arenot suitable for infants as they do not have addedmethionine, vitamins, and iron. They should not befed to infants.

Protein needs can be met by:-4.3.1 Maintaining moderate intake of breast milk,cows' milk based or soy protein isolate based infantformula together with vegetable protein foods.

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4.3.2 Ensuring adequate energy intake so as toconserve nitrogen.

4.3.3 Planning meals so as to mix complementaryproteins (examples below).10

4.3.4 Complementary protein foods:Dairy products: high in lysine and isoleucine:complement cereals, nuts and seeds (avoid nutsand seeds except as very finely powderedpreparations because of the risks of inhalation).

Legumes (beans, lentils, chick peas): low intryptophan and sulphur containing amino acidsbut quite rich in lysine: complement cerealgrains, seeds and potatoes. (Legumes requireprolonged soaking and cooking and mashingbefore they are digestible). Tofu, a pressedsoya bean preparation, and soya milk yoghurtare useful in designing weanling diets.

Grains (wheat, oats, barley, rice, etc): low inisoleucine and lysine: use with milk, yeast orlegumes, potatoes, and vegetables. Grains varyin amino acid composition and mixing grainsimproves net protein utilisation. Rice is richerin lysine than wheat. Spiked millet (bajra) hasmore balanced essential amino acids than maize(for example) and is particularly rich in iron andcasein. Oats are the cereal with the mostadequate amino acid content. All grains absorbwater when cooked and this increases bulkwhile reducing protein concentration.

Dark green leafy vegetables: these only containabout 5% protein but are a good source ofsulphur containing amino acids (and vitaminA). They complement legumes.

4.4 VITAMINS4.4.1 Infant formulas (cows' milk protein based orsoy protein based) have added vitamins and iron andagain should be consumed in preference to cows'milk for all vegetanran infants throughout theweaning period.

4.4.2 As recommended by the Department ofHealth and Social Security for all children,9 chil-dren's vitamin drops (A, C, and D as above) shouldbe given to vegetarian infants from usually 1 monthold, and certainly from the introduction of weaningfoods, until 2 (and preferably 5) years old.

4.4.3 The vitamins most likely to be deficient invegetarian diets are B12, D, and riboflavin. Lacto-ovo vegetarian diets usually have sufficient B12, D,

and riboflavin provided there is a substantial formu-la intake. Intake of vitamin D may be belowrecommended without harm provided there is con-siderable exposure to summer sunlight.13 14 The mainsource of riboflavin is milk, and eggs and milk areboth sources of B12.

4.4.4 Vitamin B12 does not occur in plant products(with the exception of uncertain amounts in seaweedand fermented soya products). Strict vegans are thustheoretically at great risk of B12 deficiency. Inpractice clinical studies suggest that problems due toB12 deficiency are less common in vegan adults thanmight be expected.15 This argument should not beused to suggest that weanlings on total vegetariandiets do not need supplementation. Fetal stores ofB12 relate more to maternal B12 intake in pregnancythan to maternal B12 stores. The infant born to atotal vegetarian mother may be born already defi-cient in B12. Breast fed infants of total vegetariansare also likely to be receiving B12 deficient milk.Their need for supplementary B12 at weaning iscritical. Various oral preparations (Tastex, Barmine50 ,tg B12/100 g) are available and these or anotherB12 supplement must be used. (Tastex and Barminehave high sodium content and should not be usedexcessively in infancy).

4.4.5 Vitamin D deficiency is common in vegetarianinfants who have had little exposure to summersunlight.14 Often these are infants born to motherswith vitamin D deficiency. If breast fed, theseinfants will continue to receive D deficient diets asbreast milk is always low in vitamin D and itsrelative content of vitamin D reflects maternalstores. The fetal state is compounded by postnataldeficiency. Vitamin D supplementation is thusadvisable before weaning and supplementation atweaning becomes essential. In older children sun-light exposure should provide sufficient vitamin D tomeet requirements by skin synthesis.13 This cannotbe relied on for weanlings particularly where minor-ity group mothers tend to stay indoors keeping theiryoung children with them.Foods which are naturally good sources of vitamin

D are liver, oily fish (sardines, herrings, mackerel),egg yolk and, to a lesser extent, dairy products witha high fat concentration: cheese and cream. Allinfant formulas, many infant cereals and otherbreakfast cereals, and margarines are supplementedwith vitamin D. Infants on other than total vegeta-rian diets should be encouraged to use some of theanimal sources in their diets. The main dietarysource of vitamin D for weanlings is likely to beinfant formula (cows' milk protein or soya proteinbased) and cereals. Margarines supplemented with

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both vitamin A (900 iig retinol/100 g) and D (8tig/100 g) should be encouraged. Ovaltine is also a

good source of vitamin D (31 ,ug/100 g). Ghee is nota good source of vitamin D.

4.4.6 Excessive vitamin intakes have no confirmedhealth advantages and may be dangerous. Recom-mended intakes of supplementary vitamins shouldnot be exceeded.

4.5 MINERALS4.5.1 Vegetarian foods may contain a wide varietyof minerals sometimes present at quite high levels.Binding to phytates or other fibre in the gut or theform (for example, Fe"' or Fe++) in which themineral is present inhibit mineral absorption fromfood. The bioavailability of the supplemental iron incommercially prepared infant cereals is uncertain.16In general vegetarian children require higher mine-ral intakes than children on mixed diets to achieve

17 1requirements 18 as absorption of minerals fromplant foods is often less efficient than from animalsources.

Iron and zinc are minerals particularly likely to beaffected by binding in the gut.'7

4.5.2 Egg yolk is a rich source of iron but eggs

appear to inhibit absorption of non-haem iron eatenwith them. Vegetable foods with high iron contentare dark green leafy vegetables, lentils, chick peas,peas, molasses, and curry powder (it is not clear howefficiently the iron in curry powder is absorbed).The phytate content, particularly of the legumes,reduces the availability of iron in vegetables. Ascor-bic acid-containing fruits and fruit juices mayincrease the availability of iron from vegetablefoods. Most commercial orange squash (not infantpreparations) does not contain ascorbic acid.

4.5.3 Many vegetarian diets are low in zinc andcalcium. It may be difficult for weanlings to achieveadequate calcium intake unless they are maintainingreasonable intakes of breast milk or formula.19 It isessential that vegetarian weanlings receive vitaminD supplementation so that the efficiency of calciumabsorption is maximised.

5 Diets which are more restrictive than just exclud-ing animal products

5.1 It is very difficult to achieve nutritional adequ-acy for energy, minerals, and certain vitamins inweanlings on strict fruitarian, Rastafarian, or mac-robiotic diets.20 Severe clinical malnutrition hasbeen described in association with the use of suchdiets.2' 22 We cannot recommend them.

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5.2 Elimination diets seem largely unnecessary inthe weaning age group. Even well designed elimina-tion diets are likely to be deficient in calcium.23These diets should only be followed after medicalrecommendation and with paediatric dietetic sup-port.

5.3 'Additive free' and 'organic' diets cannot berecommended without careful paediatric dieteticadvice and supervision over foods which cannot beexchanged or avoided. Their use in the weanling agegroup is again very limited.

6 Summary: principles of achieving a satisfactoryweaning diet for vegetarians

6.1 The basic principles of weaning outlined inPresent Day Practice in Infant Feeding9 apply toweaning vegetarian as well as omnivorous infants.

6.1.1 Weaning foods should be introduced gradu-ally and not later than 6 months of age but notnormally before 3 months of age.

6.1.2 Vitamin supplements (A, C, and D) as chil-drens' drops (five drops daily), should be given to allinfants at least from the age of weaning, if notbefore, and until 2, and preferably 5, years of age.

6.1.3 All infants should be weighed regularly as partof health surveillance. Weights should be plotted onstandard centile charts so that intervention canoccur early if there is inadequate or excessive weightgain.

6.2 A moderately high intake of milk or formulashould be maintained throughout the first year oflife. This should be breast milk, cows' milk basedinfant formula, or soya protein based infant formu-la. Breast milk or infant formula provide significantprotein and calcium and, with formula, vitamins.We cannot recommend cows' milk in the first year oflife.

6.2.1 Infants should be fed frequently: at least fourmeals a day.

6.2.2 Diets should contain a variety of foods at eachmeal and different meals should utilise differentvegetarian foods. Families should plan for each mealto contain food from a carbohydrate staple, aprotein source, and then vitamin and mineralsources (food group or food square method).10 Asource of ascorbic acid should be provided at eachmeal to facilitate mineral absorption.

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6.2.4 The energy density of foods is important.Adding fats to weaning cereals and other staples willimprove energy density.

6.2.5 Avoid sating appetite with low energy juicesbefore the meal.

6.2.6 Use margarine fortified with vitamins A andD rather than butter or ghee as fat source.

6.3 Total vegetarians require supplementary vita-min B12. This should be provided either as propriet-ary preparations (Tastex, Barmine) or as an oralpreparation once weekly.

6.4 The advice of community dietician and/or theVegan Society should be encouraged particularly forthose families weaning their infants onto totalvegetarian diets.

6.5 More limiting regimens than total vegetarianismmust be avoided in young children. Such regimensare likely to lead to unbalanced and grossly inadequ-ate diets. Families who insist on feeding theirchildren on such diets must be prepared to acceptclose supervision of their children and dietarysupplementation when indicated.

6.6 The recommendations of the COMA report onreducing the total fat in the diet and encouragingfully skimmed milk,24 do not apply to children under5 and could be dangerous in weanlings. However,the Committee on Medical Aspects of Food PolicyPanel on Child Nutrition has commented that'where semi-skimmed milk is in general use in ahome there are no strong objections to its progres-sive introduction from the age of 2 years, providedthe child's overall dietary balance is adequate.Wholly skimmed milk should not be introducedbefore the age of 5 years'.25

We should like to acknowledge Anita MacDonald, Brenda Clark,Sadru Jivani, Jane Thomas, and Stephen Vickers for their helpfuladvice during preparation of this paper. We are also grateful toJohn Wilkins and Jim Smellie for typing and correcting numerousdrafts of the manuscript.

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9 Department of Health and Social Security. Present day practicein infant feeding. 3rd report. London: HMSO, 1988.Cameron M, Hofvander Y. Manual on feeding infants and youngchildren. Oxford: Oxford University Press, 1983.Vyhmeister PH, Register UD, Sonnenberg LM. Safe vegetariandiets for children. Pediatr Clin North Am 1977;24:203-10.

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16 Fomon SJ. Bioavailability of supplemental iron in commerciallyprepared dry infant cereals. J Pediatr 1987;110:660-1.

7 Davies NT, Warrington S. The phytic acid, mineral, traceelement, protein and moisture content of UK Asian immigrantfoods. Hum Nutr: Appl Nutr 1986;40A:49-59.Helman AD, Darnton-Hill I. Vitamin and iron status in newvegetarians. Am J Clin Nutr 1987;45:785-9.

'9 Sanders JAB, Purves R. An anthropometric and dietaryassessment of vegan preschool children. Journal of HumanNutrition 1981 ;35:349-57.

20 von Staveren WA, Dhuyvetter JHM, Zeelen M, HautvastJGAJ. Food consumption and height/weight status of Dutchpreschool children on alternative diets. J Am Diet Assoc1985;85:1579-84.

21 Zmora E, Gorodischer R, Bar Ziv J. Multiple nutritionaldeficiencies in infants from a strict vegetarian community. Am JDis Child 1979;133:141-4.

22 Roberts IF, West RJ, Ogilvie D, Dillon MJ. Malnutrition ininfants receiving cult diets: a form of child abuse. Br Med J1979;i:296-8.

23 David TJ, Waddington E, Stanton RHJ. Nutritional hazards ofelimination diets in children. Arch Dis Child 1984;59:323-5.

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25 Committee on Medical Aspects of Food Policy. Statement fromthe Panel on Child Nutrition in Children's diet and change. AReport of the Child Health and Nutrition Working Party.Appendix 2. London: British Dietetic Association, 1987.

A document produced by Dr EME Poskitt on behalfof the Nutrition Standing Committee of the BritishPaediatric Association.Nutrition Committee 1986-7:Professor TE Oppe,Dr RG Whitehead,Dr BA Wharton (convener),Dr LS Taitz,Dr EME Poskitt,Dr JV Leonard (convener, British PaediatricNutrition, Metabolism, and Pharmacology Group).

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