“Bulking Up” For Sports?

Patient Presentation
A 16-year-old male came to clinic because his mother was worried about his desire to gain weight. He had played on a local, non-traveling, recreational soccer team for several years and enjoyed it. Over the past 6 months his friends, who included varsity athletes in several sports, had started to do more weight lifting with their teams. In addition to their sport specific training, this group of young men were all doing weight training twice a week together. The patient was also doing 2 more sessions/week by himself. He had increased his protein intake by “eating more meat” and was taking protein supplements. He was also restricting his diet by consuming almost no dairy products or fruits or vegetables. He ate minimal carbohydrates. He wanted to “bulk up” so that he would be more competitive at soccer and to be like his friends. He was not planning on doing any other competitive sports, nor competitive soccer. He would run 2-3 miles on days he was not lifting weights. He had always been on the heavier side in weight with a BMI around 75%. When asked how he felt, the teen said that he liked being with his friends. He said that he was learning more about weight lifting and had been slowly increasing the amount of weight he lifted. “My running has gotten slower though I notice. It’s taking me longer to run the same loops,” he offered. His mother stated that he seemed tired a lot of the time and was crabbier. “He’s also not getting enough sleep,” she complained.

The past medical history was non-contributory. The family history showed that his father was obese and short. He walked and swam for exercise. His mother was average-sized and walked and bicycled for exercise.

The pertinent physical exam showed his vital signs to be normal. His height was 171 cm (25-50%) and his weight 68.2 kg (~50-75%), BMI was 24 and abdominal circumference was 99 cm (>90%). His BMI was trending upward. He was Tanner V and had been the same height for 18 months. The rest of his physical examination was normal.

The diagnosis of a young teen with abnormal weight gain was made. The pediatrician began counseling him by emphasizing the positive aspects of exercising, being part of a friend group, and persistence in trying to achieve a goal. However he also emphasized that several behaviors were not helpful including restricting food, using supplements and poor sleep habits. “Exercise and weight training can be good but you have to do it smart. You can have some more protein along with weight training to increase muscle, but it has to be part of overall good nutrition. That means eating dairy products and some fruits and vegetable and even carbohydrates. Sleep is actually really important too for your overall health but also for your body to use the protein you are putting into it. Sleep is your rest period and the body can also try to build the muscle. Do you like the weight training?” he asked. “Yeah, I like being with my friends and I like how I feel stronger now than I did. I’d like to do better at the running because I’m going to start back with soccer soon,” he said. “Okay, would you like to talk with one of the dieticians who can help you to figure out how much protein and everything else you need to keep growing and being able to do soccer and weight training?” he asked. The teen agreed to see the dietician and also agreed to stop using the protein supplement.

The patient’s clinical course a few weeks later showed he had stopped taking the supplement, had had an average soccer season, and was still weight lifting.
“I think I hurt myself for soccer, but I am still lifting 2 times a week with my friends and we’re doing it at school now with the trainer. I’m eating better but spring soccer will be here soon, and I’ll be stronger with my running by that time,” he said.

Athletes, whether recreational or competitive, who participate in weight sensitive sports commonly gain or lose weight to achieve a particular body type or to improve performance. Athletes in duration or aesthetic sports (such as distance running, diving, dance, etc.) attempting to lose weight to be able to move the body against gravity better. Sports that emphasize strength and power including combat sports (such as football, wrestling, mixed martial arts, body building, etc.) often have athletes attempting to gain weight and lean muscle mass to improve performance. This is felt to increase the strength-to-weight ratio. Weight class sports which can include some combat sports and others such as rowing, can cause some athletes to roller-coaster between losing weight to be able to compete in a lower weight class and then gaining weight back. Rapid weight loss and rapid weight gain can have detrimental effects both acutely and long-term on the athletes. A systematic review of rapid weight loss and gain in combat sports participants found that there is poor data on rapid weight loss, and the rapid weight gain is “…influenced by the type of sports, competition structure, and recovery duration.” “[A]thletes are able to exploit the [competition] rules to compete up to three weight categories higher than at the official weigh-in.” The studies mainly involved male athletes and there was little data for females. Sports with the least amount of time between weigh in and competition, and the least time between competitions tend not to engage in rapid weight loss and gain.

Rapid weight loss can cause athletes to feel fatigued and weak, feel disoriented, anxious, dizzy or feverish, and having epistaxis and headaches. It has also lead to death in some high profile cases. Rapid weight gain can cause problems with maturation and growth and disordered eating, plus problems in immune response, endocrine, cardiovascular, renal and thermoregulatory systems. Athletes fail to realize that after 2-3 days of dehydration that is often used to “cut weight,” it can take 48 hours to replace intracellular fluids. Inadequate hydration decreases aerobic and anaerobic performance with aerobic performance being more affected.

“Athletes rely most heavily on their coaches and teammates for advice on making weight, and qualified professionals (i.e. dieticians and physical trainers) are among the least influential.”

Learning Point
“[S]ports performance may be the best indicators for an athlete’s optimal body composition and weight at his or her developmental age.”

According to the American Academy of Pediatrics healthy weight gain should:

    Be gradual weight gain that is muscle mass not increased fat

      Boys up to 0.5-1 pound/week
      Girls up to 0.25-0.75 pound/week
      Weight gain should be up to genetic potential

    If maintaining body weight and eating the recommended amount of protein, the athlete can

      Consume 300-500 kcal/day above baseline intake
      Consume extra 14 g of protein/day (or 1.5-1.8 g protein/kg/day)*
      Do strength training (this helps to incorporate the protein into muscle mass)**
      and should get adequate sleep

*As a comparison, 7 grams of protein is 1 egg, 1 tablespoon peanut butter, 1 ounce of chicken, 1/4 cup cooked beans or tofu

** The AAP does not recommend skeletally immature children or adolescents do body building, power lifting or maximal lifts.
“[S]ports performance may be the best indicators for an athlete’s optimal body composition and weight at his or her developmental age.”

Questions for Further Discussion
1. What are indications for consultation with sports medicine?
2. What are indications for consultation with a dietician?
3. How much exercise should children and teens do? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Body Weight, Diets, and Sports Fitness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Iraki J, Fitschen P, Espinar S, Helms E. Nutrition Recommendations for Bodybuilders in the Off-Season: A Narrative Review. Sports. 2019;7(7). doi:10.3390/sports7070154

Matthews JJ, Stanhope EN, Godwin MS, Holmes MEJ, Artioli GG. The Magnitude of Rapid Weight Loss and Rapid Weight Gain in Combat Sport Athletes Preparing for Competition: A Systematic Review. Int J Sport Nutr Exerc Metab. 2019;29(4):441-452. doi:10.1123/ijsnem.2018-0165

Carl RL, Johnson MD, Martin TJ, Council on Sports Medicine and Fitness. Promotion of Healthy Weight-Control Practices in Young Athletes. Pediatrics. 2017;140(3). doi:10.1542/peds.2017-1871

Carl R. Healthy Weight Practices for Child and Adolescent Athletes. Pediatr Ann. 2019;48(7):e286-e289. doi:10.3928/19382359-20190617-02

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Common is Lyme Disease Globally and in Urban Settings?

Patient Presentation
During her work commute, a pediatrician was listening to a podcast about the European outdoors. One of the segments discussed how Lyme disease was more common in urban areas of Europe than most people realized.
She saw many patients for concerns about tick bites and knew about the epidemiology in her location, but didn’t know as much about it in other locations.

Lyme disease (LD) is caused by several genospecies of Borrelia burgdorferi senu lato that are transmitted by ticks of the Ixodes ricinus complex. In the U.S. and Europe it is the most common vector-borne disease. It is named for Lyme, Connecticut in the 1970s when it was “discovered,” but there are reports of LD-type disease in Europe since 1883. There are 18 distinct genospecies with B. afzelii, B. garinii and B. burgdorferi sensu stricto being the 3 most common ones causing human infection. There are many species of Ixodes ticks but only 4 commonly bite humans. Ixodes ricinus mainly in Europe, I, persultcatus in Asia, I. scapularis in the eastern and central US, and I. pacificus in the western US and Canada. However I. pacificus is rarely infected and accounts for very few human infections.

I. scapularis lives for approximately 2 years and eats blood meals at each of its 3 stages, larval, nymph and adult. Ticks are not infected when they hatch from eggs (a single female can produce > 2000 larvae). They become infected from the blood they feed upon. For I. scapularis, reservoir hosts for larva and nymphs are small mammals (i.e. mice, shrews) and birds. Adults like larger mammals such as deer and dogs. (Dogs are used as sentinels for epidemiological studies of Borrelis sp. in the environment). Humans are dead-end hosts as the spirochetes are not sustainable in human tissues in large numbers. I. scapularis ticks need attachment to transmit LD (usually 36 hours or more). Therefore attachment prevention with long clothing, showering (within 2 hours of being outside) and tick checks have demonstrated decreased risks of ticks bites. Additionally, using insect repellents with 20-30% of DEET is recommended.

Nymph stages are particularly important in LD transmission as they are abundant and small. Nymphs tend to feed in the late spring/early summer seasons or similar time frame depending on the local global latitude. Nymph stages are sensitive to desiccation, therefore they are increased in areas of humidity.

A review of LD clinical symptoms can be found here. Serological testing for disease depends on the geography, especially the expected prevalence of the organism. “In general, serological testing is only considered useful when the prior probability of disease is between 20% and 80%. In circumstances when the risk is lower, positive laboratory tests are more likely to reflect a false-positive result than actual infection.” Therefore management decisions about testing, prophylactic antibiotic use or treatment antibiotic use depends on location.

Learning Point
LD is seen around the northern hemisphere of the world but is particularly common in Northeastern, Mid-atlantic and upper Midwest areas of the US and corresponding Canadian provinces with I. scapularis as the primary vector. Western coastal areas including British Columbia and Northeastern Mexico and the Baja, have I. pacificus ticks but the number of human cases of LD is few. In Europe LD common in all Eastern, Central and Western European countries below 1300 m2 elevation and the primary vector is I. ricinus. B. afzelii is more predominant in Northern and Eastern Europe “(e.g. Scandinavia, Baltic states, Czech Republic, Slovakia, Croatia, Bulgaria).” B. garinii is more predominant in Western Countries “(eg. Austria, Switzerland, United Kingdom).”

LD can also be seen in the northern Africa coast in northern Algeria, Morocco and Tunisia with the common species being B. lusitaniae. LD is seen in Turkey and Russia with extension into the Asian continent including Japan, Korea, Taiwan and China. There are possibly LD cases noted in the southern hemisphere in Australia, Brazil and South Africa.

In the United Kingdom, Scotland has the highest prevalence rate along with South West and Southern England. Birds are a more important vector in Europe and it is thought that this is part of the reason that Scotland and other countries with large coastlines such as Norway may have higher disease rates. Ground feeding birds, especially thrushes, carry the most ticks and therefore potentially Borrelia sp.

Studies have found ticks with I. ricinus in urban areas throughout Europe including 2 South London parks. Urban greenspaces are often not thought of as carrying ticks and other potential environmental hazards, but can. This is especially true for green spaces at the “edge” of the city (periurban) or with increased connectivity between the green spaces which helps to support the birds, mammals and other environments suitable for ticks to survive and migrate between. Even isolated pockets of green space can harbor significant urban tick populations. The green space microclimate is also important with more trees, bushes and leaf-litter supporting a more humid environment which supports tick populations, while increased gravel or paved landscapes are drier and do not support tick populations as well.

Questions for Further Discussion
1. Describe erythema marginatum?
2. What is the local prevalance of Borrelia sp. in your location?
3. What is the treatment for Lyme neuroborreliosis in children?

Related Cases

    Symptom/Presentation: None
    Age: None

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Lyme Disease and Tick Bites.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Cairns V, Wallenhorst C, Rietbrock S, Martinez C. Incidence of Lyme disease in the UK: A population-based cohort study. BMJ Open. 2019;9(8):e025916. doi:10.1136/bmjopen-2018-025916

Mead PS. Epidemiology of Lyme disease. Infect Dis Clin North Am. 2015;29(2):187-210. doi:10.1016/j.idc.2015.02.010

Heylen D, Lasters R, Adriaensen F, Fonville M, Sprong H, Matthysen E. Ticks and tick-borne diseases in the city: Role of landscape connectivity and green space characteristics in a metropolitan area. Sci Total Environ. 2019;670:941-949. doi:10.1016/j.scitotenv.2019.03.235

Rizzoli A, Silaghi C, Obiegala A, et al. Ixodes ricinus and Its Transmitted Pathogens in Urban and Peri-Urban Areas in Europe: New Hazards and Relevance for Public Health. Front Public Health. 2014;2:251. doi:10.3389/fpubh.2014.00251

Oechslin CP, Heutschi D, Lenz N, et al. Prevalence of tick-borne pathogens in questing Ixodes ricinus ticks in urban and suburban areas of Switzerland. Parasit Vectors. 2017;10(1):558. doi:10.1186/s13071-017-2500-2

Nelson C, Banks S, Jeffries CL, Walker T, Logan JG. Tick abundances in South London parks and the potential risk for Lyme borreliosis to the general public. Med Vet Entomol. 2015;29(4):448-452. doi:10.1111/mve.12137

Hansford KM, Fonville M, Gillingham EL, et al. Ticks and Borrelia in urban and peri-urban green space habitats in a city in southern England. Ticks Tick-Borne Dis. 2017;8(3):353-361. doi:10.1016/j.ttbdis.2016.12.009

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Can Radiolucent Foreign Bodies Be Identified?

Patient Presentation
A 30 month-old female came to clinic with a history of a cough for 2-3 weeks with rhinorrhea. Her mother was concerned because the day before she had an unwitnessed choking episode where the mother heard what she thought was choking but had stopped when she entered the room. The child was eating crackers at the time. The mother did not see any missing toys or toy parts in the room and the child could not answer if she had swallowed something or put something in her mouth. The mother was quite adamant that she wanted a chest x-ray because she had read on the Internet that aspiration could be diagnosed this way. She had been eating and drinking well since the episode and had no fever. The past medical history was positive for mild intermittent asthma but the mother had not been giving albuterol as it didn’t appear to be helping with this episode.

The pertinent physical exam showed a child with no respiratory distress with normal vital signs, growth parameters and an oxygen saturation of 98%. HEENT showed copious rhinorrhea with some clear fluid behind her tympanic membranes without erythema. Her lungs were difficult to auscultate because she became very fussy and didn’t want to be examined. The rest of her examination was negative.

The diagnosis of a viral syndrome in a setting of previous bronchospasm was made. The resident physician was explaining his findings to the mother who was not very happy with the diagnosis. She then stated, “I think now that she swallowed a toy piece and a want chest x-ray. Besides she’s been coughing for 2 weeks now.” The attending physician also tried to listen to the child who again refused to be examined and the mother became more vocal that she was “sure she had swallowed a toy piece.” The physicians discussed that chest x-rays were not fool-proof for diagnosing foreign bodies. The mother was adamant and the physicians acquiesced. A radiologic evaluation of a chest radiograph was done and was normal. The mother became much less agitated, and verbalized that she was now okay, “because she doesn’t have something in her lungs.”

Foreign bodies are common problems for young children particularly ages 2-4 years who will mouth many objects and aspirate or swallow them. Children will also place foreign objects in other body orifices such as ears or noses. It is also not uncommon that young girls will inadvertently have toilet paper caught in the vaginal area during hygiene. Many of these foreign bodies may work their way out naturally not causing any problems, or may come to attention later because of chronic problems such as a foul-smell or discharge. Older children may tell adults that they have placed a foreign body in an orifice and thus have it come to attention.

Because mouthing food and non-food objects is common in young children, it is not uncommon that the children will cough or choke. Usually this expels the objects and fixes the problem. Parents may not even notice the episode as coughing and choking in general occurs frequently in young children. Some children will have more significant problems if the objects lodges in the airway or at particular points in the gastrointestinal tract, and therefore have continued symptoms and come to medical attention. For example, in a 2013 retrospective review of patients who underwent bronchoscopy for suspected radiolucent foreign body aspiration, most were witnessed events (81%) in a ~2.6 year old (average age), who continued to have problems with wheezing (64%), coughing (43%), choking (39%), stridor (6%) or lethargy (0.7%). Bronchoscopy found a radiolucent foreign body in 93% of the cases which included food (68%), plastic (18%), rock (3%) or unidentifiable object (11%).

Learning Point
For unwitnessed events or when a child admits to the event, radiographs may be used to try to identify the object and location. A radioopaque object is usually easy to identify, and a mnemonic of common radiolucent objects can be found here. A radiolucent object is harder. On chest radiograph (CXR) a radiolucent object in the bronchial tree may show decreased aeration, air trapping or even lung collapse. Often the CXR is normal, which also does not exclude a foreign body. Other methods include visualization with ultrasound, computed tomography, magnetic resonance imaging and even handheld metal scanners. All of these modalities their pros and cons. Some require radiation, are expensive, require a skilled technologist or are very limited to the types of objects that can be identified.

Many, but certainly not all, radiolucent objects can be identified using plain radiographs. In a 2014 study, common radiolucent objects were placed along with control objects in a gelatin slab that was then encased in a water equivalent phantom depicting a child. A plain radiograph was taken and blinded radiologists reviewed the radiograph. Each radiologist correctly identified most of the objects (avg. 8 of 14). 4 objects were not identified by any radiologist. Objects identified were a plastic army figure, lump of clay, crayon, eraser, glass diamond bead, paperclip, drywall anchor, and ring. Items not identified were a plastic barrette, plastic beads and a Lego® brick. The radiologists also were able to identify where some other objects were placed on the radiograph but were unable to identify the specific object. Images of the objects in the study can be found here.

Questions for Further Discussion
1. How would you have handled the adamant parent situation described above?
2. Where do most gastrointestinal or respiratory tract foreign bodies lodge?
3. What types of foreign bodies can be monitored and what need to be removed because of their intrinsic properties?
4. What are some techniques for foreign body removal?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Foreign Bodies and Cough.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Saps M, Rosen JM, Ecanow J. X-ray detection of ingested non-metallic foreign bodies. World J Clin Pediatr. 2014;3(2):14-18. doi:10.5409/wjcp.v3.i2.14

Mortellaro VE, Iqbal C, Fu R, Curtis H, Fike FB, St Peter SD. Predictors of radiolucent foreign body aspiration. J Pediatr Surg. 2013;48(9):1867-1870. doi:10.1016/j.jpedsurg.2013.03.050

Behera G, Tripathy N, Maru YK, Mundra RK, Gupta Y, Lodha M. Role of virtual bronchoscopy in children with a vegetable foreign body in the tracheobronchial tree. J Laryngol Otol. 2014;128(12):1078-1083. doi:10.1017/S0022215114002837

Hamzah HB, James V, Manickam S, Ganapathy S. Handheld Metal Detector for Metallic Foreign Body Ingestion in Pediatric Emergency. Indian J Pediatr. 2018;85(8):618-624. doi:10.1007/s12098-017-2552-5

What Affects the Nutritional Quality of Plant-Based Milk Substitutes?

Patient Presentation
A 12-month-old female came to clinic with her mother for her health supervision visit. The infant was breastfeeding and had a history of cow’s milk protein and soy allergies where the patient had bloody stools or hives. The family was vegetarian but ate some dairy products and eggs. She asked about using a pea-based milk substitute to wean the infant. The family had tried eggs and peanut products without any problems for the infant. They also had tried some yogurt and felt her stools were much looser but there was no obvious blood in them. The infant ate age-appropriate complimentary foods without difficulty. The past medical history was otherwise negative.

The pertinent physical exam showed a healthy female with weight in the 25-50% and height and head circumference in the 50-75%.
Her physical examination was normal.

The diagnosis of a healthy female with food allergy or sensitivities was made.
The pediatrician knew that there could be problems with plant-based milk substitutes for young children including protein and other nutrient insufficiencies depending on the product used.
“Let me do a little research and talk with the hospital dietician who works in our gastroenterology clinic. I’ll get back to you in a few days but in the meantime, just continue the formula,” he answered.

People today may be eating more plant-based products because of:

  • Allergen avoidance – lactose or cow’s milk allergy, 14% of people with cow’s milk allergy will also have soy allergy.
  • Cultural importance
  • Contamination avoidance e.g. growth hormone or antibiotic residues in cow’s milk production
  • Specific diseases, e.g. cholesterol/lipid issues
  • Environmental impact
  • Ethical or religious considerations
  • Improved nutrition

With population growth “[t]he demand for food is expected to grow by 70% until 2050….While the expected protein consumption is believed to grow by 80%.” Protein sources are also expected to come from more resource intense foods.

Plant-based milk substitutes (PBMS) look like cow’s milk but are water-based extracts of legumes, oil seeds and nuts, cereal or pseudocereals. Soy milk and other soy products are the most common globally.

Common commercial plants utilized include:

  • Soy
  • Almond
  • Coconut
  • Hemp
  • Kamut
  • Oat
  • Maize
  • Millet
  • Peanut
  • Quinoa
  • Rice
  • Rye
  • Sesame
  • Sorghum
  • Tiger-nut (actually a tuber) – used to make Horchata
  • Wheat

Some plant-based drink examples include:

  • Amazake – rice, from Japan
  • Atole, maize, from Mexico
  • Boza – wheat, rye, millet, maize, common in south eastern Europe
  • Bushera – sorghum or millet, from Uganda
  • Chicha – grains and fruits, common in the Andes mountains
  • Horchata or tiger-nut milk, from Spain
  • Sikhye – rice, malt and sugar from South Korea
  • Soy milk – soy, from Asia especially China

The basic PBMS production process involves:

  • Taking the plant, adding water and grinding into a slurry- the plant can have water added first then is wet-milled, or is dry-milled then water is added to the resulting flour
  • Separating the solid wastes by filtration, decanting, centrifugation, etc.
  • Product formulation including other treatments such as fermenting or adding oil, flavoring, sugars, stabilizers and nutritional fortifiers
  • Homogenization to keep the product in the water suspension otherwise the particles can separate out as these are emulsions or colloidal suspensions
  • Pasteurization or ultra high temperature treatment to prevent microbial contamination
  • Packaging

Product formulations are affected by many things including temperature, pH, treatment duration, and when in the process the treatment is done. These make various nutrients more or less available (especially protein and fat) and with different qualities (i.e. textures, tastes, that make the end product more desirable to consume and nutritionally preferable). Fermentation, using bacteria, fungi or yeasts, is often used to improve nutrition, taste, and shelf life.

Additions to the basic product are exceptionally diverse because of the diverse products being made. Stabilizers prevent product degradation and nutritional supplements may be needed because naturally occurring water-soluble vitamins and other nutrients were destroyed or lost in the processing. Even different calcium types, added to fortify the product and to stabilize it, and make the calcium partially or wholy bioavailable. Calcium is less bioavailable if calcium triphosphate is used but is 100% bioavailable if calcium carbonate is used. Additions can also include animal ingredients.

Consumers often expect PBMS or other plant products to taste like cow’s milk or animal products when they are not. Some consumers complain of a chalky or pasty feel or of a beany taste. “[A] good approach…would be to appreciate the taste of the plant ingredients.” Producers are trying to make products that are nutritious, tasty and affordable for consumers.

High quality data is limited to determine the impact of protein products on the environment but they may have an improved impact utilizing less land but the issue is complex. For example, almonds are a good source of PBMS. Almonds are grown mainly in California (80%) and they require a great deal of amount of water which is limited. They also do not wind-pollinate well and therefore require bees for pollination and unfortunately the bee populations are also dwindling. Environmental contaminants can also occur in plant-based products and not solely in animal based products.

Learning Point
“In reality the nutritional properties [of plant products] vary greatly, as they depend strongly on the raw material, processing, fortification, and the presence of other ingredients such as sweeteners and oil.”

In general however, plant-based products have:

  • Lower protein and the protein is of lower quality – the protein may be of lower quality because of limiting amino acids (legumes = methionine, cereals = lysine) however again it depends on the actual product.
  • Lower cholesterol and improved lipid profile
  • Calories are about the same as skin milk
  • May have lower calcium, iodine, iron, phosphorus, vitamin B12, riboflavin, zinc, etc.
  • More or less allergens

PBMS are often lower in protein and young children are potentially at risk for protein malnutrition if PBMS are used without an understanding of the differences between animal milk and PBMS. Not only protein may be insufficient for infants but other vitamins and minerals may be insufficient. Some PBMS do have higher protein levels such as peanut or cowpea products, but again it depends on the actual product.

Questions for Further Discussion
1. What types of foods should vegetarians eat to maintain their nutrition? A review can be found here
2. How much protein does someone need to eat? A review can be found here
3. What are indications for consultation with a dietician?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Vegetarian Diet and Nutrition.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Jeske S, Zannini E, Arendt EK. Past, present and future: The strength of plant-based dairy substitutes based on gluten-free raw materials. Food Res Int Ott Ont. 2018;110:42-51.

Makinen OE, Wanhalinna V, Zannini E, Arendt EK. Foods for Special Dietary Needs: Non-dairy Plant-based Milk Substitutes and Fermented Dairy-type Products. Crit Rev Food Sci Nutr. 2016;56(3):339-349.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa