Is There an Increased Risk of Neurological Impairment in Infants under Maternal Vegan Diet?

An evaluation of Vitamin B-12 Deficiency The vegan diet is a dietary lifestyle that is rapidly growing in popularity, due to perceived health benefits such as decreased saturated fats and cholesterols, as well as an increase of ingestion of important plant-based nutrients. The social aspect of veganism, that is to say the animal rights perspective is also an appealing, and certainly admirable draw as well. For the adult, veganism is generally accepted to be relatively healthy, if certain parameters of nutrition are maintained, but does the diet affect an infant child of a vegan mother? Is there a downside to this increasingly popular trend that practitioners should be more aware of? Briefly summarized, the answer is a mixed one. Veganism is defined as [someone] who eats no animal or dairy products at all. Sometimes referred to as "strict vegetarians", vegans may also separate themselves into another subcategory dubbed "strict raw" vegan; this is a vegan who does not consume anything cooked, and often sprouts their own foods. This dietary lifestyle is not just a fad, rather it is a growing trend in the United States due to popularity as a "weight loss" diet for celebrities1. Coupled with this widely accepted promise of rapid weight loss, many proponents of the vegan lifestyle use social media to bombard people with images that do not provide information, opting instead to employ guilt-inducing images and shaming language.

Figure 1. Racism= Speciesism= Sexism: An apparently prevalent image by search query results, claims that a vegan diet can solve most all social evils. Figure 2. "Globesity": Using the image of an overweight child versus an active child to advocate the validity of a strictly plant-based diet. Figure 3. Veganism as a way to solve world hunger. The claim is made, with no references to scientific or socio-ecological inquiry (and indeed none could be found when investigated), that the food used to sustain beef cattle could instead be given to the impoverished, thereby alleviating world hunger.

It would seem that the vegan stance is one of social culpability, and not entirely based on factual evidence to support claims of nutrition or viability. Years of nutrition education are unnecessary to arrive at the conclusion that a diet rich in vegetables and fruits is ideal; however, conclude that all animal-based proteins are either lacking in benefits or are detrimental to health should be coupled with sound research, of which there is little to find. Vitamin B12 is an essential water-soluble vitamin. It is commonly found in animal products, namely fish, shellfish, meat, eggs and dairy. According to the Mayo Clinic, "Vitamin

B12 plays an important role in supplying essential methyl groups for protein and DNA synthesis."2 Deficiency is rare in omnivorous individuals due to the liver's ability to store the essential micronutrient2 and the ready access of foods rich in the vitamin. However, deficiency is not at all uncommon in vegetarians, and is especially common in vegans. According to a study published in The Journal of Nutrition, there were "significantly (P < 0.001, paired t test) lower serum vitamin B-12 concentrations in the vegans (mean 193 pmol/L, range 35-408) compared with their matched omnivorous controls (311, 131-482)" in a cross-sectional study comparing two groups of 21 individuals each, vegan and omnivorous3. While vegans who often consumed algae, namely the seaweeds Nori and Chlorella averaged almost double blood serum levels of B12, they still were dwarfed in comparison to their omnivore counterparts. What does this mean for the pregnant vegan, or rather, for her infant? In exploring the risks, an assumption must be made that the mother is vitamin B12 deficient, and if the numbers are any indicator of the norm, the likelihood of deficiency of B12 is fairly high. Deficiency in adults can lead to B12 anemia, which can cause symptoms as mild as weakness in the limbs, increased risk of bruising/bleeding, and weight loss, where more severe symptoms may progress to numbness of digits, motor function difficulty, depression, memory loss, or dementia. In infants and young children, however, a deficiency in B12 during natal development can lead to severe nervous system disorders (or, in other words, nerve damage), as well as neural tube defects4. A link can be established, logically, that a mother deficient on vitamin B12 would very likely pass on the deficiency to her infant. The recommended dietary intake (RDI) of vitamin B12 for infants is 0.4 ug/d, and though average breast milk contains 0.42 ug, a vitamin B12 anemic mother would not fall in to the "average" range. 7 The infant already may have developed in an environment deficient in the essential micronutrient, also known as cobalamin, and further consumption of milk lacking in necessary levels of the vitamin would only aggravate this issue. According to the CDC, an infant breast-fed by a vitamin B12 deficient mother's risk for severe developmental abnormalities including ataxia (motor coordination impairment), muscle weakness, stunted growth and anemia is significantly higher than an infant of mothers with B12 deficiencies, most commonly vegans or vegetarians, or those of whom have another disorder that causes B12 anemia. Again, this is working under the assumption that the mother is vitamin B12 deficient, which not all, but many, are. One such example of a neurological disorder, associated at the time with vitamin B12 deficiency, was a case study involving a breastfed infant of a strict vegetarian mother. The 9month-old exhibited symptoms of "dystrophy, weakness, muscular atrophy, loss of tendon reflexes, psychomotor regression and haematological abnormalities"5. After running a series of biochemical investigations, which revealed severe methylmalonic aciduria and homocystinuria in the infant and low concentrations of serum vitamin B12, as well as a less-severe case of methylmalonic aciduria in the mother and a similarly low concentration of serum B12, it was in the opinions of the doctors reviewing the case that the low levels of B12 were very likely a contributing factor if not the cause of the child's symptoms. Methylmalonic Acidemia is a disorder in which the body is incapable of processing certain proteins and lipids properly. An enzyme, methylmalonyl CoA mutase, works with B12 (cobalamin), to denature amino acids, lipids and cholesterol. In lacking vitamin B12, the

enzyme cannot function properly, resulting in the buildup of methylmalonyl CoA and "other potentially toxic compounds" to build up in the organs and tissues of the body. The damage caused by this disorder can lead to intellectual impairment and permanent kidney damage. It should be noted, however, that this infant also tested positive for the mutation homocystinuria, a genetic disorder in which those afflicted are expected to display reduced levels of serum vitamin B12. 5 While this study is compelling, it is both a single case study, and is also over twenty years old. The information may still be valuable, but more thorough study would need to be done on more than one instance to draw a definitive conclusion. It should be noted, however, that more cases have occurred since this more thoroughly investigated, earlier case, wherein infants were brought to the hospital for similar complaints of "weakness", "illness", "failure to thrive" and alike symptoms. In each case, a common cause arose between the infants; they had vegan mothers, were exclusively breast-fed, and had low serum vitamin B12. In each case, the infants were given diets rich in "essential elements", and given intramuscular injections of vitamin B12 every other day. 8 As stated before, these are case studies, and though they do not definitively correlate B12 anemia with the veganism of the mothers, or necessarily as the direct cause of the infant's state of illness, the similarities are compelling enough to draw suspicion. For many poorer regions of the world, vitamin B12 deficiency is not at all uncommon, though it is not for reasons like choosing a diet that specifically decreases the likelihood of ingesting sufficient levels, rather, it is because animal-based food resources (referred to as ASF or Animal Source Foods) are scarce, expensive, and sometimes unsafe to consume. In one such country, Kenya, research has uncovered that an estimated 87% of infants and schoolchildren do not meet the recommended daily intake of vitamin B1210. Regions where vegetarianism is common in the young, namely India, only an estimated 42% of children and adults would consume the requisite amounts of the vitamin from food sources, of which milk and butter were the most common ASF available. Similar reports were found in Latin America, though were not as pronounced as Kenya or India. The common thread between these three examples and the vitamin B12 deficiency in the population was a notable lack of ASF resources, which are the most readily available resource for B12. It should be noted that an alternate or joint hypothesis to the ASF food deficiency is the presence of Heliobacter pylori, a gram-negative bacteria that have been linked to peptic ulcers, chronic gastritis, duodenitis and stomach cancer in humans. Heliobacter pylori are, in this case, believed to cause malabsorption of food-bound vitamins10. In a first world nation, however, many have the luxury to choose what their diet will consist of. With an abundance of not just quantities but also options of food, the "style" of how Americans eat has come under more scrutiny than the actual healthfulness of the diet itself. There is little denying that the culture of the United States is one of fads and trends, rather than careful study and deductive reasoning. Consumers are often more effectively swayed by media bytes and impassioned claims over careful scrutiny and research; it is simply quicker and easier, and often promise rapid, extreme results. This lack of self-motivated education is unfortunate for the adult, but when it affects a child, it should be considered dangerous. While this is not a politically correct statement to make, it is one that bears consideration.

This is not meant to imply a vegan mother should be considered a "lesser" to an omnivorous mother; it should be every person's right to choose how and what they are going to feed themselves. Generally speaking, mothers share one common goal: to take good care of their baby, and ensure they will grow up healthy, and happy. Certain precautions need to be considered if a vegan pregnancy is what the mother desires, including the ingestion of some source of vitamin B12. This can come as fortified cereal, certain edible seaweeds and dietary supplements10 (though the American Dietetic Association's verdict is still out with regards to the efficacy and safety of dietary supplements, and stress that single vitamin or mineral supplements should be avoided). Consultation with a doctor is, of course, highly recommended, as well as keeping up to date on valid, peer-reviewed scientific information on nutrition. The field is a dynamic one, and new information is coming to light every day to modify and enhance our understanding of the macro and micronutrients and how they work to keep the body healthy.

In conclusion, the decision of what an adult consumes should be theirs to make. It is very uncommon that anyone achieve what dietitians would consider the "perfect diet", and though all diets are indeed not equal, many can be sustainable and healthful for the aware consumer. In the United States where individuals have access to clean sources of food and water, as well as some approved nutritional supplements, a vegan diet could provide adequate energy and nutrient needs for a developed adult. Through the research collected a conclusion can be drawn that the decision to maintain a vegan diet during pregnancy should be very carefully planned and discussed with a qualified medical professional.

References:

1. Wasserman, E. (2013, February 13). Celebrity vegans on the rise: Dietitians say its not a fad. Medill Reports. Retrieved September 17, 2013, from http://news.medill.northwestern.edu/chicago/news.aspx?id=216411 2. Vitamin B12 - MayoClinic.com. (n.d.). Mayo Clinic. Retrieved September 20, 2013, from http://www.mayoclinic.com/health/vitamin-B12/NS_patient-vitaminb12 3. Rauma, Anna-Liisa; Torronen, Riitta; Hanninen, OsmoView Profile; Mykkanen, Hannu. Vitamin B-12 status of long-term adherents of a strict uncooked vegan diet ("Living food diet") is compromised. The Journal of Nutrition 125.10 (Oct 1995): 2511-5. 4. Bailey, Lynn B.; Folate and Vitamin B12 Recommended Intakes and Status in the United States. Nutrition Reviews 62.6 (Jun 2004): S14-20; discussion S21. 5. T. Khne, R. Bubl, R. Baumgartner; Maternal vegan diet causing a serious infantile neurological disorder due to vitamin B12 deficiency. European Journal of Pediatrics January 1991, Volume 150, Issue 3, pp 205-208. 6. CDC - Manifestations of Low Levels, Vitamin B12 Deficiency - NCBDDD. (n.d.). Centers for Disease Control and Prevention. Retrieved October 2, 2013, from http://www.cdc.gov/ncbddd/b12/manifestations 7. Stabler, Sally PView Profile; Allen, Robert H.; Vitamin B12 Deficiency as a Worldwide Problem. Annual Review of Nutrition. 24 (2004): 299-326. 8. Avci, Zekai; Turul, Tuba; Sabiha Aysun; Unal, Isiil. Involuntary movements and magnetic resonance imaging findings in infantile cobalamine (vitamin B12) deficiency. American Academy of Pediatrics. Pediatrics. 112.3 (Sep 2003): 684-6. 9. McLean, Erin D; Allen, Lindsay H; Neumann, Charlott G; Peerson, Janet M; et al. Low Plasma Vitamin B-12 in Kenyan School Children Is Highly Prevalent and Improved by Supplemental Animal Source Foods. The Journal of Nutrition. 137.3 (Mar 2007): 676-82. 10. Mangels, Anne Reed; Considerations in planning vegan diets: Infants. American Dietetic Association. Journal of the American Dietetic Association. 101.6 (Jun 2001): 670-7.