Plant-Based Drinks as an Alternative to Cow’s Milk in Early Life

Summary

Background:

Plant-based milk alternatives (PBMA) are increasingly being consumed as a supplement to or replacement for cow’s milk, even in infancy and childhood. Their effects on later health and growth have been insufficiently studied. We analyze the available evidence concerning the effects of PBMA consumption on health and growth in infants, children, and adolescents.

Methods:

This review is based on publications retrieved by a structured literature search on health and growth outcomes of PBMA consumption in infancy, childhood, and adolescence.

Results:

Comparative cross-sectional and cohort studies have shown that the intake of nutrients typically found in cow’s milk, such as iodine, is lower with exclusive consumption of PBMA. Even the partial replacement of cow’s milk by PBMA is associated with reduced linear growth and a lower body-mass index (BMI). The height-for-age z-score was −0.04 [−0.07; −0.01] and the BMI- for-age z-score was −0.06 [−0.09; −0.03] for each cup of PBMA in five-year-olds, corresponding to reductions of 0.2 cm in height and 0.1 kg in weight. There have been case reports of severe malnutrition and undernutrition from the exclusive or predominant consumption of PBMA, mainly in the first two years of life, but the informational value of these reports is limited. Our search did not retrieve any longitudinal studies on long-term outcomes or any randomized intervention trials comparing the consumption of cow’s milk and PBMA.

Conclusion:

High PBMA consumption in early life may increase the risk of health impairment. The low methodological quality of the available evidence, along with residual confounding, makes the risk hard to quantify. Recommendations regarding PBMA consumption must be differentiated by life phase. Age-related special nutritional requirements must be met, and this is particularly important in early life. More research on long-term outcomes is needed.

Information on this CME.

This article has been certified by the North Rhine Academy for Continuing Medical Education. The questions on this article may be found (in German) at http://daebl.de/RY95 (Deutsches Ärzteblatt’s CME portal). Their English translation may be found in the PDF version of this article. The closing date for entries is February 19, 2027.

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While cow’s milk and its products have long played a major role in human nutrition and are important elements in the nutritional recommendations of many countries (1), plant-based milk alternatives (PBMA) are becoming increasingly popular. The sales volume of substitutes for cow’s milk in Germany was reported as € 870 million in 2024, with predicted annual growth of 13.7% (2). According to self-reports, 87% of Germans have purchased PBMA at least once (3). On top of those who exclusively purchase PBMA, 5-10 times as many consumers reported buying both PBMA and animal milk (4).

Data for the years 2014–2017 from the Children’s Nutrition Survey to Record Food Consumption (Kinder-Ernährungsstudie zur Erfassung des Lebensmittelverzehrs, KiESEL) module of the German Health Interview and Examination Survey for Children and Adolescents (Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland, KiGGS) showed that PBMA are only rarely consumed by infants and preschool children (5). Most frequently consumed were oat-based PBMA, at least once each week by 4% of 1- to 3-year-old children and 1% of 4- to 5-year-old preschoolers. Higher family social status and higher parental educational level were associated with more frequent consumption. Recent representative consumption data for Germany are lacking; on the basis of market statistics, however, an increase in the consumption of PBMA also by children and adolescents can be assumed. North American parents who prefer PBMA for their children specified a number of different reasons: in addition to medical reasons (cow’s milk allergy, lactose intolerance), they mentioned ethical/ecological factors, general health-related aspects, and taste preferences (6). In addition, a study in Florida showed that 85% of the parents surveyed believed that PBMA are equivalent or superior to cow’s milk in terms of nutritional physiology. More than half of the parents relied on physicians for information about PBMA (7).

The effects of dairy (products) on growth in height (Box 1) and on the risk of ill health in childhood and adulthood (eBox 1) have been the subject of much investigation. In contrast, the long-term effects of PBMA consumption, especially in early life, have not yet been sufficiently clarified. The aim of this study was to present the scientific evidence on the effects of PBMA consumption (whether exclusively/predominantly or partially/supplementary to cow’s milk) in infancy, childhood, and adolescence on growth and health-related outcomes.

Box 1. Cow’s milk consumption and growth (in height) in children and adolescents.

Ecological studies describe dairy products as one of the crucial nutrition-related parameters affecting height (correlation coefficient for European countries: r = 0.50, p < 0.001; worldwide: r = 0.55, p < 0.001) (e7). Prospective cohort studies show attainment of greater height with higher milk consumption (linear regression coefficient in 4-year-olds with milk consumption, n = 8950, with height-for-age Z score at age of 5 years 0.075, standard error 0.017, p < 0.001) (e8); per cup (236 mL) of cow’s milk consumed daily, height increased by 0.39 cm between the ages of 2 and 17 years (n = 708) [0.18; 10.60] (e9); with daily consumption of more than three servings of milk in the preceding year, compared with less than one serving, the annual increase in height was 0.28 cm greater (p = 0.02) (n = 5101 prepubertal girls ≥ 9 years [e10)]).

The interventional studies on milk consumption by children are heterogeneous and permit no clear conclusions with regard to growth rates, amount of milk consumed, or the duration of the intervention. Comparing supplementation with whole, unmodified dairy products (no fractionated components) to no supplementation with dairy products (n = 3895 children, 3–18 years), a meta-analysis found significantly increased height in only 6 of 13 studies and exclusively in younger children (3–10 years) (e11). In seven studies no effect was shown; in five of these the samples were small and the children older (9–18 years). An international survey supplied evidence of a positive association between the consumption of milk (from cows or goats) in the first few years of life and a reduced risk of underweight and short stature (e12).

The mechanisms by which consumption of cow’s milk promotes growth have not been completely clarified. Various factors have been discussed, including possible actions of oligosaccharides on the intestinal microbiome and the efficiency of nutrient metabolism (e13), of casein on intestinal calcium uptake (e14), and of branched-chain amino acids such as leucine on growth factors (e.g., insulin-like growth factor 1) and signaling pathways (e.g., mammalian target of rapamycin) (e15).

The extent to which growth in height influences subsequent health outcomes has not been sufficiently researched. Other factors such as the individual baseline situation (deficient versus excessive nutrition) and the amount of cow’s milk consumed are also relevant. Overall, an association between lower death rate and greater height has been described (meta-analysis of 121 prospective studies: hazard ratio 0.97 [0.96; 0.99], per 6.5 cm greater height, adjusted for age, sex, smoking, and year of birth) (e16). Besides inverse associations between height and mortality rates from various non-transmissible diseases (e.g., coronary heart disease, stroke, heart failure, chronic obstructive pulmonary disease), there were also direct associations with the risk of death due to pulmonary embolism or malignancies of the pancreas, ovary, or breast (e16).

eBox 1. The effect of cow’s milk consumption on disease risk.

Meta-analyses and umbrella reviews on numerous different health-related outcomes have analyzed the effects of consuming cow’s milk and/or dairy products in general or of specific cow’s milk products such as yoghurt. Overall, milk consumption was linked more often with benefits than with harms in relation to a number of health-related outcomes in childhood and adulthood (e48).

Cow’s milk is one of the most common food allergens in childhood; the prevalence of cow’s milk allergy in European children has been reported as 2–5% (e49). Simultaneously, observational studies, including case-control studies, point to possible protective effects of consumption of cow’s milk by the mother during pregnancy and by the child in the first year of life with regard to the subsequent occurrence of atopic dermatitis (e50, e51) and of allergic respiratory tract diseases and asthma (e52, e53).

An umbrella review with eight meta-analyses found no association between the overall mortality risk and the consumption of milk and/ or dairy products (relative risk [RR] 0.96–1.01 per 200 g milk and/or dairy products consumed daily) (e54). In adults, the consumption of milk and/or dairy products showed no impact or a favorable effect on the risk of cardiovascular events and metabolic disorders (umbrella review with 17 meta-analyses). The analyses revealed an inverse association with the incidence of or death from cardiovascular events (cardiovascular disease, coronary heart disease, stroke) with a pooled RR of < 1 or no effects. There was no impact on risk factors (blood lipids, blood pressure) (12 meta-analyses) (e55).

A favorable (inverse) association was shown between the consumption of milk and/or dairy products and the risk of (a) metabolic syndrome (meta-analysis with 12 prospective cohort studies: RR 0.73; 95% confidence interval (CI) [0.64; 0.83], n = 9) (e56) and (b) diabetes mellitus type 2 (an umbrella review with seven meta-analyses that compared high and low consumption of milk and/or dairy products in general: mean RR 0.86–0.91, significant effects in six of seven studies) (e57). With regard to the association between the consumption of milk and/or dairy products and the occurrence of overweight/obesity in childhood and adulthood, however, the evidence is limited and partially conflicting (e58).

The data on the association between the consumption of cow’s milk and the occurrence of cancer show differing, in some cases divergent, risk estimates for different types of cancer (e59). For instance, there were indications that high consumption of dairy products might lower the overall risk of colorectal cancer (meta-analysis: inverse association in three of five cohort studies and one of three case–control studies) (e60). Simultaneously, a higher risk of developing prostate cancer was observed (meta-analysis with 26 cohort studies: adjusted RR for the highest versus the lowest consumption 1.05; 95% CI [1.00; 1.09]) (e61).

Various mechanisms have been discussed as underlying factors: On the one hand, the high calcium content of milk may contribute to the sequestration of bile acids, which have been linked to a potentially carcinogenic effect in the colon and rectum. On the other hand, the conjugated linoleic acids contained in milk, which may exert a protective effect by inhibiting cell proliferation, reducing mediators of inflammation, and stimulating the immune system (e58). Moreover, roles could be played by the possible enhancement of blood estrogen and progestogen concentrations by milk consumption (e62), by the observation that the dairy protein casein exerts a growth-promoting effect on prostate cancer cells (e62), and by elevated concentrations of insulin-like growth factor 1 (e63).

In this context, the controversy around the so-called bovine milk and meat factors (BMMF) is of interest. The BMMF are molecules found in the meat and milk of European cattle. Scientists at the German Cancer Research Center believe that after enteral uptake in infancy they induce a chronic inflammatory reaction in certain tissues, thus promoting the subsequent development of cancer in the surrounding areas (e64). Others, however, have drawn attention to the inadequacy and considerable uncertainty of the data underlying this hypothesis; they are of the opinion that there is no evidence of a causal association between the presence of BMMF in the human organism and the development of disease, so no impairment of health can be expected from BMMF contained in meat or dairy products (e65).

Methods

A structured search of the literature on the effects of PBMA consumption in infancy, childhood, and adolescence on growth and health-related outcomes published between 1 January 2000 and 25 November 2024 was conducted in the PubMed database (eMethods). The following inclusion criteria were selected:

• Population: infants, children, and adolescents between 0 and 18 years of age (only adults excluded)

• Exposure: partial, predominant, or exclusive consumption of standard commercially available PBMA (no products specially formulated for study purposes)

• Comparison (if applicable): no/low PBMA consumption

• Endpoints: growth parameters, health outcomes including clinically relevant biomarkers.

Study designs

Epidemiological observational studies (cohort, cross-sectional, case–control studies), interventional studies, clinical descriptive studies (case reports, case series), and meta-analyses were included for evaluation. Laboratory studies, animal studies, study descriptions, editorials, commentaries, statements, and review articles were excluded. However, review articles were searched manually for potentially relevant studies (backward searching).

Results

Duplicates (n = 145) were removed from the original total of 1649 records. Screening of titles (and abstracts if available) led to exclusion of 1479 publications (eFigure 1). The full texts of the remaining 25 publications were viewed, resulting in the exclusion of eight of them after examination of the inclusion/exclusion criteria. Backward searching threw up a further 12 publications, so a total of 29 full texts on the effects of PBMA consumption on growth and health were eligible for analysis. They comprised three comparative cross-sectional studies and one prospective cohort study with a total of 17 905 participants (Table 1), plus 25 clinical descriptive studies/case reports with a total of 82 reported cases (eTable 1). No interventional studies were included.

eFigure 1. Flow chart of the structured literature search.

PBMA, Plant-based milk alternatives

Table 1. Cross-sectional and cohort studies on growth and health outcomes of PBMA consumption in infancy, childhood, and adolescence.

Source/study type, study population	Exposure (% of population)	Endpoint	Covariates	Results
Soczynska et al. 2024 (8)/ prospective cohort; N = 7195; children 1–10 years; Canada	Consumption of PBMA (14.6%, including 4.6% exclusively)	HAZ, BAZ	Age, sex, ethnicity, birthweight, breastfeeding duration, consumption of sugar-containing drinks, household income, parental height/BMI	Per cup*1 of PBMA consumed daily: HAZ: reduction (−0.04 [−0.07; −0.01]), i.e., height at age 5 years 0.2 cm less. Mediation analysis: effect predominantly direct (HAZ β = −0.03 [−0.06; −0.01]), to lesser extent indirect through reduced cow’s milk consumption (HAZ β = −0.01 [−0.02; −0.01]). BAZ: reduction (−0.06 [−0.09; −0.03]), i .e., body weight at age 5 years 0.1 kg less. Mediation analysis: effect predominantly direct (BAZ β = −0.04 [−0.06; −0.01]),to lesser extent indirect through reduced cow’s milk consumption (BAZ β = −0.02 [−0.03; −0.01]).
Morency et al. 2017 (9)/ cross-sectional study; N = 5034; children 2–6 years; Canada	Consumption of “non-cow’s milk”*2 (12.8%)	HAZ	Age, sex, BAZ, consumption of cow’s milk, maternal height and ethnicity, income in residential area	Per cup*1 of “non-cow’s milk”*2 consumed daily: HAZ: reduction by 0.1 [−0.2; −0.04], i.e., height at age 3 years 0.4 cm less. Mediation analysis: effect predominantly direct (HAZ β = −0.08 [−0.1; −0.03]), to lesser extent indirect through reduced cow’s milk consumption (HAZ β = −0.02 [−0.04; −0.01]).
Dineva et al. 2021 (10) / cross-sectional study; N = 2845; children ≥ 4 years and adults; UK	Consumption of PBMA (2.2% exclusively)	Iodine excretion in spontaneous urine	Age, sex, energy intake	With exclusive consumption of PBMA: Iodine excretion in urine: reduction (median 79 μg/L, 25th–75th percentiles 38–135 μg/L); on average in range of iodine deficiency according to WHO (< 100 μg/L) With exclusive consumption of cow’s milk: Median 132 μg/L, 25th–75th percentiles 80–209 pg/L; p < 0.001.
Lee et al. 2014 (11) / cross-sectional study; N = 2831; children 1–6 years; Canada	Consumption of “non-cow’s milk”*2 (10.7%, including 5.2% exclusively)	25-hydroxyvitamin D serum concentrations	Age, sex, BAZ, consumption of cow’s milk and margarine, skin pigmentation, time spent outdoors, timing of examination (season), vitamin D supplementation	With exclusive consumption of “non-cow’s milk”*2: Risk elevated for 25-hydroxyvitamin D concentration < 50 nmol/L (odds ratio 2.7 [1.6; 4.7])*3 Per cup*1 “non-cow’s milk”*2 consumed daily: 25-hydroxyvitamin D concentration: reduction by 4.2 nmol/L (median) [−7.1; −1.1])*3

^*1A cup corresponds to 250 mL.

^*2PBMA and/or milk from animals other than cows.

^*3Because cow’s milk in Canada (in contrast to Germany) is mandatorily fortified with vitamin D, the study results cannot readily be extrapolated to the German context.

BAZ, BMI-for-age Z-score; BMI, body-mass index; HAZ, height-for-age Z-score; PBMA, plant-based milk alternatives; Z-score, describes specific standard deviations in relation to a reference population

eTable 1. Clinical descriptive studies/case reports on growth and health outcomes of the consumption of plant-based milk alternatives (PBMA) in infancy, childhood, and adolescence.

Source	Age at examination/ diagnosis	Type of nutrition (if reported)	Findings/diagnoses	Country, reason for use of PBMA, other relevant diagnoses (if reported)
Children < 2 years
Mesa Medina et al. 2009 (17)	1 month	Exclusive feeding with almond-based PBMA since birth	Failure to thrive/weight loss, dehydration, hypochloremic, hypokalemic metabolic alkalosis	Spain: Preterm birth (34 weeks of gestation), otherwise no diagnoses; after exclusion of other causes (vomiting, medication use, tubulopathy, cystic fibrosis), insufficient intake of sodium and chloride via the PBMA was considered the underlying cause
Fourreau et al. 2013(16)	2.5 months	Feeding with various PBMA (chestnut, soy, hazelnut, almond, 6×110 mL) over 6 weeks	Failure to thrive, hypoalbuminemia. Hyponatremia (96 mmol/L), hypokalemia (1.5 mmol/L), respiratory acidosis	France: Hypoxic-ischemic encephalopathy following neonatal asphyxia, feeding via nasogastric tube, PBMA administered due to weight stagnation under tube feeding with infant formula; later, diagnosis of pneumonia and pneumococcal meningitis with fatal outcome
Gulledge et al. 2023 (12)	4 months	Exclusively unsweetened almond-based PBMA with high calcium and low phosphate content (1900 mg calcium/L, 85 mg phosphate/L) over one month	Weight loss/undernutrition (weight-for-length Z score: −2.46), recurring vomiting, restlessness, and lethargy, hypercalcemia with hypoparathyroidism, hypophosphatemia, and vitamin D deficiency (calcium 14.1 mg/dL, ionized calcium 2.34 mmol/L, phosphate 1.7 mg/dL, parathyroid hormone < 4 pg/ mL, 25-OH-vitamin D 21 ng/dL), bilateral nephrocal-cinosis	USA: The child had no underlying medical condition and was fed with PBMA due to a national shortage of infant formula. Fluid replacement and transition to standard infant formula led to satisfactory weight gain with normalization of the weight-for-length Z score (0.8). No electrolyte abnormalities were observed in the next month, and the nephrocalcinosis resolved within 6 months
Mesa Medina et al. 2009 (17)	4 months	Exclusive feeding with almond-based PBMA since birth	Failure to thrive, dehydration, hypochloremic, hypokalemic metabolic alkalosis, hypothyroidism, myelinization disorders (optic neuritis, hearing loss)	Spain: No relevant prior medical conditions; after exclusion of other causes (vomiting, medication use, tubulopathy, cystic fibrosis), insufficient intake of sodium and chloride via the PBMA was considered the underlying cause
Liu et al. 2001 (29)	4 months	Consumption of rice-based PBMA; duration unknown	Kwashiorkor	USA: Feeding with rice-based PBMA due to suspected cow’s milk intolerance
Diamanti et al. 2011 (28)	4 months	Exclusive consumption of rice-based PBMA over one month	Kwashiorkor	Italy: Atopic dermatitis and vomiting; feeding with rice-based PBMA because the child refused hydrolyzed infant formula and rice-protein based hydrolyzed formula; cow’s milk allergy was diagnosed in two of the three children reported
Diamanti et al. 2011 (28)	4 months	Exclusive consumption of rice-based PBMA over 2.5 months	Kwashiorkor	Italy: Feeding with rice-based PBMA because the family could not afford the hydrolyzed infant formula which had been recommended due to vomiting with regular infant formula; cow’s milk allergy was diagnosed in two of the three children reported
Diamanti et al. 2011 (28)	4 months	Exclusive consumption of rice-based PBMA over 2 months	Kwashiorkor	Italy: Atopic dermatitis and diarrhea;feeding with rice-based PBMA because the child refused hydrolyzed infant formula and rice-protein based hydrolyzed formula; cow’s milk allergy was diagnosed in two of the three children reported
Le Louer et al. 2014(14)	4.5 months	Exclusive consumption of rice-based PBMA over 2 months	Anemia (Hb 5.7 g/dL), kwashiorkor	France: Feeding with PBMA due to regurgitation, no relevant prior medical conditions
Le Louer et al. 2014(14)	5 months	Exclusive consumption of chestnut- and almond-based PBMA over 1.5 months	Hypocalcemic seizures, kwashiorkor, anemia (Hb 8.5 g/dL), vitamin D deficiency	France: Feeding with PBMA due to gastroesophageal reflux and eczema, otherwise no relevant prior medical conditions
Houck et al. 2019 (23)	5 months	Feeding with almond-based PBMA (270 mL every 4–5 hours, diluted 1:1 with water) and additional water (continuously over 3 weeks)	Hyponatremic seizures (sodium 121 mmol/L)	USA: Feeding with PBMA due to gastroesophageal reflux in an otherwise healthy, full-term female infant with sickle cell trait
Imataka et al. 2004 (18)	5 months	Consumption of soy-based PBMA over 4 months	Failure to thrive, rickets	Japan: Eczema, feeding with PBMA due to suspicion of cow’s milk allergy, no exposure to sunlight
Le Louer et al. 2014(14)	6 months	Consumption of almond- and chestnut-based PBMA over 2 months	Failure to thrive, hypokalemia	France: Feeding with PBMA due to gastroesophageal reflux and diarrhea, otherwise no relevant prior medical conditions
Le Louer et al. 2014(14)	6 months	Consumption of chestnut-based PBMA over 1.5 months	Failure to thrive	France: Feeding with PBMA due to parents’ beliefs; no relevant prior medical conditions
Novembre et al. 2003 (34)	6 months	Consumption of rice-based PBMA (660 mL/day), with additional rice pudding, vegetable soup, and apple; duration unknown	Hypoproteinemia	Italy: Atopic dermatitis, feeding with PBMA on the recommmendation of a naturopathic physician
Doron et al. 2001 (21)	6 months	Exclusive consumption of home-made almondbased PBMA over 3 months	Failure to thrive, anemia (Hb 7.7 g/dL), rickets, hypocalcemia	Israel: Feeding with PBMA because cow’s milk allergy was suspected due to diarrhea and vomiting
Le Louer et al. 2014(14)	7 months	Consumption of rice-based PBMA over 6 months	Kwashiorkor, anemia (Hb 8.7 g/dL), hyponatremia	France: Consumption of PBMA because of eczema, otherwise no relevant prior medical conditions
Katz et al. 2005 (27)	7 months	Feeding with rice-based PBMA over 5 months, with small amounts of complementary feeding and iron supplementation	Kwashiorkor, anemia	USA: Feeding with PBMA because various infant formulas, including an amino-acid-based formula, had not been tolerated since the age of 2 months
Kanaka et al. 1992 (20)	7.5 months	Consumption of a home-made almond-based PBMA over 5 months, with small amounts of cereal and fruit	Failure to thrive, hypothyroidism with iodine deficiency, carnitine deficiency, osteopenia	Switzerland: Eczema, feeding with almond-based PBMA due to suspected cow’s milk allergy
Le Louer et al. 2014(14)	8 months	Consumption of almond- and chestnut-based PBMA over 2 months	Failure to thrive, anemia (Hb 8.6 g/dL), hypoalbuminemia	France: Feeding with PBMA due to vomiting, no relevant prior medical conditions
Tierney et al. 2010 (30)	8 months	Consumption of rice-based PBMA over 4 months, with small amounts of complementary feeding in the form of sweet potato and banana	Kwashiorkor	USA: Feeding with rice-based PBMA in a child whose mother suspected intolerance of the medically recommended extensively hydrolyzed formula
Doron et al. 2001 (21)	8 months	Exclusive consumption of home-made almondbased PBMA over 3–4 months	Kwashiorkor	Israel: Status post surgical correction of vesicoureteral reflux and urethral valves; feeding with PBMA due to eczema (previous feeding with soy-based infant formula had brought no improvement)
Massa et al. 2001 (31)	8 months	Consumption of rice-based PBMA over 4 months, with fruit and vegetables	Kwashiorkor	Belgium: Feeding with rice-based PBMA because of eczema, lack of improvement with hypoallergenic and soy-based infant formula
Lemale et al. 2018(15)	8.8 ± 3.8 months (mean ± SD) n = 34 children	Almond-based PBMA (n = 15), chestnut-based PBMA (n = 4), rice-based PBMA (n = 4), soy-based PBMA (n = 1); 29% of the infants received milk from animals other than cows over a mean 3.7 ± 2.5 months (mean ± SD)	Impairment of longitudinal growth and body weight (n = 28), asthenia (n = 22), scaly erythema (n = 14), status epilepticus (n = 10), anemia with Hb < 10 g/L (n = 12, including n = 5 with Hb < 6 g/dL), hyponatremia with mean sodium 126 mmol/L (96–134 mmol/L) (n = 8, including n = 1 death with sodium 96 mmol/L following consumption of chestnut-based PBMA), severe vitamin D deficiency (< 7 μg/mL, n = 6), edema (n = 6), hypocalcemic seizures (n = 2), metabolic alkalosis (n = 1), spontaneous leg fracture with bone demineralization (n = 1); hospitalization in 19/34 cases	France: The reasons for consumption of PBMA were cow’s milk intolerance (n = 15), minor digestive problems (n = 11), and cutaneous symptoms (n = 8)
Fourreau et al. 2013(16)	9 months	Feeding with rice-based PBMA over 2 months	Kwashiorkor	France: Atopic dermatitis; feeding with rice-based PBMA because of ■difficulties” in weaning off breast milk and because the mother suspected cow’s milk allergy
Le Louer et al. 2014(14)	10 months	Consumption of almond- and rice-based PBMA over 3 months	Failure to thrive, anemia (Hb 9.2 g/dL), hypoalbuminemia	France: Consumption of PBMA, because the child refused to drink milk from a bottle; no relevant prior medical conditions
Vitoria et al. 2016 (33)	11 months	Consumption of an almond-based PBMA (680 g/day) with added almond flour, sesame powder, rice malt, and cereal porridge over 8.5 months	Failure to thrive, scurvy, osteopenia and pathological fracture with vitamin D deficiency	Spain: Feeding with almond-based PBMA with additives on a physician’s recommendation in eczema
Mori et al. 2015 (25)	Unknown (first year of life)	Consumption of rice-based PBMA since age 6 months, for first 2 months with additional consumption of fruit, rice, poultry, and vegetable broth, all subsequently refused by the child	Kwashiorkor, anemia (5.7 g/dL)	Italy: Atopic dermatitis; feeding with PBMA on the recommendation of a naturopathic physician
Keller et al. 2012 (26)	12 months	Consumption of rice-based PBMA with rolled oats and fruit over 5 months	Kwashiorkor	USA: Feeding with rice-based PBMA because vomiting and diarrhea occurred with cow’s milk nutrition, and goat’s milk and soy-based PBMA led to worsening of existing eczema
Fourreau et al. 2013(16)	13 months	Feeding with almond-based PBMA (840 mL/day) over 3 weeks, very small amounts of additional complementary feeding	Hypochloremic, hypokalemic alkalosis	France: Congenital myopathy, tracheostoma placement, feeding partially via nasogastric tube, transition from follow-up formula to PBMA due to feeding difficulties
Fourreau et al. 2013(16)	14 months	Consumption of rice-based PBMA (ca. 300 mL/day) over 2 months; previously the child had been breastfed fully for 5 months and partially for 12 months; as for complementary feeding, the child had recently started receiving fruit, vegetables, and meat, but no milk (products); the mother had had a varied diet, but had eaten little meat during pregnancy	Iron- and vitamin B12-deficiency anemia	France: No prior medical conditions; consumption of PBMA because of parents’ beliefs
Salama et al. 2024 (24)	14 months	Almost exclusive consumption of ca. 1300 mL/day almond-based PBMA with high calcium and low phosphate content (1900 mg calcium/L, 85 mg phosphate/L) over 2 months	Dehydration with hypercalcemia (14.6 mg/dL) and hypophosphatemia (phosphate 1.6 mg/dL)	USA: Status post liver transplantation at age 7 months due to biliary atresia, immunosuppression with mycophenolate and tacrolimus; consumption of PBMA due to suspected cow’s milk allergy and difficulties with solid food intake; after fluid substitution and transition to infant formula, normalization of electrolytes within 6 days; a parathyroid hormone-related cause of hypercalcemia was excluded due to absent urinary phosphate excretion; 2 months later, diagnosis of T-cell posttransplant lymphoproliferative disorder with fatal outcome
Le Louer et al. 2014(14)	14 months	Consumption of almond- and chestnut-based PBMA for 11 months	Failure to thrive, hypokalemia (2.8 mmol/L), hypocalcemia, vitamin D deficiency	France: consumption of PBMA because of infantile colic; otherwise no relevant prior medical conditions
Katz et al. 2005 (27)	14 months	Feeding with rice-based PBMA for 6 months as well as vegetables and meat (the consumption of solid food had decreased in the weeks preceding diagnosis)	Kwashiorkor, anemia	USA: Feeding with PBMA because various infant formulas were not tolerated after weaning at the age of 8 months
Barreto-Chang et al. 2010 (22)	16 months	Consumption of rice-based PBMA for 3 months; the child was partially breastfed up to the age of 1 year and received a varied diet of complementary foods (fruit, vegetables, soups, clear chicken broth—but no milk[products]) from the age of 5 months	Failure to thrive with weight loss, vitamin D deficiency rickets	USA (California): Child of Hispanic origin; eczema, several episodes of upper respiratory tract infection and bronchiolitis in first year of life; enriched soy-based PBMA was recommended by a physician due to suspected cow’s milk allergy but was not tolerated by the child, so rice-based PBMA was fed
Le Louer et al. 2014(14)	16.5 months	Consumption of almond- and hazelnut-based PBMA over 7 months	Vitamin D and calcium deficiency with fracture of left leg following minimal trauma	France: Asthma, consumption of PBMA because of parents’ beliefs
Keller et al. 2012 (26)	17 months	Consumption of rice-based PBMA, chick peas, lentils, and olives over 5 months	Kwashiorkor, anemia (Hb 7 g/dL)	USA: Consumption of PBMA in a child with pre-existing eczema and positive skin prick test for several foods, including cow’s milk
Kuhl et al. 2004 (32)	17 months	Consumption of 950 mL rice-based PBMA daily together with two dessert spoons of baby food or solid food (no meat) for 4 months	Kwashiorkor, anemia (Hb 7.8 g/dL), delayed bone age (7.5 months)	USA: Consumption of PBMA due to atopic dermatitis and multiple food allergies (including cow’s milk)
Carvalho et al. 2001 (19)	17 months	Consumption of soy-based PBMA (ca. 900 mL/day) for 7 months, together with a varied but completely vegan diet with no animal products; no data on supplements	Failure to thrive, rickets	USA: Child with dark skin pigmentation and limited exposure to sunlight, vegan feeding including soy-based PBMA because of parents’ beliefs
Keller et al. 2012 (26)	19 months	Consumption of rice-based PBMA as well as rice, potatoes, and carrots over 7 months	Kwashiorkor, subsequently tibial fracture with osteopenia	USA: Consumption of PBMA in eczema and positive skin prick test for several foods, including cow’s milk (the child refused hydrolyzed formula)
Carvalho et al. 2001 (19)	22 months	Consumption of rice-based PBMA (ca. 1.5 L/day) over 9 months; very little other food	Kwashiorkor, anemia	USA: Eczema, consumption of rice-based PBMA because the parents suspected cow’s milk intolerance
Children ≥ 2 years
Martini et al. 2018 (35)	5 years	Oat-based PBMA (> 2 years)	Failure to thrive, severe vitamin-A deficiency with irreversible vision loss, anemia	Italy: Severely restricted diet consisting mainly of oat-based PBMA in a conflict-rich mother-child relationship with little external support
Ellis and Lieb 2015 (36)	3, 9 and 10 years (n = 3)	700 to 1000 ml almond-based PBMA/day each (duration of consumption 2 years for one of the children, not reported for the others)	Dysuria (n = 3), colicky abdominal or costovertebral pain (n = 2), intermittent macrohematuria (n = 2), persisting microhematuria (n = 3), 24-hour hyperoxaluria (n = 3), detection of calcium oxalate crystals in urine (n = 2), bilateral kidney stones and ureteral stone (n = 1)	USA: PBMA were consumed due to lactose intolerance, and, in one of the children, to improve tics in Tourette syndrome; two of the children had a family history of kidney stones in first-degree relatives
Infante and Tormo 2000 (37)	2 bis 14 years (n = 4 children)	Soy-based PBMA (> 2 years), together with occasional consumption of dairy products	Low bone mineral density (measured by dual-energy X-ray absorptiometry at level of L2–L4) in range of osteopenia to osteoporosis (T score −2 to −3)	Spain: Consumption of PBMA due to lactose intolerance (n = 2) or hypercholesterolemia (n = 2)

Hb, Hemoglobin; PBMA, plant-based milk alternatives; SD, standard deviation

Results of cross-sectional and cohort studies

The prospective cohort study explored the effect of PBMA consumption on growth in height and the body mass index (BMI). After adjustment for a number of potential con-founders (including age, sex, and parental height/BMI), a dose-dependent association with lower height was found in preschool and grade-school children (height-for-age Z score [HAZ] −0.04; 95% confidence interval [95% CI] [−0.07; −0.01] per cup of PBMA consumed daily) (8) (Table 1). The consumption of PBMA was dose-dependently associated with lower BMI (BMI-for-age Z score [BAZ] −0.06 [−0.09; −0.03] per cup of PBMA consumed daily).

One cross-sectional study investigated the effects of consumption of non-cow’s milk (PBMA and/or milk from other animals) on the height of preschool and grade-school children (9) (Table 1). Here too, a dose-dependent association with lower height (GAZ −0.1 [−0.2; −0.04] per cup consumed daily) was found after adjustment for factors including age, sex, and BAZ. In both studies, mediation analysis showed that the effects were mediated predominantly by the consumption of PBMA or non-cow’s milk and only to a small extent by lower cow’s milk consumption. The other two cross-sectional studies tested the effect of consumption of PBMA or non-cow’s milk on the concentrations of iodine and vitamin D, respectively (Table 1). In children (4–18 years) and adults who consumed exclusively noncow’s milk, these studies found that the median iodine excretion was low, in the range of iodine deficiency as defined by the WHO (< 100 μg/L) (iodine excretion with exclusive PBMA consumption: median 79 μg/L, 25^th–75^th percentiles 38–135; with exclusive cow’s milk consumption: median 132 μg/L, 25^th–75^th percentiles 80–209) (10). Toddlers and preschool children who consumed exclusively non-cow’s milk rather than cow’s milk were at greater risk of decreased 25-hydroxyvitamin D serum concentrations (< 50 nmol/L) (odds ratio 2.7 [1.6; 4.7]) (11).

Results of clinical descriptive studies and case reports

Clinical manifestations, in some cases severe, were described in a total of 82 children aged 1 month to 14 years after exclusive or predominant consumption of PBMA for periods ranging from 3 weeks to more than 2 years (eTable 1). Ninety percent of the cases (74/82) were reported within the first 2 years of life, including instances of failure to thrive and weight loss (n = 43) (12–22); disorders of electrolyte or acid-base balance (hyponatremia (n = 11), in some cases with seizures (14–16, 23), including one case with fatal outcome (15), hypocalcemia (n = 5), in some cases with seizures (14, 15, 21), hypokalemia (n = 3) (14, 16), metabolic alkalosis (n = 4) (15–17), respiratory acidosis (n = 1) (16), hypercalcemia and hypophosphatemia (n = 2) (12, 24); kwashiorkor (n = 19) (14, 16, 19, 21, 25–32) (in one case after consumption of chestnutand almond-based PBMA [14] and in the remaining cases after consumption of rice-based PBMA). There were cases of anemia (n = 25) (14–16, 19, 21, 25–27, 32), including n = 7 with hemoglobin concentrations under 6 g/dL (14, 15, 25). Bone mineralization disorders (rachitis, osteopenia) occurred in n = 9 cases (14, 15, 18–22, 26, 33), including n = 4 with spontaneous or pathological fractures (14, 15, 26, 33); vitamin D deficiency without description of bone mineralization disorder was found in n = 9 cases (12, 14, 15). Furthermore, hypoproteinemia or hypoalbuminemia was found in n = 4 cases (14, 16, 34), hypothyroidism in iodine deficiency in n = 1 (17, 20), dehydration in n = 3 (17, 24), and scurvy in n = 1 (33).

Only 10% of the children (8/82) were affected after their second birthday. A 5-year-old girl who had consumed almost no foods other than an oat-based PBMA for a period of over 2 years not only exhibited failure to thrive and anemia, but also developed vision loss due to vitamin A deficiency (35). Also, three children between 3 and 10 years of age were reported in whom secondary hyperoxaluria, in one case with kidney stones, was attributed to high (over 700 mL daily, duration not reported) consumption of almond-based PBMA with high oxalate content (in the presence of a familial predisposition to kidney stones) (36). In four children aged 2–14 years who for years had drunk only soy-based PBMA (with occasional consumption of dairy products), low bone mineral density in the range of osteopenia to osteoporosis (T score −2 to −3) was diagnosed (37).

Discussion

Against the backdrop of increasing trends towards predominantly plant-based forms of nutrition, the results point to potential health risks from consuming high amounts of PBMA in early life. An inadequate supply of nutrients specific to cow’s milk can lead to clinical deficiencies, impaired bone mineralization, and secondary hyperoxaluria. Moreover, there are negative associations with BMI and longitudinal growth in childhood, although the means of BMI and height are within the normal ranges.

Detailed information on dietary history (quantities, nutrient supplementation) is often not available, particularly in the case studies of (the predominantly very young) children, or it is not stated whether, in addition to PBMA consumption, the diet was generally plant-based or vegan. Some of the reports suggest that generally inadequate dietary habits could have contributed to or aggravated nutritional deficiency syndromes, e.g., scurvy (33) or blindness due to vitamin A deficiency (35). In some cases, other illnesses or accompanying circumstances could have facilitated or intensified the occurrence of disease. These factors include, for example, reduced exposure to sunlight or ultraviolet light (19), feeding difficulties or food refusal, possibly serious enough to necessitate tube feeding (16, 24), dermatitis (possible transdermal protein loss) (14–16, 18, 20–22, 25, 26, 28, 31–34), (suspected) cow’s milk allergy (15, 16, 18, 20–22, 26, 28–30), or a familial predisposition to kidney stones (36).

Because there are no representative data on consumption of PBMA by children to use for reference, and case studies are published selectively, the case reports do not permit an actual assessment of the risk of malnutrition or undernutrition with PBMA consumption. However, they do indicate that consumption of PBMA in childhood may involve risks, particularly in the first 2 years of life. In this phase, milk feeding, with milk’s high energy content and nutrient density, supplies a significant proportion of children’s energy and nutrient requirements (38). Risks are thus present primarily in (almost) total replacement of cow’s milk by PBMA and in cases in which other feeding restrictions or diseases exist.

Most of the identified instances of malnutrition and undernutrition can be explained by differences in nutrient content between cow’s milk and PBMA (39). Milk and dairy products account on average for 10% of the energy intake of children, adolescents, and adults in Germany, plus around one third of the iodine intake. They represent the principal source of calcium and one of the main sources of vitamins B₂ and B₁₂ (1). In countries where, unlike Germany, dairy products are regularly enriched wih vitamin D, they also contribute a relevant proportion of vitamin D intake (mean 28–63% of daily supply) (40). Many of the deficiency diseases identified by our survey (kwashiorkor, iodine deficiency-related hypothyroidism, vitamin B₁₂ deficiency anemia) can be explained on the basis of the different nutrient profiles of PBMA and cow’s milk. For example, PBMA contain lower levels of energy, protein, calcium, iodine, and vitamin B₁₂; the bioavailability of micronutrients may be lower; and the biological value of plant protein is lower than that of animal protein (e1).

We conducted a supplementary investigation of the nutrient profiles of 215 PBMA commercially available in Germany, focusing on the micronutrients for which cow’s milk constitutes an important source in the early phase of life (calcium, iodine, vitamins B₂ and B₁₂; see eMethods). This showed considerable differences between PBMA and cow’s milk. With the exception of soy-based products, all PBMA contained much less protein than cow’s milk (eTable 2). Only a small minority of the PBMA examined were enriched with the relevant micronutrients (21.9% of the products with at least one nutrient, only 2.3% with all four nutrients) (eFigure 2), and none of them exhibited both a protein content comparable with cow’s milk and enrichment with all relevant micronutrients (eTable 2). This seems even more important in light of the fact that many young children in Germany have insufficient intake of some of these nutrients. The consumption data of the KiESEL study showed that the median iodine intake of 1- to 5-year-olds and the median calcium intake of 3- to 5-year-olds in Germany do not reach the recommended levels (e2). Almost half of German children are deficient in iodine (e3). In view of both the important contribution of dairy products to iodine intake and the evidence of insufficient iodine supply in children who exclusively consumed PBMA (10), the low proportion of PBMA enriched with iodine appears especially problematic.

eTable 2. Content of energy, macronutrients, and relevant micronutrients of 215 analyzed plant-based milk alternatives (PBMA) and of cow’s milk (full fat) on the German market^*.

Product	Energy (kcal/100 g)	Fat (g/100 g)	Saturated fatty acids (g/100 g)	Carbohydrates (g/100 g)	Sugar (g/100 g)	Protein (g/100 g)	Calcium (mg/100 g)	Iodine (μg/100 g)	Vitamin B2 (mg/100 g)	Vitamin B12(μg/100g)
Cow’s milk 3.5% fat	65	3.6	2.4	4.7	4.7	3.4	120	11.7	0.18	0.4
Oat-based PBMA (n = 75)
aito Organic Oat Drink Barista	59	3	0.3	7.5	4.2	0.6	n.d.	n.d.	n.d.	n.d.
aito Natural Organic Oat Drink	38	0.7	0.1	7.4	1.8	0.5	n.d.	n.d.	n.d.	n.d.
Alios Organic Oat 0% Sugar	29	0.9	0.2	4.5	0	0.6	n.d.	n.d.	n.d.	n.d.
Alios Organic Oat Barista	56	1.2	0.2	9.7	4	1	n.d.	n.d.	n.d.	n.d.
Alios Natural Organic Oat	51	1	0.2	9	4.2	1	n.d.	n.d.	n.d.	n.d.
Alios Organic Oat Without Oil	37	0.6	0	7	3.8	0.6	n.d.	n.d.	n.d.	n.d.
Alnatura Oat Alga Drink	39	1.4	0.2	6	5.2	0.6	120	n.d.	n.d.	n.d.
Alnatura Oat Drink	39	1.4	0.2	6	5.2	0.6	n.d.	n.d.	n.d.	n.d.
Alnatura Oat Drink Without Sugar	44	1.8	0.3	5.6	0.5	0.8	n.d.	n.d.	n.d.	n.d.
Alnavit Organic Gluten-Free Oat Drink	42	1.4	0.2	6.6	4.5	0.7	n.d.	n.d.	n.d.	n.d.
Alpro Barista Oat	59	3	0.3	6.7	3.3	0.8	n.d.	n.d.	0.21	n.d.
Alpro Oat Without Sugar	40	1.5	0.2	5.6	0	0.2	120	n.d.	0.21	0.38
Alpro Oat Original	46	1.5	0.2	6.6	3.3	0.8	120	n.d.	0.21	0.38
Alpro Not Milk Plant-Based & Low-Fat 1.8% Fat	44	1.8	0.2	5.6	0	0.7	120	n.d.	n.d.	n.d.
Alpro Not Milk Plant-Based & Full 3.5% Fat	59	3.5	0.4	5.7	0	0.7	120	n.d.	n.d.	n.d.
Barenmarke No Moo 1.5% Fat	38	1.6	0.2	5.2	2.2	0.4	n.d.	n.d.	n.d.	n.d.
Barenmarke No Moo 3.8% Fat	59	3.9	0.5	5.4	2.2	0.4	n.d.	n.d.	n.d.	n.d.
Berief Organic Oat Gluten-Free	46	1.4	0.2	7.6	5.2	0.7	n.d.	n.d.	n.d.	n.d.
Berief Organic Oat Without Sugar	42	1.8	0.3	5.6	0	0.8	n.d.	n.d.	n.d.	n.d.
Berief Natural Organic Oat Drink	40	1.4	0.2	6	5.2	0.6	n.d.	n.d.	n.d.	n.d.
Berief Oat + Calcium	40	1.4	0.2	6	5.2	0.6	120	n.d.	n.d.	n.d.
Bio Primo Oat Drink Barista	61	n.d.*1	0.3	9	8	1	n.d.	n.d.	n.d.	n.d.
Bio Primo Natural Oat Drink	46	n.d.*2	0.2	8	6	0.5	n.d.	n.d.	n.d.	n.d.
BioBio Natural Oat Drink	41	0.5	0.1	7.9	5.1	0.8	n.d.	n.d.	n.d.	n.d.
dennree Organic Oat Drink	42	0.8	0.1	7.8	4.5	0.7	n.d.	n.d.	n.d.	n.d.
dennree Organic Oat Drink + Alga	48	1.2	0.5	7.6	6	0.9	120	n.d.	n.d.	n.d.
dm Organic Barista Oat Drink	56	2.1	0.3	8.4	3.5	0.8	n.d.	n.d.	n.d.	n.d.
dm Organic Oat Drink Gluten-Free	42	0.8	0.1	7.7	4.5	0.7	n.d.	n.d.	n.d.	n.d.
dm Natural Organic Oat Drink	40	1.4	0.2	6	5.2	0.6	n.d.	n.d.	n.d.	n.d.
Edeka Natural Organic My Veggie Oat	40	1.4	0.2	6	5.2	0.6	n.d.	n.d.	n.d.	n.d.
Edeka Organic My Veggie Oat Without Sugar	35	2.2	0.3	2.8	0.46	0.5	n.d.	n.d.	n.d.	n.d.
Edeka My Veggie No Milk 3.5% Fat	46	3.5	0.3	3.4	1.6	0.2	n.d.	n.d.	n.d.	n.d.
enerBio Gluten-Free Oat Drink	46	1.4	0.2	7.6	5.2	0.7	n.d.	n.d.	n.d.	n.d.
enerBio Oat Drink 0% Sugar	42	1.8	0.3	5.6	0	0.8	n.d.	n.d.	n.d.	n.d.
enerBio Natural Oat Drink	42	1.4	0.2	6.6	4.5	0.7	n.d.	n.d.	n.d.	n.d.
enerBio Oat Drink Gluten-Free	46	1.2	0.2	8	5	0.5	n.d.	n.d.	n.d.	n.d.
Food for Future Organic Oat Drink	41	1.3	0.2	6.8	5	0.3	n.d.	n.d.	n.d.	n.d.
Gut Organic Natural Oat Drink	44	0.8	0.2	8.2	5.7	0.8	n.d.	n.d.	n.d.	n.d.
Gut Organic Natural Oat Drink Without Sugar	42	1.4	0.2	6.5	0	0.8	n.d.	n.d.	n.d.	n.d.
Hofgut Storzeln Oat Drink	44	1.1	0.1	7.6	4.5	0.7	n.d.	n.d.	n.d.	n.d.
Lazy Heroes Oat Allrounder	41	1.4	0.2	6.1	3.5	0.7	120	n.d.	0.21	0.38
Lazy Heroes Oat Barista	53	3	0.4	5.4	2.8	0.8	120	n.d.	0.21	0.38
My Vay Natural Organic Oat Drink	46	0.8	0.2	8.2	5.7	1.1	n.d.	n.d.	n.d.	n.d.
My Vay Oat Drink Barista	49	2.4	0.2	6.2	2.6	0.6	120	n.d.	0.21	0.38
Naarmann Oat Drink	62	3.1	0.3	7.6	2.6	1	n.d.	n.d.	n.d.	n.d.
Natumi Organic Oat & Calcium-Rich Alga	50	1.3	0.2	8.4	4.1	0.8	120	n.d.	n.d.	n.d.
Natumi Organic Oat Gluten-Free	42	0.8	0.1	7.7	4.5	0.7	n.d.	n.d.	n.d.	n.d.
Natumi Organic Oat Natural	48	1.3	0.2	7.9	3.9	0.8	n.d.	n.d.	n.d.	n.d.
Natumi Organic Oat Omega-3	50	1.4	0.3	8.9	5.9	0.4	n.d.	n.d.	n.d.	n.d.
Natumi Organic Oat Zero	25	0.8	0.1	3.9	0	0.4	n.d.	n.d.	n.d.	n.d.
Naturwert Organic Oat Drink	46	0.8	0.2	8.2	5.7	1.1	n.d.	n.d.	n.d.	n.d.
Oat Molk Organic Barista	60	3.3	0.3	6.2	2.6	1.1	n.d.	n.d.	n.d.	n.d.
Oat Molk Organic Pure	43	1.9	0.2	6.2	2.4	0.3	n.d.	n.d.	n.d.	n.d.
Oatly Barista Edition Oat	61	3	0.3	7.1	3.4	1.1	120	22.5	0.21	0.38
Oatly Organic Oat	39	0.5	0.1	7.2	3.4	1.1	n.d.	n.d.	n.d.	n.d.
Oatly Low-Fat Oat 1.5%	48	1.5	0.2	7	3.4	1.1	120	22.5	0.21	0.38
Oatly Oat Deluxe	60	2.8	0.3	7.1	3.4	1.1	120	22.5	0.21	0.38
Oatly Oat No Sugars	44	1.5	0.2	6.3	0	1	120	22.5	0.21	0.38
Oatly Full Oat 2.8% Fat	59	2.8	0.3	7	3.4	1.1	120	22.5	0.21	0.38
Provamel Organic Oat Barista	50	1.4	0.5	8.1	3.9	0.8	n.d.	n.d.	n.d.	n.d.
Provamel Organic Oat Without Sugar	34	1.4	0.2	5.2	0	0.2	n.d.	n.d.	n.d.	n.d.
Provamel Organic Oat Drink	47	1.3	0.5	8.1	3.9	0.3	n.d.	n.d.	n.d.	n.d.
Rewe Organic + Vegan Oat Drink Without Added Sugar	40	1.4	0.2	6	5.2	0.6	n.d.	n.d.	n.d.	n.d.
Share Organic Oat Barista	57	2.1	0.4	8.9	4.1	0.4	n.d.	n.d.	n.d.	n.d.
Share Organic Oat Drink Barista	56	2.1	0.3	6.4	3.5	0.8	n.d.	n.d.	n.d.	n.d.
VeLike Organic Oat Drink Barista	59	2.1	0.2	10.1	2.1	0.9	n.d.	n.d.	n.d.	n.d.
VeLike Natural Organic Oat Drink	53	1.1	0.1	9.3	1.9	0.9	n.d.	n.d.	n.d.	n.d.
Vemondo Barista Oat	63	3.4	0.3	6.7	1.6	1.1	120	n.d.	0.21	0.38
Vemondo Organic Oat Without Added Sugar	38	1.2	0.2	6	4	0.4	n.d.	n.d.	n.d.	n.d.
Voelkel Organic Oat Drink Barista	65	3.3	0.4	7.2	6	0.8	n.d.	n.d.	n.d.	n.d.
Voelkel Organic Oat Drink Gluten-Free	48	1.3	0.2	7.4	6.1	0.8	n.d.	n.d.	n.d.	n.d.
Voelkel Organic Oat Drink With Calcium-Rich Red Alga Powder	48	1.2	0.5	7.6	6	0.9	120	n.d.	n.d.	n.d.
Voelkel Fresh Organic Oat Drink	48	1.3	0.2	7.4	6.1	0.8	n.d.	n.d.	n.d.	n.d.
Voelkel Fresh Organic Oat Drink Barista	65	3.3	0.4	7.2	6	0.8	n.d.	n.d.	n.d.	n.d.
Voelkel Fresh Organic Oat Drink With Calcium-Rich Red Alga	48	1.2	0.5	7.6	6	0.9	120	n.d.	n.d.	n.d.
Soy-based PBMA(n = 21)
Alios Organic Soy 0% Sugar	41	2.3	0.6	1.1	0.5	3.6	n.d.	n.d.	n.d.	n.d.
Alios Organic Soy Barista	28	1.6	0.4	0.8	0	2.6	n.d.	n.d.	n.d.	n.d.
Alnatura Soy Alga Drink	36	1.9	0.5	1.7	0.7	3.1	120	n.d.	n.d.	n.d.
Alnatura Soy Drink	41	2.1	0.6	2	0.8	3.6	n.d.	n.d.	n.d.	n.d.
Alpro Organic Soy	38	1.8	0.3	2.3	2.3	3	n.d.	n.d.	n.d.	n.d.
Alpro Plant Protein	57	2.8	0.5	2.5	2.5	5	120	n.d.	0.21	0.38
Alpro Soy Barista	42	1.9	0.3	2.7	2.5	3.3	120	n.d.	0.21	0.38
Alpro Soy Without Sugar	33	1.8	0.3	0	0	3.3	120	n.d.	0.21	0.38
Alpro Soy Drink Original with Calcium	39	1.8	0.3	2.5	2.5	3	120	n.d.	0.21	0.38
Berief Organic Soy Without Sugar	30	1.6	0.3	0.9	0	3	n.d.	n.d.	n.d.	n.d.
Bio Primo Natural Soy Drink	37	2	0.8	0.8	0.5	3.6	n.d.	n.d.	n.d.	n.d.
BioBio Natural Soy Drink	31	1.6	0.3	0.9	0	3	n.d.	n.d.	n.d.	n.d.
dennree Organic Soy Drink	31	2	0.3	0.5	0.5	3.1	n.d.	n.d.	n.d.	n.d.
dm Organic Natural Soy Drink	38	1.9	0.5	1.8	0.7	3.2	n.d.	n.d.	n.d.	n.d.
Edeka Organic Natural My Veggie Soy	30	1.6	0.3	0.9	0	3	n.d.	n.d.	n.d.	n.d.
enerOrganic Soy Drink	30	1.6	0.3	0.9	0	3	n.d.	n.d.	n.d.	n.d.
Food for Future Organic Soy	35	1.6	0.3	1.1	0.4	3.9	n.d.	n.d.	n.d.	n.d.
Natumi Organic Soy Natural	41	2.1	0.6	2	0.8	3.5	n.d.	n.d.	n.d.	n.d.
Provamel Organic Soy Without Sugar	35	2.1	0.4	0	0	3.7	n.d.	n.d.	n.d.	n.d.
Provamel Soy Without Sugar	35	2.1	0.4	0	0	3.7	n.d.	n.d.	n.d.	n.d.
Vemondo Organic Soy Sweetened	40	1.7	0.2	3.1	2.5	3	n.d.	n.d.	n.d.	n.d.
Almond-based PBMA (n = 21)
Alios Organic Almond 0% Sugar	27	2.5	0.2	0	0	0.8	n.d.	n.d.	n.d.	n.d.
Alnatura Almond Drink	36	3.3	0.3	0.5	0.5	1.1	n.d.	n.d.	n.d.	n.d.
Alpro Roasted Almond	22	1.1	0.1	2.4	2.4	0.4	120	n.d.	0.21	0.38
Alpro Roasted Almond Without Sugar	13	1.1	0.1	0	0	0.4	120	n.d.	0.21	0.38
Alpro Almond Barista	25	1.2	0.1	2.6	2.5	0.5	120	n.d.	n.d.	n.d.
Alpro White Almond Without Sugar	13	1.1	0.1	0	0	0.5	120	n.d.	0.21	0.38
Berief Organic Almond Without Sugar	14	1.2	0.1	0.5	0	0.5	n.d.	n.d.	n.d.	n.d.
dennree Organic Almond Drink	21	1.4	0.2	1.2	0.5	0.7	n.d.	n.d.	n.d.	n.d.
dm Natural Organic Almond Drink	22	1.9	0.2	0.5	0.5	0.9	n.d.	n.d.	n.d.	n.d.
Edeka Organic My Veggie Almond Without Added Sugar	14	1.3	0.1	0.1	0.1	0.4	n.d.	n.d.	n.d.	n.d.
enerOrganic Almond Drink	35	3.3	0.3	<0.5	0.5	1.1	n.d.	n.d.	n.d.	n.d.
Food for Future Organic Almond Drink	16	1.3	0.1	0.3	0.1	0.5	n.d.	n.d.	n.d.	n.d.
Gut Organic Almond Drink Sweetened & Roasted	26	1.3	0.1	2.9	2.9	0.5	n.d.	n.d.	n.d.	n.d.
Natumi Organic Almond Barista	20	1.5	0.2	0.7	0	0.8	n.d.	n.d.	n.d.	n.d.
Natumi Organic Almond Unsweetened	28	2.5	0.2	0	0	1.1	n.d.	n.d.	n.d.	n.d.
Naturwert Organic Almond Drink	15	1.3	0.2	0.5	0.5	0.6	n.d.	n.d.	n.d.	n.d.
Provamel Organic Almond	38	2.5	0.2	2.4	2.2	1	n.d.	n.d.	n.d.	n.d.
Provamel Organic Almond Without Sugar	29	2.4	0.2	0	0	1	n.d.	n.d.	n.d.	n.d.
Rewe Organic + Vegan Almond Drink Without Sugar	23	1.9	0.2	0.5	0.5	0.9	n.d.	n.d.	n.d.	n.d.
Share Organic Almond Drink Unsweetened	18	1.4	0	0.6	0	0.6	n.d.	n.d.	n.d.	n.d.
Vemondo Organic Almond Without Sugar	13	1.2	0.1	0	0	0.5	n.d.	n.d.	n.d.	n.d.
Coconut-based PBMA (n = 12)
Alios Coconut 0% Sugar	22	1.5	1.2	1.7	0	0.2	n.d.	n.d.	n.d.	n.d.
Alnatura Organic Coconut Drink	12	0.5	0.1	1.3	1.3	1.7	n.d.	n.d.	n.d.	n.d.
Alpro Barista Coconut	33	1.4	0.7	3.3	3.3	1.5	120	n.d.	n.d.	n.d.
Alpro Coconut Without Sugar	14	1.2	1.1	0	0	0.1	120	n.d.	n.d.	0.38
Bio Primo Natural Coconut Drink	25	2.1	2	1.1	0.7	0	n.d.	n.d.	n.d.	n.d.
Coco Organic Coconut Milk	24	2	1.8	1.5	1.2	0.3	n.d.	n.d.	n.d.	n.d.
dm Organic Natural Coconut Drink	18	1.5	1.4	1	1	0.5	n.d.	n.d.	n.d.	n.d.
EcomiI Coconut Keto Low Carb	32	3.4	3.2	0.2	0	0.1	n.d.	n.d.	n.d.	n.d.
enerBio Natural Coconut Drink	18	1.5	1.4	1	1	0.5	n.d.	n.d.	n.d.	n.d.
Koko Barista Coconut Drink	49	4	2.6	2.1	1.7	1.1	120	n.d.	n.d.	0.75
Koko Original Coconut Drink	27	2	1.9	1.9	1.6	0.2	120	n.d.	n.d.	0.75
Natumi Organic Sugar-Free Coconut Drink	35	2.9	2.3	1.8	0	0.2	n.d.	n.d.	n.d.	n.d.
Rice-based PBMA (n = 10)
Alios Natural Organic Rice	60	1	0.1	14	5.5	0.5	n.d.	n.d.	n.d.	n.d.
Alnatura Rice Alga Drink	50	1.1	0.1	9.9	7.1	0.5	120	n.d.	n.d.	n.d.
Alnatura Rice Drink	50	1.1	0.1	9.9	7.1	0.5	n.d.	n.d.	n.d.	n.d.
Bio Primo Natural Rice Drink	55	1	0.1	11	n.d.*3	0.5	n.d.	n.d.	n.d.	n.d.
dennree Organic Rice Drink	64	1.1	0.1	14	6	0.5	n.d.	n.d.	n.d.	n.d.
dm Organic Natural Rice Drink	48	1.1	0.1	9.3	6.7	0.1	n.d.	n.d.	n.d.	n.d.
enerBio Natural Rice Drink	50	1.3	0.2	9.6	3.5	0.1	n.d.	n.d.	n.d.	n.d.
Natumi Organic Rice Natural	50	1.1	0.1	9.9	7.1	0.5	n.d.	n.d.	n.d.	n.d.
Provamel Organic Rice Drink	54	1.1	0.2	11	6.5	0.1	n.d.	n.d.	n.d.	n.d.
Voelkel Organic Rice Drink	46	1	0.1	8.3	6.7	0.5	n.d.	n.d.	n.d.	n.d.
Spelt-based PBMA (n = 5)
Alios Natural Organic Spelt	59	1.1	0.1	11	5.5	0.8	n.d.	n.d.	n.d.	n.d.
Alnatura Organic Spelt Drink	42	1.5	0.2	6.2	5.7	0.8	n.d.	n.d.	n.d.	n.d.
dm Natural Organic Spelt Drink	42	1.5	0.2	6.2	5.7	0.8	n.d.	n.d.	n.d.	n.d.
Natumi Organic Spelt Natural	45	1	0.1	8.7	6.7	0.5	n.d.	n.d.	n.d.	n.d.
Rewe Natural Organic + Vegan Spelt Drink Without Added Sugar	42	1.5	0.2	6.2	5.7	0.8	n.d.	n.d.	n.d.	n.d.
Pea-based PBMA (n = 5)
Alnatura Pea Barista	40	2.4	0.2	2.7	1.4	1.4	n.d.	n.d.	n.d.	n.d.
dm Organic Barista Pea Drink	40	2.4	0.2	2.7	1.4	1.4	n.d.	n.d.	n.d.	n.d.
enerBio Pea Barista	40	2.4	0.2	2.7	1.4	n.d.	n.d.	n.d.	n.d.	n.d.
Vly Pea Barista	45	3.2	0.3	2	1.4	2	120	11.7	n.d.	1.5
Vly Pea Unsweetened	37	2.5	0.3	0.2	0	2.4	120	11.7	n.d.	1.5
Cashew-based PBMA (n = 4)
Alnatura Cashew Drink	39	3.2	0.8	1.3	0.5	1.3	n.d.	n.d.	n.d.	n.d.
Alpro Cashew Drink Original	23	1.1	0.2	2.6	2	0.5	120	n.d.	0.21	0.38
dm Natural Organic Cashew Drink	35	2.9	0.6	1.1	0.5	1.1	n.d.	n.d.	n.d.	n.d.
Natumi Organic Cashew Natural	37	3	0.7	1.2	0.4	1.2	n.d.	n.d.	n.d.	n.d.
Hazelnut-based PBMA (n = 2)
Alnatura Hazelnut Drink	33	3.3	0.3	0.5	0.5	0.9	n.d.	n.d.	n.d.	n.d.
Alpro Hazelnut Drink Original	29	1.6	0.2	3.2	3.2	0.4	120	n.d.	0.21	0.38
Buckwheat-based PBMA (n = 2)
Hofgut Storzeln Buckwheat	51	1.1	0.2	8.4	5.6	1.6	n.d.	n.d.	n.d.	n.d.
Natumi Organic Buckwheat Natural	51	1.1	0.2	8.4	5.6	1.6	n.d.	n.d.	n.d.	n.d.
Rye-based PBMA (n = 1)
Alpro Creamy Rye	44	1.5	0.1	7.1	3.5	0.6	n.d.	n.d.	n.d.	n.d.
Hemp-based PBMA (n = 1)
EcomiI Hemp Nature	40	2.9	0.3	2.2	0.3	1	n.d.	n.d.	n.d.	n.d.
Millet-based PBMA(n = 1)
Natumi Organic Millet Natural	57	1.1	0.1	11	5.5	0.7	n.d.	n.d.	n.d.	n.d.
Mixed raw materials (n = 55)
Alios Organic Drink No Moo 1.5% Fat	25	1.5	0.7	2.8	1.9	0.4	n.d.	n.d.	n.d.	n.d.
Alios Organic Drink No Moo 3.5% Fat	54	3.5	1	4.8	2.2	0.6	n.d.	n.d.	n.d.	n.d.
Alios Natural Organic Oat-Almond	52	2.8	0.3	5.6	3.3	1.1	n.d.	n.d.	n.d.	n.d.
Alios Organic Rice Hazelnut	74	1.9	0.2	13	5.5	0.8	n.d.	n.d.	n.d.	n.d.
Alios Natural Organic Rice-Coconut	60	0.8	0.6	13	6.5	0.5	n.d.	n.d.	n.d.	n.d.
Alios Natural Organic Rice-Almond	81	2.6	0.4	13	5.5	1	n.d.	n.d.	n.d.	n.d.
Alnatura Barista Oat With Soy	50	2	0.3	6.3	4.3	1.5	n.d.	n.d.	n.d.	n.d.
Alnatura Organic Oat Almond	34	2.2	0.3	2.8	1.7	0.8	n.d.	n.d.	n.d.	n.d.
Alnatura Soy Rice Drink	43	1.2	0.3	6.1	4.1	1.9	n.d.	n.d.	n.d.	n.d.
Alpro Oat & Almond	23	1	0.1	2.4	1.8	0.4	120	n.d.	0.21	0.38
Alpro Dreamy and Tropical Coconut	20	0.9	0.9	2.7	1.9	0.1	120	n.d.	n.d.	0.38
Berief Organic 1.5% Fat (Soy + Oat)	31	1.5	0.2	2.6	2.1	2.2	n.d.	n.d.	n.d.	n.d.
Berief Organic 3.5% Fat (Soy + Oat)	51	3.5	0.4	2.6	2.1	2.2	n.d.	n.d.	n.d.	n.d.
Berief Organic 3.8% Fat Barista (Soy + Oat)	53	3.8	0.5	2.6	2.1	2.2	n.d.	n.d.	n.d.	n.d.
Berief Organic Barista Oat + Soy	55	2	0.3	7.8	5.6	1.4	n.d.	n.d.	n.d.	n.d.
Berief Organic Oat Almond Drink	37	1	0.2	6	4.1	1	n.d.	n.d.	n.d.	n.d.
Bio Primo Oat Drink Coconut	71	3.5	2.3	8	6.5	1.3	n.d.	n.d.	n.d.	n.d.
BioBio Oat Drink Barista	50	2	0.3	6.3	4.3	0.15	n.d.	n.d.	n.d.	n.d.
dennree Organic Barista Oat Drink With Soy	58	1.9	0.4	8.7	5.6	1.3	n.d.	n.d.	n.d.	n.d.
dennree Organic Rice Coconut Drink	52	1.1	1	10	5.7	0.5	n.d.	n.d.	n.d.	n.d.
dm Organic Barista Oat Drink With Soy	51	1.7	0.2	7.2	3	1.5	n.d.	n.d.	n.d.	n.d.
dm Organic Not M*lk and So Yummy	50	3.5	0.4	2.5	2.1	1.4	n.d.	n.d.	n.d.	n.d.
Edeka Organic My Veggie Oat Drink Barista	50	2	0.3	6.3	4.3	1.5	n.d.	n.d.	n.d.	n.d.
enerBio Oat Almond Drink	37	1	0.2	6	4.1	1	n.d.	n.d.	n.d.	n.d.
enerBio Oat Drink Barista	50	2	0.3	6.3	4.3	1.5	n.d.	n.d.	n.d.	n.d.
Food for Future Organic Oat-Soy Drink Barista	50	2	0.3	6.4	5.1	1.4	n.d.	n.d.	n.d.	n.d.
Harvest Moon Milk Alternative Barista	51	2.7	1.5	5.3	1	0.8	n.d.	n.d.	n.d.	n.d.
Harvest Moon Milk Alternative Extra Creamy	62	3.9	1.5	5.8	1	0.6	n.d.	n.d.	n.d.	n.d.
Mighty No Milk Fat-Reduced	35	2.2	0.3	1.7	1.7	2	120	n.d.	n.d.	0.38
Mighty No Milk Full	46	3.4	0.5	1.9	1.9	2	120	n.d.	n.d.	0.38
My Vay Organic Oat Drink With Almond	40	0.8	0.1	6.8	3.8	1	n.d.	n.d.	n.d.	n.d.
Natumi Organic Spelt Almond Drink	60	2.4	0.3	7.9	7.2	1.3	n.d.	n.d.	n.d.	n.d.
Natumi Organic Oat Hemp	34	2.2	0.3	2.7	1.6	0.7	n.d.	n.d.	n.d.	n.d.
Natumi Organic Oat Coconut	49	1.5	1.2	8.3	5.4	0.5	n.d.	n.d.	n.d.	n.d.
Natumi Organic Oat Almond	55	1.8	0.2	7.8	5.5	1.6	n.d.	n.d.	n.d.	n.d.
Natumi Organic Oat Soy Barista	55	1.8	0.4	8.4	5.5	1.2	n.d.	n.d.	n.d.	n.d.
Natumi Organic Rice Coconut	53	1.2	1.1	10	7.4	0.5	n.d.	n.d.	n.d.	n.d.
Natumi Organic Soy Barista Coconut	25	1.6	0.9	1	0.4	1.6	n.d.	n.d.	n.d.	n.d.
Natumi Organic Full 1.8%	35	1.8	0.2	3.3	0.7	1.1	n.d.	n.d.	n.d.	n.d.
Natumi Organic Full 3.5%	51	3.5	0.4	3.3	0.7	1.1	n.d.	n.d.	n.d.	n.d.
Naturwert Organic Oat Drink Barista	48	1.5	0.2	6.7	3.2	1.7	n.d.	n.d.	n.d.	n.d.
Naturwert Organic Oat-Almond Drink	40	0.8	0.1	6.8	3.8	1	n.d.	n.d.	n.d.	n.d.
Provamel Organic Oat Almond Drink	47	2.5	0.4	5	2.5	0.7	n.d.	n.d.	n.d.	n.d.
Provamel Organic Coconut Almond Drink	35	2.4	1	2.4	2.3	0.7	n.d.	n.d.	n.d.	n.d.
Provamel Organic Rice Coconut Drink	60	0.8	0.8	13	7.7	0.1	n.d.	n.d.	n.d.	n.d.
Rewe Organic + Vegan Barista Oat-Soy Drink Without Added Sugar	50	2	0.3	6.3	4.3	1.5	n.d.	n.d.	n.d.	n.d.
Rewe Organic + Vegan Coconut-Rice Drink	23	1.3	1.2	2.5	1.5	0.3	n.d.	n.d.	n.d.	n.d.
Rewe Organic + Vegan No Moo Drink	47	3.5	0.4	2.5	0.5	1	n.d.	n.d.	n.d.	n.d.
Vemondo Organic Coconut With Rice	23	1.3	1.2	2.7	1.9	0.1	n.d.	n.d.	n.d.	n.d.
Vemondo No Milk 1.8%	38	1.8	0.2	4.1	1.2	0.8	120	n.d.	n.d.	0.38
Vemondo No Milk 3.5%	53	3.5	0.3	4.1	1.2	0.8	120	n.d.	n.d.	0.38
Vly Low-Fat 1.5% Oat and Pea Protein Basis	33	1.5	0.1	2.7	2.1	2.1	120	11.7	n.d.	1.5
Vly Low-Fat 3.5% Oat and Pea Protein Basis	51	3.5	0.3	2.7	2.1	2.1	120	11.7	n.d.	1.5
Vly High Protein Fava Bean + Pea Protein	52	2	0.2	2.4	0.4	5.1	120	n.d.	n.d.	1.5
Voelkel Organic Oat-Almond Drink	60	2.7	0.4	6.4	5.5	1.4	n.d.	n.d.	n.d.	n.d.

^*The products were identified between 31 August 2023 and 08 November 2023 in German (organic) supermarkets, discounters, and drugstores and by a supplementary online search. The data for cow’s milk according to the German Nutrient Database (Bundeslebensmittelschlüssel) are provided for comparison (mean values stated except for iodine [median]; as of 31 August 2025).

^*1Data on manufacturer’s website implausible (43 892 g/100 g), therefore not included in table;

^*2data on manufacturer’s website implausible (43 892 g/100 g), therefore not included in table;

^*3data on manufacturer’s website implausible (43 958 g/100 g), therefore not included in table; n.d., no data

eFigure 2. Proportion of plant-based milk alternatives (PBMA).

enriched with one or more of the micronutrients for which cow’s milk represents one of the major sources in childhood (%). The following PBMA groups were analyzed: (a) N = 215 in total, (b) n = 75 oat-based, (c) n = 21 soy-based, (d) n= 21 almond-based, (e) n = 12 coconut-based.

Vit., Vitamin

PBMA contain lower mean levels of potassium, chloride, and phosphorus than cow’s milk, but slightly more sodium. However, levels fluctuate considerably between the different raw materials and among different manufacturers using the same raw materials (e4). Although it is generally assumed that no critical effects occur at normal consumption levels (e4), a few case reports show that electrolyte imbalances, sometimes life-threatening, can occur into the second year of life in children who consume only PBMA (12, 14–17, 23, 24).

As for the possible effects of PBMA consumption in childhood on bone health, there are a small number of descriptive case studies showing reduction of bone mineralization to the point of osteopenia or osteoporosis, some of them linked with the occurrence of pathological or spontaneous fractures. However, there is no systematically compiled evidence. Particularly in view of the known relevance of cow’s milk consumption in childhood for bone formation (eBox 2), further research seems urgently warranted.

eBox 2. Effect of cow’s milk consumption on bone mineralization.

Cow’s milk is generally linked with a positive influence on bone health, especially in early life. Not only the high calcium content of cow’s milk is viewed as important, but also effects mediated by the milk protein casein, lactose, and the calcium/phosphate ratio, which facilitates absorption (e32–e35), together with the enrichment of cow’s milk with vitamin D practiced in some countries (e36).

Epidemiological studies have shown a direct association between bone mineral density (BMD) and consumption of cow’s milk in childhood. In a cross-sectional study of 272 children between 6 and 12 years old, the current total milk consumption (as measured in the previous month) was associated positively with the Z score for bone mineral content (BMC; correlation coefficient β = 0.173, p = 0.002) and BMD (β = 0.120, p = 0.029) (e37). A cohort study of 3444 children showed an association between higher milk consumption at the age of 4–6 years and whole-body BMD at age 6 years (p < 0.001) (e38).

An investigation of women between 20 and 49 years of age showed that lower milk consumption in childhood (5–12 years), compared with higher milk consumption, was associated with a 5.6% reduction in BMC (p < 0.01) (e39). Lower milk consumption in adolescence (age 13–17 years) was associated with 3% lower BMC subsequently (p < 0.02). Furthermore, lower milk consumption in childhood was associated with an elevated risk of fractures over the entire life span (defined as from age 13 years onwards, p = 0.008) and for osteoporotic fractures (defined as from 50 years onwards, p = 0.04).

According to a recent review (e11), the majority of controlled clinical trials also show a direct connection between the consumption of dairy products and bone mineralization in childhood (n = 7 studies with a total of n = 1771 children/adolescents): in n = 6 studies significantly higher BMC was found at particular sites or over the whole body.

Moreover, there is evidence of an elevated occurrence of fractures in children who do not consume cow’s milk. An investigation of 50 children aged 3–10 years found that those who did not drink cow’s milk for various reasons (lactose intolerance, lifestyle) had lower overall BMC (mean ± standard deviation [SD]: −0.45 g ± 1.16, p < 0.01) and lower BMD (BMD Z score, mean ± SD: 0.72 ± 1.17, p < 0.001 for the lumbar spine and 0.72 ± 1.35, p < 0.001 for the radius [measurement site 33%]) than those in the control group, who consumed 200 mL milk daily. The group that drank no cow’s milk also had a higher incidence of fractures (e40). A total of 17 fractures were observed in 12 of these children, corresponding to an annual incidence of 3.5%. This greatly exceeds the expected annual fracture incidence of 1%. A further investigation of 30 of these children showed a higher number of past fractures than in a comparison group (16 children rather than the expected six children with fractures, X² = 31.0, p < 0.001; 22 fractures rather than the expected eight fractures, X² = 31.0, p < 0.001) (e41).

Overall, BMC and BMD are associated with fracture risk in children and in adults. For this reason, maximization of bone mass in childhood and adolescence is a central strategy for prevention of osteoporotic fractures in later life, with the aim of achieving the highest possible peak bone mass at the end of the skeletal maturation process (e42).

In contrast, studies on the impact of milk consumption in adulthood on the occurrence of osteoporosis and fractures have shown no clear results (e43): studies in the USA, where cow’s milk is routinely fortified with vitamin D, found a lower fracture risk in participants with the highest compared to the lowest consumption of dairy products (relative risk [RR] 0.75; 95% confidence interval [CI] [0.65; 0.87]). Another investigation found an inverse linear association between the consumption of dairy products and the risk of hip fractures (RR 0.93; 95% CI [0.88; 0.98]) per glass consumed daily. In contrast, studies in Scandinavia, where not all dairy products are fortified with vitamin D and the consumption of milk is generally very high (e44), showed no association between the amount of cow’s milk consumed and the fracture risk (RR 1.00; 95% CI [0.85; 1.17]) and no association between milk consumption and the risk of hip fractures (RR 1.01; 95% CI [0.95; 1.07], per glass of dairy products consumed daily).

When assessing the risk of osteoporosis and fractures, one must consider that a large number of factors can be involved. These include, for example, nutrition, breastfeeding (with effects on the breastfeeding mother and on the breastfed child), height and weight, muscle mass, and physical activity (higher peak bone mass with greater physical activity in the growth phase, lower risk of falling with well-trained muscles), age (higher prevalence of osteoporosis and higher risk of falls with increasing age), and ultraviolet light exposure (endogenous vitamin D synthesis). This has to be considered when evaluating the association between the intake of milk and calcium and the fracture risk in different populations. Moreover, it must not be forgotten that the risk of hip fractures increases with greater height (e45, e46), and populations with high cow’s milk consumption are typically taller (e7). The risk of hip fracture, which is often selected as a study endpoint, is lower in persons of Asian origin than in Caucasians owing to geometrical differences (e47).

It is interesting that the consumption of PBMA or non-cow’s milk at preschool and grade-school age is associated with lesser growth in height (8, 9). The literature includes repeated accounts of a link between cow’s milk consumption and greater longitudinal growth (Box 1). In the two studies identified here (8, 9), however, it was shown that the observed association between the consumption of PBMA or non-cow’s milk and reduced longitudinal growth was mediated only to a small extent by lower cow’s milk consumption. There is no known hypothesis to explain a direct growth inhibiting effect of PBMA or noncow’s milk. There is, however, evidence indicating that protein intake exerts a dose-dependent influence on linear growth in children (e5). Since neither study measured total protein intake, the lower height could also be attributable to a generally more plant-dominated and therefore protein-poorer diet in children who consumed PBMA or non-cow’s milk. With regard to the increasing prevalence of childhood overweight and obesity, the finding that PBMA consumption went hand-in-hand with lower BMI (8) could indicate a possible benefit of the lower energy density of PBMA than milk. Simultaneously, the importance of adequate energy and nutrient intake must be underlined.

Studies in adults point to possible health-promoting effects of consumption of (soy-based) PBMA instead of cow’s milk. Positive effects were shown on blood lipid profile (LDL cholesterol, n = 10 studies: mean difference [MD] −0.19 mmol/L [−0.29; −0.09], p < 0.001; non-HDL cholesterol, n = 7 studies: MD −0.26 mmol/L [−0.43; −0.10], p = 0.002), blood pressure (systolic blood pressure, n = 5 studies: MD −8 mm Hg [−14.9; −1.1], p = 0.023; diastolic blood pressure, n = 5 studies: MD −5 mm Hg [−9.2; −0.3], p = 0.036), and inflammation markers (C-reactive protein, n = 5 studies: MD −0.8 mg/dL [−1.26; −0.37], p < 0.001) (e6). Further research on the effects in early life is necessary.

Strengths and limitations

A strength of this study is the exhaustive literature research and the presentation of the nutrient profiles of a large number of PBMA marketed in Germany. The principal raw materials were elicited by means of a consumer survey. Limitations are the low quality of some of the studies identified, the lack of representative surveys, longitudinal studies, and randomized interventional trials, and the selective nature of case report publications. Although case reports are published worldwide, they permit no conclusions as to disease prevalences.

Conclusion

The results indicate that exclusive consumption of PBMA in the early phase of life (infancy and toddlerhood) may be associated with problems due to inadequate nutrient intake. This underscores the necessity of recommendations specific to different phases of life (Box 2) that take account of the special nutritional requirements in the first few years of life, a time of enormous growth and development potential. Research is urgently required in the form of longitudinal studies and interventional studies on the longterm consequences of early partial or complete substitution of cow’s milk by PBMA in terms of developmental outcomes such as bone mineralization.

Box 2. Feeding of children with plant-based milk alternatives and with cow’s milk: Recommendations issued by professional associations^*.

• Plant-based milk alternatives (PBMA) are no equivalent substitute for cow’s milk (1, e17) or human milk (e18), particularly in view of their very low content of protein, calcium, iodine, and B vitamins (e17). They should not be used in the preparation of milk-based infant cereal for infants and toddlers (e18).

• Rice-based drinks can be contaminated with arsenic. The German Federal Institute for Risk Assessment (BfR) therefore advises against their exclusive use for feeding infants and toddlers (e19). Almond-based PBMA may contain aflatoxins (e20) and should therefore not, according to the BfR, regularly be consumed by children under the age of 6 years.

• If cow’s milk-based feeding is impossible (e.g., in the presence of galactosemia), infant formula based on soy protein is recommended as an additional source of nutrients for infants and toddlers (e17, e21).

• If PBMA are used, soy-based PBMA enriched with calcium, iodine, and vitamins B2 and B₁₂ should be preferred (1, e22, e23).

• To ensure even nutrient distribution, PBMA should be shaken thoroughly before use, because processes such as sedimentation and colloidal instability can cause marked fluctuation of the nutrient content of PBMA (e24, e25).

• Feeding with PBMA that are enriched with only some of the above-mentioned nutrients or not at all should be accompanied by nutrient intake from other sources (foods or nutritional supplements). A qualified nutritionist should be consulted as needed (1).

Recommendations on cow’s milk consumption

• Cow’s milk and dairy products are recommended for both children and adults as part of a healthy diet and as an important source of nutrients, especially calcium, iodine, and vitamins B₂ and B₁₂. The German Nutrition Society (DGE) recommends two portions daily for adults (1).

• The “optimized mixed diet” (optimierte Mischkost, OMK) that corresponds to the current German nutritional recommendations for children and adolescents aged 1–18 years advises that milk and dairy products should make up 18% of daily energy intake. This corresponds, for instance, to 300 g of milk and dairy products for 1- to 3-year-old boys and girls, 520 g for 15- to 18-year-old girls, and 680 g for 15- to 18-year-old boys (e26).

• In the first 6 months of life, infants should ideally be exclusively breastfed, with partial breastfeeding thereafter. If that is not possible, they should receive an infant formula manufactured in accordance with the legal specifications (e27). The drinking of cow’s milk can start at the end of the first year of life, in amounts of up to 200 mL per day, in children no longer being given baby food that contains milk (e28). From an allergological perspective, the consumption of limited amounts of cow’s milk or yoghurt is generally recommended as soon as a child starts receiving solid food (e29).

eMETHODS

Search strategy

Search terms 1

Search strings (“milk alternative”[Title/Abstract] OR “milk-alternative”[Title/Abstract] OR “plant-based milk”- [Title/Abstract] OR “plant-based beverage”[Title/Abstract] OR “plant-based drink”[Title/Abstract] OR “plant-based dairy”[Title/Abstract] OR “dairy alternative”[Title/Abstract] OR “plant-based alternative”[Title/Abstract] OR “plant-based milk alternative”[Title/Abstract] OR “non-dairy milk”[Title/Abstract] OR “non-dairy beverages”[Title/Abstract] OR “nondairy bever-age”[Title/Abstract] OR “nondairy alternative”[Title/Abstract] OR “plant milk”[Title/Abstract] OR “vegan milk”[Title/Abstract] OR “vegetable milk”[Title/Abstract] OR “milk analog”- [Title/Abstract] OR “soy beverages”[Title/Abstract] OR “soy drink”[Title/Abstract] OR “soy milk”[Title/Abstract] OR “oat milk”[Title/Abstract] OR “oat drink”[Title/Abstract] OR “oat be-verage”[Title/Abstract] OR “almond milk” [Title/Abstract] OR “almond drink”[Title/Abstract] OR “almond beverage”[Title/ Abstract] OR “milk substitute” [Title/Abstract]); (((milk substitute[MeSH Terms]) NOT (breast[MeSH Terms])) NOT (breast-feeding[MeSH Terms])) NOT (formula[MeSH Terms]) with filters (human studies, age group birth to 18 years).

Search terms 2

Extension to include further terms for plant-based milk alternatives (PBMA) and thematic restriction to health/growth outcomes and the early phase of life:

(“milk alternative”[Title/Abstract] OR “milk-alternative”[Title/Abstract] OR “plant-based milk”[Title/Abstract] OR “plant-based beverage”[Title/Abstract] OR “plant-based drink”[Title/Abstract] OR “plant-based dairy”[Title/Abstract] OR “dairy alternative”[Title/Abstract] OR “plant-based alternative”[Title/Abstract] OR “plant-based milk alternative”[Title/ Abstract] OR “non-dairy milk”[Title/Abstract] OR “non-dairy beverages”[Title/Abstract] OR “nondairy beverage”[Title/Abstract] OR “nondairy alternative”[Title/Abstract] OR “plant milk”[Title/ Abstract] OR “vegan milk”[Title/Abstract] OR “vegetable milk”[Title/Abstract] OR “milk analog”[Title/Abstract] OR “soy beverages”[Title/Abstract] OR “soy drink”[Title/Abstract] OR “soy milk”[Title/Abstract] OR “oat milk”[Title/Abstract] OR “oat drink”[Title/Abstract] OR “oat beverage”[Title/Abstract] OR “almond milk” [Title/Abstract] OR “almond drink”[Title/Abstract] OR “almond beverage”[Title/Abstract] OR “milk substitute” [Title/Abstract] OR “nondairy”[Title/Abstract] OR “non-dairy”[Title/Abstract] OR “non cow’s milk”[Title/Abstract] OR “coconut drink”[Title/Abstract] OR “coconut beverage”[Title/Abstract] OR “rice drink”[Title/Abstract] OR “rice beverage”[Title/Abstract]) AND (“growth”[All Fields] OR “bone”[All Fields] OR “height”[All Fields] OR “weight”[All Fields] OR “obesity”[All Fields] OR “overweight”[All Fields] OR “underweight”[All Fields] OR “malnutrition”[All Fields] OR “metabolism”[All Fields]) AND (“early life”[All Fields] OR “infant”[All Fields] OR “child”[All Fields] OR “youth”[All Fields] OR “adolescence”[All Fields] OR “offspring”[All Fields]).

Manual backward searching of review articles identified by these search strategies.

Selective literature search for scientific/medical recommendations on consumption of PBMA and cow’s milk products and on the influence of cow’s milk consumption on growth (in height), bone mineralization, and risk of illness.

Investigation of the nutritional content of PBMA marketed in Germany

Between August and November 2023, the PBMA available in a convenience sample of 10 German (organic) supermarkets, discounters, and drugstores were identified, and the data on nutrient content found on the packaging were documented. Online research added manufacturers’ nutritional data on further products of the previously identified brands. We excluded flavored PBMA and PBMA marketed as alternatives to so-called children’s milk (specially enriched cow’s milk-based drinks for use as follow-on formulas).

We evaluated all PBMA’ content of energy, macronutrients (fat and saturated fatty acids, protein, carbohydrates, and sugar), and micronutrients, as stated by the manufacturers, compared with cow’s milk. Furthermore, the proportion of PBMA enriched with relevant micronutrients was calculated as a percentage of total PBMA and separately for the four groups of raw materials found by a consumer survey to be the most commonly used dairy substitutes in Germany (oat, soy, almond, and coconut) (30). We analyzed those micronutrients for which milk and dairy products make up more than 15% of the average amount consumed between the ages of 6 and 17 years: calcium, iodine, vitamins B₂ and B₁₂ (e31).

Questions on the article in issue 4/2026: Plant-Based Drinks as an Alternative to Cow’s Milk in Early Life

The submission deadline is 19 February 2027. Only one answer is possible per question.

Please select the answer that is most appropriate.

• Question 1

  Which of the following risks of rice-based milk alternatives is mentioned in the article?

  1. They are very rich in calories.
  2. They have a laxative effect.
  3. They often contain bitter substances.
  4. They may be contaminated with arsenic.
  5. They very quickly spoil.

• Question 2

  If cow’s milk-based feeding of infants and toddlers is impossible owing to galactosemia, which of the following additional nutrient sources is then recommended?

  1. Infant formula on soy protein basis
  2. Infant formula on almond milk basis
  3. Infant formula on rice protein basis
  4. Infant formula on oat protein basis
  5. Infant formula on fish protein basis

• Question 3

  According to German nutritional recommendations, which of the following amounts of milk and dairy products should children aged 1-3 years consume daily?

  1. 50 g
  2. 100 g
  3. 300 g
  4. 500 g
  5. 700 g

• Question 4

  What proportion of the daily energy intake of children and adolescents aged 1-18 years should be made up by milk and dairy products?

  1. 1%
  2. 5%
  3. 9%
  4. 12%
  5. 18%

• Question 5

  Milk and dairy products supply around one third of the required amount of an important trace element to children, adolescents and adults in Germany. Which of the following trace elements is concerned?

  1. Copper
  2. Manganese
  3. Iron
  4. Iodine
  5. Fluoride

• Question 6

  In the literature four children are reported who consumed soy-based milk alternatives for several years. Which of the following medical problems occurred?

  1. Low bone mineral density
  2. Kidney failure
  3. Arrhythmia
  4. Muscular dystrophy
  5. Muscular atrophy

• Question 7

  Which of the following vitamins are present in important amounts in cow’s milk, so that deficiency may arise if children do not consume any cow’s milk or dairy products?

  1. Vitamin K and vitamin E
  2. Vitamin C and vitamin K₂
  3. Vitamin B₇ and vitamin C
  4. Vitamin E₃ and vitamin B₇
  5. Vitamin B₁₂ and vitamin B₂

• Question 8

  Which of the following reasons is specified in the article for the fact that study results from Canada on the subject of feeding with plant-based milk alternatives cannot necessarily be extrapolated to Germany?

  1. Canadian plant-based milk alternatives contain more vitamins than their German counterparts.
  2. The cow’s milk in Canada contains a higher amount of saturated fatty acids than that in Germany.
  3. In contrast to Germany, enrichment of cow’s milk with vitamin D is mandatory in Canada.
  4. No fresh full-fat milk may be sold in Canada, only milk treated by heating to ultra-high temperature, influencing the vitamin content.
  5. Enrichment of cow’s milk with vitamin B₁₂ is mandatory in Canada.

• Question 9

  Which of the following plant-based milk alternatives was, according to data from KiGGS (2014–2017), consumed most frequently by 1- to 3-year-old children in Germany?

  1. Almond-based milk alternatives
  2. Oat-based milk alternatives
  3. Rice-based milk alternatives
  4. Soy-based milk alternatives
  5. Coconut-based milk alternatives

• Question 10

  Which of the following socioeconomic factors was, according to the KiGGS results, associated with higher consumption of plant-based milk alternatives by the children?

  1. Higher family social status and higher parental education level
  2. Living in a rural area and lower parental education level
  3. Family with several children and higher parental age
  4. Lower family social status and l ow parental age
  5. Families with many children in a rural area