David Stukus, MD, talks managing food allergies in pediatric patients

Children with food allergies often require dietary modifications during key periods of growth and development, raising concerns among families and clinicians about adequate nutrition. According to David Stukus, MD, professor of clinical pediatrics and director of the Food Allergy Treatment Center at Nationwide Children’s Hospital in Columbus, Ohio, true nutritional deficiencies remain uncommon for most pediatric patients when dietary management is approached carefully.

In an interview with Contemporary Pediatrics, Stukus discussed common nutritional concerns in pediatric food allergy, the role of early allergen introduction, and how evolving treatment approaches are changing dietary management.

Most children can maintain balanced nutrition

Stukus explained that most children are allergic to only 1 or 2 foods, making it possible to replace nutrients from avoided foods through other dietary sources.

“When children avoid milk or dairy products, clinicians often consider calcium and vitamin D intake, as well as other micronutrients,” Stukus said. “Similar considerations apply for children avoiding eggs, seafood, or tree nuts.”

However, he emphasized that routine screening for nutritional deficiencies is generally unnecessary in children with otherwise balanced diets. Instead, clinicians should focus on routine growth monitoring and identifying signs that may indicate underlying nutritional concerns.

“Red flags that warrant further evaluation include poor weight gain, weight loss, or failure to thrive,” Stukus said. “Additional concerning signs may include hair loss, rashes, or abnormalities of the gums or teeth.”

Early allergen introduction supports dietary diversity

Stukus noted that counseling around nutrition often becomes especially important during infancy and early childhood, particularly for infants with milk allergy transitioning away from formula or breast milk near 12 months of age.

“In our practice, we provide families with educational materials outlining the benefits and limitations of various milk alternatives, including pea protein–based milk, oat milk, soy milk, and almond milk,” he said.

Adequate fat intake remains a primary concern during infancy because of its role in brain development, while sufficient protein intake is also essential. Stukus said clinicians should encourage nutrient-dense foods whenever developmentally appropriate.

He also highlighted how evidence supporting early allergen introduction has shifted nutritional counseling practices in recent years. Current recommendations encourage introducing allergenic foods between 4 and 6 months of age for infants at higher risk of food allergy, particularly those with moderate to severe eczema.

“After introduction, maintaining these foods regularly in the diet appears to be the most effective strategy for reducing the risk of food allergy development,” Stukus said.

According to Stukus, early allergen introduction also supports dietary diversity without increasing nutritional risk.

Expanding treatment options may ease dietary restrictions

For children with multiple food allergies or conditions such as food protein–induced enterocolitis syndrome, collaboration with a registered dietitian can help families identify safe alternatives and maintain adequate calorie and micronutrient intake.

Stukus said advances in food allergy management are also changing how clinicians approach dietary restrictions. Approximately 75% of children with milk or egg allergy can tolerate baked forms of those foods, potentially allowing reintroduction of important nutrients.

“The traditional all-or-nothing approach to allergen avoidance is no longer appropriate,” Stukus said. “Instead, management should be individualized, with an emphasis on safely expanding the diet whenever possible.”

Emerging therapies such as oral immunotherapy may further reduce nutritional concerns by enabling patients to safely consume foods that were previously avoided.

Stukus cautioned that pediatricians should reconsider allergy diagnoses when children develop increasingly restrictive diets or when food avoidance is based on nonspecific symptoms alone. Broad food allergy panel testing, he said, can produce false-positive results that lead to unnecessary dietary restriction.

“Routine dietary screening during well-child visits is essential,” Stukus said. “If clinicians observe poor growth, weight loss, signs of nutritional deficiency, or other indicators of chronic illness, further evaluation and referral to an allergy specialist or dietitian are warranted.”