Nutrition considerations in pediatric food allergy

Children with food allergies often require dietary modifications during critical periods of growth and development, raising concerns about nutritional adequacy, growth, and long-term health outcomes. Balancing strict allergen avoidance with dietary diversity can be particularly challenging for infants and young children, as well as for patients with multiple or complex food allergies. In this Q&A, David Stukus, MD, professor of clinical pediatrics and director of the Food Allergy Treatment Center at Nationwide Children’s Hospital in Columbus, Ohio, discusses common nutritional concerns in pediatric food allergy, practical counseling strategies for clinicians, and how evolving evidence and emerging therapies are reshaping dietary management.

Contemporary Pediatrics:

What are some of the most common nutritional deficiencies you see in children with food allergies, particularly those avoiding milk, eggs, wheat, or multiple allergens? How do you recommend clinicians screen for them in routine care?

David Stukus, MD:

Fortunately, most children are allergic to only 1 or 2 foods. In these cases, it is usually possible to maintain a nutritionally adequate diet by replacing the nutrients typically obtained from the avoided foods. Nutritional risk depends on the child’s age, the specific foods avoided, and the total number of foods excluded from the diet.

When children avoid milk or dairy products, clinicians often consider calcium and vitamin D intake, as well as other micronutrients. Similar considerations apply for children avoiding eggs, seafood, or tree nuts. However, most children with food allergies do not require routine screening for nutritional deficiencies, as balanced diets can usually be achieved through alternative food sources.

Fruits and vegetables provide many essential micronutrients, and a well-rounded diet should be encouraged. Red flags that warrant further evaluation include poor weight gain, weight loss, or failure to thrive. Additional concerning signs may include hair loss, rashes, or abnormalities of the gums or teeth. In such cases, a more detailed nutritional assessment is appropriate. Overall, true nutritional deficiencies remain uncommon in most children with food allergies.

Contemporary Pediatrics:

How do you counsel families to balance strict allergen avoidance with adequate dietary diversity and growth during infancy and early childhood, when nutrition is especially critical?

Stukus:

This discussion frequently arises, particularly for infants with milk allergy who are approaching 12 months of age, when many children transition to whole milk. 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.

Adequate fat intake is a primary concern during this developmental stage because of its importance for brain development. Protein intake is also essential. For infants who are allergic only to milk, we often encourage other nutrient-dense foods, such as peanut butter or tree nut butters, when developmentally appropriate. This approach aligns with current evidence-based recommendations supporting early introduction of allergenic foods.

In most cases, when 1 or 2 foods are avoided, the associated nutrients can be replaced through other dietary sources. Effective counseling at the time of diagnosis and continued follow-up over time are critical, with recommendations tailored to the child’s age and specific allergies.

Contemporary Pediatrics:

How has the evidence supporting early allergen introduction changed your approach to nutritional counseling in high-risk infants, and where do you see confusion among clinicians or parents?

Stukus:

From a nutritional standpoint, the evidence supporting early allergen introduction has been highly reassuring. Current recommendations encourage introducing allergenic foods early, particularly in infants at higher risk, such as those with moderate to severe persistent eczema.

Ideally, allergenic foods are introduced between 4 and 6 months of age, once infants demonstrate developmental readiness for complementary foods, including the ability to swallow purées such as cereals, fruits, or vegetables. Readiness may vary among infants. After introduction, maintaining these foods regularly in the diet appears to be the most effective strategy for reducing the risk of food allergy development.

When implemented appropriately, early allergen introduction supports dietary diversity and does not increase the risk of nutritional deficiencies.

Contemporary Pediatrics:

For children with multiple food allergies or complex conditions such as food protein–induced enterocolitis syndrome (FPIES), what practical strategies help ensure adequate calorie, protein, and micronutrient intake?

Stukus:

For children with multiple food allergies, collaboration with a registered dietitian is often essential. Dietitians can assess family dietary patterns, cultural preferences, and nutritional needs, and identify alternative sources of nutrients that may be lacking because of food avoidance.

In addition, treatment options are now available for some patients that allow for the consumption of small amounts of allergenic foods or tolerance of specific forms of those foods. Food allergy management has evolved substantially in recent years. For example, approximately 75% of children with milk or egg allergy can tolerate these foods when they are baked, which can facilitate reintroduction of key nutrients.

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

In FPIES, trigger foods often differ from those seen in [immunoglobulin] E–mediated food allergy and may include grains, vegetables, or fruits. The same principles apply: Identify the specific trigger foods and ensure that nutritional needs are met through safe alternatives.

Contemporary Pediatrics:

As oral immunotherapy and other emerging allergy treatments become more common, how do nutrition goals and dietary restrictions shift during and after treatment?

Stukus:

Emerging treatments generally make nutritional management easier. During oral immunotherapy, patients consume very small amounts of their allergen under the supervision of a board-certified allergist. Doses are gradually increased until a maintenance dose is achieved and incorporated into the daily diet.

By allowing patients to safely consume foods that were previously avoided, these therapies reintroduce important nutrients and significantly reduce concerns about nutritional deficiencies.

Contemporary Pediatrics:

What nutrition-related red flags—such as growth faltering or overly restrictive diets—should prompt pediatricians to reconsider an allergy diagnosis or refer to a specialist?

Stukus:

An expanding list of foods removed from a child’s diet should prompt reconsideration of the diagnosis. Broad food allergy panel testing is associated with a high rate of false-positive results and can lead to unnecessary dietary restriction.

Similarly, when dietary avoidance is based on nonspecific symptoms, alternative explanations should be considered. Picky eating is common during toddlerhood and does not necessarily indicate food allergy.

Routine dietary screening during well-child visits is essential. 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.