Medical nutrition therapy can overcome the roadblocks of multiple food allergies. Registered dietitians often have an important role with patients with food allergies. The degree of nutrition risk increases each time you add an additional protein that must be avoided. The longer the list of foods to be avoided the higher the risk for nutritional deficiencies.

Compound this with other medical conditions, such as children with feeding disorders, gastrointestinal disorders with malabsorption, patients needing chemotherapy or post bariatric surgery, pediatric cardiac patients with elevated energy needs, acute and chronic kidney disorders and any patients undergoing intensive therapy programs requiring increased nutritional intake.

 What is a food allergy? An abnormal response to a food may include “allergy”, “hypersensitivity,” or “intolerance.” These reactions may occur within a spectrum of reactions ranging from immunoglobulin E (IgE) to non-IgE mechanisms.

Generally speaking, allergy or hypersensitivity refers to IgE-mediated events and intolerance refers to non-IgE events. In the case of IgE-mediated events, avoidance of the offending protein is the only proven treatment. In the case of “intolerance”, there may be a “tolerance” level that is allowed for a specific food component of the food, for example lactose. It may cause an adverse reaction but does not involve the IgE-mediated reaction.

The incidence of food allergies is increasing in the general population. Adverse reactions to foods have been reported in up to 15 percent to 20 percent of the populations with the highest prevalence in infancy and childhood. The Centers for Disease Control (CDC) reported in 2007 that an estimated 3 million children under age 18 years (3.9 percent) had a reported food allergy. Higher rates have been seen in children under age 5, with an estimated occurrence of 1 in every 17 children under age 5.

Children with food allergies are more likely to have other allergic conditions including asthma and eczema. The findings in the report, titled Food Allergy Among U.S. Children: Trends and Prevalence and Hospitalizations, were statistics from the National Health Interview Survey and National Hospital Discharge Survey, both conducted by Center for Health Statistics.


In the United States the most common food allergens are milk, soy, egg, wheat, peanut, tree nut, fish and seafood. Other foods such as legumes, sesame, poppy seed, sunflower seed, pine nuts and spices are of increasing importance as food allergens. As you consider strict avoidance of these food proteins, quickly the concern of missing key macro- and micro-nutrients arises. Therefore the goals of the registered dietitian are critical to the long-term health and wellness of patients.

First, they must provide patients and families with guidelines, education, and suggestions for successfully avoiding the allergenic foods while monitoring the intake to ensure a nutritionally adequate diet that will promote weight gain and growth in the pediatric patient as well as adequate intake to avoid deficiencies in the adult patient. All other medical conditions must be considered when setting the macro- and micro-nutrient intake goals.

It is critical to use a multi-disciplinary approach to the food allergic patients. This means the dietitian is working in conjunction with the allergist to determine accurate diagnosis of causative foods, assessment of nutritional status at time of diagnosis, initiation of a diet that eliminates the offending foods, development of a proper emergency treatment with an “action plan” in place, and treatment of associated atopic disorders.

Over-restricting of foods will only compound the difficulties in meeting the nutritional goals. Allergy tests should always correlate with clinical symptoms and caution should be used not to over-restrict.

To determine the degree of nutritional risk, the practitioner should ask the following questions:

• How many foods need to be avoided?

Risk increases with more foods being avoided.

• What is the impact on macro- and micro-nutrients?**

Risk increases with more of the macro and micro nutrients being impacted – calories, protein, fat, micronutrients.

• Are there any other concerns about food intake?

Risk increases with other medical and psychological diagnoses affecting intake, for example: swallowing/chewing difficulties, psychological diagnoses affecting intake, malabsorption, other compromising medical conditions.

If a patient is avoiding all peanuts and treenuts and has swallowing difficulties the nutrition risk is increased by the swallowing difficulties but not the food avoidance. If a second patient is admitted with swallowing difficulties but is allergic to milk and soy, this patient is at a much higher nutritional risk due to the risk of inadequate fat, protein, calcium, iron, vitamin D and other micronutrients.

It is critical for the practitioner to assess the patient’s current nutritional status, and nutrient intake, then, with that information, determine the next steps for medical nutrition therapy. When obtaining this information, all foods, supplemental formulas, and nutritional supplements such as multivitamins, calcium intake, etc, must be considered. The next step is to have a clear understanding of what the avoided foods, milk and soy, would have provided to this patient’s diet and identify what foods and/or supplements are needed to replace those key nutrients.


A common example is a 13 month old male with allergies to milk and soy. Toddlers typically transition to whole cow’s milk at this age. Since this is not an option, one may consider transition to a rice-based beverage. However, due to the lack of fat and protein in rice-based beverages, the child will be unable to meet his fat and protein needs. If this persists, it will result in severe malnutrition, even if the child is able to meet his calorie goals.

In this case, the macronutrient distribution becomes imbalanced, often resulting in carbohydrate between 80 percent to 90 percent, fat between 5 percent to 10 percent, and protein between 5 percent to 10 percent. This example demonstrates how the dietitian must consider each food allergic patient independently and put all the pieces of the puzzle (foods avoided, medical conditions, nutritional status, cultural practices, and any other factors that affect what the patient is able to consume) in place.

Patients with multiple food allergies are at high risk for inadequate intake of essential amino acids and essential fatty acids. Often specialized formulas (protein hydrolyste-based and/or amino acid-based) can be used to supplement the diet to meet these nutritional needs. If a patient presents after being on a prolonged significantly restricted diet without formula and/or multivitamin-multimineral use and malnutrition, pertinent laboratory tests of nutrient adequacy should be obtained. The clinical scenario should guide which laboratory tests are needed.

For example, a vegetarian child who is also allergic to peanuts and treenuts, who has been sustained on rice milk should be tested for anemia, zinc deficiency, essential fatty acid deficiency, and vitamin D deficiency. If a food allergy patient is managed by a dietitian with the use of specialty formulas and/or multivitamin-multimineral supplementation, often laboratory testing is not needed.

Nutrition education is the cornerstone of nutrition intervention for the food allergic patient. Anyone that is following a restricted diet must be given very clear guidelines regarding how to avoid the offending food, what substitute foods are needed to ensure adequate nutrient intake, what specialized formulas and/or multivitamin-multimineral supplementation are needed, and an understanding of their nutritional goals in order to avoid nutritional consequences and/or improve their current nutritional status.

They must also be provided with resources of where to purchase specialty foods, sources for recipes to prepare allergen-free foods, and where to obtain any supplements that have been recommended. It is also critical to provide them with resources for support groups and information regarding living with food allergies. Without education, safety, nutrition, and quality of life are all compromised.

Identification of a nutritionally complete formula is dependent upon the known food allergens. Most standard formulas are free of wheat, egg, peanut, treenut, fish and shellfish. Careful review of ingredients is critical every time a formula is recommended to a food-allergic patient.

Milk substitutes, as alluded to earlier, must be cautiously reviewed for their nutrient content before being recommended. Products continue to flood the markets so, as a practitioner, one must carefully evaluate the nutritional quality of the milk. Many provide adequate calcium, vitamin D, and B vitamins; however, some are inadequate for protein and fat, and/or missing essential amino acids.


The diagnosis of food allergy impacts the patient and family in many different ways, including: grocery shopping, cooking, socializing, travel/vacations, dining away from home, and family relationships. It is important to discuss and address these topics to assist in helping patients and families learn to live with food allergies.

The Food Allergy and Anaphylaxis Network is a non-profit organization whose mission is to raise public awareness, to provide advocacy and education, and to advance research on behalf of all those affected by food allergies and anaphylaxis. This is a great place for additional information and resources for anyone diagnosed with food allergies.

Food allergies may impact goals surrounding nutrition support in two ways: 1) when a food allergic patient requires nutrition support, and 2) when food allergies become apparent only after the initiation of nutrition support. In the first scenario, the practitioner must provide recommendations that appropriately avoid known food allergens. In the second scenario, changes to nutrition support goals will be provided as allergies are identified. Consultation with an allergist/immunologist is recommended to assist in clarification of newly identified food allergies.

Minimal data is available on parenteral nutrition support and the food-allergic patient. Two foods, egg and soy, could be cause for concern since both can be found in intravenous lipid solutions. In patients with documented egg allergy, three options should be considered: consultation with an allergist who may or may not do a skin prick test, provide lipid-free PN, or use of Liposyn II.

The first two options should be considered for those with a documented soy allergy. There are a variety of allergies to parenteral nutrition that have been described through case reports. In the event of a reaction, the parenteral nutrition needs to be stopped and appropriate drug treatment for the allergic reaction started. If the patient is going to continue to require parenteral nutrition, a multidisciplinary approach utilizing an allergist, pharmacist, nutrition-support physician and/or dietitian should be pursued.

Food allergies and medical nutrition therapy go hand in hand. With proper guidance and education, patients with food allergies will obtain optimum nutrition and avoid nutritional deficiencies. Patients with food allergies without guidance from a registered dietitian are at increased risk for nutrition related problems and deficiencies. Remember, there is a link between nutrition and food allergies, so be sure to provide your patients with the necessary expertise and resources to successfully live with food allergies.

— Mary Beth Feuling, MS, RD, CNSD, is a clinical dietitian specialist, specializing in food allergies and feeding disorders at the Milwaukee-based Children’s Hospital of Wisconsin. Questions and comments can be directed to editorial@therapytimes.com.