More Nutrition, Less Stress
Food allergies complicate what is already often a challenging part of the day for any parent – mealtimes. It may be that food allergy parents are so tired of saying no, anxious about a reaction, or overwhelmed by the idea of meal planning for the allergens that they fall into the habit of offering only a few safe foods. Foods that we know our children won’t turn down, that we know won’t cause a food reaction, and that we know we can make quickly.
Let’s first say that there’s nothing wrong with this. The information to come is intended as a resource to help you, not another article/post/critique to make you feel like you’re not doing enough or not doing well enough. You are enough, and you’re exactly what your child needs. Hopefully these tools and suggestions alleviate some of the stress that comes with meals, help save you time or money (or energy!), and give you the confidence and skills to make sure your child(ren) get what they need to grow, learn, and thrive.
Protecting Sanity
Having some foods that you know won’t be a fight can protect mental health and ensure your kids eat *something*. However, a couple problems can come with this. It might mean that you’re making 2 (or 3 or 4) different meals for different members of the family. It can also result in longer-term inadequate nutrient intake. These problems are not exclusive to food allergy parents. Especially in preschool children, inadequate micronutrient intake (vitamins and minerals) is common. Kids might be picky, parents could be tired, groceries are expensive, time is limited, there are a dozen factors that influence what ends up on the table at any meal.
Food allergy kids, on top of the universal challenges, are forced into an elimination diet. That may be avoidance of a single food such as egg or peanut, or it could be an entire food group such as dairy or shellfish. Either way, options become limited on what can be safely served. A lot of parents also struggle with whether the whole family will follow the allergen-safe diet or if they will make modifications for each child.
In our home, we choose to all follow (for the most part) the diet of our most restrictive kiddo, so no dairy and no egg (both kids are allergic to egg anyway). There are certainly exceptions; for example, my husband or preschooler may add cheese to their tacos or have milk with a meal. One child may have dairy-free yogurt and the other regular milk-containing yogurt. Some of this is preference and some is simply cost-savings. Food allergy families spend significantly more on groceries, so serving everyone alternatives can drive up costs.
On average, families navigating the food allergy world spend $4,000 more on groceries each year. That’s an extra $333 per month.
(We can do a whole conversation on this in the future!)
Nutritional Inadequacy
When following an elimination diet, no matter how old you are, there’s always the risk of not getting enough nutrition. When we think about what “nutrition” means, there are a few considerations (more than a few, but we’ll start basic):
Micronutrients – vitamins and minerals such as iron, zinc, selenium, calcium, magnesium, Vitamin D, B Vitamins, and so many more
Macronutrients – Proteins, Fats, and Carbohydrates - this is where our calories (energy) come from
Phytonutrients – these are colorful, anti-inflammatory components of food that are important for long-term health and disease prevention; beta-carotene, lycopene, and anthocyanin are a few examples.
Simple additions like colorful carrots can increase phytonutrients at meals and using a few different vegetables can improve micronutrient content.
Micronutrients (again, vitamins and minerals) are the most common deficiencies with elimination diets, though children with food allergy are also at greater risk of not getting enough protein or energy overall (energy = calories). Some of this could be coming from fear of certain foods on the part of the child or the parent. It can also be lack of knowledge in how to find alternatives for things like eggs, milk, peanuts, and or anything else. Sometimes it's lack of resources, limited access to groceries, minimal skill in the kitchen, or any other number of challenges.
Unless children are enrolled in a study or showing signs of actual deficiency, these inadequacies are often not caught. We tend to confuse being adequately fed (getting enough calorically to maintain growth) and being adequately nourished (getting enough nutrients to function optimally). Height and weight graphs are useful in catching severe problems, but just like Body Mass Index (BMI) in adults, it doesn’t tell us anything about diet quality, physical activity, or any other health marker. Even so, just considering weight for height, some research suggests that a greater percentage of food-allergic children are at risk of poor weight for height ratios compared to their non-allergic counterparts. A lot of this appears to be associated with the elimination diet itself. When those children (or rather, their parents) work with a knowledgeable Registered Dietitian, we tend to see both nutrient biomarkers (blood work) and growth improve.
The good news is, research suggests that by adolescence and adulthood, intake appears comparable between those with and without food allergy. The bad news is that they are comparable because both tend to be inadequate in micronutrients 😬.
Overcoming Mealtime Challenges
There are several strategies we can adopt to try to counter this risk of nutritional inadequacy. It doesn’t need to be complicated, and similar strategies can be implemented for families with and without food allergy. Some of these may work in your home, and others may not. The most important thing to remember as you explore these is that every single home is different. Every parent is different. Every child is different. Every single situation is unique.
Offer a Comfortable Food
Try to always put something on the plate that you know your child enjoys and that you know they’ll eat (…or expect that they’ll eat. Let’s be honest, as soon as you think you’ve figured out their preferences, they’ll change their mind). Maybe it’s a cheese stick, rice, a hot dog, chicken strips, oranges, applesauce, toast, anything at all that they like. This does a couple of things. First, it ensures there’s something familiar, so they don’t just skip the meal all together. Dealing with a hungry kid all evening (or any other time of day) doesn’t help anything. Second, it allows them to feel some small amount of control in their food. I often offer a few different options for the comfortable food, so my child has something on their plate that they chose. The rest of the plate is filled with whatever was made for the meal.
Also Offer Other Nutrient-Dense Foods
Even if you know your child probably won’t eat what you made for the meal, put it on their plate. Aim for meals that contain colorful vegetables, a good source of protein (meat, cheese, beans, etc.), and ideally a healthy fat (nuts or seeds, avocado, olives, etc.). It can take multiple introductions of a food before a child tries it or accepts it - some sources suggest up to 20 times or more. It can feel exhausting to try foods this many times or to throw away uneaten food, but the more it shows up in front of them, the more familiar that food feels and the more likely they are to try it.
Avoid Fighting
Don’t force them to eat everything on their plate or to even try certain things if they’re resistant. When mealtime is a constant fight, it can create meal anxiety for both kids and parents. It can also create long-term aversions that last into adulthood. I can’t tell you how many adult patients I’ve worked with who won’t eat certain vegetables because they were forced to eat them as children. When my child says, “I don’t like that” or “I won’t eat that”, I generally respond with something like “I’d like you to try it, but if you don’t want to today, just leave it on your plate” or “That’s made of *** and *** which are both things you like, so I think you’d enjoy it”. It’s not a big deal, it’s not a fight, it’s not shameful. Trying the food is encouraged but not forced.
Try to avoid “rewarding” with candy or dessert
Candy or dessert as a reward for eating a meal is another habit or behavior that can be carried into adulthood. It becomes something special and desired rather than just food (or food product). Consider if you’ve heard yourself say “I worked out today, so I’m going to have this donut” or “I’ve had a long day, I’ve earned some ice cream”. It’s ok to have a cookie, a piece of candy, or whatever sweet treat you enjoy, but try to avoid using it as a prize at the end of a meal. Even better, choose sweets that have nutritional benefit and incorporate them into your plan! Chia pudding, fruit, smoothies, or anything else based in whole foods can be a tasty way to end the meal while also adding in more vitamins, minerals, protein, and calories.
Encourage children to listen to their body’s cues
It’s common to say, “just take a few more bites” or “you need to clean your plate”, but this can teach children to ignore their body’s cues for hunger and fullness. Even if children indicate they are full without eating much, you can still have them stay at the table with the family, so skipping eating isn’t just a way to get back to playing, video games, tv, or anything else. Another strategy if you think they haven’t eaten enough nourishing food is to let them know that if they’re hungry again within an hour (or whatever timeframe you choose) that the rest of their dinner plate will be waiting for them in the fridge.
Try simple and creative ways to increase nutrition
Adding nutrients doesn’t have to mean a complete revamp of your family’s plan. It can be small adjustments.
Blend extra veggies into a sauce
Making smoothies or smoothie popsicles. In some situations, adding a protein powder can help if you or your children are picky about meat. Work with your care team to determine which protein powder, if any, is appropriate for your family. Keep in mind that, in most scenarios, powders or other supplements should not be the primary protein intake.
Make the meal interactive. Add a dip like hummus, guacamole, Greek yogurt veggie dip, or marinara sauce if your child enjoys condiments. These can add additional nutrients and create a more interactive experience while eating. “Playing” with food isn’t a bad thing if the food is also being consumed.
Never underestimate the power of a sticker or creative name. We’ve had an increase in banana intake since the superhero stickers showed up! Capitalize on your child’s interests and tie it into your meals. I’ve been asked several times “does Iron Man eat this?”. Yes, kiddo. Yes he does ;)
Don’t Stress
Everyone’s situation is different. It doesn’t come down to an individual meal or a single day, it’s the overall big picture of diet that matters. Not all strategies will work in all households, and sometimes this isn’t even an area that parents have the energy to deal with. Again, that’s ok. I talk a lot about emotional capacity – what do you have the emotional energy to work on at any given point. Sometimes personalized strategies are more beneficial, especially when working within the confines of elimination diets.
A few years ago, I worked with a family who had a child with extreme food aversions. He would only eat 1-2 foods (a specific brand of pretzel or only McDonald’s chicken nuggets) for weeks at a time. Our strategy in that situation was to not even approach food itself first. He was about 10 years old and loved watching YouTube videos. Our first step was finding interesting videos on how the body works, including one on the digestive system and nutrients. Then we went to growing a food, but not being pressured to eat it. Then to helping with the grocery shopping. Then to helping with meal planning and cooking. Then to finding one new food to try that feels safe. Often change doesn’t happen overnight, and the process needs to be personalized and paced.
Many families already have some level of food trauma or anxiety around meals. It’s important to make deliberate changes that slowly challenge comfort zones in order to create lasting healthy behaviors while also protecting everyone’s relationship with food, with mealtimes, and with each other. Start making change if you’re ready, or put this in your back pocket for the future!
Check out some of these resources to read more about nourishing meals.
Bailey ADL, Fulgoni Iii VL, Shah N, et al. Nutrient Intake Adequacy from Food and Beverage Intake of US Children Aged 1-6 Years from NHANES 2001-2016. Nutrients. 2021;13(3):827. Published 2021 Mar 3. doi:10.3390/nu13030827
Gupta R, Holdford D, Bilaver L, Dyer A, Holl JL, Meltzer D. The Economic Impact of Childhood Food Allergy in the United States. JAMA Pediatr. 2013;167(11):1026–1031. doi:10.1001/jamapediatrics.2013.2376
Kvammen JA, Thomassen RA, Eskerud MB, Rugtveit J, Henriksen C. Micronutrient Status and Nutritional Intake in 0- to 2-Year-old Children Consuming a Cows' Milk Exclusion Diet. J Pediatr Gastroenterol Nutr. 2018;66(5):831-837. doi:10.1097/MPG.0000000000001942
Maslin K, Venter C, MacKenzie H, Vlieg-Boerstra B, Dean T, Sommer I. Comparison of nutrient intake in adolescents and adults with and without food allergies. J Hum Nutr Diet. 2018;31(2):209-217. doi:10.1111/jhn.12495
Mehta H, Groetch M, Wang J. Growth and nutritional concerns in children with food allergy. Curr Opin Allergy Clin Immunol. 2013;13(3):275-279. doi:10.1097/ACI.0b013e328360949d
Sova C, Feuling MB, Baumler M, et al. Systematic review of nutrient intake and growth in children with multiple IgE-mediated food allergies. Nutr Clin Pract. 2013;28(6):669-675. doi:10.1177/0884533613505870
