Protudjer and Mikkelsen BMC Pediatrics(2020) 20:341
https://doi.org/10.1186/s12887-020-02236-0

REVIEW

Open Access

Veganism and paediatric food allergy: two
increasingly prevalent dietary issues thatare challenging when co-occurring
Jennifer L. P. Protudjer1,2,3,4,5*

and Andrea Mikkelsen6,7,8

Abstract
Vegan diets – defined as the exclusion of all foods of animal origin from the diet- are becoming popular. In recent
years, the prevalence of food allergy has also increased, and disproportionately affects children. When vegan diets andfood allergy co-occur, this combination can be challenging and pose risks of nutritional deficiencies, particularly duringchildhood. In this paper, we aim to summarise the major concerns regarding vegan diets and food allergy, review theliterature on this topic, and provide some suggestions for healthcare providers, particularly dietitians and nutritionists,
who work with food allergic, vegan patients and their family. When working with this patient population, a regular andcomplete medical nutrition history, including screening for any possible nutritional deficiencies, is warranted. Likewise,
the routine tracking of serum markers (especially iodine, iron, zinc, calcium, Vitamins B12, D, B2, and A, selected n-3
fatty acids and protein, which are more abundant in animal vs. plant foods) and symptoms of co-morbid diseases,
including asthma, is important, as comorbid diseases may increase energy and nutrient requirements. For infants andchildren, anthropometry ought to be tracked longitudinally at regular intervals to identify any deviations from thechild’s previous growth pattern, and to accommodate any increased requirements for growth and development.
Correct diagnoses, education and allergy management must be disseminated to the family in a clear and appropriatemanner. Children with allergy may have increased nutritional needs due to comorbidity. This is complicated bycoincident food allergy and vegan diet as both impose diet restrictions (limiting sources of important nutrients, needfor dietary variety and/or increased consumption due to reduced bioavaliability).
Keywords: Food allergy, Nutrition, Pediatrics, Vegan

Introduction
Vegan diets – defined as a diet that excludes all animal
products, including meat, poultry, fish, molluscs and crustaceans, cow’s milk, eggs, gelatin and honey [1, 2], aside
from breastmilk are increasingly popular. In the UnitedStates, 3.4% of the total population state that they follow avegan diet, with an estimate of 1% of children 8–18 yearsof age. Data from Europe support slightly lower rates, at* Correspondence: Jennifer.Protudjer@umanitoba.ca
1
Department of Pediatrics and Child Health, University of Manitoba,
Winnipeg, Canada
2
George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Canada
Full list of author information is available at the end of the article

approximately 1% of the population, with estimates unknown for mothers and children [3, 4].
In recent years, the prevalence of food allergy has increased in many parts of the world [5], as have hospitalisations due to food allergic reactions [6]. Prevalence
estimates range widely, with an accepted estimate ofprobable Immunoglobulin-E mediated food allergy inhigh income nations between approximately 2 and 7%[7, 8]. Over the past three to four decades, food allergy
prevalence has increased sharply, with some recent data
pointing toward a plateau. In an attempt to minimize
the possibility of an adverse, and potentially severe or© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
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Protudjer and Mikkelsen BMC Pediatrics(2020) 20:341

even fatal reaction, food allergy necessitates exclusion of
the allergenic food [5].
Guidelines for vegan diets amongst paediatric patients
issued by national food administrations and/or nutritionsocieties in several countries, as well as international expert groups (including the European Society of Paediatric Gastroenterology, Hepatology and Nutrition; [ESPG
HAN] [9]; Dietitians of Canada [10], and the American
Academy of Nutrition and Dietetics [10]) now endorse
well-planned and carefully monitored vegan diets. Likewise, careful monitoring of food allergy is necessary toensure the nutritional needs of affected children are met[11]. At the intersection of veganism and food allergy,
there are even greater concerns related to adequate micro- and macronutrient intakes that warrant careful consideration and monitoring. In this paper, we aimed tosummarise the major concerns regarding vegan dietsand food allergy, review the literature on this topic, andprovide some suggestions for healthcare providers, particularly dietitians and nutritionists, who work with afood allergic, vegan patient.
Vegan diets: health benefits and risks

Previously, we have referred to a definition of vegan dietby what is eliminated. However, a vegan diet can also be
described as rich in a wide variety of foods: whole grains,
legumes, vegetables, fruits, nuts, seeds, vegetable fats,
herbs and spices [3]. The high amount of macro- andmicronutrients, as well as a wide variety of carbohydrate
types seems to enhance the development of a diverse intestinal flora [12, 13], of increasing interest in disease
prevention [14]. Benefits of, and reasons for adopting avegan diet range widely, and include animal welfare [15],health benefits [15–17], personal well-being [15], improvement of disease symptoms [18], increased meat
prices [19] and environmental concerns [20, 21].
Recently, vegan diets were found to be an effectivemeans of prevention and treatment of cardiometabolic
disease [22, 23], with a decreased risk up to 40% of associated diseases. Moreover, the risk of metabolic syndrome and type 2 diabetes may be decreased by 50%,
and, if well planned, can assist in reversing atherosclerosis, and reducing blood lipids and blood pressure.
These health benefits may result, in part, from the observation that, compared to non-vegans, those following
a vegan diet have a lower body mass index (BMI) andwaist circumference. But there are some exceptions. In a
recent meta-analysis, compared to a typical Taiwanesediet, vegan diets are not associated with improved cardiometabolic outcomes or lower BMI [23, 24].
However, potential vegan diet pitfalls exist, particularly
amongst children. Young children may benefit from avariety of plant-based proteins during small and frequent
meals to allow for consumption of a large volume ofPage 2 of 11

foods [3]. Whereas many of guidelines support vegan diets for infants and children [2, 12, 13, 25, 26], there aresome exceptions to these guidelines [27].

Vegan diets and macronutrient deficiencies

Much of the literature on vegan diets and nutritional outcomes is based on adult populations [14, 22, 28–33]. Less
is known about vegan diets amongst infants and children.
Thus, these age groups need to be carefully and routinely
monitored, if following a vegan diet [34]. Infants and children have higher energy and nutrient needs, which may
be difficult to achieve on a restricted diet. Recent data support that children to age 3 years following a vegan dietconsume adequate energy intake, but compared to omnivore children, significantly more carbohydrates (and fibre)
and significantly less protein [35].
Protein requirements in vegan diets are met mainly
through vegetables, tofu, beans, whole grains, nuts andseeds. In order to achieve sufficient amounts of essential
amino acids, daily varied consumption is recommended[36]. As the above-mentioned foods often contain considerable amounts of fibre and anti-nutritional factors, i.e.
substances that prevent optimal absorption of specific nutrients, protein intakes are recommended to be increasedby 10% during periods in life when protein needs arehigher. Two of these periods are infancy and childhood[3]. Protein needs can be met in a well-planned vegan diet,provided that the caloric need is met. For this reason,vegan protein-rich alternatives with less fibre, such as tofu
and seitan, may be preferable since these foods usually result in high satiety and might support appropriate protein
intake [37, 38]. First results from a Swedish trial of infants
randomized to a diet with decreased protein intake, compared to a traditional Nordic diet has, thus far, shown nogroup differences in growth or iron status at 9 months ofage [39]. Forthcoming results will glean further insight
into the role of decreased protein intake, compared to a
traditional Nordic diet, on anthropometric outcomes,
metabolic and inflammatory biomarkers, as well as the gut
microbiome [40].
These data notwithstanding, there are case reports ofalarming nutritional deficiencies as a consequence in what
has, sometimes been described as vegan diets. However,critical review of these reports can lead to the conclusionthat these children often have very restricted vegan dietswith limited caloric intake [41], or very limited foodchoices, for example extensive use of unfortified plantbased beverages [42]. In extreme situations, these restrictions may contribute to protein-calorie malnutrition [42],or kwashiorkor, in which the child consumes adequate
calories but inadequate protein [43] as well as inadequate
micronutrients [42]. Notably, these diets cannot be considered well-planned vegan diets, and any conclusions

Protudjer and Mikkelsen BMC Pediatrics(2020) 20:341

regarding vegan diets for children based solely on these reports are misleading [3].
Vegan diets and micronutrient deficiencies

A poorly planned vegan diet can increase the risk of
micronutrient deficiencies, particularly iodine, iron, zinc,calcium, Vitamin B12, Vitamin D, Vitamin B2, VitaminA, n-3 fatty acids (docosahexanoic acid; DHA).
IodineIodine deficiency, which is poorly studied in high income nations, has been described in vegan infants whoare breastfed [44] or recently weaned [45]. In this instance, thyroid stimulating hormone levels should bemonitored and, if necessary, treated appropriately. In avegan diet, iodine requirements can be met with iodized
salt or algal source supplements [3]. That said, it warrants mention that the amount of iodine in salt varies bycountry or region [46]. It also warrants mention thatcases of iodine deficiency amongst milk allergic infants
who receive inappropriate supplementation have been
described. In a Norwegian study of 57 infants aged < 2years, 30% had urine iodine concentrations lower thanthe World Health Organization cut-off values [47].
Amongst infants predominantly breastfed, this number
doubled, to 58%. Notably, iodine deficiency was independent of poor growth status [47].
Infant foods should not have added salt [12]. As such,
iodine requirements are better met through breastmilk.
A recent study found that breastmilk iodine concentrations were not associated with pre-pregnancy weight, although maternal diet was not considered in the analyses[48]. In contrast, the Centers for Disease Control andPrevention advises that the recommended daily allowance is 290 μg iodine for breastfeeding women, and thata supplement is indicated for women who do not consume dairy products [49]. Alternatively, legally sold commercial infant formulas fortified with iodine are widely
available, and are carefully regulated [50].
Iron

Typical vegan diets often include many iron-rich foods,
including lentils, tofu (soy), chickpeas, nuts, seeds andgrains. However, unlike iron from animal sources,
termed heme iron, which is readily absorbed [51], nonheme iron from plants has poor bioavailability and lower
absorption, due to high phytate and polyphenol levels[52]. Non-heme, plant-based sources of iron must also
be consumed in larger portions than heme, animalbased sources of iron, to meet needs [53]. Vegans, aswell as vegetarians, require 1.8 times the amount of dietary iron, compared to meat eaters, as a result of poorer
bioavailability [54]. Vitamin C may enhance the absorption of non-heme iron [55]. However, many vegan

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sources of iron, particularly soy, nuts and sesame seeds,
are also common food allergens. For children who are
not allergic, iron-fortified foods, including packaged cereals, may be an additional source of iron. Through later
infancy, iron deficiency is the most prevalent micronutrient deficiency, thus highlighting the importance of adequate iron intake [56]. Amongst the very young, infant
formulas and cereals are main sources of dietary iron[57]. After age 12 months, iron-fortified formulas are
positively associated with serum ferritin levels, independent of socio-economic status and other dietary sourcesof iron [56].
But, even in the absence of allergies to common ironrich vegan foods, careful monitoring of these children
may be advised. In a study of infants with cow’s milk allergy, but otherwise well, iron deficiency anaemia wasidentified in 5% of children [58]. More strikingly, a retrospective study from Taiwan provides evidence that theprevalence of cow’s milk protein allergy amongst children with iron-deficiency anaemia (serum ferritin < 12
ng/mL) [59] was at least double the prevalence that has
been reported in the general Taiwanese population(13.7% vs. 3.4 to 7.7%) [59, 60]. Although the study ofchildren with iron-deficiency anaemia was small (N =51), it points toward an increased risk of iron-deficiency
anaemia amongst young children with cow’s milkallergy. Notably, although these children were quite ill,
as evidenced by failure to thrive, hypoalbuminemia anderosive and hemorrhagic colitis on colonoscopy, none
had eosinophila in the lamina propria and all recovered
within 7 months of cow’s milk elimination and iron supplementation [59].
Zinc

Zinc, like iron, has poor bioavailability, especially in avegan diet [52]. Vegan sources of zinc include soy andother legumes, nuts, seeds and whole grains as well as
fortified cereals. Due to the lower bioavailability of zincin plant foods, vegans (as well as vegetarians) may require 1.5 times more zinc than meat eaters [61]. Notably,
soaking, heating and fermenting zinc-rich plant foods
appears to reduce the inhibitory effect of phytate, which
contributes to greater absorption of zinc [62, 63].
Few studies have specifically examined zinc status invegan vs. omnivore children. Authors of a 2014 review
article reported no differences in serum zinc concentrations between young vegetarian, including those following a vegan diet, vs. omnivore children, although somedifferences may present in adolescence [52]. However,the same authors also note that zinc status amongst
vegan children should be monitored, and if necessary,
provided with zinc supplements [52]. Finally, as vegansources of zinc typically include prepackaged, fortified
breakfast cereals, legumes and soy, particular attention isProtudjer and Mikkelsen BMC Pediatrics(2020) 20:341

warranted when working with vegan children who must
avoid these foods due to allergy.
Calcium

Calcium is a vital mineral for bone mineral density development, but is predominantly obtained through dairy
products which are notably absent from the vegan diet.
In childhood, recommended intake of calcium is high inorder to achieve a positive balance to promote growth.
Notably, high calcium intake in western countries is correlated with higher risks of fractures [64]. Elsewhere,
many food cultures rely on vegetables, legumes and cereals as the main source of calcium. For example, a study
in China concluded that dairy products provided only
6.7% of dietary calcium [65]. This was also the case inJapan, with the addition of fish and shell-fish, and somewhat higher levels in urban areas where dairy consumption is increasing [66]. The increasing interest in otherfood cultures, alongside with increased global availabilityof novel foods may provide useful sources of calcium.
However, the allergenicity of uncommon foods may bepoorly known and inclusion of many novel foods needcareful assessment and consideration [67]. In a Dutch
study, adolescents who had followed a vegan-type diet inearly life had significantly lower bone mineral density inadolescence [68]. These differences were not explainedby current calcium intake, suggesting that early life is a
critical window for bone mineral density development.
This study was performed approximately 20 years ago.
Since that time, numerous calcium-fortified food products and plant-based milks are now available. However,caution is warranted to ensure that young vegans consume adequate levels of calcium to maximise bone mineral density. This need for caution is underscored in a
recent meta-analysis, in which, compared to omnivores,
vegetarians and vegans had lower bone mineral density,and vegans also had higher rates of fractures [69]. In
addition to the numerous calcium fortified alternatives
for dairy products available today, calcium is also foundin most green leafy vegetables, preferably those with lowlevels of oxalate as it inhibits absorption, sesame seeds,
almonds and dried figs [3, 70]. Finally, if calcium requirements are not met, supplementation may need tobe considered, eventually in combination with VitaminD, which promotes calcium absorption [71].
Vitamin B12

Vitamin B12 is perhaps the most common concern for
those following a vegan diet, as it is found almost exclusively in food of animal origin [72]. Infants born tomothers with inadequate Vitamin B12 status during pregnancy are at risk of developing various hematological,
neurological and developmental problems [73–75]. As
well, vegan mothers who breastfeed their infants should

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receive Vitamin B12 supplementation [76]. It has beensuggested that Vitamin B12 supplements or fortified foods
should be an ongoing part of the diet [77]. Whereas
supplemental Vitamin B12 may be an option for those following a plant-based diet, it warrants mention that approximately only 1% of oral Vitamin B12 supplements
cross the intestinal barrier [78], thereby necessitating substantial and sustained need for Vitamin B12 supplements.
Many plant-based beverages are fortified with Vitamin
B12, and which are palatable and readily incorporated into
the diet. Notably, most plant-based “milks” are notintended as a primary beverage until at least 2 years ofage, as they are often low in calories and/or fat, and may
not be (adequately) fortified to meet infants’ needs [79].
For children < 2 years of age with greater needs for growthand neural development, and disproportionately impacted
by food allergy, [5] breastfeeding should be promoted orappropriate formula used [9]. Children and adolescentsfollowing a vegan diet show significantly lower B12 intake
and serum vitamin B-12 concentration levels compared toomnivore peers [80, 81]. However, levels were not always
deemed as low according to guidelines [82].
Vitamin D

Despite lack of conclusive evidence, most trials and interventions indicate that vitamin D3 of animal origin is more
effective than vitamin D2 of plant source [83]. Humans
obtain much of their Vitamin D through sun exposure.
Dietary intake of Vitamin D is limited to animal products,
such as fatty fish. In western countries, as many as 40% ofchildren are Vitamin D deficient in the wintertime [84,85]. Although it could be suggested that this is due to limited sun exposure, these estimates are just as high insouthern European countries, such as Greece, where sun
exposure throughout the year is high [86].
Both vitamin D2 and D3 have been identified in a lichen species (Cladina arbuscula) suggesting a potential
vegan source candidate [87]. However, studies exploring
its efficacy are currently lacking.
Vitamin B2

Vitamin B2, or riboflavin, is necessary for the metabolism of amino acids and carbohydrates, and developmentof the nervous system. Major dietary sources include
milk, eggs and some meats, which do not form part ofthe vegan diet, as well as leafy greens, fortified grains,nuts and soy [88]. As riboflavin is abundant in many
plant products, vegan children often have adequate intakes of this vitamin [34].
Vitamin a

Vitamin A, commonly found in fortified foods and beverages, including milk, as foods of animal origin (e.g. cod
liver oil, eggs) and leafy greens rich in beta-carotene (e.g.

Protudjer and Mikkelsen BMC Pediatrics(2020) 20:341

kale, spinach). Whereas vegan diets may be rich in the latter, both male and female vegans nonetheless had significantly lower Vitamin A intakes than individuals following
a more traditional (i.e. unrestricted) diet. Vegan intakes
were also below nutritional recommendations [89].
N-3 fatty acids (DHA)

Omega-3 fatty acids demand special attention in the vegandiet, more so during pregnancy, lactation, infancy andchildhood. Inclusion of vegan, omega-3-containings foods,
such as walnuts, ground chia seeds and ground flaxseed, isadvisable [3]. At the same time, it warrants mention thatthese foods are also high in alpha linolenic acids. Although
the body can convert alpha linolenic acid into DHA andeicosapaentinoic acid, this process is not efficient [3].
Moreover, there have been concerns raised about the processing of flaxseed [90, 91]. At present, the safe amount ofground flaxseed is not well known and caution is advised[91, 92]. Algal-oil supplements have been found to be aseffective as fish-oil based alternatives [93, 94], even when
cognitive outcomes have been studied [95]. Alternatively,
supplementary sources of preformed DHA should be considered [3].
Special nutritional considerations in food allergic
individuals

An important reminder on the role of the allergy team isto help identify the specific foods to be eliminated fromthe diet and preventing further avoidance expanding towhole food groups which limits the diet unnecessarily.
For example, cooked vegetables and fruits, as well as
roasted nuts may sometimes be consumed by those withoral pollen related food syndrome (or oral allergy syndrome) due to birch-, mugwort- or other pollen allergies. Likewise, patients with soy allergy may tolerate
other beans and/or lentils within the wide pulse family.
Additionally, vegan patients with allergy to peanuts andtree nuts may consider other nuts and seeds as good alternatives. Professional advice is warranted to assist patients and prevent the unnecessary exclusion ofimportant sources of protein and nutrients in a vegandiet [96, 97].
Compared to non-food allergic children, allergic children consume significantly less calcium and protein, andare more likely to have diets that are deficient in essential
fatty acids [98]. These nutritional inadequacies are associated with other concomitant micronutrient deficiencies[99], have direct impacts on bone mineral density andphysical growth [99], and may impair learning [100]. Such
differences also appear to exist between children with different types of allergy, suggesting that the food to which achild is allergic, and thus must eliminate from his or her
diet, also needs to be considered. For example, children
with cow’s milk allergy had significantly lower calcium

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intakes than children with non-cow’s milk food allergy[101]. Importantly, any food allergy (not limited to only
cow’s milk allergy) in childhood may predict nonsignificant differences in calcium intake in adolescence[102]. Likewise, in observational studies, both zinc [71]and iodine deficiencies [103, 104] have been noted for
cow’s milk allergic children, even if the child was taking avitamin/mineral supplement [105].
The few previous studies on the associations between
anthropometry and food allergy have been crosssectional [106, 107] and thus report on anthropometricaldifferences between children with or without food allergies, rather than growth. Nonetheless, these studies provide evidence that both height and weight are negatively
impacted by the presence of food allergy. For example,
American children with food allergies were found to besignificantly shorter and lighter, but not different interms of body mass index (BMI; (weight (kg)/height(metres2))) [108], than non-food allergic peers. Notably,
many of these differences were attenuated upon consideration to type of health insurance, and also varied byage group [106]. Likewise, British researchers reported
that both underweight and short-for-age affected approximately 10% of food allergic children, compared toWorld Health Organization standards [107]. These differences became even more pronounced amongst children with multiple food allergies.
Whereas the above studies provide evidence that children with food allergy are more likely to be underweight,
in at least one study, British researchers found that children with food allergy were significantly more likely to be
overweight or obese than their non-allergic peers [107].
For children with food allergy and who follow a vegandiet, the risks of overweight and obesity are likely to be
low, provided that they follow a well-planned, nutrient
rich diet. However, this British study provides evidence
that overweight and obesity can nonetheless occur.
Even in the absence of nutrient deficiencies, height,
weight, weight-for-age, and weight-for-height may belower by as much as two standard deviations [107].
Lumbar spine bone mineral density is also significantly lower in children with cow’s milk allergy compared to children with non-cow’s milk food allergy[101]. Such differences are indicative of moderatemalnutrition, and are thus clinically relevant issues
that warrant immediate attention [107]. These previous studies were performed in high-income countries,
but which lack national school meal programs or, insome cases, widely subsidised prescriptions for allergic
children.
Finally, vegan diets have been associated with a higher
odds of atopic dermatitis [109]. Thus, food allergic individuals following a vegan diet ought to be cautioned
about this possibility. In contrast, patients with asthma

Protudjer and Mikkelsen BMC Pediatrics(2020) 20:341

who followed a vegan diet for 1 year had dramatically
improved clinical biomarkers [110].
Given the restrictions associated with a plant-based
diet, even greater attention is warranted when those following a vegan diet also have additional restrictions
resulting from food allergy. Recently, American authors
reported that people with asthma, another allergic disease but which does not mandate dietary restrictions,commonly turned to YouTube for information on vegan
diets [111]. However, such information was frequently
deemed to be of poor quality [111].
In light of the above-described concerns, it is unsurprising that numerous nutrition and dietetic societies advise that vegan diets should only be used underappropriate medical or dietetic supervision with expertise in food allergy. Moreover, parents should understandthe serious consequences of failing to follow advice regarding supplementation of the diet [9]. These guidelines
reflect a shift from a decade ago, when total avoidanceof a vegan diet in infants and young children was recommended [112]. Failure to follow dietary advice may compromise both nutrition and growth. These conditions
become even more important when the diet is further
limited by food allergy.
Soy, peanuts, tree nuts and wheat are three of the six
most usual foods IgE-mediated food allergies [113] andsoy the second most common eliciting food in non-IgE
mediated food allergies [114, 115] further restricting the
choices for vegans. Special attention has to be paid tothe amount, as well the quality of the protein in thevegan diet [3, 5, 38, 114, 116].
Of additional concern is the volume of food (i.e. portion size) needed to achieve recommended/appropriate
levels of energy and nutrients [3, 5, 38, 114, 116]. As
such, one cannot dismiss the possibility that children
with food allergy and who have allergic conditions faceparticular challenges meeting their nutrient and energy
demands through a vegan diet.
Protein is the macronutrient of concern in thisunique population. But, many plant-based, proteinrich foods are also common allergens. Soy-based formulas are a common alternative to cow’s milk formulas, for both vegan infants and those with cow’s milkallergy. However, soy-based formulas should not beprescribed to prevent the development of food allergy[117, 118]. Likewise, soy formula is not recommended
for infants aged < 6 months, due to concerns of lower
rates of absorption of minerals and trace elements
due to the phytate content in soy [119]. Nuts are also
a key source of protein and fat, but must be avoided
by those with a nut allergy. Likewise, almond milk, acommon plant-based alternative to cow’s milk, must
be avoided by those with almond allergy. Yet, almondmilk is richer in calcium and fat, yet low in calories

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compared to other plant-based milks [120]. For
vegans with a nut allergy, nut avoidance can be particularly difficult [121]. It is recommended that specific nuts to which an individual is not allergic should
be introduced. However, caution is warranted withpre-packed snacks with precautionary allergen labelling [122].
Some groups have greater energy and nutrient demand.
For infants, children and athletes who follow a vegan dietand also have food allergy, caution is warranted to ensure
optimal intakes. Achieving greater intake may be challenging due to the portion size needed to achieve recommended/appropriate levels of energy and nutrients [3].
The challenge is higher for infants and children who generally have higher needs due to growth [107, 123], as wellas in certain atopy, e.g. atopic dermatitis [124]. Recently,
biologically negligible, but statistically significant differences in resting energy expenditure, anthropometry, anddietary intake in an Italian study of 30 children with foodallergy matched to 31 healthy children were described[124]. In contrast, others have reported that sustained intestinal or skin inflammation due to allergies [125, 126]
and avoidance diets [127–129] may contribute to impaired
growth.
The above examples highlight the complexity ofmanaging cross-reactions for those with food allergy,
while limiting avoidance to only those foods thatelicit symptoms. People with cross-reactions due tobirch pollen allergy (i.e. those who test negative forthe storage proteins Ara h 1, 2, 3 and 9 and positive
for Ara h 8 for peanut and / or negative tests forCora 8, 9 and 14 storage proteins and positive for
Cor a 1 hazelnuts) are more likely to have non-lifethreatening reactions [130]. When possible, it would
be beneficial to test for reactivity to food components,
rather than only food-specific IgE [130]. In the absence of the availability of such testing, SPT may beof some benefit only if patients complain of allergic
type symptoms to both food types. Otherwise, patients may be encouraged to consume soy, lentils andchickpeas carefully (at first exposure) or ad libidum(if testing is negative, and/or if they are asymptomaticwhen consuming these foods). As these food types
represent a major calorie- and protein source forthose following a vegan diet, the elimination of thesefood types is strongly cautioned unless the peanut allergic patient has a confirmed allergy to soy, lentils
and/or chickpeas.
In cases where a vegan patient is allergic to soy, thedietitian is encouraged to review common sources of soy
in the diet, both in obvious forms, such as tofu and soybased beverages, as well as in processed foods, which
commonly contain soy lecithin. These patients should beconsideredparticularly
vulnerable
for
proteinProtudjer and Mikkelsen BMC Pediatrics(2020) 20:341

deficiencies, given than soy is a common, widely available and generally palatable source of protein in thevegan diet. True soy allergies, as confirmed by OFC, areuncommon [131]. Clinical experience suggests thatmany patients with soy allergy may tolerate soy lecithin,likely due to low antigenicity of the proteins in soy lecithin and soy oil [132]. The need of avoidance of soy lecithin seems to be reduced to a couple of case reports onchildren with severe soy allergy reacting to soy lecithinin medication [133, 134]. Further complicating the understanding of soy allergy is evidence that children may
develop tolerance to soy, not so to peanut [135]. Taken
together, these findings underline the importance of acareful diagnosis, and, when prudent, re-evaluation ofsoy allergy. Thus, the decision to include or exclude soy
lecithin should be taken on case-by-case basis.
Patients with peanut and tree nut allergies, are lesslikely to achieve clinical tolerance than patients allergic to milk or egg [5, 136]. Pea protein is an increasingly widely available vegan protein, and may be asuitable alternative to soy. However, pea allergies havebeen documented [137], most commonly amongst
those with allergies to other legumes.
Patients who are also allergic to wheat pose a challenge in that they are unable to consume wheat protein
alternatives, including seitan, as well as more widely
available vegan alternatives, such as wheat-based pastas
or breads. These foods represent protein-, calorie- andconvenience losses to the patient. Alternatives to consider are bean- and lentil-based pastas, as well as legumes in their original forms.
Pain noir, or buckwheat, is a common staple inparts of Asia and northern France, and is commonly

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found in noodles, and flour mixes originating fromthese regions, as well as many gluten free flour mixes
in these regions and beyond. Buckwheat is botanicallyrelated to grasses, rather than wheat, and thus can be
consumed freely by wheat allergy sufferers. However,cross-reactivity between buckwheat and peanut has
been demonstrated [138].
Specific recommendations when working with foodallergic individuals

Suggestions for working with a food allergic, vegan patient and their family are provided in Table 1. In
addition to regular support from health professionals,
families may also wish to engage with their local patientorganisations, as many of these organisations offer support groups. These, as well as patient and/or parentalgroups organised by healthcare have proven to be a goodsource of support and effective in encouraging families
to take necessary actions [141], not less during the challenging process of re-introducing food when the allergy
is out-grown [96, 151, 152] or any other underlining theimportance of personalised/individualized management.
Given the restrictions associated with a plant-based
diet, even greater attention is warranted when those following a vegan diet also have additional restrictions
resulting from food allergy. Recently, American authors
reported that people with asthma, another allergic disease but which does not mandate dietary restrictions,commonly turned to YouTube for information on vegan
diets [111]. However, such information was frequently
deemed to be of poor quality [111].
Finally, it warrants mention that those who follow avegan diet are typically quite health conscious andTable 1 Suggestions for working with a food allergic, vegan patient and their family
Suggestion

Reference

Caution parents of the need for professional dietary monitoring and potential needfor supplementation to meet the needs of a growing child[9]

Careful attention must be given to the amount and quality of dietary protein, particularly
as many plant-based protein rich foods are common allergens[3, 5, 38, 114, 116]

Counsel families that portion sizes needed to achieve recommended/appropriate levelsof energy and nutrients through a plant-based diet are greater than a traditional diet[3, 5, 38, 114, 116].

Caution is warranted with pre-packed snacks with precautionary allergen labelling[122]

Food labels must be read every time a food is purchased, to reduce the risk of accidental
ingestions and reactions[139]‘May contain’ labels to alert consumers to possible traces of allergens in a food product,
although the amount of allergens in a given food varies widely, resulting in a need for
consumer vigilance[140]

Encourage cautious re-introduction of a food if a child outgrows an allergy[141–143]

Encourage a diverse diet, as restrictive diets and selective eating may contribute tonutritional deficiencies[127, 144–146]

Discuss any new food and environmental allergies, as cross-reactivity can occur[147–149]

Educate families that some allergies can be influenced by season and climate[150]

Protudjer and Mikkelsen BMC Pediatrics(2020) 20:341

engage in more physical activity compared to omnivores[153, 154], although this evidence is collectively inconclusive [155]. These characteristics need to be considered when interpreting the results of studies on healthoutcomes in vegan populations.

Conclusions
Children with allergy may have increased nutritional
needs due to comorbidity. This is complicated by coincident food allergy and vegan diet as both impose diet restrictions, thereby limiting sources of important
nutrients, need for dietary variety and/or increased consumption due to reduced bioavailability.
Abbreviations
BMI: Body mass index; DHA: Docosahexanoic acid; ESPGHAN: European
Society of Paediatric Gastroenterology, Hepatology and Nutrition;
IgE: Immunoglobulin E; OFC: Oral food challenge; SPT: Skin prick test

Page 8 of 11

2.

3.

4.

5.

6.

7.

8.

9.
Acknowledgements
Not applicable.
Availability of supporting data and materials
Data sharing not applicable to this article as no datasets were generated oranalysed during the current study.

10.

11.
Authors’ contributions
JP designed the review. Both JP and AM contributed equally to the review
and synthesis of relevant studies, and writing the manuscript. Both approved
the submitted manuscript.

12.
13.

Authors’ information
Intentionally left blank.

14.

Funding
This study was funded by J Protudjer’s start up funds (Canada) and A
Mikkelsen’s award from Primary Health Care, Gothenburg and Södra
Bohuslän, Region Västra Götaland, Sweden.
Ethics approval and consent to participate
Not applicable. This was a review study of previously published literature andthus did not require ethical approval.

15.

16.

17.
Consent for publication
Not applicable.

18.

Competing interests
The authors declare that they have no competing interests.
19.
Author details
1
Department of Pediatrics and Child Health, University of Manitoba,
Winnipeg, Canada. 2George and Fay Yee Centre for Healthcare Innovation,
Winnipeg, Canada. 3Children’s Hospital Research Institute of Manitoba,
Winnipeg, Canada. 4Department of Food and Human Nutritional Sciences,
University of Manitoba, Winnipeg, Canada. 5Centre for Allergy Research,
Karolinska Institutet, Stockholm, Sweden. 6Paediatric Primary Health Care
Clinics of Västra Götaland, Västra Götaland, Sweden. 7Research andDevelopment Primary Health Care, Gothenburg and Södra Bohuslän, Region
Västra Götaland, Sweden. 8Institute of Medicine, Department of Public Healthand Community Medicine, Sahlgrenska Academy, University of Gothenburg,
Gothenburg, Sweden.

20.

21.

22.
23.
24.

Received: 11 December 2019 Accepted: 2 July 2020
25.
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