# The Difficult Alliance between Vegan Parents and Pediatrician: A Case Report
## 2 Case Report  
A 22-month-old boy came to our attention for failure to thrive. Since the age of 15 months the parents have consulted three different pediatricians and a pediatric gastroenterologist. The mother reported that she followed varied diet during last pregnancy. She had followed a vegan diet during a previous pregnancy, suspended for iron deficiency anemia onset. The baby was born at term showing a birth weight of 3460 g (56 th centile), a length of 50 cm (42 nd centile), an head circumference of 35 cm (61 st centile); perinatal course was uneventful. He was exclusively breastfed for 10 months and then he received a rice-based drink (formulation not suitable for infants). The parents reportedthat the child followed an omnivorous diet but that he preferred carbohydrates to proteins. Based on the alimentary recall diary of the previous three days we found out that the child did not have meat, eggs, or dairy. The parents stated that they were not in favour of the use of these alimentary products, however they allowed the child to have fish in a small quantities (weekly). The food intake in quantity and frequency was satisfactory: he had three main meals and two snacks. Neither swallowing issues nor coughing or vomiting during meals were reported. He had a regular intestinal transit. Psycho-motor development was normal. Vaccinations were partially carried out by choice of parents. Neither previous hospitalizations, nor surgery have been previously reported. Positive family history of celiac disease is reported in the maternal branch (grandfather). Laboratory complementary tests prescribed by the pediatric gastroenterologist showed: normal blood count, urine, liver function, calcium, phosphorus and alkaline phosphatase; decreased iron level (17 mcg/dL) [n.r. 30-130] and ferritin (10.12 ng/dL) [n.r.18, 2-341] and low total IgA (0.25 g/L) [n.r.0.8-4.5]. Celiac disease assessment revealed the presence of haplotype DR4-DQ8 (that is associated with an increased risk of celiac disease), but negativity of anti-endomysial antibody and Anti-transglutaminase IgG and IgA. Abdominal ultrasound was normal. The pediatric gastroenterologist recommended an esophagogastroduodenoscopy to rule out coeliac disease. During the visit, the physical examination was normal except for the presence of skin pallor and slightly flecked eyes. Weight: 10 kg (3 th), height: 81 cm (14 th), head circumference (26 th). The patient received oral iron supplements for about a week as prescribed by the pediatric gastroenterologist, but the mother did not respect the recommended diet.  
The patient was discharged with the advice to continue with oral iron supplements, to introduce 250 mL of soja-based infant milk in the morning and 250 mL in the evening. It was also advice to add an energy powder containing carbohydrates and fat (DUOCAL, Nutricia), (75/kcal/day), to increment the use of legumes, and to eat fish three times a week. We recommended an alimentary diary and continue the checks for failure to thrive (anti-gliadin deamidated antibodies IgG, PCR, VES, TSH, FT4, renal function, blood electrolytes, vitamins A, D, E, K, plasma albumin, LDH, urinary sodium/creatinine and albumin/creatinine ratios, steatosisort, stool occult blood, fecal calprotectin and fecal antigen research for Helycobacter Pylori). Since the parents were also not in favor of the consumption of soja, we recommended the parents replace soya milk with a rice-based infant drink (NovalacRiz, Menarini). An appointment was scheduled after 15 days. The patient did not show up on the day of the appointment and was contacted by phone. The mother reported that they had completed the alimentary diary and partially carried out the recommended laboratory tests (pending results), and also that they have yet not started with the suggested diet. We scheduled a follow-up appointment for the following week however the patient did not attend and was therefore lost to our follow-up.