Dietary Restrictions in Kids: A Parent’s Guide

In a perfect world, your child licks their plate clean after every meal you make them, no matter how many veggies and how few sweets are on their plate. But many children have medical and disability-related needs that put hard parameters on what they eat at any given time — these children require a restrictive diet. Unlike the kids in our article on picky eating, children with restrictive diets aren’t so much “picky” as they are unable to eat certain foods or eat them in the amounts we expect; this could stem from an allergy, an intolerance, a side effect of their medication, or a disability-related condition. Figuring out how to give a child consistent nutrition at home, at school, and in social or travel situations can be tricky, but it’s far from impossible.

To help parents understand how to navigate the parameters of their child’s restrictive diet, what are reasonable accommodations in public and private institutions, how to navigate life and social situations, and more, we spoke to Art Beisang, MD, a complex care pediatrician at Gillette Children’s Hospital; Leslie Lobel, Undivided’s director of health plan advocacy; and Jordan Stachel, MS, RDN, CPT, a registered dietician.

Note for parents: a restrictive diet in this context does not refer to restricting a child’s diet for the purpose of managing weight, and it does not refer to a child who has an eating disorder, such as anorexia, bulimia, or binge-eating disorder. The restrictive diets we detail in this article are due to an allergy, a medical need, or a disability-related condition and do not necessarily reflect the negative self-image that may lead a child to restrict their diet in order to change their body.

A restrictive diet refers to a diet in which the person cannot freely eat any food they want; they may have a dangerous allergic/intolerant reaction to a particular ingredient or group of foods, such as gluten or dairy or nuts, or they may have to take a medication that impacts their appetite and nutrient intake, creating a need for dietary modifications.

Some disabilities can also create dietary restrictions, such as children who are fed via a G-tube, children with autism who develop Avoidant/Restrictive Food Intake Disorder (ARFID), or children with Prader-Willi syndrome who do not feel satiation and need outside parameters put on their food consumption.

As Stachel describes in her work with pediatric patients, “There is often an underlying medical or clinical concern that causes the restrictions to take place in young kids. Sometimes it’s due to family or stress, but most of the time we find that it’s due to something else that they’re dealing with: they’re having GI issues, or there is an undiagnosed food sensitivity that’s causing symptoms.”

The most common restrictive diets are related to a food allergy or sensitivity. Symptoms for a food allergy can range from mild reactions, such as mouth tingling, moderate face swelling, and stomach pain, to severe responses that require immediate intervention, such as vomiting, collapse, or anaphylaxis.

Primary restrictive diets

Gluten-free diet

A gluten-free diet is generally associated with children who have a gluten intolerance/sensitivity or who may have celiac disease. Gluten is a protein found in grains such as wheat, barley, and rye; it is most commonly found in foods such as breads, pasta, crackers, and baked goods, but it is also used as a binder in sauces, soups, and other food products.

Symptoms of a gluten intolerance/sensitivity vary, from bloating, hives, gas, and fatigue to more severe reactions, including joint pain, migraines, and anaphylaxis. Celiac disease is different from gluten intolerance or sensitivity; it is an actual autoimmune reaction that can cause intense diarrhea, weight loss, anemia, and long-term intestinal damage that can impact the body’s ability to absorb nutrients. A gluten-free diet mitigates these reactions and symptoms by eliminating the consumption of gluten products.

Ketogenic diet

A ketogenic diet — keto for short — is a high-fat, moderate-protein, and very low-carbohydrate diet developed by Dr. Russell Wilder of the Mayo Clinic over a century ago, with the intention of minimizing seizures in adults and children with epilepsy. The keto diet uses the restrictions of certain macronutrients and food groups to shift the body’s metabolism away from relying on carbs for energy to instead relying on fat. A research review in Frontiers in Neuroscience indicates that adherence to a keto diet often drastically reduced seizures in children and adults with drug-resistant epilepsy. Other emerging applications include for people with obesity, metabolic dysfunction, diabetes, cancer, and some psychiatric conditions, but the research and evidence remain limited.

Low-glycemic index diet

A low-glycemic index diet, like keto, is intended to prevent or mitigate the negative effects of a medical condition — in this case type 1 and 2 diabetes. Note that the majority of children diagnosed with diabetes have type 1, an autoimmune condition where the body does not produce insulin, a hormone that regulates blood sugar. Type 2 diabetes is defined by the body’s metabolism becoming insulin-resistant, usually due to a combination of genetic and lifestyle factors.

Both types of diabetes impact how the body metabolizes glucose (aka blood sugar) levels, but require different health and medical interventions. People with type 1 diabetes must take synthetic insulin daily to keep blood sugar levels in a healthy range in addition to dietary restrictions, and type 2 diabetes can often be managed with exercise and medication (if needed) alongside a low-glycemic index diet. Excessive blood glucose can lead to a number of health complications, including kidney disease, fatigue, vision loss, and nerve damage.

A low-glycemic index diet controls the glucose a person consumes via glycemic index values assigned to every carbohydrate. This diet focuses on low carbohydrate consumption, limiting the intake of high glycemic index foods such as white rice and bread in favor of vegetables, fruits, and legumes. However, some sources note that the glycemic index doesn’t necessarily account for the serving size a person will eat in their day-to-day life, and every person should find their own balance.

In addition to stabilizing blood glucose levels, this diet can also lead to weight loss and more stable blood pressure and cholesterol levels. How potential weight loss may impact a growing child’s development should be discussed with the child’s care team.

Diabetic/low-sugar diet

A diabetic diet with low sugar has many similarities to the low-glycemic index diet, focusing on keeping blood glucose levels stable through diet and limited sugar intake. The low-sugar and diabetic diet focuses on consuming protein and fiber while minimizing carb and fat intake. While a diabetic diet may also refer to the glycemic index for identifying foods to include or eliminate, it isn’t always incorporated.

Gluten- and casein-free diet

A gluten- and casein-free diet refers to a diet that aims to improve a person’s gut health and digestion through eliminating gluten and casein, the latter of which is a protein found in a variety of dairy products made from sheep’s, goat’s, and cow’s milk. These products include milk, cheese, yogurt, butter, and many other products that may use casein as a thickening agent, including deli meat and processed products such as potato chips and baked goods.

Some research suggests that an elimination diet, including a gluten- and casein-free diet, can improve the behavior and certain cognitive symptoms of certain disabilities, namely autism. Some studies indicate that improving the intestinal health and digestion of children with autism can mitigate potentially undigested toxins that impact the child’s brain function. However, the validity of this connection remains underresearched, and there is no guarantee this diet will work for any given child.

Lactose-intolerant, dairy-free diet

While they seem similar, lactose intolerant and dairy free are not the same thing. Lactose is a form of sugar that naturally occurs in animal-derived milks; some people may be lactose intolerant but not allergic to other compounds found in dairy products. A diet for a child with a lactose intolerance can still include dairy products, but a child who follows a dairy-free diet will not be consuming lactose in any form. Additionally, some companies produce over-the-counter tablets and enzymes (such as Lactaid) to help mitigate uncomfortable digestive symptoms associated with lactose intolerance.

Allergen-free diet

This type of diet may restrict nuts, fish/shellfish, wheat, eggs, or soy, depending on a person’s needs. In the United States, there are nine primary allergens for children and adults (sometimes called the “Big Nine”): milk/dairy, eggs, fish, shellfish, peanuts, tree nuts, sesame, wheat/gluten, and soy.

Following a fully allergen-free diet can be hard but not impossible; in some cases, a child with such restrictions may need supplementation from medical food or formula in addition to the limited foods they can eat.

Conditions that affect appetite, digestion, and feeding

Beyond restrictive diets that center around foods, many children may benefit from or require a restricted diet because of a co-occurring health condition. These can result from conditions that impact a child’s appetite, digestion, and metabolism and are not necessarily related to a specific food. For example, diabetes diet restrictions, as we mentioned earlier, do not require the elimination of a specific food or ingredient, but rather balance certain vitamins and compounds that can be consumed across a variety of foods.

• Prader-Willi syndrome: this genetic condition affects a child’s development across multiple markers, including their growth, muscle development, and language skills. With regard to diet, children with Prader-Willi syndrome do not feel the same satiation cues as others, which can lead to health complications if their diet isn’t monitored and measured.
• Inflammatory bowel disease (IBD): inflammatory bowel disease is an umbrella name for conditions that affect the body’s digestion and digestive organs, namely Crohn’s disease and ulcerative colitis (UC). Both of these conditions create painful inflammation in the body’s organ tissues that impact digestion, namely the colon for UC and the small intestine for Crohn’s, though the inflammation can spread higher as well. IBD can make eating and using the bathroom incredibly painful, and a diet to help manage symptoms involves eliminating inflammatory foods.
• Down syndrome: some developmental disabilities can also impact a child’s dietary needs. Children born with Down syndrome, for example, are far more likely than the general population to develop celiac disease, reflux (GERD), or gastrointestinal issues such as Hirschsprung disease or duodenal atresia, that can be corrected with surgery.
• Rett syndrome: another issue is the connection between Rett syndrome and heightened cholesterol levels due to how the syndrome affects metabolism. Dr. Beisang adds, “Many of my patients [with Rett] have their gallbladders out at a very young age. A specific gene mutation might inform you of some things that you should really be following for a specific diet.”
• G-tube feeding/enteral nutrition: in some cases, a child may require a gastrostomy tube (G-tube) to consume the calories and nutrients needed to maintain their growth and health. (A G-tube is a feeding tube used for enteral nutrition.) As we discuss in our article on feeding therapy, children may require a G-tube for a number of reasons, including a motor/physical inability to swallow food (due to conditions such as cerebral palsy), a digestive concern, or a sensory aversion to food flavors and/or textures. G-tube feeding directly impacts the kinds of foods and consistencies a child can consume due to the delivery system
• Medication: in some cases, a child’s medications can also interfere with their diet and nutritional needs. For example, children who have ADHD and take a prescribed stimulant medication for it may experience appetite suppression, necessitating a more precise diet plan to ensure they consume enough nutrients. Children with epilepsy may take anti-seizure medications that can impact their appetite and weight gain in either direction (depending on the formulation taken), leading to conversations about diet. Other medications may impact how a child’s body absorbs vitamins and nutrients from the food they consume. Some diabetes drugs, for example, can weaken vitamin B12 absorption, which can influence a child’s energy levels.
• ARFID: nearly all children complain about some food or another (it’s practically a rite of passage for kids!), but for some children the avoidance of a certain food or food group runs far deeper than preference. Avoidant/Restrictive Food Intake Disorder (ARFID) is not just a child experiencing a phase of picky eating — it involves very restricted food choices and aversions to food. ARFID can often co-occur with other conditions, such as OCD, anxiety, and developmental disabilities; research analysis shows children with autism are more likely to develop ARFID. Children with ARFID often:
  • are resistant to new foods (neophobia)
  • have strong reactions to tastes, smells, or textures
  • have a fear of choking or vomiting
  • have a fear of unhealthy eating
  • have a low appetite or lack of interest in eating

In this clip, Dr. Beisang discusses the nuances of modifying a child’s diet with their disability in mind.

Barring very early diagnoses, it’s likely that parents will recognize their child’s need for a restrictive diet at home, whether it’s because they see a notable food avoidance or they witness their child having a reaction to consuming a food that they may be allergic to. Building the right care team can be complicated, but both Dr. Beisang and Stachel recommend starting with your child’s pediatrician. As a complex care pediatrician, Dr. Beisang says that when identifying whether a child’s food reactions are potentially related to a disability, early diagnosis is crucial.

“We always talk about the diagnostic odyssey,” he says. “Many times you’re going to three, four, five doctors before you finally get a diagnosis, [and] during that time parents are of course distraught because they know there’s something wrong and they’re trying to figure it out.” This process involves identifying not only the source of the diet restriction, but also how it fits into the broader scope of the child’s health. As described above, a restrictive diet encompasses so many factors of a child’s life that their primary care doctor alone can’t make every decision or identify every need.

When bringing in a specialist, such as a dietitian, Stachel says it’s normal for parents to feel anxious, but every discovery with a new healthcare team member is a step towards a child’s dietary balance. “The right team can help give you a nice, objective perspective that’s fresh,” says Stachel. “When I'm working with parents, my goal is for them to leave our sessions feeling more at ease and expanded than anything else. The only thing that would be something that I would not advise is really just waiting too long.

Who should be on your team, what do they each do, and how can they help your child? Here’s a list of some providers who may be on your child’s care team:

Pediatrician: a pediatrician will be your child’s first point of contact for their health. While they may not be able to identify the child’s dietary needs and potential restrictions, they can help connect families with in-network specialists to help coordinate care. If the child has a condition that necessitates a restricted diet, they may also need a complex care pediatrician. Dr. Beisang explains, “A lot of people don't really know what a complex care pediatrician is. We are not a substitute for a primary care doctor who is there to do child checks, provide immunizations, look for acute injuries and illness. We do a lot more coordination of care to help the primary care doctor. A lot of parents find that it's nice to come to complex care, so that we can help translate what some of the other sub-specialists are saying, and help them make sure they have all of the right sub-specialists for the care that they need.”

A gastroenterologist (GI): a GI doctor can help families determine what may be causing a child’s digestion and intestinal discomfort, and the health of all the organs and intestines involved, including the liver, pancreas, and colon. A GI is ideal for children who may have IBD or celiac​​, or a condition that may cause inflammation in these body systems.

Allergist versus immunologist: if a child is experiencing adverse reactions to certain foods, they should see a physician who specializes in either allergies or immunologies to determine if their allergy is food-related or connected to a condition with their immune system. Dr. Beisang adds that the specialties are very similar, but the child’s specific needs determine which fits their health plan better. “If you're giving a young child a new food and they're very quickly having trouble breathing, their face is getting flushed, they're getting hives, that's one area where we really need an allergist to help us sort through what the issues are.” Comparatively, an immunologist has a broader focus on the immune system, and may help contextualize care if the restrictive diet is related to an autoimmune condition.

OT/feeding therapist: feeding therapists or occupational therapists are a great option to consider when a restrictive diet can arise from a child’s physical, sensory, and behavioral needs. These specialists do not focus on food intolerances due to ingredients or medical conditions like others; rather, they work with kids to improve their physical ability to chew and swallow and desensitize themselves to foods in order to expand their palate and nutrition options.

Speech-language pathologist: a speech-language pathologist (SLP) is often consulted for children who may need interventions for delayed speech, but in the context of a child’s restrictive diet they can help children and adults who struggle with swallowing or choking disorders, also called dysphagia. Dr. Beisang explains that SLPs can conduct an assessment called a videofluoroscopic swallow study to determine the best approach for improving their swallow, whether that be through dietary changes, building the swallow muscles, or starting discussions about implementing a G-tube. “We get a referral from the primary care doctor after they've had a swallow study. . . .and at that point we work very hard to see how we can get somebody to safely take food and nutrition by mouth. Speech therapists are very good with lots of different ways to help with that.

Dietitian or nutritionist: dietitians and nutritionists are not interchangeable specialists. A dietitian, unlike a nutritionist, is a registered medical expert who received an accredited degree and passed the Commission on Dietetic Registration exam. While nutritionists do have some form of training, they may not be able to discuss restrictive diets with as much depth and nuance. “It's really not cookie-cutter,” says Stachel. “If a parent or a caregiver is noticing that their child is struggling with food, it's always a good time to reach out. It can really help to work with a care provider, like a dietitian, and sometimes it requires a larger healthcare team to to get to the bottom of why.”

Stachel says that a dietitian can also be part of the investigative process of a child’s diagnosis alongside the child’s primary care doctor. “We're trying to figure out with the parents: is this a sensitivity or an underlying medical condition, or is this something more like ARFID that the child is dealing with? We try to get an understanding: what will they eat? What does work for them day to day?”

One of the hardest aspects of managing a child’s restrictive diet is finding a sustainable (and ideally, enjoyable) balance between foods that are both safe and nutritious. Not every restrictive diet will remain consistent throughout childhood and into adulthood, and, Stachel says, a child’s care team may prioritize different health needs at different times, such as focusing on caloric intake over hitting every vitamin or nutrient in each meal.

“Growth is what's most important in young children,” says Stachel. “If your kid has ARFID and they're struggling with their growth, at the end of the day, [it’s] whatever calories that they will eat, or calories that they can consume.”

For kids with allergies, it’s more likely that they will have to avoid that food for the rest of their life. Nutrition becomes about finding alternatives, such as how to get a child to eat enough calcium if they have a dairy allergy, versus ensuring they have enough energy throughout the day if they have ARFID.

“It's two different approaches,” says Stachel. For an allergy, she adds, “It becomes a safety issue where you have to teach your kid from a young age, depending on how they react when they eat the food, that they can't have those foods.”

Introducing new foods

The hardest part of a child’s dietary restriction journey isn’t identifying what they can’t eat; working with what they can eat and how to ensure they eat enough of the nutrients they need requires long-term planning, experimentation, and collaboration with both your child and their care team. But nutritional input, Stachel says, can come from many strategies and approaches. “People can have perfectly healthy vegan diets and gluten-free diets, and whatever diet you want, but it is a degree harder. You need to be more aware of labels and what to look for and how to get the nutrients that you need.” A child on a keto diet, for example, may be meeting their protein and iron goals, but require planning for how to get enough vitamin C or potassium.

Food expansion does not only apply to children with ARFID, although children with ARFID may have a harder time willingly trying new foods. “If someone comes in and they're already gluten-free or vegan, or they have self-imposed dietary restrictions, I try to understand where those restrictions come from. [Did] they have allergy testing in the past? Is it clinical, or is it just preference? That tells me a lot about if they're open to expanding.”

When working with children who do not eat certain foods by choice, Stachel recommends a “chain of expansion” approach. Rather than load a child’s plate up with foods they avoid, the majority of their meal should be foods they will eat, at least to start. If it's preference, then my route is to always get them to expand towards more real deal foods as long as they tolerate them, and it makes them feel okay, and they're open to it. If they're not, then we work with the alternatives.”

“Let's say it's carrots,” Stachel says. “They can visually see the food, maybe you don't even expect them to eat it, but it's allowed to sit on their plate. They can touch the food, smell it, lick it. Sometimes with ARFID, it's not even about eating it, it's just about the exposure, and then eventually maybe we eat it. It's not linear, truthfully.”

Should I hide certain ingredients in other foods?

It depends. How you go about food expansion depends on how your child feels and recommendations from your child’s dietitian. “If carrots are the food that your family eats and you're trying to get them to eat more of them, you can hide them,” says Stachel. Incorporating necessary nutrients into meals can be as simple as adding, for example, extra leafy greens into a smoothie, or adding a nutrient-dense food to a safe food/meal that they already like, like baking a carrot cake muffin instead of serving them carrots alone. “You don't have to make those things weird. If you make a carrot cake muffin, you can say, ‘here's a muffin.’ There's a way to go about it where there's not an unnecessary emphasis on foods that might be hidden — they can just be there.”

Are there “recommended” diets for certain disabilities?

The last couple years have seen the rise of social media trends and online forums that give the impression that a child’s disability and its symptoms can be mitigated and even improved via diet.

But Dr. Beisang, Stachel, and a growing body of research say that the data does not really support these claims. Some common diet claims suggest that eliminating sugar for children with ADHD can help them focus better, while others claim that gluten and dairy can negatively impact cognition and brian function for children who have autism. But analysis of research published in the Journal of Affective Disorders shows that the data suggesting sugar intake influences ADHD is “conflicting” and did not indicate a cause and effect. “The research, truthfully, is lacking when it comes to a ‘one-size-fits-all diet for autism or for ADHD,” says Stachel. “In my experience working with people who have autism or ADHD, I'll understand what's working from them food-wise, and then [we] can figure out if those kinds of [dietary] changes feel appropriate. There's not a lot of clinical research to suggest, yes, 100% going gluten-free is going to help this person.” Similar results can be seen when it comes to how diet can influence the behavior of children with autism; some say children with autism would benefit from milk consumption, while others suggest dairy should be eliminated.

However, if the child has both autism and a gluten-intolerance, for example, a restricted diet may have indirectly positive impacts on the child by addressing a different area of discomfort unrelated to the child’s autism. In some cases, a restricted diet does have a direct effect on a child’s disability because they’re medically connected. As Dr. Beisang adds, “It really helps to be talking about a genetic diagnosis, for instance, Down syndrome. It's well known in the Down syndrome population that there's a higher incidence [of Celiac’s], just like we have to watch for thyroid disease. A specific gene mutation might provide you with some things that you should really be following for a specific diet.”

Some correlations are also misunderstood. Dietary needs for people with intellectual disabilities, research shows, are often unaddressed not because they’re reacting to their diet, but because they often do not have the financial and medical means to address them. Exceptions aside, the best diet for a child with restrictions comes from a holistic, nutrient-focused, and individualized approach with your care team.

Can food allergies be cured?

As of writing, there is no universal cure for food allergies. However, advancements in research pertaining to food allergies and immunotherapies now provide families with more options for mitigating and even improving allergy reactions in children.

“The very interesting part about food allergies is we’re starting to realize now we can avoid a lot of those by giving a wide variety of foods [to children] at a very young age,” says Dr. Beisang, a strong departure from the American Academy of Pediatrics (AAP)’s guidelines of a generation ago that recommended avoidance of the most common allergen foods. Now, children with food allergies may be able to “re-educate” their immune systems via allergen-specific immunotherapy (AIT), in which exposure to small amounts of the allergen over time can desensitize the child to severe reactions like anaphylaxis. “One of the things we look at is what we call immune tolerance,” he adds. “Before the age of 18 months, our bodies are trying to figure out what substances are tolerated and what substances we need to react to. If you are exposed to different substances earlier in life, your body sees those as normal and doesn't react to them.”

In 2024, the FDA approved Xolair, an injectable drug for children over 1 year of age meant to reduce allergic reactions. Before parents pursue any of these options, however, they should consult their PCP and allergist to determine both the treatment’s viability and the risk of side effects.a

Short answer? Yes! The current iteration of the Americans with Disabilities Act does make provisions for adults and children with food allergies in addition to the conditions that may impact a child’s diet. According to Dr. Jacqueline A. Pongracic, MD of the American Academy of Asthma, Allergies, and Immunology, a severe allergy is considered a condition that can limit or obstruct a person from the tenets of a healthy life, including their ability to eat, breathe, and go to school.

This is a fairly recent change due to the ADA Amendments Act of 2008, which expanded the previously held definitions of what constituted a disability under both ADA and the Section 504 of the Rehabilitation Act of 1973 — the ADA broadened the definition of “disability” to include any physical or mental impairment that substantially limits a major life activity or major bodily function of an individual. For example, sensory sensitivities related to autism may make certain food textures, temperatures, colors, or smells impossible to tolerate. Likewise, if certain foods cause gastrointestinal pain, trigger a mast cell reaction, or interfere with learning or concentration, your child may also be eligible for accommodations.

Where does ADA apply?

Most institutions, businesses, and venues that are open to the public are subject to ADA law, and thus make reasonable accommodations for people with disabilities, including extreme food allergies. These include:

• Public schools and public hospitals (which have a stronger obligation to adhere to ADA)
• Private schools, including private housing
• Theme parks
• Restaurants
• Movie theaters
• Office buildings
• Gyms
• Doctors’ offices and private hospitals

There are, however, some exemptions. Religious organizations, such as churches, mosques, and synagogues, do not need to provide accommodations, including those for allergies. However, this does not mean these organizations won’t work with families to accommodate their child’s allergies or restricted diet needs.

Airlines and passenger aircrafts, even on domestic flights, are not subject to ADA compliance. Separate legislation, the Air Carrier Access Act, determines how airlines and aircrafts accommodate passengers with disabilities. The ACAA enforces many of the responsibilities of the ADA, but individuals do bear some additional responsibilities, including giving the airline at least 48 hours’ notice if they require accommodations.

Not all ACAA accommodations apply to time in the cabin; the Food Allergy Research and Education (FARE) organization also recommends that families follow up with gate agents and speak to the in-flight crew as soon as possible. If an allergy is severe enough to create a reaction from contact with an allergen, parents can request to wipe down their seating before general boarding starts, though it isn’t a guarantee. Additionally, airlines cannot guarantee a flight will not serve food with potential allergens, or that other passengers won’t have their own food with allergens. They also cannot guarantee space or trained personnel to assist with G-tube feedings. Find more airplane travel tips in our article here.

Reasonable accommodations under ADA

While some food restrictions have ADA protections, there is a limit to the accommodations individuals and families can expect when out and about. Accommodations must be reasonable, which often depends on the context and the business plan of the provider. A small mom & pop business will not be able to provide the same accommodation as a multinational theme park. Reasonable accommodations parents could request include:

• The most common accommodation needed is information — individuals with diet restrictions might need to know about what kind of food will be served ahead of time at any public event, such as a conference or a carnival. If there is an ice cream social, you can ask them to send a screenshot of the nutrition label because no parent wants to take a child to get ice cream and then have to tell them they can't have it. In a restaurant you might need information about how food was prepared. Asking for information often feels rude or intrusive — but is a reasonable accommodation.
• Many venues, such as theme parks or theaters, have a “no outside food" rule. Being able to bring your child’s safe foods into the venue is a reasonable accommodation — unless the venue can provide safe alternatives.
• In a restaurant, it is reasonable to ask the kitchen to eliminate a certain ingredient from a dish, and often they will also let you substitute. Many restaurants will say that their kitchen is contaminated and nothing there is safe to eat. For example, if avoiding soy sauce (which often contains gluten), it may be so widely used in the kitchen that they cannot prepare a dish without it. In that case, the accommodation might be that they sit without eating while their family eats.
• At school or work, taking breaks to check blood sugar levels, eat a snack, take medication, or use the restroom. Your child may also need a safe place to rest until their blood sugar returns to a healthy range, permission to keep diabetes supplies and snacks with them throughout the day, and the ability to check blood sugar or administer insulin whenever and wherever it's needed.
• A day camp or childcare may be able to accommodate a meal replacement or might request that the parents bring their own alternative. If pricing covers meals, the camp should offer a discount. Sleepaway camps usually accommodate common dietary restrictions by providing safe alternatives.

An unreasonable accommodation would be requesting that a school or camp hire a personal chef for the child or that parents request specific meals. It is unreasonable to expect the flight crew of a plane to not serve a specific snack or food to everyone on the flight because of one passenger’s diet, or to ask the food vendor at a theme park or movie theater to prepare foods not listed on their menu.

Does it have to be life-threatening?

No! Many parents are surprised to learn that a food sensitivity or food aversion doesn't have to be life-threatening for a child to qualify for accommodations. Under the ADA, a disability is any physical or mental impairment that substantially limits a major life activity, such as eating, or a major bodily function, such as digestion or immune system function.

For example, digestion is considered a major bodily function under the ADA. This means that if your child's disability affects their ability to digest certain foods, they may qualify for accommodations. For example, a child with lactose intolerance may be entitled to a milk substitute or another meal modification, even if consuming dairy doesn't cause a severe or life-threatening reaction. Similarly, even if medication helps control your child's allergic reactions, they may still qualify for accommodations. The key is whether the condition substantially affects your child's digestion or another major life activity. So when discussing your child’s diet with providers or the school, keep this in mind.

Legislation for children with a restrictive diet can apply to a variety of situations. The ADA applies broadly to public life and institutions. Under ADA, for example, a family is entitled to certain protections if they need to provide for their child’s restrictive diet outside of the home. This includes things like allowing parents to bring prepared foods into a movie theater or theme park or being able to administer food to the child, such as through a G-tube. ADA also applies to both public and private schools and requires reasonable accommodations for students with disabilities.

As we discussed above, finding the ideal diet for a child with restrictions often involves other specialists beyond the child’s primary doctor. When it comes to insurance coverage for the appointments, specialists, and supplies that often accompany the work to find a child’s dietary limits, Lobel says, it can get complicated. Children with a qualifying disability can receive Medicaid (Medi-Cal in California) in addition to their primary or private health care plan. Lobel advises that families work first with what is covered by their primary plan; Medicaid can then be used to cover remaining costs if the services are obtained from a provider who contracts with Medi-Cal.

When making a case for coverage for a child’s diet-related needs, knowing the right language to use can help families avoid delays and back-and-forths. If a child has an allergy or a disability-related need, such as an absent swallow due to cerebral palsy, Lobel advises them to use specific terms that make it clear the child has a medical necessity for coverage. “It may be that ‘disability-related’ is an accurate term, but ‘medical diagnosis’ is more the jargon that would click with the insurance company.” There is also a difference between “covered” and “approved,” so parents should maintain a clear record of their child’s medical needs and their doctors’ recommendations. “It has to meet certain standards, which is by diagnosis or a letter from the doctor,” Lobel says.

Working with your healthcare provider to cover the costs of services and items related to a restrictive diet can be tricky, but far from impossible. We’ve covered all the different kinds of doctors, specialists, and therapists that a child may need at some point in creating a restrictive, but still nutritious, diet. The coverage a family gets for their child’s dietary needs depends on their provider, their location, and what their diet entails.

Per Lobel, one of the first steps parents can take when it comes to coverage is to understand the language to use when seeking coverage. A “restrictive diet” in and of itself may not sound like something that warrants consistent coverage. Establishing an open dialogue and understanding the limits of one’s plan. If a family has a Health Maintenance Organization plan, they will require a referral from their PCP if they want coverage for a specialist, and that specialist will be in-network. A Preferred Provider Organization, by comparison, does not require a referral, but families may incur higher costs if they see an out-of-network specialist.

In this clip, Leslie Lobel describes how insurance coverage options work for children with restrictive diets.

Does insurance cover GIs, nutritionists, and dietitians?

If parents need to see a specialist, such as a GI doctor, a dietitian, or an occupational therapist, and want it covered by their insurance, they can start by speaking to the child’s primary care doctor. Whether their restricted diet is related to a disability, allergy, or medication, and necessitates a meeting with a specialist, Lobel says, “The child’s PCP can help refer parents to the right specialist and then they can consider the network status of the providers in that speciality. If a child has a dietary reaction that warrants a hospital visit or stay, personnel at the hospital can also provide options for covered specialists.”

“They have to be willing to let the provider know what's happening at home, and they have to be open to hearing when the provider says that some intervention with the specialist might be helpful. Their primary care physician, depending on if the child has a neurological condition or an allergy, would direct them. They wouldn't necessarily self-refer to one of those specialties,” says Lobel. “They'll also want to know from the plan if they have coverage for a nutritionist or if they have coverage for a dietitian,” which, she adds, are not interchangeable and thus may incur different costs.

“The family may not be thinking necessarily that they need to go to a GI doctor or a dietitian or a nutritionist. Those are potentially unforeseen or unexpected costs,” says Lobel. From an insurance standpoint, there are some questions that parents should consider asking their child’s PCP before accepting a referral to a specialist or finding one on their own:

• How frequently will my child need to see this specialist?
• Who are the in-network specialists you recommend?
• Have you worked with this specialist before?
• Where does this specialist practice?
• Has this specialist worked with children who have my child’s same diagnosis?

Lobel acknowledges that parents may need to see an out-of-network specialist if the child’s PCP recommends it. If a family wants to explore occupational therapy for their child’s ARFID, for example, they may need to pay for an OT who specializes in food desensitization. The duration of these therapies will vary depending on the child’s needs, making out-of-pocket costs hard to predict. For long-term care with an out-of-network specialist, Lobel says parents can try to approach their insurance company for higher reimbursement with a case for their child’s health.

“The doctor may say, ‘I want you to go to this dietitian,’ and the dietitian is out-of-network,” says Lobel. “If a family was to start with someone out-of-network who had great success with working with children in this highly specific way, they could approach their plan to get higher reimbursement. It is possible to make a case that there was no one in-network who was doing that kind of work, that they need to access the services of an out-of-network provider to meet their child’s needs.” Keep in mind this does not guarantee that the insurance company will approve the family’s case.

Can families access specialist replacement products for their children through health insurance?

More often than not, yes. Lobel says that food replacement products and medical food are the most likely to get coverage.

“The way that the insurance talks about medical food, it doesn't mean that other things cannot be approached to or broached with the insurance plan for coverage, but the typical out-of-the-box thing that the health plan covers is medical food,” she says. “When you're speaking to your health insurance company, or whether you're speaking to a provider of medical food, the department at the company that you're speaking to will be called Entral Nutrition. There's a lot of nuance to get started.”

When it comes to non-food products, overage, Lobel says, is more likely if the replacement products are related to their medical food or specific health need. If a child uses a G-tube, for example, coverage should apply to both the medical food the child may need in addition to the tube kit to administer the food.

“Some plans exclude coverage from medical food. If [the child has] a secondary, they might get it through Medi-Cal. There are some plans that just flat out exclude medical food,” says Lobel. “If the family is not eligible for Medi-Cal, or Medi-Cal also excludes the food, then Regional Center can be approached.” But, she adds, there is no guarantee that Regional Center will consistently cover out-of-pocket costs, and of course many students can have a severe allergy or medical condition that warrants a restrictive diet without qualifying for Regional Center services.

In some cases, a dietitian or GI may suggest that parents add a supplement or vitamin to a child’s diet if their current intake lacks a certain nutrient. Unlike medical food, supplements are not regulated by the FDA, and thus constitute a “gray area,” Lobel says, when it comes to insurance coverage. Keeping an open dialogue with a child’s dietitian or PCP can lead to a medical recommendation for that item. “I know of a case where there was no medical food appropriate for a child that met all their nutritional needs. So, in that way, a supplement, which was a protein boost, got covered. Something that a dietitian says is necessary to complete the child's medical food intake is the kind of thing that a plan may cover.”

Can insurance or Regional Center (if in CA) cover the cost of specialty foods?

Lobel emphasizes that coverage from insurance varies widely for foods a child may need for their restrictive diet, but coverage applies mostly to medical food formulas for G-tube feedings or severe metabolic and intestinal conditions; medical food refers to a preformulated and processed food product (some are liquid, some are powders) intended to meet the nutritional needs of someone with intense dietary restrictions. If a child has celiac, for example, and the family chooses to buy gluten-free food items at the supermarket, that is not a covered expense. There are some “gray areas,” Lobel says, with non-food items like supplements and vitamins. Coverage may depend on the family’s plan and how important the care team determines the need — not all medical food brands may be available to a child depending on their plan and provider.

“The real big rub happens when a parent wants a specific food, and the health plan wants to provide a different food, right? They have their list of approved foods that they like to cover, so that becomes something that requires some back and forth. The way that a family can pick the best food or the right food is that their primary care physician would send them either to a dietitian or a nutritionist.”

There are some cases where an insurance provider may cover the costs of medical food as a reimbursement if the provider is out of network. When purchasing medical food, or even supplements, parents can ask for what’s called a “super bill,” a detailed invoice that they can submit to their insurance provider to be considered for reimbursement.

“Lobel adds, “It may or may not get authorized by the health plan out-of-network, but it definitely won't get paid for unless it is sold to them by someone who can provide a billing code. They don't have to be in-network, but they have to be a licensed provider. If you are going in-network, the network provider will obtain an authorization.”

Some specialists in-network, depending on the severity of a child’s food restriction, may not have the expertise needed for a specific child, and that can lead to out-of-pocket costs. Additionally, a food allergy or condition that restricts certain food groups does not mean that a child can get regular foods for free.

There are some circumstances under which a family may be able to access resources from their local Regional Center, which is called a payer of last resort. However, this depends heavily on the child’s initial eligibility for Regional Center, and what costs have already been covered by their primary care plan and Medi-Cal for in-network providers. Families should first check their plan’s evidence of coverage (EOC), which will detail the limitations for coverage for medical food and other specialty items.

“If they can prove that there is no coverage for medical food on their plan, and they don't have or they're not eligible for Medi-Cal, or Medi-Cal doesn't have the food that they need, it would be a good case to approach Regional Center.”

What if ARFID is so extreme that a G-tube is needed?

ARFID, unlike a food allergy, is not about a physical reaction to ingesting a particular food, but rather an “extreme food anxiety and often includes sensory avoidance of specific textures, colors, or other food characteristics” that many children with autism and other developmental disabilities can develop. It’s also listed in the DSM-5 as “a failure to meet nutritional needs leading to low weight, nutritional deficiency, dependence on supplemental feedings, and/or psychosocial impairment,” with anxiety, ADHD, and OCD as common co-occurring conditions.

A child with ARFID, as our article on picky eaters describes, may necessitate consulting with a number of specialists to find the right fit to expand their palate and manage their anxiety around eating, which can take time. If the family can demonstrate that ARFID is having a direct and profound impact on the child’s health, coverage for an ARFID-related G-tube is possible. “If their need for medical food was related to ARFID, and if a child needed a G-tube that's going to be covered,” adds Lobel. “If there's proof of the child's failure to thrive, failure to gain weight, repeated aspirations or bacterial pneumonia related to inhaling food, that's not a big worry.” Make sure that you keep a record of doctors’ notes and recommendations before discussing coverage with your provider.

Food is not just a means of nutrition; every culture and community in the world incorporates food into forms of interpersonal connection and social events. When a child cannot participate in these events like everyone else, it can create unforeseen mental health challenges for both the child and their caregivers, such as feelings of isolation and anxiety around potential adverse reactions to unsafe foods.

Dr. Beisang says that the child’s age and cognitive ability can influence how they feel about their dietary restriction from a social or emotional perspective just as much as it does their health, especially in children with more severe restrictions. He adds, “If a child is cognitively aware that they have a G-tube and nobody else does, we need to talk about that and try to make them feel the best they can. Oftentimes during school, everybody wants to be the same as everybody else. I think individual therapy is really important in those cases, especially as a child, because we're all different, and we eventually all figure that out, but at those times when you're interacting with other kids can be really important.”

Stachel also recommends discussing how a child’s dietary restrictions will impact them into adulthood. “At the end of the day you're raising adults, so I think the more involved that they are willing to be, absolutely capitalize on that.

Dr. Beisang, Dr. Pelangka, and Stachel all agree that a restrictive diet in no way prevents a child from living a vibrant, social life — it just takes a lot more communication and preparation. “As a parent, all you want is for your child to thrive,” says Stachel, “so when they're not, especially with something like food, it can be incredibly hard, and it's definitely not the parents' fault. There's not a blueprint for something like that. Most of the time, when your child's not eating, especially when they're younger, it's unexpected. My best piece of advice is to just not go it alone, because you know the right team can help just give you some really nice, objective perspective.”

In this clip, Stachel advises how parents can help support their child in social settings while managing a restrictive diet.

More often than not, children with restrictive diets will need a lot more planning ahead when they eat outside the home.

Mealtime tips at home

• Mealtimes can be both incredibly rewarding and stressful situations for the whole family when a food restriction is involved. Some children, as we discussed, may reject foods due to how they look or their texture, rather than the ingredient causing an adverse reaction. Food may need to be prepared and plated a specific way, such as keeping safe foods separate from expansion foods.
• For children with ARFID or anxiety around eating, Stachel suggests that sometimes, a little secrecy is okay. Whether it’s hiding vegetables in foods, like a carrot muffin or zucchini pancake, creating opportunities for nutrition without spiking a child’s nutrition can be very effective.
• On the flip side, some children may want to know every single ingredient that is in a recipe or food item. Talking through each food with your child can help demystify the food and give them space and safety to experiment.
• For food anxieties, introduce new foods one at a time and in small quantities, even if the food is just on the same plate as their safe foods.
• Let the child contribute to their food choices and discussions, within reason. “The more involvement the better,” says Stachel. “If they're willing to be involved, willing to talk about it, willing to expand, that's great.”
• Model comfortable eating for your child — don't push and never force eating beyond their comfort level.
• Never use a punishment contingency. Caloric intake is central to a child’s growth, so denying them one food or snack if they don’t eat enough of their nutritious options can impact both their growth and associations with different foods.
• Don’t forget that growth is the goal. There may be times that eating for growth won’t always match 100% of a child’s nutritional needs, and that’s okay in the short-term.

Tips for birthday parties, vacations, movie theaters, amusement parks, etc.

• For social events, notify the organizer/host in advance. How accommodating the host will be depends on the circumstances, but give the organizer a list of safe foods if asked. Not every child has to eat the same thing!
• If your child is attending a birthday party, notify the hosting family as soon as possible about your child’s dietary restrictions and offer to bring an alternative food for your child. It’s likely that your child won’t be the only one with a restrictive diet, and you can coordinate alternatives, such as a gluten-free pizza for a child with Celiac, or alternative desserts for children who may not be able to eat cake due to an allergy (eggs, gluten) or the constraints of their diet (low-glycemic index).
• For venues like theme parks, Undivided parent Karen Ford Cull recommends researching food policy before arrival, as they often list their allergy policies online; don’t be afraid to call in advance for clarity, as some parks are more accommodating than others.
• If you’re unsure about how a theme park or similar venue prepares their food, even if it doesn’t have an unsafe food listed, ask! “Don’t be afraid to ask questions about contamination,” says Cull. “If they stop you from bringing your own [food], it’s only fair to cater to the medical restriction.”
• Keep a copy of a child’s emergency care plan on hand to provide to venue staff if needed.
• When travelling, keep any medications or therapeutic items, like an epinephrine device (like an EpiPen) or G-tube kit in your carry-on or personal travel item. Airports and airlines cannot ensure the same levels of food or feeding accommodations, so parents should expect to pack their own food and time feedings accordingly.
• If the social situation involves food and there isn’t an adult there to supervise the child’s eating, provide an emergency kit for the child or keep one on hand.
• For places like movie theaters, always bring wipes for their seats and/or trays, depending on the type of theater. Ask staff about how they prepare popcorn (such as if the topping contains dairy), and other food items.
• For holidays like Halloween, if you hand out candy or want to give neighbors safe options for your own child, check out these gluten-free candy options, nut-free brands, and dairy-free options. Food Allergy Research & Education (FARE) lists seven important candy facts that shouldn’t be forgotten during Halloween, for example: dark chocolate often contains traces of milk. This may not affect someone with lactose intolerance, but it is considered unsafe for those with a milk allergy.

Tips for dealing with babysitters and family

• In childcare situations, such as hiring a babysitter or having a family member watch your child, their dietary restrictions and emergency responses should be clearly laid out for the caregiver, such as if the child needs an EpiPen or when a situation might warrant calling 911. Don’t assume that everyone knows which foods contain allergens (e.g., gluten), but leave explicit instructions.
• Extended family pressure (“just try it”): As a grandparent, Lobel understands the impulse to shower a child with food or use food in a celebratory situation. But creating clear boundaries with the adults in a child’s life are first and foremost to ensure the child’s health.
• If a child has friends that invite them over for a meal or a sleepover, the parents should let the friend’s parents know as soon as possible about any food restrictions. They should make clear what the child needs regarding their restrictions; some may consider creating a safe foods list and sending their child over with safe foods.
• Like with food, parents should alert other adults about any toys or activities that might expose the child to an allergen, Cull says. For example, Play-Doh contains gluten and is thus unsafe for children with celiac or an intolerance; similarly, children shouldn’t be using egg or milk cartons for arts and crafts if dairy or eggs cause allergic reactions.
• Clean clean clean! If a babysitter or family member prepares food for the child separately from their own, they should ensure that their hands and any utensils used are cleaned between uses to avoid cross-contamination.
• Holidays and traditions: Many families travel over the holidays, including the need to take a plane. If food is prepared in the kitchen, make sure any food for the child is prepared separately and with clean tools and utensils.
• Teach your children how to advocate for themselves, if possible. One way to do this would be to use a card they can show to a server at a restaurant, such as these Celiac cards, or even have the information on an AAC device.
• Don’t underestimate how a dietary restriction affects your child emotionally. “I think if a child is cognitively aware that they have a G-tube and nobody else does, we need to talk about that and try to make them feel the best they can,” says Dr. Beisang. School, especially middle school, is always a challenge because everybody wants to be the same as everybody else, and heaven forbid that you're a little different.”

Tips for ordering in a restaurant

• Restaurants are generally happy to answer questions about ingredients and the substitutions policy. Tip: If your child is an AAC user, they need to learn to do this ordering. Set them up with questions on their AAC so they can ask about the food.
• Research the restaurant and peruse the menu before heading over. Check for online reviews that mention substitutions. See apps below.
• While you can’t guarantee it, ask the kitchen about their allergen cross-contamination policy, or if your child’s food will be made in proximity to unsafe foods.
• Always ask about sauces or toppings that may not give a full ingredients list.

While you shouldn’t trust everything you see on the internet, there are a number of online resources to help parents better understand how to support their child’s restrictive diet.

Apps and resources to navigate food safely

• For checking for safe foods when looking to dine out, apps like Find Me Gluten free and AllergyEats can provide options for safe dining.
• The Food Is Good, or FIG, app, can also help you check food and product ingredients quickly if you don’t have your list of safe foods on hand.
• Spokin is another option for families who want a digital guide to safe foods and eateries when traveling, with a built-in community server for users to meet and share recommendations.
• Local Facebook groups may also provide more casual, non-professional support for families, including some for ARFID, allergies, and G-tube users.
• More and more institutions are catering to restrictive diets! The Celiac Cruise, for example, partners with existing cruise lines to offer families a cruise experience completely gluten-free, with over 10 on-ship dining options. Current locations offered for future trips include parts of Europe, the Caribbean, and Mexico.