Diet restriction of breast feeding mother for child with atopic dermatitis
Question:
8/3/2018
Eight-month-old girl initially presenting with moderate atopic dermatitis, with onset prior to three months of age. Strictly breast-fed, with mother not practicing any dietary restrictions. Allergy evaluation by Immunocap method reveals specific IgE to peanut at 2.84, almond at 2.13, wheat at 7.32, egg white at 9.85, cow's milk at 3.63. No allergic sensitivity to soy, shrimp, codfish. No allergic sensitivities identified to dust mite, dog, cat, or Alternaria. Total IgE non-elevated at 70. CBC reveals peripheral eosinophilia at 1400/mm3. Recommended skin care to include long soaking baths, frequent application of moisturizer, with the use of hydrocortisone 1% and 2.5% ointments.
Mother contacted with recommendations for avoidance of above foods in her diet while breast-feeding, with recommendations for transitioning to an extensively hydrolyzed formula because of concerns regarding the nutritional value of her breast milk (if above dietary restrictions are implemented in mother's diet). On 6 week follow-up, significant improvement noted in patient's skin condition, with mother reporting that she has continued to exclusively breast-feed, having been very compliant with implementing the above dietary restrictions. Mother reluctant to use any form of topical steroid products on patient and therefore has only been applying moisturizer.
Unfortunately, patient has lost 6 ounces in the 6 week interim since initially seen. Outside referral suggests no need for any maternal dietary restrictions in the above case, and subsequently recommends continued breast-feeding, immediately adding back to mother's diet, at the same time, cow's milk, egg, peanut, tree nut, and wheat. Practice parameters do not specifically address maternal dietary restrictions while breast feeding in such cases as described above in which atopic dermatitis already exists and patient is found to have significant food sensitivities. What are your thoughts regards this scenario?
Answer:
Eczema can generally be controlled with reasonable avoidance measures and topical therapy. Proper nutrition is critical to the growth and development of the baby and would trump any eczema concerns in my mind. It is not appropriate to utilize nutrition insufficient for growth because of a reluctance to use topical hydrocortisone. A documented, shared decision-making discussion with both parents should review the proven risks of insufficient nutrition in the child’s health and development contrasted with the lack of proven side effects of low strength topical corticosteroids. Crisaborole is not approved in infants less than 2 years of age but would provide a safe, non-corticosteroid alternative to care. Finally, in light of LEAP and other data, I would make the case to the parents that early regular exposure to foods recognized by specific-IgE would reduce the risk of developing anaphylactic sensitivity (1-4). In the long run, more symptomatic eczema would be preferred to avoidance of a food possibly for life due to anaphylaxis risk.
In summary, I would not recommend restricting calories and nutrition for treatment of eczema. The alternatives include allowing diverse diet of the mother and continue breast feeding, supplementation with formulae based upon the child’s tolerance or use of elemental formula. For long term minimization of food allergy, I would favor breast feeding with formula supplementation. I would reassure about the side effects of low strength topical corticosteroid, emphasize emollients as you have done, and consider off label use of crisaborole. You may also evaluate for sensitivity to indoor allergens and try to limit exposure to pets or dust mite if significant specific-IgE is detected.
1. Du Toit, George, et al. "Food allergy: Update on prevention and tolerance." Journal of Allergy and Clinical Immunology 141.1 (2018): 30-40.
2. du Toit, George, et al. "Prevention of food allergy." Journal of Allergy and Clinical Immunology 137.4 (2016): 998-1010.
3. Fisher, Helen, et al. "The Challenges of Preventing Food Allergy: lessons learned from LEAP and EAT." Annals of Allergy, Asthma & Immunology (2018).
4. Du Toit, George, et al. "Randomized trial of peanut consumption in infants at risk for peanut allergy." New England Journal of Medicine 372.9 (2015): 803-813.
I hope this information is of help to you and your practice.
All my best.
Dennis K. Ledford, MD, FAAAAI