Do I really need to see a doctor or dietitian before placing my child on a restricted diet?

I met a family a short time ago after their allergist referred them to me. The little girl was having issues with eczema, generalized rashes, nasal congestion, some sinus infections, and occasional upper respiratory infections. The allergist was in the process of doing blood work and skin prick testing to determine if food allergy could be a potential contributing factor to the symptoms this young girl was experiencing. 

The allergist told me that he was concerned about this girl’s height and weight growth pattern—especially her lack of height growth over time.

To be honest, I was alarmed when I saw the girl in my office. She was very small, looked frail, had thinning hair, was pale, and had very low energy for someone her age. Her growth had stalled to the point that she had “fallen off” of her growth curve for both height and weight.

After getting an extensive diet history from the parents starting at birth, I learned that she was breastfed and was supplemented with infant formula that was supposed to be “easier to digest.” Mom reported that in the past her daughter had a hard time transitioning off formula onto cow’s milk, so the family decided to use a combination of alternative milks–soy and rice milk. Recently, her diet consisted mainly of rice milk since she preferred its taste. Unfortunately rice milk is naturally a poor source of protein unlike cow or soy. She ate a variety of foods during the first 2 years of life but gradually her diet became more and more limited. At the time of the first dietitian visit, this girl was on a dairy-free, wheat-free, gluten-free, corn-free, and mostly soy-free diet. She did not include any sources of fish or shellfish and rarely ate any type of nuts.

The parents explained that they read online about how certain foods can cause food allergies and may lead to the symptoms that their daughter was having. By the way, healthcare providers cringe and maybe even cry a little bit on the inside when they hear a patient say the phrase “I read on a website…”

This little girl was not happy on this very restrictive elimination diet. The parents had difficulty finding foods that she enjoyed and she was basically eating only when her parents forced her or bribed her. Based on what I heard from the parents and the child, she ate just enough to ward off hunger.

I immediately requested additional blood tests to determine just how severe her nutritional deficiencies had become. Most of the results did not surprise me but one lab value did, and that was her very low prealbumin level. Prealbumin can reflect the body’s capability to call on protein stores to support many different body functions. It also is a useful indicator of nutritional status. Her low prealbumin level combined with “red flag findings” related to her atypical clinical and nutritional intake histories revealed she was significantly malnourished.

The parents were well intentioned when they initiated a food elimination diet that restricted major foods/food groups in order to find a way for their daughter to get relief from her symptoms. They preferred to avoid controlling her symptoms with an multiple medications or restrict her activity. What they failed to recognize is that by removing so many of the top 8 food antigens (i.e., those antigens that cause 90% of all food-related reactions in the U.S.) and even more foods from her diet without finding nutritious alternative replacement foods and/or using nutritional supplements, they were unintentionally slowly starving their daughter and putting her health as well as her potential to grow in danger.

Her malnutrition was a direct result of her overly restricted diet and the eating conflict it created that unfortunately did not provide relief from her symptoms–eczema, generalized rashes and frequent respiratory infections. In fact, her diet was making them worse because her body was not getting enough nutrients such as calories, fat, protein, vitamins, and minerals it needed to support a strong immune system to maintain health. Interestingly, pound for pound children have much higher calorie needs than adults because they experience rapid phases of growth and development.

It is critical that the body has adequate stores of protein, fat, glucose, vitamins, and minerals so that in times of illness when there are greater demands placed on the body, the body can draw from its reserves to fight off infections. This little girl was approaching the need for a lengthy hospital stay to acquire nutritional support. Her body simply did not have any reserves to fight off infections and simultaneously grow.

If your child is having symptoms that you feel could be a result of a food allergy, it is essential that you speak with your primary caregiver—a pediatrician or family medicine physician or any subspecialist that provides care for your child such as an allergist or gastroenterologist. If food allergy is suspected to be a cause of your child’s symptoms, your next visit needs to be with a dietitian that specializes in designing eliminations diets for food allergy. The dietitian will determine your child’s calorie, vitamin and mineral intake and determine what foods help meet those needs that your child is willing to eat. Simply removing foods without finding alternatives that provide a comparable nutrient profile can potentially do more harm than good.

Fortunately for this little girl, the parents were very open to change and wanted their daughter to be happy and healthy again. The allergist helped them find a regimen to control the clear up her skin, stop the itching, runny nose, and cough. Through trial and error it was determined that foods were not the cause of her allergy symptoms (the family dog and cat played a large role), and she gradually returned to a regular diet. She was placed on a high calorie supplement for a short time to help her body overcome her nutritional deficits and regain the weight it so desperately needed. She started to grow again as her overall nutritional status improved.

There are situations where food allergy does play a role in the development of rash or worsening eczema. Please see your doctor or a dietitian before starting an elimination diet to ask if removing foods from your child’s diet may help. Please make sure you are getting credible advice. Remember a diet is not supposed to be worse than the condition it is meant to treat.

Our guest blog today comes from Alexia Beauregard. Alexia Beauregard is a Registered Dietitian. The inspiration for this blog is based on her extensive experience working with the families of patients diagnosed with EoE. Please be sure to talk to members of your child’s healthcare team to determine if this information is appropriate for your child.

Published: 10/27/2016
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