ACAAI: Food Elimination for Allergies May Lead to Failure to Thrive

PHILADELPHIA, Nov. 12 -- Infants who are put on food-elimination diets to avoid allergens could be inadvertently robbed of the proteins and nutrients they need to grow, researchers warned here.

Children taking allergen avoidance diets may develop malnutrition due to the severe protein and caloric restrictions involved, said Michael B. Levy, M.D., of the Medical College of Wisconsin, and colleagues.

In a presentation at the American College of Allergy, Asthma, and Immunology meeting, the investigators reported on two patients in which the diets robbed the children of so many calories and nutrients that they developed failure to thrive.

"Intensive nutritional assessment and management should be included following the institution of restrictive allergen free diets," the Milwaukee researchers urged.

The first case was that of an 18-month-old boy who was admitted with diffuse rash, failure to thrive, diffuse edema, and irritability. He had previously been diagnosed with milk-protein sensitivity, and so had been switched to enriched rice milk six months before his admission. The rice milk comprised 75% of the boy's total calories.

His weight on admission was 10.40 kg (22.9 lbs), putting him in the 11th percentile for his age. On examination, he was found to have peripheral edema and a diffuse dry, erythematous rash.

Laboratory studies showed that he was suffering from iron deficiency anemia, an albumin level of 1.9 g/dL, and both selenium and zinc deficiency. He was also assumed to suffer from an essential fatty acid deficiency.

But when they performed a skin prick test for food sensitivity, they found that the tests were negative.

The investigators started the child on a nutritional rehabilitation program with a nasogastric feedings of a hydrolysate formula, with re-feeding syndrome addressed as needed according to daily lab values.

He was discharged after 17 days in the hospital, weighing 10.96 kg (24.1 lbs) or 5%, shooting him up from the 11th to the 31st percentile.

The second case was that of a 13-month-old girl who was admitted to the hospital secondary to severe atopic dermatitis, failure to thrive, cellulitis, and multiple food allergies.

The child had undergone Radioallergosorbent Testing (RAST) at eight months, which showed the she was sensitive to milk, wheat, egg, corn, soy and peanut.

The girl was then put on a diet that eliminated those foods, but she was not started on nutritional supplementation, and was getting from 50% to 75% of her calories from fruit juice, the investigators reported.

At admission she weighed just 7.4 kg (16.28 lbs), and was below the first percentile.

Her albumin and zinc levels were normal, but physical examination showed that she had eczematous skin lesions and left arm cellulitis.

She was started on elemental formula, a high-calorie diet, and her caregivers were instructed in allergen substitution. After four days in the hospital her weight had increased 2%, to 7.63 kg (16.79 lbs).

The authors cautioned that "fruit juice and milk substitutes composed of rice, oat, hazelnut, or almond contain very little protein and will result in protein energy malnutrition when utilized as the primary calories source by infants and young children."