Voov makes it to three--and eczema, food reactions continue

Looks like my daughter, Voov, is stuck with eczema for life. She recently turned three and had her annual checkup. The pediatrician told us what we already knew, which is that children whose eczema persists past the age of two usually carry it into adulthood.

But at least her affliction isn't severe. It's not nearly as bad as what I've dealt with myself and what I see discussed on forums and in the National Eczema Association newsletter.

We're also still waiting to see what will happen with her asthma. She takes medication twice a day through an inhaler, but only because when she gets sick, as she is now, she wheezes. She hasn't had an asthma attack.

Food allergies/reactions are another issue. God, she's been eating the same stuff for years. Let me see: chicken, turkey, soy. Rice and oatmeal. Carrots, peas, sweet potato, corn. Apple, pear, banana. That's it! How boring. We've also given her tomato, potato, orange, green beans, and pork, and she refuses to eat any of them, although she doesn't have a reaction.

Two weeks ago, my wife, Hidden B, gave her cow's milk instead of soy milk by mistake, and Voov announced she felt ill and then threw up all over the kitchen floor.

Bummer.

I like to cook, and I keep hoping that someday I'll be able to make one meal for the whole family. At the moment I cook food for Voov and then food for everyone else. We have to tell her over and over again that she can't eat what we and other people eat, because she's special. I wonder how long that fiction will hold up.

The weird thing is that she's hardly ever had an eczema flareup that we could connect to a food we've tried. Voov seems to have allergies or intolerances that aren't directly connected to eczema.

In a few weeks she's going to have a skin prick allergy test for all the same things she was tested for two years ago. We're hoping we'll find that she's grown out of some of her allergies. I myself would like to just give her foods and see whether she reacts, but Hidden B has overruled me. Probably wise, if Voov's reaction to milk is any indication.

Diversity of food eaten in first year linked to less eczema afterward

Feeding your child a variety of foods, especially yogurt, in the first year of life appears to reduce the chances he or she will develop eczema later on, a group of European scientists reported recently in the Journal of Allergy and Clinical Immunology.

The group, led by Caroline Roduit of Children's Hospital at the University of Zurich, had considerable overlap with the researchers who reported two years ago that the mother's exposure to farm animals before birth reduced the incidence of eczema. Both studies were based on data from the Protection against Allergy--Study in Rural Environments (PASTURE) project.

The authors say that, in the existing scientific literature, there is no consistent evidence that avoiding food allergens during pregnancy or infancy prevents allergies later. Because they conducted this study, it would seem they believe the opposite: that exposing kids to allergens could lead to tolerance and therefore fewer allergies. And eczema often has an allergic component, although it's sometimes difficult to classify the precise type of reaction that a patient has to a food.

The authors considered data from 1041 children, seeking to correlate the variety of foods fed eaten with whether the children developed eczema (not whether they developed food allergies). They reported an inverse correlation: the more foods eaten, the less eczema in the children. Here's Figure 2, the key graphic.

Looks to me like the first two foods make the most difference. After that, the curve is essentially flat.

Four interesting features stand out in the paper:

1) the authors observe that it is very hard to study the connection between food and eczema before a child is one year old, because if a child has symptoms of eczema early, or if one or both of the parents has allergies, the child tends to be given very few foods in addition to breast milk. So a naive researcher might immediately conclude that giving a kid only one or two foods leads to eczema. To be rigorous, the authors restricted their study to children who developed eczema after the first year.

2) yogurt, according to this data, is a special case. If a child eats yogurt, and very few other foods, it appears to reduce the odds of developing eczema to 40% of what they were to begin with. That may be because the yogurt bacteria somehow provide a probiotic effect in the gut.

3) the six major food groups that the authors consider as independent are vegetables and fruits; cereals; meat; bread; yogurt; and cake. (Cake is a separate food group in Europe?) I find this odd, given that bread and cake are made from cereals and the three groups must contain very similar allergens.

4) Europeans apparently give their children very few soy-based foods. North Americans must have been influenced by Asian cuisine and include tofu and soy sauce in their diets more than they used to. Or maybe it just looks that way because I live in the Pacific Rim.

I wouldn't make any radical changes to my kids' diet based on this paper, but you can't do any harm feeding them yogurt.

Blood tests for food allergies/sensitivities that may cause eczema

Just out in the Canadian Medical Association Journal: a primer, presumably for doctors [media summary] on how to handle patients who arrive in the doctor's office clutching printouts of blood tests taken to find what foods might be causing trouble for them.

I'd imagine this happens all the time. I don't blame patients at all. Who cares most about your health? You do. Do you think your medical providers, whatever system you use, are doing as well as they could for you? Probably not. So if you've got a chronic condition that seems to be related to what food you eat, you get a blood test done to try to find the culprit(s).

There's more than one problem with this, however. Most patients don't understand the difference between food allergy, reaction, and sensitivity. The primer's author, Elana Lavine, briefly explains:

Food allergy is an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food. Nonimmunologic adverse reactions to food are termed food intolerance and include conditions such as lactase deficiency, dietary protein–induced enterocolitis syndromes and eosinophilic gastrointestinal disease. Food sensitivity is a nonspecific term that can include any symptom perceived to be related to food and thus may be subject to a wide range of usage and interpretation.

Eczema patients (in my understanding), are usually subject to the first and third categories. We probably have IgE antibody-based allergies to one or more foods (in addition to pollen and pet dander). And our skin inflammation is exacerbated by anything that causes increased blood flow at the surface, such as spices, alcohol, and histamines from fermented or aged foods such as Parmesan.

Lavine says that many patients get blood tests based on measuring levels of IgG --a separate class of antibodies from IgE. But, she says,

neither total IgG nor IgG4 [a subclass] levels correlate with food allergy as shown on double-blind placebo controlled food challenges.

IgG4 floating around in our systems may just mean that we have been exposed to a food and become able to tolerate it.

I did a quick web search and found a company called ALCAT that claims to test for food sensitivity using their proprietary technology, which measures how white blood cells change size when exposed to antigen. I'd have to consult an expert but I have trouble believing that results from such a test would truly reflect how your body is reacting--or not--to foods.

So what can you do to determine whether food is causing your eczema to flare up? Lavine says

Making the diagnosis of a specific food allergy may include the following: a full medical history, physical examination, skin prick testing, carefully selected food-specific IgE levels and oral food challenges to suspected food allergens in some instances.

There's no easy answer. To nail an allergy, you need the whole shebang. Avoiding a food entirely and seeing whether your eczema improves is a good start. The trick is, in my experience, to eat as few processed foods as possible so you can get control of the ingredients. Beware: even something as simple as soy sauce may contain wheat, for example.

[added later] I realized that I didn't address the topic of IgE tests. I don't think that a consumer (in the US) can get this test done without a referral from a doctor. The last time I asked an allergist about getting tested for IgE (the technology available at the time was RAST), he told me that "they" didn't do RAST on atopic patients because the circulating level of IgE was so high that it inevitably saturated the measurement no matter what they tested for. However, a quick Google search reveals that Quest Diagnostics now touts the ImmunoCAP blood test as a way to determine IgE allergy. Has anyone tried ImmunoCAP?

Maybe your kid CAN eat more foods

I'm back from my weekend trip to New Haven for the science writers' conference. A smashing idea, getting about 500 of us in the same place and giving us drink tickets. The hubbub of eager networking (freelance writers have to network nonstop if they want to eat) at times almost drowned out the science-themed standup comedians and a cappella groups.

My trip was a success not only professionally, but because twice in the space of two days I got up at 4:30 am, endured the stress of making a flight, sat for 7 hours in the dry, recirculated, funky air of a Boeing 737, ate at McDonald's (Hartford airport is no food paradise), and downed my share of beer and wine-- and here I am at the end of it with dry skin, yes, but no eczema to speak of. Score!

I'm going to continue the food allergy thread today. There's a recent study out of National Jewish Health Center in Denver that found that many children with eczema are unnecessarily leaving foods out of their diets, for fear of food allergies that don't exist. The main issue the authors are making is that the proof of most food allergies is in the eating. Blood test results for IgE allergies are not believable unless they show you are positive for cow's milk, hen egg, fish, peanut, or tree nuts.

If a test shows your kid IS allergic to one of those five things, you definitely shouldn't eat it. But David Fleischer and colleagues (including Donald Leung, leader of the Atopic Dermatitis Research Network, who appears to be the heavyweight author) took 125 children who had been on restrictive diets based on IgE tests, and, in a controlled fashion, let the kids eat food that they had previously avoided. The result: "Depending on the reason for food avoidance, 84 to 93 percent of foods being avoided were restored to their diets."

This matters because your young child needs a balanced diet to develop properly, and also because substitute foods (goat milk, almond butter) are expensive.

I find the study personally interesting because Voov (18 month daughter) has been on an extremely restricted diet for many months. Skin prick tests showed allergies to a number of things and the allergist recommended, at first, some ridiculous diet--seriously, like "she can only eat sweet potato, broccoli, and chicken." Completely unreasonable, and after Hidden B protested, and we got advice from a nutritionist, the allergist relented a bit and permitted these items:

• zucchini
• broccoli
• asparagus
• sweet potato
• pears
• bananas
• chicken
• turkey
• rice
• soy

That is what Voov has been eating for at least six months, over and over. (She's also breastfed.) We're allowed to pour canola oil over her food so that she gets some omega-3 oils for her brain. She's a happy enough kid, but still has eczema flares, and she has to be getting pretty tired of this food by now. I know that I'm getting bored of making it, when it's my turn to boil the zucchini.

Fleischer et al. don't say whether skin prick tests are as useless as most IgE blood tests. But I sure would like to expand Voov's diet, so she can experience some new tastes. Wouldn't it be great if she could just eat the same things we do!

Mr. Peanut need not apply

Eczema Mom recently posted about her experience being on a plane with her kid, who's been diagnosed with severe peanut allergy-- some guy opened a bag of peanuts in the row ahead of them, and the smell drifted back, and she could do nothing but wait and see whether her kid would have a reaction. (On a plane! What are you going to do if he DOES have a reaction?)

Peanuts-- I love to eat peanut butter, and Snickers, but I'm learning that a lot of people have severe allergies to them. In fact, Voov was diagnosed with a peanut reaction on her skin prick test-- Hidden B will know all the details. Hidden B is breastfeeding Voov (who's been on solid food for a while now, being 18 months old) and has had to avoid peanut butter herself. I get in trouble for eating the sunflower and almond butter-- which somehow seem more exotic and tasty than my peanut butter.

Peanuts are in the news at the moment. There's a study out in the Journal of Allergy and Clinical Immunology by a group at the Mount Sinai School of Medicine in NYC, indicating that pregnant women ought not to eat peanuts if they can help it. The specifics-- seems only to apply to kids who are suspected of being allergic to milk or eggs, or have eczema and allergies to milk or eggs. (An odd study group, that-- but I can't see the details because my institution doesn't have access to the paper itself.)

Kids with eczema really have it tough-- the itch, the rash, the food reactions, and then they're at higher risk of developing a life-threatening peanut allergy. Life's a bitch.

I had a short email today from a reader, Jon, letting me know that his partner, who's had eczema for a long time, had recently seen a dramatic improvement after cutting out dairy products. That's awesome and I encourage anyone who has eczema and who has never tried an elimination diet to do the same thing. Cut out, one at a time and for two weeks or more, milk, soy, peanuts, wheat, and eggs. (And fish, if you eat it regularly-- Hidden B hates fish, so I never cook it.)

Here's my personal take: I draw a distinction between food ALLERGIES and food (or drink) that causes REACTIONS. I might have a food allergy; I don't know for sure. But I do know I have reactions to alcohol and hot peppers, which both dilate the blood vessels in the skin. I get itchy after drinking booze or eating a hot curry in the same way I do after I exercise. I'm guessing the heat or blood flow somehow stimulates itch nerve fibers. And then, I also have reactions (oh, so vicious) to aged cheese like real Parmesan, and to preserved foods that are high in histamine. These just have to be triggering inflammation systemically.

Does this mean I never have a drink, or enjoy a fine double Gloucester? Hell no. You have to live. But I often regret it the day afterward.