Dr. Jain is an Arizona-based pediatrician specializing in allergy, asthma and immunology. Here he talks about some memorable pediatric cases. “I’ll tell you upfront that I don’t have all the answers to all the questions,” Dr. Jain says. “These cases force me to ask questions — and to suggest treatment plans — that are sometimes difficult.
Case one: Controlling an infant’s atopic dermatitis to lower the risk of developing food allergies
When I was still in practice in Madison, a mother brought her three-month-old baby to see me. The baby’s older sister, whom I had seen along with her parents, had signiﬁcant eczema.
The baby had cradle cap by one week of age, and she seemed to be scratching and starting to have eczema by two months of age. She was being breastfed exclusively, but the mother was concerned that her baby might be allergic to foods that she was getting through her breast milk.
This case raises many questions: Are food allergies already contributing to the baby’s eczema? Can she be tested at such a young age? How accurate will those tests be? Is she at risk for developing food allergies, and as she grows up, should she avoid foods that tend to be highly allergic triggers? Should the mother be avoiding those foods while she is breastfeeding her baby? Many of these questions are hard because we don’t really have the answers.
Can allergens be passed through breast milk? Yes, they can. When you eat a food, some of the proteins do pass through intact. Most of the proteins are digested, so they are chopped up. And an allergic reaction is dependent on whether a child is allergic to the intact protein or a certain part of the protein.
How do allergies develop? From data on a mixed population of patients, it doesn’t seem as though avoiding foods early in life prevents people from developing food allergies.
But what if you just take a group of patients that have eczema and that are now having kids? Should they be avoiding foods? We don’t know the answer to that.
I said to the mother, “Is your baby at risk for developing food allergies and should she avoid some foods to prevent the onset of food allergies? Yes, because her sister has food allergies, so there is a family history of food allergies.” That does increase the risk that this baby will have food allergies. Were food allergies already contributing to her eczema? I didn’t know but I didn’t think so. She was being breastfed, and when I see eczema come on at this early age, I think it’s more likely some genetic thing going on in the skin.
I thought a bit about skin barrier dysfunction. I also considered the possibility of early colonization with staph. But regardless of this, we know that the skin, especially early in life, is a very rich immune organ. Skin is reactive, and things can happen. Say, for example, the big sister splashed some milk on the baby’s skin and she’s already got this sort of inﬂammatory process going on. That alone could be enough to cause the baby to become sensitized to milk.
I didn’t know that foods were causing the baby’s eczema at this point, but I did worry that this child will go on to develop food allergies. So I thought we should focus on trying to keep the baby’s skin as calm as possible, controlling her eczema so that maybe she won’t go on to develop food allergies.
In cases where I see bad eczema at this early stage of life, I do often do some blood work and IgE testing, but I always tell the parents I don’t necessarily know how to interpret the results. I’m just hoping to gather some additional information so we can try to ﬁgure out what to do.
Case two: Skincare, not diet to manage a toddler’s eczema
A 3-year-old boy had eczema that was difficult to control. He’s had eczema since two months. The boy has had a number of tests. He tested positive to many things, but avoidance of certain environmental triggers isn’t possible and avoidance of foods doesn’t seem to be that helpful for him.
The boy has been on certain diets, and for the most part he stayed on them. His skin always got worse in the summer and better in the fall and the winter. His mom said that sometimes they cheated on the diet and her son’s skin didn’t get worse. She was very hesitant to use any topical steroids on his skin because she was concerned about possible side effects.
This case raised these questions: Were this boy’s allergy tests accurate? Should he have avoided all these foods? Probably not. Were other factors contributing to his eczema? I thought so. So, what could be done?
Sometimes it’s my job to tell people what they don’t want to hear. Sometimes there is no easy solution, no speciﬁc food you can avoid to ﬁx this. I had to say “Look, the only way you’re ever going to get this child’s eczema under control is by taking really good care of his skin and using topical medications.” We didn’t have a way of ﬁxing those environmental allergies and I didn’t believe the foods were causing his condition and itching.
Case three: Look for the obvious when determining a child’s allergy
A young boy has had severe eczema since three to four months of age, and he has conﬁrmed food allergies to egg and peanuts with anaphylaxis developing when they are introduced.
He also tested positive for allergies to dogs, grass, weeds, and soy. There is a dog in the home, but the parents are hesitant to remove the dog because they are not convinced it’s contributing to the problem.
Should the dog be removed from the home? Absolutely. Should the boy avoid other foods? I didn’t think so. We’ve got to focus on the obvious things.
On a related note, there have not yet been any great studies to determine if a dog’s breed make a difference in terms of eczema. Some epidemiological studies have looked at breed and its inﬂuence on allergic rhinitis, and in that instance, breed doesn’t seem to matter.
There is no such thing as a hypoallergenic dog. The only things that seem to inﬂuence how severely people are affected by their animals are the size of the animal and whether they have been spayed or neutered. Spayed and neutered dogs produce more allergens than dogs that have not been spayed or neutered. Why that is we don’t know. If you don’t already have a dog and you have allergies or eczema, I’d say don’t get one.
I’m not picking on dogs. Cats are even worse. Although I’ve focused on animals here, that doesn’t mean you can ignore other allergens. I think dust mite control is equally important, as are implementing routines like showering and washing your clothes after playing on grass and practicing good skin care.
Neal Jain, M.D., is a pediatric allergist with a special interest in atopic dermatitis and food allergy. He is in private practice in Gilbert, AZ, and also teaches pediatric residents at Maricopa Medical Center in Phoenix, Arizona.