There is little evidence of any significant benefit from elimination diets in infants and young children with atopic dermatitis, a systematic review and meta-analysis has found.
The review, published in the Journal of Allergy and Clinical Immunology: In Practice, identified ten RCTs comprising 599 participants (mean age 1.5 years) comparing various elimination diets with no dietary elimination on eczema outcomes.
Some of the diets excluded cow’s milk and /or egg while others evaluated a few foods diet, an in-hospital elemental diet, hydrolysed whey or cow’s milk formulae.
The meta-analysis found dietary elimination slightly improved eczema severity (50% v 41% improved their SCORing Atopic Dermatitis score) but with low certainty.
Similarly, pruritus as measured by a daytime itch score, and sleeplessness improvised slightly but with low certainty in the few trials which reported on those outcomes.
“The slight effect of dietary elimination on eczema severity suggests food, through ingestion or contact, may be a minor contributor to causing and/or perpetuating AD,” the researchers said.
There was insufficient data for analysis of safety outcomes such as the impact on nutrition or the development of new IgE-mediated food allergy “although indirect evidence suggests an increased risk”.
The researchers said the slight improvements with dietary elimination were “potentially unimportant” when compared to the potential risk of harm.
“The role of diet in AD has been long debated; patients and caregivers commonly report strong suspicion, and historical teaching among clinicians provided greater emphasis on the role of food allergy as a driver of AD,” they said.
“However, many clinicians now cast doubt and consternation out of concern for confounding from other triggers or AD flare independent of external factors and avoiding harms that can occur with dieting practices.”
They said the health benefits, harms and practical implications of dietary elimination should be carefully considered.
“Many fully informed patients and caregivers may not consider worthwhile a slight improvement in eczema control against the potential for developing an IgE-mediated food allergy, impact of dietary restrictions on quality of life, nutrition and growth, and/or opportunistic cost of more effective treatment better aligned with treating the underlying disease.”
They noted that unhelpful discussions about dietary concerns with healthcare providers could led to unsupervised and potentially more harmful elimination diets.
The findings will inform upcoming American Academy of Allergy, Asthma & Immunology (AAAAI) and American College of Allergy, Asthma & Immunology (ACAAI) Joint Task Force on Practice Parameters guidelines on atopic dermatitis.