On 9/28/2014 2:34 PM, Rachel Myr wrote:
> With mother's permission, I'm asking for input from anyone with experience that can help this family. The child is 15 months old, and mother has been following a hypoallergenic diet since he very early on showed symptoms of allergy to many foods.
Rachel,
This is a fascinating case with too many unknowns.
Let's try to go step by step, changing my hats frequently along the way
(anyhow I am a general pediatrician who was a pediatric dermatologist in
my previous life and who is also a lactation consultant)
Agree that the initial symptoms ("colic", bloody stools, response to
strict maternal diet) are indicative to significant food allergies
and/or sensitivities.
That does frequently go (especially in infants) with the disbalance of
intestinal flora or, as we did call it in Russia "disbacteriosis".
Kids like that do frequently have eczema and the said eczema is pretty
hard to treat. At the same time skin in such children are also known to
have the overgrowth of "bad" bacteria, and the stress of the constant
itching is only making the intestinal problems worse. Add to the mix
another infectious disease - caries and we are looking for a lot of
problems in a very small and extremely miserable human being.
Without knowing all the details of the situation (you and/or mother are
more then welcome to contact me off the list) I would suggest the
multi-prong approach.
We can not and should not deal with one problem (either caries or GI
issues or skin issues) or even one part of the problem (i.e.
non-sedating antihistamines for eczema) at a time.
1. First and foremost - I would agree with continuation of breastfeeding
as (a) breastmilk is the most perfect food with all the goodness of all
the great things in it, (b) it does provide a significant comfort to the
kid and (c) I don't think that it does cause neither caries nor eczema
nor GI issues.
2. Delaying the treatment of caries is openly counter-intuitive as we do
already have a problem (caries) and the said problem should be treated
aggressively and adequately. This child should be seen by the pediatric
dentist ASAP and all his cavities should be taken care off. Pediatric
dentist should also assess the need for additional prophylactic measures
(i.e. fluoride varnish, supplementation, etc) and the need for more
frequent follow-ups. Remember, caries is an infectious disease and if
left untreated can lead to more extensive damage to milk and permanent
teeth.
3. Skin... IMHO, cetirizine has VERY little to offer to this child (the
same as Singulair, BTW - sorry, Pat). Skin should be treated
aggressively by multiple topical and systemic preparations
SIMULTANEOUSLY. We have to address the inflammation (steroids, as most
probably non-steroidal preparations would not be effective here),
secondary bacterial infection (topical antibiotic medications as I would
be extremely cautious with the oral antibiotics in this situation and
household bleach baths for the long term control), and severe itching
(room temperature should be on the low side, sedating antihistamines
would do a much better job here then non-sedating ones, topical
anti-itch preparations can be a good help, but beware of the stinging in
many of them, so using them on the open wounds is not advisable)
4. At the same time a good (I mean academic center good) pediatric
evaluation is definitely in order. The kid should be properly evaluated
for the immunological problems while addressing the said GI issues by
adhering to the hypoallergenic diet and by adding the probiotics (beware
that some of them do contain some elements of milk and thus should be
avoided) and pancreatic enzymes. Evaluating stool for ova and parasites
can be a good idea, as even infestations would not be a cause of his
problems, the inflamed gut is like an open wound - it gets infected much
easier and without proper treatment would not heal well.
Once again, all these actions should take place CONCURRENTLY, not
consequently.
Hope that helps,
--
Alla Gordina, MD, IBCLC, FAAP
General Pediatrics
Breastfeeding Medicine
Adoption and Foster Care Medicine
Global Pediatrics and Family Medicine
NJ Breastfeeding Medicine Educational Initiative
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