Elimination diets in eczema.

Correspondence Elimination diets in eczema Sir, We read with interest the paper by T J David on anaphylactic shock during elimination diets for severe atopic eczema. We recently observed a similar case. This girl had developed severe diarrhoea at 5 weeks of age while being fed an adapted cows' milk formula (Preaptamil, Milupa). During a milk free diet her symptoms subsided, but diarrhoea recurred when a full amount of adapted cows' milk formula was again given. The infant stayed well and lost little weight. Three such challenges were carried out, but after the third the severe diarrhoea persisted even when lactose-free soya protein milk was given. At age 7 weeks the baby was fed a lactalbuminhydrolysate milk formula (Alfar6, Nestle) and on this regimen she quickly recovered and gained weight. Although we believed that she suffered from cows' milk protein intolerance, it was thought that the symptoms might also have been due to a postdiarrhoeal lactose intolerance. At the age of 16 weeks, therefore, after nine weeks of receiving Alfar6, reintroduction of cows' milk formula was attempted. The baby was given 15t) ml adapted cows' milk formula (Preaptamil, Milupa) at 11 am. The feed was well tolerated and she stayed asympto-matic. The next feeds were Alfar6 at 2 pm and 5 pm. Suddenly, 91/2 hours after the cows' milk feed, she was found by the nurse nearly dead, grey and cyanotic, with gasping respirations, and vomited milk was seen around the mouth. She was rescuscitated and treated in the intensive care unit without further complications. No milk was found in the trachea and the chest film showed no aspiration pneumonia. Subsequently, however, spastic tetraplegia developed. At the time we were uncertain about the aetiology of the shock, because we had never seen delayed anaphylactic shock in cows' milk intolerance. Having read the paper by David we feel that the aetiology in our patient might be similar to that of the patients reported. Close observation might lead to a more frequent recognition of delayed anaphylactic shock and sequelae in patients challenged after long term elimination diets. Dr David comments: There is a striking resemblance between this important report, case 4 of the original paper, and the patient mentioned in the first paragraph of the discussion of the paper. The intervals between milk exposure and collapse were 91½2 hours, 10'() hours, and 8 hours respectively. The delay in onset of anaphylaxis adds …