SUMMARY. The intake of nutrients over a five day period was studied in 23 children whose atopic eczema was being treated by the avoidance of multiple foods. The results were compared with those from 23 healthy control children not on a diet. Significantly low intakes of calcium were discovered in 13 patients but not in controls. Avoidance of multiple foods is potentially hazardous and requires continued paediatric and dietetic supervision.It is recognised that atopic eczema improves in some children when certain foods are excluded from the diet1 2 but curiously the safety of such diets in eczema has never been examined. Potential hazards are often stressed, however,3 4 and inappropriate elimination diets in children with chronic diarrhoea have resulted in failure to thrive caused by restricted caloric intake.5 Having established a service for the treatment of atopic eczema by selective exclusion of foods from the diet, we decided to examine the safety of these diets. Patients and methodsSelected children with severe, chronic atopic eczema unresponsive to conventional topical treatment by a dermatologist were treated by dietary allergen avoidance. Patients in whom such a diet had failed and had been abandoned were excluded from the present study. This series comprised the first 25 patients successfully maintained on an exclusion diet. In 18 patients suspect foods were identified by the history and the use of tests for specific IgE antibodies. In 7 patients all foodstuffs except one were withdrawn, followed by the reintroduction of single foods one by one. For each patient the dietitian told the parents how to exclude suspect foods and advised on the use of milk substitutes. The diet comprised in part a soya based milk formula (Wysoy or Prosobee) in five patients, and a casein-hydrolysate formula (Pregestimil) in 7 patients. After 6 weeks on the established diet, parents were seen by the dietitian and asked to keep a record for five days of the quantity of all food and drink taken by the child. No instructions were given as to whether this five day period should or should 323 not include the weekend. Parents were not asked to record food intake as it occurred rather than waiting until the end of the day and the dietitians did not visit the homes to make spot checks on whether the recording of information was up to date. The estimation of quantities was based on household measures. These records and tables of food composition6 were used to calculate the daily intake of individual nutrients, averaged over the period. The calcium content of tap water, which is low in Manchester, was not included. The intakes of calories, protein, calcium, iron, folic acid, vitamin A, thiamine, riboflavine, nicotinic acid, and vitamins C and D were compared with the recom-

In children with atopic eczema on elimination diets, the calcium intake was below the estimated requirement in 15 out of 20 who avoided cows' milk and received no milk substitute, and in three out of 26 who avoided cows' milk but were provided with a soya or casein hydrolysate formula.

A total of 37 children with refractory widespread atopic eczema were treated with an antigen avoidance regimen comprising hospitalisation, exclusive feeding with an elemental formula for a median duration of 30 days, and measures to reduce exposure to pet and dust mite antigens at home. After the initial period of food exclusion, food challenges were performed at intervals of seven days, and the patients followed up for at least 12 months.

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