Salicylate elimination diets in children: is food restriction supported by the evidence? When a food is identified as causing allergic symptoms, that food will usually be removed from the diet. However, inappropriate use of extensive food elimination can be harmful. Salicylate elimination or “low salicylate” diets — which remove foods deemed to contain natural salicylates — can be particularly restrictive, especially as they are often implemented with restriction of other foods such as those containing amines, glutamates, synthetic food additives, gluten and dairy. These diets appear to be commonly used in New South Wales, but to our knowledge are not widely used outside of the state or in other countries. We discuss our own experiences with children who were referred for care to the allergy clinics of three public hospitals, and who had previously used these diets, and review the evidence for using low salicylate diets in treating a variety of disease indications. For which conditions are low salicylate diets prescribed in Sydney? We sought to identify the indications for which salicylate elimination is prescribed in Sydney by conducting a retrospective case note review of children attending the allergy clinics of the two main children’s hospitals, Sydney Children’s Hospital and the Children’s Hospital at Westmead, as well as a major regional allergy clinic at Campbelltown Hospital, between 1 January 2. December 2. 01. 1. We confirmed any missing details through a single telephone conversation between an immunologist or allergist and the child’s carer. Approval for the study was obtained from the South Eastern Sydney Local Health District, Human Research Ethics Committee – Northern Sector. We identified 7. 4 children who had at some point in their lives been on a low natural salicylate diet. The most common indication for initiation of the diet, reported by the patient’s carer, was eczema in 3. We found no evidence in the peer- reviewed literature to suggest a role for salicylates in any of the diseases for which the diet is prescribed. In the absence of an overt type I hypersensitivity clinical response, food is an uncommon precipitant of eczema. A 2. 00. 8 Cochrane review concluded that, with the exception of egg exclusion in patients who have positive specific Ig. E antibodies to egg, there is little evidence to support restriction of tolerated foods in eczema. On the other hand, there is good evidence that food exclusion can ameliorate the hyperkinesis symptoms of ADHD, with numerous studies showing a benefit for broad- based food exclusion diets. However, a recent randomised controlled trial suggests that much of this effect is caused by artificial food additives, and we were unable to identify any peer- reviewed evidence that natural salicylates can cause hyperactive behaviour. One published letter referred to challenge with salicylates precipitating behavioural symptoms, however the authors did not stipulate whether the challenge substance was natural salicylate or acetylsalicylic acid (aspirin)4 — aspirin being known to cause significant symptoms when natural salicylates have no effect. Finally, while foods are well known to cause a variety of gastrointestinal symptoms, from coeliac disease to irritable bowel syndrome, there is no good peer- reviewed evidence that natural salicylates cause any gastrointestinal symptoms. Do salicylate elimination diets cause harm? Although food elimination diets used to treat allergy have been associated with side effects including micronutrient deficiency,6- 8 protein or energy malnutrition,9 eating disorders,1. This is of concern given that many of the patients attending our clinics had started the diets at a young age (median, 2. Among our patients, where details were available, we identified a high occurrence of possible adverse outcomes among children who had been on low salicylate diets, with 3. Symptoms and problems experienced included weight loss or failure to thrive in 1. C deficiency, one case of protein, iron and zinc deficiency), food aversion in 6/6. Four out of 1. 3 mothers who went on the diet to benefit their breastfeeding infant suffered significant weight loss, which they perceived as problematic. While we acknowledge that our cohort has an inherent selection bias and that without a control group it is not possible to attribute the reported events to the diet, we are concerned that all adverse events were reported to have occurred after initiation of the diet. Also, beyond the possible adverse events noted in our patients, we are additionally concerned about the use of broad- based empirical food elimination in early life, with increasing evidence suggesting that food elimination at this time predisposes to the development of food allergy to the excluded foods, particularly among children with eczema, which was the largest group identified here. Who prescribes salicylate elimination diets? Among those patients where details were available, 4. We do not prescribe the diets in our practice. Oligoantigenic diet studies suggested that some. Feingold BF Hyperkinesis and learning disabilities. Salicylate sensitivity in children. And children's behaviour? And if one exists, which foods do we. In order to assess whether the diet was more widely used elsewhere, we surveyed overseas allergists. An online survey of members of the editorial boards of major European and North American allergy journals produced 2. ADHD, and only 1/2. Does the available research support a role for natural salicylates in any disease causation? As discussed above, there is no peer- reviewed evidence to support the use of low salicylate diets in treating eczema, behavioural symptoms or gastrointestinal symptoms. Many people believe that by measuring the salicylate content of various foods. Salicylate sensitivity can. Jerry had major behavior and learning problems from. One disease where the role of natural salicylates has been studied in more detail is aspirin- sensitive asthma, where doses of natural salicylic acid 1. The lack of importance of natural salicylates in this disease is well established in clinical practice, as reflected by the evidence- based clinical decision support website, Up. To. Date (http: //www. NSAID . First is the recent discovery that half of childhood CIU is autoimmune in nature, resulting from autoantibodies against the high- affinity Ig. E receptor. 1. 9 Second, evidence suggests that those few foods said to contain salicylates that may precipitate CIU (eg, tomatoes, wine, herbs) probably do so not because of their salicylate content, but because they contain volatile aromatic chemicals (eg, alcohol, ketones and aldehydes). Lack of effect of a common bread preservative? Salicylates, oligoantigenic diets. Food dyes impair performance of hyperactive children on a laboratory. SALICYLATES, OLIGOANTIGENIC DIETS, AND. Hyperkinesis and learning difficulties linked to artificial food. FAILSAFE Diet for Attention Deficit Hyperactivity. FAILSAFE Diet for Attention Deficit Hyperactivity Disorder. Salicylates, oligoantigenic diets, and. Journal of Paediatrics and Child Health, 39: 569. Synthetic food colouring and behaviour. Salicylates, oligoantigenic diets and behaviour. Third, there is evidence that the foods removed in low salicylate diets may not actually contain significant levels of salicylates, with one group suggesting that many “high salicylate foods” contain no aspirin and only tiny amounts of natural salicylates. Finally, it is important to discuss local research on salicylate intolerance performed in the early- to- mid 1. Most of that work focused on CIU, with a lesser focus on a number of other symptom complexes. The research involved placing patients on diets that removed foods containing salicylates, using food challenge to identify which constituents were responsible for any perceived improvement. However, teasing out which component of these broad- based elimination diets were responsible for any perceived benefit is difficult, given that the diets removed many food constituents, including those now known to cause symptoms, such as artificial food additives,3,1. Moreover, most of the clinical data appeared in a non- peer- reviewed format,2. These non- peer- reviewed findings of disease associations of natural salicylates have not been reproduced by other investigators, and a recent British textbook of food hypersensitivity concluded “there are no effective diagnostic tests for salicylate intolerance, and no studies showing the efficacy of dietary exclusion”. Can salicylate elimination diets be recommended for use in children? The use of low salicylate diets in children is not supported by current evidence or by expert opinion. There is also no evidence that these diets are safe, in particular for infants and their breastfeeding mothers, and for those at risk of developing eating disorders. While our retrospective case note review is insufficient to prove any risk associated with the diets, it is concerning that harm may occur when children and adolescents are placed on such restrictive diets, particularly if they stay on them for long periods. We would invite any proponents and prescribers of the diet to produce evidence of the efficacy and safety for the disorders in which they consider such a restrictive diet is indicated. Pending such evidence, we cannot recommend the use of salicylate elimination diets. Characteristics of 7. Characteristic. No. About ADHD/hyperactivity. Children with ADHD may have three basic problems, they can't pay attention, they are hyperactive, they act on impulse. It can however be difficult to draw the line between the behaviour of a child that is within the normal limits of high energy, and abnormally active behaviour. Our Checklist can help you make that assessment. Conventional treatment options typically involve behaviour therapy and/or medication. The best results we’ve seen at the Brain Bio Centre clinic in helping those with ADHD/hyperactivity are achieved by investigating a number of possible avenues. Nutritional factors include: Blood sugar problems. Essential fat deficiencies. Vitamin and mineral deficiencies. Pyroluria and the need for vitamin B6 and zinc. Food allergies. Read on for more information on how ADHD and Hyperactivity can be influenced by nutrition. If you are interested in contacting the Brain Bio Centre clinic for more information or to book a consultation please click here or call on +4. DO YOU OR YOUR CHILD HAVE ADHD? It's estimated that up to 5 per cent of school- age children in England and Wales have ADHD. That's around 3. 67,0. This means that in a class of 3. ADHD. Boys seem more likely to have ADHD than girls. In the UK, between three and nine boys are diagnosed with ADHD for every girl who's diagnosed with it but this may be because boys and girls tend to have different symptoms of ADHD. Inattention is more common among girls while hyperactivity is more common among boys. And a boy who is hyperactive (shouting, running about and getting into trouble) is more noticeable than a girl who is inattentive (daydreaming, forgetful and easily distracted). Several studies done in recent years estimate that between 3. ADHD continue to exhibit symptoms in the adult years. It can be difficult to draw the line between the behaviour of a child that is within the normal limits of high energy, and abnormally active behaviour. Use our Hyperactivity Checklist to assess your child and find out how nutritional factors such as blood sugar problems, deficiencies in essential fats, vitamins and minerals or food allergies can affect both ADHD and hyperactivity. Do the Hyperactivty Check. A score below 1. 2 is normal. If it’s higher, read on to discover workable nutritional strategies. WHAT CAUSES ADHD AND HYPERACTIVITY? Doctors aren't sure exactly what goes wrong in ADHD. But they think that the behaviour problems are linked to the way that the front part of the brain works. Studies suggest that this part of the brain works more slowly in children with ADHD than in other children. Children with ADHD may have an imbalance in the neurotransmitters in the front part of the brain. Some doctors believe they don't have enough of a neurotransmitter called dopamine. Children with ADHD may also lack the neurotransmitter noradrenaline. Without enough dopamine or noradrenaline, the front part of the brain can't deal with and react to information in the way that it should. This is why some drug treatments for ADHD aim to increase the amount of dopamine or noradrenaline in the brain. Unfortunately, there are no tests that show whether the front part of a child's brain is working normally. So doctors have to rely on what children, parents and teachers say in order to diagnose ADHD. To make a diagnosis, doctors usually ask parents and teachers about a child's behaviour. Your doctor will then compare your child's behaviour to the symptoms of ADHD put together by psychiatrists. These symptoms are listed in a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM says that to be diagnosed with ADHD, your child must have six or more symptoms of not paying attention (inattention) or six or more symptoms of being overactive (hyperactivity) and acting before thinking (impulsivity); these symptoms must have started before your child was 7 years old; your child must have been behaving like this for at least six months; your child's behaviour must be causing problems in at least two places, such as at home and at school. Your doctor may also want to rule out other medical causes of your child's symptoms. Conventional treatment options typically involve behaviour therapy and/or medication. The best results we’ve seen at the Brain Bio Centre in helping those with ADHD/hyperactivity are achieved by investigating a number of possible avenues. These include: Blood sugar problems. Essential fat deficiencies. Vitamin and mineral deficiencies. Pyroluria and the need for vitamin B6 and zinc. Food allergies. Quite apart from these nutritional factors having good psychological support and a stable home environment are also essential for affected children. To find out more about these factors read on, or click on our Action Plan to Overcome ADHD/hyperactivity. NUTRITION AND ADHD/HYPERACTIVITY: WHAT WORKSBalance Blood Sugar. Dietary studies consistently reveal that hyperactive children eat more sugar than other children, and reducing sugar has been found to halve disciplinary actions in young offenders . Other research has confirmed that the problem is not sugar itself but the forms it comes in, the absence of a well- balanced diet overall, and abnormal glucose metabolism. A study of 2. 65 hyperactive children found that more than three- quarters of them displayed abnormal glucose tolerance, – that is, their bodies were less able to handle sugar intake and maintain balanced blood sugar levels. In any case, when a child is regularly snacking on refined carbohydrates, sweets, chocolate, fizzy drinks, juices and little or no fibre to slow the glucose absorption, the levels of glucose in their blood will seesaw continually and trigger wild fluctuations in their levels of activity, concentration, focus and behaviour. These, of course, are also the symptoms of ADHD. Where’s the evidence? Search our evidence database and enter ? If sugar consumption is high and it is withdrawn suddenly, withdrawal symptoms such as headaches and irritability may ensue. Better to make gradual reductions to avoid this, without losing sight of the eventual goal of a no sugar diet. Contraindications with medication? Diabetes medication should be closely monitored since dosages may need to be lowered. See action plan for our recommendations. Increase Omega- 3 Fat. Omega- 3s have a clearly calming effect on many children with hyperactivity and ADHD. And many children with ADHD/hyperactivity have visible symptoms of essential fat deficiency such as excessive thirst, dry skin, eczema and asthma. It is also interesting that boys, whose requirement for essential fats is much higher than girls’, are also much more likely to have ADHD. Researchers have theorised that ADHD children may be deficient in essential fats not just because their dietary intake from foods such as seeds and nuts is inadequate (though this is not uncommon), but also because their need is higher, their absorption is poor, or they are unable to convert these fats well into EPA and DHA, and from DHA into prostaglandins, which are also important for brain function. So it’s of interest that the conversion of essential fats can be inhibited by most of the foods that cause symptoms in children with ADHD, such as wheat, dairy and foods containing salicylates. Zinc deficiency is common in children with ADHD. Research carried out at Purdue University in the US confirmed that children with ADHD have an inadequate intake of the nutrients required for the conversion of essential fats into prostaglandins, and have lower levels of EPA, DHA, and AA than children without ADHD. Supplementation with all these omega- 3 essential fats, pre- converted, along with the omega- 6 essential fat GLA, reduced ADHD symptoms such as anxiety, attention difficulties and general behaviour problems. Research at Oxford University using omega 3 and omega 6 fish oil supplements has proven the value of these essential fats in a double- blind trial involving 4. ADHD symptoms and specific learning difficulties. Those children receiving extra essential fats in supplements were both behaving and learning better within 1. Where’s the evidence? Search our evidence database and enter ? Rarely causes loose stools in sensitive individuals if you start on too high a dose. Contraindications with medication? Essential fats may have a . In fact, symptoms of deficiency in these minerals are very similar to the symptoms of ADHD. Low levels of magnesium, for instance, can cause excessive fidgeting, anxious restlessness, insomnia, coordination problems and learning difficulties (if accompanied by a normal IQ). Polish researchers studying 1. ADHD for their levels of magnesium found that 9. The team also noted a correlation between levels of magnesium and severity of symptoms. Supplementing 2. 00mg of magnesium for six months significantly reduced hyperactivity in the children with ADHD, but behaviour in the control group, who received no magnesium, worsened. Dr Neil Ward of the University of Surrey has come up with a finding that could explain the link between ADHD and such deficiencies. In a study of 5. 30 hyperactive children, Ward found that compared to children without ADHD, a significantly higher percentage of children with the condition had had several courses of antibiotics in early childhood. Further investigations revealed that children who had had three or more such courses before the age of three tested for significantly lower levels of zinc, calcium, chromium and selenium. This is probably because antibiotics have a disruptive effect on beneficial gut flora and consequently on overall digestive health, impairing absorption. Where’s the evidence? Search our evidence database and enter ? None reported. Contraindications with medication? None reported. See action plan for our recommendations. Avoid Allergy Food. Of all the avenues so far explored, the link between hyperactivity and food sensitivity is the most established and worthy of pursuit in any child showing signs of ADHD.
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