A 2-month-old girl is brought to the office for a well-child checkup. The patient is gaining weight appropriately and has met all developmental milestones. Her mother plans to exclusively breastfeed her until age 6 months. The patient has no medical conditions and is up to date on all recommended vaccinations. She lives with her parents, grandmother, and older brother and will start attending day care next month. No one in the household smokes, and the family has 2 dogs. Family history includes atopic dermatitis in the patient's father and older brother. The mother wants to know if she can do anything to lower the girl's risk for developing atopic dermatitis. Which of the following is the most appropriate recommendation for this patient?

Question

A 2-month-old girl is brought to the office for a well-child checkup.  The patient is gaining weight appropriately and has met all developmental milestones.  Her mother plans to exclusively breastfeed her until age 6 months.  The patient has no medical conditions and is up to date on all recommended vaccinations.  She lives with her parents, grandmother, and older brother and will start attending day care next month.  No one in the household smokes, and the family has 2 dogs.  Family history includes atopic dermatitis in the patient's father and older brother.  The mother wants to know if she can do anything to lower the girl's risk for developing atopic dermatitis.  Which of the following is the most appropriate recommendation for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0d9_754e_8f63_590449461ebf_MD0005_00 Atopic dermatitis, or eczema, is a chronic inflammatory skin disorder that typically develops at age <5, often during infancy. Major risk factors include a family history of atopy (ie, eczema, allergic rhinitis, asthma), as in this patient, and mutations affecting epidermal barrier proteins (eg, filaggrin). Pathogenesis of atopic dermatitis involves skin barrier dysfunction as well as a Th2-skewed immune response, which promotes IgE production. Normal newborn immunity is polarized toward a Th2 response but is balanced by a Th1 cytokine profile due to exposure to viral/bacterial microoganisms. Therefore, although the risk for atopic dermatitis cannot be eliminated, a protective factor for development includes shifting the adaptive immune response away from a Th2 predominance, which leads to decreased IgE production and mast cell and eosinophil recruitment. Th2 response As a result, early exposure to nonpathogenic microorganisms, such as early childhood exposure to day care, farm animals, and household dogs, may lower the risk of development of atopic dermatitis (Choice E). Breastfeeding and emollient application (to protect the skin barrier) also have some evidence of reducing the risk. (Choice B) Food sensitization (ie, the presence of IgE antibodies) to common allergens (eg, egg, milk) is increased in patients with atopic dermatitis and may result in rash exacerbation after exposure. However, the hydrolyzed proteins in breast milk have not been shown to affect atopic dermatitis in a child, and maternal elimination diets are therefore not recommended to prevent development of this condition. (Choices C and D) Solid food is typically introduced at age 4-6 months, and neither early nor delayed introduction decreases the risk for atopic dermatitis. Moreover, early introduction (eg, at 3 months) is developmentally inappropriate due to inadequate truncal tone and risk for aspiration, whereas delayed introduction (eg, 9 months) typically results in inadequate caloric and nutritional needs (eg, iron deficiency) and increases the risk for food allergy. Education objective: The pathogenesis of atopic dermatitis involves skin barrier dysfunction as well as a Th2-skewed immune response. Protective factors that may decrease the risk for developing atopic dermatitis shift the adaptive immune response away from a Th2 predominance and include early exposure to microorganisms (eg, day care, dogs). References: Atopic dermatitis and the hygiene hypothesis revisited. (http://www.ncbi.nlm.nih.gov/pubmed/21576944) The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods (http://www.ncbi.nlm.nih.gov/pubmed/30886111)

A 2-Month-Old Girl Is Brought to the Office for a Well-Child