Salicylate elimination diets in children: is food restriction supported by the evidence?

The references used by Heller et al to support their arguments are not relevant, as they do not provide any clinically useful information about the efficacy or safety of salicylate-free diets. One article refers exclusively to the potential anticancer properties of natural salicylates.1 Another discusses the clinical effects of acetylsalicylic acid (aspirin),2 which is known to cause symptoms in individuals where natural salicylates do not.3 The diagnostic test to which Heller et al allude is also a test for aspirin sensitivity, not natural salicylate sensitivity.2 A third article shows a purely biochemical change (with no clinical correlate) in a small number of aspirin-sensitive patients.4 Finally, the clinical prevalence of salicylate sensitivity mentioned by Heller et al comes from a paper5 that references a review as the source of that information; however, the review itself does not mention salicylates.6

In her letter, Breakey suggests that our paper is a “position statement”. We reject this, as our paper was submitted to the Journal as an original piece of research. She quotes her study using the few-foods diet to treat behaviour as evidence,7 however that diet also removed synthetic colours and preservatives, not just natural salicylates. Given that randomised controlled trial (RCT) data have shown that some synthetic colours and preservatives result in adverse behaviour in children,8 it is impossible to attribute the effects in Breakey’s study to natural salicylates.

In the era of evidence-based medicine, RCTs involving patients of an appropriate age and disease status should be conducted before any intervention is applied to the general population. Exclusionary diets are no exception to this rule. Until such trials are conducted, we cannot recommend the use of low salicylate diets in children.