Dietary Management in Pediatric Eosinophilic Esophagitis

Author:

Vrinda Bhardwaj, MD

Director, Eosinophilic Gastrointestinal Disorders Program

Director, Pediatric Gastrointestinal Endoscopy

Director, Transnasal Endoscopy Program

Attending Physician

Children’s Hospital Los Angeles

Citation: Bhardwaj V. Dietary management in pediatric eosinophilic esophagitis [published online April 11, 2019]. Gastroenterology Consultant.

Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus characterized clinically by symptoms reflecting esophageal dysfunction, such as dysphagia or food impaction, and histologically by an eosinophil-predominant infiltration of the esophageal mucosa.¹ The disease course in most patients is marked by persistent symptoms if improperly treated. The goals of treatment are to induce and maintain disease remission. Treatment options consist of the 3 D’s: diet, drugs, and dilation (endoscopic).

Various dietary therapeutic approaches are available for use in the management of pediatric EoE. They include the following:

• Elemental diet (amino acid-based formula use)
• Targeted elimination diet (based on allergy testing)
• Six food elimination diet (milk, soy, wheat, eggs, nuts, and fish)
• Four food elimination diet (milk, soy, wheat, and eggs)
• Two food elimination diet (milk and wheat)
• One food elimination diet (milk)

Dietary management has unique benefits and challenges in the specialized population of pediatric patients with EoE.

Elemental Diet

An elemental diet includes the complete replacement of food with an amino acid-based formula. This approach has been shown to induce histologic disease remission, maintain disease remission, and help replenish the nutritional deficits that children with EoE may have. Of several published studies on EoE, only 9 have reported the use of complete elemental diets in patients with EoE. Of these, 7 studies were in children and 2 were in adults.² This highlights the dearth of long-term studies and robust literature on this management approach. However, on the positive side, up to 90% disease remission has been reported with the use of elemental diet therapy. An elemental diet tends to be preferred for infants in whom a liquid diet is age-appropriate. Otherwise, an elemental diet is only practical for short periods.

Elimination Diet

Two approaches can be used in an elimination diet: step down and step up. A step-down approach starts with a restrictive diet and the progressive reintroduction of eliminated foods, whereas a step-up approach entails eliminating 1 or 2 foods. After each reintroduction of a food, repeated endoscopy is recommended to assess whether the disease is in remission. If disease recurs after food introduction, that food is considered a culprit food and is removed from the diet forever. Which therapy to choose for which patient depends on what the family and child can adhere to, sustain, and thrive on.² It is not unusual to see options for medications and diet therapy change as disease progresses. Targeted elimination diet is guided by allergy testing.

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