Dietary Management in Pediatric Eosinophilic Esophagitis
Vrinda Bhardwaj, MD
Director, Eosinophilic Gastrointestinal Disorders Program
Director, Pediatric Gastrointestinal Endoscopy
Director, Transnasal Endoscopy Program
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.
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.
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.
Challenges With Dietary Therapy
Dietary therapy has its own unique challenges and is not risk-free. Nutritional deficiencies, psychological stress, decreased quality of life, potential development of eating disorders, increased therapy costs, and poor insurance coverage are all challenges that need to be kept in mind when dietary therapy is offered to a family.3 It is important to remember that repeated endoscopies are recommended whenever a new food is introduced. This can lead to 4 to 6 endoscopies per year, which is disproportionately higher than in children who are placed on a medicinal approach for the management of EoE. Another challenge that providers and families might struggle with in children who are on elemental therapy is that the formulas are often not palatable. Because of this, these children require a gastrostomy tube or a nasogastric tube to allow them to receive the appropriate amount of calories. Adherence can also be a concern. Understanding diet adherence is considered multifactorial and complex.
Innovative Technology for Monitoring
It is important that children with EoE on dietary therapy reach their ultimate EoE-free diet. To assist in this, repeated endoscopies are necessary. In an effort to save children from repeated anesthesia exposure, transnasal endoscopy (TNE)—a novel technique of performing unsedated awake endoscopy—has been devised. Only 3 centers in the United States provide this service to pediatric patients. In unsedated awake endoscopy, a child sits in a chair watching virtual-reality videos while their nose is numbed with topical lidocaine. Then, an ultra-slim endoscope is introduced through the nose into the esophagus and stomach. Direct visualization is achieved, and biopsies are obtained. The entire procedure time is within 10 minutes and allows families to be in the clinic room to watch. The time of no eating or drinking prior to the procedure is also cut dramatically from 8 hours to 2 hours. The first TNE on the West Coast was performed at Children’s Hospital Los Angeles in January 2019 under my direction.
- Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011;128(1):3-20.e6.
- Cianferoni A, Shuker M, Brown-Whitehorn T, Hunter H, Venter C, Spergel JM. Food avoidance strategies in eosinophilic esophagitis. Clin Exp Allergy. 2019;49(3):269-284.
- Wolf WA, Huang KZ, Durban R, et al. The six-food elimination diet for eosinophilic esophagitis increases grocery shopping cost and complexity. Dysphagia. 2016;31(6):765-770.
- Wang R, Hirano I, Doerfler B, Zalewski A, Gonsalves N, Taft T. Assessing adherence and barriers to long-term elimination diet therapy in adults with eosinophilic esophagitis. Dig Dis Sci. 2018;63(7):1756-1762.
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