Eosinophilic Esophagitis (EoE) Diet Therapy for Children

Eosinophilic Esophagitis (EoE) is a chronic, inflammatory medical condition that affects the esophagus and is considered a rare disease.  Found in 1 out of 2,000 people, it affects all ages, genders, and ethnicities but is slightly more common in males. It occurs due to an allergic response to food and/or environmental allergens which causes increased numbers of eosinophils in the esophagus.  Eosinophils are types of white blood cells that are not typically found in the esophagus and when present in increased amounts, cause inflammation and in some cases damage to the esophagus. Common symptoms include reflux, difficulty swallowing, nausea and vomiting, abdominal or chest pain, poor appetite, feeding refusal, and poor growth.  Current therapies for EoE include medications, elimination diets, and esophageal dilation (performed mostly in adults). Dietary elimination is often recommended due to its success in achieving remission without the potential risk of medication-related side effects. However, elimination diets come with significant nutritional risks and often have a negative impact on the quality of life, so it is important to receive guidance from a health care provider.

Diet Therapy

While diet is a successful therapy for EoE, it can also be challenging as there are no current tests to determine specific EoE food triggers. There are many things to consider when choosing the appropriate diet treatment for EoE and it is important to ensure that adequate nutrition and growth goals are achieved while following these restricted diets. A diet treatment is individualized based on input from the patient and health care provider and it can be very beneficial to have a registered dietitian experienced in working with patients who have EoE to help implement this treatment.¹

Empiric Elimination Diet

The Top 8 allergens are common EoE food triggers with cow’s milk, wheat, egg and soy being the most common. Therefore, the empiric elimination diet removes common allergens from the diet without the need for food allergy testing. Different variations of this diet recommend removing six food groups, four food groups, two food groups and even milk alone. The step-up empiric plan allows for patients and physicians to work together to find the best approach for diet therapy. With this approach, the number of endoscopies needed may be reduced and prevent the need for excessive dietary restrictions.²

• Six-food group elimination diet (SFED)
  • milk, egg, wheat, soy, peanuts/tree nuts, fish/shellfish
• Four-food group elimination diet (FFED)
  • milk, wheat, egg, and soy/legumes
• Two-food group elimination diet (TFED)
  • milk, gluten
• Milk alone

Test-Directed Elimination Diet

This type of elimination diet is directed by the results of food allergy testing (skin prick or patch test). One study reported this type of elimination diet is most effective when combined with the elimination of milk and resulted in remission of EoE in 77% of children.¹ It is important to remember that even when a child with EoE tests positive to specific foods, it does not guarantee that the positive foods will be an EoE trigger. However, your allergist may feel that testing is appropriate to help guide food elimination. Anytime a child is recommended to remove multiple food groups from the diet, it is encouraged to seek advice from a registered dietitian to ensure the child is taking in adequate nutrition. With any elimination diet, an amino acid-based formula may be recommended to help supplement the child’s nutrition needs.

Elemental Diet

This form of diet treatment requires the avoidance of food proteins by essentially removing all foods from the diet and relying on an amino acid-based formula, like EquaCare Jr. and Essential Care Jr. to meet all nutrition needs. While this diet can have a significant negative impact on quality of life, it is the most effective diet in inducing remission for a majority of children with EoE and was found to be as effective as medication therapy (steroids) in relieving symptoms. It is essential for children on the Eelemental diet to work with their health care provider to establish daily formula goals to ensure nutrition needs and growth goals are being met. Because so many developmental milestones, including the development of feeding skills, are met within the first 3 years of life, a diet that removes food and consists of 100% amino acid-based (also known as elemental) formula may have a significant impact on these milestones and the development of important feeding skills.¹ Therefore, it is important to work with the child’s health care provider to establish goals for food reintroduction, even if it is just one or two foods. If possible, it is beneficial to offer variety and textures within these allowed foods to enhance quality of life and improve food acceptance.  Another obstacle with a diet that is 100% formula is flavor fatigue.  Registered dietitians can be very helpful with offering flavoring strategies and other tips to promote compliance. For those who are unable to meet their formula intake goals by drinking the formula, a feeding tube may be required to meet nutrition needs.

What Can I Expect Long Term with Diet Therapy?

Since diet therapies are individualized, the child’s health care provider will support the family with guidance on the child’s specific elimination diet plan. Resources and education such as label reading, proper food avoidance, recipes, and appropriate food substitutions are vital to success and compliance with all elimination diets. The child’s health care provider will also make recommendations for the amount of time-specific foods need to be eliminated and provide guidance on how he/she will assess tolerance of each food.  After the initial elimination period, an endoscopy is usually performed to determine if the current elimination diet is effective, but some health care providers may choose to assess effectiveness by resolution of symptoms.  If the diet is considered effective, the health care provider will provide guidance on how to reintroduce foods.  If the diet is found to be ineffective, the health care provider will likely recommend removing additional foods with the current elimination diet or may recommend choosing a different treatment method such as medication therapy. During reintroduction of foods, the child’s health care provider will help to determine which food to introduce as well as the length of time to introduce each food.  During the reintroduction phase, foods are typically introduced individually and assessed for tolerance, often with repeat endoscopies.  As foods are trialed and identified as EoE triggers, it is likely there will be a need for ongoing elimination of some trigger foods.  This is known as the maintenance diet and involves eliminating food(s) that have been determined as EoE triggers and keeping non-trigger foods in the diet.  Continuing the maintenance diet is the only way to maintain remission in EoE unless an alternative treatment option is chosen.

How can an amino acid-based formula support my child with EoE?

Regardless of diet or therapy choice, an amino acid-based hypoallergenic formula such as EquaCare Jr. or Essential Care Jr. can be beneficial to ensure adequate nutrient intake during periods of food elimination or avoidance, poor weight gain and growth. There can be a lot of unknowns with EoE; however, children and their families can take comfort in knowing that amino acid-based formulas provide safe and complete nutrition without the risk of an EoE trigger. Cambrooke’s EquaCare Jr. and Essential Care Jr. formulas offer healthy, more affordable amino acid-based formula options for the parents of children with eosinophilic esophagitis as well as other food allergies and GI disorders. Learn more about each of these beneficial products by visiting us online today or calling 1-833-377-2773.

Sources:

1. https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Parameters/March-2017-EoE-dietary-management.pdf
2. https://www.aaaai.org/global/latest-research-summaries/Current-JACI-Research/diet-eoe