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What is EoE?

Eosinophilic (e-o-sin-o-fil-ik) esophagitis (e-so-fa-gi-tis), or EoE as it is commonly referenced, is a chronic inflammatory medical condition that affects the esophagus, the muscular tube that carries food from the throat to the stomach.

Despite the increasing rate of incidence, EoE is still considered a rare disease since it only affects approximately one in 1,500 people. It can affect people of all ages, genders, and ethnicities, however, there is a higher incidence in males.

It occurs due to an allergic response to food and/or environmental allergens, which create increased numbers of eosinophils in the esophagus. Eosinophils are a type of white blood cell that are not typically found in the esophagus and, when present in increased amounts, cause inflammation and in some cases damage to the esophagus.

They play an important role in the immune system and there are always small quantities of eosinophils in the blood and intestine that are responsible for fighting parasites among other duties.

For children with seasonal allergies, eosinophils are present in the nose; for children who have asthma, eosinophils are found in the lungs; and for children who have EoE, they are present in the esophagus. Children who have EoE can often experience other allergic disorders, such as asthma, seasonal allergies, or eczema.

The Diagnosis of EoE has risen dramatically over the past five years. Researchers are not certain whether it is because of the increased prevalence of the condition, whether its because healthcare providers recognize the symptoms more often now due to increased awareness, or both.

How Do I Know If My Child Has EoE?

Children who have EoE may respond to uncomfortable symptoms by avoiding or refusing foods, complaining of discomfort, developing altered mealtime behaviors, and in some cases, a caregiver or health care provider may notice poor growth or weight loss.

It can be difficult to identify symptoms of EoE in children because they can vary in different age groups and are not always consistent. Common symptoms include:

  • Reflux
  • Difficulty swallowing or pain when swallowing
  • Nausea and/or vomiting
  • Poor weight gain, weight loss, or failure to thrive
  • Stomach and/or chest pain
  • Poor appetite and/or feeding refusal
  • Food impactions (food getting stuck in esophagus)

While these symptoms can appear in any child with EoE, some are more common in specific age groups. Younger children, such as infants and toddlers, often have poor growth due to food aversions or food refusal. These children may also show signs of reflux and do not usually respond to acid suppression medication.

In school-aged children, stomach pain that doesn’t go away or pain and difficulty when swallowing foods is more common. Older children may experience something called a food impaction, where food becomes stuck in the esophagus due to narrowing of the esophagus. Vomiting can occur in all age groups and may cause confusion for parents due to commonly occurring viral illnesses in children that often cause similar symptoms.

If you suspect EoE based on any of these symptoms, it is recommended to meet with a gastroenterologist who can help reach a proper diagnosis. If there is a family history of EoE or swallowing difficulties or if your child is also experiencing eczema, food allergies, and/or asthma, there is increased concern for EoE complications.

While an endoscopy can seem extreme, it may be recommended by your child’s allergist or gastroenterologist and is necessary for confirmation of an EoE diagnosis. An endoscopy is a procedure in which a flexible lighted instrument is used to examine different parts of the GI tract, such as the esophagus, stomach, and portions of the intestine. During the endoscopy, the doctor will look for signs of EoE such as swelling and inflammation, rings, masses of cells, or narrowing.

They will also take small tissue samples – known as biopsies – to observe under a microscope. If your child has at least 15 eosinophils per high-powered microscope field in addition to other symptoms of esophageal dysfunction, there is a high possibility of EoE.  After it has been determined that there are no other sources contributing to increased eosinophils and dysfunction in the esophagus, a diagnosis of EoE can be made.

How is EoE Treated?

A diagnosis for EoE can be overwhelming and so can the treatment options. EoE can be managed by medications, diet therapy, dilation, or a combination of these treatments.

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 consult a health care provider.

.Challenges may arise with all treatment options; therefore, observing the response to treatment may help with determining which path is best for the child. 

Potential EoE Treatments Not Related to Diet

  • Proton Pump Inhibitors (PPI) are acid suppression medications that are commonly used to treat reflux. They are often used initially in the treatment of EoE, due to their overall safety and ease of use. Although PPIs are often chosen as initial therapy, they may not be effective for complete symptoms resolution on their own.
  • Topical Steroids are administered by swallowing a steroid medication from an inhaler, commonly used to treat asthma or by drinking a mixture containing the medication, known as a slurry. This medication option is often chosen if PPIs haven’t been shown to be ineffective. There has been some concern for adrenal function or growth suppression with long-term use; however, short-term studies have shown swallowed steroids to be a safe treatment option for EoE.
  • Dilation is a procedure that stretches the narrowed portion of the esophagus. This is often done if food has become stuck in the esophagus and is more commonly performed in older children or adults where the symptoms are often more progressed. While this procedure is effective for resolving food impactions, it does not treat the underlying inflammation.

Diet Related Treatments for EoE

 There are many factors 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.

Diet management should be 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.

Below is an overview of the types of diets that may be worth considering:

Empiric Elimination Diet: A treatment that removes the most common food allergens from your child’s diet. Different variations of this diet have been proven to be effective for many individuals. One form of the diet recommends removing six food groups, another four food groups, two food groups, and even milk alone (see details below).

There are eight key allergens that 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. The step-up empiric plan allows for choosing fewer foods to eliminate in the beginning and working through additional foods if unable to obtain remission. With this approach, the number of endoscopies needed may be reduced and it may prevent the need for excessive dietary restrictions.

The step-down empiric plan starts with more foods eliminated initially with gradual reintroduction once remission is achieved. With this approach, you may be able to achieve remission more quickly than the step-up approach; however, more endoscopies may be needed to narrow down potential triggers and nutrition risks may be increased with an increased number of food groups removed from the diet.

    • 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. 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 EoE triggers. However, your allergist may feel that testing is appropriate to help guide food elimination.

Elemental Diet: This form of diet treatment requires the avoidance of food proteins by essentially removing all foods from the diet and relying solely on an amino acid-based formula, like Cambrooke’s EquaCare Jr. and Essential Care Jr. to meet all nutritional needs. While this diet can have a significant negative impact on quality of life, it is effective in inducing remission for a majority of children with EoE. Another obstacle with a diet that is solely formula is flavor fatigue.  Registered dietitians can be 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.

It is essential for children on any elimination diet to work with their health care provider to establish daily goals to ensure nutrition and growth goals are being met. This will include the daily intake of nutrients from formula and/or food.  Because so many developmental milestones, including the development of feeding skills, are met within the first three years of life, a diet that removes food and consists entirely of amino acid-based (also known as elemental) formula may have a significant impact on these milestones and the development of important feeding skills. 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 the quality of life and improve food acceptance. Although necessary for elemental diet therapy, with an elimination diet, an amino acid-based formula may be recommended to help supplement the child’s nutrition needs.

What Can I Expect Down The Road With Diet-Based 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 that need to be eliminated and provide guidance on how to 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 based on the 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 the 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.  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 that 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 identified.

In order to manage EoE, it is advised that you work closely with a gastroenterologist. They can administer the appropriate tests and can assess whether the condition is improving or getting worse. An allergist, immunologist or dietitian can help manage symptoms and related problems such as asthma, allergic rhinitis, and food allergies.

How Can an Amino Acid-Based Formula Help a 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, self-restrictive behaviors, or 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, nutritionally complete amino acid-based formula options for the parents of children over one year of age 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.