Managing eosinophilic oesophagitis in paediatrics: dietetic approaches and challenges

Eosinophilic oesophagitis (EoE) is a chronic, inflammatory condition characterised by eosinophil-predominant inflammation on histology and oesophageal dysfunction.[1] It affects approximately 50 per 100,000 children and is more prevalent in those with allergic disorders such as eczema, asthma and food allergy.[1,2]

Symptoms of EoE vary and can depend on the child’s age. Younger children may present with feeding difficulties, vomiting, food refusal or faltering growth, whereas older children often present with abdominal pain, food impaction and dysphagia.[1,3] Mealtimes may be lengthy and stressful, and children may avoid foods with challenging textures.

In severe cases, particularly where inflammation remains untreated, EoE can lead to structural changes in the oesophagus and stricture formation.[2,3]. These symptoms can affect a child's nutritional status, growth and psychosocial well-being.[4] Dietitians play a vital role in monitoring growth, ensuring nutritional adequacy, supporting dietary elimination strategies and guiding food reintroduction where indicated.[1]

EoE is diagnosed through a combination of symptoms of oesophageal dysfunction and histological findings obtained via upper gastrointestinal endoscopy and biopsy.[1,3] Multiple biopsies should be taken from different levels of the oesophagus and histological diagnosis is confirmed when there are ≥15 eosinophils per high-power field on oesophageal biopsy.[1,5].

Macroscopic findings of eosinophilic oesophagitis may appear normal despite active disease and symptom severity does not always correlate with the degree of inflammation.[1,2] Consequently, disease remission cannot be confirmed by clinical improvement alone and endoscopy with biopsy remains the gold standard for both diagnosis and monitoring treatment response.[1]

Given the complexity of the condition and its potential impact on nutrition, growth and quality of life, a multidisciplinary team approach involving paediatric gastroenterologists, dietitians, allergists and other relevant healthcare professionals is essential for effective management.[1,3]

The main aims in treatment for EoE are to improve symptoms and quality of life, maintain histological remission and prevent oesophageal fibrosis.[1,3] Treatments are individualised and vary depending on the child’s age, family preference, nutritional status and severity of disease. Swallowed topical corticosteroids and proton pump inhibitors are recommended as first-line treatment options in current guidelines and have both been shown to induce remission in children.[1]

Recently, biologic therapies such as dupilumab are emerging as treatment options for some patients. However, this varies geographically and use in the paediatric population is more limited.[2] Dietary approaches remain an important treatment for children with EoE and are useful for families who want to avoid long-term medication use or for when medications have not induced remission.

Dietary treatment involves removing common allergen foods that may be responsible for oesophageal inflammation and can achieve remission rates similar to those of medications in some patients.[5]. In children with oesophageal strictures, endoscopic dilatation may be indicated to address the structural narrowing. Dietary or pharmacological treatments should still be used alongside dilatation, as it does not treat the underlying
inflammation.[3]

Before treatment for EoE, a comprehensive dietetic assessment should be completed. Children with EoE may already be at risk of malnutrition due to food avoidance, swallowing difficulties, vomiting or prolonged mealtimes.[1] Initial assessment should include anthropometric measurements and growth history, gastrointestinal symptoms and dietary intake and feeding behaviours.

Some children with EoE may also have sensory feeding difficulties or neurological conditions that increase the risk of nutritional concerns.[6] Biochemical markers of nutrition may also be indicated; for example, if the child’s growth is faltering or there is a concern of nutritional inadequacy. This may include iron, vitamin D, vitamin B12, folate and other micronutrients.[1,6]

When assessing dietary intake, it is important to consider foods that are already being excluded from the diet due to swallowing difficulties or suspected allergies. Some children adapt their eating behaviours; for example, by avoiding certain foods and textures, such as bread or meat, or drinking large amounts of fluid with their meals.[3] In younger children, feeding skills may need to be assessed and they could need input from Speech and Language Therapy.

Coexisting atopic conditions such as food allergy and eczema should also be considered, alongside any previous dietetic interventions.

An elemental diet may be considered in children with multiple food allergies, severe disease or if other treatments have failed to induce remission.[1] An amino acid formula is given as the sole source of nutrition to exclude all dietary proteins. Studies report remission rates of over 90% in children; however, it is not often used as a first-line treatment due to social implications and poor palatability, with many children needing an enteral feeding tube.[7] Current guidelines recommend the elemental diet for 8–12 weeks.[1]

The most widely used dietary treatment in paediatric EoE is an elimination diet, which involves removing common dietary triggers. To assess response, a repeat endoscopy is then performed and the foods are reintroduced systematically. The six-food elimination diet (SFED) involves elimination of cow’s milk, wheat, egg, soya, nuts and fish/shellfish. Early paediatric studies found remission rates of approximately 70% with this approach.[8] However, more recently, less restrictive elimination diets have been favoured. This is due to the difficulty of following a multiple food exclusion diet and how it can impact quality of life and nutritional status.

Current guidance advises a ‘step up’ approach, whereby 1–2 known dietary triggers (cow’s milk +/- wheat) are initially eliminated for 8–12 weeks.[1] If there is no histological remission following this elimination, then a four-food elimination diet of cow’s milk, wheat, egg and soya can be recommended, before the six-food elimination diet if the child is still not in remission. This approach can minimise the burden on families of following restrictive diets and reduce the number of endoscopies required.[9]

As cow’s milk is recognised as the most common dietary trigger for children with EoE, an elimination of milk only is now being used more often. A recent study found histological remission rates of over 50% in paediatric patients following an elimination diet of cow’s milk only, suggesting it is an effective but more practical option for children and families.[10]

Dietitians have a vital role in supporting families with following elimination diets, whilst ensuring the child maintains adequate growth and nutritional status and has a positive relationship with food. Education should involve identifying allergens and reading food labels, as well as highlighting suitable alternatives and advising on how to manage elimination diets in different settings such as at school or when eating out.[6] One example would be recommending suitable fortified milk alternatives for children excluding cow's milk and ensuring adequate calcium, vitamin D and iodine intake. Supplementation may be required if dietary variety is lacking.[1] There is a large burden to the child and family when following these diets, so supporting them on how to adapt their diet to suit their lifestyle is essential to support adherence.[6]

Once remission of EoE has been confirmed following dietary treatment, foods must be reintroduced systematically to identify an individual’s ‘trigger’ foods. The foods are introduced one at a time and the order in which they are introduced may vary depending on local protocols and the patient’s food allergy history. Food reintroduction is an important step to ensure children are following the least restrictive diets as possible.

As symptoms alone are a poor marker of disease, the gold standard is repeat endoscopy with oesophageal biopsies after each food reintroduction.[1,5] Current guidelines advise food reintroductions every 8–12 weeks, which can be a lengthy, time-consuming and anxiety-inducing process for children and families.[1] Dietitians support families to complete food reintroductions safely, whilst maintaining a child’s nutritional status. Long-term management should focus on maintaining remission with food eliminations only if necessary.

EoE is a chronic, inflammatory condition that can have a significant impact on a child’s growth, feeding and nutritional status. Dietitians have a key role in supporting with dietary treatment, such as elimination diets, and monitoring growth and nutritional adequacy. Regular dietetic support and education are essential to provide patient-centred care and deliver effective treatment for children with EoE.

• Cow's milk is the most common dietary trigger in children with EoE.

• Symptoms do not reliably predict remission.

• Nutritional assessment should be completed before dietary restriction is commenced.

• Less restrictive elimination diets are increasingly favoured over six-food elimination.

• The goal is to achieve the least restrictive diet possible whilst maintaining remission.