Eosinophilic Esophagitis in Children

Children with eosinophilic esophagitis develop inflammation and swelling in the esophagus. The inflammation can lead to a variety of symptoms ranging from discomfort with feeds to vomiting and food impaction.

While each child may experience symptoms differently, common signs of eosinophilic esophagitis include:

• Difficulty swallowing (dysphagia)
• Food getting stuck in the throat (impaction)
• Chest pain
• Vomiting
• Poor weight gain
• Refusing to eat (especially in toddlers)
• Increased sensitivity to food texture

It's important to remember that none of these symptoms points definitively to eosinophilic esophagitis and many of the symptoms can overlap with other conditions such as gastroesophageal reflux disease. While eosinophilic esophagitis is most common in children with other allergic conditions (such as asthma, eczema, and classic food allergies), it can also occur in healthy children and adults. That's why it's important that your child is diagnosed by specialists who have a lot of experience with eosinophilic esophagitis and how it appears in children.

Eosinophilic esophagitis is an allergic condition that most often involves a reaction to food. Foods that are most commonly associated with eosinophilic esophagitis include milk and other dairy products, wheat, eggs, soy, peanuts, tree nuts, fish, and shellfish.

At this time the only reliable way to diagnose eosinophilic esophagitis is with an upper endoscopy to look for inflammation in the esophagus. During the upper endoscopy, your child's clinician will take biopsies (small samples of tissue) in order to look for a specific type of inflammatory cell called an eosinophil. If more than 15 eosinophils are present and gastroesophageal reflux and other causes of inflammation have been ruled out, this can indicate eosinophilic esophagitis.

Clinicians typically treat eosinophilic esophagitis with dietary changes, medication, or both.

Dietary modification

While eosinophilic esophagitis is a chronic condition, the vast majority of people who have it are able to eliminate their symptoms simply by avoiding the foods that trigger them. There are three main approaches to dietary therapy: avoiding the foods indicated by the allergy test, following the empirical food elimination diet, and following a strict elemental diet.

• Avoiding the foods indicated by the allergy test. With this approach, your child avoids between three and six foods for which they tested positive for allergies. Because allergy tests aren't 100 percent accurate, this approach relieves eosinophilic esophagitis symptoms in about 50 to 75 percent of patients.
• Empirical food elimination diet. With this diet, your child avoids the foods that are known to be the most common allergens, such as dairy, egg, wheat, and soy.
• Strict elemental diet. In this diet, your child gets 100 percent of their nutrition from a special formula made of amino acids, fats, sugars, vitamins, and minerals. Most of the time, this diet begins by restricting all food, and then gradually re-introduces foods until clinicians discover which ones are causing your child's allergic reactions. This approach has a 95 percent success rate. Children and adults who rely on an elemental diet can sometimes find it hard to drink enough of the formula to maintain proper nutrition, so we might use a special tube (called a "G-tube") to introduce the formula directly into your child's stomach. In extremely severe cases, nutrition may be administered directly into the blood stream.

Medication

Another approach to management of eosinophilic esophagitis is the use of medication. This most often involves topical steroids, acid-blocking agents such as proton pump inhibitors, or both. Your child's physician can help you weigh the pros and cons of managing the condition with medications as opposed to diet restrictions.

At Boston Children's Hospital, allergists, nurse practitioners, registered dietitians, clinical social workers, and other specialists work together to provide care for children and adolescents with eosinophilic esophagitis and other eosinophilic gastrointestinal diseases. There is no one-size-fits-all therapy for eosinophilic esophagitis. Options to manage it include both medication and diet restrictions, for which we advocate a team approach with specialists from many different disciplines. Both the Eosinophilic Gastrointestinal Disease Program and Aerodigestive Center offer evaluation and treatment of eosinophilic esophagitis at Boston Children‘s.