Four-food elimination diet can resolve symptoms of eosinophilic esophagitis in children

Jun 27 2017

Children with eosinophilic esophagitis (EoE) – a chronic inflammatory disease that injures the esophagus – who temporarily eliminated cow's milk, wheat, egg and soy from their diet for eight weeks had their symptoms and esophageal swelling resolve, according to a study published in Clinical Gastroenterology and Hepatology. This elimination diet is less restrictive than the standard of care six-food elimination diet that is approved to treat EoE, a condition in which an abnormal immune response is triggered by certain foods, causing symptoms that range from difficulty swallowing to abdominal pain and vomiting. After remission, foods are reintroduced one by one until the food that triggers esophageal swelling and symptoms is identified and eliminated from the child's diet. This is a lengthy process that involves multiple endoscopies to monitor the effect of reintroduced foods on the esophagus.

"Excluding many foods from a child's diet is a major challenge for families. Our study shows that we can achieve nearly the same results with four instead of six foods that children with EoE need to avoid initially," says lead author Amir F. Kagalwalla, MBBS, from Stanley Manne Children's Research Institute at Ann & Robert H. Lurie Children's Hospital of Chicago. "Also it takes much less time to reintroduce the foods and fewer endoscopies to determine which foods truly need to be avoided to maintain remission. These are a huge benefits."

First described in 1995, EoE is becoming increasingly prevalent, affecting an estimated 1 out of 10,000 people. The six-food elimination diet, which is currently the first line non-pharmacologic treatment for EoE and involves exclusion of cow's milk, wheat, egg, soy, peanut/tree nut and fish/shellfish, was also developed by Kagalwalla and the team at Lurie Children's. Left untreated, EoE can result in scarring of the esophagus, which then becomes narrowed and does not allow food to pass down.

The study by Kagalwalla and colleagues is the first, prospective elimination diet study conducted in children with EoE. It is also the largest study that included 78 children, ages 1-18, recruited at four medical centers. More than six out of 10 children achieved histologic remission after eight weeks on the four-food elimination diet. Nine out of 10 of the responders no longer experienced EoE symptoms, such as swallowing difficulty, vomiting or feeding aversion.

Cow's milk was the most common food trigger identified in 85 percent of patients, followed by egg (35 percent), wheat (33 percent) and soy (19 percent).

"The high percentage of children for whom milk was a trigger provides the basis for investigating a milk-only elimination diet approach," says Kagalwalla, Co-Director of Eosinophilic Gastrointestinal Diseases Program at Lurie Children's and Associate Professor of Pediatrics at Northwestern University Feinberg School of Medicine.​