Digestive; Pediatrics

Picky eater or something more serious? Kids and EoE

It’s not uncommon for children to be picky eaters. But in extreme cases, it may be a sign of eosinophilic esophagitis (EoE), a chronic allergic inflammatory disease of the esophagus.

Picky eating is a perpetual frustration for many parents. But in extreme cases, when a child refuses to eat or endures chronic spitting up or vomiting, it may be a sign of eosinophilic esophagitis (EoE), an allergic inflammatory disease of the esophagus.

First identified in the 1990s, EoE is caused by an immune response to specific foods, or sometimes to environmental agents such as pollen.

The esophagus is the muscular tube that carries food from the mouth to the stomach. Patients experience a buildup of white blood cells called eosinophils in the esophagus, which can lead to inflammation, trouble swallowing and choking if food gets stuck in the throat. Some of these symptoms can persist into adulthood if they are not diagnosed and treated.

Left untreated, EoE can cause permanent damage to the esophagus.

UT Southwestern offers the only academic-affiliated allergy and immunology program for children (birth to age 18) in North Texas. We manage the Dallas Eosinophilic Esophagitis Program, which combines the expertise of pediatric gastroenterologists, allergists, dietitians, and psychologists – all of whom have in-depth knowledge in treating EoE.

While the condition is not common, diagnoses of EoE are increasing. It's estimated that 1 in 2,000 people have EoE, and boys are three times more likely to be diagnosed with EoE than girls. Males typically present with symptoms in childhood, but some surface in adulthood around age 30 or 40.

Getting a diagnosis can feel like a long journey. It takes time to rule out sensory and gastrointestinal disorders, as well as undergo rounds of allergy testing. However, once we know the details, we can create a personalized treatment plan to reduce flares and potentially correct esophageal damage.

So, how can parents determine whether their child is simply being picky or it's something more serious? EoE diagnosis begins with a close examination of the child's medical history and symptoms.

Uncovering the symptoms of EoE

EoE affects every patient differently. People with EoE often also have other allergic conditions, such as asthma, hay fever, or eczema. Symptoms often change with age. The most common symptoms at different stages of life are:

Infants and toddlers Children and teens Adults
Excessive spitting up, vomiting Reflux and/or vomiting Trouble swallowing, especially solid foods
Feeding problems Abdominal pain Food getting stuck in the esophagus
Refusing certain or all solid foods Trouble swallowing, especially solid foods Reflux
Poor weight gain, growth Food getting stuck in the esophagus Heartburn or chest pain
Poor appetite

Over time, inflammation can lead to esophageal scarring, which restricts normal stretching of the esophagus and increases the risk of getting food stuck in your throat.

While this isn't a choking hazard since it doesn't involve the trachea (windpipe), it's uncomfortable. If the child can't wash the food down with liquids or vomit it back up, they may need an emergency endoscopy to remove it. The whole experience could also increase their general anxiety around eating.

How we diagnose EoE

EoE symptoms can mimic a lot of other diseases, such as gastroesophageal reflux disease (GERD). Our first step is to rule out these conditions by conducting a thorough review of your child's medical history, which may require a few laboratory tests.

If their symptoms and medical history point to EoE, there are two options to proceed:

  • Option 1: We can try medications and diet modifications to eliminate certain foods that might cause irritation. Some families are OK with symptom relief only. However, we will not know for sure whether the child has EoE or esophageal damage without more extensive testing.
  • Option 2: To get a definitive diagnosis, we will do an upper gastrointestinal (GI) endoscopy to look for inflammation, narrowing, and white spots in the esophagus. We will also take a small tissue sample to check for high levels of eosinophils. This procedure is done under anesthesia or sedation through a thin tube placed down the child's throat.

We hope to have less invasive methods to definitively diagnose EoE in the future, but until then, we’ll work with you to weigh the invasiveness of testing against the severity of symptoms to decide how to proceed. There is no cure for EoE. However, diet changes and medication can help control symptoms and prevent further damage.

Medications to manage EoE

There are currently no FDA-approved medicines specifically designed to treat EoE. But medications for other allergic or inflammatory conditions can help relieve and prevent symptoms.

Acid suppressants such as proton pump inhibitors (PPIs) such as omeprazole, esomeprazole, and lansoprazole can reduce reflux symptoms and may even help decrease inflammation. PPIs generally work best in children with mild EoE.

The inflammation involved in EoE is similar to what we see in eczema, allergic asthma, and atopic dermatitis. Corticosteroid medications designed for asthma can help control acute EoE flares and prevent long-term complications through their anti-inflammatory effects. Long-term use of strong steroids such as prednisolone is not recommended due to systemic (whole-body) side effects such as weight gain, skin changes, increased blood sugar, and insomnia. The use of steroids topically (on the surface of the esophagus) minimizes side effects and allows for long-term use safely.

We find that topical steroid medications work for EoE symptoms in 60 to 70 percent of patients – the challenge is coating the esophagus with these medications that are usually inhaled.

For example, an older child may be able to spray the asthma medication fluticasone into the mouth, mix it with their saliva, and swallow it instead of inhaling it as one would do for asthma. Younger kids may do better with a mixture of the nebulizer medication budesonide and a tasty treat such as applesauce, honey, or chocolate syrup. The thickness of the fluid helps coat the esophagus on the way down.

Controlling patients' environmental allergies with antihistamines or allergy shots may help maintain control of EoE in some patients. Antihistamine pills can help control mild allergies, and we may recommend getting allergy shots to manage and prevent more serious symptoms.

Medication research for healthier kids

UT Southwestern is currently participating in an exciting trial in hopes of finding new and effective EoE treatments. The study focuses on the effectiveness of dupilumab for EoE in kids ages 12 to 18 and adults. Dupilumab is already approved by the FDA to treat moderate to severe asthma and atopic dermatitis. Many patients with EoE suffer from one or both of these related conditions, so the ability to manage multiple problems with a single medication is quite appealing.

Later in 2021, we will begin enrolling patients ages 1 to 11 in a similar study of dupilumab and adolescents age 12 and up in a trial of a similar medication called CC-93538. We hope these studies take us one step closer to the first medication that is FDA-approved specifically to treat EoE.

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Managing EoE with diet

Eight food allergens are responsible for 90 percent of food-related reactions in children: milk, eggs, wheat, soy, peanuts, tree nuts, fish, and shellfish. Skin prick testing and blood tests are fairly accurate, when combined with a detailed medical history, at determining which foods may cause “immediate” reactions such as hives or anaphylaxis.

Unfortunately, skin prick tests are not very accurate for the identification of foods that trigger EoE because children usually can’t eat enough of a food that causes an immediate reaction to trigger a chronic problem. So instead of “targeting” elimination diets based on allergy testing results, we typically use “empiric” elimination diets. This means we eliminate the foods that most commonly cause EoE, regardless of test results.

The most common elimination diet involves removing all eight of the top allergens from your child’s diet for at least a couple months. This diet is frequently referred to as a “six-food elimination diet” (counted as six foods when peanuts and tree nuts are grouped as “nuts” and fish and shellfish are grouped as “seafood”).

Endoscopy is needed to accurately determine if the diet was successful. If it was, then slow reintroduction of the foods is done, one at a time, and watching for symptoms. This approach can be challenging, especially if the rest of the family is eating normally. It may also require multiple endoscopies to truly know whether inflammation doesn't return with each reintroduced food. It is your choice whether to do an endoscopy each time, annually, or not at all if diet changes provide enough relief and peace of mind.

Some foods that commonly cause food allergies do not commonly trigger EoE, especially fish and shellfish. Therefore, we sometimes begin with elimination of fewer foods (e.g., milk alone or milk and wheat) at the beginning and then “step up” the elimination until the EoE improves. Families may find it easier to follow the restrictions when beginning with fewer foods, and this approach may lead to identification of the culprit foods faster and with fewer endoscopies.

There’s no perfect diet that works for every child, and there may be times when your family wants to tweak the process. For example, if you’re going on vacation and you want them to be able to enjoy some favorite foods, we can make short-term medication adjustments to help prevent flare-ups.

Diagnosis and treatment of EoE has come a long way in a short time, and we are hopeful that ongoing research at UT Southwestern will provide more relief from this condition. No one wants to see their child in distress, so if you’re worried about your child’s eating habits or if they are having trouble eating, please contact our pediatric gastroenterology team.

We can help determine the problem and create an effective, customized treatment plan to help them – and you – feel better. To talk with a pediatric EoE expert, call 469-497-2504 or request an appointment online.

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