State of the Art Pediatrics: Not Just Another Picky Eater: Looking Out for Pediatric Eosinophilic Esophagitis

Column Author:  Rachel Chevalier, MD| Director of CMH Fellow's Grant Writing Curriculum, Department of Peds/GME; Medical Director of Eosinophilic Gastrointestinal Diseases Program, DOP/Gastroenterology, Hepatology and Nutrition, Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Research Assistant Professor of Pediatrics, University of Kansas School of Medicine

Column Editor: Amita Amonker, MD, FAAP | Physician Advisor, Care Management and Utilization Review, Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Allergies are a common concern of many families, especially with the prevalence of atopic conditions such as eczema and anaphylaxis. In the gastroenterology clinic, dysphagia, especially accompanied by other comorbid atopic conditions, raises concern for eosinophilic esophagitis (EoE). EoE is a chronic, Th2-predominant inflammatory disease characterized by eosinophilic infiltration of the esophagus and is frequently comorbid with other Th2 allergic conditions such as asthma, eczema, and seasonal and food allergies.¹

Potential triggers for EoE include food and/or environmental allergen exposures.² Often patients have many overlapping exposures making identification of specific triggers difficult, and currently, no blood or skin allergy testing correlates well with EoE triggers. The diagnosis of EoE is made when ≥15 eosinophils per high-powered field are found on esophageal mucosal biopsy samples taken during esophagogastroduodenoscopy (EGD),³ and unfortunately repeat EGD is the only way to monitor for complete mucosal healing. Newer modalities including transnasal endoscopy (TNE) are available at certain centers (including Children’s Mercy) to allow for evaluation of esophageal mucosa without anesthesia.  

EoE has no cure, but is currently managed with proton pump inhibitors (PPIs), elimination diets, swallowed topical steroids, and/or biologic (dupilumab) injections. All of these treatments come with their own challenges in implementation, including adherence, cost, and iatrogenic vitamin deficiencies. Treatment should be undertaken with the help of a dietician and gastroenterologist or allergist with experience in the disease. Without treatment, long-term inflammation can lead to scar tissue formation and strictures requiring endoscopic dilation or surgery. Early identification is key — some patients take years to form strictures, but some patients will present in childhood already with stricturing disease.⁴

EoE’s presentation looks different depending on age group, and a high index of suspicion is needed, especially in younger patients. Adolescents and young adults are most likely to report dysphagia, feeling of food impaction, chronic cough, and throat clearing. School-aged children may have symptoms of chronic reflux, abdominal pain, poor weight gain, or vomiting. Infants and toddlers may exhibit feeding difficulties and food refusal to the point of poor weight gain. Patients with longstanding dysphagia will develop accommodative and adaptive feeding behaviors that to them may seem normal. Additionally, EoE is more common in family members and is often undiagnosed — parents with EoE may think that their swallowing is “normal,” leading them not to question their child’s symptoms. In addition to inquiring about the above symptoms, important questions to ask include:

• Does your child drink a lot of liquids with meals or rely on sauces to make food easier to swallow?
• Does your child eat significantly slower than their peers?
• Does your child cut their food into very small pieces or chew excessively?
• Does your child avoid hard-textured foods?

Often, patients with EoE will be misidentified as having gastroesophageal reflux disease (GERD) and started on PPIs. To add a layer of difficulty to diagnosis, even though the pathophysiology is different from that of GERD, some patients with EoE have a phenotype that is responsive to PPI therapy.⁵ Thus, patients may have some improvement with symptoms on PPIs, leading to the conclusion of GERD, but these patients are then unsuccessful at weaning from the medication, even with other GERD lifestyle modifications.

Patients suspected to have EoE should be referred to a pediatric gastroenterologist for evaluation and endoscopy if warranted. Multidisciplinary clinics, including the Eosinophilic Gastrointestinal Diseases Clinic at Children’s Mercy, are available for long-term comprehensive care for patients with EoE. Patients with EoE experience a significant decrease in quality of life from their inability to eat as easily as peers and family. Management of symptoms can lead to happier, healthier kids and families with fewer mealtime struggles.

References:

1. D’Alessandro A, Esposito D, Pesce M, Cuomo R, De Palma GD, Sarnelli G. Eosinophilic esophagitis: from pathophysiology to treatment. World J Gastrointest Pathophysiol. 2015;6(4):150-158. doi:10.4291/wjgp.v6.i4.150
2. Dellon ES. Epidemiology of eosinophilic esophagitis. Gastroenterol Clin North Am. 2014;43(2):201-218. doi:10.1016/j.gtc.2014.02.002
3. Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007;133(4):1342-1363. doi:10.1053/j.gastro.2007.08.017
4. Hirano I, Aceves SS. Clinical implications and pathogenesis of esophageal remodeling in eosinophilic esophagitis. Gastroenterol Clin North Am. 2014;43(2):297-316. doi:10.1016/j.gtc.2014.02.015
5. Franciosi JP, Mougey EB, Dellon ES, et al. Proton pump inhibitor therapy for eosinophilic esophagitis: history, mechanisms, efficacy, and future directions. J Asthma Allergy. 2022;15:281-302. doi:10.2147/JAA.S274524