What are the treatment options for Eosinophilic Esophagitis (EoE) in infants?

From the Guidelines

Treatment for Eosinophilic Esophagitis (EoE) in infants should prioritize a step-up approach to dietary management, starting with a 2-food exclusion diet for at least 8-12 weeks, with support from an experienced dietitian to mitigate nutritional risks and ensure adherence to the diet 1.

Key Considerations

• The step-up approach involves gradually increasing the number of foods excluded from the diet, with regular endoscopies to assess response, and has been shown to result in higher histological remission rates compared to a single-step approach 1.
• Elemental formulas containing amino acids may be used when multiple food allergies are suspected, and medication options such as proton pump inhibitors (PPIs) or topical corticosteroids may be considered for those who do not respond to dietary changes 1.
• Regular follow-up with a pediatric gastroenterologist is essential, with repeat endoscopies typically performed after 8-12 weeks of treatment to assess response, and endoscopic dilation may be considered for infants with severe strictures causing difficulty swallowing or feeding.

Dietary Management Steps

• Start with a 2-food exclusion diet for at least 8-12 weeks (milk +/- wheat or egg) then repeat endoscopy 1.
• If not in remission, proceed to a 4-food exclusion diet for at least 8-12 weeks (milk, wheat, egg, soya), then repeat endoscopy 1.
• If still not in remission, consider a 6-food exclusion diet for at least 8-12 weeks (milk, wheat, egg, soya, fish/shellfish, and tree nuts/peanuts), then repeat endoscopy 1.

Medication Options

• Proton pump inhibitors (PPIs) such as omeprazole (0.7-3.5 mg/kg/day divided twice daily) or lansoprazole (0.5-2 mg/kg/day) may be used to reduce esophageal inflammation in some infants 1.
• Topical corticosteroids such as budesonide oral suspension (0.5-1 mg daily) or fluticasone (88-440 mcg daily, sprayed and swallowed) may be prescribed for those who do not respond to dietary changes or PPIs 1.

Importance of Dietitian Support

• Support from an experienced dietitian is strongly recommended to mitigate nutritional risks, ensure adherence to the diet, and address feeding difficulties in children with EoE 1.
• A dietitian can help structure eating plans, avoid vitamin deficiencies, and provide education on accurately eliminating foods and replacing food groups to achieve nutritional adequacy 1.

From the Research

Treatment Options for Eosinophilic Esophagitis (EoE) in Infants

• The treatment of EoE in infants typically involves dietary restrictions or drug therapies, with the goal of achieving clinical and histologic resolution of the disease 2.
• Avoiding food triggers is the only therapy that targets the cause of the disease, but currently available food allergy tests do not adequately predict food triggers for EoE 2.
• Elemental diet and empiric six-food elimination diet have consistently provided the best cure rates, but their high level of restriction and need for multiple endoscopies can be deterrents for implementation 2, 3.
• Simpler and less restrictive empirical methods, such as a four-food or two-food elimination diet, have shown encouraging results 2, 4.
• Proton pump inhibitors are currently a first-line treatment, achieving histological remission and improvement of symptoms in 54.1 and 64.9% of pediatric EoE patients, respectively 2.
• Topical corticosteroids, such as budesonide and fluticasone propionate, have been shown to be effective in decreasing eosinophil mucosal infiltration and relieving symptoms 2, 5.

Dietary Restrictions

• Elemental diet has been shown to be an effective treatment for EoE in children and adolescents, with significant improvement in symptoms and histologic evidence of disease 3, 6.
• A four-food elimination diet, which excludes cow's milk, wheat, egg, and soy, has been shown to induce clinical, endoscopic, and histologic remission in more than 60% of children with EoE 4.
• The most common food triggers that induce histologic inflammation are cow's milk, egg, wheat, and soy, with cow's milk being the most common trigger 4.

Drug Therapies

• Proton pump inhibitors are effective in achieving histological remission and improvement of symptoms in pediatric EoE patients 2.
• Topical corticosteroids, such as budesonide and fluticasone propionate, are effective in decreasing eosinophil mucosal infiltration and relieving symptoms 2, 5.
• Viscous budesonide formulas seem to be the best pharmacological therapy for EoE due to differences in drug delivery 2.