What is the treatment for allergic oesophagitis in an infant?

Treatment of Allergic Esophagitis in Infants

For infants with allergic (eosinophilic) esophagitis, the first-line treatment should be a dietary approach with an elemental formula or targeted food elimination under the supervision of an experienced dietitian, followed by pharmacological therapy with topical corticosteroids if dietary management is unsuccessful or impractical. 1

Dietary Management Options

Elemental Formula

• Elemental diets (amino acid-based formulas) have the highest histological response rate at approximately 90.8% in pediatric patients 1
• This approach completely removes all potential food allergens and is particularly effective in young infants 1
• Challenges include taste acceptance, cost, potential need for feeding tube, and social isolation created by dietary restrictions 1

Elimination Diets

• Single-Food Elimination Diet (1FED):

  • Cow's milk elimination alone can induce histological remission in over 50% of children with EoE 2
  • Milk is 8 times more likely to cause EoE compared to wheat, making it the logical first food to eliminate 3

• Two-Food Elimination Diet (TFED):

  • Typically eliminates milk plus either wheat or egg 1
  • Should be the starting point before progressing to more restrictive diets 1

• Six-Food Elimination Diet (SFED):

  • Eliminates cow's milk, wheat, egg, soy, peanuts/tree nuts, fish/shellfish 1
  • Histological response rate of approximately 72.1% 1
  • Most common food triggers identified after reintroduction: milk (74%), wheat (26%), eggs (17%), soy (10%) 3

Pharmacological Treatment

Proton Pump Inhibitors (PPIs)

• PPIs can be effective first-line therapy for some infants 4
• Recommended dosage: omeprazole 20mg twice daily for 8-12 weeks 5
• Should be given for at least 8-12 weeks before assessing histological response 4

Topical Corticosteroids

• Highly effective for inducing histological and clinical remission 4
• Preferred over systemic corticosteroids due to better safety profile 1
• Should be considered if dietary approaches are unsuccessful or impractical 4

Systemic Corticosteroids

• Reserved only for infants requiring urgent symptom relief 6
• Higher risk of side effects including weight gain and cushingoid appearance 1
• Not recommended as first-line therapy 1

Treatment Algorithm

1. Initial Approach: Start with dietary management under supervision of an experienced dietitian 1

   • For infants: Consider elemental formula first due to high success rate 1
   • For older infants able to consume solid foods: Begin with single-food (milk) elimination 2

2. If initial approach fails:

   • Progress to two-food elimination diet (milk + wheat or egg) 1
   • If still unsuccessful, consider six-food elimination diet 1

3. If dietary management is unsuccessful or impractical:

   • Initiate PPI therapy for 8-12 weeks 4
   • If no response, proceed to topical corticosteroids 4

4. Treatment Monitoring:

   • Perform endoscopy with biopsy 8-12 weeks after initiating treatment 1
   • Target: <15 eosinophils/mm² on histology 1
   • Clinical symptoms may improve before histological resolution 4

Important Considerations

• Nutritional Support: All dietary elimination approaches must be supervised by an experienced dietitian to ensure nutritional adequacy and growth 1

• Multidisciplinary Approach: Infants with refractory disease or significant concomitant atopic conditions should be jointly managed by a gastroenterologist and allergist 1

• Follow-up: Repeat endoscopy with biopsy is essential to confirm response, as symptoms may not correlate with histological activity 1

• Common Pitfalls:

  • Relying solely on allergy testing to guide elimination diets (poor predictive value) 7
  • Failing to provide adequate nutritional support during elimination diets 1
  • Not allowing sufficient time (8-12 weeks) before assessing treatment response 1
  • Missing concomitant atopic conditions that may require separate management 1