What is the initial treatment approach for mild esophagitis in children?

Treatment for Mild Esophagitis in Children

For mild esophagitis in children, initial treatment should focus on symptom relief through lifestyle modifications first, followed by topical corticosteroids or dietary elimination therapy if symptoms persist, with acid suppression reserved for cases where reflux-mediated disease is confirmed. 1

Initial Assessment and Diagnostic Considerations

Before initiating treatment, it is critical to distinguish between different types of esophagitis:

• Eosinophilic esophagitis (EoE) presents with feeding problems in young children and dysphagia in older children, often with a history of atopy 1
• Reflux esophagitis typically presents with regurgitation, vomiting, irritability, or feeding refusal 2, 3
• Endoscopy with biopsies should be performed in children with upper GI symptoms to establish the diagnosis, as treatment pathways differ significantly 1

Treatment Algorithm for Mild Eosinophilic Esophagitis

First-Line Approach: Symptom-Directed Treatment

Treatment should initially aim at improving symptoms rather than aggressive histologic resolution in mild cases. 1 The decision to advance treatment depends on:

• Degree of symptoms
• Age of the patient
• Presence of esophageal morphologic abnormalities (rings, strictures, narrowing)
• Family values and preferences 1

Therapeutic Options (in order of preference):

1. Topical Corticosteroids

• Topical corticosteroid therapy should be considered in all children diagnosed with EoE for both initial and maintenance therapy 1
• Fluticasone or oral viscous budesonide are effective options, with budesonide showing evidence of reversing esophageal fibrosis 1
• Monitor for esophageal candidiasis as a potential side effect 1
• Growth should be carefully monitored in children on chronic topical steroids 1

2. Dietary Therapy

• Dietary therapy (specific antigen removal or elemental formula) should be considered as effective therapy in all children diagnosed with EoE 1
• Six-food elimination diet (SFED) shows 72-74% histological response rate in children, eliminating: cow's milk, wheat, egg, soy, peanuts/tree nuts, fish and seafood 1
• Amino acid-based (elemental) formula is the gold standard with 92-98% effectiveness, though often requires nasogastric or gastrostomy tube due to poor palatability 1
• Consultation with a registered dietitian is strongly encouraged to ensure proper calories, vitamins, and micronutrients are maintained 1
• Consider quality of life implications, as food elimination can significantly impact the child and family 1

3. Step-Up Dietary Approach (Most Practical)

• Begin with two-food elimination diet (TFED), typically milk and wheat or milk and egg 1
• Step up to four-food elimination diet if inadequate response 1
• Reassess with endoscopy and histology between 8-12 weeks after dietary intervention 1

Treatment Algorithm for Mild Reflux Esophagitis

First-Line: Lifestyle Modifications

For infants and young children:

• Smaller, more frequent feedings to reduce gastric distension 4, 5
• Thickening formula (if formula-fed), though use caution in preterm infants due to necrotizing enterocolitis risk 4
• Maternal elimination diet (exclude milk and egg for 2-4 weeks if breastfeeding) 4
• Trial of extensively hydrolyzed or amino acid-based formula if formula-fed 4
• Upright positioning when awake and supervised 4

Second-Line: Pharmacologic Therapy

Proton Pump Inhibitors (Preferred for Moderate-Severe Disease)

• Omeprazole is more effective than H2-receptor antagonists for symptom relief and healing of erosive esophagitis 5, 6
• FDA-approved dosing for children 2-16 years:
  • 10 mg once daily for children weighing 10 to <20 kg 7, 8
  • 20 mg once daily for children weighing ≥20 kg 7, 8
• For children under 2 years (off-label use): Starting dose of 0.7 mg/kg/day, may escalate to 1.4-2.8 mg/kg/day if inadequate response 4, 7
• Administer 30 minutes before meals for optimal effect 5
• Monitor for adverse effects: headaches, diarrhea, constipation, nausea, and increased risk of lower respiratory tract infections 4

H2-Receptor Antagonists (Alternative for Mild Disease)

• Ranitidine (if available): 5-10 mg/kg/day divided in 2-3 doses for children 1 month to 16 years 9
• Famotidine: 1 mg/kg/day divided in 2 doses for children 1-16 years 5
• Limitation: Tachyphylaxis develops within 6 weeks, limiting long-term use 5, 9

Critical Pitfalls and Caveats

Avoid Overtreatment in Mild Cases

• Not all esophageal eosinophilia requires aggressive treatment if the patient is minimally symptomatic 1
• The natural history of untreated esophageal eosinophilia is not well established, making risk-benefit assessment challenging 1

PPI Use in Infants Requires Caution

• PPIs are not FDA-approved for infants under 2 years and should only be used for severe, refractory cases 4
• Increased risk of lower respiratory tract infections, community-acquired pneumonia, gastroenteritis, and candidemia in infants on PPIs 4, 5
• Long-term use (>2.5 years) associated with enterochromaffin cell hyperplasia in up to 50% of children 4, 7

Distinguish EoE from GERD

• For accurate diagnosis of EoE, PPIs should be withdrawn for at least 3 weeks prior to endoscopy and biopsy 1
• Up to 42-58% of infants may have both cow's milk protein allergy and GERD, requiring dietary elimination trial for 2-4 weeks 3

Monitoring Requirements

• Regular clinic visits to assess symptoms, compliance, and adverse effects 1
• Repeat endoscopy no sooner than 4 weeks after therapeutic intervention if histologic assessment is planned 1
• For EoE, histological assessment is the best criterion for response after initiating treatment, undertaken between 8-12 weeks 1

When to Escalate Treatment

Advance to more aggressive therapy if:

• Persistent symptoms despite initial treatment 1
• Development of esophageal morphologic abnormalities (rings, strictures, narrowing) 1
• Failure to thrive or significant feeding difficulties 2, 3
• Recurrent food bolus obstruction (requires maintenance topical steroid therapy) 1

Medications NOT Recommended

• Cromolyn sodium: No apparent therapeutic benefit for EoE 1
• Leukotriene receptor antagonists: May provide symptomatic relief but no effect on esophageal eosinophilia 1
• Systemic corticosteroids: Reserved only for emergency cases (severe dysphagia, hospitalization, weight loss) due to significant toxicity risk with long-term use 1
• Biologic agents (anti-IL-5): Await further clinical trials and cannot be recommended for routine use 1