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Eosinophilic Esophagitis (EoE) in Pediatric and Adolescent Patients
EoE in Pediatric and Adolescent Patients Overview
- What is eosinophilic esophagitis?
Eosinophilic esophagitis, or EoE for short, is a condition where the esophagus (the tube that carries food from your mouth to your stomach) gets inflamed. It is thought to be mostly caused by the body’s response to things that touch the lining of the esophagus, such as food and environmental (airborne) allergens. Allergens are things that a person is allergic to such as foods, plants, trees etc. Both adults and children can have EoE.
Symptoms
- What are the symptoms of EoE?
Symptoms, which include reflux, can vary depending on age. Symptoms of EoE are non-specific and are usually not enough to make a final diagnosis without additional testing. Infants and toddlers with EoE often have feeding problems, vomiting and poor weight gain. School-aged children may have vomiting and abdominal pain, and teens may have the feeling of food getting stuck in the throat or chest (known as dysphagia), especially with solid meals. Dysphagia can lead to food impaction, where food suddenly gets stuck in the esophagus leading to chest pain, choking, drooling and difficulty swallowing. If a food impaction occurs, an emergency endoscopy procedure may be required to remove the food.
Causes
- What causes EoE?
The cause of EoE is unknown, but doctors think EoE happens because the immune system reacts to certain allergens, which may be in food or in the air. Some people may be more likely to get EoE due to their genes.
Risk Factors
- What are the risk factors for EoE in kids and teens?
Boys are more likely to have EoE than girls. It is more common in Caucasian people, and in people who have allergies, asthma or eczema. If someone in your family has EoE, an individual may be at a higher risk.
Screening/Diagnosis
- How is EoE diagnosed?
Doctors typically start by asking questions about symptoms with a thorough medical history. Taking a complete medical history is usually enough to suggest EoE. However, a final diagnosis can only be made by performing an upper endoscopy, where they look inside the esophagus with a small camera. During this procedure, they may take tiny samples of tissue (biopsies) to check for inflammation.
Treatment
- What is the treatment for EoE?
The treatment of EoE usually involves:
- Diet Changes: Doctors may recommend avoiding foods that often cause allergic reactions. Children with EoE may respond to taking certain trigger foods out of their diet to reduce exposure. Three types of diets may be helpful:
- Common allergen elimination diet: Avoiding the most common foods that cause EoE, such as milk, soy, wheat, eggs, peanuts, and seafood.
- Elimination diet: Avoiding specific foods that may causing allergic inflammation. This may be based on the results of skin prick testing, patch testing, or blood tests.
- Elemental diet:Drinking special formulas instead of eating regular food. These formulas contain proteins that are broken down to their basic building blocks (either peptides or free amino acids) thereby reducing the body’s reaction to them.
- Medications to decrease inflammation:
- Steroids: reduce inflammation in the esophagus.
- Acid reducing medications: Medications often used for acid reflux also help reduce inflammation caused by EoE.
- Dilation: the esophagus may become too narrow from scarring, which is called a stricture or stenosis. A procedure called a dilation might be needed to stretch it out.
Sometimes, a repeat endoscopy is done to make sure the inflammation is better. Some doctors may instead choose to follow patients’ symptoms to decide if a treatment is working. If endoscopy is used to determine if an elimination diet is working, once the endoscopy shows improvement, families may be asked to reintroduce one food at a time, then repeat the endoscopy to see if the inflammation is back. This may help to identify specific allergens leading to symptoms and to see if more foods can be tolerated in the diet. Currently, less invasive tests like blood tests are not helpful for deciding whether a treatment for EoE is working.
Allergy testing may be helpful, because kids and teens with EoE often have allergies. Allergy testing may include some combination of blood, skin prick and patch tests to screen for potential food and environmental allergens.
Seeing a registered dietician is often helpful to make sure kids and teens with EoE get the calories, vitamins, and other nutrients that they need. Dieticians can help with which foods are a part of the dietary treatment. It is important to keep track of kids’ and teens’ height and weight during treatment, because the disease and its treatment may slow growth.
Medications that may be used either alone or in conjunction with diet changes include:
- Steroids: By decreasing inflammation, steroids can make it easier to swallow and help with other symptoms like vomiting and heartburn. Some are swallowed as a liquid, or sprayed from an inhaler. If the swelling is severe, doctors might give steroids as pills or through an IV, especially if it’s an emergency or someone cannot eat or is losing weight. However, steroids for a long time can cause side effects, so doctors only use them in this way when it’s really necessary. Kids who need steroids for a long time should be checked by doctors to make sure their bones stay strong and keep growing normally.
To minimize the steroid side effects, a topical steroid may be prescribed as a maintenance therapy to keep the inflammation quiet. The medication is typically sprayed from an inhaler and swallowed into the esophagus. A viscous (thick liquid) form of steroids is also available. After using topical steroids, children should rinse out their mouths because residues of the medicine in the mouth can leave them at an increased risk for an oral infection known as thrush, which may worsen feeding difficulties and cause pain. Children on long-term topical steroids should be monitored for growth issues although the effects on growth are minimal or absent due to the very limited amount of topical steroids taken up into the body. - Acid reducing medications: Medications that decrease stomach acid, which include proton pump inhibitors. These may also help with relieving further irritation to the esophagus from stomach acid. They are typically given 1-2 times per day and many different brands are available for over the counter or prescription use. These medicines should be used under the guidance of a physician. Some patients will improve with the use of a proton pump inhibitor.
- Duplimab: A new treatment called Dupilimab is an antibody that blocks certain inflammatory molecules (interleukin 4 and 13), and improves the inflammation of EoE. Dupilimab is given with an injection, and is also used for other conditions like asthma and eczema. Dupilimab may be used for EoE if other treatments do not work.
- Newer medications such as humanized monoclonal antibodies to IL-5 (interleukin- 5) which is given through an intravenous line, are being studied in adult and pediatric patients to see if they are helpful in reducing inflammation and clinical symptoms. These medications are not yet available for clinical use in the United States.
Speak with your doctor about what treatment options may be best for you.
- Diet Changes: Doctors may recommend avoiding foods that often cause allergic reactions. Children with EoE may respond to taking certain trigger foods out of their diet to reduce exposure. Three types of diets may be helpful:
Author(s) and Publication Date(s)
Anthony F. Porto, MD, MPH, Yale-New Haven Children's Hospital, New Haven, CT, and Marsha H. Kay, MD, FACG, Cleveland Clinic, Cleveland, OH – Published July 2013.
Scott L. Gabbard, MD, FACG, Cleveland Clinic, Cleveland, OH, Ryan T. Hoff, DO, PeaceHealth Gastroenterology, Vancouver, WA and Victoria Howard, PA, University of Rochester, Rochester, NY – Updated April 2025.