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European Journal of Pediatrics

, Volume 177, Issue 5, pp 649–663 | Cite as

Treatment of eosinophilic esophagitis in the pediatric patient: an evidence-based approach

  • Mery Munoz-Persy
  • Alfredo J. Lucendo
Review

Abstract

Eosinophilic esophagitis (EoE) is a unique form of non-IgE-mediated food allergy characterized by esophageal eosinophilic infiltration that commonly causes dysphagia and food impaction in children and adolescents. Assessing the efficacy of dietary restrictions or drug therapies to achieve clinical and histologic resolution of EoE through randomized controlled trials and meta-analyses has resulted in new evidence-based guidelines. Avoiding food triggers is the only therapy targeting the cause of the disease. None of the currently available food allergy tests adequately predict food triggers for EoE. Exclusively feeding with an amino acid-based elemental diet and empiric six-food elimination diet (avoiding the six foods most commonly related with food allergy) has consistently provided the best cure rates, but their high level of restriction and need for multiple endoscopies are deterrents for implementation. Simpler and less restrictive empirical methods, like a four-food (milk, gluten-containing cereals, egg, legumes) or a two-food (milk and gluten) elimination diet, show encouraging results. 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. The efficacy of topical corticosteroids in EoE assessed in several trials and summarized in meta-analyses indicates that budesonide and fluticasone propionate are significantly superior to placebos, both in decreasing eosinophil mucosal infiltration and in relieving symptoms. Owing to differences in drug delivery, viscous budesonide formulas seem to be the best pharmacological therapy for EoE.

Conclusion: Applying evidence-based therapies and a practical management algorithm provide an effective control of EoE.

What is Known:

Eosinophilic esophagitis (EoE) now constitutes the main cause of dysphagia and food impaction in children, adolescents, and young adults.

Its chronic course and frequent progression to subepithelial fibrosis leading to strictures and narrow-caliber esophagus indicate the need for treatment.

What is New:

Therapeutic goals in children with EoE include resolution of esophageal symptoms, to cure esophageal inflammation (mucosal healing) and restore a proper esophageal caliber in case of fibrostenotic endoscopic findings. Avoiding iatrogenic drug effects and nutritional deficiencies, as well as maintaining an adequate quality of life, is also essential.

Novel evidence-based guidelines, endorsed by several European scientific societies, incorporate recent advances in knowledge from several randomized controlled trials and systematic reviews to provide the best standard of care to pediatric patients, by following simple management algorithms.

Keywords

Eosinophilic esophagitis Diet therapy Drug therapy Dilation Glucocorticoids Proton pump inhibitors Disease management 

Abbreviations

AGA

American Gastroenterological Association

DSQ

Dysphagia Symptom Questionnaire

EEsAI

Eosinophilic Esophagitis Activity Index

EoE

Eosinophilic esophagitis

FFED

Four-food elimination diet

GERD

Gastroesophageal reflux disease

GRADE

Grading of Recommendations Assessment, Development and Evaluation

HPF

High-powered field

NASPGHAN

North American Society of Gastroenterology, Hepatology and Pediatric Nutrition

PEESS

Pediatric Eosinophilic Esophagitis Symptom Score

RCT

Randomized controlled trial

SFED

Six-food elimination diet

TFED

Two-food elimination diet

Notes

Authors’ Contributions

MM-P and AJL contributed equally to write the paper. All authors have read and approved the final version of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PediatricsHospital General de TomellosoTomellosoSpain
  2. 2.Department of GastroenterologyHospital General de TomellosoCiudad RealSpain
  3. 3.Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain

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