Comparative dietary therapy effectiveness in remission of pediatric eosinophilic esophagitis

Abstract

Background: Eosinophilic esophagitis is a chronic, immune-mediated inflammatory disorder that responds to dietary therapy; however, data evaluating the effectiveness of dietary therapeutic strategies are limited.

Objective: This study compared the effectiveness of 3 frequently prescribed dietary therapies (elemental, 6-food elimination, and skin prick and atopy patch-directed elimination diets) and assessed the remission predictability of skin tests and their utility in directing dietary planning.

Methods: A retrospective cohort of proton-pump inhibitor-unresponsive, non-glucocorticoid-treated patients with eosinophilic esophagitis who had 2 consecutive endoscopic biopsy specimens associated with dietary intervention was identified. Biopsy histology and remissions (<15 eosinophils/high-power field) after dietary therapy and food reintroductions were evaluated.

Results: Ninety-eight of 513 patients met the eligibility criteria. Of these 98 patients, 50% (n= 49), 27% (n= 26), and 23% (n= 23) received elemental, 6-food elimination, and directed diets, respectively. Remission occurred in 96%, 81%, and 65% of patients on elemental, 6-food elimination, and directed diets, respectively. The odds of postdiet remission versus nonremission were 5.6-fold higher (P= .05) on elemental versus 6-food elimination diets and 12.5-fold higher (P= .003) on elemental versus directed diets and were not significantly different (P= .22) on 6-food elimination versus directed diets. After 116 single-food reintroductions, the negative predictive value of skin testing for remission was 40% to 67% (milk, 40%; egg, 56%; soy, 64%; and wheat, 67%).

Conclusion: All 3 dietary therapies are effective; however, an elemental diet is superior at inducing histologic remission compared with 6-food elimination and skin test-directed diets. Notably, an empiric 6-food elimination diet is as effective as a skin test-directed diet. The negative predictive values of foods most commonly reintroduced in single-food challenges are not sufficient to support the development of dietary advancement plans solely based on skin test results.

Figure 1

Flow diagram of study participants.

Figure 2

Comparisons of pre- and post-diet therapy peak eosinophil counts/HPF for diet therapies using Kruskal-Wallis test. Data points between the dashed horizontal lines represent remission (0 to < 15 eosinophils/HPF), and data points above the upper dashed line represent non-remission (≥ 15 eosinophils/HPF). The Wilcoxon paired signed rank-test was used to compare pre- and post-diet therapy median peak eosinophil counts/HPF. The solid horizontal lines represent median values. *Adjusted P-value using the Dwass, Steel, Critchlow, Fligner correction for pairwise comparison between the post-diet therapy peak eosinophil counts/HPF for the elemental and directed diet, P = 0.01.