Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis

Abstract

Background & aims: A 6-food elimination diet induces remission in most children and adults with eosinophilic esophagitis (EoE). The effectiveness of empiric elimination of only 4 foods has not been studied in children. We performed a prospective observational outcome study in children with EoE treated with dietary exclusion of cow's milk, wheat, egg, and soy. The objective was to assess the clinical, endoscopic, and histologic efficacy of this treatment in EoE.

Methods: We recruited children (1-18 years old, diagnosed per consensus guidelines) from 4 medical centers. Study participants (n = 78) were given a proton pump inhibitor twice daily and underwent a baseline esophagogastroduodenoscopy. Subjects were instructed on dietary exclusion of cow's milk, wheat, egg, and soy. Clinical, endoscopic, and histologic assessments were made after 8 weeks. Responders had single foods reintroduced for 8 weeks, with repeat endoscopy to assess for recurrence of active disease. The primary endpoint was histologic remission (fewer than 15 eosinophils per high-powered field). Secondary endpoints included symptom and endoscopic improvements and identification of foods associated with active histologic disease.

Results: After 8 weeks on 4-food elimination diet, 50 subjects were in histologic remission (64%). The subjects' mean baseline clinical symptoms score was 4.5, which decreased to 2.3 after 8 weeks of 4-food elimination diet (P < .001). The mean endoscopic baseline score was 2.1, which decreased to 1.3 (P < .001). After food reintroduction, the most common food triggers that induced histologic inflammation were cow's milk (85%), egg (35%), wheat (33%), and soy (19%). One food trigger that induced recurrence of esophageal inflammation was identified in 62% of patients and cow's milk-induced EoE was present in 88% of these patients.

Conclusions: In a prospective study of children with EoE, 8 weeks of 4-food elimination diet induced clinical, endoscopic, and histologic remission in more than 60% of children with EoE. Although less restrictive than 6-food elimination diet, 4-food elimination diet was nearly as effective, and can be recommended as a treatment for children with EoE.

Keywords: Esophagus; Inflammation; SFED; Trial.

Figure 1.

Diagram outlining the order of food reintroduction in responders. Single foods reintroduced every 8 weeks in 4-FED responders starting with soy, egg, wheat, and milk. Inflammation-inducing trigger foods removed followed by a normal baseline EGD demonstrating remission of inflammation before the next food reintroduction. 4-FED, 4-food elimination diet.

Figure 2.

Diagram of patient flow. Ninety-six patients were screened for the study; 18 were excluded and 78 underwent upper endoscopy with biopsies after 4-FED. Fifty demonstrated histologic remission. 4-FED, 4-food elimination diet.

Figure 3.

Food triggers identified in subjects reintroducing between 1 and 4 foods in the diet and in those who reintroduced all foods back. (A) Food triggers in patients who reintroduced 1–4 foods. (B) Food triggers in 25 patients who completed reintroduction of all foods. This included 3 subjects with anaphylaxis to egg (2) and soy (1) who did not reintroduce these foods in their diet. (C) Distribution by number of food triggers in 25 who reintroduced all foods.

Figure 4.

Comparison of histology with symptom response, endoscopic findings, and weight z scores. (A) Eosinophil counts at 6 different time points: baseline; post-4-FED; and after introduction of soy, wheat, egg, and milk. (B) Symptom scores at 6 different time points: baseline; post-4-FED; and after introduction of soy, wheat, egg, and milk. (C) Endoscopic scores at 6 different time points: baseline; post-4-FED; and after soy, wheat, egg, and milk. (D) Weight z scores at 6 different time points: baseline; post-4-FED; and after soy, wheat, egg, and milk. 4-FED, 4-food elimination diet; EREFS, Edema Rings Exudate Furrowing Stricture.