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

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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.

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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

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Authors and Affiliations

  1. Department of Pediatrics, Hospital General de Tomelloso, Tomelloso, Spain

    Mery Munoz-Persy

  2. Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n, 13700 Tomelloso, Ciudad Real, Spain

    Alfredo J. Lucendo

  3. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain

    Alfredo J. Lucendo

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

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Correspondence to Alfredo J. Lucendo.

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Munoz-Persy, M., Lucendo, A.J. Treatment of eosinophilic esophagitis in the pediatric patient: an evidence-based approach. Eur J Pediatr 177, 649–663 (2018). https://doi.org/10.1007/s00431-018-3129-7

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