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

Amir F Kagalwalla*, Joshua Brian Wechsler, Katie Amsden, Sally Schwartz, Melanie Mala Makhija, Anthony Olive, Carla M. Davis, Maria Manuel-Rubio, Seth Marcus, Ronda Shaykin, Maureen Sulkowski, Kristen Johnson, Jessica N. Ross, Mary Ellen Riffle, Marion Groetch, Hector Melin-Aldana, Deborah Schady, Hannah Palac, Kwan Youn A. Kim, Barry K WershilMargaret H. Collins, Mirna Chehade

*Corresponding author for this work

Research output: Contribution to journalArticle

44 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)1698-1707.e7
JournalClinical Gastroenterology and Hepatology
Volume15
Issue number11
DOIs
StatePublished - Nov 1 2017

Fingerprint

Eosinophilic Esophagitis
Diet
Food
Triticum
Ovum
Milk
Digestive System Endoscopy
Inflammation
Recurrence
Proton Pump Inhibitors
Eosinophils
Endoscopy
Observational Studies

Keywords

  • Esophagus
  • Inflammation
  • SFED
  • Trial

ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology

Cite this

Kagalwalla, Amir F ; Wechsler, Joshua Brian ; Amsden, Katie ; Schwartz, Sally ; Makhija, Melanie Mala ; Olive, Anthony ; Davis, Carla M. ; Manuel-Rubio, Maria ; Marcus, Seth ; Shaykin, Ronda ; Sulkowski, Maureen ; Johnson, Kristen ; Ross, Jessica N. ; Riffle, Mary Ellen ; Groetch, Marion ; Melin-Aldana, Hector ; Schady, Deborah ; Palac, Hannah ; Kim, Kwan Youn A. ; Wershil, Barry K ; Collins, Margaret H. ; Chehade, Mirna. / Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis. In: Clinical Gastroenterology and Hepatology. 2017 ; Vol. 15, No. 11. pp. 1698-1707.e7.
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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",
author = "Kagalwalla, {Amir F} and Wechsler, {Joshua Brian} and Katie Amsden and Sally Schwartz and Makhija, {Melanie Mala} and Anthony Olive and Davis, {Carla M.} and Maria Manuel-Rubio and Seth Marcus and Ronda Shaykin and Maureen Sulkowski and Kristen Johnson and Ross, {Jessica N.} and Riffle, {Mary Ellen} and Marion Groetch and Hector Melin-Aldana and Deborah Schady and Hannah Palac and Kim, {Kwan Youn A.} and Wershil, {Barry K} and Collins, {Margaret H.} and Mirna Chehade",
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doi = "10.1016/j.cgh.2017.05.048",
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number = "11",

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Kagalwalla, AF, Wechsler, JB, Amsden, K, Schwartz, S, Makhija, MM, Olive, A, Davis, CM, Manuel-Rubio, M, Marcus, S, Shaykin, R, Sulkowski, M, Johnson, K, Ross, JN, Riffle, ME, Groetch, M, Melin-Aldana, H, Schady, D, Palac, H, Kim, KYA, Wershil, BK, Collins, MH & Chehade, M 2017, 'Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis', Clinical Gastroenterology and Hepatology, vol. 15, no. 11, pp. 1698-1707.e7. https://doi.org/10.1016/j.cgh.2017.05.048

Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis. / Kagalwalla, Amir F; Wechsler, Joshua Brian; Amsden, Katie; Schwartz, Sally; Makhija, Melanie Mala; Olive, Anthony; Davis, Carla M.; Manuel-Rubio, Maria; Marcus, Seth; Shaykin, Ronda; Sulkowski, Maureen; Johnson, Kristen; Ross, Jessica N.; Riffle, Mary Ellen; Groetch, Marion; Melin-Aldana, Hector; Schady, Deborah; Palac, Hannah; Kim, Kwan Youn A.; Wershil, Barry K; Collins, Margaret H.; Chehade, Mirna.

In: Clinical Gastroenterology and Hepatology, Vol. 15, No. 11, 01.11.2017, p. 1698-1707.e7.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis

AU - Kagalwalla, Amir F

AU - Wechsler, Joshua Brian

AU - Amsden, Katie

AU - Schwartz, Sally

AU - Makhija, Melanie Mala

AU - Olive, Anthony

AU - Davis, Carla M.

AU - Manuel-Rubio, Maria

AU - Marcus, Seth

AU - Shaykin, Ronda

AU - Sulkowski, Maureen

AU - Johnson, Kristen

AU - Ross, Jessica N.

AU - Riffle, Mary Ellen

AU - Groetch, Marion

AU - Melin-Aldana, Hector

AU - Schady, Deborah

AU - Palac, Hannah

AU - Kim, Kwan Youn A.

AU - Wershil, Barry K

AU - Collins, Margaret H.

AU - Chehade, Mirna

PY - 2017/11/1

Y1 - 2017/11/1

N2 - 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.

AB - 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.

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KW - Inflammation

KW - SFED

KW - Trial

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