Children with Eosinophilic Oesophagitis: The parents guide to working with a Paediatric Dietitian

What is EoE?

Eosinophilic oesophagitis (EoE) happens when white blood cells (called eosinophils) deposit in the lining of the oesophagus, which is the muscular tube that connects the mouth to the stomach. This can be the result of an allergic reaction to food or the environment.

Most cases of EoE are seen in children with other allergies such as allergic rhinitis (hay fever) and asthma. It is estimated to affect around one in 1,000 people (children and adults), and the frequency of EoE appears to be increasing. The reasons are unclear, but it is known that allergies of all types have become more common.

I've created a dietitian's guide to EoE which you should find helpful as a summary of the information to follow. Access it on my Feeding Resources page, or download it directly here - EoE Guide (pdf)

What are the symptoms of EoE?

Typically the symptoms in children include:

Slow eating,
Food impaction/food bolus obstruction (FBO) – when food gets stuck on the way down the oesophagus,
Choking or gagging on food,
Regurgitation of foods,
Abdominal (stomach) pain,
Texture aversions,
Very picky eaters,
In some cases, loose stools.

Who treats EoE?

Most children with EoE are co-managed by Paediatric Gastroenterologists (stomach/bowel medical specialists), Clinical Immunology/Allergy Specialists and specialist Paediatric Dietitians.

How is EoE diagnosed?

Diagnosis of EoE should always be confirmed by endoscopy and biopsies, which are normally performed by a Gastroenterologist:

If EoE is suspected, your Paediatrician will usually confirm this by looking at the oesophagus using an endoscope.
Three tissue samples (biopsies) will be taken at the same time and examined to look for eosinophils.

Do children with EoE usually have other allergic conditions?

Yes. Around 75% of children with EoE have other allergic conditions, such as allergic rhinitis or asthma.

Some children with EoE only have symptoms during spring time, when they are exposed to pollens. Occasionally they can also have other IgE allergies (more about IgE allergies) or non IgE allergies (more about non IgE allergies). This will be assessed by your full team, being your Paediatric Gastroenterologist, Immunologist and Paediatric Dietitian.

What are the treatment options for EoE?

EoE is not always treated with diet, so it's important not to jump to conclusions on management. EoE can be related to pollens in the air or foods and sometimes can only be treated with medications. If you suspect EoE, before trialling diet changes, it's important to speak with your Paediatrician about a referral to a Paediatric Gastroenterologist, to conduct the initial assessment and necessary investigations.

However, some of the typical treatment options for EoE include:

Proton pump inhibitor medication (tablets or liquids) – to reduce acid production and also have an anti-inflammatory action that may reduce or abolish the eosinophilic inflammation in EoE;
Swallowed corticosteroids - to help reduce inflammation and the scarring that can result from untreated EoE;
Topical asthma corticosteroid puffers (fluticasone);
Topical asthma corticosteroid liquid (budesonide) made up as a paste/slurry;
Dissolving corticosteroid tablets (budesonide);
Dietary modification - to assist children, undertaken under the direction of a Paediatric Gastroenterologist or Clinical Immunology/Allergy Specialist, and supervised by a specialist Paediatric Dietitian. When undertaking dietary modification, certain foods are removed for a period of time and then re-introduced, one at a time, to see which foods result in symptoms;
Dilation - a procedure that may be required if the oesophagus is very narrow, used with endoscopy, to open the narrowed oesophagus. This allows food to pass easier, to provide temporary relief.

What types of dietary modification are used for EoE?

When food is the cause of EoE, your Paediatric Gastroenterologist will arrange a referral to a Paediatric Dietitian to support you with dietary modifications. Milk, egg, wheat and soy are typically the major triggers followed less commonly by seafood and nuts. By working closely with your Paediatric Dietitian and Paediatric Gastroenterologist, they will help you determine what foods to exclude, based on research and symptoms.

Dietary modification for EoE is temporary, for 8 -12 weeks, to assess symptom improvement. What happens in practice is the initial removal of a few typical allergens, followed by periods of reintroduction. This is to determine if your child is indeed reacting to all, if any, dietary triggers.

Types of dietary modification used include:

Common food allergen elimination diets. These usually include the removal of cow’s milk, soy, egg, and wheat. Allergy testing or patient history may result in the removal of additional foods.
Step-up diets. Instead of removing many foods at the same time, one to two foods are removed at first, to see if symptoms improve, repeating a biopsy if they do. More foods will be removed at a later date if inflammation persists on biopsy.
Amino acid based diets. These are based on amino acid/elemental formula and can be impractical in adults and older children, but are useful and commonly used for babies with EoE.

Allergy testing, such as skin prick tests or RAST blood tests, are not considered to be a reliable indicator of response to dietary modification. These tests are not recommended unless a child has evidence of rapid onset allergic symptoms, after food consumption, as well as EoE.

Endoscopies and repeat biopsies are essential to monitor response to treatment. Symptoms alone are not a reliable guide to disease control. This process will be guided by your Paediatric Gastroenterologist.

Where your Paediatric Dietitian might begin on supporting your child with an exclusion diet for Eosinophillic Eosophagitis

A two food elimination diet of dairy and wheat:

This diet plan outlines how to follow a diet free from cow’s milk (dairy) and wheat. The diet involves strictly avoiding all foods and drinks that contain cow’s milk (dairy) and wheat, even in very small quantities.
This diet is to be used for 8 to 12 weeks, as a trial, to see if avoiding certain foods will help reduce symptoms. You should regard this diet as a test to see if foods are making symptoms worse and not necessarily a long term treatment.
You will be asked to complete diaries recording foods your child eats and details of any symptoms whilst following this diet.
The effect of the diet will be assessed by symptoms and/or a repeat endoscopy (a procedure to look inside the body with a small tube with a camera and light attached), and biopsies (samples of cells) of the oesphagus are taken.
Each food will then be reintroduced one by one. Introduction of foods will be discussed in detail by the Paediatrician and Paediatric Dietitian, at follow up appointments.

How to exclude dairy for Eosinophillic Eosophagitis (EoE)

When first trialling dairy free, I like to start people off with substitutes or swaps. For example:

Milk --> Vitasoy soy milk, So Good Oat milk Barista or So Good Almond milk Barista

Cheese --> Made With Plants cheese

Yoghurt --> Cocobella yoghurt pouch (not the tub), chobani oat yoghurt, vitasoy yoghurt

Butter --> Nuttelex

Custard --> Vanilla Custard Coyo

Ice cream --> Magnum dairy free, icy poles, coconut ice cream

These are the obvious dairy-based items to swap. With these changes, you're almost there. I specifically suggest as substitutes because of their high protein and calcium content, an important factor for children during growth development.

These are the obvious starting points. The next part is reading food labels. Here's my easy solution - take advantage of the information provided on the Woolworths and Coles websites. These websites make it easy to remove all the dairy from your searches.

How to read labels to exclude dairy

The next step is building your confidence, knowing you can read the labels independently. Nutrition labelling has become easier these days. Follow these steps:

1: Check all the words in bold. Look out for any dairy product listed.

2: Check the 'Contains' statement for milk.

3: Review the 'May contain traces of'.

Now in EoE land it is ok to consume products that state may contain traces of. Now let's check this off with an example.

Let's do this with a real label.

Step 1: Scan the ingredients list for the bold items

In this ingredient list, wheat, soy and milk are in bold. This is our first sign to say that this product is not appropriate for a child who is avoiding dairy.

Step 2: Check the 'Contains' section

Here we see that it specifically states the product contains milk. This is useful as sometimes dairy can be labelled as all kinds of things. For example 'whey, casein, caseinates, lactose, lactoblobulin' etc. The 'contains' section is useful to know for certain that this product contains dairy.

Step 3: Understanding the 'may contain traces of' section

Now for certain types of allergies or intolerances this line is important. But for EoE it isn't important. Children with EoE are allowed to have foods that say 'may contain traces' of dairy.

Knowing how to search online, before you go shopping, will make life a whole lot easier. You'll save time by removing the guess work. With knowledge comes power and convenience...

I created this How to Read Labels guide to download or view online at any time. This is specifically for wheat and gluten allergies, but the advice is the same, except you are looking out for milk. I hope it makes it easier for you to find the products you need quickly. For more helpful guides, check out my Resources page.

How to exclude wheat for Eosinophillic Eosophagitis (EoE)

Now that I've explained dairy exclusion for this diet, wheat exclusion follows roughly the same process.

Your wheat based products include breads, cereals, pasta, biscuits and cake. Packaged goods typically also contain wheat products.

Luckily for families there are plenty of wheat free product options. This table outlines some of the substitutions available that are wheat free alternatives.

Again jump on the Woolworths or Coles website and do a search of 'pasta', 'bread', 'cereal', 'biscuits' and 'crackers' to find your alternative products.

It's the same steps for wheat, as I explained for dairy. Check for the bold in the main ingredients list for wheat, review the 'contains' section to confirm that wheat is indeed in the product, remember your child can eat products that say 'may contain traces of wheat'.

Download my helpful guide for reading labels for wheat allergies.

Example meal plan for a child on an exclusion diet for Eosinophillic Eosophagitis (EoE)

Breakfast:

Eggs on gluten-free toast with Nuttelex
Oats with oat milk or almond milk with honey and fruit
Cocobella or Chobani oat yoghurt with fruit
Gluten-free rice pops or corn flakes

Lunch:

Tortilla wraps with ham, Made With Plants cheese and salad
Gluten-free bread with tuna, Made With Plants cheese and salad
Corn cakes with peanut butter or tuna
Leftovers from dinner
Sushi with avocado and tuna

Dinner:

Spaghetti bolognese with gluten-free pasta
Risotto with chicken and vegetables
Meat stir fry with rice and vegetables
Gluten-free chicken nuggets and chips

Snacks:

All fruits
Corn or rice thins with peanut butter or vegetable and Made With Plants cheese
Cocobella yoghurt, Chobani oat yoghurt, Vitasoy yoghurt
Sam's Pantry nut bars (honey salted macadamias)

How can a certified Paediatric Dietitian help?

Once EoE has been diagnosed I will work with you and your Paediatric Gastroenterologist to manage your child's nutritional plan. I’ve worked with many patients and families through the process and bring all this experience to your child's unique situation. Following the initial consultation, I'll be supporting your child by creating an individualised nutrition plan and helping them, and you, through maintenance of this specialised diet . Please feel free to ask any questions or raise concerns you encounter. I am there for you and your child.

Working with me is easy. Just follow these 3 steps and we’ll get everyone on the road to peace, health and happiness.

Book an appointment: in-person or online video call

I’ll meet with you and your child via telehealth or face to face. We’ll discuss your child’s full history from birth until today and answer all your questions.

Get a customised nutrition plan

You’ll receive a nutrition plan that meets your child’s specific needs.

See your child thrive and their confidence grow

As your child’s digestion improves happiness will return to your mealtimes.

Book an appointment

FAQs: About Eosinophillic Oesophagitis and diet management

Here are some of the common questions I've been asked by parents and carers regarding their child with EoE and how to thrive.

What are the common triggers for EoE

Common food triggers include dairy, wheat, egg, and soy. Sometimes nuts and seafoods can be a culprit. Not all children will react to each of these foods. So it is imperative to be guided by your specialists on guidance on where to begin and how to start.

What are the top triggers for EoE

Dairy and wheat are the top triggers and are often the starting point for diet therapy. I often find working on a bottom up approach works best. Starting with a few triggers then building up to other triggers if symptoms persist. This is to avoid unnecessary exclusion of foods for your child while we work on their symptoms.

Where can I find good resources for information on Eosinophillic Oesophagitis?

A lot of information on this page has been extracted from the Australian Society of Clinical Allergy and Immunology (ASCIA). Visit their website for more information on Eosinophillic Oesophagitis from ASCIA. Alternatively AusEE.org is another fantastic resource for families. They have books, magazines, recipes, virtual support groups and more.