PURPOSE OF THE STUDY.
Eosinophilic esophagitis is an inflammatory disorder that clearly responds to dietary therapy. Current food hypersensitivity testing tools have been of unclear value in guiding dietary management. This study compared the effectiveness of 3 frequently prescribed dietary therapies (elemental, arbitrary 6-food elimination [SFED], and skin prick and atopy patch test-directed elimination diets).
Subjects were recruited from the Cincinnati Center for Eosinophilic Disorders database as a retrospective cohort with the following eligibility criteria: (1) diagnosis of eosinophilic esophagitis based on at least 15 eosinophils/high-power field (eos/HPF) in at least 1 esophageal biopsy specimen with no response to high-dose proton-pump inhibitor, or normal pH probe results, along with exclusion of other causes of esophageal eosinophilia; (2) at least 2 upper endoscopies to monitor dietary therapy; (3) no oral or topical corticosteroids for at least 2 months before and during the study; and (4) being aged ≤21 years throughout the study.
Patients were treated with 1 of 3 food-elimination therapies as the sole intervention (except for acid suppression) between the 2 endoscopic assessments. The specific dietary therapy chosen for each patient was not randomly assigned but negotiated between physician and patient based on multiple factors, including past responses to dietary intervention and an assessment of the child’s and family’s ability and willingness to implement the recommended diet. The elemental diet provided all nutrition in the form of crystalline amino acids, such as Neocate (Nutricia, Liverpool, United Kingdom). The SFED empirically avoided milk, soy, wheat, egg, peanut/tree nuts, and fish/shellfish, along with restricting foods eliciting positive skin prick test and allergy patch test result, the “modified SFED.” The third group (“directed”) eliminated only foods that elicited positive results on skin prick testing and/or allergy patch testing. Remission status was defined as follows: complete remission, ≤1 eos/HPF; partial remission, 2 to 5 eos/HPF; partial resolution, 6 to 14 eos/HPF; and active disease, ≥15 eos/HPF. Food reintroductions were initiated only when eosinophil levels after diet therapy were <15 eos/HPF and were deemed successful if subsequent eosinophil levels remained <15 eos/HPF and no symptoms were reported.
Ninety-eight of 513 patients met eligibility criteria. Fifty percent received elemental diet, 27% SFED, and 23% directed diet. Remission rates were as follows: elemental, 96%; SFED, 81%; and directed, 65%. Odds of postdiet remission versus nonremission were 5.6-fold higher on an elemental diet versus a 6-food diet and 12.5-fold higher on an elemental diet versus a directed diet, but there was no significant difference between 6-food elimination and directed diets. After single-food reintroductions, the negative predictive values of skin testing for remission were as follows: milk, 40%; egg, 56%; soy, 64%; and wheat, 67%.
All 3 dietary therapies were effective, but the elemental diet was superior at inducing histologic remission. The empirical 6-food elimination was at least as effective as a food skin test–directed diet. The negative predictive values of foods most commonly reintroduced in single food challenges were not sufficient to allow dietary advancement based solely on skin test results.
The authors point out that dietary adherence is inversely related to the number of foods eliminated. With that in mind, the directed diet might be preferable to the 6-food elimination diet if substantially fewer foods need be eliminated.
- Copyright © 2013 by the American Academy of Pediatrics