Eosinophilic Esophagitis

• 75% of individuals with EoE are white males
• EoE occurs in approximately 1 in 10,000 people
• The exact cause of EoE is unknown, but it appears to be related to food allergies
• EoE is more common in patients with other allergic diseases, such as asthma
• EoE was discovered relatively recently and much remains unknown about the disease

Eosinophilic Esophagitis has only recently been identified as a disease, and many of its symptoms—particularly in children—mimic the symptoms of GERD. However, patients of different ages tend to experience different symptoms.

In children, Eosinophilic Esophagitis symptoms are usually similar to those of GERD (abdominal pain, nausea, vomiting, poor weight gain). Adolescents and adults frequently experience difficulty swallowing and food impaction.

Symptoms can include:

• Nausea
• Problems swallowing (dysphagia)
• Vomiting
• Stomach pain
• Chest pain
• Heartburn
• Loss of weight
• Food impaction

If your doctor suspects that your child has Eosinophilic Esophagitis, he or she will conduct a biopsy of the esophagus. The biopsy is usually done with a procedure called endoscopy, in which a small camera is inserted into the esophagus. Sometimes, the doctor will see rings of eosinophils (white blood cells) in the esophagus, but often it will appear normal.

After the biopsy, the tissue will be inspected for evidence of eosinophils. If an EoE diagnosis is confirmed, the doctor will likely conduct allergy testing, looking for food and environmental allergies that contribute to the patient’s EoE.

If your child is experiencing these symptoms, discuss them with your family doctor or find a pediatric gastroenterologist near you.

The most effective treatment of Eosinophilic Esophagitis involves changes to the child’s diet and nutrition. If your child is diagnosed with EoE, the doctor or medical team will work to identify which foods are causing the condition so that your child can avoid them.

The most common allergic foods include milk, eggs, nuts, beef, wheat, fish, shellfish, corn and soy, but many other foods may also be a factor in EoE.

Some children with EoE may be allergic to a single food, while others may be allergic to many foods.

Because allergy tests are often unable to determine which foods are causing your child may need to temporarily eliminate some or all normal foods from his or her diet, and gradually re-introduce them. If that’s the case, your child may need to temporarily follow an elimination diet or an elemental diet.

This video presents information about the current treatment options for Eosinophilic esophagitis (EoE). It does NOT address other types of food allergies or eosinophilic conditions beyond the esophagus.

Always consult with your health care providers when making decisions about treatment.

This type of diet removes all foods that are known to cause an allergic reaction, as well as other foods that are suspected to cause problems. The remaining foods are monitored to ensure a balanced diet.

This diet removes all sources of protein and introduces a formula made up of amino acids, fats, vitamins, minerals and sugar. Children are often placed on an elemental diet, while adults tend to supplement with other foods. In some cases tube feedings (enteral support) are necessary for growth and weight gain.

If your child improves after following an elimination or elemental diet for a few months, foods will slowly be reintroduced one at a time. Your doctor will monitor your child to make sure he or she can tolerate each food. It’s possible that your doctor will need to perform another endoscopy with biopsy to determine whether your child is responding well to the reintroduced foods.

Your child’s doctor may recommend eliminating milk/dairy from your child’s diet to treat their eosinophilic esophagitis (EoE). Milk/Dairy (also called cow’s milk protein) is the single most common food trigger for EoE, causing inflammation in 50-60% of children with this condition. By removing all milk/dairy from your child’s diet we can see if milk/dairy is triggering your child’s symptoms.

• Any foods made from cow’s milk or other mammalian milk, including sheep and goat are considered dairy or milk-containing foods
• Food and ingredients that contain milk/dairy include the following: butter, buttermilk, casein (a milk protein), cheese, cream, crème fraiche, most custard/pudding, ghee (clarified butter), milk (including lactose-free milk, whole, 2%, 1% and skim milk), whey (a milk protein), yogurt
• Many packaged foods contain milk as an ingredient. These may include bread, crackers, waffles, baked goods, beef franks, deli meat and more.

• Lactose intolerance is when the body has trouble digesting the sugar (lactose) in milk. People with lactose intolerance can often drink lactose-free milk or take lactase pills.
• EoE is triggered by the immune system reacting to proteins in milk (casein and whey), not the sugar. This means:

Since Lactose-free milk is not milk/dairy free it is NOT ALLOWED on a milk/dairy free diet for treatment of EoE. Lactose-free milk is NOT safe for your child.

 Lactase pills are not helpful in the treatment of EoE when on a milk/dairy free diet

Careful food label reading is necessary to completely avoid milk products and milk protein. Milk is one of the US top nine allergens and food labeling laws require that the presence of milk in food must be stated in clear, common terms on all food labels.  This is done in one of two ways: 

• Listing the ingredient within the ingredient list, such as “casein (milk).”
• Using a “contains” statement at the end of an ingredient list, such as “Contains: Milk.”

Currently, medication does not appear to be as effective as dietary changes in the treatment of Eosinophilic Esophagitis. Certain medications, such as pump inhibitors, oral and topical corticosteroids, and leukotriene inhibitors, have been shown to have some helpful effects on patients with EoE, but dietary modifications are the primary course of treatment. The health care community is working to identify medications that may be used in the future to treat this condition.

The current data about the role of eosinophils in EGIDs suggests that while eosinophils do play a role, they are not solely responsible for EGIDs on their own. Instead, eosinophils are just one cell type that contributes to the body’s overall immune and inflammatory response and, thus, the damage to the GI tract that occurs in EGIDs. The specific and unique role of the eosinophil in EGIDs has been evaluated in research studies that evaluate medications designed to eliminate eosinophils in the body; in these cases, even when eosinophils were eliminated, damage to the intestinal lining continued, suggesting that other cell types were also contributing to the body’s inflammatory response.  As a result, GI doctors have begun focusing on a range of changes to the GI tract in EGIDs and not simply on eosinophil cell counts.

What is most important to understand about what is known about environmental factors and EGIDs is that current information can only tell us that specific environmental triggers and EGIDs are related and not that specific triggers universally cause EGIDs. As an example,  mother and infant use of acid suppression medications has been associated with a higher risk of developing eosinophilic esophagitis (EoE) in childhood. What is not clear is whether the use of acid suppression medications early in life causes the eventual EoE, or if children who go on to be diagnosed with EoE use acid suppression medications more frequently early in life to manage early GI symptoms (that are, ultimately, diagnosed as EoE). Similarly, mother and infant antibiotic use also has been associated with developing EoE.  Additionally, there is some indication that worse environmental quality indices such as exposure to unsafe or unsanitary water have been associated with EoE. 

In the case of all of the above potential environmental factors, the unifying mechanism is thought to be the influences on the gut microbiome. More specifically, it’s been shown that certain environmental exposures can result in reduced “esophageal barrier function” allowing molecules like allergens to cross the lining of the esophagus and create conditions in which an immune reaction to the allergens causes eosinophilic esophagitis.  To better understand how these exposures might contribute to the development of eosinophilic esophagitis, continued cooperation between researchers, doctors, and patients to do long-term studies will be necessary.

EoE can affect a child’s quality of life in many areas, including eating, sleeping, attending school, interacting socially, and participating in age-appropriate activities. Children and teens may experience anxiety, especially around eating, food reactions, or mealtimes away from primary caregivers. Children also may experience low mood, frustration, or behavior changes related to managing their EoE and feeling different from their peers.

Managing EoE, including taking medications and following a restricted diet, can be difficult for anyone, especially a child. If your child seems to have difficulty coping with EoE treatment, the following strategies may help:

• Encourage your child to name their feelings and use words to describe their emotions to help them build emotional awareness and obtain support. For example: “I feel nervous eating lunch at school.”
• Practice active coping strategies such as diaphragmatic (abdominal) breathing, progressive muscle relaxation, or guided imagery to reduce stress and anxiety.
• Help your child practice explaining EoE and their treatment plan in simple language to peers, teachers, or other caregivers.
• Plan ahead for outings or events by choosing or preparing safe foods ahead of time. This can help children feel prepared and give them a sense of control.
• If possible, connect with other children who have EoE through local support groups or virtual communities.

Caregivers can be a great source of comfort and help children navigate living with EoE:

• Normalize and validate your child’s emotions. It is okay for them to feel anxious, frustrated, sad, or different sometimes. Encourage them to talk about their feelings with you, their doctor, or a trusted adult.
• Praise and reward your child’s effort to participate in caring for their EoE. For example, “Thank you for taking your medication right away!” or “You were so brave to eat that, even when you were feeling nervous.”
• Talk openly with your child and encourage them to problem-solve with you when there are difficulties or barriers to following their medical treatment plan. Stay in touch with your child’s medical providers and communicate any questions, concerns, or challenges you have so that they can help.
• Work with your child’s school to develop a health support plan (or Section 504 Plan) to address the likely need for your child to sometimes miss school due to doctors’ appointments or medical procedures and for them to have access to safe foods at school for lunch, snack times, and during classroom celebrations. 
• Consider whether a pediatric psychologist or other behavioral health provider familiar with pediatric chronic medical conditions would be helpful to include as part of your child’s healthcare team. Cognitive behavioral therapy (CBT) is an evidence-based treatment to reduce anxiety and support emotional adjustment in children with chronic medical conditions. 

Support for the NASPGHAN Foundation’s Eosinophilic Esophagitis Education Campaign was provided by AstraZeneca LP, Takeda Pharmaceuticals North America, Inc., Cephalon, and Meritage Pharma, Inc.

Contributors

Authors: Kelsey L. Jong, PhD, Kelly A. O’Neil Rodriguez, PhD, and Sandeep K. Gupta, MD
Editors: Vincent Mukkada, MD, and Amanda D. Deacy, PhD
July 2025, June 2026