Paediatric Gastro-Allergy Symposium

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Ruth Stanley

Lead Paediatric Gastroenterology Dietitian

GNCH

Aims

• Understand Eosinophilic Oesophagitis (EoE) in a nutshell

• Aware of different dietary treatments for EoE

• Appreciate the nutritional complexity of a top 6 free diet

• Realise its not all doom and gloom

Eosinophilic Oesophagitis

What is it?

• “A chronic immune condition characterised clinically by

symptoms of oesophageal dysfunction and histologically by the

presence of eosinophils in the oesophagus” (1)

• First presentation 1960, later described as a syndrome 1990 (1)

• The prevalence of EoE is increasing

• Unknown numbers in UK

• Estimated rates of prevalence between 13-49 cases per

100,000 in population based studies in Europe and USA (1)

• Past 5 years seen an increase in guidelines and case reports

Clinical Presentation

• Vary with ages, main symptoms (1,2) :

• Infants and toddlers

• Feeding difficulties which can result in poor growth

• Children

• Vomiting, abdominal or retrosternal pain

• Adolescences

• Reflux symptoms, dysphagia and food impaction

Treatment Options EoE

• Combination of medication and dietary manipulation (1,2)

• Medication

• PPI

• Corticosteroids

• Dietary

• Exclusive Amino Acid (AA) Feed

• Targeted Elimination Diet (T.E.D)

• Top 6 Free

Exclusive AA Feed

• Placed on Exclusive AA feed

• 6-8 weeks

• Re-scoped after this period to assess response

• 95-98% success rate at inducing remission (1)

• Comes with down sides:

• Taste

• Compliance

• Psychological

• Cost

Targeted Elimination Diet

• Food avoided based on allergy testing

• Varying length of time

• 45-53% success rate at inducing remission (1)

• High negative predictive value (1, 2)

Top 6 free diet

• Eliminate 6 foods most commonly associated with allergy (IgE and non IgE) • Wheat

• Egg

• Milk

• Soya

• Fish

• Nuts

• 72-74% success rate at inducing remission

• High risk of nutritional deficiency

• Compliance can be an issue

Which dietary treatment

• Joint decision with consultant

• Difficult decision with multiple factors to consider

• Age patient

• Social support

• Severity of symptoms

• Presenting nutritional status

Case Study

• 14 year old boy

• Clinical presentation of food sticking at each meal and

struggling to eat.

• Histology confirmed EoE.

• Already on PPI therapy.

• Weight over 99.6th Centile, Height 91st Centile.

Interactive Voting

• Which dietary manipulation option would you choose to

place this patient on

• A – Exclusive AA

• B - T.E.D

• C – Top 6 free diet

Case Study

continued

• Asked by consultant to place on exclusive AA to ensure EoE under control by time commence GCSE year at school. Symptoms also severe.

During dietetic consultation:

• Doesn’t like Milk or Milkshakes

• Patient very withdrawn

• Recently lost grandmother and due to attend bereavement counselling in next few weeks.

• Mum is extremely anxious

• Social information:

• Mum single parent.

• Patient has older sister on steroids who is currently being treated for depression. Also has 3 younger siblings (triplets)

Interactive Voting

• Which dietary manipulation option would you choose to

place this patient on

• A – Exclusive AA

• B - T.E.D

• C – Top 6 free diet

Case Study

Treatment in Practice

Actual Decision

• Top 6 free

• I felt patient would struggle with AA psychologically

• Very chaotic house hold

• Nutritional status ok

Outcome

• Unfortunately endoscopy after 8 weeks still showed EoE

therefore placed on AA.

Principles of a Dietetic Consultation

• Which foods need to be avoided

• Suitable alternatives to these foods

• Practical advice for living on a restricted diet

Initial tips for Parents

• Ask them to look at the tins and packets of food

already in their home

• Make time to go food shopping

• Provide a list of foods available in major

supermarkets and recipes to help plan meals

• Re-assure them it does get easier

Nutritional Deficiency

-Macronutrients

• When food is removed from the diet there is a risk that

nutritional requirements will not be met.

• 12 cases of Kwashiorkor in American children, half due to

deliberate food avoidance for suspected allergies without

adequate substitution. (3)

• Children with 2 or more food allergies are shorter based

on the population without food allergies (4).

• Weight and height can be useful and important to monitor

overall nutrition

Nutritional Deficiency

-Macronutrients

In practice

• Unfortunately common for patients to loose weight

• Food fortification advice

• Violife cream cheese (48kcal/20g)

• Oat cream ( 150kcal/100ml)

• Swap cartons coconut milk (20kcal/100ml) to tinned

(170kcal/100ml)

• Supplements

• AA based

• Calogen (add to food)

• Monitor regularly

Micronutrients contributed to diet from Top 6 Foods

Milk Egg Soy Wheat Nuts Fish

Vit A

Vit B (all)

Vit D

Vit E

Calcium

Phosphorus

Iodine

Selenium

Zinc

Folate

Iron

Nutritional Deficiency

-Micronutrients

Nutritional Deficiency

-Micronutrients

• Calcium and vitamin D deficiency can result in osteomalacia and rickets

• Increasing reports of restricted diets resulting in iodine deficiency and thyroid dysfunction (5)

• Monitoring

• Food diary analysis

• Blood test if possible

• Try to minimise risk by providing vitamin and mineral supplements.

• There is limited choice on prescription

• Increased variety to buy over the counter

Labelling

• EU food labelling laws require labels to clearly state if

common allergens are in the food product.

• Applies to all packaged and manufactured drinks as well

as foods sold loose and packed for direct sale

• “May contain” / “Made in a kitchen containing…” is often

suitable

• Gluten is ok majority of time - Just avoid wheat

• Soya lethicin - technically ok but advise to avoid all

sources to make more practical

Alternative Foods

• Good range of foods in supermarkets.

• Free from aisles (still double check labels)

• “normal aisles” have plenty of options

• Aware of hidden sources of foods – check labels

• Fussy eaters

• top 6 free diet is still achievable (just a little harder)

Main Foods Missed

• Milk

• Prescribed age appropriate

• Rice, coconut and oat milk, look for “added nutrition”

• Bread

• B-free, ENRG, Schar

• Wraps and bread rolls often better tolerated.

• Cake/biscuits

• Make own cornflake/rice-krispie bars with moo free chocolate/marshmallows

• Biscuits better choice

• Flap jacks/Oat bars (toddler food range)

Main Foods Missed

• Chocolate

• Moo Free (good website)

• Crisps

• Mainly younger children wanting “bite and dissolve” textures

• Skips suitable

• Corn based

• Gravy

• Can make own using meat juices and corn flour

• Tesco free from gravy

Economical

• Can be expensive

• Online shop for 3 days following top 6 free diet = £22.

Buying same products for a non restricted diet = £13.50

Top 6 Free suitable

food

Non restricted diet

food

Bread £3 (400g loaf) £1 (800g branded

loaf)

Milk £1.40 (1L) £0.75 (1.1L cows

milk)

Pasta £1.20 (500g) £0.59 (500g)

Economical

• Advice:

• Bulk buy suitable foods when reduced and freeze

• Try to buy most of the food from “normal aisles”

• Base meals around foods that are naturally suitable

(meat, potatoes, rice etc.)

• Ask GP to prescribe a small amount of suitable products

each month

• This is GP discretion and therefore not guaranteed

Cooking

• Good cooking skills are helpful (remember that not

everyone has these or the confidence to try making new

food)

• Supply basic recipes to help.

• After a few weeks parents tend to find that their cooking

skills and confidence with “new foods” improve.

• Currently looking at setting up top 6 free group cooking

sessions

Eating away from home

- Schools

• Send with packed lunch if possible.

• provide parents with a range of ideas for example: • Sandwich, crisps, fruit, coconut based yoghurt

• Pasta in a tomato sauce (cold), jelly, cereal bar

• Parents to speak to school catering about dietary restrictions.

• If any problems, dietitian can phone and speak to catering staff

• Send child to school with plenty of suitable snacks

• If receive school milk, consider sending own little carton of

suitable milk

Eating away from home

- Parties and Restaurants

• If going to a party take own food

• If child regularly goes to a friends house for meals,

consider proving friends parents with suitable foods to

keep in their house

• If eating out, phone restaurant or look online at menu

beforehand to see if can cater for a top 6 free diet

• Most of the main chain restaurants should be able to

cater.

• Check social media for independent restaurants.

Eating out examples

• Pizza Express • Gluten free dough balls

• Gluten free pizza (no cheese) meat and veg topping

• Sorbet

• Nandos • Any marinated chicken

• Sweetcorn +/- chips or sweet potato wedges

• Mexican style ice-cream

• McDonalds • Burger no bun

• Chips/fruit sides

Conclusion

• Top 6 free diet can induce remission in the majority or

patients with EoE

• Following a top 6 free diet can be difficult and limiting

however providing patients with education and tips can

help children to feel less isolated and excluded

• Important to check nutritional status of patients and

monitor regularly

References

1. Guidelines on eosinophilic esophagitis: evidence-based statements and

recommendations for diagnosis and management in children and adults. Lucendo,

Alfredo J, et al. 0, 2017, United European Gastroenterology Journal, Vol. 0, pp. 1-

24.

2. Management guidelines of eosinophilic esophagitis in children. Papadopoulou, A, et

al. 1, s.l. :ESPGHAN EoE Working Group/GI Committee, 2014, JPGN, Vol 58, pp.

107-118.

3. Kwashiorkor in the United States: fad diets, percieved and true milk allergy, and

nutritional ignorance. Liu T, Howard RM, Mancini AJ, Weston WL, Paller AS,

Drolet BA, et al. Archives of dermatology. 2001; 137(5):630-6. Epub 04/04/2017

4. Growth and Nutritional Concerns in Children with Food Allergy. Mehta H, Groetch M,

Wang J. Curr opin Allergy Clin Immunol. 2013; 13(3):275-279.

5. Dietary restriction causing iodine-deficient goitre. Cheetham T, Plumb E, Callaghan

J, et al. Arch Dis Child Published online First: 15.06.2015