The Ins and Outs of

Management of Chronic

Eosinophilic Esophagitis:

Nutrition and Quality of Life

Marion Groetch, MS, RDN

marion.groetch@mssm.edu

Director of Nutrition Services

Jaffe Food Allergy Institute

Objectives

▶ Understand the implications of having an EoE diagnosis and the impact of treatment

▶ Understand the nutritional risks associated with EoE

▶ Learn how to meet the nutritional needs of a patient on a long term elimination diet

▶ Identify educational resources for families with EoE

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EoE Collaborative Treatment

Allergy GI Nutrition

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…and don’t forget

▶ The patient and the patient’s family.

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Peds Quality of Life Concerns

▶ Feelings of being different

▶ Diet and medication adherence

▶ Difficulties with eating food

▶ Worry about symptoms and illness

▶ Patient and parents often have different concerns

▶ Patients with active histologic disease and those treated with diet demonstrated worse PedsQL scores.

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• Franciosi JP, Hommel KA, DeBrosse CW, et al. Quality of life in paediatric eosinophilic oesophagitis: what

is important to patients? Child: care, health and development. 2012 Jul;38(4):477-83.

• Franciosi JP, Hommel KA, Bendo CB, et al. PedsQL eosinophilic esophagitis module: feasibility,

reliability, and validity. Journal of pediatric gastroenterology and nutrition. 2013 Jul;57(1):57-66.

Parents of chronically ill children report …

▶ Increased financial burden

▶ Increased emotional strain

▶ Impact on relationships within the family (sibling and spousal)

▶ Impact on social contacts outside the family

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Kinnert, M. Psychological Impact of EoE on Children and Families.

Immunol AllergyClin N Am (29). pp 99-107. 2009.

Nutrition Risks- Before Treatment

▶ Poor dietary intake due to persistent symptoms

▶ Chronic emesis, poor growth, abdominal pain, chest pain, dysphagia, food impaction, food refusal, maladaptive feeding and eating behaviors

▶ Poor growth despite adequate intake

▶ Nutrient deficiencies

Children with multiple food allergies or cow’s

milk allergy are at increased risk of…

▶ Macronutrient/Micronutrient deficiencies or imbalances

▶ Shorter stature

▶ Failure to thrive

▶ Nutritional rickets/kwashiork/marasmus

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Mehta H, Groetch M, Wang J. Curr opin aller clin immun. 2013 Jun;13(3):275-9.

Christie L, et al. J Am Diet Assoc. 2002;102:1648–1651.

Henriksen C, et al. Acta Paediatr. 2000;89:272–278.

Isolauri E, et al. J Pediatr. 1998;132:1004–1009.

Fox AT, et al. Pediatr Allergy Immunol. 2004;15:566–569.

Fortunato JE, et al. Clin Pediatr (Phila). 2008;47:496–499.

Flammarion et al. Pediatr Allergy Immunol. 2011; 22: 161-165.

Alvares M, Pediatrics. 2013 Jul;132(1):e229-32.

With Dietary Treatment

▶ Diagnostic diet to determine causative foods- multiple foods

▶ Nutritional risks associated with the number of eliminated foods and length of the diagnostic diet

▶ Feeding problems may impact the ability of the child to accept substitute foods

▶ A very restricted diet may disrupt a child's progress along the typical developmental feeding continuum

▶ Most likely not transient

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Menard-Katcher P, Marks KL, Liacouras CA, Spergel JM, Yang YX, Falk GW. The

natural history of eosinophilic oesophagitis in the transition from childhood to

adulthood. Alimentary pharmacology & therapeutics. 2013 Jan;37(1):114-21.

Foods Most Commonly Implicated Kagalwalla AF, et al. J Pediatr Gastroenterol Nutr. 2011 Aug;53(2):145-9.

74%

26%

17%

10%

6% 0%

10%

20%

30%

40%

50%

60%

70%

80%

Milk Wheat Egg Soy Peanut Seafood

Nutrient concerns

Allergen Nutrients

Milk Protein, fat, calcium, vitamin D, vitamin A, vitamin B12,

riboflavin, pantothenic acid,

Wheat Thiamin, niacin, riboflavin, iron, folate, complex

carbohydrates, fiber (if whole grain)

Egg Protein, vitamin B12, riboflavin, biotin, selenium,

pantothenic acid

Soy Protein, riboflavin, thiamin, phosphorus, folate, calcium,

magnesium, iron, zinc, pyridoxine

Peanut Protein, fat, vitamin E, niacin, magnesium, chromium

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Comparison of Cow’s Milk (CM) substitutes

CM or

CM subs.

KCAL/

8 oz

PRO g FAT g Ca mg/

Vit.D IU

CM 150 8 8 300 / 100

Soy enriched 100 7 4 350 / 100

Oat enriched 120 4 3 300 / 100

Rice enriched 120 1 2.5 300 / 100

Coconut enriched

80 0 4.5 100-300/

100

Almond enriched

50 1 2.5 300 / 100

Avoidance with and without substitution

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Unrestricted Allergens eliminated Allergens eliminated

and substituted

Pancakes with butter

and syrup

Berries

Milk

Pancakes with butter

and Syrup

Berries

Milk

Whole Grain GF waffles

Milk-free, soy-free

margarine and syrup

Berries

Enriched alternative milk

Turkey on

Whole wheat bread

Carrots

Potato chips

Apple

Turkey on

Whole wheat bread

Carrots

Potato chips

Apple

Turkey on

GF Oat Pita Bread

Carrots with milk-free, soy

free margarine

Potato chips

Apple

Banana, pretzels, yogurt Banana, pretzels, yogurt Banana, GF pretzels,

enriched alternative milk

Grilled salmon

Couscous

Broccoli

Milk

Grilled Salmon

Couscous

Broccoli

Milk

Grilled Salmon

Quinoa

Broccoli roasted with olive

oil

Enriched alternative milk

Balanced nutrition Inadequate complex CHO,

fat, B vitamins, iron,

calcium and vitamin D

Substitute complex CHO,

fat, B vitamins, iron,

calcium and vitamin D

Nutrition Counseling

NIAID Food Allergy Guidelines recommend “all

children with food allergy receive nutrition

counseling and close growth monitoring.”

Boyce et al. Guidelines for the diagnosis and management of foods allergy in the US. JACI 2010

Questions?

American Partnership for Eosinophilic Disorders: www.apfed.org

North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN): www.naspghan.org

Consortium of Food Allergy Research: www.cofargroup.org

Children’s Hospital Cincinnati: www.cincinnatichildrens.org/service/c/eosinophilic-disorders

The Children’s Hospital of Philadelphia: www.chop.edu/service/center-for-pediatric-eosinophilic-disorders