Society: AGA

Background: While it is widely recognized that symptoms of eosinophilic esophagitis (EoE) differ in children versus adults, only a single case series has investigated symptoms of EoE in infants and toddlers, and few young children are included in studies of therapeutic response. Thus, the aims of the current study were 1) to characterize presentations of EoE in children < 2 years, and 2) to evaluate histologic and clinical response to treatment in this youngest pediatric age group.

Methods: This was a retrospective longitudinal study of children < 2 years diagnosed with EoE at a single tertiary center between 2016 and 2018. EoE was defined histologically by presence of > 15 eosinophils per high power field (eos/hpf) on at least one esophageal biopsy and a history suggestive of the diagnosis. Demographic characteristics, presenting symptoms, and EoE treatments were collected via chart review. Follow-up data were collected from all endoscopies after diagnosis, and histologic remission was defined as < 15 eos/hpf. Paired t-tests or Fisher exact tests for parametric data or Wilcoxin sign-rank test for non-parametric data were used to evaluate changes from baseline to follow-up in histology and clinical symptoms.

Results: Forty-two children ages 1.3 ± 0.4 years were followed for a mean of 3.6 ± 1.7 years and underwent 3.8 ± 2.3 (range 1 to 10) endoscopies under general anesthesia. Common presenting symptoms were feeding difficulties in 67% of patients (including gagging/coughing with feeding in 60% and difficulty with progression to pureed or solid foods in 43%), vomiting (57%), and coughing/wheezing (52%). Thirty-six children (86%) were male, and comorbidities included atopy (86%), reflux (74%), and a history of cow’s milk protein allergy (40%). Thirty-seven patients underwent repeat endoscopy after diagnosis, and 25/37 (68%) achieved histologic remission during the follow-up period. In addition to histologic improvement, there were significant reductions in all symptoms at follow-up compared to baseline (Figure 1). Treatment regimens were variable, and there was a significant effect of therapy type on histologic response (P = 0.004) with the best responses on combinations of diet/steroids or diet/proton pump inhibitor (PPI) and the worst response on PPIs alone (Figure 2). Of the 20 patients who underwent additional endoscopies after histologic remission, 13/20 (65%) had relapsed EoE on at least one follow-up endoscopy.

Discussion: The diagnosis of EoE should be considered in infants and toddlers presenting with feeding difficulties, vomiting, and cough or wheeze. EoE in this age group may mimic other common GI diagnoses, such as reflux or milk protein intolerance. Most patients show histologic and clinical improvements with standard therapies, but the endoscopic burden is significant and histologic response may not be maintained over time.

Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Eitan Rubinstein

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