Eosinophilic esophagitis (EoE) is a global health disorder affecting the esophagus with a reported incidence of 1 in 10,000. The etio-pathogenesis of this condition is yet to be characterized. Treatment of EoE is challenging and most subjects are treated with either pharmacologic agents or with diet modification. Dietary treatment with elemental diet is most efficacious. The likelihood of achieving mucosal healing is higher with this modality than other dietary or pharmacologic interventions. Additionally the residual eosinophil counts are much lower with elemental diet compared to other dietary or pharmacologic therapies establishing the superiority of this treatment over all other current treatments. The disadvantage, of this otherwise highly effective approach, is taste related poor patient compliance and impaired quality of life secondary to inability to consume regular foods. Tubes (nasogastric or gastrostomy) are often utilized to overcome the compliance resistance and these may lead to patient discomfort and parental distress. The exclusion of solid foods coupled with the same monotonous liquid nutrient diet also can be frustrating and increases likelihood of possible non-compliance with this diet. Furthermore limiting the child to exclusive elemental diet restricts the young child’s participation in social activities. Many childhood activities revolve around food leading to impaired quality of life. This formula is expensive and the cost is not always covered by most traditional insurance plans. This places a significant financial and social burden on the families. There are also additional costs related to maintenance and replacement of the tubes. For precisely all those reasons elimination diets are proposed treatment approaches. We have previously demonstrated that the 6-food elimination diet (SFED) with elimination of cow’s milk, soy, wheat, egg, peanut/tree nuts and seafood resulted in clinical and histological remission in 85% of children. This treatment approach has since been shown to be effective in adults prospectively treated with the same SFED with a reported histological improvement in 50% of adults treated. The primary advantage of elimination diet over exclusive elemental diet is that it allows intake of a variety of table foods including meats, grains, fruits, vegetables, and legumes compared to a single nutrient source taken orally or via a tube. This diet is also not a significant drain on the families’ budget. A more recent retrospective analysis of patients on the SFED demonstrated that the most common food identified to cause EoE is cow’s milk in 75% of the children. In spite of the obvious advantages of the SFED this treatment modality requires multiple endoscopies and the food re introduction process is drawn out over many months. For all of these reasons SFED is not well received by the children and their families. The data reporting efficacy of empiric cow’s milk elimination diet is retrospective and reflects the standard of care at Ann and Robert H. Lurie Children’s Hospital of Chicago (Lurie Children’s). Assessing the efficacy of empiric cow’s milk elimination diet prospectively utilizing a standardized approach is needed to overcome many of the shortcomings of the retrospective approach currently used and to validate the findings of the retrospective data presented and published so far.
Amir F. Kagalwalla, MD