Cow's milk elimination: a novel dietary approach to treat eosinophilic esophagitis.

OBJECTIVES: Cow's-milk protein is one of the food antigens responsible for causing eosinophilic esophageal inflammation in a majority of children. We describe our experience with treating eosinophilic esophagitis (EoE) in children by eliminating only cow's milk from their diets. METHODS: This retrospective study assessed the short-term clinical and histological response to eliminating cow's-milk protein from the diet of children with EoE. Only patients undergoing a subsequent upper endoscopy to assess their histological response were included in this analysis. RESULTS: We identified 17 (12 boys and 5 girls) children with EoE who excluded only cow's milk from their diet. Remission was induced in 11 of 17 (65%) patients; within the remission group, 7 (41%) achieved complete histological remission and 4 patients (24%) were in significant histological remission. The mean peak pre- and posttreatment counts for those in remission were 76 ±â€Š40 and 2 ±â€Š4 (P < 0.01), respectively. CONCLUSIONS: Elimination of cow's milk-induced clinical and histological remission in 65% (95% confidence interval 42%-88%) of children with EoE in whom it was attempted. This approach offers distinct advantages over other dietary treatment approaches for the initial management of children with EoE. The role of eliminating cow's milk alone for the treatment of EoE warrants further prospective study.

Identification of specific foods responsible for inflammation in children with eosinophilic esophagitis successfully treated with empiric elimination diet.

OBJECTIVES: Eosinophilic esophagitis (EoE) is an immune-mediated chronic inflammatory disorder triggered by food antigen(s). A 6-food elimination diet (SFED) excluding cow's milk, soy, wheat, egg, peanuts/tree nuts, and seafood has been shown to induce remission in a majority of children with EoE. The goal of the present study was to identify specific food antigens responsible for eosinophilic esophageal inflammation in children with EoE who had achieved histological remission with the SFED. PATIENTS AND METHODS: In this analysis, we retrospectively analyzed children with EoE who completed subsequent single-food reintroductions that led to identification of foods causing disease recurrence. Repeat upper endoscopy with biopsies was performed after single-food introductions. Recurrence of esophageal eosinophilia following a food reintroduction identified that food antigen as a cause of EoE. RESULTS: A total of 36/46  (25 M/11F) children who were initially successfully treated with SFED completed this trial; the mean age was 7.6  ±  4.3 years. The most common foods identified were 25 to cow's milk (74%), 8 to wheat (26%), 4 to eggs (17%), 3 to soy (10%), and 1 to peanut (6%). Milk was 8 times more likely to cause EoE compared with wheat, the next most common food (95% confidence interval 2.41-26.62, P = 0.0007). CONCLUSIONS: Serial single-food reintroductions following induction of histological remission with the SFED can lead to the identification of specific causal food antigen(s) in EoE. Cow's milk was the most common food identified in subjects with EoE treated with SFED. A subset of children with EoE may develop tolerance to their food sensitivities while on the SFED.

Fatigue and health-related quality of life in pediatric inflammatory bowel disease.

BACKGROUND & AIMS: Fatigue profoundly impacts quality of life and is a common complaint among patients with chronic disease. This study examined the degree of fatigue and health-related quality of life (HRQOL) in children with inflammatory bowel disease (IBD). METHODS: Seventy children with IBD and 157 healthy controls and their parents completed age-appropriate measures of fatigue (PedsQL Multidimensional Fatigue Scale) and HRQOL (PedsQL 4.0 Generic Core Scales). Children with IBD completed the IMPACT III Quality of Life Questionnaire, and the Children's Depression Inventory: Short form was completed by children with IBD and healthy controls. Disease activity was determined according to the diagnosis with either the Pediatric Crohn's Disease Activity Index (PCDAI) or a Physician's Global Assessment. RESULTS: Children with Crohn's disease (N = 52) had a median PCDAI of 0, and 56% with ulcerative colitis (N = 13) or indeterminate colitis (N = 5) were in remission. Mean child self-report PedsQL Multidimensional Fatigue Total Scale scores were 73.9 +/- 16.8 and 82.2 +/- 12.3 for patients with IBD and controls, respectively (P < .001). Mean child self-report PedsQL 4.0 Generic Core Total Scale scores were 76.7 +/- 14.2 and 85.9 +/- 10.4 for patients with IBD and controls, respectively (P < .0001). Children with IBD did not self-report statistically different mean total fatigue and subscale scores compared with children with rheumatologic diseases or cancer. CONCLUSIONS: In children with primarily inactive IBD, fatigue was significantly higher and HRQOL was significantly lower than in healthy controls. Results among children with IBD were comparable to children with rheumatologic diseases and cancer.

Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis.

BACKGROUND & AIMS: In children, eosinophilic esophagitis (EE) is predominantly, but not exclusively, a food-hypersensitivity disorder. A crystalline amino acid-based elemental diet (ELED) formula currently remains the most effective nutritional treatment in inducing clinical and histologic remission. However, compliance with an exclusive, poor-tasting liquid formulation is difficult. METHODS: This retrospective observational study assessed the short-term clinical and histologic responses of 2 cohorts of children with EE evaluated during 2 different time periods: one was treated with the standard 6-food elimination diet (SFED) and the other was treated with ELED. Of the 60 children who met the inclusion criteria and were compliant with the dietary protocol, 35 were treated with a diet excluding cow-milk protein, soy, wheat, egg, peanut, and seafood while allowing all other table foods and 25 were treated exclusively with ELED. Repeat esophageal biopsy specimens were obtained at least 6 weeks later. RESULTS: Twenty-six of 35 (74%) in the SFED group and 22 of 25 (88%) in the ELED group achieved significant improvement of esophageal inflammation (

The incidence of dysphagia in pediatric patients after open heart procedures with transesophageal echocardiography.

BACKGROUND: Pediatric patients who undergo open heart operations may be at risk for the development of dysphagia because of interventions such as intubation and transesophageal echocardiography. Although the occurrence of dysphagia after cardiac surgical procedures in adults is reported to be 3% to 4%, the incidence in children and adolescents has not been documented. This study was undertaken to determine the incidence of and risk factors contributing to dysphagia in pediatric patients after open heart procedures. METHODS: Fifty patients were evaluated after open heart operations with transesophageal echocardiography between March 1, 1999, and September 30, 1999. The diagnosis of dysphagia was made by a speech pathologist using a clinical swallowing evaluation. Potential predictors examined included demographic variables, anatomical diagnosis, surgical procedure, size of the transesophageal echocardiographic probe in relation to body size, length of probe insertion time, preoperative patient acuity status, duration of intubation, and time until discharge. RESULTS: Dysphagia was found in 9 (18%) of the 50 patients. Risk factors identified were age of less than 3 years (odds ratio, 20.4; 95% confidence interval, 2.7 to 157; p = 0.002), intubation prior to operation (odds ratio, 17.7; 95% confidence interval, 9.4 to 210; p = 0.004), intubation for more than 7 days (odds ratio, 74.7; 95% confidence interval, 13.8 to 405; p = 0.001), and operation for left-sided obstructive lesions (odds ratio, 1.9; 95% confidence interval, 2.2 to 8.3; p = 0.038). The size of the transesophageal echocardiographic probe in relation to the weight of the patient was found to be predictive (p = 0.0001) of dysphagia. Vocal cord paralysis was noted in 4 (8%) of the 50 patients postoperatively. Adverse events related to aspiration occurred in 2 patients (4%). At discharge, nasogastric tube feedings were required in 6 patients (12%), and thickened feedings were recommended for 3 (6%) of the 50 patients. Resolution of dysphagia ranged from 13 to 150 days. CONCLUSIONS: Eighteen percent of patients had dysphagia after an open heart operation with transesophageal echocardiography. Age of less than 3 years, preoperative patient acuity status, longer intubation times, and operation for left-sided obstructions are risk factors for dysphagia in this cohort of pediatric patients. The size of the transesophageal echocardiography probe in relation to the patient's weight was predictive of dysphagia. Physicians should consider using the new mini-multiplane transesophageal echocardiographic probes in patients weighing less than 5.5 kg. Vigilance in monitoring for the signs of preoperative and postoperative dysphagia with prompt referral to a speech therapist can substantially reduce patient morbidity, length of hospital stay, and requirement of prolonged nasogastric tube use.