Research has shown a strong connection between food allergies and eosinophilic esophagitis (EoE). Studies have shown that particular foods cause allergy cells to build up in the esophagus. While there are certain foods that are common EoE culprits, there is no way of knowing for sure which foods trigger EoE in a patient without allergy testing and eliminating foods from a child’s diet.
Directed Elimination Diet
After a child has completed a full allergy work-up, our multidisciplinary EoE team uses the information from both the skin prick test and patch test to develop a directed elimination diet in which all foods the child tests positive to will be eliminated from his or her diet. The goal is to eliminate the food(s) that may be causing the eosinophils to travel to the esophagus. Because it takes time for the esophagus to heal, patients typically follow the diet for at least eight weeks. Allergy testing is not 100% accurate, and some of the foods that may be positive on testing may not be causing a child’s EoE. Our team cannot positively know what foods are causing the EoE until we see a change in the amount of allergy cells inside the esophagus.
Children placed on the 6-food elimination typically do not test positive for allergies with the skin prick test or patch test. This diet requires families to remove the top-known food allergens from a child’s diet.
These foods are:
- Fish and shellfish
- Peanuts and Tree nuts (Nuts include almonds, beechnuts, Brazil nuts, butternuts, cashews, chestnuts, chinquapin nuts, filberts/hazelnuts, ginkgo nuts, hickory nuts, lychee nuts, macadamia nuts, Nangai nuts, pecans, pili nuts, pine nuts, pistachios, shea nuts and walnuts.) Although the Food and Drug Administration now classifies coconut as a tree nut, children following the 6-Food Elimination diet may be able to consume coconut. Check with the child’s allergist or dietitian before consuming coconut.
Research published in the journal Clinical Gastroenterology and Hepatology has shown that 74% of children who follow this diet see their EoE symptoms disappear.
Because this diet eliminates common foods that provide children with the nutrients they need to grow and be healthy, our registered dietitian closely monitors each child to make sure he or she is getting the right nutrition.
Severely Restricted Diet
Some children may test positive to multiple foods which are subsequently eliminated from the child’s diet or may be following the 6-food elimination diet with additional foods that were positive from allergy testing. These types of diets are considered severely restricted diets because of the amount of foods that are eliminated from the patient’s diet. Should this be the case, the child’s dietitian will provide detailed information on how to follow the diet and a variety of resources about available food options to ensure the child’s nutritional needs are met. An elemental formula may also be prescribed in combination with an elimination diet if it is not possible to meet nutritional requirements with an elimination diet and/or if the child has poor growth and/or weight loss.
Avoid sources of cross-contact. This occurs when a food comes into contact with another food or even leftover residue. It is difficult to determine the amount of a particular food that can cause a reaction in EoE because the symptoms do not occur immediately after eating that food. Because of this, it is encouraged to be as careful as possible to avoid the occurrence of cross-contact.
Common sources of cross-contact:
- Cutting boards, pots & pans – Wash with soap and water
- Utensils – Use separate utensils for each condiment jar
- Bulk bins – Purchase prepackaged items
- Fryer oil – Sauté items at home, avoid fried foods when eating out
- Grill – Wrap food in foil before placing on the grill, avoid ordering grilled items at restaurants unless prepared on a clean surface
- Deli slicers – Purchase prepackaged meats or from a deli that uses separate slicers for cheese & meat
- Toaster – Use a separate toaster for wheat-free breads, toast bread on foil using the oven set at broil, or use reusable toaster bags such as TOAST-it (www.toastitbags.com)
Grain Alternatives for When Wheat is Eliminated
A carbohydrate is a nutrient found in fruits, vegetables, grains, milk, yogurt, nuts and beans. Carbohydrates provide the primary fuel source for most cells in the body. Some children with eosinophilic esophagitis (EoE) may be asked to eliminate wheat from their diets as the CHOC Children’s Eosinophilic Esophagitis Clinic team works to figure out which foods trigger the child’s symptoms. Learn more about wheat alternative carbohydrates.
* Some children may need to avoid beans, peas, lentils, potatoes, oats, rye, barley and/or soy due to their specific EoE diet. Please check with the child’s allergist or dietitian if these need to be avoided as well.
Milk Alternatives for When Dairy is Eliminated
Milk provides a great source of protein, calcium, and vitamins A, B12 and D. For young children, milk may provide up to 25% of their daily caloric intake; therefore, eliminating milk may put a young child at nutritional risk. There are many milk alternatives on the market including almond, coconut, flaxseed, hemp, oat, potato, rice and soy milks. Many of these are low in protein and fat and therefore would not be an appropriate replacement for infants and toddlers. Despite their low protein and fat content, those enriched with vitamins and minerals provide an important source of calcium, vitamin B12 and vitamin D for children. (See How to read a Nutrition Facts label below to determine if a milk alternative contains the right amount of nutrition). These milks come in a variety of flavors. Rice milk has a mild flavor and is well accepted; however, it should be avoided in infants and young children due to its arsenic content. Some children may also need to eliminate soy and nuts. Check with the child’s allergist or dietitian to see if other allergens need to be avoided.
The Daily Value for calcium is set at 1,000 mg and for Vitamin D, at 400 International Units. On the Nutrition Facts label, Daily Value is written as a percentage. For example, if the label has 30% of the Daily Value for Calcium, then the product would contain 300 mg per serving (30% multiplied by 1,000 mg). A child’s nutritional needs may be more or less than the Daily Value. Talk with the child’s dietitian or pediatrician to learn how much calcium and vitamin D is recommended.
Tips to get in enough calcium and vitamin D
For milk alternatives, choose products with 30% or more of the Daily Value for calcium and 25% or more of the Daily Value for vitamin D. For milk-free yogurt and cheeses, look for those with calcium and/or vitamin D added to help increase intake of these nutrients.
If a child is following a vegan diet, look for milk alternatives that are fortified with vitamin B12.
Understanding Food Labels
Childhood allergies are on the rise and the specific allergens (foods the child is allergic to) can often be found by themselves or within foods. For example, if a child is allergic to eggs, he may not eat eggs or any foods containing eggs like baked goods, creamy salad dressings or some pastas. Finding hidden allergens is an important job and a caregiver’s most vital resource is the food label.
Food labels are found on all packaged foods—from loaves of bread to dairy products to pasta sauce and beyond. In recent years, food labels have become easier to read and must clearly state if they contain eggs, fish, milk, peanuts, shellfish, soybeans, tree nuts or wheat.
- Read all food labels carefully as manufacturers may change ingredients at any time.
- Call the manufacturer if a food label is unclear or if there is any doubt if a food product contains an ingredient that should be avoided.
- In 2004, the Food Allergen Labeling and Consumer Protection Act (FALCPA) was passed. This act requires that all food labels clearly state the presence of the top eight allergens: egg, wheat, milk, soy, peanut, tree nuts, fish, and crustacean shellfish. All labels must include the common name in the ingredient list, the allergen name in parenthesis after the ingredient or a “contains statement” after or next to the ingredient list. (example: “Contains wheat, milk” )
To learn more about reading food labels, please refer to the Food and Drug Administration’s food label consumer guide by clicking here.
Because it can be tricky to know the uncommon or alternate names for foods a child may be allergic to, The Food Allergy & Anaphylaxis Network has developed a guide on how to read food labels by allergen. Although it is not necessary to learn the uncommon names for these allergens, it is a good idea to become familiar with them as an extra precaution. Click here to learn more about reading labels.
Because elimination diets can be overwhelming for families, we have put together meal planning resources that can be helpful when trying to figure out the child’s meals. For more information go to Nutrition & Cooking Resources.
Elimination diets are supervised by the child’s medical team and should not be attempted unless prescribed by the child’s EoE specialist.
Beyond Elimination Diets
If the elimination diets do not help with the child’s EoE symptoms, we may recommend putting the child on an elemental formula diet in which all food is removed from the child’s diet. Learn more about the elemental diet.
Approximately eight weeks after starting a diet, we will perform another endoscopy to see if the child’s eosinophils have improved. If the child’s scope is clean, he or she may then begin to have food reintroduced into his or her diet under the direction of the child’s nurse practitioner or physician at the Eosinophilic Esophagitis Clinic. Learn more about food reintroduction.
Some children may require medical management of their EoE symptoms with medications. Learn more about medical management of EoE.