Food Elimination Diet for Children
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Studies have shown that certain foods may cause eosinophils (a type of white blood cell that fights disease) to build up in the esophagus. While there are certain foods that are common culprits for kids with eosinophilic esophagitis (EoE), there is no way of knowing for sure which foods trigger EoE in a patient without eliminating foods from a child’s diet.
Your child’s specialists may recommend following a 6-food elimination diet to help you identify which foods your child has trouble tolerating, especially if your child does not test positive for food allergy with a skin prick test or patch test.
Research published in the journal Clinical Gastroenterology and Hepatology has shown that 74% of children who follow this diet see their EoE symptoms disappear.
What is the 6-food elimination diet for food allergies?
The 6-food elimination diet requires families to remove these top-known food allergens from a child’s diet:
- Milk
- Egg
- Wheat
- Soy
- 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. A note on coconut: Although the FDA 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.
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 they are getting the right nutrition.
Approximately eight weeks after starting an EoE elimination diet, we will perform an endoscopy to see if the child’s EoE has improved. If the child’s scope is clean, they may then strategically begin to reintroduce food under the direction of the EoE team. If the scope is not clear, additional food eliminations or medical management may be initiated.
After an endoscopy shows that the eosinophils have gone away, our team works with the patient’s family to reintroduce foods. Foods are reintroduced slowly, usually one at a time, and are selected according to data on the most common EoE triggers, nutritional quality, the child and family’s preferences, and the expertise of the team. During this time, it is important for caregivers to monitor for EoE symptoms. Symptoms are usually similar to those that led to the child’s initial diagnosis and can range from mild reflux and food impaction to vomiting and difficulty swallowing.
Patients will undergo another endoscopy after each 1-2 food reintroductions to see if the eosinophils have returned, even if the patient does not have obvious EoE symptoms. If there are no eosinophils, the child can continue eating those “safe foods.” If the eosinophils have returned, those foods are again removed. The food reintroduction process continues until the EoE team is able to determine the food(s) causing the child’s EoE. Once the team figures out which foods cause the child’s EoE symptoms, those foods are permanently eliminated from the patient’s diet.
Avoid cross-contact
Cross-contact or contamination 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 or toast bread on foil using the oven set at broil.
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 Eosinophilic Esophagitis Clinic team works to figure out which foods trigger the child’s symptoms.
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 pea protein, almond, coconut, flaxseed, hemp, oat, rice and soy milks. Many, but not all, are 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).
How to read a nutrition facts label for children on an elimination diet
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
EoE triggers can often be found by themselves or within foods. For example, if a child is told to eliminate eggs, he may not eat eggs or any foods containing eggs like baked goods, creamy salad dressings or some pastas. Finding hidden ingredients 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”).
Elimination Diet Meal Planning Guides by Age
Elimination diets can be tough. Children on these diets typically test positive to multiple foods 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.
Children following a severly restricted diet are provided detailed information by our dietitian on what they can and cannot eat. To help families better understand what is allowed on the diet and plan their child’s meals, we have developed the meal guides below. These guides are not meant to replace information provided by the child’s EoE specialist or dietitian. Children should avoid foods in the plans that they have been told are off limits.
Frequently Asked Questions About Eosinophilic Esophagitis Special Diets
It is not uncommon for families with children on a special diet for their eosinophilic esophagitis to have many questions. Below are some of the most commonly asked questions received by the Eosinophilic Esophagitis Clinic team
What is a 6-food elimination diet?
The six foods eliminated from a patient’s diet include cow’s milk, soy, wheat, egg, to peanut and tree nut, and seafood. These are the foods that are most common EoE food triggers.
What is an elimination diet?
Elimination diets take away foods that are thought to cause an allergic reaction.
What are the complications of restricted elimination diets?
It is important for children to get all of the nutrition they need while on a restricted diet. Patients receiving treatment at the CHOC Eosinophilic Esophagitis Clinic are closely monitored by a physician or nurse practitioner and dietitian.
Is cross contamination an issue for children with eosinophilic esophagitis?
Cross contamination takes place when bits of food transfer from one food to another. This can be done if the person cooking the meal does not wash his or her hands well enough or can happen if traces of a food are left on a cleaning surface like a grill or cutting board. It is difficult to determine if cross contamination can cause symptoms or inflammation in children with EoE. It is very important to avoid any chances of cross contamination since it is not known if cross contamination can cause symptoms. Exposure to eliminated foods can have an impact on the child’s endoscopy results. Our specialists work with patients on how strict the elimination should be.
When does a child need a feeding tube?
If a child is experiencing under-nuturition (malnutrition that happens when a child does not take in enough nutrients) that will likely hinder healing and negatively affect growth and development, he or she may need a feeding tube. Difficulty swallowing, refusal to take the prescribed diet or inability to drink enough formula are common reasons for supplemental feeding tubes. A feeding tube may be for short- or long-term therapy depending upon the patient’s treatment plan.
How do I know if my child should see a dietitian?
Because food allergies are thought to be at the root of EoE symptoms, most children are put on a special diet. It is important that patients see a dietitian, at least once, to make sure they are getting proper calories, vitamins, minerals and proteins on their new diets. Elimination and elemental diets can be challenging and our dietitian offers patients and their families many helpful hints and shortcuts for success.
What do I do if my child starts losing weight on his or her new diet?
If a child begins losing weight, contact his or her pediatrician. The child’s dietitian can also recommend ideas to increase caloric intake to promote adequate weight gain.
What are the warning signs that my child is not getting all of the nutrients he or she needs?
Children who may not be getting all of the nutrients they need may have some or all of the following symptoms:
- Poor weight gain or weight loss
- Decreased energy level
- Dry, scaly skin
- Hair loss
- Poor wound healing
The dietitian at the CHOC Eosinophilic Esophagitis Clinic is available to review the child’s dietary intake and compare it to the child’s nutritional needs. This is typically done with a three-day food record. Current clinic patients may contact the dietitian for more information.
What is a food trial?
A food trial is the reintroduction of a food or foods into a diet after it has been eliminated or if a food has never been eaten before. The food is “tried out” for a set amount of time while the patient is monitored for EoE symptoms.