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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. Click here for more detailed information on elimination and elemental diets.

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. Learn more about elimination diets.

What is an elimination diet?
Elimination diets take away foods that are thought to cause an allergic reaction. Learn more about elimination diets.

What is a directed (or guided) elimination diet?
Foods are eliminated based on the results of skin prick test and/or patch test.

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.

What is an elemental diet or formula?
All foods have their own unique proteins, and most allergic reactions to food are caused by proteins. Amino acids are the building blocks of proteins. When proteins are broken down into amino acids, they are less likely to cause an allergic reaction. Elemental formulas contain protein that has been completely broken down into amino acids mixed with sugars, fats, minerals and vitamins. An elemental diet consists of removing all regular table food and beverages and consuming the specialized formula to meet all nutritional needs. Elemental formula treatment is complete nutrition but should only be provided under the guidance of health care professionals, including a doctor or dietitian. Learn more about elemental diets.

Are there other draw backs to long-term use of elemental formula?
Infants may have difficulty developing age-appropriate feeding skills if solids are not introduced at the appropriate time or there is lack of oral stimulation while only consuming an elemental formula for a long period of time. Children who have had all foods removed from their diet may have anxiety or fear as foods are reintroduced after a prolonged treatment on the elemental diet.

What do I do if my child refuses to drink the elemental formula?
Some children may have difficulty accepting the taste of the elemental formulas. Try the following tips to increase the child’s willingness to drink their formula:

  • Do not give up after the child refuses the formula when first presented with it. It is typical for a child to refuse a new food or beverage. In fact, it may take more than ten times before a child may accept the new formula.
  • Praise the child when he or she takes a sip or tries the new formula. Positive reinforcement will increase the likelihood of a child accepting the new formula and encourages the child to drink more.
  • Offer small serving sizes when the formula is first presented.
  • Some children may need to transition from a preferred beverage or formula to the elemental formula slowly by mixing a small amount of the elemental formula with a larger amount of the preferred beverage. The ratio of the elemental formula is then increased overtime while the preferred beverage is decreased until the child is able to accept the full strength elemental formula.
  • Offer choices by allowing the child to choose the cup he or she will use to drink the formula.
  • Maintain a feeding schedule or routine so that the child knows when he or she will be eating and what to expect.
  • Talk with the child’s dietitian about types of formulas available. He or she may be able to recommend a flavored formula or provide a recipe that complies with the child’s specialized diet.

If the child continues to refuse the elemental formula, contact the child’s physician at the CHOC Eosinophilic Esophagitis Clinic.

When does a child need a feeding tube?
If a child is experiencing undernuturition (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.

If a child has a feeding tube, will it be needed forever?
A feeding tube may be for short- or long-term therapy depending upon the patient’s treatment plan.

What are the complications of tube feeding?
Children receiving their nutrition through a feeding tube can sometimes take in inadequate or excessive calories or nutrients. They can also experience volume intolerance (difficulty being able to consume the prescribed amount of formula), diarrhea and emotional distress.

Are there any foods allowed while following the elemental diet?
Some foods and ingredients, in addition to the elemental formula, may be allowed while following the elemental diet. This includes pure cane sugar and candies made with pure sugar such as, DumDums, Safety-T-Pops, and Smarties, cherry and grape powdered Kool-aid and Kool-aid Jammers, Gatorade, salt, baking soda, ascorbic acid, corn syrup, highly refined oils and artificial flavorings and sweeteners. The child’s allergist or dietitian can provide families with information on acceptable foods or additives the child can have along with his or her formula.

What is cross contact?
Cross contact or cross contamination occurs when one food item comes into contact with another food or even leftover crumbs or residue. If the other food is a known or potential allergen, this can result in persistent symptoms and/or inflammation of the EoE. Learn more about cross contamination.

Is soy oil or soy lecithin safe while eliminating soy from the diet?
Research has shown that soy lecithin and highly processed soy oil do not cause an allergic reaction in most individuals with a soy allergy. This does not include cold pressed, expeller pressed or extruded soy oils. If it is not clear on the ingredient list what type of soy oil is used, then it is recommended to call the manufacturer for clarification. There may be a small amount of individuals who can react to the tiny traces of soy protein left in the soy oil and soy lecithin. Caregivers may discuss these ingredients with the child’s allergist.

Is corn syrup or corn syrup solids allowed during a corn elimination diet?
Most individuals with a corn allergy that causes EoE can safely tolerate corn syrup and corn syrup solids. The likelihood of any contamination from corn protein is very low, as corn syrup is a highly processed ingredient. If the child is highly sensitive to corn, it is best to check with the child’s allergist before including corn syrup in his or her diet.

Is goat milk allowed on a milk-elimination diet?
Goat milk contains protein that is similar to cow milk protein and should be avoided while on a milk elimination diet.

Are cocoa butter, lactic acid, cream of tartar or sodium lactate safe to consume while on a milk-elimination diet?
Cocoa butter, cream of tartar and sodium lactate are safe to consume while on a milk-elimination diet. Lactic acid is safe, but lactic acid starter culture may contain milk and should be avoided.

Is buckwheat safe to consume on a wheat-elimination diet?
Buckwheat is not related to wheat and is actually classified as a fruit not a true cereal grain. It is safe to consume while eliminating wheat from the diet.

Are kamut and spelt safe alternative grains while on a wheat-elimination diet?
Kamut and spelt are closely related to wheat and should not be consumed while following a wheat-free diet. This is tricky as they are sometimes advertised as wheat-free grains; however, this is untrue.

Is peanut oil safe for a patient with a peanut allergy?
In general, hot pressed peanut oil does not contain peanut protein but cold pressed oil does.

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 loosing 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. Learn more about food reintroduction.