Advances in Management of Eosinophilic Esophagitis in Pediatrics

Eosinophilic esophagitis is a chronic immune-mediated inflammatory disorder of the esophagus comprising symptoms of esophageal dysfunction with eosinophilic inflammation. The diagnosis is based on histopathologic criteria with elevated esophageal eosinophil count and the presence of characteristic symptoms such as dysphagia. The goal of treatment is to improve symptoms, induce histopathologic remission, and prevent progression to fibrostenotic disease. In pediatrics, maintaining growth and development are essential considerations in treatment and play a role in the selection of treatment. Mainstays of pharmacologic treatment include proton pump inhibitors, topical corticosteroids, and dietary therapy, all of which are first-line treatment options for pediatric patients with eosinophilic esophagitis. More recently, a biologic therapy, dupilumab (a monoclonal antibody against interleukin-4⍺ receptor), has been approved for eosinophilic esophagitis in patients aged ≥1 year and ≥15 kg. Esophageal dilations are used as an adjunct to medical or dietary therapy for fibrostenotic eosinophilic esophagitis, but do not treat the underlying inflammation. Several emerging biologics that target pathways implicated in the inflammatory mechanisms of eosinophilic esophagitis are currently under investigation in adults; however, studies are lacking in much of the pediatric population. This review outlines updates in treatment approaches for pediatric eosinophilic esophagitis including the use of proton pump inhibitors, new topical corticosteroid formulations, paradigm shifts in dietary therapy approaches, and use of biologics with a focus on pediatric disease.