A Single Food Milk Elimination Diet Is Effective for Treatment of Eosinophilic Esophagitis in Children

Published:April 03, 2021DOI:

      Background & Aims

      Cow’s milk protein (CMP) is the most common trigger of inflammation in children and adults with eosinophilic esophagitis (EoE). We sought to assess the clinical, endoscopic, and histologic efficacy of dietary elimination of all CMP-containing foods in EoE.


      We performed a prospective observational study in children with EoE treated with the 1-food elimination diet (1FED), excluding all CMP. Children and their caretakers were educated by a registered dietitian regarding dietary elimination of all CMP-containing foods, with substitutions to meet nutritional needs for optimal growth and development, and daily meal planning. Upper endoscopy with biopsies was performed after 8 to 12 weeks of treatment. The primary end point was histologic remission, defined as fewer than 15 eosinophils per high-power field. Secondary end points were symptomatic, endoscopic, and quality-of-life (QOL) improvements.


      Forty-one children (76% male; ages, 9 ± 4 y; 88% white) underwent 1FED education and post-treatment endoscopy with biopsies. Histologic remission occurred in 21 (51%) children, with a decrease in peak eosinophils per high-power field from a median of 50 (interquartile range, 35–70) to a median of 1 (interquartile range, 0–6; P < .0001). Endoscopic abnormalities improved in 24 (59%) patients, while symptoms improved in 25 (61%). Improved symptoms included chest pain, dysphagia, and pocketing/spitting out food. Parents perceived worse QOL, while children perceived improved QOL with the 1FED.


      One-food elimination of CMP-containing foods from the diet induced histologic remission in more than 50% of children with EoE and led to significant improvement in symptoms and endoscopic abnormalities. The ease of implementation and adherence supports the 1FED as first-line dietary treatment.


      Abbreviations used in this paper:

      1FED (1-food elimination diet), 4FED (4-food elimination diet), CMP (cow’s milk protein), EoE (eosinophilic esophagitis), eos/hpf (eosinophil per high-power field), HSS (histologic scoring system), IQR (interquartile range), PEC (peak eosinophil count), PPI (proton pump inhibitor), QOL (quality of life), SFED (6-food elimination diet)
      To read this article in full you will need to make a payment
      AGA Member Login
      Login with your AGA username and password.
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hiremath G.
        • Kodroff E.
        • Strobel M.J.
        • et al.
        Individuals affected by eosinophilic gastrointestinal disorders have complex unmet needs and frequently experience unique barriers to care.
        Clin Res Hepatol Gastroenterol. 2018; 42: 483-493
        • Kelly K.J.
        • Lazenby A.J.
        • Rowe P.C.
        • et al.
        Eosinophilic esophagitis attributed to gastroesophageal reflux: improvement with an amino acid-based formula.
        Gastroenterology. 1995; 109: 1503-1512
        • Markowitz J.E.
        • Spergel J.M.
        • Ruchelli E.
        • et al.
        Elemental diet is an effective treatment for eosinophilic esophagitis in children and adolescents.
        Am J Gastroenterol. 2003; 98: 777-782
        • Peterson K.A.
        • Byrne K.R.
        • Vinson L.A.
        • et al.
        Elemental diet induces histologic response in adult eosinophilic esophagitis.
        Am J Gastroenterol. 2013; 108: 759-766
        • Warners M.J.
        • Vlieg-Boerstra B.J.
        • Verheij J.
        • et al.
        Elemental diet decreases inflammation and improves symptoms in adult eosinophilic oesophagitis patients.
        Aliment Pharmacol Ther. 2017; 45: 777-787
        • Henderson C.J.
        • Abonia J.P.
        • King E.C.
        • et al.
        Comparative dietary therapy effectiveness in remission of pediatric eosinophilic esophagitis.
        J Allergy Clin Immunol. 2012; 129: 1570-1578
        • Kagalwalla A.F.
        • Sentongo T.A.
        • Ritz S.
        • et al.
        Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis.
        Clin Gastroenterol Hepatol. 2006; 4: 1097-1102
        • Gonsalves N.
        • Yang G.Y.
        • Doerfler B.
        • et al.
        Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors.
        Gastroenterology. 2012; 142 (quiz e14–e15): 1451-1459 e1
        • Lucendo A.J.
        • Arias A.
        • Gonzalez-Cervera J.
        • et al.
        Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease.
        J Allergy Clin Immunol. 2013; 131: 797-804
        • Arias A.
        • Gonzalez-Cervera J.
        • Tenias J.M.
        • et al.
        Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis.
        Gastroenterology. 2014; 146: 1639-1648
        • Wang R.
        • Hirano I.
        • Doerfler B.
        • et al.
        Assessing adherence and barriers to long-term elimination diet therapy in adults with eosinophilic esophagitis.
        Dig Dis Sci. 2018; 63: 1756-1762
        • Kagalwalla A.F.
        • Wechsler J.B.
        • Amsden K.
        • et al.
        Efficacy of a 4-food elimination diet for children with eosinophilic esophagitis.
        Clin Gastroenterol Hepatol. 2017; 15: 1698-1707 e7
        • Molina-Infante J.
        • Arias A.
        • Alcedo J.
        • et al.
        Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: the 2-4-6 study.
        J Allergy Clin Immunol. 2018; 141: 1365-1372
        • Kagalwalla A.F.
        • Amsden K.
        • Shah A.
        • et al.
        Cow's milk elimination: a novel dietary approach to treat eosinophilic esophagitis.
        J Pediatr Gastroenterol Nutr. 2012; 55: 711-716
        • Kagalwalla A.F.
        • Shah A.
        • Li B.U.
        • et al.
        Identification of specific foods responsible for inflammation in children with eosinophilic esophagitis successfully treated with empiric elimination diet.
        J Pediatr Gastroenterol Nutr. 2011; 53: 145-149
        • Spergel J.M.
        • Brown-Whitehorn T.F.
        • Cianferoni A.
        • et al.
        Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet.
        J Allergy Clin Immunol. 2012; 130: 461-467 e5
        • Kruszewski P.G.
        • Russo J.M.
        • Franciosi J.P.
        • et al.
        Prospective, comparative effectiveness trial of cow's milk elimination and swallowed fluticasone for pediatric eosinophilic esophagitis.
        Dis Esophagus. 2016; 29: 377-384
        • Wong J.
        • Goodine S.
        • Samela K.
        • et al.
        Efficacy of dairy free diet and 6-food elimination diet as initial therapy for pediatric eosinophilic esophagitis: a retrospective single-center study.
        Pediatr Gastroenterol Hepatol Nutr. 2020; 23: 79-88
        • Kliewer K.
        • Aceves S.S.
        • Atkins D.
        • et al.
        Efficacy of 1-food and 4-food elimination diets for pediatric eosinophilic esophagitis in a randomized multi-site study.
        Gastroenterology. 2019; 156: S172-S173
        • Teoh T.
        • Mill C.
        • Chan E.
        • et al.
        Liberalized versus strict cow's milk elimination for the treatment of children with eosinophilic esophagitis.
        J Can Assoc Gastroenterol. 2019; 2: 81-85
        • Hoofien A.
        • Dias J.A.
        • Malamisura M.
        • et al.
        Pediatric eosinophilic esophagitis: results of the European Retrospective Pediatric Eosinophilic Esophagitis Registry (RetroPEER).
        J Pediatr Gastroenterol Nutr. 2019; 68: 552-558
        • Liacouras C.A.
        • Furuta G.T.
        • Hirano I.
        • et al.
        Eosinophilic esophagitis: updated consensus recommendations for children and adults.
        J Allergy Clin Immunol. 2011; 128 (quiz 21–22): 3-20 e6
        • Dellon E.S.
        • Gupta S.K.
        A conceptual approach to understanding treatment response in eosinophilic esophagitis.
        Clin Gastroenterol Hepatol. 2019; 17: 2149-2160
        • Collins M.H.
        • Martin L.J.
        • Wen T.
        • et al.
        Eosinophilic esophagitis histology remission score: significant relations to measures of disease activity and symptoms.
        J Pediatr Gastroenterol Nutr. 2020; 70: 598-603
        • Hirano I.
        • Chan E.S.
        • Rank M.A.
        • et al.
        AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis.
        Gastroenterology. 2020; 158: 1776-1786
        • Reed C.C.
        • Fan C.
        • Koutlas N.T.
        • et al.
        Food elimination diets are effective for long-term treatment of adults with eosinophilic oesophagitis.
        Aliment Pharmacol Ther. 2017; 46: 836-844
        • Bashaw H.
        • Schwartz S.
        • Kagalwalla A.F.
        • et al.
        Tutorial: nutrition therapy in eosinophilic esophagitis-outcomes and deficiencies.
        JPEN J Parenter Enteral Nutr. 2020; 44: 600-609
        • Kaur S.
        • Rosen J.M.
        • Kriegermeier A.A.
        • et al.
        Utility of gastric and duodenal biopsies during follow-up endoscopy in children with eosinophilic esophagitis.
        J Pediatr Gastroenterol Nutr. 2017; 65: 399-403
        • Philpott H.
        • Nandurkar S.
        • Royce S.G.
        • et al.
        Allergy tests do not predict food triggers in adult patients with eosinophilic oesophagitis. A comprehensive prospective study using five modalities.
        Aliment Pharmacol Ther. 2016; 44: 223-233
        • Hirano I.
        • Collins M.H.
        • Assouline-Dayan Y.
        • et al.
        RPC4046, a monoclonal antibody against IL13, reduces histologic and endoscopic activity in patients with eosinophilic esophagitis.
        Gastroenterology. 2019; 156: 592-603.e10
        • Heine R.
        • RP
        • Cameron D.
        • et al.
        Effect of a 4-food elimination diet and omeprazole in children with eosinophilic esophagitis – a randomized, controlled trial.
        J Allergy Clin Immunol. 2019; 143: AB309

      Supplementary References

        • Collins M.H.
        • Martin L.J.
        • Alexander E.S.
        • et al.
        Newly developed and validated eosinophilic esophagitis histology scoring system and evidence that it outperforms peak eosinophil count for disease diagnosis and monitoring.
        Dis Esophagus. 2017; 30: 1-8
        • Varni J.W.
        • Seid M.
        • Kurtin P.S.
        PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations.
        Med Care. 2001; 39: 800-812
        • Franciosi J.P.
        • Hommel K.A.
        • Bendo C.B.
        • et al.
        PedsQL eosinophilic esophagitis module: feasibility, reliability, and validity.
        J Pediatr Gastroenterol Nutr. 2013; 57: 57-66
        • Cohen J.
        The Effect Size Index: q. Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale, NJ1988: 110-116