Eosinophilic esophagitis in children: Clinical perspectives and evolving therapeutic strategies

Table 1 Main differences between 2024 and 2014 guidelines by European Society of Pediatric Gastroenterology, Hepatology and Nutrition

	2024 ESPGHAN guidelines	2014 ESPGHAN guidelines
Trail of PPI as part of diagnostic criteria	PPIs no longer used as a diagnostic tool; rather as a treatment option	PPIs used to define EoE by documenting nonresponse to PPI
Eosinophilic involvement of other segments of the GI tract does not exclude the diagnosis of EoE	EoE may coexist with eosinophilic infiltration of other segments of the GI tract	Not addressed
Clinical symptom assessment tools (Pediatric EoE Symptom Score)	Advocated for assessing treatment response and monitoring	Not discussed
EREFS	EREFS score discussed; needs further evaluation	Subjective observations discussed
Biopsy protocol and reporting	Follow-up endoscopy with biopsies generally recommended 8-12 weeks after initiating or making a major change to therapy or symptom flare. Every 1-3 years in asymptomatic cases during maintenance	Not discussed in detail
Histology scores	Eosinophilic Esophagitis Histology Severity Score discussed; need for report format that is comparable between centers	Peak eosinophil cutoff/high power field discussed and subjective assessment of ancillary findings
Systemic steroids	A short course of systemic steroids may be used as treatment option for severe pediatric EoE associated strictures	Not specifically mentioned for use
Biologics	First biologic approved by Food and Drug Administration and for children > 1 years of age	No biologics advocated
Biomarkers and noninvasive techniques	Discussed in current guideline	Not discussed
Quality of life	Addressed in current guideline	Not discussed

EoE: Eosinophilic esophagitis; EREFS: Eosinophilic Esophagitis Endoscopic Reference Score; ESPGHAN: European Society of Pediatric Gastroenterology, Hepatology and Nutrition; GI: Gastrointestinal; PPI: Proton pump inhibitor.

Table 2 Potential new biomarkers for disease activity monitoring in patients with eosinophilic esophagitis

Biomarker	Tissue specimen			Clinical utility	Evidence maturity (clinical use vs investigational)
	Mucosa	Blood	Feces
Eosinophil cationic protein	Yes	Yes	Yes	Disease activity monitoring, predict endoscopy severity, predict treatment response	Investigational
Eosinophil-derived neurotoxin	Yes	Yes	Yes	Disease activity monitoring, predict treatment response	Investigational
Eosinophil peroxidase	Yes	Yes	No	Disease activity monitoring, predict treatment response	Investigational
Major basic protein	Yes	Yes	No	Disease activity monitoring	Investigational
Mast cell tryptase	Yes	No	No	Disease activity monitoring	Investigational
Chemokine (C-C motif) ligand 26	Yes	Yes	No	Disease activity monitoring	Investigational
Periostin	Yes	No	No	Disease activity monitoring	Investigational
Microbiome	Yes	No	No	Disease activity monitoring	Investigational

Table 3 Eosinophilic esophagitis: Practice changers in 2023-2025

EoE: Practice changers in 2023-2025
Removal of mandatory proton pump inhibitor trial
Routine use of endoscopic reference score/EoE histologic scoring system
Pragmatic 1-food elimination as a first step
Food and Drug Administration approval of dupilumab for refractory cases
Transnasal endoscopy for monitoring endoscopies during maintenance

EoE: Eosinophilic esophagitis.