Eosinophilic esophagitis (EoE) is a chronic immune mediated disease characterized by eosinophilic infiltration in esophageal epithelium and resulting in esophageal dysfunction.
While the exact pathogenesis is yet to be elucidated, EoE is considered an atopic disease. This classification is in part due to the inflammatory infiltrate of eosinophils, basophils and T-cells producing Th2 cytokines, yet it may also be triggered by environmental allergens. In addition, the rates of atopy are approximately 3 times higher in patients with EoE than in the general population. Furthermore, and most convincing, EoE is successfully managed with dietary exclusion of triggering groups in both pediatric and adult patients, further confirming the atopic nature of the disease.
The most frequent dietary trigger for EoE is milk, but there is limited data on the cross-reactivity of milk from other species. Guidelines addressing the diagnosis and treatment of EoE in both children and adults have not addressed the use of non-bovine milk in patients with cow's milk triggered EoE.
Restrictive diets are often challenging for patients and contribute to a reduced quality of life. Our own, anecdotal experience in two patients with milk triggered EoE who requested to introduce goat's milk into the patients' diet were that reintroduction did not trigger a clinical or histological flare of EoE. These cases of successful introduction of non-bovine milk introduces the possibility that a milk-free diet need not necessarily be exclusive of all species.
The aim of this study is to assess tolerability and safety of goat's milk in patients with EoE in whom cow's milk has been confirmed to be a trigger food for their disease.
All patients diagnosed with EoE age ≤ 17.5 years at inclusion who were confirmed to have cow's milk as a trigger by demonstrating improvement during elimination and histologic relapse following reintroduction.
Verified histologic remission on milk-free diet on endoscopy prior to intervention
Proton-pump inhibitors may be used if treatment is maintained at the same dose from the screening endoscopy throughout the trial period, and was used at the time that milk was demonstrated to be the triggering food.
Ability to consent to enrollment in the trial - legal guardians with joint consent for patients >10 years.
Patients with clinical IgE-mediated milk allergy.
Provisional exclusion: patients without a known IgE-mediated allergic reaction to milk who have a positive RAST (as per local reference range) or positive skin-prick test for cow milk or goat milk must be assessed by a certified allergist/immunologist and cleared for the trial by a supervised goat milk challenge.
Use of inhaled corticosteroids for more than 5 days per month during the trial period.
Single group
Goat milk diet
Other interventionElimination of cow milk from diet . Goat milk containing diet.
Histologic remission rate following 12 weeks exposure to ingested goat's milk products
will be assessed on biopsies collected at week 12 during upper endoscopy
Symptom scores following 12 weeks exposure to ingested goat's milk
symptom profile assessed at 6 weeks and at 12 weeks, with repeat endoscopy with routine biopsies at 12 weeks
Endoscopic remission rate following 12 weeks exposure to ingested goat's milk
endoscopy with routine biopsies at 12 weeks
Endoscopic improvement following 12 weeks exposure to ingested goat's milk
endoscopy with routine biopsies at 12 weeks
Safety of goat's milk challenge
Safety of goat's milk challenge as defined by absence of allergic reaction on exposure
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