Children diagnosed with eosinophilic esophagitis (EoE) may be encouraged by medical professionals to start an elimination diet. This type of diet removes the most common food triggers from your child’s diet with the goal of improving symptoms like vomiting, reflux and regurgitation.  

After foods have been removed from the diet and biopsies confirm inflammation has resolved, specific foods are slowly reintroduced – one at a time – back into your child’s diet. The goal of this process is to identify which food (or foods) cause an allergic reaction and inflammation in your child’s esophagus. A dietitian can help counsel your family to ensure your child’s diet is nutritionally complete and they receive the nutrients they need to grow while on an elimination diet and after. 

What is an elimination diet for EoE?

An eosinophilic esophagitis elimination diet – or EoE diet – is a diet where certain foods are eliminated from your child’s daily food intake. Dietary therapy is one of the most common treatments to control inflammation in the esophagus caused by EoE.  

By removing foods known to be the most common triggers for EoE inflammation, your child’s esophagus can rest while clinicians determine which specific food(s) trigger your child’s symptoms and adjust their regular diet to avoid them.

The most common food triggers include: 

• Milk and dairy 
• Egg 
• Wheat 
• Soy 
• Peanuts and tree nuts 
• Fish and shellfish  

How to get started on an EoE diet

EoE is a lifelong condition that requires comprehensive, specialized care and nutrition – especially for growing children. Your child’s clinical team from the Center for Pediatric Eosinophilic Disorders can help your family get started on a medically supervised EoE diet.

The following team members can help your family start dietary therapy and navigate its challenges: 

• Physicians with expertise in gastroenterology and allergy help with diagnosis and treatment planning 
• Registered dietitians can help by providing individualized counseling to patients and their families, helping you safely avoid trigger foods and offering safe alternative foods and nutrients to ensure your child’s diet remains nutritionally balanced and able to support their continued growth.  
• Psychologists can offer support and stress management for children and families dealing with an EoE diagnosis and EoE disease diet. 
• Feeding and swallowing experts are also available to help make eating more comfortable and rewarding for your child. 

Tips for following an EoE elimination diet

Following an EoE elimination diet can be challenging for both patients and families. However, with support and education from healthcare professionals, many have successfully adapted to an EoE diet and have continued to grow and thrive. 

Common diets that have been recommended for EoE management include: 

• Removing all milk and dairy products from the diet. Recent studies show that most children can do well with less restrictive diets that eliminate only milk and dairy products. 
• A two-food elimination diet, which includes removing foods containing milk or wheat as ingredients. 
• A six-food elimination diet, which includes removing milk, eggs, wheat, soy, sesame, peanuts and tree nuts, as well as fish and shellfish – and foods that contain these items – from the diet. 

At Children’s Hospital of Philadelphia, we take a more personalized approach to create an EoE elimination diet – specifically looking to eliminate the most common cause of your child’s symptoms based on their current diet. 

Avoid cross-contact with trigger foods

Avoiding cross-contact or cross-contamination with trigger foods is as important as avoiding ingesting the foods. Even a small amount of a trigger food can cause a negative reaction hours after exposure.  

Common sources of cross-contamination include:

• Utensils  
• Pots and pans 
• Cutting boards 
• Cooking surfaces like a grill or fryer 
• Toasters or toaster ovens 
• Deli slicers 

To keep your child safe from cross contamination:

• Wash all utensils, pots, pans, and cutting boards with soap and water after the item has any contact with a known or suspected allergen
• Avoid putting foods directly on cooking surfaces (e.g., use foil on the grill, change cooking oil in fryers)
• Purchase deli meats and cheeses from a business that uses separate slicers 
• Avoid fried foods when eating out 

Find grain alternatives when wheat is eliminated

If wheat is suspected as a cause of your child’s EoE symptoms, clinicians will encourage you to find alternative grains to supply your child with the carbohydrates needed to fuel their body. It’s important to find alternative sources of carbohydrates that can help create kid-friendly staples like pizza, bread and pasta. 

Some whole-grain alternatives to include on your EoE diet grocery list include: 

• Oats 
• Rice 
• Corn 
• Quinoa  

When baking, use a general all-purpose flour that is labeled “gluten free.” You can avoid a crumbly result by choosing a product with xanthan gum or adding your own to the recipe. 

Find milk alternatives when dairy is eliminated

If milk is suspected as a cause of your child’s EoE symptoms, clinicians will encourage you to find alternatives to cow’s milk.  

Some cow’s milk alternatives include plant-based beverages made with:

• Almond  
• Cashew  
• Coconut  
• Flaxseed  
• Hemp  
• Oat  
• Pea  

In addition to being alternatives for cow’s milk, beverages made from peas, oat and hemp are also good sources of protein. The other milk alternatives are not rich in protein. 

When baking with a milk alternative, you can use the same quantity as milk noted in the recipe.

Read the complete ingredient list

While it’s relatively easy to identify trigger foods when they stand alone, it can be more challenging when they are included in another product – like a baked good or prepackaged food. When using an elimination diet for EoE, you and your family will have to learn how to carefully read food labels.  

The Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), enforced by the U.S. Food and Drug Administration, requires the top eight food allergens to be clearly labeled on all packaged foods sold in the U.S. The top eight are: milk, egg, wheat, soy, peanuts, tree nuts, fish and shellfish. Sesame was added to the list in 2023 and must also be clearly identified on food labels.

Tips to read a food label when following an EoE diet: 

• Read the full list of ingredients. Food manufacturers will list allergens in either parenthesis or bold: i.e., (milk) or milk
• Look for “contains” statements. Food manufacturers can also list allergens in a set-off statement after ingredients like this: “Contains milk and wheat.”
• Be careful with advisory or precautionary labeling. Manufacturers may use phrases like “may contain,” “manufactured on the same equipment as” or “manufactured in the same factory as.” These labels are offered on a voluntary basis, and these foods are generally OK for kids with EoE unless they also have an IgE-mediated food allergy. When in doubt, contact the manufacturer and/or your child’s allergist. 
• Gluten-free and wheat-free are not the same. Gluten is found in wheat, barley and rye. When a product is labeled “gluten-free,” it should not contain wheat. But not all “wheat-free” products are also gluten free; instead, they may contain barley and/or rye.  
• Look closely at shellfish labeling. While crustaceans like crab, lobster and shrimp will be clearly identified in labels, other mollusks – including oysters, scallops, mussels and clams – are not according to the FALCPA. 
• Flavors, colors and additives must also identify any of the top nine allergens mentioned above.  
• Be careful with claims on the front of packaging. The FDA does NOT regulate claims on the front of food packaging. Even if a product says “dairy-free” on the front, always read the food label carefully and call the manufacturer if you have questions. 
• Imported packaged foods must also follow FALCPA food labeling rules.  
• Recheck food labels periodically. Manufacturers can change their products, ingredients and production processes. Even if a product has been safe for your child in the past, take a minute to double-check that a food trigger for your child is not included. 
• Dairy avoidance does not just include cow’s milk, but also milk from other mammals like goats and sheep.  

To learn more, visit the FDA’s FALCPA page. 

Get enough calcium and vitamin D on an EoE diet

If your child’s eosinophilic esophagitis diet eliminates dairy, you will need to find a way to replace nutrients – specifically calcium and vitamin D – which are needed for your child to grow and develop properly.  

When choosing milk alternatives made from almonds, cashews, coconuts, flaxseed, hemp, oat or peas, look for products with: 

• 30% or more of the daily value for calcium. The daily value is:  
  • 260 mg for babies 6-12 months old 
  • 700 mg for toddlers 1-3 years old 
  • 1,000 mg for children aged 4-8 
  • 1,300 mg for youth aged 9-18 
• 25% or more of the daily value for vitamin D. The daily value is:  
  • 400 IU for infants 12 months and younger 
  • 600 IU for children aged 1-18  

For children on a vegan diet, look for milk alternatives fortified with vitamin B12. Learn more about vitamin D supplements. 

Understand food labels for an EoE diet

EoE food triggers can be found alone – for example, milk or eggs – or may be found within other products – like baked goods, prepared foods, salad dressings and more.  

All packaged foods are required to have food labels and must clearly state if they contain milk, egg, wheat, soy, peanut, tree nuts, sesame, fish and shellfish.  

Families who have a child with EoE should: 

• Read all food labels carefully – every time you purchase the product.  
• Manufacturers are required to list if any of the top nine allergens are included (i.e. milk, peanuts, wheat); but the information may be listed within the full ingredient list or at the end of the list (i.e. Contains milk, peanuts and wheat). 
• Call the manufacturer if you have questions about a specific product or its ingredients. 

Frequently asked questions about eosinophilic esophagitis diets

If you have questions about your child’s eosinophilic esophagitis diet, you are not alone. Below, we answer some of the most common questions asked at CHOP’s Center for Pediatric Eosinophilic Disorders. 

What are the complications of elimination diets?

Elimination diets require your child to stop eating certain foods that may trigger their EoE symptoms. While these diets can be useful in identifying which foods produce symptoms, they can also lead to nutritional deficiencies in core nutrients like calcium, iron and fiber. Complications can affect a child’s physical health, as well as psychological and emotional health. 

It is important to talk to your child’s physician about any type of elimination diet and how best to ensure your child can get the nutrients they need to best grow and develop. Patients receiving EoE treatment at CHOP are closely monitored by a team of clinicians including a physician, dietitian and nurses.  

How do I know if my child should see a dietitian?

If your child is struggling to adjust to an EoE elimination diet, is a picky eater, or has difficulty gaining weight, you may need support from a pediatric dietitian who can help your family with meal planning, creative ways to avoid your child’s food triggers, as well as tips and techniques to encourage your child to eat the food you have prepared. Our team has a dedicated dietitian specializing in EoE and food allergies.  

When does a child need a feeding tube?

Your child with EoE may need a feeding tube to meet or supplement their nutritional needs if they have:  

• Failure to thrive and struggle to grow or gain weight 
• Malnutrition or undernutrition  
• Difficulty swallowing 
• Difficulty following the prescribed diet  
• An inability to drink enough formula
• A neurological condition that leads to eating difficulties 
• A respiratory problem that affects breathing and makes eating difficult
• Severe food allergies 

If your child needs a feeding tube, our team will work closely with you to teach you how to handle feedings at home, and how to properly care for your child’s feeding tube.

How CHOP can help with your child’s EoE elimination diet

Clinicians from CHOP’s Center for Pediatric Eosinophilic Disorders are available to help your family navigate your child’s EoE diagnosis and treatments – from the EoE elimination diet and beyond.  

Our registered dietitians can help you: 

• Learn how to read food labels and spot hidden ingredients 
• Safely navigate the grocery store  
• Avoid cross contamination at home, school or anywhere your child may eat food 
• Handle social activities that are centered around food like birthday parties, holidays and school events