Clinical Context

Eosinophilic esophagitis (EoE) is characterized by the infiltration of eosinophils into the esophageal mucosa, and it is increasing in prevalence. The authors of the current study provide a brief review of EoE as part of their research.

EoE is associated with a range of upper gastrointestinal symptoms, including dysphagia, vomiting, regurgitation, and feeding difficulties. As expected with an eosinophilic disease, three quarters of children with EoE have other atopic illness.

EoE appears to predominantly affect boys more than girls, with a ratio of approximately 3:1. EoE has also been thought to affect White children in 85% to 90% of cases. However, more recent evidence suggests that EoE may be more common among Black individuals than previously thought. The current study addresses the question of whether there are differences in the clinical journey of EoE based on race.

Study Synopsis and Perspective

Black children with EoE are more likely to present with atopic comorbidities and failure to thrive and are less likely to adhere to therapy than non-Black children, suggests the largest study to date to compare the 2 groups.

According to the researchers, Black children were more likely to have food allergies, atopic dermatitis, asthma, and allergic rhinitis. In addition, failure to thrive at presentation was more than twice as common among Black patients, whereas non-Black patients were around 3 times as likely to present with abdominal pain.

Although there were no significant differences in the rates of remission on medical therapy between the 2 groups, Black patients were substantially more likely to be nonadherent to regimens than their non-Black counterparts.

"Overall, there were some important differences between our two cohorts suggesting Black patients may present with more severe symptoms or have issues with access to care," said lead researcher Sofia Edwards-Salmon, MD, from Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, and colleagues.

The findings were published online in the Journal of Pediatric Gastroenterology and Nutrition.

According the authors, EoE is an increasingly common chronic, immune-related condition characterized by eosinophilic infiltration of the esophagus, causing regurgitation, dysphasia, feeding difficulties, and vomiting. Atopic comorbidities accompany the disease in around 75% of patients.

Although the pathogenesis of EoE is not fully understood, males are predominately affected (male-to-female ratio of 3:1), and 85% to 90% of cases occur in White people.

The authors note that recent smaller studies have suggested that Black children are affected by EoE to a greater degree than previously thought, raising questions over the clinical care of Black individuals.

To investigate further, they conducted a retrospective chart review of patients aged from 1 to 17 years who were diagnosed with EoE. The researchers identified eligible Black patients and then identified a sample of non-Black patients who were matched by age and sex. In all, 143 Black children and 142 non-Black children were included. The median age at diagnosis was 5.1 years and 6.7 years, respectively. More than twice as many Black children than non-Black children had public health insurance (66.2% vs 30.7%).

The authors found that non-Black children were significantly more likely to present with abdominal pain (33.1% vs 11.2%), whereas Black children were more likely to present with failure to thrive/poor growth (32.2% vs 12.7%).

In regard to endoscopic findings, Black children were more likely to have strictures (3.5% vs 0.0%), but no other significant differences were found. The 2 groups underwent a similar number of esophagogastroduodenoscopies during follow-up (mean number of procedures, 4 among Black patients vs 3 among non-Black patients).

In addition, atopic comorbidities were more common among Black children than non-Black children: food allergies (52.4% vs 35.9%), atopic dermatitis (50.3% vs 27.5%), asthma (47.7% vs 28.9%), and allergic rhinitis (40.6% vs 23.9%). A family history of atopy was recorded for 65% of Black patients vs 47.2% of non-Black patients.

Notably, the authors found no overall significant differences in the therapies used for Black and non-Black patients. There also was no significant difference in the proportion of patients who achieved remission at some point (58.7% of Black patients vs 66.2% of non-Black patients). However, nonadherence to medical therapy was significantly more prevalent among Black patients (33.6% vs 10.9%).

Similar proportions were lost to follow-up (46.9% of Black patients vs 43.6% of non-Black patients).

Dr Edwards-Salmon told Medscape Medical News that although there are many potential reasons for the differences, the most likely would be access to care and/or socioeconomic differences.

She explained that their biggest hope in publishing the results of their study is to increase physician awareness of EoE in the Black pediatric population and how its presentation may differ. The aim is to achieve earlier treatment and earlier remission, and therefore better outcomes, she said.

Dr Edwards-Salmon suggested that adherence could be improved by including patient surveys on medication access and affordability, as well as having information regarding a parent or guardian's daily schedule, which would enable providers to come up with a plan on how to most easily supervise medication.

Reached for comment, Vincent A. Mukkada, MD, associate professor, University of Cincinnati Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, said it was "interesting that they are not seeing major differences in treatment response between the Black population compared to their other patients."

He told Medscape Medical News that, in contrast, "we and other groups have seen that some of these patients, particularly the very young ones with multiple atopic diseases, have been very challenging to treat effectively."

Dr Mukkada, who was not involved in the study, said that although he agrees that socioeconomics and access to care play major roles in the differences seen, he would hesitate to jump to the conclusion that these are the sole or dominant forces.

"In fact, the increased prevalence of other atopic diseases and failure to thrive in the Black cohort might just as well be due to a biologic difference in atopic predisposition, or perhaps the greater proportion of patients with failure to thrive might be secondary to their increased atopic burden," he said.

Dr Mukkada added that it would have been interesting to have seen other objective markers, such as blood counts, to see whether peripheral eosinophilia, for instance, was increased among the Black patients. In addition, it would be interesting to look at gene expression profiles.

The study was funded by the Children's Healthcare of Atlanta Butcher Resident Research Award and Emory School of Medicine Research Training in Translational GI and Liver. Dr Edwards-Salmon and Dr Mukkada have disclosed no relevant financial relationships.

J Pediatr Gastroenterol Nutr. Published online July 6, 2022.^[1]

Clinical Implications

• EoE is increasing in prevalence and is associated with a range of upper gastrointestinal symptoms, including dysphagia, vomiting, regurgitation, and feeding difficulties. Three quarters of children with EoE have other atopic illness, and it is more common among boys than girls.
• The current study found that Black children were diagnosed with EoE earlier than non-Black children, and Black children were more likely to present with failure to thrive. Atopic comorbid illness was more common in Black children, although remission rates were similar regardless of race.
• Implications for the healthcare team: The healthcare team should consider that Black children with EoE may present at a younger age compared with non-Black children, and their presentation may be more likely to include poor weight gain. Members of the healthcare team should be aware of this clinical presentation difference to prevent health disparities.

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