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Health Disparities, Access to Care Issues Emerge in Children With Eosinophilic Esophagitis

  • Authors: News Author: Liam Davenport; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 9/9/2022
  • Valid for credit through: 9/9/2023
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Target Audience and Goal Statement

This activity is intended for primary care physicians, gastroenterologists, pediatricians, family medicine, nurses, physician assistants, and other clinicians who treat and manage children with eosinophilic esophagitis.

The goal of this activity is for learners to be better able to distinguish differences in presentation and outcome among Black and White children with eosinophilic esophagitis.

Upon completion of this activity, participants will:

  • Assess the epidemiology and clinical presentation of eosinophilic esophagitis
  • Distinguish differences in Black and White children with eosinophilic esophagitis
  • Outline implications for the healthcare team


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News Author

  • Liam Davenport

    Freelance writer, Medscape


    Liam Davenport has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

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  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC


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  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

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Health Disparities, Access to Care Issues Emerge in Children With Eosinophilic Esophagitis

Authors: News Author: Liam Davenport; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/9/2022

Valid for credit through: 9/9/2023


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.

An Increasingly Common Condition

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).

Raising Awareness

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]

Study Highlights

  • Study data were drawn from 2 urban clinics in the United States. Researchers reviewed medical records of children and adolescents between 1 and 17 years of age who were treated between 2010 and 2018.
  • Patients who had other eosinophilia in the gastrointestinal track were excluded from the study.
  • The main study outcomes were case presentation, treatment and response, and how insurance affected the diagnosis and management of EoE. The main study variable was Black and non-Black race. Black children with a case of EoE were paired with non-Black children based on age and sex.
  • 143 Black children were compared with 142 non-Black children. 69% of the cohort was male.
  • In the Black cohort, the median age at the time of diagnosis of EoE was 5.1 years compared with a median age of 6.7 years in the non-Black cohort.
  • Rates of having public insurance in the Black and non-Black cohorts were 66.2% and 30.7%, respectively.
  • Presenting symptoms were different based on race: 33.1% of non-Black children presented with abdominal pain compared with just 11.1% of Black children. In contrast, 32.2% of Black children presented with failure to thrive/poor growth compared with 12.7% of non-Black children.
  • Atopic conditions such as food allergies, atopic dermatitis, and asthma were fairly common in both racial cohorts, but significantly more common among Black vs White children. Black children were also more likely to have a family history of atopic illness.
  • The most common findings on upper endoscopy were normal esophagus, furrows, and plaques. Furrows were more common among Non-Black vs Black children. However, the concentration of eosinophils on biopsy was similar between groups.
  • The mean number of endoscopies performed was 4 in the Black group and 3 in the non-Black group.
  • Nonadherence to treatment was documented in 33.6% of Black children and just 10.9% of non-Black children.
  • Remission rates were similar in the 2 racial cohorts: 58.7% in the Black cohort and 66.2% in the non-Black group.
  • Patients generally received proton pump inhibitors, swallowed topical corticosteroids, and diet elimination. Treatment distribution was similar regardless of race.
  • The non-Black patients were more likely to achieve remission with proton pump inhibitors.
  • There was no significant interaction between insurance type and outcome based on race.

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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