Question:

Good morning. My 7-year-old daughter has a confirmed diagnosis of Eosinophilic Esophagitis and, in the past, tested positive on skin prick testing and serum IgE testing for cow’s milk proteins and casein.

After the diagnosis of EoE, she has never included cow’s milk proteins in her diet. Her esophagitis is currently in symptomatic and histological remission.

We would like an opinion on possible desensitisation through milk intake.

What are the risks and benefits, considering that she has EoE?

What might be an appropriate timing for histological monitoring?

Answer:

Dear Madam,

You state that your daughter has EoE in both histological and symptomatic remission, but you have not indicated which treatment she is currently following.

There are not many studies investigating the relationship between oral desensitisation to cow’s milk proteins and EoE. The only review with meta-analysis does not highlight risks specifically related to this type of treatment, but it does emphasise the need for particular caution because of the increased risk of eosinophilic esophagitis (Front Immunol. 2025 Jun 4;16:1570050. doi: 10.3389/fimmu.2025.1570050).

Clearly, if the patient is receiving pharmacological treatment with budesonide or dupilumab, the risk is considerably reduced. If, on the other hand, the patient is being treated with an elimination diet, I would be firmly against desensitisation. Immunology and allergy specialists may probably be able to add further considerations.

As regards the timing of endoscopy: if the response to treatment has been clearly defined — meaning that the first endoscopic and histological follow-up has already been performed, confirming remission, and maintenance therapy has been started — I would suggest a follow-up endoscopy after 4–6 months to confirm the effectiveness of the maintenance therapy.

Subsequently, I would suggest annual endoscopic follow-up and clinical follow-up every six months, or earlier in the event of any change in symptoms.

If everything remains stable over time, with a stable clinical picture — symptomatic remission without adaptive behaviours — and histology shows deep remission, with 0–1 eosinophils per high-power field, endoscopic follow-up may also be extended to every two years.

Nicola de Bortoli
Associate Professor of Medicine
Department Translational Research and New Technologies in Medicine and Surgery
Division of Gastroenterology
Head of Gastroenterology Training Program
University of Pisa

Good morning everyone. Yes, I confirm: if the child is on a milk-free diet and this is the only treatment for her esophagitis, desensitisation is contraindicated, unless the treatment strategy is changed. However, this is something that must be discussed with the medical team currently managing the child.

If, on the other hand, pharmacological treatment is ongoing, the risks — including possible reactivation of the esophagitis — and the benefits, particularly in terms of quality of life, should be discussed in depth with the doctors following the child. In that case, closer follow-up may need to be planned.

dott.ssa Francesca Racca
Specialista in Allergologia e Immunologia Clinica
Ospedali Humanitas Gavazzeni e Castelli - Bergamo

Please remember that the answers provided are opinions and do not constitute medical advice. They cannot replace a consultation, a medical examination, or the review of the patient’s medical documentation.