Jonathan M. Spergel, MD, PhD, Professor of Pediatrics at The Children’s Hospital of Philadelphia talks about EOE and how the patch is working to help patients with milk allergies.
Interview conducted by Ivanhoe Broadcast News in August 2019.
My first question is about the actual esophageal issues that they get when they drink something with milk. How difficult is that for the child?
SPERGEL: So when you have this disease – eosinophilic esophagitis – when you drink or eat you cause inflammation in the esophagus. And that inflammation will present in different ways depending on the kid and the age of the child. In some kids it just causes inflammation, irritation, so it actually hurts to eat. As the kids get a little bit older they present with more abdominal pain and vomiting, and if they leave it untreated for years, the esophagus gets narrowed into a structure and food actually gets stuck. So this is the complication. That’s why we really want to treat it in children because we don’t want them to have a narrow esophagus such that you’re eating mush. You can’t eat regular food anymore.
There must be an issue with the parents recognizing or even maybe a physician that’s not familiar with it.
SPERGEL: It is. It takes patients often years cause every child has a belly pain. Belly pain is so common. And so it takes a long time – like the belly pain’s not getting better. Once patients recognize, hey, I’m vomiting all the time. They know that’s not normal, right? But also what happens is sort of interesting. Some patients develop compensation mechanisms. They know that hey, for me to eat a piece of bread, I need to drink two glasses of water and really chew it down really well. They can eat a bagel really quickly. They have to sort of sit there and think about chewing now. OK drink my water. Swallow. OK. Next bite. And they think that’s normal because they’ve slowly learned this behavior. And we’re like, no, that’s not the way you’re supposed to eat. You’re supposed to just eat and you need a drink of water, that’s fine. But you shouldn’t have to sit there and concentrate on eating. So patients have developed this tolerance and it takes some time to realize until bad event happens often, they won’t know it unless the patient has been vomiting all the time.
And segueing into that bad event, how much do they need to get to trigger that and how bad is it?
SPERGEL: So it really. This is not like when we think of milk or anaphylaxis when you have a glass of milk or eat peanuts and you get hives. Eosinophilic Esophagitis is from chronic exposure over months or years. The episode may not be due to you having an allergy to the chicken. It’s because you’ve had untreated disease for months to years and that’s caused the inflammation. It’s not that that piece of chicken or that piece of bread is bad. It’s that oh I’m allergic to milk and I’ve been having my glass of milk and my ice cream every day for the last ten years, and now my esophagus is so narrow it gets stuck. In terms of what happens, some patients are fine and they can just say, oh, I’m better. I can just sort of swallow or they sort of do a Heimlich maneuver and they loosen it up themselves. Some patients have to go to the E.R. and get that piece of food taken out.
Do most of the patients know about their allergy, percentage wise?
SPERGEL: That’s the issue. Most patients don’t know what the food is because they think, oh, I ate the chicken. That’s what caused the food to get stuck. And in this disease, we don’t have a great diagnostic test or a standard allergy testing which is the specific IGE. The blood test or the skin prick test really don’t identify foods in this disease because this disease is a different mechanism. It’s not the hive reactions, not IGE immediate. So it’s a more delay so we don’t have a test. So we as clinicians know because we’ve been treating this at least for the last 10 to 20 years that, hey, we know what the most common foods are. We know by your dietary history, what are you eating? We know that these are the most likely foods to cause disease. But patients sometimes can pop up more often than not who simply don’t know.
Do they present to you? By the time they get to you, they’ve probably already been to somebody else and presented with belly pain.
SPERGEL: Right. As an allergist they present to me sort of in two different ways. The more common scenario is they’ve been presented to a gastroenterologist. They’ve been to a G.I. doctor and the GI doctor has been walking them up for the abdominal pain and they diagnose them by doing an endoscopy. When you put a little fiberoptic scope down into the stomach and the esophagus and they look for inflammation, they take a little piece of tissue, take a biopsy and they say oh this inflammation – there’s these eosinophils and these eosinophils are the allergy cells and hence the name eosinophilic esophagitis. There is another group that presents us sort of interestingly. Most of these patients with eosinophilic esophagitis have regular allergies, whether it’s asthma, seasonal allergies or the anaphylactic reactions. So we see those patients now getting really chronic abdominal pain. We sort of say, hey, you need to go to G.I. now, and be seen and maybe you have this disease. So it is a disease that’s really teamwork, that you need an allergist, you need a gastroenterologist. And once we deal with diets we need to deal with registered dietitian all working together to really help to get these patients better.
Is there average age in which the patient is diagnosed?
SPERGEL: The average age is usually school age so 8 to 12-year old’s. But there’s another peak in adulthood. But since I’m a pediatrician, it’s really eight to twelve is when we normally see it.
If a parent at home is watching this right now, what would you tell them to be concerned about?
SPERGEL: If you notice your kid like hey my kid has abdominal pain all the time, is not getting better, or throwing up all the time, talk to your doctor. There’s lots of reasons to have abdominal pain. And the most common reasons are like constipation. My kid doesn’t need eat enough veggies. I mean, you got to make sure they don’t have the common stuff. But once you rule out those common things, that hey it’s not constipation or not school anxiety, that my kid really has something all the time, it may need to be seen by a gastroenterologist to say hey, something’s not right. Does my child have persistent reflux or does the child have this disease, eosinophilic esophagitis?
Let’s switch over to the patch and what it does.
SPERGEL: With the patches, it’s a technology developed by this company out of France called DBV technologies. They created a patch which basically had some milk in it and there was just milk protein that was basically put on this little round patch. And we placed it on the back of our patients and the milk would slowly dissolve into the back of the patients. And the body’s immune cells would recognize the milk and say hey this is not a danger protein now. It’s not something I’m supposed to react to. This is something we should be used to. And this idea of inducing tolerance, saying this is OK, is something we’ve done in allergy immunology for years. It’s like the same principle of allergy shots. You slowly get exposed to something, your body gets used to it. You couldn’t do it by what we do in other diseases so either eating it or shots because it doesn’t get to the right part of the immune system. And you can’t drink at all because you would actually induce the reaction so you had to induce it a different way. So we put the patches on their backs and you change the patches every day. And then after doing that we sort of looked after a period of time nine months to see that, hey, we gave milk in the beginning. We reintroduced milk. Was the disease still there? And for some patients, it wasn’t. It didn’t work on all the patients, but for some patients, they’re now able to take milk, which they couldn’t before, which is sort of wonderful.
Is milk the culprit? Because it’s included in so many foods.
SPERGEL: Milk is by far the majority food. For most patients, it’s not the only food. For about a third of the patients, milk is the only food. If you cured milk, you’d cure a third of the patients. But about 70 percent of the patients have milk plus something else. Half the patients will have milk plus egg or wheat or soy – some other food. But milk is by far the most common food that causes disease.
END OF INTERVIEW
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