Prevalence and Predictors of Compromised Bone Mineral Density in Pediatric Eosinophilic Esophagitis

Abstract

To determine if patients with eosinophilic esophagitis (EoE) have decreased bone mineral density (BMD) more than what would be expected for their age and determine if the decreased bone density is more associated with certain comorbidities or treatments.A total of 269 patients with EoE were evaluated at the Cincinnati Children’s Hospital Medical Center Gastroenterology Outpatient Clinic. The inclusion criteria were patients 3 to 21 years who have a diagnosis of EoE on the basis of clinical history and pathology and have undergone a lumbar spine dual-energy radiograph absorptiometry (DXA) scan between January 1, 2014, to December 31, 2017.This study was a retrospective chart review. Specifically, charts were evaluated to find the patient’s first DXA scan within the study period. Demographic data included age at the time of the scan and EoE disease burden. Investigators also documented any comorbidities such as history of atopic disease, connective tissue diseases, eosinophilic gastrointestinal diseases, and immunoglobulin E (IgE)-mediated food allergies. Treatment information collected included corticosteroids, proton pump inhibitors (PPIs), 5-food and 6-food elimination diet, and elemental diet. From each chart, they noted if patients had ever been on these treatments in their lifetime, within the year preceding the DXA scan, or at the time of the DXA scan.The mean lumbar spine BMD z score of −0.5 was lower than the expected value of 0, and the prevalence of low BMD was 8.6% in comparison with the predicted value of 2.5%, both statistically significant. By using predictive multivariate models, PPI use at any point in the patient’s lifetime, the 5-food or 6-food elimination diet, and a history of IgE-mediated food allergies had negative correlations with BMD scores (−0.65, −0.27, and −0.28, respectively). Boys were at an increased risk of low BMD scores (odds ratio (OR): 4.84). Of note, corticosteroid use was not associated with lower BMD scores. Patients with a higher BMI, with a higher height-for-age, and who had active EoE were less likely to have a low BMD (OR: 0.43, OR: 0.33, and OR: 0.34, respectively).Pediatric patients with EoE have a lower BMD than their peers and a higher prevalence of low BMD. Risk factors to consider for these patients to develop low BMD include a history of IgE-mediated food allergies. Treatments such as restrictive food-elimination diets and PPI use also increase the risk of these patients developing lower BMD.There is prominent use of PPIs in pediatric patients with EoE, both to treat esophageal inflammation and protect the gastric mucosa with steroids treatment. Additionally, the use of dietary modifications to eliminate potential triggers is commonly used to treat EoE. Although both forms of treatments are effective in managing EoE, in this study, it is indicated that there may be negative impacts on bone health that should be considered in their management plan. Because this study is a retrospective analysis, it supports the need for a prospective study to evaluate factors that contribute to low BMD in pediatric patients with EoE and potential screening tools to identify those at greater risk of low BMD in this population.