Management of Pediatric Eosinophilic Esophagitis: Current Therapies, Emerging Treatments, and Future Directions—A Narrative Review

Background: Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by esophageal dysfunction and eosinophil-predominant inflammation. Its increasing recognition in children and risk of progressive remodeling demand effective, sustainable treatment. Methods: We conducted a narrative review of PubMed/MEDLINE, Embase, and Cochrane Library publications through 2026. Pediatric clinical studies, systematic reviews, meta-analyses, and international guidelines addressing dietary, pharmacological, and biologic therapies were qualitatively synthesized, with selected adult evidence included when pediatric data were unavailable. Results: Empiric elimination diets remain effective first-line options, with step-up strategies reducing unnecessary restriction and treatment burden. Elemental diets achieve histological remission in more than 90% of patients but are limited by palatability, cost, and adherence. Allergy test-directed diets have low predictive value and are not routinely recommended. Proton pump inhibitors and swallowed topical corticosteroids are established first-line therapies with favorable safety profiles. Real-world evidence suggests that treatment choice depends on age, phenotype, local practice, and family preference, whereas comparative effectiveness data remain limited. Dupilumab, the first biologic approved for EoE, produces substantial histological and endoscopic improvement across pediatric age groups and is particularly relevant for difficult-to-control disease or coexisting type 2 conditions. Other targeted agents reduce eosinophilia, but symptomatic benefit and pediatric evidence remain inconsistent. Conclusions: Pediatric EoE management should combine shared decision-making with objective histological monitoring and attention to growth, nutrition, adherence, and quality of life. Future research should define optimal treatment sequencing and maintenance, validate noninvasive biomarkers, and establish the long-term safety and effectiveness of emerging therapies in diverse pediatric populations and clinical settings.