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A 2-year-old female was referred to a paediatric gastroenterology clinic for the consideration of gastrostomy due to an unsafe swallow and recurrent chest infections. She had no other atopy. Other past medical history includes global developmental delay, previous subglottic stenosis and previous obstructive sleep apnoea.Video fluoroscopic Swallow Study (VFSS) confirmed oropharyngeal dysphagia, characterised by delayed swallow initiation, and reduced airway closure, suggesting a significant aspiration risk. At the time of referral, the patient was receiving 75% of her estimated average requirements (EAR) via NGT using a whole protein feed. Small amounts of pureed foods were tolerated orally, and all liquids were administered via the NGT.Upper gastrointestinal (GI) contrast study revealed a long delay in the passage, suggesting suboptimal oesophageal motility. pH impedance testing was within normal limits. Endoscopy performed in June 2022, concurrent with gastrostomy placement, identified active eosinophilic esophagitis (EoE), with 46, 18 and 1 eosinophils per high power field (eos/hpf) in the proximal, mid and distal oesophagus respectively. The patient was started on proton pump inhibitor (PPI) therapy.A repeat endoscopy in November 2022 demonstrated persistent active EoE (36, 22 and 14 eos/hpf in the proximal, mid and distal oesophagus respectively). The patient’s oral intake had improved, with greater consumption of soft-textured foods, but continued unsafe swallow for liquids. Gastrostomy feeds were reduced to 50% of EAR. A milk- and wheat-free diet (2 food exclusion diet [2FED]) was initiated to manage EoE as per BSG/BSPGHAN guidelines (Dhar, 2022), and the gastrostomy feed was changed to an amino acid formula (AAF).By May 2023, repeat endoscopy showed EoE in histological remission on the 2FED. EAR was met via oral intake of family meals of varying textures, and gastrostomy feeds were discontinued. Liquids continued to be administered via the gastrostomy; a repeat VFSS was planned. Wheat was reintroduced into the diet, while a dairy-free diet continued.In October 2023, endoscopy confirmed continued histological remission of EoE. The patient was advised to transition to a fully unrestricted diet, no feeds were administered via the gastrostomy, although this was still required for liquids. By April 2024, no active EoE was detected, although a slight increase in eosinophil count (4 eos/hpf in the proximal oesophagus) was noted. The patient achieved full oral nutrition and hydration, with the gastrostomy used exclusively for medication. Repeat VFSS indicated significant improvement in swallow physiology, with only mild residual difficulties in timing and coordination.This case highlights the complex interplay between oropharyngeal dysphagia and EoE in paediatric patients. With a MDT approach, the patient achieved histological remission of EoE and significant improvement in swallowing function, leading to the eventual cessation of gastrostomy feeding and return to an unrestricted diet. This case underscores the importance of tailored, long-term management strategies in paediatric patients with coexisting gastrointestinal and swallowing disorders.Reference Dhar A, Haboubi HN, Attwood SE. British society of gastroenterology (BSG) and British society of paediatric gastroenterology, hepatology and nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut. 2022;71:1459–1487.