Tony is a five and a half-year-old boy who has been a patient in your primary care practice since he was adopted at birth. He has been treated by a child and adolescent psychiatrist for behavioral concerns starting at age 3 years and has been diagnosed with autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD) combined type, anxiety disorder, and insomnia. He presents today with complaints of repeated emesis and refusal to eat or drink over the past 2 weeks and is now dehydrated.

Tony was born at 30 weeks' gestational age by vaginal delivery with a birth weight of 4lbs 15oz and was described as minimally responsive at birth. There was known prenatal exposure to tobacco and methamphetamine and inadequate prenatal care. The maternal history is notable for a reported diagnosis of bipolar affective disorder, prostitution, and being unhoused at the time of delivery. Tony received antibiotics after delivery for presumed newborn infections. As an infant, he had kidney reflux, low serum ferritin, insomnia, and failure to thrive. Regarding developmental milestones, Tony was sitting up at 7 months, walking at 14 months, talking at 18 months, and speaking in full sentences by 24 months.

When he presented to the psychiatric service at age 3 years, behavioral problems included irritability with destructive rages, excessive fears, separation anxiety, hyperactivity, and impulsivity with a lack of awareness of danger to the extent that he required a safety harness when in public and security locks in the home because of repeated elopements. Tony also had at the time of his initial presentation significant defiance, extreme tantrums, violent aggressive outbursts, cognitive rigidity, repetitive behaviors, resistance to change, frequent nondirected vocalizations, and self-injurious behaviors including slapping himself on the head and biting of his hands and feet. Review of systems includes complaints of frequent abdominal and neck pain, persistent insomnia, night terrors, restrictive eating habits with poor weight gain, and reduced sensitivity to pain. Treatment history included gabapentin and subsequently divalproex for seizure-like episodes (despite negative EEG) described as frequent staring spells with repetitive biting of his lips. Psychotropic medications were risperidone for irritability associated with autism and clonidine extended release for ADHD. He also took melatonin for sleep.

During his well-child check at the age of 5 years, Tony is making good progress from a developmental standpoint, has age-appropriate expressive and receptive language skills, is fluent in both English and Spanish, is able to recite the alphabet, counts to 20, has learned to swim, and is demonstrating interest in planets and astrology. He is reported to have a secure attachment to his adoptive parents and is described as emotionally sensitive, caring, kind, considerate, and empathetic. He has good eye contact and can read facial expressions. He is affectionate and protective of his infant sibling, his biological sister, who is also adopted by his parents and now living in the home.

Tony made an excellent adjustment to the start of kindergarten and up until this point was responding positively to his psychotropic medication regimen. But then at age five and a half, Tony experienced sudden and unexplained behavioral worsening, which was followed by the onset of recurrent vomiting and refusal to eat or drink. Comprehensive medical workup including upper endoscopy and biopsy resulted in a diagnosis of eosinophilic esophagitis (EoE). What would be your next step?

托尼是一个五岁半的男孩，自从他出生以来，他一直是您初级保健诊所的患者。他从 3 岁起就因行为问题接受儿童和青少年精神科医生的治疗，并被诊断患有自闭症谱系障碍、注意力缺陷/多动障碍 (ADHD) 混合型、焦虑症和失眠症。今天，他主诉过去两周内反复呕吐和拒绝进食或饮水，目前处于脱水状态。

托尼 (Tony) 在孕 30 周时通过阴道分娩出生，出生体重为 4 磅 15 盎司，出生时被描述为反应迟钝。已知存在产前接触烟草和甲基苯丙胺且产前护理不足的情况。值得注意的是，她的母亲曾被诊断患有双相情感障碍、卖淫和分娩时无家可归。托尼在分娩后因推测的新生儿感染而接受了抗生素治疗。婴儿时期，他患有肾脏反流、血清铁蛋白低、失眠和发育迟缓。至于发育里程碑，托尼在 7 个月时能坐起来，在 14 个月时能走路，在 18 个月时能说话，在 24 个月时能说出完整的句子。

当他 3 岁时到精神科就诊时，行为问题包括易怒、破坏性愤怒、过度恐惧、分离焦虑、多动以及缺乏危险意识的冲动，以至于在公共场合和外出时需要系上安全带。由于屡次私奔，家里被锁上了安全锁。托尼在初次陈述时还表现出明显的反抗、极端发脾气、暴力攻击性爆发、认知僵化、重复行为、抵制改变、频繁的非定向发声以及自残行为，包括拍打自己的头和咬自己的手和脚。系统审查包括频繁的腹部和颈部疼痛、持续失眠、夜惊、体重增加不良的限制性饮食习惯以及对疼痛的敏感性降低的主诉。治疗史包括加巴喷丁和随后的双丙戊酸治疗癫痫样发作（尽管脑电图呈阴性），描述为频繁凝视并反复咬嘴唇。精神药物包括治疗自闭症相关烦躁的利培酮和治疗多动症的可乐定缓释药物。他还服用褪黑激素来帮助睡眠。

在 5 岁时的儿童健康检查中，托尼从发育的角度来看取得了良好的进步，具有适合年龄的表达和接受语言能力，英语和西班牙语流利，能够背诵字母表、数数20 岁，学会了游泳，并对行星和占星学表现出兴趣。据报道，他对养父母有一种安全的依恋，情绪敏感、有爱心、善良、体贴、善解人意。他目光接触良好，能读懂面部表情。他深情地保护着他的小弟妹，也就是他的亲生妹妹，她也被他的父母收养，现在住在家里。

托尼在幼儿园开始时做出了出色的调整，直到此时为止，他对他的精神药物治疗方案做出了积极的反应。但在五岁半的时候，托尼突然出现了不明原因的行为恶化，随后出现反复呕吐和拒绝进食或饮水。包括上消化道内窥镜检查和活检在内的综合医学检查结果诊断为嗜酸性粒细胞性食管炎（EoE）。您的下一步计划是什么？