There is an increasing amount of evidence to suggest that chronic oesophageal inflammation and motility disorders play a more significant role in oesophageal food impaction (EFI) in children compared to structural defects. The authors conducted a retrospective study of children (<18 years) who presented to the emergency department of their tertiary institution with EFI. Between 1 November 2006 and 31 October 2013, 48 children presented with the condition. Of these, 13 had a second foreign body (mostly coins) along with the food impaction and thus were excluded; 35 patients were included (mean age 12.3 years). Rigid oesophagoscopy was used in the 14 (40%) cases managed by otolaryngology, while flexible oesophagoscopy was used in 21 (60%) cases managed by paediatric gastroenterology or general surgery. Thirty patients had a biopsy at the time of food bolus removal, of which four showed normal histology while 26 (87%) showed eosinophilic oesophagitis (EoE). Five (14%) of the 35 cases were due to neurological or motility disorders and four (12%) had prior oesophageal surgery. Despite normal oesophageal appearances of six cases, two out of four of those biopsied had EoE. Linear furrowing on endoscopy increased the odds of EoE (OR 26.66, P<0.001). The authors built a multivariable logistic regression model to predict the presence of EoE. Only linear furrowing remained a significant risk factor in each model. The authors conclude that most paediatric EFI cases are associated with EoE and thus EoE must be considered in all EFI cases in children. Oesophageal biopsies should be strongly considered at the time of endoscopic management.