Celiac disease in children
Dr. Lev Dorfman wrote this professional chapter , Who is a pediatrician and specializes in pediatric gastro who I greatly appreciate his professionalism. I just styled a bit to suit the spirit of the site …
So what is celiac disease?
Celiac disease is a disease that belongs to the group of autoimmune diseases, that is, conditions in which the body attacks itself.
The disease is caused by exposure to gluten in combination with hereditary and environmental factors.
Gluten is a protein found in wheat in barley and rye. Without exposure to gluten celiac disease can not develop.
What causes celiac disease?
In people with celiac disease, exposure to gluten-containing foods causes an immune response that damages the small intestinal mucosa.
The mucosal damage disrupts the absorption of nutrients that are important to the body and as a result can be caused that is secondary to the various nutritional deficiencies.
What are the symptoms of celiac disease in children?
The previous Hebrew name of the disease, tummy tuck, hinted at the common representation in the past – children with a swollen abdomen. Because of the high awareness of the disease and early diagnosis in recent years, we are seeing fewer and fewer children coming to the clinic with this clinical picture and the disease is detected earlier today and with other diverse representations.
Some children are diagnosed without any symptoms, others will be represented with nonspecific abdominal pain, diarrhea or alternatively constipation, deficiency of nutrients (mainly iron deficiency anemia), bone density damage, growth disorder (breakage of weight or height percentages), vomiting and more.
As awareness of the disease increases over the years, many pediatricians perform targeted blood tests on suspicion of celiac disease and there are increasing cases where the disease is diagnosed early with or without symptoms.
Prevalence of celiac disease in the population:
In Israel, the prevalence is probably approaching 1% of the population. That is, there is no school in Israel where there are no number of children with celiac disease. Some have been diagnosed and some have not yet. There is a thought that even in Western countries, most celiac patients in the population are still undiagnosed, and it is said that the patients diagnosed constitute the "tip of the iceberg".
Celiac disease is 2 to 3 times more common in women.
Who is at risk for developing celiac disease?
There are different populations where celiac disease is more common. So common that it is recommended in these populations to perform screening tests to detect the disease and they are:
- First-degree relatives of a diagnosed celiac patient
- Children with IgA antibody deficiency
- Other autoimmune diseases such as thyroid disease, juvenile diabetes, arthritis and more
- Genetic diseases such as Down Syndrome, Turner Syndrome and Williams Syndrome.
Who should be tested for celiac disease?
Except for the conditions listed above, because of the prevalence of the disease and the variety of different symptoms that celiac disease can cause, it is worth thinking about a possible diagnosis of celiac disease in the following situations:
- Children with gastrointestinal symptoms: Chronic diarrhea / intermittent diarrhea, Chronic constipation Unresponsive to treatment, abdominal pain, abdominal bloating, nausea and recurrent vomiting.
- Children suffering from non-gastrointestinal symptoms: weight loss, lack of prosperity, growth retardation, delayed puberty, chronic weakness, restlessness, joint pain, chronic anemia, bone density disorder, recurrent fractures, recurrent aphthae (ulcers) in the oral cavity, rash Typically, disruption of the outer tooth layer and disruption of liver enzymes.
Of course, one of the conditions mentioned above does not necessarily mean that there is a diagnosis of celiac disease that is hidden and it is only a suspicion, but in light of the incidence of the disease and the relatively simple initial clarification (blood test), its performance should be considered in consultation with the pediatrician.
Celiac and heredity
The genetic component of the disease can be learned from the fact that it is more common among first-degree family members. People with certain genes are known to be more likely to develop celiac disease.
However, it is important to emphasize that the genetic component is only part of the combination of components necessary for the onset of the disease and therefore most relatives of a celiac patient, do not suffer from celiac disease.
How is celiac disease diagnosed?
Let’s start with the fact that the person who diagnoses the disease is a Gastroenterologist. Many times the suspicion and clarification will start at the pediatrician through blood tests that check the level of typical antibodies of the anti-TTG type and the anti-EMA type.
These are IgA antibodies, so it is important to make sure that the boy or girl who is being tested does not belong to a group of children who are deficient in IgA antibodies. A situation that will cause us to get wrong answers. Interestingly, in celiac patients in particular, the incidence of IgA antibody deficiency is higher.
This is why the doctor who sends the test for the specific antibodies to celiac will always also check the amount of IgA antibodies at the same time. In some labs this test is done automatically, when a celiac test is sent to the lab.
In patients with IgA deficiency, the initial diagnosis is based on other anti-DGP antibodies.
Depending on the type of antibodies in the blood and their level, the existence of the disease can be suspected.
Are gastroscopy and biopsy required to diagnose celiac disease in children?
Until a few years ago the diagnosis of the disease was always based on performing a gastroscopy. Gastroscopy is a relatively short test in which a flexible tube with a camera is inserted through the mouth, transferred to the esophagus, stomach and the beginning of the small intestine (duodenum) and during which samples are taken from the gastrointestinal tract (biopsies). A biopsy of a celiac patient has a characteristic picture of the flattening of the intestinal lining of the duodenum.
It is very important to eat food that contains gluten while performing blood tests for celiac antibodies as well as until the moment of gastroscopy. Avoiding gluten will mislead the lab results and biopsy results, and will not allow a correct diagnosis of the condition.
Several years ago, the European Association of Pediatric Gastroenterology published clinical guidelines that allowed the diagnosis of celiac disease based on symptoms, a certain level of antibodies, and genetic testing, so that for the first time some celiac patients were diagnosed without the need for a gastroscopy.
This year (2020) new guidelines have been published, which allow in certain cases to determine a diagnosis of celiac disease in children, not only without the need for gastroscopy, but also without the need for genetic testing and in children with no symptoms at all.
It is important to remember that a diagnosis of celiac disease is Lifetime diagnosis , And this should be taken seriously. It is therefore important to arrive at a diagnosis in the most certain way, so that no questions arise about the correctness of the diagnosis later on. For this, it is necessary to consult a specialist pediatric gastroenterologist who, together with the family and the child and in accordance with the results of the inquiry, will decide on the best way of diagnosis.
Is it possible to diagnose celiac disease at any age?
Indeed, celiac disease can be diagnosed at any age. It is not uncommon for cases where after a diagnosis in one of the children, one of the parents is also diagnosed. It is important to note that a negative result among children at risk (siblings of a child with celiac disease) is gratifying, but does not negate 100% that they will not develop the disease later. Therefore, these children should continue to be tested for celiac disease once a year. According to recent articles, it is probably best to continue to be tested every year until the age of 12 years.
Another interesting statistic is that celiac tests are less reliable in young babies (under one and a half years old).
Even in these children, if the results of the blood tests for antibodies against celiac disease are negative, it is worth repeating the tests later if there is still a clinical suspicion.
What is a potential celiac disease?
This is a condition in which despite the presence of typical antibodies in the blood, the biopsy results are normal / do not allow diagnosis of celiac disease. These children have the potential to develop celiac disease in the future and require gastroenterological follow-up, with continued exposure to gluten. During follow-up, if the antibodies continue to be positive or if their level even rises, repeat gastroscopy will be performed to reassess whether there is a diagnosis of celiac disease or not.
What is the genetic test for celiac disease?
Celiac disease occurs in people who have certain types of genes (HLA). These are genes that are present in about 40% of the population, so a positive test (ie the presence of the genes) says nothing, except the possibility that the same boy / girl can develop celiac disease.
If the test did not find the presence of certain genes from the HLA group – then it can in very high percentages rule out the disease.
I want to say that this is a test that can rule out the disease, but does not help us diagnose it, and therefore is almost never used.
The test is performed only privately and its use is not common in children.
What is the treatment for celiac disease in children?
The good news is that there is a treatment and it is called a gluten-free diet. Although it is not a drug, but the effect of this diet is curative.
It is very important to follow a gluten-free diet in the best possible way and educate the children to check for themselves the foods they eat.
Fortunately, we live in an age where there are many and varied substitutes and this is a market that is only growing. The variety of options allows for a varied and satisfying diet.
It is important to adhere to foods that are explicitly stated to be gluten-free, meaning they contain gluten in an amount of less than 20 PPM. What are those PPMs? This is an abbreviation of Parts Per Million and refers to the manufacturer’s commitment that there is less than 20 milligrams of gluten in one kilogram of product.
What about products that are labeled "may contain gluten"? As their name implies they are. These products may indeed contain gluten and should be avoided.
During the medical evaluation of celiac patients, an examination will be performed of nutritional deficiencies caused as a result of the disease, which are supplemented as supplements if necessary.
It is important to emphasize that in patients with celiac disease that is unbalanced There is a little chance of developing a lymphoma-type cancerous growth.
This is one of the reasons why awareness and early diagnosis are needed, as well as maintaining a gluten-free diet in the diagnosed.
Adherence to a gluten-free diet restores the condition and the increased risk of lymphoma passes.
Is the damage of celiac disease reversible?
Yes. Adherence to a gluten-free diet causes recovery and recovery of intestinal tissue. In other words, this is a reversible condition, which, although it requires a significant change in lifestyle, allows for complete recovery of the tissue. It should be emphasized that exposure to gluten, even if short and not reflected in an increase in antibodies in the blood test, is of health significance. Therefore, a gluten-free diet should be adhered to unconditionally.
Is celiac disease transient?
An impression can be created in children and parents that after adhering to a gluten-free diet – and after they feel good and no hint of celiac disease can be detected in the blood tests, the disease has passed.
Unfortunately, this is a mistake.
It is very important to understand that celiac disease is a diagnosis that accompanies the patient for life. With each re-exposure to gluten, the autoimmune process that causes damage to the liver will begin againWith all the implications outlined above. The same damage takes time to repair. We will also mention that unbalanced celiac disease has many consequences outside the digestive system, including damage to bone density, damage to growth and fertility, and more.
Hence the importance of adhering to a gluten-free diet.
Is it necessary to follow up on the diagnosis of celiac disease in children?
Definitely. Patients with celiac disease should be under gastroenterological follow-up and usually visit one clinic every six months to a year. As part of the follow-up, the typical antibody levels are examined and a nutritional assessment is performed.
Celiac disease proves that indeed "man will not live on bread alone" (Deuteronomy 8: 3), and it is possible that David Ben-Gurion also had an awareness of celiacs when he said "I have no bread, I have a vision."
A low suspicion threshold is required for diagnosing celiac disease in children. It is a disease with an excellent prognosis in those children who adhere to a gluten-free diet, which allows for a full and happy life.
In addition, previously the IDF avoided recruiting security service candidates with a diagnosis of celiac disease, now all celiac patients are recruited with the matching of a disability clause, which allows them to serve full service in a wide variety of roles.
In recent years, the awareness of parents as well as of pediatricians for the disease has risen, leading to early diagnosis in many children. However, it is clear that there are many children (and adults) among us who are not yet diagnosed.
Additional relevant information on the Celiac Israel website https://www.celiac.org.il/