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Krueger A, Fahey L, Sun Q, Regis S, Khavari N, Jericho H, Badalyan V, Absah I, Verma R, Leonard MM, Weisbrod V, Hajjat T, Lee D, Shull M, Silvester JA, Mallon D. Clinical presentation and factors associated with gluten exposure in children with celiac disease. J Pediatr Gastroenterol Nutr 2024. [PMID: 39149789 DOI: 10.1002/jpn3.12321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/17/2024] [Accepted: 06/22/2024] [Indexed: 08/17/2024]
Abstract
OBJECTIVES The prevalence of celiac disease (CeD) is increasing, yet it is still underdiagnosed, in part because of its heterogeneous presentation. Diagnostic criteria are evolving and management with strict adherence to a gluten-free diet is challenging for many. We aimed to characterize the clinical presentation of CeD among a large multicenter cohort of pediatric patients and to identify factors associated with gluten-free diet adherence. METHODS Patients with CeD aged 0-18 years were recruited from 11 United States health centers. Parents completed surveys about gluten-free diet adherence and patient electronic health records were reviewed. Logistic regression analyses were performed to identify risk factors associated with gluten exposure. RESULTS Charts were reviewed for 460 children with a median age of 6.4 years. Abdominal pain was reported in 57% of the cohort, but diverse symptoms were identified. Parent surveys were completed for 455 participants. Sixty-five (14%) participants were at high risk for gluten exposure based on parental reports of weekly or daily gluten exposure or eating gluten by choice in the past year. Participants under the age of 5 years had a lower risk of gluten exposure, while participants without repeat serology testing 18 months after initial diagnosis were at higher risk of gluten exposure. CONCLUSIONS In a large, multicenter cohort of pediatric CeD patients, clinical presentation is highly variable, necessitating a high index of suspicion to make a diagnosis. Parent surveys indicate that 14% of patients are at high risk of gluten exposure, with patient age and lack of close follow-up associated with gluten-free diet adherence.
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Affiliation(s)
- Andrew Krueger
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Lisa Fahey
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Qin Sun
- Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stephanie Regis
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nasim Khavari
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Celiac Disease Center, Stanford University, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Hilary Jericho
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Celiac Disease Center, Stanford University, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Vahe Badalyan
- Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Imad Absah
- Division of Pediatric Gastroenterology Hepatology and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ritu Verma
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago, Chicago, Illinois, USA
| | - Maureen M Leonard
- Department of Pediatrics, Harvard Medical School, Division of Pediatric Gastroenterology and Nutrition, Mass General Hospital for Children, Boston, Massachusetts, USA
- Harvard Medical School, Center for Celiac Research and Treatment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vanessa Weisbrod
- Department of Pediatrics, Harvard Medical School, Harvard Celiac Research Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Temara Hajjat
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dale Lee
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mary Shull
- Department of Pediatrics, Colorado Center for Celiac Disease, Digestive Health Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jocelyn A Silvester
- Department of Pediatrics, Harvard Medical School, Harvard Celiac Research Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniel Mallon
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Klöti S, Schaad J, Spalinger J, Schibli S, Hart L, Sokollik C, Righini-Grunder F. Outcome in pediatric celiac disease is independent of the diagnostic approach in patients with high antibody levels. J Pediatr Gastroenterol Nutr 2024; 79:84-91. [PMID: 38769762 DOI: 10.1002/jpn3.12251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/31/2024] [Accepted: 05/09/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVES European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines enable the diagnosis of celiac disease (CD) without biopsies in patients with immunoglobulin A (IgA)-antibodies against tissue transglutaminase (TGA-IgA) ≥ 10× the upper limit of normal (ULN) and positivity of endomysial antibodies in a second blood sample. Limited data exist comparing the biopsy versus the nonbiopsy diagnostic approach regarding long-term outcomes in CD patients. Our study aimed to investigate the influence of the diagnostic approach on adherence to gluten-free diet (GFD), serological remission (defined as normalization of TGA-IgA during follow-up (FU)) and clinical remission in CD patients with TGA-IgA ≥ 10× ULN. METHODS Retrospective multicenter study. Patients with CD and TGA-IgA ≥ 10× ULN at diagnosis were included in the study. Patients with confirmed diagnosis by biopsy were compared to patients diagnosed by nonbiopsy approach using univariate analysis, Kaplan-Meier survival curve, and logistic regression models. RESULTS A total of 282 CD patients (192 [68.1%] in the biopsy group; 90 [31.9%] in the nonbiopsy group) were analyzed. The median time to normalization of TGA-IgA was 16.5 months [interquartile range, IQR: 13, 28] in the biopsy and 15 months [IQR: 12, 26] in the nonbiopsy group; p = 0.14). Rates of normalized TGA-IgA at first to third-year FU were comparable between both groups. Adherence to GFD did not seem to be influenced by the diagnostic approach. CONCLUSIONS The nonbiopsy approach is not inferior to the biopsy approach in terms of adherence to GFD and serological remission in patients with CD.
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Affiliation(s)
- Simon Klöti
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital of Central Switzerland, Lucerne, Switzerland
| | - Joachim Schaad
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital of Central Switzerland, Lucerne, Switzerland
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Spalinger
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital of Central Switzerland, Lucerne, Switzerland
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Susanne Schibli
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lara Hart
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, McMaster University, Hamilton, Ontario, Canada
| | - Christiane Sokollik
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Franziska Righini-Grunder
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital of Central Switzerland, Lucerne, Switzerland
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Abstract
Celiac disease (CeD) is a chronic immune-mediated enteropathy, which occurs in genetically predisposed individuals by the ingestion of gluten proteins present in wheat, barley and rye. The global pooled prevalence of CeD is 0.7% and it has been reported from nations all around the globe and can affect individuals of any age. It has a wide clinical spectrum ranging from being asymptomatic to being symptomatic with severe manifestations. Though initial descriptions of CeD focused on the classical presentation with gastrointestinal manifestations, in recent years it has been found that more patients have non-classical manifestations such as anemia, osteoporosis, increased transaminases, failure to thrive or short stature. The definitive diagnosis of CeD is based on a combination of clinical history, serologic testing with/without examination of duodenal biopsies. The preferred initial serologic test regardless of age for the detection of CeD is the tissue transglutaminase (IgA anti-tTG). Children with a high tTG-IgA (≥10 ULN) AND a positive anti-endomysial IgA antibody (EMA) can be diagnosed to have CeD without the need for duodenal biopsies. The rest should undergo biopsies with at least 4 biopsies from the distal duodenum and at least 1 from the bulb. A correctly orientated biopsy showing increased intraepithelial cells and a villous to crypt ratio of <2 is suggestive of CeD. The management of CeD is a lifelong complete dietary avoidance of gluten. IgA-TGA acts as a surrogate marker for healing of the small-bowel mucosa and should be performed every 6 mo until normalization and then every 12-24 mo thereafter.
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Affiliation(s)
- Rishi Bolia
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, 501, Stanley Street, South Brisbane, QLD, 4101, Australia.
| | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, 501, Stanley Street, South Brisbane, QLD, 4101, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
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Singh SK, Srivastava A. Transition of Care in Celiac Disease. Indian J Pediatr 2023; 90:1142-1148. [PMID: 37273133 DOI: 10.1007/s12098-023-04611-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/17/2023] [Indexed: 06/06/2023]
Abstract
Celiac disease (CD) is a gluten related disorder which affects all age-groups and occurs in genetically susceptible population after introduction of gluten in diet. The worldwide prevalence of CD is ~1% and it is higher in certain "at-risk groups". The clinical features are variable, ranging from classical diarrhea to an asymptomatic state. Diagnosis requires serology and duodenal histology although a non-biopsy diagnosis is recommended by European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) for a select group of children. Treatment of CD is with a life-long strict gluten free diet (GFD) along with correction of nutritional deficiencies. Regular follow-up to assess compliance and efficacy of GFD is mandatory. Non-responsive CD needs evaluation by a specialist as it can be due to incorrect diagnosis, poor dietary compliance, coexisting conditions like small bowel bacterial overgrowth, pancreatic insufficiency etc. and lastly, refractory CD. Most patients diagnosed as CD in childhood receive no medical or dietary supervision after transition to adulthood and nearly a third are non-compliant to GFD. No requirement of medications, patient's perception of understanding GFD and absence of symptoms with intermittent non-compliance leads to neglect of care after transition. Poor dietary adherence leads to nutritional deficiencies, osteoporosis, fertility issues and risk of malignancy. It is mandatory that the patients know about CD, need of strict GFD, regular follow-up, disease complications, and are capable of communicating with the health-care personnel before transition. Formulating a phased transition care program with joint pediatric and adult clinics is required for a successful transition and improving the long-term outcome.
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Affiliation(s)
- Sumit K Singh
- Department of Pediatrics, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
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Simón E, Molero-Luis M, Fueyo-Díaz R, Costas-Batlle C, Crespo-Escobar P, Montoro-Huguet MA. The Gluten-Free Diet for Celiac Disease: Critical Insights to Better Understand Clinical Outcomes. Nutrients 2023; 15:4013. [PMID: 37764795 PMCID: PMC10537989 DOI: 10.3390/nu15184013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
The gluten-free diet (GFD) remains a complex paradigm in managing celiac disease (CeD) in children and adults, and there are many reasons why GFD adherence should be strict to improve outcomes. However, this is a challenging task for patients, since they need to have access to quality healthcare resources that facilitate optimal GFD adherence. Understanding the strengths and weaknesses of the GFD, tackling coexisting nutritional deficiencies, and dealing with complex situations, such as seronegative CeD or non-responsive CeD, all require the involvement of a multidisciplinary team. The short- and long-term follow-up of CeD patients should preferably be performed by a combined Gastroenterology and Nutrition service with well-defined quality standards and the multidisciplinary involvement of physicians, nurses, dietitians, and psychologists. Nutritional advice and counseling by an experienced dietitian can reduce the costs associated with long-term follow-up of CeD patients. Likewise, psychological interventions may be essential in specific scenarios where implementing and sustaining a lifelong GFD can cause a significant psychological burden for patients. This manuscript aims to provide guidelines to improve clinical practice in the follow-up and monitoring of CeD patients and provide information on the nutritional risks of an ill-advised GFD. Clinicians, biochemists, food technologists, dietitians, and psychologists with a global view of the disease have been involved in its writing.
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Affiliation(s)
- Edurne Simón
- GLUTEN3S Research Group, Department of Nutrition and Food Science, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain
| | - Marta Molero-Luis
- Laboratory of Gastroenterology and Trace Elements, Department of Laboratory Medicine, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Ricardo Fueyo-Díaz
- PROSAM Research Group (S69-23R), Department of Psychology and Sociology, Universidad de Zaragoza, 50009 Zaragoza, Spain;
| | - Cristian Costas-Batlle
- Department of Nutrition and Dietetics, Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD9 6DA, UK;
| | - Paula Crespo-Escobar
- ADViSE Research Group, Department of Health Science, European University Miguel de Cervantes, 47012 Valladolid, Spain;
- Department of Nutrition and Obesity, Hospital Recoletas Campo Grande, 47007 Valladolid, Spain
| | - Miguel A. Montoro-Huguet
- Gastroenterology, Hepatology and Nutrition Unit, University Hospital San Jorge, 22004 Huesca, Spain
- Department of Medicine, Faculty of Health and Sport Sciences, University of Zaragoza, 22002 Huesca, Spain
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain
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Wessels M, Auricchio R, Dolinsek J, Donat E, Gillett P, Mårild K, Meijer C, Popp A, Mearin ML. Review on pediatric coeliac disease from a clinical perspective. Eur J Pediatr 2022; 181:1785-1795. [PMID: 35034201 DOI: 10.1007/s00431-022-04379-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/19/2022]
Abstract
Coeliac disease is an immune-mediated condition characterized by chronic inflammation of the small bowel with villous atrophy driven by gluten ingestion in genetically predisposed individuals. It occurs frequently in both children and adults, affecting 1-4% of the population. The disease is associated with both gastrointestinal and extra-intestinal symptoms related to malabsorption and/or immune activation, and autoantibodies to tissue transglutaminase. Removal of gluten from the diet results in resolution of symptoms and enteropathy in the majority of patients. A good diagnostic work-up is important to avoid unnecessary restrictive diets in children. In this review on pediatric coeliac disease, we address epidemiology including predisposing environmental factors and possible preventive strategies, as well as the clinical presentation, diagnosis and follow-up. What is Known: •Primary prevention of coeliac disease is not possible; however, secondary prevention by targeting high-risk groups is recommended. •The diagnosis is safe without duodenal biopsies if specific conditions are met, also in asymptomatic children. What is New: •HLA-DQ typing is not routinely required for the diagnosis, whereas it can rule out coeliac disease if HLA-DQ2 and HLA-DQ8 are absent. •Follow-up could be improved by a more rational use of (laboratory) tests, increased intention to dietary compliance and quality of life.
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Affiliation(s)
- Margreet Wessels
- Department of Pediatrics, Rijnstate Hospital, Arnhem, the Netherlands.
| | - Renata Auricchio
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Jernej Dolinsek
- Department of Pediatrics, Hepatology and Nutrition Unit and Medical Faculty, Dept. of Pediatrics, University Medical Centre Maribor, GastroenterologyMaribor, Slovenia
| | - Ester Donat
- Pediatric Gastroenterology and Hepatology Unit, Celiac Disease and Digestive Immunopathology Unit, Hospital Universitari I Politècnic La Fe, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Peter Gillett
- Department of Pediatric Gastroenterology, Royal Hospital for Children and Young People, Scotland, Edinburgh, UK
| | - Karl Mårild
- Department of Pediatrics, Institute of Clinical Sciences, Department of Pediatric Gastroenterology, Sahlgrenska Academy, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Caroline Meijer
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Alina Popp
- University of Medicine and Pharmacy ''Carol Davila'', National Institute for Mother and Child Health, Bucharest, Romania
| | - M Luisa Mearin
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
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Letter to the Editor for the article "20-year follow-up study of celiac patients identified in a mass school screening: compliance to gluten-free diet and autoimmunity". J Pediatr Gastroenterol Nutr 2022; 74:e101. [PMID: 35703950 DOI: 10.1097/mpg.0000000000003351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Abstract
Celiac disease is an autoimmune enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. In patients with suspected celiac disease, measurement of serum IgA antibodies to tissue transglutaminase-2 has a high sensitivity and specificity and is the first screening test that should be ordered. The diagnosis of celiac disease is based on the presence of mucosal damage in small intestinal biopsies in patients having circulating celiac disease-specific antibodies. Celiac disease management includes lifelong adherence to a gluten-free diet and continuous long-term follow-up.
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Affiliation(s)
- Jennifer Jimenez
- Division of Pediatric Gastroenterology and Nutrition, Jersey Shore University Medical Center, K. Hovnanian Children's Hospital, Hackensack Meridian Health, 19 Davis Avenue, 5th Floor, Neptune, NJ 07753, USA
| | - Beth Loveridge-Lenza
- Division of Pediatric Gastroenterology and Nutrition, Jersey Shore University Medical Center, K. Hovnanian Children's Hospital, Hackensack Meridian Health, 19 Davis Avenue, 5th Floor, Neptune, NJ 07753, USA
| | - Karoly Horvath
- Florida State University, Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando Health, 60 W Gore Street, Orlando, FL 32806, USA.
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