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Singh A, Kleinhenz J, Brill H, Fahey L, Silvester JA, Sparks B, Verma R, Lee D, Mallon D, Leonard MM. A Clinician's Guide to Gluten Challenge. J Pediatr Gastroenterol Nutr 2023; 77:698-702. [PMID: 37608439 PMCID: PMC10872809 DOI: 10.1097/mpg.0000000000003923] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Gluten challenge is an essential clinical tool that involves reintroducing or increasing the amount of gluten in the diet to facilitate diagnostic testing in celiac disease (CD). Nevertheless, there is no consensus regarding the applications of gluten timing, dosing, and duration in children. This review aims to summarize the current evidence, discuss practical considerations, and proposes a clinical algorithm to help guide testing in pediatric patients. Childhood development, social circumstances, and long-term health concerns must be considered when identifying a candidate for gluten challenge. Based on previous studies, the authors suggest baseline serology followed by a minimum of 3-6 grams of gluten per day for over 12 weeks to optimize diagnostic accuracy for evaluation of CD. A formal provider check-in at 4-6 weeks is essential so the provider and family can adjust dosing or duration as needed. Increasing the dose of gluten further may improve diagnostic yield if tolerated, although in select cases a lower dose and shorter course (6-12 weeks) may be sufficient. There is consensus that mild elevations in celiac serology (<10 times the upper limit of normal) or symptoms, while supportive are not diagnostic for CD. Current North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines recommend histologic findings of intraepithelial lymphocytosis, crypt hyperplasia, and villous atrophy as the accurate and most appropriate endpoint for gluten challenge.
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Affiliation(s)
- Arunjot Singh
- Division of Gastroenterology, Hepatology & Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA
- University of Pennsylvania – Perelman School of Medicine, Philadelphia, PA
| | - Julia Kleinhenz
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, The University of Chicago, Chicago, IL
| | - Herbert Brill
- Division of Gastroenterology and Nutrition, McMaster Children’s Hospital, Hamilton, Ontario, Canada
- Department of Pediatrics, William Osler Health System, Etobicoke, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Fahey
- Division of Gastroenterology, Hepatology & Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA
- University of Pennsylvania – Perelman School of Medicine, Philadelphia, PA
| | - Jocelyn A. Silvester
- Celiac Research Program, Harvard Medical School, Boston, MA
- Department of Medicine, Boston Children’s Hospital, Boston, MA
| | - Brandon Sparks
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Ritu Verma
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, The University of Chicago, Chicago, IL
| | - Dale Lee
- Department of Pediatrics, Division of Gastroenterology, Seattle Children’s Hospital and University of Washington, Seattle, WA
| | - Daniel Mallon
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, OH
| | - Maureen M. Leonard
- Celiac Research Program, Harvard Medical School, Boston, MA
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA
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