Balancing health benefits and social sacrifices: a qualitative study of how screening-detected celiac disease impacts adolescents' quality of life

Vulnerability in Children with Celiac Disease: Findings from a Scoping Review

(1) Background: The scientific literature highlights that children diagnosed with celiac disease (CD) are at a heightened risk of experiencing physical, psychological, and social challenges, impacting their overall healthy childhood development. However, there remains a lack of a clear understanding regarding the factors that contribute to this vulnerability. The purpose of this study is to analyze and map the evidence on the sociopsychosomatic vulnerability of these children and identify gaps in this topic. (2) Methods: Following Joanna Briggs Institute's guidelines for scoping reviews, we executed a detailed search of key electronic databases and explored the grey literature to capture a broad spectrum of studies. Our focus was on identifying research that looked into the multiple dimensions of vulnerability-physical, psychological, and social-in children with CD. We included a diverse range of study designs as well as systematic reviews, ensuring a comprehensive analysis. The selection process was stringent, utilizing clearly defined inclusion and exclusion criteria. (3) Results: We identified 61 studies that met our inclusion criteria. The review highlighted significant adverse health outcomes in children with CD and elucidated various individual and environmental determinants that influenced these vulnerabilities. It also underscored the lack of assessment tools to evaluate the risk of health problems in this population. (4) Conclusions: The findings underscore a critical need for further research to deepen our understanding of the vulnerabilities associated with CD in children. Developing targeted assessment tools will be crucial in stratifying health risks and enhancing care strategies for this vulnerable population.

Love beyond gluten: self-esteem, illness identity, and social support in romantic rejection concerns among adolescents with celiac disease

Introduction

Fear of stigmatization, high perceived partner burden, or refraining from self-disclosure may manifest in romantic rejection concerns among adolescents with celiac disease (CD), potentially impacting their health-related quality of life (HRQOL). This study examined the prevalence, predictors, and consequences of romantic rejection concerns among adolescents and young adults with CD.

Methods

A cross-sectional online survey was conducted among 165 German adolescents and young adults (aged 14-22) with self-reported CD. Participants completed measures of romantic rejection concerns, illness identity, self-esteem, peer support, and CD-specific HRQOL.

Results

Participants reported moderate levels of concerns about the impact of CD on their romantic relationships, with no significant gender differences. Participants involved in romantic relationships expressed lower concerns of rejection, but similar preference for a "gluten-free partner." Hierarchical regression analysis revealed that higher illness acceptance and peer support predicted lower rejection concerns. Significant interactions emerged between self-esteem and illness acceptance, and between self-esteem and peer support. Higher illness acceptance predicted fewer rejection worries only among those with high self-esteem, while peer support played a mitigating role only for those with low self-esteem. Romantic rejection concerns significantly predicted lower CD-specific HRQOL across all domains.

Discussion

Anxieties about CD's impact on romantic relationships are prevalent among adolescents and may hinder their HRQOL. The findings highlight the complex interplay between self-esteem, illness identity, and social support in shaping romantic concerns. Targeted interventions focusing on peer support and fostering positive illness identity are recommended to alleviate rejection fears and improve HRQOL among youth with CD.

Global Approach to Follow-Up of Celiac Disease

Celiac disease, an autoimmune disorder induced by the ingestion of gluten, affects approximately 1.4% of the population. Gluten damages the villi of the small intestine, producing symptoms such as abdominal pain, bloating and a subsequent loss of nutrient absorption, causing destabilization of the nutritional status. Moreover, gluten can trigger extra intestinal symptoms, such as asthma or dermatitis, but also mental disorders such as depression or anxiety. Moreover, people suffering from celiac disease sometimes feel misunderstood by society, mainly due to the lack of knowledge about the disease and the gluten-free diet. Thus, the treatment and follow-up of patients with celiac disease should be approached from different perspectives, such as the following: (1) a clinical perspective: symptomatology and dietary adherence monitorization; (2) nutritional assessment: dietary balance achievement; (3) psychological assistance: mental disorders avoidance; and (4) social inclusion: educating society about celiac disease in order to avoid isolation of those with celiac disease. The aim of this narrative review is to gain deep insight into the different strategies that currently exist in order to work on each of these perspectives and to clarify how the complete approach of celiac disease follow-up should be undertaken so that the optimum quality of life of this collective is reached.

One-Year Outcomes Among Children Identified With Celiac Disease Through a Mass Screening Program

BACKGROUND & AIMS

Celiac disease (CD) mass screening remains controversial in part because of a paucity of data to support its benefit. The Autoimmunity Screening for Kids study is a mass screening study for pediatric CD and type 1 diabetes in Colorado.

METHODS

This study prospectively follows up children ages 1 to 17 years who screened positive for tissue transglutaminase IgA autoantibodies in the Autoimmunity Screening for Kids study subsequently referred for diagnostic evaluation. Children diagnosed with CD by biopsy or serologic criteria were included in this study. Evaluation at baseline and 12 month follow-up evaluation included demographics, laboratory studies, symptoms, health-related quality of life, anxiety/depression, and gluten-free diet adherence. Paired Student t test, chi-square, and Wilcoxon sign rank tests compared baseline and follow-up data. For symptom scores, odds of improvement were assessed.

RESULTS

Of the 52 children with CD enrolled, 42 children completed 12-month follow-up evaluation. On the symptom questionnaire completed at diagnostic evaluation, 38 of 42 children reported 1 or more symptoms. CD mean symptom severity and frequency scores improved from baseline to follow-up evaluation (P < .001). Reported health-related quality of life scores improved among caregivers (P = .002). There was no significant change in reported anxiety or depression. Iron deficiency without anemia was common at baseline (21 of 24 children; 87.5%) and normalized at follow-up evaluation (11 of 21 children; 52.3%). Twenty-six of 28 families reported good or excellent gluten-free diet adherence.

CONCLUSIONS

This novel study of children with CD identified through a mass screening program demonstrated improvement in symptoms, quality of life, and iron deficiency after 1 year follow-up evaluation. This demonstrates that there may be benefit to CD mass screening.

Population level screening for celiac disease: is now the time?

PURPOSE OF REVIEW

As incidence and prevalence of celiac disease is increasing, subclinical and asymptomatic presentations are more commonly identified through celiac disease screening. However, the United States Preventive Services Task Force released a statement in 2017 maintaining that there is insufficient evidence to recommend general population screening for celiac disease for asymptomatic individuals. This review summarizes the current available evidence on celiac disease screening.

RECENT FINDINGS

Literature demonstrates that by limiting screening to individuals with recognized symptoms, celiac disease diagnosis is frequently delayed or missed entirely. Most individuals with screening-identified celiac disease have previously unrecognized symptoms that improve through treatment with a gluten-free diet. Screening-identified individuals also demonstrate signs of impaired nutrition, growth, bone health, and quality of life which improve with treatment. Overall, celiac disease screening is viewed favorably by those identified through celiac disease screening programs.

SUMMARY

Individuals with screening-identified celiac disease may still incur complications from untreated disease and receive benefit from treatment with a gluten-free diet. More data is needed to determine the cost effectiveness of different mass screening approaches that incorporate the societal perspective towards screening.

Uncovering the Concerns and Needs of Individuals with Celiac Disease: A Cross-Sectional Study

The treatment for celiac disease (CD) involves a strict gluten-free diet, which can be challenging and lead to questions for patients. Pinpointing these uncertainties can enable the creation of efficient educational resources. In this study, a questionnaire was specifically designed to gain insights into the knowledge, concerns, and needs of individuals with CD and their supporters. The questionnaire was distributed through the Instagram social network and received adequate responses from 300 participants, 258 (86%) being female and 152 (50.7%) falling in the age range of 25-44 years. The concerns of individuals with celiac disease and celiac supporters were rated on a 1-4 scale, with a mean score of 3.5 indicating significant concern. A total of 255 (85%) of all participants expressed that their principal concern was the social limitations they faced, such as difficulties in eating out and sharing food with others. Every participant evaluated their overall disease knowledge, averaging at 2.92 out of 4, indicating a reasonable level of awareness. When asked if they believed that improving general knowledge about CD in the general population would enhance their quality of life, the vast majority responded affirmatively. This finding underscores the importance of not only educating individuals with CD but also reaching out to the wider population, especially those who have a direct impact on the daily lives of individuals with CD, such as family members, friends, and food service providers.

Examining the Psychosocial Well-Being of Children and Adolescents With Coeliac Disease: A Systematic Review

This review aimed to synthesize the available literature regarding the psychosocial well-being of children and adolescents with coeliac disease (CD). Research on psychosocial well-being outcomes in children and adolescents with CD under the age of 18 were identified through a systematic search in the PsychInfo, Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases in July 2021. Outcomes, including health-related quality of life (HRQOL), psychological adjustment, mental health, and social functioning were examined. Changes in outcomes over time and the geographic representation of the included studies were also analyzed. A total of 43 studies were included. Mixed results were found in the domain of HRQOL and mental health. Both challenges with psychological adjustment and adaptive coping strategies were identified. Social functioning was found to be an area of difficulty for children and adolescents with CD. However, there was high heterogeneity in methodology and participant characteristics between studies. This review concluded there were mixed findings regarding the HRQOL and mental health of young people with CD. However, CD and the gluten-free diet initiates a need for psychological adjustment and impacts on social functioning. The review highlights the need for the integration of physical and psychosocial care, and further research to determine the most appropriate screening measures, and the most efficacious psychological interventions for this group. Future research should continue examining changes in psychosocial outcomes over time given the increase in the availability of gluten-free foods and changes in food labeling policies.

ESPGHAN Position Paper on Management and Follow-up of Children and Adolescents With Celiac Disease

OBJECTIVES

To gather the current evidence and to offer recommendations for follow-up and management.

METHODS

The Special Interest Group on Celiac Diseases of the European Society of Paediatric Gastroenterology Hepatology and Nutrition formulated ten questions considered to be essential for follow-up care. A literature search (January 2010-March 2020) was performed in PubMed or Medline. Relevant publications were identified and potentially eligible studies were assessed. Statements and recommendations were developed and discussed by all coauthors. Recommendations were voted upon: joint agreement was set as at least 85%.

RESULTS

Publications (n = 2775) were identified and 164 were included. Using evidence or expert opinion, 37 recommendations were formulated on: The need to perform follow-up, its frequency and what should be assessed, how to assess adherence to the gluten-free diet, when to expect catch-up growth, how to treat anemia, how to approach persistent high serum levels of antibodies against tissue-transglutaminase, the indication to perform biopsies, assessment of quality of life, management of children with unclear diagnosis for which a gluten-challenge is indicated, children with associated type 1 diabetes or IgA deficiency, cases of potential celiac disease, which professionals should perform follow-up, how to improve the communication to patients and their parents/caregivers and transition from pediatric to adult health care.

CONCLUSIONS

We offer recommendations to improve follow-up of children and adolescents with celiac disease and highlight gaps that should be investigated to further improve management.

Celiac disease screening at a pediatric outpatient clinic: a feasibility study

OBJECTIVES

Celiac disease (CD) is a common yet largely underdiagnosed disease. This study aimed to test the feasibility of incorporating a non-targeted CD screening in a pediatric outpatient setting and evaluate its short-term impact on children with serological evidence of disease.

METHODS

Over five months, 500 children (aged 2-17 years) attending a general pediatric outpatient clinic in Gothenburg, Sweden, were enrolled and surveyed for current symptoms, quality of life, and background characteristics; 481 children were screened for tissue-transglutaminase antibodies (tTGA); repeated tTGA-positivity was defined as CD autoimmunity (CDA). Children with CDA were investigated for CD and for one year monitored for changes in symptoms, and quality of life.

RESULTS

Eleven of 481 (2.3%) screened children had CDA. Children with CDA were younger (median 3.8 years) than those without CDA (8.8 years). No other major between-group differences were reported in background characteristics, symptoms, or quality of life. The screening was well-accepted by the families/participants. During 1-year follow-up, 8 of 11 children with CDA were diagnosed with CD. Children with screening-detected CD reported no significant changes in symptoms and quality of life and the dietary adherence rate was good.

CONCLUSIONS

Non-targeted screening for CD was feasible in a general pediatric outpatient setting. While hampered by small sample size, our results are in line with previous screening studies indicating that symptoms do not differentiate CDA from non-CDA children. Also, among an overall minimal-symptomatic group of children, diagnosing CD and installation of treatment did not significantly change their well-being during 1-year follow-up.

The costs of celiac disease: a contingent valuation in Switzerland

This paper proposes a first monetary measure of the private costs of celiac disease, including intangible costs (physical symptoms, logistical constraints, etc.) in Switzerland. This auto-immune disease damages the intestine when patients ingest gluten. The only treatment currently available is a gluten-free diet, which implies great nutritional constraints. To get a monetary equivalent of the costs borne by celiac patients, we used a contingent valuation. The scenario suggested to celiac patients a treatment in form of a daily pill, which would allow them to eat normally and avoid any physical pain from celiac disease. Mean Willingness To Pay (WTP) for the treatment is found to be around CHF 87 (approx. USD 87) per month. WTP is positively influenced by direct and indirect costs of the disease. Oppositely, individuals, who find the gluten-free diet healthier are willing to pay less. Finally, unlike symptoms before diagnostic, the current presence or intensity of physical symptoms are found to be insignificant. The latter result can be explained by the fact that, individuals facing stronger symptoms are more likely to adhere strictly to the GFD and hence to reduce their frequency.

Illness Identity in Adolescents With Celiac Disease

OBJECTIVES

The aim was to examine the reliability and validity of the Illness Identity Questionnaire (IIQ) among adolescents with celiac disease (CD), to describe their illness identity characteristics, and to examine relationships between illness identity and self-reported participation in food-related activities and quality of life.

METHODS

Adolescents with CD (n = 91) were recruited for this cross-sectional study via social media interest groups. Participants completed online questionnaires: the IIQ, the CD Children's Activities Chart (CD-Chart), and the Pediatric Quality of Life Inventory (PedsQL).

RESULTS

Internal reliability was established for IIQ items (α = 0.87) and for its 4 components (α = 0.75--0.90). The positive components (acceptance, enrichment) significantly differed from the negative components (rejection, engulfment), t(90) = 11.45, P < 0.001, d = 1.98. Feelings were more positive (M = 3.48, SD = 0.67) than negative (M = 2.06, SD = 0.76). The total IIQ was positively associated with the CD-Chart amount of activities (r = 0.30, P < 0.01) and enjoyment (r = 0.34, P < 0.001) and with the PedsQL social scale (r = 0.53, P < 0.001).

CONCLUSIONS

The IIQ established acceptable reliability and validity. In all, the adolescents with CD exhibited an illness identity profile that was more positive and adaptive than negative. The IIQ can contribute to understanding the developmental status of illness identity during the critical transition process from adolescence to adulthood.

Evaluation of Daily Lives of Children and Adolescents with Celiac Disease and Nursing Approaches

The incidence of celiac disease has been increasing in recent years. Celiac disease is an autoimmune enteropathy that emerges mostly in the childhood period. This disorder is a chronic condition of the small intestine due to gluten intake in individuals with genetic predisposition. In the treatment of celiac disease, gluten-free diet therapy is applied. However, the adaptation process to the diet may create difficulties for patients. Compliance with diet is much more difficult among patients with celiac disease in childhood and adolescence than in adult patients. Children and adolescents face distinct difficulties in their homes, at school, and in their social lives. Besides following dietary treatment, children and adolescents living with celiac disease need peer support to manage their daily routines. In this article, we aimed to discuss the problems experienced by children and adolescents living with celiac disease and nursing approaches to these problems.

Approaches to Photoprotection and Normalization in Highly Adherent Families of Children With Xeroderma Pigmentosum in the United Kingdom

In this study, we examine photoprotection for children with Xeroderma pigmentosum (XP), a rare genetic skin disease requiring rigorous photoprotection, to reduce risks of severe burning and skin cancers from exposure to ultraviolet radiation (UVR). We elicit the views and experiences of both children and their parents to inform the care and support provided. Qualitative semistructured interviews were undertaken with 12 child-parent dyads recruited from the National XP Specialist service in London. We employed a framework approach to analysis. This identified a high level of photoprotection based either on "protection" to facilitate normal activities or "avoidance" of outdoor activity with priority given to normality in the future. These approaches were shaped by perceptions of clinical risk, the emphasis given to a normal family life and families' circumstances and resources. The findings contribute to notions of normalization and coping with demanding care regimens and inform approaches to working with families.

Lack of long-term follow-up after paediatric-adult transition in coeliac disease is not associated with complications, ongoing symptoms or dietary adherence

BACKGROUND

Follow-up of coeliac disease is recommended to prevent complications associated with unsuccessful treatment.

OBJECTIVE

The objective of this article is to evaluate the implementation and significance of long-term follow-up.

METHODS

Medical data were collected from 585 and follow-up questionnaires sent to 559 current adult coeliac disease patients diagnosed in childhood. Diagnostic features and adulthood health outcomes were compared between those with and without adulthood follow-up.

RESULTS

Of paediatric patients, 92% were followed up 6-24 months after diagnosis. A total of 235 adults responded to the questionnaires a median of 18 years after diagnosis, and 25% of them reported regular follow-up. They were diagnosed more recently than those without follow-up (median year 2001 vs 1995, p = 0.001), being otherwise comparable at diagnosis. Those with follow-up were less often smokers (5% vs 16%, p = 0.042) and relatives of coeliac patients (48% vs 66%, p = 0.018), and more often students (48% vs 28%, p = 0.005) and type 1 diabetics (19% vs 4%, p = 0.001). Lack of follow-up was not associated with complications, ongoing symptoms, poorer general health or dietary adherence. All completely non-adherent patients were without follow-up.

CONCLUSIONS

Most coeliac disease patients diagnosed in childhood were not followed up according to recommendations in adulthood. The individual effect of this on long-term treatment outcomes varied markedly.

Daily Life Restrictions are Common and Associated with Health Concerns and Dietary Challenges in Adult Celiac Disease Patients Diagnosed in Childhood

The prevalence and associated factors of daily life restrictions due to a gluten-free diet in adult celiac disease patients diagnosed in childhood are poorly known. We investigated these issues by collecting the medical data of 955 pediatric patients and sending questionnaires evaluating various health outcomes to the 559 patients who had reached adulthood. Of the 231 respondents, 46% reported everyday life restrictions caused by dietary treatment. Compared with those without restrictions, they more often had anemia at diagnosis (37% vs. 22%, p = 0.014), but the groups were comparable in other diagnostic features. In adulthood, patients with restrictions reported more overall symptoms (32% vs. 17%, p = 0.006), although the symptoms measured with the Gastrointestinal Symptom Rating Scale questionnaire were comparable. Despite strict dietary adherence in both groups, the experience of restrictions was associated with dietary challenges (34% vs. 9%, p < 0.001), health concerns (22% vs. 13%, p = 0.050), and lower vitality scores in the Psychological General Well-Being questionnaire. The groups did not differ in their current age, socioeconomic status, family history of celiac disease, general health or health-related lifestyle, the presence of co-morbidities, or regular follow up. Our results encourage healthcare professionals to discuss the possible health concerns and dietary challenges with patients to avoid unnecessary daily life restrictions, especially when young patients start to take responsibility for their treatment.

Diminished quality of life among adolescents with coeliac disease using maladaptive eating behaviours to manage a gluten-free diet: a cross-sectional, mixed-methods study

BACKGROUND

Certain approaches to managing a strict gluten-free diet (GFD) for coeliac disease (CD) may lead to impaired psychosocial well-being, a diminished quality of life (QOL) and disordered eating. The present study aimed to understand adolescents' approaches to managing a GFD and the association with QOL.

METHODS

Thirty adolescents with CD (13-17 years old) following the GFD for at least 1 year completed the Celiac Dietary Adherence Test (CDAT) and QOL survey. Their approaches to GFD management were explored using a semi-structured interview, where key themes were developed using an iterative process, and further analysed using a psychosocial rubric to classify management strategies and QOL. CDAT ratings were compared across groups.

RESULTS

Gluten-free diet management strategies were classified on a four-point scale. Adaptive eating behaviours were characterised by greater flexibility (versus rigidity), trust (versus avoidance), confidence (versus controlling behaviour) and awareness (versus preoccupation) with respect to maintaining a GFD. Approximately half the sample (53.3%) expressed more maladaptive approaches to maintaining a GFD and those who did so were older with lower CD-Specific Pediatric Quality of Life (CDPQOL) scores, mean subscale differences ranging from 15.0 points for Isolation (t = 2.4, P = 0.03, d.f. = 28) to 23.4 points for Limitations (t = 3.0, P = 0.01, d.f. = 28).

CONCLUSIONS

Adolescents with CD who manage a GFD with maladaptive eating behaviours similar to known risk factors for feeding and eating disorders experience diminished QOL. In accordance with CD management recommendations, we recommend ongoing follow-up with gastroenterologists and dietitians and psychosocial support referrals, as needed.

Development and Validation of the Celiac Disease-Children's Activities Report (CD-Chart) for Promoting Self-Management among Children and Adolescents

Adherence to a restrictive gluten-free diet is the only known treatment for celiac disease (CD). Children and adolescents with CD encounter challenges while managing the diet in daily activities. Understanding their participation characteristics is lacking. The aim was to describe the development and validation process of the Celiac Disease-Children's Activities Report (CD-Chart). The final CD-Chart includes nine food-related activities that are measured by six core dimensions: frequency, preference, preparation, involvement, help, and self-determination. Participants were 126 children (8-11 years) and adolescents (12-18 years) with CD, and 30 healthy matched controls. Factor analysis was performed and psychometric properties were measured. Content and face validity was established and the CD-Chart showed adequate internal consistency as measured by the preference dimension (α = 0.81). Factor analysis revealed two distinct factors, social environment and close family environment. Construct validity demonstrated that the group with CD required significantly more pre-preparation for food-related activities than controls, (t(38) = 76.25, p < 0.001) and further differences as well as similarities were found between groups. Primary results indicate that the CD-Chart may serve as a practical tool for acquiring information about participation characteristics in food-related activities, strengths and challenges of children and adolescents with CD, to promote self-management, diet adherence, and well-being.

Coeliac disease and psychiatric comorbidity: epidemiology, pathophysiological mechanisms, quality-of-life, and gluten-free diet effects

Coeliac Disease (CD) is an autoimmune disease in which an environmental factor, gluten, triggers a pathological reaction. It results in intra- and entra-intestinal manifestations of disease, including, most frequently, diarrhoea, weight loss, and anaemia. CD occurs in ∼1% of the western population, being one of the most common autoimmune lifelong disorders, and may present with a variety of psychiatric comorbidities. Psychiatric comorbidity in CD often complicates the diagnosis, reduces the quality-of-life, and worsens the prognosis of affected patients. This review summarizes the epidemiological studies that underline this connection, and focuses on the potential mechanisms related to this comorbility, such as nutritional deficiencies, immune responses, interference in brain processes, and dysfunctions in the gut-brain axis. Factors that play a central role on patients' quality of life, psychological well-being and adherence are presented. Finally, evidence of regression in psychiatric symptoms following the introduction of a gluten-free diet is underlined as well.

Activities, Participation and Quality of Life Concepts in Children and Adolescents with Celiac Disease: A Scoping Review

Celiac disease (CD) is a food-related chronic condition and adherence to a strict gluten-free diet is the only available treatment. Adherence to the restrictive diet is challenging among children, especially adolescents. The aim was to describe existing knowledge about food-related activities, participation, and quality of life in daily life among children and adolescents with CD and to illuminate gaps in knowledge. The scoping review methodology was applied and literature searches were conducted in electronic databases. Twenty-three articles met the inclusion criteria. Food-related activities were identified, classified, and coded under the International Classification of Functioning, Disability, and Health adapted for children and youth (ICF-CY) concepts of activities and participation. A wide variety of study populations, objectives, methods, and tools involving 55 different food-related activities were found. Incorporation of the ICF-CY concepts and quality of life captures new insights into everyday challenges. Reviewing the CD literature using this different lens reveals areas yet to receive sufficient attention. Further research can deepen the understanding of daily functioning of children with CD and the underlying skills required to participate in daily food-related activities while adhering to the diet. This can lead to the development of standardized disease-specific assessment tools and suitable intervention programs.

Perceptions and experiences underlying self-management and reporting of symptoms in teens with asthma

BACKGROUND

Teens often have inadequate asthma self-management and control. However, little is known of their perceptions of or rationales for self-management behaviors.

OBJECTIVES

To explore how teens self-manage asthma, including experiences, perceptions, responses to and reporting of symptoms.

METHODS

A case-based, qualitative-descriptive design was used. Data were collected from minority and non-minority teens with controlled and uncontrolled asthma and their respective parents (N = 28). There were four data-collection points, including: (1) a primary teen interview; (2) parent interview; (3) 2-week self-management voice-diary; and (4) follow-up teen interview, incorporating symptom-response card-sorting to map symptoms and associated self-management responses. Seventy data sources were included in the analysis.

RESULTS

Teens thought of their asthma symptoms as normal or unusual relative to their personal baseline symptom pattern; Those with uncontrolled asthma normalized higher levels of asthma symptoms than their counterparts with controlled asthma. Second, teens' decisions to treat symptoms of asthma with rescue medication were based on perceived benefits, burdens and accessibility of treatment balanced against perceived normalcy of symptoms. Teens with uncontrolled asthma had substantially higher treatment thresholds and delayed responses to symptoms compared to controlled peers. Third, teens never reported perceived normal symptoms of asthma to parents or providers, who were thus only aware of unusual or visible/audible symptoms.

CONCLUSIONS

Teen's perceptions of symptoms and understanding of what is normal is the basis for self-management decisions. Improving self-management will likely entail modifying perceptions of symptoms and benefits/burdens of treatment to achieve healthier self-management patterns.

Quality of Life in Type 1 Diabetes and Celiac Disease: Role of the Gluten-Free Diet

OBJECTIVE

To evaluate quality of life (QoL) and glycemic control in youth with type 1 diabetes (T1D) and celiac disease vs T1D only. We hypothesized that QoL scores would be lower in youth with T1D and celiac disease and those nonadherent to the gluten-free diet (GFD).

STUDY DESIGN

This case control study included 35 youth with T1D and 35 with T1D  and  celiac disease matched for age, sex, diabetes duration, and hemoglobin A1c level. QoL was assessed in participants and parents using the Pediatric Quality of Life Inventory Generic Core Scale, Pediatric Quality of Life Inventory Diabetes Module. and the General Well-Being Scale; youth with T1D and celiac disease also completed the celiac disease-specific DUX questionnaire and parents completed the Pediatric Quality of Life Inventory Family Impact Scale. Questionnaires were scored from 0 to 100; higher scores indicate better QoL or well-being. Scores were compared between T1D vs T1D with celiac disease, with subgroup analysis by GFD adherence vs nonadherence and therapy (continuous subcutaneous insulin infusion vs multiple daily injections).

RESULTS

Youth with T1D  and celiac disease reported similar generic and diabetes-specific QoL to T1D only. GFD nonadherent vs adherent youth reported lower diabetes-specific QoL (mean score 58 vs 75, P = .003) and lower general well-being (57 vs 76, P = .02), as did their parents (50 vs 72, P = .006), and hemoglobin A1c was higher (9.6% vs 8.0%, P = .02). Youth with T1D  and  celiac disease using continuous subcutaneous insulin infusion vs multiple daily injections had similar generic and diabetes-specific QoL and A1C (8.6 vs 8.2%, P = .44), but were less happy having to follow a lifelong diet (59 vs 29, P = .007).

CONCLUSIONS

Youth with T1D  and celiac disease who do not adhere to the GFD have lower QoL and worse glycemic control. Novel strategies are required to understand and improve adherence in those with both conditions.

NASPGHAN Clinical Report on the Diagnosis and Treatment of Gluten-related Disorders

Dietary exclusion of gluten-containing products has become increasingly popular in the general population, and currently ∼30% of people in the United States are limiting gluten ingestion. Although celiac disease (CD), wheat allergy (WA), and nonceliac gluten sensitivity (NCGS) constitute a spectrum of gluten-related disorders that require exclusion of gluten from the diet, together these account for a relatively small percentage of those following a gluten-free diet, and the vast majority has no medical necessity for doing so. Differentiating between CD, WA, and NCGS has important prognostic and therapeutic implications. Because of the protean manifestations of gluten-related disorders, it is not possible to differentiate between them on clinical grounds alone. This clinical report will compare and contrast the manifestations of gluten-related disorders, emphasize the importance of differentiating between these conditions, discuss initial and subsequent tests needed to confirm the diagnosis, and provide recommendations on treatment and follow-up for each condition.

Children and adolescents living with diabetes and celiac disease

Objective To understand the experience of children and adolescents living with type 1 diabetes and celiac disease. Method This is a qualitative exploratory-descriptive study. The participants were 3 children and 2 adolescents. The data were collected by means of semi-structured interviews between January and September 2012 at the participant's residence or at the diabetic outpatient clinic of the Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo in São Paulo, Brazil. The content analysis technique was used to process the data. Results The key aspect of the illness experience of the patients was their diet, but with different meanings. The children had difficulty following the diet, while the adolescents reported that they had greater difficulty coping with the social and affective aspects of their diet. Conclusion The results reinforce the importance of nurses who seek strategies, together with the patients and their families, that help minimize the difficulties of these patients, especially with regard to managing the diet imposed by both diseases.

Translation, cultural adaptation, and validation of the celiac disease DUX (CDDUX)

OBJECTIVE

To translate, cross-culturally adapt, and validate a specific questionnaire for the evaluation of celiac children and adolescents, the celiac disease DUX (CDDUX).

METHODS

The steps suggested by Reichenheim and Moraes (2007) were followed to obtain conceptual, item, semantic, operational, and measurement equivalences. Four pediatric gastroenterologists; a researcher with tool validation background; three English teachers; and 33 celiac patients, aged 8-18 years, and their caregivers participated in the study. The scores of celiac patients and those obtained from their caregivers were compared. Among the patients, the scores were compared in relation to gender and age.

RESULTS

All items were considered relevant to the construct and good semantic equivalence of the version was acquired. During measurement equivalence, the exploratory factor analysis showed appropriate weight of all items and good internal consistency, with Cronbach's α of 0.81. Significant difference was found among the final scores of children and their caregivers. There was no difference among the final scores in relation to gender or age.

CONCLUSION

The questionnaire was translated and adapted according to all the proposed steps, with all equivalences adequately met. It is a valid tool to access the QoL of celiac children and adolescents in the translated language.

The Perceived Social Burden in Celiac Disease

In the present paper, we discuss the change in celiac disease (CD) awareness and perception through patients' concerns and the most recent literature. Nowadays CD has moved in the public awareness (both doctors and population) from a rare disease to a common one and the gluten free diet (GFD) is no longer the exclusive therapy for CD patients but is becoming a popular health choice for everybody. Gluten-free food, once hard to find and requiring home preparation, is now available at restaurants and grocery stores. However, the quality of life of those affected by CD seems to be still compromised and this is particularly true for those who find it difficult to adhere to a GFD and those who were asymptomatic at the time of diagnosis. Intervention at diagnosis and follow-up to improve the patients' adaptation to the condition and its limitations should be implemented.

Screening for celiac disease in the general population and in high-risk groups

BACKGROUND

Celiac disease (CD) occurs in approximately 1% of the Western population. It is a lifelong disorder that is associated with impaired quality of life (QOL) and an excessive risk of comorbidity and death.

OBJECTIVES

To review the literature on screening for CD in relation to the current World Health Organization (WHO) criteria for mass screening.

METHODS

We performed a PubMed search to identify indexed papers on CD screening with a publication date from 1900 until 1 June 2014. When we deemed an abstract relevant, we read the corresponding paper in detail.

RESULTS

CD fulfills several WHO criteria for mass screening (high prevalence, available treatment and difficult clinical detection), but it has not yet been established that treatment of asymptomatic CD may reduce the excessive risk of severe complications, leading to higher QOL nor that it is cost-effective.

CONCLUSIONS

Current evidence is not sufficient to support mass screening for CD, but active case-finding may be appropriate, as we recognize that most patients with CD will still be missed by this strategy. Although proof of benefit is still lacking, screening for CD may be appropriate in high-risk groups.

High adherence to a gluten-free diet in adolescents with screening-detected celiac disease

OBJECTIVES

The aim of the study was to evaluate the gluten-free diet (GFD) adherence after 1 year of follow-up in children with screening-detected celiac disease (CD) in a general population.

METHODS

A total of 18,325 twelve-year-olds were invited to participate in a population-based CD screening (Exploring the Iceberg of Celiacs in Sweden), of whom 13,279 participated. In 240 children, CD was detected through elevated anti-tissue transglutaminase antibodies 2 (TG2-IgA) and verified by a small-intestinal biopsy. This substudy included 210 children with TG2-IgA, evaluated both at the initial biopsy occasion and at 1-year follow-up. GFD adherence was evaluated by a combination of TG2-IgA measurements and self-reported adherence (n = 193).

RESULTS

After 1 year, 85% (179/210) had normalized TG2-IgA levels (<5 U/mL). Among those who had >50 U/mL at diagnosis, 25% (16/63) still had elevated TG2-IgA, but for the majority their initial values were more than halved. Most reported a high level of GFD adherence ("always" 82% [158/193] and "often" 16% [30/193]), and 75% [145/193] reported always adhering combined with normalized TG2-IgA. Although reporting that they were always adherent, 13 (6.7%) had not yet normalized their TG2-IgA levels completely; however, a majority of these initially had the highest TG2-IgA levels.

CONCLUSIONS

GFD adherence is high in adolescents with CD detected by screening of the general population of Swedish 12-year-olds. Almost all of them had normalized serology and reported GFD adherence at the 1-year follow-up. A few adolescents who reported GFD adherence, however, had elevated TG2-IgA levels, suggesting more severe disease and/or nonadherence.

Impact on parents of HLA-DQ2/DQ8 genotyping in healthy children from coeliac families

Due to the association of coeliac disease and HLA-specificities DQ2 and DQ8, HLA-typing can be used for risk determination of the disease. This study was designed to evaluate the knowledge of parents from coeliac families regarding HLA-typing and the impact of HLA-typing on the perception of the health of their children. A structured questionnaire was sent to the Dutch, Spanish and German parents participating with their child in the European PreventCD study on disease prevention in high-risk families, addressing parents' understanding of and attitude towards HLA-typing, distress related to HLA-typing and perceived health and health-related quality of life of their children. Sixty-eight percent of parents of 515 children returned the questionnaires, with 85% of children being DQ2/DQ8 positive. The majority of all parents answered the questions on knowledge correctly. Forty-eight percent of parents of DQ2/DQ8-negative children thought their child could develop coeliac disease. More distress was reported by parents of DQ2/DQ8-positive children (P<0.001). All parents showed few regrets and would repeat HLA-typing in future children. Perceived health and health-related quality of life were similar. In conclusion, we can say that misinterpretation of DQ2/DQ8-negative results by parents is frequent. DQ2/DQ8-positive results do not affect perceived health and health-related quality of life of children but may cause temporary negative feelings among parents. Parents of coeliac families seem to support HLA-typing.

Internalizing the threat of risk--a qualitative study about adolescents' experience living with screening-detected celiac disease 5 years after diagnosis

BACKGROUND

Mass screening could identify those with unrecognized celiac disease (CD), but the experience of being detected through screening and living with screening-detected CD should be explored before considering this as acceptable intervention. For this study we invited screening-detected adolescents to describe their experience living with screening-detected CD five years after diagnosis with the aim to explore how their perceptions, practices, and beliefs evolved.

METHODS

Adolescents who were diagnosed through a population-based CD screening were invited to write narratives after being diagnosed. Of 153 adolescents who were eventually diagnosed through the screening, 91 wrote narratives one year after diagnosis and 72 five years after diagnosis. A qualitative content analysis resulted in a theme and categories that describe the experience living with screening-detected CD five years after diagnosis.

RESULTS

The overall theme--Internalizing the threat of risk--illustrates that being detected through screening and the internalized threat of future health complications have impacted how these adolescents felt about the diagnosis, coped with the gluten-free diet (GFD), and thought about CD screening. This theme is supported by four categories: maintaining an imposed disease identity describes how they continued to define their diagnosis in relation to the screening. They also expressed moving from forced food changes to adapted diet routines by describing habits, routines, coping strategies, and the financial burden of the GFD. They had enduring beliefs of being spared negative consequences, however, even after five years, some doubted they had CD and worried that being detected and eating a GFD might not be beneficial, i.e. continuing to fear it is "all in vain".

CONCLUSIONS

There was maintenance and evolution in the perceptions, practices, and beliefs of the adolescents after five years. Some have adjusted to the disease and adapted new habits and coping strategies to deal with the GFD, while others still doubt they have CD or that being detected was beneficial. The transition to adapting to the disease and GFD is ongoing, illustrating the importance of providing ongoing support for those with screening-detected CD as they adjust to this chronic disease and the GFD.

Health-related quality of life is not impaired in children with undetected as well as diagnosed celiac disease: a large population based cross-sectional study

Background

Knowledge regarding the health-related quality of life (HRQoL) of children with celiac disease remains limited and inconclusive. We investigated the HRQoL of three groups of 12-year-olds with: i) undetected celiac disease ii) clinically diagnosed celiac disease, and iii) without celiac disease.

Methods

A school-based cross-sectional multicenter screening study invited 18 325 children, whereof 68% consented to participate. Participants provided a blood sample, which was later analyzed for anti-tissue-tranglutaminase antibodies, and alongside filled in a questionnaire. When anti-tissue-tranglutaminase antibodies were elevated, a small intestinal biopsy verified the screening-detected celiac disease diagnosis. Self-reported HRQoL was measured using Kidscreen, a generic 52 items instrument with proven reliability and validity. Scores were linearly transformed into a 0–100 scale with higher values indicating better HRQoL. Mean values with standard deviations (mean ± SD) were compared, and uni- and multivariate logistic regression models tested the odds of a low HRQoL among children with undetected or diagnosed celiac disease, respectively.

Results

Children with undetected celiac disease (n = 238) reported similar HRQoL as children without celiac disease (n = 12 037) (83.0 ± 11.0 vs. 82.5 ± 11.3, P = 0.51), and also similar HRQoL (82.2 ± 12.2, P = 0.28) to that of children with diagnosed celiac disease (n = 90), of whom 92% were adherent to treatment. Having undetected celiac disease did not increase the odds of low overall HRQoL, independent of sex, area of residence, study year and occurrence of gastrointestinal symptoms (adjusted odds ratio 0.77, 95% CI 0.54-1.10). Comparable results were seen for diagnosed celiac disease cases (adjusted odds ratio 1.11, 95% CI 0.67-1.85).

Conclusion

Children with undetected celiac disease reported comparable HRQoL as their peers with diagnosed celiac disease, and those without celiac disease, when reporting prior to receiving the diagnosis through screening. Thus, children with celiac disease, both untreated and diagnosed, perceive their HRQoL as unimpaired by their disease.

What happens to food choices when a gluten-free diet is required? A prospective longitudinal population-based study among Swedish adolescent with coeliac disease and their peers

A dietary survey was performed during a large screening study in Sweden among 13-year-old adolescents. The aim was to study how the intake of food groups was affected by a screening-detected diagnosis of coeliac disease (CD) and its gluten-free (GF) treatment. Food intake was reported using a FFQ, and intake reported by the adolescents who were diagnosed with CD was compared with the intake of two same-aged referent groups: (i) adolescents diagnosed with CD prior to screening; and (ii) adolescents without CD. The food intake groups were measured at baseline before the screening-detected cases were aware of their CD, and 12–18 months later. The results showed that food intakes were affected by screen-detected CD and its dietary treatment. Many flour-based foods were reduced such as pizza, fish fingers and pastries. The results also indicated that bread intake was lower before the screened diagnosis compared with the other studied groups, but increased afterwards. Specially manufactured GF products (for example, pasta and bread) were frequently used in the screened CD group after changing to a GF diet. The present results suggest that changing to a GF diet reduces the intake of some popular foods, and the ingredients on the plate are altered, but this do not necessarily include a change of food groups. The availability of manufactured GF replacement products makes it possible for adolescents to keep many of their old food habits when diagnosed with CD in Sweden.

Usefulness of symptoms to screen for celiac disease

OBJECTIVE

To describe the frequency of symptoms and associated conditions among screening-detected celiac disease (CD) cases and non-CD children and to evaluate questionnaire-based case-finding targeting the general population.

METHODS

In a population-based CD screening of 12-year-olds, children and their parents completed questionnaires on CD-associated symptoms and conditions before knowledge of CD status. Questionnaire data for those who had their CD detected in the screening (n = 153) were compared with those of children with normal levels of CD markers (n = 7016). Hypothetical case-finding strategies were also evaluated. Questionnaires were returned by 7054 (98%) of the children and by 6294 (88%) of their parents.

RESULTS

Symptoms were as common among screening-detected CD cases as among non-CD children. The frequency of children with screening-detected CD was similar when comparing the groups with and without any CD-related symptoms (2.1% vs 2.1%; P = .930) or CD-associated conditions (3.6% vs 2.1%; P = .07). Case-finding by asking for CD-associated symptoms and/or conditions would have identified 52 cases (38% of all cases) at a cost of analyzing blood samples for 2282 children (37%) in the study population.

CONCLUSIONS

The current recommended guidelines for finding undiagnosed CD cases, so-called active case-finding, fail to identify the majority of previously undiagnosed cases if applied in the general population of Swedish 12-year-olds. Our results warrant further studies on the effectiveness of CD case-finding in the pediatric population, both at the clinical and population-based levels.

Health-related quality of life in children and adolescents with celiac disease: survey of a population from central Italy

Background

Celiac Disease (CD) is an increasingly common autoimmune disorder. It requires a strict lifelong adherence to a gluten-free diet (GFD) which can influence health-related quality of life (HRQOL). This study assesses HRQOL in children and adolescents with CD and explores how several demographic and clinical characteristics and GFD adherence affect their perceived health status.

Methods

We recruited 140 consecutive children and adolescents with CD confirmed by small bowel biopsy. HRQOL was assessed using the SF-12 questionnaire plus some CD-specific questions exploring wellbeing and lifestyle. Patients, aged 10 to 18 years, were identified by pediatric gastroenterologists and guided in filling out the questionnaire by trained psychologists. Parametric or non-parametric tests were applied to analyze continuous variables and frequencies as appropriate.

Results

The SF-12 mean mental component summary score (MCS12) was lower than in the general Italian population (p < 0.001), whereas differences in terms of physical health were not significant (p = 0.220). More than one third of those interviewed reported feeling angry “always” or “most of the time” about having to follow the GFD, and nearly 20% reported feeling different from others and misunderstood because of CD “always” or “most of the time”.

Conclusions

Our findings highlight the need for health professionals to identify adolescents with major disease-related problems. The food industry should improve its range of gluten-free food products and public bodies and institutions should promote informative campaigns and help promote the overall quality of life of children and adolescents with CD.

Health-related quality of life in adolescents with screening-detected celiac disease, before and one year after diagnosis and initiation of gluten-free diet, a prospective nested case-referent study

Background

Celiac disease (CD) is a chronic disorder in genetically predisposed individuals in which a small intestinal immune-mediated enteropathy is precipitated by dietary gluten. It can be difficult to diagnose because signs and symptoms may be absent, subtle, or not recognized as CD related and therefore not prompt testing within routine clinical practice. Thus, most people with CD are undiagnosed and a public health intervention, which involves screening the general population, is an option to find those with unrecognized CD. However, how these screening-detected individuals experience the diagnosis and treatment (gluten-free diet) is not fully understood. The aim of this study is to investigate the health-related quality of life (HRQoL) of adolescents with screening-detected CD before and one year after diagnosis and treatment.

Methods

A prospective nested case-referent study was done involving Swedish adolescents who had participated in a CD screening study when they were in the sixth grade and about 12 years old. Screening-detected adolescents (n = 103) and referents without CD who participated in the same screening (n = 483) answered questionnaires at the time of the screening and approximately one year after the screening-detected adolescents had received their diagnosis that included the EQ-5D instrument used to measure health status and report HRQoL.

Results

The HRQoL for the adolescents with screening-detected CD is similar to the referents, both before and one year after diagnosis and initiation of the gluten-free diet, except in the dimension of pain at follow-up. In the pain dimension at follow-up, fewer cases reported problems than referents (12.6% and 21.9% respectively, Adjusted OR 0.50, 95% CI 0.27-0.94). However, a sex stratified analysis revealed that the significant difference was for boys at follow-up, where fewer screening-detected boys reported problems (4.3%) compared to referent boys (18.8%) (Adjusted OR 0.17, 95% CI 0.04-0.73).

Conclusions

The findings of this study suggest that adolescents with unrecognized CD experience similar HRQoL as their peers without CD, both before and one year after diagnosis and initiation of gluten-free diet, except for boys in the dimension of pain at follow-up.

Burden of illness in screen-detected children with celiac disease and their families

OBJECTIVES

Because of a variable clinical picture, most children with celiac disease remain unrecognized without active serologic screening. Because, however, many patients are asymptomatic, the justification for screening remains unclear. We assessed health and well-being and the effect of a 1-year gluten-free diet in a nationwide cohort of children with celiac disease detected by screening in at-risk groups.

METHODS

A total of 222 newly detected children received a validated questionnaire covering aspects of the burden caused by the undiagnosed celiac disease. After 1 year, adherence to the diet and difficulties attending this, attitudes toward and effects of disease and diet on daily life, and parents' satisfaction with the diagnosis were inquired about. The children's health and parents' concern for it were asked about at diagnosis and on treatment. The outcomes of screen-detected children were compared with those of children diagnosed on the basis of clinical symptoms.

RESULTS

Forty-three screen-detected and 88 symptom-detected children responded. Also, 65% of the screen-detected patients experienced symptoms; these, however, being less troublesome and of shorter duration than in symptom-detected subjects. There were no differences between the groups in dietary adherence (71% vs 84% strict diet), management of the diet (80% vs 80%), alleviation of symptoms (78% vs 86%), and improvement in daily life (73% vs 69%), or in satisfaction with the diagnosis (93% vs 88%). Improved health and reduced parental concern were observed in both groups.

CONCLUSIONS

Screen-detected children with celiac disease can attain satisfactory dietary adherence and benefit from treatment similarly to symptom-detected patients. The results support intensified screening for celiac disease in at-risk children.

Health-related quality-of-life in children with coeliac disease, measured prior to receiving their diagnosis through screening

OBJECTIVE

To compare the health-related quality-of-life (HRQoL) of children with screening-detected coeliac disease (CD), before they learned of their diagnosis, with that of children without CD and in those previously diagnosed with CD.

METHODS

In a cross-sectional CD screening study ('ETICS': Exploring the Iceberg of Coeliacs in Sweden), of 10,041 Swedish 12-year-olds invited, 7567 (75%) consented to participate, and 7208 (72%) children without previously diagnosed CD had serological markers analysed. Before the screening results were known, 7218 children (72%) and 6524 of their parents (65%) answered questionnaires. Questionnaires included the Swedish child-friendly pilot version of the EQ-5D instrument and proxy version of the EQ-5D instrument, which are generic tools used to describe HRQoL.

RESULTS

We found no significant difference in HRQoL between the groups of children with screening-detected CD, without CD, and those previously diagnosed with CD.

CONCLUSION

The HRQoL reported by 12-year-olds with screening-detected CD, before they learned of their diagnosis, was not worse than that of the children without CD or those previously diagnosed with CD. Thus, mass screening for CD should not be justified on the basis that children with unrecognized CD have a poor HRQoL. However, because these children rated their HRQoL before diagnosis and treatment, they may not have recognized or perceived symptoms as severe enough to seek medical attention which demonstrates how difficult clinical/active case finding can be. Mass screening may still, therefore, be considered if the aim is early detection and prevention of future complications.

Mass screening for celiac disease from the perspective of newly diagnosed adolescents and their parents: a mixed-method study

Background

Mass screening for celiac disease (CD) as a public health intervention is controversial. Prior to implementation, acceptability to the targeted population should be addressed. We aimed at exploring adolescents' and parents' experiences of having the adolescents' CD detected through mass screening, and their attitudes towards possible future mass screening.

Methods

All adolescents (n = 145) with screening-detected CD found in a Swedish school-based screening study, and their parents, were invited to this study about one year after diagnosis. In all, 14 focus group discussions were conducted with 31 adolescents and 43 parents. Written narrative was completed by 91 adolescents (63%) and 105 parents (72%), and questionnaires returned by 114 parents (79%). Data were analyzed using qualitative content analysis. In addition, narratives and questionnaire data allowed for quantified measures.

Results

Adolescents and parents described how they agreed to participate "for the good of others," without considering consequences for themselves. However, since the screening also introduced a potential risk of having the disease, the invitation was regarded as "an offer hard to resist." For the majority, receiving the diagnosis was described as "a bolt of lightning," but for some it provided an explanation for previous health problems, and "suddenly everything made sense." Looking back at the screening, the predominant attitude was "feeling grateful for being made aware," but some adolescents and parents also expressed "ambivalent feelings about personal benefits." Among parents, 92% supported future CD screening. The most common opinion among both adolescents and parents was that future CD mass screening should be "a right for everyone" and should be offered as early as possible. However, some argued that it should be "only for sufferers" with symptoms, whereas others were "questioning the benefits" of CD mass screening.

Conclusions

Although the incentives to participate in the CD screening were partly non-personal, and diagnosis was met with surprise, adolescents and parents felt grateful that they were made aware. They welcomed future CD screening, but suggested that it should be conducted earlier in life. Thus, CD mass screening seemed acceptable to most of those who were diagnosed and their parents.