Growth and adult height in atypical coeliac patients, with or without growth hormone deficiency

Linear growth of children with celiac disease after the first two years on gluten- free diet: a controlled study

Background: Celiac disease (CD) is a lifelong disorder with gluten-induced manifestations in different organs especially growth. Gluten free diet (GFD) is required to achieve remission and prevent abnormal growth. Study reports on growth of children with celiac disease on long-term GFD are not consistent. Objective: We evaluated the effect of GFD on growth of children with the classical form of CD (diagnosed by serology and small intestine mucosal biopsy) on log-term GFD (>2 years). Methods: We studied growth parameters (weight gain/day, BMI and BMI-SDS, height growth velocity, Ht-SDS) and lab data in 30 prepubertal children, aged 7.4±2.6 years, with CD, who were on GFD since the age of 3.2±1.6 years of age (>2 years on GFD) for duration of 1 year. The anthropometric data of 30 randomly selected normal, age and sex matched, children were used as control. Lab investigations of CD children included complete blood count (CBC), renal and liver functions (aspartate transaminase - AST, alanine aminotransferase - ALT, and alkaline phosphatase- ALP, serum albumin, fasting blood glucose, vitamin D, and thyroid function and antibodies. Results: The weight gain per day was on average or above, for age and sex, in 27 children and below average in 3. Two out of those 3 children had slow linear growth (decreased Ht-SDS by -0.56 and -0.1, over one year). BMI-SDS was normal in 26/30 patients (>-1.5). BMI-SD changed from -0.36±1.1 to -0.33±1.1 during the year of treatment. BMI-SDS decreased in 9 children during the follow up period that was explained by their fast-linear growth (increased Ht-SDS) in seven of them. The Ht-SDS was <-2 in four out of 30 children at the beginning of the study (2 years after being on GFD) and in 2 children after a year of follow-up (catch-up growth). Ht-SDS remained normal or increased in 28/30 children during the year of treatment (-0.38 ±1.2 to -0.22±1.1), with a positive trend: 0.15±0.4 SDS. Only one patient crossed down 1 Ht-SDS during the year of follow up, with low weight gain/day and decreased BMI-SDS that can be explained by poor compliance with GFD. Ht-SDS and BMI-SDS increased significantly in the CD group versus controls during the year of follow-up. All patients had normal serum albumin, liver enzyme and hemoglobin levels. 33.3% of patients had low serum ferritin level and 33.3% had a vitamin D deficiency. Conclusions: Most of our children with CD grew normally both in height and weight during GFD. Significant catch-up growth occurred in some of them after 2 years of being on GFD. Those with low BMI-SDS and/or Ht-SDS needed further management, including reinforcement on the importance of GFD and investigations on factors affecting growth pattern. Measuring weight gain /day appears to be a sensitive indicator for monitoring growth in these children. Vitamin D and iron status should be monitored, and deficiencies corrected. (www.actabiomedica.it)

Endocrine complications of celiac disease: a case report and review of the literature

PURPOSE

The purpose of this article is to review recent literature regarding endocrine disorders related to celiac disease (CD).

METHODS

We describe a case report and review existing literature on the endocrine manifestations of CD.

RESULTS

CD is an autoimmune disorder characterized by intestinal inflammation in response to gluten. CD can cause a wide range of extra-intestinal complications, including endocrine manifestations. Metabolic bone disease including osteoporosis and osteopenia, vitamin D deficiency, secondary hyperparathyroidism and less frequently osteomalacia can be seen. In CD, fracture risk is increased by 30-40%, while risk for hip fracture is approximately doubled. The risk for other endocrine disorders, particularly autoimmune endocrinopathies, is also increased in those with CD compared to the general population. Epidemiologic data indicate the risk for hypothyroidism is 3-4 times higher among those with CD, while risk of type 1 diabetes is greater than double. Risk for primary adrenal insufficiency is a striking 11-fold higher in those with versus without CD, though the absolute risk is low. Fertility is reduced in women with CD before diagnosis by 37% while male fertility in the absence of hypogonadism does not appear to be affected. Other endocrine conditions including hyperthyroidism, ovarian failure, androgen insensitivity, impaired growth and growth hormone deficiency and autoimmune polyendocrine syndromes have also been associated with CD.

CONCLUSIONS

CD is associated with a wide range of endocrine manifestations.

Nutritional Status in Short Stature Children Is Related to Both Ghrelin and Insulin-like Growth Factor I Concentrations

OBJECTIVES

Ghrelin plays an important role in the growth processes in children. In addition, it regulates appetite. The aim of the study was to assess ghrelin and insulin-like growth factor type I (IGF-I) concentrations in children with idiopathic short stature, dependent on nutritional status.

METHODS

The study group included 116 children, ages 10.6 ± 3.5 years (mean ± standard deviation), with idiopathic short stature (height <-2.0 standard deviation scores [SDS], maximal growth hormone [GH] secretion during 2 GH-stimulating tests->10 ng/mL). In each child, fasting ghrelin, IGF-I, insulin-like growth factor binding protein 3 (IGFBP-3), glucose, insulin, lipids, leptin, adiponectin, and resistin concentrations were assessed. The IGF-I/IGFBP-3 molar ratio was calculated to determine the IGF-I bioavailability. According to body mass index SDS calculated for height age, the children were divided into 3 groups: poorly nourished (thin), normal, and obese. The control group consisted of 19 healthy children, ages 11.0 ± 3.5 years, with normal body weight and height.

RESULTS

Ghrelin concentration was significantly higher in short, thin children than in short, obese children (1458.3 ± 798.5 vs 917.2 ± 303.0 pg/mL; P < 0.005). In turn, IGF-I/IGFBP-3 molar ratio was significantly lower in short, thin children than in short, obese children (0.16 ± 0.06 vs 0.28 ± 0.15; P < 0.005).

CONCLUSIONS

In short, thin children, despite elevated ghrelin production, the low IGF-I concentration is observed, probably due to undernutrition and worse IGF-I formation. In short, normal-weight children and in short, obese ones, ghrelin and IGF-I production is normal, and it seems that mechanisms responsible for their short stature are other than low IGF-I.

Transition from childhood to adulthood in coeliac disease: the Prague consensus report

The process of transition from childhood to adulthood is characterised by physical, mental and psychosocial development. Data on the transition and transfer of care in adolescents/young adults with coeliac disease (CD) are scarce. In this paper, 17 physicians from 10 countries (Sweden, Italy, the USA, Germany, Norway, the Netherlands, Australia, Britain, Israel and Denmark) and two representatives from patient organisations (Association of European Coeliac Societies and the US Celiac Disease Foundation) examined the literature on transition from childhood to adulthood in CD. Medline (Ovid) and EMBASE were searched between 1900 and September 2015. Evidence in retrieved reports was evaluated using the Grading of Recommendation Assessment, Development and Evaluation method. The current consensus report aims to help healthcare personnel manage CD in the adolescent and young adult and provide optimal care and transition into adult healthcare for patients with this disease. In adolescence, patients with CD should gradually assume exclusive responsibility for their care, although parental support is still important. Dietary adherence and consequences of non-adherence should be discussed during transition. In most adolescents and young adults, routine small intestinal biopsy is not needed to reconfirm a childhood diagnosis of CD based on European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) or North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) criteria, but a biopsy may be considered where paediatric diagnostic criteria have not been fulfilled, such as, in a patient without biopsy at diagnosis, additional serology (endomysium antibody) has not been performed to confirm 10-fold positivity of tissue transglutaminase antibodies or when a no biopsy strategy has been adopted in an asymptomatic child.

Total and acylated ghrelin levels in children with poor growth

Ghrelin, an enteric hormone with potent appetite stimulating effects, also stimulates growth hormone release. We hypothesized that altered levels of total ghrelin (TG) or acylated ghrelin (AG) could affect growth by altering growth hormone secretion, subsequently affecting insulin-like growth factor-1 (IGF-1) generation or by altering appetite and food intake. After institutional review board approval, 52 children presenting for evaluation of chronic gastrointestinal symptoms (group 1), poor weight gain (group 2), or poor linear growth (group 3) were evaluated for fasting TG and AG levels in addition to their regular evaluation. Serum ghrelin, IGF-1, and prealbumin were compared between groups. No difference was observed for mean fasting TG between groups. However, mean fasting AG was highest in patients in group 2 (465 ± 128 pg/mL) versus group 1 (176 ± 37 pg/mL) and group 3 (190 ± 34 pg/mL). IGF-1 was lowest in patients in group 2 despite similar prealbumin levels among the three groups. We conclude that serum AG levels are highest in children with isolated poor weight gain compared with children with short stature or chronic gastrointestinal symptoms, suggesting the possibility of resistance to AG in underweight children. Additional studies are needed to further clarify ghrelin's role in growth and appetite.

Is adult height of patients with celiac disease influenced by delayed diagnosis?

OBJECTIVES

Short stature is one of the presenting symptoms of celiac disease (CD), and growth acceleration can be achieved with gluten-free diet (GFD). However, the data regarding final adult height of CD patients are scarce and inconclusive. Our aim was to evaluate the adult height of CD patients in relation to the age at diagnosis: < or =18 yr or >18 yr.

METHODS

Questionnaires were sent to CD patients > or =18 yr of age, who were either members of the Israeli Celiac Association or patients followed by the pediatric gastroenterology unit, including questions about height, weight, gender, age at diagnosis, and GFD adherence. The height Z scores were calculated for each patient.

RESULTS

In total, 290 patients (M/F = 83/207), age 38.9 +/- 15.5 yr (range 18-76), were included: 113 were diagnosed before and 177 after 18 yr of age (groups 1 and 2, respectively). The mean adult height was: 178.4 +/- 6.6 cm and 176.2 +/- 8.6 cm for men (P= 0.22), and 163.0 +/- 6.6 cm and 162.6 +/- 6.5 cm for women (P= 0.68) in groups 1 and 2, respectively. The height Z scores were 0.230 +/- 0.931 and -0.07 +/- 1.19 for men (P= 0.22), and -0.05 +/- 1.02 and -0.101 +/- 0.990 for women (P= 0.68) in groups 1 and 2, respectively. The final height inversely correlated with age at diagnosis in men (R =-0.275, P= 0.012) but not in women (R =-1.0, P= not significant [NS]).

CONCLUSIONS

The final height of patients with CD is similar to the general population. The adult height of male patients with CD is inversely related to the age at diagnosis. Delayed diagnosis of CD may lead to a shorter adult height in men but not in women.

Osteoporosis in celiac disease and in endocrine and reproductive disorders

As the increase in lifespan brings to light diseases that were previously not clinically detectable, osteoporosis has become an issue of worldwide significance. The disease is marked by a loss of bone mass; the bones become less dense, fragile and more prone to fracturing. Because it is regulated by endocrine and environmental factors, osteoporosis presents a multifactorial etiopathogenesis, with the genetic component accounting for 70% of an individual variation in bone mass density (BMD), the principal determinant, with age, of fracture risk. Pathological conditions such as celiac disease (CD) exacerbate the process of bone loss, so that the occurrence of osteoporosis in celiac subjects is of particular note: indeed, the screening of osteoporosis patients for this disease is advisable, since it may be the only sign of undiagnosed CD. An increase in interleukin IL-1β, of the IL-1 system, in the relatives of celiac patients confirms the genetic predisposition to osteoporosis and its presence is evidence of an association between the two conditions. The direct effect on the bones of CD is secondary to poor absorption of calcium and vitamin D. In women osteoporosis is indirectly associated with early menopause and amenorrhea, and it may follow prolonged breast-feeding and frequent pregnancies, while in men it is associated with hypogonadism and GH deficit. These endocrine and non-endocrine factors exert their effects on bones by modulating the RANK/RANK-L/OPG system. An appropriate lifestyle from adolescence onwards, together with early diagnosis of and treatment for CD and primary and secondary endocrine pathologies are important for the prevention of damage to the bones.

Growth hormone treatment in prepubertal children with celiac disease and growth hormone deficiency

OBJECTIVE

To evaluate the growth response to growth hormone (GH) replacement therapy during a gluten-free diet in patients with celiac disease (CD) associated with GH deficiency (GHD).

PATIENTS AND METHODS

A total of 14 prepubertal children affected by CD and GHD with no catch-up growth after >/=12 months of gluten-free diet and a reversion to seronegativity for antiendomysium antibodies and 10 age-matched prepubertal children with idiopathic GHD (IGHD) entered the study. All of the patients were treated with the same GH dosage (0.25 mg/kg subcutaneously each week). Height, growth rate, and body mass index were measured at the time of diagnosis of CD, at the time of endocrinological evaluation, and after the first, second, and third year of GH replacement therapy.

RESULTS

Growth rate strikingly increased (P < 0.005) during the first year of therapy in a similar way in subjects with CD/GHD and IGHD (from a median standard deviation score [SDS] of -2.34 to an SDS of 3.25 and from an SDS of -1.29 to an SDS of 2.79, respectively). During the second and third years of GH treatment, the growth rate tended to decrease but the values at the third year were always positive (CD/GHD, median SDS, 1.10; IGHD, median SDS, 0.11), indicating continued catch-up growth.

CONCLUSIONS

In patients with CD with GH deficiency confirmed after >/=12 months of gluten-free diet, GH replacement therapy should be started to allow complete catch-up growth in children. In addition, the effect of GH treatment in patients who comply with a gluten-free diet seems to be comparable to that observed in children with IGHD.