New developments in childhood celiac disease

Support for patients with celiac disease: A literature review

BACKGROUND

Celiac disease (CD) is a lifelong disorder. Patients are at increased risk of complications and comorbidity.

OBJECTIVES

We conducted a review of the literature on patient support and information in CD and aim to issue recommendations about patient information with regards to CD.

DATA SOURCE

We searched PubMed for English-language articles published between 1900 and June 2014, containing terms related to costs, economics of CD, or education and CD.

STUDY SELECTION

Papers deemed relevant by any of the participating authors were included in the study.

DATA SYNTHESIS

No quantitative synthesis of data was performed. Instead we formulated a consensus view of the information that should be offered to all patients with CD.

RESULTS

There are few randomized clinical trials examining the effect of patient support in CD. Patients and their families receive information from many sources. It is important that health care personnel guide the patient through the plethora of facts and comments on the Internet. An understanding of CD is likely to improve dietary adherence. Patients should be educated about current knowledge about risk factors for CD, as well as the increased risk of complications. Patients should also be advised to avoid other health hazards, such as smoking. Many patients are eager to learn about future non-dietary treatments of CD. This review also comments on novel therapies but it is important to stress that no such treatment is available at present.

CONCLUSION

Based on mostly observational data, we suggest that patient support and information should be an integral part of the management of CD, and is likely to affect the outcome of CD.

Management of celiac disease

Celiac disease (CD) is an enteropathy-induced immune response that occurs on exposure to toxic gluten in the diet and is reversible once gluten is withdrawn. A gluten-free diet is the preferred treatment for CD and leads to reversal of villous atrophy. Counseling, nutritional support, and follow-up are vital aspects in CD management. The pickup rate of CD has improved with the availability of serologic tests, and this has led to a reduction in morbidity in treated CD cases. Managing CD can potentially prevent or cure some of the associated conditions, such as neurologic complications, nutritional deficiencies, and osteoporosis.

Questionnaire-based case finding of celiac disease in a population of 8- to 9-year-old children

OBJECTIVE

Antibody screenings and diagnosis of celiac disease (CD) among children with type 1 diabetes have suggested that a considerable proportion of children with CD may, in fact, have preclinical (undiagnosed) symptoms. We aimed to test if a questionnaire would lead to significant case finding in an unselected population of 8- to 9-year-old children.

PATIENTS AND METHODS

The study population included 9880 children aged 8 to 9 years. Before the study, 13 children from the study population were known to have CD. We developed a questionnaire on the basis of 5 simple items suggestive of CD and mailed the questionnaire to the families of all children in the study population who resided in the County of Funen, Denmark. In total, 7029 respondents returned the questionnaire (70%); among them, 2835 children had 1 or more symptoms. These children were invited for a blood test to determine their human serum immunoglobulin A (IgA) anti-tissue transglutaminase antibody (anti-tTG) levels.

RESULTS

Of the 1720 children who were tested for the human serum IgA anti-tTG, 24 participants had a positive result (range: 20 to >150 U). Seventeen of these children underwent an upper endoscopy procedure. Fourteen children had histologic signs of CD (Marsh classification stage III). Fourteen children met the diagnostic criteria for CD. The prevalence proportion of patients who were newly diagnosed with CD was 0.14% (95% CI: 0.08-0.24) (14 of 9967), and the estimate of the minimum total prevalence proportion of children with CD was 0.27% (95% CI: 0.18-0.39) (27 of 9980). The maximal prevalence proportion of patients with newly diagnosed CD was 1.22% (95% CI: 0.76-1.90) (21 of 1720), including those participants who had a positive anti-tTG result but not a final diagnosis of CD. The ratio of known to minimally symptomatic CD was approximately 1:1.

CONCLUSION

A number of preclinical and low-grade symptomatic patients with CD may be identified by their responses to a mailed questionnaire.

Celiac disease: presentation of 109 children

PURPOSE

The clinical features of patients with celiac disease (CD) are variable. In the present study, clinical and laboratory features of 109 patients with CD were retrospectively evaluated.

MATERIALS AND METHODS

In all cases, diagnosis of CD was made by European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) criteria and clinical and laboratory findings, including hematological and biochemical analyses, immunoglobulin levels, autoantibodies [antinucler antibody (ANA), antidouble stranded DNA (dsDNA), antimitochondrial antibody (AMA), anti-smooth muscle antibody (ASMA), liver kidney antibody (LKM-1), anti thyroid peroxidase (TPO), anti thyroglobulin (Tg)], bone mineral density (BMD), and electroencephalogram were evaluated. The type of CD was recorded.

RESULTS

Of 109 patients with CD, 66 (60.6%) were classical type, 41 (37.6%) were atypical type and 2 (1.8%) were silent type. The mean age was 8.81 +/- 4.63 years and the most common symptom was diarrhea (53.2%) followed by failure to thrive, short stature, and abdominal pain. Paleness (40.4%), underweight (34.8%), and short stature (31.2%) were the most common findings. Iron deficinecy anemia (81.6%), zinc deficiency (64.1%), prolonged prothrombin time (35.8%), and elevated transaminase levels (24.7%) were the most common laboratory findings. Eight percent of patients had at least 1 autoantibody, and 28 of 52 patients had low BMD. Four of 38 patients had abnormalty in electroencephalograms. The prevalance of selective immunoglobulin (Ig) A deficiency was 9.1%. Histocompatibility antigen HLA-DQ and/or DQ8 genotypes were found in 91% of patients. Abdominal distention, iron deficiency, prolonged prothrombine time, hypoalbuminemia, and elevated transaminase levels were more significantly frequent in the classical type than atypical type (p < 0.005).

CONCLUSION

Although classical CD was seen in most patients in the present study, clinical variability of the condition should be kept in mind.

Histomorphology of healthy oral mucosa in untreated celiac patients: unexpected association with spongiosis

BACKGROUND

The jejunal mucosa is the major site involved in celiac disease, but modifications have also been found in the gastric, rectal and esophageal mucosa. Few studies have focused on the histomorphological features of the oral mucosa in celiac disease patients. Our objectives were: (i) to assess the presence, quality and intensity of lymphocytic infiltrate in clinically healthy oral mucosa and its relation to celiac disease severity (villous height to crypt depth ratio); and (ii) to detect any other histological features connected to celiac disease.

METHODS

Twenty-one untreated celiac disease patients (age range 13-68 years) with clinically healthy oral mucosa were enrolled and compared with 14 controls. Intestinal and oral biopsies were carried out and specimens were evaluated after staining with hematoxylin and eosin.

RESULTS

Intra-epithelial lymphocyte B and T infiltrates of the oral mucosa were found to be similar in both groups; likewise, intensity of the lymphocytic infiltrate in the lamina propria was similar in both groups and was not related to intestinal damage; important signs of spongiosis were found to be more significantly present in celiac disease patients compared with controls (P = 0.0002).

CONCLUSIONS

Our study showed that the healthy oral mucosa of untreated patients does not reflect the intestinal damage by celiac disease, but it is unexpectedly affected by spongiosis, as being detected for the first time in the literature. This latter feature could be related to gliadin ingestion and could contribute to explain the higher susceptibility of celiac disease patients to suffering from oral mucosa lesions.

[Study of celiac disease in the pediatric population of Cantabria (Spain) and first-degree relatives]

BACKGROUND

Celiac disease (CD) is an autoimmune disease that affects genetically predisposed individuals. The HLA-DQ2 heterodimer is present in nearly 90% of patients while HLA-DQ8 is found in the remaining 10%.

AIM

To study the characteristics of CD in pediatric patients in Cantabria and their first-degree relatives, with special emphasis on factors related to haplotype, serology, and forms of clinical presentation.

PATIENTS AND METHODS

Eighty-six patients with CD and 215 first-degree relatives were HLA genotyped. Clinical, laboratory, immunologic, and histological data were obtained from all patients.

RESULTS

Clinical presentation was classical in 95% of the patients and mono-symptomatic in the remaining 5%. Anti-gliadin antibodies (AGA) and anti-transglutaminase antibodies (ATGA) were positive in 95% of the patients and negative in 5% (all with IgA deficiency). DQ2 was found in 71% of the patients (homozygotes or heterozygotes) and DQ8 was found in 9.5%. No heterodimers of risk were found in 22%. CD was found in six relatives (three were positive for AGA and four were positive for ATGA). Forty-nine percent of the relatives carried the DQ2 heterodimer and 15% the DQ8 heterodimer; no heterodimers of risk were found in 40%.

CONCLUSIONS

The most prevalent HLA found in patients with CD in the autonomous region of Cantabria was DQ2 (71%). This prevalence is clearly lower than that reported in other Spanish regions. The prevalence of CD among first-degree relatives was similar to that found in other studies performed in Spain (2.8%). Our data support the need for systematic study of the first-degree relatives of patients with CD.

Coeliac disease: oral ulcer prevalence, assessment of risk and association with gluten-free diet in children

AIMS

Oral mucosal lesions may be markers of chronic gastrointestinal disorders, such as those causing malabsorption. Our objectives were to assess the prevalence of recurrent oral aphthous-like ulcers in coeliac disease patients living in the Mediterranean area, and to evaluate the impact of a gluten-free diet.

METHODS

A test group of 269 patients (age range 3-17 years) with coeliac disease confirmed both serologically and histologically was compared with a control group of 575 otherwise clinically healthy subjects for the presence, or a positive history of aphthous-like ulcers. Coeliac disease patients with aphthous-like ulcers were re-evaluated 1-year after starting a gluten-free diet.

RESULTS

Aphthous-like ulcers were found significantly more frequently in coeliac disease, in 22.7% (61/269) of patients with coeliac disease versus 7.1% (41/575) of controls (p=<0.0001; chi-square=41.687; odds ratio=4.3123; 95% confidence interval=2.7664:6.722). Most coeliac disease patients with aphthous-like ulcers and adhering strictly to gluten-free diet (71.7%; 33/46) reported significant improvement on gluten-free diet, with no or reduced episodes of aphthous-like ulcers (p=0.0003; chi-square=13.101; odds ratio=24.67; 95% confidence interval=2.63:231.441).

CONCLUSIONS

The epidemiological association found between coeliac disease and aphthous-like ulcers suggests that recurrent aphthous-like ulcers should be considered a risk indicator for coeliac disease, and that gluten-free diet leads to ulcer amelioration.

Lower economic status and inferior hygienic environment may protect against celiac disease

BACKGROUND

The populations in adjacent Russian Karelia and Finland are equally exposed to grain products and share partly the same ancestry, but live in completely different socioeconomic environments.

AIM

This creates an ideal epidemiological setting to study gene-environmental interactions in pathogenesis of celiac disease.

METHODS

The prevalence of celiac disease and predisposing human leukocyte antigen (HLA) alleles was compared between Russian Karelia and Finland. Tissue transglutaminase antibodies and HLA-DQ alleles were screened from 1988 schoolchildren from Karelia and 3654 children from Finland. Children with transglutaminase antibodies were invited to small-bowel biopsy. Results. Transglutaminase antibodies were less frequent in Russian Karelia than in Finland (0.6% versus 1.4%, P = 0.005). Immunoglobulin class G (IgG) antigliadin antibodies were also less frequent in Russian Karelia (10.2% versus 28.3%, P<0.0001). Celiac disease was confirmed by duodenal biopsy in four of the eight transglutaminase antibody-positive Karelian children, giving a prevalence of 1 in 496 compared to 1 in 107 children in Finland. The same HLA-DQ alleles were associated with celiac disease and transglutaminase antibody positivity in both populations.

CONCLUSIONS

The prevalence of transglutaminase antibodies and celiac disease is lower in Russian Karelia than in Finland. This may be associated with a protective environment characterized by inferior prosperity and standard of hygiene in Karelia.

A rare condition associated with celiac disease: Evans syndrome

Celiac disease (CD) is one of the most common chronic disorders in childhood. Autoimmune and nonautoimmune disorders including dermatitis herpetiformis, type 1 diabetes mellitus, and autoimmune thyroiditis can be encountered associated with CD. Common hematologic manifestations of CD include anemia owing to iron, folate, or vitamin B12 deficiency. We report a case with CD associated with Evans syndrome of whom to our knowledge, is the first child to be reported in the literature.

Lack of association between celiac disease and dental enamel hypoplasia in a case-control study from an Italian central region

BACKGROUND

A close correlation between celiac disease (CD) and oral lesions has been reported. The aim of this case-control study was to assess prevalence of enamel hypoplasia, recurrent aphthous stomatitis (RAS), dermatitis herpetiformis and atrophic glossitis in an Italian cohort of patients with CD.

METHODS

Fifty patients with CD and fifty healthy subjects (age range: 3-25 years), matched for age, gender and geographical area, were evaluated by a single trained examiner. Diagnosis of oral diseases was based on typical medical history and clinical features. Histopathological analysis was performed when needed. Adequate univariate statistical analysis was performed.

RESULTS

Enamel hypoplasia was observed in 26% cases vs 16% in controls (p > 0.2; OR = 1.8446; 95% CI = 0.6886: 4.9414). Frequency of RAS in the CD group was significantly higher (36% vs 12%; p = 0.0091; OR = 4.125; 95% CI = 1.4725: 11.552) in CD group than that in controls (36% vs 12%). Four cases of atrophic glossitis and 1 of dermatitis herpetiformis were found in CD patients vs 1 and none, respectively, among controls.

CONCLUSION

The prevalence of enamel hypoplasia was not higher in the study population than in the control group. RAS was significantly more frequent in patients with CD.

Coeliac disease in children

Although coeliac disease (CD) can present at any age, including the elderly, typical cases often manifest in early childhood. The clinical spectrum in children is wide and includes: (1) typical cases presenting early in life with signs of intestinal malabsorption (chronic diarrhea, weight loss, abdominal distention, etc); (2) atypical cases showing milder, often extra-intestinal, symptoms; (3) silent cases that are occasionally discovered because of serological screening; (4) potential/latent cases showing isolated positivity of coeliac serology at first testing and eventually the typical intestinal damage later in life. Many CD-associated problems, which were originally described mostly in adults, can indeed be observed in children or adolescents, e.g. reduced bone mineral density, neurological problems and associated autoimmune disorders. It is instrumental that both primary pediatricians and pediatric subspecialists have a high degree of awareness and embrace a 'liberal' use of serological CD tests in order to identify these cases in a timely fashion to prevent serious complications secondary to untreated CD.

Clinical presentation of celiac disease in the pediatric population

Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten-containing grains (including wheat, rye, and barley) in genetically susceptible individuals. CD is associated with HLA molecules DQ2 (90%-95%) and DQ8 (5%-10%), and in the continued presence of gluten the disease is self-perpetuating. CD is one of the most common lifelong disorders worldwide and is characterized by a variety of clinical presentations. These include the typical malabsorption syndrome (classic symptoms) and a spectrum of symptoms potentially affecting any organ or body system (nonclassic symptoms). Because CD often is atypical or even clinically silent, many cases go undiagnosed and are exposed to the risk of long-term complications. There is growing interest in the social aspects of CD because the burden of illness related to this condition is doubtless higher than previously thought.

Presentation of pediatric celiac disease in the United States: prominent effect of breastfeeding

Childhood celiac disease (CD) is considered rare in the United States. Consequently there are few data concerning its clinical presentation. A validated questionnaire was distributed to families of children with CD. One hundred forty-one children with biopsy-proven CD were included in the study. We found significant differences in the clinical spectrum of children based on their infant feeding history. Exclusively breastfed children were significantly less likely to report failure to thrive (69% vs 88%, p<0.05) and short stature (37% vs 62%, p<0.05), and had a higher rate of "atypical'' symptoms (p<0.01). Breastfeeding alters the presentation and contributes to atypical presentations of CD and diagnostic delay. Pediatricians need to be aware of the diverse manifestations of celiac disease to reduce diagnostic delay.

Emerging concepts in celiac disease

PURPOSE OF REVIEW

There has been an explosion in knowledge about celiac disease (CD) in the last decade based on the availability of serologic screening tests and the elucidation of some of the important disease susceptibility genes. What has been discovered is that CD is among the most common inherited diseases with a worldwide prevalence of almost 1% of the population. Also, there has been a tremendous expansion of the possible clinical presentations in patients with CD, many of them predominantly or even exclusively extraintestinal. Over the last year, both the North American Society of Pediatric Gastroenterology and Nutrition, and the NIH, through the mechanism of a consensus development conference held in May 2004, have published guidelines outlining the current state of knowledge and the areas where more research is needed.

RECENT FINDINGS

This review will stress the most recent findings in CD in the areas of genetics, pathogenesis, epidemiology, screening and diagnosis, and natural history. It will stress the importance of HLA DQ2 and DQ8 as disease susceptibility genes, and the interaction of the environmental triggers (gliadins and glutenins) with these gene products to trigger the immunologic response in the gut that is responsible for the pattern of injury. Recent reports that stress the importance of screening high-risk groups (i.e. siblings of index cases and first degree relatives, patients with Type I diabetes, patients with Downs syndrome, patients with IgA deficiency) will be highlighted. The identification of the most sensitive and specific screening tests will be summarized with an explanation of special situations that affect the interpretation of these tests. Finally, the long-term morbidities associated with CD will be characterized supporting the case for early diagnosis and treatment.

SUMMARY

The implications of these recent findings are of tremendous importance for both pediatricians and internists. Screening of high-risk groups, and of patients with the common symptoms of irritable bowel syndrome, iron deficiency anemia, unexplained arthritis, and even chronic elevations of aminotransferases is becoming the accepted standard of practice. Much research remains to be done to further refine our understanding of CD, and to devise more effective strategies for treatment, compliance, and prevention of long-term complications.

CALCIUM AND BONE MINERAL METABOLISM IN CHILDREN WITH CHRONIC ILLNESSES

Increased longevity and improved medical management of children with chronic illnesses has led to a focus on the short- and long-term consequences of these conditions on bone health. Bone loss is influenced by diet, malabsorption, and disease-related imbalances in bone turnover. It may be exacerbated by common medications, especially corticosteroids. Assessment of bone mass and quality, calcium absorption, kinetically derived rates of bone turnover, and biochemical markers of bone turnover have increased our knowledge of the pathophysiology of bone loss in these children as well as provided insights into possible therapeutic interventions. Increased intake of calcium and vitamin D, while useful, is unlikely to prevent or resolve bone loss in many chronically ill children. Emphasis on combination of nutritional interventions with exercise and newer bone-sparing therapies may be necessary.