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Coeliac disease and gluten-related disorders in childhood

Key Points

  • The fundamental step in diagnosing coeliac disease is awareness of symptom diversity; anti-transglutaminase antibodies are very specific for the diagnosis and, in children, duodenal biopsies can sometimes be omitted

  • Prospective studies show that coeliac disease manifests at a young age, more often in girls, and is related to the HLA genotype, but not the timing of gluten introduction or breastfeeding

  • Wheat allergy is one of the most common food allergies in children beginning in early childhood; it is less common in adolescents and adults; most children outgrow wheat allergy by 12 years

  • Noncoeliac gluten sensitivity is a clinical condition in which symptoms are triggered by gluten ingestion in the absence of coeliac disease and wheat allergy

  • No biological markers exist for noncoeliac gluten sensitivity, exclusion of coeliac disease and of wheat allergy is the most important diagnostic step

  • Once a gluten-related disorder is diagnosed, children should be referred to a paediatric dietitian for in-depth guidance about the necessary dietary treatment

Abstract

Gluten-related disorders such as coeliac disease, wheat allergy and noncoeliac gluten sensitivity are increasingly being diagnosed in children. Coeliac disease occurs frequently, affecting 1–3% of the Western population. The condition manifests at a very young age, more so in girls, and is related to the HLA genotype. Coeliac disease might be considered a public health problem and, as primary prevention is not possible, the debate on mass screening should be reopened. Wheat proteins, including gluten, are responsible for one of the most common food allergies in children: wheat allergy. Unlike coeliac disease and wheat allergy, noncoeliac gluten sensitivity is an unclear and controversial entity. These three gluten-related disorders are treated with a gluten-free diet. In coeliac disease, the diet should be strictly followed, whereas wheat allergy only requires wheat elimination and in noncoeliac gluten sensitivity occasional trials of gluten reintroduction can be done. A good diagnostic work-up is important for gluten-related disorders in childhood to avoid unnecessary restrictive diets in children. In this Review, we provide an overview of the pathogenesis, diagnosis and management of the most common gluten-related disorders in children.

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Figure 1: Flow-chart of the diagnostic process in a child with a suspected gluten-related disorder.
Figure 2: Schematic representation of the immune response to gluten peptides in the small bowel mucosa of patients with coeliac disease.
Figure 3: ESPGHAN algorithm for the diagnosis of coeliac disease in children and adolescents with symptoms.
Figure 4: ESPGHAN algorithm for the diagnosis of coeliac disease in asymptomatic children and adolescents with a genetic risk of coeliac disease.

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Acknowledgements

We thank Dr D. Amado, visiting paediatrician at Leiden University Medical Centre, for editing the manuscript.

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Correspondence to M. Luisa Mearin.

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Vriezinga, S., Schweizer, J., Koning, F. et al. Coeliac disease and gluten-related disorders in childhood. Nat Rev Gastroenterol Hepatol 12, 527–536 (2015). https://doi.org/10.1038/nrgastro.2015.98

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