Use Caution When Prescribing a Gluten-Free Diet

The growing popularity of a gluten-free diet among adults appears to be spilling over to children, with help from the pediatrician’s office.

“An increasing number of primary care physicians, who are seeing children with symptoms possibly related to gluten intolerance, are advising them to try a gluten-free diet without any initial investigations or work-up to exclude celiac disease or other causes,” says Ivor Hill, MD, chief of the Section of Gastroenterology, Hepatology and Nutrition at Nationwide Children’s Hospital and director of Nationwide Children’s Celiac Disease Center. “It’s creating a bit of a problem.”

Changes caused by the diet mask the underlying condition, and each underlying condition has different long-term health consequences. Physicians need to know what is causing the symptoms in order to best treat and monitor a child, specialists say.

At the request of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition,  Dr. Hill assembled and led a group of authorities who have written a report to help  general pediatricians distinguish among conditions that benefit from a gluten-free diet and apply best practices. The paper is published in the Journal of Pediatric Gastroenterology and Nutrition.

“We wanted to specifically encourage pediatricians not to advise children to go on a gluten-free diet before they’ve done some testing,” says Dr. Hill, who is also a professor of Clinical Pediatrics at The Ohio State University College of Medicine.

Three conditions benefit from removal of gluten from the diet. In order to test for them, children must be on a diet containing gluten. If already on a gluten-free diet, patients must be returned to a regular diet. (Note that health risks and often-uncomfortable symptoms may come back when gluten is reintroduced).

The conditions are:

• Celiac disease
  Celiac disease requires lifelong adherence to a gluten-free diet and monitoring for other autoimmune diseases and associated health risks.”Pediatricians need to have a high index for suspicion for celiac disease,” Dr. Hill says. He concedes symptoms are broad and highly variable, but says that if the symptoms are compatible with the disease, a pediatrician should run a serological test early on.Children older than 2 years of age usually only need to be tested for one antibody, tissue transglutaminase. For younger children, tests for two antibodies are needed.The specialists suggest that when antibody tests are positive — or even if they’re negative but a strong clinical suspicion for celiac disease remains — pediatricians should consider referring the child to a pediatric gastroenterologist to have the diagnosis confirmed.
• Wheat allergy
  Wheat allergy may range from mild (and something most children outgrow) to deadly.A number of tests may indicate a wheat allergy, but a food challenge administered by a food allergy specialist is usually needed to confirm the diagnosis, Dr. Hill and his colleagues say.
• Nonceliac gluten sensitivity (NCGS)
  NCGS is a less-well-defined gluten intolerance with less-well-defined consequences.There are currently no initial tests for NCGS. Experts recommend that pediatricians first exclude celiac disease and wheat allergy as underlying causes.  After that, the clinical response to changing from a general diet to gluten-free, and from gluten-free back to a regular diet helps diagnose NCGS.

Reference:

Hill ID, Fasano A, Guandalani S, Hoffenberg E, Levy J, Reilly N, Verma R. NASPGHAN clinical report on the diagnosis and treatment of gluten-related disorders.. Journal of Pediatric Gastroenterology and Nutrition. 2016 Jul;63(1):156-65.