How to manage pediatric celiac disease
Children with celiac disease should be managed with multivitamins because of the lack of supplementation and enrichment in gluten-free flours. Families also should be counseled on age-appropriate intake and supplementation of calcium and vitamin D to head off decreased bone density that may be present at the time of diagnosis. Butzner says that children, unlike adults, are able to recover bone density lost as a result of severe malabsorption or metabolic bone disease after 1 year on a gluten-free diet.
A review of the child’s growth and health should occur at 1 year after diagnosis, and then every 1 to 2 years thereafter, preferably by both a physician and a dietician. Review should include growth measurements, interim health history, a complete blood count, and follow-up celiac serology (IgA-tissue transglutaminase) to monitor compliance with the gluten-free diet, Butzner says.
Children that had not received a hepatitis B vaccination at the time they were diagnosed also should have their immunization status reviewed, Butzner advises. “Literature suggests that 30% to 70% of children with untreated celiac disease are nonresponsive to the hepatitis B vaccine,” he says.
Butzner also recommends screening for hypothyroidism, particularly at ages of rapid growth.
Celiac isn’t as rare as was once thought, Butzner says, which is actually a good thing in terms of management. Roughly 1 in 133 North Americans have celiac disease and gluten-free food options are now readily available, making strict adherence to a gluten-free diet more manageable than it once was.
The key for pediatric populations is teaching children to manage their own diets, Butzner says. “They need to be involved in grocery shopping, menu planning, restaurant assessment, food ordering, and trip organization in regard to a gluten-free diet,” he says.
A commentary on the guidelines, also published in Pediatrics, champions the suggestion that pediatric celiac patients be screened for hepatitis B immunity—a lesser-known complication of celiac disease.
The commentary authors, Tracy R Ediger, MD, PhD, a pediatric gastroenterologist at Nationwide Children’s Hospital in Columbus, Ohio, and Ivor D Hill, MD, MB, ChB, pediatric gastroenterologist and director of the Celiac Disease Center at Nationwide Children’s Hospital, also praise the research team for crafting a set of guidelines that can provide clinicians with clear directions for follow-up care.
“Studies clearly show that those with celiac disease who have regular follow-up are more likely to remain adherent to a gluten-free diet and have a better long-term prognosis,” Ediger and Hill write in the commentary. “This article provides a useful roadmap to healthcare providers for the associated testing at diagnosis and during follow-up visits to monitor for comorbidities associated with the underlying disease, or as a consequence of the dietary restrictions, and to ensure the optimal health and well-being of the patient.”
Although not mentioned in the guidelines, there has been recent research suggesting that all celiac patients benefit from pneumococcal immunization. Only about a quarter of celiac patients in the study had been vaccinated at the time of diagnosis, but the study warns that patients with celiac disease are 28% more likely to contract community-acquired pneumonia as a result of hyposplenism caused by their celiac disease.