Pediatric Nutrition in Practice

Celiac Disease 191

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extraintestinal symptoms (iron deficiency ane-
mia, neurological problems, alterations in liver
function tests, enamel defects and osteoporosis)
to asymptomatic cases [3]. Also, the small intes-
tinal lesions may range from epithelial lympho-
cyte infiltration with preserved villous archi-
tecture to severe villous atrophy [4]. The nutri-
tion status at diagnosis depends mostly on the
extent of the intestinal damage. The classic pre-
sentation is accompanied by steatorrhea and fat-
soluble vitamin deficiency. Malabsorption of
iron, calcium and folic acid is also frequent, as
these are absorbed in the proximal small intes-
tine [5].
The diagnostic approach has recently been re-
vised [1]. Children found positive for CD-spe-
cific antibodies (anti-TG2, EMA and anti-DGP)
should undergo duodenal biopsies unless certain
conditions are fulfilled which allow the option to
omit the confirmatory biopsies. In children and
adolescents with signs or symptoms suggestive of
CD and very high anti-TG2 (or anti-DGP) titers
with levels exceeding 10 times the upper limit of
normal, the likelihood for villous atrophy (Marsh
score 3) is high. In this situation, the pediatric
gastroenterologist may discuss with the parents
and patient (as appropriate for the patient’s age)
the option of performing further laboratory test-
ing (EMA, HLA) in order to make the diagnosis
of CD without biopsies. In the case of an asymp-

tomatic child or adolescent with CD-associated

conditions, duodenal biopsies are still advocated

in all cases.

G l u t e n - F r e e D i e t

The only treatment for CD is lifelong strict adher-

ence to a gluten-free diet (GFD; table  1 ). GFD

consist of the dietary exclusion of grains contain-

ing gluten (wheat, rye, barley, triticale, couscous,

spelt and Kamut). Rice, corn and buckwheat do

not contain gluten and can be eaten. Potato,

chestnut, tapioca, sorghum, quinoa and ama-

ranth are also tolerated. Although there is now a

large body of clinical evidence suggesting oats

lacking toxicity for CD patients, there are still

some important aspects to consider [6]. There are

documented cases of oat-dependent villous atro-

phy in patients with oat-specific mucosal T cell

reactivity. Furthermore, there is also the possibil-

ity that symptoms are related to wheat proteins

contaminating oats during the harvesting and

milling process. Another issue that warrants fur-

ther investigation is related to the great heteroge-

neity of oat cultivars. On the other hand, the in-

corporation of oats into a GFD provides high fi-

ber and vitamin B content, increased palatability

and beneficial effects on cardiovascular health.

However, it seems wise to add oats only when the

Ta b l e 1. Fundamentals of the GFD

Grains that should be
avoided

Wheat (including spelt, Kamut, semolina and triticale), rye and barley

(including malt)

Safe grains (gluten free) Rice, amaranth, buckwheat, corn, millet, quinoa, sorghum, teff
(an Ethiopian cereal grain) and oats (?)

Sources of gluten-free
starches that can be
used as flour alternatives

Cereal grains: rice, amaranth, buckwheat, corn, millet, quinoa, sorghum and teff

Tubers: potato, arrowroot, jicama, taro and tapioca

Legumes: chickpeas, lentils, kidney beans, navy beans, pea beans, peanuts and

soybeans

Nuts: almonds, walnuts, chestnuts, hazelnuts and cashews

Seeds: sunflower, flax and pumpkin

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 190–194
DOI: 10.1159/000367874