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| Case Study, Biomed Biopharm Res., 2023; 20(1):150-155 doi: 10.19277/bbr.20.1.309; PDF version [+]; Portuguese html [PT] |
Celiac disease in children (Clinical case)
Bruno Sousa 1,2,3 
✉️ & José Luís Nunes 3
1 - School of Sciences and Health Technologies, Universidade Lusófona de Humanidades e Tecnologias, Lisboa, Portugal
2 - CBIOS - Center for Biosciences & Health Technologies, Universidade Lusófona de Humanidades e Tecnologias, Lisboa, Portugal
3 - Health Service of Autonomous Region of Madeira
Introduction
11-year-old female child. Sent to the Nutrition Consultation due to suspicion of celiac disease and to start a gluten-free diet, after analytical values with positive IgA anti-gliadin and IgA anti-transglutaminase antibodies and associated symptoms: asthenia, anorexia, abdominal pain, abdominal distension and diarrhea.
Subsequently, for further analytical research and to perform an upper digestive endoscopy with biopsy, a gluten diet was reintroduced.
The child is followed in pedopsychiatry for attention deficit hyperactivity disorder and challenging personality.
Keywords: Celiac disease, children, gluten-free diet
To Cite: Sousa, B. & Nunes J. L. (2023) Celiac disease in children (Clinical case). Biomedical and Biopharmaceutical Research, 20(1), 150-155.
Correspondence to:
Received 19/05/2023; Accepted 11/06/2023
Anthropometric evaluation
Weight: 39.3 kg
Height: 152 cm
BMI: 17 kg/m2
Body composition assessment (TANITA TBF 300®)
Body fat: 15.4%
Fat mass: 6.1 kg
Fat-free mass: 33.2 kg
Total body water: 24.3 kg
Analytical parameters
Hematology
Leukocytes: 4.9 10^3/μL (4.0 – 10.0)
Erythrocytes: 4.21 10^6/μL (3.80 – 5.70)
Hemoglobin: 11.8 g/dL (11.9 – 16.9)
Hematocrit: 35.1% (34.0 - 47.0)
Mean corpuscular volume: 83.4 fL (77.0 – 91.0)
Mean corpuscular hemoglobin: 28.0pg (>27.2)
Platelets: 379 10^3/μL (144 – 440)
Biochemistry
Glucose: 91 mg/dL (60.0 - 100.0)
Urea: 20 mg/dL (8.0 – 50.0)
Creatinine: 0.38 mg/dL (0.58 – 0.79)
Sodium: 140.0 mEq/L (136 - 145)
Potassium: 4.0 mEq/L (3.5 – 5.10)
Chorine: 105.0 mEq/L (98-107)
Alanine Aminotransferase: 24.5 U/L (<=33.0)
Aspartate Aminotransferase: 25.0 U/L (<=32)
Gamaglutamyltransferase: 13.2 U/L (5.0 – 36.0)
Hematinic factors
Ferritin: 33.0 ng/mL (13-150)
Folic Acid: 3.95 ng/mL (>3.89)
Vitamin B12: 532 pg/mL (197 - 771)
Immunology
IgA (serum): 69.7 mg/dL (45.0 - 250)
Ac. Anti-Gliadin, IgG: 62.1 U/mL (Positive: >10)
Ac. Anti-Gliadin, IgA: 72.7 U/mL (Positive: >10)
Ac. Anti-Transglutaminase, IgG: 0.0 U/mL (Positive: >10)
Ac Anti-Transglutaminase, IgA: >200 U/mL (Positive: >10)
Complementary diagnostic exams
Upper Digestive Endoscopy:
Duodenum and bulb with "cobblestone" appearance. Performed biopsies.
Anatomopathological report:
Morphological aspects suggestive of Celiac Disease, to be evaluated in the clinical context.
If there are clinical and analytical criteria for Celiac Disease, then the aspects observed in the biopsy correspond to grade 3 of the modified Marsh classification (Marsh-Oberhuber).
Clinical evaluation
Personal background
- Attention deficit hyperactivity disorder
Medication
- Methylphenidate
- Risperidone
- Melatonin
Intestinal transit
Regular (after gluten-free diet)
Eating habits
Wake up at 6:45 am
Breakfast: 7 am
Gluten-free bread (50 g) with boiled egg or oat pancakes with banana
1 natural or aroma yoghurt
Morning snack: 10 am
Gluten-free bread (50 g) with 1 slice of cheese
1 medium piece of fruit
Lunch: 1 pm
Dish: Half a plate of white rice or gluten-free pasta + meat or fish (120 g) + vegetables (about 100 g)
Water to drink
Afternoon snack: 4 pm
1 flavoured liquid yoghurt
Gluten-free bread (50 g) with 1 slice of cheese
Dinner: 8:30 pm
Dish: Half a plate of white rice or gluten-free pasta + meat or fish (120 g) + vegetables (about 100 g)
Dessert: 1 medium piece of fruit
Water to drink
Supper: 9 pm
1 medium piece of fruit
Going to bed at 9:45 pm
Water consumption: about 1.5 L per day
Environment, behaviour and social
The child lives with her mother and older sister. Parents separated.
She eats most of her meals at home and has a healthy diet routine. However, she does like fast food and particularly pizza.
She is active, not only at school and particularly in physical education, and practices judo twice a week.
Questions (answers below)
1. Is it possible to make a secure diagnosis of celiac disease in children without a biopsy?
2. After diagnosis, should adherence to a gluten-free diet be assessed?
3. Is it recommended to detect immunogenic gluten peptides when assessing adherence to a gluten-free diet?
4. In the follow-up of a child with celiac disease, what care should be taken in growth assessment?
5. Is it necessary to implement a lactose-free diet for a child with celiac disease?
Author Contributions Statement
The contribution to the preparation of this Case Study was identical for both authors.
Acknowledgements
The authors wish to express their thanks to the child and the caregiver who allowed the elaboration of the case study.
Conflict of Interests
The authors declare there are no financial and personal relationships that could present a potential conflict of interests.
Answers
1. Yes, with elevated IgA anti-transglutaminase antibody values equal to or 10 times the upper limit of normal, with accurate IgA endomysial antibody testing positive on a second serum sample.
2. Yes, there is no standard method, but it should be assessed multidimensionally through dietary surveys, symptom assessment, and laboratory tests.
3. Currently, there is no recommendation for the determination of immunogenic gluten peptides in stool/urine as a way to assess adherence to the gluten-free diet in clinical practice, and more data are needed to support this recommendation.
4. If significant growth in the child's stature is not achieved within one year of starting the gluten-free diet, when adherence to this diet is present, further investigations are recommended to exclude other causes of short stature.
5. No. If, with adherence to a gluten-free diet, there are symptoms suggestive of lactose intolerance, such as continuous diarrhoea or abdominal pain, then a test with a reduced-lactose diet is recommended. However, initially, especially in severe forms of the disease, temporary lactose intolerance may coexist (due to villus atrophy and reduction of lactase), and in these cases foods containing lactose should be consumed in moderation.
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