Celiac disease in children - a new look at an old problem

Gluten intolerance is a chronic digestive disorder characterized by damage to the small intestine when exposed to gluten.

Celiac disease develops in children who carry the HLA-DQ protein. Gluten intolerance affects 1% of the population in Europe and North America. In Ukraine, celiac disease occurs in 0.5% of the population. Most children are asymptomatic or have minimal symptoms. Some have atypical forms with obvious signs of the disease.

The only treatment with proven effectiveness is a strict gluten-free diet, so if the diet is followed, the disease does not make itself felt. In this article we will examine the following questions: what gluten is, what foods contain it, how celiac disease manifests itself, methods for diagnosing and treating the disease. It should be remembered: celiac disease is not a death sentence, but a way of life.

What is gluten

Gluten or gluten is a plant protein. It is contained in plants as a nutritional reserve for sprouts. Gluten is found mainly in cereals: wheat, rye and barley. Gluten is in demand in food production: gluten gives dough elasticity and retains its shape, so it makes up 80% of the total protein contained in bread.

With celiac disease, this protein is not absorbed by the body. Despite this, a child who does not get gluten from food develops healthy. As a protein, gluten is neutral: it does not harm, but does not benefit the child (if we talk about an adequate amount). It is a simple food additive that industrialists use to give the product shape and elasticity. Therefore, often “gluten-free” labels on food products from unscrupulous companies are a marketing ploy that makes people think that gluten is harmful and choose a “safe” product. In reality, gluten is only harmful to children with celiac disease.

Some parents are afraid that if their children eat gluten-containing foods, they will develop celiac disease. This is not true: gluten intolerance is a congenital disease that occurs in children due to malfunctions in the genetic apparatus and immune system. Therefore, children without celiac disease can eat gluten in complementary foods and other foods.

Catering and gluten-free food

Most people with celiac disease are forced to avoid catering establishments or order a special menu from them in advance.

“I stopped going to cafes because I know there will be problems,” continues Diana Pankova. — Employees can’t always help; usually they don’t really know what gluten is, much less where it is found. They need to explain. I always feel awkward. The menu often does not list all the ingredients, for example, sauces - what do they consist of? Many dishes contain gluten in one way or another. The meat is rolled in flour or breadcrumbs. You constantly have to ask the waiters to go to the chef and find out. If I go to a cafe, I always order the same dish that I’m sure of. In Europe, restaurants write on the menu: “Gluten-free” or “May contain gluten.”

Products containing gluten

List of foods that may contain gluten:

wheat (bread, pasta, baked goods);
rye, oats, barley;
breakfast cereals (except real corn flakes);
sausages;
canned food;
sweets;
thick sauces;
yoghurts;
bread and confectionery: bread, crackers, waffles, pies, crackers, cookies, muffins, cakes, baked goods made from flour in the previous list, corn flakes and sticks, barley malt and molasses, confectionery powders, glazes, baking powder, powdered sugar and baking powder ;
pasta from wheat and grains: spelled, spelt, triticale and durum;
meat, fish and semi-finished products: sausage, pate, dumplings, ham, frankfurters, dumplings, cutlets, products in breadcrumbs, canned food in tomato sauce, bouillon cubes, crab sticks;
desserts: cream, jams, marmalade, chocolate, snacks, syrup;
drinks: powdered tea concentrates, beer and kvass, barley and oatmeal jelly;
other products: vinegar, chewing gum, dyes.

The list of products is taken from the Regional Gluten Intolerance Center information website. Some of these products contain small amounts of gluten because gluten particles are introduced into the raw materials during food production.

Before purchasing a product, familiarize yourself with its chemical composition. Manufacturers usually write “gluten free” on their product, meaning the product is approved for children with celiac disease.

Symptoms of Gluten Allergy

Symptoms are most pronounced in children under 1-2 years of age. The first period of the disease is latent or hidden. It continues from the moment the parents introduced gluten into the child’s diet. The latent period lasts from a couple of days to several years. There are no symptoms at this stage. The next period is activation. It manifests itself with severe symptoms.

Signs of gluten intolerance in children:

stomach ache;
profuse diarrhea with an unpleasant odor;
particles of fat are found in the stool;
bloating and excessive gas;
vomit;
constipation;
decreased appetite;
slowing of psychomotor development;
periodic weight loss;
weakening of muscle strength;
lethargy and lack of initiative of the child.

As a rule, the activation period begins 1.5-2 months after the introduction of complementary foods with gluten into the diet: crackers, bread, semolina, wheat and multigrain porridges. Sometimes the period of vivid symptoms begins after the child has suffered from an infectious disease. Most often it is an intestinal or respiratory viral disease.

The symptoms of gluten intolerance are consistent. Usually bowel disorders occur first. It becomes foamy, greasy, released in large volumes and emits an unpleasant odor. Over time, appetite decreases and the child begins to vomit. The patient himself becomes lethargic, irritable, often cries and sleeps poorly.

In school-age children, the symptoms of celiac disease are slightly different:

constant fatigue and fatigue;
irritability and loss of interest in hobbies;
frequent abdominal pain;
nausea and vomiting;
excessive gas formation;
constipation;
small areas of inflammation appear on the skin;
hair loss;
sores appear in the mouth and lips;
caries and enamel defects on teeth;
bones and joints hurt;
headaches, lack of coordination, shallow sleep;
delayed sexual development.

At the onset of the disease, older children usually complain of dull and aching pain in the abdomen. Often a child with abdominal pain points to the umbilical region.

Chronic celiac disease, which goes undiagnosed for a long time, can lead to other diseases:

malignant tumors: adenocarcinoma of the small intestine or esophagus, non-Hodgkin lymphoma. According to research, these pathologies occur more often in sick children with celiac disease than in healthy children;
osteoporosis: bone density decreases and the concentration of minerals in tissues decreases;
reproductive ailments: the first menstruation occurs later, which can lead to infertility in boys;
Autoimmune diseases occur 10 times more often in children with celiac disease: diabetes mellitus, thyroid pathologies, cardiomyopathy.

The problem with celiac disease is that there is no specific symptom that could indicate the disease itself. In addition, celiac disease can be asymptomatic. Gluten intolerance often occurs in diabetes mellitus, epilepsy, Addison's disease, autoimmune myocarditis, hepatitis, cholangitis, Down syndrome, Shereshevsky-Turner and Sjögren's syndrome, neuropathy, ulcerative colitis and Crohn's disease. If a child has one of these diseases, he is at risk of developing celiac disease.

Diagnosis of celiac disease in children

Diagnosis of celiac disease is based on a general examination and test results. At the appointment, the doctor examines the child and asks the parents about individual symptoms: what is the nature of the stool, does the child complain of abdominal pain, what is his appetite, how often he is irritated. However, the most accurate and informative diagnostic methods are serological tests and endoscopic examination of the small intestine.

The first method is serological (Anti-tTG). It aims to detect antibodies to tissue transglutaminase, which are formed in the small intestine upon contact with gluten. The Anti-tTG method is a highly sensitive method that finds antibodies in 98% of cases. For research, blood is taken from a vein. There is a quick alternative - a rapid test (POC tests), which allows you to find antibodies to tissue transglutaminase in 10 minutes.

The second serological method is the detection of antibodies to endomysium (EMA), which are formed in the intercellular substance of the mucous membrane of the small intestine. To carry out diagnostics, special equipment is needed. Therefore, the previous method, Anti-tTG, is most often used.

If antibodies are detected in the blood serum, a study of tissues and cells of the mucous membrane of the small intestine is prescribed. For this purpose, the method of esophagogastroduodenoscopy is used. The probe is inserted into the child's digestive tube and reaches the duodenum, where the doctor takes 4 pieces of tissue (biopsy) for examination in the laboratory.

An endoscopic examination should be performed when a child consumes gluten. Otherwise, the mucous membrane of the small intestine can quickly recover, making diagnosis difficult. To assess the condition of the intestines, the crypts and villi, which are most damaged in celiac disease, are examined under a microscope.

If the endoscopist detects tissue damage and the child has antibodies to tissue transglutaminase in the blood serum, the doctor diagnoses celiac disease. However, in 2012, the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) developed a protocol according to which only the results of a serological test are sufficient to make a diagnosis. Sometimes, due to an attempt at self-medication, parents give their child gluten-free foods. Then, to diagnose gluten intolerance, a provocative test is prescribed, in which the child consumes foods containing gluten. To monitor the condition of the intestine, two endoscopies need to be performed: the first - against the background of a gluten-free diet, the second - after the onset of symptoms of celiac disease. This is necessary in order to assess changes in the mucous membrane of the small intestine upon contact with gluten.

Pathogenesis

There is no doubt that celiac disease does not occur without gluten, but there are still no clear opinions about its pathogenesis, so there are a number of hypotheses.

1) Sensitization with gliadin,

as a result, the intestinal epithelium becomes a target for the development of the immunological process. Once in the mucous membrane, the protein antigen (gluten) undergoes cleavage in the macrophage lysosomes into peptides. Peptides bind to HLA class II molecules located in the endoplasmic reticulum of the same cell. In this case, the peptides undergo deamination in the presence of the tissue transglutaminase enzyme – TG2, which ensures closer binding of gluten peptide residues to the DQ2 and DQ8 molecules. This complex is presented on the macrophage membrane and is recognized by lymphocytes that have passed through Peyer's patches. Activated T-lymphocytes turn into cytotoxic cells carrying CD8 markers (killer cells) and helpers (Th1 and Th2), which are CD4-positive. At the same time, the content of CD4 lymphocytes in the lamina propria of the mucous membrane increases almost 50 times, and CD8 T cells in the epithelium - almost 10 times. Th1 produces IL-2, tumor necrosis factor (TNF) and interferon-γ, which induce inflammation and activate a cytotoxic immune response; Th2 – a significant amount of IL-4, 5 and 10, inhibiting Th1 activity. In turn, TNF activates metalloproteases, in particular MMP-3 and MMP-1, disrupting the structure of the subepithelial region of the mucosa and destroying collagen. B lymphocytes potentiate the production of antibodies to gluten and tissue transglutaminase. In parallel, the production of autoantibodies to TG2 occurs, which in the form of IgA deposits are located in the subepithelial layer of the intestine, on fibroblasts, as well as in the liver, lymph nodes, muscles, and blood vessels. Blocking tissue transglutaminase by autoantibodies leads to destruction of the epithelium and mucosa, villous atrophy and proliferation of crypt epithelial cells, which increases the permeability of the mucosa, including gluten.

2) The role of viruses

in the pathogenesis of celiac disease (in some patients, an increase in antibody titers to adenovirus type 12 is detected in the blood, a decrease in which was noted when the patients’ condition improved on the background of the agliadine diet).

In celiac disease, there is an autosomal dominant type of inheritance with incomplete penetrance. In the patient's closest relatives, the incidence of the disease varies from 2 to 12% according to histological examination of the mucous membrane of the small intestine. In identical twins, concordance for celiac disease is approximately 70%, and in HLA-identical individuals it is up to 30%. Parents of patients with celiac disease themselves suffer from latent celiac disease in approximately 14% of cases.

How to treat celiac disease

Current standards for the treatment of celiac disease require a strict gluten-free diet throughout life. The diet is prescribed for both children with and without obvious symptoms. During diet treatment, the child should be under the supervision of a nutritionist and pediatrician. It is important to refuse not only products that contain gluten in large quantities, but also products that contain “hidden” gluten, that is, those that contain gluten as an additive.

If, against the background of celiac disease, a child develops severe protein-energy deficiency with a violation of the water-salt balance, he should be hospitalized in a gastroenterological hospital. There they will conduct diagnostics, restore impaired metabolism and select nutrition. Hospitalization lasts from 14 days. If a child's symptoms of celiac disease are mild, he can be treated in a day hospital for two weeks. In cases where the disease is asymptomatic, the child can be treated at home on the recommendation of a doctor.

A patient with celiac disease should be monitored for life. A pediatric gastroenterologist or certified nutritionist is assigned to the child. After diagnosis, you should visit your doctor every 6 months for the first two years. Starting from the third year, one visit to the doctor per year is enough. The child is also recommended to be vaccinated against pneumococcal infection, as there is an increased risk of infection. The vaccination is done during the period of remission.

Celiac disease treatment

And now about the treatment of celiac disease.

Key points in the treatment of patients with celiac disease:

1) Consultation with a skilled dietitian.

2) Education about the disease.

3) Lifelong adherence to a gluten-free diet.

4) Diagnosis and treatment of nutritional deficiencies.

5) Access to an advocacy group.

6) Continuous long-term followup by a multidisciplinary team.

Diet for celiac disease

An individual gluten-free diet is prescribed by a nutritionist during consultation. A gluten-free diet is a complete abstinence from foods containing gluten. These include any food that contains wheat, barley and rye. Allowed foods:

all fresh and dried fruits and vegetables, not processed with flour and starch;
Bread and cereals: You can only consume those products that are produced by enterprises. Usually they indicate on the packaging the symbol of a crossed out ear. You can eat gluten-free foods: bread, pasta, sweets and add flour mixtures to dishes;
buckwheat, rice, millet, amaranth, quinoa;
Meat and fish: You can eat them if you buy them in a store and keep them in a separate section from breaded and processed foods. You can eat sausages, smoked meats and sausages if the packaging indicates gluten-free;
dairy products: milk, cottage cheese, hard cheeses, Camembert cheese without additives, kefir, butter, yogurt and processed cheese without additives, condensed milk with the “gluten-free” sign;
additives and seasonings: yeast, glucose-fructose syrup, vanilla sugar, soy sauce, mayonnaise, cocoa;
drinks: leaf tea and brewed coffee, juices without pulp, chicory drinks, cocoa drinks, fruit and berry compotes.

Usually, large stores and stores with imported products sell special gluten-free products: mixtures, flour, sweets, bars, cereals. These products are labeled according to European Union standards - “gluten-free”. This means that the product’s components have been tested in the laboratory and can be added to the diet of children with gluten intolerance.

Rules for handling products that all parents of children with celiac disease should know:

allocate a separate place, for example, a cabinet, for gluten-free products: otherwise, particles of regular porridge may get into the gluten-free flour mixture;
Always clean your kitchen work surfaces thoroughly after preparing gluten-containing foods;
use separate dishes and space in the refrigerator for gluten-free dishes;
Do not use the same kitchen utensils for mixing food;
before preparing food, make sure that there is no dust from wheat flour in the air in the kitchen;
Gluten-containing foods and gluten-free foods should not be placed on the same tray, plate, board or pan.

A nutritionist will help you create a daily menu, taking into account the child’s age and individual culinary preferences.

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Author: Mikusko-Petrova Olga Zosimovna

Pediatric gastroenterologist. Highest category. Work experience 13 years.