If you suspect your child has coeliac disease, it’s best to get a confirmed diagnosis because people with wheat intolerance can eat small amounts of wheat, while those with coeliac disease cannot. Coeliac disease causes damage to the small intestine which then decreases the bodies’ ability to absorb nutrients from food. If this continues without treatment, over time, ill-health continues, development is affected, and more medical conditions generally emerge. At present, there is no medicine or drug that can treat coeliac disease. Currently, a gluten-free diet is seen as the required ‘medicine’ for this condition.

Symptoms (1) of coeliac disease can strike at any age and might include:

- Diarrhea

- Bloating or abdominal pain

- Flatulence or a ‘noisy’ stomach

- Decreased appetite

- Weight loss

- Tiredness, fatigue and lack of interest in usual activities

- Vomiting

- Emotional distress after eating.

- Decreased school performances

- More symptoms can be found here

Diagnosing Coeliac Disease

Gluten causes the damage being measured by the tests your doctor needs to perform to diagnose coeliac disease. Therefore, do not remove wheat foods (eg bread, pasta) from your child’s diet until testing is complete, otherwise, the tests will not be considered valid. If wheat and gluten has already been removed from your child’s diet, a ‘gluten challenge’ consuming daily wheat bread, crackers and pasta foods, for 6-8 weeks will be required. To begin the investigation your GP usually orders a coeliac-specific antibody blood screening test. If the results are out of the expected range, typically a small intestinal biopsy with a Paediatric Gastroenterologist follows. This is a day stay procedure that your doctor will discuss with you. Blood tests alone should not be relied upon, as this is a condition that will affect your child for the rest of their life. In saying that, Europe has produced some guidelines which set down some conditions that the blood tests must meet if it was decided not to proceed with the biopsy (2). Discuss this with your doctor.

What next if your child is diagnosed with coeliac disease?

Coeliac disease was characterised in the late 1940s by diarrhoea, wasted muscles, protruded bellies and failure to thrive in young children. It was believed to be a childhood disease of the gastrointestinal tract. Today, we know coeliac disease can be diagnosed at any age and coeliac disease is recognised as a multi-organ autoimmune disease with a wide range of presentations. More than half present with non-gastrointestinal symptoms (1) such as headaches, brain fog, decreased school performances, anxiety and defects of tooth enamel to name some. Young children cannot tell you about some of these symptoms. Our understanding of how Coeliac disease develops has advanced considerably since the 1940’s, but there is still more to learn. Essentially, coeliac disease is a condition where the lining of the small bowel is damaged due to a protein found only in select grains, called gluten. Gluten has a complex chemical structure that varies a little in the different grains.

The chemical structure of the gluten in wheat, rye, triticale and barley will always cause small bowel damage in those with coeliac disease. Oat gluten is quite different and has been shown to affect only 5-8% of people with coeliac disease (3,4). Because of this low figure, specially grown oats called ‘gluten-free oats’ internationally, are allowed to be eaten by those with coeliac disease in many countries of the world. Currently, Australia refers to these oats as ‘wheat free’, ‘contaminant-free’ or ‘pure oats’ and their inclusion is not allowed in a food labelled gluten-free. Recent figures suggest that 1 in 70 people in Australia have Coeliac disease (5). It’s more common in people of European descent, but it could affect anyone of any race, who carries the HLA-DQ2 or HLA-DQ8 genetics. It is estimated that 30-40% of the people in the world carry those genetics, but only 3% of people with those genetics go on to develop Coeliac disease (6). Environmental triggers such as gastrointestinal upsets that temporarily affect the lining on the gut are thought to play a part in triggering the disease in those who are susceptible (7). If your child is diagnosed with coeliac disease, it is essential to exclude gluten from your child’s diet. Eating even small amounts can result in further damage to the gut and can affect your child’s growth and development. Don’t rely on symptoms to tell you whether or not your child has eaten gluten, as symptoms don’t always appear. Talk to a dietician about creating a gluten-free diet (GFD).

What foods are gluten-free?

Many foods are naturally gluten-free and your child can eat as many of these foods as they want:

- Fresh fruit

- Fresh vegetables and herbs

- Unprocessed fresh meats, poultry, fish and seafood

- Eggs, nuts and seeds

- Legumes and lentils

- Plain milk, plain yoghurt, plain cheese

- Products labelled gluten-free (GF)

If any of these plain foods are mixed with other ingredients such as in chocolate milk, strawberry ice-cream, marinated meat, sausages, falafel or pie apple, then you will need to read the food label to determine whether a gluten-containing ingredient has been added. Because gluten is found in grains:- Breakfast cereals, biscuits, crackers, pasta, bread, baking flours, thickening agents and baked goods will need to be replaced with gluten-free alternatives.

Gluten-free grains can be freely eaten

- All forms of rice

- Corn /maize/polenta/cornmeal

- Buckwheat

- Quinoa

- Soy

- Sorghum

- Amaranth

- Millet/teff/ fonio

- Legume flours/lupin/besan/gram

- Tapioca/Sago/Arrowroot/Maize/Potato starches

What to avoid

All forms of wheat need to be avoided. This includes:

- Atta

- Burghul

- Couscous

- Cracked wheat

- Durum

- Einkorn/Emmer

- Farina/ Farro

- Flour (plain, self-raising, wholemeal, enriched, cake flour, all-purpose)

- Khorisan/Kamut

- Seitan

- Semolina

- Spelt

- Wheat bran

- Wheat germ

- Wheat starch/wheat cornflour

Gluten is also found in other grains such as:

- Barley

- Rye/Pumpernickel

- Triticale

- To a much lesser degree in oats

Gluten may be hidden in common ingredients:

- Barley malt

- Chocolate bars

- Common seasonings

- Confectionery

- Crisps

- Dressings

- Gravies

- Malt vinegar

- Processed lunch meats

- Sauces

- Soups

- Stocks

As you can see, gluten is hiding in many different foods, so caution is required when you are around foods you have not prepared. Unfortunately, going “gluten-free” is not quite as simple as cutting sandwiches out of your child’s life.

References

1. Brown AC. Gluten sensitivity: problems of an emerging condition separate from celiac disease. Expert Review of Gastroenterology & Hepatology, 2012;6(1), 43-55, DOI: 10.1586/egh.11.79

2. Husby S et al. AGA Clinical Practice Update on Diagnosis and Monitoring of Celiac Disease: Changing Utility of Serology and Histologic Measures: Expert Review. Gastroenterology. 2018 Dec 19. PubMed PMID: 30578783.

3. Comino I et al. Diversity in oat potential immunogenicity: basis for the selection of oat varieties with no toxicity in coeliac disease. Gut 2011;60:915-922

4. Hardy et al. Ingestion of oats and barley in patients with celiac disease mobilizes cross-reactive T cells activated by avenin peptides and immuno-dominant hordein peptides. J Autoimmunity, 2015;56:56-65

5. Anderson R et al. A novel serogenetic approach determines the community prevalence of Celiac Disease and informs improved diagnostic pathways. BMC medicine, 2013;11(1):188.

6. Green PHR and Jabri B. Celiac Disease. Annual Review of Medicine. 2006,Vol 57:207-221. https://doi.org/10.1146/annurev.med.57.051804.122404

7. Myléus et al. Early infections are associated with increased risk for celiac disease: an incident case-referent study. BMC Pediatrics 2012, 12:194 http://www.biomedcentral.com/1471-2431/12/194