PURPOSE OF THE STUDY.
The goal of this study was to evaluate the characteristics of gluten sensitivity in children.
The study included 15 children (10 boys, 5 girls) with a median age of 10.3 years (range: 1.6–15 years) who were diagnosed at 2 pediatric gastroenterology tertiary centers in Italy. Patients were referred for excluding an adverse food reaction to wheat.
The diagnosis of gluten sensitivity was made after symptoms were associated with wheat ingestion despite a negative celiac disease evaluation. All children included in this case series tested negative for IgA endomysial antibodies, IgA tissue transglutaminase antibodies, wheat-specific IgE, gluten-specific IgE, skin prick testing to wheat, and atopy patch testing to wheat. A small bowel biopsy was offered to all 15 patients (11 of 15 consented). Tissue transglutaminase IgA, endomysial antibody and native antigliadin antibody IgA and IgG, HLA typing, and multiple hematologic measurements were obtained before initiation of a gluten-free diet. Patients followed a gluten-free diet for 8 weeks, followed by an open, hospital-based 5-g gluten challenge and monitoring for 48 hours. Symptom diaries were used. A 30% increase in a symptom score after the gluten challenge was deemed significant. A group of 15 patients with functional gastrointestinal disorders without celiac disease and without food-associated symptoms and 15 patients with celiac disease served as the control and comparison groups, respectively.
The median time to symptom onset after the open gluten challenge was 44 hours (range: 38–80 hours). Abdominal pain was the most frequently reported symptom postchallenge, reported in 12 (80%) of 15 children, followed by diarrhea (73%), fatigue (33%), and bloating (26%). Limb pain, vomiting, constipation, headache, and failure to thrive were also reported. Antigliadin antibody IgG was detected in 10 (66%) of 15 children with a diagnosis of gluten sensitivity, in 13 children (86%) with celiac disease, and in 2 (13%) of the control children. Titers of antigliadin antibody IgG were significantly lower in children with gluten sensitivity compared with those with celiac disease (P < .001). Antigliadin antibody IgA was detected in 1 child with gluten sensitivity and in 11 children with celiac disease (P < .001). HLA-DQ2 was present in all children with celiac disease and in 7 (46%) of the 15 children with gluten sensitivity. Results of small bowel biopsies of gluten-sensitive children revealed 9 (82%) of 11 had normal mucosa, and 2 (18%) of 11 had Marsh stage 1 mucosa (increased intraepithelial lymphocytes).
Children with gluten sensitivity lack reliable serologic or genetic markers of the disease, as is the case in adults with gluten sensitivity. However, similar to previous observations in adult gluten-sensitive patients, this study found that native antigliadin antibody IgG positivity and presence of HLA-DQ2 are more common in children with gluten sensitivity compared with control subjects.
Antigliadin antibodies are commonly present in any patient with a disrupted gastrointestinal barrier, and they have actually fallen out of favor in the diagnosis of celiac disease. Thus, antigliadin antibody IgG positivity in nonceliac gluten-sensitive patients should be considered with caution. No biomarker for gluten sensitivity exists, and gluten sensitivity remains a clinical diagnosis. Other studies suggest that fermentable, oligo-, di, monosaccharides and polyols (FODMAPs) may be the symptom-inducing components of wheat, and not gluten itself. Carefully crafted prospective, double-blind studies are needed to further characterize gluten sensitivity and to clarify whether FODMAPs are involved.
- Copyright © 2014 by the American Academy of Pediatrics