*Ask the Expert*- Pediatric GI

A pediatric gastroenterology expert weighs in on your questions for this month’s ‘Ask the Expert’ segment. Remember to look out for these segments across social media (Facebook, Instagram, and Twitter) to send in your own questions.

Is it sufficient at this day and age to diagnose celiac disease with just the antibodies and without an endoscopy, which is so much more invasive?

According to the AGA (American Gastroenterological Association) and NASPGHAN (North American Society for Pediatric Gastroenterology, Hepatology and Nutrition) guidelines, antibodies are used to screen for celiac disease and endoscopy with biopsy is used to confirm the diagnosis. It is not sufficient to diagnose celiac disease without a small bowel biopsy. There are two exceptions to performing the endoscopy, 1. if there is a skin biopsy with proven dermatitis-herpetiformis, and 2. if the patient is already placed upon a gluten-free diet. 75% of dermatitis-herpetiformis patients have villous atrophy upon their small bowel biopsy, which is pathognomonic for celiac disease. If a patient is already placed upon a gluten-free diet, which is the treatment for celiac disease, then their biopsies will likely be normal.

If a mother has celiac, what is the right age to introduce gluten to her infant? And how? Our home is 100% gluten free but I understand that if you don’t expose babies to foods, they can end up with more severe reactions later.. or is that a myth?

If a mother has celiac disease, it is recommended to breast feed as immunoglobulins (IgA specifically) cross over, which helps build the intestinal and respiratory linings, and may protect against celiac disease for the first 6 months. Gluten, wheat protein, is usually introduced between 4-6 months of age via cereals, as most infants. There is no change in when you introduce gluten to babies with family members with celiac disease. Yes, it is a myth, and it is false that if babies are not exposed to foods, then they would have more severe reactions later. Celiac disease is not an allergy, it is not IgE mediated, and in fact, IgE mediated allergic reactions produce more severe reactions (i.e. hives, breathing problems, swelling, etc.) when exposed more than once to the aggravating food.

If children are diagnosed with celiac disease, is there a reason to blindly screen their parents?

Yes, if children are diagnosed with celiac disease, all first degree family members should be screened whether symptomatic or not. There is a 10% increased risk for developing celiac disease in first degree relatives.

Is there legitimacy to gluten sensitivity? You read in the media about how it’s all just a placebo, but then you read that it’s actually a real thing. Which one is it?

Yes, there is a phenomenon called gluten sensitivity. It is when patients have symptoms with gluten, such as, diarrhea or abdominal pain, which resolve once gluten is removed. Studies have been performed upon adults and prove this to be a true diagnosis. However, it is NOT celiac disease, without antibodies nor small bowel damage, and therefore, there are no comorbidities associated with this condition.

Any new Crohn’s Disease treatments out?

In regards to Crohn’s disease, entyvio (vedolizumab) infusions (integrin blocker) and stelara (ustekinumab) infusions (interleukin blocker) have been implemented in children, though, not FDA approved in those younger than 18. In addition, the SCD (specific carbohydrate diet) diet has been proven to help with remission in those patients with refractory inflammatory bowel disease.

Since you specialize in celiac disease, what wise words do you have for a young child, or for the parents of a child, who is diagnosed with this disease?

As a pediatric gastroenterologist who specializes in celiac disease and as a mother, wise words which I have to offer a family with the new diagnosis of celiac disease are: “A new diagnosis of celiac disease can be overwhelming. I know a gluten-free diet is hard. A dietician will help educate your family on how to start and be compliant with a gluten-free diet. It is imperative you are compliant with a gluten-free diet, as there is a risk for developing other autoimmune diseases; such as, autoimmune hepatitis or thyroid disease. There is a small risk of cancer in adult-hood, and the risk becomes less than 1% when you keep a strict gluten-free diet. There are not many diseases out there that are cured only by diet. You can do it. You are not alone. There are many excellent support groups out there, especially, celiac.org. Find the local support groups in your area. As your doctor, I will hold your hand along the way. Feel free to ask any questions.”

Dr. Michele J. Alkalay, MD Assistant Professor in Pediatric Gastroenterology Director of the Celiac Program University of Texas at Southwestern Children’s Health Plano and Dallas.


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