Category Archives: Children

Univ of Chicago CD Center

Update on Pediatric Celiac Disease from the University of Chicago 12/2014

I’ve been so busy learning new information about celiac disease and non celiac-gluten sensitivity that I haven’t had a chance to post for a while. I was fortunate to be one of 30 practitioners selected for the 2014 Preceptorship Program at the University of Chicago Celiac Disease Center, which took place 12/4-12/5. We had an intense 2 days filled with lectures on topics ranging from “The Pathology of Celiac Disease” to “Celiac Disease and the Skin” to “Celiac Disease and Developmental Disorders.” I was also able to spend time with Dr. Guandalini in the pediatric celiac clinic at the University of Chicago. Overall it was a great experience and I learned a TON about this disease which I hope to be able to share in upcoming months with other doctors, nurses, patients, friends and family, and all of you.

As both a pediatrician and mother of 4 children who are all at high risk of eventually developing celiac disease, I was especially interested in Dr. Guandalini’s lecture entitled “Celiac Disease: Update on the Pediatric Perspective.”  Here are some of the “take home” points of Dr. Guandalini’s presentation.

  • The incidence of celiac disease is definitely increasing. In 1990 5.2/100,000 Americans had celiac disease. In 2010 19.1/100,000 did.
  • The increases in celiac disease appears to be multifactorial and may be related to antibiotic use, Western diet, elimination of H pylori from GI tracts, birth by c-section, infant feeding practices, and reduced exposures to infections during childhood. The final common pathway appears to be a change in microbiota (bacterial balance), or dysbiosis, in genetically predisposed individuals.
  • He emphasized that glycophosphate, also known as “Round Up,” does not cause celiac disease, and used this as an example of the misinformation that is found online.
  • Children who carry 2 copies of the HLA-DQ2 gene are at very high risk of developing celiac disease. By age 5 to 6, 40% of homozygous DQ2 children have celiac autoimmunity, and approximately 25% have celiac disease.  I specifically asked Dr. Guandalini about the significance of celiac disease autoimmunity (positive celiac antibodies) v. celiac disease and I was told that it needs to be taken as seriously as celiac disease in kids, i.e. these kids need to be gluten free.
  • All of the following disorders are associated with celiac disease: gastrosophageal reflux, eosinophilic esophagitis, seziures, asthma, kidney stones, restless leg syndrome, sarcoidosis, psoriasis, vitiligo, idiopathic thrombocytopenia purpura (ITP), idiopathic dilated cardiomyopathy, hyperparathyroidism, and multiple sclerosis.
  • Based on recent studies, breastfeeding, and length of breastfeeding, do not seem to have any effect on preventing or delaying the development of celiac disease. Breastfeeding at the time of gluten introduction does not appear to make a difference either.
  • Also, based on recent research, the optimal time to introduce gluten to an infant is at about 6 months of age.  Delaying gluten introduction until after 12 months does not prevent celiac disease in children, nor does early introduction (4-6 months).
  • Children can be diagnosed with celiac disease without undergoing an endoscopy and biopsy if they all of the following: symptoms, a TTG IgA antibody level that is greater than 10x normal, and a positive EMA IgA antibody titer.  If the EMA IgA is negative, then a small bowel biopsy must be performed to confirm diagnosis.
  • There is no reliable method to detect celiac disease antibodies from stool samples.
  • Most doctors re-check TTG IgA antibodies in kids after 3-4 months on the GF diet. TTG IgA levels decrease in 75% of children after 3 months on the GF diet but it can take longer to normalize, especially if the level is sky high at the time of diagnosis.
  • Children who are newly diagnosed with celiac disease should have all of the following monitored: Vitamin D level, complete blood count, iron studies, thyroid function studies, and close monitoring of growth (weight, height, and body mass index).
  • Children with celiac disease experience rapid small bowel healing compared to adults. Almost 90% show remission after 1 year on the gluten-free diet.
  • Kids who are at risk of celiac disease but do not have symptoms should be screened at age 3 and then every 3 years (obviously sooner if symptoms develop)–I put this in bold because this is a question that I’ve had a very difficult time finding an answer to over the years.

I hope to be able to post more information that I learned at the preceptorship over the next few months. In the meantime please let me know if you have any questions or need me to clarify anything that I wrote about above.  As you know, it’s the holiday season, and we are starting to plan our cross-country move, so my mind is being pulled in a million directions right now! Thank you for understanding.

We had an entirely gluten free dinner for all preceptors and faculty on 12/4 at the Palmer House Hilton. I am in the front row in black. It was wonderful to be able to eat en entire catered meal without fear of getting sick!

We had an entirely gluten free dinner for all preceptors and faculty on 12/4 at the Palmer House Hilton. I am in the middle of the front row in black. It was wonderful to be able to eat en entire catered meal without fear of getting sick! Thank you again to the University of Chicago Celiac Disease Center for including me.

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Introducing Gluten to the Baby At-Risk for Celiac Disease (2014 update)

My youngest daughter, Claire, who I had in 2012, was my first baby born after my celiac diagnosis. I really struggled during her infancy to figure out if/when I should ever feed her gluten, as I wanted to do everything possible to prevent her from developing this disease. Based on all of the available research at the time, I made the decision to introduce her to small amounts of gluten when she was about 5 months old, and I breastfed her as long as I could (see my previous post for more details). I also freaked out a bit, as I was pretty sure that I had introduced gluten at the “wrong” times for my 3 oldest kids, beyond the 4-6 month “window” that had been supported by the literature, and I had not even been breastfeeding when my 2nd child was given gluten for the first time.

Fortunately, thanks to two recent studies published in the October 2nd New England Journal of Medicine, moms of infants at-risk of celiac disease will no longer need to struggle with their decision making the way that I did. Both of these beautifully designed, randomized, placebo-controlled European studies, including large numbers of subjects, demonstrate that neither the timing of gluten introduction, nor breastfeeding during gluten introduction, make any difference in the eventual development of celiac disease in at-risk babies. I wish that these results had been available in 2012 when I was struggling with my decision-making for baby Claire!

The first paper, entitled “Introduction of Gluten, HLA Status, and the Risk of Celiac Disease in Children,” discusses results from the Italian Risk of Celiac Disease and Age at Gluten Introduction (CELIPREV) trial. In this study, 707 infants who were at risk of celiac disease (having either a parent and/or sibling with celiac) were randomized to be introduced to gluten at either 6 months of age (Group A) or 12 months of age (Group B). Infants in the study who carried the celiac genes (HLA-DQ2 and/or DQ8, n=553) were then followed for the development of celiac disease via repeated celiac antibody testing at age 15 months, 24 months, and 3, 5, 8, and 10 years of age. Celiac disease autoimmunity was defined as having positive results for celiac antibodies. In total, 117 of the 553 subjects met the criteria for celiac disease autoimmunity during the study, and 91 of the 117 with celiac disease autoimmunity were diagnosed with celiac disease.

In the CELIPREV trial, earlier introduction of gluten was associated with earlier development of both celiac disease and celiac autoimmunity, but by age 5 there was no difference in the rates of celiac disease or celiac disease autoimmunity between the groups. At age 2, there were significantly more children with celiac disease from study Group A (early introduction) than study group B (late introduction), 12% v. 5%, but by age 5, the percentages of children with celiac disease in both the early and late groups were the same (16%). Likewise, although there was a significantly higher risk of celiac disease autoimmunity in the early group v. the late group at age 2 (16% v. 7%), the difference resolved by age 5 years (21% v. 20%). In addition, breastfeeding duration was not associated with the development of celiac disease. The authors conclude that postponing the introduction of gluten until 12 months of age had no effect on the eventual development of celiac disease in at-risk children.

The second paper, “Randomized Feeding Intervention in Infants at High Risk of Celiac Disease,” discusses results from ongoing the Prevent CD trial. In this study, infants at-risk for celiac disease (defined as having both a first degree relative with celiac disease and the presence of one of the 2 main celiac genes) were randomized to be given either gluten (n=475) or placebo (n=469) between 16 and 24 weeks of age. All of the infants were then followed closely for the development of celiac disease until they were 3 years old. Overall, 80 of the subjects developed celiac disease by age 3. Rates of celiac disease in the gluten v. placebo groups were similar at age 3 (5.9% in the gluten group v. 4.5% in the placebo group) and breastfeeding duration was not found to have an influence on the development of celiac. When evaluated by gender, however, there was a small increase in celiac disease at age 3 in girls who were exposed to gluten v. placebo (8.9% v. 5.5% in boys), which the authors speculate may be due to the fact that there were more girls who were double DQ2 positive, or homozygous (this is the highest risk gene combination for celiac disease). The authors conclude that giving small amounts of gluten between 4 and 6 months of age makes no difference in the eventual development of celiac in genetically predisposed infants.

In conclusion, we now know that there is nothing that we can do, feeding-wise, to prevent the development of celiac disease in our at-risk babies. While these results are sobering, as I know that many of us wish that we could do something to prevent out babies from developing celiac, I hope that future moms will be able to be a little easier on themselves than I was regarding the timing of gluten introduction. As a mom and neonatologist (pediatrician) I am a huge advocate of breastfeeding, and despite the aforementioned research showing that it does not seem to effect celiac disease development, it has numerous other health benefits for babies. I encourage moms to provide breast milk, in at least some capacity, during infancy (realizing that exclusive breastfeeding is sometimes not possible). Lastly, I feel much less guilty for exposing my 4 kids to gluten as babies, as I now know that if they do develop celiac, that it is not because of how I fed them!

Thank you for reading! As always, comments, questions, stories, etc. are appreciated!

References

Lionetti, E., Castellaneta, S., Francavilla, R., et al. Introduction of Gluten, HLA Status, and the Risk of Celiac Disease in Children. New England Journal of Medicine. 2014. 371: 1295-1303.

Vriezinga, S., Auricchio, R., Bravi, E., et al. Randomized Feeding Intervention in Infants at High Risk of Celiac Disease. New England Journal of Medicine. 2014. 371: 1304-1315.

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Celiac Disease Autoimmunity

I first came across the term “celiac disease autoimmunity” a few weeks ago as I read summaries of the article “Risk of Pediatric Celiac Disease According to HLA Haplotype and Country” that was published in the July 3, 2014 issue of the New England Journal of Medicine (NEJM).

Based on my reading and interpretation of the article, it seems that celiac disease autoimmunity is interchangeable with the more commonly used term “potential celiac disease.” Both are used to describe cases in which people have abnormally high levels of celiac antibodies (TTG IgA)  in their blood but their small intestinal biopsies do not show changes consistent with celiac disease. In other words, there is an autoimmune response to gluten that has yet to cause destruction to the villi of the small intestine. For the sake of this study, the subjects had to have abnormally high TTG IgA levels on 2 separate occasions, at least 3 months apart, to be labeled as having celiac disease autoimmunity.

The results published in NEJM come from the multinational TEDDY study, which is prospectively following a large cohort of children who are at genetically at risk of developing Type 1 (juvenile) diabetes mellitus.  Since some children with both Type 1 diabetes and celiac disease share the same “at-risk” genes, HLA-DQ2 and DQ8, the researchers have also been able to follow a large group of genetically-susceptible children for the development of celiac disease. The study is ongoing and subjects are being followed for the development of both diabetes and celiac disease from infancy until age 15. This is one of many papers that have already come from the TEDDY study.

Thus far, 6403 study subjects have been found to have genes that predispose to celiac disease.  Subjects have been placed into 4 risk groups:

-HLA DQ2/HLA DQ2 (homozygous for DQ2)

-HLA DQ2/HLA DQ8

-HLA DQ8/HLA DQ8 (homozygous for DQ8)

-HLA DQ8/HLA DQ4

As you can see, the first 3 groups of kids all have 2 copies of celiac-risk genes, and the 4th group has only one copy of DQ8, so only one gene associated with celiac disease. Subjects’ testing for celiac disease autoimmunity started at age 24 months and has been repeated every year. In all, 786 of the 6403 (11%) at risk subjects were found to have celiac disease autoimmunity (elevated blood TTG IgA antibodies at least twice) at time of data analysis Overall, 25% of the children with celiac disease autoimmunity had a diagnosis of celiac disease by age 3.

The researchers broke down the risk of both celiac disease autoimmunity and celiac disease by genes and found the following risks by age 5:

Celiac Disease Autoimmunity Risk in Children with Celiac Genes by Age 5:

HLA DQ2/HLA DQ2 (homozygous for DQ2): 26%

HLA DQ2/HLA DQ8: 11%

HLA DQ8/HLA DQ8 (homozygous for DQ8): 8%

HLA DQ8/HLA DQ4: 3%

Celiac Disease Risk in Children with Celiac Genes by Age 5:

HLA DQ2/HLA DQ2 (homozygous for DQ2): 11%

HLA DQ2/HLA DQ8: 3%

HLA DQ8/HLA DQ8 (homozygous for DQ8): 3%

HLA DQ8/HLA DQ4: less than 1%

Children with both celiac disease and celiac disease autoimmunity were found to be at a higher risk of having diabetes than the general population (1% for celiac disease autoimmunity and 2% for celiac disease v. 0.3% risk for general U.S. population).

In summary, in this large study, over 25% of children with the DQ2/DQ2 genotype were found to have celiac disease autoimmunity by age 5 and greater than 10% with DQ2/DQ2 were diagnosed with celiac disease by age 5.  Over half of these children had no symptoms of celiac disease, therefore, there is a good chance that many of these diagnoses would have been missed if these children had not been subjects in this study.

After reading this article I am a much stronger proponent of genetic testing of children at risk for celiac disease, if possible. And, as my husband and I both carry genes associated with celiac disease, I feel much less guilty for making my own kids get screened for celiac disease, via TTG IgA blood testing, every 2 years (you can see my post from May 2014 for more details). Lastly, I feel much more at peace for making my at-risk youngest go through having an endoscopy and small bowel biopsy earlier this summer. The statistics from this study are definitely eye-opening.

Reference: Liu E, Lee HS, Aronsson CA, et al. TEDDY Study Group. Risk of pediatric celiac disease according to HLA haplotype and country. N Engl J Med. 2014 Jul 3;371(1):42-9.

Also, if you are a research geek like I am, here are some other interesting findings from the TEDDY study thus far (found via a Pubmed.gov search):

  • The HLA-DQ2/2 genotype may predispose to obesity among 2-4-year-old children.
  • Between 15% and 20% of the infants in the study were introduced to solid foods before the age of 4 months.
  • The median age of early-onset diabetes is at 2.3 years. 33% of the subjects with an early diagnosis of diabetes had no symptoms of diabetes.
  • Findings have not supported the presence of viremia (recent viral infection) around the time of seroconversion in young children with rapid-onset type 1 diabetes.

The Scope is Clear (At Least for Now)

clairebear1

Claire is the youngest of our four children and was the first born after my diagnosis with celiac disease. She was a very healthy baby and I can’t recall her having any health issues during her infancy other than one or two mild colds and a touch of constipation.  Then, when she was about a 13 months old she began to have very high fevers, up to 104.5-105 F, that would come out of the blue and last between 2 and 5 days.  During these fevers she would have no other signs or symptoms of infection (i.e. rashes, vomiting, cough), she looked good, and, for the most part, her blood and other lab tests were normal. She had 9 or 10 total episodes of fever without a source during her 2nd year of life. Celiac disease was always in the back of my mind but I could not link her fevers with eating gluten. Although our home is 100% gluten-free, my kids do eat gluten outside of the home, in part so that I can keep tabs on whether or not they develop symptoms after eating it.

Claire’s fevers stopped in December, only to be replaced by episodes of diarrhea. Her poop was tested for bacteria, parasites, white blood cells, and all kinds of other good stuff.  I opted out of blood screening labs for celiac disease at this point as 1.) The celiac antibody panels are not often reliable in her age group, especially in kids who are “gluten-light” at baseline like Claire was, 2.) I couldn’t bear the thought of making her go through any more blood draws after all the times she’d had to be poked for her fevers, and 3.) I did not want her to have to go through a gluten challenge to get a reliable small bowel biopsy via endoscopy (since she was eating such small amounts of gluten at baseline). Our gut instinct was that her system was reacting to something in her diet. So, we put her on a gluten-free and milk-free diet in January, started her on a high-potency probiotic, and, her poops become normal and the fevers did not return.

Our oldest daughter had a milk protein allergy during infancy, so I prayed that Claire’s symptoms were from a milk protein intolerance of some sort, as most kids outgrow this. However,  when we re-introduced milk, none of Claire’s symptoms returned. But when she accidentally ate gluten the diarrhea and abdominal bloating returned on 2 separate occasions.  And then, when we let her eat a non-GF chicken nugget in April on purpose, both the diarrhea and fever returned with a vengeance.

Although I wanted to be able to keep Claire gluten-free forever, I knew that it was time for her to be formally evaluated for celiac disease.  As a doctor, I feel very uncomfortable trying to diagnose my own kids with anything. It seemed that she was sensitive to gluten, but in order to diagnose a child with non-celiac gluten sensitivity, I knew that celiac disease needs to be ruled out.

We met with a pediatric gastroenterologist named Dr. N who is affiliated with a very well-respected tertiary children’s hospital. Dr. N was phenomenal and very knowledgeable about celiac disease. He assured me that he would take enough duodenal biopsy samples (at least 5) and that he would include the duodenal bulb (in some cases, this is the only part of the small intestine where the damage from celiac can be found). He agreed that even if Claire’s small bowel biopsy showed only Marsh 1 damage (mildest findings seen in celiac disease) that he would give her a celiac diagnosis based on her symptoms and family history. We began to give Claire foods with gluten to eat, and for weeks she enjoyed non-GF pizza, Oreos, ice cream with cereal bits on top, and all kinds of other treats that she does not normally eat. Interestingly enough, she did not develop diarrhea but instead became mega-constipated. She did not develop a fever. I almost cancelled the biopsy at this point but decided to go through with it as Dr. N. said that he’d seen this happen with previous gluten challenges in kids who ended up having celiac disease.

Claire could only have clear liquids on the morning of the scope, so all four of our kiddos drank white grape juice and ate yellow jello and popsicles for breakfast. I let her watch Frozen during the 2 hour drive to the hospital. Claire was in great hands with the nurses, anesthesiologist, and other staff who we met at the children’s hospital on the morning of her endoscopy. She was given a medication called Versed which made her sleepy and 20 minutes later they wheeled her away to the O.R. The entire procedure took 15 to 20 minutes and we were reunited about half an hour later when she woke up.  She was a bit cranky at this point, much like she would have been if we woke her from a deep sleep at home, but soon after she was drinking juice and eating peanut butter out of little individual cups with a spoon.  She then ate a huge bowl of GF mac and cheese followed by about 8 cookies. Two hours later she was running around outside in the sunshine, sharing a GF pizza from California Pizza Kitchen with me, and as happy as could be, and since then she seems to have total amnesia for the entire experience. Thankfully.

We received results 4 days later that her duodenal biopsies were normal and did not show celiac disease.  Since the biopsy results came back she has eaten gluten several times without getting ill or having digestive symptoms. I am glad that we went through with the testing. I’m not sure that this will last forever (just because she doesn’t have celiac disease now doesn’t mean that she won’t develop it in the future) and I have no idea why she was having the diarrhea or fevers, but for now I am grateful.

Out of curiosity, has anyone else had a toddler who seemed to have reactions to gluten that disappeared?

 

gab

Frequency of Screening for Celiac Disease in Children with Siblings and/or Parents with Celiac Disease

I had the opportunity to moderate a discussion on celiac disease in children during my local celiac support group meeting last week.  One of the topics that we discussed was how often the siblings (or children) of those with celiac disease need to be screened. Research has shown that between 5 to 10% of first degree relatives of those with celiac disease will eventually develop it, and there is consensus that all at-risk children need to be tested at least once.

I have opted to have all of my kids screened with celiac antibody panels starting at age 4, in the absence of symptoms, and then we’ve planned on having them re-screened every 2 to 3 years, as we know that celiac disease can develop at any time during life. That being said, as my group discussion continued, I felt sort of dumb, as I was unable to recall where I had heard the advice about repeated screening of at-risk children. And I started to worry that perhaps I am having my kids tested too often…if you are new to my blog, you will learn that I get a bit neurotic about things from time to time.

My youngest, Claire, went to see her pediatric gastroenterologist a few days after the support group meeting, and he told me that he recommends that all siblings of Celiacs have an initial celiac antibody panel done, but that he recommends repeat testing only if symptoms develop.

I became more confused, so I decided to explore PubMed as well as the internet, to see what I could find…

The first article that I came across is called “Screening for Celiac Disease in Family Members: Is Follow-Up Testing Necessary?” written by Drs. Goldberg, Kryszak, Fasano, and Green and published in 2007. They found that of 171 family members who were negative for celiac disease on initial screening, 3.5% did have elevated celiac antibodies on repeat testing. The average time interval between the normal baseline celiac screening tests and development of celiac disease was 1.7 years. Interestingly enough, in this study, most of the family members who developed celiac disease did not have any symptoms. Based on their results, the authors of this study suggested that at-risk family members be screened every 4 to 5 years. Unfortunately, I was unable to find any other studies that have examined this topic.

The University of Chicago Celiac Center recommends that testing in at-risk individuals occur on a regular or periodic basis. According to another one of my other favorite celiac websites, CeliacCorner, “Some Celiac research centers recommend screening only for family members who are symptomatic, though this is not a consensus among the medical community.   It is agreed upon that children should be screened, because they may be too young to describe symptoms accurately. Important to note: Even if the antibody blood test is negative at the time of initial testing, Celiac can be triggered later at any point in life, so follow-up testing should occur for family members, certainly if experiencing classic gastrointestinal symptoms.” However, I was unable to find information on the recommended time interval between screening tests.

Do any of you have any resources and/or guidance for how often at-risk children, without symptoms, need to be screened for celiac disease? Am I having my kids tested too often, or not often enough? Any advice would be much appreciated. Thank you!

Also, if you are reading this because you are trying to figure out whether or not your child needs screened for celiac disease in the first place, you can check out my post from 2013.

My Kids are Bakery-Deprived

We just returned from a spending a week in Florida to celebrate Easter with my grandparents. As we were flying back I asked my 3 oldest kids what their favorite part of the trip was, expecting that the one thing they’d agree on would be “playing at the beach,” “exploring the park with four playgrounds,” or “going to the Easter egg scramble.”  Instead, they all agreed that their favorite experience was actually going to a bakery. On our very first day in Florida we went to a gluten-free restaurant and bakery in Melbourne Beach called The Bald Strawberry. Since it was just a few days before Easter, the glass display cases at The Bald Strawberry were filled with cupcakes, and cookies, tortes, and macaroons, and we let each of the kids pick out a treat to take home.

bald strawberry

We somehow ended up with an extra chick cupcake, which I gladly ate, but since I’m not used to eating sugar anymore, found to be very sweet.

Although I had spent my entire childhood going to bakeries with my mom, for my kids the Bald Strawberry was a novel experience. I realized that since my celiac diagnosis 4 years ago, all of my GF bakery experiences (Sweet Marie’s, Pip’s Place, Happy Bellies Bakeshop) have been when traveling without kids. As far as I know, my kids had not even stepped foot in a bakery since our entire family went gluten-free in 2012.

So, I am asking for your help. This summer we plan to travel to Boston, NYC, Cleveland, Madison, WI, and Chicago. Do any of you have dedicated GF bakery recommendations for any of these cities? I appreciate your help in advance, as do my 4 little ones, as you will help them to overcome their bakery deprivation.

Also, as a total aside, my grandparents are celebrating their 67th wedding anniversary this summer! Congratulations G&G!

 

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Celiac Disease in Children (Summary of January 2014 Review Article)

Drs. Guandalini and Assiri have written a summary of pediatric celiac disease that was published in the online edition of the journal JAMA Pediatrics last week. In this post I will share some of the highlights of their review article.

Although the overall prevalence of celiac disease is 1% in the pediatric population, only 10-15% of children with celiac disease have been diagnosed and treated.

The celiac genes (HLA-DQ2 and DQ8) contribute 40% of the risk of developing celiac. Environmental risk factors for celiac disease include infant feeding patterns, early infections, gut microbiota, and the amount and timing of initial gluten exposure.

The two major autoantibodies used in the diagnosis of celiac disease include the anti-TTG IgA and antiendomysial IgA. The antibody against deamidated gliadin peptides IgG (DGP IgG) is a 3rd antibody that has been identified. The DGP IgG may be the best one to use for diagnosing celiac disease in young children (under the age of 2) as it has the highest sensitivity in this age group.

During the past few decades there has been a shift from children presenting with celiac disease having typical symptoms (gastrointestinal) to having extraintestinal (atypical) symptoms.

“Typical” symptoms include abdominal pain (most common), diarrhea, chronic constipation, weight loss, vomiting, abdominal distension, and malnutrition.

“Atypical” (extraintestinal) symptoms in children include all of the following:

  • fatigue
  • iron deficiency anemia
  • dermatitis herpetiformis
  • dental enamel defects
  • aphthous ulcers (canker sores)
  • arthritis and arthralgias (joint pains)
  • low bone mineral density, fractures of bones
  • elevated liver enzymes
  • short stature
  • delayed puberty
  • cerebellar ataxia
  • recurring headaches
  • peripheral neuropathy
  • seizures
  • psychiatric disorders, including anxiety, panic attacks, depression

Celiac disease is associated with other pediatric conditions, including type 1 diabetes mellitus, selective IgA deficiency, Down syndrome, Turner syndrome, and Williams syndrome.

Patients with celiac disease are at an increased risk of all of the following (I was not aware of many of these associations until I read this article):

  • adrenal insufficiency
  • asthma
  • IgA nephropathy
  • lupus
  • pancreatitis
  • hyperparathyroidism
  • endometriosis
  • cataracts
  • ischemic heart disease
  • dilated cardiomyopathy

Dr. Guandalini recommends that celiac diagnosis in children involve celiac antibody testing, endoscopy with small bowel biopsy, and response to the gluten free diet. He does discuss that the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) has recently issued guidelines for diagnosis in which, in select cases, the small bowel biopsy can be omitted. Dr. Guandalini’s major concern is that if children undergoing evaluation do not have biopsies done, that other GI diagnoses that may need treatment, such as eosinophilic esophagitis, can be missed.

Celiac Disease resources that were discussed toward the end of the article include the Academy of Nutrition and Dietetics website, www.eatright.org, and an e-book created by the University of Chicago Celiac Disease Center called “Jump Start Your Gluten-Free Diet.”

In summary, this is a nicely written paper that is a great summary for pediatricians and other practitioners who need to be on the look out for celiac disease in their pediatric patients. I also thought that some of you non-medical folks might be interested as well!

Reference: Guandalini S, Assiri A. Celiac Disease: A Review. JAMA Pediatr. 2014 Jan 6. doi: 10.1001/jamapediatrics.2013.3858.

Lastly, the super cute children in the photo are my baby brothers and nieces who are now in their late teens and twenties. Since none of them read my blog, as they seem to be in denial that they have a risk of celiac disease, I had no qualms about sharing their adorable photo. Also, I became an aunt for 19th time this past week! Welcome baby Gabriel Dominic and congratulations to my sister and her family on his birth.

Thank you for reading!

 

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Non-celiac gluten sensitivity in children

I was thrilled to come across a paper about non-celiac gluten sensitivity in children in the Journal of Pediatrics, one of the main pediatric journals. Many of my pediatrician colleagues read this journal on a regular basis. In this article, a group of Italian researchers have described the symptoms and lab test results in 15 children with gluten sensitivity (GS) compared to 15 children with active celiac disease and 15 controls (children with IBS-type symptoms that have no correlation with gluten intake). None of the children included in the GS group had an IgE-mediated wheat allergy causing symptoms. Most of the children in the study were between 8 and 10 years old.

Here is a brief overview of the research study:

  • The main symptoms in the gluten sensitive group included abdominal pain, chronic diarrhea, bloating, failure to thrive (poor growth), vomiting, and constipation. These symptoms were similar to those seen in the group of children with active celiac disease. The “control” group of children with functional (IBS-type symptoms) had only abdominal pain and indigestion as symptoms.
  • The gluten sensitive children had “extraintestinal” symptoms of tiredness, headaches, and limb pains. Interestingly, these were not seen in children with active celiac disease. The celiac group of children had anemia and elevated liver function enzymes but the gluten sensitive children did not.
  • Two thirds of the gluten sensitive children had abnormally high antigliadin IgG antibodies (this is an older antibody that was used in the past to assess for celiac disease, but is no longer used because it is non-specific for celiac disease). None of the gluten sensitive children had elevated celiac antibodies (TTG IgA and endomysial IgA). All of the children with active celiac disease had abnormally high TTG IgA and endomysial IgA levels and 13/15 with celiac disease had elevated antigliadin antibodies. The control group kiddos with functional abdominal pain were negative for all antibodies (antigliadin, TTG, and endomysial).
  • Seven of the 15 children with GS had one of the celiac genes (DQ2/8) and 8 did not. The 8 gluten sensitive children who were DQ2/8 negative all had some combination of HLA DQ1, DQ5, and DQ7.
  • Eleven of the 15 GS children had an intestinal biopsy while on a gluten-containing diet. All of those with GS had normal to mildly inflamed intestinal mucosa, corresponding to Marsh stage 0 to 1.

In summary, the authors provide findings that support the existence of gluten sensitivity in children as a distinct problem from celiac disease. Children with gluten sensitivity have celiac-like symptoms that resolve on a gluten free diet and return when gluten is reintroduced. Although gluten sensitive children often have elevated antigliadin IgG levels, they have normal TTG IgA and endomysial IgA levels, at least in this study. Their small bowel biopsies show no evidence of villous blunting and, in the majority of cases, the biopsies are normal. In addition, these children’s symptoms are not as a result of being allergic to wheat. Although this is a small study, it is a step in the right direction toward the recognition of non-celiac gluten sensitivity in the pediatric population, and I am thankful that there is finally a research study to support its existence. I am looking forward to being able to read and share similar articles with you.

Reference:

Francavilla, R., Cristofori, F., Castellaneta, S., et al. Clinical, serologic, and histologic features of gluten sensitivity in children. Journal of Pediatrics. E-pub ahead of print. Nov. 16, 2013.

girl with sandwich

Should Your Child be Screened for Celiac Disease?

I have four children, who are all at high risk for developing Celiac Disease. I was diagnosed with Celiac Disease 3 years ago, but have had symptoms since early childhood. My husband does not have Celiac Disease, but he carries one of the two main Celiac genes, DQ2. Due to my children’s risk, I have had their pediatrician screen them when they turn 4 years old with a Celiac panel (blood test with Celiac antibodies). My third child, Gabby, just turned 4 so she will have her first Celiac panel at her well-child visit in a few weeks, along with all of her four year old immunizations. I think I’ll try to get my husband to take her!

Since starting this page I have had a lot of people ask me if their children should be screened for Celiac Disease. The latest, evidence-based, recommendations for screening are as follows:

Children should be screened for Celiac Diease if they have any of the following symptoms:

  • short or underweight for age, especially if growth has slowed down
  • diarrhea that lasts for more than a few weeks
  • recurring constipation, abdominal pain, and/or vomiting
  • tooth problems called dental enamel defects
  • delayed puberty
  • iron deficiency anemia that does not respond to treatment with supplements

“High risk” children who belong to the following groups should also be screened (even if they have none of the above symptoms):

  • 1st degree relative (child or sibling) of someone with Celiac Disease
  • Type 1 diabetes
  • Down syndrome
  • Turner syndrome
  • Selective IgA deficiency
  • Williams syndrome
  • Autoimmune thyroid disease

The first step in screening is to have Celiac antibodies measured in the blood. For small children, especially those under the age of 2, it is important for the antibody tests to include the deamidated gliadin peptide, or DGP, antibody. Please see my post from April for more details. While most Celiac panels include TTG IgA and IgG antibodies and endomysial IgA and IgG antibodies, not all include the DGP antibodies.

The second step in testing, if Celiac antibodies are abnormal, and/or there are enough symptoms that Celiac Disease is suspected, is to have an endoscopy and biopsy. During the endoscopy a flexible tube with a camera on the end is inserted into the mouth, down the esophagus, and into the small intestine. Small pieces of the small intestine (biopsies) are obtained, which are evaluated by pathologists. In Celiac Disease, the small fingerlike projections (villi) of the walls of the small intestine are flat, or blunted, which impairs the ability of the body to absorb essentials vitamins and nutrients.

In the absence of symptoms, we are having our kids have Celiac antibody tests every two years or so starting at the age of 4. If any of them develop overt symptoms of Celiac Disease and/or have abnormal antibodies, we will go the route of having an endoscopy and biopsy done to be able to have a firm diagnosis of Celiac Disease. Although we keep a strictly gluten free household, for my sake, as I am very sensitive to any gluten cross-contamination, we do allow our older kids to eat gluten outside of our home. This enables them to have a small “dose” of gluten in their systems on a regular basis. We feel this is important because it enables us to monitor them for symptoms when they do eat gluten and will enable their Celiac blood tests to be as accurate as possible. One of the most common causes of falsely negative Celiac antibody tests is that patients are already gluten free when their tests are performed.

For more information on Celiac Disease testing I recommend that you check out the National Foundation for Celiac Awareness and the University of Chicago Center for Celiac Disease Center websites.

Reference: Patient information: Celiac disease in children (Beyond the Basics). Authors Ivor D Hill, MD and Anne Roland Lee, MSEd, RD, LD; Section Editor William J Klish, MD; Deputy Editor Alison G Hoppin, MD. Literature review current through: May 2013. This topic last updated: Dec 3, 2012. www.uptodate.com.

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Celiac Disease (Out of the Mouths of My Babes)

I am not going to be able to write a new post for a while due to time constraints, but I’d like to share the answers to some questions about Celiac Disease which I recently asked my 7, 5, and 3 year old children. I promised them that I would post the answers from their “interviews.” I did not interview the 1 year old for obvious reasons!

  1. What is Celiac Disease?

3 y.o.: “It’s dumb.”

5 y.o.: “It makes you not eat gluten foods.”

7  y.o.: “If you eat gluten, even by mistake or accident, you get really sick.”

  1. What is gluten?

3 y.o.: “A butt ”(followed by a lot of giggling!)

5 y.o.: “A type of thing that Celiacs cannot eat.”

7 y.o.: “Stuff made out of wheat. Foods with crumbs usually have it.” I am pretty sure that this answer is better than what you would get from the general public if asked the same question.

  1. What foods have gluten?

Collaborative effort:  bread, bagels, vanilla wafers, donuts, frosting and cake, ice cream, pizza, milk, French fries, hamburgers, hot dogs, sausages. Not sure where the milk came from, but they had recently experienced my disappointment on Mother’s Day when we found out that the ice cream at our local (favorite) ice cream shop now contains gluten.  My husband was the recipient of my free Mother’s Day dish.

  1. What foods do you miss?

Collaborative effort: Daddy’s oatmeal (Quaker Instant), Cheezits, pizza bagels, Goldfish crackers, vanilla wafers, ice cream sandwiches. I am truly not sad that they cannot eat these foods anymore.

  1. If you found out you had Celiac Disease, how would you feel?

3 y.o.: “Happy, because I can’t eat gluten anymore.”

5 y.o.: “Sad, because I would miss the gluten.”

7 y.o.: “Kind of happy and kind of sad.”  This is most similar to how I felt after diagnosis….

  1. What are your favorite gluten free foods?

Again, a collaborative effort:  Salmon, Annie’s Bunnies, lentils, hamburgers, chocolate, raisins, yogurt, Fruity Pebbles, popcorn, tortilla chips, Cinnamon Chex. I realized that I have not been as good about removing processed foods from our house as I thought I had been!

As life settles down a bit I hope to write about dermatitis herpetiformis, the relationship between Celiac Disease and other autoimmune diseases, non celiac gluten sensitivity, yoga, DNA testing, and much more. Please let me know if you have any topics/areas which you’d like me to try to tackle, and thanks for all of your support.

 

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Update on Celiac Disease Screening in Infants and Toddlers

There are multiple reasons why a young child may need to be evaluated for Celiac Disease. The most obvious reason is if he or she has symptoms, such as chronic diarrhea, poor growth, and/or anemia. Other reasons include having a first degree relative (parent or sibling) who has Celiac Disease or having another autoimmune disorder, such as Type 1 diabetes.

The main blood tests to screen for Celiac Disease are tissue transglutaminase IgA (TTG IgA) antibodies and endomysial IgA (EMA IgA) antibodies. These tests are highly sensitive, which means that if the tests are negative, Celiac Disease can be ruled out most of the time. The problem with using these tests in infants and toddlers is that the sensitivity of these tests is much lower for children under the age of 2 than it is for older children and adults. Some believe that this is because young children with Celiac Disease have not had enough time to develop TTG and EMA IgA antibodies which can be measured. Needless to say, there are probably many toddlers with Celiac Disease who are walking around undiagnosed because they did not have elevated TTG and/or EMA IgA antibodies when they were tested.

Deamidated gliadin peptides (DGPs) are a new test for antibodies against gliadin and are being used with increased frequency for screening for Celiac Disease in the U.S. and Europe. A group of Italian researchers recently studied the utility of using DGP IgG antibodies to screen for Celiac Disease in children under the age of 2. They found that 100% of children under the age of 2 with biopsy-proven Celiac Disease had abnormally high DGP IgG antibodies on blood testing. They also found that DGP antibodies were abnormally high in 4 toddlers who had malabsorption (diarrhea) but who did not have a biopsy consistent with Celiac Disease. One of the 4 children with an abnormal DGP did have mild villous blunting and eventually developed Celiac Disease. The other 3 children with diarrhea and elevated DGPs all had the genes that predispose to Celiac Disease. They plan to follow these 3 children closely for the development of Celiac Disease. The researchers also found that DGP levels correlate very well with the extent of damage on the duodenal biopsies of the children with Celiac Disease and postulate that in the future, children with markedly elevated DGP antibodies may not need to be biopsied for diagnosis with Celiac Disease.

Out of curiosity, I went to the internet sites of some of the major labs that perform Celiac Disease blood screening tests. Labs which DO include DGP IgG antibodies on their celiac panels include Prometheus, Labcorp, ARUP, and Mayo Medical Labs. Labs which DO NOT include DGP IgG antibodies on their celiac panels include Kimball Genetics and Quest Diagnostics (as of 4/17/2013).

If you suspect that your young child may have Celiac Disease, but he or she did not have positive antibodies, it may be helpful to find out which lab their blood was sent to so that you can learn whether or not DGP IgG antibodies were part of the testing.  I recommend that you discuss any concerns with your child’s physician.

References:

1. Antibodies to deamidated gliadin peptides: an accurate predictor of celiac disease in infancy. Amarri, S., et al. J Clin Immunol. Published online 4/5/2013.

2. ARUP Consult. A Physician’s Guide to Laboratory Test Selection and Test Interpretation. Celiac Disease. www.arupconsult.com/assets/print/CeliacDisease.pdf.

3. Screening for celiac disease in average-risk and high-risk populations. Aggarwal, S., Lebwohl, B, and Green, P. Therap Adv Gastroenterol. Jan 2012; 5 (1): 37-47.

baby bottle

A New Food “Allergy” of Infancy: Food Protein Induced Enterocolitis Syndrome (FPIES)

My oldest daughter, Grace, had horribly bad reactions to cow’s milk protein as an infant, which included vomiting, chronic diarrhea with mucus, irritability, reflux, and poor growth. Her first reaction occurred shortly after getting her initial supplemental bottle of formula. She was predominantly breastfed at first, but I did have to supplement her due to milk supply issues (which, looking back, I believe were a result of my undiagnosed Celiac Disease). She went through a series of formula changes (from regular to soy to Alimentum and Nutramigen), and it was not until she was started on Neocate, an amino acid based formula, at 2 months, that she began to grow and thrive. Looking back, I am pretty sure that she had food protein induced enterocolitis syndrome, which is also called FPIES.

FPIES is a severe food sensitivity/intolerance which causes digestive symptoms in infants. Although it is considered by many to be an “allergy,’” it does not involve the formation of IgE antibodies like other food allergies. The most common triggers for FPIES in babies are cow’s milk and soy proteins, although rice, oats, barley, fruits, and vegetables have also been documented as triggers for older infants who have been started on solid foods. Based on recent studies it is believed that 0.3% of infants have an FPIES reaction to cow’s milk. This is in addition to the 3-5% of infants who have milder non-IgE reactions (allergies) to cow’s milk protein during the first year of life.

Infants with FPIES have symptoms shortly after consuming cow’s milk and/or soy proteins, usually within 1-4 hours. The usual trigger is a cow’s milk based formula, but breast fed infants can react to milk proteins in their mother’s breast milk as well. Symptoms can include projectile vomiting, chronic diarrhea with blood and/or mucus, low blood pressure, lethargy, irritability, and/or an elevated white blood cell count. 50% of infants with FPIES who react to milk will also react to soy.

It has recently been recognized that older infants can develop FPIES after solid foods are introduced during the 2nd six months of life. Rice is the most common trigger, followed by oats, barley, chicken, turkey, egg whites, green peas, peanuts, and potatoes. I recently learned that 80% of infants with one solid food trigger will have reactions to at least one other food, and that it is common for infants to have FPIES reactions to multiple foods.

Diagnosing FPIES is difficult because there are currently no blood tests that can be used in detection. This is because the immune reaction of FPIES does not involve the formation of IgE antibodies against the offending foods. This is much different than the IgE-mediated immune reaction that occurs in older children with food allergies. IgE allergies can be detected by blood and/or skin testing.  If a baby has adverse reactions after multiple exposures to the same food, FPIES can be diagnosed clinically. If the diagnosis is unclear, an oral food challenge (OFC) should be performed. It is recommended that an OFC be performed under close medical supervision (i.e. doctor’s office), as there is a risk for low blood pressure and/or dehydration to develop during a food challenge. In the worst cases an infant can develop shock. In some cases infants may need IV fluids after a reaction. Steroids are sometimes needed in severe cases. Based on what I have read, it seems that reactions to trigger foods may get more severe with time, i.e. it may take less and less of the offending food to trigger a reaction.

Research has shown that FPIES to milk and/or soy protein resolves by 3 years of age. It is recommended that children with FPIES get oral food challenges every 12 to 24 months. My oldest daughter is now 7 years old and she has no problems with dairy products (she eats yogurt, cheese, and ice cream) but she has refused to drink plain cow’s milk and has a tendency to avoid soy as well.

Reading and learning about FPIES led me to have many questions and concerns:

1. Why are so many infants born with this problem and why is it increasing in severity? Is it somehow related to their moms having undiagnosed Celiac Disease, and/or some other process causing “leaky gut” while pregnant?

2.  Is this the same disease process which those of us who have multiple food intolerances are experiencing, only babies are getting sicker and having more severe reactions since their immune and digestive systems are less mature?

3. How under-diagnosed is this problem? I had never heard of it 7 years ago when my daughter had it (and I was in my pediatric residency at the time). What are the real numbers?

4. Do infants with FPIES go on to develop Celiac Disease or gluten sensitivity when they are older? Is FPIES, even though it resolves, some sort of marker for the future development of food issues in a patient?

5. Is this somehow linked to the dramatic increase in autism over the last few years? Do the FPIES episodes have some sort of effect on the developing brain of an infant?

6. Does the microflora of the gut play a role? Would probiotics prevent and/or ameliorate the problem?

7. I was going to speculate a bit about GMOs, but I am not sure that I am ready to write about that yet…

I suspect that we are going to hear a lot more about this problem in the future. I wrote this article to share the little which I know about FPIES with you, in hopes that we can learn about it together.

References:

1. American Academy of Allergy, Asthma, and Immunology website: www.acaai.org/allergist/allergies/Types/food-allergies/Pages/food-protein-induced-enterocolitis-syndrome-fpies.aspx

2. Medscape Pediatrics. “FPIES: The ‘Other” Food Allergy.” Dr. Anna Nowak-Wegrzyn, MD. Published online April 3, 2013.

3. Curr Opin Pediatr. 2012 Dec;24(6):739-45. Clinical diagnosis and management of food protein-induced enterocolitis syndrome. Leonard, S. and Nowak-Wegrzyn, A. www.ncbi.nlm.nih.gov/pubmed/23042254

4. Clin Exp Allergy. 2012 Aug;42(8):1257-65. A multicentre retrospective study of 66 Italian children with food protein-induced enterocolitis syndrome: different management for different phenotypes. Sopo, S., et al. Department of Pediatrics, University of Sacred Heart Agostino Gemelli Rome, Rome, Italy. www.ncbi.nlm.nih.gov/pubmed/22805473

 

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Yes, it is “Safe” to Raise Non Celiac Kids Gluten Free

I’ve realized that I have not written for almost a week and I think I am okay with this. When I started this blog two months ago, I anticipated being able to post about once a week, so I think I am on track. Between working full-time, running, and trying to squeeze in some sleep, the main reason  that I have not had time is that I have four small children. I am trying my best to cherish this phase of our family life, as I know that someday I will have four teenagers at once!

None of my kids have Celiac Disease, but I consider them all to be at high risk for its development. Although I was diagnosed when I was 33, I have probably had Celiac Disease since early childhood. My mother also has it, and interestingly enough, was diagnosed after I was. Through conversations with aunts and uncles, it seems there is some “gluten sensitivity” in my deceased dad’s family. Although my husband, Tom, does not have Celiac, we do know that he is HLA-DQ2 positive, as he was tested by his GI doctor.  He has both an aunt and cousin with Celiac Disease as well. If none of my children go on to develop Celiac Disease, I will be truly amazed!

We started off my Celiac journey with a shared kitchen. I read up on this as much as I could after diagnosis, and I had my own “gluten free” cabinet, pasta strainer and pasta pot, cooking utensils, baking dish, etc. I also kept separate GF butter, peanut butter, and other condiments to avoid cross contamination.  I always put my items on a piece of aluminum foil when toasting because I was never able to find the “toaster bags” which people would discuss on the Internet forums. I thought that I was doing everything right and although our GF/non GF set-up did work for a while, I kept on getting sick. In 2012 I developed a peripheral neuropathy, which is persistent numbness and tingling from nerve inflammation, and was evaluated for multiple sclerosis. My neuropathy ended up being Celiac Disease related, as a result of continued exposure to traces of gluten. We made our whole home gluten free in 2012 and I have had minimal problems since then.  My exposure to tiny hands and mouths with gluten crumbs was much more damaging than I could ever have imagined when I was diagnosed in 2010.

Through starting this blog I have been able to interact with a lot of moms with Celiac Disease and/or raising kids with Celiac Disease. Many of us have decided to raise all of our kids gluten free, however, this seems to be controversial.  I have learned that many people are being advised by their doctors that it is not “safe” to raise their non Celiac children gluten free, because they are being told that by doing so that they are depriving their kids of essential vitamins and nutrients.  I have researched this and have not found any evidence that this is the case, as long as gluten free kids are given a wide variety of non-processed, nutrient-rich foods.

Our youngest is now 10 months old and, freakishly enough, has 7 teeth, so she is eating table foods at dinner. We eat a lot of vegetables, fruits, meats, eggs, beans, and fish. Our “starches” consist of potatoes, rice and risotto, squash, and sweet potatoes.  Once a week or so we will make a GF pizza of some sort. Lately we have been making a cauliflower pizza crust which I adapted from a recipe I found on Pinterest (I will post it on the “Recipes” page of this blog soon). We occasionally make tacos, enchiladas and other Mexican foods, pasta or lasagna, and Indian dishes, usually a chicken curry of some sort.  For snacks our kids eat fresh fruit, applesauce, popcorn, dried fruits and nuts, yogurt, string cheese, GF crackers and rice cakes.  We always have a few “treats” in our home, usually Annie’s GF Bunny crackers, ice cream, and a tortilla chip of some sort.  I bake a lot of treats for the kids as well. We’ve made delicious chocolate chunk cookies using almond flour 2 or 3 times in the past week (see link). We’ve said goodbye to a lot of convenience foods like chicken nuggets and frozen macaroni and cheese.

I do not see any evidence that my children are nutritionally deprived. They are growing and thriving, are not anemic, and interestingly enough, my two oldest have grown quite a bit since going off of gluten last year.  I give all of them a calcium and vitamin D supplement once a day, but I have done this for years. We live in the midwest, where vitamin D deficiency is rampant in both kids and adults, and a deficiency is associated with the development of autoimmune diseases.  I have not given them any other vitamins or supplements. I am pretty certain that they are getting enough protein, fat, vitamins, minerals and calories for proper growth and development through their diets.

I am not trying to say that what I am doing for my family is right or best for all families. I am sharing my story in hopes that it may help others to make the decision whether or not to make their entire household gluten free. Looking back, I wish that I would have made the transition much earlier in my journey, as it would likely have prevented me from developing neurologic complications from Celiac Disease. Thank you for reading!

 *Also, a quick reminder that this is a blog. I am summarizing medical literature, but also adding in my own thoughts and opinions on what I have read. I am not trying to tell anyone what they should do for their own health, nor am I giving medical advice through this page. Thank you!

 

 

 

Book Review: “Adam’s Gluten Free Surprise” by Debbie Simpson

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I discovered this book by reading a review written by “Celiac Yoga Momma.” I ordered my own copy, snuggled up with my three oldest kids over the weekend, and gave it a read. It could not have come at a better time as we’ve recently transitioned to being a totally gluten free household, which has been easier said than done.

This book shares the struggles of a little boy with celiac disease named Adam. His classroom is “typical” in the sense that parents and teachers provide treats on a regular basis, i.e. ice cream cones and pizza parties. As the school year progresses, Adam’s teacher and classmates gain a better understanding of what it means to have celiac disease and live gluten free. There is a great surprise at the end which I will not ruin for you!

“Adam’s Gluten Free Surprise” is a excellent book to read to any child with celiac disease, gluten sensitivity, and/or other food allergies. It is also an important read for any child who would benefit from having a better understanding of food allergies and intolerances, especially siblings and classmates of such children.

After we were finished with this book, my first grader and I had a nice discussion about all of the kids in her classroom who have food allergies. My preschoolers both gained a better understanding of celiac disease and why I have to be so careful to avoid foods with gluten. They asked me multiple times if I ever get sad like Adam does about not being able to eat “gluten foods” anymore…

Although Adam is an 8 year old boy, I found myself able to relate to him throughout the book. Just today I walked into our break room at work and it looked as if a “gluten bomb” had gone off. The tables and countertops were piled with cupcakes, pretzels, Chex mixes, Christmas cookies, muffins, breads, etc. and there were about one million crumbs on the floor. I related to little Adam very well as I carefully heated up my gluten free lunch and ran out.

Please check out author Debbie Simpson’s website at www.dsimpsonbooks.com. The book can be ordered through amazon.com and there are reduced prices between now and New Year’s.

This is one of my favorite pages from the book. I hope that you enjoy it as much as I did.

brown (celiac)