Recognizing Which Children Should Be Screened For Celiac Disease

Doctor Examining Child While some countries may be able to screen many or most of their children for celiac disease, others are trying to decide which children are most likely to have undiagnosed celiac disease and therefore need screening quickly.

Screening does not mean diagnosing children who doctors believe might have celiac disease based on their symptoms and family history. It means screening children who do not have the typical signs and symptoms of the disease. Approximately 1% of people in the United States are believed to have celiac disease, and most have not been diagnosed. Screening criteria should help find a high percentage of affected people.

A recently published study found a group of children in which more than 4% were found to have celiac disease. This was a group of children with abdominal pain and other symptoms leading to a diagnosis of irritable bowel syndrome (IBS). These children were more likely to have celiac disease than children with other diagnosed intestinal problems.

Screening children needs to be done on those that do not have the typical signs and symptoms of the disease

The study used specific criteria to identify groups of children with the following diagnoses, all with intestinal symptoms – IBS, functional dyspepsia and functional abdominal pain.

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These children were not suspected of having celiac disease. They were diagnosed according to what are called the Rome criteria, a list of criteria that gastroenterologists have agreed on to make these diagnoses. The criteria, most of which are symptoms, must occur at least once a week for at least 2 months before any of these diagnoses can be made. There cannot be any other obvious inflammatory, anatomic, metabolic or cancerous condition that explains the symptoms.

In addition to the frequency of symptoms, a long-enough time period, and absence of other illnesses, the diagnostic criteria in children or teenagers for each of these disorders are described below (descriptions are adapted from the Rome criteria).

Kids At Home Playing Symptoms of IBS include abdominal discomfort (an uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:

  • improvement with a bowel movement
  • onset associated with a change in the frequency of bowel movements
  • onset associated with a change in the appearance of the stool

Symptoms of functional dyspepsia include persistent or recurrent pain or discomfort centered in the upper abdomen (above the belly button). The pain or discomfort is not relieved by having a bowel movement or associated with the onset of a change in stool frequency or stool appearance. These last two are what separate it from irritable bowel syndrome.

It was believed for a long time that children with celiac disease are always extremely and obviously sick – but sometimes this is not the case

Symptoms of functional abdominal pain syndrome include episodic or continuous abdominal pain and not enough symptoms to diagnose one of the other conditions mentioned here.

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What may be confusing is the idea that doctors must be certain that no other illnesses are present. It could be concluded that for the purposes of the study as well as in general, doctors should check patients for celiac disease before making one of these diagnoses. In reality, these diagnoses may be made without a lot of invasive testing based on symptoms.

Doctors may not consider celiac disease in a child who has a normal blood count, normal liver and kidney function, no significant diarrhea, and no evidence of system-wide inflammation. This is especially true if the child is gaining weight normally. It was believed for a long time that children with celiac disease are always extremely and obviously sick. The fact that a lot of people, including children, have undiagnosed and less symptomatic CD is what is prompting researchers to try and figure out how to find these less symptomatic patients.

The study of 782 children was undertaken in Italy between 2006 and 2012. The children had been sent by their regular doctors to a center specializing in intestinal disorders.

These doctors did diagnose the children as having one of the above three disorders using the Rome III criteria. IBS was diagnosed in 270 children. 201 were diagnosed with functional dyspepsia. The other 311 children were diagnosed with functional abdominal pain.

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All of the children were then screened for celiac disease with blood tests. The blood tests included measuring total IgA, IgA antitissue transglutaminase, and endomysial antibodies. Any child with positive blood tests then had an intestinal biopsy to confirm celiac disease.

Children presenting with IBS have a 4 times higher risk of having celiac disease than children without IBS

In total, 15 of the patients tested positive for celiac disease. 12 of the 270 patients with IBS were found to have celiac disease, which was 4.4% of them. On the other hand, only 2 of the 201 children with functional dyspepsia (1%) and 1 of the 311 children with functional abdominal pain (0.3%) had celiac disease.

The researchers concluded that “Children presenting with IBS have a 4 times higher risk of having celiac disease than children without IBS.”

Based on this clear difference, the researchers recommended that children diagnosed with IBS be screened for celiac disease, which seems very reasonable. This particular study did not include any adults.

If you have a child with stomachaches who has been diagnosed with IBS, make sure he or she is tested for celiac disease. Making the diagnosis will lead to treatment with a gluten-free diet and should eliminate most or all symptoms.

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Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders
Fernanda Cristofori,Claudia Fontana, Annamaria Magistà et al. Increased Prevalence of Celiac Disease Among Pediatric Patients With Irritable Bowel Syndrome. A 6-Year Prospective Cohort Study. JAMA Pediatr. 2014;168(6):555-560. doi:10.1001/jamapediatrics.2013.4984.

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