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Guideline for the Diagnosis and Treatment of Celiac

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Guideline for the Diagnosis and Treatment of Celiac JOBNAME: gas 40#1 2005 PAGE: 1 OUTPUT: Wed December 15 18:39:15 2004 lww/gas/84141/MPG157309 Prod #: MPG157309 MS #xxx Journal of Pediatric Gastroenterology and Nutrition 40:1–19 Ó January 2005 Lippincott Williams & Wilkins, Philadelphia Clinical Guideline Guideline for the Diagnosis and Treatment of Celiac Disease in Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition ABSTRACT The Committee examined the indications for testing, the value Celiac disease is an immune-mediated enteropathy caused by of serological tests, human leukocyte antigen (HLA) typing and a permanent sensitivity to gluten in genetically susceptible in- histopathology and the treatment and monitoring of children dividuals. It occurs in children and adolescents with gastroin- with celiac disease. It is recommended that children and ado- testinal symptoms, dermatitis herpetiformis, dental enamel lescents with symptoms of celiac disease or an increased risk defects, osteoporosis, short stature, delayed puberty and persis- for celiac disease have a blood test for antibody to tissue tent iron deficiency anemia and in asymptomatic individuals transglutaminase (TTG), that those with an elevated TTG be with type 1 diabetes, Down syndrome, Turner syndrome, Williams referred to a pediatric gastroenterologist for an intestinal biopsy syndrome, selective immunoglobulin (Ig)A deficiency and first and that those with the characteristics of celiac disease on degree relatives of individuals with celiac disease. The Celiac intestinal histopathology be treated with a strict gluten-free Disease Guideline Committee of the North American Society diet. This document represents the official recommendations of for Pediatric Gastroenterology, Hepatology and Nutrition has the North American Society for Pediatric Gastroenterology, formulated a clinical practice guideline for the diagnosis and Hepatology and Nutrition on the diagnosis and treatment of treatment of pediatric celiac disease based on an integration of celiac disease in children and adolescents. JPGN 40:1–19, a systematic review of the medical literature combined with 2005. Ó 2005 Lippincott Williams & Wilkins expert opinion. SYNOPSIS vomiting, constipation and abdominal distension. How- ever, there is little information currently available about Who to Test? the precise prevalence of CD in children with these spe- cific types of GI symptoms. There is strong evidence for Celiac disease (CD) is an immune-mediated enterop- an increased occurrence of CD in children with der- athy caused by a permanent sensitivity to gluten in matitis herpetiformis, dental enamel defects, type 1 di- genetically susceptible individuals. It occurs in symp- abetes, IgA deficiency, Down syndrome, Turner syndrome, tomatic children and adolescents with gastrointestinal Williams syndrome and first-degree relatives of patients and nongastrointestinal symptoms. It also occurs in some with CD. There is moderate evidence for an increased asymptomatic individuals who have conditions that are prevalence of CD in children with short stature and some associated with CD. Based on a number of studies in Eu- evidence for an increased prevalence of CD in children rope and the United States, the prevalence of CD in with autoimmune thyroiditis. There is evidence that children between 2.5 and 15 years of age in the general anemia is common in children with CD, and an increased population is 3 to 13 per 1000 children, or approximately prevalence of unexplained anemia as a presenting feature 1:300 to 1:80 children. is well described in adults with CD. Other conditions that Numerous studies demonstrate that children with CD have been described in association with CD include a frequently have gastrointestinal (GI) symptoms such as variety of neurologic disorders; however, the evidence diarrhea with failure to thrive (FTT), abdominal pain, for these associations in children is poor. It is recommended that CD be an early consideration in Address requests for reprints to: Executive Director, NASPGHAN, the differential diagnosis of children with FTT and per- 1501 Bethlehem Pike, PO Box 6, Flourtown PA 19031. sistent diarrhea. In addition, it is recommended that CD Disclaimer: The guidance in this report does not indicate an exclu- sive course of treatment or serve as a standard of medical care. be considered in the differential diagnosis of children Variations, taking into account individual circumstances, may be with other persisting GI symptoms, including recurrent appropriate. abdominal pain, constipation and vomiting. Testing is 1 JOBNAME: gas 40#1 2005 PAGE: 2 OUTPUT: Wed December 15 18:39:15 2004 lww/gas/84141/MPG157309 2 HILL ET AL. recommended for children with nongastrointestinal symp- case of seronegative CD or to detect other mucosal toms of CD (dermatitis herpetiformis, dental enamel hy- disorders accounting for the symptoms. poplasia of permanent teeth, osteoporosis, short stature, It is recommended that confirmation of the diagnosis delayed puberty and iron-deficient anemia resistant to oral of CD require an intestinal biopsy in all cases. Because iron). Testing is also recommended for asymptomatic the histologic changes in CD may be patchy, it is rec- children who have conditions associated with CD (type 1 ommended that multiple biopsy specimens be obtained diabetes mellitus, autoimmune thyroiditis, Down syn- from the second or more distal part of the duodenum. drome, Turner syndrome, Williams syndrome, selective There is good evidence that villous atrophy (Marsh type IgA deficiency and first-degree relatives of celiac 3) is a characteristic histopathologic feature of CD. The patients). It is recommended that testing of asymptomatic presence of infiltrative changes with crypt hyperplasia children who belong to groups at risk begin around 3 (Marsh type 2) on intestinal biopsy is compatible with years of age provided they have had an adequate gluten- CD but with less clear evidence. Diagnosis in these cases containing diet for at least 1 year before testing. is strengthened by the presence of positive serological There is good evidence that in certain groups (type 1 tests (TTG or EMA) for CD. In the event the serological diabetes, first-degree relatives of affected individuals and tests are negative, other conditions for the intestinal Down syndrome) some individuals who initially have changes are to be considered and, if excluded, the diag- a negative serological test may subsequently develop nosis of CD is reconsidered. The presence of infiltrative a positive test on repeat testing over a period of years and changes alone (Marsh type 1) on intestinal biopsy is not have biopsies compatible with CD. Therefore, it is rec- specific for CD in children. Concomitant positive sero- ommended that asymptomatic individuals with negative logical tests for CD (TTG or EMA) increases the like- serological tests who belong to groups at risk be con- lihood such an individual has CD. In circumstances sidered for repeat testing at intervals. As there is no good where the diagnosis is uncertain additional strategies can evidence that CD is more common in children with au- be considered, including determination of the HLA type, tism, there is no indication to routinely test patients with repeat biopsy or a trial of treatment with a gluten-free autism for CD. diet (GFD) and repeat serology and biopsy. The diagnosis of CD is considered definitive when there is complete symptom resolution after treatment with a How to Test? strict GFD in a previously symptomatic individual with characteristic histologic changes on small intestinal biopsy. Based on the current evidence and practical consid- A positive serological test that reverts to negative after erations, including accuracy, reliability and cost, mea- treatment with a strict GFD in such cases is further sup- surement of IgA antibody to human recombinant tissue portive evidence for the diagnosis of CD. transglutaminase (TTG) is recommended for initial test- ing for CD. Although as accurate as TTG, measurement of IgA antibody to endomysium (EMA) is observer de- Who to Treat? pendent and therefore more subject to interpretation error and added cost. Because of the inferior accuracy of the Treatment with a GFD is recommended for all antigliadin antibody tests (AGA), the use of AGA IgA symptomatic children with intestinal histopathologic ab- and AGA IgG tests is no longer recommended for de- normalities that are characteristic of CD. Clinical ex- tecting CD. perience has demonstrated that children with persistent Individuals with CD who are also IgA deficient will diarrhea and poor weight gain resulting from CD have not have abnormally elevated levels of TTG IgA or EMA complete resolution of symptoms on treatment with a GFD. IgA. The occurrence of both CD and IgA deficiency in There is good evidence that treatment with a GFD re- the same individual appears to be rare in asymptomatic verses the reduced bone mineralization in children with individuals (approximately 1:8500 of the general pop- CD, and decreases the rate of spontaneous abortions and ulation) but is more likely in symptomatic children with frequency of low birth weight infants in adult women with CD (approximately 2%). Therefore, when testing for CD CD. Epidemiological evidence suggests treatment of CD in children with symptoms suspicious for CD, measure- can decrease the risk for some intestinal cancers and ment of quantitative serum IgA can facilitate interpreta- lower mortality rates to that of the general population.
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