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Epidemiological and Clinical Features in Immigrant Children with Coeliac Disease: an Italian Multicentre Study

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Epidemiological and Clinical Features in Immigrant Children with Coeliac Disease: an Italian Multicentre Study Digestive and Liver Disease 36 (2004) 722–729 Alimentary Tract Epidemiological and clinical features in immigrant children with coeliac disease: an Italian multicentre study F. Cataldoa,∗, N. Pitarresia, S. Accomandoa, L. Grecob SIGENP and GLNBI Working Groups on Coeliac Disease1 a Paediatrics Department, University of Palermo, Palermo, Italy b Paediatrics Department, Federic II University of Naples, Naples, Italy Received 23 January 2004; accepted 30 March 2004 Available online 25 August 2004 See related commentary on pages 712–713 Abstract Background. There are no available data concerning the incidence and the clinical pattern of coeliac disease in immigrant children coming to Italy from developing countries. Aims. To evaluate the epidemiological and clinical features of coeliac immigrant children coming to Italy. Patients and methods. Hospital records of 1917 children diagnosed in 22 Italian Centres from 1999 to 2001 as having coeliac disease were retrospectively reviewed, comparing immigrant patients versus Italian ones. Results. 36/1917 (1.9%) coeliac children were immigrant. This prevalence was similar to that of the immigrant children among the whole paediatric population living in Italy. Prevalence was influenced by geographical factors, being higher in Northern Italy (1.7%) and in Central Italy (2.5%) than in Southern–Insular Italy (1.5%), as consequence of a higher proportion of immigrants in these regions. The native areas of the immigrant children were East Europe (15/36), Northern Africa (14/36), Southern Asia (4/36), West Africa (1/36), East Africa (1/36) and the Middle East (1/36). The clinical spectrum and dietary habits in immigrant patients were similar to those of the Italian children. Conclusions. Coeliac disease among the immigrant children coming from developing countries is an emerging problem, and physicians need to be fully aware of it. An important risk factor for coeliac disease in immigrant children appears to be sharing of the same dietary habits with the Italian population. The finding of coeliac disease in children coming from many countries worldwide suggests that coeliac disease is a global public health problem. © 2004 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Coeliac disease; Immigrant children 1. Introduction of the 20th century, and the condition is now being seen as a worldwide health problem. Indeed, until about a decade ago Coeliac disease (CD) is a permanent enteropathy caused the prevalence of gluten intolerance appeared to be 1/1000 in by the ingestion of gluten, a protein occurring in wheat, rye Europe [1], and CD was considered a very uncommon dis- and barley, in genetic-susceptible individuals. Epidemiolog- ease in the United States [2,3], in South America [4,5] and in ical knowledge concerning CD saw great changes at the end developing countries [6–12]. However, more recently, several serological population screenings have shown that the preva- ∗ Corresponding author. Fax: +39 091 703 5478. lence of CD in Europe is 1/200 or greater [13–18]. Similarly, E-mail address: [email protected] (F. Cataldo). in the United States [19–21], in Latin America [22–25] and in 1 See Appendix A for the list of members. Australia [26,27], it is more common than previously consid- 1590-8658/$30 © 2004 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2004.03.021 F. Cataldo et al. / Digestive and Liver Disease 36 (2004) 722–729 723 ered, probably because the majority of Caucasian American, carried out under the auspices of both the ‘Gruppo di Lavoro Latin American and Australian people share a common Eu- Nazionale per il Bambino Immigrato’ (GLNBI), affiliated ropean ancestry. Furthermore, a very high incidence of CD to the Italian Society of Paediatrics and the Italian Society has been recently reported in some developing areas of the of Paediatric Gastroenterology Nutrition and Hepatology World, such as North Africa [28–32], South Asia [33–36], (SIGENP). the Middle East [37–41], while in the Old World there have Eight of the participant centres, with 768 patients, were been some sporadic case reports on native coeliac patients in Northern Italy (Cuneo, Milano 1, Milano 2, Novara, from developing countries [42,43]. Padova, Parma, Reggio Emilia, Venezia-Mirano), eight with In the last 25 years, the migratory flow from developing 603 patients were in Central Italy (Ascoli Piceno, Bologna, countries towards Italy has progressively increased. In De- L’Aquila, Lucca, Modena, Pisa, Roma 1, Roma 2) and six cember 2001, in our country the number of adult immigrants with 546 patients were in Southern and Insular Italy (Bari, with regular residence permits was 1,362,630 [44]. A large Catania, Messina 1, Messina 2, Palermo 1, Palermo 2). proportion of them have permanent residence in Italy and Thirty-six CD-affected immigrant children (ages ranging get married. The direct consequence has been an increase in from 6 months to 15 years, mean age 7.3 years, 15 males the number of infants born in Italy to immigrant parents, as and 21 females) were recruited. From the clinical histories well as of children coming from their native countries to join of these immigrant patients we recorded: (1) parents’ native their original families. In December 2001, the number of im- countries; (2) patients’ country of birth; (3) reasons for their migrant children living in our nation was 326,101, mainly in presence in Italy (adoption, family rejoining, birth in Italy, Northern and Central Italy (respectively, 200,264, 61.4% and casual presence in our country); (4) clinical findings of CD at 82,742, 25.4%) and less in Southern–Insular Italy (43,095, diagnosis (classic, atypical, silent or latent forms), comparing 13.2%), amounting to 2% of the entire paediatric popula- them to those of the control group. The control group con- tion living in Italy [44]. These children share the same envi- sisted of Italian CD children, matched for sex and age with ronment and the same dietary habits as the Italian children. immigrant CD children (1881 patients, ages ranging from 6 Therefore, if they have predisposing CD genetic factors (i.e. months to15 years, mean age 7.9 years; 891 males and 990 fe- HLA DQ and non-DQ alleles), they may be at risk of gluten males), diagnosed in the same period, using the same criteria, intolerance. in the same centres; (5) feeding practices of immigrant CD To our knowledge, there are no available data concern- children by means of a non-quantitative dietary recall. In this ing the prevalence and the clinical pattern of CD, as well as regard, the parents of the immigrant CD children were called the predisposing environmental risk factors for CD, in im- in each centre participating to the study, in order to request migrant children coming to Italy from developing countries. in the same manner and using the same criteria by means The aims of the present study were to evaluate: (1) the preva- of the same standardised questionnaire notices on breast or lence of immigrant children with CD in our country; (2) the bottle-feeding practices, duration of breast-feeding, age of clinical findings of CD in these patients; and (3) the possible the weaning, age at introduction of gluten-containing diets; relationship between immigration, dietary habits and CD in (6) age of the onset of symptoms compared to the age of childhood. their coming to Italy; (7) age at diagnosis of CD, compared to the age of the onset of symptoms (diagnostic delay); (8) compliance to the gluten-free diet (GFD). 2. Patients and methods This was a nationwide study with the co-operation of 3. Results 22 paediatric Centres of Gastroenterology or Immigration Centres. It was retrospective, with a review of the hospital 36/1917 CD patients (1.9%) were immigrant. Table 1 medical records from January 1999 to December 2001 of shows their distribution through the Italian geographical ar- 1917 patients (both Italian and immigrant), consecutively eas (Northern, Central, Southern–Insular Italy), and Table 2 diagnosed as having CD. The revised criteria of the Euro- shows the native continents and the native countries of their pean Society of Paediatric Gastroenterology and Nutrition parents. 5/36 of the immigrant CD children had only one (ESPGAN) for CD diagnosis were used [45]. The study was immigrant parent. Table 1 Geographic distribution of immigrant children in Italy (December 2001, source: Caritas, Rome) and geographic distribution in our country of the immigrant CD patients Italian areas Immigrant children Immigrant CD Total CD patients Prevalence of immigrant CD (n = 326,101) patients (n = 36) (n = 1917) patients/total CD patients Northern 200,264 (61.4%) 13 768 1.7% Central 82,742 (25.4%) 15 603 2.5% Southern–Insular 43,095 (13.2%) 8 546 1.5% 724 F. Cataldo et al. / Digestive and Liver Disease 36 (2004) 722–729 Table 2 Table 5 Native continents and native countries of the parents’ CD immigrant children Clinical pattern at diagnosis in Italian and in immigrant CD children (number of the immigrant CD children in the brackets) Italian CD children Immigrant CD East Europe (n = 15/36) Macedonia (1), Rumania (4), Poland (2), Rus- (n = 1881) children (n = 36) sia (1), Serbia (1), Albania (5), Ukraine (1) Classical forms 1276 (67.8%) 25 (69.4%) North Africa (n = 14/36) Egypt (1), Morocco (6), Tunisia (5), Saharawi Atypical forms 510 (27.1%) 9 (25%) (2) Silent forms 95 (5.1%) 2 (5.5%) West Africa (n = 1/36) Cape Verde (1) 2 East Africa (n = 1/36) Somalia (1) No significant differences were observed between the two groups (χ test). Middle East (n = 1/36) Syria (1) Southern Asia (n = 4/36) Sri Lanka (1), Pakistan (3) during the observed years (1999–2001) in relation to their native continents.
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