Dr. A. K. Patwari *
Professor of Pediatrics and Incharge, Division of Pediatric Gastroenterology & Nutrition, Lady Hardinge Medical College & Kalawati Saran Children's Hospital, New Delhi. *
Celiac Disease (CD), once believed to be rare in India, has increasingly been reported as a common cause of malabsorption in North Indian children. 368 children were diagnosed as CD in the Division of Pediatric Gastroenterology & Nutrition, Kalawati Saran Children's Hospital, New Delhi from 1992 onwards as per ESPGHAN criteria. Typical endoscopic findings of scalloping and nodularity of duodenal mucosa were seen in majority of the cases. Diagnosis was also supported by a positive serology for CD (antigliadin antibody IgG and IgA, antireticulin antibody and anti-endomysial antibody). More recently Anti tissue transglutaminase antibodies (tTG) is employed as a single serological test for screening of suspected cases, asymptomatic "at risk" individuals and for monitoring dietary compliance in some children.

Diagnostic delay has been a feature of CD in Indian children with age at diagnosis ranging from 2.5 to 12 years (mean 7.6 ± 2.37 years) with duration of symptoms ranging from 3 months to 10 years (mean 5.8 ± 2.6 years). Clinical profile included stunted growth (100%), anemia (100%), diarrhea (93.8%), and abdominal distension (70.8%). 12 children were hospitalized in acutely ill condition with celiac crisis and one of them presented after she was diagnosed and started on gluten-free diet (GFD) but remained non-complaint. Non-gastrointestinal manifestations included Dermatitis herpetiformis, Dental enamel hypoplasia of permanent teeth, Osteopenia/Osteoporosis and delayed Puberty. On enrolment all the children had a hemoglobin level <11 gm%, 78% had microcytic hypochromic anemia and 22% had dimorphic anemia, with lower mean MCV, MCH and Serum ferritin levels, and higher mean TIBC.

Children diagnosed with CD were started on a Gluten Free Diet (GFD) and followed up in the Pediatric Gastroenterology and Nutrition Clinic. Children were encouraged to attend this clinic every month for the first 6 months, every 2 months over the following 6 months. Quarterly for the next and every 6 months thereafter. On regular follow-up, the children were assessed for details of diet (to ascertain compliance and quality of food intake), symptomatic improvement and anthropometric assessment.

GFD consisted of "chapatti" made of soybean - rice flour (1:3 w/w protein 15 g, energy 366 kJ per 100 g), rice-bengal gram flour (1:1 w/w protein 11.9 g, energy 353 kJ per 100 g) or maize-soybean flour 3:1 w/w protein 19.1 g, energy 364 kJ per 100 g). During hospitalization, the GFD was prepared in the hospital kitchen and the families were shown how to make "wheat-free chapattis" in the hospital and after discharge from the hospital the GFD was prepared and served by the families themselves. In view of a potential risk of adulteration with wheat practices while milling the non-wheat cereals, the families were specifically counseled to mill the rice, soybean, maize or Bengal gram in special mills or in a domestic mixer. Compliance with the GFD was ensured by a thorough counseling of the child during every visit, counseling of all the family members (school teachers as well when requested by the parents or deemed necessary by the staff), and accidental ingestion was prevented by forbidding foodstuffs known to contain gluten and checking the composition and commercial labels of all unknown food items, including toffees, chocolates, ice creams, juices, etc. All the children received iron and folic acid supplementation.

In the follow up, compliance was a major problem due to non-availability of gluten free wheat/flour in the market and some of the parents/cases not liking the taste of 'chapatti' made of rice/soybean/maize, inability to resist temptation/feeling of deprivation, ignorance about ingredients in candies/toffees/commercially available snacks, eating out, social pressures especially in adolescents. Mean hemoglobin levels were normal in the follow up but the cases continued to have lower mean MCV, MCH, serum ferritin levels and higher mean TIBC. Serum ferritin levels showed a negative correlation with the grade of villous atrophy and lamina propria infiltrate. There was a significant correlation between serum prolactin levels and disease activity.

GFD leads to a normalization of body mass (evaluated as weight-for-height) and a substantial improvement in height-for-age in developing countries such as India where children have minimal access to nutritionally suitable alternatives to wheat. Apart from the GFD, careful follow up and good compliance with the dietary rules are mandatory for optimizing children's growth potential. Our observations highlight that there is a linear catch-up growth in terms of height during the initial follow-up on the GFD. The increments in height may be influenced by age at the time of diagnosis of CD and to some extent by the educational and economic status. Children with an early diagnosis demonstrated better increments in height than children diagnosed late. In the long term follow up of our cases, it was observed that GFD leads to normalization of body mass and significant but incomplete recovery in height for age Z scores.
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