I received an email via our iPhone App from a mother who was concerned because her 2 year old son had skinny arms and legs, but a “big tummy” and she thought this might be a symptom of celiac disease. Most toddlers have “big tummies” even if they are skinny kids as their abdominal musculature (future 6 pack) is not developed.
I often have questions from concerned parents whose children are growing perfectly normally, but their “belly sticks out”. This is often a comment made about little girls (gender specific concerns already!) and I tell the parents that there are not many toddlers that don’t have protuberant little tummies.
If you go to the pool in the next several months, check out the baby pool, as this is not a good age to wear a bikini or “speedo” with that big tummy pushing down the bottoms, save that look for later on.
Now, what do you typically look for in child who you suspect might have celiac disease? Celiac disease typically causes failure to thrive in young children. I know this well, as I got this question wrong on my oral boards many years ago, and have spent the last 20 years making sure never to miss a case. (maybe I should leave that little tidbit out?)
At any rate, you see symptoms like persistent diarrhea, weight loss or failure to gain weight, a large protuberant abdomen, and a lack of appetite (no, being a picky eater does not count). Because celiac disease is an auto-immune disease where the body responds abnormally to a protein (gluten) found in foods like wheat, rye, barley and many other prepared foods, it differs from a food allergy. A food allergy typically causes symptoms like hives, wheezing or vomiting.
The first step in testing for possible celiac disease will be a blood test on your child. This will show if there are elevated levels of antibodies, called tissue-trans-glutaminase (tTG), in the blood. If a child has high levels of these antibodies (tTG), then a biopsy of the small intestine may be taken to confirm the diagnosis.
A small bowel biopsy is done while a child is sedated, through an endoscope, and actually takes a small piece of the lining of the intestine to see if the villi are flattened and damaged. The gluten in the diet of a child with celiac disease causes these changes to the intestine, and once gluten is removed from the diet the villi will return to normal and normal absorption of food will take place.
If a child is confirmed to have celiac disease (which is as lifelong problem) they have to remain on a gluten free diet, which means restricting many foods and drinks. A gluten free diet, while seemingly difficult to adhere to at first, will allow the child to grow and develop normally and your child will typically have more energy and feel better in general. After being on a gluten free diet another blood test may be done to confirm that the tTG level has come down.
With the advent of more gluten free products it has become easier for parents and children to follow a gluten free diet. There are many websites that help teach a family to read labels (similar to those with a food allergy) and to also provide resources for recipes or products that are gluten free.
Although I continue to look for a patient with celiac disease, I have yet to diagnose one, and remember to consider the diagnosis in any child who is having “failure to thrive”.
That's your daily dose for today. We'll chat again tomorrow!