Gluten – What You Should Know

The South Lake Pediatrics blog continues to focus on the topic of nutrition and your child in 2022. Each month, we will bring you information on one of many topics in this subject. If there is a particular nutritional question you think would be interesting to learn more about, please feel free to leave a comment below.

Gluten is a family of proteins found in certain grains, notably wheat, barley and rye. When people with celiac disease eat gluten, it causes an abnormal immune response that damages the small intestine. The small intestine’s lining, when healthy, looks like a thick shag carpet with many small protrusions called villi. In people with celiac disease, the vili get flattened making the lining of the intestine looks like an old worn-out rug. The small intestine is where many nutrients are absorbed into the body. When it is damaged, it is harder for the body to absorb these nutrients. As a result, common symptoms of celiac disease in children include:

weight loss or poor growth
nutrient deficiencies such as iron deficiency and low vitamin D
fatigue
stomachaches, bloating, diarrhea, or constipation.

Other symptoms can include:

mood changes, sleep problems
tooth enamel defects
a blistering, itchy skin disease called dermatitis herpetiformis

Celiac disease is different from a food allergy. Some common food allergens are peanut, tree nuts, eggs, dairy, soy, fish, and wheat. When you have a food allergy, your body’s immune system mistakenly identifies a food as harmful which triggers an allergic response. This reaction usually happens very quickly. Symptoms of a food allergy include:

hives (raised itchy welts)
swelling of the lips or tongue
wheezing and trouble breathing
abdominal pain, diarrhea and vomiting.

Food allergies can cause a life-threatening allergic reaction called anaphylaxis. Children who have food allergies need to completely avoid contact with the allergenic food and always have an epipen with them in case of a severe reaction.

Children with wheat allergy need to avoid a lot of the same foods as children with celiac disease. A wheat allergy usually is diagnosed when the food is first introduced to infants. Many kids outgrow it. In contrast, celiac disease can develop at any age and is lifelong. Celiac disease does not cause anaphylaxis.

Celiac disease can be screened for with a blood test (typically looking at an antibody called TTG). The definitive diagnosis is made with a biopsy of the intestines so if a child has an abnormal blood test, we will refer them to a gastroenterologist. The tests for celiac disease (both the blood test and the biopsy) go back to normal when patients follow a gluten-free diet. If you think your child may have celiac disease, it is important to do the testing BEFORE eliminating gluten.

People with celiac disease are at risk for other autoimmune conditions such as type I diabetes and thyroid disease which we screen for with blood tests. Children who have a family member with celiac disease, or who have certain genetic conditions such as Down syndrome, are at higher risk for developing celiac disease and should be monitored.

The treatment for celiac disease is a strict gluten-free (GF) diet. When a child is diagnosed with celiac disease, it is important for them to meet with a dietician to help the family make these changes.

GF means avoiding all products containing wheat, barley and rye. Rice, corn, buckwheat, quinoa, and potatoes are all safe. Gluten is in many common foods including bread, cereals, cookies, cakes, and pasta. It is also found in many places you may not expect such as soups and sauces (because flour is often used as a thickener), soy sauce, protein and candy bars, some supplements, and some medications. Processed foods, such as pre-made meals or processed lunch meat, are at risk for having gluten. I was recently shopping for hash brown potatoes and found out there was wheat in one of the packages, despite the fact that potatoes themselves do not have gluten – so always read labels! When eating at restaurants, you also need to be thoughtful about cross contamination. For example, corn tortilla chips should not have gluten, but they may have been prepared in a fryer that was also used to prepare gluten-containing food.

GF diets have become very popular. As pediatricians, we often have parents asking if a GF diet is healthier. The main medical reasons we would recommend a GF/wheat-free diet is because a child has celiac disease or a wheat allergy. There is no question that gluten/wheat is unhealthy for patients who have these conditions (and in the case of wheat allergy, potentially life threatening). We do not have good scientific evidence to universally recommend a GF diet. Like most fad diets that advocate for elimination of a certain food, the answer for many people probably lies in practicing moderation rather than complete elimination. Plenty of diets would benefit from replacing some portions of breads, pasta and pizza with more fruits and vegetables and eating less processed foods. I do caution people about using GF substitutes (such as gluten free breads) thinking they are ‘healthier’. They often are not. Many GF substitutes are heavily refined and contain less fiber. They are often more calorie-dense. They may have fewer vitamins than wheat-based bread because wheat flours are required to be fortified with vitamins such as niacin, riboflavin, folate and iron. Non-wheat flours are not held to the same standards. If your child can tolerate gluten, choose whole-wheat bread over gluten-free bread. If he/she can’t, then try to incorporate grains like quinoa, amaranth and buckwheat which are all gluten-free and have a lot of fiber.

I was diagnosed with celiac disease when I was 18, so I have personal experience with dealing with a GF diet. It was a difficult transition at first but there is a lot more awareness of GF now than when I was diagnosed. Labeling of foods has improved and it’s easier to eat at a restaurant than it used to be. While the GF diet is restricting in some ways, it forced me to try new things, to be more thoughtful about what I eat, and to learn to cook. I was a very picky eater as a child, but now I have a more varied diet. I actually do eat the ‘5 servings of fruits and veggies per day’ that I am always recommending to my patients! If your child needs to go GF and they are old enough to help out in the kitchen, I would encourage you to get them involved in cooking and trying new recipes. And as always, if you have questions or concerns about celiac disease or the GF diet for your child, talk to your primary pediatrician or nurse practitioner.

Here are a few online resources on allergen/gluten free diets and celiac disease:

https://gikids.org/celiac-disease