My first exposure to cases of pediatric celiac disease confirmed what was published in a text I read by Walker-Smith and Murch back in 1999 titled Diseases of the Small Intestine in Childhood. 4th ed.1 The authors were describing dominant symptoms that differed from what were referred to as more common symptoms of the disease in the adult population.
Five years later, Ludvigsson and colleagues published a paper in the Journal of Pediatric Gastroenterology and Nutrition discussing the same topic with regard to Swedish children with celiac disease. This paper covered the signs and symptoms of celiac disease in a pediatric population that were part of a previous prospective cohort study that aimed to identify risk in the pediatric population of Sweden for immune system diseases, including celiac disease.2 The researchers agree with Walker-Smith and Murch that celiac disease presents with different symptoms in pediatric cases.1
Combining Walker-Smith, Murch and the findings of Ludvigsson and colleagues, dominant celiac disease symptoms in children greater than 2 years of age but less than 15 years of age include having short stature, thin extremities, fatigue, abdominal distension, delayed onset of puberty, personality disorders and anemia.1 In the <2 pediatric population, I was seeing what was being published in the clinical literature, which is failure to thrive.
At the time of the Ludvigsson et al. paper, these symptoms were considered atypical. Yet, as this study and others have shown, these symptoms can be the predominant celiac disease symptoms in the >2 years and <19 years demographic.
In mid-2013, I was reading the American College of Gastroenterology abstracts and Su1098 caught my attention. The abstract titled Age Stratification of Presenting Symptoms and Biochemical Markers of Pediatric Patients with Celiac Disease by Srinath and colleagues focused on the objective of identifying the most common presenting symptoms of celiac disease in a pediatric cohort of patients, and further examine symptoms across age groups.3 They performed what is known as a retrospective chart review for pediatric patients diagnosed between 2002-2012 and their inclusion criteria included ages 0 to 18 years of age divided into three categories (0-6, 7-13, 14-18 years of age).3 A retrospective chart review uses data that was already collected for standard medical purposes, not research purposes. They identified that a significant proportion of diagnosed celiac disease patients aged 14-18 years old presented with nausea, which was not a classic symptom of celiac disease.3 Additionally, they noticed that the most common reported symptom among the 7 to 13 age group and 14 to 18 age group was abdominal pain.3 Interestingly 32.3% of those aged 0 to 6 years old experienced both abdominal pain and abdominal distention as the primary celiac disease symptom.3 Additional symptoms for the 0 to 6-year category included vomiting, arthralgia, failure to thrive and constipation and diarrhea.
As I mentioned in my article The Celiac and Obesity Connection Venkatasubramani and colleagues published a study in the Journal of Pediatric Gastroenterology and Nutrition concluding that obesity is more common in children with celiac disease than previously recognized.4 Finally, in the Journal of Gastroenterology, Alessio Fassano, MD confirms there is a general trend of deferred symptoms of celiac disease in children aged 5 to 7 years, and that this population is more prone to unusual intestinal complaints including recurrent abdominal pain, nausea, vomiting, bloating, constipation and short stature.5
Health care practitioners such as the primary care pediatrician and family members alike need to be hypervigilant of the symptoms associated with pediatric celiac disease found in the table below, and proper testing should commence once even just one symptom is present in a child.
|Pediatric Presentation of Celiac Disease|
|Delayed Onset of Puberty|
|Failure to Thrive|
1. Walker-Smith J, Murch S. Diseases of the Small Intestine in Childhood. 4th ed. Oxford: Isis Medical Media Ltd; 1999;258–9.↩
2. Ludvigsson JF, Ansved P, Fälth-Magnusson K, Hammersjö JA, Johansson C, Edvardsson S, Ljungkrantz M, Stenhammar L, Ludvigsson J. Symptoms and signs have changed in Swedish children with coeliac disease. J Pediatr Gastroenterol Nutr. 2004 Feb;38(2):181-6.↩
3. Srinath, AI, Carroll E., Ozolek J, Goyal A. Su1098 Age Stratification of Presenting Symptoms and Biochemical Markers of Pediatric Patients With Celiac Disease. Gastroenterology, ISSN: 0016-5085, Vol: 144, Issue: 5, Page: S-398.↩
4. Venkatasubramani N, Telega G, Werlin SL. Obesity in Pediatric Celiac Disease. J Ped Gastroenterol Nutr. 2010;51:295-297.↩
5. Fassano, A. Clinical presentation of celiac disease in the pediatric population, Gastroenterology, Volume 128, Issue 4, Supplement 1, 2005; S68-S73.↩