The popularity of gluten-free diets continues to grow as people increasingly turn to diet as a way to manage copious symptoms from gastrointestinal disturbances, which can range from headaches to skin rashes, behavioral problems, and psychological difficulties. Data from the NPD Group Dieting Monitor, which regularly tracks dieting and nutrition-related issues, show a steady increase in the percentage of American adults who say they are cutting down or trying to avoid gluten in their diets. As of 2012, 30% of American adults aged older than 50 years and 26% of adults aged 18 to 49 years claimed to be cutting down or avoiding gluten completely.1,2
For parents who are trying to provide the healthiest environment for their children, the media-hyped benefits of a gluten-free diet may help steer them to placing their child on a gluten-free diet in the belief that it will provide symptom relief, prevent celiac disease, or just be healthier.3
Such a diet, however, is not for all children and can actually be less healthy for otherwise healthy children because of the reduced nutritional benefits and often-enhanced sugar and fat content of gluten-free diets if not monitored carefully. Along with the lack of supplementation of vitamins and minerals in most gluten-free foods, gluten-free diets also are often more expensive for families.
For children diagnosed with celiac disease, the role of a gluten-free diet as definitive therapy is well established. Other conditions as well warrant consideration of this diet in children, including wheat allergy and gluten sensitivity. Other children with gastrointestinal symptoms with no obvious cause also may benefit, as perhaps subgroups of children with autism spectrum disorder (ASD).
To help pediatricians navigate through the morass of information emerging on gluten-free diets, John Snyder, MD, FAAP, professor of pediatrics and chief, Division of Gastroenterology, Hepatology, and Nutrition, at Children's National Health System in Washington, DC, spoke on indications for a gluten-free diet in children and key issues to keep in mind when talking to parents and children about a gluten-free diet in his presentation "The gluten-free diet - not for everyone?" at the American Academy of Pediatrics 2015 National Conference and Exhibition, Washington, DC.4
Definition of and indications for a gluten-free diet
Gluten is a complex of water-insoluble proteins found in wheat, rye, barley, and crossbreed grains such as wheat-rye (ie, triticale).4,5 The 2 main proteins found in gluten are called gliadins and glutenins, and they provide dough with characteristics of elasticity, shape, and chewy texture.
A gluten-free product, as defined by the US Food and Drug Administration (FDA), is a food that is inherently free of gluten or one that contains no ingredient that is: 1) a gluten-containing grain such as spelt wheat; 2) derived from a grain in which the gluten has not been removed such as wheat flour; or 3) derived from a good in which gluten has been removed but greater than 20 parts per million (ppm) of gluten remain in the product.4,6
Indications for considering a gluten-free diet in a child include, most importantly, the diagnosis of celiac disease for which a gluten-free diet is definitive treatment. Along with celiac disease, the other 2 primary conditions for which a gluten-free diet should be considered are wheat allergy and gluten sensitivity. Because the symptoms of all of these conditions are similar, and may include chronic diarrhea, weight loss, and abdominal distension, a thoughtful approach to making the diagnosis is critical (Table 1).4,7,8
To make the accurate diagnosis for celiac disease, Snyder highlighted the importance of using the recommended screening tests to measure quantitative immunoglobulin A (IgA) level and the IgA anti-tissue transglutaminase (tTG) antibody level for celiac disease followed by endoscopic intestinal biopsy of the small intestine in patients with symptoms and positive screening serology (Table 1).4,7,8 If celiac disease is not found, consideration of a wheat allergy or gluten sensitivity can then be considered.