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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.
Reviewed by John Snyder, MD, FAAP
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
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.
It is particularly important to accurately diagnose children with celiac disease because these children, unlike those diagnosed with a wheat allergy or gluten sensitivity, are at increased risk of a number of other comorbidities, including the development of other autoimmune diseases, and increased risk of cancer later in life if they do not carefully follow a gluten-free diet (Table 2).8
Other situations in which pediatricians may consider a gluten-free diet are for children with ASD and those with chronic problems with no obvious cause, according to Snyder. Although the recent consensus report on gastrointestinal disorders in persons with ASD found no definitive data on specific patterns of gastrointestinal abnormalities in these people or efficacy in any specific diet, the report does specify that the data did not look at whether subgroups of patients may benefit from such diets. For patients who try a restricted diet, the report recommends professional supervision, including the input of an experienced dietitian, to prevent nutritional inadequacies.9 Before the trial is undertaken, the child should be tested for celiac disease.
For children who present with chronic problems with no obvious cause, Snyder said that a trial of dietary therapy is often considered after celiac disease has been ruled out. For these children and all children who go on a gluten-free diet, he emphasized the need to work with a dietitian experienced in using the gluten-free diet to ensure a balanced, healthy diet.
For children who are placed on a gluten-free diet, involving a dietitian is highly recommended. "Involve a dietitian since gluten-free foods can be deficient in macronutrients' and micronutrients and are often not enriched with vitamins and minerals," emphasized Snyder.
The need to ensure that children on a gluten-free diet receive sufficient nutrients is highlighted by studies showing that these children may be getting low amounts of important vitamins and minerals as well as dietary fiber. Along with the lack of nutrient fortification in gluten-free products, many of these products also have increased saturated fat and sugar content,10,11 which can leads to obesity, new-onset insulin resistance, and metabolic syndrome.3
Along with ensuring proper nutrition, involvement of a dietitian can help with choosing foods that are gluten-free. Because even small amounts of gluten can be harmful, particularly for children on definitive treatment for celiac disease, working with a trained professional can help identify safe foods. For example, although oats are safe for most people, trace amounts of gluten may be found in them because of contamination with gluten during transportation, storage, and processing.11
In addition to talking to patients and guiding them in food choices to reduce or avoid eating diets too low in nutrients, pediatricians working with dieticians can address other potential limitations of gluten-free diets such as cost and issues of adherence (Table 3).3,4 Adhering to a gluten-free diet can be costly, and for many children may affect their psychosocial well-being because of the restrictions of the diet that may lead to social isolation.1,12
As with any therapy, follow-up visits with children on a gluten-free diet are important to ensure adherence to the diet as well as to evaluate symptoms and monitor for complications. Pediatricians, working with dieticians, can help improve adherence by ongoing education and support to families.12
With the increasingly popularity of gluten-free diets, questions of who actually may benefit from this type of diet need some answers. Prior to initiating a gluten-free diet, all children need to be tested for celiac disease. If diagnosed, a gluten-free diet is required as definitive and lifelong treatment. Other conditions that also warrant a gluten-free diet include wheat allergy and gluten sensitivity. For all children, education on adhering to a healthy, balanced diet is needed, and involving a dietician is integral to their care.
1. Percentage of U.S. adults trying to cut down or avoid gluten in their diets reaches new high in 2013, reports NPD [press release]. Port Washington, NY: NPD Group Inc; March 6, 2013. Available at: https://www.npd.com/wps/portal/npd/us/news/press-releases/percentage-of-us-adults-trying-to-cut-down-or-avoid-gluten-in-their-diets-reaches-new-high-in-2013-reports-npd/. Accessed May 23, 2016.
2. NPD Group Inc. Is gluten-free eating a trend worth noting? NPD website. Available at: https://www.npd.com/perspectives/food-for-thought/gluten-free-2012.html. Accessed May 23, 2016.
3. Reilly NR. The gluten-free diet: recognizing fact, fiction, and fad. J Pediatr. May 10, 2016. Epub ahead of print.
4. Snyder J. The gluten-free diet - not for everyone? Session H3011. Presented at: American Academy of Pediatrics (AAP) National Conference and Exhibition; October 26, 2015; Washington, DC. Available at: http://aap.planion.com/EvalCenter/AAP/Blobs/150576_6_150576_6_SNYDER.HANDOUT.pdf. Accessed May 23, 2016.
5. Ludvigsson JF, Leffler DA, Bai J, et al. The Oslo definitions for coeliac disease and related terms. Gut. 2013;62(1):43-52.
6. US Food and Drug Administration (FDA). Foods labeled gluten-free must now meet FDA's definition. Available at: http://www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm407867.htm. Updated August 5, 2014. Accessed May 23, 2016.
7. Fasano A, Catassi C. Clinical practice. Celiac disease. N Engl J Med. 2012;367(25):2419-2426.
8. Pietzak M. Celiac disease, wheat allergy, and gluten sensitivity: when gluten free is not a fad. JPEN J Parenter Enteral Nutr. 2012;36(1 suppl):68S-75S.
9. Buie T, Campbell DB, Fuchs GJ 3rd, et al. Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report. Pediatrics. 2010;125 suppl 1:S1-S18.
10. Ohlund K, Olsson C, Hernell O, Ohlund I. Dietary shortcomings in children on a gluten-free diet. J Hum Nutr Diet. 2010;23(3):294-300.
11. National Institutes of Health Consensus Development Conference Statement on Celiac Disease, June 28-30, 2004. Gastroenterology. 2005;128(4):S1-S9.
12. Rashid M, Cranney A, Zarkadas M, et al. Celiac disease: evaluation of the diagnosis and dietary compliance in Canadian children. Pediatrics. 2005;116(6):e754-e759.
Ms Nierengarten, a medical writer in Minneapolis, Minnesota, has over 25 years of medical writing experience, authoring articles for a number of online and print publications, including various Lancet supplements, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.