Celiac is an autoimmune, chronic disease of the gastrointestinal tract that is not easy to diagnose in adults. So, it is no surprise that things are even more complicated at an early age.
However, a timely diagnosis of autoimmune disorders is critical, considering the fact that an early on-set disease may be associated with poorer prognosis. The atypical presentation is often characteristic of early-onset autoimmune diseases; it is true not only for celiac disease1,2.
Many people living with celiac disease either remain undiagnosed or only get diagnosed after years of suffering. It happens due to the mixed presentation of the disease. However, when it comes to young children, things are even messier. They get gastrointestinal pain or discomfort due to any possible reason; they may often get diarrhea, constipation, gastroesophageal reflux, and have various kind of food intolerances3. In toddlers, even the flu may start with gastrointestinal symptoms. Then there are colic babies, who keep on crying or complaining due to no apparent reason. So, finding the cause of stomach upset is not a straightforward thing in young ones.
If you think that celiac is the disease of the older generation, you could be gravely wrong. It is true that for the initiation of the disease there needs to be an exposure to gluten-containing food like wheat products. In most cases this exposure happens quite early, just think of the biscuits. There are cases when celiac disease started in children who are a few months old; there are confirmed cases of celiac in children as young as nine months. At such a young age, doctors are more likely to think in the direction of lactose intolerance rather than celiac disease. Further, data indicates that the presentation in young age may be more severe, and maybe even associated with intestinal failure4.
However, the real risk of celiac is more in toddlers as compared to infants, as it is the age when small kids start consuming a gluten-rich diet in quantity. Toddlers or preschoolers are highly active; it is the age when people learn most of their skills, a time when the majority of learning happens. Any health issue at this age may leave a permanent mark on the individual. Celiac disease of young kids may present as a sleep problem, aggression, anxiety, and other behavioral issues. A recent study by Smith et al. published in the journal Pediatrics indicate that psychological manifestations are common in young patients with celiac disease.
Although there have been many studies, regarding the gastrointestinal symptoms of celiac, however, it is one of the first studies to look into psychological aspects of celiac in toddlers.
Toddlers present many of the gastrointestinal symptoms of celiac disease like loose stools, abdominal discomfort, malabsorption syndrome, and general weakness. However, it seems that they also show many psychological signs from the very early days, which may be masked in adults. Usually, a diagnosis of celiac disease would be confirmed through the demonstration of so-called tissue transglutaminase autoantibodies or tTGA.
A study by Smith et al. demonstrated that children living with celiac disease were prone to depression, stunted mental growth, and sleep problems, and they quickly get irritated or aggressive and may suffer from an attention deficit disorder. These children would be slow to pick up many essential skills.
Smith and colleagues analyzed the disease history of more than 4000 children from the US and some European nations, who were at higher risk of developing celiac disease or type 1 diabetes due to familial history. They enrolled the infants in the study that visited the clinics on a quarterly basis until the age of 4 and half-yearly until they were 15 years old. From two years onwards children were also screened for tTGA antibodies on an annual basis.
Apart from immunological examination and general physical checkup, researchers asked the parent about the gluten consumption in diet, and they also gave the psychological questionnaire to assess the cognitive and emotional wellbeing.
During the celiac screening, 66 children were tested positive before they reached 3 and a half years of age and another 40 tested before reaching 4 and a half years of age. These were children whose parents were not aware that their child has celiac disease. There were another 440 children who tested positive for celiac disease by the age of 3. However, their parents were aware of the diagnosis.
The study reported the higher prevalence of anxiety and depression among children that were suffering from celiac but remained undiagnosed as compared to those who were either healthy or knew their diagnosis. These undiagnosed, but celiac positive cases had more events of aggressive behavior, sleep-related issues, and withdrawn behavior when compared to those who were aware of the diagnosis of the presence of celiac disease.
Interestingly, these behavioral differences were only reported in young children. However, the study did not show any behavioral differences by the time kids achieved 4 and a half years of age, regardless of whether they knew that they have celiac disease or not.
Researchers concluded that younger children were more probable to demonstrate the non-verbal agitation when suffering from celiac, which may be somewhat related to the limited development of communication skills in young children. Investigators recommended that any behavioral changes should not be taken lightly at a young age. It is better to visit the physician more often and be at a peace of mind, instead of missing the diagnosis that may have a negative impact on their development – both physical and psychological.
Smith and colleagues agree that a diagnosis of celiac disease in young children is not an easy task, both due to the vagueness of symptoms and presence of gastrointestinal disturbances in a wide array of other health problems. However, they strongly recommend that the presence of celiac disease must be considered if these vague symptoms persist over an extended period, and most of the common pediatric ailments of the gastrointestinal tract have been excluded.
1. Walsh SJ, Rau LM. Autoimmune diseases: a leading cause of death among young and middle-aged women in the United States. Am J Public Health. 2000;90(9):1463-1466.
2. Amador-Patarroyo MJ, Rodriguez-Rodriguez A, Montoya-Ortiz G. How Does Age at Onset Influence the Outcome of Autoimmune Diseases? Autoimmune Diseases. doi:10.1155/2012/251730
3. Zoppi G. [The most common gastrointestinal problems in pediatric practice]. Pediatr Medica E Chir Med Surg Pediatr. 1996;18(2):131-139.
4. Calvi A, Gandullia P, Vignola S, Arrigo S, Tibaldi J. Early-onset of celiac disease with intestinal failure. Dig Liver Dis. 2014;46:e115. doi:10.1016/j.dld.2014.07.134
5. Smith LB, Lynch KF, Kurppa K, et al. Psychological Manifestations of Celiac Disease Autoimmunity in Young Children. Pediatrics. February 2017:e20162848. doi:10.1542/peds.2016-2848