Is gluten challenge really necessary for the diagnosis of coeliac disease in children younger than age 2 years?
OBJECTIVE
In the diagnosis of coeliac disease (CD), gluten challenge is recommended for children under the age of 2 years at initial biopsy. The aim of the study was to investigate the diagnostic yield of gluten challenge in this group of children.


METHODS
We included children aged 2 years or younger who were analysed for possible CD and who had villous atrophy at initial small bowel biopsy in the period 1993-2004. We subsequently identified all patients who underwent a complete gluten challenge.


RESULTS
We identified 333 children with possible CD. In 100 children (30%), a gluten challenge was performed, with the diagnosis being confirmed in 97. Retrospectively, in 2 of the 3 children without mucosal relapse, data available before gluten challenge did not justify the initial diagnosis of CD. In the third patient, transient gluten intolerance could not be excluded. At first biopsy, the 2 children without mucosal relapse had negative serological parameters, whereas the third patient had IgA antigliadin antibodies, but no IgA anti-endomysium antibodies (EMA). Indeed, all of the patients with EMA at diagnosis had a relapse at gluten challenge.


CONCLUSIONS
Routine gluten challenge in children younger than 2 years at initial diagnosis of CD has an extremely low diagnostic yield. We suggest that routine gluten challenge in this group of patients is not necessary when patients have villous atrophy in combination with EMA. Therefore, a revision of the current diagnostic criteria has to be considered.
Department of Paediatric Gastroenterology, University Medical Centre Utrecht, P.O. Box 85090, Utrecht 3508 AB, The Netherlands. v.m.wolters@umcutrecht.nl
Victorien M
VM
Wolters
Cissy
C
van de Nadort
Susan A M
SA
Gerritsen
C M Frank
CM
Kneepkens
Fiebo J W
FJ
Ten Kate
Caroline F M
CF
Gijsbers
Joachim J
JJ
Schweizer
Peter G J
PG
Nikkels
Marc A
MA
Benninga
Roderick H J
RH
Houwen
D001323:Autoantibodies / Q000097:blood*; D002446:Celiac Disease / Q000175:diagnosis*; D005983:Glutens / Q000008:administration & dosage; D006801:Humans; D007070:Immunoglobulin A / Q000097:blood*; D007223:Infant; D007413:Intestinal Mucosa / Q000473:pathology*; D007583:Jejunum / Q000473:pathology*; D012189:Retrospective Studies
D001323:Autoantibodies; D007070:Immunoglobulin A; D005983:Glutens