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Celiac Disease (Malabsorption Syndrome; Gluten-Induced Enteropathy

Disease wherein there is sensitivity or abnormal immunologic response to protein, particularly

the gluten factor of protein found in grainswheat, rye, oats and barley. When children with celiac

disease ingest gluten, changes occur in their intestinal mucosa or villi that prevent the absorption of

foods across the intestinal villi into the bloodstream. Most noticeably, children develop an inability tabsorb fat. As a result, they develop steatorrhea (bulky, foul-smelling, fatty stools); deficiency of fat-

soluble vitamins A,D,K and E (the vitamins are not absorbed because the fat is not absorbed);

malnutrition; and a distended abdomen from fat, bulky stools. Because vitamin D is one of the fat

soluble vitamins, rickets may occur. Hypoprothrombinemia may occur from loss of vitamin K. In

addition, children may have hypochromic anemia (iron deficiency anemia) and hypoalbuminemia from

poor protein absorption.

Although gluten-induced enteropathy is relatively rare condition, early recognition is essential

so that treatment can be provided, along with early support and nutritional guidance from the parents.

The illness occurs most frequently in the children of a Northern European background. It is apparently a

dominantly inherited illness; children have different degrees of involvement. There is also an increased

incidence in children with Down Syndrome.

Assessment

Children with the syndrome tend to be anorectic and irritable. They gradually fall behind

children their age in height and weight. They appear skinny, with spindly extremities and wasted

buttocks. The face, however, in contrast to children with true starvation, may be plmp and well

appearing.

Symptoms such as bulky stools, malnutrition, distended abdomen, and anemia becomenoticeable between 6 and 18 months of ae. The diagnosis is based on history; clinical symptoms; serum

analysis of antibodies against gluten (IgA antiglidian antibodies); and a biopsy of the intestinal mucosa

(done by endoscopy), which establishes the typical changes in the intestinal villi. Children may have an

oral glucose tolerance test, which will reveal poor absorption, and their stool may be collected to test

for fat content, which will be increased.

In addition, the childs response to gluten is observed by placing him or her in a gluten-free diet.

In most instances, the response to this diet is dramatic: the child begins to gain weight, steatorhhea

improves, and the irritability fades.

Therapeutic Management

Treatment is to continue the gluten-free diet for life, because there is some suggestion that these

children are more prone to GI carcinoma later in life if they do not continue the diet in adulthood. In

addition to this, children need to have water soluble forms of vitamins A and D administered. Both iron

and foliate may be necessary as well to correct any anemia present.

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Nursing Diagnoses and Related Interventions

Nursing Diagnosis: Imbalanced Nutrition, less than body requirements, related to malabsorption of food

Outcome Evaluation: Childs weight is maintained on a percentile curve on a growth chart; skin

turgor is good; steatorrhea is minimal; parents verbalize appropriate gluten-free food choices.

Parents need a great deal of nutritional counselling when their child is first placed on a gluten-

free diet. Gluten is a part of wheat, flour, gravy soups, and sauces. Packaged and frozen foods usually

contain gluten as fillers. Teach parents to be careful food shoppers and read food labels carefully.

Because children are anorectic when they are first introduced to the diet, getting them to eat it may be

a problem. Remember that toddlers often eat small servings, better than larger ones. Help parents

create incentives such as inviting dolls to tea or eating a picnic outside in a nice weather.

As children reach school age, preparing a gluten-free diet grows more and more difficult,

because favourite school age foods (e.g. spaghetti, pizza, hotdogs, cake, and cookies) are not allowed.

Selecting a diet in a school cafeteria may be impossible. Holidays pose special problems birthday cake,turkey stuffing, and holiday cookies are prohibited. Until children can recognize which foods they can or

cannot eat, parents often find it difficult to let them stay at friends houses or go to summer camp

activities important to childrens learning independence.