Kids and The Gluten - Free Diet

THE CELIAC DIET, SERIES #6
Carol Rees Parrish, R.D., M.S., Series Editor
Kids and the Gluten-Free Diet
Mary K. Sharrett
Pam Cureton
The gluten-free diet presents unique challenges for children with celiac disease and
their families. Prior to diagnosis, children may be quite ill, suffering from poor growth
and developmental delay. Upon accurate diagnosis and treatment, children usually
improve quickly; however despite rapid improvement of symptoms, compliance with
diet may be less than optimal, putting the child once again at risk for the complications
of untreated celiac disease. Because children may feel uncomfortable being singled out
as “different,” a diet that calls attention to their condition, and thus their differences,
presents a unique challenge to parents and caregivers trying to meet the treatment
guidelines. Frequent follow-up and monitoring, along with educational resources and
support groups can aid families in maintaining a gluten-free diet and provide creative
ways to deal with the challenges inherent in a gluten-free lifestyle.
INTRODUCTION
ments can be an arduous task for parents and caregivers.
Enjoying pizza, birthday cake and breakfast cereals It can be difficult to manage the child’s diet when other
are all common food experiences for American
family members, friends, teachers, and caregivers are
families. Having a child with celiac disease (CD)
not clear about the strict guidelines of a GFD.
presents challenges in providing these experiences as
Recent studies indicate that the prevalence of CD
the gluten-free diet (GFD) excludes the traditional ver-
in children across the world may be as high as 1 in 80
sion of these “All American” favorite foods. Finding
(1). The number of families dealing with the GFD is on
look-a-like substitutes for these foods in order to mini-
the rise, since CD is ranked as the most common
mize the attention drawn to the child’s food require-
chronic disease among children. The age at diagnosis
also appears to be increasing (>3 years of age) (2).
While the reason is not known, it has been attributed to
Mary K Sharrett, MS, RD, LD, CNSD, Nutrition Sup-
changes in feeding practices and to new recommenda-
port Dietitian, Children’s Hospital, Columbus, OH.
tions for screening the associated high-risk groups (2).
Pam Cureton, RD, LDN, Center for Celiac Research,
Growth and Nutrition Clinic, Baltimore, MD.
(continued on page 52)
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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
(continued from page 49)
drome is reported to be 5%–12%. Relatives of people
Table 1
with CD are also at a higher risk for developing CD
Symptoms of CD in Children
(2). Many children have no intestinal symptoms or
Gastrointestinal symptoms: “Classic”
“silent CD”; screening this at risk population is rec-
• Weight loss
ommended to catch the disease early and prevent com-
• Gas/bloating
plications before they affect quality of life (1,8).
• Diarrhea with failure to thrive
• Constipation
• Abdominal pain/distention
PROTECTIVE FACTOR
• Vomiting
Infants who have an increased risk for developing CD
(Table 2) may have onset of the disease delayed by
Non-GI symptoms: “Atypical”
breastfeeding. Studies have suggested that breastfeed-
• Delayed growth
ing infants may result in a later onset of CD, with some
• Irritability
evidence supporting that it is the gradual introduction
• Failure to thrive
of gluten while breastfeeding that acts to delay the
• Behavioral changes, learning difficulties
• Dental enamel defects
onset of the disease. There is currently no evidence,
• Low bone mineral density/osteopenia/osteoporosis
however, demonstrating that breastfeeding prevents
• Short stature
the development of CD (9). The timing of the intro-
• Delayed onset menarche
duction of gluten into the diet may also influence the
• Iron deficient anemia
development of CD. One study suggests that introduc-
• Delayed motor development
ing gluten to infants between four and six months pro-
vided a lower risk of CD autoimmunity than did the
DIAGNOSIS
introduction of gluten before the age of three months
or after seven months (10). These results have yet to be
Children diagnosed before the age of 24 months are
replicated, and more information is needed to identify
more likely to exhibit “classic” symptoms of CD such
the optimal time to introduce gluten.
as weight loss, diarrhea and failure to thrive (Table 1).
Symptoms typically appear shortly after the introduc-
tion of gluten to their diet. Some infants develop
TREATMENT: THE GLUTEN-FREE DIET (GFD)
severe hypoproteinemia and edema, and although
Symptoms such as decreased lean body mass,
uncommon may present in a shock-like state, referred
decreased fat mass, anemia, poor growth velocity and
to as “celiac crisis” (3–5).
other nutritional deficiencies improve dramatically on
Older children are more likely to present with
the GFD (11,12). This rapid improvement is a great
atypical or extra-intestinal symptoms of CD. These
relief to parents. However, it may take up to a year or
can include: anemia, short stature, delayed motor
more for the villous atrophy to completely resolve.
development, and learning or concentration difficul-
(continued on page 55)
ties. Research indicates that 2%–8% of children with
short stature may have CD (3–5). Children may
Table 2
develop dental enamel defects, seizures, epilepsy,
Conditions associated with an increased risk
ataxia, and neuropathy or other neurological symp-
of celiac disease
toms if CD is left untreated (5,6).
• Type 1 diabetes
CD can be found in combination with certain pedi-
• Autoimmune thyroiditis
atric disorders and syndromes including Type 1 dia-
• Downs Syndrome
betes, Down syndrome, Turner Syndrome, Williams
• Turner Syndrome
Syndrome and selective IgA deficiency (Table 2).
• Williams Syndrome
• Selective IgA deficiency
Patients with Type 1 Diabetes have up to an 8% inci-
• First degree relative of a person with CD
dence of CD (1). The incidence of CD in Down syn-
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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
(continued from page 52)
Compliance in children with the GFD has been
Table 3
reported to be 45% to 80%. These figures may be over-
Gluten-free Childrens Vitamins*
estimated as some people who reported strict compli-
• Sesame Street Complete
ance had positive biopsies (1). A recent survey from
• Schiff Children’s chewable
the Canadian Celiac Association reported a compli-
• Pioneer Chewables for children
ance rate of 95%, which was attributed in part to the
• Freeda Vitamins
fact that their members had access to accurate educa-
*Please note that at the time of this writing, these vitamins were GF,
tional materials (2); improved compliance was also
however, products can change so be sure to check labels each time
associated with experiencing adverse symptoms when
before purchasing—especially if the food is now labeled “new” or
eating gluten, a diagnosis of CD proven by biopsy, and
“improved.”
being diagnosed at a young age.
NUTRITIONAL CONCERNS
Table 4
Specific Nutrients of Concern
At the time of diagnosis, parents and
children should meet with a registered
Nutrient
Age (years)
Recommended
Sources
dietitian who is knowledgeable about
Calcium
1–3
500 mg
1 c. milk = 300 mg
CD and the GFD. The family and
4–8
800 mg
2 oz. cheese = 400 mg
child (if at an appropriate age) should
9–18
1300 mg
6 oz. yogurt = 300 mg
be educated regarding the negative
3 oz. almonds = 210 mg
consequences of untreated CD
1c. calcium fortified orange
including nutrition related complica-
juice = 240 mg
1c. broccoli = 72 mg
tions such as osteopenia and osteo-
porosis, iron deficiency anemia, as
Iron
1–10
10 mg
3oz. beef = 1.8 mg
well as other autoimmune diseases.
11–18 (M)
12 mg
3oz.chicken = 1 mg
11–18 (F)
15 mg
1?2 c. spinach, cooked = 3.2 mg
Lactose intolerance is common in
1?2 c. red kidney beans = 2.6 mg
newly diagnosed adults, however, it
1?2 c. enriched rice = 1.2 mg
occurs rarely in newly diagnosed
1?3 c. raisins = 1.1 mg
children. Decreased bone density may
Folate
1–3 150
mcg
1?2 c. spinach, cooked =
occur as a result of a decrease in calcium
130 mcg
absorption due to villous blunting. (1).
4–8 200
mcg
1?2 c. navy bean = 125 mcg
Little is known about the nutri-
9–18 300
mcg
1?2 avocado = 55 mcg
tional quality of the GFD in children
1 orange = 45 mcg
hence, their intake should also be
1 oz. peanuts = 30 mcg
reviewed for nutritional adequacy. An
Thiamin
1–3
0.5 mg
3 oz beef liver = 9.2 mg
age appropriate GF multivitamin with
4–8
0.6 mg
3 oz. pork = 0.9 mg
minerals should be recommended due
9–13
0.9 mg
Enriched corn tortilla = 0.2 mg
14–18 (F)
1 mg
1?2 c. enriched rice, cooked = 0.2
to the malabsorption that occurred
14–18 (M)
1.2 mg
prior to the diagnosis (Table 3). Nutri-
ents of particular concern include
Riboflavin
1–3
0.5 mg
1 cup Milk = 0.45 mg
4–8
0.6 mg
1 cup Yogurt = 0.45 mg
calcium, iron, folate, thiamin and
9–13
0.9 mg
1 Egg = 0.27 mg
riboflavin (Table 4). Despite resolu-
14–18 (F)
1 mg
Enriched corn tortilla = 0.2 mg
tion of symptoms and no further con-
14–18 (M)
1.3 mg
3 oz. ground beef, cooked =
cern for malabsorption, most children
0.16 mg
will continue to require a GF multivi-
M = Male; F = Female
tamin because many GF grain prod-
ucts are not fortified or enriched.
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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
Table 5
Resources
Children’s Books on Celiac Disease
College
Gluten—Free Friends: An Activity Book For Kids
Beyond Rice Cakes: A Young Person’s Guide to Cooking, Eating
By Nancy Patin-Falini
& Living Gluten-Free
www.savorypalate.com
By Vanessa Maltin
Available at: www.celiaccentral.org
Kids with Celiac Disease: A Family Guide to Raising Happy,
Healthy, Gluten-free Children
Web Sites and Support Groups
By Danna Korn
Childrens Digestive Health and Nutrition Foundation
www.woodbinehouse.com
www.celiachealth.org
Nothing Beats Gluten-free Cooking
A Child’s Guide to Dealing with Celiac Disease
Cookbook for Children
www.celiaccenter.org
Celiac Disease Center at Columbia
www.celiacdiseasecenter.columbia.edu
R.O.C.K Raising Our Celiac Kids Web site
www.celiackids.com
Wheat-free Gluten-free Cookbook for Kids & Busy Adults
By Connie Sarros
Kids Korner
www.gfbooks.homestead.com
Celiac Disease Foundation
www.gluten.org
Incredible Edible Gluten-Free Food For Kids-
By Sheri L Sanderson
Cel-Kids Network
Available at www.woodbinehouse.com
CSA/USA
www.csaceliacs.org
Growing Up Celiac
Canadian Celiac Association
Kids Corner
www.celiac.ca
Celiac Disease Center at Columbia
www.celiacdiseasecenter.columbia.edu
Preschool
Eating Gluten-Free with Emily
Kids Baking Club
Written by Bonnie J. Kruszka
Lynn Rae-Ries
Illustrated by Richard S. Cihlar
www.glutenfreecookingclub.com
www.woodbinehouse.com
Kids Health
Pre-Adolescent
The Gluten-free Kid. A Celiac Disease Survival Guide
www.kidshealth.org/kid/health_problems/stomach/
by Melissa London
celiac.html
www.woodbinehouse.com
Understanding Your Student
Gluten Intolerance Group (GIG)
www.gluten.net
EMPOWER THE CHILD
come in contact with the child with CD. Additionally,
Children of all ages should learn about their disease and
Nancy Falini, RD, LDN, created a workbook for the
their diet along with their family or caregiver(s). Sev-
child with CD titled Gluten-Free Friends: An Activity
eral helpful resources are listed in Table 5. Eating with
Book for Kids that may prove helpful. See Table 6 for
Emily, about a little girl with CD—is a favorite with
many other suggestions to help a child take a more pos-
young children ages 3 to 7. This book may also be help-
itive and assertive role in managing his or her diet.
ful in teaching other children and schoolmates who
(continued on page 58)
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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
(continued from page 56)
Table 6
Empowering your child
• Start reading labels early.
when eating with friends, or at parties, it is important to help
Show children the word “wheat” on labels to help them recog-
the child understand that their foods are different. By under-
nize the word even before they can read. This helps to place
standing that their “look-a-like” food is not the same as regular
the “blame” for not being able to eat a food item on the label
foods (i.e., cupcakes), the child is better able to make safe
rather than on the parent. As the reading skills of the child
choices when the parent is not available to help. For example,
improve, they can look for the other gluten containing ingredi-
Mom may make “Rice Krispies Treats®” at home with a
ents (rye, barley, malt) that must be avoided. It will later help
gluten-free rice cereal. If regular rice treats are offered to the
give confidence to a child spending time away from home to
child at a friend’s birthday party, this may be misconstrued as
find safe foods to eat.
a safe food and unknowingly accepted.
• Involve the Child in Meal Planning and Preparation
• Parents can set an example by maintaining a positive attitude
Children should be encouraged to participate in meal planning,
Even very young children look to their parents for emotional
purchasing groceries and preparation of meals. Young children
cues and strategies for handling stressful events. For these
can select produce at the grocery store, set the table, and help
reasons, it is important for parents to be positive, even if they
wash vegetables or fruits. Older children can help choose the
have to fake it! Parents who keep their cool in a restaurant set-
menu, select grocery items, and make all or part of a meal by
ting and look for the bright side when birthday parties come
reading recipes and ingredient lists. A notebook or journal with
up unexpectedly show their child that the GFD doesn’t have to
recipes, notes about brand names of products used in the
hinder their social outings. These strategies may help the child
recipe and ideas for improvement can help families keep track
become more independent and confident in managing the GFD.
of their adventures in GF cooking. All of these activities teach
children about healthy eating and provide the family with qual-
• Gluten-free household?
ity time together.
Some families may choose to make the entire household GF.
This comes with pros and cons. The advantages include
• Role play
reduced risk of cross contamination, avoids child helping
Practicing what a child will say to an adult when offered a
themselves to a snack that contains gluten and not making the
questionable food is important. Most parents teach their chil-
child feel deprived by eating regular items in front of them.
dren to be polite and respectful to other adults and those in
The biggest disadvantage to the GF household is the cost of GF
authority such as a teacher or parent volunteer. Saying “no”
items. A loaf of bread is over $5.00 a loaf vs. wheat bread at
to such an adult will be difficult for a child if they do not know
less than $2.00 per loaf. Pastas, cookies and crackers are at
what to say. Practice by providing an age-appropriate and
least double to triple the price of wheat items. Many household
respectful script for your child and then having your child or
budgets would be strained with such extra cost. Realize that a
another family member pretend they are the adult.
child will need to learn how to survive in a “wheat world”;
beginning these survival skills in a supervised (i.e. home) envi-
• Identify “look-a-like” foods
ronment may prove beneficial in the long run.
It is very common for families to find “look-a-like” foods for
the child with CD. While this helps the child feel less isolated
CHALLENGES FOR CHILDREN AND THE GFD
school nurse and provide them with information about
the GFD. The Gluten Intolerance Group (GIG)
School
(www.gluten.net) and Celiac Sprue Association (CSA)
Parents and children need to be prepared to deal with
(http://www.csaceliacs.org/CelKidsSchool.php) have
the challenge of eating away from home. Daycare,
diet materials that can be printed out and discussed
preschool, and school present multiple opportunities
with appropriate school personnel. Schools usually
for contamination, “cheating” on the diet, and acciden-
require a letter from the child’s health care provider
tal exposure to gluten. To prevent mishaps, each year
before changes or restrictions can be put into place.
parents should meet with the principal, teachers and the
(continued on page 60)
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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
(continued from page 58)
Table 7a
Table 7b
For Occasional Treats: Gluten-free Candies*
For Occasional Treats: Gluten-free Candies*
• All M&M’s except “Krispies”
Just Born, Inc (Customer Service—(888) /645-3453)
All of our candies are derived from corn; therefore, to the best
• Big Hunk
to our knowledge, they are gluten-free. The modified food starch
• Dove Chocolate bars
we use in the manufacture of our jellybean candies is corn-
starch. Following is a complete list of our current product line:
• Dove Ice Cream
• Hershey bars (plain), chocolate syrup
YEAR-ROUND CANDIES
Mike and Ike—Original Fruits, Tropical Typhoon, Berry Blast,
• Juju’s
Jolly Joes-Grape
• Kisses
Hot Tamales and Super Hot Tamales
Zours
• Life Savers
Teenee Beanee Gourmet Jelly Beans
• Mars bar
FEATURE FLAVORS
• Milky Way (dark chocolate only, now called the “Midnight
Mike and Ike—Cotton Candy, Lemonade
Bar”)
• Rolo Caramels
VALENTINE’S DAY
Strawberry and Vanilla Crème Flavored Marshmallow Peeps
• Skittles
Hearts
• Snickers—all including the new Munch and Cruncher bars
Mike and Ike Valentine Treats
• Snickers Ice Cream
EASTER
• Starbursts (including jelly beans, candy canes, hard candies
Marshmallow Peeps, Bunnies and Giant Bunnies
and juice bars)
Strawberry and Vanilla Crème Flavored Marshmallow
Peeps Eggs
• Cambridge Sugar Babies and Sugar Daddies
Mike and Ike Easter Treats
• Three Musketeers (800-551-0698)
Just Born Jelly Beans
Peeps Jelly Beans
• Tootsie Rolls
HALLOWEEN
*Please note that at the time of this writing, these candies were GF,
Marshmallow Peeps Pumpkins, Spooky Cats and Ghosts
however, products can change so be sure to check each time before
purchasing, especially if the label says new or improved.
Individually wrapped Vanilla Crème Flavored Marshmallow
Peeps Ghosts
Snack Pack and Variety Pack Bags—Mike and Ike, Hot Tamales
and Zours
Other school survival ideas include:
CHRISTMAS
• Write a letter to be shared with other parents in the
Marshmallow Peeps Christmas Trees and Snowmen
class to ask to be notified when they are bringing in
Holiday Cookie Flavored Marshmallow Peeps Cutouts
a treat for the class.
Teenee Beanee Holiday Mix
• Providing a list of GF foods that the child likes is
very helpful for teachers and room mothers.
• Ask the teacher for a list of birthdays so a special
• Volunteering at school as a room parent is another
treat is on hand for the child with CD as the others
strategy to help stay abreast of classroom activities.
eat cupcakes, cookies, cake or pizza, etc.
• Discuss the possibility that craft activities can be a
• Provide a “survival box” with a stash of GF treats in
source of gluten ingestion for some children. Play
the classroom for those occasions when unplanned
Doh® is made with flour and although it is believed
treats are offered to the children (see Table 7a and b
gluten cannot be absorbed through the skin, young
for a list of GF treats).
children may eat it or put their hands in their mouths
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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
encounter (e.g., birthday parties, sports activities,
Table 8
sleepovers, school lunch, camping, vacations, back
School Lunch Ideas
yard barbeques, holiday parties, field trips, picnics,
Monday
etc.). Sending GF food with the child, bringing a GF
Chef salad with cheese and ham, GF salad dressing, rice crack-
dish to share, and bringing extra GF foods or snacks
ers and yogurt
are strategies that work well for many families. Parents
often find it helpful to volunteer to be scout leaders or
Tuesday
Peanut butter (Jif peanut butter comes in ‘to go’ single serving
to volunteer to plan menus or purchase the food. For a
2 oz cups) on rice cakes, apple slices or celery, plus a thermos
list of activities for GF fun see Table 9.
of GF soup
Going away to summer camp for a week or two is
a big challenge. Some families have been able to pack
Wednesday
up food for the week and send it along with the camper
Turkey or ham and cheese roll-ups on corn tortillas, corn
after talking with the food service director. There are a
chips, and fruit cup
growing number of camps for kids with CD. The
Thursday
Gluten Intolerance Group (GIG) offers camps for chil-
Home made ‘Lunchables’ with lunch meat and cheese cut into
dren with CD (see www.gluten.net). The Celiac Dis-
small squares or use cookie cutters for fun shapes, rice
ease Foundation also has a list of celiac camps on their
cracker, pudding cup and fresh fruit
website www.gluten.org. Family vacations require
Friday
advanced planning that should include coolers with a
Tuna ‘lunch to go’ kits (with the wheat crackers removed) rice
supply of food, hotel rooms with refrigerators and
crackers, carrot and celery sticks with GF ranch dressing for
checking with whomever is at the final destination for
dipping and fresh fruit or fruit cup
availability of GF food. There are also a growing num-
ber of vacation destinations that offer a great deal of
support for their GF guests, with the Walt Disney
while playing with it (Table 5 has several books that
Parks topping the list of most accommodating.
have recipes for GF Play Doh®).
School Lunch
Off to College
For those who are going to college, it will be important
Under the Americans with Disabilities Act (CD is not
to keep the GFD in mind when “interviewing” col-
considered a disability but is covered under a section
leges. When visiting prospective campuses, in addition
for food allergies), public schools are required to make
to all of the academic considerations, food options
reasonable accommodations to provide for children
must also be considered. It may be beneficial for the
requiring a GFD. Children must present a physician’s
student and parents to meet with the food service
statement of need. Parents should meet with the school
director to gather information on the availability of GF
dietitian and/or the food service director to review the
items and alternatives. Some college food service pro-
menus and look at labels. Most families find it easier
grams have GF food items and/or lists of their food
to pack a lunch than to rely on school-provided meals.
items that are naturally GF or can easily be made GF.
There are many GF items children can enjoy bringing
This information can sometimes be found on the col-
in their lunches such as fruit or pudding cups, yogurts,
lege web site. Some college dorms will allow refriger-
fruit snacks, and potato chips are but a few (see Table
ators, microwaves and hot plates so that a stash of GF
8 for more lunch ideas).
food can be kept in the room. College students have
also reported that they have been able get permission
Activities Away From Home
to live off campus where they have their own kitchen.
Children and parents can work together to find strate-
Before going to college, your patient will need a letter
gies for dealing with the many activities they will
from their physician stating their diagnosis and treat-
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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
Table 9
Activities and Snacks
Activities
Toddlers & Preschool
School Age & Adolescents
Cooking
Wash vegetables or fruits with a brush
Read ingredients
Set table with paper goods
Plan menus
Serve vegetables fruits etc in baggies
Start a GF cookbook
Help mix GF play dough
Learn to use basic cooking utensils & kitchen safety
Decorate GF cookies
Mix a GF trail mix or cereal snack mix
School Food & Snacks
Fresh fruit slices
String cheese
Fruit cups
Yogurt (tube yogurt)
Homemade cereal snack mix
Popcorn
Yogurt & tube yogurt
Nuts or pumpkin seeds
Dried fruit
Homemade GF trail mix
Home made GF cereal snack mix
GF energy bars
GF cereal or breakfast bars
GF cookies
Lunch meat or cheese rolled up
Soft corn tortilla wrapped around lunchmeat or leftovers
Parties
Ice cream
Ice cream cakes
Ice cream cakes
Build your own taco, omelet or sundae
Keep GF cupcakes in the freezer
Bring a GF dish to the party
Survival Boxes
GF cookies
Energy Bars
GF candy
Individual Servings of Peanut butter
GF chips
GF crackers
GF cookies
GF candy bar
GF chips or pretzels
ment in order for the college to make the special pro-
tical Gastroenterology for an entire article dedicated to
vision necessary to maintain a GFD. Some important
eating out.
tips for college living are listed on Table 10.
Support Groups
Eating Out
Support groups for families living with CD are invalu-
Eating out GF is always a challenge for families as
able. These groups share information about which
well as for older children who want to go out with their
foods to buy, where to buy them as well as how to deal
friends. Many restaurants have websites and on-line
with the many challenges they are facing. Many fami-
menus, availability of GF selections can be checked
lies and children find great comfort in just knowing
out ahead of time. Children should be encouraged to
other people who are dealing with the same issues.
make a list of a few favorites, so when there is an
There are many national and local support groups
opportunity, they can eat out safely with friends.
available to help families learn to work with the GF
Younger children report great satisfaction from an
diet including one just for kids, R.O.C.K. (Raising our
excursion with friends even if they only order a drink
Celiac Kids). See Table 5 for additional support groups
and plain potato chips! See the November 2006 Prac-
(continued on page 64)
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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
(continued from page 62)
Table 10
Table 11
College Survival 101
Kid Friendly Gluten-free foods
• Contact the food service department before visiting the cam-
Gluten-free ‘Look-A-Likes’
pus and ask them to prepare a gluten-free meal during your
visit. Take written materials on the GFD to give to the man-
Chicken Fingers
ager. Diet information can be obtained from the Gluten Intol-
• Bell & Evans gluten-free breaded chicken breast nuggets
erance Group www.gluten.net or www.celiachealth.org for
(www.bellandevans.com)
the Gluten-free Diet Guide.
• Wellshire Chicken nuggets (www.wellshirefarms.com)
• Dietary Specialties chicken nuggets (www.dietspec.com)
• It may be more important that the food service department is
• Ian’s Chicken nuggets (www.allergenfreefoods.com/Ians.html)
willing to accommodate you, than the meal they serve, espe-
cially if they have to go out of their way to provide your GF
Macaroni and Cheese
dish. Once you’ve chosen a college, one way to ensure an eas-
• Annies GF rice pasta & cheddar
ier dietary experience is to keep in touch with food service staff
(http://www.annies.com/products/gluten_free_pasta.htm)
and find out when they order food supplies each semester.
• Amy’s Rice Macaroni and Cheese (www.amyskitchen.com)
• When you’ve made your college-decision, it is important to
have ongoing discussion with the food service department.
Pizza
While it may have been acceptable to serve the GF food sepa-
• Gluten-free pizza by Foods by George
rately when you visited, it may become more challenging if it
(www.foodsbygeorge.com)
must happen every day for every meal.
• Frozen pizza crust: Kinnikinnick (www.kinnikinnick.ca);
• Review menus for all the meals the college will serve, includ-
Whole Foods (www.wholefoods.com)
ing special dinners (when parents or famous alumni visit, hol-
iday dinners, etc.) and find out which items are safe to eat.
Hamburger Helper Dinner
• Mrs. Leeper’s lasagna/beef stroganoff (www.celiac.com)
• Discuss the potential risk of cross contamination with the
food service director and brainstorm ways to prevent it.
Fish Sticks
• Most college food services run on a cycle menu, meaning the
• Dietary Specialties fish sticks (www.dietspec.com)
selection will be repeated every 2 to 4 weeks. Look over the
• Ian’s Fish Sticks (www.allergenfreefoods.com/Ians.html)
menu and verify that each day you will have something to
eat, and talk about having something in reserve for the days
Breakfast Cereal
when the selection does not include GF items.
• Nature’s Path Envirokidz, etc.: Amazon Frosted Flakes,
Gorilla Munch, Koala Crisps, Panda Puffs, Cornflakes,
• College students love care packages from home, and parents
Honey’d Cornflakes, MesaSunrise Flakes, Crispy Rice
can time the delivery of these special goodies for stressful
(www.naturespath.com)
times during the semester, such as exams or special occa-
• Enjoy Life: Cinnamon Crunch, Very Berry Crunch, Cranapple
sions as birthdays and holidays.
Crunch (www.enjoylifefoods.com)
• PerkyO’s: PerkyO’s Original, Apple Cinnamon, Nutty Flax,
Nutty Rice (www.glutenfreemall.com)
and resources. Health care providers should be aware
of such groups within their communities or refer fam-
Oreo Cookies
ilies to online sources at www.celiac.com for addi-
• Kinnikinnick (www.kinnikinnick.ca)
tional information.
Animal Crackers
• MiDel GF animal cookies (www.liberyrichter.com)
FOLLOW-UP CARE
Easy Bake Oven Cake Mixes
Frequent follow-up is important to ensure that symp-
• GF Easy Bake cake mixes
toms have resolved and growth has improved. Families
(http://www.foodtek.com/Products/QBKids.php)
often encounter conflicting information so the diet
should also be reviewed to clear up any confusion and
identify any potential sources of gluten. NASPGHAN
(North American Society of Pediatric Gastroenterol-
64
PRACTICAL GASTROENTEROLOGY • FEBRUARY 2007

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Kids and the Gluten-Free Diet
THE CELIAC DIET, SERIES #6
ogy, Hepatology and Nutrition) recommends periodic
5. Abdulkarim AS, Murray JA. Review article: The diagnosis of
celiac disease. Aliment Pharmacol Ther, 2003;17:987-995.
visits for assessment of symptoms, growth, physical
6. Peitzak MM, Catassi C, Drago S, et al. Celiac disease: going
examination and adherence to the GFD. Tissue Transg-
against the grains. Nutr Clin Pract, 2001;16:335-334.
lutaminase (TTG) should be measured after six months
7. Bucci P, Carile F, Sangianantoni A, et al. Oral apthous ulcers and
dental enamel defects in children with coeliac disease. Acta Pae-
of starting a GFD and then at one-year intervals. In
diatr, 2006:95(2):203-207.
addition, TTG should be drawn any time a patient has
8. Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of Celiac Dis-
ease in At-Risk and Not-At-Risk Groups in the United States. A
recurrent or persistent symptoms. A decrease in TTG
large multicenter study. Arch Intern Med, 2003; 163:286-292.
indicates compliance with the diet, and conversely, a
9. Ivarsson A, Hernell O, Stenlund H, et al. Breast-feeding protects
against celiac disease. Am J Clin Nutr, 2002; 75:914-921.
rise will indicate non-compliance (1).
10. Norris JM, Barriga K, Hoffenberg EJ, et al. Risk of celiac disease
autoimmunity and timing of gluten introduction in the diet of
infants at increased risk of disease. JAMA, 2005:293(19):2343-
CONCLUSION
2351.
11. Barera G, Mora S, Brambilla P, et al. Body composition in chil-
According to the NASPGHAN Clinical Practice
dren with celiac disease and the effects of a gluten-free diet: a
prospective case-control study. Am J Clin Nutr, 2000;72:71-75.
Guidelines Summary for CD, within a pediatric prac-
12. Patwari AK, Anand VK, Kapur G, et al. Clinical and nutritional
tice of 1,500 children there are probably between five
profile of children with celiac disease. Indian Pediatr,
2003;40:337-342.
and 20 children with CD, either diagnosed or undiag-
nosed (1). As the number of patients with CD
increases, it is important to continue making progress
in the research, knowledge, and treatment options for
PRACTICAL
CD. Diagnosis of the disease is only the beginning, as
the practitioner must provide the education and sup-
GASTROENTEROLOGY
port for life-long compliance to the GFD. The new
food labeling law, the Food Allergen Labeling and
R E P R I N T S
Protection Act, has improved our knowledge about the
source of many ingredients. The GF food industry has
expanded tremendously to provide many new GF
Practical Gastroenterology reprints are valuable,
products including chicken nuggets, instant chocolate
cake, and cereals that are appealing to children (Table
authoritative, and informative. Special rates are
11). Lastly, frequent follow-up by medical profession-
available for quantities of 100 or more.
als and participation in educational activities and sup-
port groups will not only encourage compliance and
prevent future complications of untreated CD, but will
also improve quality of life. ?
For further details on rates
or to place an order:
References
Practical Gastroenterology
1. Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diagnosis
and treatment of celiac disease in children: Recommendations of
Shugar Publishing
the North American Society for Pediatric Gastroenterology,
Hepatology and Nutrition. J Pediatr Gastroenterol Nutr,
99B Main Street
2005;40:1-19. (NASPGHAN CDHNF Diagnosis and Treatment
of Celiac Disease in Children Clinical Practice Guideline Sum-
Westhampton Beach, NY 11978
mary www.celaichealth.org.)
2. Rashid M, Cranney A, Zarkadas M, et al. Celiac disease: evalua-
Phone: 631-288-4404
tion of the diagnosis and dietary compliance in Canadian chil-
dren. Pediatrics, 2005;116(6):e754-759.
Fax: 631-288-4435
3. Fasano A, Catassi C. Current approaches to diagnosis and treat-
ment of celiac disease: an evolving spectrum. Gastroenterology,
2001;120:631-651.
www.practicalgastro.com
4. Murray JA. The widening spectrum of celiac disease. Am J Clin
Nutr, 1999;69:354-365.
PRACTICAL GASTROENTEROLOGY • FEBRUARY 2007
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