Celiac Disease In Children

Yasin Sahin^1,2*Nafiye Urganci³Michal Kori⁴Eylem Sevinc⁵

• ¹Department of Pediatric Gastroenterology, Gaziantep Islam Science and Technology University, Faculty of Medicine, Gaziantep, Türkiye
• ²Clinic of Pediatric Gastroenterology, TC Saglik Bakanligi Gaziantep Sehir Hastanesi, Şahinbey, Türkiye
• ³Department of Pediatric Gastroenterology, TC Saglik Bakanligi Sisli Hamidiye Etfal Egitim ve Arastirma Hastanesi, Şişli, Türkiye
• ⁴Department of Pediatric Gastroenterology, Kaplan Medical Center, Rehovot,, Hebrew University of Jerusalem School of Medicine, Jerusalem, Israel
• ⁵Department of Pediatric Gastroenterology, Karabuk Universitesi Tip Fakultesi, Karabük, Türkiye

Editorial Celiac Disease In Children The aim of this Research Topic was to gather original research articles, case reports, as well as review articles focusing on several aspects of pediatric celiac disease (CD) in 2025 and contribute to the literature. This editorial reviewed 17 articles, 11 of which were accepted for publication by the reviewers and Editors in the Research Topic '' Celiac Disease In Children''. These articles cover the prevalence of acute reactions to inadvertent gluten contamination, molar incisor hypomineralisation, serum levels of vitamin D and calcium-phosphorus, allergic and immunological evaluation, clinical manifestations, and no-biopsy strategy in children with CD, celiac disease screening and depression, and anxiety in adolescents with CD. Celiac disease is an immune-mediated enteropathy triggered by dietary gluten consumption in genetically predisposed people, marked by the presence of specific antibodies, and variable degrees of small intestine mucosal damages (1). In addition to genetic susceptibility and gluten exposure; the pathogenesis of CD autoimmunity is considered to be multifactorial including impaired intestinal barrier function, gluten-induced proinflammatory innate immune response, and inappropriate adaptive immune response (1,2). Intestinal fatty acid binding protein (i-FABP) and fecal zonulin (FZ) are crucial for preserving intestinal physiological functions and may be indicators of enterocyte damage (3). It has been shown that a relationship between the clinical manifestations of CD and the levels of FZ and i-FABP (3). The authors stated that the increase in the values of FZ and i-FABP can serve as marker of increased permeability and damage of the intestinal barrier, which will open up new possibilities for understanding the processes of restoration of the small intestinal mucosa. Due to increasing physician awareness and the extensive use of highly sensitive and specific diagnostic tests for CD, the prevalence rate of CD has dramatically increased over the past three decades (1). Approximately 95% of cases of CD remain undiagnosed despite increased awareness and the availability of trustworthy testing techniques (1,4). There is a notable range in the clinical presentation of CD, however, there has been a considerable change in the way in which CD presents over the last three decades. Infants typically have distinct symptoms as apposed to older children. Infants may present with malabsoptive symtopms including diarrhea, anorexia, abdominal distension, and failure to thrive. Young children may present with any one of the above symptoms and/ or abdominal pain and iron deficiency anemia which are the most common presentatinfg symptoms in young children. While the symptoms of older children are either limited or atypical, some develop non-specific gastrointestinal symptoms, such as constipation, or extraintestinal symptoms, or signs such as short stature, iron deficiency, and delayed puberty. In older children and adults common presentations include; infertility, dermatitis herpetiformis, osteoporosis, enamel defects, neurologic manifestations such as ataxia, anxiety, and recurrent headaches (1,5). Many children are diagnosed without any symptoms due to screening of family members with CD, or screening of patients with associated autoimmune or genetic disease. As consistent with literature, the most prevalent symptoms among children with CD include abdominal pain, diarrhea, failure to thrive, and which was shown in a recent study conducted in Lebanon (1,6,7). In addition to having considerably lower vitamin D levels and higher tissue transglutaminase levels, recently identified and noncompliant children with CD are more likely to have molar-incisor hypomineralization (8). About 75% of patients with CD have osteopenia, and up to 30% have osteoporosis, as a result of inadequate absorption of calcium and vitamin D consequent to the mucosal damage (1,9). It ds known that adequate exposure to sunldght dncreases vdtamdn D levels. However, Kamdlova et al. (10) found that hdgh prevalence of vdtamdn D defdcdency ds also seen dn chdldren wdth CD ldvdng dn a regdon wdth dncreased sun ldght exposure. Individuals with autoimmune thyroid disorders, selective immunoglobulin A (IgA) deficiency, type 1 diabetes mellitus, psoriasis, as well as those with genetic syndromes such as Turner, Down, and Williams syndromes are recognized to have an increased risk of developing the disease. (1,11). Patients with these diseases should always be evaluated for CD because of these known correlations. Children with CD may potentially have immunologic abnormalities and allergic disorders. Beyond the well-known correlation with selective IgA deficiency, the recent study demonstrated a notable prevalence of immunologic abnormalities (partial IgM deficiency, unclassified hypogammaglobulinemia, etc.) and allergic diseases (aeroallergen sensitivity, allergic rhinitis, allergic conjunctivitis, food allergy, and asthma) in children with CD (12). ESPGHAN guidelines from 2020 recommend that CD is diagnosed without intestinal biopsy under certain conditions (13). According to a recent study from_Romania, serology-based diagnosis results in less compilance with follow-up, more dietary violations, and shorter mucosal healing than biopsy-proven patients (14). Additionally, the authors suggested that management should be improved, paying particular attention to individuals who were diagnosed with the no-biopsy diagnosis according to new ESPGHAN guidelines (14). A wide range of neurological symptoms such as anxiety, ataxia, headaches, and body image dissatisfaction may occur in patients with CD especially adolescents (15). It is critical to recognize mood disorder and body image dissatisfaction symptoms early in order to improve the general welfare of adolescents with CD and provide appropriate patient management. Periodic follow-up is necessary to identify mood-related symptoms and assess the teenagers' acceptance of their body. The wide spectrum of clinical manifestations makes CD challenging to diagnose, often leading to significant delay in diagnosis. According to reports, the delay to diagnose CD might range from months to a decade (1,4,16). It is crucial to diagnose CD early in order to avoid long-term consequences. The sole curative option is a lifelong gluten-free diet. Despite good adherence to a GFD, nutritional inadequacies has been shown in children with CD in a recent study, (17). Nutritional assessment should be done at each visit. Any identified deficiency; vitamin D, folate, B vitamins, iron, calcium, zinc, should be replaced. The accidental gluten ingestion is a significant issue troubling patients and physicians as well. It has been reported that one-third of children with CD on a GFD suffer from acute gastrointestinal symptoms such as vomiting, and nausea as a result of accidental gluten ingestion (18). To enhance the quality of life, by avoiding accidental exposue to gluten in individuals with CD, it's critical to educate, monitor and regulate accidental gluten consumption. In this special issue, we hope that you will enjoy reading and the new studies on pediatric CD, which we believe contribute to the literature, and have been evaluated through peer review and deemed appropriate for publication by the editors.