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Changing Pattern of Childhood Celiac Disease Epidemiology: Contributing Factors
Alina Popp1,2, Markku Mäki1
1Faculty of Medicine and Health Technology, Tampere Center of Child Health Research, Tampere University and Tampere University Hospital, Tampere, Finland.
Insights
Celiac disease (CD) presentation shifted from severe infant symptoms to milder forms, altering its epidemiology. Environmental factors like gluten introduction timing and cow's milk influenced this change, increasing CD prevalence.
Area of Science:
- Gastroenterology
- Pediatrics
- Epidemiology
Background:
- Celiac disease (CD) presentation evolved from severe infant symptoms (diarrhea, malabsorption, failure to thrive) to milder forms.
- This transformation led to a significant shift in the age of CD diagnosis, particularly from the 1970s onwards.
- Observed changes in CD presentation altered the disease's epidemiology, with notable variations between and within countries.
Purpose of the Study:
- To discuss potential causes and environmental factors contributing to the observed clinical changes in celiac disease presentation.
- To identify new clues from studies published during the period of CD's clinical transformation.
- To recommend future epidemiological studies on environmental factors influencing the shift in CD presentation.
Main Methods:
- Review of studies published during the period of celiac disease (CD) clinical transformation.
- Analysis of factors including breastfeeding, gluten introduction timing and volume, cereal type in weaning foods, and cow's milk properties.
- Examination of epidemiological data and clinical presentation patterns of CD.
Main Results:
- Breastfeeding was found to postpone, but not prevent, CD diagnosis.
- Early gluten introduction (around 2 months) was associated with malabsorption and failure to thrive in infants.
- Factors like gluten intake volume, cereal type, and cow's milk osmolarity played significant roles in CD presentation.
Conclusions:
- The changing clinical nature of celiac disease (CD) and the use of case-finding tools are crucial for understanding its evolving epidemiology.
- Environmental factors, including infant feeding practices and early gluten exposure, significantly impact CD presentation and prevalence.
- Continued epidemiological research is recommended to further elucidate the environmental influences on CD presentation shifts, especially in regions still observing these changes.
Abstract:
Up until the 1960s and 1970s, diarrhea, malabsorption syndrome, and failure to thrive were the presenting symptoms and signs of celiac disease (CD) in young infants; however this disease was also at the same time reported to be disappearing. Indeed, clinical childhood CD was seen to transform into a milder form, resulting in an upward shift in age at diagnosis during the 1970s (and years later for many countries). This changing pattern of CD presentation then altered the epidemiology of the disease, with major differences between and within countries observed. An awareness of the changing clinical nature of CD and use of case-finding tools to detect even clinically silent CD became an important factor in this changing epidemiology. Countries report both low and high prevalence but it seems to be on the increase resulting in a population-based level of 1-2%. This paper discusses the potential causes and environmental factors behind these observed clinical changes, identifying new clues from different studies published at the time this transformation took place. For instance, it was found that breastfeeding postponed the diagnosis of the disease but did not altogether prevent it. Moreover, gluten introduction at a young age, specifically at the mean age of 2 months, seemed to also have a clear impact in inducing malabsorption syndrome and failure to thrive in young infants in addition to other factors such as gluten intake volume and type of cereal present in the weaning food. Further, the impact of cow's milk and its high osmolarity might have played an important role; humanized milk formulas were not yet invented. Future epidemiological studies on the contributing environmental factors to the shift in CD presentation are thus recommended for countries in which these changing clinical features are still being observed.
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