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No need to repeat celiac screening for five years after negative serology

Archives of Disease in Childhood
Reuters Health - 19/01/2022 - If children test negative for celiac disease on antibody screening, the risk of receiving a clinical diagnosis within five years is "very low," researchers say. 

However, children with potential celiac disease (positive antibodies against transglutaminase, but normal tissue samples) have a high risk of conversion to celiac disease and should be followed up. 

The current study is the five-year follow-up of a screening study done in 2013, Dr. Olof Sandstrom of Umea University in Sweden told Reuters Health by email. "We show that as many as one third of children with potential celiac disease develop overt celiac disease during the five years following the screening. This implies the need to follow these children for a longer period, which needs to be emphasized in guidelines." 

Only one case of celiac disease was identified within five years among close to 13,000 children with normal antibody levels, he added. "We had expected more cases in (this) group of children, so this was something of a surprise." 

As reported in Archives of Disease in Childhood, the 2013 mass screening among 12-year-olds in two birth cohorts (1993 and 1997) resulted in 296 seropositive children, including 281 who agreed to intestinal biopsy and 242 who were diagnosed with celiac disease. 

Two hundred and thirty (77%) attended the follow-up appointment, including 34 of 39 with positive serology but negative histology at baseline; of these, 11 (32%) had converted to celiac disease. 

Screened children who were seronegative were linked to the National Swedish Childhood Coeliac Disease Register to find cases diagnosed in healthcare during the same period. As Dr. Sandstrom noted, only one new case was identified. 

However, the authors noted considerable differences between the two birth cohorts. Children in the 1993 cohort were born during a celiac disease epidemic, and they had significantly higher prevalence of disease at follow-up compared with the 1997 birth cohort. "We cannot exclude that the environmental factors increasing the risk for celiac disease in the 1993 cohort also affected the risk for potential celiac disease and conversion to celiac disease," they write. 

Nonetheless, Dr. Sandstrom added, "It is important that future guidelines emphasize the need to follow up cases with potential celiac disease since many develop celiac disease. This is also something that pediatricians and GPs need to know." 

Dr. Arunjot Singh, Co-Director of the Center for Celiac Disease at Children's Hospital of Philadelphia (CHOP), commented on the study in an email to Reuters Health. He agrees about the value of screening; nevertheless, he said, "The utility of repeat screening in adolescents appears to have diminishing returns. At CHOP, we recommend screening of all first-degree relatives with celiac disease every 1-2 years until they reach puberty, after which it may be extended to every few years." 

"Although longer follow up and additional studies are needed," he said, "the authors' position of a greater than 5-year gap for repeat testing may be reasonable in those without risk factors, lack of symptoms and negative serology." 

"A major concern is the reliability and inclusion of cases in the National Swedish Childhood Coeliac Disease Register," he noted. "Although this a reputable registry for celiac disease, it is still limited to subjects reporting their diagnosis if they subsequently were diagnosed. An even greater concern is that asymptomatic individuals may never have been tested again, which may have missed cases of silent celiac disease." 

Although a high conversion rate from potential celiac disease was identified, "it is important to take this with caution given both the small sample size (n=35) and considerably different results (10% versus 40% conversion) between the two birth cohorts," Dr. Singh said. 

Dr. Supriya Nair, a UTHealth pediatric gastroenterologist affiliated with Children's Memorial Hermann Hospital in Houston, also commented by email. Like Dr. Singh, she noted that in the U.S., "it is common practice to only screen for celiac disease if there is a first-degree relative with celiac disease, or if there are symptoms (even as subtle as only abdominal pain)," because of a lower overall prevalence of the disease in the U.S. compared with Sweden. 

However, she said, since the 1993 epidemic, "celiac disease rates (in Sweden) decreased due to changes in dietary recommendations of delaying introduction of gluten to infants and decreasing the recommended daily intake of gluten." 

"As we learn more about the role of immunogenicity of the COVID-19 virus, clinicians will need to observe for possible increased risk of celiac disease after COVID-19 infection in children," she added. "A recent study published in the International Journal of Clinical Practice (https://bit.ly/3GJ10BR/) hypothesizes a mechanism via an increased intestinal permeability as a result of viral invasion of the brush border of intestinal enterocytes. This disruption in intestinal permeability is an essential step in the development of the immune reaction to gliadin, leading to celiac disease." 

SOURCE: https://bit.ly/3FJWOjK Archives of Disease in Childhood, online December 17, 2021. 

By Marilynn Larkin 

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