Gluten Sensitivity in Pediatrics: A Clinical Conundrum

Non-celiac gluten sensitivity (NCGS) is a condition in which symptoms are triggered by gluten ingestion, in which both allergic and autoimmune mechanisms have been ruled out. The “classical” presentation of NCGS is a combination of gastrointestinal symptoms (including abdominal pain, bloating, and bowel habit abnormalities) and extra-intestinal manifestations. So far, NCGS has been described extensively in adults, and few data are available for the pediatric population. Due to lack of a serological or histological marker, the diagnosis of NCGS remains clinical and it is based on the exclusion of celiac disease and wheat allergy and on gluten challenge. G is a 2.5-year-old child referred to our Center for chronic diarrhea, diurnal abdominal pain, and mild failure to thrive. His mother reported that symptoms were related to wheat ingestion and that resolved on a gluten-free diet; therefore, she was worried about Celiac Disease. However, blood tests did support neither celiac disease because of anti-transglutaminase-IgA, anti-endomysium, and anti-gliadin-IgA negativity nor wheat allergy for the absence of specific IgE for wheat or gluten. G was positive just to anti-gliadin-IgG. We reassured the mother and concluded for a chronic unspecific diarrhea to be treated conservatively without elimination diets. On the follow-up visit, G was still complaining with same symptoms, and his growth was further slowing; we ,therefore, decided to repeat the blood tests (with similar results), to define the HLA status (DQ1/7), and to perform intestinal duodenal biopsies. These showed normal villous architecture and a modest increase of intraepithelial lymphocytes. Based on the clear association between clinical symptoms and wheat ingestion, the final diagnosis was “non IgE-mediated adverse reaction to wheat,” although G had no other clue to support this diagnosis such as personal or family history of atopy and/or eczema. G was started on a gluten-free diet with resolution of symptoms. This diagnosis was confirmed 6 months later with a double-blind placebo-controlled challenge that resulted in the onset of diarrhea and abdominal pain 30 h after wheat ingestion. This was happening in 2006 and 2 years later a “new” disease entity might have better explained the symptoms of this child: NCGS.