A case study of a toddler with Celiac Disease

REGINA PHALANGE

Danielle Selden, Alicia Armeli, Brooke Atterbury, and Ryan

Brilhante

CLIENT: REGINA PHALANGE

• 3.5 year old, toddler, female • Weight: 14.35 Kg/ 98.75 cm/ BMI: 14.6 (22nd

percentile)• Recent decline in weight and eating habits

caused Regina’s mom to take her into the doctor.

• Bowel movements have changed in the past two months, diarrhea is common almost daily.

• Hard to get Regina to eat at times her “tummy hurts”; her mother is worried she may have a food allergy.

• Her mother is also concerned she is not getting her daily nutritional requirements, she does not want this to affect her growth and development.

• Regina’s favorite treat is her “fruity Pebbles” (made with rice) because they don’t give her a tummy ache. Her mom is having trouble getting her to eat anything else.

Atopic food intolerances seen in her mother and grandmother

Father had eczemaPaternal grandfather has IBS

FAMILY HISTORY:

Typical healthy 3-year old with minor health concerns:

Eczema since she was born. Normal height and weight development. Irregular eating habits and bowel movements

did not develop until 2 months ago.

REGINA’S PAST MEDICAL HISTORY:

How Active is Regina?

PHYSICAL ACTIVITY LEVEL:

Average 3 year old play until a couple months ago:

• Plays at preschool- runs around a lot

• Plays at the park- swings and jungle gym

• Plays with “Spot” her dog• Rides her tricycle • She is now “cranky” and

doesn’t play as much as she used to because she is tired.

• frequency: Daily activity at home and school

Regina’s weight measurements are in the 50 th percentile except the last weight measurement (40 th percentile).

Stature For Age has remained at 63 rd percentile

2 years old; 12.1kg/ 86.2cm 2.5 years old: 13kg/ 91.3cm 3 years old: 13.8kg/ 95.3cm3.5 years old: 14.36kg/ 98.75cm (40 th percentile)

Measurements were taken every 6 months for the past 2 years

EVALUATION OF REGINA’S WEIGHT

AMDR’sCarbohydrates: 45-65% of kcal per day, 732kcal, 183gFats: 30-35% of kcal per day, 512Kcal, 57gProtein: 5-20% of kcal per day, 220kcal, 55g

~protein 1.1g/kg/day

DAILY MACRONUTRIENT RECOMMENDATIONS:

Regina has been very tired lately even though she gets 8 hours of sleep a night.

Breakfast in the morning with mom and dadShe has dinner nightly with the family. Her parents

are having a hard time getting her to eat “certain things”

Sometimes she does not finish her food because her “tummy hurts”, evidence is seen in her “runny” stools.

Goes to preschool 3 days a week Goes to daycare 4 days a weekShe gets a daily snack of graham crackers at daycare

LIFESTYLE FACTORS

Breakfast: Oatmeal with maple and brown sugar (1 pkg.)Milk (6 fl. Oz)

Morning Snack:Animal crackers (4)

Lunch:Peanut butter & Jelly Sandwich (1/2)Apple-slices (1/2)Milk (6 fl. Oz.)

Afternoon Snack:Strawberry yogurt tube (1)Chocolate chip cookie (1)

REGINA’S “TYPICAL” DIET – BEFORE DIET:

Dinner:Chicken nuggets (4)White rice (3 Tbsp.)Peas (3 Tbsp.)Milk (6 fl. Oz)

Evening Snack:Chocolate milk (6 fl. Oz)

REGINA’S BEFORE DIET CONTINUED:

Based on estimated nutritional needs Macro nutrients within AMDR:

Protein: 14% (AMDR 5-20%) Fat: 32% (AMDR 30-35%) Carbohydrate: 55% (AMDR 45-65%) Iron (119% RDI) Calcium (171% RDI) Zinc (167% RDI)

Concerns: The following nutrients are too low: Omega 3 fatty acids Vitamin A Vitamin D Vitamin E Vitamin K Potassium

EVALUATION OF BEFORE DIET:

ETIOLOGY OF GLUTEN

INTOLERANCE: The cause is unknown, like most autoimmune diseases: • One out of 133 in the US is affected with with

CD. • CD occurs in 5-15% of the offspring and siblings

of a person with CD. • In 70% identical twin pairs, both twins have the

disease. • It is strongly suggested that family members are

tested. • Family members who have an autoimmune

disease are at a 25% increase risk of having CDCELIAC DISEASE IS NOT A FOOD ALLERGY: its an autoimmune disease. Food allergies, including wheat allergy, are conditions that people can sometimes grow out of. This is NOT the case with Celiac Disease.

An Autoimmune disease characterized by inflammation of the small intestine lining resulting from a genetically based intolerance to a component of gluten. The inflammation produces diarrhea, fatty stools, weight loss, and vitamin and mineral deficiencies.

AKA: Tropical spruce and gluten-sensit ive enteropathy.

WHAT IS CELIAC DISEASE?

When people that have CD eat foods that contain gluten, it creates an immune-mediated toxic reaction that causes damage to the small intestine and does not allow food to be properly absorbed.

Damage can happen even when there are no symptoms present.

WHAT HAPPENS IN CELIAC DISEASE

CD & DIGESTIVE SYSTEM ORGANS

Those who have a genetic susceptibility to the protein gliadin found in the gluten component of wheat, rye, and barley. Oats do NOT contain gluten, but commercial oats and oat products may be cross-contaminated by grains that do.

People who have one or both of the gene variance HLA-DQ2 and HLA-DQ8

People who have lactose intolerance are more susceptible, as these disorders are often seen together.

It is common in Scandinavians, Italians, Irish, British, South Americans, Eastern Europeans, Pakistanis, Cubans, and North Africans.

WHO IS AT RISK FOR CELIAC DISEASE?

Symptoms of CD:GI symptoms: inflammation of the SI mucosa resulting in diarrhea, weight loss, abdominal pain, anorexia, abdominal distention, flatulence

Can result in malabsorption of nutrientsNon-GI symptoms: iron-deficiency anemia, dermatitis herpetiformis, eczema, chronic fatigue, joint pain, migraines, depression, ADD, epilepsy, osteoporosis/osteopenia, infertility and/or recurrent fetal loss, short stature, failure to thrive, delayed puberty, dental enamel defects, and autoimmune disorders

LITERATURE REVIEW OF CELIAC DISEASE

Diagnosis: Small-bowel biopsy Improvement on a gluten-free diet Stool examination for malabsorption of nutrients Measurement of specific serum antibodies (i.e., Tissue

transglutaminase, Antigliadin) Presence of specific pairs of allele variants in HLA (MFC)

producing genes (HLA-DQA1 and HLA-DQB1) Key factors that influence the effi ciency of gluten presentation

include: (1) the level of gluten intake, (2) the enzyme tissue transglutaminase 2 which modifies gluten into high affi nity binding peptides for HLA-DQ2 and HLA-DQ8, (3) the HLA-DQ typeHLA-DQ2 binds a wider range of gluten peptides than HLA-DQ8! (4) the level of gene expression of HLA-DQ2 and HLA-DQ8 (5) additional genetic polymorphisms that may influence T cell reactivity

Presence of CD-associated HLA alleles is not diagnostic of CD; however, their absence essentially excludes a diagnosis of CD.

LITERATURE REVIEW CONT.

Management: Strict, life-long GF diet (avoid wheat, barley, rye) Treatment of nutritional deficiencies that may occur

(iron, zinc, calcium, fat-soluble vitamins, folic acid); standard treatment of osteoporosis

Genetic Counseling: CD results from the interaction of HLA-DQA1 and HLA-

DQB1 gene variants known to be associated with CD susceptibility, less well-recognized variants in non-HLA genes, gliadin (a subcomponent of gluten), and other environmental factors.

Since it appears to have atopic tendencies, genetic information is available for at-risk relatives.

LITERATURE REVIEW CONT.

Gluten: A protein found in wheat, oats, barley, rye, and triticale, (all in the genus Triticum); gliadin is the toxic fraction of gluten

Gluten is a common name for the proteins in specific grains that are harmful to persons with celiac disease. THESE MUST BE ELIMINATED FROM THE DIET.

Gluten creates an immune-mediated toxic reaction

GLUTEN’S ROLE

Gluten-Free: A food labeling term that indicates a product does not contain any species of wheat, rye, barley, or their hybrids, or ingredients that contain these grains, or 20 or more parts per million (ppm) gluten (about 6 mg per servings). (FDA-proposed definition.)

Adhering to a diet that contains non-gluten containing items.

Living a lifestyle without Gluten containing foods.

WHAT DOES GLUTEN FREE MEAN?

Gluten-Free is a life-long commitment. Some helpful starting tips: Quick Start Gluten-Free Diet Guide (overview of the gluten-free diet):

http://www.celiac.org/images/stories/PDF/quick-start.pdf Celiac Disease Foundation Gluten-Free Resources:

http://www.celiac.org/images/stories/PDF/gfresources.pdf Gluten in Medications, vitamins and supplements:

http://www.celiac.org/images/stories/PDF/gluten-in-meds.pdf Attention Pharmacists: Tips from a pharmacist: http://www.celiac.org

/images/stories/PDF/Medications_and_Celiac_Disease.pdf

*All of the following resources are located on the Celiac Disease Foundation Website- Diet and Lifestyle: http://www.celiac.org/index.php?option=com_content&view=article&id=11&Itemid=16

LIFESTYLE RESOURCES FOR LIVING WITH CELIAC DISEASE:

Our “toddler approved” prepared food snack that is Gluten Free

ANTS ON A LOG

Prep Time: 5 minReady in: 5 min

Ingredients:5 stalks celery½ cup peanut butter¼ cup raisins

Directions:

Cut the celery stalks in half. Spread with peanut butterSprinkle with raisins

Nutritional information: Amount Per Serving: Cal: 91Total Fat: 6.6gGluten: Omg

Toddles and Preschoolers – age (1-5)

NUTRIENTS OF CONCERN:

• Calcium • Iron • Vitamin D (often low)• Vitamin E (often low)• Vitamin A• Fat intake (Brain is still developing)• Zinc (often low)• B6• Folic Acid (often low)

May also have to treat deficiencies related to:

IronZincCalciumFat-soluble vitaminsFolic Acid

CELIAC DISEASE NUTRIENTS OF CONCERN:

Regina is required to follow a “Gluten-free” diet.

Breakfast: Strawberry yogurt (4 Oz.)Strawberries (3)Milk (4 fl. Oz.)

Morning Snack: Rice Crackers (6)Small Banana (1/2)Raisins (15)

Lunch Peanut Butter & Jelly Sandwich on gluten-free bread (1)Apple (1/2)

REGINA’S “AFTER DIET” RECOMMENDATIONS:

Afternoon Snack:Baby carrots (4)Gluten free cookies (2)Lite ranch dressing (2 Tbsp.)

Dinner:Brown rice (4 Tbsp.)Peas (3 Tbsp.)Gluten-free bread roll (1)Milk (4 fl. Oz)Butter (2 tsp.)

Evening Snack:Gluten-free mini cookies (3)

AFTER DIET, CONTINUED:

Before Menu: Total Kcals: 1439

CHO: 198g or 792 Kcals

Protein: 52g or 208 Kcals

Fat: 51g or 459 Kcals

Saturated fat: 17g

After Total Kcals: 1336

CHO: 198g or 792 Kcals

Protein: 33g or 132 Kcals

Fat: 49g or441 Kcals

Saturated fat: 13g

REGINA’S AFTER DIET MENU ANALYSIS:

Regina’s fi ber is slightly low: 75% RDIVitamin B1 56.81%Vitamin D 19.01%Vitamin E 62.06%Folate 54.71%Vitamin K 51.58%Calcium 48.83%Potassium 39.8% Dietary suggestions: Green smoothies with almond milk

will add calcium, Vitamins B, D, E, folate & potassiumAn assortment of fruits and veggies on diff erent days

will help Regina reach her RDI’s Note about excess protein

AFTER DIET ANALYSIS

1. CD is characterized by all of the following EXCEPT:

a. weight lossb. abdominal distensionc. iron-deficiency

anemiad. squamous cell

metaplasiae. migraines

2. How can CD be diagnosed?

a. Small-bowel biopsy b. Presence of

improvement on a gluten-free diet

c. Measurement of specific serum antibodies

d Stool examination for malabsorption of nutrients

e. all of the above

MULTIPLE CHOICE QUESTIONS:

Steatorrhea is a symptom of CD? True or False?

TRUE/ FALSE QUESTION:

The Celiac Disease foundation: www.celiac.org

Raising our celiac kids-Celiac Disease & Gluten-free Diet information: www.celiackids.com

Gluten-free summer camps: http://celiacdisease.about.com/od/raisingaglutenfreechild/tp/SummerCamps.htm

Glutenfreeda.com- largest collection of gluten free recipes in the world: http://www.glutenfreeda.com/ index.asp

Select a company’s name and get a l ist of the gluten-free products it sells, or select a food type and receive a l ist of companies that sell the glulten-free version of the food: www.gfco.org/products.php

JUST FOR KIDS Books:

“How I eat without wheat”By Karen Finewww.karenfi ne.com

“Gluten-Free Friends: An Activ ity Book for Kids”By: Nancy Patin Fal in i

Order both on:www.cel iac.com

SUPPORT AND RESOURCES

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Brown JE. Nutrition through the l ifecycle . 4 t h ed. Belmont, CA: Wadsworth, Cengage Learning; 2011: 32, 79, 81-82, 84, 86, 266-295, 278 (Table 10.5), 303

Celia Disease Foundation: www.celiac.org. Accessed November 24, 2011

Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Food and Nutrition Board, National Academy Press, Washington, D.C. 2005: 769-879.

Google Images. Digestive organs. http://www.google.com/imgres?imgurl=http://0.tqn.com/d/hepatitis/1/0/S/-/-/-/1090.jpg&imgrefurl=http://hepatitis.about.com/od/overview/ig/Organs-of-Digestive-System/Digestive-System-Organs.htm&h=320&w=400&sz=18&tbnid=MjraAbJHgt7ZoM:&tbnh=90&tbnw=113&prev=/search%3Fq%3Ddigestive%2Bsystem%2Borgans%26tbm%3Disch%26tbo%3Du&zoom=1&q=digestive+system+organs&docid=LTs7zE7Q0xmKPM&sa=X&ei=S9bSTur6NaeciQK_n5jwCw&ved=0CDAQ9QEwAQ&dur=937. Accessed November 25, 2011

REFERENCES:

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REFERENCES CONT.

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