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.
Highlights
Celiac disease (CD) has earlier been considered to be a rare intestinal disease occurring only in children, a disease that Samuel Gee in 1888 presented as the “coeliac affection” [1]
As summarized by John Walker-Smith, Gee was very accurate in his description of childhood CD: “it is a kind of chronic indigestion, which is especially apt to affect children between 1 and 5 years old and where signs of the disease are yielded by the feces, being loose, but not watery, bulky, and pale
When addressing the changing epidemiology of childhood CD in 1992 [39], we suggested the following environmental factors to play a role: genetic background of the population, infantile gastroenteritis/other infections, unmodified/adapted cow’s milk formulas, breastfeeding, age at gluten introduction, quantity of gluten, quality of cereals, and quality of wheat gluten [62]
Summary
Celiac disease (CD) has earlier been considered to be a rare intestinal disease occurring only in children, a disease that Samuel Gee in 1888 presented as the “coeliac affection” [1]. As summarized by John Walker-Smith, Gee was very accurate in his description of childhood CD: “it is a kind of chronic indigestion, which is especially apt to affect children between 1 and 5 years old and where signs of the disease are yielded by the feces, being loose, but not watery, bulky, and pale
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