Associated conditions and other complications

Celiac disease

• Occurs in 1–10% of children and adolescents with type 1 diabetes (prevalence is 10–50 times greater than in the general population and this varies between different geographical regions)
• Should be considered whenever a child with diabetes has gastrointestinal signs or symptoms including diarrhea, abdominal pain, flatulence, dyspeptic symptoms or recurrent aphthous ulceration
• Is often asymptomatic
• Non-gastrointestinal presentations are not uncommon, e.g. poor growth, iron deficiency anemia, delayed puberty, unexplained recurrent hypoglycemia (particularly with poor weight gain), dermatitis herpetiformis

Immunological tests

• Antiendomysial IgA antibody (EMA) is the most specific test
• EMA should be combined with total IgA level to exclude false-negative results
  
  [Antigliadin IgG and IgA antibodies are sensitive screening tests but are less specific]
• Seroconversion to positive EMA after onset of diabetes predicts later celiac disease but this may take months or years to develop

Definitive diagnosis

• Jejunal biopsy showing villous atrophy
• A normal mucosa in a seropositive child does not preclude later development of celiac disease. Seropositive patients require regular reassessment

Treatment

• GFD may improve growth and wellbeing in previously ‘asymptomatic’ patients
• GFD may or may not alter insulin requirements
• GFD may or may not alter metabolic control
• GFD should be associated with disappearance of EMA

Screening

• Controversy exists as to the need for and frequency of screening tests to detect clinically asymptomatic cases of celiac disease
• In some geographical areas annual screening for celiac disease is recommended

Consider the possibility of celiac disease in any child or adolescent with gastrointestinal symptoms, unexplained poor growth or anemia Immunological screening should be considered close to the time of diagnosis of diabetes and repeated if clinical circumstances suggest the possibility of celiac disease