Synopsis
Recognise the varied childhood presentation of coeliac disease, preserve gluten exposure for valid testing, complete paediatric specialist confirmation and support lifelong nutritionally adequate gluten exclusion with growth surveillance.
- Test for persistent gastrointestinal symptoms, faltering growth, prolonged fatigue, unexplained iron deficiency, mouth ulcers, dermatitis herpetiformis or high-risk autoimmune and family contexts.
- The child must continue eating gluten during diagnosis; NICE advises gluten in more than one meal daily for at least 6 weeks before testing where tolerated.
- First-line serology is total IgA and IgA tTG; use EMA when tTG is weakly positive and IgG-based tests when IgA deficient.
- Do not use HLA-DQ2 or DQ8 as an initial non-specialist test; absence can help exclude disease only in selected specialist uncertainty.
- Refer every child with positive serology, and any child with persistent strong suspicion despite negative serology, to paediatric gastroenterology.
- Specialists may use a validated paediatric no-biopsy pathway in carefully selected very-high-titre cases with confirmatory testing, but families must not infer diagnosis from one result.
- Start a lifelong gluten-free diet only after confirmation, with specialist paediatric dietetic teaching on wheat, barley, rye, oats, labels, contamination and balanced substitutes.
- Monitor symptom resolution, tTG trend, weight, height, puberty, iron, folate, B12, calcium, vitamin D and adherence; investigate non-response rather than intensifying restriction blindly.
Key red flags
Weight loss, marked faltering growth, oedema, severe anaemia or delayed puberty indicates clinically important malabsorption.
Persistent vomiting, bilious emesis, abdominal guarding or major bleeding is not explained by uncomplicated coeliac disease and needs urgent assessment.
IgA deficiency can make standard tTG-IgA falsely negative; laboratory testing must include total IgA.
Starting a gluten-free diet before testing can normalise serology and histology and may necessitate a difficult gluten challenge.
Ongoing symptoms on a gluten-free diet require review of diagnosis, hidden exposure, nutritional deficiency and alternative disease rather than automatic refractory labelling.
First-degree relatives and children with type 1 diabetes, autoimmune thyroid disease, Down, Turner or Williams syndrome have increased risk and lower testing threshold.
Investigation priorities
Screen for coeliac autoimmunity while verifying whether IgA-based testing is reliable.
Management branches
Symptoms, deficiency or a high-risk condition raises coeliac probability.
- Confirm adequate gluten intake and explain why premature exclusion obscures diagnosis.
- Request total IgA and tTG-IgA with reflex EMA or IgG testing as appropriate.
- Refer positive results and persistent high clinical suspicion to paediatric gastroenterology.