Setting This study was conducted at K.E.M Hospital Pune which is a tertiary care centre and major pediatric gastroenterology centre of Maharashtra with many patients referred from the state and outside the state.

Subjects: All children diagnosed as CD and satisfying inclusion criteria were enrolled in the study.

PART 1: Subjects included were those that presented to KEM Hospital, Pune during the study period.

PART 2: Subjects included those that had been diagnosed as CD since 2010 and who was on our Celiac registry & were on regular follow up.

Study period

1. Prospective -Newly diagnosed patients of celiac from 1^st March 2015 to 28^th Feb 2016.
2. Retrospective-Previously confirmed patients of celiac from 2010 onwards.

Study Design -Observational descriptive study

Inclusion criteria

1. All children presenting to Gastroenterology Department of K.E.M Pune with clinical features suspected* of celiac disease and confirmed by intestinal biopsy.
2. Consent
3. Age-1 to 15 yrs

*CD was suspected in patients presenting with the following symptomatology:

1. Chronic or intermittent diarrhea
2. Failure to thrive or faltering growth (in children)
3. Persistent or unexplained gastrointestinal symptoms including nausea and vomiting
4. Recurrent abdominal pain, cramping or distension
5. Sudden or unexpected weight loss
6. Unexplained iron-deficiency anemia
7. Type 1 diabetes mellitus

Exclusion criteria

1. Age<1 or>15 yrs
2. Non-consent
3. Not confirmed as celiac

Each endoscope had its specifications and use. Endoscopic visualization of the intestinal mucosa along with 4 biopsy specimen taken—three from the second part of the duodenum distal to the papilla, and one from the duodenal bulb. All samples were preserved in formalin and sent to KEM lab for histopathologic examination. The patient was observed inward for any complications following the biopsy.

This study was done for one year from 26/2/2015 to 25/2/2016. Children from age group 1 year to 15 years were included. In our study, we included 50 patients of whom 19 were diagnosed and followed up prospectively, while 31 were previously diagnosed patients of CD (since 2010), who were being followed up regularly in our OPD. Both these sets of patients are analyzed together. The following results were observed:

Demographics

Table 1. Age distribution of the cases studied with Celiac Disease (n= 50).

Values are n (% of cases).

Of the 50 cases studied, the majority were below age 5.0 years that is 25 (50.0%), 16 (32.0%) had their age between 5.0 – 10.0 years and 9 cases (18.0%) had their age above 10.0 years. The mean ± standard deviation of the age of the entire group was 5.9 ± 3.7 years. The youngest was diagnosed at 1.6 years while the oldest was 14 years.

Table 2. Gender Distribution of cases studied with Celiac Disease (n= 50).

Values are n (% of cases).

Of the 50 cases studied, 22 (44.0%) were males and 28 (56%) were females. The male: female sex ratio was 0.8: 1.0 in the entire study group.

Clinical manifestations

P-value<0.05 is considered to be statistically significant. *P-value<0.05 **P-value<0.01, ***P-value<0.001, NS: Statistically Non-Significant.

Distribution of age group wise prevalence of clinical features of the cases studied with Celiac Disease.

1. The prevalence of chronic diarrhea did not differ significantly across the three age groups studied (P-value>0.05).
2. The prevalence of not gaining weight did not differ significantly across the three age groups studied (P-value>0.05).
3. The prevalence of abdominal pain differs significantly across the three age groups studied (P-value<0.01). This may be due to increased reporting in the older age group.
4. Prevalence of abdominal distension did not differ significantly across the three age groups studied (P-value>0.05).
5. The prevalence of vomiting differs significantly across the three age groups studied (P-value<0.05).
6. The prevalence of weight loss did not differ significantly across the three age groups studied (P-value>0.05).
7. The prevalence of anorexia differs significantly across the three age groups studied (P-value<0.01). This is a subjective finding and is assumed to be more reported in the older age group.
8. Prevalence of other clinical features (fever, blood in stool, fatigue and constipation) did not differ significantly across the three age groups studied (P-value>0.05).

Table 5. Distribution of abnormal findings - investigations at the time of diagnosis amongst the cases studied with Celiac Disease (n=50).

Prevalence of anemia differs significantly across three age groups of the cases with celiac disease studied (P-value<0.05). Anemia was most common in below 5 yrs(23 of 25 cases) and least common above 10 yrs of age (4 of 9 cases) in our study though in all age group anemia was a significant finding. Table 6

Table 7. Distribution of the cases studied with Celiac Disease according to serum ferritin (n=19).

Values are n (% of cases).

Ferritin levels were done in all prospective cases. Ferritin levels of <12µg/l (<5yrs) and <15 µg/l(>5years) was taken as deficient [16]. Of the total 19 cases investigated for Ferritin deficiency, 11 (57.9%) had a deficiency, 8 (42.1%) had sufficiency indicating that iron deficiency anemia was the most common anemia in CD.

Table 8. Distribution of the cases studied with Celiac Disease according to vitamin D deficiency (n=19).

Values are n (% of cases).

Vitamin D levels were done in all prospective cases. Vitamin D levels were classified as: Severe Deficiency (<5), Deficiency (5 – 20), Sufficiency (>20) as per Indian reference data(101). Of 19 cases investigated for Vit D deficiency, 2 (10.5%) had a severe deficiency, 14 (73.5%) had a deficiency and 3 (15.8%) had a sufficiency. This suggests that vitamin D deficiency was an important laboratory finding in CD.

Serology

Table 9. Distribution of the cases studied with Celiac Disease according to levels of TGA (n=50).

Gender: Amongst the study population, 56 were males and 44 females, which was similar to the study in the west by Wingren et al [19]. In another study by Singh et al. there was female predominance. Stone et al [17]. had a similar observation. A simple explanation for this gender difference is elusive but may relate to dissimilar hormonal and immune responses to injury and inflammation in the presence of gluten introduction; related gender differences have been observed in other immune system-mediated disorder. [20,21].

Clinical manifestations: Regarding the clinical manifestations, chronic diarrhea was the most common clinic manifestation (92%) overall in all age groups which was similar to the study done by Poddar et al. and by Mohindar et al [22]. where chronic diarrhea was observed at 88% and 86% respectively. Stone et al. [17]. in his study showed the most common presenting symptom in younger children (those <5 years) was diarrhea (59%), followed by irritability (34%) and weight loss (38%). In older children (≥ 5 years), the most common presenting feature was abdominal pain (55%) followed by diarrhea (26%). In our study not gaining weight was noted in 86% of which was 45% as reported by Tanpowpong et al [18]. In our study abdominal pain was seen in 17% and 13% of the study population had abdominal distension which was mainly seen in school-aged and adolescence while abdominal pain and abdominal distension was reported to be 45% and 9% respectively by Tanpowpong et al. [18]. In our study constipation was seen in 2% of children while it was seen in 20% of children in a study by Tanpowpong et al [18]. This observation was similar to that reported by Sharma et al. [23]. and Rashid et al [24]. In our study 10% of children had vomiting while it was seen in 20% of the study population by Tanpowpong et al [18]. Vomiting was seen in 24 % of children in a study by Stone et al [17]. These all disparities might be because of various reporting and/or referral issues by the caregivers and healthcare providers, a possibility that requires further investigation. Generally, the younger children could likely have limited capability to express subjective symptoms when compared with the older individuals. Natural courses, environmental factors (e.g., breastfeeding and gluten 8introduction), and disease pathogenesis could be different between younger and older children. 18 4% of our cases had a positive family history in 1^st-degree relatives while in the study Tanpowpong et al [18]. it was 19%.

Limitations: This study has some potential limitations. A part of the study was conducted in a retrospective fashion at a large teaching hospital.

Although we acknowledge the possibility of incomplete information, both recall and information biases as well as the inability to control for all of the parent- or patient-reported data with the physicians’ interpretation, we believe that our novel findings will provide a platform for the development of age-related approaches for evaluation and management of CD.

In a study period of 12 months we diagnosed 19 children with Celiac disease which goes to go prove that CD is not rare in western Maharashtra. In the present study, maximum patients out of 50 enrolled patients belonged to the age group 1-5 years (50%).

The majority of patients were females (56%). Chronic diarrhea was the most common presenting complaint in all age groups (92%) followed by failure to thrive, not gaining weight and abdominal pain. Constipation was least common.

Anemia was the most common laboratory-confirmed finding and the most common type of anemia was iron deficiency anemia. Vit D deficiency was also more common in CD than in the general population (84%). The majority of cases studied (80%) had Positive tTGA indicating its importance in the screening of CD.

• Contrary to the general belief Celiac disease is not rare in western Maharashtra.
• Age-wise prevalence of symptoms in children with Celiac disease.
• Diagnosis should be confirmed only on positive duodenal biopsies & supportive serology (tTGA). Early referral for endoscopic duodenal biopsy if serological studies are positive is recommended.

• Funding: None
• Conflict of interest: None declared
• Ethical approval: The study was approved by the institutional ethical committee.