Short Stature

What Is Short Stature?

[dropcap]S[/dropcap]hort stature means the individual has not reached a normal height as a result of failure to thrive and severe growth delay in children.¹

What Is Short Stature In Celiac Disease and/or Gluten Sensitivity?

• Relationship between short stature and celiac disease. Short stature is a classic symptom of celiac disease and a common presenting feature of untreated celiac disease.
• Relationship between short stature and features. In celiac disease short stature is characterized by normal physiology (appearance) with normal growth hormone level.²
• Relationship between short stature and missed diagnosis of celiac disease in children. Missing the diagnosis of celiac disease in a symptomatic child may lead to short stature. Multivariate analysis showed that short stature correlated with duration of symptoms before diagnosis.³

How Prevalent Is Short Stature In Celiac Disease and/or Gluten Sensitivity?

• Short stature is a common presentation at diagnosis in Isreali children with untreated celiac disease (13.5%).⁴
• A prospective study of 300 children newly diagnosed with celiac disease found stunting in 60% of cases in India. On follow-up (19.4 +/- 15.5 months), symptoms subsided in all cases of celiac disease with a significant weight and height gain.⁵
• A study of 109 children with celiac disease  found an incidence rate of 31.2% for short stature at diagnosis.⁶
• Prevalence of 58% in patients diagnosed with celiac disease at a hospital endocrinology department in India.⁷
• Prevalence of 100% was found in newly diagnosed children with failure to thrive, diarrhea, and anemia.⁸
• A retrospective study of children diagnosed with non-diarrheal celiac disease observed a prevalence of 18.8% with isolated short stature.⁹

What Are The Symptoms Of Short Stature?

• Short stature is marked by failure to achieve normal height.
• May include edema of the feet, anemia, rickets, clubbing of the fingers, and features of vitamin A and B-vitamin deficiency.⁸

How Does Short Stature Develop In Celiac Disease and/or Gluten Sensitivity?

• Short stature results from malabsorption in celiac disease causing deficiencies of zinc, calcium, protein, iron, vitamin A, B vitamins, and omega-6 fatty acids. Poor appetite may contribute.

Does Short Stature Respond To Gluten-Free Diet?

Yes. Short stature responds to a gluten free diet while child is still growing.

6 Steps To Improve Short Stature:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both height and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.¹⁰
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.¹¹
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.¹¹
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.¹¹.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.¹¹
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.¹¹
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.¹¹[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes all green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

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Certain medications deplete one or more of these nutrients that can cause short stature: zinc, calcium, protein, iron, and omega-6 fatty acids.  Ask your doctor or pharmacist about this possible adverse effect if taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Calcium, Iron.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Calcium, Iron.
• Alka Seltzer®, Baking Soda deplete Proteins.

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

•  Tetracyclines deplete Calcium, Iron.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium.
• Aspirin and Salicylates deplete Calcium, Iron.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Calcium, Carnitine.

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete Carnitine.
• Foscanet depletes Calcium. 

DIURETICS

• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Calcium.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Calcium.

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

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The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
• Ferrous fumarate or gluconate as prescribed following blood test for iron status, but do not take at same time as calcium because they compete for absorption.
• Zinc as prescribed following blood test for status.
• Omega-6 fatty acids (linoleic acid and arachidonic acid) should be obtained in the diet of a child rather than by supplement.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Short Stature In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Celiac disease presentation in a tertiary referral centre in India: current scenario.” This facility-based retrospective observational study comparing the clinical spectrum of nondiarrheal celiac disease  (NDCD) with that of diarrheal/classical celiac disease (CCD) found a prevalence of short stature in 18.8% of patients with NDCD.

Study included consecutive patients diagnosed with celiac disease (as per modified ESPGHAN criteria) from October 2009 to August 2011. A total of 381 patients were diagnosed with celiac disease during the study period. NDCD was present in 192 (51.8 %). NDCD had higher mean age at presentation (5.8 years vs. 6.9  years respectively) and longer duration of symptoms prior to diagnosis (2.9 vs. 3.6 ) as compared to CCD.

In the NDCD group, common extraintestinal manifestations included failure to thrive in 109 (56.8 %), isolated short in 36 (18.8 %), persistent anemia in 83 (43.2 %) and hepatomegaly/splenomegaly or both in 56 (29.2 %).¹²

“Endocrine manifestations of celiac disease.” This study investigating the prevalence of endocrine disorders in 36 patients who were diagnosed with celiac disease at a hospital endocrinology department found short stature was the commonest presentation (25%) for celiac disease and the most common manifestation of celiac disease (58%).

The other endocrine manifestations include (after complete evaluation) delayed puberty (31%), elevated alkaline phospahatase (67%), low calcium (22%), X-rays suggestive of osteomalacia or rickets (8%), carpopedal spasm (6%), and night blindness (6%). Anti-TPO antibody positivity was found in 53%, hypothyroidism in 28%, subclinical hypothyroidism in 17%, and type-1 DM in 25% of the patients. A total of 14% patients had no gastrointestinal symptoms.⁷

“Celiac Disease: Presentation of 109 Children.” In this study, clinical and laboratory features of 109 patients with celiac disease were retrospectively evaluated to determine presentation and manifestations. Of 109 patients with celiac disease, 66 (60.6%) were classical type, 41 (37.6%) were atypical type and 2 (1.8%) were silent type. The mean age was 8.81 ± 4.63 years and the most common symptom was diarrhea (53.2%) followed by failure to thrive, short stature, and abdominal pain. Paleness (40.4%), underweight (34.8%), and short stature (31.2%) were the most common findings.

Iron deficiency anemia (81.6%), zinc deficiency (64.1%), prolonged prothrombin time (35.8%), and elevated transaminase levels (24.7%) were the most common laboratory findings. Abdominal distention, iron deficiency, prolonged prothrombin time, hypoalbuminemia, and elevated transaminase levels were more significantly frequent in the classical type than atypical type.¹³

“Clinical features of celiac disease in Indian children: are they different from the West?” This prospective study investigating the clinical features of celiac disease in a large group of Indian children and to comparing them with those from the West found that the majority presents with classic symptoms of diarrhea, failure to thrive, and anemia.

Over a period of 5 years, a total of 549 children younger than 14 years with a clinical suspicion of celiac disease were evaluated. Their detailed clinical features, investigations, and follow-up data were recorded. Complete hemogram, endoscopic duodenal biopsy, andceliac serology were done in all of the cases. Celiac disease was diagnosed on the basis of modified European Society of Paediatric Gastroenterology, Hepatology and Nutrition criteria.

RESULTS:  Celiac disease was diagnosed in 300 children; 39 were excluded because of lack of follow-up or poor response to gluten-free diet. The remaining 210 had normal villous architecture and served as controls. The mean age of children with celiac disease was 6.7 +/- 3 years, and the mean duration of symptoms was 3.5 +/- 2.5 years. The majority (84%) presented with diarrhea; other features were failure to thrive in 91%, anemia in 84%, muscle wasting in 87%, and stunting in 60% of cases. On follow-up (19.4 +/- 15.5 months), symptoms subsided in all cases of celiac disease with a significant weight and height gain.¹⁴

“Coeliac disease in Indian children: assessment of clinical, nutritional and pathologic characteristics.” This study to determine the prevalence, clinical, anthropometric and histological profiles of Celiac Disease in 246 children with with FTT, chronic diarrhea, and anemia attending a tertiary referral center in India demonstrated Celiac Disease in16.6% of the children. Examination showed 100% with short stature.⁸

CASE REPORT SUMMARIES

“Bone pain and extremely low bone mineral density due to severe vitamin D deficiency in celiac disease.” This case study describes finding a non-detectible vitamin D blood level in a 29-year-old wheelchair-bound woman with short stature who had lived in the Netherlands all her life and was born of Moroccan parents. Her medical history revealed iron deficiency, growth retardation, and celiac disease, for which she was put on a gluten-free diet but did not follow.

She had progressive bone pain for 2 years, difficulty with walking, and about 15 kg weight loss. She had a short stature, scoliosis (curvature), and pronounced kyphosis of the spine with thoracic and lumbar percussion pain (pain on tapping). Pelvis and shoulders also were painful on touching. There was muscle atrophy and symmetrical loss of proximal muscle strength. She was short of breath during normal daily activities and poor condition of her teeth. She had a regular menstrual cycle, and her menarche was at 17 years of age. She had neither abdominal complaints nor diarrhea. On physical examination, she was pale. Her body height was 148 cm (previously 156 cm) and her weight, 38 kg.

Laboratory results showed hypocalcemia, an immeasurable serum 25-hydroxyvitamin D level, and elevated parathyroid hormone and alkaline phosphatase levels. Spinal rx-rays showed unsharp, low contrast vertebrae. Bone mineral density (bone scan) measurement at the lumbar spine and hip showed a T-score of -6.0 and -6.5, respectively. A bone scintigraphy showed multiple hotspots in ribs, sternum, mandible, and long bones. A bone biopsy showed severe osteomalacia but normal bone volume. A duodenal biopsy revealed villous atrophy (Marsh 3C) and positive antibodies against endomysium, transglutaminase, and gliadin, compatible with active celiac disease. She was treated with calcium intravenously and later orally. Furthermore, she was treated with high oral doses of vitamin D and a gluten-free diet. After a few weeks of treatment, her bone pain decreased, and her muscle strength improved.¹⁵

Sources:

1. Catassi C, Fasano A. Celiac disease as a cause of growth retardation in childhood. OpinionCurrent  in Pediatrics. Aug 2004;16(4):445-9. [↩]
2. Jansson UH, Kristiansson B, Albertsson-Wikland K, Bjarnason R. Short-term gluten challenge in children with coeliac disease does not impair spontaneous growth hormone secretion. Journal of Pediatric Endocrinology and Metabolism: JPEM. Jun 2003;16(5):771-8.286 [↩]
3. Cosnes J, Cosnes C, Cosnes A, et al. Undiagnosed celiac disease in childhood. Gastroenterologie Clinique et Biologique. Jun-Jul 2002;26(6-7)616-23 [↩]
4. Zelnick N, Pacht A, Obeid R, Lerner A. Range of Neurologic Disorders in patients with celiac disease. Pediatrics. Jun 2004;113(6):1672-1676. [↩]
5. Poddar U, Thapa BR, Singh K. Clinical features of celiac disease in Indian children: are they different from the West? J Pediatr Gastroenterol Nutr. 2006 Sep;43(3):313-7.
6. Prevalence of 26% in French patients who had undiagnosed symptomatic celiac disease in childhood compared to a matched control group and a cohort of patients who had been diagnosed with celiac disease during childhood. ((Cosnes J, Cosnes C, Cosnes A, et al. Undiagnosed celiac disease in childhood. Gastroenterologie Clinique et Biologique. Jun-Jul 2002;26(6-7)616-23 [↩]
7. Kuloğlu Z, Kirsaçlioğlu CT, Kansu A, Ensari A, Girgin N. Celiac Disease: Presentation of 109 Children. Yonsei Med J. 2009 October 31; 50(5): 617–623. [↩]
8. Philip R, Patidar P, Saran S, Agarwal P, Gupta K. Endocrine manifestations of celiac disease. Indian J Endocrinol Metab. 2012 December; 16(Suppl 2): S506–S508. [↩] [↩]
9. Mohindra S, Yachha SK, Srivastava A, Krishnani N, Aggarwal R, Ghoshal UC. Coeliac disease in Indian children: assessment of clinical, nutritional and pathologic characteristics. Journal of Health, Population, and Nutrition. Sep 2001;19(3):204-8. [↩] [↩] [↩]
10. Bhattacharya M, Kapoor S, Dubey AP. Celiac disease presentation in a tertiary referral centre in India: current scenario. Indian J Gastroenterol. 2013 Mar;32(2):98-102. doi: 10.1007/s12664-012-0240-y. Epub 2012 Aug 19. [↩]
11. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
12. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
13. Bhattacharya M, Kapoor S, Dubey AP. Celiac disease presentation in a tertiary referral centre in India: current scenario. Indian J Gastroenterol. 2013 Mar;32(2):98-102. doi: 10.1007/s12664-012-0240-y. [↩]
14. Kuloğlu Z, Kirsaçlioğlu CT, Kansu A, Ensari A, Girgin N. Celiac Disease: Presentation of 109 Children. Yonsei Med J. 2009 October 31; 50(5): 617–623. [↩]
15. Poddar U, Thapa BR, Singh K. Clinical features of celiac disease in Indian children: are they different from the West? J Pediatr Gastroenterol Nutr. 2006 Sep;43(3):313-7.

    “Undiagnosed celiac disease in childhood.” This study investigating the proportion of adult patients with Celiac Disease who had had undiagnosed symptoms during childhood and the consequences of such diagnostic delay demonstrated that short stature and low fertility correlated with duration of symptoms before diagnosis and concluded that missing the diagnosis of Celiac Disease in a symptomatic child may lead to short stature and low female fertility. Compared with the control group, patients with Celiac Disease were shorter (men 171.4 +/- 9.0cm vs. 176.4 +/- 6.9 cm, P<0.01; women 159.7 +/- 7.3 cm vs 162.7 +/- 6.2 cm, P<0.01 and had a higher prevalence of symptomatic osteoporosis (5%), cancer (10%), and autoimmune disease (25%).

    Compared with matched controls, and with patients whose Celiac Disease had been diagnosed during childhood, or who had remained symptom-free), patients who had undiagnosed symptomatic Celiac Disease during childhood exhibited higher prevalence of short stature (26%), low female fertility or low birth weight (36%). Multivariate analysis showed that short stature and low fertility correlated with duration of symptoms before diagnosis; osteoporosis and cancer correlated with age. The prevalence of autoimmune disease was unrelated to early onset of symptoms or delay in diagnosis. ((Cosnes J, Cosnes C, Cosnes A, et al. Undiagnosed celiac disease in childhood. Gastroenterologie Clinique et Biologique. Jun-Jul 2002;26(6-7)616-23 [↩]

16. Rabelink NM, Westgeest HM, Bravenboer N, Jacobs MA, Lips P. Bone pain and extremely low bone mineral density due to severe vitamin D deficiency in celiac disease. Arch Osteoporos. 2011 Dec;6(1-2):209-13. doi: 10.1007/s11657-011-0059-7. [↩]