Failure To Thrive And Growth Retardation

What Is Failure To Thrive And Growth Retardation?

[dropcap]F[/dropcap]ailure to thrive (FTT) and growth retardation are conditions affecting children characterized by weight consistently below the 3rd percentile for age or a decrease in the expected rate of growth based on the child’s previously defined growth curve, irrespective of whether below the 3rd parcentile.¹

Q: Why do failure to thrive and growth retardation occur?

A: Failure to thrive and growth retardation occur because there is inadequate nutrition for weight gain and growth to occur.

What Is Failure To Thrive And Growth Retardation In Celiac Disease and/or Gluten Sensitivity?

• Failure to thrive and growth retardation are classic symptoms of celiac disease.
• Failure to thrive and growth retardation are common presenting features of untreated celiac disease.
• Failure to thrive is related to zinc deficiency.²
• A study investigating the possible change in spontaneous growth hormone (GH) secretion during a standardized gluten challenge demonstrated there is no impaired growth hormone secretion. Decreased growth rate in celiac disease may not be primarily caused by changes in GH secretion. Instead it may be caused by changed peripheral sensitivity to GH.³
• There is a high incidence of failure to thrive in Down’s syndrome.⁴ 
• Recent epidemiologic studies suggest that celiac disease-associated growth retardation is becoming a tangible health problem in developing countries where the problem has been historically overlooked.⁵

How Prevalent Is Failure To Thrive And Growth Retardation In Celiac Disease and/or Gluten Sensitivity?

• Failure to thrive is the most frequent presentation in celiac disease in the pediatric age group, but severe growth delay is less commonly seen in developed countries.⁵
• A retrospective study of children in India diagnosed with non-diarrheal celiac disease observed a prevalence of 56.8% with failure to thrive.⁶
• The prevalence of celiac disease is 16.6% of children with failure to thrive, diarrhea, and anemia. In the opposite, failure to thrive was found in 90% of children with celiac disease.⁷
• Failure to thrive was found in 13% of the children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in these children with gluten sensitivity.⁸

What Are The Symptoms Of Failure To Thrive And Growth Retardation?

Failure to thrive is marked by failure to gain weight and/or weight loss and short stature. Symptoms may include:

• Edema of the feet.
• Anemia.
• Rickets.
• Clubbing of the fingers.
• Features of vitamin A deficiency and B-vitamin deficiency.⁹

How Does Failure To Thrive And Growth Retardation Develop In Celiac Disease and/or Gluten Sensitivity?

• Failure to thrive results from inadequate nutrition due to malabsorption, especially deficiencies of vitamin A, B vitamins and zinc.
• Decreased growth rate may be due to changed peripheral sensitivity to growth hormone.¹⁰

Does Failure To Thrive And Growth Retardation Respond To Gluten-Free Diet?

Yes. Growth responds to gluten free diet.¹¹ Nutritional supplementation may be needed.

6 Steps To Improve Failure To Thrive And Growth Retardation In Celiac Disease and/or Gluten Sensitivity:

• [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 growth 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.¹²
• 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.¹³
• 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.¹³
• 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.¹³.
• 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.¹³
• 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.¹³
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.¹³[/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 lettuce, kale, 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:

[box type=”shadow” ]

Certain medications deplete vitamin A, B vitamins and zinc that promote failure to thrive and growth retardation in celiac disease. Ask your doctor or pharmacist about this possible adverse effect if you are 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 Vitamin A, Vitamin B12 (a B vitamin), Zinc.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Vitamin A, Vitamin B12, Zinc.
• Prevacid®, Prilosec® deplete Vitamin B12.
• Alka Seltzer®, Baking Soda deplete Folic Acid (a B vitamin).

ANTI-DEPRESSANTS

• Adapin®, Aventyl®, Elavil®, Pamelor®, and others deplete Vitamin B12 (a B vitamin).

ANTIBIOTICS disrupt intestinal permeability.

• Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins.
•  Tetracyclines deplete Vitamin B6, Zinc, Riboflavin (vitamin B2).
• Cipro depletes Zinc.

ANTI-INFLAMMATORIES disrupt intestinal permeability.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Zinc, Vitamin B6, Vitamin B12, Folic Acid (a B vitamin).
• NSAIDS (Motrin®, Aleve®, Advil®, Anaprox®, Dolobid®, Feldene®, Naprosyn® and others) deplete Folic acid (a B vitamin).
• Aspirin and Salicylates deplete Folic acid (a B vitamin).

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Folic Acid (a B vitamin), Biotin (a B vitamin), Vitamin B12, Vitamin B1, Zinc.

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete  Zinc, Vitamin B12.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Zinc.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Vitamin B1, Vitamin B6, Zinc.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Folic Acid (a B vitamin), Zinc.[/box]

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

[box type=”shadow” ]

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. Contains B vitamins.
• Vitamin B12 and folic acid as prescribed following blood test for status.
• Vitamin A as prescribed following blood test for status.
• Chelated zinc as prescribed but do not take at same time as calcium because they compete for absorption.

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 Failure To Thrive And Growth Retardation In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Clinical, serologic, and histologic features of gluten sensitivity in children.”  This study seeking to describe the clinical, serologic, and histologic characteristics of children with gluten sensitivity demonstrated findings that support the existence of gluten sensitivity in children across all ages with clinical, serologic, genetic, and histologic features similar to those of adults. Failure to thrive was found in 13% of the children with gluten sensitivity.

 Subjects were 15 children (10 males and 5 females; mean age, 9.6 ± 3.9 years) with gluten sensitivity who were diagnosed based on a clear-cut relationship between wheat consumption and development of symptoms, after excluding celiac disease and wheat allergy, along with 15 children with active celiac disease (5 males and 10 females; mean age, 9.1 ± 3.1 years) and 15 controls with a functional gastrointestinal disorder (6 males and 9 females; mean age, 8.6 ± 2.7 years). All children underwent celiac disease panel testing (native antigliadin antibodies IgG and IgA, anti-tissue transglutaminase antibody IgA and IgG, and anti-endomysial antibody IgA), hematologic assessment (hemoglobin, iron, ferritin, aspartate aminotransferase, erythrocyte sedimentation rate), HLA typing, and small intestinal biopsy (on a voluntary basis in the children with gluten sensitivity).

Abdominal pain was the most prevalent symptom in the children with gluten sensitivity (80%), followed by chronic diarrhea in (73%), tiredness (33%), bloating (26%), limb pain, vomiting, constipation, headache (20%), and failure to thrive (13%). Native antigliadin antibodies IgG was positive in 66% of the children with gluten sensitivity. No differences in nutritional, biochemical, or inflammatory markers were found between the children with gluten sensitivity and controls. HLA-DQ2 was found in 7 children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in the children with gluten sensitivity.¹⁴

“Celiac disease presentation in a tertiary referral centre in India: current scenario.” This facility-based retrospective observational study compared the clinical spectrum of nondiarrheal celiac disease  (NDCD) with that of diarrheal/classical celiac disease (CCD) included consecutive patients diagnosed with celiac disease (CD) (as per modified ESPGHAN criteria) from October 2009 to August 2011. A total of 381 patients were diagnosed with CD during the study period. NDCD was present in 192 (51.8 %). NDCD had higher mean age at presentation (5.8 ± 2.8 years vs. 6.9 ± 2.9 years respectively) and longer duration of symptoms prior to diagnosis (2.9 ± 1.7 years vs. 3.6 ± 2.2 years) as compared to CCD.

In the NDCD group, the most frequent gastrointestinal (GI) symptoms were recurrent abdominal pain [122 (63.5 %)] and abdominal distension [102 (53.1 %)] followed by constipation [48 (25 %)], vomiting [76 (39.6 %)] and recurrent oral ulcers [89 (46.4 %)]. Vomiting and constipation were more frequently seen in NDCD as compared to CCD. Common extraintestinal manifestations in NDCD included failure to thrive [109 (56.8 %)], isolated short stature [36 (18.8 %)], persistent anemia [83 (43.2 %)] and hepatomegaly/splenomegaly or both [56 (29.2 %)].

Associated comorbidities included autoimmune thyroiditis [11 (5.7 %)], type 1 diabetes mellitus [8 (4.2 %)], bronchial asthma [23 (11.9 %)], idiopathic pulmonary hemosiderosis [4 (2.1 %)], Down’s syndrome [3 (1.6 %)], alopecia areata [6 (3.1 %)], polyarthritis [2 (1.0 %)], dermatitis herpetiformis [6 (3.1 %)] and chronic liver disease [6 (3.1 %)].⁶

“Short-term gluten challenge in children with coeliac disease does not impair spontaneous growth hormone secretion.” This study investigating the possible change in spontaneous growth hormone (GH) secretion during a standardized gluten challenge demonstrated there is no impaired growth hormone secretion. Decreased growth rate in celiac disease may not be primarily caused by changes in GH secretion. Instead it may be caused by changed peripheral sensitivity to GH.¹⁰

“Undiagnosed celiac disease in childhood.” This study investigating the proportions of adult patients with celiac disease who had undiagnosed symptoms during childhood and the consequences of such diagnostic delay demonstrated missing the diagnosis of celiac disease in a symptomatic child may lead to short stature and low female fertility which correlated with duration of symptoms before diagnosis.¹⁵

“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 failure to thrive (FTT), chronic diarrhea, and anemia attending a tertiary referral center in India demonstrated celiac disease in 16.6% of the children. 90% of the children with celiac disease had a history of FTT, 88% had a history of chronic diarrhea, and 14.2% had a history of anemia. Examination showed 100% with short stature. The ages at onset of symptoms were 0.5 to 10 years.

Onset of FFT was earlier in children with subtotal villous atrophy than in those with partial villous atrophy. Celiac disease should be considered in the differential diagnosis, particularly in children without any symptoms of diarrhea.¹⁶

Sources:

1. Arnason JA, Gudjonsson H, Freysdottir J, Jonsdottir I, Valdimarsson H. Do adults with high gliadin antibody concentrations have subclinical gluten intolerance? Gut. 1992 February; 33(2): 194–197. [↩]
2. Odetti P, Valentini S, Aragno I, Garibaldi S, Pronzato MA, Rolandi E, Barreca T. Oxidative stress in subjects affected by celiac disease. Free Radical Research. Jul 1998;29(1):17-24. [↩]
3. 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. [↩]
4. Cogulu O, Ozkinay F, Gunduz C, et al. Celiac disease in children with Down syndrome: importance of follow-up and serological screening. Pediatrics International: Official Journal of the Japan Pediatric Society. Aug 2003;45(4):395-9. [↩]
5. Catassi C, Fasano A. Celiac disease as a cause of growth retardation in childhood. Current Opinion in Pediatrics. Aug 2004;16(4):445-9. [↩] [↩]
6. 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. [↩] [↩]
7. 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.)285 [↩]
8. Francavilla R, Cristofori F, Castellaneta S, Polloni C, Albano V, Dellatte S, Indrio F, Cavallo L, Catassi C. Clinical, serologic, and histologic features of gluten sensitivity in children. J Pediatr. 2014 Mar;164(3):463-7.e1. doi: 10.1016/j.jpeds.2013.10.007. [↩]
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. 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. [↩] [↩]
11. Catassi C, Fasano A. Celiac disease as a cause of growth retardation in childhood. Current Opinion in Pediatrics. Aug 2004;16(4):445-9. [↩]
12. 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. [↩]
13. 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. [↩] [↩] [↩] [↩] [↩] [↩]
14. Francavilla R, Cristofori F, Castellaneta S, Polloni C, Albano V, Dellatte S, Indrio F, Cavallo L, Catassi C. Clinical, serologic, and histologic features of gluten sensitivity in children. J Pediatr. 2014 Mar;164(3):463-7.e1. doi: 10.1016/j.jpeds.2013.10.007. [↩]
15. 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. 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. [↩]