Gluten can cause gastro-oesophageal reflux disease!
Dr Rodney Ford MD MBBS FRACPPaediatrician specialising in gastroenterology & allergy
Associate Professor Paediatrics.
I present you clear evidence that gluten causes gastro-oesophageal reflux in some children.
New finding: Many children with persistent GORD are sensitive to gluten
My main message is that any child (or adult), who has persistent gastro-oesophageal reflux which requires acid suppression, should be tested to see if they are gluten-sensitive. I became aware of this problem about five years ago. Since then, the data has become so strong that now is the time to tell the story.
Gluten-free diets have become part of my treatment strategy for children with reflux.
Elisabeth’s sad story
My first clue of this link between gluten and GORD came in the shape a little girl called Elisabeth, about 15 years ago. She was tiny, she had just turned five years old and had recently started school. She was miserable – burping and refluxing constantly. She had tummy pains and smelled of acid. She was shunned by her schoolmates because she was unpleasant to be near.
Previously, she had been thoroughly investigated by a number of paediatricians looking for coeliac disease – all her tests had been normal. Reflux treatment was not helping her much. Her family was desperate.
|Coeliac disease of the oesophagus!|
As I listened to her mother telling this depressing story, I wondered if she could have coeliac disease of her oesophagus! She had all of the other symptoms of coeliac disease, but her small bowel biopsy was normal. Could gluten be causing this reflux?
With this new idea, I suggested that Elisabeth go gluten-free for a few months to check out this novel idea. With nothing to lose, she cut out gluten. To our amazement, within days, she felt hugely better! She has kept herself gluten-free and has made a remarkable recovery. She began to grow again, she made friends and was able to stop all her medication! She was cured!
All those years ago there were no gluten blood tests available. But this experience has changed my approach to managing people with GORD.
What is gluten?
Gluten is a protein found in wheat, rye and barley. This protein is quite resistant to being broken down in your intestine. This allows the gluten protein to more readily sensitise you. Once you become sensitised, then you may react to gluten in your diet.
Traditionally, gluten toxicity has only been associated with the condition coeliac disease. Coeliac disease (or gluten sensitive enteropathy) is a disease where the gluten attacks the small bowel and causes damage (called villus atrophy). This gut damage leads to poor absorption of food and a multitude of other symptoms.
What is gluten-sensitivity?
Gluten can do very much more than cause coeliac disease. There is now excellent evidence that gluten can upset you at any point in the gastrointestinal tract. This includes your oesophagus. The oesophagus can be a target organ for gluten.
Reflux – GORD
As you will know, gastrooesophageal reflux disease (GORD) occurs when the stomach contents (acid and enzymes as well as food) regurgitates back into the oesophagus causing damage. When acid back tracks up from the stomach to the oesophagus, it burns the delicate lining of the oesophagus. This causes pain and distress. Babies can only show this pain by becoming very distressed and crying. Adults experience heartburn and chest pain as well as indigestion.
The classic treatment for gastrooesophageal reflux is to use acid suppressants. These drugs such as Ranitidine and Omeprazole reduce or stop the acid production in the stomach. This means that when the gastric contents regurgitate back into the oesophagus, it does less damage. However, there are still enzymes that can damage the oesophageal tissues.
Who gets reflux?
It is thought that the reasons why babies get reflux include:
They have inefficient motility of their oesophagus or stomach.
The lower oesophageal sphincter at the bottom end of the oesophagus is immature and does not close adequately to stop the acid from regurgitation.
Some babies they produce copious amounts of acid which could overwhelm their protective mechanisms.
Some babies get sensitised to foods (especially cow’s milk) which predisposes them to reflux.
As time goes by, as these babies develop their neural and immune systems, their reflux symptoms and problems slowly go away.
Can some foods cause reflux?
Yes! There is a lot of very good evidence showing that dairy products can precipitate reflux. Early studies looking at babies with “colic” showed that a third of these babies improved when mother went off cow’s milk. There is a huge amount of data showing that cow’s milk can get into the mothers breastmilk and therefore into your baby.
|Cow’s milk can cause reflux|
This very small amount of cow’s milk can cause a lot of problems including GORD. Of course, formula fed babies get even more cow milk proteins. In a group of children with gastrooesophageal reflux, a third of these babies improve when they are taken off all dairy products. So, trying dairy free is a good idea.
Gluten – the new bad food
It is now clear to me that gluten can cause similar problems to dairy. It appears that gluten can come through in breastmilk, just the same as cows milk can. Some mothers, who have children with severe reflux, find that if they go off gluten, then their baby substantially improves.
It is my observation that children who have persistent reflux (that is continuing problems through their second year of life) are usually intolerant to gluten. It is my practice to do gluten antibody blood tests on all reflux children at 18 months of age to see if their immune system is reacting to gluten. The blood test is to measure the level of IgG-gliadin antibodies.
I have a large number of children who react adversely to gluten. When they go gluten-free they get better.
|Gluten can cause reflux|
The table presents the symptoms reported in 123 children who I am looking after who have responded to a gluten-free diet.
|Gluten-sensitive symptoms of 123 children|
|GORD = Gastro oesophageal reflux Disease|
As you can see, this is a long list of symptoms. Importantly, a quarter of these children had GORD.
Gastro-oesophageal reflux Disease (GORD)
Over a quarter (27%) of these children had GORD. This shows up as crying, vomiting and regurgitation in an infant. Older children experience regurgitatioin, epigastric pain and belching. Most of these children required acid-suppression medication (ranitidine or omeprazole). But as soon as they went gluten-free most were able to stop their medications. In addition, going gluten-free solves many of their other health problems.
Amazing responses to gluten-free
I now investigate all GORD children for gluten antibodies if they are still needing acid suppression medication past 18 months of age. The amazing fact is that the majority of these children turn out to be gluten-sensitive.
How do you know if your baby is gluten-sensitive?
In my experience, the most accurate way to determine if you child is sensitive to gluten is to do a blood test. The blood test is for the IgG-gliadin antibody. This is an antibody to gluten. It is usually found to be at high levels in people with coeliac disease. However, high levels of this antibody are found in many other gastrointestinal illnesses. I have found that one-in-ten people are gluten-sensitive. Everyone with chronic symptoms needs to have this blood test.
Isabell – a happy story
I have just seen yet another baby with reflux precipitated by gluten. Her name is Isabell, 15 months old and now perfectly happy. She was one of these children who was forever crying, spilling, writhing and distressed. She was always needing to be carried around and never slept for more than an hour or so. Her parents had been exhausted. She had made a good response to a dairy free diet and high doses of omeprazole.
At 13 months her blood tests showed a high IgG-gliadin antibody level. She went onto a gluten-free diet and within a few days she began to sleep through the night, she stopped grizzling, she began to eat well, she laughed and played – she was happy at last. She stopped her omeprazole last month without any relapse. She is cured.
I have now seen many many children with GORD who have responded to a gluten-free diet. Blood tests show high IgG-gliadin antibodies and going gluten-free solves all of their problems. A few still have to avoid dairy as well. If your child has persistent problems then get a blood test done.
|Check to see if you or your child is gluten-sensitive|
For more information of blood tests and gluten-free advice you can see my webpage – www.drrodneyford.com
Questions about infants with gastric reflux disease
This article has provoked a number of questions.
Here are Dr Rodney Ford’s responses.
Breastfeeding and gluten-free
Is it a good idea for a breastfeeding mother to exclude gluten from her diet to see if there is an improvement in her baby’s symptoms, or would this be best left for those infants who do not respond fully to medication and their mother’s cow’s milk free diet? Any ideas on how long it would need to be trialled for at the most?
I deal with many breastfeeding mothers who have very distressed babies. They can be having reactions to food allergens in their mum’s breastmilk. Cow’s milk reactions are the best documented. About a third of distressed babies respond to mother cutting out dairy products from her diet.
I therefore recommend a trial of the mother being milk free (all milk products removed) whilst breastfeeding for one to two weeks.
But, in my experience many of these babies are reacting to gluten in the breastmilk. I am now suggesting a week off gluten to see the response. It is the answer for many of these babies.
When do you suggest a gluten-free diet?
I’m presuming that gluten sensitivity is most relevant to those with silent reflux. Where in your treatment recommendations do you suggest trying a gluten free diet (for either the mother and/or the infant)?
At this stage, the data on gluten precipitating reflux is lacking. A lot depends on the amount of distress of the child. I start with cow’s milk elimination. After a week, if no benefit I start acid reduction medications (ranitidine or omeprazole). Next, I look at a gluten-free diet for mother. Some of these reflux babies may spill or vomit a lot. Gluten-free is not only for the “silent” refluxers.
What age should I introduce gluten?
Considering the evidence that you now have that GORD may be aggravated by gluten-sensitivity, at what age would you recommend introducing gluten containing foods into the child’s own diet? Current recommendations are anywhere from 6-7 months of age.
The evidence to date is that delayed gluten introduction (at about 12 months) reduces subsequent risk of coeliac disease. However, this risk is also reduced if gluten is started in the baby’s diet whilst still breastfeeding. It is thought that this may be because the mother’s milk contains antibodies to gliadin (component of gluten) which will prevent a sensitivity developing. I am now in favour of delayed gluten introduction – especially in the reflux babies.
Is there a genetic predisposition?
Is gluten-sensitivity likely to develop in these children because of a genetic predisposition, regardless of what age it is introduced?
I cannot fully answer this point. There is a proven genetic predisposition to develop coeliac disease (the HLA DQ2 and DQ8 types). But to date, with the more common gluten-sensitivity there is no such gene link been found. My data shows that one-in-ten people are sensitive to gluten. My intuition is that delaying the introduction of gluten is a sensible course of action.
Are cow’s milk and gluten related?
Do you have figures on what percentage of children whom you have diagnosed as being gluten sensitive were allergic/intolerant to cow’s milk in their early infancy?
Of the children who are gluten-sensitive, about a quarter of them are also intolerant to dairy products. In my experience, both of these foods are very commonly implicated in significant ill health.
How common is gluten-sensitivity in older GORD children?
Do you have any figures on what percentage of your patients with GORD over the age of 18 months are better on a gluten free diet?
My figures show that about 80% (that is 8 out of 10 children) with GORD symptoms, who are more than 18 months old, are sensitive to gluten. This is demonstrated by blood tests (an elevated IgG-gliadin antibody). These toddlers quickly recover when they go gluten-free.
Please will you tell me more about the blood tests?
Can you explain more about the blood screening used for testing for gluten-sensitivity and/or coeliac screening, and your interpretation of the possible results?
This is a big question! I have written an entire book about it (Are you gluten-sensitive? Your questions answered – this is available from our website www.drrodneyford.com). I will give you the bare bones of the problem.
Most medical practitioners are focussed on the illness “coeliac disease” – the blood test which most specific for this is called tTG (tissue transglutaminase antibody).
My research shows that the gluten antibody test IgG-gliadin is the best test to diagnose gluten-sensitivity.
The crucial thing to understand is that coeliac disease (also called gluten-sensitive enteropathy) is only a small part of the bigger picture that I call gluten-sensitivity.
Currently, most doctors dismiss the IgG-gliadin antibodies as meaningless. I disagree.
|You can’t tell if you don’t test|
My catch cry is: “You can’t tell if you don’t test”. I recommend that all children with ongoing reflux symptoms be tested for IgG-gliadin levels. If elevated, then go on a trial gluten-free diet for six weeks. You will be amazed.
Please send your queries to Dr Rodney Ford.
He will be very pleased to hear from you.
Copyright 2005 Dr Rodney Ford www.drrodneyford.com Used with permission.
This page may be printed for the personal use of families, as long as the copyright and source (i.e. Crying Over Spilt Milk‘s URL-www.cryingoverspiltmilk.co.nz) is also printed. It may not be copied to other websites or publications without permission from Dr Rodney Ford.
Thank you to Rodney Ford for writing this article for GRSNNZ.
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