REGINA PHALANGE
Danielle Selden, Alicia Armeli, Brooke
Atterbury, and Ryan Brilhante
A case study
of a toddler
with Celiac
Disease
CLIENT: REGINA PHALANGE
• 3.5 year old, toddler, female
• Weight: 14.35 Kg/ 98.75 cm/ BMI: 14.6 (22nd
percentile)
• Recent decline in weight and eating habits caused
Regina’s mom to take her into the doctor.
• Bowel movements have changed in the past two
months, diarrhea is common almost daily.
• Hard to get Regina to eat at times her “tummy hurts”;
her mother is worried she may have a food allergy.
• Her mother is also concerned she is not getting her
daily nutritional requirements, she does not want this to
affect her growth and development.
• Regina’s favorite treat is her “fruity Pebbles” (made
with rice) because they don’t give her a tummy ache.
Her mom is having trouble getting her to eat anything
else.
FAMILY HISTORY:
 Atopic food intolerances seen in her mother and
grandmother
 Father had eczema
 Paternal grandfather has IBS
REGINA’S PAST MEDICAL HISTORY:
Typical healthy 3-year old with minor health concerns:
 Eczema since she was born.
 Normal height and weight development.
 Irregular eating habits and bowel movements did not
develop until 2 months ago.
PHYSICAL ACTIVITY LEVEL:
Average 3 year old play until a couple
months ago:
• Plays at preschool- runs around a lot
• Plays at the park- swings and jungle
gym
• Plays with “Spot” her dog
• Rides her tricycle
• She is now “cranky” and doesn’t play
as much as she used to because she
is tired.
• frequency: Daily activity at home
and school
How Active
is Regina?
EVALUATION OF REGINA’S WEIGHT
 Regina’s weight measurements are in the 50 th percentile
except the last weight measurement (40 th percentile).
 Stature For Age has remained at 63 rd percentile
 2 years old; 12.1kg/ 86.2cm
 2.5 years old: 13kg/ 91.3cm
 3 years old: 13.8kg/ 95.3cm
 3.5 years old: 14.36kg/ 98.75cm (40 th percentile)
 Measurements were taken every 6 months for the past 2
years
DAILY MACRONUTRIENT
RECOMMENDATIONS:
 AMDR’s
Carbohydrates: 45-65% of kcal per day, 732kcal, 183g
Fats: 30-35% of kcal per day, 512Kcal, 57g
Protein: 5-20% of kcal per day, 220kcal, 55g
~protein 1.1g/kg/day
LIFEST YLE FACTORS
 Regina has been very tired lately even though she gets 8
hours of sleep a night.
 Breakfast in the morning with mom and dad
 She has dinner nightly with the family. Her parents are having
a hard time getting her to eat “certain things”
 Sometimes she does not finish her food because her “tummy
hurts”, evidence is seen in her “runny” stools.
 Goes to preschool 3 days a week
 Goes to daycare 4 days a week
 She gets a daily snack of graham crackers at daycare
REGINA’S “T YPICAL” DIET – BEFORE DIET:
 Breakfast:
Oatmeal with maple and brown sugar (1 pkg.)
Milk (6 fl. Oz)
 Morning Snack:
Animal crackers (4)
 Lunch:
Peanut butter & Jelly Sandwich (1/2)
Apple-slices (1/2)
Milk (6 fl. Oz.)
 Afternoon Snack:
Strawberry yogurt tube (1)
Chocolate chip cookie (1)
REGINA’S BEFORE DIET CONTINUED:
 Dinner:
Chicken nuggets (4)
White rice (3 Tbsp.)
Peas (3 Tbsp.)
Milk (6 fl. Oz)
 Evening Snack:
Chocolate milk (6 fl. Oz)
EVALUATION OF BEFORE DIET:
 Based on estimated nutritional needs
 Macro nutrients within AMDR:






Protein: 14% (AMDR 5-20%)
Fat: 32% (AMDR 30-35%)
Carbohydrate: 55% (AMDR 45-65%)
Iron (119% RDI)
Calcium (171% RDI)
Zinc (167% RDI)
 Concerns: The following nutrients are too low:






Omega 3 fatty acids
Vitamin A
Vitamin D
Vitamin E
Vitamin K
Potassium
ETIOLOGY OF GLUTEN INTOLERANCE :
The cause is unknown, like most autoimmune diseases:
• One out of 133 in the US is affected with with CD.
• CD occurs in 5-15% of the offspring and siblings of a
person with CD.
• In 70% identical twin pairs, both twins have the disease.
• It is strongly suggested that family members are tested.
• Family members who have an autoimmune disease are
at a 25% increase risk of having CD
CELIAC DISEASE IS NOT A FOOD ALLERGY: its an
autoimmune disease. Food allergies, including wheat
allergy, are conditions that people can sometimes grow out
of. This is NOT the case with Celiac Disease.
An Autoimmune disease
characterized by
inflammation of the small
intestine lining resulting
from a genetically based
intolerance to a component
of gluten. The
inflammation produces
diarrhea, fatty stools,
weight loss, and vitamin
and mineral deficiencies.
WHAT IS
CELIAC
DISEASE?
AKA:
Tr o p i ca l s p r uc e
a n d g l ute n sensitive
e n te r o p a t hy.
WHAT HAPPENS IN CELIAC DISEASE
 When people that have CD eat foods that contain gluten, it
creates an immune-mediated toxic reaction that causes
damage to the small intestine and does not allow food to be
properly absorbed.
 Damage can happen even when there are no symptoms
present.
CD & DIGESTIVE SYSTEM ORGANS
WHO IS AT RISK FOR CELIAC DISEASE?
 Those who have a genetic susceptibility to the protein gliadin
found in the gluten component of wheat, rye, and barley. Oats
do NOT contain gluten, but commercial oats and oat products
may be cross-contaminated by grains that do.
 People who have one or both of the gene variance HLA -DQ2
and HLA -DQ8
 People who have lactose intolerance are more susceptible, as
these disorders are often seen together.
 It is common in Scandinavians, Italians, Irish, British, South
Americans, Eastern Europeans, Pakistanis, Cubans, and North
Africans.
LITERATURE REVIEW OF CELIAC DISEASE
 Symptoms of CD:
 GI symptoms: inflammation of the SI mucosa
resulting in diarrhea, weight loss, abdominal pain,
anorexia, abdominal distention, flatulence
 Can result in malabsorption of nutrients
 Non-GI symptoms: iron-deficiency anemia, dermatitis
herpetiformis, eczema, chronic fatigue, joint pain,
migraines, depression, ADD, epilepsy,
osteoporosis/osteopenia, infertility and/or recurrent
fetal loss, short stature, failure to thrive, delayed
puberty, dental enamel defects, and autoimmune
disorders
LITERATURE REVIEW CONT.
 Diagnosis:
Small-bowel biopsy
Improvement on a gluten-free diet
Stool examination for malabsorption of nutrients
Measurement of specific serum antibodies (i.e., Tissue
transglutaminase, Antigliadin)
 Presence of specific pairs of allele variants in HLA (MFC) producing
genes (HLA-DQA1 and HLA-DQB1)




 Key factors that influence the efficiency of gluten presentation include: (1)
the level of gluten intake, (2) the enzyme tissue transglutaminase 2 which
modifies gluten into high affinity binding peptides for HLA -DQ2 and HLADQ8, (3) the HLA-DQ typeHLA-DQ2 binds a wider range of gluten
peptides than HLA-DQ8! (4) the level of gene expression of HLA -DQ2 and
HLA-DQ8 (5) additional genetic polymorphisms that may influence T cell
reactivity
 Presence of CD-associated HLA alleles is not diagnostic of CD;
however, their absence essentially excludes a diagnosis of CD.
LITERATURE REVIEW CONT.
 Management:
 Strict, life-long GF diet (avoid wheat, barley, rye)
 Treatment of nutritional deficiencies that may occur (iron, zinc,
calcium, fat-soluble vitamins, folic acid); standard treatment of
osteoporosis
 Genetic Counseling:
 CD results from the interaction of HLA-DQA1 and HLA-DQB1
gene variants known to be associated with CD susceptibility,
less well-recognized variants in non-HLA genes, gliadin (a
subcomponent of gluten), and other environmental factors.
 Since it appears to have atopic tendencies, genetic information
is available for at-risk relatives.
GLUTEN’S ROLE
Gluten: A protein found in wheat, oats, barley,
rye, and triticale, (all in the genus Triticum);
gliadin is the toxic fraction of gluten
Gluten is a common name for the proteins in
specific grains that are harmful to persons
with celiac disease. THESE MUST BE
ELIMINATED FROM THE DIET.
Gluten creates an immune-mediated toxic
reaction
WHAT DOES GLUTEN FREE MEAN?
 Gluten-Free: A food labeling term that indicates a
product does not contain any species of wheat, rye,
barley, or their hybrids, or ingredients that contain
these grains, or 20 or more parts per million (ppm)
gluten (about 6 mg per servings). (FDA -proposed
definition.)
 Adhering to a diet that contains non -gluten
containing items.
 Living a lifestyle without Gluten containing foods.
LIFEST YLE RESOURCES FOR LIVING WITH
CELIAC DISEASE:
 Gluten-Free is a life-long commitment. Some helpful starting
tips:
 Quick Start Gluten-Free Diet Guide (overview of the gluten-free diet):
http://www.celiac.org/images/stories/PDF/quick -start.pdf
 Celiac Disease Foundation Gluten-Free Resources:
http://www.celiac.org/images/stories/PDF/gfresources.pdf
 Gluten in Medications, vitamins and supplements:
http://www.celiac.org/images/stories/PDF/gluten -in-meds.pdf
 Attention Pharmacists: Tips from a pharmacist:
http://www.celiac.org/images/stories/PDF/Medications_and_Celiac_Dis
ease.pdf
 *All of the following resources are located on the Celiac Disease
Foundation Website- Diet and Lifestyle:
http://www.celiac.org/index.php?option=com_content&view=article&id=
11&Itemid=16
ANTS ON A LOG
Prep Time: 5 min
Ready in: 5 min
Ingredients:
5 stalks celery
½ cup peanut butter
¼ cup raisins
Directions:
Cut the celery stalks in half.
Spread with peanut butter
Sprinkle with raisins
Nutritional information:
Amount Per Serving:
Cal: 91
Total Fat: 6.6g
Gluten: Omg
Our “toddler
approved”
prepared
food snack
that is
Gluten Free
NUTRIENTS OF
CONCERN:
•
•
•
•
•
•
•
•
•
Calcium
Iron
Vitamin D (often low)
Vitamin E (often low)
Vitamin A
Fat intake (Brain is still developing)
Zinc (often low)
B6
Folic Acid (often low)
Toddles and
Preschoolers
– age (1-5)
CELIAC DISEASE NUTRIENTS OF
CONCERN:
 May also have to treat deficiencies related to:
 Iron
 Zinc
 Calcium
 Fat-soluble vitamins
 Folic Acid
REGINA’S “AFTER DIET”
RECOMMENDATIONS:
 Regina is required to follow a “Gluten -free” diet.
 Breakfast:
Strawberry yogurt (4 Oz.)
Strawberries (3)
Milk (4 fl. Oz.)
 Morning Snack:
Rice Crackers (6)
Small Banana (1/2)
Raisins (15)
 Lunch
Peanut Butter & Jelly Sandwich on gluten-free bread (1)
Apple (1/2)
AFTER DIET, CONTINUED:
 Afternoon Snack:
Baby carrots (4)
Gluten free cookies (2)
Lite ranch dressing (2 Tbsp.)
 Dinner:
Brown rice (4 Tbsp.)
Peas (3 Tbsp.)
Gluten-free bread roll (1)
Milk (4 fl. Oz)
Butter (2 tsp.)
 Evening Snack:
Gluten-free mini cookies (3)
REGINA’S AFTER DIET MENU ANALYSIS:
Before Menu:
After
 Total Kcals: 1439
 Total Kcals: 1336
 CHO: 198g or 792 Kcals
 CHO: 198g or 792 Kcals
 Protein: 52g or 208 Kcals
 Protein: 33g or 132 Kcals
 Fat: 51g or 459 Kcals
 Fat: 49g or441 Kcals
 Saturated fat: 17g
 Saturated fat: 13g
AFTER DIET ANALYSIS
Regina’s fiber is slightly low: 75% RDI
Vitamin B1 56.81%
Vitamin D 19.01%
Vitamin E 62.06%
Folate 54.71%
Vitamin K 51 .58%
Calcium 48.83%
Potassium 39.8%
Dietary suggestions: Green smoothies with almond milk will
add calcium, Vitamins B, D, E, folate & potassium
 An assortment of fruits and veggies on dif ferent days will help
Regina reach her RDI’s
 Note about excess protein









MULTIPLE CHOICE QUESTIONS:
1. CD is characterized by all
of the following EXCEPT:
a. weight loss
b. abdominal distension
c. iron-deficiency anemia
d. squamous cell
metaplasia
 e. migraines




2. How can CD be
diagnosed?
 a. Small-bowel biopsy
 b. Presence of improvement
on a gluten-free diet
 c. Measurement of specific
serum antibodies
 d Stool examination for
malabsorption of nutrients
 e. all of the above
TRUE/ FALSE QUESTION:
 Steatorrhea is a symptom of CD?
 True or False?
 The Celiac Disease foundation: www.celiac.org
 Raising our celiac kids -Celiac Disease & Gluten free Diet information: www.celiackids.com
 Gluten-free summer camps:
http://celiacdisease.about.com/od/raisingaglute
nfreechild/tp/SummerCamps.htm
 Glutenfreeda.com- largest collection of gluten
free recipes in the world:
http://www.glutenfreeda.com/ index.asp
 Select a company’s name and get a list of the
gluten-free products it sells, or select a food type
and receive a list of companies that sell the
glulten-free ver sion of the food:
www.gfco.org/products.php
SUPPORT
AND
RESOURCES
J U S T FO R K I D S
Books:
“How I eat
w i t h o ut w h e a t ”
By Karen Fine
w w w. ka r e n fi n e .
com
“ G l ute n - Fr e e
Fr i e n d s : A n
Activity Book
for Kids”
By: Nancy
P a t i n Fa l i ni
Order both on:
w w w. c el i a c .c o
m
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wp-content/uploads/2010/09/flin 1 .jpg&w=2501&h=1779&ei= QkT TTqPUOIOPiAKmnbj M CA&z o om =1&iact=hc
&vpx=252&vpy=177&dur=1048&hovh=1 89&hovw=266&tx=232&ty=146& si
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