The Pediatric Insider
© 2015 Roy Benaroch, MD
Alice asked, “These days it seems like all the cool moms are claiming that their children have gluten sensitivity and putting them on gluten-free diets. I’m skeptical because it seems like all the symptoms are non-specific– mood swings, irritability, poor attention span– which all seem to me like symptoms of normal childhood. What is the medical basis for gluten sensitivity? I’ve heard that eliminating gluten will reduce toddler tantrums and help children perform better in school. If that’s true I want to try it, but are there any reputable studies to that effect?”
Is gluten the New Boogeyman? It’s been implicated as the Root of Many Evils, not just limited to belly pain and other GI symptoms. Gluten is blamed for behavior issues, autism, ADD, “wheat belly”, “brain fog”, and, presumably, the second and third Matrix movies*. Can one food be the cause of so many symptoms?
Gluten is a protein (ok, a mixture of two proteins… let’s not get technical) that’s naturally found in wheat, rye, and barley. The word comes from the same root as glue, and the substance itself is kind of glue-like and sticky. It’s the stickiness that makes it useful in cooking—it holds strands together, giving bagels and French bread that chewy springy sort of texture. For some people, it definitely causes objective and serious health problems; for many other people, it doesn’t. Then there’s that grey zone in between.
First, the definites: gluten is The Cause of celiac disease, an autoimmune-ish disorder that causes gut damage and problems in other organ systems, triggered by ingested gluten. Stop eating gluten—all gluten—and all of the symptoms of celiac ought to disappear. Celiac disease occurs in about 1 in 100 people, and can be reliably diagnosed by blood tests with biopsy confirmation. People with proven celiac disease should not eat gluten.
Another definite: some people are allergic to wheat proteins, including gluten. Symptoms can include classic (or IgE-mediated) symptoms like hives or wheezing; or intense, quickly-developing vomiting, diarrhea, and symptoms of dehydration (in young children, this can be so-called “FPIES”, or Food Protein Induced Enterocolitis Syndrome. Rice and other foods can cause this, too.) True wheat allergy can be established by a careful history and sometimes by an “open challenge” of eating the food under controlled circumstances, with treatment readily available (do NOT try this at home.) People with proven wheat or gluten allergy should not eat wheat or gluten.
Then we get into a bit of a grey zone. There are many people with non-specific gut symptoms including pain, bloating, diarrhea, constipation, or an unpleasantly fast urge to defecate that feel better if they reduce or eliminate the gluten in their diet. When tested, most of these people do not have objective evidence of celiac disease (by the way, anyone who does have these symptoms should be tested for celiac before deciding they don’t have it.) Often, diagnostically, children and adults with these symptoms who have a negative workup are said to have “irritable bowel syndrome,” or IBS. If it seems to be associated with wheat, it’s sometimes also called “non celiac gluten intolerance” or “wheat sensitivity”.
So should people with IBS try a diet that eliminates gluten? Maybe. What may be even more promising, though, is looking at broader dietary changes following a so-called “low FODMAP” diet. A few good studies have shown that it isn’t just the gluten—in many people, wheat is one of several foods that include certain carbohydrates (FODMAPs) that are difficult to digest. Focusing on wheat may help, some, because we eat a lot of it; but reducing all of the FODMAP sources may be both more effective and easier than eliminating all gluten.
But what Alice wanted to know about wasn’t abdominal pain or belly symptoms. She wanted to know if eliminating gluten could change her child’s behavior for the better. Symptoms like “mood swings, irritability, poor attention span”—symptoms that pretty much define early childhood—are being attributed to “gluten sensitivity”. Is there any reason to think that could be the case?
Now, it gets really murky. If “non celiac gluten sensitivity” or “wheat intolerance” represent a kind of diagnostic grey zone, isolated behavior changes caused by gluten are more of an “inky blackness.” There’s some enthusiasm for gluten-free diets for children with autism spectrum disorders, but it’s been difficult to document whether reported improvements are a real effect. Small, open-label or non-placebo studies based on parent reports have shown some promise; but the only truly blinded, placebo-controlled study of a gluten-free diet showed no effect at all.
And studies of gluten restriction to help behavior challenges in neurotypical kids? There are none.
So, Alice, there’s no evidence that reducing gluten is likely to help behaviors like mood swings, irritability, or poor attention span in your toddler, and no evidence that it’s likely to improve school performance either. And, I agree, it does seem to be a bit of a fad to blame all sorts of things on gluten. Could there be a (wheat) germ of truth to all of this? Maybe. But I haven’t seen it yet.
*And, obviously, the last three Star Wars movies. Jar Jar, I believe, was the result of an out of control wheat binge. Look it up.
For more about FODMAPs, gluten, and the evolving story of non-celiac gluten sensitivity or wheat intolerance syndrome, visit my friend Jay Hochman’s blog and search for “gluten”. He’s a pediatric gastroenterologist with a great eye for science, and his blog does a great job reviewing and referencing the latest research.