Celiac disease in children: Impact on bone health

Celiac disease is a chronic enteropathy caused by permanent intolerance to gluten and similar proteins found in wheat, barley and rye. The intestinal mucosa of susceptible individuals is crossed by undigested gluten, which leads to a marked inflammatory response. The clinical features may vary from overt intestinal symptoms to silent disease. Bone health has been found to be markedly affected in children and adolescents with untreated celiac disease, regardless of clinical presentation. Bone mass measurements are greatly reduced compared to healthy youth. As indicated by surrogate markers of bone turnover, bone formation rates are depressed and bone resorption rates enhanced in untreated patients. The causes underlying alterations in bone metabolism are still under investigation, but are attributed to non-intestinal factors. Increased production of inflammatory cytokines and presence of specific autoantibodies may together disrupt bone metabolism equilibrium in children and adolescents with celiac disease. Gluten withdrawal is able to restore bone mass quite rapidly, with a normalization of levels of bone formation and bone resorption markers. Good adherence to gluten-free diet is mandatory to maintain optimal bone health. Monitoring of dietary compliance is important to ensure appropriate bone mass accrual through childhood and puberty in these patients, to maximize peak bone mass and reduce fracture risk later in life.