High prevalence rates of adult silent coeliac disease, as seen in Sweden, must be expected in Denmark.

AIM: To disclose the prevalence of adult "silent" coeliac disease in Denmark and Sweden. EXPERIMENTAL DESIGN: 1573 Danish and 1866 Swedish healthy blood donors were screened for the presence of serum anti-gliadin antibodies (AGA) by enzyme-linked immunosorbent assay. AGA-positive serum samples were further analysed for IgA anti-endomysium antibodies (EmA) by indirect immunofluorescence microscopy. MAIN RESULTS: The Danish donor population had a higher mean age than the Swedish (41.4 years versus 37.6 years) and a higher proportion of females (41% versus 32%), and had a lower mean level of AGA (17.3 units versus 20.6 units). Sixty-one (3.9%) Danish donors had AGA above the cut-off limit, and four of these also had positive EmA tests. Sixty (3.2%) Swedish donors had AGA above the cut-off limit, and five of these also had positive EmA. Coeliac pathology was proven by biopsy in all five coeliac disease-suspected Swedish donors. No small intestinal biopsy was performed in the coeliac disease-suspected Danish donors. CONCLUSIONS: Based upon the finding of EmA in AGA-positive serum samples, silent coeliac disease may be suspected in 1 per 394 Danish blood donors (2.5 per 1,000). A similar rate was proven in 1 per 373 Swedish blood donors (2.7 per 1,000), indicating no major differences in the prevalence of adult silent coeliac disease between the two neighbouring countries.

Epidemic of coeliac disease in Swedish children.

Coeliac disease has emerged as a public health problem. The aim of the present study was to analyse trends in the occurrence of symptomatic coeliac disease in Swedish children from 1973 to 1997, and to explore any temporal relationship to changes in infant dietary patterns. We established a population-based prospective incidence register of coeliac disease in 1991, and, in addition, retrospective data from 1973 were collected. A total of 2151 cases fulfilled the diagnostic criteria. Furthermore. We collected national data on a yearly basis on duration of breastfeeding, intake of gluten-containing cereals and recommendations on when and how to introduce gluten into the diet of infants. From 1985 to 1987 the annual incidence rate in children below 2 y of age increased fourfold to 200-240 cases per 100000 person years, followed from 1995 by a sharp decline to the previous level of 50-60 cases per 100000 person years. This epidemic pattern is quite unique for a chronic disease of immunological pathogenesis, suggesting that prevention could be possible. The ecological observations made in this study are compatible with the epidemic being the result, at least in part, of a change in and an interplay among three factors within the area of infant feeding, i.e. amount of gluten given, age at introduction of gluten, and whether breastfeeding was ongoing or not when gluten was introduced. Other factor(s) may also have contributed, and the search for these should be intensified.

[Proposed criteria for diagnosis of celiac disease in children]. / Förslag till kriterier för celiakidiagnos hos barn.

At a seminar arranged in September 1997 by the Swedish Paediatric Working Group for Coeliac Disease, a diagnostic protocol proposed by the working group was approved by a majority of the paediatricians present, representing almost all paediatric units in Sweden. Briefly, a small bowel biopsy is called for in all children, both at presentation and as a control during gluten-free dieting. Subsequent gluten challenge and biopsy are mandatory only in cases of atypical presentation or if the diagnosis is questioned at some future date. Serum antigliadin and anti-endomysial antibody tests are complementary tools. Agreement was also reached regarding the institution of a national coeliac disease registry.

[Celiac disease in children on the two sides of the Sound]. / Morbus coeliacus hos børn på de to sider af Oresund.

Of 771 children (381 Swedish and 390 Danish) investigated during 1972-1989 because of suspected coeliac disease (CD), 179 proved to have the disease. Surprisingly only 24 CD patients were Danish whereas 155 were Swedish, despite the very similar ethnic, geographical, and cultural backgrounds of the two populations. The Danish CD children were diagnosed at an older age (mean 5.5 versus 1.5 years). Breastfeeding habits were comparable. The estimated content of gliadin in the officially recommended diets of the two countries in 1987 differed substantially, the Swedish diet containing more than 40 times more gliadin than the Danish (4400 mg versus 100 mg) at the age of eight months, and four times more (3600 mg versus 900 mg) at the age of 12 months. Compared to the Swedish diet, the Danish infant diet contained significantly larger amounts of rye flour, which is low in gluten. The earlier introduction of food items with a high gluten content in the Swedish as compared with the Danish diet could be a possible explanation for the great difference in incidence and symptomatology of CD between the two populations.

Small bowel biopsy in Swedish paediatric clinics.

The capsule technique for small bowel biopsy performed at Swedish paediatric clinics was evaluated using two questionnaires in 1990 and 1993, respectively. Replies were received from all 45 centres which together perform approximately 2300 biopsies per year. Clotting function tests prior to biopsy were carried out in 42% of the centres. The biopsies were performed under intubation anaesthesia in 13% of the centres. The most striking difference between the answers to the two questionnaires was the mode of sedation. The use of intravenous sedatives increased from 40% of the centres in the first questionnaire to 59% in the second one. The use of the oral, rectal and intramuscular routes decreased correspondingly. The most frequently used drugs for intravenous sedation were benzodiazepines, in the first questionnaire diazepam and in the second one midazolam. The failure rate was approximately 5%. In the first questionnaire, no complication was encountered. In the second questionnaire, three cases of intramural duodenal haematoma were reported, one of which led to pancreatitis. We conclude that by focusing on questions of sedation these rather simple questionnaires may have resulted in more effective sedation of children undergoing small bowel biopsy.

Striking differences in the incidence of childhood celiac disease between Denmark and Sweden: a plausible explanation.

Among 771 children (381 Swedish and 390 Danish) investigated between 1972 and 1989 because of suspected celiac disease (CD), 179 proved to have the disease. Surprisingly only 24 CD patients were found among the Danish children, compared with 155 in the Swedish group, despite the close ethnic, geographical, and cultural background of the two populations. The Swedish CD children were diagnosed at an earlier age than the Danish children (mean, 1.5 vs. 5.5 years). The symptoms of the Swedish patients were dominated by failure to thrive (93 vs. 71%), whereas a higher proportion of the Danish CD patients suffered from stomach pain (21 vs. 5%). Breast-feeding habits were comparable. The estimated content of gliadin in the officially recommended diets of the two countries in 1987 differed substantially, the Swedish diet containing more than 40 times more gliadin than the Danish (4,400 vs. 100 mg) at the age of 8 months, and 4 times more (3,600 vs. 900 mg) at the age of 12 months. The Danish infant diet differed significantly from the Swedish in containing a larger amount of the lower gluten-containing rye flour. The earlier introduction of food items with a high gluten content in the Swedish compared with the Danish diet seems to be an obvious explanation for the great difference in incidence and symptomatology of CD between the two populations.

Increasing incidence of childhood coeliac disease in Sweden. Results of a national study.

A survey of the incidence of coeliac disease was carried out by asking all 43 paediatric departments in Sweden to report the number of children born between 1978 and 1987 in whom coeliac disease had been diagnosed. Thirty-four departments representing a population of 7.18 million reported 1944 cases of coeliac disease among 804,935 children born between 1978 and 1987. The cumulative incidence of coeliac disease was 1.7 per 1000 live births in children born between 1978 and 1982 and doubled to 3.5 per 1000 live births in children born after 1982. The highest incidence was found in the southern and south-eastern regions of the country. The observed increase may have been influenced by changes in infant feeding practices such as the postponed age of introduction of gluten from four to six months of age and an increase in gluten content of proprietary baby foods.

Serum IgA and IgG gliadin antibodies and small intestinal mucosal damage in children.

Serum immunoglobulin (Ig) A and IgG gliadin antibodies were determined with a simple, rapid, and inexpensive method--diffusion-in-gel enzyme-linked immunosorbent assay (DIG-ELISA)--and the results were related to small intestinal mucosal morphology in 234 children suspected of having malabsorption. Fifty-six of 58 children with flat intestinal mucosa had increased IgA and/or IgG gliadin antibody levels (sensitivity 97%). Fifty-four of the 58 children had celiac disease (CD) (n = 25) or probable CD (n = 29). Four children with flat mucosa had cow's milk protein and/or soy protein intolerance and three of these had increased gliadin antibody levels. Seventeen percent of 132 children with normal intestinal mucosa had increased IgA and/or IgG gliadin antibody levels. IgA and IgG gliadin antibody levels decreased significantly in the celiac children on a gluten-free diet and increased significantly after gluten challenge. Determination of serum IgA and IgG gliadin antibodies by means of DIG-ELISA is a sensitive test for small intestinal mucosal damage in children. When malabsorption is suspected, we suggest that this assay be used to select children for a small intestinal biopsy. It is also very useful for the follow-up of adherence to a gluten-free diet and to determine the effect of gluten challenge in celiac children.

Lyme disease in a 12-year-old girl.

We report the case of a 12-year-old girl with erythema chronicum migrans, aseptic meningitis and knee arthralgia. Rise of specific antibody titre against an Ixodes ricinus spirochaete was demonstrated. Circulating immune complexes and high levels of C1r-C1s-C1IA complexes indicating activation of the complement system via the classical pathway were found. The clinical features and the laboratory findings warranted a diagnosis of Lyme disease.

Postprandial gastric acid secretion in infants.

Gastric acid secretion in response to meals of infant formula was studied in 8 healthy infants aged 4 to 24 weeks. The technique involved intragastric volume determinations using a marker and measurement of the acidity of the gastric contents. In the 2-hour postprandial period, pH declined from 7 to 5.2. The one-hour postprandial gastric acid output was 236 +/- 49 mumol/kg body weight.

Reservoir and emptying function of the stomach of the premature infant.

Gastric emptying of meals of human milk and infant formula was studied in 11 healthy preterm (AGA) infants using a marker dilution technique. Gastric emptying rate and gastric half-emptying time were compared with data from 17 healthy infants aged 4 weeks to 6 months. The amounts of human milk emptied from the stomach per 0.1 m2 of body surface area were 19.4 +/- 4.5 ml in preterm infants and 29.5 +/- 4.6 ml in term infants. The corresponding amounts with meals of infant formula were 13.8 +/- 2.8 and 22.7 +/- 4.2 ml, respectively. With the volumes given gastric half-emptying times for meals of human milk and infant formula were 25.1 +/- 11.5 and 51.9 +/- 9.8 min, respectively, in preterm infants. The corresponding half-emptying times for term infants were 48 +/- 15 and 78 +/- 14 min, respectively. The differences in gastric emptying rate as well as in gastric half-emptying time between the two meals were significant (p less than 0.01) both in preterm and term infants.

Gastric emptying in infants with cystic fibrosis.

Gastric emptying of meals of pasteurized human milk or infant formula was studied in 4 infants aged 5 weeks to 4 months with cystic fibrosis (CF) and pancreatic insufficiency. A marker dilution technique was used. Three of the patients showed gastric emptying rates higher than those of controls during the first hour after receiving the meal. The gastric emptying rate of the remaining patients, both after a meal of human milk and of infants formula, was similar to that of the controls.

Gastric emptying in infants fed human milk or infant formula.

Gastric emptying of meals of human milk or infant formula was studied in 17 healthy infants aged 4 weeks to 6 months using a marker dilution technique. In the 24 studies performed gastric emptying followed a biphasic pattern in 11 and a linear pattern in 12 studies. The average gastric half-emptying time for meals of human milk was 48 min, and for meals of infant formula 78 min. After 1 hour an average of 29.5 ml of human milk and 22.7 ml of infant formula per 0.1 m2 of body surface area had emptied from the stomach.

Effect of feeding an infant formula with high energy density on gastric emptying in infants with congenital heart disease.

Gastric emptying of meals of standard infant formula and formula fortified with a glucose polymer (Caloreen) were compared in 7 infants with severe congenital heart disease aged 9 days to 5 months. A marker dilution technique was used in estimating gastric emptying. Gastric half-emptying times were significantly longer for meals containing Caloreen than for meals of standard infant formula. Although significantly smaller amount of meal containing Caloreen had left the stomach after 2 hours, the net transfer of energy to the intestine was larger than after feeding a standard meal.

Gastric emptying in infants with congenital heart disease.

Gastric emptying of infant formula using a marker dilution technique was studied in 8 infants with congenital heart disease aged 1 week to 5 months. Six infants were in heart failure and 4 failed to grow. Gastric emptying followed a linear pattern in 5 and a biphasic pattern with an initial slow phase in 2 infants. The amounts of meal emptied after 1 and 2 hours, 14.7 and 31.0 ml per 0.1 m2 of body surface area, respectively, were significantly smaller than the corresponding amounts found in a group of healthy infants.