Severe acute malnutrition (SAM) afflicts nearly 6.4% of children below 60 months of age in India [1]. Celiac disease is an immune-mediated enteropathy that occurs in genetically susceptible individuals. The clinical features of CD such as diarrhea, failure to thrive, vomiting, abdominal distension, anaemia and weight loss overlap with the common manifestations of children with SAM [2].Considering the increasing reports of high prevalence of CD among the children of North India, it could also be a major contributor or co-morbid condition in children with SAM [3-7]. The diagnosis of CD has management implication as SAM with CD will need gluten free foods during rehabilitative phase. There is little information currently available regarding the prevalence of CD among children with SAM.

This study was a prospective observational study which included 76 consecutive children of either gender, aged 9–59 months admitted in pediatric ward of a tertiary care hospital and meeting the case definition of severe acute malnutrition ( weight-for-length/height <-3 SD and/or, bi-pedal edema and / or mid arm circumference <11.5 cm) between April 2010 to February 2011. Children with known chronic medical or surgical disorders and known celiac serology or HIV status were excluded. After informed consent they were screened for celiac disease (ELISA based anti tissue transglutaminse {tTG} with a kit sensitivity of 95% and specificity of 96%), HIV and tuberculosis. Ethical clearance was taken from the institutional ethical committee. All patients with positive celiac serology were subjected to endoscopy and duodenal biopsy. Histopathology was expressed according to Marsh classification [8]. Subjects were diagnosed as CD when both Anti tTG was positive and biopsy showed partial or total villous atrophy along with increased intraepithelial lymphocytes [5].

Out of a total 76 children enrolled (42 male and 34 female) CD was diagnosed in 10 (13.1%; 95% CI 6.49 - 22.87) subjects. Mean age of presentation of patients with CD was 36.3±16 months with male to female ratio of 2.3:1. The mean weight for height (W/Ht) Z score of the subjects with CD was -4.5±1.7 and the height for age (Ht/age) Z score was -2.4±2.5 as compared to –4.5±1.0 and -3.8±1.9, respectively in SAM children without CD. 7 (9.3%) had TB (pulmonary TB 4, tubercular meningitis 2, disseminated TB 1) and 3 (4%) had positive HIV serology. The clinical features of SAM children with CD and without CD are highlighted in Table 1. Clinical features of both group were similar except for abdominal distension (P=0.04). Our study highlights higher prevalence of CD in SAM as compared to reported prevalence of CD around 1% in general population. Further distinction between celiac and non-celiac patients was difficult on clinical grounds; with abdominal distension being the only parameter higher in CD patients.

Our study has the limitation of a small sample size, being conducted in a tertiary hospital and included extremely malnourished children with W/H below –4 SD. Further studies with adequate number of cases from community will be needed to document the true association. Considering that there is no previous similar study our results highlight importance of identifying this subset of SAM, as the management for this subset of patients has to be gluten-free diet-based nutritional rehabilitation.

1. International Institute for Population Sciences. National Family Health Survey 3, 2005-6. Mumbai. India: International Institute of Population Sciences, 2006.

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6. Poddar U, Thapa BR, Nain CK, Prasad A, Singh K. Celiac disease in India: are they true cases of celiac disease? J Pediatr Gastroenterol Nutr. 2002;35:508-12.

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