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Dr. Andrew Rynne
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Dr. Andrew Rynne

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Suggest treatment for anemia despite taking gluten free diet

Answered by
Dr.
Dr. Pradeep Kumar

Pediatrician, Cardiology

Practicing since :2006

Answered : 1975 Questions

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Posted on Mon, 26 Oct 2015 in General Health
Question: Hi there,
my daughter is 6 yrs of age and she weighs around 17 kgs and height is 106 cms. 3 months back we got her routine investigations done and the reports are as follows:
Hb- 7.1
vitamin D3 -25.3 ng/ml
anti transglutaminase antibody- 156.
after that we had started giving her gluten free diet and from the last three months she is on strict gluten free diet considering the fact that she is suffering from coeliac disease.
just yesterday we repeated her hb levels and it has come out to be 6.9 g/dl
vitamin D3 levels- 28.4 ng/ml
my queries are:
why there is no improvement in Hb levels and vitamin D 3 levels despite discontinuing gluten rich food.
are we dealing with some other disease or it wll take some time for the hb levels to improve.
is there any further investigation required for finding out the cause of Anemia.
are we really dealing with coeliac disease. what can we do to improve Hb levels as 6.9 is really less.
doctor
Answered by Dr. Pradeep Kumar 46 minutes later
Brief Answer:
Cause of anemia need to be investigated

Detailed Answer:
Hello

Thanks for asking on this platform

I can understand your concern.
I have gone through the detail.Although the weight and height appears to be at low,if we follow the XXXXXXX growth chart the weight of your child is at 50th centile(normal between 25th to 75 centile)and height is above 3rd centile(which is also considered to be normal).
The most common cause of anemia in this age is Iron and or vitamin B12 deficiency.
Again in case of iron deficiency anemia it can be due to poor intake,poor absorption or increased loss.
Celiac disease should be ruled out as this is a common cause of iron deficiency due to poor absorption.
In your case I don't know the kind of anemia which was present,but I assume it to be iron deficiency anemia.
TTG level is high in your child case which is suggestive or celiac disease,but it is not a confirmatory test.False positive result is very common and it could be due to some other disease.This is why to confirm the diagnosis of celiac disease 'Intestinal biopsy'must be done.
I would like to know whether intestinal biopsy was done in your case or not.
From complete blood count and RBC indices(MCV,MCH,MCHC)a clue to the diagnosis of iron deficiency can be made,but it should also be confirmed with iron profile(serum iron,Tissue iron binding capacity and saturation),as there are few other condition like Thalassemia which may mimic with iron deficiency.
Once the baby was put on celiac diet the level of hemoglobin should have improved by now(as 3 months have been passed),so other diagnosis should be strongly suspected now.

I would request you to attach the previous and current report and if possible prescription (from prescription I can get the clinical finding like enlargement of liver or spleen if any)also so that I better able to help you out.

Regards


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Pradeep Kumar 12 minutes later
well so far we haven't done the intestinal biopsy for our daughter.

also in 2012 that's 3 yrs back, the Hb levels were 10.2 g/dl. we had done Hb electrophoresis 3 months back to rule out thallesemia and its nt there.

Wat shall we do to increase the Hb levels.. would any replenishment in form of Iron syrup help or we should get the tests done first to confirm the diagnosis. kindly opine.
Also since the child is now on gluten free diet for the last 3 months , would intestinal biopsy still be of any help or we would again have to introduce gluten rich food like wheat and all and get the biopsy done after a months time.kindly suggest.
doctor
Answered by Dr. Pradeep Kumar 32 minutes later
Brief Answer:
First the cause of anemia should be established

Detailed Answer:
Thanks for writing back

I would like to confirm the diagnosis by RBC indices,iron profile, and stool for occult blood(to check any hidden blood loss from intestine)before starting the therapy.
For accurate biopsy result the baby should be on gluten rich diet at least for one month.

Please let me know if you have any more query.
Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Pradeep Kumar 17 hours later
Hello sir,
thanks a lot for answering my queries.
actually this time also we had sent the anti transglutaminase antibody levels and they have come out to be > 300. the report came just today.

My question is despite being on gluten free diet on 3 months why are the antibody levels still high. they were 156 3 months back and nw > 300.

should we confirm the diagnosis of coeliac first by intestinal biopsy or should we rule out the cause of Anemia first. I'm really confused doctor.pls suggest.

also since the antibody levels are so high can we get the intestinal biopsy now itself or then also we should give her gluten rich food like wheat n all and get it done after 1 month time.
doctor
Answered by Dr. Pradeep Kumar 1 hour later
Brief Answer:
Persistently high antibody levels are more suggestive of celiac disease

Detailed Answer:
Thanks for follow up

As per the guideline the gluten free diet should be started only after confirmation of the diagnosis by intestinal biopsy.
Persistently high level of TTG is more suggestive of celiac disease and there is high chance of getting positive biopsy report.
It has been seen that there is correlation between the TTG level and intestinal finding.As the half life of TTG antibody is 6 months it may remain elevated for few months to even years even being on gluten free diet(GFD).But the rising titre raises the suspicion regarding the strict adherence to GFD.
As I feel, you may go for the intestinal biopsy right now.
I like to know whether you are strictly following the GFD diet.
As hemoglobin level is very low I would like to get her investigated for anemia at the same time,so that we can take early steps regarding the management.

I hope this helps.
I shall be glad to answer if you have any more doubt.
Regards


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Pradeep Kumar 8 minutes later
Thanks a lot for a quick reply.

sir,
we have been following strict gluten free diet for my daughter for the last three months. anyways I think we would follow ur advice and get the intestinal biopsy done for my daughter to confirm the diagnosis.

as far as low hemoglobin levels are concerned would get the evaluation done as soon as possible.would get back to you once I'm done with the investigations.
Thanks once again.
doctor
Answered by Dr. Pradeep Kumar 3 minutes later
Brief Answer:
Happy to help

Detailed Answer:
It's my pleasure that you found my suggestions helpful.
Please be in follow up.
Take care and all the best.
Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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