Carol Rees Parrish, R.D., M.S., Series Editor Kids And The .
THE CELIAC DIET, SERIES #6Carol Rees Parrish, R.D., M.S., Series EditorKids and the Gluten-Free DietMary K. SharrettPam CuretonThe gluten-free diet presents unique challenges for children with celiac disease andtheir families. Prior to diagnosis, children may be quite ill, suffering from poor growthand developmental delay. Upon accurate diagnosis and treatment, children usuallyimprove quickly; however despite rapid improvement of symptoms, compliance withdiet may be less than optimal, putting the child once again at risk for the complicationsof untreated celiac disease. Because children may feel uncomfortable being singled outas “different,” a diet that calls attention to their condition, and thus their differences,presents a unique challenge to parents and caregivers trying to meet the treatmentguidelines. Frequent follow-up and monitoring, along with educational resources andsupport groups can aid families in maintaining a gluten-free diet and provide creativeways to deal with the challenges inherent in a gluten-free lifestyle.INTRODUCTIONnjoying pizza, birthday cake and breakfast cerealsare all common food experiences for Americanfamilies. Having a child with celiac disease (CD)presents challenges in providing these experiences asthe gluten-free diet (GFD) excludes the traditional version of these “All American” favorite foods. Findinglook-a-like substitutes for these foods in order to minimize the attention drawn to the child’s food require-EMary K Sharrett, MS, RD, LD, CNSD, Nutrition Support Dietitian, Children’s Hospital, Columbus, OH.Pam Cureton, RD, LDN, Center for Celiac Research,Growth and Nutrition Clinic, Baltimore, MD.ments can be an arduous task for parents and caregivers.It can be difficult to manage the child’s diet when otherfamily members, friends, teachers, and caregivers arenot clear about the strict guidelines of a GFD.Recent studies indicate that the prevalence of CDin children across the world may be as high as 1 in 80(1). The number of families dealing with the GFD is onthe rise, since CD is ranked as the most commonchronic disease among children. The age at diagnosisalso appears to be increasing ( 3 years of age) (2).While the reason is not known, it has been attributed tochanges in feeding practices and to new recommendations for screening the associated high-risk groups (2).(continued on page 52)PRACTICAL GASTROENTEROLOGY FEBRUARY 200749
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6(continued from page 49)Table 1Symptoms of CD in ChildrenGastrointestinal symptoms: “Classic” Weight loss Gas/bloating Diarrhea with failure to thrive Constipation Abdominal pain/distention VomitingNon-GI symptoms: “Atypical” Delayed growth Irritability Failure to thrive Behavioral changes, learning difficulties Dental enamel defects Low bone mineral density/osteopenia/osteoporosis Short stature Delayed onset menarche Iron deficient anemia Delayed motor developmentDIAGNOSISChildren diagnosed before the age of 24 months aremore likely to exhibit “classic” symptoms of CD suchas weight loss, diarrhea and failure to thrive (Table 1).Symptoms typically appear shortly after the introduction of gluten to their diet. Some infants developsevere hypoproteinemia and edema, and althoughuncommon may present in a shock-like state, referredto as “celiac crisis” (3–5).Older children are more likely to present withatypical or extra-intestinal symptoms of CD. Thesecan include: anemia, short stature, delayed motordevelopment, and learning or concentration difficulties. Research indicates that 2%–8% of children withshort stature may have CD (3–5). Children maydevelop dental enamel defects, seizures, epilepsy,ataxia, and neuropathy or other neurological symptoms if CD is left untreated (5,6).CD can be found in combination with certain pediatric disorders and syndromes including Type 1 diabetes, Down syndrome, Turner Syndrome, WilliamsSyndrome and selective IgA deficiency (Table 2).Patients with Type 1 Diabetes have up to an 8% incidence of CD (1). The incidence of CD in Down syn52PRACTICAL GASTROENTEROLOGY FEBRUARY 2007drome is reported to be 5%–12%. Relatives of peoplewith CD are also at a higher risk for developing CD(2). Many children have no intestinal symptoms or“silent CD”; screening this at risk population is recommended to catch the disease early and prevent complications before they affect quality of life (1,8).PROTECTIVE FACTORInfants who have an increased risk for developing CD(Table 2) may have onset of the disease delayed bybreastfeeding. Studies have suggested that breastfeeding infants may result in a later onset of CD, with someevidence supporting that it is the gradual introductionof gluten while breastfeeding that acts to delay theonset of the disease. There is currently no evidence,however, demonstrating that breastfeeding preventsthe development of CD (9). The timing of the introduction of gluten into the diet may also influence thedevelopment of CD. One study suggests that introducing gluten to infants between four and six months provided a lower risk of CD autoimmunity than did theintroduction of gluten before the age of three monthsor after seven months (10). These results have yet to bereplicated, and more information is needed to identifythe optimal time to introduce gluten.TREATMENT: THE GLUTEN-FREE DIET (GFD)Symptoms such as decreased lean body mass,decreased fat mass, anemia, poor growth velocity andother nutritional deficiencies improve dramatically onthe GFD (11,12). This rapid improvement is a greatrelief to parents. However, it may take up to a year ormore for the villous atrophy to completely resolve.(continued on page 55)Table 2Conditions associated with an increased riskof celiac disease Type 1 diabetesAutoimmune thyroiditisDowns SyndromeTurner SyndromeWilliams SyndromeSelective IgA deficiencyFirst degree relative of a person with CD
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6(continued from page 52)Table 3Gluten-free Childrens Vitamins* Sesame Street CompleteSchiff Children’s chewablePioneer Chewables for childrenFreeda Vitamins*Please note that at the time of this writing, these vitamins were GF,however, products can change so be sure to check labels each timebefore purchasing—especially if the food is now labeled “new” or“improved.”Compliance in children with the GFD has beenreported to be 45% to 80%. These figures may be overestimated as some people who reported strict compliance had positive biopsies (1). A recent survey fromthe Canadian Celiac Association reported a compliance rate of 95%, which was attributed in part to thefact that their members had access to accurate educational materials (2); improved compliance was alsoassociated with experiencing adverse symptoms wheneating gluten, a diagnosis of CD proven by biopsy, andbeing diagnosed at a young age.NUTRITIONAL CONCERNSTable 4Specific Nutrients of ConcernNutrientAge 0 mg800 mg1300 mg1 c. milk 300 mg2 oz. cheese 400 mg6 oz. yogurt 300 mg3 oz. almonds 210 mg1c. calcium fortified orangejuice 240 mg1c. broccoli 72 mgIron1–1011–18 (M)11–18 (F)10 mg12 mg15 mg3oz. beef 1.8 mg3oz.chicken 1 mg1 2 c. spinach, cooked 3.2 mg1 2 c. red kidney beans 2.6 mg1 2 c. enriched rice 1.2 mg1 3 c. raisins 1.1 mgFolate1–3150 mcg14–89–18200 mcg300 mcgThiamin1–34–89–1314–18 (F)14–18 (M)0.5 mg0.6 mg0.9 mg1 mg1.2 mg3 oz beef liver 9.2 mg3 oz. pork 0.9 mgEnriched corn tortilla 0.2 mg1 2 c. enriched rice, cooked 0.2Riboflavin1–34–89–1314–18 (F)14–18 (M)0.5 mg0.6 mg0.9 mg1 mg1.3 mg1 cup Milk 0.45 mg1 cup Yogurt 0.45 mg1 Egg 0.27 mgEnriched corn tortilla 0.2 mg3 oz. ground beef, cooked 0.16 mgM Male; F Female 2 c. spinach, cooked 130 mcg1 2 c. navy bean 125 mcg1 2 avocado 55 mcg1 orange 45 mcg1 oz. peanuts 30 mcgAt the time of diagnosis, parents andchildren should meet with a registereddietitian who is knowledgeable aboutCD and the GFD. The family andchild (if at an appropriate age) shouldbe educated regarding the negativeconsequences of untreated CDincluding nutrition related complications such as osteopenia and osteoporosis, iron deficiency anemia, aswell as other autoimmune diseases.Lactose intolerance is common innewly diagnosed adults, however, itoccurs rarely in newly diagnosedchildren. Decreased bone density mayoccur as a result of a decrease in calciumabsorption due to villous blunting. (1).Little is known about the nutritional quality of the GFD in childrenhence, their intake should also bereviewed for nutritional adequacy. Anage appropriate GF multivitamin withminerals should be recommended dueto the malabsorption that occurredprior to the diagnosis (Table 3). Nutrients of particular concern includecalcium, iron, folate, thiamin andriboflavin (Table 4). Despite resolution of symptoms and no further concern for malabsorption, most childrenwill continue to require a GF multivitamin because many GF grain products are not fortified or enriched.PRACTICAL GASTROENTEROLOGY FEBRUARY 200755
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6Table 5ResourcesChildren’s Books on Celiac DiseaseGluten—Free Friends: An Activity Book For KidsBy Nancy Patin-Faliniwww.savorypalate.comKids with Celiac Disease: A Family Guide to Raising Happy,Healthy, Gluten-free ChildrenBy Danna Kornwww.woodbinehouse.comNothing Beats Gluten-free CookingCookbook for ChildrenCeliac Disease Center at free Gluten-free Cookbook for Kids & Busy AdultsBy Connie Sarroswww.gfbooks.homestead.comIncredible Edible Gluten-Free Food For KidsBy Sheri L SandersonAvailable at www.woodbinehouse.comGrowing Up CeliacCanadian Celiac Associationwww.celiac.caPreschoolEating Gluten-Free with EmilyWritten by Bonnie J. KruszkaIllustrated by Richard S. Cihlarwww.woodbinehouse.comPre-AdolescentThe Gluten-free Kid. A Celiac Disease Survival Guideby Melissa Londonwww.woodbinehouse.comEMPOWER THE CHILDChildren of all ages should learn about their disease andtheir diet along with their family or caregiver(s). Several helpful resources are listed in Table 5. Eating withEmily, about a little girl with CD—is a favorite withyoung children ages 3 to 7. This book may also be helpful in teaching other children and schoolmates who56PRACTICAL GASTROENTEROLOGY FEBRUARY 2007CollegeBeyond Rice Cakes: A Young Person’s Guide to Cooking, Eating& Living Gluten-FreeBy Vanessa MaltinAvailable at: www.celiaccentral.orgWeb Sites and Support GroupsChildrens Digestive Health and Nutrition Foundationwww.celiachealth.orgA Child’s Guide to Dealing with Celiac Diseasewww.celiaccenter.orgR.O.C.K Raising Our Celiac Kids Web sitewww.celiackids.comKids KornerCeliac Disease Foundationwww.gluten.orgCel-Kids NetworkCSA/USAwww.csaceliacs.orgKids CornerCeliac Disease Center at Columbiawww.celiacdiseasecenter.columbia.eduKids Baking ClubLynn Rae-Rieswww.glutenfreecookingclub.comKids Healthwww.kidshealth.org/kid/health problems/stomach/celiac.htmlUnderstanding Your StudentGluten Intolerance Group (GIG)www.gluten.netcome in contact with the child with CD. Additionally,Nancy Falini, RD, LDN, created a workbook for thechild with CD titled Gluten-Free Friends: An ActivityBook for Kids that may prove helpful. See Table 6 formany other suggestions to help a child take a more positive and assertive role in managing his or her diet.(continued on page 58)
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6(continued from page 56)Table 6Empowering your child Start reading labels early.Show children the word “wheat” on labels to help them recognize the word even before they can read. This helps to placethe “blame” for not being able to eat a food item on the labelrather than on the parent. As the reading skills of the childimprove, they can look for the other gluten containing ingredients (rye, barley, malt) that must be avoided. It will later helpgive confidence to a child spending time away from home tofind safe foods to eat.when eating with friends, or at parties, it is important to helpthe child understand that their foods are different. By understanding that their “look-a-like” food is not the same as regularfoods (i.e., cupcakes), the child is better able to make safechoices when the parent is not available to help. For example,Mom may make “Rice Krispies Treats ” at home with agluten-free rice cereal. If regular rice treats are offered to thechild at a friend’s birthday party, this may be misconstrued asa safe food and unknowingly accepted. Involve the Child in Meal Planning and PreparationChildren should be encouraged to participate in meal planning,purchasing groceries and preparation of meals. Young childrencan select produce at the grocery store, set the table, and helpwash vegetables or fruits. Older children can help choose themenu, select grocery items, and make all or part of a meal byreading recipes and ingredient lists. A notebook or journal withrecipes, notes about brand names of products used in therecipe and ideas for improvement can help families keep trackof their adventures in GF cooking. All of these activities teachchildren about healthy eating and provide the family with quality time together. Parents can set an example by maintaining a positive attitudeEven very young children look to their parents for emotionalcues and strategies for handling stressful events. For thesereasons, it is important for parents to be positive, even if theyhave to fake it! Parents who keep their cool in a restaurant setting and look for the bright side when birthday parties comeup unexpectedly show their child that the GFD doesn’t have tohinder their social outings. These strategies may help the childbecome more independent and confident in managing the GFD. Role playPracticing what a child will say to an adult when offered aquestionable food is important. Most parents teach their children to be polite and respectful to other adults and those inauthority such as a teacher or parent volunteer. Saying “no”to such an adult will be difficult for a child if they do not knowwhat to say. Practice by providing an age-appropriate andrespectful script for your child and then having your child oranother family member pretend they are the adult. Identify “look-a-like” foodsIt is very common for families to find “look-a-like” foods forthe child with CD. While this helps the child feel less isolatedCHALLENGES FOR CHILDREN AND THE GFDSchoolParents and children need to be prepared to deal withthe challenge of eating away from home. Daycare,preschool, and school present multiple opportunitiesfor contamination, “cheating” on the diet, and accidental exposure to gluten. To prevent mishaps, each yearparents should meet with the principal, teachers and the58PRACTICAL GASTROENTEROLOGY FEBRUARY 2007 Gluten-free household?Some families may choose to make the entire household GF.This comes with pros and cons. The advantages includereduced risk of cross contamination, avoids child helpingthemselves to a snack that contains gluten and not making thechild feel deprived by eating regular items in front of them.The biggest disadvantage to the GF household is the cost of GFitems. A loaf of bread is over 5.00 a loaf vs. wheat bread atless than 2.00 per loaf. Pastas, cookies and crackers are atleast double to triple the price of wheat items. Many householdbudgets would be strained with such extra cost. Realize that achild will need to learn how to survive in a “wheat world”;beginning these survival skills in a supervised (i.e. home) environment may prove beneficial in the long run.school nurse and provide them with information aboutthe GFD. The Gluten Intolerance Group (GIG)(www.gluten.net) and Celiac Sprue Association (CSA)(http://www.csaceliacs.org/CelKidsSchool.php) havediet materials that can be printed out and discussedwith appropriate school personnel. Schools usuallyrequire a letter from the child’s health care providerbefore changes or restrictions can be put into place.(continued on page 60)
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6(continued from page 58)Table 7aFor Occasional Treats: Gluten-free Candies*Table 7bFor Occasional Treats: Gluten-free Candies* All M&M’s except “Krispies”Just Born, Inc (Customer Service—(888) /645-3453)All of our candies are derived from corn; therefore, to the bestto our knowledge, they are gluten-free. The modified food starchwe use in the manufacture of our jellybean candies is cornstarch. Following is a complete list of our current product line: Big Hunk Dove Chocolate bars Dove Ice Cream Hershey bars (plain), chocolate syrup Juju’s Kisses Life SaversYEAR-ROUND CANDIESMike and Ike—Original Fruits, Tropical Typhoon, Berry Blast,Jolly Joes-GrapeHot Tamales and Super Hot TamalesZoursTeenee Beanee Gourmet Jelly Beans Mars bar Milky Way (dark chocolate only, now called the “MidnightBar”) Rolo Caramels Skittles Snickers—all including the new Munch and Cruncher bars Snickers Ice Cream Starbursts (including jelly beans, candy canes, hard candiesand juice bars) Cambridge Sugar Babies and Sugar Daddies Three Musketeers (800-551-0698) Tootsie Rolls*Please note that at the time of this writing, these candies were GF,however, products can change so be sure to check each time beforepurchasing, especially if the label says new or improved. Other school survival ideas include:Write a letter to be shared with other parents in theclass to ask to be notified when they are bringing ina treat for the class.Providing a list of GF foods that the child likes isvery helpful for teachers and room mothers.Ask the teacher for a list of birthdays so a specialtreat is on hand for the child with CD as the otherseat cupcakes, cookies, cake or pizza, etc.Provide a “survival box” with a stash of GF treats inthe classroom for those occasions when unplannedtreats are offered to the children (see Table 7a and bfor a list of GF treats).60PRACTICAL GASTROENTEROLOGY FEBRUARY 2007FEATURE FLAVORSMike and Ike—Cotton Candy, LemonadeVALENTINE’S DAYStrawberry and Vanilla Crème Flavored Marshmallow PeepsHeartsMike and Ike Valentine TreatsEASTERMarshmallow Peeps, Bunnies and Giant BunniesStrawberry and Vanilla Crème Flavored MarshmallowPeeps EggsMike and Ike Easter TreatsJust Born Jelly BeansPeeps Jelly BeansHALLOWEENMarshmallow Peeps Pumpkins, Spooky Cats and GhostsIndividually wrapped Vanilla Crème Flavored MarshmallowPeeps GhostsSnack Pack and Variety Pack Bags—Mike and Ike, Hot Tamalesand ZoursCHRISTMASMarshmallow Peeps Christmas Trees and SnowmenHoliday Cookie Flavored Marshmallow Peeps CutoutsTeenee Beanee Holiday Mix Volunteering at school as a room parent is anotherstrategy to help stay abreast of classroom activities. Discuss the possibility that craft activities can be asource of gluten ingestion for some children. PlayDoh is made with flour and although it is believedgluten cannot be absorbed through the skin, youngchildren may eat it or put their hands in their mouths
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6Table 8School Lunch IdeasMondayChef salad with cheese and ham, GF salad dressing, rice crackers and yogurtTuesdayPeanut butter (Jif peanut butter comes in ‘to go’ single serving2 oz cups) on rice cakes, apple slices or celery, plus a thermosof GF soupWednesdayTurkey or ham and cheese roll-ups on corn tortillas, cornchips, and fruit cupThursdayHome made ‘Lunchables’ with lunch meat and cheese cut intosmall squares or use cookie cutters for fun shapes, ricecracker, pudding cup and fresh fruitFridayTuna ‘lunch to go’ kits (with the wheat crackers removed) ricecrackers, carrot and celery sticks with GF ranch dressing fordipping and fresh fruit or fruit cupwhile playing with it (Table 5 has several books thathave recipes for GF Play Doh ).School LunchUnder the Americans with Disabilities Act (CD is notconsidered a disability but is covered under a sectionfor food allergies), public schools are required to makereasonable accommodations to provide for childrenrequiring a GFD. Children must present a physician’sstatement of need. Parents should meet with the schooldietitian and/or the food service director to review themenus and look at labels. Most families find it easierto pack a lunch than to rely on school-provided meals.There are many GF items children can enjoy bringingin their lunches such as fruit or pudding cups, yogurts,fruit snacks, and potato chips are but a few (see Table8 for more lunch ideas).Activities Away From HomeChildren and parents can work together to find strategies for dealing with the many activities they willencounter (e.g., birthday parties, sports activities,sleepovers, school lunch, camping, vacations, backyard barbeques, holiday parties, field trips, picnics,etc.). Sending GF food with the child, bringing a GFdish to share, and bringing extra GF foods or snacksare strategies that work well for many families. Parentsoften find it helpful to volunteer to be scout leaders orto volunteer to plan menus or purchase the food. For alist of activities for GF fun see Table 9.Going away to summer camp for a week or two isa big challenge. Some families have been able to packup food for the week and send it along with the camperafter talking with the food service director. There are agrowing number of camps for kids with CD. TheGluten Intolerance Group (GIG) offers camps for children with CD (see www.gluten.net). The Celiac Disease Foundation also has a list of celiac camps on theirwebsite www.gluten.org. Family vacations requireadvanced planning that should include coolers with asupply of food, hotel rooms with refrigerators andchecking with whomever is at the final destination foravailability of GF food. There are also a growing number of vacation destinations that offer a great deal ofsupport for their GF guests, with the Walt DisneyParks topping the list of most accommodating.Off to CollegeFor those who are going to college, it will be importantto keep the GFD in mind when “interviewing” colleges. When visiting prospective campuses, in additionto all of the academic considerations, food optionsmust also be considered. It may be beneficial for thestudent and parents to meet with the food servicedirector to gather information on the availability of GFitems and alternatives. Some college food service programs have GF food items and/or lists of their fooditems that are naturally GF or can easily be made GF.This information can sometimes be found on the college web site. Some college dorms will allow refrigerators, microwaves and hot plates so that a stash of GFfood can be kept in the room. College students havealso reported that they have been able get permissionto live off campus where they have their own kitchen.Before going to college, your patient will need a letterfrom their physician stating their diagnosis and treatPRACTICAL GASTROENTEROLOGY FEBRUARY 200761
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6Table 9Activities and SnacksActivitiesToddlers & PreschoolSchool Age & AdolescentsCookingWash vegetables or fruits with a brushSet table with paper goodsServe vegetables fruits etc in baggiesHelp mix GF play doughDecorate GF cookiesRead ingredientsPlan menusStart a GF cookbookLearn to use basic cooking utensils & kitchen safetyMix a GF trail mix or cereal snack mixSchool Food & SnacksFresh fruit slicesFruit cupsHomemade cereal snack mixYogurt & tube yogurtString cheeseYogurt (tube yogurt)PopcornNuts or pumpkin seedsDried fruitHomemade GF trail mixHome made GF cereal snack mixGF energy barsGF cereal or breakfast barsGF cookiesLunch meat or cheese rolled upSoft corn tortilla wrapped around lunchmeat or leftoversPartiesIce creamIce cream cakesKeep GF cupcakes in the freezerIce cream cakesBuild your own taco, omelet or sundaeBring a GF dish to the partySurvival BoxesGF cookiesGF candyGF chipsEnergy BarsIndividual Servings of Peanut butterGF crackersGF cookiesGF candy barGF chips or pretzelsment in order for the college to make the special provision necessary to maintain a GFD. Some importanttips for college living are listed on Table 10.tical Gastroenterology for an entire article dedicated toeating out.Support GroupsEating OutEating out GF is always a challenge for families aswell as for older children who want to go out with theirfriends. Many restaurants have websites and on-linemenus, availability of GF selections can be checkedout ahead of time. Children should be encouraged tomake a list of a few favorites, so when there is anopportunity, they can eat out safely with friends.Younger children report great satisfaction from anexcursion with friends even if they only order a drinkand plain potato chips! See the November 2006 Prac62PRACTICAL GASTROENTEROLOGY FEBRUARY 2007Support groups for families living with CD are invaluable. These groups share information about whichfoods to buy, where to buy them as well as how to dealwith the many challenges they are facing. Many families and children find great comfort in just knowingother people who are dealing with the same issues.There are many national and local support groupsavailable to help families learn to work with the GFdiet including one just for kids, R.O.C.K. (Raising ourCeliac Kids). See Table 5 for additional support groups(continued on page 64)
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6(continued from page 62)Table 10College Survival 101Table 11Kid Friendly Gluten-free foods Contact the food service department before visiting the campus and ask them to prepare a gluten-free meal during yourvisit. Take written materials on the GFD to give to the manager. Diet information can be obtained from the Gluten Intolerance Group www.gluten.net or www.celiachealth.org forthe Gluten-free Diet Guide.Gluten-free ‘Look-A-Likes’ It may be more important that the food service department iswilling to accommodate you, than the meal they serve, especially if they have to go out of their way to provide your GFdish. Once you’ve chosen a college, one way to ensure an easier dietary experience is to keep in touch with food service staffand find out when they order food supplies each semester. When you’ve made your college-decision, it is important tohave ongoing discussion with the food service department.While it may have been acceptable to serve the GF food separately when you visited, it may become more challenging if itmust happen every day for every meal. Review menus for all the meals the college will serve, including special dinners (when parents or famous alumni visit, holiday dinners, etc.) and find out which items are safe to eat. Discuss the potential risk of cross contamination with thefood service director and brainstorm ways to prevent it. Most college food services run on a cycle menu, meaning theselection will be repeated every 2 to 4 weeks. Look over themenu and verify that each day you will have something toeat, and talk about having something in reserve for the dayswhen the selection does not include GF items. College students love care packages from home, and parentscan time the delivery of these special goodies for stressfultimes during the semester, such as exams or special occasions as birthdays and holidays.and resources. Health care providers should be awareof such groups within their communities or refer families to online sources at www.celiac.com for additional information.Chicken Fingers Bell & Evans gluten-free breaded chicken breast nuggets(www.bellandevans.com) Wellshire Chicken nuggets (www.wellshirefarms.com) Dietary Specialties chicken nuggets (www.dietspec.com) Ian’s Chicken nuggets (www.allergenfreefoods.com/Ians.html)Macaroni and Cheese Annies GF rice pasta & cheddar(http://www.annies.com/products/gluten free pasta.htm) Amy’s Rice Macaroni and Cheese (www.amyskitchen.com)Pizza Gluten-free pizza by Foods by George(www.foodsbygeorge.com) Frozen pizza crust: Kinnikinnick (www.kinnikinnick.ca);Whole Foods (www.wholefoods.com)Hamburger Helper Dinner Mrs. Leeper’s lasagna/beef stroganoff (www.celiac.com)Fish Sticks Dietary Specialties fish sticks (www.dietspec.com) Ian’s Fish Sticks (www.allergenfreefoods.com/Ians.html)Breakfast Cereal Nature’s Path Envirokidz, etc.: Amazon Frosted Flakes,Gorilla Munch, Koala Crisps, Panda Puffs, Cornflakes,Honey’d Cornflakes, MesaSunrise Flakes, Crispy Rice(www.naturespath.com) Enjoy Life: Cinnamon Crunch, Very Berry Crunch, CranappleCrunch (www.enjoylifefoods.com) PerkyO’s: PerkyO’s Original, Apple Cinnamon, Nutty Flax,Nutty Rice (www.glutenfreemall.com)Oreo Cookies Kinnikinnick (www.kinnikinnick.ca)Animal Crackers MiDel GF animal cookies (www.liberyrichter.com)FOLLOW-UP CAREFrequent follow-up is important to ensure that symptoms have resolved and growth has improved. Familiesoften encounter conflicting information so the dietshould also be reviewed to clear up any confusion andidentify any potential sources of gluten. NASPGHAN(North American Society of Pediatric Gastroenterol64PRACTICAL GASTROENTEROLOGY FEBRUARY 2007Easy Bake Oven Cake Mixes GF Easy Bake cake mixes(http://www.foodtek.com/Products/QBKids.php)
Kids and the Gluten-Free DietTHE CELIAC DIET, SERIES #6ogy, Hepatology and Nutrition) recommends periodicvisits for assessment of symptoms, growth, physicalexamination and adherence to the GFD. Tissue Transglutaminase (TTG) should be measured after six monthsof starting a GFD and then at one-year intervals. Inaddition, TTG should be drawn any time a patient hasrecurrent or persistent symptoms. A decrease in TTGindicates compliance with the diet, and conversely, arise will indicate non-compliance (1).CONCLUSIONAccording to the NASPGHAN Clinical PracticeGuidelines Summary for CD, within a pediatric practice of 1,500 children there are probably between fiveand 20 children with CD, either diagnosed or undiagnosed (1). As the number of patients with CDincreases, it is important to continue making progressin the r
the gluten-free diet (GFD) excludes the traditional ver-sion of these “All American” favorite foods. Finding look-a-like substitutes for these foods in order to mini-mize the attention drawn to the child’s food require-ments can be an arduous task for parents and caregivers. It can b
Revenge of the Cyst –Part II NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55 Joe Krenitsky, MS, RD, Nutrition Support Specialist; Diklar Makola, MD, MPH, PhD, Gastroen-terology Fellow; Carol Rees Parrish MS, RD, Nutrition Support Specialist all at Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA.
Parrish Village News. page 2 Parrish Village News Official publication of the Parrish Civic Association, a non profit coporation. P. O. Box 257 Parrish, FL 34219
WEST COAST HOTEL CO. v. PARRISH. 379 Syllabus. WEST COAST ttOTEL CO. v. PARRISH ET AL. APPEAL FROM THE SUPREME COURT OF WASHINGTON. No. 293. Argued December 16, 17, 1936.-Decided March 29, 1937. 1. Deprivatio
WEST COAST HOTEL CO. v. PARRISH. 379 Syllabus. WEST COAST ttOTEL CO. v. PARRISH ET AL. APPEAL FROM THE SUPREME COURT OF WASHINGTON. No. 293. Argued December 16, 17, 1936.-Decided March 29, 1937. 1. Deprivation of liberty to contract is forbidden by the Constitution if without due process of law; but restraint or regulation of this .
REEs and Electronics REEs have been used in electronics and advanced machinery for nearly three-quarters of a century. Demand for REEs in electronics began in earnest in the 1960s with the introduction of the first color television sets, which initially used europium to produce the color images on the screen.15 Since then,
Carol’s mother, Emilia, dies when Carol is just 8 years old. Young Carol takes the Blessed Virgin Mary as his mother. Carol enters a secret seminary in 1942, and is ordained a priest in 1946. Carol Wojtyla is elected Pope in 1978, and takes the name John Paul II. Pope John Paul II travels to more countries and canonizes more saints than
Ø A 3-minute interview with Carol Dweck on The Growth Mindset by Sal Khan of Khan Academy Ø A 10-minute TED talk on Developing a Growth Mindset by Carol Dweck Ø The cover story from the Stanford Alumni Journal presents a nice overview of Carol and her work. “The Effort Effect” Ø A short news article on Carol in the UK’s SchoolsWeek
A Sesame Street Christmas Carol (2010; with Kristin Chenoweth and Tim Curry; in Children’s) Doctor Who: A Christmas Carol (2011; BBC science fiction) The Smurfs: A Christmas Carol (2011; animated; part of The Smurfs Collection, in Children’s) A Christmas Carol (2012; scary Pop T
