Another study (MR Khan et al. J Pediatr 2020; 224: 158-61. The Utility of IgA-Based Serologic Markers in Diagnosing Celiac Disease in Children 24 Months of Age or Younger) shows that tissue transglutaminase (TTG) IgA is the best first test, even in children less than 2 years of age.

This was a multicenter retrospective study with 150 children, mean age was 18 months.

Key findings:

• ~98% of children <2 years of age with celiac disease had an elevated TTG IgA
• “These findings are consistent with recently published European guidelines, which endorse TTG IgA…as the initial screening test regardless of age.”
• IgG-based test should be reserved for IgA-deficient children, which was noted in 5.5% of this cohort.
• Endomysial antibody (EMA) had excellent specificity in this study but was less sensitive; it was negative in 13 of 66 (19.7%) of children with celiac disease (positive in 80%).

My take: TTG IgA is a good first step; based on clinical presentation, further testing (eg. endoscopy) could be warranted in highly-selected cases with negative results.

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