Background
ESPGHAN guidelines have streamlined paediatric coeliac disease (CD) diagnosis by permitting a non-biopsy pathway in selected children with strongly positive serology.¹ Diagnostic testing, however, remains dependent on adequate gluten exposure, and children who reduce or cease gluten before completing investigations may require gluten reintroduction to achieve diagnostic certainty.²
Aim
To evaluate completion of a protocol-driven statewide paediatric CD diagnostic pathway and identify barriers preventing definitive diagnosis.
Methods
A retrospective analysis was undertaken using a prospectively maintained clinical database of children referred to Queensland Children’s Hospital for suspected CD between October 2017 and October 2023. A registrar-led telephone clinic applied a standardised diagnostic algorithm incorporating ESPGHAN biopsy and non-biopsy pathways.
Results
A total of 1,088 children were captured in the statewide registry, with 990 commencing the diagnostic pathway. CD was confirmed in 741 children and excluded in 180. Serological diagnosis was achieved in 393 children, while 348 were diagnosed by biopsy. Importantly, 107/1,088 (9.8%) children were unable to complete conventional diagnostic testing because they could not maintain or reintroduce gluten. Children who transitioned to private care were analysed separately.
Conclusion
A structured statewide pathway successfully operationalised guideline-based paediatric CD diagnosis, including substantial use of non-biopsy testing. However, approximately one in ten referred children were unable to complete conventional diagnosis because of the requirement for ongoing gluten exposure. Diagnostic strategies that reduce or avoid prolonged gluten challenge may address an important residual gap in paediatric coeliac care.