Gluten contact in kids with coeliac disease: hygiene is key

A quantitative assessment showed that gluten cross-contact in school environments may pose a concern for children with coeliac disease (CD), underscoring hygiene practices to mitigate the risk of gluten transfer.

As CD rates in children continue to increase, learning facilities are faced with the challenge of meeting their gluten-free (GF) demands. [Avicenna J Med 2017;7:171-175] Contact with gluten, which is inherent in some school supplies, could instigate fear and anxiety in parents of children with CD, leading to hypervigilance and decreased quality of life. [J Pediatr Gastroenterol Nutr 2018;66:58-63; J Pediatr Nurs 2015;30:353-363; Dig Dis Sci 2018;63:1438-1448]

“[T]ouching any gluten-containing school supplies … can be challenging, especially for young children,” said study author Vanessa Weisbrod from the Children’s National Hospital in Washington, DC, US, in a press release. “Understanding how children may be exposed to gluten within the school environment and how this may be mitigated would facilitate safe participation [in learning activities for children with GF needs].”

Thirty children (50 percent female, median age 8 years) without CD or gluten intolerance participated in five, 5-minute sensory play activities. All kids participated in the modelling clay and baking project activities, while 10 kids joined the paper mâché and dry and cooked pasta experiments. Kids were then instructed to clean hands using either soap and water, water alone, or wet wipes. Gluten transfer was measured through GF bread rubbed on the kids’ hands and table surfaces after activity. Efficacy of cleaning methods was measured from different bread samples rubbed post washing (modelling clay and baking project participants only). [J Pediatr Gastroenterol Nutr 2020;70:289-294]

All post-activity bread samples from modelling clay and dry pasta users revealed a negligible amount of gluten transfer (<20 ppm), with almost all dry pasta arm samples (n=9) having undetectable gluten levels (<5 ppm). Conversely, the paper mâché, cooked pasta, and baking project activities led to gluten transfer rates that were far greater than the 20-ppm threshold*, with most samples exceeding the upper limit of >84 ppm.

“These findings make an easy distinction – dry and non-sticky [supplies] show very low gluten transfer while … wet and pasty ones cling heavily to hands and table surfaces [thus] posing a higher risk of gluten exposure,” said Weisbrod.

These results underline the importance of having GF supplies in schools or devising a strategy (eg, substitution) for gluten cross-contact prevention, noted the researchers. For instance, the white flour in traditional paper mâché may be replaced by rice flour or corn starch. Corn- and rice-based pastas, which are now increasingly available, may substitute gluten-containing ones.

Wash, wash, wash

Regardless of handwashing method, gluten levels in all post-washing bread samples in the modelling clay arm were <5ppm. The levels were also undetectable in 63 percent of samples in the baking project arm, with the soap-and-water tandem reigning supreme for gluten removal.

“Whether you’re protecting from bacteria or gluten, handwashing and surface hygiene are key … [T]his study shows that the number one thing we can do is teach our kids to wash their hands,” said Weisbrod.

The risk of ingestion also highlights the importance of sanitation, noted the researchers. “[Handwashing] should be required … following [activity], and workspaces should be cleaned to prevent transfer, especially if food will be consumed later in the same space.”

Co-author Dr Amy Damast from Temple Sinai in Summit, New Jersey, US said that the study is a “win” for both students and their schools. “[Our] findings should reassure us all routine, careful handwashing and surface-cleaning methods will keep children with CD safe and healthy while allowing them to participate in more activities that may involve gluten-containing materials.”

The educational, social, emotional toll

Evidence has shown that untreated CD may impact school performance, ranging from lack of focus to absenteeism, subsequently leading to lower educational attainment. [J Pediatr Gastroenterol Nutr 2019;69:690-695; Arch Dis Child 2018;103:143-148; Scand J Gastroenterol 2005; 40:1407-1412]

Moreover, children aware of their plight are often compelled to refuse social invitations, noted the researchers. “[They] report feeling left out and different from their peers because they had to eat something they brought from home or had to say no … They often feel isolated.”

Therefore, effective management should consider the social and emotional impact of CD on children. Parents of kids with CD are encouraged to work closely with the appropriate school authorities, noted the researchers. A combined effort will help foster an environment that suits the needs of children with CD so they may fully immerse in all activities instrumental for learning, social, and emotional development, they added.