While celiac disease can begin at any age, the condition typically presents in early childhood. As if feeding young children wasn't tricky enough with the standard issues of pickiness, food jags, neophobia and sugary predilections, feeding them on a restricted diet complicates matters even further. So when a gluten-free diet becomes a medical necessity for your growing kid, how do you manage?
Full disclosure: I have celiac disease myself, but I'm not raising my three-year-old twins on a gluten-free diet. Still, I strongly believe in shared family meals where adults and kids eat the same food. As a result, I spend a good deal of time planning menus that are both gluten-free and nutritionally appropriate for everyone in the family. Here are a few pointers I can offer as both a gluten-free mom and dietitian:
-- Remember that gluten-free junk food is still junk food. When children are diagnosed with celiac disease, parents can sometimes project feelings of deprivation and exclusion onto them. As a result, many wind up overcompensating for the dietary restriction by filling their pantry with gluten-free versions of every possible treat that's off-limits to their child. Nowadays, there are gluten-free versions of Oreo cookies, s'mores and Betty Crocker cake mixes -even Dunkin' Donuts is launching a gluten-free doughnut later this year. So it's worth stating that the absence of wheat does not make these gluten-free sweets any healthier than the standard versions. Don't buy gluten-free varieties of junk foods whenever you shop just because you can. Dole them out as judiciously as you would if your child did not have celiac disease.
-- Seek out gluten-free sources of iron and folate. Refined (white) wheat flour has been enriched with iron since the 1940s and fortified with folic acid (a B vitamin) since the late 1990s. Not surprisingly, flour-based kid staples such as breads, crackers, pasta and cereals have come to contribute a substantial amount of these important nutrients to the average American child's diet. Therefore, kids on gluten-free diets, who are consuming wheat-free versions of these foods that tend to not be fortified with folic acid, may be at elevated risk for deficiency.
Indeed, a 2011 study of more than 7,000 children ages one through 18 found that, on average, American children consumed only about 25 percent of their daily folate from naturally occurring sources alone. The remainder came from fortified-enriched cereal grain products (such as those listed above), fortified breakfast cereals and dietary supplements.
Similarly, up to half of people who are newly diagnosed with celiac disease are iron-deficient due to malabsorption from intestinal damage. As it is, iron deficiency is the most common nutritional deficiency among even healthy American children as the result of inadequate intake, their high needs to support rapid growth and their high intake of milk, which both crowds out tummy-space for iron-rich foods and whose calcium can compete with iron for absorption. In this context, it's easy to see how kids with celiac disease are particularly at risk.
While your pediatrician may recommend a supplement based on your child's nutrition status at the time of diagnosis, ongoing intake of iron- and folate-rich foods is important to ensure a nutritionally adequate diet. Child-friendly, iron-rich foods include red meat (such as burgers and meatballs), dark meat poultry (such as chicken thighs or ground turkey), beans, shrimp, lentils, tofu, cashews, baked potatoes, chia seeds and certified gluten-free oatmeal. Foods rich in folate include beans and lentils, edamame, peanut butter or sunflower seed butter, avocados, oranges and strawberries. (Green leafies and beets are super high in folate too, but I recognize that they're not the most popular among the under-4-feet-tall set.)
A few of the winning dinners in my house that are both iron- and folate-rich include black bean tacos with avocado, turkey and white bean chili and Indian takeout of creamed spinach and chickpeas (chana saag). Staple snacks include nuts, dry roasted chickpeas, baked oatmeal squares with peanut butter and chia seeds, clementines and banana with peanut butter.
-- Don your baking mitts. While my kids haven't (yet) embraced gluten-free grains such as quinoa or kasha (buckwheat) like their celiac mom has, they'll gobble up pancakes made with these flours, or happily nibble on cookies, bars or mini muffins made with other nutritious gluten-free grains such as teff, sorghum and millet. Pancakes and gluten-free baking are great ways to diversify the standard gluten-free diet, and there are plenty of terrific low-sugar recipes online.
My favorite baking ingredients are certified gluten-free oats and oat flour for cookies, bars and pancakes, as well as almond flour for mini muffins and quick breads. Seek out recipes based on nut meals, coconut flour and the whole-grain flours described above rather than starchy gluten-free staples such as rice flour, tapioca flour or potato starch. Or consider starting a Sunday morning from-scratch pancake tradition - just measure out the dry and wet ingredients, respectively, the night before. Then, all you need to do is combine and cook in the morning.
-- Stock your pantry with gluten-free essentials. It's no harder to get a family-friendly gluten-free dinner on the table every night than a wheat-based one - so long as you've got a few key pantry staples always on hand. I'm never without gluten-free tamari soy sauce for marinades, stir-fries and dressings; gluten-free breadcrumbs for meatballs; a box of gluten-free pasta; and a bag of chickpea flour for breading schnitzel (chicken cutlets) or fish. With these four ingredients in supply, I can make gluten-free versions of just about any recipe I come across. I also keep a loaf of my favorite whole-grain, gluten-free bread in the freezer for when only a peanut-butter and jelly will do.
-- Plan ahead for birthday parties. It's safe to assume that there will be little available at the typical pizza and cupcake party that's safe for a child with celiac disease. So call the host in advance and offer to provide a suitable stand-in for your child if necessary. A mom I know, whose 3-year-old daughter has celiac disease, keeps a dozen gluten-free cupcakes in her freezer to pull out for such occasions as needed. Larger cities may even have delivery options for gluten-free pizza!
-- Talk to your child's school about a 504 plan. Children on medically necessary diets who attend public schools (or federally-funded private schools) may be eligible for an individualized, written agreement between the family and the school to ensure that appropriate accommodations are made for the kids' needs. A 504 plan for a child with celiac disease might, for example, address the availability of gluten-free foods in the cafeteria, call for kitchen staff training in label reading and prevention of cross-contamination and set parameters for in-classroom food for birthday parties or boxed lunches for field trips. Several sample 504 plans for children with celiac disease are available online and can be used as a starting point.
As I've written here previously, gluten is just one of many available proteins in our varied American diet. It's not essential for human health or childhood development, and there's nothing inherently nutritionally inadequate about a gluten-free diet. While gluten-free living in the modern world may at times be inconvenient -particularly for parents of young children with celiac disease - investing the energy into planning a nutritious gluten-free diet for your child is foundational to good long term health and eating habits.
Tamara Duker Freuman , MS, RD, CDN, is a registered dietitian whose NYC-based clinical practice specializes in digestive disorders, Celiac Disease, and food intolerances. Her personal blog, www.tamaraduker.com, focuses on healthy eating and gluten-free living.
Please note that the author cannot offer individualized medical advice to readers who contact her via email.