Next visit

You have been invited to the gastroenterology clinic by the specialist to join the consultation with Davina and her parents. You explain the course of events that led to the referral. The consultant listens, and explains that it is a difficult diet to follow for young children and their parents. The time that it is introduced also is at the same time as food fads and eating behavioural problems are common, adding to the difficulty. If there is absolute certainty about the diagnosis, it is easier to be clear and directive. Without a biopsy, you cannot be certain.

You also mention that Davina’s mother seems quite emotional about having to use formula milk as opposed to breast feeding her daughter. The consultant explains that, with children, and especially with diet advice, understanding and working with parents is essential to develop a good therapeutic relationship.

Davina’s parents are told about the importance of the diet and the need for a biopsy. They understand this, but are confused that this was not made clear before. They ask if it would not just be better to really stick to the diet and thereby avoid the biopsy.

Two weeks later you see Davina again with her parents in the gastroenterology clinic with the specialist.

The procedure went well, although Davina’s parents report that she was frightened before she went to sleep.

The biopsy results are back now and show that she has villous atrophy in the duodenal and jejunal specimens that were taken. This confirms that she has coeliac disease.

Her parents had been expecting this and are pleased that this is now clear. However they are annoyed by the delay and point out that the hospital could have got to this point at months earlier. Meanwhile, she has not been growing for this time and effectively lost 2 months of growth.

The gastroenterologist agrees, and then takes them back to the dietician. Some iron and vitamin supplements are also prescribed.