Complete workup with sweat test, iron, B12, folate, C-reactive protein and ESR, repeat thyroid function

You discuss the results with Davina’s parents. You explain that the antibody tests show that she has antibody’s against gluten, which is a protein found in wheat, so is present in bread, pasta, biscuit. This finding, combined with her poor weight gain, might suggest that she has coeliac disease, which is an allergic condition of the small intestine. In this condition, the lining of the intestine becomes inflamed because of the gluten in the diet. The consequence of this is that the intestine does not absorb nutrients properly.

The parents ask you what can be done about this.

You explain that other conditions also can cause poor growth and these need to be looked for too. She is anaemic, and you need to know why before specific supplements can be given. She may also have cystic fibrosis and this needs to be tested for too.

Davina’s parents understand the need for caution but do not like the idea of further tests for her. They reluctantly agree.

Two weeks later you see Davina again. All the results are now back, with normal thyroid function, normal sweat test and low B₁₂, folate and ferritin.

You explain these disorders have been excluded but you will now need to refer her for an endoscopy and biopsy of her intestine to confirm coeliac disease.

Davina’s parents are very angry about this and refuse to consent to her having another invasive procedure. As a different approach, they request to see the dietician, to start a gluten free diet at this stage.

You explain that the protocol suggests that a biopsy is important at this stage.

As a compromise you also arrange for her to be seen by a gastroenterologists.

The parents leave the room, muttering about ‘seeing someone who actually knows what to do’.