Review for 10.1186/1471-230X-14-38 (2014)

Reviewer's report
Title:How well do Italian family paediatricians approach and manage celiac
disease? A cross-sectional study in Puglia Region, 2012
Version: 2Date:28 August 2013
Reviewer: Anna Myleus
Reviewer's report:
Today it has become increasingly evident that the majority of celiac disease
cases are undiagnosed. Furthermore, children diagnosed experience difficulties
in their daily life with respect to their gluten free diet. Pediatricians play an
important role in both diagnosis and management of celiac disease, however the
knowledge regarding their knowledge of the disease (and lack thereof), including
need for support remains to a large extent unknown. Therefore, the current
manuscript by Fortunato et al. has its merits.
- Major Compulsory Revisions
1. While it was the FP who suspected celiac disease in their patients in 90% of
the cases (Results paragraph 3) suggesting the FP have good knowledge about
celiac disease (Authors conclusion) I would like the authors to further discuss the
clinical picture which lead to suspicion of celiac disease (discussion paragraph
5). As noted by the authors, it seems important to find also those celiac disease
cases without clear typical symptoms. In the study weight loss and stunting were
the most commonly reported symptoms (45%). These symptoms could be
classified as “classical” i.e. gastrointestinal or signs of under nutrition. When
adding the other “classical symptoms” in Table 1 this clinical picture is seen in
about 80% of the children. Previous screening-studies have suggested that about
30% of the celiac disease cases have “classical/typical clinical picture” (e.g. from
Italy A Tommasini A et al., Arch Dis Child 2004;89:512-515 and Nenna R et al. J
Pediatr Gastroenterol Nutr. 2013 Apr;56(4):416-21). Could this suggest that the
FPs have good knowledge about the classical celiac disease picture and are
good at finding these cases but are less good at finding the ones without this
classical picture?
2. As the Authors acknowledge, the findings do not reflect all FPs since less than
half participated (Discussion paragraph 10). It could be supposed that those
without knowledge of celiac disease hesitated to participate. Could this limitation
in the study possibly impact the results and conclusion regarding the knowledge
among FPs?
3. Regarding the findings of celiac disease risk and recommended age at gluten
introduction:
a. Introduction paragraph 3. The recommendation that introduction of solid foods
should be avoided before the end of 3rd month is not exclusive to infants at risk
of developing allergies. Please correct.
b. Results paragraph 4. Please also provide number (%) of FPs who
recommended gluten introduction before 6 months and after 6 months,
respectively.
c. Discussion paragraph 6. I think professor Guandalini is being wrongly cited
(reference 25). In reference 25 it says “gluten be introduced in small amounts in
the diet between 4 and 6 months” and not after 6 months as written by the
authors. Furthermore, this is similar recommendation as given by both
ESPGHAN and EFSA (reference 18-20 in the manuscript).
d. Please revise the interpretation of your findings as it seems like you have
found the opposite risk pattern compared previous studies (see references above
and e.g. Silano M, Agostoni C, Guandalini S. Effect of the timing of gluten
introduction on the development of celiac disease. World J Gastroenterol. 2010
Apr 28;16(16):1939-42. or Szajewska H. et al. Systematic review: early infant
feeding and the prevention of coeliac disease Aliment Pharmacol Ther. 2012
Oct;36(7):607-18.)
- Minor Essential Revisions
1. When using abbreviations, please write out the full text the first time it appears
and thereafter use the abbreviation consequently (e.g. celiac disease CD,
confidence interval CI).
2. To be clear, please add the statistical tests used for calculating OR and how
statistical significance was judged for ORs (Methods paragraph 2).
3. There is an inconsistency in the numbers in Results paragraph 1. The FPs
(n=218) covered approximately 185 000 children but each FP does not have
more than 800 children which sums up to 174 400.
4. Results paragraph 7. I think there is a mistake regarding the p-value, compare
Table 7.
Minor issues not for publication
5. Gluten-free diet is used both with and without – (gluten free diet and
gluten-free diet).
6. Abstract, Method row 4: there needs to be an “and” before clinical.
7. Abstract, Results row 2 child population”
8. Abstract, Results row 7 82% participating FPs, respectively.
- Discretionary Revisions
1. Introduction paragraph 1. The reference regarding how underdiagnosed celiac
disease is (75-90%) comes from an editorial and not from a scientific study.
Although the number is not unrealistic, reference to studies which has estimated
the degree of underdiagnoses e.g. screening-studies or a systematic review
would be more appropriate.
2. Introduction paragraph 3. I recommend you clarify if, and it that case how, the
Italian recommendation for celiac disease diagnostics (reference 17) is different
from the ESPGHAN recommendation (reference 24 should be added here). For
completeness, also include something about last year’s changes in
recommendations e.g. regarding the biopsy.
3. Result paragraph 1. Present median age with some measurement of the
spread around the median e.g. inter quartile range
4. Results paragraph 3. It would be interesting to know how many FPs requested
anything in addition to the anti-tTG?
5. In the discussion paragraph 5 references is given to ESPGHAN guidelines
(24). I suggest this reference is added in the introduction paragraph 3 regarding
diagnosis of celiac disease and a more appropriate reference regarding
long-term complications is added here to back up the reasoning.
6. Regarding the abbreviation FP for Family Pediatrician. To my knowledge FP is
more commonly used for Family Physician, or Family Practitioner. If this is not
the same specialty in Italy the Authors could consider not using FP to avoid
potential misunderstandings.
7. It would be interesting if there is data on breastfeeding, breastfeeding duration
and overlap with gluten introduction in addition to age at gluten introduction.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests