OBJECTIVES: European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines recommend first-line serology for suspected celiac disease (CeD), measuring only transglutaminase antibodies (TGA-immunoglobulin A [IgA]) plus total IgA. If TGA-IgA is ≥10 times the normal value, pediatric gastroenterologists (pedGI) may diagnose CeD without biopsies if autoantibodies against endomysial antibodies (EMA-IgA) are positive in a 2nd blood sample. This Quality-of-Care (QoC) project benchmarked diagnostic workup in clinical practice using ESPGHAN CeD guidelines as reference. METHODS: A pseudonymized survey on CeD practices was sent to 141 hospitals within the ESPGHAN QoC-network in 28 countries. RESULTS: Questionnaires were completed by 129/141 (91.5%) hospitals, with 121 (94%) having pedGI staff. As reasons conflicting with good QoC for CeD in their setting, responders assumed knowledge deficits among the public (57%), primary care providers (64%), non-GI physicians (16%), and pedGIs (0%). For initial testing, 66% of physicians ordered only total IgA and TGA-IgA, 7% did not use this combination, and 29% ordered additional serology (TGA-IgG, EMA, antibodies against deaminated gliadin peptide, or native gliadin). Regarding conflicting results for TGA-IgA and histopathology in IgA-sufficient children, 61% incorrectly classified negative TGA-IgA with Marsh 2 and 57% with Marsh 3 lesions as "potential CeD," while 49% excluded CeD in the case of villous atrophy and negative TGA-IgA. Routine practice did not align with the ESPGHAN recommendations regarding performance of duodenal biopsies (27%), EMA-testing (34%), and diagnosis of CeD in IgA-deficient children (32%). CONCLUSIONS: We identified areas for improving QoC regarding both effectiveness and efficacy, in pediatric patients with suspected CeD, and consequently developed easy-to-use tools to improve guideline implementation.

Central Lisbon University Hospital Centre Lisbon Portugal

Department of Hygiene and Epidemiology Faculty of Public Health Prof Paraskev Stoyanov Medical University Varna Bulgaria

Department of Pediatric Gastroenterology Hepatology and Nutrition Emma Children's Hospital Amsterdam UMC Amsterdam The Netherlands

Department of Pediatrics and Inherited Metabolic Disorders 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Department of Pediatrics Division of Pediatric Gastroenterology and Hepatology Dr von Hauner Children's Hospital LMU University Hospital Munich LMU Munich Munich Germany

Department of Pediatrics Gastroenterology and Nutrition School of Medicine Collegium Medicum University of Warmia and Mazury Olsztyn Poland

Human Nutrition School of Medicine University of Glasgow Glasgow United Kingdom of Great Britain and Northern Ireland

i HeALTH Strategic Research Group Department of Health Sciences Miguel de Cervantes European University Valladolid Spain

Referral Center for Pediatric Gastroenterology and Nutrition Children's Hospital Zagreb Zagreb Croatia

Stiftung Kindergesundheit c o Dr von Hauner Children's Hospital LMU University Hospital Munich LMU Munich Munich Germany

The European Society for Paediatric Gastroenterology Hepatology and Nutrition Geneva Switzerland

Unit of Nutrition and Obesity Hospital Recoletas Campo Grande Valladolid Spain

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