STUDENT’S NAME: ____________________________________________ DOB______________
My child has Celiac Disease/ Gluten Intolerance? YES_________NO_________
DEFINITION: Celiac Disease (also called “Gluten Intolerance”) is an autoimmune disease caused by the body’s inability to digest gluten. Gluten is the protein found in WHEAT, RYE, BARLEY, SPELT & most OATS. Even small amounts of gluten act like a TOXIN to a person with Celiac Disease, triggering the body to attack itself in the small intestines. There are fingerlike projections called “villi” which line the small intestines. Normally the villi are responsible for absorbing all nutrients. When the villi become exposed to gluten, they become damaged or blunted-off, which leaves the person without the ability to absorb ANY nutrients!!! This is typically diagnosed from blood tests and a biopsy of the small intestines, which shows damage to the villi.
TREATMENT: THE ONLY TREATMENT IS STRICT ADHERENCE TO A GLUTEN-FREE DIET.
HOW DO YOU KNOW WHAT FOODS ARE GLUTEN-FREE?
Some EXAMPLES of foods which need to be substituted for gluten free versions include breads, cereal, breakfast bars, donuts, muffins, pasta/ noodles, cake, cookies, crackers, pretzels, breaded meats, soups & pizza. The main starchy foods that a person with Celiac Disease can eat are made with Rice, Corn, Potatoes, Soy, Quinoa and Tapioca. Other starches that can be used are buckwheat, Bean flours & Amaranth. Most people with Celiac Disease may eat any plain fruits & vegetables, nuts, dairy products and meats that are not prepared with gluten containing ingredients. Many people with Celiac Disease tolerate “Gluten-Free Oats” and these may be served to a child with parental permission. Oats are often contaminated with gluten while harvested, shipped, stored and processed thus making them unsafe for a person with Celiac Disease.) However, oats are often not tolerated on a gluten free diet because the protein in oats is similar to gluten.
PLEASE INDICATE IF CHILD HAS OTHER FOOD INTOLERANCES or FOOD ALLERGIES:
If “YES” please complete “Allergy” form with necessary treatment. (Please cross off any foods listed above which your child cannot eat.)
AVOID CROSS-CONTAMINATION - A CRITICAL PART OF MANAGING CELIAC DISEASE IS TO ASSURE FOODS AND SURFACES REMAIN GLUTEN FREE (GF) DURING FOOD PREPARATION & SERVING & DURING CLASSROOM PROJECTS. PLEASE DEVELOP THESE HABITS:
Avoid ingestion of art supplies - paints, play-dough & licking stamps & envelopes that may contain gluten. Use gluten-free paints and play-dough if possible – include other children at the same table.
Wash tables after art projects or eating in classroom to reduce amount of gluten in classroom. All children need to wash hands after art projects or eating in classroom to reduce gluten in classroom.
Have the person with Celiac Disease wash their hands prior to eating. Younger children may need assistance to remove gluten from hands - nail brush may help.
Wash eating surface and chairs prior to meals to free of gluten particles – between lunch groups in cafeteria. Provide person w/ Celiac disease adequate eating space to avoid cross-contamination from others. Supervise other children who may cross-contaminate the eating area or utensils during the meal. Use fresh serving utensils or fresh gloves to serve gluten-free foods 1st, & then serve the gluten-filled foods. Avoid touching plates with utensils while serving food. Keep separate containers designated as GF for butter/peanut butter/jelly/cream cheese/mayo & frosting. Use a separate cutting board/work surface for food preparation. Have a designated GF toaster too. Use separate pan, water and utensils for cooking – example: GF noodles in fresh water in separate pan.
_______________________________ HAS HAD THE FOLLOWING SYMPTOMS IN THE PAST AS A RESULT OF (OR IN RESPONSE) TO EATING GLUTEN. PLEASE INDICATE KNOWN SYMPTOMS YOUR CHILD HAS HAD AS A RESULT OF EATING TO GLUTEN:
__Tummy pain, abdominal cramps, nausea
__Flatulence (passing gas)
__Loss of appetite
__Weight loss or Failure to gain weight
__Short stature, not growing in height
__Protruding abdomen, muscles wasting away
__Teeth staining or being prone to cavities
__Hair loss, lack of hair growth
__Being lethargic/low energy
__Irritability or other Behavior changes
Other related autoimmune diseases:
__Other - SPECIFY:_____________________
Currently there is no medicine or remedy for accidentally ingesting Gluten.
NOTIFY PARENT IMMEDIATELY IF CHILD CONSUMES GLUTEN.
Unlike a food allergy, exposure to gluten for a person with Celiac Disease may or may not have visible or outward symptoms.
The degree of reaction can vary with the amount consumed.
The reaction can vary between being as severe as diarrhea, vomiting & behavior changes or seizures to having outward visible symptoms.
It can take days for the healing to occur in the intestines and symptoms to resolve in the intestines from even a small, accidental gluten exposure.
Please note: Whether or not there are visible symptoms when gluten is ingested, intermittent exposure to gluten can cause inflammation and damage to the intestines - which can lead to malnutrition and osteoporosis and often predispose the person to certain types of cancers. Thus, your cooperation & efforts are important in managing Celiac Disease. Please contact parent if there are any foods in question since gluten is hidden in many foods and medication.
Mother's Phones: ______________________________________________________________
Father's Phones _______________________________________________________________
Parent signature ______________________________________ date_____________
Physician’s signature (optional) ______________________________date_____________