One in Four Kids With Celiac Disease Have Anemia at Diagnosis, Study Finds

Celiac.com 03/28/2026 - Celiac disease is an immune condition triggered by gluten that damages the lining of the small intestine. In children, it can present with digestive symptoms such as diarrhea or poor weight gain, but it can also appear with symptoms outside the digestive system. One of the most important of these is iron deficiency anemia.

Iron deficiency anemia occurs when the body does not have enough iron to make healthy red blood cells. In celiac disease, this can happen because the upper part of the small intestine, where iron is absorbed, becomes inflamed and damaged. In some children, anemia may be the first or only noticeable sign of celiac disease.

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Although anemia in children with celiac disease has been studied in other countries, there has been limited data from southern Saudi Arabia. This study aimed to fill that gap.

How the Study Was Conducted

The researchers reviewed medical records of children and adolescents between one and eighteen years of age who were diagnosed with celiac disease between 2016 and 2023 at the Armed Forces Hospital Southern Region. All diagnoses followed established pediatric guidelines used at the time, either through intestinal biopsy or blood testing.

To be included, children needed to have blood test results at diagnosis and follow-up blood tests at one and two years after starting a gluten-free diet. Children with other known causes of anemia were excluded, ensuring that the focus remained on anemia related to celiac disease.

The main goal was to determine how many children had iron deficiency anemia at the time of diagnosis. The researchers also wanted to see how many children still had anemia one and two years later and whether factors such as age, sex, growth problems, or treatment details affected outcomes.

Who Was Included in the Study

A total of ninety-seven children with confirmed celiac disease were included. About sixty percent were girls. Most children were diagnosed between six and ten years of age, followed by those aged eleven to fourteen. Only a small number were diagnosed before age five or after age fifteen.

Many children did not present with classic digestive symptoms. Some were diagnosed through screening, particularly those with other conditions such as type one diabetes. Others had short stature or poor weight gain. A notable portion had no symptoms at the time of diagnosis.

This reflects the evolving understanding of celiac disease, which increasingly includes children with non-traditional or silent presentations.

How Common Was Iron Deficiency Anemia?

The study found that approximately one in four children, or 25.8 percent, had iron deficiency anemia at the time they were diagnosed with celiac disease. This rate falls within the range reported in international pediatric studies.

However, the researchers noted an important context: iron deficiency is also common in the general pediatric population in Saudi Arabia. This means that not every case of anemia in children with celiac disease can automatically be blamed on intestinal damage from gluten. Some cases may reflect broader nutritional factors.

When the researchers looked for patterns, they found that anemia was slightly more common in children diagnosed between six and ten years of age. However, age, sex, short stature, poor weight gain, and syndromic conditions were not statistically linked to a higher risk of anemia. In other words, no specific demographic or clinical profile reliably predicted which child would have anemia at diagnosis.

What Happened After Starting a Gluten-Free Diet?

The gluten-free diet is the primary treatment for celiac disease. By removing gluten, inflammation in the small intestine gradually improves, allowing nutrients such as iron to be absorbed more effectively.

Among the twenty-five children who had anemia at diagnosis, follow-up data were available for all at one and two years. After one year on a gluten-free diet, anemia had resolved in about sixty-eight percent of affected children. By two years, recovery increased to eighty-eight percent.

This gradual improvement supports the idea that intestinal healing plays a major role in correcting iron deficiency in many children. As the intestinal lining recovers, iron absorption improves, and hemoglobin levels rise.

Still, a small group of children continued to have anemia even after two years. This highlights that recovery is not always immediate or complete. Persistent anemia may be related to ongoing inflammation, accidental gluten exposure, or additional nutrient deficiencies.

Role of Iron Supplements

Not all children with anemia received iron supplements. When supplementation was used, it was given orally, most often once daily for about three months using standard pediatric weight-based dosing.

The study did not find a clear link between the type or duration of iron therapy and whether anemia persisted. This suggests that, for many children, the gluten-free diet alone may be sufficient to correct anemia over time. However, supplements remain important in children with more severe or symptomatic anemia.

What the Study Did Not Find

One of the most interesting findings was what the researchers did not discover. No demographic, clinical, or treatment-related factor was clearly associated with either the presence of anemia at diagnosis or its persistence after one year.

This underscores the unpredictable nature of iron deficiency in children with celiac disease. It also suggests that clinicians cannot rely on symptoms or growth patterns alone to determine who might be anemic.

Strengths and Limitations

The study’s strengths include its clearly defined pediatric group and consistent follow-up over two years. All children with anemia had complete follow-up data, which strengthens confidence in the recovery findings.

However, the study was retrospective, meaning it relied on existing medical records. The sample size was modest, which may limit the ability to detect subtle risk factors. Additionally, not all children had detailed information about intestinal damage severity or iron metabolism markers.

Why This Study Matters for Families Affected by Celiac Disease

For families navigating a new diagnosis of celiac disease, anemia can be an alarming complication. This study provides reassuring news: although iron deficiency anemia is relatively common at diagnosis, most children improve significantly after starting a gluten-free diet.

It also reinforces several practical lessons. First, children diagnosed with celiac disease should be routinely screened for anemia, even if they have no digestive complaints. Second, blood tests should continue during follow-up, particularly in the first two years. Finally, if anemia persists, further evaluation may be needed to check dietary adherence, hidden gluten exposure, or other nutrient deficiencies.

Ultimately, this research highlights that iron deficiency anemia is an important but often treatable aspect of pediatric celiac disease. With early diagnosis, careful monitoring, and consistent adherence to a gluten-free diet, most children can achieve both intestinal healing and normal blood counts, supporting healthy growth and development over time.

Read more at: cureus.com