Early childhood educators' and daycare staff's guide to celiac disease

Being informed about celiac disease and the gluten-free diet, and how you can best support someone living with celiac disease, are important steps to meet the needs of a child with celiac disease at your childcare centre.

What is celiac disease?

Celiac disease is a lifelong autoimmune condition treated with a strict gluten-free diet. In people with celiac disease, any contact with gluten triggers a reaction from the body’s immune system. This immune response to gluten results in damage to the lining of the small intestine, causing gastrointestinal symptoms, such as abdominal pain or a need for frequent bathroom breaks, and extra-intestinal symptoms, such as fatigue. This damage makes it harder for the body to absorb nutrients, such as vitamins and minerals, that are vital for health and functioning.

What is gluten and the gluten-free diet?

Gluten is the common name of a family of proteins found in grains that cause intestinal damage in people with celiac disease.

Gluten is found in all forms of:

• wheat
• barley
• rye
• related grains such as triticale (a mix of wheat and rye)

A strict gluten-free diet, with no trace amounts of gluten, is the only treatment for celiac disease. While some sources of gluten are obvious to us, such as wheat-based breads, pastas, and baked goods, others can be hidden in things like soups, ice creams, or personal care items such as hand creams. Some craft items, such as playdough or wheat-based paper mâché, also contain gluten. Carefully read labels to determine what foods and products are gluten-free.

It is also important to avoid gluten cross-contact. Cross-contact occurs when gluten is transferred from one food or object to another food or object, making it unsafe for people with celiac disease. Within the childcare centre, gluten cross-contact can happen through shared desk surfaces or the use of gluten-containing art supplies. Handwashing and cleaning surfaces with soap and water can help to prevent gluten cross-contact at your childcare centre.

Watch the Celiac disease and Gluten-free diet modules from AboutKidsHealth’s Celiac disease learning hub to learn more about how to best support your students with celiac disease.

How to create a safe and inclusive environment for children with celiac disease

The key to creating a safe and inclusive environment for children living with celiac disease and following a strict gluten-free diet is clear communication and collaboration among parents/caregivers and childcare staff or cooks.

Here are some tips to support a child with celiac disease at your childcare centre:

Activities, events and celebrations

• Prepare activities and events that do not include foods and products containing wheat, barley, rye and other related grains, such as triticale.
• Provide advance notice to a child’s parents or caregivers about upcoming events or celebrations such as field trips, birthdays or preschool graduations, where gluten-containing foods may be served. Providing advance notice will allow parents/caregivers to prepare gluten-free foods so that their child can safely participate in the event or celebration.
• If a child’s parents/caregivers provide gluten-free snacks or treats to be used at celebratory events, make sure that they are clearly labelled for the child and stored away from gluten-containing items.
• Use non-food items, such as colouring books, picture books, crayons or stickers for birthdays or celebrations.

Preventing gluten cross-contact

• Ensure all children practice good hand hygiene by frequently washing their hands with soap and water. All children should wash their hands before and after eating, or after a craft activity to prevent gluten exposure. Hand sanitizer WILL NOT remove gluten.
• Frequently clean work and eating surfaces with soap and water. Make sure to clean these surfaces before and after eating or after class activities that use gluten-containing foods or items.
• Toys and play surfaces can be sources of cross-contact with gluten. If possible, regularly clean these items and avoid placing food served to children on these surfaces.
• Closely supervise children during meals and snacks to ensure there is no sharing of foods or cross-contact.
• Encourage a “hands to yourself” rule with children at your centre, especially while eating.
• Create a system with your childcare cook on how to safely identify and provide gluten-free meals and snacks to a child with celiac disease (e.g., use different-colour plates or utensils to indicate a gluten-free meal, have a specific gluten-free snacks cupboard, etc.).

Providing safe meals and snacks

• If your childcare centre uses a caterer to provide food to your centre, ask them about their gluten-free options that are safe for children living with celiac disease. Ask them if they practice safe food handling, for example, avoiding cross-contact. Make sure to provide the child’s family with the weekly or monthly caterer menu in advance and keep copies of the menu on hand in case a reaction occurs.
• If you are responsible for preparing snacks at your childcare centre, prepare gluten-free snacks before preparing any gluten-containing food to avoid cross-contact.
• If you are not sure if a food or product is gluten-free, it is best not to provide it to the child. It’s better to be safe than sorry!

What to do in case of gluten exposure

• Notify the child's parents/caregivers if there is an incident of gluten exposure.
• If a child with celiac disease is exposed to gluten and experiences symptoms, provide them with unrestricted access to the bathroom and a place to rest.

Potential sources of gluten in the childcare centre

Childcare supplies and activities can sometimes contain gluten and pose a risk to children with celiac disease. Although gluten cannot penetrate the skin, cross-contact can still occur if a child puts their hands on their mouth or nose, or touches food that they eat after contact with a surface, utensil, food or product that contains gluten. Here are 10 common gluten-containing supplies and classroom activities with easy substitutions to ensure a safe classroom environment:

1. Playdough or modelling clay products can be made using a wheat base. Choose gluten-free doughs or modelling clay that uses gluten-free bases such as rice flour or corn starch. You can make your own by following this gluten-free playdough recipe.
2. Paper mâché is often made with wheat flour. Using wheat flour is a high-risk situation for children with celiac disease as the flour can easily disperse in the air and come in contact with other surfaces. Use corn starch or rice flour instead of wheat flour when doing paper mâché arts and crafts activities.
3. Salt dough crafts for handprints and ornaments are popular around holidays, especially as a Mother’s or Father’s Day gift. Most salt dough recipes call for all-purpose flour. Use gluten-free flour to make the craft safe and inclusive for all children at your centre.
4. Finger paints will sometimes contain wheat or oats in their ingredient list. Make sure to carefully read the labels to make sure there is no gluten.
5. Sunscreen and lotions. Some sunscreens and lotions may contain gluten ingredients. Placing sunscreen or lotion on a child’s hands or face may lead to accidental ingestion of gluten. Speak with the child’s parents/caregivers to check for safe, gluten-free sunscreens and lotion, or use the sunscreen or lotion provided by the child’s parents/caregivers.
6. Glue or craft paste may contain wheat. Read the ingredients list to find a gluten-free option.
7. Pasta art. Pasta is made from wheat flour or durum semolina, a product of wheat. Swap gluten-containing pasta for gluten-free options such as dry and natural/unprocessed corn, quinoa, beans, lentils or rice, or choose any other pasta that is labelled as gluten-free.
8. Sensory tables or sand trays are a great tool to build children’s fine motor skills. However, sometimes items used in sensory tables or sand trays, such as gluten-containing cereals (e.g., Froot Loops* from Kellogg’s®), oats or pasta, are not gluten-free and pose a risk to small children who may put these items or their hands in their mouth. Use other gluten-free foods or non-food objects such as pipe cleaners, pom-poms or shaving cream.
9. Toys and play surfaces may be contaminated with gluten if children touch them after eating or playing with gluten-containing foods or items. Frequent hand washing and regularly cleaning plastic toys and play surfaces with soap and water can help minimize potential gluten exposures and cross-contact for the child(ren) with celiac disease.
10. Counting or sorting activities that use gluten-containing food items such as pasta or cereals are not safe for children with celiac disease. Use non-food items or pictures to demonstrate counting or sorting.

As a childcare educator, you are an important advocate for children with celiac disease in the learning environment. Creating a safe and inclusive environment for a child with celiac disease can build trust and ensure a positive experience in your care.