Over the past decades the clinical spectrum of paediatric coeliac disease has profoundly changed, from a classical presentation with distended abdomen, diarrhoea and failure to thrive to more atypical symptoms. These days, children commonly present with symptoms such as recurrent abdominal pain, fatigue, iron deficiency anaemia and constipation. Age at diagnosis has also increased over the past few years. In the past 20 years the incidence of the disease in the Netherlands has increased from 12.3 to 21.1 per 100,000 inhabitants, reaching a stable level in the past 5 years. In approximately 10% of children, serological test results are negative on first examination but become positive after repeated testing in the years that follow, emphasising the need for alertness when first tests are negative and symptoms persist. We underscore the guidelines' advice to apply a low threshold in testing for coeliac disease in children with atypical symptoms.