New guidelines reverse previous recommendations on gluten introduction to prevent celiac disease
Based on new evidence, the age of introduction of gluten into the infant diet—or the practice of introducing gluten during breast-feeding—does not reduce the risk of celiac disease in infants at risk, according to a Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). The statement appears in the Journal of Pediatric Gastroenterology and Nutrition (JPGN), official journal of ESPGHAN and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
Contrary to previous advice, gluten may be introduced anytime between four to twelve completed months of age, the updated recommendations state. Although breastfeeding should be promoted for its other well-established health benefits, current evidence suggests that neither any breastfeeding nor breastfeeding during gluten introduction can reduce the risk of celiac disease.
No Evidence that Timing of Gluten Introduction Affects Celiac Disease Risk
Celiac disease is a unique genetic autoimmune disease affecting the gut and other organs, developing in response to consumption of a specific food ingredient—namely gluten. Occurring only in persons carrying one or more susceptibility genes, celiac disease affects approximately one to three percent of the general population in most parts of the world.
In 2008, ESPGHAN issued a recommendation to avoid both early (less than 4 months) and late (7 months or later) introduction of gluten, and to introduce gluten while the infant is still being breastfed. Those recommendations were based on observational studies suggesting that this approach to gluten introduction reduced the risk for celiac disease.
But since then, two randomized controlled trials have shown that the age at gluten introduction does not affect overall rates (incidence and prevalence) of celiac disease during childhood. Earlier gluten introduction causes the disease to present itself at an earlier age. "These findings suggest that primary prevention of celiac disease through nutritional interventions is not possible at the present time," Prof. Szajewska of The Medical University of Warsaw, the lead author of the new Position Paper, comments.
Meanwhile, new observational evidence shows no difference in celiac disease risk when gluten is introduced while the infant is still breast-feeding, compared to after weaning. Because of its many other health benefits, breastfeeding is recommended for all infants, regardless of celiac disease risk.
The updated recommendations are based on studies of infants with known risk genes for celiac disease. However, because this information is generally not known at the time solid foods are introduced, the recommendations apply to all infants.
Celiac disease risk genes are present in 30 to 40 percent of the general European population, as well as in 75 to 80 percent of children who have a close relative (parent or sibling) with celiac disease. For now, there is not enough evidence to make specific recommendations for infants with a family history of celiac disease.
The authors highlight the need for recommendations on screening strategies for children with affected family members. They also call for further studies to determine the best approaches to introducing gluten into the diet—currently, there is no evidence on the effects of delaying gluten introduction for longer than one year.