Celiac Expert Weighs in on When to Introduce Gluten

Gluten Introduction to Infant Feeding and Risk of Celiac Disease – published by the National Foundation of Celiac Disease Awareness (NFCA)


introduction of gluten“A team of researchers with The Journal of Pediatrics conducted a systematic review of 15 previous studies related to the topics of gluten introduction to infants, gluten consumption at weaning (transition from liquid to solid food in infants) and the effect of breastfeeding on celiac disease.

To date, the recommended age of gluten introduction has been between 4 and 6 months of life, with late introduction defined as over 6 months. The results of the review found that there was a 25 percent increase in the risk of developing celiac disease with late gluten introduction. It was found, however, that there was no effect of breastfeeding versus not breastfeeding on celiac disease risk.

There is currently no evidence to support that early introduction of gluten increases the risk of celiac disease and more studies will need to be conducted in order to better understand this relationship.

NFCA hosted a webinar on this topic, titled “What Wikipedia Can’t Tell You About Celiac Disease Prevention: Hear it from the Experts,” featuring Doctors Alessio Fasano, Carlo Catassi and Sabine Vriezinga.

To learn more about this topic the NFCA contacted one of the authors of this study, Stefano Guandalini, MD, Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago.

Q. Given this review, what are the breastfeeding and gluten introduction recommendations for families with celiac disease? Do recommendations differ based on which family member is diagnosed with celiac disease?

A. In reality, there is not much change in the current recommendations. In fact, even though we have no hard evidence that early introduction may be detrimental, good common sense  still advises for an introduction not before the 5th month of life. And since a relatively small 25% increase was found in introduction of gluten beyond 6 month, as you see we end up by having our best shot at identifying 5-6 months of age as the likely best time (not a surprise, since Mother Nature has the first teeth appear at exactly that age!).

As for breast feeding, even though our analysis failed to show a significant protective effect toward celiac disease, we should never forget the solid evidence for the high value of breast feeding in a Million other areas, so please do breast feed your babies!

Q. Are there any other health complications related to late introduction of gluten, aside from increased risk of celiac disease?

A. Not that we know. However, keep in mind that the most recent evidence for prevention ofallergy favors an early, rather than late, introduction of potentially allergenic foods, so perhaps in this line of thoughts one wants to avoid an excessively late exposure to wheat.

Q. What would you say to parents who are thinking about not introducing any gluten at all because celiac disease runs in their families and they are nervous/scared?

A. I would recommend checking the child’s genetic asset for celiac disease; if the baby has not celiac-related HLA haplotypes, then obviously gluten ceases to be an issue; on the other hand, if the baby has a genetic predisposition, then I would not recommend avoiding completely gluten introduction: sooner or later the child will be eating gluten-containing foods anyway, and this is better done in “regular” times and amounts, so any untoward effect can be soon identified, monitored and properly addressed.

Q. Do you have anything else to add on this topic that you think the readers should know?

A. Perhaps the only other thing to add would be to be extra-careful when monitoring a baby girl born in a family at risk: in fact, the study by Vriezinga et al (the large an important “PreventCD” cohort study published in 2014) showed that girls who were HLA-DQ2 homozygous and were exposed to gluten at 4 months had a much higher probability of developing celiac disease at an early age. Thus, such infants should definitely not be exposed to gluten so soon, and in any case they should be followed more closely for the possible development of celiac autoimmunity, so to achieve an early as possible diagnosis.

Note: NFCA maintains the position that views and information presented on articles and websites we link to are those of the authors, and not necessarily those of NFCA.”

Stephano Guandalini

Gastroenterologist Stefano Guandalini, MD (Photo by Robert Kozloff)

Stefano Guandalini, MD
Professor of Pediatrics, University of Chicago
Chief of Pediatric Gastroenterology, Hepatology, and Nutrition University of Chicago Children’s Hospital
Founder and Medical Director, The University of Chicago Celiac Disease Center

Dr. Guandalini is founder and medical director of The University of Chicago Celiac Disease Center. Dr. Guandalini received his medical degree from the University of Messina, Italy, in 1971, where he graduated with high honors. After his pediatric residency at the University of Messina, he completed his fellowship in pediatric gastroenterology at the prestigious University of Naples, where he became an assistant professor. He spent 2 years (1977-1979) as a research associate in the Department of Medicine at the University of Chicago, where he did active bench research on the pathophysiology of diarrheal disease. Shortly after he returned to Italy, he received a promotion to associate professor and then became a full professor at the University of Naples in 1988. From 1990 to 1995, Dr. Guandalini served as the Chairman of Pediatrics at the University of Catanzaro.

Dr. Guandalini’s scientific and professional career has focused on diarrheal diseases of children, with a major emphasis on celiac disease. In 1990, he coordinated a national effort in Italy resulting in the publication of the largest series of patients ever published, which resulted in the revision of the 20-year-old European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines for diagnosing celiac disease. These new guidelines are currently used worldwide for both pediatric and adult celiac disease patients.

Dr. Guandalini joined the University of Chicago Department of Pediatrics in 1996, where he serves as section chief of the Department of Pediatrics Gastroenterology, Hepatology, and Nutrition.

Dr. Guandalini was president of ESPGHAN from 1998 to 2001, and was selected from a worldwide pool of candidates as the first president of the Federation of International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN). Dr. Guandalini was born in Rome, and spent his childhood in Messina, Italy, where his mother’s family originated. His father’s family is from the northern Italian town of Modena.

alice bast, NFCA

Alice Bast
President & CEO
National Foundation for Celiac Awareness

National Foundation of Celiac Disease Awareness (NFCA)

The National Foundation for Celiac Awareness advances widespread understanding of celiac disease as a serious genetic autoimmune condition and works to secure early diagnosis and effective management. We empower our community to live life to the fullest, and serve as a leading and trusted resource that inspires hope, accelerates innovation and forges pathways to a cure.

NFCA is affiliated with the leading researchers internationally and supports collaboration and partnership among scientists and institutions to optimize research potential with the goal of improving the quality of life for those who have celiac disease and other gluten-related disorders.

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