Infants with a first-degree relative (parent or sibling) with celiac disease, and who carry an at-risk (DQ2 or DQ8) gene, have a higher risk of developing the autoimmune disorder triggered by gluten-containing foods. Many parents, especially those with a family history of celiac disease, are understandably nervous about introducing gluten into their child’s diet. They wonder whether there is an ideal time to introduce gluten, if they can prevent celiac disease by never introducing gluten, and for those with celiac disease, how to incorporate gluten into their child’s diet without getting sick themselves.
Previously it was thought that there might be an ideal “window” to introduce gluten to infants that would decrease the risk of developing celiac disease. However, recent research shows that this is not the case. Additionally, while breastfeeding provides many benefits to an infant, there is no evidence that it prevents or protects against the development of celiac disease in at-risk children. Therefore, we currently recommend that gluten be introduced into an infant’s diet anytime after four months of age, even if the child is known to have an increased risk of developing celiac disease.
We base this recommendation primarily on data collected from two studies which followed “at-risk infants, ” which are defined as those with both a first-degree relative diagnosed with celiac disease and a genetic predisposition to develop the disease. These studies, published in the New England Journal of Medicine in October 2014 explored the timing of gluten introduction in infants at risk for celiac disease to see how it affected development of the disease. One study followed approximately 500 infants in Italy and found that introducing gluten at 12 months of age, as compared to 6 months of age, delayed but did not prevent the development of celiac disease.
In this study, the same number of infants in each group developed celiac disease by the time they reached five years of age. In separate work, the European PreventCD study followed 944 at-risk infants and examined whether introducing small amounts of gluten at 4to 6 months of age might prove protective against celiac disease by priming the immune system. Again, this study found no difference in the frequency of celiac disease between infants who received this small amount of gluten and those who did not. A similar number of infants in both groups developed celiac disease by age three.
Since the publication of these studies, additional research has further evaluated whether the amount of gluten introduced in early life matters. A nested-case control study of Swedish children found that the amount of gluten consumed during the first two years of life increased the risk of celiac disease by 2-fold in genetically at-risk children. However, an analysis of 715 children from the PreventCD high-risk infant cohort found that the amount and pattern of gluten consumption between 11 and 36 months of age did not influence the risk of developing celiac disease. Authors from the PreventCD study suggest that these discrepant findings between studies may be due to the way in which gluten intake was categorized for purposes of the research.
Ultimately, there is no optimal time to introduce gluten to infants, although before four months of age has been associated with an increased risk of celiac disease. There is no known ideal amount or type of gluten to introduce at weaning, or offer during the first years of life, that is protective for children at risk for celiac disease. Breastfeeding has not been shown to be protective against the development of celiac disease. Families with celiac disease can offer their infant gluten-containing snacks throughout the day and meals inside or outside of the home. To limit the possibility of cross contamination for those in the home with celiac disease, careful hand washing will suffice. While never introducing gluten into an infant’s diet would prevent the development of celiac disease, it is important to note that even infants with the highest risk of developing celiac disease (those with two copies of HLA DQ2) have a 75 percent chance of not developing celiac disease by age 5. Therefore, until we have additional evidence to guide gluten introduction and ingestion in high-risk children, our best advice is to “let them eat cake” — at least once in a while.
Maureen Leonard is clinical director, Center for Celiac Research and Treatment, MassGeneral Hospital for Children, Boston, MA. She can be reached on Twitter @celiacdoc.
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