Timing gluten introduction won't prevent celiac disease, despite past recommendations

Contrary to previous advice, recent evidence shows that the age when gluten is introduced into an infant’s diet doesn’t reduce the risk of celiac disease, according to a new position paper from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). The statement was published online January 13, 2016, in the Journal of Pediatric Gastroenterology and Nutrition.

In 2008, ESPGHAN had 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, which suggested that this approach to gluten introduction would reduce the risk for celiac disease, were based on observational studies.

But recent randomized controlled trials have shown that the age when the infant is introduced gluten has no effect on the incidence or prevalence of celiac disease during childhood.

Also, neither breastfeeding during gluten introduction nor breastfeeding in general reduces the risk of celiac disease, the ESPGHAN authors noted. (They still recommend breastfeeding for all infants, regardless of celiac disease risk, because of its other health benefits.)

“These findings suggest that primary prevention of celiac disease through nutritional interventions is not possible at the present time,” said the position paper’s lead author Hania Szajewska, MD, PhD, Professor and Chair of the Pediatrics Department at the Medical University of Warsaw, Poland.

The authors did note that consuming large amounts of gluten at weaning and during the first 2 years of life may increase the risk of celiac disease during childhood. While this association hasn’t been proven in clinical trials, ESPGHAN recommended against consuming large amounts of gluten during the first months after introducing gluten in infants.

The updated recommendations are based on studies of infants with known risk genes for celiac disease, which are present in 30% to 40% of the general European population and in 75% to 80% of children who have a parent or sibling with celiac disease. For now, the authors wrote, there is not enough evidence to make specific recommendations for infants with a family history of celiac disease.

Lastly, the ESPGHAN group called for rigorous clinical trials to determine the optimal type and amount of gluten to introduce into the diet. For instance, no evidence exists on whether delaying gluten introduction for longer than 1 year reduces celiac disease.