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Breastfeeding, Gluten Introduction, and Risk of Celiac Disease

A study published yesterday in the journal Pediatrics suggests that later introduction of gluten and breastfeeding beyond 12 months both increase the risk of a child developing celiac disease. These new findings add to the already muddy waters of our current understanding of the role of infant feeding in celiac disease.

Photo by Shree Krishna Dhital, via Wikimedia Commons

Celiac disease is an immune response to gluten, a protein found in wheat, barley, and rye. Celiac is characterized by inflammation and damage to the small intestine, leading to symptoms such as diarrhea and digestive pain. In the U.S., celiac disease is present in about 1 in 141 people, although many of these cases go undiagnosed. Infants that develop celiac disease often have poor growth or weight loss, because intestinal damage compromises nutrient absorption. They also may have chronic diarrhea and a swollen, painful belly.

Celiac can usually be treated with a gluten-free diet, but there isn’t a cure for the disease. Multiple genetic markers have been identified for celiac disease, but many genetically susceptible individuals tolerate gluten and never develop symptoms, leading to speculation about other risk factors, including early childhood nutrition.

This latest study was a large, prospective survey of infant feeding practices and development of celiac disease in Norwegian children. Parents were asked when they first introduced gluten and how long they breastfed their babies. Children that developed celiac disease were tracked through Norway’s national medical system. The study included 324 children with diagnosed celiac disease and 81,843 without celiac. The researchers then looked for patterns in the data that might help to explain why some children developed celiac disease and others did not.

There were two major findings to emerge from this study:

  1. Children that had not yet tried gluten by 6 months of age were more likely to develop celiac disease.
  2. Breastfeeding at the time of introduction to gluten did NOT appear to be protective. In fact, breastfeeding for longer than 12 months was associated with an increased risk, although it was borderline significant (P=0.046).

Both of these findings are contradictory to current infant feeding advice in the U.S. The AAP’s Section on Breastfeeding recommends exclusive breastfeeding for about 6 months before introducing solid foods, followed by “continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.” The same AAP policy goes on to say, “There is a reduction of 52% in the risk of developing celiac disease in infants who were breastfed at the time of gluten exposure.” But this Norwegian study effectively found that following the current advice of the AAP seems to increase a baby’s risk of celiac, not decrease it.

Obviously, we need more information here. And as usual, one study isn’t enough to give us the full picture of what we know and don’t know about this topic.

To understand the evolving hypotheses around celiac disease and infant feeding, we need to go back to Sweden in the mid-1980’s, when the rates of celiac disease in young kids suddenly quadrupled from an incidence of 1 in 1000 births to 4 in 1000 births over just a few years. It was an epidemic, and it appeared to be isolated to Sweden; neighboring countries weren’t affected. What’s more, celiac was showing up in really young kids. The median age of diagnosis during the epidemic was just about a year old. In 1995, celiac disease in Sweden plummeted back to pre-epidemic levels, and the median age of diagnosis increased to 4 years of age.

In 2005, researchers screened more than 7500 Swedish 12-year-olds, born at the height of the epidemic, and found that 3% of them had celiac disease. That number stood in marked contrast to a 1999 study that found 0.5% of Swedish adults had celiac.

During and following Sweden’s celiac epidemic, infant feeding practices went under the microscope. Could they explain the dramatic increase in celiac rates in young children, and the just-as-dramatic declines?

In fact, there were some very big changes in infant feeding during this time, and it is assumed that these drove the epidemic. Prior to 1982, the national recommendation was to introduce gluten to babies between 4 and 6 months of age. At the end of that year, the advice changed to waiting until the 6-month birthday. Breastfeeding rates in Sweden were around 50% at 6 months. “Follow-on” formulas, marketed for older babies, were growing in popularity. These formulas were thickened with wheat flour, and intake of gluten among babies more than doubled during the mid-1980’s. So, during the celiac epidemic, you had a lot of babies suddenly getting a lot of gluten around 6 months of age – much of it coming not from solid foods but from formula.

When the epidemic ended in 1995, infant feeding practices were quite different. The popularity of the follow-on formulas had declined, and gluten intake dropped (probably because of media coverage of the epidemic). Breastfeeding rates had increased gradually over the previous decade, reaching around 75% at 6 months by the mid-1990’s. And the recommendation for gluten introduction changed back; now parents were again advised to begin introducing gluten in small amounts between 4 and 6 months of age. As the epidemic ended, babies were being gradually introduced to gluten, often prior to 6 months and while still breastfeeding.

The Swedish epidemic was a unique opportunity to try to tease apart feeding factors associated with celiac disease, and a retrospective case control study of Swedish kids revealed some patterns from the epidemic. Children that developed celiac, most of them diagnosed before age 2, were less likely to be breastfed during and beyond gluten introduction. They were more likely to eat large amounts of gluten within the first couple of weeks of introduction, and the major source was the formulas with added flour. In this cohort, there was no association between celiac risk and age of gluten introduction.

The story of the Swedish epidemic is really compelling, but it can only tell us so much. For one thing, it was retrospective, so it relied on parents’ memories of how they fed their babies, sometimes years later. That’s particularly problematic when you’re comparing kids with and without a disease with digestive symptoms. Children with celiac probably suffered from diarrhea and failure to thrive during their first years of life, and their parents might thus recall their feeding practices differently from those never affected by the disease. There were also a lot of confounding factors. For example, babies that weren’t breastfed at the time of gluten introduction were more likely to get large doses of gluten in the form of flour-based formula. So was it the lack of breast milk, or was it the bunch of gluten, or was it a combination of these factors? These are things that the researchers tried to model statistically, but there are limitations to this approach. The observations from Sweden were important though, and they compelled researchers to look more closely at these questions.

Outside of wartime, this might not be the best advice. FDA poster, ca 1918.

Outside of wartime, this might not be the best advice. FDA poster, ca 1918.

We now have a decent body of research (reviewed here and here) on early nutrition and celiac disease, but much of it is conflicting. This latest study from Norway only adds to the confusion. Here’s what we know and don’t know so far:

Timing of Gluten Introduction: In addition to the Swedish studies cited above, others have found no association between timing of gluten introduction and celiac. However, the best-designed study of this question (prospective, accurate feeding records, excellent celiac screening) actually did find an effect. Led by Dr. Jill Norris of the University of Colorado, this study found that children introduced to gluten in the first 3 months of life had a 5-fold increased risk of celiac. Those introduced after 7 months also had a marginally increased risk. However, this study only included kids at high-risk for celiac (based on genetic markers or a first-degree relative with the disease), so it might not apply to the general population. But now we can add in the recent findings from Norway that introducing gluten beyond 6 months of age may increase risk. So, different studies have come to different conclusions on this question, but let me simplify: Don’t introduce gluten before 4 months of age (and there are lots of good reasons for this beyond the celiac issue). Waiting too long beyond 6-7 months may increase celiac risk, but more importantly, delaying your baby’s first taste of gluten doesn’t seem to be protective.

Amount of Gluten Fed: The Swedish research indicated that gradual introduction of gluten might be protective against celiac. However, this effect was only observed in kids diagnosed before age 2, so some researchers wonder if large amounts of gluten simply accelerate appearance of symptoms. This question really requires more and better research; retrospective case control studies do a poor job of capturing a detail like the amount of gluten fed. The latest Norwegian study did not attempt to measure gluten amounts so did not help clarify this question. For now, it seems prudent to introduce gluten slowly, as part of a varied diet.

Role of Breastfeeding: Multiple studies (mostly retrospective, case control studies, summarized here) have found that breastfeeding at the time of gluten introduction is associated with lower incidence of celiac. However, several other studies have either found no protection from breastfeeding or even a trend towards greater risk of celiac with more breastfeeding. And the prospective study by Norris, which focused on kids at high risk for celiac, did not find a protective effect of breastfeeding. In fact, the celiac positive kids were breastfed on average for 1.4 additional months compared to those negative for the disease. The latest study from Norway found no protective effect of breastfeeding at the time of gluten introduction, as well as a slightly greater risk of celiac in children breastfed beyond 12 months.

So when it comes to celiac, is breastfeeding helpful or is it harmful? Given the conflicting findings on this question, I suggest some caution in jumping to one or the other conclusion. I don’t find the evidence that breastfeeding is protective all that compelling, but I also have my doubts about this latest finding that it is harmful. For example, I can imagine that babies that are at risk for celiac might exhibit more early feeding issues, such as food sensitivities. Moms of these babies might be more likely to breastfeed longer to try to compensate for a slow start at solids, or they might consciously choose to keep breastfeeding because they’ve heard that it could protect their babies from celiac. All of these factors that go into our decision to breastfeed for 4 or 6 or 12 months are hard to measure and hard to control for in an observational study.

If you’re confused by now, so am I. What we do know is this: Breastfeeding, early influence of nutrition, and celiac disease are all hot research topics at the moment. As new data emerge, hypotheses rapidly evolve – sometimes before we really know what we’re talking about. What we really need are randomized controlled trials. At least two of those are in progress right now (mentioned here and here), so I hope we’ll have more useful data on this topic soon.

In the meantime, I think the best advice is to begin introducing gluten slowly around 6 months, using developmental readiness for solids as your guide. A further preventative measure is to follow the CDC immunization schedule and have your child vaccinated for rotavirus, as childhood rotavirus infections are associated with a greater risk of celiac disease.

UPDATE: The research on gluten introduction and celiac disease continues to evolve. Be sure to read a more recent post from October 2014 about two randomized controlled trials that clarified several of the issues discussed in the post above: New Research on Gluten Introduction to Infants and Risk of Celiac Disease

28 Comments
  1. Reblogged this on Gabbie cbg.

    Like

    October 8, 2013
  2. I need to re read this thoroughly but I am interested, if longer breast feeding correlated with late introduction to gluten.

    Like

    October 9, 2013
    • Hi Dawn ~
      The recent study from Norway didn’t report this result – it’s a great question. Norris et al. (the Denver study) DID – they found that breastfeeding duration was correlated with age at first exposure to rice cereal and oat cereal (longer breastfeeding –> later introduction) but not with cereals with gluten (wheat, barley, rye). Also, all of these studies include breastfeeding as a covariate in their statistical models. So even though the Norway study didn’t report this information, their analysis should have accounted for it.

      Like

      October 9, 2013
  3. There is still a lot of controversy with gluten free diets. It may not be so good to not have it in our diets, much like cholesterol. More studies must be done and it should not become the new fad.

    Like

    October 9, 2013
    • stanmrak #

      uh… eating cholesterol (and saturated fat) is NOT harmful. Your body needs cholesterol and eliminating it doesn’t have any effect on your blood levels. Bad science.

      Like

      October 28, 2013
      • I think you misread this comment – the commenter is saying that the fad of eliminating cholesterol from diets turned out to be misguided. I agree, and I think you do too.

        Like

        November 8, 2013
  4. Shannon #

    This is an interesting read. I’m looking forward to more studies on gluten in general, just because there’s so much hype and I’m left guessing. My father has ulcerative colitis and when he eats gluten, he has celiac-like symptoms (he’s never been diagnosed despite my cajoling him) and even trace amounts leave him ill for days. I’ve found that I seem to have a sensitivity (I say ‘seem’ because when I asked my doctors about any type of testing they said there wasn’t any and if I felt better, then that was good enough). Not knowing for sure drives me crazy as I prefer to defer to science on these things and gluten-free is all the rage these days so people sometimes think I’m into all kinds of alternative stuff when, no, I was having symptoms I was trying to alleviate and the doctor kept prescribing more and more meds.

    :-/ Because of this, I’m trying to make sure I pay attention to my children (my oldest has no problems, my youngest is only 2 months, so we have some time). This was a helpful bit of information! Thanks.

    Like

    October 9, 2013
    • Hi Shannon, are you aware of the Body Ecology Diet? With your and your dadś sensitivities you mention, I would certainly try to incorporate lots of probiotic rich foods in your family’s table. I have a child with gluten and dairy sensitivities….

      Like

      May 23, 2014
  5. maggie #

    Is all gluten the same? Could a compounding factor here be that gluten introduced by parents as solid food is different than that processed into a formula thickner? We know from immunology that shape is as important as substance for triggering an immune response – so if the gluten is bonded into its natural form, maybe it is masking an attachment point that the immune system uses as a marker.
    Alternatively, could there be something associated with the maternal immune system as transmitted to the infant? Could it be triggered by the maternal immune system response to teh gluten in the formula? Before six months, the infant should still be getting anitbiodes in breastmilk, and that could be playing a role.

    Like

    October 9, 2013
  6. did any of the studies include if the mom ate gluten while breastfeeding?

    just curious 🙂

    Sent from my iPod

    Like

    October 9, 2013
    • No, of all the studies and reviews I read on this topic, the question of gluten consumption during breastfeeding was never mentioned, which is sort of surprising. It would be interesting to look at, since many of the babies at risk for celiac (as in the Norris study) would have moms with celiac who might be avoiding gluten.

      I did a quick search this morning to see if I can find more info, and I found this little blurb from the University of Chicago Celiac Center:

      Home / FAQs / Is gluten found in breast milk?
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      “There is little to no human research about the effect of gliadin, which is the portion of gluten that passes through breast milk. However, in animal studies it has been shown to have a protective effect, or help the child build up a tolerance to gluten.

      We don’t know for certain, but the best evidence we have indicates that a child who is at risk for celiac disease being breastfed by a mother who eats a normal diet would not be harmed by this, and in fact, might be helped.”

      http://www.cureceliacdisease.org/archives/faq/is-gluten-found-in-breast-milk-2

      Like

      October 9, 2013
      • thanks for the info – i was signed in to the wrong account so only saw this once my husband was working on his wordpress.

        Like

        January 5, 2014
  7. Jasmin J #

    Having read all the research I could get my hands on while my son was still “cooking” (his father and grandfather have celiacs) I had decided to introduce gluten between the ages of 4 and 6 months, while I was still breastfeeding, in small amounts, while continuing to eat wheat myself, since gluten has been detected in breast milk. I query the findings of this study on breastfeeding beyond 12 months increasing risk, and of no protective effect of breastfeeding at time of introduction – these results are marred by the fact that children who are still BF at 12 months are more likely to have been exclusively breastfed at 6 months, so are more likely to have had solids (and gluten) introduced after 6 months, thus increasing the risk due to delayed introduction of gluten. Does that make sense? Its such a fascinating and complex area of nutritional science, with so many developments in recent years, especially around the contribution of microbiota, I’m keenly awaiting more studies! 🙂

    Like

    October 9, 2013
    • I think I understand. You’re wondering if babies that were breastfed >12 months were more likely to have “late” gluten introduction (>6 months)? They don’t provide this information in the paper. I agree that it’s a good factor to investigate – add that to the list of subtle things that this paper didn’t look at! I don’t think we can assume that there is a pattern there one way or another – we’d need the authors to go back to the data to answer that.

      The data on effect of breastfeeding during gluten introduction were actually incomplete in this study, and the authors recognize that and don’t really emphasize these findings. They only assessed feeding at 6 months, so all they knew was whether gluten was introduced before or after 6 months. Breastfeeding data were collected every 3 months until 18 months. They looked at whether breastfeeding at gluten introduction was associated with celiac only in babies introduced to it BY 6 months. After that, their data didn’t allow them to ask this question in children introduced to gluten after 6 months. Not a strong study in that area.

      Hope that makes sense. I know it is confusing!

      Like

      October 10, 2013
  8. g2-3c47729e08e1c5022cd20af43d90137f #

    My celiac son could not tolerate even the tiniest bit of gluten that I ate and came through my breastmilk. He was exclusively breastfed. If I ate any, he would have diarrhea and vomiting. I knew nothing about celiac at the time. I was a huge gluten eater because i had been vegetarian for 18 years and all my meat substitutes were gluten. He had chronic diarrhea and vomiting until his pediatrician had me do an elimination diet. First dairy, no change. Then soy, no change. Then gluten, and everything stopped. I had a healthy happy baby with normal baby poops. When ever I cheated or tested to see if he had grown out of his sensitivity, he would get explosive diarrhea and vomit. So yeah, it matters if mom was eating it during the pregnancy and during breastfeeding and until the research takes that into account it’s all a bunch of BS.

    Like

    October 10, 2013
    • I’m so glad that you were able to figure out what was going on with your son! And I agree that gluten consumption during pregnancy and lactation are absolutely important factors to investigate. (I didn’t say that it didn’t matter – just that we know very little about it.) In your son’s case, he was obviously reacting to wheat proteins coming through your breast milk from the first days of his life, and so then you’re looking for whatever you can do to treat this so that he can be healthy. But that doesn’t tell us what to do with kids who are maybe at high risk for celiac (first degree relative with celiac or have been identified as genetically-susceptible, which gives them about a 10% chance at developing it). Should their moms eat gluten during pregnancy and breastfeeding? We don’t know. Animal studies suggest that gradual exposure to gliadin through breast milk (assuming everyone tolerates it) might help build tolerance, but that definitely needs to be studied in humans.

      Like

      October 10, 2013
  9. b #

    Did the study mention anything about how the celiac disease was diagnosed? I’ve heard varying things about blood test results in very small children and the age at which the test is or isn’t valid. Is a celiac blood test accurate on a 6 month old?

    Like

    October 10, 2013
  10. Forget all the studies… get off wheat and gluten for 30 days and you’ll see the difference.

    Like

    October 28, 2013
    • I think most of my readers are actually really interested in the studies – that’s why they’re here and why I focus on what the science tells us.

      Like

      November 8, 2013
  11. Amy #

    I’d love to see more posts like these on the conflicting allergy studies. It is so hard to know what is the right thing to do.

    Like

    January 14, 2014
  12. Cassandra #

    I have celiac so i was very careful when introducing gluten to my children. My first child i introduced at 9 months and he did fine but i had him tested at 12months anyway and it came back negative as expected. My second I tried to introduce around 8 or 9months also but she got sick every time I tried so I never got her tested (she would have to eat gluten regularly for 3 months before) and I don’t feed her gluten.
    I wonder if my not eating gluten when I was pregnant and nursing had any effect.

    Like

    July 31, 2014
  13. Tamara #

    This article is questionable as it has no links or actual references to the studies it talks about, like someone above has mentioned also there is no information on how the diagnosis were made, and lastly it does not take into account that celiac disease is NOT an allergy, it is an auto immune disease where the body attacks its own cells confusing them with gluten proteins, it is not about tolerance, I would not be trusting this information, do lots of research on your own from legitimate scientific sources before making a decision. As a pregnant woman with celiac disease I certainly intend too.

    Like

    August 19, 2014
  14. Jennifer #

    I have been told to give my baby gluten between 4 and 6 months. He is 5 months and I am just starting him on food, witch he loves. His older sister has Celiac disease, and she had always had symptoms but her DR did not offer any testing till she was three and I told them I could not take her crookneck scramming any more we. Over 36 months of blood curtailing scramming. So I am very hesitant with the baby. I know I need to but there is no good information on how to do this. We tried to give him food at 4 months but he would gust gag so we stopped. So it comes down to how much and in what form do you give gluten to him in?

    Like

    September 4, 2014
    • g2-3c47729e08e1c5022cd20af43d90137f #

      Exclusively breast feed until 6 months. The majority of experts have concluded that is best. Just ignore the dr who says start at 4 months. Next, you don’t have to give your baby gluten at all, in fact, your baby will not get celiac if they don’t eat gluten. One of your children has celiac, so the house should be gf anyways. Who needs a baby throwing gluten around the house? Read Leading celiac expert doctor Alessio Fasano’s new book, “gluten freedom.” He explains that the research is quite contradictory about when to start gluten, if at all. He says the only clear research is that starting too early really increases the risk. He says after a year, if you are going to at all, but that it’s not necessary to feed a person gluten.

      Like

      September 5, 2014

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