InfantRisk Center

Early Feeding and Risk of Celiac Disease in a Prospective Birth Cohort

**This is the first guest post on my page by Cristen Pantano, an incredibly talented scientist and mother of two children. Her youngest child was diagnosed with Celiac disease earlier this year. Many thanks to Cristen for tackling this challenging topic! 

Celiac is known to have a large genetic component and people with Celiac disease carry the HLA-DQ2 or HLA-DQ8 genes. However, only around 4% of people that carry these genes develop Celiac. The big question then is, what else is contributing to the development of Celiac?

Scientists are currently looking at other candidate genes, and so far, seven additional genes that make individuals more susceptible to developing Celiac have been identified. Genes are a great place to start, but as we all know, gluten is the big culprit in Celiac. It is the known environmental “trigger” for Celiac. Why is it that some people that carry the “Celiac genes” develop the disease after gluten exposure while others don’t?

Scientists and doctors are asking this question a lot these day. One area that is being investigated is infant feeding. Studies looking back on the Swedish Celiac epidemic of the 1980-1990s have shown that more than half of the epidemic could be explained by infant feeding practices (see link). During the time of the epidemic, Swedish infants were being introduced to gluten, on average, at around five months of age. Breastfeeding ended around this time and was replaced with formula thickened with wheat flour. When breastfeeding averages extended toward seven months and the popularity of wheat-laden formulas decreased, so did the rates of Celiac.

The Swedish epidemic got researchers thinking about infant feeding and many studies have since been published showing an effect of the age of gluten introduction, the amount of gluten introduced, and breast feeding on Celiac development.

A new study looking at the effect of these factors on the development of Celiac was recently published in the journal Pediatrics. This study, out of Norway, looked at the early feeding practices in 324 children that developed Celiac disease compared to a cohort with 81,843 children that did not develop the disease. The strength of the study is that it was prospective. Unlike most population studies where parents have to look back in time and remember details of early milestones, in a prospective study, parents fill out surveys to provide information in real time.

So what did this most recent study find? The authors found that 3.68/1000 children developed Celiac when introduced to gluten at six months compared to 4.24/1000 when introduced at four months and 4.15/1000 after six months. The increased risk for Celiac disease when gluten is introduced before four months, or after six, has been previously observed.

In this new study, the average length of breastfeeding in children that developed Celiac was 10.4 months compared to 9.9 months in the control population. The researchers found a positive association of prolonged (greater than 12 months) breastfeeding and  the development of Celiac disease. When all their breastfeeding data was adjusted for confounding factors such as maternal Celiac disease, this increased risk was borderline significant. That means that statistically speaking, the data set is on the weaker side and needs to be interpreted with caution. However, it does still demonstrate that in this data set, children that were nursed for twelve months or more had a greater risk for developing Celiac.

These findings have been met with frustration by many mothers of children with Celiac. Are women responsible for the development of their child’s Celiac disease because they chose to hold off solid foods and nurse up to, or past, one year? Of course they aren’t, and the authors of this study are not saying that they are. In their discussion, the authors caution that while their data on age of gluten introduction closely matches data from earlier studies, their data on breastfeeding does not.

Many, if not all, previous studies looking at breastfeeding and Celiac disease have found a protective effect from nursing. A 2006 review of the literature found that breastfeeding at the time of gluten introduction provided a 52% reduction in the development of Celiac disease. In 2005, two Swedish studies found a significant reduction in the onset of Celiac in babies that were nursed at the time of gluten introduction and continued to be nursed after that first introduction.

This latest study found that breastfeeding did not protect against Celiac and that nursing past twelve months increased the risk. Sounds strange right? In their discussion, the authors hypothesize that the greater risk in those breastfed past 12 months may have more to do with gluten than with breast milk. When a child is breastfed longer, the introduction of gluten may be later, after six months of age. Furthermore, since the child is older at gluten introduction, he may be exposed to larger amounts. The authors also mention that some mothers may have nursed longer due to perceived food sensitivities.

In the end, what is the take away from this study, and others, looking at infant feeding and the development of Celiac? It seems that there may be a window for gluten introduction between 5-6 months. Introduction before and after this time seem to increase the risk of Celiac. As far as breastfeeding, most studies point toward a large protective effect.

The development of Celiac Disease seems to be a perfect storm of genetic and environmental factors. Factors that may be out of any one person’s control. Studies should continue to look at early infant feeding and disease development, but all data should also be interpreted knowing that as hard as we try, some times, some things just can’t be prevented.

10 thoughts on “Early Feeding and Risk of Celiac Disease in a Prospective Birth Cohort

  1. Deb

    I think the relationship between breastfeeding longer and celiac is interesting, but as the mom of two kids who breastfed for 2 and 3 years respectively, I have to wonder if the relationship is the reverse – that celiac (or developing celiac or other autoimmune issues) is a risk factor for longer breastfeeding. My kids were both very food averse, and given what I know about their food sensitivities and autoimmune issues now, I suspect that encouraged longer breastfeeding.

    It sounds like the original researchers were careful to consider the ways their data could be interpreted, and not assume breastfeeding longer was the culprit – but I don’t always trust media reports to do the same. I hope moms don’t end up getting a negative message about longer breastfeeding!

    1. Jess Post author

      Hi Deb,
      I think that you bring up a great point about the longer duration of breastfeeding being confounded by the possibility of food aversions. Cristen, the author, expressed similar sentiments on my FB page and experienced this with her own daughter who has Celiac Disease. I hope that she pipes in as well!
      There’s been more and more research showing that an overabundance of bad gut bacteria can play a role in the development of Celiac Disease, and there is definitely no better probiotic for babies than their mom’s breastmilk!
      Thanks so much for taking the time to share your thoughts on this topic!
      Jess

    2. Cris

      Deb,

      I agree with you 100%

      I nursed both children well past a year, but our daughter was very adverse to solids and nursed a lot for comfort. She nursed until almost three years old. At her four year well visit, she was tested for Celiac, and a month later, it was confirmed.

      Looking back at pictures, I can see my vibrant baby turn into a pale, tired toddler, with a protruding belly. I definitely think that she nursed longer because she felt sick. She was looking for comfort and hardly ate solids for a very long time.

      Thank you for reading and commenting!

      Cristen Pantano

      1. Deb

        My daughter didn’t get any classic celiac symptoms. She just fell off the growth charts. Totally normal while we were still primarily nursing, and then she tumbled into tininess. Looking back now, I can totally imagine that food didn’t sit very well on her belly, and one of the reasons I kept nursing was how little she ate.

        Really interesting stuff!

  2. jodi stewart

    Hey Jess, this is a very interesting article. So glad Cristen shared it. I’ve always heard that breastfeeding past a year helps protect children from food issues like allergies and celiac disease, but it hasn’t been that way in our house. My older two were nursed longer than a year and my 2nd has obvious problems with gluten. My younger two both weaned themselves at around 8-9 months and so far they seem okay with gluten. (though #3 couldn’t eat rice cereal as a baby.)
    If you have a minute, would you share a link to this post on Freedible? It would be great information for the “Celiac Disease” section in Blogs.

    1. Jess Post author

      Hi Jodi,
      Yes, I will absolutely put it up on Freedible. I was acutually just about to post it there the other day (and catch up on the other recent Freedible posts) and we had some sort of minor accident or catastrophe that interrupted me (so minor that I can’t even remember it now, it’s been one of those weeks!)
      A few random thoughts on all of this. As far as I know, the recommendations a few decades ago to delay the introduction of solids to prevent food allergies and intolerances were made on pretty weak research. I will be reading up more on this area soon so that I can write about it. If you have any insight or are versed in all of this (or know someone who is, please share!)
      Secondly, in my work as a Neonatologist, we have seen an explosion in the number of babies who are born with milk protein allergies over the last 5 years. It seems that they are being sensitized to casein in utero, as many of them get sick in the first few days of life. It affects about 3-5% of newborns and I am starting to wonder if the mothers of these infants have some sort of leaky gut process from either Celiac or gluten sensitivity that is leading to a poor breakdown of casein that is then crossing the placenta into the fetus. And I also wonder if both gluten and casein are crossing the placenta in these cases.
      Last of all, I recently came across an interesting internet thread in which there were several moms whose babies did not receive gluten during their 1st year of life, and their first exposures to gluten were when eating their 1st birthday cakes (made with wheat flour). Perhaps in a predisposed infant, who perhaps was sensitized to gluten in utero, a piece of gluten-filled cake as a first exposure is enough to throw him or her over the edge into Celiac?
      Now I feel like I am totally rambling, so I will stop, but I would love to hear if any other readers have any ideas/input/information to share!
      Jess

  3. Pingback: Risk Factors for Celiac Disease | The Patient Celiac

  4. Lucente

    Hi,
    What to make of this study?
    http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0033387

    It was on Dr. Fasano’s impressions that we decided to delay introducing gluten to our younger, genetically predisposed, son until one year of age. We never got to see if that was wise, because his caregiver started him on wheat bread at 6 months, against our will. He started throwing up, got diarrhea and skin rashes. That was all the evidence we needed to keep him off gluten indefinitely.

    1. Jess Post author

      Hi Lucente,
      Thanks so much for sharing this study. I’ve been doing a lot of writing about the microbiome and celiac disease as a side project but I had not come across this study.
      I think Itis a beautifully designed study, but I believe the sample size is too small to really draw any meaningful conclusions from. If it was to be repeated on a larger scale, with similar findings, I think the the results of the timing of introduction of gluten would be much more powerful. This other limitation to this study, as well as many others in the area, is that the outcome is Celiac Disease at age 2. What happens at age 4 or 6 or 10? There is a great need for long term follow up. Do the “early” babies get sick earlier (and diagnosed earlier) and the the “late” babies have a milder presentation that gets missed for years and years? This would be important to know.
      I am sorry that your son was started in gluten against your will, but it sounds fortunate that he was diagnosed so early on. Out of curiosity, have you opted to out him on a probiotic?
      Jess

      1. Lucente

        Hi Jess, thanks for your feedback. No, he was never put on a probiotic; after we removed him from the caregiver’s house, all symptoms stopped, and he has never been sick after that, not even a cold (so he hasn’t been on an antibiotic up until now, but if he were to need it, I’d give him a probiotic). My oldest son, a diagnosed celiac at 22 months, classic presentation, negative serology with IgA deficiency, and Marsh 3, had several bouts of illness until his diagnosis. Apart from the occasional low grade fever in the few times when he was accidentally glutened, he hasn’t been sick since. I know my “study group” is small, but my feeling is that gluten is a major player in children’s health, even in those that aren’t celiac, but then again, just my feeling.

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