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Answers from a Dietitian


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Hi Lisa. We currently understand that environment and lifestyle, in addition to genetics, play a role in the development of celiac disease. Studies have shown that quickly introducing large amounts of gluten while not being breastfed appears to increase the risk of developing celiac disease in infants1. Gradually introducing gluten while the infant is still breastfeeding appears to lower the risk, with even more protection against the disease occurring with a longer duration of breastfeeding1,2,3.

ESPGHAN (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) recommends exclusively breastfeeding for around six months and encourages breastfeeding while introducing new foods into the infant’s diet4. In particular, this society recommends introducing gluten when the infant is between four and six months old and, ideally, while the infant is breastfeeding4.
More research is needed to understand whether breastfeeding and the current recommendation for how to introduce gluten truly offer protection and reduce the risk or simply change the symptoms which then appear later in life5,6. More studies also need to address the question of the age interval. Is it from four to six months as some findings suggest7, or by delaying gluten introduction to up to one year of age as is currently being explored in another study8? Finally, environmental factors, such as infections in early life, socioeconomic conditions, the season in which one is born, gender5, and a person’s own genetic makeup need to be examined to determine how, in relation to one another, they may play a role in the development of celiac disease.
In summary, the current recommendations are to introduce wheat (as gluten-containing cereal) to an infant in small amounts beginning between four and six months old and continue to breastfeed while doing so. Although there are no exact guidelines and no prospective studies on the amount to introduce, a suggested amount is to start with 1 teaspoon of gluten-containing cereal and work up gradually to approximately 1 serving (2-3 teaspoons) once or twice a day9. Please note that much work needs to be done in this area, and the recommendations are based on our understanding at this point. For more specific discussion and individualized recommendations, talk to your pediatric doctor or gastroenterologist.
Melinda Dennis, MS, RD, LDN
  1. Ivarsson A, Persson LA, Nystrom L, et al. Epidemic of coeliac disease in Swedish children. Acta Paediatr 2000;89:165-71.
  2. Ivarsson A, Hernell O, Stenlund H, et al. Breast-feeding protects against celiac disease. Am J Clin Nutr 2002;75:914-21.
  3. Alobeng AK, Ramanan AV, Buchan I, et al. Effects of breast feeding on risk of celiac disease; a systematic review and meta-analysis of observational studies. Arch Dis child 2006;91:39-43.
  4. ESPGHAN (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) Committee on Nutrition. Complementary feeding: A commentary by the ESPGHAN Committee on Nutrition, J Pediatr Gastroenterol Nutr 2008;46:99-110.
  5. Ivarsson A, Myleus A, Wall S. Towards preventing celiac disease: an epidemiological approach. In Fasano A, Troncone R, Branski D, Eds. Frontiers in Celiac Disease. Pediatr Adolesc Med Basel:Karger 2008, p. 198-209.
  6. Troncone R, Ivarsson A, Szajewska H, et al, Future research on coeliac disease; a position report from the European multistakeholder platform on coeliac disease (CDEUSSA). Aliment Pharmacol Ther 2008;27:1030-43.
  7. Norris JM, Barriga K, Hoffenberg EJ, et al. Risk of celiac disease autoimmunity and timing of gluten introduction in the diet of infants at increased risk of disease. JAMA 2005;293:2343-51.
  8. Fasano A. Surprises from celiac disease. Sci Am 2009;301(Aug):54-61.
  9. Conversation with Dr. Alan Leichtner, Associate Chief, Division of Gastroenterology and Nutrition and Director of the Center for Celiac Disease, Children’s Hospital, Boston, MA. August 11, 2010.



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