As a coeliac parent, should you give your baby gluten?
What’s New? A research update from Kristina Richardson
When someone with coeliac disease (CD) becomes a parent, they may understandably feel some trepidation when it comes time to introduce gluten to their baby's diet. When should you give them gluten? Should you give them gluten at all? Is it better to wait until a certain age? How much gluten should you give? How often? Is there a particular protocol to follow to lower their risk of developing CD?
Whilst it is generally recommended to introduce allergenic foods, such as fish, egg, peanut, sesame, etc., within a certain window to decrease the risk of developing food allergies, it has yet to be demonstrated that any optimal window exists for the introduction of gluten and lowering the risk of CD.
Previously, it was recommended (based on observational studies) that gluten be introduced between 4 and 7 months of age, alongside breastfeeding. However, more recent, better-designed studies turned this recommendation on its head, showing neither really made a difference. However, researchers remained curious as to whether it wasn’t just the timing of gluten introduction that mattered, but perhaps sudden large doses or different patterns of consumption.
Now, a new publication* in the American Journal of Clinical Nutrition should help to alleviate some of the concerns that new parents may have about whether they are “doing the right thing”. This report gives us more evidence that there just doesn’t seem to be a particular “right thing” to do. This study followed 715 children living in 5 different countries in Europe: Spain, Germany, Netherlands, Hungary and Italy. All the children were considered high risk for developing CD because they carried “coeliac genes” (various combinations of HLA haplotypes DQ2 and/or DQ8) and had an immediate family member with CD.
The first part of the study (published previously**) was a randomised controlled trial. As babies, half the children were introduced to a small, controlled amount of gluten from 4 to 6 months of age (100mg per day, which is approximately equivalent to a small bite of toast). The other half had no gluten, only placebo. After this, the parents of all children were told to give incremental doses of gluten over the next four months, going from 250mg at 6 months, up to 1,500mg at 9 months. From age 10 months onwards, they were told not to restrict gluten at all. From this point, the amount of gluten they consumed was calculated using 7-day food records every few months up to 3 years of age (or, until they developed CD).
What they wanted to see, was if the change from controlled gluten intake to an unrestricted intake (whatever was normal for their family/nationality/culture) and the pattern of intake over the next couple of years, made the children more or less likely to develop CD.
Gluten intake increased for all the children when they went on an unrestricted diet, but it differed quite a bit between countries. For example, in Netherlands and Hungary, the children's gluten intake skyrocketed straight from 1,500mg to 5,200mg/day (which is equivalent to nearly 2½ slices of bread), whereas for Spanish children, it only increased to 2,550mg/day. If sudden, sharp increases in gluten intake were a risk factor for CD, then surely more of the Dutch and Hungarian children would develop CD, right? But they didn’t.
It didn’t matter which country the children were from, whether gluten was introduced at 4 or 6 months of age, or whether their gluten intake rose gently, sharply, steadily or flat-lined when unrestricted; the risk of developing CD remained the same.
The only thing that independently made a difference to the children’s CD risk was the combination of HLA haplotypes the children carried. Children with the highest risk carried the genotypes DQ2.5/DQ2.5 and DQ2.5/DQ2.2. However, there was an interesting finding related to the children with the DQ2.2/DQ7 genotype. For these children only, a gluten consumption pattern that increased sharply between the ages of 11 and 18 months seemed to increase CD risk. The authors speculate that perhaps, for some people not in the highest genetic risk category, it is possible that gluten intake in infancy may play a role. However, as there were only eleven DQ2.2/DQ7-positive children in this study, no firm conclusions can be drawn about this just yet.
Kristina Richardson, BHlthSc(Nutr&Diet)(Hons), worked with Coeliac Queensland for a number of years after being diagnosed with coeliac disease herself in 2008. Kristina studied at the Queensland University of Technology and is a qualified dietitian. After receiving an Australian Postgraduate Award, Kristina is now undertaking doctoral research in the field of coeliac disease, investigating health-related outcomes of diagnosis and treatment.
Kristina has presented numerous seminars and workshops for hospital staff, health professionals and the general public on coeliac disease, nutrition and healthy eating.