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PREVENTCD's Celiac Prevention Strategy for New Mothers

Celiac.com 11/07/2012 - When it comes to whether or not mothers with celiac disease should breastfeed their children, there has been a fair amount of conflicting information in circulation. Some studies have found that breastfeeding renders a protective role when combined with a 'windowed' introduction of gluten, but others have shown no such protective effect. Furthermore, some researchers question the longevity of the protection offered. An international project called PREVENTCD seeks to boil down current information from a number of studies, in order to produce a primary prevention strategy for infants at risk of developing celiac disease.

Photo: CC--Rich MoffittThe PREVENTCD project aims to answer the following questions:

  1. Breastfeeding (BF) and CD (Does any BF reduce the risk of developing CD in early childhood? Is there a difference between any or exclusive BF in regard to risk reduction? Is the duration of BF related to the risk of developing CD?).
  2. BF at the time of gluten introduction and CD (Is gluten consumption while being breastfed important for risk reduction?).
  3. Timing of gluten introduction (Is age of gluten introduction important to the risk of developing CD?).
  4. Amount of gluten at weaning (and later) and CD (Is the amount of gluten ingested an independent risk factor for the development of CD in early childhood? Is there a threshold level of gluten consumption for developing CD in early childhood?).
  5. Does the administration of microbial supplements (probiotics) and/or substrates (prebiotics) has an effect on the risk of CD?

For this report, a collection of studies (preference given to randomized controlled trials) involving infants at risk of developing celiac disease and breastfeeding practices were examined independently by a number of researchers. Inclusion criteria were applied independently and quality of each study's data was examined using the Cochrane Collaboration's tool for assessing bias risk. Meta-analysis was planned, but outcomes and definitions were inconsistent.

29 studies were initially identified. Of those, 12 studies were included in the analysis. Collating the data from each, the questions were answered as follows:

Effect of Breastfeeding on Celiac Disease: Some studies show a protective effect of breastfeeding children at risk of developing celiac disease, but some show no effect and no studies show a long-term preventative effect. Thus, the main controversy surrounding breastfeeding celiac children is whether it has a significant long-term effect. This should not be interpreted as evidence that suggests breastfeeding does not render long-term protection, but rather that no studies have adequately addressed the question yet (partially due to methodological challenges). Studies showing protective effect have postulated that the protection offered by breastfeeding is the result of introducing cytokines, as well as IgA antibodies, lactoferrin and other enzymes (as well as small amounts of gluten) that contribute to passive immunity by reducing the number of infections in the gut. Data from the studies also suggests that longer breastfeeding periods have a more pronounced effect on celiac disease risk. However, there was no evidence to suggest that 'pure' breastfed children were at any less risk than those both breastfed and formula fed.

Effect of Breastfeeding at Time of Gluten Introduction on Celiac Disease: Data from five case-control studies suggests that breastfeeding at the time of gluten introduction is associated with lower risk of celiac disease compared to formula feeding. The quality of the data is questionable, as most feeding patterns were gathered retrospectively. Again, it is also unclear whether the protective effect merely 'postpones' celiac disease. One study also showed no effect of breastfeeding at the time of gluten introduction on celiac disease autoimmunity (effect on biopsy-proven celiac disease is unknown).

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Timing of Gluten Introduction: While the role of age at time of gluten introduction in determining celiac disease risk is unclear, data from observational studies suggests that early and late introduction of celiac disease may increase risk of celiac disease. Early is defined as before 3 months, while late is defined as later than 7 months. One randomized controlled trial showed that gluten introduction after 12 months might be beneficial, but sample size and unclear risk of bias make this finding inconclusive.

Effect of Amount of Gluten at Weaning (and Later) on Celiac Disease: One study documented that introducing gluten in large amounts versus small or medium amounts increased celiac disease risk. This echoes old data collected during Sweden's 1980s celiac disease epidemic, but it is unclear whether this is a dose-response effect or a threshold effect. However, a recent study proposes a quantitative model for a HLA-DQ2 gene dose effect in the development of celiac disease.

Administratioin of Probiotics and/or Prebiotics: There have been no studies examining the effect of probiotics and prebiotics on celiac disease risk in infants, but it is reasonable to assume that manipulating gut microbiotia in early stages of life could affect celiac disease risk. Future studies should investigate this possibility.

In conclusion, there are still a lot of holes in the data, but what we know thus far tells us that:

  1. Breastfeeding seems to offer some form of protective effect (whether long or short term) on celiac disease risk in infants. Longer breastfeeding periods seem to offer more protection, but some formula feeding doesn't appear to affect celiac disease risk.
  2. Gluten should be introduced in small quantities between 4 and 7 months.
  3. Gluten should only be introduced while/if the infant is breastfeeding.

The committee on Nutrition of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) believes that this strategy map will not only decrease rates of celiac disease, but type 1 diabetes, mellitus and wheat allergy as well.

Most of these recommendations have been in place for a while and there is a lot of room for more data, but in the meantime, this is probably the safest strategy for feeding infants who are at risk of developing celiac disease.

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3 Responses:

 
Nicole
Rating: ratingfullratingfullratingfullratingfullratingempty Unrated
said this on
12 Nov 2012 5:25:13 AM PDT
Quite interesting. In my own experience, breastfeeding did not prevent celiac disease in my sons. However, I do believe it helped them from being sicker. Despite very positive blood work and biopsy (my sons were 4 and 2 at diagnosis), both had minimal symptoms. In addition to breastfeeding until 20 and nearly 24 months respectively, I also gave my sons probiotics and vitamins. While I will never know, I do feel this kept them healthier despite the damage. How long that would have remained true is questionable.

I have had two more children since my sons' diagnosis and we have treated food differently. Both girls were breastfed. The oldest is three, started gluten at one year, and so far has shown no problems. The other is 10 months, still breastfeeding, and barely eats any table food. She seems to have issues with food in general. No gluten has been introduced yet with all the trouble she has with simple, supposedly low allergenic foods.

 
Wendy
Rating: ratingfullratingfullratingfullratingemptyratingempty Unrated
said this on
12 Nov 2012 6:23:06 PM PDT
Why is the baby sucking the top of a bottle of Australan wine? I know this wine and the kangaroo is very obvious. What does this have to do with the story?

 
gryphon
( Author)
said this on
13 Nov 2012 3:40:43 PM PDT
You can only put so many stock images of babies being breastfed or cradled by their mothers before you are tempted to put something a little more... interesting. It's just a cute, silly picture.




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Have been dealing with splinter hemorrhages on three of my toe nails since February. I did go to my doctor who rightly so did a very complete blood work-up ruling out other diseases such as lupus and RA and referred me to several other doctors to make sure that it was not cancer, endocarditis, or something serious. I went to the doctors. I have done some research on vitamin deficiency and it seems that some link splinter hemorrhages to vitamin C deficiency. For the past 2 1/2 weeks I have been eating 3 clementines a day (in addition to the usual multivitamin that I take) and it seems to be helping the splinter hemorrhages. One has grown out and not returned. Visited my GI doctor today and talked about malabsorption of nutrients as a potential issue. We are doing more blood work and checking nutrient levels. I have to believe it has something to do with the celiac. Sorry I don't have a better answer, but like you am trying to figure this out. Please let me know if you find any answers, and yes, be sure to check with your doctor to rule out anything serious.

You only need one positive on the celiac panel. I tested positive only to the DGP IgA and had a Marsh Stage IIIB intestinal damage. Good luck!

Welcome to the forum. First, you need to get copies of your celiac test to confirm you actually had it done and what the results were. Second, to confirm a diagnosis, you must obtain biopsies via an endoscopy. Were the doctors gastroenterologists? Third you need to research celiac disease. Yes, you can be asymptomatic, but could still have instestinal damage as the small intestine is vast. here is a good place to start: http://www.cureceliacdisease.org/screening/ You might think you are a silent celiac, but ever been anemic? Had your bones checked?

That's good to know about Texas Children's, unfortunately I don't believe they accept our insurance. Our former pediatrician joined with one of their medical groups and we had to find a new one due to insurance. I'll check out their site though.

9 months ago I went to my doctor for normal blood work. She called me to tell me everything looked great, but o yeah, my gluten sensitivity levels were extremely high. I should probably stop eating gluten since it looks like I have celiac. She hung up and I never heard from her again. I cut out gluten completely, even though I have never experienced one single symptom of celiac. 9 months later, I decided to reach out to another doctor to get a second opinion, as I experienced absolutely zero change on 9 months of strict gluten free diet. All this doctor did was request the results from the previous doctor, tell me it is confirmed I have celiac, and hung up the phone. This angers me tremendously on two counts. One, I have absolutely zero symptoms of celiac, and would NEVER know if I was "glutened". Two, the complete lack of information or support from both doctors is horrifying to me. And finally, I simply do not believe the diagnosis and as considering just starting to eat a normal diet again. I would never know the difference. I am really just venting because this situation upsets me so much, and I have suffered mentally and socially from going gluten free. Since I have absolutely zero symptoms, even if I was actually celiac, I highly doubt anything would ever come of it if I continued to eat gluten. I could just pretend I never heard from either terrible doctor and go on living my life. Someone has to have been in the same situation as me, right?