Introducing gluten into a baby’s diet is a common concern for many parents, especially when there is a family history of coeliac disease. Many studies have tried to identify if the amount and/or timing of gluten introduction can affect an infant’s risk of developing coeliac disease. The results of these recent studies have shown different, and at times conflicting, results; providing definitive recommendations about gluten introduction and coeliac disease risk is therefore difficult. Be mindful that most of the risk for coeliac disease development relates to the genes the child is born with. In addition to gluten, other environmental factors may be involved in the risk and/or prevention of coeliac disease. Identifying and influencing these factors may lead to preventive strategies in the future. More research on this is required.
When to introduce gluten?
Current evidence suggests that the introduction of gluten should not be delayed. This applies even to infants at higher risk of coeliac disease, such as when one or both parents have coeliac disease. Gluten should be introduced as per standard feeding practices followed in any other child (see below).
How much gluten to introduce?
Some studies in infants who are genetically susceptible to coeliac disease (for example, have a parent with coeliac disease) have made an association between the amount of gluten consumed and the subsequent development of coeliac disease. However, more studies are needed to confirm the role of gluten in this association and determine whether a certain level of gluten in the diet is associated with risk for coeliac disease. Currently, there is insufficient evidence to define a “safe” or “unsafe” level of gluten that infants can be fed. Furthermore, there is no evidence that avoiding gluten altogether is helpful; this approach is not recommended as it could unnecessarily restrict the intake of important nutrients necessary for growth and development in childhood.
Aim for a broad and nutritious diet in all infants, including those who are genetically susceptible to coeliac disease. It is reasonable to introduce gluten in small amounts at the usual time and increase slowly as tolerated. If symptoms suggestive of coeliac disease develop, such as diarrhoea, then testing for coeliac disease should be discussed with your child’s doctor.
Note: It is NOT helpful to avoid the introduction of gluten. This is not recommended.
Standard feeding practices
In Australia, it is recommended that infants be exclusively breastfed (meaning no other foods or liquids other than breast milk) until around 6 months of age, when solid foods are introduced. It is further recommended that breastfeeding be continued, if possible, until 12 months of age and beyond, for as long as the mother and child desire.
If an infant is not breastfed or is partially breastfed, commercial infant formulas should be used as an alternative to breast milk until 12 months of age.
At around the age of 6 months (but not before 4 months), infants are ready for new foods, textures and modes of feeding. They also need more nutrients than can be provided by breast milk or formula alone. By 12 months of age and beyond, a variety of nutritious foods from the five food groups, as described in the Australian Dietary Guidelines, is recommended.
There is no particular order suggested for the introduction of the first solid foods, or rate that new foods should be offered. Most importantly, first foods should be nutritious, iron-rich and of suitable texture for the child’s stage of development.
All infants should be given allergenic solid foods, including peanut butter, cooked egg, dairy and wheat products, sometime during their first year. Once introduced, continue to give these foods to your baby regularly (twice weekly), as part of a varied diet.
Breastfeeding provides important health benefits for both mother and child. Although breastfeeding does not seem to help prevent the development of coeliac disease, this in no way negates the importance or benefits of breastfeeding for both mother and child.
More information and references:
NHMRC Australian Dietary Guidelines – Infant Feeding Guidelines. www.eatforhealth.gov.au
Australasian Society of Clinical Immunology and Allergy (ASCIA); Infant feeding and allergy prevention Guidelines, 2016. www.allergy.org.au
Aronsson CA, Lee HS et al. Association of Gluten Intake During the First 5 Years of Life With Incidence of Celiac Disease Autoimmunity and Celiac Disease Among Children at Increased Risk. JAMA. 2019 Aug 13;322(6):514-523. doi: 10.1001/jama.2019.10329.
Mårild K, Dong F et al Gluten Intake and Risk of Celiac Disease: Long-Term Follow-up of an At-Risk Birth Cohort. Am J Gastroenterol 2019;00:1–8. https://doi.org/10.14309/ajg.0000000000000255
Aronsson CA, Lee HS, Koletzko S et al. Effects of Gluten Intake on Risk of Celiac Disease: A Case-Control Study on a Swedish Birth Cohort. Clinical Gastroenterology and Hepatology 2016;14:403–409
Silano M, Agostoni C, Sanz Y, et al Infant feeding and risk of developing celiac disease: a systematic
review BMJ Open 2016;6:e009163. doi: 10.1136/bmjopen-2015-009163 https://bmjopen.bmj.com/content/6/1/e009163
Meijer C, Shamir R, Szajewska H and Mearin L (2018) Celiac Disease Prevention. Front. Pediatr. 6:368. doi: 10.3389/fped.2018.00368 https://www.frontiersin.org/articles/10.3389/fped.2018.00368/full#B38