New MGH research finds that neither breastfeeding nor delayed introduction of gluten-containing foods provide significant protection against celiac disease.

Is it possible for parents with celiac disease to prevent or delay the development of the autoimmune disorder in their children? Massachusetts General Hospital researchers Carlo Catassi, MD, MPH, and Alessio Fasano, MD, recently published results of a 10-year study that shed some light on the complex subject. Their report in the Oct. 2, 2014 issue of The New England Journal of Medicine finds that loss of tolerance to gluten, a protein found in wheat, rye and barley, is a dynamic process. Research conducted with more than 700 children shows that neither breastfeeding nor delaying the introduction of gluten-containing foods provides significant protection against the condition.

“One of our most important findings was that the timing of gluten introduction—whether early or late in the first year of life—made no difference to the subsequent development of celiac disease,” says Dr. Catassi, co-director of the Center for Celiac Research and Treatment and principal investigator of the study. “While earlier studies led to the hypothesis that gluten could be safely introduced to at-risk children between 4 and 7 months of age, our results show that we can tell mothers not to worry so much about when they introduce gluten into their children’s diet.”

Dr. Fasano, director of the Center for Celiac Research and Treatment and a co-author of the NEJM report adds: “Of the several factors we studied, it’s very clear that genetic background is by far the most important in determining which infants will develop this autoimmune condition. We were particularly surprised that breastfeeding at any age provided no protective effect.”

A Series of Key Discoveries

The findings are the latest in a series of key discoveries involving Dr. Fasano, an international leader in the field, who moved the Center for Celiac Research and Treatment to Mass General in 2013. “Having Dr. Fasano and his team of researchers and clinicians brings another dimension to the care of our patients with celiac disease at Mass General,” says Ronald Kleinman, MD, physician-in-chief at MassGeneral Hospital for Children. “We are very fortunate to have him here as a leading member of our faculty.”

“Having Dr. Fasano and his team of researchers and clinicians brings another dimension to the care of our patients with celiac disease at Mass General.”

For the recent study, between 2003 and 2008, researchers with the Italian Baby Study on Weaning and CD Risk enrolled more than 700 infants with a parent or sibling with celiac disease. Participants at 20 centers in Italy were randomly assigned to two groups. The first group was introduced to gluten-containing foods at six months of age and the second received gluten-containing food at 12 months.

Along with the amount of gluten ingested, intestinal infections, breastfeeding and other factors thought to have an effect on celiac risk were gathered. Researchers followed children for at least five years, periodically testing them for the presence of immune system factors (antibodies) that showed gluten-associated autoimmune reactions. If signs of autoimmunity were detected, intestinal biopsies were conducted to determine whether or not celiac disease had developed.

Screening for Celiac Disease

While a greater percentage of infants who had been introduced to gluten at six months had evidence of possible celiac disease at the two-year follow up, there was little difference between the two groups at five years of age. Overall, 64 children in the early-introduction group developed celiac disease, while 53 in the late-introduction group did so, a difference not considered to be statistically significant. The only factor that the study found to increase risk was whether infants had inherited the genetic profile associated with celiac disease from both parents.

Dr. Catassi notes that a simple blood test showing certain genetic markers could quickly determine which infants are at high risk of celiac disease. Delaying the development of celiac disease by later introduction to gluten also could prove to be beneficial by reducing the impact of the condition on developing organs, such as the brain, according to Dr. Catassi. The fact that 80 percent of the children who did develop celiac disease did so within the first three years of life, he adds, points to the importance of screening children when they reach school age.

“The results will “pave the way for breakthrough studies that will capitalize on these findings and lead to preventive interventions,” says Dr. Fasano. One of the most recent developments in the treatment and study of autoimmunity is the role of the gut microbiome, the microbial colonies of the gastrointestinal system. The Center for Celiac Research and Treatment is embarking on a large study enrolling approximately 500 infants to determine how a wide variety of factors, including the microbiome, contribute to the development of celiac disease.

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