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Gluten Introduction and the Risk of Coeliac Disease: A Position Paper by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Szajewska, Hania; Shamir, Raanan; Mearin, Luisa; Ribes-Koninckx, Carmen; Catassi, Carlo; Domellöf, Magnus; Fewtrell, Mary S.; Husby, Steffen; Papadopoulou, Alexandra; Vandenplas, Yvan; Castillejo, Gemma; Kolacek, Sanja; Koletzko, Sibylle; Korponay-Szabó, Ilma R.; Lionetti, Elena; Polanco, Isabel; Troncone, Riccardo

Journal of Pediatric Gastroenterology & Nutrition: March 2016 - Volume 62 - Issue 3 - p 507–513
doi: 10.1097/MPG.0000000000001105
Position Paper

Background: The European Society for Paediatric Gastroenterology, Hepatology and Nutrition recommended in 2008, based on observational data, to avoid both early (<4 months) and late (≥7 months) introduction of gluten and to introduce gluten while the infant is still being breast-fed. New evidence prompted ESPGHAN to revise these recommendations.

Objective: To provide updated recommendations regarding gluten introduction in infants and the risk of developing coeliac disease (CD) during childhood.

Summary: The risk of inducing CD through a gluten-containing diet exclusively applies to persons carrying at least one of the CD risk alleles. Because genetic risk alleles are generally not known in an infant at the time of solid food introduction, the following recommendations apply to all infants, although they are derived from studying families with first-degree relatives with CD. Although breast-feeding should be promoted for its other well-established health benefits, neither any breast-feeding nor breast-feeding during gluten introduction has been shown to reduce the risk of CD. Gluten may be introduced into the infant's diet anytime between 4 and 12 completed months of age. In children at high risk for CD, earlier introduction of gluten (4 vs 6 months or 6 vs 12 months) is associated with earlier development of CD autoimmunity (defined as positive serology) and CD, but the cumulative incidence of each in later childhood is similar. Based on observational data pointing to the association between the amount of gluten intake and risk of CD, consumption of large quantities of gluten should be avoided during the first weeks after gluten introduction and during infancy. The optimal amounts of gluten to be introduced at weaning, however, have not been established.

*Department of Paediatrics, Medical University of Warsaw, Poland

Sackler Faculty of Medicine, Tel-Aviv University, Israel

Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands

§Pediatric Gastroenterology and Hepatology, La Fe University Hospital, Valencia, Spain

||Department of Pediatrics, Marche Polytechnic University, Ancona, Italy

Department of Clinical Sciences, Pediatrics, Umea University, Umea, Sweden

#Childhood Nutrition Research Centre, UCL Institute of Child Health, London, UK

**Hans Christian Andersen Children's Hospital, Odense University Hospital, Denmark

††Division of Gastroenterology & Hepatology, First Department of Pediatrics, University of Athens, Children's Hospital Agia Sophia, Athens, Greece

‡‡Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium

§§Pediatric Gastroenterology Unit, Hospital Universitari de Sant Joan de Reus, IISPV, URV, Reus, Spain

||||Department of Pediatrics, Zagreb Medical University, Children's Hospital, Zagreb, Croatia

¶¶Dr von Hauner Children's Hospital, Ludwig Maximilians University, Munich, Germany

##Department of Paediatrics, University of Debrecen Medical School, Debrecen, and Heim Pál Children's Hospital, Budapest, Hungary

***Department of Pediatrics, University of Catania, Catania, Italy

†††Autonomous University, La Paz Children's University Hospital, Madrid, Spain

‡‡‡University of Naples Federico II, Naples, Italy.

Address correspondence to Hania Szajewska, MD, PhD, Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland (e-mail:

Received 27 January, 2015

Accepted 6 January, 2016

H.S. and R.S. are the coordinators. M.D. and M.S.F. are members of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition; C.R.K., A.P., Y.V. are the members of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Gastroenterology Committee; S.H. is the member of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Working Group on Coeliac Disease; H.S., R.S., L.M., C.R.K., G.C., S.K., S.K., I.R.K-S, I.P., R.T. are the members of PreventCD Study Group.

The authors report no conflicts of interest.

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© 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,