When should gluten be introduced into an infant’s diet? Can breastfeeding reduce the risk of developing coeliac disease? Does the amount of gluten consumed during the first years of life have an impact?

These questions have been the subject of research for many years, particularly in children with a genetic predisposition to developing the condition.

In 2024, the Special Interest Group on Coeliac Disease (SIG-CD) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published an update to its position paper on early feeding and the risk of coeliac disease.

Its conclusions help clarify what is currently known about breastfeeding and coeliac disease, the timing of gluten introduction, and the amount consumed during the first years of life.

Another issue examined is the optimal timing for introducing gluten.

According to the position paper, gluten may be introduced between four completed months of age (that is, from 17 weeks onwards) and 12 months of age, without the timing chosen within this interval appearing to influence the cumulative risk of developing coeliac disease autoimmunity or coeliac disease itself during childhood.

This means that delaying gluten introduction within this timeframe has not been shown to prevent coeliac disease.

There is, however, an important nuance: earlier introduction may be associated with an earlier onset of seroconversion and coeliac disease. In other words, it may influence when the disease develops, but not necessarily the overall risk of developing it.

The paper also does not identify any specific gluten-containing food as being preferable during this stage. Available evidence has not shown that the type of gluten introduced affects risk, and therefore no specific recommendations can be made regarding which gluten-containing food source should be used.

However, these findings do not allow a specific amount of gluten to be identified as optimal or safe.

The quantities examined vary considerably between studies because of differences in dietary habits across countries and the various methods used to estimate gluten intake.

For this reason, the position paper concludes that it is currently not possible to recommend a specific amount of gluten during weaning or the first years of life, either for children with unknown risk status or for those with a known predisposition to developing coeliac disease.

Likewise, there is insufficient evidence to recommend restricting gluten in healthy children as a strategy to prevent coeliac disease.

The 2024 update reinforces an important message: despite advances in our understanding of early feeding and coeliac disease, there is still no gluten introduction strategy that has been proven to prevent the development of the condition.

Based on the evidence reviewed by the ESPGHAN Special Interest Group, several key points emerge for clinical practice:

1. Breastfeeding has not been shown to reduce the risk of developing coeliac disease.
2. Continuing breastfeeding while introducing gluten has not been shown to provide a specific protective effect.
3. Gluten may be introduced between four completed months (17 weeks) and 12 months of age without affecting the cumulative risk of developing coeliac disease.
4. Higher gluten consumption during the first years of life has been associated in observational studies with a greater risk in predisposed children, but neither an optimal intake nor a safe threshold has been established.
5. No specific amount of gluten can be recommended for the prevention of coeliac disease.
6. There is insufficient evidence to recommend any particular gluten-containing food when introducing gluten.
7. There is insufficient evidence to support different recommendations on gluten intake based on HLA risk profile.

Therefore, recommendations regarding gluten in infants should not be viewed as a specific strategy for preventing coeliac disease. The available evidence continues to leave important questions unanswered, particularly regarding the amount of gluten consumed during the first years of life.