Prevention of Celiac Disease

Prevention of Celiac Disease Raanan Shamir, MD Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Sack...
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Prevention of Celiac Disease Raanan Shamir, MD Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel

Alba, April 26, 2016

I have the following financial relationships to disclose: Nestle: advisory board member, speaker Danone: advisory board member, speaker Abbott: advisory board member, speaker

No Products or services produced by this (these) company (companies) are relevant to my presentation.

Lecture Layout 1. Timing of gluten introduction 2. Breastfeeding and CD 3. Breastfeeding at the time of gluten introduction and CD 4. Amount of gluten at weaning (and later) and CD 5. Type of gluten (“vital wheat gluten.”) 6. Gluten during lactation  Gastrointestinal infections

 Viral infections  Gut microbiota (Cesarian section

Learning Objectives Upon completion of this session, the learner will be able to…

1. Acknowledge timing of gluten introduction to infants diet in relation to CD 2. Recognize the relationship between breastfeeding and CD 3. Be familiar with the recommendations on breastfeeding at the time of gluten introduction

Ivarsson A et al. Acta Pæ diatr 2000, Myleus A, et al. ESPGHAN 2007

JPGN 2009; 49:170–176

Post Epidemic Cohort

% of BF infants (11% at 6 mo.) BF duration (2 mo.) Gluten introduction While BF (8%) Gluten amount eaten Clinically detected CD Total CD

0.87%

2.9%

0.6% 2.2%

Ivarsson A, et al. Pediatrics 2013

Timing of gluten introduction

Age at Introduction

Norris JM, et al. JAMA 2005;293:2343-51

PreventCD Project Hypothesis: Childhood celiac disease may be prevented

By introduction of gluten - in small amounts - 4-6 months of age - preferably while being breastfed

PreventCD 17 partners www.preventcd.com

PreventCD Intervention Study

Cumulative Incidence of CD by HLA-Type 14.9% 3.9%

0.9%

N Engl J Med 2014

Frequency of celiac disease was not significantly different between the 475 children who received 100 mg gluten and the 469 children who received placebo daily at age 16 - 24weeks. N Engl J Med 2014

Timing of Gluten introduction Observational studies

Szajewska H and Shamir R. APT 2015

Timing of Gluten introduction Primary Outcome 3 years 2 years 5 years Szajewska H and Shamir R. APT 2015

All Interventional Trials

Lerodiakonou D, et al. JAMA 2016

Breastfeeding and CD

Effect of BF on the risk of CD Observational studies

Szajewska H and Shamir R. APT 2015

Effect of BF on the risk of CD Interventional trials

Szajewska H and Shamir R. APT 2015

Breastfeeding >12 months was associated with increased risk (adjusted odds ratio, 1.49 [95% confidence interval, 1.01-2.21], P =.046).

The Question of prolonged breast feeding was not included in the meta-analysis

Breastfeeding at Time of Gluten Introduction

Breast Feeding at Gluten Introduction Observational studies

All studies

Case-Control

Cohorts

Szajewska H and Shamir R. APT 2015

Breast Feeding at Gluten Introduction Interventional trials

Szajewska H and Shamir R. APT 2015

Questions for New ESPGHAN Guidelines • BF and CD.

 Does any BF compared with no BF reduce the risk of developing CD?

• BF at the time of gluten introduction and CD.  Does BF at the time of gluten introduction reduce the risk of developing CD? • Timing of gluten introduction.  Is the age of gluten introduction important to the risk of

developing CD? • Amount of gluten at the time of gluten introduction (and later) and CD. •

 Is the amount of gluten ingested an independent risk factor for the development of CD during early childhood Type of gluten.

 Does the type of cereal at gluten introduction influence CD risk?

ESPGHAN Guidelines 2016 Timing of gluten introduction

JPGN 2016

ESPGHAN Guidelines 2016 Timing of gluten introduction

JPGN 2016

ESPGHAN Guidelines 2016 BF compared with no BF

JPGN 2016

ESPGHAN Guidelines 2016 BF at the time of gluten introduction and CD

JPGN 2016

New ESPGHAN Guidelines March 2016 • BF and CD.

 Does any BF compared with no BF reduce the risk of developing CD? No

• BF at the time of gluten introduction and CD.  Does BF at the time of gluten introduction reduce the risk of developing CD? No • Timing of gluten introduction.  Is the age of gluten introduction important to the risk of

developing CD? No • Amount of gluten at the time of gluten introduction (and later) and CD. •

 Is the amount of gluten ingested an independent risk factor for the development of CD during early childhood Unknown Type of gluten.

 Does the type of cereal at gluten introduction influence CD risk? Unknown

Thanking All participating children and parents and all partners:

Supported by a grant from the Azrieli Foundation

ESPGHAN Guidelines 2016 Type and Amount

JPGN 2016