primary prevention of coeliac disease - Associazione Italiana ...

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46 INFANT FEEDING PRACTICES AND COELIAC DISEASE Temporal relationship Plausibility Consistency Strength Dose-response relationship Reversibility Study design Coherence of evidence 41 Adapted from . Breast feeding Table. Guidelines for the evaluation of causality. Does the possible cause precede the effect? Is the association consistent with other knowledge? Have similar results been shown in other studies? What is the strength of the association between the possible cause and the effect? Is increased exposure to the possible cause associated with increased effect? Does the removal of a possible cause lead to reduction of disease risk? Is the evidence based on a strong study design? How many lines of evidence support the conclusion? 42-45 Based on increasing knowledge about the immunological impact of breast milk , it seems plausible that introduction of a dietary antigen while the child is still breast-fed might increase the likelihood of developing oral tolerance to that antigen. Whether or not this relationship holds true for dietary gluten and the risk for development of coeliac disease has not been conclusively established. Based on observations of coeliac disease patients, it was suggested as early as the 46 1950s that breast-feeding delays onset of the disease , a view supported by later similar 47-48 studies . Furthermore, an increase in breast-feeding was suggested as a possible factor contributing to the declining incidence of coeliac disease in the early 1970s in 49-51 England, Scotland and Ireland . 52 In the 1980s, the Italian case-referent studies by Auricchio et al (216 cases/289 53 siblings) and Greco et al (201 cases/1949 referents) demonstrated that coeliac disease cases were breast-fed for a shorter duration than the referents. This was confirmed in a 54 Swedish case-referent study by Fälth-Magnusson et al (72 cases/288 referents), and 55 recently in a German study by Peters et al (143 cases/137 referents). In contrast, in a 56 family study Ascher et al did not find a difference in breast-feeding duration when comparing screening-detected cases with their siblings (8 cases/73 siblings). This study was comparatively small, and the design involved overmatching with respect to dietary factors, constraints discussed by the authors. Taken together, the case-referent studies demonstrate that coeliac disease cases in general have been breast-fed for a shorter period than other children. However, these studies could not clarify whether breast-feeding had a direct causal effect, or if the protective effect was indirect as a consequence of the postponed introduction of infant formula (more specifically cow's milk protein), or if it occurred through reduction of the amount of dietary gluten ingested at an early age. We have recently reported results from a case-referent study (491 cases/781 57 referents) , which could eliminate some of the above-mentioned constraints through a somewhat different design in comparison with the previously mentioned studies. Our
OR (95%CI) INFANT FEEDING PRACTICES AND COELIAC DISEASE 47 study was population-based, with a high participation rate, and the results should thus be representative for Sweden at large. Since our findings are consequences of biological phenomena, they should be valid for infants in general. Only incident cases, i.e. newly diagnosed cases, were included, which reduced the recall period. A comprehensive questionnaire concerning children's diet and health in general was mailed to the families; it did not reveal our special interest in coeliac disease. A semiquantitative food frequency questionnaire was used to assess both the consumption of gluten-containing cereals at the time when these cereals were introduced into the diet and the total amount consumed by seven months of age. The amount of glutencontaining flour in homemade foods was calculated based on standard Swedish recipes and the amount in industrially produced foods was obtained from the manufacturers. Multivariate analyses were used to adjust risk estimates for confounding and to suggest 57 causal relationships . Our main finding was that the risk for coeliac disease was reduced if the child was breast-fed during the time period when gluten-containing foods were introduced [Odds 57 Ratio (OR) = 0.59, 95% Confidence Interval (CI) 0.42-0.83] . This protective effect was even more pronounced if the child was also breast-fed beyond the period of gluten introduction (OR=0.36, 95% CI 0.26-0.51) (Fig. 2). These risk estimates were adjusted for the age of the infant when gluten was introduced into the diet and the amount of gluten that was given. 4 2 1 ½ ¼ Discontinued Continued Continued beyond Breast feeding status at introduction of gluten Fig. 2. Breast-feeding status (BF) at introduction of gluten-containing flour into the diet and risk (OR, 95% CI) for coeliac disease before two years of age. A protective effect of breast-feeding was supported by our ecological study of the Swedish epidemic, i.e. using aggregated data to explore any temporal relationship between the changes in incidence rate and changes in infant dietary patterns. Both the rise and later fall in incidence had a temporal relationship to a change in the proportion 36 of infants introduced to gluten while still being breast-fed . It is important to note that at the time of these studies the majority of Swedish
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Perspectives on Coeliac Disease Vol
Page 4:
The AIC Meeting was held in the Aul
Page 8 and 9:
Italian Coeliac Society, Via Picott
Page 11 and 12: Preface Coeliac disease (CD) is a u
Page 13: Contents Current understanding of t
Page 16 and 17: 2 THE BASIS OF COELIAC DISEASE hapl
Page 18 and 19: 4 THE BASIS OF COELIAC DISEASE 1 pr
Page 20 and 21: 6 THE BASIS OF COELIAC DISEASE spre
Page 22 and 23: 8 THE BASIS OF COELIAC DISEASE Ackn
Page 24 and 25: 10 THE BASIS OF COELIAC DISEASE glu
Page 27 and 28: Catassi C, Fasano A, Corazza GR (ed
Page 29: T CELL RESPONSES TO GLUTEN PEPTIDES
Page 32 and 33: 18 A DOMINANT EPITOPE IN GLUTEN PEP
Page 42 and 43: 28 ROLE OF A-GLIADIN 31-49 PEPTIDE
Page 47 and 48: COELIAC DISEASE IN THE SAHARAWI 33
Page 55: COELIAC DISEASE IN THE SAHARAWI 41
Page 58 and 59: 44 INFANT FEEDING PRACTICES AND COE
Page 66 and 67: Age (years) 52 INFANT FEEDING PRACT
Page 76 and 77: 62 MECHANISMS OF ORAL TOLERANCE the
Page 78 and 79: 64 MECHANISMS OF ORAL TOLERANCE pot
Page 80 and 81: 66 MECHANISMS OF ORAL TOLERANCE Epi
Page 82 and 83: 68 MECHANISMS OF ORAL TOLERANCE typ
Page 84 and 85: 70 MECHANISMS OF ORAL TOLERANCE 51
Page 86 and 87: 72 MECHANISMS OF ORAL TOLERANCE 23.
Page 91 and 92: GENETICALLY DETOXIFIED GRAINS 77 to
Page 93 and 94: • • GENETICALLY DETOXIFIED GRAI
Page 95 and 96: GENETICALLY DETOXIFIED GRAINS 81 3.
Page 99 and 100: IMMUNOTHERAPY OF COELIAC DISEASE 85
Page 101 and 102: IMMUNOTHERAPY OF COELIAC DISEASE 87
Page 105 and 106: RECENT ADVANCES ON GLUTEN TOXICITY
Page 107 and 108: Index A Antiendomysium antibodies (
Page 109: INDEX 95 W Wheat, 7, 23, 27, 31, 53
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