Quand doit-on introduire le gluten dans l’alimentation des nourrissons ?

Gluten-Free Diet Compliance in Children With Celiac Disease and Its Effect on Clinical Symptoms: A Retrospective Cohort Study

A gluten-free diet (GFD) is the only scientifically proven treatment for celiac disease (CD). Strict adherence to this diet in children yields excellent results in terms of the clinical symptoms present at the time of diagnosis. Despite the constraints associated with following this diet, it remains the only hope for children with CD to have a better quality of life and life expectancy.

METHODS

A retrospective descriptive cohort study was carried out on children diagnosed with CD in the pediatrics department of the Hassan II University Hospital in Fez, Morocco. The children were followed up for 18 months, during which time they were seen as outpatients at different frequencies depending on their clinical condition and degree of compliance with the diet.

RESULTS

Only half of the diagnosed children continued to follow our structure. Compliance with the gluten-free diet varied from 58.7% (n = 84) of children who strictly followed the GFD to 3.5% (n = 5) of children who never followed the diet. Compliance was significantly correlated with the child's age, with adolescents being the least compliant (p = 0.03). Similarly, a correlation was observed between compliance with the diet and the disappearance of symptoms (p <0.01), the persistence of certain symptoms (p = 0.02), and the occurrence of complications (p = 0.01). The majority of children (87.3%) had their clinical symptoms resolved within a mean delay of 6.4±3.6 months, with a mode of three months. The speed of symptom resolution differed from one symptom to another but remained statistically correlated with the degree of GFD compliance (p = 0.03).

CONCLUSION

Despite the excellent results of a GFD on clinical symptoms in children, the discrepancies observed between compliance and non-compliance call for close follow-up of children with CD to avoid complications and repercussions on the vital prognosis in adulthood.

[Complementary feedings and socioeconomic factors]

INTRODUCTION

In order to limit the risk of food allergies, it is recommended to begin complementary feedings for infants between the ages of 4 and 6 months old. The objective of this study is to describe how complementary feedings are carried out until the age of 1 year old and to analyze criteria, especially socio-economic, that influence compliance with recommendations.

METHODS

This observational and descriptive quantitative study lasted from November 21st, 2016 to February 21st, 2017 and took place in 10 doctor's offices around the city of Saint-Etienne. Anonymous surveys were distributed to the mothers of children aged between 12 and 47 months old inclusive, born at term, and with a weight above 2.5 kg.

RESULTS

More than 2/3rds of the 163 children included started complementary feedings between 4 and 6 months old. Gluten (P = 0.02) and meat (P = 0.016) were introduced later and infant formulas (P = 0.005) were stopped sooner when the mother's education level was low. The average number of fruit and vegetables was smaller when the mother had a low socio-economic level or if she was multiparous. At the age of one, fewer than 20% of the children had consumed fat content rich in omega-3. At the same age, 70% had consumed egg and 12.3% nuts, which are some of the major allergens.

CONCLUSION

These outcomes show the need for general practitioners to inform parents, especially those with a low socio-economic level, about early food introduction, including allergens.

[Infant food diversification. Assessment of practices in relation to French recommendations in pediatricians and pediatric residents in southern France]

Infant food diversification has undergone a rapid succession of good practice recommendations in France, but there has been no assessment of pediatrician practices on food diversification.

OBJECTIVE

To assess the practices of pediatricians in relation to current recommendations of the French Society of Pediatrics on infant food diversification.

METHODS

This was an observational study conducted from 1 November 2014 to 31 March 2015. The study population consisted of 97 pediatricians in the Var department and 84 pediatric residents assigned to the University of Aix-Marseille in France. A questionnaire was sent by email or post to determine physician characteristics, food diversification methods in healthy children and those at atopic risk, and how the pediatric consultation was conducted. The expected answers were based on the most recent recommendations of the French Society of Pediatrics published in 2008, updated from 2003. In summary, breastfeeding is recommended up to 6 months. Food diversification can be started between 4 and 6 months in children with no allergy risk. Gluten, honey, legumes and cow's milk are introduced between 4 and 7 months, after 12 months and after 36 months, respectively. In atopic children, food diversification is delayed until after 6 months and the most allergenic foods (nuts, exotic fruits, peanuts, and shellfish) are introduced after the age of 12 months.

RESULTS

Eighty-four responses were obtained (51%): 50 pediatricians and 34 pediatric residents. Sixteen items were classified depending on whether or not an update after 2003 existed. Over 80% of the physicians responded as recommended for the recently updated items for the age of introduction of "solid food in healthy children", "gluten", "cow's milk protein hydrolysates", and "the time until introduction of cow's milk in the atopic child". At best, 65% of physicians responded in accordance with recommendations for items without a recent update, age of introduction of "cow's milk", "milk desserts", "animal proteins", "fats", "vegetables", "use of a hypoallergenic infant formula", and "breastfeeding extension with atopic child". Pediatric residents had the same responses as pediatricians. Seventy-two physicians did not consider the allergenic status of the children to delay the introduction of the most allergenic foods. The lack of complete updating the introduction of solid foods schedule could explain the differences between pediatrician practices and recommendations. Moreover, old recommendations on allergenic food eviction are still available.

CONCLUSION

Pediatricians and pediatric residents partially applied the current recommendations on the introduction of solid food.

Gluten Introduction to Infant Feeding and Risk of Celiac Disease: Systematic Review and Meta-Analysis

OBJECTIVE

To assess the evidence regarding the effect of time of gluten introduction and breastfeeding on the risk of developing celiac disease (CD).

STUDY DESIGN

We included randomized controlled trials and observational studies evaluating the proper timing for introducing gluten to the infant diet, the appropriate quantity of gluten consumption at weaning, and the effect of breastfeeding on CD risk. Studies were located through the electronic databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), EMBASE (Ovid), and System for Information on Grey Literature in Europe (SIGLE). Two independent authors collected the data.

RESULTS

A total of 1982 studies were identified, 15 of which were eligible for data extraction. A meta-analysis was performed on 2 randomized controlled trials, 10 cohort studies, and 1 case-control study. There was a 25% increase in CD risk with late (>6 months) vs recommended (4-6 months) gluten introduction (risk ratio [RR], 1.25; 95% CI, 1.08-1.45). There was no significant effect of breastfeeding vs no breastfeeding on CD risk (OR, 0.55; 95% CI, 0.28-1.10), with substantial heterogeneity (I(2) = 92%) among studies.

CONCLUSION

There is currently no evidence to support that early introduction of gluten to the infant diet increases the risk of CD; however, late introduction of gluten may be associated with increased risk of CD. More studies are needed that control for potential confounders and that evaluate environmental factors in low-risk families.