Infants Delivered By Cesarean May Be More Likely to Develop Celiac Disease

Cesarean delivery is related to a higher incidence of pediatric celiac disease, according to an article published online May 17 in Pediatrics.

After birth, an infant's environment shifts from a sterile space to one colonized by bacteria. Almost immediately, microbial products and live bacteria can be seen, but only in a part of the baby's intestine. The arrival of solid food several months later establishes a complex bacterial flora throughout the entire bowel. The composition of the flora has been shown to vary significantly depending on whether the birth was vaginal or cesarean.

"Differences in the microbial flora and impaired priming of the enteric epithelial surface in individuals who are born by cesarean delivery might therefore contribute to inflammatory conditions of the intestinal mucosa later in life," write lead author Evalotte Decker, from the Department of Pediatrics, Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Germany, and colleagues. "Indeed, the rate of cesarean delivery as well as the incidence of [inflammatory bowel disease] and celiac disease have increased in recent decades."

The investigators conducted a retrospective, multicenter, case-control study of 1950 pediatric patients to examine a possible relationship between inflammatory intestinal disease and cesarean delivery. From May 2008 through May 2009, 1088 of the child and adolescent subjects received treatment at gastrointestinal outpatient clinics for any 1 of the following: Crohn's disease, ulcerative colitis, celiac disease, or other gastrointestinal issues. The remaining 862 patients served as the control group.

The study authors gathered information that included the participants' disease type, method of birth, gestational age at delivery, complications after birth, and breast-feeding. Their results follow.

* Between 1991 and 2007, the rate of cesarean delivery rose from 15% to 30% (1.2% increase per year; odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94 - 0.99; P = .015).
* A substantially greater rate of cesarean delivery was discovered in children with celiac disease (27.6% vs 17.2% for the control group; OR, 1.83; 95% CI, 1.18 - 2.85).
* Significant increases in cesarean delivery rates were not found in children with Crohn's disease (19.3%; OR, 1.14; 95% CI, 0.83 - 1.58), ulcerative colitis (15.4%; OR, 0.87; 95% CI, 0.55 - 1.38), or other gastrointestinal conditions (OR, 1.03; 95% CI, 0.62 - 1.69).
* Adjusting for age, sex, complications after birth, and duration of breast-feeding using binomial logistic regression underscored the relationship between cesarean delivery and celiac disease (OR, 1.80; 95% CI, 1.13 - 2.88; P = .014) but not Crohn's disease (OR, 1.27; 95% CI, 0.87 - 1.84; P = .208) or ulcerative colitis (OR, 0.89; 95% CI, 0.51 - 1.54; P = .673).

"Our results demonstrated a significant and previously undescribed association between cesarean delivery and celiac disease," the authors write. "In our study, patients with [Crohn's disease or ulcerative colitis] were not more likely than healthy control subjects to be born by cesarean delivery."

The results also showed that celiac disease was related to a higher rate of breast-feeding (OR, 1.99; 95% CI, 1.12 - 3.51) compared with the control participants (P = .015).

There were no explicitly stated limitations to the study, but the investigators did note that future studies would be strengthened by the inclusion of several additional factors, including socioeconomic status, birth order, previous cesareans, hygiene status, smoking during pregnancy, family history, genetic testing, and initial disease presentation.

The study authors also said that further research might yet reveal a relationship between cesarean delivery and more inflammatory bowel diseases. It would also be useful in corroborating their findings regarding the association between cesarean delivery and celiac disease.

"Although this association needs to be confirmed in a larger investigation, our results indicate that alterations of the intestinal flora observed after cesarean delivery might impair the establishment of the host–microbe homeostasis and intestinal mucosal integrity and contribute to the pathogenesis of enteric inflammatory diseases," the authors write.

The German Research Foundation and the German Ministry for Science and Education supported this study. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online May 17, 2010.