Very interesting - I recall this group had a similar finding some years back with regard to coeliac disease. At the time I recall they had some preliminary evidence that starting gluten in the 3 - 6 month window might reduce the risk of Type 1 DM, but it was based on some sort of surrogate marker rather than the actual outcome. I'd missed the fact that they now have this study out, and it's good to know - thanks. I'll definitely have to get a copy of this.
Anyway, to turn your question around - why would it be a problem for this woman to start solids at 4 months? The Kramer & Kakuma WHO review found the outcomes in the developed world for 6 months vs. 4 months to be the same in almost every study; as I recall, the only study showing a problem with introducing solids before 6 months was the PROBIT trial showing a 1 in 40 risk of diarrhoea with the mixed-fed group. (Which is impossible to interpret in terms of a risk with solids specifically since babies starting *any* form of mixed feeding in the 3 - 6 month age group were all lumped together, and thus the group would almost certainly have included a lot of babies who were partly on formula feeds at the expense of their breastmilk intake, which would likely be more risky.)
So, at worst, we're looking at a fairly minor risk associated with starting solids at 4 months, and I don't think even that one has ever been confirmed. Obviously in most cases it would make sense to go with 6 months anyway and avoid that risk, but if we're balancing a study showing a possible increased risk of a short-term bout of diarrhoea in infancy against a study showing a possible decreased risk of a lifelong, potentially life-threatening disease with serious potential complications and major medical complications... well, for goodness' sake, that one seems to me to be a no-brainer. I'd make exactly the same decision in her shoes.
A couple of practical points that it would be worth clarifying to her:
Firstly, according to the abstract, the reduced risk didn't seem to be with solids generally but with oats/rice, and I believe earlier work has suggested early gluten is also associated with the reduced risk (hence the tie-in with the coeliac disease study, though that part isn't relevant to her). The abstract says that early fruit intake was actually associated with increased risk, and we have the evidence from other studies that early introduction of cow's milk protein *might* be associated with increased risk, so she'd be best advised to avoid fruit/cheese/yoghurt until 6 months and concentrate on oat-based/grain-based things at the moment (and possibly puréed meats if there's any reason to suspect iron deficiency, but of course that's a whole other topic).
Secondly, I recall from reading the work on coeliac disease that it seemed important to start the gluten in small quantities, increase the amount gradually, and keep breastfeeding until well after the point when gluten had been introduced. Seems a reasonable precaution (and obviously sensible advice anyway with introducing solids at this age).
Thirdly, obviously wise to make sure she has the usual advice about trying food only after baby has already had the breast, to make sure the tastes of food are in addition to the breastmilk but aren't replacing it this early. Of course, I'm sure you'd be telling her that anyway!
Hope that helps.
Best wishes,
Dr Sarah Vaughan, GP
MB ChB MRCGP
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