Gastrointestinal consequences of cesarean section birth: A systematic review of short- and long-term effects in infancy and beyond

Table 12 Summary of studies on cesarean delivery and risk of celiac disease

Ref.	Country	Sample size	Follow-up	Association with CD	Notable modifiers	Risk of bias
Andersen et al[53], 2020	Denmark	2.7 million births	40 years	↑ Risk of celiac disease and other inflammatory diseases	Parental autoimmune disease	Low (large national cohort, robust adjustments)
Soullane et al[62], 2021	Canada	934873 children	7.4 years	No increased celiac disease risk (HR = 0.86)	Hospitalization data	Low (large cohort, good registry linkage)
Iorfida et al[63], 2024	Italy	3259 celiac disease patients	40 years	↑ C-section rate in celiac disease group; earlier onset in emergency C-section	Emergency vs elective C-section	Moderate (case-control; retrospective risk)
Mårild et al[64], 2012	Sweden	11749 cases; 53887 controls	35 years	↑ Risk with elective C-section (aOR = 1.15)	SGA status, labor exposure	Low (matched controls, well-powered)
Dydensborg Sander et al[65], 2018	Denmark & Norway	Approximately 1.6 million births	15-18 years	No significant association	Country-level consistency	Low (multinational, controlled)
Emilsson et al[66], 2015	Norway	114500 children	8-10 years	No significant association	Maternal celiac disease, type 1 DM, gluten timing	Low (adjusted for strong confounders)
TEDDY Study (Koletzko et al[67], 2018)	United States, Europe	6087 HLA-positive children	5-10 years	No significant association after adjustments	Genetics, breastfeeding, country	Low (high-quality longitudinal cohort)
Tanpowpong et al[68], 2023	United States	44539 mother-child pairs	> 6 years	↑ Risk in C-section without labor (aHR = 1.56)	Labor status at delivery	Moderate (good follow-up, stratified labor data)
Decker et al[69], 2010	Germany	1950 children	Retrospective	↑ Celiac disease in C-section-born (OR = 1.8)	Breastfeeding, postnatal complications	Moderate (retrospective, smaller size)
Bielik et al[70], 2024	Slovakia	1226 (534 celiac disease patients)	Cross-sectional	No C-section-celiac disease link; breastfeeding protective	Antibiotics, family history	High (cross-sectional design, recall bias)

Clinical Pearls 6: Some studies suggest a slight increase in celiac disease risk following cesarean section, particularly elective cesarean section without labor, possibly due to altered microbial exposure at birth. However, results are inconsistent across populations, and large cohort studies have found no significant association. Feeding practices, genetic predisposition, and perinatal factors may play a more influential role than delivery mode alone. aOR: Adjusted odds ratio; aHR: Adjusted hazard ratio; C-section: Cesarean section; CD: Crohn's disease; DM: Diabetes mellitus; HLA: Human leukocyte antigens; SGA: Small for gestational age.