Breast Feeding & Asthma :Should
   we promote breast feeding?
It is not controversial that breast-feeding
is the preferred...
Sicherer et al.JACI 2008   -
Does breastfeeding protect
       against development of
     atopy & asthma in childhood
                  ?


          ...
Large unselected population-based birth cohort study



                                                            SPT
  ...
Methods

• Current asthma = positive response to
  question “Do you (does your child) have
  asthma?” together with sympto...
Results
• 1,037 kids  early childhood characteristics not
  differ from 102 kids who did not participate
• 45% (463) not ...
Results
• 1,037 kids  early childhood characteristics not
  differ from 102 kids who did not participate
• 45% (463) not ...
Characteristics of BF group


•   First-born                                 Bias?

•   Higher socioeconomic status
•   No...
The effect with current asthma persisted
         at all ages to 26 years
Effect of BF not effected by FH
1.72   ---    1.91   1.53   1.55




2.09    ---   2.54   1.86   1.73
Adjust SES, birth order, sheepskin use in infancy, maternal smoking
Conclusion
• No duration of exclusive BF had a protective effect
  against development of atopy & asthma in later
  childh...
Appraising the Controversy
&
A Rebuttal

   Pete et al.Pediatric Pulmonology 2003.35:331-4
   Sear et al.Pediatric Pulmono...
Issues
 1. Heterogenicity of breast feeding
    groups
 2. Recall bias & unclear whether recalled
    reported were adjust...
Answers

Breast feeding data was recorded systematically by
interviewers at 3 years old and were compared with data
record...
4. Selection bias : hospital-based cohort
   & European ethnics only

5. Confounding factors

6. Causality : no dose respo...
Population-based birth cohort study

                            Access
                         early childhood
         ...
Methods

2 populations were accessed :
- BF (never, < month, to < months,
   to < months, and >= months)

- Exclusive brea...
71.5 %




Adjusted by sex, maternal age, maternal smoking, environmental tobacco smoke
             , maternal asthma, ma...
57 %




Maternal age and maternal history of allergy : most important confounders
55 %
Results

Slightly protective effect of breast feeding
on wheeze in early life did not extend into
later childhood which is...
Results
• Bayesian joint model (reverse causation
  effect, loss follow-up group)

• Reverse causation effect = children
 ...
Results
• modest difference in duration of breast-feeding
  based on early infant wheezing was not
  sufficient to bias th...
Benefits
• Large birth cohort study
• Objective measurement
• Bayesian joint model


Weakness
• High drop-out rate
• Crite...
Even breast feeding does not protect
asthma or atopy in later life


Breastfeeding is a natural
phenomenon, providing bala...
Breast Feeding And Asthma
Breast Feeding And Asthma
Breast Feeding And Asthma
Breast Feeding And Asthma
Breast Feeding And Asthma
Breast Feeding And Asthma
Breast Feeding And Asthma
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Breast Feeding And Asthma

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Breast Feeding And Asthma

  1. 1. Breast Feeding & Asthma :Should we promote breast feeding? It is not controversial that breast-feeding is the preferred method of infant nutrition because of its nutritional, immunological, and psychological benefits Effects on reducing early childhood wheezing, GI tract infections and atopic eczema (in early life) was demonstrated by several studies Effects on childhood asthma is controversial especially in mother who has asthma Friedman et al.JACI 2005 -
  2. 2. Sicherer et al.JACI 2008 -
  3. 3. Does breastfeeding protect against development of atopy & asthma in childhood ? Objective To assess long-term outcomes of asthma & atopy related to breastfeeding in a New Zealand birth cohort study
  4. 4. Large unselected population-based birth cohort study SPT aeroallergen FH of allergy 69% 87% 1,037 (91%) of 1,661 1,139 kids who live-born were in Otago 5 7 9 11 13 15 18 21 26 yr at age 3 y Comprehensive Questionnaire Verify BF Spirometry record (investigators Metacholine challenge/ unaware of Bronchodilator response test outcome) Investigators unaware of data for infant feeding determined all respiratory outcomes
  5. 5. Methods • Current asthma = positive response to question “Do you (does your child) have asthma?” together with symptoms reported within previous 12 mo • SPT to Dp, cat, dog , horse hair, rye grass, kapok, wool, fungus (positive = wheal > 2 mm than negative control at 15 min)
  6. 6. Results • 1,037 kids  early childhood characteristics not differ from 102 kids who did not participate • 45% (463) not breastfed • 7% (70) kids discontinued breastfed before 4 wk 51% (533) BF < 4 wk 49% (504) BF >= 4 wk • Mean duration of BF in BF group = 21.1 wk (SD 16.6) • Term “BF” not necessarily mean exclusive BF
  7. 7. Results • 1,037 kids  early childhood characteristics not differ from 102 kids who did not participate • 45% (463) not breastfed • 7% (70) kids discontinued breastfed before 4 wk 51% (533) BF < 4 wk preliminary report : bias?? 49% (504) BF >= 4 wk • Mean duration of BF in BF group = 21.1 wk (SD 16.6) : 4 wk until 47 wk • Term “BF” not necessarily mean exclusive BF
  8. 8. Characteristics of BF group • First-born Bias? • Higher socioeconomic status • Non-smoking mothers • More likely to have a sheepskin on their bed • Family history of hayfever or asthma (mother or father) and sex did not differ to non-BF group
  9. 9. The effect with current asthma persisted at all ages to 26 years
  10. 10. Effect of BF not effected by FH
  11. 11. 1.72 --- 1.91 1.53 1.55 2.09 --- 2.54 1.86 1.73
  12. 12. Adjust SES, birth order, sheepskin use in infancy, maternal smoking
  13. 13. Conclusion • No duration of exclusive BF had a protective effect against development of atopy & asthma in later childhood • BF > 4 wks likelihood of skin test response to common allergens at age 13 y and more than doubled the risk of diagnosed asthma in mid- childhood, with effects persisting into adulthood • Role of BF in protection of kids against atopy & asthma cannot be supported
  14. 14. Appraising the Controversy & A Rebuttal Pete et al.Pediatric Pulmonology 2003.35:331-4 Sear et al.Pediatric Pulmonology 2003:36:366-8
  15. 15. Issues 1. Heterogenicity of breast feeding groups 2. Recall bias & unclear whether recalled reported were adjusted when the two methods differed 3. Reporting bias : most mothers aware that a longer duration of breastfeeding is desirable
  16. 16. Answers Breast feeding data was recorded systematically by interviewers at 3 years old and were compared with data recorded prospectively by nurse with 98.9% agreement When data from nurse records were not provided : authors said they analyzed that it is not recall bias (how to?) Giving mothers the benefit of the doubt would not lead to any significant difference in outcomes (how to show?)
  17. 17. 4. Selection bias : hospital-based cohort & European ethnics only 5. Confounding factors 6. Causality : no dose response effect
  18. 18. Population-based birth cohort study Access early childhood Ask whether wheezing diagnosed asthma 14,062 13,978 alive live 3 4 7 8 births at age 1 y Verify BF SPT record aeroallergen Spirometry & Metacholine challenge
  19. 19. Methods 2 populations were accessed : - BF (never, < month, to < months, to < months, and >= months) - Exclusive breast-feeding (never,< months, >= months) SPT to 3 core aeroallergens (cat, mixed grass pollen, house dust mite) - positive >= 2 mm than negative control at 15 min)
  20. 20. 71.5 % Adjusted by sex, maternal age, maternal smoking, environmental tobacco smoke , maternal asthma, maternal allergy, and older siblings
  21. 21. 57 % Maternal age and maternal history of allergy : most important confounders
  22. 22. 55 %
  23. 23. Results Slightly protective effect of breast feeding on wheeze in early life did not extend into later childhood which is consistent with most other studies However no evidence of deleterious effect of breast feeding on atopic sensitization and later wheezing
  24. 24. Results • Bayesian joint model (reverse causation effect, loss follow-up group) • Reverse causation effect = children with early wheezing were more likely to be breast-fed longer and to have allergic outcomes • Mean duration of breast-feeding for children who did not wheeze in the first months of life was . months compared with . months for children with wheeze (P < .
  25. 25. Results • modest difference in duration of breast-feeding based on early infant wheezing was not sufficient to bias the relationships between breast-feeding and the health outcomes examined • No evidence that the pattern of missing data in this study appreciably influenced outcome
  26. 26. Benefits • Large birth cohort study • Objective measurement • Bayesian joint model Weakness • High drop-out rate • Criteria definition of atopy
  27. 27. Even breast feeding does not protect asthma or atopy in later life Breastfeeding is a natural phenomenon, providing balanced nutrition and mother–infant bonding, as well as a number of health benefits Breast feeding is still preferable method for infantile feeding

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