Does breast feeding help protect against atopic disease? Biology, methodology, and a golden jubilee of controversy

doi:10.1016/S0022-3476(88)80054-4

The Journal of Pediatrics

Volume 112, Issue 2, February 1988, Pages 181-190

https://doi.org/10.1016/S0022-3476(88)80054-4 Get rights and content

To help shed some light on the 50-year-old controversy concerning the possible protective effect of breast feeding on subsequent atopic disease, I developed 12 standards pertaining to both biologic and methodologic aspects of exposure (infant feeding), outcome (atopic conditions), and statistical analysis for studies of atopic eczema, asthma, allergic rhinitis, cow milk allergy, and other food allergy. Among the published studies on atopic eczema, the nine claiming a protective benefit of breast feeding performed less well than the 12 not making such a claim on “methodologic” standards relating to strict diagnostic criteria and blind ascertainment of outcome. The positive studies were somewhat stronger, however, on the “biologic” standards bearing on sufficient duration and exclusivity of breast feeding and on separate analysis of children at high risk. For the other atopic conditions, there were no important differences between positive and negative studies. In few negative or positive studies was there adequate control for confounding variables or examination of potential benefits relating to the severity or age at onset of atopic disease. To avoid another 50 years of unresolved controversy, future studies should improve both the biologic and methodologic aspects of their design and analysis.

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Cited by (206)

Exclusive breast-feeding, the early-life microbiome and immune response, and common childhood respiratory illnesses
2022, Journal of Allergy and Clinical Immunology
Citation Excerpt :
Limiting the effect of confounders has been especially problematic in this field, because breast-feeding is more common in mothers of certain backgrounds.2,10 To address this, we (1) created primary and secondary models adjusting for multiple confounders of the association identified on the basis of available literature4,8-10 and (2) conducted sensitivity analyses using PS matching to balance covariates between groups. Our results remained similar across the different statistical analyses, which suggests that confounding by measured covariates is unlikely.
The impact of breast-feeding on certain childhood respiratory illnesses remains controversial.
We sought to examine the effect of exclusive breast-feeding on the early-life upper respiratory tract (URT) and gut microbiome, the URT immune response in infancy, and the risk of common pediatric respiratory diseases.
We analyzed data from a birth cohort of healthy infants with prospective ascertainment of breast-feeding patterns and common pediatric pulmonary and atopic outcomes. In a subset of infants, we also characterized the URT and gut microbiome using 16S ribosomal RNA sequencing and measured 9 URT cytokines using magnetic bead–based assays.
Of the 1949 infants enrolled, 1495 (76.71%) had 4-year data. In adjusted analyses, exclusive breast-feeding (1) had an inverse dose-response on the ⍺-diversity of the early-life URT and gut microbiome, (2) was positively associated with the URT levels of IFN-α, IFN-γ, and IL-17A in infancy, and (3) had a protective dose-response on the development of a lower respiratory tract infection in infancy, 4-year current asthma, and 4-year ever allergic rhinitis (odds ratio [95% CI] for each 4 weeks of exclusive breast-feeding, 0.95 [0.91-0.99], 0.95 [0.90-0.99], and 0.95 [0.92-0.99], respectively). In exploratory analyses, we also found that the protective association of exclusive breast-feeding on 4-year current asthma was mediated through its impact on the gut microbiome (P = .03).
Our results support a protective causal role of exclusive breast-feeding in the risk of developing a lower respiratory tract infection in infancy and asthma and allergic rhinitis in childhood. They also shed light on potential mechanisms of these associations, including the effect of exclusive breast-feeding on the gut microbiome.
Prevention of food and airway allergy: Consensus of the Italian Society of Preventive and Social Paediatrics, the Italian Society of Paediatric Allergy and Immunology, and Italian Society of Pediatrics
2016, World Allergy Organization Journal
Background Allergic sensitization in children and allergic diseases arising therefrom are increasing for decades. Several interventions, functional foods, pro- and prebiotics, vitamins are proposed for the prevention of allergies and they can’t be uncritically adopted.
Objective This Consensus document was developed by the Italian Society of Preventive and Social Paediatrics and the Italian Society of Paediatric Allergy and Immunology.
The aim is to provide updated recommendations regarding allergy prevention in children.
Methods The document has been issued by a multidisciplinary expert panel and it is intended to be mainly directed to primary care paediatricians.
It includes 19 questions which have been preliminarily considered relevant by the panel. Relatively to each question, a literature search has been performed, according to the Italian National Guideline Program. Methodology, and a brief summary of the available literature data, has been provided.
Many topics have been analyzed including the role of mother’s diet restriction, use of breast/formula/hydrolyzed milk; timing of introduction of complementary foods, role (if any) of probiotics, prebiotics, vitamins, exposure to dust mites, animals and to tobacco smoke.
Results Some preventive interventions have a strong level of recommendation. (e.g., the dehumidifier to reduce exposure to mite allergens). With regard to other types of intervention, such as the use of partially and extensively hydrolyzed formulas, the document underlines the lack of evidence of effectiveness.
No preventive effect of dietary supplementation with polyunsaturated fatty acids, vitamins or minerals has been demonstrated.
There is no preventive effect of probiotics on asthma, rhinitis and allergic diseases. It has demonstrated a modest effect, but steady, in the prevention of atopic dermatitis.
Conclusions The recommendations of the Consensus are based on a careful analysis of the evidence available.
The lack of evidence of efficacy does not necessarily imply that some interventions may not be effective, but currently they can’t be recommended.
Breast-Always Best?
2016, Allergy, Immunity and Tolerance in Early Childhood: The First Steps of the Atopic March
The first few months of life represent a window of opportunity for neonatal oral tolerance induction and prevention of allergy. Maternal rather than paternal atopic status has a greater effect on the atopic outcome of the progeny, which raises the question of whether maternal factors such as immune status, breastfeeding, and immunologic constituents of breast milk and dietary and environmental exposure have a role. In mice, breastfeeding has a role in tolerance induction and protection against asthma using adoptive nursing models. In epidemiologic studies, there is conflicting evidence regarding the protective impact of breastfeeding against allergic diseases, which may be attributable at least in part to differences in breast milk composition, the genetic predisposition of the infants, or gene–environment interactions. This chapter will review epidemiologic studies assessing the protective role of breast milk and the impact of maternal interventions during lactation on development of atopic diseases in children. The immunologic composition of breast milk will also be discussed.
Human Milk: Its Components and Their Immunobiologic Functions
2015, Mucosal Immunology: Fourth Edition
Whereas a neonate is born is sterile, immediate exposure to its mother's mucosal surfaces allows it to acquire microflora, which plays an important role in defense against potential pathogens. This initial stimulus helps the immature immune system of the newborn to develop the capacity to respond with specific immunologic tolerance while avoiding the development of allergic and autoimmune disease. Breast-feeding provides nutritional and developmental, along with anti-infectious, advantages to the infant. The significant protection conferred by breast-feeding against varied infections such as acute and prolonged diarrhea, neonatal septicemia, respiratory tract infections, acute and recurrent otitis media, and urinary tract infections is observed worldwide. Human breast milk contains numerous components, including antibodies, cytokines, hormones, enzymes, and major proteins with multiple activities (microbicidal, tumoricidal, anti-inflammatory, autoimmune, etc.). Breast-feeding can strikingly reduce infant mortality, as well as the fertility of the breast-feeding mother. In this manner, breast-feeding provides significant benefits for lactating mothers and their offspring, in addition to society as a whole.
Breast-Always Best?
2015, Allergy, Immunity and Tolerance in Early Childhood: The First Steps of the Atopic March
The first few months of life represent a window of opportunity for neonatal oral tolerance induction and prevention of allergy. Maternal rather than paternal atopic status has a greater effect on the atopic outcome of the progeny, which raises the question of whether maternal factors such as immune status, breastfeeding, and immunologic constituents of breast milk and dietary and environmental exposure have a role. In mice, breastfeeding has a role in tolerance induction and protection against asthma using adoptive nursing models. In epidemiologic studies, there is conflicting evidence regarding the protective impact of breastfeeding against allergic diseases, which may be attributable at least in part to differences in breast milk composition, the genetic predisposition of the infants, or gene–environment interactions. This chapter will review epidemiologic studies assessing the protective role of breast milk and the impact of maternal interventions during lactation on development of atopic diseases in children. The immunologic composition of breast milk will also be discussed.
Breastfeeding and risk of atopic dermatitis up to the age 42 months: A birth cohort study in Japan
2014, Annals of Epidemiology
Citation Excerpt :
These differences may stem from differences in study design, the definitions of exposure and outcome, sample size, or adjustment for confounders [13–15]. Kramer [14] proposed 12 criteria to assess study designs addressing the relationship between breastfeeding and atopic disease. Those criteria included nonreliance on prolonged maternal recall, strict diagnostic criteria, severity of outcome, assessment of effect in children at high risk, and adequate statistical power.
The purpose of this study was to investigate the association between breastfeeding and atopic dermatitis (AD) up to the age 42 months.
Data from a nationally representative population-based birth cohort study in Japan were used (N = 38,757). Feeding pattern and breastfeeding duration were investigated via questionnaires when infants were aged 6 months. Physician-diagnosed AD during the previous 1 year was ascertained via questionnaires when the children were aged 18, 30, and 42 months. The associations between feeding patterns or breastfeeding duration and physician-diagnosed AD from the age 6 to 42 months, categorized by AD status (no history of AD, episodic AD, and persistent AD), were analyzed using ordered logistic regression adjusted for covariates.
Breastfeeding was positively associated with AD, with dose-response association (P for trend < .001). Exclusively breastfed infants were 1.26 times more likely to have AD (95% confidence interval, 1.12–1.41) than infants fed formula alone. Furthermore, children with a longer breastfeeding duration were also significantly more likely to have AD (P for trend < .001).
Breastfeeding is associated with an increased risk of AD up to the age 42 months. Further study is needed to elucidate the mechanism underlying the association between breastfeeding and AD.

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^*: Presented in part at the annual meeting of the Ambulatory Pediatric Association, Anaheim, California, April 30, 1987.

¹: Dr. Kramer is a National Health Research Scholar of the National Health Research and Development Program, Health and Welfare Canada.

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Special articleDoes breast feeding help protect against atopic disease? Biology, methodology, and a golden jubilee of controversy*

J Pediatr

Lancet

Lancet

J Pediatr

Lancet

Lancet

J Allergy Clin Immunol

Lancet

Lancet

Lancet

Lancet

Early Hum Dev

Lancet

J Allergy Clin Immunol

Breast feeding, eczema, asthma, and hayfever

J Epidemiol Commun Health

Atopic eczema in European and Negro West Indian infants in London

Br J Dermatol

1981 milk feeding patterns in the United States during the first 12 months of life

Pediatrics

Respiratory symptoms in children and parental smoking and phlegm production

Br Med J

Parental smoking, presence of older siblings, and family history of asthma increase risk of bronchiolitis

Am J Dis Child

Effects of smoking on breast feeding

Arch Dis Child

The familial incidence of allergic disease

Ann Allergy

Atopic disease in seven-year-old children

Acta Paediatr Scand

Occurrence of atopic diseases in three generations

Scand J Soc Med

Simple interval-estimation of risk ratio

Am J Epidemiol

Statistical aspects of the analysis of data from retrospective studies of disease

JNCI

A coefficient of agreement for nominal scales

Educ Psychol Meas

Diet and heredity in infantile atopic dermatitis

Arch Dermatol

Childhood asthma in Finland

Acta Allergy

Prospective studies of the effect of breast feeding on incidence of infection and allergy

Acta Paediatr Scand

Clinical manifestations of allergy related to breast and cow's milk feeding

Arch Dis Child

Special article
Does breast feeding help protect against atopic disease? Biology, methodology, and a golden jubilee of controversy*