Abstract
Background
Children with asthma, hay fever, and food allergy may have several factors that increase their risk of speech disorder, including allergic inflammation, ADD/ADHD, and sleep disturbance. However, few studies have examined a relationship between asthma, allergic disease, and speech disorder. We sought to determine whether asthma, hay fever, and food allergy are associated with speech disorder in children and whether disease severity, sleep disturbance, or ADD/ADHD modified such associations.
Methods
We analyzed cross-sectional data on 337,285 children aged 2–17 years from 19 US population-based studies, including the 1997–2013 National Health Interview Survey and the 2003/4 and 2007/8 National Survey of Children’s Health.
Results
In multivariate models, controlling for age, demographic factors, healthcare utilization, and history of eczema, lifetime history of asthma (odds ratio [95% confidence interval]: 1.18 [1.04–1.34], p = 0.01), and one-year history of hay fever (1.44 [1.28–1.62], p < 0.0001) and food allergy (1.35 [1.13–1.62], p = 0.001) were associated with increased odds of speech disorder. Children with current (1.37 [1.15–1.59] p = 0.0003) but not past (p = 0.06) asthma had increased risk of speech disorder. In one study that assessed caregiver-reported asthma severity, mild (1.58 [1.20–2.08], p = 0.001) and moderate (2.99 [1.54–3.41], p < 0.0001) asthma were associated with increased odds of speech disorder; however, severe asthma was associated with the highest odds of speech disorder (5.70 [2.36–13.78], p = 0.0001).
Conclusion
Childhood asthma, hay fever, and food allergy are associated with increased risk of speech disorder. Future prospective studies are needed to characterize the associations.
Keywords: asthma, hay fever, food allergy, speech disorder, speech delay, allergy, atopic disease, ADD/ADHD, sleep disturbance
Allergic diseases such as asthma, hay fever, and food allergy are common childhood inflammatory disorders with considerable impact on the lives of those affected (1). Children with allergic disease utilize substantial healthcare services and incur significant medical expenses compared to children with no disease (2–4). Additionally, allergic diseases are associated with decreased quality of life (1, 5), increased risk of psychological disorders (6), and numerous medical and non-medical comorbidities.
Childhood speech and language disorders are a heterogeneous group of conditions with varying developmental consequences. Primary speech and language impairment affects between 2 and 7% of children (7). We recently reported on the association between eczema and speech disorder in US children (8). We hypothesized that such association was related to the effects of chronic disease during childhood development and chronic sleep deprivation. Similarly, childhood asthma and allergic rhinitis are associated with sleep disturbance (9, 10), allergic inflammation (11, 12), and Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ADHD) (13, 14), which may affect neurocircuitry involved in speech and language and increase the risk of childhood speech disorders (15–17). Food allergy may increase the risk of speech disorder through allergic inflammation and a possible, though controversial, link to chronic otitis media (18, 19). Several small studies found abnormalities in vocal quality and articulation in children with chronic asthma and allergic rhinitis, potentially related to inhaled corticosteroids (20–23). However, an epidemiologic study found no significantly increased prevalence of asthma and allergy in children with speech disorder (24). Our a priori hypothesis was that childhood asthma, hay fever, and food allergy are associated with increased risk of speech disorder. Additionally, we hypothesized that severe allergic disease and allergic disease accompanied by sleep disturbance or ADD/ ADHD were associated with even higher risk of speech disorder. This study sought to determine whether there is an association between childhood allergic disease and speech disorders.
Methods
Study sources
After approval from the institutional review board at Northwestern University, cross-sectional data from 19 different population-based studies, including the 1997–2013 National Health Interview Survey (NHIS) and the 2003/4 and 2007/8 National Survey of Children’s Health (NSCH), were assessed. The specific characteristics of each survey are presented in Table S1. Briefly, both the NHIS, collected in-person by trained interviewers, and NSCH, collected over telephone, were surveys designed and overseen by the National Center for Health Statistics (NCHS), for the purpose of estimating the prevalence of health issues affecting children in the United States. In households that were selected to participate in NHIS or NSCH, one child was randomly chosen to be the subject of an interview with the caregiver, and each study year included a sample of subjects drawn independently from previous years. Inherent to each survey’s design is a complex, multistage probability sample that incorporated demographic data from the U.S. Census bureau. From this incorporated data, the NCHS created sample weights that allow for prevalence estimations that are representative of the US population of non-institutionalized children. In this study, prevalence estimates of data from either NHIS or NSCH reflect this complex weighting process. However, in pooled prevalence estimates of data from all 19 surveys, sample weights could not be combined due to differences in sampling methodology between the two survey vehicles.
Outcomes
The questions used in this study are presented in Table S2. Associations between speech disorder and lifetime history of asthma, one-year history of hay fever, and food allergy were assessed in all 19 surveys. Asthma history was stratified into current vs. past asthma, and association with speech disorders was assessed in 15 surveys. NSCH 2007/8 assessed for caregiver-reported severity of allergic disease and speech disorder. NSCH 2003/4 and 2007/8 assessed for ADD/ADHD and adequate nights of sleep per week. Finally, the association between asthma, hay fever, food allergy, and speech disorder, as modified by sleep disturbance, defined by less than 4 nights of adequate sleep per week, or ADD/ADHD, was assessed by testing two-way interaction terms.
Statistical analysis
Data analyses were performed using SAS version 9.4. (SAS Institute, Cary, North Carolina) SURVEY procedures were utilized to estimate prevalence and construct logistic regression models that accounted for the complex survey weighting. Bivariate associations were examined with history of speech disorder as the dependent variable and asthma, asthma severity, hay fever, or food allergy as the independent variables. We were concerned that sociodemographic factors, rates of outpatient healthcare utilization, and comorbidity with eczema (8) might be confounders in the association of asthma with speech disorder. Multivariate models included history of eczema (Y/N), sex (male/female), age (2–6/7–11/12–17), race/ethnicity (Hispanic/ non-Hispanic white/non-Hispanic black/multiracial or other), household income (0–99%/100–199%/200–399%/400% Federal Poverty Level [FPL]), highest level of household/parental education (less than high school [HS]/HS or equivalent/more than HS), birthplace in the US (Y/N), insurance coverage (Y/N), and outpatient healthcare utilization over the past year (0/1/2–3/ 4–9/10–12/13+ visits) as additional independent variables. In logistic regression models of pooled data from either NHIS or NSCH, sample weights were combined due to similar sampling methodologies between survey years. Due to differences in methodology between NHIS and NSCH, sample weights could not be combined. Thus, pooled analyses were assessed by performing meta-analysis of individual survey effects using a robust variance estimation method (25). Odds ratios (OR) and 95% confidence ratios (CI) were determined. Complete data analysis was performed. The frequency of missing values is presented in Table S3.
Results
The prevalence and demographics of childhood speech disorders in the examined studies have been described previously (8). Briefly, the pooled prevalence of speech disorder in US children was 2.4% and speech disorder was positively associated with male sex, younger age, and lower socioeconomic status.
Allergy and speech disorder
In bivariate models of data pooled from NHIS 1997–2013, NSCH 2003/4 & 2007/8, and in meta-analysis, lifetime asthma, one-year history of hay fever, and food allergy were all associated with increased odds of speech disorder (p <0.0001 for all). Multivariate modeling of data pooled from NHIS 1997 to 2013 found lifetime asthma (aOR [95% CI]: 1.18 [1.04–1.34], p = 0.01), one-year history of hay fever (1.44 [1.28–1.62], p < 0.0001), and one-year history of food allergy (1.35 [1.13–1.62], p = 0.001) to be associated with increased odds of speech disorder (Table 1). Multivariate modeling of data pooled from NSCH found lifetime asthma (1.55 [1.33–1.82], p < 0.0001), one-year history of hay fever (1.51 [1.30–1.74], p < 0.0001), and food allergy (2.30 [1.78–2.98], p <0.0001) to be associated with increased odds of speech disorder. In meta-analysis of the multivariate model effects from all 19 studies, lifetime asthma (1.23 [1.12–1.35], p < 0.0001), hay fever (1.51 [1.31–1.71], p < 0.0001), and food allergy (1.44 [1.19–1.70], p = 0.0002) were associated with increased odds of speech disorder. No interactions were found between allergic disease and age, indicating the associations occurred at all ages throughout childhood.
Table 1.
Association between allergic disease and speech disorder in NHIS 1997–2013 and NSCH 2003/4 and 2007/8
| No speech disorder | Speech disorder
|
|||||||
|---|---|---|---|---|---|---|---|---|
| Study | Allergic disease | Freq | Freq | % Prev (95% CI) | Crude OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
| Pooled NHIS (1997–2013) | Lifetime asthma† | |||||||
| No | 142,590 | 2212 | 1.5 (1.5–1.6) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 24,093 | 732 | 2.8 (2.6–3.1) | 1.86 (1.67–2.07) | <0.0001 | 1.18 (1.04–1.34) | 0.01 | |
| Asthma status§ | ||||||||
| Never | 104,611 | 1657 | 1.6 (1.5–1.7) | 1 [ref] | – | 1 [ref] | – | |
| Past, not current | 5999 | 134 | 1.9 (1.5–2.4) | 1.24 (0.99–1.57) | 0.07 | 0.99 (0.76–1.29) | 0.94 | |
| Current | 12,484 | 443 | 3.3 (2.9–3.7) | 2.15 (1.88–2.46) | <0.0001 | 1.28 (1.09–1.50) | 0.002 | |
| Hay fever† | ||||||||
| No | 135,324 | 2065 | 1.5 (1.4–1.6) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 31,071 | 874 | 2.6 (2.4–2.8) | 1.75 (1.59–1.94) | <0.0001 | 1.44 (1.28–1.62) | <0.0001 | |
| Food allergy† | ||||||||
| No | 159,943 | 2672 | 1.6 (1.6–1.7) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 6733 | 271 | 3.3 (2.8–3.7) | 2.02 (1.74–2.36) | <0.0001 | 1.35 (1.13–1.62) | 0.001 | |
| Pooled NSCH | Lifetime asthma‡ | |||||||
| No | 139,860 | 4147 | 3.2 (3.0–3.4) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 21,854 | 1160 | 6.4 (5.6–7.1) | 2.07 (1.80–2.37) | <0.0001 | 1.55 (1.33–1.82) | <0.0001 | |
| Asthma status¶ | ||||||||
| Never | 144,007 | 4147 | 3.2 (3.0–3.4) | 1 [ref] | – | 1 [ref] | – | |
| Past, not current | 6615 | 220 | 3.8 (2.7–4.8) | 1.19 (0.89–1.60) | 0.24 | 1.07 (0.77–1.50) | 0.94 | |
| Current | 15,239 | 940 | 7.5 (6.6–8.4) | 2.46 (2.12–2.85) | <0.0001 | 1.73 (1.46–2.06) | <0.0001 | |
| Hay fever‡ | ||||||||
| No | 132,451 | 3813 | 3.2 (3.0–3.4) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 29,083 | 1496 | 5.7 (5.2–6.3) | 1.84 (1.63–2.08) | <0.0001 | 1.51 (1.30–1.74) | <0.0001 | |
| Food allergy‡ | ||||||||
| No | 155,292 | 4766 | 3.4 (3.2–3.5) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 6435 | 545 | 10.5 (8.7–12.4) | 3.39 (2.76–4.17) | <0.0001 | 2.30 (1.78–2.98) | <0.0001 | |
| Pooled (all) | Lifetime asthma†† | |||||||
| No | 282,450 | 6359 | 2.2 (2.1–2.3) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 45,947 | 1892 | 4.0 (3.8–4.1) | 1.89 (1.73–2.05) | <0.0001 | 1.23 (1.12–1.35) | <0.0001 | |
| Asthma status†† | ||||||||
| Never | 244,571 | 5804 | 2.3 (2.3–2.4) | 1 [ref] | – | 1 [ref] | – | |
| Past, not current | 12,614 | 354 | 2.7 (2.4–3.0) | 1.25 (0.95–1.55) | 0.06 | 0.99 (0.77–1.21) | 0.95 | |
| Current | 27,723 | 1383 | 4.8 (4.5–5.0) | 2.20 (1.96–2.44) | <0.0001 | 1.37 (1.15–1.59) | 0.0003 | |
| Hay fever†† | ||||||||
| No | 267,775 | 5878 | 2.1 (2.1–2.2) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 60,154 | 2370 | 3.8 (3.6–3.9) | 1.82 (1.58–2.05) | <0.0001 | 1.51 (1.31–1.71) | <0.0001 | |
| Food allergy†† | ||||||||
| No | 315,235 | 7438 | 2.3 (2.3–2.4) | 1 [ref] | – | 1 [ref] | – | |
| Yes | 13,168 | 816 | 5.8 (5.4–6.2) | 2.15 (1.82–2.47) | <0.0001 | 1.44 (1.19–1.70) | 0.0002 | |
Binary logistic regression models were constructed with speech disorder as the dependent variable and hay fever, food allergy, lifetime history of asthma and asthma status (never, past, current) as the binary independent variables. Multivariate logistic regression models were then constructed that additionally included history of eczema, sex, age, race, household income, highest level of household education, US vs. foreign birthplace, insurance coverage, and outpatient healthcare utilization in the past year as the independent variables. Adjusted prevalence odds ratios and 95% confidence intervals were estimated.
Pooled analyses were performed by merging the datasets and dividing NHIS sample weights by the number of studies (n = 17).
Pooled analyses were performed by merging the datasets and dividing NSCH sample weights by the number of studies (n =2).
Pooled analyses were performed by merging the datasets and dividing NHIS sample weights by the number of studies (n = 13).
Pooled analyses were performed by merging the datasets and dividing NSCH sample weights by the number of studies (n = 2).
Due to differences in sampling methodology between NHIS and NSCH, sample weights could not be combined. Unweighted prevalence estimates are presented. Pooled prevalence odds ratios were determined by meta-analysis of weighted multivariate regression analysis effects, using a robust variance estimation method. Bold values indicate P < 0.05.
Current and past asthma and speech disorder
In bivariate models of data pooled from NHIS 2001 to 2013, current (2.15 [1.88–2.46], p < 0.0001) but not past (1.24 [0.99–1.57], p = 0.07) asthma was associated with increased odds of speech disorder (Table 1). These associations remained significant in multivariate models. Similar results were found in data pooled from NSCH. In meta-analysis of bivariate model effects from all 15 individual studies, current (2.20 [1.96–2.44], p < 0.0001) but not past (p = 0.06) asthma were associated with increased odds of speech disorder. Meta-analysis of individual multivariate model effects found current (1.37 [1.15–1.59], p = 0.0003) but not past (p = 0.95) asthma to be associated with increased risk of speech disorder.
Severity of allergy and speech disorder
Mild (1.99 [1.56–2.55], p < 0.0001) and moderate (3.93 [2.60–5.92], p < 0.0001) asthma were associated with increased odds of speech disorder. However, severe asthma was associated with dramatically higher odds of speech disorder (11.82 [5.79–24.12], p < 0.0001) in bivariate modeling (Table 2). All three associations remained significant in multivariate models.
Table 2.
Association between allergic disease severity and speech disorder in NSCH 2007/8
| History of speech disorder
|
|||||||
|---|---|---|---|---|---|---|---|
| No (n = 77,196) | Yes (n = 2676)
|
||||||
| Allergic disease severity | Freq | Freq | % Prevalence | Crude OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
| Current asthma | |||||||
| None | 70,106 | 2177 | 3.3 (3.0–3.6) | 1.00 | – | 1.00 | – |
| Mild | 5129 | 286 | 6.3 (5.0–7.7) | 1.99 (1.56–2.55) | <0.0001 | 1.58 (1.20–2.08) | 0.001 |
| Moderate | 1525 | 142 | 11.8 (7.6–15.9) | 3.93 (2.60–5.92) | <0.0001 | 2.29 (1.54–3.41) | <0.0001 |
| Severe | 251 | 55 | 28.6 (14.2–43.1) | 11.82 (5.79–24.12) | <0.0001 | 5.70 (2.36–13.78) | 0.0001 |
| Hay fever | |||||||
| None | 62,525 | 1893 | 3.3 (3.0–3.7) | 1.00 | – | 1.00 | – |
| Mild | 10,239 | 453 | 4.9 (3.9–5.9) | 1.50 (1.18–1.90) | 0.0009 | 1.39 (1.07–1.79) | 0.01 |
| Moderate | 3762 | 257 | 8.4 (6.4–10.4) | 2.67 (2.02–3.53) | <0.0001 | 2.08 (1.46–2.97) | <0.0001 |
| Severe | 474 | 65 | 10.6 (6.6–14.6) | 3.44 (2.23–5.30) | <0.0001 | 1.54 (0.90–2.66) | 0.12 |
| Food allergy | |||||||
| None | 73,563 | 2370 | 3.5 (3.2–3.8) | 1.00 | – | 1.00 | – |
| Mild | 1782 | 124 | 5.3 (3.7–6.8) | 1.52 (1.09–2.11) | 0.01 | 1.21 (0.83–1.75) | 0.32 |
| Moderate | 992 | 102 | 16.9 (9.7–24.1) | 5.59 (3.32–9.39) | <0.0001 | 3.48 (1.97–6.16) | <0.0001 |
| Severe | 738 | 71 | 10.9 (5.8–15.9) | 3.33 (1.96–5.68) | <0.0001 | 2.02 (1.03–3.97) | 0.04 |
Binary logistic regression models were constructed with history of speech disorder as the binary dependent variable. The independent (explanatory) variable was severity of asthma, hay fever, or food/digestive allergy (mild/moderate/severe). Prevalence odds ratios (OR) and 95% confidence intervals (95% CI) were determined. Multivariate logistic regression models were created that included allergic disease severity, history of eczema, age, gender, race/ethnicity, Hispanic origin, household income, birthplace in the United States, highest level of education in the household, insurance coverage, and outpatient healthcare utilization in the past year (all categorical) as independent variables. Adjusted prevalence odds ratios (aOR) and 95% confidence intervals (95% CI) were determined. Bold values indicate P < 0.05.
Similarly, mild (1.50 [1.18–1.90], p = 0.0009), moderate (2.67 [2.02–3.53], p < 0.0001), and severe (3.44 [2.23–5.30], p < 0.0001) hay fever were associated with increased odds of speech disorder. The associations of mild and moderate hay fever remained significant in multivariate models.
Finally, mild (1.52 [1.09–2.11], p = 0.01), moderate (5.59 [3.32–9.39], p < 0.0001), and severe (3.33 [1.96–5.68]), p < 0.0001) food allergy were also significantly associated with increased risk of speech disorder. The associations of moderate and severe food allergy remained significant in multivariate models.
Allergy, sleep, and speech disorder
Children with either sleep disturbance (1.50 [1.16–1.94], p = 0.002) or current asthma (2.38 [1.83–2.92], p < 0.0001) had increased odds of speech disorder compared to children without either condition alone. However, even higher odds of speech disorder were found in children with both asthma and sleep disturbance (3.10 [1.93–5.01], p < 0.0001) (Table 3). This pattern was consistent in multivariate models. Similar results were found in bivariate and multivariate models of hay fever or food allergy and sleep disturbance (Table 3).
Table 3.
Association between allergic disease, adequate nights of sleep per week, and speech disorder in NSCH 2003/4 and 2007/8
| History of speech disorder
|
||||||||
|---|---|---|---|---|---|---|---|---|
| No (n = 128,075) | Yes (n = 3555)
|
|||||||
| Nights of adequate sleep per week | Freq | Freq | % Prevalence | Crude OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value | |
| Current asthma | ||||||||
| No | 4–7 | 105,686 | 2632 | 2.7 (2.5–2.9) | 1.00 | – | 1.00 | – |
| No | 0–3 | 9652 | 296 | 3.9 (3.0–4.8) | 1.50 (1.16–1.94) | 0.002 | 1.76 (1.32–2.34) | 0.0001 |
| Yes | 4–7 | 11,025 | 541 | 6.1 (5.0–7.2) | 2.38 (1.93–2.92) | <0.0001 | 1.56 (1.22–1.983) | 0.0003 |
| Yes | 0–3 | 2049 | 112 | 7.8 (4.4–11.2) | 3.10 (1.92–5.01) | <0.0001 | 2.51 (1.64–3.88) | <0.0001 |
| Hay fever | ||||||||
| No | 4–7 | 95,000 | 2275 | 2.7 (2.5–2.9) | 1.00 | – | 1.00 | – |
| No | 0–3 | 8492 | 243 | 4.0 (2.9–5.1) | 1.52 (1.13–2.04) | 0.005 | 1.81 (1.33–2.48) | 0.0002 |
| Yes | 4–7 | 21,862 | 902 | 4.4 (3.9–4.9) | 1.67 (1.43–1.94) | <0.0001 | 1.29 (1.09–1.53) | 0.003 |
| Yes | 0–3 | 2579 | 135 | 6.0 (4.3–7.7) | 2.32 (1.70–3.18) | <0.0001 | 2.06 (1.46–2.91) | <0.0001 |
| Food allergy | ||||||||
| No | 4–7 | 112,700 | 2881 | 2.8 (2.6–3.0) | 1.00 | – | 1.00 | – |
| No | 0–3 | 10,541 | 328 | 4.1 (3.1–5.0) | 1.50 (1.16–1.92) | 0.002 | 1.76 (1.35–2.29) | <0.0001 |
| Yes | 4–7 | 4280 | 296 | 9.3 (6.9–11.6) | 3.60 (2.69–4.81) | <0.0001 | 2.35 (1.61–3.43) | <0.0001 |
| Yes | 0–3 | 545 | 49 | 12.1 (6.7–17.6) | 4.88 (2.92–8.14) | <0.0001 | 3.80 (2.13–6.79) | <0.0001 |
Binary logistic regression models were constructed with history of speech disorder as the dependent variable and the interaction between current asthma, hay fever, or food allergy and nights of adequate sleep per week (0–3/4–7) as the independent variable. Multivariate models were also constructed that additionally included history of eczema, sex, age, race, household income, highest level of household education, US vs. foreign birthplace, insurance coverage, and outpatient healthcare utilization in the past year (all categorical) as independent variables. Adjusted prevalence odds ratios and 95% confidence intervals were estimated. Bold values indicate P < 0.05.
Allergy, ADD/ADHD, and speech disorder
Moreover, ADD/ADHD alone (3.83 [3.28–4.47], p < 0.0001) or current asthma alone (2.21 [1.86–2.53], p < 0.0001) were both associated with increased odds of speech disorder in bivariate modeling. However, children with both ADD/ADHD and current asthma had the highest odds of speech disorder (8.00 [6.03–10.61], p < 0.0001). This pattern was consistent in multivariate models, and similar results were found in bivariate and multivariate models of hay fever or food allergy and ADD/ ADHD disturbance (Table 4).
Table 4.
Association between allergic disease, ADD/ADHD, and speech disorder in NSCH 2003/4 and 2007/8
| History of speech disorder
|
||||||||
|---|---|---|---|---|---|---|---|---|
| No (n = 161,934) | Yes (n = 5329)
|
|||||||
| ADD/ADHD | Freq | Freq | % Prevalence | Crude OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value | |
| Current asthma | ||||||||
| No | No | 135,527 | 3377 | 2.7 (2.5–2.9) | 1.00 | – | 1.00 | – |
| No | Yes | 10,597 | 948 | 9.6 (6.4–10.8) | 3.83 (3.28–4.47) | <0.0001 | 3.88 (3.25–4.63) | <0.0001 |
| Yes | No | 12,892 | 621 | 5.8 (4.9–6.6) | 2.21 (1.86–2.63) | <0.0001 | 1.71 (1.40–2.09) | <0.0001 |
| Yes | Yes | 1885 | 281 | 18.1 (14.0–22.1) | 8.00 (6.03–10.61) | <0.0001 | 6.29 (4.53–8.73) | <0.0001 |
| Hay fever | ||||||||
| No | No | 122,640 | 2943 | 2.7 (2.5–2.8) | 1.00 | – | 1.00 | – |
| No | Yes | 9499 | 831 | 10.0 (8.6–11.4) | 4.07 (3.43–4.83) | <0.0001 | 4.12 (3.38–5.02) | <0.0001 |
| Yes | No | 25,987 | 1074 | 4.6 (4.1–5.1) | 1.77 (1.54–2.03) | <0.0001 | 1.59 (1.35–1.88) | <0.0001 |
| Yes | Yes | 3013 | 401 | 14.2 (11.6–16.8) | 6.07 (4.86–7.59) | <0.0001 | 5.35 (4.11–6.96) | <0.0001 |
| Food allergy | ||||||||
| No | No | 143,061 | 3628 | 2.8 (2.6–2.9) | 1.00 | – | 1.00 | – |
| No | Yes | 11,857 | 1090 | 10.1 (8.9–11.2) | 3.94 (3.42–4.54) | <0.0001 | 3.83 (3.26–4.51) | <0.0001 |
| Yes | No | 5746 | 389 | 8.3 (6.6–9.9) | 3.17 (2.53–3.99) | <0.0001 | 2.15 (1.64–2.81) | <0.0001 |
| Yes | Yes | 666 | 143 | 25.8 (17.3–34.3) | 12.18 (7.77–19.10) | <0.0001 | 9.11 (4.92–16.88) | <0.0001 |
Binary logistic regression models were constructed with history of speech disorder as the dependent variable and the interaction between current asthma, hay fever, or food allergy and ADD/ADHD (Y/N) as the independent variable. Multivariate models were also constructed that additionally included history of eczema, sex, age, race, household income, highest level of household education, US vs. foreign birthplace, insurance coverage, and outpatient healthcare utilization in the past year (all categorical) as independent variables. Adjusted prevalence odds ratios and 95% confidence intervals were estimated. Bold values indicate P < 0.05.
Severity of speech disorder and allergy
Children with current asthma compared to those without asthma had significantly higher odds of mild (3.33 [2.45–4.52], p < 0.0001), moderate (2.19 [1.47–3.26], p = 0.0001), and severe (2.51 [1.57–4.01], p = 0.0001) speech disorder in bivariate models (Table S4). The association between mild (2.37 [1.72–3.26], p < 0.0001) and moderate (1.55 [1.05–2.30], p = 0.03) but not severe speech disorder (p = 0.14) remained significant in multivariate models. Hay fever and food allergy were both significantly associated with mild, moderate, and severe speech disorder in bivariate and multivariate models (p < 0.05 for all) (Table S4).
Discussion
The present study found that current history of asthma and one-year history of hay fever and food allergy were significantly associated with increased risk of speech disorder. In a single study that assessed caregiver-reported allergic disease severity, a dose–response effect was determined with severe asthma having a much stronger association with speech disorder than mild or moderate disease, although this dose–response pattern did not hold for hay fever and food allergy. Finally, asthma, hay fever, and food allergy in combination with sleep disturbance or ADD/ADHD were associated with increased risk of speech disorder than any allergy alone.
The characteristics of speech disorder in children with asthma, hay fever, and food allergy have not been fully elucidated. A previous epidemiologic analysis reported on the associations of childhood speech disorder, using data from the 1995 Australian Health Survey on 12,388 children aged 0–14 years, and found the prevalence of childhood speech disorder to be 1.7% (24). This was comparable to the pooled prevalence of 2.4% in the samples analyzed by the present study. However, although the previous study increased prevalence of asthma and allergy in children with speech disorder, the difference was not significant (24). Another study evaluated measures of vocal quality in 40 adults with asthma and 40 age- and sex-matched controls via subjective self-assessment, clinician evaluation, acoustic analyses, and videolaryngostroboscopy (22). Using both self-assessment and clinician assessment, significantly more asthmatics were found to have abnormalities in vocal quality compared to controls. Using videolaryngostroboscopy, patients with asthma were found to have significantly higher rates of at least one abnormality (97.5%) compared with controls (40%). Other studies evaluated the correlation between inhaled corticosteroids and voice disturbances in asthmatics, although these studies did not examine speech patterns or language mastery. A small study found that speech therapy resulted in earlier and longer-lasting control of asthma and allergic rhinitis symptoms in mouth-breathing children (26). Notably, none of these studies controlled for disease severity, medical comorbidity, or sleep disturbance on the association between asthma or hay fever and speech disorder.
The mechanisms of association of childhood asthma and hay fever with speech disorder are likely multifactorial, including the effects of chronic allergic inflammation and sleep disturbance. Asthma and hay fever are associated with immunologic aberrancy including IgE hypersecretion and a Th2 cytokine profile (11, 12). These inflammatory cytokines may cross the blood–brain barrier (27) and affect behavioral, executive, and emotional neurocircuitry. Indeed, a previous functional magnetic resonance imaging study of individuals undergoing asthma episodes found increased activation of the anterior cingulate cortex (ACC) (28), a portion of the brain active during normal speech (29). Abnormal activation of the ACC has also been demonstrated during silent reading and speech tasks in individuals who stutter (30). It is possible that repeated inflammatory insults to neurocircuitry relevant to speech and language increase risk of speech disorders in children with allergy. Similar mechanisms have been posited for the relationship between allergy and ADHD (13, 31). Sleep disturbance may impact language development in childhood (15, 16). One study compared the early-life sleep patterns of 1029 sets of twins from the Quebec Newborn Twin study using assessments of expressive and receptive vocabulary. Children with more consolidated sleep at 6 and 18 months of age had better language skills at ages 18, 30, and 60 months, suggesting that sleep consolidation may have a causal effect on language development (16). Another study found that short sleep duration was associated with a threefold higher risk of poor performance on standardized language assessment, indicating a role for adequate sleep in language acquisition (15). Thus, sleep disturbance in asthma and hay fever may negatively impact on language development. Indeed, the present study found that children with asthma or hay fever and sleep disturbance had the highest odds of speech disorder. However, even children with asthma or hay fever and no sleep disturbance had higher odds of speech disorder compared to children without allergic disease. Future, prospective studies could help determine the etiology of speech disorder in children with asthma and hay fever.
Our study also found a significant association between food allergy and speech disorder, with an effect size similar to the association of asthma and speech disorder. This association may be related to increased allergic inflammation (32) similarly to asthma and hay fever, or due to a link between childhood food allergy and chronic otitis media (18, 19). To our knowledge, there are no previous epidemiologic or prospective analyses that have evaluated any interplay between food allergy and speech disorder. Future, prospective and laboratory studies are needed to illuminate the reasons for these findings.
The present study has several strengths, including the use of 19 population-based studies, each with a large sample size and minimal selection bias, allowing for the assessment of asthma, hay fever, food allergy, and speech disorder in children of all ages and demographic backgrounds. Furthermore, the use of multivariate logistic regression models allowed for the control for potentially confounding variables. The association between allergic disease and speech disorder was highly reproducible and consistent between each study. However, there are several limitations. Asthma, hay fever, and food allergy history were determined by caregiver report and not verified by physician evaluation. Past validation studies have generally found good concordance of asthma and hay fever self-report and that determined by clinician evaluation (33, 34). Speech disorder was also determined by caregiver report and not confirmed by physician or speech pathologist. As such, we were unable to determine what patterns of speech disorder are associated with asthma, hay fever, and food allergy. The questions assessing speech disorder between NSCH and NHIS were slightly different, with NSCH assessing for ‘stuttering, stammering, and other speech problems’ and NHIS assessing for only ‘stuttering or stammering’. This difference might be responsible for possible heterogeneity among respondents of the different surveys. The cross-sectional design prevents any conclusions from being made on causality or direction of association. It is possible that asthma somehow interferes with language development impacting speech disorder. It is also possible that there are unknown genetic or environmental factors that influence both the development of asthma or allergic disease and speech disorder. Finally, we were unable to determine whether treatments for asthma, hay fever, or sleep disturbance could affect manifestation of speech disorder or vice versa. One previous case report found subjective improvement in vocal quality of a patient with asthma after undergoing allergen immunotherapy (35). A small study found that patients with allergic rhinitis or asthma who had undergone allergen immunotherapy for more than 2 years had a significantly lower prevalence of vocal symptoms than those who had not (36). Given these findings and the theorized impact that inflammation may have on speech-related neurocircuitry, it may be that early control of asthma or allergic inflammation mitigates the development of speech disorder. Future experimental and prospective clinical studies with precise determination of speech disorder and allergic disease could help provide this knowledge.
Supplementary Material
Table S1. Survey characteristics.
Table S2. Questions used in this study.
Table S3. Frequency of missing values for variables used in the study.
Table S4. Association between allergic disease and severity of speech problems in NSCH 2007–2008.
Acknowledgments
Funding
This publication was made possible with support from the Agency for Healthcare Research and Quality (AHRQ), grant number K12HS023011, and the Dermatology Foundation. No honorarium, grant or other form of payment was given to anyone to produce the manuscript.
Abbreviations
- aOR
adjusted odds ratio
- CI
confidence interval
- FPL
Federal Poverty Level
- GED
general educational development
- NCHS
National Center for Health Statistics
- NHIS
National Health Interview Survey
- NSCH
National Survey of Children’s Health
- OR
odds ratio
- Prev
prevalence
Footnotes
Additional Supporting Information may be found in the online version of this article
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1. Survey characteristics.
Table S2. Questions used in this study.
Table S3. Frequency of missing values for variables used in the study.
Table S4. Association between allergic disease and severity of speech problems in NSCH 2007–2008.