SUMMARY
OBJECTIVE:
The objective of this study was to investigate the association between breastfeeding, the introduction of specific foods in the first year of life, and asthma symptoms at 6 years of age.
METHODS:
A longitudinal study was conducted involving 956 children in southern Brazil. Asthma symptoms were assessed through the International Study of Asthma and Allergies in Childhood questionnaire. Information regarding breastfeeding and the introduction of complementary foods during the first year of life was obtained through interviews with mothers conducted at home. A multivariate analysis was performed using Poisson regression, and relative risks were estimated to assess the magnitude of the associations.
RESULTS:
Among the 956 children included in the study, 18.7% exhibited asthma symptoms. Male children had a 3% higher incidence [RR=1.03 (95%CI 1.01–1.06); p=0.023]. Children with a family history of asthma showed a 9% higher incidence [RR=1.09 (1.06–1.13); p<0.001] compared to those without such a history. Nonbreastfed children had an 8% higher incidence [RR=1.08 (95%CI 1.02–1.15); p=0.015]. Moreover, children who were introduced to wheat flour during the first year of life had a 4% higher incidence [RR=1.04 (95%CI 1.01–1.06); p=0.020] of asthma symptoms.
CONCLUSION:
Significant and independent associations were observed between asthma symptoms at 6 years of age and male sex, family history of asthma, breastfeeding, and the introduction of wheat flour during the first year of life.
KEYWORDS: Asthma, Breastfeeding, Child nutrition, Children
INTRODUCTION
Asthma, as defined by the 2024 Global Initiative for Asthma (GINA) guidelines, is a chronic respiratory condition characterized by inflammation of the airways, leading to recurrent episodes of wheezing, shortness of breath, cough, and chest tightness. These episodes are often triggered by factors such as allergens, environmental pollutants, physical exertion, and other stimuli. The condition results in airway obstruction, which is generally reversible but can become persistent if not properly managed. Asthma is commonly associated with a history of hypersensitivity and airway inflammation, making it variable in terms of symptom severity and frequency 1 .
Given the complexity of confirming asthma diagnoses in children, epidemiological studies often use questionnaires to identify asthma symptoms 2 . To enhance the value of epidemiological studies on asthma and allergic diseases, the International Study of Asthma and Allergies in Childhood (ISAAC) 3 was developed, providing a standardized method to facilitate international collaboration.
The latest report from the GINA estimates that approximately 300 million people worldwide live with asthma. Additionally, the report warns that the prevalence of asthma has been increasing globally, particularly in urban areas, due to factors such as air pollution, climate change, and lifestyle changes 1 .
Several factors have been proposed to explain this increase, including environmental, economic, psychosocial, and particularly nutritional aspects 4,5 . Asthma is thus associated with a complex set of etiological processes. Some studies 6,7 suggest that dietary patterns may contribute to the increased prevalence of respiratory complications and asthma in children.
Recently, the role of diet, particularly during the first 2 years of life, has been implicated in asthma development, with breastfeeding identified as a significant protective factor 8 . Exclusive breastfeeding for 4 months reduces the risk of asthma between four and 6 years of age 9 . Conversely, the early introduction of cow's milk after discontinuing exclusive breastfeeding is associated with asthma diagnosis in this age group 9 . Lima et al. 10 showed evidence regarding the role of nutrient-rich foods and how their gradual introduction may help modulate the immune response, with a particular focus on avoiding early exposure to specific food allergens, which could be crucial in preventing sensitizations and the development of asthma in childhood. Additionally, the consumption of fruits and vegetables and adherence to the Mediterranean diet are protective factors against asthma 11 .
On the other hand, the increasing prevalence of ultraprocessed foods in family diets may contribute to higher asthma incidence in children due to the poor nutritional quality of these foods 12 .
However, studies exploring the relationship between factors influencing childhood asthma remain limited 13 . Thus, investigating this topic is crucial, as improper dietary habits during early life can lead to chronic inflammatory diseases such as asthma later. Understanding the association between the introduction of various food types in the first 2 years of life and asthma onset may help prevent the disease and improve children's quality of life. This study aimed to examine the possible association between the introduction of different foods during the first year of life and asthma symptoms at 6 years of age.
METHODS
A longitudinal epidemiological study was conducted using data from the Coorte Brasil Sul cohort 14 . This cohort study was carried out in Palhoça, SC, a municipality in the Brazilian Southern state of Santa Catarina with a population of approximately 227,000 inhabitants.
The study population comprised children born in 2009 who were followed up until 2015, when they were 6 years old. The minimum sample size calculation for this study used the following parameters: a population of 1,756 children, an anticipated prevalence of asthma symptoms (p=50%), a 95% confidence level, and a 4% relative error, resulting in a minimum sample size of 448 children. The dataset contained information on 956 children, and all were included in this study.
The Coorte Brasil Sul study 14 collected data through interviews using the ISAAC questionnaire 2 and structured instruments for sociodemographic information. Interviews were conducted with the mothers in their homes or, in their absence, with the child's primary caregiver. Data collection was carried out by the Coorte Brasil Sul 14 research team, supported by trained community health agents from Palhoça, SC. Duplicate data collection was performed on 5% of the sample population, selected randomly, to monitor the reproducibility of the information.
The dependent variable in this study was the mother's report of asthma symptoms at 6 years of age, based on the ISAAC questionnaire 3 question: "Has your child had wheezing in the chest in the last 12 months?" (yes or no). Independent variables included: child's sex (male or female); skin color (white or non-white); maternal education at birth (up to eight years of schooling or more than eight years); family history of asthma (yes or no); breastfeeding (yes or no); presence of smokers in the household (yes or no); and the consumption of specific foods in the first year of life: eggs, wheat products (e.g., pasta, bread, and cake), soy, corn, seafood, and fish (yes or no).
The dataset was prepared using Excel software and analyzed with SPSS version 18.0 (SPSS Inc., Chicago, IL., USA). Variables were described using proportions and 95% confidence intervals. Bivariate analysis was conducted using the chi-square test, with a significance level of p<0.05. The multivariate analysis included variables with p<0.20 in the bivariate analysis and used Poisson regression. Variables with p<0.05 were considered significant and independent. Relative risk (RR) and 95% confidence intervals were used as measures of association. The research project was approved by the Ethics Committee of the Universidade do Sul de Santa Catarina, Brazil, under the approval number 38240114.0.0000.5369.
RESULTS
A total of 956 6-year-old children participated in the study, of whom 491 (51.4%) were male and 798 (83.3%) were white. Additional sociodemographic variables are shown in Table 1.
Table 1. Results of the association study between asthma symptom reports at 6 years of age and sociodemographic variables, breastfeeding, family history of asthma, and smoking within the household (Palhoça, SC, Brazil).
| Variables | Asthma symptoms | p-value | |||
|---|---|---|---|---|---|
| Yes | No | Total | |||
| n (%) | n (%) | n (%) | |||
| Sex (n=956) | |||||
| Male | 103 (21.0) | 388 (79.0) | 491 (51.4) | 0.066 | |
| Female | 76 (16.3) | 389 (83.7) | 465 (48.6) | ||
| Skin color (n=956) | |||||
| Non-white | 40 (25.0) | 120 (75.0) | 160 (16.7) | 0.025 | |
| White | 88 (17.5) | 417 (82.5) | 505 (83.3) | ||
| Maternal education at birth (years) (n=901) | |||||
| ≤8 years | 139 (17.5) | 657 (82.5) | 796 (46.3) | 0.094 | |
| >8 years | 88 (21.1) | 329 (78.9) | 417 (53.7) | ||
| Breastfeeding (n=956) | |||||
| Yes | 81 (16.7) | 403 (83.3) | 484 (91.1) | <0.001 | |
| No | 150 (17.2) | 721 (82.8) | 871 (8.9) | ||
| Family history of asthma (n=946) | |||||
| Yes | 28 (32.9) | 57 (67.1) | 85 (45.7) | <0.001 | |
| No | 121 (28.0) | 311 (72.0) | 432 (54.3) | ||
| Smoking within household (n=956) | |||||
| Yes | 54 (25.7) | 136 (74.3) | 183 (19.2) | 0.007 | |
| No | 132 (17.1) | 641 (82.9) | 773 (80.8) | ||
The reported prevalence of asthma symptoms in the past 12 months was 18.7% (95%CI 16.2–21.1), with associations observed for skin color (p=0.025), breastfeeding (p<0.001), family history of asthma (p<0.001), and the presence of smokers in the household (p=0.007) (Table 1). Table 2 presents data on the introduction of specific foods in the first year of life, with wheat products showing a significant association with asthma symptoms (p=0.006).
Table 2. Results of the association study between the introduction of specific foods in the first year of life and asthma symptoms at 6 years of age (Palhoça, SC, Brazil).
| Variables | Asthma symptoms | p-value | |||
|---|---|---|---|---|---|
| Yes | No | Total | |||
| n (%) | n (%) | n (%) | |||
| Cow's milk and dairy products (n=949) | |||||
| Yes | 162 (18.7) | 704 (81.3) | 866 (91.2) | 0.899 | |
| No | 16 (19.3) | 67 (80.7) | 83 (8.8) | ||
| Wheat flour (n=956) | |||||
| Yes | 133 (21.3) | 493 (78.7) | 626 (65.5) | 0.006 | |
| No | 46 (13.9) | 284 (86.1) | 330 (34.5) | ||
| Soy and derivatives (n=953) | |||||
| Yes | 152 (19.2) | 638 (80.8) | 790 (82.9) | 0.198 | |
| No | 25 (15.3) | 138 (84.7) | 163 (17.1) | ||
| Corn and derivatives (n=956) | |||||
| Yes | 41 (23.2) | 136 (76.8) | 177 (18.5) | 0.090 | |
| No | 138 (17.7) | 641 (82.3) | 779 (81.5) | ||
| Chicken egg (n=947) | |||||
| Yes | 95 (19.8) | 384 (80.2) | 479 (50.6) | 0.318 | |
| No | 81 (17.3) | 387 (82.7) | 468 (49.4) | ||
| Fish (n=956) | |||||
| Yes | 70 (18.8) | 303 (81.2) | 373 (39.0) | 0.959 | |
| No | 163 (18.9) | 702 (81.1) | 865 (90.5) | ||
| Seafood (n=956) | |||||
| Yes | 109 (18.7) | 474 (81.3) | 583 (61.0) | 0.777 | |
| No | 16 (17.6) | 75 (82.4) | 91 (9.5) | ||
The multivariate analysis results are detailed in Table 3. Boys had a 3% higher incidence of asthma symptoms than girls, which was statistically significant and independent [RR=1.03 (95%CI 1.01–1.06); p=0.023]. Similarly, children with a family history of asthma had a 9% higher incidence of symptoms compared to those without a family history [RR=1.09 (95%CI 1.06–1.13); p<0.001]. Nonbreastfed children had an 8% higher incidence [RR=1.08 (95%CI 1.02–1.15); p=0.015], and children introduced to wheat products before 1 year of age had a 4% higher incidence [RR=1.04 (95%CI 1.01–1.06); p=0.020].
Table 3. Results of the multivariate analysis between asthma symptom reports at 6 years of age and the studied independent variables (Palhoça, SC, Brazil).
| Variables | RRc (95%CI) | p-value | RRa (95%CI) | p-value | |
|---|---|---|---|---|---|
| Sex | |||||
| Female | 1.00 | 0.066 | 1.00 | 0.023 | |
| Male | 1.03 (0.99; 1.05) | 1.03 (1.01; 1.06) | |||
| Skin color | |||||
| White | 1.00 | 0.025 | 1.00 | 0.118 | |
| Non-white | 1.04 (1.01; 1.09) | 1.03 (0.99–1.08) | |||
| Maternal education at birth (years) | |||||
| >8 years | 1.00 | 0.094 | 1.00 | 0.270 | |
| ≤8 years | 1.02 (0.99; 1.05) | 1.02 (0.99–1.05) | |||
| Family history of asthma | |||||
| No | 1.00 | <0.001 | 1.00 | <0.001 | |
| Yes | 1.10 (1.07; 1.13) | 1.09 (1.06–1.13) | |||
| Breastfeeding | |||||
| Yes | 1.00 | <0.001 | 1.00 | 0.015 | |
| No | 1.09 (1.03; 1.16) | 1.08 (1.02–1.15) | |||
| Smoking within household | |||||
| No | 1.00 | 0.007 | 1.00 | 0.428 | |
| Yes | 1.05 (1.01; 1.09) | 1.02 (0.98–1.06) | |||
| Introduction of wheat flour in the first year of life | |||||
| No | 1.00 | 0.006 | 1.00 | 0.020 | |
| Yes | 1.04 (1.01; 1.07) | 1.04 (1.01–1.06) | |||
| Introduction of soy and derivatives in the first year of life | |||||
| No | 1.00 | 0.198 | 1.00 | 0.449 | |
| Yes | 1.03 (0.98; 1.07) | 1.01 (0.97–1.07) | |||
| Introduction of corn and derivatives in the first year of life | |||||
| No | 1.00 | 0.090 | 1.00 | 0.971 | |
| Yes | 1.03 (0.99; 1.07) | 1.01 (0.96–1.05) | |||
RRc: crude relative risk; RRa: adjusted relative risk; 95%CI: 95% confidence interval. Omnibus test p=0.757.
DISCUSSION
This study found an 18.7% prevalence of asthma symptoms among 6-year-olds, using the ISAAC questionnaire 3 . This rate is lower than that reported in a study 15 conducted in São Paulo, SP, Brazil, using a similar methodology, which observed a prevalence of 31.2%. Similar studies conducted in 20 other Brazilian cities among the same age group reported prevalences of 24.4% in Manaus, AM, 29.9% in Natal, RN, and 20.6% in Itajaí, SC 15 .
While this study's methods do not allow for definitive explanations of the prevalence differences, sociodemographic characteristics and the time elapsed between studies may account for these contrasts. Environmental factors, particularly air pollution, have been associated with higher asthma prevalence in urban areas 16 .
Asthma is a complex, multifactorial disease characterized by chronic airway inflammation, with genetic and environmental determinants of its allergic phenotype 1 . Factors such as sex, family history of asthma, breastfeeding, and the introduction of dietary allergens in the first year of life are associated with asthma 17,18 .
In the Holt et al. study 17 , boys had a 3% higher incidence of asthma symptoms than girls, consistent with evidence that being male is a risk factor in childhood, although this trend reverses in adolescence 17 . This sex-related difference may be explained by narrower airways in boys during childhood, though this remains a controversial topic 17 .
Family genetics also play a critical role in asthma, with parental asthma being a strong predictor of asthma in children 19 . Studies indicate that children are three times more likely to develop asthma if one parent has the disease and six times more likely if both parents are affected 18 . This study supports this finding, as it observed that children with a family history of asthma had a 9% higher incidence of asthma symptoms compared to those without a family history of the disease.
Breastfeeding emerged as a protective factor against asthma. Breast milk provides immunological components, such as IgA and IgG, which contribute to passive immunization, as well as anti-inflammatory agents, immunomodulators, and essential nutrients absent in nonmaternal milk 19 . Introducing nonmaternal milk before four months of age increases asthma and atopy risks later in childhood 20 . Furthermore, delaying the introduction of nonbreast milk until at least four months of age may protect against asthma and atopy later in childhood 21 . Accordingly, this study aligns with previous research, highlighting breastfeeding as a protective factor against asthma, showing that nonbreastfed children had an 8% higher incidence of asthma.
This study also found a significant association between the introduction of wheat products before one year of age and asthma symptoms at 6 years. Wheat is one of the most common triggers of allergic reactions in children due to proteins such as albumins, globulins, and gliadins, which activate the immune system 22,23 . A study 24 found a 64% incidence of asthma in children sensitized to gliadin. Additionally, another study 25 on childhood allergies demonstrated that children sensitized to six common food allergens (egg, milk, soy, peanut, wheat, and fish) had higher rates of asthma-related hospitalizations. This aligns with the present study, which showed that children introduced to wheat flour in their diet before the age of one had a 4% higher incidence of asthma symptoms. However, in this study, no statistically significant and independent associations were observed with the introduction of cow's milk and its derivatives, soy and its derivatives, corn and its derivatives, chicken eggs, fish, or seafood during the first year of life.
While these findings are significant, some limitations should be noted, such as potential recall bias in caregiver reports and insufficient depth in exploring certain variables. The use of the ISAAC [3] allows for symptom reporting but not an asthma diagnosis. Moreover, some variables require more in-depth investigation to better clarify their actual influence on the final outcome, such as whether breastfeeding was exclusively maternal or supplemented. Longitudinal studies are needed to further investigate the role of early dietary factors in asthma development, including foods for which there is some evidence, but which were not confirmed in this study.
In conclusion, this study identified higher asthma symptom incidence among boys, children with a family history of asthma, nonbreastfed children, and those introduced to wheat products before 1 year of age.
Funding Statement
this work was supported by the FAPESC/Brazil under Grant 09/2015.
Footnotes
Funding: this work was supported by the FAPESC/Brazil under Grant 09/2015.
DATA AVAILABILITY STATEMENT.
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.