Cesarean Section and Risk of Severe Childhood Asthma: A Population-Based Cohort Study

doi:10.1016/j.jpeds.2008.01.029

The Journal of Pediatrics

Volume 153, Issue 1, July 2008, Pages 112-116.e1

https://doi.org/10.1016/j.jpeds.2008.01.029 Get rights and content

Objective

To explore the possible association between delivery by cesarean section (CS) and later development of asthma.

Study design

A population-based cohort study of 1,756,700 singletons reported to the Medical Birth Registry of Norway between 1967 and 1998, followed up to age 18 years or the year 2002. Exposure was the mode of delivery (spontaneous vaginal, instrumental vaginal, or CS, with planned and emergency CS separately from 1988 onward). Outcome was asthma registered in the National Insurance Scheme, which provides cash benefits to families of children with severe chronic illnesses. We used multivariate Cox proportional hazard models to examine associations between exposure and outcome.

Results

The cumulative incidence of asthma was 4.0/1000. Children delivered by CS had a 52% increased risk of asthma compared with spontaneously vaginally delivered children (adjusted hazard ratio [HR] = 1.52; 95% confidence interval [CI] = 1.42 to 1.62). Between 1988 and 1998, planned and emergency CS was associated with a 42% (HR = 1.42; 95% CI = 1.25 to 1.61) and 59% (HR = 1.59; 95% CI = 1.44 to 1.75) increased risk of asthma, respectively.

Conclusion

We found a moderately increased risk of asthma in the children delivered by CS. The possibly stronger association with emergency CS compared with planned CS could be worth pursuing to investigate possible causal mechanisms.

Section snippets

Methods

Established in 1967, the Medical Birth Registry of Norway (MBRN) is based on compulsory notification of all live births and stillbirths after 16 weeks of gestation.¹⁸ The MBRN contains data on mode of delivery (spontaneous vaginal, instrumental vaginal [forceps or vacuum extraction], or CS), year of birth, maternal age and marital status, birth order, maternal diagnoses, and infant gestational age, sex, and medical condition. The MBRN is routinely linked to the Central Population Registry, to

Results

The rate of CS gradually increased from 1.7% in 1967 to a plateau of 11% to 12% between 1985 and 1998 (Figure). The cumulative incidence of asthma by year of birth increased until 1992. The subsequent observed decrease likely was due to the fact that many children born thereafter had not yet developed asthma or applied for benefits by 2002. The overall cumulative incidence of asthma (by age 18 or year 2002) was 4.0/1000.

The prevalence of asthma was 2.3% in the women who delivered by CS, 1.9% in

Discussion

Between 1967 and 1998, children born by CS had a moderately increased risk and children born by instrumental vaginal delivery had a slightly increased risk of developing asthma. Between 1988 and 1998, this association apparently was stronger for emergency CS than for planned CS. The association also was consistently stronger for preterm children than for term children.

Important strengths of our study include the large, population-based cohort of children and the long follow-up period. The

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La Guía Española para el Manejo del Asma, mejor conocida por su acrónimo en español, GEMA, está a nuestra disposición desde hace más de veinte años. Veintiuna sociedades científicas o grupos relacionados, tanto de España como de otros países, han participado en la preparación y desarrollo de la edición actualizada de GEMA que, de hecho, se ha posicionado en la actualidad a nivel mundial como la guía de referencia sobre asma en lengua española.
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Short-term and long-term effects of cesarean section on asthma and wheezing: A cohort study and meta-analysis
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To describe the short-term and long-term effects of cesarean section on childhood asthma and wheezing.
Firstly, in the cohort study, 6640 infants were included in the cohort baseline from January 2018 to December 2019, in which 6501 children completed the follow-up study for respiratory diseases at age 2 years. The effect of cesarean section on asthma and wheezing was estimated by the logistic regression model. Secondly, we conducted a meta-analysis of studies with outcomes of childhood asthma and wheezing under 2 years of age and over 2 years of age, respectively, to investigate the short-term and long-term effects of cesarean section on asthma and wheezing.
In our cohort study, the cumulative incidence of asthma and wheezing was 1.3% (84/6501). 45.5% of children (2961/6501) were born by cesarean section. The adjusted odds ratio for the effect of cesarean section on asthma and wheezing in children under 2 years of age was 1.14 (95%CI 0.73–1.78). Combining previous studies (outcomes of asthma and wheezing under 2 years of age) with our results for a meta-analysis, the odds ratio was 1.15 (95%CI 1.05–1.25, I² = 46.82%). Meanwhile, cesarean section had a long-term effect on asthma and wheezing in the child population over 2 years of age (OR = 1.17, 95%CI 1.11–1.24, P < 0.001, I² = 79.38%).
Cesarean section had a short-term effect on asthma and wheezing before the age of 2, in addition, the long-term effect of cesarean section on asthma and wheezing persisted in the child population (under 18).
Should we apply a treatable traits approach to asthma care?
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To explore the evidence for adopting a “treatable traits” approach to asthma management.
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The above-mentioned databases were searched for randomized, controlled phase III or IV trials of adults containing the word “asthma” in the title published in the previous 10 years and for all articles containing the title words “treatable AND trait(s),” “asthma AND biomarker(s) OR smoking OR obesity OR laryngeal OR management” published within the previous 5 years. Articles were excluded if they were not published in English. Our search identified 257 articles for consideration. We also manually searched the reference lists of studies identified and searched the websites of the British Thoracic Society, European Respiratory Society, National Institute for Health and Care Excellence, and Global Initiative for Asthma for specific guidance related to asthma management.
The “treatable traits” are described within 3 domains of pulmonary, extrapulmonary, or behavioral and lifestyle traits. We consider whether treatment should be targeted toward these traits where they are present in asthma patients, based on currently available evidence, rather than increasing treatment in response to symptoms in line with current step-up, step-down asthma management guidelines.
We advocate that a treatable traits approach should be applied more broadly to the assessment and management of inadequately controlled asthma, rather than a step-up, step-down approach based on patient symptoms. This approach should be focused on the 2 treatable pulmonary traits of T_H2 inflammation and airflow obstruction along with smoking cessation, in the first instance.
Are children born by cesarean delivery at higher risk for respiratory sequelae?
2022, American Journal of Obstetrics and Gynecology
Globally, the number of children born by cesarean delivery is constantly increasing. However, hormonal and physiological changes associated with labor and vaginal delivery are considered necessary for lung maturation.
We aimed to assess whether the mode of delivery is associated with changes in respiratory and atopic outcomes during infancy and at school age.
We included 578 children, born at ≥37 weeks of gestation, from a prospective birth cohort study. We compared weekly respiratory symptoms throughout the first year of life and infant lung function (tidal breathing and multiple-breath washout) at 5 weeks of age between children born by cesarean delivery (N=114) and those born by vaginal delivery (N=464) after term pregnancy in healthy women. At a follow-up visit conducted at 6 years of age (N=371, of which 65 were delivered by cesarean delivery), we assessed respiratory, atopic, and lung function outcomes (spirometry, body plethysmography, and multiple-breath washout). We performed adjusted regression analyses to examine the association between cesarean delivery and respiratory and atopic outcomes. To account for multiple testing, we used the Bonferroni correction, which led to an adapted significance level of P<.002.
During infancy, children born by cesarean delivery did not have more respiratory symptoms than those born by vaginal delivery (median, 4 weeks; interquartile range, 7 weeks vs median, 5 weeks; interquartile range, 7 weeks; adjusted incidence rate ratio, 0.8; 95% confidence interval, 0.6–1.0; P=.02). Infant lung function was similar between the groups. Children born by cesarean delivery did not have a higher incidence of “ever wheezing” (adjusted odds ratio, 0.9; 95% confidence interval, 0.5–1.8; P=.78) or current asthma (adjusted odds ratio, 0.4; 95% confidence interval, 0.0–3.5; P=.42) at school age than those born by vaginal delivery. There was no difference in the lung function parameters between the groups.
Cesarean delivery was not associated with respiratory symptoms in the first year of life, nor with different respiratory or atopic outcomes at school age, when compared with vaginal delivery. Our results indicate that there are no long-term consequences on the respiratory health of the child associated with cesarean delivery.
The effect of gestational diabetes mellitus on the risk of asthma in offspring
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To examine the effect of maternal gestational diabetes mellitus on the risk of asthma in the offspring.
This cohort study used data from 19,933 children in the National Longitudinal Survey of Children and Youth (NLSCY), 1994/1995–2008/2009, Canada. Children were followed until the first-time report of having health professional-diagnosed asthma (hereafter incident asthma), loss to follow-up, or end of the NLSCY follow-up, whichever occurred first. As a surrogate for Cox proportional hazards regression, pooled logistic regression models, crude and adjusted for potential confounders, were fitted to estimate the effect of gestational diabetes mellitus on the risk of asthma in the offspring.
Among the 19,933 children, 1,178 (5.9%) had mothers with gestational diabetes mellitus. The median duration of follow-up was 4 (interquartile range: 4) years. A total of 1639 children in the cohort had reported incident asthma during the follow-up, and 119 of them had mothers with gestational diabetes mellitus. The adjusted hazard ratio for the association between gestational diabetes mellitus and incident asthma in offspring was 1.25 (95% confidence interval [CI] 1.03, 1.51).
Our findings suggest that gestational diabetes mellitus increases the risk of asthma in the offspring.
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View all citing articles on Scopus

: This study was funded by the Research Council of Norway, which had no involvement in the authors' work.

: The authors have no conflicts of interest to declare.

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Original articleCesarean Section and Risk of Severe Childhood Asthma: A Population-Based Cohort Study

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

Paediatr Respir Rev

Am J Obstet Gynecol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Pediatr

Am J Obstet Gynecol

Soc Sci Med

Am J Obstet Gynecol

Role of intestinal flora in the development of allergy

Curr Opin Allergy Clin Immunol

Influence of mode of delivery on gut microbiota composition in seven-year-old children

Gut

Original article
Cesarean Section and Risk of Severe Childhood Asthma: A Population-Based Cohort Study