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Breastfeeding and risk of childhood asthma: a systematic review and meta-analysis

Mike Xue, Emily Dehaas, Nagendra Chaudhary, Paul O'Byrne, Imran Satia, Om P. Kurmi
ERJ Open Research 2021 7: 00504-2021; DOI: 10.1183/23120541.00504-2021
Mike Xue
1Dept of Family Medicine, Queen's University, Kingston, Canada
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Emily Dehaas
2Dept of Medicine, University of Toronto, Toronto, Canada
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Nagendra Chaudhary
3Dept of Pediatrics, Universal College of Medical Sciences, Bhairahawa, Nepal
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  • ORCID record for Nagendra Chaudhary
Paul O'Byrne
4Dept of Medicine, Division of Respirology, McMaster University, Hamilton, Canada
5Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
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Imran Satia
4Dept of Medicine, Division of Respirology, McMaster University, Hamilton, Canada
5Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
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Om P. Kurmi
4Dept of Medicine, Division of Respirology, McMaster University, Hamilton, Canada
5Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
6Faculty Centre for Intelligent Healthcare, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
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  • For correspondence: om.kurmi@coventry.ac.uk
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  • FIGURE 1
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    FIGURE 1

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart highlighting the article identification process.

  • FIGURE 2
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    FIGURE 2

    Pooled effect sizes and quality# of main analyses. a) More¶ exclusive+ breastfeeding versus less exclusive breastfeeding; b) more breastfeeding versus less breastfeeding; and c) ever versus never breastfed. Random-effects restricted maximum likelihood model. #: Coloured bar represents proportion of groups of good/fair/poor quality; ¶: “more” implying longer duration of breastfeeding; +: “exclusive” indicating breastmilk only with no other solids/liquids.

  • FIGURE 3
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    FIGURE 3

    Pooled effect sizes of all meta-analyses including breastfeeding type, duration, age and study quality.

  • FIGURE 4
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    FIGURE 4

    Funnel plots evaluating for publication bias in the main analyses. a) More# exclusive¶ breastfeeding versus less exclusive breastfeeding; b) more breastfeeding versus less breastfeeding; and c) ever versus never breastfed. #: “more” implying longer duration of breastfeeding; ¶: “exclusive” indicating breastmilk only with no other solids/liquids.

Tables

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  • TABLE 1

    Study quality based on modified# Newcastle–Ottawa Scale (NOS) for cohort studies

    First author, year [reference]1) Representativeness of the exposed cohort2) Selection of the nonexposed cohort3) Ascertainment of exposure4) Appropriate temporality for breastfeeding assessment#5) Comparability of cohorts based on the design or analysis controlled for confounders (out of 2)6) Assessment of outcome7) Appropriate number of follow-ups conducted for detection of outcome#8) Adequacy of follow-up of cohortsTotal (out of 9)Quality¶
    Ajetunmobi, 2015 [14]⋆⋆⋆⋆⋆⋆6Fair
    Alm, 2008 [15]⋆⋆⋆⋆⋆⋆6Fair
    Bacopoulou, 2009 [16]⋆⋆⋆⋆4Low
    Bion, 2016 [17]⋆⋆⋆⋆⋆⋆⋆⋆⋆9Good
    Burr, 1993 [18]⋆⋆⋆⋆⋆5Low
    Chiu, 2016 [19]⋆⋆⋆⋆⋆⋆⋆⋆8Good
    Davidson, 2010 [20]⋆⋆⋆⋆4Low
    den Dekker, 2016 [21]⋆⋆⋆⋆⋆5Fair
    Elliott, 2008 [22]⋆⋆⋆⋆4Low
    Fredriksson, 2007 [23]⋆⋆⋆⋆⋆5Fair
    Karmaus, 2008 [24]⋆⋆⋆⋆⋆⋆⋆7Good
    Kiechl-Kohlendorfer, 2007 [25]⋆⋆⋆⋆⋆⋆6Fair
    Klingberg, 2019 [26]⋆⋆⋆⋆⋆⋆⋆7Good
    Klopp, 2017 [27]⋆⋆⋆⋆⋆⋆⋆7Good
    Kull, 2002 [28]⋆⋆⋆⋆⋆⋆6Fair
    Lee, 2017 [29]⋆⋆⋆⋆⋆⋆⋆⋆8Good
    Leung, 2016 [30]⋆⋆⋆⋆⋆⋆⋆⋆8Good
    Mandhane, 2007 [31]⋆⋆⋆⋆⋆5Low
    McConnochie, 1986 [32]⋆⋆⋆⋆4Low
    Midodzi, 2010 [33]⋆⋆⋆⋆⋆⋆⋆7Good
    Midwinter, 1987 [34]⋆⋆⋆⋆4Low
    Mihrshahi, 2007 [35]⋆⋆⋆⋆⋆⋆⋆⋆8Fair
    Milner, 2004 [36]⋆⋆⋆3Low
    Miyake, 2008 [37]⋆⋆⋆⋆⋆5Fair
    Nwaru, 2013 [38]⋆⋆⋆⋆⋆⋆⋆⋆8Good
    Nwaru, 2013 [39]⋆⋆⋆⋆⋆5Low
    Oddy, 2002 [40]⋆⋆⋆⋆⋆⋆⋆7Good
    Oddy, 2004 [41]⋆⋆⋆⋆⋆⋆⋆7Good
    Sbihi, 2016 [42]⋆⋆⋆⋆⋆⋆⋆7Low
    Silvers, 2009 [43]⋆⋆⋆⋆⋆⋆⋆7Good
    Silvers, 2012 [44]⋆⋆⋆⋆⋆⋆⋆7Good
    Standl, 2012 [45]⋆⋆⋆⋆⋆5Low
    Strömberg Celind, 2018 [46]⋆⋆⋆⋆⋆⋆6Fair
    Sunyer, 2006 [47]⋆⋆⋆⋆⋆⋆6Fair
    Turner, 2008 [48]⋆⋆⋆⋆⋆7Fair
    van Meel, 2017 [49]⋆⋆⋆⋆⋆⋆⋆7Good
    von Kobyletzki, 2012 [50]⋆⋆⋆⋆⋆5Fair
    Wickman, 2003 [51]⋆⋆⋆⋆⋆⋆6Fair
    Wilson, 1998 [52]⋆⋆⋆⋆⋆⋆6Fair
    Wright, 2000 [53]⋆⋆⋆⋆⋆⋆6Fair
    Wright, 2001 [54]⋆⋆⋆⋆⋆5Low
    Yamakawa, 2015 [55]⋆⋆⋆⋆⋆⋆6Fair

    #: NOS modifications. 1) Selection: demonstration that outcome of interest was not present at the start of the study; since this is essentially an assessment of temporality of the exposure, but is not particularly applicable to the types of articles we are screening, we changed it to “Does the article assess for breastfeeding at an appropriate time to avoid recall bias (i.e. <2 years of age)?”. 2) Comparability: our three adjusted confounders were family history of asthma or atopy, gestational age and cigarette exposure pre- or post-natally (studies received one star for adjusting for all three, and an additional star for adjusting for other confounders). 3) Outcome (follow-up length): follow-up length is not relevant for the detection of outcome we are looking for; instead we looked at the frequency of follow-up as this is more sensitive for transient asthma diagnoses that may not be chronic; this will be rater-dependent; however, points that will be considered include the total number of follow-ups as well as the timing of the follow-ups (i.e. asthma at 10 years: four well-spaced follow-ups versus three in the first year and one at 10 years). ¶: NOS conversion to Agency for Healthcare Research and Quality low-, fair- and good-quality scale. Low: <4 NOS stars OR no adjustment for confounders (5 stars) OR nonrepresentative population (1 star) OR major flaw in methodology as determined by assessors; fair: 4–6 NOS stars with adjustment of confounders (5 stars) AND representative sample (1 star) AND an appropriate number of follow-ups conducted for detection of outcome (7 stars); good: >6 NOS stars AND adjustment of confounders with the inclusion of key confounders (5 stars) AND representative sample (1 stars) AND an appropriate number of follow-ups conducted for detection of outcome (7 stars) AND assessment of breastfeeding at a temporally appropriate time to reduce recall bias (4 stars).

    Supplementary Materials

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      Supplementary material 00504-2021.SUPPLEMENT

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    Breastfeeding and risk of childhood asthma: a systematic review and meta-analysis
    Mike Xue, Emily Dehaas, Nagendra Chaudhary, Paul O'Byrne, Imran Satia, Om P. Kurmi
    ERJ Open Research Oct 2021, 7 (4) 00504-2021; DOI: 10.1183/23120541.00504-2021

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    Breastfeeding and risk of childhood asthma: a systematic review and meta-analysis
    Mike Xue, Emily Dehaas, Nagendra Chaudhary, Paul O'Byrne, Imran Satia, Om P. Kurmi
    ERJ Open Research Oct 2021, 7 (4) 00504-2021; DOI: 10.1183/23120541.00504-2021
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