epiH Search


Epidemiol Health > Volume 36; 2014 > Article
Khalkhali, Oshnouei, Salarilak, Rahimi Rad, Karamyar, and Khashabi: Effects of antibiotic consumption on children 2-8 years of age developing asthma



Antibiotic exposure in children is a possible contributor to the increasing asthma prevalence in several countries. The present study aimed to investigate the association between antibiotic exposure and the risk of developing childhood asthma at 2-8 years of age.


A case-control study was undertaken among children aged 2-8 years old between March and September 2010 in the Urmia district in the northwest of Iran. The cases were doctor-diagnosed asthmatic children based on Global Initiative for Asthma criteria (n=207), and the controls were children without respiratory symptoms (n=400) selected by frequency matching by age and gender. Clinical data including antibiotic exposure was collected by a validated and reliable questionnaire, which was completed by interviewing parents/guardians.


Antibiotic consumption during the first year of life increased the odds ratio [OR] of asthma symptoms at 2-8 years of age (crude OR, 2.26; 95% confidence interval [CI], 1.53-3.35; p<0.01), and the strength of association was similar after adjusting for a family history of asthma or atopic disorder, preterm delivery, birth order, and delivery method (adjusted OR, 1.91; 95% CI, 1.27-2.88; p=0.03).


Our study suggests that antibiotic consumption in children was associated with an increased risk of childhood asthma, and an additional confirmative study is needed.


Asthma is the most common chronic disease in childhood, affecting up to 300 million people in the world [1]. During the last decades, many lifestyle behaviors including, dietary patterns, and health behaviors related with life style have changed the pattern of asthma and other respiratory disorders across the world, particularly in developing countries [2].
Antibiotics are broadly used to treat various infections in childhood. A great deal of evidence suggests that gastrointestinal flora plays a prominent role in developing a healthy immune system and resistance to allergic sensitization [3]. Newer studies have shown that antibiotic consumption in early life may increase the development of asthma by reducing the protective effect of bacterial infections and disturbance of the normal gut bacterial flora [4,5]. but no significant association between antibiotic exposure and developing asthma and other allergic disorders in childhood has been identified [6]. Nevertheless, decreasing excess antibiotic consumption in childhood is recommended [7].
This article reports on data drawn from a observational study investigating potential risk factors for the development of childhood asthma in subjects 2-8 years of age in the city of Urmia, in the northwest of Iran, and the primary objective was to investigate the association between antibiotic exposure and the risk of developing childhood asthma.


This investigation was a case-control study conducted between March and September 2010 in Urmia, Iran.
The study was approved by the Human Research Ethics Committee of Urmia University of Medical Sciences, and the questionnaire was administered by the author after verbal consent was obtained from all of the participating children’s parents.
The cases (n=207) were selected from among children 2-8 years of age who were referred to the Motahhari Children’s Polyclinic and the Asthma and Allergy Pediatric Center. To recruit incident asthmatic patients, we adopted the Global Initiative for Asthma (GINA) criteria prospectively between March and September 2010. The patient’s history of lower respiratory infections was assessed in the questionnaire in order to reduce the likelihood of reverse causation and reduce the likelihood of needing a differential diagnosis between asthma and respiratory tract infections, all of the patients with a history of severe respiratory infections during the first two years of life were excluded from the study population.
Controls (n=400) were selected from among children of the same age range whose parents did not report any history of asthma or allergic disorders. To reduce selection bias, we selected controls from hospitalized and healthy children who visited the Motahhari Children’s Polyclinic, matched by age and gender using the frequency matching method: The hospitalized controls were selected from among the patients without any allergic or respiratory disease, and the healthy controls were selected from among the children that were referred to the health centers for their routine growth monitoring. Additional controls were recruited from areas of the city in which the cases were living to reduce socioeconomic differences and other unknown confounding factors between cases and controls.
A validated questionnaire prepared by the International Study of Asthma and Allergies in Childhood (ISSAC, Phase III) was used for data collection. It was translated into the Persian language first, and data related to the history of antibiotic consumption in the first year of life and during pregnancy were collected by interviewing the parents/guardians.
All of the questionnaires were completed by one interviewer in order to enhance the reliability of the results.
Because all of the risk factors in the childhood asthma-based ISSAC hypotheses were evaluated in this study, we used procedures to identify factors related to childhood asthma.
The Pearson chi-squared test was applied to assess the association between antibiotic exposure and risk of childhood asthma. We fitted multiple logistic regression models using a stepwise selection strategy with statistically significant variables that were reported as confounding factors in previous studies including maternal smoking, history of asthma or atopic disease in the first- and second-degree relatives, duration of breastfeeding, number of older/younger siblings in the household, preterm delivery, and delivery method [8,9]. STATA version 10.0 (StataCorp, College Station, TX, USA) was used for data analysis.


Antibiotics were used by 45 cases (23.7%), 43 healthy controls (14.9%), and 40 (20.5%) hospitalized control mothers of patients. Maternal antibiotic consumption during pregnancy had no significant effects on the risk of developing asthma in the study population; therefore, it was not entered in the regression model (crude odds ratio [OR], 1.20; 95% confidence interval [CI], 0.76-0.84; p=0.42).
Antibiotics were used by 120 cases (71.9%) and 205 controls (56.7 and 49.2% of hospitalized and healthy controls, respectively) during the first year of life, and this had a significant effect on the risk of asthma (p<0.01). All of mothers was not report history of smoking during pregnancy (Table 1).
Table 2 shows crude and adjusted odds ratios for the association of antibiotic consumption and other important risk factors during the first year of life and the risk of asthma in children 2-8 years of age. Interactions between antibiotic consumption and other asthma risk factors were not statistically significant and were thus removed in a stepwise selection method (p>0.05). Antibiotic consumption during the first year of life increased the risk of asthma symptoms at 2-8 years of age (crude OR, 2.26; 95% CI, 1.50-3.35; p<0.01 and adjusted OR, 1.91; 95% CI, 1.27-2.88; p<0.05).


Antibiotic exposure during the first year of life significantly increased the risk of asthma at 2-8 years of age. Even though antibiotic exposure during fetal development was higher among the cases than the control groups (23.7% of cases vs. 22.6% of controls), the difference was not statistically significant (p=0.57).
Although our study design has the same limitations of other case-control studies, we tried to reduce interviewer bias by having a single trained nurse conduct all interviews. The standard GINA criteria were used to avoid the common differential in childhood asthma. Antibiotic consumption during the first year of life increased odds of asthma at 2-8 years, and this association was persistent even after adjusting for significant risk factors in the multiple regressions.
Our antibiotic hypotheses were based on Wickens’ study, which showed an associated risk of asthma, allergic rhino-conjunctivitis, and atopic eczema in patients who were administered antibiotics in early childhood [10]. ISSAC Phase III has investigated many factors that have been hypothesized to increase the risk of asthma and other allergic disorders in childhood. That study investigated the effect of antibiotic consumption and the subsequent increased risk of these allergic disorders in 193, 412 children from 71 centers in 29 countries using cross-sectional surveys. Although it was found that acetaminophen use was associated with an increased risk of asthma and other allergic disorders, the same data set yielded a much stronger association for antibiotics compared to acetaminophen exposure [11].
A recent review study by Murk and colleagues has suggested two probable confounders for such relationships: “reverse causality” and “protopathic bias” [12]. A significant association has also been reported between antibiotic consumption and increased risk of childhood asthma through a prospective study and a sensitivity analysis has also been performed to evaluate protopathic bias [13,14], Kozyrskyj et al. [15] have shown this association using a cohort study of 13,116 children (OR, 1.86; 95% CI, 1.02-3.37), in which the risk of asthma was stronger in children who had received more courses of antibiotics (OR,1.46; 95% CI, 1.14-1.88). Risnes and colleagues have concluded that antibiotic consumption increased the risk of developing childhood asthma even in children not having experienced respiratory tract infections and in children whose disease was diagnosed after 3 years of age and all cases whose disease was diagnosed before 2 years of age were excluded from the case group to reduce the risk of protopathic bias well as the risk of reverse causation [14].
In conclusion, we found the odds of childhood asthma to be associated with antibiotic use in children. We recommend a further prospective cohort studies on the association between antibiotic use in early life and childhood asthma.


This article and its results were extracted from thesis of Oshnouei S, Master of Epidemiology, and the study was conducted in Urmia University of Medical Sciences. This study was funded by the Research Deputy of Urmia University of Medical Sciences. We thank our colleagues at the Motaharri Pediatric Center, health professionals in the Urmia health centers; and all the centers and children who participated. We also thank Dr. Khashabi and her secretary for helping to identify study patients.


The authors have no conflicts of interest to declare for this study.

Table 1.
Distribution of demographic and other features in the study population
Variables Cases Healthy controls Hospitalized controls p-value1
Antibiotic use during the first year of life No 47 (28.1) 84 (43.3) 98 (50.8) < 0.01
Yes 120 (71.9) 110 (56.7) 95 (49.2)
Exposure to antibiotics during pregnancy No 145 (76.3) 130 (75.1) 155 (79.5) 0.57
Yes 45 (23.7) 43 (14.9) 40 (20.5)
Sex Male 121 (58.1) 113 (56.5) 115 (57.5) 0.91
Female 85 (41.3) 87 (43.5) 85 (41.3)
Living area Urban 195 (95.6) 179 (89.9) 181 (91.0) 0.08
Rural 9 (4.4) 20 (10.1) 18 (9.0)
Age at time of diagnosis (yr) 2-4 230 (38.4)
4-6 208 (34.7)
6-8 161 (26.9)
History of passive smoking (yr) Never 147 (71.0) 150 (75.0) 140 (70.0) 0.89
<10 34 (16.4) 30 (15.0) 32 (16.0)
11-19 5 (2.4) 4 (180.0) 4 (1.9)
≥20 21 (10.2) 16 (8.2) 24 (12.1)
Birth order 1-2 191 (95.5) 179 (89.5) 163 (81.5) < 0.01
≥3 16 (4.5) 20 (10.5) 37 (18.5)
Birth weight (g) <2,500 15 (7.6) 10 (5.2) 10 (5.2) 0.51
≥2,500 182 (92.4) 183 (94.8) 183 (94.8)
Delivery method Vaginal 84 (40.6) 91 (45.7) 116 (58.0) < 0.01
Caesarean 123 (59.4) 108 (54.3) 84 (42.0)
Preterm delivery (≤37 wk) No 174 (84.5) 178 (89.4) 189 (94.5) < 0.01
Yes 32 (15.5) 21 (10.6) 11 (5.5)
History of mother smoking No 203 (99.5) 197 (98.5) 198 (99.0) 0.54
Yes 1 (0.5) 3(1.5) 0 (0)
History of asthma or atopic disorders in the first or second degree relatives None 52 (25.5) 86 (43.2) 119 (59.5) < 0.01
Asthma 44 (21.6) 30 (15.1) 15 (7.5)
Atopic disorders 78 (38.2) 64 (32.2) 58 (29)
Both 30 (14.7) 19 (9.5) 8 (4)

Values are presented as number (%).

1Chi squared or Fisher’s exact test.

Table 2.
Distribution of antibiotic consumption and other risk factors during the first year of life and risk of asthma at 2-8 years
Variables Crude OR (95% CI) p-value1 Adjusted OR (95% CI) p-value1
Antibiotic use during the first year of life
 No 1.00 <0.01 1.00 <0.05
 Yes 2.26 (1.53 -3.35) 1.91 (1.27-2.88)
Adjusted variables
 History of asthma or atopic disorders in the first- or second-degree relatives
  None 1.00 <0.01 1.00 <0.01
  Asthma 3.85 (2.30-6.45) 3.36 (1.83-5.81)
  Atopic disorders 2.52 (1.66-3.82) 2.65 (1.67-4.20)
  Asthma/atopic disorders 4.38 (2.39-8.00) 4.43 (2.31-8.49)
 Preterm delivery (≤37 wk)
  No 1.00 <0.01 1.00 <0.01
  Yes 2.10 (1.25-3.55) 2.21 (1.23-3.99)
 Birth order
  1-2 1.00 0.01 NA
  ≥3 0.7 (0.52-0.94)
 Delivery method
  Vaginal 1.00 <0.01 NA
  Caesarean 1.57 (1.12-2.21)

OR, odds ratio; CI, confidence interval; NA, not applicable.

1p-value in the univariate regression model.


1. World Health Organization. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach. Geneva: World Health Organization; 2007, p. 65..

2. Beasley R, Crane J, Lai CK, Pearce N. Prevalence and etiology of asthma. J Allergy Clin Immunol 2000;105:S466-S472. PMID: 10669525
crossref pmid
3. Holt PG, van den Biggelaar AH. 99th Dahlem conference on infection, inflammation and chronic inflammatory disorders: the role of infections in allergy: atopic asthma as a paradigm. Clin Exp Immunol 2010;160:22-26. PMID: 20415847
crossref pmid pmc
4. Mendall MA, Kumar D. Antibiotic use, childhood affluence and irritable bowel syndrome (IBS). Eur J Gastroenterol Hepatol 1998;10:59-62. PMID: 9512954
crossref pmid
5. Farooqi IS, Hopkin JM. Early childhood infection and atopic disorder. Thorax 1998;53:927-932. PMID: 10193389
crossref pmid pmc
6. Foliaki S, Nielsen SK, Björkstén B, Von Mutius E, Cheng S, Pearce N, et al. Antibiotic sales and the prevalence of symptoms of asthma, rhinitis, and eczema: The International Study of Asthma and Allergies in Childhood (ISAAC). Int J Epidemiol 2004;33:558-563. PMID: 15020566
crossref pmid
7. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875-877. PMID: 9516004
crossref pmid
8. Droste JH, Wieringa MH, Weyler JJ, Nelen VJ, Vermeire PA, Van Bever HP. Does the use of antibiotics in early childhood increase the risk of asthma and allergic disease? Clin Exp Allergy 2000;30:1547-1553. PMID: 11069562
crossref pmid
9. Marra F, Marra CA, Richardson K, Lynd LD, Kozyrskyj A, Patrick DM, et al. Antibiotic use in children is associated with increased risk of asthma. Pediatrics 2009;123:1003-1010. PMID: 19255032
crossref pmid
10. Wickens K, Pearce N, Crane J, Beasley R. Antibiotic use in early childhood and the development of asthma. Clin Exp Allergy 1999;29:766-771. PMID: 10336592
crossref pmid
11. Foliaki S, Pearce N, Björkstén B, Mallol J, Montefort S, von Mutius E, et al. Antibiotic use in infancy and symptoms of asthma, rhinoconjunctivitis, and eczema in children 6 and 7 years old: International Study of Asthma and Allergies in Childhood Phase III. J Allergy Clin Immunol 2009;124:982-989. PMID: 19895986
crossref pmid
12. Murk W, Risnes KR, Bracken MB. Prenatal or early-life exposure to antibiotics and risk of childhood asthma: a systematic review. Pediatrics 2011;127:1125-1138. PMID: 21606151
crossref pmid
13. Martel MJ, Rey E, Malo JL, Perreault S, Beauchesne MF, Forget A, et al. Determinants of the incidence of childhood asthma: a two-stage case-control study. Am J Epidemiol 2009;169:195-205. PMID: 19033160
crossref pmid
14. Risnes KR, Belanger K, Murk W, Bracken MB. Antibiotic exposure by 6 months and asthma and allergy at 6 years: Findings in a cohort of 1,401 US children. Am J Epidemiol 2011;173:310-318. PMID: 21190986
crossref pmid pmc
15. Kozyrskyj AL, Ernst P, Becker AB. Increased risk of childhood asthma from antibiotic use in early life. Chest 2007;131:1753-1759. PMID: 17413050
crossref pmid


Browse all articles >

Editorial Office
Department of Preventive Medicine, Yonsei University College of Medicine
50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
TEL: +82-2-745-0662   FAX: +82-2-764-8328    E-mail: office.epih@gmail.com

Copyright © 2022 by Korean Society of Epidemiology.

Developed in M2PI

Close layer
prev next