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Table 4 Perinatal factors with significant, independent effect on Crohn’s disease in the child Perinatal risk factor Odds ratio 95% CI Maternal age (yr) 14-34 1.00 Ref. 35-49 4.81 2.32-9.98 Maternal smoking during pregnancy No 1.00 Ref. Yes 2.04 1.06-3.92 the outcome measure. Our study is therefore not subject to potential interviewer and recall bias, e.g. about whether the mother smoked during pregnancy, which can affect studies based on interviews or self-reporting, and which provide much of the evidence about IBD and perinatal risk factors. The Oxford record linkage study has also been used as the basis of previous studies of perinatal risk factors [7,10,13,14] . The study has several limitations. There was variable follow-up after birth, with shorter durations of follow-up for those born in the more recent years of the study period. However, there was at least 10 years follow-up for all IBD cases among offspring. Maternities during the early years of the study period, and among younger mothers, had fewer years of pre-pregnancy inclusion to ascertain maternal IBD, while data for three of the 20 risk factors (social class, smoking and breastfeeding), were not available for the first four years of the study period. The study would not have identified offspring who were diagnosed with IBD after migrating out of the ORLS region, which would reduce the number of observed cases of IBD. The identification of cases of IBD in the offspring was restricted to those who were admitted as inpatients or day cases. We will have missed some cases of IBD where the only inpatient or day case admission was for a diagnostic endoscopy and biopsy in patients with suspected IBD, and where the pathology results were not available to create a record of the diagnosis at the time of discharge. We will also have missed people without any day case or inpatient care. Migration over time in the Oxford region population would also have lowered our observed incidence of IBD, particularly among adults. Our age-specific cumulative incidence rates of 1.6 and 0.9 per 100 000 for CD and UC among 0-29 year olds, and 1.0 and 0.5 respectively among 0-19 year olds, are lower than those in some UK studies, but comparable with those in other UK studies [2,3,15-18] . There were two cases of CD in both the mother and child. Previous studies have identified associations between both maternal CD and maternal UC and IBD in offspring [19,20] , which are part of a well-established genetic association of IBD in families [21-23] . There was some evidence of increased risks of CD, but not UC, among children whose mothers smoked during pregnancy. Previous studies have reported no association with smoking during pregnancy [19,24] , although one case-control study found modest protection against both CD and UC [25] . Our data refers to smoking by the mother: in the general literature, there is strong evidence that active smoking increases the WJG|www.wjgnet.com Roberts SE et al . Perinatal factors and inflammatory bowel disease risk and perhaps the severity of CD [26,27] . Although we did not have information on smoking status of the IBD subjects themselves, it is of some interest that we found an association between maternal smoking and CD. Some studies have identified slightly increased risks of IBD among children from lower socio-economic groups [11,20] , others have reported reduced risks of CD among children from lower socio-economic backgrounds [18,28] , and some have found no association between social background and IBD [29,30] . More generally, studies that have investigated the relationship between IBD and socio-economic group have often reported conflicting findings [31-37] . Overall, this indicates that any possible association between socio-economic background and subsequent IBD in children is probably quite weak. We did not find a significant association between social class and either CD or UC. A systematic review and meta analysis of (mainly casecontrol) studies reported a small but significant protective effect of breastfeeding against subsequent IBD in offspring [12] , although it concluded that new larger studies were required. More recent studies have shown little association between breastfeeding and IBD [19] , or even increased risks of CD [30,38] . We found no association between breastfeeding at the time of discharge from hospital and IBD, although this includes those who subsequently discontinued breastfeeding after discharge, and is therefore an incomplete marker of breastfeeding. Through the use of multivariate analysis, we found higher risks of CD, but not UC, among children of older mothers (aged 35+ years). This is consistent with a Swedish study that reported an increased risk of paediatric CD among female offspring born to older mothers [35] , although other studies have identified no link between mother’s age and IBD in children [25,39] . Births among older mothers are sometimes associated with increased risks of prenatal medical and obstetric complications, intrapartum complications, perinatal and neonatal morbidity and mortality, as well as increased subsequent risks of various disorders. It is possible that children born to older mothers may be more exposed, or more susceptible, to factors associated with the aetiology of subsequent CD, but not with UC, in their children. It is also possible that our finding on maternal age, though significant, was a chance one, especially as our study investigated 20 perinatal factors. It is worth noting, however, that the finding was highly significant (P < 0.01 in multivariate analysis). We found an indication of reduced risks of IBD, particularly UC, among children of mothers who were unmarried at the time of birth, which is consistent with findings from Sweden [11] and Australia [28] . It has been suggested that caesarean section might increase the risk of subsequent IBD in children, because there is less exposure to maternal bacteria than in vaginal delivery [40] . The reasoning behind this is that, according to the hygiene hypothesis, inadequate exposure to microorganisms in early life might result in higher levels of immune-mediated pathology in later life. Although one study found an increased risk of CD for elective caesarean 747 February 14, 2011|Volume 17|Issue 6|
Roberts SE et al . Perinatal factors and inflammatory bowel disease sections [28] , another found no association for either CD or UC [19] . We also found no association for either CD or UC. We found no association between maternal parity and IBD. Although increased risks of IBD have been reported occasionally for first born [41,42] , or subsequent siblings [43] , most studies have found no association between birth order and IBD [11,20,25,30,39] . We also found no association between IBD and any of the other perinatal factors studied, including pre-eclampsia, birthweight, gestational age and Apgar score. These perinatal factors have not usually been associated with IBD in previous studies [11,19,25,28,30] . To summarise, of the 20 perinatal risk factors investigated in this study, we found that maternal CD, smoking during pregnancy and advanced maternal age were associated with increased risks of CD in offspring. For UC, there were no factors associated with increased risks after multivariate adjustment. This, and the fact that the few factors that were associated with CD had quite small effect sizes, suggests that perinatal risk factors have only a minor role in the aetiology of IBD. ACKNOWLEDGMENTS The Oxford Record Linkage Study database was funded by the former Oxford Regional Health Authority in the years covered by the maternity data collection and, over many years, it was built by Leicester Gill, Glenys Bettley and Myfanwy Griffith. The views expressed in this paper are those of the authors and not necessarily those of the funding body. COMMENTS Background Both Crohn's disease (CD) and ulcerative colitis (UC) are considered to be immune-mediated disorders, although the exact pathogenetic mechanisms are not yet clear. Perinatal risk factors have been linked with other immune-mediated diseases, including asthma and type 1 diabetes. Other than a suggested, small protective effect of breastfeeding, little has been reported on the role of perinatal factors for either CD or UC. Research frontiers This study investigated associations between 20 perinatal risk factors relating to the maternity or the birth and subsequent inflammatory bowel disease (IBD) in offspring in the Oxford region, UK. Risk factors investigated included maternal characteristics such as maternal age, IBD, social class, marital status, smoking in pregnancy, ABO blood group, rhesus status and parity; and characteristics of the birth such as caesarean delivery, number of babies delivered, gestational age, birthweight, breastfeeding and Apgar scores. Innovations and breakthroughs The study found increased risks of CD among children of mothers with CD, among children of mothers who smoked during pregnancy, and of older mothers aged 35+ years. There were no significant associations between CD and the 17 other perinatal risk factors investigated, and no associations for UC. Applications The findings indicate that these three perinatal risk factors might have some influence on subsequent IBD in children. Overall, however, perinatal factors appear to have a limited role in the aetiology of IBD. This study will help stimulate further research into the influence of perinatal risk factors on IBD. The findings should also provide an important source of information for future systematic reviews and meta analyses of perinatal factors and IBD. Terminology Odds ratios were used to assess any increased risks of developing IBD. These denote the chance or odds of developing IBD for a child exposed to a given WJG|www.wjgnet.com perinatal risk factor (e.g. caesarean delivery) as a ratio of the chance or odds for a child not exposed to caesarean delivery. The study used record linkage of maternity exposure data and IBD outcome data, which were collected independently of each other. Peer review This is a very well written original article. I would like to congratulate the authors on such a nicely done original paper that contributes a lot of new information about perinatal and early risk factors for IBD. REFERENCES 1 Logan RF. Inflammatory bowel disease incidence: up, down or unchanged? Gut 1998; 42: 309-311 2 Fellows IW, Freeman JG, Holmes GK. Crohn's disease in the city of Derby, 1951-85. Gut 1990; 31: 1262-1265 3 Lee FI, Costello FT. Crohn's disease in Blackpool--incidence and prevalence 1968-80. Gut 1985; 26: 274-278 4 Thia KT, Loftus EV Jr, Sandborn WJ, Yang SK. An update on the epidemiology of inflammatory bowel disease in Asia. Am J Gastroenterol 2008; 103: 3167-3182 5 Dik N, Tate RB, Manfreda J, Anthonisen NR. Risk of physician-diagnosed asthma in the first 6 years of life. Chest 2004; 126: 1147-1153 6 Metsälä J, Kilkkinen A, Kaila M, Tapanainen H, Klaukka T, Gissler M, Virtanen SM. Perinatal factors and the risk of asthma in childhood--a population-based register study in Finland. Am J Epidemiol 2008; 168: 170-178 7 Davidson R, Roberts SE, Wotton CJ, Goldacre MJ. Influence of maternal and perinatal factors on subsequent hospitalisation for asthma in children: evidence from the Oxford record linkage study. BMC Pulm Med 2010; 10: 14 8 Dahlquist G, Bennich SS, Källén B. Intrauterine growth pattern and risk of childhood onset insulin dependent (type I) diabetes: population based case-control study. BMJ 1996; 313: 1174-1177 9 Cardwell CR, Carson DJ, Patterson CC. Parental age at delivery, birth order, birth weight and gestational age are associated with the risk of childhood Type 1 diabetes: a UK regional retrospective cohort study. Diabet Med 2005; 22: 200-206 10 Ievins R, Roberts SE, Goldacre MJ. Perinatal factors associated with subsequent diabetes mellitus in the child: record linkage study. Diabet Med 2007; 24: 664-670 11 Ekbom A, Adami HO, Helmick CG, Jonzon A, Zack MM. Perinatal risk factors for inflammatory bowel disease: a case-control study. Am J Epidemiol 1990; 132: 1111-1119 12 Klement E, Cohen RV, Boxman J, Joseph A, Reif S. Breastfeeding and risk of inflammatory bowel disease: a systematic review with meta-analysis. Am J Clin Nutr 2004; 80: 1342-1352 13 Jones ME, Swerdlow AJ, Gill LE, Goldacre MJ. Pre-natal and early life risk factors for childhood onset diabetes mellitus: a record linkage study. Int J Epidemiol 1998; 27: 444-449 14 Roberts SE, Williams JG, Meddings D, Davidson R, Goldacre MJ. Perinatal risk factors and coeliac disease in children and young adults: a record linkage study. Aliment Pharmacol Ther 2009; 29: 222-231 15 Tresadern JC, Gear MW, Nicol A. An epidemiological study of regional enteritis in the Gloucester area. Br J Surg 1973; 60: 366-368 16 Devlin HB, Datta D, Dellipiani AW. The incidence and prevalence of inflammatory bowel disease in North Tees Health District. World J Surg 1980; 4: 183-193 17 Cosgrove M, Al-Atia RF, Jenkins HR. The epidemiology of paediatric inflammatory bowel disease. Arch Dis Child 1996; 74: 460-461 18 Armitage EL, Aldhous MC, Anderson N, Drummond HE, Riemersma RA, Ghosh S, Satsangi J. Incidence of juvenileonset Crohn's disease in Scotland: association with northern latitude and affluence. Gastroenterology 2004; 127: 1051-1057 19 Sonntag B, Stolze B, Heinecke A, Luegering A, Heidemann 748 February 14, 2011|Volume 17|Issue 6|
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