Trop Doct 2008;38:235-236
doi:10.1258/td.2008.070404
© 2008 Royal Society of Medicine Press
Does breast feeding provide protection against acute appendicitis? A case-control study
João Guilherme Bezerra Alves MD PhD
José Natal Figueiroa BSc MSc
Isabela Barros
Instituto Materno Infantil Prof. Fernando Figueira (IMIP), Escola Pernambucana de Medicina (Faculdade Boa Viagem – FBV/IMIP), Recife, Brazil
Correspondence to: João Guilherme Bezerra Alves, Instituto Materno Infantil Prof. Fernando Figueira (IMIP), Rua dos Coelhos, 300, Boa Vista, Recife, Pernambuco, Brazil, CEP: 50.070-550 Email: joaoguilherme{at}imip.org.br
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SUMMARY
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Breast feeding stimulates a more tolerant lymphoid tissue at
the base of the appendix and this could provide protection against
acute appendicitis. Two studies reported that children and adolescents
with appendicitis were less likely to have been breast fed.
In a case-control study of 200 children with histologically
confirmed acute appendicitis matched by 200 siblings with the
same sex and difference age – up to three-year-old –
we found breast feeding in at least the first two months of
life and for more than four months provides protection against
acute appendicitis. These findings suggesting that breast feeding
may possibly give protection against the development of appendicitis.
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Introduction
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Acute appendicitis is the most common acute surgical condition
of the abdomen in children and teenagers.
1 Approximately 7%
of the population will suffer from appendicitis at sometime
in their life.
2 Information about the risk factors for appendicitis
and the role played by diet is poor.
3 Breast feeding provides
an efficient protection against infections and actively stimulates
the development of the infant's own immune system. This could
create more tolerant lymphoid tissues at the base of the appendix.
4 It could also provide protection against acute appendicitis.
5,6 Epidemiologists agree that appendicitis is less common in developing
countries where a less refined, high fibre diet is typically
consumed. However, the improvement in living standards and sanitation
correlates with an increasing risk of appendicitis.
7–9 The aim of this study was to see if, in a developing country,
an alimentary diet based on exclusive breast feeding constitutes
a protection factor against the development of acute appendicitis
during childhood or adolescence.
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Methods and patients
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The study population consisted of 243 children and adolescents
who underwent surgery for suspected appendicitis at our hospitals
– Instituto Materno Infantil Professor Fernando Figueira
(IMPI) and Hospital da Restauracao (HR) – in Recife, northeast
Brazil between 1 August 2006 and 30 March 2007. The 200 of these
who did have histologically confirmed appendicitis were recruited
to the study, matched by 200 familial controls (i.e. a sibling
of the same gender and age within three years without a history
of appendicitis). All the mothers were interviewed during the
hospital stay. The study was approved by the ethics committee
at the IMIP. We asked mothers how and for how long were their
children – those with and those without appendicitis –
fed milk during the first year of life and if they were breast
feed only, given a mixture of breast and bottle or bottle feed
only.
The sample size was based on the assumption that a 15% difference in the prevalence of breast feeding between the two groups would be clinically significant. The SPSS 12.0 for Windows (SPSS, Inc, Chicago, IL, USA) was used for the analysis of data. Quantitative data were expressed as means ± standard deviation (SD). Differences in continuous variables were analysed by the Mann-Whitney U-test or Student's t-test. Differences in categorical variables were assessed with the Fisher's exact test and the chi-squared test with Yate's correction: a P value < 0.05 was considered statistically significant.
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Results
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This analysis included completed interview data from the mothers
of 400 children – 200 cases and 200 controls. The mean
± SD age of the population was 10.4 ± 3.8 years
and there were 22 (63%) males. The
per capita income ranged
from US $0.7 to 1.5 and it was less than US $1.00 in 241 (60.2%)
families. There was no difference in the ages of cases (10.4
± 3.8 years) and controls in cases and controls (10.5
± 3.5 years) (
P = 0.829). The bivariate analysis is shown
in Table
1 and there was a statistical difference between
those who were only breast fed in the first two months of life
and those fed for more than four months (
P < 0.001).
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Discussion
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Our data are consistent with those of Pisacane
et al.5 and Gomez-Alcala
and Hurtado-Guzman
6 who reported that children and adolescents
with appendicitis were less likely to have been breast fed.
These two studies, the only ones to fully investigate the association
between breast feeding and appendicitis, and our study have
two major design differences.
- We used ‘familial controls’ which we considered to be better controls because of the hereditary factor which could be significant in paediatric patients with appendicitis.10
- Our population study were all living on a low income (between US $0.7 and 1.5 per capita), were all attending the Brazilian public health service (Sistema Único de Saúde). This does not support the hygiene hypothesis on the development of appendicitis.
A potential source of
bias in this study is the inaccurate recall of breast feeding
– some mothers may have been recalling events from earlier
years. However, in our study recall bias has the same impact
upon the cases and the controls because, as a result of our
using familial controls, the mother gave the information for
both.
There are some reasons that could explain our results. The immune components of human milk provide an antigen avoidance system that can decrease the severity of infection and the associated inflammatory reactions.4 This milder inflammatory response could programme the immune system and it could be associated with a more tolerant lymphoid tissue at the base of the appendix. We believe that the results show how much a child's upbringing can affect the resistance to disease in childhood and adulthood.4,8 We also believe that our findings suggest that breast feeding may possibly provide protection against appendicitis which would add to the reported evidence indicating the many beneficial effects of breast feeding. However, additional studies investigating the association between breast feeding and appendicitis should be conducted in order to confirm these results. There should also be studies which explore the biological mechanism underlying these findings.
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Acknowledgements
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Isabela Barros was sponsored by CNPq – Programa Institucional
de Bolsa de Iniciação Cientifica (PIBIC).
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References
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- Heaton KW. Aetiology of acute appendicitis. Br Med J 1987;294:1632–3[Free Full Text]
- Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910–25[Abstract/Free Full Text]
- Coggon D, Barker DJP, Cruddas M, Oliver RHP. Housing and appendicitis in Anglesey. J Epidemiol Community Health 1991; 45:244–6[Abstract/Free Full Text]
- Hanson LA, Korotkova M, Telemo E. Breast-feeding, infant formulas, and the immune system. Ann Allergy Asthma Immunol 2003;90:59–63[Medline]
- Pisacane A, De Luca U, Impagliazzo N, Russo M, De Caprio C, Caracciolo G. Breast feeding and acute appendicitis. Br Med J 1995;310:836–7[Free Full Text]
- Gomez-Alcala AV, Hurtado-Guzman A. Short term breastfeeding as a risk factor for acute appendicitis in children. Gac Med Mexico 2005;141:501–4[Medline]
- Burkitt DP. The aetiology of appendicitis. Br J Surg 1971;58: 695–9[Medline]
- Prystowsky JB, Pugh CM, Nagle AP. Current Problems in surgery. Appendicitis. Curr Prob Surg 2005;42:688–742[Medline]
- Barker DJ. Acute appendicitis and dietary fibre an alternative hypothesis, Br Med J 1985;290:1125–7[Abstract/Free Full Text]
- Gauderer MWL, Crane MM, Green JA, DeCou JM, Abrams RS. Acute appendicitis in children: the importance of family history. J Pediatr Surg 2001;36:1214–7[Medline]
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SUMMARY
Introduction
