Description of the ABIS study

From October 1997 through October 1999, parents to babies born in southeast Sweden were invited to participate in the ABIS cohort project. This project examines the role of environmental factors for the development of autoimmune and allergic diseases. Of the 21,700 babies born during the study period, the parents of 17,055 children (78.6%) gave their informed consent to participate. In the maternity ward, the mothers received an at-birth questionnaire that was completed by 16,070 mothers. Of the 10,932 that participated in the 2.5-year follow-up, 8,805 completed the 2.5-years-questionnarie. Study participants [17] were more often born in Sweden, compared to the general population. We compared prospectively assessed measures of stress between children with CD with those without a diagnosis of CD.

Definition of CD

Data on CD were collected on two occasions. The majority of children with CD were identified through a study on symptoms and signs in CD [18]. In 2007-2008, we again contacted the same eight paediatric departments participating in the study published in 2004 [18] and asked them to report additional ABIS children with biopsy-verified CD (partial or subtotal-total villous atrophy) diagnosed before 1^st Dec 2006. For this diagnosis we also requested symptoms/signs and antibody markers consistent with the diagnosis of CD (for further details, see earlier study [18]). In the current study, date of CD diagnosis equals date of first positive small intestinal biopsy. The ABIS child population was not actively screened for CD, and we do not have population-based data on CD serology in study participants. Hence, cases of CD were diagnosed due to symptoms, and signs, or through screening for clinical (i.e. non-research) purposes.

We identified 83 children with CD, 10 of these were diagnosed before age 1 year and excluded from the analyses since the diagnosis per se might have influenced the way the parents responded to the questions about stress and life events occurring within the first year of life. The remaining 73 were included in all analyses referring to stress until age 1 year, of these 43 were diagnosed after 2.5 year of age and were also included in the analyses referring to stress until age 2.5 year.

Definition of psychological stress

Three domains concerning psychological stress were assessed: 1) Exposure to a serious life event in the family was assessed at 1 and 2.5 years of age with the following two yes/no questions: At 1 year of age we asked: "Has your child been exposed to something which you perceive as a serious life event since his/her birth?". At 2.5 years of age we asked: "Have you [the parent] been exposed to something which you perceive as a serious life event since you're child's birth?". Examples given were death of a relative, serious disease in the family, serious accident in the family, divorce, exposure to violence, and unemployment. We had data on serious life event in 10,541 children (447; 4.2% had been exposed) in the first year of life, and in 8,722 children until age 2.5 years (2,119; 24.3% exposed). 2) Parenting stress was assessed at 1 and 2.5 years of age with the Swedish Parenting Stress Questionnaire (SPSQ) [19], which has a good validity and good stability [19]. In our sample Chronbach's alpha was 0.88 at age 1 and 0.89 at age 2.5. SPSQ consists of 34 items tapping the dimensions incompetence (11 items), spouse relationship problems (5 items), role restriction (7 items), social isolation (7 items), and health problems (4 items). On each item a 6-point Likert-type response scale was used ranging from "strongly disagree" to "strongly agree". A mean value was calculated if less than six items were missing. Dichotomized variables were created using the 95^th percentile as a cut-off, defining exposure to parenting stress at each age. 3) Parental worries were assessed at 2.5 years of age with six items, each describing a potential risk for the child (i.e. that the child falls seriously ill, is harmed, is going to be handicapped, is not going to develop normally, is going to be exposed to abuse, and is not going to survive). For each item the parent estimated on a 6-point Likert-type response scale ranging from "very calm" to "very worried" how worried they were that their child might become affected. Chronbach's alpha was 0.89 in our sample. Mean values for answered items (if one or no item was missing) above the 95^th percentile defined exposure to parental worries.

Finally, a composite measure of psychological stress at age 2.5 was created (from 8,369 children) in order to estimate the overall amount of stress experienced in the family, by counting in how many of the domains the child had been exposed to stress at age 2.5 (composite measures of this kind have been used in e.g. the papers by Ostberg et al [20] and Wekerle et al [21]). If a child had not been exposed in any of the domains the score for the composite measure was 0 and if the child had been exposed in all three domains the score was 3. Since only 11 children had been exposed in all three domains, they were grouped together with those exposed in two domains. This group will onwards be referred to as children exposed to high stress in the family.

Statistics

To avoid potential recall bias, we excluded individuals with a diagnosis of CD before the age of 1 year from our main analyses (since knowledge of CD in one's child might have influenced the way the questionnaires were completed by parents) (and before 2.5 years of age in relevant analyses). Hence follow-up began at 1 year of age.

Chi-2 test, and when appropriate Fisher' exact test, and logistic regression estimated the association between the psychological stress variables and CD. Exact odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare children 'exposed' and 'not exposed' concerning each psychological stress domain, respectively, as well as for comparing 'not exposed', 'exposed in one domain', and 'high stress in the family' (i.e. exposed in at least two domains) for the composite measure. The dependent variables in the analyses were CD after age 1 year (n = 73), CD after age 2.5 years (n = 43), and ever having a diagnosis of CD (n = 83). Due to lack of data on stress (not all study participants filled out the questionnaires at 1 year and 2.5 years of age or all questions in the questionnaires), the actual number of children with CD included in the analyses was lower (1 year: n = 48-51; 2.5 year: n = 24-26).

Since earlier data have suggested that breastfeeding pattern may influence the risk of CD [2], we chose to adjust for breastfeeding duration in a number of post-hoc analyses. We had data on duration of breastfeeding in 8,428 individuals. Children were divided into four categories (≤ 90 days, 91-180 days, 181-270 days and ≥ 271 days of breastfeeding). In individual analyses, numbers may be lower due to missing data on outcome measures.

Statistical significance was defined as 95% CI for estimates not including 1.0 and p < 0.05. We used SPSS 15.0 to perform the analyses.

Ethics

This study was part of the ABIS study, which has been approved by the Research Ethics Committees of the Faculty of Health Sciences, Linkoping University, and the Medical Faculty of Lund University. Mothers gave their consent after careful written as well as oral information and information via videotape.

Background data

More than 70% of patients with CD were girls compared to about 48% in those without a diagnosis of CD (see Additional file 1). A family history of T1 D and CD was more common among children with CD compared to the reference group. The children were followed-up until Dec 1^st 2006, which corresponded to 8 years of age in the average participant. The mean maternal age at childbirth was close to 30 years.

Serious life event

Parenting stress

Only 1/525 children exposed to such stress developed CD (0.19%) (compared with 47 non-exposed children who developed CD (0.47%); Table 1). OR for CD in children exposed to parenting stress at age 1 was 0.40 (95% CI = 0.01-2.38; P = 0.73). The corresponding OR at 2.5 years was 0.74 (95% CI = 0.01-4.56; P = 1.00) (Table 2).

Parental worries

In 438 children (out of 8,520), parents had reported worries in the first 2.5 years of life. None of these children later developed CD (compared with 25 non-exposed children). CD was hence not associated with parental worries during the first 2.5 year of life (Table 2). When we included all individuals with CD, also those with a diagnosis prior to the 1-year-questionnaire there was still no association between parental worries and CD (OR = 0.80; 95% CI = 0.09-3.08; P = 1.00).

Composite measure of psychological stress

In a final analysis we used logistic regression to estimate the association between a composite measure of psychological stress across three different domains (serious life event, parenting stress and parental worries) and CD. However, CD was not associated with stress in one or more domains (Table 2).

Post-hoc analyses adjusting for duration of breastfeeding

Adjustment for duration of breastfeeding did not influence any of the above risk estimates more than marginally (complete data not shown). E.g. there were no increased risk of future CD in individuals with a serious life event at age 1 (adjusted OR = 0.61; 95% CI = 0.08-4.47; P = 0.63), parenting stress at age 1 (adjusted OR = 0.54; 95% CI = 0.07-3.94; P = 0.54), or composite measure of high stress in the family at age 2.5 (adjusted OR = 1.35; 95% CI = 0.18-10.26; P = 0.77).