Effect of maternal sleep, physical activity and screen time during pregnancy on the risk of childhood respiratory allergies: a sex-specific study

The prevalence of childhood allergic diseases continues to rise with the development of economy and urbanization all around the world. China has the largest population in the world, and quantities of rural people flooded into cities with the acceleration of urbanization since 1980s [1, 2]. Shanghai is one of the fastest urbanizing cities in China, where the prevalence of childhood asthma increased almost fivefold from 1990 to 2011 [3]. Data from a national survey covering 10 cities across China demonstrated that childhood allergic diseases, except for wheezing, were most prevalent in Shanghai [4]. Although numerous potential environmental risk factors have been proposed, it is still far away to explain the rapid rise. It has been a general recognition that early-life in utero is a special period for imprinting, programming and the establishment of epigenome [5]. Accumulating studies were providing evidence that early life exposure has not only short term effects on fetal growth but also long-term impacts on individual’s health and disease susceptibility in later life [5].

To date, there are several shreds of evidence suggesting that early life exposure during pregnancy may be implicated in the development of the immune system. Rodent model has long shown that air pollution exposure during pregnancy increased the susceptibility of neonates to allergic asthma [6]. A meta-analysis on epidemiology evidence similarly suggested that prenatal exposures to NO₂, SO₂, and PM₁₀ increased the risk of wheezing and asthma in childhood [7]. Besides, the association between prenatal nutritional exposures and childhood allergies were also proposed in the last two decades [8]. Meanwhile, a few studies reported that maternal behavior choice was involved in childhood allergies [8, 9]. Early in 1998, Boston conducted a prospective birth cohort study in 505 mother-infant pairs, revealing that maternal smoking during pregnancy could increase the risk of childhood wheezing in the first year of life [9]. A newly published cross-sectional study also reported that maternal smoking was associated with a higher risk of asthma in their offspring [10]. However, data on maternal lifestyle such as sleeping and physical activity are largely lacking. With rapid modernization, sleep duration, physical activity, and screen using are indeed lifestyle choices people face every day. It has been a growing concern that unhealthy and sedentary lifestyle, including chronic sleep loss, inactivity, and excessive screen exposure, is quite common [11]. A national school-based health survey in Greece revealed that physical activity during pregnancy was significantly associated with childhood obesity [12]. A prospective study found that sleep difficulties during pregnancy affected the social development of their offspring when they were 1 year old [13]. However, none of the studies have investigated whether maternal lifestyle factors during pregnancy had an impact on childhood allergies.

Sex dimorphism has long been known to childhood allergies [3, 14], but the sex difference by the same risk exposure has rarely been studied. The genetic background has considered being a risk factor for allergies [15]. Therefore, attention to sex differences, taking familial heredity into account, would help us deeply understand the childhood allergy, which should be the basis of personalized allergy intervention.

A citywide study was conducted in Shanghai to explore the association of maternal lifestyle factors, including sleep duration, daily physical activity, and screen exposure, with the risk of respiratory allergies in their offspring. Specifically, sex differences will be a focus.

This is the first study exploring the associations of maternal lifestyle choice during pregnancy with the risk of childhood respiratory allergic diseases. Our findings demonstrated that all of the three unhealthy maternal lifestyles, including short sleep duration, lack of physical activity and too much screen exposure, were independent risk predictors. Also of concern was significant dose-response trend, the more concentrations of maternal unhealthy lifestyles during pregnancy, the greater risk of respiratory allergies in their children. Moreover, significant sex difference was identified that males were more susceptible to the adverse effects. The results, in most cases, can be verified in the Allergen Test Subgroup and the single type of disease, which further enforced the evidence. The present study drew the attention on the association of maternal behavior exposure with immune development and allergic disease susceptibility in their offspring, in which sex difference should be taken into consideration.

The rapid increase in childhood allergic disease may be related to rapid economic growth or modernization [3]. In developed countries, the prevalence of childhood allergic respiratory symptoms appears to have peaked and stabilized [25]. China, as a developing country, is rapidly urbanizing and the prevalence of childhood respiratory allergies is now on the rise, especially in fast-growing cities such as Shanghai [3]. Allergic diseases was usually higher prevalent in urban area than in rural areas within a geographical region [26], though there existing some inconsistent results [27]. Urbanization is accompanied by a modern style of life, electronic screen exposure is more frequent, sedentary time is increasing while sleeping time is decreasing [11], and it has been proved that pregnant women spend at least half their time on sedentary behaviors [28].

Our results provided new evidence to the hypothesis that a mother’s lifestyle choice during pregnancy could affects offspring’s long-term health, herein childhood respiratory allergies. Previous studies exploring the effect of lifestyle during pregnancy on the long-term health of children largely focused on the neurological and behavioral development [29‐32]. A rodent model found that maternal lack of sleep in the third trimester can impair autonomic responses in male offspring with a long-term effect [29]. Cohort data among 83,884 mother-child pairs from five countries revealed that maternal cellphone use during pregnancy increased the risk of hyperactivity in their offspring [30]. Another two prospective studies found that adequate physical activity during pregnancy could promote language development in children [31, 32]. This study, for the first time, focused on maternal lifestyle choice and the susceptibility of childhood allergic disease. Besides, most of the previous studies only assessed one aspect of maternal lifestyles, and their combined effects have never been studied. In our study, a clear dose-response relationship was established, the more exposures to maternal unhealthy lifestyles during pregnancy, the higher risk of childhood respiratory allergies.

Early life exposure in utero can affect the fetal airway and lung development, as well as immune function [33]. As suggested by previous studies, maternal smoking, unqualified diet, vitamin D deficiency and exposure to air pollution should be potential risk factors [7, 34‐37]. A retrospective follow-up study was conducted among 1201 Los Angeles women between 3 and 6 months after delivery, where it was shown that children whose mothers ate more fast food during pregnancy had an increased risk of asthma [34]. Although there existed different conclusions [35, 36], a more recent meta-analysis revealed that maternal prenatal vitamin D supplementation was associated with a lower risk of allergic diseases in children [37]. Compared to these studies, we focused on daily lifestyle choices, including sleep duration, physical activity, and screen using, and established the relationship between them and the risk of childhood respiratory allergies with a dose-response pattern. As far as we know, to date, this is the only population-based study establishing the associations. To test the association, the analysis was further applied in subgroup whose allergen test was positive, and the similar results further enforced the evidence that maternal daily lifestyle choices are involved in childhood susceptibility to respiratory allergic diseases.

Although this is the first epidemiological study to explore the relationship between maternal lifestyle choice and offspring allergies, several potential explanations were in biological mechanisms to support the relationship. Several studies have demonstrated that early-life adverse exposure in utero can block the production of the immune response of fetal cytokines to Th1 type and affect the programming of fetal immune function [33, 38, 39]. Besides, increased stress and inflammatory response were put forward to explain the pathway. Sleep deprivation may lead to oxidative stress and inflammation, thus affecting early embryonic development [40]; while regular exercise can effectively buffer stress and prevent inflammation-related diseases through the mother-fetus connection [41]. Moreover, prenatal unhealthy behavioral exposure may also affect the microbiota of pregnant women, thereby transferring maternal bacteria to the fetus [42]. The imbalance of intestinal flora in infancy may lead to the deviation of immune function and allergic reactions [43].

It was impressed that respiratory allergies were mainly prevalent in males when their mothers were exposed to adverse lifestyle behaviors during pregnancy. After adjusting for socioeconomic factors, it turned out that the significance of maternal lifestyle in relation to childhood allergic diseases disappeared in females. This demonstrated that socio-economic factors did have an impact on the health effects of mothers on their offspring and that there were sex differences in these health effects. In a rat model, maternal high-fat diet during pregnancy was associated with neonatal cardiac dysfunction, reduced respiratory capacity and oxidative stress only in male offspring, indicating that adverse prenatal exposures impaired dynamism with sex-divergent characteristic [38]. A previous longitudinal study in the US also examined the sex-specific relationship between prenatal risk factors and offspring’s asthma outcomes, and the significant result was observed also only in males [44]. It has been recognized that male and female possessed different immune responses, especially in T-helper cells [39]. In referring to genetics, this pattern of inheritance may be linked to an X-linked gene, which is more likely to be exposed in boys with only one X-chromosome [45]. For example, IL-9 has impact on the development of the allergic disease by taking function in enhancing the synthesis of IgE and maturation of mast cell [46]. The IL-9 receptor gene, situated within the pseudoautosomal region of X and Y chromosomes, escaped X inactivation and its Y allele was also expressed [46, 47]. Another pro-inflammatory cytokine, IL-1β, is also been suspected of involvement in the pathogenesis of sex-specific allergic diseases in adult male asthma patients [48]. And the IL-1 family of molecules is among candidate genes of allergic susceptibility [49]. Sex hormones may also play a part, which respiratory genes could involve in the production of sex hormones [15]. Estrogen, the primary female sex hormone, has been regarded as an immune-stimulating factor [15]. While testosterone, as male sex hormones, tends to have immunosuppressive effects [15]. Nevertheless, the association was observed primarily in preschool children, suggesting that hormonal factors may not well explain the observed sex differences. Currently, the exact mechanism underlying has not been elucidated yet. Our results indicate the need for future studies to explore the association between prenatal factors and childhood asthma with consideration of possible sex-specific pathway.

This study has several limitations. First, information on maternal behavioral exposure was obtained from questionnaires, and thus the recall bias was inevitable. However, due to pregnancy was a special period, and China’s one-child policy in the past decades, the recall bias can be minimal. Second, a cross-sectional study was poor in determining causal links. However, the dependent variables and the outcome variables we analyzed were mothers’ lifestyles during pregnancy and their children’s respiratory allergies respectively, which had a time sequence, thus revealing a certain causal relationship. Third, allergic diseases were not diagnosed by professionals. However, the international standard ISAAC questionnaire was applied worldwide with quite good reliability and validity [22]. In addition, children with positive allergen tests were analyzed as a subgroup, which further verified our findings. Finally, even though many confounding factors were taken into account, residual confounding may remain. And environmental variables were obtained by questions, the field sampling data was unavailable. However, given that the results were broadly consistent across all the respiratory allergies in this study, the evidence for the link between maternal behavioral exposure and childhood allergic disease appeared to be robust.

This study is the first to emphasize the association between maternal unhealthy behaviors such as lack of sleep, physical inactivity, and prolonged use of electronic devices during pregnancy and the risk of childhood allergies in a sex-specific manner. In particular, there appeared to have a clear dose-response relationship, the more unhealthy maternal behaviors, the greater risk of childhood respiratory allergies. However, this risk mainly affects males. Our findings should be of interventional significance in early-life since maternal lifestyle behaviors are modifiable.