J Epidemiol Community Health 56:209-217 doi:10.1136/jech.56.3.209
  • Research report

Does a higher number of siblings protect against the development of allergy and asthma? A review

  1. W Karmaus,
  2. C Botezan
  1. Department of Epidemiology, Michigan State University, USA
  1. Correspondence to:
 Dr W Karmaus, Department of Epidemiology, Michigan State University, 4660 S Hagadorn Road, Suite 600, East Lansing, MI 48823, USA;
  • Accepted 24 July 2001


Study objective: To review the “protective” effects of having a higher number of siblings for the risk of atopic eczema, asthma wheezing, hay fever, and allergic sensitisation.

Method: Review of the literature (Medline since 1965 and references).

Main results: 53 different studies were identified. For eczema, 9 of 11 studies reported an inverse relation with number of siblings; for asthma and wheezing, 21 of 31 reported the inverse association; for hay fever, all 17 studies showed the effect; for allergic sensitisation or immunoglobulin E reactivity 14 of 16 studies supported the “protective” effect of a higher number of siblings. The studies emphasise a “theory” that is based exclusively on epidemiological associations.

Conclusions: Research has not yet answered the question of which causal factors explain the sibling effect. Causal factors must meet two criteria; they must vary with sibship size and they must protect against atopic manifestations. The prevailing “hygiene hypothesis” failed to explain the findings adequately. Alternative explanations include in utero programming or endocrine explanatory models. The epidemiology research into siblings and atopic disorders has entered an intellectually challenging phase. Possessing sufficient knowledge about the causal factors might prevent at least 30% of all cases of asthma, eczema, and hay fever.