Associations between autistic traits and early ear and upper respiratory signs: a prospective observational study of the Avon Longitudinal Study of Parents and Children (ALSPAC) geographically defined childhood population

Amanda Hall, Richard Maw, Yasmin Iles-Caven, Steven Gregory, Dheeraj Rai, Golding Jean*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


OBJECTIVE: To determine whether early ear and upper respiratory signs are associated with the development of high levels of autistic traits or diagnosed autism. DESIGN: Longitudinal birth cohort: Avon Longitudinal Study of Parents and Children (ALSPAC). SETTING: Area centred on the city of Bristol in Southwest England. Eligible pregnant women resident in the area with expected date of delivery between April 1991 and December 1992 inclusive. PARTICIPANTS: 10 000+ young children followed throughout their first 4 years. Their mothers completed three questionnaires between 18-42 months recording the frequency of nine different signs and symptoms relating to the upper respiratory system, as well as ear and hearing problems. OUTCOME MEASURES: Primary-high levels of autism traits (social communication, coherent speech, sociability, and repetitive behaviour); secondary-diagnosed autism. RESULTS: Early evidence of mouth breathing, snoring, pulling/poking ears, ears going red, hearing worse during a cold, and rarely listening were associated with high scores on each autism trait and with a diagnosis of autism. There was also evidence of associations of pus or sticky mucus discharge from ears, especially with autism and with poor coherent speech. Adjustment for 10 environmental characteristics made little difference to the results, and substantially more adjusted associations were at p<0.001 than expected by chance (41 observed; 0.01 expected). For example, for discharge of pus or sticky mucus from ears the adjusted odds ratio (aOR) for autism at 30 months was 3.29 (95% CI 1.85 to 5.86, p<0.001), and for impaired hearing during a cold the aOR was 2.18 (95% CI 1.43 to 3.31, p<0.001). CONCLUSIONS: Very young children exhibiting common ear and upper respiratory signs appear to have an increased risk of a subsequent diagnosis of autism or demonstrated high levels of autism traits. Results suggest the need for identification and management of ear, nose and throat conditions in autistic children and may provide possible indicators of causal mechanisms.

Original languageEnglish
Article numbere067682
Number of pages9
JournalBMJ Open
Issue number3
Publication statusPublished - 24 Apr 2023

Bibliographical note

Copyright © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Funding: This publication was made possible through the support of grants from
the Medical Research Council (G0400085) and the John Templeton Foundation
(ref no. 61917). The UK Medical Research Council and Wellcome Trust (Grant ref:
217065/Z/19/Z) and the University of Bristol (grant ref: N/A) currently provide
core support for ALSPAC. This publication is the work of the authors who will
serve as guarantors for the contents of this paper. A comprehensive list of grants funding is available on the ALSPAC website ( The opinions expressed in this publication are those of the author(s) and do not necessarily reflect the views of the John Templeton Foundation.


  • Autistic Disorder
  • Child
  • Child, Preschool
  • Female
  • Humans
  • Longitudinal Studies
  • Parents
  • Pregnancy
  • Prospective Studies
  • Suppuration


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