How effective is the early support program Babylotse-Plus for psychosocially burdened mothers and their infants? A comparative intervention study

Objectives

Our aim was to examine the effects of an early perinatal prevention program offered to mothers and families suffering from significant psychosocial burden.

Methods

All mothers giving birth in a Berlin university hospital during Jan-Aug 2013 were screened with a standardized 27-item questionnaire by trained staff. Mothers with a screening-score ≥ 3, who were not enrolled in other public support programs, were defined as psychosocially burdened. They received a detailed needs assessment and were followed up with counseling. When necessary, affected mothers were voluntarily guided through to specialized ‘early support’ institutions during the 12-month-intervention period. The historical control group (care-as-usual) consisted of children born at the same hospital the year before.

At 12 months postnatally, we interviewed mothers in both groups to assess their stress burden and coping skills by Parenting Stress Index and assessed the current childcare condition. Differences between the groups were compared by multivariable logistic regression analyses adjusting for potential confounders.

Results

The intervention group and the control group included 225 and 157 families, respectively. After 12-months, mothers in the ‘early support’ intervention group had significantly less often depression (adjusted odds ratio 0.25, 95%-confidence interval 0.07–0.94), less often a disturbed relationship with the parenting partner (0.34, 0.10–1.14) and reported reduced stress due to the child’s demands (0.40, 0.15–1.10) compared to the control group. Childcare indicators did not differ between the 2 groups.

Conclusions

In mothers at high psychosocial risk, the ‘early support’ intervention program Babylotse-Plus seemed to reduce the occurrence of depression and several stress indicators in the first postnatal year.

What does lung function tell us about respiratory multimorbidity in childhood and early adulthood? Results from the MAS birth cohort study

BACKGROUND

Interaction between respiratory multimorbidity and lung function has not been examined in longitudinal population studies. We aimed to assess the association of multimorbidity of asthma and rhinitis with lung function and bronchial hyperresponsiveness in comparison with single and no allergies from early school age to young adulthood.

METHODS

In 1990, the Multicenter Allergy Study birth cohort recruited 1314 newborns from 5 German cities. At 7, 13, and 20 years, we performed lung function and bronchial challenge tests. We assessed symptoms, medications, and doctor's diagnoses for asthma and rhinitis for 3 outcomes: current multimorbidity (both coexisting), asthma only, and rhinitis only.

RESULTS

From 7 to 20 years, multimorbidity prevalence more than doubled from 3.5% to 7.7%, current asthma only (without rhinitis co-occurring) decreased by half from 2.8% to 1.3%, and current rhinitis only (without asthma co-occurring) increased from 14.3% to 41.6%. Resting lung function parameters differed between allergic and asymptomatic participants but showed no considerable differences between the allergic phenotypes. Frequency and severity of bronchial hyperresponsiveness were particularly associated with multimorbidity. At the age of 20 years, participants with multimorbidity showed a clearly higher severity in hyperresponsiveness compared to participants who suffered only asthma (P = .049) or rhinitis (P = .008) or were asymptomatic (P < .001).

CONCLUSION

Single lung function measurements from childhood ongoing do not seem to discriminate between subjects with multimorbidity, single allergies, and no allergy. Our results show that multimorbidity is associated with more severe symptoms compared to those suffering only a single allergic disease.

Growth attainment in German children born preterm, and cardiovascular risk factors in adolescence. Analysis of the population representative KiGGS data

AIM

To compare the growth attainment of preterm children and their cardiovascular risk factors at adolescence with the values measured in term children in Germany.

METHODS

About 17,641 children aged 0 to <18 years were studied between 2003 and 2006 in the population representative German KiGGS survey ("German Health Interview and Examination Survey for Children and Adolescents") using questionnaires, physical examinations, standardized anthropometric and blood pressure measurements, and blood sample analyses. Analysis of covariance (ANCOVA) was employed for the analyses of anthropometric parameters.

RESULTS

About 11.8% of the 16,737 children with complete and valid data had been born preterm. After adjustment for covariates the estimated z-scores over the total age range were larger in term compared to preterm children for length/height (P<0.001; estimated difference B=0.277, 95% CI 0.191-0.362), head circumference (P<0.001; B=0.238, 95% CI 0.144-0.333), BMI (P=0.001; B=0.160, 95% CI 0.069-0.252), and skinfold thickness (P=0.220; B=0.058, 95% CI -0.035 to 0.151). The onset of pubertal development was slightly (but not significantly) earlier in term compared to preterm children. At 14 to <18 years, anthropometric and biochemical indicators of cardiovascular diseases were not worse in preterm compared to term children.

CONCLUSIONS

Preterm-born German adolescents remained significantly shorter, lighter, and had a smaller head circumference than term-born adolescents, but the risk indicators for cardiovascular diseases were not higher.

Latent class analysis reveals clinically relevant atopy phenotypes in 2 birth cohorts

BACKGROUND

Phenotypes of childhood-onset asthma are characterized by distinct trajectories and functional features. For atopy, definition of phenotypes during childhood is less clear.

OBJECTIVE

We sought to define phenotypes of atopic sensitization over the first 6 years of life using a latent class analysis (LCA) integrating 3 dimensions of atopy: allergen specificity, time course, and levels of specific IgE (sIgE).

METHODS

Phenotypes were defined by means of LCA in 680 children of the Multizentrische Allergiestudie (MAS) and 766 children of the Protection against allergy: Study in Rural Environments (PASTURE) birth cohorts and compared with classical nondisjunctive definitions of seasonal, perennial, and food sensitization with respect to atopic diseases and lung function. Cytokine levels were measured in the PASTURE cohort.

RESULTS

The LCA classified predominantly by type and multiplicity of sensitization (food vs inhalant), allergen combinations, and sIgE levels. Latent classes were related to atopic disease manifestations with higher sensitivity and specificity than the classical definitions. LCA detected consistently in both cohorts a distinct group of children with severe atopy characterized by high seasonal sIgE levels and a strong propensity for asthma; hay fever; eczema; and impaired lung function, also in children without an established asthma diagnosis. Severe atopy was associated with an increased IL-5/IFN-γ ratio. A path analysis among sensitized children revealed that among all features of severe atopy, only excessive sIgE production early in life affected asthma risk.

CONCLUSIONS

LCA revealed a set of benign, symptomatic, and severe atopy phenotypes. The severe phenotype emerged as a latent condition with signs of a dysbalanced immune response. It determined high asthma risk through excessive sIgE production and directly affected impaired lung function.

Factors for Preterm Births in Germany - An Analysis of Representative German Data (KiGGS)

Introduction: Preterm birth is a global scourge, the leading cause of perinatal mortality and morbidity. This study set out to identify the principal risk factors for preterm birth, based on the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). A range of possible factors influencing preterm birth were selected for inclusion in the questionnaire, covering factors such as gender, national origin, immigrant background, demography, living standard, family structure, parental education and vocational training. Methods: All data were taken from the aforementioned KiGGS survey conducted between 2003 and 2006. A total of 17 641 children and adolescents (8656 girls and 8985 boys) drawn from 167 German towns and municipalities deemed to be representative of the Federal Republic of Germany were included in the study. Gestational age at birth was available for 14 234 datasets. The questionnaire included questions from the following areas as possible factors influencing preterm birth: gender, national origins, immigrant background, demography, living standard, family structure, parental education and vocational training. Results: The preterm birth rate was 11.6 %, higher than that of other national statistical evaluations. Around 57.4 % of multiple pregnancies and 10 % of singleton pregnancies resulted in preterm delivery. Multiple pregnancy was found to be the most important risk factor (OR 13.116). With regard to national origins and immigration background, mothers from Turkey, the Middle East, and North Africa had a higher incidence of preterm birth. Preterm birth was more prevalent in cities and large towns than in small towns and villages. Conclusion: Risk factors associated with preterm birth were identified. These should help with the early identification of pregnant women at risk. The preterm birth rate in our survey was higher than that found in other national statistical evaluations based on process data. More than half of all multiple pregnancies ended in preterm birth.

Allergic multimorbidity of asthma, rhinitis and eczema over 20 years in the German birth cohort MAS

BACKGROUND

The occurrence of allergic multimorbidity (coexistence of asthma, allergic rhinitis and eczema) has not been evaluated longitudinally from early childhood up to adulthood in a population-based study sample. We aimed to determine the prevalence of allergic multimorbidity up to age 20 stratified by parental allergies and sex/gender using extensive prospective follow-up data from two decades of a birth cohort study.

METHODS

In 1990, we recruited 1314 healthy newborns from 6 maternity wards across Germany for the population-based MAS birth cohort study. The sample was purposely risk-enriched by increasing the proportion of children at high allergy risk (i.e. at least 2 allergic family members among parents and siblings) from 19% in the source population to 38% in the final sample. The remaining 62% of all MAS children had a low or no allergy risk. Symptoms, medication and doctor's diagnoses of allergic diseases have been assessed using standardized questionnaires including validated ISAAC questions in 19 follow-up assessments up to age 20. Allergic multimorbidity at each time point was defined as the coexistence of at least 2 of the following diseases in one participant: asthma, allergic rhinitis and eczema.

RESULTS

Response at age 20 was 72% (n = 942) of all recruited participants. At age 20, 18.5% (95% CI, 15.0-22.5%) of all participants with allergic parents had 2 or 3 concurrent allergies as compared to only 6.3% (95% CI, 4.3-9.0%) of those with non-allergic parents. At this age, allergic multimorbidity was similar in women and men (12.7% (95% CI, 9.7-16.2%) vs. 11.6% (95% CI, 8.9-14.8%)), whereas single allergic diseases were slightly more common in women than men (24.2% (95% CI, 20.2-28.5%) vs. 20.1% (95% CI, 16.6-24.0%)). Asthma occurred more frequently with coexisting allergic rhinitis and/or eczema than as a single entity from pre-puberty to adulthood.

CONCLUSION

Having parents with allergies is not only a strong predictor to develop any allergy, but it strongly increases the risk of developing allergic multimorbidity. In males and females alike, coexisting allergies were increasingly common throughout adolescence up to adulthood. Particularly asthma occurred in both sexes more frequently with coexisting allergies than as a single entity.

The novel 10-item asthma prediction tool: external validation in the German MAS birth cohort

Background

A novel non-invasive asthma prediction tool from the Leicester Cohort, UK, forecasts asthma at age 8 years based on 10 predictors assessed in early childhood, including current respiratory symptoms, eczema, and parental history of asthma.

Objective

We aimed to externally validate the proposed asthma prediction method in a German birth cohort.

Methods

The MAS-90 study (Multicentre Allergy Study) recorded details on allergic diseases prospectively in about yearly follow-up assessments up to age 20 years in a cohort of 1,314 children born 1990. We replicated the scoring method from the Leicester cohort and assessed prediction, performance and discrimination. The primary outcome was defined as the combination of parent-reported wheeze and asthma drugs (both in last 12 months) at age 8. Sensitivity analyses assessed model performance for outcomes related to asthma up to age 20 years.

Results

For 140 children parents reported current wheeze or cough at age 3 years. Score distribution and frequencies of later asthma resembled the Leicester cohort: 9% vs. 16% (MAS-90 vs. Leicester) of children at low risk at 3 years had asthma at 8 years, at medium risk 45% vs. 48%. Performance of the asthma prediction tool in the MAS-90 cohort was similar (Brier score 0.22 vs. 0.23) and discrimination slightly better than in the original cohort (area under the curve, AUC 0.83 vs. 0.78). Prediction and discrimination were robust against changes of inclusion criteria, scoring and outcome definitions. The secondary outcome ‘physicians’ diagnosed asthma at 20 years' showed the highest discrimination (AUC 0.89).

Conclusion

The novel asthma prediction tool from the Leicester cohort, UK, performed well in another population, a German birth cohort, supporting its use and further development as a simple aid to predict asthma risk in clinical settings.

Verhaltensauffälligkeiten mit 9 Jahren zur Vorhersage von Schulproblemen im Alter von 11 und 15 Jahren

Verhaltensauffälligkeiten im Kindesalter stellen einen Risikofaktor für psychische Auffälligkeiten und verminderte schulische Leistungsfähigkeit dar. Die Studie untersucht, ob eine geringere Funktionalität im Grundschulalter die Auftretenswahrscheinlichkeit von Schulproblemen in der Adoleszenz erhöht. Fragebogendaten der 9-, 11- und 15-Jahres Nachuntersuchungen der MAS-Geburtskohorte (N=1314 Baselineerhebung bei Geburt; 47.9 % Mädchen, 52.1 % Jungen) werden ausgewertet. Erhoben werden Funktionalität auf den Dimensionen Psychisches Wohlergehen, Körperlicher Status, Soziale Beziehungen und Alltagsfunktionsfähigkeit zu 9 Jahren sowie das Vorkommen von Schulproblemen mit 11 und 15 Jahren. Eine geringere Funktionalität im Alter von 9 Jahren geht mit einer erhöhten Auftretenswahrscheinlichkeit von Schulproblemen mit 11 (adjustierte Odds Ratio [aOR]=3.53, 95 %Konfidenzintervall [KI] 2.20 – 5.66) und 15 Jahren (aOR=3.22, 95 %KI 1.85 – 5.62) einher. Diese Effekte zeigen sich deutlicher für Jungen als für Mädchen. Bereits Grundschulkinder können Einschränkungen in ihrer Funktionalität zeigen, welche über Jahre stabil zu bleiben scheinen und mit Schulproblemen in der Adoleszenz einhergehen können.

Breastfeeding is natural but not always easy: intervention for common medical problems of breastfeeding mothers - a review of the scientific evidence

Natural processes do not always function perfectly. In breastfeeding, problems are encountered in up to 80% of mother-infant dyads. Altogether, in Western societies, the difficulties reduce the breastfeeding rate within the first months drastically. To deal with the problems of breastfeeding efficiently requires a profound understanding of its physiology, as well as of its psychological and social determinants. This review focuses on the current knowledge of breastfeeding physiology, only touching the psychosocial factors, which are included in the promotion strategies. Subsequently, it scrutinizes definitions, incidences, prevention, and treatment of breastfeeding problems faced most frequently by nursing mothers and their consultants. Not all measures used in counseling mothers and not all treatments for the most common medical problems withstand a careful evaluation on the basis of current scientific data. However, applying proven prevention strategies will significantly improve the well being of mothers and their infants, and may contribute to an affective attitude that increases the success, frequency, and duration of breastfeeding.

Does docosahexaenoic acid (DHA) status in pregnancy have any impact on postnatal growth? Six-year follow-up of a prospective randomized double-blind monocenter study on low-dose DHA supplements

Fetuses and breastfed children depend on the maternal docosahexaenoic acid (DHA) supply, which might have long-lasting consequences. We studied the growth of 6-year-old children whose mothers received supplemental DHA from midpregnancy to 3 months after delivery. One hundred and forty-four pregnant women had been randomized to receive one of three vitamin-mineral supplements, one supplying an additional 200 mg/day DHA. Of the original sample, 120 children were measured at age 6 years with standardized methods. As one objective of the follow-up was to investigate the DHA influence on normal growth, the DHA group was compared with the pooled controls after exclusion of five premature infants. The weight, length, body mass index (BMI), head circumference, and skin-fold thickness at 6 years were similar in the 41 children of the DHA group and the 74 controls. Longitudinally, the BMI z-scores of the DHA group increased up at a later age than that of the controls. We found a highly significant negative correlation between height at 6 years and the increase in red blood cell DHA concentration of mothers from 22 to 37 weeks of pregnancy. We conclude that DHA supplements during midpregnancy corrected a low maternal DHA status (which correlated with children's height) and was favorable in regard to the BMI development up to 6 years.

Molecular spreading and predictive value of preclinical IgE response to Phleum pratense in children with hay fever

BACKGROUND

IgE sensitization against grass pollen is a cause of seasonal allergic rhinitis.

OBJECTIVE

We sought to investigate the evolution at the molecular level and the preclinical predictive value of IgE responses against grass pollen.

METHODS

The German Multicentre Allergy Study examined a birth cohort born in 1990. A questionnaire was administered yearly, and blood samples were collected at 1, 2, 3, 5, 6, 7, 10, and 13 years of age. Grass pollen-related seasonal allergic rhinitis (SARg) was diagnosed according to nasal symptoms in June/July. Serum IgE antibodies to Phleum pratense extract and 8 P pratense molecules were tested with immune-enzymatic singleplex and multiplex assays, respectively.

RESULTS

One hundred seventy-seven of the 820 examined children had SARg. A weak monomolecular/oligomolecular IgE response to P pratense was observed very frequently before SARg onset. These initial IgE responses increased in concentration and molecular complexity during the preclinical and clinical process. A typical progression of IgE sensitization was observed: Phl p 1 (initiator in >75% of cases); then Phl p 4 and Phl p 5; then Phl p 2, Phl p 6, and Phl p 11; and then Phl p 12 and Phl p 7. At age 3 years, IgE sensitization predicted SARg by age 12 years (positive predictive value, 68% [95% CI, 50% to 82%]; negative predictive value, 84% [95% CI, 80% to 87%]). At this preclinical prediction time, the number of recognized molecules and the serum levels of IgE to P pratense were significantly lower than at 3 or more years after SARg onset.

CONCLUSIONS

The IgE response against grass pollen molecules can start years before disease onset as a weak monosensitization or oligosensitization phenomenon. It can increase in serum concentration and complexity through a "molecular spreading" process during preclinical and early clinical disease stages. Testing IgE sensitization at a preclinical stage facilitates prediction of seasonal allergic rhinitis at its molecular monosensitization or oligosensitization stage.

[Early health promotion and prevention at the beginning of the 20th and 21st centuries. Data and thoughts on the 100th anniversary of the opening of the Empress Auguste Victoria House in Berlin]

In June 1909, The Empress Auguste Victoria House in Berlin was opened. This first institute for preventive paediatrics had the objective to overcome infant mortality in Germany. This objective was attained. Since then, an unprecedented decrease of mortality in all age groups occurred as well as a doubling of life expectancy. With this "retreat of death", our concepts of health changed fundamentally, and a new spectrum of diseases emerged. This article discusses some mile stones of this change, and explains why we find more illness despite the great improvement in the field of health. The "new diseases" amenable to early prevention are presented in a table. To make disease prevention successful requires the participation of the individual. Therefore, it is important to know the demand to make a good programme effective in the population. Empirical results of a nationwide representative study on the demand by expecting and young parents for preventive consultation are presented. Anticipatory guidance of young parents is a modern approach to health promotion and disease prevention. A controlled trial shows that this approach improved knowledge, behaviour, health risk indicators, health, and development during the first two years after delivery. Future studies should focus on long term effects of early health promotion.

[Smoking during pregnancy: rates, trends, risk factors]

Knowledge of the risks of smoking during pregnancy induces only part of the pregnant women to give up smoking. How many pregnant women in Germany smoke from the beginning to delivery, and what characterises these smokers, is the topic of this article.

METHODS

Results from the German Mikrozensus, several national surveys, perinatal statistics and Euro-scip III are presented, compared, and assessed. Findings of our own studies conducted between 1999 and 2002 at the obstetric department and gynacological practices in Berlin allow an insight into the magnitude of "underreporting".

RESULTS

In the ages 15-45 years 36-45 % of German women smoke, prevalence rates that probably are valid even for the beginning of pregnancy. While smoking prevalence in men has decreased during the last 20 years, there is an increasing trend in women. The prevalence is higher in pregnant women of low social status, living with smoking partners and those of German nationality. At most, half of the women give up smoking during pregnancy. Assuming an "underreporting" in pregnant women of at least one third, the prevalence of smoking up to delivery is 24 %. Although 76 % of the practicing gynacologists in Berlin feel responsible for smoking counselling, only 12 % are convinced that it is successful.

CONCLUSIONS

A quarter of the pregnant women in Germany smoke through to delivery, which means that 150 000 newborns per year have been exposed to passive smoking in utero, and its long-term health effects, which is a national disaster.

Supplementation with 200 mg/day docosahexaenoic acid from mid-pregnancy through lactation improves the docosahexaenoic acid status of mothers with a habitually low fish intake and of their infants

BACKGROUND/AIMS

The supply of docosahexaenoic acid (DHA, 22:6omega-3), important for fetal/infant neurodevelopment, depends on the maternal fatty acid (FA) status, which may be marginal in central Europe. Therefore, we investigated the effect of a daily vitamin/mineral supplement with and without 200 mg DHA from mid-pregnancy through lactation on the DHA concentrations in maternal and infant red blood cell phospholipids (RBC%), and in breast milk FA (%).

METHODS

At 21 weeks' gestation, 144 women were enrolled into a randomised, double-blind clinical trial receiving daily: (1) a basic vitamin-mineral supplement (Vit/Min group), (2) Vit/Min plus 4.5 g fructo-oligosaccharide (FOS group), or (3) Vit/Min plus 4.5 g FOS plus 200 mg fish oil-derived DHA (DHA-FOS group). FAs were determined by capillary gas-liquid chromatography.

RESULTS

While maternal RBC-DHA% at enrolment was not different, at 37 weeks gestation, and 3 months after delivery RBC-DHA% were significantly higher in the DHA-FOS group. The breast milk DHA% was twice as high in the DHA-FOS group (0.50%) than in the two others (0.25 %) (p < 0.001), and the ratio ARA/DHA in the DHA-FOS group was 1.0 +/- 0.43, in the others 2.1 +/- 0.43 (p < 0.001). The RBC-DHA% of the infants in the DHA-FOS group was also significantly higher, and correlated significantly with maternal RBC-DHA% before and 3 months after delivery.

CONCLUSIONS

In central Europe, a dose of 200 mg/day DHA from mid-pregnancy through lactation seems appropriate to improve the DHA status of mothers and infants.

Undernutrition and growth restriction in pregnancy

Newborn size is the result of intrauterine growth. Premature, low birthweight of <2,500 g, small for gestational age (SGA, <10th percentile), or intrauterine growth-restricted (IUGR) newborns may have similar weights. Serial fetal biometry (ultrasound), required for the diagnosis, timing and severity of intrauterine growth restriction in the individual infant, is still not common in epidemiological studies. SGA newborns have less lean body mass, but they particularly lack fat mass. The most important etiological determinants of intrauterine growth restriction in developed countries is cigarette smoking, while in developing countries it is usually longstanding food deprivation. Follow-up studies of SGA newborns consistently showed a positive association between birthweight and later lean body mass, whereas associations with adiposity were more variable. Most SGA infants had catch-up in length/height. Signs of the metabolic syndrome accompanied the catch-up in bodyweight and central adiposity. So far, no overarching model is available to explain how the epigenetic and hormonal tunings, which accompany intrauterine malnutrition from preconception through pregnancy, can program the regulatory systems of fundamental life processes. The theoretical concepts of a thrifty phenotype (Hales and Barker) and of a predictive adaptive response (Gluckman and Hanson) offer a comprehensive approach to understanding the empirical and experimental findings.

Does maternal docosahexaenoic acid supplementation during pregnancy and lactation lower BMI in late infancy?

We compared growth of infants whose mothers either did or did not receive docosahexaenoic acid (DHA) supplements during pregnancy and lactation. At 21 weeks' gestation, 144 women were enrolled into a randomized, double-blind clinical trial receiving: (1) a basic supplement consisting of vitamins and minerals (BS), or (2) BS plus 4.5 g fructooligosaccharide (BSF), or (3) BSF plus fish oil DHA (200 mg) until the end of the third month of lactation. Infants' length, weight and head circumference were measured at birth and at 1, 3 and 21 months. A total of 51 mothers/infants were lost to follow-up by the third month and 24 at 21 months. The two groups not receiving DHA were combined into a control group. Analysis with mixed models adjusted for confounding factors showed a significant time dependent effect for the DHA group on the development of the body mass index (BMI) (P=0.037), and of weight (P=0.046), but no effect on the development of length (P=0.537), or of head circumference (P=0.267). At 21 months, weight of the DHA group was lower by -601 g (95% CI -171; -1030 g) and BMI was lower by -0.76 kg/m(2) (95% CI -0.07; -1.46) compared to controls. The results indicate that DHA taken by pregnant and lactating mothers may reduce BMI in late infancy.

Körpermaße bei Kindern und Jugendlichen in Deutschland

In the nationwide German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a number of anthropometric parameters were assessed in a standardised way in 17,641 boys and girls. To this end, body weight and height, head circumference and upper arm length, as well as two skinfold thicknesses (triceps, subscapular) were measured for the entire age range (0-12 years); starting from 6 years of age, elbow breadth and from 11 years of age waist and hip circumference were measured in addition. For all parameters, means with confidence intervals are reported per age (in years) and gender. Median graphs depict the changes with increasing age according to gender for each body measurement. The complex age-related anthropometric developments along with significant gender specificity show the full range of the dynamic physical development in boys and girls. Based on skinfold measurement data, the body fat percentage was estimated. Thickness and location of the skinfolds, as well as the calculated waist-to-hip ratio is used as an indicator for gender-specific fat distribution. Using the frame index, it is attempted to estimate skeletal robustness. For the anthropometric parameters studied, hardly any regional differences were found. However, head circumference, frame index and all parameters strongly associated with body fat show a significant social status gradient. Children and adolescents with migration background have on average a lower height, larger waist circumference and higher percentage of body fat.

Perinatale Einflussfaktoren auf die spätere Gesundheit

KIGGS is a health survey on 17,641 children and adolescents in 167 communities representative for Germany, conducted between May 2003 and May 2006. Of the perinatal indicators, only a small proportion of data important for long-term outcomes was available for statistical analysis, and is presented here. In the past 20 years the mean weight gain during pregnancy has increased significantly by 2 kg, the mean birth weight has increased significantly by an average of 50 g, there has been no significant time trend for smoking and alcohol consumption in pregnancy. Birth weight and pregnancy weight gain of the mother correlate significantly. Pregnancy weight gain explains 5% of the birth weight in first-born infants. 17-18% of the mothers smoked during pregnancy, 4 times as many in the lower than the upper social class. 14% of the mothers consumed alcohol in pregnancy, but only 1% regularly. Only 5% of the migrants, but 3 times as many of the non-migrants consumed alcohol in pregnancy, and 2 1/2 times as many of the upper class compared to the lower class. With respect to smoking and alcohol consumption during pregnancy there seems to be an urgent need for political action.

The prevalence of preterm deliveries in Berlin has not changed over 7 years: the impact of multiple births

The problem of preterm deliveries has worsened in developed countries over the past decade. To evaluate whether multiple deliveries had an impact on this development, we analyzed the data of the Berlin Perinatal Survey from 1993-1999 for 206,308 deliveries. The prevalence of preterm deliveries was fairly constant during this period, and the proportion of preterm deliveries in the case of multiples remained constant. But the prevalence of preterm neonates increased significantly in Berlin due to an increased prevalence of multiple births. There was a significant increase of mothers aged over 30, of German nationality, and with preceding infertility treatment, while the prevalence rates of nearly all other risk factors for prematurity decreased over time. The risk of infertility treatments resulting in multiple deliveries increased in these years. On average, infertility treatment led to an about 10 times higher risk of producing multiples than singletons OR (95% CI) of 9.6 (8.6-10.6).

Prevalence of adverse reactions to food in Germany - a population study

OBJECTIVE

A population study was performed to identify the prevalence of all kinds of adverse reactions to food.

METHODS

In a representative cross-sectional survey performed in 1999 and 2000 in Berlin, 13 300 inhabitants of all ages were addressed by questionnaire. This questionnaire was answered by 4093 persons. All respondents mentioning any sign of food intolerance or the existence of allergic diseases (n = 2298) were followed up by telephone and, in case food intolerance could not be ruled out by patient history, were invited to attend to the clinic for personal investigation including double-blind, placebo-controlled food challenge tests (DBPCFC).

RESULTS

The self-reported lifetime prevalence of any adverse reaction to food in the Berlin population (mean age 41 years) was 34.9%. Eight hundred and fourteen individuals were personally investigated according to the guidelines. The point prevalence of adverse reactions to food confirmed by DBPCFC tests in the Berlin population as a mean of all age groups was 3.6% (95% confidence interval [3.0-4.2%]) and 3.7% in the adult population (18-79 years, 95% confidence interval [3.1-4.4.%]). Two and a half percent were IgE-mediated and 1.1% non-IgE-mediated, females were more frequently affected (60.6%). Based on a statistical comparison with available data of adults from the nationwide German Health Survey from 1998, adverse reactions to food in the adult population of Germany (age 18-79) were calculated with 2.6% [2.1-3.2%]).

CONCLUSIONS

The study gives for the first time information about the point prevalence of both immunological and nonimmunological adverse reactions to food and underlines the relevance of this issue in public health. The data also show that an individualized stepwise approach including provocation tests is mandatory to confirm the diagnosis.

Secular trends in neonatal macrosomia in Berlin: influences of potential determinants

To investigate the trend in the prevalence of neonatal macrosomia and to evaluate the influences of potential determinants, key features of 206 308 hospital deliveries (97% of all) in Berlin in the years 1993-99, collected by the Berlin Medical Board, were analysed using SPSS 10.0. After exclusion of multiple births and preterm infants, there was a significant increase over 7 years (P < 0.01) in the prevalence of birthweights >or= 4000 g, maternal age >or= 30 years, height of >or= 165 cm, prepregnancy BMI (body mass index) >or= 26 kg/m2 and pregnancy weight gain> 16 kg, but no substantial trend in the prevalence of recognised diabetes or maternal smoking. The adjusted model (OR [95% CI]) for delivering a newborn >or= 4000 g was statistically significant for post-term delivery (2.56 [2.39, 2.75]), women aged >or= 30 years (1.06 [1.02-1.11]), >or= 165 cm tall (1.94 [1.87,2.01]), multiparae (1.98 [1.91, 2.05]), not smoking in pregnancy (2.03 [1.93, 2.14]), prepregnancy BMI >or= 26 compared with < 20 (4.01 [3.77, 4.26]), pregnancy weight gain >or= 16 kg compared with < 10 kg (3.37.[3.22, 3.53]) and for recognised diabetes (1.85.[1.69, 2.04]). It is speculated that this increase in the prevalence of neonatal macrosomia may contribute to the secular trend of overweight and obesity under affluent living conditions.

[Strategies of prevention]

Prematurity is one of the most stubborn health problems in our society, no other problem impairs afflicted children more seriously and long lasting. In spite of remarkable progress in the treatment of premature infants, the outcomes are still not satisfying and the prematurity rate is still increasing. Prevention of prematurity therefore seems a public health goal with a high priority in obstetrics. Health promotion should be an important issue of counseling in the gynecological practice, recommending favorable living habits in and before pregnancy. Risk factors have to be identified and adverse influences removed for the primary prevention of premature delivery. Secondary prevention requires screening with predictors for the treatment or avoidance of an imminent premature delivery, while the goal of tertiary prevention is the avoidance of health consequences for mother and newborn from a premature delivery and the prevention of recurrence. Not all risk factors for prematurity are known, so far. The identification and removal of unfavorable factors in the society and the individual are important tasks for the future. Better predictors for screening have to be identified and evaluated for the prevention of a premature delivery in order to make tertiary prevention a rare necessity. The prevention of prematurity remains a persistent challenge to obstetrics.

Early determinants of childhood overweight and adiposity in a birth cohort study: role of breast-feeding

BACKGROUND

The prevalence of adiposity in childhood is increasing. Is breast-feeding protective as suggested by cross-sectional studies?

OBJECTIVE

In a longitudinal birth cohort study, we tested whether breast-feeding for more than 2 months has preventive effects against overweight and adiposity at 6 y.

DESIGN

Of 1314 children representing the catchment areas of six delivery units, 918 could be followed up to the age of 6 y. Height, weight, and skin-fold thickness were measured at regular visits. As the criteria of overweight, obesity, and adiposity in the children, the 90th and the 97th percentiles of BMI and skin-fold values were used. Parents with a BMI at or above the 90th percentile, which was 27 kg/m(2) or more, were considered overweight. Infants bottle-fed from birth or breast-fed for less than 3 months were classified as 'bottle-fed' (BO), and those breast-fed for 3 months and more as 'breast-fed' (BR). Univariate comparisons and logistic regression analysis were performed applying SAS 6.12. The final logistic model consisted of the 480 cases for whom complete data for all variables were available. The potential effect of loss to follow-up was analysed by the Cochran-Mantel-Haenzel test: the outcomes were not significantly influenced by loss to follow-up.

RESULTS

At birth BMIs were nearly identical in both groups. By 3 months, BO had significantly higher BMIs and thicker skin folds than BR. From 6 months on, compared to BR, a consistently higher proportion of BO children exceeded the 90th and the 97th percentile of BMI and skin-fold thickness reference values. From the age of 4 y to 5 and 6 y, in BO the prevalence of obesity nearly doubled and tripled, respectively. With only minor changes of obesity prevalence in BR, the difference of BMI and skin-fold thickness between groups became statistically significant. Logistic regression analysis revealed that overweight of the mother, maternal smoking during pregnancy, bottle feeding, and low social status remained important risk factors for overweight and adiposity at 6 y of age.

CONCLUSION

A maternal BMI of > or =27, bottle-feeding, maternal smoking during pregnancy, and low social status are risk factors for overweight and adiposity at 6 y of age. Early bottle-feeding brings forward the obesity rebound, predictive of obesity in later life.

[Laboratory tests in The Child and Adolescent Health Survey]

Laboratory tests will be performed as part of the National Health Survey for Children and Adolescents to identify health risks and to determine the seroprevalence of disease markers. The parameters were selected from haematology, clinical chemistry, allergology, endocrinology and serology of infectious diseases as indicators of individual health risks, to validate information collected by means of the questionnaires and to identify age specific immunity gaps of vaccine-preventable diseases.

[The Child and Adolescent Health Survey: collection of health behavior data from parents and children]

The first German Health Survey for Children and Adolescents will start in 2003. During three years, a representative sample of children and adolescents between 0 and 18 years of age shall be examined and will, together with their parents, be interviewed on health-relevant issues. With this survey, health information on about 18,000 children will be gathered. The health behaviour of the parents as far as their children's health is concerned, as well as the personal health behaviour during adolescence will be assessed, since this will be highly relevant for future health. Questions on nutrition behaviour, eating disorders, alcohol consumption, smoking as well as leisure-time behaviour, with special emphasis on physical activity, will be asked. These questions were tested for feasibility in a one-year pilot study. With this survey, the occurrence of certain unhealthy behaviour characteristics may be documented and risk groups may be identified. This may help to conceptualize prevention measures.

[The Child and Adolescent Health Survey--a foundation for prevention, health promotion and health goals]

At the beginning of the 21st century, the German Health Interview and Examination Survey of Children and Adolescents will for the first time provide the data essential for programmes of disease prevention and health promotion as well as for the development of health targets. This it will create key information for an evidence-based health policy. The results of the study can be projected to the general population of children and adolescents in Germany. The data will be collected conjunct at the level of the individual subject. They will facilitate valid and distinct description of prevalent physical, psychological and social health problems, as well as on who has them under which circumstances and settings. Information on the impact, e.g., in terms of utilisation of the health system or impairments of quality of life, will also be available from the same subjects. In addition, indicators of risks to health in later life are included. Hence, the data will support prevention of health problems in infancy, childhood and adolescence as well as of chronic diseases in later life. Finally, the data shall be a basis for the definition of new reference values for many variables. This will improve valid and clear judgement not only in epidemiological studies but also in medical care.

[The National Child and Adolescent Health Survey. The complete concept]

The German National Health Interview and Examination Survey for Children and Adolescents aims at obtaining generalisable and practically convertible data and knowledge of the health situation of children and adolescents aged between 0 and 18 and living in Germany. After an extensive preparatory period of conceptional work by the Robert Koch Institute the beginning of this study is planned for spring 2003. Over a period of three years a representative sample of 18,000 young people will be medically examined and will be interviewed together with their parents. The investigational programme of the survey consists of a central part encompassing questionnaires and medical analyses of the most important health topics in childhood and adolescence. In addition, complementary modules will analyse subpopulations in-depth and extensively for specific aspects and questions. These modules are usually developed and financed by cooperating partners of the Robert Koch Institute. Soon after completion of the survey data first results will be made freely available to the scientific community in Public Use Files. These Files will become relevant sources for future health reporting addressing children and adolescents. Furthermore, they represent a reliable data base for epidemiological research and prevention programmes.

[The physical examination within the scope of The Child and Adolescent Health Survey]

The National Health Survey for Children and Adolescents intends a comprehensive description of the health status of children and adolescents. In this context physical examination of children and adolescents permits collection of objective data concerning physical development, certain body functions and selected performance parameters. Most important are indicators pointing towards increasing developmental and health problems in children and adolescents, which are partly predictive for the health status as an adult. Body measurements including stages of puberty will be taken, the blood pressure measured, vision tests carried out, coordination skills and endurance tested. Besides, if acute symptoms are detected, severity of atopic dermatitis is recorded. The methods and instruments have been tested in a pilot study over a period of one year and were optimised for the main study.

[Pilot study of The Child and Adolescent Health Survey: methodological aspects and procedure]

In the pilot study of the National Health Survey for Children and Adolescents which has been conducted under the responsibility of the Robert Koch Institute from March 12th 2001 to March 15th 2002, 1,630 children and adolescents from 0 to 17 years as well as their parents have been included. Methodological issues have been very prominent. Questionnaires regarding properties, indicators (for example for psychic well-being) were developed and evaluated, different methods of access to the study participants as well as methods to increase the motivation to participate in the study were tested, and the property for generalisation or validity of the obtained information was investigated. The conduct of the pilot study resulted in a number of experiences and findings that will contribute to an optimised approach in the main course of the survey.

[Obstetrical care in Berlin: possibilities for delivery from the gynaecologists' point of view]

BACKGROUND

Berlin offers a variety of delivery facilities: maternity clinics, birth centres, obstetrical practices and ambulant working midwives for the various options and kinds of delivery. To select an individual service is a difficult task for most women. In this process of decision-making the gynaecologist plays an important part. This raised the question as to how established gynaecologists appraise the available services, which delivery sites they recommend, and what criteria are decisive for their recommendation.

METHODS

A postal survey of all the 523 gynaecologists of Berlin was conducted anonymously, 273 (52.2 %) of whom completed the questionnaire.

RESULTS

The results of the study demonstrated that the most important aspects for the recommendation of a delivery place are the technological equipment and qualification of the staff. However, characteristics of good care and support and an atmosphere of kindness and mutual trust are equally important. According to these goals, criticism has been expressed especially in the area of care and kindness, larger obstetrical divisions having more defaults in this regard.

CONCLUSIONS

Future developments in delivery units of hospitals should take into consideration that both safety and optimal care are expected.

Iron deficiency is prevalent in a sample of pregnant women at delivery in Germany

OBJECTIVE

To determine the prevalence and risk factors of iron deficiency in pregnancy, since iron supplements are not routine in Germany.

STUDY DESIGN

Soluble transferrin receptor (sTfR), ferritin, hemoglobin (Hb), C-reactive protein (CRP) and leucocyte counts were determined in venous blood samples of 378 women before delivery; 191 of them filled in a questionnaire. Statistical analysis was performed using SPSS 9.0.1.

RESULTS

CRP and leucocyte count correlated significantly with ferritin values, while sTfR values were independent. Iron deficiency (sTfR >3.3 mg/dl) was found in 40.7% of pregnant women, and anemia (Hb<11.0 g/dl) in 13.6%. Non-German nationality, low educational level and young maternal age were significant risk factors for iron deficiency, while alcohol use in pregnancy, iron and folic acid supplements were protective. After adjusting for all other factors in a logistic regression equation, not taking any iron supplements in pregnancy (odd ratios (OR) 3.3 and 95% confidence interval (CI) 1.1-9.4), and young maternal age (OR 2.86 and 95% CI 1.1-7.7) remained significant risks.

CONCLUSION

Iron deficiency in pregnant women in Germany is prevalent; it could be prevented by routine iron supplements.

Breastfeeding duration is a risk factor for atopic eczema

BACKGROUND

The results of numerous studies on the influence of breastfeeding in the prevention of atopic disorders are often contradictory. One of the most important problems is confounding by other lifestyle factors.

OBJECTIVE

The aim of the present study was to analyse the effect of any breastfeeding duration on the prevalence of atopic eczema in the first seven years of life taking into account other risk factors.

METHODS

In an observational birth cohort study 1314 infants born in 1990 were followed-up for seven years. At 3, 6, 12, 18, 24 months and every year thereafter, parents were interviewed and filled in questionnaires, children were examined and blood was taken for in vitro allergy tests. Generalized Estimation Equations (GEE)-models were used to model risk factors for the prevalence of atopic eczema and for confounder adjustment

RESULTS

Breastfeeding was carried out for longer if at least one parent had eczema, the mother was older, did not smoke in pregnancy, and the family had a high social status. The prevalence of atopic eczema in the first seven years increased with each year of age (OR 1.05; 95% CI 1.01-1.09 for each year), with each additional month of breastfeeding (1.03; 1.00-1.06 for each additional month), with a history of parental atopic eczema (2.06; 1.38-3.08), and if other atopic signs and symptoms appeared, especially specific sensitization (1.53; 1.25-1.88), and asthma (1.41; 1.07-1.85). Although breastfeeding should be recommended for all infants, it does not prevent eczema in children with a genetic risk.

CONCLUSION

Parental eczema is the major risk factor for eczema. But in this study, each month of breastfeeding also increased the risk.

Socioeconomic status is a risk factor for allergy in parents but not in their children

BACKGROUND

Allergic diseases are more prevalent in affluent countries, which has been attributed to life-style factors. Life-style habits may also differ between socioeconomic (SES) classes. The objective of this paper therefore was to evaluate if SES had an impact on the development of atopic disorders.

METHODS

A total of 1314 German children were followed-up in an observational birth cohort study to 6 years of age. Parents filled in questionnaires, and had multi-allergen screening tests for sensitization. Indoor allergen concentrations were determined by ELISA. Children were examined regularly up to 6 years, specific serum IgE values were determined by CAP-Rast-Feia.

RESULTS

The risk of aeroallergen sensitization (odds ratio 1.76; 95% CI 1.30-2.37), and the lifetime prevalence of hay fever (2.36; 1.76-3.17), and asthma (1.74; 1.08-2.80), but not of atopic dermatitis (AD: 0.90; 0. 54-1.51) was elevated in parents of high compared to low SES. With high SES the risk of smoking in pregnancy (0.35; 0.23-0.51), in the home (0.31; 0.21-0.46), pet ownership (0.37; 0.26-0.55), high mite (0.42; 0.25-0.74), and high cat (0.38; 0.18-0.82) allergen concentration in house dust was reduced, but elevated for breastfeeding over more than 6 months (4.67; 2.9-7.48). In children, even after controlling for other risk factors, only the risk of AD from 3 to 6 years (2.42; 1.42-4.14) was elevated in families with high SES, but not of AD in infancy or of any other atopic disorder.

CONCLUSIONS

While parents of high SES have a higher prevalence of inhalative allergies, their favourable life-style prevents the development of atopic disorders in their children, except for AD beyond infancy.

Injury mortality in East Germany

OBJECTIVES

This study determined the effects of social changes in East Germany since 1989 on patterns of injury mortality.

METHODS

Death certificate data regarding injuries from 1980 through 1995 and police data regarding traffic injuries in East Germany from 1980 through 1998 were compared with similar data from West Germany.

RESULTS

The number of motor vehicle-related injuries and deaths in East Germany increased dramatically between 1989 and 1991, whereas those in West Germany declined slightly. The increased mortality in the more rural East has especially involved young men driving automobiles on rural roads and has persisted since reunification of East and West Germany. Falls, other accidents, and suicides have shown no such effect. Homicide among East German men has increased but remains uncommon.

CONCLUSIONS

Recent social changes in East Germany, including increased access to motor vehicles and decreased restrictions on personal freedom, have been associated with increased motor vehicle crashes and mortality, especially among young men and on rural roads.

[Competent parenting: expectations of young parents of counseling on pregnancy and labor]

BACKGROUND

Are expecting parents prepared to change their lifestyle to benefit their unborn child? Do they see a need for more knowledge and competence to be good parents? What are the key expectations with respect to pregnancy, delivery conditions, and infant health care? To answer these questions, a study presented them to expecting and young parents in Germany.

METHODS

123 delivery units were selected to represent the 1120 delivery facilities of Germany identified in 1997 from all accessible sources. 109 participated, and of 7862 distributed questionnaires 5900 (75%) were filled-in completely by parents.

RESULTS

Most parents (73%) expect information about pregnancy, birth and child health care in any instance. 25% would request information but only in problem situations. Preferred topics were prevention of diseases of the mother and her child (97%), intra-uterine development, preparation for delivery as well as breastfeeding, and nutrition of the infant (90% each). Although books had been the most frequent source of information, pediatricians, midwives, and gynecologists received the highest scores for satisfaction with their advice. The majority of expecting and new parents wished to get personal advice. For the choice of the delivery place, 59% had consulted friends and relatives, 43% their gynecologist. The most important criteria for their decision were high medical standards (95%), the hospital's attitude towards breast feeding and rooming-in (94% each), as well as the availability of neonatal care (89%). Also of prime interest were mother-child-contact immediately after delivery (99%), and well-rested personnel (96%).

CONCLUSIONS

Across social classes, most expecting and new parents see a need of a broad spectrum of topics in health information and education related to pregnancy, delivery and the expected infant. As far as delivery is concerned, most expect a perfect combination of modern medical care and safety on the one hand, and the undisturbed humane experience of the birth on the other.

[Prevalence and risk factors of iron deficiency in young mothers]

Quality of life and achievements are impaired by unrecognised iron deficiency. The iron requirement of women during their child-bearing age is high and increases in pregnancy. The aim of this study was to determine the prevalence and risk factors for iron deficiency in young mothers under contemporary German life conditions. Between September 1997 and August 1998 the iron status of 507 mothers of one-year old children was assessed. The data was derived from venous blood and questionnaires. Besides conventional methods, the concentration of soluble transferrin receptor was used as leading indicator of iron status. 9.5% had cellular iron deficiency and 2.2% of all mothers had iron deficiency anemia. In addition to absence of school education non-German nationality, a high number of children and vegetarian food are risk factors for iron deficiency. In contrast, high alcohol intake and cigarette smoking are associated with a better iron status. Children of mothers with insufficient iron supply are also at higher risk of iron deficiency.

[Anthropometric data and obesity]

In the German National Health Interview and Examination Survey 1998 several anthropometric data were obtained from 7124 men and women, aged 18-79 years. These data were analysed and compared with 1990/92 survey data. On average, people form the Western part of Germany are somewhat taller than those from the Eastern part, the differences being smallest in the youngest age group. With the use of the Body Mass Index (BMI) as the criterion, the prevalence of overweight (BMI > or = 25 kg/m2) ranges from 52% for West German women to 67% for West German men, and of obesity (BMI < or = 30 kg/m2) from 18% for West German men to 24.5% for East German women. Generally, overweight is more prevalent in the East than in the West. In the male population, aged 25-69 years, the prevalence of obesity increased by 5.9% in the East and by 11.5% in the West during the last decade. Among females the prevalence of obesity increased by 6.4% in the West, but decreased by 6.3% in the East. Still obesity is more prevalent among East German females. Since obesity is a key health risk, these recent German prevalence figures are alarming.

[Health objectives--chances for modern health policy]

If politicians, citizens, decision makers, patients and scientists develop health objectives they aim at a specific health outcome in a certain period of time. They intend thereby to improve the health of the population, quality of life, and quality-adjusted life expectancy as well as to assign resources more effectively to achieve a certain outcome. As health goals should be realistic and achievable participation and cooperation of citizens, patients, politicians, and scientists appears to be of crucial importance. The primary goals should not be mixed up with the ways, steps, processes and structures that are only tools to achieve the goals. A profound comprehension and valid data of the health status in the population and, where possible, projection computations are an important basis for the development of health goals. While health policy generally may be a defensive business, health objectives offer the chance of shaping future health, of acting instead of reacting.

An indirect method for the estimation of osteoporotic fractures from injury and fracture profiles

Study objective was to develop a valid epidemiological method for the estimation of osteoporotic fracture risk, using administrative databases and accounting for variable baseline risks of injury. Design is the secondary analysis of inpatient and outpatient utilization data. A baseline injury risk was estimated by the incidence of primary utilization of medical services for soft tissue injuries (ICD-9 diagnostic codes 910-929), and the risk profile was compared after normalization with the overall primary utilization rate for fractures (ICD-9 diagnostic codes 800-829). The setting is a county with approximately 100,000 inhabitants in the former East Germany. Participants were all inhabitants of the county who had a physician contact (inpatient or outpatient) during 1987-1988, as well as hospital inpatients for all of Germany in 1989. The number of fractures increased with age, especially in women, when compared to the number of fractures expected from the incidence of soft tissue injury. Similar patterns were identified in hospitalization data from East and West Germany. Estimating the prevalence of osteoporosis directly from certain "osteoporotic" fracture types associated with higher age is potentially biased, since it neglects the underlying risk of injury. Our model distinguished the osteoporotic fracture risk as the excess risk over an expected injury-related fracture risk for a given age and sex, and may allow a more valid quantification of osteoporotic fractures in different populations.