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.

[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]. / Frühe Gesundheitsförderung und Prävention am Beginn des 20. und des 21. Jahrhunderts. Daten und Gedanken zum 100. Jahrestag der Eröff nung des Kaiserin Auguste Victoria Hauses zu 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]. / Rauchen in der schwangerschaft: verbreitung, trend, risikofaktoren.

UNLABELLED: 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.

[Multiple roles and quality of life of mothers two years after the birth of the first child]. / Berufstätigkeit und Lebensqualität von Müttern zwei Jahre nach der Geburt des ersten Kindes.

TOPIC: We studied those characteristics of mothers that are related to occupational activity two years after the birth of the first child. Differences in the health-related quality of life between working mothers and mothers who are not working were also analysed, taking other parameters into account, in particular household income. METHODOLOGY: 311 mothers with a first child were given a questionnaire on the quality of life based on WHOQOL-BREF, on depression (also surveyed one year before for 139 mothers), on their work situation, socio-demography and other possible confounders. The probability of vocational activity was analysed using logistic regression and the influence of multiple roles on the quality of life was analysed using multiple linear regression. RESULTS: About 60% of mothers were not working two years after the birth of their first child, 25% were working part-time and 11% full time, with 4% in training or education. Working mothers were more likely to have a higher level of education (60% vs. 31%) and less likely to have a household income below the poverty line (13% vs. 47%). The results of the logistic regression showed that the odds ratio for being employed was six times higher for mothers with higher education than mothers with a lower level of education [OR 5.99; 95% confidence interval (CI) 2.58-13.91], whereas the odds ratio for mothers with additional children against those with only one child was 0.14; (95% CI 0.05-0.40), and for mothers with German nationality against those of other ethnicities the odds ratio was 2.37 (95% CI 1.12-5.04). Working mothers give more positive ratings than non-working mothers for their physical and mental quality of life (both p<0.01), their social relationships (p<0.05), as well as their global quality of life and their depression score (p<0.10). Even after adjusting for the depression score one year before working mothers reported less depression (p<0.05). The influence of income on the quality of life was low, except for the assessment of the quality of the environment, and this explains only a small part of the positive effect of the vocational activity. CONCLUSIONS: Vocational activity of mothers of two-year old children reduces the risk of poverty and additionally contributes to an improved physical and mental quality of life of the mother and also to improved social relationships.

[Body measurements of children and adolescents in Germany. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. / Körpermasse bei Kindern und Jugendlichen in Deutschland. Ergebnisse des Kinder- und Jugendgesundheitssurveys (KiGGS).

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.

[Perinatal risk factors for long-term health. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. / Perinatale Einflussfaktoren auf die spätere Gesundheit. Ergebnisse des Kinder- und Jugendgesundheitssurveys (KiGGS).

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.

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.

[Strategies of prevention]. / Strategien der Prävention.

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.

[Obstetrical care in Berlin: possibilities for delivery from the gynaecologists' point of view]. / Geburtshilfe in Berlin: Die Entbindungsmöglichkeiten aus der Sicht der niedergelassenen Frauenärztinnen und Frauenärzte.

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.

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.

[The National Child and Adolescent Health Survey. The complete concept]. / Der bundesweite Kinder- und Jugendgesundheitssurvey. Das Gesamtkonzept.

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]. / Die körperliche Untersuchung im Rahmen des Kinder- und Jugendgesundheitssurveys.

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.

[Laboratory tests in The Child and Adolescent Health Survey]. / Laboruntersuchungen im Kinder- und Jugendgesundheitssurvey.

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]. / Der Kinder- und Jugendgesundheitssurvey: Ermittlung des Gesundheitsverhaltens von Eltern und Kindern.

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]. / Der Kinder- und Jugendgesundheitssurvey--eine Grundlage für Prävention, Gesundheitsförderung und Gesundheitsziele.

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.

[Pilot study of The Child and Adolescent Health Survey: methodological aspects and procedure]. / Der Pretest des Kinder- und Jugendgesundheitssurveys: Methodische Aspekte und Durchführung.

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.

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.