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.

[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.

[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.

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.

[Competent parenting: expectations of young parents of counseling on pregnancy and labor]. / Kompetente Elternschaft: Erwartungen von jungen Eltern an die Beratung in der Schwangerschaft und an die Entbindung.

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]. / Prävalenz und Risikofaktoren von Eisenmangel bei jungen Müttern.

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.

[Health objectives--chances for modern health policy]. / Gesundheitsziele--Chancen für eine moderne Gesundheitspolitik.

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.

Prevalence and role of serum IgE antibodies to the Staphylococcus aureus-derived superantigens SEA and SEB in children with atopic dermatitis.

BACKGROUND: The skin of patients with atopic dermatitis exhibits a striking susceptibility to colonization and infection with Staphylococcus aureus. In this context it has been previously shown that S aureus-derived superantigens could function as classic allergens, inducing production of functionally relevant specific IgE antibodies. OBJECTIVE: The aim of this study was to determine the prevalence and the role of circulating staphylococcal enterotoxin A (SEA)- and staphylococcal enterotoxin B (SEB)-specific IgE antibodies in children with atopic dermatitis. METHODS: In a cross-sectional study of 58 children with atopic dermatitis, the presence of IgE antibodies to SEA and SEB was correlated with the severity of the disease and the total and other unrelated allergen-specific IgE titers and density of colonization with S aureus strains on atopic skin and episodes of superficial S aureus skin infections. RESULTS: Twenty of 58 children (34%) were sensitized to superantigens (45% to SEB, 10% to SEA, 45% to SEA and SEB). In this group, severity of atopic dermatitis and levels of specific IgE to food and air allergens were significantly higher. The degree of disease severity correlated to a higher extent with the presence of SEA/SEB-specific antibodies than with total serum IgE levels. Density of colonization with superantigen-secreting S aureus strains was higher in the superantigen IgE-positive group. Sixty-three percent of these children experienced repeated episodes of superficialS aureus skin infections. CONCLUSIONS: Sensitization to S aureus-derived superantigens may be involved in disease exacerbation. The presence of SEA/SEB-specific antibodies had additional explanatory value for disease severity and therefore may be helpful in the characterization of children with severe atopic dermatitis.

Atopic dermatitis in early infancy predicts allergic airway disease at 5 years.

BACKGROUND: Screening tests for atopy risk in newborns have a low predictive value. If early atopic symptoms and signs could be used as predictors for the next expected atopic disorder then secondary prevention could be employed. The aim of this study was to evaluate the capacity of early atopic dermatitis to predict aeroallergen sensitization and the manifestation of respiratory atopic disorders at 5 years of age. METHODS: 1314 children of a German prospective birth cohort study MAS-90 were followed from birth up to 5 years of age. Atopic dermatitis, asthma and rhinoconjunctivitis were diagnosed from symptoms and signs at physical examinations and by interviews of the parents. Blood was drawn at 1, 2, 3, and 5 years of age. Aeroallergen sensitization was diagnosed by a specific IgE value of at least 0.35 kU/L (CAP class > or = 1) against any of five respiratory allergens (mite, cat, dog, birch, grass). RESULTS: Atopic dermatitis in the first 3 months was a risk factor for aeroallergen sensitization at 5 years. The risk increased with a positive family history for atopic diseases. Seventy-seven per cent of children with two atopic parents and early atopic dermatitis were sensitized against aeroallergens at 5 years, i.e. could have been predicted in early infancy without any laboratory tests. Although these risk factors were also significantly associated with the manifestation of allergic airway disease, the positive predictive value for this outcome at age 5 years was not yet as high, i.e. 50%. CONCLUSION: Infants with very early signs of atopic dermatitis and a positive family history are candidates for early intervention measures against respiratory allergies.

Cord blood-IgE as risk factor and predictor for atopic diseases.

BACKGROUND: Cord blood-IgE as risk factor or predictor for atopic diseases in infants has been discussed in a large number of papers with contradictory results. Our aim was to evaluate cord blood-IgE as risk factor and predictor for atopic dermatitis, recurrent wheezing and sensitization with emphasis on a clear-cut distinction between risk factor and predictor. METHODS: A cohort of 1314 newborns was recruited in six German obstetric departments and followed-up for 5 years. Four hundred and ninety-nine infants (38%) were considered to be at high risk with at least two atopic family members and/or a cord blood-IgE value above the threshold of 0.9 kU/L. At follow-up visits, parents filled in a questionnaire, the infants were clinically examined, and blood samples were taken. RESULTS: With regard to early onset atopic dermatitis up to 12 months we found that the odds ratios at the cord blood-IgE cut-off points of 0.70 kU/L and 1.25 kU/L with values of 0.53 and 0.32, respectively, were smaller than one (i.e. protective factors) and highly statistically significant. No significant association was found between elevated cord blood-IgE and recurrent wheezing. There was a strong positive association between elevated cord blood-IgE levels and sensitization at 12 months, but even in this case the predictive performance was rather poor: a maximum positive predictive value of 42% was attained with a cut-off point of 3.0 kU/L, but the sensitivity was only 10%. CONCLUSION: We conclude that even when elevated cord blood-IgE levels are identified as a strong risk factor for sensitization, their poor predictive performance may make them useless as a basis for preventive measures.

Early life markers of atopy and asthma.

Since early intervention could modulate the natural course of atopic disease, the availability of predictive markers is of considerable interest. As long as specific genetic markers are not available, early IgE-responses (hen's egg) together with a positive family history of atopy can be proposed as highly specific and predictive markers, which could define subgroups as potential candidates for secondary prevention.

Predictability of early atopy by cord blood-IgE and parental history.

BACKGROUND: Atopic family history and cord blood IgE have been used as predictors of atopic disease in newborns for about 20 years, but at least for cord blood IgE the sensitivity has been shown to be very low. The objective of this paper was to evaluate whether parental history and cord blood-IgE were more accurate predictors for the appropriate atopic phenotypes in the infants rather than for any atopy. METHODS: A total of 1314 newborn infants was recruited in six German obstetric departments in 1990 and followed-up for 2 years. Four hundred and ninety-nine (38%) were at high risk for atopy with at least two first degree atopic family members and/or elevated cord-blood IgE concentrations. RESULTS: The cumulative incidence of atopic dermatitis over the first 2 years of life (AD24) amounted to 20.1%, and there was a significant association with AD history of the mother (OR 2.5, 95%CI 1.46-4.26) and of the father (OR 3.53, 95%CI 1.90-6.54). The cumulative incidence of recurrent wheezing in the first 2 years of life (RW24) amounted to 16.1%, and was positively associated with asthma history (OR 2.11, 95%CI 1.33-3.60) and sensitization history (OR 1.64, 95%CI 1.34-2.36) of the mother, but with neither for the father. RW24 was less prevalent in girls than in boys (OR 0.64, 95%CI 0.47-0.89). Thirty-one per cent of infants were sensitized (CAP test value > 0.35 kU/L) against at least one of nine food or inhalative allergens (S24) and this was significantly associated with cord blood-IgE value (OR 2.43, 95%CI 1.69-3.49), and sensitization history of the mother (OR 1.64, 95%CI 1.18-2.41). Using multiple logistic regression analysis, the prediction of AD24 by AD of parents, of RW24 by asthma of parents, and of sensitization by cord blood IgE was of low accuracy. CONCLUSION: The predictive capacity of parental history and cord blood IgE is not high enough to recommend them as screening instruments for primary prevention. The majority of atopic manifestations and of sensitization occur in infants with no demonstrable risk at birth.

The allergy march: from food to pollen.

There is epidemiological evidence, especially from longitudinal studies, that clinical manifestations of atopy as well as IgE antibodies against food and aeroallergens show a systematic sequence of events. The atopic march begins with food allergy associated gastrointestinal disorders and atopic dermatitis followed by respiratory allergies, i.e. asthma and atopic rhino-conjunctivitis. Detectable food antibodies, especially against egg and milk proteins, usually precede or accompany the early clinical symptoms and signs. Similarly, aeroallergen sensitization, first against indoor allergen antibodies, succeeded by outdoor allergen antibodies, precede the clinical manifestation of respiratory allergy. Early atopic events, either manifestation or sensitization can be used as risk markers or even predictors of atopic disorders to implement preventive measures. Early atopic dermatitis as well as elevated serum IgE antibodies against food allergens in the first two years of life in combination with a family history can be used as a predictor for aeroallergen sensitization.