Martina Kohlhuber

Breastfeeding rates and duration in Germany: a Bavarian cohort study

Breastfeeding is the recommended feeding for all healthy infants. The aim of our study was to assess the current state of breastfeeding prevalence, duration and behaviour in Bavaria, Germany as a basis for targeting breastfeeding promotion measures. The Bavarian Breastfeeding Study is a prospective cohort study of 3822 mothers who delivered in April 2005 in Bavaria, Germany. Breastfeeding duration and determinants such as socioeconomic status, attitudes towards breastfeeding, birth mode and breastfeeding problems were assessed by questionnaires 2-6 d after birth and 2, 4, 6, and 9 months after birth. The initial breastfeeding rate was 90 %. After 4 months 61 % still breastfed (any breastfeeding). In the multivariate analyses the main influencing factor reducing breastfeeding initiation was the partners negative attitude towards breastfeeding (OR 21.79; 95 % CI 13.46, 35.27). No initial breastfeeding was also associated with lower education, maternal grandmothers negative attitude and pre-term birth. Protective factors were primary breastfeeding experience and information on breastfeeding before birth. Breastfeeding duration < 4 months was strongly associated with breastfeeding problems (OR 7.56; 95 % CI 6.21, 9.19), smoking, lower education, partners negative attitude and Caesarean section. Since the attitude of family members is an important influencing factor on breastfeeding rates, breastfeeding promotion should also target the partners of pregnant women and the families of newborn infants. Public health interventions such as more effective support for the management of breastfeeding problems, especially in lower social status families, should be implemented and their effectiveness should be critically evaluated.

Environmental inequalities among children in Europe--evaluation of scientific evidence and policy implications

BACKGROUND Socio-economic inequalities in the living environment are major contributing factors to health inequalities. Consequently, protecting children from undesirable environmental exposures by taking socio-economic conditions into account has been identified as a policy priority area in Europe. This review aims to evaluate the evidence on environmental inequalities among children in Europe and to discuss its policy implications. METHODS A systematic literature search was conducted in various literature databases. Further sources for information were reviews, international reports and working documents for a WHO expert meeting on environmental inequalities in 2009. One major inclusion criterion for publications was consideration of socio-economic factors as influencing factors, not merely as confounder. RESULTS The overall pattern based on the available fragmentary data is that children living in adverse social circumstances suffer from multiple and cumulative exposures. A low socio-economic position is associated with an increased exposure of children to traffic-related air pollution, noise, lead, environmental tobacco smoke, inadequate housing and residential conditions and less opportunities for physical activity. For most topics and exposures reviewed here there were no studies investigating the modification of the exposure-response function by socio-economic factors. Due to a variety of methodological approaches and studies on one hand and lack of data for many topics and countries on the other hand it was not possible to quantify the magnitude of environmental inequalities. CONCLUSION Action is needed along the whole causal pathway of the social divide in environmental hazards with priority to policy measures aiming at removing socially determined differences in environmental conditions.

Breastfeeding duration and exclusivity associated with infants’ health and growth: data from a prospective cohort study in Bavaria, Germany

Aim: To investigate the relationship between breastfeeding and infant health and to describe growth in the first 9 months.

Exposure to multiple environmental agents and their effect

Introduction: All children are exposed to multiple physical, chemical and biological challanges that can result in adverse health effects before and after birth. In this context, the danger of multiple exposures cannot be assessed from a single‐chemical approach as used in classical toxicology. Aim: To open up a ‘negotiation space’ for the problem of multiple exposure to environmental stressors, defined as any physical, chemical or biological entity that can induce an adverse response. In this context, two further questions obtain: to what extent can synergistic risks be assessed, and how far could potential adverse effects be prevented by enhanced regulation?Methods: A discussion of two general approaches is taken: 1 ) the investigation of mixtures such as smoking or air pollution without specifying the individual agents, and 2 ) the investigation of individual substances with a focus on possible interactions in the context of dose to receptor. Results: Although mixtures of compounds can have effects, it may not be possible to ascribe causation to a single compound. Furthermore, cumulative low‐dose insult can, in some circumstances, be more toxic than a single high‐dose exposure, e.g. endocrine disruptive effects of a combination of PCBs and dioxins which disrupt the thyroid hormone status; this tends to contradict elements of classical toxicology,. These cumulative insults may further combine with heavy metals and can disrupt the heme synthesis. It is possible that groups of pollutants could be used to test their cumulative capacity to multiple stress‐susceptible receptor targets as is done in smoking and air pollution. This methodology could be used for further groups of potential pollutants, for example those associated with cleaning products, or cosmetics. Testing individual substances with a focus on interactions means that not only chemicals but also concurrent diseases should be taken into account. We suggest that the enhanced regulation of potential multiple stressors falls into two discrete categories. The first comprises a more precautionary approach (as demonstrated by the banning of chemicals such as some brominated flame retardants in Europe). The second comprises a more ‘permissive’ liberal approach involving the initial study of an individual compound, and subsequent interrogation of that compound in combination with another (as demonstrated by lowering the carcinogenicity of aflatoxin by vaccination against hepatitis B).

Infant feeding practices and associated factors through the first 9 months of life in Bavaria, Germany

Objectives: To investigate infant feeding and breast-feeding practices during the first 9 months of life in Bavaria, Germany, in relation to recommendations and to identify factors associated with early feeding of semisolid food. Materials and Methods: Data from 3103 infants throughout Bavaria, Germany, were collected in a prospective cohort study. Questionnaires were administered at the age of 6 days, and 2, 4, 6, and 9 months. Results: There was a considerable variety concerning the time when complementary feeding was introduced. Only 16.4% of the infants ate solid/semisolid food before the age of 5 months. Most of the infants received as their first solid food a mash of vegetable, meat, and potato. Compared to national guidelines fluids were introduced early. More than 37% of the breast-fed infants received additional fluids/formula. The strongest risk factor associated with complementary feeding before the fifth month was breast-feeding duration of less than 4 months (any breast-feeding) with an odds ratio of 8.57 (95% confidence interval 6.16–11.94). Other factors were low level of education, young age of the mother, smoking habit of the mother, and mother not being born in Germany. Conclusions: Further improvements in nutrition of infants may be achieved in 2 ways: promotion of breast-feeding according to current recommendations and better counselling on the correct timing of introduction of semisolid food—especially for parents of not- or short-time breast-fed babies and focused on young mothers with low levels of education.

Today's epidemics in children: possible relations to environmental pollution and suggested preventive measures.

Background: Facts and hypotheses on the relationship between some childrens diseases or disorders and external stressors during the developmental stage of a child, both prenatally and postnatally are described in literature. In this paper the following changes in patterns and causes of the main childhood illnesses are summarized and recommendations for actions are made.

Children's environmental health: why should social disparities be considered?

Background/Methods: The aim of workpackage 5 ‘Environmental exposures and childrens health: impact of socioeconomic factors’ in the EU‐funded network PINCHE (Policy Interpretation Network on Childrens Health and Environment) was to review and interpret the current knowledge of social inequalities in environmental exposures and childrens health. Socioeconomic factors may impact on childrens environmental health in two ways: 1) environmental exposures may differ according to socioeconomic status; 2) given a certain level of harmful environmental exposure, socioeconomic factors may modify the health effects by influencing the susceptibility characteristics of children. Results: There is a lack of information to evaluate and quantify the effect of socioeconomic factors on environmental exposures and childrens health in Europe. In most circumstances there seems to be an inverse social gradient with increased burden concerning exposures and health outcomes in children of lower social status.

No further increase in the parent reported prevalence of allergies in Bavarian preschool children: Results from three cross-sectional studies

BACKGROUND After three decades of an increase in the prevalence of asthma and allergies, new findings show a plateau in the prevalence of industrialized nations. The objective of this study was to determine whether there was a change in the parent reported prevalence of asthma and allergies among Bavarian preschool children since 2004. METHODS A parent questionnaire was administered as part of the Bavarian school entrance examination in three cross-sectional studies from 2004/2005, 2006/2007 and 2012/2013. The questionnaire included items on allergy testing history, identified allergens, symptoms (e.g. wheezing, itchy eyes, rash), medically diagnosed asthma, hay fever and atopic dermatitis. Logistic regression was performed to observe time patterns and adjust for risk factors. RESULTS Data were available for 6350 (2004/2005), 6483 (2006/2007) and 5052 (2012/2013) individuals. Symptoms and diseases were more frequent in boys, except for allergies which affect the skin. From 2004 to 2012 the parent reported prevalence of asthma (2.6% to 2.8%), hay fever (4.7% to 4.0%) and atopic dermatitis (12.4% to 11.1%) either remained quite stable or decreased not significantly. CONCLUSIONS Results from these three cross-sectional surveys of parent reports suggest that the parent reported prevalences of asthma and allergies are quite stable with small fluctuations since 2004 for Bavarian preschool children. Future research is needed to determine if this trend will continue.

Stillraten und Stilldauer in Bayern – Ergebnisse der Studie „Stillverhalten in Bayern“

Schlussfolgerungen fur Stillforderung Zielgerichtete Information fur Mutter und Vater – fruhzeitig in der Schwangerschaft uber die gesundheitlichen Vorteile des Stillens fur Mutter und Kind Vermeidung von Stillproblemen durch vorausschauende Beratung und Verbesserung der Hilfestellung bei Stillproblemen Spezielle Masnahmen fur sozial benachteilige Mutter und Familien Integrierte Betreuung von Muttern in Schwangerschaftsvorsorge und Geburtsnachsorge Abb. 1: Stillraten in den ersten 24 Lebenswochen 0,6 0,23 0,37*** Information 0,42 0,15 0,25*** Stillerfahrung 4,01 1,29 2,27** Realschulabschluss vs. Abitur 7,12 2,11 3,88*** Hauptschulabschluss vs. Abitur 25,64 0,14 1,91 kein Schulabschluss vs. Abitur 5,81 2,26 3,62*** negative Einstellung der Mutter 35,27 13,46 21,79*** negative Einstellung des Partners 95%-KI OR