Urban environment in pregnancy and postpartum depression: An individual participant data meta-analysis of 12 European birth cohorts

BACKGROUND

Urban environmental exposures associate with adult depression, but it is unclear whether they are associated to postpartum depression (PPD).

OBJECTIVES

We investigated associations between urban environment exposures during pregnancy and PPD.

METHODS

We included women with singleton deliveries to liveborn children from 12 European birth cohorts (N with minimum one exposure = 30,772, analysis N range 17,686-30,716 depending on exposure; representing 26-46 % of the 66,825 eligible women). We estimated maternal exposure during pregnancy to ambient air pollution with nitrogen dioxide (NO2) and particulate matter (PM2.5 and PM10), road traffic noise (Lden), natural spaces (Normalised Difference Vegetation Index; NDVI, proximity to major green or blue spaces) and built environment (population density, facility richness and walkability). Maternal PPD was assessed 3-18 months after birth using self-completed questionnaires. We used adjusted logistic regression models to estimate cohort-specific associations between each exposure and PPD and combined results via meta-analysis using DataSHIELD.

RESULTS

Of the 30,772 women included, 3,078 (10 %) reported having PPD. Exposure to PM10 was associated with slightly increased odds of PPD (adjusted odd ratios (OR) of 1.08 [95 % Confidence Intervals (CI): 0.99, 1.17] per inter quartile range increment of PM10) whilst associations for exposure to NO2 and PM2.5 were close to null. Exposure to high levels of road traffic noise (≥65 dB vs. < 65 dB) was associated with an OR of 1.12 [CI: 0.95, 1.32]. Associations between green spaces and PPD were close to null; whilst proximity to major blue spaces was associated with increased risk of PPD (OR 1.12, 95 %CI: 1.00, 1.26). All associations between built environment and PPD were close to null. Multiple exposure models showed similar results.

DISCUSSION

The study findings suggest that exposure to PM10, road traffic noise and blue spaces in pregnancy may increase PPD risk, however future studies should explore this causally.

Type 2 diabetes risk after gestational diabetes according to country/region of origin. A nationwide register-based study

CONTEXT

The risk of gestational diabetes mellitus (GDM) differs between the Danish population and several migrant groups. However, it is unclear if the incidence and timing of type 2 diabetes mellitus (T2DM) following GDM vary similarly.

OBJECTIVE

To investigate the incidence of T2DM according to migration background based on country/region of origin among women with a previous GDM diagnosis and explore the role of time since GDM diagnosis on the association.

METHOD

Using nationwide registry data, we followed women diagnosed with GDM in Denmark during 2004-2018 to Dec 31, 2020. Poisson regression models were used to estimate incidence rates (IRs) of T2DM according to country/region of origin, adjusted for age, education, and body mass index.

RESULTS

The study included 20,873 women with a GDM diagnosis, of whom 22.3% were of migrant background and 77.7% were Danish. The mean follow-up time was 7.3 years, and 10.9% were registered with T2DM during the study period. Generally, migrant women had higher IRs of T2DM compared to Danish women, with substantial variations in risk between migrant groups. Women from Pakistan and Sri Lanka had three-four times higher IRs compared to Danish women. The timing of T2DM onset also varied, with women from Sri Lanka and Pakistan having an earlier onset of T2DM compared to other migrant and Danish women.

CONCLUSION

This study demonstrated that country/region of origin is an important risk factor for T2DM in women with GDM. These findings underscore the importance of prevention programs targeting women with GDM and a high-risk origin.

Residential exposure to mold, dampness, and indoor air pollution and risk of respiratory tract infections: a study among children ages 11 and 12 in the Danish National Birth Cohort

BACKGROUND

The burden of respiratory tract infections (RTIs) is high in childhood. Several residential exposures may affect relative rates.

OBJECTIVES

To determine risk of RTIs in children ages 11 and 12 by residential exposures.

METHODS

We included children in the Danish National Birth Cohort (DNBC) at ages 11 and 12. We estimated incidence risk ratios (IRR) and 95% confidence intervals (CI) for counts of RTIs within the last year by exposure to mold/dampness, gas stove usage, summer and winter candle-burning, fireplace usage, cats and dogs indoors, and farmhouse living. We also estimated IRR and 95% CI for RTIs for predicted scores of four extracted factors ('owned house', 'mold and dampness', 'candles', and 'density') from exploratory factor analyses (EFA).

RESULTS

We included 42 720 children with complete data. Mold/dampness was associated with all RTIs (common cold: IRRadj 1.09[1.07, 1.12]; influenza: IRRadj 1.10 [1.05, 1.15]; tonsillitis: IRRadj 1.19 [1.10, 1.28]; conjunctivitis: IRRadj 1.16 [1.02, 1.32]; and doctor-diagnosed pneumonia: IRRadj 1.05 [0.90, 1.21]), as was the EFA factor 'mold/dampness' for several outcomes. Gas stove usage was associated with conjunctivitis (IRRadj 1.25 [1.05, 1.49]) and with doctor-diagnosed pneumonia (IRRadj 1.14 [0.93, 1.39]). Candle-burning during summer, but not winter, was associated with several RTIs, for tonsillitis in a dose-dependent fashion (increasing weekly frequencies vs. none: [IRRadj 1.06 [0.98, 1.14], IRRadj 1.16 [1.04, 1.30], IRRadj 1.23 [1.06, 1.43], IRRadj 1.29 [1.00, 1.67], and IRRadj 1.41 [1.12, 1.78]).

CONCLUSION

Residential exposures, in particular to mold and dampness and to a lesser degree to indoor combustion sources, are related to the occurrence of RTIs in children.

Unlocking the mechanisms of change in the MAMAACT intervention to reduce ethnic disparity in stillbirth and newborns' health: integration of evaluation findings

Ethnic disparities in stillbirth exist in Europe and suboptimal care due to miscommunication is one contributing cause. The MAMAACT intervention aimed to reduce ethnic disparity in stillbirth and newborns' health through improved management of pregnancy complications. The intervention encompassed training of antenatal care midwives in cultural competencies and intercultural communication combined with health education materials for the expecting parents about symptoms of pregnancy complications. The evaluation consisted of a qualitative in-depth implementation analysis and a process evaluation embedded in a cluster randomized trial including 19 of 20 maternity wards in Denmark. In this article, the findings from the different evaluation perspectives are integrated. The integration follows the principles of realist evaluation by analyzing to what extent the MAMAACT activities were generating mechanisms of change in interaction with the context. The integration analysis shows that the health education materials in the MAMAACT intervention contributed to heightened health literacy concerning pregnancy complications among pregnant women. Additionally, the training of midwives in cultural competency and intercultural communication raised awareness among midwives. Nonetheless, the exclusive emphasis on midwives and the inflexibility in care provision hindered them from changing their communication practices. To enhance the cultural competence in maternity care, it is essential to implement more comprehensive initiatives involving healthcare professionals in maternity care at all levels, from pregraduate to postgraduate. Adequate interpreter services and management support should also be ensured. Currently, the Danish antenatal care system faces challenges including inadequate information transfer between healthcare sectors, insufficient differentiation of care, and inflexibility in midwife scheduling. This results in a lack of responsiveness to the individual needs of women with immigrant backgrounds, potentially reproducing health inequities.

The relation between preterm birth and self-reported spinal pain in pre-adolescence-a study of 47,063 subjects from the Danish National Birth Cohort

Repeated exposure to pain and stress in early life may cause alterations in pain sensitivity later in life. Children born preterm are often exposed to painful invasive procedures. This study aimed to explore the relationship between being born preterm and self-report of spinal pain in pre-adolescence. This prospective study was based on the Danish National Birth Cohort and consisted of 47,063 11-14-year-olds. Data from the Danish National Birth Cohort were linked with national registers through Statistics Denmark. Analyses were performed as multiple logistic regression models estimating odds ratios and 95% confidence intervals. Spinal pain (neck, mid back, and/or low back pain) was assessed using a subdivision of the Young Spine Questionnaire. Severe spinal pain was defined as having pain often or once in a while with an intensity of four to six on the Revised Faces Pain Scale. Inverse probability weighting was used to account for potential selection bias. Girls born very preterm (< 34 full weeks of gestation) were less likely to report spinal pain (OR: 0.60; 95% CI: 0.40-0.93) compared with those term-born. The associations were weaker when examining moderate to severe spinal pain and when examining the three spinal regions separately. None of these was statistically significant.

CONCLUSION

We found no associations for boys. In conclusion, this study indicates that girls born very preterm are seemingly less likely to have severe spinal pain in pre-adolescence than girls born at term.

WHAT IS KNOWN

• Spinal pain is one of the largest disease burdens globally, and the evidence regarding the etiology of spinal pain in children and adolescents is limited. • Repeated exposure to pain and stress in early life (i.e., being preterm) may cause alterations in pain sensitivity later in life.

WHAT IS NEW

• Girls born very preterm (< 34 full weeks of gestation) seem less likely to report severe spinal pain in pre-adolescence compared with girls born at full term. • There is no association between gestational age and later experience of spinal pain in pre-adolescent boys.

Exposure to different residential indoor characteristics during childhood and asthma in adolescence: a latent class analysis of the Danish National Birth Cohort

BACKGROUND

Many residential indoor environments may have an impact on children's respiratory health.

OBJECTIVES

The aims of this study were to identify latent classes of children from the Danish National Birth Cohort (DNBC) who share similar patterns of exposure to indoor home characteristics, and to examine the association between membership in the latent classes and asthma in adolescence.

METHODS

We included data on residential indoor characteristics of offspring from the DNBC whose mothers had responded to the child's 11-year follow-up and who had data on asthma from the 18-year follow-up. Number of classes and associations were estimated using latent class analysis. To account for sample selection, we applied inverse probability weighting.

RESULTS

Our final model included five latent classes. The probability of current asthma at 18 years was highest among individuals in class one with higher clustering on household dampness (9, 95%CI 0.06-0.13). Individuals in class four (with higher clustering on pets ownership and living in a farm) had a lower risk of current asthma at age 18 compared to individuals in class one (with higher clustering on household dampness) (OR 0.53 (95%CI 0.32-0.88), p = .01).

CONCLUSION

Our findings suggest that, in a high-income country such as Denmark, groups of adolescents growing up in homes with mold and moisture during mid-childhood might be at increased risk of current asthma at age 18. Adolescents who grew-up in a farmhouse and who were exposed to pets seem less likely to suffer from asthma by age 18.

Body height and spinal pain in adolescence: a cohort study from the Danish National Birth Cohort

OBJECTIVES

To investigate how body height and trajectories of height from infancy through childhood and adolescence were associated with spinal pain in pre- and late adolescence.

METHODS

This prospective study included 43,765 individuals born into The Danish National Birth Cohort (DNBC) from 1996 to 2003. DNBC-data were linked with health and social data identified from Statistics Denmark registers. Spinal pain was self-reported in both the 11-year- and 18-year follow-up of DNBC and classified according to severity. Body height was measured from birth and onwards and further modelled as distinct developmental height trajectories by using latent growth curve modelling. Associations were estimated by using multinomial logistic regression models.

RESULTS

Taller body height in childhood and adolescence was associated with approximately 20% increased likelihood of spinal pain in pre- and late adolescence among girls compared to their peers in the normal height group. For boys, taller body height was associated with spinal pain by late adolescence only. Spinal pain in pre-adolescence almost doubled the likelihood of spinal pain in late adolescence regardless of body height at age 18. Height trajectories confirmed the relationship for girls with the tall individuals being most likely to have spinal pain in both pre- and late adolescence.

CONCLUSION

Tall body height during childhood and adolescence predisposes to spinal pain among girls in both pre-and late adolescence, and among boys in late adolescence. Body height is a contributing factor to the pathogenesis of spinal pain in adolescence; however, the mechanisms may be related to growth velocity, but for now uncertain.

Exposure to residential mold and dampness and the associations with respiratory tract infections and symptoms thereof in children in high income countries: A systematic review and meta-analyses of epidemiological studies

BACKGROUND

Multiple reviews have been conducted on the associations between residential mold and dampness and respiratory outcomes in children, with few specifically investigating respiratory tract infections (RTIs).

OBJECTIVE

We aimed to review and synthesize the available epidemiological literature on mold and dampness and risk of RTIs and respiratory symptoms compatible with RTIs in children living in high-income countries.

METHOD

We performed a systematic search of literature available from MEDLINE, Embase, and Web of Science for observational studies. We conducted meta-analyses using two-level random effects (RE) and multi-level random effects (ML) models for contrasts of three exposure and three outcome categories, including multiple estimates reported by single studies. We report central estimates for pooled odds ratios (OR) and 95 % confidence intervals (CI).We conducted a risk of bias assessment using the Joanna Briggs Initiative (JBI) checklists for cross-sectional, case-control, and cohort studies. We additionally report on cumulative meta-analyses, leave-one-out analyses of single estimates, subgroup analyses by study quality and study design and inclusion of all effect estimates.

RESULTS

Of the 932 studies initially screened by title and abstract, we included 30 studies with 267 effect estimates that met the inclusion criteria. Most were cross-sectional (n = 22), with fewer cohort (n = 5) and case-control (n = 3) studies. Most of the studies were according to the bias assessment of poor or fair quality (n = 24). The main meta-analyses generally provided similar results regardless of statistical model and central estimates ranged from OR 1.28 (95 % CI; 1.08, 1.53) for dampness and RTIs to OR 1.76 (95 % CI; 1.64, 1.88) for mold and respiratory symptoms. Most analyses were of moderate heterogeneity. Funnel plots did not indicate strong publication bias.

CONCLUSION

Our results are compatible with a weak to moderate effect of residential mold and or dampness on risk of RTIs in children in high-income countries. However, these results are based primarily on cross-sectional studies.

Early environmental risk factors and coeliac disease in adolescents: a population-based cohort study in Denmark

OBJECTIVES

Our aim was to investigate the association between early environmental factors and the development of coeliac disease (CeD) in adolescents, recruited from a cohort nested in the Danish National Birth Cohort (DNBC).

DESIGN

The study was designed as a prospective cohort study, nested in DNBC PARTICIPANTS: The Glutenfunen cohort comprises 1266 participants, nested in DNBC. All participants were screened for CeD, and in total, 28 cases of biopsy proven CeD were identified. Data about breastfeeding, timing of introduction to solid food in infancy, use of antibiotics, infections and symptoms were parentally reported prospectively at 6 months and 18 months, respectively. We estimated ORs and 95% CIs of CeD in adolescents using logistic regression analysis.

RESULTS

Viral croup reported at 18 months of age was associated with CeD in adolescents with an OR of 3.2 (95% CI: 1.2 to 8.7). Furthermore, otitis media also reported at 18 months of age was linked with CeD with an OR of 3.2 (95% CI: 1.5 to 7.3). We were not able to find any statistical associations between CeD and breastfeeding, frequency of infections, parentally reported use of antibiotic and timing of solid foods.

CONCLUSION

In this study, we present an overview of the relationship between early environmental factors and occurrence of CeD in adolescents. Our findings, despite limitations due to a limited number of cases of CeD, suggest a role of viral infections in the pathogenesis of CeD.

Associations of Maternal Educational Level, Proximity to Greenspace During Pregnancy, and Gestational Diabetes With Body Mass Index From Infancy to Early Adulthood: A Proof-of-Concept Federated Analysis in 18 Birth Cohorts

International sharing of cohort data for research is important and challenging. We explored the feasibility of multi-cohort federated analyses by examining associations between three pregnancy exposures (maternal education, exposure to green vegetation and gestational diabetes) with offspring BMI from infancy to 17 years. We used data from 18 cohorts (n=206,180 mother-child pairs) from the EU Child Cohort Network and derived BMI at ages 0-1, 2-3, 4-7, 8-13 and 14-17 years. Associations were estimated using linear regression via one-stage IPD meta-analysis using DataSHIELD. Associations between lower maternal education and higher child BMI emerged from age 4 and increased with age (difference in BMI z-score comparing low with high education age 2-3 years = 0.03 [95% CI 0.00, 0.05], 4-7 years = 0.16 [95% CI 0.14, 0.17], 8-13 years = 0.24 [95% CI 0.22, 0.26]). Gestational diabetes was positively associated with BMI from 8 years (BMI z-score difference = 0.18 [CI 0.12, 0.25]) but not at younger ages; however associations attenuated towards the null when restricted to cohorts which measured GDM via universal screening. Exposure to green vegetation was weakly associated with higher BMI up to age one but not at older ages. Opportunities of cross-cohort federated analyses are discussed.

Association between perinatal mortality and morbidity and customised and non-customised birthweight centiles in Denmark, Finland, Norway, Wales, and England: comparative, population based, record linkage study

Objectives

To compare the risk of adverse perinatal outcomes according to infants who are born small for gestational age (SGA; <10th centile) or large for gestational age (LGA; >90th centile), as defined by birthweight centiles that are non-customised (ie, standardised by sex and gestational age only) and customised (by sex, gestational age, maternal weight, height, parity, and ethnic group).

Design

Comparative, population based, record linkage study with meta-analysis of results.

Setting

Denmark, Finland, Norway, Wales, and England (city of Bradford), 1986-2019.

Participants

2 129 782 infants born at term in birth registries.

Main outcome measures

Stillbirth, neonatal death, infant death, admission to neonatal intensive care unit, and low Apgar score (<7) at 5 minutes.

Results

Relative to those infants born average for gestational age (AGA), both SGA and LGA births were at increased risk of all five outcomes, but observed relative risks were similar irrespective of whether non-customised or customised charts were used. For example, for SGA versus AGA births, when non-customised and customised charts were used, relative risks pooled over countries were 3.60 (95% confidence interval 3.29 to 3.93) versus 3.58 (3.02 to 4.24) for stillbirth, 2.83 (2.18 to 3.67) versus 3.32 (2.05 to 5.36) for neonatal death, 2.82 (2.07 to 3.83) versus 3.17 (2.20 to 4.56) for infant death, 1.66 (1.49 to 1.86) versus 1.54 (1.30 to 1.81) for low Apgar score at 5 minutes, and (based on Bradford data only) 1.97 (1.74 to 2.22) versus 1.94 (1.70 to 2.21) for admission to the neonatal intensive care unit. The estimated sensitivity of combined SGA or LGA births to identify the three mortality outcomes ranged from 31% to 34% for non-customised charts and from 34% to 38% for customised charts, with a specificity of 82% and 80% with non-customised and customised charts, respectively.

Conclusions

These results suggest an increased risk of adverse perinatal outcomes of a similar magnitude among SGA or LGA term infants when customised and non-customised centiles are used. Use of customised charts for SGA/LGA births-over and above use of non-customised charts for SGA/LGA births-is unlikely to provide benefits in terms of identifying term births at risk of these outcomes.

Early-Life Exposure to Ambient Air Pollution from Multiple Sources and Asthma Incidence in Children: A Nationwide Birth Cohort Study from Denmark

BACKGROUND

Ambient air pollution exposure has been associated with childhood asthma, but previous studies have primarily focused on prevalence of asthma and asthma-related outcomes and urban traffic-related exposures.

OBJECTIVE

We examined nationwide associations between pre- and postnatal exposure to ambient air pollution components and asthma incidence in children age 0-19 y.

METHODS

Asthma incidence was identified from hospital admission, emergency room, and outpatient contacts among all live-born singletons born in Denmark between 1998 and 2016. We linked registry data with monthly mean concentrations of particulate matter (PM) with aerodynamic diameter ≤2.5μm (PM2.5) and PM with aerodynamic diameter ≤10μm (PM10), nitrogen dioxide (NO2), nitrogen oxides, elemental carbon, and organic carbon (OC), sulfur dioxide, ozone, sulfate, nitrate, ammonium, secondary organic aerosols, and sea salt. Associations were estimated with Cox proportional hazard models using fixed prenatal exposure means and time-varying postnatal exposures.

RESULTS

Of the 1,060,154 children included, 6.1% had asthma during the mean follow-up period of 8.8 y. The risk of asthma increased with increasing prenatal exposure to all pollutants except for O3 and sea salt. We also observed increased risk after restriction to asthma after age 4 y, after additional adjustment for area-specific socioeconomic status, and for postnatal exposure to most pollutants. The hazard ratio (HR) associated with an interquartile range increase of 2.4 and 8.7 μg/m3 in prenatal exposure was 1.06 [95% confidence interval (CI): 1.04, 1.08] for PM2.5 and 1.04 (95% CI: 1.02, 1.05) for NO2, respectively. This association with PM2.5 was stable after adjustment for NO2, whereas it attenuated for NO2 to 1.01 (95% CI: 0.99, 1.03) after adjustment for PM2.5. For a 0.5-μg/m3 increase in prenatal OC exposure, for which biomass is an important source, the HR was 1.08 (95% CI: 1.06, 1.10), irrespective of adjustment for PM2.5.

DISCUSSION

These findings suggest that early-life exposure to ambient air pollution from multiple sources contributes to asthma development. https://doi.org/10.1289/EHP11539.

Improving health literacy responsiveness to reduce ethnic and social disparity in stillbirth and infant health: A cluster randomized controlled effectiveness trial of the MAMAACT intervention

OBJECTIVE

The MAMAACT intervention aims to reduce ethnic and social disparities in stillbirth and infant death by improving communication between pregnant women and midwives regarding warning signs of pregnancy complications. This study evaluates the effect of the intervention on pregnant women's health literacy (two domains from the Health Literacy Questionnaire) and complication management - interpreted as improved health literacy responsiveness among midwives.

DESIGN

Cluster randomized controlled trial, 2018-2019.

SETTING

19 of 20 Danish maternity wards.

PARTICIPANTS

Cross-sectional survey data were collected using telephone interviews (n = 4150 pregnant women including 670 women with a non-Western immigrant background).

INTERVENTION

A six-hour training session for midwives in intercultural communication and cultural competence, two follow-up dialog meetings, and health education materials for pregnant women on warning signs of pregnancy complications - in six languages.

MAIN OUTCOME MEASURES

Differences in mean scores at post-implementation of the domains Active engagement with healthcare providers (Active engagement) and Navigating the healthcare system from the Health Literacy Questionnaire, and differences in the certainty of how to respond to pregnancy complication signs between women in the intervention and control group.

RESULTS

No difference was observed in women's level of Active engagement or Navigating the healthcare system. Women from the intervention group were more certain of how to respond to complication signs: Redness, swelling, and heat in one leg: 69.4 % vs 59.1 %; aOR 1.57 (95 % CI 1.32-1.88), Severe headache: 75.6 % vs 67.3 %; aOR 1.50 (95 % CI 1.24-1.82), and Vaginal bleeding: 97.3 % vs 95.1 %; aOR 1.67 (95 % CI 1.04-2.66).

CONCLUSION

The intervention improved women's certainty of how to respond to complication signs, but was unable to improve pregnant women's health literacy levels of Active engagement and Navigating the healthcare system, likely due to barriers related to the organization of antenatal care. A reorganization of antenatal care and a care model sensitive to diversity within the entire healthcare system might help reduce disparities in perinatal health.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03751774.

The influence of early-life animal exposure on the risk of childhood atopic dermatitis, asthma and allergic rhinoconjunctivitis: findings from the Danish National Birth Cohort

BACKGROUND

Early-life animal exposure has been associated with both protective and harmful effects on asthma and allergic disease. We aimed to explore factors that may modify associations of early-life animal exposure with asthma and allergic disease, so as to better understand these differences in findings.

METHODS

We used data from ≤84 478 children from the Danish National Birth Cohort recruited during pregnancy between 1996 and 2002, and linked registry data up to the child's 13th birthday. Adjusted Cox models were used to examine associations of early-life cat, dog, rabbit, rodent, bird and livestock exposure with atopic dermatitis, asthma and allergic rhinoconjunctivitis overall, and by source of exposure (domestic or occupation), parental history of asthma or allergy, maternal education level and timing of exposure.

RESULTS

Overall, associations between animal exposure and the three outcomes of interest were weak. However, dog exposure was associated with marginally lower risk of atopic dermatitis and asthma [adjusted hazard ratio (aHR) = 0.81, 95% CI: 0.70-0.94 and 0.88, 95% CI: 0.82-0.94, respectively], whereas prenatal domestic bird exposure was associated with slightly increased risk of asthma (aHR = 1.18, 95% CI: 1.05-1.32). Source of exposure, parental history of asthma or allergy and timing of exposure modified associations. Early-life animal exposure did not appear to increase the risk of allergic rhinoconjunctivitis (aHR range = 0.88, 95% CI: 0.81-0.95 to 1.00, 95% CI: 0.91-1.10).

CONCLUSIONS

The overall weak associations observed between animal exposure and atopic dermatitis, asthma and allergic rhinoconjunctivitis were modified by type of animal, source of exposure, parental history of asthma or allergy and timing of exposure, suggesting that these factors should be considered when assessing the risks associated with early-life animal exposure.

Correction: Gestational age at birth and body size from infancy through adolescence: An individual participant data meta-analysis on 253,810 singletons in 16 birth cohort studies

[This corrects the article DOI: 10.1371/journal.pmed.1004036.].

Severe COVID-19 during pregnancy in Sweden, Norway, and Denmark

INTRODUCTION

Pregnancy is a risk factor for severe coronavirus disease 2019 (COVID-19) and adverse pregnancy outcomes. We aimed to explore maternal characteristics, pregnancy outcomes, vaccination status, and virus variants among pregnant women admitted to intensive care units (ICU) with severe COVID-19.

MATERIAL AND METHODS

We identified pregnant women admitted to ICU in Sweden (n = 96), Norway (n = 31), and Denmark (n = 16) because of severe COVID-19, from national registers and clinical databases between March 2020 and February 2022 (Denmark), August 2022 (Sweden), or December 2022 (Norway). Their background characteristics, pregnancy outcome, and vaccination status were compared with all birthing women and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test-positive pregnant women during the same time period. We calculated the number admitted to ICU per 10 000 birthing and per 1000 SARS-CoV-2 test-positive women during the Index, Alpha, Delta, and Omicron periods.

RESULTS

Women admitted to ICU had a higher mean body mass index, were more often of non-Scandinavian origin, had on average lower education and income levels, had a higher proportion of chronic and pregnancy-related conditions, delivered preterm, had neonates with low Apgar scores, and had more infants admitted to neonatal care, compared with all birthing and test-positive pregnant women. Of those admitted to ICU, only 7% had been vaccinated before admission. Overall, the highest proportion of women admitted to ICU per birthing was during the Delta period (4.1 per 10 000 birthing women). In Norway, the highest proportion admitted to ICU per test-positive pregnant women was during the Delta period (17.8 per 1000 test-positive), whereas the highest proportion of admitted per test-positive in Sweden and Denmark was seen during the Index period (15.4 and 8.9 per 1000 test-positive, respectively).

CONCLUSIONS

Admission to ICU because of COVID-19 in pregnancy was a rare event in the Scandinavian countries, but women who were unvaccinated, of non-Scandinavian origin, and with lower socio-economic status were at higher risk of admission to ICU. In addition, women admitted to ICU for COVID-19 had higher risk of adverse pregnancy outcomes.

Maternal fever during pregnancy and male offspring reproductive health: A longitudinal cohort study in young Danish males

BACKGROUND

Maternal fever during pregnancy has been associated with an increased risk of genital malformations, but the implication for long-term reproductive health in the offspring is unknown.

OBJECTIVES

To investigate associations between timing, duration, and temperature of fetal exposure to maternal fever and sons' semen quality, testicular volume, and levels of reproductive hormones in early adulthood. Further, to examine whether concurrent use of antipyretics and/or antibiotics modified the effect.

MATERIALS AND METHODS

We used the Fetal Programming of Semen Quality cohort consisting of men born to women enrolled in the Danish National Birth Cohort. Self-reported information on maternal fever was collected twice during pregnancy (median 16 and 31 pregnancy weeks) and categorized as any fever during pregnancy, fever during early pregnancy (weeks 1-15), and fever exclusively during late pregnancy (weeks 16-42). Semen quality and concentrations of reproductive hormones were measured at a clinical examination at the age of 18.9 years. We used negative binomial regression to examine the associations, adjusting for maternal age at birth, maternal smoking, family occupational status, and precision variables related to semen quality and hormonal levels, for example, abstinence time.

RESULTS

986 men were included in the study, of which 23% had mothers reporting at least one episode of fever. We found no strong indications of associations between maternal fever during pregnancy and male reproductive health in young men. Concurrent use of antipyretics and antibiotics did not modify the association.

DISCUSSION

Strengths include the large sample size, prospectively collected data, and the adjustment for maternal factors during pregnancy and important precision variables. A limitation is the crude self-reported information on maternal fever.

CONCLUSION

We found no evidence to support that timing, duration, or temperature of maternal fever during pregnancy has a long-term impact on semen characteristics, testicular volume, or level of reproductive hormones in male offspring.

Gestational age and trajectories of body mass index and height from birth through adolescence in the Danish National Birth Cohort

Preterm birth is associated with smaller body dimensions at birth. The impact on body size in later life, measured by body mass index (BMI) and height, remains unclear. A prospective register-based cohort study with 62,625 singletons from the Danish National Birth Cohort born 1996-2003 for whom information on gestational age (GA) at birth, length or weight at birth, and at least two growth measurements scheduled at the ages of 5 and 12 months, and 7, 11 and 18 years were available. Linear mixed effects with splines, stratified by sex, and adjusted for confounders were used to estimate standardised BMI and height. GA was positively associated with BMI in infancy, but differences between preterm and term children declined with age. By age 7, preterm children had slightly lower BMI than term children, whereas no difference was observed by adolescence (mean difference in BMI z-score - 0.28 to 0.15). GA was strongly associated with height in infancy, but mean differences between individuals born preterm and term declined during childhood. By adolescence, the most preterm individuals remained shorter than their term peers (mean difference in height z-score from - 1.00 to - 0.28). The lower BMI in preterm infants relative to term infants equalizes during childhood, such that by adolescence there is no clear difference. Height is strongly positively associated with GA in early childhood, whilst by end of adolescence individuals born preterm remain slightly shorter than term peers.

Joint exposure to parental cancer and income loss during childhood and the child's socioeconomic position in early adulthood: a Danish and Norwegian register-based cohort study

BACKGROUND

Parental cancer as well as economic hardship in the family during childhood can affect the child negatively. Our aim was to examine the association between the joint exposure to parental cancer and income loss in childhood and the child's socioeconomic position in early adulthood.

METHODS

We conducted a register-based prospective cohort study of children born in Denmark between 1978 and 1986 and in Norway between 1979 and 1987. The children were followed from 1 January 1994 (in Denmark) or 1995 (in Norway). Educational level and personal income were measured at age 30 years. Children who experienced parental cancer between the years they turned 8 and 16 years were identified, and exposure to income loss was measured in the same period. Adjusted multinomial logistic regression model was used to estimate relative risk ratios for the joint exposure of parental cancer and income loss during childhood.

RESULTS

Children who experienced parental cancer and an income loss during childhood had an increased risk of low education and lower income at age 30 years. The associations were weaker for children only exposed to income loss and less clear for those only exposed to parental cancer. Further, exposure to parental cancer with a severe cancer type was associated with lower educational level.

CONCLUSION

The child's educational attainment and income level in early adulthood were negatively affected by exposure to income loss in childhood, and even more so if exposed to both parental cancer and income loss. The associations with educational attainment were stronger for more severe cancer types.

Effectiveness evaluation of an antenatal care intervention addressing disparities to improve perinatal outcomes in Denmark: A nationwide register-based analysis of a cluster randomised controlled trial (MAMAACT)

OBJECTIVE

To evaluate whether MAMAACT, an antenatal care (ANC) intervention, aimed at reducing ethnic and social disparities in perinatal mortality, affected perinatal health outcomes.

DESIGN

Cluster randomised controlled trial.

SETTING

Nineteen of 20 maternity wards in Denmark.

POPULATION

All newborn children within a pre-implementation period (2014-2017) or an implementation period (2018-2019) (n = 188 658).

INTERVENTION

A 6-h training session for midwives in intercultural communication and cultural competence, two follow-up dialogue meetings, and health education materials for pregnant women on warning signs of pregnancy complications in six languages.

METHODS

Nationwide register-based analysis of the MAMAACT cluster randomised controlled trial. Mixed-effects logistic regression models were used to estimate the change in outcomes from pre- to post-implementation in the intervention group relative to the control group. Results were obtained for the overall study population and for children born to immigrants from low- to middle-income countries, separately. Models were adjusted for confounders selected a priori.

MAIN OUTCOME MEASURES

A composite perinatal mortality and morbidity outcome, including stillbirths, neonatal deaths, Apgar score <7, umbilical arterial pH < 7.0, admissions to a neonatal intensive care unit (NICU) >48 h, and NICU admissions for mechanical ventilation. Additional outcomes were the individual measures.

RESULTS

The intervention increased the risk of the composite outcome (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 0.99-1.34), mainly driven by differences in NICU admission risk (composite outcome excluding NICU, aOR 0.98, 95% CI 0.84-1.14). The intervention slightly increased the risk of low Apgar score and decreased the risk of low arterial pH, reflecting, however, small differences in absolute numbers. Other outcomes were unchanged.

CONCLUSIONS

Overall, the MAMAACT intervention did not improve the composite perinatal mortality and morbidity outcome (when excluding NICU admissions). The lack of effects may be due to contextual factors including organisational barriers in ANC hindering the midwives from changing practices.

Gestational age at birth and body size from infancy through adolescence: An individual participant data meta-analysis on 253,810 singletons in 16 birth cohort studies

BACKGROUND

Preterm birth is the leading cause of perinatal morbidity and mortality and is associated with adverse developmental and long-term health outcomes, including several cardiometabolic risk factors and outcomes. However, evidence about the association of preterm birth with later body size derives mainly from studies using birth weight as a proxy of prematurity rather than an actual length of gestation. We investigated the association of gestational age (GA) at birth with body size from infancy through adolescence.

METHODS AND FINDINGS

We conducted a two-stage individual participant data (IPD) meta-analysis using data from 253,810 mother-child dyads from 16 general population-based cohort studies in Europe (Denmark, Finland, France, Italy, Norway, Portugal, Spain, the Netherlands, United Kingdom), North America (Canada), and Australasia (Australia) to estimate the association of GA with body mass index (BMI) and overweight (including obesity) adjusted for the following maternal characteristics as potential confounders: education, height, prepregnancy BMI, ethnic background, parity, smoking during pregnancy, age at child's birth, gestational diabetes and hypertension, and preeclampsia. Pregnancy and birth cohort studies from the LifeCycle and the EUCAN-Connect projects were invited and were eligible for inclusion if they had information on GA and minimum one measurement of BMI between infancy and adolescence. Using a federated analytical tool (DataSHIELD), we fitted linear and logistic regression models in each cohort separately with a complete-case approach and combined the regression estimates and standard errors through random-effects study-level meta-analysis providing an overall effect estimate at early infancy (>0.0 to 0.5 years), late infancy (>0.5 to 2.0 years), early childhood (>2.0 to 5.0 years), mid-childhood (>5.0 to 9.0 years), late childhood (>9.0 to 14.0 years), and adolescence (>14.0 to 19.0 years). GA was positively associated with BMI in the first decade of life, with the greatest increase in mean BMI z-score during early infancy (0.02, 95% confidence interval (CI): 0.00; 0.05, p < 0.05) per week of increase in GA, while in adolescence, preterm individuals reached similar levels of BMI (0.00, 95% CI: -0.01; 0.01, p 0.9) as term counterparts. The association between GA and overweight revealed a similar pattern of association with an increase in odds ratio (OR) of overweight from late infancy through mid-childhood (OR 1.01 to 1.02) per week increase in GA. By adolescence, however, GA was slightly negatively associated with the risk of overweight (OR 0.98 [95% CI: 0.97; 1.00], p 0.1) per week of increase in GA. Although based on only four cohorts (n = 32,089) that reached the age of adolescence, data suggest that individuals born very preterm may be at increased odds of overweight (OR 1.46 [95% CI: 1.03; 2.08], p < 0.05) compared with term counterparts. Findings were consistent across cohorts and sensitivity analyses despite considerable heterogeneity in cohort characteristics. However, residual confounding may be a limitation in this study, while findings may be less generalisable to settings in low- and middle-income countries.

CONCLUSIONS

This study based on data from infancy through adolescence from 16 cohort studies found that GA may be important for body size in infancy, but the strength of association attenuates consistently with age. By adolescence, preterm individuals have on average a similar mean BMI to peers born at term.

Maternal stress during pregnancy and gestational duration: A cohort study from the Danish National Birth Cohort

BACKGROUND

Preterm birth is one of the most important contributors to neonatal mortality and morbidity. Experiencing stress during pregnancy may increase the risk of adverse birth outcomes, including preterm birth. This association has been observed in previous studies, but differences in measures used limit comparability.

OBJECTIVE

The objective of the study was to investigate the association between two measures of maternal stress during pregnancy, life stress and emotional distress, and gestation duration.

METHODS

Women recruited in the Danish National Birth Cohort from 1996 to 2002, who provided information on their stress level during pregnancy and expecting a singleton baby, were included in the study. We assessed the associations between the level of life stress and emotional distress in quartiles, both collected at 31 weeks of pregnancy on average, and the rate of giving birth using Cox regression within intervals of the gestational period.

RESULTS

A total of 80,991 pregnancies were included. Women reporting moderate or high levels of life stress vs no stress had a higher rate of giving birth earlier within all intervals of gestational age (e.g. high level: 27-33 weeks: hazard ratio (HR) 1.38, 95% confidence interval (CI) 1.04, 1.84; 34-36 weeks: 1.10, 95% CI 0.97, 1.25; 37-38 weeks: 1.21, 95% CI 1.15, 1.28). These associations between life stress and preterm birth were mainly driven by pregnancy worries. For emotional distress, a high level of distress was associated with shorter length of gestation in the preterm (27-33 weeks: 1.38, 95% CI 1.02, 1.86; 34-36 weeks: 1.05, 95% CI 0.91, 1.19) and early term (1.11, 95% CI 1.04, 1.17) intervals.

CONCLUSIONS

Emotional distress and life stress were shown to be associated with gestational age at birth, with pregnancy-related stress being the single stressor driving the association. This suggests that reverse causality may, at least in parts, explain the earlier findings of stress as a risk factor for preterm birth.

Towards an Interoperable Ecosystem of Research Cohort and Real-world Data Catalogues Enabling Multi-center Studies

OBJECTIVES

Existing individual-level human data cover large populations on many dimensions such as lifestyle, demography, laboratory measures, clinical parameters, etc. Recent years have seen large investments in data catalogues to FAIRify data descriptions to capitalise on this great promise, i.e. make catalogue contents more Findable, Accessible, Interoperable and Reusable. However, their valuable diversity also created heterogeneity, which poses challenges to optimally exploit their richness.

METHODS

In this opinion review, we analyse catalogues for human subject research ranging from cohort studies to surveillance, administrative and healthcare records.

RESULTS

We observe that while these catalogues are heterogeneous, have various scopes, and use different terminologies, still the underlying concepts seem potentially harmonizable. We propose a unified framework to enable catalogue data sharing, with catalogues of multi-center cohorts nested as a special case in catalogues of real-world data sources. Moreover, we list recommendations to create an integrated community of metadata catalogues and an open catalogue ecosystem to sustain these efforts and maximise impact.

CONCLUSIONS

We propose to embrace the autonomy of motivated catalogue teams and invest in their collaboration via minimal standardisation efforts such as clear data licensing, persistent identifiers for linking same records between catalogues, minimal metadata 'common data elements' using shared ontologies, symmetric architectures for data sharing (push/pull) with clear provenance tracks to process updates and acknowledge original contributors. And most importantly, we encourage the creation of environments for collaboration and resource sharing between catalogue developers, building on international networks such as OpenAIRE and research data alliance, as well as domain specific ESFRIs such as BBMRI and ELIXIR.

Exposure to natural environments during pregnancy and birth outcomes in 11 European birth cohorts

Research suggests that maternal exposure to natural environments (i.e., green and blue spaces) promotes healthy fetal growth. However, the available evidence is heterogeneous across regions, with very few studies on the effects of blue spaces. This study evaluated associations between maternal exposure to natural environments and birth outcomes in 11 birth cohorts across nine European countries. This study, part of the LifeCycle project, was based on a total sample size of 69,683 newborns with harmonised data. For each participant, we calculated seven indicators of residential exposure to natural environments: surrounding greenspace in 100m, 300m, and 500m using Normalised Difference Vegetation Index (NDVI) buffers, distance to the nearest green space, accessibility to green space, distance to the nearest blue space, and accessibility to blue space. Measures of birth weight and small for gestational age (SGA) were extracted from hospital records. We used pooled linear and logistic regression models to estimate associations between exposure to the natural environment and birth outcomes, controlling for the relevant covariates. We evaluated the potential effect modification by socioeconomic status (SES) and region of Europe and the influence of ambient air pollution on the associations. In the pooled analyses, residential surrounding greenspace in 100m, 300m, and 500m buffer was associated with increased birth weight and lower odds for SGA. Higher residential distance to green space was associated with lower birth weight and higher odds for SGA. We observed close to null associations for accessibility to green space and exposure to blue space. We found stronger estimated magnitudes for those participants with lower educational levels, from more deprived areas, and living in the northern European region. Our associations did not change notably after adjustment for air pollution. These findings may support implementing policies to promote natural environments in our cities, starting in more deprived areas.

Fetal death after the introduction of COVID-19 mitigation measures in Sweden, Denmark and Norway: a registry-based study

It remains unclear whether the rate of fetal death has changed during the COVID-19 pandemic. We assessed the impact of COVID-19 mitigation measures on fetal death in Sweden (449,347 births), Denmark (290,857 pregnancies) and Norway (261,057 pregnancies) using robust population-based registry data. We used Cox regression to assess the impact of the implementation of pandemic mitigation measures on March 12th, 2020, on miscarriage (fetal loss before gestational week 22) and stillbirth (fetal loss after gestational week 22). A total of 11% of 551,914 pregnancies in Denmark and Norway ended in miscarriage, while the proportion of stillbirths among 937,174 births across the three countries was 0.3%. There was no difference in the risk of fetal death during the year following pandemic mitigation measures. For miscarriage, the combined hazard ratio (HR) for Norway and Denmark was 1.01 (95% CI 0.98, 1.03), and for stillbirth, the combined HR for all three countries was 0.99 (95% CI 0.89, 1.09). We observed a slightly decreased risk of miscarriage during the first 4 months, with an HR of 0.94 (95% CI 0.90, 0.99) after lockdown. In conclusion, the risk of fetal death did not change after the implementation of COVID-19 pandemic mitigation measures in the three Scandinavian countries.

Association of Assisted Reproductive Technology With Offspring Growth and Adiposity From Infancy to Early Adulthood

Importance

People conceived using assisted reproductive technology (ART) make up an increasing proportion of the world's population.

Objective

To investigate the association of ART conception with offspring growth and adiposity from infancy to early adulthood in a large multicohort study.

Design, Setting, and Participants

This cohort study used a prespecified coordinated analysis across 26 European, Asia-Pacific, and North American population-based cohort studies that included people born between 1984 and 2018, with mean ages at assessment of growth and adiposity outcomes from 0.6 months to 27.4 years. Data were analyzed between November 2019 and February 2022.

Exposures

Conception by ART (mostly in vitro fertilization, intracytoplasmic sperm injection, and embryo transfer) vs natural conception (NC; without any medically assisted reproduction).

Main Outcomes and Measures

The main outcomes were length / height, weight, and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared). Each cohort was analyzed separately with adjustment for maternal BMI, age, smoking, education, parity, and ethnicity and offspring sex and age. Results were combined in random effects meta-analysis for 13 age groups.

Results

Up to 158 066 offspring (4329 conceived by ART) were included in each age-group meta-analysis, with between 47.6% to 60.6% females in each cohort. Compared with offspring who were NC, offspring conceived via ART were shorter, lighter, and thinner from infancy to early adolescence, with differences largest at the youngest ages and attenuating with older child age. For example, adjusted mean differences in offspring weight were -0.27 (95% CI, -0.39 to -0.16) SD units at age younger than 3 months, -0.16 (95% CI, -0.22 to -0.09) SD units at age 17 to 23 months, -0.07 (95% CI, -0.10 to -0.04) SD units at age 6 to 9 years, and -0.02 (95% CI, -0.15 to 0.12) SD units at age 14 to 17 years. Smaller offspring size was limited to individuals conceived by fresh but not frozen embryo transfer compared with those who were NC (eg, difference in weight at age 4 to 5 years was -0.14 [95% CI, -0.20 to -0.07] SD units for fresh embryo transfer vs NC and 0.00 [95% CI, -0.15 to 0.15] SD units for frozen embryo transfer vs NC). More marked differences were seen for body fat measurements, and there was imprecise evidence that offspring conceived by ART developed greater adiposity by early adulthood (eg, ART vs NC difference in fat mass index at age older than 17 years: 0.23 [95% CI, -0.04 to 0.50] SD units).

Conclusions and Relevance

These findings suggest that people conceiving or conceived by ART can be reassured that differences in early growth and adiposity are small and no longer evident by late adolescence.

Parental socio-economic position and the risk of type 1 diabetes in children and young adults in Denmark: A nation-wide register-based study

AIM

Diabetes mellitus type 1 is one of the most common serious chronic diseases in childhood and the incidence is increasing. Insight into risk factors may inform our etiologic understanding of the disease and subsequent prevention. Any socio-economic gradient in disease risk indicates a potential for prevention, since this points towards socially patterned environmental risk factors. The aim of this study was to investigate the association between measures of parental socio-economic position and the onset of type 1 diabetes in offspring based on individual data in the entire Danish population.

METHODS

In a study population of all children born in Denmark between 1 January 1987 and 31 December 2010, we examined the association between parental socio-economic position and the risk of type 1 diabetes up to the age of 25 years. The risk of type 1 diabetes was estimated according to maternal education, paternal education and household income using Cox proportional hazards regression, with adjustments for the a priori selected confounding variables: year of birth, maternal age at birth and parental type 1 diabetes.

RESULTS

In the study population of 1,433,584 children, a total of 4610 developed type 1 diabetes. We found no clear pattern in type 1 diabetes risk according to parental educational attainment or parental household income.

CONCLUSIONS

In this large population covering study of the risk of type 1 diabetes according to individual-level parental socio-economic position, we found no strong indication of a socially patterned disease risk.

Early-life respiratory tract infections and the risk of school-age lower lung function and asthma: a meta-analysis of 150 000 European children

Background

Early-life respiratory tract infections might affect chronic obstructive respiratory diseases, but conclusive studies from general populations are lacking. Our objective was to examine if children with early-life respiratory tract infections had increased risks of lower lung function and asthma at school age.

Methods

We used individual participant data of 150 090 children primarily from the EU Child Cohort Network to examine the associations of upper and lower respiratory tract infections from age 6 months to 5 years with forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), FEV₁/FVC, forced expiratory flow at 75% of FVC (FEF_75%) and asthma at a median (range) age of 7 (4–15) years.

Results

Children with early-life lower, not upper, respiratory tract infections had a lower school-age FEV₁, FEV₁/FVC and FEF_75% (z-score range: −0.09 (95% CI −0.14– −0.04) to −0.30 (95% CI −0.36– −0.24)). Children with early-life lower respiratory tract infections had a higher increased risk of school-age asthma than those with upper respiratory tract infections (OR range: 2.10 (95% CI 1.98–2.22) to 6.30 (95% CI 5.64–7.04) and 1.25 (95% CI 1.18–1.32) to 1.55 (95% CI 1.47–1.65), respectively). Adjustment for preceding respiratory tract infections slightly decreased the strength of the effects. Observed associations were similar for those with and without early-life wheezing as a proxy for early-life asthma.

Conclusions

Our findings suggest that early-life respiratory tract infections affect development of chronic obstructive respiratory diseases in later life, with the strongest effects for lower respiratory tract infections.

This meta-analysis of 150 000 children suggests that mostly lower respiratory tract infections are associated with an increased risk of asthma and lower lung function. This is independent from preceding respiratory tract infections or early-life asthma.https://bit.ly/3weE62I

Fetal exposure to maternal cigarette smoking and male reproductive function in young adulthood

Maternal smoking during pregnancy constitutes a potential, major risk factor for adult male reproductive function. In the hitherto largest longitudinal cohort, we examined biomarkers of reproductive function according to maternal smoking during the first trimester and investigated whether associations were mitigated by smoking cessation prior to the fetal masculinization programming window. Associations between exposure to maternal smoking and semen characteristics, testicular volume and reproductive hormones were assessed among 984 young men from the Fetal Programming of Semen Quality (FEPOS) cohort. Maternal smoking was assessed through interview data and measured plasma cotinine levels during pregnancy. We applied negative binomial, logistic and linear regression models to estimate differences in outcomes according to levels of maternal smoking. Sons of light smokers (≤ 10 cigarettes/day) had a 19% (95% CI - 29%, - 6%) lower sperm concentration and a 24% (95% CI - 35%, - 11%) lower total sperm count than sons of non-smokers. These estimates were 38% (95% CI - 52%, - 22%) and 33% (95% CI - 51%, - 8%), respectively, for sons of heavy smokers (> 10 cigarettes/day). The latter group also had a 25% (95% CI 1%, 54%) higher follitropin level. Similarly, sons exposed to maternal cotinine levels of  > 10 ng/mL had lower sperm concentration and total sperm count. Smoking cessation prior to gestational week seven was not associated with a higher reproductive capacity. We observed substantial and consistent exposure-response associations, providing strong support for the hypothesis that maternal smoking impairs male reproductive function. This association persisted regardless of smoking cessation in early pregnancy.

Preterm birth after the introduction of COVID-19 mitigation measures in Norway, Sweden, and Denmark: a registry-based difference-in-differences study

BACKGROUND

Although some studies have reported a decrease in preterm birth following the start of the COVID-19 pandemic, the findings are inconsistent.

OBJECTIVE

This study aimed to compare the incidences of preterm birth before and after the introduction of COVID-19 mitigation measures in Scandinavian countries using robust population-based registry data.

STUDY DESIGN

This was a registry-based difference-in-differences study using births from January 2014 through December 2020 in Norway, Sweden, and Denmark. The changes in the preterm birth (<37 weeks) rates before and after the introduction of COVID-19 mitigation measures (set to March 12, 2020) were compared with the changes in preterm birth before and after March 12 from 2014 to 2019. The differences per 1000 births were calculated for 2-, 4-, 8-, 12-, and 16-week intervals before and after March 12. The secondary analyses included medically indicated preterm birth, spontaneous preterm birth, and very preterm (<32 weeks) birth.

RESULTS

A total of 1,519,521 births were included in this study. During the study period, 5.6% of the births were preterm in Norway and Sweden, and 5.7% were preterm in Denmark. There was a seasonal variation in the incidence of preterm birth, with the highest incidence during winter. In all the 3 countries, there was a slight overall decline in preterm births from 2014 to 2020. There was no consistent evidence of a change in the preterm birth rates following the introduction of COVID-19 mitigation measures, with difference-in-differences estimates ranging from 3.7 per 1000 births (95% confidence interval, -3.8 to 11.1) for the first 2 weeks after March 12, 2020, to -1.8 per 1000 births (95% confidence interval, -4.6 to 1.1) in the 16 weeks after March 12, 2020. Similarly, there was no evidence of an impact on medically indicated preterm birth, spontaneous preterm birth, or very preterm birth.

CONCLUSION

Using high-quality national data on births in 3 Scandinavian countries, each of which implemented different approaches to address the pandemic, there was no evidence of a decline in preterm births following the introduction of COVID-19 mitigation measures.

Impact of housing conditions on changes in youth's mental health following the initial national COVID-19 lockdown: a cohort study

We aimed to investigate if declines in youth’s mental health during lockdown were dependent on housing condition among 7445 youth (median age ~ 20 years) from the Danish National Birth Cohort (DNBC), with data collected at 18 years of age and again three weeks into the first national lockdown (April 2020). We examined associations between housing conditions (access to outdoor spaces, urbanicity, household density, and household composition) and changes in mental health (mental well-being, Quality of Life (QoL) and loneliness). We report results from multivariate linear and logistic regression models. Youth without access to outdoor spaces experienced greater declines in mental well-being (vs. garden; mean difference: − 0·75 (95% CI − 1·14, − 0·36)), and correspondingly greater odds of onset of low mental well-being (vs. garden; OR: 1·72 (95% CI 1·20, 2·48)). Youth in higher density households vs. below median or living alone vs. with parents only also had greater odds of onset of low mental well-being (OR: 1·26 (95% CI 1·08, 1·46) and OR: 1·62 (95% CI 1·17, 2·23), respectively). Living in denser households (vs. below median; OR: 1·18 (95% CI 1·06, 1·33), as well as living alone (vs. with parents; OR: 1·38 (95% CI 1·04, 1·82) was associated with onset of low QoL. Living alone more than doubled odds of onset of loneliness compared to living with parents, OR: 2·12 (95% CI 1·59, 2·82). Youth living alone, in denser households, and without direct access to outdoor spaces may be especially vulnerable to mental health declines.

Indoor home environments of Danish children and the socioeconomic position and health of their parents: A descriptive study

BACKGROUND

Housing and indoor home environments are associated with the risk of infections and asthma in children. To better understand the determinants and characteristics of these environments, we aimed to describe the associations between parental health and socioeconomic position and housing and indoor home environments of children in Denmark, and the clustering of the factors within these environments.

METHODS

Offspring in the Danish National Birth Cohort (DNBC) whose parents responded to the 11-year follow-up were eligible for inclusion. We included complete cases only. Data on the indoor and housing environments (i.e. variables on housing, sources of gaseous and particle pollution, mould and moisture, and pets) were collected through an online questionnaire responded to by a parent. Data on socioeconomic position were obtained through linkage with registry data on maternal education at offspring birth and household equivalized income at offspring birth. Data on parental health were obtained by linking self-reported data from the 11-year follow-up for mother and father with administrative registry data for the mother. We present descriptive statistics and exploratory factor analyses.

RESULTS

A total of 42 723 offspring were included for analyses. The distributions of nearly all indoor and housing environments differed according to educational and income strata, with patterns similar for both education and income. Generally, higher parental educational and income strata had more favorable indoor and housing environments (less secondhand smoking, gas stove use, mould and condensation and higher house ownership, detached house dwellings and newer building age). However, candle use was approximately similar between strata, fireplace use among lower educational and income strata tended towards the extremes (none or daily), and water damage was more common among higher educational and income strata. Parental health was strongly associated with housing and indoor home environment factors - especially parental affective disorders was strongly associated with mould. Four factors were extracted from the exploratory factor analyses, relating primarily in order of extraction to: housing ownership, mould and moisture, candle use and household density.

CONCLUSION

Parental health and socioeconomic position are strongly related to housing and indoor home environments. Additionally, several factors in these environments correlate strongly and cluster together. Observational studies on associations and causal effects of factors in the indoor and housing environments of children on their morbidity, must consider both of these conclusions to arrive at valid estimates and effects.

Gestational Age, Parent Education, and Education in Adulthood

BACKGROUND

Adults born preterm (<37 weeks) have lower educational attainment than those born term. Whether this relationship is modified by family factors such as socioeconomic background is, however, less well known. We investigated whether the relationship between gestational age and educational attainment in adulthood differed according to parents' educational level in 4 Nordic countries.

METHODS

This register-based cohort study included singletons born alive from 1987 up to 1992 in Denmark, Finland, Norway, and Sweden. In each study population, we investigated effect modification by parents' educational level (low, intermediate, high) on the association between gestational age at birth (25-44 completed weeks) and low educational attainment at 25 years (not having completed upper secondary education) using general estimation equations logistic regressions.

RESULTS

A total of 4.3%, 4.0%, 4.8%, and 5.0% singletons were born preterm in the Danish (n = 331 448), Finnish (n = 220 095), Norwegian (n = 292 840), and Swedish (n = 513 975) populations, respectively. In all countries, both lower gestational age and lower parental educational level contributed additively to low educational attainment. For example, in Denmark, the relative risk of low educational attainment was 1.84 (95% confidence interval 1.44 to 2.26) in adults born at 28 to 31 weeks whose parents had high educational level and 5.25 (95% confidence interval 4.53 to 6.02) in adults born at 28 to 31 weeks whose parents had low educational level, compared with a reference group born at 39 to 41 weeks with high parental educational level.

CONCLUSIONS

Although higher parental education level was associated with higher educational attainment for all gestational ages, parental education did not mitigate the educational disadvantages of shorter gestational age.

Migration, Gestational Diabetes, and Adverse Pregnancy Outcomes: A Nationwide Study of Singleton Deliveries in Denmark

CONTEXT

It remains unclear if migrants have different odds for adverse outcomes associated with gestational diabetes mellitus (GDM).

OBJECTIVE

We investigated if the associations between GDM and adverse pregnancy outcomes are modified by country of origin and examined the odds of these outcomes according to GDM status and country of origin.

METHODS

Data were extracted from a nationwide register-based study of singleton deliveries in Denmark, 2004-2015. We used logistic regression models and tested for interaction.

RESULTS

Among the 710 413 singleton deliveries, 2.6% had GDM and 14.4% were immigrants. Country of origin modified the association between GDM and pre-eclampsia, large for gestational age (LGA), and small for gestational age (SGA) but not between GDM and planned or emergency cesarean section and preterm delivery. GDM increased the risk of pre-eclampsia among women from Denmark (OR 1.28; 95% CI, 1.18-1.39), Lebanon (OR 3.34; 95% CI, 1.35-8.26), and Morocco (OR 2.28; 95% CI, 1.16-6.88). GDM was associated with increased odds of LGA among women from most countries, particularly women from Sri Lanka (OR 4.20; 95% CI, 2.67-6.61), and was associated with reduced odds of SGA in some countries. Compared with Danish-born women with GDM, the odds of LGA were significantly lower and the odds of SGA higher among women with GDM from India, Lebanon, Pakistan, Iraq, and Somalia.

CONCLUSIONS

Our study documents that different immigrant groups have higher odds of different GDM-associated adverse pregnancy outcomes and also among countries of origin often grouped together. This highlights the importance of increased awareness to both immigrant background and GDM status in the clinical assessment.

Social, demographic and health characteristics of men fathering children at different ages

The aim of this study was to examine associations between selected sociodemographic, socioeconomic, and health characteristics and the rates of fatherhood in different age groups. We investigated rates between 2011 and 2015 in a population-based register study including all men born from 1945 to 1995 residing in Denmark in 2011. The study population consisted of 1,867,108 men who fathered 268,612 children during the follow-up. The associations were quantified as incidence rate ratios using Poisson regression. Young men had higher rates of fathering a child if they lived outside the Capital Region, had a relatively high income, were previously diagnosed with cardiovascular disease, psychoactive substance abuse, personality disorders, schizophrenia or behavioural and emotional disorders. Men of advanced age had higher rates of fathering a child when born outside Denmark, living in the Capital Region, were in the lower or upper 10th percentile income group, were self-employed or unemployed or previously diagnosed with depression. Men of advanced age had lower rates of fathering a child if previously diagnosed with somatic diseases, psychoactive substance abuse or mental retardation. The findings highlight the importance of consideration of various sociodemographic, socioeconomic, and health characteristics when studying associations between paternal age and offspring health.

The influence of parental age on timing of puberty: A study in the Danish National Birth Cohort

Aims: Concerns have been raised about the potential negative biological effect of postponed parenthood upon the health of subsequent generations, including reproductive health. This study aimed to estimate if high parental age at birth was associated with accelerated pubertal timing in offspring. Methods: In this large-scale cohort study, 15,819 children born by mothers in the Danish National Birth Cohort from 2000 to 2003 participated in a nationwide puberty cohort (participation rate 71%). Between 2012 and 2018, the children reported half-yearly information on pubertal status using web-based questionnaires from 11 years throughout puberty or 18 years of age. Information on parental age was drawn from nationwide registers. We estimated adjusted mean differences in months for age at attaining the pubertal milestones and pubertal timing overall between the pre-specified parental age groups: 20-29 (reference), 30-34 and advanced parental age groups (35-44 years for mothers and >35 years for fathers). Results: Overall, parental age at birth of the child was not associated with pubertal timing in daughters or sons. For sons of older fathers (>35 years), we observed indications towards slightly earlier pubertal timing in the range of 0.3-2.4 months for nearly all pubertal milestones, but all confidence intervals were wide, and many included the null. Conclusions: We found no strong association between parental age and timing of puberty, and we find it unlikely that the decreasing age in pubertal timing is a result of parental decision to delay childbearing.

The EU Child Cohort Network's core data: establishing a set of findable, accessible, interoperable and re-usable (FAIR) variables

The Horizon2020 LifeCycle Project is a cross-cohort collaboration which brings together data from multiple birth cohorts from across Europe and Australia to facilitate studies on the influence of early-life exposures on later health outcomes. A major product of this collaboration has been the establishment of a FAIR (findable, accessible, interoperable and reusable) data resource known as the EU Child Cohort Network. Here we focus on the EU Child Cohort Network's core variables. These are a set of basic variables, derivable by the majority of participating cohorts and frequently used as covariates or exposures in lifecourse research. First, we describe the process by which the list of core variables was established. Second, we explain the protocol according to which these variables were harmonised in order to make them interoperable. Third, we describe the catalogue developed to ensure that the network's data are findable and reusable. Finally, we describe the core data, including the proportion of variables harmonised by each cohort and the number of children for whom harmonised core data are available. EU Child Cohort Network data will be analysed using a federated analysis platform, removing the need to physically transfer data and thus making the data more accessible to researchers. The network will add value to participating cohorts by increasing statistical power and exposure heterogeneity, as well as facilitating cross-cohort comparisons, cross-validation and replication. Our aim is to motivate other cohorts to join the network and encourage the use of the EU Child Cohort Network by the wider research community.

Spinal pain in pre-adolescence and the relation with screen time and physical activity behavior

Background

To investigate how screen time and physical activity behavior were associated with spinal pain in pre-adolescence.

Methods

This study included 45,555 pre-adolescents who participated in the 11-year follow-up of the Danish National Birth Cohort. The 11-year follow-up included self-reported information on computer and TV behavior, aspects of physical activity, as well as frequency and intensity of spinal pain (neck-, mid back- and low back pain). Data were linked with parental socioeconomic data from Statistics Denmark registers. Associations were estimated using multinomial logistic regression models. To account for sample selection, we applied inverse probability weighting.

Results

Duration of screen time was stepwise associated with the degree of spinal pain. Compared with those spending < 2 h/day in front of a screen, screen time of ≥6 h/day was associated with a substantially increased relative risk ratio (RRR) of severe pain for both girls (RRR: 2.49, 95% CI: 2.13–2.92) and boys (RRR: 1.95, 95% CI: 1.65–2.32). Being physical inactive was likewise associated with higher likelihood of severe spinal pain (RRR: 1.22, 95% CI: 1.10–1.34) relative to those being moderately active. We observed that being physically active was seemingly associated with lower risk of spinal pain among boys with high frequency of screen time.

Conclusion

Findings indicate that both duration of screen time and physical inactivity are correlated with spinal pain in pre-adolescents with the strongest associations for screen time. Reducing screen time or increasing physical activity might help preventing spinal pain in pre-adolescents, particularly among high frequent screen users. Future prospective studies investigating the causal relationship are necessary.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04263-z.

Use of Fertility Drugs and Risk of Malignant Melanoma: Results from a Large Danish Population-Based Cohort Study

Fertility drugs have not definitively been linked to malignant melanoma. By the use of data from a large nationwide cohort of women aged 20.0-45.0 years and living in Denmark between January 1, 1995 and December 31, 2011, we assessed the association between the use of fertility drugs and the risk of malignant melanoma. Information on fertility status and the use of fertility drugs was obtained from the population-based Danish Infertility Cohort. Cox proportional hazard regression models were applied to estimate hazard ratios and 95% confidence intervals with adjustment for potential confounders. The study population comprised 1,330,954 women, of whom 86,231 (6.5%) were treated with fertility drugs. During a median follow-up of 21.0 years, 6,139 women were diagnosed with malignant melanoma. Compared with fertile women, women with fertility challenges who had used any fertility drugs had an increased risk of malignant melanoma (hazard ratio = 1.14; 95% confidence interval = 1.02-1.27). Furthermore, the use of specific types of fertility drugs (clomiphene, gonadotropins, human chorionic gonadotropin, gonadotropin-releasing hormone preparations, and progesterone) was also associated with an increased risk of malignant melanoma, with hazard ratios ranging between 1.09 and 1.13; however, the association did not reach statistical significance. Our findings indicate that the use of fertility drugs was associated with a modestly increased risk of malignant melanoma.

Mortality Among Young Adults Born Preterm and Early Term in 4 Nordic Nations

IMPORTANCE

Adverse long-term outcomes in individuals born before full gestation are not confined to individuals born at extreme gestational ages. Little is known regarding mortality patterns among individuals born in the weeks close to ideal gestation, and the exact causes are not well understood; both of these are crucial for public health, with the potential for modification of risk.

OBJECTIVE

To examine the risk of all-cause and noncommunicable diseases (NCD) deaths among young adults born preterm and early term.

DESIGN, SETTING, AND PARTICIPANTS

This multinational population-based cohort study used nationwide birth cohorts from Norway, Sweden, Denmark, and Finland for individuals born between 1967 and 2002. Individuals identified at birth who had not died or emigrated were followed up for mortality from age 15 years to 2017. Analyses were performed from June 2019 to May 2020.

EXPOSURES

Categories of gestational age (ie, moderate preterm birth and earlier [23-33 weeks], late preterm [34-36 weeks], early term [37-38 weeks], full term [39-41 weeks] and post term [42-44 weeks]).

MAIN OUTCOMES AND MEASURES

All-cause mortality and cause-specific mortality from NCD, defined as cancer, diabetes, chronic lung disease, and cardiovascular disease (CVD).

RESULTS

A total of 6 263 286 individuals were followed up for mortality from age 15 years. Overall, 339 403 (5.4%) were born preterm, and 3 049 100 (48.7%) were women. Compared with full-term birth, the adjusted hazard ratios (aHRs) for all-cause mortality were 1.44 (95% CI, 1.34-1.55) for moderate preterm birth and earlier; 1.23 (95% CI, 1.18-1.29) for late preterm birth; and 1.12 (95% CI, 1.09-1.15) for early-term birth. The association between gestational age and all-cause mortality were stronger in women than in men (P for interaction = .03). Preterm birth was associated with 2-fold increased risks of death from CVD (aHR, 1.89; 95% CI, 1.45-2.47), diabetes (aHR, 1.98; 95% CI, 1.44-2.73), and chronic lung disease (aHR, 2.28; 95% CI, 1.36-3.82). The main associations were replicated across countries and could not be explained by familial or individual confounding factors.

CONCLUSIONS AND RELEVANCE

The findings of this study strengthen the evidence of increased risk of death from NCDs in young adults born preterm. Importantly, the increased death risk was found across gestational ages up to the ideal term date and includes the much larger group with early-term birth. Excess mortality associated with shorter gestational age was most pronounced for CVDs, chronic lung disease, and diabetes.

The effect of maternal pre-/early-pregnancy BMI and pregnancy smoking and alcohol on congenital heart diseases: a parental negative control study

BACKGROUND

Congenital heart diseases (CHDs) are the most common congenital anomaly. The causes of CHDs are largely unknown. Higher prenatal body mass index (BMI), smoking and alcohol consumption are associated with increased risk of CHDs. Whether these are causal is unclear.

METHODS AND RESULTS

Seven European birth cohorts including 232,390 offspring (2,469 CHD cases [1.1%]) were included. We applied negative exposure paternal control analyses to explore the intrauterine effects of maternal BMI, smoking and alcohol consumption during pregnancy, on offspring CHDs and CHD severity. We used logistic regression and combined estimates using a fixed-effects meta-analysis. Analyses of BMI categories resulted in similar increased odds of CHD in overweight (mothers OR: 1.15 (1.01, 1.31) and fathers 1.10 (0.96, 1.27)) and obesity (mothers OR: 1.12 (0.93, 1.36) and fathers 1.16 (0.90, 1.50)). The association of mean BMI with CHD was null. Maternal smoking was associated with increased odds of CHD (OR: 1.11 (0.97, 1.25)) but paternal smoking was not (OR: 0.96 (0.85, 1.07)). The difference increased when removing offspring with genetic/chromosomal defects (mothers OR: 1.15 (1.01, 1.32) and fathers 0.93 (0.83, 1.05)). The positive association with maternal pregnancy smoking appeared to be driven by non-severe CHD cases (OR: 1.22 (1.04, 1.44)). Associations with maternal (OR: 1.16 (0.52, 2.58)) and paternal (OR: 1.23 (0.74, 2.06)) moderate/heavy pregnancy alcohol consumption were similar.

CONCLUSIONS

We found evidence of an intrauterine effect for maternal smoking on offspring CHDs, but no evidence for higher maternal BMI or alcohol consumption. Our findings provide further support for why smoking cessation is important during pregnancy.

Advanced maternal age and risk of adverse perinatal outcome among women with congenital heart disease: A nationwide register-based cohort study

BACKGROUND

Women with maternal congenital heart disease have a higher risk of preterm birth (PTB) and giving birth to a small for gestational age (SGA) infant. Advanced maternal age (≥35 years) likewise increases the risk of PTB and SGA, probably explained by poorer cardiovascular status. It is likely that advanced maternal age is particularly detrimental in women with congenital heart disease.

OBJECTIVES

We aimed to determine whether the pattern of higher risk of PTB and SGA with higher maternal age varied among women with and without congenital heart disease. We hypothesised that the effect of age is higher among women with congenital heart disease.

METHODS

We did a cohort study using Danish nationwide registers. Births from 1997 to 2014 were included. Cox regressions were used to estimate hazard ratios (HRs) for PTB and SGA. Universal and congenital heart disease-specific references were used for comparison.

RESULTS

We included 932 772 births among 548 314 women. HRs of PTB and SGA were 1.55 (95% confidence interval [CI] 1.37, 1.77) and 1.43 (95% CI 1.29, 1.58) in women with congenital heart disease as compared to women without. For both PTB and SGA, HRs were higher for women ≥35 years as compared to women aged 25-29 years. HRs of PTB and SGA were higher among women with congenital heart disease within all strata of maternal age as compared to women without (eg 3.71, 95% CI 1.80, 7.63 vs 1.63, 95% CI 1.56, 1.70) for SGA for women aged 40-44 years). The pattern of higher risk of PTB and SGA with higher maternal age was, however, similar among women with and without congenital heart disease.

CONCLUSIONS

Women with congenital heart disease had a higher risk of PTB and giving birth to an SGA infant at all maternal ages. These two risk factors did not, however, seem to potentiate each other.

Understanding pathways to inequalities in child mental health: a counterfactual mediation analysis in two national birth cohorts in the UK and Denmark

OBJECTIVES

We assessed social inequalities in child mental health problems (MHPs) and how they are mediated by perinatal factors, childhood illness and maternal mental health in two national birth cohorts.

DESIGN

Longitudinal cohort study SETTING: We used data from the UK Millennium Cohort Study and the Danish National Birth Cohort.

PRIMARY AND SECONDARY OUTCOME MEASURES

We applied causal mediation analysis to longitudinal cohort data. Socioeconomic conditions (SECs) at birth were measured by maternal education. Our outcome was child MHPs measured by the Strength and Difficulty Questionnaire at age 11. We estimated natural direct, indirect and total effects (TEs) of SECs on MHPs. We calculated the proportion mediated (PM) via three blocks of mediators-perinatal factors (smoking/alcohol use during pregnancy, birth weight and gestational age), childhood illness and maternal mental health.

RESULTS

At age 11 years, 9% of children in the UK and 3.8% in Denmark had MHPs. Compared with high SECs, children in low SECs had a higher risk of MHPs (relative risk (RR)=4.3, 95% CI 3.3 to 5.5 in the UK, n=13 112; and RR=6.2, 95% CI 4.9 to 7.8 in Denmark, n=35 764). In the UK, perinatal factors mediated 10.2% (95% CI 4.5 to 15.9) of the TE, and adding maternal mental health tripled the PM to 32.2% (95% CI 25.4 to 39.1). In Denmark, perinatal factors mediated 16.5% (95% CI 11.9 to 21.1) of the TE, and including maternal mental health increased the PM to 16.9% (95% CI 11.2 to 22.6). Adding childhood illness made little difference in either country.

CONCLUSION

Social inequalities in child mental health are partially explained by perinatal factors in the UK and Denmark. Maternal mental health partially explained inequalities in the UK but not in Denmark.

Trajectories of childhood adversity and mortality in early adulthood: a population-based cohort study

BACKGROUND

Childhood is a sensitive period with rapid brain development and physiological growth, and adverse events in childhood might interfere with these processes and have long-lasting effects on health. In this study, we aimed to describe trajectories of adverse childhood experiences and relate these to overall and cause-specific mortality in early adult life.

METHODS

For this population-based cohort study, we used unselected annually updated data from Danish nationwide registers covering more than 1 million children born between 1980 and 1998. We distinguished between three different dimensions of childhood adversities: poverty and material deprivation, loss or threat of loss within the family, and aspects of family dynamics such as maternal separation. We used a group-based multi-trajectory clustering model to define the different trajectories of children aged between 0 and 16 years. We assessed the associations between these trajectories and mortality rates between 16 and 34 years of age using a Cox proportional hazards model and an Aalen hazards difference model.

FINDINGS

Between Jan 1, 1980 and Dec 31, 2015, 2 223 927 children were included in the Danish Life Course cohort. We excluded 1 064 864 children born after 1998, 50 274 children who emigrated before their 16th birthday, and 11 161 children who died before their 16th birthday, resulting in a final sample of 1 097 628 children. We identified five distinct trajectories of childhood adversities. Compared with children with a low adversity trajectory, those who had early-life material deprivation (hazard ratio 1·38, 95% CI 1·27-1·51), persistent deprivation (1·77, 1·62-1·93), or loss or threat of loss (1·80, 1·61-2·00) had a moderately higher risk of premature mortality. A small proportion of children (36 081 [3%]) had multiple adversities within all dimensions and throughout the entire childhood. This group had a 4·54 times higher all-cause mortality risk (95% CI 4·07-5·06) than that of children with a low adversity trajectory, corresponding to 10·30 (95% CI 9·03-11·60) additional deaths per 10 000 person-years. Accidents, suicides, and cancer were the most common causes of death in this high adversity population.

INTERPRETATION

Almost half of Danish children in our study experienced some degree of adversity, and this was associated with a moderately higher risk of mortality in adulthood. Among these, a small group of children had multiple adversities across social, health, and family-related dimensions. This group had a markedly higher mortality risk in early adulthood than that of other children, which requires public health attention.

FUNDING

None.