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The role of prenatal, perinatal and postnatal factors in the explanation of socioeconomic inequalities in preschool asthma symptoms: the Generation R Study
  1. Esther Hafkamp-de Groen1,2,
  2. Lenie van Rossem1,2,
  3. Johan C de Jongste3,
  4. Ashna D Mohangoo1,2,4,
  5. Henriëtte A Moll3,
  6. Vincent W V Jaddoe1,3,5,
  7. Albert Hofman5,
  8. Johan P Mackenbach2,
  9. Hein Raat2
  1. 1The Generation R Study Group, Erasmus MC, Rotterdam, The Netherlands
  2. 2Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
  3. 3Department of Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
  4. 4TNO, Netherlands Organisation for Applied Scientific Research, Department Child Health, Leiden, The Netherlands
  5. 5Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
  1. Correspondence to Esther Hafkamp-de Groen, Public Health/Generation R Study, Erasmus Medical Center, PO Box 2040 (Room Ae−003), Rotterdam 3000 CA, The Netherlands; e.hafkamp{at}


Background The authors assessed whether socioeconomic inequalities in asthma symptoms were already present in preschool children and to what extent prenatal, perinatal and postnatal risk factors for asthma symptoms mediate the effect of socioeconomic status (SES).

Methods The study included 3136 Dutch children participating in the Generation R Study, a prospective cohort study. Adjusted ORs of asthma symptoms for low and middle SES (household income and maternal education) compared to high SES were calculated after adjustment for potential confounders and also adjusted for prenatal, perinatal and postnatal mediators at preschool age.

Results At age 1 year, low-SES children had a 40% lower risk of asthma symptoms compared to high-SES children (p<0.01). However, the risk of asthma symptoms in 3- and 4-year-old low-SES children was 1.5 times higher compared to their high-SES age mates (p<0.05). The positive associations at age 1 year were particularly modified by postnatal factors (up to 38%). In toddlers, prenatal factors explained up to 58% of the negative associations between SES and asthma symptoms.

Conclusions SES indirectly affects asthma symptoms at preschool age. The inverse association between SES and asthma symptoms emerges at age 3 years. This is particularly due to a high level of adverse prenatal circumstances in low-SES toddlers. Future research should evaluate public health programs (during pregnancy) to reduce socioeconomic inequalities in childhood asthma.

  • Asthma
  • child health
  • preventive medicine
  • social inequalities
  • birth defects
  • infant mortality
  • perinatal epidemiology
  • public health
  • social epidemiology
  • health expectancy
  • asthma symptoms
  • maternal educational level
  • household income
  • preschool children
  • socioeconomic status

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  • Funding The first phase of the Generation R Study was funded by Erasmus Medical Centre and Erasmus University Rotterdam and the Netherlands Organization for Health Research and Development (ZonMw). The present study was supported by an additional grant from ZonMw (grant number 22000128).

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval The Medical Ethics Committee of the Erasmus Medical Center, Rotterdam, approved the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.