Understanding social inequalities in childhood asthma: Quantifying the mediating role of modifiable early-life risk factors in seven european birth cohorts

Pinot de Moira, Angela; García Aymerich, Judith; Vrijheid, Martine; Nybo Andersen, Anne-Marie

doi:http://dx.doi.org/10.1016/j.jaip.2025.02.032

Understanding social inequalities in childhood asthma: Quantifying the mediating role of modifiable early-life risk factors in seven european birth cohorts

License

Citation

Pinot de Moira A, Aurup AV, Avraam D, Zugna D, Jensen AKG, Welten M, et al. Understanding social inequalities in childhood asthma: Quantifying the mediating role of modifiable early-life risk factors in seven european birth cohorts. J Allergy Clin Immunol Pract. 2025 Jun;13(6):1385-96. DOI: 10.1016/j.jaip.2025.02.032

Abstract

Background: Children growing up in disadvantaged socioeconomic circumstances (SECs) have an increased risk of asthma. Objective: To increase our understanding of the pathways to inequalities in asthma and potential targets for intervention by (1) examining how the social patterning of asthma and its early-life risk factors varies across countries and (2) quantifying the mediation of observed inequalities by early-life risk factors. Methods: We used data for 107,884 mother-child dyads from 7 European birth cohorts across 6 countries. Maternal education was the primary exposure measure of early-life SECs. The outcome was current asthma in childhood (3-12 years). Inequalities were examined using multivariable regression and random effects meta-analysis. The mediating effects of early-life risk factors (maternal smoking during pregnancy, adverse birth outcomes, and breastfeeding duration) were examined using counterfactual mediation analysis. Results: In meta-analysis, children of mothers with low/medium versus high education had a 17% (95% confidence interval: 8%-27%, I2 = 21.6%) increased risk of asthma. Cohort-specific risk ratios ranged between 1.07 (0.97-1.18, Danish National Birth Cohort, Denmark) and 1.61 (1.08-2.40, study on the pre- & early postnatal determinants of child health & development, France). The early-life risk factors were similarly socially patterned, but with greater heterogeneity across cohorts (I2 range = 66.2%-95.3%). The mediation analysis suggested that these factors play a relevant role in mediating observed inequalities (proportion mediated range: 0.08-0.72). Conclusions: There was a consistent tendency for children from disadvantaged SECs to be at greater risk of asthma in the European cohorts examined. Our results suggest that early-life risk factors partially mediate these disparities and, therefore, that public health interventions in the perinatal period may help to address inequalities in asthma.