PROCEEDINGS of the
23rd International Congress on Acoustics
9 to 13 September 2019 in Aachen, Germany

Associations of traffic noise and air pollution with birth outcomes in
Alpine areas: Results from the UIT and BBT surveys
Angel M. DZHAMBOV1; Iana MARKEVYCH2; Peter LERCHER3
1
2

Department of Hygiene and Ecomedicine, Faculty of Public Health, Medical University of Plovdiv, Bulgaria

Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich,Germany; Institute of Epidemiology, Helmholtz Zentrum München – German Research Center for Environmental
Health, Germany;3

Institute for Highway Engineering and Transport Planning, Graz University of Technology, Austria

ABSTRACTThe present study investigated associations between traffic noise and air pollution and birth outcomes inseveral Alpine areas. We used data from two representative cross-sectional studies (UIT, n = 573 and BBT, n= 518) in the Tyrol Region (Austria and Italy). Only mothers who had lived in their current residence during
the whole pregnancy were included. They completed a questionnaire, and medical records were used to draw
data on birth weight, low birth weight (LBW), preterm birth, and small for gestational age (SGA).
Road/railway traffic noise (Ldn, Lden) and air pollution (NO2) were assessed using a combination ofsophisticated modelling and field measurements. In the UIT survey, higher Ldn was associated with higher
odds of LBW, while no significant associations were observed for NO2. In the BBT survey, Lden was
associated with lower birth weight in some subgroups and NO2 was associated with lower birth weight inpreterm babies. Future studies should re-confirm the discovered associations of traffic emissions with birthoutcomes in the Alpine region.
Keywords: Pregnancy outcomes, Birth weight, Preterm birth

1. INTRODUCTION
Birth weight and gestational age at delivery not only have critical importance for early -life
mortality (1), but also affect long-term programming of health and disease (2). Besides well-known
contributors to adverse birth outcomes, such as genetics, sociodemographics, and lifestyle, there isincreasing recognition that the surrounding environment also takes its toll on intrauterine growth anddevelopment. For example, some air pollutants can cross the pulmonary epithelium entering thecirculation, and thus, promote systemic inflammatory responses and oxidative stress, leading toplacental dysfunction and restricted fetal growth (3). The biological mechanisms underlying the effectof traffic noise, another related factor, involve neuroendocrine stress reaction in the maternal organism,
which in turn may disrupt normal placental function (impaired blood supply, elevated corticotropin
releasing hormone secretion), affect the hypothalamic-pituitary-adrenal axis of the fetus, and thereby
lead to preterm delivery, small for gestational age, and low birth weight (LBW; < 2500 g) ( 4).
Moreover, a noisy and polluted residential environment is not only stressful in itself but may beperceived as unattractive setting for physical activity and social interactions, limiting the opportunities
for outdoor recreation (5).
Multiple studies have looked into effects of air pollution exposure during pregnancy and founda higher risk of LBW/preterm birth in association with increased concentrations of some pollutants (3).
Although it is thinner, the epidemiological literature on traffic noise also points to a potential
association with poor birth outcomes (4). Results of the few studies that investigated the joined effectsof traffic noise and air pollution were inconsistent (6-9). Understanding the interplay between these1

angelleloti@gmail.com
iana.markevych@helmholtz-muenchen.de3
peter.lercher@tugraz.at
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spatially correlated exposures is essential for planning healthy settlements.
Another caveat is that most previous research was undertaken in highly urbanized areas, whichmeans that the findings cannot be directly extrapolated to settings where the spatial relationships
between traffic emissions differ. In addition to urbanicity, terrain features, such as steepness andaltitude, may confound or modify the effects during pregnancy. For instance, higher altitude has been
linked to intrauterine growth retardation and a subsequent reduction in birth weight ( 10), while living
in a hilly area may increase physical activity and protect of type 2 diabetes (11), thereby supporting
normal birth weight (12). No previous study has accounted for these factors though.
In the present explorative study, we had a unique opportunity to investigate the association ofresidential traffic noise and air pollution with birth outcomes in several Alpine areas. The Alps cover
190 959 km2 and are home to 14 million Europeans (13). Because of the idiosyncratic topography of
the region, previous findings may not apply to children born there. Furthermore, given their landform,
natural ventilation, and transport infrastructure, some valleys are characterized by temperature
inversions and propagation of sound waves over great distances, which can lead to higher levels of air
pollution and noise (14). Hence, undertaking a study in this geographic context will help advance theliterature on the subject by expanding earlier research.

2. MATERIAL AND METHODS
2.1 Study Area
The present study takes advantage of data originally collected to assess relationships between
environmental quality and children’s well-being within the framework of two epidemiological studies
in the Tyrol Region – the UIT survey (conducted in the Lower Inn valley, Unterinntal, in Austria) andthe BBT survey (conducted in the Wipp valley, Wipptal, and its side valleys on both sides of theBrenner pass in Austria and Italy, as well as partially in Lower Inn valley). Both valleys are part of themost important access route for heavy goods traffic over the Brenner Pass, which links central andnorthern Europe’s traffic to southern Europe. The settlements consist of densely populated small towns
and villages with a mix of industrial, small business, touristic, and agricultural activities. Maintransportation lines (a highway and a railway) run through the valleys, with main roads connecting to
the various small villages and causing high levels of noise (5). (See Figure 1)

Figure 1 – Participants’ home addresses in the UIT (yellow dots) and BBT (purple dots) survey
areas. Note. The red lines are the Austrian-German (north) and Austrian-Italian (south) borders.
The UIT survey site extends about 40 km east of Innsbruck towards the Austrian -German borderacross a relatively broad U-shaped valley floor and up to the foothills of the Alpine comb. The area is7097

characterized by a combination of high levels of air pollution and traffic noise (1 5, 16). The narrow
V-shaped Wipp valley extends along the river Sill southward from Innsbruck up to the Brenner Pass at
the Austro-Italian border. South of the border the Wipp valley stretches along the river Isarco down toFortezza in Italy. Owing to differences in meteorology (stronger winds versus a lot of temperature
inversions) and topography (north-south versus east-west), air pollution levels in the Wipp valley are
considerably lower than in the Lower Inn valley.
2.2 Study Design
The UIT survey was undertaken in June 1998 and recruited a total of 1280 children recruited from
26 local schools (grades 3 – 4) with a response rate of 79.5% (17). The BBT survey included complete
records of 1251 children (response rate = 85.5%) in the same age group recruited in 2004/2005 from 49
schools (18). In both surveys, children’s mothers completed a nearly identical self-administered,standardized questionnaire which asked about sociodemographic information, lifestyle, perinatal data,
housing, and duration of residence at the current address. The mothers or legal guardians of allparticipants provided written informed consent.
In order to reduce exposure misclassification, the present study was limited to children born tomothers who had lived in their current residence during the whole pregnancy. In one of sensitivity
analyses, we also present the results for the entire sample. We also excluded all cases for which theexact address could not be geocoded. This resulted in final analytic samples of 573 children in the UIT
survey and 518 children in the BBT survey.
Comparison between characteristics of those mothers who lived at the residence since the time ofconception and pregnancy and those who moved in later (movers and non -movers) indicated somedifferences. In both surveys, non-movers were older and more often multiparous. They were also more
likely to live in a single family home and less likely to be smokers. In the UIT survey, the prevalence sof single mothers and those who gave birth to SGA were higher in movers. In the BBT survey, theprevalence of those who gave birth to children of LBW was somewhat higher in non-movers.
2.3

Birth Outcomes Assessment
Prenatal and perinatal data were drawn from doctor’s entries in the Mutter-Kind-Pass, which
every pregnant woman in Austria receives. In the southern BBT area in Italy (Alto Adige) w hich has
close relations to Austria, the equivalent “Mutterpass” was available. The two primary outcomes werebirth weight and LBW (defined as weight less than 2500 g). We also considered preterm birth (birth
before the 37 th gestational week) and small for gestational age (SGA) (birth weight below the 10 thpercentile for the gestational age in Tyrol).
2.4 Traffic Noise and Air Pollution Assessment
We only had data on traffic noise and air pollution calculated about 10 years after birth, therefore,
they were used as surrogates for exposure levels during pregnancy. For the UIT survey, the three majornoise sources (highway, railway, and local main roads) were modelled in 1997 – 1998 at a resolution of
25 m x 25 m, and source-specific and total day-night noise levels (L dn ) were assessed for each
respondent. Nitrogen dioxide (NO 2 ) served as a proxy for annual average traffic-related air pollution
in 1995, and was calculated at a resolution of 100 m x 100 m using an adapted Gaussian propagation
model procedure considering the meteorological and topographic specifics of the study area. The
resulting modelled estimates were calibrated against measurements and corrected where needed (19).
In the BBT survey, noise emissions were assessed in 2003/2004. Since there are no railways in theside valleys, road and railway traffic were not considered as separate noise sources. Total
day-evening-night noise level (L den ) was calculated at the most exposed façade, and reflected onlyroad traffic noise for residents of the side-valleys and combined road traffic and railway noise for thoseliving in the Wipp valley. Annual means for NO 2 were calculated in 2003/2004 at a resolution of 10 x
10 m. Calculations were supplemented with additional traffic counting and micro -simulations, andwere evaluated against measurements.
2.5 Covariates
Potential confounders and effect modifiers were selected based on theory and literature precedent(6, 8, 20) and included: mother’s education, smoking during pregnancy, house type, season ofpregnancy, altitude, slope, duration of residence before conception, maternal age at birth, child’s sex,
and birth order. In the UIT survey, we also had additional information on single mother status.

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2.6 Statistical Analysis
Given the systematic differences between the two survey areas in terms of environmental
conditions and year of deliveries, and that the BBT area partially overlaps with the UIT area, we
decided to analyze the two samples separately. Because less than ≈ 5 – 6% of values were missing frommost of the variables, they were imputed using the expectation-maximization algorithm. Missing
values in noise and air pollution were only imputed if other geographic variables were available.
Prior to the multivariate analyses, the linearity of the shape of relationships between L dn/Lden andNO2 and birth outcomes was tested, and no deviation from linearity was detected. Thus, we employedmultivariate linear regression models to investigate the association between continuous environmental
exposures and continuously-measured birth weight, and multivariate logistic regression models for
LBW, preterm birth, and SGA. The models were adjusted for sex of child, age of mother at birth,gestational age, single mother status (only in the UIT models), mother’s education, smoking during
pregnancy, duration of residence before conception, and house type. Effect estimates of L dn/Lden andNO2 are reported per 10 dB and 10 μg/m 3 increase, respectively.
In a series of sensitivity analyses, we tested the robustness of our findings for LBW and birthweight. First, the models were repeated on all UIT and BBT mothers (movers and non -movers),
hypothesizing that associations would be attenuated due to exposure misclas sification. Second, themodels were additionally individually adjusted for slope and altitude. Next, we adjusted for birth order.
Finally, because of relevant differences in the prevalence of perinatal indicators and air pollution
across the BBT region, sensitivity analyses were conducted with models limited to mothers residing in
the Lower Inn valley and the northern (Austrian) region of the BBT-study.
Finally, several factors were tested as potential modifiers of the association between the exposuresand birth weight: duration of residence, preterm birth, birth order, single mother status, mother’education, and altitude. We conducted moderation analysis using the PROCESS v. 2. 16 macro for
SPSS (21). Additionally, we ran interaction analyses.

3. RESULTS
3.1 Characteristics of the UIT and BBT Samples and Bivariate Associations
Characteristics of the UIT and BBT participants are presented in Table 1. The two samples had
some notable differences. There was a higher prevalence of LBW and SGA in BBT children compared
to UIT children. Altitude and slope were greater than in the UIT survey. The most pronounced
difference, however, was in the air pollution levels. Participants of the BBT survey (except for thoseliving in the Lower Inn valley) were exposed to considerably lower air pollution than those of the UIT
survey. In addition, noise and air pollution were stronger correlated in the UIT survey (r s = 0.69 vs0.50). Results from the tests of the bivariate associations between participants’ characteristics andbirth outcomes indicate that birth weight was positively related to male sex, higher birth order, andolder age of the mother.
3.2 Associations between Traffic Noise and Air Pollution and Birth Outcomes
There were differences in associations between exposure variables and birth outcomes across thestudy areas (Table 2). In the UIT survey, the single exposure models indicated that higher L dn from allconsidered sources was associated with higher odds for LBW. Associations with NO 2 were in the same
direction as with noise but non-significant.
In the BBT survey, the association of L den with birth weight was in the expected direction but withwide confidence intervals including 0 and 1, respectively. Still, when adjusted for NO 2 , L den was
associated with lower birth weight. Unexpectedly, we observed lower odds for SGA in relation withhigher L dn .

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Table 1 – Participant key characteristics in the UIT and BBT surveys
Characteristic

UIT survey (N = 573)

BBT survey (N = 518)

Maternal age (mean years, SD)

28.52 (4.77)

30.07 (4.60)

Male child (n, %)290 (50.61)

262 (50.58)

Single mother (n, %)27 (4.71)-

Smoking during pregnancy (n, %)45 (7.85)

49 (9.46)

Basic

147 (25.65)

130 (25.10)

Skilled labor

188 (32.81)

168 (32.43)

Vocational

148 (25.83)

128 (24.71)

A-level90 (15.71)

92 (17.76)

3384.99 (528.76)

3221.72 (564.71)

Low birth weight (n, %)26 (4.54)

53 (10.23)

Preterm birth (n, %)81 (14.14)

64 (12.36)

Small for gestational age (n, %)22 (3.84)

34 (6.56)

Ldn total (median dB, IQR)

52.26 (10.64)

52.53 (14.39)

Ldn main road (median dB, IQR)

46.36 (13.80)

49.66 (14.30)

Ldn railway (median dB, IQR)

49.88 (10.32)-

31.23 (6.87)

12.32 (9.92)

Mother’s education (n, %)Birth weight (mean grams, SD)

3NO2 (median μg/m , IQR)

Table 2 – Multivariate associations between traffic noise and air pollution and birth outcomes
UIT survey (N = 573)

BBT survey (N = 518)

LBW

Birth weight

LBW

Birth weight

OR (95% CI)

β (95% CI)

OR (95% CI)

β (95% CI)

Ldn total

2.03 (1.16, 3.54)-17.63 (-71.77, 36.51)

0.96 (0.66, 1.39)-35.45 (-73.43, 2.53)

Ldn road

1.76 (1.03, 3.00)-5.50 (-54.58, 43.58)

0.90 (0.61, 1.32)-31.49 (-72.80, 9.82)

Ldn railway

1.93 (1.11, 3.33)-11.96 (-67.55, 43.64)

-

-

NO2

2.04 (0.87, 4.79)-31.37 (-103.62, 40.9)

1.06 (0.68, 1.65)

11.56 (-33.91, 57.03)

Ldn total (+ NO2)

1.99 (0.95, 4.17)-2.59 (-77.65, 72.48)

0.93 (0.61, 1.40)-47.05 (-88.49, -5.6)

NO2 (+ Ldn total)

1.04 (0.34, 3.21)-28.98 (-129.18, 71.2)

1.10 (0.67, 1.81)

34.26 (-15.22, 83.73)

3.3 Effect Modification and Sensitivity Analyses
In the UIT survey, no effect modification was observed for L dn . For NO 2 , the association was more
pronounced in first born babies and mothers living with a partner. We saw borderline interactions
between L dn and NO 2 – inverse associations with birth weight were only seen when the other exposure
was low. In the BBT survey, L den was related to lower birth weight in preterm babies (β = -140.57 g;
95% CI: -260.51, -20.63), as was NO 2 (β = -168.45 g; 95% CI: -321.66, -15.25).
When all mothers (non-movers and those who moved after delivery) were included, the effects in
the UIT survey were no longer there. Adjusting for slope considerably enhanced the observed
associations for L dn and NO 2 in the UIT survey. When we limited the analysis to residents of thenorthern (Austrian) BBT subregion, higher L den was associated with lower birth weight (β = -62.47 g;
95% CI: -115.52, -9.41).

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4. DISCUSSION
4.1 General Findings
In the present study, we investigated the associations of traffic noise and air pollution with birthoutcomes in several Alpine areas with unique geographic features. Surprisingly, we saw contrast
across the study areas. In the Lower Inn valley, noise was associated with higher odds for LBW, andthis association was no longer significant after correcting for NO 2 . Conversely, in the BBT survey,
significant associations were present only in subgroups.
There are a number of possible reasons for this discrepancy. The most apparent difference between
the study areas is the much higher air pollution levels in the Lower Inn valley. Another noteworthy
difference between the surveys is the higher prevalence of perinatal outcomes (LBW and SGA) in the
BBT area, which may reflect other confounding/modifying factors unaccounted for, such as healthcare.
Another interpretation of the inconsistent findings could be presence of structural confounding in thedata (i.e. systemic differences in covariates related to both the exposure and the outcome acrosscommunities). The BBT villages are smaller than the UIT villages, and the relationship between
socioeconomic position and residential location differs from village to village depending on theresidential layout. We reckon that the stronger (or more pronounced) geographic and traffic
heterogeneity of the BBT area with its several side valleys, coupled with heterogeneity in prevalenceof birth outcomes, might have contributed to a greater overdispersion in the data, which might havetranslated into larger standard errors of some estimates making them less precise and not reachingstatistical significance. We are also mindful of the temporal difference between the two surveys that
could explain part of the differences in the results. Unfortunately, at this point we cannot offer astraightforward explanation of our findings.
Traffic noise was associated with higher risk for LBW in the UIT survey, while in the BBT survey,
the association with continuous birth weight was marginally significant for in the main model, andsignificant only when air pollution was adjusted for, and in subgroups. The recent WHO review on
traffic noise and birth outcomes found few studies and low quality evidence that traffic noise leads to
LBW, preterm birth, and SGA (4). In general, the evidence is mixed, with some studies pointing to anincreased risk (e.g., 6), whereas others were not supportive of such associations (e.g., 9, 20, 23).
Nieuwenhuijsen et al. (4) pointed out the need for studies on different sources of noise, but to ourknowledge, only a few earlier studies (6, 7, 22) have considered combined exposure to road andrailway traffic noise. In the UIT survey, we evidenced associations for both road traffic and railway
noise before NO 2 adjustment. Gehring et al. (6) reported a 19 g (95% CI: - 23, - 15) decrease of term
birth weight for every 6-dB increase in road traffic noise exposure and similar estimates for combinedroad, aircraft, and railway noise. Hjortebjerg et al. (7), conversely, did not observe an association ofnoise with newborn's size indicators.
The evidence from air pollution studies is larger and more convincing. A comprehensive
meta-analysis of 14 population-based mother-child cohorts indicated 9% higher odds of term LBW for10 μg/m3 increase of NO 2 (24). In the present study, no consistent associations were observed for NO 2
– in the UIT models, the estimates had the expected sign albeit they were non -significant, but in the
BBT survey, such association was observed only in preterm babies. The effect modification of
association with NO 2 by preterm birth in the BBT survey is in line with the conjecture that preterm
babies may be particularly vulnerable – environmental stressors may be stronger associated with fetal
growth restriction during developmental periods before the 37 th gestational week (25, 26), whereas
infants who have reached full maturity may have had time to “catch-up” on weight gain, thus, partially
offsetting the adverse environmental influences. However, this could also be a statistical artefact.
Ours is one of the few attempts to disentangle the interplay of traffic noise and air pollution (cf. 6,
7, 8, 27). For instance, in a population-based cohort study in London, an increase in NO 2 wasassociated with 3% increased odds for term LBW and 1% increased odds for term SGA ( 8), while theeffect of road traffic noise was strongly attenuated when adjusted for primary traffic -related air
pollutants. According to Hjortebjerg et al. (7), traffic noise was not related to newborn's size at birth inDenmark, whilst in Canada (6), joint air pollution-noise models revealed that associations between
noise and term birth weight were robust to adjustment for air pollution but not the other way around. It
stands to reason that the interplay between the exposures is complex and area -specific.
4.2 Strengths and Limitations
The present study has several novel features. First, the Alpine region is a unique setting which

7101differs from settings of previously reported studies. In addition, this study relied on high -quality
biomedical data and state-of-the-art noise and air pollution modeling tailored to the Alpine region.
We also recognize several limitations of the current study. The sample sizes were modest , which
could explain some null findings. Concerns about raising type II error prevented us from c ontrolling
for the increase in familywise error across the reported statistical analyses. Furthermore, excluding
mothers whose address at the time of pregnancy was unknown could have resulted in residual
self-selection bias and undermined the representativeness of the reduced analysis samples.
In terms of exposure assessment, noise and air pollution levels were originally calculated for theyear of the surveys, that is, about 9 – 10 years after children’s birth. This inherent design feature could
not be overcome. Traffic volume has steadily increased in the period 1995 – 2005 in most segments,
with some 20 – 30% along the Inn valley study area and 30 – 40% across the BBT area
(http://tirolatlas.uibk.ac.at/). This gives us reason to suggest that it increased in a homogeneous
manner possibly preserving spatial contrasts in traffic immissions. A further limitation is that we
assigned annual mean air pollution to each pregnant woman’s address, rather than using time -varying
season-specific NO 2 .
Various air pollutants have been linked to adverse birth outcomes (24), but we only considered NO 2 .
Unaccounted for residual confounding could have led to counterintuitive findings.

5. CONCLUSIONS
Our findings provide inconclusive evidence that traffic noise might be associated with adverse birthoutcomes in mountainous areas. Given the disparate associations across the study areas, further
research with larger representative samples is warranted.

ACKNOWLEDGEMENTS
We want to thank first the inhabitants of the Lower Inn and Wipp valleys. We also thank theAustrian Ministry of Science and Transportation for funding the framework of the Environmental
Health Impact Assessment (EHIA), the government of the Tyrol region for providing GIS -data andinformational support from the BEG (Brenner Eisenbahn Gesellschaft). The BBT survey got support
from the BBT company within the framework of a legally required EHIA through EU-support. The
noise mapping was done by INTEC, Ghent, and the air pollution assessment by an Italian -Austrian
consortium. Finally, we want to thank the large EHIA-teams in both studies, who did the field work.

REFERENCES
1. McCormick MC. The contribution of low birth weight to infant mortality and childhood morbidity.
N Engl J Med. 1985;312(2):82-90.
2. Barker DJ. The origins of the developmental origins theory. J Intern Med 2007;261(5):412 –17.
3. Sapkota A, Chelikowsky AP, Nachman KE, Cohen AJ, Ritz B. Exposure to particulate matter andadverse birth outcomes: a comprehensive review and meta-analysis. Air Qual Atmos Health2012;5:369-381.
4. Nieuwenhuijsen MJ, Ristovska G, Dadvand P. WHO Environmental Noise Guideline s for theEuropean Region: A Systematic Review on Environmental Noise and Adverse Birth Outcomes.
International Journal of Environmental Research and Public Health. 2017;14(10):1252 .
5. von Lindern E, Hartig T, Lercher P. Traffic-related exposures, constrained restoration, and health in
the residential context. Health Place. 2016;39:92-100.
6. Gehring U, Tamburic L, Sbihi H, Davies HW, Brauer M. Impact of noise and air pollution on
pregnancy outcomes. Epidemiology. 2014;25(3):351-8.
7. Hjortebjerg D, Andersen AM, Ketzel M, Pedersen M, Raaschou-Nielsen O, Sørensen M.
Associations between maternal exposure to air pollution and traffic noise and newborn's size atbirth: A cohort study. Environ Int. 2016; 95:1-7.
8. Smith RB, Fecht D, Gulliver J, Beevers SD, Dajnak D, Blangiardo M, et al. Impact of London'sroad traffic air and noise pollution on birth weight: retrospective population base d cohort study.
BMJ. 2017;359:j5299.
9. Barba-Vasseur M, Bernard N, Pujol S, Sagot P, Riethmuller D, Thiriez G, et al. Does low tomoderate environmental exposure to noise and air pollution influence preterm delivery in
medium-sized cities? Int J Epidemiol. 2017;46(6):2017-2027.
10. Waldhoer T, Klebermass-Schrehof K. The impact of altitude on birth weight depends on further

7102

mother- and infant-related factors: a population-based study in an altitude range up to 1600 m inAustria between 1984 and 2013. J Perinatol. 2015;35(9):689-94.
11. Fujiwara T, Takamoto I, Amemiya A, Hanazato M, Suzuki N, Nagamine Y, et al. Is a hilly
neighborhood environment associated with diabetes mellitus among older people? Results from the
JAGES 2010 study. Soc Sci Med. 2017;182:45-51.
12. Kc K, Shakya S, Zhang H. Gestational diabetes mellitus and macrosomia: a literature review. Ann
Nutr Metab. 2015;66 Suppl 2:14-20.
13. Onida M. The Alps: eight countries, a single territory. Permanent Secretariat of the Alpine
Convention.
Innsbruck(Austria);
2009.
Availableat:
http://www.alpconv.org/en/publications/alpine/Documents/AlpenkonventionsBuch.pdf
14. Heimann D, de Franceschi M, Emeis S, Lercher P, Seibert P. (Eds.). Air Pollution, Traffic Noise andRelated Health Effects in the Alpine Space – A Guide for Authorities and Consulters. ALPNAP
comprehensive report. Università degli Studi di Trento, Dipartimento di Ingegneria Civile e
Ambientale, Trento, Italy; 2007, p. 335.
15. Lercher P, Kofler WW. Behavioral and health responses associated with road traffic noise exposure
along alpine through-traffic routes. Sci Total Environ. 1996;189:85-89.
16. Lercher P, Schmitzberger R, Kofler W. Perceived traffic air pollution, associated behavior andhealth in an alpine area. Sci Total Environ. 1995;169(1-3):71-74.
17. Lercher P, Evans GW, Widmann U. The ecological context of soundscapes for children's bloodpressure. J Acoust Soc Am. 2013;134(1):773-81.
18. Lercher P, Eisenmann A, Dekonick L, Botteldooren D. The relation between disturbed sleep inchildren and trafﬁc noise exposure in alpine valleys. Proceedings of the 42nd International
Congress and Exposition on Noise Control Engineering, InterNoise, Innsbruck, Austria, 15–18
September; 2013.
19. Lercher P, Widmann U, Thudium J. Hypotension and environmental noise: a replication study. Int J
Environ Res Public Health. 2014;11(9):8661-88.
20. Dadvand P, Ostro B, Figueras F, Foraster M, Basagaña X, Valentín A, et al. Residential proximity tomajor roads and term low birth weight: the roles of air pollution, heat, noise, and road -adjacenttrees. Epidemiology. 2014;25(4):518-25.
21. Hayes A. Introduction to mediation, moderation, and conditional p rocess analysis: A
regression-based approach. New York: Guilford Press; 2013.
22. Cusack L, Sbihi H, Larkin A, Chow A, Brook JR, Moraes T, et al. Residential green space andpathways to term birth weight in the Canadian Healthy Infant Longitudinal Development (CHILD)
Study. Int J Health Geogr. 2018;17:43.
23. Wallas A, Ekström S, Bergström A, Eriksson C, Gruzieva O, Sjöström M, et al. Traffic noise
exposure in relation to adverse birth outcomes and body mass between birth and adolescence.
Environmental Research 2019;169:362–367.
24. Pedersen M, Giorgis-Allemand L, Bernard C, Aguilera I, Andersen AM, Ballester F, et al. Ambient
air pollution and low birthweight: a European cohort study (ESCAPE). Lancet Respir Med.
2013;1(9):695-704.
25. Iñiguez C, Ballester F, Estarlich M, Esplugues A, Murcia M, Llop S, et al. Prenatal exposure totraffic-related air pollution and fetal growth in a cohort of pregnant women. Occup Environ Med.
2012;69(10):736-44.
26. Wu H, Jiang B, Zhu P, Geng X, Liu Z, Cui L, et al. Associations between maternal weekly air
pollutant exposures and low birth weight: a distributed lag non-linear model. Environ. Res. Lett.
2018;13:024023.
27. Nieuwenhuijsen MJ, Agier L, Basagaña X, Urquiza J, Tamayo-Uria I, Giorgis-Allemand L, et al.
Influence of the Urban Exposome on Birth Weight. Environ Health Perspect. 2019;127(4):47007.
doi: 10.1289/EHP3971.

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