Reversing Metabolic Dysfunction-Associated Steatotic Liver Disease Promotes Healthy Pediatric Cardiovascular Structures: The PROC Study.

INTRODUCTION: We investigated the impact of metabolic dysfunction-associated steatotic liver disease (MASLD) on cardiovascular structure development in children. METHODS: We followed 1,356 children with the mean age of 6.6 years for 4.5 years in Beijing, China. We assessed the association of MASLD with cardiovascular structure (carotid intima-media thickness and left ventricular mass) outcomes at baseline and follow-up. RESULTS: Over follow-up, 59 children had persistent MASLD, 109 had incident MASLD (progression), and 35 had normalization of liver health. Children with MASLD normalization showed a significantly lower mean development in carotid intima-media thickness (0.161 vs 0.188 mm) and left ventricular mass (4.5 vs 12.4 g) than children with persistent MASLD. DISCUSSION: The control of MASLD was associated with improved cardiovascular structure development.

Sex differences in cardiovascular health among children aged 6-8 years in Beijing City / 中国学校卫生

Objective@#To explore sex difference in the cardiovascular health (CVH) status of 6-8 year old children in Beijing, so as to inform the early intervention of CVH related lifestyles.@*Methods@#Based on the Beijing Children s Growth and Health Cohort (PROC), baseline physical examination, sequential questionnaire survey, and laboratory tests were conducted among 1 914 grade 1 students. Children s CVH and its subscales (health behaviors and health factors) scores were calculated according to the Life s Essential 8 (LE 8) index and categorized into high, moderate, and low CVH. CVH scores were reported as medians and interquartile ranges; sex differences were compared using the Chi square test and Wilcoxon test.@*Results@#Among the 1 914 participants, the percentages of high, moderate, and low CVH were 35.7%, 63.5%, and 0.8%, respectively, and the percentages of high, moderate, and low health behavior scores were 25.9%, 67.5%, and 6.6%, respectively, with no statistically significant differences between sex ( χ 2=2.30, 0.07, P >0.05). The rates of high, moderate, and low health factor scores for boys and girls were 61.1%, 36.0%, 2.9% and 71.1%, 28.4%, 0.5%, respectively, with a statistically significant sex difference ( χ 2=31.88, P < 0.01). The overall CVH score was 76.0(70.0, 83.0), 76.0(69.0, 82.0) for boys, and 77.0(71.0, 83.0) for girls. Among the health behavior metrics, sleep scores were the best and physical activity scores were the worst[100.0(90.0,100.0), 40.0(20.0, 80.0 )]; among the health factor metrics, blood glucose scores were the best and lipid scores were the worst[100.0(100.0,100.0), 60.0(40.0,100.0)]. In respect to health factors, there were significant gender differences in body mass index, blood lipids, blood sugar, and blood pressure scores ( Z =-6.92, 3.01, -6.60, -2.30, <0.05), but there were no significant gender differences in diet, physical activity, nicotine exposure, or sleep scores with regards to health behaviors ( Z =0.99, 0.88, -0.13, 0.36, P > 0.05 ). Compared to boys, girls in the low and moderate CVH groups had high health factor scores despite low health behavior scores.@*Conclusion@#Most 6 to 8-year-old children in Beijing were found to have relatively good CVH, and optimization of children s CVH status can be achieved by promoting healthier lifestyles and monitoring health factors, especially among boys.

Sex-Specific Differences in Left Ventricular Mass and Volumes with Body Mass Index among Children Aged 6 to 8: A Cross-Sectional Study in China.

Few studies have examined the sex differences in left ventricle (LV) structure and physiology from early life stages. We aimed to assess the role of sex and overweight/obesity on left ventricular mass (LVM) and LV volume in Chinese children without preexisting cardiovascular risk factors. We selected 934 healthy children aged 6-8 years from an existing cohort in Beijing, China. Linear regression models were used to regress body mass index (BMI), fat mass, systolic blood pressure, diastolic blood pressure, waist circumference, and visceral fat area (VFA) with LVM, left ventricle end-diastolic volume (LVEDV) and end-systolic volume (LVESV). Higher BMI, fat mass, waist circumference, VFA, and stroke volume (SV) predicted higher LVM, LVEDV, and LVESV in both sexes. Multivariable analysis showed that boys with an elevated BMI had greater LV hypertrophy. LVEDV and LVESV were higher among boys than among girls and increased with higher BMI in both boys and girls. LVEDV and LVESV were associated with VFA in boys. We observed sex differences in LVM, LVESV, and LVEDV among prepubertal children, independent of obesity, with higher values observed in boys. Sex differences in cardiac structure in children may help explain the higher incidence of cardiovascular disease in male adults. Whether interventions to reduce childhood obesity can improve the trajectory of cardiac dynamics is worth investigating.

Validation of "Life's Essential 8" Metrics With Cardiovascular Structural Status in Children: The PROC Study in China.

Background Life's Essential 8 (LE8) metrics for cardiovascular health (CVH) aid primordial prevention in US populations. Methods and Results We conducted a child cohort study (PROC [Beijing Child Growth and Health Cohort]) with baseline (2018-2019) and follow-up (2020-2021) assessments, enrolling disease-free 6- to 10-year-old children from 6 elementary schools in Beijing. We collected LE8-assessed components via questionnaire surveys and 3 cardiovascular structural parameters by 2-dimensional M-mode echocardiography: left ventricular mass (LVM), LVM index, and carotid intima-media thickness. Compared with 1914 participants (mean age, 6.6 years) at baseline, we saw lower mean CVH scores at follow-up (n=1789; 8.5 years). Among LE8 components, diet presented the lowest perfect-score prevalence (5.1%). Only 18.6% of participants had physical activity ≥420 min/wk, 55.9% had nicotine exposure, and 25.2% had abnormal sleep duration. Prevalence of overweight/obesity was 26.8% at baseline and 38.2% at follow-up. We noted optimal blood lipid scores in 30.7%, while 12.9% of children had abnormal fasting glucose. Normal BP was 71.6% at baseline and 60.3% at follow-up. LVM (g), LVM index (g/m2.7), and carotid intima-media thickness (mm) were significantly lower in children with high (56.8, 33.2, 0.35) or moderate CVH scores (60.6, 34.6, 0.36), compared with children with low CVH scores (67.9, 37.1, 0.37). Adjusting for age/sex, LVM (ß=11.8 [95% CI, 3.5-20.0]; P=0.005), LVM index (ß=4.4 [95% CI, 0.5-8.3]; P=0.027), and carotid intima-media thickness (ß=0.016 [95% CI, 0.002-0.030]; P=0.028) were higher in the low-CVH group. Conclusions CVH scores were suboptimal, declining with age. LE8 metrics indicated worse CVH in children with abnormal cardiovascular structural measurements, suggesting the validity of LE8 in assessing child CVH. Registration URL: https://www.chictr.org.cn/index.html; Unique identifier: ChiCTR2100044027.

Maternal emotional regulation strategy is associated with newborn feeding practices within 72 h after delivery: Cross sectional analyses of a multi-center study in China.

BACKGROUND: Early feeding practices have a great impact on the growth and development of infants, and the health of mothers. Maternal emotional regulation (ER) is closely related to infant feeding practices. Exploring the relationship between ER strategy and feeding practice can inform early exclusive breastfeeding (EBF) interventions. METHODS: Using baseline survey of a longitudinal study, 965 mothers in Chongqing municipality, Guangzhou city, and Huizhou city were enrolled. At baseline, the study used self-administrated questionnaires to investigate the socio-demographic characteristics, maternal ER strategies and feeding practice within 72 h of delivery. Chi-square test and logistic regression were used to determine the associations of the mothers' ER and feeding practices within 72 h postpartum. RESULTS: Among 965 participants, 27.8 % of mothers practiced EBF, and 69.5 % of mothers reported getting breastfeeding education from health providers. The average scores on the cognitive reappraisal and the expressive suppression of the ERQ were 29.95 ± 7.24 and 14.47 ± 5.16 respectively. Multivariable analysis showed women with expressive suppression were less likely to practice EBF (aOR = 0.96, 95%CI: 0.93-0.98, p = 0.002), while receiving breastfeeding education was positively associated with EBF (aOR = 1.52, 95%CI: 1.09-2.12, p = 0.013). LIMITATIONS: Because the study started during the COVID-19 pandemic, the lock-down measures paused recruitments for quite some time reducing the enrollment of participation. The data we used was within 72 h postpartum, hence the period of time to study feeding practices was short. CONCLUSION: Mothers' ER strategy and breastfeeding education need to be addressed as part of interventions designed to improve EBF rates during the newborn period in China.

A follow up study of body fat distribution and blood pressure among 6-9 years old children in Beijing / 中国学校卫生

Objective@#To explore the association of body fat mass and distribution indices including fat mass percentage (FMP), visceral fat area (VFA) and percentage of trunk fat mass (%TFM) with blood pressure in children to inform early management of blood pressure in children.@*Methods@#Based on the Beijing Child Growth and Health Cohort in Shunyi District, lifestyle questionnaire survey, baseline and follow up physical examination were conducted among children from October to November 2018 and September 2020. Bioelectrical impedance analysis (BIA) was used to measure the body composition, and 1 098 participants with completed data were finally included.@*Results@#Both body fat indices and blood pressure increased with age in boys and girls. For FMP, VFA, and %TFM, no significant differences presented between sex at baseline, while FMP, VFA, and %TFM were significantly higher in boys than girls at follow up ( t=2.73, 3.76, 3.41, P <0.01). Before and after adjusting for age, height and lifestyles or not, linear mixed effect models showed longitudinal associations existing between body fat indices and blood pressure in both boys and girls ( β=0.64-3.48, P <0.05). The association coefficients of body fat indices with systolic blood pressure were ranked as %TFM>FMP>VFA in both boys and girls. The association coefficients of body fat indices with diastolic blood pressure were ranked sequentially as FMP>%TFM>VFA in boys, and VFA>FMP>%TFM in girls.@*Conclusion@#Longitudinal associations are observed between body fat indices and blood pressure in children. Primordial prevention of high pressure should pay attention on body fat distribution.

Interplay of Lymphocytes with the Intestinal Microbiota in Children with Nonalcoholic Fatty Liver Disease.

Abnormally high lymphocyte counts are seen in persons with nonalcoholic fatty liver disease (NAFLD). Gut microbiota dysbiosis is a risk factor for NAFLD. We assessed the gut microbiota of 63 healthy children and 63 children with NAFLD using 16S rRNA gene and metagenomic sequencing to explore the relationships. Compared with healthy children (HC group), the Bacteroidetes, Verrucomicrobia, and Akkermansia were less abundant, while the Actinobacteria were more abundant in children with NAFLD (FLD group). To understand the effect of lymphocytes on the gut microbiota of children with NAFLD, we compared the microbiota of 41 children with NAFLD and high numbers of lymphocytes (FLD_HL group) and 22 children with NAFLD and low numbers of lymphocytes (FLD_LL group). The abundances of Bacteroidetes, Verrucobacterium, and Akkermansia increased and Actinobacteria decreased in the FLD_LL group compared to the FLD_HL group. Akkermansia was negatively correlated with lymphocyte count. NAFLD may disturb the gut microbiota in children through reducing the abundance of Akkermansia and increasing the abundance of proinflammatory bacteria, such as Escherichia-Shigella. Conclusions: High lymphocyte counts are associated with disturbances of gut microbiota and emergence of opportunistic pathogens in children with NAFLD.

Predictors of Influenza Vaccination among Chinese Middle School Students Based on the Health Belief Model: A Mixed-Methods Study.

Influenza vaccination rates among Chinese middle school students are low. This study aims to explore the influencing factors of vaccination among middle school students and promote vaccination. We conducted a mixed-methods study, integrating a questionnaire survey among 9145 middle school students in four cities in China and semi-structured interviews with 35 middle school students to understand their attitudes and perceptions toward vaccination based on the Health Belief Model. We found the overall vaccination rate was 38.2% (3493/9145), with students in Beijing, boarding at school, or senior high school showing higher values than their counterparts (p < 0.05). Multiple logistic regression results showed that non-boarding (OR = 0.46, 95%CI: 0.42−0.51) and perceived barriers (OR = 0.97, 95%CI: 0.96−0.98) were unfavorable factors for influenza vaccination, whereas perceived susceptibility (OR = 1.07, 95%CI: 1.05−1.08), perceived benefits (OR = 1.02, 95%CI: 1.01−1.04), cues to action (OR = 1.08, 95%CI: 1.05−1.11), and self-efficacy (OR = 1.04, 95%CI: 1.02−1.07) were facilitators. Qualitative results indicated that positive health beliefs, school, and the home environment contribute to vaccination. In conclusion, the influenza vaccination rate among middle school students remains low. The concerns about the safety and potential side effects of vaccines are the main barriers to vaccination, underscoring the need for strengthening communication, education, and information among students and their teachers/parents.

Passive Smoking Exposure Modifies Cardiovascular Structure and Function: Beijing Child Growth and Health Cohort (PROC) Study.

Passive smoking exposure in children is prevalent worldwide and exposes children to respiratory and systemic toxins. In this study, we enrolled 568 children to study how secondhand smoke (SHS) might affect children's cardiovascular health in China. The measurement of nicotine and its metabolites in urine showed that 78.9% of children were exposed to SHS. Children exposed to SHS had greater interventricular septum thickness (p = 0.005) and left ventricular mass index (p = 0.008) than nonexposed children. Urinary norcotinine levels were associated with increased ascending aorta diameter (ß = 0.10, 95%CI 0.02-0.17) and decreased left ventricular end systolic diameter (ß = -0.10, 95%CI -0.19 to -0.01). The effects of SHS exposure on cardiovascular function: norcotinine levels associated with lower left ventricular mass index (ß = -0.32, 95%CI -0.59 to -0.05), left ventricular end diastolic volume index (ß = -0.43, 95%CI -0.85 to -0.02), and left ventricular end systolic volume index (ß = -0.20, 95%CI -0.37 to -0.03). Moreover, there no no significant associations of nicotine, cotinine, and trans-3'-hydroxycotinine with cardiovascular health. Overall, SHS exposure in children remains prevalent in Beijing and may affect children's cardiovascular development, in both structure and function. It suggests that stricter and practical measures are needed toward the elimination of tobacco use in children's environments.

Hearing thresholds elevation and potential association with emotional problems among 1,914 children in Beijing, China.

Objectives: School-aged children may experience hearing loss and emotional problems. Previous studies have shown a bidirectional relationship between hearing loss and emotional problems in the elderly population, and we aimed to analyze the association between hearing thresholds and emotional problems in school-aged children. Methods: Based on the Beijing Child Growth and Health Cohort (PROC) study, the hearing screenings were conducted in November 2019 using pure tone audiometry. A total of 1,877 parents completed the Strengths and Difficulties Questionnaire (SDQ) to assess children's emotional and behavioral status. We used generalized linear regression analysis to assess the potential association of emotional problems with hearing thresholds, based on multiple imputed datasets with a sample size of 1,914. Results: The overall pass rate of hearing screening was 91.5%. The abnormal rate of SDQ total difficulties was 55.8%. Emotional symptoms were positively associated with left ear average hearing thresholds (ß = 0.24, 95%CI: 0.08-0.40), and right ear average hearing thresholds (ß = 0.18, 95%CI: 0.04-0.32). Conduct problems, hyperactivity/inattention, peer problems, and prosocial behaviors had no association with the pass rate of the hearing screening. Regarding emotional symptoms, boys with many fears and who are easily scared coincided with increased right ear average hearing thresholds (ß = 0.67, 95%CI: 0.01-1.33). Girls having many worries, frequently feeling unhappy and downhearted were positively associated with left and right ear average hearing thresholds, respectively (ß = 0.96, 95%CI: 0.20-1.73; ß = 0.72, 95%CI: 0.07-1.37). Conclusions: The co-occurrence of hearing problems and emotional problems of children aged 6-8 in Beijing attracts attention. It is important to address undiscovered hearing loss and emotional problems from the perspective of comorbidity driving factors.

Good Adherence to the Mediterranean Diet Lowered Risk of Renal Glomerular Impairment in Children: A Longitudinal Study.

Healthy diet patterns have a positive effect on chronic non-communicable diseases in the pediatric population, but the evidence is limited on the association between kidney impairment and adherence to a Mediterranean diet. We aim to determine the associations between Mediterranean diet adherence and longitudinal tubular and glomerular impairment in children. Based on four waves of urine assays conducted from October 2018 to November 2019, we assayed urinary ß2-microglobulin (ß2-MG) and microalbumin (MA) excretion to determine transient renal tubular and glomerular impairment during the follow-up of the child cohort (PROC) study in Beijing, China. We assessed Mediterranean diet adherence using the 16-item Mediterranean Diet Quality Index in children and adolescents (KIDMED) among 1914 primary school children. Poor, intermediate, and good adherence rates for the Mediterranean diet were 9.0% (KIDMED index 0-3), 54.4% (KIDMED index 4-7) and 36.5% (KIDMED index 8-12), respectively. A short sleep duration was more prevalent in children with lower Mediterranean diet adherence, with no significant differences presenting in the other demographic and lifestyle covariates. The results of linear mixed-effects models showed that a higher urinary MA excretion was inversely associated with a higher KIDMED score (ß = -0.216, 95%CI: -0.358, -0.074, p = 0.003), after adjusting for sex, age, BMI z-score, SBP z-score, screen time, sleep duration and physical activity. Furthermore, in generalized linear mixed-effects models, consistent results found that transient renal glomerular impairment was less likely to develop in children with intermediate Mediterranean diet adherence (aOR = 0.68, 95%CI: 0.47, 0.99, p = 0.044) and in children with good Mediterranean diet adherence (aOR = 0.60, 95%CI: 0.40, 0.90, p = 0.014), taking poor Mediterranean diet adherence as a reference. We visualized the longitudinal associations between each item of the KIDMED test and kidney impairment via a forest plot and identified the main protective eating behaviors. Children who adhere well to the Mediterranean diet have a lower risk of transient glomerular impairment, underscoring the necessity of the early childhood development of healthy eating patterns to protect kidney health.

Interaction of Hydration Status and Physical Activity Level on Early Renal Damage in Children: A Longitudinal Study.

Background: Optimal water intake positively affects various aspects of human physiology, especially renal function. Physical activity (PA) may have an impact on hydration status and renal health, but the interaction of hydration status and PA level on renal function is not well-studied in children. Methods: We conducted four waves of urine assays in our child cohort (PROC) study from October 2018 to November 2019 in Beijing, China. We measured urinary specific gravity, ß2-microglobulin (ß2-MG), and microalbumin (MA) excretion to assess hydration status and renal damage in the context of PA level and other covariates among 1,914 primary school children. We determined the associations of renal damage with the interaction of hydration status and PA level using generalized linear mixed-effects models. Results: The prevalence of dehydration was 35.0%, 62.1%, 63.9%, and 63.3%, and the prevalence of insufficient PA was 86.2%, 44.9%, 90.4%, and 90.2% from wave 1 to wave 4 among 1,914 primary school children. From wave 1 to wave 4, the prevalence of renal tubular damage had a significant increasing trend of 8.8%, 15.9%, 25.7%, and 29.0% (Z = 16.9, P < 0.001), while the prevalence of glomerular damage revealed a declining trend of 5.6%, 5.5%, 4.4%, and 4.1% (Z = -2.4, P = 0.016). There were stable longitudinal associations of renal tubular and glomerular damage with hydration status (euhydration: OR = 0.50 and 0.33, respectively) but not with PA level. In multivariate analysis, significant interactions of hydration status and PA level were noted with renal tubular damage (ß = 0.43, P = 0.014) and glomerular damage (ß = 0.60, P = 0.047). Children with euhydration and insufficient PA were less likely to have renal tubular damage (OR = 0.46, 95% CI: 0.39, 0.53) or glomerular damage (OR = 0.28, 95% CI: 0.20, 0.39); children with euhydration and sufficient PA were also less likely to have renal tubular damage (OR = 0.57, 95% CI: 0.44, 0.75) or glomerular damage (OR = 0.47, 95% CI: 0.30, 0.74), adjusting for age, sex, BMI z-score, standardized SBP, sleep duration, computer/cell phone screen time, and fruit and vegetable intake. Conclusion: Children with euhydration and either sufficient or insufficient PA were less likely to have early renal damage. Adequate daily water intake for children is important, especially after PA.

Timing of Breastfeeding Initiation Mediates the Association between Delivery Mode, Source of Breastfeeding Education, and Postpartum Depression Symptoms.

Background: Emergency cesarean section (EMCS) and breastfeeding difficulties increase the risk of postpartum depressive (PPD) symptoms. Early initiation of breastfeeding (EIBF) may not only alleviate PPD symptoms but also facilitate subsequent breastfeeding success. EMCS is a risk factor for not practicing EIBF. Therefore, it is important to understand the relationship between EMCS, EIBF, and PPD symptoms. Methods: We conducted a prospective cohort study in three areas of China. At baseline, a total of 965 mothers completed electronic questionnaires within 72 h postpartum. Women were screened for PPD symptoms using the Edinburgh Postpartum Depression Scale (EPDS). Multivariate logistic regression was used to identify the determinants of PPD symptoms. Mediation analysis was used to determine if EIBF mediated the relationship between delivery mode or breastfeeding education source and PPD symptoms. Results: The prevalence of EIBF was 40.6%; 14% of 965 mothers experienced EMCS, and 20.4% had PPD symptoms. The risk factors for developing PPD symptoms were excessive gestational weight gain (adjusted odds ratio [aOR] = 1.55, confidence interval [95% CI]: 1.03−2.33, p = 0.037) and EMCS (aOR = 2.05, 95% CI: 1.30−3.25, p = 0.002). The protective factors for developing PPD symptoms were monthly household income over CNY 10000 (aOR = 0.68, 95% CI: 0.47−0.97, p = 0.034), EIBF (aOR = 0.49, 95% CI: 0.34−0.72, p < 0.001), and prenatal breastfeeding education from nurses (aOR = 0.46, 95% CI: 0.29−0.73, p = 0.001). EIBF indirectly affected PPD symptoms in patients who had undergone EMCS (percentage mediated [PM] = 16.69, 95% CI: 7.85−25.25, p < 0.001). The source of breastfeeding education through EIBF also affected PPD symptoms (PM = 17.29, 95% CI: 3.80−30.78, p = 0.012). Conclusion: The association between EMCS on PPD symptoms was mediated by EIBF. By providing breastfeeding education, nurses could also help alleviate PPD symptoms.

Insufficient Fruit and Vegetable Intake and Low Potassium Intake Aggravate Early Renal Damage in Children: A Longitudinal Study.

Insufficient fruit and vegetable intake (FVI) and low potassium intake are associated with many non-communicable diseases, but the association with early renal damage in children is uncertain. We aimed to identify the associations of early renal damage with insufficient FVI and daily potassium intake in a general pediatric population. We conducted four waves of urine assays based on our child cohort (PROC) study from October 2018 to November 2019 in Beijing, China. We investigated FVI and other lifestyle status via questionnaire surveys and measured urinary potassium, ß2-microglobulin (ß2-MG), and microalbumin (MA) excretion to assess daily potassium intake and renal damage among 1914 primary school children. The prevalence of insufficient FVI (<4/d) was 48.6% (95% CI: 46.4%, 50.9%) and the estimated potassium intake at baseline was 1.63 ± 0.48 g/d. Short sleep duration, long screen time, lower estimated potassium intake, higher ß2-MG and MA excretion were significantly more frequent in the insufficient FVI group. We generated linear mixed effects models and observed the bivariate associations of urinary ß2-MG and MA excretion with insufficient FVI (ß = 0.012, 95% CI: 0.005, 0.020; ß = 0.717, 95% CI: 0.075, 1.359), and estimated potassium intake (ß = −0.042, 95% CI: −0.052, −0.033; ß = −1.778, 95% CI: −2.600, −0.956), respectively; after adjusting for age, sex, BMI, SBP, sleep duration, screen time and physical activity. In multivariate models, we observed that urinary ß2-MG excretion increased with insufficient FVI (ß = 0.011, 95% CI: 0.004, 0.018) and insufficient potassium intake (<1.5 g/d) (ß = 0.031, 95% CI: 0.023, 0.038); and urinary MA excretion increased with insufficient FVI (ß = 0.658, 95% CI: 0.017, 1.299) and insufficient potassium intake (ß = 1.185, 95% CI: 0.492, 1.878). We visualized different quartiles of potassium intake showing different renal damage with insufficient FVI for interpretation and validation of the findings. Insufficient FVI and low potassium intake aggravate early renal damage in children and underscores that healthy lifestyles, especially adequate FVI, should be advocated.

COVID-19 Vaccine Hesitancy among Adolescents: Cross-Sectional School Survey in Four Chinese Cities Prior to Vaccine Availability.

To address the novel coronavirus disease (COVID-19) pandemic, development and regulatory evaluations have been accelerated for vaccines, authorizing emergency use. To anticipate vaccine preparedness in adolescents, we studied COVID-19 vaccination awareness and willingness to vaccinate before the vaccine became available. We conducted a cross-sectional survey among 9153 (4575 boys, 50%) students with a mean age of 14.2 years old in four cities in China to collect information on demographic characteristics and their COVID-19 vaccination concerns. Multinomial logistic regression was used to analyze the influencing factors of vaccine hesitancy ("not sure") and resistance ("do not want it"). The results showed that 2891 (31.6%) were hesitant and 765 (8.4%) were resistant to being vaccinated. Additionally, multivariable analyses showed that vaccine hesitancy and vaccine resistance were associated with living in the Beijing area (OR = 1.62; 95% CI: 1.40-1.88; OR = 1.81; 95% CI: 1.44-2.28), lack of influenza vaccination experience (OR = 1.33; 95% CI: 1.14-1.55; OR = 1.57; 95% CI: 1.25-1.98), no perceived susceptibility (OR = 1.72; 95% CI: 1.50-1.97; OR = 3.57; 95% CI: 2.86-4.46), and perceiving no cues to action (OR = 3.24; 95% CI: 2.56-4.11; OR = 27.68; 95% CI: 21.81-35.13). Postulating a highly effective vaccine (OR = 0.84; 95% CI: 0.72-0.98; OR = 0.66; 95% CI: 0.52-0.83) decreased both vaccine hesitancy and resistance. Vaccine hesitancy alone was associated with girls (OR = 1.21; 95% CI: 1.09-1.36) and was less common among students boarding at school (OR = 0.79; 95% CI: 0.68-0.92), postulating convenient vaccine access (OR = 0.84; 95% CI: 0.73-0.96), and having doctors' recommendation (OR = 0.86; 95% CI: 0.76-0.98). In conclusion, the results of the study showed that vaccine hesitancy among students in China was associated with limited health literacy and lower risk awareness. Our findings in China suggest that educating youth regarding COVID-19 and the safety and effectiveness of immunization help reduce concerns and increase vaccine confidence and acceptance.

Dehydration Status Aggravates Early Renal Impairment in Children: A Longitudinal Study.

Dehydration is common in children for physiological and behavioral reasons. The objective of this study was to assess changes in hydration status and renal impairment across school weekdays. We conducted a longitudinal study of three repeated measures of urinalysis within one week in November 2019 in a child cohort in Beijing, China. We measured urine specific gravity (USG) to determine the dehydration status, and the concentration of ß2-microglobulin (ß2-MG) and microalbumin (MA) to assess renal function impairment among 1885 children with a mean age of 7.7 years old. The prevalence of dehydration was 61.9%, which was significantly higher in boys (64.3%). Using chi-square tests and linear mixed-effects regression models, we documented the trends of the renal indicators' change over time among different hydration statuses. Compared to Mondays, there were apparent increases of ß2-MG concentrations on Wednesdays (ß = 0.029, p < 0.001) and Fridays (ß = 0.035, p < 0.001) in the dehydrated group, but not in the euhydrated group. As for the MA concentrations, only the decrease on Fridays (ß = -1.822, p = 0.01) was significant in the euhydrated group. An increased trend of elevated ß2-MG concentration was shown in both the euhydrated group (Z = -3.33, p < 0.001) and the dehydrated group (Z = -8.82, p < 0.001). By contrast, there was a decreased trend of elevated MA concentrations in the euhydrated group (Z = 3.59, p < 0.001) but not in the dehydrated group. A new indicator ratio, ß2-MG/MA, validated the consistent trends of renal function impairment in children with dehydration. Renal impairment trends worsened as a function of school days during the week and the dehydration status aggravated renal impairment during childhood across school weekdays, especially tubular abnormalities in children.

Predictors of non-alcoholic fatty liver disease in children.

OBJECTIVE: Abdominal obesity is strongly associated with the development of non-alcoholic fatty liver disease (NAFLD). Early identification and intervention may reduce the risk. We aim to improve pediatric NAFLD screening by comparing discriminative performance of six abdominal obesity indicators. METHODS: We measured anthropometric indicators (waist circumference [WC], waist-to-hip ratio [WHR], waist-to-height ratio [WHtR]), body composition indicators (trunk fat index [TFI], visceral fat area [VFA]), and endocrine indicator (visceral adiposity index [VAI]) among 1350 Chinese children aged 6-8 years. Using Spearman correlation, receiver operating characteristic (ROC) curves, and Logistic regression, we validated their ability to predict NAFLD. RESULTS: All six indicators can predict NAFLD robustly, with area under the curve (AUC) values ranged from 0.69 to 0.96. TFI, WC, and VFA rank in the top three for the discriminative performance. TFI was the best predictor with AUC values of 0.94 (0.92-0.97) and 0.96 (0.92-0.99), corresponding to cut-off values of 1.83 and 2.31 kg/m2 for boys and girls, respectively. Boys with higher TFI (aOR = 13.8), VFA (aOR = 11.1), WHtR (aOR = 3.1), or VAI (aOR = 2.8), and girls with higher TFI (aOR = 21.0) or VFA (aOR = 17.5), were more likely to have NAFLD. CONCLUSION: User-friendly body composition indicators like TFI can identify NAFLD and help prevent the progress of liver disease. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR) ( www.chictr.org.cn/enIndex.aspx , No. ChiCTR2100044027); retrospectively registered on 6 March 2021. IMPACT: Abdominal obesity increases the risk of pediatric non-alcoholic fatty liver disease (NAFLD). This study compared the discriminative performance of multiple abdominal obesity indicators measured by different methods in terms of accuracy and fastidious cut-off values through a population-based child cohort. Our results provided solid evidence of abdominal obesity indicators as an optimal screening tool for pediatric NAFLD, with area under the curve (AUC) values ranged from 0.69 to 0.96. User-friendly body composition indicators like TFI show a greater application potential in helping physicians perform easy, reliable, and interpretable weight management to prevent the progress of liver damage.

Influence of school climate on influenza vaccination among middle school students in four cities in China / 中国学校卫生

Objective@#This study aims to explore the influencing factors of influenza vaccination in middle school students, and to provide a theoretical basis for improving the influenza vaccination rate and inform interventions.@*Methods@#By using mixed research method, a combination of qualitative research and quantitative research, a survey was conducted among 9 145 middle school students selected from Beijing, Anhui, Shaanxi, Guangdong via the online survey using Wenjuanxing software. Multivariate Logistic regression models were used to analyze the influencing factors of influenza vaccination. After a purposeful sampling, 35 middle school students were invited for semi structured interviews and NVivo plus software were used for data analysis.@*Results@#The self reported influenza vaccination rate of the middle school students was 38.2%. No experience of discussing an influenza vaccine with others ( OR=1.37, 95%CI =1.17-1.60) and devaluing the discussion about vaccination ( OR=1.30, 95%CI =1.08-1.57) was negatively associated with vaccination( P <0.05); The head teacher suggestion(OR=0.39, 95%CI =0.32-0.48), peers vaccination( OR= 0.29, 95%CI =0.25-0.33), and awareness of what the vaccine was and being able to explain it clearly( OR=0.68, 95%CI =0.61-0.75), discussing with others( OR=0.76, 95%CI =0.67-0.86), feeling the discussion is valuable( OR=0.66, 95%CI = 0.59- 0.73), being able to positively influence others( OR=0.61, 95%CI =0.55-0.68), being positively influenced by others ( OR= 0.62, 95%CI =0.54-0.71) were more likely to take vaccination via separated models( P <0.05). The interview results showed that the teacher s cognition and attitude towards the influenza vaccine could directly or indirectly affect the students vaccination decision, and the positive school opinion atmosphere may improve students vaccination rate.@*Conclusion@#It is suggested that the schools should increase students vaccination rate through head teachers guidance and organizing students to participate in discussion on influenza topics.

Association between maternal parenting stress and sleep problems among first grade primary students / 中国学校卫生

Objective@#To investigate the sleeping status of the first grade primary students aged 6-8 in Beijing, to investigate the association between maternal parenting stress and children s sleep, and to inform intervention of addressing sleep problems among children in Beijing.@*Methods@#Online survey was conducted based on the child cohort study designed to study puberty, obesity, and cardiovascular risk (PROC). The Children s Sleep Habits Questionnaire (CSHQ) and Parenting Stress Index Short Form (PSI-SF) were completed by parents, and 1 136 school aged children and their mothers were included as study participants. Logistic regression models were used to determine the association between maternal parenting stress and children s sleep.@*Results@#The prevalence of sleep problems among first grade primary students was 78.52%. Among the children who received PSI-SF, the score of children with sleeping problems(86.66±17.31) was higher than that of the children with no sleeping problems(78.59±17.75)( t =6.42, P <0.01). After adjusting sociodemographic characteristics, multivariable logistic regression results showed children of mothers with parenting stress were more likely to have sleep problems ( OR =2.52, 95% CI =1.55-4.11, P <0.01). Taking 3 dimensions in PSI-SF as independent variables, the analysis indicated that compared with the children having mothers free from parental stress and difficult children, the children with mothers with parental stress were more likely to suffer from the sleeping problems( OR = 1.66 ,1.76, P <0.05).@*Conclusion@#Sleep problems are prevalent among first grade primary students, and it underscores providing psychological support to alleviate maternal parenting stress to address children s sleep problems.