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Eslami O, Cuskelly GJ, O'Connor Á. Adherence to vitamin D supplementation guidelines in children under five years of age: a systematic literature review. Eur J Nutr 2024; 63:79-92. [PMID: 37792100 DOI: 10.1007/s00394-023-03255-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 09/11/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Despite the presence of guidelines on vitamin D supplementation in infants and young children, little is known about parental adherence to their recommendations. This review aims to summarise the evidence from observational studies investigating adherence to vitamin D supplementation guidelines in children under five years of age. METHODS Databases of PubMed, Scopus, Web of Science, and CINAHL were searched from January 2000 until July 2022. Qualitative data synthesis was used to summarise evidence on supplementation adherence. The adherence rate was categorised as low, moderate, and high if it was ≤ 50%, between 50 and 70%, and ≥ 70%, respectively. RESULTS Eleven studies investigating adherence to eight different vitamin D supplementation guidelines from European countries, USA and Canada were included. The majority of studies were cross-sectional and conducted among infants. Overall, the adherence rate ranged between 14.29% and 95.6%. Low, moderate, and high adherence to supplementation guidelines were reported in six, three, and two studies, respectively. CONCLUSION There is generally poor adherence to vitamin D supplementation guidelines in children under five years of age. Nevertheless, the evidence comes from a limited number of studies, mainly conducted in infants, with high methodological heterogeneity in terms of the vitamin D supplementation guideline assessed and the definition of supplementation adherence in the study population. Further research is warranted to identify effective health promotion interventions to increase supplementation adherence and reduce the risk of vitamin D deficiency at this critical life stage.
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Affiliation(s)
- Omid Eslami
- SHE Research Group, Department of Sport and Health Sciences, Technological University of the Shannon, Athlone, Ireland
| | - Geraldine J Cuskelly
- SHE Research Group, Department of Sport and Health Sciences, Technological University of the Shannon, Athlone, Ireland
| | - Áine O'Connor
- SHE Research Group, Department of Sport and Health Sciences, Technological University of the Shannon, Athlone, Ireland.
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How Much Does Serum 25(OH)D Improve by Vitamin D Supplement and Fortified Food in Children? A Systematic Review and Meta-Analysis. J Pediatr Gastroenterol Nutr 2022; 74:e87-e97. [PMID: 34520402 DOI: 10.1097/mpg.0000000000003300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES This study was conducted to respond certain important questions regarding the efficacy of vitamin D fortification and supplementation in children using a meta-analytical approach. METHODS MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar were searched, and 2341 studies were found in a preliminary search. After screening of titles and abstracts, 31 studies were selected. RESULTS Significant raises in circulating 25-hydroxy vitamin D (25(OH)D) concentrations were observed in both groups that took vitamin D supplement (mean difference [MD] 28.7, 95% confidence interval [CI] 22.5-34.9) and vitamin D-fortified foods (MD 20.29, 95% CI 13.3-27.2). The meta-regression revealed a significant association between age of participants (B -1.4, 95% CI -2.8, -0.02, P = 0.047) and dose of vitamin D (B 0.007, 95% CI 0.003, 0.01, P < 0.001), with the effect on serum 25(OH)D concentrations. The analysis showed that serum 25(OH)D concentration increases by 0.7 nmol/L for every 100 IU of vitamin D intake after adjustment for age, baseline serum 25(OH)D and latitude which is far less than the reported amount in adults. CONCLUSIONS Altogether, these findings indicate that in a mass vitamin D fortification program, circulating 25(OH)D concentration response in children may be lower in children than in adults and vitamin D supplementation may still be needed in this subpopulation.
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Improving Vitamin D Intake in Young Children-Can an Infographic Help Parents and Carers Understand the Recommendations? Nutrients 2021; 13:nu13093140. [PMID: 34579017 PMCID: PMC8469200 DOI: 10.3390/nu13093140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/02/2021] [Accepted: 09/07/2021] [Indexed: 12/30/2022] Open
Abstract
Vitamin D deficiency is a serious public health issue in the United Kingdom. Those at increased risk, such as pregnant women, children under 5 years and people from ethnic groups with dark skin, are not all achieving their recommended vitamin D. Effective vitamin D education is warranted. A qualitative study was undertaken to evaluate the acceptability and understanding of a vitamin D infographic, developed using recommendations from previous research. Fifteen parents/carers, recruited through local playgroups and adverts on popular parent websites, participated in focus groups and telephone interviews. The majority were female, White British and educated to degree level. A thematic analysis methodology was applied. The findings indicated that understanding and acceptability of the infographic were satisfactory, but improvements were recommended to aid interpretation and create more accessible information. These included additional content (what vitamin D is; other sources; its health benefits; methods/doses for administration and scientific symbols used) and improved presentation (eye-catching, less text, simpler language, more images and a logo). Once finalized, the infographic could be a useful tool to educate families around vitamin D supplementation guidelines, support the UK Healthy Start vitamins scheme and help improve vitamin D status for pregnant and lactating women and young children.
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Day RE, Krishnarao R, Sahota P, Christian MS. We still don't know that our children need vitamin D daily: a study of parents' understanding of vitamin D requirements in children aged 0-2 years. BMC Public Health 2019; 19:1119. [PMID: 31416429 PMCID: PMC6694627 DOI: 10.1186/s12889-019-7340-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/19/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Vitamin D deficiency has been highlighted as a serious public health problem in the United Kingdom. One in four toddlers are not achieving the recommended intake for their healthy development. This study uses quantitative and qualitative methods to explore parents' perceptions, awareness and behaviours around vitamin D intake, and the acceptability of and factors affecting purchasing of food and drink fortified with Vitamin D in children aged 0-2 years old. METHODS One hundred and ninety-four parents completed an online questionnaire, advertised to parents with one child aged up to 2 years on popular social media websites. The majority of participants were mothers, White-British ethnic background, aged 25-44 years. Participants provided an email address if they wanted to be contacted about the focus groups. Recruitment posters advertising the focus groups were placed in community centres. Eighteen participated in 5 focus groups (13 parents), and 5 individual interviews. A thematic analysis methodology was applied. RESULTS Fifty-seven percent (n = 110) of parents reported receiving information about vitamin D during pregnancy and 52% (n = 100) after the birth of their child. Parents reported a low level of satisfaction with vitamin D information: many thought it was limited and recommendations on supplements were unclear. Parents wanted more information about vitamin D requirements for their child (80%, n = 153 out of 192 respondents, 2 non-response), about vitamin D and breastfeeding (56%, n = 108) and vitamin D and pregnancy (49%, n = 94). The recommendations were for simpler, easier to read, with specific and clearer guidelines; delivered regularly during routine appointments, at timely stages throughout pregnancy and after the birth. 23% (n = 45, out of 194 respondents) of parents did not know why vitamin D is important for health. Only 26% (n = 49, out of 192 respondents) of parents reported giving their youngest child a vitamin D supplement on most days of the week. The majority of parents (interview/focus group) wanted more information about foods/drinks fortified with vitamin D. CONCLUSION Parents were generally not aware of the importance of vitamin D, dietary requirements including supplementation and the availability of vitamin D fortified foods. Major improvements are required for the effective promotion of vitamin D information to parents.
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Affiliation(s)
- Rhiannon Eleanor Day
- School of Clinical and Applied Sciences, Leeds Beckett University, CL615A, City Campus, Leeds, LS1 3HE, UK
| | - Roxane Krishnarao
- School of Clinical and Applied Sciences, Leeds Beckett University, CL615A, City Campus, Leeds, LS1 3HE, UK
| | - Pinki Sahota
- School of Clinical and Applied Sciences, Leeds Beckett University, CL615A, City Campus, Leeds, LS1 3HE, UK
| | - Meaghan Sarah Christian
- School of Clinical and Applied Sciences, Leeds Beckett University, CL615A, City Campus, Leeds, LS1 3HE, UK.
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Uday S, Högler W. Prevention of rickets and osteomalacia in the UK: political action overdue. Arch Dis Child 2018; 103:901-906. [PMID: 29661756 DOI: 10.1136/archdischild-2018-314826] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 12/26/2022]
Abstract
The consequences of vitamin D and dietary calcium deficiency have become a huge public health concern in the UK. The burden of disease from these deficiencies includes rickets, and hypocalcaemic seizures, dilated cardiomyopathy and mostly occult myopathy and osteomalacia. The increasing burden of the disease is intrinsically linked to ethnicity and the population demographic changes in the UK. Three facts have led to the resurfacing of the English disease: (1) the UK has no ultraviolet sunlight for at least 6 months of the year, (2) dark skin produces far less vitamin D than white skin per unit ultraviolet light exposure, and (3) non-European Union immigration over the last century. To date, the UK government demonstrates incomplete understanding of these three facts, and its failure to adjust its prevention programmes to changing demographics is endangering the health and life of UK residents with dark skin, of whom infants are the most vulnerable. Establishing accountability through the implementation of monitored antenatal and infantile supplementation programmes and mandatory food fortification is overdue.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Uday S, Fratzl-Zelman N, Roschger P, Klaushofer K, Chikermane A, Saraff V, Tulchinsky T, Thacher TD, Marton T, Högler W. Cardiac, bone and growth plate manifestations in hypocalcemic infants: revealing the hidden body of the vitamin D deficiency iceberg. BMC Pediatr 2018; 18:183. [PMID: 29940979 PMCID: PMC6019205 DOI: 10.1186/s12887-018-1159-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/25/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whilst hypocalcemic complications from vitamin D deficiency are considered rare in high-income countries, they are highly prevalent among Black, Asian and Minority Ethnic (BAME) group with darker skin. To date, the extent of osteomalacia in such infants and their family members is unknown. Our aim was to investigate clinical, cardiac and bone histomorphometric characteristics, bone matrix mineralization in affected infants and to test family members for biochemical evidence of osteomalacia. CASE PRESENTATION Three infants of BAME origin (aged 5-6 months) presented acutely in early-spring with cardiac arrest, respiratory arrest following seizure or severe respiratory distress, with profound hypocalcemia (serum calcium 1.22-1.96 mmol/L). All infants had dark skin and vitamin D supplementation had not been addressed during child surveillance visits. All three had severely dilated left ventricles (z-scores + 4.6 to + 6.5) with reduced ejection fraction (25-30%; normal 55-70), fractional shortening (7 to 15%; normal 29-40) and global hypokinesia, confirming hypocalcemic dilated cardiomyopathy. They all had low serum levels of 25 hydroxyvitamin D (25OHD < 15 nmol/L), and elevated parathyroid hormone (PTH; 219-482 ng/L) and alkaline phosphatase (ALP; 802-1123 IU/L), with undiagnosed rickets on radiographs. One infant died from cardiac arrest. At post-mortem examination, his growth plate showed a widened, irregular zone of hypertrophic chondrocytes. Histomorphometry and backscattered electron microscopy of a trans-iliac bone biopsy sample revealed increased osteoid thickness (+ 262% of normal) and osteoid volume/bone volume (+ 1573%), and extremely low bone mineralization density. Five of the nine tested family members had vitamin D deficiency (25OHD < 30 nmol/L), three had insufficiency (< 50 nmol/L) and 6/9 members had elevated PTH and ALP levels. CONCLUSIONS The severe, hidden, cardiac and bone pathology described here exposes a failure of public health prevention programs, as complications from vitamin D deficiency are entirely preventable by routine supplementation. The family investigations demonstrate widespread deficiency and undiagnosed osteomalacia in ethnic risk groups and call for protective legislation.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology & Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Nadja Fratzl-Zelman
- 1st Medical Department Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of WGKK and AUVA Trauma Centre, Meidling, Vienna, Austria
| | - Paul Roschger
- 1st Medical Department Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of WGKK and AUVA Trauma Centre, Meidling, Vienna, Austria
| | - Klaus Klaushofer
- 1st Medical Department Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of WGKK and AUVA Trauma Centre, Meidling, Vienna, Austria
| | - Ashish Chikermane
- Department of Cardiology, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vrinda Saraff
- Department of Endocrinology & Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Ted Tulchinsky
- Emeritus, Braun School of Public Health and Community Medicine, Hadassah Medical Center, Hebrew University-Hadassah, Ein Karem, Jerusalem, Israel
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tamas Marton
- Department of Cellular Pathology, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Wolfgang Högler
- Department of Endocrinology & Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK. .,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Uday S, Kongjonaj A, Aguiar M, Tulchinsky T, Högler W. Variations in infant and childhood vitamin D supplementation programmes across Europe and factors influencing adherence. Endocr Connect 2017; 6:667-675. [PMID: 28924002 PMCID: PMC5655685 DOI: 10.1530/ec-17-0193] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 09/18/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Nutritional rickets is a growing global public health concern despite existing prevention programmes and health policies. We aimed to compare infant and childhood vitamin D supplementation policies, implementation strategies and practices across Europe and explore factors influencing adherence. METHODS European Society for Paediatric Endocrinology Bone and Growth Plate Working Group members and other specialists completed a questionnaire on country-specific vitamin D supplementation policy and child health care programmes, socioeconomic factors, policy implementation strategies and adherence. Factors influencing adherence were assessed using Kendall's tau-b correlation coefficient. RESULTS Responses were received from 29 of 30 European countries (97%). Ninety-six per cent had national policies for infant vitamin D supplementation. Supplements are commenced on day 1-5 in 48% (14/29) of countries, day 6-21 in 48% (14/29); only the UK (1/29) starts supplements at 6 months. Duration of supplementation varied widely (6 months to lifelong in at-risk populations). Good (≥80% of infants), moderate (50-79%) and low adherence (<50%) to supplements was reported by 59% (17/29), 31% (9/29) and 10% (3/29) of countries, respectively. UK reported lowest adherence (5-20%). Factors significantly associated with good adherence were universal supplementation independent of feeding mode (P = 0.007), providing information at neonatal unit (NNU) discharge (P = 0.02), financial family support (P = 0.005); monitoring adherence at surveillance visits (P = 0.001) and the total number of factors adopted (P < 0.001). CONCLUSIONS Good adherence to supplementation is a multi-task operation that works best when parents are informed at birth, all babies are supplemented, and adherence monitoring is incorporated into child health surveillance visits. Implementation strategies matter for delivering efficient prevention policies.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and DiabetesBirmingham Children's Hospital, Birmingham, UK
| | - Ardita Kongjonaj
- MEAL Specialist at Save the Children InternationalAlbania Country Office, Tirana, Albania
| | - Magda Aguiar
- Health Economics UnitUniversity of Birmingham, Birmingham, UK
| | - Ted Tulchinsky
- Braun School of Public Health and Community Medicineand Ashkelon College, Ashkelon, Israel
| | - Wolfgang Högler
- Department of Endocrinology and DiabetesBirmingham Children's Hospital, Birmingham, UK
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
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Uday S, Högler W. Nutritional Rickets and Osteomalacia in the Twenty-first Century: Revised Concepts, Public Health, and Prevention Strategies. Curr Osteoporos Rep 2017; 15:293-302. [PMID: 28612338 PMCID: PMC5532418 DOI: 10.1007/s11914-017-0383-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Nutritional rickets and osteomalacia are common in dark-skinned and migrant populations. Their global incidence is rising due to changing population demographics, failing prevention policies and missing implementation strategies. The calcium deprivation spectrum has hypocalcaemic (seizures, tetany and dilated cardiomyopathy) and late hypophosphataemic (rickets, osteomalacia and muscle weakness) complications. This article reviews sustainable prevention strategies and identifies areas for future research. RECENT FINDINGS The global rickets consensus recognises the equal contribution of vitamin D and dietary calcium in the causation of calcium deprivation and provides a three stage categorisation for sufficiency, insufficiency and deficiency. For rickets prevention, 400 IU daily is recommended for all infants from birth and 600 IU in pregnancy, alongside monitoring in antenatal and child health surveillance programmes. High-risk populations require lifelong supplementation and food fortification with vitamin D or calcium. Future research should identify the true prevalence of rickets and osteomalacia, their role in bone fragility and infant mortality, and best screening and public health prevention tools.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Geng SS, Ma JQ, Liu SS, Zhang J, Sheng XY. Vitamin D Insufficiency and Its Association with Biochemical and Anthropometric Variables of Young Children in Rural Southwestern China. Chin Med J (Engl) 2017; 129:1273-9. [PMID: 27231162 PMCID: PMC4894035 DOI: 10.4103/0366-6999.182834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND With recognition of the important roles of Vitamin D (VitD) in various physiological processes, increasing attention has been drawn to the status of VitD in early life. However, the VitD status of young children and the related factors in rural areas of Southwestern China remain unclear. This study aimed to explore VitD status and its seasonal variation in 18-month-old children living in rural Southwestern China. The association of VitD with biochemical and anthropometric variables was also investigated. METHODS A total of 177 18-month-old children in a rural area of Yunnan Province, Southwestern China, were enrolled. Serum concentrations of 25-hydroxy Vitamin D (25(OH)D) were measured through high-performance liquid chromatogram-tandem mass spectrometry. Parathyroid hormone (PTH) levels were measured with a chemiluminescence assay. Serum concentrations of calcium, phosphorus, and alkaline phosphatase (ALP) were also measured. Anthropometric data and the outdoor activity time of each participant were collected. RESULTS The serum 25(OH)D concentration was 26.61 ± 7.26 ng/ml; concentrations lower than 30 ng/ml accounted for 70.6% of the participants and concentrations lower than 20 ng/ml accounted for 16.4%. The level of serum 25(OH)D was not significantly different among four seasons (P >0.05). A positive relationship was found between 25(OH)D concentration and the time of outdoor activities (r = 0.168, P < 0.05). Serum PTH concentration was negatively correlated with 25(OH)D concentration (r = -0.163, P < 0.05). A positive relationship was found between the serum concentrations of 25(OH)D and calcium (r = 0.154, P < 0.05). No significant association was observed between 25(OH)D and ALP, phosphorus, or anthropometric variables. CONCLUSIONS The prevalence of VitD insufficiency is high among young children in the rural Southwestern China regardless of the seasons. VitD supplementation is still essential to maintain VitD sufficiency for children living in rural area.
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Affiliation(s)
- Shan-Shan Geng
- Department of Children and Adolescents Health Care, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092; MOE-Shanghai Key Laboratory of Children's Environmental Health, Shanghai Institute for Pediatric Research, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Jing-Qiu Ma
- Department of Children and Adolescents Health Care, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092; MOE-Shanghai Key Laboratory of Children's Environmental Health, Shanghai Institute for Pediatric Research, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Shan-Shan Liu
- Department of Children and Adolescents Health Care, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092; MOE-Shanghai Key Laboratory of Children's Environmental Health, Shanghai Institute for Pediatric Research, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Jie Zhang
- Department of Anesthesia, The Children's Hospital, School of Medicine, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, China
| | - Xiao-Yang Sheng
- Department of Children and Adolescents Health Care, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092; MOE-Shanghai Key Laboratory of Children's Environmental Health, Shanghai Institute for Pediatric Research, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
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