Sleep Duration and Factors Related to Sleep Loss in 3-14-Year-Old Children in Beijing: A Cross-Sectional Survey

Sleep disturbance associations between parents and children with overweight and obesity

This cross-sectional study examined sleep disturbance associations between parents and their school-age children with overweight and obesity. A 7-day wrist-worn actigraph recording was performed on 246 children aged 6-9 years with overweight and obesity recruited from 10 public elementary schools in Taipei, Taiwan. Children's sleep disturbance was assessed using the Children's Sleep Habits Questionnaire. Parental subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index, with parental depressive symptoms measured using the Epidemiologic Studies-Depression Scale. General linear models were used to examine sleep disturbance associations within parent-child dyads. The results showed that 208 (84.6%) children had a clinically significant sleep disturbance score, and 123 (50%) parents had poor sleep quality. Higher children's sleep disturbance scores significantly predicted poorer parental sleep quality (b = 0.11, p < 0.001). Poorer parental sleep quality was associated with more severe sleep disturbances in children (b = 0.46, p < 0.001). This association was independent of children's actigraphic sleep (all p > 0.05) and was not attenuated by adjustment for parental depressive symptoms (b = 0.14, p < 0.001). Findings from our study suggest that sleep disturbances occur in both parents and their school-age children with overweight and obesity, with a significant bidirectional association between the two. Nurses and healthcare professionals should proactively assess and screen for sleep disturbances in parent-child dyads of children with overweight and obesity. Future studies should develop family-based sleep interventions and evaluate their effects on the sleep, health, and well-being of children with overweight and obesity and their parents.

Exposure to Smartphones and Tablets, Physical Activity and Sleep in Children From 5 to 10 Years Old: A Systematic Review and Meta-Analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to verify the association between smartphone/tablet exposure and physical activity and sleep in children from 5 to 10 years old. Data Source: This study followed the guidelines of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and included studies that met eligibility criteria based on the "PECO" strategy: participants (children from 5 to 10 years old), exposure (smartphone and tablet use), and outcome (physical activity and sleep).

STUDY INCLUSION AND EXCLUSION CRITERIA

The inclusion criteria were observational studies published in indexed scientific journals and written in Portuguese, English, and Spanish that verified the association of exposure to smartphones/tablets with physical activity and sleep in children aged 5 to 10 years of both sexes. Studies were considered eligible only if they met the previous criteria. Data Extraction: The search was conducted in January 2023 on databases from electronic journals without the restriction of the period. To meta-analyze were extracted and grouped using models of fixed and random effects, the coefficients Odds Ratio (OR), Beta (β), Standard Error (SE), and Confidence Intervals of 95% (95%CI). Data Synthesis: 2396 potentially relevant papers were identified, and 17 met the inclusion criteria.

RESULTS

It can be verified that there was an inverse association between smartphones with physical activity and sleep. Studies indicate that for every additional hour of smartphone and tablet use, sleep can be expected to decrease by an average of 11 minutes (β = - 0.11; 95%CI = -0.13; -0.09). Children using smartphones and tablets were 1.79 times (OR = 1.79; 95%CI = 1.72-1.86) more likely to have shorter sleep duration and 1.53 times (OR = 1.53; 95%CI = 1.41-1.65) more likely to have worse sleep quality. Children with shorter smartphone and tablet usage were 1.19 times more likely to be active (OR = 1.19; 95% CI = 1.03-1.37).

CONCLUSION

Children of 5 to 10 years who are more often exposed to smartphones and tablets are prone to have worse quality and quantity of sleep, as well as less practice of physical activity. Health promotion actions can be encouraged based on the results, aiming to reduce the use time of these devices and improve children's health and quality of life.

Postweaning intermittent sleep deprivation enhances defensive attack in adult female mice via the microbiota-gut-brain axis

Sleep is one of the most important physiological activities in life and promotes the growth and development of an individual. In modern society, sleep deprivation (SD), especially among adolescents, has become a common phenomenon. However, long-term SD severely affected adolescents' neurodevelopment leading to abnormal behavioral phenotypes. Clinical studies indicated that sleep problems caused increased aggressive behavior in adolescents. Aggressive behavior was subordinate to social behaviors, in which defensive attack was often the last line for survival. Meanwhile, increasing studies shown that gut microbiota regulated social behaviors by affecting specific brain regions via the gut-brain axis. However, whether postweaning intermittent SD is related to defensive attack in adulthood, and if so, whether it is mediated by the microbiota-gut-brain axis are still elusive. Combined with microbial sequencing and hippocampal metabolomics, the present study mainly investigated the long-term effects of postweaning intermittent SD on defensive attack in adult mice. Our study demonstrated that postweaning intermittent SD enhanced defensive attack and impaired long-term memory formation in adult female mice. Moreover, microbial sequencing and LC-MS analysis showed that postweaning intermittent SD altered the gut microbial composition and the hippocampal metabolic profile in female mice, respectively. Our attention has been drawn to the neuroactive ligand-receptor interaction pathway and related metabolites. In conclusion, our findings provide a new perspective on the relationship of early-life SD and defensive attack in adulthood, and also highlight the importance of sleep in early-life, especially in females.

Factors associated with sleep disorders among adolescent students in rural areas of China

Background

This study aimed to determine sleep patterns and the prevalence and association factors of sleep disorders in a regionally representative sample in Mo Jiang, China.

Methods

A total of 2,346 (participation rate 93.5%) Grade 7 students (aged 13-14 years) from 10 middle schools, including 1,213 (51.7%) boys and 1,133 (48.3%) girls, participated in the study. All the participants were invited to complete questionnaires that acquired information on sleep patterns, academic performance, academic stress, and sociodemographic factors. Sleep disorders were assessed using the Chinese version of the Children's Sleep Habits Questionnaire. Logistic regression models were used to investigate factors associated with sleep disorders.

Results

The prevalence of sleep disorders among rural adolescents was 76.4%, which is higher than that among urban adolescents. Compared with previous findings in urban areas, our results indicate that sleep loss is much more severe in rural adolescents. Sleep disorders were positively associated with factors, such as watching TV [odds ratio (OR) = 1.22, p = 0.001], academic performance (OR = 1.80, p < 0.001), and academic stress (OR = 1.38, p = 0.04). In addition, girls were more likely to suffer from sleep disorders than boys (OR = 1.36, p = 0.01).

Conclusion

Insufficient sleep and sleep disorders have become common health problems in rural Chinese adolescents.

Sleep health and its related influencing factors in primary and middle school students in Fuzhou: A large multi-center cross-sectional study

Background

This current study set out to investigate the status of sleep health in 7–20-year-old students in Fuzhou and explore the related influencing factors of sleep health.

Methods

A total of 38,467 children and adolescents in Fuzhou were included in the study through a random stratified cluster sampling. Data were collected from May to June 2019, in 18 primary schools and 18 middle schools from nine districts, Fuzhou. Children's parents and adolescents of sampled classes were invited to fill out a series of questionnaires about the performance of the last 6 months (sociodemographic characteristics, sleep-related lifestyle behaviors, and electronic-products usage). Multiple linear regression was carried out to analyze data.

Results

Of the total 40,888 questionnaires we released, 38,467 were valid and effective with the response rate was 94.08%. The age of the surveyed participants was 11.85 ± 3.1, including 20,013 boys and 18,454 girls. The multiple linear regression analysis identified factors associated with sleep health (p < 0.05): Boy (coef = 0.073, 95% CI: 0.030–0.115), age (coef = 1.797, 95% CI: 0.224–0.243), key school (coef = 2.069, 95% CI: 0.105–0.193), urban (coef = 0.096, 95% CI: 0.054–0.139), excessive daytime sleepiness (coef = 0.535, 95% CI: 0.432–0.639), unhealthy sleep habits (coef = 0.363, 95% CI: 0.307–0.419), eating before sleep (coef = 0.578, 95% CI: 0.527–0.630), using electronic products in bedroom (coef = 0.074, 95% CI: 0.028–0.121), screen time per day during school (coef = 0.260, 95% CI: 0.235–0.284), frequency of using electronics 30 min before bedtime (coef = 0.150, 95% CI: 0.134–0.166), strained relationship with parents (coef = 0.361, 95% CI: 0.270–0.452), strained relationship with peers (coef = 0.267, 95% CI: 0.171–0.363), excessive homework or learning (coef = 0.189, 95% CI: 0.141–0.237), time for doing homework (coef = 0.266, 95% CI: 0.245–0.287), and mood swings frequently (coef = 1.174, 95% CI: 1.127–1.221) negatively impact sleep health. Sleep alone (coef = −0.204, 95% CI: −0.262–0.147) were the risk factors for sleep health. Furthermore, frequent mood swings was considered the most influential factor on overall variables.

Conclusions

Sleep health is associated with factors covered sociodemographic characteristics, family sleep habits, and routine activities before bedtime. Multiple measures should be taken to improve sleep quality in a targeted manner.

The association between child maltreatment and sleep disturbances among preschoolers

BACKGROUND

Child maltreatment (CM) can result in lifelong detrimental consequences, but its association with sleep disturbances in young children remains unclear.

OBJECTIVE

This study aimed to investigate the association of CM with sleep disturbances and short sleep duration among Chinese preschoolers.

PARTICIPANTS AND SETTING

Data were from a representative sample of 17,023 children (6.17 ± 0.29 years old, 51.96% boys) at their graduation year of preschool in September 2019, as a subset of the Shanghai Children's Health, Education and Lifestyle Evaluation-Preschool (SCHEDULE-P) study.

METHODS

Parents reported children's CM of different types and the Children's Sleep Habits Questionnaire (CSHQ). Logistic regression was used to evaluate the risk of sleep disturbances and short sleep duration linked to CM.

RESULTS

Of the children, 12,583(73.92%) demonstrated sleep disturbances (CSHQ total score > 41) and 3017(17.72%) demonstrated short sleep duration (<9 h/night). After adjusting covariates, physical abuse (aOR = 1.16, 95%CI = 1.05-1.28) and emotional abuse (aOR = 1.50, 95% CI = 1.39-1.62) were associated with global sleep disturbances. Physical abuse (aOR = 1.16, 95% CI = 1.06-1.28), physical neglect (aOR = 1.29, 95%CI = 1.12-1.49), and emotional abuse (aOR = 1.19, 95% CI = 1.09-1.30) were associated with short sleep duration. Sexual abuse was not significantly associated with global sleep disturbances or short sleep duration. A cumulative association was noted that more CM types were associated with increased global sleep disturbances and short sleep duration.

CONCLUSIONS

CM is associated with sleep disturbances and short sleep duration in young children. This highlights the efforts to prevent and reduce CM in favor of optimal sleep and whole health in young children.

Timing of sedentary behaviour and access to sedentary activities in the bedroom and their association with sleep quality and duration in children and youth: a systematic review

BACKGROUND

The purpose of this study was to systematically review the relationship between the timing of sedentary behaviours and access to sedentary activities in the bedroom with sleep duration and quality in children and youth. A secondary purpose was to examine whether these relationships differ when comparing screen-based and non-screen-based sedentary activities.

METHODS

We searched four databases for peer-reviewed studies published between 1 January 2010 and 19 January 2021. Risk of bias assessment for each study and certainty of evidence were assessed using the GRADE framework.

RESULTS

We identified 44 eligible papers reporting data from 42 separate datasets and including 239 267 participants. Evening participation in screen-based sedentary behaviours and access to screen-based devices in the bedroom were associated with reduced sleep duration and quality. Daytime screen use was also associated with reduced sleep duration, although this was examined in relatively few studies. Whether performed during the day or night, non-screen-based sedentary behaviours were not consistently associated with sleep duration or quality. The quality of evidence was rated as low to very low for all outcomes.

CONCLUSION

In order to maximize sleep duration and quality, children and youth should be encouraged to minimize screen time in the evening and remove screens from bedrooms. (PROSPERO registration no.: CRD42020189082).

Perceived Overqualification and Innovative Behavior: High-Order Moderating Effects of Length of Service

Perceived overqualification has been a hot topic in the field of organizational behavior in recent years and has become very common with the spread of education. In addition, in the current era of open innovation, the demand for innovative behaviors by enterprises is increasing day by day. Therefore, this study intended to link the two to explore the relationship between them. Based on self-evaluation theory and face theory, taking enterprise employees as the research object, this paper discusses the impact of perceived overqualifications on employees’ innovative behavior and the internal mechanism and examines the first-order and high-order moderating effects of ability–face pressure and length of service in turn. The results showed that perceived overqualifications had a positive impact on employees’ innovation behavior, and felt trust had a mediating role in the relationship. Ability face pressure played a negative moderating role in the impact of felt trust on innovative behavior and played a negative moderating role in the impact of perceived overqualifications on innovative behavior. With the increase in the length of service, the negative moderating effect of ability face pressure on the relationship between perceived overqualifications and employees’ innovative behavior weakened. It is expected that these results will enable companies to understand the internal mechanisms of employee perceived overqualification, enlighten leaders to give more trust to employees, help companies to improve employees’ innovative behavior, and pay attention to the psychological factors of employees, which will help to create a sustainable work environment and promote sustainable business development.

The Current Status of Insufficient Sleep Duration and Its Influencing Factors Among Children and Adolescents: A Household Based Cross-Sectional Study in Zhejiang Province, China

PURPOSE

Insufficient sleep duration is common among children and adolescents worldwide, and the decline of sleep duration during the recent years is troubling. This study aimed to learn the status of insufficient sleep duration and to explore its influencing factors among children and adolescents in Zhejiang Province, China.

DESIGN AND METHODS

A stratified sampling technique was employed in the present cross-sectional study. Demographic characteristics, sports time as well as sedentary behavior were investigated.

RESULTS

A greater proportion of children than adolescents reported insufficient sleep duration (36.4% versus 19.2%, p = 0.001). For children, insufficient sleep duration was associated with age (OR = 1.290, 95%CI: 1.069-1.557), watching movies or TV shows with smartphones after school (OR = 3.098, 95%CI: 1.293-7.420), surf the internet after school (OR = 0.113, 95%CI: 0.013-0.969), walk to school (OR = 0.289, 95%CI: 0.105-0.793). For adolescents, insufficient sleep duration was associated with watch TV after school (OR = 0.379, 95%CI: 0.148-0.970), watching movies or TV shows with smartphones after school (OR = 4.744, 95%CI: 1.799-12.507), do homework after school (OR = 0.265, 95%CI: 0.086-0.813).

CONCLUSIONS

An unhealthy sedentary screen lifestyle profile may have influence on insufficient sleep duration. Urgent actions are needed to improve sleep duration among children and adolescents.

Short duration of sleep and incidence of overweight or obesity in Chinese children and adolescents: A systematic review and meta-analysis of prospective studies

BACKGROUND AND AIMS

Overweight and obesity in children have become a global public health problem. Epidemiological studies suggest that sleep duration may contribute to the incidence of overweight and obesity in all stages of life. China has an increasing prevalence of overweight and obesity, and sleep deprivation is common among Chinese children. The aim of this study was to assess the prospective relationship between short sleep duration and overweight or obesity in Chinese children and to gain an estimate of the risk.

METHODS AND RESULTS

A systematic search was performed on 28/04/2020 by using Medline, PubMed and Web of Science. The exposure was the duration of sleep, and the outcome measure the incidence of overweight or obesity. The odds ratios (OR) and hazard ratios (HR) and 95% confidence intervals (C.I.) were extracted to calculate the pooled relative risk (RR) by a random effect model. Heterogeneity and publication bias of the studies were checked by sensitivity analysis. Seven studies fulfilled the criteria for a systematic review, and 5 studies for a meta-analysis. The total of 33,206 participants included boys and girls, aged 6-17 years old. In Chinese children the pooled RR for short sleep duration and overweight or obesity combined was 1.47 (95% C.I. 1.26, 1.71, p < 0.00001, n = 32,607), and for obesity alone 1.40 (95% C.I. 1.01, 1.95, p = 0.04, n = 17,038). There was no significant heterogeneity or publication bias between studies.

CONCLUSION

Short sleep duration is associated with the development of overweight and obesity in Chinese children.

Relationship between Poorly Controlled Asthma and Sleep-Related Breathing Disorders in Children with Asthma: A Two-Center Study

Objective

Asthma and sleep-related breathing disorders (SRBD) are common chronic respiratory diseases in children. The relationship between asthma and SRDB is bidirectional. However, only a few studies have analyzed the relationship between asthma control status and risk of SRBD. The aim of this study was to evaluate the relationship between asthma control and SRBD and further assess the relationship between therapy/atopy/lung function of children with asthma and SRBD.

Methods

A total of 209 children aged 3-16 years were enrolled in this study. Pediatric sleep questionnaire (PSQ) scores were used to identify children at high risk of developing SRBD. Data on asthma control status, therapy, allergy, lung function, and exhaled nitric oxide were collected.

Results

A significantly higher risk of SRBD was found among children with poorly controlled asthma (34.25% vs. 13.97%, P < 0.01) and allergic rhinitis (AR) (34.29% vs. 13.92%, P < 0.01) than among children with well-controlled asthma and AR. The prevalence of SRBD was also significantly higher in asthmatic children with obesity than that with just obesity (42.11% vs. 20.00%, P < 0.05). Multiple logistic regression analysis showed that poorly controlled asthma (OR, 2.746 (95% CI, 1.215-6.209); P < 0.05) and poorly controlled AR (OR, 3.284 (95% CI, 1.430-7.544); P < 0.01) increased the odds of having SRBD.

Conclusion

Poorly controlled asthma and AR increase the risk of SRBD. A routine check of the level of asthma control and appropriate use of medication for AR are important because of their influence on SRBD.

Analysis of the impact of allergic rhinitis on the children with sleep disordered breathing

OBJECTIVES

We assessed the influence of allergic rhinitis (AR) on sleep disordered breathing (SDB) in children with adenotonsillar hypertrophy (ATH), and compared sleep quality and polysomnographic data in habitually snoring children with or without AR.

METHODS

Children with snoring resulting from adenoid/tonsils hypertrophy were recruited between Jan 1st, 2018 and Jun 30th, 2018. The exclusion criteria were congenital disorders, metabolic disorders, neurological disorders and pulmonary diseases, such as, asthma etc. Overnight polysomnography (PSG) and Sleep Questionnaire (SQ) were assessed on each participant to identify children with obstructive sleep apnea (OSA). Cross-sectional study design was used to examine PSG and SQ data. The diagnosis of AR was based upon history of allergies and positive clinical examinations, then confirmed by allergen test. Participants were categorized into four groups (AR and Non-OSA group; AR and OSA group; Non-AR and Non-OSA group; Non-AR and OSA group). Non-parametric rank sum test was used for statistical analysis.

RESULTS

Six hundred and sixty children (age between 3yrs and 14yrs) with SDB were enrolled in the study (mean age 6.7 ± 2.1yrs, 67.4% male). The number of children diagnosed with OSA was 495 (74.3%). The prevalence of AR among all participating SDB children was 25.8%, and AR with OSA was19.4%. The behavioral problems scores in SQ showed significant difference among SDB children with AR (P<.0001). No difference was observed in the OAHI (obstructive apnea-hypopnea index) and AHI (apnea-hypopnea index) between the groups of children with and without AR regardless whether OSA was coexisting. The percentage of time spent in the rapid eye movement (REM) sleep stage was shortened among children with AR without OSA (P = 0.031), however, the percentage of time spent in the REM sleep stage was not different among children with OSA (P = 0.98). The total sleep time was shorter among children with AR (OSA P = 0.02; without OSA P = 0.03).

CONCLUSIONS

Despite the high prevalence of AR in patients with SDB, AR is not an aggravating factor for the severity of AHI. High risk behavioral problems link to SDB with AR. AR is associated with shortened REM sleep stage in children with SDB without sleep apnea, and shortened total sleep time in children with SDB.

Cross-Sectional Associations of 24-Hour Sedentary Time, Physical Activity, and Sleep Duration Compositions with Sleep Quality and Habits in Preschoolers

Although some studies indicate physical activity and sleep quality are positively associated in children, most reports examined physical activity independent of other 24-h behaviors and focused on older children. The aim of this cross-sectional study was to examine the predicted changes in sleep efficiency and habits when reallocating time between movement behaviors using compositional isotemporal substitution in preschool-aged children. Accelerometers were worn by 288 participants (51.6 ± 9.5 months) for up to 16 days. Sleep outcomes included sleep efficiency, nap frequency, sleep disturbances, and bedtime resistance. Compositional isotemporal substitution analyses demonstrated that the combined effect of 24-h movement behaviors was associated with sleep efficiency (p < 0.001) and nap frequency (p < 0.003). When sleep increased by 30 min at the expense of stationary time or light physical activity, estimates of sleep efficiency and bedtime resistance decreased while nap frequency increased. When stationary time increased by 30 min from moderate to vigorous physical activity, estimated sleep efficiency increased and sleep disturbances decreased. Although this study presents preliminary evidence that 24-h movement behavior compositions in early childhood are associated with sleep quality and nap frequency, estimated effects from theoretical time reallocations across sleep outcomes were mixed.

Sleep Duration, Bedtime, and Myopia Progression in a 4-Year Follow-up of Chinese Children: The Anyang Childhood Eye Study

Purpose

To investigate the relationship between sleep duration and bedtime with myopia progression and axial elongation during a 4-year follow-up in primary school children.

Methods

This study included 1887 children (aged 7.09 ± 0.41 years) who had cycloplegic refractions data at baseline and a fourth visit and 2209 children (aged 7.10 ± 0.41 years) for axial length. All children underwent comprehensive ophthalmologic examinations, including cycloplegic refraction and ocular biometry, and standardized questionnaires, including average night-time sleep duration (h/d) and bedtime (time to bed). Myopia was defined as spherical equivalent < –0.5 diopters.

Results

At the last follow-up, the mean myopia progression and axial elongation for all children were –1.89 ± 1.28 diopters and 1.22 ± 0.57 mm. After stratifying the sleep duration into tertile groups, myopia progression and axial elongation were slower in children with highest sleep duration tertile (P = 0.04 and P =0.014) in girls but not in boys, compared with the middle sleep duration tertile. However, after adjusting for potential confounders, no significant association was found for sleep duration with myopia progression and axial elongation for the children (P = 0.255 and P = 0.068), and the association with axial elongation was only of borderline significance in girls (P = 0.045). The bedtime was not associated with myopia progression and axial elongation in the regression analyses (P = 0.538; P = 0.801).

Conclusions

These results show that there was no significant association between sleep duration and bedtime with myopia progression and axial elongation among children. The findings in girls might be related to the earlier onset of puberty.

Characteristics and risk factors of children with sleep-disordered breathing in Wuxi, China

Background

Sleep-disordered breathing (SDB) is a common syndrome in children, related to their immune responses, cardiovascular function, and neurocognitive function. This study aimed to determine the prevalence of SDB among children in Wuxi, China, and to evaluate the protective and risk factors of SDB in children.

Methods

A cross-sectional study was conducted on children attending different schools across Wuxi, China, aged 3–14 years old. Of a total of 5630 questionnaires distributed to the parents of the children, 3997 (71.0%) were deemed to be valid. The data on the general sociodemographic factors, children’s allergy and sleep characteristics, and the parents’ sleep characteristics were also collected. The Paediatric Sleep Questionnaire (PSQ) score was used to identify children at high risk of SDB. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by logistic regression.

Results

The prevalence of SDB in this cohort was 13.4% (N = 534). SDB prevalence significantly differed in children with asthma (28.2% vs. 12.8%, P < 0.001), eczema (19.0% vs. 10.0%, P < 0.001), urticaria (16.4% vs. 12.9%, P < 0.01) and rhinitis (21.4% vs. 10.7%, P < 0.001). No significant differences were found in SDB prevalence with respect to pillow material or quilt material. On multivariate logistic regression analysis, asthma (OR 1.986 (95% CI 1.312–3.007), P < 0.01), eczema (OR 1.675 (95% CI 1.377–2.037), P < 0.001), rhinitis (OR 1.998 (95% CI 1.635–2.441), suffered from familial sleep sickness (OR 2.416 (95% CI 1.975–2.955), P < 0.001) and whose mothers slept for a shorter duration (6 h–8 h: OR 1.370 (95% CI 1.089–1.724), P < 0.01; <6 h: OR 3.385(95% CI 2.098–5.461), P < 0.001) increased the odds of having SDB. The incidence of SDB significantly decreased with children’s age (6–11 years old: 0R 0.768 (95% CI 0.597–0.989), P < 0.05; 12–14 years old: OR 0.691 (95% CI 0.530–0.901), P < 0.01).

Conclusion

The results of this study demonstrated that atopic diseases (asthma, eczema, and rhinitis) and family sleep habits were risk factors for SDB in children in Wuxi, China.