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Gu J, Jin Z, Wu G, Dang S, Yao F, Zheng Z, Ren L, Yang J, Chen D, Zhang L, Lin R. Correlation between essential and toxic elements in maternal blood during early pregnancy and atrial septal defects/ventricular septal defects/patent ductus arteriosus in offspring. Birth Defects Res 2024; 116:e2282. [PMID: 38192201 DOI: 10.1002/bdr2.2282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Congenital heart defects (CHDs) are the most common congenital malformation in the world. Recent studies have found that essential and toxic trace element levels may play a crucial role in the risk of neonatal malformation. However, the relationships between element levels in early pregnancy and CHD risk among humans remain unclear. This study investigates the association between maternal essential element (copper [Cu], zinc [Zn], calcium [Ca], manganese [Mg] and iron [Fe]) and toxic element (lead [Pb] and cadmium [Cd]) levels during early pregnancy and CHDs. METHODS A hospital-based case-control study was conducted, including 181 cases and 218 controls. Eligible participants underwent antenatal examination during gestational weeks 11-14 and trace element levels were detected by the atomic absorption method. Multi-variable logistic regression was used to examine the associations between the level of maternal trace elements and CHD risks. RESULTS Higher levels of Ca in early pregnancy were associated with lower risk of ASD/VSD risks. Moreover, higher Fe, Pb, and Cd levels in the first trimester were associated with higher risks of all CHD and the subtypes risks, and the tests for trend were significant (all p < .05). The restricted cubic spline analysis showed that there was a nonlinear inverted u-shaped dose-response relationship between levels of Zn, Pb, and Cd in the first trimester and risk of CHDs (non-linearity test p < .05). CONCLUSIONS A moderate increase in Zn and Ca levels and a decrease in Pb and Cd levels during early pregnancy are needed to reduce the incidence of CHDs in the Chinese population.
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Affiliation(s)
- Jianli Gu
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center, Xi'an, China
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Zhen Jin
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Guiqing Wu
- Department of Obstetrics, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Shaonong Dang
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Feng Yao
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zihan Zheng
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Lingxuan Ren
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Jianjun Yang
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Danli Chen
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Li Zhang
- Department of Geriatrics, Xi'an Hospital of Traditional Chinese Medicine, Xi'an, China
| | - Rong Lin
- Department of Pharmacology, Xi'an Jiaotong University Health Science Center, Xi'an, China
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Kawai S, Pak K, Iwamoto S, Kawakami C, Inuzuka R, Maeda J, Furutani Y, Kamisago M, Takatsuki S, Uyeda T, Yamagishi H, Ito S, Kobayashi T. Association Between Maternal Factors in Early Pregnancy and Congenital Heart Defects in Offspring: The Japan Environment and Children's Study. J Am Heart Assoc 2023; 12:e029268. [PMID: 37642029 PMCID: PMC10547327 DOI: 10.1161/jaha.122.029268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 08/01/2023] [Indexed: 08/31/2023]
Abstract
Background Many prenatal factors are reported to be associated with congenital heart defects (CHD) in offspring. However, these associations have not been adequately examined using large-scale birth cohorts. Methods and Results We evaluated a data set of the Japan Environmental and Children's Study. The primary outcome was a diagnosis of CHD by age 2 years. We defined the following variables as exposures: maternal baseline characteristics, fertilization treatment, maternal history of diseases, socioeconomic status, maternal alcohol intake, smoking, tea consumption, maternal dietary intake, and maternal medications and supplements up to 12 weeks of gestation. We used multivariable logistic regression analysis to assess the associations between various exposures and CHD in offspring. A total of 91 664 singletons were included, among which 1264 (1.38%) had CHD. In multivariable analysis, vitamin A supplements (adjusted odds ratio [aOR], 5.78 [95% CI, 2.30-14.51]), maternal use of valproic acid (aOR, 4.86 [95% CI, 1.51-15.64]), maternal use of antihypertensive agents (aOR, 3.80 [95% CI, 1.74-8.29]), maternal age ≥40 years (aOR, 1.59 [95% CI, 1.14-2.20]), and high maternal hemoglobin concentration in the second trimester (aOR, 1.10 per g/dL [95% CI, 1.03-1.17]) were associated with CHD in offspring. Conclusions Using a Japanese large-scale birth cohort study, we found 6 maternal factors to be associated with CHD in offspring.
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Affiliation(s)
- Shun Kawai
- Department of PediatricsYokohama City UniversityYokohamaJapan
| | - Kyongsun Pak
- Biostatistics Unit, Department of Data ScienceNational Center for Child Health and DevelopmentTokyoJapan
| | - Shintaro Iwamoto
- Biostatistics Unit, Department of Data ScienceNational Center for Child Health and DevelopmentTokyoJapan
| | | | - Ryo Inuzuka
- Department of PediatricsThe University of Tokyo HospitalTokyoJapan
| | - Jun Maeda
- Department of CardiologyTokyo Metropolitan Children’s Medical CenterTokyoJapan
| | - Yoshiyuki Furutani
- Department of Pediatric Cardiology and Adult Congenital CardiologyTokyo Women’s Medical UniversityTokyoJapan
| | - Mitsuhiro Kamisago
- Department of PediatricsNippon Medical School Tama Nagayama HospitalTokyoJapan
| | | | - Tomomi Uyeda
- Department of Pediatric CardiologySakakibara Heart InstituteTokyoJapan
| | | | - Shuichi Ito
- Department of PediatricsYokohama City UniversityYokohamaJapan
| | - Tohru Kobayashi
- Department of Data ScienceNational Center for Child Health and DevelopmentTokyoJapan
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The Association of Folic Acid, Iron Nutrition during Pregnancy and Congenital Heart Disease in Northwestern China: A Matched Case-Control Study. Nutrients 2022; 14:nu14214541. [PMID: 36364804 PMCID: PMC9657607 DOI: 10.3390/nu14214541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background: The purpose of this study was to investigate the relationship between folic acid and iron nutrition during pregnancy and congenital heart disease (CHD) in the offspring. Methods: Conditional logistic regression models and nonlinear mixed-effects models were used to analyze the effects of folic acid and iron nutrition during pregnancy on CHD in offspring. Results: After adjusting for confounders, folic acid or iron supplementation during pregnancy reduced the risk for fetal CHD (OR = 0.60 (0.45, 0.82) or 0.36 (0.27, 0.48)). Similarly, dietary iron intake during pregnancy (≥29 mg/d) was associated with a reduced risk of fetal CHD (OR = 0.64 (0.46, 0.88)). Additionally, compared with women who only supplemented folic acid (OR = 0.59 (0.41, 0.84)) or iron (OR = 0.32 (0.16, 0.60)), women who supplemented both folic acid and iron had lower risk for newborns with CHD (OR = 0.22 (0.15, 0.34)). Similarly, compared with women who only supplemented folic acid (OR = 0.59 (0.41, 0.84)) or higher dietary iron intake (≥29 mg/d) (OR = 0.60 (0.33, 1.09)), women who supplemented both folic acid and higher dietary iron intake (≥29 mg/d) had lower risk for the newborn with CHD (OR = 0.41 (0.28, 0.62)). The combined effects were significant in the multiplication model (OR = 0.35 (0.26, 0.48) or 0.66 (0.50, 0.85)) but not in the additive model. Conclusions: Our study found that folic acid and iron nutrition during pregnancy were associated with a reduced risk of CHD in the offspring and confirmed a statistically significant multiplicative interaction between folic acid and iron nutrition on the reduced risk of CHD in offspring.
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Zhang M, Sun Y, Zhao X, Liu R, Yang BY, Chen G, Zhang W, Dong GH, Yin C, Yue W. How Parental Predictors Jointly Affect the Risk of Offspring Congenital Heart Disease: A Nationwide Multicenter Study Based on the China Birth Cohort. Front Cardiovasc Med 2022; 9:860600. [PMID: 35722125 PMCID: PMC9204142 DOI: 10.3389/fcvm.2022.860600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveCongenital heart disease (CHD) is complex in its etiology. Its genetic causes have been investigated, whereas the non-genetic factor related studies are still limited. We aimed to identify dominant parental predictors and develop a predictive model and nomogram for the risk of offspring CHD.MethodsThis was a retrospective study from November 2017 to December 2021 covering 44,578 participants, of which those from 4 hospitals in eastern China were assigned to the development cohort and those from 5 hospitals in central and western China were used as the external validation cohort. Univariable and multivariable analyses were used to select the dominant predictors of CHD among demographic characteristics, lifestyle behaviors, environmental pollution, maternal disease history, and the current pregnancy information. Multivariable logistic regression analysis was used to construct the model and nomogram using the selected predictors. The predictive model and the nomogram were both validated internally and externally. A web-based nomogram was developed to predict patient-specific probability for CHD.ResultsDominant risk factors for offspring CHD included increased maternal age [odds ratio (OR): 1.14, 95% CI: 1.10–1.19], increased paternal age (1.05, 95% CI: 1.02–1.09), maternal secondhand smoke exposure (2.89, 95% CI: 2.22–3.76), paternal drinking (1.41, 95% CI: 1.08–1.84), maternal pre-pregnancy diabetes (3.39, 95% CI: 1.95–5.87), maternal fever (3.35, 95% CI: 2.49–4.50), assisted reproductive technology (2.89, 95% CI: 2.13–3.94), and environmental pollution (1.61, 95% CI: 1.18–2.20). A higher household annual income (100,000–400,000 CNY: 0.47, 95% CI: 0.34–0.63; > 400,000 CNY: 0.23, 95% CI: 0.15–0.36), higher maternal education level (13–16 years: 0.68, 95% CI: 0.50–0.93; ≥ 17 years: 0.87, 95% CI: 0.55–1.37), maternal folic acid (0.21, 95% CI: 0.16–0.27), and multivitamin supplementation (0.33, 95% CI: 0.26–0.42) were protective factors. The nomogram showed good discrimination in both internal [area under the receiver-operating-characteristic curve (AUC): 0.843] and external validations (development cohort AUC: 0.849, external validation cohort AUC: 0.837). The calibration curves showed good agreement between the nomogram-predicted probability and actual presence of CHD.ConclusionWe revealed dominant parental predictors and presented a web-based nomogram for the risk of offspring CHD, which could be utilized as an effective tool for quantifying the individual risk of CHD and promptly identifying high-risk population.
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Affiliation(s)
- Man Zhang
- Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
- Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Yongqing Sun
- Beijing Maternal and Child Health Care Hospital, Beijing, China
- Prenatal Diagnosis Center, Beijing Obstetrics and Gynecology Hospital, Beijing Maternal and Child Health Care Hospital, Capital Medical University, Beijing, China
| | - Xiaoting Zhao
- Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
- Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Ruixia Liu
- Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
- Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Bo-Yi Yang
- Guangzhou Key Laboratory of Environmental Pollution and Health Risk Assessment, Guangdong Provincial Engineering Technology Research Center of Environmental and Health Risk Assessment, Department of Preventive Medicine, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Gongbo Chen
- Guangzhou Key Laboratory of Environmental Pollution and Health Risk Assessment, Guangdong Provincial Engineering Technology Research Center of Environmental and Health Risk Assessment, Department of Preventive Medicine, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Wangjian Zhang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Wangjian Zhang,
| | - Guang-Hui Dong
- Guangzhou Key Laboratory of Environmental Pollution and Health Risk Assessment, Guangdong Provincial Engineering Technology Research Center of Environmental and Health Risk Assessment, Department of Preventive Medicine, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Guang-Hui Dong,
| | - Chenghong Yin
- Beijing Maternal and Child Health Care Hospital, Beijing, China
- Prenatal Diagnosis Center, Beijing Obstetrics and Gynecology Hospital, Beijing Maternal and Child Health Care Hospital, Capital Medical University, Beijing, China
- Chenghong Yin,
| | - Wentao Yue
- Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
- Beijing Maternal and Child Health Care Hospital, Beijing, China
- Wentao Yue,
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Zhang X, Liu L, Chen W, Wang F, Cheng Y, Liu Y, Lai Y, Zhang R, Qiao Y, Yuan Y, Lin Y, Xu W, Cao J, Gui Y, Zhao J. Gestational Leucylation Suppresses Embryonic T-Box Transcription Factor 5 Signal and Causes Congenital Heart Disease. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2201034. [PMID: 35320615 PMCID: PMC9130917 DOI: 10.1002/advs.202201034] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Indexed: 06/01/2023]
Abstract
Dysregulated maternal nutrition, such as vitamin deficiencies and excessive levels of glucose and fatty acids, increases the risk for congenital heart disease (CHD) in the offspring. However, the association between maternal amino-acid levels and CHD is unclear. Here, it is shown that increased leucine levels in maternal plasma during the first trimester are associated with elevated CHD risk in the offspring. High levels of maternal leucine increase embryonic lysine-leucylation (K-Leu), which is catalyzed by leucyl-tRNA synthetase (LARS). LARS preferentially binds to and catalyzes K-Leu modification of lysine 339 within T-box transcription factor TBX5, whereas SIRT3 removes K-Leu from TBX5. Reversible leucylation retains TBX5 in the cytoplasm and inhibits its transcriptional activity. Increasing embryonic K-Leu levels in high-leucine-diet fed or Sirt3 knockout mice causes CHD in the offspring. Targeting K-Leu using the leucine analogue leucinol can inhibit LARS activity, reverse TBX5 K-Leu modification, and decrease the occurrence of CHD in high-leucine-diet fed mice. This study reveals that increased maternal leucine levels increases CHD risk in the offspring through inhibition of embryonic TBX5 signaling, indicating that leucylation exerts teratogenic effects during heart development and may be an intervening target of CHD.
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Affiliation(s)
- Xuan Zhang
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Lian Liu
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Wei‐Cheng Chen
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Feng Wang
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Yi‐Rong Cheng
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Yi‐Meng Liu
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Yang‐Fan Lai
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Rui‐Jia Zhang
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Ya‐Nan Qiao
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Yi‐Yuan Yuan
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Yan Lin
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
- Key Laboratory of Reproduction Regulation of NPFPC and Institutes of Biomedical SciencesFudan UniversityShanghai200438P. R. China
| | - Wei Xu
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
- Key Laboratory of Reproduction Regulation of NPFPC and Institutes of Biomedical SciencesFudan UniversityShanghai200438P. R. China
| | - Jing Cao
- School of Basic Medical SciencesZhengzhou UniversityZhengzhou450001China
| | - Yong‐Hao Gui
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
| | - Jian‐Yuan Zhao
- Children's Hospital of Fudan UniversityObstetrics & Gynecology Hospital of Fudan UniversityFudan University Shanghai Cancer CenterState Key Laboratory of Genetic Engineeringand School of Life SciencesShanghai200438P. R. China
- School of Basic Medical SciencesZhengzhou UniversityZhengzhou450001China
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Cheng Z, Gu R, Lian Z, Gu HF. Evaluation of the association between maternal folic acid supplementation and the risk of congenital heart disease: a systematic review and meta-analysis. Nutr J 2022; 21:20. [PMID: 35346212 PMCID: PMC8962131 DOI: 10.1186/s12937-022-00772-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Folic acid (FA), as a synthetic form of folate, has been widely used for dietary supplementation in pregnant women. The preventive effect of FA supplementation on the occurrence and recurrence of fetal neural tube defects (NTD) has been confirmed. Incidence of congenital heart diseases (CHD), however, has been parallelly increasing worldwide. The present study aimed to evaluate whether FA supplementation is associated with a decreased risk of CHD. Methods We searched the literature using PubMed, Web of Science and Google Scholar, for the peer-reviewed studies which reported CHD and FA and followed with a meta-analysis. The study-specific relative risks were used as summary statistics for the association between maternal FA supplementation and CHD risk. Cochran's Q and I2 statistics were used to test for the heterogeneity. Results Maternal FA supplementation was found to be associated with a decreased risk of CHD (OR = 0.82, 95% CI: 0.72–0.94). However, the heterogeneity of the association was high (P < 0.001, I2 = 92.7%). FA supplementation within 1 month before and after pregnancy correlated positively with CHD (OR 1.10, 95%CI 0.99–1.23), and high-dose FA intake is positively associated with atrial septal defect (OR 1.23, 95%CI 0.64–2.34). Pregnant women with irrational FA use may be at increased risk for CHD. Conclusions Data from the present study indicate that the heterogeneity of the association between maternal FA supplementation and CHD is high and suggest that the real relationship between maternal FA supplementation and CHD may need to be further investigated with well-designed clinical studies and biological experiments. Supplementary Information The online version contains supplementary material available at 10.1186/s12937-022-00772-2.
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Affiliation(s)
- Zhengpei Cheng
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.,Strathclyde Institute of Pharmacology and Biomedical Science, University of Strathclyde, 16 Richmond St Glasgow, Glasgow, G1 1XQ, Scotland
| | - Rui Gu
- College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing, China
| | - Zenglin Lian
- Institute of Biological Chinese Medicine, Beijing Yichuang Institute of Biotechnology Industry, Beijing, China
| | - Harvest F Gu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
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Maternal Zinc, Copper, and Selenium Intakes during Pregnancy and Congenital Heart Defects. Nutrients 2022; 14:nu14051055. [PMID: 35268030 PMCID: PMC8912688 DOI: 10.3390/nu14051055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/01/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023] Open
Abstract
The effects of zinc, copper, and selenium on human congenital heart defects (CHDs) remain unclear. This study aimed to investigate the associations of the maternal total, dietary, and supplemental intakes of zinc, copper, and selenium during pregnancy with CHDs. A hospital-based case-control study was performed, including 474 cases and 948 controls in Northwest China. Eligible participants waiting for delivery were interviewed to report their diets and characteristics in pregnancy. Mixed logistic regression was adopted to examine associations and interactions between maternal intakes and CHDs. Higher total intakes of zinc, selenium, zinc to copper ratio, and selenium to copper ratio during pregnancy were associated with lower risks of total CHDs and the subtypes, and the tests for trend were significant (all p < 0.05). The significantly inverse associations with CHDs were also observed for dietary intakes of zinc, selenium, zinc to copper ratio, selenium to copper ratio, and zinc and selenium supplements use during pregnancy and in the first trimester. Moreover, high zinc and high selenium, even with low or high copper, showed a significantly reduced risk of total CHDs. Efforts to promote zinc and selenium intakes during pregnancy need to be strengthened to reduce the incidence of CHDs in the Chinese population.
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Strzelecka I, Biedrzycka M, Karuga FF, Szmyd B, Batarowicz K, Respondek-Liberska M. Seasonality of Hypoplastic Left Heart Syndrome and Single Ventricle Heart in Poland in the Context of Air Pollution. J Clin Med 2021; 10:3207. [PMID: 34361990 PMCID: PMC8347882 DOI: 10.3390/jcm10153207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/18/2021] [Accepted: 07/20/2021] [Indexed: 01/17/2023] Open
Abstract
Hypoplastic left heart syndrome (HLHS) and single ventricle (SV) remain a significant cause of cardiac deaths occurring in the first week of life. Their pathogenesis and seasonal frequency are still unknown. Therefore, we attempt to look at the genesis of the HLHS and SV in the context of territorial distribution as well as seasonality. A total of 193 fetuses diagnosed with HLHS and 92 with SV were selected. The frequency was analyzed depending on the year, calendar month, quarter and season (fall-winter vs. spring-summer). The spatial distribution of HLHS and SV in Poland was analyzed. We observed a statistically significant overrepresentation of HLHS formation frequency in March: 27 (14.00%) in comparison to a monthly median of 15 (IQR: 13.75-16.25; p = 0.039), as well as a significantly higher frequency of HLHS in 2007-2009: 65 cases (33.68%) in comparison to the annual mean of 13.79 ± 6.36 (p < 0.001). We noted a higher frequency of SV among parous with the last menstrual period reported in the fall/winter season of 58 vs. 34 in the spring/summer season (p = 0.014). The performed analysis also revealed significant SV overrepresentation in 2008: 11 cases (12.00%) in comparison to the annual mean of 6.57 ± 2.71 (p = 0.016). Every single case of HLHS was observed when the concentration of benzo(a)pyrene and/or PM10 exceeded the acceptable/target level. Our research indicates that both the season and the level of pollution are significant factors affecting the health of parous women and their offspring. The reason why HLHS and SV develop more frequently at certain times of the year remains unclear, therefore research on this topic should be continued, as well as on the effects of PM10 and benzo(a)pyrene exposure.
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Affiliation(s)
- Iwona Strzelecka
- Department for Diagnoses and Prevention, Medical University of Lodz, 93-338 Łódź, Poland; (I.S.); (K.B.); (M.R.-L.)
| | - Małgorzata Biedrzycka
- Student’s Scientific Association Prenatal Cardiology, Medical University of Lodz, 93-338 Łódź, Poland;
| | - Filip Franciszek Karuga
- Student’s Scientific Association Prenatal Cardiology, Medical University of Lodz, 93-338 Łódź, Poland;
| | - Bartosz Szmyd
- Department of Pediatrics, Oncology, and Hematology, Medical University of Lodz, 91-738 Łódź, Poland;
| | - Katarzyna Batarowicz
- Department for Diagnoses and Prevention, Medical University of Lodz, 93-338 Łódź, Poland; (I.S.); (K.B.); (M.R.-L.)
| | - Maria Respondek-Liberska
- Department for Diagnoses and Prevention, Medical University of Lodz, 93-338 Łódź, Poland; (I.S.); (K.B.); (M.R.-L.)
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital, 93-338 Łódź, Poland
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9
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Zhang R, Guo L, Zhao D, Qu P, Dang S, Yan H. Maternal B-vitamin intake and B-vitamin supplementation during pregnancy in relation to neonatal congenital heart defects: a case-control study with propensity score matching. Eur J Clin Nutr 2020; 75:782-791. [PMID: 33199851 DOI: 10.1038/s41430-020-00804-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 10/09/2020] [Accepted: 10/31/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/OBJECTIVES The effect of dietary folate intake or folic acid (FA) supplementation during pregnancy on neonatal congenital heart defects (CHDs) remains inconclusive. There are limited data about non-folate-B-vitamin intake and the risk of CHDs. Furthermore, few studies have investigated dietary B-vitamin intake and B-vitamin supplement use simultaneously in relation to the risk of CHDs. This study aimed to explore the associations between maternal folate, vitamin B6, and vitamin B12 intake (dietary intake, total intake from diet and supplements); B-vitamin supplement use during pregnancy; and the risk of CHDs using the propensity score matching (PSM) method. METHODS We conducted a case-control study and included 760 cases and 1600 controls in Shaanxi Province, China. Diet, supplement use and other information were collected through a questionnaire interview. By using the 1:2 ratio PSM method, 396 cases were matched with 792 controls. Conditional logistic regression was used to investigate the associations between maternal B-vitamin intake and supplement use during pregnancy and CHDs. RESULTS Higher maternal dietary and total intake of folate and vitamin B12 were associated with reduced risk of CHDs, and the tests for linear trend were significant. Compared with non-users, maternal FA + VB6 + VB12 containing supplement use during pregnancy (OR 0.61, 95%CI 0.40-0.94), FA supplement use during pregnancy (OR 0.70, 95%CI 0.50-0.98) and in the first trimester (OR 0.62, 95%CI 0.46-0.85) were associated with a lower risk of CHDs. CONCLUSIONS The findings of this study suggest that a higher intake of folate and vitamin B12 during pregnancy reduces the risk of CHDs.
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Affiliation(s)
- Ruo Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 Xiwu Road, Xi'an, 710004, Shaanxi Province, China
| | - Leqian Guo
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi Province, China
| | - Doudou Zhao
- Translational Medicine Center, Northwest Women's and Children's Hospital of Xi'an Jiaotong University Health Science Center, 1616 Yanxiang Road, Xi'an, 710061, Shaanxi Province, China
| | - Pengfei Qu
- Translational Medicine Center, Northwest Women's and Children's Hospital of Xi'an Jiaotong University Health Science Center, 1616 Yanxiang Road, Xi'an, 710061, Shaanxi Province, China
| | - Shaonong Dang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, 76 Yanta West Road, Xi'an, 710061, Shaanxi Province, China. .,Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, 710061, Shaanxi Province, China.
| | - Hong Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, 76 Yanta West Road, Xi'an, 710061, Shaanxi Province, China. .,Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, 710061, Shaanxi Province, China. .,Nutrition and Food Safety Engineering Research Center of Shaanxi Province, Xi'an, 710061, Shaanxi Province, China.
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Yang J, Cheng Y, Zeng L, Dang S, Yan H. Maternal dietary diversity during pregnancy and congenital heart defects: a case-control study. Eur J Clin Nutr 2020; 75:355-363. [PMID: 32235888 DOI: 10.1038/s41430-020-0617-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 03/11/2020] [Accepted: 03/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND/OBJECTIVES Maternal diet is critical to fetal development. This study aimed to explore the association between maternal dietary diversity during pregnancy and congenital heart defects (CHD) in Chinese population. METHODS A hospital-based case-control study was conducted including 474 cases and 948 controls in Northwest China. We recruited eligible women waiting for delivery in the hospital and gathered their diets during the whole pregnancy by a validated food frequency questionnaire. According to the FAO Minimum Dietary Diversity for Women (MDD-W) guideline, the participants were categorized into "inadequate dietary diversity score (DDS)" (DDS < 5) and "adequate DDS" (DDS ≥ 5) groups. The association between dietary diversity and CHD was estimated using the mixed logistic regression models. RESULTS Case mothers had a lower DDS during pregnancy than the controls (P < 0.001). The proportions of women consuming all the ten defined food groups were lower in the inadequate DDS group than in the adequate DDS group among both cases and controls (all P < 0.001). The prevalence of inadequate micronutrient intake was higher in the inadequate DDS group than in the adequate DDS group among both cases and controls (all P < 0.05). Women in the adequate DDS group had reduced risks of having fetuses with total CHD (OR = 0.62, 95% CI = 0.45-0.84) and ventricular septal defects (OR = 0.58, 95% CI = 0.38-0.88). CONCLUSIONS Adequate DDS during pregnancy might be associated with a lower risk of CHD in offspring. Efforts to promote dietary diversity during pregnancy need to be strengthened to reduce the prevalence of CHD in Chinese population.
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Affiliation(s)
- Jiaomei Yang
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Yue Cheng
- Department of Nutrition and Food Safety, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Lingxia Zeng
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Shaonong Dang
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China. .,Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, China.
| | - Hong Yan
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China. .,Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, China. .,Nutrition and Food Safety Engineering Research Center of Shaanxi Province, Xi'an, Shaanxi, China.
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11
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Parental non-hereditary teratogenic exposure factors on the occurrence of congenital heart disease in the offspring in the northeastern Sichuan, China. Sci Rep 2020; 10:3905. [PMID: 32127562 PMCID: PMC7054293 DOI: 10.1038/s41598-020-60798-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/14/2020] [Indexed: 11/09/2022] Open
Abstract
Nonhereditary factors play an important role in the occurrence of congenital heart disease (CHD). This study was to explore the possible parental nonhereditary exposure factors relevant to the occurrence of CHD in the northeastern Sichuan area. A total of 367 children with CHD and 367 children without congenital malformations aged 0 to 14 years old were recruited from the Affiliated Hospital of North Sichuan Medical College and Nanchong Central Hospital between March 2016 and November 2018. This study was designed as a case-control study with 1:1 frequency matching, in which the parents of cases and controls were interviewed with the same questionnaire according to the gestational age of the child, maternal age during pregnancy and the same maternal race/ethnicity. Then, 322 matched case-control pairs were analysed by SPSS 22. Thirty-one suspicious factors were entered into the binary logistic regression analysis after univariate regression analysis of 55 factors (alpha = 0.05). The analysis results showed that 7 factors were significantly associated with the occurrence of CHD. Thus, augmenting maternal mental healthcare, improving the quality of drinking water, obtaining adequate nutrition, maintaining a healthy physical condition during pregnancy, enhancing parents’ level of knowledge and maintaining a healthy lifestyle may lower the occurrence of CHD.
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12
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Kalisch-Smith JI, Ved N, Sparrow DB. Environmental Risk Factors for Congenital Heart Disease. Cold Spring Harb Perspect Biol 2020; 12:a037234. [PMID: 31548181 PMCID: PMC7050589 DOI: 10.1101/cshperspect.a037234] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Congenital heart disease (CHD) has many forms and a wide range of causes. Clinically, it is important to understand the causes. This allows estimation of recurrence rate, guides treatment options, and may also be used to formulate public health advice to reduce the population prevalence of CHD. The recent advent of sophisticated genetic and genomic methods has led to the identification of more than 100 genes associated with CHD. However, despite these great strides, to date only one-third of CHD cases have been shown to have a simple genetic cause. This is because CHD can also be caused by oligogenic factors, environmental factors, and/or gene-environment interaction. Although solid evidence for environmental causes of CHD have been available for almost 80 years, it is only very recently that the molecular mechanisms for these risk factors have begun to be investigated. In this review, we describe the most important environmental CHD risk factors, and what is known about how they cause CHD.
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Affiliation(s)
| | - Nikita Ved
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, Oxfordshire OX1 3PT, United Kingdom
| | - Duncan Burnaby Sparrow
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, Oxfordshire OX1 3PT, United Kingdom
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13
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Yang J, Kang Y, Cheng Y, Zeng L, Shen Y, Shi G, Liu Y, Qu P, Zhang R, Yan H, Dang S. Iron intake and iron status during pregnancy and risk of congenital heart defects: A case-control study. Int J Cardiol 2020; 301:74-79. [DOI: 10.1016/j.ijcard.2019.11.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 10/14/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
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Xia YQ, Zhao KN, Zhao AD, Zhu JZ, Hong HF, Wang YL, Li SH. Associations of maternal upper respiratory tract infection/influenza during early pregnancy with congenital heart disease in offspring: evidence from a case-control study and meta-analysis. BMC Cardiovasc Disord 2019; 19:277. [PMID: 31791237 PMCID: PMC6889668 DOI: 10.1186/s12872-019-1206-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 09/24/2019] [Indexed: 01/04/2023] Open
Abstract
Background Evidences regarding the associations between maternal upper respiratory tract infection/influenza during pregnancy and the risk of congenital heart disease (CHD) is still controversial. This study was specifically designed to examine the associations by a case-control study and a meta-analysis of the published evidences and our finding. Methods A hospital-based case-control study involving 262 children with simple CHD and 262 children with complex CHD, along with 262 control children, was conducted through June, 2016 to December, 2017. All children were aged 0–2 years old. Furthermore, a meta-analysis based on both previously published studies and our case-control study was performed. Results In the case-control study, after adjusting for possible confounders, maternal upper respiratory tract infection/influenza during early pregnancy was found to be related to an increased risk of CHD (OR = 3.40 and 95% CI: 2.05–5.62 for simple CHD; OR = 2.39 and 95% CI: 1.47–3.88 for complex CHD). After a meta-analysis, the adverse impact was still kept significant (OR = 1.47 and 95% CI: 1.28–1.67 for simple CHD; OR = 1.44 and 95% CI: 1.14–1.75 for complex CHD). The very similar associations were also observed among single type of CHD, herein, ventricular septal defects (VSD) and tetralogy of fallot (TOF) in the case-control study. In the subsequent meta-analysis, however, the significant association only existed in VSD. Conclusions Although there is still conflicting in TOF, the results are overall consistent, which provide new enforced evidence that maternal upper respiratory tract infection/influenza during early pregnancy, in general, play an important role in the occurrence of CHD.
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Affiliation(s)
- Y Q Xia
- School of Public Health, Shanghai Jiao Tong University, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China
| | - K N Zhao
- School of Public Health, Shanghai Jiao Tong University, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China
| | - A D Zhao
- School of Public Health, Shanghai Jiao Tong University, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China
| | - J Z Zhu
- China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - H F Hong
- Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Y L Wang
- Prenatal Diagnosis Department, International Peace Maternity & Child Health Hospital, Shanghai Jiao Tong University School of Medicine, 910 Hengshan Road, Xuhui District, Shanghai, 200030, China.
| | - S H Li
- School of Public Health, Shanghai Jiao Tong University, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China.
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Zhang S, Wang L, Yang T, Chen L, Zhao L, Wang T, Chen L, Ye Z, Zheng Z, Qin J. Parental alcohol consumption and the risk of congenital heart diseases in offspring: An updated systematic review and meta-analysis. Eur J Prev Cardiol 2019; 27:410-421. [PMID: 31578093 DOI: 10.1177/2047487319874530] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this study was to provide updated evidence to assess the association between parental alcohol consumption and the risk of total congenital heart diseases (CHDs) and specific CHD phenotypes in offspring, and explore the possible dose-response pattern. METHODS PubMed, Embase and Chinese databases were searched with an end-date parameter of July 24, 2019 to identify studies meeting pre-stated inclusion criteria. A random-effects model was used to calculate the overall combined risk estimates. A meta-analysis of the dose-response relationship was performed. Subgroup analysis, sensitivity analysis, and Galbraith plot were conducted to explore potential heterogeneity moderators. RESULTS A total of 55 studies involving 41,747 CHD cases and 297,587 controls were identified. Overall, both maternal (odds ratio (OR) = 1.16; 95% confidence interval (CI): 1.05-1.27) and paternal (OR = 1.44; 95% CI: 1.19-1.74) alcohol exposures were significantly associated with risk of total CHDs in offspring. Additionally, a nonlinear dose-response relationship between parental alcohol exposure and risk of total CHDs was observed. With an increase in parental alcohol consumption, the risk of total CHDs in offspring also gradually increases. For specific CHD phenotypes, a statistically significant association was found between maternal alcohol consumption and risk of tetralogy of fallot (OR = 1.20; 95% CI: 1.08-1.33). Relevant heterogeneity moderators have been identified by subgroup analysis, and sensitivity analysis yielded consistent results. CONCLUSIONS Although the role of potential bias and evidence of heterogeneity should be carefully evaluated, our review indicates that parental alcohol exposures are significantly associated with the risk of CHDs in offspring, which highlights the necessity of improving health awareness to prevent alcohol exposure during preconception and conception periods.
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Affiliation(s)
- Senmao Zhang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Lesan Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Tubao Yang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Lizhang Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Lijuan Zhao
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Letao Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Ziwei Ye
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Zan Zheng
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
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Dong Y, Zhang Y, Tong S, Jiang Z, Xu Z, Li X, Wang W. Analysis of the Seasonal Trend of Congenital Heart Defects. J Pediatr 2019; 207:29-33.e1. [PMID: 30922502 DOI: 10.1016/j.jpeds.2018.12.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the seasonal trend of congenital heart defects (CHDs) in China using hospital-based clinical data. STUDY DESIGN We included 40 501 patients with CHD hospitalized at the Shanghai Children Medical Center between 2006 and 2017. The birth rate of CHD in each month was adjusted by sex, year of birth, and monthly birth rate of the general population. Negative binomial regression models were used to assess the seasonal trend of CHD. RESULTS The included patients consisted of 22 600 boys (55.8%), resulting in a male-to-female ratio of 1.26:1. Among subtypes of CHDs, ventricular septal defects and atrial septal defects were the most common, accounting for 39.7% and 12.6%, respectively. A statistically significant seasonal trend in the monthly birth rate of patients with CHDs was found; the highest relative rate of CHD was found in October and the lowest in April. After adjusting for the potential confounders, the highest relative rate of CHD was found in October and the lowest in November. CONCLUSIONS There seems to be a significant monthly birth rate variation of CHDs in China. The highest relative rate of CHDs occurred in October, suggesting possible maternal exposure to environmental hazards from January to March. These hazards may include air pollution, virus infection, and unhealthy lifestyle behaviors during the Spring Festival.
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Affiliation(s)
- Yuanyuan Dong
- Child Health Advocacy Institute, Shanghai Children's Medical Center, Shanghai Jiaotong University, School of Medicine, Shanghai, PR China
| | - Yunting Zhang
- Child Health Advocacy Institute, Shanghai Children's Medical Center, Shanghai Jiaotong University, School of Medicine, Shanghai, PR China
| | - Shilu Tong
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Department of Clinical Epidemiology and Biostatistics, Shanghai Children's Medical Center, Shanghai Jiaotong University, School of Medicine, Shanghai, PR China
| | - Zhongyi Jiang
- Child Health Advocacy Institute, Shanghai Children's Medical Center, Shanghai Jiaotong University, School of Medicine, Shanghai, PR China
| | - Zhiwei Xu
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Xinyue Li
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT
| | - Wei Wang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University, School of Medicine, Shanghai, PR China.
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