Prevalence and Influencing Factors of Eczema Among Preschool Children in Urumqi City: A Cross-Sectional Survey

doi:10.21203/rs.3.rs-132229/v1

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Prevalence and Influencing Factors of Eczema Among Preschool Children in Urumqi City: A Cross-Sectional Survey

https://doi.org/10.21203/rs.3.rs-132229/v1

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published 16 Aug, 2021

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Background: We explored the prevalence of eczema and indoor environmental factors in preschool children in Urumqi, Xinjiang, to provide a strong basis for the prevention and control of preschool eczema.

Methods: Using stratified random cluster sampling, we conducted a self-administered questionnaire survey among 8153 parents of children aged 2–8 years in 60 kindergartens in six districts of Urumqi City during August 2019.

Results: For the 8153 preschool children with valid data, the parent-reported prevalence of eczema was 12.0%. Multivariate logistic regression analysis showed that cesarean section (odds ratio [OR] = 1.18, 95% confidence interval [CI]: 1.03–1.36), being an only child (OR = 1.36, 95% CI: 1.18–1.57), mold or moisture in the mother’s residence before pregnancy (OR = 1.53, 95% CI: 1.17–2.00), flies or mosquitoes in the dwelling currently (OR = 1.31, 95% CI: 1.10–1.55), pets kept in the child’s current residence (OR = 1.23, 95% CI: 1.01–1.51), presence of pets when the child is 0–1 year old (OR = 1.45, 95% CI: 1.14–1.85), and family history of eczema (OR = 3.53, 95% CI: 2.98–4.19) are risk factors, whereas ethnicity other than Han Chinese (OR = 0.77, 95% CI: 0.61–0.96) is a protective factor, for eczema.

Conclusion: Preschool children in Urumqi are at a high risk of eczema, especially those of Han Chinese ethnicity. Parents should pay close attention to the indoor living environment of children and must reduce indoor humidity, pay attention to pest control and elimination, and avoid raising pets to reduce the risk of children developing eczema.

Pediatrics

indoor environment

preschool children

eczema

pets

Eczema is an allergic skin condition with symptoms including skin damage, swelling, itching and recurrent rashes. The symptoms in children have a complex etiology and are usually thought to be caused by a combination of environmental and genetic factors[1]. Eczema causes itching, which can lead to sleep disturbances in children and even affect physical and mental development in severe cases. Eczema can develop into asthma or rhinitis, and the treatment of eczema and its triggers can also impose an economic burden on the patient[2–4].

Many domestic and international studies have analyzed the factors associated with the prevalence of eczema in preschool children. In one such study conducted in 10 provinces and cities in China, a survey analysis of acute allergies and eczema showed that the prevalence of eczema in children ranged from 4.8 to 15.8%[5]. In contrast, two studies in the United States and Sweden showed that the prevalence of eczema was 20% and 23%, respectively[6–7]. In recent years, China’s economy has developed rapidly, the demand for housing has increased, and a large number of families are keeping pets at home. Eczema has been associated with animal contact, poor ventilation, and living in a large city with heavy traffic[8]. Located in the central part of Xinjiang, Urumqi is a multi-ethnic gathering place with a hot and dry climate. Moreover, due to the special living and eating habits of Xinjiang people, the incidence of asthma, pneumonia, and allergic rhinitis is relatively high[5, 9], but large-scale epidemiological investigation of eczema has been rare. There is a lack of research on the prevalence of eczema and the factors influencing the prevalence of eczema in minority-populated areas of Xinjiang, and even less research on the effects of eczema in preschool children.

For the above reasons, this survey, considering the actual situation and special environment of Urumqi, was conducted in August 2019 in Urumqi’s 60 kindergartens in six districts: Xinshi, Saybag, Tian Shan, Shuimugou, Toutunhe, and Midong. We surveyed the parents of 8,153 preschool children regarding their indoor living conditions and the prevalence of eczema. The risk factors influencing the prevalence of eczema in preschool children were investigated with the expectation that relevant indoor environmental factors of childhood eczema could be identified. The results of this survey are summarized and analyzed to provide recommendations for future prevention and control of eczema in preschool children in Xinjiang.

Subjects

In this cross-sectional study, children were selected using a stratified random cluster sampling method in daycare centers in Urumqi. Stratified by six administrative areas in Urumqi (including Xinshi, Tian Shan, Toutunhe, Saybag, Midong, and Shuimogou), eight to twelve daycare centers in each administrative area were randomly selected. The parents of all the children in each daycare center were invited to participate in the questionnaire survey. The parents of 8153 children in 60 daycare centers received the questionnaire. The ethnic distribution of responders was primarily Han, with fewer ethnic minority participants, mainly composed of Uyghurs, Kazaks, and other unnamed minorities, accounting for approximately 13.1%. The survey was conducted in the summer of 2019.

Questionnaire

The questionnaire survey was conducted in daycare centers. We contacted the Urumqi Education Bureau and the head of each kindergarten and conducted unified professional training for the teachers in charge of the surveyed classes before the survey. The questionnaires were sent to the kindergartens, and the kindergarten teachers distributed them to the parents of the children They took the questionnaire home and were supposed to complete and return it within 1 week to the teacher in charge of the kindergarten. The teacher then sent the questionnaire to the head of the kindergarten. After the head of the school collected all the questionnaires from the kindergarten, the completed questionnaires were sent to the Urumqi Education Bureau.

The questionnaire was made in accord with the ALLHOME-2 in Naydenov’s[10] doctoral thesis and the questionnaire used by Bornehag in the Dampness in Buildings and Health survey study[11], with some minor revisions based on specific conditions in China and Urumqi. The survey had the following six components: (1) demographic characteristics, including sex, ethnicity, education level, and home address; (2) feeding status, including whether the child is an only child, whether the child was breastfed, the duration of breastfeeding, and the age at which the child attended kindergarten; (3) health conditions of the child and family members, including wheezing, asthma, pneumonia, allergic rhinitis, and other related symptoms; (4) the child’s living environment, including the type of housing, whether it is furnished, and the presence of new furniture, ventilation, and smoke extraction; (5) living habits, including animals, plants, frequency of cleaning, and smoking in the child’s residence; and (6) eating habits, including type and frequency of food consumption. The questionnaires were completed by the parents of the children, and all questionnaires were reviewed by two or more trained members of the team to eliminate incomplete questionnaires.

Eczema was considered to be present if parents reported having a clear diagnosis of eczema. The frequency of cleaning the child’s room was categorized as frequent if cleaning occurred at least twice a week; occasional if cleaning occurred less than twice a week but more than once every 2 weeks; and rarely if cleaning occurred less than once every 2 weeks[12]. Passive smoking refers to the exposure of a nonsmoker to smoke from a lit cigarette or smoke exhaled by a smoker at least 1 day per week[13].

Statistical analyses

A database was created using Epi Data 3.1 software. A single-factor c2 test was performed using SPSS 25.0 software, and a multifactor logistic regression model was used to analyze potential eczema risk factors. P < 0.05 was considered statistically significant.

A total of 8,153 preschool children were surveyed in this study. The total number of people investigated was 10,000, yielding a response rate of 81.5% (Table 1). Boys comprised 4235 (51.9%) and girls comprised 3918 (48.1%) of the children. The youngest child was 2 years old, the oldest was 7.83 years old, and the average age was 5.27 ± 1.10 years. There are 7,081 Han Chinese, accounting for 86.9% of the total, and 1,072 belonging to other ethnic groups, accounting for 13.1% of the total.

Table 1

Prevalence of eczema among preschool children with different characteristics in Urumqi (n = 8,153)
Characteristics	Number of people surveyed	Number of cases of recurrent rashes for 6 months in the past 12 months	Percentage (%)	P	Number of previous cases of recurrent rash for 6 months	Percentage (%)	P	Number of confirmed eczema cases	Percentage (%)	P
Sex
Boys	4235	103	2.4	0.69	364	8.6	< 0.01	530	12.5	0.12
Girls	3918	90	2.3	0.69	271	6.9	< 0.01	447	11.4	0.12
Nationality
Han Chinese	7081	172	2.1	0.35	567	8.0	0.06	873	12.3	0.01
Other	1072	21	0.3	0.35	68	6.3	0.06	104	9.7	0.01
Age (years)
2–4	1033	31	3.0	0.34	83	8.0	0.93	112	10.8	0.48
4–6	4828	108	2.2		372	7.7		585	12.1
6–8	2292	54	2.4		180	7.9		280	12.2
Mode of birth
Normal childbirth	4187	97	2.3	0.76	313	7.5	0.28	449	10.7	< 0.01
Cesarean delivery	3966	96	2.4	0.76	322	8.1	0.28	528	13.3	< 0.01
Only child
Yes	4569	112	2.5	0.57	374	8.2	0.13	605	13.2	< 0.01
No	3584	81	2.2	0.57	261	7.3	0.13	372	10.4	< 0.01
Totals	8153	193	2.4		635	7.8		977	12.0

The percentage of those who had recurrent rashes for 6 months in the past 12 months was 2.3%, with no significant differences between characteristics (all P > 0.05); 7.8% had previous cases of recurrent rash for 6 months, with a higher incidence in boys than in girls (P < 0.05). The percentage of participants with confirmed eczema was 12.0%, with a higher incidence among Han Chinese than among other ethnic minorities. There was also a higher incidence of eczema in children born via cesarean delivery compared with those born via normal delivery and in only children compared with children with siblings (all P < 0.05) (Table 1).

The survey showed that the following were the main environmental risk factors influencing the development of eczema in preschool children: purchase and use of new furniture and furnishings and mildew or dampness in the mother’s home before and during pregnancy and during the time the child is 0–1 year old; air conditioning; windows being open while sleeping; the presence of cockroaches, flies or mosquitoes in the dwelling currently and when the child is 0–1 year old; pets or flowering plants in the dwelling; passive smoking in the residence currently, when the child is 0–1 year old, and during the mother’s pregnancy; frequency of room cleaning; and family history of eczema (all P < 0.05) (Table 2).

Table 2

Single-factor analysis of eczema and indoor environmental variables (n = 8,153)
Factors	Diagnosed with eczema
	Number of cases	%	P
Housing area
< 75 m2	239	12.1	0.91
≥ 75 m2	738	12.0	0.91
Carpeting or mats in the home
Yes	133	13.9	0.06
No	844	11.7	0.06
Acquisition of new furniture in the mother's pre-pregnancy home
Yes	255	14.3	< 0.01
No	722	11.3	< 0.01
Renovation of the mother's pre-pregnancy home
Yes	182	15.2	< 0.01
No	795	11.4	< 0.01
Mold or dampness in the mother's pre-pregnancy dwelling
Yes	176	20.1	< 0.01
No	801	11.0	< 0.01
Acquisition of new furniture in the mother's residence during pregnancy
Yes	135	15.5	< 0.01
No	842	11.6	< 0.01
Renovation of the mother's residence during pregnancy
Yes	100	17.0	< 0.01
No	877	11.6	< 0.01
Mold or dampness in the mother's home during pregnancy
Yes	137	20.1	< 0.01
No	840	11.2	< 0.01
Purchase of new furniture in the residence when the child is 0–1 year old
Yes	117	16.0	< 0.01
No	860	11.6	< 0.01
Renovation of the residence when the child is 0–1 year old
Yes	85	17.5	< 0.01
No	892	11.6	< 0.01
Mold or dampness in the residence when the child is 0–1 year old
Yes	116	19.0	< 0.01
No	861	11.4	< 0.01
Drying bedding
Yes	883	12.1	0.37
No	94	11.0	0.37
Use of air conditioning
Yes	337	13.2	0.02
No	640	11.4	0.02
Open window while sleeping
Yes	893	12.4	< 0.01
No	84	8.9	< 0.01
Cockroaches
Yes	319	14.2	< 0.01
No	658	11.1	< 0.01
Flies or mosquitoes
Yes	778	13.4	< 0.01
No	199	8.5	< 0.01
Pets in the child's current residence
Yes	203	17.5	< 0.01
No	774	11.1	< 0.01
Flowering plants in the child's current residence
Yes	343	14.0	< 0.01
No	634	11.1	< 0.01
Keeping pets in the child's residence when the child is 0–1 year old
Yes	136	20.6	< 0.01
No	841	11.2	< 0.01
Flowering plants in the child's home at the age of 0–1 year
Yes	274	14.7	< 0.01
No	703	11.2	< 0.01
Passive smoking in the child's current residence
Yes	417	14.0	< 0.01
No	560	10.8	< 0.01
Passive smoking in the dwelling when the child is 0–1 year old
Yes	359	14.6	< 0.01
No	618	10.9	< 0.01
Passive smoking in the mother's residence during pregnancy
Yes	315	15.3	< 0.01
No	662	10.9	< 0.01
Frequency of room cleaning
Regularly	809	11.6	0.02
Occasionally	156	14.5
Very seldom	12	14.6
Family history of eczema
Yes	252	30.3	< 0.01
No	725	8.9	< 0.01

The variables that were meaningful in the single-factor analysis together with whether or not the child had eczema as the dependent variable (0 = no; 1 = yes) were included in our multifactorial logistic regression analysis. The eight variables that were eventually included as main effects in the logistic regression model were associated with the onset of eczema. Of these, birth mode, only child, presence of mold or moisture in the mother's prepregnancy residence, flies or mosquitoes, pets in the child’s current residence, pets in the child’s residence at age 0–1 year, and family history of eczema were risk factors; ethnicity (i.e., not Han Chinese) was deemed a protective factor against eczema (Table 3).

Table 3

Multifactorial logistic regression analysis of risk factors for eczema in preschool children in Urumqi (n = 8,153)
Factors	Reference group	P	OR	95% CI
Ethnicity	Han ethnic group	0.02	0.77	0.61–0.96
Mode of birth	Normal childbirth	0.02	1.18	1.03–1.36
Only child	No	< 0.01	1.36	1.18–1.57
Mildew or dampness in the mother's pre-pregnancy dwelling	No	< 0.01	1.53	1.17–2.00
Flies or mosquitoes	No	< 0.01	1.31	1.10–1.55
Pets in the child's current residence	No	0.04	1.23	1.01–1.51
Keeping pets in the child's residence when the child is 0–1 year old	No	< 0.01	1.45	1.14–1.85
Family history of eczema	No	< 0.01	3.53	2.98–4.19
Abbreviations: OR, odds ratio; CI, confidence interval.

Eczema is a multifactorial inflammatory skin reaction, and a meta-analysis has shown that the prevalence of eczema is nearly 30%[14] in developed countries. The current study showed that 2.4% of preschool children aged 2–8 years in Urumqi, Xinjiang, reported recurrent rash symptoms in the past 12 months, 7.8% of children reported a previous recurrent rash that lasted for 6 months, and 12.0% of children reported having been diagnosed with eczema. A damp home environment, the presence of flies or mosquitoes, and keeping pets indoors were risk factors for the development of eczema. In a 2010 survey of preschool children in 10 Chinese cities, Zhang et al.[5] found a 13.3% prevalence of eczema in children in Urumqi in the past 12 months, and in 2011, Wang et al.[6] found a previous prevalence of eczema of 15%. These results along with findings in other cities such as Wuhan[15] and Shenyang[4] indicate that Urumqi has a relatively low prevalence of eczema, which may be related to the environment of Urumqi.

Previous foreign studies found a significant association between a previous allergic disease in either the father or mother and the development of eczema in infants[16-17], suggesting that genetic factors may be involved in the development of eczema. The present study also confirms the finding that a family history of eczema is a risk factor for the development of eczema. It has been suggested that genetic factors that contribute to the development of eczema may be related to the filagrin gene (FLG), which is the main gene encoding filoproteinogen, and patients with acute eczema can have reduced FLG activity[18-19]. Furthermore, animal studies conducted by Ge et al.[20] have suggested that acute eczema may be due to decreased FLG expression and increased protease-activated receptors and the amount of transepidermal water loss in skin tissue, thereby disrupting skin barrier function and inducing eczema[20]. The FLG gene is also prone to mutation, and mutations in FLG can affect the integrity of the skin, thus reducing the skin’s barrier capacity against allergens. Invasion by foreign substances stimulates the antigen-presenting cells to activate Th2 cells, which then induces metamorphosis[21-22].

This survey found that ethnicity is a protective factor for eczema, with ethnic minorities having a lower prevalence of eczema than Han Chinese, which is similar to the results of Zhao et al.[23], who found that the incidence of eczema was higher in the Han Chinese than in the Uyghur population in spring, autumn, and winter. However, owing to the lack of comparative studies between the Han Chinese and other ethnic groups, the reasons for this are not yet known. With this study, we speculate that the reason for this is not only related to the genetic differences between the ethnic minorities and Han populations, but also most likely to be a result of the living habits of the different ethnic groups. The people in Xinjiang have unique dietary patterns, especially the ethnic minorities, who prefer pasta and beef and mutton and use less seafood. Studies have proposed that maternal use of allergenic foods such as seafood during pregnancy and delivery is a key risk factor for the development of eczema in infants[24]. In addition to these factors, the living and resting patterns and family and marital relationships of ethnic minorities in Xinjiang also differ greatly from those of the Han Chinese. These factors may be associated with the onset of eczema[22]. Therefore, the risk of eczema is lower in ethnic minorities than in Han Chinese. Regarding birth mode, a number of studies have confirmed that cesarean section has an important impact on the development and maturation of the neonatal immune system, which may be due to the imbalance of the intestinal flora of these infants, leading to immune dysfunction and increasing the immunity, which in turn can lead to the occurrence of conditions such as allergies and autoimmunity[25-26]. This conclusion was confirmed in the investigation by Azad et al.[27] who showed that the richness and diversity of the intestinal flora of infants born via cesarean section were low.

Pets can increase levels of endotoxins and allergens in the environment, and many studies have shown that exposure to such substances early in life is effective in reducing the risk of asthma and allergic disease[28-29]; however, many other studies have also cited household pets as a risk factor for the development of asthma and allergic disease[11,30-32]. This difference may be related to the dry climate of Xinjiang, which is suitable for the dispersal of endotoxins and allergens from the environment. Children are exposed to excessive amounts of endotoxins and allergens from prolonged contact with pets, thereby increasing the risk of eczema. Therefore, pets should be avoided in children’s homes. In addition, flies and mosquitoes were also risk factors for the development of eczema in this study, but there is a lack of information on flies and mosquitoes in China and abroad. Eczema and other allergic diseases have been studied, and we consider the causes to be the same as pets causing the onset of eczema, in addition to mosquito bites, which can cause skin irritation. As the weather in Xinjiang is hot and dry, few families have dampness in their homes, and a humid environment is more suitable for mosquitoes to grow and breed. It is also suitable for the growth of dust mites and fungi in the house. According to Chen et al.[33], the second most common allergen of eczema is mold, consistent with this study’s finding that the presence of mold or dampness indoors is a risk factor for the development of eczema; thus, good pest control and dehumidification can help reduce the incidence of eczema in children.

In summary, identification of indoor environmental risk factors for the development of eczema is of great practical importance in preventing the onset of eczema in children.

Eczema has higher risk among preschoolers in Xinjiang, especially han children. cesarean section, mold or moisture in the mother’s residence before pregnancy, flies or mosquitoes in the dwelling currently, pets kept in the child’s current residence, presence of pets when the child is 0–1 year old, and family history of eczema, can increase the risk of eczema in children.

CI: confidence interval; OR: odds ratio

Acknowledgements

Acknowledgement is given to National Natural Science Foundation of China (grant no. 81861138005) and National Natural Science Foundation of China (grant no. 81860179) for initiatingthe original research project. Researchers within the Department of Public health of Xinjiang Medical University and Urumqi Education Bureau must also beacknowledged for assisting with data collection.

Authors Contributions

Nanhao Shi designed the study, participated in the field investigation phase, and wrote the airicle.

Tingting Wang and Guangsheng Wan onceptualized and designed the study, and reviewed and revised the manuscript.

Jia Zhu, Lan Jiang, Shaowei Ma, Jian Yao, Zhe Yin, Murizhati Maimaiti, Huijuan Dong participated in the field investigation phase.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Funding

All phases of this study were supported by National Natural Science Foundation of China (grant no. 81861138005) and National Natural Science Foundation of China (grant no. 81860179).

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due the data belongs to the School of Public Health of Fudan University but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study passed the ethical review of the First Affiliated Hospital of Xinjiang Medical University, and obtained the informed consent of parents and head teachers of all the children investigated.

Consent for publication

N/A

Competing interests

The authors declare that they have no competing interests.

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Prevalence and Influencing Factors of Eczema Among Preschool Children in Urumqi City: A Cross-Sectional Survey

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