What Causes a 1 Year Old Baby to Have Low Iron

Blood Res. 2016 Dec; 51(4): 268–273.

Atomic number 26 deficiency anemia in infants and toddlers

Eun Immature Joo

Department of Pediatrics, Inha University College of Medicine, Incheon, Korea.

Keun Young Kim

Department of Pediatrics, Inha Academy College of Medicine, Incheon, Korea.

Dong Hyun Kim

Department of Pediatrics, Inha University College of Medicine, Incheon, Korea.

Ji-Eun Lee

Department of Pediatrics, Inha University College of Medicine, Incheon, Korea.

Before long Ki Kim

Section of Pediatrics, Inha Academy College of Medicine, Incheon, Korea.

Received 2016 Jul 29; Revised 2016 October 20; Accustomed 2016 Nov 18.

Abstruse

Groundwork

In Korea, the prevalence of anemia and fe deficiency anemia (IDA) among older infants and young children remains high. To discover IDA early on and to reduce its adverse impact, nosotros assessed the characteristics of infants and young children who had IDA or were at adventure of developing IDA, or who exhibited characteristics associated with severe anemia.

Methods

Among the 1,782 IDA-affected children anile half-dozen months to 18 years who visited the infirmary, we retrospectively analyzed the medical records and laboratory information of 1,330 IDA-affected children aged 6–23 months who were diagnosed between 1996 and 2013. We excluded patients with a C-reactive poly peptide level ≥v mg/dL.

Results

IDA was predominant in boys (2.14:ane) during infancy and early childhood. The peak IDA incidence was noted among infants aged ix–12 months. Just 7% patients exhibited symptoms of IDA, while 23.6% patients with astringent IDA demonstrated classic symptoms/signs of IDA. Low nascence weight (LBW) infants with IDA demonstrated low adherence to iron supplementation. In a multivariate assay, prolonged breastfeeding without iron fortification (odds ratio [OR] 5.70), and a LBW (OR 6.49) were identified as take a chance factors of astringent anemia.

Conclusion

LBW infants need more attention in social club to increase their adherence to iron supplementation. For the early detection of IDA, nutritional status of all infants, and atomic number 26 batteries of high-risk infants (LBW infants, infants with prolonged breastfeeding, picky eaters, and/or infants with the presence of IDA symptoms) should be evaluated at their health screening visits.

Keywords: Iron deficiency anemia, Baby, Kid, Risk factors, Breastfeeding, Low nascence weight

INTRODUCTION

The prevalence of anemia and fe deficiency anemia (IDA) remains high in tardily infancy and early childhood despite the increased breastfeeding rate, improvements in public health, and development of fe-fortified foods [1,2,3,iv]. Hopkins et al. [2], using the anemia definition fix forth by the Earth Health Organization (WHO) (hemoglobin [Hb] <11 g/dL), showed that the prevalence of anemia was 23% at 8 months of age, and eighteen% at 12 months of age. The prevalence of non-anemic iron deficiency may exist as loftier equally thirty% in toddlers from developed countries [3,5,half dozen]. Co-ordinate to the WHO criteria, anemia prevalence was estimated at 15% in Korean preschool-aged children (6–59 mo), and to date, anemia remains an important wellness concern [vii]. Additionally, the demands and expenses for infirmary intendance for IDA-affected children take increased from 2006 to 2014 [8].

IDA in infants remains underdiagnosed as infant blood sampling and obtaining sufficient blood volume for laboratory detection of IDA are difficult. Virtually infants do not undergo blood tests unless reasonable clinical events are nowadays. Farther, the symptoms of IDA (pallor, irritability, poor feeding, fatigue, languor, and pica) are non-specific. Although anemia and fe deficiency are usually corrected by the age of 2–3 years, children are adversely affected by IDA.

IDA is associated with dumb neurocognitive function and exercise intolerance [nine,x,eleven,12], and the association exists even after its successful treatment [11]. Therefore, preventing the progression of atomic number 26 deficiency is peculiarly important during infancy and early babyhood when the rapid growth and development rate, especially of the brain [12], increases the vulnerability to IDA-induced impairment.

To observe IDA at an early age and to reduce the adverse affect of iron deficiency, nosotros assessed the clinical characteristics of infants and young children with IDA who visited the Inha University Hospital in the last 17 years. Nosotros investigated the distribution of IDA according to age (in months) and gender and analyzed the take a chance factors of severe IDA.

MATERIALS AND METHODS

Patients and written report design

Of the i,782 IDA patients who visited the pediatric section of the Inha University Hospital Pediatric Department between January 1997 and December 2013, 1,330 IDA patients aged 6–23 months were included in the study. Nosotros retrospectively reviewed the medical records of these patients. Additionally, nosotros conducted a questionnaire-based survey for IDA at pediatric hemato-oncology outpatient clinic to collect data regarding the following.: (ane) late initiation of weaning food – age at the initiation of weaning nutrient >half dozen months; (two) use of not-atomic number 26-fortified weaning food; (three) picky eaters, or infants who required more than 1 month for successful weaning; (4) moo-cow's milk intake during infancy or a high intake of cow's milk (>700 mL/day) after infancy; (5) IDA symptoms and signs such every bit pallor, pica or dark crying twice or more than per night; and (half dozen) no iron supplementation in low birth weight (LBW) infants.

From venous blood sampling, laboratory tests for Hb, hematocrit, mean corpuscular book (MCV), mean corpuscular hemoglobin (MCH), red cell distribution width (RDW), ferritin, and transferrin saturation (iron/total iron bounden capacity×100) were performed on venous claret samples. Laboratory test data were recorded for inpatients on the day of discharge, and for outpatients on their 2d visit except for when they visited the infirmary for health screening, vaccination, or symptoms of anemia. Anemia was defined and classified co-ordinate to the WHO criteria [xiii], and the severity of anemia was defined according to patients' Hb levels (severe anemia, Hb<7.0 yard/dL; moderate anemia, Hb vii.0–9.9 yard/dL; and balmy anemia, Hb 8.0–ten.9 thou/dL). IDA was divers as anemia with aberrant values for ii out of the three iron status parameters. The cut-off values for fe condition parameters were as follows: RDW elevation ≥15%, serum ferritin level <12 ng/mL, and/or transferrin saturation (TS) <sixteen%. Toddlers with microcytic anemia (MCV<70 fL), who did non exhibit whatsoever abnormal iron batteries, were diagnosed with IDA if an Hb increment of >i k/dL was observed after iv weeks of atomic number 26 treatment [13,xiv,fifteen]. We excluded children with a C-reactive protein (CRP) level ≥5 mg/dL to rule out active inflammation or bacterial infection. Prolonged breastfeeding was defined every bit sectional breastfeeding until >6 months of historic period. LBW was defined as a torso weight of <two.v kg at birth. Follow-upwards finish point was divers as Hb ≥eleven g/dL, and/or an Hb increment of >1 g/dL. Follow-up loss was defined as no visit after an IDA diagnosis or no Hb test results after iron supplementation treatment.

Statistical analysis

Statistical analysis was performed using IBM SPSS statistics software version 19. Descriptive statistics [hateful, standard difference (SD), and proportion] were calculated. Unpaired t-tests were used for group comparisons. Logistic regression and multiple regression analyses were performed to stratify the risk factors of severe anemia. For all statistical analyses, a P<0.05 was considered significant.

RESULTS

IDA was observed predominantly in boys than in girls [906 boys (M), and 424 girls (F); M:F=two.14:1]. The mean CRP level of the written report population was 0.62 (±i.01) mg/dL. The median follow-up duration was 10 days (range, 0–11 mo), and the follow-up loss rate was 47.ii% (N=628). The mean age of IDA was 11.9 (±3.9) months. The acme IDA incidence was observed among infants aged nine–12 months; the incidence and so decreased until the age of 18 months and exhibited a plateau thereafter (Fig. 1). The proportions of mild, moderate, and severe anemia were 36.9% (N=491), 59.3% (N=789), and iii.8% (Due north=50), respectively. Laboratory-based measurements for all parameters (MCV+ferritin+TS+RDW) were conducted in only 59.2% (Due north=788) of the patients, while simply MCV and RDW levels were measured in 86.5% of the patients (Table ane). In this written report, the mean gestational age of LBW infants was 35 (±2.5) weeks. Among the LBW infants, marginally LBW (MLBW) (body weight≤2 kg and <two.5 kg) was noted in 68.iv% infants.

Distribution of iron deficiency anemia in patients aged half dozen–23 months.

Table 1

Clinical characteristics of iron deficiency anemia in infants and young children aged <24 months (Due north=1,330).

The chief complaint at the time of hospital visit was the presence of upper respiratory symptoms (46.6%), followed past gastrointestinal symptoms such as airsickness or diarrhea (Table 2). Only vii.0% (North=96) of the patients visited the hospital due to symptoms of IDA, such as pallor, night irritability (≥ii arousals and/or cries), or pica. Fifty-fifty in cases where a subsequent diagnosis of severe anemia was made, simply 23.6% patients presented to the hospital with symptoms of IDA, and the remaining 76.4% were diagnosed based solely on laboratory tests, without any accompanying symptoms. The incidence of bleeding-induced IDA (melena, hematuria, epistaxis) was 0.viii% (N=11) in our study population.

Table 2

Primary complaints in infants and young children with iron deficiency anemia at the time of hospital visit.

The well-nigh common cause of IDA was prolonged breastfeeding without the use of iron-fortified foods or atomic number 26 supplementation (35.6%, N=474). Other causes of IDA included allergic diseases such as food allergy and atopic dermatitis (9.ii%, Northward=123), LBW (seven.i%, Northward=95), and a failure to thrive (2.8%, North=37), as listed in Table three.

Table three

The frequency of take chances factors in iron deficiency anemia affected infants and young children aged half-dozen to 23 months (multiple answers).

Yet, a multivariate analysis showed that a history of low birth weight was the mostly likely indicator of increased severe anemia risk (odds ratio [OR], half-dozen.49; 95% conviction interval [CI], 3.34–12.60). Prolonged breastfeeding without iron fortification (OR, v.70; 95% CI, two.67–12.19) was likewise associated with an increased risk of severe IDA in infants. Failure to thrive and the presence of allergic diseases did not increase the risk of severe anemia at infancy (Table 4). The rate of breastfeeding among LBW infants was 56.8%. Amidst the LBW infants, none of the MLBW infants received regular atomic number 26 supplements after belch from the neonatal unit of measurement, while merely 13% of the non-MLBW infants received regular atomic number 26 supplements.

Tabular array 4

Risk factors identified in a multiple regression analysis to exist associated with iron deficiency anemia and severe atomic number 26 deficiency anemia.

DISCUSSION

Nosotros assessed the clinical characteristics of IDA in infants and immature children. Similar to studies conducted in the U.s.a. [16], Sweden [17], and in Southeast Asia [18], IDA in infants was more prevalent in boys than in girls (K:F=2.14:one; historic period<2 yr). According to Domellöf et al. [17], at nine months of historic period, male infants have significantly lower Hb level and showroom a x-fold college run a risk of being diagnosed with IDA than female person infants. They further suggested that the reasons for increased IDA risk in the male infants were a college pre- and post-natal growth rate, an increased fetal erythropoietic activity resulting in a low iron storage state [17,nineteen], lower atomic number 26 absorption, larger intestinal iron loss, and more than frequent infections in boys than in girls. However, these gender-based differences disappear when iron-fortified foods are administered, and the amount of oral iron requirement is reported to be 6–ten mg/mean solar day [17,18].

In this written report, the highest prevalence of IDA was noted in the infants aged ix–12 months. This is due to an inadequate iron supply despite a high atomic number 26 requirement at this age [fourteen]. The estimated requirement for absorbed iron during the first year of infancy ranges between 0.55 mg/day and 0.75 mg/day [20]. Nonetheless, after 6 months of age, obtaining enough iron through breastfeeding lone becomes difficult. The mean iron level in chest milk is approximately 0.four mg/Fifty, and although half of the iron contained in breast milk is captivated due to its high bioavailability, just 0.2 mg/twenty-four hours of total iron tin exist absorbed by exclusive breastfeeding even if the baby consumes 1 L breast milk daily, which is nonetheless considerably less than the required iron corporeality [20,21]. Moreover, as the low fe-containing rice soup is unremarkably fed to the Korean infants during the early stages of weaning, infants may hands develop an atomic number 26 deficiency.

LBW infants are generally considered a take a chance grouping for IDA due to low iron stores at birth. Hence, iron supplementation is recommended for them; however, their adherence to fe supplementation is low. Preterm infants, who comprise a large proportion of LBW infants, have lower fe stores due to shorter third gestational trimesters when most of the atomic number 26 is accumulated. These infants have college iron requirements for catch-upwardly growth, and preterm infants should thus receive supplements of elemental atomic number 26 (2 mg/kg/24-hour interval) from 1 month to 12 months of age [22]. In this study, none of the MLBW infants had received iron supplements for more than than thirty days at the fourth dimension of IDA diagnosis. The demand for iron supplementation in MLBW infants has been debated in the past; however, iron supplementation has recently been recommended for MLBW infants (at a dose of 2 mg/kg/day) from half dozen weeks to 6 months of age [23]. We have previously reported significant differences in atomic number 26 supplementation and breastfeeding practices between LBW infants in the IDA and the non-IDA groups [24]. In LBW infants, the use of human milk fortifier until attainment of a body weight of 3 kg can also prevent IDA. We considered atopic dermatitis equally a possible take a chance factor for IDA as many mothers with atopic dermatitis-affected infants tend to breastfeed, and thus limit the food selection. Still, despite the prevalence of atopic dermatitis in Korea (26.five% among 12–23 mo-old children), our results point that atopic dermatitis is not a contributing factor to total IDA and has no effect on the adventure of severe anemia (OR, 1.38; 95% CI, 0.39–4.90).

The undiminishing prevalence of IDA amidst Korean toddlers could be due to several reasons. Commencement, according to the Korea National Health and Nutrition Examination Survey Half dozen-two, the charge per unit of breastfeeding has increased from 10.2% in 2000 to 45.6% in 2012 [25], while the implementation of iron supplementation has non been sufficient. Second, 47% of the exclusively breastfed infants require two months or more to conform to the weaning [26], and many homemade weaning foods accept low iron content. Third, in Korea, the incidence of LBW has increased from 2.7% in 1993 to v.half-dozen% in 2010. 4th, adherence to atomic number 26 supplementation is depression in LBW infants. Specifically, more than encouragement is required to implement iron supplementation in the MLBW infants. The inappropriate consumption of cow's milk is another important factor for the presence of IDA; an early introduction of cow's milk can cause IDA. The mean cow'southward milk introduction age is 14 months; yet, 6.half dozen% infants drink moo-cow's milk before 12 months of historic period [25,27]. An inappropriately high intake of cow's milk (0.seven L/day) afterwards infancy tin can too lead to IDA.

In Korea, infants are brought to the clinic approximately five times until the historic period of 1 year for vaccinations and health screenings. However, only 7.1% IDA-affected infants were identified during vaccination and health screening in this study, indicating that many clinicians overlook the seriousness of IDA in growing children. The American Academy of Pediatrics (AAP) recommends IDA screening for all infants anile 9–12 months [22]. Recently, the United States Preventive Service Task Force ended that the evidence of IDA screening in asymptomatic children is bereft [28] due to the decrement in IDA incidence. However, IDA is notwithstanding high amid infants and young children in Korea. Therefore, we recommend the screening of iron nutrition, particularly in infants at a loftier hazard of iron deficiency. Although the Hb level can exist assessed using a finger prick examination, other fe measurements crave peripheral blood sampling which is difficult to perform in infants. The Iron Score board [29] is useful in selecting infants who demand atomic number 26 status evaluations for appropriate screening and treatment. The score board includes following criteria: (1) age of initiation of weaning food >half-dozen months; (ii) intake of only homemade weaning food; (3) successful weaning in >1 month; (4) low iron content in weaning foods; (5) duration of breastfeeding; (vi) feeding method; and (vii) response to weaning foods. Using this score board, IDA could be predicted with 86.8% sensitivity in infants exhibiting 3 or more than of the above-mentioned criteria. This is especially useful as it can help prevent atomic number 26 deficiency in infants without the need for unnecessary laboratory tests.

IDA in infants and young children is fundamentally a nutritional problem, compared to IDA in older children, where it is mainly acquired by blood loss. Therefore, nutritional counseling is important, and recommendations include almost daily intake of i serving of either fish; meat; chicken; or eggs as complementary nutrient, or the use of micronutrient powders [30]. The AAP recommends iron supplementation (2 mg/kg/day) for LBW infants, including the MLBW infants, from the age of vi weeks to half dozen months. It further recommends fe supplementation (1 mg/kg/twenty-four hour period) for breastfed term infants starting at 4 months of age and maintained until appropriate iron-containing complementary foods have been introduced [29].

The limitation of our study is that as this was a third hospital-based study, there may accept been a possible selection bias, and the affliction severity may have been exaggerated. Further, every bit this study was based on a retrospective survey of medical records, there was a lack of information regarding prenatal maternal anemia status, the fourth dimension course of weaning to food, and the degree of postnatal weight proceeds. The follow-up loss was considerable, particularly in the balmy anemia group, and thus, the treatment response evaluation could non be completed in many cases.

In determination, a large proportion of children with IDA were not followed-up equally many clinicians exercise not consider IDA to be a existent health issue. Thus, clinicians should recommend appropriate iron supplementation to children, especially to infants at a college risk of developing iron deficiency. Notably, the MLBW infants need special attending to ensure adherence to atomic number 26 supplementation. Pediatricians should collect an accurate history of baby feeding practices (feeding type, the timing of weaning initiation, and contents of weaning food) during health screening visits in social club to allow the early detection of IDA, and should recommend blood tests to high-risk infants. The questionnaire along with the assessment of iron nutrition is recommended for the detection of anemia and fe status in pediatric clinics. In add-on, a prospective and well-organized risk assessment report in infants and young children is necessary to ameliorate fe nutritional status and to command IDA.

Footnotes

This piece of work was supported by an Inha University Enquiry grant (53780-01).

Authors' Disclosures of Potential Conflicts of Interest: No potential conflicts of interest relevant to this article were reported.

References

two. Hopkins D, Emmett P, Steer C, Rogers I, Noble S, Emond A. Babe feeding in the second 6 months of life related to iron status: an observational study. Arch Dis Child. 2007;92:850–854. [PMC free article] [PubMed] [Google Scholar]

3. Looker AC, Dallman PR, Carroll Medico, Gunter EW, Johnson CL. Prevalence of iron deficiency in the United States. JAMA. 1997;277:973–976. [PubMed] [Google Scholar]

iv. Zlotkin SH, Christofides AL, Hyder SM, Schauer CS, Tondeur MC, Sharieff W. Decision-making iron deficiency anemia through the use of home-fortified complementary foods. Indian J Pediatr. 2004;71:1015–1019. [PubMed] [Google Scholar]

v. Soh P, Ferguson EL, McKenzie JE, Homs MY, Gibson RS. Atomic number 26 deficiency and risk factors for lower iron stores in 6-24-month-sometime New Zealanders. Eur J Clin Nutr. 2004;58:71–79. [PubMed] [Google Scholar]

six. Grant CC, Wall CR, Brunt D, Crengle S, Scragg R. Population prevalence and risk factors for iron deficiency in Auckland, New Zealand. J Paediatr Child Health. 2007;43:532–538. [PubMed] [Google Scholar]

7. World Wellness Organization. The global prevalence of anaemia in 2011. Geneva, Switzerland: Globe Wellness Organization; 2015. [Google Scholar]

8. Korean Statistical Information Service. National health insurance statistical annual report classification of 298 disease categories by historic period, national health insurance service, health insurance review, and cess service. Daejeon, Korea: Korean Statistical Information Service; 2014. [Accessed June thirty, 2016]. at http://kosis.kr/statHtml/statHtml.do?orgId=350&tblId=TX_35001_A061&conn_path=I2. [Google Scholar]

9. Pollitt Due east. Atomic number 26 deficiency and cognitive role. Annu Rev Nutr. 1993;13:521–537. [PubMed] [Google Scholar]

10. Carter RC, Jacobson JL, Burden MJ, et al. Iron deficiency anemia and cognitive function in infancy. Pediatrics. 2010;126:e427–e434. [PMC free article] [PubMed] [Google Scholar]

11. Lozoff B, Jimenez Eastward, Hagen J, Mollen Eastward, Wolf AW. Poorer behavioral and developmental issue more than 10 years after treatment for atomic number 26 deficiency in infancy. Pediatrics. 2000;105:E51. [PubMed] [Google Scholar]

12. Khedr E, Hamed SA, Elbeih E, El-Shereef H, Ahmad Y, Ahmed S. Fe states and cognitive abilities in immature adults: neuropsychological and neurophysiological cess. Eur Arch Psychiatry Clin Neurosci. 2008;258:489–496. [PubMed] [Google Scholar]

13. Earth Wellness Organization. Haemoglobin concentrations for the diagnosis of anaemia and cess of severity. Vitamin and Mineral Nutrition Information Organization. Geneva, Switzerland: Earth Wellness Organization; 2011. [Accessed Jan 11, 2016]. at http://www.who.int/vmnis/indicators/haemoglobin.pdf. [Google Scholar]

14. Globe Wellness Organization. Serum ferritin concentrations for the assessment of iron status and iron deficiency in populations. Vitamin and Mineral Nutrition Information System. Geneva, Switzerland: World Wellness Organization; 2011. [Accessed January xi, 2016]. at http://www.who.int/vmnis/indicators/serum_ferritin.pdf. [Google Scholar]

fifteen. Wu AC, Lesperance L, Bernstein H. Screening for fe deficiency. Pediatr Rev. 2002;23:171–178. [PubMed] [Google Scholar]

xvi. Lozoff B, Kaciroti N, Walter T. Iron deficiency in infancy: applying a physiologic framework for prediction. Am J Clin Nutr. 2006;84:1412–1421. [PMC gratuitous article] [PubMed] [Google Scholar]

17. Domellöf M, Lönnerdal B, Dewey KG, Cohen RJ, Rivera LL, Hernell O. Sex activity differences in iron status during infancy. Pediatrics. 2002;110:545–552. [PubMed] [Google Scholar]

eighteen. Wieringa FT, Berger J, Dijkhuizen MA, et al. Sex differences in prevalence of anaemia and iron deficiency in infancy in a large multi-country trial in S-East Asia. Br J Nutr. 2007;98:1070–1076. [PubMed] [Google Scholar]

19. Choi JW, Kim CS, Pai SH. Erythropoietic action and soluble transferrin receptor level in neonates and maternal claret. Acta Paediatr. 2000;89:675–679. [PubMed] [Google Scholar]

twenty. Calvo EB, Galindo AC, Aspres NB. Iron condition in exclusively chest-fed infants. Pediatrics. 1992;90:375–379. [PubMed] [Google Scholar]

21. Shin PJ, Bae CW, Choi YM. A comparative study of cherry claret cell indices and anemia by feeding patterns. J Korean Pediatr Soc. 1999;42:1104–1110. [Google Scholar]

22. Baker RD, Greer FR Committee on Nutrition American University of Pediatrics. Diagnosis and prevention of fe deficiency and iron-deficiency anemia in infants and young children (0-3 years of age) Pediatrics. 2010;126:1040–1050. [PubMed] [Google Scholar]

23. Berglund S, Westrup B, Domellöf K. Atomic number 26 supplements reduce the risk of iron deficiency anemia in marginally low birth weight infants. Pediatrics. 2010;126:e874–e883. [PubMed] [Google Scholar]

24. Park SH, Kim JS, Jun YH, Kim SK. Weaning food practice in low birth weight infants with iron deficiency anemia. Clin Pediatr Hematol Oncol. 2014;21:52–58. [Google Scholar]

25. Ministry of Health and Welfare. Korea Wellness Statistics 2014: Korea National Wellness and Diet Examination Survey (KNHANES VI-two) Cheongju, Korea: Korea Centers for Illness Control and Prevention; 2015. [Google Scholar]

26. Kim BY, Choi EH, Kang SK, Jun YH, Hong YJ, Kim SK. Weaning food exercise and cess in children with iron deficiency anemia. Korean J Pediatr Gastroenterol Nutr. 2009;12:215–220. [Google Scholar]

27. Kim YH, Lee SG, Kim SH, Vocal YJ, Chung JY, Park MJ. Nutritional condition of Korean toddlers: From the Korean National Health and Nutrition Test Survey 2007∼2009. Korean J Pediatr Gastroenterol Nutr. 2011;14:161–170. [Google Scholar]

28. Siu AL Usa Preventive Services Chore Force. Screening for iron deficiency anemia in young children: USPSTF recommendation statement. Pediatrics. 2015;136:746–752. [PubMed] [Google Scholar]

29. Kim HJ, Kim DH, Lee JE, et al. Is information technology possible to predict the fe condition from an babe's diet history? Pediatr Gastroenterol Hepatol Nutr. 2013;16:95–103. [PMC free article] [PubMed] [Google Scholar]

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