Title: Food Insecurity and Health: Practices and Policies to Address Food Insecurity among Children
Abstract: Pediatricians can and should play a critical role in addressing food insecurity, a health-related social need with harmful impacts on child health, development, and well-being.1American Academy of PediatricsPromoting food security for all children.Pediatrics. 2015; 136: e1431-e1438Crossref PubMed Scopus (254) Google Scholar Food insecurity is a term defined by the US Department of Agriculture (USDA) that indicates that the availability of nutritionally adequate and safe food, or the ability to acquire such food, is limited or uncertain for a household.2Coleman-Jensen A Rabbitt MP Gregory CA Household Food Security in the United States in 2018. US Department of Agriculture, Economic Research Service, Washington, DC2019https://www.ers.usda.gov/publications/pub-details/?pubid=94848Google Scholar A variety of strategies exist for pediatricians to address food insecurity among children in the United States, including screening for food insecurity in health care settings, connecting children and their families to the benefits in the federal nutrition programs, and advocating for policies to alleviate food insecurity and its root causes.1American Academy of PediatricsPromoting food security for all children.Pediatrics. 2015; 136: e1431-e1438Crossref PubMed Scopus (254) Google Scholar This commentary will briefly describe the prevalence of and risk factors for food insecurity among children, consequences of food insecurity for children, federal nutrition programs that improve household food security and child health, and actions pediatricians can take in their practice and through advocacy to meaningfully address food insecurity among children. Food insecurity is a significant public health concern given the high prevalence and negative consequences for nutrition, health, and well-being. In 2018, approximately 11.2 million children lived in food-insecure households.2Coleman-Jensen A Rabbitt MP Gregory CA Household Food Security in the United States in 2018. US Department of Agriculture, Economic Research Service, Washington, DC2019https://www.ers.usda.gov/publications/pub-details/?pubid=94848Google Scholar This represents 15.2% of all children. Research shows that certain households with children are more vulnerable to food insecurity, including those headed by a single female, Black or Hispanic, and households with incomes under 185% of the federal poverty line.2Coleman-Jensen A Rabbitt MP Gregory CA Household Food Security in the United States in 2018. US Department of Agriculture, Economic Research Service, Washington, DC2019https://www.ers.usda.gov/publications/pub-details/?pubid=94848Google Scholar US-citizen children of immigrant mothers also face an increased risk of household food insecurity.3Chilton M Black MM Berkowitz C et al.Food insecurity and risk of poor health among US-born children of immigrants.Am J Public Health. 2009; 99: 556-562Crossref PubMed Scopus (156) Google Scholar Furthermore, an emerging body of evidence indicates that the COVID-19 pandemic has increased food insecurity among US families and children, with one report concluding that, based on April 2020 data, "young children are experiencing food insecurity to an extent unprecedented in modern times."4Bauer L. The COVID-19 Crisis has Already Left Too Many Children Hungry in America. Brookings Institution, Washington, DC2020https://www.brookings.edu/blog/up-front/2020/05/06/the-covid-19-crisis-has-already-left-too-many-children-hungry-in-america/Google Scholar,5Karpman M Zuckerman S Gonzalez D et al.The COVID-19 Pandemic is Straining Families' Abilities to Afford Basic Needs. Urban Institute, Washington, DC2020https://www.urban.org/sites/default/files/publication/102124/the-covid-19-pandemic-is-straining-families-abilities-to-afford-basic-needs_4.pdfGoogle Scholar While food insecurity has direct and indirect consequences across the lifespan, food insecurity—and even marginal food security (a less severe level of food insecurity)6Cook JT Black M Chilton M et al.Are food insecurity's health impacts underestimated in the US population? Marginal food security also predicts adverse health outcomes in young US children and mothers.Adv Nutr. 2013; 4: 51-61Crossref PubMed Scopus (220) Google Scholar,7Grineski SE Morales DX Collins TW et al.Transitional dynamics of household food insecurity impact children's developmental outcomes.J Dev Behav Pediatr. 2018; 39: 715-725Crossref PubMed Scopus (36) Google Scholar—is especially detrimental to the health, development, and well-being of children.1American Academy of PediatricsPromoting food security for all children.Pediatrics. 2015; 136: e1431-e1438Crossref PubMed Scopus (254) Google Scholar,8Shankar P Chung R Frank DA Association of food insecurity with children's behavioral, emotional, and academic outcomes: a systematic review.J Dev Behav Pediatr. 2017; 38: 135-150Crossref PubMed Scopus (265) Google Scholar Research shows a link for children between food insecurity and low birth weight,9Borders AE Grobman WA Amsden LB et al.Chronic stress and low birth weight neonates in a low-income population of women.Obstet Gynecol. 2007; 109: 331-338Crossref PubMed Scopus (204) Google Scholar,10Grilo SA Earnshaw VA Lewis JB et al.Food matters: food insecurity among pregnant adolescents and infant birth outcomes.J Appl Res Child. 2015; 6 (Article 4): 1-14Google Scholar birth defects,11Carmichael SL Yang W Herring A et al.Maternal food insecurity is associated with increased risk of certain birth defects.J Nutr. 2007; 137: 2087-2092Crossref PubMed Scopus (118) Google Scholar iron deficiency anemia,12Metallinos-Katsaras E Colchamiro R Edelstein S et al.Household food security status is associated with anemia risk at age 18 months among low-income infants in Massachusetts.J Acad Nutr Diet. 2016; 116: 1760-1766Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,13Eicher-Miller HA Mason AC Weaver CM et al.Food insecurity is associated with iron deficiency anemia in US adolescents.Am J Clin Nutr. 2009; 90: 1358-1371Crossref PubMed Scopus (160) Google Scholar poor or fair health status,14Ryu JH Bartfeld JS Household food insecurity during childhood and subsequent health status: the early childhood longitudinal study ‐ kindergarten cohort.Am J Public Health. 2012; 102: e50-e55Crossref PubMed Scopus (105) Google Scholar,15Drennen CR Coleman SM Ettinger de Cuba S et al.Food insecurity, health, and development in children under age four years.Pediatrics. 2019; 144e20190824Crossref PubMed Scopus (78) Google Scholar poor dietary quality and less physical activity,16Fram MS Ritchie LD Rosen N et al.Child experience of food insecurity is associated with child diet and physical activity.J Nutr. 2015; 145: 499-504Crossref PubMed Scopus (103) Google Scholar cardiometabolic risk factors,17Robson SM Lozano AJ Papas M Food insecurity and cardiometabolic risk factors in adolescents.Prev Chronic Dis. 2017; 14: e110Crossref PubMed Scopus (36) Google Scholar high blood pressure,18South AM Palakshappa D Brown CL Relationship between food insecurity and high blood pressure in a national sample of children and adolescents.Pediatr Nephrol. 2019; 34: 1583-1590Crossref PubMed Scopus (16) Google Scholar more frequent colds and stomachaches,19Alaimo K Olson CM Frongillo Jr, EA et al.Food insufficiency, family income, and health in US preschool and school-aged children.Am J Public Health. 2001; 91: 781-786Crossref PubMed Scopus (352) Google Scholar asthma,20Mangini LD Hayward MD Dong YQ et al.Household food insecurity is associated with childhood asthma.J Nutr. 2015; 145: 2756-2764Crossref PubMed Scopus (45) Google Scholar lower bone density (among boys),21Eicher-Miller HA Mason AC Weaver CM et al.Food insecurity is associated with diet and bone mass disparities in early adolescent males but not females in the United States.J Nutr. 2011; 141: 1738-1745Crossref PubMed Scopus (52) Google Scholar untreated dental caries (ie, tooth decay),22Chi DL Masterson EE Carle AC et al.Socioeconomic status, food security, and dental caries in US children: mediation analyses of data from the National Health and Nutrition Examination Survey, 2007–2008.Am J Public Health. 2014; 104: 860-864Crossref PubMed Scopus (103) Google Scholar developmental risk,23Rose-Jacobs R Black MM Casey PH et al.Household food insecurity: associations with at-risk infant and toddler development.Pediatrics. 2008; 121: 65-72Crossref PubMed Scopus (253) Google Scholar behavioral and social-emotional problems (eg, hyperactivity),24Johnson AD Markowitz AJ. Associations between household food insecurity in early childhood and children's kindergarten skills.Child Dev. 2018; 89: e1-e17Crossref PubMed Scopus (73) Google Scholar,25Poole-Di Salvo E Silver EJ Stein RE Household food insecurity and mental health problems among adolescents: what do parents report.Acad Pediatr. 2016; 16: 90-96Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar mental health problems (eg, depression, anxiety, suicidal ideation),26McLaughlin KA Green JG Alegría M et al.Food insecurity and mental disorders in a national sample of US adolescents.J Am Acad Child Adolesc Psychiatry. 2012; 51: 1293-1303Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar,27McIntyre L Williams JV Lavorato DH Patten S Depression and suicide ideation in late adolescence and early adulthood are an outcome of child hunger.J Affect Disord. 2013; 150: 123-129Crossref PubMed Scopus (141) Google Scholar poor educational performance and academic outcomes,28Nelson BB Dudovitz RN Coker TR et al.Predictors of poor school readiness in children without developmental delay at age 2.Pediatrics. 2016; 138e20154477Crossref PubMed Scopus (47) Google Scholar,29Howard LL. Does food insecurity at home affect non-cognitive performance at school? A longitudinal analysis of elementary student classroom behavior.Econ Educ Rev. 2011; 30: 157-176Crossref Scopus (119) Google Scholar and increased hospitalizations and hospital charges.6Cook JT Black M Chilton M et al.Are food insecurity's health impacts underestimated in the US population? Marginal food security also predicts adverse health outcomes in young US children and mothers.Adv Nutr. 2013; 4: 51-61Crossref PubMed Scopus (220) Google Scholar,30Ettinger de Cuba S Casey PH Cutts D et al.Household food insecurity positively associated with increased hospital charges for infants.J Appl Res Child. 2018; 9 (Article 8): 1-19Google Scholar Research also links food insecurity in households with young children to unfavorable outcomes for the family unit, including increased maternal depressive symptoms and parental arguing.31Johnson AD Markowitz AJ Food insecurity and family well-being outcomes among households with young children.J Pediatr. 2018; 196: 275-282Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar These findings are not surprising given the heightened stress and pressure facing parents with low incomes who struggle to feed their families.1American Academy of PediatricsPromoting food security for all children.Pediatrics. 2015; 136: e1431-e1438Crossref PubMed Scopus (254) Google Scholar Furthermore, because of limited financial resources, families who are food insecure may use coping strategies to stretch budgets that are harmful for health and nutrition, such as diluting or rationing infant formula32Burkhardt MC Beck AF Kahn RS et al.Are our babies hungry? Food insecurity among infants in urban clinics.Clin Pediatr. 2012; 51: 238-243Crossref PubMed Scopus (28) Google Scholar or making trade-offs between food and other basic necessities (eg, housing, medicine).33Knowles M Rabinowich J Ettinger de Cuba S et al.Do you wanna breathe or eat?": parent perspectives on child health consequences of food insecurity, trade-offs, and toxic stress.Matern Child Health J. 2016; 20: 25-32Crossref PubMed Scopus (144) Google Scholar Finally, food insecurity can complicate and compound the health challenges and expenses faced by households with children who have special health care needs—populations at high risk for food insecurity.34Rose-Jacobs R Goodhart Fiore J Ettinger de Cuba S et al.Children with special health care needs, supplemental security income, and food insecurity.J Dev Behav Pediatr. 2016; 37: 140-147Crossref PubMed Scopus (26) Google Scholar,35Balistreri KS. Food insufficiency and children with special healthcare needs.Public Health. 2019; 167: 55-61Crossref PubMed Scopus (13) Google Scholar For example, children with epilepsy living in food-insecure households have significantly worse health-related quality of life and more medication side effects than their counterparts in food-secure households.36O'Malley JA Klett BM Klein MD et al.Revealing the prevalence and consequences of food insecurity in children with epilepsy.J Community Health. 2017; 42: 1213-1219Crossref PubMed Scopus (14) Google Scholar One critical strategy to address food insecurity and its negative consequences is to connect children and their families to the major federal nutrition programs that benefit children and their families – that is, the Supplemental Nutrition Assistance Program (SNAP); Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); National School Lunch Program; School Breakfast Program; Child and Adult Care Food Program (CACFP); Summer Nutrition Programs; and Afterschool Nutrition Programs. The Table provides descriptions of these programs, all of which are administered by the USDA.TableFederal Nutrition Programs Available to Children*Adapted with permission from the AAP and FRAC Federal Nutrition Programs and Emergency Food Referral Chart (available at: https://frac.org/aaptoolkit). Primarily for use in healthcare settings, the referral chart includes key information on nutrition programs available to children and their families.Program NameGeneral Program Eligibility†WIC, school meals, and the other Child Nutrition Programs are not included in a public charge determination. Receipt of traditional, federally-funded SNAP benefits by the immigrant for themselves may be included in a public charge determination, pursuant to a new federal rule change that, at press time, was subject to litigation. Nonetheless, the scope of public charge has limits. For example, receipt of SNAP for dependents eligible for SNAP benefits, such as a US citizen, does not affect a public charge determination. Public charge is also not a factor for green card holders seeking US citizenship or renewing their green card documents. For additional information and updates, visit https://frac.org/hunger-poverty-america/hunger-among-immigrants.Program DescriptionSupplemental Nutrition Assistance Program (SNAP)The program may be called something else in your state.Low-income individuals of all ages who meet income and asset tests (that can vary by state)Monthly benefits are provided on an Electronic Benefit Transfer (EBT) card to purchase food at grocery stores, farmers' markets, and other food retail outlets across the country that accept SNAPSpecial Supplemental Nutrition Program for Women, Infants, and Children (WIC)Low-income pregnant, breastfeeding, and postpartum women, and infants and children up to age five deemed nutritionally at risk by a health care professionalNutritionally tailored monthly food packages are provided to families and redeemed in grocery stores and food retailers that accept WIC; additional services include breastfeeding support, nutrition education and counseling, and health referralsNational School Lunch Program and School Breakfast ProgramSchool-aged children of families at low or moderate income levels can qualify for free or reduced-price mealsBreakfasts and lunches meeting federal nutrition standards are provided in participating schoolsChild and Adult Care Food Program (CACFP)Children, typically up to age five, attending eligible child care centers and homes, Head Start, and Early Head StartUp to two free meals and a snack meeting federal nutrition standards are provided to infants and young children at participating centersSummer Nutrition Programs(available through the Summer Food Service Program or the National School Lunch Program)Children 18 years of age and under visiting participating sitesUp to two free meals meeting federal nutrition standards are provided at approved school and community sites during summer vacationAfterschool Nutrition Programs(available through CACFP or the National School Lunch Program)Children 18 years of age and under visiting participating sitesFree, healthy snacks and/or meals meeting federal nutrition standards are provided in participating enrichment programs running afterschool, on weekends, or during school holidays Adapted with permission from the AAP and FRAC Federal Nutrition Programs and Emergency Food Referral Chart (available at: https://frac.org/aaptoolkit). Primarily for use in healthcare settings, the referral chart includes key information on nutrition programs available to children and their families.† WIC, school meals, and the other Child Nutrition Programs are not included in a public charge determination. Receipt of traditional, federally-funded SNAP benefits by the immigrant for themselves may be included in a public charge determination, pursuant to a new federal rule change that, at press time, was subject to litigation. Nonetheless, the scope of public charge has limits. For example, receipt of SNAP for dependents eligible for SNAP benefits, such as a US citizen, does not affect a public charge determination. Public charge is also not a factor for green card holders seeking US citizenship or renewing their green card documents. For additional information and updates, visit https://frac.org/hunger-poverty-america/hunger-among-immigrants. Open table in a new tab There is considerable evidence about the effective role that participation in the federal nutrition programs plays in alleviating food insecurity and poverty. For instance, children in households that participated in SNAP for 6 months are approximately one-third less likely to be food insecure than children in households recently approved for SNAP but not yet receiving it, based on a national sample of SNAP households with children.37Mabli J Worthington J Supplemental nutrition assistance program participation and child food security.Pediatrics. 2014; 133: 610-619Crossref PubMed Scopus (52) Google Scholar WIC reduces the prevalence of household food insecurity by at least 20%, based on a national sample of children under the age of 5 who lived in households that were income-eligible for WIC.38Kreider B Pepper JV Roy M Identifying the effects of WIC on food insecurity among infants and children.South Econ J. 2016; 82: 1106-1122Crossref Scopus (59) Google Scholar Additional peer-reviewed studies demonstrate improvements in food security with school breakfast,39Bartfeld JS Ahn HM. The School Breakfast Program strengthens household food security among low-income households with elementary school children.J Nutr. 2011; 141: 470-475Crossref PubMed Scopus (87) Google Scholar,40Fletcher JM Frisvold DE. The relationship between the school breakfast program and food insecurity.J Consum Aff. 2017; 51: 481-500Crossref PubMed Scopus (36) Google Scholar school lunch,41Gundersen C Kreider B Pepper J The impact of the national school lunch program on child health: a nonparametric bounds analysis.J Econom. 2012; 166: 79-91Crossref Scopus (154) Google Scholar,42Arteaga I Heflin C. Participation in the national school lunch program and food security: an analysis of transitions into kindergarten.Children and Youth Serv Rev. 2014; 47: 224-230Crossref Scopus (42) Google Scholar summer meals,43Nord M Romig K. Hunger in the summer: seasonal food insecurity and the national school lunch and summer food service programs.J Child Poverty. 2006; 12: 141-158Crossref Google Scholar,44Miller DP. Accessibility of summer meals and the food insecurity of low-income households with children.Public Health Nutr. 2016; 19: 2079-2089Crossref PubMed Scopus (27) Google Scholar and CACFP45Heflin C Arteaga I Gable S The child and adult care food program and food insecurity.Soc Serv Rev. 2015; 89: 77-98Crossref Scopus (24) Google Scholar participation. In terms of poverty, SNAP, school lunch, and WIC lifted 3.2 million, 1.4 million, and 302,000 people above the poverty line in 2018, respectively, based on Census Bureau data on poverty and income in the United States.46Fox L. The Supplemental Poverty Measure: 2018. US Census Bureau, Washington, DC2019https://www.census.gov/library/publications/2019/demo/p60-268.htmlGoogle Scholar These national figures include approximately 1.3 million, 800,000, and 169,000 children, respectively. Beyond their antihunger and antipoverty impacts, the federal nutrition programs are important health interventions for children in the short and long terms. For instance, children participating in SNAP are less likely to have obesity, underweight, developmental risk, nutritional risk, or fair or poor health status47Lee BJ Mackery-Bilaver L Chin M Effects of WIC and Food Stamp Program Participation on Child Outcomes. 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The impact of WIC on infant immunizations and health care utilization.Health Serv Res. 2018; 53: 2952-2969Crossref PubMed Scopus (17) Google Scholar cognitive development and school performance,56Jackson M Early childhood WIC participation, cognitive development and academic achievement..Soc Sci Med. 2015; 126: 145-153Crossref PubMed Scopus (54) Google Scholar and birth outcomes (including a lower risk of preterm birth, low birth weight, and perinatal death).57Fingar KR Lob SH Dove MS et al.Reassessing the association between WIC and birth outcomes using a fetuses-at-risk approach.Matern Child Health J. 2017; 21: 825-835Crossref PubMed Scopus (21) Google Scholar,58Sonchak L. The impact of WIC on birth outcomes: new evidence from South Carolina.Matern Child Health J. 2016; 20: 1518-1525Crossref PubMed Scopus (30) Google Scholar WIC is cost-saving, too, investing $1 in prenatal WIC services saves about $2.48 in medical, educational, and productivity costs over a newborn's lifetime by preventing preterm birth, based on simulations of WIC participation in California.59Nianogo RA Wang MC Basurto-Davila R et al.Economic evaluation of California prenatal participation in the special supplemental nutrition program for women, infants and children (WIC) to prevent preterm birth.Prev Med. 2019; 124: 42-49Crossref PubMed Scopus (14) Google Scholar Participation in CACFP, a program primarily targeting infants and young children, is associated with better dietary intake,60Korenman S Abner KS Kaestner R Gordon RA The child and adult care food program and the nutrition of preschoolers.Early Child Res Q. 2013; 28: 325-336Crossref PubMed Scopus (82) Google Scholar,61Andreyeva T Kenney EL O'Connell M et al.Predictors of nutrition quality in early child education settings in Connecticut.J Nutr Educ Behav. 2018; 50: 458-467Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar improved weight outcomes,60Korenman S Abner KS Kaestner R Gordon RA The child and adult care food program and the nutrition of preschoolers.Early Child Res Q. 2013; 28: 325-336Crossref PubMed Scopus (82) Google Scholar,62Lumeng JC Kaciroti N Sturza J et al.Changes in body mass index associated with head start participation.Pediatrics. 2015; 135: e449-e456Crossref PubMed Scopus (60) Google Scholar and a lower likelihood of being hospitalized or in fair or poor health.63Gayman A Ettinger de Cuba S March E et al.Child Care Feeding Programs Support Young Children's Healthy Development. Children's HealthWatch, Boston, Mass2010https://childrenshealthwatch.org/child-care-feeding-programs-support-young-childrens-healthy-development/Google Scholar For school-aged children, national and local studies demonstrate the value of school breakfast and lunch in improving student dietary intake and quality.64Vernarelli JA O'Brien B. A vote for school lunches: school lunches provide superior nutrient quality than lunches obtained from other sources in a nationally representative sample of US children.Nutrients. 2017; 9: e924Crossref PubMed Scopus (23) Google Scholar,65Fox MK Gearan E School Nutrition and Meal Cost Study: Summary of Findings. US Department of Agriculture, Food and Nutrition Service, Alexandria, Va2019https://www.fns.usda.gov/school-nutrition-and-meal-cost-studyGoogle Scholar The programs support and improve student health, including weight-related outcomes such as overweight or obesity,41Gundersen C Kreider B Pepper J The impact of the national school lunch program on child health: a nonparametric bounds analysis.J Econom. 2012; 166: 79-91Crossref Scopus (154) Google Scholar,66Wang S Schwartz MB Shebi FM et al.School breakfast and body mass index: a longitudinal observational study of middle school students.Pediatr Obes. 2017; 12: 213-220Crossref PubMed Scopus (25) Google Scholar and program participation, particularly for school breakfast, is associated with improved school attendance and academic performance.67Frisvold DE Nutrition and cognitive achievement: an evaluation of the school breakfast program.J Public Econ. 2015; 124: 91-104Crossref PubMed Scopus (88) Google Scholar,68Anzman-Frasca S Djang HC Halmo MM et al.Estimating impacts of a breakfast in the classroom program on school outcomes.JAMA Pediatr. 2015; 169: 71-77Crossref PubMed Scopus (52) Google Scholar Furthermore, summer nutrition programs are an important strategy for preventing summer weight gain69Kimbro RT Rigby E Federal food policy and childhood obesity: a solution or part of the problem?.Health Aff. 2010; 29: 411-418Crossref PubMed Scopus (27) Google Scholar,70Franckle R Adler R Davison K Accelerated weight gain among children during summer versus school year and related racial/ethnic disparities: a systematic review.Prev Chronic Dis. 2014; 11: e101Crossref PubMed Scopus (168) Google Scholar and learning loss among school-aged children.71Augustine CH McCombs JS Pane JF et al.Learning from Summer: Effects of Voluntary Summer Learning Programs on Low-Income Urban Youth. RAND Corporation, Santa Monica, Calif2016https://www.rand.org/pubs/research_reports/RR1557.htmlCrossref Google Scholar,72Bruce JS De La Cruz MM Moreno G Lunch at the library: examination of a community-based approach to addressing summer food insecurity.Public Health Nutr. 2017; 20: 1640-1649Crossref PubMed Scopus (24) Google Scholar Similarly, the afterschool nutrition programs provide good nutrition and enrichment activities during out-of-school time periods.73Kenney EL Austin SB Cradock AL et al.Identifying sources of children's consumption of junk food in Boston after-school programs, April–May 2011.Prev Chronic Dis. 2014; 11: e205Crossref PubMed Scopus (10) Google Scholar In a 2015 policy statement, Promoting Food Security for All Children, the American Academy of Pediatrics (AAP) recommended that "pediatricians engage in efforts to mitigate food insecurity at the practice level and beyond," including connecting families to and advocating for the federal nutrition programs.1American Academy of PediatricsPromoting food security for all children.Pediatrics. 2015; 136: e1431-e1438Crossref PubMed Scopus (254) Google Scholar To assist pediatricia