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Persa L, Shaw DW, Amlie-Lefond C. Why Would a Child Have a Stroke? J Child Neurol 2022; 37:907-915. [PMID: 36214173 DOI: 10.1177/08830738221129916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Identifying the etiology of childhood arterial ischemic stroke helps prevent stroke recurrence. In addition, stroke may herald a serious underlying condition requiring treatment, such as acquired heart disease, malignancy, or autoimmune disorder. Evidence-based guidelines exist for adults to identify and treat common risk factors for primary and secondary stroke, including hypertension, diabetes, elevated lipids, atrial fibrillation, and sleep apnea, which are rarely relevant in children. However, guidelines do not exist in pediatrics. Identifying the cause of childhood stroke may be straightforward or may require extensive clinical and neuroimaging expertise, serial evaluations, and reassessment based on the evolving clinical picture. Risk factors may be present but not necessarily causative, or not causative until a triggering event such as infection or anemia occurs. Herein, we describe strategies to determine stroke etiology, including challenges and potential pitfalls.
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Affiliation(s)
- Laurel Persa
- Department of Neurology, 7274Seattle Children's Hospital, Seattle, Washington, USA
| | - Dennis Ww Shaw
- Department of Radiology, 7274Seattle Children's Hospital, Seattle, Washington, USA
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Fink M, Slavova N, Grunt S, Perret E, Regényi M, Steinlin M, Bigi S. Posterior Arterial Ischemic Stroke in Childhood. Stroke 2019; 50:2329-2335. [DOI: 10.1161/strokeaha.119.025154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Literature on the clinical manifestation and neuroradiological findings in pediatric patients with posterior circulation arterial ischemic stroke is scarce. This study aims to describe epidemiological features, clinical characteristics, and neuroimaging data on pediatric posterior circulation arterial ischemic stroke in Switzerland using the population-based Swiss Neuropediatric Stroke Registry.
Methods—
Children aged from 1 month to 16 years presenting with an isolated posterior circulation arterial ischemic stroke between 2000 and 2016 were included. Epidemiology, clinical manifestation, stroke cause, and neuroradiological features were summarized using descriptive statistics. Stroke severity was assessed using the pediatric National Institutes of Health Stroke Scale. Correlation analysis was performed using the Spearman correlation coefficient.
Results—
Forty-three children with posterior circulation arterial ischemic stroke were included (27 boys [62.8%], median age 7.9 years, interquartile range, 5 to 11.7 years). The incidence of posterior circulation arterial ischemic stroke is Switzerland was 0.183/100 000 and represented 16% of all childhood arterial ischemic strokes. Most patients presented with nonspecific neurological complaints, such as headache (58.1%) and nausea/vomiting (46.5%). The most frequent clinical manifestations were ataxia (58.1%) and motor/sensory hemisyndrome (53.5%/51.2%). Unilateral focal cerebral arteriopathy was the most common cause (11 children, 25.6%). Most infarcts were located in the cerebellum (46.5%) and thalamus (39.5%). A shorter diagnostic delay correlated with more severe stroke symptoms at presentation (rho= −0.365,
P
=0.016).
Conclusions—
Pediatric posterior circulation arterial ischemic stroke was caused by focal cerebral arteriopathy in one quarter of the patients in our cohort. The frequently reported nonspecific clinical symptoms, especially when associated with mild neurological findings, risk delaying the diagnosis of stroke. A high index of suspicion and increased awareness are required for timely diagnosis and treatment initiation.
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Affiliation(s)
- Mirjam Fink
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Nedelina Slavova
- Department of Neuroradiology, Bern University Hospital, University of Bern, Switzerland (N.S.)
| | - Sebastian Grunt
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Eveline Perret
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Maria Regényi
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Maja Steinlin
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Sandra Bigi
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
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Ischaemic stroke in children with cardiopathy: An epidemiological study. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Andrade A, Bigi S, Laughlin S, Parthasarathy S, Sinclair A, Dirks P, Pontigon AM, Moharir M, Askalan R, MacGregor D, deVeber G. Association Between Prolonged Seizures and Malignant Middle Cerebral Artery Infarction in Children With Acute Ischemic Stroke. Pediatr Neurol 2016; 64:44-51. [PMID: 27663488 DOI: 10.1016/j.pediatrneurol.2016.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Malignant middle cerebral artery infarct syndrome is a potentially fatal complication of stroke that is poorly understood in children. We studied the frequency, associated characteristics, and outcomes of this condition in children. METHODS Children, aged two months to 18 years with acute middle cerebral artery infarct diagnosed at our center between January 2005 and December 2012 were studied. Associations with malignant middle cerebral artery infarct syndrome were sought, including age, seizures, neurological deficit severity (Pediatric National Institute of Health Stroke Severity Score), stroke etiology, fever, blood pressure, blood glucose, infarct location, infarct volume (modified pediatric Alberta Stroke Program Early Computed Tomography Score), and arterial occlusion. Death and neurological outcomes were determined. RESULTS Among 66 children with middle cerebral artery stroke, 12 (18%) developed malignant middle cerebral artery infarct syndrome, fatal in three. Prolonged seizures during the first 24 hours (odds ratio, 25.51; 95% confidence interval, 3.10 to 334.81; P = 0.005) and a higher Pediatric National Institute of Health Stroke Severity Score (odds ratio, 1.22; 95% confidence interval, 1.08 to 1.45; P = 0.006) were independently associated with malignant middle cerebral artery infarct syndrome. All children aged greater than two years with a Pediatric National Institute of Health Stroke Severity Score ≥8 and initial seizures ≥5 minutes duration developed malignant middle cerebral artery infarct syndrome (100%). CONCLUSIONS Malignant middle cerebral artery infarct syndrome affects nearly one in five children with acute middle cerebral artery stroke. Children with higher Pediatric National Institute of Health Stroke Severity Scores and prolonged initial seizures are at greatly increased risk for malignant middle cerebral artery infarct syndrome. Children with middle cerebral artery infarcts warrant intensive neuroprotective management and close monitoring to enable early referral for hemicraniectomy surgery.
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Affiliation(s)
- Andrea Andrade
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
| | - Sandra Bigi
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Laughlin
- Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Division of Neuroradiology, Department of Medical Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Sujatha Parthasarathy
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Adriane Sinclair
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Peter Dirks
- Division of Neurosurgery, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Ann Marie Pontigon
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Rand Askalan
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Daune MacGregor
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences Program, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Abstract
The child presenting with possible sentinel transient ischemic event or stroke requires prompt diagnosis so that strategies to limit injury and prevent recurrent stroke can be instituted. Cerebral arteriopathy is a potent risk factor for arterial ischemic stroke in childhood. Though acute imaging study in the setting of possible stroke is often a head computed tomography, when possible magnetic resonance imaging (MRI) is recommended as the first-line study as confirmation and imaging evaluation of ischemic stroke will typically require MRI. The MRI scanning approach should include diffusion-weighted imaging (DWI) early in the sequence order, since normal DWI excludes acute infarct with rare exception. In most cases, arterial imaging with time-of-flight (TOF) magnetic resonance angiography (MRA) is warranted. Dedicated MRA may not be possible in the acute setting, but should be pursued as promptly as possible, particularly in the child with findings and history suggestive of arteriopathy, given the high risk of recurrent stroke in these children. MRA can overestimate the degree of arterial compromise due to complex/turbulent flow, and be insensitive to subtle vessel irregularity due to resolution and complex flow. In cases with high imaging suspicion for dissection despite normal MRA findings, catheter angiogram is indicated. A thoughtful, stepwise approach to arterial neuroimaging is critical to optimize diagnosis, treatment, and primary and secondary prevention of childhood stroke.
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Affiliation(s)
| | - Dennis Shaw
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA
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Vázquez-López M, Castro-de Castro P, Barredo-Valderrama E, Miranda-Herrero MC, Gil-Villanueva N, Alcaraz-Romero AJ, Jiménez-de Domingo A, Pascual-Pascual SI. Ischaemic stroke in children with cardiopathy: An epidemiological study. Neurologia 2016; 32:602-609. [PMID: 27296499 DOI: 10.1016/j.nrl.2016.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 03/13/2016] [Accepted: 03/29/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Ischaemic stroke is rare during childhood. Congenital and acquired heart diseases are one of the most important risk factors for arterial ischaemic stroke (AIS) in children. PATIENTS AND METHODS We conducted a retrospective study of all children with AIS and heart disease diagnosed between 2000 and 2014. RESULTS We included 74 children with heart disease who were eligible for inclusion. 60% were boys with a mean stroke age of 11 months. 20% of the patients died during the study period. 90% of the patients had a congenital heart disease, while cyanotic heart disease was identified in 60%. Hypoplastic left heart syndrome was the most frequent heart disease. In 70% of patients AIS was directly associated with heart surgery, catheterisation or ventricular assist devices. Most patients with AIS were in the hospital. Seizures and motor deficit were the most frequent symptoms. Most patient diagnoses were confirmed by brain CT. The AIS consisted of multiple infarcts in 33% of the cases, affected both hemispheres in 27%, and involved the anterior and posterior cerebral circulation in 10%. CONCLUSIONS Arterial ischaemic strokes were mainly associated with complex congenital heart diseases, and heart procedures and surgery (catheterisation). AIS presented when patients were in-hospital and most of the patients were diagnosed in the first 24hours.
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Affiliation(s)
- M Vázquez-López
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España.
| | - P Castro-de Castro
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - E Barredo-Valderrama
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - M C Miranda-Herrero
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - N Gil-Villanueva
- Sección de Cardiología Infantil, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - A J Alcaraz-Romero
- Sección de Unidad de Cuidados Intensivos Pediátricos, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - A Jiménez-de Domingo
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España
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Lopes JM, Sanchis GJB, Medeiros JLAD, Dantas FG. Hospitalização por acidente vascular encefálico isquêmico no Brasil: estudo ecológico sobre possível impacto do Hiperdia. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2016; 19:122-34. [DOI: 10.1590/1980-5497201600010011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 07/14/2015] [Indexed: 11/22/2022] Open
Abstract
RESUMO: Objetivo: O estudo avaliou a tendência de hospitalização por acidente vascular encefálico isquêmico (HAVEI) e a sua mortalidade hospitalar no Brasil nos últimos 15 anos, assim como o impacto do programa Hiperdia nesse cenário. Métodos: Delineou-se um estudo ecológico com abordagem analítica e dados coletados no Sistema de Internação Hospitalar sobre episódios de AVEI, referentes aos anos de 1998 a 2012. Todos os dados foram estratificados por sexo e faixa etária, criando-se um indicador para HAVEI e proporção de mortalidade hospitalar. A fim de estimar a tendência dos dados criou-se uma curva polinomial de melhor aderência e para a averiguar o impacto do Hiperdia aplicou-se o Modelo Linear Generalizado tomados como desfecho a HAVEI e a mortalidade hospitalar. Adotou-se um nível de significância de 5% para minimizar um erro tipo I. Resultados: Foi evidenciada redução das HAVEI de 37,57/105 habitantes em 1998 a 2001 para 10,33/105 habitantes em 2002 a 2005, declinando 73,64%. A redução aconteceu em ambos os sexos, assim como para todas as faixas etárias. A mortalidade hospitalar por AVEI também declinou no Brasil a partir de 2002, tanto em homens como em mulheres, porém em menos de 3% e apenas nas faixas entre 0 e 14 anos e acima de 80 anos não detectamos tendência. Conclusão: Portanto, o declínio das HAVEI coincidiu temporalmente com a implementação do Hiperdia no ano de 2002 e essa tendência se mantém até hoje.
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Kornfeld S, Delgado Rodríguez JA, Everts R, Kaelin-Lang A, Wiest R, Weisstanner C, Mordasini P, Steinlin M, Grunt S. Cortical reorganisation of cerebral networks after childhood stroke: impact on outcome. BMC Neurol 2015; 15:90. [PMID: 26058895 PMCID: PMC4466862 DOI: 10.1186/s12883-015-0309-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/17/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Recovery after arterial ischaemic stroke is known to largely depend on the plastic properties of the brain. The present study examines changes in the network topography of the developing brain after stroke. Effects of brain damage are best assessed by examining entire networks rather than single sites of structural lesions. Relating these changes to post-stroke neuropsychological variables and motor abilities will improve understanding of functional plasticity after stroke. Inclusion of healthy controls will provide additional insight into children's normal brain development. Resting state functional magnetic resonance imaging is a valid approach to topographically investigate the reorganisation of functional networks after a brain lesion. Transcranial magnetic stimulation provides complementary output information. This study will investigate functional reorganisation after paediatric arterial ischaemic stroke by means of resting state functional magnetic resonance imaging and transcranial magnetic stimulation in a cross-sectional plus longitudinal study design. The general aim of this study is to better understand neuroplasticity of the developing brain after stroke in order to develop more efficacious therapy and to improve the post-stroke functional outcome. METHODS The cross-sectional part of the study will investigate the functional cerebral networks of 35 children with chronic arterial ischaemic stroke (time of the lesion >2 years). In the longitudinal part, 15 children with acute arterial ischaemic stroke (shortly after the acute phase of the stroke) will be included and investigations will be performed 3 times within the subsequent 9 months. We will also recruit 50 healthy controls, matched for age and sex. The neuroimaging and neurophysiological data will be correlated with neuropsychological and neurological variables. DISCUSSION This study is the first to combine resting state functional magnetic resonance imaging and transcranial magnetic stimulation in a paediatric population diagnosed with arterial ischaemic stroke. Thus, this study has the potential to uniquely contribute to the understanding of neuronal plasticity in the brains of healthy children and those with acute or chronic brain injury. It is expected that the results will lead to the development of optimal interventions after arterial ischaemic stroke.
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Affiliation(s)
- Salome Kornfeld
- Division of Neuropaediatrics, Development and Rehabilitation, Children's University Hospital, Inselspital, Bern, Switzerland. .,Center for Cognition, Learning and Memory, University of Bern, Bern, Switzerland.
| | - Juan Antonio Delgado Rodríguez
- Division of Neuropaediatrics, Development and Rehabilitation, Children's University Hospital, Inselspital, Bern, Switzerland. .,Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Regula Everts
- Division of Neuropaediatrics, Development and Rehabilitation, Children's University Hospital, Inselspital, Bern, Switzerland. .,Center for Cognition, Learning and Memory, University of Bern, Bern, Switzerland.
| | | | - Roland Wiest
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, Inselspital, Bern, Switzerland.
| | - Christian Weisstanner
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, Inselspital, Bern, Switzerland.
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, Inselspital, Bern, Switzerland.
| | - Maja Steinlin
- Division of Neuropaediatrics, Development and Rehabilitation, Children's University Hospital, Inselspital, Bern, Switzerland. .,Center for Cognition, Learning and Memory, University of Bern, Bern, Switzerland.
| | - Sebastian Grunt
- Division of Neuropaediatrics, Development and Rehabilitation, Children's University Hospital, Inselspital, Bern, Switzerland.
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Steinlin M. Cerebrovascular disorders in childhood. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1053-64. [PMID: 23622311 DOI: 10.1016/b978-0-444-52910-7.00023-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cerebrovascular problems in childhood include diverse problems of vascular supply to the brain and occur with an overall frequency of from 5 to 8/100000 children/year. Signs and symptoms at manifestation are manifold. They depend not only on localization of the infarction but also on age at injury and specific risk factors. Acute arterial ischemic insult in neonates is oligosymptomatic (short-lasting seizures); hemiparesis is the most common symptom in children. Risk factors are multiple for both neonates and children, with more thromboembolic events in neonates and (infection-related) vasculopathies or cardiac problems in children. MRI (diffusion weighted) is the golden standard for diagnosis. In the absence of evidence for treatment in both groups, guidelines suggest use of platelet aggregation. There are some special indications for anticoagulation. Thrombolysis should be evaluated. Two-thirds of children and neonates face lifelong neurological and neuropsychological problems. Spinal artery ischemia presents with acute spinal symptoms, mostly paraplegia. Risk factors and prognosis are similar to cerebral insults. Sinus venous thromboses are significantly less common. Provoking factors in newborns are mainly neonatal problems, and in children infections, especially in the ENT region. For diagnosis the delta sign in CT is less sensitive than MR/MR venography. In the absence of any evidence, LMWH or heparinization for 3-6 months are recommended. Prognosis is better in children than in neonates. Deep vein thrombosis and/or young age worsen the outcome.
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Affiliation(s)
- Maja Steinlin
- Neuropaediatric Department, University Children's Hospital Inselspital, Bern, Switzerland.
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Ng J, Ganesan V. Expert opinion on emerging drugs in childhood arterial ischemic stroke. Expert Opin Emerg Drugs 2011; 16:363-72. [DOI: 10.1517/14728214.2011.565050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Vijeya Ganesan
- Institute of Child Health, University College London, London, UK
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