Editorial Opinion
Although the effect of expanded measles immunization in the United States has been a substantial decrease in morbidity, a notable effect in developing countries has been a substantial decrease in mortality. The aim of Millennium Development Goal 4 is to reduce the overall number of deaths among children by two-thirds by 2015, compared with the level in 1990. There are now 550 000 fewer annual deaths from measles today than there were a decade ago. Fully one-fourth of all mortality reduction toward Millennium Development Goal 4 has been due to measles control.8 Over 30 African countries now have more than 80% measles vaccination coverage resulting in a 91% decline in measles mortality.9 The success of global measles and rubella control is largely due to an innovative partnership, the Measles-Rubella Initiative, which was started in 2001 and has since supported delivering more than 1 billion doses of vaccine. Special recognition is due to the American Red Cross, which convened and hosts the initiative, and its partners, the United Nations Foundation, the Centers for Disease ARTICLE INFORMATION Author Affiliation: Office of the Secretary General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria, New York, New York. Corresponding Author: Mark Grabowsky, MD, MPH, Office of the Secretary General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria, 650 Madison Ave, 22nd Floor, New York, NY 10022 (MGrabowsky @mdghealthenvoy.org). Published Online: December 5, 2013. doi:10.1001/jamapediatrics.2013.4603. Conflict of Interest Disclosures: None reported. REFERENCES 1. Papania MJ, Wallace GS, Rota PA, et al. Elimination of endemic measles, rubella, and congenital rubella syndrome from the Western hemisphere: the US experience [published online December 5, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.4342.
Control and Prevention, the United Nations Children’s Fund, and the World Health Organization. The ending of the measles and rubella pandemic in the Western hemisphere is a stepping stone to global eradication. There is a consensus that the global eradication of measles will proceed if there is progress toward these regional goals.10 Has such progress been made? With close to 20 million people, São Paolo in Brazil may be the largest city in the world. With an estimated population of 4 million people, Mexico City’s NezaChalco-Itza is considered to be the largest slum on the planet. New York City is one of the largest and most visited cities in the world. Disease transmission has such an advantage in these cities that it would seem implausible to control any infectious diseases, much less eliminate 2 of the most infectious ones. And yet, even in these settings, measles and rubella have been eliminated for a decade. The world need look no further for proof that global eradication of measles and rubella can be successful.
2. Centers for Disease Control and Prevention (CDC). Measles—United States, January 1–August 24, 2013. MMWR Morb Mortal Wkly Rep. 2013;62(36):741-743. 3. Hinman AR, Orenstein WA, Papania MJ. Evolution of measles elimination strategies in the United States. J Infect Dis. 2004;189(suppl 1):S17-S22.
immunization, and the risks of vaccine-preventable diseases. N Engl J Med. 2009;360(19):1981-1988. 7. Texas megachurch of center of measles outbreak [transcript]. Weekend Edition Sunday. National Public Radio. September 1, 2013. http://www.npr .org/2013/09/01/217746942/texas-megachurch -at-center-of-measles-outbreak. Accessed October 16, 2013.
4. Vaccines and immunizations: statistics and surveillance. Coverage with individual vaccines from the inception of NIS, 1994 through 2012. Centers for Disease Control and Prevention website. http://www.cdc.gov/vaccines/stats-surv /nis/figures/2012_map.htm. Accessed October 16, 2013.
8. Strebel PM, Cochi SL, Hoekstra E, et al. A world without measles. J Infect Dis. 2011;204(suppl 1):S1-S3.
5. World Health Organization. Measles and rubella elimination 2015: package for accelerated action: 2013-2015. http://www.euro.who.int/__data/assets /pdf_file/0020/215480/PACKAGE-FOR -ACCELERATED-ACTION-20132015.pdf. Accessed October 13, 2013.
10. World Health Organization. Global eradication of measles: report by the Secretariat. http://apps.who.int/gb/ebwha/pdf_files/WHA63 /A63_18-en.pdf. Published March 25, 2010. Accessed November 19, 2013.
9. Centers for Disease Control and Prevention (CDC). Progress in global measles control and mortality reduction, 2000-2006. MMWR Morb Mortal Wkly Rep. 2007;56(47):1237-1241.
6. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory
To Eat or Not to Eat What Foods Are Safe to Consume During Pregnancy? Ruchi Gupta, MD, MPH
Mothers-to-be often seek advice from physicians on what is safe to eat during pregnancy in order to give their child the best chance of being healthy. Historically, understanding the relationship between a woman’s diet during pregnancy and Related article page 156 neonatal outcomes has been critical to avoiding negative sequelae. Two well-known examples include the following: (1) adequate dietary folic acid intake to prevent neural tube defects1; and (2) avoidance of soft unpasteurized cheeses to prejamapediatrics.com
vent Listeria infections, which can result in fetal death or other long-term consequences.2,3 With the recent increase in childhood food allergies,4 it is no surprise that women are seeking added guidance on whether diet during pregnancy can influence their child’s risk of developing food allergy. Yet, guidelines, experts, and the science itself continue to change at a rate that leaves women confused. For example, recommendations regarding the ingestion of potentially allergenic foods during pregnancy have flipflopped for more than a decade. Although guidelines in 2000 JAMA Pediatrics February 2014 Volume 168, Number 2
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Opinion Editorial
called for women to remove peanuts and tree nuts from their diets during pregnancy,5 the guidelines were rescinded when more recent research did not substantiate the association between maternal diet and risk of food allergy development.6-8 In fact, some studies actually showed that avoiding peanuts during pregnancy increased the risk of the child developing peanut sensitization.9-11 Current guidelines recommend that mothers should not restrict their diets during pregnancy,6 but this recommendation remains a widely debated topic among food allergy experts. To gain further clarity, the article by Frazier et al12 provides insight into what the latest science suggests regarding whether women should consume nuts during pregnancy. In the Growing Up Today Study 2, the research team prospectively followed up a cohort of 10 907 mothers and their children from peripregnancy to preadolescence. Specifically, mothers were asked to describe their diet around the time of their pregnancy, which included reporting intake of peanuts and tree nuts. In total, 140 children had a physician-confirmed peanut and/or tree nut allergy. Furthermore, Frazier and colleagues report a strong inverse association between peripregnancy nut intake and the risk of nut allergy in children among mothers who did not have nut allergies. In other words, if a mother ate nuts more than 5 times a month, the risk of her child developing a nut allergy was lowered. Although the dietary surveys were not specific for the actual dates of the ARTICLE INFORMATION Author Affiliation: Department of Pediatrics, Program for Maternal and Child Health, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois. Corresponding Author: Ruchi Gupta, MD, MPH, Northwestern University Feinberg School of Medicine, Center for Healthcare Studies, 750 N Lakeshore Dr, 10th Floor, Chicago, IL 60611 (r-gupta @northwestern.edu). Published Online: December 23, 2013. doi:10.1001/jamapediatrics.2013.4602. Conflict of Interest Disclosures: None reported. REFERENCES 1. MRC Vitamin Study Research Group. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet. 1991;338(8760):131-137. 2. Vázquez-Boland JA, Kuhn M, Berche P, et al. Listeria pathogenesis and molecular virulence determinants. Clin Microbiol Rev. 2001;14(3): 584-640. 3. Farber JM, Peterkin PI. Listeria monocytogenes, a food-borne pathogen. Microbiol Rev. 1991;55(3):476-511. 4. Branum AM, Lukacs SL. Food allergy among children in the United States. Pediatrics. 2009;124(6):1549-1555.
pregnancy, these findings support recent recommendations that women should not restrict their diets during pregnancy. Certainly, women who are allergic to nuts should continue avoiding nuts. Understanding how maternal nutrition is associated with the development of childhood food allergy is likely just one piece of the research puzzle. Childhood food allergy is an emerging disease of public health importance. Today, food allergy affects 1 in 13 children in the United States, and nearly 40% of those affected have a history of severe, potentially lifethreatening reactions.13 Moreover, food allergy often impairs quality of life, limits social interactions,14-17 and negatively affects family finances.18 Further research—including better understanding how maternal diet affects food allergy development—needs to be conducted to better understand the questions of why more and more children are developing food allergy and how we can prevent it. Once we have a better understanding of the why, we will then be able to more confidently give advice and develop more specific preventive recommendations. For now, though, guidelines stand: pregnant women should not eliminate nuts from their diet as peanuts are a good source of protein and also provide folic acid, which could potentially prevent both neural tube defects and nut sensitization. So, to provide guidance in how to respond to the age-old question “To eat or not to eat?” mothers-to-be should feel free to curb their cravings with a dollop of peanut butter!
5. American Academy of Pediatrics, Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics. 2000;106(2, pt 1):346-349.
is associated with peanut sensitization in atopic infants. J Allergy Clin Immunol. 2010;126(6):11911197.
6. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183-191.
12. Frazier AL, Camargo CA Jr, Malspeis S, Willett WC, Young MC. Prospective study of peripregnancy consumption of peanuts or tree nuts by mothers and the risk of peanut or tree nut allergy in their offspring [published online December 23, 2013]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.4139.
7. Lack G, Fox D, Northstone K, Golding J; Avon Longitudinal Study of Parents and Children Study Team. Factors associated with the development of peanut allergy in childhood. N Engl J Med. 2003;348(11):977-985. 8. Hourihane JOB, Aiken R, Briggs R, et al. The impact of government advice to pregnant mothers regarding peanut avoidance on the prevalence of peanut allergy in United Kingdom children at school entry. J Allergy Clin Immunol. 2007;119(5):11971202. 9. Frank L, Marian A, Visser M, Weinberg E, Potter PC. Exposure to peanuts in utero and in infancy and the development of sensitization to peanut allergens in young children. Pediatr Allergy Immunol. 1999;10(1):27-32. 10. Hourihane JO, Dean TP, Warner JO. Peanut allergy in relation to heredity, maternal diet, and other atopic diseases: results of a questionnaire survey, skin prick testing, and food challenges. BMJ. 1996;313(7056):518-521. 11. Sicherer SH, Wood RA, Stablein D, et al. Maternal consumption of peanut during pregnancy
110
13. Gupta RS, Springston EE, Warrier MR, et al. The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics. 2011;128(1):e9-e17. 14. Springston EE, Smith B, Shulruff J, Pongracic J, Holl J, Gupta RS. Variations in quality of life among caregivers of food allergic children. Ann Allergy Asthma Immunol. 2010;105(4):287-294. 15. Akeson N, Worth A, Sheikh A. The psychosocial impact of anaphylaxis on young people and their parents. Clin Exp Allergy. 2007;37(8):1213-1220. 16. Avery NJ, King RM, Knight S, Hourihane JOB. Assessment of quality of life in children with peanut allergy. Pediatr Allergy Immunol. 2003;14(5): 378-382. 17. Primeau MN, Kagan R, Joseph L, et al. The psychological burden of peanut allergy as perceived by adults with peanut allergy and the parents of peanut-allergic children. Clin Exp Allergy. 2000;30(8):1135-1143. 18. Patel DA, Holdford DA, Edwards E, Carroll NV. Estimating the economic burden of food-induced allergic reactions and anaphylaxis in the United States. J Allergy Clin Immunol. 2011;128(1):110-115, e5.
JAMA Pediatrics February 2014 Volume 168, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of California - San Diego User on 06/09/2015
jamapediatrics.com
Although the effect of expanded measles immunization in the United States has been a substantial decrease in morbidity, a notable effect in developing countries has been a substantial decrease in mortality. The aim of Millennium Development Goal 4 is to reduce the overall number of deaths among children by two-thirds by 2015, compared with the level in 1990. There are now 550 000 fewer annual deaths from measles today than there were a decade ago. Fully one-fourth of all mortality reduction toward Millennium Development Goal 4 has been due to measles control.8 Over 30 African countries now have more than 80% measles vaccination coverage resulting in a 91% decline in measles mortality.9 The success of global measles and rubella control is largely due to an innovative partnership, the Measles-Rubella Initiative, which was started in 2001 and has since supported delivering more than 1 billion doses of vaccine. Special recognition is due to the American Red Cross, which convened and hosts the initiative, and its partners, the United Nations Foundation, the Centers for Disease ARTICLE INFORMATION Author Affiliation: Office of the Secretary General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria, New York, New York. Corresponding Author: Mark Grabowsky, MD, MPH, Office of the Secretary General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria, 650 Madison Ave, 22nd Floor, New York, NY 10022 (MGrabowsky @mdghealthenvoy.org). Published Online: December 5, 2013. doi:10.1001/jamapediatrics.2013.4603. Conflict of Interest Disclosures: None reported. REFERENCES 1. Papania MJ, Wallace GS, Rota PA, et al. Elimination of endemic measles, rubella, and congenital rubella syndrome from the Western hemisphere: the US experience [published online December 5, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.4342.
Control and Prevention, the United Nations Children’s Fund, and the World Health Organization. The ending of the measles and rubella pandemic in the Western hemisphere is a stepping stone to global eradication. There is a consensus that the global eradication of measles will proceed if there is progress toward these regional goals.10 Has such progress been made? With close to 20 million people, São Paolo in Brazil may be the largest city in the world. With an estimated population of 4 million people, Mexico City’s NezaChalco-Itza is considered to be the largest slum on the planet. New York City is one of the largest and most visited cities in the world. Disease transmission has such an advantage in these cities that it would seem implausible to control any infectious diseases, much less eliminate 2 of the most infectious ones. And yet, even in these settings, measles and rubella have been eliminated for a decade. The world need look no further for proof that global eradication of measles and rubella can be successful.
2. Centers for Disease Control and Prevention (CDC). Measles—United States, January 1–August 24, 2013. MMWR Morb Mortal Wkly Rep. 2013;62(36):741-743. 3. Hinman AR, Orenstein WA, Papania MJ. Evolution of measles elimination strategies in the United States. J Infect Dis. 2004;189(suppl 1):S17-S22.
immunization, and the risks of vaccine-preventable diseases. N Engl J Med. 2009;360(19):1981-1988. 7. Texas megachurch of center of measles outbreak [transcript]. Weekend Edition Sunday. National Public Radio. September 1, 2013. http://www.npr .org/2013/09/01/217746942/texas-megachurch -at-center-of-measles-outbreak. Accessed October 16, 2013.
4. Vaccines and immunizations: statistics and surveillance. Coverage with individual vaccines from the inception of NIS, 1994 through 2012. Centers for Disease Control and Prevention website. http://www.cdc.gov/vaccines/stats-surv /nis/figures/2012_map.htm. Accessed October 16, 2013.
8. Strebel PM, Cochi SL, Hoekstra E, et al. A world without measles. J Infect Dis. 2011;204(suppl 1):S1-S3.
5. World Health Organization. Measles and rubella elimination 2015: package for accelerated action: 2013-2015. http://www.euro.who.int/__data/assets /pdf_file/0020/215480/PACKAGE-FOR -ACCELERATED-ACTION-20132015.pdf. Accessed October 13, 2013.
10. World Health Organization. Global eradication of measles: report by the Secretariat. http://apps.who.int/gb/ebwha/pdf_files/WHA63 /A63_18-en.pdf. Published March 25, 2010. Accessed November 19, 2013.
9. Centers for Disease Control and Prevention (CDC). Progress in global measles control and mortality reduction, 2000-2006. MMWR Morb Mortal Wkly Rep. 2007;56(47):1237-1241.
6. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory
To Eat or Not to Eat What Foods Are Safe to Consume During Pregnancy? Ruchi Gupta, MD, MPH
Mothers-to-be often seek advice from physicians on what is safe to eat during pregnancy in order to give their child the best chance of being healthy. Historically, understanding the relationship between a woman’s diet during pregnancy and Related article page 156 neonatal outcomes has been critical to avoiding negative sequelae. Two well-known examples include the following: (1) adequate dietary folic acid intake to prevent neural tube defects1; and (2) avoidance of soft unpasteurized cheeses to prejamapediatrics.com
vent Listeria infections, which can result in fetal death or other long-term consequences.2,3 With the recent increase in childhood food allergies,4 it is no surprise that women are seeking added guidance on whether diet during pregnancy can influence their child’s risk of developing food allergy. Yet, guidelines, experts, and the science itself continue to change at a rate that leaves women confused. For example, recommendations regarding the ingestion of potentially allergenic foods during pregnancy have flipflopped for more than a decade. Although guidelines in 2000 JAMA Pediatrics February 2014 Volume 168, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of California - San Diego User on 06/09/2015
109
Opinion Editorial
called for women to remove peanuts and tree nuts from their diets during pregnancy,5 the guidelines were rescinded when more recent research did not substantiate the association between maternal diet and risk of food allergy development.6-8 In fact, some studies actually showed that avoiding peanuts during pregnancy increased the risk of the child developing peanut sensitization.9-11 Current guidelines recommend that mothers should not restrict their diets during pregnancy,6 but this recommendation remains a widely debated topic among food allergy experts. To gain further clarity, the article by Frazier et al12 provides insight into what the latest science suggests regarding whether women should consume nuts during pregnancy. In the Growing Up Today Study 2, the research team prospectively followed up a cohort of 10 907 mothers and their children from peripregnancy to preadolescence. Specifically, mothers were asked to describe their diet around the time of their pregnancy, which included reporting intake of peanuts and tree nuts. In total, 140 children had a physician-confirmed peanut and/or tree nut allergy. Furthermore, Frazier and colleagues report a strong inverse association between peripregnancy nut intake and the risk of nut allergy in children among mothers who did not have nut allergies. In other words, if a mother ate nuts more than 5 times a month, the risk of her child developing a nut allergy was lowered. Although the dietary surveys were not specific for the actual dates of the ARTICLE INFORMATION Author Affiliation: Department of Pediatrics, Program for Maternal and Child Health, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois. Corresponding Author: Ruchi Gupta, MD, MPH, Northwestern University Feinberg School of Medicine, Center for Healthcare Studies, 750 N Lakeshore Dr, 10th Floor, Chicago, IL 60611 (r-gupta @northwestern.edu). Published Online: December 23, 2013. doi:10.1001/jamapediatrics.2013.4602. Conflict of Interest Disclosures: None reported. REFERENCES 1. MRC Vitamin Study Research Group. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet. 1991;338(8760):131-137. 2. Vázquez-Boland JA, Kuhn M, Berche P, et al. Listeria pathogenesis and molecular virulence determinants. Clin Microbiol Rev. 2001;14(3): 584-640. 3. Farber JM, Peterkin PI. Listeria monocytogenes, a food-borne pathogen. Microbiol Rev. 1991;55(3):476-511. 4. Branum AM, Lukacs SL. Food allergy among children in the United States. Pediatrics. 2009;124(6):1549-1555.
pregnancy, these findings support recent recommendations that women should not restrict their diets during pregnancy. Certainly, women who are allergic to nuts should continue avoiding nuts. Understanding how maternal nutrition is associated with the development of childhood food allergy is likely just one piece of the research puzzle. Childhood food allergy is an emerging disease of public health importance. Today, food allergy affects 1 in 13 children in the United States, and nearly 40% of those affected have a history of severe, potentially lifethreatening reactions.13 Moreover, food allergy often impairs quality of life, limits social interactions,14-17 and negatively affects family finances.18 Further research—including better understanding how maternal diet affects food allergy development—needs to be conducted to better understand the questions of why more and more children are developing food allergy and how we can prevent it. Once we have a better understanding of the why, we will then be able to more confidently give advice and develop more specific preventive recommendations. For now, though, guidelines stand: pregnant women should not eliminate nuts from their diet as peanuts are a good source of protein and also provide folic acid, which could potentially prevent both neural tube defects and nut sensitization. So, to provide guidance in how to respond to the age-old question “To eat or not to eat?” mothers-to-be should feel free to curb their cravings with a dollop of peanut butter!
5. American Academy of Pediatrics, Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics. 2000;106(2, pt 1):346-349.
is associated with peanut sensitization in atopic infants. J Allergy Clin Immunol. 2010;126(6):11911197.
6. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183-191.
12. Frazier AL, Camargo CA Jr, Malspeis S, Willett WC, Young MC. Prospective study of peripregnancy consumption of peanuts or tree nuts by mothers and the risk of peanut or tree nut allergy in their offspring [published online December 23, 2013]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.4139.
7. Lack G, Fox D, Northstone K, Golding J; Avon Longitudinal Study of Parents and Children Study Team. Factors associated with the development of peanut allergy in childhood. N Engl J Med. 2003;348(11):977-985. 8. Hourihane JOB, Aiken R, Briggs R, et al. The impact of government advice to pregnant mothers regarding peanut avoidance on the prevalence of peanut allergy in United Kingdom children at school entry. J Allergy Clin Immunol. 2007;119(5):11971202. 9. Frank L, Marian A, Visser M, Weinberg E, Potter PC. Exposure to peanuts in utero and in infancy and the development of sensitization to peanut allergens in young children. Pediatr Allergy Immunol. 1999;10(1):27-32. 10. Hourihane JO, Dean TP, Warner JO. Peanut allergy in relation to heredity, maternal diet, and other atopic diseases: results of a questionnaire survey, skin prick testing, and food challenges. BMJ. 1996;313(7056):518-521. 11. Sicherer SH, Wood RA, Stablein D, et al. Maternal consumption of peanut during pregnancy
110
13. Gupta RS, Springston EE, Warrier MR, et al. The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics. 2011;128(1):e9-e17. 14. Springston EE, Smith B, Shulruff J, Pongracic J, Holl J, Gupta RS. Variations in quality of life among caregivers of food allergic children. Ann Allergy Asthma Immunol. 2010;105(4):287-294. 15. Akeson N, Worth A, Sheikh A. The psychosocial impact of anaphylaxis on young people and their parents. Clin Exp Allergy. 2007;37(8):1213-1220. 16. Avery NJ, King RM, Knight S, Hourihane JOB. Assessment of quality of life in children with peanut allergy. Pediatr Allergy Immunol. 2003;14(5): 378-382. 17. Primeau MN, Kagan R, Joseph L, et al. The psychological burden of peanut allergy as perceived by adults with peanut allergy and the parents of peanut-allergic children. Clin Exp Allergy. 2000;30(8):1135-1143. 18. Patel DA, Holdford DA, Edwards E, Carroll NV. Estimating the economic burden of food-induced allergic reactions and anaphylaxis in the United States. J Allergy Clin Immunol. 2011;128(1):110-115, e5.
JAMA Pediatrics February 2014 Volume 168, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of California - San Diego User on 06/09/2015
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