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The Journal of Pediatrics Nov 2017To analyze published reports of unintentional cannabis ingestions in children to determine presenting signs and symptoms, route of exposure, treatment, and outcome. (Review)
Review
OBJECTIVE
To analyze published reports of unintentional cannabis ingestions in children to determine presenting signs and symptoms, route of exposure, treatment, and outcome.
STUDY DESIGN
PubMed, OpenGrey, and Google Scholar were systematically searched. Articles were selected, reviewed, and graded using Oxford Center for Evidence-Based Medicine guidelines.
RESULTS
Of 3316 articles, 44 were included (3582 children age ≤12 years). We found no high quality (Oxford Center for Evidence-Based Medicine level I or II) studies and 10 level III studies documenting lethargy as the most common presenting sign and confirming increasing incidence of unintentional ingestion in states having decriminalized medical and recreational cannabis. We identified 16 level IV case series, and 28 level V case reports with 114 children, mean age 25.2 ± 18.7 months, range 8 months to 12 years, and 50 female children (44%). The most common ingestion (n = 43, 38%) was cannabis resin, followed by cookies and joints (both n = 15, 13%). Other exposures included passive smoke, medical cannabis, candies, beverages, and hemp oil. Lethargy was the most common presenting sign (n = 81, 71%) followed by ataxia (n = 16, 14%). Tachycardia, mydriasis, and hypotonia were also commonly observed. All cases were cared for in the emergency department or admitted, and mean length of stay was 27.1 ± 27.0 hours. Twenty (18%) were admitted to the pediatric intensive care unit, and 7 (6%) were intubated.
CONCLUSIONS
Unintentional cannabis ingestion by children is a serious public health concern and is well-documented in numerous studies and case reports. Clinicians should consider cannabis toxicity in any child with sudden onset of lethargy or ataxia.
Topics: Cannabis; Child; Child, Preschool; Eating; Emergency Service, Hospital; Female; Humans; Infant; Male; Marijuana Abuse
PubMed: 28888560
DOI: 10.1016/j.jpeds.2017.07.005 -
World Journal of Pediatrics : WJP Dec 2017To review the available evidence from prospective studies on the safety and tolerability of the ketogenic diet (KD) for the treatment of refractory childhood epilepsy. (Review)
Review
BACKGROUND
To review the available evidence from prospective studies on the safety and tolerability of the ketogenic diet (KD) for the treatment of refractory childhood epilepsy.
METHODS
A comprehensive bibliographic search was performed with the aim of retrieving prospective studies that monitored adverse effects (AEs) in children after receiving the classic or medium-chain triglyceride KD therapy for refractory epilepsy.
RESULTS
A total of 45 studies were retrieved, including 7 randomized controlled trials. More than 40 categories of AEs were reported. The most common AEs included gastrointestinal disturbances (40.6%), hyperlipidemia (12.8%), hyperuricemia (4.4%), lethargy (4.1%), infectious diseases (3.8%) and hypoproteinemia (3.8%). Severe AEs, such as respiratory failure and pancreatitis, occurred in no more than 0.5% of children. Specifically, patients receiving KD therapy should be monitored for osteopenia, urological stones, right ventricular diastolic dysfunction, and growth disturbance. The total retention rates of the diet for 1 year and 2 years were 45.7% and 29.2%, respectively. Nearly half of the patients discontinued the diet because of lack of efficacy. AEs were not the main reason for the KD discontinuation. None of the 24 deaths reported after initiation of the diet was attributed to the KD.
CONCLUSIONS
KD is a relatively safe dietary therapy. However, because the KD can cause various AEs, it should be implemented under careful medical supervision. Continuous follow-up is needed to address the long-term impact of the diet on the overall health of children.
Topics: Adolescent; Child; Child, Preschool; China; Diet, Ketogenic; Drug Resistant Epilepsy; Female; Humans; Infant; Male; Patient Safety; Prognosis; Prospective Studies; Risk Assessment; Severity of Illness Index; Treatment Outcome
PubMed: 28702868
DOI: 10.1007/s12519-017-0053-2 -
The Cochrane Database of Systematic... Jun 2017Schizophrenia and related disorders such as schizophreniform and schizoaffective disorder are serious mental illnesses characterised by profound disruptions in thinking... (Review)
Review
BACKGROUND
Schizophrenia and related disorders such as schizophreniform and schizoaffective disorder are serious mental illnesses characterised by profound disruptions in thinking and speech, emotional processes, behaviour and sense of self. Clozapine is useful in the treatment of schizophrenia and related disorders, particularly when other antipsychotic medications have failed. It improves positive symptoms (such as delusions and hallucinations) and negative symptoms (such as withdrawal and poverty of speech). However, it is unclear what dose of clozapine is most effective with the least side effects.
OBJECTIVES
To compare the efficacy and tolerability of clozapine at different doses and to identify the optimal dose of clozapine in the treatment of schizophrenia, schizophreniform and schizoaffective disorders.
SEARCH METHODS
We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (August 2011 and 8 December 2016).
SELECTION CRITERIA
All relevant randomised controlled trials (RCTs), irrespective of blinding status or language, that compared the effects of clozapine at different doses in people with schizophrenia and related disorders, diagnosed by any criteria.
DATA COLLECTION AND ANALYSIS
We independently inspected citations from the searches, identified relevant abstracts, obtained full articles of relevant abstracts, and classified trials as included or excluded. We included trials that met our inclusion criteria and reported useable data. For dichotomous data, we calculated the relative risk (RR) and the 95% confidence interval (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) again based on a random-effects model. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.
MAIN RESULTS
We identified five studies that could be included. Each compared the effects of clozapine at very low dose (up to 149 mg/day), low dose (150 mg/day to 300 mg/day) and standard dose (301 mg/day to 600 mg/day). Four of the five included studies were based on a small number of participants. We rated all the evidence reported for the main outcomes of interest as low or very low quality. No data were available for the main outcomes of global state, service use or quality of life. Very low dose compared to low doseWe found no evidence of effect on mental state between low and very low doses of clozapine in terms of average Brief Psychiatric Rating Scale-Anchored (BPRS-A) endpoint score (1 RCT, n = 31, MD 3.55, 95% CI -4.50 to 11.60, very low quality evidence). One study found no difference between groups in body mass index (BMI) in the short term (1 RCT, n = 59, MD -0.10, 95% CI -0.95 to 0.75, low-quality evidence). Very low dose compared to standard doseWe found no evidence of effect on mental state between very low doses and standard doses of clozapine in terms of average BPRS-A endpoint score (1 RCT, n = 31, MD 6.67, 95% CI -2.09 to 15.43, very low quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 58, MD 0.10, 95% CI -0.76 to 0.96, low-quality evidence) Low dose compared to standard doseWe found no evidence of effect on mental state between low doses and standard doses of clozapine in terms of both clinician-assessed clinical improvement (2 RCTs, n = 141, RR 0.76, 95% CI 0.36 to 1.61, medium-quality evidence) and clinically important response as more than 30% change in BPRS score (1 RCT, n = 176, RR 0.93, 95% CI 0.78 to 1.10, medium-quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 57, MD 0.20, 95% CI -0.84 to 1.24, low-quality evidence).We found some evidence of effect for other adverse effect outcomes; however, the data were again limited. Very low dose compared to low doseThere was limited evidence that serum triglycerides were lower at low-dose clozapine compared to very low dose in the short term (1 RCT, n = 59, MD 1.00, 95% CI 0.51 to 1.49). Low dose compared to standard doseWeight gain was lower at very low dose compared to standard dose (1 RCT, n = 27, MD -2.70, 95% CI -5.38 to -0.02). Glucose level one hour after meal was also lower at very lose dose (1 RCT, n = 58, MD -1.60, 95% CI -2.90 to -0.30). Total cholesterol levels were higher at very low compared to standard dose (1 RCT, n = 58, n = 58, MD 1.00, 95% CI 0.20 to 1.80). Low dose compared to standard doseThere was evidence of fewer adverse effects, measured as lower TESS scores, in the low-dose group in the short term (2 RCTs, n = 266, MD -3.99, 95% CI -5.75 to -2.24); and in one study there was evidence that the incidence of lethargy (RR 0.77, 95% CI 0.60 to 0.97), hypersalivation (RR 0.70, 95% CI 0.57 to 0.84), dizziness (RR 0.56, 95% CI 0.39 to 0.81) and tachycardia (RR 0.57, 95% CI 0.45 to 0.71) was less at low dose compared to standard dose.
AUTHORS' CONCLUSIONS
We found no evidence of effect on mental state between standard, low and very low dose regimes, but we did not identify any trials on high or very high doses of clozapine. BMI measurements were similar between groups in the short term, although weight gain was less at very low dose compared to standard dose in one study. There was limited evidence that the incidence of some adverse effects was greater at standard dose compared to lower dose regimes. We found very little useful data and the evidence available is generally of low or very low quality. More studies are needed to validate our findings and report on outcomes such as relapse, remission, social functioning, service utilisation, cost-effectiveness, satisfaction with care, and quality of life. There is a particular lack of medium- or long-term outcome data, and on dose regimes above the standard rate.
Topics: Agranulocytosis; Antipsychotic Agents; Clozapine; Humans; Psychotic Disorders; Schizophrenia
PubMed: 28613395
DOI: 10.1002/14651858.CD009555.pub2 -
The Journal of Nutrition Mar 2017Effective treatments for the core symptoms of autism spectrum disorder (ASD) are still lacking. We aimed to update the data on the effectiveness of ω-3 (n-3) fatty... (Meta-Analysis)
Meta-Analysis Review
Effective treatments for the core symptoms of autism spectrum disorder (ASD) are still lacking. We aimed to update the data on the effectiveness of ω-3 (n-3) fatty acid (FA) supplementation as a treatment for ASD. The Cochrane Library, MEDLINE, and EMBASE databases were systematically searched up until August 2016 with no language restrictions for randomized controlled trials (RCTs) comparing ω-3 FA supplementation with placebo or with no supplementation. Participants were children diagnosed with ASD. All functional outcome measures reported were considered. For dichotomous outcomes, the results for individual studies and pooled statistics were reported as RRs. Mean differences (MDs) were calculated for continuous outcomes. Five RCTs (183 participants) were included. With 4 exceptions, there were no statistically significant differences in ASD symptoms between groups measured by validated scales. Among studies that used the Aberrant Behavior Checklist, parents' ratings indicated significant improvement in lethargy symptoms in the ω-3 FA group compared with the placebo group (2 RCTs) (pooled MD: 1.98; 95% CI: 0.32, 3.63). Among studies that used the Behavioral Assessment System for Children, parents' ratings indicated significant worsening of both externalizing behavior (2 RCTs) (pooled MD: -6.22; 95% CI: -10.9, -1.59) and social skills (1 RCT) (MD: -7; 95% CI: -13.62, -0.38) in the ω-3 FA group compared with the placebo group. One RCT reported a significant improvement in the ω-3 FA group for the daily-living component of the Vineland Adaptive Behavior Scale (MD: 6.2; 95% CI: 0.37, 12.03). Adverse effects were similar in both groups. Because of the limited number of included studies and small sample sizes, no firm conclusions can be drawn. However, the limited data currently available suggest that ω-3 FA supplementation does not enhance the performance of children with ASD.
Topics: Autism Spectrum Disorder; Child; Dietary Supplements; Fatty Acids, Omega-3; Humans
PubMed: 28077731
DOI: 10.3945/jn.116.242354 -
The Cochrane Database of Systematic... Nov 2016Restless legs syndrome (RLS) is defined as the spontaneous movement of the limbs (mainly legs) associated with unpleasant, sometimes painful sensation which is relieved... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Restless legs syndrome (RLS) is defined as the spontaneous movement of the limbs (mainly legs) associated with unpleasant, sometimes painful sensation which is relieved by moving the affected limb. Prevalence of RLS among people on dialysis has been estimated between 6.6% and 80%. RLS symptoms contribute to impaired quality of life and people with RLS are shown to have increased cardiovascular morbidity and mortality.Various pharmacological and non-pharmacological interventions have been used to treat primary RLS. However, the evidence for use of these interventions in people with chronic kidney disease (CKD) is not well established. The agents used in the treatment of primary RLS may be limited by the side effects in people with CKD due to increased comorbidity and altered drug pharmacokinetics.
OBJECTIVES
The aim of this review was to critically look at the benefits, efficacy and safety of various treatment options used in the treatment of RLS in people with CKD and those undergoing renal replacement therapy (RRT). We aimed to define different group characteristics based on CKD stage to assess the applicability of a particular intervention to an individual patient.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Specialised Register to 12 January 2016 through contact with the Information Specialist using search terms relevant to this review.
SELECTION CRITERIA
Randomised controlled trials (RCT) and quasi-RCTs that assessed the efficacy of an intervention for RLS in adults with CKD were eligible for inclusion. Studies investigating idiopathic RLS or RLS secondary to other causes were excluded.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed studies for eligibility and conducted risk of bias evaluation. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes.
MAIN RESULTS
We included nine studies enrolling 220 dialysis participants. Seven studies were deemed to have moderate to high risk of bias. All studies were small in size and had a short follow-up period (two to six months). Studies evaluated the effects of six different interventions against placebo or standard treatment. The interventions studied included aerobic resistance exercise, gabapentin, ropinirole, levodopa, iron dextran, and vitamins C and E (individually and in combination).Aerobic resistance exercise showed a significant reduction in severity of RLS compared to no exercise (2 studies, 48 participants: MD -7.56, 95% CI -14.20 to -0.93; I = 65%), and when compared to exercise with no resistance (1 study, 24 participants: MD -11.10, 95% CI -17.11 to -5.09), however there was no significant reduction when compared to ropinirole (1 study, 22 participants): MD -0.55, 95% CI -6.41 to 5.31). There were no significant differences between aerobic resistance exercise and either no exercise or ropinirole in the physical or mental component summary scores (using the SF-36 form). Improvement in sleep quality varied. There was no significant difference in subjective sleep quality between exercise and no exercise; however one study reported a significant improvement with ropinirole compared to resistance exercise (MD 3.71, 95% CI 0.89 to 6.53). Using the Epworth Sleepiness Scale there were no significant differences between resistance exercise and no exercise, ropinirole, or exercise with no resistance. Two studies reported there were no adverse events and one study did not mention if there were any adverse events. In one study, one patient in each group dropped out but the reason for dropout was not reported. Two studies reported no adverse events and one study did not report adverse events.Gabapentin was associated with reduced RLS severity when compared to placebo or levodopa, and there was a significant improvement in sleep quality, latency and disturbance reported in one study when compared to levodopa. Three patients dropped out due to lethargy (2 patients), and drowsiness, syncope and fatigue (1 patient).Because of a short duration of action, rebound and augmentation were noted with levodopa treatment even though it conferred some benefit in reducing the symptoms of RLS. Reported adverse events were severe vomiting, agitation after caffeine intake, headaches, dry mouth, and gastrointestinal symptoms.One study (25 participants) reported iron dextran reduced the severity of RLS at weeks one and two, but not at week four. Vitamins C, E and C plus E (1 study, 60 participants) helped the symptoms of RLS with minimal side effects (nausea and dyspepsia) but more evidence is needed before any conclusions can be drawn.
AUTHORS' CONCLUSIONS
Given the small size of the studies and short follow-up, it can only be concluded that pharmacological interventions and intra-dialytic exercise programs have uncertain effects on RLS in haemodialysis patients. There have been no studies performed in non-dialysis CKD, peritoneal dialysis patients, or kidney transplant recipients. Further studies are warranted before any conclusions can be drawn. Aerobic resistance exercise and ropinirole may be suitable interventions for further evaluation.
Topics: Amines; Anticonvulsants; Ascorbic Acid; Cyclohexanecarboxylic Acids; Dopamine Agonists; Exercise Therapy; Gabapentin; Humans; Indoles; Iron-Dextran Complex; Levodopa; Quality of Life; Randomized Controlled Trials as Topic; Renal Insufficiency, Chronic; Renal Replacement Therapy; Resistance Training; Restless Legs Syndrome; Vitamin E; Vitamins; gamma-Aminobutyric Acid
PubMed: 27819409
DOI: 10.1002/14651858.CD010690.pub2 -
The Cochrane Database of Systematic... Oct 2016Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebrovascular disease. However, the sedative effects of GABA receptor agonists have limited their wider application in people with acute stroke, due to the potential risk of stupor. This is an update of a Cochrane review first published in 2013, and previously updated in 2014.
OBJECTIVES
To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke.
SEARCH METHODS
We searched the Cochrane Stroke Group Trials Register (accessed March 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) 2016, Issue 3, part of the Cochrane Library (accessed March 2016), MEDLINE (from 1949 to March 2016), Embase (from 1980 to March 2016), CINAHL (from 1982 to March 2016), AMED (from 1985 to March 2016), and 11 Chinese databases (accessed March 2016). In an effort to identify further published, unpublished, and ongoing trials we searched ongoing trials registers, reference lists, and relevant conference proceedings, and contacted authors and pharmaceutical companies.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for people with acute stroke (within 12 hours after stroke onset), with the primary outcomes of efficacy and safety.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy, and assessed the risk of bias.
MAIN RESULTS
We included five trials with 3838 participants (3758 analyzed). The methodological quality of the included trials was generally good, with an unclear risk for selection bias only. Four trials (N = 2909) measured death and dependency at three months for chlormethiazole versus placebo; pooled results did not find a significant difference (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.96 to 1.11). One trial (N = 849) measured this outcome for diazepam versus placebo (RR 0.94, 95% CI 0.82 to 1.07). The most frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95; two trials; N = 2527) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46; two trials; N = 2527).
AUTHORS' CONCLUSIONS
This review provides moderate-quality evidence that fails to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of people with acute stroke. More well-designed RCTs with large samples of participants with total anterior circulation syndrome are required to determine if there are benefits for this subgroup. Somnolence and rhinitis are frequent adverse events related to chlormethiazole.
Topics: Acute Disease; Chlormethiazole; Diazepam; Disorders of Excessive Somnolence; GABA Agonists; Humans; Neuroprotective Agents; Randomized Controlled Trials as Topic; Rhinitis; Stroke
PubMed: 27701753
DOI: 10.1002/14651858.CD009622.pub4 -
Psychosomatics 2016Withdrawal from alcohol and sedative-hypnotics can be complicated by seizures, hallucinations, or delirium. Withdrawal catatonia is another, less commonly discussed... (Review)
Review
Alcohol and Sedative-Hypnotic Withdrawal Catatonia: Two Case Reports, Systematic Literature Review, and Suggestion of a Potential Relationship With Alcohol Withdrawal Delirium.
BACKGROUND
Withdrawal from alcohol and sedative-hypnotics can be complicated by seizures, hallucinations, or delirium. Withdrawal catatonia is another, less commonly discussed complication that clinicians should appreciate.
METHODS
We present a case of alcohol withdrawal catatonia and a case of benzodiazepine withdrawal catatonia and offer a systematic review of previous cases of alcohol or sedative-hypnotic withdrawal catatonia. We outline clinical features that suggest a potential link between withdrawal catatonia and withdrawal delirium.
RESULTS
We identified 26 cases of withdrawal catatonia in the literature-all principally with catatonic stupor-with an average age of 56 years (range: 27-92) and balanced prevalence between sexes. Withdrawal catatonia tends to occur only after chronic use of alcohol or sedative-hypnotic agents with a typical onset of 3-7 days after discontinuation and duration of 3-10 days. Withdrawal catatonia is responsive to benzodiazepines or electroconvulsive therapy. Features that suggest a parallel between withdrawal catatonia and withdrawal delirium include time course, neurobiologic convergence, efficacy of benzodiazepines and electroconvulsive therapy, typical absence of abnormal electroencephalographic findings, and phenotypic classification suggested by a recent literature in sleep medicine.
CONCLUSION
Alcohol and sedative-hypnotic withdrawal may present with catatonia or catatonic features. The clinical and neurobiologic convergence between withdrawal catatonia and withdrawal delirium deserves further attention. In view of these similarities, we propose that withdrawal delirium may represent excited catatonia: these new viewpoints may serve as a substrate for a better understanding of the delirium-catatonia spectrum.
Topics: Alcohol Withdrawal Delirium; Benzodiazepines; Catatonia; Central Nervous System Depressants; Clonazepam; Electroconvulsive Therapy; Ethanol; Female; Humans; Hypnotics and Sedatives; Male; Middle Aged; Substance Withdrawal Syndrome
PubMed: 26949118
DOI: 10.1016/j.psym.2015.12.007 -
Dengue in children: a systematic review of clinical and laboratory factors associated with severity.Expert Review of Anti-infective Therapy 2015Dengue is a potentially life-threatening illness, and children are at higher risk of severity. This review aimed to systematize the identified clinical and laboratory... (Review)
Review
Dengue is a potentially life-threatening illness, and children are at higher risk of severity. This review aimed to systematize the identified clinical and laboratory parameters associated with severe dengue in children, as monitoring these signs and fluid-replacement therapy are actually the cornerstones of dengue treatment. Of the 527 studies initially reviewed, 21 were selected as follows: three cohort studies, three case-control studies, 14 cross-sectional studies and one not defined. Eighteen studies were carried out in Asia and three in the Americas. Hepatomegaly, lethargy, abdominal pain, bleeding, hemoconcentration and thrombocytopenia, all referenced as warning signs in the WHO 2009 Guidelines, were the clinical and laboratory parameters independently associated with severity in more than one study. The recognition of these known warning signs associated to severe dengue disease underlines the usefulness of the WHO 2009 classification.
Topics: Abdominal Pain; Biomarkers; Case-Control Studies; Child; Cohort Studies; Cross-Sectional Studies; Dengue; Exanthema; Fluid Therapy; Hemorrhage; Humans; Risk Factors; Severity of Illness Index
PubMed: 26536064
DOI: 10.1586/14787210.2015.1100534 -
Journal of Human Lactation : Official... Feb 2016There are increasing reports on hypernatremia, a potentially devastating condition, in exclusively breastfed newborn infants. Our purposes were to describe the clinical... (Review)
Review
There are increasing reports on hypernatremia, a potentially devastating condition, in exclusively breastfed newborn infants. Our purposes were to describe the clinical features of the condition and identify the risk factors for it. We performed a review of the existing literature in the National Library of Medicine database and in the search engine Google Scholar. A total of 115 reports were included in the final analysis. Breastfeeding-associated neonatal hypernatremia was recognized in infants who were ≤ 21 days of age and had ≥ 10% weight loss of birth weight. Cesarean delivery, primiparity, breast anomalies or breastfeeding problems, excessive prepregnancy maternal weight, delayed first breastfeeding, lack of previous breastfeeding experience, and low maternal education level were significantly associated with breastfeeding-associated hypernatremia. In addition to excessive weight loss (≥ 10%), the following clinical findings were observed: poor feeding, poor hydration state, jaundice, excessive body temperature, irritability or lethargy, decreased urine output, and epileptic seizures. In conclusion, the present survey of the literature identifies the following risk factors for breastfeeding-associated neonatal hypernatremia: cesarean delivery, primiparity, breastfeeding problems, excessive maternal body weight, delayed breastfeeding, lack of previous breastfeeding experience, and low maternal education level.
Topics: Breast Feeding; Female; Humans; Hypernatremia; Infant, Newborn; Risk Factors; Weight Loss
PubMed: 26530059
DOI: 10.1177/0890334415613079