Vitamin D and iron deficiencies in children and adolescents with cerebral palsy

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VitaminaD: suficiente, 25-hidroxivitaminaD (25OHD) ≥30ng/ml; insuficiencia +deficiencia de VD 25OHD <30ng/ml. Ferritina: valores de normalidad para mujeres, entre 13-150ng/ml; para hombres, entre 30-400ng/ml." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Le Roy, S. Barja, C. Sepúlveda, M.L. Guzmán, M. Olivarez, M.J. Figueroa, M. Alvarez" "autores" => array:7 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Le Roy" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Barja" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Sepúlveda" ] 3 => array:2 [ "nombre" => "M.L." "apellidos" => "Guzmán" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Olivarez" ] 5 => array:2 [ "nombre" => "M.J." "apellidos" => "Figueroa" ] 6 => array:2 [ "nombre" => "M." 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Arrows indicate motor neurons in the ventral horn containing the primary dendrites where dendritic spines were counted. Scale bar: 100μm. Below: representative photomicrographs showing a typical thin spine (t), mushroom spine (m), and stubby spine (s) (arrows), which were counted in our study. Scale bar: 2μm." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N.I. Martínez-Torres, D. González-Tapia, M. Flores-Soto, N. Vázquez-Hernández, H. Salgado-Ceballos, I. González-Burgos" "autores" => array:6 [ 0 => array:2 [ "nombre" => "N.I." "apellidos" => "Martínez-Torres" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "González-Tapia" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Flores-Soto" ] 3 => array:2 [ "nombre" => "N." "apellidos" => "Vázquez-Hernández" ] 4 => array:2 [ "nombre" => "H." "apellidos" => "Salgado-Ceballos" ] 5 => array:2 [ "nombre" => "I." 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Subanálisis por comunidades autónomas" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3333 "Ancho" => 2504 "Tamanyo" => 674414 ] ] "descripcion" => array:1 [ "en" => "Percentage of patients presenting changes in “off” time and “on” times with and without disabling dyskinesia after continuous infusion of levodopa–carbidopa intestinal gel (LCIG)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Santos-García, M.J. Catalán, V. Puente, F. Valldeoriola, I. Regidor, P. Mir, J. Matías-Arbelo, J.C. Parra, F. Grandas" "autores" => array:9 [ 0 => array:2 [ "nombre" => "D." 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Le Roy, S. Barja, C. Sepúlveda, M.L. Guzmán, M. Olivarez, M.J. Figueroa, M. Alvarez" "autores" => array:7 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Le Roy" "email" => array:1 [ 0 => "catalinaleroy@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Barja" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Sepúlveda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M.L." "apellidos" => "Guzmán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Olivarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "M.J." "apellidos" => "Figueroa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 6 => array:3 [ "nombre" => "M." "apellidos" => "Alvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Departamento de Gastroenterología y Nutrición Pediátrica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Gastroenterología y Nutrición Pediátrica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Hospital Josefina Martínez, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Programa NANEAS, Hospital Padre Hurtado, Facultad de Medicina, Universidad del Desarrollo-CAS, Santiago, Chile" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Centro de Genética Humana, Facultad de Medicina, Universidad del Desarrollo-CAS, CRS Hospital Padre Hurtado, Santiago, Chile" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Programa NANEAS, Hospital Sótero del Río, Santiago, Chile" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Deficiencia de vitamina D y de hierro en niños y adolescentes con parálisis cerebral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1139 "Ancho" => 2333 "Tamanyo" => 71276 ] ] "descripcion" => array:1 [ "en" => "Percentage of patients with vitamin D and ferritin deficiency in our sample of patients with cerebral palsy. Vitamin D sufficiency: 25-hydroxyvitamin D level≥30ng/mL; vitamin D insufficiency+deficiency: 25-hydroxyvitamin D level<30ng/mL. Normal ferritin levels: females, 13-150ng/mL; males, 30-400ng/mL." ] ] ] "textoCompleto" => "IntroductionChildren with cerebral palsy (CP) are at greater risk of malnutrition than the healthy paediatric population. Malnutrition is associated with greater cognitive impairment and more severe gross motor dysfunction.<a class="elsevierStyleCrossRef" href="#bib0205">1</a>Feeding difficulties influence nutrition, with many of these patients needing caregiver support. Feeding difficulties increase in parallel with severity of gross motor dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0210">2–4</a>Feeding difficulties, the feeding route used (oral, nasogastric tube, gastrostomy), and the type of food play a role in energy and micronutrient deficiencies (potassium, iron, magnesium, zinc, selenium, calcium, niacin, copper, folate, and vitamins A, D, and E).<a class="elsevierStyleCrossRefs" href="#bib0220">4–8</a>Nutritional deficiencies are not only identifiable by analysing these patients’ diet; laboratory analysis reveals lower levels of iron, vitamin D, copper, magnesium, folate, vitamin E, vitamin B6, zinc, and selenium in these patients than in the healthy paediatric population.<a class="elsevierStyleCrossRefs" href="#bib0225">5,8</a> Each type of deficiency is associated with specific factors.<a class="elsevierStyleCrossRef" href="#bib0245">9</a>In Chile, children with CP can access multidisciplinary care through the public healthcare system; however, micronutrient deficiencies are not routinely evaluated. No information is available on nutritional deficiencies in children with CP in our setting; given their high overall survival rate, thorough, personalised nutritional assessment is required.Vitamin D and iron deficiencies are frequent in children with CP; the levels of these 2 micronutrients are easily analysed and corrected with supplements. The objective of this study was to describe vitamin D and iron levels in patients with CP and to evaluate some of the main factors involved in vitamin D and iron deficiencies.Patients and methodsWe conducted a prospective, descriptive, cross-sectional study of a sample of patients with CP gathered between April 2014 and March 2015. Participants were selected by convenience sampling; the sample included 69 patients aged 2-21 years. We initially selected all outpatients with CP included in the healthcare programme for children and adolescents with special needs (NANEAS, for its Spanish initials) of Hospital Padre Hurtado and Hospital Dr. Sótero del Río; both healthcare centres belong to the South East Metropolitan Health Service. Candidate patients were invited to participate through a telephone call to their primary caregiver, or at routine follow-up consultations. Caregivers read and signed informed consent forms before patients were included in the study; participants were not required to give informed consent due to intellectual and/or motor impairment preventing them from understanding the aims of the study or signing the form.We included all patients diagnosed with CP by a paediatric neurologist and under follow-up at one of the 2 participating hospitals. We excluded all patients admitted to hospital in the month previous to study onset, and/or those with acute diseases; a minimum period of one month after symptom resolution was established for these patients to be included in the study.We gathered demographic data and information about the primary caregiver, the feeding route (oral, nasogastric tube, gastrostomy), history of bone fractures, and use of antiepileptics or other drugs or nutritional supplements.The physical examination evaluated gross motor function with the Gross Motor Function Classification System (GMFCS),<a class="elsevierStyleCrossRef" href="#bib0250">10</a> which establishes the following levels: level I, walks without difficulty; level II, walks with limitations; level III, walks using a hand-held mobility device; level IV, self-mobility is limited and patients may use a powered wheelchair; and level V, cannot walk independently, transported in a wheelchair. Gross motor dysfunction was regarded as mild for GMFCS levels I–III and moderate-to-severe for levels IV and V.Weight was measured with a scale; patients unable to stand were weighed with a chair scale. Height was either measured with an infantometer or estimated based on tibia length using the equation proposed by Stevenson<a class="elsevierStyleCrossRef" href="#bib0255">11</a>: [height=(length from the superomedial edge of the tibia to the inferior edge of the medial malleolus [cm]×3.26)+30.8]. We recorded each patient's GMFCS level and feeding route, and evaluated their nutritional status according to the reference patterns for CP, expressed in percentiles, for each sex.<a class="elsevierStyleCrossRef" href="#bib0260">12</a> The normal height-for-age percentile was set at p5 to p95. The nutritional status was established based on body mass index – for-age (BMI/A): a BMI/A≤p10 was regarded as low weight, BMI/A between p10 and p75 was considered to indicate normal weight, and BMI/A≥p75 was considered overweight.Fasting blood samples were taken to determine plasma levels of 25-hydroxyvitamin D (25[OH]D), albumin, and ferritin; analyses were performed by a nurse. A 25(OH)D level≥30ng/mL was regarded as vitamin D sufficiency, levels ranging from 21 to 29ng/mL were considered vitamin D insufficiency, and levels≤20ng/mL were regarded as vitamin D deficiency. 25(OH)D levels were determined with liquid chromatography–tandem mass spectrometry.Serum ferritin levels were determined with electrochemiluminescence immunoassay (Cobas, Roche): normal values range from 13 to 150ng/mL for females and from 30 to 400ng/mL for males.Serum albumin levels were determined using the colorimetric method; concentrations≥3.5g/dL were considered normal. All analyses were performed at the central laboratory of the UC CHRISTUS Healthcare Network.Statistical analysisData were anonymised and analysed with Stata, version 12. We performed a descriptive statistical analysis. Continuous variables were tested for normality with the Shapiro–Wilk test; all variables were normally distributed, and are therefore expressed as means (SD). The t test, Pearson correlation coefficient, chi-square test, and Fisher exact test were used to analyse data, with statistical significance set at P<.05.The study complies with the ethical principles of the Declaration of Helsinki (2013) and was approved by the research ethics committees of the South East Metropolitan Health Service (22 August 2013) and the Pontificia Universidad Católica de Chile (No. 14-124).ResultsOur study included 69 patients. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises participants’ demographic and clinical characteristics. Information on gestational age was available for 66 participants: 19 (28.8%) were born before 37 weeks.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Thirty-four patients (49.3%) were fed orally, 4 (5.8%) via nasogastric tube exclusively, 26 (37.7%) via gastrostomy exclusively, 2 (2.9%) orally plus via nasogastric tube, and the remaining 3 (4.3%) were fed orally plus via gastrostomy. For the purposes of our analysis, patients were classified as feeding either orally (34 [49.3%]) or via nasogastric tube or gastrostomy, either alone or in combination (35 [50.7%]).The primary caregiver was the patient's mother in 58 cases (84.1%), the patient's grandmother in 7 (10.1%), and another person in 4 (5.8%).During the study period, 26 patients (37.7%) were admitted to hospital during autumn and winter, and 43 (62.3%) during spring and summer.One of the hospitals provided data on history of bone fractures, which was recorded in 4 of the 32 patients attended at that hospital (6.6%). Fractures affected the femur in 2 patients, the ribs in one, and a foot in the remaining patient.Regarding pharmacological treatment, 7.6% of patients were receiving no medication, 33.3% were taking 1-2 drugs daily, 43.9% were taking 3-5 drugs, and 15.2% received 6 or more drugs daily; 16.1% were not taking antiepileptics, 62.9% were taking 1-2 antiepileptic drugs, and 21% were receiving 3-5 antiepileptic drugs.Twenty patients (29%) were receiving vitamin D supplements: 14 at a dose ≤ 400IU/day and the remaining 6 at a dose>400IU/day. Doses ranged from 200IU/day to 800IU/day. Four patients (6.1%) were receiving iron supplementation; none of these were being treated for iron-deficiency anaemia.All patients showed normal albumin levels, with a mean (SD) of 4.6 (0.4) g/dL (range, 3.6-5.4).Mean 25(OH)D concentration was 24.3 (8.8) ng/mL (range, 5.4-48.7). Fifteen patients (21.8%) presented vitamin D sufficiency, 33 (47.8%) vitamin D insufficiency, and 21 (30.4%) vitamin D deficiency; therefore, vitamin D levels were suboptimal in 78.2% of patients.Ferritin levels were normal in 33 patients (47.8%) and below the normal range in 36 (52.2%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>No association was observed between nutritional status and sex, pre-term birth, GMFCS level, feeding route, and use of vitamin D or iron supplements.No association was found between risk of bone fractures and GMFCS level. No other variables were analysed in association with the risk of bone fractures, as they were not evaluated at the time of the fracture.We found no association between GMFCS level and number of drugs taken, although we did observe a correlation between GMFCS level and antiepileptic drug use: patients with moderate-to-severe CP received more antiepileptic drugs than those with mild CP (P=.04).No association was observed between 25(OH)D concentration and sex, GMFCS level, nutritional status, pre-term birth, seasonality (autumn-winter vs spring-summer), feeding route, vitamin D supplementation, or number of medications or antiepileptic drugs used (regardless of whether the drugs induced vitamin D metabolism). No correlation was observed between 25(OH)D concentration and age (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>An association was observed between ferritin level and age: patients with low ferritin levels had a mean age (SD) of 12.3 (5.1) years, whereas those with normal ferritin levels had a mean age of 9.8 (4.4) years (P=.03). Low ferritin levels were associated with male sex (P=.006) and feeding via nasogastric tube/gastrostomy (P=.006). We observed no correlation between ferritin level and any of the remaining study variables (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).DiscussionOur sample included a large percentage of patients with moderate to severe CP (81%); these patients are more likely to have more health problems, difficulties feeding, and nutritional deficiencies.<a class="elsevierStyleCrossRefs" href="#bib0220">4,12</a> Levels of the 2 micronutrients studied (vitamin D and ferritin) were low in a large percentage of the sample.Prevalence of CP is inversely correlated with gestational age.<a class="elsevierStyleCrossRefs" href="#bib0265">13,14</a> One-third of our sample were born pre-term; this proportion is higher than that observed in the Chilean population (8.4%) and among children and adolescents with CP (11%-14%).<a class="elsevierStyleCrossRefs" href="#bib0240">8,15,16</a>Primary carers were most frequently the patients’ mothers, followed by grandmothers; 95% of patients were cared for by direct relatives. This is consistent with the results of previous studies published in the United States.<a class="elsevierStyleCrossRef" href="#bib0220">4</a>Half of our patients were fed via nasogastric tube or gastrostomy; this proportion is similar to those reported by other studies including children with moderate-to-severe CP.<a class="elsevierStyleCrossRefs" href="#bib0215">3,7</a> Feeding difficulties are closely linked to more severe motor impairment. This finding was therefore to be expected, given the high percentage of patients with moderate-to-severe CP in our sample.<a class="elsevierStyleCrossRefs" href="#bib0210">2–4</a>Our study participants require moderate-to-high complexity care, since they have greater needs involving different areas of healthcare; most patients were receiving long-term pharmacological treatment, and 60% were taking more than 3 drugs daily.<a class="elsevierStyleCrossRef" href="#bib0285">17</a>All patients presented normal albumin levels, as reported in previous series; nutritional intake met patients’ protein requirements.<a class="elsevierStyleCrossRefs" href="#bib0220">4,5,18,19</a>These patients are at a greater risk of presenting vitamin D deficiency.<a class="elsevierStyleCrossRefs" href="#bib0300">20–24</a> We determined serum vitamin D concentrations in children and adolescents with CP attended at NANEAS units from 2 public hospitals; these units have no protocol for routine determination of 25(OH)D levels or vitamin D supplementation, which may explain the low percentage of patients receiving vitamin D supplements in our sample. Mean 25(OH)D concentrations were lower in our sample than in the healthy school-age population of Santiago de Chile, with a high percentage of participants displaying suboptimal vitamin D levels. Several studies into the healthy school-age population of Santiago de Chile have reported mean 25(OH)D levels ranging from 25.2 (8.3) to 32.1 (9.2)ng/mL. One study reported suboptimal vitamin D concentrations in 39.7% of the sample, a significantly lower rate than that found in our study (78.2%).<a class="elsevierStyleCrossRefs" href="#bib0325">25,26</a>However, our sample showed a lower rate of vitamin D deficiency than those including children and adolescents with similar GMFCS levels from the United States, Turkey, and Norway (30.4% vs 52.6%-72%).<a class="elsevierStyleCrossRefs" href="#bib0235">7,19,27</a>No association was observed with known risk factors for vitamin D deficiency, such as severe gross motor dysfunction, use of antiepileptic drugs, and insufficient vitamin D supplementation. This may be explained by the fact that our sample included a large percentage of patients with moderate-to-severe CP and few patients receiving vitamin D supplements.<a class="elsevierStyleCrossRefs" href="#bib0295">19,27–29</a> Dietary vitamin D intake is insufficient in these patients, even in those patients consuming vitamin D – fortified milk.<a class="elsevierStyleCrossRefs" href="#bib0225">5,6,29</a>Other studies of patients with CP report no differences in 25(OH)D concentrations over the course of the year, which suggests low exposure to sunlight at all times of year.<a class="elsevierStyleCrossRefs" href="#bib0230">6,7,27</a>Bone mineral density is lower in children with CP than the healthy population, resulting in an increased risk of fractures. Factors including severe gross motor dysfunction, poor calcium intake, use of antiepileptic drugs, feeding difficulties, and malnutrition have been reported in association with low bone mineral density.<a class="elsevierStyleCrossRefs" href="#bib0235">7,19,27,30</a> Few studies have analysed the prevalence of bone fractures in children with CP. Two studies conducted in the United States report prevalence rates of 12% (N=418) and 15.5% (N=297).<a class="elsevierStyleCrossRefs" href="#bib0355">31,32</a> The small size of our sample prevents comparison with these findings. We did not perform a factor analysis for bone fractures since the study variables were not evaluated at the time of fracture.No association was found between bone mineral density and 25(OH)D levels, although the former improves with vitamin D supplementation.<a class="elsevierStyleCrossRefs" href="#bib0235">7,19,27,33–35</a> In line with the available evidence, vitamin D supplementation is regarded as a measure potentially affecting bone mineral density; experts recommend calcium and vitamin D supplementation in these patients.<a class="elsevierStyleCrossRefs" href="#bib0315">23,24</a> Vitamin D doses in our sample were similar to those recommended for the general paediatric population (400-600IU/day); risk populations are advised to take 600-1000IU/day.<a class="elsevierStyleCrossRef" href="#bib0380">36</a> The main goal of vitamin D supplementation is to achieve vitamin D sufficiency; 25(OH)D concentrations should be closely monitored.<a class="elsevierStyleCrossRefs" href="#bib0315">23,24</a> Weight-bearing activities, such as assisted standing, may improve or maintain bone mineral density; the effectiveness and indications for this type of intervention are currently under study.<a class="elsevierStyleCrossRefs" href="#bib0315">23,24,37</a>Adequate 25(OH)D levels are associated with multiple benefits, including a lower risk of respiratory tract infections, according to studies on the general paediatric population.<a class="elsevierStyleCrossRef" href="#bib0390">38</a>Serum ferritin concentrations reflect iron deposits, acting as an early marker of iron deficiency; however, determination of ferritin is not routinely performed in all public hospitals. None of our patients presented anaemia, although half of the sample showed low ferritin concentrations, in line with the data reported in other studies. These patients have been found to have a lower iron intake, low serum iron and ferritin concentrations, and iron-deficiency anaemia. Factors associated with low ferritin levels include male sex, older age, feeding by gastrostomy, and high proportion of milk intake; the first 3 factors were observed to be significantly associated with low ferritin levels in our study.<a class="elsevierStyleCrossRefs" href="#bib0205">1,4,8,39</a> Another factor associated with anaemia is gastro-oesophageal reflux, which may cause chronic blood loss secondary to oesophagitis: a study of patients with CP found more cases of anaemia and malnutrition among patients with gastro-oesophageal reflux than among those without.<a class="elsevierStyleCrossRef" href="#bib0400">40</a> Ferritin concentrations should therefore be closely monitored.One limitation of our study is that the sample was relatively homogeneous in terms of GMFCS level; the fact that most of our patients had moderate-to-severe gross motor dysfunction may have limited the association between GMFCS level and nutritional deficiencies. Our sample was drawn from medium-to-low-income populations, which prevents us from generalising our results.In conclusion, we identified a high frequency of vitamin D deficiency and low ferritin levels in children and adolescents with moderate-to-severe CP, and analysed some of the associated risk factors. Vitamin D and iron levels should be determined in these patients, given the availability of pharmacological treatments for vitamin D and iron deficiency, which may improve overall health in this vulnerable patient population.FundingThis study was funded by the Nutrition section of the Chilean Society of Paediatrics and FONDECYT 1131012 (M. Álvarez).Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1469037" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients and method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1338098" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1469036" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Pacientes y método" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1338097" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-01" "fechaAceptado" => "2017-11-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1338098" "palabras" => array:3 [ 0 => "Vitamin D" 1 => "Cerebral palsy" 2 => "Ferritin" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1338097" "palabras" => array:3 [ 0 => "Vitamina D" 1 => "Parálisis cerebral" 2 => "Ferritina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionChildren and adolescents with cerebral palsy (CP) are at a greater risk of malnutrition and micronutrient deficiencies. Two deficiencies that we can study and treat are vitamin D (VD) and iron deficiencies; however, no studies have described these deficiencies in Chile. ObjectiveTo describe the status of VD and iron in patients with CP and evaluate the relationship with certain factors associated with deficiencies of these micronutrients. Patients and methodWe performed a descriptive, cross-sectional study including 69 patients aged between 2 and 21years, from two public hospitals. Data were obtained on demographic variables, motor function, use of feeding tube, and pharmacological treatment. We performed a nutritional assessment according to patterns of CP and determined 25-hydroxyvitamin D (25[OH]D) ferritin, and albumin levels. ResultsPatients’ mean age was 11.1±4.9years; 43 (62.3%) were male; and 56 (81.2%) had moderate-to-severe CP. Thirty-five (50.7%) used a nasogastric tube and/or gastrostomy; 15.4% were underweight and 73.8% were eutrophic, all with normal height. Twenty (29%) and 4 patients (6.2%) received VD and iron supplementation, respectively. Albuminaemia was normal in all patients. Mean 25(OH)D level was 24.3±8.8ng/mL; 33 patients (47.8%) had insufficiency and 21 (30.4%) deficiency; 36 patients (52.2%) had low ferritin levels. There was no association between 25(OH)D level and the other variables studied. Low ferritin levels were found to be associated with older age (P=.03), being male (P=.006), and feeding tube use (P=.006). ConclusionsThe patients studied mainly had moderate-to-severe CP, with a high frequency of suboptimal VD values and low plasma ferritin; few patients received VD and/or iron supplementation. We suggest monitoring 25(OH)D and ferritin levels due to the high rate of deficiency of these nutrients; public hospitals should be equipped with drugs to treat these deficiencies." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients and method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLos niños y adolescentes con parálisis cerebral (PC) tienen mayor riesgo de desnutrición y deficiencias de micronutrientes. Dos de los que podemos estudiar y tratar son la vitamina D (VD) y el hierro. No disponemos de estudios que describan estas deficiencias en Chile. ObjetivoDescribir el estado de ambos micronutrientes y evaluar la asociación con algunos factores que favorecen su déficit. Pacientes y métodoEstudio descriptivo, corte transversal. Se estudiaron 69 sujetos, de entre 2 a 21años de edad, de dos hospitales públicos. Se obtuvieron datos demográficos, función motora, uso de sonda de alimentación y fármacos en uso. Se realizó evaluación nutricional según patrones para PC, y se determinó 25-hidroxivitaminaD (25OHD), ferritinemia y albuminemia. ResultadosEdad promedio 11,1±4,9años, 43 (62,3%) varones, 56 (81,2%) tenían PC moderada-severa. Utilizaban sonda nasogástrica y/o gastrostomía 35 (50,7%), el 15,4% estaban con peso bajo y el 73,8% eutróficos, todos con talla normal. Recibían suplementación de VD 20 (29%), y de hierro, 4 (6,1%). La albuminemia fue normal en todos. El promedio de 25OHD fue 24,3±8,8ng/ml, 33 (47,8%) presentaron insuficiencia y 21 (30,4%) deficiencia. Tuvieron ferritina baja 36 (52,2%). No se encontró asociación entre 25OHD y variables estudiadas. Se encontró asociación entre ferritina baja y mayor edad (p=0,03), ser hombre (p=0,006) y uso de sonda de alimentación (p=0,006). ConclusionesEl grupo estudiado fue principalmente PC moderada-severa, con alta frecuencia de valores subóptimos de VD y baja ferritina plasmática, además de escasa suplementación de ambos. Sugerimos realizar seguimiento de 25OHD y ferritina, por su alta frecuencia de deficiencia y por contar con fármacos para su tratamiento en los hospitales públicos." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Pacientes y método" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Le Roy C, Barja S, Sepúlveda C, Guzmán ML, Olivarez M, Figueroa MJ, et al. Deficiencia de vitamina D y de hierro en niños y adolescentes con parálisis cerebral. Neurología. 2021;36:112–118." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This study was presented in poster format at the 55th Congress of the Chilean Society of Paediatrics in Puerto Varas, Chile, 2015." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1139 "Ancho" => 2333 "Tamanyo" => 71276 ] ] "descripcion" => array:1 [ "en" => "Percentage of patients with vitamin D and ferritin deficiency in our sample of patients with cerebral palsy. Vitamin D sufficiency: 25-hydroxyvitamin D level≥30ng/mL; vitamin D insufficiency+deficiency: 25-hydroxyvitamin D level<30ng/mL. Normal ferritin levels: females, 13-150ng/mL; males, 30-400ng/mL." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Normal ferritin levels: females, 13-150ng/mL; males, 30-400ng/mL.25(OH)D: 25-hydroxyvitamin D; BMI: body mass index<a class="elsevierStyleCrossRef" href="#bib0260">12</a>; GMFCS: Gross Motor Function Classification System<a class="elsevierStyleCrossRef" href="#bib0250">10</a>; SD: standard deviation.Vitamin D sufficiency: 25(OH)D level≥30ng/mL; vitamin D insufficiency: 25(OH)D level 21–29ng/mL; vitamin D deficiency, 25(OH)D level≤20ng/mL." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (62.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.1 (4.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Motor function (GMFCS), n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I to III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (18.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IV or V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56 (81.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Feeding route, n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral only \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (49.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nasogastric tube, gastrostomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (50.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nutritional status (BMI – for-age), n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">< p10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p10 to p75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 (73.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> p75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (10.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25(OH)D (ng/mL)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.3 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sufficiency, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (21.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insufficiency, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 (47.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deficiency, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (30.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ferritin, n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 (47.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (52.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Albumin (g/dL)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2527916.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic characteristics of our sample." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "GMFCS: Gross Motor Function Classification System.<a class="elsevierStyleCrossRef" href="#bib0250">10</a>Nutritional status was established based on body mass index (BMI).<a class="elsevierStyleCrossRef" href="#bib0260">12</a>Low weight: BMI – for-age<p10; normal weight: BMI – for-age p10-p75; overweight: BMI – for-age>p75.Normal ferritin levels: females, 13-150ng/mL; males, 30-400ng/mL.Mild gross motor dysfunction: levels I to III; moderate-to-severe gross motor dysfunction: levels IV and V.Vitamin D sufficiency: 25-hydroxyvitamin D level≥30ng/mL; vitamin D insufficiency+deficiency: 25-hydroxyvitamin D level<30ng/mL." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vitamin D</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ferritin</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sufficiency \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Insufficiency+deficiency \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normal \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Low \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (21.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 (78.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 (47.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (52.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years), mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.5 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.3 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.8 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.3 (5.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (73.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (59.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (45.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (77.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GMFCS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate-to-severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Feeding route \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nasogastric tube, gastrostomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nutritional status \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low weight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal weight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Overweight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2527915.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Factors associated with vitamin D and ferritin levels in 69 children and adolescents with cerebral palsy." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cerebral palsy in children as a risk factor for malnutrition" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Perenc" 1 => "G. Przysada" 2 => "J. Trzeciak" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000431330" "Revista" => array:6 [ "tituloSerie" => "Ann Nutr Metab" "fecha" => "2015" "volumen" => "66" "paginaInicial" => "224" "paginaFinal" => "232" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26111638" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0210" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Feeding method and health outcomes of children with cerebral palsy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B. Roger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jpeds.2004.05.019" "Revista" => array:7 [ "tituloSerie" => "J Pediatr" "fecha" => "2004" "volumen" => "145" "numero" => "Suppl. 2" "paginaInicial" => "S28" "paginaFinal" => "S32" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15292884" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0215" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nutrition support for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "NASPGHAN Committee on Nutrition" "etal" => false "autores" => array:2 [ 0 => "V. Manchand" 1 => "K. 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Deficiencia de vitamina D y de hierro en niños y adolescentes con parálisis cerebral

C. Le Roya,

Corresponding author

catalinaleroy@yahoo.es

Corresponding author.

, S. Barjab, C. Sepúlvedac, M.L. Guzmánd, M. Olivareze, M.J. Figueroae, M. Alvarezf

a Departamento de Gastroenterología y Nutrición Pediátrica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile

b Departamento de Gastroenterología y Nutrición Pediátrica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Hospital Josefina Martínez, Santiago, Chile

c Programa NANEAS, Hospital Padre Hurtado, Facultad de Medicina, Universidad del Desarrollo-CAS, Santiago, Chile

d Centro de Genética Humana, Facultad de Medicina, Universidad del Desarrollo-CAS, CRS Hospital Padre Hurtado, Santiago, Chile

e Programa NANEAS, Hospital Sótero del Río, Santiago, Chile

f Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile

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the feeding route used &#40;oral&#44; nasogastric tube&#44; gastrostomy&#41;&#44; and the type of food play a role in energy and micronutrient deficiencies &#40;potassium&#44; iron&#44; magnesium&#44; zinc&#44; selenium&#44; calcium&#44; niacin&#44; copper&#44; folate&#44; and vitamins A&#44; D&#44; and E&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#8211;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Nutritional deficiencies are not only identifiable by analysing these patients&#8217; diet&#59; laboratory analysis reveals lower levels of iron&#44; vitamin D&#44; copper&#44; magnesium&#44; folate&#44; vitamin E&#44; vitamin B<span class="elsevierStyleInf">6</span>&#44; zinc&#44; and selenium in these patients than in the healthy paediatric population&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;8</span></a> Each type of deficiency is associated with specific factors&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In Chile&#44; children with CP can access multidisciplinary care through the public healthcare system&#59; however&#44; micronutrient deficiencies are not routinely evaluated&#46; No information is available on nutritional deficiencies in children with CP in our setting&#59; given their high overall survival rate&#44; thorough&#44; personalised nutritional assessment is required&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Vitamin D and iron deficiencies are frequent in children with CP&#59; the levels of these 2 micronutrients are easily analysed and corrected with supplements&#46; The objective of this study was to describe vitamin D and iron levels in patients with CP and to evaluate some of the main factors involved in vitamin D and iron deficiencies&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a prospective&#44; descriptive&#44; cross-sectional study of a sample of patients with CP gathered between April 2014 and March 2015&#46; Participants were selected by convenience sampling&#59; the sample included 69 patients aged 2-21 years&#46; We initially selected all outpatients with CP included in the healthcare programme for children and adolescents with special needs &#40;NANEAS&#44; for its Spanish initials&#41; of Hospital Padre Hurtado and Hospital Dr&#46; S&#243;tero del R&#237;o&#59; both healthcare centres belong to the South East Metropolitan Health Service&#46; Candidate patients were invited to participate through a telephone call to their primary caregiver&#44; or at routine follow-up consultations&#46; Caregivers read and signed informed consent forms before patients were included in the study&#59; participants were not required to give informed consent due to intellectual and&#47;or motor impairment preventing them from understanding the aims of the study or signing the form&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We included all patients diagnosed with CP by a paediatric neurologist and under follow-up at one of the 2 participating hospitals&#46; We excluded all patients admitted to hospital in the month previous to study onset&#44; and&#47;or those with acute diseases&#59; a minimum period of one month after symptom resolution was established for these patients to be included in the study&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We gathered demographic data and information about the primary caregiver&#44; the feeding route &#40;oral&#44; nasogastric tube&#44; gastrostomy&#41;&#44; history of bone fractures&#44; and use of antiepileptics or other drugs or nutritional supplements&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The physical examination evaluated gross motor function with the Gross Motor Function Classification System &#40;GMFCS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> which establishes the following levels&#58; level I&#44; walks without difficulty&#59; level II&#44; walks with limitations&#59; level III&#44; 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We recorded each patient&#39;s GMFCS level and feeding route&#44; and evaluated their nutritional status according to the reference patterns for CP&#44; expressed in percentiles&#44; for each sex&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> The normal height-for-age percentile was set at p5 to p95&#46; The nutritional status was established based on body mass index &#8211; for-age &#40;BMI&#47;A&#41;&#58; a BMI&#47;A<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>p10 was regarded as low weight&#44; BMI&#47;A between p10 and p75 was considered to indicate normal weight&#44; and BMI&#47;A<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>p75 was considered overweight&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Fasting blood samples were taken to determine plasma levels of 25-hydroxyvitamin D &#40;25&#91;OH&#93;D&#41;&#44; albumin&#44; and ferritin&#59; analyses were performed by a nurse&#46; A 25&#40;OH&#41;D level<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL was regarded as vitamin D sufficiency&#44; levels ranging from 21 to 29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL were considered vitamin D insufficiency&#44; and levels<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ng&#47;mL were regarded as vitamin D deficiency&#46; 25&#40;OH&#41;D levels were determined with liquid chromatography&#8211;tandem mass spectrometry&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Serum ferritin levels were determined with electrochemiluminescence immunoassay &#40;Cobas&#44; Roche&#41;&#58; normal values range from 13 to 150<span class="elsevierStyleHsp" style=""></span>ng&#47;mL for females and from 30 to 400<span class="elsevierStyleHsp" style=""></span>ng&#47;mL for males&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Serum albumin levels were determined using the colorimetric method&#59; concentrations<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dL were considered normal&#46; All analyses were performed at the central laboratory of the UC CHRISTUS Healthcare Network&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Data were anonymised and analysed with Stata&#44; version 12&#46; We performed a descriptive statistical analysis&#46; Continuous variables were tested for normality with the Shapiro&#8211;Wilk test&#59; all variables were normally distributed&#44; and are therefore expressed as means &#40;SD&#41;&#46; The <span class="elsevierStyleItalic">t</span> test&#44; Pearson correlation coefficient&#44; chi-square test&#44; and Fisher exact test were used to analyse data&#44; with statistical significance set at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The study complies with the ethical principles of the Declaration of Helsinki &#40;2013&#41; and was approved by the research ethics committees of the South East Metropolitan Health Service &#40;22 August 2013&#41; and the Pontificia Universidad Cat&#243;lica de Chile &#40;No&#46; 14-124&#41;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">Our study included 69 patients&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises participants&#8217; demographic and clinical characteristics&#46; Information on gestational age was available for 66 participants&#58; 19 &#40;28&#46;8&#37;&#41; were born before 37 weeks&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Thirty-four patients &#40;49&#46;3&#37;&#41; were fed orally&#44; 4 &#40;5&#46;8&#37;&#41; via nasogastric tube exclusively&#44; 26 &#40;37&#46;7&#37;&#41; via gastrostomy exclusively&#44; 2 &#40;2&#46;9&#37;&#41; orally plus via nasogastric tube&#44; and the remaining 3 &#40;4&#46;3&#37;&#41; were fed orally plus via gastrostomy&#46; For the purposes of our analysis&#44; patients were classified as feeding either orally &#40;34 &#91;49&#46;3&#37;&#93;&#41; or via nasogastric tube or gastrostomy&#44; either alone or in combination &#40;35 &#91;50&#46;7&#37;&#93;&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The primary caregiver was the patient&#39;s mother in 58 cases &#40;84&#46;1&#37;&#41;&#44; the patient&#39;s grandmother in 7 &#40;10&#46;1&#37;&#41;&#44; and another person in 4 &#40;5&#46;8&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">During the study period&#44; 26 patients &#40;37&#46;7&#37;&#41; were admitted to hospital during autumn and winter&#44; and 43 &#40;62&#46;3&#37;&#41; during spring and summer&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">One of the hospitals provided data on history of bone fractures&#44; which was recorded in 4 of the 32 patients attended at that hospital &#40;6&#46;6&#37;&#41;&#46; Fractures affected the femur in 2 patients&#44; the ribs in one&#44; and a foot in the remaining patient&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding pharmacological treatment&#44; 7&#46;6&#37; of patients were receiving no medication&#44; 33&#46;3&#37; were taking 1-2 drugs daily&#44; 43&#46;9&#37; were taking 3-5 drugs&#44; and 15&#46;2&#37; received 6 or more drugs daily&#59; 16&#46;1&#37; were not taking antiepileptics&#44; 62&#46;9&#37; were taking 1-2 antiepileptic drugs&#44; and 21&#37; were receiving 3-5 antiepileptic drugs&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Twenty patients &#40;29&#37;&#41; were receiving vitamin D supplements&#58; 14 at a dose &#8804; 400<span class="elsevierStyleHsp" style=""></span>IU&#47;day and the remaining 6 at a dose<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>400<span class="elsevierStyleHsp" style=""></span>IU&#47;day&#46; Doses ranged from 200<span class="elsevierStyleHsp" style=""></span>IU&#47;day to 800<span class="elsevierStyleHsp" style=""></span>IU&#47;day&#46; Four patients &#40;6&#46;1&#37;&#41; were receiving iron supplementation&#59; none of these were being treated for iron-deficiency anaemia&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">All patients showed normal albumin levels&#44; with a mean &#40;SD&#41; of 4&#46;6 &#40;0&#46;4&#41; g&#47;dL &#40;range&#44; 3&#46;6-5&#46;4&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Mean 25&#40;OH&#41;D concentration was 24&#46;3 &#40;8&#46;8&#41; ng&#47;mL &#40;range&#44; 5&#46;4-48&#46;7&#41;&#46; Fifteen patients &#40;21&#46;8&#37;&#41; presented vitamin D sufficiency&#44; 33 &#40;47&#46;8&#37;&#41; vitamin D insufficiency&#44; and 21 &#40;30&#46;4&#37;&#41; vitamin D deficiency&#59; therefore&#44; vitamin D levels were suboptimal in 78&#46;2&#37; of patients&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Ferritin levels were normal in 33 patients &#40;47&#46;8&#37;&#41; and below the normal range in 36 &#40;52&#46;2&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">No association was observed between nutritional status and sex&#44; pre-term birth&#44; GMFCS level&#44; feeding route&#44; and use of vitamin D or iron supplements&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">No association was found between risk of bone fractures and GMFCS level&#46; No other variables were analysed in association with the risk of bone fractures&#44; as they were not evaluated at the time of the fracture&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">We found no association between GMFCS level and number of drugs taken&#44; although we did observe a correlation between GMFCS level and antiepileptic drug use&#58; patients with moderate-to-severe CP received more antiepileptic drugs than those with mild CP &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">No association was observed between 25&#40;OH&#41;D concentration and sex&#44; GMFCS level&#44; nutritional status&#44; pre-term birth&#44; seasonality &#40;autumn-winter vs spring-summer&#41;&#44; feeding route&#44; vitamin D supplementation&#44; or number of medications or antiepileptic drugs used &#40;regardless of whether the drugs induced vitamin D metabolism&#41;&#46; No correlation was observed between 25&#40;OH&#41;D concentration and age &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">An association was observed between ferritin level and age&#58; patients with low ferritin levels had a mean age &#40;SD&#41; of 12&#46;3 &#40;5&#46;1&#41; years&#44; whereas those with normal ferritin levels had a mean age of 9&#46;8 &#40;4&#46;4&#41; years &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41;&#46; Low ferritin levels were associated with male sex &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;006&#41; and feeding via nasogastric tube&#47;gastrostomy &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;006&#41;&#46; We observed no correlation between ferritin level and any of the remaining study variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">Our sample included a large percentage of patients with moderate to severe CP &#40;81&#37;&#41;&#59; these patients are more likely to have more health problems&#44; difficulties feeding&#44; and nutritional deficiencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;12</span></a> Levels of the 2 micronutrients studied &#40;vitamin D and ferritin&#41; were low in a large percentage of the sample&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Prevalence of CP is inversely correlated with gestational age&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;14</span></a> One-third of our sample were born pre-term&#59; this proportion is higher than that observed in the Chilean population &#40;8&#46;4&#37;&#41; and among children and adolescents with CP &#40;11&#37;-14&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">8&#44;15&#44;16</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Primary carers were most frequently the patients&#8217; mothers&#44; followed by grandmothers&#59; 95&#37; of patients were cared for by direct relatives&#46; This is consistent with the results of previous studies published in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Half of our patients were fed via nasogastric tube or gastrostomy&#59; this proportion is similar to those reported by other studies including children with moderate-to-severe CP&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;7</span></a> Feeding difficulties are closely linked to more severe motor impairment&#46; This finding was therefore to be expected&#44; given the high percentage of patients with moderate-to-severe CP in our sample&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Our study participants require moderate-to-high complexity care&#44; since they have greater needs involving different areas of healthcare&#59; most patients were receiving long-term pharmacological treatment&#44; and 60&#37; were taking more than 3 drugs daily&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">17</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">All patients presented normal albumin levels&#44; as reported in previous series&#59; nutritional intake met patients&#8217; protein requirements&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;5&#44;18&#44;19</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">These patients are at a greater risk of presenting vitamin D deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#8211;24</span></a> We determined serum vitamin D concentrations in children and adolescents with CP attended at NANEAS units from 2 public hospitals&#59; these units have no protocol for routine determination of 25&#40;OH&#41;D levels or vitamin D supplementation&#44; which may explain the low percentage of patients receiving vitamin D supplements in our sample&#46; Mean 25&#40;OH&#41;D concentrations were lower in our sample than in the healthy school-age population of Santiago de Chile&#44; with a high percentage of participants displaying suboptimal vitamin D levels&#46; Several studies into the healthy school-age population of Santiago de Chile have reported mean 25&#40;OH&#41;D levels ranging from 25&#46;2 &#40;8&#46;3&#41; to 32&#46;1 &#40;9&#46;2&#41;<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; One study reported suboptimal vitamin D concentrations in 39&#46;7&#37; of the sample&#44; a significantly lower rate than that found in our study &#40;78&#46;2&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">However&#44; our sample showed a lower rate of vitamin D deficiency than those including children and adolescents with similar GMFCS levels from the United States&#44; Turkey&#44; and Norway &#40;30&#46;4&#37; vs 52&#46;6&#37;-72&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">7&#44;19&#44;27</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">No association was observed with known risk factors for vitamin D deficiency&#44; such as severe gross motor dysfunction&#44; use of antiepileptic drugs&#44; and insufficient vitamin D supplementation&#46; This may be explained by the fact that our sample included a large percentage of patients with moderate-to-severe CP and few patients receiving vitamin D supplements&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19&#44;27&#8211;29</span></a> Dietary vitamin D intake is insufficient in these patients&#44; even in those patients consuming vitamin D &#8211; fortified milk&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;6&#44;29</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Other studies of patients with CP report no differences in 25&#40;OH&#41;D concentrations over the course of the year&#44; which suggests low exposure to sunlight at all times of year&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;7&#44;27</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Bone mineral density is lower in children with CP than the healthy population&#44; resulting in an increased risk of fractures&#46; Factors including severe gross motor dysfunction&#44; poor calcium intake&#44; use of antiepileptic drugs&#44; feeding difficulties&#44; and malnutrition have been reported in association with low bone mineral density&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">7&#44;19&#44;27&#44;30</span></a> Few studies have analysed the prevalence of bone fractures in children with CP&#46; Two studies conducted in the United States report prevalence rates of 12&#37; &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>418&#41; and 15&#46;5&#37; &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>297&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">31&#44;32</span></a> The small size of our sample prevents comparison with these findings&#46; We did not perform a factor analysis for bone fractures since the study variables were not evaluated at the time of fracture&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">No association was found between bone mineral density and 25&#40;OH&#41;D levels&#44; although the former improves with vitamin D supplementation&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">7&#44;19&#44;27&#44;33&#8211;35</span></a> In line with the available evidence&#44; vitamin D supplementation is regarded as a measure potentially affecting bone mineral density&#59; experts recommend calcium and vitamin D supplementation in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">23&#44;24</span></a> Vitamin D doses in our sample were similar to those recommended for the general paediatric population &#40;400-600<span class="elsevierStyleHsp" style=""></span>IU&#47;day&#41;&#59; risk populations are advised to take 600-1000<span class="elsevierStyleHsp" style=""></span>IU&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> The main goal of vitamin D supplementation is to achieve vitamin D sufficiency&#59; 25&#40;OH&#41;D concentrations should be closely monitored&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">23&#44;24</span></a> Weight-bearing activities&#44; such as assisted standing&#44; may improve or maintain bone mineral density&#59; the effectiveness and indications for this type of intervention are currently under study&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">23&#44;24&#44;37</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Adequate 25&#40;OH&#41;D levels are associated with multiple benefits&#44; including a lower risk of respiratory tract infections&#44; according to studies on the general paediatric population&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">38</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Serum ferritin concentrations reflect iron deposits&#44; acting as an early marker of iron deficiency&#59; however&#44; determination of ferritin is not routinely performed in all public hospitals&#46; None of our patients presented anaemia&#44; although half of the sample showed low ferritin concentrations&#44; in line with the data reported in other studies&#46; These patients have been found to have a lower iron intake&#44; low serum iron and ferritin concentrations&#44; and iron-deficiency anaemia&#46; Factors associated with low ferritin levels include male sex&#44; older age&#44; feeding by gastrostomy&#44; and high proportion of milk intake&#59; the first 3 factors were observed to be significantly associated with low ferritin levels in our study&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;4&#44;8&#44;39</span></a> Another factor associated with anaemia is gastro-oesophageal reflux&#44; which may cause chronic blood loss secondary to oesophagitis&#58; a study of patients with CP found more cases of anaemia and malnutrition among patients with gastro-oesophageal reflux than among those without&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> Ferritin concentrations should therefore be closely monitored&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">One limitation of our study is that the sample was relatively homogeneous in terms of GMFCS level&#59; the fact that most of our patients had moderate-to-severe gross motor dysfunction may have limited the association between GMFCS level and nutritional deficiencies&#46; Our sample was drawn from medium-to-low-income populations&#44; which prevents us from generalising our results&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">In conclusion&#44; we identified a high frequency of vitamin D deficiency and low ferritin levels in children and adolescents with moderate-to-severe CP&#44; and analysed some of the associated risk factors&#46; Vitamin D and iron levels should be determined in these patients&#44; given the availability of pharmacological treatments for vitamin D and iron deficiency&#44; which may improve overall health in this vulnerable patient population&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0240" class="elsevierStylePara elsevierViewall">This study was funded by the <span class="elsevierStyleGrantSponsor" id="gs1">Nutrition section of the Chilean Society of Paediatrics</span> and <span class="elsevierStyleGrantSponsor" id="gs2">FONDECYT 1131012</span> &#40;M&#46; &#193;lvarez&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Children and adolescents with cerebral palsy &#40;CP&#41; are at a greater risk of malnutrition and micronutrient deficiencies&#46; Two deficiencies that we can study and treat are vitamin D &#40;VD&#41; and iron deficiencies&#59; however&#44; no studies have described these deficiencies in Chile&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the status of VD and iron in patients with CP and evaluate the relationship with certain factors associated with deficiencies of these micronutrients&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients and method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We performed a descriptive&#44; cross-sectional study including 69 patients aged between 2 and 21<span class="elsevierStyleHsp" style=""></span>years&#44; from two public hospitals&#46; Data were obtained on demographic variables&#44; motor function&#44; use of feeding tube&#44; and pharmacological treatment&#46; We performed a nutritional assessment according to patterns of CP and determined 25-hydroxyvitamin D &#40;25&#91;OH&#93;D&#41; ferritin&#44; and albumin levels&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients&#8217; mean age was 11&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;9<span class="elsevierStyleHsp" style=""></span>years&#59; 43 &#40;62&#46;3&#37;&#41; were male&#59; and 56 &#40;81&#46;2&#37;&#41; had moderate-to-severe CP&#46; Thirty-five &#40;50&#46;7&#37;&#41; used a nasogastric tube and&#47;or gastrostomy&#59; 15&#46;4&#37; were underweight and 73&#46;8&#37; were eutrophic&#44; all with normal height&#46; Twenty &#40;29&#37;&#41; and 4 patients &#40;6&#46;2&#37;&#41; received VD and iron supplementation&#44; respectively&#46; Albuminaemia was normal in all patients&#46; Mean 25&#40;OH&#41;D level was 24&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;8<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; 33 patients &#40;47&#46;8&#37;&#41; had insufficiency and 21 &#40;30&#46;4&#37;&#41; deficiency&#59; 36 patients &#40;52&#46;2&#37;&#41; had low ferritin levels&#46; There was no association between 25&#40;OH&#41;D level and the other variables studied&#46; Low ferritin levels were found to be associated with older age &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41;&#44; being male &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;006&#41;&#44; and feeding tube use &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;006&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The patients studied mainly had moderate-to-severe CP&#44; with a high frequency of suboptimal VD values and low plasma ferritin&#59; few patients received VD and&#47;or iron supplementation&#46; We suggest monitoring 25&#40;OH&#41;D and ferritin levels due to the high rate of deficiency of these nutrients&#59; public hospitals should be equipped with drugs to treat these deficiencies&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Patients and method"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los ni&#241;os y adolescentes con par&#225;lisis cerebral &#40;PC&#41; tienen mayor riesgo de desnutrici&#243;n y deficiencias de micronutrientes&#46; Dos de los que podemos estudiar y tratar son la vitamina D &#40;VD&#41; y el hierro&#46; No disponemos de estudios que describan estas deficiencias en Chile&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir el estado de ambos micronutrientes y evaluar la asociaci&#243;n con algunos factores que favorecen su d&#233;ficit&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pacientes y m&#233;todo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo&#44; corte transversal&#46; Se estudiaron 69 sujetos&#44; de entre 2 a 21<span class="elsevierStyleHsp" style=""></span>a&#241;os de edad&#44; de dos hospitales p&#250;blicos&#46; Se obtuvieron datos demogr&#225;ficos&#44; funci&#243;n motora&#44; uso de sonda de alimentaci&#243;n y f&#225;rmacos en uso&#46; Se realiz&#243; evaluaci&#243;n nutricional seg&#250;n patrones para PC&#44; y se determin&#243; 25-hidroxivitamina<span class="elsevierStyleHsp" style=""></span>D &#40;25OHD&#41;&#44; ferritinemia y albuminemia&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Edad promedio 11&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;9<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; 43 &#40;62&#44;3&#37;&#41; varones&#44; 56 &#40;81&#44;2&#37;&#41; ten&#237;an PC moderada-severa&#46; Utilizaban sonda nasog&#225;strica y&#47;o gastrostom&#237;a 35 &#40;50&#44;7&#37;&#41;&#44; el 15&#44;4&#37; estaban con peso bajo y el 73&#44;8&#37; eutr&#243;ficos&#44; todos con talla normal&#46; Recib&#237;an suplementaci&#243;n de VD 20 &#40;29&#37;&#41;&#44; y de hierro&#44; 4 &#40;6&#44;1&#37;&#41;&#46; La albuminemia fue normal en todos&#46; El promedio de 25OHD fue 24&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;8<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; 33 &#40;47&#44;8&#37;&#41; presentaron insuficiencia y 21 &#40;30&#44;4&#37;&#41; deficiencia&#46; Tuvieron ferritina baja 36 &#40;52&#44;2&#37;&#41;&#46; No se encontr&#243; asociaci&#243;n entre 25OHD y variables estudiadas&#46; Se encontr&#243; asociaci&#243;n entre ferritina baja y mayor edad &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#44; ser hombre &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41; y uso de sonda de alimentaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El grupo estudiado fue principalmente PC moderada-severa&#44; con alta frecuencia de valores sub&#243;ptimos de VD y baja ferritina plasm&#225;tica&#44; adem&#225;s de escasa suplementaci&#243;n de ambos&#46; Sugerimos realizar seguimiento de 25OHD y ferritina&#44; por su alta frecuencia de deficiencia y por contar con f&#225;rmacos para su tratamiento en los hospitales p&#250;blicos&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivo"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Pacientes y m&#233;todo"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
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          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
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    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Le Roy C&#44; Barja S&#44; Sep&#250;lveda C&#44; Guzm&#225;n ML&#44; Olivarez M&#44; Figueroa MJ&#44; et al&#46; Deficiencia de vitamina D y de hierro en ni&#241;os y adolescentes con par&#225;lisis cerebral&#46; Neurolog&#237;a&#46; 2021&#59;36&#58;112&#8211;118&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This study was presented in poster format at the 55th Congress of the Chilean Society of Paediatrics in Puerto Varas&#44; Chile&#44; 2015&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Percentage of patients with vitamin D and ferritin deficiency in our sample of patients with cerebral palsy&#46; Vitamin D sufficiency&#58; 25-hydroxyvitamin D level<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; vitamin D insufficiency<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>deficiency&#58; 25-hydroxyvitamin D level<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; Normal ferritin levels&#58; females&#44; 13-150<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; males&#44; 30-400<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;</p>"
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      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Normal ferritin levels&#58; females&#44; 13-150<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; males&#44; 30-400<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">25&#40;OH&#41;D&#58; 25-hydroxyvitamin D&#59; BMI&#58; body mass index<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a>&#59; GMFCS&#58; Gross Motor Function Classification System<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a>&#59; SD&#58; standard deviation&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Vitamin D sufficiency&#58; 25&#40;OH&#41;D level<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; vitamin D insufficiency&#58; 25&#40;OH&#41;D level 21&#8211;29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; vitamin D deficiency&#44; 25&#40;OH&#41;D level<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;</p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;3 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sufficiency&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;21&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufficiency&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;47&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Deficiency&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;30&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Ferritin&#44; n</span> &#40;<span class="elsevierStyleItalic">&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;47&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;52&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Albumin &#40;g&#47;dL&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;6 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2527916.png"
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographic characteristics of our sample&#46;</p>"
        ]
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      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">GMFCS&#58; Gross Motor Function Classification System&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a></p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Nutritional status was established based on body mass index &#40;BMI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a></p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Low weight&#58; BMI &#8211; for-age<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>p10&#59; normal weight&#58; BMI &#8211; for-age p10-p75&#59; overweight&#58; BMI &#8211; for-age<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>p75&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Normal ferritin levels&#58; females&#44; 13-150<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; males&#44; 30-400<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Mild gross motor dysfunction&#58; levels I to III&#59; moderate-to-severe gross motor dysfunction&#58; levels IV and V&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Vitamin D sufficiency&#58; 25-hydroxyvitamin D level<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; vitamin D insufficiency<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>deficiency&#58; 25-hydroxyvitamin D level<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vitamin D</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ferritin</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sufficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Insufficiency<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;21&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54 &#40;78&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;47&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;52&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age &#40;years&#41;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;5 &#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;3 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;8 &#40;4&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;3 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Male sex&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;73&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;59&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;45&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;77&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">GMFCS</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                      "titulo" => "Cerebral palsy in children as a risk factor for malnutrition"
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                          "etal" => false
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                            0 => "B&#46; Roger"
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                    0 => array:2 [
                      "doi" => "10.1016/j.jpeds.2004.05.019"
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                        "tituloSerie" => "J Pediatr"
                        "fecha" => "2004"
                        "volumen" => "145"
                        "numero" => "Suppl&#46; 2"
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                          "colaboracion" => "NASPGHAN Committee on Nutrition"
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Article information

ISSN: 21735808
Original language: English

DOI:10.1016/j.nrleng.2017.11.005

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Year/Month	Html	Pdf	Total

2024 November	3	0	3
2024 October	39	4	43
2024 September	58	7	65
2024 August	86	11	97
2024 July	54	8	62
2024 June	53	8	61
2024 May	72	14	86
2024 April	59	22	81
2024 March	83	0	83
2024 February	90	8	98
2024 January	88	4	92
2023 December	87	17	104
2023 November	94	20	114
2023 October	100	19	119
2023 September	72	12	84
2023 August	67	6	73
2023 July	77	9	86
2023 June	83	1	84
2023 May	173	14	187
2023 April	107	10	117
2023 March	97	18	115
2023 February	57	3	60
2023 January	71	4	75
2022 December	58	9	67
2022 November	63	11	74
2022 October	38	10	48
2022 September	43	5	48
2022 August	24	9	33
2022 July	38	8	46
2022 June	26	6	32
2022 May	28	10	38
2022 April	31	7	38
2022 March	35	10	45
2022 February	40	5	45
2022 January	58	9	67
2021 December	37	13	50
2021 November	45	7	52
2021 October	31	9	40
2021 September	22	10	32
2021 August	40	6	46
2021 July	18	11	29
2021 June	20	10	30
2021 May	28	9	37
2021 April	52	44	96
2021 March	42	11	53
2021 February	15	6	21
2021 January	9	8	17
2020 December	12	14	26
2020 November	9	10	19
2020 October	9	8	17
2020 September	8	7	15
2020 August	17	8	25
2020 July	16	6	22
2020 June	8	17	25
2020 May	9	17	26
2020 April	7	3	10
2020 March	10	14	24
2020 February	15	10	25
2020 January	11	7	18
2019 December	14	17	31
2019 November	9	7	16
2019 October	5	7	12
2019 September	4	2	6
2019 August	4	6	10

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