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Bremer AA. Prioritizing Nutrition in Medical Education-the Time Has Come. Adv Nutr 2024:100231. [PMID: 38744658 DOI: 10.1016/j.advnut.2024.100231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
- Andrew A Bremer
- Office of Nutrition Research, National Institutes of Health, Bethesda, MD, United States.
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Jimenez EY, Lamers-Johnson E, Long JM, McCabe G, Ma X, Woodcock L, Bliss C, Abram JK, Steiber AL. Predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators to diagnose malnutrition tool in hospitalized adults: a cohort study. Am J Clin Nutr 2024; 119:779-787. [PMID: 38432715 DOI: 10.1016/j.ajcnut.2023.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The lack of a widely accepted, broadly validated tool for diagnosing malnutrition in hospitalized patients limits the ability to assess the integral role of nutrition as an input and outcome of health, disease, and treatment. OBJECTIVES This study aimed to evaluate the predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (ASPEN) indicators to diagnose malnutrition (AAIM) tool and determine if it can be simplified. METHODS A prospective cohort study was conducted from August 2019 to September 2022 with 32 hospitals in United States. At baseline, 290 adult patients were evaluated for a diagnosis of malnutrition using the AAIM tool, which assesses weight loss, inadequate energy intake, subcutaneous fat and muscle loss, edema, and hand grip strength. Healthcare outcomes were extracted from the medical record: composite incidence of emergency department (ED) visits and hospital readmissions within 90 d postdischarge; length of hospital stay (LOS); and Medicare Severity Disease Related Group (MS-DRG) relative weight (i.e., healthcare resource utilization). We used multilevel, multivariable negative binomial or generalized linear regression models to evaluate relationships between malnutrition diagnosis and healthcare outcomes. RESULTS After adjusting for disease severity and acuity and sociodemographic characteristics, individuals diagnosed with severe malnutrition had a higher incidence rate of ED visits and hospital readmissions (incidence rate ratio: 1.89; 95% CI: 1.14, 3.13; P = 0.01), and individuals diagnosed with moderate malnutrition had a 25.2% longer LOS (95% CI: 2.0%, 53.7%; P = 0.03) and 15.1% greater healthcare resource utilization (95% CI: 1.6%, 31.9%; P = 0.03) compared with individuals with no malnutrition diagnosis. Observed relationships remained consistent when only considering malnutrition diagnoses supported by at least 2 of these indicators: weight loss, subcutaneous fat loss, muscle wasting, and inadequate energy intake. CONCLUSIONS Findings from this multihospital study confirm the predictive validity of the original or simplified AAIM tool and support its routine use for hospitalized adult patients. This trial was registered at clinicaltrials.gov as NCT03928548 (https://classic. CLINICALTRIALS gov/ct2/show/NCT03928548).
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Affiliation(s)
- Elizabeth Yakes Jimenez
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL, United States; Department of Pediatrics, University of New Mexico Health Sciences Center, 1 University of New Mexico, Albuquerque, NM, United States; Department of Internal Medicine, University of New Mexico Health Sciences Center, 1 University of New Mexico, Albuquerque, NM, United States; College of Population Health, University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM, United States
| | - Erin Lamers-Johnson
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL, United States
| | - Julie M Long
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL, United States
| | - George McCabe
- Department of Statistics, Purdue University, West Lafayette, IN, United States
| | - Xingya Ma
- Department of Pediatrics, University of New Mexico Health Sciences Center, 1 University of New Mexico, Albuquerque, NM, United States
| | - Lindsay Woodcock
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL, United States
| | - Courtney Bliss
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL, United States
| | - Jenica K Abram
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL, United States
| | - Alison L Steiber
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL, United States.
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Raiten DJ, Steiber AL, Dary O, Bremer AA. The Value of an Ecological Approach to Improve the Precision of Nutritional Assessment: Addressing Contributors and Implications of the "Multiple Burdens of Malnutrition". Nutrients 2024; 16:421. [PMID: 38337706 PMCID: PMC10857452 DOI: 10.3390/nu16030421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Globally, children are exposed to multiple health risks associated with diet and nutrition. Rather than simply being a condition of having too much or too little food, malnutrition is more a syndrome comprising multiple burdens of coexisting and reciprocal malnutrition, infection, or other conditions. Importantly, children with such syndromes (e.g., stunting and anemia, which are neither specific nor necessarily sensitive to nutritional status) are more likely to also have irreversible functional outcomes such as poor growth, impaired immune function, or cognitive delays. The global health community has identified nutrition-related targets (e.g., Sustainable Development Goals (SDGs) and World Health Organization (WHO) Global Nutrition Targets) that, for multiple reasons, are difficult to address. Moreover, as the complexity of the global health context increases with persistent pandemics of infectious diseases and the rising prevalence of noncommunicable diseases, there is a growing appreciation that conditions selected as nutrition/health targets indeed represent syndromes for which nutritional status serves as both an input and outcome. In recognition of the impact of these combined challenges and the role of the multiple manifestations of malnutrition, we suggest an approach to nutritional assessment that is intended to improve the precision of context-specific, equitable approaches to health promotion, disease prevention, and treatment.
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Affiliation(s)
- Daniel J. Raiten
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20817, USA;
| | | | - Omar Dary
- USAID, Bureau for Global Health, Division of Nutrition and Environmental Health, Washington, DC 20523, USA;
| | - Andrew A. Bremer
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20817, USA;
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Raiten DJ, Moorthy D, Hackl LS, Dary O. Exploring the Anemia Ecology: A New Approach to an Old Problem. J Nutr 2023; 153 Suppl 1:S1-S6. [PMID: 37778890 PMCID: PMC10797548 DOI: 10.1016/j.tjnut.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/28/2023] [Accepted: 07/31/2023] [Indexed: 10/03/2023] Open
Abstract
Our ability to identify anemia and all its permutations demands an approach that integrates the key elements of a complex "ecology," which intertwines biology and mechanistic aspects of nutrients with both the health status and underlying factors-physical, economic, social, behavioral, demographic, and environmental. The complexity of anemia demands an ecologic approach that appreciates systems biology, translates sensitive and specific assessment methodologies and interventions, and ultimately improves clinical and public health outcomes. This series of technical papers on anemia by the U.S. Agency for International Development (USAID) Advancing Nutrition Anemia Task Force (ATF) is a first step in translating our ecologic approach to anemia with a view toward balancing research with its translation to effective programs, interventions, and policy. This introductory overview describes the components of our ecologic approach-linking the biology of anemia with its assessment and using the learning from that confluence to devise context-specific interventions. This introductory review briefly discusses the topics that underlie the biology and primary etiologies of anemia and presents a framework for public health assessment of anemia, leading to appropriate public health interventions. The other 3 manuscripts in the supplement provide the details of the arguments laid out in the introduction.
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Affiliation(s)
- Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Denish Moorthy
- USAID Advancing Nutrition, JSI Research and Training Institute, VA, United States.
| | - Laura S Hackl
- USAID Advancing Nutrition, JSI Research and Training Institute, VA, United States
| | - Omar Dary
- Division of Nutrition and Environmental Health, Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, DC, United States
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Williams AM, Brown KH, Allen LH, Dary O, Moorthy D, Suchdev PS. Improving Anemia Assessment in Clinical and Public Health Settings. J Nutr 2023; 153 Suppl 1:S29-S41. [PMID: 37778891 PMCID: PMC11002965 DOI: 10.1016/j.tjnut.2023.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/28/2023] [Accepted: 05/10/2023] [Indexed: 10/03/2023] Open
Abstract
We aim to provide a practical approach to assess anemia and its primary causes, both in clinical settings and in the context of public health programs. Anemia remains a global challenge; thus, to achieve goals for anemia reduction and assess progress, standardized approaches are required for the assessment of anemia and its causes. We first provide a brief review of how to assess anemia, based on hemoglobin concentrations and cutoffs that correspond to age, sex, and physiologic status. Next, we discuss how to assess the likely causes of anemia in different settings. The causes of anemia are classified as non-nutritional (for example, because of infection, inflammation, blood loss, or genetic disorders) or nutrition-specific (for example, because of deficiencies of iron, vitamin A, riboflavin, vitamin B12, or folate). There is an important overlap between these 2 categories, such as the increased likelihood of iron deficiency in the context of inflammation. Given the multifaceted nature of anemia etiology, we introduce a framework for anemia assessment based on the "ecology of anemia," which recognizes its many overlapping causes. This conceptual framework is meant to inform what data on anemia causes may need to be collected in population surveys. The framework has a supporting table with information on the diagnostic tests, biomarkers and proposed cutoffs, characteristics, and feasibility of collecting the myriad information that can help elucidate the anemia etiology. We also provide examples of how this framework can be applied to interpret the anemia risk factor data from population-based surveys that can inform decisions about context-specific interventions. Finally, we present research gaps and priorities related to anemia assessment.
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Affiliation(s)
- Anne M Williams
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand; Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States; Emory University, Atlanta, GA, United States.
| | - Kenneth H Brown
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA, United States
| | - Lindsay H Allen
- United States Department of Agriculture, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA, United States
| | - Omar Dary
- Division of Nutrition and Environmental Health, Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, DC, United States
| | | | - Parminder S Suchdev
- Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States; Emory University, Atlanta, GA, United States
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Raiten DJ, Bremer AA. An Ecological Approach for Advancing the Understanding of Nutrition and Health. JAMA Pediatr 2023; 177:748-750. [PMID: 37306982 DOI: 10.1001/jamapediatrics.2023.1613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This Viewpoint discusses 2 new programs of the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Pediatric Growth and Nutrition Branch that apply an ecological approach to understanding nutrition and public health.
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Affiliation(s)
- Daniel J Raiten
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Andrew A Bremer
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Bremer AA, Raiten DJ. The Reciprocal Relationship between Climate and Environmental Changes and Food Systems and Its Impact on Food/Nutrition Security and Health. Nutrients 2023; 15:2824. [PMID: 37447151 DOI: 10.3390/nu15132824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
Changes in our climate and physical environments are having profound effects on all aspects of human existence, and the ability to develop sustainable and resilient food systems is critical not just to the environment but to all aspects of human health. The Pediatric Growth and Nutrition Branch (PGNB) of the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the US National Institutes of Health has adopted a new paradigm to undergird the study of nutrition that recognizes the complex and reciprocal nature of the relationships between nutrition and health outcomes. This conceptual framework, termed the "nutritional ecology," views humans as complex biological systems interacting with both their internal and external environments. Herein, we focus on: (i) the reciprocal relationship between climate and environmental changes and food systems and their impact on food/nutrition security and health; and (ii) how PGNB is utilizing the "nutritional ecology" framework to support science addressing the interactions among health, nutrition, food systems, climate, and the environment.
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Affiliation(s)
- Andrew A Bremer
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, 6710B Rockledge Drive-Rm 2444, Bethesda, MD 20892, USA
| | - Daniel J Raiten
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, 6710B Rockledge Drive-Rm 2444, Bethesda, MD 20892, USA
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Donovan SM, Abrams SA, Azad MB, Belfort MB, Bode L, Carlson SE, Dallas DC, Hettinga K, Järvinen K, Kim JH, Lebrilla CB, McGuire MK, Sela DA, Neu J. Summary of the joint National Institutes of Health and the Food and Drug Administration workshop titled "exploring the science surrounding the safe use of bioactive ingredients in infant formula: Considerations for an assessment framework". J Pediatr 2022; 255:30-41.e1. [PMID: 36463938 PMCID: PMC10121942 DOI: 10.1016/j.jpeds.2022.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/20/2022] [Accepted: 11/18/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Sharon M Donovan
- Department of Food Science and Human Nutrition, University of Illinois, Urbana, IL
| | - Steven A Abrams
- Department of Pediatrics Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Meghan B Azad
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada; Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Mandy B Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lars Bode
- Department of Pediatrics and Mother-Milk-Infant Center of Research Excellence (MOMI CORE), University of California, San Diego, La Jolla, CA
| | - Susan E Carlson
- Department of Dietetics and Nutrition, Kansas University Medical Center and The University of Kansas, Kansas City, KS
| | - David C Dallas
- Department of Nutrition, Oregon State University, Corvallis, OR
| | - Kasper Hettinga
- Department of Food Sciences and Agrotechnology, Wageningen University, Wageningen, Netherlands
| | - Kirsi Järvinen
- Department of Pediatrics, Golisano Children's Hospital and University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jae H Kim
- Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - David A Sela
- Department of Food Science, University of Massachusetts, Amherst, Amherst, MA
| | - Josef Neu
- Department of Pediatrics, University of Florida, Gainesville, FL.
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Fujita M, Wander K, Tran T, Brindle E. Characterizing the extent human milk folate is buffered against maternal malnutrition and infection in drought‐stricken northern Kenya. AMERICAN JOURNAL OF BIOLOGICAL ANTHROPOLOGY 2022; 179:171-183. [PMCID: PMC9805107 DOI: 10.1002/ajpa.24603] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 04/09/2022] [Accepted: 07/20/2022] [Indexed: 09/29/2023]
Abstract
Objectives Folate is an essential nutrient fundamental to human growth and development. Human milk maintains high folate content across the maternal folate status range, suggesting buffering of milk folate with prioritized delivery to milk at the expense of maternal depletion. We investigated whether and how the extent of this buffering may diminish under prolonged nutritional and/or disease stress, while taking into consideration infants' varying vulnerability to malnutrition‐related morbidity/mortality. Methods A cross‐sectional study analyzed milk specimens from northern Kenyan mothers (n = 203), surveyed during a historic drought and ensuing food shortage. Multiple regression models for folate receptor‐α (FOLR1) in milk were constructed. Predictors included maternal underweight (BMI < 18.5), iron‐deficiency anemia (hemoglobin <12 g/dl and dried‐blood‐spot transferrin receptor >5 mg/L), folate deficiency (hyperhomocysteinemia, homocysteine >12 or 14 μmol/L), inflammation (serum C‐reactive protein >5 mg/L), infant age and sex, and mother‐infant interactions. Results In adjusted models, milk FOLR1 was unassociated with maternal underweight, iron‐deficiency anemia and inflammation. FOLR1 was positively associated with maternal folate deficiency, and inversely associated with infant age. There was interaction between infant age and maternal underweight, and between infant sex and maternal folate deficiency, predicting complex changes in FOLR1. Conclusions Our results suggest that mothers buffer milk folate against their own nutritional stress even during a prolonged drought; however, the extent of this buffering may vary with infant age, and, among folate‐deficient mothers, with infant sex. Future research is needed to better understand this variability in maternal buffering of milk folate and how it relates to folate status in nursing infants. Human mothers might have the capacity to buffer milk nutrient content against undue fluctuations under nutritional or disease stress. In the case of the micronutrient folate, this buffering is most apparent for younger infants.
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Affiliation(s)
- Masako Fujita
- Department of AnthropologyMichigan State UniversityEast LansingMichiganUSA
- Biomarker Laboratory for Anthropological ResearchMichigan State UniversityEast LansingMichiganUSA
| | - Katherine Wander
- Department of AnthropologyBinghamton University (SUNY)BinghamtonNew YorkUSA
- Laboratory for Anthropometry and BiomarkersBinghamton UniversityBinghamtonNew YorkUSA
| | - Tin Tran
- Biomarker Laboratory for Anthropological ResearchMichigan State UniversityEast LansingMichiganUSA
- College of PharmacyUniversity of IowaIowa CityIowaUSA
| | - Eleanor Brindle
- Maternal, Newborn and Child Health & NutritionPATHSeattleWashingtonUSA
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Bell KA, Matthews LG, Cherkerzian S, Prohl AK, Warfield SK, Inder TE, Onishi S, Belfort MB. Associations of body composition with regional brain volumes and white matter microstructure in very preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 107:533-538. [PMID: 35058276 PMCID: PMC9296693 DOI: 10.1136/archdischild-2021-321653] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 12/20/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine associations between body composition and concurrent measures of brain development including (1) Tissue-specific brain volumes and (2) White matter microstructure, among very preterm infants at term equivalent age. DESIGN Prospective observational study. SETTING Single-centre academic level III neonatal intensive care unit. PATIENTS We studied 85 infants born <33 weeks' gestation. METHODS At term equivalent age, infants underwent air displacement plethysmography to determine body composition, and brain MRI from which we quantified tissue-specific brain volumes and fractional anisotropy (FA) of white matter tracts. We estimated associations of fat and lean mass Z-scores with each brain outcome, using linear mixed models adjusted for intrafamilial correlation among twins and potential confounding variables. RESULTS Median gestational age was 29 weeks (range 23.4-32.9). One unit greater lean mass Z-score was associated with larger total brain volume (10.5 cc, 95% CI 3.8 to 17.2); larger volumes of the cerebellum (1.2 cc, 95% CI 0.5 to 1.9) and white matter (4.5 cc, 95% CI 0.7 to 8.3); and greater FA in the left cingulum (0.3%, 95% CI 0.1% to 0.6%), right uncinate fasciculus (0.2%, 95% CI 0.0% to 0.5%), and right posterior limb of the internal capsule (0.3%, 95% CI 0.03% to 0.6%). Fat Z-scores were not associated with any outcome. CONCLUSIONS Lean mass-but not fat-at term was associated with larger brain volume and white matter microstructure differences that suggest improved maturation. Lean mass accrual may index brain growth and development.
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Affiliation(s)
- Katherine Ann Bell
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lillian G Matthews
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
- Victorian Infant Brain Study (VIBeS), Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Sara Cherkerzian
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna K Prohl
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Simon K Warfield
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Mandy B Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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