COMMENTARY |
An Update on Type 2 Diabetes in Youth From the National Diabetes Education Program
Diabetes in Children Adolescents Work Group of the National Diabetes Education Program
Abbreviations: AAP, American Academy of Pediatrics • ADA, American Diabetes Association • NDEP, National Diabetes Education Program • NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases • CDC, Centers for Disease Control and Prevention • BMI, body mass index • LDL, low-density lipoprotein
In the year 2000, the American Academy of Pediatrics (AAP) and American Diabetes Association (ADA) issued a joint consensus statement on type 2 diabetes in children and adolescents.1,2 The statement presented current knowledge concerning the classification, epidemiology, and pathophysiology of type 2 diabetes in youth and provided management guidance for providers concerning testing, treating, and preventing this serious and costly disease. Because it is clear that glucose intolerance develops on a continuum from normal blood glucose to frank type 2 diabetes in children and adults, early interventions in this process may effectively reduce risk for diabetes complications.
This commentary provides an update for pediatric health care providers on new research findings, the costs related to obesity and diabetes, and gains made in national initiatives focused on youth with or at risk for type 2 diabetes. A goal of the National Diabetes Education Program (NDEP) is to assist health care providers and consumers to better meet the needs of children with or at risk for type 2 diabetes. NDEP is jointly sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Centers for Disease Control and Prevention (CDC) and works in partnership with >200 professional and consumer organizations including the AAP, ADA, and Juvenile Diabetes Research Foundation International.
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PREVALENCE ESTIMATES |
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 TOP PREVALENCE ESTIMATES COSTS RELATED TO OBESITY...IDENTIFYING CHILDREN WITH TYPE...HEALTH CARE PROVIDER ISSUESTREATMENT AND PREVENTION...FEDERAL GOVERNMENT INITIATIVESCONCLUSIONSREFERENCES |
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True population-based prevalence data are not available yet, but existing statistics indicate that the prevalence of type 2 diabetes in youth is increasing. Although no ethnic group is free of the problem, the disease disproportionately affects American Indian, African American, Mexican American, and Pacific Islander youth.3–5 In 15- to 19-year-old Pima Indians of Arizona, the prevalence of type 2 diabetes is 5%.3 In several clinic-based studies, the percentage of children with newly diagnosed diabetes who are classified as having type 2 diabetes has risen from <5% before 1994 to 30% to 50% in the subsequent years.3,4
Children and adolescents diagnosed with type 2 diabetes are mostly overweight, are insulin-resistant, have a family history of type 2 diabetes, and often have acanthosis nigricans.6 The increasing frequency of exposure to diabetes in utero has been hypothesized to account for some of the increase in diabetes prevalence in Pima Indian children.7 Diabetes complications such as micro- and macroalbuminuria and clustering of cardiovascular risk factors such as dyslipidemia and hypertension have been observed among teenage Pima Indians3 and in other pediatric populations in the United States.8,9
Type 2 diabetes in children, as in adults, is associated with excess weight and decreased energy expenditure.10,11 A recent study of very overweight youth with a body mass index (BMI) >95th percentile for age and gender found that 25% of the 55 children and 21% of the 112 adolescents studied had impaired glucose tolerance that placed them at high risk for developing type 2 diabetes.12 The prevalence of overweight has nearly tripled in adolescents in the past 20 years; 10.4% of children 2 to 5 years old, 15.3% of children 6 to 11 years old, and 15.5% of adolescents 12 to 19 years old in the United States were overweight in 1999–2000.13 These estimates use the most recent National Health and Nutrition Examination Survey data with measured weights and heights and define overweight among those 2 to 19 years old as 
95th percentile of the gender-specific BMI-for-age growth charts. See the CDC BMI for Children and Teens charts at www.cdc.gov/nccdphp/dnpa/bmi/index.htm
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COSTS RELATED TO OBESITY AND DIABETES |
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TOPPREVALENCE ESTIMATESCOSTS RELATED TO OBESITY...IDENTIFYING CHILDREN WITH TYPE...HEALTH CARE PROVIDER ISSUESTREATMENT AND PREVENTION...FEDERAL GOVERNMENT INITIATIVESCONCLUSIONSREFERENCES |
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Among all hospital discharges for youths 6 to 17 years old, the proportion with obesity-associated disease has increased dramatically in the past 20 years. Discharges for diabetes, obesity, sleep apnea, and gallbladder disease were studied to explore the trend of the disease burden. The discharges for diabetes nearly doubled (from 1.43% in 1979 to 2.30% in 1999). The overall increase in these hospital discharges has led to a significant growth in economic costs. Based on hospital utilization and average hospital cost per day adjusted for inflation, annual hospital costs for obesity-associated disease increased >3-fold from approximately $35 million in 1979–1981 to approximately $127 million in 1997–1999.14 These estimates may be conservative, because many overweight youths do not have overweight or obesity listed as a diagnosis.
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IDENTIFYING CHILDREN WITH TYPE 2 DIABETES |
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TOPPREVALENCE ESTIMATESCOSTS RELATED TO OBESITY...IDENTIFYING CHILDREN WITH TYPE...HEALTH CARE PROVIDER ISSUESTREATMENT AND PREVENTION...FEDERAL GOVERNMENT INITIATIVESCONCLUSIONSREFERENCES |
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Data from National Health and Nutrition Examination Survey III suggest that up to one third of adults who have type 2 diabetes may be undiagnosed. A similar situation may exist with children. Children who are not tested as part of a school physical may be undiagnosed until symptoms develop. Case-finding in high-risk individuals who are asymptomatic, therefore, is an appropriate response to this public health challenge because, in adults, risk factors for cardiovascular disease are already present at the time of diagnosis.15
According to criteria for testing asymptomatic populations, only children at substantial risk for the presence or the development of type 2 diabetes should be tested.2 The AAP and ADA consensus panel noted that, although more definitive data are needed, the following testing criteria and diabetes risk factors can be used to help health care providers identify type 2 diabetes in children early2:
- Criteria:
- Overweight (BMI >85th percentile for age and gender, weight for height >85th percentile, or weight >120% of ideal for height), and
- Any 2 of the following risk factors: family history of type 2 diabetes in first- or second-degree relative; race/ethnicity of American Indian, African American, Hispanic/Latino, Asian American, or Pacific Islander; and/or signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome)
- Overweight (BMI >85th percentile for age and gender, weight for height >85th percentile, or weight >120% of ideal for height), and
- Age to begin testing: 10 years or at onset of puberty if puberty occurs earlier
- Frequency of testing: every 2 years
- Test: fasting plasma glucose
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HEALTH CARE PROVIDER ISSUES |
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TOPPREVALENCE ESTIMATESCOSTS RELATED TO OBESITY...IDENTIFYING CHILDREN WITH TYPE...HEALTH CARE PROVIDER ISSUESTREATMENT AND PREVENTION...FEDERAL GOVERNMENT INITIATIVESCONCLUSIONSREFERENCES |
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A random survey of 940 pediatricians, pediatric nurse practitioners, and registered dietitians showed that these health care providers did not frequently use BMI to assess degree of overweight.16 Investigators concluded that there is a need for continued educational efforts to increase health care provider awareness of diabetes risk and for tools to facilitate more complete patient evaluation during office visits.
The same survey found that most pediatric providers believed that childhood excess weight was a condition that needs treatment and affects chronic disease risk and future quality of life. All 3 groups expressed high interest in additional training on weight management of children and adolescents, especially in the area of behavioral strategies and ways to encourage family involvement.17
These findings seem to indicate that pediatric health care providers need increased access to available tools and materials that will help them identify and treat children at risk for type 2 diabetes. Proper assessment of growth and BMI are important diagnostic elements. Additionally, increased availability and awareness of, as well as referral to, innovative community programs and resources that promote eating healthy foods and physical activity could help providers lower their patients’ risk for diabetes.
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TREATMENT AND PREVENTION STRATEGIES |
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TOPPREVALENCE ESTIMATESCOSTS RELATED TO OBESITY...IDENTIFYING CHILDREN WITH TYPE...HEALTH CARE PROVIDER ISSUESTREATMENT AND PREVENTION...FEDERAL GOVERNMENT INITIATIVESCONCLUSIONSREFERENCES |
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Because diet and exercise alone are effective in <10% of youth with type 2 diabetes, pharmacological agents are required to achieve adequate metabolic control.4 In most surveys, practitioners prescribed insulin or an oral agent, most often metformin.4 US Food and Drug Administration approval of metformin in children was granted in December 2000, and package inserts have carried information about use of this drug in children since January 2001.18 Patients with substantial ketosis, ketoacidosis, or markedly elevated blood glucose levels are treated initially with insulin, followed by a tapering of the dose and the addition or substitution of an oral agent after blood glucose control is established and symptoms subside.19,20 Education about self-monitoring blood glucose, healthy eating habits, and daily physical activity is essential and should involve all family members.21
Because children with type 2 diabetes may have hypertriglyceridemia, low levels of high-density lipoprotein, as well as elevated levels of total and low-density lipoprotein (LDL)-cholesterol levels, testing for dyslipidemia is strongly recommended.22 No studies of the risk/benefit of treatment for dyslipidemia in children are available. The ADA, however, recently published consensus guidelines for the management of dyslipidemia in children and adolescents with diabetes.23 These guidelines recommend that children >12 years old with type 1 diabetes should be screened at diagnosis after glycemic control is achieved and again every 5 years if the result is normal. All children with type 2 diabetes should be screened at diagnosis after glycemic control is achieved and again every 2 years if the result is normal. Optimal lipid levels are: LDL, <100 mg/dL; high-density lipoprotein, >35 mg/dL; and triglycerides, <150 mg/dL. Statin drug therapy should be considered for an LDL of 130 to 159 mg/dL, and medication should begin for an LDL of 160 mg/dL.
Blood pressure should be assessed regularly in all patients. No studies of the risk/benefit of treatment for hypertension in children with diabetes are yet available. However, hypertension is increasingly being recognized in overweight children.24
Diabetes prevention in children requires modifying a complex set of behavior patterns.25 Peer pressure and the social environment are especially influential in children. Family and community involvement is essential for developing a health program and for providing a supportive environment in which to help children achieve and maintain behavior changes.25 Strengthening self-efficacy through skills practice and mastery seems to be a key factor for successful behavior change.26
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FEDERAL GOVERNMENT INITIATIVES |
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TOPPREVALENCE ESTIMATESCOSTS RELATED TO OBESITY...IDENTIFYING CHILDREN WITH TYPE...HEALTH CARE PROVIDER ISSUESTREATMENT AND PREVENTION...FEDERAL GOVERNMENT INITIATIVESCONCLUSIONSREFERENCES |
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The joint consensus statement 2 years ago and widespread recognition of this problem have sparked a number of federal initiatives to help stem the rising tide of type 2 diabetes in youth and to treat those affected safely and effectively. The NIDDK is funding clinical trials for the primary prevention and treatment of type 2 diabetes in children in the United States. These clinical trials, now in the planning phase, will focus on developing prevention strategies that can be widely applied in schools across the country and will determine optimal treatment approaches for those children with type 2 diabetes. Additionally, in cooperation with the ADA and the Juvenile Diabetes Research Foundation, the NIDDK is now establishing joint programs for the research training and career development of pediatric endocrinologists to foster a diverse and highly trained workforce to carry out biomedical and behavioral research efforts in pediatric diabetes (http://grants2.nih.gov/grants/guide/rfa-files/RFA-DK-01-011.html).
In November 2000, the CDC and NIDDK cofunded cooperative agreements to establish a multicenter registry system to define childhood diabetes and monitor diagnosed diabetes among young people in the United States over the next 5 years. The registry will study the prevalence, incidence, natural history, and quality of care of children with diabetes and address racial and ethnic disparity issues. It also will help identify future programs and interventions (www.cdc.gov/diabetes/projects/cda2.htm).
A large national multicultural media campaign was launched in July 2002 to promote a healthier lifestyle for 9- to 13-year-olds. The "VERB: It’s What You Do" (www.verbnow.com) youth media campaign will use television and radio spots and the Internet to reach youth across the country. The primary goal of the campaign is to reduce the proportion of children and adolescents who are overweight by encouraging them in a lifetime pursuit of regular physical activity and healthy behaviors. Currently, this age group spends an average of 4.5 hours each day in front of a variety of screens including television, video game, and computer screens.
The NDEP children’s initiative involves a Web-based resource developed with partner organizations to help inform health care providers, parents, school personnel, and the media about the onset and management of diabetes in children. The following resources are currently available at http://ndep.nih.gov/diabetes/youth/youth.htm:
- Diabetes in children and adolescents fact sheet: an informative guide for consumers and health care providers about the different types of diabetes, special issues related to children, legal considerations, and resources
- School guide: a guide to educate school personnel about diabetes and to share a set of essential practices that can help every school create a safe environment for students with diabetes, primarily those who use insulin to control diabetes. The guide was distributed in 2003 to schools nationwide
- Easy-to-read tip sheets: 4 short tip sheets on diabetes, healthy eating, weight loss, and physical activity for children with type 2 diabetes and their families
- "Move It!" campaign: cosponsored with the Association of American Indian Physicians, this campaign is targeted to American Indian youth and involves schools and families in helping students to increase their physical activity and reduce their risk for diabetes
- Resource directory–diabetes in children and adolescents: a Web-based directory that provides links to governmental, educational, and voluntary organizations that offer information and resources related to children and adolescents with diabetes
- Annotated bibliography: a resource for health care providers and parents of children with diabetes that provides abstracts of articles from the biomedical literature about diabetes in youth, risk factors, and high-risk populations
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CONCLUSIONS |
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TOPPREVALENCE ESTIMATESCOSTS RELATED TO OBESITY...IDENTIFYING CHILDREN WITH TYPE...HEALTH CARE PROVIDER ISSUESTREATMENT AND PREVENTION...FEDERAL GOVERNMENT INITIATIVESCONCLUSIONSREFERENCES |
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Type 2 diabetes in children and adolescents is a sizable and growing problem among American Indians and an emerging public health problem among other ethnic groups in the United States. Overweight children are at increased risk for developing type 2 diabetes during childhood and later in life. The increase in incidence of type 2 diabetes in youth is a "first consequence" of the epidemic of obesity among young people.27 Changes in the energy balance of young people (physical activity balanced with caloric consumption) have influenced this trend.8,9 Associations have been made between the obesity epidemic among youth and increased sugared beverage consumption,28 as well as long hours in front of television screens29 and reduced physical activity.30
Intensive efforts to reduce obesity in children and youth who have impaired glucose tolerance through increased physical activity and better eating habits are likely to help to prevent their developing type 2 diabetes. A number of government initiatives are underway, including studies to define the extent of the problem of type 2 diabetes in youth; clinical trials to develop effective primary diabetes prevention strategies and determine the most effective treatment strategies; the development of a national registry for youth with type 2 diabetes; a multicultural media campaign to promote a healthier lifestyle in young people; and the NDEP children’s initiative.
Ongoing efforts to prevent and treat type 2 diabetes will require community and government involvement to reduce obesity and increase physical activity in both pediatric and adult populations,15 including women of childbearing age.8 Greater pediatric health care provider awareness and monitoring of the disease and its risk factors will contribute to this effort, as will their adoption of management strategies that are shown to be effective among youth of diverse backgrounds.
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FOOTNOTES |
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Received for publication Mar 4, 2003; Accepted Nov 20, 2003.
Reprint requests to National IHS Diabetes Program, 5300 Homestead Rd NE, Albuquerque, NM 87110. E-mail: kelly.moore{at}0040mail.ihs.gov
Members of the Diabetes in Children and Adolescents Work Group of the National Diabetes Education Program who contributed to this manuscript were: Nichole Bobo, RN, MSN, ANP; Alison Evert, RD, CDE; Joanne Gallivan, MS, RD; Giuseppina Imperatore, MD, PhD; Jane Kelly, MD; Barbara Linder, MD, PhD; Rodney Lorenz, MD; Saul Malozowski, MD, PhD, MBA; Catherine Marschilok, MSN, RN, CDE; Regan Minners; Kelly Moore, MD, FAAP, Chairperson; Adolpho Perez Comas, MD, PhD; Dawn Satterfield, PhD; Janet Silverstein, MD; Gladys Gary Vaughn, PhD; and Elizabeth Warren-Boulton, RN, MSN.
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REFERENCES |
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1. American Academy of Pediatrics, American Diabetes Association. Type 2 diabetes in children and adolescents. Pediatrics. 2000;105 :671 –680
2. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23 :381 –379[Web of Science][Medline]
3. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136 :664 –672[CrossRef][Web of Science][Medline]
4. Kaufman FR. Type 2 diabetes mellitus in children and youth: a new epidemic. J Pediatr Endocrinol Metab. 2002;15(suppl 2) :737 –744
5. Acton KJ, Burrows NR, Moore K, Querec L, Geiss LS, Engelgau MM. Trends in diabetes prevalence among American Indian and Alaska native children, adolescents, and young adults.
Am J Public Health. 2002;92
:1485
–1490
6. Stuart CA, Gilkison CR, Smith MM, Bosma AM, Keenan BS, Nagamani M. Acanthosis nigricans as a risk factor for non-insulin dependent diabetes mellitus. Clin Pediatr (Phila). 1998;37 :73 –79
7. Dabelea D, Pettitt DJ. Intrauterine diabetic environment confers risks for type 2 diabetes mellitus and obesity in the offspring, in addition to genetic susceptibility. J Pediatr Endocrinol Metab. 2001;14 :1085 –1091[Web of Science][Medline]
8. Deckelbaum RJ, Williams CL. Childhood obesity: the health issue. Obes Res. 2001;9(suppl 4) :239S –243S
9. Crawford PB, Story M, Wang MC, Ritchie LD, Sabry ZI. Ethnic issues in the epidemiology of childhood obesity. Pediatr Clin North Am. 2001;48 :855 –878[CrossRef][Web of Science][Medline]
10. Dabelea D, Hanson RL, Bennett PH, Roumain J, Knowler WC, Pettitt DJ. Increasing prevalence of type II diabetes in American Indian children. Diabetologia. 1998;41 :904 –910[CrossRef][Web of Science][Medline]
11. Caspersen CJ, Pereira MA, Curran KM. Changes in physical activity patterns in the United States, by sex and cross-sectional age. Med Sci Sports Exerc. 2000;32 :1601 –1609[Web of Science][Medline]
12. Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity.
N Engl J Med. 2002;346
:802
–810
13. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999–2000.
JAMA. 2002;288
:1728
–1732
14. Wang G, Dietz WH. Economic burden of obesity in youths aged 6 to 17 years: 1979–1999. Pediatrics. 2002;109(5) . Available at: www.pediatrics.org/cgi/content/full/109/5/e81
15. Rosenbloom AL. Increasing incidence of type 2 diabetes in children and adolescents: treatment considerations. Paediatr Drugs. 2002;4 :209 –221[Medline]
16. Barlow SE, Dietz WH, Klish WJ, Trowbridge FL. Medical evaluation of overweight children and adolescents: reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics. 2002;110(1 pt 2) :222 –228
17. Story MT, Neumark-Stzainer DR, Sherwood NE, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 pt 2) :210 –214
18. Jones KL. Treatment of type 2 diabetes mellitus in children.
JAMA. 2002;287
:716
19. Silverstein JH, Rosenbloom AL. Treatment of type 2 diabetes mellitus in children and adolescents. J Pediatr Endocrinol Metab. 2000;13(suppl 6) :1403 –1409
20. Zuhri-Yafi MI, Brosnan PG, Hardin DS. Treatment of type 2 diabetes mellitus in children and adolescents. J Pediatr Endocrinol Metab. 2002;15(suppl 1) :541 –546
21. Mensing C, Boucher J, Cypress M, et al. National standards for diabetes self-management education.
Diabetes Care. 2000;23
:682
–689
22. Taha D. Hyperlipidemia in children with type 2 diabetes mellitus. J Pediatr Endocrinol Metab. 2002;15(suppl 1) :505 –507
23. American Diabetes Association. Management of dyslipidemia in children and adolescents with diabetes.
Diabetes Care. 2003;26
:2194
–2197
24. Sorof JM, Poffenbarger T, Franco K, Bernard L, Portman RJ. Isolated systolic hypertension, obesity, and hyperkinetic hemodynamic states in children. J Pediatr. 2002;140 :660 –666[CrossRef][Web of Science][Medline]
25. Burnet D, Plaut A, Courtney R, Chin MH. A practical model for preventing type 2 diabetes in minority youth.
Diabetes Educ. 2002;28
:779
–795
26. Resnicow K, Yaroch AL, Davis A, et al. GO GIRLS!: results from a nutrition and physical activity program for low-income, overweight African American adolescent females.
Health Educ Behav. 2000;27
:616
–631
27. Fagot-Campagna A, Burrows NR, Williamson DF. The public health epidemiology of type 2 diabetes in children and adolescents: a case study of American Indian adolescents in the Southwestern United States. Clin Chim Acta. 1999;286 :81 –95[CrossRef][Web of Science][Medline]
28. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357 :505 –508[CrossRef][Web of Science][Medline]
29. Robinson TN. Television viewing and childhood obesity. Pediatr Clin North Am. 2001;48 :1017 –1025[CrossRef][Web of Science][Medline]
30. Kimm SY, Glynn NW, Kriska AM, et al. Decline in physical activity in black girls and white girls during adolescence.
N Engl J Med. 2002;347
:709
–715
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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