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Pediatrics
September 2016, VOLUME 138 / ISSUE 3
Review Article

Mobile Phone Interventions for Adolescent Sexual and Reproductive Health: A Systematic Review

Kelly L. L’Engle, Emily R. Mangone, Angela M. Parcesepe, Smisha Agarwal, Nicole B. Ippoliti
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Abstract

CONTEXT: Interventions for adolescent sexual and reproductive health (ASRH) are increasingly using mobile phones but may not effectively report evidence.

OBJECTIVE: To assess strategies, findings, and quality of evidence on using mobile phones to improve ASRH by using the mHealth Evidence Reporting and Assessment (mERA) checklist recently published by the World Health Organization mHealth Technical Evidence Review Group.

DATA SOURCES: Systematic searches of 8 databases for peer-reviewed studies published January 2000 through August 2014.

STUDY SELECTION: Eligible studies targeted adolescents ages 10 to 24 and provided results from mobile phone interventions designed to improve ASRH.

DATA EXTRACTION: Studies were evaluated according to the mERA checklist, covering essential mHealth criteria and methodological reporting criteria.

RESULTS: Thirty-five articles met inclusion criteria. Studies reported on 28 programs operating at multiple levels of the health care system in 7 countries. Most programs (82%) used text messages. An average of 41% of essential mHealth criteria were met (range 14%–79%). An average of 82% of methodological reporting criteria were met (range 52%–100%). Evidence suggests that inclusion of text messaging in health promotion campaigns, sexually transmitted infection screening and follow-up, and medication adherence may lead to improved ASRH.

LIMITATIONS: Only 3 articles reported evidence from lower- or middle-income countries, so it is difficult to draw conclusions for these settings.

CONCLUSIONS: Evidence on mobile phone interventions for ASRH published in peer-reviewed journals reflects a high degree of quality in methods and reporting. In contrast, current reporting on essential mHealth criteria is insufficient for understanding, replicating, and scaling up mHealth interventions.

  • Abbreviations:
    ART —
    antiretroviral therapy
    ASRH —
    adolescent sexual and reproductive health
    HPV —
    human papillomavirus
    LIC —
    lower-income country
    m4RH —
    Mobile for Reproductive Health
    mERA —
    mHealth Evidence and Reporting Assessment
    mHealth —
    mobile phone interventions for health improvement
    PRISMA —
    Preferred Reporting Items for Systematic Review and Meta-Analyses
    RCT —
    randomized controlled trial
    SRH —
    sexual and reproductive health
    SMS —
    Short Message Service
    STI —
    sexually transmitted infection

    • Globally, mobile phone use is increasingly rapidly, and a large proportion of mobile phone subscribers are young people.1,2 Four of every 5 citizens in developed countries and 1 of every 2 citizens in developing countries have a mobile phone subscription.3 Young people ≤29 years of age are the most likely to own a mobile phone,2,4 and 15- to 24-year-olds are more likely than older age groups to own a smartphone, indicating this group’s eagerness to use new mobile technologies.2,5,6 Given their popularity among youth, adolescent health professionals are increasingly using mobile phones to link young people to health information and services across global settings.7–10

    This promising approach is called mHealth, the use of mobile phones to improve health knowledge, behaviors and outcomes, and it has advantages when used in health programming for young people. Adolescents commonly report low sexual and reproductive health (SRH) knowledge and risky sexual behaviors,11,12 but they also face barriers to care such as provider bias and fear of stigma, refusal, and embarrassment in seeking information and services.13–17 Mobile phone solutions may help overcome many of these barriers by providing accurate, timely, and engaging information and appropriate care for highly sensitive adolescent sexual and reproductive health (ASRH) topics. Mobile phones are inexpensive, portable, and accessible. They offer privacy in comparison with face-to-face meetings with health care providers, and they can provide young people with tailored and anonymous health information without stigma or judgment. Furthermore, young people are responsive to and excited about using new technologies for SRH promotion.18–21

    Better assessments of mHealth solutions for young people are needed to rigorously evaluate whether they are a viable and effective strategy for reaching adolescents and improving ASRH behaviors in particular. Although a few published reviews have examined digital health solutions to ASRH, none have focused exclusively on mobile phone interventions and used a comprehensive definition of ASRH.8–10 The goals of this research are to assess the strategies, findings, and reporting quality from evidence on mobile phone interventions for ASRH.

    We conducted a systematic review of research from peer-reviewed journal articles by using the new mHealth Evidence and Reporting Assessment (mERA) checklist.22 The checklist was developed by the World Health Organization mHealth Technical Evidence Review Group specifically to assess evidence from mobile phone intervention research for health improvement. The recently published mERA checklist is a valuable tool to assess the quality and completeness of intervention reporting for the many mHealth interventions for ASRH. Effective and comprehensive reporting may help improve program design, foster collaboration between service providers, reduce duplication of efforts, and ultimately increase the impact and ability to scale effective mHealth interventions for ASRH.

    Methods

    Search Strategy

    In August 2014 we searched 8 databases in the fields of medicine and social science: PubMed, Embase, Global Health, PsycINFO, Popline, Cochrane Library, Web of Science, and mHealthevidence.org. Search terms were grouped under 3 domains: adolescence, SRH, and mobile technology (Supplemental Table 6). Because our interest was in the intersection of these domains, the presence of ≥1 search term from each domain was required for inclusion. We also hand-searched the references of 21 relevant systematic reviews. Finally, we issued a global call for resources on mHealth interventions for ASRH, which was widely promoted via social media, relevant electronic mailing lists, and partner Web sites.

    Eligibility

    We took an inclusive approach and used the World Health Organization definition of young people ages 10 to 2423 and included peer-reviewed articles that either presented disaggregated data for young people 10 to 24 or did not disaggregate results but described the sample as having ≥70% of respondents between 10 and 24 years of age. We used the United Nations Family Planning Association definition of sexual and reproductive health,24 which includes contraception, antenatal care, delivery, postnatal care, infertility, abortion, reproductive tract infections, HIV/AIDS, sexually transmitted infections (STIs), sexuality, and violence against women and related practices (eg, female genital mutilation). Included articles also had to describe the use of a mobile device, such as a mobile phone or tablet, to provide SRH information and support, and describe results or feedback from the mobile technology intervention. Systematic reviews, gray literature, documents that were not in English, and documents published before January 1, 2000 were excluded.

    Literature Search Results

    The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow diagram was used to document the search strategy and article selection process (Fig 1).25 A total of 5040 articles were retrieved from the 8 databases described above. After we removed duplicate articles and articles published before January 1, 2000, 2806 records remained.

    FIGURE 1
    FIGURE 1

    PRISMA flow diagram of article inclusion.

    All 2806 titles and abstracts were screened and resulted in the exclusion of 2550 unique records; records could be excluded for multiple reasons. The full texts of the 256 remaining records were screened and resulted in the final inclusion of 35 articles. No additional articles meeting inclusion criteria were identified through the search of systematic reviews or through the global call for evidence.

    Two reviewers screened a random selection of 11% of all abstracts (n = 300 out of 2806) for inclusion in the study. There was 94% agreement on article inclusion between the reviewers. Another check was conducted for 20% of documents (n = 50 out of 256) at the full text level. Again, this resulted in a high interrater reliability agreement of 92%. When reviewers did not agree, a third reviewer was consulted to make the final determination about whether the article met eligibility criteria for inclusion.

    Data Extraction and Synthesis

    One reviewer extracted data from included studies and a second reviewer independently confirmed accuracy. Data extraction for each article included name of the mHealth intervention program, study design, population, and aim, and key results. Study design (for each individual article) and program purpose (for each unique mHealth program) were used as classification schemes for synthesizing data. Study designs were cataloged as randomized controlled trials (RCTs), quasiexperimental, observational, or descriptive research. Program purpose included health promotion campaign, curriculum addition, screening and follow-up service utilization, provider counseling, and patient adherence.

    Grading

    Evidence was graded according to the mERA checklist.22 The core checklist defines 14 essential mHealth criteria to support completeness of reporting and replication of the mHealth intervention by addressing its content, context, and implementation features (Supplemental Table 7). In addition, mERA also provides a checklist for reporting on study methods, because the field of mHealth includes a range of research designs and methods. This second checklist defines 30 core elements of research reporting required to facilitate the synthesis of mHealth research findings, regardless of study design (Supplemental Table 8).

    This manuscript is the first review of published literature to use the mERA checklist. Three reviewers were trained on the mERA checklist, and they graded 4 randomly selected articles to yield interrater reliability scores of 82%, 84%, 93%, and 95%, sequentially.

    Results

    Program Strategies

    The 35 articles reported on 28 different mHealth intervention programs where mobile phones were used to address ASRH. Three-quarters of all programs (n = 21) were implemented in the United States. Four were conducted in Australia or New Zealand, and 1 was conducted in the Netherlands. One program was implemented in Tanzania and 1 in the Democratic Republic of the Congo.

    Eight programs focused on pregnancy; 4 of these aimed to increase adoption and correct use of contraceptive methods,20,26–30 2 focused on youth assets and broader pregnancy prevention messaging,19,31 and 2 provided information to pregnant or parenting adolescents.32,33 STIs were the focus of 8 programs, with most of them targeting links to services for STI vaccination,34,35 screening,36,37 or treatment.10,34,38,39 Seven programs targeted general ASRH issues.40–47 Five mHealth programs specifically focused on HIV/AIDS; 3 of them provided adherence support for HIV-positive youth,48–51 and 2 focused on HIV prevention.18,43,52,53

    Health promotion campaigns were the most common purpose of mHealth programs for ASRH included in the review (43%; n = 12). These programs provided a mobile phone platform for youth to text SRH questions to health professionals,33,40,46,47 allowed adolescents to retrieve on-demand SRH content,20,30,44 and offered “push” messaging where SRH content was texted to adolescents on a regular schedule.21,32,41,43,45,51 Two programs complemented delivery of an in-person, evidence-based ASRH curriculum with a mobile phone component to extend program reach particularly to ethnic and minority youth and to stay current on the communication channels frequently used by young people.18,19,52,53

    The 7 mHealth programs for screening and follow-up service utilization included human papillomavirus (HPV) vaccination text message reminders for follow-up,34,35 notification for positive chlamydia and other STI results,10,38,53,54 and chlamydia screening promotion.36,37 Patient adherence to medications or health recommendations was addressed in 7 additional programs that provided text message reminders for taking daily oral contraceptive pills27,28 or antiretroviral therapy (ART) for HIV-positive young people49,50 and in programs that provided regular counseling over the mobile phone to improve adherence to contraception use and continuation26,29 or adherence to ART for HIV-positive youth48,51 or to delay subsequent pregnancy among adolescent mothers.31

    Short message service (SMS) or text messaging was used by the majority of programs (82%, n = 23). Three programs added mobile phone voice calls,39,46,54 and 4 programs used mobile phone voice calls exclusively.26,29,31,48,51 Only a few programs used other communication formats, such as providing mobile phone videos,42 e-mail,37 instant messaging,40 or sparse use of other multimedia applications.18,52,53

    Study Findings

    Research on health promotion interventions (Table 1) that provided a forum for asking SRH questions confidentially via mobile phone33,40,46,47 found that adolescents texted about a wide range of highly sensitive SRH topics, suggesting robust acceptability and relevance of this strategy. Content analyses of text questions found that adolescents commonly asked about sexual acts and practices46,47 physical and sexual development,47 abortion,40 and contraception and unplanned pregnancy.40,47 However, a comprehensive array of SRH topics was mentioned in adolescents’ texts.

    View this table:
    TABLE 1

    Study Characteristics and Results for mHealth Health Promotion Campaigns

    Health promotion campaigns that provided on-demand or pushed out mobile phone messages were found to be highly acceptable to young people20,21,29,32,41,43–45,55 because they liked the confidentiality of mobile phone communication30 and found the SRH content simple to understand,21,30 informative,21,41,55 and easily shared.21,30 Furthermore, research on these campaigns along with a study on a mobile phone curriculum addition53 (Table 2) demonstrated that mHealth intervention exposure was associated with increased sexual health knowledge and awareness,33,43,45,53 lower rates of unprotected sex and higher rates of condom use,42,53,55 and greater STI testing.45

    View this table:
    TABLE 2

    Study Characteristics and Results for mHealth Curriculum Additions

    Several studies of health promotion campaigns investigated levels of mHealth program access among adolescents and lower-income and minority subgroups. Results pointed to a few programs that have successfully reached the general youth population in Africa20,30,46 and specific youth subgroups at higher risk of negative SRH outcomes in the United States.40,44 For example, more than half of the Planned Parenthood Federation of America (PPFA) Chat/Text program users in year 1 were African American, Latino, or from other ethnic or racial minority groups,40 and the Mobile for Reproductive Health (m4RH) program in Kenya found that 22% of users were ≤19 years old, and an additional 56% were 20 to 29 years old.30 On the other hand, research on Text4Baby in the United States showed that younger women with lower income and education were less likely to enroll in the subscription-based text message program for pregnant or parenting women than older, higher-income, and better-educated women.32

    Studies of mHealth applications for screening and follow-up for STIs (Table 3) documented improved submission of biological samples for screening in Australia36 and the Netherlands37 and timely recall and treatment of youth who test positive for STIs in New Zealand,56 Australia,38 and the United States.39,54 An important finding from the Stamp Out Chlamydia program in Australia is that combining text messages with a small financial incentive to encourage screening resulted in a dramatically reduced time period for recruitment, from collecting 638 specimens in 6 months to collecting 472 specimens in just 4 days.36 Finally, 2 studies of HPV vaccination reminders sent via SMS to parents or teens in the United States yielded higher rates of receiving second and third doses of the HPV vaccine and more timely completion of the HPV vaccine series.34,35

    View this table:
    TABLE 3

    Study Characteristics and Results for mHealth Screening and Follow-Up Service Utilization

    Using the mobile phone to place calls to adolescent patients to conduct provider counseling (Table 4) appeared to have limited utility. Two RCTs tested the impact of cell phone calls as a mechanism to improve adolescents’ contraception use.26,29 Both studies took place in the United States. In the California study, calls to 805 adolescents were difficult to complete, and there was no significant impact on contraceptive use, attendance or satisfaction with the clinic, or pregnancy and STI rates29; in the Texas study, mobile phone calls to 1115 young people showed no significant impact on adherence to oral contraceptive pills or condom use at last intercourse.26 A third study of 249 adolescent mothers in Washington, DC that relied on mobile phone calls alone showed low feasibility, with only half of the sessions completed and nonsignificant outcome results from intent-to-treat analyses.31 The remaining program that relied on this intervention approach targeted HIV-positive youth and demonstrated a significant impact on medication adherence and viral load, although the sample size was only 37 participants.48

    View this table:
    TABLE 4

    Study Characteristics and Results for mHealth Provider Counseling

    In contrast, interventions that used text messaging as the primary strategy to increase patient adherence (Table 5) were associated with increased oral contraceptive pill knowledge28 and continuation27 and ART adherence in a small observational study of 87 HIV-positive youth.50

    View this table:
    TABLE 5

    Study Characteristics and Results for mHealth Patient Adherence Programs

    Range and Quality of Evidence

    Articles included in the review reflected study designs across the research spectrum along with variable quality of research reporting (Fig 2). RCTs (n = 9) on average met nearly half (47%) of the essential mHealth criteria and the highest percentage of methodological criteria (93%) of all study designs. Quasiexperimental studies (n = 11) on average met the lowest percentage of essential mHealth criteria (35%) but 80% of methodological criteria. Observational studies (n = 10) on average met 40% of essential mHealth criteria and 73% of methodological criteria. Descriptive studies (n = 5) on average met nearly half of the mHealth criteria (47%) but only 82% of methodological criteria.

    FIGURE 2
    FIGURE 2

    Percentage of mERA reporting criteria met, by article and study design.

    Across all 35 studies, fewer criteria for essential mHealth reporting were met than criteria for methodological reporting. In the mERA checklist for mHealth reporting, an average of 41% (range 14%–79%) of criteria was achieved among all 35 studies (Fig 3). The mHealth criteria least commonly reported were contextual adaptation (11%) and cost assessment (17%). Only 3 mHealth reporting criteria were met in more than half of studies: intervention delivery (91%), intervention content (60%), and infrastructure (57%). In the mERA reporting and methodology checklist, an average of 82% (range 52%–100%) of criteria were met across all 35 studies (Fig 4). However, only about half of all graded articles met the criteria for assessing bias, calculating sample size, or having a comparator, and only one-third met criteria for presentation of the study logic model or consideration of generalizability of research findings.

    FIGURE 3
    FIGURE 3

    Percentage of articles that met mERA essential mHealth criteria. HIS, health information system.

    FIGURE 4
    FIGURE 4

    Percentage of articles that met mERA reporting and methodology criteria.

    Sample sizes and recruitment strategies were diverse, reflecting varied study designs and study aims. Sample sizes ranged from 8 respondents in a study to improve medication adherence among HIV-positive youth in California51 to 52 628 youth who were contacted to undergo chlamydia screening in an observational study in the Netherlands.37 Most studies recruited youth participants from health care facilities and clinics, several used community organizations and schools, and population-based studies relied on national registries, mass media advertising, and community events such as music festivals.

    Discussion

    mHealth Program Strategies

    The diversity and ingenuity of mHealth intervention programs identified in this review reflect how ASRH professionals are embracing mobile phones to improve adolescents’ health at myriad levels of the health care system. The interventions identified for this review aimed to promote positive and preventive SRH behaviors, increase adoption and continuation of contraception, support medication adherence for HIV-positive young people, support teen parents, and encourage use of health screening and treatment services. Mobile phones were used to increase health program reach to adolescents and ethnic and minority subgroups, increase confidentiality in providing sensitive SRH information to young people, and provide a supportive “friend in your pocket” who reminds and encourages good health.

    The large majority of mHealth interventions for ASRH relied on SMS platforms. Notably, only 4 mHealth programs included in this review used other technological communication formats in place of or in addition to SMS. From a programmatic lens this is a strategic and defensible choice because SMS remains the most frequently used mobile phone communication format among youth in the world and is often cost-effective, costing just pennies per text at implementation.2,5,57 However, text messaging requires clear and concise content within the 160-character restrictions of SMS and basic literacy for reading and understanding message content. Overall, mHealth interventions demand substantial attention to the user interface and content delivery, yet there is limited knowledge of best practices in mobile phone communication for health promotion.58 Because smartphone and Internet adoption is increasing globally, ASRH professionals should give greater consideration to message content, developing and testing additional communication formats, and criteria for evaluating these innovations.

    Summary of Evidence

    Although the mHealth field has been criticized for producing limited evidence about efficacy and effectiveness of mHealth interventions,59–61 a variety of robust research designs and methods were used in the 35 studies we identified. The 9 RCTs tested the impact of the mHealth intervention on SRH knowledge, sexual behavior, medication adherence, and contraception use, among other ASRH outcomes. Many of the 11 quasiexperimental studies focused on quality improvement of health service delivery and relied on uptake of health screening and treatment services to assess effectiveness of the mHealth intervention. The 10 observational research studies tended to focus on implementation of the mHealth program to track reach and adoption by using a variety of methods such as electronic data monitoring, analysis of national registry data, in-person interviews, and phone calls to participants. The 5 descriptive studies used qualitative methods such as focus group discussions but also content analyses of SRH questions posed by adolescents to assess reactions to intervention content or delivery. This variety of research designs, methods, and aims indicates the development of a robust evidence base at the intersection of mobile phones and ASRH.

    Findings from the reviewed studies provide support for distinct uses of mobile phones to improve ASRH. First, health promotion campaigns implemented with text messaging evidenced robust acceptability and relevance for young people globally and led to improved SRH knowledge, less unprotected sex, and more STI testing. Additionally, young people across races and genders accessed these health promotion programs, suggesting excellent reach into the general youth population and key youth subgroups. Data from both higher-income countries and lower-income countries (LICs) suggests widespread youth access, although caution is needed in reaching conclusions about young people in LICs because few of the included studies were conducted in these settings. Second, leveraging mobile phones to increase youth contact for STI screening and follow-up yielded higher rates of screening and recall and more timely and complete STI treatment and vaccination. These results were found across this body of research conducted in Australia, the Netherlands, New Zealand, and the United States. Third, using text messaging to increase adolescent patient adherence to medication (oral contraceptive pills and ART) was shown to be promising in experimental research conducted with adolescents in the United States. However, using mobile phone calls to provide adolescent patient counseling was ineffective, except for 1 small study of HIV-positive young people. Therefore, results from this review suggest that programs that aim to improve adolescents’ adherence to medication should use text messaging rather than phone calls for reminders and support and that more research should be conducted in this important area.

    mERA Checklist

    The mERA checklist provided a valuable platform for assessing the range and quality of reporting on mHealth interventions for ASRH. Notably, twice the percentage of mERA reporting and methodology criteria were met (81%) compared with essential mHealth criteria (41%), reflecting a high degree of reporting and methodology quality in the 35 reviewed studies and a lower level of reporting completeness on essential features of the mHealth intervention. Guidelines for research reporting are widely available, and our results suggest high dissemination of reporting standards regardless of study design. On the other hand, reporting on mHealth programs is new, and the mERA checklist is the first reporting tool available for complete and transparent reporting on mHealth intervention research. Therefore, low scores for essential mHealth reporting are unsurprising. Increased dissemination and adoption of the mERA checklist will facilitate better reporting and improved ability to synthesize evidence on mHealth interventions.

    Only 3 articles in this review studied mHealth interventions for young people in LICs.20,30,46 The dearth of peer-reviewed evidence from LIC contexts is concerning, especially in light of the high use of mobile phones in these settings and existing reports that have identified many mobile phone interventions in LICs.62,63 Robust research is needed to make evidence-based recommendations about the strategic use of mobile phones to improve ASRH in LICs, where limited resources make the need for evidence about impactful and cost-effective programs even more pressing. It is possible that our search strategy failed to identify peer-reviewed studies from LICs, although the global call for resources was disseminated through numerous channels to tap health researchers and programs in both high-income countries and LICs. In addition, we may have inadvertently excluded eligible articles during screening, and relevant studies may have been discounted because they were not published in peer-reviewed journals or in English, in accordance with our study eligibility requirements. Finally, the mERA checklist is in its infancy, and this review is the first to apply the criteria in their entirety and with some of the rigor of the PRISMA guidelines, and therefore mERA grading results should be considered with caution.

    Conclusions

    This review highlights many innovative, youth-engaging, and effective uses of mobile phones to improve ASRH globally, but room remains for additional evidence and innovation. Research on mHealth interventions increasingly uses robust research designs and is accumulating evidence about the potential impact on ASRH knowledge, behavior, and service utilization. Yet the evidence base would benefit from larger sample sizes, more experimental studies, and primary outcomes focused on a variety of SRH norms and behaviors. Conducting this research in LICs is imperative.

    Additional research also is needed to determine the optimal communication format for mobile phone interventions for ASRH. Data on the cost and cost-effectiveness of mHealth interventions for improving ASRH outcomes, along with cost-effectiveness data comparing mobile phones with other communication channels (such as in-person counseling or community outreach events) also would be beneficial. Finally, as the field matures, we hope the mERA checklist will serve as an important tool to support mHealth evidence evaluation, synthesis, and generation of best practices for adolescents’ health.

    Acknowledgments

    We thank Kate Plourde for support with gathering resources and abstracting studies, and Garret Mehl, Tigest Tamrat, and Lianne Gonsalves for support on search terms and the global call for resources. Details of how to obtain additional data from the study (codebook and dataset) are available from the corresponding author.

    Footnotes

      • Accepted June 29, 2016.
    • Address correspondence to Kelly L. L’Engle, PhD, MPH, School of Nursing and Health Professions, University of San Francisco, 2130 Fulton St, San Francisco, CA 94117. E-mail: klengle{at}usfca.edu

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: The World Health Organization, Department of Reproductive Health and Research, funded the review. Additional support was provided by the US Agency for International Development (USAID) through the Knowledge for Health project. The funders had no influence on the process or conclusions of the article. The views expressed are those of the authors and not necessarily those of the World Health Organization or USAID. Dr Agarwal and Ms Mangone were supported by the FHI360-UNC Research Fellowship.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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    Mobile Phone Interventions for Adolescent Sexual and Reproductive Health: A Systematic Review
    Kelly L. L’Engle, Emily R. Mangone, Angela M. Parcesepe, Smisha Agarwal, Nicole B. Ippoliti
    Pediatrics Sep 2016, 138 (3) e20160884; DOI: 10.1542/peds.2016-0884
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