Evaluation of quality of life in schoolchildren with a history of early severe malnutrition

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De Grandis, P.A. Armelini, E. Cuestas" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E.S." "apellidos" => "De Grandis" "email" => array:1 [ 0 => "esdegrandis@msn.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P.A." "apellidos" => "Armelini" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Cuestas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Medicina, Universidad Católica de Córdoba, Córdoba, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Privado INICSA-CONICET, Cátedra de Estadística Médica, Facultad de Medicina, Universidad Católica de Córdoba, Córdoba, Argentina" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación de la calidad de vida en escolares con antecedentes de desnutrición temprana severa" ] ] "textoCompleto" => "IntroductionThe risk of mortality in severe malnutrition is 5%,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and it is estimated that over one third of deaths in children younger than 5 years can be attributed to malnutrition.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Cognitive development and learning may be affected beyond the period of acute complications. Severe malnutrition before age 3 years (a critical period in brain development) may have sequelae such as delays in cognitive development and school failure.<a class="elsevierStyleCrossRefs" href="#bib0005">1–4</a> Nutrients modify brain plasticity and function, and nutritional deficiencies produce changes in signalling cascades that delay myelination and result in a reduced number of neurons, altering neural structure and function.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>Other factors such as poverty, infection, hospitalisation, and parental level of education may have a negative influence on cognitive development and academic performance.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Early alterations in the mother-infant interaction may cause or exacerbate deficiencies related to malnutrition.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> These sequence of alterations in severe malnutrition has consequences on the development, learning, and interpersonal relationships of over half of the surviving children.<a class="elsevierStyleCrossRefs" href="#bib0005">1–8</a> The reduced ability of the individual to interact with the environment and with other individuals may limit his or her potential to have a healthy, happy, and productive life.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a>Our working hypothesis was that schoolchildren with a history of early malnutrition have biological, psychological, and psychosocial sequelae, and since quality of life is intimately related to these developments, the evaluation of the different dimensions measured by the health-related quality of life scale (HRQoL) would yield significantly lower values in this group of patients.It is now recognised that individuals with the same objective health status can report very different subjective quality of life due to differences in resiliency and adjustment skills.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> The HRQoL assesses the impact of health in other dimensions of human experience, such as personal achievement, satisfaction, wellbeing, happiness, and self-esteem.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>Until recent years, organisation of care was based on mortality rates, population diseases, and the cost-benefit of preventing or curing the latter.<a class="elsevierStyleCrossRefs" href="#bib0050">10–13</a> The World Health Organization (WHO) has acknowledged the critical link between physical and psychosocial health. In recent decades, the assessment of HRQoL has started to consider the individual from an integral perspective, measuring the impact of disease from the perspective of the patient or his or her family.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a>For the above reasons, the aim of this study was to assess the impact on HRQoL in its physical, emotional, social, and school dimensions from the perspective of the parents of children with a history of early severe malnutrition, measured using the Spanish version of the Pediatric Quality of Life Inventory, Version 4.0 Generic Core Scale<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> (PedsQL) validated for Argentina.Patients and methodsWe designed a comparative study of a population of children of both sexes aged 5 to 12 years that included 29 patients with a history of severe malnutrition before age 2 years, and excluded 19 patients with severe malnutrition associated to chronic disease. We defined severe malnutrition<a class="elsevierStyleCrossRef" href="#bib0085">17</a> as: weight-for-length <−3SD (or <70% of the ideal weight for length), height-for-age <−3 SD (or <85% of the ideal height for age) or malnutrition with symmetrical oedema. We collected the socioeconomic and anthropometric data retrospectively from the medical records of patients. The sample was obtained by successive sampling based on hospital records from between January 1997 and June 2005, and then we visited the respective families at their homes or contacted them by phone when a visit was not possible. In administering the quality of life questionnaires to the parents, children with a history of early severe malnutrition were considered the study group, and their healthy school-aged siblings the control group. The interviews took place between March 2009 and May 2010. We calculated the minimum sample size for a power of 95%, a 95% confidence interval, and an accuracy of 1% in estimating a difference in the total PedsQL score of at least 2 points (out of a total of 52).There is evidence that the survey can be administered to low-income populations and can adequately discriminate between healthy and diseased children.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>A single researcher performed the interviews in person or by telephone, whichever applied, confirming the data collected from the medical history, obtaining informed consent, and giving the survey to the respondent (father, mother, or caregiver) for its completion.We collected data on age; sex; socioeconomic status (SES) described according to the index defined by the Centro de Estudios sobre Nutrición Infantil (Centre for the Study of Child Nutrition [CESNI]),<a class="elsevierStyleCrossRef" href="#bib0090">18</a> modified in the Córdoba, lactancia, crecimiento y desarrollo (CLACyD) study and summarised into 3 strata: (1) High and middle, (2) low and (3) Very low<a class="elsevierStyleCrossRef" href="#bib0095">19</a>; maternal level of education, single- or two-parent household; the child's school level; and current anthropometric measurements (weight and height recorded in the charts of the health care centre that provided care for the child).We assessed the HRQoL using the PedsQL, considering all 23 items for the global score, arranged in four multidimensional scales – physical, emotional, social, and school – and two summary scores – for psychosocial health (the average of the last three dimensions) and for physical health (which corresponded to the physical dimension). Due to the poor cognition characteristics expected in our patients and to the difficulties that children aged 5–7 years have in understanding and completing the questionnaire, described by Roizen et al.,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> we used the parent-proxy version for parents of children 5–7 years and children 8–12 años,<a class="elsevierStyleCrossRefs" href="#bib0075">15,16,20</a> with 5-point Likert scales (from 0: never a problem to 4: always a problem). The parent responses had to refer to the month preceding the administration of the survey (one month recall period). Subsequently, the items were reverse-scored and transformed to a 0–100 scale (lower to higher HRQoL).We described continuous variables with normal distributions as mean±standard deviation, and those with non-normal distributions as medians and ranges. Discrete variables were expressed as percentages for a 95% CI. We used Student's t-test or the Kruskall–Wallis test, when applicable, to compare continuous variables, and the chi squared test to compare discrete variables. The level of statistical significance was set at P<.05.The study was assessed and approved by the Comité Institucional de Ética de Investigación en Salud (Institutional Ethics Committee for Health Research [CIEIS]) of the Polo Sanitario area and the Consejo de Evaluación Ética de Investigación en Salud (Ethical Evaluation Board for Health Research [CoEIS]), of the Ministerio de Salud (Health Ministry) of the government of Córdoba (Argentina). It has been entered in the Registro Provincial de Investigaciones en Salud (Provincial Registry of Health Studies [REPIS]), of the Ministerio de Salud of the government of the province of Cordoba (Argentina).We obtained the informed consent of the parents who responded to the survey, explaining the objective of the study, the possible link between malnutrition and quality of life, and underscoring the confidentiality of the data.ResultsWe reviewed 357 medical histories with a diagnostic code of malnutrition or severe malnutrition, and identified 48 patients that met the inclusion criteria based on admissions data. After applying the exclusion criteria, we obtained a sample of 29 eligible patients. Two of the home addresses were not correct, and two families refused to participate: four families out of 29 (13/8%; 95% CI, 3.8–31.6). We included 25 patients in the study group and 28 healthy school-aged siblings.The HRQoL assessment was performed in 53 school-aged children from 25 families (25 children in the study group [47.2%; 95% CI, 33.5–62.6] and 28 children in the control group [52.8; 95% CI, 52.8–67.2]). The time that had elapsed since the diagnosis of malnutrition ranged from 3.5 to 9.9 years.The data of the sociodemographic and baseline characteristics of the sample are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The current anthropometric measurements showed a mean weight z score of −1.36 (±0.17) in the study group and −0.49 (±0.20) in the control group (P<.0500). In the study group, the mean height z score was −1.44 (±1.50) vs. −1.33 (±0.90) in the control group (P=.0600).The HRQoL scores obtained with the PedsQL scale in children with a history of malnutrition, compared to their healthy siblings, were: global score 80.82±1.94 vs 89.18±1.84 (P=.0001), physical health dimension 87.75±3.37 vs 94.75±1.87 (P=.0001), psychosocial health 77.77±2.90 vs 86.57±1.42 (P=.0001), emotional dimension 67.80±4.40 vs 78.75±2.96 (P=.0001), social dimension 88.80±3.05 vs 95.71±1.52 (P=.0001), and school dimension 74.58±3.80 vs 85.00±3.51 (P=.0001) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe main finding of this study was that early severe malnutrition was significantly associated with a considerable reduction in quality of life during school-age years in all areas studied (physical dimension/health and psychosocial health scores, and emotional, social, and school dimensions). To the best of our knowledge, this is the first report of this kind.Malnutrition in young children continues to be a serious public health problem in our country and across the world. Globally, there are 165 million children stunted by malnutrition, and the prevalence of wasting is 8%, according to a report published by the WHO in 2012.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> In Argentina, the prevalence of severe malnutrition ranges from 1.9%<a class="elsevierStyleCrossRef" href="#bib0105">21</a> to 3.9%.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Sequelae of the central nervous system contribute to delays in skill development, learning disabilities, impaired adjustment skills, and loss of educational and occupational opportunities. In the long term, malnourished children will not have the same professional opportunities; human capital and productivity are affected in adulthood.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> In 1973, Cravioto described the worst consequence of early malnutrition, its spiral effect: survivors of malnutrition will raise children under conditions that will give rise, almost inevitably, to a new generation of malnourished individuals.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> The demographic data of the families in our sample revealed that they belonged to a socially disadvantaged group, with households typically sustained by informal employment. Most mothers had only completed elementary education. These sociodemographic circumstances in our patients, which predated participation in the study, carry a risk of non-organic malnutrition.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a>Other family and social factors present among the respondents and associated with nutritional neglect and risk were, among others, employment instability,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> poverty,<a class="elsevierStyleCrossRefs" href="#bib0095">19–29</a> single-parent household,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> and degree of overcrowding. Kleinman described children with insufficient nutrition and hunger who showed psychosocial dysfunction more frequently than those of the same communities that did not report similar experiences.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>Our patients were severely malnourished at an early age, with risk of serious sequelae in the mid- and long-term. In current anthropometric measurements, the mean z score for weight and height in cases and controls shows deviations lower than ≤2, and while height is multifactorial, the finding of a lower height z score in cases compared to their control siblings seemed to suggest a chronic evolution.Falling behind in school occurred in one fifth of participants, including cases and controls. The regression analysis performed by Alaimo on 3286 children and 2063 adolescents with insufficient nutrition revealed that they had lower arithmetic scores and were more likely to have repeated a grade, have seen a psychologist, and have had difficulty getting along with their peers.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> Sameroff studied the intelligence scores of a group of children aged 4 to 13 years in relation to family and social risk factors, and found that the lowest intelligence coefficients were associated with a collection of factors rather than to isolated ones.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> The low level of maternal educational attainment and unskilled labour as the source of income may have contributed to malnutrition in our sample, and therefore to poor academic achievement in study participants. Cases and controls in our study share the same risk factors for falling behind in school, yet children with a history of malnutrition scored lower on the school dimension. From the perspective of parents, this finding could be explained by combined emotional and social integration challenges that would add to the barriers to academic achievement.The results obtained by applying the PedsQL 4.0 scale to 25 patients with a history of severe malnutrition and 28 controls showed differences between the groups that may be related to the effect of early malnutrition on HRQoL in patients that had been affected by the condition.The work of Roizen, carried out in Argentina with patients of sociodemographic characteristics similar to those of our patients, allows for comparisons based on belonging to a low stratum of SES and maternal educational level.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> The study analysed 287 families with children and adolescents that had chronic diseases, comparing the perceived HRQoL as reported by children and adolescents, parents, and the treating physicians. There was agreement between the HRQoL reports of parents and children, and lower scores in the reports by physicians.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>When we analysed the four dimensions and the physical and psychosocial health scores for the HRQoL reports by the parents, we found differences between malnourished and healthy children. This was the main finding of our study.Since there are no previous studies on HRQoL in malnourished children, comparisons may be made with other research on chronic conditions associated with malnutrition: cystic fibrosis, gastrointestinal diseases,<a class="elsevierStyleCrossRef" href="#bib0165">33</a> cerebral palsy,<a class="elsevierStyleCrossRef" href="#bib0165">33</a> cancer<a class="elsevierStyleCrossRef" href="#bib0080">16</a> and AIDS.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>The global HRQoL score, and the physical and psychosocial health scores in healthy children were similar to those reported by Varni for children in developed countries,<a class="elsevierStyleCrossRefs" href="#bib0075">15–33</a> and higher than those reported by Roizen for Argentina<a class="elsevierStyleCrossRef" href="#bib0080">16</a>.In all our comparisons with other studies, the physical health score in the malnourished children was higher, an unexpected result given that the motor sequelae of malnutrition mainly affect fine motor skills,<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> while in the conditions they are compared to, physical deterioration is often associated with the chronic diseases mentioned above.<a class="elsevierStyleCrossRefs" href="#bib0080">16–33</a>The dimensions that we considered most important in the context of our study were the emotional, social and school dimensions, which may be affected in malnourished children.The psychosocial health scores in healthy children were similar to those reported in studies by Varni<a class="elsevierStyleCrossRefs" href="#bib0075">15–33</a> in other countries, and higher than those reported by Roizen for Argentina.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> The scores of malnourished children in our sample were similar to those reported for children with chronic conditions.<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a>Our working hypothesis was confirmed: early malnutrition can affect HRQoL in children due to its impact on wellbeing, happiness, and self-esteem. Galler reported that in the absence of appropriate interventions to manage malnutrition, compromised behavioural function may persist long beyond the episode, have a lasting impact on survivors, and increase the cost to society.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> The comparison of HRQoL in children with a history of severe malnutrition and their healthy siblings can contribute to elucidating the consequences of nutrient deficiencies during critical periods of development.Even in extreme poverty, there can be protective factors such as a mother's care, social support networks, and the skill to adapt to unfavourable environments.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> It was the parents of the patients and the healthy siblings of those patients that filled out the questionnaires, so the social, economic, and cultural conditions are the same, and intrafamilial differences in HRQoL cannot be accounted for.Were there early problems in attachment in malnourished children that influenced the care that they received? Did malnourished children have physiological or psychological characteristics that stunted their growth? If so, could this fact have affected their HRQoL? Research on the psychological and sociological features of these families could provide answers to these questions.Our patients may not have reached their developmental potential due to malnutrition. The care received by children with a history of malnutrition has an impact on their personal futures and also on society, where the spiral effect will propagate the consequences of the nutritional deficiencies they experienced for generations. The assessment of HRQoL should be part of the holistic care of these patients, in order to adjust treatment as needed and promote parent involvement in care.In describing HRQoL in children with severe malnutrition, this study suggests a way to make a more thorough follow up of the evolution of sequelae. It would also be possible to study whether the malnutrition associated to chronic conditions can contribute to a reduction in the quality of life in the children who suffer them.Some strengths of this study are that it is the first study that describes the association between malnutrition and a reduction in quality of life, with few losses to follow-up and recovery, resulting in a strong statistical significance.There are limitations to this study, as the initial data were collected retrospectively, which could lead to missing data bias, recall bias, and selection bias.The results of this study show that patients with a history of early severe malnutrition had a significant reduction in HRQoL compared to their healthy siblings in the areas of physical, psychosocial, emotional, social, and school functioning.FundingThis study is part of the Programa de Evaluación de la Calidad de Vida en los Niños (Programme for the Evaluation of Quality of Life in Children) of the Universidad Católica de Córdoba (Argentina).Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres388687" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec367273" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres388686" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y método" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec367274" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-31" "fechaAceptado" => "2013-11-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec367273" "palabras" => array:3 [ 0 => "Child nutrition disorders" 1 => "Child development disorders" 2 => "Quality of life" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec367274" "palabras" => array:3 [ 0 => "Trastornos de la nutrición del niño" 1 => "Discapacidades del desarrollo" 2 => "Calidad de vida" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionSevere malnutrition in young children may lead to long-term complications, in particular learning and psychosocial disorders linked to health related quality of life (HRQOL). The aim of this study was to evaluate HRQOL in children whit a history of severe malnutrition before 2 years of life, expecting to find lower scores in these patients. Materials and methodsA comparative study was performed on schoolchildren between 5 and 12 years with a history of early severe malnutrition, excluding those with chronic diseases. The Controls were healthy siblings of patients. The sample size was estimated as 26 subjects per group (Total=52). Sociodemographic variables were recorded and the HRQOL was assessed with PedsQL4.0. Chi square and Student t test were applied. Significance level: P<.05. ResultsA total of 25 patients and 28 controls were studied. The HRQOL scores obtained from PedsQL for children with history of malnutrition, compared with their healthy siblings, were: Total: 80.82±1.94 vs 89.18±1.84 (P<.0001), physical health/dimension: 87.75±3.37 vs 94.75±1.87 (P<.0001), psychosocial health: 77.77±2.90 vs 86.57±1.42 (P<.0001), emotional dimension: 67.80±4.40 vs 78.75±2.96 (P<.0001), social dimension: 88.80±3.05 vs 95.71±1.52 (P<.0001), and school dimension: 74.58±3.80 vs 85.00±3.51 (P<.0001). ConclusionsPatients with a history of early severe malnutrition, showed significantly lower HRQOL scores compared with controls." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa desnutrición severa en niños pequeños produce secuelas a largo plazo, especialmente trastornos del aprendizaje y de adaptación psicosocial. Dichos aspectos están vinculados con la calidad de vida relacionada a la salud (CVRS). La calidad de vida en niños desnutridos no ha sido suficientemente estudiada. El objetivo fue evaluar CVRS en escolares con antecedentes de desnutrición severa antes de los 2 años de vida, estimando encontrar puntuaciones más bajas en estos pacientes. Material y métodoEn un estudio comparativo se incluyeron escolares de 5 a 12 años con antecedentes de desnutrición severa y se excluyeron aquellos con enfermedades crónicas. Los controles fueron los hermanos sanos de los pacientes. Muestreo por conveniencia; tamaño muestral estimado en 26 sujetos por grupo (52 en total). Se midieron CVRS con formulario PedsQL4.0 y variables sociodemográficas. Las diferencias se analizaron con la prueba de la Chi cuadrado y el test de la «t» de Student. El nivel de significación fue: p<0,05. ResultadosSe estudiaron 25 pacientes y 28 controles. Las puntuaciones de CVRS obtenidas por los niños con antecedentes de desnutrición, en comparación con sus hermanos sanos, fueron: total 80,82±1,94 vs 89,18±1,84 (p=<0,0001), salud/dimensión física: 87,75±3,37 vs 94,75±1,87 (p=<0,0001), salud psicosocial: 77,77±2,90 vs 86,57±1,42 (p=<0,0001), dimensión emocional: 67,80±4,40 vs 78,75±2,96 (p=<0,0001), dimensión social: 88,80±3,05 vs 95,71±1,52 (p=<0,0001), dimensión escolar: 74,58±3,80 vs 85,00±3,51 (p=<0,0001). ConclusionesLos pacientes con antecedentes de desnutrición severa temprana presentaron puntuaciones significativamente menores de CVRS comparados con los controles." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: De Grandis ES, Armelini PA, Cuestas E. Evaluación de la calidad de vida en escolares con antecedentes de desnutrición temprana severa. An Pediatr (Barc). 2014;81:368–373." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:4 [ 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"><td 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" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Study groupN (% [95% CI]) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Control groupN (% [95% CI]) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of participants</td></tr><tr title="table-row"><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">Participants \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">25/53 (47.2 [32.8–61.5]) \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">28/53 (52.8 [38.4–67.2]) \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">0.4334 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab598065.png" ] ] 1 => 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"><td 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">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Study group</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Control group</td></tr><tr title="table-row"><td 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" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Mean (range) SD \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Mean (range) SD \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age of participant</td></tr><tr title="table-row"><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">5–7 years \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">9/25 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.30 (4.93–5.90) 0.12 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4/28 \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">5.88 (5.18–6.66) 0.31 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8–12 years \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">16/25 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.74 (7.05–10.77) 0.4 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24/28 \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">10.01 (7.03–12.99) 0.32 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab598068.png" ] ] 2 => 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"><td 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" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Study group \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Control groupN (% [95% CI]) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex</td></tr><tr title="table-row"><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">Male \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">9/25 (36 [15.2–56.8]) \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">12/28 (43 [22.7–62.9]) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4706 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab598070.png" ] ] 3 => 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"><td 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" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Study group N (% [95% CI]) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Control group N (% [95% CI]) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Schooling</td></tr><tr title="table-row"><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">Age-appropriate level of schooling \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">20 (80 [59.2–93.3]) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (72 [57.2–92.8]) \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">0.5210 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab598069.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline sociodemographic characteristics of our sample for the study and control groups." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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"><td 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" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">N (% [95% CI]) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><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">Description of parents’ marital status</td></tr><tr title="table-row"><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">Married or two-parent family \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 (52 [30.4–73.5]) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other: single, separated \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 (48 [26.4–69.5]) \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">Mothers’ level of education</td></tr><tr title="table-row"><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">Illiterate \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 (4 [0.1–20.3]) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Did not complete elementary school \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 (8 [0.9–26.1]) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Completed elementary school \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 (84 [69.9–95.4]) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Completed secondary school \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">0 (0 [0–13.7]) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Completed college or tertiary degree \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 (4 [0.1–20.3]) \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">SES score</td></tr><tr title="table-row"><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">Stratum I \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 (8 [0.9–26.1]) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stratum II \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 (12 [2.5–31.2]) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stratum 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">20 (80 [59.2–93.2]) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab598066.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Sociodemographic characteristics of the 25 families in the sample." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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"><td 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" style="border-bottom: 2px solid black">Scale \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Study groupMean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Control groupMean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Global score \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">80.82±1.94 \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">89.18±1.84 \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"><.0001 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Health/physical dimension \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">87.75±3.37 \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">94.75±1.87 \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"><.0001 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Psychosocial health \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">77.77±2.90 \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">86.57±1.42 \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"><.0001 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emotional dimension \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">67.80±4.40 \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">78.75±2.96 \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"><.0001 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Social dimension \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">88.80±3.05 \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">95.71±1.52 \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"><.0001 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">School dimension \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">74.58±3.80 \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">85.00±3.51 \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"><.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab598067.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Description of the Spanish version of the PedsQL 4.0 scale for Argentina." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Malnutrition and brain development" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.R. Galler" 1 => "J.S. Shumsky" 2 => "P.J. Morgane" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Nutrition in pediatrics" "paginaInicial" => "196" "paginaFinal" => "212" "serieFecha" => "1997" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "UNICEFWHO-World Bank. Joint child malnutrition estimates" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "United Nations Children's Fund" 1 => "World Health Organization" 2 => "The World Bank" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2012" "editorial" => "UNICEF/WHO/The World Bank" "editorialLocalizacion" => "New York/Geneva/Washington, DC" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term effects of early kwashiorkor compared with marasmus: III. Fine motor skills" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.R. Galler" 1 => "F. Ramsey" 2 => "P. Salt" 3 => "E. Archer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Pediatr Gastroenterol Nutr" "fecha" => "1987" "volumen" => "6" "paginaInicial" => "855" "paginaFinal" => "959" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3119813" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does schooling buffer the effects of early risk" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Gorman" 1 => "E. Pollitt" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Child Dev" "fecha" => "1996" "volumen" => "67" "paginaInicial" => "314" "paginaFinal" => "326" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8625715" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effect of human diet on caudate volumes and IQ" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Isaacs" 1 => "D. Gadian" 2 => "S. Sabatini" 3 => "W. Chong" 4 => "B. Quinn" 5 => "B. 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Evaluation of quality of life in schoolchildren with a history of early severe malnutrition

Evaluación de la calidad de vida en escolares con antecedentes de desnutrición temprana severa

E.S. De Grandisa,b,

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esdegrandis@msn.com

Corresponding author.

, P.A. Armelinib, E. Cuestasc

a Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina

b Facultad de Medicina, Universidad Católica de Córdoba, Córdoba, Argentina

c Hospital Privado INICSA-CONICET, Cátedra de Estadística Médica, Facultad de Medicina, Universidad Católica de Córdoba, Córdoba, Argentina

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and nutritional deficiencies produce changes in signalling cascades that delay myelination and result in a reduced number of neurons&#44; altering neural structure and function&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Other factors such as poverty&#44; infection&#44; hospitalisation&#44; and parental level of education may have a negative influence on cognitive development and academic performance&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Early alterations in the mother-infant interaction may cause or exacerbate deficiencies related to malnutrition&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These sequence of alterations in severe malnutrition has consequences on the development&#44; learning&#44; and interpersonal relationships of over half of the surviving children&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;8</span></a> The reduced ability of the individual to interact with the environment and with other individuals may limit his or her potential to have a healthy&#44; happy&#44; and productive life&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Our working hypothesis was that schoolchildren with a history of early malnutrition have biological&#44; psychological&#44; and psychosocial sequelae&#44; and since quality of life is intimately related to these developments&#44; the evaluation of the different dimensions measured by the health-related quality of life scale &#40;HRQoL&#41; would yield significantly lower values in this group of patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is now recognised that individuals with the same objective health status can report very different subjective quality of life due to differences in resiliency and adjustment skills&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> The HRQoL assesses the impact of health in other dimensions of human experience&#44; such as personal achievement&#44; satisfaction&#44; wellbeing&#44; happiness&#44; and self-esteem&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Until recent years&#44; organisation of care was based on mortality rates&#44; population diseases&#44; and the cost-benefit of preventing or curing the latter&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;13</span></a> The World Health Organization &#40;WHO&#41; has acknowledged the critical link between physical and psychosocial health&#46; In recent decades&#44; the assessment of HRQoL has started to consider the individual from an integral perspective&#44; measuring the impact of disease from the perspective of the patient or his or her family&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">For the above reasons&#44; the aim of this study was to assess the impact on HRQoL in its physical&#44; emotional&#44; social&#44; and school dimensions from the perspective of the parents of children with a history of early severe malnutrition&#44; measured using the Spanish version of the Pediatric Quality of Life Inventory&#44; Version 4&#46;0 Generic Core Scale<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> &#40;PedsQL&#41; validated for Argentina&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We designed a comparative study of a population of children of both sexes aged 5 to 12 years that included 29 patients with a history of severe malnutrition before age 2 years&#44; and excluded 19 patients with severe malnutrition associated to chronic disease&#46; We defined severe malnutrition<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> as&#58; weight-for-length &#60;&#8722;3<span class="elsevierStyleHsp" style=""></span>SD &#40;or &#60;70&#37; of the ideal weight for length&#41;&#44; height-for-age &#60;&#8722;3 SD &#40;or &#60;85&#37; of the ideal height for age&#41; or malnutrition with symmetrical oedema&#46; We collected the socioeconomic and anthropometric data retrospectively from the medical records of patients&#46; The sample was obtained by successive sampling based on hospital records from between January 1997 and June 2005&#44; and then we visited the respective families at their homes or contacted them by phone when a visit was not possible&#46; In administering the quality of life questionnaires to the parents&#44; children with a history of early severe malnutrition were considered the study group&#44; and their healthy school-aged siblings the control group&#46; The interviews took place between March 2009 and May 2010&#46; We calculated the minimum sample size for a power of 95&#37;&#44; a 95&#37; confidence interval&#44; and an accuracy of 1&#37; in estimating a difference in the total PedsQL score of at least 2 points &#40;out of a total of 52&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">There is evidence that the survey can be administered to low-income populations and can adequately discriminate between healthy and diseased children&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A single researcher performed the interviews in person or by telephone&#44; whichever applied&#44; confirming the data collected from the medical history&#44; obtaining informed consent&#44; and giving the survey to the respondent &#40;father&#44; mother&#44; or caregiver&#41; for its completion&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We collected data on age&#59; sex&#59; socioeconomic status &#40;SES&#41; described according to the index defined by the Centro de Estudios sobre Nutrici&#243;n Infantil &#40;Centre for the Study of Child Nutrition &#91;CESNI&#93;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> modified in the C&#243;rdoba&#44; lactancia&#44; crecimiento y desarrollo &#40;CLACyD&#41; study and summarised into 3 strata&#58; &#40;1&#41; High and middle&#44; &#40;<span class="elsevierStyleSmallCaps">2&#41;</span> low and &#40;<span class="elsevierStyleSmallCaps">3&#41;</span> Very low<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#59; maternal level of education&#44; single- or two-parent household&#59; the child&#39;s school level&#59; and current anthropometric measurements &#40;weight and height recorded in the charts of the health care centre that provided care for the child&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We assessed the HRQoL using the PedsQL&#44; considering all 23 items for the global score&#44; arranged in four multidimensional scales &#8211; physical&#44; emotional&#44; social&#44; and school &#8211; and two summary scores &#8211; for psychosocial health &#40;the average of the last three dimensions&#41; and for physical health &#40;which corresponded to the physical dimension&#41;&#46; Due to the poor cognition characteristics expected in our patients and to the difficulties that children aged 5&#8211;7 years have in understanding and completing the questionnaire&#44; described by Roizen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> we used the parent-proxy version for parents of children 5&#8211;7 years and children 8&#8211;12 a&#241;os&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16&#44;20</span></a> with 5-point Likert scales &#40;from 0&#58; never a problem to 4&#58; always a problem&#41;&#46; The parent responses had to refer to the month preceding the administration of the survey &#40;one month recall period&#41;&#46; Subsequently&#44; the items were reverse-scored and transformed to a 0&#8211;100 scale &#40;lower to higher HRQoL&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We described continuous variables with normal distributions as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; and those with non-normal distributions as medians and ranges&#46; Discrete variables were expressed as percentages for a 95&#37; CI&#46; We used Student&#39;s <span class="elsevierStyleItalic">t</span>-test or the Kruskall&#8211;Wallis test&#44; when applicable&#44; to compare continuous variables&#44; and the chi squared test to compare discrete variables&#46; The level of statistical significance was set at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The study was assessed and approved by the Comit&#233; Institucional de &#201;tica de Investigaci&#243;n en Salud &#40;Institutional Ethics Committee for Health Research &#91;CIEIS&#93;&#41; of the Polo Sanitario area and the Consejo de Evaluaci&#243;n &#201;tica de Investigaci&#243;n en Salud &#40;Ethical Evaluation Board for Health Research &#91;CoEIS&#93;&#41;&#44; of the Ministerio de Salud &#40;Health Ministry&#41; of the government of C&#243;rdoba &#40;Argentina&#41;&#46; It has been entered in the Registro Provincial de Investigaciones en Salud &#40;Provincial Registry of Health Studies &#91;REPIS&#93;&#41;&#44; of the Ministerio de Salud of the government of the province of Cordoba &#40;Argentina&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We obtained the informed consent of the parents who responded to the survey&#44; explaining the objective of the study&#44; the possible link between malnutrition and quality of life&#44; and underscoring the confidentiality of the data&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">We reviewed 357 medical histories with a diagnostic code of malnutrition or severe malnutrition&#44; and identified 48 patients that met the inclusion criteria based on admissions data&#46; After applying the exclusion criteria&#44; we obtained a sample of 29 eligible patients&#46; Two of the home addresses were not correct&#44; and two families refused to participate&#58; four families out of 29 &#40;13&#47;8&#37;&#59; 95&#37; CI&#44; 3&#46;8&#8211;31&#46;6&#41;&#46; We included 25 patients in the study group and 28 healthy school-aged siblings&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The HRQoL assessment was performed in 53 school-aged children from 25 families &#40;25 children in the study group &#91;47&#46;2&#37;&#59; 95&#37; CI&#44; 33&#46;5&#8211;62&#46;6&#93; and 28 children in the control group &#91;52&#46;8&#59; 95&#37; CI&#44; 52&#46;8&#8211;67&#46;2&#93;&#41;&#46; The time that had elapsed since the diagnosis of malnutrition ranged from 3&#46;5 to 9&#46;9 years&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The data of the sociodemographic and baseline characteristics of the sample are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The current anthropometric measurements showed a mean weight <span class="elsevierStyleItalic">z</span> score of &#8722;1&#46;36 &#40;&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;17&#41; in the study group and &#8722;0&#46;49 &#40;&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;20&#41; in the control group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0500&#41;&#46; In the study group&#44; the mean height z score was &#8722;1&#46;44 &#40;&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;50&#41; vs&#46; &#8722;1&#46;33 &#40;&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;90&#41; in the control group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0600&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The HRQoL scores obtained with the PedsQL scale in children with a history of malnutrition&#44; compared to their healthy siblings&#44; were&#58; global score 80&#46;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;94 vs 89&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;84 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; physical health dimension 87&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;37 vs 94&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;87 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; psychosocial health 77&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;90 vs 86&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;42 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; emotional dimension 67&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;40 vs 78&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;96 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; social dimension 88&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;05 vs 95&#46;71<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;52 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; and school dimension 74&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;80 vs 85&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;51 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The main finding of this study was that early severe malnutrition was significantly associated with a considerable reduction in quality of life during school-age years in all areas studied &#40;physical dimension&#47;health and psychosocial health scores&#44; and emotional&#44; social&#44; and school dimensions&#41;&#46; To the best of our knowledge&#44; this is the first report of this kind&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Malnutrition in young children continues to be a serious public health problem in our country and across the world&#46; Globally&#44; there are 165 million children stunted by malnutrition&#44; and the prevalence of wasting is 8&#37;&#44; according to a report published by the WHO in 2012&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In Argentina&#44; the prevalence of severe malnutrition ranges from 1&#46;9&#37;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> to 3&#46;9&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Sequelae of the central nervous system contribute to delays in skill development&#44; learning disabilities&#44; impaired adjustment skills&#44; and loss of educational and occupational opportunities&#46; In the long term&#44; malnourished children will not have the same professional opportunities&#59; human capital and productivity are affected in adulthood&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> In 1973&#44; Cravioto described the worst consequence of early malnutrition&#44; its spiral effect&#58; survivors of malnutrition will raise children under conditions that will give rise&#44; almost inevitably&#44; to a new generation of malnourished individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The demographic data of the families in our sample revealed that they belonged to a socially disadvantaged group&#44; with households typically sustained by informal employment&#46; Most mothers had only completed elementary education&#46; These sociodemographic circumstances in our patients&#44; which predated participation in the study&#44; carry a risk of non-organic malnutrition&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Other family and social factors present among the respondents and associated with nutritional neglect and risk were&#44; among others&#44; employment instability&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> poverty&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;29</span></a> single-parent household&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and degree of overcrowding&#46; Kleinman described children with insufficient nutrition and hunger who showed psychosocial dysfunction more frequently than those of the same communities that did not report similar experiences&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Our patients were severely malnourished at an early age&#44; with risk of serious sequelae in the mid- and long-term&#46; In current anthropometric measurements&#44; the mean <span class="elsevierStyleItalic">z</span> score for weight and height in cases and controls shows deviations lower than &#8804;2&#44; and while height is multifactorial&#44; the finding of a lower height <span class="elsevierStyleItalic">z</span> score in cases compared to their control siblings seemed to suggest a chronic evolution&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Falling behind in school occurred in one fifth of participants&#44; including cases and controls&#46; The regression analysis performed by Alaimo on 3286 children and 2063 adolescents with insufficient nutrition revealed that they had lower arithmetic scores and were more likely to have repeated a grade&#44; have seen a psychologist&#44; and have had difficulty getting along with their peers&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Sameroff studied the intelligence scores of a group of children aged 4 to 13 years in relation to family and social risk factors&#44; and found that the lowest intelligence coefficients were associated with a collection of factors rather than to isolated ones&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The low level of maternal educational attainment and unskilled labour as the source of income may have contributed to malnutrition in our sample&#44; and therefore to poor academic achievement in study participants&#46; Cases and controls in our study share the same risk factors for falling behind in school&#44; yet children with a history of malnutrition scored lower on the school dimension&#46; From the perspective of parents&#44; this finding could be explained by combined emotional and social integration challenges that would add to the barriers to academic achievement&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The results obtained by applying the PedsQL 4&#46;0 scale to 25 patients with a history of severe malnutrition and 28 controls showed differences between the groups that may be related to the effect of early malnutrition on HRQoL in patients that had been affected by the condition&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The work of Roizen&#44; carried out in Argentina with patients of sociodemographic characteristics similar to those of our patients&#44; allows for comparisons based on belonging to a low stratum of SES and maternal educational level&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The study analysed 287 families with children and adolescents that had chronic diseases&#44; comparing the perceived HRQoL as reported by children and adolescents&#44; parents&#44; and the treating physicians&#46; There was agreement between the HRQoL reports of parents and children&#44; and lower scores in the reports by physicians&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">When we analysed the four dimensions and the physical and psychosocial health scores for the HRQoL reports by the parents&#44; we found differences between malnourished and healthy children&#46; This was the main finding of our study&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Since there are no previous studies on HRQoL in malnourished children&#44; comparisons may be made with other research on chronic conditions associated with malnutrition&#58; cystic fibrosis&#44; gastrointestinal diseases&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> cerebral palsy&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> cancer<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and AIDS&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The global HRQoL score&#44; and the physical and psychosocial health scores in healthy children were similar to those reported by Varni for children in developed countries&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;33</span></a> and higher than those reported by Roizen for Argentina<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In all our comparisons with other studies&#44; the physical health score in the malnourished children was higher&#44; an unexpected result given that the motor sequelae of malnutrition mainly affect fine motor skills&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> while in the conditions they are compared to&#44; physical deterioration is often associated with the chronic diseases mentioned above&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;33</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">The dimensions that we considered most important in the context of our study were the emotional&#44; social and school dimensions&#44; which may be affected in malnourished children&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The psychosocial health scores in healthy children were similar to those reported in studies by Varni<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;33</span></a> in other countries&#44; and higher than those reported by Roizen for Argentina&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The scores of malnourished children in our sample were similar to those reported for children with chronic conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Our working hypothesis was confirmed&#58; early malnutrition can affect HRQoL in children due to its impact on wellbeing&#44; happiness&#44; and self-esteem&#46; Galler reported that in the absence of appropriate interventions to manage malnutrition&#44; compromised behavioural function may persist long beyond the episode&#44; have a lasting impact on survivors&#44; and increase the cost to society&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The comparison of HRQoL in children with a history of severe malnutrition and their healthy siblings can contribute to elucidating the consequences of nutrient deficiencies during critical periods of development&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Even in extreme poverty&#44; there can be protective factors such as a mother&#39;s care&#44; social support networks&#44; and the skill to adapt to unfavourable environments&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> It was the parents of the patients and the healthy siblings of those patients that filled out the questionnaires&#44; so the social&#44; economic&#44; and cultural conditions are the same&#44; and intrafamilial differences in HRQoL cannot be accounted for&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Were there early problems in attachment in malnourished children that influenced the care that they received&#63; Did malnourished children have physiological or psychological characteristics that stunted their growth&#63; If so&#44; could this fact have affected their HRQoL&#63; Research on the psychological and sociological features of these families could provide answers to these questions&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Our patients may not have reached their developmental potential due to malnutrition&#46; The care received by children with a history of malnutrition has an impact on their personal futures and also on society&#44; where the spiral effect will propagate the consequences of the nutritional deficiencies they experienced for generations&#46; The assessment of HRQoL should be part of the holistic care of these patients&#44; in order to adjust treatment as needed and promote parent involvement in care&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In describing HRQoL in children with severe malnutrition&#44; this study suggests a way to make a more thorough follow up of the evolution of sequelae&#46; It would also be possible to study whether the malnutrition associated to chronic conditions can contribute to a reduction in the quality of life in the children who suffer them&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Some strengths of this study are that it is the first study that describes the association between malnutrition and a reduction in quality of life&#44; with few losses to follow-up and recovery&#44; resulting in a strong statistical significance&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">There are limitations to this study&#44; as the initial data were collected retrospectively&#44; which could lead to missing data bias&#44; recall bias&#44; and selection bias&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The results of this study show that patients with a history of early severe malnutrition had a significant reduction in HRQoL compared to their healthy siblings in the areas of physical&#44; psychosocial&#44; emotional&#44; social&#44; and school functioning&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0205" class="elsevierStylePara elsevierViewall">This study is part of the Programa de Evaluaci&#243;n de la Calidad de Vida en los Ni&#241;os &#40;Programme for the Evaluation of Quality of Life in Children&#41; of the Universidad Cat&#243;lica de C&#243;rdoba &#40;Argentina&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Severe malnutrition in young children may lead to long-term complications&#44; in particular learning and psychosocial disorders linked to health related quality of life &#40;HRQOL&#41;&#46; The aim of this study was to evaluate HRQOL in children whit a history of severe malnutrition before 2 years of life&#44; expecting to find lower scores in these patients&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A comparative study was performed on schoolchildren between 5 and 12 years with a history of early severe malnutrition&#44; excluding those with chronic diseases&#46; The Controls were healthy siblings of patients&#46; The sample size was estimated as 26 subjects per group &#40;Total<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>52&#41;&#46; Sociodemographic variables were recorded and the HRQOL was assessed with PedsQL4&#46;0&#46; Chi square and Student <span class="elsevierStyleItalic">t</span> test were applied&#46; Significance level&#58; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 25 patients and 28 controls were studied&#46; The HRQOL scores obtained from PedsQL for children with history of malnutrition&#44; compared with their healthy siblings&#44; were&#58; Total&#58; 80&#46;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;94 vs 89&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;84 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; physical health&#47;dimension&#58; 87&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;37 vs 94&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;87 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; psychosocial health&#58; 77&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;90 vs 86&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;42 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; emotional dimension&#58; 67&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;40 vs 78&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;96 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; social dimension&#58; 88&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;05 vs 95&#46;71<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;52 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; and school dimension&#58; 74&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;80 vs 85&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;51 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Patients with a history of early severe malnutrition&#44; showed significantly lower HRQOL scores compared with controls&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La desnutrici&#243;n severa en ni&#241;os peque&#241;os produce secuelas a largo plazo&#44; especialmente trastornos del aprendizaje y de adaptaci&#243;n psicosocial&#46; Dichos aspectos est&#225;n vinculados con la calidad de vida relacionada a la salud &#40;CVRS&#41;&#46; La calidad de vida en ni&#241;os desnutridos no ha sido suficientemente estudiada&#46; El objetivo fue evaluar CVRS en escolares con antecedentes de desnutrici&#243;n severa antes de los 2 a&#241;os de vida&#44; estimando encontrar puntuaciones m&#225;s bajas en estos pacientes&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En un estudio comparativo se incluyeron escolares de 5 a 12 a&#241;os con antecedentes de desnutrici&#243;n severa y se excluyeron aquellos con enfermedades cr&#243;nicas&#46; Los controles fueron los hermanos sanos de los pacientes&#46; Muestreo por conveniencia&#59; tama&#241;o muestral estimado en 26 sujetos por grupo &#40;52 en total&#41;&#46; Se midieron CVRS con formulario PedsQL4&#46;0 y variables sociodemogr&#225;ficas&#46; Las diferencias se analizaron con la prueba de la Chi cuadrado y el test de la &#171;t&#187; de Student&#46; El nivel de significaci&#243;n fue&#58; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 25 pacientes y 28 controles&#46; Las puntuaciones de CVRS obtenidas por los ni&#241;os con antecedentes de desnutrici&#243;n&#44; en comparaci&#243;n con sus hermanos sanos&#44; fueron&#58; total 80&#44;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;94 vs 89&#44;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;84 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; salud&#47;dimensi&#243;n f&#237;sica&#58; 87&#44;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;37 vs 94&#44;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;87 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; salud psicosocial&#58; 77&#44;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;90 vs 86&#44;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;42 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; dimensi&#243;n emocional&#58; 67&#44;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;40 vs 78&#44;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;96 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; dimensi&#243;n social&#58; 88&#44;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;05 vs 95&#44;71<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;52 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; dimensi&#243;n escolar&#58; 74&#44;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;80 vs 85&#44;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;51 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los pacientes con antecedentes de desnutrici&#243;n severa temprana presentaron puntuaciones significativamente menores de CVRS comparados con los controles&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; De Grandis ES&#44; Armelini PA&#44; Cuestas E&#46; Evaluaci&#243;n de la calidad de vida en escolares con antecedentes de desnutrici&#243;n temprana severa&#46; An Pediatr &#40;Barc&#41;&#46; 2014&#59;81&#58;368&#8211;373&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of participants</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Participants&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">25&#47;53 &#40;47&#46;2 &#91;32&#46;8&#8211;61&#46;5&#93;&#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">28&#47;53 &#40;52&#46;8 &#91;38&#46;4&#8211;67&#46;2&#93;&#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">0&#46;4334&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Control group</td></tr><tr title="table-row"><td 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" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Mean &#40;range&#41; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Mean &#40;range&#41; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age of participant</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#8211;7 years&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">9&#47;25&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
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                  \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
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                  \t\t\t\t">4&#47;28&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
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                  \t\t\t\t">5&#46;88 &#40;5&#46;18&#8211;6&#46;66&#41; 0&#46;31&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  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&#47;25&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">8&#46;74 &#40;7&#46;05&#8211;10&#46;77&#41; 0&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#47;28&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;01 &#40;7&#46;03&#8211;12&#46;99&#41; 0&#46;32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&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
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                  \t\t\t\t">9&#47;25 &#40;36 &#91;15&#46;2&#8211;56&#46;8&#93;&#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">12&#47;28 &#40;43 &#91;22&#46;7&#8211;62&#46;9&#93;&#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">0&#46;4706&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab598070.png"
              ]
            ]
            3 => 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"><td 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" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Study group <span class="elsevierStyleItalic">N</span> &#40;&#37; &#91;95&#37; CI&#93;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Control group <span class="elsevierStyleItalic">N</span> &#40;&#37; &#91;95&#37; CI&#93;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Schooling</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Age-appropriate level of schooling&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">20 &#40;80 &#91;59&#46;2&#8211;93&#46;3&#93;&#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">21 &#40;72 &#91;57&#46;2&#8211;92&#46;8&#93;&#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">0&#46;5210&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab598069.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Baseline sociodemographic characteristics of our sample for the study and control groups&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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"><td 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" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37; &#91;95&#37; CI&#93;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><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">Description of parents</span>&#8217; <span class="elsevierStyleItalic">marital status</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Married or two-parent family&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">13 &#40;52 &#91;30&#46;4&#8211;73&#46;5&#93;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other&#58; single&#44; separated&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 &#40;48 &#91;26&#46;4&#8211;69&#46;5&#93;&#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">Mothers</span>&#8217; <span class="elsevierStyleItalic">level of education</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Illiterate&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">1 &#40;4 &#91;0&#46;1&#8211;20&#46;3&#93;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Did not complete elementary school&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 &#40;8 &#91;0&#46;9&#8211;26&#46;1&#93;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Completed elementary school&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;84 &#91;69&#46;9&#8211;95&#46;4&#93;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Completed secondary school&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">0 &#40;0 &#91;0&#8211;13&#46;7&#93;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Completed college or tertiary degree&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">1 &#40;4 &#91;0&#46;1&#8211;20&#46;3&#93;&#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">SES score</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Stratum I&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 &#40;8 &#91;0&#46;9&#8211;26&#46;1&#93;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Stratum II&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">3 &#40;12 &#91;2&#46;5&#8211;31&#46;2&#93;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Stratum III&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">20 &#40;80 &#91;59&#46;2&#8211;93&#46;2&#93;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab598066.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Sociodemographic characteristics of the 25 families in the sample&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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"><td 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" style="border-bottom: 2px solid black">Scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Study groupMean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Control groupMean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Global score&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">80&#46;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;94&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">89&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;84&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">&#60;&#46;0001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Health&#47;physical dimension&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">87&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;37&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">94&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;87&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">&#60;&#46;0001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Psychosocial health&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">77&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;90&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">86&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;42&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">&#60;&#46;0001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emotional dimension&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">67&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;40&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">78&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;96&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
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2013.11.011

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	11	10	21
2024 October	42	57	99
2024 September	56	30	86
2024 August	56	50	106
2024 July	40	32	72
2024 June	44	20	64
2024 May	50	23	73
2024 April	33	30	63
2024 March	38	26	64
2024 February	38	20	58
2024 January	33	24	57
2023 December	53	19	72
2023 November	39	22	61
2023 October	67	30	97
2023 September	36	23	59
2023 August	34	15	49
2023 July	30	24	54
2023 June	34	34	68
2023 May	34	16	50
2023 April	32	12	44
2023 March	45	23	68
2023 February	40	16	56
2023 January	21	19	40
2022 December	57	22	79
2022 November	56	38	94
2022 October	37	37	74
2022 September	47	31	78
2022 August	57	44	101
2022 July	25	38	63
2022 June	74	28	102
2022 May	48	35	83
2022 April	37	50	87
2022 March	47	47	94
2022 February	38	35	73
2022 January	24	38	62
2021 December	26	35	61
2021 November	39	50	89
2021 October	41	51	92
2021 September	25	39	64
2021 August	29	56	85
2021 July	18	27	45
2021 June	28	30	58
2021 May	36	39	75
2021 April	67	40	107
2021 March	48	24	72
2021 February	41	18	59
2021 January	27	15	42
2020 December	43	20	63
2020 November	23	15	38
2020 October	31	11	42
2020 September	29	23	52
2020 August	23	12	35
2020 July	28	22	50
2020 June	18	13	31
2020 May	29	19	48
2020 April	33	14	47
2020 March	36	18	54
2020 February	27	18	45
2020 January	30	13	43
2019 December	45	17	62
2019 November	31	17	48
2019 October	19	10	29
2019 September	31	12	43
2019 August	65	24	89
2019 July	41	47	88
2019 June	18	40	58
2019 May	45	33	78
2019 April	83	20	103
2019 March	32	13	45
2019 February	50	14	64
2019 January	47	19	66
2018 December	46	35	81
2018 November	135	20	155
2018 October	266	40	306
2018 September	132	30	162
2018 August	2	0	2
2018 July	1	0	1
2018 June	13	0	13
2018 May	5	0	5
2018 April	23	0	23
2018 March	9	0	9
2018 February	9	0	9
2018 January	18	0	18
2017 December	15	0	15
2017 November	12	0	12
2017 October	12	0	12
2017 September	13	0	13
2017 August	15	0	15
2017 July	12	0	12
2017 June	22	8	30
2017 May	25	12	37
2017 April	11	5	16
2017 March	11	0	11
2017 February	9	5	14
2017 January	9	1	10
2016 December	25	11	36
2016 November	36	14	50
2016 October	47	6	53
2016 September	37	11	48
2016 August	21	2	23
2016 July	18	5	23

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