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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The WHO and the Spanish Paediatric Association &#40;Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a&#44; AEP&#41; recommend exclusive breastfeeding for 6 months before introduce complementary foods&#44; continuing breastfeeding for at least 2 years&#46; However&#44; few mothers follow these recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Low breastfeeding rates are a public health issue&#44; with overwhelming evidence in the literature of the risks of artificial feeding&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;3</span></a> in addition to the economical burden for the community implied by early weaning&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4</span></a> Paediatricians play an essential role in the initiation&#44; maintenance and duration rates of breastfeeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;6</span></a> However&#44; it is widely acknowledged that their training is deficient&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#8211;11</span></a> There are various questionnaires on this topic&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#8211;13</span></a> but&#44; as far as we know&#44; there are no validated tools to assess the breastfeeding knowledge of professionals&#46; Our objective is to develop and validate a questionnaire about breastfeeding knowledge and skills for paediatricians&#46; Quantifying knowledge should aid towards planning and justifying steps to improve paediatric training&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Definition of construct and questionnaire development</span><p id="par0010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Objective&#58;</span> to quantify breastfeeding knowledge and skills&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Target population&#58;</span> paediatricians and resident paediatricians&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Concepts to be measured&#58;</span> basic breastfeeding knowledge&#44; together with skills in daily handling of breastfeeding issues&#46; Some knowledge areas are proposed &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; based on earlier suggestions&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#44;14&#44;15</span></a> After defining these&#44; it was decided that not all of them would be represented&#44; since to be applicable the test duration could not exceed 15&#8211;20<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;12&#44;16</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Item selection&#58;</span> a preliminary prototype was designed and tested in 54 questionnaires &#40;before and after a breastfeeding course&#41;&#44; after which 3 non-discriminating questions &#40;correct by more than 95&#37; of the sample&#41; were removed&#46; Following this&#44; a second prototype was proposed&#44; tested on 10 paediatric residents&#44; and examined by a panel of judges&#44; after which the definitive questionnaire was generated&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Composition&#58;</span> the questionnaire&#44; entitled &#8220;Questionnaire about breastfeeding knowledge&#8221; &#40;Encuesta sobre conocimientos en lactancia&#44; ECoLa&#41;&#44; comprises 22 questions with a maximum score of 26 points &#40;anexo 1&#41;&#46; There are also questions &#8211; from 23 onwards &#8211; that are not scored&#44; although they reflect variables which may have an influence on the study objective&#46; Items 18 and 21 deserve special mention since they allow free text&#44; limited to very few words&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><p id="par0040" class="elsevierStylePara elsevierViewall">Item 18 asks for 5 aspects of breastfeeding &#40;one point for every correct answer&#41;&#46; Those shown in the WHO breastfeeding observation form were deemed correct&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> This list was expanded by the judges &#40;Annexe 2&#41;&#46; An answer is correct if it is included in the checklist&#44; although at the discretion of the evaluator an answer not included in the list may be deemed correct&#46; This should only occur exceptionally and be consistent with current breastfeeding knowledge&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><p id="par0045" class="elsevierStylePara elsevierViewall">Item 21 assesses the ability to obtain quick and reliable information about drugs and breastfeeding&#46; Adalimumab was chosen&#44; which&#44; while being safe&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">18&#8211;20</span></a> is listed in its data sheet as incompatible&#44; even up to 5 months after the last injection&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> E-lactancia<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> and LactMed<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> were defined as valid resources&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> or any other website with direct links to either of the above&#46; A correct response&#44; accepting a minimum transcription error&#44; is defined as one which upon being entered in Google shows either of the 2 correct websites among the first five hits&#46; Other sources such as PubMed are not deemed useful because of the time needed to perform searches in these databases&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> Google is unsuitable due to the huge number of pages it retrieves&#44; not all of which contain pertinent information&#46;</p></li></ul></p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Subjects</span><p id="par0050" class="elsevierStylePara elsevierViewall">Convenience sampling was use&#44; with subjects selected from two groups&#58; &#40;a&#41; paediatricians and resident paediatricians at the Hospital Infantil Ni&#241;o Jes&#250;s &#40;HNJ&#41;&#44; a high complexity hospital without International Humanitarian Assistance Network &#40;IHAN&#41; accreditation&#44; where there is no maternity ward and residents need to rotate to another hospital during their 2nd or 3rd year of residency&#46; Paper questionnaires were delivered following a general session&#44; and then sent via email &#40;2 emails with a 15-day interval&#41; to &#40;a&#41; 49 paediatricians and 48 residents&#44; to include those who were not present during the session&#59; and &#40;b&#41; paediatricians in the virtual forum LactanciaMat&#44; an email distribution list for RedIris users&#44; comprising 365 professionals with special interest in breastfeeding&#44; specifically polling paediatricians &#40;unknown number&#41;&#46; Forty students from a basic AEP course for paediatricians and paediatric residents were also questioned about breastfeeding knowledge &#40;May 2014&#41;&#46; The questionnaire was delivered on paper&#44; before and after the course&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Validation requirements</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Validity</span><p id="par0055" class="elsevierStylePara elsevierViewall">This is the extent to which the instrument measures what it is supposed to measure&#44; and is therefore fit for purpose&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> Validity considers various aspects&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Content validity refers to whether the questionnaire is an indicator of what is intended to be measured&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">24&#44;25</span></a> To examine content validity&#44; it was submitted for examination by 14 judges<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3 consultant breastfeeding-expert paediatricians&#44; and members of the Breastfeeding Committee of the AEP &#40;anexo 3&#41;&#46; The group of experts was enlarged during this work&#44; adding 5 new members who joined the Committee during this period&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Judges were asked to assess 3 aspects of each item&#58; the correct response&#59; the importance of the item&#44; rated on a scale of 1&#8211;5&#59; and whether a conflict might exist about the correct answer&#46; In addition&#44; all judges were encouraged to voice their opinions about each item&#44; competence areas&#44; and the questionnaire as a whole&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To quantify their responses&#44; the agreement index was used &#40;number of agreements&#47;total number of responses&#41;&#46; Values of &#62;0&#46;80 were deemed valid&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> Aiken&#39;s V coefficient was not used since non-ordinal variables were included&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Items 18 and 22 are mentioned separately&#58;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Item 18 asks for 10 criteria about breastfeeding assessment&#44; included in the checklist&#46; Respondents were asked whether any of the elements might be open to dispute&#44; if there were other relevant criteria other than those considered&#44; and the degree of subjectivity involved in amending the question&#46; They were asked to grade their answers on a Likert scale&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Item 22&#58; since this is about the self-perception of confidence while observing a breastfeed&#44; it is not considered <span class="elsevierStyleItalic">correct</span> but rather <span class="elsevierStyleItalic">desirable</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Criterion validity is about the extent to which one particular answer estimates the value of a gold standard which we assumed is exactly what we want to measure&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">24&#44;25</span></a> Since there is no such standard&#44; an approach was made by examining the starting hypotheses&#58; &#40;a&#41; knowledge should be greater among LactanciaMat specialists&#44; followed by hospital specialists&#44; and less extensive among residents&#59; and &#40;b&#41; students should improve their knowledge after completing the course&#44; especially those with lower initial knowledge&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Reliability</span><p id="par0095" class="elsevierStylePara elsevierViewall">This is the degree of accurate&#44; error free measurement by an instrument&#46; It is a reflection of its capability to repeatedly offer true and consistent results under similar circumstances&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">1&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Internal consistency is the degree to which items are related to each other&#44; and may therefore be accumulated in a global score&#46; Internal consistency was examined with the Kuder&#8211;Richardson 20 &#40;KR20&#41; formula&#44;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">29&#44;30</span></a> since all items were codified as dichotomous &#40;correct&#47;incorrect&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">2&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Inter-observer concordance was assessed with the Kappa coefficient in items 18 and 21&#44; independently classified by both authors as correct or incorrect&#46; Blank responses were excluded&#44; since they were automatically coded by the spreadsheet&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">3&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Temporal stability &#40;test&#8211;retest&#41; was assessed with 10 subjects with a difference of 2&#8211;3 weeks&#44; calculating the intraclass correlation coefficient &#40;ICC&#41;&#46;</p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Alternative version</span><p id="par0115" class="elsevierStylePara elsevierViewall">Since open questions may be difficult to interpret and score&#44; a short version of the test that excludes these items may be used&#46; Therefore&#44; the validity and reliability of the questionnaire without items 18 and 21 will be evaluated &#40;over a total of 20 points&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Data analysis</span><p id="par0120" class="elsevierStylePara elsevierViewall">Data was processed and analysed with the free software Libre Office and R with the interface RKWard &#40;Available for free download at&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.libreoffice.org/y">http&#58;&#47;&#47;www&#46;libreoffice&#46;org&#47;y</a><a id="intr0015" class="elsevierStyleInterRef" href="http://rkward.sourceforge.net/">http&#58;&#47;&#47;rkward&#46;sourceforge&#46;net&#47;</a>&#41;&#46; Scoring was classified as <span class="elsevierStyleItalic">grades</span> for easier interpretation&#58; &#60;55&#37; very insufficient&#44; 55&#8211;70&#37; insufficient&#44; 70&#8211;85&#37; good &#40;10&#41;&#44; &#62;85&#37; excellent&#46; Confidence intervals &#40;CI&#41; were used for group comparisons&#44; instead of hypotheses contrast&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical considerations</span><p id="par0125" class="elsevierStylePara elsevierViewall">No ethical conflicts were identified&#44; in line with prior works of similar nature&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">32&#44;33</span></a> Questionnaires were completed voluntarily and anonymously&#44; and the project was endorsed by the Breastfeeding Committee of the AEP&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><p id="par0130" class="elsevierStylePara elsevierViewall">Twenty three paper questionnaires and 25 online questionnaires were completed at the hospital&#59; 6 questionnaires were rejected since they did not belong to the study group&#44; with an approximate response rate of 46&#37; among residents and 41&#37; among attendant doctors &#40;the exact rate cannot be calculated since the overlap between face to face and email subjects is unknown&#46;&#41; Sixty questionnaires were received via email from LactanciaMat&#44; 20 of which were rejected since they were not from paediatricians&#46; Seventy six paper questionnaires were completed before and after the breastfeeding course&#44; of which 62 were paired questionnaires completed by 31 individuals&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Validity</span><p id="par0135" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">1&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Content validity&#46; The summary of the judges&#8217; opinion is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The items that did not pass the test were openly discussed until an agreement was reached to redraft or removed them entirely&#46; Items 5 and 7 were added at the suggestion of the judges&#44; and they were likewise subject to discussion until a consensus was reached&#46; A third item was added later at their suggestion&#44; and was later removed as non-discriminating&#46; With regard to items 18 and 21&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><p id="par0145" class="elsevierStylePara elsevierViewall">Item 18 &#40;from 1 &#8211;lowest&#8211; to 5 &#8211;highest&#8211;&#41;&#58; potentially controversial criteria&#58; average 1&#46;6&#59; possibility of existence of other clinically relevant criteria besides those considered&#58; average 2&#46;3&#59; and subjectivity risk upon assessing this question&#58; average 1&#46;6&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><p id="par0150" class="elsevierStylePara elsevierViewall">Item 21&#58; although there was wide agreement on the correct response &#40;13&#47;14 recommended e-lactancia&#41;&#44; many believed it was not the only alternative&#44; and 6 also suggested LactMed&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> After specifying the assessment criteria&#44; a unanimous decision was reached to leave the question unchanged&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">2&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Criterion validity&#46; Group scores are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The 95&#37; CI of the LactanciaMat median does not overlap with the others&#44; but there is overlapping among hospital specialists and residents&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li></ul></p><p id="par0160" class="elsevierStylePara elsevierViewall">Regarding the percentage of correct answers from course participants&#44; both before and after the course&#44; an improvement in scoring is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; with less dispersion and no overlapping in the CI of medians&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> compares the increased score of each student relative to their initial score&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Reliability</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">1&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Internal consistency&#46; KR20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;87&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">2&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Inter-observer concordance&#58;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0095"><p id="par0180" class="elsevierStylePara elsevierViewall">Item 18&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>627&#44; kappa 0&#46;82 &#40;CI 95&#37;&#58; 0&#46;75&#8211;0&#46;87&#41;&#44; maximum kappa 0&#46;98&#44; prevalence index 0&#46;66 and bias index 0&#46;01&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><p id="par0185" class="elsevierStylePara elsevierViewall">Item 21&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>144&#44; kappa 0&#46;44 &#40;CI 95&#37;&#58; 0&#46;10&#8211;0&#46;78&#41;&#44; maximum kappa 0&#46;60&#44; prevalence index 0&#46;91&#44; bias index 0&#46;03&#44; prevalence and bias adjusted kappa 0&#46;90&#46; Given the difficult interpretation of kappa in this case&#44; a contingency table is provided &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">3&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Temporal stability &#40;test&#8211;retest&#41;&#46; Global scoring&#58; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;82 &#40;CI 95&#37;&#58; 0&#46;44&#8211;0&#46;95&#41;&#44; and grouped as <span class="elsevierStyleItalic">grades</span>&#58; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;70 &#40;CI 95&#37;&#58; 0&#46;20&#8211;0&#46;91&#41;&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Alternative version</span><p id="par0195" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> shows scores grouped as grades from the short version&#44; together with those from the full version&#46;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">1&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Criterion validity&#46; The median of the LactanciaMat group &#40;Me<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>95 &#91;95&#37; CI&#58; 92&#46;5&#8211;97&#46;5&#93;&#41; did not overlap with other groups&#44; which did overlap each other &#40;specialists Me<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>75 &#91;95&#37; CI&#58; 70&#46;6&#8211;79&#46;4&#93;&#44; residents Me<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>65 &#91;95&#37; CI&#58; 56&#46;6&#8211;73&#46;4&#93;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">2&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Internal consistency&#46; KR20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;76&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">3&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Temporal stability&#46; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;76 &#40;95&#37; CI&#58; 0&#46;35&#8211;0&#46;94&#41; and grouped as grades ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;72 &#40;0&#46;24&#8211;0&#46;92&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion and conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall">The poor breastfeeding training of many paediatricians has been documented both internationally<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10&#44;12</span></a> as well as in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a> and also in relation to specialists from other fields&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;35</span></a> Despite their poor training&#44; however&#44; doctors may have confidence in their skills&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">However&#44; we have no record of any validated questionnaire documenting this lack of training&#46; A questionnaire in English is claimed to be validated&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> but its validation is insufficiently documented&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> ECoLa is&#44; to our knowledge&#44; the first questionnaire that has complied fully with the validation process&#44; is reasonably brief&#44; and can be self-administered both on paper and online&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The requirement that questionnaires must be analysed by a panel of judges has been of great benefit in this case&#46; Not only has it required agreement about the correct response&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> but also about potential conflict&#44; thereby placing high demand for each item&#46; Amendments enabled us to reach almost unanimous agreement about the correct answer &#40;&#62;0&#46;90&#41; with a minimum amount of conflict &#40;only 2 items are between 0&#46;85 and 0&#46;90&#44; the others exceeding 0&#46;90 of agreement&#41;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">We offer a tool that quantifies the breastfeeding knowledge and skills of paediatricians&#46; Even though it does not encompass the entire range of basic required knowledge&#44; it is a good starting point for further tests&#46; Likewise&#44; although its objective is to assess basic knowledge and skills&#44; it clearly reveals the attitudes of the respondent&#58; question 21 assesses knowledge of documentation sources&#44; but also deals with unconsulted weaning if a drug is compatible with breastfeeding&#59; or the question &#40;scoreless&#41; about whether it is appropriate to breastfeed in public&#46; Question 19&#44; about advertising aimed at pregnant women&#44; shows whether most respondents in the study group blame the mothers or underestimate the importance of breastfeeding&#46; However&#44; the questionnaire is not designed to assess attitudes&#44; and the statistical model confirms the internal consistency of the questionnaire&#44; with KR20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;87&#44; higher than the recommended 0&#46;70<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> or 0&#46;85&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> and lower than 0&#46;90&#8211;0&#46;95 which would suggest redundancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">25&#44;29</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The objective of this work has been to validate the questionnaire&#44; not to document the state of knowledge of our sample&#46; Therefore&#44; we cannot draw conclusions about the rate of response&#44; since the equation denominators have not been globally determined&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The hypothesis that a group with interest in breastfeeding has better scores is confirmed&#46; However&#44; no differences were shown between hospital paediatricians and residents&#46; Heterogeneity between residents is notable&#44; and has led to a wide median and interquartile range confidence interval&#44; in which not even a minimum as low as 19&#37; or a maximum as high as 85&#37; are considered extremes&#46; Attending doctors have a low median &#40;69&#37;&#41; similar to that of residents&#44; although there is less dispersion since there are fewer extremely low scores&#44; with a score of 58&#37; being the lowest end of the <span class="elsevierStyleItalic">whisker</span>&#59; therefore lower values are deemed eccentric &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Another approach to criterion validity&#44; in the absence of a gold standard for benchmarking&#44; is the second hypothesis&#44; which is confirmed in its two aspects&#58; students improve their scores after the course&#44; especially those who start with little knowledge&#46; The more basic knowledge the student has&#44; the less improvement is observed in the questionnaire score which is consistent with a basic knowledge course and a test assessing basic knowledge&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The reduced sample size is a limitation&#58; statistical analysis was satisfactory&#44; although the kappa and the ICC have a wide CI&#44; including values that might be unacceptable&#46; ICC results may not only be due to the small sample size&#44; but also to the nature of the knowledge questionnaire&#46; Encouraged by the test itself&#44; subjects may seek the answers to certain questions after completing the first questionnaire&#44; thus acquiring new knowledge before completing the second test&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> and reducing the test&#8211;retest value&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">With regard to the inter-observer test&#44; a good kappa index has been obtained in item 18&#46; In item 21&#44; even if we consider the degree of agreement as high&#44; the kappa has a low absolute value &#40;0&#46;44&#41;&#44; affected by a high prevalence index &#40;0&#46;91&#41;&#44; in what has been called one of the kappa paradoxes&#46; Additional information has been supplied to facilitate interpretation of this phenomenon&#44; in which the maximum kappa &#40;0&#46;60&#41;&#44; prevalence-adjusted and bias-adjusted kappa &#40;0&#46;90&#41; and the contingency table &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; should be noted&#44; as recommended in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> This scenario is foreseeable&#44; since it is an open question which usually has few incorrect answers&#58; if the respondent knows the answer he will answer correctly&#44; and he will not answer if he does not&#46; It should be noted that blank responses have been automatically tabulated&#44; excluding them from the analysis and penalising the kappa&#46; This question raises the issue that the test must be manually corrected and requires Internet connection&#46; Internet is not available in some offices&#44; and we consider this to be a limitation for the professional providing care to breastfeeding women&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Since validity is not an inherent feature of the test&#44; rather it is related to the sample to which it is administered&#44; it would be advisable to re-examine the psychometric properties of the questionnaire in other samples&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">A reduced version is provided&#44; which presents the advantage that it may be corrected by untrained personnel&#44; or automatically with a spreadsheet&#46; Even though it does not seem advisable to us&#44; it could be used in particular cases&#59; although in our sample all the subgroups improved their scores&#44; especially those whose scores were closer to the &#8220;pass&#8221; cut off point &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Thus&#44; in our sample of hospital paediatricians&#44; only 45&#37; pass with the full version&#44; and 5&#37; are <span class="elsevierStyleItalic">excellent</span>&#59; however&#44; with the reduced version 85&#37; pass and 35&#37; are excellent&#46; This version overrates those with a good theoretical level&#44; but who are unfamiliar with essential practical aspects&#44; such as the observation of a breastfeed&#46; To use it&#44; it would be convenient to review the cut off points suggested for the full version&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">We believe it is important to document the lack of breastfeeding training among paediatricians&#44; to justify the implementation of measures to counteract this deficit&#44; both at the official level and locally&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">36&#44;38</span></a> Therefore&#44; we have developed and validated this questionnaire&#44; which may be the basis for versions in other languages or for different medical specialities&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors state there is no conflict of interest&#46;</p></span></span>"
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              "titulo" => "Validity"
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    "fechaRecibido" => "2014-09-08"
    "fechaAceptado" => "2015-01-14"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec611978"
          "palabras" => array:6 [
            0 => "Breastfeeding"
            1 => "Questionnaire"
            2 => "Validation studies"
            3 => "Paediatrics"
            4 => "Physicians"
            5 => "Medical education"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:6 [
            0 => "Lactancia materna"
            1 => "Cuestionarios"
            2 => "Estudios de validaci&#243;n"
            3 => "Pediatr&#237;a"
            4 => "M&#233;dicos"
            5 => "Educaci&#243;n m&#233;dica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Paediatricians play a key role in the start and duration of breastfeeding&#46; Although it is known that they lack formal education on this subject&#44; there are currently no validated tools available to assess paediatrician knowledge regarding breastfeeding&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To develop and validate a Breastfeeding Knowledge and Skills Questionnaire for Paediatricians&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Once the knowledge areas were defined&#44; a representative sample of them was chosen to carry out the survey&#46; After pilot testing&#44; non-discriminating questions were removed&#46; Content validity was assessed by 14 breastfeeding experts&#44; yielding 22 scorable items &#40;maximum score&#58; 26 points&#41;&#46; To estimate criterion validity&#44; it was hypothesised that a group of paediatricians with a special interest in breastfeeding &#40;1&#41; would obtain better results than paediatricians from a hospital without a maternity ward &#40;2&#41;&#44; and the latter would obtain a higher score than paediatric residents receiving training in the same hospital &#40;3&#41;&#46; The questionnaire was also evaluated before and after a basic course in breastfeeding&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Breastfeeding experts have an index of agreement of &#62;0&#46;90 for each item&#46; The 3 groups &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>82&#41; were compared&#44; finding significant differences between group &#40;1&#41; and the rest&#46; Moreover&#44; an improvement was observed in the participants who attended the breastfeeding course &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31&#41;&#44; especially among those with less initial knowledge&#46; Reliability&#44; internal consistency &#40;KR-20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;87&#41;&#44; interobserver agreement&#44; and temporal stability were examined&#44; with satisfactory results&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A practical and self-administered tool is presented to assess paediatrician knowledge regarding breastfeeding&#44; with a documented validity and reliability&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material and methods"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los pediatras desempe&#241;an un papel fundamental en el establecimiento y mantenimiento de la lactancia&#46; Aun conociendo su carencia de formaci&#243;n en este campo&#44; no se dispone actualmente de herramientas validadas para documentarla&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Crear y validar un cuestionario sobre conocimientos y habilidades en lactancia para pediatras&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se definen las &#225;reas de conocimiento&#44; escogi&#233;ndose una muestra representativa de estas&#46; Se realiza una prueba piloto y se eliminan las preguntas no discriminantes&#46; La validez de contenido se establece por 14 expertos en lactancia&#44; obtien&#233;ndose 22 &#237;tems puntuables &#40;26 puntos m&#225;ximos&#41;&#46; Para aproximarse a la validez de criterio&#44; se hipotetiz&#243; que un grupo de pediatras con especial inter&#233;s en lactancia &#40;1&#41; obtendr&#237;a mejores resultados que pediatras &#40;2&#41; de un hospital sin maternidad y estos que los residentes &#40;3&#41; de pediatr&#237;a del mismo hospital&#46; Tambi&#233;n se analizaron las notas antes y despu&#233;s de un curso b&#225;sico en lactancia&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los jueces tienen un &#237;ndice de acuerdos &#62;<span class="elsevierStyleHsp" style=""></span>0&#44;90 para cada &#237;tem&#46; Se comparan los 3 grupos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>82&#41;&#44; hallando diferencias entre el grupo con inter&#233;s en lactancia y el resto&#59; y se observa mejor&#237;a de la puntuaci&#243;n en los alumnos del curso &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31&#41;&#44; especialmente en aquellos que part&#237;an de peores conocimientos&#46; Respecto de la fiabilidad se examinan la consistencia interna &#40;Kuder-Richardson 20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;87&#41;&#44; concordancia interobservadores y estabilidad temporal&#44; con resultados satisfactorios&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se ofrece una herramienta para evaluar el conocimiento de los pediatras en lactancia&#44; de la que se documentan validez y fiabilidad&#44; adaptada a nuestro contexto&#44; breve y autoadministrable en papel u <span class="elsevierStyleItalic">online</span>&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as&#58; G&#243;mez Fern&#225;ndez-Vegue M&#44; Men&#233;ndez Orenga M&#46; Validaci&#243;n de un cuestionario sobre conocimientos y habilidades en lactancia materna&#46; An Pediatr &#40;Barc&#41;&#46; 2015&#59;83&#58;387&#8211;396&#46;</p>"
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            "apendice" => "<p id="par0290" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Group scoring&#46; Box and whisker plot&#46; For each group&#44; a box represents the interquartile range &#40;IQR&#41;&#44; the centre line represents the median&#44; and the notches the 95&#37; confidence interval of the median&#46; The upper and lower whiskers reach respectively the maximum or minimum value at a distance of 1&#46;5&#42;IQR from the box&#46; Extreme values are represented individually&#46; The thick horizontal line at 70&#37; represents <span class="elsevierStyleItalic">sufficient</span>&#46;</p>"
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        "etiqueta" => "Figure 2"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Scores before and after breastfeeding course&#46; Box and whisker plot&#46; For each group&#44; a box represents the interquartile range &#40;IQR&#41;&#44; the centre line represents the median&#44; and the notches&#44; 90&#37; confidence interval of the median&#46; The upper and lower whiskers reach respectively the maximum and minimum values&#46; The thick horizontal line at 70&#37; represents <span class="elsevierStyleItalic">sufficient</span>&#46;</p>"
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        "etiqueta" => "Figure 3"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Scoring increase based on the previous grade of each individual&#46;</p>"
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        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Scores shown as grades of the full and reduced versions&#46; A comparison of both versions of the questionnaire&#46; The improvement of all groups is remarkable&#44; especially among paediatricians of the Hospital Ni&#241;o Jes&#250;s &#40;HNJ&#41;&#44; after the open questions are removed&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Breakdown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Physiology</span></td><td class="td" title="table-entry  " align="left" valign="top">Breastfeeding in normal conditions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prematurity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Extended breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Public health</span></td><td class="td" title="table-entry  " align="left" valign="top">Official recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Risks of artificial feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Issues during the first days</span></td><td class="td" title="table-entry  " align="left" valign="top">Hypoglycaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cracks and pain while breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mastitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dehydration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Jaundice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Late issues</span></td><td class="td" title="table-entry  " align="left" valign="top">Inadequate production of milk&#47;poor weight gain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Crying&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Breastfeeding crisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Return to work&#46; Supplementary feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Assessment of feeding</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Maternal factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Drugs&#44; illnesses&#44; toxic substances&#44; prior surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Attitudes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Promotion of breastfeeding&#46; Empathy and counselling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Basic areas of breastfeeding knowledge and skills&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Questions 5&#44; 7&#44; 18&#44; 21 and 22 are discussed in the text&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Summarised question<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Relevancy &#40;1&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Agreement about correct option &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">I&#46;A&#46; about correct option<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Agreement about absence of conflict&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">I&#46;A&#46; about lack of conflict<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resulting action&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final I&#46;A&#46; about correct option&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final I&#46;A&#46; about lack of conflict&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Screening for neonatal hypoglycaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More reliable signs to appreciate intake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The main cause of hypernatremic dehydration in a newborn is the delay start of lactation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deleted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mastitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Feeding as needed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Risks of formula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Need for bottle with caesarean-section&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phototherapy and breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Choice of breastfeeding with large prematures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8220;Calm&#8221; infant at risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extended breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor weight gain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breastfeeding and supplementary feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Watery milk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor attachment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cracks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Case of growth spurts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnant woman hesitant about bottle feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICMBS<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            ]
            1 => array:3 [
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              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Index of agreement about the correct response&#46; I&#46;A&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>agreements&#47;agreements<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>disagreements&#46;</p>"
            ]
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Index of agreement about the absence of conflict regarding the correct response&#46;</p>"
            ]
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              "identificador" => "tblfn0020"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">International code of marketing of breast milk substitutes&#46;</p>"
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            4 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Later removed due to being non-discriminating &#40;answered correctly by more than 95&#37; of subjects&#41;&#46;</p>"
            ]
          ]
        ]
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Results of examination by judges&#46;</p>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">The theoretical maximums throwing a maximum kappa of 0&#46;60 are between brackets&#46; Note the high frequency of correct responses &#40;prevalence index 0&#46;91&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Evaluator 2</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Incorrect&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">134 &#40;135&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Incorrect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">140&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">144&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Observations of the two evaluators in item 21&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:38 [
            0 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Factores asociados al abandono precoz de la lactancia materna en una regi&#243;n del este de Espa&#241;a"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; Rius"
                            1 => "J&#46; Ortu&#241;o"
                            2 => "C&#46; Rivas"
                            3 => "M&#46; Maravall"
                            4 => "M&#46;A&#46; Calzado"
                            5 => "A&#46; L&#243;pez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
                        "fecha" => "2014"
                        "volumen" => "80"
                        "paginaInicial" => "6"
                        "paginaFinal" => "15"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The burden of suboptimal breastfeeding in the United States&#58; a pediatric cost analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Bartick"
                            1 => "A&#46; Reinhold"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2009-1616"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2010"
                        "volumen" => "125"
                        "paginaInicial" => "e1048"
                        "paginaFinal" => "e1056"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20368314"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The risks of not breastfeeding for mothers and infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46; Stuebe"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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        "texto" => "<p id="par0280" class="elsevierStylePara elsevierViewall">We would like to thank the members of the breastfeeding committee of the AEP&#44; and in particular&#58; Dr Josefa Aguayo Maldonado&#44; Dr Susana Ares Segura&#44; Dr Marta Costa Romero&#44; Dr Marta D&#237;az G&#243;mez&#44; Dr Blanca Esp&#237;nola Doc&#237;o&#44; Dr Beatriz Flores Ant&#243;n&#44; Dr Ana Gimeno Navarro&#44; Dr Adolfo G&#243;mez Pap&#237;&#44; Dr Mar&#237;a Teresa Hern&#225;ndez Aguilar&#44; Dr Ana Jim&#233;nez Moya&#44; Dr Paula Lalaguna Mallada&#44; Dr Juan Jos&#233; Lasarte Velillas&#44; Dr Jes&#250;s Mart&#237;n-Calama Valero&#44; Dr Jos&#233; Manuel Mart&#237;n Morales&#44; Dr Carmen Rosa Pall&#225;s Alonso&#44; Dr Jos&#233; Mar&#237;a Paricio Talayero and Dr Laura Sanfeliciano Mart&#237;n&#46;</p>"
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Original Article
Development and validation of a Breastfeeding Knowledge and Skills Questionnaire
Validación de un cuestionario sobre conocimientos y habilidades en lactancia materna
M. Gómez Fernández-Veguea,
Corresponding author
martagfv@gmail.com

Corresponding author.
, M. Menéndez Orengab
a Comité de Lactancia Materna de la AEP, Madrid, Spain
b Servicio Madrileño de Salud, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The WHO and the Spanish Paediatric Association &#40;Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a&#44; AEP&#41; recommend exclusive breastfeeding for 6 months before introduce complementary foods&#44; continuing breastfeeding for at least 2 years&#46; However&#44; few mothers follow these recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Low breastfeeding rates are a public health issue&#44; with overwhelming evidence in the literature of the risks of artificial feeding&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;3</span></a> in addition to the economical burden for the community implied by early weaning&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4</span></a> Paediatricians play an essential role in the initiation&#44; maintenance and duration rates of breastfeeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;6</span></a> However&#44; it is widely acknowledged that their training is deficient&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#8211;11</span></a> There are various questionnaires on this topic&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#8211;13</span></a> but&#44; as far as we know&#44; there are no validated tools to assess the breastfeeding knowledge of professionals&#46; Our objective is to develop and validate a questionnaire about breastfeeding knowledge and skills for paediatricians&#46; Quantifying knowledge should aid towards planning and justifying steps to improve paediatric training&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Definition of construct and questionnaire development</span><p id="par0010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Objective&#58;</span> to quantify breastfeeding knowledge and skills&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Target population&#58;</span> paediatricians and resident paediatricians&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Concepts to be measured&#58;</span> basic breastfeeding knowledge&#44; together with skills in daily handling of breastfeeding issues&#46; Some knowledge areas are proposed &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; based on earlier suggestions&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#44;14&#44;15</span></a> After defining these&#44; it was decided that not all of them would be represented&#44; since to be applicable the test duration could not exceed 15&#8211;20<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;12&#44;16</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Item selection&#58;</span> a preliminary prototype was designed and tested in 54 questionnaires &#40;before and after a breastfeeding course&#41;&#44; after which 3 non-discriminating questions &#40;correct by more than 95&#37; of the sample&#41; were removed&#46; Following this&#44; a second prototype was proposed&#44; tested on 10 paediatric residents&#44; and examined by a panel of judges&#44; after which the definitive questionnaire was generated&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Composition&#58;</span> the questionnaire&#44; entitled &#8220;Questionnaire about breastfeeding knowledge&#8221; &#40;Encuesta sobre conocimientos en lactancia&#44; ECoLa&#41;&#44; comprises 22 questions with a maximum score of 26 points &#40;anexo 1&#41;&#46; There are also questions &#8211; from 23 onwards &#8211; that are not scored&#44; although they reflect variables which may have an influence on the study objective&#46; Items 18 and 21 deserve special mention since they allow free text&#44; limited to very few words&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><p id="par0040" class="elsevierStylePara elsevierViewall">Item 18 asks for 5 aspects of breastfeeding &#40;one point for every correct answer&#41;&#46; Those shown in the WHO breastfeeding observation form were deemed correct&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> This list was expanded by the judges &#40;Annexe 2&#41;&#46; An answer is correct if it is included in the checklist&#44; although at the discretion of the evaluator an answer not included in the list may be deemed correct&#46; This should only occur exceptionally and be consistent with current breastfeeding knowledge&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><p id="par0045" class="elsevierStylePara elsevierViewall">Item 21 assesses the ability to obtain quick and reliable information about drugs and breastfeeding&#46; Adalimumab was chosen&#44; which&#44; while being safe&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">18&#8211;20</span></a> is listed in its data sheet as incompatible&#44; even up to 5 months after the last injection&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> E-lactancia<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> and LactMed<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> were defined as valid resources&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> or any other website with direct links to either of the above&#46; A correct response&#44; accepting a minimum transcription error&#44; is defined as one which upon being entered in Google shows either of the 2 correct websites among the first five hits&#46; Other sources such as PubMed are not deemed useful because of the time needed to perform searches in these databases&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> Google is unsuitable due to the huge number of pages it retrieves&#44; not all of which contain pertinent information&#46;</p></li></ul></p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Subjects</span><p id="par0050" class="elsevierStylePara elsevierViewall">Convenience sampling was use&#44; with subjects selected from two groups&#58; &#40;a&#41; paediatricians and resident paediatricians at the Hospital Infantil Ni&#241;o Jes&#250;s &#40;HNJ&#41;&#44; a high complexity hospital without International Humanitarian Assistance Network &#40;IHAN&#41; accreditation&#44; where there is no maternity ward and residents need to rotate to another hospital during their 2nd or 3rd year of residency&#46; Paper questionnaires were delivered following a general session&#44; and then sent via email &#40;2 emails with a 15-day interval&#41; to &#40;a&#41; 49 paediatricians and 48 residents&#44; to include those who were not present during the session&#59; and &#40;b&#41; paediatricians in the virtual forum LactanciaMat&#44; an email distribution list for RedIris users&#44; comprising 365 professionals with special interest in breastfeeding&#44; specifically polling paediatricians &#40;unknown number&#41;&#46; Forty students from a basic AEP course for paediatricians and paediatric residents were also questioned about breastfeeding knowledge &#40;May 2014&#41;&#46; The questionnaire was delivered on paper&#44; before and after the course&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Validation requirements</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Validity</span><p id="par0055" class="elsevierStylePara elsevierViewall">This is the extent to which the instrument measures what it is supposed to measure&#44; and is therefore fit for purpose&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> Validity considers various aspects&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Content validity refers to whether the questionnaire is an indicator of what is intended to be measured&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">24&#44;25</span></a> To examine content validity&#44; it was submitted for examination by 14 judges<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3 consultant breastfeeding-expert paediatricians&#44; and members of the Breastfeeding Committee of the AEP &#40;anexo 3&#41;&#46; The group of experts was enlarged during this work&#44; adding 5 new members who joined the Committee during this period&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Judges were asked to assess 3 aspects of each item&#58; the correct response&#59; the importance of the item&#44; rated on a scale of 1&#8211;5&#59; and whether a conflict might exist about the correct answer&#46; In addition&#44; all judges were encouraged to voice their opinions about each item&#44; competence areas&#44; and the questionnaire as a whole&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To quantify their responses&#44; the agreement index was used &#40;number of agreements&#47;total number of responses&#41;&#46; Values of &#62;0&#46;80 were deemed valid&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> Aiken&#39;s V coefficient was not used since non-ordinal variables were included&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Items 18 and 22 are mentioned separately&#58;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Item 18 asks for 10 criteria about breastfeeding assessment&#44; included in the checklist&#46; Respondents were asked whether any of the elements might be open to dispute&#44; if there were other relevant criteria other than those considered&#44; and the degree of subjectivity involved in amending the question&#46; They were asked to grade their answers on a Likert scale&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Item 22&#58; since this is about the self-perception of confidence while observing a breastfeed&#44; it is not considered <span class="elsevierStyleItalic">correct</span> but rather <span class="elsevierStyleItalic">desirable</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Criterion validity is about the extent to which one particular answer estimates the value of a gold standard which we assumed is exactly what we want to measure&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">24&#44;25</span></a> Since there is no such standard&#44; an approach was made by examining the starting hypotheses&#58; &#40;a&#41; knowledge should be greater among LactanciaMat specialists&#44; followed by hospital specialists&#44; and less extensive among residents&#59; and &#40;b&#41; students should improve their knowledge after completing the course&#44; especially those with lower initial knowledge&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Reliability</span><p id="par0095" class="elsevierStylePara elsevierViewall">This is the degree of accurate&#44; error free measurement by an instrument&#46; It is a reflection of its capability to repeatedly offer true and consistent results under similar circumstances&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">1&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Internal consistency is the degree to which items are related to each other&#44; and may therefore be accumulated in a global score&#46; Internal consistency was examined with the Kuder&#8211;Richardson 20 &#40;KR20&#41; formula&#44;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">29&#44;30</span></a> since all items were codified as dichotomous &#40;correct&#47;incorrect&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">2&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Inter-observer concordance was assessed with the Kappa coefficient in items 18 and 21&#44; independently classified by both authors as correct or incorrect&#46; Blank responses were excluded&#44; since they were automatically coded by the spreadsheet&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">3&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Temporal stability &#40;test&#8211;retest&#41; was assessed with 10 subjects with a difference of 2&#8211;3 weeks&#44; calculating the intraclass correlation coefficient &#40;ICC&#41;&#46;</p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Alternative version</span><p id="par0115" class="elsevierStylePara elsevierViewall">Since open questions may be difficult to interpret and score&#44; a short version of the test that excludes these items may be used&#46; Therefore&#44; the validity and reliability of the questionnaire without items 18 and 21 will be evaluated &#40;over a total of 20 points&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Data analysis</span><p id="par0120" class="elsevierStylePara elsevierViewall">Data was processed and analysed with the free software Libre Office and R with the interface RKWard &#40;Available for free download at&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.libreoffice.org/y">http&#58;&#47;&#47;www&#46;libreoffice&#46;org&#47;y</a><a id="intr0015" class="elsevierStyleInterRef" href="http://rkward.sourceforge.net/">http&#58;&#47;&#47;rkward&#46;sourceforge&#46;net&#47;</a>&#41;&#46; Scoring was classified as <span class="elsevierStyleItalic">grades</span> for easier interpretation&#58; &#60;55&#37; very insufficient&#44; 55&#8211;70&#37; insufficient&#44; 70&#8211;85&#37; good &#40;10&#41;&#44; &#62;85&#37; excellent&#46; Confidence intervals &#40;CI&#41; were used for group comparisons&#44; instead of hypotheses contrast&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical considerations</span><p id="par0125" class="elsevierStylePara elsevierViewall">No ethical conflicts were identified&#44; in line with prior works of similar nature&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">32&#44;33</span></a> Questionnaires were completed voluntarily and anonymously&#44; and the project was endorsed by the Breastfeeding Committee of the AEP&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><p id="par0130" class="elsevierStylePara elsevierViewall">Twenty three paper questionnaires and 25 online questionnaires were completed at the hospital&#59; 6 questionnaires were rejected since they did not belong to the study group&#44; with an approximate response rate of 46&#37; among residents and 41&#37; among attendant doctors &#40;the exact rate cannot be calculated since the overlap between face to face and email subjects is unknown&#46;&#41; Sixty questionnaires were received via email from LactanciaMat&#44; 20 of which were rejected since they were not from paediatricians&#46; Seventy six paper questionnaires were completed before and after the breastfeeding course&#44; of which 62 were paired questionnaires completed by 31 individuals&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Validity</span><p id="par0135" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">1&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Content validity&#46; The summary of the judges&#8217; opinion is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The items that did not pass the test were openly discussed until an agreement was reached to redraft or removed them entirely&#46; Items 5 and 7 were added at the suggestion of the judges&#44; and they were likewise subject to discussion until a consensus was reached&#46; A third item was added later at their suggestion&#44; and was later removed as non-discriminating&#46; With regard to items 18 and 21&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><p id="par0145" class="elsevierStylePara elsevierViewall">Item 18 &#40;from 1 &#8211;lowest&#8211; to 5 &#8211;highest&#8211;&#41;&#58; potentially controversial criteria&#58; average 1&#46;6&#59; possibility of existence of other clinically relevant criteria besides those considered&#58; average 2&#46;3&#59; and subjectivity risk upon assessing this question&#58; average 1&#46;6&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><p id="par0150" class="elsevierStylePara elsevierViewall">Item 21&#58; although there was wide agreement on the correct response &#40;13&#47;14 recommended e-lactancia&#41;&#44; many believed it was not the only alternative&#44; and 6 also suggested LactMed&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> After specifying the assessment criteria&#44; a unanimous decision was reached to leave the question unchanged&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">2&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Criterion validity&#46; Group scores are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The 95&#37; CI of the LactanciaMat median does not overlap with the others&#44; but there is overlapping among hospital specialists and residents&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li></ul></p><p id="par0160" class="elsevierStylePara elsevierViewall">Regarding the percentage of correct answers from course participants&#44; both before and after the course&#44; an improvement in scoring is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; with less dispersion and no overlapping in the CI of medians&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> compares the increased score of each student relative to their initial score&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Reliability</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">1&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Internal consistency&#46; KR20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;87&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">2&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Inter-observer concordance&#58;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0095"><p id="par0180" class="elsevierStylePara elsevierViewall">Item 18&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>627&#44; kappa 0&#46;82 &#40;CI 95&#37;&#58; 0&#46;75&#8211;0&#46;87&#41;&#44; maximum kappa 0&#46;98&#44; prevalence index 0&#46;66 and bias index 0&#46;01&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><p id="par0185" class="elsevierStylePara elsevierViewall">Item 21&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>144&#44; kappa 0&#46;44 &#40;CI 95&#37;&#58; 0&#46;10&#8211;0&#46;78&#41;&#44; maximum kappa 0&#46;60&#44; prevalence index 0&#46;91&#44; bias index 0&#46;03&#44; prevalence and bias adjusted kappa 0&#46;90&#46; Given the difficult interpretation of kappa in this case&#44; a contingency table is provided &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">3&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Temporal stability &#40;test&#8211;retest&#41;&#46; Global scoring&#58; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;82 &#40;CI 95&#37;&#58; 0&#46;44&#8211;0&#46;95&#41;&#44; and grouped as <span class="elsevierStyleItalic">grades</span>&#58; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;70 &#40;CI 95&#37;&#58; 0&#46;20&#8211;0&#46;91&#41;&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Alternative version</span><p id="par0195" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> shows scores grouped as grades from the short version&#44; together with those from the full version&#46;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">1&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Criterion validity&#46; The median of the LactanciaMat group &#40;Me<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>95 &#91;95&#37; CI&#58; 92&#46;5&#8211;97&#46;5&#93;&#41; did not overlap with other groups&#44; which did overlap each other &#40;specialists Me<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>75 &#91;95&#37; CI&#58; 70&#46;6&#8211;79&#46;4&#93;&#44; residents Me<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>65 &#91;95&#37; CI&#58; 56&#46;6&#8211;73&#46;4&#93;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">2&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Internal consistency&#46; KR20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;76&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">3&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Temporal stability&#46; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;76 &#40;95&#37; CI&#58; 0&#46;35&#8211;0&#46;94&#41; and grouped as grades ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;72 &#40;0&#46;24&#8211;0&#46;92&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion and conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall">The poor breastfeeding training of many paediatricians has been documented both internationally<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10&#44;12</span></a> as well as in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a> and also in relation to specialists from other fields&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;35</span></a> Despite their poor training&#44; however&#44; doctors may have confidence in their skills&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">However&#44; we have no record of any validated questionnaire documenting this lack of training&#46; A questionnaire in English is claimed to be validated&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> but its validation is insufficiently documented&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> ECoLa is&#44; to our knowledge&#44; the first questionnaire that has complied fully with the validation process&#44; is reasonably brief&#44; and can be self-administered both on paper and online&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The requirement that questionnaires must be analysed by a panel of judges has been of great benefit in this case&#46; Not only has it required agreement about the correct response&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> but also about potential conflict&#44; thereby placing high demand for each item&#46; Amendments enabled us to reach almost unanimous agreement about the correct answer &#40;&#62;0&#46;90&#41; with a minimum amount of conflict &#40;only 2 items are between 0&#46;85 and 0&#46;90&#44; the others exceeding 0&#46;90 of agreement&#41;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">We offer a tool that quantifies the breastfeeding knowledge and skills of paediatricians&#46; Even though it does not encompass the entire range of basic required knowledge&#44; it is a good starting point for further tests&#46; Likewise&#44; although its objective is to assess basic knowledge and skills&#44; it clearly reveals the attitudes of the respondent&#58; question 21 assesses knowledge of documentation sources&#44; but also deals with unconsulted weaning if a drug is compatible with breastfeeding&#59; or the question &#40;scoreless&#41; about whether it is appropriate to breastfeed in public&#46; Question 19&#44; about advertising aimed at pregnant women&#44; shows whether most respondents in the study group blame the mothers or underestimate the importance of breastfeeding&#46; However&#44; the questionnaire is not designed to assess attitudes&#44; and the statistical model confirms the internal consistency of the questionnaire&#44; with KR20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;87&#44; higher than the recommended 0&#46;70<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> or 0&#46;85&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> and lower than 0&#46;90&#8211;0&#46;95 which would suggest redundancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">25&#44;29</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The objective of this work has been to validate the questionnaire&#44; not to document the state of knowledge of our sample&#46; Therefore&#44; we cannot draw conclusions about the rate of response&#44; since the equation denominators have not been globally determined&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The hypothesis that a group with interest in breastfeeding has better scores is confirmed&#46; However&#44; no differences were shown between hospital paediatricians and residents&#46; Heterogeneity between residents is notable&#44; and has led to a wide median and interquartile range confidence interval&#44; in which not even a minimum as low as 19&#37; or a maximum as high as 85&#37; are considered extremes&#46; Attending doctors have a low median &#40;69&#37;&#41; similar to that of residents&#44; although there is less dispersion since there are fewer extremely low scores&#44; with a score of 58&#37; being the lowest end of the <span class="elsevierStyleItalic">whisker</span>&#59; therefore lower values are deemed eccentric &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Another approach to criterion validity&#44; in the absence of a gold standard for benchmarking&#44; is the second hypothesis&#44; which is confirmed in its two aspects&#58; students improve their scores after the course&#44; especially those who start with little knowledge&#46; The more basic knowledge the student has&#44; the less improvement is observed in the questionnaire score which is consistent with a basic knowledge course and a test assessing basic knowledge&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The reduced sample size is a limitation&#58; statistical analysis was satisfactory&#44; although the kappa and the ICC have a wide CI&#44; including values that might be unacceptable&#46; ICC results may not only be due to the small sample size&#44; but also to the nature of the knowledge questionnaire&#46; Encouraged by the test itself&#44; subjects may seek the answers to certain questions after completing the first questionnaire&#44; thus acquiring new knowledge before completing the second test&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> and reducing the test&#8211;retest value&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">With regard to the inter-observer test&#44; a good kappa index has been obtained in item 18&#46; In item 21&#44; even if we consider the degree of agreement as high&#44; the kappa has a low absolute value &#40;0&#46;44&#41;&#44; affected by a high prevalence index &#40;0&#46;91&#41;&#44; in what has been called one of the kappa paradoxes&#46; Additional information has been supplied to facilitate interpretation of this phenomenon&#44; in which the maximum kappa &#40;0&#46;60&#41;&#44; prevalence-adjusted and bias-adjusted kappa &#40;0&#46;90&#41; and the contingency table &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; should be noted&#44; as recommended in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> This scenario is foreseeable&#44; since it is an open question which usually has few incorrect answers&#58; if the respondent knows the answer he will answer correctly&#44; and he will not answer if he does not&#46; It should be noted that blank responses have been automatically tabulated&#44; excluding them from the analysis and penalising the kappa&#46; This question raises the issue that the test must be manually corrected and requires Internet connection&#46; Internet is not available in some offices&#44; and we consider this to be a limitation for the professional providing care to breastfeeding women&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Since validity is not an inherent feature of the test&#44; rather it is related to the sample to which it is administered&#44; it would be advisable to re-examine the psychometric properties of the questionnaire in other samples&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">A reduced version is provided&#44; which presents the advantage that it may be corrected by untrained personnel&#44; or automatically with a spreadsheet&#46; Even though it does not seem advisable to us&#44; it could be used in particular cases&#59; although in our sample all the subgroups improved their scores&#44; especially those whose scores were closer to the &#8220;pass&#8221; cut off point &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Thus&#44; in our sample of hospital paediatricians&#44; only 45&#37; pass with the full version&#44; and 5&#37; are <span class="elsevierStyleItalic">excellent</span>&#59; however&#44; with the reduced version 85&#37; pass and 35&#37; are excellent&#46; This version overrates those with a good theoretical level&#44; but who are unfamiliar with essential practical aspects&#44; such as the observation of a breastfeed&#46; To use it&#44; it would be convenient to review the cut off points suggested for the full version&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">We believe it is important to document the lack of breastfeeding training among paediatricians&#44; to justify the implementation of measures to counteract this deficit&#44; both at the official level and locally&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">36&#44;38</span></a> Therefore&#44; we have developed and validated this questionnaire&#44; which may be the basis for versions in other languages or for different medical specialities&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors state there is no conflict of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Paediatricians play a key role in the start and duration of breastfeeding&#46; Although it is known that they lack formal education on this subject&#44; there are currently no validated tools available to assess paediatrician knowledge regarding breastfeeding&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To develop and validate a Breastfeeding Knowledge and Skills Questionnaire for Paediatricians&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Once the knowledge areas were defined&#44; a representative sample of them was chosen to carry out the survey&#46; After pilot testing&#44; non-discriminating questions were removed&#46; Content validity was assessed by 14 breastfeeding experts&#44; yielding 22 scorable items &#40;maximum score&#58; 26 points&#41;&#46; To estimate criterion validity&#44; it was hypothesised that a group of paediatricians with a special interest in breastfeeding &#40;1&#41; would obtain better results than paediatricians from a hospital without a maternity ward &#40;2&#41;&#44; and the latter would obtain a higher score than paediatric residents receiving training in the same hospital &#40;3&#41;&#46; The questionnaire was also evaluated before and after a basic course in breastfeeding&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Breastfeeding experts have an index of agreement of &#62;0&#46;90 for each item&#46; The 3 groups &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>82&#41; were compared&#44; finding significant differences between group &#40;1&#41; and the rest&#46; Moreover&#44; an improvement was observed in the participants who attended the breastfeeding course &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31&#41;&#44; especially among those with less initial knowledge&#46; Reliability&#44; internal consistency &#40;KR-20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;87&#41;&#44; interobserver agreement&#44; and temporal stability were examined&#44; with satisfactory results&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A practical and self-administered tool is presented to assess paediatrician knowledge regarding breastfeeding&#44; with a documented validity and reliability&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material and methods"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los pediatras desempe&#241;an un papel fundamental en el establecimiento y mantenimiento de la lactancia&#46; Aun conociendo su carencia de formaci&#243;n en este campo&#44; no se dispone actualmente de herramientas validadas para documentarla&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Crear y validar un cuestionario sobre conocimientos y habilidades en lactancia para pediatras&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se definen las &#225;reas de conocimiento&#44; escogi&#233;ndose una muestra representativa de estas&#46; Se realiza una prueba piloto y se eliminan las preguntas no discriminantes&#46; La validez de contenido se establece por 14 expertos en lactancia&#44; obtien&#233;ndose 22 &#237;tems puntuables &#40;26 puntos m&#225;ximos&#41;&#46; Para aproximarse a la validez de criterio&#44; se hipotetiz&#243; que un grupo de pediatras con especial inter&#233;s en lactancia &#40;1&#41; obtendr&#237;a mejores resultados que pediatras &#40;2&#41; de un hospital sin maternidad y estos que los residentes &#40;3&#41; de pediatr&#237;a del mismo hospital&#46; Tambi&#233;n se analizaron las notas antes y despu&#233;s de un curso b&#225;sico en lactancia&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los jueces tienen un &#237;ndice de acuerdos &#62;<span class="elsevierStyleHsp" style=""></span>0&#44;90 para cada &#237;tem&#46; Se comparan los 3 grupos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>82&#41;&#44; hallando diferencias entre el grupo con inter&#233;s en lactancia y el resto&#59; y se observa mejor&#237;a de la puntuaci&#243;n en los alumnos del curso &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31&#41;&#44; especialmente en aquellos que part&#237;an de peores conocimientos&#46; Respecto de la fiabilidad se examinan la consistencia interna &#40;Kuder-Richardson 20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;87&#41;&#44; concordancia interobservadores y estabilidad temporal&#44; con resultados satisfactorios&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se ofrece una herramienta para evaluar el conocimiento de los pediatras en lactancia&#44; de la que se documentan validez y fiabilidad&#44; adaptada a nuestro contexto&#44; breve y autoadministrable en papel u <span class="elsevierStyleItalic">online</span>&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Material y m&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as&#58; G&#243;mez Fern&#225;ndez-Vegue M&#44; Men&#233;ndez Orenga M&#46; Validaci&#243;n de un cuestionario sobre conocimientos y habilidades en lactancia materna&#46; An Pediatr &#40;Barc&#41;&#46; 2015&#59;83&#58;387&#8211;396&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0290" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0090"
          ]
        ]
      ]
    ]
    "multimedia" => array:10 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1437
            "Ancho" => 1582
            "Tamanyo" => 75081
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Group scoring&#46; Box and whisker plot&#46; For each group&#44; a box represents the interquartile range &#40;IQR&#41;&#44; the centre line represents the median&#44; and the notches the 95&#37; confidence interval of the median&#46; The upper and lower whiskers reach respectively the maximum or minimum value at a distance of 1&#46;5&#42;IQR from the box&#46; Extreme values are represented individually&#46; The thick horizontal line at 70&#37; represents <span class="elsevierStyleItalic">sufficient</span>&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1398
            "Ancho" => 1572
            "Tamanyo" => 70118
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Scores before and after breastfeeding course&#46; Box and whisker plot&#46; For each group&#44; a box represents the interquartile range &#40;IQR&#41;&#44; the centre line represents the median&#44; and the notches&#44; 90&#37; confidence interval of the median&#46; The upper and lower whiskers reach respectively the maximum and minimum values&#46; The thick horizontal line at 70&#37; represents <span class="elsevierStyleItalic">sufficient</span>&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1435
            "Ancho" => 1570
            "Tamanyo" => 88405
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Scoring increase based on the previous grade of each individual&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1274
            "Ancho" => 2499
            "Tamanyo" => 143660
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Scores shown as grades of the full and reduced versions&#46; A comparison of both versions of the questionnaire&#46; The improvement of all groups is remarkable&#44; especially among paediatricians of the Hospital Ni&#241;o Jes&#250;s &#40;HNJ&#41;&#44; after the open questions are removed&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Breakdown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Physiology</span></td><td class="td" title="table-entry  " align="left" valign="top">Breastfeeding in normal conditions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prematurity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Extended breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Public health</span></td><td class="td" title="table-entry  " align="left" valign="top">Official recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Risks of artificial feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Issues during the first days</span></td><td class="td" title="table-entry  " align="left" valign="top">Hypoglycaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cracks and pain while breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mastitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dehydration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Jaundice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Late issues</span></td><td class="td" title="table-entry  " align="left" valign="top">Inadequate production of milk&#47;poor weight gain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Crying&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Breastfeeding crisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Return to work&#46; Supplementary feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Assessment of feeding</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Maternal factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Drugs&#44; illnesses&#44; toxic substances&#44; prior surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Attitudes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Promotion of breastfeeding&#46; Empathy and counselling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab976851.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Basic areas of breastfeeding knowledge and skills&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Questions 5&#44; 7&#44; 18&#44; 21 and 22 are discussed in the text&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Summarised question<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Relevancy &#40;1&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Agreement about correct option &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">I&#46;A&#46; about correct option<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Agreement about absence of conflict&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">I&#46;A&#46; about lack of conflict<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resulting action&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final I&#46;A&#46; about correct option&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final I&#46;A&#46; about lack of conflict&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Screening for neonatal hypoglycaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More reliable signs to appreciate intake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The main cause of hypernatremic dehydration in a newborn is the delay start of lactation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deleted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mastitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Feeding as needed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Risks of formula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Need for bottle with caesarean-section&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phototherapy and breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Choice of breastfeeding with large prematures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8220;Calm&#8221; infant at risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extended breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor weight gain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breastfeeding and supplementary feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Watery milk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor attachment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cracks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unchanged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Case of growth spurts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Modified&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Factores asociados al abandono precoz de la lactancia materna en una regi&#243;n del este de Espa&#241;a"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; Rius"
                            1 => "J&#46; Ortu&#241;o"
                            2 => "C&#46; Rivas"
                            3 => "M&#46; Maravall"
                            4 => "M&#46;A&#46; Calzado"
                            5 => "A&#46; L&#243;pez"
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                      "Revista" => array:5 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
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                        "paginaFinal" => "15"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The burden of suboptimal breastfeeding in the United States&#58; a pediatric cost analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Bartick"
                            1 => "A&#46; Reinhold"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2009-1616"
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                        "tituloSerie" => "Pediatrics"
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                        "paginaInicial" => "e1048"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20368314"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Obstet Gynecol"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                            0 => "M&#46;C&#46; Bartick"
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                            4 => "A&#46;G&#46; Reinhold"
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                      "titulo" => "Factores que determinan la duraci&#243;n de la lactancia materna durante los tres primeros meses de vida"
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                    0 => array:1 [
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                      "titulo" => "Why do women stop breastfeeding&#63; Findings from the pregnancy risk assessment and monitoring system"
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                            0 => "I&#46;B&#46; Ahluwalia"
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                      ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2005-0013"
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                          "autores" => array:6 [
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                            2 => "J&#46; Sorenson"
                            3 => "J&#46;A&#46; Lohr"
                            4 => "R&#46; Cefalo"
                            5 => "P&#46; Curtis"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
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                0 => array:2 [
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                          "autores" => array:4 [
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                            3 => "R&#46;A&#46; Lawrence"
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                    0 => array:2 [
                      "doi" => "10.1001/archpedi.162.12.1142"
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                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0280" class="elsevierStylePara elsevierViewall">We would like to thank the members of the breastfeeding committee of the AEP&#44; and in particular&#58; Dr Josefa Aguayo Maldonado&#44; Dr Susana Ares Segura&#44; Dr Marta Costa Romero&#44; Dr Marta D&#237;az G&#243;mez&#44; Dr Blanca Esp&#237;nola Doc&#237;o&#44; Dr Beatriz Flores Ant&#243;n&#44; Dr Ana Gimeno Navarro&#44; Dr Adolfo G&#243;mez Pap&#237;&#44; Dr Mar&#237;a Teresa Hern&#225;ndez Aguilar&#44; Dr Ana Jim&#233;nez Moya&#44; Dr Paula Lalaguna Mallada&#44; Dr Juan Jos&#233; Lasarte Velillas&#44; Dr Jes&#250;s Mart&#237;n-Calama Valero&#44; Dr Jos&#233; Manuel Mart&#237;n Morales&#44; Dr Carmen Rosa Pall&#225;s Alonso&#44; Dr Jos&#233; Mar&#237;a Paricio Talayero and Dr Laura Sanfeliciano Mart&#237;n&#46;</p>"
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Article information
ISSN: 23412879
Original language: English
DOI:10.1016/j.anpede.2015.09.018
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