Preethi Govindarajan, BS,​a,b​ Henry A. Spiller, MS, DABAT,​c,​d Marcel J. Casavant, MD,​a,​c,​d E-CigaretteThitphalak Chounthirath, MS,​a Gary A.and Smith, MD, DrPHLiquida,​d,​e Nicotine Exposures Among Young Children OBJECTIVES: abstract

To investigate exposures to liquid nicotine (including electronic cigarette devices and liquids) among children <6 years old in the United States and evaluate the impact of METHODS: legislation requiring child-resistant packaging for liquid nicotine containers. Liquid nicotine exposure data from the National Poison Data System for January RESULTS: 2012 through April 2017 were analyzed. There were 8269 liquid nicotine exposures among children <6 years old reported to US poison control centers during the study period. Most (92.5%) children were exposed through ingestion and 83.9% were children <3 years old. Among children exposed to liquid nicotine, 35.1% were treated and released from a health care facility, and 1.4% were admitted. The annual exposure rate per 100000 children increased by 1398.2% from 0.7 in 2012 to 10.4 in 2015, and subsequently decreased by 19.8% from 2015 to 8.3 in 2016. Among states without a preexisting law requiring child-resistant packaging for liquid nicotine containers, there was a significant decrease in the mean number of exposures − − during the 9 months before compared with the 9 months after the federal child-resistant packaging law went into effect, averaging 4.4 (95% confidence interval: 7.1 to 1.7) fewer CONCLUSIONS: exposures per state after implementation of the law. Pediatric exposures to liquid nicotine have decreased since January 2015, which may, in part, be attributable to legislation requiring child-resistant packaging and greater public awareness of risks associated with electronic cigarette products. Liquid nicotine continues to pose a serious risk for young children. Additional regulation of these products is warranted. a Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, Columbus, WHAT’S KNOWN ON THIS SUBJECT: Since their Ohio; bRutgers New Jersey Medical School, Newark, New Jersey; cCentral Ohio Poison Center, Columbus, Ohio; dDepartment of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio; and eChild Injury introduction to the US market in 2007, use of Prevention Alliance, Columbus, Ohio electronic cigarettes has been increasing. There has been a concurrent increase in liquid nicotine Ms Govindarajan conducted the data analysis and drafted and revised the manuscript; Mr Spiller exposures reported to US poison control centers and Dr Casavant contributed to the conceptualization of the study, assisted in data analysis, among children <6 years old. and critically reviewed the manuscript; Mr Chounthirath assisted in data analysis and revised the manuscript; Dr Smith contributed to the conceptualization of the study, assisted in data WHAT THIS STUDY ADDS: From January 2012 analysis, and critically reviewed and revised the manuscript; and all authors approved the final through April 2017, there were 8269 liquid nicotine manuscript. exposures reported among young children, peaking DOI: https://​doi.​org/​10.​1542/​peds.​2017-​3361 in January 2015. The annual exposure rate increased Accepted for publication Feb 21, 2018 by ∼1400% from 2012 to 2015 and then decreased by 20% from 2015 to 2016. Address correspondence to Gary A. Smith, MD, DrPH, Center for Injury Research and Policy, The ∼ Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2018 by the American Academy of Pediatrics To cite: Govindarajan P, Spiller HA, Casavant MJ, et al. E-Cigarette and Liquid Nicotine Exposures Among Young Children. Pediatrics. 2018;141(5):e20173361

Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 141, number 5, May 2018:e20173361 ARTICLE TABLE 1 States With and Without a State Law Requiring Child-Resistant Packaging for Liquid Nicotine Containers Before the Federal Law Electronic cigarettes (e-cigarettes) Legislation Type State Effective Date are handheld devices that produce States with a state law an aerosol (commonly known New York December 29, 2014 as a vapor) for inhalation from a Illinois, Minnesota, and Vermont January 1, 2015 solution that often contains1 nicotine, New Mexico June 19, 2015 flavoring, and solvents. Since their Indiana and Wyoming July 1, 2015 introduction, there has been an Arkansas July 22, 2015 North Dakota August 1, 2015 increase in the use2, 3​of e-cigarettes in Missouri August 28, 2015 the United States. ‍ There also has Texas October 1, 2015 been an increase in liquid nicotine Virginia October 1, 2015a exposures from e-cigarette devices North Carolina December 1, 2015 and liquids reported to US poison Maine and Tennessee January 1, 2016 Massachusetts March 15, 2016 control centers (PCCs), frequently Washington June 28, 2016 among children4,5​ younger than 6 Oregon July 1, 2016 years of age. These exposures are States without a state law concerning because a small volume Alabama, Alaska, Arizona, California, Colorado, July 26, 2016 of concentrated nicotine solution Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, could easily deliver the estimated Kentucky, Louisiana, Maryland, Michigan, lethal dose of 6.5 to 13.06 mg/kg body Mississippi, Montana, Nebraska, Nevada, weight to a young– child,​ and at least New Hampshire, New Jersey, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, 2 young children7 10 have already died of liquid nicotine. ‍ Children exposed South Dakota, Utah, West Virginia, and Wisconsin to e-cigarette liquid nicotine have a 5.2 times higher odds of a health Retailers could sell previous inventory until January 1, 2016. care facility admission and 2.6 times higher odds of having a serious medical outcome than children 8 characteristics and trends of liquid identified by using the Thomson exposed to cigarettes. 21 nicotine exposures and is the first to Reuters Westlaw database. Official Authors of case reports have compare liquid nicotine exposures legislative databases for individual described liquid– nicotine exposures among young children before and states were accessed for additional in both adults7,10​ 16and children in several after adoption of legislation requiring details as needed. A list was compiled countries. ‍ ‍‍ In state-specific child-resistant liquid nicotine of the effective dates for state studies, an increase in e-cigarette packaging. legislation, defined as the date when exposures reported17,18​ to PCCs has METHODS it was illegal for liquid nicotine been noted. Authors of other to be sold without child-resistant Study Design and Data Sources studies using the National Poison packaging in that state (Table 1). Data System (NPDS) have described Case Selection Criteria trends in exposures to cigarettes 9 and e-cigarettes in all age groups Data from the NPDS were analyzed to and specifically8 among children <6 investigate liquid nicotine exposures years old. Increased awareness of (including e-cigarette devices and Liquid nicotine exposures among the risks of liquid nicotine exposures liquids) among children <6 years children <6 years old from January led to state and federal legislation old. The NPDS is maintained by the 1, 2012, through April 30, 2017, requiring child-resistant packaging19 American Association of Poison were extracted from the NPDS by for liquid nicotine containers. Control Centers (AAPCC) and using the AAPCC generic codes for Although there have been previous includes reported exposure data e-cigarette devices and liquids. studies of liquid nicotine exposure from the regional PCCs serving the In this study, we only included among young children, there has 50 US states, District of Columbia, single-substance human exposures not been a study on exposure rates and several US territories. Exposure – occurring within the 50 US states or after the passage of laws requiring “ – ” data from the PCCs are uploaded to 20 District of Columbia with the reason child-resistant packaging for liquid “ the NPDS on a near real time basis. Unintentional General. Cases with nicotine containers. ” “ ” Federal and state legislation a medical outcome of confirmed In this study, we analyze data requiring child-resistant packaging nonexposure or unrelated effect from the NPDS to investigate the for liquid nicotine containers was were excluded. Downloaded from www.aappublications.org/news by guest on October 1, 2021 2 GOVINDARAJAN et al Study Variables – years with 12 months of complete children exposed to liquid nicotine data (2012 2016). Trends for the experienced 1 or more related Liquid nicotine exposures were n monthly number of exposures were clinical effects. Severe clinical effects characterized by age and sex of n analyzed by using piecewise linear were rare, and included coma ( = 4), the child, date of exposure, route n n regression with breakpoints at seizure ( = 4), respiratory arrest of exposure, level of health care “ ” November 2012 and January 2015. ( = 3), and cardiac arrest ( = 1). received, medical outcome, and Exposure Rates and Trends “ ” To assess the effect of the federal related clinical effects. The “ ” “ ” law for liquid nicotine child-resistant AAPCC defines minor effect,​ containers, only states without moderate effect,​ and major effect – “ ” a similar preexisting law were For years with 12 months of for medical outcome as follows. included. The difference in number complete data (2012 2016), the Minor effect indicates that the of exposures before and after the rate of liquid nicotine exposure individual developed some minimally law was calculated for each state by was 6.4 exposures per 100000 US bothersome signs and symptoms, – using data from 9-month periods children <6 years old. State-specific typically limited to the skin or – before (October 2015 June 2016) rates ranged from 1.6 (Washington, mucous membranes, which resolved “ and after (August 2016 April 2017) DC) to 22.2 (OK) (Fig 1). The quickly with no resulting disability t ” the federal law went into effect. overall exposure rate per 100000 or disfigurement. In a moderate A paired test was used to assess children increased by 1398.2% from effect,​ the individual exhibited the equality of the mean number 0.7 in 2012 to 10.4 in 2015, and signs or symptoms that were not of exposures during the 9 months subsequently decreased by 19.8% life-threatening but were more before and after the federal law went from 10.4 in 2015 to 8.3 in 2016 pronounced, prolonged, or systemic α into effect. Statistical significance (Fig 2). than minor symptoms. Treatment was determined by using = .05. was indicated, and the individual ’ The monthly number of liquid “ ” The institutional review board of the had no residual disability or nicotine exposures was lowest in authors institution judged this study disfigurement. In a major effect,​ the February and July 2012 (8 exposures as exempt. individual displayed life-threatening each month) and peaked in January signs or symptoms, or symptoms that RESULTS 2015 (274 exposures; Fig 3). There caused significant residual disability was no significant change in the 20 General Characteristics monthly number of exposures from or disfigurement. − P January through November of 2012 For this study, the 50 states (m = 0.3, = .816), followed by a and District of Columbia were P From January 1, 2012, to April significant increase of 2390.1% dichotomized into states with and 30, 2017, there were 8269 liquid (m = 8.6, < .001) from November without a child-resistant packaging nicotine exposures among children 2012 through January 2015, and law for liquid nicotine containers − P <6 years old reported to US PCCs. then a significant decrease of 48.2% (Table 1). States were considered The median age of exposed children – (m = 3.9, < .001) from January to have such a law if that law went wasn 2.0 years (interquartile range = 2015 through April 2017. From into effect before July 26, 2016, the 1.3 2.0). The number of exposures August 2016 (175 exposures), the date when the federal Child Nicotine ( = 3146) peakedn at 1 year of age, first month after the federal Child Poisoning Prevention Act of 2015 and children <3n years old accounted Nicotine Poisoning Prevention Act (Public Law No. 114-116) went into 22 for 83.9% ( = 6940) of exposures. went into effect, to April 2017 Statisticaleffect. Analysis and Ethical Most (92.5%,n = 7649) children (142 exposures), there was an 18.9% Considerations were exposed through ingestion decrease in the number of monthly and 55.3% ( n= 4572) of exposures liquid nicotine exposures. were among boys. More than one- SPSS 24.0 (IBM Corp, Armonk, NY) third (35.1%, = 2902) of exposed AmongP states without a preexisting and SAS Enterprise Guide 7.11 childrenn were treated and/or law, there was a significant difference HF3 (SAS Institute, Inc, Cary, NC) evaluated and released, and 1.4% ( = .002) in the mean number of were used to analyze data. Overall n( = 115) were admitted to the hospital. exposures during the 9 months and state-specific exposure rates One-fifth of exposed children (20.3%, before compared with the 9 months were calculated by using the July n = 1677) experienced a minor neffect, after the Child Nicotine Poisoning 1 US Census Bureau population followed by moderate effect (1.6%, Prevention Act of 2015 went into – − − estimates for children23 <6 years = 132) and major effect (0.1%,n = 8). effect, averaging 4.4 (95% confidence old for 2012 2016. Exposure One death occurred to a 1-year-old interval: 7.1 to 1.7) fewer rates were only calculated for the boy. One-fourth (24.6%, = 2032) of exposures per state during the Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 141, number 5, May 2018 3 9 months after implementation of the law. DISCUSSION

During the study period, there were >8200 exposures to liquid nicotine among children <6 years old reported to US PCCs. Although serious medical outcomes were not common, authors of previous studies have found that e-cigarette and liquid nicotine exposures more often are serious and result in health care

facility admission than exposures8,9​ to traditional cigarettes. ‍ Previous reports have described the severe consequences– that can occur from

liquid 7nicotine16 exposure, including FIGURE 1 death. ‍ ‍ State-specific rates of liquid nicotine exposure per 100 000 children <6 years old, NPDS 2012–2016. AK, Alaska; AL, Alabama; AR, Arkansas; AZ, Arizona; CA, California; CO, Colorado; CT, Connecticut; DE, The use of e-cigarettes has increased Delaware; FL, Florida; GA, Georgia; HI, Hawaii; IA, Iowa; ID, Idaho; IL, Illinois; IN, Indiana; KS, Kansas; KY, rapidly since their introduction in Kentucky; LA, Louisiana; MA, Massachusetts; MD, Maryland; ME, Maine; MI, Michigan; MN, Minnesota; the United States in 2007. In 2009, MO, Missouri; MS, Mississippi; MT, Montana; NC, North Carolina; ND, North Dakota; NE, Nebraska; NH, 0.6% of US adults reported ever New Hampshire; NJ, New Jersey; NM, New Mexico; NV, Nevada; NY, New York; OH, Ohio; OK, Oklahoma; OR, Oregon; PA, Pennsylvania; RI, Rhode Island; SC, South Carolina; SD, South Dakota; TN, Tennessee; using an e-cigarette, with2, studies24​ TX, Texas; UT, Utah; VA, Virginia; VT, Vermont; WA, Washington; WI, Wisconsin; WV, West Virginia; WY, reporting increasing use. ‍ The Wyoming. authors of a 2014 report indicated that 12.6% of adults had ever used – 25 an e-cigarette. Younger adults

(18 24 years old) have reported a26 high prevalence of e-cigarette use. Among middle and high school students, e-cigarettes were the most commonly used tobacco product in

2016, with 4.3% and3 11.3% reporting use, respectively. E-cigarette sales

at convenience stores and other 27 outlets grew from 2011 to 2015. Furthermore, from 2014 to 2015,

there was a 303.7% increase in 27 e-cigarette liquid sales specifically. Although nicotine-free products are available, 99.0% of e-cigarette

products sold in the United28 States in 2015 contained nicotine. As the use of e-cigarettes increased, so did the number of liquid nicotine exposures reported to US PCCs. The authors of 1 study reported that exposures among children <6 years FIGURE 2 old increased by 0.55 additional Annual number and rate of liquid nicotine exposures among children <6 years old, NPDS 2012–2016. exposures per month between June 2010 and December 2012 and then accelerated to 6.03 Downloaded from www.aappublications.org/news by guest on October 1, 2021 4 GOVINDARAJAN et al may have influenced child exposures even in states without liquid nicotine packaging laws because manufacturers may have begun to distribute child-resistant containers throughout the United States rather than produce different products for states with and without these requirements. We were unable to detect differences in monthly liquid nicotine exposures before and after enactment of individual state legislation requiring child-resistant packaging for liquid nicotine containers because of the small number of exposures in individual states. Other factors also may have washed out the effects FIGURE 3 of these laws, such as continued Monthly number of liquid nicotine exposures among children <6 years old by state child-resistant – presence of previously-purchased packaging law status, NPDS January 2012–April 2017. ’ non child-resistant containers in children s homes. In addition, manufacturers and retailers were aware of the impending additional exposures per month During the 9 months after the implementation dates of these state laws and may have begun to between January 42013 and effective date (July 26, 2016) of September 2013. The authors the federal law, there was an distribute child-resistant liquid ∼ of another study observed an overall decrease of 18.9% in the nicotine containers before these 1500% increase in monthly monthly number of liquid nicotine Preventiondates. e-cigarette and liquid nicotine exposures. Among states that had exposures among children not previously enacted a similar <6 years old from8 January 2012 state law, there was a significant Although child-resistant packaging to April 2015. Our study is the decrease in the mean number of requirements for liquid nicotine first to report a more recent liquid nicotine exposures among containers have been established, reversal in this trend. In this children <6 years old when more comprehensive requirements study, the monthly number of comparing the 9 months before could further reduce the likelihood reported liquid nicotine exposures of serious poisonings. Flow and after the federal law. Although ’ climbed until January 2015, the federal law may have contributed restrictors effectively limit young followed by an overall downward to this decline, its impact is uncertain children s ability to empty the trend through April 2017. contents of liquid medicine because of a number of potentially 30 bottles. Applying this technology confounding factors and the lack In July 2014, the Child Nicotine to liquid nicotine bottles could of a comparison group. The frequency Poisoning Prevention Act was limit the dose ingested by children of exposures had been decreasing initially introduced in the US who gain access to these bottles. 29 ’ before its enactment. Various Congress. By mid-January Additionally, the Child Nicotine 2015, at the peak of the children s factors likely contributed to the Poisoning Prevention Act only exposures, state legislation in New observed decrease, including state applies to liquid nicotine bottles York, Minnesota, Vermont, and legislation requiring child-resistant and does not address the packaging Illinois requiring child-resistant packaging; efforts by public health or design of e-cigarette devices packaging for liquid nicotine professionals, clinicians, and child themselves. Chambers in refillable containers had gone into effect. safety advocates to inform child e-cigarette devices in which the Fourteen additional states caregivers of the risk of liquid liquid nicotine is held are another ’ (Table 1) soon followed before 22 nicotine exposures; and widespread source of exposure. Child-resistant the federal law s effective date. media attention. State legislation chambers in e-cigarette devices could Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 141, number 5, May 2018 5 help prevent liquid nicotine exposure liquid nicotine exposure and outcome was uncertain, thus limiting the among young children. rates among young children. ability to assess the impact of child-resistant packaging laws Liquid nicotine comes in a variety The FDA passed a final rule on May 10, that only apply to e-cigarette of candy, fruit, dessert, and other 2016, deeming all tobacco products, liquid containers. Although calls flavors that may be attractive to including e-cigarettes and liquid to PCCs regarding liquid nicotine young children. By 2014, there nicotine refill containers, under its exposures have decreased since were 7764 unique flavors found authority. This required all e-cigarette 31 January 2015, the relationship of across all e-cigarette brands. products that went into market this decline with child-resistant The majority of exposures in this after February 15, 2007, to apply for packaging legislation is only an study occurred through ingestion, FDA approval and also established association; there are many other which is associated with the several requirements that had to be 36 factors that may have influenced exploratory behavior common implemented by varying deadlines. exposures and call rates. Despite among young children, but also may However, in May 2017, the FDA these limitations, the NPDS is a be influenced by the attractiveness announced delays in enforcement comprehensive data source useful of liquid nicotine flavors, scents, of future compliance deadlines for investigating liquid nicotine and packaging to a young child. For for several of these requirements. “ exposures in the United States. instance, a bestselling e-liquid sold Additionally, in July 2017, the FDA ” CONCLUSIONS at an online site is named Fruit revealed a new regulatory plan that includes extending premarket Hoops and has packaging that 32 review for e-cigarettes to August features images of colorful cereal. “ The American Academy of Pediatrics 2022 and seeking public comment Liquid nicotine can pose a serious ” poisoning risk for young children. and other health organizations have on regulation of kid-appealing37 called on the US Food and Drug flavors in e-cigarettes. ‍ In addition, The frequency of liquid nicotine the US Department of Justice has exposures among children <6 years Administration (FDA) to ban the use ’ of flavors and attractive labeling for requested extensions in lawsuits that old has decreased since January 33 2015, which may, in part, be liquid nicotine. have challenged the FDA s authority38 to enforce its deeming rule. The attributable to adoption of child- E-cigarette liquid can be purchased ’ final outcome of these actions will resistant packaging laws for liquid at different nicotine concentrations, determine the FDA s future role in nicotine containers and greater typically varying from 0 to 36 34 regulating e-cigarettes and liquid public awareness of the risks mg/mL. Concentrated nicotine nicotine. associated with these products. solutions, such as 60 mg/mL, are Study Limitations Additional measures, including also available to consumers, who child-resistant e-cigarette devices, can then dilute and16, mix34​ their own use of flow restrictors on liquid e-cigarette liquids. ‍ A young This study has several limitations. nicotine containers, and regulations child can easily ingest a lethal dose 6 Exposure calls to PCCs are voluntary; on e-cigarette liquid flavoring, in 1 swallow. In 1 case report, a 15 therefore, the NPDS underestimates labeling, and concentrations, could month-old child died after ingesting the true incidence of exposures to further reduce the incidence of a dose of 4.1 mg/kg of liquid 10 liquid nicotine nationwide. NPDS these exposures and the likelihood nicotine. The 1 death in our study 7 data may not be representative of of serious medical outcomes when was previously reported. Fatalities the entire spectrum of liquid nicotine exposures do occur. from liquid nicotine poisonings could exposures because of potential be prevented by limiting the volume ABBREVIATIONS reporting bias. Exposures reported and concentration of liquid nicotine to PCCs do not necessarily represent packaged in containers to a sublethal ingestion, poisonings, or overdoses dose for an average young child. AAPCC: American Association of ’ because exposures are not generally This approach has been used for >50 Poison Control Centers confirmed with definitive laboratory years for such products as children s e-cigarette: electronic cigarette 35 testing. Information provided to aspirin. FDA: Food and Drug PCCs is by self-report, which cannot Administration Future research should be conducted be completely verified by the PCCs NPDS: National Poison Data to assess the effect of flow restrictors, or AAPCC. Differentiation of liquid System flavoring, labeling, concentration, nicotine exposures due to e-cigarette PCC: poison control center and other product-related factors on devices versus e-cigarette liquids

Downloaded from www.aappublications.org/news by guest on October 1, 2021 6 GOVINDARAJAN et al FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Ms Govindarajan received a research stipend from the National Student Injury Research Training Program at the Center for Injury Research and Policy at Nationwide Children’s Hospital funded by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (grant R49CE002106) and the Child Injury Prevention Alliance while she worked on this study. The interpretations and conclusions in this article do not necessarily represent those of the funding organizations. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on October 1, 2021 8 GOVINDARAJAN et al E-Cigarette and Liquid Nicotine Exposures Among Young Children Preethi Govindarajan, Henry A. Spiller, Marcel J. Casavant, Thitphalak Chounthirath and Gary A. Smith Pediatrics originally published online April 23, 2018;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2018/04/19/peds.2 017-3361 References This article cites 31 articles, 7 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2018/04/19/peds.2 017-3361#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Injury, Violence & Poison Prevention http://www.aappublications.org/cgi/collection/injury_violence_-_poi son_prevention_sub Hazardous Exposure http://www.aappublications.org/cgi/collection/hazardous_exposure_s ub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on October 1, 2021 E-Cigarette and Liquid Nicotine Exposures Among Young Children Preethi Govindarajan, Henry A. Spiller, Marcel J. Casavant, Thitphalak Chounthirath and Gary A. Smith Pediatrics originally published online April 23, 2018;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2018/04/19/peds.2017-3361

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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