|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 3 | Page : 96-104
Anthropometry of children with cerebral palsy at the Lagos University Teaching Hospital
Titilayo Olubunmi Adekoje1, Mike Nwachukwu Ibeabuchi2, Foluso Ebun Afolabi Lesi3
1 Paediatric Unit, Lagoon Hospital Ikeja, Lagos, Nigeria
2 Department of Anatomy, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Paediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
|Date of Web Publication||4-Jul-2016|
Foluso Ebun Afolabi Lesi
Department of Paediatrics, College of Medicine, University of Lagos, PMB 12003, Lagos
Source of Support: None, Conflict of Interest: None
Background: Cerebral palsy (CP) is one the most common causes of disability among children in developing countries and is often associated with poor growth. The assessment of growth and nutrition of children is an important aspect of health monitoring and is one of the determinants of child survival. Aim: To assess the nutritional status of children with CP as seen in Lagos University Teaching Hospital (LUTH). Subjects and Methods: A prospective case-control study was conducted on children with CP attending the weekly pediatric neurology clinic of the LUTH between April 2005 and March 2006. Controls were apparently healthy children being followed up at the children's out-patient clinic of LUTH for acute illness that had resolved. Anthropometric measurements of weight, length/height, mid-upper arm circumference, and skinfold thickness were taken according to the protocols recommended by the International Society of the Advancement of Kinanthropometry. Statistical Analysis: EPI-INFO (version 6.04) was used for analysis. Chi-square test was used to determine associations. Student's t-test was used to compare means of patients and matched controls. Probability P < 0.05 were taken as statistically significant. Results: The controls had higher weight than the patients with mean weight (standard deviation) of 13.7 (4.8) kg, and 12.0 (4.5) kg, respectively (P = 0.01). There were also statistically significant differences in the subscapular and biceps skinfold measurements between the patient and control groups (P = 0.00004 and 0.000008), respectively. Twenty-four (25.8%) and 5 (5.4%) of the patients had moderate and severe undernutrition compared to 6 (6.1%) and none, respectively, in the control group (P = 0.00005). Conclusion: Children with CP had significantly lower mean anthropometric parameters and were more malnourished compared with the control group of children matched for age, sex, and social class.
Keywords: Anthropometry, cerebral palsy, malnutrition, Nigeria
|How to cite this article:|
Adekoje TO, Ibeabuchi MN, Lesi FE. Anthropometry of children with cerebral palsy at the Lagos University Teaching Hospital. J Clin Sci 2016;13:96-104
|How to cite this URL:|
Adekoje TO, Ibeabuchi MN, Lesi FE. Anthropometry of children with cerebral palsy at the Lagos University Teaching Hospital. J Clin Sci [serial online] 2016 [cited 2021 Jun 23];13:96-104. Available from: https://www.jcsjournal.org/text.asp?2016/13/3/96/185245
| Introduction|| |
Cerebral palsy (CP) is a disorder of movement and posture resulting from a permanent nonprogressive defect or lesion of the immature brain.  It is reported to be the most common cause of motor deficiency in childhood both in developing and developed countries. ,,, The overall prevalence of CP in developed countries has remained unchanged in the past three-four decades, despite remarkable improvement in obstetrical and perinatal care. ,,, These improvements include the increasing availability of fetal heart monitoring and fetal ultrasonography, the establishment of neonatal intensive care units, the implementation of policies to encourage the regionalization of care, and the transport of mothers carrying high-risk fetuses before delivery. , These advancements have enhanced the survival of very low birth weight babies who are particularly at risk of developing the condition, and who would otherwise have died. ,, The prevalence of CP in the USA has remained at 4/1000 live births, and 2/1000 at school entry. ,, In the United Kingdom, a prevalence of 2/1000 live births has been reported. , However, in Nigeria, as in many developing countries, the exact incidence of CP is not known. An earlier study carried out by Animashaun  in Lagos, Nigeria estimated a prevalence rate of 10/1000 of the population of the children. In Enugu, a prevalence of 5/1000 was reported in a community-based population survey of children under 16 years of age.  The high prevalence rate reported by Animashaun  was attributed to the poor standard of obstetric care, partial patronage of the meagre existing facilities by pregnant women, high incidence of prematurity and multiple births, and the ravages of communicable diseases.
It has been well documented in the literature that the children with CP frequently manifest with poor growth. ,,, Studies have shown that children with CP have significantly smaller weights for height, heights for age, and weights for age than siblings or control groups matched for age and sex. , The main cause of poor growth in children with CP has been attributed to inadequate nutritional intake resulting from feeding difficulties. ,,, These include weak suckling, poor coordination of the swallowing mechanisms, coughing and choking during feeding, inability to self-feed, vomiting with aspiration secondary to gastroesophageal reflux (GER). ,,,, Motor handicap with associated speech difficulty in children with CP has also been found to limit their ability to access food or communicate hunger. , Assessment of growth and nutritional status is an essential part of community health monitoring in developing countries.  It forms an important component of childhood survival strategies in these countries. Nutritional assessment can be approached through several procedures such as anthropometry, clinical examination, and biochemical assessment. 
Of all the methods of growth assessment in children, anthropometry is the single most portable, universally applicable, inexpensive, and noninvasive technique.  The measurements must, however, be related to those expected from standard populations. , While the nutritional status of children with CP has been a subject of extensive studies in Europe and America, ,, only a few studies have emerged from developing countries and Africa in particular. ,,
The aim of this study was to assess the nutritional status of children with CP as seen in Lagos University Teaching Hospital (LUTH).
| Subjects and methods|| |
A prospective case-control study was conducted on children with CP attending the weekly pediatric neurology clinic of the LUTH between April 2005 and March 2006. Approval was obtained from the Hospital Research and Ethics Committee before the commencement of the study. Verbal informed consent was also obtained from each parent or guardian at the time of the interview.
Lagos is a cosmopolitan city located in the South-Western part of Nigeria. It is predominantly populated by indigenous Yoruba, but there is a large representation of nonindigenous from other Nigerian ethnic groups. The LUTH is located in Idi-Araba, a densely populated area of urban Lagos. The hospital serves as a tertiary referral center for most of the general hospitals, local government health centres and private hospitals in and around Lagos as well as some other hospitals in the country.
Pediatric services are rendered through out-patient clinics, an emergency room, neonatal unit and general wards. The out-patient clinics run every weekday except on Wednesdays, with an average of 9,984 children seen annually. The neurology clinic runs once weekly on Mondays, with an average yearly attendance of 96 new cases of CP. 
Study population and patient selection
All new patients attending the neurology clinic with a diagnosis of CP, aged between 1-12 years, whose parents gave consent were consecutively recruited for the study. The diagnosis of CP was based on the neurological examination carried out by one of the researchers (TOA), subject to confirmation by the consultant pediatric neurologist (FEAL). CP was defined as a nonprogressive disorder of tone or posture in children over 12 months.
- Presence of any other chronic systemic illness other than that relating to CP, for example cardiac, renal, pulmonary disorders, hemoglobinopathy
- Presence of an acute illness with potential for affecting nutritional status, for example, severe gastroenteritis, within a period of <2 weeks before the study, or patient ill enough to be admitted at the time of study
- Prolonged use of medications; for example, steroids, quinolones, methylphenidate; that are known to affect growth
- Presence of any congenital malformation; for example, cleft lip/palate which would affect food intake.
The control group of this study was selected from apparently healthy children being followed up at the children's outpatient clinic of LUTH for acute illness that had resolved. The children included those who did not have any evidence of chronic illness (for example, cardiac, chronic lung disease, hemoglobinopathy) or any other disease known to affect growth. The children who were ill enough to be admitted and those with feeding problems were excluded from the study. The controls were matched with the subjects for age, sex, and social class.
Before measurement was commenced one of us (TOA) received training in anthropometry under the supervision of an International Society of the Advancement of Kinanthropometry (ISAK)-certified level-2 anthropometrist (MNI). This included reliability testing to achieve technical competence within internationally accepted limits. All anthropometric measurements were performed according ISAK (2001) international guidelines,  for anthropometric assessment, triplicate measures were taken with the median used for calculation. Quality control to obtain reliable measurements with errors within internationally accepted limits was assured by using the technical error of measurement (TEM).
Intra-tester technical error of measurement
Triplicate measurements were taken by the researcher on the same set of subjects and then repeated. The three "pairs" of measurement were then compared using the equation given as follows:
TEM = (Σd2/ 2n) 0.5
d = difference between the first and second estimates of each measurement used.
n = number of measurement sites of the subjects.
This test was used as the measure of precision of the individual researcher's measures.
Intertester technical error of measurement
Triplicate measurements were each taken by both the researcher and the certified anthropometrist on the same set of subjects. These "pairs" of measurements were also compared using the equation given above. The intertester TEM was then used as the measure of accuracy of measurements.
At the end of the training program, the interclass correlation coefficient of >0.90, obtained by comparing the intratester and inter-tester TEMs indicated that the researcher had acquired reliability competencies within internationally accepted standards. The exercise was repeated at intervals during the entire study to further assure strict quality control.
All parents or caregivers were interviewed following informed consent. Information obtained from the parent/caregiver and from the case file of each child using a structured questionnaire included:
- Demographic characteristics: Name of patient, age, sex, date of birth, birth order, and residential address
- Socioeconomic status: The social class was determined by the social classification criteria designed by Oyedeji.  This comprises of five social Classes (I-V), according to a scoring system based on the education level and occupation of both parents. The social class was calculated from the mean of four scores (two each for the father and mother) to the nearest whole number. Social Classes I and II represent the elites, Class III are the middle class, and Class IV and V occupy the lowest rungs of the socioeconomic ladder
- Classification of CP using the modified Swedish classification  of CP
- The severity of motor impairment was assessed using the gross motor function classification system (GMFCS) 
- Anthropometric measurements of weight, length/height, mid upper arm circumference (MUAC), skin fold thickness (biceps, triceps, subscapular, and suprailiac) were taken according to the protocols recommended by the ISAK.  The diagnosis of malnutrition in the children was based on the above anthropometric measurements compared with the median of International references National Center for Health Statistics (NCHS)  for their age and sex, expressing the results in standard deviation scores (SDs) wherein:
Moderate underweight : Weight-for-age (WAz) <−2SD
Moderate stunting : Height-for-age (HAz) <−2SD Moderate wasting : Weight-for-height (WHz) <−2SD
Severe malnutrition : Measurement <−3SD for WAz, HAz or WHz.
- Clinical classification was based on the description of the motor presentation. Spastic if muscle tone was increased, hypotonic if muscle tone was reduced, athetoid if the child presented with writhing movements, ataxic if the child has unsteady movements, and mixed if child has any combination of the above
- Anatomic classification was based on the number and distribution of affected limbs.
The measurement of body weight was carried out using the basinet or electronic weighing scale whichever was appropriate. The basinet (Waymaster, England) calibrated in 50 g units measures maximum weight of 13 kg. Children who weighed above 13 kg were measured with the electronic scale (Seca™ Alpha model 770, Germany) calibrated to the nearest 100 g. The weighing scales were calibrated before use with standard weights, and accuracy confirmed after every five subjects. Length/height was measured using a stadiometer, re-calibrated before use with a GPM Siber-Hegner™ anthropometer. The stadiometer fitted with a footplate also had a sliding headpiece calibrated in millimeters. The recumbent/supine length was measured to the nearest 0.5 cm with a customized anthropometric board with a fixed head plate and a movable foot piece. The MUAC was measured using a Lufkin™ executive flexible steel anthropometric tape (Rosscraft, Surrey, Canada) calibrated to the nearest 0.1 cm. The skinfold thickness was measured with the Slim Guide™ Skinfold Caliper (Bodycare, Warwickshire, England) calibrated to the nearest 1 mm. The same instruments were used throughout the period of study.
All the anthropometric measurements were performed by TOA, with the assistance of a hospital aide. Measurements were carried out between 0830 and 1300 h on clinic days (Mondays). A general physical examination was conducted on the children for stigmata of systemic disease such as frontal bossing, jaundice, gnathopathy, murmurs to exclude those with chronic medical diseases. The weight, height/recumbent length, MUAC and four skinfold sites, including, biceps, triceps, subscapular and supraspinale (suprailiac) were measured following the protocol recommended by 1SAK. 
Children were weighed nude or in minimal clothing using the bassinet or electronic scale. Children who could not stand and whose weight had exceeded the range on the bassinet (13 kg) were weighed in the arms of the mother as suggested by Jelliffe.  The combined weight of mother and child was obtained, and then mother was weighed alone. The difference between the weight of mother and child and the weight of mother alone was recorded as the child's weight. Older children who were able to stand were measured using the electronic scale. Zeroing of the scale was done, and then the subject stood on the center of the scale. Extra care was taken to ensure that the child stood still without the support and with the weight distributed evenly on both feet. The child's weight was recorded to the nearest 100 g.
Stature (standing height) was measured with the stadiometer for children (subjects and controls) above the age of 2 years, who could stand flat-footed and straight. The child stood erect, bare-footed, feet kept together on the platform of the stadiometer, facing the researcher, with the heels, buttocks, shoulders, and upper back of the subject touching the vertical surface of the instrument. The head was held comfortably with the orbitale (the lower edge of the orbit) in the same horizontal plane as the tragion (the notch superior to the tragus of the ear), known as the Frankfort plane. When aligned, the vertex is the highest point on the skull. While keeping the head in the Frankfort plane, gentle upward pressure was applied with the hands under the child's mandible and mastoid process. The assistant made sure that the feet of the child did not come off the platform. The headpiece was then lowered to make firm contact with the vertex, crushing the hair as much as possible. Measurement was read off to the nearest 0.1 cm.
Subjects and controls under the age of 2 years, those who were unable to stand erect, and those who did not have severe contractures were measured using the recumbent length technique, using a customized board with a fixed headrest and a movable foot piece. The child lay supine on the table, while the assistant held the subject's head in contact with the fixed headpiece, with the orbitale and the tragion in the same plane (Frankfort plane), perpendicular to the table. Throughout the measurement, it was ensured that the head, shoulders, buttocks, legs, and heels were all touching the table. The legs were straightened, the feet turned upward to be at right angles to the legs, and the sliding board brought in contact with the child's heels. The length was read off to the nearest 0.5 cm.
For patients with severe contractures, their body lengths were measured segmentally using the tibial length with the aid of a flexible tape as described by Stevenson.  According to this method, the children's stature was derived using the following equation:
S = (3.26 × TL) +30.8
where S indicated estimated stature in centimeters, and TL was the tibial length measured from the superomedial edge of the tibia to the inferior edge of the medial malleolus. Each measurement was taken twice and the mean value was used for data analysis.
Mid upper arm circumference
The MUAC was obtained in children aged 1-5 years only. The upper arm length was measured in the right arm in centimeters from the acromion process of the scapula (acromiale) to the proximal and lateral border of the head of the radius (radiale). The midpoint of the upper arm length, the mid-acromiale-radiale was marked on the skin and projected around to the posterior and anterior surfaces of the arm. The tape was then applied to measure the MUAC. Care was taken not to apply too much pressure to distort the limb contours. In patients with right hemiplegia, the left arm was used.
All measurements were made were made on the right side of the body. Sites for measurement of skinfold thickness are indicated below:
Skinfold : Site
The posterior aspect of the triceps in the midline, at the level of the marked mid-acromiale-radiale landmark
The most anterior part of the biceps at the level of the mid-acromiale-radiale landmark
The undermost tip of the inferior angle of the scapula, at a 45° angle to horizontal
Supraspinale (suprailiac) :
A vertical fold raised at the intersection of two lines (i) a line from the inferior part of the tip of the anterior superior iliac spine (iliospinale) to the anterior axillary border, and (ii) a horizontal line drawn from the most lateral edge of the iliac crest (iliocristale).
Prior to measuring, the researcher ensured that the needle of the skinfold caliper was on zero. The skinfold sites were carefully located using the correct anatomical landmarks and marked with a felt pen. The skinfold was gently picked up at the marked line, grasped and lifted so that a double fold of skin plus the underlying subcutaneous adipose tissue was held between the thumb and index finger of the left hand. Care was taken not to incorporate underlying muscle tissue in the grasp by rolling the fold slightly. The caliper was held perpendicular (at 90°) to the surface of the skinfold site at all times. The researcher made sure that the fold remained held while the caliper was in contact with the skin, which measured the skinfold thickness in millimeters.
Triplicate measurements were taken, and the skinfold sites measured in succession, that is, a complete data set was obtained before repeating the measurements for the second and then third time. The mean of the three measurements was utilized for statistical analysis and anthropometric calculations.
The anthropometric data were analyzed using International NCHS  population as reference. This is the most widely accepted reference at the present time, which has been adopted by the WHO and recommended for international use.  The use of international reference also facilitated comparison with studies done elsewhere. The data were subjected to statistical analysis using the EPI-INFO (version 6.04) Centres for Disease Control and Prevention. Chi-square test was used to determine associations. Student's t-test was used to compare means of patients and matched controls. Probability figures <5% (P < 0.05) were taken as statistically significant.
| Results|| |
A total of 102 patients (63 males and 39 females) with CP in the age range of 1-12 years were seen in the clinic between April 2005 and May 2006. Using the stated exclusion criteria nine patients were excluded from the study. These included the following: One case of spastic hemiplegia secondary to cerebrovascular accident in a known sickle cell disease patient, three children with CP who were acutely ill at the time of recruitment, one case of CP who was also being managed for acyanotic congenital heart disease (ventricular septal defect), and five cases whose data were incomplete because the caregivers who brought them to the clinic could not supply the required information. In all, a total of 93 children with CP (59 males and 34 females) were included in the study. Similarly, using the stated criteria, 99 controls matched for age, sex, and socioeconomic class were also recruited into the study.
[Table 1] compares the biodemographic characteristics of patients and control groups. There were 59 (63.4%) males and 34 (36.6%) females, with a male to female ratio of 1.7:1. Fifty-nine (63.4%) of the cases were aged 2 years or below while 36.6% were above the age of 2 years.
|Table 1: Comparison of biodemographic characteristics of patients and control groups|
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[Figure 1] shows that 54 (58.1%) of the patients had the spastic type, of which spastic quadriplegia accounted for 39 (41.9%). This was followed by the mixed type 23 (24.7%) and the athetoid 10 (10.7%). The least common varieties were ataxic 5 (5.4%) and hypotonic 1 (1.1%) types.
Pattern of severity of CP in the children classified using GMFCS Levels I-V, and in relation to the different types of CP is shown in [Table 2]. Sixty-two (66.7%) of the patients had severe motor impairment with GMFCS Levels IV and V, whereas Level I had only 9 (9.7%) patients. Thirty-two (82.1%) of the 39 patients with spastic quadriplegia, 17 (73.9%) and 6 (60%) of those with mixed and athetoid types, respectively, were severely impaired. None of the patients with hypotonic and ataxic types was severely impaired.
|Table 2: Pattern of severity in relation to the different types of cerebral palsy|
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[Table 3] shows the summary analysis of the measured biometric variables among the patients and controls. The controls were heavier than the patients with mean weight (SD) of 13.7 (4.8) kg, and 12.0 (4.5) kg, respectively (P = 0.01). Although the controls were taller than the patients, with mean height (SD) of 91.7 (15.4) cm and 88.7 (15.1) cm, respectively; this was, however, not statistically significant. There were also statistically significant differences in the subscapular and biceps skinfold measurement between the patient and control groups (P = 0.00004 and P = 0.000008), respectively.
[Table 4] shows the prevalence of malnutrition among the patient and control groups using the weight for age Z-score (WAz), height for age Z-score (HAz), and weight for height Z-score (WHz). The overall prevalence of moderate to severe underweight malnutrition (WAz <−2SD), stunting (HAz <−2SD), and wasting (WHz <−2SD) were higher among the children with CP compared with controls, and these were highly significant with WAz and WHz. Twenty-four (25.8%) and 5 (5.4%) of the patients had moderate and severe undernutrition, respectively. In the control group, 6 (6.1%) children had moderate undernutrition, whereas none was severely undernourished the difference between the two groups was statistically significant with P = 0.00005.
|Table 3: A comparison of mean (standard deviation) anthropometric values of patients and controls|
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|Table 4: Prevalence of malnutrition in patient and control groups using Z-scores|
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About eleven (11.8%) and five (5.4%) of the children with CP had moderate and severe stunting, respectively, compared to 5 (5.1%) and 2 (2.0%), respectively, in the control group (P = 0.096). Fifteen (16.1%) and 6 (6.5%) of the patients had moderate and severe wasting, respectively, compared to 3 (3.0%) and 1 (1.0%), respectively, in the control group (P = 0.0007).
| Discussion|| |
Of the 93 cases of CP reviewed in the present study, there was a preponderance of males compared to females (1.7:1). This was similar to earlier prospective studies carried out in the same hospital, in which a male to female ratio of approximately 1.2:1 was reported in both series. , This finding is also comparable to that of Izuora and Okoro,  in Enugu who reported a male to female ratio of 2.4:1. No obvious explanation could be found for the predominance of males compared to females in the present study.
The majority (63.4%) of the patients recruited were in the age range of 1-2 years. This agreed with the finding by Izuora and Okoro,  in Enugu, where 73% of the subjects were in the age group of up to 2 years. A more recent study by Iloeje and Ejike-Orji,  in the same hospital showed that 92.3% of the 155 cases of CP studied were 4 years or less. This finding was also similar to those from elsewhere in Nigeria  and India  in which 69% and 50%, respectively, of the children were below the age of 2 years. Several reasons have been advanced to explain why older children with CP attending out-patient clinics in this environment are few. Izuora and Okoro  explained that this may partly be due to high early mortality rate, and partly because of the frustration of relatives as a result of nonspectacular response of their handicapped children to treatment.
The most prevalent clinical type of CP in the present study was the spastic variety (58%), of which the quadriplegic type was the most predominant (41.9%). This is similar to reports from earlier studies in other parts of Nigeria and Africa. ,, The second most prevalent variety of CP in the present study was the mixed type, which consisted of a high percentage of spasticity combined with athetosis (50%). This finding conforms with that of other authors. ,
Twenty (21.5%) of the 93 subjects in the present study had mild motor impairment (I and II), whereas 78.5% had moderate to severe impairment (III-V). This differs from the 53.5% and 46.5% of mild and moderate to severe motor impairment, respectively, reported in the series by Ozturk et al. in Turkey. Generally, the proportion of patients with severe impairment in any study is affected by the distribution of types of CP among the patients studied. Reports have shown that the quadriplegic, mixed, and dystonic types of CP are associated with severe motor impairment while diplegic and hemiplegic types are associated with mild to moderate impairment. , In the present study, spastic quadriplegia, mixed and dyskinetic (athetoid) varieties were the most predominant types, constituting 77.4% of the patients. It is therefore not surprising that the majority of the subjects had moderate to severe impairment. On the other hand, in the series by Ozturk et al.,  diplegic and hemiplegic types constituted the majority (58.2%) of the subjects.
The overall prevalence of undernutrition (WAz <−2SD) among children with CP in the present study was 31.2% while that of stunting (HAz <−2SD) and wasting (WHz <−2SD) were 17.2% and 22.6%, respectively. The prevalence of undernutrition in the present study (31.2%) was comparable to that of 34.9% and 30% documented in the series by Ozturk et al.  in Turkey and Stallings et al.  in the United States, respectively.
Similarly, the present study has shown that the children with CP had significantly lower mean weight, biceps, and subscapular skinfold thickness when compared with controls matched for age, sex, and social class. This finding agrees with those of other researchers.  The observed differences in the nutritional status between the two groups are not surprising, considering the associated deficits that adversely affect food intake in children with CP. Gastrointestinal co-morbidities have been observed to be a major chronic problem in 80-90% of children with CP, who are at special risk of developing malnutrition because of uncoordinated swallowing, GER and constipation.  The mean values of the height, triceps, and suprailiac skinfold measurements were lower in the patients when compared with the controls, the differences were not statistically significant. No overweight children were encountered in the patient and control groups. This is contrary to reports from other developed countries where overnutrition was reported in 4-19% of patients with CP. , It indicates that most of the nutritional problems in the developing world are still under-nutrition, in contrast with overnutrition in more advanced countries.
| Conclusion|| |
Children with CP had significantly lower mean weight, subscapular, and biceps skinfold measurement, compared with the control group of children matched for age, sex, and social class. The prevalence of moderate to severe underweight malnutrition, stunting, and wasting among the children with CP as measured by WAz, HAz, and WHz scores were high at 31.2%, 17.2%, and 22.6%, respectively. Regular nutritional and growth assessment should be an integral part of the overall management of children with CP. A nutritional component should be incorporated into rehabilitation programmes of children with CP to facilitate early detection of growth retardation and commencement of appropriate nutritional intervention programme.
This is to declare that one of the authors (FEAL) is a member of the Editorial Committee of the Journal of Clinical Sciences. However, the above said author is not involved in any of the editorial processes and does not participate in the decisions of the Editor-in-Chief.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]