Skip to main content
Top
Published in: European Journal of Pediatrics 3/2016

01-03-2016 | Original Article

Physical activity and cardiorespiratory fitness, but not sedentary behavior, are associated with carotid intima-media thickness in obese adolescents

Authors: António Ascenso, António Palmeira, Luís Mendes Pedro, Sandra Martins, Helena Fonseca

Published in: European Journal of Pediatrics | Issue 3/2016

Login to get access

Abstract

This study aimed to analyze the associations between sedentary behavior, physical activity (PA), and cardiorespiratory fitness (CRF), with carotid intima-media thickness (cIMT), a marker of atherosclerosis already present at an early stage among obese adolescents. The associations between anthropometric measures, sedentary time, PA, CRF, and cIMT of 54 Caucasian obese adolescents were analyzed using partial correlations (controlling for age and sex) and multiple linear regressions. Differences between participants with and without a healthy CRF were also analyzed using independent sample t test. Sedentary time did not correlate with any of the variables. Light physical activity correlated positively with mean cIMT (r(38) = 0.36, p = 0.024). Moderate physical activity (MPA) correlated positively with both mean (r(38) = 0.37, p = 0.018) and maximum (r(38) = 0.33, p = 0.039) cIMT. CRF was inversely associated with mean cIMT (r(40) = −0.36, p = 0.019), even when controlling for sedentary time (r(37) = −0.35, p = 0.030). The best predictors of cIMT were MPA and weight. No significant differences in cIMT were found between participants with healthy and unhealthy CRF.
Conclusion: Although we need to be cautious due to the limitations of the study, the results suggest that despite the importance of decreasing sedentary time, increasing PA intensity may be more effective in improving endothelial structural health among obese adolescents.
What is Known:
Pediatric obesity is associated with increased carotid intima-media thickness (cIMT).
Physical activity may have a relevant role in cIMT development.
What is New:
Cardiorespiratory fitness (CRF) may be a key moderator of this process.
Inherited CRF may be protective against cIMT development in obese adolescents.
Literature
1.
go back to reference Aires L, Silva P, Silva G, Santos MP, Ribeiro JC, Mota J (2010) Intensity of physical activity, cardiorespiratory fitness, and body mass index in youth. J Phys Act Health 7:54–59PubMed Aires L, Silva P, Silva G, Santos MP, Ribeiro JC, Mota J (2010) Intensity of physical activity, cardiorespiratory fitness, and body mass index in youth. J Phys Act Health 7:54–59PubMed
2.
go back to reference American College of Sports Medicine (2005) ACSM’s guidelines for exercise testing and prescription. Lippincott Williams & Wilkins American College of Sports Medicine (2005) ACSM’s guidelines for exercise testing and prescription. Lippincott Williams & Wilkins
3.
go back to reference Arnold C, Wenta D, Müller-Ehmsen J, Sreeram N, Graf C (2010) Progenitor cell number is correlated to physical performance in obese children and young adolescents. Cardiol Young 20:381–386CrossRefPubMed Arnold C, Wenta D, Müller-Ehmsen J, Sreeram N, Graf C (2010) Progenitor cell number is correlated to physical performance in obese children and young adolescents. Cardiol Young 20:381–386CrossRefPubMed
4.
go back to reference Barlow SE, Committee E (2007) Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 120(Suppl 4):S164–S192CrossRefPubMed Barlow SE, Committee E (2007) Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 120(Suppl 4):S164–S192CrossRefPubMed
5.
go back to reference Bauer M, Caviezel S, Teynor A, Erbel R, Mahabadi AA, Schmidt-Trucksäss A (2012) Carotid intima-media thickness as a biomarker of subclinical atherosclerosis. Swiss Med Wkly 142:w13705PubMed Bauer M, Caviezel S, Teynor A, Erbel R, Mahabadi AA, Schmidt-Trucksäss A (2012) Carotid intima-media thickness as a biomarker of subclinical atherosclerosis. Swiss Med Wkly 142:w13705PubMed
6.
go back to reference Beauloye V, Zech F, Tran HT, Clapuyt P, Maes M, Brichard SM (2007) Determinants of early atherosclerosis in obese children and adolescents. J Clin Endocrinol Metab 92:3025–3032CrossRefPubMed Beauloye V, Zech F, Tran HT, Clapuyt P, Maes M, Brichard SM (2007) Determinants of early atherosclerosis in obese children and adolescents. J Clin Endocrinol Metab 92:3025–3032CrossRefPubMed
7.
go back to reference Brodersen NH, Steptoe A, Boniface DR, Wardle J (2007) Trends in physical activity and sedentary behaviour in adolescence: ethnic and socioeconomic differences. Br J Sports Med 41:140–144PubMedCentralCrossRefPubMed Brodersen NH, Steptoe A, Boniface DR, Wardle J (2007) Trends in physical activity and sedentary behaviour in adolescence: ethnic and socioeconomic differences. Br J Sports Med 41:140–144PubMedCentralCrossRefPubMed
9.
go back to reference Carlson JA, Crespo NC, Sallis JF, Patterson RE, Elder JP (2012) Dietary-related and physical activity-related predictors of obesity in children: a 2-year prospective study. Child Obes 8:110–115PubMedCentralPubMed Carlson JA, Crespo NC, Sallis JF, Patterson RE, Elder JP (2012) Dietary-related and physical activity-related predictors of obesity in children: a 2-year prospective study. Child Obes 8:110–115PubMedCentralPubMed
10.
go back to reference Cole TJ, Bellizzi MC, Flegal KM, Dietz WH (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320:1240–1243PubMedCentralCrossRefPubMed Cole TJ, Bellizzi MC, Flegal KM, Dietz WH (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320:1240–1243PubMedCentralCrossRefPubMed
12.
go back to reference Deckelbaum RJ, Williams CL (2001) Childhood obesity: the health issue. Obes Res 9(Suppl 4):239S–243SCrossRefPubMed Deckelbaum RJ, Williams CL (2001) Childhood obesity: the health issue. Obes Res 9(Suppl 4):239S–243SCrossRefPubMed
13.
go back to reference Denton SJ, Trenell MI, Plötz T, Savory LA, Bailey DP, Kerr CJ (2013) Cardiorespiratory fitness is associated with hard and light intensity physical activity but not time spent sedentary in 10–14 year old schoolchildren: the HAPPY study. PLoS One 8:e61073PubMedCentralCrossRefPubMed Denton SJ, Trenell MI, Plötz T, Savory LA, Bailey DP, Kerr CJ (2013) Cardiorespiratory fitness is associated with hard and light intensity physical activity but not time spent sedentary in 10–14 year old schoolchildren: the HAPPY study. PLoS One 8:e61073PubMedCentralCrossRefPubMed
14.
go back to reference Eisenmann JC, Welk GJ, Ihmels M, Dollman J (2007) Fatness, fitness, and cardiovascular disease risk factors in children and adolescents. Med Sci Sports Exerc 39:1251–1256CrossRefPubMed Eisenmann JC, Welk GJ, Ihmels M, Dollman J (2007) Fatness, fitness, and cardiovascular disease risk factors in children and adolescents. Med Sci Sports Exerc 39:1251–1256CrossRefPubMed
15.
go back to reference Ekelund U, Luan J, Sherar LB, Esliger DW, Griew P, Cooper A, Collaborators ICsADI (2012) Moderate to vigorous physical activity and sedentary time and cardiometabolic risk factors in children and adolescents. JAMA 307:704–712PubMedCentralCrossRefPubMed Ekelund U, Luan J, Sherar LB, Esliger DW, Griew P, Cooper A, Collaborators ICsADI (2012) Moderate to vigorous physical activity and sedentary time and cardiometabolic risk factors in children and adolescents. JAMA 307:704–712PubMedCentralCrossRefPubMed
16.
go back to reference Fang J, Zhang JP, Luo CX, Yu XM, Lv LQ (2010) Carotid intima-media thickness in childhood and adolescent obesity relations to abdominal obesity, high triglyceride level and insulin resistance. Int J Med Sci 7:278–283PubMedCentralCrossRefPubMed Fang J, Zhang JP, Luo CX, Yu XM, Lv LQ (2010) Carotid intima-media thickness in childhood and adolescent obesity relations to abdominal obesity, high triglyceride level and insulin resistance. Int J Med Sci 7:278–283PubMedCentralCrossRefPubMed
17.
go back to reference Fonseca H, Palmeira AL, Martins SC, Falcato L, Quaresma A (2014) Managing paediatric obesity: a multidisciplinary intervention including peers in the therapeutic process. BMC Pediatr 14:89PubMedCentralCrossRefPubMed Fonseca H, Palmeira AL, Martins SC, Falcato L, Quaresma A (2014) Managing paediatric obesity: a multidisciplinary intervention including peers in the therapeutic process. BMC Pediatr 14:89PubMedCentralCrossRefPubMed
18.
go back to reference Green DJ, Maiorana A, O’Driscoll G, Taylor R (2004) Effect of exercise training on endothelium-derived nitric oxide function in humans. J Physiol 561:1–25PubMedCentralCrossRefPubMed Green DJ, Maiorana A, O’Driscoll G, Taylor R (2004) Effect of exercise training on endothelium-derived nitric oxide function in humans. J Physiol 561:1–25PubMedCentralCrossRefPubMed
19.
go back to reference Gutin B, Yin Z, Humphries MC, Barbeau P (2005) Relations of moderate and vigorous physical activity to fitness and fatness in adolescents. Am J Clin Nutr 81:746–750PubMed Gutin B, Yin Z, Humphries MC, Barbeau P (2005) Relations of moderate and vigorous physical activity to fitness and fatness in adolescents. Am J Clin Nutr 81:746–750PubMed
20.
go back to reference Huang K, Zou CC, Yang XZ, Chen XQ, Liang L (2010) Carotid intima-media thickness and serum endothelial marker levels in obese children with metabolic syndrome. Arch Pediatr Adolesc Med 164:846–851PubMed Huang K, Zou CC, Yang XZ, Chen XQ, Liang L (2010) Carotid intima-media thickness and serum endothelial marker levels in obese children with metabolic syndrome. Arch Pediatr Adolesc Med 164:846–851PubMed
21.
go back to reference Iannuzzi A, Licenziati MR, Acampora C, Salvatore V, Auriemma L, Romano ML, Panico S, Rubba P, Trevisan M (2004) Increased carotid intima-media thickness and stiffness in obese children. Diabetes Care 27:2506–2508CrossRefPubMed Iannuzzi A, Licenziati MR, Acampora C, Salvatore V, Auriemma L, Romano ML, Panico S, Rubba P, Trevisan M (2004) Increased carotid intima-media thickness and stiffness in obese children. Diabetes Care 27:2506–2508CrossRefPubMed
22.
go back to reference Kozàkovà M, Palombo C, Morizzo C, Nolan JJ, Konrad T, Balkau B, Investigators R (2010) Effect of sedentary behaviour and vigorous physical activity on segment-specific carotid wall thickness and its progression in a healthy population. Eur Heart J 31:1511–1519CrossRefPubMed Kozàkovà M, Palombo C, Morizzo C, Nolan JJ, Konrad T, Balkau B, Investigators R (2010) Effect of sedentary behaviour and vigorous physical activity on segment-specific carotid wall thickness and its progression in a healthy population. Eur Heart J 31:1511–1519CrossRefPubMed
23.
go back to reference Lewis TV, Dart AM, Chin-Dusting JP, Kingwell BA (1999) Exercise training increases basal nitric oxide production from the forearm in hypercholesterolemic patients. Arterioscler Thromb Vasc Biol 19:2782–2787CrossRefPubMed Lewis TV, Dart AM, Chin-Dusting JP, Kingwell BA (1999) Exercise training increases basal nitric oxide production from the forearm in hypercholesterolemic patients. Arterioscler Thromb Vasc Biol 19:2782–2787CrossRefPubMed
24.
go back to reference Martínez-Gómez D, Eisenmann JC, Gómez-Martínez S, Veses A, Marcos A, Veiga OL (2010) Sedentary behavior, adiposity and cardiovascular risk factors in adolescents. The AFINOS study. Rev Esp Cardiol 63:277–285CrossRefPubMed Martínez-Gómez D, Eisenmann JC, Gómez-Martínez S, Veses A, Marcos A, Veiga OL (2010) Sedentary behavior, adiposity and cardiovascular risk factors in adolescents. The AFINOS study. Rev Esp Cardiol 63:277–285CrossRefPubMed
25.
go back to reference Meyer AA, Kundt G, Lenschow U, Schuff-Werner P, Kienast W (2006) Improvement of early vascular changes and cardiovascular risk factors in obese children after a six-month exercise program. J Am Coll Cardiol 48:1865–1870CrossRefPubMed Meyer AA, Kundt G, Lenschow U, Schuff-Werner P, Kienast W (2006) Improvement of early vascular changes and cardiovascular risk factors in obese children after a six-month exercise program. J Am Coll Cardiol 48:1865–1870CrossRefPubMed
26.
go back to reference Nassis GP, Papantakou K, Skenderi K, Triandafillopoulou M, Kavouras SA, Yannakoulia M, Chrousos GP, Sidossis LS (2005) Aerobic exercise training improves insulin sensitivity without changes in body weight, body fat, adiponectin, and inflammatory markers in overweight and obese girls. Metabolism 54:1472–1479CrossRefPubMed Nassis GP, Papantakou K, Skenderi K, Triandafillopoulou M, Kavouras SA, Yannakoulia M, Chrousos GP, Sidossis LS (2005) Aerobic exercise training improves insulin sensitivity without changes in body weight, body fat, adiponectin, and inflammatory markers in overweight and obese girls. Metabolism 54:1472–1479CrossRefPubMed
27.
go back to reference Ortega FB, Ruiz JR, Castillo MJ, Sjöström M (2008) Physical fitness in childhood and adolescence: a powerful marker of health. Int J Obes (Lond) 32:1–11CrossRef Ortega FB, Ruiz JR, Castillo MJ, Sjöström M (2008) Physical fitness in childhood and adolescence: a powerful marker of health. Int J Obes (Lond) 32:1–11CrossRef
28.
go back to reference Ortega FB, Tresaco B, Ruiz JR, Moreno LA, Martin-Matillas M, Mesa JL, Warnberg J, Bueno M, Tercedor P, Gutiérrez A, Castillo MJ, Group AS (2007) Cardiorespiratory fitness and sedentary activities are associated with adiposity in adolescents. Obesity (Silver Spring) 15:1589–1599CrossRef Ortega FB, Tresaco B, Ruiz JR, Moreno LA, Martin-Matillas M, Mesa JL, Warnberg J, Bueno M, Tercedor P, Gutiérrez A, Castillo MJ, Group AS (2007) Cardiorespiratory fitness and sedentary activities are associated with adiposity in adolescents. Obesity (Silver Spring) 15:1589–1599CrossRef
29.
go back to reference Prior BM, Yang HT, Terjung RL (2004) What makes vessels grow with exercise training? J Appl Physiol (1985) 97:1119–1128CrossRef Prior BM, Yang HT, Terjung RL (2004) What makes vessels grow with exercise training? J Appl Physiol (1985) 97:1119–1128CrossRef
30.
go back to reference Ruiz JR, Ortega FB, Martínez-Gómez D, Labayen I, Moreno LA, De Bourdeaudhuij I, Manios Y, Gonzalez-Gross M, Mauro B, Molnar D, Widhalm K, Marcos A, Beghin L, Castillo MJ, Sjöström M, Group HS (2011) Objectively measured physical activity and sedentary time in European adolescents: the HELENA study. Am J Epidemiol 174:173–184CrossRefPubMed Ruiz JR, Ortega FB, Martínez-Gómez D, Labayen I, Moreno LA, De Bourdeaudhuij I, Manios Y, Gonzalez-Gross M, Mauro B, Molnar D, Widhalm K, Marcos A, Beghin L, Castillo MJ, Sjöström M, Group HS (2011) Objectively measured physical activity and sedentary time in European adolescents: the HELENA study. Am J Epidemiol 174:173–184CrossRefPubMed
31.
go back to reference Sardinha LB, Baptista F, Ekelund U (2008) Objectively measured physical activity and bone strength in 9-year-old boys and girls. Pediatrics 122:e728–e736CrossRefPubMed Sardinha LB, Baptista F, Ekelund U (2008) Objectively measured physical activity and bone strength in 9-year-old boys and girls. Pediatrics 122:e728–e736CrossRefPubMed
32.
go back to reference Sardinha LB, Santos R, Vale S, Silva AM, Ferreira JP, Raimundo AM, Moreira H, Baptista F, Mota J (2011) Prevalence of overweight and obesity among Portuguese youth: a study in a representative sample of 10–18-year-old children and adolescents. Int J Pediatr Obes 6:e124–e128CrossRefPubMed Sardinha LB, Santos R, Vale S, Silva AM, Ferreira JP, Raimundo AM, Moreira H, Baptista F, Mota J (2011) Prevalence of overweight and obesity among Portuguese youth: a study in a representative sample of 10–18-year-old children and adolescents. Int J Pediatr Obes 6:e124–e128CrossRefPubMed
33.
go back to reference Network SBR (2012) Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours”. Appl Physiol Nutr Metab 37:540–542CrossRef Network SBR (2012) Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours”. Appl Physiol Nutr Metab 37:540–542CrossRef
34.
go back to reference Silva G, Oliveira NL, Aires L, Mota J, Oliveira J, Ribeiro JC (2012) Calculation and validation of models for estimating VO2max from the 20-m shuttle run test in children and adolescents. Arch Exerc Health Dis 3:145–152 Silva G, Oliveira NL, Aires L, Mota J, Oliveira J, Ribeiro JC (2012) Calculation and validation of models for estimating VO2max from the 20-m shuttle run test in children and adolescents. Arch Exerc Health Dis 3:145–152
35.
go back to reference Stabouli S, Kotsis V, Karagianni C, Zakopoulos N, Konstantopoulos A (2012) Blood pressure and carotid artery intima-media thickness in children and adolescents: the role of obesity. Hellenic J Cardiol 53:41–47PubMed Stabouli S, Kotsis V, Karagianni C, Zakopoulos N, Konstantopoulos A (2012) Blood pressure and carotid artery intima-media thickness in children and adolescents: the role of obesity. Hellenic J Cardiol 53:41–47PubMed
36.
go back to reference Stein JH, Korcarz CE, Hurst RT, Lonn E, Kendall CB, Mohler ER, Najjar SS, Rembold CM, Post WS, Force ASoECI-MTT (2008) Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force. Endorsed by the Society for Vascular Medicine. J Am Soc Echocardiogr 21:93–111, quiz 189-190CrossRefPubMed Stein JH, Korcarz CE, Hurst RT, Lonn E, Kendall CB, Mohler ER, Najjar SS, Rembold CM, Post WS, Force ASoECI-MTT (2008) Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force. Endorsed by the Society for Vascular Medicine. J Am Soc Echocardiogr 21:93–111, quiz 189-190CrossRefPubMed
37.
go back to reference Teran-Garcia M, Rankinen T, Bouchard C (2008) Genes, exercise, growth, and the sedentary, obese child. J Appl Physiol (1985) 105:988–1001CrossRef Teran-Garcia M, Rankinen T, Bouchard C (2008) Genes, exercise, growth, and the sedentary, obese child. J Appl Physiol (1985) 105:988–1001CrossRef
38.
go back to reference Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, Bornstein N, Csiba L, Desvarieux M, Ebrahim S, Fatar M, Hernandez Hernandez R, Jaff M, Kownator S, Prati P, Rundek T, Sitzer M, Schminke U, Tardif JC, Taylor A, Vicaut E, Woo KS, Zannad F, Zureik M (2007) Mannheim carotid intima-media thickness consensus (2004-2006). An update on behalf of the Advisory Board of the 3rd and 4th Watching the Risk Symposium, 13th and 15th European Stroke Conferences, Mannheim, Germany, 2004, and Brussels, Belgium, 2006. Cerebrovasc Dis 23:75–80CrossRefPubMed Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, Bornstein N, Csiba L, Desvarieux M, Ebrahim S, Fatar M, Hernandez Hernandez R, Jaff M, Kownator S, Prati P, Rundek T, Sitzer M, Schminke U, Tardif JC, Taylor A, Vicaut E, Woo KS, Zannad F, Zureik M (2007) Mannheim carotid intima-media thickness consensus (2004-2006). An update on behalf of the Advisory Board of the 3rd and 4th Watching the Risk Symposium, 13th and 15th European Stroke Conferences, Mannheim, Germany, 2004, and Brussels, Belgium, 2006. Cerebrovasc Dis 23:75–80CrossRefPubMed
39.
go back to reference Tremblay MS, LeBlanc AG, Kho ME, Saunders TJ, Larouche R, Colley RC, Goldfield G, Connor Gorber S (2011) Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act 8:98PubMedCentralCrossRefPubMed Tremblay MS, LeBlanc AG, Kho ME, Saunders TJ, Larouche R, Colley RC, Goldfield G, Connor Gorber S (2011) Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act 8:98PubMedCentralCrossRefPubMed
40.
go back to reference Trost SG, Pate RR, Sallis JF, Freedson PS, Taylor WC, Dowda M, Sirard J (2002) Age and gender differences in objectively measured physical activity in youth. Med Sci Sports Exerc 34:350–355CrossRefPubMed Trost SG, Pate RR, Sallis JF, Freedson PS, Taylor WC, Dowda M, Sirard J (2002) Age and gender differences in objectively measured physical activity in youth. Med Sci Sports Exerc 34:350–355CrossRefPubMed
41.
go back to reference Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, Allen K, Lopes M, Savoye M, Morrison J, Sherwin RS, Caprio S (2004) Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 350:2362–2374CrossRefPubMed Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, Allen K, Lopes M, Savoye M, Morrison J, Sherwin RS, Caprio S (2004) Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 350:2362–2374CrossRefPubMed
42.
go back to reference Welk GJ, Laurson KR, Eisenmann JC, Cureton KJ (2011) Development of youth aerobic-capacity standards using receiver operating characteristic curves. Am J Prev Med 41:S111–S116CrossRefPubMed Welk GJ, Laurson KR, Eisenmann JC, Cureton KJ (2011) Development of youth aerobic-capacity standards using receiver operating characteristic curves. Am J Prev Med 41:S111–S116CrossRefPubMed
43.
go back to reference Woo KS, Chook P, Yu CW, Sung RY, Qiao M, Leung SS, Lam CW, Metreweli C, Celermajer DS (2004) Overweight in children is associated with arterial endothelial dysfunction and intima-media thickening. Int J Obes Relat Metab Disord 28:852–857CrossRefPubMed Woo KS, Chook P, Yu CW, Sung RY, Qiao M, Leung SS, Lam CW, Metreweli C, Celermajer DS (2004) Overweight in children is associated with arterial endothelial dysfunction and intima-media thickening. Int J Obes Relat Metab Disord 28:852–857CrossRefPubMed
44.
go back to reference Wunsch R, de Sousa G, Toschke AM, Reinehr T (2006) Intima-media thickness in obese children before and after weight loss. Pediatrics 118:2334–2340CrossRefPubMed Wunsch R, de Sousa G, Toschke AM, Reinehr T (2006) Intima-media thickness in obese children before and after weight loss. Pediatrics 118:2334–2340CrossRefPubMed
Metadata
Title
Physical activity and cardiorespiratory fitness, but not sedentary behavior, are associated with carotid intima-media thickness in obese adolescents
Authors
António Ascenso
António Palmeira
Luís Mendes Pedro
Sandra Martins
Helena Fonseca
Publication date
01-03-2016
Publisher
Springer Berlin Heidelberg
Published in
European Journal of Pediatrics / Issue 3/2016
Print ISSN: 0340-6199
Electronic ISSN: 1432-1076
DOI
https://doi.org/10.1007/s00431-015-2654-x

Other articles of this Issue 3/2016

European Journal of Pediatrics 3/2016 Go to the issue