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participating in the myelination and synaptogenesis processes&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Regarding embryonic life&#44; the importance of iron in the first three months is mostly related to the embryogenesis of the nervous system&#44; whereas in the last trimester of pregnancy the fetus needs to form its own iron stores&#46; Studies suggest that the peak of iron uptake in the CNS coincides with the myelination peak&#44; especially in the late fetal and early postnatal stages&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Iron deficiency &#40;ID&#41; is the most common nutritional deficiency in the world&#44; affecting about a quarter of the world population&#44; and these numbers increase even more during pregnancy&#44; reaching 59&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> In addition&#44; some maternal and fetal pathologies may affect the newborn&#39;s &#40;NB&#41; iron stores&#44; such as hypertension&#44; diabetes mellitus&#44; intrauterine fetal growth restriction&#44; smoking during pregnancy&#44; and premature birth&#44; making the perinatal period especially susceptible to nutritional deficiency of this element&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">ID anemia has well-known impacts on CNS&#44; such as reduced nerve conduction velocity and cognitive-behavioral changes&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> Iron deficiency without anemia&#44; which has a prevalence 3&#8211;5 times higher than that of iron deficiency anemia&#44; can also harm the CNS&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> Oligodendrocytes&#44; the cells responsible for myelin production&#44; are particularly sensitive to iron deficiency<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> and it has been shown that NBs submitted to intrauterine iron deficiency presented long-term CNS damage&#44; reaching lower language scores and motor development at 5 years of age compared to those born with normal iron stocks&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Being part of the CNS&#44; the developing auditory system is particularly vulnerable to nutritional changes during early fetal and postnatal life&#44; especially due to the accelerated process of neuronal growth and development&#44; myelination&#44; and establishment of the synaptic network&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> Neural maturation of the auditory system progresses in the caudal&#8211;rostral direction and myelination of the auditory nerve pathway is considered an index of cerebral myelination&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Brainstem evoked response audiometry &#40;BERA&#41; consists of recording the electrical stimulus from the inner ear to the brainstem in response to an acoustic stimulus&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> This test evaluates the electrophysiological activity of the auditory system at the level of the brainstem from the cochlear nerve&#44; cochlear nuclei&#44; superior olivary complex&#44; and the bridge to the inferior-mesencephalic colliculus&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The waves evaluated by BERA comprise three larger waves &#40;I&#44; III&#44; and V&#41; that can be reliably measured in newborns with a gestational age of more than 34 weeks&#46; The absolute latencies for each of the waves and their intervals&#44; as determined by BERA&#44; are influenced by the degree of myelination&#44; neuronal development&#44; synaptic function&#44; and axonal growth of the auditory nervous system&#59; they are a measure of the nerve conduction velocity at different levels of the auditory pathway&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> As the relationship between these latencies and myelination is negative&#44; less latency means greater &#40;better&#41; myelination and vice versa&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although data from the literature show the close relationship between the development of the auditory system and iron homeostasis&#44; the changes that ID without anemia cause&#44; also called latent iron deficiency &#40;LID&#41;&#44; are still not completely clear&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13&#8211;15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Considering the possible negative repercussions of LID on the CNS myelination process&#44; 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had their blood collected and underwent otologic evaluation with BERA&#44; and 109 full-term NBs with weight &#62;2500<span class="elsevierStyleHsp" style=""></span>g&#44; born without fetal distress &#40;Apgar<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>7&#41;&#44; who fulfilled the inclusion criteria&#44; were fully studied &#40;<a class="elsevierStyleCrossRef" href="#sec0045">Supplementary Fig&#46; 1</a>&#41;&#46; All the mothers answered a sociodemographic questionnaire designed by the researchers&#46; Maternal and NB data were obtained from hospital clinical records&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">After delivery&#44; umbilical cord blood was collected to determine the ferritin and hematocrit levels&#46; The samples were then kept at room temperature until their determination&#44; up to 4<span class="elsevierStyleHsp" style=""></span>h after collection&#46; All NBs underwent an otologic evaluation within the first 28 days after birth&#46; Two tests were carried out&#58; the otoacoustic emission test &#40;OAE&#41; and BERA&#46; OAE was performed before hospital discharge&#44; between 24<span class="elsevierStyleHsp" style=""></span>h and 48<span class="elsevierStyleHsp" style=""></span>h after birth&#44; and BERA was carried out after hospital discharge&#44; up to 28 days&#46; The audiological evaluations were performed by a single qualified phonoaudiologist&#44; who did not have prior access to the blood test results&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Inclusion criteria</span>&#58; NBs of both genders with 37 weeks or more of GA&#44; weight &#62;2500<span class="elsevierStyleHsp" style=""></span>g&#44; born at the Santa Casa de Misericordia Maternity Hospital during the study period&#44; from the public or supplementary health care system&#46; Only NBs with a normal hematocrit value &#40;&#8805;42&#37; and &#8804;60&#37;&#41; were included in the study&#46; NBs whose mothers had arterial hypertension or diabetes mellitus were included in the study&#44; given the higher probability of these NBs being iron deficient&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Exclusion criteria</span>&#58; NBs at risk of hearing impairment &#40;family history of congenital hearing loss in first-degree relatives&#41;&#44; those with congenital infections &#40;toxoplasmosis&#44; rubella&#44; cytomegalovirus&#44; herpes&#44; syphilis&#44; HIV&#41;&#44; genetic syndromes&#47;chromosomal abnormalities&#44; perinatal problems &#40;hemolytic disease&#44; hypoglycaemia&#44; prolonged jaundice&#44; neonatal sepsis&#41;&#44; intensive care unit &#40;ICU&#41; permanence&#44; and presence of craniofacial abnormality&#44; as any of these comorbidities could alone cause changes in BERA results&#46; NBs with a 1 or 5<span class="elsevierStyleHsp" style=""></span>min Apgar score less than 7 and ferritin &#60;11<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; as well as children of mothers with a T-ACE score equal or greater than 2 and a Fagerstr&#246;m test score equal or greater than 5 during gestation were excluded as well&#46; T-ACE is an alcohol screening questionnaire adapted to identify risk drinking during pregnancy and the Fagerstr&#246;m test is a standard instrument for assessing the level of addiction to nicotine&#46; NBs with increased TSH &#40;thyroid stimulating hormone&#41; values in neonatal screening program &#40;blood spot TSH<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mUI&#47;L&#41; &#40;cut-off APAE-SP&#41; were also excluded&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">NBs were divided into two groups&#58; Group 1 &#40;control&#41;&#58; value of ferritin in umbilical cord &#62;75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; infants without iron deficiency&#59; Group 2 &#40;LID&#58; value of ferritin in umbilical cord &#8805;11 and &#8804;75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; infants with LID&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13&#44;15&#8211;17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Hematocrit was measured using the method proposed by Wintrobe et al&#46; in 1987&#46; Ferritin determination was performed by a solid phase chemiluminescent immunoassay enzyme assay &#40;Immulite&#47;Immulite 1000 Ferritin &#8211; Siemens Healthcare Diagnostics&#44; United Kingdom&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The OAE was done using a &#8220;pass or fail&#8221; screening mode and the BERA using a diagnostic mode&#46; Only infants who underwent auditory screening using the OAE&#44; and passed&#44; were recruited for BERA&#46; The OAE was carried out by the same phonoaudiologist responsible for the BERA test&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The equipment used for BERA was the Bio-Logic Navigator Pro&#174; &#40;stimulus&#58; click&#59; transducer&#58; insertion earphones&#59; polarity&#58; alternating&#41;&#46; The test was run while the NB was asleep in a quiet environment with electrical insulation and dimmed light&#44; and did not require sedation&#46; Headphones with monaural stimulation were used&#46; Sound stimulus with an intensity of 80 dBNA&#44; at a rate of 27&#46;7<span class="elsevierStyleHsp" style=""></span>clicks&#47;second &#40;Hood Standardization &#8211; 1998&#41; was used&#46; The impedance between the electrodes was considered to be less than 3<span class="elsevierStyleHsp" style=""></span>kOhms&#44; according to the equipment&#39;s instruction manual&#46; The parameters utilized were&#58; alternating polarity clicks&#44; low pass filter 100<span class="elsevierStyleHsp" style=""></span>Hz and high pass 1500<span class="elsevierStyleHsp" style=""></span>Hz&#44; a total of 2000 stimuli&#44; a presentation rate of 27&#46;7<span class="elsevierStyleHsp" style=""></span>stimuli&#47;s and a window analysis of 10&#46;66<span class="elsevierStyleHsp" style=""></span>ms&#46; Each record was duplicated to ensure reproducibility of the results&#46; For each patient&#44; the lower latency of each wave and interpeak interval between the two ears was selected&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">To analyze the effect of mothers&#8217; diabetes mellitus &#40;DM&#41; and&#47;or hypertension on BERA values&#44; the authors designed a variable named <span class="elsevierStyleItalic">patho</span> that was categorized as&#58; 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>no pathology and 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>hypertension or&#47;and DM&#44; for statistical calculations&#46; Accounting for the main role of ferritin as a cutoff variable &#40;determining two significant different groups&#58; higher or lower than 75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#44; the authors analyzed LID&#39;s contribution to BERA results through the variable named <span class="elsevierStyleItalic">LID</span>&#44; where 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>no LID and 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>presence of LID&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Basic statistical analysis was performed by using GraphPad prism&#44; version 7 for Windows &#40;GraphPad Software&#44; CA&#44; USA&#41; and multivariate models by SPSS &#40;SPSS for Windows&#44; Chicago&#44; USA&#41;&#46; Results were presented as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41;&#44; median &#40;minimum&#8211;maximum&#41;&#44; or percentage&#44; depending on the variable&#46; The statistical significance of the differences was determined by the nonparametric <span class="elsevierStyleItalic">t</span>-test &#40;Mann&#8211;Whitney&#41; or the Fisher&#39;s exact test&#44; as needed&#46; The linear correlation among all variables was calculated by the Spearman method&#46; Multivariate regression models were utilized for multiple correlation analysis in two ways&#58; &#40;1&#41; the variables that were significant at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;10 in the univariate model &#40;Spearman correlation&#41; were included in the multiple model to evaluate the contribution of each one of these variables&#59; &#40;2&#41; analysis in a stepwise processes where the non-contribute predictors were excluded by the statistical process&#44; highlighting the most significant correlates of BERA values&#46; Analysis of covariance was carried out to evaluate the influence of LID on BERA results&#44; taking into account NB gestational age&#46; The significance level adopted was 5&#37;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0110" class="elsevierStylePara elsevierViewall">Blood samples&#44; OEA&#44; and BERA were carried out on 109 NBs&#46; OAE was normal in all individuals&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">After dividing the groups&#44; 71 NBs had normal serum ferritin &#40;&#62;75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; and comprised the control group&#59; 38 NBs presented LID &#40;&#8805;11 and &#8804;75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; and were included in the LID group &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; There was no significant difference between the groups regarding maternal age&#44; number of pregnancies&#44; previous abortions&#44; and number of prenatal consultations&#46; The LID group presented a higher number of pregnant women presenting DM and&#47;or hypertension &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Birth weight was significantly higher and the GA significantly lower in the LID group compared to the control group&#46; The birth weight for the control group was 3273<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>343&#46;9<span class="elsevierStyleHsp" style=""></span>g and the LID group 3573<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>374&#46;7<span class="elsevierStyleHsp" style=""></span>g &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; The mean GA of the control group was 274&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;9 days and for the LID group&#44; 272&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;5 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46; Postnatal age and the corrected gestational age for BERA testing were not significantly different between groups&#44; as well as the Apgar scores&#44; birth length&#44; and gender distribution &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Hematocrit values were 47&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;6 for the control group and 48&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;3 for LID group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;10&#41;&#46; Ferritin values were 160&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>94&#46;2 for the control group and 49&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;1 for LID group&#46; Ferritin values were significantly different between groups as a result of the study design &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The V-wave latency values &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; intervals I&#8211;III &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#44; I&#8211;V &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0003&#41; and III&#8211;V &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41; were significantly higher in the LID group compared to the control group &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; All these parameters presented a significant nonparametric negative correlation with ferritin and positive with LID&#58; V-wave &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;29&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;29&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#44; interval I&#8211;III &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;24&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;29&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#44; interval I&#8211;V &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;35&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0002&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;29&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; and interval III&#8211;V &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;25&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;29&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Multiple correlation analysis of the significant variables for each BERA interval and V-wave are represented in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Utilizing the stepwise approach&#44; the most significantly predictor of V-wave values was test gestational age &#40;standardized <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;255&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#59; for interval I&#8211;III was LID &#40;standardized <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;233&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#41;&#59; for interval I&#8211;V were LID &#40;standardized <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;249&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;08&#41; and Apgar 1<span class="elsevierStyleHsp" style=""></span>minute score &#40;standardized <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;206&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;027&#41;&#59; for interval III&#8211;V they were LID &#40;standardized <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;229&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41; and Apgar 1<span class="elsevierStyleHsp" style=""></span>minute score &#40;standardized <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;263&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The analysis of covariance showed that LID contributed to the results of all BERA intervals&#44; even taking into account the gestational age&#58; interval I&#8211;III &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;087&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;026&#41;&#44; interval I&#8211;V &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#46;436&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41; and interval III&#8211;V &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;856&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#41;&#46; The significance for V-wave was borderline &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;909&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;91&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">The developing brain and auditory system are particularly vulnerable to nutritional changes during early fetal and postnatal life&#44; especially due to the accelerated process of neuronal growth and development&#44; myelination&#44; and formation of the cerebral synaptic network&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> Perinatal ID results in deficiency of the redox reactions of the hippocampus and frontal cortex energetic metabolism&#44; modifications of the glutamate and dopamine concentrations&#44; and of the neuronal myelination pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">This study showed that LID determined a significant increase in V-wave and all interpeak interval latencies in BERA&#44; with an inverse proportional correlation between serum ferritin concentrations and BERA parameters&#46; In animal studies&#44; iron deficiency without anemia resulted in a decreased number of synapses and in a lower wave amplitude in BERA&#44; with increased susceptibility to noise-induced hearing loss&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Other animal studies also reported significant functional consequences on BERA as a result of borderline iron deficiency&#44; and in Long&#8211;Evans rats&#44; the severity of the changes in BERA correlated with the level of serum iron&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> In 2012&#44; Lee et al&#46; analyzed BERA in iron-deficient female rats and showed a significant decrease in nerve conduction velocity at 40 days of life&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> Other studies on rodents have demonstrated that neurobehavioral changes resulting from iron deficiency during pregnancy and lactation persist even when iron concentrations are normalized after weaning&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Studies on humans also suggest that LID causes damage to the neuropsychomotor development of preterm and full-term infants&#46; In 2002&#44; Tamura et al&#46; reported lower motor skills and language development at 5 years of age in NBs with serum ferritin in the lower quartile compared to those with ferritin above this value&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> In another study&#44; infants of diabetic mothers with a low serum ferritin level in the cord serum had a lower auditory recognition memory at birth and lower psychomotor development scores at 1 year of age&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In a study that showed a relationship between LID and BERA waves&#44; 33 NBs with normal ferritin compared to 12 NBs with LID&#44; with a gestational age &#8805;35 weeks&#44; finding significantly increased latency in individuals with LID&#44; as was shown in the present study&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Another study evaluated NBs with a gestational age &#8805;34 weeks and the results indicated a higher V-wave and I&#8211;V and III&#8211;V interpeak intervals latency in the LID group&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> In 2016&#44; Lou also showed that at 10 months&#44; infants born with LID still had a decrease in the V-wave amplitude and an increase in I-wave latency&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> All these studies&#44; including the&#44; demonstrated changes in the I&#8211;V interval&#44; which may mean that the whole auditory pathway can be affected by intrauterine iron deficiency&#46; The degree of reversibility of BERA changes secondary to LID in utero is not well established and there are a lack of studies that define to what extent and until when the changes caused by LID can last&#44; just as the factors that affect the reversibility of these alterations&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> For example&#44; in 2011 Berglund et al&#46; realized an iron intervention trial and did not show a significant auditory effect of postnatal iron supplementation in marginally low birth-weight infants&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In this study&#44; there was a significant difference in gestational age between the two groups&#44; which could be a confounding factor for the analysis&#44; although the whole group studied was at term and the BERA age test and the postnatal age test were not significantly different between groups&#46; The correlation among GA and BERA values &#40;wave V&#44; intervals I&#8211;III and I&#8211;V&#41; showed that&#44; even in term NBs&#44; the gestational age have an influence on BERA values&#46; Nevertheless&#44; this study and recent studies with a similar methodological design that included NBs &#8805;35 weeks<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> or &#8805;34 weeks<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> demonstrated a significant relationship between LID and higher latencies in BERA&#44; even after controlling GA as a variable&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The authors used ferritin concentration to define a state of LID&#44; a parameter also utilized in recent studies on the subject&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Although there are newer iron store assays&#44; in addition to ferritin&#44; they have not been standardized for use on neonates and are not readily available&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">An unanswered question is whether the alterations in myelination of the auditory pathways are representative of the development of white matter in other brain areas&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> It is also unclear whether infants at risk for iron deficiency should be routinely assessed for their iron status shortly after birth&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> This may be critical for populations in which maternal iron deficiency during pregnancy is very common&#44; such as the Brazilian population&#46; Currently&#44; iron supplementation is not recommended for full-term infants during the first months after birth<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26&#44;27</span></a> and there is no evidence that early iron replacement in the neonatal period is capable of reversing the changes in the CNS development and the auditory system&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">23&#44;28&#44;29</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">One limitation of this study is that&#44; as in other observational studies&#44; a causal relationship could not be established between BERA changes and LID&#44; and currently there is no data regarding subsequent follow up of these NBs&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> More research is needed to answer these questions&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In conclusion&#44; iron deficiency anemia is still a very prevalent pathology&#44; and this research&#44; in addition to other studies on the subject&#44; points to serious and perhaps irreversible auditory maturation damage related to LID in utero&#46; Therefore&#44; it is important to take effective measures for the prevention and adequate management of this nutritional challenge in the different phases of life&#44; such as iron supplementation during pregnancy&#44; control of diseases that pose a risk for ID during the gestational period&#44; and screening and treatment of anemia at any stage of life&#44; especially in the most vulnerable and at risk individuals&#44; such as NBs and pregnant women&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Compliance with ethical standards</span><p id="par0185" class="elsevierStylePara elsevierViewall">The research was approved by the Human Research Ethics Committee at the Federal University of S&#227;o Carlos &#40;process 791&#44;511&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">This work was supported by the <span class="elsevierStyleGrantSponsor" id="gs1">S&#227;o Paulo Research Foundation &#40;Funda&#231;&#227;o de Amparo a Pesquisa do Estado de S&#227;o Paulo &#91;FAPESP&#93;</span>&#59; grant number <span class="elsevierStyleGrantNumber" refid="gs1">2015&#47;15471-4</span>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2018-07-05"
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            0 => "BERA"
            1 => "Ferritin"
            2 => "Newborn"
            3 => "Latent iron deficiency"
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          "clase" => "keyword"
          "titulo" => "Palavras-chave"
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          "palabras" => array:4 [
            0 => "PEATE"
            1 => "Ferritina"
            2 => "Rec&#233;m-nascido"
            3 => "Defici&#234;ncia de ferro latente"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This study analyzed the relationship between latent iron deficiency evaluated by ferritin&#44; and the myelination of the central nervous system evaluated through the brainstem evoked response audiometry test&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of 109 full-term newborns&#44; born without anemia and risk factor for hearing deficiency&#44; were enrolled&#46; After delivery&#44; umbilical cord blood was collected to determine ferritin and hematocrit levels&#46; The brainstem evoked response audiometry test was carried out in the first 28 days of life&#46; Analysis was performed between the control group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#41; with ferritin greater than 75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; and the latent iron deficiency group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#41; with ferritin between 11 and 75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; Results were presented as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; Statistical analysis was performed using GraphPad prism7 and SPSS with a significance level of 5&#37;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A significant higher V-wave &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; and interpeak intervals I&#8211;III &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#44; I&#8211;V &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0003&#41;&#44; and III-V &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0002&#41; latencies were found in the latent iron deficiency group&#44; as well as a significant inversely proportional correlation between ferritin and the same wave and intervals &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0013&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0002&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#44; respectively&#41;&#46; Multiple correlation analysis showed a significant correlation of latent iron deficiency with all interpeak intervals&#44; even taking into account newborn gestational age&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Iron deficiency anemia is a prevalent pathology&#59; this study showed auditory delayed maturation associated to intrauterine iron deficiency&#44; even in its latent form&#46; This reinforces the importance of adopting effective measures&#44; on a global scale&#44; to prevent and treat this pathology in different life periods&#44; especially in the most vulnerable population&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Este estudo analisou a rela&#231;&#227;o entre defici&#234;ncia de ferro latente avaliada pela ferritina e a mieliniza&#231;&#227;o do sistema nervoso central avaliada pelo teste de Potenciais Evocados Auditivos de Tronco Encef&#225;lico&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram inclu&#237;dos no estudo 109 rec&#233;m-nascidos a termo&#44; nascidos sem anemia e fator de risco para defici&#234;ncia auditiva&#46; Ap&#243;s o parto&#44; o sangue do cord&#227;o umbilical foi coletado para determinar os n&#237;veis de ferritina e hemat&#243;crito&#46; O teste de Potenciais Evocados Auditivos de Tronco Encef&#225;lico foi realizado nos primeiros 28 dias de vida&#46; A an&#225;lise foi realizada entre o grupo controle &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#41; com ferritina acima de 75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL e o grupo com defici&#234;ncia de ferro latente &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#41; com ferritina entre 11 e 75<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; Os resultados foram apresentados como m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desvio-padr&#227;o&#46; A an&#225;lise estat&#237;stica foi realizada utilizando o software GraphPad prism7 e SPSS com n&#237;vel de signific&#226;ncia de 5&#37;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Lat&#234;ncias significativamente maiores da onda V &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41; e dos intervalos interpicos I-III &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#41;&#44; I-V &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#41; e III-V &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0002&#41; foram encontradas no grupo de defici&#234;ncia de ferro latente&#44; assim como uma correla&#231;&#227;o significativa inversamente proporcional entre a ferritina e a mesma onda e intervalos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0013&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0002&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;009&#44; respectivamente&#41;&#46; A an&#225;lise de correla&#231;&#227;o m&#250;ltipla mostrou uma correla&#231;&#227;o significativa da defici&#234;ncia de ferro latente com todos os intervalos interpicos&#44; mesmo se levarmos em considera&#231;&#227;o a idade gestacional do rec&#233;m-nascido&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A anemia ferropriva &#233; uma patologia prevalente e este estudo demonstrou matura&#231;&#227;o auditiva tardia associada &#224; defici&#234;ncia intrauterina de ferro&#44; mesmo em sua forma latente&#46; Isso refor&#231;a a import&#226;ncia da ado&#231;&#227;o de medidas efetivas&#44; em escala global&#44; para prevenir e tratar essa patologia em diferentes per&#237;odos da vida&#44; principalmente na popula&#231;&#227;o mais vulner&#225;vel&#46;</p></span>"
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            "identificador" => "abst0025"
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            "identificador" => "abst0030"
            "titulo" => "M&#233;todo"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0045">Please cite this article as&#58; Pallone LV&#44; Jesus FA&#44; Gon&#231;alves GA&#44; Navarra LC&#44; Melo DG&#44; Ferreira RA&#44; et al&#46; Effects of intrauterine latent iron deficiency on auditory neural maturation in full-term newborns&#46; J Pediatr &#40;Rio J&#41;&#46; 2020&#59;96&#58;202&#8211;9&#46;</p>"
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            "apendice" => "<p id="par0210" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="fig0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0045"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">DM&#44; diabetes mellitus&#59; Fagerstr&#246;m test&#44; standard instrument for assessing the level of addiction to nicotine&#59; LID&#44; latent iron deficiency&#59; SD&#44; standard deviation&#59; T-ACE&#44; alcohol screening questionnaire adapted to identify risk drinking during pregnancy&#59; max&#44; maximum&#59; min&#44; minimum&#59; TSH&#44; thyroid stimulating hormone&#46;</p>"
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                  \t\t\t\t">Supplemental health care &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="char" valign="middle">0&#46;55<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Public health care &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of pregnanciesmedian &#40;min&#8211;max&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;59<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of abortionsmedian &#40;min&#8211;max&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;98<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of prenatal visitsmedian &#40;min&#8211;max&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;4&#8211;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;7&#8211;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;36<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maternal DM or&#47;and hypertension &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;06<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fagerstr&#246;m test &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Smoker 4Non-smoker 96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Smoker 0Non-smoker 100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;55<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T-ACE scoremedian &#40;min&#8211;max&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#8211;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#8211;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;59<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apgar score 1&#8242;median &#40;min&#8211;max&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;7&#8211;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;7&#8211;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;51<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apgar score 5&#8242;median &#40;min&#8211;max&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;9&#8211;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;9&#8211;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;80<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Birth weight &#40;g&#41;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3273<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>343&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3573<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>374&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001<a class="elsevierStyleCrossRefs" href="#tblfn0005"><span class="elsevierStyleSup">a&#44;c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Birth length &#40;cm&#41;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;12<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Female &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="char" valign="middle">0&#46;23<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gestational age &#40;days&#41;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">274&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">272&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;04<a class="elsevierStyleCrossRefs" href="#tblfn0005"><span class="elsevierStyleSup">a&#44;c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gestational age test &#40;days&#41;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">289&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">287&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;21<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postnatal age test &#40;days&#41;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">Number of prenatal visits&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;729&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Apgar score 1&#8242;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;006</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Apgar score 5&#8242;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;682&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;125&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;196&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;590&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;0&#46;058&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;546&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hematocrit &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;0&#46;056&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;562&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;113&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;244&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;071&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;461&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;070&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ferritin &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#8722;0&#46;287&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;003</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#46;237&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;013</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#46;351&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;000</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#46;249&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;009</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">LID&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;240&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;012</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;265&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;005</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;365&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;000</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;294&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;002</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gestational age test &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;316&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;001</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#46;039&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;687&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;002</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#46;151&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postnatal age test &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;018&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;849&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#46;170&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;077&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;0&#46;059&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;388&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;853&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">V-Wave&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Interval I&#8211;III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Interval III&#8211;V&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Correlation coefficient &#40;<span class="elsevierStyleItalic">r</span>&#41; and level of significance &#40;<span class="elsevierStyleItalic">p</span>&#41; of correlation analysis &#40;Spearman&#41; of V-wave&#44; interval I&#8211;III&#44; interval I&#8211;V&#44; interval III&#8211;V&#44; and all relevant variables&#46;</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">LID&#44; variable accounting for the role of ferritin as a cutoff &#40;where 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>no latent iron deficiency and 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>latent iron deficiency&#41;&#46;</p>"
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Multiples correlationsSignificant independent variables</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Standardized <span class="elsevierStyleItalic">&#946;</span> coefficient</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Predictors of the variable</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Standardized <span class="elsevierStyleItalic">&#946;</span> coefficient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">V-Wave</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of prenatal visits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;141&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Birth weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;531&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ferritin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;047&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;676&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LID&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gestational age test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;226&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;073</span><a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;255&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;007</span><a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postnatal age test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;979&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Interval I&#8211;III</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Birth weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;059&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;563&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ferritin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;916&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LID&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;249&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;042</span><a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;233&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;015</span><a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Interval I&#8211;V</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Birth weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;087&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;394&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apgar score 1&#8242;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;191&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;041</span><a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;206&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;027</span><a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ferritin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;879&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LID&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;206&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Journal Information
Vol. 96. Issue 2.
Pages 202-209 (March - April 2020)
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3994
Vol. 96. Issue 2.
Pages 202-209 (March - April 2020)
Original article
Open Access
Effects of intrauterine latent iron deficiency on auditory neural maturation in full-term newborns
Efeitos da deficiência de ferro latente intrauterino na maturação neural auditiva em recém-nascidos a termo
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3994
Leticia Valerio Pallone, Felipe Alves de Jesus, Gleice Aline Gonçalves, Laura Carvalho Navarra, Débora Gusmão Melo, Rodrigo Alves Ferreira, Carla Maria Ramos Germano
Corresponding author
Universidade Federal de São Carlos, Departamento de Medicina, São Carlos, SP, Brazil
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Abstract
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Tables (4)
Table 1. Maternal and neonatal characteristics of control and LID groups.
Table 2. BERA values for control and LID groups.
Table 3. Correlation coefficient (r) and level of significance (p) of correlation analysis (Spearman) of V-wave, interval I–III, interval I–V, interval III–V, and all relevant variables.
Table 4. Multiple correlation analyses for V-wave and intervals I–III, I–V, III–V.
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Abstract
Objective

This study analyzed the relationship between latent iron deficiency evaluated by ferritin, and the myelination of the central nervous system evaluated through the brainstem evoked response audiometry test.

Method

A total of 109 full-term newborns, born without anemia and risk factor for hearing deficiency, were enrolled. After delivery, umbilical cord blood was collected to determine ferritin and hematocrit levels. The brainstem evoked response audiometry test was carried out in the first 28 days of life. Analysis was performed between the control group (n=71) with ferritin greater than 75ng/mL, and the latent iron deficiency group (n=38) with ferritin between 11 and 75ng/mL. Results were presented as mean±standard deviation. Statistical analysis was performed using GraphPad prism7 and SPSS with a significance level of 5%.

Results

A significant higher V-wave (p=0.02) and interpeak intervals I–III (p=0.014), I–V (p=0.0003), and III-V (p=0.0002) latencies were found in the latent iron deficiency group, as well as a significant inversely proportional correlation between ferritin and the same wave and intervals (p=0.003, p=0.0013, p=0.0002, p=0.009, respectively). Multiple correlation analysis showed a significant correlation of latent iron deficiency with all interpeak intervals, even taking into account newborn gestational age.

Conclusion

Iron deficiency anemia is a prevalent pathology; this study showed auditory delayed maturation associated to intrauterine iron deficiency, even in its latent form. This reinforces the importance of adopting effective measures, on a global scale, to prevent and treat this pathology in different life periods, especially in the most vulnerable population.

Keywords:
BERA
Ferritin
Newborn
Latent iron deficiency
Resumo
Objetivo

Este estudo analisou a relação entre deficiência de ferro latente avaliada pela ferritina e a mielinização do sistema nervoso central avaliada pelo teste de Potenciais Evocados Auditivos de Tronco Encefálico.

Método

Foram incluídos no estudo 109 recém-nascidos a termo, nascidos sem anemia e fator de risco para deficiência auditiva. Após o parto, o sangue do cordão umbilical foi coletado para determinar os níveis de ferritina e hematócrito. O teste de Potenciais Evocados Auditivos de Tronco Encefálico foi realizado nos primeiros 28 dias de vida. A análise foi realizada entre o grupo controle (n=71) com ferritina acima de 75ng/mL e o grupo com deficiência de ferro latente (n=38) com ferritina entre 11 e 75ng/mL. Os resultados foram apresentados como média±desvio-padrão. A análise estatística foi realizada utilizando o software GraphPad prism7 e SPSS com nível de significância de 5%.

Resultados

Latências significativamente maiores da onda V (p=0,02) e dos intervalos interpicos I-III (p=0,014), I-V (p=0,0003) e III-V (p=0,0002) foram encontradas no grupo de deficiência de ferro latente, assim como uma correlação significativa inversamente proporcional entre a ferritina e a mesma onda e intervalos (p=0,003, p=0,0013, p=0,0002, p=0,009, respectivamente). A análise de correlação múltipla mostrou uma correlação significativa da deficiência de ferro latente com todos os intervalos interpicos, mesmo se levarmos em consideração a idade gestacional do recém-nascido.

Conclusão

A anemia ferropriva é uma patologia prevalente e este estudo demonstrou maturação auditiva tardia associada à deficiência intrauterina de ferro, mesmo em sua forma latente. Isso reforça a importância da adoção de medidas efetivas, em escala global, para prevenir e tratar essa patologia em diferentes períodos da vida, principalmente na população mais vulnerável.

Palavras-chave:
PEATE
Ferritina
Recém-nascido
Deficiência de ferro latente
Full Text
Introduction

Nutrition is critical for the normal development of the central nervous system (CNS) and is particularly important throughout pregnancy and childhood. These are essential time periods for brain growth and for establishing adequate cognitive, motor, and psychosocial development in childhood, as well as in adulthood. Thus, nutritional deficiencies during these periods have the potential to impair cognition, behavior, and productivity in school years and adulthood. Among the nutritional deficiencies, iron deficiency occupies a prominent place.1

Iron plays a fundamental role in neural development, participating in the myelination and synaptogenesis processes.2 Regarding embryonic life, the importance of iron in the first three months is mostly related to the embryogenesis of the nervous system, whereas in the last trimester of pregnancy the fetus needs to form its own iron stores. Studies suggest that the peak of iron uptake in the CNS coincides with the myelination peak, especially in the late fetal and early postnatal stages.3

Iron deficiency (ID) is the most common nutritional deficiency in the world, affecting about a quarter of the world population, and these numbers increase even more during pregnancy, reaching 59%.4 In addition, some maternal and fetal pathologies may affect the newborn's (NB) iron stores, such as hypertension, diabetes mellitus, intrauterine fetal growth restriction, smoking during pregnancy, and premature birth, making the perinatal period especially susceptible to nutritional deficiency of this element.2

ID anemia has well-known impacts on CNS, such as reduced nerve conduction velocity and cognitive-behavioral changes.5 Iron deficiency without anemia, which has a prevalence 3–5 times higher than that of iron deficiency anemia, can also harm the CNS.3 Oligodendrocytes, the cells responsible for myelin production, are particularly sensitive to iron deficiency6 and it has been shown that NBs submitted to intrauterine iron deficiency presented long-term CNS damage, reaching lower language scores and motor development at 5 years of age compared to those born with normal iron stocks.2

Being part of the CNS, the developing auditory system is particularly vulnerable to nutritional changes during early fetal and postnatal life, especially due to the accelerated process of neuronal growth and development, myelination, and establishment of the synaptic network.7 Neural maturation of the auditory system progresses in the caudal–rostral direction and myelination of the auditory nerve pathway is considered an index of cerebral myelination.8

Brainstem evoked response audiometry (BERA) consists of recording the electrical stimulus from the inner ear to the brainstem in response to an acoustic stimulus.9 This test evaluates the electrophysiological activity of the auditory system at the level of the brainstem from the cochlear nerve, cochlear nuclei, superior olivary complex, and the bridge to the inferior-mesencephalic colliculus.10

The waves evaluated by BERA comprise three larger waves (I, III, and V) that can be reliably measured in newborns with a gestational age of more than 34 weeks. The absolute latencies for each of the waves and their intervals, as determined by BERA, are influenced by the degree of myelination, neuronal development, synaptic function, and axonal growth of the auditory nervous system; they are a measure of the nerve conduction velocity at different levels of the auditory pathway.11 As the relationship between these latencies and myelination is negative, less latency means greater (better) myelination and vice versa.12

Although data from the literature show the close relationship between the development of the auditory system and iron homeostasis, the changes that ID without anemia cause, also called latent iron deficiency (LID), are still not completely clear.13–15

Considering the possible negative repercussions of LID on the CNS myelination process, this study aimed to analyze the relationship between LID through serum ferritin of the umbilical cord, and myelination of the auditory nerve through BERA in NBs of gestational age (GA) equal to or greater than 37 weeks.

Methods

This study was performed at the Santa Casa de Misericordia Maternity Hospital in a city of 240,000 inhabitants of Sao Paulo state (Brazil), from August 2016 to January 2018. The Santa Casa de Misericordia Maternity Hospital is currently the only institution responsible for all the births in the city and its micro region.

The project was approved by the Institutional Research Human Ethics Committee (Process 791,511). Only NBs whose parents or legal representatives signed the informed consent were included in the study.

One-hundred sixty five newborns (NBs) had their blood collected and underwent otologic evaluation with BERA, and 109 full-term NBs with weight >2500g, born without fetal distress (Apgar7), who fulfilled the inclusion criteria, were fully studied (Supplementary Fig. 1). All the mothers answered a sociodemographic questionnaire designed by the researchers. Maternal and NB data were obtained from hospital clinical records.

After delivery, umbilical cord blood was collected to determine the ferritin and hematocrit levels. The samples were then kept at room temperature until their determination, up to 4h after collection. All NBs underwent an otologic evaluation within the first 28 days after birth. Two tests were carried out: the otoacoustic emission test (OAE) and BERA. OAE was performed before hospital discharge, between 24h and 48h after birth, and BERA was carried out after hospital discharge, up to 28 days. The audiological evaluations were performed by a single qualified phonoaudiologist, who did not have prior access to the blood test results.

Inclusion criteria: NBs of both genders with 37 weeks or more of GA, weight >2500g, born at the Santa Casa de Misericordia Maternity Hospital during the study period, from the public or supplementary health care system. Only NBs with a normal hematocrit value (≥42% and ≤60%) were included in the study. NBs whose mothers had arterial hypertension or diabetes mellitus were included in the study, given the higher probability of these NBs being iron deficient.

Exclusion criteria: NBs at risk of hearing impairment (family history of congenital hearing loss in first-degree relatives), those with congenital infections (toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis, HIV), genetic syndromes/chromosomal abnormalities, perinatal problems (hemolytic disease, hypoglycaemia, prolonged jaundice, neonatal sepsis), intensive care unit (ICU) permanence, and presence of craniofacial abnormality, as any of these comorbidities could alone cause changes in BERA results. NBs with a 1 or 5min Apgar score less than 7 and ferritin <11ng/ml, as well as children of mothers with a T-ACE score equal or greater than 2 and a Fagerström test score equal or greater than 5 during gestation were excluded as well. T-ACE is an alcohol screening questionnaire adapted to identify risk drinking during pregnancy and the Fagerström test is a standard instrument for assessing the level of addiction to nicotine. NBs with increased TSH (thyroid stimulating hormone) values in neonatal screening program (blood spot TSH15mUI/L) (cut-off APAE-SP) were also excluded.

NBs were divided into two groups: Group 1 (control): value of ferritin in umbilical cord >75ng/mL, infants without iron deficiency; Group 2 (LID: value of ferritin in umbilical cord ≥11 and ≤75ng/mL, infants with LID.13,15–17

Hematocrit was measured using the method proposed by Wintrobe et al. in 1987. Ferritin determination was performed by a solid phase chemiluminescent immunoassay enzyme assay (Immulite/Immulite 1000 Ferritin – Siemens Healthcare Diagnostics, United Kingdom).

The OAE was done using a “pass or fail” screening mode and the BERA using a diagnostic mode. Only infants who underwent auditory screening using the OAE, and passed, were recruited for BERA. The OAE was carried out by the same phonoaudiologist responsible for the BERA test.

The equipment used for BERA was the Bio-Logic Navigator Pro® (stimulus: click; transducer: insertion earphones; polarity: alternating). The test was run while the NB was asleep in a quiet environment with electrical insulation and dimmed light, and did not require sedation. Headphones with monaural stimulation were used. Sound stimulus with an intensity of 80 dBNA, at a rate of 27.7clicks/second (Hood Standardization – 1998) was used. The impedance between the electrodes was considered to be less than 3kOhms, according to the equipment's instruction manual. The parameters utilized were: alternating polarity clicks, low pass filter 100Hz and high pass 1500Hz, a total of 2000 stimuli, a presentation rate of 27.7stimuli/s and a window analysis of 10.66ms. Each record was duplicated to ensure reproducibility of the results. For each patient, the lower latency of each wave and interpeak interval between the two ears was selected.15

To analyze the effect of mothers’ diabetes mellitus (DM) and/or hypertension on BERA values, the authors designed a variable named patho that was categorized as: 0=no pathology and 1=hypertension or/and DM, for statistical calculations. Accounting for the main role of ferritin as a cutoff variable (determining two significant different groups: higher or lower than 75ng/mL), the authors analyzed LID's contribution to BERA results through the variable named LID, where 0=no LID and 1=presence of LID.

Basic statistical analysis was performed by using GraphPad prism, version 7 for Windows (GraphPad Software, CA, USA) and multivariate models by SPSS (SPSS for Windows, Chicago, USA). Results were presented as mean±standard deviation (SD), median (minimum–maximum), or percentage, depending on the variable. The statistical significance of the differences was determined by the nonparametric t-test (Mann–Whitney) or the Fisher's exact test, as needed. The linear correlation among all variables was calculated by the Spearman method. Multivariate regression models were utilized for multiple correlation analysis in two ways: (1) the variables that were significant at p<0.10 in the univariate model (Spearman correlation) were included in the multiple model to evaluate the contribution of each one of these variables; (2) analysis in a stepwise processes where the non-contribute predictors were excluded by the statistical process, highlighting the most significant correlates of BERA values. Analysis of covariance was carried out to evaluate the influence of LID on BERA results, taking into account NB gestational age. The significance level adopted was 5%.

Results

Blood samples, OEA, and BERA were carried out on 109 NBs. OAE was normal in all individuals.

After dividing the groups, 71 NBs had normal serum ferritin (>75ng/mL) and comprised the control group; 38 NBs presented LID (≥11 and ≤75ng/mL) and were included in the LID group (Table 1). There was no significant difference between the groups regarding maternal age, number of pregnancies, previous abortions, and number of prenatal consultations. The LID group presented a higher number of pregnant women presenting DM and/or hypertension (p=0.06; Table 1).

Table 1.

Maternal and neonatal characteristics of control and LID groups.

  Control group(n=71)  LID group(n=38)  p-Value 
Maternal age(mean±SD)  30.6±5.8  32.0±6.1  0.28a 
Supplemental health care (%)  56.3  50  0.55b
Public health care (%)  43.7  50 
Number of pregnanciesmedian (min–max)  2 (1–4)  2 (1–6)  0.59a 
Number of abortionsmedian (min–max)  0 (0–3)  0 (0–4)  0.98a 
Number of prenatal visitsmedian (min–max)  10 (4–15)  10 (7–15)  0.36a 
Maternal DM or/and hypertension (%)  21.1  0.06b 
Fagerström test (%)  Smoker 4Non-smoker 96  Smoker 0Non-smoker 100  0.55b 
T-ACE scoremedian (min–max)  0 (0–1)  0 (0–1)  0.59a 
Apgar score 1′median (min–max)  9 (7–10)  9 (7–10)  0.51a 
Apgar score 5′median (min–max)  10 (9–10)  10 (9–10)  0.80a 
Birth weight (g)mean±SD  3273±343.9  3573±374.7  <0.0001a,c 
Birth length (cm)mean±SD  48.3±2.6  48.9±2.1  0.12a 
Female (%)  46.5  34.2  0.23b
Male (%)  53.5  65.8 
Gestational age (days)mean±SD  274.5±5.9  272.1±6.5  0.04a,c 
Gestational age test (days)mean±SD  289.1±8.1  287.3±7.1  0.21a 
Postnatal age test (days)mean±SD  14.6±5.9  15.3±5.7  0.40a 
TSH (mUI/L)mean±SD  5.1±2.7  4.8±2.5  0.68a 

DM, diabetes mellitus; Fagerström test, standard instrument for assessing the level of addiction to nicotine; LID, latent iron deficiency; SD, standard deviation; T-ACE, alcohol screening questionnaire adapted to identify risk drinking during pregnancy; max, maximum; min, minimum; TSH, thyroid stimulating hormone.

a

Nonparametric t-test (Mann–Whitney).

b

Fisher's exact test.

c

Differences between groups were significant at p<0.05.

Birth weight was significantly higher and the GA significantly lower in the LID group compared to the control group. The birth weight for the control group was 3273±343.9g and the LID group 3573±374.7g (p<0.0001). The mean GA of the control group was 274.5±5.9 days and for the LID group, 272.1±6.5 (p=0.04). Postnatal age and the corrected gestational age for BERA testing were not significantly different between groups, as well as the Apgar scores, birth length, and gender distribution (Table 1).

Hematocrit values were 47.0±3.6 for the control group and 48.4±4.3 for LID group (p=0.10). Ferritin values were 160.1±94.2 for the control group and 49.6±17.1 for LID group. Ferritin values were significantly different between groups as a result of the study design (p<0.0001).

The V-wave latency values (p=0.02), intervals I–III (p=0.014), I–V (p=0.0003) and III–V (p=0.002) were significantly higher in the LID group compared to the control group (Table 2). All these parameters presented a significant nonparametric negative correlation with ferritin and positive with LID: V-wave (r=−0.29; p=0.003; r=−0.29; p=0.003), interval I–III (r=−0.24; p=0.013; r=−0.29; p=0.003), interval I–V (r=−0.35; p=0.0002; r=−0.29; p=0.003) and interval III–V (r=−0.25; p=0.009; r=−0.29; p=0.003), respectively (Table 3).

Table 2.

BERA values for control and LID groups.

  Control(n=71)  LID(n=38)  p-Value 
I-Wavemean±SD(median)  1.8±0.1(1.7)  1.7±0.1(1.7)  0.33a 
III-Wavemean±SD(median)  4.4±0.1(4.4)  4.4±0.2(4.4)  0.59a 
V-wavemean±SD(median)  6.9±0.1(6.9)  7.0±0.2(7.0)  0.02 a,b 
Interval I–IIImean±SD(median)  2.6±0.1(2.6)  2.7±0.1(2.7)  0.01a,b 
Interval I–Vmean±SD(median)  5.1±0.1(5.1)  5.2±0.2(5.2)  0.0003a,b 
Interval III–Vmean±SD(median)  2.4±0.1(2.4)  2.5±0.1(2.5)  0.002a,b 

BERA, brainstem evoked response audiometry test; LID, latent iron deficiency group; SD, standard deviation.

a

Nonparametric t-test (Mann–Whitney).

b

Differences between groups were significant at p<0.05.

Table 3.

Correlation coefficient (r) and level of significance (p) of correlation analysis (Spearman) of V-wave, interval I–III, interval I–V, interval III–V, and all relevant variables.

  V-waveInterval I–IIIInterval I–VInterval III–V
  r  p  r  p  r  p  r  p 
Maternal age  −0.047  0.629  −0.134  0.165  −0.042  0.668  0.049  0.612 
Number of pregnancies  0.009  0.924  −0.150  0.120  0.072  0.459  0.163  0.091 
Number of abortions  −0.002  0.981  −0.067  0.490  0.025  0.793  0.150  0.120 
Number of prenatal visits  0.214  0.025a  0.020  0.839  0.165  0.087  0.079  0.412 
Patho  0.084  0.385  0.124  0.198  0.150  0.120  0.136  0.159 
Gestational age (days)  −0.246  0.010a  −0.033  0.731  −0.221  0.021a  −0.150  0.118 
Birth weight (g)  0.034  0.729  0.043  0.657  0.117  0.224  0.219  0.022a 
Birth length (cm)  −0.016  0.871  0.089  0.358  0.042  0.664  0.114  0.238 
Apgar score 1′  −0.177  0.066  0.040  0.677  −0.217  0.023a  −0.262  0.006a 
Apgar score 5′  0.040  0.682  0.125  0.196  0.052  0.590  −0.058  0.546 
Hematocrit (%)  −0.056  0.562  −0.113  0.244  0.071  0.461  0.174  0.070 
Ferritin (ng/mL)  −0.287  0.003a  −0.237  0.013a  −0.351  0.000a  −0.249  0.009a 
LID  0.240  0.012a  0.265  0.005a  0.365  0.000a  0.294  0.002a 
Gestational age test (days)  −0.316  0.001a  −0.039  0.687  −0.294  0.002a  −0.151  0.116 
Postnatal age test (days)  −0.193  0.045a  0.018  0.849  −0.170  0.077  −0.059  0.541 
I-Wave  0.575  0.000a  −0.106  0.272  −0.006  0.954  0.018  0.849 
III-Wave  0.730  0.000a  0.595  0.000a  0.388  0.000a  0.018  0.853 
V-Wave  0.000a  0.324  0.001a  0.743  0.000a  0.491  0.000a 
Interval I–III  0.324  0.001a  0.000a  0.485  0.000a  −0.065  0.500 
Interval I–V  0.743  0.000a  0.485  0.000a  0.000a  0.626  0.000a 
Interval III–V  0.491  0.000a  −0.065  0.500  0.626  0.000a  0.000a 

LID, variable accounting for the role of ferritin as a cutoff (where 0=no latent iron deficiency and 1=latent iron deficiency); Patho, variable that account for the effect of mothers diabetes mellitus (DM) or hypertension (categorized as 0=no pathology. 1=hypertension and/or DM); p, p-value; r, correlation coefficient.

a

Variables that presented significant simple correlation (row×column) at p<0.05.

Multiple correlation analysis of the significant variables for each BERA interval and V-wave are represented in Table 4. Utilizing the stepwise approach, the most significantly predictor of V-wave values was test gestational age (standardized β=0.255, p=0.007); for interval I–III was LID (standardized β=0.233, p=0.015); for interval I–V were LID (standardized β=0.249, p=0.08) and Apgar 1minute score (standardized β=0.206, p=0.027); for interval III–V they were LID (standardized β=0.229, p=0.013) and Apgar 1minute score (standardized β=0.263, p=0.05). The analysis of covariance showed that LID contributed to the results of all BERA intervals, even taking into account the gestational age: interval I–III (F=5.087, p=0.026), interval I–V (F=6.436, p=0.013) and interval III–V (F=5.856, p=0.017). The significance for V-wave was borderline (F=2.909, p=0.91).

Table 4.

Multiple correlation analyses for V-wave and intervals I–III, I–V, III–V.

VariableMultiples correlationsSignificant independent variablesMultiples correlationsStepwise
Standardized β coefficientp-ValuePredictors of the variable
Standardized β coefficient  p-Value 
V-WaveNumber of prenatal visits  0.141  0.143     
Birth weight  0.66  0.531     
Ferritin  −0.047  0.676     
LID  0.125  0.300     
Gestational age test  −0.226  0.073b  −0.255  0.007a 
Postnatal age test  −0.003  0.979     
Interval I–IIIBirth weight  −0.059  0.563     
Ferritin  −0.012  0.916     
LID  0.249  0.042a  0.233  0.015a 
Interval I–VBirth weight  0.087  0.394     
Apgar score 1′  −0.191  0.041a  −0.206  0.027a 
Ferritin  0.017  0.879     
LID  0.206  0.084b  0.249  0.008a 
Gestational age  −0.027  0.829     
Gestational age test  −0.175  0.164     
Interval III–VBirth weight  0.189  0.061b     
Apgar score 1′  −0.255  0.006a  −0.263  0.005a 
Ferritin  0.087  0.430     
LID  0.185  0.114  0.229  0.013a 
Gestational age  −0.123  0.196     

LID, variable accounting for the role of ferritin as a cutoff (where 0=no latent iron deficiency and 1=latent iron deficiency).

a

Independent variables that presented significant correlation with the dependent variable (first column) at p<0.05.

b

Independent variables that presented significant correlation with the dependent variable (first column) at p<0.1.

Discussion

The developing brain and auditory system are particularly vulnerable to nutritional changes during early fetal and postnatal life, especially due to the accelerated process of neuronal growth and development, myelination, and formation of the cerebral synaptic network.3 Perinatal ID results in deficiency of the redox reactions of the hippocampus and frontal cortex energetic metabolism, modifications of the glutamate and dopamine concentrations, and of the neuronal myelination pattern.18

This study showed that LID determined a significant increase in V-wave and all interpeak interval latencies in BERA, with an inverse proportional correlation between serum ferritin concentrations and BERA parameters. In animal studies, iron deficiency without anemia resulted in a decreased number of synapses and in a lower wave amplitude in BERA, with increased susceptibility to noise-induced hearing loss.19 Other animal studies also reported significant functional consequences on BERA as a result of borderline iron deficiency, and in Long–Evans rats, the severity of the changes in BERA correlated with the level of serum iron.14 In 2012, Lee et al. analyzed BERA in iron-deficient female rats and showed a significant decrease in nerve conduction velocity at 40 days of life.6 Other studies on rodents have demonstrated that neurobehavioral changes resulting from iron deficiency during pregnancy and lactation persist even when iron concentrations are normalized after weaning.20

Studies on humans also suggest that LID causes damage to the neuropsychomotor development of preterm and full-term infants. In 2002, Tamura et al. reported lower motor skills and language development at 5 years of age in NBs with serum ferritin in the lower quartile compared to those with ferritin above this value.21 In another study, infants of diabetic mothers with a low serum ferritin level in the cord serum had a lower auditory recognition memory at birth and lower psychomotor development scores at 1 year of age.22

In a study that showed a relationship between LID and BERA waves, 33 NBs with normal ferritin compared to 12 NBs with LID, with a gestational age ≥35 weeks, finding significantly increased latency in individuals with LID, as was shown in the present study.15 Another study evaluated NBs with a gestational age ≥34 weeks and the results indicated a higher V-wave and I–V and III–V interpeak intervals latency in the LID group.13 In 2016, Lou also showed that at 10 months, infants born with LID still had a decrease in the V-wave amplitude and an increase in I-wave latency.16 All these studies, including the, demonstrated changes in the I–V interval, which may mean that the whole auditory pathway can be affected by intrauterine iron deficiency. The degree of reversibility of BERA changes secondary to LID in utero is not well established and there are a lack of studies that define to what extent and until when the changes caused by LID can last, just as the factors that affect the reversibility of these alterations.16 For example, in 2011 Berglund et al. realized an iron intervention trial and did not show a significant auditory effect of postnatal iron supplementation in marginally low birth-weight infants.23

In this study, there was a significant difference in gestational age between the two groups, which could be a confounding factor for the analysis, although the whole group studied was at term and the BERA age test and the postnatal age test were not significantly different between groups. The correlation among GA and BERA values (wave V, intervals I–III and I–V) showed that, even in term NBs, the gestational age have an influence on BERA values. Nevertheless, this study and recent studies with a similar methodological design that included NBs ≥35 weeks15 or ≥34 weeks13 demonstrated a significant relationship between LID and higher latencies in BERA, even after controlling GA as a variable.

The authors used ferritin concentration to define a state of LID, a parameter also utilized in recent studies on the subject.16 Although there are newer iron store assays, in addition to ferritin, they have not been standardized for use on neonates and are not readily available.17

An unanswered question is whether the alterations in myelination of the auditory pathways are representative of the development of white matter in other brain areas.24 It is also unclear whether infants at risk for iron deficiency should be routinely assessed for their iron status shortly after birth.25 This may be critical for populations in which maternal iron deficiency during pregnancy is very common, such as the Brazilian population. Currently, iron supplementation is not recommended for full-term infants during the first months after birth26,27 and there is no evidence that early iron replacement in the neonatal period is capable of reversing the changes in the CNS development and the auditory system.23,28,29

One limitation of this study is that, as in other observational studies, a causal relationship could not be established between BERA changes and LID, and currently there is no data regarding subsequent follow up of these NBs.16 More research is needed to answer these questions.

In conclusion, iron deficiency anemia is still a very prevalent pathology, and this research, in addition to other studies on the subject, points to serious and perhaps irreversible auditory maturation damage related to LID in utero. Therefore, it is important to take effective measures for the prevention and adequate management of this nutritional challenge in the different phases of life, such as iron supplementation during pregnancy, control of diseases that pose a risk for ID during the gestational period, and screening and treatment of anemia at any stage of life, especially in the most vulnerable and at risk individuals, such as NBs and pregnant women.

Compliance with ethical standards

The research was approved by the Human Research Ethics Committee at the Federal University of São Carlos (process 791,511).

Funding

This work was supported by the São Paulo Research Foundation (Fundação de Amparo a Pesquisa do Estado de São Paulo [FAPESP]; grant number 2015/15471-4).

Conflicts of interest

The authors declare no conflicts of interest.

Acknowledgements

To all the families who took part in this research, as well as the Santa Casa de Misericordia Maternity Hospital. They authors also wish to thank the Sao Paulo Research Foundation (FAPESP) for the funding to carry out this research project.

Appendix A
Supplementary data

The following are the supplementary data to this article:

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Please cite this article as: Pallone LV, Jesus FA, Gonçalves GA, Navarra LC, Melo DG, Ferreira RA, et al. Effects of intrauterine latent iron deficiency on auditory neural maturation in full-term newborns. J Pediatr (Rio J). 2020;96:202–9.

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