Critical and Sensitive Periods in Development and Nutrition

In a sensitive period, the degree of plasticity is relatively higher, but plasticity never ends. As a result, the end states from a critical ... × Title (Title) Mr Ms Dr. Professor FirstName* LastName* Company/Institution E-Mail* Message *indicatesrequiredfields ThissiteisprotectedbyreCAPTCHAandtheGooglePrivacyPolicyandTermsofServiceapply. 0 0 × Journals Books Courses Collections SubjectGuide Login 0 0 JournalMenu JournalHome AboutThisJournal Guidelines JournalContact SubscriptionRates RelatedArticles Contents:allyears × AnnalsofNutritionandMetabolism DownloadFulltextPDF YoungBrain–BigAppetite FreeAccess CriticalandSensitivePeriodsinDevelopmentandNutrition ColomboJ.a·GustafsonK.M.b·CarlsonS.E.c Authoraffiliations aDepartmentofPsychologyandSchiefelbuschInstituteforLifeSpanStudies,UniversityofKansas,Lawrence,KS,USAbHoglundBrainImagingCenter,UniversityofKansasMedicalCenter,KansasCity,KS,USAcDepartmentofDieteticsandNutrition,UniversityofKansasMedicalCenter,KansasCity,KS,USA CorrespondingAuthor JohnColomboDepartmentofPsychologyandSchiefelbuschInstituteforLifeSpanStudiesUniversityofKansas,1000SunnysideAvenueLawrence,KS66045(USA)[email protected] Keywords:CriticalperiodSensitiveperiodNutritionalprogramming RelatedArticlesfor"" AnnNutrMetab2019;75(suppl1):34–42 https://doi.org/10.1159/000508053 Abstract FullText PDF References Extras:2 Abstract Criticalorsensitiveperiodsinthelifeofanorganismduringwhichcertainexperiencesorconditionsmayexertdisproportionateinfluence(eitherforharmorbenefit)onlong-termdevelopmentaloutcomeshavebeenthesubjectofinvestigationforoveracentury.Thischapterreviewsresearchinthecontextofthedevelopmentofsocialpreferencesandsensorysystems,withasummaryofthecriteriafordefiningsuchaperiodandtheevidencenecessarytoestablishitsexistence.Thenotionofnutritionalprogramming,centraltotheBarker/DevelopmentalOriginshypothesesofhealthanddisease,representsavariantofthecritical/sensitiveperiodconcept.Itisimplicitinthesehypothesesthatthefetalperiodisatimeduringwhichmetabolicandphysiologicalsystemsaremalleableandthussusceptibletoeitherinsultorenhancementbynutrientintake.Evidenceforcritical/sensitiveperiodsornutritionalprogrammingrequiresasystematicmanipulationoftheageatwhichnutritionalconditionsorsupplementsareimplemented.Whilecommoninresearchusinganimalmodels,theapproachisdifficulttoestablishinepidemiologicalstudiesandvirtuallynonexistentinhumanclinicaltrials.Futureworkseekingtoestablishdefinitiveevidenceforcritical/sensitiveperiodsorprogrammingmaybeadvancedbyharmonizedoutcomemeasuresinexperimentaltrialsacrosswhichthetiming,duration,anddoseofnutrientsisvaried. ©2020S.KargerAG,Basel KeyMessagesTheconceptofcriticalperiodisofteninvokedwithreferencetophenomenainthefieldofnutrition.Thehistoryandevolutionofthecriticalperiodconceptindevelopmentisbrieflyreviewed.Acriticalperiod(oritslessrestrictiveform,asensitiveperiod)carrieswithitanumberofmethodologicalcriteriathataretypicallynotmetintheliteratureonearlynutrition.Thephenomenonofprogrammingisplacedwithinthisdevelopmentalconcept.Implicationsofthesedevelopmentalphenomenaforthedesignofpreclinicalresearchandclinicaltrialsthatseektodemonstratetrueprogrammingorcritical/sensitiveperiodeffectsaredescribed.CriticalandSensitivePeriodsinDevelopmentTheideathatearlynutritionalstatusiscriticaltolifelonghealthispervasiveinthescientificliterature[1].Althoughmuchofthewritingonthistopichasbeenfocusedonthepotentialearly-lifedeterminantsofadultobesity[2-5],muchhasalsobeenwrittenabouttheimportanceofnutritioninthefirst1,000daysfollowingconception[6]andthepotentialimpactofnutritionandnutritionalstatusonbothbiological[7]andbehavioral[8]systemslaterinlife.Inmanyofthesepapers,authorsmakedirectreferencetocriticalperiodsasadevelopmentalbasisfortheseproposals[9,10].Whilethecriticalperiodphenomenonhasbeenatopicofextensivediscussioninthebiobehavioralanddevelopmentalsciences,therehavebeenfewdetailedexpositionsoftheconceptanditsimplicationswithinthenutritionliterature.Oneobjectiveofthischapteristoprovideabackgroundonthehistoryofandcriteriaforcriticalperiodsfornutritionresearchers.Asecondobjectiveistointegratethenotionoffetal/neonatalprogramming–acommonconceptwithinthenutritionfield–withintheframeworkofcriticalperiodsanddevelopmentalscience.Finally,thechapterseekstodelineatetheimplicationsofcritical/sensitiveperiodsforthedesignoffuturepreclinicalresearchandclinicaltrials.HistoryoftheConceptofCriticalPeriodsAsnotedabove,theconceptofcriticalperiodshasalonghistoryinthefieldofdevelopmentalpsychology[11-13].Thebasicphenomenonwasfirstidentifiedfromresearchinembryology[14],wheretheeffectofexposurestotoxicsubstancesondevelopingembryoswasobservedtovarysystematicallywiththetimingoftheexposure.Toxicexposuresoccurringintheembryonicperiodproducedpervasiveandsevereeffectsacrossmultiplebiologicalsystems;however,thesameexposureordoselaterindevelopmentresultedinsomewhatmildereffects,whichwereconstrainedmorenarrowlytoparticularorspecificsystems.Indeed,thesameexposureappliedevenlaterindevelopmentmighthavenodemonstrableeffectsorresultineffectsevidentonlyuponsystemicchallengesorstressors.Thesecommonsequelaeledinvestigatorstothelogicalconclusionthatthebiologicalsystemswerebroadlymalleableveryearlyinlife,andthatastheorganismmaturedandthosesystemsbecamesettledinformandfunction,theybecamelessvulnerabletoenvironmentalinsult.ImprintingandCriticalPeriodsTheextensionofthisworktothebehavioralsciencescamewithLorenz’s[15]expositionofimprintinginbirds.Inthisphenomenon,precocialbirdspeciesdevelopedstrongsocialpreferencesforobjectstowhichtheywereexposedimmediatelyafterhatching;youngbirdswouldthenattachemotionallyandmaintainproximitytosuchobjectsuntilfledging.Theevolutionaryadaptivenessofthisphenomenonisobvious,ashatchlingsaretypicallyexposedimmediatelyafterhatchingtotheirownmother(oratleast,aconspecificfromthesamespecies),andaneuralmechanismthatpromotedhatchlings’emotionalandphysicalaffiliationwiththeirmotherverylikelyincreasedtheprobabilityoftheirsurvival.Indeed,thisframeworkwasadaptedforuseintheearlyevolutionary-basedaccountsforexplaininghumaninfants’attachmenttotheirownmothers[16].Ofcriticalimportancetothecurrentdiscussion,however,twopointsshapedfuturethinkingaboutthenatureofcriticalperiodsindevelopment.First,thenatureoftheobjectstowhichhatchlingscouldbeimprintedwasextremelygeneral;duringthisperiodyoungbirdscouldbemanipulatedtoformsocialpreferencesfornearlyanyobject,whetheritwasLorenz[17]himselforamovingtennisball[18].TheotherpointswerederivedfromLorenz’sclaimthatthedevelopmentofthesestrongsocialaffiliationscouldonlybeformedduringaverybriefperiodoftimeduringthehatchlings’develop­-ment–onceimprintinghadoccurred,itcouldnotbeundone[19]–andthatnonimprintedorganismswerenotabletoimprintbeyondthehatchlingperiod[20].Thus,theeffectsofexposureduringthisearlyperiodoflifewereclaimedtobebothirreversibleandunrecoverable,thusbringingaboutthelabeloftheperiodascritical.However,muchoftheliteraturethatemergedimmediatelyaftertheseinitialclaimsdemonstratedsubstantialreversibilityandflexibility[21]inimprinting.Thus,whiletheearlyperiodoflifemightrepresentheightenedmalleabilityorplasticity,theperiodmightnotbeasrigidlyboundoressentialasithadoriginallybeendesignated,makingthetermsensitiveperiodmoreappropriate.Thephenomenonwaslatergeneralizedtothenotionoffoodimprinting[22-25]inseveralspecies,wherethefoodpreferencestypicallyexhibitedbycertainanimalscouldbesubstantiallyalteredbyearlyexposuretoalternatefoods.CriticalPeriodsintheDevelopmentoftheVisualSystemThe1960sand1970sproducedthemostcomprehensivedescriptionsofcriticalperiodsinmammalianbiologyandbehaviorinHubelandWiesel’sprogramofresearchonthedevelopmentofthevisualsysteminthecat[26-28].Briefly,theseinvestigatorsusedtechniquesformeasuringtheactivityofsingleneuronsinthecatvisualcortex,mappedtheresponsivenessoftheseneuronstodifferentvisualstimuli,andthensoughttomapthematurationofthisneuronalactivityfrombirthtoadulthood.Whilesomeneuronsinthevisualcortexwerededicatedfrombirthtoprocessingspecifictypesofinput(e.g.,acceptingfromoneorbotheyes,orrespondingtohorizontalvs.verticalbars),theyalsodeterminedthroughcarefulexperimentationthatthefateofmanycellsinthecortexwasdeterminedbyboththequantityandqualityofpostnatalinput[29,30]andthattheperiodduringwhichthatinputwasreceivedwaslimitedtothefirst4–7weeksoflife.Similartoimprinting,recoveryofnormalvisionafterdeprivationofinputduringthatperiodoflifewasinitiallyreportedtobelimited[31],suggestingthatthiswasanotherclearmanifestationofatrue“critical”period.Thesefindingsfromthecatwerelargelyconfirmedinprimates[32,33],andobservationalstudiesofhumansdeprivedofvariousvisualinputwerefoundtobegenerallyconsistentwiththeprinciplesoutlinedinthiswork[34-36].Sincetheemergenceofthisseminallineofresearchinbiobehavioraldevelopment,numerousrefinementshavebeenexploredinisolatingthespecificmechanismsunderlyingtheearlyplasticityofthesystemandtheprocesseswhichbringthatplasticitytoanend[37].Forexample,itisclearthatthisisasensitiveperiod,ratherthanacriticalperiod,assomelevelofrecoveryofvisualfunctioncanbeattainedaftertheendoftheperiod[38,39].Inaddition,eyemovementsplayamajorroleintheneuralprocessingthatcontributestothededicationofneuronstovisualinputs[30],andboththeonsetandtheeventualendofthesensitiveperiodistriggeredbytheinitiationofvisualinput[40].Inkeepingwiththegeneralprinciplesofearlyplasticity,earlydisruptionsinthenormalcourseofsensoryexposurehavebeenfoundtoaltertheorderinwhichsensorysystemsdevelopandinwhichsensorypreferencesorprioritiesareexpressedinpostnatallife[41,42].SummaryThephenomenonofcritical/sensitiveperiodsinbiobehavioraldevelopmenthasbeenexploredindomainsbeyondthatofimprintingandsensorysystems;forexample,thereisalsoasubstantialliteratureonacritical/sensitiveperiodforlanguagedevelopment[43-45].Severalgeneralitiescanbedrawnfromthisbriefandadmittedlyperfunctoryreview,however.First,theprinciplesregardingearlyvulnerabilitiesoforganismstofrankenvironmentalinsultorcompromiseappeartobereliableandrobust;earlydamagewillyieldsevereandwidespreadeffects,whilelaterdamagewilltendtobelesssevereandmorespecificallylocalized.Second,inthebehavioralrealm,wherevera“critical”periodhasinitiallybeendescribed,includingclaimsofabsoluteirreversibilityorinabilitytorecoverfromdeprivation,subsequentworkhasgenerallyshownthatsomedegreeofrecoveryispossibleunderspecialconditionsorwithtargetedremedialactions.Organismsmaybebothrelativelymorevulnerabletoenvironmentaldeprivationandrelativelybetterabletobenefitfromenvironmentalenhancementearlyinlife,butitislikelybettertocharacterizetheseearlyperiodsofmalleabilityassensitiveperiodsratherthantrulycriticalperiods[13].Figure1schematicallyrepresentsthedifferencebetween“critical”and“sensitive”periodsandtheirinteractionwithbothpositive(beneficial)andnegative(harmful)events.Thatsaid,giventhatevidencesuggeststhatearlyinterventionswillberelatively(ratherthanabsolutely)moreeffectivethanlaterinterventions,thereiscleareconomicvalueinunderstandingthesedevelopmentalprinciples.Fig. 1.Schematicrepresentationofthedifferencebetweenacriticalperiod(a,b)andasensitiveperiod(c,d).Time/agemovesfromlefttoright.Notethat,inacriticalperiod,theperiodofmalleabilityorplasticityissharplydefinedasabox,withaclearbeginningandend,andnogradientovertime.Inasensitiveperiod,thedegreeofplasticityisrelativelyhigher,butplasticityneverends.Asaresult,theendstatesfromacriticalperiodareirreversibleorirretrievable,whileinasensitiveperiodsomedegreeoffutureenhancementorfuturerecoveryfromharmispossible.Scottetal.[46]haveofferedonecharacterizationofthesephenomenaindevelopment,notingthatcritical/sensitiveperiodsmerelyrepresentperiodsofrapiddevelopmentwithinsystems,suchthatenhancementordeprivationduringtheseperiodsofemergentandrapidmaturationcanrespectivelybringeithersubstantialbenefitorwreaksubstantialhavoconthesystemsinvolved.Ashasbeensummarizedpreviously[11],iftherearequalitativelydistinctstagesofmalleabilityindevelopment,thenonemustdefinethemintermsofthespecificsysteminvolved,aswellasbytheonsetandterminusoftheperiodandthespecificinputsthatarepresumedtoenhanceordisruptnormaldevelopment.Atthispoint,weturntodiscussprogramming,aphenomenonsimilartothecritical/sensitiveperiodasreferencedinthenutritionliterature.EarlyProgrammingandCriticalPeriodsThenotionofnutritionalprogramming[47]isapopularoneamongthenutritionsciencecommunity;asearchonthephraseinGoogleScholarTMinlate2019generatedover190,000entries.ThisnotionemergedfromacomprehensiveepidemiologicalstudyoftheDutchhungerwinter[48]inwhichfoodshortagesprecipitatedbyweather,badcrops,war,andaNaziembargooffoodtransporttopartsoftheNetherlandslimitedpregnantwomen’snutritionalintaketoonly400–800caloriesperday.Thisrestrictedintakeresultedinaremarkableincreaseintheincidenceofcoronaryheartdiseaseintheoffspringwhosemothers’wereexposedtorestrictedfoodintakeearlyingestation,markersofreducedrenalfunctionamongthoseexposedinmid-gestation,andlifetimegrowthrestrictionamongthoseexposedlateingestation[48].TheBarkerhypothesiswasderivedfromobservationsintheUKthatdisproportionatefetalgrowthinmiddletolategestationprogrammedlatercoronaryheartdiseaseintheoffspring.ThehypothesisregardingthefetaloriginsofadultdiseaseexpandedtotheDevelopmentalOriginshypothesis[49-52],thenotionthat,byinfluencingepigeneticprocesses,metabolicsetpoints,orearlyinflammatorystatus,prenatalnutritioninsomeway“programs”thefetusormaladaptivelypreparesthefetusforanenvironmentthatwillinduceadiposity/obesity[53,54]orothermetabolic-baseddiseases[55].ItisaclearimplicationoftheBarker/DevelopmentalOriginshypothesisthattheearlypartoflifeisinsomewayspecialinitsmalleabilityorcapacityforenactinglong-termchangesintheorganism.Suchstudieswouldpresumetorevealacritical-periodphenomenoninthatitistheearlystagesoftheorganism’sdevelopmentthatservesasacausalvehiclefortheefficacyoftheexposure.Furthermore,thenotionthattheorganismis“programmed”comesfromthefactthattheoutcomesassociatedwithfetalconditionsreachfarintothefutureandrepresenthealthandneurodevelopmentalstatusinadulthood.AkeypointabouttheoriginalBarkerstudywasthat,foranobservationalstudy,itcontrolledfairlywellforthetimingofthedeprivation.Forexample,subsequentsecondaryanalysesnotedthattheeffectsvariedasafunctionofthegestationalstateofthefetus[56];malnutritioninearlypregnancywasassociatedwithahigherriskofcoronaryheartdiseaseandacceleratedcognitiveaging[57],mid-gestationexposurehadanincreasedprevalenceofbronchialdisease,andlate/mid-gestationexposurewasrelatedtopoorerglucosemetabolism.Itisnotafarreachtoextrapolatethistotheideathatearlynutritionextendingintothepostnatalperiodmayalsobringaboutprogrammingeffects;indeed,thiscasehasbeenmadeforanumberofdifferentfunctions[58-60],andthisargumenttakesonimmediateweightgivenwhatisknownaboutthepostnataldevelopmentofthecentralnervoussystemandthepotentialeffectsofcertainnutrientsonbrainandbehavioralfunction[61-63].AgeandTiminginNutritionalStudiesLikemuchofthecritical/sensitive-periodresearch,studieslendingsupporttoearlynutritionalprogramminghavelargelybeenconductedwithanimalmodels[64].Whileithasbeenarguedthattheanimaldatacoupledwithhumanclinicaltrialsshowingtheeffectsofearlynutritionalmanipulationsarecompelling[65],intheabsenceofsystematicexperimentaldatainwhichtheageofexposureismanipulated,claimsaboutearlynutritionalprogrammingremainlargelyspeculative.Inordertodefinitivelyestablishatruecritical/sensitiveperiodorprogrammingeffects,onemustmanipulatethetimingoftheearlyintervention[11].Thatis,itmustbeshownthatvulnerabilitytoriskorabilitytobenefitfromenhancedconditionsataparticulartimeduringdevelopmentiseitherabsolutelyorrelativelyhigheratonetimeduringdevelopmentoverothers.Ofcourse,humanstudiestoexperimentallyvarythetimingofadverseinterventionstodemonstratethecritical/sensitiveperiod-programmingeffectsareunethical,butitispossibleandethicaltofocusontiminginclinicaltrialsthatpurporttoprovideinterventionsthatbenefittotheirparticipants;indeed,fromaneconomicpointofview,onecouldarguethatsuchafocusisnecessary.Furthermore,goingbacktotheoriginalpointinthecriticalperiodphenomenonaboutthedoseofexposureinteractingwithtiming[11],onemightfurtherarguethatdesignsfeaturingdose×timinginteractionswouldbeideal.Evenaquickperusaloftheliterature,however,showsthattheextantnutritionclinicaltrialsalmostentirelyexcludethetimingorageatwhichmanipulationsareimplemented.Forthemostpart,nutritionalinterventionsareimplementedasearlyaspossibleininfancy,andiftheyshowefficacythatpersists,ashasbeenestablishedinsomecases[66],itistemptingtoproposethatanearlyprogrammingeffecthastakenhold.However,intheabsenceofexposuretoanutrientforanequivalentdurationatalaterage,itisbynomeansclearthatthisprogrammingeffectisendemictoearlyprenatalorpostnatallife.Thosewhodesignsuchtrialslikelyunderstandthepotentialimportanceoftimingwell,buttheconductofsuchtrialsobviouslyrequirestremendousresourcestosimplyestablishefficacy;establishingthatanutrient’sefficacyisgreateratoneagethanatanothermayseemlikealuxury.However,untilthereisevidencethatbenefitvarieswiththeageatwhichanutrientisprovided,onecannothaveevidenceforacritical/sensitiveperiodorforanage-specificprogrammingeffect.Intheabsenceofclinicaltrialsthatcomprehensivelyaddresstheissueofageandtimingintheirdesigns,onewaytoexaminetherelativeefficacyacrossagesistocomparecompletedtrialsthathavevariedtheageoftheirinterventions,butwhereoutcomemeasuresweremoreorlessharmonized.Thishasbeendonetosomedegreefortheexaminationofdifferencesinoutcomeasafunctionofdose[67],althoughdosestillremainsanunderstudiedfactorinmuchoftheliteratureonearlynutrition.Onepotentialexampleapproximatingthisapproachisrepresentedby2trialsconductedinourlaboratoryoverthelast2decades.TheDIAMONDtrial[66,68]involvedpostnatalsupplementationwith4dosesofdocosahexaenoicacid(DHA)butwithaconstantlevelofarachidonicacid(ARA)comparedtoaplacebo.TheKUDOStrial[69-71]involvedprenatalsupplementationwith1doseofDHA,againcomparedtoaplacebo.Whilethetrialsaretoodifferentintheirmanipulationandintheirfundamentalsampledemographicstocomparedirectlyhere,theydoshareafairnumberofharmonizedoutcomevariablesinthedomainofpostnatalcognitivedevelopmenttoinviteaputativeinferencethatpostnatalsupplementationmightproducemorepervasivelong-termpositiveeffectsoninfantchildneurocognition[72]thanprenatalsupplementation.Ontheotherhand,theprenatalsupplementationproducedclearmetaboliceffects[73]thatwerenotevidentfromthepostnataltrial.Whiletheseoutcomesandcomparisonscannotbeconsidereddefinitive,theydoinviteavisionofwhatmightbepossiblewithbroadlyharmonizedoutcomesforclinicaltrialsinthefutureinthefieldofnutrition.SummaryandConclusionsCriticalandsensitivedevelopmentalperiodshavebeenkeyconceptsindevelopmentalscienceforoveracentury;theyhavealonghistoryforbiobehavioraldevelopmentandhaveparticularlyspecialimportancewithrespecttotheplasticityofthebrain.Insuchdevelopmentalperiods,certainexperiences,exposures,orconditionsarethoughttoexertdisproportionateinfluenceoverthelong-termdevelopmentoftheorganismduetothefactthattheorganismisinaparticularlymalleablestate.Examplesofputativecritical/sensitiveperiodsinbiobehavioraldevelopmentincludetheestablishmentofsocialandfoodpreferences(imprinting),shapingthestructureandfunctionofsensorysystems,andpossiblytheareaoflanguageandlanguageacquisition.Thereisstillconsiderabledebateoverthenatureofcritical/sensitiveperiods,butonehypothesisisthatsuchphasesaresimplytheepiphenomenonofsystemsthatareundergoingrapidmaturationorchange.Whilecritical-andsensitive-periodconceptshaveoftenbeenusedwithrespecttostudiesofearlynutrition,theyalsounderlietheconceptofnutritionalprogramming,astheimplicationofprogramming(particularlywithinthecontextoftheFetal/DevelopmentalOriginshypothesis)isthattheprenatalperiodispresumablyatimewhenvariousmetabolicsystemsaremalleableandcanbeinfluencedbyconditionsofmaternalphysiologyandenvironmentalexposures,includingnutrientintake.Criticaltotheestablishmentofanycritical/sensitiveperiod(andbyextension,toanyclaimforprenatalprogramming)isthedemonstrationthataninterventionshowsimprovedefficacywhenimplementedatoneagerelativetootherages.Forexample,inordertoestablishtheexistenceofacriticalperiodforomega-3effectsonneurodevelopment,onewouldhavetoshowthatsupplementationat,say,birthto6monthsofage,wouldhavefarmoreinfluenceonoutcomemeasuresthansupplementationfrom6to12months;obviously,fromadesignstandpoint,thiswouldnecessitatefeeding2agegroupsforanequivalentduration.Whileparametricmanipulationoftheageofnutritionalinterventionsisrelativelycommonplaceinanimalmodels,theresultsofpreclinicalstudiesdonotnecessarilytranslatetohumantrials[74],andso,anyconclusionaboutthecritical/sensitiveperiodsinnutritionornutritionprogrammingmustbeviewedasspeculative.Itmaybethatifenoughtrialshaveharmonizedoutcomes,meta-analysesthatincludeageoffeeding,durationoffeeding,anddosewouldadvancethefieldascloseaspossibletoansweringthisquestion.DisclosureStatementThisworkwassupportedbyNIHgrantsU54HD090216,R01HD086001,R01HD083292,andR01HD083292.ThewritingofthisarticlewassupportedbyNestléNutritionInstitute.Theauthorsdeclarenootherconflictsofinterest. 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ExternalResources Pubmed/Medline(NLM) Crossref(DOI) AuthorContacts JohnColomboDepartmentofPsychologyandSchiefelbuschInstituteforLifeSpanStudiesUniversityofKansas,1000SunnysideAvenueLawrence,KS66045(USA)[email protected] Article/PublicationDetails First-PagePreview Received:December03,2019Accepted:March16,2020Publishedonline:June18,2020 Issuereleasedate:June2020 NumberofPrintPages:9 NumberofFigures:1 NumberofTables:0 ISSN:0250-6807(Print)eISSN:1421-9697(Online) Foradditionalinformation:https://www.karger.com/ANM Copyright/DrugDosage/Disclaimer Copyright:Allrightsreserved.Nopartofthispublicationmaybetranslatedintootherlanguages,reproducedorutilizedinanyformorbyanymeans,electronicormechanical,includingphotocopying,recording,microcopying,orbyanyinformationstorageandretrievalsystem,withoutpermissioninwritingfromthepublisher. DrugDosage:Theauthorsandthepublisherhaveexertedeveryefforttoensurethatdrugselectionanddosagesetforthinthistextareinaccordwithcurrentrecommendationsandpracticeatthetimeofpublication.However,inviewofongoingresearch,changesingovernmentregulations,andtheconstantflowofinformationrelatingtodrugtherapyanddrugreactions,thereaderisurgedtocheckthepackageinsertforeachdrugforanychangesinindicationsanddosageandforaddedwarningsandprecautions.Thisisparticularlyimportantwhentherecommendedagentisanewand/orinfrequentlyemployeddrug. 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