Talk:Kwashiorkor

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This article was the subject of a Wiki Education Foundation-supported course assignment, between 29 June 2020 and 21 August 2020. Further details are available on the course page. Student editor(s): Kkellohen, Amanukyan UCSF, Adjlopez, Mkardouh.

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This article was the subject of a Wiki Education Foundation-supported course assignment, between 7 June 2021 and 27 August 2021. Further details are available on the course page. Student editor(s): J.Choi, Future UCSF Pharm.D., Jerlam8, J. Chang, Future UCSF Pharm.D., Jvalenciachavez. Peer reviewers: M. Frank, Future UCSF Pharm.D., Mmuskat, Mbanawis.

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Wiki Education Foundation-supported course assignment

This article was the subject of a Wiki Education Foundation-supported course assignment, between 1 July 2019 and 23 August 2019. Further details are available on the course page. Student editor(s): Alexuang, Dannymrowr, Brendado425. Peer reviewers: Pkhouder, Kylett1.

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Not a protein-deficiency at all

I will not edit medical pages, but think quick quick review on http://nutritionfacts.org/video/the-great-protein-fiasco/ contains a lot of references to research debunking that protein deficiency is the cause of Kwashiorkor. Please change. — Preceding unsigned comment added by 2001:980:93A5:1:4D3B:55D3:2103:7F5D (talk) 12:30, 27 June 2016 (UTC)

second

I will second this. Most research now points to complex interaction between microbiome, infection and malnutrition. The association with weaning is likely not linked to the lack of protein, just the lack of calories in general. If/when I have more time will find some sources and edit.

Also the image is NOT a child with kwashiorkor. The child is predominantly marasmic with maybe a touch of edema (combined picture). Ibrmrn (talk) 14:07, 26 October 2016 (UTC)

third

Very much agree that this the picture is not a good example of kwashiorkor.

There is also a large body of evidence building that, while kwashiorkor may not be due to a deficiency of protein per se, it may be due to a deficiency in particular amino acids. Sulfur amino acids are one of the most promising culprits currently being investigated.

Roediger WEW, Waterlow JP. New Views on the Pathogenesis of Kwashiorkor: Methionine and Other Amino Acids. Journal of Pediatric Gastroenterology & Nutrition. 1995;21(2):130-6. Phadke MA, Khedkar VA, Pashankar D, Kate SL, Mokashi GD, Gambhir PS, Bhate SM. Serum Amino Acids and Genesis of Protein Energy Malnutrition. Indian Pediatrics. 1995;32:301-6. Jahoor F. Effects of decreased availability of sulfur amino acids in severe childhood undernutrition. Nutrition Reviews. 2012;70(3):176-87. Jahoor F, Badaloo A, Reid M, Forrester T. Protein kinetic differences between children with edematous and nonedematous severe childhood undernutrition in the fed and postabsorptive states. The American Journal of Clinical Nutrition. 2005;82(4):792-800. Jahoor F, Badaloo A, Reid M, Forrester T. Sulfur amino acid metabolism in children with severe childhood undernutrition: cysteine kinetics. The American Journal of Clinical Nutrition. 2006;84(6):1393-9. Badaloo A, Hsu JW, Taylor-Bryan C, Green C, Reid M, Forrester T, Jahoor F. Dietary cysteine is used more efficiently by children with severe acute malnutrition with edema compared with those without edema. The American Journal of Clinical Nutrition. 2012;95(1):84-90. Badaloo A, Reid M, Forrester T, Heird WC, Jahoor F. Cysteine supplementation improves the erythrocyte glutathione synthesis rate in children with severe edematous malnutrition. The American Journal of Clinical Nutrition. 2002;76(3):646-52. — Preceding unsigned comment added by 130.64.25.58 (talk) 17:11, 4 May 2017 (UTC)

Please read: https://www.ncbi.nlm.nih.gov/m/pubmed/23363771/ Jbulleit (talk) 15:39, 11 April 2019 (UTC)

fourth

Here are links to some of the references that discuss the cause of kwashiorkor: "The cause of kwashiorkor remains obscure," (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667500/), "there is no real evidence of dietary protein deficiency," (Kwashiorcor revisited: https://academic.oup.com/trstmh/article-abstract/78/4/436/1893691?redirectedFrom=PDF), and "The mechanisms responsible for oedema formation in kwashiorkor remain obscure," (https://adc.bmj.com/content/76/1/54).

I would appreciate if someone qualified in the field would edit the article to remove its inaccuracies regarding the cause of kwashiorkor. — Preceding unsigned comment added by Thomaswayneriddle (talk • contribs) 15:27, 12 April 2019 (UTC)

The underlying cause is a lack of protein, more particularly amino acids needed for growth. You (and these authors) are confusing this with the precise physiological mechanism that causes the oedema. If the latter is viewed as the main problem to be treated (and thus the definition of kwashiorkor), then yes, the causes remain "obscure". 2A01:CB0C:CD:D800:B418:5FD3:6F8B:F7F7 (talk) 17:04, 17 November 2022 (UTC)

Do

Do you have any pictures of people with kwashiorkor? [[User:NazismIsntCool|{{NazismIsntCool/sig}} Nazism isn't cool]] 05:41, 2 September 2005 (UTC)

another mechanism for Kwashiorkor

A professor gave me a math problem concerning the hypoosmotic effects of reduced serum albumin (which has colligative properties, as any other molecule would) due to reduced protein intake/production. This would lead to an overall decrease in oncotic pressure in the capillaries, in turn increasing the osmotic flux through the capillary wall, resulting in edema. —The preceding unsigned comment was added by Raleightodd (talk • contribs) 01:43, 28 February 2007 (UTC).

The edema of kwashiokor gets better after the first phase of treatment BEFORE the albumin levels are corrected by the liver. —Preceding unsigned comment added by 167.206.17.116 (talk) 19:02, 29 May 2010 (UTC)

Under treatment, there's currently 10 WHO guidelines, but only 8 are listed. Consider updating that

Meaning (derivation)

French & English Wikipedia conflict on derivation.

Here it is said:

The name is derived from one of the Kwa languages of coastal Ghana and means "the one who is displaced"

And in wp:fr they say:

Le terme, qui signifie enfant (kwashi) rouge (orkor) dans la langue des Ashanti du Ghana

So they mention the concrete language and give a completely different meaning... Which one is right? --83.32.66.149 19:49, 20 May 2007 (UTC)

(What it actually says here is:

...Jamaican pediatrician Dr. Cicely D. Williams introduced the name into the medical community in her 1935 Lancet article.[3] The name is derived from the Ga language of coastal Ghana, translated literally "first-second"[4][citation needed], and reflecting the development of the condition in an older child who has been weaned from the breast when a younger sibling comes.[5] Breast milk contains proteins and amino acids vital to a child's growth. In at-risk populations, kwashiorkor may develop after a mother weans her child from breast milk and replaces the diet with foods high in starches and carbohydrates and deficient in protein. )

The cited Lancet article is listed as

3. "Williams CD (1935). "Kwashiorkor: a nutritional disease of children associated with a maize diet". Lancet 226: 1151–2. doi:10.1016/S0140-6736(00)94666-X."

This is a bona fide Lancet article found in PubMed and cited by other recent PubMed abstracts of studies of Kwashiorkor.

Some additional evidence of derivation appears in footnote 4 of the English WP article:

4. ^ "Jamaica Gleaner : Pieces of the Past: A Pioneer, A Survivor: Dr. Cicely Williams". "... she asked an African nurse if it had a name. She learned it was called "kwashiorkor" meaning the sickness the older child gets when the next baby is born. Cicely surmised that this meant that weanling children were not receiving enough to eat". http://www.jamaica-gleaner.com/pages/history/story0037.htm. Retrieved 2009-12-27.

Can anyone reference the Lancet article referenced in footnote 3 as the source and give us a short fair-use quote?

If the Lancet article is correctly cited as the source, the French Wikipedia article may need to be corrected. Ga is the particular member of the Kwa language family suggested in the footnoted sources. A Ga/Kwa/Ashanti linguistic scholar might shed more light, but the suggested "red child" meaning does not match the syndrome actually observed in Kwashiorkor. Meanwhile, the the Ga language meaning is closely tailored to the most common presentation.

The very rare cases found in developed countries almost invariably occur when an infant is weaned off of breast milk after only a few months, but the needed protein and plethora of other breast milk nutrients (EFAs, etc., etc. -- the list of know benefits of nursing and mother's milk is very long and growing) is not replaced. Rather than willing neglectfulness, the parents are generally well-educated, know that the protein needs of adults can be amply satisfied by a purely vegan diet, but tragically lack the information that developing children need the protein and other ingredients in breast milk for normal health and development. A vegan mother may be able to supply these nutrients in her breast milk while the mother continues to consume a purely vegan diet, but an infant or toddler cannot do the same during the several years that breast feeding is recommendable. (Actually, a nursing mother who supplements her own vegan diet with fish oil and fish may provide her milk with more of the DHA needed for optimal brain development). If anything, vegans should breast-feed longer than meat-eaters, and this information is tragically not everywhere available, even to the well-educated, leading to very rare prosecutions for abuse or neglect if the Kwashiorkor is not diagnosed in time to save the child's life and health. Occasionally in the absence of breast feeding or other protein sources, fears of allergy to cow's milk, may also lead to Kwashiorkor's.

If the mother is severely malnourished, or has a second pregnancy while nursing, her milk dries up. If this happens while the first child still needs nursing and other protein sources (particularly fish sources) are not available (but starch sources are) the result is Kwashiorkor.

The Lancet is not to be trusted on matters linguistic (or even medical, in some cases!). If all the sources are correct, then the most likely explanation is that it really does mean "red child" in Asante-Twi and that the term was subsequently borrowed by Ga speakers, who explained the term in descriptive terms "the sickness the baby gets when the new baby comes" (and the former baby is weaned, which is what brings on the condition). 2A01:CB0C:CD:D800:B418:5FD3:6F8B:F7F7 (talk) 16:53, 17 November 2022 (UTC)

Humor: "Queasy-Kosher" When they won't eat it because they think it's "gross" leading to malnutrition. — Preceding unsigned comment added by KarlHegbloom (talk • contribs) 13:28, 2 December 2013 (UTC)

Yeah, that's not funny at all. Moreover, children are not typically picky about high-protein items. If the joke were physiologically correct, I could stomach its bad taste, but as it is: just no. 2A01:CB0C:CD:D800:B418:5FD3:6F8B:F7F7 (talk) 16:55, 17 November 2022 (UTC)

Pathophysiology

I removed the following paragraph:

The swollen abdomen is generally attributed to two causes: First, the appearance of ascites due to increased capillary permeability from the increased production of cysteinyl leukotrienes (LTC4 and LTE4) as a result of generalized intracellular deficiency of glutathione. Tolga is thought to be attributed to the effect of malnutrition on reducing plasma proteins (discussed below), resulting in a reduced oncotic pressure and therefore increased osmotic flux through the capillary wall. A second cause may be due to a grossly enlarged liver due to fatty liver. This fatty change occurs because of the lack of apolipoproteins which transport lipids(cholesterol) from the liver to tissues throughout the body.

The first assertion, that children w/ kwashiorkor have ascites is incorrect; they abdominal distention is NOT caused by ascites. Since the rest of the paragraph is unsourced, I removed it; if you can find a reliable source, please reintroduce this information. This article needs some serious work. --Wawot1 (talk) 15:43, 5 April 2009 (UTC)

Ascites is the correct medical term. It describes what is going on inside the abdomen (physiologically and anatomically) whereas edema is the term for the presentation (the swollen belly that is apparent). It is a shame you removed a good para simply because you don't understand medical terminology. 2A01:CB0C:CD:D800:B418:5FD3:6F8B:F7F7 (talk) 16:58, 17 November 2022 (UTC)

A useful source

Management of acute moderate and severe childhood malnutrition. http://www.bmj.com/cgi/content/full/337/nov13_1/a2180?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=kwashiorkor&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT#REF2

--Wawot1 (talk) 15:43, 5 April 2009 (UTC)

Is it allowed to use the WHO guidelines? http://www.who.int/nutrition/publications/guide_inpatient_text.pdf — Preceding unsigned comment added by Szadeh4 (talk • contribs) 03:50, 17 February 2016 (UTC)

Can it be said to be "virulent"?

"Kwashiorkor is a virulent form of childhood malnutrition" would seem to indicate that it is caused by a virus and is infectious. Could that be the case?

--alagahd (talk) 11:13, 22 May 2009 (UTC)

"Virulent" can mean "deadly" or "serious" but as you recognize, it connotes contagion. Replacement with "deadly" or "extremely serious" would avoid this ambiguity by specifying the meaning intended.

Micronutrients

I am going to edit the sections about the reason for Kwashiorkor being "micronutrients" and antioxidants. There is no mention of that in the literature. Only Zink deficiency (Acrodermatitis enteropathica) shows a similar picture but is a diagnosis on it's own. I am also deleting the part about aflatoxin because alfatoxin is not the cause for Kwashiorkor as written in the article. Higher alfatoxin levels are the consequence of impaired liver function due to Kwashiorkor. (Sources: peer reviewed journals: Pediatrics. 1991 Aug;88(2):376-9. Kwashiorkor: the hypothesis that incriminates aflatoxins., Hendrickse RG. Aflatoxin Exposure and its Relationship to Kwashiorkor in African Children K. C. Househam and H. K. L. Hundt, J Trop Pediatr (1991) 37 (6): 300-302. doi: 10.1093/tropej/37.6.300 Ann Trop Paediatr. 1992;12(3):241-7, Aflatoxins and kwashiorkor in Durban, South Africa. Ramjee G, Berjak P, Adhikari M, Dutton MF.) I will expand the section about sign and symptoms — Preceding unsigned comment added by Jadram2011 (talk • contribs) 18:45, 26 July 2012 (UTC)

I was just trying to edit the Kwashiorkor article to include micronutrients and antioxidants. Protein deficiency in children is rare. Children at 1-2yrs only need 5-6% of calories from protein. The symptoms of kwashiorkor (e.g. edema) are not cured by high protein diets. WHO guidelines stated that for the first week you give micronutrients (except iron), a diet with 5-6% protein calories, and you treat infections, hypoglycemia, dehydration. After the first week the child's edema will lessen (before any change in plasma albumin) and their appetite should return. That's when you give them high protein diets for catch up growth. Diets consumed by 1-2yr olds in most of the affected regions have about 6.4-8.8% protein calories. — Preceding unsigned comment added by Szadeh4 (talk • contribs) 03:47, 17 February 2016 (UTC)

Young children do not take many calories from protein, that is correct. They do need protein to grow, however. The lack of protein leads to low muscle mass and arrested growth, which in turn cause the abnormal disposition of energy reserved in the liver (which would otherwise be expended on growth) and subsequent impairments (which among other things leads to elevated aflatoxins). You are correct in stating that in treatment of kwashiorkor, a reversal of the liver morbidities (including micronutrients, compensating for impaired liver function) is a priority. Moreover, a very high protein content would only be counterproductive as the system is not capable of accommodating this and only makes the child sicker. Nevertheless, the underlying cause remains protein shortage (that is, lack of biochemical available nitrogen) and a steadily increasing amino acid content in the diet is essential to full recovery. 2A01:CB0C:CD:D800:B418:5FD3:6F8B:F7F7 (talk) 16:49, 17 November 2022 (UTC)

Reader feedback: This article can be improved...

112.205.39.127 posted this comment on 11 July 2012 (view all feedback).

This article can be improved by adding more explanation on symptoms and other signs of kwashiorkor.

Also add pictures of people with kwashiorkor in front view.

There have also been many other feedback requests for more pictures and about how the disease is treated.

Puffin ^{Let's talk!} 21:06, 26 January 2014 (UTC)

Literal translation

There are conflicting sources on the web (none referenced here, however). Some agree with the Wikipedia translation, but others claim that while this may be the most meaningful translation, the literal one is "red-haired boy". If they are in fact different, the Wikipedia article needs both. 72.200.151.13 (talk) 14:18, 11 July 2014 (UTC)

The French wiki page says the word literally means "red child" in the language of the Ashanti. The latter speak Twi, whereas the English-language page here claims it comes from Ga. I have no idea how similar these languages are, and I rather suspect one of them has borrowed the term from the other. If all the sources are correct, then the most likely explanation is that it really does mean "red child" in Asante-Twi and that it was borrowed by Ga speakers, who explained the term to the ethnographer in descriptive terms "the sickness the baby gets when the new baby comes" (and the former baby is weaned, which is what brings on the condition). 2A01:CB0C:CD:D800:B418:5FD3:6F8B:F7F7 (talk) 16:50, 17 November 2022 (UTC)

Foundations 2 2019, Group 3b goals

This article is being edited as part of the Foundations II course at UCSF

Proposed edits:

1. Expand "diagnosis" section to include specific labs and diagnostic algorithms, definition of muscle wasting
2. Add section on Treatment
3. add information about prevalence/epidemiology
4. literature for up-to-date information on pathophysiology

-insufficient protein intake / amino acids / hypoalbuminemia

-kidney dysfunction

-dysadaptation to a low protein high carbohydrate diet

-aflatoxins

-oxidative stress (free radicals)

-gut microbiota

//current references

Oedema in kwashiorkor is caused by hypoalbuminaemia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462841/

Kwashiorkor - Statpearls https://www.ncbi.nlm.nih.gov/books/NBK507876/

Management of complicated severe acute malnutrition in children in resource-limited countries https://www.uptodate.com/contents/management-of-complicated-severe-acute-malnutrition-in-children-in-resource-limited-countries

Malnutrition in children in resource-limited countries: Clinical assessment https://www.uptodate.com/contents/malnutrition-in-children-in-resource-limited-countries-clinical-assessment#H4

Dermatosis in children with oedematous malnutrition (Kwashiorkor): a review of the literature https://onlinelibrary.wiley.com/doi/full/10.1111/jdv.12452

The Immune System in Children with Malnutrition—A Systematic Review https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0105017

--Alexuang (talk) 21:41, 29 July 2019 (UTC)

FYI, check editing tags I used for future reference, in particular the citation added (use "Cite" dropdown). Some of the suggested sources appear to be good reviews while others are quite specific; as noted summary articles are better, where available (but they may not be!) Health policy (talk) 04:38, 31 July 2019 (UTC)

References

Foundations 2 Group 3a peer review

Part 1

Under treatment, there's currently 10 WHO guidelines, but only 8 are listed. Consider updating that The article contains sections that are easy to understand, a clear chronological structure (from describing the general information, to explaining the signs and symptoms, to the causes/diagnoses, to treatment, prevention, and prognosis). Sources used are reliable and up to date (2019). The lead provided a general view on the topic which allowed me to get a good grasp on what the article is about. Kylett1 (talk) 16:24, 6 August 2019 (UTC)

Yes, the group’s edits have substantially improved the article. Addition of diagnostic characteristics and explanation of the unclear etiologies of kwashiorkor all come from reliable secondary sources and are written neutrally. The group achieved their proposed goals for improvement by expanding on diagnosis, treatment, and epidemiology.Pkhouder (talk) 04:52, 6 August 2019 (UTC)

Yes the groups edits have increased the articles integrity, and they have addressed the goals that were sought out to complete.Kmhudson22 (talk) 16:31, 6 August 2019 (UTC)

Part 2 A: yes the article additions reflect a neutral point Kmhudson22 (talk) 16:31, 6 August 2019 (UTC) B:the article contains many sources that are reliable and up to date (2019) (with many secondary articles from Pubmed) Kylett1 (talk) 16:24, 6 August 2019 (UTC) C: YesPkhouder (talk) 04:52, 6 August 2019 (UTC) D:

WikiProject Medicine

As a member of WP:WikiProject Medicine I have volunteered to watch this article while it is a Wikipedia:Wiki Ed/UCSF/Foundations II (Summer 2020) assignment. Feel free to ask me questions here or on my Talk page. David notMD (talk) 00:42, 9 August 2020 (UTC)

Foundations II 2021

Expand the organization; clean it up

Add new references and replace old ones

Improve the quality or writing. Use more inclusive language

Expand more on the prognosis if there are more articles to refer to

Also include a more reflective image(s)

Expand the treatment. List the options that are available.

a. We have reviewed all references which should now be correctly formatted according to the Manual of Style.

b. We were unable to identify any references from predatory publishers.

c. Numerous references were identified as duplicates and were consolidated as follows:

  i. References 10, 39, and 47 were identified as duplicates through the peer review; We consolidated all callouts in the text, which now refer to reference 10.
 ii. References 2, 6, 11, 21, 35, and 38 were identified as duplicates through peer review; We consolidated all callouts in the text, which now refer to reference 2.
iii. References 3, 13,14, and 40 were identified as duplicates; We consolidated all callouts in the text, which now refer to reference 3.  

J.Choi, Future UCSF Pharm.D. (talk) 21:06, 4 August 2021 (UTC)

Peer Review - Group 20

1) Comparing the current article to the version of the article from a couple weeks ago, I would agree that the group substantially improved the article. Looking at the "Guiding Framework" for peer review on Wikipedia, the main aspects of the framework include the lead, content, tone/blanace, sources/references, organization, images/media, and overall impressions. In respect to the the article's lead, there was improvement through the addition of more sources and further clarifications. The article had a concise introductory sentence, and the group added further details to describe most of the article's major sections. However, there was no talk of Effects on PK, a section in the article contents, in the lead. I believe the article lead was sufficient length. The content added was up-to-date, relevant and equitable. The sections they added, like mechanisms and prevention, were useful additions. Additionally, the content was neutral and had reliable secondary sources to back up their information added. I would also agree that the organization of the article was both improved and acceptable. Looking at the group's goals to improve the article's organization, add references, and expand on some sections, I would agree that the group achieved its overall goals for improvement. It seemed that another goal the group had was to include more images. However, it seems like they were unable to do that. Despite this, I thought their addition of the table in the "Welcome's classification" was a useful addition, as finding images to add without copyright infringement can be challenging.
2) I believe the draft submission reflects a neutral point of view. When trying to assess whether the point of view is neutral, the material should be presented fairly, proportionately, and without editorial bias. Additionally, the sources used should be reliable and verifiable. Throughout the article, the group members made sure to not state opinions as facts. They also addressed the unclear etiology of the disease and changed wording throughout the article to reflect that uncertainty. Additionally, the group used language throughout the article that promoted neutrality and didn't endorse points of view that could imply a lack of credibility. When looking through the references, there were over 50 citations, with more than 20 of them being new. This dependence on new references for the article improvementis another indication of an article being less biased. Going through the reference list, the references added were accessible and credible, further improving the credibility and neutrality of this article.

Mmuskat (talk) 21:22, 2 August 2021 (UTC)

The article successfully accomplishes many of the goals outlined by the group prior to editing, and I think the group made successful additions to the article in accordance with Wikipedia's guiding framework. I think the structure of the article is done very well, as the article presents all physiologic information before shifting to more clinical aspects, like treatment or prevention. In terms of improvement, I believe that there are some grammar/syntax errors that could be corrected so the article will be even clearer and more concise. Specifically, some points in the lead section are a bit wordy and come off unclear. Overall, great additions when compared to the article before. The article does a good job of following the Wikipedia Manual of Style for medical articles, hitting all pertinent point of the desired structure. Additionally, citations are listed properly and frequently and the language presented is clear and easy to understand for the average reader. Additionally, the language presented does not skew towards one audience over another, as material is presented without jargon, includes multiple follow-up links to learn more, and a clear neutral voice.M. Frank, Future UCSF Pharm.D. (talk) 21:35, 2 August 2021 (UTC)

The group's edits have successfully improved the article by adding and expanding to existing sections. The lead does not seem to be edited much by the current group, so I focused on reading the treatment and prognosis to which they added information and references. Though the information added to these sections were provided in a clear manner, I think that the sentence variety could be improved in order to improve the flow of the paragraphs. Overall, information in the article is presented in a neutral, factual way and the article as a whole is organized very well. After comparing the past version of the article to the current one, I can conclude that the group was able to expand on several topics and back up their information with good sources. As for the references listed, most of them are secondary sources that are freely available to the public. However, source 50 is a case report and 4 and 47 require you to pay. Some of the references are also repeated, such as 39 and 47, and 2, 6, 11, 21, 35 and 38. The link to 31 leads to the home site and not to the specific one indicated. Though some of the references have some issues, most of the ones listed come from reputable sources and are all good secondary sources such as textbooks or systematic reviews. Mbanawis (talk) 13:54, 3 August 2021 (UTC)

References

This article and social media

Just FYI, due to the unclothed child in the photo in this article, if you share the article in a group on Facebook, it will result in a strike or against your account. ++Arx Fortis (talk) 23:13, 24 November 2024 (UTC)