{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T17:38:41Z","timestamp":1787161121419,"version":"build-2736575974"},"reference-count":34,"publisher":"Springer Science and Business Media LLC","issue":"6","license":[{"start":{"date-parts":[[2024,4,3]],"date-time":"2024-04-03T00:00:00Z","timestamp":1712102400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,4,3]],"date-time":"2024-04-03T00:00:00Z","timestamp":1712102400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100007950","name":"Tanta University","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100007950","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Eur J Pediatr"],"abstract":"<jats:sec>\n                    <jats:title>Abstract<\/jats:title>\n                    <jats:p>Myocardial injury in open-heart surgery is related to several factors including ischemia\u2013reperfusion injury, generation of reactive oxygen species, increased production of inflammatory mediators, and enhancement of apoptosis of cardiomyocytes. The aim of this study was to study the effect of L-carnitine on myocardial injury in children undergoing open-heart surgery. This clinical trial was performed on 60 children with congenital heart disease (CHD) who underwent open-heart surgery. They were randomized into two groups: L-carnitine group who received L-carnitine 50 mg\\kg\\day once daily for 1 month before cardiac surgery and control group who received placebo for 1 month before cardiac surgery. Left ventricular cardiac function was assessed by conventional echocardiography to measure left ventricular ejection fraction (LVEF) and two-dimensional speckle tracking echocardiography (2D-STE) to determine left ventricular global longitudinal strain (2D-LV GLS). Blood samples were obtained pre-operatively at baseline before the administration of L-carnitine or placebo and 12 h post-operatively to measure the level of malondialdehyde (MDA), superoxide dismutase (SOD), fas, caspase-3, creatinine kinase-MB (CK-MB), and troponin I. L-carnitine group had significantly lower post-operative level of oxidative stress marker (MDA), apoptosis markers (fas and caspase-3), and myocardial injury markers (CK-MB and troponin I), but they had significantly higher SOD post-operative level compared to the control group. In addition, post-operative LVEF and 2D-LVGLS were significantly lower in the control group compared to L-carnitine group.<\/jats:p>\n                    <jats:p>\n                      <jats:italic>\u00a0 Conclusion<\/jats:italic>\n                      : L-carnitine can reduce myocardial injury, improve post-operative left ventricular cardiac function, and may provide myocardium protection in children with CHD who underwent open-heart surgery.\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:italic>\u00a0 Trial registration<\/jats:italic>\n                      :\u00a0The clinical trial was registered at\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"http:\/\/www.pactr.org\">www.pactr.org<\/jats:ext-link>\n                      with registration number PACTR202010570607420 at 29\/10\/2020 before recruiting the patients.\n                      <jats:table-wrap>\n                        <jats:table>\n                          <jats:tbody>\n                            <jats:tr>\n                              <jats:td colspan=\"2\">\n                                <jats:bold>What is Known:<\/jats:bold>\n                                <jats:italic>\u2022 Myocardial injury in open-heart surgery is related to several factors including ischemia\u2013reperfusion injury, generation of reactive oxygen species, increased production of inflammatory mediators, and enhancement of apoptosis of cardiomyocytes.<\/jats:italic>\n                                <jats:italic>\u2022 L-carnitine was reported to have myocardial protective effects in rheumatic valvular surgery and coronary artery bypass graft (CABG) in adults; however, there is no evidence on its effectiveness in children undergoing open-heart surgery.<\/jats:italic>\n                              <\/jats:td>\n                            <\/jats:tr>\n                            <jats:tr>\n                              <jats:td colspan=\"2\">\n                                <jats:bold>What is New:<\/jats:bold>\n                                <jats:italic>\u2022 L-carnitine significantly lowered the post-operative level of oxidative stress marker (MDA), apoptosis markers (fas and caspase-3), and myocardial injury markers (CK-MB and troponin I) in the treatment group.<\/jats:italic>\n                                <jats:italic>\u2022 L-carnitine can reduce myocardial injury, improve post-operative left ventricular cardiac function, and may provide myocardium protection in children with CHD who underwent open-heart surgery.<\/jats:italic>\n                              <\/jats:td>\n                            <\/jats:tr>\n                          <\/jats:tbody>\n                        <\/jats:table>\n                      <\/jats:table-wrap>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00431-024-05534-2","type":"journal-article","created":{"date-parts":[[2024,4,3]],"date-time":"2024-04-03T11:02:05Z","timestamp":1712142125000},"page":"2783-2789","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["L-carnitine decreases myocardial injury in children undergoing open-heart surgery: A randomized controlled trial"],"prefix":"10.1007","volume":"183","author":[{"given":"Wael","family":"El Feky","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dalia","family":"El-Afify","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dina","family":"Abdelhai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed","family":"Elkashlan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmed","family":"Fakhreldin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Doaa","family":"El Amrousy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,4,3]]},"reference":[{"issue":"4","key":"5534_CR1","doi-asserted-by":"publisher","first-page":"1438","DOI":"10.1016\/j.athoracsur.2006.10.073","volume":"83","author":"M Ma","year":"2007","unstructured":"Ma M, Gauvreau K, Allan CK, Mayer JE Jr, Jenkins KJ (2007) Causes of death after congenital heart surgery. Ann Thorac Surg 83(4):1438\u20131445","journal-title":"Ann Thorac Surg"},{"issue":"10","key":"5534_CR2","doi-asserted-by":"publisher","first-page":"S220","DOI":"10.1097\/00003246-200110001-00004","volume":"29","author":"DL Wessel","year":"2001","unstructured":"Wessel DL (2001) Managing low cardiac output syndrome after congenital heart surgery. Crit Care Med 29(10):S220\u2013S230","journal-title":"Crit Care Med"},{"issue":"1","key":"5534_CR3","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1203\/PDR.0b013e31821b1a92","volume":"70","author":"YW Peng","year":"2011","unstructured":"Peng YW, Buller CL, Charpie JR (2011) Impact of N-acetylcysteine on neonatal cardiomyocyte ischemia\u2013reperfusion injury. Pediatr Res 70(1):61\u201366","journal-title":"Pediatr Res"},{"issue":"1","key":"5534_CR4","doi-asserted-by":"publisher","first-page":"e43","DOI":"10.1016\/j.carpath.2010.01.012","volume":"20","author":"MS Oliveira","year":"2011","unstructured":"Oliveira MS, Floriano EM, Mazin SC, Martinez EZ, de Vicente WV, A, Peres LC, Rossi MA, Ramos SG (2011) Ischemic myocardial injuries after cardiac malformation repair in infants may be associated with oxidative stress mechanisms. Cardiovasc Pathol 20(1):e43\u2013e52","journal-title":"Cardiovasc Pathol"},{"issue":"1","key":"5534_CR5","first-page":"16","volume":"37","author":"R Turkoz","year":"2013","unstructured":"Turkoz R (2013) Myocardial protection in pediatric cardiac surgery Artif Organs 37(1):16\u201320","journal-title":"Myocardial protection in pediatric cardiac surgery Artif Organs"},{"issue":"4","key":"5534_CR6","doi-asserted-by":"publisher","first-page":"746","DOI":"10.1007\/s00246-016-1345-3","volume":"37","author":"N Sznycer-Taub","year":"2016","unstructured":"Sznycer-Taub N, Mackie S, Peng YW, Donohue J, Yu S, Aiyagari R, Charpie J (2016) Myocardial oxidative stress in infants undergoing cardiac surgery. Pediatr Cardiol 37(4):746\u2013750","journal-title":"Pediatr Cardiol"},{"key":"5534_CR7","doi-asserted-by":"publisher","first-page":"2934","DOI":"10.1161\/01.CIR.99.22.2934","volume":"99","author":"R Von Harsdorf","year":"1999","unstructured":"Von Harsdorf R, Li PF, Dietz R (1999) Signaling pathways in reactive oxygen species\u2014induced cardiomyocyte apoptosis. Circulation 99:2934\u20132941","journal-title":"Circulation"},{"key":"5534_CR8","doi-asserted-by":"publisher","first-page":"304","DOI":"10.1016\/j.ejcts.2003.12.003","volume":"25","author":"A Anselmi","year":"2004","unstructured":"Anselmi A, Abbate A, Girola F, Nasso G, Biondi-Zoccai GG, Possati G, Gaudino M (2004) Myocardial ischemia, stunning, inflammation, and apoptosis during cardiac surgery: a review of evidence. Eur J Cardiothorac Surg 25:304\u2013311","journal-title":"Eur J Cardiothorac Surg"},{"key":"5534_CR9","doi-asserted-by":"publisher","first-page":"984","DOI":"10.1016\/S1010-7940(03)00113-1","volume":"23","author":"UM Fischer","year":"2003","unstructured":"Fischer UM, Klass O, Stock U, Easo J, Geissler HJ, Fischer JH, Bloch W, Mehlhorn U (2003) Cardioplegic arrest induces apoptosis signal-pathway in myocardial endothelial cells and cardiac myocytes. Eur J Cardiothorac Surg 23:984\u2013990","journal-title":"Eur J Cardiothorac Surg"},{"key":"5534_CR10","doi-asserted-by":"publisher","first-page":"915","DOI":"10.1161\/01.CIR.102.8.915","volume":"102","author":"I Jeremias","year":"2000","unstructured":"Jeremias I, Kupatt C, Martin-Villalba A, Habazettl H, Schenkel J, Boekstegers P et al (2000) Involvement of CD95\/Apo1\/Fas in cell death after myocardial ischemia. Circulation 102:915\u2013920","journal-title":"Circulation"},{"issue":"suppl I","key":"5534_CR11","first-page":"I257","volume":"114","author":"B Ramlawi","year":"2006","unstructured":"Ramlawi B, Feng J, Mieno S, Szabo C, Zsengeller Z, Clements R, Sodha N, Boodhwani M, Bianchi C, Sellke FW (2006) Indices of apoptosis activation after blood cardioplegia and cardiopulmonary bypass. Circulation 114(suppl I):I257\u2013I263","journal-title":"Circulation"},{"issue":"2","key":"5534_CR12","doi-asserted-by":"publisher","DOI":"10.1016\/j.sjbs.2022.103555","volume":"30","author":"AH Alhasaniah","year":"2023","unstructured":"Alhasaniah AH (2023) L-carnitine: nutrition, pathology, and health benefits. Saudi J Biol Sci 30(2):103555","journal-title":"Saudi J Biol Sci"},{"key":"5534_CR13","doi-asserted-by":"publisher","first-page":"6274854","DOI":"10.1155\/2017\/6274854","volume":"2017","author":"X Song","year":"2017","unstructured":"Song X, Qu H, Yang Z, Rong J, Cai W, Zhou H (2017) Efficacy and safety of l-carnitine treatment for chronic heart failure: a meta-analysis of randomized controlled trials. Biomed Res Int 2017:6274854","journal-title":"Biomed Res Int"},{"key":"5534_CR14","doi-asserted-by":"publisher","first-page":"9491615","DOI":"10.1155\/2021\/9491615","volume":"2021","author":"Y Weng","year":"2021","unstructured":"Weng Y, Zhang S, Huang W, Xie X, Ma Z, Fan Q (2021) Efficacy of L-carnitine for dilated cardiomyopathy: a meta-analysis of randomized controlled trials. Biomed Res Int 2021:9491615","journal-title":"Biomed Res Int"},{"issue":"6","key":"5534_CR15","doi-asserted-by":"publisher","first-page":"1485","DOI":"10.1053\/j.jvca.2016.06.006","volume":"30","author":"M Li","year":"2016","unstructured":"Li M, Xue L, Sun H, Xu S (2016) Myocardial protective effects of L-carnitine on ischemia-reperfusion injury in patients with rheumatic valvular heart disease undergoing cardiac surgery. J Cardiothorac Vasc Anesth 30(6):1485\u20131493","journal-title":"J Cardiothorac Vasc Anesth"},{"issue":"1","key":"5534_CR16","doi-asserted-by":"publisher","first-page":"22","DOI":"10.5606\/tgkdc.dergisi.2018.14620","volume":"26","author":"C Furat","year":"2018","unstructured":"Furat C, \u0130lhan G, Bayar E, Bozok S, G\u00fcvener M, Y\u0131lmaz M (2018) L-carnitine on myocardial function after coronary artery bypass grafting. Turkish Journal of Thoracic and Cardiovascular Surgery 26(1):22\u201329","journal-title":"Turkish Journal of Thoracic and Cardiovascular Surgery"},{"issue":"2","key":"5534_CR17","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1006\/phrs.1997.0281","volume":"37","author":"O Pastoris","year":"1998","unstructured":"Pastoris O, Dossena M, Foppa P, Catapano M, Arbustini E, Bellini O, Dal Bello B, Minzioni G, Ceriana P, Barzaghi N (1998) Effect of L-carnitine on myocardial metabolism: results of a balanced, placebo-controlled, double-blind study in patients undergoing open heart surgery. Pharmacol Res 37(2):115\u2013122","journal-title":"Pharmacol Res"},{"issue":"21","key":"5534_CR18","first-page":"1887","volume":"83","author":"D Xiang","year":"2003","unstructured":"Xiang D, Yan X, Yang S, Liu X, Hu X, Zhou T (2003) Myocardial protective effect of L-carnitine in cardioplegia solution on patients undergoing heart valve replacement operation. Zhonghua Yi Xue Za Zhi 83(21):1887\u20131890","journal-title":"Zhonghua Yi Xue Za Zhi"},{"key":"5534_CR19","doi-asserted-by":"publisher","first-page":"1229","DOI":"10.1016\/S0003-4975(02)03401-X","volume":"73","author":"JP Schmitt","year":"2002","unstructured":"Schmitt JP, Schroder J, Schunkert H, Birnbaum DE, Aebert H (2002) Role of apoptosis in myocardial stunning after open heart surgery. Ann Thorac Surg 73:1229\u20131235","journal-title":"Ann Thorac Surg"},{"key":"5534_CR20","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1016\/j.jtcvs.2003.11.034","volume":"128","author":"UM Fischer","year":"2004","unstructured":"Fischer UM, Tossios P, Huebner A, Geissler HJ, Bloch W, Mehlhorn U (2004) Myocardial apoptosis prevention by radical scavenging in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 128:103\u2013108","journal-title":"J Thorac Cardiovasc Surg"},{"issue":"8","key":"5534_CR21","doi-asserted-by":"publisher","first-page":"628","DOI":"10.1046\/j.1525-1594.2000.06591.x","volume":"24","author":"K Kawahito","year":"2000","unstructured":"Kawahito K, Misawa Y, Fuse K (2000) Transient rise in serum soluble Fas (APO-1\/CD95) in patients undergoing cardiac surgery. Artif Organs 24(8):628\u2013631","journal-title":"Artif Organs"},{"issue":"1","key":"5534_CR22","doi-asserted-by":"publisher","first-page":"137","DOI":"10.1067\/mtc.2002.118685","volume":"123","author":"U Joashi","year":"2002","unstructured":"Joashi U, Tibby SM, Turner C, Mayer A, Austin C, Anderson D, Durward A, Murdoch IA (2002) Soluble Fas may be a proinflammatory marker after cardiopulmonary bypass in children. J Thorac Cardiovasc Surg 123(1):137\u2013144","journal-title":"J Thorac Cardiovasc Surg"},{"key":"5534_CR23","doi-asserted-by":"publisher","first-page":"899","DOI":"10.1016\/j.amjcard.2018.12.019","volume":"123","author":"M Kim","year":"2019","unstructured":"Kim M, Lorinsky MK, Gold CA, BSa, Lahey SJ, Fusco DS, Rosinski DJ, Pawlak D, Liang BT, (2019) Usefulness of circulating Caspase-3 p17 and Caspase-1 p20 peptides and cardiac Troponin 1 during cardioplegia to gauge myocardial preservation. Am J Cardiol 123:899\u2013904","journal-title":"Am J Cardiol"},{"issue":"1","key":"5534_CR24","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1016\/j.bbrc.2011.07.039","volume":"412","author":"E Oyanagi","year":"2011","unstructured":"Oyanagi E, Yano E, Uchida M, Utsumi K, Sasaki J (2011) Protective action of L-carnitine on cardiac mitochondrial function and structure against fatty acid stress. Biochem Biophys Res Commun 412(1):61\u201367","journal-title":"Biochem Biophys Res Commun"},{"key":"5534_CR25","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1016\/S0014-5793(00)01817-2","volume":"478","author":"MC Mutomba","year":"2000","unstructured":"Mutomba MC, Yuan H, Konyavko M, Adachi S, Yokoyama CB, Esser V, McGarry JD, Babior BM, Gottlieb RA (2000) Regulation of the activity of caspases by L-carnitine and palmitoyl carnitine. FEBS Lett 478:19\u201325","journal-title":"FEBS Lett"},{"key":"5534_CR26","doi-asserted-by":"publisher","first-page":"746","DOI":"10.1007\/s00246-016-1345-3","volume":"37","author":"N Sznycer-Taub","year":"2016","unstructured":"Sznycer-Taub N, Mackie S, Peng YW, Donohue J, Yu S, Aiyagari R, Charpie J (2016) Myocardial oxidative stress in infants undergoing cardiac surgery. Pediatr Cardiol 37:746\u2013750","journal-title":"Pediatr Cardiol"},{"issue":"2","key":"5534_CR27","doi-asserted-by":"publisher","first-page":"326","DOI":"10.3349\/ymj.2011.52.2.326","volume":"52","author":"W Xia","year":"2011","unstructured":"Xia W, Liu Y, Zhou Q, Tang Q, Zou H (2011) Comparison of the effects of propofol and midazolam on inflammation and oxidase stress in children with congenital heart disease undergoing cardiac surgery. Yonsei Med J 52(2):326\u2013332","journal-title":"Yonsei Med J"},{"key":"5534_CR28","doi-asserted-by":"publisher","first-page":"1001","DOI":"10.1111\/1440-1681.13155","volume":"46","author":"M Li","year":"2019","unstructured":"Li M, Xu S, Geng Y, Sun L, Wang R, Yan Y, Wang H, Li Y, Yi Q, Zhang Y, Hao J, Deng C, Li W, Xue L (2019) The protective effects of L-carnitine on myocardial ischemia\u2013reperfusion injury in patients with rheumatic valvular heart disease undergoing CPB surgery are associated with the suppression of NF-\u03baB pathway and the activation of Nrf2 pathway. Clin Exp Pharmacol Physiol 46:1001\u20131012","journal-title":"Clin Exp Pharmacol Physiol"},{"key":"5534_CR29","doi-asserted-by":"publisher","DOI":"10.12659\/MSM.923251","volume":"26","author":"T Zhao","year":"2020","unstructured":"Zhao T, Chen S, Wang B, Cai D (2020) L-carnitine reduces myocardial oxidative stress and alleviates myocardial ischemia-reperfusion injury by activating nuclear transcription-related factor 2 (Nrf2)\/heme oxygenase-1 (HO-1) signaling pathway. Med Sci Monit 26:e923251","journal-title":"Med Sci Monit"},{"key":"5534_CR30","doi-asserted-by":"publisher","first-page":"4028297","DOI":"10.1155\/2018\/4028297","volume":"2018","author":"F Vacante","year":"2018","unstructured":"Vacante F, Senesi P, Montesano A, Frigerio A, Luzi L, Terruzzi I (2018) L-carnitine: an antioxidant remedy for the survival of cardiomyocytes under hyperglycemic condition. J Diabetes Res 2018:4028297","journal-title":"J Diabetes Res"},{"key":"5534_CR31","first-page":"263","volume":"57","author":"BS Allen","year":"2020","unstructured":"Allen BS (2020) Myocardial protection: a forgotten modality. Eur J Cardiothorac Surg 57:263\u2013270","journal-title":"Eur J Cardiothorac Surg"},{"key":"5534_CR32","doi-asserted-by":"publisher","first-page":"e90","DOI":"10.1016\/j.ejcts.2010.12.052","volume":"39","author":"Z Jin","year":"2011","unstructured":"Jin Z, Duan W, Chen M, Yu S, Zhang H, Feng G, Xiong L, Yi D (2011) The myocardial protective effects of adenosine pretreatment in children undergoing cardiac surgery: a randomized controlled clinical trial. Eur J Cardiothorac Surg 39:e90\u2013e96","journal-title":"Eur J Cardiothorac Surg"},{"key":"5534_CR33","first-page":"726","volume":"23","author":"H Zhong","year":"2013","unstructured":"Zhong H, Gao Z, Chen M, Zhao J, Wang F, Li L, Dong H, Liu L, Wang Q, Xiong L (2013) Cardioprotective effect of remote ischemic postconditioning on children undergoing cardiac surgery: a randomized controlled trial Pediatric Anesthesia 23:726\u2013733","journal-title":"Cardioprotective effect of remote ischemic postconditioning on children undergoing cardiac surgery: a randomized controlled trial Pediatric Anesthesia"},{"issue":"4","key":"5534_CR34","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1007\/s10557-005-3349-8","volume":"19","author":"R Lango","year":"2005","unstructured":"Lango R, Smole\u0144ski RT, Rogowski J, Siebert J, Wujtewicz M, S\u0142omi\u0144ska EM, Lysiak-Szyd\u0142owska W, Yacoub MH (2005) Propionyl-L-carnitine improves hemodynamics and metabolic markers of cardiac perfusion during coronary surgery in diabetic patients. Cardiovasc Drugs Ther 19(4):267\u2013275","journal-title":"Cardiovasc Drugs Ther"}],"container-title":["European Journal of Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00431-024-05534-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00431-024-05534-2\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00431-024-05534-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,5,16]],"date-time":"2024-05-16T02:08:36Z","timestamp":1715825316000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00431-024-05534-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,3]]},"references-count":34,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2024,6]]}},"alternative-id":["5534"],"URL":"https:\/\/doi.org\/10.1007\/s00431-024-05534-2","relation":{},"ISSN":["1432-1076"],"issn-type":[{"value":"1432-1076","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,4,3]]},"assertion":[{"value":"19 December 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 March 2024","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 March 2024","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"3 April 2024","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Local ethical committee of Faculty of Medicine, Tanta University, approved the study. The study is in accordance with the ethical standards of institutional research committee and with the 1964 Helsinki Declaration and its later amendments.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"Informed consent was obtained from all parents of included children in the study.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}]}}