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Should All Deaf Children Learn

Sign Language?
Nancy K. Mellon, MSa, John K. Niparko, MDb, Christian Rathmann, PhDc, Gaurav Mathur, PhDd, Tom Humphries, PhDe,
Donna Jo Napoli, PhDf, Theresa Handley, BAf, Sasha Scambler, PhDg, John D. Lantos, MDh

abstract Every year, 10 000 infants are born in the United States with sensorineural
deafness. Deaf children of hearing (and nonsigning) parents are unique
among all children in the world in that they cannot easily or naturally learn
the language that their parents speak. These parents face tough choices.
Should they seek a cochlear implant for their child? If so, should they also
learn to sign? As pediatricians, we need to help parents understand the
risks and benefits of different approaches to parent–child communication
when the child is deaf. The benefits of learning sign language clearly outweigh
the risks. For parents and families who are willing and able, this approach
seems clearly preferable to an approach that focuses solely on oral
communication.

a
The River School, Washington, District of Columbia;
b
Department of Otolaryngology, University of Southern Every year, 10 000 infants are born in children, with or without a CI, should
California; cInstitute for German Sign Language and
Communication of the Deaf, University of Hamburg; the United States with sensorineural be taught a sign language. Others
d
Graduate School, Gallaudet University; eDepartment of deafness. The incidence of worry that learning a sign language
Education Studies, University of California at San Diego;
f
sensorineural deafness is similar in will interfere with the extensive and
Swarthmore College; gKing’s College London; and
h
Children’s Mercy Hospital most high-income countries and is intensive rehabilitation that is
higher in some low-income countries.1 necessary to reap the most benefit
Ms Mellon conceptualized the study and drafted the
initial manuscript; Dr Niparko drafted the initial
Many more infants become deaf before from a CI or that asking parents to
manuscript; Drs Scambler, Rathmann, Mathur, 2 years of age. In such situations, learn a new language to communicate
Humphries, and Lantos and Ms Handley helped parents face difficult choices. Should with their child is too onerous.
design the study and drafted the initial manuscript; they seek a cochlear implant (CI)? If so,
and Dr Napoli conceptualized the study, helped To address these dilemmas, we asked
should they also learn to sign and teach experts in otolaryngology and language
design the study, and drafted the initial manuscript.
All authors approved the final manuscript as their child to do so? What about speech development to discuss the pros and
submitted. reading? There is no time to wait: cons of teaching sign language in
www.pediatrics.org/cgi/doi/10.1542/peds.2014-1632 Experts agree that a child must be addition to teaching oral language. Our
exposed to an accessible language on experts included Nancy K. Mellon,
DOI: 10.1542/peds.2014-1632
a regular and frequent basis before founder and head of school at The
Accepted for publication Aug 27, 2014 5 years of age to develop full language River School in Washington, DC;
Address correspondence to John D. Lantos, MD, competence.
Children’s Mercy Hospital, 2401 Gillham Rd, Kansas
John K. Niparko, MD, chair of the
City, MO 64108. E-mail: jlantos@cmh.edu Prosthetic approaches to hearing Department of Otolaryngology at the
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
restoration are being applied to University of Southern California;
1098-4275). younger children at increasing rates; Sascha Scambler, PhD, senior lecturer
Copyright © 2015 by the American Academy of
some estimates indicate that more than in Sociology, King’s College London;
Pediatrics one-half of US children with early- Christian Rathmann, PhD, professor of
FINANCIAL DISCLOSURE: The authors have indicated
onset deafness have received a CI.2,3 sign languages and sign interpretation
they have no financial relationships relevant to this Children with CIs require intensive at the University of Hamburg; Gaurav
article to disclose. rehabilitation throughout childhood to Mathur, PhD, associate professor of
FUNDING: No external funding. learn to communicate orally. Even with linguistics at Gallaudet University; Tom
POTENTIAL CONFLICT OF INTEREST: The authors have
this training, some children become Humphries, PhD, associate professor in
indicated they have no potential conflicts of interest better oral communicators than others. the Department of Education Studies at
to disclose. Some experts suggest that all deaf the University of California at San

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29, 2018 Volume 136, number 1, July 2015
Diego; and Donna Jo Napoli, PhD, and Drug Administration approved implantation is associated with
professor of linguistics, and Theresa the multichannel CI for children in accelerated rates of spoken language
Handley, both of Swarthmore 1990. Almost 100 000 children have learning after implantation.10
College. John D. Lantos directs the used CIs successfully to develop For a child who receives a CI, the
Children’s Mercy Hospital Bioethics spoken language. However, a CI can timely activation of the device begins
Center. None of the authors is a child enable strong spoken language only a fuller experience with sound.
or adolescent. The views of when used with intensive auditory- Reliance on sign language over an
adolescents can be found in oral exposure in extended, salient, extended period of time may
Christiansian’s 2014 paper.3 and child-initiated interactions.6 negatively affect the child’s capacity
Three of our experts are deaf Without a full linguistic and auditory to learn spoken language after
professionals. Three of them are experience, the effects of deafness- cochlear implantation.11 Prolonged,
parents of profoundly deaf children, associated deprivation can derail the inadequate auditory input that fails to
2 of whom have bilateral CIs. In spoken language learning process support spoken language learning at
creating this article, these experts before it begins. age-appropriate rates is related to
reviewed each other’s comments gaps in speech and language after
The timing of intervention is critical.
and consulted via electronic cochlear implantation.10 Importantly,
An infant’s nervous system is
communication. even extensive rehabilitative efforts
genetically predisposed to accept only
a limited range of potential stimuli to will not produce the language
THE CASE drive the developmental learning of sophistication that can be achieved by
language. Experiences that produce exposure to spoken language during
A newborn is identified as having sensitive periods of development.
language occur in a “biologically
sensorineural deafness. The parents
expensive” period in which neural A child’s ability to successfully
have normal hearing and no
circuits are undecided yet amenable acquire spoken language requires
knowledge of sign language. A hearing
to commitment. During this sensitive a framework of rich, bidirectional
aid is not medically indicated. They
have a few months to decide whether period, use of neural circuits communication with language
to opt for a CI. In the meantime, should generates the impulse traffic that mentors and immersion in an oral
they learn a sign language and begin differentiates neural development. If language environment. Because the CI
to communicate with their child by a child misses the needed experiences is designed to equip a child with skills
using that sign language? If they within an optimal time frame, to communicate in a hearing world,
eventually opt for a CI, should they essential elements in that child’s we strongly advocate for educational
continue to sign? emergent language, either spoken programs that allow children to
or signed, may be missing.7 access the pragmatics of spoken
Should a parent use sign language language in interactions with their
NANCY K. MELLON, MS, AND JOHN with a young child who will receive hearing peers.
K. NIPARKO, MD, COMMENTS:
a CI? As reviewed by Geers et al,8 the Although sign language can promote
Parents often view the diagnosis of case-series reports are mixed on the early parent–child communication,
a child’s deafness through a prism effects of sign language before the focus of intervention should
determined by their own hearing implantation. We suggest that early immediately shift to highlighting the
status. Parents who are deaf may sign language, when used for a short acoustic properties of speech as
view the diagnosis through a cultural time preimplant as a bridge to spoken consistently as possible after cochlear
lens, welcoming a child who can language, cannot hurt and may be implantation to optimize a child’s
easily share their language and beneficial. Early experience with sign ability to talk and listen.
culture. However, .95% of deaf language may support a child’s
children are born to hearing parents.4 participation in the kind of
Hearing parents typically think of SASHA SCAMBLER, PHD, COMMENTS:
bidirectional parent–child
deafness as a disability.5 Their views interactions that form the foundation I write as a hearing parent of
are shaped by their desire to share of language learning, for example, by a profoundly deaf child. I am also
their own language and culture with enabling joint attention.9 However, an a medical sociologist.
their child. important caveat should be Until the last few decades, there were
A deaf child born to hearing parents considered. The use of any residual few choices to be made by hearing
and unable to gain meaningful speech hearing should be maximized. Data parents of deaf children. Today,
recognition from hearing aids will from a prospective, national trial in with CIs and with the successful
typically meet the criteria for early progress indicate that verbal introduction of newborn hearing
cochlear implantation. The US Food language learned before cochlear screening programs, infants are

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diagnosed within the first few weeks a useful additional tool but will only opportunities available. It would,
of their lives, and they can receive result, at best, in 60% accuracy with therefore, seem reasonable to
a CI well before their first birthday. If English language.13 An alternative encourage the family of a deaf child to
parents decide a CI is the option to form of communication is therefore sign with their child. It is essential
pursue, the first few months of the needed. that these families are given the
child’s life are then occupied with support they need to do so, however.
Sign language is a useful tool for the
tests, suitability assessments (for This support includes time and space
family of a deaf child regardless of
both the parents and children), and to psychologically adjust to the new
whether the child is able to make full
medical examinations. If the child is world in which they find themselves
use of CIs. Learning sign language as
found to be a suitable recipient, the as well as practical and/or financial
a hearing family is not without
parents then face the phenomenally assistance.
problems, however. Once the child
difficult decision about whether to We are well aware that CIs do not
has had his or her CI activated, the
have their child undergo implantation give our son normal hearing. We
family will be surrounded by
with the knowledge that there is no are also aware that he works
professionals giving advice on
guarantee that the implant will work considerably harder that his hearing
language development, listening
or that it will result in clear, peers to access sound and
skills, ways to provide a language-rich
intelligible speech. Parents are asked communicate by using oral/aural
environment, and methods of
to decide whether to subject their language. Ultimately, he will have to
maximizing the potential of the
child to a long operation with all of choose whether to continue with
technology the child has been
the associated risks and with no oral/aural language, to use sign
provided with. Fitting signing into an
guarantee of success. language, or to use a combination of
already full schedule is difficult. This
Parents are also often told that it additional responsibility is before the 2 approaches. We have tried to
would be best for their child if they, meeting the needs of other children give him the best foundations with
the parents, would learn a completely within the family as well as one’s own which to make that decision.
new, alien language. Sign language is professional and career obligations.
clearly beneficial for deaf children,
but families need time and space to
Another important factor is that the CHRISTIAN RATHMANN, PHD, AND
adjust and come to terms with
level of signing support available to GAURAV MATHUR, PHD, COMMENTS:
families depends on the area in which
everything that is happening to them There are 3 strong reasons to learn
they live. Sign language lessons can
and to the reality of being the parents both signed and written/spoken
be expensive if no subsidies are language. First, a speech-only
of a deaf child.
available. Signing clubs can also be approach risks linguistic deprivation
As the hearing parent of a profoundly intimidating places for hearing at a crucial period of development.
deaf son with bilateral CIs, this issue families. Some people in the deaf The risk arises because of the
is close to my heart.12 My son has community are overtly hostile to CI variability in the spoken language
had his CIs for 5 years. He has age- users. development of deaf children who
appropriate oral/aural language skills
We, as a family, are in the process of have CIs.15 In contrast, both sign
and attends a mainstream primary
learning sign language. We use it in language and early reading are
school with support from a specialist
conjunction with spoken English. We visually accessible to the deaf child.
teacher for the deaf. Despite his CIs
chose this approach because we need This bilingual approach virtually
and spoken language skills, he
it when our son is not wearing his guarantees that the child will develop
remains deaf and always will be.
implants or is unable to hear linguistic competence.
There are times when my son is
sufficiently because of background Second, bilingualism is beneficial.
unable to wear his implants or is
noise. We also believe that it is Bilingual children display better
unable to hear because of excessive
background noise. CIs have the same
important that he has access to sign mental flexibility and cognitive
language as a deaf person. control as well as more creative
limitations as other artificial hearing
devices; they work best in close range We have adopted the approach thinking, especially in problem
with little background noise. Given advocated by Perier who suggested solving.16,17 These benefits extend to
these limitations, it is essential that that deaf children be given access to social and academic settings.
we have a means of communicating both oral/aural and signed language Third, sign language development
with him, and he with us, when to enable them to make their own correlates positively with
hearing is not an option. Research choice when old enough to do so.14 written18–21 and spoken22 language
suggests that speech reading (lip This stance seems entirely development. No evidence has been
reading plus facial expression) can be reasonable, maximizing the found that the use of a visual

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language affects the outcome of moral and emotional development. As hide from each other the fact that
cochlear implantation.23 In fact, the deaf child grows, the family is not they sign sometimes with their
children with CIs with early exposure enough, and a large amount of the children. All of these actions are
to and, importantly, continued use of child’s time is spent away from home. misguided because there are no
a sign language outperform children With sign language, the deaf child is reliable predictors of which children
with only CIs on a variety of able to travel through various social (among those who receive training)
standardized language measures of situations and communities without will succeed and which will not. The
English, even when both groups have difficulty and not be confined to fact is, acquiring a firm foundation in
the same age of implantation and the communicating only with family and a sign language gives the child the
same years of CI use. It seems that friends, as is often the case for deaf base upon which to build skills in
early and continued exposure to sign children who have no knowledge of reading and, sometimes, speaking
language “may provide a ‘framework’ sign language. a second language; it is impossible,
for early spoken language however, to learn to read without first
development”24 in deaf children having a firm foundation in some
within hearing families as well as DONNA JO NAPOLI, PHD, AND THERESA language.35
within deaf families.25 HANDLEY COMMENTS:
Raising a deaf child requires great
All deaf children should be taught
effort no matter what language choice
a sign language as soon as their
TOM HUMPHRIES, PHD, COMMENTS: the parents make.36 Raising a deaf
hearing status is determined, in
child with a sign language as well as
The most important advice anyone conjunction with training in spoken
spoken language requires learning
can give parents of deaf children is to language (for as long as they show
a sign language. But raising a deaf
immediately join an active signing progress and interest); their chances
of developing a firm linguistic child strictly orally requires daily
community of both parents and training in vocalization and speech-
children. This first step is vital in foundation are thus maximized.
reading throughout childhood, which
achieving the type of language, Simply put, late language learners certainly demands as much effort as
cognitive, and social development have a range of problems, particularly learning to sign and could still have
that deaf children will need for with literacy,28,29 whereas signing no positive effects on language
school. deaf children, with or without a CI, development because it is impossible
From birth to 3 years of age, a deaf perform better on literacy and those to predict which children will succeed
child needs to be part of a language cognitive skills that require a firm with a CI.15
and cognitive ecosystem in which language foundation, regardless of
whether their parents are Deaf infants need exposure to good
unambiguous linguistic input and rich
hearing17–20 or deaf.30 They signing models (ie, people using
interaction with print prepare the
experience overall benefit with no a sign language with all of its
child for both the acquisition of basic
drawbacks if they continue to sign grammatical richness), not just to
interpersonal communication skills
while oral training is still in good speakers. Various combinations
and for academic language
progress.17,31 Sign and speech of speech, gestures, and rudimentary
development. By acquiring sign
facilitate each other, rather than one signing can help in family
language early, the child can develop
hindering the other.32 The communication, and such systems
theory of mind26 and achieve the
misperception that signing interferes often have some structural
requisite domestication of vision
with speech is based on what some similarities to natural language.37,38
(eg, eye tracking for reading)27 to be
call neuropolitics on the part of both However, these systems are no
ready for schooling.
the medical profession and the substitute for bona fide language, nor
Academic language development is community of parents of children do they allow the child to
what we expect of children in school, with CIs.33,34 In this common communicate with others outside the
the language that children must both scenario, the medical profession puts family.39–42 If families permit their
access and demonstrate knowledge the burden of success with a CI not on deaf children to interact with signing
in. Being able to communicate in sign the technology but on the deaf adults, these deaf adults will
language with the teacher and with rehabilitative training the child serve as the resource that allows first
classroom peers affords the deaf child receives, which amounts to putting language acquisition to develop
the socially and intellectually engaged that burden primarily on the parents. naturally. Deaf children also need to
interaction that comprises so much of Parents, in turn, tend to be proud if interact with other deaf children who
the school day. their children make progress and take sign. One can find these language and
This social development is critical to the blame if they do not; these social opportunities through
students’ ability to learn and to their parents shame each other and even community support groups such as

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deaf advocacy groups, local deaf and a positive attitude toward being ACKNOWLEDGMENTS
hard-of-hearing community centers, and deaf is on the road to establishing We thank Poorna Kushalnager, PhD,
local and/or state deaf services bureaus. a healthy identity; interacting of the Rochester Institute of
comfortably with other deaf people Technology, and Scott Smith, MD,
The family can begin sign language
via a sign language may be a strong MPH, of the University of Rochester
classes as soon as the diagnosis of
aid.51 Medical Center for consulting on this
deafness is confirmed. Some family
members may become fluent signers, research and reviewing drafts.
while others may always feel
awkward at signing; the quality of the
JOHN D. LANTOS, MD, COMMENTS:
family’s signing is far less important, For more than a century, physicians, ABBREVIATION
however, than the fact that the family parents, educators, and others have CI: cochlear implant
communicates with the child. Deaf debated how best to raise children
children who sign with their hearing who are deaf. Newborn screening for
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45. Holzrichter AS, Meier RP. Child-directed with a hearing loss: what can we learn by Eye. Mahwah, NJ: Lawrence Erlbaum
signing in American sign language. In: from mothers who are deaf? J Early Associates; 2000:3–24
Chamberlain C, Morford JP, Mayberry RI, Interv. 1992;16:64–78 50. Lieberman AM, Hatrak M, Mayberry RI.
eds. Language Acquisition By Eye. 48. Harris M, Clibbens J, Chasin J, Tibbitts R. Learning to look for language:
Mahwah, NJ: Lawrence Erlbaum The social context of early sign language Development of joint attention in
Associates; 2000:25–40 development. First Lang. 1989;9:81–97 young deaf children. Lang Learn Dev.
46. Masataka N. Motherese in a signed 49. Masataka N. The role of modality and 2014;10(1)
language. Infant Behav Dev. 1992;15: input in the earliest stages of language 51. Leigh I. A Lens on Deaf Identities. Oxford:
453–460 acquisition: studies of Japanese sign Oxford University Press; 2009

HOW LONG DOES TWO MINUTES LAST?: The NCAA Men’s Basketball tournament,
otherwise known as “March Madness”, recently concluded. Many of my friends
commented on what an exciting tournament it had been and how much they enjoyed
watching the games. While I enjoy college athletics, I do not enjoy watching bas-
ketball as much as other sports. One reason is that the games seem to stretch on for
such a long time. Perhaps I feel this way because I like to watch soccer. Each half lasts
45 minutes, and I have a pretty good idea when the game will end. That is not the case
with college basketball.
As reported in The Wall Street Journal (Life: March 24, 2015), the last two minutes of
a basketball game usually last much longer than that. In the first 52 games of the
2015 tournament, on average the last two minutes of the games took just over nine
minutes to complete. In games in which the teams were separated by less than 10
points with two minutes to play, the last two minutes took on average 10.5 minutes to
complete. Amazingly, in one game the last two minutes lasted 18.5 minutes. The
games stretch on for several reasons, but chiefly because of intentional fouling and
timeouts. A foul results in a stoppage of play of approximately 50 seconds. If a player
fouls out, coaches are given an additional 20 seconds to make a substitution. Coaches
can reserve timeouts. As there are many television timeouts during a tournament
game, coaches may have several 30 second and even a 60 second timeout at their
disposal late in the game. In one game, five timeouts were called in the last two
minutes. Three were called with only two seconds remaining in the game.
So, while March Madness can be a lot of fun, the way the last two minutes of the game
can stretch on for such a long time seems not much fun at all.
Noted by WVR, MD

176 Downloaded from http://pediatrics.aappublications.org/ by guest on March 29, 2018 MELLON et al


Should All Deaf Children Learn Sign Language?
Nancy K. Mellon, John K. Niparko, Christian Rathmann, Gaurav Mathur, Tom
Humphries, Donna Jo Napoli, Theresa Handley, Sasha Scambler and John D. Lantos
Pediatrics 2015;136;170
DOI: 10.1542/peds.2014-1632 originally published online June 15, 2015;

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/136/1/170
References This article cites 35 articles, 1 of which you can access for free at:
http://pediatrics.aappublications.org/content/136/1/170.full#ref-list-1
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Developmental/Behavioral Pediatrics
http://classic.pediatrics.aappublications.org/cgi/collection/developme
nt:behavioral_issues_sub
Cognition/Language/Learning Disorders
http://classic.pediatrics.aappublications.org/cgi/collection/cognition:l
anguage:learning_disorders_sub
Ethics/Bioethics
http://classic.pediatrics.aappublications.org/cgi/collection/ethics:bioe
thics_sub
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .

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ERRATA

E R R ATA Mellon et al. Should All Deaf Children Learn Sign Language? Pediatrics.
2015;136(1):170–176
Errors occurred in the article by Nancy K. Mellon et al, titled “Should All Deaf
Children Learn Sign Language?” published in the July 2015 issue of Pediatrics
(2015;136[1]):170–176; doi:10.1542/2014-1632).

On page 170, in the list of authors, the first author should have been Donna Jo Naploli.
The corrected list of authors should have read: Donna Jo Napoli, PhDa, Nancy K. Mellon,
MSb, John K. Niparko, MDc, Christian Rathmann, PhDd, Gaurav Mathur, PhDe, Tom
Humphries, PhDf, Theresa Handley, BAa, Sasha Scambler, PhDg, and John D. Lantos, MDh

The updated list of author affiliations should have read: aSwarthmore College; bThe
River School, Washington, District of Columbia; cDepartment of Otolaryngology,
University of Southern California; dInstitute for German Sign Language and
Communication of the Deaf, University of Hamburg; eGraduate School, Gallaudet
University; fDepartment of Education Studies, University of California at San
Diego; gKing’s College London; and hChildren’s Mercy Hospital

Also on page 170, the abstract appeared as follows: “Every year, 10 000 infants are
born in the United States with sensorineural deafness. Deaf children of hearing
(and nonsigning) parents are unique among all children in the world in that they
cannot easily or naturally learn the language that their parents speak. These
parents face tough choices. Should they seek a cochlear implant for their child? If
so, should they also learn to sign? As pediatricians, we need to help parents
understand the risks and benefits of different approaches to parent–child
communication when the child is deaf. The benefits of learning sign language
clearly outweigh the risks. For parents and families who are willing and able, this
approach seems clearly preferable to an approach that focuses solely on oral
communication.”

This should have read: “Every year, 10 000 infants are born in the United States
with sensorineural deafness. Deaf children of hearing (and nonsigning) parents
are unique among all children in the world in that they cannot easily or naturally
learn the language that their parents speak. These parents face tough choices.
Should they seek a cochlear implant for their child? If so, should they also learn
to sign? As pediatricians, we need to help parents understand the risks and
benefits of different approaches to parent–child communication when the child is
deaf.”
doi:10.1542/peds.2015-2443

Devore CD, Schutze GE; AAP, Council on School Health, Committee on


Infectious Dises. Head Lice. Pediatrics. 2015;135(5):e1355–e1365
Three clarifications are issued for the following American Academy of Pediatrics
clinical report, titled “Head Lice” published in the May 2015 issue of Pediatrics.
2015;135(5):e1355–e1365.
1. On page e1358, in the section on Malathion (0.5%), the second-to-last sentence
should have read: “Safety and effectiveness of malathion lotion have not been
established in children younger than 6 years, and the product is not rec-
ommended.” (instead of “…the product is contraindicated”).

PEDIATRICS Volume 136, number 4, October 2015 781


Should All Deaf Children Learn Sign Language?
Nancy K. Mellon, John K. Niparko, Christian Rathmann, Gaurav Mathur, Tom
Humphries, Donna Jo Napoli, Theresa Handley, Sasha Scambler and John D. Lantos
Pediatrics 2015;136;170
DOI: 10.1542/peds.2014-1632 originally published online June 15, 2015;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/136/1/170

An erratum has been published regarding this article. Please see the attached page for:
http://pediatrics.aappublications.org//content/136/4/781.1.full.pdf

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .

Downloaded from http://pediatrics.aappublications.org/ by guest on March 29, 2018