Abstract

Background: vitamin D deficiency is a problem among children that used to describe low level of serum 25- hydroxy vitamin D. Children with cerebral palsy have many risk factors for osteopenia and fracture. Aim: To evaluate effect of mothers' health education based on health belief model to prevent vitamin D deficiency in children with cerebral palsy. Design: A quasi-experimental design was utilized. Setting: The study was conducted at Outpatient Clinic of Benha University Hospital, Benha Teaching Hospital, and Benha Specialized Pediatric Hospital. Sample: A convenience sample of 105 mothers and their children have cerebral palsy. Tools of data collection: structured interview sheet; baseline characteristics of mothers and children, mothers' knowledge regarding vitamin D deficiency, vitamin D questionnaire, Health belief model questionnaire. Result: the result of the present study revealed that mothers had satisfactory knowledge, competent practice, and positive attitude after health education implantation. Conclusion: Health education program was effective and help mothers to prevent vitamin D deficiency among their children with cerebral palsy. Recommendation: continuous health education should be implemented for mothers to prevent vitamin D deficiency in children with cerebral palsy.

1. Introduction

Vitamin D is a vital metabolically active compound that is either synthesized by the body using UVB light or absorbed via the digestive system from certain foods. The role of vitamin D is to facilitate calcium absorption from the gut and maintain calcium homeostasis ¹. Severely low levels of vitamin D can result in soft, brittle bones; bone pain; and muscle pain and weakness ².

Vitamin D is important for healthy bones that can be low in children who have poor nutritional intake or decreased exposure to sunlight. Supplement with regular Vit D2/3 (800-1000 international units per day). However, vitamin D level should be checked if possible, to reach baseline and then repeat after 6 months to ensure that the children is in the normal range Wherefore, it is necessary to determine and know the optimal dose of vitamin D to ensure Vitamin D sufficiency ³.

Deficiency of vitamin D is implicated in a great number of orthopedic conditions, including SUFE, Perthes, osteomalacia and fragility fractures ¹. There are two types of Vitamin D: Ergocalciferol (Vitamin D2) a plant product and Colecalciferol (Vitamin D3) which is a fish or mammal product ⁴. Furthermore, children who are decrease exposure to sunshine as over clothing, and exclusively breast feeding especially if their mothers have vitamin D deficient are at risk to vit D deficiency ⁵.

People at a high risk of vitamin D deficiency and particularly those with a combination of risk factors should be treated with vitamin D supplementation. Additionally, they should be encouraged to seek some sun exposure - keeping in mind that short periods of sun exposure to a large area of skin is best for vitamin D production,

The best strategies for preventing vitamin D deficiency are Eating foods rich in vitamin D and spending 15-20 minutes each day in natural sunlight. Also, other lifestyle strategies that may support healthy vitamin D levels include, using vitamin D supplement, and maintain a healthy body weight by walking outside to get daily exercise and exposure to sunlight ⁶. All infants and children are advised to take a vitamin D supplement containing 400 international units (10 micrograms) of vitamin D, starting within days of birth. For infants and children, vitamin D is included in most nonprescription infant multivitamin drops ⁷.

Health Belief Model (HBM) is one of the most widely used conceptual frameworks for understanding health behavior ⁸. Health belief model is a theoretical model that used to guide in health promotion and disease prevention. Help to explain and predict individual changes in health behaviors. It is one of the most widely used models for understanding health behaviors. ⁹. in addition, health Belief Model focus on individual beliefs about health conditions, which predict individual health-related behaviors. The model defines the key factors that influence health behaviors as an individual's perceived threat to sickness or disease ¹⁰.

Cerebral palsy refers to a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination Cerebral palsy (CP) is caused by damage to or abnormalities inside the developing brain that disrupt the brain’s ability to control movement and maintain posture and balance ¹¹.

In an Egyptian study conducted by ¹² the prevalence of CP it was 2.04 per 1000 live births. However, it is not accurately estimated in Egypt due to lack of relevant medical records and registries of the total number of affected children. Children with cerebral palsy that have severe motor impairment such as spastic diplegia and quadriplegia will experience oropharyngeal dysphagia resulting in -nutrient deficiencies as well as, vitamin D deficiency ¹³.

Children with cerebral palsy have feeding problem leading to inadequate dietary intake of vitamin D and calcium that causing vit D deficiency ¹⁴. Low serum Vitamin D level is another major deficiency noted in children with cerebral palsy ¹⁵. Inadequate exposure to sunshine results in decreased mean bone mineral density, causing muscular weaknesses, development of contractures, functional impairment, and fractures ^{16, 17}.

Vitamin D deficiency is the most common nutritional deficiency worldwide ¹⁸. The greatest burden of disease world-wide appears to be in Africa, the Middle East and Asia ¹⁹. Adequate vitamin D levels are essential for normal skeletal system development and mineralization. There has been a marked increase in diagnosis of vitamin D deficiency in children over the past decade. Future research should explore the drivers for this change in diagnostic behavior and the reasons prompting investigation of vitamin D status in clinical practice. Recent global consensus guidelines recommend that all infants from birth to 12 months of age, independent of their mode of feeding are treated with colecalciferol 400 units/day to prevent rickets ²⁰. In addition, vitamin D deficiency is very common in the Arabian countries such as Egypt, with a prevalence of 50%–90% in the general pediatric population with a higher incidence in critically ill children ²¹.

Children with cerebral palsy have low bone mineral density bones that cause their bones are weak and at risk for fragility fractures this is because children wit may have poor nutrition and decreased exposure to sunlight. Vitamin D is essential for bone health. Infants up to age 12 months require 400 international units (IU) daily of vitamin D, children and adolescents require 600 IU daily ²². Supplementing 400 IU daily of Vitamin D, as recommended by the American Academy of Pediatrics (AAP) and the Institute of Medicine, or up to 800 IU as recommended by the Canadian Pediatric Society may provide sufficient vitamin D to prevent rickets, but higher doses may be needed to achieve other health benefits ²³.

The most of mothers have limitation of current knowledge related vit D deficiency, and benefit of vitamin D. In recent years there has been increasing awareness of the importance of vitamin D to prevent disease and disability ²⁴. Therefore, the researchers found urgent to conduct this research to increases mothers' health education based on health belief model to prevent vitamin D deficiency. Meanwhile, improve children with cerebral palsy general health and outcomes.

The study aim was to evaluate the effect of mothers' health education based on health belief model to prevent vitamin D deficiency in children with cerebral palsy.

The study results were testing the following hypotheses:

Mothers who received health education based on health belief model will have higher mean score of knowledge to prevent vitamin D deficiency in children with cerebral palsy.

2. Subjects and Method

A quasi- experimental research design was utilized to conduct the current study.

The study carried out in the outpatient Clinic of Benha University Hospital, Benha Teaching Hospital and Benha Specialized Pediatric Hospital, which Affiliated to the Ministry of Health.

None probability convenience sample was used to collect the data from (105) mothers and their children the samples were collected from previous setting. Their inclusion criteria were, their age between 1-3 years, children with cerebral palsy.

Tool I:

Structured questionnaires were used to collect the data. The questionnaires were designed by the researcher after reviewing related literature, it was written in English language, then translated to simple Arabic language to fit the sample measures and it consisted of five parts:

Part 1: characteristics of the studied children as age and gender

Part 2: characteristics of the studied mothers as age, educational level, occupation and residence.

Part 3: mothers’ knowledge related to vitamin D deficiency

a. General knowledge consisted of 10 questions as children, who remain indoors, are at high risk of vitamin D deficiency; Vitamin D intake more than dietary recommendations could be harmful, and children are at high risk of vitamin D deficiency etc….

b. Knowledge related to nutrition consisted of 5 questions as dairy products are one of the main dietary sources of vitamin D; eggs are one of the main dietary sources of vitamin D; meat and poultry are the main dietary sources of vitamin D; fatty fishes are one of the main dietary sources of vitamin D and fruits are one of the main dietary sources of vitamin D.

Part 4: Mother’s attitude related to vitamin D deficiency consisted of 12 questions to measures mothers’ attitude according to liker scale as full time indoor prevents the sun exposure required for production of vitamin D; inefficient education regarding benefits of sun exposure prevents production of required vitamin D through sun exposure; a shortage of public places for outdoor activities prevents the sun exposure required for production of vitamin D and urbanization prevents sun exposure and production of required vitamin D. etc…….

Part 5: Reported vitamin D practices Questionnaire was developed based on review of literature to assess vitamin D practice recommendations among mothers of cerebral palsy. Such as sufficient exposure to sunlight the child walk outdoors daily; during the day the child directly exposed to sunlight (outdoors); in order to be vitamin D sufficient, the child consumes fish at least twice a week; for sufficient exposure to sunlight the child regularly engage in outdoor physical activities and during the day the child indirectly exposed to sunlight (through glass) etc…

Each item was assigned a score of (2) given when the answer was correct and a score (0) was given when the answer was incorrect / do not know. Mothers’ total knowledge score was 30 and classified as the following; unsatisfactory score was < 60%and satisfactory when total score was ≥ 75%.

The Questionnaire consisted of 12 items to assess mother’s attitude to prevent vitamin D deficiency in children with cerebral palsy; and asked respondents to use a Liker scale of 1-3.

Corresponding disagree took (1) score, no idea took (2) score and agree took (3) score. The total attitude was 36divided into positive if the total scores above 75 and negative if less than 75.

The Questionnaire consisted of 9 items to assess how much they concur with statements to prevent vitamin D deficiency in children with cerebral palsy; and asked respondents to use a Liker scale of 1-3.

Corresponding never took (1) score, sometimes took (2) score and always took (3) score. The total reported practice was 27divided into competent if the total scores above 75 and incompetent if less than 75.

Tool II: The questionnaire included key questions developed using constructs of the HBM.

It included perceived susceptibility, perceived severity, perceived barriers, perceived benefits and cues to action ^{25, 26}

This tool was included a 25-item to measures:

Ÿ perceived susceptibility included five items (the chances of vitamin D deficiency affecting my child, I worry a lot about vitamin D deficiency, vitamin D deficiency is a big problem, There is a good possibility that my child will die from vitamin D deficiency and Within the next year, I know that a baby could die vitamin D deficiency).

Ÿ Perceived severity included five items such as (I am afraid to even think about vitamin D deficiency, The thought of vitamin D deficiency scares me, the vitamin D deficiency hopeless condition, When I think about vitamin D deficiency my heart beats faster, I am afraid to Bone pain and fatigue from vitamin D deficiency).

Ÿ Perceived benefits included four items such as (exposure of sunshine will prevent vitamin D deficiency, It’s best for babies to exposure to sunshine and give vitamin D supplementation , Its best for child to eat food that contain source of vitamin D I don’t worry so much about vitamin D deficiency when a baby exposure to sunlight ).

Ÿ Perceived barriers included six items such as (I can’t reduce the chance of child complication from vitamin D deficiency, The best exposure to sunshine for child from 11-to 12 Am, the better for the child when exposure to sunshine with wear more clothes, my family/friends would make fun of me if I exposure the child to sunshine, Putting a baby on sunshine would require starting a new habit, which is Difficult and I prefer placing child with his clothes during exposure to sunshine).

Ÿ Cues to action included five items such as (I receive much of my child care information from health professionals such as doctors and nurses; I receive much of my child care information from family members, I know the food that contain vitamin D, I know changes that accord from vitamin Deficiency and I know of a child that died of vitamin D deficiency).

• The Questionnaire consisted of 25 items used a 5-point Liker scale (ranging from strongly agree to strongly disagree) to measure perceptions of behavior related SIDS (Strongly agree took one score. - Agree took 2 score - Natural took 3 score. - Disagree took 4 score. - Strongly disagree took 5 score).

• Perceived susceptibility included 5 questions (a min score of 5 and a max score of 25).

• Perceived severity included five questions (a min of 5 and a max score of 25).

• Perceived benefits included four questions (a min of 4 and a max score 20).

• Perceived barriers included six questions (a min score of 6 and a max score of 30).

• Cues to action included five questions (a min score of 5 and a max score of 25).

Data collection tools were submitted to five experts of pediatric nursing to test the content validity. The experts agreed on the content. Regarding reliability, the reliability coefficients alpha between questions was 0.72.

An official permission was obtained from the director of Benha University Hospital, Benha Teaching Hospital and Benha Specialized Pediatric Hospital after clarifying the purpose of the study and the time for beginning the study. All mothers received written and verbal explanations about the nature of the study; their participation will be voluntary; what study involvement would entail; anonymity and confidentiality issues; and their right to withdraw from the study at any time and based on the basic ethical principle of beneficence.

A pilot study was conducted on 10% of the studied sample (10 mothers) to test the clarity and applicability of the tools and then they excluded from the studied sample.

The study was carried out from beginning of March 2018 to the end of May 2018, covering a period of 3 months. Official approvals and letters to conduct this study were obtained from the Dean of Faculty of Nursing to Director of Benha University Hospital, Benha Teaching Hospital and Benha Specialized Hospital. To fulfill the aim of the current study the health education was constructed in four phases: interviewing and assessment, planning, implementation, and evaluation.

The Health education was designed by the researcher after extensive review of related literature.

The first part of the health education was conducted 14 days in outpatient clinic. It focused on gave the mothers description about vitamin D, assessed her knowledge about vitamin D, mother’s attitude and reported practice and health belief model.

The second part of the health education involved provision of health education activities, provided by the researcher included a half-hour session with each mother. Post follow-up care after 1-month post-visit of each child during each follow-up to reinforce the mother’s knowledge attitude, reported practice and health belief model which provided during first part of the program.

This phase encompassed interviewing the participant to collect baseline data, at the beginning of the interview the researchers greeted the participation, introduced herself to each participant included in the study, explained all information about the study purpose, duration, and activities and taken oral consent. The average time for the completion of each participant interview was around (30-45minutes). Average number collected was 10 participant/day. The total sample was divided into 11 groups according to their hospital then every hospital group divided into subgroups included 5 participants for each session.

Based on the results obtained from the assessment phase and relevant review of literature, a booklet about vitamin D health education was designed by the researchers. This was prepared in simple Arabic language to suit mothers' level of understanding and distributed to all recruited mothers. As well as, different methods of teaching and instructional media were determined.

The researchers visited the previously mentioned settings five days/week (Sunday and Wednesday) in the University hospital; (Monday and Tuesday) in the Specialized hospitals and (Saturday) in Teaching Hospital, from 11.00 Am to 2.00 Pm. The average time consumed to fill in the tools was 30-45 minutes. The health education was conducted in 4 sessions each session took approximately 30 to 45 minutes, during this time the mothers were able to provide interventions that included all knowledge and skills regarding vitamin D practice. The health education included illustrated Arabic booklet involve instructions to improve mothers’ knowledge, attitude and reported practice regarding vitamin D, and the posttest done after one month from the health education implementation

The health education was implemented; it included 4 sessions.

- At the beginning of the first session; each mother was given a brief explanation related to vitamin D for children with cerebral palsy and importance of giving vitamin D supplementation.

- The second session was held about the beliefs, assumptions and incorrect beliefs about vitamin D and issues that may be a barrier to vitamin D supplement practice and proper behaviors.

- The third session, the mothers are encouraged to be sensitive about the vitamin D and problems if they do not act in future (perceived susceptibility) and depth perception of complications that may be occurred with unsafe practice (perceived severity).

- The fourth and final session about the benefits of healthy exposure to sun (perceived benefits) during this period was discussed and safety practice (exposure to sunrise during activity outside the door, or through glasses, take nutrition high in calcium and vitamin D, importance of vitamin D supplementation).

Each session started with a feedback about the previous session and the objectives of the new session, using simple Arabic language to suit mothers’ level of understanding. At the end of each session, mothers’ inquiries were discussed to correct any misunderstanding. Methods of teaching were used including modified lectures and group discussions. Instructional media included colored poster about vitamin D.

The mothers’ knowledge, attitude and reported practice and health belief model was evaluated after 1 month from implementation of health education used tool 1 (part 3, 4 and 5) and tool 11. The researcher evaluated and compared the effect of health education on mothers’ knowledge, attitude and reported practice and health belief model pre and after 1 month.

3. Results

Table 1. Marked that 55.2% of them were female. 37.1% of them their age ranged from 18- <24 month their mean of age was 24.361± 6.403 month. On the same context 46.7% of them from children specialized Hospital.

Table 2 revealed that the mean age of mothers was 32.257 ±7.494years. 40% of mothers read and write. More than half (59%) of mothers were housewives and nearly two third of them from rural residence.

Table 3. Indicated that the mothers’ general knowledge regarding vitamin D deficiency, more than half (66.7%, 67.6%, 68.6 & 64.8% respectively) of them had incorrect knowledge about children, who remain indoors, are at high risk of vitamin D deficiency, Vitamin D intake more than dietary recommendations could be harmful, Inappropriate dietary intakes are related to vitamin D deficiency and Vitamin D supplement intake requirements, differ for different age groups respectively. To evaluate the knowledge retention among mothers after health education implementation at 1 month 81,0%, 79.0%, 81.9% & 82.9% respectively of the mothers had correct of knowledge and there was statistically significant difference between pre and after 1 month from implementation (p=<0.001).

The same table also illustrated the more than half (61,9 %, 63.8% , 54.3% & 57.1respectively) of them had incorrect knowledge about Fatty fishes are one of the main dietary sources of vitamin D, Dairy products are one of the main dietary sources of vitamin D, Eggs are one of the main dietary sources of vitamin D, Meat and poultry are the main dietary sources of vitamin D and Fruits are one of the main dietary sources of vitamin D. respectively. To evaluate the knowledge retention among mothers after 1 month After health education implementation 74.3%, 85.7, 80.2,89.5& 84.8% respectively of the mothers had correct of knowledge and there was statistically significant difference between pre and after 1 month (p=<0.001).

Table 4. The study results revealed nearly two third mothers (71.4%, 70.5, 71.4%, & 76.2. % respectively) had disagree about urbanization prevents sun exposure and production of required vitamin D, inefficient education regarding benefits of sun exposure prevents production of required vitamin D through sun exposure, in vitamin D deficiency, supplement intake is more effective compared to dietary intake and sun exposure, Taking supplement is only necessary in case of lack of exposure to sunlight and a high expense of dietary sources of vitamin D is one of the barriers of providing this nutrient respectively. While after one month they had agreed a high expense of dietary sources of vitamin D is one of the barriers of providing this nutrient. On the same mentioned items. There was statistically significant relation between pre health education implementation and after one month from implementation (p=<0.001).

Table 5. The study results proved that more than half of mothers (63.8%, 69.5, 61.0%, 68.6& 61.9% respectively) had never reported practice about For sufficient exposure to sunlight the child regularly engage in outdoor physical activities, to be vitamin D sufficient, the child consumes fortified milk, in order to be vitamin D sufficient, the child consumes fish at least twice a week, to be vitamin D sufficient, the child takes vitamin D supplements, during the day the child directly exposed to sunlight (outdoors), and during the day the child indirectly exposed to sunlight (through glass) respectively. While after one month they had always reported practice on the same mentioned items. There was statistically significant relation between pre health education implementation and after one month from implementation (p=<0.001).

Table 6. Demonstrated that there was statistically significant difference between pre and after 1 month from health education (p=<0.001) related to health belief models items it showed that increase mean score of health belief model of the mothers after implementation of health education.

Table 7. The total mothers’ knowledge regarding vitamin D deficiency, indicated that most half (83.8%) of them had unsatisfactory level of knowledge before health education implementation. And 89.5% of them had negative attitude. To evaluate the knowledge retention and attitude among mothers after 1 month from health education implementation the same table proved that 84.8% of the mothers had satisfactory knowledge and 90% of them had positive attitude. There was statistically significant difference between pre and after 1 month from health education (p=<0.001). The same table illustrated that the total mother’s reported practice, indicated that 7.6% have adequate reported practice before health education implantation. While after one month from implementation 92.4% has adequate reported practice.

4. Discussion

Cerebral palsy is the most common movement disorder in children ²⁷. Therefore, their disabilities affect different aspects of health and behavior of their families ²⁸. Children with cerebral palsy are at an increased risk for vitamin D deficiency may be due to insufficient sunlight exposure, motor disabilities, and feeding difficulties. The study conducted by ²⁹ illustrated that children with cerebral had lower level of vitamin D. The study conducted by ³⁰ showed that there was a significant correlation between level of vitamin D and any health problem associated with impairment as cerebral palsy.

Therefore, the aim of this study was to evaluate the effect of mothers' health education based on health belief model to prevent vitamin D deficiency in children with cerebral palsy. The result of the present study revealed that the mean age of the child was 24.361± 6.403 cerebral palsy is diagnosed around 12 to 24 months of age ³¹.

Regarding to, the child characteristics, the present study revealed that the number of females was more than male. This result was disagreed with ³² indicated that the number of females was more than male. In relation to, the mother’s characteristics, the result of the present study illustrates that most of the studied sample was from rural area. According to ³³ showed that the prevalence of CP is higher in developing countries such as Egypt, than it is in Europe. In addition, CP is more frequent in rural area than urban. This may be due inadequate health services in rural area that providing knowledge and education about importance of vitamin D.

Concerning, mothers' knowledge regarding vitamin D the result of the current study showed that more than half of them had incorrect knowledge about vitamin D. This finding was similarly to ³⁴. Also, the study conducted in Poland by ³⁵ reported in her study that mothers had insufficient knowledge about vitamin D. However, mothers' knowledge related to vitamin D supplement intake requirement the present study revealed insufficient knowledge regarding vitamin D supplement. This result agreement with ³⁶ illustrated in their study conducted in Saudi Arabia that mothers had low knowledge level about vitamin supplement.

On the other hand, mothers' knowledge about sources of vitamin D the result of the present study emphasized poor mothers' knowledge about vitamin D resources. This result was consistent with the result of ³⁷. Meanwhile, the study carried out by ³⁸ reported that mothers had poor knowledge regarding source of vitamin D. additionally supplementing of vitamin D in children with cerebral palsy increase bone density, and helps prevent fragility fractures ³⁹. The result of the present study revealed that more than half of mother had incorrect knowledge about fatty fishes are one of the main dietary sources of vitamin D, dairy products are one of the main dietary sources of vitamin D, eggs are one of the main dietary sources of vitamin D, meat and poultry are the main dietary sources of vitamin D and fruits are one of the main dietary sources of vitamin D. This result was the same with ^{40, 41}. Regarding mothers' practice about exposure to sunlight the study revealed that more than half of them had insufficient education about importance of vitamin D. Sunlight is considering the most important source for vitamin D. This result was in the same with ⁴².

As regard to mothers' attitude regarding vitamin D the most of mothers had negative attitude about vitamin D pre health education implementation. This result agrees with ⁴³ showed that mothers had poor attitude about vitamin D supplements. Moreover ⁴⁴ revealed that the majority of the study participants had limited knowledge, poor practices, and negative attitude toward vitamin D in addition ⁴⁵ indicated in her study that mothers had poor knowledge, attitude and practice among mothers regarding vitamin D supplement for their infants. From the researcher' point of view mothers' awareness about vitamin D sources, and supplement about are very important to prevent vitamin D deficiency for their children with cerebral palsy and for better quality of the child life and further outcomes.

In relation to, mothers' health belief models mean score, the result of the present study showed that there was a statistically significant difference between pre and after 1 month from health education (p=<0.001) related to health belief models items it showed that increase mean score of health belief model of the mothers. This results supported by ⁴⁶ illustrate that by applying the health belief model in the experimental group, a significant difference was observed. Also, the study conducted by ⁴⁷ revealed that, there were significant differences between the mean score of the studied mothers on prevention of vitamin D deficiency. Moreover, the item of health belief model as Perceived susceptibility there was a significant difference after health education implementation. This result was agreement with ⁴⁸. The mean score of perceived severity also reported a significant difference. This result was consistent with study conducted by ⁴⁹. Perceived benefits showed a significant difference after implementation of health education. This result supported by the result by ⁵⁰. As well, perceived barrier reported a significant difference. This result was consistent with study conducted by ⁴⁷. The mean score of cues to action, the result revealed a significant difference after health education implementation than before. This result was consistent with study conducted by ⁵¹.

The research point of view emphasized on the importance of health education programs should focus on the sources of vitamin D, including sun exposure, vitamin supplementation, and food sources, and should clarify the available food fortified with vitamin D. They also need to increase the awareness about the long-term effect of vitamin D deficiency and its correlation with chronic disease. Health education programs should also highlight the importance of the consumption of vitamin D supplements as an affordable way to improve vitamin D status and should indicate the required amount of time of sunlight exposure in order to have sufficient vitamin D status.

5. Conclusion

Based on the results of the present study, it can be concluded that, Health education program was effective and help mothers to prevent vitamin D among their children with cerebral palsy.

6. Recommendations

- Health educational program for mothers aimed at increasing vitamin D knowledge, and to educate them about the importance of vitamin D

- Booklets should be available and distributed in all health care centers to all mothers about the disease and health-related practices.

- Further studies focusing on the associations between vitamin D and general health.

Acknowledgments

The authors are thankful for the great help and cooperation received from the mothers enrolled in the current study. They acknowledge the significant effort and major collaboration of all health professionals (Neurologist, pediatricians, nurses and nursing assistants) in outpatient clinic at Benha Specialized Pediatric Hospital, Benha Teaching Hospital and University Hospital.

References