Monolaurin (Glycerol Monolaurate): A Comprehensive Reference
1. Identity: Names, Chemistry, and Physical Characteristics
Monolaurin (also called glycerol monolaurate, glyceryl laurate, and 1-lauroyl-glycerol) is a monoglyceride. It is the monoester formed from glycerol and lauric acid. Its chemical formula is C15H30O4. Additional synonyms registered in regulatory databases include monododecanoyl glycerol, monoglycerol laurate, monolauroyl glycerol, monolauroylglycerin, and the trade designations Lauricidin and POEM M-300, among others. Lauric acid is a naturally occurring 12-carbon medium-chain saturated fatty acid.
Monolaurin is a monoglyceride of lauric acid with amphipathic properties, meaning it contains both hydrophilic and lipophilic components. This structure allows it to interact with lipid membranes. It is characterized by its white to off-white solid form at room temperature, with a slightly waxy texture. It is soluble in organic solvents and has limited solubility in water, which influences its application in various formulations.
Monolaurin is most commonly used as a nonionic surfactant and preservative in cosmetics and packaged foods. Monolaurin is also marketed as a dietary supplement. The compound is registered with the FDA under a unique ingredient identifier (UNII: Y98611C087), and it appears in chemical databases under CAS number 142-18-7.
2. Natural Sources
The richest dietary source of GML is coconut oil. GML is also found in human breast milk and palm kernel oil. Although the body can convert lauric acid into GML by enzymatic activity, it is not known how much this process actually occurs in vivo.
Coconut oil, coconut cream, grated coconut, and other products are sources of lauric acid and, consequently, monolaurin. Palm kernel oil also contains lauric acid, though at lower concentrations than coconut oil, comprising approximately 40–45% of its fatty acid profile.
Human breast milk stands out as a particularly concentrated biological source. Human milk contains approximately 3,000 µg/mL of monolaurin; cow's milk has approximately 150 µg/mL; most foods (coconut and palm oil) have only trace, variable amounts. Human breast milk contains a substantial amount of lauric acid, which plays a critical role in immune support for newborns, helping to protect them from infections during early development.
Manufacturers synthesize monolaurin commercially from plant oils that are rich in lauric acid, mainly coconut and palm-kernel oils. Commercially, monolaurin generally is not extracted from milk.
3. Common Preparations and Dosage Forms
Monolaurin is available in several commercial forms as a dietary supplement. Monolaurin typically appears on product labels as "Monolaurin," "Glycerol Monolaurate," or "Glyceryl Laurate." Supplement formulations include capsules, pellets, and powders. One of the earliest and best-known commercial preparations delivers the compound as small 30 mg mini-pellets intended for oral ingestion. It is commonly used as a food emulsifier and preservative due to its stability and low toxicity profile.
4. Historical Context: Discovery, Traditional Precursors, and Early Research
Traditional Use of Coconut as a Precursor
While monolaurin itself was not known to ancient or traditional medical systems, its precursor lauric acid—via coconut—has a long history of use in traditional healing, especially in Ayurvedic and Polynesian medicine. Coconut oil was used topically for wounds, infections, and skin disorders and consumed to support digestion, energy, and immunity. These traditional uses indirectly harnessed the benefits of lauric acid and, to a lesser extent, the monolaurin naturally produced during digestion.
Scientific Discovery in the 20th Century
Monolaurin all begins with lauric acid, which was first discovered in the early 19th century by French chemist Michel Chevreul. Lauric acid is a saturated fatty acid that naturally occurs in various plant and animal fats, with coconut oil being one of the richest sources. However, it wasn't until more recent decades that scientists began to isolate and study the specific properties of monolaurin.
Monolaurin was first isolated and identified by Dr. Jon Kabara in the 1960s. Dr. Kabara, a pioneering researcher in the field of medium-chain fatty acids, recognized the potential health benefits of monolaurin and lauric acid, leading to extensive studies on their immune-supporting properties. Dr. Kabara subsequently developed and commercialized a purified monolaurin supplement under the trade name Lauricidin. Monolaurin first became available as a nutritional formulation in the mid-1960s and today is sold worldwide as a nutritional supplement that is touted as a support for immune system function, healthy balance of intestinal flora, and beneficial levels of yeast.
Scientific exploration of monolaurin began in the mid-20th century. Researchers discovered its potent antimicrobial activity and began testing it in food preservation and pharmaceutical applications. Its early use was concentrated in the food industry, where it was studied as a natural preservative against spoilage bacteria and, later, in the cosmetics industry as an emulsifier. Its use has been associated with a variety of disorders, including the common cold, influenza, swine flu, herpes simplex, shingles, and chronic fatigue syndrome.
5. Key Constituents and Mechanisms of Action
5.1 The Compound Itself
Monolaurin is itself the active compound of interest rather than a complex botanical extract containing multiple constituents. Its biological activity is intrinsic to its molecular structure: monolaurin is a monoglyceride derived from lauric acid through a reaction with glycerol. This process either occurs enzymatically within the human body or through chemical synthesis outside the body. Unlike lauric acid, which primarily serves as a source of energy when metabolized, monolaurin exhibits potent antimicrobial properties.
5.2 Membrane Disruption: The Primary Antimicrobial Mechanism
Because GML is a surfactant, it has been used for decades as a dispersant and emulsifier in the cosmetics industry and as a food additive in the food industry, acting as an emulsifier and preservative. The antimicrobial activity of fatty acids and their esters is well known, with chain length, unsaturation (cis, trans), and functional groups all being variables that affect this activity. This antimicrobial activity appears mainly to be by disruption of lipid bilayers. GML is one of the more potent of these antimicrobial agents, being up to 200 times more effectual than lauric acid in bactericidal activity against certain microbes in in vitro studies.
Monolaurin, like any fatty acid ester, is a lipophilic compound and hence its inhibitory activity is probably through interactions with the cytoplasmic membrane. Although the mechanism of antibacterial action of fatty acids and their derivatives is not defined, it has been suggested to involve disruption of the cell membrane permeability barrier and inhibition of amino acid uptake.
Mechanistic analyses revealed that these compounds increased membrane permeability, thereby compromising cell viability in S. aureus persister cells. Tween 80 attenuated both the bactericidal effect and the increase in membrane permeability, supporting the involvement of membrane disruption in their mode of action.
5.3 Inhibition of Bacterial Exotoxin Production and Signal Transduction
A second mechanism, separate from direct membrane disruption, involves interference with bacterial gene transcription. Monolaurin can block the release of gram-positive bacterial exotoxins such as enterotoxins and streptococcal pyrogenic exotoxins. Monolaurin can also bind to the lipid bilayer membrane of enveloped viruses and inhibit viral activity by compromising viral integrity and infectivity. Notably, research published in the Journal of Bacteriology demonstrated that GML inhibits the synthesis of most staphylococcal toxins and other exoproteins at the transcriptional level, specifically blocking induction pathways for beta-lactamase and toxic shock syndrome toxin-1 (TSST-1).
5.4 Antiviral Activity Against Enveloped Viruses
Purified and human milk-derived monoglycerides provide antiviral activity against enveloped viruses, including herpes simplex virus 1 (HSV-1) and HSV-2, vesicular stomatitis virus (VSV), and visna virus, but are ineffective against nonenveloped picornaviruses, including poliovirus and rhinovirus. Although the mechanism of action is not well characterized, electron microscopy (EM) of VSV treated with linoleic acid revealed disruption of the viral envelope and of particle integrity. Similar EM results were obtained from treatment of influenza A virus and coronavirus (CoV) infections with a monolaurin mixture.
Separation of hepatitis A virus into nonenveloped and enveloped virions confirmed the importance of viral envelopes for GML antiviral activity. These findings are consistent with those reported by others showing that monoglycerides inhibited enveloped HSV-1 and HSV-2, VSV, and visna virus infections but were unable to restrict nonenveloped poliovirus or rhinovirus infection.
5.5 Immunomodulatory Effects on T Cells
At concentrations greater than 5 micrograms/mL, GML inhibited lymphocyte proliferation and blocked the proliferative effects of the lymphocyte mitogens phorbol myristate acetate and concanavalin A and the potent T-cell mitogen toxic shock syndrome toxin-1. Studies using purified immune cell subsets indicated that GML at a concentration of 0.1 microgram/mL optimally induced proliferation of T cells but did not affect B cells. At higher concentrations, GML inhibited the toxic shock syndrome toxin-1 mitogenic effects on T cells but did not inhibit the lipopolysaccharide-induced stimulation of B cells, suggesting that GML preferentially affects the T-cell population. GML-induced proliferation was blocked by the immunosuppressive drug cyclosporin A, suggesting that GML may be exerting its T-cell-proliferative effects along the calcium-dependent inositol phospholipid signal transduction pathway.
A 2016 mechanistic investigation published in Scientific Reports provided additional molecular detail: GML treatment drastically altered the balance of ordered vs. disordered lipid phases in the membrane. As a consequence, TCR-induced LAT, PLC-γ, and AKT microcluster formation from aggregation of smaller nanocluster units, PI3K-AKT signaling axis, and calcium influx were potently inhibited by GML treatment. Overall, these defects resulted in decreased TCR-induced cytokine production. This is the first mechanistic evidence showing that GML suppresses the human immune system. The authors noted the dual nature of this finding: these findings further the current understanding of this compound but also open up the possibility that GML could serve as a potent immunosuppressant.
6. Scientific Evidence by Area of Application
6.1 Antibacterial Activity
Evidence level: Strong in vitro; limited in vivo animal data; no controlled human clinical trials as an oral supplement.
The antibacterial activity of GML in vitro is well documented. As a lipid, monolaurin can bind to the phospholipid bilayer of bacteria and disrupt the normal physiological processes of the bacteria, thereby inducing a bacteriostatic effect. Monolaurin is also reported to have a strong inhibitory effect on the growth and reproduction of gram-positive bacteria such as Staphylococcus aureus, Listeria monocytogenes, Helicobacter pylori, Bacillus, and Campylobacter jejuni, among others.
A key distinction in spectrum of activity has been established: fatty acid monoesters, such as glycerol monoesters of lauric, caprylic, capric, and heptanoic acid and/or propylene glycol monoesters of lauric, caprylic, capric, and heptanoic acid, are active against Gram-positive bacteria, fungi, yeasts, and lipid-coated viruses but alone are not generally active against Gram-negative bacteria. However, in combination with chelating agents such as EDTA, activity against Gram-negative organisms can be enhanced.
Biofilm activity: GML is also effective against several bacterial biofilms, including those produced by Staphylococcus aureus, Enterococcus faecalis, Pseudomonas aeruginosa, and Acinetobacter baumannii. Surgical incisions in rabbits inoculated with S. aureus, P. aeruginosa, or A. baumannii were painted with a carrier gel alone or with GML. The GML gel reduced the bacterial count measured in colony-forming units and the inflammatory redness at the infected site compared to carrier gel alone.
An in vitro study of clinical Staphylococcus epidermidis isolates using a micro broth dilution technique determined that the Minimal Inhibition Concentration (MIC) was determined by incubating bacteria added with 1-monolaurin (1000–1953 μg/mL) or rifampicin (250–0.488 μg/mL) for 24 hours. The results showed that 1-monolaurin can eradicate the formation of biofilm in S. epidermidis clinical isolates. The BEC50 and BEC80 1-monolaurin values were 322.504 μg/mL and 1338.681 μg/mL.
Exotoxin suppression and MRSA: In an in vitro study by Schlievert and Peterson (2012), the antibacterial activity of glycerol monolaurate (GML) was tested against gram-positive bacteria, Staphylococcus aureus. GML prevented biofilm formation of S. aureus with no drug resistance developing at a sub-growth inhibitory concentration. GML inhibits the generation of Gram-positive exotoxins and eliminates pre-existing S. aureus biofilms. The use of monolaurin, which precisely targets key stages involved in biofilm formation and has shown antimicrobial activity, would be a prudent approach for lowering the risk of infections caused by S. aureus biofilms.
A notable human in vivo study (oral/mucosal): In a human in vivo study, rinsing with a mouthwash containing lysine and GML decreases oral Helicobacter pylori infection better than the traditional treatment of teeth cleaning. This increased the success rate of eradication of a concurrent gastric H. pylori infection in the population studied. This represents one of the very few human-use data points available in the peer-reviewed literature. The overall assessment, however, from a 2020 systematic review published in a peer-reviewed journal is that the PubMed search yielded 190 articles, none of which were human clinical trials using GML as a nutritional supplement.
6.2 Antiviral Activity
Evidence level: Moderate in vitro; limited animal studies; observational metabolomic human data; no randomized controlled trials in humans.
There are in vitro studies that have shown that GML has antiviral activity against HIV-1, herpes simplex virus (HSV)-2, and cytomegalovirus, but not human rhinovirus 2. An in vivo monkey study has shown that daily use of intravaginal GML protected against occult infection from repeated high doses of simian immunodeficiency virus.
Previous in vivo macaque studies of simian immunodeficiency virus (SIV) vaginal transmission confirmed that GML protected subjects from acute and systemic high-dose intravaginal SIV infection. GML also reduced HIV-1-induced secretion of proinflammatory cytokines, MIP-3α, and interleukin-8 (IL-8), further supporting the hypothesis of an immunoregulatory effect during infection.
Coronavirus and influenza (preclinical and observational): Among modulated molecules, monolaurin levels were twice as high in subjects protected from SARS-CoV-2 infection. Monolaurin is a monoglyceride of lauric acid and a naturally occurring fatty acid ester with antibacterial and antifungal activity. In addition, several studies have shown that monolaurin possesses virucidal effects against enveloped RNA and DNA viruses. Medium-chain saturated fatty acids are highly active against enveloped viruses such as coronaviruses, causing the disintegration of the viral particles. The authors of this metabolomic study explicitly noted that a randomized controlled trial of monolaurin supplements is required to confirm these observational findings before any therapeutic recommendations can be made.
Key limitation: Monolaurin targets the lipid envelope around herpes simplex virus — the structural coating the virus depends on. That membrane-disruption mechanism is well supported in laboratory research, but monolaurin has not been proven in human cold-sore or herpes treatment trials.
6.3 Antifungal Activity
Evidence level: Preliminary in vitro and early in vivo animal data; no human clinical trials.
GML has shown in vitro antifungal activity to Candida albicans in biofilms. There is also both in vitro and in vivo evidence in women that intravaginal gels containing GML reduce counts of several Candida species and Gardnerella vaginalis, although control gels also reduce G. vaginalis counts.
In a 2016 in vitro study published in PeerJ (PMC4924139), the antifungal activity of monolaurin against Candida albicans biofilms (ATCC strain SC5314/MYA2876) was evaluated in a co-culture model. The results showed the MIC and MFC of monolaurin were in the range 62.5–125 µM and 125–250 µM, respectively. Biofilm antifungal assay showed significant reduction in Log (CFU/mL) of biofilms treated with 1,250 and 2,500 µM of 1-monolaurin when compared to the control groups. There was also a significant down-regulation of IL-1α and IL-1β in the co-culture treated with monolaurin.
A follow-up in vivo study published in Biological and Pharmaceutical Bulletin (2018) further examined monolaurin's antifungal activity against Candida albicans biofilms in an animal model, though human data remain absent.
6.4 Vaginal Health and Sexually Transmitted Infections
Evidence level: Preclinical animal model data (macaques) and limited human topical/tampon studies; no oral supplement trials.
Intravaginal application of GML in an in vivo rabbit model decreases the lethality of TSST-1 apparently by stabilizing the host cell membranes and blocking signal transduction. In women, tampons with GML reduce vaginal TSST-1 and production of the cytokine interleukin-8 compared with tampons without GML.
In women, tampons with GML have been shown to reduce vaginal S. aureus and Staphylococcus epidermidis at concentrations that do not adversely affect the growth of commensal ocular bacteria in an in vitro model.
6.5 Gut Microbiota and Intestinal Health
Evidence level: Preclinical (animal) only; no human trials.
Dose-related monolaurin has been found to improve body weight, regulation of gut microbiota, and systemic inflammation in mice fed a low-fat diet. These studies show a significant positive correlation between monolaurin and the increased abundance of probiotics, such as Lactobacillus reuteri and Ruminococcus gnavus. Normal intestinal flora is necessary for the integrity of the tight junctions of the intestinal tract. Monolaurin significantly improves the health of the intestinal tract, which reduces the chance of viruses invading the intestinal epithelial cells and the bloodstream.
6.6 Skin Conditions and Topical Applications
Evidence level: In vitro data and limited topical human/animal data; no large-scale controlled trials.
A study published in the Journal of Drugs in Dermatology demonstrated that monolaurin extracts showed broad-spectrum in vitro activity against bacterial species associated with superficial skin infections, including Staphylococcus aureus and Streptococcus spp., with most isolates exhibiting no resistance. This was an in vitro laboratory study, not a clinical trial. In vivo rabbit studies of GML gel applied to surgical incisions inoculated with S. aureus, P. aeruginosa, or A. baumannii showed that the GML gel reduced bacterial counts and inflammatory redness at infected sites compared to carrier gel alone.
6.7 COVID-19 and SARS-CoV-2 (Metabolomics)
Evidence level: Observational metabolomic study only; highly preliminary.
A 2021 metabolomics study (PMC8257707) found that circulating monolaurin levels were approximately twice as high in individuals who remained uninfected with SARS-CoV-2 compared with those who became infected. A recent trial investigated the effects of virgin coconut oil (VCO), which is rich in monolaurin, on clinical outcomes. The authors of the metabolomics study were careful to note that the association is observational only and that a randomized controlled trial would be required to draw therapeutic conclusions.
7. Body Systems and Health Areas of Research Association
- Immune system: Modulation of T-cell proliferation and cytokine signaling; inhibition of bacterial superantigens (TSST-1) that can trigger pathological immune responses.
- Integumentary system (skin): In vitro and limited in vivo topical antibacterial activity against skin pathogens including MRSA; potential anti-biofilm action on wound surfaces.
- Reproductive and genitourinary system: Intravaginal antifungal and antibacterial activity (Candida spp., Gardnerella vaginalis, S. aureus); preclinical evidence for reduction of HIV-1/SIV transmission risk.
- Gastrointestinal system: Preclinical data on modulation of gut microbiota composition; oral rinse study showing adjunctive effects on H. pylori eradication.
- Respiratory system: In vitro virucidal activity against influenza A and coronaviruses (enveloped); observational metabolomic association with SARS-CoV-2 protection.
- Oral/dental health: In vitro inhibition of S. mutans biofilm (associated with dental plaque) at 95 μg/mL; adjunctive role in H. pylori oral eradication in one human study.
8. Dosage: Forms and Amounts Reported in the Literature
No regulatory body has established a standard therapeutic dosage for monolaurin as a dietary supplement, and the Food and Drug Administration (FDA) has granted GML the status of generally recognized as safe but has published no standard dosing guidelines.
Some supplement companies and health practitioners recommend gradually increasing the oral daily adult dose up to 1 to 5 grams of GML (less in children). One vendor, quoted by several commercial websites, endorses up to 9 g of GML daily as an adult maintenance dose.
Dr. Jon Kabara, who first reported on monolaurin and now markets it under the brand name Lauricidin, suggests that people age 12 and older start with 750 milligrams (mg) of monolaurin two to three times per day. From there, he suggests they work their way up to 3,000 mg two to three times per day. These recommendations are made from Kabara's clinical experience only and aren't supported by any specific research.
Topical concentrations used in studies: Monolaurin is recognized as GRAS as a food additive by the FDA, with topical doses of up to 100 mg/mL (Title 21, Code of Federal Regulations, Part 184).
In vitro concentrations from published studies: Minimum inhibitory concentrations (MICs) in laboratory studies have varied widely depending on the organism tested. For S. epidermidis clinical isolates, MIC values of 1,000–1,953 μg/mL were recorded. For Candida albicans biofilms, MIC values of 62.5–125 µM and minimum fungicidal concentrations (MFC) of 125–250 µM were reported. One study showed monolaurin had a 66% inhibitory effect on S. aureus biofilm at a concentration of 48 μg/mL. Monolaurin can inhibit biofilm formation in S. mutans, the main bacterium on human dental plaques, at a concentration of 95 μg/mL. These concentrations are laboratory values and do not directly translate to supplemental dosing.
Conversion from coconut oil: Lauric acid can be ingested in coconut oil and the body will convert it into monolaurin, but researchers are unsure of the conversion rates. Because of this, it is impossible to say how much coconut oil would need to be ingested to receive a therapeutic dose of monolaurin.
9. Safety Profile and Notable Considerations
9.1 Regulatory Status
Monolaurin is recognized as GRAS (Generally Recognized as Safe), as a food additive by the FDA (Food and Drug Administration), with topical doses of up to 100 mg/mL (Title 21, Code of Federal Regulations, Part 184). Toxicological evaluations have found monolaurin to be well tolerated when consumed at levels commonly present in food products and dietary supplements.
9.2 Adverse Effects at Supplement Doses
Given the paucity of articles and the total lack of human clinical trials, no formal adverse event profiles have been established for supplemental use. Very little research has been done to study the effects of monolaurin supplements on the body, and their safety and benefits are not well defined. High-dose oral supplement use has not been tested in large, long-term human trials.
9.3 Immunosuppressive Potential at High Concentrations
A mechanistically significant safety consideration arises from the immunomodulatory research. Defects in TCR-mediated signaling resulted in decreased TCR-induced cytokine production. This is the first mechanistic evidence showing that GML suppresses the human immune system. These findings further the current understanding of this compound but also open up the possibility that GML could serve as a potent immunosuppressant. This in vitro finding at defined concentrations has not been characterized in vivo at typical supplement doses, but it represents a scientifically documented pharmacological effect that warrants attention.
9.4 Spectrum Limitations and the Gram-Negative Problem
Fatty acid monoesters are active against Gram-positive bacteria, fungi, yeasts, and lipid-coated viruses but alone are not generally active against Gram-negative bacteria. When the fatty acid monoesters are combined with enhancers [such as chelating agents], the composition is active against Gram-negative bacteria. This means the antimicrobial spectrum of monolaurin used alone is incomplete.
9.5 No Development of Microbial Resistance: A Claimed Advantage
In an in vitro study, GML prevented biofilm formation of S. aureus with no drug resistance developing at a sub-growth inhibitory concentration. This is a notable finding because resistance development is a major concern with conventional antibiotics, but it has only been demonstrated in vitro and requires further investigation.
9.6 Solubility and Bioavailability Considerations
The stability and solubility of GML are low in an aqueous environment. It is soluble in organic solvents and has limited solubility in water, which influences its application in various formulations. These physicochemical limitations affect the translation of in vitro findings to oral bioavailability and systemic activity. Research into nanoemulsion formulations of monolaurin has been explored as a strategy to improve delivery, particularly for antiviral applications.
9.7 Interactions
No documented clinically significant drug-drug interactions with oral monolaurin as a dietary supplement have been identified in the peer-reviewed literature reviewed for this article. The total lack of human clinical trials means that interaction data of the type routinely generated in pharmacokinetic studies does not exist for this compound at supplement doses. The immunosuppressive mechanism identified in T-cell research (disruption of TCR-mediated signaling) is a theoretical basis for caution in immunocompromised populations or those on immunosuppressive therapy, but this has not been clinically quantified.
9.8 Effect on Beneficial Microbiota
An important practical consideration is the selectivity of GML's antimicrobial activity. Published research has noted that GML inhibits Candida and Gardnerella vaginalis in vitro but does not inhibit commensal Lactobacillus species. The protective properties of GML with respect to the vaginal mucosa and inhibitory effects on cytokine production suggest that GML may confer protection during HIV-1 transmission, as immune activation and inflammation increase susceptibility to HIV-1. This selective activity — harming pathogens while sparing beneficial flora — is an actively studied characteristic, though it requires further clinical confirmation.
10. Overall Evidence Assessment
Monolaurin has a well-established mechanistic and in vitro evidence base for antimicrobial activity, particularly against Gram-positive bacteria, enveloped viruses, and certain fungi. The compound's lipid membrane-disrupting mechanism is biologically plausible and reproducibly demonstrated in laboratory conditions. However, the translation of this in vitro activity to clinically relevant effects in humans via oral supplementation remains largely undemonstrated.
A thorough PubMed search (through April 2018) yielded 190 articles, none of which were human clinical trials using GML as a nutritional supplement. Since that review, some animal and observational human data have emerged (e.g., the SARS-CoV-2 metabolomics study, porcine antiviral studies), but no registered, controlled human clinical trials have been published demonstrating efficacy of oral monolaurin supplementation for any specific health condition. The most substantive human data involves topical applications (tampon studies, intravaginal gels, oral rinse), not the oral supplement form most commonly marketed to consumers.
Many medium-chain fatty acid monoesters are Generally Recognized as Safe (GRAS) by the U.S. Food and Drug Administration, and some have been reported to possess antibacterial activity at concentrations far below levels that affect mammalian cell viability (at least a five-fold difference). This differential cytotoxicity is encouraging but requires prospective human validation before clinical recommendations can be made.
References
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