1
|
Brockway M. The role of antibiotic exposure and the effects of breastmilk and human milk feeding on the developing infant gut microbiome. Front Public Health 2024; 12:1408246. [PMID: 38903564 PMCID: PMC11187292 DOI: 10.3389/fpubh.2024.1408246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/28/2024] [Indexed: 06/22/2024] Open
Abstract
The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of life followed by complementary foods and sustained breastfeeding for at least 2 years, underscoring its pivotal role in reducing infant mortality and preventing various illnesses. This perspective delves into the intricate relationship between breastfeeding practices, early life antibiotic exposure, and infant gut microbiome development, highlighting their profound influence on child health outcomes. Antibiotics are extensively prescribed during pregnancy and childhood, disrupting the microbiome, and are related to increased risks of allergies, obesity, and neurodevelopmental disorders. Breastfeeding is a significant determinant of a healthier gut microbiome, characterized by higher levels of beneficial bacteria such as Bifidobacterium and lower levels of potential pathogens. Despite widespread recognition of the benefits of breastfeeding, gaps persist in healthcare practices and support mechanisms, exacerbating challenges faced by breastfeeding families. This highlights the pressing need for comprehensive research encompassing breastfeeding behaviors, human milk intake, and their impact on infant health outcomes. Additionally, promoting awareness among healthcare providers and families regarding the detrimental effects of unnecessary formula supplementation could facilitate informed decision-making and bolster exclusive breastfeeding rates. Moreover, donor human milk (DHM) is a promising alternative to formula, potentially mitigating disruptions to the infant gut microbiome after antibiotic exposure. Overall, prioritizing breastfeeding support interventions and bridging research gaps are essential steps towards improving child health outcomes on a global scale.
Collapse
Affiliation(s)
- Meredith Brockway
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
2
|
Boscarino G, Romano R, Iotti C, Tegoni F, Perrone S, Esposito S. An Overview of Antibiotic Therapy for Early- and Late-Onset Neonatal Sepsis: Current Strategies and Future Prospects. Antibiotics (Basel) 2024; 13:250. [PMID: 38534685 DOI: 10.3390/antibiotics13030250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/28/2024] Open
Abstract
Neonatal sepsis is a clinical syndrome mainly associated with a bacterial infection leading to severe clinical manifestations that could be associated with fatal sequalae. According to the time of onset, neonatal sepsis is categorized as early- (EOS) or late-onset sepsis (LOS). Despite blood culture being the gold standard for diagnosis, it has several limitations, and early diagnosis is not immediate. Consequently, most infants who start empirical antimicrobial therapy do not have an underlying infection. Despite stewardship programs partially reduced this negative trend, in neonatology, antibiotic overuse still persists, and it is associated with several relevant problems, the first of which is the increase in antimicrobial resistance (AMR). Starting with these considerations, we performed a narrative review to summarize the main findings and the future prospects regarding antibiotics use to treat neonatal sepsis. Because of the impact on morbidity and mortality that EOS and LOS entail, it is essential to start an effective and prompt treatment as soon as possible. The use of targeted antibiotics is peremptory as soon as the pathogen in the culture is detected. Although prompt therapy is essential, it should be better assessed whether, when and how to treat neonates with antibiotics, even those at higher risk. Considering that we are certainly in the worrying era defined as the "post-antibiotic era", it is still essential and urgent to define novel strategies for the development of antibacterial compounds with new targets or mechanisms of action. A future strategy could also be to perform well-designed studies to develop innovative algorithms for improving the etiological diagnosis of infection, allowing for more personalized use of the antibiotics to treat EOS and LOS.
Collapse
Affiliation(s)
- Giovanni Boscarino
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Rossana Romano
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Carlotta Iotti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Francesca Tegoni
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Serafina Perrone
- PNeonatology Unit, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| |
Collapse
|
3
|
Sturrock S, Sadoo S, Nanyunja C, Le Doare K. Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations. Res Rep Trop Med 2023; 14:121-134. [PMID: 38116466 PMCID: PMC10728307 DOI: 10.2147/rrtm.s410785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Neonatal sepsis causes significant global morbidity and mortality, with the highest burden in resource-limited settings where 99% of neonatal deaths occur. There are multiple challenges to achieving successful treatment of neonates in this setting. Firstly, reliable and low-cost strategies for risk identification are urgently needed to facilitate treatment as early as possible. Improved laboratory capacity to allow identification of causative organisms would support antimicrobial stewardship. Antibiotic treatment is still hampered by availability, but also increasingly by antimicrobial resistance - making surveillance of organisms and judicious antibiotic use a priority. Finally, supportive care is key in the management of the neonate with sepsis and has been underrecognized as a priority in resource-limited settings. This includes fluid balance and nutritional support in the acute phase, and follow-up care in order to mitigate complications and optimise long-term outcomes. There is much more work to be done in identifying the holistic needs of neonates and their families to provide effective family-integrated interventions and complete the package of neonatal sepsis management in resource-limited settings.
Collapse
Affiliation(s)
- Sarah Sturrock
- Centre for Neonatal and Paediatric Infection, St George’s, University of London, London, UK
| | - Samantha Sadoo
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Carol Nanyunja
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Kirsty Le Doare
- Centre for Neonatal and Paediatric Infection, St George’s, University of London, London, UK
- UK Health Security Agency, Salisbury, UK
- Makerere University, Johns Hopkins University, Kampala, Uganda
| |
Collapse
|
4
|
Rosel-Pech C, Pinto-Cardoso S, Chávez-Torres M, Montufar N, Osuna-Padilla I, Ávila-Ríos S, Reyes-Terán G, Aguirre-Alvarado C, Matías Juan NA, Pérez-Lorenzana H, Vázquez-Rosales JG, Bekker-Méndez VC. Distinct fecal microbial signatures are linked to sex and chronic immune activation in pediatric HIV infection. Front Immunol 2023; 14:1244473. [PMID: 37711620 PMCID: PMC10497879 DOI: 10.3389/fimmu.2023.1244473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/09/2023] [Indexed: 09/16/2023] Open
Abstract
Introduction Our understanding of HIV-associated gut microbial dysbiosis in children perinatally-infected with HIV (CLWH) lags behind that of adults living with HIV. Childhood represents a critical window for the gut microbiota. Any disturbances, including prolonged exposure to HIV, antiretroviral drugs, and antibiotics are likely to have a significant impact on long-term health, resulting in a less resilient gut microbiome. The objective of our study was to characterize the gut microbiota in CLWH, and compare it with HIV-unexposed and -uninfected children. Methods We enrolled 31 children aged 3 to 15 years; 15 were CLWH and 16 were HUU. We assessed dietary patterns and quality; quantified soluble and cellular markers of HIV disease progression by flow cytometry, enzyme-linked immunosorbent and multiplex-bead assays, and profiled the gut microbiota by 16S rRNA sequencing. We explored relationships between the gut microbiota, antibiotic exposure, dietary habits, soluble and cellular markers and host metadata. Results Children had a Western-type diet, their median health eating index score was 67.06 (interquartile range 58.76-74.66). We found no discernable impact of HIV on the gut microbiota. Alpha diversity metrics did not differ between CLWH and HUU. Sex impacted the gut microbiota (R-squared= 0.052, PERMANOVA p=0.024). Male children had higher microbial richness compared with female children. Two taxa were found to discriminate female from male children independently from HIV status: Firmicutes for males, and Bacteroides for females. Markers of HIV disease progression were comparable between CLWH and HUU, except for the frequency of exhausted CD4+ T cells (PD-1+) which was increased in CLWH (p=0.0024 after adjusting for confounders). Both the frequency of exhausted CD4+ and activated CD4+ T cells (CD38+ HLADR+) correlated positively with the relative abundance of Proteobacteria (rho=0.568. false discovery rate (FDR)-adjusted p= 0.029, and rho=0.62, FDR-adjusted p=0.0126, respectively). Conclusion The gut microbiota of CLWH appears similar to that of HUU, and most markers of HIV disease progression are normalized with long-term ART, suggesting a beneficial effect of the latter on the gut microbial ecology. The relationship between exhausted and activated CD4+ T cells and Proteobacteria suggests a connection between the gut microbiome, and premature aging in CLWH.
Collapse
Affiliation(s)
- Cecilia Rosel-Pech
- Posgrado en Ciencias Biológicas, Unidad de Posgrado, Universidad Nacional Autónoma de México (UNAM), Ciudad de México, Mexico
- Unidad de Investigación Médica en Inmunología e Infectología, Hospital de Infectología “Dr. Daniel Méndez Hernández”, Centro Médico Nacional “La Raza”, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Sandra Pinto-Cardoso
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, Mexico
| | - Monserrat Chávez-Torres
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, Mexico
| | - Nadia Montufar
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, Mexico
| | - Iván Osuna-Padilla
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, Mexico
| | - Santiago Ávila-Ríos
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, Mexico
| | - Gustavo Reyes-Terán
- Posgrado en Ciencias Biológicas, Unidad de Posgrado, Universidad Nacional Autónoma de México (UNAM), Ciudad de México, Mexico
| | - Charmina Aguirre-Alvarado
- Unidad de Investigación Médica en Inmunología e Infectología, Hospital de Infectología “Dr. Daniel Méndez Hernández”, Centro Médico Nacional “La Raza”, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Norma Angelica Matías Juan
- Hospital de Infectología “Dr. Daniel Méndez Hernández”, Centro Médico Nacional “La Raza”, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Héctor Pérez-Lorenzana
- UMAE Hospital General Dr. Gaudencio González Garza, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - José Guillermo Vázquez-Rosales
- Hospital de Pediatría “Doctor Silvestre Frenk Freund”, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México, Mexico
| | - Vilma Carolina Bekker-Méndez
- Unidad de Investigación Médica en Inmunología e Infectología, Hospital de Infectología “Dr. Daniel Méndez Hernández”, Centro Médico Nacional “La Raza”, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| |
Collapse
|
5
|
Barbini MC, Perniciaro S, Bresesti I, Folgori L, Barcellini L, Bossi A, Agosti M. The Management of Neonates ≥34 Weeks' Gestation at Risk of Early Onset Sepsis: A Pilot Study. Antibiotics (Basel) 2023; 12:1306. [PMID: 37627726 PMCID: PMC10451212 DOI: 10.3390/antibiotics12081306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Early onset sepsis (EOS) is a potentially fatal condition in neonates, and its correct management is still challenging for neonatologists. Early antibiotic administration in the neonatal period may carry short- and long-term risks. Neonatal EOS calculator has been recently introduced as a new strategy to manage infants at risk of sepsis, and has shown promising results. METHODS In this single-center observational retrospective study, 1000 neonates ≥ 34 weeks' gestation were enrolled with the aim to evaluate our standard protocol for the management of suspected EOS compared to the EOS calculator. Outcome measures included the following: (1) incidence of EOS and (2) proportion of infants in need of sepsis evaluations and antibiotics using our standard protocol versus theoretical application of EOS calculator. RESULTS A total of 223/1000 infants underwent blood investigations versus 35/1000 (3.5%) if EOS calculator had been applied (p < 0.0001; k = 0.18). Furthermore, 48/1000 infants received antibiotics with our protocol versus 35/1000 with EOS calculator (p = 0.12; k = 0.58). Three infants had a positive blood culture that EOS calculator would have missed. CONCLUSIONS In our study, EOS calculator could have reduced investigations but not antibiotic therapy. EOS calculator is an effective and promising tool, but further studies are required to improve it.
Collapse
Affiliation(s)
- Maria Cristina Barbini
- Neonatal Intensive Care Unit, “Filippo del Ponte” Hospital, ASST Settelaghi, 21100 Varese, Italy; (M.C.B.); (S.P.); (A.B.); (M.A.)
| | - Simona Perniciaro
- Neonatal Intensive Care Unit, “Filippo del Ponte” Hospital, ASST Settelaghi, 21100 Varese, Italy; (M.C.B.); (S.P.); (A.B.); (M.A.)
| | - Ilia Bresesti
- Neonatal Intensive Care Unit, “Filippo del Ponte” Hospital, ASST Settelaghi, 21100 Varese, Italy; (M.C.B.); (S.P.); (A.B.); (M.A.)
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Laura Folgori
- Department of Pediatrics, “V. Buzzi” Children’s Hospital, ASST FBF Sacco, 20154 Milan, Italy; (L.F.); (L.B.)
| | - Lucia Barcellini
- Department of Pediatrics, “V. Buzzi” Children’s Hospital, ASST FBF Sacco, 20154 Milan, Italy; (L.F.); (L.B.)
| | - Angela Bossi
- Neonatal Intensive Care Unit, “Filippo del Ponte” Hospital, ASST Settelaghi, 21100 Varese, Italy; (M.C.B.); (S.P.); (A.B.); (M.A.)
| | - Massimo Agosti
- Neonatal Intensive Care Unit, “Filippo del Ponte” Hospital, ASST Settelaghi, 21100 Varese, Italy; (M.C.B.); (S.P.); (A.B.); (M.A.)
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| |
Collapse
|
6
|
Kozhakhmetov S, Meiirmanova Z, Mukhanbetzhanov N, Jarmukhanov Z, Vinogradova E, Mureyev S, Kozhakhmetova S, Morenko M, Shnaider K, Duisbayeva A, Kushugulova A. Compositional and functional variability of the gut microbiome in children with infantile colic. Sci Rep 2023; 13:9530. [PMID: 37308527 DOI: 10.1038/s41598-023-36641-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/07/2023] [Indexed: 06/14/2023] Open
Abstract
The inconsolable crying of a child for no apparent reason at an early age is a source of excitement and anxiety for parents. Previous studies have reported that crying may be caused by discomfort associated with the occupation of the intestines of the newborn by microbiota and its vital activity. We conducted a prospective observational study in which 62 newborns and their mothers were recruited. The study comprised two groups, each consisting of 15 infants with colic and 21 controls. Colic and control groups were vaginally born and exclusively breastfed. Fecal samples from children were collected over time from day 1 to 12 months. Full metagenomic sequencing of fecal samples from children and their mothers was carried out. It was determined that the trajectory of the development of the intestinal microbiome of children with colic was different from the group without colic. In the colic group, a depleted relative abundance of Bifidobacterium and enrichment of Bacteroides Clostridiales was found, while the microbial biodiversity in this group was enriched. Metabolic pathway profiling showed that the non-colic group was enriched by amino acid biosynthetic pathways, while the feces microbiome of the colic group was enriched by glycolysis metabolic pathways that correlated with the Bacteroides taxon. This study shows that infantile colic has a definite relationship with the microbiome structure of infants.
Collapse
Affiliation(s)
- Samat Kozhakhmetov
- Laboratory of Microbiome, Center for Life Sciences, National Laboratory Astana, Nazarbayev University, 53 Kabanbay batyr ave., Block S1, Nur-Sultan, Z05H0P9, Republic of Kazakhstan.
| | - Zarina Meiirmanova
- Department of Children's Diseases with Courses in Allergology, Hematology and Endocrinology, NJSC "Astana Medical University", Astana, Z01G6C5, Kazakhstan
| | - Nurislam Mukhanbetzhanov
- Laboratory of Microbiome, Center for Life Sciences, National Laboratory Astana, Nazarbayev University, 53 Kabanbay batyr ave., Block S1, Nur-Sultan, Z05H0P9, Republic of Kazakhstan
| | - Zharkyn Jarmukhanov
- Laboratory of Microbiome, Center for Life Sciences, National Laboratory Astana, Nazarbayev University, 53 Kabanbay batyr ave., Block S1, Nur-Sultan, Z05H0P9, Republic of Kazakhstan
| | - Elizaveta Vinogradova
- Laboratory of Microbiome, Center for Life Sciences, National Laboratory Astana, Nazarbayev University, 53 Kabanbay batyr ave., Block S1, Nur-Sultan, Z05H0P9, Republic of Kazakhstan
| | - Shamil Mureyev
- Laboratory of Microbiome, Center for Life Sciences, National Laboratory Astana, Nazarbayev University, 53 Kabanbay batyr ave., Block S1, Nur-Sultan, Z05H0P9, Republic of Kazakhstan
| | | | - Marina Morenko
- Department of Children's Diseases with Courses in Allergology, Hematology and Endocrinology, NJSC "Astana Medical University", Astana, Z01G6C5, Kazakhstan
| | - Kseniya Shnaider
- Department of Children's Diseases with Courses in Allergology, Hematology and Endocrinology, NJSC "Astana Medical University", Astana, Z01G6C5, Kazakhstan
| | - Arailym Duisbayeva
- Department of Children's Diseases with Courses in Allergology, Hematology and Endocrinology, NJSC "Astana Medical University", Astana, Z01G6C5, Kazakhstan
| | - Almagul Kushugulova
- Laboratory of Microbiome, Center for Life Sciences, National Laboratory Astana, Nazarbayev University, 53 Kabanbay batyr ave., Block S1, Nur-Sultan, Z05H0P9, Republic of Kazakhstan.
| |
Collapse
|
7
|
Cong S, Fan X, Yu P, Zhou C, Wang L, Wang R, Song X, Feng J, Sun X, Sha L, Zhu Z, Zhang A. Spontaneous behaviors during breast crawling and factors influencing self-locating mothers' breasts in newborns: A cross-sectional study. Heliyon 2023; 9:e16440. [PMID: 37260903 PMCID: PMC10227327 DOI: 10.1016/j.heliyon.2023.e16440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/29/2023] [Accepted: 05/16/2023] [Indexed: 06/02/2023] Open
Abstract
Breast crawling in newborns to propel themselves to their mothers' breasts normally occurs upon skin-to-skin contact with mothers immediately after birth but is often missed by the neglect of hospital staff and insufficient evidence support. Hence, this study described the behavioral characteristics of 135 newborns from China during breast crawling and further explored the factors influencing newborns' self-locating mothers' breasts (measured by whether fail to experience the familiarization stage, initial time and duration of the familiarization stage) using multivariable analysis. The findings supported and extended previous studies that newborns could emerge in nine instinctive stages and corresponding spontaneous behaviors early in life. Moreover, abnormal fetal heart rate during labor appeared to interfere with newborns experiencing the familiarization stage (aOR = 9.27, 95% CI: 1.41 to 61.07, P = 0.021), while using synthetic oxytocin (β = 5.94, 95% CI: 0.35 to 11.54, P = 0.037), using antibiotics (β = 11.09, 95% CI: 4.11 to 18.07, P = 0.002), and newborns' gender (β = -5.69, 95% CI: 11.26 to -0.12, P = 0.045) would alter the initial time of the familiarization stage. Finally, this study proposes evidence-based strategies to prevent abnormal fetal heart rates and improve medication use.
Collapse
Affiliation(s)
- Shengnan Cong
- Department of Nursing, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Xuemei Fan
- Department of Nursing, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Ping Yu
- Department of Nursing, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Chunxiu Zhou
- Department of Nursing, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Lingzhi Wang
- Department of Nursing, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Rui Wang
- School of Nursing, Nanjing Medical University, Jiangsu, China
| | - Xiaowei Song
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical University, Jiangsu, China
| | - Jingyi Feng
- Faculty of Science, The Hong Kong Polytechnic University, Hong Kong, China
| | - Xiaoqing Sun
- School of Nursing, Nanjing Medical University, Jiangsu, China
| | - Lijuan Sha
- School of Nursing, Nanjing Medical University, Jiangsu, China
| | - Zhu Zhu
- Department of Nursing, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Aixia Zhang
- Department of Nursing, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
- School of Nursing, Nanjing Medical University, Jiangsu, China
| |
Collapse
|