DOI: https://doi.org/10.18370/2309-4117.2016.32.50-58

Neuropsychiatric status of infants with intrauterine growth retardation

Н. П. Веропотвелян, И. С. Цехмистренко, П. Н. Веропотвелян

Abstract


The article studied and analyzed multiple publications, reflecting the results of studies features of neuropsychiatric status of children born with intrauterine growth retardation, at birth and during the neonatal period.

As the findings of the analyzed studies, children born with intrauterine growth retardation, are a special cohort of infants, which characterized by a high risk of disorders of physical and psychomotor development. In children with expressed backlog of index of weight and growth the frequency of brain lesions is higher than children, which corresponded for gestational age. The high frequency of disorders of neuropsychiatric development necessitates the evaluation of neurological status of the newborn from the first days of life with using different scales, as well as using the methods of neurovisualization and neurophysiology.

Magnetic resonance imaging with additional methods (diffusional-tensor, functional, volume, magnetic resonance spectroscopy) gives the most accurate picture of the brain architectonics, allows to detect and make the quantitative assessment of non-cystic white matter lesions and metabolic relations in various areas of the brain. Using multi-voxel magnetic resonance spectroscopy allows to assess the ratio of different metabolites in several brain regions at once. Therefore, the disorders of metabolic ratio may be an important prognostic sign.

In addition to neurovisualization methods, for obtain a comprehensive assessment of neurological status must be performed the neurophysiological studies, which include electroencephalography, amplitude-integrated electroencephalography and method of evoked acoustic, visual and somatosensory potentials.

Special attention is given to the method of evoked potentials, which allows to obtain reliable information about the integrity and degree of maturity of pathways and, therefore, about the degree of maturity of the child’s nervous system, and predict the risk of developing blindness, deafness and cerebral palsy early enough.

At the same time the authors of the study concluded that for early detection of disorders in the neonatal period and carrying out the targeted rehabilitation therapy needed the further study of infants born with intrauterine growth retardation.


Keywords


intrauterine growth retardation; preterm children; psychomotor status

References


Hellstrom-Westas, L., de Vries, L.S., Rosen, I. An atlas of amplitude-integrated EEGs in the newborn. London. Parthenon Publ. (2003).

Hellstrom-Westas, L., Rosen, I., de Vries, L.S., Greisen, G. “Amplitude-integrated EEG classification and interpretation in preterm and term infants.” NeoReviews 7.2 (2006): 76–87.

Kauma, S.W. “Cytokines in implantation.” J Reprod Fertil 55 (2000): 31–42.

Benavente-Fernandez, I., Lubian-Lopez, S.P., Jimenez-Gomez, G., et al. “Low-voltage pattern and absence of sleep-wake cycles are associated with severe hemorrhage and death in very preterm infants.” Eur J Pediatr 174.1 (2015): 85–90. DOI: 10.1007/s00431-014-2360-0

Pike, A., Marlow, N. “The role of cortical evoked responses in predicting neuromotor outcome in very preterm infants.” Early Hum Dev 57.2 (2000): 123–35.

Kontio, T., Toet, M.C., Hellström-Westas, L., et al. “Early neurophysiology and MRI in predicting neurological outcome at 9–10 years after birth asphyxia.” Clin Neurophysiol 124.6 (2013): 1089–94.

Nevalainen, P., Rahkonen, P., Pihko, E., et al. “Evaluation of somatosensory cortical processing in extremely preterm infants at term with MEG and EEG.” Clin Neurophysiol 126.2 (2015): 275–83. DOI: 10.1016/j.clinph.2014.05.036

Bayley, N. Bayley scales of infant development. New York. The Psychological Corporation (1969).

Luttikhuizen dos Santos, E.S., de Kieviet, J.F., Konigs, M., et al. “Predictive value of the Bayley scales of infant development on development of very preterm/very low birth weight children: a meta-analysis.” Early Hum Dev 89.7 (2013): 487–96.

Ellison, P.H., Horn, J.L., Browning, C.A. “Construction of an Infant neurological International Battery (INFANIB) for the assessment of neurological integrity in infancy.” Phys Ther 65 (1985): 1326–31.

Kirillova, E. A., Ushakova, L.V., Bychenko, G.V. “Assessment of neuropsychiatric status of children with intrauterine growth retardation in neonatal practice.” Journal of Obstetrics and gynecology 1 (2016): 22–7.

Griffiths, R. Manual: The Griffiths mental development scales from birth to 2 years. UK. Association for Research in Infant and Child Development. 1996 Revision.

Krishna, U., Bhalerao, S. “Placental insufficiency and fetal growth restriction.” J Obstet Gynaecol India 61.5 (2011): 505–11.

Levine, T.A., Grunau, R.E., McAuliffe, F.M., et al. “Early childhood neurodevelopment after intrauterine growth restriction: a systematic review.” Pediatrics 135.1 (2015): 126–41.

Batalle, D., Munoz-Moreno, E., Figueras, F., et al. “Normalization of similarity-based individual brain networks from gray matter MRI and its association with neurodevelopment in infants with intrauterine growth restriction.” Neuroimage 83 (2013): 901–11.

Evseeva, Z.P., Sagamonova, K.Y., Palieva, N.A, et al. “Criteria for early diagnosis of placental insufficiency and the syndrome of fetal growth retardation.” Russian Herald of obstetrician-gynecologist 3 (2008): 12–15.

Cruz-Martinez, R., Tenorio, V., Padilla, N., et al. “Risk of neonatal brain ultrasound abnormalities in intrauterine growth restricted fetuses born between 28 and 34 weeks: relationship with gestational age at birth and fetal Doppler.” Ultrasound Obstet Gynecol (2015). DOI: 10.1002/uog.14920

Gladstone, M.J., Lancaster, G.A., Umar, E., et al. “The Malawi Developmental Assessment Tool (MDAT): the creation, validation, and reliability of a tool to assess child development in rural African settings.” PLoS Med 7.5 (2010): e1000273.

Khan, N.Z., Muslima, H., Begum, D., et al. “Validation of rapid neurodevelopmental assessment instrument for under-two-year-old children in Bangladesh.” Pediatrics 125.4 (2010): 755–62.

Mukhin, K.Y., Petrukhin, S.A., Glukhova, L.Y. Epilepsy. Atlas of electro-clinical diagnostics. Moscow. Alvarez Publishing (2004): 106–13.

Ballard, J.L., Khoury, J.C., Wedig, K., et al. “New Ballard Score, expanded to include extremely premature infants.” J Pediatr 119.3 (1991): 417–23.

Sasidharan, K., Dutta, S., Narang, A. “Validity of New Ballard Score until 7th day of postnatal life in moderately preterm neonates.” Arch Dis Child Fetal Neonatal Ed 94.1 (2009): 39–44.

Frankenburg, W.K., Dobbs, J.B. “The Denver developmental screening test.” J Pediatr 71.2 (1967): 181–91.

Kolker, I.A. “Visual evoked potentials in neurology.” International neurological journal 5.9 (2006).

Kohelet, D., Arbel, E., Goldberg, M., Arlazzoroff, A. “Intrauterine growth retardation and brainstem auditory-evoked response in preterm infants.” Acta Paediatr 89.1 (2000): 73–6.

Barker, D.J., Forsen, T., Eriksson, J.G., Osmond, C. “Growth and living conditions in childhood and hypertension in adult life: a longitudinal study.” J Hypertens 20.10 (2002): 1951–6.

Ellingson, R.J. “Development of visual evoked potentials and photic driving responses in normal full term, low risk premature and trisomy-21 infants during the first year of life.” Electroencephalogr Clin Neurophysiol 63.4 (1986): 309–16.

Apkarian, P., Mirmiran, M., Tijssen, R. “Effects of behavioural state on visual processing in neonates.” Neuropediatrics 22.2 (1991): 85–91.

Thordstein, C.M., Sultan, B.L., Wennergren, M.M., et al. “Visual evoked potentials in disproportionately growth-retarded human neonates.” Pediatr Neurol 30.4 (2004): 262–70.

Wickremasinghe, A.C., Hartman, T.K., Voigt, R.G., et al. “Evaluation of the ability of neurobiological, neurodevelopmental and socio-economic variables to predict cognitive outcome in premature infants.” Child Care Health Dev 38.5 (2011): 683–9.

de Vries, L.S., Benders, M.J., Groenendaal, F. “Imaging the premature brain: ultrasound or MRI?” Neuroradiology 55 Suppl. 2 (2013): 13–22.

Deoni, S.C.L., Mercure, E., Blasi, A., et al. “Mapping infant brain myelination with magnetic resonance imaging.” J Neurosci 31.2 (2011): 784–91.

Csutak, R., Unterassinger, L., Rohrmeister, C., et al. “Three-dimensional volume measurement of the lateral ventricles in preterm and term infants: evaluation of a standardized computer-assisted method in vivo.” Pediatr Radiol 33.2 (2003): 104–9.

Pistorius, L.R., Stoutenbeek, P., Groenendaal, F., et al. “Grade and symmetry of normal fetal cortical development: a longitudinal two- and three-dimensional ultrasound study.” Ultrasound Obstet Gynecol 36.6 (2010): 700–8.

Klebermass-Schrehof, K., Moerth, S., Vergesslich-Rothschild, K., et al. “Regional cortical development in very low birth weight infants with normal neurodevelopmental outcome assessed by 3D-ultrasound.” J Perinatol 33.7 (2013): 533–7.

Plaisier, A., Raets, M.M., Ecury-Goossen, G.M., et al. “Serial cranial ultrasonography or early MRI for detecting preterm brain injury?” Arch Dis Child Fetal Neonatal Ed 100.4 (2015): 293–300. DOI: 10.1136/archdischild-2014-306129

Sarikaya, B., McKinney, A.M., Spilseth, B., Truwit, C.L. “Comparison of spin-echo T1- and T2-weighted and gradient-echo T1-weighted images at 3T in evaluating very preterm neonates at term-equivalent age.” AJNR Am J Neuroradiol 34.5 (2013): 1098–103. DOI: 10.3174/ajnr.A3323

Shim, S.Y., Jeong, H.J., Son, D.W., et al. “Serial diffusion tensor images during infancy and their relationship to neuromotor outcomes in preterm infants.” Neonatology 106.4 (2014): 348–54.

Thompson, D.K., Inder, T.E., Faggian, N., et al. “Corpus callosum alterations in very preterm infants: perinatal correlates and 2-year neurodevelopmental outcomes.” Neuroimage 59.4 (2012): 3571–81.

Volpe, J.J., Kinney, H.C., Jensen, F.E., Rosenberg, P.A. “The developing oligodendrocyte: key cellular target in brain injury in the premature infant.” Int J Dev Neurosci 29.4 (2011): 423–40.

Wisnowski, J.L., Blum, S., Paquette, L., et al. “Altered glutamatergic metabolism associated with punctate white matter lesions in preterm infants.” PLoS One 8.2 (2013): e56880.

Counsell, S.J., Shen, Y., Boardman, J.P., et al. “Axial and radial diffusivity in preterm infants who have diffuse white matter changes on magnetic resonance imaging at term-equivalent age.” Pediatrics 117.2 (2006): 376–86.

Jeon, T.Y., Kim, J.H., Yoo, S.Y., et al. “Neurodevelopmental outcomes in preterm infants: comparison of infants with and without diffuse excessive high signal intensity on MR images at near-term-equivalent age.” Radiology 263.2 (2012): 518–26.

Calloni, S.F., Cinnante, C.M., Bassi, L., et al. “Neurodevelopmental outcome at 36 months in very low birth weight premature infants with MR diffuse excessive high signal intensity (DEHSI) of cerebral white matter.” Radiol Med 120.11 (2015): 1056–63.

Xu, D., Bonifacio, S.L., Charlton, N.N., et al. “Spectroscopy of normative premature newborns.” Magn Reson Imaging 33.2 (2011): 306–11. DOI: 10.1002/jmri.22460

Yerushalmy-Fel, A., Marom, R., Peylan, T., et al. “Electroencephalographic characteristics in preterm infants born with intrauterine growth restriction.” J Pediatr 164.4 (2014): 756–61.

Viniker, D.A., Maynard, D.E., Scott, D.F. “Cerebral function monitor studies in neonates.” Clin Electroenceph 15 (1984): 185–92.

Klebermass, K., Olischar, M., Waldhoer, T., et al. “Amplitude-integrated EEG pattern predicts further outcome in preterm infants.” Pediatr Res 70.1 (2011): 102–8.

Welch, C., Helderman, J., Williamson, E., O’Shea, T.M. “Brain wave maturation and neurodevelopmental outcome in extremely low gestational age neonates.” J Perinatol 33.11 (2013): 867–71. DOI: 10.1038/jp.2013.79

Vesoulis, Z.A., Paul, R.A., Mitchell, T.J., et al. “Normative amplitude-integrated EEG measures in preterm infants.” J Perinatol 35.6 (2015): 428–33. DOI: 10.1038/jp.2014.225

The Order of the Ministry of Health of Ukraine No 782 from 29.12.2005. “On approval of clinical protocols on obstetrical and gynecological care.”

Ballard, J.L., et al. “New Ballard Score, expanded to include extremely premature infants.” J Pediatr 119.3 (1991): 417–23.

Hellstrom-Westas, L., Rosen, I. “Amplitude-integrated electroencephalogram in newborn infants for clinical and research purposes.” Acta Paediatr 91 (2002): 1028–30.


GOST Style Citations


1. Hellstrom-Westas, L., de Vries, L.S., Rosen, I. An atlas of amplitude-integrated EEGs in the newborn. London. Parthenon Publ. (2003).

2. Hellstrom-Westas, L., Rosen, I., de Vries, L.S., Greisen, G. “Amplitude-integrated EEG classification and interpretation in preterm and term infants.” NeoReviews 7.2 (2006): 76–87.

3. Kauma, S.W. “Cytokines in implantation.” J Reprod Fertil 55 (2000): 31–42.

4. Benavente-Fernandez, I., Lubian-Lopez, S.P., Jimenez-Gomez, G., et al. “Low-voltage pattern and absence of sleep-wake cycles are associated with severe hemorrhage and death in very preterm infants.” Eur J Pediatr 174.1 (2015): 85–90. DOI: 10.1007/s00431-014-2360-0

5. Pike, A., Marlow, N. “The role of cortical evoked responses in predicting neuromotor outcome in very preterm infants.” Early Hum Dev 57.2 (2000): 123–35.

6. Kontio, T., Toet, M.C., Hellström-Westas, L., et al. “Early neurophysiology and MRI in predicting neurological outcome at 9–10 years after birth asphyxia.” Clin Neurophysiol 124.6 (2013): 1089–94.

7. Nevalainen, P., Rahkonen, P., Pihko, E., et al. “Evaluation of somatosensory cortical processing in extremely preterm infants at term with MEG and EEG.” Clin Neurophysiol 126.2 (2015): 275–83. DOI: 10.1016/j.clinph.2014.05.036

8. Bayley, N. Bayley scales of infant development. New York. The Psychological Corporation (1969).

9. Luttikhuizen dos Santos, E.S., de Kieviet, J.F., Konigs, M., et al. “Predictive value of the Bayley scales of infant development on development of very preterm/very low birth weight children: a meta-analysis.” Early Hum Dev 89.7 (2013): 487–96.

10. Ellison, P.H., Horn, J.L., Browning, C.A. “Construction of an Infant neurological International Battery (INFANIB) for the assessment of neurological integrity in infancy.” Phys Ther 65 (1985): 1326–31.

11. Kirillova, E. A., Ushakova, L.V., Bychenko, G.V. “Assessment of neuropsychiatric status of children with intrauterine growth retardation in neonatal practice.” Journal of Obstetrics and gynecology 1 (2016): 22–7.

12. Griffiths, R. Manual: The Griffiths mental development scales from birth to 2 years. UK. Association for Research in Infant and Child Development. 1996 Revision.

13. Krishna, U., Bhalerao, S. “Placental insufficiency and fetal growth restriction.” J Obstet Gynaecol India 61.5 (2011): 505–11.

14. Levine, T.A., Grunau, R.E., McAuliffe, F.M., et al. “Early childhood neurodevelopment after intrauterine growth restriction: a systematic review.” Pediatrics 135.1 (2015): 126–41.

15. Batalle, D., Munoz-Moreno, E., Figueras, F., et al. “Normalization of similarity-based individual brain networks from gray matter MRI and its association with neurodevelopment in infants with intrauterine growth restriction.” Neuroimage 83 (2013): 901–11.

16. Evseeva, Z.P., Sagamonova, K.Y., Palieva, N.A, et al. “Criteria for early diagnosis of placental insufficiency and the syndrome of fetal growth retardation.” Russian Herald of obstetrician-gynecologist 3 (2008): 12–15.

17. Cruz-Martinez, R., Tenorio, V., Padilla, N., et al. “Risk of neonatal brain ultrasound abnormalities in intrauterine growth restricted fetuses born between 28 and 34 weeks: relationship with gestational age at birth and fetal Doppler.” Ultrasound Obstet Gynecol (2015). DOI: 10.1002/uog.14920

18. Gladstone, M.J., Lancaster, G.A., Umar, E., et al. “The Malawi Developmental Assessment Tool (MDAT): the creation, validation, and reliability of a tool to assess child development in rural African settings.” PLoS Med 7.5 (2010): e1000273.

19. Khan, N.Z., Muslima, H., Begum, D., et al. “Validation of rapid neurodevelopmental assessment instrument for under-two-year-old children in Bangladesh.” Pediatrics 125.4 (2010): 755–62.

20. Mukhin, K.Y., Petrukhin, S.A., Glukhova, L.Y. Epilepsy. Atlas of electro-clinical diagnostics. Moscow. Alvarez Publishing (2004): 106–13.

21. Ballard, J.L., Khoury, J.C., Wedig, K., et al. “New Ballard Score, expanded to include extremely premature infants.” J Pediatr 119.3 (1991): 417–23.

22. Sasidharan, K., Dutta, S., Narang, A. “Validity of New Ballard Score until 7th day of postnatal life in moderately preterm neonates.” Arch Dis Child Fetal Neonatal Ed 94.1 (2009): 39–44.

23. Frankenburg, W.K., Dobbs, J.B. “The Denver developmental screening test.” J Pediatr 71.2 (1967): 181–91.

24. Kolker, I.A. “Visual evoked potentials in neurology.” International neurological journal 5.9 (2006).

25. Kohelet, D., Arbel, E., Goldberg, M., Arlazzoroff, A. “Intrauterine growth retardation and brainstem auditory-evoked response in preterm infants.” Acta Paediatr 89.1 (2000): 73–6.

26. Barker, D.J., Forsen, T., Eriksson, J.G., Osmond, C. “Growth and living conditions in childhood and hypertension in adult life: a longitudinal study.” J Hypertens 20.10 (2002): 1951–6.

27. Ellingson, R.J. “Development of visual evoked potentials and photic driving responses in normal full term, low risk premature and trisomy-21 infants during the first year of life.” Electroencephalogr Clin Neurophysiol 63.4 (1986): 309–16.

28. Apkarian, P., Mirmiran, M., Tijssen, R. “Effects of behavioural state on visual processing in neonates.” Neuropediatrics 22.2 (1991): 85–91.

29. Thordstein, C.M., Sultan, B.L., Wennergren, M.M., et al. “Visual evoked potentials in disproportionately growth-retarded human neonates.” Pediatr Neurol 30.4 (2004): 262–70.

30. Wickremasinghe, A.C., Hartman, T.K., Voigt, R.G., et al. “Evaluation of the ability of neurobiological, neurodevelopmental and socio-economic variables to predict cognitive outcome in premature infants.” Child Care Health Dev 38.5 (2011):  683–9.

31. de Vries, L.S., Benders, M.J., Groenendaal, F. “Imaging the premature brain: ultrasound or MRI?” Neuroradiology 55 Suppl. 2 (2013): 13–22.

32. Deoni, S.C.L., Mercure, E., Blasi, A., et al. “Mapping infant brain myelination with magnetic resonance imaging.” J Neurosci 31.2 (2011): 784–91.

33. Csutak, R., Unterassinger, L., Rohrmeister, C., et al. “Three-dimensional volume measurement of the lateral ventricles in preterm and term infants: evaluation of a standardized computer-assisted method in vivo.” Pediatr Radiol 33.2 (2003): 104–9.

34. Pistorius, L.R., Stoutenbeek, P., Groenendaal, F., et al. “Grade and symmetry of normal fetal cortical development: a longitudinal two- and three-dimensional ultrasound study.” Ultrasound Obstet Gynecol 36.6 (2010): 700–8.

35. Klebermass-Schrehof, K., Moerth, S., Vergesslich-Rothschild, K., et al. “Regional cortical development in very low birth weight infants with normal neurodevelopmental outcome assessed by 3D-ultrasound.” J Perinatol 33.7 (2013): 533–7.

36. Plaisier, A., Raets, M.M., Ecury-Goossen, G.M., et al. “Serial cranial ultrasonography or early MRI for detecting preterm brain injury?” Arch Dis Child Fetal Neonatal Ed 100.4 (2015): 293–300. DOI: 10.1136/archdischild-2014-306129

37. Sarikaya, B., McKinney, A.M., Spilseth, B., Truwit, C.L. “Comparison of spin-echo T1- and T2-weighted and gradient-echo T1-weighted images at 3T in evaluating very preterm neonates at term-equivalent age.” AJNR Am J Neuroradiol 34.5 (2013): 1098–103. DOI: 10.3174/ajnr.A3323

38. Shim, S.Y., Jeong, H.J., Son, D.W., et al. “Serial diffusion tensor images during infancy and their relationship to neuromotor outcomes in preterm infants.” Neonatology 106.4 (2014): 348–54.

39. Thompson, D.K., Inder, T.E., Faggian, N., et al. “Corpus callosum alterations in very preterm infants: perinatal correlates and 2-year neurodevelopmental outcomes.” Neuroimage 59.4 (2012): 3571–81.

40. Volpe, J.J., Kinney, H.C., Jensen, F.E., Rosenberg, P.A. “The developing oligodendrocyte: key cellular target in brain injury in the premature infant.” Int J Dev Neurosci 29.4 (2011): 423–40.

41. Wisnowski, J.L., Blum, S., Paquette, L., et al. “Altered glutamatergic metabolism associated with punctate white matter lesions in preterm infants.” PLoS One 8.2 (2013): e56880.

42. Counsell, S.J., Shen, Y., Boardman, J.P., et al. “Axial and radial diffusivity in preterm infants who have diffuse white matter changes on magnetic resonance imaging at term-equivalent age.” Pediatrics 117.2 (2006): 376–86.

43. Jeon, T.Y., Kim, J.H., Yoo, S.Y., et al. “Neurodevelopmental outcomes in preterm infants: comparison of infants with and without diffuse excessive high signal intensity on MR images at near-term-equivalent age.” Radiology 263.2 (2012): 518–26.

44. Calloni, S.F., Cinnante, C.M., Bassi, L., et al. “Neurodevelopmental outcome at 36 months in very low birth weight premature infants with MR diffuse excessive high signal intensity (DEHSI) of cerebral white matter.” Radiol Med 120.11 (2015): 1056–63.

45. Xu, D., Bonifacio, S.L., Charlton, N.N., et al. “Spectroscopy of normative premature newborns.” Magn Reson Imaging 33.2 (2011): 306–11. DOI: 10.1002/jmri.22460

46. Yerushalmy-Fel, A., Marom, R., Peylan, T., et al. “Electroencephalographic characteristics in preterm infants born with intrauterine growth restriction.” J Pediatr 164.4 (2014): 756–61.

47. Viniker, D.A., Maynard, D.E., Scott, D.F. “Cerebral function monitor studies in neonates.” Clin Electroenceph 15 (1984): 185–92.

48. Klebermass, K., Olischar, M., Waldhoer, T., et al. “Amplitude-integrated EEG pattern predicts further outcome in preterm infants.” Pediatr Res 70.1 (2011): 102–8.

49. Welch, C., Helderman, J., Williamson, E., O’Shea, T.M. “Brain wave maturation and neurodevelopmental outcome in extremely low gestational age neonates.” J Perinatol 33.11 (2013): 867–71. DOI: 10.1038/jp.2013.79

50. Vesoulis, Z.A., Paul, R.A., Mitchell, T.J., et al. “Normative amplitude-integrated EEG measures in preterm infants.” J Perinatol 35.6 (2015): 428–33. DOI: 10.1038/jp.2014.225

51. The Order of the Ministry of Health of Ukraine No 782 from 29.12.2005. “On approval of clinical protocols on obstetrical and gynecological care.”

52. Ballard, J.L., et al. “New Ballard Score, expanded to include extremely premature infants.” J Pediatr 119.3 (1991): 417–23.

53. Hellstrom-Westas, L., Rosen, I. “Amplitude-integrated electroencephalogram in newborn infants for clinical and research purposes.” Acta Paediatr 91 (2002): 1028–30.





Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

ISSN 2411-1295 (Online), ISSN 2309-4117 (Print)