An integrative review of neonatal nasal injuries from nasal CPAP in low-resource settings
DOI:
https://doi.org/10.67210/afna.v4i3.1Keywords:
Nasal continuous positive airway pressureAbstract
Nasal continuous positive airway pressure (nCPAP) is a strongly recommended intervention for the care of premature neonates worldwide; however, it is often associated with a range of nasal injuries. Characteristics and prevention strategies of nCPAP associated injuries are not well characterized for low-resource settings. A literature search of Embase, MEDLINE, PubMed, and Google Scholar was conducted for peer-reviewed English-language studies published between January 1, 2013, and September 12, 2025. Search terms included combinations of “neonates,” “CPAP,” “non -invasive ventilation,” and “nasal injury.” Titles and abstracts were screened, and relevant data were extracted and synthesized. No formal risk-of-bias assessment was performed. Of the 97 manuscripts screened, 72 were relevant to the research question and therefore included in this review. The reported incidence of nasal injuries varied widely. Risk factors included improper interface sizing, prolonged therapy, and inadequate monitoring. Preventive strategies included correct interface application, protective barriers or lubricants, structured nursing bundles, frequent skin assessment, and staff training. Low-cost measures, such as proper prong sizing, skin monitoring, stabilization of the interface, and standardized protocols, are feasible in low-resource settings. In conclusion, affordable, context-appropriate interventions may reduce nCPAP-related nasal injuries. Further research is needed to evaluate effectiveness and scalability in low-resource settings.
References
1. World Health Organization. WHO recommendations for care of the preterm or low-birth-weight infant [Internet]. Geneva: World Health Organization; 2022 Nov [cited 2023 July 25] p. 75. Available from: https://www.who.int/publications-detailredirect/9789240058262
2. Abelenda VLB, Valente TCO, Marinho CL, Lopes AJ. Effects of underwater bubble CPAP on very-low-birth-weight preterm newborns in the delivery room and after transport to the neonatal intensive care unit. J Child Health Care. 2018 June;22(2):216–27. DOI: https://doi.org/10.1177/1367493517752500
3. Jamaux M, Gibier C, Dillenseger L, Fourie G, Langlet-Muteau C, Rondel J, et al. Nasal Injuries Related to Respiratory Support Interfaces in Preterm Infants: Neonatal Course and 12-Month Outcome. Children. 2025 June 26;12(7):840. DOI: https://doi.org/10.3390/children12070840
4. Ribeiro DDFC, Barros FS, Fernandes BL, Nakato AM, Nohama P. Incidence and Severity of Nasal Injuries in Preterm Infants Associated to Non-Invasive Ventilation Using Short Binasal Prong. Glob Pediatr Health. 2021 Jan;8:2333794X211010459. DOI: https://doi.org/10.1177/2333794X211010459
5. Zores C, Zana‐Taïeb E, Caeymaex L, Fumeaux CF, Kuhn P, the Group of Reflection and Evaluation of the Environment of Newborns study group of the French Neonatology Society. French Neonatal Society issues recommendations on preventing nasal injuries in preterm newborn infants during non‐invasive respiratory support. Acta Paediatr. 2023 Sept;112(9):1849–59. DOI: https://doi.org/10.1111/apa.16857
6. Dada S, Ashworth H, Sobitschka A, Raguveer V, Sharma R, Hamilton RL, et al. Experiences with implementation of continuous positive airway pressure for neonates and infants in low-resource settings: A scoping review. PLOS ONE. 2021 June 11;16 (6):e0252718. DOI: https://doi.org/10.1371/journal.pone.0252718
7. Sessions KL, Ruegsegger L, Mvalo T, Kondowe D, Tsidya M, Hosseinipour MC, et al. Focus group discussions on low-flow oxygen and bubble CPAP treatments among mothers of young children in Malawi: a CPAP IMPACT substudy. BMJ Open. 2020 May;10(5):e034545. DOI: https://doi.org/10.1136/bmjopen-2019-034545
8. Thukral A, Sankar MJ, Chandrasekaran A, Agarwal R, Paul VK. Efficacy and safety of CPAP in low- and middle-income countries. J Perinatol Off J Calif Perinat Assoc. 2016 May;36 Suppl 1 (Suppl 1):S21-28. DOI: https://doi.org/10.1038/jp.2016.29
9. Prado NCDC, Santos RSDC, Lima DMD, Medeiros KSD, Fernandes MIDCD, Lira ALBDC, et al. Nasal injury in neonates: A scoping review and conceptual analysis. J Neonatal Nurs. 2024 Dec;30 (6):576–82. DOI: https://doi.org/10.1016/j.jnn.2024.03.011
10. Priyanka M, Nor KM, Kulasegarah J, Orl-Hns F. Columella necrosis in a child secondary to nasal continuous positive airway pressure during neonatal period. Med J Malays. 2021;76(5):771–3.
11. Cavicchioli P, Silecchia V, Valerio E, Fantinato M, Giovannini I, Grimalt R, et al. nCPAP-induced Nasal Injury: Case Series and Brief Literature Review. J Respir Res. 2019;4 (2):185–6.
12. Maruccia M, Fanelli B, Ruggieri M, Onesti MG. Necrosis of the columella associated with nasal continuous positive airway pressure in a preterm infant. Int Wound J. 2014 June;11(3):335–6. DOI: https://doi.org/10.1111/j.1742-481X.2012.01121.x
13. Aykanat A, Çelik HT, Günaydın RÖ, Yiğit Ş. Iatrogenic nasal synechiae in a premature newborn. Turk J Pediatr. 2020 June 25;62(3):505–8. DOI: https://doi.org/10.24953/turkjped.2020.03.023
14. Jang W, Nguyen D, Demke J. Nasal necrosis following use of nasal cannula: A case report. Otolaryngol Case Rep. 2023 Nov;29:100556. DOI: https://doi.org/10.1016/j.xocr.2023.100556
15. Li Y, Sepulveda A, Buchanan EP. Late presenting nasal deformities after nasal continuous positive airway pressure injury: 33-year experience. J Plast Reconstr Aesthet Surg. 2015 Mar;68(3):339–43. DOI: https://doi.org/10.1016/j.bjps.2014.10.036
16. Fischer C, Bertelle V, Hohlfeld J, Forcada-Guex M, Stadelmann-Diaw C, Tolsa JF. Nasal trauma due to continuous positive airway pressure in neonates. Arch Dis Child - Fetal Neonatal Ed. 2010 Nov 1;95(6):F447–51. DOI: https://doi.org/10.1136/adc.2009.179416
17. Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement—The National Pressure Ulcer Advisory Panel. Decubitus. 1989 May; 2(2):24–8.
18. Anjum S, Lingaldinna S, Cherukuri N, Alimelu M, Singh H. A quality improvement initiative in reducing nasal trauma during the application of nasal bubble continuous positive airway pressure in a tertiary care neonatal unit. Indian J Child Health. 2020 Feb 25;7(2):89–92. DOI: https://doi.org/10.32677/IJCH.2020.v07.i02.013
19. Ribeiro DDFC, Barros FS, Fernandes BL, Nakato AM, Nohama P. Nasal Prongs: Risks, Injury Incidence, and Preventive Approaches Associated with Their Use in Newborns. J Multidiscip Health c. 2020 June; Volume 13:527–37. DOI: https://doi.org/10.2147/JMDH.S252017
20. Grebinski ATKG, Silva CCD, Tonial DA, Zilly A, Silva RMMD. Lesão de septo nasal em recém-nascidos hospitalizados: estudo descritivo exploratório. Online Braz J Nurs [Internet]. 2023 May 1 [cited 2024 Dec 18];22. Available from: https://www.objnursing.uff.br/index.php/nursing/article/view/6630 DOI: https://doi.org/10.17665/1676-4285.20236630
21. Khan J, Sundaram V, Murki S, Bhatti A, Saini SS, Kumar P. Nasal injury and comfort with jet versus bubble continuous positive airway pressure delivery systems in preterm infants with respiratory distress. Eur J Pediatr. 2017 Dec;176 (12):1629–35. DOI: https://doi.org/10.1007/s00431-017-3016-7
22. Biazus GF, Kaminski DM, Silveira RDC, Procianoy RS. Incidence of nasal pressure injury in preterm infants on nasal mask noninvasive ventilation. Rev Paul Pediatr. 2023;41:e2022093. DOI: https://doi.org/10.1590/1984-0462/2023/41/2022093
23. Lund CH, Osborne JW. Validity and reliability of the neonatal skin condition score. J Obstet Gynecol Neonatal Nurs JOGNN. 2004 June;33(3):320–7. DOI: https://doi.org/10.1177/0884217504265174
24. Gökdoğan O, İleri F. Nasal Complications Related With-CPAP Treatment. ENT Updat. 2018 Oct 30;133–8. DOI: https://doi.org/10.32448/entupdates.476313
25. Broom M, Kent AL, Chaudhari T. Reducing device-related pressure injuries in high-risk neonates receiving nasal continuous positive airway pressure: a quality improvement study. Arch Dis Child - Fetal Neonatal Ed. 2025 Mar 26; fetalneonatal-2024-327798. DOI: https://doi.org/10.1136/archdischild-2024-327798
26. Pascual A, Wielenga JM. Nasal pressure injuries among newborns caused by nasal CPAP: An incidence study. J Neonatal Nurs. 2023 June;29(3):477–81. DOI: https://doi.org/10.1016/j.jnn.2022.09.006
27. Wu A, Mukhtar-Yola M, Luch S, John S, Adhikari BR, Bakker C, et al. Innovations and adaptations in neonatal and pediatric respiratory care for resource constrained settings. Front Pediatr. 2022 Oct 31;10:954975. DOI: https://doi.org/10.3389/fped.2022.954975
28. Dai T, Lv L, Liu X, Chen J, Ye Y, Xu L. Nasal Pressure Injuries Due to Nasal Continuous Positive Airway Pressure Treatment in Newborns: A Prospective Observational Study. J Wound Ostomy Continence Nurs. 2020 Jan;47 (1):26–31. DOI: https://doi.org/10.1097/WON.0000000000000604
29. Guimarães AR, Rocha G, Rodrigues M, Guimarães H. Nasal CPAP complications in very low birth weight preterm infants. J Neonatal-Perinat Med. 2020 June 11;13(2):197–206. DOI: https://doi.org/10.3233/NPM-190269
30. Hameed N. Continuous Positive Airway Pressure and Nasal Trauma in Neonates: A Descriptive Prospective Study. ISOR-JDMS. 2015 Nov 1;14:110–6.
31. Bonfim S de FSF, Vasconcelos MGL de, Sousa NFC de, Silva DVC da, Leal LP. Nasal septum injury in preterm infants using nasal prongs. Rev Lat Am Enfermagem. 2014 Oct;22(5):826–33. DOI: https://doi.org/10.1590/0104-1169.3451.2486
32. Primo CC, Barateia MS, Valladares MLP, Alvarenga SC, Lima E de FA, Leite F MC. Risk factors associated with nasal injury by use of positive pressure device in newborns/Fatores de riscoassociados a lesao nasal pordispositivo de pressaopositivaemrecem- nascidos/Factores de riesgoasociados con lesion nasal pordispositivo de presionpositivaenreciennacidos. Rev Enferm UERJ. 2014;22 (1):16.
33. Sousa NFCD, Bonfim SDFSF, Vasconcelos MGLD, Bezerra JLDO, Silva DVCD, Leal LP. Prevalência de lesão do septo nasal emprematuros no uso de prongs nasais. Rev Esc Enferm USP. 2013 Dec 1;47(6):1285–90. DOI: https://doi.org/10.1590/S0080-623420130000600005
34. Robertson NJ, McCarthy LS, Hamilton PA, Moss AL. Nasal deformities resulting from flow driver continuous positive airway pressure. Arch Dis Child - Fetal Neonatal Ed. 1996 Nov 1;75(3):F209–12. DOI: https://doi.org/10.1136/fn.75.3.F209
35. Yeh TF, Srinivasan G, Pildes RS. Nasal Septal Perforation: A Complication of Nasal Continuous Positive Airway Pressure. Arch Otolaryngol - Head Neck Surg. 1978 Aug 1;104(8):473–473. DOI: https://doi.org/10.1001/archotol.1978.00790080055016
36. Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Arch Dis Child - Fetal Neonatal Ed. 2018 Jan;103(1):F29–35. DOI: https://doi.org/10.1136/archdischild-2017-313418
37. August DL, Kandasamy Y, Ray R, Lindsay D, New K. Fresh Perspectives on Hospital-Acquired Neonatal Skin Injury Period Prevalence From a Multicenter Study: Length of Stay, Acuity, and Incomplete Course of Antenatal Steroids. J Perinat Neonatal Nurs. 2021 July;35(3):275–83. DOI: https://doi.org/10.1097/JPN.0000000000000513
38. Fu Y, Li X, Yu Y, Li R, Shi T. Summary of the best evidence for the prevention of nasal injury in preterm infants with nasal noninvasive ventilation. Transl Pediatr. 2024 Feb;13 (2):224–35. DOI: https://doi.org/10.21037/tp-23-465
39. Haymes E. The effects of continuous positive airway pressure (CPAP) on nasal skin breakdown. J Neonatal Nurs. 2020 Feb;26(1):37–42. DOI: https://doi.org/10.1016/j.jnn.2019.09.007
40. Grosvenor J, Dowling M. Prevention of neonatal pressure injuries. J Neonatal Nurs. 2018 June;24(3):122–5. DOI: https://doi.org/10.1016/j.jnn.2017.09.004
41. Gong T, Yu JL, Yang H, Tang YF, Huang A, Wang YX. Prevention of nasal injury in preterm infants during positive pressure Ventilation: a systematic review of interface and dressing selection. BMC Pediatr. 2025 May 27;25 (1):423. DOI: https://doi.org/10.1186/s12887-025-05875-3
42. Sandhu M, Kaur R, Kalyan G, Kumar P. Barriers and Facilitators Related to Nasal Injury Among Preterm Neonates in Selected Neonatal Units of a Tertiary Care Centre, North India. Nurs Midwifery Res J. 2023 July;19(3):156–65. DOI: https://doi.org/10.1177/0974150X231185646
43. Naha N, Pournami F, Prabhakar J, Jain N. Nasal Injury with Continuous Positive Airway Pressure: Need for “Privileging” Nursing Staff. Indian J Pediatr. 2019 July;86 (7):595–8. DOI: https://doi.org/10.1007/s12098-019-02960-1
44. Sharma D, Kaur A, Farahbakhsh N, Agarwal S. To compare nasal mask with binasal prongs in delivering continuous positive airway pressure for reducing need of invasive ventilation: randomized controlled trial. J Matern Fetal Neonatal Med. 2021 June 18;34(12):1890–6. DOI: https://doi.org/10.1080/14767058.2019.1651272
45. Bashir T, Murki S, Kiran S, Reddy VK, Oleti TP. Nasal mask’ in comparison with ‘nasal prongs’ or ‘rotation of nasal mask with nasal prongs’ reduce the incidence of nasal injury in preterm neonates supported on nasal continuous positive airway pressure (nCPAP): A randomized controlled trial. Penzel T, editor. PLOS ONE. 2019 Jan 31;14 (1):e0211476. DOI: https://doi.org/10.1371/journal.pone.0211476
46. Solanki JR, Bhil DL. Comparative study of nasal mask versus nasal prong in terms of nasal septal necrosis for delivering nasal continuous positive airway pressure in newborns with respiratory distress. Indian J Child Health. 2019 Nov 26;6(11):601–4. DOI: https://doi.org/10.32677/IJCH.2019.v06.i11.007
47. Goel S, Mondkar J, Panchal H, Hegde D, Utture A, Manerkar S. Nasal mask versus nasal prongs for delivering nasal continuous positive airway pressure in preterm infants with respiratory distress: A randomized controlled trial. Indian Pediatr. 2015 Dec;52 (12):1035–40. DOI: https://doi.org/10.1007/s13312-015-0769-9
48. Ram MK, Kumar A, Singh A. Comparative Study of Incidence and Severity of Nasal Complications While using Nasal Prongs and Nasal Mask as CPAP Interface in Preterm Neonates: An Experimental Study. Int J Pharm Clin Res. 2023;15(3):903–8.
49. Shamim M, Patra T, Kumari N. A Randomized Controlled Comparative Assessment of the of Incidence and Severity of Nasal Complications While using Nasal Prongs and Nasal Mask as CPAP Interface in Preterm Neonates. Int J Pharm Clin Res. 2023;15(1):832–7.
50. Prakash S, Dubey A, Malik S. A comparative study of outcomes of nasal prongs and nasal mask as CPAP interface in preterm neonates: A randomized control trial. J Clin Neonatol. 2019;8(3):147. DOI: https://doi.org/10.4103/jcn.JCN_8_19
51. Gautam G, Gupta N, Sasidharan R, Thanigainathan S, Yadav B, Singh K, et al. Systematic rotation versus continuous application of ‘nasal prongs’ or ‘nasal mask’ in preterm infants on nCPAP: a randomized controlled trial. Eur J Pediatr. 2023 Mar 27;182(6):2645–54. DOI: https://doi.org/10.1007/s00431-023-04933-1
52. Magalhães PAF, D’Amorim ACG, Oliveira EFALD, Ramos MEA, Mendes APDDA, Barbosa JFDS, et al. Rotating nasal masks with nasal prongs reduces the incidence of moderate to severe nasal injury in preterm infants supported by noninvasive ventilation. Rev Bras Ter Intensiva [Internet]. 2022 [cited 2024 Dec 18]; 34(2). Available from: https://criticalcarescience.org/article/rotating-nasal-masks-withnasal-prongs-reduces-theincidence-of-moderate-tosevere-nasal-injury-in-preterm-infants-supported-bynoninvasive-ventilation/ DOI: https://doi.org/10.5935/0103-507X.20220022-en
53. Newnam KM, McGrath JM, Salyer J, Estes T, Jallo N, Bass WT. A comparative effectiveness study of continuous positive airway pressurerelated skin breakdown when using different nasal interfaces in the extremely low birth weight neonate. Appl Nurs Res. 2015 Feb;28(1):36–41. DOI: https://doi.org/10.1016/j.apnr.2014.05.005
54. Lawrence C, Mohr LD, Geistkemper A, Murphy S, Fleming K. Sustained Reduction of Nasal Pressure Injuries in the Neonatal Intensive Care Unit With the Use of Bubble Continuous Positive Airway Pressure: A Quality Improvement Project. J Wound Ostomy Continence Nurs. 2021 Mar;48(2):101–7. DOI: https://doi.org/10.1097/WON.0000000000000748
55. Xie LH. Hydrocolloid dressing in preventing nasal trauma secondary to nasal continuous positive airway pressure in preterm infants. World J Emerg Med. 2014;5(3):218. DOI: https://doi.org/10.5847/wjem.j.issn.1920-8642.2014.03.011
56. Boyar V. Pressure Injuries of the Nose and Columella in Preterm Neonates Receiving Noninvasive Ventilation via a Specialized Nasal Cannula: A Retrospective Comparison Cohort Study. J Wound Ostomy Continence Nurs. 2020 Mar;47 (2):111–6. DOI: https://doi.org/10.1097/WON.0000000000000616
57. Krzyzewski JJ, Rogers KK, Ritchey AM, Farmer CR, Harman AS, Machry JS. Reducing Device-Related Pressure Injuries Associated With Noninvasive Ventilation in the Neonatal Intensive Care Unit. Respir Care. 2022 Jan;67(1):24–33. DOI: https://doi.org/10.4187/respcare.08850
58. Rezaei P, Jafari-Mianaei S, Sadeghnia A, Heidari Z. Protective Dressings, Injury, and Device Failure in Preterm Infants Receiving Nasal Continuous Positive Airway Pressure: A Randomized Controlled Trial. Adv Skin Wound Care. 2021 Sept;34(9):1–6. DOI: https://doi.org/10.1097/01.ASW.0000767344.37591.b6
59. Ngaisah SN, Rustinah Y. Hydrocolloids reduce nasal injuries in infants receiving CPAP: a systematic review. JNKI J Ners Dan Kebidanan Indones J Nurs Midwifery. 2022 Jan 22;9 (4):263. DOI: https://doi.org/10.21927/jnki.2021.9(4).263-272
60. Imbulana DI, Owen LS, Dawson JA, Bailey JL, Davis PG, Manley BJ. A Randomized Controlled Trial of a Barrier Dressing to Reduce Nasal Injury in Preterm Infants Receiving Binasal Noninvasive Respiratory Support. J Pediatr. 2018 Oct;201:4-39.e3. DOI: https://doi.org/10.1016/j.jpeds.2018.05.026
61. Badr LK, Zeineddine MH, Abbas H, Charafeddine L. NeoSeal to Prevent Nasal Injury in Preterm Infants Receiving Oxygen Therapy. Neonatal Netw. 2016;35(4):228–33. DOI: https://doi.org/10.1891/0730-0832.35.4.228
62. Camillo Ribeiro DDF, Barros FS, Fernandes BL, Nakato AM, Nohama P. Hydrocolloid versus silicone gel for the prevention of nasal injury in newborns submitted to noninvasive ventilation: A randomized clinical trial. Heliyon. 2020 July;6(7):e04366. DOI: https://doi.org/10.1016/j.heliyon.2020.e04366
63. McCoskey L. Nursing Care Guidelines for Prevention of Nasal Breakdown in Neonates Receiving Nasal CPAP. Adv Neonatal Care. 2008 Apr;8 (2):116–24. DOI: https://doi.org/10.1097/01.ANC.0000317260.99072.ae
64. Brunherotti MAA, Martinez FE. Influence of body position on the displacement of nasal prongs in preterm newborns receiving continuous positive airway pressure. Rev Paul Pediatr Engl Ed. 2015 Sept;33 (3):280–5. DOI: https://doi.org/10.1016/j.rppede.2015.06.007
65. Chen CY, Chou AK, Chen YL, Chou HC, Tsao PN, Hsieh WS. Quality Improvement of Nasal Continuous Positive Airway Pressure Therapy in Neonatal Intensive Care Unit. Pediatr Neonatol. 2017 June;58(3):229–35. DOI: https://doi.org/10.1016/j.pedneo.2016.04.005
66. Mariam S, Buddhavarapu S. Impact of Systematic Training and CPAP Checklist in the Prevention of NCPAP Related Nasal Injuries in Neonates—A Quality Improvement Study. Indian J Pediatr. 2020 Apr;87 (4):256–61. DOI: https://doi.org/10.1007/s12098-019-03146-5
67. Jabraeili M, Eskandari S, Bagher Hosseini M, Rahmani P. The effect of body position on pain due to nasal continuous positive airway pressure (CPAP) in premature neonates: a cross-over clinical trial study. Int J Pediatr [Internet]. 2017 Sept [cited 2023 Feb 14]; (Online First). Available from: https://doi.org/10.22038/ijp.2017.26364.2258
68. Güner Başara S, Çalışır H, Kaynak Türkmen M. Effectiveness of Using Checklist in Preventing Facial, Nasal, and Head Pressure Injuries in Preterm Infants in Nasal Noninvasive Mechanic Ventilation: A Quasi-Experimental Study. J Perinat Neonatal Nurs. 2025 July;39(3):E7–20. DOI: https://doi.org/10.1097/JPN.0000000000000856
69. Mohamed M, Noaman A, Nour I, Abdel-Hady H. Impact of a Nursing Intervention Bundle of Care on Nasal-CPAP-Related Nasal Injuries in Preterm Infants: A Quality Improvement Initiative. Open Access Maced J Med Sci. 2023 May 26;11(B):592–8. DOI: https://doi.org/10.3889/oamjms.2023.11685
70. Rossell-Perry P. An Innovative Method for Nasal Injury Repair after Use of Continuous Positive Airway Pressure in Newborns. Plast Reconstr Surg. 2021 Jan;147(1):179e–80e. DOI: https://doi.org/10.1097/PRS.0000000000007481
71. Chang CS, Swanson JW, Wilson A, Low DW, Bartlett SP. Columellar Reconstruction following Nasal Continuous Positive Airway Pressure Injury. Plast Reconstr Surg. 2018 Jan;141(1):99e–102e. DOI: https://doi.org/10.1097/PRS.0000000000003978
72. Falsaperla R, Biondi GM, Motta M, Gallerano P, Tancredi G, Pavone P, et al. Impressive Nasal Septum Regeneration after Cord Blood Platelet Gel (CBPG) in Extreme Premature Neonate with Non-Invasive Ventilation: A Case Report. Children. 2022 Nov 17;9(11):1767. DOI: https://doi.org/10.3390/children9111767
Downloads
Published
Issue
Section
License
Copyright (c) 2026 JOURNAL OF AFRICAN NEONATOLOGY
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
This is an open-access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
How to Cite
