Hostname: page-component-6766d58669-kl59c Total loading time: 0 Render date: 2026-05-18T02:27:03.024Z Has data issue: false hasContentIssue false
  • English
  • Français

Infants of diabetic mothers: epidemiology, pathophysiology, fetal heartassessment, structural and functional heart consequences: A narrative review

Published online by Cambridge University Press:  07 January 2025

Ayed A. Shati Open the ORCID record for Ayed A. Shati [Opens in a new window] ,
Syed E. Mahmood Open the ORCID record for Syed E. Mahmood [Opens in a new window] ,
Youssef A. Alqahtani ,
Saleh M. Al-Qahtani ,
Tajudeen M. Bushari  and
Ashib Parvez
Ayed A. Shati
Affiliation:
Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
Syed E. Mahmood*
Affiliation:
Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
Youssef A. Alqahtani
Affiliation:
Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
Saleh M. Al-Qahtani
Affiliation:
Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
Tajudeen M. Bushari
Affiliation:
Pediatric Cardiology Department, Prince Khaled Bin Sultan Cardiac Centre, Armed Forces Hospital Southern Region, Khamis Mushayt, Saudi Arabia
Ashib Parvez
Affiliation:
Department of Community Medicine, F.H. Medical College, Agra, Uttar Pradesh, India
*
Corresponding author: Syed E. Mahmood; Email: smahmood@kku.edu.sa
Get access Rights & Permissions [Opens in a new window]

Abstract

Infants of diabetic mothers are neonates born to a woman who had periodic hyperglycaemia during pregnancy. Consequently, infants of diabetic mothers are at higher risks of illness besides morbidity and mortality due to teratogenic effects on the fetal cardiovascular system, causing most frequent CHDs. The primary purpose of this review is to present, on this topic, a better-comprehended review covering pertinent material and data to be informed of severe risks to a newborn’s cardiac system and function. These conditions can affect maternal, fetal, neonatal, and future adult health. Further research should be addressed towards the early detection of diabetes, its magnitude, and management. Immediate interventions should be proposed to lessen the diabetes burden and its adversative effects during the prenatal period.

Keywords

cardiac structuregestational diabetesinfant of diabetic motherfetuspregnancyprenatal

Information

Type
Review
Information
Cardiology in the Young , Volume 34 , Issue 10 , October 2024 , pp. 2068 - 2073
Check for updates
Copyright
© The Author(s), 2025. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Kamana, KC, Shakya, Sumisti, Zhang, Hua. Gestational diabetes mellitus and macrosomia: A literature review. Ann Nutr Metab 2015; 66: 14–20. DOI: 10.1159/000371628 Google Scholar
Korra, A, Ezzat, MH, Bastawy, M, et al. Cardiac troponin I levels and its relation to echocardiographic findings in infants of diabetic mothers. Ital J Pediatr 2012; 38: 39. DOI: 10.1186/1824-7288-38-39 CrossRefGoogle Scholar
Opara, PI, Jaja, T, Onubogu, UC. Morbidity and mortality amongst IDMadmitted into a special care baby unit in Port Harcourt, Nigeria. Ital J Pediatr 2010; 36: 77. DOI: 10.1186/1824-7288-36-77.CrossRefGoogle ScholarPubMed
Hăşmăşanu, MG, Bolboacă, SD, Matyas, M, Zaharie, GC. Clinical and echocardiographic findings in newborns of diabetic mothers. Acta Clin Croat 2015 Dec; 54: 458–466.Google ScholarPubMed
Demirpençe, S, Demirpençe, Bİ., Meşe, T, et al. Predictors of postnatal complications and congenital cardiac diseases in infants of mothers with pregestational and gestational diabetes. Turk Pediatri Ars 2014; 49: 299–306. DOI: 10.5152/tpa.2014.1017 CrossRefGoogle ScholarPubMed
Chou, HH, Chiou, MJ, Liang, FW, et al. Association of maternal chronic disease with risk of congenital heart disease in offspring. CMAJ 2016; 188: E438–E46. DOI: 10.1503/cmaj.160061 CrossRefGoogle ScholarPubMed
Paulik’s, LB. The effect of pregestational diabetes on fetal heart function. Expert Rev Cardiovasc Ther 2015; 13: 67–74.CrossRefGoogle Scholar
Wren, C, Birrell, G, Hawthorne, G. Cardiovascular malformations in infants of diabetic mothers. Heart 2003; 89: 1217–1220. DOI: 10.1136/heart.89.10.1217 CrossRefGoogle ScholarPubMed
Sharland, G. Routine fetal cardiac screening: what are we doing and what should we do? Prenat Diagn 2004; 24: 1123–1129. DOI: 10.1002/pd.1069 CrossRefGoogle Scholar
Lisowski, LA, Verheijen, PM, Copel, JA, et al. Congenital heart disease in pregnancies complicated by maternal diabetes mellitus. An international clinical collaboration, literature review, and metaanalysis. Herz 2010; 35: 19–26.CrossRefGoogle ScholarPubMed
Nikyar, B, Sedeghi, M, Mirfazeli, A, et al. Prevalence and pattern of congenital heart disease among neonates in gorgan, northern Iran (2007-2008. Iran J Pediatr 2011; 21: 307–312.Google Scholar
El-Ganzoury, MM, El-Masry, SA, El-Farrash, RA, et al. Infants of diabetic mothers: echocardiographic measurements and cord blood IGF-I and IGFBP-1. Pediatr Diabetes 2012; 13: 189–196. DOI: 10.1111/j.1399-5448.2011.00811.x CrossRefGoogle ScholarPubMed
Tabib, A, Shirzad, N, Sheikhbahaei, S, et al. Cardiac malformations in fetuses of gestational and pre gestational diabetic mothers. Iran J Pediatr 2013; 23: 664–668.Google ScholarPubMed
Cedergren, MI, Selbing, AJ, Källén, BA. Risk factors for cardiovascular malformation - a study based on prospectively collected data. Scand J Work Environ Health 2002; 28: 12–17. DOI: 10.5271/sjweh.641 CrossRefGoogle ScholarPubMed
Akbariasbagh, P, Shariat, M, Akbariasbagh, N, Ebrahim, B. Cardiovascular malformations in infants of diabetic mothers: A retrospective case-control study. Acta Med Iran 2017; 55: 103–108.Google ScholarPubMed
Dolk, H, Loane, M, Garner, E. European surveillance of congenital Anomalies working G. Congenital heart defects in Europe: prevalence and perinatal mortality, 2000 to 2005. Circulation 2011; 123: 841–849. DOI: 10.1161/CIRCULATIONAHA.110.958405 CrossRefGoogle Scholar
Wu, MH, Chen, HC, Lu, CW, et al. Prevalence of congenital heart disease at live birth in Taiwan. J Pediatr 2010 May; 156: 782–785. DOI: 10.1016/j.jpeds.2009.11.062 CrossRefGoogle ScholarPubMed
Starikov, R, Bohrer, J, Goh, W, et al. Hemoglobin A1c inpregestational diabetic gravidas and the risk of congenital heart disease in the fetus. PediatrCardiol 2013; 34: 1716–1722. DOI: 10.1007/s00246-013-0704-6 Google ScholarPubMed
Moazzen, H, Lu, X, Ma. NL, etal, N-acetylcysteine prevents congenital heart defects induced by pregestational diabetes. Cardiovasc Diabetol 2014; 13: 46. DOI: 10.1186/1475-2840-13-46 CrossRefGoogle Scholar
Stuart, A, Amer-Wåhlin, I, Persson, J, et al. Long-term cardiovascular risk in relation to birth weight and exposure to maternal diabetes mellitus. Int J Cardiol 2013; 3: 2653–2657. DOI: 10.1016/j.ijcard.2013.03.032 CrossRefGoogle Scholar
ArslanD, Guvenc O, Cimen, D, et al. Prolonged QT dispersion in the infants of diabetic mothers. PediatrCardiol 2014; 35: 1052–1056. DOI: 10.1007/s00246-014-0897-3 Google Scholar
Yu, Y, Arah, OA, Liew, Z, et al. Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up. BMJ 2019; 367: l6398.Google ScholarPubMed
Clausen, TD, Mathiesen, E, Ekbom, P, et al. Poor pregnancy outcome in women with type 2 diabetes. Diabetes Care 2005; 28: 323–328. DOI: 10.2337/diacare.28.2.323 CrossRefGoogle ScholarPubMed
Wahabi, H, Fayed, A, Esmaeil, S, et al. Prevalence and complications of pregestational and gestational diabetes in Saudi women: analysis from Riyadh mother and baby cohort study (RAHMA). Biomed Res Int 2017; 2017: 6878263. DOI: 10.1155/2017/6878263 CrossRefGoogle ScholarPubMed
Alsoufi, M, AlSuwaidi, MAQ. Association between maternal diabetes and congenital heart diseases in fetuses amongst UAE residents between 2015 and 2017: a retrospective cohort study. J Cardiol Curr Res 2018; 11: 292–295. DOI: 10.15406/jccr.2018.11.00419 CrossRefGoogle Scholar
Agarwal, MM, Dhatt, GS, Shah, SM. Gestational diabetes mellitus: simplifying the international association of diabetes and pregnancy diagnostic algorithm using fasting plasma glucose. Diabetes Care 2010; 33: 2018–2020. DOI: 10.2337/dc10-0572 CrossRefGoogle ScholarPubMed
Moses, RG. Gestational diabetes mellitus: implications of an increased frequency with IADPSG criteria. Diabetes Care 2012; 35: 461–462. DOI: 10.2337/dc11-2237 CrossRefGoogle ScholarPubMed
Bener, A, Saleh, NM, Al-Hamaq, A. Prevalence of gestational diabetes and associated maternal and neonatal complications in a fast-developing community: global comparisons. Int J Women’s Health 2011; 3: 367–373. DOI: 10.2147/IJWH.S26094.CrossRefGoogle Scholar
Al-Rubeaan, K, Al-Manaa, HA, Khoja, TA, et al. A community-based survey for different abnormal glucose metabolism among pregnant women in a random household study (SAUDI-DM). BMJ Open 2014; 4: e005906. DOI: 10.1136/bmjopen-2014-005906 CrossRefGoogle Scholar
Guariguata, L, Linnenkamp, U, Beagley, J, et al. Global estimates of the prevalence of hyperglycemia in pregnancy. Diabetes Res ClinPract 2014; 103: 176–185. DOI: 10.1016/j.diabres.2013.11.003 Google Scholar
Wahabi, HA, Esmaeil, SA, Fayed, A, et al. Gestational diabetes mellitus: maternal and perinatal outcomes in king khalid university hospital, saudi Arabia. J Egypt Public Health Assoc 2013; 88: 104–108. DOI: 10.1097/01.epx.0000430392.57811.20 CrossRefGoogle Scholar
Marchi, J, Berg, M, Dencker, A, et al. Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews. Obes Rev 2015; 16: 621–638.CrossRefGoogle Scholar
Wahabi, HA, Esmaeil, SA, Fayed, A, et al. Pre-existing diabetes mellitus and adverse pregnancy outcomes. BMC Res Notes 2012; 5: 496. DOI: 10.1186/1756-0500-5-496 CrossRefGoogle ScholarPubMed
Chou, F-S, Chakradhar, R, Ghimire, LV. Socioeconomic and racial disparities in the prevalence of congenital heart disease in infants of diabetic mothers. J Matern Fetal Neonatal Med, 2021; 34: 4167–4170. DOI: 10.1080/14767058.2019.1702955 CrossRefGoogle ScholarPubMed
Asoglu, MR, Gabbay-Benziv, R, Turan, OM, et al. Exposure of the developing heart to the diabetic environment and early cardiac assessment: A review. Echocardiography 2018; 35: 244–257. DOI: 10.1111/echo.13811 CrossRefGoogle Scholar
Narchi, H, Kulaylat, N. Heart disease in infants of diabetic mothers. Images Paediatr Cardiol 2000; 2: 17–23.Google ScholarPubMed
Lehtoranta, L, Vuolteenaho, O, Laine, VJ, et al. Maternal hyperglycemia leads to fetal cardiac hyperplasia and dysfunction in a rat model. Am J Physiol Endocrinol Metab 2013; 305: E611–E619. DOI: 10.1152/ajpendo.00043.2013 CrossRefGoogle ScholarPubMed
Higgins, M, Mc Auliffe, F. A review of maternal and fetal growth factors in diabetic pregnancy. Curr Diabetes Rev 2010; 6: 116–125. DOI: 10.2174/157339910790909431 CrossRefGoogle ScholarPubMed
Boucher, J, Kleinridders, A, Kahn, CR. Insulin receptor signaling in normal and insulin-resistant states. Cold Spring Harb Perspect Biol 6: 2014, a009191. DOI: 10.1101/cshperspect.a009191 CrossRefGoogle ScholarPubMed
Arslan, D, Oran, B, Vatansev, H, et al. The usefulness of plasma asymmetric dimethylarginine (ADMA) levels and tissue doppler echocardiography for heart function in term infants born to mothers with gestational diabetes mellitus. J Matern Fetal Neo 2013; 26: 1742–1748. DOI: 10.3109/14767058.2013.798288 CrossRefGoogle ScholarPubMed
Basu, M, Garg, V. Maternal hyperglycemia and fetal cardiac development: clinical impact and underlying mechanisms. Birth Defects Res 2018; 110: 1504–1516. DOI: 10.1002/bdr2.1435 CrossRefGoogle ScholarPubMed
Basu, M, Zhu, JY, LaHaye, S, et al. Epigenetic mechanisms underlying maternal diabetes-associated risk of congenital heart disease. JCI Insight 2017; 2: e95085. DOI: 10.1172/jci.insight.95085 CrossRefGoogle ScholarPubMed
MedlinePlus. Hypertrophic cardiomyopathy [Internet]. Bethesda (MD): National Library of Medicine (US); 2020 [updated 2020 Jun 24; cited 2020 Jul 1]. Available from: https://medlineplus.gov/ Google Scholar
Goulopoulou, S, Hannan, JL, Matsumoto, T, et al. Augmented dilation to nitric oxide in uterine arteries from rats with type 2 diabetes: implications for vascular adaptations to pregnancy. Am J Physiol Heart Circ Physiol 2014; 306: H610–H618. DOI: 10.1152/ajpheart.00588.2013 CrossRefGoogle ScholarPubMed
Pisaneschi, S, Boldrini, A, Genazzani, AR, et al. Feto-placental vascular dysfunction as a prenatal determinant of adult cardiovascular disease. Intern Emerg Med 2013; 8: S41–S45. DOI: 10.1007/s11739-013-0925-y CrossRefGoogle ScholarPubMed
Cvitic, S, Desoye, G, Hiden, U. Glucose, insulin, and oxygen interplay in placental hypervascularisation in diabetes mellitus. Biomed Res Int 2014; 2014: 145846. DOI: 10.1155/2014/145846 CrossRefGoogle ScholarPubMed
Yajnik, CS. Transmission of obesity-adiposity and related disorders from the mother to the baby. ANM 2014; 64: 8–17. DOI: 10.1159/000362608 Google ScholarPubMed
Cordero, L, Paetow, P, Landon, MB. Neonatal outcomes of macrosomic infants of diabetic and non-diabetic mothers. J Neonatal Perinatal Med 2015; 8: 105–112. DOI: 10.3233/NPM-15814102 CrossRefGoogle ScholarPubMed
Barnes-Powell, LL. Infants of diabetic mothers: the effects of hyperglycemia on the fetus and neonate. Neonatal Netw 2007; 26: 283–290. DOI: 10.1891/0730-0832.26.5.283 CrossRefGoogle ScholarPubMed
Chu, C, Gui, YH, Ren, YY, Shi, LY. The impacts of maternal gestational diabetes mellitus (GDM) on fetal hearts. Biomed Environ Sci 2012; 25: 15–22. DOI: 10.3967/0895-3988.2012.01.003 Google ScholarPubMed
Garcia-Flores, J, Jañez, M, Gonzalez, MC, et al. Fetal myocardial morphological and functional changes associated with well-controlled gestational diabetes. Eur J Obstet Gynecol Reprod Biol 2011; 154: 24–26. DOI: 10.1016/j.ejogrb.2010.08.002 CrossRefGoogle ScholarPubMed
Al-Biltagi, M, El Razaky, O, El Amrousy, D. Cardiac changes in infants of diabetic mothers. World J Diabetes 2021; 12: 1233–1247. DOI: 10.4239/wjd.v12.i8.1233 CrossRefGoogle ScholarPubMed
Samanth, J, Padmakumar, R, Vasudeva, A, et al. Persistent subclinical myocardial dysfunction among infants of diabetic mothers. J Diabetes Complicat 2022; 36: 108079. DOI: 10.1016/j.jdiacomp.2021.108079 CrossRefGoogle ScholarPubMed
Begum, S, Dey, SK. Clinical profile and pattern of congenital heart disease in infants of diabetic mother and infants of the non-diabetic mother at a tertiary care hospital. J Neonatal Perinatal Med 2017; 10: 403–408. DOI: 10.3233/NPM-170176 CrossRefGoogle ScholarPubMed
Ferdousi, SA, Sarker, F, Jahan, N, et al. Pattern of congenital heart disease in infants of diabetic mother. Bangladesh J Child Health 2014; 38: 74–78.CrossRefGoogle Scholar
Muhammad, A, Khan, M, Khan, I, Anwar, T. Frequency of congenital heart diseases in IDM referred to the pediatrics department. J Postgrad Med Inst 2014; 28: 37–41.Google Scholar
Abu-Sulaiman, RM, Subaih, B. Congenital heart disease in infants of diabetic mothers: an echocardiographic study. Pediatr Cardiol 2004; 25: 137–140. DOI: 10.1007/s00246-003-0538-8 CrossRefGoogle ScholarPubMed
Øyen, N, Diaz, LJ, Leirgul, E, Boyd, HA, et al. Prepregnancy diabetes and offspring risk of congenital heart disease: a nationwide cohort study. Circulation 2016; 133: 2243–2253. DOI: 10.1161/CIRCULATIONAHA.115.017465 CrossRefGoogle ScholarPubMed
Lawson, TB, Scott-Drechsel, DE, Chivukula, VK, et al. Hyperglycemia alters the structure and hemodynamics of the developing embryonic heart. J Cardiovasc Dev Dis 2018; 5: 13. DOI: 10.3390/jcdd5010013 Google ScholarPubMed
Meyer-Wittkopf, M, Simpson, JM, Sharland, GK. Incidence of congenital heart defects in fetuses of diabetic mothers: a retrospective study of 326 cases. Ultrasound Obstet Gynecol 1996; 8: 8–10. DOI: 10.1046/j.1469-0705.1996.08010008.x CrossRefGoogle ScholarPubMed
Wheller, JJ, Reiss, R, Allen, HD. Clinical experience with fetal echocardiography. Am J Dis Child 1990; 144: 49–53. DOI: 10.1001/archpedi.1990.02150250059031 Google ScholarPubMed
Kinda, G, Millogo, GR, Koueta, F, et al. Cardiopathies congénitales: aspects épidémiologiques et échocardiographies à propos de 109 cas au centre hospitalier universitaire pédiatrique Charles de Gaulle (CHUP-CDG) de Ouagadougou, Burkina Faso [Congenital heart disease: epidemiological and echocardiography aspects about 109 cases in pediatric Teaching hospital Charles de Gaulle (CDG CHUP) in Ouagadougou, Burkina Faso]. Pan Afr Med J 2015; 29: 81. DOI: 10.11604/pamj.2015.20.81.5624 Google Scholar
Costa, VN, Nomura, RMY, Reynolds, KS, et al. Effects of maternal glycemia on fetal heart rate in pregnancies complicated by pregestational diabetes mellitus. Eur J Obstet Gynecol Reprod Biol 2009; 143: 14–17. DOI: 10.1016/j.ejogrb.2008.10.019 CrossRefGoogle ScholarPubMed
Roodpeyma, S, Rafieyian, S, Khosravi, N, et al. Cardiovascular complications in infants of diabetic mothers: An observational study in a pediatric cardiology clinic in Tehran. J Compr Ped 2013; 4: 119–123. DOI: 10.17795/compreped-8432 CrossRefGoogle Scholar
Paauw, ND, Stegeman, R, de Vroede, MAMJ, et al. Neonatal cardiac hypertrophy: the role of hyperinsulinism-a review of literature. Eur J Pediatr 2020; 179: 39–50. DOI: 10.1007/s00431-019-03521-6 CrossRefGoogle ScholarPubMed
Balli, S, Pac, FA, Ece, İ., et al. Assessment of cardiac functions in fetuses of gestational diabetic mothers. Pediatric Cardiol 2014; 35: 30–37. DOI: 10.1007/s00246-013-0734-0 CrossRefGoogle ScholarPubMed
Zielinsky, P, Piccoli, AL. Myocardial hypertrophy and dysfunction in maternal diabetes. Early Hum Dev 2012; 88: 273–278. DOI: 10.1016/j.earlhumdev.2012.02.006 CrossRefGoogle ScholarPubMed
Dawid, G, Węgrzynowski, J, Kwiatek, M, et al. A fetal dilated and hypertrophic cardiomyopathy associated with maternal gestational diabetes--a case report. PediatrEndocrinol Diabetes Metab 2010; 16: 123–125.Google ScholarPubMed
Osterholm, EA, Barthell, JE, Georgieff, MK. Infants of Diabetic Mothers. In: Buonocore, G, Bracci, R, Weindling, M (eds). Neonatology: A Practical Approach to Neonatal Diseases. Springer International Publishing, Cham, 2016: pp. 1–14. DOI: 10.1007/978-3-319-18159-2_195-1 Google Scholar
Al-Qahtani, MH. Infants of diabetic mothers: 4 years analysis of neonatal care unit in a teaching hospital, saudi Arabia. Saudi J Med Med Sci 2014; 2: 151. DOI: 10.4103/1658-631X.142499 CrossRefGoogle Scholar
Iwashima, S, Hayano, S, Murakami, Y, et al. Cardiac function in infants born to mothers with gestational diabetes - estimation of early diastolic intraventricular pressure differences. Circ Rep 2019; 1: 378–388. DOI: 10.1253/circrep.CR-19-0062 CrossRefGoogle ScholarPubMed
Bogo, MA, Pabis, JS, Bonchoski, AB, et al. Cardiomyopathy and cardiac function in fetuses and newborns of diabetic mothers. J Pediat 2021; 97: 520–524. DOI: 10.1016/j.jped.2020.10.003 CrossRefGoogle ScholarPubMed
Papazoglou, AS, Moysidis, DV, Panagopoulos, P, et al. Maternal diabetes mellitus and its impact on the risk of delivering a child with congenital heart disease: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2022; 35: 7685–7694. DOI: 10.1080/14767058.2021.1960968 CrossRefGoogle ScholarPubMed
Smith, A, Franklin, O, McCallion, N, et al. Effect of gestational diabetes mellitus on neonatal myocardial function. Neonatology 2021; 118: 64–72. DOI: 10.1159/000513041 CrossRefGoogle ScholarPubMed
Depla, AL, De Wit, L, Steenhuis, TJ, et al. Effect of maternal diabetes on fetal heart function on echocardiography: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2021; 57: 539–550. DOI: 10.1002/uog.22163 CrossRefGoogle ScholarPubMed
D’Ambrosi, F, Rossi, G, Soldavini, CM, et al. Evaluation of assessment parameters in pregnancies with well-controlled gestational diabetes. Arch Gynecol Obstet 2021; 304: 337–344. DOI: 10.1007/s00404-020-05948-x CrossRefGoogle Scholar
Di Bernardo, SC, Lava, SAG, Epure, AM, et al. Consequences of gestational diabetes mellitus on neonatal cardiovascular health: mySweetHeart cohort study. Pediatr Res 2023; 94: 231–238. DOI: 10.1038/s41390-022-02390-4 CrossRefGoogle ScholarPubMed
Lookzadeh, H, Alipour, MR, Vakili-Zarch, A, Ekraminasab, S. Prevalence of Congenital Heart Diseases in Neonates of Diabetic Mothers: A Cross Sectional Study in Yazd. J Peri & Neonatol, 5: 2022: 24–29. DOI: 10.18502/wjpn.v5i1.10125 Google Scholar