BREASTFEEDING MEDICINE

Volume 13, Number 4, 2018 Review

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2017.0222

Association Between Breastfeeding

and Childhood Breathing Patterns:
A Systematic Review and Meta-Analysis

Eun Hae Park,1–3 Jae-Gon Kim,2–4 Yeon-Mi Yang,2–4 Jae-Gyu Jeon,5

Jun-Il Yoo,6 Jin-Kyu Kim,7 and Dae-Woo Lee2–4
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Abstract

Objectives: This systematic review aimed to evaluate the association between breastfeeding and breathing
patterns in children.
Materials and Methods: We searched PubMed, EMBASE, Web of Science, CINAHL, and the Cochrane
Central Register of Controlled Trials for publications from inception to October 1, 2017. The breastfeeding
duration and period of exclusive breastfeeding were selected as primary outcomes. The odds ratio (OR) and
95% confidence interval (CI) were calculated. A meta-analysis was conducted to synthesize the evidence. The
Newcastle-Ottawa Score was used for quality and comparability assessment.
Results: Of the 54 articles identified, three observational studies met the inclusion criteria for this meta-
analysis, representing 1,046 participants. The results of the meta-analysis revealed that the prevalence rate of
mouth breathing (OR = 2.04; 95% CI, 1.26–3.31; p = 0.004) was significantly higher in subjects who were
breastfed for less than 6 months, but no significant difference was observed within the periods of exclusive
breastfeeding (6 months or less) (OR = 1.27; 95% CI, 0.73–2.21; p = 0.40).
Conclusion: We found only limited evidence about the association between breastfeeding and breathing
patterns. However, the current evidence supports the association between breastfeeding and childhood
breathing patterns. Based on this review, we found that the frequency of normal nasal respiration increases
with the duration of breastfeeding. The methodological quality of the studies included was moderate. Thus,
future studies should aim to correct the confounding factors related to breathing patterns, to use standardized
diagnostic criteria of mouth breathing, and to conduct a prospective research to reduce the recall bias.

Keywords: breastfeeding, mouth breathing, exclusive breastfeeding, meta-analysis, child, systematic review

Introduction Exclusive breastfeeding until 6 months of age helps protect

an infant from gastrointestinal infections in both developing

E xclusive breastfeeding is defined as ‘‘an infant’s

consumption of human milk with no supplementation
of any type (no water, no juice, no nonhuman milk, and no
foods).’’1 The WHO recommends that exclusive breast-
feeding for 6 months is the optimal way of feeding in-
fants, and infants should receive complementary foods with
continued breastfeeding up to 2 years of age or beyond.2
and industrialized countries. Furthermore, it is known to re-
duce infant mortality due to common childhood illnesses such
as diarrhea or pneumonia and to help for a quicker recovery
during illness.3,4
The mouth-breathing syndrome is defined as when a child
has mixed breathing or exclusive oral breathing. Normal
nasal breathing is an unequaled way of providing optimal air

1
Department of Radiology, Chonbuk National University Medical School and Hospital, Jeonju, Republic of Korea.
2
Department of Pediatric Dentistry, Research Institute of Clinical Medicine of Chonbuk National University, Jeonju, Republic of Korea.
3
Department of Pediatric Dentistry, National University Hospital, Jeonju, Republic of Korea.
4
Department of Pediatric Dentistry and Institute of Oral Bioscience, School of Dentistry, Chonbuk National University, Jeonju, Republic
of Korea.
5
BK21 Program, Department of Preventive Dentistry, School of Dentistry, Chonbuk National University, Jeonju, Republic of Korea.
6
Department of Orthopaedic Surgery, School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea.
7
Department of Pediatrics, Chonbuk National University School of Medicine, Jeonju, Korea.

1
 2 PARK ET AL.
for the healthy growth and development of infants; it is also
an integral part of the craniofacial growth process, which has
a significant impact on the growth and development of the
craniofacial skeleton.5–7 Furthermore, abnormal mouth
breathing patterns are more predisposed to sleep disorders,
learning difficulty, atopic dermatitis, and allergic rhinitis.8–11
The results of recent systematic literature reviews reported
that breastfeeding could affect the occlusion of the teeth.12–16
Breastfeeding stimulates optimal craniofacial development
by inducing intense muscle activity, including proper lip clo-
sure, mandibular functional movement, and precisely locating
the tongue against the palate. The mechanism of breastfeeding
in newborn infants is a complicated action that involves sucking,
breathing, and swallowing simultaneously and works in con-
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junction with the central nervous system.17 During breastfeed-
ing, the lip and tongue movements obtain milk through squeeze
action, while bottle-feeding children exercise more passive
motion to gain milk, which causes less stimulation to the or-
ofacial structure.17,18
Although previous studies have suggested that mouth
breathing pattern may be related to the breastfeeding dura-
tion,19–21 there is no firm evidence supporting the claim that
breastfeeding duration affects the breathing patterns in chil-
dren. Therefore, the present systematic review and meta-
analysis aimed to examine the current evidence on the pos-
sible effects of breastfeeding on the breathing patterns and to
assess the methodological quality of the individual studies.
Materials and Methods
Protocol
This systematic review was conducted under the recom-
mendation of the MOOSE (Meta-analysis of Observational
Studies in Epidemiology) guidelines for design, implementa-
tion, and reporting.22
Eligibility criteria (PICOS)
The systematic review was designed to answer the fol-
lowing focused questions: ‘‘Is there a relationship between
breastfeeding duration and breathing patterns?’’ and ‘‘Is there
a relationship between exclusively breastfeeding and breath-
ing patterns?’’ The PICOS (population, the exposure or in-
tervention, comparisons, outcome, study design) method was
used to define the following eligibility criteria: P (population)
comprised children who are breastfed or not breastfed by their
mother without age restrictions, I (exposure or intervention) is
related to the duration of breastfeeding, C (comparisons) were
the measurement values of breastfeeding duration and periods
of exclusive breastfeeding, O (outcomes considered) is the
difference in breathing patterns of children, and S (study type)
in not limited. Eligible articles were assessed according to the
following inclusion criteria: (1) studies related to the associ-
ation of breastfeeding and breathing patterns, (2) studies that
have clearly defined criteria for assessing breathing patterns,
and (3) studies evaluating any duration of breastfeeding or
periods of exclusive breastfeeding. The exclusion criteria
were as follows: (1) studies without duration of breastfeeding
assessment; (2) literature or systematic reviews, narrative
review, and case reports; (3) protocols, comments, editorials,
letters, and interviews; and (4) studies not conducted in human
subjects.
Information sources and search strategy
Electronic search. We searched the following databases
for publication articles from the earliest available date to
October 1, 2017 that explore the association between breast-
feeding and breathing patterns: MEDLINE, EMBASE, Web of
Science, CINAHL, and Cochrane Central Register of Con-
trolled Trials. The strategy used was a combination of Mesh
terms and free text words, including ‘‘breastfeeding’’ [Mesh
terms], ‘‘breastfeeding’’ [text word], ‘‘mouth breathing’’
[Mesh terms], ‘‘mouth breathing’’ [text word], and ‘‘breathing
patterns’’ [text word]. There were no language restrictions.
The detailed search strategy used in this study is shown in
Appendix Table A1. The gray literature was searched using the
opengrey (opengrey.eu), and unpublished or ongoing trials
were identified using the electronically searching ProQuest
Dissertations and thesis database, ClinicalTrials.gov, and Na-
tional Research Register.
Hand search. The reference lists of the included studies
and previously published articles related to the topic were
screened for identification of any additional studies.
Study selection
Each identified article was independently screened by title and
abstract by the two authors (D.W. and E.H.) to remove duplicate
entries and studies that failed to meet the inclusion criteria. To
avoid excluding potentially relevant articles, abstracts providing
unclear results were included in the full-text analysis. Any dis-
agreement was resolved by discussion. The full-text articles of
the remaining studies were assessed according to the previously
defined inclusion and exclusion criteria and then eligible arti-
cles were selected. The review authors were not blinded to the
authors of the study, the institutions, or the publication. The
references of the included articles were further checked man-
ually. If the retrieved articles were unclear, we contacted the
author by e-mail to clarify the incomplete information.
Data collection process
Two of the authors (D.W. and E.H.) independently ex-
tracted the data from each included article into the predesigned
data collection forms on Microsoft Excel: (1) study identifi-
cation: first author’s name, year of publication, and country;
(2) study design; (3) population (participants): sample size,
mean age, and numbers of male and female participants; (4)
diagnosis criteria of breathing patterns; (5) method of asses-
sing the breastfeeding information; (6) exposure or interven-
tion; and (7) primary outcome measures and time of
assessment. Discrepancies were resolved by discussion.
Data items
The primary outcome measures were duration of breast-
feeding and periods of exclusive breastfeeding. When the data
were not provided, the calculations were performed based on
the raw data reported in the article if present, or we contacted
the author by e-mail to clarify the incomplete information.
Risk of bias in individual studies
Two of the authors (D.W. and E.H.) independently eval-
uated the risk of bias of the enrolled studies in our meta-
 EFFECT OF BREASTFEEDING ON BREATHING PATTERN
analysis using the Newcastle-Ottawa Score.23 The observa-
tional studies included were evaluated mainly through eight
methodological items. Each study can be awarded only one
star for each item, with the exception of comparability, for
which up to two stars can be given; thus, the maximum
possible score for each study is nine stars. The quality of the
studies was assessed independently by two reviewers. If they
disagreed, a consensus was reached by discussion.
Summary measures and synthesis of the results
To answer the research question, the data regarding the as-
sociation of breastfeeding and breathing patterns, in the form of
dichotomous variables, were aggregated from the previous
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studies. To perform the meta-analysis, data extraction was
performed based on the number of patients and the number of
cases in the exposure (intervention) and the control group. The
surveys on the duration of breastfeeding conducted by the in-
cluded studies were not unified; thus, the breathing patterns
were analyzed based on the period of exclusive breastfeeding
(6 months) recommended by the WHO guideline. For the
breastfeeding duration and periods of exclusive breastfeeding
outcomes, a weighted treatment effect (prevalence rate) was
calculated, and the results were expressed as odds ratio (OR)
and 95% confidence interval (CI). We used the fixed effect
model in this study because the population and exposure of
the individual studies integrated into the meta-analysis were
considered homogeneous. In addition, we cannot estimate the
between-study variance when the number of studies con-
ducted through the meta-analysis is very small. Hence, we
used the generic inverse variance estimation method to esti-
mate the weights in the fixed effect model. The inverse var-
iance method is the most common method of meta-analysis
and uses the inverse of the effect estimate variance as the
FIG. 1. Flow diagram for identi-
fication of relevant studies.
3
weight of individual studies. This is an effective method if the
number of studies to be combined is small, but the number of
participants in each study is large. The weighted mean effect
size was calculated using the RevMan software v.5.1 (Co-
chrane Collaboration, Oxford, UK). We provided forest plots
to describe the results of the meta-analysis. A heterogeneity
analysis was conducted to examine if all the effect sizes in the
sample were from the same population using the I2 test and the
Q statistic. A p value of Q statistic <0.05 was the indicator of
heterogeneity, and the data were considered heterogeneous
for I2 value higher than 40%.
Risk of bias across the studies
The funnel plot is a scatter plot showing the estimated
effect sizes of the individual studies based on the sample size
of the study. The interpretation of asymmetry can only be
applied if at least 10 studies are included.
Additional analysis
In this study, we could not perform a subgroup analysis
because of the small number of studies included.
Results
Study selection
Database searches identified 54 publications (Fig. 1). After
eliminating duplicates, 45 articles were selected; 21 of these
were excluded after the screening of titles and abstracts. A
total of 21 articles were reviewed for eligibility by assessing
the full text. The reasons for the study exclusion during the
final review were as follows: not related with the topic
(n = 9), evaluation on the impact of breastfeeding on mal-
occlusion (n = 8), evaluation on the impact of breastfeeding
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Table 1. Characteristics of the Included Studies

Method for
assessing the
Study Study Participants Diagnosis criteria breastfeeding Exposure Primary Secondary
(year) Country design Age range (no. of subjects) of breathing pattern information (intervention) outcomes outcomes
Lopes Brazil Observational Aged 30 252 children who To determine the Semistructured Duration of Breathing Non-nutritive
et al. study to 48 months participated breathing patterns questionnaire was breastfeeding patterns sucking
(2014) in a dental care that the children had administered to the and exclusive associated habits and
program for mothers developed; medical children’s mothers breastfeeding with mouth use of bottle
and newborns. history and clinical assessing the form or nasal
(109: mouth breather, examination and duration of breathing
143: nasal breather) were used. breastfeeding and
the oral habits
of non-nutritive
sucking

4
Limeira Brazil Observational Aged between 732 children Clinical examination Duration of
Questionnaire was Breathing None
et al. study 6 and 9 years (351: mouth was used to analyze breastfeeding
used to assess the patterns
(2013) breather, 381: breathing pattern, and exclusive
form and duration associated
nasal breather) including Glatzel breastfeeding
of breastfeeding with mouth
mirror test, Water or nasal
test, and lip closure breathing
assessment.
Trawitzki Brazil Observational Aged between 62 children Otorhinolaryngological Standardized Duration of Breathing Formula
et al. study 3 years and (40: mouth breather, evaluation consisted questionnaire breastfeeding patterns feeding
(2005) 3 months to 22: nasal breather) in a survey related to investigate the associated periods,
6 years to breathing behavior form, breastfeeding with mouth oral habits,
and 11 months of the child, period, and presence or nasal suction
radiological of deleterious breathing habits, and
examination, oral habit biting habits
nasofibroscopy,
anterior rhinoscopy,
and oroscopy
 EFFECT OF BREASTFEEDING ON BREATHING PATTERN
on temporomandibular disorder (n = 1), evaluation on the
impact of breastfeeding on otitis media (n = 1), and review
and note (n = 2). We included the remaining three articles
for quantitative and qualitative analyses.19–21
Study characteristics
Study design and population. The main characteristics of
all included studies are shown in Table 1. Included studies
were published between 2005 and 2014. All trials were
considered as observational studies, including 1,046 partici-
pants. Most of the participants in the included studies were
between the ages of 3 and 9 years. All three studies included
were conducted in Brazil.
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Type of exposures. Most studies have been surveyed
about breastfeeding duration; two among those studies sur-
veyed examined the periods of exclusive breastfeeding.
Type of outcome measure. The included studies evalu-
ated about breastfeeding duration and/or periods of exclusive
breastfeeding. Two trials investigated the breastfeeding du-
ration and/or periods of exclusive breastfeeding, while one
trial included only breastfeeding duration. The descriptions
of the diagnostic criteria for breathing patterns and the
measurement tools for assessing breastfeeding information
were reported clearly by the authors of all studies. The three
studies included a total of 1,046 participants, of which the
mouth breather group consisted of 500 persons, while the
nasal breather group comprised 546 persons. The methods for
diagnosing the breathing pattern included otorhinolaryngo-
logical evaluation or clinical examination such as the Glatzel
mirror test, water test, and lip closure assessment. The in-
formation related to breastfeeding duration was obtained
mainly from questionnaires.
Synthesis of results
Effect of breastfeeding duration on breathing patterns. The
three included studies provided three effect sizes that ex-
amined the effect of the duration of breastfeeding on the types
of breathing patterns. Subjects breastfed for less than 6
months showed increased levels of mouth breathing patterns
(OR = 2.04; 95% CI, 1.26–3.31; p = 0.004) compared with
those breastfed more than 6 months under the fixed model
(Fig. 2). The present meta-analysis found that children who
were breastfed for up to 12 months presented 1.78 times
more risk of mouth breathing pattern than those breastfed
for more than 12 months. Subjects breastfed for less than 24
months showed increased levels of mouth breathing patterns
(OR = 1.63; 95% CI, 1.20–2.21; p = 0.002) compared with
those breastfed for more than 24 months under the fixed
model. Under the fixed effects model, the Higgin’s I2 test
and the Q statistic for heterogeneity testing explained the
heterogeneity in the effects of breastfeeding duration on the
breathing patterns, with I2 = 45.0% and chi-square = 3.36
( p = 0.16), respectively.
Effect of periods of exclusive breastfeeding on breathing
patterns. The three included studies provided two effect
sizes that examined the effect of the periods of exclusive
breastfeeding on the types of breathing pattern; however, no
significant difference was observed between the subjects
5
breastfed for more than 6 months or less (OR = 1.27; 95% CI,
0.73–2.21; p = 0.40) and subjects who had breastfed for more
than 6 months under the fixed model (Fig. 2). Under the fixed
effects model, the Higgin’s I2 test and the Q statistic for
heterogeneity testing explained the heterogeneity in the ef-
fects of breastfeeding duration on the breathing patterns, with
I2 = 72.0% and chi-square = 3.60 ( p = 0.06), respectively.
Risk of bias within individual studies
The quality assessment of observational trials using the
Newcastle-Ottawa Score Tool is summarized in Table 2. All
three included studies were described as observational stud-
ies. The representation of the exposed individuals and the
selection of the nonexposed individuals were considered
appropriate in all included studies. Although the ascertain-
ment of the exposures was considered as inadequate in all
cohort studies because they were conducted through ques-
tionnaire surveys, it is unlikely that the survey method used to
evaluate the breastfeeding duration will increase the risk of
bias. Demonstrations that malocclusion was not present at the
start of study were not reported in all included studies. With
regard to comparability, the exposure of interest (mouth
breathing) was adjusted only for age factor, not for other
confounding factors. The appropriate assessment of outcome
was used in all observational studies, including clinical test,
otorhinolaryngological examination, or Moyer’s methods,
for evaluating a lack of lip seal. A follow-up duration was
long enough for outcomes (mouth breathing) to occur in all
included studies.
Discussion
This systematic review examines the current evidence on the
possible effects of breastfeeding on the development of breath-
ing patterns. Our findings suggested that the duration of breast-
feeding is related to the breathing patterns. Possible explanations
for such a relationship are as follows. The forward movement of
the mandible and the tongue up and down movements promote
the development of balanced muscles, while the bottle feeding
promotes muscle action to contract the buccinator and orbicu-
laris oris muscles and narrow the maxilla. Electromyography
studies have confirmed that muscle activation is different
between breastfeeding and bottle feeding, with less use of the
mentalis and masseter muscles and more use of the bucci-
nator and orbicularis oris muscles in bottle feeding.24–26 A
recent meta-analysis found that the risk of posterior crossbite
increases as the duration of breastfeeding decreases.14,27 This
is the result of the excessive action of the buccinator muscles
and the abnormal location of the tongue and lack of motor
function. Human infants are able to experiment with different
sucking pressure and different lip, tongue, and jaw move-
ments to maximize the amount of milk they need to obtain or
reduce an uncomfortably fast flow. These compensations will
be adaptive for the infant and comfortable for the mother, but
this compensation does not occur for bottle feeding. If breast-
feeding is sure to affect the breathing pattern and occlusion, the
importance of breastfeeding should be more emphasized to
prevent side effects, such as long face syndrome, from abnor-
mal oral breathing habits.
However, for the periods of exclusive breastfeeding, the
results were different and homogenous conclusions could not
be reached. In this study, only two studies have reported on
 6 PARK ET AL.
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FIG. 2. (A) Duration of breastfeeding: OR for mouth breathing pattern, comparing breastfeeding up to 6 months or more,
12 months or more, and 24 months or more. (B) Duration of exclusive breastfeeding: OR for mouth breathing pattern,
comparing exclusive breastfeeding up to 6 months or more. OR, odds ratio.

exclusively breastfeeding,19,20 and the results were not in the
same direction, so we could not find a possible association
with breathing patterns.
Infants take breathing breaks whenever they need to to
maintain normal blood oxygen levels, as long as the flow of
milk is under their control. This ability to self-regulate is one
of the reasons that physiology stability is greater during
breastfeeding than during bottle feeding. However, the
studies included in this review did not reveal the breathing
patterns during breastfeeding, as it measured the effects of
breathing patterns after breastfeeding in children aged 3 to 9
years. The sample sizes of studies included were large and

Table 2. Quality of the Studies on the Newcastle-Ottawa Quality Assessment Scale

for Observational Studies
Selection Comparability Outcome
Author (year) 1 2 3 4 5a 5b 6 7 8 Total score
Lopes et al. (2014) * * * * * * 6
Limeira et al. (2013) * * * * * * 6
Trawitzki et al. (2005) * * * * * * 6
Criteria: (1) Representativeness of the exposed cohort. (2) Selection of the nonexposed cohort. (3) Ascertainment of exposure. (4)
Demonstration that outcome of interest was not present at start of study. (5) Comparability of cohorts on the basis of the design or analysis,
(5a) for age factor and (5b) for additional factor. (6) Assessment of outcome. (7) Duration of follow-up period. (8) Adequacy of follow-up.
 EFFECT OF BREASTFEEDING ON BREATHING PATTERN
representative, with the smallest sample being 62 and the
largest sample being 732. For enhancing the reliability of
research, two studies have attempted to measure the sample
size. All the studies were performed only in Brazil. Thus,
further research is needed in other races.
This study had the following limitations. First the method
of diagnosis of mouth breathing differs across studies. One
study performed a clinical examination, one study performed
otorhinolaryngological examination, and another study used
Moyer’s methods for evaluating a lack of lip seal. The
problem with most studies related to breathing is that it is not
easy to integrate the results between studies as no single
clinical protocol is available for the diagnosis mouth
breathing. However, the methods used in the studies included
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in this study were reliable because they analyzed breathing
patterns using at least one clinical test.
Second, all the studies included in this review retrospec-
tively collected information related to breastfeeding using
self-entry questionnaires or interviews, so breastfeeding data
may have a recall bias for breastfeeding periods. In addition,
two studies examined the duration of breastfeeding by dis-
tinguishing the subjects exclusively breastfeeding, but one
study did not distinguish between exclusive breastfeeding and
breastfeeding. Therefore, future prospective research designs
should be used to reduce recall bias. In addition, exclusive
breastfeeding, breastfeeding, and bottle feeding should be
clearly distinguished. Third, since the studies included in this
review were conducted in one country (Brazil), it is important
to question whether the findings reflect local environmental
factors or specific genetic predisposition. Therefore, there is a
need for further research in other regions and populations to
ascertain if this is a universal phenomenon. Finally, the in-
cluded studies did not consider the confounding factors such as
environmental factors that can affect breathing patterns and
genetic factors related to respiratory diseases. The observa-
tional studies are aimed at examining the association between
an exposure and an outcome, but can typically be affected by
residual confounding, undetected bias, or reverse causality,
which may generate associations that are not reliable indica-
tors of causality. Therefore, to provide useful information
about causality and to increase the certainty, future observa-
tional studies should aim to correct the confounding factors
related to breathing patterns.
Conclusion
We found only limited evidence about the association
between breastfeeding and breathing patterns. However, the
current evidence supports the association between breast-
feeding and breathing patterns. Based on this review, we
found that the frequency of normal nasal respiration increases
with the duration of breastfeeding, but we could not confirm
the effects of exclusive breastfeeding up to 6 months or more.
The methodological quality of all included studies was
moderate. Therefore, future studies should aim to correct the
confounding factors related to breathing patterns, to use
standardized diagnostic criteria of mouth breathing, and to
conduct prospective research to reduce recall bias.
Acknowledgments
The authors thank J.C. Justin Lee, DDS, PhD (Head of
Children’s Dental Center) for his help to get an insight into the
7
breastfeeding. The work was supported by Fund of Biomedical
Research Institute, Chonbuk National University Hospital.
Disclosure Statement
No competing financial interests exist.
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Appendix
Table A1. Detailed Search Strategies for Each Database
Database Detailed search strategies Records found
MEDLINE/ (‘‘breast feeding’’[MeSH Terms] OR ‘‘breast feeding’’[All Fields]) 24
PUBMED AND (‘‘mouth breathing’’[Mesh Terms] OR ‘‘mouth breathing’’[All Fields]
OR ‘‘breathing pattern’’[All Fields])
EMBASE (‘‘breastfeeding’’/exp OR ‘‘breastfeeding’’) AND (‘‘mouth breathing’’/ 20
exp OR ‘‘mouth breathing’’ OR ‘‘breathing pattern’’)
Cochrane central (‘‘breast feeding’’ OR ‘‘bottle feeding’’) AND (‘‘mouth breathing’’ 2
register of OR ‘‘breathing pattern’’)
controlled trials
Web of Science (‘‘breast feeding’’[MeSH] OR ‘‘breast feeding’’) AND 4
(‘‘mouth breathing’’[MesH] OR ‘‘mouth breathing’’ OR ‘‘breathing pattern’’)
CINAHL (‘‘breast feeding’’[MeSH] OR ‘‘breast feeding’’) AND 4
(‘‘mouth breathing’’[MesH] OR ‘‘mouth breathing’’ OR ‘‘breathing pattern’’)
Mesh terms, search terms, and combinations of the two were used for each database search.
There were no restrictions regarding language, setting, or geographic area of study. Ultimately, 54 records were found, 24 from
MEDLINE/PubMed, 20 from EMBASE, 2 from the Cochrane Library, 4 from the Web of Science, and 4 from CINAHL. Studies were
further selected according to the inclusion criteria listed in the Material and Methods (Fig. 1).
OR, odds ratio.