Sensorial saturation in neonatal and infant pain management compared to other non-pharmacological and pharmacological analgesic techniques: a systematic review

Introduction

Background

Neonatal pain has historically been underestimated, often considered negligible or not effectively manageable, due to the complexity of the interaction between pain and neonatal behavior (1). In recent years, neonatal pain management has received increasing attention, especially in settings where infants, including preterm babies, are subjected to numerous painful procedures, such as heel stick and intramuscular injections. Scientific literature has widely demonstrated that untreated pain in neonates can have negative effects on the development of the central nervous system, increasing the risk of altered pain sensitivity, and other long-term consequences (1-4).

Thus, the interest in the use of non-pharmacological and non-invasive analgesic methods has spread, particularly for the physiological weakness of the newborns.

Rationale and knowledge gap

Among the emerging non-pharmacological techniques for pain control, sensorial saturation (SS) has attracted particular interest. In this review, we use the term “sensorial saturation (SS)” as originally described by Bellieni et al., referring to a specific form of multisensory stimulation involving taste, touch, and auditory input. While “multisensory stimulation” is a broader term, SS represents a structured clinical application of this concept. SS combines a simultaneous stimulation of multiple senses—taste (oral sugar solution), touch (massage), and hearing (reassuring voice)—to reduce the perception of pain in the newborn during painful medical procedures (3,4). This technique is based on two main mechanisms: the activation of descending inhibitory pathways and promotion of the production of endorphins through gentle, pleasant, and engaging stimulations (made up of words, sugar, and physical contact), and pain control via the “gate control” mechanism at spinal level, which modulates pain transmission through intermediate interneurons, through skin massage (4,5).

Evidence from various studies indicates that SS is particularly effective compared to other non-pharmacological analgesic methods, such as the sole use of sugar solutions, both in term and preterm infants. Furthermore, it has been shown to be safe and easily applicable also by parents facilitating active involvement of the family in neonatal pain management and promoting a care approach centered on the infant and the family (4). However, despite its growing interest, the comparative effectiveness of SS versus other analgesic interventions still needs more investigation.

Objective

Several studies have explored the efficacy of SS compared to other analgesic techniques, such as oral sucrose or skin-to-skin contact, showing that SS can produce significant pain reduction, especially in common procedures such as heel sticks. Previous systematic reviews, such as the one conducted by Locatelli and Bellieni in 2018, examined evidence on the efficacy of SS in neonatal pain management, analyzing studies published between 2001 and 2017 (4). This review highlighted the effectiveness of SS in painful procedures such as heel prick, eye examination, and intramuscular injection. However, since this evidence was limited to studies published until 2017, an updated review is required to incorporate recent findings and provide a more comprehensive assessment of SS efficacy (Table 1).

Therefore, this systematized review aims to:

• Assess the efficacy of SS in neonatal and infant pain management, compared with other non-pharmacological analgesic techniques.
• Determine whether new evidence published between 2017 and 2025 confirms or changes the conclusions drawn from the previous review by Locatelli and Bellieni (4).
• Explore potential differences in SS efficacy based on factors such as gestational age, type of painful procedure, and parental involvement in applying the technique.

We present this article in accordance with the PRISMA reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-105/rc).

Methods

This review follows these steps: (I) definition of inclusion and exclusion criteria; (II) search in two databases using predefined keywords; (III) screening of titles and abstracts; (IV) full-text analysis; (V) data extraction and synthesis.

We examined articles on the application of SS in neonates, both term and preterm, published from January 2017 to June 2025.

A comprehensive search was conducted in two databases (MEDLINE and Scopus) to identify relevant studies. We used the following key-words “Sensory saturation”, “Multisensory stimulation”, “multisensorial stimulation”, “sensorial stimulation”, “pain”, “newborn”, “analgesia”, “infant”, associating the first four terms (“sensory saturation”, “multisensory stimulation”, multi sensorial stimulation”, “sensorial stimulation”) with the other four (“pain”, “newborn”, “analgesia”, “infant”) with the Boolean operator AND from 2017 to June 2025.

Inclusion criteria for the studies to be retrieved were: being randomized clinical trials, comparing SS with at least another analgesic treatment for pain management in neonates or infants. We included studies of both total SS (smell, touch, sight, taste, and hearing) and partial SS, which implies that in addition to the sense of taste, another sense is also included, up to a total of four. During the screening phase, records were excluded if they did not meet these criteria—for instance, studies involving adult participants or using sensory stimulation for non-analgesic purposes (e.g., for neuromuscular diseases or dementia). We included in preterm infants with gestational age <37 weeks and term infants with gestational age ≥37 weeks.

Exclusion criteria were: reviews, case reports, and commentaries; studies on animals; articles focusing on non-pain-related interventions (e.g., neuromuscular diseases or dementia); studies conducted in adult populations; and studies on children older than 1 year of age.

Two independent reviewers screened the titles and abstracts for relevance. Full-text articles were assessed independently by the same reviewers to determine eligibility. Disagreements were resolved through discussion.

Extracted information included study design, sample size, population characteristics, intervention details, control conditions, pain outcomes, and results. Data extraction was performed independently by two reviewers to ensure accuracy using a predefined table including sample size, pain scale, intervention, and outcomes. Any discrepancies were resolved by consensus. Studies that lacked essential data for key outcomes were excluded from quantitative synthesis but were still described qualitatively if they provided relevant insights. However, no major data gaps were detected that warranted further analysis.

The Cochrane Risk of Bias Tool (RoB 2) was used to assess the risk of bias in randomised controlled trials (RCTs) (6). Each domain was evaluated as presenting low risk, high risk, or unclear risk.

Due to the heterogeneity of interventions and outcomes across the included studies, a narrative synthesis was performed. The results were grouped according to the type of painful procedure (e.g., heel prick, eye examination, vaccination) age of the baby, parental involvement where available and intervention method (e.g., complete, or partial SS).

Results

A total of 7 studies met the inclusion criteria. The PRISMA flow diagram (Figure 1) illustrates the studies selection process, including the number of records identified, screened, excluded, and included in the final synthesis. The initial search identified 960 articles. After removing duplicates and records marked as ineligible by the filters integrated into the database, such as the type of research and the publication date, 513 records remained for screening. Following title and abstract screening, 11 full-text articles were assessed for eligibility. Two studies were excluded because of the wrong context (one focused on sensory saturation to promote feeding and psychomotor development in preterm infants, the other concerned the effectiveness of interventions on early neurodevelopment of preterm infants), one for the wrong population (SS programs in dementia) and one because the senses were not stimulated simultaneously but at different times, stimulating a single sense at a time. Instead, 7 randomized controlled trials were included in the final review. Most were conducted in hospital neonatal units in Asia. All confirmed the superior analgesic effect of SS.

Figure 1 PRISMA 2020 diagram flow. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Reasons for exclusion at the full-text stage included studies focusing on adult populations and articles investigating interventions unrelated to pain management.

The results of the quality assessment of the studies included in the review are summarized in Table 2. Overall, all included randomized controlled trials showed a low risk of bias for random sequence generation, selective reporting, other sources of bias, and incomplete outcome data. Allocation concealment was adequately reported in three studies (3,8,9), while it remained unclear in the remaining trials (2,7,10,11). Regarding blinding, only one study reported adequate blinding of both participants/personnel and outcome assessment (8) through the use of noise-canceling headphones for investigators. In contrast, most studies presented either unclear or high risk of bias in the blinding domains (2,7,9,10), particularly for participants and personnel (2,3,7,9-11). This high risk is largely attributable to the nature of non-pharmacological interventions (such as breastfeeding, maternal touch, and multisensory stimulation), which inherently prevent the masking of the treatment from those administering it.

Furthermore, the quality of outcome assessment was affected by specific methodological constraints: in some cases, the absence of video recordings (2) prevented an independent blinded review of neonatal pain responses, while in other trials (7), it was not possible to maintain blinding during the NIPS score evaluation. Regarding outcome measurement, the Soltani et al.’s study (3) was limited by the lack of objective biochemical markers, such as cortisol levels, relying solely on behavioral tools; a study did not include a control group receiving a placebo (sterile water) (10); meanwhile, in one specific case (11), the analysis was restricted to transient vaccine-related pain, which may differ from responses to acute or chronic stimuli. Other critical issues involved the sample and setting, with small sample sizes (3,10) potentially affecting statistical power and single-center designs (7) limiting the generalizability of the findings. Finally, the presence of confounding factors, such as the concomitant use of oral sucrose (8) or the inability to strictly control pre-procedure conditions, including feeding times (8) or undergoing other painful procedures (2), may have influenced the magnitude of the observed analgesic effect.

Consequently, these aspect makes most of the studies high risk of bias (2,3,7,9-11), except one (8).

These 7 included studies involved a total of 700 participants, including 246 preterm newborns (115 male, 83 female and 48 newborns of unspecified sex; average weight 1,500–2,300 grams; age 4–30 days), 283 term newborns (158 male and 125 female; average weight 3,100–3,200 grams; age 2–23 days), and 171 newborns (79 male and 92 female) aged 4–6 months (6,700 grams and 7,500 grams, respectively), ranging from preterm neonates (≤32 weeks) to term neonates and infants up to 6 months of age and comparing the effect of SS in its complete or partial form with other analgesic methods (Table 3). Three studies included preterm infants (2,3,9), three included term infants (7,8,10), and one study included children aged 4 or 6 months (11). Three studies used heel prick as a painful stimulus (7,8,10), one study used eye examination (9), one study used venipuncture (2), one used bathing (3) and one used pentavalent vaccination (11). Details of the included studies, including sample size, intervention methods, and outcome measures, are summarized in Table 3.

The analgesic efficacy of 24% oral sucrose administration with non-nutritive sucking was compared with 10% oral glucose administration in term infants (10).

Two studies compared SS with breast milk administration alone (one study in preterm infants and one in children aged 4 and 6 months) (9,11).

One study compared the administration of tactile, sound, olfactory and gustatory stimuli with the administration of tactile and sound alone or tactile, sound and olfactory stimuli in full-term newborns (7).

One study evaluated the administration of SS with 24% sucrose or breast milk with 24% sucrose alone in preterm infants (2).

Sound stimulation accompanied by sucrose administration was analyzed compared to 24% sucrose alone in full-term infants (8).

One study analyzed the validity of SS with maternal supportive interventions on the stress caused by swaddled bathing in preterm infants (3).

Compared to sucrose or breast milk alone, SS proved to be the most effective analgesic approach in all studies (2,8,9,11). One study highlighted a greater analgesic capacity if the tactile, auditory and olfactory stimulus is also added to the gustatory stimulus (7).

One study (2) highlighted a greater analgesic capacity of SS compared to the administration of oral sucrose alone and showed no differences between the administration of SS with sucrose and the administration of SS with breast milk.

SS was administered to newborns without congenital cardiac or neurological diseases, without cardiopulmonary resuscitation or other emergency interventions. Some factors that can affect SS efficacy could be the gestational age, the type of painful procedure and the parental involvement.

The studies provide evidence that SS effectiveness varies with gestational age.

In preterm neonates (28–36 weeks gestation) SS resulted in a higher behavioral state component of the Premature Infant Pain Profile score compared to breastmilk or sucrose administration alone (2,9). For premature infants during retinopathy screening, SS was effective in reducing pain scores and the intervention group receiving it reached baseline scores more quickly than those receiving breast milk alone (9). The SS performed by mothers is effective on reduce the stress caused by swaddled bathing in preterm infants (3).

In contrast, term neonates showed strong responses to multisensory approaches. Music combined with sucrose was highly efficacious in reducing pain in term neonates undergoing heel prick procedures (8). Additionally, multisensory breastmilk interventions (odor + taste + routine care) significantly reduced pain scores during heel sticks in newborns compared to routine care alone (7).

Different painful procedures showed varying responses to SS:

• Venipuncture: for preterm newborn SS with both sucrose (SSS) and breast milk (SSB) were more effective than oral sucrose alone, with no significant difference between SSS and SSB (2). For term newborns beyond the first week of life, oral sucrose with nonnutritive sucking significantly reduced pain scores during venipuncture (10).
• Heel stick procedures: multiple studies demonstrated effectiveness across different populations. For newborn screening in term neonates, multisensory breastmilk interventions significantly reduced pain during and after heel sticks in term neonates (7). Music as an adjuvant to sucrose also proved effective in term neonates (8).
• Eye examinations: during retinopathy screening in premature infants, both SS and breast milk reduced pain scores compared to controls, though SS showed slightly greater effect (9).
• Bathing: sensory saturation carried out by the mother through cuddling, talking, touching, kissing, and eye-to-eye contact with the infant during bathing helps reduce the stress of the preterm infant (3).
• Vaccination: for pentavalent vaccination in 4 and 6-month-old infants, SS was more effective than breastfeeding alone in reducing behavioral pain responses and crying duration (11).

Several studies in the review confirmed the feasibility and acceptability of parental involvement in the execution of SS. In the study by Karimi et al. [2022], mothers were instructed to breastfeed their infants during the vaccination procedure. The intervention was well accepted by both the parents and the healthcare staff, supporting the use of non-pharmacological strategies managed by caregivers (11).

When mothers provided multisensory supportive interventions during swaddled bathing in preterm infants, stress levels did not significantly increase, unlike the control group where mothers were only present without active intervention (3).

Moreover, no difficulties were reported by parents—most often the mother—when correctly instructed to perform SS, confirming the method’s simplicity and reproducibility in real clinical settings.

In a related context, Lan et al. [2021] described how rhythmic multisensory stimulation provided by mothers had a significant regulatory effect on the behavioral states of preterm infants. These actions were effective in calming and soothing the neonates, further supporting the role of the parent as an active agent in developmental and analgesic care (7).

The combination of breastmilk odor and taste with routine care (gentle touch + verbal comfort) provided superior pain relief compared to routine care alone, indicating that incorporating maternal elements enhances intervention effectiveness (7).

The Cochrane Risk of Bias Tool (RoB 2) was applied to assess the included RCTs (Table 2). Six studies were rated as having a high risk of bias (2,3,7,9-11) and one as having same concerns (8).

From the results of the analyzed studies, it emerges that SS represents the most effective analgesic approach (2,3,7,8,9,11). In particular, SS conducted with breastfeeding or sucrose has been shown to be superior to 24% sucrose alone (2) or breastfeeding alone (7). The administration of 24% sucrose has been shown to be more effective than 10% glucose (10). The data also show that the analgesic efficacy increases with the increase in the number of senses involved: the combination of multiple sensory stimuli (tactile, gustatory, auditory and olfactory) determines a significantly greater effect compared to partial or single stimulation (2,3,7,8,9-11).

Discussion

Key findings

In accordance with the results already highlighted by Locatelli and Bellieni (4), SS has proven to be effective in pain management in procedures such as heel prick and eye examination, but also in other procedures, such as vaccination (11). Furthermore, the greater efficacy of SS is confirmed compared to the administration of sugar alone (3) and compared to an incomplete SS (7). It is also noted that SS is more effective than the administration of breast milk alone (9). The data confirm once again the possibility of delegating the execution of SS to the parents of newborns, so that the family becomes an active promoter of the child’s care and the nurses are supported by the family itself during the procedures [such as a ROP (9) or swaddled bathing (3) performed in the absence of colleagues]. Direct breastfeeding showed effectiveness in reducing pain responses during vaccination, though SS proved more effective than breastfeeding alone (11). This suggests that while parental involvement through breastfeeding is beneficial, structured multisensory approaches may provide superior pain relief. SS can be recommended as free, non-pharmacological treatment approaches, that parental involvement is possible but not essential for their implementation and effectiveness, and that the newborn in particular benefits from the introduction of maternal elements included in the SS.

This systematic review confirms that SS is a highly effective non-pharmacological intervention for procedural pain management in neonates and infants. Across all included studies, SS was more effective than single-modality strategies such as oral sucrose, breastfeeding, or swaddling. Notably, studies comparing SS with breast milk (9) or sucrose alone (7) found that SS provided faster and more significant pain relief. These findings support SS as the most comprehensive and consistent analgesic approach currently available for newborns undergoing minor painful procedures. Furthermore, evidence shows that parents can successfully administer SS after brief training, making it feasible in both high- and low-resource clinical settings (11). This involvement not only facilitates pain management but also reinforces parent-infant bonding and increases parental satisfaction (3).

Strengths and limitations

Despite the strengths of this systematized review, several limitations must be acknowledged. Firstly, the number of included studies was relatively small and most of them were conducted in Asia, which may limit the generalizability of the findings. Additionally, while all included studies adhered to recognized methodological standards, some lacked clear descriptions of randomization procedures or blinding techniques, raising concerns about potential biases. Furthermore, the exclusion of non-English-written articles may have led to the omission of relevant research, thereby introducing language bias. Most studies had some risk of bias, particularly due to the impossibility of blinding caregivers and parents, a common challenge in non-pharmacological intervention studies (2,3,7,9,11). Moreover, the review included studies in both term and preterm neonates, as well as different painful procedures, thus enhancing the robustness of conclusions. Our analysis includes a still preliminary number of studies, all of which give the same indication, but which require further investigation for the painful stimuli less used in these studies (eye examination, intramuscular puncture) and for cases beyond neonatal age.

Comparison with similar research

Previous systematic reviews have investigated the efficacy of SS in neonates, but with different scopes and outcomes.

Cignacco et al. [2007] stressed the importance of familiar sensory cues, such as the mother’s scent and voice, in modulating neonatal pain responses. The authors reported that infants are particularly responsive to olfactory cues emanating from their mothers’ nipple regions and that these familiar odors may stimulate the release of cholecystokinin, a neuropeptide with calming and analgesic effects. These mechanisms reinforce the physiological basis of sensorial stimulation, its superiority over isolated interventions like sucrose alone and the importance of the parents involving (12).

Oliveira et al.’s [2017] review highlights the need to assess both pain and stress as distinct yet interrelated constructs (13). Oliveira et al. also reported that sensory-based interventions were among the most effective in reducing both pain and stress, which directly supports our inclusion and analysis of SS protocols involving combined sensory cues.

Similarly, the review by Shayani & Marães [2023] concludes that combined non-pharmacological interventions such as sensory stimulation and familiar odors are more effective than isolated techniques, a finding mirrored in our analysis (14). Our review adds to this by specifying the importance of parental involvement in delivering these interventions, enhancing both clinical and ethical impact.

Similarly, Locatelli and Bellieni (4) provided an earlier review of SS in neonatal pain management, concluding that SS was effective in reducing pain across various procedures, including heel pricks, eye examinations, and intramuscular injections. Our current review updates and extends these findings by including studies published from 2017 to 2025, confirming the superior analgesic efficacy of SS compared to sucrose, breast milk, and swaddling. This continuity reinforces the reliability of SS as a consistent and effective non-pharmacological intervention. Regarding endotracheal suctioning, SS has not been shown to be effective (4). This may be explained by the procedure itself: during endotracheal suctioning in intubated neonates, the tube should not extend beyond the tip of the endotracheal tube and is therefore not expected to come into contact with mucosal tissue (4). Consequently, although the procedure may be stressful, it is unlikely to cause true nociceptive pain (4).

Our findings further support the idea that multisensory strategies like SS are more effective due to their ability to engage multiple sensory channels simultaneously, enhancing endogenous analgesic mechanisms.

In summary, while previous reviews have addressed either developmental outcomes or broader non-pharmacological strategies, our review is unique in synthesizing recent evidence that isolates and confirms the specific analgesic superiority of SS, particularly in preterm infants and in a broader range of procedures.

Explanations of findings

One of the main reasons for the effectiveness of SS lies in its ability to simultaneously combine multiple sensory inputs, amplifying the analgesic effect. Compared to single interventions, SS has proven more effective: for example, Dehghani et al. [2021] observed that, although both SS and breast milk effectively reduced pain scores during retinopathy screening, SS produced slightly faster relief (9).

Breastfeeding itself represents a natural example of multisensory stimulation: the newborn benefits from skin-to-skin contact, can perceive the mother’s scent, hear her voice, and taste the milk, which possesses analgesic properties due to its sweet taste and ability to stimulate the release of endogenous opioids. This effect is comparable to that of sucrose, but without the potential risks associated with repeated exposure to the latter.

Previous studies also suggest that the mother’s presence and familiarity with her milk contribute to reducing physiological and behavioral responses to pain in newborns (7,9).

Unlike interventions that rely solely on one sensory modality (e.g., sucrose or breastfeeding), SS integrates these elements into a single, structured practice. This synergy may explain its faster onset and greater analgesic effect.

Furthermore, SS has been shown to be more effective than single interventions such as breast milk alone. Dehghani et al. observed that although both SS and breast milk effectively reduced pain scores, SS showed a slightly faster onset of pain relief than breast milk during retinopathy screening (9).

The involvement of parents in delivering SS is not only ethically aligned with family-centered care models but may also contribute to its effectiveness. Familiar sensory cues, such as the mother’s voice and scent, have been shown to reduce newborns’ behavioral and physiological pain responses (3). Additionally, engaging parents reduces their perceived stress and increases trust in the healthcare team, further reinforcing the care relationship (3).

Implications and actions needed

Another important element in favor of SS is its ethical and relational value in neonatal care. Unlike other non-pharmacological methods, SS not only offers superior analgesic efficacy, but also allows direct and active involvement of parents during painful procedures. This participation not only strengthens the emotional bond between parent and newborn, but also contributes to reducing parental stress and improving trust in healthcare professionals and the overall care process (3,11). In particular, family-centered interventions such as SS and breastfeeding have been shown to enhance both physiological and emotional outcomes in neonates, while empowering parents to play an active role in procedural pain management (1). From an ethical point of view, SS represents a preferable option, since it combines clinical efficacy and respect for the vulnerability of the newborn, avoiding repeated exposure to pharmacological substances potentially associated with neurotoxic effects (4,11). In this sense, SS is configured as a humanistic, economic, safe, and reproducible intervention, in line with the principles of patient-centered medicine and respect for the dignity of the newborn.

The findings of this review highlight the efficacy of SS as a non-pharmacological intervention for neonatal pain management. Given its safety, cost-effectiveness, and ease of implementation, SS should be considered as a standard approach in clinical practice for managing neonatal procedural pain. However, additional research is required to strengthen the evidence base. Future studies should focus on standardizing SS protocols, ensuring consistency in intervention duration, intensity, and delivery methods.

Conclusions

Our study not only confirms and strengthens the evidence reported by Locatelli and Belleni (4), but also demonstrates that SS can be successfully used in infants, going beyond the limit of application to neonates only. This result represents a crucial step forward: the adoption of SS proves to be an effective option also in other age groups, contributing to the management of pain in neonates and infants with a significant reduction in the use of drugs. This approach opens new perspectives for a safer and more innovative treatment of pediatric pain. However, the methodological quality of the included studies must be carefully considered. According to the Cochrane Risk of Bias Tool, a high risk of performance bias was identified in the majority of the trials (6 out of 7), as the nature of non-pharmacological sensory interventions makes it difficult the blinding of personnel and participants. Furthermore, several specific limitations emerged, such as the lack of objective biochemical markers (e.g., cortisol levels) (3), small sample sizes in some trials (3,10), and the presence of potential confounding factors like the administration of oral sucrose or variations in pre-procedure feeding (8). These elements suggest that, while clinically effective, the results should be interpreted with caution.

Given its consistent efficacy, safety, and feasibility, SS should be prioritized as a first-line non-pharmacological intervention in neonatal care. Nevertheless, future research should prioritize high-quality, standardized trials with blinded outcome assessors and objective physiological monitoring to consolidate these findings, exploring its scalability, integration in routine protocols, and long-term neurodevelopmental impact. We conducted this review on a limited number of studies, which results support—but do not yet definitively establish—its superiority over other methods.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-105/rc

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-105/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-105/coif). C.V.B. serves as an unpaid editorial board member of Pediatric Medicine from October 2024 to September 2026. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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