Caesarean section is currently the most frequently performed intervention after episiotomy in obstetrics and one of the most common abdominal operations overall. Rates of caesarean section have been rising globally. Given the increasing rate worldwide it is therefore necessary and important to understand how caesarean section affects child development. Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioural disorder in children. ADHD is characterized by a combination of symptoms including inattention, impulsivity and hyperactivity. Caesarean section may affect psychological development through changes in microbiota or stress response, and birth by caesarean section can be associated with a small increased risk of ADHD. In the current literature, there is no systematic review or protocol of the systematic review answering the question of whether the mode of delivery has influence on the risk of ADHD development.The objective of this review is to synthesize the best available evidence regarding the epidemiological association between the mode of delivery (caesarean section versus vaginal delivery) as exposure and ADHD as the outcome.A three-step strategy will be utilized in this review, aiming to find both published and unpublished studies. The initial search will be conducted using the MEDLINE, CINAHL and EMBASE. The second search will involve 21 databases and sources. Following the Preferred Reporting Items for Systematic Review and Meta-analysis statement analysis of title, abstracts and full texts, critical appraisal and data extraction will be carried out on selected studies using standardized instruments developed by Joanna Briggs Institute. All steps will be performed by two independent reviewers. If possible, statistical meta-analysis using Joanna Briggs Institute within the System for the Unified Management, Assessment and Review of Information will be pooled. Statistical heterogeneity will be assessed.The results will be disseminated by publishing in a peer-reviewed journal. Ethical assessment is not needed - we will search/evaluate the existing sources of literature.

Czech National Centre for Evidence Based Healthcare and Knowledge Translation Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno

Department of Midwifery Faculty of Health Sciences Palacký University Olomouc

Department of Midwifery Faculty of Health Sciences Palacký University Olomouc Neonatal Department University Hospital Olomouc Olomouc Czech Republic

Department of Public Health Faculty of Medicine and Dentistry Department of Midwifery Faculty of Health Sciences Palacký University Olomouc

Neonatal Department University Hospital Olomouc Olomouc Czech Republic

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$a The association between mode of birth delivery and attention-deficit/hyperactivity disorder: a systematic review protocol of epidemiological evidence / $c J. Klugarová, K. Janoušková, M. Procházka, J. Hálek, V. Šibravová, M. Klugar,

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$a Caesarean section is currently the most frequently performed intervention after episiotomy in obstetrics and one of the most common abdominal operations overall. Rates of caesarean section have been rising globally. Given the increasing rate worldwide it is therefore necessary and important to understand how caesarean section affects child development. Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioural disorder in children. ADHD is characterized by a combination of symptoms including inattention, impulsivity and hyperactivity. Caesarean section may affect psychological development through changes in microbiota or stress response, and birth by caesarean section can be associated with a small increased risk of ADHD. In the current literature, there is no systematic review or protocol of the systematic review answering the question of whether the mode of delivery has influence on the risk of ADHD development.The objective of this review is to synthesize the best available evidence regarding the epidemiological association between the mode of delivery (caesarean section versus vaginal delivery) as exposure and ADHD as the outcome.A three-step strategy will be utilized in this review, aiming to find both published and unpublished studies. The initial search will be conducted using the MEDLINE, CINAHL and EMBASE. The second search will involve 21 databases and sources. Following the Preferred Reporting Items for Systematic Review and Meta-analysis statement analysis of title, abstracts and full texts, critical appraisal and data extraction will be carried out on selected studies using standardized instruments developed by Joanna Briggs Institute. All steps will be performed by two independent reviewers. If possible, statistical meta-analysis using Joanna Briggs Institute within the System for the Unified Management, Assessment and Review of Information will be pooled. Statistical heterogeneity will be assessed.The results will be disseminated by publishing in a peer-reviewed journal. Ethical assessment is not needed - we will search/evaluate the existing sources of literature.

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$a Janoušková, Kateřina $u Department of Public Health, Faculty of Medicine and Dentistry. Department of Midwifery, Faculty of Health Sciences, Palacký University Olomouc.

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$a Hálek, Jan $u Neonatal Department, University Hospital Olomouc, Olomouc, Czech Republic.

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$a Šibravová, Věra $u Department of Midwifery, Faculty of Health Sciences, Palacký University Olomouc. Neonatal Department, University Hospital Olomouc, Olomouc, Czech Republic.

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$a Klugar, Miloslav $u Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech CEBHC JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno.

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