International Journal of Research in Medical Sciences

Adebami OJ et al. Int J Res Med Sci. 2015 Oct;3(10):2605-2612

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20150799
Research Article

Assessment of knowledge on causes and care of neonatal jaundice at the

Nigerian primary and secondary health institutions
Olusegun Joseph Adebami*

Department Paediatrics and Child Health, College of Health Sciences, Ladoke Akintola University of Technology,
Osogbo, Nigeria

Received: 10 August 2015

Accepted: 07 September 2015

*Correspondence:
Dr. Olusegun Joseph Adebami,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Neonatal jaundice is the most common condition that requires medical attention in new-borns.
However, missed diagnosis of jaundice, poor monitoring, and prescriptions of wrong and ineffective medications by
the health workers for jaundice are known to be responsible for the persistence of acute bilirubin encephalopathy in
the sub region. Therefore, the aim of the present study was therefore to assess the knowledge in the care of neonatal
jaundice at the primary and secondary health care delivery in Nigeria so as to improve it.
Methods: A cross-sectional study conducted at 12 local government primary health and maternity centers and 2 state
owned general hospitals (secondary health facilities) in Osun State, Southwest Nigeria between January and June
2014. Consent was obtained from the health workers at the health facilities. A structured questionnaire was
administered to all the staffs on duty and during the shifts of duty. The questionnaire contained questions to assess the
knowledge of the health workers with regard to neonatal jaundice causes, treatment and complications. Staff
judgment on the effectiveness of methods and drugs being prescribed were also assessed.
Results: One hundred and forty one (67.5 percent) were primary health care workers and 68 (32.5percent) were staff
in secondary health care facilities. There was significantly better understanding of causes, management and
complications of neonatal jaundice among secondary health care workers than primary health care workers (p at least
0.007). Common pharmacological agents prescribed were Ampiclox (Ampicillin-Claxacillin formulation), Glucose
water, Multivitamins, phenobarbitone, other antibiotics and injections at both health care levels.
Conclusions: There is therefore urgent need to train health workers of all cadres on causes, care, effective treatment
and complications of neonatal jaundice to reduce the high prevalence of bilirubin encephalopathy. Facilities like
effective phototherapy units should be made available at health facilities and training centres.

Keywords: Assessment, Knowledge, Health workers, Neonatal jaundice, Nigeria

INTRODUCTION physiological jaundice is retrospective because

sometimes jaundice can start with bilirubin in the
Neonatal jaundice which is yellow coloration of the skin physiological range and then escalate or become
and sclera in newborns from the accumulation of prolonged or show signs of cholestasis.1 More
unconjugated bilirubin occurs in most newborn infants importantly is the neurotoxicity (acute bilirubin
and it is the most common condition that requires encephalopathy) or death in newborns and lifelong
medical attention in newborns. Most jaundice is benign neurologic sequelae in infants who survive (kernicterus)
(physiological) and usually need no treatment as it from excessive rise of unconjugated bilirubin. For these
resolves within two weeks. However, the diagnosis of reasons, newborn infants with jaundice must be identified

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 Adebami OJ et al. Int J Res Med Sci. 2015 Oct;3(10):2605-2612

early and the level of jaundice monitored to identify those RESULTS

who might develop severe jaundice, acute bilirubin
encephalopathy and kernicterus. The Respondents: Location, Experience and Post Held

Severe neonatal jaundice is 100-fold more frequent in Out of three and forty three hundred questionnaires, 238
Nigeria than in industrialized countries1 Acute bilirubin were filled and returned covering 12 primary health
encephalopathy (ABE) is also very common in Nigeria.2 facilities and 2 state hospitals in the State. Twenty nine
It is known that missed diagnosis of jaundice, trivializing questionnaires were not analyzed because of
all cases of neonatal jaundice, poor monitoring, inappropriate entries and confusing information. Only the
prescriptions of wrong and ineffective medications for 219 questionnaires returned and appropriately filled were
jaundice has been found responsible for the persistence of analyzed. One hundred and forty one (67.5 percent) were
acute bilirubin encephalopathy and cerebral palsy in the birth attendants at the primary health care centers and 68
subregion.2 Among the babies who presented late with (32.5percent) were staff in secondary health care
acute bilirubin encephalopathy in a teaching hospital, facilities.
about 80% were seen by at least a health worker 24 hr.
before the brain damage and were given ineffective Of the 141 respondents at the Primary health care centers,
prescription, wrong counsel and reassurance.2 17 were Nursing officers, 8 Chief Community Health
officers, 9 Chief Community Health Extension Workers
Primary and the secondary health facilities and the (CHEW), 14 Principal CHEW, 26 CHEW, 32 Junior
workers are the closest health care providers to the CHEW and 35 Health Assistants.
community in terms of availability, accessibility and
affordability. The role of primary and secondary health Details of the 68 respondents at the secondary health care
care levels is very critical to neonatal jaundice were 5 Chief Nursing Officers, 7 Assistant Chief Nursing
management. Parents heavily depend in most cases on the Officers, 10 Principal Nursing Officers and 39 Nursing
advice and care being provided by these facilities without officers and 7 CHEW.
cross checking whether they are right or not. The aim of
the present study therefore, was to assess the knowledge The years of experience in practice ranged between 2 and
and ongoing practices in the care of neonatal jaundice at 32 years and average of 13.7 years among secondary
the primary and secondary health care delivery in Nigeria health care workers while the range was between 1 and
so as to improve it. 34 years and average of 17.8 years among the primary
level health workers.
METHODS
Knowledge of neonatal jaundice causes and treatment
This was a cross-sectional study conducted at twelve
local government primary health and maternity centers Table I shows the comparison of knowledge of neonatal
and two state owned general hospitals (secondary health jaundice causes and treatment among primary and
facilities) in Osun State, Southwest Nigeria between secondary health care birth workers. There was
January and June 2014. These centers were chosen significantly better understanding of neonatal jaundice
because of their closeness in terms of location to the causes such as blood group incompatibility, G6PD
tertiary hospitals in the State. It was assumed that their deficiency, low birth weight and infection among
geographical closeness to the two teaching hospitals secondary health care workers than primary care workers
would bring the knowledge and practice in them close to (p at least 0.007). Similarly, secondary health care
the optimum. workers were better informed on appropriate approach to
management of neonatal jaundice like the need for
Consent was obtained from the health care workers. A referral, laboratory tests to determine the cause(s) and
structured questionnaire was administered to all the staffs severity, possible treatment options like phototherapy and
on duty during the shifts of duty. Excluded was those /or exchange blood transfusion when severe (p=0.000).
staff that was off duty or on leave. The questionnaire
contained questions on years of experience, questions to Counsel of health workers to mothers on the modalities
assess the knowledge of the health workers with regard to of treatment for neonatal jaundice
neonatal jaundice causes, treatment and complications.
Staff judgment on the usual counsel to mothers of babies Table II shows the comparison of usual counsel of health
with jaundice and the effectiveness of treatment usually workers to mothers of babies with neonatal jaundice on
prescribed. Mode and places of referral were also the treatment of jaundice in their babies. The secondary
assessed. The data generated were entered into HP health care workers significantly counseled better on the
personal computer and analyzed with the Statistical need for follow up, need for phototherapy and need/or
Package for the Social Sciences (SSPS version 17). exchanged blood if severe.
Simple frequencies and chi-square test of significance
were calculated. The level of significance was taken as p
<0.05.

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Table 1: Comparison of knowledge of neonatal jaundice causes and treatment among Primary and Secondary
Health Care Birth Attendants.

Primary Health Care Secondary health

Variable χ2 p value
Workers n(% of 141) workers n (% of 68)
Knowledge blood group incompatibility as cause
of jaundice
 Good 62 (44.0) 64 (94.1)
 Poor 79 (56.0) 04 (5.9) 48.2 0.000
Knowledge of G6PD deficiency as cause
of jaundice
 Good 13 (9.2) 34 (50.0)
 Poor 128 (90.8) 34 (50.0) 43.8 0.000
Knowledge of neonatal infection as a cause of
jaundice
 Good 74(52.5) 49(72.1)
 Poor 67(47.5) 19(27.9) 7.3 0.007
Knowledge of drugs or
substances that can provoke jaundice in some
babies
 Good 54(38.3) 47(69.1)
 Poor 87(61.7) 21(30.9) 17.5 0.000
Knowledge of low birth weight (unusually small)
babies predispose to severe jaundice
 Good 74(52.5) 59(86.8)
 Poor 67(47.5) 9(13.2) 122.4 0.000
Knowledge of the need for babies with jaundice to
have referral for laboratory tests to determine the
cause(s) and severity
 Good 58(41.1) 54(79.4)
 Poor 83(58.9) 14(20.6) 34.1 0.000
Knowledge of use of phototherapy for
treatment for jaundice
 Good 34(34.1) 60(82.4)
 Poor 107(75.9) 08(17.6) 27.0 0.000
Knowledge of use of exchange blood transfusion
as treatment for severe jaundice
 Good 23(16.3) 42(61.8)
 Poor 118(83.7) 26(38.2) 44.2 0.000
Knowledge of risk of
brain damage (kernicterus) occurring in severe
jaundice
 Good 31(22.0) 58(55.9)
 Poor 110(78.0) 10(44.1) 75.2 0.000
Knowledge of risk of
death in severe jaundice
 Good 71(50.4) 55(80.9)
 Poor 70(49.6) 13(19.1) 17.9 0.000
Knowledge of danger of exposing baby to
unfiltered sunlight to treat jaundice
 Good 23(16.3) 37(54.4)
 Poor 118(97.9) 31(45.6) 32.5 0.000

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Table 2: Comparison of frequency of usual counsel to mothers on the modalities of treatment of neonatal jaundice
of health workers among Primary and Secondary Health Care Birth Attendants.

Primary Health Care Birth Secondary Health Care Midwives

Attendants n=141 n=68
Always Sometimes Never Always n Sometimes Never
Method p-value
n (%) n (%) n (%) (%) n (%) n (%)
Need no treatment 10(7.1) 47(33.3) 84(59.6) 28(41.2) 22(32.4) 18(26.5) 0.000
Need referral 21(14.9) 54(38.3) 66(46.8) 22(32.4) 15(22.1) 31(45.6) 0.005
Need laboratory test 39(27.7) 38(27.0) 64(45.4) 28(41.2) 17(25.0) 23(33.8) 0.1
Need observation 43(30.5) 65(46.1) 33(23.4) 18(26.5) 27(39.7) 23(33.8) 0.2
Need follow up in the
19(13.5) 54(38.3) 68(48.2) 18(26.5) 25(36.8) 25(36.8) 0.06
heath unit
May need
Phototherapy (Special 31(22.0) 15(10.6) 95(67.4) 45(66.2) 14(20.6) 9(13.2) 0.000
treatment light)

Table 3: Comparison of frequency of prescription for neonatal jaundice among 141 Primary and 68 Secondary
Health Care Birth Attendants.

Secondary Health Care Midwives

Primary Health Care Birth Attendants
n=141 n=68

Always Sometimes Never Always n Sometimes Never

Method p-value
n (%) n (%) n (%) (%) n (%) n (%)
Use of
Pharmacological
agent
Ampiclox 71(50.4) 54(38.3) 16(11.3) 12(17.6) 38(55.9) 18(26.5) 0.000
Glucose water 85(60.3) 42(29.8) 14(9.9) 22(32.4) 26(38.2) 20(29.4) 0.000
Multivitamins 69(48.9) 67(47.5) 5(3.5) 34(50.0) 10(14.7) 24(35.3) 0.000
Other antibiotics
43(30.5) 65(46.1) 33(23.4) 10(14.7) 15(22.1) 43(63.2) 0.000
and injections
Phenobarb 54(38.3) 50(35.5) 37(26.2) 23(33.8) 29(42.6) 16(23.5) 0.4
Use of Non-
Pharmacologic
agent
Pawpaw leaves in
39(27.7) 59(41.8) 43(30.5) 8(11.8) 11(16.2) 49(72.0) 0.000
water
Pawpaw seed in
39(27.7) 64(45.4) 38(27.0) 8(11.8) 9(13.2) 51(75.0) 0.000
water
Camphor
(Naphthalene 28(19.9) 33(23.4) 80(56.7) 2(2.9) 5(7.4) 61(89.7) 0.000
balls) in water
Herbs/Native
23(16.3) 12(8.5) 106(75.2) 2(2.9) 5(7.4) 61(89.7) 0.005
Concoctions
Scarification
0(0.0) 03(2.2) 138(97.8) 0(0.0) 0(0.0) 68(100.0) 0.6
marks
Exposure to early
118(83.7) 19(13.5) 4(2.8) 47(69.1) 15(22.1) 6(8.8) 0.04
morning sunlight
No treatment at
12 (8.5) 45(31.9) 84(59.6) 28(41.2) 26(38.2) 14(20.6) 0.000
all

Frequency of prescription for neonatal jaundice

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Table III shows comparison of frequency of prescription Knowledge of dangers (Complications) of severe
for neonatal jaundice among 141 Primary and 68 jaundice
secondary health workers. Common pharmacological
agents prescribed were Ampiclox (Ampicillin-Claxacillin Table IV shows comparison of knowledge of dangers
formulation), Glucose water, Multivitamins, (Complications) of severe jaundice among the primary
phenobarbitone, other antibiotics and injections. Others and secondary health care workers. The secondary health
were solution extracts made from pawpaw leaves and/or care workers were better informed about severe jaundice
seed in water, exposure to early sunlight, native herbal causing visual, auditory, speech/ language handicapping,
preparations and solution of naphthalene balls in water. cerebral palsy and even death.
Significantly higher proportions of primary health care
workers prescribed non-pharmacologic medications more
for babies with jaundice.
Table 4: Comparison of knowledge of dangers (Complications) of severe jaundice
among 141 Primary and 68 Secondary Health Care Birth Attendants.

Primary health care birth attendants Secondary health care midwives n=68
n=141
Variable Yes No I don‟t know Yes No I don‟t know p-
n (%) n (%) n (%) n (%) n (%) n (%) value
Poor vision 28 (19.9) 31 (22.0) 82 (58.1) 42 (61.8) 12 (17.6) 14(20.6) 0.000
Poor hearing and 23 (16.3) 27 (19.1) 91(64.5) 48 (70.6) 10 (14.7) 10 (14.7) 0.000
deafness
Poor speech and 25 (17.7) 32 (22.7) 84 (59.6) 41 (60.3) 07 (10.3) 20 (29.4) 0.000
language
development
Poor development 28 (19.9) 49 (34.8) 64(45.4 ) 48 (70.6) 09 (13.2) 11 (16.2) 0.000
like delayed sitting,
crawling, standing,
walking
Convulsion/Epilepsy 27 (19.1) 53 (37.6) 61(43.3) 37 (54.4) 12 (17.6) 19 (27.9) 0.000
Brain damage 23 (16.3) 44 (31.2) 74(52.5) 33 (48.5) 14 (20.6) 21 (30.9) 0.000
Poorly growth and 15 (10.6) 39 (27.7) 87(61.7) 35 (51.5) 11 (16.2) 22 (32.4) 0.000
stained teeth
Death 13 (9.2) 29 (20.6) 99 (70.2) 39 (57.4) 17 (25.0) 12 (17.6) 0.000

DISCUSSION It was also postulated that the wrong information may

have percolated to the mothers to explain why many
The present study shows that primary health care workers mothers gave similar responses to same questions and
in the range of 9.2 to 52.5% had good knowledge on similar unorthodox practices in the management of
various parameters tested while it was 50.0 to 94.1% neonatal jaundice. Adebami in Ilesa,5 Su Yuen Ng et al,6
among workers in the secondary health facilities. Boo et al7 in Malaysia, Khalesi et al in Iran,8 Egule et al
Conversely, 49.6% to 90.8% did not have adequate in Benin,9 Olusoga et al3 and Ogunlesi et al10 in Sagamu
knowledge among the primary health workers and 5.9 to had all observed at various degree of lack of attention,
50.0% among the secondary health workers had self-treatment, use of inappropriate medicine, use of
inadequate knowledge in diverse parameters tested. It medicinal herbs and traditional remedies as treatment for
shows therefore, that though many of the health workers neonatal jaundice among mothers or expectant mothers in
at both primary and secondary heath care facilities had their respective regions.
good knowledge about neonatal jaundice causes,
treatment, complications and counseling of mothers yet Ignorance of health workers based on the causes,
there are still many areas of paucity of knowledge on the care/treatment and complications of severe neonatal
causes and effects of jaundice in the newborn. Olusoga et jaundice will have very serious consequences on the
al in Sagamu3 and Ekanem et al in Calabar4 also had management of neonatal jaundice and can pose serious
similar observations of weak understanding of neonatal challenge on the reduction of bilirubin induced
jaundice in terms of definitions, knowledge of causes, neurologic dysfunction in the community.
treatment and possible complications of severe jaundice
among the health workers at primary health care levels. It is of note that many health workers do not know about
Glucose 6 phosphate dehydrogenase (G6PD) deficiency

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 Adebami OJ et al. Int J Res Med Sci. 2015 Oct;3(10):2605-2612

which is regarded as the most important cause of severe hemolysis, inadequate conjugation, low levels of binding
jaundice and bilirubin encephalopathy in Nigeria.11 In the proteins (albumin, Y and Z proteins), low levels of
present study, 9.2% and 50.0% of primary health care and enzymatic activities, inadequate intake with increased
secondary health care workers were aware of G6PD entero-hepatic circulations and poor blood brain
deficiency respectively. This is higher than 3.4% barrier.16-18 Preterms are therefore more susceptible to the
observed by Ekanem et al among 205 primary health care development of bilirubin encephalopathy and those who
staff in Calabar.4 Olusoga et al3 did not include the are jaundiced among them should be referred early.17-19
knowledge of G6PD in the survey among the community
health workers in Sagamu; because they thought it will be The knowledge of phototherapy and /or exchanged blood
too technical. Glucose-6-phosphate dehydrogenase (G-6- transfusion is quite low among the primary health
PD) deficiency is the most common disease producing workers in the present study where 24.1% and 16.3% of
enzymopathy in humans. G6PD catalyzes the entry step respondents had knowledge of phototherapy and
of G6P into the Pentose Phosphate Shunt (PPS) in the red exchanged blood transfusion respectively; hence the use
cells. While many other body cells have other of non-conventional method of treatment for neonatal
mechanisms of generating NADPH, the red blood cells jaundice. Finding of present study is however lower than
rely completely on G-6PD activity because it is the only 39.5% in calabar4 and 54.5% in Sagamu.3 The present
source of NADPH that protects the cell against oxidative study also reported 82.4% and 61.8% for phototherapy
stress and injury.12 Deficiency of this enzyme which and exchanged blood transfusion respectively among the
occurs in an X-linked recessive inheritance mode nurses /midwives at the secondary health facilities. Use
(therefore commoner in males) predisposes the individual of sunlight phototherapy is popular among the
to severe haemolysis, jaundice and anaemia when respondents of both health facilities similar to other
exposed to infections, certain foods and some previous studies.3,4 For moderate to severe jaundice,
medications. Prevalence of G6PD deficiency vary from phototherapy with electric generated blue-light or light-
20.6% in Ibadan13 to 37.3% in Ilorin.14 Ignorance of this emitting diode (LED) devices is the treatment of choice,
important cause is reflected in the continuous use of failing which exchange transfusion becomes necessary to
iatrogenic and highly provocative agents like naphthalene avert bilirubin-induced neurologic dysfunction.20-22 In
balls on babies, more so, in the treatment of jaundice. many resource-limited settings, there is no phototherapy
Many of the local herbal preparations contain menthol at all in the primary health care centers and sparsely used
which is contraindicated in G6PD deficient individuals. in the most secondary health facilities. The use of
effective phototherapy for jaundiced infants is frequently
Also, the act of prescribing oral antibiotics for treatment hampered by non-availability of conventional
of jaundice is a reflection of ignorance on the seriousness phototherapy devices powered by electricity.23-25 Several
of neonatal sepsis as a cause of jaundice. In the present studies especially in the tropics have reported a common
study, more than 80% and 70% of primary and secondary practice of exposing jaundiced infants to direct sunlight
health workers respectively favoured the use oral as a form of treatment despite concerns about the
antibiotics as part of the management for neonatal potential dangers from infrared and ultraviolet rays and
jaundice. This is higher than Olusoga et al finding of sunburn.9,23 Exposure of newborns to direct and
54.5% in Sagamu3 and Ekanem et al of 70.7% in unfiltered sunlight should be discouraged because of the
Calabar.4 Though prevalence of neonatal sepsis is high in potential and invisible harms from ultraviolet radiation
the developing countries because many deliveries are and infrared rays.20
unsupervised and occur in unhygienic environment.
However, treatment of sepsis in the newborn should be The prevalence of „physiological jaundice‟ which needs
intensive when sepsis is perceived to be the cause of the no treatment and therefore responds to any “treatment”
jaundice. Newborn babies especially the preterm are and give a fictitious confidence to many health workers
physiologically immunocompromised.15 Sepsis in and has been attributed to the underestimation of
newborn result in poor sucking, dehydration, release of irreversible brain damage that could occur in bad
hemolysis with resultant hemolysis, increased blood brain management of severe jaundice.2 Moreso, many of the
barrier permeability for unconjugated bilirubin, thereby health workers are unaware of the deleterious effects
increasing the probability of bilirubin encephalopathy severe jaundice can cause on the immature brain of a
development. Therefore, sepsis, in newborn is managed newborn. In the present study, less than 20% of the
with parenteral antibiotics. Use of oral antibiotics usually primary health workers are aware of the sequelae of
result in ineffective treatment of babies with sepsis, late severe neonatal jaundice. This is lower than 49.3% at a
presentation or may precipitate development of antibiotic primary health post in Calabar7 and 67% among the
resistance to commonly used and cheaper antibiotics. mothers attending antenatal care clinic in Benin.9

Significantly higher proportions of health care workers at There is therefore urgent need to train health workers of
the primary health care level in the present study were all cadres on causes, care, effective treatment and
ignorant of predisposition of low birth weight and complications of neonatal jaundice to reduce the high
preterm to severe jaundice. It is known that about 80% of prevalence of bilirubin encephalopathy being reported in
preterm may be jaundiced as a result of higher rate of the developing countries. Teaching health institutions

International Journal of Research in Medical Sciences | October 2015 | Vol 3 | Issue 10 Page 2610
 Adebami OJ et al. Int J Res Med Sci. 2015 Oct;3(10):2605-2612

should ensure good exposure of potential health workers 10. Ogunlesi TA, Fetuga MB, Adekanmbi AF. Mothers‟
in training (students) to adequate knowledge, skill, knowledge about birth asphyxia: The need to do
experience to manage common neonatal conditions which more! Niger J Clin Pract 2013;16:31-6.
jaundice is very significant. Facilities like effective 11. Owa JA, Taiwo O, Adebiyi JAO, Dogunro SA.
phototherapy units should be made available at health Neonatal jaundice at Wesley Guild Hospital, Ilesa
facilities. Also to reduce knowledge gap specialists like and Ife State Hospital, Ile-ife. Nig J Paediatr
Paediatricians should be involved in the training of health 1989;16:23-30.
workers of both primary and secondary health facilities. 12. Chan TK, Todd D, Tso SC. Drug-induced
haemolysis in glucose-6-phosphate dehydrogenase
ACKNOWLEDGEMENTS deficiency. BMJ 1976;2:1227-29.
13. Effiong CE, AimakuVE, Bienzle V, Oyedeji GA,
Health workers (Community health workers and nurses) Ikpe DE. Neonatal jaundice in Ibadan: Incidence,
at the primary and secondary health facilities at both Ilesa aetiological factors in babies born in hospitals. J
and Osogbo cities are hereby acknowledged. Natl Med Assoc 1975;67:208-13.
14. Obasa TO, Mokuolu OA, Ojuawo A. Glucose 6
Funding: No funding sources phosphate dehydrogenase levels in babies delivered
Conflict of interest: None declared at the University of Ilorin teaching hospital. Nig J
Ethical approval: The study was approved by the Paediatr 2011;38(4)165-169.
Institutional Ethics Committee 15. Wynn JL, Levy O. Role of innate host defences in
susceptibility to Early- onset neonatal sepsis Clin
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