A STUDY TO ASSESS THE FACTORS AFFECTING NEONATAL JAUNDICE. AND THE IMPACT OF THE SAME, ON GROWTH AND DEVELOPMENT OF CHILDREN LESS THAN 3 YEARS, ATTENDING THE OUT PATIENT DEPARTMENT AT A SELECTED HOSPITAL KOLAR.

PROFORMA FOR REGISTRATION OF STUDENTS FOR DISSERTATION

NAVEEN HEROLD SIMON. H

A.E & C.S. PAVAN COLLEGE OF NURSING, KOLAR

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

01 NAME OF THE CANDIDATE & ADDRESS

MR.NAVEEN HEROLD SIMON. HB-30 BHARATH NAGARBEMLNAGAR POST,K.G.F.

02 NAME OF THE INSTITUTIONAE & CS PAVAN COLLEGE OF NURSING, KOLAR

03 COURSE OF STUDYM.SC NURSINGPEADIATRIC

04 DATE OF ADMISSION TO THE COURSE

31 MAY, 2007

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TITLE OF THE TOPIC:A STUDY TO ASSESS THE FACTORS AFFECTING NEONATAL JAUNDICE. AND THE IMPACT OF THE SAME, ON GROWTH AND DEVELOPMENT OF CHILDREN LESS THAN 3 YEARS, ATTENDING THE OUT PATIENT DEPARTMENT AT A SELECTED HOSPITAL KOLAR.

6. BRIEF RESUME OF THE INTENDED WORK :

Introduction“Today’s child is tomorrow’s future. The child is the heritage of the family and children’s health is India’s health. Just as it is essential for the young shoot of the plant to be healthy for the foundation of a strong healthy tree, healthy children are also essential for healthy India”.

The total population of the world is 6,574 Million of which Asia’s population is 3712 Million. Three quarters of the world’s Six billion people living developing countries. Each year the

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population of the world is increasing more than 270 million, over half the birth taken place in Asia (i.e.s, 120 Million). Children form a substantial proportion between 35 to 50% of the population, in the most developing country, amongst them 10 to 15% are neonatal. The period of life from birth to one month is commonly referred to as the neonatal period. 1

During this phase of life, the newborn functioning and behavior are mostly reflexive. Stabilization of major body function is the primary task of the neonate and occurs in a definite sequence of the physiologic events from the first day of life. During this period, the neonates are at risk of acquiring many problems. Among these, the major health problems are jaundice, infections, nutritional deficiency, Trauma and regulation of body temperature. 2

Approximately of 60% of the million new borns are clinically jaundiced although most available data are based on infants, whose birth rate are more than 2500 grams and more than 37 completed weeks of gestation. Under certain circumstance severe hyper bilirubinemia can cost complication knows as Kernicterus. The affects of Kernicterus range from fever, seizures and high pitched crying leading to mental retardation, bilirubin may be toxic to the central nervous systems and may cause neurological impairment in full term new borns.3

Physiological jaundice is a normal occurrence between the second and fourth day of life and appears in approximately 50% of all full term newborns. Bilirubin levels may reach 6 to 10 mg/dl and resolution generally occurs during the seventh or eighth day. A bilirubin level exceeding 12 mg/dl for the full term infant is suggestive of more than normal physiology and would be considered hyperbilirobinemia (Behrman). 4In the studies conducted by Newman TB, neonatal bilirubin exceeding 10 mg/dl seems to have little effect on IQ (Intelligent Quotient), neurological abnormalities and hearing loss. While higher bilirubin levels (20 mg/dl) are associated with minor motor abnormalities. Nelson explain that a Physiological limits are exceeded the bilirubin crosses the blood brain barrier and produces toxics symptoms of bilirubin encephalopathy. In some cases there is a poor chance of survival. 5As per the records of a selected hospital in Kolar the in patient service has and ever increasing number of patients presenting with neonatal jaundice.

Year No. of Cases No. of Child Undergone Phototherapy Referred Hospital

2003 624 550 74

2004 936 900 36

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2005 1248 1220 28

2006 1560 1500 60

2007 1872 1760 112

The above table shows the prevalence of jaundice cases and this indicates that people are not aware of the seriousness of the problem. The prevalence of decease is increasing day by day in our country. Since appropriate medical care is not available in the hospitals, antenatal mothers and other people having less knowledge regarding the disease condition. At this selected hospital daily 150 to 200 children attend the outpatient department, among them 15 to 20 children who had suffered from neonatal jaundice. Hence the researches intention is to study the effects of neonatal jaundice on growth and development of the children less than 3 years. 6.1) NEED FOR THE STUDY:

The role of developmental assessment is to see that the child is progressing as per norms set by a large majority of children of the same age. It is by no means a predictor of future intelligent quotient and any deviation from the normal is brought to the notice of the parents, only in reassuring ways. The cause and effect relation between developmental deficits and risk factors can be much more complicated than we imagine. We cannot presume that neonatal jaundice will lead to mental retardation, fine and gross motor abnormalities, hearing loss and vision problems. But most of the children have developmental disabilities after neonatal jaundice. 6

Hence it is ideal to have some sort of developmental evaluation for all babies like measuring length, Head Circumference, Chest Circumference, Midarm Circumference, weighing weight & reflexes of the neonates. And using Trivandrum developmental screening chart and Denver developmental screening test. The Preliminary analysis and statistics from many child developmental centers and out-patient departments in hospitals have showed that babies with neonatal hyperbilirubinemia have higher incidence of delayed developmental milestones and other associated problems. 7

Hence the investigators were prompted to follow the children who suffered from neonatal jaundice in order to identify the complications very early and promote optimum growth & development of the children.

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6.2 REVIEW OF LITERATURE:

Related literature was reviewed to broaden the understanding and gain insight in to the selection problem under study. This study aimed to assess the factors affecting neonatal jaundices and the impact of the same on growth and development of children less than 3 years.

The literature that was reviewed is presented under the following heading.1 Associated factors of mother affecting neonatal jaundice2 Associated factors of neonates affecting neonatal jaundice3 Investigations of neonatal jaundices4 Treatment of neonatal jaundice5 The effect of neonatal jaundice in growth and development. 8

ASSOCIATED FACTORS OF MOTHER AFFECTING NEONATAL JAUNDICE:

Heier HE, Fugelseth D, Lindemann R, Qvigstad E.

The present prospective study indicates that children of mothers with blood group O run a double risk of hyperbilirubinemia requiring treatment as compared to children of mothers of blood group A, and 5-10 times increased risk of needing exchange transfusion. The most frequent cause of need for exchange transfusion was ABO-incompatibility between mother and child. A positive direct ant globulin reaction in an ABO-incompatible child in need of treatment doubles the risk of exchange transfusion being required. Blood group O in the mother should be considered to be an independent risk factor for the child, and O-pregnant women should be ABO-grouped for this reason. 9

Neonatal jaundice due to ABO incompatibility in Sri Lankan.

Lucas GN.

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A prospective study was carried out on 101 neonates with jaundice due to ABO incompatibility. The direct Coomb's test was weakly positive in 4 cases. The indirect Coomb's test using the eluate was positive in 8 cases. In the maternal blood either IgG anti-A or anti-B haemolysin was present in high titer in every case. Phototherapy was given when the indirect serum bilirubin level exceeded 9 mg/dl. Exchange transfusion was done-in 39 cases, 9 babies requiring multiple exchanges. There were 2 deaths. 10

Neonatal hyperbilirubinemia following the use of oxytocin in labour.

Beazley JM, Alderman B.

A prospective study of 1353 labours and the relevant newborn failed to reveal any significant difference between the incidence of neonatal hyperbilirubinemia (defined as a level of 12 mg. or more per 100 ml.) following spontaneous labour, and after labour induced or accelerated by oxytocin. The incidence of unexplained neonatal hyperbilirubinemia after spontaneous labour was 6-3 per cent. Following induced labour however there was a highly significant (P less than 0-001) association between the mean total dose of oxytocin used for induction and the incidence of neonatal hyperbilirubinemia. The proportion of babies who developed hyperbilirubinemia increased in direct relation to the total dose of oxytocin used for the induction. In this series the incidence of hyperbilirubinemia increased sharply when the total dose of oxytocin exceeded 20 units as it did hyperbilirubinemia and birth weight, or duration of spontaneous labour. When labour was induced, however, the proportion on newborn babies with hyperbilirubinemia increased with the duration of labour. The significance of these findings is discussed. 11

ASSOCIATED FACTORS OF NEONATES AFFECTING NEONATAL JAUNDICE:

BREAST FEEDING:Brown– In her study on breast feeding and jaundice demonstrated that jaundice occurs in 50 – 75% of newborn infants and is noted to occur more frequently and with greater, severity in breastfed infants. However, despite years of investigation of this common problem, many aspects of neonatal jaundice in healthy breastfed infants remain unexplained. Knowledge of the types, pattern and causes of jaundice in healthy breastfed neonates is reviewed and the potential effect of treatment options is discussed. She concluded that practices and interventions used by health care professionals decrease the duration of breastfeeding and increase the incidence and severity of jaundice. 12

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Corchia–et al studied idiopathic hyperbilirubinemia (in Sardinian infants) in the first 4 days of life among 431 healthy full term infants with birth weight >2,500 gms. All infants were free from malformations or any disease, requiring treatment other than jaundice. They were ABO and Rh incompatible with their mothers and were not G6PD deficient. The regression analysis indicated that high alpha-fetoprotein concentrations in cord blood. History of neonatal jaundice in previous full term siblings, delayed first meconium passage and weight loss were associated with jaundice. These results suggest the high rate of constitutional and possible hereditary factors. 13

Rosenthal–et al.– assessed liver function and hyperbilirubinemia in the newborn. “Liver Function” is assessed, by either measuring the concentration of substances produced by the hepatocyte, measuring the serum content of substances that are changed by hepatocyte damage. Evaluating the serum concentrations of substances released from the cells as a result of injury, assessing the ability of the liver to perform a metabolic task such as conjugation or detoxification, or by measuring enzyme activity and substitute content of the cell and its organisms. After birth with cessation of placental functions, the neonatal liver must assume many different tasks. Distinct developmental sequences rapidly progress for numerous hepatic functions as the newborn adapts to its environment. Lastly they concluded that the manuscript is an attempt to provide guidelines for the evaluation and management of the newborn infant by assessing live function and hyperbilirubinemia. 14

Jaundice and breastfeeding.

Gartner LM, Herschel M.

Optimal management of breastfeeding does not eliminate neonatal jaundice and elevated serum bilirubin concentrations. Rather, it leads to a pattern of hyperbilirubinemia that is normal and, possibly, beneficial to infants. Excessive frequency of exaggerated jaundice in a hospital or community population of breastfed infants may be a warning that breastfeeding policies and support are not ideal for the establishment of good breastfeeding practices. The challenge to clinicians is to differentiate normal patterns of jaundice and hyperbilirubinemia from those that indicate an abnormality or place an infant at risk. 15

B Wood, P Culley, C Roginski, J Powell and J Waterhouse

Plasma bilirubin was estimated on 690 term infants on about the 6th day of life. Perinatal factors were recorded and the results analysed. Hyperbilirubinemia was defined as a level greater than 205 micromol/1 (12 mg/100 ml) and this was present in 20% of cases. Three

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factors-- epidural analgesia, breast feeding, and poor weight recovery--showed highly significant associations with jaundice. The relative importance of these is discussed and compared with recent reports. Induction of labour, for reasons other than postmaturity, and a gestational age less than 39 weeks showed a slightly increased incidence of jaundice. There was no correlation with other factors tested including oxytocin drug administration. Despite the high incidence (20%) of hyperbilirubinemia, only 2.5% infants needed treatment and none required exchange transfusion. Radical changes in obstetric management or infant feeding are not indicated. 16

TREATMENT OF THE NEONATAL JAUNDICE:

Ablfors – et al. performed a study on the criteria for exchange transfusion in jaundiced newborns, which lowers critical bilirubin concentrations when the serum albumin falls to <2.5 g/dl. This study investigates using the biirubin / albumin ration instead of the single albumin concentration eliminate this potential ambiguity in the criteria. They concluded that the bilirubin / albumin ration is a simple, non-ambiguous way of incorporating the serum albumin concentration in to exchange transfusion criteria. The bilirubin / albumin ratio was defined as a reliable indicator of bilirubin / albumin binding of the frequency curves of specific unbound bilirubin concentrations are normally distributed functions of the ratio. Therefore, the bilirubin / albumin ratios at which the unbound bilirubin reached the 10, 15 and 20 nmon/1 were determined by the peroxides method in 35 well full term, 10 ill full term and 19 ill pre term neonates. The frequency curves for each unbound bilirubin concentration was plotted against the bilirubin / albumin ratio were tested for normality. Furthermore, the mean ratio at which each unbound bilirubin occurred did not differ significantly among the groups of neonates. The author concluded that the bilirubin / albumin ratio is a simple, non-ambiguous way of incorporating the serum albumin concentration into exchange transmission criteria. 17

Rubaltelli – et al. Carried out a study on management of neonatal hyperbilirubinemia and prevention of kernicterus. Hyperbilirubinemia remains as one of the most common and more important pathological conditions in the newborn. Current methodologies for suppressing severe neonatal jaundice include; (a) attempts to stimulate liver conjugating enzymes using drugs such as Phenobarbital; (b) attempts to degrade bilirubin with phototherapy; and (c) exchange transfusion. It is too soon to consider tin-protoporphyrin as a drug for the prevention and treatment of neonatal hyperbilirubinemia. However, if it can be shown that tin-protoporphyrin can serve as a safe and less costly alternate treatment, a considerable

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improvement in the management of neonatal jaundice can be achieved. 18

Tan - et al. studied the efficacy of “high-intensity” blue-light and “standard” daylight phototherapy for non hemolytic hyperbillirubinemia. They stated that, nursing of infants under high-intensity blue light was more difficult and inconvenient as was clinical monitoring. The light also cause more stress to the nursing and medical personnel. However, the infants tolerated both types of phototherapy equally well. High-intensity blue-light phototherapy would seem to be the treatment of choice for infants with rapidly increasing or very high bilirubin levels, as well as, in those not responding adequately to daylight phototherapy. 19

And carried out a study on phototherapy and the brain-stem auditory evoked response in neonatal hyperbilirubinemia, The brain-stem auditory evoked response of infants with hyperbilirubinemia were significantly greater before phototherapy than after phototherapy. Theses values of the brain stem auditory-evoked response improved significantly during phototherapy and correlated significantly with the declining bilirubin levels. Improvement continued after phototherapy, despite a rebound of serum bilirubin concentrations. 20

Altha Roberts Edgren - Full-term infants rarely require an exchange transfusion if intense phototherapy is initiated in a timely manner. It should be considered if the total serum bilirubin level is approaching 20 mg/dL and continues to rise despite intense in-hospital phototherapy. Exchange transfusion corrects anemia associated with the destruction of red blood cells and is effective in removing sensitized red blood cells before they are destroyed. It also removes about 60 percent of bilirubin from the plasma, resulting in a clearance of about 30 percent to 40 percent of the total bilirubin. If a transfusion is not performed and bilirubin levels get higher, the infant progresses through three phases. In the first two to three days the infant is lethargic, has muscle weakness, and sucks weakly. Progression is marked by a tensing of the muscles, arching, fever, seizures, and high-pitched crying. In the final phase, the patient is hypotonic for several years. 21

THE EFFECT OF NEONATAL JAUNDICE I GROWTH AND DEVELOPMENT:

Newman – et al. examined the association between neonatal bilirubin levels and subsequent neuro developmental outcome. He carried out a study on 41, 24 singleton white or black infants with birth weight > 2.500 gms, who had neonatal bilirubin measurement recorded and survived at least 1 year. Lastly, he concluded neonatal bilirubin levels seem to have little

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effect on IQ, definite neurological abnormalities or hearing loss. Higher bilirubin levels are associated with minor motor abnormalities.

Bysshe studied deafness in childhood. In his study, he stated the risk factors for deafness are low birth weight, neonatal jaundice, family history of deafness etc.

De-Caceres – et Al. evaluated behavioral differences in healthy newborns in relationship to bilirubin serum levels within the normal physiological range. They concluded that physiological bilirubin levels cause significant neurological disturbances; these results suggest that newborns with higher physiological bilirubin levels have some difficulties interacting with their caretakers. 22

Ozmert – et al. carried out a retrospective follow up study to evaluate the suitability of the recently reported exchange transfusion limits (serum indirect bilirubin level of 428-496 mumol/1, 25-29 mg/dl) for Turkey. Children were grouped according to their maximum serum bilirubin levels and direct Coomb’s test results. Physical and neurological examinations, visual and brainstem auditory evoked potentials and the Wechsler Intelligence Scale for children were performed. They concluded that children whose direct Coomb’s tests were positive, had significantly lower IQ scores and more prominent neurological abnormalities (P<0.05). 23

6.3 OBJECTIVES OF THE STUDY:

1. To assess the associated factors for physiological and pathological Jaundice

2. To assess the growth and development of children affected by neonatal Jaundice.

3. To prepare the guidelines on neonatal jaundice, care and prevention to the mothers with special emphasis to the nurses.

4. To find out the association between the factors affecting jaundice with the impact on growth and development.

6.4 OPERATIONAL DEFINITIONS:

Neonatal jaundice is the term used when a newborn has an excessive Amount of

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bilirubin in the blood. Bilirubin is a yellowish red pigment that Is formed and released into the blood stream when red blood cells are broken down.

HYPERBILIRUBINEMIA/JAUNDICE:

Refers to increased bilirubin levels in the blood. It’s principle manifestations is a yellowish discoloration of the skin.

PHYSIOLOGICAL JAUNDICE:

This is a result of the immaturity of hepatic functions in the newborn Combined with an increased bilirubin load from pronounced hemolysis of red blood cells which causes yellowish discoloration of the skin (12-20mg/dl).

PATHOLOGICAL JAUNDICE:

This is a risk in serum bilirubin more than 20mg/dl in term weight greater than 2,500gms.

6.5 ASSUMPTIONS:

1. Any associated factors of the mother will result in increasing the bilirubin level of the neonates.

2. Any associated factors of the neonates will result increasing the bilirubin level.

3. The jaundice affecting during neonatal period will result in delayed growth and development of children.

6.6 VARIABLES UNDER STUDY:

Dependent variable: To assess the associated factors affecting neonatal jaundice.

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Independent variables:

Socio demographic variables i.e., education, occupation, income, age, sex, religion, parents age, type of marriage.

7 MATERIALS AND METHODS:

7.1 Sources of data:

Mothers having children below three years attending the out patient department at a selected hospital Kolar, will be interviewed for samples.

7.2. Methods of data collection :

7.2.1. Research design

The research design of the study is a descriptive study using the cross sectional method.

7.2.2. Setting of the study

The study will be conducted at the out patient department at a selected hospital in Kolar.

7.2.3. Population:

Children less than 3years who had suffered from neonatal jaundice and attending out patient department at a selected hospital, Kolar.

7.2.4 Sample size:

There are more than 200 hundred children attending the Out Patient Department but only 100 samples will be taken for the study.

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7.2.5Sample Technique:

Convenience sampling technique will be used to select the samples and the investigator will scrutinizes the child record, interview the mother, will assess the growth & development of children and compare them with standard scale.

7.2.6Sampling criteria

Inclusion criteria - The study includes:- Mothers giving birth to neonates with jaundice

- Mothers who have brought to OPD at selected hospital during study period- Mothers with children less than 3 years who are willing to participate- Mothers who can speak and understand local language like Kannada & Telugu

Exclusion criteria:

- Mothers who are not attending the OPD at a selected hospital - Mothers with children less than 3 years who are not willing to participate

- Children above 3 years

7.2.7 Tools:

Structure interview methodTools consists of two section

Section A - Demography Characteristics:

Consists of age, sex, religion, education, occupation, income of the family and type of marriage.

Section B:1. General Medical History of the Mother:

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Blood group, medical history and menstrual history.

2. Antenatal History:

Antepartum hemorrhage, diabetes, drugs, hyperemesis, hypertension, infections, nutritional deficiency, trauma, blood transfusions.

3. Previous obstetric History:

Abortion, still birth, neonatal death and sibling history.

4. Natal and neonatal history:Place of delivery, order of birth, induction of labour, birth cry and asphyxia, breast feeding, meconium passed, neonatal seizure, treatment for jaundice baby.

Section C - Development Assessment:Trivandrum development screening chart and Denver developmental screening test and Anthropometric measurement.

7.2.8 Method of data collectionIn the sample selection procedure, a non randomized convenience sampling technique will be used to select the sample. The mother will be briefed about the purpose of interview schedule to sort there co-operation during the study.

7.2.9 Data analysis and interpretationDescriptive statistical method and chi – square will be used to determine the association between the variables for data analysis and will be presented in the form of tables, diagrams and graphs

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7.3 Does the study require any investigation or intervention to be conducted from patients or other people or animals if so please describe briefly.

The study is going to be conducted on a mother who is having children less than 3 years. Since it is a descriptive study, the study does not require intervention.

7.4 Has ethical clearance been obtained from concerned authorities

Prior to the study, permission will be obtained from the concerned authorities to conduct the study and also from research committee of Pavan College of Nursing, Kolar. The purpose of the study will be explained to the respondents.

8. References:

1. International Programs Center, U.S. Census Bureau, the total population of the World, projected to 11/28/07 at 19:04 GMT (EST+5) 2007

2. Whaley and Wong: Nursing care of infants and children, C.V Mosby company, St.Louis, 1979.P.153-160

3. Maisels, M. Jeffrey, and Jon F. Watchko, eds. Neonatal Jaundice. Amsterdam: Harwood Academic, 2000.

4. Behrman, Richard K. et at, Nelson text book of Paediatrics, Ed.12, W.B Saundens Company, Philadelphia, 1983, P. 177-180

5. Newman TB, Paediatrics, Standard recommendation for evaluating and treating jaundice in term babies. 1992 May: 89 (5Pt 1): 809-18. Arch Dermatol. 2007

Sep;143(9):1216; author reply 1216-7. No abstract available. PMID: 17875896 [PubMed -

6. Blackmon, Lillian R., et al. "Research on Prevention of Bilirubin-Induced Brain Injury and Kernicterus: National Institute of Child Health and Human Development Conference Executive Summary." Pediatrics 114, no. 1 (July 2004): 229.

7. Suraj Gupta, the short text book of Paediatrics, 9 Millennium Ed 2001. P, 27 to 50

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8. Dorothy R. Marlow, et a. Text book of Pediatrics Nursing, B.B. Saunders international edition, both edition, 2005.P.415-420

9. Heier HE Fugelseth D, Lindemanna R, 2007 Blood Bank of Immunologic Blodbank og immunologisk avdeling, maternal blood group O as a risk factor for hyperbilirubinemia requiring treatment 1996 Jan 10;116(34)6

10.Lucas GN Lady Ridgeway Hospital for Children, Colombo, Sri Lanka. A study on ABO incompatibility PMID: 10830015 {PubMed – indexed for MELINE}

11.Beachy JM, Neonatal Netw. 2007 Sep-Oct;26(5):327-33. Review. No abstract available. PMID: 17926661 [PubMed - indexed for MEDLINE]

12.Brown Journal of Obstetrics Gynaecology Jaundice Clinical Practice 1997 Aug 213.Chen-JY et al. American journal of perinatal, Early meconium evacuation; effect on

neonatal hyperbilirubinemia. 1995 July 12 (4): 232-Y. 14.Corchia C Sanna MC; et al. “Paediactric and perinatal epidemiology” Idiopathic jaundice

Sardinian full-term newborn infants; a multivariate study, 1993 Jan 7(1)55-66.15.Rosenthal P. Clinical chemistry, assessing liver function and hyperbilirubinemia in the

newborn. 1997 Jan.: 43(1):220-3416.Gartner LM Herschel M. Department of Pediatrics, Obstetrics and Gunecology,

University of Chicago, Chicago, Illinois, USA, gart@midway.uchicago.edu17.B Wood, P culley, C Roginski, J Powell and J Waterhouse, Factors affecting neonatal

jaundice (pubmed.com)18.Rubaltelli FF. et al. Drugs – Management of neonatal hyperbilirubinemia and prevention

of Kernicterus, 1992 June, 43(6): 864-72.19.Bennett et al. Myles text book for midwives, Ed. 11 E.11 E.L.B.S. Churchill Livingstone,

1989. P. 541-55120.Tan KL – Acta paediatrics, Efficacy of high intensity, blue light and standard daylight

phototherapy for non-hemolytic hyperbilirubinemia, 1992 Nov.81(11) 870-421.Altha Roberts Edgren, criteria for exchange transfusion in jaundiced newborns. 1997

Mar. 93(3) 488-9422.De-caceres Y. et al. An ESP paediatrics, physiologic level of bilirubin and behaviors in

healthy infants during the neonatal period. 1992 Dec.: 37(5): 466.8.23.Ozmert-E, et al. Acta paediatrics – Long term – followup of indirect hyperbrilirubinemia

in full term Turkish infants – 1996 Dec. 1440-4

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