Why is kernicterus still a major cause of deathand disability in low-income and middle-incomecountries?Bolajoko O Olusanya,1 Tinuade A Ogunlesi,2 Tina M Slusher3

▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/archdischild-2013-305506).1Centre for Healthy StartInitiative, Ikoyi, Lagos, Nigeria2Department of Paediatrics,Olabisi Onabanjo UniversityTeaching Hospital, Sagamu,Nigeria3Department of Pediatrics,University of Minnesota &Hennepin County MedicalCenter, Minneapolis,Minnesota, USA

Correspondence toDr Bolajoko O Olusanya,Centre for Healthy StartInitiative, 286A CorporationDrive, Dolphin Estate, Ikoyi,P.O. Box 75130 VI,Lagos, Nigeria;boolusanya@aol.com,bolajoko.olusanya@uclmail.net

Received 9 February 2014Revised 17 June 2014Accepted 29 July 2014Published Online First14 August 2014

To cite: Olusanya BO,Ogunlesi TA, Slusher TM.Arch Dis Child2014;99:1117–1121.

ABSTRACTNeonatal jaundice is predominantly a benign conditionthat affects 60%–80% of newborns worldwide butprogresses to potentially harmful severehyperbilirubinaemia in some. Despite the proventherapeutic benefits of phototherapy for preventingextreme hyperbilirubinaemia, acute bilirubinencephalopathy or kernicterus, several low-income andmiddle-income countries (LMIC) continue to report highrates of avoidable exchange transfusions, as well asbilirubin-induced mortality and neurodevelopmentaldisorders. Considering the critical role of appropriatetiming in treatment effectiveness, this review set out toexamine the contributory factors to the burden of severehyperbilirubinaemia and kernicterus based on the ‘threedelays model’ described by Thaddeus and Maine in the91 most economically disadvantaged LMICs with GrossNational Income per capita ≤US$6000 and medianhuman development index of 0.525 (IQR: 0.436–0.632).Strategies for addressing these delays are proposedincluding the need for clinical and public healthleadership to curtail the risk and burden of kernicterusin LMICs.

INTRODUCTIONSevere neonatal jaundice or hyperbilirubinaemiaremains the most common cause of morbidity inthe first week of life, affecting 60%–80% of new-borns worldwide.1 2 The incidence of severe hyper-bilirubinaemia in industrialised countries based onobjective assessment of bilirubin levels ranges from2.0 to 45 per 100 000 live births and of acute bili-rubin encephalopathy (ABE)/kernicterus from 0.4to 2.7.3 4 Unfortunately, similar estimates usingpopulation-based data are lacking in low-incomeand middle-income countries (LMIC) as severity ofhyperbilirubinaemia is commonly based on clinicaljudgement and the need for phototherapy and/orexchange transfusion.5 However, the burden ofsevere hyperbilirubinaemia is commonly projectedto be significantly higher due to the prevalence ofaetiological/risk factors, such as glucose-6-phosphate dehydrogenase (G6PD) deficiency, bloodgroup incompatibilities, low birth weight/prematur-ity and sepsis/meningitis.6–9 For example, a recentreport on the global burden of hyperbilirubinaemiaspearheaded by the Child Health EpidemiologyReference Group suggests that sub-Saharan Africaand South Asia are the leading contributors to anestimated 1.1 million babies who would developsevere hyperbilirubinaemia worldwide every year.8

Additionally, several hospital-based studies consist-ently report substantially higher rates of exchange

transfusion and bilirubin-induced neurological dys-functions (ABE/kernicterus) than reported in devel-oped countries.10–12 It is, therefore, not surprisingthat bilirubin-induced mortality11–16 and neuro-logical disorders, such as auditory deficits, cerebralpalsy, autistic spectrum disorders, epilepsy andgeneral developmental delays secondary to ABE/kernicterus,17–20 are commonly reported in theregion (see web table 1).The onset of severe hyperbilirubinaemia in the

vast majority of infants worldwide occurs outsidehospitals. Whereas the inability to identify andmanage at-risk infants prior to hospital discharge ina timely manner is often cited as the major rootcause of adverse outcomes in developed coun-tries,21 the high proportion of non-institutionaliseddelivery in residential or traditional maternityhomes in the vast majority of LMICs suggests thatthe contributory factors are likely to transcendsystems failure. For example, while phototherapyand/or exchange transfusion are proven treatmentsto prevent or treat ABE and kernicterus worldwide,high rates of adverse outcomes among infantstreated with phototherapy and/or exchange transfu-sion are not uncommon,22 underscoring the poten-tial role of appropriate timing for the effectivetreatment of the affected infants.11–14 We, there-fore, set out to explore the available evidence inthe literature on the care-seeking pathways forinfants with neonatal jaundice in LMICs based onthe conceptual framework proposed by Thaddeusand Maine23 which focuses on three phases ofdelay: the decision to seek appropriate care, reach-ing an appropriate health facility and receivingadequate/appropriate care.

PATHWAYS TO THE CARE OF JAUNDICEDINFANTS IN LMICSEligible focus countries and literature searchstrategyIn view of the wide variation in income distributionand developmental status among approximately140 countries classified as LMICs by the WorldBank, we selected the 91 countries with GrossNational Income per capita of ≤US$6000 using theHuman Development Report 2013 published byUnited Nations Development Programme in orderto focus on the most disadvantageous LMICs (seeonline supplementary appendix 1 and the box 1).24

An extensive literature search of publicationsbetween 1970 and 2013 was conducted to identifythe range of issues directly or indirectly related tothe three phases of delay as reported in the eligiblecountries. The search terms ‘neonatal jaundice’ OR

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‘neonatal hyperbilirubinaemia’ AND ‘country name’ wasapplied to PubMed, Scopus, Ovid EMBASE, Cumulative Indexto Nursing and Allied Health Literature, WHO LibraryDatabase, African Index Medicus and African Journals Online.The key findings which may vary in scope across the countriesare summarised in figure 1.

Delay in seeking appropriate care (phase 1)Delay in seeking care promptly for newborn illness as a majorcontributor to adverse neonatal outcomes is well documented.25

The leading causes of such delays for infants with neonataljaundice include late or failed recognition of the onset of severejaundice, poor perception of the severity, recourse to self-medication as well as financial or sociocultural barriers.11–13 26–30

Several studies suggest, more commonly among multiparous

mothers, a high level of awareness and recognition of neonataljaundice typically from the yellowish discolouration of thebaby’s skin, sclera and mucous membranes.13 26 However, poorknowledge of the risks and dangers inherent in severe newbornjaundice, the temptation from prior experience to presume thatall jaundice is physiological, or inappropriate advice from healthworkers often account for delay in taking prompt action.13 28 29

In some cultures, mothers may also be reluctant to leave homebefore the traditional naming ceremony typically from the 8thday of delivery. Frequently, they only begin to worry when theirbabies become unusually lethargic, irritable and restless bywhich time neurological damage would have occurred.12 26 It isnot uncommon also for mothers to resort to self-medicationwith antibiotics, vitamins or various traditional therapies includ-ing herbal preparations and exposure to direct sunlight as first-line treatment.13 26–28 For example, in one survey enquiringknowledge of possible treatment options for jaundice amongmothers, exposure to sunlight by mothers was cited by abouthalf (51%), giving glucose drinks to the baby by 27% and useof oral antibiotics by 23% of the respondents.27 It is only whenthese efforts prove ineffective that frantic attempts are made toseek medical attention. This sequential health-seeking practiceresults in significant delays to hospital presentation, oftennecessitating emergency treatment with exchange transfu-sions.11–13 25 26

Delay in presenting at ‘appropriate’ health facility (phase 2)In general, when mothers choose to seek care outside theirhomes, they may be constrained by difficulties with accessibilityto health facilities and/or finances or identifying an ‘appropriate’hospital that routinely admits and provides essential care forsick babies.13 25 It is, therefore, not uncommon for suchmothers to present first to the nearest primary health centres/local private clinics most of which are ill-equipped to providespecial care for neonates. As typified in one study from Egypt,the mothers of 109 (83.8%) of 130 severely jaundiced out-borninfants admitted to the university children’s hospital earliersought medical attention at local clinics, during which only 28infants had serum bilirubin ordered.13 At these clinics, 87mothers (79.8%) were advised by doctors to ‘place the infantunder neon light’ at home, 75 were advised to supplementbreastfeeding with herbal infusions or formula milk and 15infants were prescribed a variety of medications, including vita-mins. In 22 cases, doctors immediately referred the infants to ahospital; despite that, parents of nine of these infants took no

Box 1 Profile of eligible low-income and middle-incomecountries used for this review

The Human Development Report 2013, published by UnitedNations Development Programme, presents country rankingsusing a Human Development Index (HDI), a robust compositemeasure of the average achievement in three basic dimensionsof human development namely: a long and healthy life (health),knowledge (education) and a decent standard of living(income). The eligible 91 countries account for 64.2% of thetotal annual live births of roughly 135 million globally, havemedian institutionalised delivery of 65% (IQR: 43.8%–82.8%)and a median HDI of 0.525 (IQR: 0.436–0.632) compared with0.878 (IQR: 0.825–0.878) for the 50 most developed countries.By world regions, 42 (46%) countries are from sub-SaharanAfrica (SSA), 18 (20%) from East Asia & Pacific (EAP), 10 (11%)from Latin America & Caribbean (LAC), 8 (9%) from Middle East& North Africa (MEN), 7 (8%) from South Asia (SOA) and 6(6%) from Europe & Central Asia (ECA). Urbanised populationaverages 27% in SOA, 36% in SSA, 37% in EAP, 44% in ECA,52% in MEN and 56% in LAC. It ranges from 11% in Burundito 83% in Jordan. About a third (33 countries) have at least halfa million live births annually accounting for over half (58%) ofglobal births and with a median institutionalised delivery rate of47% (IQR: 35%–65%). Some 65 countries are within thetropical zone.

Figure 1 Phases of delay in the management of neonatal hyperbilirubinaemia in low-income and middle-income countries.

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action until the babies became lethargic. At the time of hospitalarrival, parents of 41 infants had already gone to 2–3 hospitalsin search of available or affordable phototherapy with sometravelling >5 h before locating the university hospital. Anotherstudy also found that over 25% of community health workers atprimary care centres were likely to prescribe antibiotics, natural(direct sunlight) phototherapy or herbal therapies.29 Mothers inrural communities also consult traditional healers who prescribevarious herbal preparations for treating jaundice.30

Delay in receiving appropriate and adequate care at‘appropriate’ health facility (phase 3)The lack of local practice guidelines for the management ofjaundice and tools for real-time objective measurement/monitor-ing of bilirubin levels is common. These often prompt over-reliance by hospital personnel on visual assessment of the cepha-locaudal progression or ominous signs of ABE/kernicterus par-ticularly among out-born infants. Similarly, laboratoryinvestigations to rule out possible risk factors like G6PD defi-ciency, ABO and Rhesus incompatibilities are not available rou-tinely.6 31 Where such facilities are available, the turn-aroundtime in obtaining results for prompt clinical decision is usuallyunhelpful. Many studies from India, Nigeria and Cameroun alsoexemplify the widespread problem of suboptimal phototherapyemissions well below therapeutic range in most secondary andtertiary hospitals in LMICs.32–34 The ideal first-line treatmentwith conventional blue-light phototherapy requires light emis-sion spectrum within the bilirubin absorption spectrum of 400–520 nm (peak 450±20 nm); irradiance level ≥30 μW/cm2/nm,exposed to ∼80% of an infant’s body surface area; and opti-mised duration of exposure.35 However, in one study fromNigeria, the majority (94%) of 63 phototherapy devices tested in12 referral-level hospitals delivered irradiances of ≤10 μW/cm2/nm and none were ≥30 μW/cm2/nm.32 Many hospitals also haveto contend with erratic power supply and frequent breakdownsdue to poor device maintenance.11 Valuable time is, therefore,often lost exposing infants to prolonged ineffective phototherapyleading to exchange transfusion. Such system failures and latepresentation account for high rates of avoidable exchange trans-fusion with its attendant risks and potential complications.11 12 36

Another important but less common cause of delay is occasionalrefusal by parents to accept clinically indicated exchange transfu-sion for their babies for religious reasons.11

Additionally, despite the high risk of neurodevelopmentalimpairments among infants treated for severe hyperbilirubinae-mia, routine monitoring of affected infants for these long-termsequelae is rarely practiced in most LMICs.20 37 Establishedscreening programmes for early detection of hearing deficits aswell as other neurological deficits are uncommon for reasons ofdearth of skilled personnel, paucity of appropriate equipmentand poor awareness. The delay in the initiation of appropriaterehabilitative measures thus exacerbates the burden of severehyperbilirubinaemia for the surviving infants and their families,especially in communities with unfavourable cultural dispositionto child disability.

IMPROVING THE CARE OF INFANTS WITH OR AT RISK OFSEVERE HYPERBILIRUBINAEMIAAddressing all the wide range of potential risk factors associatedwith severe hyperbilirubinaemia is unquestionably a dauntingchallenge for most LMICs already beleaguered with several fataland communicable diseases. The main thrust of interventions tocurtail the burden of neonatal jaundice must be twofold: first,to identify infants with the most prevalent and readily

detectable risk factors and second, to eliminate, or reduce to thebarest minimum, avoidable delays to effective recognition,timely detection, presentation and treatment of infants at risk ofsevere hyperbilirubinaemia at appropriate health facilities. Sincemothers and other caregivers are often the first to come incontact with infants with jaundice, routine antenatal and predis-charge counselling on avoidance of domestic haemolytic agentsand the value of early recognition of jaundice should be activelypromoted. This is especially important because recognition ofillness is often defined by the patient’s view/perception of realitywhich may be discordant with the health professional’s medicalcriteria.23 Thus, it is important to foster closer collaborationbetween paediatricians and their obstetric and primary care col-leagues for this purpose. Health education of expectant mothersmust be complemented with the training and re-training ofhealth workers on the principles and value of timely recogni-tion, prevention and management of neonatal jaundice.Professionally led national initiatives on the control of severeneonatal jaundice similar to the existing ‘Helping BabiesBreathe’ programme would be valuable in this respect.

The perceived benefits of traditional health providers cannot bedismissed outright, as some mothers may rely on testimonials ofprior ‘success’ stories related possibly to physiological jaundice.Visual presentation of well-documented cases of mismanagedsevere jaundice resulting in neonatal deaths or physical disability isa powerful educational tool to emphasise the potential dangers ofrecourse to inappropriate health facilities and the importance oftimely appropriate treatment. Unfortunately, it is quite challengingfor mothers to identify private clinics or primary care centres/hos-pitals adequately resourced to provide requisite treatment. It is,therefore, necessary to disseminate information about appropriatecentres/hospitals for managing severe hyperbilirubinaemia in eachlocality. Provision of emergency ambulance services and commu-nity loan funds to address accessibility and financial constraints arealso worth considering.25

Failure to offer appropriate treatment when infants arepresent at secondary/tertiary hospitals that routinely admit sickbabies undermines the credibility of the entire health system andfosters future reluctance and significant delay in seeking helpfrom these facilities. It also encourages recourse to unorthodoxmedicine. The need to provide health workers with the requisitetraining and tools for effective management of infants with or atrisk for severe hyperbilirubinaemia cannot be overemphasised.The strategic goal in every hospital is to eliminate or curtail theneed for exchange transfusion through timely and effectivephototherapy. And when exchange transfusion is inevitable, itmust be provided promptly and safely to prevent or treat ABE/kernicterus. The cost of providing intensive/special care forjaundiced newborns could be prohibitive and, perhaps, nextonly to that of caring for preterm babies in LMICs.38 39 Thedevelopment of affordable phototherapy devices, as well assimple inexpensive adjustments to devices, such as hangingwhite curtains around units, changing bulbs periodically andoptimising the distance between baby and lamps are effective inimproving the quality of care and should be widelypromoted.33 40

Common practice guidelines for neonatal jaundice do notsupport use of direct exposure to sunlight primarily due tosafety concerns regarding potentially harmful infrared and ultra-violet rays and possible sunburn.9 41 42 But, mothers/caregiverswith or without the support of health workers continue toexpose their jaundiced babies to direct sunlight,27 28 even indeveloped countries.43–45 Following the successful piloting offiltered sunlight phototherapy for safety and efficacy, a clinical

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trial is currently ongoing to compare the effectiveness of thisnovel intervention with conventional blue-light phototherapy.46

This low-cost technology holds promise especially in tropicalLMICs where the application of conventional phototherapy isconstrained by costs and exogenous factors outside the controlof the health system. Also promising is the emerging low-cost,minimally invasive, point-of-care tools for plasma/serum biliru-bin monitoring.47 Pharmacotherapies, such as metalloporhyrinsand clofibrate, also hold promise as potential low-cost treat-ments. However, the available evidence is still quite limited tojustify their routine application presently. Crucially, develop-mental surveillance including objective hearing evaluationshould be considered routinely for infants treated for severehyperbilirubinaemia. Local adaptation of guidelines in the devel-oped world,9 41 including WHO Handbook for HospitalCare,48 may serve as a possible take-off point for the develop-ment of relevant algorithms for the optimal management ofsevere hyperbilirubinaemia as exemplified in someLMICs.40 49 50 Overall, policy, public health and clinical leader-ship are urgently needed to comprehensively address the rangeof issues required to effectively curtail the burden of severehyperbilirubinaemia and kernicterus in LMICs.

CONCLUSION AND WAY FORWARDSevere hyperbilirubinaemia portends significant risks of avoid-able mortality and severe long-term neurodevelopmental seque-lae in LMICs. The burden is likely to be exacerbated by lack ofpoor or timely access to proven therapies that are taken forgranted in the developed world. International collaborations areimperative for improved epidemiological data to address theinherent limitations in most of the available research and for thedevelopment of affordable and effective technologies for man-aging hyperbilirubinaemia. Each country must target effortstowards improved public and maternal/antenatal education onthe potential dangers of severe neonatal jaundice, timely detec-tion of high-risk infants, adequate resourcing of special carebaby units in all referral-level hospitals, as well as the develop-ment and active promotion of pragmatic and contextually rele-vant clinical practice guidelines.

Acknowledgements We thank Jon F Watchko, Yvonne E Vaucher and Ashok KDeorari for valuable comments made on earlier drafts of this paper.

Contributors BOO conceptualised the paper and wrote the first draft withcontributions from TAO and TMS. All authors participated in the literature search,selection and review; critically reviewed the manuscript for intellectual content andapproved the submitted version.

Competing interests None.

Provenance and peer review Commissioned; internally peer reviewed.

Data sharing statement Human Development Report 2013, UNDP, New York,2013; The State of the world’s children 2013, UNICEF, New York, 2013.

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middle-income countries?death and disability in low-income and Why is kernicterus still a major cause of

Bolajoko O Olusanya, Tinuade A Ogunlesi and Tina M Slusher

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1  

Web Table 1. Mortality and neurodevelopmental outcomes in infants with severe neonatal hyperbilirubinaemia in LMICs

SN Studies Country Adverse outcome(s)

1. Rasul CH, Hasan MA, Yasmin F. Outcome of neonatal hyperbilirubinemia in a tertiary care hospital in Bangladesh. Malays J Med Sci 2010;17:40-4.

Bangladesh Mortality

2. Islam MN, Siddika M, Hossain MA, Bhuiyan MK, Ali MA. Morbidity pattern and mortality of neonates admitted in a tertiary level teaching hospital in Bangladesh. Mymensingh Med J. 2010;19:159-62.

Bangladesh Mortality 

3. Iskander I, Gamaleldin R, Kabbani M. Root causes for late presentation of severe neonatal hyperbilirubinaemia in Egypt. East Mediterr Health J 2012;8:882-7.

Egypt Mortality

4. Welbeck J, Biritwum RB, Mensah G. Factors affecting the survival of the "at risk" newborn at Korle Bu Teaching Hospital, Accra, Ghana. West Afr J Med 2003;22:55-8.

Ghana Mortality 

5. Dutta D, Bhattacharya MK, Bhattacharya SK, et al. Influence of admission weight on neonatal mortality amongst hospitalised neonates in Calcutta. J Indian Med Assoc 1992;90:308-9.

India Mortality 

6. Bose A, Sinha S, Choudhary N, Aruldas K, Moses PD, Joseph A. Experiences of neonatal care in a secondary level hospital. Indian Pediatr. 1999;36:802-806.

India Mortality 

7. Singhal PK, Singh M, Paul VK, Deorari AK, Ghorpade MG. Spectrum of neonatal hyperbilirubinemia: an analysis of 454 cases. Indian Pediatr 1992;29:319-325.

India Mortality

8. Hameed NN, Na' Ma AM, Vilms R, Bhutani VK. Severe neonatal hyperbilirubinaemia and adverse short-term consequences in Baghdad, Iraq. Neonatology 2011;100:57-63.

Iraq Mortality

9. Mwaniki MK, Gatakaa HW, Mturi FN, et al. An increase in the burden of neonatal admissions to a rural district hospital in Kenya over 19 years. BMC Public Health 2010;10:591.

Kenya Mortality 

10. Turner C, Carrara V, Aye Mya Thein N, Chit Mo Mo Win N, Turner P, Bancone G, White NJ, McGready R, Nosten F. Neonatal Intensive Care in a Karen Refugee Camp: A 4 Year Descriptive Study. PLoS ONE 2013;8:e72721.

Myanmar Mortality 

11. Nepal D, Banstola D, Khakal AK, Mishra U, Maheseth C. Clinico-Laboratory Profile and Immediate Outcomes of Hyperbilirubinemic Babies Admitted in Kanti Children Hospital. J Nepal Paediatr Soc 2010;30:31-6

Nepal Mortality

12. Shehu UA, Hassan-Hanga F, Ibrahim M. Morbidity amd mortality pattern among 3869 consecutive admissions at Aminu Kano Teaching Hospital, Kano. Niger J Paediatr 2008;35:67-74.

Nigeria Mortality

13. Ogunlesi TA, Dedeke IO, Adekanmbi AF, Fetuga MB, Ogunfowora OB. The incidence and outcome of bilirubin encephalopathy in Nigeria: a bi-centre study. Niger J Med 2007;16:354-9.

Nigeria Mortality, Cerebral palsy, hearing impairment

14. Ahmed H, Yukubu AM, Hendrickse RG. Neonatal jaundice in Zaria, Nigeria—a second prospective study. West Afr J Med 1995;14:15-23.

Nigeria Mortality

2  

15. Ezeaka VC, Ogunbase OA, Awogbemi OT, Grange AO. Why Our Chlldren Die: A Review of Paediatric Mortality in a Tertiary Centre in Lagos, Nigeria. Nig Qtr J Hosp Med 2003;13:17-21.

Nigeria Mortality

16. Ibekwe RC, Ibekwe MU, Muoneke VU. Outcome of exchange blood transfusions done for neonatal jaundice in Abakaliki, South eastern Nigeria. J Clin Neonatol 2012;1:34-7.

Nigeria Mortality

17. Fajolu IB, Egri-Okwaji MTC. Childhood mortality in children emergency centre of the Lagos University Teaching hospital. Niger J Paediatr 2011;38:131-135.

Nigeria Mortality 

18. Iliyasu A, Abubakar IS, Gajida AU. Magnitude and leading causes of in-hospital mortality at Aminu Kano Teaching Hospital, Kano, northern Nigeria: A 4-year prospective analysis. Niger J Med. 2009;19:400-6.

Nigeria Mortality 

19. Okechukwu A, Achonwa A. Morbidity and mortality patterns of admissions into the special care baby unit of University of Abuja Teaching Hospital. Niger J Clin Pract 2009;4:389-94.

Nigeria Mortality 

20. Ojukwu JU, Ogbu CN. Analysis and outcome of admissions in the special care baby unit of the Ebonyi State University Teaching Hospital, Abakaliki. J Coll Med; 2004.9: 2, 93-96.

Nigeria Mortality 

21. Omoigberale AI, Sadoh WE, Nwaneri DU. A 4 Year Review of Neonatal Outcome at the University of Benin Teaching Hospital, Benin City. Niger J Clin Pract 2010;13:321-325.

Nigeria Mortality 

22. Owa JA, Osinaike AI. Neonatal morbidity and mortality in Nigeria. Indian J Pediatr. 1998;65(3):441-449. Nigeria Mortality 

23. Udo JJ, Anah MU, Ochigbo SO, Etuk IS, Ekanem AD. Neonatal Morbidity and Mortality in Calabar, Nigeria: A Hospital-Based Study. Niger J Clin Pract. 2008;11:285-289.

Nigeria Mortality 

24. Ibrahim I, Udomah MG and Adbulwahab I. Infant Mortality at Usmanu Danfodiyo University Teaching Hospital, Sokoto. Niger J Paediatr 1993;20:17-20.

Nigeria  Mortality

25. Adebami OJ, Joel-Medewase VI, Oyedji OA, Oyedeji GA. A review of Neonatal Admissions in Osogbo Southwestern, Nigeria. Niger Hosp Pract. 2010;5:36-41.

Nigeria  Mortality

26. Eneh AU, Oruamabo RS. Neonatal jaundice in a Special Care Baby Unit (SCBU) in Port Harcourt, Nigeria: a prospective study. Port Harcourt Med J 2008;2:110-7.

Nigeria  Mortality

27. Ayoola OO, Orimadegun AE, Akinsola AK, Osinusi K. A five-year review of childhood mortality at the University College Hospital, Ibadan. West Afr J Med 2005;24:175-9.

Nigeria  Mortality

28. Israel-Aina YT, Omoigberale AI. Risk factors for neonatal jaundice in babies presenting at the University of Benin Teaching Hospital, Benin City. Niger J Paediatr 2012;39:159-63.

Nigeria  Mortality

29. Onyearugha CN, Onyire BN, Ugboma HAA. Neonatal jaundice: prevalence and associated factors as seen in Federal Medical Centre Abakaliki, Southeast Nigeria. J Clin Med Res 2011;3:40-45.

Nigeria  Mortality

30. Effiong CE, Aimaku VE, Bienzle U, Oyedeji GA, Ikpe DE. Neonatal jaundice in Ibadan. Incidence and etiologic factors in babies born in hospital. J Natl Med Assoc 1975;67:208-13.

Nigeria  Mortality

3  

31. Udoma EJ, Udo JJ, Etuk SJ, Duke ES. Morbidity and Mortality among Infants with Normal Birthweight in a New Born Baby Unit. Niger J Paediatr 2001;28:13-17.

Nigeria  Mortality

32. Khan QA, Iqbal H, Rehman HU. Pattern of neonatal diseases in special care baby unit (SCBU) Khyber Teaching Hospital, Peshawar. Pakistan Paediatr J 2011:35:149-53.

Pakistan Mortality

33. Jimmy S, Kemiki AD, Vince JD. Neonatal outcome at Modilon Hospital, Madang: a 5-year review. P N G Med J 2003;46:8-15.

Papua New Guinea

Mortality

34. Brown N. How should very low birthweight babies best be managed in Papua New Guinea? P N G Med J. 1996;39:12-5.

Papua New Guinea

Mortality 

35. Imbert P, Burguet A, Teyssier J. Neonatal mortality factors at the Dakar General Hospital. Medecine Tropicale 1988; 48:33-38.

Senegal Mortality 

36. Mmbaga BT, Lie RT, Olomi R, Mahande MJ, Kvåle G, Daltveit AK. Cause-specific neonatal mortality in a neonatal care unit in Northern Tanzania: a registry based cohort study. BMC Pediatrics 2012;12:116

Tanzania Mortality 

37. Suvanand S, Kapoor SK, Reddaiah VP, Singh U, Sundaram KR. Risk factors for cerebral palsy. Indian J Pediatr 1997;64:677-85.

India Cerebral palsy

38. Hassan KH. Cerebral palsy among Kurdish children in the city of Dohuk: A case-series study. Jordan Med J 2009;43:205-11.

Iraq Cerebral palsy

39. Okike CO, Onyire BN, Ezeonu CT, Agumadu HU, Adeniran KA, Manyike PC. Cerebral palsy among children seen in the neurology clinic of Federal Medical Centre (FMC), Asaba. J Community Health 2013;38:257-60.

Nigeria Cerebral palsy

40. Ogunlesi, T., Ogundeyi, M., Adekanmbi, F., Fatuga, B., Ogunfowora, O., & Olowu, A. Socio-clinical issues in cerebral palsy in Sagamu, Nigeria. South Afr J Child Health 2008;3:50–8.

Nigeria Cerebral palsy

41. Aronu AE, Ibekwe RC, Ojinnaka NC. Epilepsy in Nigerian children with cerebral palsy in Enugu. J Pediatr Neurol 2013;11:23–27

Nigeria Cerebral palsy

42. Belonwu RO, Gwarzo GD, Adeleke SI. Cerebral palsy in Kano, Nigeria--a review. Niger J Med 2009;18:186-9. Nigeria Cerebral palsy

43. Frank-Briggs AI, Alikor EAD. Sociocultural issues and causes of cerebral palsy in Port Harcourt, Nigeria. Niger J Paediatr 2011;38:115-9.

Nigeria  Cerebral palsy

44. Saluja S, Agarwal A, Kler N, Amin S. Auditory neuropathy spectrum disorder in late preterm and term infants with severe jaundice. Int J Pediatr Otorhinolaryngol 2010;74:1292-7.

India Auditory neuropathy spectrum disorder

45. Sharma P, Chhangani NP, Meena KR, Jora R, Sharma N, Gupta BD. Brainstem evoked response audiometry (BAER) in neonates with hyperbilirubinemia. Indian J Pediatr 2006;73:413-6.

India Hearing impairment

46. Sharma P, Chhangani NP, Meena KR, Jora R, Sharma N, Gupta BD. Brainstem evoked response audiometry (BAER) in neonates with hyperbilirubinemia. Indian J Pediatr 2006;73:413-6.

India Hearing impairment

4  

47. Attias J, Al-Masri M, Abukader L, Cohen G, Merlov P, Pratt H, Othman-Jebara R, Aber P, Raad F, Noyek A. The prevalence of congenital and early-onset hearing loss in Jordanian and Israeli infants. Int J Audiol 2006;45:528-36.

Jordan Hearing impairment

48. Somefun OA, Lesi FE, Danfulani MA, Olusanya BO. Communication disorders in Nigerian children. Int J Pediatr Otorhinolaryngol 2006;70:697-702.

Nigeria  Hearing impairment & Communication disorders

49. Olusanya BO, Okolo AA. Adverse perinatal conditions in hearing-impaired children in a developing country. Paediatr Perinat Epidemiol 2006;20:366-71.

Nigeria  Hearing impairment

50. Olusanya BO, Somefun AO. Sensorineural hearing loss in infants with neonatal jaundice in a developing country: a community-based study. Ann Trop Paediatr. 2009;29:119-28.

Nigeria Hearing impairment

51. Coly PI, Moreau JC, Tending G, Diouf A, Diop EM, Diadhiou F, Diop LS. Test for detection of deafness in newborns at risk. Apropos of 1048 tests. Dakar Med J 1993;38:133-137.

Senegal Hearing impairment

52. Ogunrin OA, Adeyekun A, Adudu P. Etiologies of epilepsy and health-seeking itinerary of patients with epilepsy in a resource poor setting: analysis of 342 Nigerian Africans. Seizure 2013;22:572-6.

Nigeria Epilepsy

53. Mamidala MP, Polinedi A, P T V PK, Rajesh N, Vallamkonda OR, Udani V, Singhal N, Rajesh V. Prenatal, perinatal and neonatal risk factors of Autism Spectrum Disorder: a comprehensive epidemiological assessment from India. Res Dev Disabil. 2013;34:3004-13.

India Autism

54. Alao MJ, Ayivi B, Lacombe D. Management of Children with Intellectual and Developmental Disability in an African Setting. In Tan U (Ed.): Latest Findings in Intellectual and Developmental Disabilities Research, 2012. [Available from: http://www.intechopen.com/books/latest-findings-in-intellectual-and-developmental-disabilitiesresearch/management-of-children-with-intellectual-and-developmental-disability-in-an-african-setting].

Benin Intellectual & developmental disabilities

55. Arun Babu T, Bhat B V, Joseph NM. Association between peak serum bilirubin and neurodevelopmental outcomes in term babies with hyperbilirubinemia. Indian J Pediatr 2012;79:202-6.

India Neurodevelopmental disabilities

56. Mukhopadhyay K, Chowdhary G, Singh P, Kumar P, Narang A. Neurodevelopmental outcome of acute bilirubin encephalopathy. J Trop Pediatr 2010;56:333-6.

India Neurodevelopmental disabilities

57. Gordon AL, English M, Tumaini Dzombo J, Karisa M, Newton CR. Neurological and developmental outcome of neonatal jaundice and sepsis in rural Kenya. Trop Med Int Health 2005;10:1114-20.

Kenya Neurodevelopmental disabilities

58. Adebami OJ, Onigbinde OM, Joel-Medewase V, Oyedeji AG, Afolabi AA. Neurological disorders among children in Osogbo, southwestern Nigeria. J Pediatr Neurol 2011;9:341-345.

Nigeria Multiple disabilities

59. Egdell HG, Stanfield JP. Paediatric neurology in Africa: a Ugandan report. Br Med J 1972;1:548-52. Uganda Neurodevelopmental disabilities

60. Wolf MJ, Wolf B, Beunen G, Casaer P. Neurodevelopmental outcome at 1 year in Zimbabwean neonates with extreme hyperbilirubinaemia. Eur J Pediatr 1999;158:111-4.

Zimbabwe