PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR …



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

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|1 |Name of the candidate and Address |MS. DIANA V |

| | |I YEAR M.Sc NURSING, |

| | |NAVANEETHAM COLLEGE OF NURSING. |

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|2 |Name of the Institution |NAVANEETHAM COLLEGE OF NURSING, BANGALORE- 43 |

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|3 |Course of study and subject |1ST YEAR M.Sc NURSING (OBSTETRICS AND GYNAECOLOGY) |

| |Date of admission |30-06-2012 |

|4 | | |

| | |“A STUDY TO ASSESS THE EFFECTIVENESS OF STP ON KNOWLEDGE OF POSTNATAL|

|5 |TITLE OF THE TOPIC |MOTHERS REGARDING CARE OF JAUNDICED NEONATES IN PHOTOTHERAPY IN |

| | |SELECTED HOSPITAL OF BANGALORE.” |

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

A mother’s yearning feels the presence of the cherished child even in the degraded

man.

- George Eliot

Neonatal jaundice occur in 60 % of term healthy neonates and 80 % of preterm neonates.1 Neonatal jaundice is a term for elevated total serum bilirubin in newborns and infants less than one month of age. In other words neonatal Jaundice is the yellow discoloration of the skin and the white part of the eye (the sclera). It results from having too much of substance called bilirubin in the blood. Bilirubin is formed when the body breaks down old red blood cells. The liver usually processes and removes the bilirubin from the blood. Neonatal jaundice in babies usually occurs because of a normal increase in the red blood cell break down and the fact that their immature livers are not efficient at removing bilirubin from the bloodstream.

There are mainly two types of neonatal jaundice.

• Physiological jaundice

• Pathological jaundice

PHYSIOLOGICAL JAUNDICE is due to the physiologic immaturity, immaturity in

Bilirubin metabolism at multiple steps results in the occurrence of neonatal jaundice in the first few days of life .

CHARACTERS OF PHYSIOLOGIC JAUNDICE :

First appears between 24-72 hours of age, Maximum intensity seen on 4-5th day in term neonates, Does not exceed 15 mg/dl and clinically undetected after 14 days.

PATHOLOGICAL JAUNDICE:

Bilirubin levels that deviate from Normal range and require intervention i.e. presence of any of the following signs denotes that jaundice is pathological. Treatment is required in the form of phototherapy.

Clinical jaundice detected before 24 hours of age, Rise in serum bilirubin by more than 5 mg/ dl/ day, Serum bilirubin more than 15 mg / dl, Jaundice persisting beyond 14 days of life and direct bilirubin >2 mg / dl at any time.

PHOTOTHERAPY:

Phototherapy has been used on hundreds of thousands of infants in united states, and perhaps millions of infants worldwide. Infants with neonatal jaundice are treated with colored light called as phototherapy introduced into routine use in the late 1960’s. Phototherapy has been proven effective in several large clinical trials (brown et al . , 1985;Tan and Boey, 1986) and no significant toxicity has been identified.2 Phototherapy involves exposure of the naked baby to blue light of wave length 450-460 nm. The light waves convert the water soluble non toxic forms which are then easily excreted. The advantages of phototherapy are that it is non invasive , effective, inexpensive and easy to use. The disadvantage is that it causes dehydration and skin rashes that disappears when baby is fed and kept hydrated adequately. Frequent feeding every second hourly and change of posture should be promoted in an infant. Eye shades should be fixed, external genitalia may be covered as long as the infant receiving phototherapy.

6.1. NEED FOR THE STUDY

| A mother holds her children’s hand for a while, their hearts forever. |

|Neonatal jaundice is the condition most commonly seen in neonates up to three week. It is the presence of increased concentration |

|of bilirubin in the blood. |

|Many studies have been conducted on neonatal jaundice worldwide. A prospective study was conducted at University of Chicago on |

|persistence of maternal concerns surrounding neonatal jaundice in 47 Spanish and English speaking breastfeeding mothers. The data |

|was collected by ethnographic interviews using grounded theory method. After data collection, the researcher found that guilt was |

|common with mothers believing that they had caused the jaundice. Mothers voiced alarm about yellow skin and |

|discomfort about jaundice management, and worried about perceived short-term and long-term effects. Key factors in |

|creating perception of jaundice included unexpectedness of and lack of knowledge about jaundice, quality of information |

|received, level of interventions and prolonged duration of illness, and yellow skin colour. The researcher concluded that the |

|practitioner needed to address the persisting misconceptions and concerns about neonatal jaundice with mothers.3 |

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|A study was conducted in California on readmission for neonatal jaundice during 1991-2000. The study population was |

|healthy routinely discharged infants. The hospital discharge records were the source of diagnoses, hospital charges, |

|and length of stay information. After the study, the researcher found that readmission rates for jaundice gradually rose |

|after 1994 and peaked at 1998 at 11.34 per 1000. The readmission rates for preterm infants over the study period remained at less |

|than 2 per 1000. Factors associated with hospital readmission for jaundice included gestational age 34-36 weeks, birth weight < |

|2500 gm, and male gender. In 2000, the readmission rates remained 6% higher than that in 1991.4 |

| According to the All India institute of Medical Sciences protocol in neonatology, neonatal jaundice is the commonest |

|morbidity in neonatal period and 5-10% of all the newborns require interventions for pathological jaundice. Neonates on exclusive |

|breastfeeding have different pattern of physiological jaundice as compared to artificially fed babies. Separate guidelines have |

|been provided for the management of jaundice in sick term babies, preterm and low birth weight babies for jaundice secondary to |

|haemolysis and for prolonged neonatal jaundice. |

|Nowadays, the incidence of neonatal jaundice is very high. A wide range of literature suggests that the increased incidence of |

|neonatal jaundice is due to the lack of knowledge regarding identification and prevention. Studies support that education to |

|postnatal mothers on neonatal jaundice will be helpful in reducing the incidence.5 |

|The researcher from her own experience, discussion with experts and casual talk with mothers realised that neonatal jaundice is a |

|common problem. So the investigator felt the need to educate the mothers regarding neonatal jaundice. |

|These studies shows that postnatal mothers lack knowledge regarding care of neonates with jaundice and its |

|treatment and are in necessity in gaining information and knowledge about the same. The STP that will be |

|conducted will help mothers gain adequate information and knowledge. |

6.2. REVIEW OF LITERATURE

Review of literature is the writings of recognised authorities and of previous research, which provides the evidence that the researcher is familiar with what is already known and what is still unknown.

|Studies related to knowledge of postnatal mothers regarding care of jaundiced neonate. |

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|A cross-sectional study conducted to determine the knowledge, attitude and behaviour of mothers about neonatal |

|jaundice at Ali-ebne Abitaleb Hospital in Zaheban, Iran during April and May 2006. Four hundred mother were |

|interviewed to complete a 21-point questionnaire. After data collection and analysis, the researcher found that the |

|mean attitude score was 18.5±3.7 out of 25 and the mean behaviour score was 6.8±2.3 out of 10.5. Knowledge had a |

|significant association with mother’s attitude and educational level. The results showed a direct correlation between |

|knowledge, attitude and behaviour. The researchers concluded that increasing mothers’ knowledge about jaundice|

|of neonates can be the first step to continue healthy behaviour through education programmes during pregnancy.6|

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|An ethnographic study from the USA examined maternal concerns about neonatal |

|jaundice. In all, 47 mothers of healthy breastfeeding babies with jaundice were interviewed. The mean maternal age |

|was 27 years. Over half of multiparous mothers had a previous baby with jaundice and three-quarters had breastfed|

|a previous baby. Neonatal jaundice was defined as serum bilirubin > 170 micromol/litre. The interviews were held between 2.5 |

|and 14.5 weeks postpartum. Regarding causes of jaundice, 26 mothers (55%) believed that the quality and quantity of breastfeeding|

|was pertinent to this. In all, 27 mothers (57%) perceived neonatal jaundice to be a serious condition. Of the 20 mothers who were |

|not concerned, ten reported that their baby appeared healthy and was feeding well despite being jaundiced. Of these 20 mothers, |

|five of their babies had breast milk jaundice and five had had blood tests but did not require treatment. The remaining ten women |

|had no concerns because they had received prompt information and reassurance about jaundice. Maternal anxiety increased in |

|proportion to the severity of neonatal jaundice. Most women expressed a preference for being informed about jaundice |

|prenatally, while others wanted information at discharge or only in the event of their baby becoming jaundiced. Preferred |

|formats for communicating information included individual verbal communication, small group discussions, written pamphlets and |

|videos. Mothers requested more detailed information regarding causes of jaundice, information that addressed maternal |

|responsibilities, management procedures, potential effects of jaundice and its treatment, anticipated duration of jaundice, and |

|measures that they could take themselves to prevent jaundice and to care for jaundiced babies.7 |

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|A study was conducted on a group of Iranian mothers with icteric newborn in order to identify any wrong knowledge and improper |

|practices related to the neonatal jaundice between June 2004 and February 2007 on 1666 mothers with icteric newborn hospitalised |

|at a single centre. A questionnaire was used to assess the participants' knowledge and practice of neonatal jaundice. A knowledge |

|score was calculated based on the responses. The mean knowledge score was 3.38±1.23 (out of 6). About 77% of the mothers had |

|moderate-to-high level of knowledge of neonatal jaundice. Approximately one-third of the mothers consulted a physician within 24 |

|hour of appearance of jaundice and 13.8% declared that they waited and managed their children with traditional remedies until they|

|sought medical advices. Furthermore, 32.2% of the mothers discontinued feeding their icteric offspring with coloured foods and |

|colostrums. Hence, 42.8% of the mothers acted weakly with regard to their icteric offspring. The health care workers were the |

|participants' major source of information about neonatal jaundice. The study determined a fairly inadequate knowledge of Iranian |

|mothers about the neonatal jaundice with incomparable level of related practices.8 |

A study was conducted to evaluate maternal knowledge level about neonatal jaundice.

This study was conducted on 161 mothers who had given birth to healthy newborns at Izmir Aegean Gynecology and Obstetrics Hospital between January 2010 and April 2010. A questionnaire was used to assess the mothers' knowledge on neonatal jaundice. Knowledge was evaluated as "sufficient" or "insufficient" based on responses. Sufficiently informed mothers were compared with insufficiently informed group for the knowledge level about neonatal jaundice. The rate of insufficiently informed mothers was 53.6%. Low education level was found to increase the probability of the mothers' knowledge level to be insufficient by 2.1 folds. Being informed beforehand by a previous offspring with jaundice increased the probability of the mothers' knowledge to be sufficient by twofolds. It is found that the mothers' knowledge about neonatal jaundice is insufficient.9

A observational cross-sectional study was conducted to determine the knowledge, attitude & behavior on neonatal jaundice of postnatal mothers in Provincial General Hospital (PGH), Badulla.  396 mothers, who delivered at PGH Badulla from 1st May 2010 to 15thJune 2010, were interviewed using a structured questionnaire. The questionnaire was used to assess the participant’s knowledge, attitude and behaviour  The mean knowledge score was 31±14, the mean attitude score 65.7±20.6 and the mean behaviour score 66.1±18.8.on neonatal jaundice.  The knowledge of neonatal jaundice among postnatal mothers was low. There was significant correlation between mothers’ attitude and behaviour scores with the knowledge scores.10

A cross sectional study was conducted on Malaysian mothers knowledge and practices

on Care of Neonatal Jaundice. 400 mothers who attended the obstetric clinics or were admitted to the obstetric wards of a general hospital were included. They were surveyed

with a structured set of questionnaire. The results showed that a majority (93.8%) of them knew about neonatal jaundice, and 71.7% knew that jaundice lasting more than 2

weeks was abnormal. However, only 34.3% of them were aware that jaundice appearing during the first 36 hours of life was abnormal. . This study revealed that there

was a wide knowledge gap among Malaysian mothers on care of neonatal jaundice. Placing infants under the direct sun was still a common practice.11

 A cross-sectional study was conducted to identify level of knowledge, belief and attitude on neonatal jaundice among Malay pregnant mothers who live in Seberang Perai Utara state. A total of 150 mothers attended clinics in Seberang Perai Utara, were chosen by systematic random sampling and were interviewed using a pretested questionaire. Results showed about 50.0% of the respondent had inadequate general knowledge on neonatal jaundice, especially the knowledge on complications and identifying the best method of jaundice detection.12

A study was conducted on perceptions of mother towards neonatal jaundice and its management. The results show that some mothers believed that they had caused the jaundice using phrases like “got it from me, did something wrong. Not being a good mother”. Most mothers indicated that the blood testing process was difficult to watch and child, mothers used “screamed” or “suffered” to describe reactions of their neonates. Study concluded that as bilirubin levels increased and higher levels of interventions were needed, mother’s concerns increased. Mothers worried that infants would overheat or become blind and that the lights would be ineffective in lowering bilirubin levels. Several mothers said that the yellow eyes caused them to worry about their infant’s vision.13

Studies related to importance and effectiveness of phototherapy in care of jaundice neonates:

A study was conducted to determine the incidence of severe neonatal jaundice in the newborn, and to identify associated clinical and demographic variables, and short-term outcomes in uk. A prospective population based study was designed in U K and Republic of Ireland, between 1 may 2003 and 31 may 2005. Infants in the first month of life with severe neonatal jaundice were included. 108 infants met the case definition, 106 from U K and 2 from Republic of Ireland. The UK incidence of severe neonatal jaundice was 7.1/100 000 live births (95% CI 5.8 to 8.6). Only 20 cases presented in hospital; 88 were admitted with severe jaundice. 64 (60.4%) cases were male, and 56 (51.8%) were of ethnic minority origin. 87 (80.5%) cases were exclusively breast fed. This is the first large, prospective, population-based study of the incidence of severe neonatal jaundice in the newborn. The clinical and demographic associations and short-term outcomes identified.14

A study was conducted to determine whether either neonatal jaundice or inpatient phototherapy is associated with increased subsequent outpatient visit rates. Three groups of well term infants who were between 1995 and 2004 in northern California Kaiser hospitals were compared. Group 1 never had a documented total serum bilirubin (TSB) level > or =12 mg/dL, group 2 had a TSB level > or =17 and or =2000 g born at > or =35 weeks' gestation at 12 Northern California Kaiser hospitals from 1995 to 2004, they identified 22,547 infants who had a "qualifying total serum bilirubin level" within 3 mg/dL of the American Academy of Pediatrics 2004 guideline phototherapy threshold. Of the 22 547 eligible newborns, 5251 received hospital phototherapy within 8 hours of their qualifying bilirubin level within 48 hours. It concluded that While hospital phototherapy is effective, the number needed to treat according to current guidelines varies considerably across different infant subgroups.16

A study was conducted to estimate the effect of phototherapy on the risk of total serum bilirubin (TSB) >or= 25 mg/dL in infants with a TSB of 17 to 22.9 mg/dL at age >or= 48 hours. All infants exhibiting a TSB >or= 25 mg/dL were selected as cases for the study. From a cohort of 285295 infants >or= 34 weeks gestation and >or= 2000 g born between 1995 and 2004 in northern California Kaiser hospitals, they identified 17986 with a TSB of 17 to 22.9 mg/dL at age >or= 48 hours. All infants exhibiting a TSB >or= 25 mg/dL were selected as cases for the study. Four randomly selected controls were matched to each case based on the difference between their qualifying TSB and the American Academy of Pediatrics' phototherapy threshold. A total of 62 cases were identified. Six of these received in patient phototherapy within 8 hours. Phototherapy was 85% effective in preventing TSB >or= 25 mg/dL.17

A study was Conducted to evaluate the effect of LED phototherapy as compared to conventional phototherapy in decreasing serum total bilirubin levels and duration of treatment in neonates with jaundice. Quasi-randomised method was used. The standard methods of The Cochrane Collaboration and its Neonatal Review Group for data collection and analysis were used.Six randomized controlled trials met the criteria. Four studies compared LED and halogen light sources. Two studies compared LED and compact fluorescent light sources. The duration of phototherapy (six studies, 630 neonates) was comparable in LED and non LED phototherapy group. The rate of decline of serum total bilirubin (STB) (four studies, 511 neonates) was similar in the two groups. The result was LED light source phototherapy is efficacious in bringing down levels of serum total bilirubin at rates that are similar to phototherapy with conventional (compact fluorescent lamp (CFL) or halogen) light sources.18

A study was conducted to compare the efficacy of light-emitting diode (LED) phototherapy with special blue fluorescent (BB) tube phototherapy in the treatment of neonatal jaundice. 66 infants > or = 35 weeks of gestation were randomly assigned to receive phototherapy using an LED device. After 15+/-5 h of phototherapy, the rate of decline in the total serum bilirubin (TSB) was 0.35+/-0.25 mg/dl/h in the LED group vs 0.27+/-0.25 mg/dl/h in the BB group (P=0.20).It concluded that LED phototherapy is as effective as BB phototherapy in lowering serum bilirubin.19

A study was conducted to establish the efficacy of treatments (namely phototherapy) for neonatal jaundice in the reduction of peak bilirubin levels, reduction in duration of jaundice. Healthy infants of at least 34 weeks' gestation, or with a birth weight of at least 2,500 g, were eligible.

Twenty studies were identified, 2 non-randomised controlled trials(RCT)1 retrospective cohort 6 prospective cohorts one retrospective cohort and 8 within-group comparison studies. Three studies investigated the efficacy of phototherapy in preventing the total serum bilirubin (TSB) levels from rising above 20 mg/dL). Nine studies examined the effect of treatments for neonatal jaundice on neurodevelopmental outcomes, of which seven focused on phototherapy. In these studies, no changes in neurodevelopmental outcomes, including orientation, motor responses and IQ, were found with phototherapy. Three studies evaluated the effect of phototherapy on visual outcomes. All 3 studies found no change in visual function after phototherapy. The most effective treatment for healthy infants with jaundice was phototherapy in addition to cessation of breast-feeding. The conclusion was also that phototherapy does not have any long-term adverse effects on the neurodevelopment of healthy infants.20

6.3. STATEMENT OF THE PROBLEM

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE OF POST NATAL MOTHERS REGARDING CARE OF JAUNDICED NEONATES IN PHOTOTHERAPY IN SELECTED HOSPITAL.

6.4 OBJECTIVE OF THE STUDY

➢ To assess the pre-test knowledge of the postnatal mothers regarding care of child in phototherapy.

➢ To assess the post-test knowledge of the mothers regarding care of child in phototherapy.

➢ To evaluate the effectiveness of the structured teaching programme regarding care of child in phototherapy

➢ To find out the association of knowledge among postnatal mothers on care of child in phototherapy with selected demographic variables.

6.5. OPERATIONAL DEFINITIONS

1 .EFFECTIVENESS: It refers to the desired change brought about by the structured Teaching programme & measured in terms of significant knowledge gain in the post test scores.

2. STRUCTURED TEACHING PROGRAMME: It refers to consisted, well structured & Informative teaching program that will be given to postnatal mothers .

3. KNOWLEDGE: Knowledge refers to a person’s range of information. In this study postnatal mothers will gain knowledge regarding care of neonates in phototherapy.

4. POSTNATAL MOTHERS: A mother in this study is considered as postnatal mothers who after a term pregnancy have given birth to a baby.

5. NEONATAL JAUNDICE: Neonatal jaundice is defined as the yellowish discolouration of the skin, mucosa and other tissues of the neonate due to increase in serum bilirubin above 5 mg/dl within a period of birth to 28 days.

6. PHOTOTHERAPY: It is the treatment for neonatal jaundice using a light in which baby will be exposed that helps in decreasing level of bilirubin.

6.6. ASSUMPTIONS

This study was based on the following assumptions:

➢ postnatal mothers will have interest to participate in the study.

➢ postnatal mothers may have some knowledge about jaundice and phototherapy.

➢ Structured teaching program will enhance the knowledge regarding care of child in phototherapy.

6.7. HYPOTHESIS:

H1: There will be significant difference between the mean, pre test & post test score of postnatal mothers regarding care of child in phototherapy.

H2: There will be significant association between the demographic variables & The mean scores of the postnatal mothers regarding care of child in phototherapy.

6.8. DELIMITATIONS:

The study is limited to;

1. Postnatal mothers only

2. The postnatal mothers available during the time of data collection.

7. MATERIALS AND METHODS

7.1. SOURCE OF DATA:

The data will be collected from the postnatal mothers.

7.2. METHOD OF DATA COLLECTION:

Research method : Quasi experimental method

Experimental Design : One group pre-test post-test design

Sampling technique : Purposive sampling technique

Sampling size : 60 postnatal mothers

Setting of the study : A study will be conducted in postnatal

wards in selected hospital in Bangalore.

7.2.1. CRITERIA FOR SELECTION OF SAMPLE

Inclusion criteria :

1. Postnatal mothers who are admitted to postnatal ward.

2. Postnatal mothers who are able to read and write Kannada.

3. Postnatals mothers who are available at the time of data collection.

Exclusion criteria :

1. High risk mothers who are confined to bed.

2. Postnatal mothers who have exposure to teaching on neonatal jaundice.

3. Postnatal mothers whose previous children had neonatal jaundice and

received treatment.

7.2.2 DATA COLLECTION TOOL

Permission will be obtained from the concerned authorities. Using purposive sampling 10-12 samples from the newly admitted postnatal mothers will be selected daily till the desired sample size is obtained. The purpose of the study will be explained and informed consent will be obtained from selected sample. Data will be collected using interview schedule method. After collecting data a group structured teaching programme will be given. The group will consist of 10-12 samples. On seventh day after structured teaching programme post-test will be conducted using the same method of pre-test. Data collection will last for one month.

7.2.3 METHOD OF DATA ANALYSIS

Descriptive and inferential statistics will be used to analyse the data. The findings will be presented in the form of tables and figures. Demographic data will be analyzed in terms of frequency and percentage. The knowledge scores before and after the structured teaching programme will be analyzed in terms of frequency, percentage, mean, and standard deviation. The significant difference between the mean pre-test and post-test knowledge score will be determined by‘t’ test. The association between selected demographic variables and pre-test knowledge score regarding neonatal jaundice will be determined by Chi-square test.

7.3. DOES THE STUDY REQUIRE ANY INTERVENTION?

YES

1. Intervention or structure teaching programme will be conducted on postnatal

mothers.

2. No other invasive procedure are performed as a intervention in this study.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED?

YES

1. Confidentiality and anonymity of the sample will be maintained.

2. Informed consent will be obtained from the subject

3. A written permission from institutional authority and hospital management

will be obtained prior to the study.

BIBLIOGRAPHY

1. patients/patientinfo/Neonataljaundice_Incidence.

2. Browns (Phototherapy for neonatal jaundice) volume 47 no 6. Pp.876 1983

3. Hannon PR, Willis SK, Scrimshaw SC. Department of Pediatrics, College of Medicine, University of Illinois at Chicago Med. 2001 Dec;155(12):1357-63.

4. Burgos AE, Schmitt SK, Phibbs CS. Readmission for neonatal jaundice in California, 1991-2000: trends and implications. Paediatrics 2008 Apr; 121(4):813.

5. of neonatal jaundice. [Accessed on 18.07.2009]

6. Research center for child and adolescent health zahedan university of medical sciences,zahedan,Iran (Knowledge, attitude and behaviour of mothers on neonatal jaundice).

7.

8. Amirshaghaghi A, Ghabili K, Shoja MM Kooshavar H. Neonatal jaundice: knowledge and practice of Iranian mothers with icteric new borns. Pak J Biol Sci.2008 Mar 15;11(6);942-5.

9. J Maternal Fetal Neonatal Med. 2012 Aug; 25(8):1387-9.

10. Sri Lanka Journal of Child Health, 2011; 40(4): 164-168.  Vol 40, No 4 (2011).

11. International Medical University Malaysia (research project number:IMU 160/2008) . Med J Malaysia Vol 66 No 3 August 2011: 465-12.

12. Journal kesihatan masyarakat journal.1994 1, (1). ISSN 1675-1663.

13. Patricia R, Hannon MD, Sharla K, Susan C. “Perception of neonatal jaundice”. Indian J. Pediatr 2003; 70(6): P-463-6.

14. Donal Manning, Peter Todd, Melanie Maxwell, and Mary Jane Platt Arch Dis Child Fetal Neonatal Ed. 2007 September; 92(5): F342–F346

15.

16. Newman TB, Kuzniewicz MW, Liljestrand P, Wi S, McCulloch C, Escobar GJ (Numbers needed to treat with phototherapy according to American Academy of Pediatrics guidelines). Dept of epidemiology and biostatistics.

17. Kuzniewicz MW, Escobar GJ, Wi S, Liljestrand P, McCulloch C, Newman TB ,Division of neonatology, university of California San Francisco,USA. J Pediatr. 2008 August; 153(2): 234–240.

18. CENTRAL, The Cochrane Library 2010, Issue 1), MEDLINE (1966 to April 30, 2010) and EMBASE (1988 to July 8, 2009).

19. WHO collaborating centre for Training and Research in Newborn Care

20. J Perinatol, Maisels MJ, Kring EA, DeRidder, 2007 sep;27(9):565-7

21. 20 Ip S, Glicken S, Kulig J, O'Brien R, Sege R. Management of neonatal hyperbilirubinemia. Rockville, MD, USA: Agency for Healthcare Research and Quality

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