|Year : 2015 | Volume
| Issue : 3 | Page : 158-163
Neonatal Jaundice: Knowledge, Attitude and practices of mothers in Mosan-Okunola community, Lagos, Nigeria
Olayinka O Goodman1, Omolara A Kehinde2, Babatunde A Odugbemi1, Toriola T Femi-Adebayo1, Olumuyiwa O Odusanya1
1 From the Department of Community Health and PHC, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
2 From the Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
|Date of Web Publication||30-Nov-2015|
Olayinka O Goodman
From the Department of Community Health and PHC, Lagos State University Teaching Hospital, Ikeja, Lagos
Source of Support: None, Conflict of Interest: None
Background: A community-based survey was conducted amongst mothers aged 15–49 years living in Mosan-Okunola, Lagos, Nigeria to determine the knowledge of, attitudes to, preventive and treatment practices towards neonatal jaundice (NNJ).
Materials and Methods: The mothers were selected using a multi-stage sampling technique. A pre-tested interviewer-administered structured questionnaire was used to obtain data. The knowledge of the mothers was scored and scores lower than 50% were graded as poor, 50–74% as fair and ≥75% as good. The practice was also categorised as appropriate if one correct option was identified and was categorised as inappropriate where an incorrect option(s) was identified singly or in combination with a correct option.
Results: Three hundred and fifty-eight mothers were recruited. The mean age was 34.8 ± 9.05 years. Two hundred and seventy (75.4%) mothers had ever heard about the condition. Two hundred and forty-seven (91.4%) mothers correctly identified the condition and infection was the only most common known cause (47%). Only 34% of the mothers knew that NNJ could cause brain damage, and 40% identified refusal of feeds as a danger sign. Up to 64% of the mothers believed attending antenatal care could prevent the condition, and 58% were of the opinion that exposing babies to sunlight could prevent the condition. Sixty-eight percent (68.9%) of the mothers had a poor level of knowledge. Age and educational qualification did not show any statistically significant relationship with knowledge about NNJ (P < 0.05) but increasing maternal age had a significant association with an appropriate treatment practice (P < 0.05), the association was negative (r = −0.32).
Conclusion: Knowledge about NNJ was low in this community and ineffective preventive practices were utilised. Efforts should be made to increase it, and health workers should play a leading role.
Keywords: Kernicterus, knowledge, mothers, neonatal jaundice
|How to cite this article:|
Goodman OO, Kehinde OA, Odugbemi BA, Femi-Adebayo TT, Odusanya OO. Neonatal Jaundice: Knowledge, Attitude and practices of mothers in Mosan-Okunola community, Lagos, Nigeria. Niger Postgrad Med J 2015;22:158-63
|How to cite this URL:|
Goodman OO, Kehinde OA, Odugbemi BA, Femi-Adebayo TT, Odusanya OO. Neonatal Jaundice: Knowledge, Attitude and practices of mothers in Mosan-Okunola community, Lagos, Nigeria. Niger Postgrad Med J [serial online] 2015 [cited 2020 Nov 25];22:158-63. Available from: https://www.npmj.org/text.asp?2015/22/3/158/170741
| Introduction|| |
Neonatal jaundice (NNJ) is the yellowing of the sclera and skin of the newborn, due to elevated bilirubin in the blood. Bilirubin is formed from haem and neonates produce bilirubin at more than twice the production rate in adults, primarily because of relative polycythaemia and increased red blood cell turnover. Twenty-four million (18% of 134 million live births ≥32 weeks of gestational age from 184 countries) neonates were found to be at risk for neonatal hyperbilirubinemia related adverse outcomes. In Pakistan, the incidence of NNJ was 39.7/1000 live births.
It is a common cause of paediatric emergency in Nigeria.,, NNJ usually occurs in the first 1 week of life by which time the mothers are likely to have left the hospital, as many mothers are discharged from the hospital 24–48 h post-partum. This may be part of the reasons for the late presentation of children with NNJ to hospitals in Nigeria.,, The effects of jaundice are often irreversible and include lethargy, poor feeding, high pitched cry, hypertonia, seizures, high-frequency hearing loss, cerebral palsy and mental retardation evident at 3 years of age. Predisposing factors include feto-maternal ABO/rhesus incompatibility, prematurity, infections, exposure of glucose-6-phosphate dehydrogenase deficient babies to icterogenic substances such as naphthalene balls or menthol, polycythaemia, previous history of jaundice in sibling and some drugs.
In Iran, a study amongst post-partum mothers showed inadequate knowledge about causes, complications, symptoms and prevention of NNJ. Only 37% of the mothers correctly identified jaundice as appearing on the eyes, the skin, palms and soles of the feet. The knowledge of the mothers was found to have a significant association with the history of NNJ (P = 0.033), mother's age (P < 0.001) and child's birth rank (P = 0.001). Knowledge of treatment of NNJ in the country was reported as good, up to 48% of study participants indicated that both blood transfusion and phototherapy could be used in the treatment, and 38% had indicated the use of only phototherapy. A second study from Iran reported that 77% of mothers with infants who had NNJ had a moderate-to-high level of knowledge. Thirty-three percent of these mothers consulted a physician within 24 h of onset of jaundice while 14% waited and used traditional medicines before seeking medical advice.
In Nigeria, studies on NNJ have also been conducted amongst women attending antenatal clinics and immunisation clinic in Benin, Port Harcourt and Sagamu.,, The Benin study reported a high awareness and recognition of symptoms in the pregnant women attending antenatal clinics, but there was poor knowledge of causes and danger signs, which is similar to the findings from Port Harcourt  and Sagamu. The study in Benin, Nigeria reported that 40% of women indicated phototherapy as a form of treatment, and 26% knew about exchange blood transfusion.
The attitudes of respondents to NNJ were generally good as many of the respondents in previous studies reported that they would bring their babies to the hospital if jaundice occurred.,, Treatment practices of the condition were divergent as a number of harmful practices such as cutting post-auricular area of an infant, burning of the body, the use of herbal treatment, exposure of infants to the sunshine and giving glucose water to infants.,,,,, Studies in Nigeria reported a common practice of mothers administering antibiotics and multivitamins to babies with the condition.,
Misconceptions about causes of NNJ were common to all these studies and included drinking of cold water by the pregnant woman, eating of groundnuts, eating of yellow coloured foods.,,,,, These show gaps in knowledge that needed to be addressed. Considering the common occurrence of NNJ and the high morbidity, it poses if not recognised early enough to be properly managed, it is important to determine the knowledge, attitude and practices of mothers when this condition presents in order to put in place interventions that can enhance early presentation at hospitals and prevention of its sequelae. Therefore, the purpose of this study was to determine the knowledge and preventive practices of mothers in Mosan-Okunola, a community in Lagos, Nigeria towards NNJ.
| Subjects and Methods|| |
The study was a descriptive cross-sectional study. Mosan-Okunola is 1 of 37 Local Council Development Areas (LCDAs) in Lagos State, created out of Alimosho Local Government Area (LGA). The community has a mix of public and private health facilities. Mosan-Okunola LCDA has 10 clusters used by the health authorities for health programmes such as national immunisation days, and insecticide-treated net distribution. The study group was women of the reproductive group (15–49 years) and post-menopausal women. Female members of the household who were not mothers were excluded. Duration of study was 8 months (October 2014–May 2015).
Sample size determination and selection of participants
The calculated minimum sample size for this study was determined using Fisher's formula for sample size estimation for descriptive studies. The statistical assumptions were a type 1 error rate of 5%, 70% knowledge of the condition  and a precision of ± 5% points. The calculated minimum sample size was 323 women. A multi-stage sampling technique was used for the study. In the first stage, four clusters were selected from the 10 clusters by balloting and 12 streets were also selected by balloting from each of the selected clusters. The streets in the area formed the sampling frame for the study. In the second stage, houses were then selected by systematic random sampling using a sampling interval of seven. In the third stage, the household to be interviewed in each house was selected by balloting, and only one eligible woman was interviewed in each household if they were more than one.
Survey instrument, data collection and analysis
Data were collected using a structured pre-tested interviewer-administered questionnaire. The instrument was developed after a careful review of literature on the subject. The instrument inquired if the mothers had never heard of NNJ, the sources of information, knowledge of causes, complications, danger signs and actions they would take if their child developed NNJ, what they did to prevent jaundice and how the condition could be treated. The questionnaire was pre-tested in a different community, Ipodo, Ikeja LGA. Data were collected by six research assistants (medical officers and junior registrars) who were trained.
Data analysis was done using SPSS version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, version 20.0. Amonk, NY: IBM Corp). The respondents' answers were graded, and 19 questions were utilised in creating a knowledge score with each correct answer being scored one mark. Knowledge was graded as good ≥75% (≥15 marks), fair 50–74% (10–14 marks) and poor 50% (≤9 marks). Treatment practices were categorised as appropriate where only one correct practice was identified, but categorised as inappropriate where an incorrect treatment practice was singly identified or in combination with a correct practice. Chi-square test was used to test the association between sociodemographic characteristics, knowledge score and treatment practices and a Spearman's correlation coefficient was used to determine the direction of the association. The level of significance was at P < 0.05.
Ethical approval was obtained from the Health Research and Ethics Committee of the Lagos State University Teaching Hospital (LASUTH). The LCDA Health Department was also informed about the study. The purpose of research was explained to each respondent and written informed consent was obtained.
| Results|| |
Three hundred and fifty-eight women were recruited into the study. The mean age was 34.8 ± 9.05 years. Almost half of respondents (46.6%) were in the 25–34 years age group. The majority (74.3%) of respondents had two or more children. More than half of respondents (64.5%) had a minimum of secondary school education [Table 1]. Only 270 (75.4%) respondents had heard about NNJ. One hundred and fifteen (42.6%) mothers claimed to have received most of the information from health workers, 51 (18.9%) received the information from family members, 30 (11.1%) from neighbours and 8 (3%) from friends (32.9%), while 43 (15.9%) identified television, 18 (6.7%) identified radio and 5 (1.9%) indicated posters as their sources of information.
|Table 1: Sociodemographic and family (parity) characteristics of respondents|
Click here to view
Ninety-one percent of the 270 women (91.5%) correctly identified jaundice as yellowish discolouration of the eyes and skin. Less than half of respondents (47%) and 11% correctly identified infection and blood compatibility, respectively as causes of NNJ, while 25.9% of the respondents could not identify any cause of jaundice. Other causes of jaundice include cold water, eating of groundnuts, eating of palm oil and other foods mothers took during pregnancy or while breastfeeding were identified by 56.3% of the respondents. One hundred and ninety-nine (73.7%) mothers identified infancy as the period of life during which effect of NNJ is most pronounced. The most correctly identified effects of NNJ were brain damage (33.7%) and death (31.5%). Refusal of feeds (40%) and fever (29.6%) were the most frequently identified danger signs of NNJ [Table 2].
More than half (56.3%) of respondents reported that if their neonate developed jaundice, their initial likely action would be to watch for a few days before taking the child to the hospital. Thirty-seven (13.7%) reported that they would treat with herbs. Two hundred and forty-four (90.4%) respondents would be willing to take their baby to the hospital [Table 3]. The majority of respondents (64.1%) indicated regular attendance at antenatal care clinics as a means of preventing NNJ in their babies. Twenty-one percent (21.1%) of the respondents did not consciously do anything to prevent NNJ. Only two (0.7%) respondents reported the practice of avoiding the use of naphthalene balls as a means of preventing NNJ. Over 50% of respondents will put the baby in the sun as treatment of NNJ while 35.6% will take the child to a hospital [Table 4]. One hundred and eighty-six (68.9%) respondents had poor knowledge of NNJ. There was no statistically significant association (P > 0.05) between knowledge score and maternal age or level of education [Table 5]. Maternal age had a positive but non-significant correlation with knowledge score (r = 0.077, P = 0.211). Maternal level of education also had a positively significant correlation with knowledge score (r = 0.183, P = 0.003). There was a statistically significant association (P < 0.05) between maternal age and appropriate treatment practices [Table 6] but the direction of the association was negative (r = −0.32, P = 0.605). There was no statistically significant association between the level of maternal education and an appropriate treatment practice (P > 0.05) although the association was positive and significant (r = 0.13, P = 0.03). Knowledge score did not have a statistically significant association with the appropriateness of treatment (P > 0.44) even though the correlation was positive but not significant (r = 0.10, P = 0.09).
|Table 6: Association between sociodemographic characteristic, knowledge score and treatment practices|
Click here to view
| Discussion|| |
One strength of this study is that it is community-based, unlike others which are hospital based.,,,,,, This may add to providing a more complete understanding of knowledge of mothers about NNJ to health care workers and guide in planning appropriate interventions rather than amongst mothers with children who have suffered from the condition. The awareness of NNJ in this study was high (75.4%); it is lower than rates reported from other studies in Nigeria partly because these studies were hospital based.,, The majority (91.5%) of respondents knew that NNJ was yellowness of the eyes and 87% of the mothers correctly indicated the eyes as the part of the body where jaundice is first noticed is similar to findings in other studies in Iran,, and Port Harcourt, Nigeria. The commonest source of information from this study is the health worker (42.6%), while others (friends, family members and neighbours) ranked second as a source of information. This finding is comparable to previous studies in Nigeria , where the health worker was the most commonly identified source of information. The mass media as a source of information ranked low in this study as with other studies.,,
Despite the high level of awareness amongst mothers, knowledge was low on many aspects of the condition; whether it was on common causes, recognition of danger signs or complications. The knowledge of the causes of NNJ was low as 25.9% of the respondents did not know of any cause, and 56.3% had reported wrong causes such as eating of groundnut or palm oil, drinking of cold water showing a lot of misconceptions. The only fairly well-known cause of NNJ in this study was infections (47% of mothers) while knowledge of other common causes was remarkably low. This finding is similar to other findings in Iran,, Benin, Port Harcourt, and Sagamu, but higher than the 8% obtained from respondents in a multi-centre study (Lagos, Port Harcourt and Abuja) in Nigeria. Almost 40% of respondents in this study (38.5%) did not know the effect or had indicated that NNJ had no effect on the child in keeping with findings in Benin, and Sagamu , and may be indicative of likely poor actions by these mothers.
Knowledge of danger signs was fair in this study as 35.9% of respondents had indicated there was either no danger sign or they did not know any. The low level of knowledge of danger signs contrasts with a study from Malaysia where up to 70% of mothers knew that jaundice could cause death and brain damage. The inability of the mothers in this study to recognise danger signs quickly may be contributory to a late presentation at health facilities and the high rates of kernicterus seen in Nigeria.,
Respondents' attitudes to NNJ in this study were generally good as the majority (90.4%) of respondents had willingness to take baby to the hospital if their babies developed NNJ. The initial likely actions of the mothers were, however, suggestive of a potential delay in seeking help at hospitals as 56% of the respondents had reported they would watch for some days before taking to the hospital. This was corroborated by the findings in Sagamu  where it was observed that mothers with both good and poor knowledge had delayed at least 48 h before seeking care at the hospital.
Majority of the mothers in this study (64%) attended antenatal care as a means of preventing NNJ and up to 45% of the mothers consciously avoided certain things (such as cold water, groundnuts and palm oil) which could not prevent NNJ. The mothers were involved in a variety of practices to prevent NNJ and are likely to have utilised both useful practices (such as attendance of antenatal, prompt treatment of infections and avoidance of naphthalene balls on baby's clothing) and some ineffective practices such as avoiding palm oil and groundnuts. In terms of preventive practice, it is not surprising that <1% of mothers would avoid the use of naphthalene balls (which is widely used) as only 11% could recognise it as a predisposing factor. The use of ineffective practices in this study has been reported in other places.,
The practices of the respondents regarding the treatment of NNJ in this study varied. The commonest practice, however, was putting the baby in the sun which was done by 58% of the respondents in keeping with a study from Turkey. A multi-centre study in Nigeria also reports more than half (56%) of respondents indicated using potentially harmful menthol substances in treating NNJ or for some other purposes.
Up to 70% of our respondents had poor knowledge of the subject. This is in keeping with studies on the subject in Nigeria ,,, but is rather surprising with the high proportion (36%) of respondents in this study who had tertiary education. Though other studies have found that maternal education was significantly associated with knowledge on NNJ,, our study did not find such an association. This may be due to a generally low level of health literacy even amongst mothers with a high level of education. It may also be that information obtained on the subject is not sufficient to produce an adequate level of knowledge. Therefore, concerted action is necessary if the high rates of complications from NNJ seen in Nigeria are to be reduced., Maternal age was found to have an inverse relationship with the use of appropriate treatment practice. This is not unexpected as younger mothers are more likely to have many sources of information than older women and would more readily bring their children to health facilities than older women. The study being cross-sectional in nature was unable to establish any relationship between knowledge of the subject and the actions they would take if they were faced with a child suffering from NNJ. It also suffers from courtesy and recall biases, but efforts were made to minimise these by assuring respondents of the confidentiality of the information obtained.
| Conclusion|| |
This study shows that although there was a high awareness of NNJ amongst mothers in this community, knowledge on several aspects of the condition was poor. The mothers had good attitudes towards the condition but utilised ineffective preventive and treatment practices. We recommend that NNJ be given more prominent attention in antenatal care clinics; health workers should provide more detailed information and utilise every contact with women of reproductive age to provide information on the subject. The mass media should be encouraged to disseminate more information on the condition.
We are grateful to the mothers who participated in the study and to the Registrars and Medical Officers in the Department of Community Health and Primary Health Care, LASUTH, who assisted with data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gartner LM, Herschel M. Jaundice and breastfeeding. Pediatr Clin North Am 2001;48:389-99.
Bhutani VK, Zipursky A, Blencowe H, Khanna R, Sgro M, Ebbesen F, et al.
Neonatal hyperbilirubinemia and Rhesus disease of the newborn: incidence and impairment estimates for 2010 at regional and global levels. Pediatr Res 2013;74 Suppl 1:86-100.
Tikmani SS, Warraich HJ, Abbasi F, Rizvi A, Darmstadt GL, Zaidi AK. Incidence of neonatal hyperbilirubinemia: a population-based prospective study in Pakistan. Trop Med Int Health 2010;15:502-7.
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;11:285-9.
Iliyasu Z, 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 2010;19:400-6.
Ekwochi U, Ndu IK, Nwokoye IC, Ezenwosu OU, Amadi OF, Osuorah D. Pattern of morbidity and mortality of newborns admitted into the sick and special care baby unit of Enugu State University Teaching Hospital, Enugu state. Niger J Clin Pract 2014;17:346-51.
Dennery PA, Seidman DS, Stevenson DK. Neonatal hyperbilirubinemia. N Engl J Med 2001;344:581-90.
Khalesi N, Rakhshani F. Knowledge, attitude and behaviour of mothers on neonatal jaundice. J Pak Med Assoc 2008;58:671-4.
Amirshaghaghi A, Ghabili K, Shoja MM, Kooshavar H. Neonatal jaundice: knowledge and practice of Iranian mothers with icteric newborns. Pak J Biol Sci 2008;11:942-5.
Egube BA, Ofili AN, Isara AR, Onakewhor JU. Neonatal jaundice and its management: knowledge, attitude, and practice among expectant mothers attending antenatal clinic at University of Benin Teaching Hospital, Benin City, Nigeria. Niger J Clin Pract 2013;16:188-94.
Eneh AU, Ugwu RO. Perception of neonatal jaundice among women attending children out patient and immunization clinics of the UPTH Port Harcourt. Niger J Clin Pract 2009;12:187-91.
Ogunfowora OB, Adefuye PO, Fetuga MB. What do expectant mothers know about neonatal jaundice? Int Electron J Health Educ 2006;9:134-40.
Ogunlesi TA, Abdul AR. Maternal knowledge and care-seeking behaviors for newborn jaundice in Sagamu, Southwest Nigeria. Niger J Clin Pract 2015;18:33-40.
Ezeaka CV, Ugwu RO, Mukhtar-Yola M, Ekure EN, Olusanya BO. Pattern and predictors of maternal care-seeking practices for severe neonatal jaundice in Nigeria: a multi-centre survey. BMC Health Serv Res 2014;14:192.
Boo NY, Gan CY, Gian YW, Lim KS, Lim MW, Krishna-Kumar H. Malaysian mothers' knowledge and practices on care of neonatal jaundice. Med J Malaysia 2011;66:239-43.
Olusanya BO, Akande AA, Emokpae A, Olowe SA. Infants with severe neonatal jaundice in Lagos, Nigeria: incidence, correlates and hearing screening outcomes. Trop Med Int Health 2009;14:301-10.
Sutcuoglu S, Dursun S, Halicioglu O, Ozturk C, Akman S, Yaprak I, et al.
Evaluation of maternal knowledge level about neonatal jaundice. J Matern Fetal Neonatal Med 2012;25:1387-9.
Aladag N, Filiz TM, Topsever P, Gorpelioglu S. Parents' knowledge and behaviour concerning sunning their babies; a cross-sectional, descriptive study. BMC Pediatr 2006;6:27.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
|This article has been cited by|
||Knowledge and attitude on neonatal jaundice among women of reproductive age group in rural community in northern Nigeria
| ||ChineduJohn-Camillus Igboanusi,AwawuGrace Nmadu,IstifanusAnekoson Joshua,MaryOjonema Onoja-Alexander,Benjamin Olatubosun |
| ||Sahel Medical Journal. 2020; 23(3): 184 |
|[Pubmed] | [DOI]|
||Prevalence of and mothers’ knowledge, attitude and practice towards glucose-6-phosphate dehydrogenase deficiency among neonates with jaundice: a cross-sectional study
| ||Zeinab A Kasemy,Wael A Bahbah,Sally M El Hefnawy,Safa H Alkalash |
| ||BMJ Open. 2020; 10(2): e034079 |
|[Pubmed] | [DOI]|
||Maternal Instruction About Jaundice and the Incidence of Acute Bilirubin Encephalopathy in Nigeria
| ||Richard P. Wennberg,Stephen Oguche,Zainab Imam,Zubaida L. Farouk,Isa Abdulkadir,Paul D. Sampson,Tina M. Slusher,Fidelia Bode-Thomas,Bose O. Toma,Christopher S. Yilgwan,David Shwe,Akinyemi O. Ofakunrin,Udochukwu M. Diala,Chris Isichei,Victor Pam,Zuwaira Hassan,Shehu U. Abdullahi,Fatima Usman,Binta W. Jibir,Idris Y. Mohammed,Hadiza A. Usman,Muhammed Abdusalam,Aisha Kuliya-Gwarzo,Fatima I. Tsiga-Ahmad,Laila Umar,William N. Ogala,Fatimatu Abdullahi,Laila Hassan,Saratu Purdue,Troy Lund,Carlos D. Coda-Zabetta |
| ||The Journal of Pediatrics. 2020; |
|[Pubmed] | [DOI]|
||Care-seeking behavior for neonatal jaundice in rural northern Nigeria
| ||Z. Iliyasu,Z. Farouk,A. Lawal,M.M. Bello,N.S. Nass,M.H. Aliyu |
| ||Public Health in Practice. 2020; : 100006 |
|[Pubmed] | [DOI]|
||Knowledge Level and Determinants of Neonatal Jaundice: A Cross-Sectional Study in the Effutu Municipality of Ghana
| ||Prince Adoba,Richard K. D. Ephraim,Kate Adomakowaah Kontor,Joseph-Josiah Bentsil,Patrick Adu,Maxwell Anderson,Samuel Asamoah Sakyi,Paul Nsiah |
| ||International Journal of Pediatrics. 2018; 2018: 1 |
|[Pubmed] | [DOI]|
||Patterns of acute bilirubin encephalopathy in Nigeria: a multicenter pre-intervention study
| ||Udochukwu M Diala,Richard P Wennberg,Isa Abdulkadir,Zubaida L Farouk,Carlos D. Coda Zabetta,Efe Omoyibo,Abieyuwa Emokpae,Aleksandr Aravkin,Bose Toma,Stephen Oguche,Tina Slusher |
| ||Journal of Perinatology. 2018; |
|[Pubmed] | [DOI]|
||Perceptions, practices, and traditional beliefs related to neonatal jaundice among Egyptian mothers
| ||Eman Mohamed Ibraheim Moawad,Enas Abdallah Ali Abdallah,Yahia Zakaria Abdelalim Ali |
| ||Medicine. 2016; 95(36): e4804 |
|[Pubmed] | [DOI]|