Determinants and Outcomes for Neonatal Septicaemia at the Federal Medical Centre Bida, North Central Nigeria.

BACKGROUND: Neonatal septicaemia (NNS) occurs during the first 28 days of life and is characterized by systemic bacterial infection proven by blood culture. It is a leading cause of morbidity and mortality in neonates. Determinants of NNS vary between locations forming the basis for this study. OBJECTIVE: To determine the prevalence and the predisposing factors to neonatal septicaemia among neonates admitted to the neonatal intensive care unit (NICU) of Federal Medical Centre, Bida (FMC Bida). METHODS: This was a one-year prospective observational study, 167 neonates admitted to the neonatal intensive care unit (NICU) of FMC Bida, were selected by purposive sampling method to participate in the study from 13th May, 2015 to 30th April, 2016. A structured questionnaire was filled out by consenting parents and blood samples were collected for laboratory analysis. The data was analyzed using SPSS version 20 (2016). The data were summarized using frequency distributions, means, standard deviation, charts and tables while statistical significance was determined using the chisquare test and Fisher's exact test at a 5% level of significance as well as Odd's Ratio (OR) as appropriate. RESULTS: Of the 167 neonates recruited, 97(58.1%) were males, 70(41.9%) were females and a male: female ratio of 1.4:1. Outborns were 100 (60%), inborns were 67(40%). Mean age was 4.3 ± 1.5 days and the mean weight of 2589 ± 743.9g. The overall prevalence of neonatal sepsis was 2.33% while the blood culture's positive rate was 9.58%. Risk factors identified in the neonates in this study were prolonged rupture of membranes (PROM), chorioamnionitis, meconium-stained liquor, foul-smelling vaginal discharge, being an outborn, having a low birth weight, inability to cry at birth and prematurity but, PROM was the only risk factor significantly associated with septicaemia (OR 5.4; 95% CI 2.2-13.5) while Escherichia coli was the leading bacterial isolate. CONCLUSION: In conclusion, prolonged rupture of membrane was mostly responsible for neonatal septicaemia in this study.

CONTEXTE: La septicémie néonatale (SN) survient au cours des 28premiers jours de vie et se caractérise par une infection bactérienne systémique prouvée par hémoculture. C'est l'une des principales causes de morbidité et de mortalité chez les nouveau-nés. Les déterminants de la NNS varient d'un endroit à l'autre, ce qui constitue la base de cette étude. OBJECTIF: Déterminer la prévalence et les facteurs prédisposant à la septicémie néonatale parmi les nouveau-nés admis dans l'unité de soins intensifs néonatals (USIN) du Centre médical fédéral de Bida (CMF Bida). MÉTHODES: Il s'agissait d'une étude observationnelle prospective d'un an, 167 nouveau-nés admis à l'unité de soins intensifs néonatals (USIN) du FMC Bida, ont été sélectionnés par la méthode d'échantillonnage à dessein pour participer à l'étude du 13 mai 2015 au 30 avril 2016. Un questionnaire structuré a été rempli par les parents consentants et des échantillons de sang ont été prélevés pour des analyses de laboratoire. Les données ont été analysées à l'aide de SPSS version 20 (2016). Les données ont été résumées à l'aide des distributions de fréquence, des moyennes, de l'écart-type, des graphiques et des tableaux, tandis que la signification statistique a été déterminée à l'aide du test du chi-carré et du test exact de Fisher à un niveau de signification de 5 %, ainsi que du rapport d'Odd (OR), le cas échéant. RÉSULTATS: Sur les 167 nouveau-nés recrutés, 97 (58,1 %) étaient des garçons, 70 (41,9 %) étaient des filles, soit un rapport hommes/femmes de 1,4:1. Les nouveau-nés étaient au nombre de 100 (60 %) et les nouveau-nés au nombre de 67 (40 %). L'âge moyen était de 4,3 ± 1,5 jours et le poids moyen de 2589 ± 743,9g. La prévalence globale de la septicémie néonatale était de 2,33 %, tandis que le taux d'hémoculture positive était de 9,58 %. Les facteurs de risque identifiés chez les nouveaunés de cette étude étaient la rupture prolongée des membranes (RPM), la chorioamnionite, la liqueur méconiale, les pertes vaginales nauséabondes, la naissance d'un enfant, le faible poids de naissance, l'incapacité à pleurer à la naissance et la prématurité, mais la RPM était le seul facteur de risque significativement associé à la septicémie (OR 5,4 ; 95% CI 2,2-13,5) tandis qu'Escherichia coli était l'isolat bactérien principal. CONCLUSION: En conclusion, la rupture prolongée des membranes était principalement responsable de la septicémie néonatale dans cette étude. Mots-clés: Nouveau-nés, Septicémie, Facteurs de risque.

Correlation of sonographic inferior vena cava and aorta diameter ratio with dehydration in Nigerian children.

BACKGROUND: Accurate assessment of the degree of dehydration is essential in the management and fluid therapy of dehydrated children. The invasiveness of central venous pressure limits its routine clinical use. Fortunately, some studies have suggested that ultrasonographic measurement of inferior vena cava (IVC) diameter: aorta diameter ratio (IADR) is an objective method of assessing intravascular volume. OBJECTIVES: To determine the clinical usefulness of ultrasound measurement of IADR in assessment of children with dehydration. METHODOLOGY: This was a cross-sectional study which compared dehydrated children to age- and sex-matched euvolemic healthy children as controls. The maximum anteroposterior diameter of the abdominal aorta (at peak systole) and maximum IVC diameter (in expiration) were measured. RESULTS: A total of 120 subjects and 120 controls were evaluated. The mean age was 21.73 ± 20.89 months for subjects and 21.19 ± 22.13 months for control. The mean IADR for children with mild, moderate, and severe dehydration was 0.75 ± 0.07, 0.55 ± 0.07, and 0.33 ± 0.05, respectively. The mean IADR for controls was 0.99 ± 0.06. IADR had an inverse relationship with the degree of dehydration in the subjects. A cut-off point of 0.86, with a sensitivity and specificity of 96.7% in predicting dehydration, was derived, with the sensitivity and specificity increasing with increasing level of dehydration. CONCLUSION: IADR is sensitive and specific for assessing moderate and severe dehydration in Nigerian children.

Role of Risk-Based Approach in the Prevention of Vertical Transmission of Neonatal Sepsis.

AIMS AND OBJECTIVES: Vertical transmission of infections remains a common cause of neonatal morbidity and mortality worldwide. We studied the risk-based approach in preventing the vertical transmission of neonatal sepsis. PATIENTS AND METHODS: A prospective case control study of 154 pregnant women with risk factors for vertical transmission of infections (subjects) and 154 pregnant women without the risk factors (control) at University of Ilorin Teaching Hospital, Ilorin from 1st July to 31st December, 2010. After counseling and consent taking, all participants had active management of labour and all subjects had parenteral intrapartum antibiotic prophylaxis with Ampicillin. There was postnatal evaluation of all babies for signs of neonatal sepsis followed by blood culture and treatment of culture positive babies. The outcome measures were signs and symptoms of neonatal sepsis, neonatal positive blood culture and maternal postpartum morbidity. RESULTS: Neonatal sepsis occurred in 16 babies (subjects=11, control=5); three babies had Early Onset Group B Streptococcal Disease (EOGBSD) (subjects=2, control=1; P=0.501) while 13 had non Group B Streptococcal (GBS) infections (subjects=9, control=4; P=0.113); onset of signs and symptoms was < 24hrs in all cases, incidence of EOGBSD were 12.9/1000 (subjects) and 6.5/1000 (controls). Subjects whose babies had sepsis had multiple risk factors; one dose of antibiotics and antibiotics to delivery interval < 2hours. There was no sepsis in babies of mothers who had adequate antibiotic prophylaxis. There was no maternal or neonatal death but 17.5% of subjects had maternal postpartum morbidities. CONCLUSION: The risk-based approach is a practicable alternative in preventing vertical transmission of neonatal sepsis if antibiotic prophylaxis is adequate before delivery.

Neck trauma: a red-herring to diagnosis of chemodectoma.

Chemodectoma, a neuroendocrine tumour of the paraganglionic cells in the carotid body remains an uncommon tumour. We report the first case from University of Ilorin Teaching Hospital, Ilorin, Nigeria. Though with a red herring history of trauma induced swelling, clinical and radiologic features were characteristic of chemodectoma. Histologic features of the excised lesion are presented.

Posterior reversible encephalopathy syndrome in a adult female.

Posterior reversible encephalopathy syndrome is a clinico-neuroradiologic diagnosis, with rapidly evolving neurologic condition, characterized by headache, confusion, altered mental status, seizures, cortical blindness, lethargy, stupor, and occasionally, focal neurological signs accompanied by a typical computed tomography or magnetic resonance imaging pattern. With early recognition and treatment, complete resolution of symptoms occurs. Typical imaging findings characteristically involve the white matter bilaterally in the parieto-occipital regions. Atypical imaging finding of contrast enhancement of lesion can occur, but is less common. A 20-year-old primiparous lady presented with posterior reversible encephalopathy syndrome. To the best of our knowledge, this is the first documented case in Nigeria. This case-report highlights the importance of recognizing the salient imaging features in this lethal but reversible entity with prompt management.

Congenital giant hydroureteric cistern in a duplex system of an infant.

Duplex collecting system is a congenital genitourinary anomaly commonly found incidentally. Our experience with a duplex system associated with giant hydroureter presenting as mobile abdominal swelling that was noticed from birth, constipation, and failure to thrive is described. Ultrasound and IVU did not assist in making the diagnosis, while a barium enema suggested a colonic duplication. Congenital giant hydroureter should be considered as a differential diagnosis in infants with cystic abdominal swelling. A preserved renal moiety attributed to a dilated ureteric cistern was a unique theory in this case.

Screening programme for retinopathy of prematurity in Ilorin, Nigeria: a pilot study.

BACKGROUND: The Neonatal Intensive Care Unit (NICU) of our hospital has a 30% survival rate among babies born premature weighing <1,000g. This hospital serves about 10 million people; there was no retinopathy of prematurity (ROP) screening program in place in Nigeria. MATERIALS AND METHODS: Babies born premature were recruited based on preset criteria: ≤ 35 weeks Gestation Age and birth weight ≤ 1.9 kg. The first retina examination was done at 3-4 weeks post-delivery and were documented on a proforma and analyzed with SPSS 15 Statistical Package. RESULTS: 58 eyes of 29 babies were examined. The birth weight range was 950-1900g, 17(58.6%) babies were ≤ 1500g, and 12 (41.4%) 1500-1900g. The Gestation age range was 27-35 weeks with a mean of 30. Avascularity in retina zones 2&3 was found in 52(89.6%) eyes mostly among babies <32 weeks gestation age and <1500g. Risk factors associated with retinal avascularity are highlighted. The challenges were with co-ordination of follow-up visits and accessibility to treatment such as laser and newer treatment methods. CONCLUSION: A cost effect screening criteria for ROP in Nigeria is suggested to include birth weight ≤ 1500g and gestational age ≤ 32 weeks. Dedicated staff & resources for treatment and imaging are needed for a successful program. An opportunity exists to study the effect of genetics on the development and severity of ROP among native African babies.

Pattern of perinatal mortality in babies delivered at the university of ilorin teaching hospital, ilorin, Nigeria.

BACKGROUND: Perinatal mortality remains a significant aspect of under-5 mortality, accounting for over 20% of under-five mortality in Nigeria. OBJECTIVE: To determine the pattern of perinatal mortality in the University of Ilorin Teaching Hospital, Ilorin. METHODS: This was a prospective study conducted at the University of Ilorin Teaching Hospital. Data on socio-biologic, antenatal and peripartum characteristics of 1969 gravid women was obtained over a 7-month period (April 2006-October 2006). Data on the 2042 babies delivered was also taken and these babies were followed up till discharge or death. RESULTS: There were 166 perinatal deaths (106 stillbirths and 60 perinatal deaths) out of the 2042 live and stillbirths during the study period (%). The perinatal mortality rate was 81 per 1000 live and stillbirths with a stillbirth rate of 52 per 1000 live and stillbirths and an early neonatal mortality rate of 31 per 1000 livebirths. Among the stillbirths, fresh stillbirths predominated over macerated stillbirths (1.4:1). Severe perinatal asphyxia was the most important cause of death in all birthweight categories except in extremely low birthweight babies were immaturity was more important. Prolonged labour was responsible for 42.6 % of those with severe perinatal asphyxia. CONCLUSIONS: There is an urgent need to improve the monitoring of women in labour to reduce the prevalence of prolonged obstructed labour and increase capacity to provide essential newborn care. There is also need to improve on capacity and facilities for the management of babies with severe perinatal asphyxia and prematurity.

Sickle cell Nephropathy in children seen in an African Hospital - Case Report.

AIMS AND OBJECTIVES: To determine and report the occurrence of overt renal presentations in children with sickle cell disease seen over the last 14 years (1995-2009) at the Emergency Paediatric Unit and Paediatric Ward and followed up at the Paediatric Nephrology clinic of University of Ilorin Teaching Hospital, Ilorin (UITH). PATIENTS AND METHODS: The five cases with overt renal presentations seen during the period were reported and analyzed for age, sex, and renal manifestations. RESULTS: The age range of the children was 9-15years with a mean of 11years. Four of the five patients were females, with one male. Three of the four females presented with features suggestive of nephrotic syndrome (NS) while the other one had gross haematuria which resolved within 24 hours. The only male had enuresis. The NS in one of the patients progressed to end stage renal disease requiring renal replacement therapy. CONCLUSION: Children with sickle cell disease should be screened for renal complications especially from the late first decade of life. This will help in the early detection of renal disorder that could lead to chronic kidney disease. It is also suspected that the severe forms of SCN such as NS may have a predilection for the female gender. A more extensive study is needed to test the veracity of this observation.

Bladder stone in a three-year-old Nigerian child with posterior urethral valve: a case report.

BACKGROUND: Stone in the bladder is an uncommon presentation in the tropics, especially in children. Its rarity makes the index of suspicion to be low. Patients presenting with it may be mistaken for urinary tract infection (UTI) because of the presence of frequency and dysuria. OBJECTIVE: To present a rare cause of urinary bladder stone in a child in the tropics. METHODS: The patient, a three-year-old boy, presented with recurrent episodes of dysuria and stragury for a duration of about one year. Work up included clinical evaluation and laboratory assessments, results of which informed surgical intervention. RESULTS: The child had been treated repeatedly for urinary tract infection. He was acutely ill with suprapubic tenderness dysuria and poor urinary stream. He was hypertensive. Micturating cystourethrography showed posterior urethral valves and a bladder stone. He had vesicolithotomy and valvotomy with improvement of his blood pressure. CONCLUSION: The coexistence of bladder stone with PUV coupled with delayed diagnosis may be a predisposing factor to hypertension in children. Conventional surgical treatment gives good results.

Methicillin resistant Staphylococcus aureus: awareness, knowledge and disposition to screening among healthcare workers in critical care units of a Nigerian hospital.

BACKGROUND: Awareness level about methicillin resistant Staphylococcus aureus (MRSA) is high in the western world but the status in developing countries is not well defined. OBJECTIVE: To assess MRSA awareness level, knowledge and disposition to screening among critical healthcare givers (HCGs) in Nigeria. METHODS: A self-administered questionnaire was used to assess the level of awareness and knowledge of HCGs in critical care units of the University of Ilorin Teaching Hospital, Ilorin, Nigeria on MRSA and their willingness to submit to screening. RESULTS: Only 103 (52.0%) of the 198 participants were aware of MRSA but all were favourably disposed to screening for the organism. Awareness was through hospital rounds 65(63.1%) and journals/ textbooks 35(34.0%), and Many, 120 (60.6%) considered MRSA as a threat in the hospital, while only 27 (13.6%) thought otherwise and 51(25.8%) were indifferent. Most HCGs, 124 (87.9%) reported that there were no MRSA control measures in their respective duty post. The age, cadre of work, and number of years in the hospital's critical care units correlated positively with awareness level. CONCLUSION: Methicillin resistant Staphylococcus aureus awareness level among the HCGs in our hospital is just a little above 50.0% with substantial proportion of them not realizing the medical implication of the organism. However, majority are well disposed to MRSA screening. Inadequate publicity is a major contributor to poor knowledge and awareness. There is need for educational intervention and sensitization programs on MRSA and other infection control techniques for HCGs in developing nations especially Nigeria.

Peripheral vascular surgical procedures in Ilorin, Nigeria: indications and outcome.

BACKGROUND: Data on peripheral vascular surgical interventions from Nigeria is scanty. Reports form Western and Eastern Nigeria dates back about two decades. This study therefore analyses the various etiological conditions necessitating intervention, and their outcome. METHODS: A retrospective analysis of patients requiring surgical intervention on peripheral vessels from a prospectively collected single surgeon database over a two-year period was conducted. Data were analysed using SPSS version 15.0 windows statistical package. RESULTS: Fourteen peripheral vascular surgical procedures were performed. The age range was 2-70 years (24.4 ± 16.3) with five cases (35.7%) in 20-29 year group. Trauma accounted for 11 (73.3%) cases. Upper limb involvement occurred in 7 (63.6%) of the traumatic cases whereas all 2 true aneurysm occurred in the lower limb. Direct repair was possible in re-establishing anatomic continuity in about 64% of cases. Of the six morbidities, wound infection accounted for 50% followed by failure of re-vascularizaton (33.3%) and there was one mortality. CONCLUSION: Trauma is the leading cause of peripheral vascular condition necessitating surgery from our study. Young adults predominate. Though direct repair are often feasible, there is a need for the availability of graft options. Wound infection constitutes the highest post-operative morbidity.

Haemophilus meningitis in an African neonate: time for active surveillance and institution of appropriate control measure.

BACKGROUND: Childhood routine immunization in Nigeria, like most developing nations, do not include vaccination against Haemophilus influenzae type b (Hib) infection. This is probably because infection with Hib is uncommon in children younger than two months due to passive acquisition of maternal antibodies which protects newborn till about four to six months of life. OBJECTIVE: To illustrate a case of neonatal meningitis caused by Haemophilus influenzae and to highlight its other peculiarities. METHODS: A 22-day old baby presented with excessive crying, refusal of feed, progressive abdominal distension, fever and vomiting. Besides clinical assessment, body fluids were cultured. RESULTS: The baby had tachypnoea (90 bpm), tachycardia (182 bpm), and tympanitic and hypoactive abdomen. The musculoskeletal and central nervous systems appeared clinically normal. Haemophilus influenzae was isolated by culture from the cerebrospinal fluid. The baby responded well to treatment with ceftriaxone and gentamycin. Neurological examination has remained normal after discharge for up to three months at follow-up visit. CONCLUSION: There is the need to provide serological and molecular facilities for typing Nigerian Haemophilus infulenzae strain(s) to enhance the development of appropriate vaccine that will be most suitable for prevention of infection due to this organism in Nigeria. However, presently available Haemophilus influenzae vaccine needs to be listed in the National Programme for Immunization (NPI) for the control of infections associated with this organism especially in childhood.

Traumatic diaphragmatic hernia masquerading as left-sided hydropneumothorax: a case report.

Traumatic diaphragmatic rupture (TDR) is rare in children and can be easily overlooked because of lack of awareness of late presentation and concomitant injuries. A 4-year-old girl presented with respiratory distress 2 months after a road traffic accident. The initial differential diagnosis was pneumonia or pulmonary tuberculosis with associated pleural effusion. On further assessment, a diaphragmatic hernia was suspected. The initial radiograph showed left hydropneumothorax. Fluoroscopy, follow-up chest radiographs and barium swallow confirmed the diagnosis of left TDR. Surgery was undertaken but unfortunately she did not survive. Awareness of delayed presentation of TDR is essential for prompt management.

Gastrointestinal duplications: Experience in seven children and a review of the literature.

BACKGROUND/AIM: Enteric duplication (ED) is a rare congenital anomaly that can occur anywhere along the alimentary tract from the mouth , down to the anus and the nearby organs. This uncommon anomaly may be asymptomatic or presents with vague symptoms mimicking other common pathologies. We aim to present our experience, management challenges and patterns of ED with a review of the literature. SETTINGS AND DESIGN: The study was carried out at a Nigerian Tertiary Hospital (2005-2008 inclusive). MATERIALS AND METHODS: We retrospectively analyzed seven patients with ED managed in our hospital for sex, age, clinical presentations, duplication size and site, presence of ectopic tissue, complications, associated anomalies, radiological workups, and prognosis. Data was analyzed using SPSS 11.0 for window. RESULTS: Seven children between the age range of 44 hours-10 years had ED, one sublingual and six intraabdominal duplications. Midgut volvulus with long segment bowel gangrene complicated two cases. The diagnosis was incidental in all. Three cases were diagnosed following conventional radiological contrast examination and the rest at surgery. Ultrasound was not helpful in making diagnosis in all the six intraabdominal duplications. Though surgery was recommended for all, one of the patients declined. Only one patient had unsuccessful surgery. CONCLUSIONS: ED requires high index of clinical suspicion and careful management. Many cases of nonspecific abdominal pains should be properly evaluated before patients suffer avoidable complications.

Determinants of mortality of preterm babies in the university of Ilorin Teaching Hospital, Ilorin Nigeria.

AIMS AND OBJECTIVES: A prospective study to identify the determinants of mortality among 185 preterm babies at the University of Ilorin Teaching Hospital, Ilorin. SUBJECTS AND METHODS: Data on 185 preterm babies and their mothers were collected over a nine month period in a tertiary hospital to identify the determinants of mortality among these babies. RESULTS: Factors identified as significant determinants of mortality were severe perinatal asphyxia (p = 0.000; OR = 71.31; 95% CI = 17.63-308.24), apnoea (p = 0.000; OR = 178.20; 95% CI = 20.64-7709.02), necrotizing entero-colitis (p = 0.001) and resuscitation duration (p = 0.003; OR = 5.33; 95% CI = 1.62-19.02). CONCLUSION: The primary causes of death are severe perinatal asphyxia, respiratory distress syndrome and infection. In Nigeria, survival below 28 weeks gestation is less than 20%. The findings in this study highlight the need for prompt and effective resuscitation of these infants by a trained health worker with verifiable competence in newborn resuscitation. It also highlights the need for availability of functional facilities like ventilators and resources like surfactant.

Congenital gastric outlet obstruction and nonimmune hydrops fetalis: a prenatal sonographic diagnosis of a case with hydrothorax and ascites.

A case of a male fetus with sonographic diagnosis of hydrops fetalis at 19-week gestation is reported. The fetus had anasarca, bilateral massive pleural effusion, and ascites, in addition to cardiac arrhythmia and congenital gastric outlet obstruction. Mother's clinical history and laboratory workup excluded immune hydrops. The etiological dilemma and fetal outcome are discussed. We concluded, based on this case, that when fetal hydrops occurs early and is associated with multiple congenital anomalies, prolonging the pregnancy may be futile.

Poisoning due to yam flour consumption in five families in Ilorin, Central Nigeria.

BACKGROUND: Food poisoning is known to occur sporadically from time to time due to poor hygienic preparation. Its occurrence rarely assumes epidemic proportion. OBJECTIVE: To report the ccurrence of food poisoning due to yam flour consumption among five families and to create public awareness about the condition. CASE REPORT: Food poisoning due to yam flour consumption which occurred almost in quick succession between February and July 2005 among five family clusters in Ilorin is reported. They presented variedly with diarrhoea, vomiting, abdominal pain, convulsion and loss of consciousness. They all recovered within 48 hours of admission. Even though we could not carry out toxicological tests, yam flour consumption was highly implicated as the cause. Investigations indicated that the use of certain lethal preservatives for the processing of the yam flour might be responsible. CONCLUSION: Poisoning from consumption of yam flour should be a differential diagnosis of acute seizure disorder or the occurrence of vomiting, diarrhoea and abdominal pain in the tropics. We recommend education on proper processing of all food products in view of the public health implication of doing otherwise.

Digitally recycled incubators: better economic alternatives to modern systems in low-income countries.

UNLABELLED: The need to maintain a neutral thermal environment is critical to newborn care. AIM: To investigate reasons for the insufficiency of functional incubators and develop a cost-effective technique for using electronic digital components to recycle obsolete incubators in Nigeria. METHODS: Following interview of 84 clinicians and administrators in Nigerian hospitals, it was identified that inadequate funding was the main reason for lack of functional incubators. Two groups of incubator units were then created and their performance compared. Sixteen units of modern (group A) and 19 units of obsolete (group B) incubators were obtained from six hospitals. An assembly design applying independent generic components for recycling systems was specified and produced. These were sourced through the internet at competitive cost and fitted into the reconstructed panels of the obsolete systems. The functional performance of each recycled system was rigorously monitored for 6 months and graded using ten performance indices. The same indices were used to quantify group A systems. RESULTS: The performance of the recycled incubators (group B) was found to be similar to those of modern incubators. Group B's cost index was found to be 25% of that of group A's. CONCLUSION: Appropriate incubator recycling is a cost-effective method of re-equipping hospitals in low-income countries.