Clinical Outcomes and Determinants of Neonatal Hyperbilirubinemia Among NICU Admissions: A Retrospective Study in Ethiopia

Clinical Outcomes and Determinants of Neonatal Hyperbilirubinemia Among NICU Admissions: A Retrospective Study in Ethiopia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Outcomes and Determinants of Neonatal Hyperbilirubinemia Among NICU Admissions: A Retrospective Study in Ethiopia Bacha Gishu (BG) 1, Ayalneh Demissie This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8675828/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Neonatal hyperbilirubinemia is a significant clinical concern in developing nations. This institution-based retrospective cross-sectional study assessed the clinical outcomes and determinants of jaundice at the Asella Referral and Teaching Hospital (ARTH) NICU in South East Ethiopia. Out of 183 randomly selected neonates, the prevalence of hyperbilirubinemia was 16.4% (95% CI: 11–21.8). The majority of jaundiced neonates presented with high admission total serum bilirubin levels between 15 and 19 mg/dL. Multivariate logistic regression identified inadequate breastfeeding (AOR 9.507, 95% CI: 1.244–72.671, p = 0.030) and neonatal sepsis (AOR 3.707, 95% CI: 1.337–10.276, p = 0.012) as the primary independent predictors. Clinical outcomes were generally positive (93.3% improvement), though high admission bilirubin levels suggest delays in recognition. Management was robust, with 26.7% requiring exchange transfusion. These findings highlight the urgent need for universal pre-discharge screening and robust lactation support to mitigate preventable neurological sequelae in Ethiopian neonates. Pediatrics Neonatal jaundice Ethiopia sepsis breastfeeding failure hyperbilirubinemia clinical outcomes NICU Figures Figure 1 Introduction Neonatal hyperbilirubinemia results from an imbalance between bilirubin production and clearance, characterized by the accumulation of unconjugated bilirubin pigment in the skin and mucus membranes [ 1 , 2 ]. For most neonates, this is a benign transition; however, excessive levels can cross the blood-brain barrier, leading to irreversible bilirubin-induced neurologic dysfunction or kernicterus [ 3 , 4 , 5 ]. Globally, 1.1 million babies develop severe hyperbilirubinemia annually, with 75% of the burden concentrated in sub-Saharan Africa and South Asia [ 6 ]. In Ethiopia, where the neonatal mortality rate remains high at 33 per 1,000 live births, jaundice is recognized by the WHO as a critical danger sign [ 7 , 8 ]. Recent systematic reviews indicate a pooled prevalence of neonatal jaundice in Ethiopia of 30.96% (95% CI 16.61%–45.31%) [ 9 ]. The physiological basis involves higher red blood cell turnover and immature hepatic conjugation enzymes [ 1 , 2 , 10 ]. Pathological factors—such as sepsis, hemolytic diseases, or inadequate caloric intake—exacerbate this process [ 11 – 13 ]. While multi-center studies in Ethiopia have shown high prevalence in preterm populations, localized data for specialized care settings like Asella remain scarce [ 14 , 15 ]. This study aims to identify the clinical outcomes and maternal/neonatal determinants driving jaundice in this region to help transition from reactive to proactive management strategies [ 6 , 16 ]. Results Sociodemographic and clinical characteristics of NICU admissions, ARTH The study included 183 neonates with a slight male preponderance (53%). The majority (62.8%) were admitted within the first two days of postnatal life (Table 1 ). Most neonates (64%) had a birth weight between 2500g and 4000g, and 70% were born at term [ 1 ]. Table 1 Sociodemographic and clinical characteristics of NICU admissions, ARTH (N = 183) Characteristic Category Frequency (n) Jaundiced Cases (n = 30) Gender Male 97 14 Female 86 16 Age at Admission 14 days 12 0 Gestational Age Preterm (< 37 weeks) 53 7 Term (37–42 weeks) 128 23 Birth Weight 4000g 11 3 Magnitude and Causes of neonatal jaundice among NICU admissions, AURTH The prevalence of confirmed hyperbilirubinemia was 16.4% (30 cases) [ 1 ]. As shown in Fig. 1 , the primary underlying cause was sepsis (20%), followed by ABO incompatibility (23.3%, n = 7), prematurity (16.7%), Rh-isoimmunization (13.3%), and breastfeeding failure jaundice (13.3%). Contributing factors of neonatal jaundice in NICU, ARTH Multivariate logistic regression revealed that inadequate breastfeeding and neonatal sepsis were the only independent predictors of jaundice (Table 2 ). Neonates with inadequate breastfeeding were nearly 10 times more likely to develop hyperbilirubinemia (AOR 9.507), while those with sepsis faced a nearly 4-fold risk (AOR 3.707). Table 2 Multivariate analysis of determinants for neonatal jaundice at ARTH NICU Variable Category AOR (95% CI) P-value Breastfeeding Inadequate vs. Adequate 9.507 (1.244–72.671) 0.030 * Neonatal Sepsis Yes vs. No 3.707 (1.337–10.276) 0.012 * Birth Injury Yes vs. No 0.843 (0.179–3.972) 0.829 Mode of Delivery C-Section vs. SVD 1.120 (0.450–2.780) 0.806 Clinical Outcomes and Management Management was robust: 73.3% received phototherapy alone, while 26.7% required double-volume exchange transfusion [ 1 ]. Clinical outcomes were positive for 93.3% (n = 28) of jaundiced neonates who improved and were discharged. One death (3.3%) and one referral for further management (3.3%) were recorded. Discussion The 16.4% prevalence of neonatal hyperbilirubinemia at Asella is higher than the 13.3% reported at St. Paul’s Hospital but significantly lower than the 44.9% at Tikur Anbessa Specialized Hospital [ 17 , 20 ]. Our finding is also slightly lower than recent data from Southwest Oromia, where a 2023 multi-center study reported a prevalence of 20.5% [ 15 ]. These variations likely reflect institutional referral patterns and local screening protocols; for instance, Jimma Medical Center recently reported prevalence as high as 42.3% [ 21 ]. The identification of inadequate breastfeeding as a dominant determinant (AOR 9.5) aligns with international literature and recent 2025 Ethiopian studies highlighting "breastfeeding failure" as a leading risk factor (AOR 5.35 in Gurage Zone) [ 22 ]. Caloric deprivation in these infants leads to decreased bowel movements and increased enterohepatic circulation of bilirubin [ 1 , 2 , 23 ]. Neonatal sepsis remains a critical etiologic cause (20%) and determinant (AOR 3.7), mirroring findings in Northern Ethiopia and 2025 follow-up studies [ 13 , 16 , 24 ]. Haemolytic causes, including ABO and Rh incompatibilities, accounted for a third of cases, emphasizing gaps in Rh prophylaxis [ 6 , 25 ]. Regarding clinical outcomes, the high rate of exchange transfusion (26.7%) suggests that neonates often present late with advanced bilirubin levels [ 26 , 27 ]. This trend of late presentation and high exchange requirements (up to 24.1% in some automated assessments) underscores the ongoing challenge of early detection in the region. Universal pre-discharge screening and improved maternal lactation support are essential for reducing the burden of severe hyperbilirubinemia and improving clinical outcomes in Ethiopia [ 7 , 8 , 28 , 29 ]. Strengths and Limitations Strengths: This study provides localized data for the Arsi Zone, filling a critical gap in regional neonatal health statistics. The use of multivariate analysis allowed for the isolation of specific independent predictors (sepsis and breastfeeding), providing clear targets for clinical intervention. The inclusion of very recent 2024 and 2025 data ensures the study reflects current clinical trends in Ethiopia. Limitations As a retrospective cross-sectional study, it relies on the accuracy of existing medical records, which may have occasional missing data points. The study was conducted at a single referral center; therefore, the findings may not be fully generalizable to primary healthcare settings or home births. The sample size, while statistically calculated, limited the ability to perform sub-group analyses on rarer etiologies of jaundice. Conclusion and Recommendations Conclusion The prevalence of neonatal hyperbilirubinemia at ARTH (16.4%) is a significant public health concern. Inadequate breastfeeding and neonatal sepsis are the primary drivers of jaundice in this population. While clinical outcomes are largely positive, the high rate of exchange transfusions (26.7%) indicates that neonates are often identified and treated only after reaching critical bilirubin thresholds. Recommendations For Clinicians : Implement universal pre-discharge bilirubin screening for all neonates, regardless of whether they appear jaundiced. For Hospital Management : Strengthen lactation support services within the NICU and postnatal wards to prevent "breastfeeding failure" jaundice. For Policy Makers : Integrate neonatal jaundice awareness into antenatal care (ANC) and postnatal care (PNC) packages to encourage early hospital presentation. For Researchers : Future prospective studies should investigate the long-term neurodevelopmental outcomes of neonates who underwent exchange transfusions. Methods Study Design, Setting and period This was an institution-based retrospective cross-sectional study conducted at the Asella Teaching and Referral Hospital (ARTH), Ethiopia [ 1 ]. Data were reviewed for neonates admitted to the 42-bed NICU between September 1, 2023, and August 31, 2024. Population and Selection Criteria Source and Study Population The source population consisted of all neonates admitted to the Neonatal Intensive Care Unit (NICU) at ARTH in the Southeast Oromia Region, Ethiopia. The study population specifically included all neonates admitted to the ARTH NICU between September 1, 2023, and August 31, 2024. Inclusion and Exclusion Criteria Inclusion Criteria : All neonates admitted to the NICU with a diagnosis of jaundice during the defined study period were eligible for inclusion. Exclusion Criteria : To ensure the study focused on neonatal unconjugated hyperbilirubinemia and its primary determinants, the following were excluded: Neonates with cholestasis or conjugated bilirubin levels exceeding 15% of the total bilirubin. Neonates transferred from other primary or general hospitals specifically for exchange transfusion. This exclusion was applied to minimize referral bias and ensure the findings reflect the local clinical determinants and outcomes of the immediate catchment area. Selection Criteria and Sampling The study population included neonates admitted with complete medical records. Sample size was determined using a single population proportion formula based on a previous 13.3% prevalence [ 17 , 18 ]. After a 10% dropout adjustment and correction for the 1,350 annual admissions, a final sample of 183 was reached [ 1 ]. Systematic random sampling was used to select every 7th record (K = 7). Variables and Definitions The primary outcome was hyperbilirubinemia (TSB > 5 mg/dL) [ 3 , 10 ]. Independent variables included socio-demographics, neonatal factors (sepsis, prematurity), and maternal factors (blood groups). Breastfeeding failure was defined by poor intake and frequency in the first few days [ 1 , 19 ]. Operational Definitions Neonatal Hyperbilirubinemia : Defined as a total serum bilirubin (TSB) level greater than 85µmol/l (5mg/dl) [ 7 , 10 ]. Breastfeeding Jaundice : Jaundice occurring within the first few days of life, specifically related to inadequate breast milk intake and decreased feeding frequency [ 1 , 2 ]. Breast Milk Jaundice : Late-onset jaundice beginning after the 4th to 7th day of life, caused by increased reabsorption of unconjugated bilirubin [ 1 , 2 , 23 ]. Bilirubin Encephalopathy : A clinical syndrome associated with bilirubin toxicity in the central nervous system, resulting in chronic and permanent neurological sequelae [ 5 , 12 ]. Data Collection Procedure Data were collected using a structured checklist developed by the investigators following an extensive review of relevant literature. To ensure the reliability of the instrument, the checklist was pretested on 5% of the sample size prior to full data collection; necessary adjustments were made by the investigators based on the pre-test findings. The checklist was designed to capture maternal sociodemographic data and neonatal clinical information. To maintain confidentiality, patient names and medical card numbers were excluded from the data collection tool. Data Quality Assurance To ensure the integrity of the findings, the research team implemented rigorous quality control measures. Data collection was closely monitored by supervisors to ensure completeness, consistency, and accuracy . As noted, a 5% pre-test was conducted to standardize data extraction. During the main collection phase, the research team held regular review sessions to address any discrepancies and ensure a uniform understanding of the clinical records. Statistical Analysis The data were meticulously cleaned to address inconsistencies and missing values before analysis. Data entry was performed using Epi-data version 4.6.0.2 , and subsequently exported to STATA version 17 for statistical processing. Descriptive statistics, including means with standard deviations for continuous variables and frequencies with percentages for categorical variables, were computed to summarize the cohort's characteristics. To identify determinants of neonatal hyperbilirubinemia, a two-stage regression approach was employed: Bivariable Logistic Regression : Each predictor variable was initially screened; variables with a p-value < 0.25 were considered candidates for the final model. Multivariable Logistic Regression This was performed to control for confounding factors. Results were reported as Adjusted Odds Ratios (AOR) with 95% Confidence Intervals (CI). A p-value < 0.05 was used to define statistical significance [ 1 ]. The model's goodness-of-fit was validated using the Hosmer-Lemeshow test , and the absence of multicollinearity among independent variables was confirmed using Variance Inflation Factors (VIF) . Finally, the results were presented using a combination of text, tables, and graphical representations. Ethical Approval and Consent to Participate Ethical approval was obtained from the Ethical Review Committee (ERC) of the College of Health Sciences, Arsi University ( Protocol/ID: A/CHS/RC/103/2024, August 2024 ). Due to the retrospective nature of the study, the requirement for informed consent was waived by the ERC. All patient information retrieved from medical records was handled with strict confidentiality. To preserve anonymity, patient names were replaced with unique identification numbers during data extraction and analysis. All procedures were conducted in accordance with relevant national guidelines, regulations, and the principles of the Declaration of Helsinki. Declarations Funding This research received no funding. Author Contributions B.G. and T.G. conceived the study, designed the methodology, and performed data curation. B.G. conducted the software-based data collection, statistical analysis, and data interpretation. T.G. , A.D. , G.W. , and A.W. performed validation and reviewed the manuscript for critical intellectual content. All authors read and approved the final version for submission. Acknowledgements The authors would like to express their sincere gratitude to Arsi University, College of Health Sciences, for providing the ethical clearance and support necessary to conduct this study. We extend our appreciation to the staff of the Asella Referral and Teaching Hospital (ARTH) medical records office for their technical assistance during the data collection process. Finally, we thank the healthcare providers at the ARTH NICU for their dedication to improving neonatal outcomes in the region. Data Availability All data generated or analyzed during this study are included in this published article. Further datasets are available from the corresponding author on reasonable request. Competing Interests The authors declare no competing interests. References Hoskins NM (1976) Nelson Textbook of Pediatrics User A, Bank EK (2015) Fanaroff and Martin’s Neonatal-Perinatal Medicine Jamir AS (2016) A study of neonatal hyperbilirubinemia in India Brown SB, King RFGJ (1978) The mechanism of haem catabolism Das S, Landeghem FKH (2019) Spectrum of bilirubin encephalopathy Olusanya BO et al (2018) Neonatal jaundice and global child mortality UNICEF & WHO. Caring for the Newborn at Home (2012) Kaewkiattikun K (2017) Effects of postpartum contraceptive counseling Belay HG et al (2022) Determinants of neonatal jaundice in Ethiopia: meta-analysis Anderson NB, Calkins KL (2020) Neonatal indirect hyperbilirubinemia Roma KM et al (2017) Neonatal hyperbilirubinemia in Nepal Du L, Ma X (2012) Guidelines for Management of Hyperbilirubinemia Ochigbo SO et al (2016) Bilirubin encephalopathy in Nigeria Aynalem S et al (2020) Hyperbilirubinemia in Preterm Infants in Ethiopia Gemechu K et al (2023) Jaundice in southwest Oromia, Ethiopia Nyangabyaki-Twesigye C et al (2020) Treatment outcome in Uganda Haile MT (2020) Neonatal Jaundice at St Paul’s Hospital Bhutani VK et al (1999) Predictive ability of predischarge bilirubin Mehta S et al (2018) Study from a tertiary care hospital in India Hariyati (2017) Magnitude of neonatal hyperbilirubinemia at Black Lion Hospital Jimma Medical Center Study. Prevalence and associated factors (2024) Gurage Zone Study. Determinants among neonates in NICU (2025) Pandey N et al (2013) Physiological jaundice: role in oxidative stress Ameya Primary Hospital Study. Incidence and predictors (2025) Patel AS et al (2017) Association of ABO and Rh incompatibility Kalraiya A et al (2018) Clinico-etiological profile of neonates Althomali R et al (2018) Neonatal jaundice causes and management Brits H et al (2018) Prevalence of neonatal jaundice in Bloemfontein Ogunlesi TA et al (2011) Predictors of acute bilirubin encephalopathy Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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For most neonates, this is a benign transition; however, excessive levels can cross the blood-brain barrier, leading to irreversible bilirubin-induced neurologic dysfunction or kernicterus [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Globally, 1.1\u0026nbsp;million babies develop severe hyperbilirubinemia annually, with 75% of the burden concentrated in sub-Saharan Africa and South Asia [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In Ethiopia, where the neonatal mortality rate remains high at 33 per 1,000 live births, jaundice is recognized by the WHO as a critical danger sign [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent systematic reviews indicate a pooled prevalence of neonatal jaundice in Ethiopia of 30.96% (95% CI 16.61%\u0026ndash;45.31%) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The physiological basis involves higher red blood cell turnover and immature hepatic conjugation enzymes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Pathological factors\u0026mdash;such as sepsis, hemolytic diseases, or inadequate caloric intake\u0026mdash;exacerbate this process [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While multi-center studies in Ethiopia have shown high prevalence in preterm populations, localized data for specialized care settings like Asella remain scarce [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This study aims to identify the clinical outcomes and maternal/neonatal determinants driving jaundice in this region to help transition from reactive to proactive management strategies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and clinical characteristics of NICU admissions, ARTH\u003c/h2\u003e \u003cp\u003eThe study included 183 neonates with a slight male preponderance (53%). The majority (62.8%) were admitted within the first two days of postnatal life (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most neonates (64%) had a birth weight between 2500g and 4000g, and 70% were born at term [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and clinical characteristics of NICU admissions, ARTH (N\u0026thinsp;=\u0026thinsp;183)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJaundiced Cases (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at Admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;6 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u0026ndash;14 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;14 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational Age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreterm (\u0026lt;\u0026thinsp;37 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTerm (37\u0026ndash;42 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth Weight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2500g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2500g \u0026ndash; 4000g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;4000g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMagnitude and Causes of neonatal jaundice among NICU admissions, AURTH\u003c/h3\u003e\n\u003cp\u003eThe prevalence of confirmed hyperbilirubinemia was 16.4% (30 cases) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the primary underlying cause was sepsis (20%), followed by ABO incompatibility (23.3%, n\u0026thinsp;=\u0026thinsp;7), prematurity (16.7%), Rh-isoimmunization (13.3%), and breastfeeding failure jaundice (13.3%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eContributing factors of neonatal jaundice in NICU, ARTH\u003c/h3\u003e\n\u003cp\u003eMultivariate logistic regression revealed that inadequate breastfeeding and neonatal sepsis were the only independent predictors of jaundice (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Neonates with inadequate breastfeeding were nearly 10 times more likely to develop hyperbilirubinemia (AOR 9.507), while those with sepsis faced a nearly 4-fold risk (AOR 3.707).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analysis of determinants for neonatal jaundice at ARTH NICU\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBreastfeeding\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInadequate vs. Adequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.507 (1.244\u0026ndash;72.671)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeonatal Sepsis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes vs. No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.707 (1.337\u0026ndash;10.276)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth Injury\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes vs. No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.843 (0.179\u0026ndash;3.972)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of Delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC-Section vs. SVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.120 (0.450\u0026ndash;2.780)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.806\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eClinical Outcomes and Management\u003c/h3\u003e\n\u003cp\u003eManagement was robust: 73.3% received phototherapy alone, while 26.7% required double-volume exchange transfusion [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Clinical outcomes were positive for 93.3% (n\u0026thinsp;=\u0026thinsp;28) of jaundiced neonates who improved and were discharged. One death (3.3%) and one referral for further management (3.3%) were recorded.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe 16.4% prevalence of neonatal hyperbilirubinemia at Asella is higher than the 13.3% reported at St. Paul\u0026rsquo;s Hospital but significantly lower than the 44.9% at Tikur Anbessa Specialized Hospital [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our finding is also slightly lower than recent data from Southwest Oromia, where a 2023 multi-center study reported a prevalence of 20.5% [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These variations likely reflect institutional referral patterns and local screening protocols; for instance, Jimma Medical Center recently reported prevalence as high as 42.3% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe identification of inadequate breastfeeding as a dominant determinant (AOR 9.5) aligns with international literature and recent 2025 Ethiopian studies highlighting \"breastfeeding failure\" as a leading risk factor (AOR 5.35 in Gurage Zone) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Caloric deprivation in these infants leads to decreased bowel movements and increased enterohepatic circulation of bilirubin [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Neonatal sepsis remains a critical etiologic cause (20%) and determinant (AOR 3.7), mirroring findings in Northern Ethiopia and 2025 follow-up studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHaemolytic causes, including ABO and Rh incompatibilities, accounted for a third of cases, emphasizing gaps in Rh prophylaxis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Regarding clinical outcomes, the high rate of exchange transfusion (26.7%) suggests that neonates often present late with advanced bilirubin levels [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This trend of late presentation and high exchange requirements (up to 24.1% in some automated assessments) underscores the ongoing challenge of early detection in the region. Universal pre-discharge screening and improved maternal lactation support are essential for reducing the burden of severe hyperbilirubinemia and improving clinical outcomes in Ethiopia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eStrengths:\u003c/h2\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e This study provides localized data for the Arsi Zone, filling a critical gap in regional neonatal health statistics.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe use of multivariate analysis allowed for the isolation of specific independent predictors (sepsis and breastfeeding), providing clear targets for clinical intervention.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe inclusion of very recent 2024 and 2025 data ensures the study reflects current clinical trends in Ethiopia.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAs a retrospective cross-sectional study, it relies on the accuracy of existing medical records, which may have occasional missing data points.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe study was conducted at a single referral center; therefore, the findings may not be fully generalizable to primary healthcare settings or home births.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe sample size, while statistically calculated, limited the ability to perform sub-group analyses on rarer etiologies of jaundice.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e "},{"header":"Conclusion and Recommendations","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e The prevalence of neonatal hyperbilirubinemia at ARTH (16.4%) is a significant public health concern. Inadequate breastfeeding and neonatal sepsis are the primary drivers of jaundice in this population. While clinical outcomes are largely positive, the high rate of exchange transfusions (26.7%) indicates that neonates are often identified and treated only after reaching critical bilirubin thresholds.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFor Clinicians\u003c/b\u003e: Implement universal pre-discharge bilirubin screening for all neonates, regardless of whether they appear jaundiced.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFor Hospital Management\u003c/b\u003e: Strengthen lactation support services within the NICU and postnatal wards to prevent \"breastfeeding failure\" jaundice.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFor Policy Makers\u003c/b\u003e: Integrate neonatal jaundice awareness into antenatal care (ANC) and postnatal care (PNC) packages to encourage early hospital presentation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFor Researchers\u003c/b\u003e: Future prospective studies should investigate the long-term neurodevelopmental outcomes of neonates who underwent exchange transfusions.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eStudy Design, Setting and period\u003c/h2\u003e \u003cp\u003eThis was an institution-based retrospective cross-sectional study conducted at the Asella Teaching and Referral Hospital (ARTH), Ethiopia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Data were reviewed for neonates admitted to the 42-bed NICU between September 1, 2023, and August 31, 2024.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePopulation and Selection Criteria\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eSource and Study Population\u003c/h2\u003e \u003cp\u003eThe source population consisted of all neonates admitted to the Neonatal Intensive Care Unit (NICU) at ARTH in the Southeast Oromia Region, Ethiopia. The study population specifically included all neonates admitted to the ARTH NICU between September 1, 2023, and August 31, 2024.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInclusion Criteria\u003c/b\u003e: All neonates admitted to the NICU with a diagnosis of jaundice during the defined study period were eligible for inclusion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eExclusion Criteria\u003c/b\u003e: To ensure the study focused on neonatal unconjugated hyperbilirubinemia and its primary determinants, the following were excluded:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eNeonates with \u003cb\u003echolestasis\u003c/b\u003e or conjugated bilirubin levels exceeding 15% of the total bilirubin.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNeonates \u003cb\u003etransferred from other primary or general hospitals\u003c/b\u003e specifically for exchange transfusion. This exclusion was applied to minimize referral bias and ensure the findings reflect the local clinical determinants and outcomes of the immediate catchment area.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSelection Criteria and Sampling\u003c/h2\u003e \u003cp\u003eThe study population included neonates admitted with complete medical records. Sample size was determined using a single population proportion formula based on a previous 13.3% prevalence [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. After a 10% dropout adjustment and correction for the 1,350 annual admissions, a final sample of 183 was reached [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Systematic random sampling was used to select every 7th record (K\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eVariables and Definitions\u003c/h2\u003e \u003cp\u003eThe primary outcome was hyperbilirubinemia (TSB\u0026thinsp;\u0026gt;\u0026thinsp;5 mg/dL) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Independent variables included socio-demographics, neonatal factors (sepsis, prematurity), and maternal factors (blood groups). Breastfeeding failure was defined by poor intake and frequency in the first few days [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eOperational Definitions\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eNeonatal Hyperbilirubinemia\u003c/b\u003e: Defined as a total serum bilirubin (TSB) level greater than 85\u0026micro;mol/l (5mg/dl) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eBreastfeeding Jaundice\u003c/b\u003e: Jaundice occurring within the first few days of life, specifically related to inadequate breast milk intake and decreased feeding frequency [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eBreast Milk Jaundice\u003c/b\u003e: Late-onset jaundice beginning after the 4th to 7th day of life, caused by increased reabsorption of unconjugated bilirubin [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eBilirubin Encephalopathy\u003c/b\u003e: A clinical syndrome associated with bilirubin toxicity in the central nervous system, resulting in chronic and permanent neurological sequelae [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Procedure\u003c/h2\u003e \u003cp\u003eData were collected using a structured checklist developed by the investigators following an extensive review of relevant literature. To ensure the reliability of the instrument, the checklist was \u003cb\u003epretested on 5% of the sample size\u003c/b\u003e prior to full data collection; necessary adjustments were made by the investigators based on the pre-test findings. The checklist was designed to capture maternal sociodemographic data and neonatal clinical information. To maintain confidentiality, patient names and medical card numbers were excluded from the data collection tool.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eData Quality Assurance\u003c/h2\u003e \u003cp\u003eTo ensure the integrity of the findings, the research team implemented rigorous quality control measures. Data collection was closely monitored by supervisors to ensure \u003cb\u003ecompleteness, consistency, and accuracy\u003c/b\u003e. As noted, a \u003cb\u003e5% pre-test\u003c/b\u003e was conducted to standardize data extraction. During the main collection phase, the research team held regular review sessions to address any discrepancies and ensure a uniform understanding of the clinical records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were meticulously cleaned to address inconsistencies and missing values before analysis. Data entry was performed using \u003cb\u003eEpi-data version 4.6.0.2\u003c/b\u003e, and subsequently exported to \u003cb\u003eSTATA version 17\u003c/b\u003e for statistical processing.\u003c/p\u003e \u003cp\u003eDescriptive statistics, including means with standard deviations for continuous variables and frequencies with percentages for categorical variables, were computed to summarize the cohort's characteristics. To identify determinants of neonatal hyperbilirubinemia, a two-stage regression approach was employed:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eBivariable Logistic Regression\u003c/b\u003e: Each predictor variable was initially screened; variables with a \u003cb\u003ep-value\u0026thinsp;\u0026lt;\u0026thinsp;0.25\u003c/b\u003e were considered candidates for the final model.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMultivariable Logistic Regression\u003c/strong\u003e \u003cp\u003eThis was performed to control for confounding factors. Results were reported as \u003cb\u003eAdjusted Odds Ratios (AOR)\u003c/b\u003e with 95% Confidence Intervals (CI). A \u003cb\u003ep-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/b\u003e was used to define statistical significance [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe model's \u003cb\u003egoodness-of-fit\u003c/b\u003e was validated using the \u003cb\u003eHosmer-Lemeshow test\u003c/b\u003e, and the absence of multicollinearity among independent variables was confirmed using \u003cb\u003eVariance Inflation Factors (VIF)\u003c/b\u003e. Finally, the results were presented using a combination of text, tables, and graphical representations.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e \u003cp\u003eEthical approval was obtained from the Ethical Review Committee (ERC) of the College of Health Sciences, Arsi University (\u003cb\u003eProtocol/ID: A/CHS/RC/103/2024, August 2024\u003c/b\u003e). Due to the retrospective nature of the study, the requirement for informed consent was waived by the ERC. All patient information retrieved from medical records was handled with strict confidentiality. To preserve anonymity, patient names were replaced with unique identification numbers during data extraction and analysis. All procedures were conducted in accordance with relevant national guidelines, regulations, and the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no funding.\u003c/p\u003e\u003ch2\u003eAuthor Contributions\u003c/h2\u003e \u003cp\u003e \u003cb\u003eB.G.\u003c/b\u003e and \u003cb\u003eT.G.\u003c/b\u003e conceived the study, designed the methodology, and performed data curation. \u003cb\u003eB.G.\u003c/b\u003e conducted the software-based data collection, statistical analysis, and data interpretation. \u003cb\u003eT.G.\u003c/b\u003e, \u003cb\u003eA.D.\u003c/b\u003e, \u003cb\u003eG.W.\u003c/b\u003e, and \u003cb\u003eA.W.\u003c/b\u003e performed validation and reviewed the manuscript for critical intellectual content. All authors read and approved the final version for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003e The authors would like to express their sincere gratitude to Arsi University, College of Health Sciences, for providing the ethical clearance and support necessary to conduct this study. We extend our appreciation to the staff of the Asella Referral and Teaching Hospital (ARTH) medical records office for their technical assistance during the data collection process. Finally, we thank the healthcare providers at the ARTH NICU for their dedication to improving neonatal outcomes in the region.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e \u003cp\u003eAll data generated or analyzed during this study are included in this published article. Further datasets are available from the corresponding author on reasonable request.\u003c/p\u003e \u003cp\u003eCompeting Interests\u003c/p\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHoskins NM (1976) Nelson Textbook of Pediatrics\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUser A, Bank EK (2015) Fanaroff and Martin\u0026rsquo;s Neonatal-Perinatal Medicine\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJamir AS (2016) A study of neonatal hyperbilirubinemia in India\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown SB, King RFGJ (1978) The mechanism of haem catabolism\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas S, Landeghem FKH (2019) Spectrum of bilirubin encephalopathy\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlusanya BO et al (2018) Neonatal jaundice and global child mortality\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF \u0026amp; WHO. Caring for the Newborn at Home (2012)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaewkiattikun K (2017) Effects of postpartum contraceptive counseling\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelay HG et al (2022) Determinants of neonatal jaundice in Ethiopia: meta-analysis\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson NB, Calkins KL (2020) Neonatal indirect hyperbilirubinemia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoma KM et al (2017) Neonatal hyperbilirubinemia in Nepal\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDu L, Ma X (2012) Guidelines for Management of Hyperbilirubinemia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOchigbo SO et al (2016) Bilirubin encephalopathy in Nigeria\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAynalem S et al (2020) Hyperbilirubinemia in Preterm Infants in Ethiopia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGemechu K et al (2023) Jaundice in southwest Oromia, Ethiopia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyangabyaki-Twesigye C et al (2020) Treatment outcome in Uganda\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaile MT (2020) Neonatal Jaundice at St Paul\u0026rsquo;s Hospital\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhutani VK et al (1999) Predictive ability of predischarge bilirubin\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehta S et al (2018) Study from a tertiary care hospital in India\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHariyati (2017) Magnitude of neonatal hyperbilirubinemia at Black Lion Hospital\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJimma Medical Center Study. Prevalence and associated factors (2024)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurage Zone Study. Determinants among neonates in NICU (2025)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePandey N et al (2013) Physiological jaundice: role in oxidative stress\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmeya Primary Hospital Study. Incidence and predictors (2025)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel AS et al (2017) Association of ABO and Rh incompatibility\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalraiya A et al (2018) Clinico-etiological profile of neonates\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlthomali R et al (2018) Neonatal jaundice causes and management\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrits H et al (2018) Prevalence of neonatal jaundice in Bloemfontein\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgunlesi TA et al (2011) Predictors of acute bilirubin encephalopathy\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Arsi University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Neonatal jaundice, Ethiopia, sepsis, breastfeeding failure, hyperbilirubinemia, clinical outcomes, NICU","lastPublishedDoi":"10.21203/rs.3.rs-8675828/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8675828/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eNeonatal hyperbilirubinemia is a significant clinical concern in developing nations. This institution-based retrospective cross-sectional study assessed the clinical outcomes and determinants of jaundice at the Asella Referral and Teaching Hospital (ARTH) NICU in South East Ethiopia. Out of 183 randomly selected neonates, the prevalence of hyperbilirubinemia was 16.4% (95% CI: 11\u0026ndash;21.8). The majority of jaundiced neonates presented with high admission total serum bilirubin levels between 15 and 19 mg/dL. Multivariate logistic regression identified inadequate breastfeeding (AOR 9.507, 95% CI: 1.244\u0026ndash;72.671, p\u0026thinsp;=\u0026thinsp;0.030) and neonatal sepsis (AOR 3.707, 95% CI: 1.337\u0026ndash;10.276, p\u0026thinsp;=\u0026thinsp;0.012) as the primary independent predictors. Clinical outcomes were generally positive (93.3% improvement), though high admission bilirubin levels suggest delays in recognition. Management was robust, with 26.7% requiring exchange transfusion. These findings highlight the urgent need for universal pre-discharge screening and robust lactation support to mitigate preventable neurological sequelae in Ethiopian neonates.\u003c/p\u003e","manuscriptTitle":"Clinical Outcomes and Determinants of Neonatal Hyperbilirubinemia Among NICU Admissions: A Retrospective Study in Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 03:14:39","doi":"10.21203/rs.3.rs-8675828/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7546bc53-331b-49b8-a7f9-7505b3720bcd","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61623032,"name":"Pediatrics"}],"tags":[],"updatedAt":"2026-01-28T03:14:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 03:14:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8675828","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8675828","identity":"rs-8675828","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}