Neonatal jaundice is a common cause of hospitalisation for both full-term and preterm neonates (Mojtahedil et al, 2018). Almost all newborns have a total serum bilirubin level of >1mg/dL, the upper limit of normal for adults (Aynalem et al, 2020). High levels (≥5mg/dL) manifest clinically as jaundice and, a consequence of increased breakdown of red blood cells and/or decreased hepatic excretion of bilirubin, producing a yellow-orange discoloration of the skin and sclera (Brits et al, 2018; Olatubi et al, 2019). Neonatal jaundice commonly occurs in the first week after birth, although it is not harmful, is self-limiting and usually improves without treatment (Awang et al, 2020; Ricci et al, 2021).
Factors associated with the development of neonatal jaundice include prematurity, ABO incompatibility, Rh incompatibility, glucose-6-phosphate dehydrogenase (G6PD), sepsis, breast problems (eg sore or cracked nipples or breast engorgement, associated with inadequate intake of breast milk), breastfeeding patterns, prolonged labor, having siblings who had neonatal jaundice, high birth weight, primiparity, male gender, mode of birth and maternal diabetes mellitus (Olatubi et al, 2019; Seyedi et al, 2019; Abbas et al, 2020; Aynalem et al, 2020; Boskabadi et al, 2020; West and Josiah, 2020; Bogale et al, 2021; Karasneh et al, 2021; Wongnate, 2021). Acute bilirubin encephalopathy (kernicterus) is a major complications of hyperbilirubinemia, which can cause a spectrum of neurologic problems (Aynalem et al, 2020). Surviving neonates may have long-term neurodevelopmental deficits, such as cerebral palsy, sensorineural hearing loss, intellectual difficulties and gross developmental delays (Aynalem et al, 2020).
The prevalence of neonatal jaundice in high-income countries is low, affecting approximately 4.4 per 10 000 live births in America and 3.2 in Europe (Slusher et al, 2017). In low- and middle-income countries, the prevalence is significantly higher; at 31.6% in Ethiopia (Bogale et al, 2021), 35.9% in Nigeria (Olatubi et al, 2019), 44.4% in Rwanda (Murekatete et al, 2020), 55.2% in South Africa (Brits et al, 2018) and 63% in South Asian countries, such as Malaysia (Awang et al, 2020).
Little is known about the prevalence of neonatal jaundice in the Arab world. To the best of the authors' knowledge, only four published studies have been conducted on the prevalence of neonatal jaundice in the Middle Eastern region. These studies indicated higher prevalence rates than in high-income countries. The prevalence of neonatal jaundice in Iraq was 13.5%, with ABO incompatibility and Rh incompatibility identified as major risk factors (Sadeq et al, 2015). Another study from Iraq reported a 17.3% prevalence, and found that male neonates were at increased risk of developing neonatal jaundice than females (Abbas et al, 2020). In Egypt the prevalence of neonatal jaundice was 45.6%, with ABO incompatibility, Rh incompatibility and G6PD found to be the leading causes of hyperbilirubinemia (Abd Elmoktader et al, 2019). A case-control study in Gaza highlighted breastfeeding as a risk factor for the development of neonatal jaundice in comparison to bottlefeeding, but this may be because 74.7% of the case group were breastfeeding (Abu Mostafa et al, 2017). Despite these findings, there is a lack of research on the association between maternal/neonatal factors and neonatal jaundice.
In Jordan, there has been no specific investigation of the prevalence and factors associated with the development of neonatal jaundice. There is also an absence of national guidelines for the evaluation and management of jaundice. Khasawneh et al (2013; 2020) determined that Jordanian doctors did not adhere to the American Academy of Pediatrics Guidelines (2004) when managing neonatal jaundice. More recently, an investigation of the clinical profile of neonatal admissions found that 10.7% were related to hyperbilirubinemia (Khasawneh et al, 2020).
This study is intended to provide a baseline for determining the prevalence and correlated factors of neonatal jaundice, which can help healthcare providers develop appropriate management strategies. Therefore, the study aimed to investigate the prevalence of neonatal jaundice in Jordan, and the maternal and neonatal factors associated with its development.
Methods
A hospital-based unmatched case-control study design was used. A case-control design has many benefits, including that less time is required to conduct the study than is needed for a cohort study; this is because the condition has already occurred, which allows researchers to consider multiple risk factors simultaneously, and is useful in a preliminary study to establish an association.
For the purposes of this study, a case was defined as any neonate (term or preterm) admitted to the neonatal intensive care unit of one of the two selected hospitals and diagnosed as having jaundice by a pediatrician/physician, with a total serum bilirubin ≥5mg/dl as shown by laboratory test. A control was defined as any neonate (term or preterm) admitted to a neonatal intensive care unit with total serum bilirubin <5mg/dl and with no sign and symptoms of jaundice or liver disease. The two hospitals were purposively selected for the study, as they included neonatal intensive care units.
Sample
Based on a literature review, it was assumed that 33% of admissions to the neonatal intensive care units would have primary jaundice and there was a finite population size of 1000, according to the admission rates at the selected hospitals from 2020. The sample size was calculated using an online calculator (Calculator.net, 2024) with a confidence level of 95% and a margin of error of 5%, yielding a sample size of 254 neonates. To account for non-response and incomplete records, the sample size was adjusted to approximately 300, to be split between 100 neonates admitted with jaundice as the primary cause (cases) and 200 neonates admitted for causes other than jaundice (controls).
As identifying matched control groups is time-consuming (Shukla and Agarwal, 2016), convenience sampling was used. Consenting mothers who were Jordanian and could speak and read Arabic were included in the study. Neonates whose mothers did not consent or were diagnosed with liver problems were excluded from the study. Neonates with no laboratory proof of their total serum bilirubin level were also excluded.
Recruitment
Recruitment was conducted in the neonatal intensive care units of two government hospitals in the north of Jordan: the Princess Badeah Teaching Hospital and the Al-Mafraq Obstetrics and Gynecology Hospital. Confirmed cases of jaundice and control cases admitted between January and July 2021 were identified. Mothers were approached by a member of the team about the study when they came to visit their baby in the neonatal intensive care unit. Of the 810 mothers contacted, 362 met the inclusion criteria and were included in the study. A total of 50 mothers were excluded for missing data in medical records (n=13), withdrawal (n=22), and no response (n=15). The final sample of 312 consisted of 106 neonates who had developed jaundice (and their mothers, referred to as cases) and 206 neonates who had not developed jaundice (and their mothers, referred to as controls) giving a sample of 312 neonates (including both term and preterm neonates) and their mothers.
Data collection
Data were collected by reviewing the medical records of both neonates and their mothers. Identified mothers were interviewed using a structured questionnaire to validate the data from the medical records and collect any data not available in the record. The questionnaire was developed by the researchers based on the literature topic (Mullany et al, 2010; Onyearugha et al, 2011; Israel-Aina and Omoigberale, 2012; Bhutani et al, 2013). The first section of the questionnaire gathered sought maternal sociodemographic characteristics. The second section collected neonatal data. The third and final section collected etiological factors.
The lead researcher met with the directors of participating hospitals and the chairperson of the neonatal intensive care unit to explain the purpose of the study and data collection. Participant mothers were interviewed by phone at a convenient time of their choice. All women were interviewed in their native language (Arabic) by research assistants who were trained in conducting interviews.
Data analysis
Data were analysed using the Statistical Package of Social Science (version 25). Frequencies means and standard deviations were calculated for demographic variables. Pearson's chi-square test was performed to determine associations between risk factors and neonatal jaundice. Multiple logistic regression analysis was performed to determine the odds ratios of risk factors that were significantly associated with neonatal jaundice. Multiple logistic regression analysis was performed to identify predictors of neonatal jaundice and establish the existence of specific differences among selected risk factors (independent factors). An alpha level of 0.05 was used for all statistical tests.
Ethical considerations
Ethical approval was obtained from the Institutional Review Board of Jordan University of Science and Technology (approval number: #724-2020) and from the Ministry of Health in Jordan. Mothers of eligible neonates who consented to participate were notified of confidentiality and their right to refuse participation, withdraw from the study at any time without explanation, not answer any questions and ask questions or clarifications at any time. Oral and written informed consent was obtained from the mothers. All communication was in Arabic.
Results
Maternal demographic characteristics are shown in Table 1. The largest proportion of participant mothers (38.5%) were 25–35 years old. Around one-third (35.9%) had completed high school, while 8.7% were illiterate. More than half were employed (54.5%). The largest proportion of mothers were in blood group A (28.8%), just over half (51.9%) had a vaginal birth and less than half (43.3%) had never had a baby who was jaundiced.
Table 1. Maternal characteristics
| Characteristic | Frequency, n (%) | |||
|---|---|---|---|---|
| Case, n=106 | Control, n=206 | Total, n=312 | ||
| Age (years) | <25 | 30 (28.3) | 40 (19.4) | 70 (22.4) |
| 25–35 | 42 (39.6) | 78 (37.9) | 120 (38.5) | |
| >35 | 28 (26.4) | 84 (40.8) | 112 (35.9) | |
| Missing | 6 (5.7) | 4 (1.9) | 10 (3.2) | |
| Education | None | 16 (15.1) | 11 (5.3) | 27 (8.7) |
| Primary | 30 (28.3) | 41 (19.9) | 71 (22.8) | |
| High school | 45 (42.5) | 67 (32.5) | 112 (35.9) | |
| Bachelor or higher | 15 (14.2) | 83 (40.3) | 98 (31.4) | |
| Missing | 0 (0.0) | 4 (1.9) | 4 (1.3) | |
| Occupation | Employed | 69 (65.1) | 101 (49.0) | 132 (42.3) |
| Unemployed | 31 (29.2) | 101 (49.0) | 170 (54.5) | |
| Missing | 6 (5.7) | 4 (1.9) | 10 (3.2) | |
| Blood group | A | 37 (34.9) | 53(25.7) | 90 (28.8) |
| B | 23 (21.7) | 57(27.7) | 80 (25.6) | |
| AB | 22 (20.8) | 48(23.3) | 70 (22.4) | |
| O | 24 (22.6) | 48 (23.3) | 72 (23.1) | |
| Mode of birth | Vaginal | 71 (67.0) | 91 (44.2) | 162 (51.9) |
| Caesarean section | 34 (32.1) | 112 (54.4) | 146 (46.8) | |
| Assisted | 1 | 1 | Not included | |
| Missing | 1 (0.9) | 3 (1.5) | 4 (0.3) | |
| History of baby with jaundice | Yes | 55 (51.9) | 80 (38.8) | 135 (43.3) |
| No | 45 (42.5) | 124 (60.2) | 169 (54.2) | |
| Missing | 6 (5.7) | 2 (1.0) | 8 (2.5) | |
The demographic characteristics of the neonates are shown in Table 2. More than half (57.4%) were preterm and the largest proportion (45.8%) had a birth weight of 2.5–4kg. Approximately half (53.8%) were female. One-third of neonates (30.8%) were in blood group B, more than half of the neonates (53.5%) were breastfeeding and nearly two-thirds (62.2%) were suckling properly. Mothers reported that 105 neonates (33.7%) had <5 feeds per day. A small proportion of neonates had possible ABO blood incompatibility (10.6%), Rhesus incompatibility (6.7%) or G6PD (4.8%).
Table 2. Neonatal characteristics
| Characteristic | Frequency, n (%) | |||
|---|---|---|---|---|
| Case, n=106 | Control, n=206 | Total, n=312 | ||
| Gestational age (weeks) | <37 | 87 (82.1) | 92 (44.7) | 179 (57.4) |
| ≥37 | 19 (17.9) | 114 (55.3) | 133 (42.6) | |
| Missing | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Birth weight (kg) | <2.5 | 43 (40.6) | 45 (21.8) | 88 (28.2) |
| 2.5–4.0 | 46 (43.4) | 97 (47.1) | 143 (45.8) | |
| <4.0 | 17 (16.0) | 63 (30.6) | 80 (25.6) | |
| Missing | 0 (0.0) | 1 (0.5) | 1 (0.5) | |
| Sex | Male | 61 (57.5) | 83 (40.3) | 144 (46.2) |
| Female | 45(42.5) | 123 (59.7) | 168 (53.8) | |
| Blood group | A | 23 (21.7) | 46 (22.3) | 69 (22.1) |
| B | 24 (22.6) | 72 (35.0) | 96 (30.8) | |
| AB | 25 (23.6) | 50 (24.3) | 75 (24.0) | |
| O | 34 (32.1) | 38 (18.4) | 72 (23.1) | |
| Feeding | Breast | 53 (50.0) | 114 (55.3) | 167 (53.5) |
| Bottle | 47 (44.3) | 89 (43.2) | 136 (43.6) | |
| Missing | 6 (5.7) | 3 (1.5) | 9 (2.8) | |
| Ability to suckle | Yes | 64 (64.4) | 130 (63.1) | 194 (62.1) |
| No | 36 (34.0) | 74 (35.9) | 110 (35.2) | |
| Missing | 6 (5.7) | 2 (1.0) | 8 (2.5) | |
| Feeds per day | <5 | 48 (48.0) | 57 (28.1) | 105 (33.7) |
| 5–8 | 31 (31.0) | 75 (36.9) | 106 (34.0) | |
| 9–12 | 21 (21.0) | 71 (35.0) | 92 (29.5) | |
| Missing | 6 (1.93) | 3 (9.66) | 9 (2.9) | |
| ABO blood incompatibility | Yes | 19 (18.1) | 14 (6.8) | 33 (10.6) |
| No | 86 (81.9) | 192 (93.2) | 278 (89.1) | |
| Missing | 1 (0.3) | 0 (0.0) | 1 (0.3) | |
| Rhesus disease | Yes | 9 (8.5) | 12 (5.9) | 21 (6.7) |
| No | 97 (91.5) | 193 (94.1) | 290 (92.9) | |
| Missing | 0 (0.0) | 1 (0.3) | 1 (0.3) | |
| G6PD | Yes | 7 (6.8) | 8 (3.9) | 15 (4.8) |
| No | 96 (93.2) | 196 (96.1) | 292 (96.6) | |
| Missing | 3 (0.96) | 2 (0.64) | 5 (1.6) | |
Prevalence of neonatal jaundice
Of the 810 admissions to the neonatal intensive care unit during the data collection period (6 months), 170 (20.9%) were for jaundice. The time of onset varied, with 72.6% developing jaundice 24 hours after birth, and neonates had a mean total serum bilirubin of 18.06mg/dl (±3.81mg/dl). Less than a third (27.4%) developed jaundice within 24 hours of birth, with a mean total serum bilirubin of 14.44mg/dl (±4.00mg/dl). Almost half (49.1%) had severe jaundice, with a mean total serum bilirubin of 18.8mg/dl (±2.0mg/dl). Table 3 summarises the prevalence of different types and severity of jaundice among the cases.
Table 3. Jaundice characteristics among case group
| Characteristic | Frequency, n=106 (%) | Mean total serum bilirubin ± standard deviation (mg/dl) | |
|---|---|---|---|
| Time of onset (hours) | Within 24 (pathological) | 29 (27.4) | 14.44 ± 4.00 |
| After 24 (physiological) | 77 (72.6) | 18.06 ± 3.81 | |
| Severity | Mild | 3 (2.8) | 8.6 ± 5.5 |
| Moderate | 51 (48.1) | 12.3 ± 2.8 | |
| Severe | 52 (49.1) | 18.8 ± 2.0 | |
Factors associated with neonatal jaundice
Pearson's chi-square test showed significant associations between total serum bilirubin and five maternal variables: age (P=0.03), education (P=0.001), occupation (P=0.002), mode of birth (P=0.001) and history of a baby with jaundice (P=0.009) (Table 4). There were also significant associations with six neonatal variables: gestational age (P=0.001), birth weight(P=0.001), sex (P=0.004), blood group (P=0.028), number of daily feeds (P=0.002) and potential ABO incompatibility (P=0.002) (Table 5).
Table 4. Association between neonatal jaundice and maternal factors
| Characteristic | Frequency, n (%) | X2 | P value | ||
|---|---|---|---|---|---|
| Case | Control | ||||
| Age (years) | <25 | 30 (28.3) | 40 (19.4) | 6.5 | 0.03 |
| 25–35 | 42 (39.6) | 78 (38.9) | |||
| >35 | 28 (26.4) | 84 (40.8) | |||
| Missing | 6 (5.7) | 4 (1.9) | |||
| Education | None | 16 (15.1) | 11 (5.3) | 26.81 | 0.001 |
| Primary | 30 (28.3) | 41 (19.9) | |||
| High school | 45 (42.5) | 67 (32.5) | |||
| Bachelor or higher | 15 (14.2) | 83 (40.3) | |||
| Missing | 0 (0.0) | 4 (1.9) | |||
| Occupation | Employed | 69 (69.0) | 101 (49.0) | 9.8 | 0.002 |
| Unemployed | 31 (31.0) | 101 (49.0) | |||
| Missing | 6 (5.7) | 4 (1.9) | |||
| Mode of birth | Vaginal | 71 (67.0) | 91 (44.2) | 14.4 | 0.001 |
| Caesarean | 34 (32.1) | 112 (54.4) | |||
| Missing | 1 (0.9) | 3 (1.5) | |||
| History of baby with jaundice | Yes | 55 (51.9) | 80 (38.8) | 6.7 | 0.009 |
| No | 45 (42.5) | 124 (60.2) | |||
| Missing | 6 (5.7) | 2 (1.0) | |||
| Blood group | A | 37 (34.9) | 53 (25.7) | 3.2 | 0.35 |
| B | 23 (21.7) | 57 (27.7) | |||
| AB | 22 (20.8) | 48 (23.3) | |||
| O | 24 (22.6) | 48 (23.3) | |||
| Missing | 0 (0.0) | 0 (0.0) | |||
Table 5. Association between neonatal jaundice and neonatal factors
| Characteristic | Frequency | X2 | P value | ||
|---|---|---|---|---|---|
| Case | Control | ||||
| Gestational age (weeks) | <37 | 87 (82.1) | 92 (44.7) | 40.06 | 0.001 |
| ≥37 | 19 (17.9) | 114 (55.3) | |||
| Birth weight (kg) | <2.5 | 43(40.6) | 45 (21.8) | 14.6 | 0.001 |
| 2.5–4.0 | 46 (43.4) | 97 (47.1) | |||
| >4.0 | 17 (16.0) | 63 (30.6) | |||
| Missing | 0 (0.0) | 1 (0.5) | |||
| Sex | Male | 61 (57.5) | 83 (40.3) | 8.3 | 0.004 |
| Female | 45 (42.5) | 123(59.7) | |||
| Blood group | A | 23 (21.7) | 46 (22.3) | 9.1 | 0.028 |
| B | 24 (22.6) | 72 (35.0) | |||
| AB | 25 (23.6) | 50 (24.3) | |||
| O | 34 (32.1) | 38 (18.4) | |||
| Feeds per day | <5 | 48 (45.3) | 57 (27.7) | 12.6 | 0.002 |
| 5–8 | 31 (29.2) | 75 (36.4) | |||
| 9–12 | 21 (19.8) | 71 (34.5) | |||
| Missing | 6 (5.7) | 3 (1.5) | |||
| ABO blood incompatibility | Yes | 19 (17.9) | 14 (6.8) | 9.3 | 0.002 |
| No | 86 (81.1) | 192 (93.2) | |||
| Missing | 1 (0.9) | 0 (0.0) | |||
| Rhesus incompatibility | Yes | 9 (8.5) | 12 (5.8) | 0.77 | 0.380 |
| No | 97 (91.5) | 193 (93.7) | |||
| Missing | 0 (0.0) | 1 (0.5) | |||
| Neonatal G6PD | Yes | 7 (6.6) | 8 (3.9) | 1.21 | 0.270 |
| No | 96 (90.6) | 196 (95.1) | |||
| Missing | 3 (2.8) | 2 (1.0) | |||
Maternal and neonatal factors associated with total serum bilirubin were entered into multiple logistic regression (Table 6). Of the maternal factors, only education, occupation and mode of birth were significantly associated with jaundice. Lower education (P=0.001), being employed (P=0.001) and having a caesarean section (P=0.003) increased the odds of developing jaundice. Among the neonatal factors, gestational age, number of feeds per day and ABO incompatibility were significantly related to jaundice. Preterm neonates (P=0.02), those who had fewer feeds per day (P<0.001) and those who were ABO incompatible (P=0.01) were more likely to develop jaundice.
Table 6. Multiple logistic regression
| Variable | Subgroup odds ratio | P value | Crude odds ratio (95% confidence interval) | Adjusted odds ratio (95% confidence interval) | P value | |
|---|---|---|---|---|---|---|
| Education | None | Reference | ||||
| Primary | 0.30 (0.08–1.08) | 0.060 | 0.82 (0.63–1.07) | 0.47 (0.34–0.66) | 0.001 | |
| Secondary | 0.30 (0.90–1.00) | 0.050 | ||||
| High school | 0.04 (0.01–0.17) | 0.001 | ||||
| Occupation | Employed | Reference | ||||
| Unemployed | 0.32 (0.15–0.64) | 0.001 | 0.67 (0.49–0.90) | 0.55 (0.32–0.93) | 0.001 | |
| Mode of birth | Vaginal | Reference | ||||
| Caesarean | 0.24 (0.12–0.49) | 0.001 | 0.90 (0.73–1.12) | 1.01 (0.94–1.09) | 0.003 | |
| Gestational age (weeks) | <37 | Reference | ||||
| ≥37 | 0.14 (0.06–0.30) | 0.008 | 1.2 (1.01–1.58) | 0.19 (0.10–0.38) | 0.020 | |
| Feeds per day | <5 | Reference | ||||
| 5–8 | 0.42 (0.10–1.77) | 0.03 | 0.24 (0.17–0.35) | 0.72 (0.50–1.03) | <0.001 | |
| 9–12 | 0.20 (0.04–0.87) | 0.01 | ||||
| ABO incompatibility | No | Reference | ||||
| Yes | 3.48 (1.21–9.98) | 0.059 | 2.1 (1.32–3.46) | 3.59 (1.35–9.58) | 0.010 |
Discussion
This mismatched case-control study to examine factors associated with neonatal jaundice is the first targeted study of neonatal jaundice in Jordan, to the authors' knowledge. The prevalence of neonatal jaundice was 20.9%, which is consistent with rates reported in China (20.3%) and Uganda (22.7%) (Awang et al, 2019; Nyangabyaki-Twesigye et al, 2020). The prevalence was lower than some other low- and middle-income countries, such as Africa, Nepal, India, South Asia and Egypt, where the prevalence of neonatal jaundice is repotedly between 31% and 67% (Brits et al, 2018; Abd Elmoktader et al, 2019; Awang et al, 2019; Olatubi et al, 2019; Oppong et al, 2019; Bogale et al, 2021). Lower rates have been reported in Iraq (13.5%) (Sadeq et al, 2019), Ethiopia (13.3%) (Haile, 2020), Indonesia (4.1%) (Yahya et al, 2017) and Turkey (3.6%) (Bozkurt et al, 2019). These differences may be the result of variations in study design, setting, time and method of data collection. However, they may also be the result of differences in socio-cultural and economic conditions, level of obstetrics care, and gestational age (Tender, 2018).
Several demographic and birth-related variables were associated with the development of neonatal jaundice. Neonates of educated mothers were at higher risk of developing jaundice than babies of less educated mothers. This is consistent with previous studies, which have reported that neonates of educated mothers are at increased risk of jaundice (Aiswarya and Sajeeth, 2016). Women with higher education are more likely to be employed, which was also significantly linked with increased risk of jaundice in both the present study and in the wider literature (Aiswarya and Sajeeth, 2016; Adoba et al, 2018; Tender, 2018).
Higher education and employment can impact infant feeding, and number of feeds was significantly associated with neonatal jaundice both in the present study and in the literature (Adoba et al, 2018; Alkhaldi et al, 2023). These women may prefer an infant feeding method and schedule that will not restrict their daily activities (Alkhaldi et al, 2023). This may be linked to a preference for formula feeding, although feeding method was not significantly associated with jaundice. However, breastfeeding promotion programmes and initiatives that educate women on the role of breastfeeding may be beneficial.
Mode of birth was linked with the development of neonatal jaundice, with caesarean section increasing the risk of jaundice. This is similar to studies in Malaysia and South Africa, where babies born via a caesarean section were at increased risk of jaundice than those born via vaginal birth (Budi Wijaya, 2017; Awang et al, 2019; Murekatete et al, 2020). This may be related to the anesthesia used during caesarean section (isoflurane and bupivacaine), which could increase bilirubin levels in neonates (Budi Wijaya, 2017). In addition, mothers who gave birth via caesarean section are more likely to experience breastfeeding problems (Li et al, 2021), which, as explained above, can be linked with higher risk of jaundice.
In the present study, prematurity was significantly associated with the development of neonatal jaundice. A preterm neonate (born before 37 weeks' gestation) may not be capable of eliminating bilirubin as rapidly as full-term babies, who have a more mature liver (Jena and Dash, 2018). This is consistent with most previous studies, which emphasised the risks associated with prematurity (Devi and Vijaykumar, 2017; Oppong et al, 2019; Boskabadi et al, 2020; Murekatete et al, 2020; West and Josiah, 2020; Acharya and Paneru, 2021; Wongnate, 2021). Although one study from Ghana reported that prematurity was not a significant factor in the development of neonatal jaundice, only a small proportion of their sample were preterm babies (Tender, 2018).
While it is known that ABO incompatibility can result in neonatal jaundice (Abd Elmoktader et al, 2019; Lake et al, 2019; Sadeq et al, 2019; Boskabadi et al, 2020; Murekatete et al, 2020; West and Josiah, 2020; Bogale et al, 2021; Faustina et al, 2021; Wongnate, 2021), the findings from this study demonstrated that neonates with ABO blood incompatibility were over three times as likely to develop neonatal jaundice. ABO incompatibility leads to hemolysis disorder (destruction of red blood cells), increasing the level of bilirubin in the blood (Ricci et al, 2021).
Fewer daily feeds increased the odds of developing jaundice. This is may be because a reduction in the volume and frequency of feeding can hinder defecation and the removal of bilirubin through the bowels (Neal-Kluever et al, 2018). Similarly, frequent feeding prevents dehydration and facilitates frequent urination (Neal-Kluever et al, 2018). Several other studies have also reported that decreased frequency of feeding and feeding problems increase the risk for neonatal jaundice (Hassan and Zakerihamidi, 2017; Seyedi et al, 2019; Haile, 2020).
Limitations
This study had several limitations, including using a mismatched case-control design and selection bias, which limited the researchers' ability to identify the temporal relationship between various risk factors and neonatal jaundice. In addition, this study was conducted in one region, and more studies are needed in different settings to confirm the findings.
Implications for practice
To improve neonatal survival and reduce severe morbidities, early identification of risk factors for jaundice is vital, so that appropriate interventions can be implemented. It is essential to integrate accurate assessment as part of routine care for mother and neonate, in order to decrease the prevalence of this disorder, which is considered a neglected element of clinical practice in Jordan (Al-Lawama et al, 2018). Healthcare providers need education and training on the prevalence, risk factors and negative effects of jaundice for mothers, infants and families as a whole.
Raising awareness among mothers by conducting antenatal education is recommended, particularly for high-risk mothers. In Jordan, there is no national practice guideline for the assessment and management of neonatal jaundice. Decision-makers should work to establish a national guideline to screen high-risk neonates for jaundice and follow up with them during the postnatal period. Using evidence-based guidelines for the assessment and management of risk factors of jaundice helps to reduce the prevalence of jaundice among neonates (Al-Lawama et al, 2018). Addressing neonatal jaundice is also likely to reduce length of stay in intensive care, additionally reducing financial strains on the family and healthcare institutions.
Conclusions
The present study showed significant associations between a mother's education and occupation, mode of childbirth, prematurity, ABO incompatibility, reduced feeding, and the development of jaundice among neonates in northern Jordan. Identifying these factors will allow neonatal nurses to educate parents in an effort to prevent jaundice. Further research on management of jaundice and development of national guidelines may also allow healthcare providers address the issue. Preventing prematurity and low birth weight in babies also will be beneficial.
Key points
- Neonatal jaundice is a common cause of neonatal morbidity.
- Identifying at-risk factors will allow prevention and lessen length of hospital stay for the neonates.
- It is essential to integrate accurate assessment as a part of routine care provided to the mother and her neonate to decrease the prevalence of this disorder.
- Using evidence-based guidelines for the assessment and management of risk factors of jaundice helps in reducing the prevalence of jaundice among neonates.