Background
Neonatal jaundice is a condition that develops in approximately 85% of live births and becomes severe when total serum bilirubin (TSB) levels surpass 85 µmol/L and physical signs appear including yellow skin, yellowish eye appearance, pale stools, and dark urine. If untreated, kernicterus, an irreversible brain injury, occurs. As diagnosis of severe neonatal jaundice (SNJ) remains a challenge globally, it is imperative to address existing gaps, which have prompted this literature. The goals of our project include: 1) To consolidate diagnostic practices for SNJ in ten 
countries, 2) To determine gaps in screening measures, and 3) To provide feedback on areas of improvement.

Methods
Our search was conducted using the PubMed database to include 13 papers published between 2013 to 2023. The search terms used were “neonatal jaundice screening challenges,” “screening challenges in neonatal hyperbilirubinemia,” “prevalence of neonatal jaundice,” and “neonatal screening in developing countries.” We reviewed diagnostic practices and screening gaps for SNJ in ten countries including Malawi, Nigeria, India, Egypt, Netherlands, Bangladesh, Sweden, South Africa, Indonesia, and Turkey.

Results
Within our review of screening issues, four specific areas of improvement in diagnostic approach were identified: 1) access to healthcare facilities with appropriate resources for transcutaneous 
bilirubin (TcB) or TSB testing, 2) timely pre-discharge testing, 3) diagnostic education of SNJ for parents and community healthcare workers, and 4) compliance to the diagnostic guidelines by healthcare providers. In Malawi, Nigeria, India, Egypt, Netherlands, and South Africa, families with newborns had difficulty with accessing TcB or TSB testing. In Sweden and Turkey, appropriate pre-discharge testing needed 48-72 hours post-birth did not occur. Within Malawi, Bangladesh, and Indonesia, parents of newborns and community health workers did not receive adequate education to identify symptoms of SNJ. Studies in Nigeria and the Netherlands 
highlighted overuse of visual assessments to diagnose SNJ without use of additional tests to confirm diagnosis.

Conclusion
The following three recommendations were developed using the weaknesses in diagnostic approach in ten countries: 1) to design future healthcare facilities that have TcB or TSB testing and are geographically accessible to rural populations, 2) to offer community forums for community health workers, parents, and healthcare providers to educate on key symptoms and diagnostic tests of SNJ, and 3) to monitor compliance with diagnostic guidelines by healthcare providers. Key limitations of this review were the rising number of births occurring outside of 
the hospitals and inadequate financial resources to implement these recommendations.

Global Analysis of Challenges in Diagnosing Severe Neonatal Jaundice: Identifying Areas of Improvement

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Global Analysis of Challenges in Diagnosing Severe Neonatal Jaundice: Identifying Areas of Improvement

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