Abstract
Background: Cardiovascular abnormalities are a major contributor to morbidity in critically ill neonates. Echocardiography plays a pivotal role in the early identification of structural and functional cardiac abnormalities in neonatal intensive care unit (NICU) settings. However, data on the frequency, spectrum, and associated clinical factors of echocardiographic abnormalities in NICU populations remain limited. Objective: To determine the frequency and spectrum of echocardiographic abnormalities among critically ill neonates undergoing echocardiographic evaluation in the NICU and to identify clinical factors associated with abnormal echocardiographic findings. Methods: This retrospective hospital-based cross-sectional study included neonates admitted to the neonatal intensive care unit (NICU) of Mogadishu Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital who underwent echocardiographic evaluation between January 2023 and February 2026. A total of 352 records were reviewed, of which 233 neonates were included after exclusion of incomplete, duplicate, placeholder, or non-analyzable records. Clinical variables, including respiratory distress, birth asphyxia, and sepsis, were analyzed in relation to structural and functional echocardiographic findings. Comparative analysis and exploratory multivariable logistic regression were used to evaluate associated clinical factors. Model discrimination was assessed using the area under the receiver operating characteristic curve and 10-fold cross-validation. Results: Abnormal echocardiographic findings were identified in 122 of 233 evaluated neonates (52.4%). The most frequent structural abnormalities were atrial septal defect (34.6%), ventricular septal defect (11.7%), and patent ductus arteriosus (11.3%). Pulmonary hypertension was present in 7.3%, and reduced ejection fraction in 2.1%. Respiratory distress was associated with higher odds of abnormal echocardiographic findings (adjusted OR 2.06, 95% CI 1.08–3.91; p = 0.028). Birth asphyxia showed an inverse statistical association (adjusted OR 0.31, 95% CI 0.13–0.74; p = 0.009). This unexpected inverse association was not interpreted as protective or causal and should be regarded as hypothesis-generating because it may reflect outcome definition, incomplete measurement of asphyxia severity, residual confounding, or selection bias. The model showed modest discrimination (AUC 0.64; cross-validated AUC 0.56). Conclusion: Echocardiographic abnormalities were frequent among clinically selected NICU neonates who underwent echocardiographic evaluation, with structural lesions predominating. Respiratory distress was associated with abnormal findings and may support prioritization for early echocardiographic assessment. The inverse association observed with birth asphyxia should not be interpreted as biologically protective and requires confirmation in studies with standardized definitions and detailed severity measures. Clinical variables alone had limited discriminatory value; therefore, echocardiography should remain an adjunct to comprehensive clinical assessment.