Heat loss in Nigerian newborn infants in the delivery room

Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants

BACKGROUND

Newborn admission temperature is a strong predictor of outcomes across all gestations. Hypothermia immediately after birth remains a worldwide issue and, if prolonged, is associated with harm. Keeping preterm infants warm is difficult even when recommended routine thermal care guidelines are followed in the delivery room.

OBJECTIVES

To assess the efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room, compared with routine thermal care or any other single/combination of intervention(s) also designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5), MEDLINE via PubMed (1966 to 30 June 2016), Embase (1980 to 30 June 2016), and CINAHL (1982 to 30 June 2016). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Trials using randomised or quasi-randomised allocations to test interventions designed to prevent hypothermia (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery room for infants at < 37 weeks' gestation and/or birth weight ≤ 2500 grams.

DATA COLLECTION AND ANALYSIS

We used Cochrane Neonatal methods when performing data collection and analysis.

MAIN RESULTS

Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies); external heat sources (three studies); and combinations of interventions (four studies).Barriers to heat loss Plastic wrap or bag versus routine carePlastic wraps improved core body temperature on admission to the neonatal intensive care unit (NICU) or up to two hours after birth (mean difference (MD) 0.58°C, 95% confidence interval (CI) 0.50 to 0.66; 13 studies; 1633 infants), and fewer infants had hypothermia on admission to the NICU or up to two hours after birth (typical risk ratio (RR) 0.67, 95% CI 0.62 to 0.72; typical risk reduction (RD) -0.25, 95% CI -0.29 to -0.20; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 4 to 5; 10 studies; 1417 infants). Risk of hyperthermia on admission to the NICU or up to two hours after birth was increased in infants in the wrapped group (typical RR 3.91, 95% CI 2.05 to 7.44; typical RD 0.04, 95% CI 0.02 to 0.06; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 17 to 50; 12 studies; 1523 infants), but overall, fewer infants receiving plastic wrap were outside the normothermic range (typical RR 0.75, 95% CI 0.69 to 0.81; typical RD -0.20, 95% CI -0.26 to -0.15; NNTH 5, 95% CI 4 to 7; five studies; 1048 infants).Evidence was insufficient to suggest that plastic wraps or bags significantly reduce risk of death during hospital stay or other major morbidities, with the exception of reducing risk of pulmonary haemorrhage.Evidence of practices regarding permutations on this general approach is still emerging and has been based on the findings of only one or two small studies.External heat sourcesEvidence is emerging on the efficacy of external heat sources, including skin-to-skin care (SSC) versus routine care (one study; 31 infants) and thermal mattress versus routine care (two studies; 126 infants).SSC was shown to be effective in reducing risk of hypothermia when compared with conventional incubator care for infants with birth weight ≥ 1200 and ≤ 2199 grams (RR 0.09, 95% CI 0.01 to 0.64; RD -0.56, 95% CI -0.84 to -0.27; NNTB 2, 95% CI 1 to 4). Thermal (transwarmer) mattress significantly kept infants ≤ 1500 grams warmer (MD 0.65°C, 95% CI 0.36 to 0.94) and reduced the incidence of hypothermia on admission to the NICU, with no significant difference in hyperthermia risk.Combinations of interventionsTwo studies (77 infants) compared thermal mattresses versus plastic wraps or bags for infants at ≤ 28 weeks' gestation. Investigators reported no significant differences in core body temperature nor in the incidence of hypothermia, hyperthermia, or core body temperature outside the normothermic range on admission to the NICU.Two additional studies (119 infants) compared plastic bags and thermal mattresses versus plastic bags alone for infants at < 31 weeks' gestation. Meta-analysis of these two studies showed improvement in core body temperature on admission to the NICU or up to two hours after birth, but an increase in hyperthermia. Data show no significant difference in the risk of having a core body temperature outside the normothermic range on admission to the NICU nor in the risk of other reported morbidities.

AUTHORS' CONCLUSIONS

Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection. Many observational studies have shown increased mortality among preterm hypothermic infants compared with those who maintain normothermia, yet evidence is insufficient to suggest that these interventions reduce risk of in-hospital mortality across all comparison groups. Hypothermia may be a marker for illness and poorer outcomes by association rather than by causality. Limitations of this review include small numbers of identified studies; small sample sizes; and variations in methods and definitions used for hypothermia, hyperthermia, normothermia, routine care, and morbidity, along with lack of power to detect effects on morbidity and mortality across most comparison groups. Future studies should: be adequately powered to detect rarer outcomes; apply standardised morbidity definitions; focus on longer-term outcomes, particularly neurodevelopmental outcomes.

A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants < 2000 g in Nigeria using continuous ambulatory temperature monitoring

Although skin-to-skin contact (or kangaroo mother care, KMC) for preterm infants is a practical alternative to incubator care, no studies have compared these methods using continuous ambulatory temperature monitoring. To compare thermal regulation in low birthweight infants (< 2000 g) managed by KMC alternating with conventional care (CC) and to determine the acceptability to mothers of KMC, an experimental study with a crossover design with observational and qualitative data collected on temperature patterns and mothers attitudes to skin-to-skin care was conducted in the neonatal wards of three hospitals in Lagos, Nigeria. Thirteen eligible infants were nursed by their mothers or surrogates in 38 4-hour sessions of KMC and the results compared with 38 sessions of incubator care. The risk of hypothermia was reduced by > 90% when nursed by KMC rather than conventional care, relative risk (RR) 0.09 (0.03-0.25). More cases of hyperthermia (> 37.5 degrees C) occurred with KMC, and coreperiphery temperature differences were widened, but the risk of hyperthermia > 37.9 degrees C (RR 1.3, 0.9-1.7) was not significant. Micro-ambient temperatures were higher during KMC, although the average room temperatures during both procedures did not differ significantly. Mothers felt that KMC was safe, and preferred the method to CC because it did not separate them from their infants, although some had problems adjusting to this method of care. Where equipment for thermal regulation is lacking or unreliable, KMC is a preferable method for managing stable low birthweight infants.

Children and newborn skin care and prevention

Neonatal skin suffers a progressive adaptation to the extrauterine environment and special care is needed during this period. This skin is very sensitive, thin and fragile. Immaturity of the epidermal barrier reduces the defense against the excessive proliferation of microbes and makes the skin more vulnerable to trauma and percutaneous drug toxicity. Because of the peculiar characteristics of newborn, infant and children's skin, the use of cosmetic products designed for hygiene and protection requires caution. In order to preserve the integrity of neonatal and child's skin, this article reviewed basic preventive care practices in relation to hygiene, bathing, cleansing agents, topical products and their percutaneous toxicity.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants

BACKGROUND

Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within 10 minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

We used the standard search strategy of the Cochrane Neonatal Review Group (CNRG). The review was updated in October 2009.

SELECTION CRITERIA

Trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </= 2500 g.

DATA COLLECTION AND ANALYSIS

We used the methods of the CNRG for data collection and analysis.

MAIN RESULTS

1) Barriers to heat loss [5 studies; plastic wrap or bag (3), plastic cap (1), stockinet cap (1)]:Plastic wraps or bags were effective in reducing heat losses in infants < 28 weeks' gestation (4 studies, n = 223; WMD 0.68 degrees C; 95% CI 0.45, 0.91), but not in infants between 28 to 31 week's gestation. Plastic caps were effective in reducing heat losses in infants < 29 weeks' gestation (1 study, n = 64; MD 0.80 degrees C; 95% CI 0.41, 1.19). There was insufficient evidence to suggest that either plastic wraps or plastic caps reduce the risk of death within hospital stay. There was no evidence of significant differences in other clinical outcomes for either the plastic wrap/bag or the plastic cap comparisons. Stockinet caps were not effective in reducing heat losses.2) External heat sources [2 studies; skin-to-skin (1), transwarmer mattress (1)]:Skin-to-skin care (SSC) was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants (1 study, n = 31; RR 0.09; 95% CI 0.01, 0.64). The transwarmer mattress reduced the incidence of hypothermia on admission to NICU in VLBW infants (1 study, n = 24; RR 0.30; 95% CI 0.11, 0.83).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, plastic caps, SSC and transwarmer mattresses all keep preterm infants warmer leading to higher temperatures on admission to neonatal units and less hypothermia. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants

BACKGROUND

Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), associated with morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within ten minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to July Week 4 2007 ), CINAHL (1982 to July Week 4 2007), EMBASE (1974 to 01/08/2007), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2007), conference/symposia proceedings using ZETOC (1993 to 17/08/2007), ISI proceedings (1990 to 17/08/2007) and OCLC WorldCat (July 2007). Identified articles were cross-referenced. No language restrictions were imposed.

SELECTION CRITERIA

All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </=2500 g.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent review authors. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes.

MAIN RESULTS

Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories:1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03), but not in infants between 28 to 31 week's gestation. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress kept infants </=1500 g significantly warmer and reduced the incidence of hypothermia on admission to NICU(one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.

The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial

AIM

To elucidate the impact of bathing on the prevalence of hypothermia among newborn babies exposed to the skin-to-skin (STS) care technique before and after bathing.

METHODS

Non-asphyxiated newborns after vaginal delivery (n = 249) in a Ugandan referral hospital were consecutively enrolled and randomized either to bathing at 60 min postpartum (n = 126) or no bathing (n = 123). All mothers practised skin-to-skin care of their newborns. Four rectal and tympanic registrations of newborn temperatures were carried out in both groups directly after drying at birth, and at 60, 70 and 90 min postpartum.

RESULTS

Bathing of newborns in the first hour after delivery resulted in a significantly increased prevalence of hypothermia, defined as temperature <36.5 degrees C, at 70 and at 90 min postpartum despite the use of warmed water and the application of the STS method. There was no neonatal mortality. Aside from the bathing procedure, no background factor potentially predisposing the newborns to hypothermia was identified.

CONCLUSION

Bathing newborn babies shortly after birth increased the risk of hypothermia despite the use of warm water and STS care for thermal protection of the newborn.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight babies

BACKGROUND

Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), with associated morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions, designed for prevention of hypothermia in preterm and/or low birthweight infants, applied within 10 minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to May Week 4 2004 ), CINAHL (1982 to May Week 4 2004), EMBASE (1974 to 09/07/04), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2004), conference/symposia proceedings using ZETOC (1993 to July 2004), ISI proceedings (1990 to 09/07/2004) and OCLC WorldCat (July 2004). Identified articles were cross-referenced. No language restrictions were imposed.

SELECTION CRITERIA

All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </=2500 g.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent reviewers. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes.

MAIN RESULTS

Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories: 1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and 2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03) but not in the 28 to 31 week group. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress significantly kept infants </=1500 g warmer and reduced the incidence of hypothermia on admission to NICU (one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.

Effect of early suckling on term neonates' core body temperature

The purpose of this study was to determine whether the practice of early suckling, through an effect on maternal behaviour, would improve neonatal temperature control. One hundred and sixty mothers having daytime spontaneous deliveries of healthy babies at term were randomized into two groups. The treatment group were encouraged to put the baby to the breast immediately after delivery. In the control group, the baby was placed in a cot immediately after birth and breastfeeding occurred some time later at a time of the mother's choice. Observations of the mother's behaviour towards her baby and the baby's core body temperature were recorded at 2 and 4 hours after birth and at 8 a.m. the next day. The early suckling group mothers were observed breastfeeding their babies more often than those of the control group. Significantly more of the control babies had temperatures below 36.5 degrees C at 8 a.m. the next day. Women of either group who were breastfeeding immediately prior to temperature recording were significantly less likely to have a baby with a low body temperature. It is concluded that a policy of early suckling, when compared with one of delayed contact, appears to reduce the incidence of low body temperature in the neonate.