The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival

Decreasing Variation to Enhance Accurate Identification of Hypothermic Infants in Pediatric Primary Care

Hypothermia can be the first and only sign of sepsis in young infants, yet there is a paucity of standard recommendations for pediatric primary-care office management of those infants identified. The SMART aim of this study was to standardize the identification and care of infants age 0 to 49 days at risk of hypothermia in pediatric primary care by decreasing the percent of infants with temperatures ≤36.5°C from 24% to 10% within 2 years. Over the course of this project, variation in documented temperatures ≤36.5°C decreased from 24% to 7% of encounters. Temperatures ≤36.5°C were documented for 951 infants or 13.4% (1078 of 8020 encounters). Of the 951 infants with temperatures ≤36.5°C, 96.1% were rewarmed in the office. Thirty-one patients ultimately required hospitalization. Application of quality improvement in a primary-care office decreased low temperatures by standardizing care, empowering staff, and triaging at-risk infants to the most appropriate level of care.

Incidence and risk factors of neonatal hypothermia: A systematic review and meta-analysis

AIM

Hypothermia poses a threat to the health and lives of newborns. Therefore, it is essential to identify the factors that influence neonatal hypothermia and provide targeted intervention suggestions for clinical practice to reduce its occurrence.

METHODS

We conducted a literature search to identify factors influencing neonatal hypothermia and performed a meta-analysis to determine the prevalence of neonatal hypothermia and its associated factors. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of cohort and case-control studies, while the Agency for Healthcare Research and Quality (AHRQ) was used to evaluate the quality of cross-sectional studies.

RESULTS

Eighteen studies involving 44 532 newborns from 13 countries were included. The incidence of neonatal hypothermia was 52.5% (95% CI: 0.37, 0.68). Factors such as no skin-to-skin contact, prematurity, low birth weight, delayed breastfeeding, asphyxiation and resuscitation after birth, low APGAR score, not wearing a cap, and caesarean section were found to affect neonatal hypothermia.

CONCLUSION

Multiple factors influence neonatal hypothermia, and clinicians can utilise these factors to develop targeted intervention measures to prevent and reduce the incidence of neonatal hypothermia.

Time to death and predictors of mortality among early neonates admitted to neonatal intensive care unit of Addis Ababa public Hospitals, Ethiopia: Institutional-based prospective cohort study

INTRODUCTION

The largest risk of child mortality occurs within the first week after birth. Early neonatal mortality remains a global public health concern, especially in sub-Saharan African countries. More than 75% of neonatal death occurs within the first seven days of birth, but there are limited prospective follow- up studies to determine time to death, incidence and predictors of death in Ethiopia particularly in the study area. The study aimed to determine incidence and predictors of early neonatal mortality among neonates admitted to the neonatal intensive care unit of Addis Ababa public hospitals, Ethiopia 2021.

METHODS

Institutional prospective cohort study was conducted in four public hospitals found in Addis Ababa City, Ethiopia from June 7th, 2021 to July 13th, 2021. All early neonates consecutively admitted to the corresponding neonatal intensive care unit of selected hospitals were included in the study and followed until 7 days-old. Data were coded, cleaned, edited, and entered into Epi data version 3.1 and then exported to STATA software version 14.0 for analysis. The Kaplan Meier survival curve with log- rank test was used to compare survival time between groups. Moreover, both bi-variable and multivariable Cox proportional hazard regression model was used to identify the predictors of early neonatal mortality. All variables having P-value ≤0.2 in the bi-variable analysis model were further fitted to the multivariable model. The assumption of the model was checked graphically and using a global test. The goodness of fit of the model was performed using the Cox-Snell residual test and it was adequate.

RESULTS

A total of 391 early neonates with their mothers were involved in this study. The incidence rate among admitted early neonates was 33.25 per 1000 neonate day's observation [95% confidence interval (CI): 26.22, 42.17]. Being preterm birth [adjusted hazard ratio (AHR): 6.0 (95% CI 2.02, 17.50)], having low fifth minute Apgar score [AHR: 3.93 (95% CI; 1.5, 6.77)], low temperatures [AHR: 2.67 (95%CI; 1.41, 5.02)] and, resuscitating of early neonate [AHR: 2.80 (95% CI; 1.51,5.10)] were associated with increased hazard of early neonatal death. However, early neonatal crying at birth [AHR: 0.48 (95%CI; 0.26, 0.87)] was associated with reduced hazard of death.

CONCLUSIONS

Early neonatal mortality is high in Addis Ababa public Hospitals. Preterm birth, low five-minute Apgar score, hypothermia and crying at birth were found to be independent predictors of early neonatal death. Good care and attention to neonate with low Apgar scores, premature, and hypothermic neonates.

Normal range and risk factors for deviating body temperatures during the first 24 hours in term-born infants under standardised care: an observational study

OBJECTIVE

Body temperature for a known ambient temperature is not known for infants born at term. We aimed to determine the normal range and the incidences of hypothermia and hyperthermia during the first 24 hours of life in healthy term-born infants nursed according to WHO recommendations.

DESIGN

Prospective observational study.

SETTING

Norwegian single centre district hospital. Infants were observed during skin-to-skin care or when dressed in cots.

PARTICIPANTS

Convenience sample of 951 healthy infants born at term.

METHODS

Delivery room temperature was aimed at 26-30°C and rooming-in temperature at 24°C. We measured rectal and room temperatures at 2, 4, 8, 16 and 24 hours of age.

MAIN OUTCOME MEASURES

Percentile curves for rectal temperature. Proportions and risk factors for hypothermia and hyperthermia.

RESULTS

The mean (SD) room temperature was 24.0°C (1.1), 23.8°C (1.0), 23.8°C (1.0)., 23.7°C (0.9) and 23.8°C (0.9). The median (2.5, 97.5 percentile) rectal temperature was 36.9°C (35.7-37.9), 36.8°C (35.9-37.5), 36.9°C (36.1-37.5), 37.0°C (36.4-37.7) and 37.1°C (36.5-37.7). Hypothermia (<36.5°C) occurred in 28% of the infants, 82% of incidents during the first 8 hours. Risk factors for hypothermia were low birth weight (OR 3.1 (95% CI, 2.0 to 4.6), per kg), male sex, being born at night and nursed in a cot versus skin to skin. Hyperthermia (>37.5°C) occurred in 12% and most commonly in large infants after 8 hours of life. Risk factors for hyperthermia were high birth weight (OR 2.2 (95% CI, 1.4 to 3.5), per kg), being awake, nursed skin to skin and being born through heavily stained amniotic fluid.

CONCLUSIONS

Term-born infants were at risk of hypothermia during the first hours after birth even when nursed in an assumed adequate thermal environment and at risk of hyperthermia after 8 hours of age.

Association between Neonatal Outcomes and Admission Hypothermia among Very Preterm Infants in Chinese Neonatal Intensive Care Units: A Multicenter Cohort Study

OBJECTIVE

 We aimed to investigate the relationship between admission hypothermia and outcomes among very preterm infants (VPIs) in neonatal intensive care units (NICUs) in China. We also investigated the frequency of hypothermia in VPIs in China and the variation in hypothermia across Chinese Neonatal Network (CHNN) sites.

STUDY DESIGN

 This retrospective cohort study enrolled infants with 240/7 to 316/7 weeks of gestation with an admission body temperature ≤37.5 °C who were admitted to CHNN-participating NICUs between January 1 and December 31, 2019.

RESULTS

 A total of 5,913 VPIs were included in this study, of which 4,075 (68.9%) had hypothermia (<36.5 °C) at admission. The incidence of admission hypothermia varied widely across CHNN sites (9-100%). Lower gestational age (GA), lower birth weight, antenatal steroid administration, multiple births, small for GA, Apgar scores <7 at the 5th minute, and intensive resuscitation were significantly associated with admission hypothermia. Compared with infants with normothermia (36.5-37.5 °C), the adjusted odds ratios (ORs) for composite outcome among infants with admission hypothermia <35.5 °C increased to 1.47 (95% confidence interval [CI], 1.15-1.88). The adjusted ORs for mortality among infants with admission hypothermia (36.0-36.4 and <35.5 °C) increased to 1.41 (95% CI, 1.09-1.83) and 1.93 (95% CI, 1.31-2.85), respectively. Admission hypothermia was associated with a higher likelihood of bronchopulmonary dysplasia, but was not associated with necrotizing enterocolitis ≥stage II, severe intraventricular hemorrhage, cystic periventricular leukomalacia, severe retinopathy of prematurity, or sepsis.

CONCLUSION

 Admission hypothermia remains a common problem for VPIs in a large cohort in China and is associated with adverse outcomes. Continuous quality improvement of admission hypothermia in the future may result in a substantial improvement in the outcomes of VPIs in China.

KEY POINTS

· Admission hypothermia is common in VPIs.. · The incidence of admission hypothermia in VPIs remains high in China.. · Admission hypothermia is associated with adverse outcomes in VPIs..

A retrospective data analysis on prevalence and risk factors for hypothermia among sick neonates at presentation to the neonatal intensive care unit of the Tamale Teaching Hospital

Neonatal hypothermia, defined as an axillary temperature of <36.5C in a neonate, is common in neonatal intensive care units and is almost universal across all geographic and climatic regions of the world. This is even though environmental temperature is a known risk factor for its occurrence. We conducted a retrospective study in the Neonatal Intensive Care Unit of the Tamale Teaching Hospital (TTH) to document the prevalence and risk factors associated with hypothermia at presentation to the hospital. The study spanned the period from January 2019 to December 2019 and involved all neonates with axillary temperature documented at the time of admission. The prevalence of neonatal hypothermia in this study was 54.76%. Hypothermia was most common in neonates diagnosed with meconium aspiration syndrome (87/105, 82.86%), prematurity and low birth weight (575/702, 81.91%), and birth asphyxia (347/445, 77.98%). Neonates who were delivered vaginally were less likely to develop hypothermia compared to those delivered via Cesarean section. Inborn neonates (delivered in TTH) were 3.2 times more likely to be hypothermic when compared to those who were delivered at home. Neonates with low birth weight and APGAR scores < 7 at 1 and 5 minutes were more likely to be hypothermic. The dry season was found to be protective against hypothermia when compared to the rainy season. The overall mortality rate was 13.68% and the mortality in the subgroup with hypothermia at presentation was 18.87%. Our study documented a high prevalence of hypothermia with higher rates in neonates requiring intervention at birth. It is therefore crucial for perinatal care providers to adhere to the warm chain precautions around the time of birth.

Thermoregulation for very preterm infants in the delivery room: a narrative review

Abnormal temperature in preterm infants is associated with increased morbidity and mortality. Infants born prematurely are at risk of abnormal temperature immediately after birth in the delivery room (DR). The World Health Organization (WHO) recommends that the temperature of newly born infants is maintained between 36.5-37.5oC after birth. When caring for very preterm infants, the International Liaison Committee on Resuscitation (ILCOR) recommends using a combination of interventions to prevent heat loss. While hypothermia remains prevalent, efforts to prevent it have increased the incidence of hyperthermia, which may also be harmful. Delayed cord clamping (DCC) for preterm infants has been recommended by ILCOR since 2015. Little is known about the effect of timing of DCC on temperature, nor have there been specific recommendations for thermal care before DCC. This review article focuses on the current evidence and recommendations for thermal care in the DR, and considers thermoregulation in the context of emerging interventions and future research directions. IMPACT: Abnormal temperature is common amongst very preterm infants after birth, and is an independent risk factor for mortality. The current guidelines recommend a combination of interventions to prevent heat loss after birth. Despite this, abnormal temperature is still a problem, across all climates and economies. New and emerging delivery room practice (i.e., delayed cord clamping, mobile resuscitation trolleys, early skin to skin care) may have an effect on infant temperature. This article reviews the current evidence and recommendations, and considers future research directions.

Factors Influencing the Implementation of Infant Warming Devices Among Healthcare Workers in Malawian Hospitals

Objectives. Preterm infants are at risk of hypothermia. This study described the available infant warming devices (IWDs) and explored the barriers and facilitators to their implementation in neonates in Malawi. Methods. A qualitative descriptive study was conducted among 19 health care workers in Malawi from January to March 2020. All interviews were digitally recorded, transcribed, and managed using NVivo and analyzed using a thematic approach. Results. The warming devices included radiant warmers, Blantyre hot-cots, wall-mounted heaters, portable warmers, and incubators. Inadequate equipment and infrastructure and gaps in staff knowledge and capacity were reported as the main challenges to optimal IWD implementation. Caregiver acceptance was described as the main facilitator. Strategies to optimize implementation of IWD included continuous practical training and adequate availability of equipment and spare parts. Conclusion. Implementation of warming devices for the management of neonatal hypothermia is effective when there are adequate human and material resources.

Polyethylene bags before cord clamping in very preterm infants: a randomised controlled trial

OBJECTIVE

Hypothermia on admission to the neonatal intensive care unit (NICU) is associated with an increased risk of death in preterm infants. There are currently no evidence-based recommendations for thermal care before cord clamping (CC). We wished to determine whether placing very preterm infants in a polyethylene bag (PB) before CC, compared with after CC, results in more infants with a temperature in the normal range on NICU admission.

DESIGN

Randomised controlled trial.

SETTING

Tertiary maternity hospital.

PATIENTS

Inborn infants<32 weeks' gestational age (GA).

INTERVENTIONS

Infants were randomly assigned to have a PB placed before or after CC.

MAIN OUTCOME

Rectal temperature within the normal range (36.5°C-37.5°C) on NICU admission.

RESULTS

Between July 2020 and September 2022, 198/220 (90%) eligible infants were enrolled in this study; 99 (44 (44%) girls) were randomly assigned to BEFORE and 99 (53 (54%) girls) to AFTER. Median (IQR) GA 29 (27-31) vs 29 (27-31) weeks, mean (SD) birth weight 1206 (429) vs 1138 (419) g, respectively. The proportion of infants who had normal temperature on NICU admission did not differ between the groups (BEFORE 54/99 (55%) vs AFTER 55/98 (56%), p 0.824). The proportion of infants with a temperature outside of the normal range was similar between the groups; hypothermia (BEFORE 34/99 (34%) vs AFTER 33/98 (34%), hyperthermia (BEFORE 10/99 (10%) vs AFTER 10/98 (10%)).

CONCLUSIONS

Placing a PB before CC did not increase the proportion of preterm infants with normal temperature on NICU admission. A large proportion of preterm infants had abnormal temperature. Further studies on thermoregulation before CC are needed.

TRIAL REGISTRATION NUMBER

NCT04463511.

Feasibility and acceptability of a novel biomedical device to prevent neonatal hypothermia and augment Kangaroo Mother Care in Kenya: Qualitative analysis of focus group discussions and key Informant Interviews

Hypothermia is a leading newborn complication, especially among premature and/or low birth weight infants. Within low/middle-income countries where incubators and radiant warmers are often in short supply, leading to gaps in the thermal care chain, neonatal hypothermia underlies high rates of newborn morbidity and mortality. Kangaroo Mother Care/Skin-to-skin care is an effective method for prevention of hypothermia in premature and low birthweight babies but can be very burdensome for families and healthcare providers. Our international multidisciplinary team has developed a prototype for a wearable biomedical device ("NeoWarm") to provide continuous thermal care and augment kangaroo mother care practices in low-resource settings. The objective of this study was to assess the feasibility and acceptability of NeoWarm and to obtain user design feedback for an early prototype from among adult end-users in Western Kenya. We performed key informant interviews (n = 17) among healthcare providers and 5 focus group discussions (FGDs) among 3 groups of adult stakeholders of premature babies, including: (1) parents/family members of premature babies aged 6 weeks or less (3 FGDs); (2) healthcare providers of newborns (e.g., nurses; physicians; 1 FGD); (3) community opinion leaders and stakeholders (e.g., traditional birth attendants; pastors; village elders; 1 FGD). Content and thematic analyses of transcripts indicate that NeoWarm is acceptable and feasible in promoting facility-based kangaroo mother care in the Kenyan setting. Novel findings derived from respondents include (1) the ability of the device to potentially overcome several barriers to traditional kangaroo mother care methods and (2) user-driven encouragement to expand the use case of the device to potentially include community-based kangaroo mother care and neonatal transport. User design feedback obtained during the interviews informed several key design iterations for subsequent prototypes of the device.

Hypothermia amongst neonatal admissions in Kenya: a retrospective cohort study assessing prevalence, trends, associated factors, and its relationship with all-cause neonatal mortality

Background

Reports on hypothermia from high-burden countries like Kenya amongst sick newborns often include few centers or relatively small sample sizes.

Objectives

This study endeavored to describe: (i) the burden of hypothermia on admission across 21 newborn units in Kenya, (ii) any trend in prevalence of hypothermia over time, (iii) factors associated with hypothermia at admission, and (iv) hypothermia's association with inpatient neonatal mortality.

Methods

A retrospective cohort study was conducted from January 2020 to March 2023, focusing on small and sick newborns admitted in 21 NBUs. The primary and secondary outcome measures were the prevalence of hypothermia at admission and mortality during the index admission, respectively. An ordinal logistic regression model was used to estimate the relationship between selected factors and the outcomes cold stress (36.0°C-36.4°C) and hypothermia (<36.0°C). Factors associated with neonatal mortality, including hypothermia defined as body temperature below 36.0°C, were also explored using logistic regression.

Results

A total of 58,804 newborns from newborn units in 21 study hospitals were included in the analysis. Out of these, 47,999 (82%) had their admission temperature recorded and 8,391 (17.5%) had hypothermia. Hypothermia prevalence decreased over the study period while admission temperature documentation increased. Significant associations were found between low birthweight and very low (0-3) APGAR scores with hypothermia at admission. Odds of hypothermia reduced as ambient temperature and month of participation in the Clinical Information Network (a collaborative learning health platform for healthcare improvement) increased. Hypothermia at admission was associated with 35% (OR 1.35, 95% CI 1.22, 1.50) increase in odds of neonatal inpatient death.

Conclusions

A substantial proportion of newborns are admitted with hypothermia, indicating a breakdown in warm chain protocols after birth and intra-hospital transport that increases odds of mortality. Urgent implementation of rigorous warm chain protocols, particularly for low-birth-weight babies, is crucial to protect these vulnerable newborns from the detrimental effects of hypothermia.

Skin-to-skin transfer from the delivery room to the neonatal unit for neonates of 1,500g or above: a feasibility and safety study

Objective

Immediate skin-to-skin contact (SSC) is already standard care for healthy term newborns, but its use for term or preterm newborns requiring admission to neonatal intensive care unit (NICU) with or without respiratory support is challenging. This study aimed to assess the safety and feasibility of SSC during the transfer of newborn infants, using a new purpose-built mobile shuttle care-station, called "Tandem".

Material and methods

A monocentric prospective observational study was conducted at the tertiary referral center of the Université libre de Bruxelles in Brussels, Belgium after ethical approval by Hopital Erasme's Ethics Committee (ClinicalTrials.gov ID: NCT06198478). Infants born with a birth weight above 1,500 g were included. Following initial stabilization, infants were placed in SSC with one of their parents and transferred to the NICU using the Tandem.

Results

Out of 65 infants initially included, 64 (98.5%) were successfully transported via SSC using the Tandem. One transfer was not successful due to last minute parental consent withdrawal. The median (range) duration of continuous skin-to-skin contact after birth was 120 min (10-360). SSC transfers were associated with gradually decreasing heart rate (HR) values, stable oxygen saturation levels (SpO2), and no increase in median fraction of inspired oxygen (FiO2). Heatloss was predominantly observed during initial setup of SSC. There was no significant difference in the occurrence of tachycardia, desaturation or hypothermia between preterm and term neonates. No equipment failures compromising the transfer were recorded.

Conclusion

Skin-to-skin transfer of infants with a birthweight of equal or above 1,500 g using the Tandem shuttle is feasible and associated with stable physiological parameters. This method facilitates early bonding and satisfies parents.

Clinical Trial Registration

ClinicalTrials.gov (NCT06198478).

Prewarming Parturients for Cesarean Section Does Not Raise Wound Temperature But Body Heat and Level of Comfort: A Randomized Trial

PURPOSE

Prewarming before cesarean section lowers the rates of surgical site infections (SSIs). We hypothesized that this effect is explained due to a higher core temperature resulting in a higher wound temperature.

DESIGN

We conducted an open-labeled randomized study with on-term parturients scheduled for elective cesarean section under spinal anesthesia. Participants were randomized into an intervention group (prewarming) and a control group.

METHODS

Core and wound temperature, comfort level, and examination results were taken at defined times until discharge from the postanesthesia care unit (PACU). There was a follow-up visit and interview 1 day after the procedure. The primary outcome was a difference in wound temperature. The secondary outcomes were differences in core temperature, patient comfort, blood loss, SSI, and neonatal outcome.

FINDINGS

We randomized a total of 60 patients, 30 per group. Prewarming lead to a significantly higher core temperature. Additionally, patient comfort was significantly higher in the prewarming group even after discharge from PACU. We did not find a difference in wound temperature, SSI, neonatal outcome, or blood loss.

CONCLUSIONS

Prewarming before cesarean section under spinal anesthesia maintains core temperature and improves patient comfort but does not affect wound temperature.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Young Infants Clinical Signs Study 8-sign Algorithm for Identification of Sick Infants Adapted for Routine Home Visits: A Systematic Review and Critical Appraisal of its Measurement Properties

Objective. The 8-sign algorithm adapted from the Young Infants Clinical Signs Study (YICSS) is widely used to identify sick infants during home visits (YICSS-home algorithm). We aimed to critically appraise the development and evidence of measurement properties, including sensibility, reliability, and validity, of the YICSS-home algorithm. Methods. Relevant studies were identified through a systematic literature search. Results. The YICSS-home algorithm has good sensibility. The algorithm demonstrated at least moderate inter-rater reliability and sensitivity ranging from 69% to 80%. However, the algorithm was developed among sick infants brought for care to a health facility and not initially developed for use by community health workers (CHWs) during home visits. Some important risk factors were omitted at item generation. Inter-CHW reliability and construct validity have not been estimated. Conclusion. Future research should build on the strengths of the YICSS-home algorithm and address its limitations to develop a new algorithm with improved predictive accuracy.

Introduction of a novel neonatal warming device in Malawi: an implementation science study

BACKGROUND

Neonatal hypothermia significantly contributes to infant morbidity and mortality in low-resource settings like Malawi. Kangaroo mother care (KMC) is essential but faces challenges in providing continuous thermal support. The Dream Warmer is a neonatal warming device that was developed to complement KMC. We studied its implementation outside a research environment.

METHODS

Using an implementation science approach, we conducted a prospective interventional cohort study in two hospitals and four health centres in Malawi. Through audits and surveys, we assessed the effect of the Dream Warmer on neonatal hypothermia as well as healthcare provider (HCP) and parent attitudes regarding thermoregulation and related issues.

RESULTS

The Dream Warmer raised no safety concerns and effectively treated hypothermia in 90% of uses. It was positively received by HCPs and parents, who reported it had a favourable effect on the care of small and sick newborns. Challenges identified included a scarcity of water and electricity, lack of availability of the device and HCPs forgetting to prepare it in advance of need or to use it when indicated. Feedback for future training was obtained. The Dream Warmer's strong safety and effectiveness performance is consistent with results from strict research studies. Training materials can be adapted to optimize integration into daily practice and provide educational content for parents.

CONCLUSIONS

The Dream Warmer is a safe and effective device to treat neonatal hypothermia, particularly when KMC is insufficient. We gained an understanding of how to optimize implementation through robust HCP and family education to help combat hypothermia.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Care During Labour, Childbirth, and Immediate Newborn Care in India: A Review

India is committed to achieve a single-digit neonatal mortality rate (NMR) and stillbirth rate (SBR) by 2030 through India Newborn Action Plan (INAP) 2014. However, the current rate of decline is not enough to achieve the target neonatal mortality rate. Course correction and renewed efforts are required. This review outlines the current scenario and proposed scale-up of services included during labour, childbirth, and the immediate newborn period. The article summarises the challenges and bottlenecks in achieving a reduction in neonatal mortality rate and INAP targets. India has achieved over 80% coverage of three of the four ENAP coverage targets, but antenatal care coverage is still poor. There are concerns about the quality and completeness of antenatal care visits and other program interventions. The ongoing quality assurance should be strengthened through continuous supportive supervision by involving the medical colleges in a hub and spoke model and other key stakeholders. There is a need for effective and strategic engagement of the private sector in these initiatives. The states need to systematically assess the gaps as per population requirements and find effective solutions to overcome them quickly. The state and district-wise data maps show immense variations in coverage between states and within states, mirroring the variations in NMR. This indicates the need to ensure contextual micro-plans and provides an opportunity for the districts and states to learn from each other. The recent initiatives to strengthen primary healthcare should be used as a platform for all stillbirth and neonatal mortality prevention interventions in India.

Hypothermia and adverse outcomes during the transfer of extremely low birth weight infants

AIM

We aimed to explore whether hypothermia during the transfer of extremely low birth weight (ELBW) infants was associated with increased morbidity and mortality.

METHODS

Retrospective cohort study of transfers of ELBW infants by the London Neonatal Transfer Service between April 2015 and January 2017. Hypothermia was defined as an axillary temperature below 36.5°C.

RESULTS

Hypothermia was recorded in 36-47% of the 146 transfers depending on the time point of measurement from admission at the referring unit to admission at the receiving unit. Infants with hypothermia had a lower gestational age [25.1 (24.1-26.6) versus 26.0 (25.3-27.0) weeks, p < 0.001], birth weight [750 (600-830) versus 800 (730-885) gr, p = 0.004) and age at referral [1 (0.8-3) versus 1.5 (1-4) hours, p = 0.049] compared to infants without hypothermia. Infants with hypothermia had a longer median (IQR) duration of invasive ventilation [22(6-44) days] compared to infants without hypothermia [10 (4-21) days, p = 0.002]. Infants with hypothermia had a higher incidence of a patent ductus arteriosus and mortality before discharge from neonatal care compared to infants without hypothermia (79% vs. 27%, p = 0.043 and 29% vs. 13%, p = 0.025, respectively).

CONCLUSION

Among ELBW infants, hypothermia during transfer was common, particularly in infants of lower gestational age. Hypothermia was associated with a longer duration of ventilation and increased mortality before discharge from neonatal care.

Promoting metabolic inefficiency for metabolic disease

Recent advances in pharmacotherapies that promote appetite suppression have shown remarkable weight loss. Therapies targeting energy expenditure lag behind, and as such none have yet been identified to be safe and efficacious for sustaining negative energy balance toward weight loss. Multiple energy dissipating pathways have been identified in adipose tissue and muscle. The molecular effectors of some of these pathways have been identified, but much is still left to be learned about their regulation. Understanding the molecular underpinnings of metabolic inefficiency in adipose tissue and muscle is required if these pathways are to be therapeutically targeted in the context of obesity and obesity-accelerated diseases.

Development, implementation, and evaluation of neonatal thermoregulation decision support web application

OBJECTIVES

Thermoregulation is important for all age groups, and in neonates, it is considered a crucial event to adapt to extrauterine life. Therefore, using systems that provide frequent reminders in different ways in the field of thermoregulation can help thermal stability in neonates. The present study aimed to develop, implement, and evaluate a neonatal thermoregulation decision support system (DSS) as a web application.

METHODS

The present research was a multi-method study because it included the three phases of development, implementation, and evaluation of the neonatal thermoregulation decision support web application. In the system designing phase, the waterfall model is used. The second and third phases of the study, implementation, and evaluation, were conducted as a quasi-experimental study.

RESULTS

The results of this study were presented in two parts: the developed web application, and the results of the evaluation of the web application. The results of the statistical tests revealed that the use of the web application had a positive and significant effect on both the adjustment of the temperature of the incubator (maintaining the neutral temperature) and the maintenance of the temperature of the neonate's body (p = 0.000).

CONCLUSIONS

These results indicate that a nurse's sensitization and guidance with a neonatal thermoregulation decision support system can help to effectively neonate thermoregulation and the nurse has brought the temperature care close to the standard care based on the conditions of each neonate.

Hats Off for Full-Term Healthy Newborns: No Benefits for Thermoregulation

BACKGROUND

Hyperthermia is a known risk for sudden unexpected infant death. The practice of hat placement at birth to prevent transient hypothermia may not be necessary and sets an early standard for clothing infants that may lead to hyperthermia postnatally.

OBJECTIVE

To examine the elimination of hats on thermoregulation (eg, hypothermia, <97.6°F) in full-term newborns with no abnormalities within 24 hours of birth.

METHODS

In 2018, an institution guideline discontinued the use of hats at birth. Subsequently, newborn body temperatures were respectively extracted from electronic health records and data were compared from 482 infants (>38 weeks' gestation and newborn birth weight >2500 g) prior to ( n = 257) and following ( n = 225) the practice change. Body temperatures prior to and after the practice change to eliminate hats use were compared.

RESULTS

No statistically significant difference was observed: (1) in the proportion of infants experiencing hypothermia with or without hat use, respectively, 23.7% compared with 31.1% ( P = .09) and (2) in the odds of an infant experiencing hypothermia when adjusting for relevant covariates (odds ratio = 1.44; 95% confidence interval 0.89-2.32; P = .14).

CONCLUSIONS

Our findings demonstrate that the use of hats on infants at birth had no measurable impact on newborn thermoregulation.

Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis

AIM

To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation.

METHODS

Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines.

RESULTS

DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient.

CONCLUSIONS

DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.

Neonatal Admission Temperature in Middle- and High-Income Countries

BACKGROUND AND OBJECTIVES

Despite being preventable, neonatal hypothermia remains common. We hypothesized that the proportion of newborns with hypothermia on admission would be high in all settings, higher in hospitals in middle-income countries (MIC) compared with high-income countries (HIC), and associated with morbidity and mortality.

METHODS

Using the Vermont Oxford Network database of newborns with birth weights 401 to 1500 g or 22 to 29 weeks' gestational age from 2018 to 2021, we analyzed maternal and infant characteristics, delivery room management, and outcomes by temperature within 1 hour of admission to the NICU in 12 MICs and 22 HICs.

RESULTS

Among 201 046 newborns, hypothermia was more common in MIC hospitals (64.0%) compared with HIC hospitals (28.6%). Lower birth weight, small for gestational age status, and prolonged resuscitation were perinatal risk factors for hypothermia. The mortality was doubled for hypothermic compared with euthermic newborns in MICs (24.7% and 15.4%) and HICs (12.7% and 7.6%) hospitals. After adjusting for confounders, the relative risk of death among hypothermic newborns compared with euthermic newborns was 1.21 (95% confidence interval 1.09-1.33) in MICs and 1.26 (95% confidence interval 1.21-1.31) in HICs. Every 1°C increase in admission temperature was associated with a 9% and 10% decrease in mortality risk in MICs and HICs, respectively.

CONCLUSIONS

In this large sample of newborns across MICs and HICs, hypothermia remains common and is strongly associated with mortality. The profound burden of hypothermia presents an opportunity for strategies to improve outcomes and achieve the neonatal 2030 Sustainable Development Goal.

Temperature Monitoring in Children: An Agreement Study

Background:

Noncontact infrared thermometer (NCIT) measures temperature rapidly and noninvasively. It is commonly used at forehead, but other potential sites such as axilla and abdomen are yet to be explored. We assessed agreement of temperature recordings of axillary temperature by glass mercury thermometer (the “gold standard”) with axillary temperature by the digital thermometer as well as with NCIT at forehead, axilla, mid abdomen, and at right hypochondriac areas.

Methods:

Neonates and children below 5 years admitted in neonatal and pediatrics wards were enrolled in the study through convenience sampling. For each participant, temperature was measured using NCIT at forehead, mid abdomen, right hypochondrium, and right axilla as well as using digital thermometer at right axilla and using glass mercury thermometer at right axilla. The agreement between methods was presented as mean difference (95% limits of agreement) using Bland-Altman analysis.

Results:

Total 400 temperature readings were taken for each method from 132 participants. There was a good agreement between mercury axillary with digital axillary in both the groups, that is, neonates and children (>1 month to 5 years) (Mean difference [95% limits of agreement] = –0.046 [–0.26 to 0.169]°C and –0.028 [–0.183 to 0.128]°C, respectively). While for all the methods using NCIT, there was a poor agreement with mercury axillary temperature in both the groups.

Conclusion:

Agreement between axillary temperatures using digital and glass mercury thermometers was good, while agreements between the axillary temperature using glass mercury thermometer with NCIT readings at different sites were poor in neonates and children below 5 years.

Quality Improvement Study With Low-Cost Strategies to Reduce Neonatal Admission Hypothermia

Background Admission hypothermia is still an underappreciated major challenge for new-born survival in low-resource settings. The WHO recommends skin-to-skin contact as the simplest and safest way for maintaining the body temperature even during transportation. Quality improvement initiatives for hospitalised new-borns have shown benefits like a reduction in neonatal morbidity and mortality. This study was undertaken in a resource-constrained public hospital in southern India with an aim to reduce neonatal hypothermia at admission to <20%. Method It was a prospective, quality improvement study undertaken over 20 weeks. All neonates born in the selected delivery room (DR), requiring transportation to the neonatal intensive care unit, were included. The primary outcome indicators were the mean axillary temperature of neonates measured upon arrival at the neonatal intensive care unit and the percentage of neonates with hypothermia at admission. Improving the thermoregulatory practices and ambient DR temperature to >25˚C, transportation by the kangaroo method, and a portable infant warmer (PIW) were implemented in three successive Plan-Do-Study-Act (PDSA) cycles. Result In the third PDSA cycle, the mean admission temperature (36.51˚C ±0.82) was significantly (p<0.0001) higher when compared with the baseline phase (35.41˚C ±1.09), and there was a significant (p<0.001) reduction in hypothermia (33.33%). The aim was achieved in the last two weeks of the third cycle with a reduction in hypothermia to 17.6%. Conclusion Implementation of appropriate thermoregulatory practices and low-cost strategies like the kangaroo method and PIW using quality improvement methodology significantly reduced admission hypothermia.

Neonatal warming devices: What can be recommended for low-resource settings when skin-to-skin care is not feasible?

Hypothermia occurs frequently among clinically unstable neonates who are not suitable to place in skin-to-skin care. This study aims to explore the existing evidence on the effectiveness, usability, and affordability of neonatal warming devices when skin-to-skin care is not feasible in low-resource settings. To explore existing data, we searched for (1) systematic reviews as well as randomised and quasi-randomised controlled trials comparing the effectiveness of radiant warmers, conductive warmers, or incubators among neonates, (2) neonatal thermal care guidelines for the use of warming devices in low-resource settings and (3) technical specification and resource requirement of warming devices which are available in the market and certified medical device by the US Food and Drug Administration or with a CE marking. Seven studies met the inclusion criteria, two were systematic reviews comparing radiant warmers vs. incubators and heated water-filled mattresses vs. incubators, and five were randomised controlled trials comparing conductive thermal mattresses with phase-change materials vs. radiant warmers and low-cost cardboard incubator vs. standard incubator. There was no significant difference in effectiveness between devices except radiant warmers caused a statistically significant increase in insensible water loss. Seven guidelines covering the use of neonatal warming devices show no consensus about the choice of warming methods for clinically unstable neonates. The main warming devices currently available and intended for low-resource settings are radiant warmers, incubators, and conductive warmers with advantages and limitations in terms of characteristics and resource requirements. Some devices require consumables which need to be considered when making a purchase decision. As effectiveness is comparable between devices, specific requirements according to patients' characteristics, technical specification, and context suitability must play a primary role in the selection and purchasing decision of warming devices. In the delivery room, a radiant warmer allows fast access during a short period and will benefit numerous neonates. In the neonatal unit, warming mattresses are low-cost, effective, and low-electricity consumption devices. Finally, incubators are required for very premature infants to control insensible water losses, mainly during the first one to two weeks of life, mostly in referral centres.

Birth asphyxia related mortality in Northwest Ethiopia: A multi-centre cohort study

BACKGROUND

Birth asphyxia is the second leading cause of neonatal death in Ethiopia, next to preterm-associated infections. Understanding the causes of death in asphyxiated newborns will help to design appropriate care. This study identifies predictors of neonatal mortality in asphyxiated newborns in selected hospitals in Northwest Ethiopia.

METHODS

An institution-based prospective cohort study of 480 newborns with birth asphyxia was conducted at Debre Markos Comprehensive Specialized Hospital, Shegaw Motta District Hospital, and Injibara General Hospital. All newborns with asphyxia admitted to the neonatal critical care unit from the first of November 2018 to the first of November 2019 were included. Data were obtained prospectively from mothers using an interviewer's administered questionnaire. The Kaplan-Meier survival curve was used to estimate survival time, and Log rank test was used to compare the survival curves. Bivariable and multivariable Cox proportional hazards models were fitted to identify the independent predictors of mortality in asphyxiated newborns. Adjusted hazard Ratios (AHRs) with 95% Cis (Confidence Intervals) were used to measure the strength of association and test statistical significance.

RESULTS

The overall cumulative incidence of mortality among asphyxiated newborns was 42.29% (95% CI: 38%, 46). Asphyxiated neonates with other comorbidities (sepsis, neonatal anemia) (AHR = 2.63, 95% CI:1.69, 4.10), oxygen saturation of 50-69 (AHR = 4.62, 95% CI:2.55, 8.37), oxygen saturation of 70-89 (AHR = 2.82, 95% CI: 1.80, 4.42), severe Apgar score at one minute (AHR = 1.59, 95% CI:1.12, 2.25), neonates with Hypoxic Ischemic Encephalopathy (HIE) (AHR = 6.12, 95% CI:2.23, 16.75) were at higher risk of mortality.

CONCLUSIONS

The mortality rate among asphyxiated neonates remains high, and slightly higher than previous studies. Asphyxiated newborns with other comorbidities, severe Apgar score at one minute, who develop HIE, and low oxygen saturation were at higher risk of death. Therefore, designing appropriate interventions and prevention methods should be considered for identified variables.

Use of access port covers in transport incubators to improve thermoregulation during neonatal transport

Hypothermia in newborns increases the risk of health complications and mortality. This study aimed to evaluate the effectiveness of using covers over snap-open access ports of a transport incubator to maintain the temperature within. The change in temperature inside the transport incubator was evaluated over a 15-min period at three ambient room temperatures (20 °C, 24 °C, and 28 °C), as well as for three snap-open access port conditions: closed, where ports are closed; open, where the two ports on one side are open; and covered, where the two ports on one side are open but a cover is used. The automatic temperature control of the incubator was set to 37 °C for all conditions. We repeated the same experiments three times. The temperature decrease inside the incubator was greater for the open than for the closed or covered access port conditions at all three 4 °C-increasing room temperatures (p < 0.05). The incubator temperature decreased as a function of decreasing room temperature only for the open condition, with no significant difference between the closed and covered conditions. Therefore, snap-open access port covers provide an option to maintain a constant temperature within the transport incubator, which may lower the risk of neonatal hypothermia.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Exploring caregivers' experiences of Kangaroo Mother Care in Bangladesh: A descriptive qualitative study

BACKGROUND

Kangaroo Mother Care (KMC) is an evidence-based intervention recommended by the World Health Organization (WHO) to reduce preterm mortality and morbidity. The aim of this study was to explore caregivers' experiences of providing KMC in hospital settings and after continuation at home in Bangladesh in order to assess enablers and barriers to optimal implementation.

METHODS

Interviews with fifteen caregivers were conducted using an interview guide with semi-structured questions in August 2019 and March 2020. Convenience sampling was used to select hospitals and participants for the study. The inclusion criteria were being a caregiver currently performing KMC in the hospital or having been discharged one week earlier from the KMC ward. The interviews were audio recorded, transcribed verbatim, and translated. The data were analyzed using thematic analysis with an inductive approach.

RESULTS

Three themes were identified as regards the caregivers' experiences of providing KMC: conducive conditions, an empowering process, and suboptimal implementation. The results showed that there are supporting circumstances for caregivers performing KMC in Bangladesh, including social support structures and positive attitudes to the method of care. It also appeared that the caregivers felt strengthened in their roles as caregivers by learning and performing KMC. However, the implementation of KMC was suboptimal due to late initiation of KMC, difficulties with keeping the baby skin-to-skin, and pain after cesarean section hampering skin-to-skin practice.

CONCLUSIONS

The social and cultural conditions for the caregivers to perform KMC as well as the empowerment the parents felt in their roles as caregivers when performing KMC are facilitating factors for this method of care. Initial separation and late initiation of KMC, as well as disregard for the mothers' needs for care and support, were barriers to optimal practice leading to missed opportunities. These facilitators and barriers need to be addressed in order to succeed in scaling up the national KMC program.

Occurrence of neonatal hypothermia and associated risk factors among low birth weight (LBW) infants in Accra, Ghana

Background

Neonatal hypothermia is a prominent issue in low-resource settings. Preterm and low birth weight (LBW) infants are at increased risk for developing hypothermia. If left untreated, hypothermia can lead to hypoxia, sepsis, hypoglycemia, apnea, and poor weight gain in neonates, contributing to neonatal morbidity and mortality. Identifying risk factors for neonatal hypothermia is important, especially in low-resource settings, where the burden of neonatal mortality is highest. The study sought to describe the distribution of neonatal hypothermia and examine risk factors associated with neonatal hypothermia among LBW infants admitted to Korle-Bu Teaching Hospital in Accra, Ghana.

Methods

Infants in the neonatal intensive care unit (NICU) at Korle-Bu Teaching Hospital, who were less than 28 days old, weighing less than <2,500 grams, and clinically stable, were enrolled. Infants of mothers under 18 years old and those expected to be discharged within 24 hours were excluded from the study. A standardized questionnaire was administered to collect information on the mother, infant, pregnancy, and birth characteristics. Axillary temperature readings were taken every 4 hours over a 24-hour monitoring period and during hypothermic events detected by the continuous temperature monitoring bracelet. Univariate and multivariate linear regression analyses with generalized estimating equations were used to examine risk factors associated with temperature.

Results

Of the 254 infants included in the analysis, 42.1% were male, 49.6% were very LBW (<1,500 grams), and 94.1% were preterm (<37 weeks). Of the 1,948 temperature readings, 44.5% were hypothermic (<36.5oC). Hypothermia occurred in 85.8% of infants during the 24-hour monitoring period. Multivariate linear regression demonstrated that being very LBW, having no skin-to-skin contact immediately after birth, not being wrapped or treated in an incubator at the time of temperature, and mixed feeding (compared to exclusive breastfeeding) were associated with lower neonatal temperatures.

Conclusions

Neonatal hypothermia was common among infants admitted to the NICU. The findings highlight the importance of thermal practices such as wrapping, exclusive breastfeeding and skin-to-skin contact. Increased education to promote thermal care is needed.

Early Baby Bathing Practice and its Associated Factors Among Mothers who Give Birth in the Past One Month in Gurage Zone, Ethiopia, 2022

Background

Ethiopia has still suffered the highest burden of neonatal morbidity and mortality. The World Health Organization's practical guide for the thermal protection of newborns recommends delaying the bathing of newborns for at least 24 h following delivery, as it is crucial to prevent neonatal mortality and morbidity and to achieve 2030 sustainable development goals. However, little is known about delayed newborn bathing practices in Ethiopia. Therefore, the purpose of this study was to assess early baby bathing practices and associated factors among postpartum women.

Methods

A mixed community-based cross-sectional study was conducted among a total of 582 postnatal mothers. A multistage sampling technique was used to select study participants. A pre-tested and structured questionnaire was used to collect data. The data was entered into Epi-Data version 4.2.0 and exported into SPSS version 23 for analysis. Three focus group discussions with postnatal mothers were used for qualitative data. A purposive sampling method was used. Thematic analysis was used for qualitative data. Bivariate and multivariate logistic regression analyses were used in the analysis. To declare statistically significant, p-values of .05 were used.

Result

This study revealed that 250 (43%) mothers were practicing early newborn bathing. Early baby bathing was associated with antenatal care (ANC) follow-up (AOR  =  5.1  =  .95% CI  =  (2.6-9.9)), having no recent complications during birth (AOR  =  1.9  =  95% CI  =  (1.02-3.6), having information about the time of baby bathing (AOR  =  6.02, 95% CI  =  (3.9, 9.3)), knowledge of hypothermia (AOR  =  3.3  =  95.6% CI (1.9-5.8), and poor knowledge about neonatal danger signs.

Conclusion and Recommendation

ANC follow-up, recent complications during birth, having information, knowledge about hypothermia, and neonatal danger signs were significantly associated with early baby bathing. Continuous health education on the appropriate time of baby bathing and neonatal danger signs and enhanced ANC service utilization are recommended.

The utilization of clinical decision support tools to identify neonatal hypothermia and its associated risk factors: A prospective observational study

Hypothermia (axillary temperature less than 36.5°) is a major source of neonatal morbidity and mortality, with a disproportionate burden of disease in low- and middle-income countries. Despite the importance of thermoregulation on newborn outcomes, the global epidemiologic landscape of neonatal hypothermia is poorly characterized. Clinical decision support (CDS) software provides point-of-care recommendations to guide clinical management and may support data capture in settings with limited informatics infrastructure. Towards this end, we conducted a prospective observational study of the NoviGuide, a novel CDS platform for newborn care, at four health facilities in Uganda between September 2022 to May 2021. Data were extracted from clinical information (e.g. axillary temperature, birth weight, gestational age) entered into the NoviGuide by nurses and midwives on newborns within 24 hours of delivery. Descriptive statistics and multivariable logistic regression were used to evaluate neonatal temperature profiles and the association between hypothermia and clinical features. Among 1,027 completed assessments, 30.5% of entries had neonatal hypothermia with significant variation across study sites. On multivariable logistic regression analysis, we found that hypothermia was independently associated with pre-term birth (Adjusted Odd's Ratio [aOR] 2.62, 95% Confidence interval [CI] 1.38-4.98), sepsis/concern for sepsis (aOR 2.73, 95% CI 2.90-3.94), and hypoglycemia/concern for hypoglycemia (aOR 1.78, 95% CI 1.17-2.72). Altogether, neonatal hypothermia was commonly entered into the NoviGuide and associated clinical characteristics aligned with previous studies based on conventional data collection instruments. Our results should be contextualized within unique technical and operational features of CDS tools, including a bias towards acutely ill patients and limited quality control. Nonetheless, this study demonstrates that a CDS used voluntarily by clinicians has the potential to fill key data gaps and drive quality improvement towards reducing neonatal hypothermia in low resource settings.

Hypothermia on admission and its association with neonatal mortality and morbidity in neonatal intensive care unit

BACKGROUND

Neonatal hypothermia is a drop in the newborn's core temperature less than 36.5°C. It is crucial in neonatal morbidity and mortality, particularly in preterm infants. This research aimed to assess the incidence and risk factors of neonatal hypothermia and its effect on neonatal mortality and short-term morbidity during Neonatal Intensive Care Unit (NICU) admission.

METHODS

This observational study was conducted on all neonates admitted to the NICU at Benha University Hospital. The core temperature was measured on admission for all admitted neonates and were followed up to assess the impact of hypothermia on short-term outcomes and mortality.

RESULTS

A total of 323 neonates were admitted to the NICU throughout the research period. Thirty-five cases were excluded due to congenital anomalies or missing or late admission temperature recordings. The study included 288 neonates whose mean gestational age was 34.6±3.4 weeks, and their mean birth weight was 2.35±0.9 kg. Two-thirds (66%) of the neonates had core temperatures indicating hypothermia (axillary temperature of less than 36.5°C), one-third (33%) were normothermic, and only three (1%) were hyperthermic. Neonates with hypothermia had statistically lower gestational age, higher frequency of multiple births, prolonged need for respiratory support, higher rates of pulmonary hemorrhage, sepsis, intraventricular hemorrhage (IVH), and necrotizing enterocolitis, longer hospital stay, and mortality.

CONCLUSIONS

There is a high incidence of neonatal hypothermia at NICU admission. Lower gestational age, increased multiples, lower APGAR score, lower birth weight, and lack of antenatal steroids were significantly associated with hypothermia at NICU admission. Hypothermia was found to be a significant factor contributing to increased mortality and morbidity rates in affected neonates.

Early detection of cold stress to prevent hypothermia: A narrative review

Temperature monitoring is essential for assessing neonates and providing appropriate neonatal thermal care. Thermoneutrality is defined as the environmental temperature range within which the oxygen and metabolic consumptions are minimum to maintain normal body temperature. When neonates are in an environment below thermoneutral temperature, they respond by vasoconstriction to minimise heat losses, followed by a rise in metabolic rate to increase heat production. This condition, physiologically termed cold stress, usually occurs before hypothermia. In addition to standard axillary or rectal temperature monitoring by a thermometer, cold stress can be detected by monitoring peripheral hand or foot temperature, even by hand-touch. However, this simple method remains undervalued and generally recommended only as a second and lesser choice in clinical practice. This review presents the concepts of thermoneutrality and cold stress and highlights the importance of early detection of cold stress before hypothermia occurs. The authors suggest systematic clinical determination of hand and foot temperatures by hand-touch for early detection of physiological cold stress, in addition to monitoring core temperature for detection of established hypothermia, particularly in low-resource settings.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Survival status and predictors of mortality among low-birthweight neonates admitted to KMC units of five public hospitals in Ethiopia: Frailty survival regression model

Background

Low birth weight (LBW) and preterm birth are leading causes of under-five and neonatal mortality globally. Data about the timing of death and outcomes for LBW and preterm births are limited in Ethiopia and could be used to strengthen neonatal healthcare. This study describes the incidence of neonatal mortality rates (NMR) stratified by newborn size at birth for gestational age and identifies its predictors at five public hospitals in Ethiopia.

Methods

A prospective follow-up study enrolled 808 LBW neonates from March 2017 to February 2019. Sex-specific birthweight for gestational age percentile was constructed using Intergrowth 21st charts. Mortality patterns by birthweight for-gestational-age-specific survival curves were compared using the log-rank test and Kaplan-Meier survival curves. A random-effects frailty survival model was employed to identify predictors of time to death.

Results

Among the 808 newborns, the birthweight distribution was 3.2% <1000 g, 28.3% <1500 g, and 68.1% <2000 g, respectively. Birthweight for gestational age categories were 40.0% both preterm and small for gestational age (SGA), 20.4% term SGA, 35.4% appropriate weight for gestational age, and 4.2% large for gestational age (LGA). The sample included 242 deaths, of which 47.5% were both preterm and SGA. The incidence rate of mortality was 16.17/1000 (95% CI 14.26–18.34) neonatal-days of observation.

Neonatal characteristics independently related to increased risk of time-to-death were male sex (adjusted hazards ratio [AHR] 3.21 95% CI 1.33–7.76), born preterm (AHR 8.56 95% CI 1.59–46.14), having been diagnosed with a complication (AHR 4.68 95% CI 1.49–14.76); some maternal characteristics and newborn care practices (like lack of effective KMC, AHR 3.54 95% CI 1.14–11.02) were also significantly associated with time-to-death.

Conclusions

High mortality rates were measured for low birthweight neonates–especially those both preterm and SGA births–even in the context of tertiary care. These findings highlight the need for improved quality of neonatal care, especially for the smallest newborns.

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis

AIM

Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation).

METHODS

Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed.

RESULTS

25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes.

CONCLUSIONS

Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

Admission Hypothermia and Factors Associated with Mortality among Admitted Hypothermic Preterm Neonates in Neonatal Intensive Care Units of Public Hospitals of Addis Ababa, Ethiopia

Background

Limited knowledge on the proportion of admission hypothermia and factors of death in hypothermic preterm neonates is hindering early and appropriate interventions in Ethiopia. Thus, studies on the proportion of admission hypothermia and factors of death in hypothermic preterm neonates are critical to enhancing preterm infants' survival.

Methods

Hospital-based cross-sectional study was conducted on 398 participants using the systematic sampling method from October 10, 2021, to December 15, 2022. A pretested data extraction tool was used to collect data. EpiData version 4.6 and STATA version 16 were used for data entry and analysis. Multivariable logistic regression analysis evaluated the association between independent and outcome variables with a 95% confidence interval (CI). Hosmer and Lemeshow test and variance inflation factor were assessed to check model fitness and collinearity, respectively. Pvalue < 0.05 was considered statistically significant.

Result

Of the 398 admitted preterm neonates, 331(83.2%) had hypothermia at admission. Factors that were significantly associated with mortality included outborn babies [Adjusted hazard ratio (AOR) = 2.18 : 95% CI (1.03-4.62)], GA less than 32 weeks [AOR = 6.64 : 95% CI (1.87-13.58)], weight less than 1500 gram [AOR = 7.91 : 95% CI (1.21-15.38)], thrombocytopenia [AOR = 3.36 : 95% CI (1.49-7.58)], and kangaroo mother care [AOR = 0.38 : 95% CI (0.16-0.88)].

Conclusion

The proportion of admission hypothermia was high. Outborn babies, birth weight less than 1500 gram, gestational age < 32 weeks, being thrombocytopenic, and lack of kangaroo mother care were identified as risk factors for hypothermic preterm neonatal mortality. Preterm labor prevention, improved inborn delivery, and kangaroo mother care may alleviate the high proportion of admission hypothermia and related mortalities in preterm neonates.

Conductive thermal mattress versus routine care to reduce neonatal hypothermia during transport among low-birthweight neonates: An experimental study with historical controls

Background

Neonatal hypothermia at delivery, during transport and in the postnatal wards is common, under-recognized and infrequently monitored with prevalence ranging from 32% to 85%. This study compared conductive thermal mattress to routine care for prevention of hypothermia among low-birthweight (LBW) neonates during transport.

Methods

From July 2015 to November 2016 (historical controls), all eligible LBW neonates (1500-2499 g) were transported from the labour room/operation theatre to the neonatal intensive care unit (NICU)/postnatal wards using routine care (towels, blankets, cap, mittens and socks) and from December 2016 to December 2018 using conductive thermal mattress (EMBRACETM) Axillary temperature was measured before transport and at arrival in the NICU/postnatal wards using a digital thermometer.

Results

A total of 154 and 102 neonates were transported using conductive thermal mattress and routine care, respectively. The mean standard deviation (SD) axillary temperature at arrival in the postnatal wards in conductive thermal mattress and routine care group was 36.6 (0.6) ⁰C and 36.4 (0.5) ⁰C, respectively (p-value 0.005). Relative Risk (RR) of mild and moderate neonatal hypothermia among neonates transported using conductive thermal mattress compared to routine care group was 0.59 (0.33,1.07), number needed to treat (NNT) of 13 and 0.22 (0.04,1.07), NNT 22 respectively.

Conclusions

Use of conductive thermal mattress for transport among LBW neonates led to a significant, although clinically small improvement in admission temperatures at the NICU/postnatal ward and non-significant decrease in the incidence of hypothermia.

Multiprofessional cross-site working between a level 1 and a level 3 neonatal unit: a retrospective cohort study

OBJECTIVE

To assess the association of short-term neonatal outcomes with cross-site working of multiple healthcare professional teams between a level 3 and a level 1 neonatal unit.

DESIGN

Retrospective cohort study.

SETTING

A level 1 neonatal unit in London.

PATIENTS

All infants admitted to the neonatal unit, between 2010 and 2021.

INTERVENTIONS

The clinical service was rearranged in 2014 with the introduction of cross-site working between the level 1 unit and a level 3 unit of neonatal doctors, nurses and allied healthcare professionals.

MAIN OUTCOME MEASURES

Admission of infants with a temperature less than 36°C, length of stay and time to first consultation by a senior team member.

RESULTS

A total of 4418 infants were admitted during the study period. The percentage of infants delivered at a gestation below 32 weeks was higher in the pre-cross-site period (8.9%) compared with the cross site period (3.6%, p<0.001). The percentage of infants with an Apgar score less than 8 at 10 min was higher in the pre-cross-site period (6.2%) compared with the cross-site period (3.4%, p=0.001). More infants were admitted with a temperature less than 36°C in the pre-cross site period (12.3%) compared with the cross site period (3.7%, p<0.001). The median (IQR) duration of time to first consultation by a senior team member was higher in the pre-cross-site period (1 (0.5-2.6) hours) compared with the cross-site period (0.5 (0.2-1.3) hours) (p<0.001). The median (IQR) length of stay was 4 (2-11) days in the pre-cross-site period and decreased to 2 (1-4) days in the cross-site period (p<0.001).

CONCLUSIONS

Cross-site working was associated with lower rates of admission hypothermia, shorter duration of stay and earlier first senior consultation.

Skilled maternal healthcare and good essential newborn care practice in rural Bangladesh: A cross-sectional study

Background and Aims

Essential newborn care (ENC) practices play an important role in reducing the risk of infant mortality and morbidity. Therefore, more studies are needed on ENC practices. Skilled maternal healthcare can be a good strategy to increase the practice. Learn about the independent and joint effects of skilled maternal healthcare during pregnancy and childbirth on newborn care practices.

Methods

The study used a cross-sectional data obtained from Bangladesh Multiple Indicator Cluster Survey, 2019. To investigate the association between maternal healthcare utilization and good ENC practice (cord care, delayed bathing, and immediate breast-feeding), χ 2 test and t-test in bivariate and binary logistic regression analysis, respectively have been performed after taking into account complex survey design.

Results

Only about 24% (95% confidence interval [CI]: 22.95%-25.89%) women given birth at home in rural Bangladesh followed good newborn care practice. The results obtained from adjusted regression analysis showed that a woman was 24%, 49%, and 75% more likely of having good ENC practice if she received four or more skilled checkups during antenatal period only (adjusted odds ratios [AOR]: 1.24, 95% CI: 0.97, 1.60), received assistance from SBA during delivery only (AOR: 1.49, 95% CI 1.12, 1.97) and received skilled healthcare in both pregnancy and delivery (AOR: 1.75, 95% CI 1.13, 2.71), respectively compared to a woman who did not get an opportunity to receive skilled healthcare during pregnancy and delivery. Among the selected confounders, maternal age at birth, birth order, education of household heads and religion showed a significant association with good ENC practice.

Conclusion

The study revealed that proper maternal healthcare during pregnancy and childbirth from skilled health personnel can improve the rate of ENC practices. For this, more training programs should be started, especially at the community level, and health promotion activities are needed to create awareness about efficient maternal healthcare practices.

Clinical detection of 'cold stress' is overlooked: an online survey of healthcare workers to explore the gap in neonatal thermal care in low-resource settings

BACKGROUND

Neonatal hypothermia has been widely regarded as a major contributory factor to neonatal mortality and morbidity in low-resource settings. The high prevalence of potentially preventable hypothermia today urges an investigation into why neonates still become hypothermic despite awareness of the problem and established thermal care guidelines. This study aimed to explore the gaps in knowledge and practices of neonatal thermal care among healthcare workers in low-resource settings.

METHODS

A cross-sectional, questionnaire-based survey was performed online among healthcare workers in low-resource settings. We applied a purposive and snowballing sampling method to recruit participants through a two-round international online survey. Questionnaires were developed using themes of neonatal thermal care extracted from existing neonatal care guidelines.

RESULTS

55 neonatal care professionals participated in the first-round survey and 33 in the second. Almost all participants (n=44-54/55) acknowledged the importance of the WHO's warm chain to keep a neonate warm. However, fewer participants (n=34-46/55) responded to practice them. When asked about cold stress, defined as a condition in which neonates are below optimum environmental temperature and using more oxygen and energy while maintaining normal body temperature, 15 out of 55 participants answered that checking extremity temperatures by hand touch was useless. Some participants reported concern about the extremity temperature's inaccuracy compared with core temperature. Opinions and preferences for rewarming methods differed among participants, and so did the availability of warming equipment at their institutions.

CONCLUSION

An inadequate understanding of cold stress underestimates the potential benefits of extremity temperatures and leads to missed opportunities for the timely prevention of hypothermia. The current thermal care guidelines fail to highlight the importance of monitoring cold stress and intervening before hypothermia occurs. Therefore, we urge introducing the concept of cold stress in any neonatal thermal care guidelines.

Duration of skin-to-skin care and rectal temperatures in late preterm and term infants

Background

Hypothermia during the newborn period is widely regarded as a major contributory cause of significant morbidity and mortality of newborn infants. Thermoprotective behaviours such as skin-to-skin care (SSC) or the use of appropriate devices have been recommended as simple tools for the avoidance of neonatal hypothermia. We examined the relation between the duration of skin-to-skin care and infant temperature change after birth in suboptimal delivery room temperatures.

Methods

We reviewed the medical charts of all vaginally born infants of gestational age ≥ 35 weeks born January-July 2018 and admitted to the well-baby nursery. After SSC was discontinued, the infant’s rectal temperature was measured to determine the frequency and severity of hypothermia.

Results

The charts of 688 vaginally born infants were examined. Our mean delivery room temperature was 21.7 (SD 2.2) °C, well below the WHO recommendation of 25 °C. After SSC 347 (50.4%) infants were normothermic (temperature 36.5–37.5 °C), 262 (38.0%) were mildly hypothermic (36.0-36.4 °C), and 79 (11.4%) were moderately hypothermic (32.0-35.9 °C). The mean skin-to-skin time in infants was 63.9 (SD 20.9) minutes. SSC duration was associated with increase in rectal temperature for patients of gestational ages ≥ 38 weeks and with decrease in rectal temperature in patients of gestational age < 38 weeks.

Conclusion

SSC is effective, even at suboptimal delivery room temperatures, for promoting normothermia in infants of ≥ 38 weeks’ gestation but may not provide adequate warmth for infants of < 38 weeks.

Importance of breastfeeding and complementary feeding for management and prevention of childhood diarrhoea in low- and middle-income countries

Background

Early and exclusive breastfeeding have been shown to protect young infants from all-cause and diarrhoea-related mortality. Ideally breastfeeding should be initiated within the first hour of birth. Despite efforts to increase rates of early and exclusive breastfeeding in low- and middle-income countries (LMICs), challenges with uptake remain. This analysis reviews trends in early and exclusive breastfeeding, and the impact of infant feeding interventions in reducing childhood diarrhoea.

Methods

We conducted a detailed review of articles written in English between 1990 and 2020 on the impact and efficacy of breastfeeding and complementary feeding on diarrhoea in children aged 0-2 years in LMICs. Using data from 86 countries and all WHO global regions collected from the mid-1980s through 2018 obtained from publicly available Demographic Health Surveys, we assessed trends in five-year intervals of timing of breastfeeding initiation, exclusive breastfeeding, median and mean duration of exclusive breastfeeding, and complementary feeding.

Results

The literature search identified ten articles that described variable rates of early initiation of breastfeeding from 20% in Pakistan to 76% in Egypt. An analysis of 288 DHS studies found that the proportion of women who reported initiating breastfeeding within an hour of birth increased from 32% in the early 1990s to 55% between 2016 and 2020. Exclusive breastfeeding increased from 20% in the late 1980s to 48% between 2016 and 2020 and the mean duration of exclusive breastfeeding of 2-to-4-month-old infants doubled. Early initiation of breastfeeding and exclusive breastfeeding was associated with reductions in diarrhoea prevalence in the South East Asian, Western Pacific, Eastern Mediterranean, and African regions. Eight studies evaluating the effectiveness of different maternal education interventions, health care worker training, and media campaigns demonstrated improvements in exclusive breastfeeding, and most resulted in reductions in the incidence or duration of diarrhoea.

Conclusions

During the last two decades, early and exclusive breastfeeding have increased. Nevertheless, the uptake of this basic, low-cost intervention remains suboptimal across all global regions. Given the potential benefits the in reduction of diarrhoea and diarrhoea-associated mortality, interventions for improving the uptake of early and exclusive breastfeeding in different sociological contexts need to be designed, implemented, and evaluated.

Improvement in thermoregulation outcomes following the implementation of a thermoregulation bundle for preterm infants

AIM

Hypothermia is associated with increased morbidity and mortality in preterm infants. A local audit revealed 60% preterm infants ≤32 weeks gestation and/or very low birth weight (VLBW) infants (<1500 g) had an abnormal body temperature at admission. This study compares thermoregulatory outcomes before and after the implementation of a thermoregulation bundle in the birthing environment.

METHODS

This retrospective cohort study reviewed thermoregulatory data for all inborn preterm (≤32 weeks) and/or VLBW infants for a period of 30 months before (Group 1: 1st January 2013 to 30 June 2015) and after changes to thermoregulation practice (Group 2: 1st July 2015 to 31 December 2017). The key practice changes included: improved anticipation and staff preparedness, wrapping infant in a polyethylene sheet, using a polyethylene lined bonnet, using servo-control mode at birth and during transport.

RESULTS

There were 282 and 286 infants in group 1 and group 2 respectively, with similar baseline characteristics. A clinically and statistically significant improvement was observed in the proportion of infants with normothermia (33% in group 1 to 60% in group 2, P < 0.0001) including the sub-group of extremely preterm (<28 weeks gestation) infants (38 to 60%, P = 0.0083). A higher mean admission temperature was observed for group 2 (36.10°C ± 0.78 in group 1 vs 36.52°C ± 0.61 in group 2, P < 0.0001). Moderate hypothermia was reduced by two-thirds in group 2 (41-12%, P = <0.0001).

CONCLUSIONS

The introduction of a thermoregulation bundle improved admission temperature, improved the proportion of normothermia and reduced moderate hypothermia in preterm infants.