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

Risk factors and neonatal/infant mortality risk of small-for-gestational-age and preterm birth in rural Nepal

OBJECTIVE

Our study seeks to elucidate risk factors for and mortality consequences of small-for-gestational-age (SGA) and preterm birth in rural Nepal. In contrast with previous literature, we distinguish the epidemiology of SGA and preterm birth from each other.

METHODS

We analyzed data from a maternal micronutrient supplementation trial in rural Nepal (n = 4130). We estimated adjusted risk ratios (aRR) for risk factors of SGA and preterm birth, and aRRs for the associations between SGA/preterm birth and neonatal/infant mortality. We used mutually exclusive categories of term-appropriate-for-gestational-age (AGA), term-SGA, preterm-AGA, and preterm-SGA (with term-AGA as reference) in our analyses.

RESULTS

Stunted (<145 cm) and wasted (<18.5 kg/m(2)) women both had increased risk of having term-SGA (aRR 1.36, 95% CI: 1.14-1.61, aRR 1.22, 95% CI: 1.09-1.36 respectively) and preterm-SGA (aRR 2.48, 95% CI: 1.29-4.74, aRR 1.99, 95% CI: 1.33-2.97 respectively), but not preterm-AGA births. Similar results were found for low maternal weight gain per gestational week. Those born preterm-SGA generally experienced the highest neonatal and infant mortality risk, although term-SGA and preterm-AGA newborns also had statistically significantly high mortality risks compared to term-AGA babies.

CONCLUSIONS

SGA and preterm birth have distinct risk factors and mortality patterns. Maternal chronic and acute malnutrition appear to be associated with SGA outcomes. Because of high SGA prevalence in South Asia and the increased neonatal and infant mortality risk associated with SGA, there is an urgent need to intervene with effective interventions.

The incidence and prevention of hypothermia in newborn bonding after cesarean delivery: a randomized controlled trial

BACKGROUND

Little is known about thermoregulation of the newborn while bonding on the mother's chest immediately after cesarean delivery. Newborn hypothermia is associated with serious complications and should be avoided. Therefore, we evaluated whether newborns develop hypothermia during intraoperative bonding while positioned on their mothers' chests and investigated the effects of active cutaneous warming of the mothers and babies during a 20-minute intraoperative bonding period.

METHODS

We enrolled 40 parturients scheduled for elective cesarean delivery under spinal anesthesia. Mothers and their newborns were randomized to receive either passive insulation or forced-air skin-surface warming during the surgical procedure and bonding period. The primary outcome was neonatal core temperature at the end of the bonding period. Core temperatures of the newborns were measured with a rectal probe. Body temperatures of the mothers were assessed by sublingual measurements. Skin temperatures, thermal comfort of the mothers, and perioperative shivering were evaluated.

RESULTS

Without active warming from the beginning of the surgical procedure until the end of the bonding period, the mean (SD) neonatal core temperature decreased to 35.9 (0.6)°C. Seventeen of 21 (81%) newborns became hypothermic (defined as a core temperature below 36.5°C). Active skin-surface warming from the beginning of the surgical procedure until the end of the bonding period resulted in a neonatal core temperature of 37.0 (0.2)°C and a decreased incidence of hypothermia (1 of 19 (5%) newborns (P < 0.0001)). In addition, active warming increased the mean skin temperatures of the infants, maternal core and skin temperatures, maternal thermal comfort, and reduced perioperative shivering.

CONCLUSIONS

Active forced-air warming of mothers and newborns immediately after cesarean delivery reduces the incidence of infant and maternal hypothermia and maternal shivering, and increases maternal comfort.

Delivery room management of extremely low birthweight infants shows marked geographical variations in Italy

AIM

To evaluate any geographical variations in practice and adherence to international guidelines for early delivery room management of extremely low birthweight (ELBW) infants in the North, Centre and South of Italy.

METHODS

A questionnaire was sent to all 107 directors of Italian level III centres between April and August 2012.

RESULTS

There was a 92% (n = 98) response rate. A polyethylene bag/wrap was used by 54 centres (55.1%), with the highest rate in Northern Italy (77.5%) and the lowest rate in Southern (37.7%) areas. In Northern regions, one centre (2.5%) said it used oxygen concentrations >40% to initiate positive pressure ventilation in ELBW infants. These proportions were higher in the Central (14.3%) and Southern (16.2%) areas. A T-piece device for positive pressure ventilation was more frequently available in the Northern (95%) units than in those in the Central (66.7%) and Southern (69.4%) regions. A median of 13% (IQR: 5%-30%) of ELBW infants received chest compressions at birth in Italy: 5%, 18% and 22% in Northern, Central and Southern units, respectively.

CONCLUSION

In Italy, delivery room management of ELBW infants showed marked geographical variations. Implementation of national training programmes could increase adherence to the guidelines and reduce such discordance.

Medicine: a rethink? Are entrants to the profession and the way it is organised fit for purpose?

The health burden in most countries has changed. Although acute care is needed for trauma, acute illness and exacerbations of chronic disease, most of the burden is now long term. These patients need different approaches, with more emphasis upon supporting self-management, enhancing lifestyle changes, aiding compliance by shared decision-making and providing more convenient follow-up that appreciates the likelihood of multimorbidity. Integrated care will increasingly be offered from within the community. The current hospital- and doctor-centric focus needs to change to one where specialists work in the community as much as in hospitals and share this different type of care with others. For potential future doctors, the scientific basis of medicine will still underpin their unique role in diagnosis and prescribing, but they will need to understand these other changes and to be selected according to attributes compatible with their future role, and then be trained and assessed accordingly.

Effect of early skin-to-skin contact following normal delivery on incidence of hypothermia in neonates more than 1800 g: randomized control trial

OBJECTIVE

To investigate the impact of early skin-to-skin contact (SSC) provided for first 24 h on incidence of hypothermia in stable newborns weighing 1800 g or more during first 48 h of life.

STUDY DESIGN

Stable newborns (term and late preterm: Mean gestational age 37.7 (1.35) weeks, range 34-40 weeks) having birth weight 1800 g or more (Mean weight 2605.6 (419.8) grams) were enrolled after approval from Institutional Human Research Ethics Committee (CTRI/2013/06/003790) and randomized into early SSC (intervention group) and conventional care (control group). Initial care in the delivery room for few minutes immediately after birth in both the groups was given under radiant warmer. In the intervention group, newborns were provided SSC by their mother started between 30 min and 1 h after birth for first 24 h with minimal interruption and were provided conventional care other than SSC for next 24 h of life. In the control group, newborns were kept with their mother and received conventional care other than SSC for first 48 h. Temperature and heart rate of newborns were recorded at 30 min, 1, 2, 3, 4, 5, 6, 12, 24 and at 48 h of life in both the groups. Independent Samples t-Test and relative risk were used to analyze the data.

RESULT

Both groups had 50 neonates each with similar baseline characteristics. Heart rates were in normal range in both the groups. The intervention group provided an average (s.d.) of 16.98 (0.28) h of SSC over the first 24 h period. The mean temperature was significantly high in the SSC group at all time intervals starting from 1 to 48 h (P<0.05 for all). In the SSC group only two newborns (4%) had mild hypothermia (cold stress), and, of these two newborns, one had two episodes of hypothermia. All these three episodes of hypothermia occurred within first 3 h of life. In the control group 16 newborns (32%) developed hypothermia (temperature<36.5 °C) during first 48 h of life. Of them, 11 newborns had single episode, 4 newborns had two episodes and one newborn had three episodes of hypothermia. Of these 22 hypothermic episodes, 20 occurred in the first 6 h of life and 2 episodes occurred at 48 h of life. Moderate hypothermia was seen in two newborns, whereas rest had mild hypothermia. The relative risk of developing hypothermia in the control group as compared with the SSC group was 8.00 (95% CI 1.94-32.99). There was no seasonal variation in incidence of hypothermia in both the groups.

CONCLUSION

Newborns in the SSC group achieved rapid thermal control as compared with the control group. Early SSC for 24 h after birth decreases incidence of hypothermia for initial 48 h of life. Early SSC needs to be aggressively promoted in term and late-preterm newborns to reduce incidence of hypothermia.

Prevention and management of neonatal hypothermia in rural Zambia

Background

Neonatal hypothermia is increasingly recognized as a risk factor for newborn survival. The World Health Organization recommends maintaining a warm chain and skin-to-skin care for thermoprotection of newborn children. Since little is known about practices related to newborn hypothermia in rural Africa, this study's goal was to characterize relevant practices, attitudes, and beliefs in rural Zambia.

Methods and Findings

We conducted 14 focus group discussions with mothers and grandmothers and 31 in-depth interviews with community leaders and health officers in Lufwanyama District, a rural area in the Copperbelt Province, Zambia, enrolling a total of 171 participants. We analyzed data using domain analysis. In rural Lufwanyama, community members were aware of the danger of neonatal hypothermia. Caregivers' and health workers' knowledge of thermoprotective practices included birthplace warming, drying and wrapping of the newborn, delayed bathing, and immediate and exclusive breastfeeding. However, this warm chain was not consistently maintained in the first hours postpartum, when newborns are at greatest risk. Skin-to-skin care was not practiced in the study area. Having to assume household and agricultural labor responsibilities in the immediate postnatal period was a challenge for mothers to provide continuous thermal care to their newborns.

Conclusions

Understanding and addressing community-based practices on hypothermia prevention and management might help improve newborn survival in resource-limited settings. Possible interventions include the implementation of skin-to-skin care in rural areas and the use of appropriate, low-cost newborn warmers to prevent hypothermia and support families in their provision of newborn thermal protection. Training family members to support mothers in the provision of thermoprotection for their newborns could facilitate these practices.

Neonatal adenoviral infection: a seventeen year experience and review of the literature

OBJECTIVES

To describe the clinical manifestations and short-term outcomes of adenoviral infections in neonates and review all published cases to better determine impact and treatment outcomes.

STUDY DESIGN

Retrospective cohort study of all neonates hospitalized at Children's Medical Center (CMC) and Parkland Memorial Hospital (PMH), Dallas, TX with laboratory-confirmed adenoviral infection from January 1,1995-December 31, 2012. Neonates were identified by review of the CMC Virology Laboratory's prospective database of all positive adenovirus tests performed in the inpatient and ambulatory settings, and at PMH, of a prospective neonatal database that included all neonatal intensive care unit admissions. Patients also were identified by discharge International Classification of Disease, 9th edition codes for adenoviral infection. The medical records were reviewed, and a review of the English literature was performed.

RESULTS

During 17 years, 26 neonates had adenoviral infection (25, CMC; 1, PMH). The principle reasons for hospitalization were respiratory signs (88%) and temperature instability (65%). Five (19%) had disseminated disease and 4 (80%) of these infants died. Ribavirin or cidofovir treatment, as well as immune globulin intravenous, did not improve outcomes except in 1 neonate. Literature review (n = 72) combined with our data found that disseminated infection was associated with death (68% vs 21% with localized infection, P < .001). In addition, neonates <14 days of age were more likely to have disseminated disease (44% vs 12%, P = .004) and death (48% vs 8%; P < .001).

CONCLUSION

Adenoviral infection in hospitalized neonates was associated with severe morbidity and mortality, especially when infection was disseminated and involved the respiratory tract. Development of new therapeutic strategies is needed.

Poor thermal care practices among home births in Nepal: further analysis of Nepal Demographic and Health Survey 2011

Introduction

Hypothermia is a major factor associated with neonatal mortality in low and middle income countries. Thermal care protection of newborn through a series of measures taken at birth and during the initial days of life is recommended to reduce the hypothermia and associated neonatal mortality. This study aimed to identify the prevalence of and the factors associated with receiving ‘optimum thermal care’ among home born newborns of Nepal.

Methods

Data from the Nepal Demographic and Health Surveys (NDHS) 2011 were used for this study. Women who reported a home birth for their most recent childbirth was included in the study. Factors associated with optimum thermal care were examined using Chi-square test followed by logistic regression.

Results

A total of 2464 newborns were included in the study. A total of 57.6 % were dried before the placenta was delivered; 60.3% were wrapped; 24.5% had not bathing during the first 24 hours, and 63.9% were breastfed within one hour of birth. Overall, only 248 (10.7%; 95% CI (8.8 %, 12.9%)) newborns received optimum thermal care. Newborns whose mothers had achieved higher education (OR 2.810; 95% CI (1.132, 6.976)), attended four or more antenatal care visits (OR 2.563; 95% CI (1.309, 5.017)), and those whose birth were attended by skilled attendants (OR 2.178; 95% CI (1.428, 3.323)) were likely to receive optimum thermal care.

Conclusion

The current study showed that only one in ten newborns in Nepal received optimum thermal care. Future newborn survival programs should focus on those mothers who are uneducated; who do not attend the recommended four or more attend antenatal care visits; and those who deliver without the assistance of skilled birth attendants to reduce the risk of neonatal hypothermia in Nepal.

Hypothermia and early neonatal mortality in preterm infants

OBJECTIVE

To evaluate intervention practices associated with hypothermia at both 5 minutes after birth and at neonatal intensive care unit (NICU) admission and to determine whether hypothermia at NICU admission is associated with early neonatal death in preterm infants.

STUDY DESIGN

This prospective cohort included 1764 inborn neonates of 22-33 weeks without malformations admitted to 9 university NICUs from August 2010 through April 2012. All centers followed neonatal International Liaison Committee on Resuscitation recommendations for the stabilization and resuscitation in the delivery room (DR). Variables associated with hypothermia (axillary temperature <36.0 °C) 5 minutes after birth and at NICU admission, as well as those associated with early death, were analyzed by logistic regression.

RESULTS

Hypothermia 5 minutes after birth and at NICU admission was noted in 44% and 51%, respectively, with 6% of early neonatal deaths. Adjusted for confounding variables, practices associated with hypothermia at 5 minutes after birth were DR temperature <25 °C (OR 2.13, 95% CI 1.67-2.28), maternal temperature at delivery <36.0 °C (OR 1.93, 95% CI 1.49-2.51), and use of plastic bag/wrap (OR 0.53, 95% CI 0.40-0.70). The variables associated with hypothermia at NICU admission were DR temperature <25 °C (OR 1.44, 95% CI 1.10-1.88), respiratory support with cold air in the DR (OR 1.40, 95% CI 1.03-1.88) and during transport to NICU (OR 1.51, 95% CI 1.08-2.13), and cap use (OR 0.55, 95% CI 0.39-0.78). Hypothermia at NICU admission increased the chance of early neonatal death by 1.64-fold (95% CI 1.03-2.61).

CONCLUSION

Simple interventions, such as maintaining DR temperature >25 °C, reducing maternal hypothermia prior to delivery, providing plastic bags/wraps and caps for the newly born infants, and using warm resuscitation gases, may decrease hypothermia at NICU admission and improve early neonatal survival.

Importance of maintaining the newly born temperature in the normal range from delivery to admission

Over the last 50 years an increasing amount of evidence on neonatal resuscitation and stabilisation practices has led to written recommendations on all aspects of newborn care in the first few minutes of life. Much evidence for thermoregulatory management of both term and preterm infants has existed for decades and more recently research has identified new techniques to maintain normothermia in newly born infants. The use of increased environmental temperatures, skin-to-skin care, radiant warmers, plastic coverings and hats, exothermic mattresses and heated humidified gases have or are undergoing evaluation. However, despite the apparent acceptance of these techniques, a substantial number of infants continue to become hypothermic soon after delivery, leading to an increased risk of comorbidities and of death. Gaps in our knowledge remain and further research opportunities are available. However, we must also ensure that established thermoregulatory methods for which the evidence already exists are given as much emphasis as other aspects of newborn care and are implemented meticulously in all healthcare settings.

Medicine for global health: can "simple interventions" improve the worldwide burden of disease?

Improvements to medical practice and delivery of treatment has been the focus of many international collaborations aiming to address the delivery of appropriate health care in low- and middle-income countries. However, this is compounded by various social, cultural as well as resource allocation issues. This Editorial marks the launch of an article collection on Medicine for Global Health (http://www.biomedcentral.com/bmcmed/series/medicine_for_global_health), and here, guest editor Gretchen Birbeck discusses the challenges, importance and increasing relevance of global health.