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Penzias RE, Bohne C, Gicheha E, Molyneux EM, Gathara D, Ngwala SK, Zimba E, Rashid E, Odedere O, Dosunmu O, Tillya R, Shabani J, Cross JH, Ochieng C, Webster HH, Chiume M, Dube Q, Wainaina J, Kassim I, Irimu G, Adudans S, James F, Tongo O, Ezeaka VC, Salim N, Masanja H, Oden M, Richards-Kortum R, Hailegabriel T, Gupta G, Cousens S, Lawn JE, Ohuma EO. Quantifying health facility service readiness for small and sick newborn care: comparing standards-based and WHO level-2 + scoring for 64 hospitals implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania. BMC Pediatr 2024; 23:656. [PMID: 38475761 DOI: 10.1186/s12887-024-04578-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 01/18/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Service readiness tools are important for assessing hospital capacity to provide quality small and sick newborn care (SSNC). Lack of summary scoring approaches for SSNC service readiness means we are unable to track national targets such as the Every Newborn Action Plan targets. METHODS A health facility assessment (HFA) tool was co-designed by Newborn Essential Solutions and Technologies (NEST360) and UNICEF with four African governments. Data were collected in 68 NEST360-implementing neonatal units in Kenya, Malawi, Nigeria, and Tanzania (September 2019-March 2021). Two summary scoring approaches were developed: a) standards-based, including items for SSNC service readiness by health system building block (HSBB), and scored on availability and functionality, and b) level-2 + , scoring items on readiness to provide WHO level-2 + clinical interventions. For each scoring approach, scores were aggregated and summarised as a percentage and equally weighted to obtain an overall score by hospital, HSBB, and clinical intervention. RESULTS Of 1508 HFA items, 1043 (69%) were included in standards-based and 309 (20%) in level-2 + scoring. Sixty-eight neonatal units across four countries had median standards-based scores of 51% [IQR 48-57%] at baseline, with variation by country: 62% [IQR 59-66%] in Kenya, 49% [IQR 46-51%] in Malawi, 50% [IQR 42-58%] in Nigeria, and 55% [IQR 53-62%] in Tanzania. The lowest scoring was family-centred care [27%, IQR 18-40%] with governance highest scoring [76%, IQR 71-82%]. For level-2 + scores, the overall median score was 41% [IQR 35-51%] with variation by country: 50% [IQR 44-53%] in Kenya, 41% [IQR 35-50%] in Malawi, 33% [IQR 27-37%] in Nigeria, and 41% [IQR 32-52%] in Tanzania. Readiness to provide antibiotics by culture report was the highest-scoring intervention [58%, IQR 50-75%] and neonatal encephalopathy management was the lowest-scoring [21%, IQR 8-42%]. In both methods, overall scores were low (< 50%) for 27 neonatal units in standards-based scoring and 48 neonatal units in level-2 + scoring. No neonatal unit achieved high scores of > 75%. DISCUSSION Two scoring approaches reveal gaps in SSNC readiness with no neonatal units achieving high scores (> 75%). Government-led quality improvement teams can use these summary scores to identify areas for health systems change. Future analyses could determine which items are most directly linked with quality SSNC and newborn outcomes.
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Affiliation(s)
- Rebecca E Penzias
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK.
| | - Christine Bohne
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
- Ifakara Health Institute, Ifakara, Tanzania
| | - Edith Gicheha
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
| | - Elizabeth M Molyneux
- Kamuzu University of Health Sciences (Formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - David Gathara
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Samuel K Ngwala
- Kamuzu University of Health Sciences (Formerly College of Medicine, University of Malawi), Blantyre, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Evelyn Zimba
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
| | - Ekran Rashid
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
- Aga Khan University Hospital, Nairobi, Kenya
| | - Opeyemi Odedere
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
- APIN Public Health Initiatives, Abuja, Nigeria
| | | | | | | | - James H Cross
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Christian Ochieng
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Harriet H Webster
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Msandeni Chiume
- Kamuzu University of Health Sciences (Formerly College of Medicine, University of Malawi), Blantyre, Malawi
- Department of Paediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - John Wainaina
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust, Nairobi, Kenya
| | | | - Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Steve Adudans
- Academy for Novel Channels in Health and Operations Research (ACANOVA) Africa, Nairobi, Kenya
| | - Femi James
- Newborn Branch, Federal Ministry of Health, Abuja, Nigeria
| | - Olukemi Tongo
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Nahya Salim
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | | | - Maria Oden
- Rice360 Institute for Global Health Technologies, Rice University, Texas, USA
| | | | | | - Gagan Gupta
- Program Group, Health Programme UNICEF Headquarters, New York, NY, USA
| | - Simon Cousens
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Eric O Ohuma
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
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Srivastava A, Saxena S, Srivastava P, Mahmood SE, Pandey R, Saxena A. Newborn thermal care in western Uttar Pradesh - gap analysis between knowledge and practices. Arch Public Health 2022; 80:55. [PMID: 35172889 PMCID: PMC8848645 DOI: 10.1186/s13690-022-00809-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 01/30/2022] [Indexed: 11/24/2022] Open
Abstract
Background The provision of health care services including maternal and newborn care is a dynamic system of entitlement and obligations among the community, the service providers, and the government. Thermal control remains poor in newborns owing to immaturity of the thermoregulatory center and newborn become vulnerable to hypothermia especially premature babies, intrauterine growth retardation and LBW babies, and even normal babies.This study aimed to assess the knowledge & practices regarding thermal protection their determinants. Methods Cross-sectional study was conducted in the Amroha district. The study population comprised women of reproductive age (15 to 49 years) who have delivered a live baby within the past 12 weeks before the conduct of the study. Out of 6 blocks, 2 most populous villages were selected. Total 61 villages from 6 blocks were covered under the study. Knowledge and practices regarding newborn thermal care were expressed in percentages and compared. Results The knowledge domain on thermal protection of baby, 60.9% of the respondents were well aware of how to keep baby warm after delivery, 71.4% of respondents knew that baby should be dried soon after birth, 64.9% of the respondents had an idea of time to dry the baby, 69.6% of the respondents knew that baby should be wrapped soon after birth. Conclusion The findings of the study provides an insight into the existing knowledge and necessitate a need for quantitative studies in the study area to access knowledge & practices related to thermal protection of newborns. The authors emphasize a need for improving community awareness for the promotion of newborn care and improve the health system to meet the demands of birthing mothers and the needs of newborns. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-022-00809-2.
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Affiliation(s)
| | - Sumit Saxena
- Autonomous State Medical College & Allied Pt Ram Prasad Bismil Memorial Hospital, Shahjahanpur, India
| | | | - Syed Esam Mahmood
- College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia
| | - Ruchi Pandey
- Government Institute of Medical Sciences, Greater Noida, India.
| | - Anju Saxena
- Rohilkhand Medical College & Hospital, Bareilly, India
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Cordeiro RCO, Ferreira DMDLM, Reis HD, Azevedo VMGDO, Protázio ADS, Abdallah VOS. Hypothermia and neonatal morbimortality in very low birth weight preterm infants. REVISTA PAULISTA DE PEDIATRIA 2021; 40:e2020349. [PMID: 34614133 PMCID: PMC8543787 DOI: 10.1590/1984-0462/2022/40/2020349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the prevalence of hypothermia in the delivery room, at admission, and 2 to 3 hours after admission in the neonatal intensive care unit (NICU), factors associated and possible relationship with morbidity and mortality in preterm infants with very low birth weight (VLBW). METHODS Cross-sectional study with data collection based on a retrospective review of medical records and including infants born in 2016 and 2017, with birth weights <1500g, and gestational ages <34 weeks. Data about VLBW preterm infants, maternal data and temperature in the delivery room were analyzed. Hypothermia was considered when axillary temperature <36°C. For statistical analysis, the chi-square test or G test, canonical and Spearman correlation, and logistic regression were used. RESULTS 149 newborns (NB) were included in the study. The prevalence of hypothermia in delivery room, at admission to the NICU and 2 to 3 hours after admission was 25.8%, 41.5% and 40.2%, respectively. The temperature of NBs was directly proportional to gestational age (p<0.010), birth weight (p<0.010), and Apgar score (p<0.050). There was an inverse association with hypothermia in the delivery room and cesarean delivery (OR 0.25; p=0.016). CONCLUSIONS Hypothermia was a prevalent problem in the studied population. The neonatal temperature was directly proportional to gestational age, birth weight and Apgar score. Hypothermia was associated with maternal factors, such as cesarean delivery. It is necessary to implement and improve strategies for its prevention.
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Singh S, Singh VK, Rai G. Identification of Differentially Expressed Hematopoiesis-associated Genes in Term Low Birth Weight Newborns by Systems Genomics Approach. Curr Genomics 2020; 20:469-482. [PMID: 32655286 PMCID: PMC7327969 DOI: 10.2174/1389202920666191203123025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 11/29/2019] [Accepted: 11/29/2019] [Indexed: 11/22/2022] Open
Abstract
Background Low Birth Weight (LBW) (birth weight <2.5 Kg) newborns are associated with a high risk of infection, morbidity and mortality during their perinatal period. Compromised innate immune responses and inefficient hematopoietic differentiation in term LBW newborns led us to evaluate the gene expression status of hematopoiesis. Materials and Methods In this study, we compared our microarray datasets of LBW-Normal Birth Weight (NBW) newborns with two reference datasets to identify hematopoietic stem cells genes, and their differential expression in the LBW newborns, by hierarchical clustering algorithm using gplots and RcolorBrewer package in R. Results Comparative analysis revealed 108 differentially expressed hematopoiesis genes (DEHGs), of which 79 genes were up-regulated, and 29 genes were down-regulated in LBW newborns compared to their NBW counterparts. Moreover, protein-protein interactions, functional annotation and pathway analysis demonstrated that the up-regulated genes were mainly involved in cell proliferation and differentiation, MAPK signaling and Rho GTPases signaling, and the down-regulated genes were engaged in cell proliferation and regulation, immune system regulation, hematopoietic cell lineage and JAK-STAT pathway. The binding of down-regulated genes (LYZ and GBP1) with growth factor GM-CSF using docking and MD simulation techniques, indicated that GM-CSF has the potential to alleviate the repressed hematopoiesis in the term LBW newborns. Conclusion Our study revealed that DEHGs belonged to erythroid and myeloid-specific lineages and may serve as potential targets for improving hematopoiesis in term LBW newborns to help build up their weak immune defense against life-threatening infections.
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Affiliation(s)
- Sakshi Singh
- 1Department of Molecular and Human Genetics, Institute of Science, Banaras Hindu University, Varanasi, India; 2Centre for Bioinformatics, School of Biotechnology, Institute of Science, Banaras Hindu University, Varanasi, India
| | - Vinay K Singh
- 1Department of Molecular and Human Genetics, Institute of Science, Banaras Hindu University, Varanasi, India; 2Centre for Bioinformatics, School of Biotechnology, Institute of Science, Banaras Hindu University, Varanasi, India
| | - Geeta Rai
- 1Department of Molecular and Human Genetics, Institute of Science, Banaras Hindu University, Varanasi, India; 2Centre for Bioinformatics, School of Biotechnology, Institute of Science, Banaras Hindu University, Varanasi, India
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Sai Kiranmayee P, Kalluri V. India to gear up to the challenge of "third epidemic" of retinopathy of prematurity in the world. Indian J Ophthalmol 2019; 67:726-731. [PMID: 31124480 PMCID: PMC6552629 DOI: 10.4103/ijo.ijo_700_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Many of the causes of childhood blindness are avoidable, being either preventable or treatable. Retinopathy of prematurity (ROP) remains one of the most preventable causes of childhood blindness worldwide. Currently, India is facing the third epidemic of ROP. In India, the health system involving the mother and child health services needs to be strengthened with a policy to cover the existing inadequacies in neonatal care and implementation of program covering newborn, especially premature. The access, availability, and affordability of services related to the care of premature babies need strengthening in India. ROP-trained ophthalmologists and neonatal care pediatricians and a professional togetherness is a big issue. Inadequacies in awareness of ROP among the parents, health care workers, counsellors add up to the problem. Community-based health workers such as Accredited Social Health Activist are a good dependable force in India and are needed to be trained in awareness and establishing a proper identification for prompt referral. ROP prevention needs a multidisciplinary team approach. ROP management stands as a good example of all the strategies for prevention, which includes primary prevention (improving obstetric and neonatal care), secondary prevention (screening and treatment programs), and tertiary prevention (treating complications and rehabilitation to reduce disability). Given its demographic and cultural diversity, India faces numerous challenges, with significant rural-urban, poor-rich, gender, socioeconomic, and regional differences. So, we need to gear up to face the present challenge of the third epidemic of ROP and prevent ROP-related childhood blindness as it is the need of the hour.
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Affiliation(s)
- P Sai Kiranmayee
- Department of Vitreo-Retinal Services, Pushpagiri Vitreo-Retinal Institute, West Marredpally, Secunderabad, Telangana, India
| | - Viswanath Kalluri
- Department of Vitreo-Retinal Services, Pushpagiri Vitreo-Retinal Institute, West Marredpally, Secunderabad, Telangana, India
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Improving Thermal Support in Very and Extremely Low Birth Weight Infants during Interfacility Transport. Pediatr Qual Saf 2019; 4:e170. [PMID: 31579869 PMCID: PMC6594787 DOI: 10.1097/pq9.0000000000000170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 04/01/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction: Review of very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates transported by our specialized pediatric/neonatal transport team revealed hypothermia in up to 52% of admissions. This project aimed to decrease the incidence of hypothermia in VLBW and ELBW neonates requiring transport between facilities from 52% to <20% over 1 year. Methods: In response to gaps in knowledge and barriers to care revealed by a survey administered to transport personnel, we used a standard quality improvement plan-do-study-act model to introduce new equipment and a comprehensive thermoregulation protocol via standardized education. The primary outcome measure was the incidence of hypothermia (axillary temperature < 36.5°C) in transported VLBW and ELBW neonates. The process measure was compliance with the protocol. The balancing measures were unintended hyperthermia and transport team ground time. Transport personnel were updated on progress via meetings and run charts. Results: We reduced the incidence of hypothermia to 17% in 1 year. Compliance with the protocol improved from 60% to 76%. There was no increase in unintended hyperthermia (5% preintervention, 4% intervention, 7% surveillance, P = 0.76) or transport team ground time (in hours) (1.2 ± 0.9 preintervention versus 1.3 ± 0.8 intervention versus 1.2 ± 0.7 surveillance, P = 0.2). Conclusions: Quality improvement methods were used to develop an evidence-based, standardized approach to thermal support in VLBW and ELBW neonates undergoing transport between facilities. Following the implementation of this approach, we achieved the desired percent decrease in the incidence of hypothermia.
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Abstract
The following guideline is designed to give recommendations for the routine care of all neonates immediately after delivery, and the resuscitation and delivery room approach of all high-risk infants in light of recent literature. The guideline has been prepared as three different parts. The first part is about routine procedures that have to be performed to all healthy term and preterm infants in delivery room care. The second part summaries the basic principles of resusucitation including the latest changes that were mentioned in the International Liaison Committee on Resuscitation (ILCOR)-2015 guideline. Recommendations about the delivery room management of rare clinical conditions have been discussed in the last part. The social, medical conditions, and the resourses of Turkey have also been taken into consideration in its preparation. We hope it will be useful for all pediatricians and neonatologists for use as a essential guideline in delivery room care.
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Affiliation(s)
- Nihal Oygür
- Division of Neonatology, Department of Pediatrics, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - E Esra Önal
- Division of Neonatology, Department of Pediatrics, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Aysegül Zenciroğlu
- Health Sciences University Dr. Sami Ulus Gynecology, Obstetrics, Pediatrics SAUM Neonatology Clinic, Ankara, Turkey
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McCall EM, Alderdice F, Halliday HL, Vohra S, Johnston L. Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2018; 2:CD004210. [PMID: 29431872 PMCID: PMC6491068 DOI: 10.1002/14651858.cd004210.pub5] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Newborn admission temperature is a strong predictor of outcomes across all gestations. Hypothermia immediately after birth remains a worldwide issue and, if prolonged, is associated with harm. Keeping preterm infants warm is difficult even when recommended routine thermal care guidelines are followed in the delivery room. OBJECTIVES To assess the efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room, compared with routine thermal care or any other single/combination of intervention(s) also designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5), MEDLINE via PubMed (1966 to 30 June 2016), Embase (1980 to 30 June 2016), and CINAHL (1982 to 30 June 2016). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Trials using randomised or quasi-randomised allocations to test interventions designed to prevent hypothermia (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery room for infants at < 37 weeks' gestation and/or birth weight ≤ 2500 grams. DATA COLLECTION AND ANALYSIS We used Cochrane Neonatal methods when performing data collection and analysis. MAIN RESULTS Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies); external heat sources (three studies); and combinations of interventions (four studies).Barriers to heat loss Plastic wrap or bag versus routine carePlastic wraps improved core body temperature on admission to the neonatal intensive care unit (NICU) or up to two hours after birth (mean difference (MD) 0.58°C, 95% confidence interval (CI) 0.50 to 0.66; 13 studies; 1633 infants), and fewer infants had hypothermia on admission to the NICU or up to two hours after birth (typical risk ratio (RR) 0.67, 95% CI 0.62 to 0.72; typical risk reduction (RD) -0.25, 95% CI -0.29 to -0.20; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 4 to 5; 10 studies; 1417 infants). Risk of hyperthermia on admission to the NICU or up to two hours after birth was increased in infants in the wrapped group (typical RR 3.91, 95% CI 2.05 to 7.44; typical RD 0.04, 95% CI 0.02 to 0.06; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 17 to 50; 12 studies; 1523 infants), but overall, fewer infants receiving plastic wrap were outside the normothermic range (typical RR 0.75, 95% CI 0.69 to 0.81; typical RD -0.20, 95% CI -0.26 to -0.15; NNTH 5, 95% CI 4 to 7; five studies; 1048 infants).Evidence was insufficient to suggest that plastic wraps or bags significantly reduce risk of death during hospital stay or other major morbidities, with the exception of reducing risk of pulmonary haemorrhage.Evidence of practices regarding permutations on this general approach is still emerging and has been based on the findings of only one or two small studies.External heat sourcesEvidence is emerging on the efficacy of external heat sources, including skin-to-skin care (SSC) versus routine care (one study; 31 infants) and thermal mattress versus routine care (two studies; 126 infants).SSC was shown to be effective in reducing risk of hypothermia when compared with conventional incubator care for infants with birth weight ≥ 1200 and ≤ 2199 grams (RR 0.09, 95% CI 0.01 to 0.64; RD -0.56, 95% CI -0.84 to -0.27; NNTB 2, 95% CI 1 to 4). Thermal (transwarmer) mattress significantly kept infants ≤ 1500 grams warmer (MD 0.65°C, 95% CI 0.36 to 0.94) and reduced the incidence of hypothermia on admission to the NICU, with no significant difference in hyperthermia risk.Combinations of interventionsTwo studies (77 infants) compared thermal mattresses versus plastic wraps or bags for infants at ≤ 28 weeks' gestation. Investigators reported no significant differences in core body temperature nor in the incidence of hypothermia, hyperthermia, or core body temperature outside the normothermic range on admission to the NICU.Two additional studies (119 infants) compared plastic bags and thermal mattresses versus plastic bags alone for infants at < 31 weeks' gestation. Meta-analysis of these two studies showed improvement in core body temperature on admission to the NICU or up to two hours after birth, but an increase in hyperthermia. Data show no significant difference in the risk of having a core body temperature outside the normothermic range on admission to the NICU nor in the risk of other reported morbidities. AUTHORS' CONCLUSIONS Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection. Many observational studies have shown increased mortality among preterm hypothermic infants compared with those who maintain normothermia, yet evidence is insufficient to suggest that these interventions reduce risk of in-hospital mortality across all comparison groups. Hypothermia may be a marker for illness and poorer outcomes by association rather than by causality. Limitations of this review include small numbers of identified studies; small sample sizes; and variations in methods and definitions used for hypothermia, hyperthermia, normothermia, routine care, and morbidity, along with lack of power to detect effects on morbidity and mortality across most comparison groups. Future studies should: be adequately powered to detect rarer outcomes; apply standardised morbidity definitions; focus on longer-term outcomes, particularly neurodevelopmental outcomes.
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Affiliation(s)
- Emma M McCall
- Queen's University BelfastSchool of Nursing and MidwiferyMedical Biology Centre97 Lisburn RoadBelfastNorthern IrelandUK
| | - Fiona Alderdice
- Nuffield Department of Population Health, University of OxfordNational Perinatal Epidemiology UnitOxfordUK
| | - Henry L Halliday
- Retired Honorary Professor of Child Health, Queen's University Belfast74 Deramore Park SouthBelfastNorthern IrelandUKBT9 5JY
| | - Sunita Vohra
- University of AlbertaDepartment of Pediatrics8B19 11111 Jasper AvenueEdmontonABCanadaT5K 0L4
| | - Linda Johnston
- University of TorontoLawrence S Bloomberg Faculty of NursingHealth Sciences Building155 College StreetTorontoOntarioCanadaM5T 2S8
- Soochow UniversityTaipeiTaiwan
- The University of MelbourneMelbourneAustralia
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Valizadeh L, Mahallei M, Safaiyan A, Ghorbani F, Peyghami M. Comparison of the Effect of Plastic Cover and Blanket on Body Temperature of Preterm Infants Hospitalized in NICU: Randomized Clinical Trial. J Caring Sci 2017; 6:163-172. [PMID: 28680870 PMCID: PMC5488671 DOI: 10.15171/jcs.2017.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 01/11/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction: Preterm infants are unable to regulate their
body temperature and there are insufficient research evidences on different kinds of
covers for hospitalized preterm infants; therefore, the present study was conducted with
the aim of comparing the effects of plastic and blanket covers on the body temperature of
preterm infants under radiant warmer. Methods: This randomized cross-over clinical trial was
carried out upon 80 infants with the gestational age of 28-30 weeks and birth weight of
800- 1250 gr who were in Neonatal Intensive Care Unit on the second day of their
hospitalization. The study lasted for two days. In group 1, the plastic cover was used
during the first day of the study while the blankets were used during the second day.
Infants’ heads were kept out of the cover and coated with a hat. In group 2, the plastic
cover was used during the first day of the study while the blanket was used during second
day. Digital thermometer was used to measure infants’ axillary temperature. The data was
analyzed using SPSS ver 13 and MiniTab software. Descriptive statistics, (Mean (SE),
95%CI) and inferential statistics (Repeated measurement and ANCOVA tests) were used. Results: The mean body temperature of the infants in the
group covered with the plastic was calculated to be higher and the warmer was set on low
temperature. Conclusion: Using plastic cover during the first few days of
hospitalization in NICU resulted in regulation of preterm infants’ body temperature.
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Affiliation(s)
- Leila Valizadeh
- Department of Pediatric Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Majid Mahallei
- Department of Pediatrics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abdolrasoul Safaiyan
- Department of Biostatistics and Epidemiology, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Ghorbani
- Department of Pediatric Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Peyghami
- Department of Pediatric Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
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Bazzano AN, Taub L, Oberhelman RA, Var C. Newborn Care in the Home and Health Facility: Formative Findings for Intervention Research in Cambodia. Healthcare (Basel) 2016; 4:E94. [PMID: 28009812 PMCID: PMC5198136 DOI: 10.3390/healthcare4040094] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 12/19/2022] Open
Abstract
Global coverage and scale up of interventions to reduce newborn mortality remains low, though progress has been achieved in improving newborn survival in many low-income settings. An important factor in the success of newborn health interventions, and moving to scale, is appropriate design of community-based programs and strategies for local implementation. We report the results of formative research undertaken to inform the design of a newborn health intervention in Cambodia. Information was gathered on newborn care practices over a period of three months using multiple qualitative methods of data collection in the primary health facility and home setting. Analysis of the data indicated important gaps, both at home and facility level, between recommended newborn care practices and those typical in the study area. The results of this formative research have informed strategies for behavior change and improving referral of sick infants in the subsequent implementation study. Collection and dissemination of data on newborn care practices from settings such as these can contribute to efforts to advance survival, growth and development of newborns for intervention research, and for future newborn health programming.
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Affiliation(s)
- Alessandra N Bazzano
- Department of Global Community Health and Behavioral Sciences, Tulane School Public Health and Tropical Medicine, New Orleans, LA 70112, USA.
| | - Leah Taub
- Department of Global Community Health and Behavioral Sciences, Tulane School Public Health and Tropical Medicine, New Orleans, LA 70112, USA.
| | - Richard A Oberhelman
- Department of Global Community Health and Behavioral Sciences, Tulane School Public Health and Tropical Medicine, New Orleans, LA 70112, USA.
| | - Chivorn Var
- Reproductive Health Association of Cambodia, P.O. Box 905, Phnom Penh, Cambodia.
- National Institute of Public Health, P.O. Box 1300, Phnom Penh, Cambodia.
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Li S, Guo P, Zou Q, He F, Xu F, Tan L. Efficacy and Safety of Plastic Wrap for Prevention of Hypothermia after Birth and during NICU in Preterm Infants: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0156960. [PMID: 27281027 PMCID: PMC4900561 DOI: 10.1371/journal.pone.0156960] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 05/22/2016] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE This meta-analysis aimed to investigate the efficacy and safety of plastic wrap applied after birth and during NICU in preterm infants for prevention of heat loss in preterm infants. STUDY METHODS The Medline (1950 to August 2015), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7, 2015), CINAHL (1982 to August 2015) and the Embase (1974 to August 2015) databases were searched for randomized controlled trials (RCTs) or quasi-RCTs with main outcomes related to the core temperature (baseline temperature and/or post-stabilization temperature), hypothermia, mortality rate and hyperthermia. RESULT The included studies were of low to moderate quality. Compared with unwrapped infants, plastic wrap was associated with a significantly higher baseline temperature and post-stabilization temperature both in infants < 28 weeks of gestation (mean difference [MD] = 0.62, 95% CI 0.38 to 0.85; MD = 0.41, 95% CI 0.33 to 0.50, respectively), and in infants between 28 to 34 weeks of gestation (MD = 0.54, 95% CI 0.21 to 0.87; MD = 0.64, 95% CI 0.45 to 0.82, respectively). Use of plastic wrap was associated with lower incidence of hypothermia (relative risk [RR] = 0.70, 95% CI 0.63 to 0.78). However, use of plastic wrap in preterm infants was not associated with decrease in mortality (RR: 0.88, 95% CI 0.70 to 1.12, P = 0.31). Incidence of hyperthermia was significantly higher in the plastic wrap group as compared to that in the control group (RR = 2.55, 95% CI: 1.56 to 4.15, P = 0.0002). Hyperthermia in the plastic wrap group was resolved within one or two hours after unwrapping the babies. CONCLUSION Plastic wrap can be considered an effective and safe additional intervention to prevent hypothermia in preterm infants. However, its cost-effectiveness and long-term effect on mortality needs to be ascertained by conducting well-designed studies with longer follow-up period.
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Affiliation(s)
- Shaojun Li
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Pengfei Guo
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Key Laboratory of Pediatrics in Chongqing, Chongqing, China
| | - Qing Zou
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Fuxiang He
- Key Laboratory of Pediatrics in Chongqing, Chongqing, China
| | - Feng Xu
- Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Liping Tan
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
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12
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English M, Karumbi J, Maina M, Aluvaala J, Gupta A, Zwarenstein M, Opiyo N. The need for pragmatic clinical trials in low and middle income settings - taking essential neonatal interventions delivered as part of inpatient care as an illustrative example. BMC Med 2016; 14:5. [PMID: 26782822 PMCID: PMC4717536 DOI: 10.1186/s12916-016-0556-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/12/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pragmatic randomized trials aim to examine the effects of interventions in the full spectrum of patients seen by clinicians who receive routine care. Such trials should be employed in parallel with efforts to implement many interventions which appear promising but where evidence of effectiveness is limited. We illustrate this need taking the case of essential interventions to reduce inpatient neonatal mortality in low and middle income countries (LMIC) but suggest the arguments are applicable in most clinical areas. DISCUSSION A set of basic interventions have been defined, based on available evidence, that could substantially reduce early neonatal deaths if successfully implemented at scale within district and sub-district hospitals in LMIC. However, we illustrate that there remain many gaps in the evidence available to guide delivery of many inpatient neonatal interventions, that existing evidence is often from high income settings and that it frequently indicates uncertainty in the magnitude or even direction of estimates of effect. Furthermore generalizing results to LMIC where conditions include very high patient staff ratios, absence of even basic technologies, and a reliance on largely empiric management is problematic. Where there is such uncertainty over the effectiveness of interventions in different contexts or in the broad populations who might receive the intervention in routine care settings pragmatic trials that preserve internal validity while promoting external validity should be increasingly employed. Many interventions are introduced without adequate evidence of their effectiveness in the routine settings to which they are introduced. Global efforts are needed to support pragmatic research to establish the effectiveness in routine care of many interventions intended to reduce mortality or morbidity in LMIC. Such research should be seen as complementary to efforts to optimize implementation.
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Affiliation(s)
- Mike English
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Jamlick Karumbi
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
- Ministry of Health, Nairobi, Kenya.
| | - Michuki Maina
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya.
| | - Archna Gupta
- Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western University, Western Centre for Public Health and Family Medicine, London, Canada.
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western University, Western Centre for Public Health and Family Medicine, London, Canada.
| | - Newton Opiyo
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
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13
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Leng H, Wang H, Lin B, Cheng G, Wang L. Reducing Transitional Hypothermia in Outborn Very Low Birth Weight Infants. Neonatology 2016; 109:31-6. [PMID: 26485388 DOI: 10.1159/000438743] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 07/15/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Transitional hypothermia (TH) is associated with increased morbidity and mortality in very low birth weight (VLBW) infants worldwide. OBJECTIVES To assess the effect of a quality improvement project (QIP) on outborn TH and the associated mortality/morbidity among VLBW neonates. METHODS We conducted a multi-intervention QIP to reduce TH (<36°C) among outborn VLBW neonates. This cohort study compared a historical group (group I, n = 86) to a prospective group (group II, established after QIP implementation, n = 86). The primary outcome was axillary temperature measured in the delivery room (DR) and upon admission to the neonatal intensive care unit (NICU). RESULTS The baseline characteristics of the two groups were similar. After introducing the QIP, the mean DR and NICU admission temperatures of the patients rose from 35.5 to 36.1°C and from 34.6 to 36.2°C, respectively (p < 0.01), and the percentage of patients with temperatures <36°C in the DR and NICU decreased from 80 to 40% and from 81 to 42% (p < 0.01), respectively. Meanwhile, the percentage of patients with a normal temperature in the DR and NICU rose from 20 to 58% and from 19 to 56% (p < 0.01), respectively, which was accompanied by significantly decreased mortality (p < 0.02) and other improvements. CONCLUSION Implementation of a QIP resulted in a decrease in the number of moderately hypothermic VLBW neonates and a sustained improvement in normothermia rates during DR stabilization and transfer to the NICU in outborn VLBW neonates.
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Affiliation(s)
- Haiqing Leng
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, PR China
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14
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Abstract
Delivery room management, especially in the first 'golden' minute, is of the utmost importance. An exact and universal definition of when a baby is born is needed to obtain agreement on what is meant by the first minute of life. Education of young girls is a basic requirement to optimize the health of the mother and baby. Interventions in pregnancy should as far as possible be evidence based. Antenatal care, the selection of birth mode and antenatal steroid therapy when indicated also contribute to obtaining the best outcome. Delayed cord clamping is recommended for both preterm and term infants. However, more data are needed regarding the most immature infants. Routine suctioning of the mouth and airways is not required. Thermal control is important - keep the temperature in the delivery room at 26°C and wrap infants <28 weeks of gestation in plastic. However, this procedure does not reduce mortality. Since delayed cord clamping increases mean birth weight by approximately 30 g/kg, the present birth weight charts based on early clamping need to be corrected. Preterm infants in need of ventilatory support should start with CPAP from the first breath. A T-piece device seems to have some advantages compared to self-inflating bags. Surfactant instillation is often not needed prophylactically provided the mother has received antenatal steroids. Less invasive methods for administering surfactant may be useful. If ventilatory support is needed, start with air in term and near-term infants. For babies of 29-33 weeks of gestation start with 21-30% oxygen and for infants <29 weeks start with 30% oxygen and adjust according to the response obtained.
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Affiliation(s)
- Ola Didrik Saugstad
- Department of Pediatric Research, Oslo University Hospital, University of Oslo, Oslo, Norway
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15
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Rabin Fastman B, Howell EA, Holzman I, Kleinman LC. Current Perspectives on Temperature Management and Hypothermia in Low Birth Weight Infants. ACTA ACUST UNITED AC 2014. [DOI: 10.1053/j.nainr.2014.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Khanal V, Gavidia T, Adhikari M, Mishra SR, Karkee R. Poor thermal care practices among home births in Nepal: further analysis of Nepal Demographic and Health Survey 2011. PLoS One 2014; 9:e89950. [PMID: 24587145 PMCID: PMC3938557 DOI: 10.1371/journal.pone.0089950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 01/24/2014] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Vishnu Khanal
- School of Public Health, Curtin University, Perth, Australia
- * E-mail:
| | - Tania Gavidia
- Centre for International Health, Curtin University, Perth, Australia
| | | | | | - Rajendra Karkee
- School of Public Health, Curtin University, Perth, Australia
- School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
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17
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Darlow BA, Gilbert CE, Quiroga AM. Setting up and improving retinopathy of prematurity programs: interaction of neonatology, nursing, and ophthalmology. Clin Perinatol 2013; 40:215-27. [PMID: 23719306 DOI: 10.1016/j.clp.2013.02.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Retinopathy of prematurity (ROP) programs require collaboration between neonatologists, ophthalmologists, nurses, and allied health personnel, together with parents. The concept of a ROP program will vary according to the setting. However, in every situation there should be 2 main aspects: primary prevention of ROP through better overall care, and secondary prevention through case detection (often called screening), treatment, and follow-up. ROP programs will have different content and emphasis according to whether the setting is in an economically advanced or developing country.
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Affiliation(s)
- Brian A Darlow
- Department of Paediatrics, University of Otago Christchurch, PO Box 4345, Christchurch 8140, New Zealand.
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18
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Fairchild KD, Sun CCJ, Gross GC, Okogbule-Wonodi AC, Chasm RM, Viscardi RM. NICU admission hypothermia, chorioamnionitis, and cytokines. J Perinat Med 2011; 39:731-6. [PMID: 21838601 PMCID: PMC4026090 DOI: 10.1515/jpm.2011.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether neonatal intensive care unit (NICU) admission hypothermia is associated with an intrauterine inflammatory response. METHODS We analyzed a cohort of 309 very low birthweight infants to determine relationships between admission hypothermia, chorioamnionitis, and serum and cerebrospinal fluid (CSF) interleukin (IL)-1β, IL-6, and tumor necrosis factor-α. RESULTS Admission hypothermia <36°C occurred in 72% of patients <26 weeks and 44% of patients ≥26 weeks gestational age. NICU admission hypothermia was not associated with histologic chorioamnionitis or with elevated serum cytokine concentrations. CSF IL-6 concentrations ≥6.3 pg/mL were associated with admission hypothermia in infants <26 weeks' gestation. Clinical chorioamnionitis was associated with a lower risk of admission hypothermia, while cesarean section delivery was associated with increased risk. CONCLUSIONS NICU admission hypothermia is common among preterm infants and is not associated with the fetal inflammatory response syndrome. Hypothermia is less common in the setting of clinical chorioamnionitis and more common in cesarean section deliveries, identifying two groups in whom extra attention to appropriate thermoregulation is warranted.
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Affiliation(s)
- Karen D. Fairchild
- Department of Pediatrics , University of Virginia School of Medicine, Charlottesville, VA
| | - Chen-Chih J. Sun
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | - George C. Gross
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Rose M. Chasm
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - Rose M. Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
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19
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Miller SS, Lee HC, Gould JB. Hypothermia in very low birth weight infants: distribution, risk factors and outcomes. J Perinatol 2011; 31 Suppl 1:S49-56. [PMID: 21448204 DOI: 10.1038/jp.2010.177] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to study the epidemiology of neonatal hypothermia in preterm infants using World Health Organization (WHO) temperature criteria. STUDY DESIGN A population-based cohort of 8782 very low birth weight (VLBW) infants born in California neonatal intensive care units in 2006 and 2007. Associations between admission hypothermia and maternal and neonatal characteristics and outcomes were determined using logistic regression. RESULT In all, 56.2% of infants were hypothermic. Low birth weight, cesarean delivery and a low Apgar score were associated with hypothermia. Spontaneous labor, prolonged rupture of membranes and antenatal steroid administration were associated with decreased risk of hypothermia. Moderate hypothermia was associated with higher risk of intraventricular hemorrhage (IVH). Moderate and severe hypothermic conditions were associated with risk of death. CONCLUSION Hypothermia by WHO criteria is prevalent in VLBW infants and is associated with IVH and mortality. Use of WHO criteria could guide the need for quality improvement projects targeted toward the most vulnerable infants.
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Affiliation(s)
- S S Miller
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, School of Medicine, 750 Welch Road, Palo Alto, CA 94304, USA.
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Abstract
AIM To determine whether the mortality for out-of-hospital (OOH) premature births was higher than for in-hospital premature births and identify additional risk factors. PATIENTS AND METHODS A historical cohort study of a consecutive series of live-born, OOH, births of 24-35 weeks gestation cared for by two Transport Teams working in and around Paris, France 1994-2005. Matching with in-hospital births was according to gestational age, antenatal steroid use, the mode of delivery and nearest year of birth. RESULTS Eighty-five OOH premature births were identified, of whom 83 met inclusion criteria, and 132 matching in-hospital premature births were selected. There was 18% mortality in the OOH group compared with 8% for the in-hospital group [p = 0.04, OR 2.9, (CI 95% 1.0-8.4)]. Variables significantly associated (p < 0.05) with the OOH birth were HIV infection, lower maternal age and endo-tracheal intubation, lack of medical follow-up during pregnancy, low temperature and low birth weight. CONCLUSIONS Mortality was more than twice as high in out-of-hospital deliveries than for in-hospital matched controls. Hypothermia was an important associated risk factor. Measures such as oxygen administration to maintain an appropriate saturation for gestational age, the provision of polyethylene plastic wraps and skin-to-skin contact are recommended.
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Affiliation(s)
- P Jones
- AP-HP, Hôpital Robert Debré, University of Paris VII, Cedex, France.
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Simon P, Dannaway D, Bright B, Krous L, Wlodaver A, Burks B, Thi C, Milam J, Escobedo M. Thermal defense of extremely low gestational age newborns during resuscitation: exothermic mattresses vs polyethylene wrap. J Perinatol 2011; 31:33-7. [PMID: 20410908 DOI: 10.1038/jp.2010.56] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the effectiveness of thermal warming mattresses compared with wrapping in a polyethylene sheet during resuscitation in extremely low gestational age newborns (ELGANs) in preventing admission hypothermia in the neonatal intensive care unit. STUDY DESIGN Patients delivered between 24 and 28 weeks gestation and ≤1250 g were eligible for this prospective, randomized study. In the delivery room, the resuscitation team opened a sealed opaque envelope for treatment group assignment to either the wrap or the sodium acetate mattress group. Resuscitation followed protocols recommended by the Neonatal Resuscitation Program. The primary outcome for this study was comparison of axillary temperatures recorded at the time of neonatal intensive care unit admission between the two groups. RESULT Thirty-nine patients were enrolled in the study. The mattress group's mean admission temperature was 36.5±0.67, whereas the plastic wrap group's was 36.1±0.66 (P=0.0445). CONCLUSION Thermal mattresses improved admission temperature for ELGANs over plastic wrap. Although both plastic wrap and thermal mattresses improve the thermal status of ELGANs, all current interventions fall short of truly protecting all these vulnerable patients from thermal stress.
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Affiliation(s)
- P Simon
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
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Knobel RB, Holditch-Davis D, Schwartz TA. Optimal body temperature in transitional extremely low birth weight infants using heart rate and temperature as indicators. J Obstet Gynecol Neonatal Nurs 2010; 39:3-14. [PMID: 20409098 DOI: 10.1111/j.1552-6909.2009.01087.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To explore body temperature in relationship to heart rate in extremely low birth weight (ELBW) infants during their first 12 hours to help identify the ideal set point for incubator control of body temperature. DESIGN Within subject, multiple-case design. SETTING A tertiary neonatal intensive care unit (NICU) in North Carolina. PARTICIPANTS Ten infants born at fewer than 29 weeks gestation and weighing 400 to 1,000 g. METHODS Heart rate and abdominal body temperature were measured at 1-minute intervals for 12 hours. Heart rates were considered normal if they were between the 25th and 75th percentile for each infant. RESULTS Abdominal temperatures were low throughout the 12-hour study period (mean 35.17-36.68 degrees C). Seven of 10 infants had significant correlations between abdominal temperature and heart rate. Heart rates above the 75th percentile were associated with low and high abdominal temperatures; heart rates less than the 25th percentile were associated with very low abdominal temperatures. The extent to which abdominal temperature was abnormally low was related to the extent to which the heart rate trended away from normal in 6 of the 10 infants. Optimal temperature control point that maximized normal heart rate observations for each infant was between 36.8 degrees C and 37 degrees C. CONCLUSIONS Hypothermia was associated with abnormal heart rates in transitional ELBW infants. We suggest nurses set incubator servo between 36.8 degrees C and 36.9 degrees C to optimally control body temperature for ELBW infants.
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Affiliation(s)
| | - Diane Holditch-Davis
- Marcus E. Hobbs Distinguished Professor of Nursing and associate dean of Research Affairs, Duke University School of Nursing, Durham, NC
| | - Todd A Schwartz
- Department of biostatistics and the School of Nursing at the University of North Carolina at Chapel Hill, Chapel Hill, NC
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Use of self-heating gel mattresses eliminates admission hypothermia in infants born below 28 weeks gestation. Eur J Pediatr 2010; 169:795-9. [PMID: 19957190 DOI: 10.1007/s00431-009-1113-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 11/16/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Hypothermia at birth is strongly associated with mortality and morbidity in pre-term infants. BACKGROUND A local audit showed limited effectiveness of occlusive wrapping in preventing admission hypothermia in very pre-term infants. Self-heating acetate gel mattresses were introduced as a result to prevent hypothermia at birth in infants born at or below 28 weeks gestation. METHODS A retrospective audit was conducted to evaluate the effectiveness of self-heating acetate gel mattresses at resuscitation of infants born at or below 28 weeks to prevent hypothermia at birth. All infants born at or below 28 weeks gestation during 18 months before and 18 months after self-heating acetate gel mattresses were introduced during resuscitation were included. RESULTS One hundred five babies were born when acetate gel mattresses were not used, and 124 were born during the period when they were. Four (3.3%) babies were hypothermic (temperature <36 degrees C) at admission when the mattresses were used compared to 21 (22.6%) babies who were hypothermic during the period it was not (p < 0.001). Hyperthermia (temperature >37 degrees C) rose from 30.1% prior to use of gel mattresses to 49.6% when they were used (p = 0.004). CONCLUSIONS Self-heating acetate gel mattresses are highly effective in reducing admission hypothermia in infants born at or below 28 weeks gestation. The use of these mattresses is associated with a significant increase in hyperthermia.
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Nyqvist KH, Anderson GC, Bergman N, Cattaneo A, Charpak N, Davanzo R, Ewald U, Ludington-Hoe S, Mendoza S, Pallás-Allonso C, Peláez JG, Sizun J, Widström AM. State of the art and recommendations. Kangaroo mother care: application in a high-tech environment. Acta Paediatr 2010; 99:812-9. [PMID: 20219028 DOI: 10.1111/j.1651-2227.2010.01794.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
UNLABELLED Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low income settings, the original KMC model is implemented. This consists of continuous (24 h/day, 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding; and, adequate follow-up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC model in all types of settings was discussed at the 7th International Workshop on KMC. Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability. CONCLUSION Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.
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Turner TJ, Barnes H, Reid J, Garrubba M. Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help? BMC Public Health 2010; 10:170. [PMID: 20350326 PMCID: PMC3091544 DOI: 10.1186/1471-2458-10-170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 03/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid. METHODS Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings. RESULTS Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid. CONCLUSIONS We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.
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Affiliation(s)
- Tari J Turner
- Monash Institute of Health Services Research, Monash University, Locked Bag 29, Clayton 3168 Australia
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Hayley Barnes
- previously of the Australasian Cochrane Centre, Monash University, Locked Bag 29, Clayton 3168 Australia
| | - Jane Reid
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
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McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S. Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants. Cochrane Database Syst Rev 2010:CD004210. [PMID: 20238329 DOI: 10.1002/14651858.cd004210.pub4] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite. OBJECTIVES To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within 10 minutes after birth in the delivery suite compared with routine thermal care. SEARCH STRATEGY We used the standard search strategy of the Cochrane Neonatal Review Group (CNRG). The review was updated in October 2009. SELECTION CRITERIA Trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </= 2500 g. DATA COLLECTION AND ANALYSIS We used the methods of the CNRG for data collection and analysis. MAIN RESULTS 1) Barriers to heat loss [5 studies; plastic wrap or bag (3), plastic cap (1), stockinet cap (1)]:Plastic wraps or bags were effective in reducing heat losses in infants < 28 weeks' gestation (4 studies, n = 223; WMD 0.68 degrees C; 95% CI 0.45, 0.91), but not in infants between 28 to 31 week's gestation. Plastic caps were effective in reducing heat losses in infants < 29 weeks' gestation (1 study, n = 64; MD 0.80 degrees C; 95% CI 0.41, 1.19). There was insufficient evidence to suggest that either plastic wraps or plastic caps reduce the risk of death within hospital stay. There was no evidence of significant differences in other clinical outcomes for either the plastic wrap/bag or the plastic cap comparisons. Stockinet caps were not effective in reducing heat losses.2) External heat sources [2 studies; skin-to-skin (1), transwarmer mattress (1)]:Skin-to-skin care (SSC) was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants (1 study, n = 31; RR 0.09; 95% CI 0.01, 0.64). The transwarmer mattress reduced the incidence of hypothermia on admission to NICU in VLBW infants (1 study, n = 24; RR 0.30; 95% CI 0.11, 0.83). AUTHORS' CONCLUSIONS Plastic wraps or bags, plastic caps, SSC and transwarmer mattresses all keep preterm infants warmer leading to higher temperatures on admission to neonatal units and less hypothermia. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given.
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Affiliation(s)
- Emma M McCall
- School of Medicine, Dentistry & Biomedical Sciences, Queen's University Belfast, Microbiology Building, Grosvenor Road, Belfast, Northern Ireland, UK, BT12 6BN
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Abstract
The "Quality Chasm" exists in neonatal intensive care. Despite years of clinical research in neonatology, therapies continue to be underused, overused, or misused. A key concept in crossing the quality chasm is system redesign. The unpredictability of human factors and the dynamic complexity of the neonatal ICU are not amenable to rigid reductionist control and redesign. Change is best accomplished in this complex adaptive system by use of simple rules: (1) general direction pointing, (2) prohibitions, (3) resource or permission providing. These rules create conditions for purposeful self-organizing behavior, allowing widespread natural experimentation, all focused on generating the desired outcome.
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Affiliation(s)
- Dan L Ellsbury
- The Center for Research, Education, and Quality, Pediatrix Medical Group, 1301 Concord Terrace, Sunrise, FL 33323, USA.
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Abstract
The authors have conducted video review of neonatal resuscitations since 1999. Over this 10-year period 3 phases of our experience have been recognized. Our early reviews helped us recognize what we were doing in the delivery room, an area that had been ignored in improved intervention. It was noted that on many occasions multiple people were trying to accomplish the same task, that bag and mask ventilation was almost exclusively the purview of the respiratory therapists and was not performed well by others, and that infants with low birth weight were often hypothermic on admission. After determining what was being done and how well it was being done, we moved on to how to do it better. This period included making environmental changes by warming the room, the use of occlusive wrap, determining the effectiveness of bag and mask ventilation with colorimetric CO(2) detectors, and the introduction of crew resource management to develop consistent and effective communication. The third and current phase of our experience is to determine how these interventions affect delivery room and potentially later outcomes. Well-designed clinical trials are still needed to further establish the most optimal resuscitation interventions.
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Affiliation(s)
- Wade D Rich
- Division of Neonatology, University of California San Diego, 402 Dickenson Street, Suite 1-140, San Diego, CA 92103-8774, USA
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Halliday HL. Neonatal management and long-term sequelae. Best Pract Res Clin Obstet Gynaecol 2009; 23:871-80. [PMID: 19632899 DOI: 10.1016/j.bpobgyn.2009.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Accepted: 03/26/2009] [Indexed: 01/21/2023]
Abstract
Intrauterine or fetal growth restriction is best defined by using customised birth weight percentiles based upon the growth potential for an individual infant. Growth restriction in utero may be classified as asymmetric or symmetric depending upon the duration of the process. Asymmetric growth restriction is caused by placental insufficiency, maternal hypertensive conditions, long-standing maternal diabetes, smoking, living at altitude or multiple gestation. Symmetric growth restriction may be due to congenital infections, chromosomal or other abnormalities, fetal alcohol syndrome, low socioeconomic status or be constitutional. The underlying cause of growth restriction often predicts the potential adverse effects on the foetus and newborn and later effects in childhood and adulthood. With placental insufficiency, there may be chronic or acute on chronic fetal hypoxia with birth asphyxia and hypothermia, neonatal hypoglycaemia, polycythaemia and coagulopathy. Management is directed at prevention or early treatment of these conditions. In contrast, symmetrically growth-restricted infants should be examined carefully to look for congenital infections and malformations that may need specific interventions. Infants with constitutional short stature generally do not need any specific management. Feeding of growth-restricted infants is important to overcome deficiencies incurred in utero. Most infants show catch-up growth although about 10% do not. Those with excessive catch-up growth may be at greatest risk of developing insulin resistance in adulthood leading to diabetes, obesity and heart disease. The so-called fetal origins of disease may actually have a postnatal onset related more to excessive weight gain in infancy. There is still controversy over the indications for growth hormone treatment in growth-restricted infants who remain of short stature in early childhood. Intrauterine growth restriction is also associated with a five- to seven-fold increased risk of cerebral palsy probably due to chronic placental insufficiency.
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Affiliation(s)
- Henry L Halliday
- Perinatal Medicine, Royal Maternity Hospital, and Department of Child Health, Queen's University Belfast, Belfast, Northern Ireland.
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Kumar V, Shearer JC, Kumar A, Darmstadt GL. Neonatal hypothermia in low resource settings: a review. J Perinatol 2009; 29:401-12. [PMID: 19158799 DOI: 10.1038/jp.2008.233] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hypothermia is increasingly recognized as a major cause of neonatal morbidity and mortality in resource poor settings. High prevalence of hypothermia has been reported widely from warmer high mortality regions of Africa and South Asia. The World Health Organization recognizes newborn thermal care as a critical and essential component of essential newborn care; however, hypothermia continues to remain under-documented, under-recognized and under-managed. OBJECTIVE This review aims to provide a thorough patho-physio-epidemiological discussion of neonatal hypothermia applied to local risk factors within the developing country context with particular emphasis on prevention, recognition and management. METHOD All available published literature on neonatal hypothermia relevant to resource poor settings were reviewed. Studies from the developing country settings were primarily reviewed for epidemiology, domiciliary risk factors as well as potential interventions for thermal care. RESULT AND DISCUSSION Functional integrity and efficiency of biological systems is critically dependent on an optimal and very narrow range of core body temperature. Risk factors for neonatal hypothermia differ markedly within low resource settings. A combination of physiological, behavioral and environmental factors universally put all newborns, irrespective of birth weight, at risk of hypothermia. The knowledge deficit along the continuum from health providers to primary care givers has sustained the silent epidemic of hypothermia. The challenges of recognition, understanding of local risk factors and communication have meant a lack of informed thermal care for newborns. Simple, feasible interventions exist, but need to be applied, based on local risk factors that disrupt the warm chain. Further research is needed to document local risk factors, develop better techniques for recognition, evaluation of thermal care within essential newborn care and communication strategies for program effectiveness.
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Affiliation(s)
- V Kumar
- Department of International Health, International Center for Advancing Neonatal Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Ogunlesi TA, Ogunfowora OB, Adekanmbi FA, Fetuga BM, Olanrewaju DM. Point-of-admission hypothermia among high-risk Nigerian newborns. BMC Pediatr 2008; 8:40. [PMID: 18837973 PMCID: PMC2567312 DOI: 10.1186/1471-2431-8-40] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2008] [Accepted: 10/06/2008] [Indexed: 11/14/2022] Open
Abstract
Background Facilities which manage high-risk babies should frequently assess the burden of hypothermia and strive to reduce the incidence. Objective To determine the incidence and outcome of point-of-admission hypothermia among hospitalized babies. Methods The axillary temperatures of consecutive admissions into a Nigerian Newborn Unit were recorded. Temperature <36.5°C defined hypothermia. The biodata and outcome of these babies were studied. Results Of 150 babies aged 0 to 648 hours, 93 had hypothermia with an incidence of 62%. Mild and moderate hypothermia accounted for 47.3% and 52.7% respectively. The incidence of hypothermia was highest (72.4%) among babies aged less than 24 hours. It was also higher among out-born babies compared to in-born babies (64.4% vs 58.3%). Preterm babies had significantly higher incidence of hypothermia (82.5%) compared with 54.5% of term babies (RR = 1.51; CI = 1.21 – 1.89). The incidence of hypothermia was also highest (93.3%) among very-low-birth-weight babies. The Case-Fatality-Rate was significantly higher among hypothermic babies (37.6% vs 16.7%; RR = 2.26, CI = 1.14 – 4.48) and among out-born hypothermic babies (50% vs 17.1%; RR = 0.34, CI = 0.16 – 0.74). CFR was highest among hypothermic babies with severe respiratory distress, sepsis, preterm birth and asphyxia. Conclusion The high incidence and poor outcome of hypothermia among high-risk babies is important. The use of the 'warm chain' and skin-to-skin contact between mother and her infant into routine delivery services in health facilities and at home may be useful.
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Affiliation(s)
- Tinuade A Ogunlesi
- Department of Paediatrics, College of Health Sciences, Olabisi Onabanjo University, Sagamu, Nigeria.
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32
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Molloy EJ, McCallion N, O'Donnell CPF, Davis PG. Heliox for prevention of morbidity and mortality in ventilated newborn infants. Hippokratia 2008. [DOI: 10.1002/14651858.cd007304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Eleanor J Molloy
- National Maternity Hospital; Neonatal Unit; Holles Street Dublin 2 Ireland
| | - Naomi McCallion
- National Maternity Hospital; Neonatal Unit; Holles Street Dublin 2 Ireland
| | - Colm PF O'Donnell
- National Maternity Hospital; Neonatal Unit; Holles Street Dublin 2 Ireland
| | - Peter G Davis
- Royal Women's Hospital; Department of Obstetrics and Gynaecology; 132 Grattan Street Carlton Victoria Australia 3053
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