Temperature monitoring with ThermoSpots in Malawi

Improvement of temperature surveillance of neonates in low-resource settings by a simple low-cost device: a descriptive study

INTRODUCTION

Neonatal hypothermia in low-resource settings is prevalent and closely associated with high morbidity and mortality. We examined if an easy-to-read temperature detector device improves health outcomes.

METHODS

In a descriptive study, 1009 admissions to a neonatal ward in a tertiary care hospital in Lilongwe, Malawi, were analysed and divided into a baseline and a trial group. The data of 531 newborns with standard care (SC) before the trial were compared with 478 newborns during the implementation of the device (device care=DC). Staff and caregivers were trained on using the device and how to react in case of hypothermia. Data were collected from patient files, device documentation sheets, interviews and focus group discussions. Hypothermia was defined as a body temperature <36.5°C.

RESULTS

During the trial, body temperatures throughout the hospital stay were significantly more often obtained (p<0.0001). The median temperature measurements per newborn per day were 1.3 times with SC and 1.6 times with DC, and mild hypothermia was more frequently detected. Moderate hypothermia was avoided in the lightest weight group possibly contributing to significantly shorter hospital stays of surviving newborns (p=0.007). Many caregivers had difficulties using and interpreting the device correctly, and 47% of the reported colours did not match the registered temperatures. Contrary to the above, a questionnaire and focus group discussions with caregivers and health workers showed a high acceptance and the overall opinion that the device was beneficial.

CONCLUSION

With more frequent temperature checks, infants with lower birth weight possibly benefited from implementing an easy-to-read continuous temperature indicator, but hypothermia rates remained high. Our data and experiences reveal structural, communicational and consistency/interpretation deficits. Although specifically designed for low-resource settings, the implementation of the device needs a well-working and structured environment, especially regarding staff and caregiver communication.

Effect of an integrated neonatal care kit on neonatal health outcomes: a cluster randomised controlled trial in rural Pakistan

Introduction

In 2016, 2.6 million children died during their first month of life. We assessed the effectiveness of an integrated neonatal care kit (iNCK) on neonatal survival and other health outcomes in rural Pakistan.

Methods

We conducted a community-based, cluster randomised, pragmatic, open-label, controlled intervention trial in Rahim Yar Khan, Punjab, Pakistan. Clusters, 150 villages and their lady health workers (LHWs), were randomly assigned to deliver the iNCK (intervention) or standard of care (control). In intervention clusters, LHWs delivered the iNCK and education on its use to pregnant women. The iNCK contained a clean birth kit, chlorhexidine, sunflower oil, a continuous temperature monitor (ThermoSpot), a heat reflective blanket and reusable heat pack. LHWs were also given a hand-held scale. The iNCK was implemented primarily by caregivers. The primary outcome was all-cause neonatal mortality. Outcomes are reported at the individual level, adjusted for cluster allocation. Enrolment took place between April 2014 and July 2015 and participant follow-up concluded in August 2015.

Results

5451 pregnant women (2663 and 2788 in intervention and control arms, respectively) and their 5286 liveborn newborns (2585 and 2701 in intervention and control arms, respectively) were enrolled. 147 newborn deaths were reported, 65 in the intervention arm (25.4 per 1000 live births) compared with 82 in the control arm (30.6 per 1000 live births). Neonatal mortality was not significantly different between treatment groups (risk ratio 0.83, 95% CI 0.58 – 1.18; p = 0.30).

Conclusion

Providing co-packaged interventions directly to women did not significantly reduce neonatal mortality. Further research is needed to improve compliance with intended iNCK use.

Point-of-care diagnostics to improve maternal and neonatal health in low-resource settings

Each day, approximately 830 women and 7400 newborns die from complications during pregnancy and childbirth. Improving maternal and neonatal health will require bringing rapid diagnosis and treatment to the point of care in low-resource settings. However, to date there are few diagnostic tools available that can be used at the point of care to detect the leading causes of maternal and neonatal mortality in low-resource settings. Here we review both commercially available diagnostics and technologies that are currently in development to detect the leading causes of maternal and neonatal mortality, highlighting key gaps in development where innovative design could increase access to technology and enable rapid diagnosis at the bedside.

The community-based delivery of an innovative neonatal kit to save newborn lives in rural Pakistan: design of a cluster randomized trial

Background

Worldwide, an estimated 2.9 million neonatal deaths occurred in 2012, accounting for 44% of all under-five deaths. In Pakistan, more than 200,000 newborns die annually and neonatal mortality rates are higher than in any other South Asian country and haven’t changed over the last three decades. The high number of neonatal deaths highlights the urgent need for effective and sustainable interventions that target newborn mortality in Pakistan.

Method/Design

This cluster randomized trial aims at evaluating the impact of delivering an integrated neonatal kit to pregnant women during the third trimester of pregnancy and providing education on how to use the contents (intervention arm) compared to the current standard of care (control arm) in the district of Rahimyar Khan, Punjab province, Pakistan. The kit, which will be distributed through the national Lady Health Worker program, comprises a clean delivery kit (sterile blade, cord clamp, clean plastic sheet, surgical gloves and hand soap), sunflower oil emollient, chlorhexidine, ThermoSpot™, Mylar infant sleeve, and a reusable instant heat pack. Lady health workers will be provided with a standard portable hand-held electric weighing scale. The primary outcome measure is neonatal mortality (death in the first 28 days of life).

Discussion

While many cost-effective, evidence-based interventions to save newborn lives exist, they are not always accessible nor have they been integrated into a portable kit designed for home-based implementation entirely by caregivers. The implementation of cost-effective, portable, and easy-to-use interventions has tremendous potential for sustainably reducing neonatal mortality and long-term improvements in population health. The bundling of interventions and commodities together also has much potential for cost-effective delivery and maximizing gains from points of contact. This study will provide empirical evidence on the feasibility and effectiveness of the delivery of an innovative neonatal kit to pregnant women in Pakistan. Together, these findings will help inform policy on the most appropriate interventions to improve newborn survival.

Trial registration

ClinicalTrial.gov NCT02130856. Registered May 1, 2014.

Neonatal hypothermia in low resource settings: a review

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.

Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence

BACKGROUND

Infant and under-5 childhood mortality rates in developing countries have declined significantly in the past 2 to 3 decades. However, 2 critical indicators, maternal and newborn mortality, have hardly changed. World leaders at the United Nations Millennium Summit in September 2000 agreed on a critical goal to reduce deaths of children <5 years by two thirds, but this may be unattainable without halving newborn deaths, which now comprise 40% of all under-5 deaths. Greater emphasis on wide-scale implementation of proven, cost-effective measures is required to save women's and newborns' lives. Approximately 99% of neonatal deaths take place in developing countries, mostly in homes and communities. A comprehensive review of the evidence base for impact of interventions on neonatal health and survival in developing-country communities has not been reported.

OBJECTIVE

This review of community-based antenatal, intrapartum, and postnatal intervention trials in developing countries aimed to identify (1) key behaviors and interventions for which the weight of evidence is sufficient to recommend their inclusion in community-based neonatal care programs and (2) key gaps in knowledge and priority areas for future research and program learning.

METHODS

Available published and unpublished data on the impact of community-based strategies and interventions on perinatal and neonatal health status outcomes were reviewed. Evidence was summarized systematically and categorized into 4 levels of evidence based on study size, location, design, and reported impact, particularly on perinatal or neonatal mortality. The evidence was placed in the context of biological plausibility of the intervention; evidence from relevant developed-country studies; health care program experience in implementation; and recommendations from the World Health Organization and other leading agencies.

RESULTS

A paucity of community-based data was found from developing-country studies on health status impact for many interventions currently being considered for inclusion in neonatal health programs. However, review of the evidence and consideration of the broader context of knowledge, experience, and recommendations regarding these interventions enabled us to categorize them according to the strength of the evidence base and confidence regarding their inclusion now in programs. This article identifies a package of priority interventions to include in programs and formulates research priorities for advancing the state of the art in neonatal health care.

CONCLUSIONS

This review emphasizes some new findings while recommending an integrated approach to safe motherhood and newborn health. The results of this study provide a foundation for policies and programs related to maternal and newborn health and emphasizes the importance of health systems research and evaluation of interventions. The review offers compelling support for using research to identify the most effective measures to save newborn lives. It also may facilitate dialogue with policy makers about the importance of investing in neonatal health.

Temperature monitoring in newborns using thermospot

OBJECTIVE

Hypothermia is a common problem in newborns. This is more so in community environment especially in low-birth weight and preterm babies.

METHODS

A simple liquid crystal temperature monitoring device was used in 20 infants on a continuous basis to monitor for hypothermia. This was compared with the measurement of rectal temperature using a rectal thermometer. The colour changes and measures to be taken when hypothermia occurs was explained to the mothers and was well understood by all.

RESULTS

The Thermo Spot was in agreement with the rectal temperature in 310 out of 313 measurements. This includes 299 times when temperature was normal; and 11 times when the temperature was hypothermic. It underestimated the temperature of three infants, falsely indicating hypothermia in a normothermic child with normal body temperature. It correctly identified hypothermia in every case.

CONCLUSION

ThermoSpot device is a simple accurate device allowing continuous thermal monitoring of low birth weight infants, especially in resource poor setting.

Randomized controlled trial of kangaroo care: cardiorespiratory and thermal effects on healthy preterm infants

PURPOSE

To determine the safety and effects on healthy preterm infants of three continuous hours of kangaroo care (KC) compared to standard NICU care by measuring cardiorespiratory and thermal responses.

DESIGN

Randomized controlled trial-pretest-test-posttest control group design.

SAMPLE

Twenty-four healthy preterm infants (33-35 weeks gestation at birth) nearing discharge. Eleven of the infants received KC; 13 received standard NICU care.

MAIN OUTCOME VARIABLES

Heart rate, respiratory rate, oxygen saturation, and abdominal skin temperature were manually recorded every minute. Apnea, bradycardia, periodic breathing, and regular breathing were captured continuously on a pneumocardiogram printout. Three consecutive interfeeding intervals (three hours each) on one day constituted the pretest, test, and posttest periods.

RESULTS

Mean cardiorespiratory and temperature outcomes remained within clinically acceptable ranges during KC. Apnea, bradycardia, and periodic breathing were absent during KC. Regular breathing increased for infants receiving KC compared to infants receiving standard NICU care.

ThermoSpot in the detection of neonatal hypothermia

Thermal care is a critical part of caring for neonates. The need to identify simple, affordable and effective tools for detecting hypothermia in newborn infants that can be used by mothers and other caregivers in resource-poor countries remains crucial in our efforts to reduce perinatal and neonatal mortality and morbidity. The objective of this study was to determine the effectiveness of ThermoSpot in detecting hypothermia in newborn infants in a developing country. The prevalence of hypothermia (< 36 degrees C) in our study population was 51.4%. The ThermoSpot disc indicated green (normothermia) in 82% of infants whose axillary temperature was between 32 and 35.9 degrees C. However, the disc had a 100% specificity and positive predictive value at body temperatures below 36 degrees C and axillary temperatures below 36 degrees C or above 37.5 degrees C. Sensitivity, negative predictive value and accuracy were 19%, 52% and 57%, respectively. Mortality was significant in infants with black or blue ThermoSpot disc colours compared with green. For ThermoSpot discs placed on the abdomen, the risk of dying was 2.67 times higher if the disc colour was black compared with green and 2.43 times higher if the disc colour was blue compared with green. Similarly for ThermoSpot discs placed in the axilla, the risk of dying was 2.54 times higher if the disc colour was black and 2.5 times higher if the disc colour was blue as opposed to green. There is a need to improve the sensitivity and accuracy of ThermoSpot in detecting hypothermia before its widespread use.