Warming preterm infants in the delivery room: polyethylene bags, exothermic mattresses or both?

Rectal and axillary admission temperature in preterm infants less than 32 weeks' gestation, a prospective study

Objectives

The purpose of this research was to evaluate the differences between rectal and axillary temperature measurements in preterm infants who were born less than 32 weeks' gestation using digital thermometers upon their admission to the Neonatal Intensive Care Unit (NICU).

Methods

Prospective, observational, single centre study. Rectal and axillary temperatures measurements were performed using a digital thermometer. The study examined various maternal and neonatal factors to describe the study group, including the use of prenatal corticosteroids, the occurrence of maternal diabetes and hypertension, a history of maternal prolonged rupture of membranes (PROM), maternal chorioamnionitis, the mode of delivery, along with the neonate's gender, birth weight, and gestational age. The Pearson correlation coefficient (R) was calculated to ascertain the linear relationship between the temperatures taken at the rectal and axillary sites. The concordance between the two sets of temperature data was analyzed using the Bland-Altman method.

Results

Eighty infants with a mean gestational age of 28.4 weeks (SD = 2.9) and a mean birth weight of 1,229 g (SD = 456) were included in the study. The mean axillary temperature was 36.4 °C (SD = 0.7), which was lower than the mean rectal temperature of 36.6 °C (SD = 0.6) (p = 0.012). Rectal temperatures surpassed axillary measurements in 59% of instances, while the reverse was observed in 21% of cases. Rectal and axillary temperatures had a strong correlation (Pearson correlation coefficient of 0.915, p < 0.001). Bland-Altman plot showed a small mean difference of 0.1C between the two temperatures measurements but the limits of agreement were wide (+0.7 to -0.6 °C). For hypothermic infants, the mean difference between rectal and axillary temperatures was 0.27 °C, with a wide limit of agreement ranging from -0.5 °C to +1 °C. Conversely, for normothermic infants, the mean difference was smaller at 0.1 °C, with a narrower limit of agreement from -0.4 °C to +0.6 °C.

Conclusions

While there is a good correlation between axillary and rectal temperatures, the wider limits of agreement indicate variability, particularly in hypothermic infants. For a more accurate assessment of core body temperature in hypothermic infants, clinicians should consider using rectal measurements to ensure effective thermal regulation and better clinical outcomes.

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

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

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

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Research in the Delivery Room: Can You Tell Me It's Evolution?

Many of the recommendations for newborn care in the delivery room (DR) are based on retrospective observational studies, preclinical studies of mannequins or animal models, and expert opinion. Conducting DR research is challenging. Many deliveries occur in fraught circumstances with little prior warning, making it difficult to get prospective consent from parents and buy-in from clinicians. Many DR interventions are difficult to mask for the purpose of a clinical trial and it is not easy to identify appropriate outcomes for studies that are sufficiently "short-term" that they are likely to be influenced by the intervention, yet sufficiently "long-term" to be considered clinically important. However, despite these challenges, much information has been accrued from clinical studies in recent years. In this article, we outline our experience of conducting clinical research in the DR. In our initial studies almost 20 years ago, we found wide variation in the equipment used both nationally and internationally, reflecting the paucity of evidence to support practice. This started a journey that has included many observational studies and randomized controlled trials that have attempted to refine how we care for newborn infants in the DR. Each has given further information and, inevitably, raised many more questions about the approach to caring for newborns in the DR.

Comparison of rectal and axillary temperature measurements in preterm newborns

OBJECTIVE

To compare rectal and axillary temperatures in preterm newborns on admission to the neonatal intensive care unit (NICU).

DESIGN

Secondary analysis of data collected in a randomised controlled trial (RCT).

SETTING

Maternity hospital, level 3 NICU.

PATIENTS

Seventy-two newborns <31 weeks who were enrolled in the BAMBINO RCT (A randomised trial of exothermic mattresses to prevent heat loss in preterm infants at birth, ISRCTN31707342).

INTERVENTIONS

Newborns were placed in polyethylene bags and were randomised to placement on exothermic mattresses, or not in the delivery room. All infants had rectal and axillary temperatures measured in immediate succession using a digital thermometer on NICU admission.

OUTCOME MEASURES

Admission rectal and axillary temperatures.

RESULTS

Mean (SD) gestational age was 28 (2) weeks and birth weight was 1138 (374) g. Mean rectal-axillary temperature difference was 0.1 (0.5°C) (range -1.4°C to +1.5°C). Rectal and axillary temperatures differed by ≥0.5°C in 18/72 (25%) infants; axillary temperature was higher than rectal in 6 (8%) and lower in 12 (17%). There was a positive linear relationship between rectal and axillary measurements (Pearson's correlation R=0.84). Applying the Bland-Altman technique, the width of 95% prediction interval was 1.8°C (-0.8°C to 1.0°C) implying that rectal and axillary measurements may vary by up to 1.0°C. Axillary temperature had a sensitivity of 65% when used to detect rectal hyperthermia and 100% sensitivity for hypothermia.

CONCLUSION

Paired rectal and axillary temperature measurements in preterm newborns on NICU admission vary significantly. Axillary temperature was sensitive at detecting rectal hypothermia but not hyperthermia. Axillary temperature may not be an accurate proxy for rectal temperature measurement in all preterm newborns on NICU admission.

Singapore Neonatal Resuscitation Guidelines 2021

Neonatal resuscitation is a coordinated, team-based series of timed sequential steps that focuses on a transitional physiology to improve perinatal and neonatal outcomes. The practice of neonatal resuscitation has evolved over time and continues to be shaped by emerging evidence as well as key opinions. We present the revised Neonatal Resuscitation Guidelines for Singapore 2021. The recommendations from the International Liaison Committee on Resuscitation Neonatal Task Force Consensus on Science and Treatment Recommendations (2020) and guidelines from the American Heart Association and European Resuscitation Council were compared with existing guidelines. The recommendations of the Neonatal Subgroup of the Singapore Resuscitation and First Aid Council were derived after the work group discussed and appraised the current available evidence and their applicability to local clinical practice.

Maintaining normothermia: Why and how?

A high incidence of postnatal hypothermia has been reported in high-as well low-resource countries and it remains an independent predictor of neonatal morbidity and mortality, especially in very preterm infants in all settings. The temperature of newly born infants should be maintained between 36.5 and 37.5 °C after birth through admission and stabilization. Interventions to achieve this may include environmental temperature 23-25 °C, use of radiant warmers, exothermic mattresses, woollen or plastic caps, plastic wraps, humidified and heated gases. Skin-to-skin contact has been used, especially in low-resource settings. The combinations of these interventions applied to quality improvement initiatives, including staff training, use of checklists, and continuous feedback with the staff involved in the management of the neonate, are key factors to prevent heat loss from delivery room to admission to the neonatal intensive care unit. The admission temperature should be recorded as a predictor of outcomes as well as a quality indicator.

Association of admission temperature and death or adverse neurodevelopmental outcomes in extremely low-gestational age neonates

OBJECTIVE

Preterm infants are at higher risk of developing hypothermia and complications from cold stress, resulting in high mortality and short-term morbidity. Our objective is to evaluate the association between admission temperatures of extremely low-gestational age neonates (ELGAN) (<29 weeks') and adverse short-term neurodevelopmental outcomes.

STUDY DESIGN

In this retrospective study, we included ELGAN admitted to NICUs across Canada between April 2009 and September 2011, who underwent neurodevelopmental assessment at 18-21 months' corrected age.

RESULTS

Of 2739 infants with a complete data set identified during the study period, 968 (35.3%) had admission temperatures ≤36.4 °C (hypothermia group), 1489 (54.5%) had temperature of 36.5-37.2 °C (normothermia group), and 282 (10.3%) had hyperthermia (≥37.3 °C). Their mean birth weight was 823 ± 230 g, 944 ± 227 g and 927 ± 223 g, respectively (p < 0.01). More than 50% of infants born at 23-24 weeks were in the hypothermic group compared to 28.5-36.1% at higher gestational ages. We found 39.5% of infants in the hypothermic group had primary composite outcome of death or severe neurodevelopmental impairment (sNDI). Multivariate logistic regression revealed an increased adjusted odd of primary composite outcome (OR = 1.32; 95% CI = [1.05, 1.66]) in the hypothermic group, compared to infants with normothermia on admission.

CONCLUSIONS

In our cohort of ELGAN, hypothermia on admission was associated with increased risk of death or sNDI.

Effectiveness of a measure program to prevent admission hypothermia in very low-birth weight preterm infants

OBJECTIVE

To evaluate the effectiveness of a thermoregulation bundle for preventing admission hypothermia in very low-birth weight preterm infants.

METHODS

Interventional study with retrospective evaluation of data undertaken in a tertiary neonatal unit including all very low-birth weight preterm infants (<1500g) born at and admitted to the unit. Two periods were compared: before intervention (PI; 01/01/2012 to 02/28/2014_ and after intervention (PII; 04/01/2014 to 11/30/2016). The intervention started in March 2014. At PI procedures in the delivery room were: placement in a crib with a radiant heat source, doors always closed, polyethylene body plastic bag, double cap (plastic and cotton mesh), room temperature between 24 to 27°C and transport to neonatal unit in a pre-heated incubator (36-37.0°C). At PII, there was a reinforcement on not opening the plastic bag during the entire resuscitation process, even at an advanced stage, and the anthropometric measures and routine care were performed in the neonatal unit. Maternal, delivery, and neonatal variables were compared. Admission hypothermia was considered when admission axillary temperature was <36.0°C. Periodic results were shown to the team every six months and results were discussed.

RESULTS

The incidence of admission hypothermia was reduced significantly in PII (37.2 vs. 14.2%, p<0.0001) and admission temperature medians were higher (36.1 vs. 36.5°C, p<0.001). At PII, there was an increase in the number of infants transported with oxygen (49.5 vs. 75.5%, p<0.0001). No differences were observed regarding birth weight and gestational age.

CONCLUSION

There was a very important reduction in admission hypothermia incidence and a higher median admission temperature after continued protocol implementation.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

A Randomized Trial of Conditioned or Unconditioned Gases for Stabilizing Preterm Infants at Birth

OBJECTIVE

To determine whether the use of heated-humidified gases for respiratory support during the stabilization of infants <30 weeks of gestational age (GA) in the delivery room reduces rates of hypothermia on admission to the neonatal intensive care unit (NICU).

STUDY DESIGN

A multicenter, unblinded, randomized trial was conducted in Melbourne, Australia, between February 2013 and June 2015. Infants <30 weeks of GA were randomly assigned to receive either heated-humidified gases or unconditioned gases during stabilization in the delivery room and during transport to NICU. Infants born to mothers with pyrexia >38°C were excluded. Primary outcome was rate of hypothermia on NICU admission (rectal temperature <36.5°C).

RESULTS

A total of 273 infants were enrolled. Fewer infants in the heated-humidified group were hypothermic on admission to NICU (36/132 [27%]) compared with controls (61/141 [43%], P < .01). There was no difference in rates of hyperthermia (>37.5°C); 20% (27/132) in the heated-humidified group compared with 16% (22/141) in the controls (P = .30). There were no differences in mortality or respiratory outcomes.

CONCLUSIONS

The use of heated-humidified gases in the delivery room significantly reduces hypothermia on admission to NICU in preterm infants, without increased risk of hyperthermia.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Register (www.anzctr.org.au) ACTRN12613000093785.

Total body polyethylene wraps for preventing hypothermia in preterm infants: a randomized trial

OBJECTIVE

To evaluate whether a polyethylene total body wrapping (covering both the body and head) is more effective than conventional treatment (covering up to the shoulders) in reducing perinatal thermal losses in very preterm infants.

STUDY DESIGN

This was a multicenter, prospective, randomized, parallel 1:1, unblinded, controlled trial of infants<29 weeks' gestation age, comprising two study groups: experimental group (total body group; both the body and head covered with a polyethylene occlusive bag, with the face uncovered) and control group (only the body, up to the shoulders, covered with a polyethylene occlusive bag). The primary outcome was axillary temperature on neonatal intensive care unit admission immediately after wrap removal.

RESULTS

One hundred randomly allocated infants (50 in the total body group and 50 controls) completed the study. Mean axillary temperature on neonatal intensive care unit admission was similar in the two groups (36.5±0.6°C total body vs 36.4±0.8°C controls; P=.53). The rate of moderate hypothermia (temperature<36°C) was 12% in the total body group and 20% in the control group (P=.41). Three subjects in each group (6.0%) had an axillary temperature>37.5°C on admission, and one subject in control group had an axillary temperature>38°C.

CONCLUSION

Total body wrapping is comparable with covering the body up to the shoulders in preventing postnatal thermal losses in very preterm infants.

Controversies in neonatal resuscitation

Despite recent advances in perinatal medicine and in the art of neonatal resuscitation, resuscitation strategy and treatment methods in the delivery room should be individualized depending on the unique characteristics of the neonate. The constantly increasing evidence has resulted in significant treatment controversies, which need to be resolved with further clinical and experimental research.

Reducing hypothermia in preterm infants following delivery

BACKGROUND

Moderate hypothermia (temperature <36°C) at birth is common in premature infants and is associated with increased mortality and morbidity.

METHODS

A multidisciplinary practice plan was implemented to determine in premature infants <35 weeks old whether a multifaceted approach would reduce the number of inborn infants with an admitting axillary temperature <36°C by 20% without increasing exposure to a temperature >37.5°C. The plan included use of occlusive wrap a transwarmer mattress and cap for all infants and maintaining an operating room temperature between 21°C and 23°C. Data were obtained at baseline (n = 66), during phasing in (n = 102), and at full implementation (n = 193).

RESULTS

Infant axillary temperature in the delivery room (DR) increased from 36.1°C ± 0.6°C to 36.2°C ± 0.6°C to 36.6°C ± 0.6°C (P < .001), and admitting temperature increased from 36.0°C ± 0.8°C to 36.3°C ± 0.6°C to 36.7°C ± 0.5°C at baseline, phasing in, and full implementation, respectively (P < .001). The number of infants with temperature <36°C decreased from 55% to 6.2% at baseline versus full implementation (P < .001), and intubation at 24 hours decreased from 39% to 17.6% (P = .005). There was no increase in the number of infants with a temperature >37.5°C over time. The use of occlusive wrap, mattress, and cap increased from 33% to 88% at baseline versus full implementation. Control charts showed significant improvement in DR ambient temperature at baseline versus full implementation.

CONCLUSIONS

The practice plan was associated with a significant increase in DR and admitting axillary infant temperatures and a corresponding decrease in the number of infants with moderate hypothermia. There was an associated reduction in intubation at 24 hours. These positive findings reflect increased compliance with the practice plan.

Initial resuscitation and stabilization of the periviable neonate: the Golden-Hour approach

There is a paucity of data to support recommendations for stabilization and resuscitation of the periviable neonate in the delivery room. The importance of delivery at a tertiary center with adequate experience, resuscitation team composition, and training for a periviable birth is reviewed. Evidence for delayed cord clamping, delivery room temperature stabilization, strategies to establish functional residual capacity, and adequate ventilation as well as oxygen use in the delivery room is generally based on expert consensus, physiologic plausibility, as well as data from slightly more mature extremely low gestational-age neonates. Little is known about optimal care in the delivery room of these most fragile infants, and thus the need for research remains critical.

Application of plastic wrap to improve temperatures in infants born less than 30 weeks gestation: a randomized controlled trial

PURPOSE

The primary aim of the study was to evaluate whether the application of a plastic wrap immediately after birth is more effective than the standard care of temperature management for improving admission temperatures to the neonatal intensive care unit (NICU) in infants <30 weeks gestation.

DESIGN

A randomized controlled trial was conducted. Infants in the intervention group were transferred to a prewarmed radiant heater immediately after birth and encased in NeoWrap from the neck down without being dried. The infant's head was dried with a prewarmed towel and a hat added. The control group received usual care for the unit; the infant was transferred to the prewarmed radiant warmer and dried, and warm towels and a hat are then applied.

SAMPLE

A total of 92 infants were analyzed: 49 in the control group and 43 in the intervention group; 48 (52.2 percent) were <27 weeks gestation, and 44 (47.8 percent) were <30 weeks gestation. The infants' temperatures were assessed for two hours following admission.

A randomized trial of exothermic mattresses for preterm newborns in polyethylene bags

BACKGROUND AND OBJECTIVE

Hypothermia on admission to the NICU is associated with increased mortality in preterm infants. Many newborns are hypothermic on admission despite using polyethylene bags (PBs). Using exothermic mattresses (EMs) in addition to PBs may reduce hypothermia but increase hyperthermia. We wished to determine whether placing preterm newborns in PBs on EMs in the DR results in more infants with rectal temperature outside the range 36.5 to 37.5°C on NICU admission.

METHODS

Infants <31 weeks were randomly assigned before birth to treatment with or without an EM. All infants were placed in a PB and under radiant heat immediately after birth and brought to NICU in a transport incubator. Infants randomly assigned to EM were placed on a mattress immediately after delivery and remained on it until admission. Randomization was stratified by gestational age. Rectal temperature was measured with a digital thermometer on NICU admission.

RESULTS

The data safety monitoring committee recommended stopping for efficacy after analyzing data from half the planned sample. We report data for 72 infants enrolled at this time. Fewer infants in PBs on EMs had temperatures within the target range (15/37 [41%] vs 27/35 [77%], P = .002) and more had temperatures >37.5°C (17/37 [46%] vs 6/35 [17%], P = .009).

CONCLUSIONS

In very preterm newborns, using EMs in addition to PBs in the DR resulted in more infants with temperatures outside the normal range and more hyperthermia on NICU admission.