The effect of thermoregulation quality improvement initiatives on the admission temperature of premature/very low birth-weight infants in neonatal intensive care units: A systematic review

Thermoregulation, incubator humidity, and skincare practices in appropriate for gestational age ultra-low birth weight infants: need for more evidence

BACKGROUND

Although not universal, active care is being offered to infants weighing < 500 g at birth, referred to as ultra-low birth weight (ULBW) infants appropriate for gestational age. These infants have the greatest risk of dying or developing major morbidities. ULBW infants face challenges related to fluid and heat loss as well as skin injury in the initial days of life from extreme anatomical and physiological immaturity of the skin. Although there is an emerging literature on the outcomes of ULBW infants, there is a paucity of evidence to inform practice guidelines for delivering optimal care to this cohort of infants.

DATA SOURCES

A comprehensive review of the literature was performed using the PubMed and Embase databases. Searched keywords included "thermoregulation or body temperature regulation", "incubator humidity", "skin care", "infant, extremely low birth weight" and "ultra-low birth weight infants".

RESULTS

Evidences for thermoregulation, incubator humidity, and skincare practices are available for preterm infants weighing < 1500 g at birth but not specifically for ULBW infants. Studies on thermoregulation, incubator humidity, or skincare practices had a small sample size and did not include a sub-group analysis for ULBW infants. Current practice recommendations in ULBW infants are adopted from research in very and/or extremely low birth weight infants.

CONCLUSIONS

This narrative review focuses on challenges in thermoregulation, incubator humidity, and skincare practices in ULBW infants, highlights current research gaps and suggests potential developments for informing practices for improving health outcomes in ULBW infants. Video abstract (MP4 1,49,115 kb).

Skin-to-Skin Contact for Transferring Preterm Infants from the Delivery Room to the Neonatal Intensive Care Unit Is Promising Despite Moderate Heat Loss during the Procedure

OBJECTIVE

The principal aim of this prospective observational study was to assess the feasibility of skin-to-skin contact (SSC) with fathers during the transfer of preterm infants from the delivery room to the neonatal intensive care unit (NICU) in comparison with incubator transfers.

STUDY DESIGN

The study population comprised preterm singletons born between May and December 2019 in our maternity ward who did not require invasive ventilation. Physiological parameters (axillary temperature, heart rate, and fraction of inspired oxygen) of the newborns were recorded at prespecified steps during the transfers. The impact of the transfer mode on early blood glucose level, blood gas, and neonatal morbidities and mortality and the delay in the first SSC in the NICU and breastfeeding implementation and maintenance were also analyzed.

RESULTS

Twenty-eight preterm infants were transferred in incubators, and 29 infants were transferred using SSC. The SSC transfer induced heat loss (mean, -0.45°C; standard deviation [SD], 0.58). However, the decrease in temperature was similar to that observed during transfer in the incubator (mean, -0.30°C; SD, 0.49; p = 0.3). The transfer using SSC was not an independent factor associated with hypothermia at admission in the NICU (adjusted odds ratio, 2.6 [0.68-9.75]; p = 0.16). Neonatal morbidities and mortality were similar regardless of the transfer mode. The SSC transfer promoted early SSC in the neonatal unit (median hour [range], incubator 26 [2-126] vs SSC 13 [1-136], p = 0.03) and breastfeeding at discharge (incubator 35.7% vs SSC 69%, p = 0.01).

CONCLUSION

The SSC transfer of preterm infants was feasible and promoted earlier SSC and breastfeeding. Nevertheless, the SSC transfer, like the transfer in the incubator, induced moderate heat losses that exacerbated hypothermia at admission in the NICU. The improvement of thermal conservation during infant positioning and the continuation of SSC in the unit could help in preventing hypothermia.

KEY POINTS

· The SSC transfer was associated with heat loss during the transfer procedure.. · The SSC transfer promoted earlier SSC in the neonatal unit.. · The SSC transfer was likely to encourage breastfeeding..

Quality improvement in the golden hour for premature infants: a scoping review

BACKGROUND AND OBJECTIVE

Evidence-based research has shown that golden hour quality improvement (QI) measures can improve the quality of care and reduce serious complications of premature infants. Herein, we sought to review golden hour QI studies to evaluate the impact on the outcome of preterm infants.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, and SinoMed databases from inception to April 03, 2023. Only studies describing QI interventions in the golden hour of preterm infants were included. Outcomes were summarized and qualitative synthesis was performed.

RESULTS

Ten studies were eligible for inclusion. All studies were from single centers, of which nine were conducted in the USA and one in Israel. Seven were pre-post comparative studies and three were observational studies. Most included studies were of medium quality (80%). The most common primary outcome was admission temperatures and glucose. Five studies (n = 2308) reported improvements in the admission temperature and three studies (n = 2052) reported improvements in hypoglycemia after QI. Four studies (n = 907) showed that the incidence of bronchopulmonary dysplasia (BPD) was lower in preterm infants after QI: 106/408 (26.0%) vs. 122/424(29.5%) [OR = 0.68, 95% CI 0.48-0.97, p = 0.04].

CONCLUSIONS

Our study showed that the golden hour QI bundle can improve the short-term and long-term outcomes for extremely preterm infants. There was considerable heterogeneity and deficiencies in the included studies, and the variation in impact on outcomes suggests the need to use standardized and validated measures. Future studies are needed to develop locally appropriate, high-quality, and replicable QI projects.

Advances in the Prevention and Treatment of Neonatal Hypothermia in Early Birth

Neonates are vulnerable to hypothermia in the early postnatal period due to a low temperature environment, physiological function, and many other factors. In this article, the definition, occurrence status, related factors, hazards, and prevention strategies of neonatal hypothermia are reviewed. The interventions for hypothermia are mainly achieved through three processes, that is, intervention in the delivery room before and after birth, intervention on the way from the delivery room to the neonatal intensive care unit (NICU), and intervention after arrival at the NICU. Rewarming is the main intervention measure after the occurrence of hypothermia and slow rewarming is advocated, based on related studies of early neonatal cold injury syndrome and mild hypothermia treatment of hypoxic-ischemic encephalopathy. Rapid rewarming has been proposed in recent years but remains controversial. There are no detailed guidelines yet for rewarming for early neonatal hypothermia, and there is no precise definition of "rapid rewarming" and "slow rewarming" in terms of the rewarming rate.

Reducing Admission Hypothermia in Neonates Born at Less Than 32 Weeks or 1500 g

PURPOSE

The purpose of this quality improvement project was to decrease admission hypothermia in neonates born at less than 32 weeks or less than 1500 g.

METHODS

At delivery, neonates born less than 1500 g or at less than 32 weeks received polyurethane bags, polyurethane hats, and chemical mattresses. New practice guidelines from 2016 promoted this practice for all neonates born at less than 32 weeks, but the authors' prior work indicated that all neonates born less than 1500 g were at risk (regardless of gestational age) and would benefit from these interventions.

FINDINGS/RESULTS

After the intervention, only 2.1% (n = 2) of neonates born less than 1500 g or at less than 32 weeks were admitted moderately hypothermic (<36°C) compared with 9.6% in 2016, 20.2% in 2015, and 32.4% in 2014. Overall, the mean admission temperature in 2017 was 37°C, improved from 36.6°C in 2016, 36.3°C in 2015, and 36.2°C in 2014 (P < .001).

IMPLICATIONS FOR PRACTICE

The intervention significantly reduced the number of neonates admitted moderately hypothermic (<36.0°C) to this neonatal intensive care unit. Using chemical mattresses and polyurethane bags with neonates born less than 1500 g or at less than 32 weeks (compared with only <1000 g) improved admission temperatures. It is important to include all neonates born less than 1500 g in these practice interventions and not only those born at less than 32 weeks; both gestational age and weight should guide practice.

IMPLICATIONS FOR RESEARCH

More research is needed on the effects of thermoregulation interventions and hyperthermia in neonates, as well as best practice thermoregulation interventions for preterm and ill neonates of all gestational ages and weights.

Thermal management with and without servo-controlled system in preterm infants immediately after birth: a multicentre, randomised controlled study

BACKGROUND

The thermal servo-controlled systems are routinely used in neonatal intensive care units (NICUs) to accurately manage patient temperature, but their role during the immediate postnatal phase has not been previously assessed.

OBJECTIVE

To compare two modalities of thermal management (with and without the use of a servo-controlled system) immediately after birth.

STUDY DESIGN AND SETTING

Multicentre, unblinded, randomised trial conducted 15 Italian tertiary hospitals.

PARTICIPANTS

Infants with estimated birth weight <1500 g and/or gestational age <30⁺⁶ weeks.

INTERVENTION

Thermal management with or without a thermal servo-controlled system during stabilisation in the delivery room.

PRIMARY OUTCOME

Proportion of normothermia at NICU admission (axillary temperature 36.5°C-37.5°C).

RESULTS

At NICU admission, normothermia was achieved in 89/225 neonates (39.6%) with the thermal servo-controlled system and 95/225 neonates (42.2%) without the thermal servo-controlled system (risk ratio 0.94, 95% CI 0.75 to 1.17). Thermal servo-controlled system was associated with increased mild hypothermia (36°C-36.4°C) (risk ratio 1.48, 95% CI 1.09 to 2.01).

CONCLUSIONS

In very low birthweight infants, thermal management with the servo-controlled system conferred no advantage in maintaining normothermia at NICU admission, while it was associated with increased mild hypothermia. Thermal management of preterm infants immediately after birth remains a challenge.

TRIAL REGISTRATION NUMBER

NCT03844204.