Thermoregulatory effects of swaddling in Mongolia: a randomised controlled study

Too hot to thrive: a qualitative inquiry of community perspectives on the effect of high ambient temperature on postpartum women and neonates in Kilifi, Kenya

OBJECTIVE

To understand community perspectives on the effects of high ambient temperature on the health and wellbeing of neonates, and impacts on post-partum women and infant care in Kilifi.

DESIGN

Qualitative study using key informant interviews, in-depth interviews and focus group discussions with pregnant and postpartum women (n = 22), mothers-in-law (n = 19), male spouses (n = 20), community health volunteers (CHVs) (n = 22) and stakeholders from health and government ministries (n = 16).

SETTINGS

We conducted our research in Kilifi County in Kenya's Coast Province. The area is largely rural and during summer, air temperatures can reach 37˚C and rarely go below 23˚C.

DATA ANALYSIS

Data were analyzed in NVivo 12, using both inductive and deductive approaches.

RESULTS

High ambient temperature is perceived by community members to have direct and indirect health pathways in pregnancy and postpartum periods, including on the neonates. The direct impacts include injuries on the neonate's skin and in the mouth, leading to discomfort and affecting breastfeeding and sleeping. Participants described babies as "having no peace". Heat effects were perceived to be amplified by indoor air pollution and heat from indoor cooking fires. Community members believed that exclusive breastfeeding was not practical in conditions of extreme heat because it lowered breast milk production, which was, in turn, linked to a low scarcity of food and time spend by mothers away from their neonates performing household chores. Kangaroo Mother Care (KMC) was also negatively affected. Participants reported that postpartum women took longer to heal in the heat, were exhausted most of the time and tended not to attend postnatal care.

CONCLUSIONS

High ambient temperatures affect postpartum women and their neonates through direct and indirect pathways. Discomfort makes it difficult for the mother to care for the baby. Multi-sectoral policies and programs are required to mitigate the negative impacts of high ambient temperatures on maternal and neonatal health in rural Kilifi and similar settings.

Numerical investigation of the convective heat transfer coefficient for a sleeping infant in a ventilation room

This study aimed to investigate the influence of wind speed and direction on the convective heat transfer from a sleeping infant in different postures. A computational fluid dynamics (CFD) model of a virtual infant manikin with realistic dimensions was developed to obtain the convective heat transfer coefficient (h_c ) at the body surface and the airflow and temperature distributions. The numerical model was validated beforehand using experimental data collected from infant thermal manikin experiments. The simulation results revealed that the infant's whole-body h_c increased from 4.00 to 15.73 W/m² ·K when wind speed varied from 0.12 to 1 m/s. Infants lost heat more quickly than adults under ventilation, with about 2 W/m² ·K higher h_c than adults in still air, and the discrepancy widened as the wind speed increased. Wind from the floor generated the highest h_c , approximately 66.4% greater than the wind from the feet at 1 m/s wind speed. Considering the wind from the feet caused the most evenly distributed h_c , ventilation equipment was suggested to be placed on the side of the infant's feet to reduce local discomfort. Based on the simulation results, empirical models of h_c were developed, which lay a solid theoretical foundation for further study on the interaction between infants and environments.

Comparison of the Effect of Nesting and Swaddling on Sleep Duration and Arousal Frequency among Preterm Neonates: A Randomized Clinical Trial

Introduction: Sleep contributes a pivotal part in neurological improvement of new borns. New-borns admitted to neonatal intensive care unit (NICU) perceive many sounds of monitors and this disturb their rest period. To enhance the sleep duration of neonates many non-pharmacological methods are available like placing newborn in a nest made with rolled cotton bed sheet and wrapping the baby with white cotton cloth. In this research effect of these two positions were assessed.

Methods: A randomized clinical trial was carried out on 76 preterm neonates in NICU of a tertiary care center. Neonates were included in the study by random method. Sleep duration and frequency of arousal was assessed through direct observation. Physiological parameters were assessed by using cardiac monitor. The information collected were analyzed using SPSS version 21.

Results: Sleep duration of nesting group showed significantly higher than swaddling group, which mean (SD) was 206.4 (28), 183.1 (34.78) minutes, respectively. Additionally, waking up was observed less frequency in the nesting group.

Conclusion: Nesting enhances the duration of sleep among preterm neonates and hence this can be given priority in NICU.

Can infant sleeping bags be recommended by medical professionals as protection against sudden infant death syndrome?

Clinical scenario: A mother brought her infant to the hospital with bronchiolitis and incidentally asked if I would recommend the use of infant sleeping bags to protect against Sudden Infant Death Syndrome as several of her friends use them. Structured question: Can infant sleeping bags be recommended by medical professionals as protective against Sudden Infant Death Syndrome? Methods: A literature search was performed. Trials were included if they had an English version available and the papers examined the impact that sleeping bag use had on risk of SIDS or its risk factors. Cochrane Library search found eight trials, two of which were found to meet inclusion criteria. MEDLINE was searched using the search terms ((baby sleeping bag) OR infant sleeping bag) OR cotton sleeping sack. Forty-seven papers were found, two of which were found to meet the inclusion criteria, one of which had already been found in the Cochrane Library search. One further paper was found through searching citations of the papers included. Discussion: Sleeping bags are used in 48-95% of infants in the UK and advocated for by the Lullaby Trust for their safety in the prevention of SIDS. The case control studies included found that sleeping bags are as safe, if not safer than other bedding when examining SIDS as an outcome. For sleeping bags to be safe they must be well made and appropriately used, which includes the correct size, Tog, clothing and other bedding for bedroom temperature.

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.