Association between admission hypothermia and outcomes in very low birth weight infants in China: a multicentre prospective study

Hypothermia in preterm infants admitted to low-resource neonatal units in northern Nigeria: an observational study of occurrence and risk factors

BACKGROUND

Hypothermia is an important cause of morbidity and mortality among preterm and low-birth-weight neonates. In resource-constrained settings, limited referral infrastructure and technologies for temperature control potentiate preterm hypothermia. While there is some documentation on point-of-admission hypothermia from single center studies, there are limited multicenter studies on the occurrence of hypothermia among preterm infants in resource-limited-settings. Therefore, we conducted a multicenter study to determine the prevalence and risk factors for hypothermia at the time of admission and during the first 72 h after admission in northern Nigeria.

METHOD

We carried out a prospective cohort study on preterm infants admitted to four referral hospitals in northern Nigerian between August 2020 and July 2021. We documented temperature measurements at admission and the lowest and highest temperatures in the first 72 h after admission. We also collected individual baby-level data on sociodemographic and perinatal history data. We used the World Health Organization classification of hypothermia to classify the babies' temperatures into mild, moderate, and severe hypothermia. Poisson regression analysis was used to identify risk factors for moderate-severe hypothermia.

RESULTS

Of the 933 preterm infants enrolled, 682 (72.9%) had hypothermia at admission although the prevalence of hypothermia varied across the four hospitals. During the first 24 h after admission, 7 out of every 10 babies developed hypothermia. By 72 h after admission, between 10 and 40% of preterm infants across the 4 hospitals had at least one episode of moderate hypothermia. Gestational age (OR = 0.86; CI = 0.82-0.91), birth weight (OR = 8.11; CI = 2.87-22.91), presence of a skilled birth attendant at delivery (OR = 0.53; CI = 0.29-0.95), place of delivery (OR = 1.94 CI = 1.13-3.33) and resuscitation at birth (OR = 1.79; CI = 1.27-2.53) were significant risk factors associated with hypothermia.

CONCLUSION

The prevalence of admission hypothermia in preterm infants is high and hypothermia is associated with low-birth-weight, place of delivery and presence of skilled birth attendant. The prevalence of hypothermia while in care is also high and this has important implications for patient safety and quality of patient care. Referral services for preterm infants need to be developed while hospitals need to be better equipped to maintain the temperatures of admitted small and sick newborns.

Incidence and risk factors of neonatal hypothermia: A systematic review and meta-analysis

AIM

Hypothermia poses a threat to the health and lives of newborns. Therefore, it is essential to identify the factors that influence neonatal hypothermia and provide targeted intervention suggestions for clinical practice to reduce its occurrence.

METHODS

We conducted a literature search to identify factors influencing neonatal hypothermia and performed a meta-analysis to determine the prevalence of neonatal hypothermia and its associated factors. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of cohort and case-control studies, while the Agency for Healthcare Research and Quality (AHRQ) was used to evaluate the quality of cross-sectional studies.

RESULTS

Eighteen studies involving 44 532 newborns from 13 countries were included. The incidence of neonatal hypothermia was 52.5% (95% CI: 0.37, 0.68). Factors such as no skin-to-skin contact, prematurity, low birth weight, delayed breastfeeding, asphyxiation and resuscitation after birth, low APGAR score, not wearing a cap, and caesarean section were found to affect neonatal hypothermia.

CONCLUSION

Multiple factors influence neonatal hypothermia, and clinicians can utilise these factors to develop targeted intervention measures to prevent and reduce the incidence of neonatal hypothermia.

Association between Neonatal Outcomes and Admission Hypothermia among Very Preterm Infants in Chinese Neonatal Intensive Care Units: A Multicenter Cohort Study

OBJECTIVE

 We aimed to investigate the relationship between admission hypothermia and outcomes among very preterm infants (VPIs) in neonatal intensive care units (NICUs) in China. We also investigated the frequency of hypothermia in VPIs in China and the variation in hypothermia across Chinese Neonatal Network (CHNN) sites.

STUDY DESIGN

 This retrospective cohort study enrolled infants with 240/7 to 316/7 weeks of gestation with an admission body temperature ≤37.5 °C who were admitted to CHNN-participating NICUs between January 1 and December 31, 2019.

RESULTS

 A total of 5,913 VPIs were included in this study, of which 4,075 (68.9%) had hypothermia (<36.5 °C) at admission. The incidence of admission hypothermia varied widely across CHNN sites (9-100%). Lower gestational age (GA), lower birth weight, antenatal steroid administration, multiple births, small for GA, Apgar scores <7 at the 5th minute, and intensive resuscitation were significantly associated with admission hypothermia. Compared with infants with normothermia (36.5-37.5 °C), the adjusted odds ratios (ORs) for composite outcome among infants with admission hypothermia <35.5 °C increased to 1.47 (95% confidence interval [CI], 1.15-1.88). The adjusted ORs for mortality among infants with admission hypothermia (36.0-36.4 and <35.5 °C) increased to 1.41 (95% CI, 1.09-1.83) and 1.93 (95% CI, 1.31-2.85), respectively. Admission hypothermia was associated with a higher likelihood of bronchopulmonary dysplasia, but was not associated with necrotizing enterocolitis ≥stage II, severe intraventricular hemorrhage, cystic periventricular leukomalacia, severe retinopathy of prematurity, or sepsis.

CONCLUSION

 Admission hypothermia remains a common problem for VPIs in a large cohort in China and is associated with adverse outcomes. Continuous quality improvement of admission hypothermia in the future may result in a substantial improvement in the outcomes of VPIs in China.

KEY POINTS

· Admission hypothermia is common in VPIs.. · The incidence of admission hypothermia in VPIs remains high in China.. · Admission hypothermia is associated with adverse outcomes in VPIs..

Thermoregulation of the Extremely Low Birth Weight Neonate

The birth of an extremely low birth weight (ELBW) neonate is complex because of their immaturity. Respiratory and hemodynamic stabilization often takes precedence in the immediate delivery period. While establishing effective breathing and circulation is vital to the survival of the neonate, it is crucial to understand that other adverse outcomes can occur during the resuscitation and transport of the ELBW neonate. Impaired thermoregulation is one of the most detrimental adverse outcomes during the golden hour period and later in the neonatal intensive care unit. Hypothermia is an independent risk factor for increased morbidity and mortality and can impact multiple body systems, making management even more challenging. This article discusses the physiology of thermoregulation while exploring interventions to maintain normothermia in the ELBW neonate, ultimately improving long-term outcomes.

Development and validation of a model to predict mortality risk among extremely preterm infants during the early postnatal period: a multicentre prospective cohort study

BACKGROUND

Recently, with the rapid development of the perinatal medical system and related life-saving techniques, both the short-term and long-term prognoses of extremely preterm infants (EPIs) have improved significantly. In rapidly industrialising countries like China, the survival rates of EPIs have notably increased due to the swift socioeconomic development. However, there is still a reasonably lower positive response towards the treatment of EPIs than we expected, and the current situation of withdrawing care is an urgent task for perinatal medical practitioners.

OBJECTIVE

To develop and validate a model that is practicable for EPIs as soon as possible after birth by regression analysis, to assess the risk of mortality and chance of survival.

METHODS

This multicentre prospective cohort study used datasets from the Sino-Northern Neonatal Network, including 46 neonatal intensive care units (NICUs). Risk factors including maternal and neonatal variables were collected within 1 hour post-childbirth. The training set consisted of data from 41 NICUs located within the Shandong Province of China, while the validation set included data from 5 NICUs outside Shandong Province. A total of 1363 neonates were included in the study.

RESULTS

Gestational age, birth weight, pH and lactic acid in blood gas analysis within the first hour of birth, moderate-to-severe hypothermia on admission and adequate antenatal corticosteroids were influencing factors for EPIs' mortality with important predictive ability. The area under the curve values for internal validation of our prediction model and Clinical Risk Index for Babies-II scores were 0.81 and 0.76, and for external validation, 0.80 and 0.51, respectively. Moreover, the Hosmer-Lemeshow test showed that our model has a constant degree of calibration.

CONCLUSIONS

There was good predictive accuracy for mortality of EPIs based on influencing factors prenatally and within 1 hour after delivery. Predicting the risk of mortality of EPIs as soon as possible after birth can effectively guide parents to be proactive in treating more EPIs with life-saving value.

TRIAL REGISTRATION NUMBER

ChiCTR1900025234.

The Electronic Health Record as a Quality Improvement Tool: Exceptional Potential with Special Considerations

The electronic health record (EHR) offers an exciting opportunity for quality improvement efforts. An understanding of the nuances of a site's EHR landscape including the best practices in clinical decision support design, basics of data capture, and acknowledgment of the potential unintended consequences of technology change is essential to ensuring effective usage of this powerful tool.

Factors influencing hypothermia in very low/extremely low birth weight infants: a meta-analysis

Introduction

Previous studies have explored factors that influence the occurrence of hypothermia in very low/extremely low birth weight (VLBW/ELBW) infants, but the factors associated with hypothermia in VLBW or ELBW infants remain inadequately evaluated due to limited prospective data and inconsistency in study populations. Therefore, it is necessary to systematically evaluate the risk factors of hypothermia in VLBW/ELBW infants in order to provide a theoretical basis for clinical practice.

Methods

PubMed and other databases were used to search for case-control or cohort studies on factors influencing the occurrence of hypothermia in VLBW/ELBW infants. The search time was set from database creation to June 30th, 2022. Literature screening, quality evaluation, and data extraction were performed independently by two investigators according to predefined inclusion and exclusion criteria. Meta-analysis was performed using RevMan 5.3.

Results

A total of 10 papers were finally included in this study and 12 factors were established by meta-analysis: body weight (six papers), failure to keep warm in time (three papers), neonatal resuscitation (seven papers), gestational age (three papers), premature rupture of membranes (three papers), maternal combined complications (four papers), cesarean section (six papers), antenatal steroids (four papers), multiple birth (two papers), small for gestational age (two papers), 1 min Apgar score (three papers), and 5 min Apgar score (three papers). Since only one study included race, age (hour), socio-economic status, and spontaneous labor, these factors could not be fitted into RevMan 5.3 for the analysis.

Conclusion

Although there were differences in the study design of the included literature, the influencing factors described in each study were relatively similar. The influencing factors identified in this study may contribute to the construction of related intervention strategies for hypothermia in VLBW/ELBW infants.

Hypothermia on admission and its association with neonatal mortality and morbidity in neonatal intensive care unit

BACKGROUND

Neonatal hypothermia is a drop in the newborn's core temperature less than 36.5°C. It is crucial in neonatal morbidity and mortality, particularly in preterm infants. This research aimed to assess the incidence and risk factors of neonatal hypothermia and its effect on neonatal mortality and short-term morbidity during Neonatal Intensive Care Unit (NICU) admission.

METHODS

This observational study was conducted on all neonates admitted to the NICU at Benha University Hospital. The core temperature was measured on admission for all admitted neonates and were followed up to assess the impact of hypothermia on short-term outcomes and mortality.

RESULTS

A total of 323 neonates were admitted to the NICU throughout the research period. Thirty-five cases were excluded due to congenital anomalies or missing or late admission temperature recordings. The study included 288 neonates whose mean gestational age was 34.6±3.4 weeks, and their mean birth weight was 2.35±0.9 kg. Two-thirds (66%) of the neonates had core temperatures indicating hypothermia (axillary temperature of less than 36.5°C), one-third (33%) were normothermic, and only three (1%) were hyperthermic. Neonates with hypothermia had statistically lower gestational age, higher frequency of multiple births, prolonged need for respiratory support, higher rates of pulmonary hemorrhage, sepsis, intraventricular hemorrhage (IVH), and necrotizing enterocolitis, longer hospital stay, and mortality.

CONCLUSIONS

There is a high incidence of neonatal hypothermia at NICU admission. Lower gestational age, increased multiples, lower APGAR score, lower birth weight, and lack of antenatal steroids were significantly associated with hypothermia at NICU admission. Hypothermia was found to be a significant factor contributing to increased mortality and morbidity rates in affected neonates.

Incidence, time to recovery and predictors among neonates admitted with respiratory distress to the neonatal intensive care unit at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2021

BACKGROUND

One of the major factors contributing to newborn morbidity and mortality across the globe is respiratory distress. In resource-constrained developing nations like Ethiopia, it is a significant issue. Depending on the quality of the care provided, the incidence and time to recovery may differ amongst medical facilities. However, Ethiopia still lacks appropriate data on the incidence and time to recovery from respiratory distress.

OBJECTIVE

The aim of the study was to assess the incidence, time to recovery, and predictors among neonates admitted with respiratory distress in the neonatal intensive care unit at the University of Gondar Comprehensive Specialized Hospital.

METHODS

An institution-based retrospective follow-up study design was conducted among 452 neonates with respiratory distress. Data were collected using a data extraction checklist from the medical registry. The extracted data were entered into EPI INFO version 7.2.1.0 and then exported to STATA version 14 for analysis. The median time to recovery, the Kaplan Meier curve, and the log-rank test was computed. Both bi-variable and multivariable Cox regression models were applied to analyze the data. p-value ≤ 0.05 was considered statistically significant.

RESULTS

Of all respiratory distressed neonate,311 were recovered. The overall incidence rate of neonates admitted with from respiratory distress was 11.5 per 100-neonate day (95% CI: 10.30-12. 87) with 2,703-person day observation and the median time to recovery from respiratory distress was 7 days with (IQR = 3-13 days). Predictors of time to recovery from respiratory distress were very low birth weight (AHR = 0.17, 95% CI: 0.08-0.41), low birth weight (AHR = 0.50, 95% CI: 0.31-0.81), very preterm (AHR = 0.42,95% CI:0.20-0.89), sepsis (AHR = 0.50 95% CI: 0.38-0.65), hypothermia (AHR = 0.61, 95% CI: 0.39-0.81), and Apgar scores less than seven at first (AHR = 0.35, 95% CI: 0.15-0.79) and fifth minute (AHR = 0.45, 95% CI: 0.20-0.97).

CONCLUSION

The incidence and time to recovery in this study were discreetly acceptable as compared to previous study. The aforementioned predictors could be used to identify neonates with respiratory distress who are at risk of developing a long-term illness and guide prompt referral to hospitals. This will also provide clinicians with prognostic information, as longer recovery times have economic and social implications in resource limited countries like Ethiopia.

[Pulmonary hemorrhage in very low birth weight infants: risk factors and clinical outcome]

OBJECTIVES

To investigate the risk factors for pulmonary hemorrhage and its clinical outcome in very low birth weight infants (VLBWIs).

METHODS

The medical data were collected from all live VLBWIs (gestational age <35 weeks) who were admitted to Jiangsu Women and Children Health Hospital and Children's Hospital of Nanjing Medical University between January 1, 2020 and December 31, 2021. Based on inclusion and exclusion criteria, 574 VLBWIs were included in the study, with 44 VLBWIs in the pulmonary hemorrhage group and 530 VLBWIs in the non-pulmonary hemorrhage group. The clinical data were compared between the two groups. A multivariate logistic regression analysis was used to identify the risk factors for pulmonary hemorrhage.

RESULTS

There were significant differences between the two groups in maternal age, rate of positive-pressure ventilation for resuscitation, rate of tracheal intubation for resuscitation, and minimum body temperature within 1 hour after birth (P<0.05). The pulmonary hemorrhage group had a higher proportion of VLBWIs with grade Ⅲ-Ⅳ respiratory distress syndrome or early-onset sepsis than the non-pulmonary hemorrhage group (P<0.05). The pulmonary hemorrhage group also had a higher proportion of VLBWIs with a capillary refilling time of >3 seconds within 1 hour after birth and with the maximum positive end-expiratory pressure (PEEP) of <5 cmH₂O within 24 hours after birth (P<0.05). The multivariate regression analysis showed that maternal age of 30-<35 years (OR=0.115, P<0.05) was a protective factor against pulmonary hemorrhage, while a lower temperature (<34°C) within 1 hour after birth, the maximum PEEP of <5 cm H₂O within 24 hours after birth, and early-onset sepsis were risk factors for pulmonary hemorrhage (OR=11.609, 11.118, and 20.661, respectively; P<0.05). For all VLBWIs, the pulmonary hemorrhage group had a longer duration of invasive ventilation and a higher mortality rate than the non-pulmonary hemorrhage group (P<0.05); for the survival VLBWIs, the pulmonary hemorrhage group had a higher incidence rate of bronchopulmonary dysplasia than the non-pulmonary hemorrhage group (P<0.05).

CONCLUSIONS

Maintaining the stability of temperature, giving appropriate PEEP, and identifying sepsis as early as possible can reduce the incidence rate of pulmonary hemorrhage, thereby helping to reduce the incidence of bronchopulmonary dysplasia and mortality in VLBWIs.

Admission Hypothermia and Factors Associated with Mortality among Admitted Hypothermic Preterm Neonates in Neonatal Intensive Care Units of Public Hospitals of Addis Ababa, Ethiopia

Background

Limited knowledge on the proportion of admission hypothermia and factors of death in hypothermic preterm neonates is hindering early and appropriate interventions in Ethiopia. Thus, studies on the proportion of admission hypothermia and factors of death in hypothermic preterm neonates are critical to enhancing preterm infants' survival.

Methods

Hospital-based cross-sectional study was conducted on 398 participants using the systematic sampling method from October 10, 2021, to December 15, 2022. A pretested data extraction tool was used to collect data. EpiData version 4.6 and STATA version 16 were used for data entry and analysis. Multivariable logistic regression analysis evaluated the association between independent and outcome variables with a 95% confidence interval (CI). Hosmer and Lemeshow test and variance inflation factor were assessed to check model fitness and collinearity, respectively. Pvalue < 0.05 was considered statistically significant.

Result

Of the 398 admitted preterm neonates, 331(83.2%) had hypothermia at admission. Factors that were significantly associated with mortality included outborn babies [Adjusted hazard ratio (AOR) = 2.18 : 95% CI (1.03-4.62)], GA less than 32 weeks [AOR = 6.64 : 95% CI (1.87-13.58)], weight less than 1500 gram [AOR = 7.91 : 95% CI (1.21-15.38)], thrombocytopenia [AOR = 3.36 : 95% CI (1.49-7.58)], and kangaroo mother care [AOR = 0.38 : 95% CI (0.16-0.88)].

Conclusion

The proportion of admission hypothermia was high. Outborn babies, birth weight less than 1500 gram, gestational age < 32 weeks, being thrombocytopenic, and lack of kangaroo mother care were identified as risk factors for hypothermic preterm neonatal mortality. Preterm labor prevention, improved inborn delivery, and kangaroo mother care may alleviate the high proportion of admission hypothermia and related mortalities in preterm neonates.

Reducing intraventricular hemorrhage following the implementation of a prevention bundle for neonatal hypothermia

Introduction

In very low birth weight (VLBW) infants, hypothermia immediately following birth is common even in countries rich in medical resources. The purpose of this study is to design a standard prevention bundle that decreases the rate of hypothermia among infants after birth and to investigate efficacy of the bundle and short-term outcomes for VLBW infants.

Methods

This quality improvement project was conducted from February 2017 to July 2018 on all VLBW preterm infants admitted at a single referral level III neonatal intensive care unit. The infants were classified into the pre-intervention (February to September 2017) and post-intervention (October 2017 to July 2018) groups according to the time periods when they were recruited. During the pre-intervention period, we analyzed the primary causes of hypothermia, developed solutions corresponding to each cause, integrated all solutions into a prevention bundle, and applied the bundle during the post-intervention period. Afterwards, the incidence of neonatal hypothermia and short-term outcomes, such as intraventricular hemorrhage (IVH), acidosis, and shock requiring inotropic agents, in each group were compared.

Results

A total of 95 VLBW infants were enrolled in the study, including 37 pre-intervention, and 58 post-intervention cases. The incidence of hypothermia in preterm infants decreased significantly upon the implementation of our prevention bundle, both in the delivery room (from 45.9% to 8.6%) and on admission (59.5% to 15.5%). In addition, the short-term outcomes of VLBW infants improved significantly, especially with the decreased incidence of IVH (from 21.6% to 5.2%, P = 0.015).

Conclusions

Our standardized prevention bundle for preventing hypothermia in VLBW infants is effective and decreased the IVH rate in VLBW infants. We strongly believe that this prevention bundle is a simple, low-cost, replicable, and effective tool that hospitals can adopt to improve VLBW infant outcomes.

A standardized implementation of multicenter quality improvement program of very low birth weight newborns could significantly reduce admission hypothermia and improve outcomes

Background

Admission hypothermia (AH, < 36.5℃) remains a major challenge for global neonatal survival, especially in developing countries. Baseline research shows nearly 89.3% of very low birth weight (VLBW, < 1500 g) infants suffer from AH in China. Therefore, a prospective multicentric quality improvement (QI) initiative to reduce regional AH and improve outcomes among VLBW neonates was implemented.

Methods

The study used a sequential Plan—Do—Study—Act (PDSA) approach. Clinical data were collected prospectively from 5 NICUs within the Sino-Northern Neonatal Network (SNN) in China. The hypothermia prevention bundle came into practice on January 1, 2019. The clinical characteristics and outcomes data in the pre-QI phase (January 1, 2018– December 31, 2018) were compared with that from the post-QI phase (January 1, 2019–December 31, 2020). Clinical characteristics and outcomes data were analyzed.

Results

A total of 750 in-born VLBW infants were enrolled in the study, 270 in the pre-QI period and 480 in the post- QI period, respectively. There were no significant differences in clinical characteristics of infants between these two phases. Compared with pre-QI period, the incidence of AH was decreased significantly after the QI initiative implementation in the post-QI period (95.9% vs. 71.3%, P < 0.01). Incidence of admission moderate-to-severe hypothermia (AMSH, < 36℃) also decreased significantly, manifesting a reduction to 38.5% in the post-QI (68.5% vs 30%, P < 0.01). Average admission temperature improved from after QI (35.5 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 0.7℃ vs. 36.0 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 0.6℃, P < 0.01). There was no increase in proportion the number of infants with a temperature of > 37.5 °C or thermal burns between the two groups. The risk ratio of mortality in infants during the post-QI period was significantly lower in the post-QI period as compared to the pre-QI period [adjusted risk ratio (aRR): 0.26, 95% confidence interval (CI): 0.13–0.50]. The risk ratio of late-onset neonatal sepsis (LOS) also significantly lowered in the post-QI period (aRR: 0.66, 95% CI: 0.50–0.87).

Conclusion

Implementation of multicentric thermoregulatory QI resulted in a significant reduction in AH and AMSH in VLBW neonates with associated reduction in mortality. We gained a lot from the QI, and successfully aroused the attention of perinatal medical staff to neonatal AH. This provided a premise for continuous quality improvement of AH in the future, and might provide a reference for implementation of similar interventions in developing countries.

Trial registration

Trial registration number: ChiCTR1900020861. Date of registration: 21 January 2019(21/01/2019). Prospectively registered. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03310-5.

Implementation of a temperature bundle improves admission hypothermia in very-low-birth-weight infants in China: a multicentre study

Background

Hypothermia is a common problem that is associated with increased mortality and morbidity among preterm infants, especially in China. The objective of this study was to evaluate the efficacy of a targeted quality improvement (QI) project that applied hypothermia prevention measures for very-low-birth-weight (VLBW) infants in three tertiary neonatal intensive care units (NICUs) in China.

Problem

Between January 2018 and December 2018, we conducted a prospective analysis and found that the incidence of AH was 88.2% among VLBW infants.

Methods

The study enrolled preterm infants born at less than 32 weeks’ gestation with a VLBW of less than 1500 g who were delivered at three academic tertiary-care hospitals between January 2018 and December 2019. The primary outcome measure was the incidence of hypothermia. The outcomes of the pre-QI group (1 January–31 December 2018) were compared with those of the post-QI group (1 January–31 December 2019).

Interventions

Based on the literature, our preliminary findings and the needs of each unit, a temperature bundle that included a transport incubator, prewarmed hats, polyethylene wrap, team training and education, and temperature documentation and workflows were implemented in consecutive plan–do–study–act cycles.

Results

Of the 530 VLBW infants, 235 infants (36.9%) belonged to the pre-QI group, and 295 infants (46.4%) belonged to the post-QI group. The incidence of hypothermia decreased significantly, from 92.3% to 62% (p<0.001), and the mean body temperature on admission to the NICU increased significantly, from 35.5°C to 36°C±0.7°C (p<0.001). There was one case of hyperthermia during the study period. Infants in the post-QI group had a lower mortality rate (16.1% vs 8.8%, p=0.01).

Conclusions

Targeted interventions can dramatically reduce admission hypothermia and improve the outcome of VLBW infants in China.

Trial registration number

Chi CTR 1900020861.

Relationship between Admission Temperature and Risk of Cerebral Palsy in Infants Admitted to Special Care Unit in a Low Resource Setting: A Retrospective Single-Center Study

Background: Deviations from normothermia affect early mortality and morbidity, but the impact on neurodevelopment of the survivors is unclear. We aimed to investigate the relationship between neonatal temperature at admission and the risk of cerebral palsy (CP) at one month of age in a low-resource setting. Methods: This retrospective study included all inborn neonates admitted to the Special Care Unit of Tosamaganga Hospital (Tanzania) between 1 January 2019 and 31 December 2020. The neurological examination at one month of age was performed using the Hammersmith method. The relationship between the admission temperature and the risk of CP was investigated using logistic regression models, with temperature modeled as the non-linear term. Results: High/moderate risk of CP was found in 40/119 (33.6%) of the neonates at one month of age. A non-linear relationship between the admission temperature and moderate/high risk of CP at one month of age was found. The lowest probability of moderate/high risk of CP was estimated at admission temperatures of between 35 and 36 °C, with increasing probability when departing from such temperatures. Conclusions: In a low-resource setting, we found a U-shaped relationship between the admission temperature and the risk of CP at one month of life. Expanding the analysis of the follow-up data to 12–24 months of age would be desirable in order to confirm and strengthen such findings.

Maintaining Normothermia in Preterm Babies during Stabilisation with an Intact Umbilical Cord

Background: We had experienced an increase in admission hypothermia rates during implementation of deferred cord clamping (DCC) in our unit. Our objective was to reduce the number of babies with a gestation below 32 weeks who are hypothermic on admission, whilst practising DCC and providing delivery room cuddles (DRC). Method: A 12 month quality improvement project set, in a large Neonatal Intensive Care Unit, from January 2020 to December 2020. Monthly rates of admission hypothermia (<36.5 °C) for all eligible babies, were tracked prospectively. Each hypothermic baby was reviewed as part of a series of Plan, Do, Study Act (PDSA) cycles, to understand potential reasons and to develop solutions. Implementation of these solutions included the dissemination of the learning through a variety of methods. The main outcome measure was the proportion of babies who were hypothermic (<36.5 °C) on admission compared to the previous 12 months. Results: 130 babies with a gestation below 32 weeks were admitted during the study period. 90 babies (69.2%) had DCC and 79 babies (60%) received DRC. Compared to the preceding 12 months, the rate of hypothermia decreased from 25/109 (22.3%) to 13/130 (10%) (p = 0.017). Only 1 baby (0.8%) was admitted with a temperature below 36 °C and 12 babies (9.2%) were admitted with a temperature between 36 °C and 36.4 °C. Continued monitoring during the 3 months after the end of the project showed that the improvements were sustained with 0 cases of hypothermia in 33 consecutive admissions. Conclusions: It is possible to achieve low rates of admission hypothermia in preterm babies whilst providing DCC and DRC. Using a quality improvement approach with PDSA cycles is an effective method of changing clinical practice to improve outcomes.

Decreased moderate admission hypothermia in extremely preterm newborns

BACKGROUND

Admission temperature is inversely correlated with mortality and morbidity risk in extremely preterm newborns (EPNs). As almost all EPNs require advanced resuscitation at birth, we improved a simple and comprehensive management protocol to reduce admission hypothermia. This study reports the changes over the past 15 years in the rate of admission hypothermia in all EPNs. It clarified the distribution of admission temperature and the risk factors for developing admission hypothermia in recent EPNs.

METHODS

This single-center study retrospectively analyzed the EPNs delivered at our institution between January 2006 and December 2020. The comprehensive management protocol, including warming equipment, plastic wrapping, aluminum-polyethylene sheet, and room temperature, was applied to avoid heat loss during resuscitation. On admission, the rectal temperature was measured and defined as moderate (32.0-35.9 °C) or mild (36.0-36.4 °C) hypothermia.

RESULTS

Overall (n = 432), the rate of admission with moderate hypothermia decreased from 48% in 2006 to 8% in 2020. In the recent evaluation of 80 EPNs delivered in 2017-2020, 10 (13%) and 26 (33%) had moderate and mild hypothermia on admission, respectively. Extremely preterm newborns with moderate-to-mild hypothermia had a significantly smaller gestational age and lower birthweight than those without hypothermia. No significant differences in the other perinatal and environmental risk factors were observed between EPNs with and without hypothermia.

CONCLUSIONS

Our comprehensive management protocol reduced the rate of moderate hypothermia on admission in EPNs to only 13%. However, eliminating mild hypothermia remains a challenge and requires continuous improvement, especially in smaller EPNs.

Outcomes of neonatal hypothermia among very low birth weight infants: a Meta-analysis

BACKGROUND

Neonatal admission hypothermia (HT) is a frequently encountered problem in neonatal intensive care units (NICUs) and it has been linked to a higher risk of mortality and morbidity. However, there is a disparity in data in the existing literature regarding the prevalence and outcomes associated with HT in very low birth weight (VLBW) infants. This review aimed to provide further summary and analyses of the association between HT and adverse clinical outcomes in VLBW infants.

METHODS

In July 2020, we conducted this review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic database search was conducted in MEDLINE (PubMed), Google Scholar, ScienceDirect, World Health Organization Virtual Health Library, Cochrane Library databases, and System for Information on Grey Literature in Europe (SIGLE). We included studies that assessed the prevalence of HT and/or the association between HT and any adverse outcomes in VLBW infants. We calculated the pooled prevalence and Odds Ratio (OR) estimates with the corresponding 95% Confidence Interval (CI) using the Comprehensive meta-analysis software version 3.3 (Biostat, Engle-wood, NJ, USA; http://www.Meta-Analysis.com ).

RESULTS

Eighteen studies that fulfilled the eligibility criteria were meta-analyzed. The pooled prevalence of HT among VLBW infants was 48.3% (95% CI, 42.0-54.7%). HT in VLBW infants was significantly associated with mortality (OR = 1.89; 1.72-2.09), intra-ventricular hemorrhage (OR = 1.86; 1.09-3.14), bronchopulmonary dysplasia (OR = 1.28; 1.16-1.40), neonatal sepsis (OR = 1.47; 1.09-2.49), and retinopathy of prematurity (OR = 1.45; 1.28-1.72).

CONCLUSION

Neonatal HT rate is high in VLBW infants and it is a risk factor for mortality and morbidity in VLBW infants. This review provides a comprehensive view of the prevalence and outcomes of HT in VLBW infants.

Association between hypothermia in the first day of life and survival in the preterm infant

OBJECTIVE

Hypothermia is associated with elevated mortality in the preterm infant. The preterm infant's thermoregulatory capacity is limited, and the thermal environment in an incubator is often perturbed by nursing procedures. We evaluated the incidence of a postnatal low body temperature and hypothermia in preterm infants and its association with mortality.

METHODS

We measured the lowest body temperature during the first 24h of life (T_{Body Nadir 24h}) and hypothermia (T_{Body Nadir 24h}<36.0°C) in preterm infants (gestational age: 23⁰-31⁶ weeks) in a neonatal intensive care unit. Prenatal and neonatal characteristics associated with mortality were identified in univariate and multivariable analyses.

RESULTS

A total of 102 preterm infants were included, with a mean gestational age at birth of 28.4±2.3 weeks. The incidence of hypothermia during the first 24h was 53%. A Cox multivariate regression model indicated that T_{Body Nadir 24h} (hazard ratio (HR) [95% confidence interval]: 0.57 [0.36-0.90]; P=0.017), gestational age (0.62 [0.50-0.76]; P<0.001), and amine use (4.55 [2.01-10.28]; P=0.001) were significantly associated with mortality. When considering a threshold for T_{Body Nadir 24h}, a value of 35.0°C had the highest HR (3.30 [1.42-7.68]; P<0.01).

CONCLUSION

In preterm infants, the incidence of hypothermia during the first 24h of life was 53%. T_{Body Nadir 24h} had an influence on mortality, independently of other factors (notably birth weight and amine use). Within the framework of a quality improvement strategy, the implementation of a thermoregulation bundle is required to prevent hypothermia and decrease mortality in preterm infants.