Preventing admission hypothermia in very low birth weight neonates

Assessment of Skin Maturity by LED Light at Birth and Its Association With Lung Maturity: Clinical Trial Secondary Outcomes

BACKGROUND

Clinicians face barriers when assessing lung maturity at birth due to global inequalities. Still, strategies for testing based solely on gestational age to predict the likelihood of respiratory distress syndrome (RDS) do not offer a comprehensive approach to addressing the challenge of uncertain outcomes. We hypothesize that a noninvasive assessment of skin maturity may indicate lung maturity.

OBJECTIVE

This study aimed to assess the association between a newborn's skin maturity and RDS occurrence.

METHODS

We conducted a case-control nested in a prospective cohort study, a secondary endpoint of a multicenter clinical trial. The study was carried out in 5 Brazilian urban reference centers for highly complex perinatal care. Of 781 newborns from the cohort study, 640 were selected for the case-control analysis. Newborns with RDS formed the case group and newborns without RDS were the controls. All newborns with other diseases exhibiting respiratory manifestations were excluded. Skin maturity was assessed from the newborn's skin over the sole by an optical device that acquired a reflection signal through an LED sensor. The device, previously validated, measured and recorded skin reflectance. Clinical data related to respiratory outcomes were gathered from medical records during the 72-hour follow-up of the newborn, or until discharge or death, whichever occurred first. The main outcome measure was the association between skin reflectance and RDS using univariate and multivariate binary logistic regression. Additionally, we assessed the connection between skin reflectance and factors such as neonatal intensive care unit (NICU) admission and the need for ventilatory support.

RESULTS

Out of 604 newborns, 470 (73.4%) were from the RDS group and 170 (26.6%) were from the control group. According to comparisons between the groups, newborns with RDS had a younger gestational age (31.6 vs 39.1 weeks, P<.001) and birth weight (1491 vs 3121 grams, P<.001) than controls. Skin reflectance was associated with RDS (odds ratio [OR] 0.982, 95% CI 0.979-0.985, R2=0.632, P<.001). This relationship remained significant when adjusted by the cofactors antenatal corticosteroid and birth weight (OR 0.994, 95% CI 0.990-0.998, R2=0.843, P<.001). Secondary outcomes also showed differences in skin reflectance. The mean difference was 0.219 (95% CI 0.200-0.238) between newborns that required ventilatory support versus those that did not and 0.223 (95% CI 0.205-0.241) between newborns that required NICU admission versus those that did not. Skin reflectance was associated with ventilatory support (OR 0.996, 95% CI 0.992-0.999, R2=0.814, P=.01) and with NICU admission (OR 0.994, 95% CI 0.990-0.998, R2=0.867, P=.004).

CONCLUSIONS

Our findings present a potential marker of lung immaturity at birth using the indirect method of skin assessment. Using the RDS clinical condition and a medical device, this study demonstrated the synchrony between lung and skin maturity.

TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR-3f5bm5; https://tinyurl.com/9fb7zrdb.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2018-027442.

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.

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.

Neonatal Intensive Care Unit Admission Temperatures of Infants 1500 g or More: The Cold Truth

BACKGROUND

Smaller preterm infants often receive extra attention with implementation of additional thermoregulation interventions in the delivery room. Yet, these bundles of interventions have largely remained understudied in larger infants.

PURPOSE

The purpose of this study was to evaluate initial (or admission) temperatures of infants born weighing 1500 g or more with diagnoses requiring admission to the neonatal intensive care unit (NICU).

METHODS

Retrospective medical record review of 388 infants weighing 1500 g or more admitted to the NICU between January 2016 and June 2017.

RESULT

In total, 42.5% of infants weighing 1500 g or more were admitted hypothermic (<36.5°C), 54.4% with a normothermic temperature, and 2.8% were hyperthermic. Of those infants admitted hypothermic, 30.4% had an admission temperature ranging from 36°C to 36.4°C and 12.1% had an admission temperature of less than 36°C. When compared with infants weighing less than 1500 g, who were born at the same institution and received extra thermal support interventions, there was a statistically significant difference (P < .001) between admission temperatures where infants less than 1500 g were slightly warmer (36.8°C vs 36.5°C).

IMPLICATIONS FOR PRACTICE

Ongoing admission temperature monitoring of all infants requiring NICU admission regardless of birth weight or admission diagnosis is important if we are going to provide the best support to decrease mortality and morbidity for this high-risk population.

IMPLICATIONS FOR RESEARCH

While this study examined short-term outcomes, effects on long-term outcomes were not addressed. Findings could be used to design targeted interventions to support thermal regulation for all high-risk infants.

CONCLUSION

Neonates admitted to the NICU weighing 1500 g or more are at high risk for developing hypothermia, similar to smaller preterm infants.

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

PURPOSE

The purpose of this review was to ascertain the impact of thermoregulation quality improvement initiatives (QIs) on the admission temperatures of premature/very-low-birth-weight infants in neonatal intensive care units (NICUs).

METHODS

A systematic search of databases Cumulative Index to Nursing and Allied Health Literature, Medline, Embase, and the Cochrane library was carried out. Specific inclusion and exclusion criteria were adhered to, with no publication date limitations added. The chosen studies were examined for quality, data were extracted and analysed, before a narrative synthesis was performed. The last search occurred on January 7, 2019, with PRISMA flow diagrams completed for identified studies.

RESULTS

Ten studies of varying methodology design were included in this review. Variations of thermoregulation interventions were included in the 10 studies. Nevertheless, all of them demonstrated that admission temperature rates can be significantly improved by implementing a thermoregulation QI. The multidisciplinary team and ongoing education were seen as much needed components to the overall sustainability, and continuing success of the QI's.

PRACTICAL IMPLICATIONS

This systematic review determines that thermoregulation QIs can positively impact the admission temperatures of premature/very-low-birth-weight infants in the NICU. Prevention of hypothermia is aimed at reducing the risks of developing major neonatal morbidities. The pooling of the results from the 10 studies helps in the sharing of outcome measures and thus, improving quantitative synthesis. More frequent monitoring of the axillary temperature would help in preventing hypothermia and hyperthermia occurring. Ongoing education and staff training are essential for managing thermoregulation successfully. Examining the compliance rates to such quality initiatives, and the variations in interventions would benefit from further research to ensure better standardisation of clinical practice.

Differences in Temperature Changes in Premature Infants During Invasive Procedures in Incubators and Radiant Warmers

Premature infants tend to lose heat quickly. This loss can be aggravated when they have received an invasive procedure involving a venous puncture. This research uses crossover design by conducting 2 intervention tests to compare 2 different treatments on the same sample. This research involved 2 groups with 18 premature infants in each. The process of data analysis used a statistical independent t test. Interventions conducted in an open incubator showed a p value of .001 which statistically related to heat loss in premature infants. In contrast, the radiant warmer p value of .001 statistically referred to a different range of heat gain before and after the venous puncture was given. The radiant warmer saved the premature infant from hypothermia during the invasive procedure. However, it is inadvisable for routine care of newborn infants since it can increase insensible water loss.

Comparison of the Effect of Plastic Cover and Blanket on Body Temperature of Preterm Infants Hospitalized in NICU: Randomized Clinical Trial

Introduction: Preterm infants are unable to regulate their body temperature and there are insufficient research evidences on different kinds of covers for hospitalized preterm infants; therefore, the present study was conducted with the aim of comparing the effects of plastic and blanket covers on the body temperature of preterm infants under radiant warmer.

Methods: This randomized cross-over clinical trial was carried out upon 80 infants with the gestational age of 28-30 weeks and birth weight of 800- 1250 gr who were in Neonatal Intensive Care Unit on the second day of their hospitalization. The study lasted for two days. In group 1, the plastic cover was used during the first day of the study while the blankets were used during the second day. Infants’ heads were kept out of the cover and coated with a hat. In group 2, the plastic cover was used during the first day of the study while the blanket was used during second day. Digital thermometer was used to measure infants’ axillary temperature. The data was analyzed using SPSS ver 13 and MiniTab software. Descriptive statistics, (Mean (SE), 95%CI) and inferential statistics (Repeated measurement and ANCOVA tests) were used.

Results: The mean body temperature of the infants in the group covered with the plastic was calculated to be higher and the warmer was set on low temperature.

Conclusion: Using plastic cover during the first few days of hospitalization in NICU resulted in regulation of preterm infants’ body temperature.

Skin-to-Skin Care After Birth for Moderately Preterm Infants

OBJECTIVE

To investigate the feasibility and safety of skin-to-skin care after birth for moderately preterm infants.

DESIGN

Prospective cohort study.

SETTING

The study was conducted at the maternity wards and NICUs of three study sites in Norway.

PARTICIPANTS

Ninety preterm infants born vaginally with gestational ages of 32 weeks/0 days to 34 weeks/6 days.

METHODS

Comparison of groups of preterm infants who received skin-to-skin care or conventional treatment in incubators after birth.

RESULTS

Median gestational age and birth weight were similar in the two groups: 33 weeks/5 days versus 34 weeks/3 days (p = .464) and 2,100 versus 2,010 g (p = .519). There were no differences in the first body temperature (p = .841) and blood glucose level (p = .539) between the groups.

CONCLUSION

Early skin-to-skin contact in the delivery room for moderately preterm infants may be feasible and safe.

Quality Appraisal: Part I

Quality appraisal is an essential step in the evidence-based practice process. This column focuses on designating the level of evidence of the scientific research.

The role of birth weight on litter size and mortality within 24h of life in purebred dogs: What aspects are involved?

In humans, scientific evidence emphasizes the role of birth weight on neonatal welfare, morbidity and mortality. In canine species, defining normal ranges of birth weight is a harder issue due to a great morphological variability in size, body weight and breed. The aim of this study was to correlate birth weight with litter size and mortality within 24h of life in 789 pups from 140 litters of purebred dogs and to investigate the aspects that might affect these factors. Birth weight was influenced by maternal size, weight and age (P<0.001). The lightest pups were from toy sized or weighing up to 10 kg bitches. Conversely, bitches aged 2-8 years whelped heavier pups than younger and older mothers. Birth weight was also related both to litter size, with heavier pups in smaller rather than in larger litters from medium sized bitches, and breed (P<0.05). Unexpectedly, birth weight did not differ between live born and stillborn pups. However, birth weight was lower in pups dying within 24h of life (P<0.05). High mortality of pups was related both to short pregnancies (P<0.05), also showing lighter litters (P<0.001), and to dystocic parturitions (P<0.001). Litter size was associated with parity, type and number of mating, and length of pregnancy (P<0.001). Low birth weight appears to predispose to early neonatal mortality suggesting a predominant role of the breed rather than size and weight in determining birth weight in pups.

To Bathe or Not to Bathe: The Neonatal Question

After delivery, newborns go through a series of physiologic changes in an effort to adapt to extrauterine life, with preterm newborns more likely to experience medical problems following this transition. Neonatal hypothermia, defined as a temperature <36.5 °C, is a major contributor to neonatal mortality and morbidity. Early bathing may be a contributing factor to hypothermia and interfere with the premature neonate's ability to safely adapt to an extrauterine environment. Skin physiology, the physiologic changes that result from bathing, the importance of maintaining vernix for temperature stability, and how policy change and education-based programs for developmentally supportive care will be discussed in an attempt to improve patient care outcomes for neonates in the NICU.