A low cost, re-usable electricity-free infant warmer: evaluation of safety, effectiveness and feasibiliy

Introduction of a novel neonatal warming device in Malawi: an implementation science study

BACKGROUND

Neonatal hypothermia significantly contributes to infant morbidity and mortality in low-resource settings like Malawi. Kangaroo mother care (KMC) is essential but faces challenges in providing continuous thermal support. The Dream Warmer is a neonatal warming device that was developed to complement KMC. We studied its implementation outside a research environment.

METHODS

Using an implementation science approach, we conducted a prospective interventional cohort study in two hospitals and four health centres in Malawi. Through audits and surveys, we assessed the effect of the Dream Warmer on neonatal hypothermia as well as healthcare provider (HCP) and parent attitudes regarding thermoregulation and related issues.

RESULTS

The Dream Warmer raised no safety concerns and effectively treated hypothermia in 90% of uses. It was positively received by HCPs and parents, who reported it had a favourable effect on the care of small and sick newborns. Challenges identified included a scarcity of water and electricity, lack of availability of the device and HCPs forgetting to prepare it in advance of need or to use it when indicated. Feedback for future training was obtained. The Dream Warmer's strong safety and effectiveness performance is consistent with results from strict research studies. Training materials can be adapted to optimize integration into daily practice and provide educational content for parents.

CONCLUSIONS

The Dream Warmer is a safe and effective device to treat neonatal hypothermia, particularly when KMC is insufficient. We gained an understanding of how to optimize implementation through robust HCP and family education to help combat hypothermia.

An Implementation Science Study of a Heat-Producing Wrap to Complement KMC in Rwanda

Background: Neonatal hypothermia is a major cause of preventable morbidity and mortality, especially among the world's poorest newborns. A heat-producing wrap is necessary when kangaroo mother care (KMC) is insufficient or unavailable, yet there is little published research on such wraps. The Dream Warmer is a wrap designed to complement KMC and has been extensively studied in formal research settings but not in real-world conditions. Objectives: We used implementation science methodology to understand the safety, effectiveness, and functionality of the Dream Warmer (hereafter, "Warmer"); its effect on clinical workflows; its interaction with other aspects of care such as KMC; and the Warmer's reception by healthcare providers (HCPs) and parents. Methods: We conducted a prospective, interventional, one-arm, open-label, mixed-methods study in 6 district hospitals and 84 associated health centers in rural Rwanda. Our intervention was the provision of the Warmer and an educational curriculum on thermoregulation. We compared pre and post intervention data using medical records, audits, and surveys. Findings: The Warmer raised no safety concerns. It was used correctly in the vast majority of cases. The mean admission temperature rose from slightly hypothermic (36.41 °C) pre, to euthermic (36.53 °C) post intervention (p = 0.002). Patients achieved a temperature ≥36.5 °C in 86% of uses. In 1% of audits, patients were hyperthermic (37.6-37.9 °C). Both HCPs and parents reported a generally positive experience with the Warmer. HCPs were challenged to prepare it in advance of need. Conclusions: The Warmer functions similarly well in research and real-world conditions. Ongoing education directed toward both HCPs and parents is critical to ensuring the provision of a continuous heat chain. Engaging families in thermoregulation could ease the burden of overtaxed HCPs and improve the skill set of parents. Hypothermia is a preventable condition that must be addressed to optimize neonatal survival and outcome.

Preclinical validation of NeoWarm, a low-cost infant warmer and carrier device, to ameliorate induced hypothermia in newborn piglets as models for human neonates

Introduction

Approximately 1.5 million neonatal deaths occur among premature and small (low birthweight or small-for gestational age) neonates annually, with a disproportionate amount of this mortality occurring in low- and middle-income countries (LMICs). Hypothermia, the inability of newborns to regulate their body temperature, is common among prematurely born and small babies, and often underlies high rates of mortality in this population. In high-resource settings, incubators and radiant warmers are the gold standard for hypothermia, but this equipment is often scarce in LMICs. Kangaroo Mother Care/Skin-to-skin care (KMC/STS) is an evidence-based intervention that has been targeted for scale-up among premature and small neonates. However, KMC/STS requires hours of daily contact between a neonate and an able adult caregiver, leaving little time for the caregiver to care for themselves. To address this, we created a novel self-warming biomedical device, NeoWarm, to augment KMC/STS. The present study aimed to validate the safety and efficacy of NeoWarm.

Methods

Sixteen, 0-to-5-day-old piglets were used as an animal model due to similarities in their thermoregulatory capabilities, circulatory systems, and approximate skin composition to human neonates. The piglets were placed in an engineered cooling box to drop their core temperature below 36.5°C, the World Health Organizations definition of hypothermia for human neonates. The piglets were then warmed in NeoWarm (n = 6) or placed in the ambient 17.8°C ± 0.6°C lab environment (n = 5) as a control to assess the efficacy of NeoWarm in regulating their core body temperature.

Results

All 6 piglets placed in NeoWarm recovered from hypothermia, while none of the 5 piglets in the ambient environment recovered. The piglets warmed in NeoWarm reached a significantly higher core body temperature (39.2°C ± 0.4°C, n = 6) than the piglets that were warmed in the ambient environment (37.9°C ± 0.4°C, n = 5) (p < 0.001). No piglet in the NeoWarm group suffered signs of burns or skin abrasions.

Discussion

Our results in this pilot study indicate that NeoWarm can safely and effectively warm hypothermic piglets to a normal core body temperature and, with additional validation, shows promise for potential use among human premature and small neonates.

The Journey Toward Establishing Inpatient Care for Small and Sick Newborns in Ethiopia, India, Malawi, and Rwanda

BACKGROUND

Limited information is available about the approaches used and lessons learned from low- and middle-income countries that have implemented inpatient services for small and sick newborns. We developed descriptive case studies to compare the journeys to establish inpatient newborn care across Ethiopia, India, Malawi, and Rwanda.

METHODS

A total of 57 interviews with stakeholders in Ethiopia (n=12), India (n=12), Malawi (n=16), and Rwanda (n=17) informed the case studies. Our heuristic data analysis followed a deductive organizing framework approach. We informed our data analysis via targeted literature searches to uncover details related to key events. We used the NEST360 Theory of Change for facility-based care, which reflects the World Health Organization (WHO) Health Systems Framework as a starting point and added, as necessary, in an edit processing format until data saturation was achieved.

FINDINGS

Results highlight the strategies and innovation used to establish small and sick newborn care by health system building block and by country. We conducted a gap analysis of implementation of WHO Standards for Improving Facility-Based Care. The journeys to establish inpatient newborn care across the 4 countries are similar in terms of trajectory yet unique in their implementation. Unifying themes include leadership and governance at national level to consolidate and coordinate action to improve newborn quality of care, investment to build staff skills on data collection and use, and institutionalization of regular neonatal data reviews to identify gaps and propose relevant strategies.

CONCLUSION

Efforts to establish and scale inpatient care for small and sick newborns in Ethiopia, India, Malawi, and Rwanda over the last decade have led to remarkable success. These country examples can inspire more nascent initiatives that other low- and middle-income countries may undertake. Documentation should give voice to lived country experience, not all of which is fully captured in existing, peer-reviewed published literature.

Safety and effectiveness of a non-electric infant warmer for hypothermia in Rwanda: A cluster-randomized stepped-wedge trial

BACKGROUND

Neonatal hypothermia is a common source of morbidity and mortality in low resource settings. We developed the Dream Warmer, a low cost, re-usable non-electric infant warmer to prevent and treat hypothermia.

METHODS

We conducted a cluster-randomized stepped-wedge trial. The primary aim was to assess the effect on overall euthermia rates of introducing the warmer compared to standard of care in rural Rwandan hospitals. The secondary aims were to assess effects of warmer introduction on mortality, as well as the safety and feasibility of the warmer. Ten district hospitals participated in the study from November 19th 2019 to July 15th 2020. Patients were eligible to use the warmer if they were 1) hypothermic (temp < 36·5 °C) or 2) or at risk of hypothermia (weight < 2·5 kg or estimated post menstrual age < 35 weeks) when Kangaroo Mother Care was not available. An encounter was defined as the data from an individual infant on a single day. Trial of a Non Electric Infant Warmer for Prevention and Treatment of Hypothermia in Rwanda [NCT03890211].

FINDINGS

Over the study period, 3179 patients were enrolled across the ten neonatal wards, yielding 12,748 encounters; 464 unique infants used the warmer 892 times, 79% eligible due to hypothermia. Because of limited study nurse resources, the warmer was used in only 18% of eligible encounters. Despite this low rate of warmer use, the rate of euthermia rose from 51% (95% CI 50-52%) of encounters pre-intervention to 67% (66-68%) post-intervention; p < 0·0001. Among the encounters in which the warmer was used, only 11% (9-13%) remained hypothermic. While mortality rates pre- and post-intervention did not change, mortality rate among those who used the warmer was significantly lower than among those who did not (0·9% vs 2·8%, p = 0·01). Use of the warmer did not affect hyperthermia rates. There were no safety concerns or instances of incorrect warmer use.

INTERPRETATION

Introduction of the warmer increased rates of euthermia with no associated safety concerns.

Performance of a Nonelectric Infant Warmer in Rwandan Health Centers

Background. Neonatal hypothermia remains a challenge in resource-limited settings. Methods. We conducted a prospective mixed-methods cohort study in rural Rwandan health centers to assess the performance of an infant warmer we designed for low-resource settings. All hypothermic infants were eligible for enrollment. Outcomes. Safety: incidence of adverse reactions. Effectiveness: attainment of euthermia, rate of temperature rise. Feasibility: correct use of warmer, signs of wear. Interviews of caregivers and nurses. Findings. Of 102 encounters, there were no adverse reactions. Of 80 encounters for hypothermia when infants on warmer for ≥1 hour, 79 achieved euthermia; 73 in ≤2 hours. Of the 80 encounters, 64 had temperature rise ≥0.5°C/h. Of the 102 encounters, there were no instances of the warmer being prepared, used, or cleaned incorrectly. Five out of the 12 warmers exhibited wear. Interview participants were predominantly positive; some found time for readiness of warmer challenging. Interpretation. The warmer performed well. It is appropriate to study in larger scale.