Temperature Control in the Neonate

Introduction

Hypothermia associated w/ increased morbidity/mortality in newborns of all birth weights/ages

Now considered independent risk factor for mortality in preterm

Western philosophy of conventional care premature baby should be

Placed under radiant warmer Uncovered for full visualization and to allow radiant heat to reach body

More attn now focused on thermal care immediately after birth and during resuscitation

Premature Susceptibility to Heat Loss

High surface area to volume ratio Thin non-keratinized skin Lack of insulating subQ fat Lack of thermogenic brown adipose tissue (BAT) Inability to shiver Poor vasomotor response

Thermoregulation

Metabolic rate of fetus per tissue wt. higher than adult

Heat also transferred from mother to fetus via placenta/uterus

Fetal temp consistently 0.3-0.5 deg C higher than mothers (always in parallel)

Even when mothers temp elevates (eg fever) Exposed to adenosine and prostaglandin E2 inhibitors of non-shivering thermogenesis (NST) Metabolic adaptation for physiologically hypoxic fetus since NST requires oxygenation Inhibition of NST allows accumulation of BAT

Despite BAT in utero, fetus cannot produce extra heat

Thermoregulation

Heat gain/loss controlled by hypothalamus and limbic system

Thermoregulatory system immature in newborns (esp premature newborn)

In term infant, response to cold stress relies on oxidation of brown fat (NST)

Development begins 20th wk until shortly after birth (comprises 1% body wt at that time) High concentration stored TGs Rich capillary network densely innervated by sympathetic nerve endings Temperature sensors on posterior hypothalamus stimulate pituitary to produce thyroxine (T4) and adrenals to produce norepinephrine Lipolysis stimulated energy produced in form of heat in mitochondria instead of phosphate bonds by uncoupling protein-1 (aka thermogenin)

Risk Factors

All neonates in 1st 8-12hrs of life Prematurity SGA CNS problems Prolonged resuscitation efforts Sepsis

Adverse Consequences of Hypothermia

High O2 consumption hypoxia, bradycardia High glucose usage hypoglycemia / decreased glycogen stores High energy expenditure reduced growth rate, lethargy, hypotonia, poor suck/cry Low surfactant production RDS Vasoconstriction poor perfusion metabolic acidosis Delayed transition from fetal to newborn circulation Thermal shock DIC death

Modes of Heat Loss

Conduction - direct heat transfer from skin to object (eg mattress) Convection - heat loss through air flow

Also depends on air temp

Radiation - direct transfer by electromagnetic radiation in infrared spectrum

Heat gained by radiation from external radiant energy source Heat lost by radiation to cooler walls of incubator

Evaporation - heat loss when water evaporates from skin and respiratory tract

Depends on maximum relative humidity of surroundings less humidity = more evaporation

Heat Loss at Birth

Hammarlund et al, 1980 Evaporative H20 loss

81-125 gm/m2/h when unwiped in ambient temp ~25.8deg C and 42% humidity

Heat loss through

Evaporation: 60-80 W/m2 Radiation: 50 W/m2 Convection: 25 W/m2 Conduction: negligible Total heat loss = 135-155 W/m2

All babies that were >3250g - body temp decreased 0.9deg C in 15min

Heat Loss at Birth

Hammarlund et al, 1979

Naked infants <28wks need ambient temp ~40deg C to maintain nl temp in 20% humidity

Increasing humidity to 60% halved losses

Attempt to Overcome Losses

Radiant heaters insufficient to warm preterm baby

Esp during resuscitation 750g baby w/ surface area of ~ 0.06m2 requires at least 9.3W to compensate for losses at birth At mattress lvl, max of 9W absorbed by baby if radiant heat absorbed by, at least, 50% of mattress

Thermoneutral Environment

Temp and environmental conditions at which metabolic rate and O2 consumption are lowest Silverman et al

Maintaining constant abdominal skin temp b/w 36.2-36.5 deg C optimal

WHO classification of hypothermia

Mild: 36-36.4deg C Mod: 32-35.9deg C Severe: <32deg C

Kangaroo Mother Care (KMC)

Introduced in 1983 by Rey and Martinez in Colombia

LBW infants nursed naked (wearing only cloth diaper) between mothers breasts Data from other countries show infants nursed by KMC have

Fewer apneic episodes Similar or better blood oxygenation Lower infxn rtes Are alert longer and cry less Are breastfed longer and have better bonding Improved survival in low-resource settings

KMC

Bergman et al, 2004

Randomized controlled trial comparing KMC to pre-warmed servo-controlled closed incubator after birth 20 infants b/w 1200-2199g using KMC vs 14 controls

Excluded if C-sec, mother too ill to look after self/infant, known HIV, BW outside 1200-2199g, 5min Apgar <6, congenital malformations

1/20 subjects vs 8/14 controls had initial temps < 35.5deg C (P = 0.006) 1/20 subjects vs 3/14 controls had bl glucoses < 2.6 mmol/L (though 40mg/dL = 2.2mmol/L) Stability of cardio-respiratory system in preterm infants (SCRIP) score was 2.88 points higher w/in 1st 6hrs in KMC group (95% CI 0.3-5.46)

SCRIP Score
SCRIP HR RR 2 Regular Regular 1 Decel to 80-100 Apnea <10s or periodic breathing 80-89% 0 Rte <80 or >200 bpm Apnea >10s or tachypnea >80 <80%

O2 sat

>89%

Barriers to Heat Loss

Cochrane database review 4 studies compared barriers to heat loss vs. no barriers

2 comparison subgroups

Plastic wrap/bag vs routine care Stockinet cap vs routine care

Plastic wrap/bag vs routine care

3 studies involving 200 infants all <36wks All placed under radiant warmer, wrapped to shoulders while still wet, heads dried and resuscitated according to guidelines GA <28wks: wrap group had temps 0.76deg C higher than controls (95% CI 0.49-1.03) GA 28-31wks: no statistical difference

Barriers to Heat Loss

Plastic wrap/bag vs routine care (cont)

1hr after admission for GA <28wks, no statistical difference (though direction was in favor of intervention) Plastic wrap significantly reduced risk of hypothermia (core temp <36.5deg C) on admission to NICU

RR 0.63 (95% CI 0.42-0.93) NNT found to be 4 (95% CI 3-17) - so 4 infants would need to be wrapped in plastic to prevent 1 from becoming hypothermic

No significant differences found in duration of O2 therapy, major brain injury, duration of hospitalization, or death

Barriers to Heat Loss

Stockinet cap vs routine care

1 study involving 40 AGA infants w/ GAs 32-36wks Exclusion critera: 5min Apgar <7, SSx CNS defect, sepsis, or maternal temp >37.8deg C during labor Cap group had caps placed ASAP after drying under radiant warmer and infants <2500g were transported in incubator BW <2000g: Cap group had core temps 0.7deg C higher than control (95% CI -0.01-1.41) - borderline statistical difference BW >/= 2000g: no sig dif No sig dif in preventing hypothermia

External Heat Sources

Cochrane database review 2 studies compared external heat sources to routine care

2 comparison subgroups
Skin-to-skin vs routine care (already mentioned) Transwarmer mattress vs routine care

External Heat Sources

Brennan et al, 1996 24 infants w/ BW </= 1500g Transport Mattress (TM) - made of sodium acetate activated to ~40deg C when delivery imminent

Infant placed upon blankets covering mattress, dried, then placed on TM directly

Control group = same intervention but w/o TM Both groups resuscitated according to guidelines then transferred to NICU on radiant warmer surface

External Heat Sources

Brennan et al, cont Increase of 1.6deg C in TM group (95% CI 0.832.37) Evidence suggests that TM significantly reduces risk of hypothermia w/ RR 0.3 (95% CI 0.110.83)

NNT = 2 (95% CI 1-4)

No adverse occurrences reported in this study, though other studies have had infants sustain 3rd deg burns

In Conclusion

Plastic barriers effective in reducing heat loss in newborns <28wks No evidence yet to suggest plastic barriers decrease duration of O2 therapy, hospitalization, or incidence of major brain injury/death Stockinet caps effective in reducing hypothermia in newborns <2000g, but not >/= 2000g KMC shown to be effective in stable newborns down to 1200g in reducing risk of hypothermia TM decreases incidence of hypothermia </= 1500g In the end, the smaller the baby, the more likely any intervention will be of benefit

Areas of Further Study

Need more studies w/ larger population bases Short- and long-term outcomes need to be studied further (especially w/ neurdevelopmental F/U) Secondary outcomes that need further study:
RDS ARF Intubation/ventilation Growth Length of stay Adverse events

Hypoglycemia Metabolic acidosis

Neonatal Energy Triangle

References

Laroia, N. Double wall versus single wall incubator for reducing heat loss in very low birth weight infants in incubators. Cochrane Database of Systematic Reviews. Vol (3) 2007. Fienady, V. Radiant warmers versus incubators for regulating body temperature in newborn infants Cochrane Database of Systematic Reviews. Vol (3) 2007. Asakura, H. Fetal and Neonatal Thermoregulation. Journal of Nippon Medical School. Vol. 71 (2004) , No. 6. Ibe, O.E. A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants <200 g in Nigeria using continuous ambulatory temperature monitoring. Annals of Tropical Paediatrics (2004) 24, 245-251. Bergman, N.J. Randomized controlled trial of skin-to-skin contract from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatrica (2004) 93: 779-785. McCall, E.M. Interventions to prevent hypothermia at birth in preterm and/or low birthweight babies. Cochrane Database of Systematic Reviews. Vol (3), 2007. Watkinson, M.A. Temperature Control of Premature Infants in the Delivery Room. Clin Perinaol 33 (2006) 43-53. Knobel, R.B. Heat Loss Prevention for Preterm Infants in the Delivery Room. J Perinaol 25 (2005) 304-308. The neonatal energy triangle Part 2: Thermoregulatory and respiratory adaptation. Paediatric Nursing. Sept. Vol 18 no 7.