THERMOREGULATION IN THE NEONATE

Odalis L. Zamora, Nov.28, 2011

Why Worry About Thermoregulation?

Body temperature is one of the primary vital signs. In terms of ABCs think:
A - Airway B - Breathing C - Circulation D - Degrees

Goal of Thermoregulation
Maintain correct body temperature range in order to: maximize metabolic efficiency reduce oxygen use protect enzyme function

reduce calorie expenditure

Challenges of thermoregulation in Neonatal care

Prior to delivery infants do not maintain temperature independently Infants in-utero temp is generally 0.5C higher than mothers temp Rapid cooling occurs after delivery

Neurologic adaptation: Thermoregulation

Maintenance of body temp is a major task Skin is thin & blood vessels are close to the surface Have little subcutaneous fat to serve as barrier to heat loss Term Infants have 3x the surface to body mass of an adult Preterm infants and SGA infants have 4x the surface mass to body mass of an adult Preterm infants are especially susceptible to heat loss due to poor tone, fat and thinner skin than term infants
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Definitions
To understand the role of thermoregulation in the care of infants, we need to understand a few simple definitions.

Neutral Thermal Temperature

A neutral thermal temperature is the body temperature at which an individual's oxygen use and energy expenditure are minimized. Minimal metabolic rate Minimal oxygen consumption
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Body temperature in the newborn infant

Classification of hypothermia is based on core temperature
NORMAL 36.5 to 37.3C (97.7 99.2F) Cold Stress 36.0 to 36.4C (96.8 97.6 F)
Cause for concern

Moderate hypothermia 32 35.9C (89.6-96.6F)

Danger, warm infant

Severe hypothermia below 32C (89.6 F)

Outlook grave, skilled care urgently needed

Neutral Thermal Environment (NTE)

The air temperature surrounding the baby supports maintenance of a neutral thermal body temperature.

Thermoneutrality
When the air temperature is in the correct range and the infants body maintains a neutral thermal temperature, we have achieved thermoneutrality

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Why Are Infants At Greater Risk for Thermoregulation Problems?

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Thermoregulation Risk Factors

Premature SGA Neuro problems Endocrine Cardiac / respiratory problems Large open areas in the skin Sedated Infants Drug exposure
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Why are they at Risk???

Brown Adipose Tissue Body surface area SQ Fat Glycogen stores Body water content Posture Hypoxia Hypoglycemia Anomalies CNS Sedation

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What Do We Know?
Infants have more skin surface per pound of body weight than older children or adults More skin means more radiant heat and more insensible water loss.

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Risk factors for Preterm Infants

less brown fat and glycogen stores
decreased ability to maintain flexion increased body surface area compared to weight
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What Do We Know?
The majority of an infants thermal receptors are found

in the face, neck, and shoulder

area. Stimulation of these

receptors will result in chilling

and calorie expenditure
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What Do We Know?
Shivering, which is the main way in which older children and adults generate heat, is impossible or not effective in infants. Neonates and young infants generate heat by burning brown fat.
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What do we know?
Physiologic response to hypothermia Temperature regulation controlled by hypothalamus
Activates norepinephrine release triggering
Pulmonary and peripheral vasoconstriction Increased pulmonary vascular resistance

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Production of Heat
Metabolic Processes Voluntary Muscle Activity Peripheral Vasoconstriction Nonshivering Thermogenesis

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Metabolic Process
Heat Generation by
Oxidative metabolism
Glucose Fats Protein

Metabolic Energy
Brain Heart Adrenal Gland

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Voluntary Muscle Activity

Postural changes Restless movements Limited use to Newborn

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Peripheral Vasoconstriction
Reduces skin blood flow Decreases loss of heat from the body

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Nonshivering Thermogenesis
Metabolism of brown adipose tissue Initiated in hypothalamus Sympathetic nervous system Norepinephrine release at the site of brown fat

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What is Brown Fat?

Brown fat is an energy source for infants It can be found:
Near Kidneys and adrenals Neck, mediastinum, scapular,

and the axilla areas. Can not be replaced once used

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Brown Fat
In full term infants brown fat is 4 % -10% of adipose deposits. In preterm infants, brown fat will not be found until 26-30 weeks gestation, and then only in small amounts. Brown fat generally disappears 3-6 months after birth, except in cold stressed infants (where it will disappear sooner.) Hypoxia causes impairment of brown fat metabolism
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So What?
When the air temperature around the baby is cool, thermoreceptors in the skin are stimulated. Nonshivering thermogenesis is initiated and brown fat is burned for energy to keep the body temperature stable. This is the infants initial response.
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What Next?
Conversion of brown fat uses oxygen and glucose, therefore, the cold stressed infant will become hypoxic and hypoglycemic. Blood gas and glucose levels are affected. Growth is affected as calories are used to stay warm rather than grow.
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What are the Signs and Symptoms of Thermal Instability?

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Methods of heat loss

Peripheral Vasodilatation
blood flow facilitates heat transfer from periphery to environment

Sweating
evaporative heat loss postnatal age increases the ability to sweat Appears first on term newborn head

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Healthy Vs. Sick Neonate

Healthy Newborn
Brown adipose tissue Produces heat and loses heat as needed

Sick or Low birth wt infants

Increased energy demand Decreased energy store Vulnerable to heat stress

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Hypothermia Signs/symptoms
Body cool to touch Mottling or pallor Central cyanosis Acrocyanosis Poor Feeding Abdominal distension Hypotonia Hypoglycemia gastric residuals Bradycardia Tachypnea Restlessness Shallow or Irregular Respirations Apnea Lethargy

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Signs and Symptoms of Hypothermia in Infants

Vasoconstriction
Peripheral vasoconstriction occurs in an effort to limit heat loss via blood vessels close to the skin surface. Pallor and cool skin may be noted, due to poor peripheral perfusion

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Signs and Symptoms of Hypothermia in Infants

Increased Respiratory Rate
Pulmonary vasoconstriction occurs secondary to metabolic acidosis. Increasing Respiratory Distress Related to decreased surfactant production, hypoxia, & acidosis
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Signs and Symptoms of Hypothermia in Infants

Restlessness
Restlessness may be a type of behavioral thermoregulation used to generate heat through muscle movement. The first sign may be an alteration in sleep patterns. Restlessness also indicates a change in mental status as cerebral blood flow diminishes, due to vasoconstriction.
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Signs and Symptoms of Hypothermia in Infants

Lethargy
If thermo-instability goes unrecognized, the infant will become more lethargic, as cerebral blood flow continues to diminish and hypoxemia and hypoglycemia become more pronounced.
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Signs and Symptoms of Hypothermia cont.

Metabolic Disturbances
Metabolic acidosis

Hypoxemia
Hypoglycemia
progress due to continued metabolism of brown fat, release of fatty acids and anaerobic metabolism (lactic acid)
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Signs and Symptoms of Hypothermia

Cardiac
As central blood volume increases, initially the heart rate and blood pressure increase

Arrhythmias
May result from depressed myocardial contractility and irritability caused by hypothermia
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Signs and Symptoms of Hypothermia

Poor Feeding/Weight Loss
Poor weight gain occurs

when:
calories consumed brown fat stores are used to make body heat.

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Even the smallest weight loss may take days or even weeks to recover, as infants are limited in the volume of food they can eat and number of calories they can tolerate.
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Consequences of Hypothermia
Hypoxemia from Oxygen consumption Hypoglycemia from glucose metabolism Respiratory & metabolic acidosis secondary to anaerobic metabolism Inhibition of surfactant production related to acidosis
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Consequences of Hypothermia
pulmonary blood flow related to pulmonary vasoconstriction in response to body temperature pulmonary vascular resistance compromises the delivery of oxygen at the cell level risk of developing PPHN in the near term, term or post term infant
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Prevention of Hypothermia
Hypothermia can be prevented by maintaining a neutral thermal environment and reducing heat loss. A neonate is in a neutral thermal environment when the axillary temperature remains at 36.5 - 37.3 (97.7 - 99.2 F) with minimal oxygen and calorie consumption
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Prevention of Hypothermia
Reduction of heat loss
Consider the four ways by which the neonate experiences heat loss and intervene appropriately.

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Prevention of Hypothermia
Prevention of hypothermia is the best treatment but if it occurs anyway, the following is a list of what you can do to relieve the cold stress. Increase ambient air temperature Apply external heat sources
Warm hat Warm blankets or diapers Chemical mattress

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Prevention of Hypothermia
Avoid stressing the baby Monitor skin temperature carefully and when it normalizes remove the external heat sources one at a time to prevent rebound hypothermia

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Hyperthermia

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Hyperthermia
HYPERTHERMIA also has negative consequences for the neonate. Defined as a rectal / axillary temperature greater than 37.3c (99.2F)

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Risk factors for Hyperthermia

Excessive environmental temp Sepsis Dehydration Alterations in the hypothalamic control mechanism
Birth Trauma Anomalies Drugs
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Signs of Hyperthermia
Tachypnea Apnea Tachycardia Flushing Hypotension Irritability Poor Feeding Skin Temp > Core Temp
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Consequences of Hyperthermia
in Metabolic rate oxygen consumption Dehydration from insensible water loss Peripheral vasodilatation/ hypotension Fluid, electrolyte abnormalities seizures
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There Are a Lot of Factors to Consider. How Can I Be Sure My Patient Maintains Thermoneutrality?
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It Is Important to Review and Understand the Four Methods of Heat Transfer

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Convection and Radiation

Convection
Occurs when air flow carries heat to or away from the body

Radiation
Radiant energy exchange occurs between two objects that are not in direct contact with each other.
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Conduction and Evaporation

Conduction
Heat exchange that occurs between objects that are in direct contact with one another

Evaporation

Occurs when liquid is turned to vapor, as with amniotic fluid on a newly delivered infant.

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Possible Sources of Heat Loss

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Baby
Radiation
Cold Room Temp. Cold Walls Cold Items on Bed

Conduction
Cold Scale Cold X-ray plates Cold Blankets

Convection
Bed Near Air Vent Oxygen left on Passing Traffic

Evaporation
Wet Diaper Bath Tachypnea
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Strategies to prevent heat loss:

CONVECTIVE HEAT LOSS can be prevented by:
Providing warm ambient air temperature
Placing infants less than 1500 grams in incubators Keeping portholes of the incubator closed Warming all inspired oxygen On open warmers keeping sides up and covering infant if possible Using Infant Servo Temperature Control
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Strategies to prevent heat loss:

RADIANT HEAT LOSS can be prevented by:
Avoiding placement of incubators, warming tables and bassinets near cold windows, walls, air conditioners, etc.. Placing a knit hat on the infants head Wrapping tiny babies in saran or bubble wrap environmental temperature
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Strategies to prevent heat loss:

CONDUCTIVE HEAT LOSS can be prevented by:
Placing a warm diaper or blanket between the neonate and cold surfaces Placing infant on pre-warmed table at time of delivery Warming all objects that come in contact with the neonate Admitting infant to a pre-warmed Skin to skin contact

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Strategies to prevent heat loss:

EVAPORATIVE HEAT LOSS can be prevented by:
Keeping the neonate and his/her environment dry. Drying the baby immediately after delivery. Placing preterm or SGA infant in occlusive wrap/bag at delivery Delay bath until temperature is stable
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Interventions for at Risk Infants

Pre-warmed radiant warmer bed Pre-warmed incubator Do not leave a warmer bed or incubator in the manual mode Servo mode allows the baby to control the heat output of the warmer units Heated water pad Heat lamp Warm and humidify inspired gases Occlusive wrap/bag at delivery
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Interventions for at Risk Infants

Open incubator portholes and doors only when necessary Blanket over incubator Cluster care

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Use of Skin Servo Monitoring

Incubators and radiant warmers are designed to work using skin temperature to regulate the thermal environment
As temperature is higher in brown fat areas, avoid placing the temperature probe over brown fat deposit areas, such as the axilla, neck, or back.
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If the temperature probe is placed over brown fat deposit areas, the probe will be reading a core body temperature and not a skin temperature. As the core temperature will be higher than the skin temp., the warming device will cool the environment. The infant will then need to burn fat and calories to stay warm
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Skin servo control

Temperature Probe Placement

Secure the temperature probe at/or about the costal margin of the chest, midway between the xiphoid and the navel. This placement should assure accurate skin temperature measurement. Never lay infants on the probe, as this will also cause a falsely high temperature to be registered.
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Skin temperature Probes

Do Not lay infant on skin probe Do not place over:
Bony prominences Areas of brown fat deposits Poorly vascular areas Excoriated areas Keep probe exposed to heat source Keep probe securely attached
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Safety Considerations
Make sure the sides of radiant warmers are up, unless medically unable. This protects the infant from air currents in the room that might stimulate thermal receptors.

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Interventions to Consider
Cover thermoreceptor-rich areas, such as the head. Dry well after baths, especially the head and neck area. Dress and cover infants, when in cribs, to prevent them from chilling. Warm fluids prior to dressing changes Rewarm slowly to prevent a potential subsequent drop in blood pressure.
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Rewarming the Hypothermic Infant

Always be prepared to intervene Rewarm slowly (0.5C per hour) Monitor closely (vital signs every 15 30min)
Core temp Skin temp will be higher than axillary Blood pressure
Rewarming may lead to vasodilation - hypotension

Heart rate and rhythm

Bradycardia & arrhythmias common with hypothermia

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Rewarming
Monitor Respiratory rate and effort
Increased distress Apnea

Oxygen saturations
Hypoxemia / desaturations Be prepared for need for respiratory support Monitor acid/base status

Blood glucose
Monitor- infant at increase risk for hypoglycemia

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Guidelines for Rewarming

Incubator better control than warmer Set temp 1 1.5C above core temp Assess infant temp every 15-30 minutes As infants core temp reaches set temp and infant is not showing signs of deterioration increase set temp again. Continue process until temp within normal range
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Signs of Deterioration during rewarming

Tachycardia due to in cardiac output Cardiac arrhythmia Hypotension Hypoxemia / Desaturations Worsening respiratory distress Worsening acidosis

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Cooling the overheated neonate

Extended position- not flexed Expose skin- remove clothing Keep active temp reduction methods to a minimum to prevent dramatic heat loss Monitor temperature and VS every 15 30minutes Be prepared to intervene
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Key Points to Know in Preventing Hypothermia

Infant most vulnerable
Premature and SGA infants Neonates requiring prolonged resuscitation Acutely ill Open skin defects (abdomen, spine)

Remember the basics

Warm, humidified oxygen ASAP Warm objects before contact with infant Pre warmed Radiant warmer/incubator utilize servo control

Rewarm cautiously- Be prepared to resuscitate

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Conclusions
Hypothermia in the newborn is due more to a lack of knowledge than to lack of equipment. Hypothermia is a preventable condition that has well documented impact on morbidity and mortality. Therefore, assisting the infant to maintain a normal body temperature and preventing hypothermia during stabilization is critical

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