Neonatal hypothermia

neonatal hypothermia is a very emergency condition. if we identify this in early stage we can save the life of neonate. all should know about the maintaining the temperature if the neonate is in our home.

1. NEONATAL HYPOTHERMIA Presented by MR. ABHIJIT P. BHOYAR M SC NURSING CHILD HEALTH DEPARTMENT

2. INTRODUCTION Hypothermia is considered as silent killer in neonates. It increases the neonatal morbidity and mortality . Maintenance of warmth of the neonates enhances their survival

3. CONTI.. Piere Budin (1900 ) first drew attention to the high neonatal mortality due to cold. Optimum thermal environment for neonates was identified in mid 1960s, as they are easily influenced by the extremes of environmental temperature. Thermal protection of the newborn babies is considered as one of important essential neonatal care.

4. DEFINITION Hypothermia is a common alteration of state of the neonates. Neonatal hypotherrnia occurs the body temperature drops below 36.5 in the newborn infant (WHO). Normal body temperature is 36 . 5 to 37 . 5 C.

5. STAGES OF NEONATAL HYPOTHERMIA The thermo-neutral state of the neonates is considered within range of 36.5 to 37.5 C. The stages of hypothermia are as follows: SEVERE HYPOTHERMIA MODERATE HYPOTHERMIA COLD STRESS HYPOTHERMIA

6. A skin temperature change is the initial indicator of cold stress. A decreased core temperature (rectal) is a late warning sign indicating that the neonate is already compromised.

7. FACTORS RESPONSIBLE FOR NEONATAL HYPOTHERMIA Awareness and attention , about the importance for neonates, among health care providers. Inappropriate care of the baby immediately after birth by inadequate drying and wrapping. Separation of baby from the mother. Cold environment at the place of delivery and baby care areas.

8. Change of temperature from womb to cooler extrauterine environment. Inadequate warming procedure before and during transport of the baby. Excessive heat loss by evaporation, conduction, convection and radiation from wet baby to the cold linen, cold room and cold air.

9. Certain characteristics of neonates, i.e. large body surface area per unit of body weight, large head, developmental immaturity of heat regulation center , poor insulation due to less subcutaneous fat in LBW baby and reduced brown adipose tissue ( BAT) as heat source. high Risk neonate- lbw baby, birth asphyxia, congenital malformations and mother having anesthetic drugs.

10. PROCESS OF THERMOREGULATION Thermoregulation is maintained by the process of heat production or gain and heat loss. The mechanism of heat production in neonates is known as nonshivering thermogenesis (NST) and the site of heat production is brown adipose tissue (BAT). When heat loss begins, thermoreceptors of subcutenous tissue, spinal cord and hypothalamus are stimulated and NST is triggered.

11. The noradrenaline released from sympathetic nervous system which acts on brown fat and in heat production. I n full-term neonates BAT accounts for 4 percent of total fat , which is less in LBW infants, BAT is located in the axillary , neck , interscapular region, m ediastinum , around kidney and adrenal glands. It helps in chemical thermogenesis

12. The heat loss in neonates occur by evaporation, conduction, convection and radiation. Heat loss by evaporation occurs immediately after birth if the baby is not dried and not covered adequately. If humidity of the room is less, then evaporative heat loss increased from exposed areas. Neonate may loss heat by conduction , i.e. direct contact with cooler object or surface (e.g. cold table, mackintosh, towel, tray, hands, weighing scale, etc.).

13. Heat loss by convection takes place, when the baby is placed in the cooler air and air movement is present there, (e.g. open window, fans). By radiation the infant loses heat to cooler object. Colder the object and closer it is to the neonate, the greater the loss of heat by radiation.

14. CLINICAL FEATURES EARLY CLINICAL SIGNS Skin temperature of the neonate is below 36. 5 C Hands, feet, abdomen are cold to touch Weak sucking ability, weak cry and lethergy Blue hands and feet due to peripheral vasoconstriction.

15. LATE SIGNS Late signs due to persistent hypothermia Gradual fall of body temperature Slow, shallow and irregular respiration Slow heart rate Lethargy and poor response

16. Pale body with face and extremities of bright red color Central cyanosis may present Edema and sclerema (localized hardening of the tissue) may be present Weight loss. Consequence of Neonatal Hypothermia

17. Neonatal hypothermia has a number of serious consequences . It has both immediate and long-term effects. The effects are hypoxia (due to more oxygen consumption), Hypoglycemia (due to increased metabolism), Metabolic acidosis (due to BAT hydrolysis), Respiratory distress ,

18. Neonatal sepsis, Neonatal jaundice, Sclerema , Pulmonary hemorrhage , Impaired cardiac function, Coagulopathy , Sudden infant death syndrome, Delayed growth and development, Mental retardation, etc. Sudden infant death syndrome  ( SIDS ) is the unexplained death, usually during sleep, of a seemingly healthy baby less than a year old.

19. CONCEPT OF "WARM CHAIN" The concept of warm chain was introduced to describe a set of interlinked procedures to minimize the likelihood of hypothermia in all neonates. The links of warm chain are

20. These should be maintained by the following activities : A. Warm delivery room (more than 2 5 C ) which is free from draught. - Warm reception and resuscitation of all neonates

21. - Immediate drying and wrapping DRYING WRAPPING

22. Skin to skin contact between the mother and neonate (kangaroo mother care ) Putting in mother's breast within half an hour of birth

23. - Appropriate clothing, and bedding and covering head properly - Mother and baby nursed together (bedding in or rooming-in) in the delivery room or in lying in w ard

24. B . Warm and safe transportation. C. Warmth in special neonatal care unit . - Training of all health care provider who are involved in birth and subsequent care of the neonate , especially on prevention of hypothermia, for improvement of awareness about the silent killer.

25. PREVENTION OF NEONATAL HYPOTHERMIA The following measures should be taken for neonatal hypothermia A) At the time of birth in delivery room Delivery room should be warm and free from draught . Immediate drying and wrapping of the neonate in layers of soft cloths or prewarm towel.

26. Ensuring that head is well-covered. Wet cloth to be changed immediately. Provision of extrawarmth by radiant warmer or room heater or 200 W bulb, as available. Baby should be kept by skin to skin contact or by the side of the m other so that mother's warmth will keep the baby Warm

27. Fans to be kept Off to prevent air be kept closed to prevent draught. Room temperature to be maintain 28 + 2 degree C or according to baby's weight and postnatal age . Baby bath should be postponed. Cleaning of blood and meconium should be done with lukewarm water. Undue exposure of the baby should be avoided during nursing procedures.

28. Allowing breastfeeding with half an hour of birth or as early as possible to provide warmth, nutrition and protection . Continuous observation of thermal state and other vital Keep the baby in skin to skin contact with mother in kangaroo me thod at least for one hour to rnaintain temperature, facilitate breastfeeding and improve mother-infant bonding .

29. B . During transportation Transportation is the potential weakness link Of warm chain. Temperature maintenance during transport is an important aspect of prevention of neonatal hypothermia . Baby should be transferred after establishment of thermal stability. Assess the baby's condition and temperature. Baby's hands and feet should be as warm as abdomen.

30. Baby can be transferred in skin to skin contact with mother in kangaroo method or mother can keep the baby close to her chest. Baby should be wrapped in prewarmed cloth. Baby's head, and extremities should be covered properly avoid undressing the baby unnecessarily .   Baby can be transferred within thermocol box with prewarmed linen, plastic bubble sheet or silver swaddler .

31. Silver Swaddler Simple open transport trolley should be avoided to transport the baby

32. C. At neonatal care unit When mother is sick and unable to take care of her baby then neonates are kept in the neonatal care unit. Precautions should be taken to prevent hypothermia along with other essential care . - Receiving the neonate in prewarmed cot . - Covering the baby with adequate clothing including head and extremities and avoiding undue exposure.

33. - Keeping the ambient atmospheric temperature warm for baby's weight and age ( 28-32 deegree C ). - Maintaining humidity around 50 percent . - Early feeding with breast milk . - Avoiding dip bath during hospital stay, till the umbilical cord has fallen off . - Sponge bath can be given with warm water in warm room quickly and gently then wrapping promptly .

34. - Monitoring baby's temperature 3 hourly, during initial postnatal days considering axillary temperature is as good as core temperature . - Gradual rewarming of the baby if she or he is cold. Using extra warming devices whenever needed like radiant warmer, room heater, heated water filled mattress, isolette or incubator. Avoiding direct use of hot water bottles. - Decrease heat loss by convection, conduction and radiation.

35. D. At home Nurse should teach the mother and family members about neonatal care at home especially for maintenance of and breastfeeding. Warmth to be maintained by wa rm room (rooming-in), skin to skin contact (kangarooing), adequate clothing, exclusive breastfeeding, bathing with wa rm water in warm room, oil massage and use of solar heat.

36. Mother should be taught to assess the thermal state by touch. The warm and pink feet of the baby indicate that the baby is in thermal comfort. But when feet are cold and abdomen is warm to touch, the baby is in cold stress. In hypothermia both feet and abdomen are cold to touch.

37. Assessment of Temperature in Neonates Low reading thermometer should be used to measure the neonate's body temperature. Same thermometer should be used in an individual neonate at the same site. Auxiliary temperature is preferable as it is safe and It reflects rectal temperature if taken properly. For A ccurate results, the neonate’s arm should be adducted with the thermometer bulb deep in the auxiliary pit.

38. Auxiliary temperature is as good as core temperature , provided thermometer kept for 3 to 5 minutes. Normal auxiliary temperatures ranges is 36.3 to 37.2 degree c. Skin temperature is measured bv thermistor ( tele -thermometer) t aped to skin of abdomen . The normal skin temperature for full term babies is 36 to 36.5 degree C and in preterm babies 36.2 to 37.2 degree c.

39. Rectal temperature is not recorded in neonates for routine monitoring. It is used only for sick hypothermic newborns. Normal rectal temperature in neonates is 36.6 to 37.2 degree C . Rectal thermometer can be inserted with precaution in backward and downward direction. The depth of insertion should be 3 cm for term babies and 2 cm for preterm babies.

40. Baby's temperature can be assessed with reasonable precision by human touch. Touch the baby by dorsum of hand. When feet are cold and abdomen is warm to touch, the baby is in cold stress. In hypothermia both feet and abdomen are cold to touch. Both feet and abdomen are warm; indicate baby is in thermal comfort and normothermic.

41. Abdominal temperature is representative of the core temperature and reliable in the diagnosis of hypothermia.

42. Management of Neonatal Hypothermia A hypothermic neonate should be rewarmed as quickly as possible. Rewarming procedure depends upon the severity of hypothermia and available facilities

43. In moderate hypothermia In moderate hypothermia ( 32-35.9 degree C ), the neonate should be placed with mother in skin-to-skin contact in a warm room and warm bed. Radiant warmer or incubator can be used if available. Rewarming should be continued till the temperature reaches normal range. Monitor temperature every 15 to 30 minutes.

44. In severe hypothermia In severe hypothermia, rewarming should be done with air heated incubator (air temperature 35-36 degree C ) or manually operated radiant warmer or thermostatically controlled heated mattress set at 37 to 38 degree C . When body temperature reaches 34 degree C , the rewarming process should be slowed down.

45. Room heater, or 200 W bulb or infrared bulb can also be used. Monitor blood pressure, heart rate, temperature and blood glucose level. Preventive measures to reduce heat losses from the baby should be followed. IV infusion with 10% dextrose, oxygen therapy and vitamin K injection (1 mg for term baby and 0.5 mg for preterm baby) should be administered along with routine and supportive care

46. Preventive measures should be implemented against neonatal hypothermia to reduce morbidity and improved survival of newborn babies, which are easier than the curative management and rewarming for neonatal hypothermia. Good quality obstetrical and neonatal care services and attention of concerned health care providers are essential for prevention of this health hazards.

47. The health worker and mother should have knowledge and skill for assessment and prevention of hypothermia with use of common sense, which is more important than the availability of expensive equipment to keep the baby warm.

48. THANK YOU FOR MY CARE