Neonatal hypothermia, the situation in low-resourced countries

Neonatal hypothermia has a significant impact on morbidity and mortality. It is a global health problem but the prevalence is high in low-resourced countries. Early detection and intervention can prevent complications. The WHO warm is set of guidelines proposed to prevent hypothermia in the early hours and days after birth. Hypothermia may be useful (Therapeutic hypothermia) when done appropriately in the context of hypoxix ischemic encephalopathy.

1. NEONATAL HYPOTHERMIA DR. OSEI MENSAH

2. OBJECTIVES Explain neonatal hypothermia and its temperature classifications . Describe how newborns regulate body temperature and influencing factors . List the environmental, physiological, behavioral, and healthcare-related risk factors . Identify the signs and symptoms of different hypothermia levels in newborns . Introduce the WHO Warm Chain and best practices for prevention and management . Reintroduce Therapeutic Hypothermia

3. DEFINITION Neonatal hypothermia is a condition where a newborn's body temperature drops below the normal range of 36.5°C . This condition can occur due to inadequate heat production or excessive heat loss. A dditionally broken down into three categories of mild hypothermia (cold stress) between (36 °C and 36.4 °C ), moderate hypothermia (32 °C and 35. 9 °C ), and severe hypothermia ( less than 32 °C ).

4. FACTS Prevalent in every country ( 11 % to 95 %) , more in developing and low-resourced countries , Korle Bu (92.7%). Significantly affects morbidity and mortality. Regardless of gestational age and weight at birth, neonatal hypothermia increases the risk of death fivefold . (Pellegrino et al., 2023) For every degree Celsius drop in neonatal body temperature, the risk of mortality increases by 80 %. I ncreases the risk of developing comorbidities like hypoxia, sepsis, hypoglycemia, apnea, and poor weight gain.

5. MECHANISM OF HEAT LOSS IN NEONATES The temperature inside the mother’s womb is around 37- 38 ° C . 4 main mechanisms : evaporation, conduction, convection and radiation . Evaporation- of amniotic fluid from the baby’s body Conduction- If the baby is placed naked on a cold surface ( eg . Table , weighing scale or cold mattress ). Convection - If the naked newborn is exposed to cooler surrounding air. Radiation- From the baby to cooler objects in the vicinity ( eg . cold wall or window even if the baby is not actually touching them).

6. Heat loss in neonates Source: Science Direct ( Cinar and Filiz , 2006)

7. PHYSIOLOGY OF THERMOREGULATION Through sophisticated mechanisms of body temperature regulation controlled by the hypothalamus. Mediated by endocrine pathways through shivering and non-shivering thermogenesis (NST). Non-shivering thermogenesis occurs in  brown adipose tissue and to a lesser degree also in skeletal muscle, liver, brain, and white fat. Heat is produced by metabolism of brown fat found around the scapulae, kidneys, adrenal glands, head, neck, heart, great vessels, and axillary regions.

8. Thermogenesis cont … Source:

9. Risk FACTORS FOR NEONATAL HYPOTHERMIA Classified into four: Environmental Physiological Behavioural Healthcare

10. ENVIRONMENTAL RISK FACTORS Cold Delivery Room (<25C) Wet Environment Drafts and Air Movement

11. Physiological risk factors Metabolic ie . Hypoglycemia Conditions presenting with immature thermal regulation ie . Low Birth Weight, Prematurity, Intrauterine Growth Restriction , Asphyxia and Congenital defects like abdominal wall defects. Disorders that impair thermoregulation ie . Sepsis , Intracranial Hemorrhage

12. PHYSIOLOGICAL RISK FACTORS CONT. Preterm infants have difficulty maintaining body temperature after birth due to: A large surface area-to- body mass ratio Little subcutaneous adipose tissue, Less brown fat A thin stratum corneum (immature skin ) and altered skin blood flow High body water content Poorly developed metabolic mechanism

13. BEHAVIOURAL RISK FACTORS Early bathing Removal of vernix caseosa , Reduced contact with mother and Delayed initiation of breastfeeding Socioeconomic factors: having a young and inexperienced mother, coming from a family with low socioeconomic status.

14. HEALTHCARE RISK FACTORS Poor understanding of healthcare providers about the physiology of thermoregulation Caesarean Delivery Neonatal transport is almost always done poorly Procedures for neonatal care such as surgery, placement of umbilical lines, and radiological investigations such as MRI

15. CLINICAL FEATURES OF NEONATAL HYPOTHERMIA Mild hypothermia : cold extremities, lethargy, poor feeding Moderate hypothermia : respiratory distress, bradycardia Severe hypothermia: apnea, cyanosis, hypoglycemia

16. Mechanism Feature Peripheral vasoconstriction Acrocyanosis , cool/pale extremities , and decreased peripheral perfusion Central nervous system (CNS) depression Lethargy, hypotonia , bradycardia, apnea, and poor feeding Increased metabolism Hypoglycemia, hypoxia, and metabolic acidosis Increased pulmonary artery pressure Respiratory distress and tachypnea Chronic signs Disseminated intravascular coagulation (DIC) and poor weight gain

17. COMPLICATIONS Hypoglycemia Respiratory Distress Syndrome Bronchopulmonary Dysplasia Pulmonary Hemorrhage / Edema Metabolic Acidosis Acute Kidney Injury Arrythmia Hyperkalemia Hypotension Shock Apnea Neonatal sepsis Retinopathy of prematurity Intraventricular Hemorrhage

18. PREVENTION The WHO Warm Chain   A set of interlinked procedures to be taken at birth and during the next few hours and days in order to minimize heat loss in all newborns It emphasizes the importance of keeping newborns warm immediately after birth and throughout the early days of life. Failure to implement any one of these procedures will break the chain and put the newborn baby at risk of getting cold.

19. WARM CHAIN

20. WARM CHAIN CONT. (DELIVERY ROOM/THEATRE) 1. Draught free and warm delivery room temperature of 25–28°C . 2. Immediate Drying with a warm and dry linen if baby is doing well 3. Skin to Skin Contact 4. Breastfeeding can be started immediately and the baby and the mother are covered with a warm blanket 5. Delay bathing. No bathing in the hospital

21. WARM CHAIN CONT. 6. Appropriate Clothing/bedding- Prewarm all the linen and clothes/cap before delivery . 7. Keeping mother and baby together . 8.Warm transport (if necessary ), 9. Warm Resuscitation (if required, should be done under the radiant warmer and heated humidified gases to be used if oxygen or PPV is required ) 10. Training and Awareness Raising

22. TRANSPORT In-Utero transfer of baby For a sick infant, transport incubator is the preferred method of transport from delivery room to NICU or intrahospital transfers or from one hospital to another. In the absence of transport incubators, baby should be well wrapped with head covered . For Preterm babies : use plastic bag / skin-to-skin + cap can be used.

23. IN THE NICU I ncubator R adiant warmer KMC Use of plastic tents (cling wrap) and applying cream/oil (like coconut oil) reduces both convection heat loss and insensible water loss. Warm IV Fluids and blood products

24. POSTNATAL WARD Ensure skin-to-skin care of these neonates regardless of gestation/weight as well as ensuring shared bedding with mother . Initiate and establish breastfeeding .

25. MANAGEMENT Based on severity A vailability of staff and equipments . Look out for precipitating factors and manage accordingly .

26. MANAGEMENT Mild Hypothermia Cover adequately with warm clothes Warm room (at least 25C) Ensure skin to skin contact with mother; if not possible, keep fully clothed baby next to mother Breast feeding

27. MANAGEMENT CONTINUED Moderate Hypothermia Provide warmth : Skin to Skin contact Breastfeeding In a warm room Under a radiant warmer

28. MANAGEMENT In an incubator at 35-36 0 C Using a heated water filled mattress The rewarming process should be continued until the baby’s temperature reaches the normal range. Rewarm at a maximum of 0.5° every 30 minutes The temperature should be checked every hour and the baby should continue to be fed

29. MANAGEMENT Severe Hypothermia Fast rewarming over a few hours is preferable to slow rewarming over several days. Rapid rewarming can be achieved by using an air-heated incubator, with the air temperature set at 35-36 0 C or a radiant warmer.

30. MANAGEMENT Once baby’s temperature reaches 34°C the rewarming process is slowed down. Supportive management with oxygen, feeding and fluids should be started along with appropriate monitoring of vitals and blood sugar .

31. OUTCOMES Increased length of hospital stay Cardiac Arrest Death

32. SUMMARY OF MANAGEMENT Mild Hypothermia Moderate Hypothermia Severe Hypothermia Keep Room Warm Kangaroo (skin-to-skin) care and cover the baby adequately Admit in hospital and rewarm in an incubator or a radiant warmer Cover the baby adequately with warm clothes Rewarm in an incubator or a radiant warmer, if available Use a heated water filled mattress The temperature is set at 35–36°C and rapidly rewarmed. Once baby’s temperature reaches 34°C the rewarming process is slowed down Kangaroo (skin-to skin) care and cover the baby adequately Breastfeeding Rewarm at a maximum of 0.5° every 30 minutes Supportive management with oxygen and fluids should be started along with appropriate monitoring of vitals and blood sugar

33. THERAPEUTIC HYPOTHERMIA Used in neonatal hypoxic-ischemic encephalopathy. Only specific therapy proven to reduce the incidence of death and disability in neonates with HIE. (Chawla, 2024 ). The principle is to reduce a newborn's body temperature in order to prevent or minimize brain damage caused by lack of oxygen. Therapeutic hypothermia aims to lower the temperature of the vulnerable deep brain structures to 33-34°C.

34. THERAPEUTIC HYPOTHERMIA  It modifies the cells programmed for apoptosis leading to their survival.  Hypothermia may also protect neurons by reducing cerebral metabolic rate . Hypothermia is not without risk and thus it is important to manage the patient safely during induction and maintenance of hypothermia and during the rewarming process.  The aim of cooling is to achieve the target temperature within 1 hour of commencement (core temperature between 33.0°C – 34.0°C). The total period of cooling and rewarming is for 84 hours, consists of 2 phases: Active cooling - for 72 hours from the initiation of cooling. Rewarming - 12 hours of active gradual rewarming time after completion of 72hrs of cooling. 

35. THERAPEUTIC HYPOTHERMIA Criteria for Therapeutic Hypothermia: ≥ 35 weeks gestational age and more than 1.8kgs.   < 6hrs post birth   Evidence of asphyxia  Assessment of relative contraindications/not moribund and with plans for full care . Clinically defined moderate or severe HIE   Moderate to severely abnormal background activity on EEG At the neonatal consultant’s discretion to commence therapeutic cooling

36. THERAPEUTIC HYPOTHERMIA Take note (Complications): Increase temperature by 0.5ºC every 2 hours and progress until 37°C +/- 0.2 . (Slow rewarming). Monitor temperature frequently following rewarming to prevent rebound hyperthermia.   Observe infant closely for complications during the rewarming stage as they may be at a higher risk of seizures, hypotension or PPHN. Monitor for sepsis and pay attention to the skin ( colour , perfusion, skin breakdown and for signs of subcutaneous fat necrosis).

37. APPRECIATION Dr. Richard Mawuli Letsa (Specialist Paediatrician ) Patricia Sarpomah Entire Paediatrics Team (NGH) Obstetrics and Gynecology Team (NGH)

38. SUMMARY Neonatal hypothermia has a significant impact on morbidity and mortality. It is a global health problem but the prevalence is high in low-resourced countries. Early detection and intervention can prevent complications. The WHO warm is set of guidelines proposed to prevent hypothermia in the early hours and days after birth. Hypothermia may be useful (Therapeutic hypothermia) when done appropriately in the context of hypoxix ischemic encephalopathy.

39. REFERENCES Nelson Textbook of Paediatrics , 32Ed https:// www.nationwidechildrens.org/specialties/neonatology/our-programs/neonatal-therapeutic-hypothermia https:// www.rileychildrens.org/health-info/therapeutic-hypothermia https:// www.msdmanuals.com/professional/pediatrics/perinatal-problems/hypothermia-in-neonates#Prevention_v1514766 Dr. Anna Fokuoh-Boadu and team’s research on neonatal hypothermia

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