1 HIPOTHERMIA Perinatology Division Dept. of Child Health Medical School University of Sumatera Utara

2 HIPOTHERMIA Significant problem in neonates at birth and even at 24 hours of age and beyond Mortality rate twice in hypothermic babies contributes to significant morbidity & mortality

3 Why are newborns prone to develop hypothermia Larger surface area per unit body weight Decreased thermal insulation due to lack of subcutaneous fat Reduced amount of brown fat (LBW infant)

4 Non - shivering thermogenesis Heat is produced by increasing metabolism, especially in brown adipose tissue Blood is warmed as it passes through the brown fat, and it in turn warms the body

5 FOUR WAYS A NEWBORN MAY LOSE HEAT TO THE ENVIRONMENT

6 HEAT LOSS.  CONDUCTION  CONVECTION  EVAPORATION  RADIATION Transfer of body heat to skin surface. Dry and wrap the baby Place in a warm mattress

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8 HEAT LOSS  CONDUCTION  CONVECTION  EVAPORATION  RADIATION Skin heat loss depends on air temperature/flow. Wrap the baby and control room temperature

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10 HEAT LOSS.  CONDUCTION  CONVECTION  EVAPORATION  RADIATION Depend upon air humidity Control humidity and room temperature

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12 HEAT LOSS  CONDUCTION  CONVECTION  EVAPORATION  RADIATION The transfer of body heat to environmental temperature Radiant heater and control room temperature

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14 Warm chain Warm delivery room (>25°C) Warm resuscitation Immediate drying Skin-to skin contact Breastfeeding Bathing postponed Appropiate clothing Mother & baby together Warm transportation Professional alert

15 Normal range Cold stress Moderate hypothermia Severe hypothermia Outlook grave, skilled care urgently needed Danger, warm baby Cause for concern 37.5 o 36.5 o 36.0 o 32.0 o Axillary temperature in the newborn ( 0 C)

16 Temperature recording Axillary temperature recording for 3 minutes is recommended for routine monitoring Don’t record rectal temperature in all babies as a standard protocol Record rectal temperature in a sick hypothermic neonate

17 Diagnosis of hypothermia by human touch Feel by touch Trunk Trunk Feel by touch Extremities ExtremitiesInterpretation WarmWarmNormal WarmCold Cold stress ColdColdHypothermia

18 Prevention of hypothermia at birth Delivery in warm room Don’t bathe immediately after birth Dry baby immediately with warm clean towel Wrap baby in pre-warmed cloth, cover head Keep next to mother KMC = Kangaroo Mother Care

19 Signs and symptoms of hypothermia Peripheral vasoconstriction - acrocyanosis, cold extremities - decreased peripheral perfusion CNS depression -lethargy, bradycardia, apnea, poor feeding 19

20 Signs and symptoms (cont..) Increased pulmonary artery pressure -respiratory distress, tachypnea Chronic signs -weight loss, failure to thrive

21 Management: Cold stress Cover adequately - remove cold clothes and replace with warm clothes Warm room/bed Take measures to reduce heat loss Ensure skin-to-skin contact with mother; if not possible, keep next to mother after fully covering the baby Breast feeding Monitor axillary temperature every ½ hour till it reaches C, then hourly for next 4 hours, 2 hourly for 12 hours thereafter and 3 hourly as a routine

22 Management: Moderate hypothermia(32.0°C to 35.9°C ) Skin to skin contact Warm room/bed Take measures to reduce heat loss Provide extra heat -Heater, warmer, incubator -Apply warm towels

23 Infant Warmer Incubator

24 Management: Severe hypothermia (<32 0 C ) Provide extra heat preferably under radiant warmer or air heated incubator -rapidly warm till 34 0 C, then slow re-warming Take measures to reduce heat loss IV fluids: ml/kg of 10% Dextrose Oxygen If still hypothermic, consider antibiotics assuming sepsis Monitor HR, BP, Glucose (if available )

25 Kangaroo Mother Care

26 What is KMC n A special way of caring for Low birth weight (LBW) babies n It promotes  Effective thermal control  Breast feeding  Prevention of infection  Parental bonding

27 Components of KMC n Skin-to-skin contact Early, continuous and Early, continuous and prolonged skin-to- prolonged skin-to- skin contact skin contact n Exclusive breast feeding Promotes lactation and facilitates feeding Promotes lactation and facilitates feeding

28 Benefits of KMC n Breast feeding  Increased breast feeding rates  Increased duration of breast feeding feeding n Thermal control  Effective thermal control  Equivalent to conventional incubator care incubator care

29 Benefits of KMC (cont..) n Early discharge » Better weight gain  Early discharge n Lesser morbidity » Regular breathing » Decreased episodes of apnea » Protection from nosocomial infections

30 n Other benefits  Less stress to the infant  Stronger bonding  Deep satisfaction for mother  More confident parents Benefits of KMC (cont..)

31 Requirements for KMC implementation n Training Nurses, physicians and other staff Nurses, physicians and other staff n Educational material Information sheets, posters and video films on Information sheets, posters and video films on KMC KMC n Furniture Semi-reclining easy chairs Semi-reclining easy chairs Beds with adjustable back rest Beds with adjustable back rest

32 Eligibility criteria: Baby n Birth weight >1800 gm: Start at birth Start at birth n Birth weight gm: Hemodynamically stable Hemodynamically stable n Birth weight <1200 gm: Hemodynamically stable Hemodynamically stable Hemodynamic stability is a MUST

33 n Willingness n General health & nutrition n Hygiene n Supportive family n Supportive community Eligibility criteria: Mother

34 Preparing for KMC n Counseling  Demonstrate procedure  Ensure family support  KMC support group n Mother’s clothing  Front-open, light dress as per the local culture n Baby’s clothing  Cap, socks, nappy and front-open sleeveless shirt

35 KMC procedure: Kangaroo positioning n Place baby between the mother’s breasts in an upright position n Head turned to one side and slightly extended n Hips flexed and abducted in a “frog” position; arms flexed n Baby’s abdomen at mother’s epigastrium n Support baby’s bottom

36 KMC procedure: Kangaroo positioning (cont..) Head turned to one side Frog-leg position Baby between mother’s breasts Support baby’s bottom

37 Monitoring during KMC Check if n Neck position is neutral n Airway is clear n Breathing is regular n Color is pink n Temperature is being maintained

38 Initiation of KMC n Baby should be stable n Short KMC sessions can be initiated even if the baby is receiving  IV fluids  Oxygen therapy  Orogastric tube feeding

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40 Duration of Kangaroo Mother Care n Start KMC sessions in the nursery n Practice one hour sessions initially n Transit from conventional care to longer KMC n Transfer baby to post-natal ward and continue KMC n Increase duration up to 24 hours a day

41 KMC during sleep and resting Resting n Reclining or semi-recumbent position n Adjustable bed n Several pillows on an ordinary bed n Easy reclining chair Sleep n Supporting garment restraint for baby

42 Father & other family members can also provide skin-to-skin care

43 KMC during sleep

44 Discharge criteria n Baby is well with no evidence of infection n Feeding well (predominant breast milk) n Gaining weight (15-20 gm/kg/day) n Maintaining body temperature (in room temperature) n Mother confident of taking care of the baby n Follow-up visits ensured

45 Discontinuation of KMC n Term gestation n Weight ~ 2500 gm n Baby uncomfortable  Wriggling out  Pulls limbs out  Cries and fusses Mother can continue KMC after giving the baby a bath and during cold nights