Improving Neonatal Thermal Monitoring And Care - JINJA REGIONAL REFERRAL HOSPITAL Improving Neonatal Thermal Monitoring And Care - The Role of the Champion Parent Dr Jenny Woodruff Dr Johanna Gaiottino Sister Anguparu Maburuka Special Care Baby Unit, Jinja Regional Referral Hospital

Why? Neonatal mortality contributes 40% of under 5 mortality worldwide 14% of births worldwide are of low birth weight

Is neonatal hypothermia a big problem in Africa? ................the simple answer is yes! Prevalence data: Zambia 44% - 69% Ethiopia 53% Nigeria 62% - 68% Zimbabwe 85% The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival Karsten Lunze,1 David E Bloom,2 Dean T Jamison,3 and Davidson H Hamer4,5 Lunze et al. BMC Medicine 2013, 11:24. The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival

Hypothermia – why does it matter? WHO definitions of hypothermia Mild 36.0 – 36.5 Mod 32.0 – 36.0 Severe <32.0 - now thought to be outdated We need to correct the myth that the only temperature worth worrying about is <32oC!

Hypothermia - why does it matter? Hypothermia means the baby is more likely to die! Definition (Mullany et al, 2010) Temperature range (oC) Risk of death (adjusted for age/ambient temp) Normothermic 36.5 – 37.5 1 Mild hypothermia 36.0 – 36.4 1.8 times higher Moderate hypothermia 35.0 – 35.9 3 times higher Severe hypothermia 34.0 – 34.9 10 times higher Very severe hypothermia ≤33.9 25 times higher Arch Pediatr Adolesc Med. 2010 Jul;164(7):650-6. Risk of mortality associated with neonatal hypothermia in southern Nepal. Mullany et al. Looked at 23240 infants in first 72 hrs of life. First recorded temperature used in above data. WHO definitions were: (with adjusted risk ratio of death, adj for age and ambient temperature) Normothermic 36.5 – 37.5 (1) Mild 36.0 – 36.5 (1.7x) Mod 32.0 – 36.0 (4.7x) Severe <32.0 (23.4x) But the moderate category encompassed 3x the risk to 20x the risk so they proposed the above new definitions

Hypothermia - why does it matter? Hypothermia means the baby is more likely to die! Definition (Mullany et al, 2010) Temperature range (oC) Risk of death (adjusted for age/ambient temp) Normothermic 36.5 – 37.5 1 Mild hypothermia 36.0 – 36.4 1.8 times higher Moderate hypothermia 35.0 – 35.9 3 times higher Severe hypothermia 34.0 – 34.9 10 times higher Very severe hypothermia ≤33.9 25 times higher Arch Pediatr Adolesc Med. 2010 Jul;164(7):650-6. Risk of mortality associated with neonatal hypothermia in southern Nepal. Mullany et al. Looked at 23240 infants in first 72 hrs of life. First recorded temperature used in above data. WHO definitions were: (with adjusted risk ratio of death, adj for age and ambient temperature) Normothermic 36.5 – 37.5 (1) Mild 36.0 – 36.5 (1.7x) Mod 32.0 – 36.0 (4.7x) Severe <32.0 (23.4x) But the moderate category encompassed 3x the risk to 20x the risk so they proposed the above new definitions

What about in Uganda? In 2006 in SCU in Mulago, 29% of newborn deaths were associated with hypothermia 79% of 300 newborns in St Francis Hospital, Nsambya, were hypothermic within 90 minutes of delivery Higher frequency in babies who did not have skin to skin contact with their mothers, or who were bathed within 1 hour of birth Ministry of Health. Situation analysis of newborn health in Uganda: current status and opportunities to improve care and survival. Kampala: Government of Uganda. Save the Children, UNICEF, WHO; 2008 Byaruhanga et al, Neonatal hypothermia in Uganda: prevalence and risk factors. J Trop Pediatr. 2005

What we did... Made use of the resources available

What did the parents do? Parents asked to record temperatures 6 hourly Solar thermometers used Chart included simple instructions on what to do in the case of mild, moderate or severe hypothermia Temperature monitoring champion parent oversaw the process

But did this intervention help? Methods Retrospective audit of notes Inclusion criteria: Birth weight <2kg Admitted September-October 2014 Admitted February-March 2015 Every temperature recorded in the notes was analysed (517 temperatures in Sept-Oct and 534 temperatures in Feb-Mar) Sept – Oct 45 patients, 517 temps recorded, 435 patient days Feb – March 36 patients, 534 temps recorded, 283 patient days

Results: number of temperatures recorded Average numbers of temperatures recorded per day of admission increased from 1.2 temperatures taken per day to 1.9 (p<0.001) Highly significant change, despite absence of several temperature charts from the post-intervention notes From patients notes audited: Sept – Oct 45 patients Feb – Mar 36 patients. 14 temp charts present and studied, 8 mentioned but not present on analysis. 14 presumed not given a chart

Results: average temperature Average temperature increased from 36.28oC (95% CI +/-0.08) to 36.43oC (95% CI +/- 0.06) (p<0.01) Sept – Oct 45 patients, 517 temps recorded, 435 patient days Feb – March 36 patients, 534 temps recorded, 283 patient days Sept to Oct Feb to Mar

Results: temperatures by category Sept – Oct 45 patients, 517 temps recorded, 435 patient days Feb – March 36 patients, 534 temps recorded, 283 patient days

Results: Severely hypothermic temperatures (≤34.9oC) reduced significantly from 8.9% to 2.8% (p<0.0001). Moderately and severely hypothermic temperatures (≤35.9oC) decreased significantly from 27.9% to 19.9% (p<0.01).

Results: Did not reach significance The percentage of days of admission with severe hypothermia (≤34.9oC) reduced from 8.1% to 4.6% (p<0.07) but did not reach statistical significance. The number of deaths, discharges and “runaways” did not change significantly. The number of days of “thermal care” being mentioned on ward round notes did not change

Conclusion Increased number of temperatures measured per patient admission day Increase in average temperature A decrease in moderate and severe hypothermic temperatures Empowerment of mothers to monitor their babies’ temperatures

What next? Continue to empower mothers – new charts