1. 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

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

3. 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

4. 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- now thought to be outdated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!

5. 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 Jul;164(7): Risk of mortality associated with neonatal hypothermia in southern Nepal. Mullany et al. Looked at 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

6. 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 Jul;164(7): Risk of mortality associated with neonatal hypothermia in southern Nepal. Mullany et al. Looked at 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

7. 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

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

10. 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

11. 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

12. 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

13. 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

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

15. 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).

16. 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

17. 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

18. What next?
Continue to empower mothers – new charts