Background: Hypothermia in neonates is a common problem and is associated with increased morbidity and mortality. Prevention of hypothermia is therefore an essential aspect of neonatal care especially in the immediate neonatal period. Aim: To evaluate the efficacy of thermal care of the neonate in the labour ward at St Luke's Hospital, Malta. Method: Retrospective study analysing the temperature on admission to the nursery from the labour ward. A consecutive sample of 754 neonates admitted during 2002 was studied. Results: The proportion of babies admitted with normal body temperature (36.5-37.5°C) was 25.5%. The rest were mildly (36.0-36.5°C) (42.2%) or moderately (<36.0°C) (32.2%) hypothermic. Significantly less normothermia was evident in winter births (19.6%) than in summer births (38.1%) (Chi squared=26.5, p<0.0001). Implications: The results indicate the need for an improvement in thermal support in the labour ward.peer-reviewe

Mizzi, Joseph

Sultana, Paul

English

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22 Malta Medical Journal    Volume 15   Issue 02   November 2003Hypothermia in the Early Neonatal PeriodOriginal ArticleJoseph Mizzi, Paul SultanaIntroductionThermal care of the newborn infant should ensure that bodytemperature is maintained within normal limits, i.e. 36.5-37.5°C. Newborns are prone to become hypothermic becauseof their limited ability to generate and conserve heat.Immediately after birth, the wet newborn starts losing heat andunless active measures are taken, hypothermia developsrapidly1 . Hypothermia is common and occurs in allenvironments, including places with warm climates2.Moreover, hypothermia is an important cause of morbidity.The baby becomes lethargic, hypotonic and sucks poorly. Coldstress results in profound metabolic disturbances includinghypoxia, acidosis and hypoglycaemia3.Hypothermia in neonates is defined as a core temperaturebelow 36.5°C; 36-36.5°C is mild hypothermia (cold stress);32-36°C is moderate hypothermia; <32°C is severehypothermia4.In this study, we evaluate thermal care of the newborn bylooking at the proportion of neonates admitted withhypothermia to the nursery from the labour ward.MethodsThis retrospective study analyses the temperature of healthyterm babies on admission to the nursery from the labour wardat St Luke’s Hospital, Malta. The temperature of the infant onadmission to the nursery reflects the efficacy of thermal carefrom the time of birth, the period in the labour ward, and thetransfer to the nursery.Following a WHO publication on thermal care4, we adaptedthe following index as a suitable indicator of thermal care duringthe first few hours after birth:Number of infants admitted with a temperature of >36.5°CTotal number of admissionsA secondary objective of this study was to compare anypossible effect on the incidence of hypothermia between thesummer and winter months. It is known that the environmentalJoseph Mizzi MD, MRCPPaediatric Department, St Luke’s Hospital, Guardamangia, MaltaEmail: joemizzi@global.net.mtPaul Sultana MD MRCPPaediatric Department, St Luke’s Hospital, Guardamangia, MaltaKeywordsHypothermia, newborn, Malta.AbstractBackground: Hypothermia in neonates is a commonproblem and is associated with increased morbidity andmortality. Prevention of hypothermia is therefore an essentialaspect of neonatal care especially in the immediate neonatalperiod.Aim: To evaluate the efficacy of thermal care of the neonatein the labour ward at St Luke’s Hospital, Malta.Method: Retrospective study analysing the temperature onadmission to the nursery from the labour ward. A consecutivesample of 754 neonates admitted during 2002 was studied.Results: The proportion of babies admitted with normalbody temperature (36.5-37.5°C) was 25.5%. The rest were mildly(36.0-36.5°C) (42.2%) or moderately (<36.0°C) (32.2%)hypothermic. Significantly less normothermia was evident inwinter births (19.6%) than in summer births (38.1%) (Chisquared=26.5, p<0.0001).Implications : The results indicate the need for animprovement in thermal support in the labour ward.Malta Medical Journal    Volume 15   Issue 02   November 2003 23DiscussionThe very high incidence of hypothermia (74.5%) clearlyindicates an inadequacy in the thermal care of neonates in thecrucial hours after birth. Typically, a period of two hours elapsesbetween delivery and admission to the nursery. Only a quarterof all infants admitted to the nursery had a normal bodytemperature.A similar study in a UK hospital involving 69 infants showedthat 14% had a temperature of less than 36°C on the postnatalward5.  In our study, 32% had a temperature of less than 36°Con admission to the nursery.Temperature measurements in the nursery are takenrectally. This practice is considered hazardous, but it correlatesbetter with core temperature than the axillary site6,7. TheAmerican Academy of Pediatrics recommends the axillary sitefor temperature measurement, mainly because of the risk ofrectal perforation 8,9. The use of mercury-in-glass thermometershas been banned in most centres and the electronicthermometer, which is accurate, safe and measures thetemperature quickly, should substitute it. The SI unit fortemperature, the Celsius, should be adopted as in mostEuropean countries. If the temperature is <36.5°C, activemeasurements should be taken to re-warm the baby.The problem of hypothermia is worse in January andFebruary and this suggests that the indoor temperature is lowerduring winter. The delivery rooms are warmed by radianttemperature has a significant effect on the risk to the newbornof developing hypothermia. Newborns need a much warmerenvironment than adults do, and though the indoor temperatureduring the winter times may be perfectly comfortable for adults,it may be far too low for the neonate to maintain normal bodytemperature.On admission to nursery, the rectal temperature of all babiesis taken routinely by the nursing staff and recorded in the‘nursery notes.’ A clinical mercury-in-glass thermometer is used.After discharge, the nursery notes are archived at the childrenoutpatients department. The data for January, February, Julyand August 2002 was collected from the nursery notes.Chi-square analysis was performed to compare the numberof normothermic infants admitted during the winter andsummer months; Student’s t-test was used to compare the meaninfant temperature on admission between the 2 groups.ResultsThere were 754 nursery notes available, of which 53 did nothave a record of the admission temperature. The numbers ofinfants with normal body temperature, and with mild andmoderate hypothermia were tabulated (Table 1).179 infants out of a total of 701 admissions had atemperature of 36.5°C or more. Thus, 25.5% of new admissionsto nursery had a normal body temperature. 74.5% werehypothermic; 42.2% were mildly hypothermic; 32.2% weremoderately hypothermic.The mean temperature recorded in neonates in the winterperiod was significantly lower (0.3 degrees centigrade) than themean temperature in summer (p<0.0001). The number ofinfants admitted with a normal body temperature duringJanuary and February was 93 out of 475 (19.6%); and duringJuly and August, 86 out of 226 (38.1%). Significantly lessnormothermia was evident in winter births than in summerbirths (Chi squared=26.5, p<0.0001) (Figure 1).Comparison between the proportion of admissions ofneonates to the nursery with hypothermia and normothermiaduring winter (January/February) and summer (July/August),2002.Percent of AdmissionsFigure 1: Proportion of normothermia on admissionNormal body Total numberModerate hypothermia Mild hypothermia Hypothermia (total) temperature of infants<36°C <36.5-36°C <36.5°C >36.5°CJan/Feb 181 (38.1%) 201 (42.3%) 382 (80.4%) 93 (19.6%) 475Jul/Aug 45 (19.9%) 95 (42.0%) 140 (61.9%) 86 (38.1%) 226Totals 226 (32.2%) 296 (42.2%) 522 (74.5%) 179 (25.5%) 701Table 1. The number of infants classified under various temperature groups.24 Malta Medical Journal    Volume 15   Issue 02   November 2003Table 2: Guidelines for thermal care in the labour ward,adapted from a WHO publication4.1. The temperature of the delivery room should be at least25°C and there should be no draughts.2. Immediately dry the newborn after birth with a warmtowel, and remove wet blankets.3. Place a cap on the baby’s head.4. Place in skin-to-skin contact with mother and cover witha warm blanket; or bundle in warm blankets, and givethe baby to mother to hold; or dress in warm clothes,and place in a pre-warmed closed incubator(temperature 33°C).5. Initiate breast-feeding within one hour of birth.6. Bathing and weighing should be postponed. The babyshould be bathed at least 6 hours after birth, andpreferably on the second day of life, and only if the babyis healthy and has normal body temperature.7. During transportation, use skin-to-skin contact withmother; or dress and wrap the baby in blankets.heaters but there are no wall thermometers to measure theambient temperature. No temperature records of the deliveryrooms are available. The operating theater is centrally heatedand the temperature is kept at 24°C during Caesarian Sections.When using spinal anaesthesia, the temperature is maintainedat higher value (28°C) because the newborn remains with themother.The average temperature in the Maltese islands duringJanuary and February is 12°C (the mean high is 16°C and themean low is 9°C). During July and August, the averagetemperature is 26°C (the mean high is 31°C and the mean lowis 21°C)10.  The difference is ambient temperature is reflected inthe increased incidence of hypothermia (80.4%) in wintercompared with 61.9% in summer. This implies the need for moreactive warming of the delivery rooms during winter. Yet, thewarm summer months should not be taken with a laisser-faireattitude since hypothermia is still very common during thisperiod.Certain factors in the current practice in the labour wardmay contribute to the occurrence of hypothermia. The deliveryrooms may not be warmed sufficiently since there are no wallthermometers to measure and control the ambient temperature.Many babies are washed soon after birth and a cap is rarelyused.References1 Dahm LS, James LS. Newborn temperature and calculated heatloss in the delivery room. Pediatrics, 1972; 49:504-513.2 Tafari N. Hypothermia in the tropics: epidemiologic aspects. In:Sterky G, Tafari N, Tunell R. (eds). Breathing and warmth atbirth. Sarec Report: 53-58, 1985.3 Gomella TL. Temperature Regulation. In: Neonatology. 4th ed.New York: Appleton & Lange; 1999. p. 38-42.4 Thermal protection of the newborn, a practical guide, WHO/RHT/MSM/97.2 [online] 1997 [cited 2002 Sept 15]. Availablefrom: URL: www.who.int/reproductive-health/publications/MSM_97_2_Thermal_protection_of_the_newborn/MSM_97_2_table_of_contents_en.html.5 Hutton-Taylor RS. Incidence of and contributing factors tohypothermia in the newborn at term. Midwifery ResearchDatabase [serial online] 1993 [cited 2002 Sep 13] Available from:URL: http://129.11.5.57/miru/miriad/s0455.htm.6 Brown PJ, Christmas BF, Ford RP. Taking an infant’s tempera-ture: Axillary or rectal thermometer? N Z Med J 1992;105:309-11.7 Morley CJ, Hewson PH, Thornton AJ. Axillary and rectaltemperature measurements in infants. Arch Dis Child 1992; 67:122-25.8 Kresch MJ. Axillary temperature as a screening test for fever inchildren. J Paediatr 1994;104:596-9.9 Frank JD, Brown S. Thermometers and rectal perforation in theneonate. Arch Dis Child 1978; 53(10): 824-25.10 Monthly Averages for Valletta, Malta. The Weather Channel[online] [cited 2003 April 21]. Available from: URL:www.weather.com/outlook/travel/climatology/monthly/MTXX0001htt.Given the high incidence of hypothermia in the first hoursafter birth, it is recommended that, following discussions withthe midwifery staff, there is an immediate implementation ofthe WHO recommendations for thermal protection in the labourward (Table 2).A future audit is indicated to reassess thermal care in thelabour ward after the implementation of these measures.AcknowledgementsWe thank Dr Victor Grech for his assistance in the statisticalanalysis of the results.

Axillary and rectal temperature measurements in infants. Arch Dis Child

Axillary temperature as a screening test for fever in children.

Breathing and warmth at birth. Sarec Report:

Incidence of and contributing factors to hypothermia in the newborn at term. Midwifery Research Database [serial online]

Monthly Averages for Valletta, Malta. The Weather Channel [online] [cited

Taking an infant’s temperature: Axillary or rectal thermometer?

Temperature Regulation. In: Neonatology. 4th ed.

Thermal protection of the newborn, a practical guide, WHO/ RHT/MSM/97.2 [online]

Thermometers and rectal perforation in the neonate. Arch Dis Child

Hypothermia in the early neonatal period

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Hypothermia in the early neonatal period

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