European Journal of Cardiovascular Medicine

Immediate postnatal hypothermia is a worldwide issue leading to significant neonatal morbidity and mortality. Prematurity, intrauterine growth restriction, asphyxia, and certain congenital anomalies are associated with increased risk of neonatal hypothermia. Temperature control during resuscitation in the delivery room as well as during transport is important in reducing mortality and morbidity in very low birth infants (1,2). In the very preterm newborn infant, there will be a drop in body temperature after birth unless measures are taken to prevent this heat loss. Current resuscitation guidelines recommend placing the infant under a radiant warmer, drying the skin, removing wet linen, and placing the infant on a dry pre- warmed blanket to reduce heat loss(3). Despite these measures, preterm infants are at very high risk for cold stress. The EPICURE study showed that with decreasing gestational age, there was a very high incidence of cold stress. In this study, more than 40% of infants at 24 weeks gestational age had admission temperatures of <35^oC (Costello et al 2000) (4).  Heat loss from the newborn is mainly due to evaporation of amniotic fluid from the body surface.  At birth, the newly born infant is suddenly exposed to a wet and cold environment and responds by increasing heat production and attempts to conserve heat by cutaneous vasoconstriction. In the absence of thermal protection, the newborn may lose considerable heat, resulting in a drop of the infant’s body temperature at a rate of 0.2 to 1.00C/ min. Within the first minutes following birth, skin temperature of the baby typically falls by 3 to 4 degree C.  Neonatal hypothermia is defined as an abnormal thermal state in which the newborn’s body temperature drops below 36.50C (97.70F).

WHO has categorized hypothermia into three stages- mild, moderate and severe hypothermia. (5)

According to an East African study published in 2020, prevelance of hypothermia in hospital and home settings was 32-85% and 11-92% respectively [ 6]. In India, according to National Neonatal Perinatal Database (NNPD) 2002-2003, the incidence of hypothermia among extramural babies was 18.4%.[7]

Hypothermia can occur during neonatal transport. Various devices available for neonatal transport include: transport incubators, thermocol boxes, baskets, polyethene wraps, covering the babies using cloth etc with each device having different efficacy in preventing neonatal hypothermia and their own pros and cons.

SELECTION PROCEDURE- 1^st baby was selected was selected randomly to be transported via cloth alone, thereafter transportation was done on an alternate basis via cloth and cloth- trolley combination.

INCLUSION CRITERIA: All newborns with an indication for admission in NICU in a government hospital in central India.

EXCLUSION CRITERIA- none

MATERIALS USED

1. Plyboard
2. Thermocol
3. Ragazine fabric
4. Nails
5. Trolley
6. Cardboard
7. Digital thermometer
8. Weighing scale.
9. Manpower

DATA COLLECTION- Baby was delivered in GLR, after resuscitation and primary stabilization (if needed) was done, axillary temperature was recorded at GLR using digital thermometer. Then baby was transported on an alternate basis using cloth alone or cloth – trolley combination. Axillary temperature was recorded again on arrival at NICU and data collected.

DATA ANALYSIS- The data was recorded in the predesigned proforma and was entered in MS excel. Data was analysed using Statistical Package for Social Sciences Version 20 [SPSS] with help of biostatistician. Continuous variables were compared using student t-test. Categorical variables were compared using Chi- square test. A p -value of <0.05 was considered significant.

ETHICS- study was conducted after taking clearance from institutional ethical         committee.

 TABLE-1 Distribution of subjects according to temperature recorded at NICU

• Cloth and trolley combination was significantly efficacious in preventing hypothermia in all neonates as compared to transportation with cloth alone.
• P value was 0.001 which was statistically significant.

TABLE-2 Distribution of preterm neonates according to temperature recorded at NICU

• Cloth and trolley combination was efficacious in preventing hypothermia in preterm babies also, as compared to transportation using cloth alone.
• P value was 0.001 which was statistically significant.

TABLE-3 Distribution of LBW babies according to temperature recorded at NICU

• Cloth and trolley combination was efficacious in preventing hypothermia in LBW babies as compared to transportation using cloth alone.

P value was 0.001 which was statistically significant.

TABLE-4 Distribution of subjects according to duration of hospitalisation

• No significant difference was observed in duration of hospitalization of newborns in the 2 groups irrespective of the mode of transport.
• P value was 0.72 which was statistically insignificant.

TABLE-5 Distribution of subjects according to their final outcome

• No significant difference was seen in the final outcome of the newborns in the two groups irrespective of the mode of transport.
• P value was 0.73 which was statistically insignificant.

Neonatal hypothermia remains a major contributor to neonatal morbidity and mortality. It associated with a 5 fold higher mortality during first 5 days of life. For each 1 degree C fall in neonate’s temperature, mortality risk increases by 80%. Therefore by intervening at this level, we can significantly reduce neonatal morbidity and mortality. For preventing neonatal hypothermia we have built an indigenous transporting device in this study. It has been shown in previous studies that morbidity and mortality related to transport are directly proportional to each degree of body temperature lost during transport (8,9).

 In our study a total of 317 neonates were included out of which 158 were transported using cloth alone, 159 were transported via cloth and trolley combination. 246 neonates had a gestational age of <37 weeks, out of which 120 (48.78%) were transported using cloth alone while 126 (51.22%) were transported using cloth plus trolley. 71 neonates who had a gestational age ≥37 weeks, out of which 39(54.93%) were transported using cloth alone while 32 (45.07%) were transported using cloth plus trolley. This is similar to the studies of Sabzehei MK et al [10], Luiza Vieira AP et al [11] and Narang M et al [12].  262 neonates had a birth weight of < 2.5 kg, 131 (50%) were transported using cloth alone, while remaining 131 (50%) were transported using cloth plus trolley. Out of 55 neonates who had a birth weight of >2.5 kg, 28 (50.91%) were transported using cloth alone, while 27 (49.09%) were transported using cloth plus trolley. This is comparable to the cross sectional study conducted by Luiza Vieira AP et al . So, the subjects in  both the groups were comparable to each other in terms of birth weight, gestational age etc. Out of 159 neonates who were transported using cloth alone as many as 145 (91%) had hypothermia while only 14 (9%) were normothermic. 158 neonates were transported using cloth plus trolley combination out of which 107 (67%) had hypothermia while 51 (33%) were normothermic. We found that our indigenous transporting device significantly prevented neonatal hypothermia during intrahospital transport of neonates (p value<0.05). In a similar study, Kevin Tran et al tried to create a low cost incubator to be used in low resource settings, which was quite efficacious in preventing neonatal hypothermia.(13) We found that amongst 124 preterm neonates who were transported using cloth alone, 112(90%) had hypothermia while only 12 (10%) had normothermia. 122 preterm neonates were transported via cloth plus trolley combination out of which 83 (68%) had hypothermia while 39 (32%) were normothermic. Amongst 135 LBW neonates who were transported using cloth alone 122 (90%) had hypothermia while only 13 (10%) were normothermic. 127 LBW neonates were transported via cloth plus trolley combination out of which 80 (62%) had hypothermia while 47 (38%) were normothermic. So our transporting device also prevented hypothermia in high risk babies like preterm and LBW babies (p value <0.05).

In this study, out of 224 neonates who were hospitalised for <5 days, 109(48.66%) were transported using cloth alone, while 115(51.34%) were transported using cloth plus trolley. Out of 51 neonates who were hospitalised for 5-7 days, 27(52.94%) were transported using cloth alone, while 24 (47.06%) were transported using cloth plus trolley. Out of 42 neonates who were hospitalised for >7 days, 23(54.76%) were transported using cloth alone, while 19(45.24%) were transported using cloth plus trolley. We observed in our study that most neonates who were transported using cloth trolley combination had a lesser duration of hospitalisation as compared to those transported using cloth alone, although the p value was not statistically significant (p>0.05). This could be because there are various other independent factors contributing to neonatal morbidity and mortality like prematurity, LBW, birth asphyxia, sepsis, congenital malformations etc which we did not take into account in our study, so the results were not statistically significant.

In this study, it was observed that , out of total 72 neonates who died, 38(52.78%) were transported using cloth alone while 34(47.22%) were transported using cloth plus trolley. Out of 195 neonates who were discharged, 94(48.21%) were transported using cloth alone while 101 (51.79%) were transported using cloth plus trolley. Out of 17 neonates who left against medical advice, 8(47.06%) were transported using cloth, while 9(52.94%) were transported using trolley. We observed that a greater number of neonates who were transported using cloth had a poor outcome (death) as compared to those transported using cloth and trolley combination, although the p value was not statistically significant (p>0.05). This would again be because neonatal morbidity and mortality is multifactorial and does not only depend upon hypothermia. 

From our study we have concluded that our indigenous transporting device significantly prevented hypothermia in all neonates including high risk babies like preterm and LBW babies and was more efficacious than transportation using cloth alone. But no significant difference was obtained in duration of hospitalization and final outcome of these patients. We do not discourage the use of transporting incubators since they are definitely efficacious in preventing hypothermia, but looking at present day scenarios where availability and maintenance of these incubators is a problem not only in peripheries but also at tertiary care centers, we have tried to build a device which is efficacious and can be made easily available everywhere.

Funding- None to declare

Conflict of interest- None to declare

Acknowledgement- None to declare

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