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Vinyl bags prevent hypothermia at birth in preterm infants

Article  in  The Indian Journal of Pediatrics · March 2007

DOI: 10.1007/s12098-007-0039-5 · Source: PubMed

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37

Original Article

Vinyl Bags Prevent Hypothermia at Birth in Preterm

Infants
Bobby Mathew, Satyan Lakshminrusimha, Katherine Cominsky, Eileen Schroder and Vivien Carrion

Division of Neonatology, Department of Pediatrics1, Women and Children’s Hospital of Buffalo, Buffalo, USA
[Received : March 28, 2006; accepted : November 2, 2006]

ABSTRACT
Objective. To compare the effect of standard care vs. the use of vinyl bags (Vi-Drape® isolation bag) on admission
temperature in extremely premature infants ≤ 28 weeks gestational age at birth.

Methods. Twenty seven premature infants with similar baseline characteristics were assigned and placed in vinyl bags (n=14)
immediately following delivery without drying or received standard care (controls, n=13), including drying and placement under
a radiant warmer. Axillary temperature was recorded on admission to the neonatal unit.

Results. The average temperature in the vinyl bag group was significantly higher (35.9 ± 0.13 vs 34.9 ± 0.24°C, p=0.002).
Although the cord blood pH was similar between the two groups (7.33+0.02 in the vinyl bag group and 7.33 ± 0.01 in the control
group), the worst pH in the first 6 hours of life was significantly lower in the control group (7.32 ± 0.02 vs 7.22 ± 0.04, p=0.03).
There was a significant increase in maximal oxygen requirement during the first 24h in the control group (82.9 vs 43.3% in
the vinyl bag group, p=0.0004).

Conclusion. Vinyl bags prevent heat loss and are a simple and effective intervention in preventing hypothermia in the delivery
room and early acidosis in premature infants. [Indian J Pediatr 2007; 74 (3) : 249-253] E-mail : vcarrion@upa.chob.edu

Key words : Hypothermia; Vinyl bags; Prematurity.

Temperature control during resuscitation in the delivery
room is particularly 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 very preterm infants are at 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°C
(Costello et al 2000). 4 The introduction of different
transparent membranes has made it possible to limit
evaporative and convective heat loss and to permit heat
gain through radiation. Vohra et al conducted a
randomized control study using polyethylene skin
Correspondence and Reprint requests : Dr. Vivien Carrion,
Division of Neonatology, Women & Children’s Hospital of Buffalo,
219 Bryant St, Buffalo NY 14222, United States. Fax: 001-716 878
7945.
Indian Journal of Pediatrics, Volume 74—March, 2007
wrapping in very low birth weight (VLBW) infants
(Vohra S et al., 1999) (Vohra S et al, 2004).5, 6 Wrapped
infants < 28 weeks GA had higher mean rectal admission
temperatures. Knobel et al recently showed similar results
with polyurethane wrapping.7, 8 This appears to be a very
inexpensive and effective mode of preventing
hypothermia in extremely premature infants.
At birth the infant is exposed to a colder temperature
than it has experienced in utero. The fetus is surrounded
by amniotic fluid at maternal body temperature (Fig. 1).
Following birth, there is a significant drop (more than
10°C) in the surrounding temperature. If the infant is
placed on a cold blanket, considerable amount of heat is
lost through conduction. Cold air draft increases
convective heat loss. Evaporative heat loss due to
transcutaneous loss of water is probably the most
important contributor in preterm infants.9-12 Neonates less
than 28 weeks gestational age (GA) have an immature
epidermal barrier, characterized by absence of a
competent stratum corneum, and high transepidermal
water loss.13 They also lack a protective mantle of vernix
caseosa.14 Premature infants also have a high body surface
area to weight ratio contributing to increased heat loss.
Adaptive mechanisms to cold stress such as ‘non­
249

B. Mathew et al
shivering thermogenesis’ are deficient in premature
infants. Premature infants also have low deposits of
brown fat and glycogen and are not capable of vigorous
physical activity – limiting their heat generating capacity.
This results in increased cold stress leading to hypoxia
and acidosis (Fig. 2).
Fig 1. Fetal thermoregulation: Heat production in the fetus from
metabolism is dissipated through the umbilical circulation or
by natural convection into the amniotic fluid or conduction
to uterine wall and maternal tissues.
Fig. 2. Mechanisms of heat loss following delivery in extremely low
birth weight infants. Heat is lost by conduction to the
surrounding structures and convection into the cold air
draft. Evaporative heat loss secondary to transepidermal
water loss is very important in premature infants. Cold stress
can result in pulmonary and systemic vasoconstriction. *
refers to mechanisms that are deficient in premature
neonates.
Based on the results of the above studies, 5-8 starting
from August 2004, Vi-Drape® isolation bags (Medical
Concepts Development, St Paul, MN) have been used in
the delivery room instead of drying for all premature
infants ≤ 28 weeks gestation. The authors retrospectively
reviewed charts of all in born premature infants ≤ 28
250
38
weeks GA born three months prior to and following
adoption of this policy. We present the results of this
analysis and briefly review the possible mechanism of
heat loss prevention with vinyl bags.
MATERIALS AND METHODS
This study was conducted at the neonatal intensive care
unit at the Women and Children’s Hospital of Buffalo
between August and November 2004. This study was
approved by the Institutional Review Board for children
and adolescents at the State University of New York at
Buffalo. The medical records of very low birth weight
infants ≤ 28 weeks gestational age who were resuscitated
in vinyl bags (Vi-Drape® isolation bag) were compared
with those following standard care in the delivery room.
Admission temperature, morbidity and mortality were
compared between the two groups.
Infants with major congenital malformations, open
neural tube defects, abdominal wall defects or blistering
skin conditions were excluded. The authors used the
ohmeda ohio® infant warmer system in the delivery
room. All preterm deliveries less than 35 weeks
gestational age were conducted in the operating rooms in
the obstetric suite. The temperature of the OR was
maintained between 20 - 21°C for these deliveries. The
radiant warmers are set at maximal heat output in
preparation for these deliveries as soon as the delivery
room nurse is notified of an impending preterm delivery.
All infants were resuscitated on a radiant warmer with a
radiant heat source. Infants were either placed in a Vi-
Drape® bag or received conventional drying and
placement under a radiant warmer as per NRP
guidelines.3 The Vi Drape® bag is a sterile transparent
non-permeable bag that has been used for infants born
with abdominal wall defects. The infants resuscitated in
Fig. 3. Axillary temperature on admission to the NICU: the black
squares denote admission temperatures of infants
resuscitated in vinyl bags and open circles, the infants that
received conventional care. No infants in the bag group had
admission temperature less than 35° C.
Indian Journal of Pediatrics, Volume 74—March, 2007
39

Vinyl Bags Prevent Hypothermia at Birth in Preterm Infants

the vinyl bags were placed in the bag upto the neck admission temperature < 35.0°C as compared to none in
immediately following delivery without drying (Fig. 4 the treatment group (Table 2). There were no infants in
and 5). The bag was secured loosely around the neck by the treatment group that had a temperature over 38°C in
the straps. Only the head was dried and covered by a hat. the treatment group (Fig. 3). Despite starting off with a
Auscultation was done over the bag and if umbilical
access was required a hole was cut in the bag to provide
access. The infants were transported to the NICU in a
prewarmed Air Shields TI 100 transport incubator set at
35°C. Following admission to the NICU the infant was
immediately transferred into a prewarmed isolette
(Giraffe® Omnibed®, Ohmeda Medical) adjusted to the
neutral thermal environment for the gestational age of the
infant. Axillary temperature was then measured using an
electronic thermometer, (Suretemp Welch Allyn®). Our
NICU admits an average of 66 very low birth weight
infants per year. Based on pilot data from our unit to
detect a 0.5 degree C difference between the treatment
and control groups with a power of 80% and alpha error Fig. 4. Possible mechanisms of prevention of heat loss with a vinyl
probability of 0.05% the expected number of infants bag. By providing an occlusive barrier, heat loss by
needed in the study was 8 in each arm. 15 The present evaporation of water is prevented. The barrier also prevents
convective heat loss from a cold draft in the delivery room.
study enrolled 27 patients. Fourteen infants were placed The baby continues to receive heat from the radiant warmer
in vinyl bags immediately following delivery without through the transparent vinyl bag.
drying.
Thirteen control infants received standard care with
drying and placement under a radiant warmer. Vital
signs including axillary temperature were taken on
admission to the neonatal unit. Gestational age (GA) was
assessed by the last menstrual period or from early
ultrasound scans in the first trimester. Patient
characteristics such as GA, birth weight, sex, race,
prenatal care, antenatal steroids, and chorioamnionitis
based on the histological examination were ascertained
from the maternal and pathology records. The worst pH
and base deficit in the first 6 hours, highest oxygen
requirement in the first 24 hours, intraventricular
hemorrhage (IVH) and mortality at 30 days were
evaluated. The two groups were compared using an
Fig. 5. Photograph of 26-week gestation infant in vinyl bag
unpaired ‘t’ test for continuous variables and Fisher’s
(photograph published with parental consent)
exact test for non-continuous variables. Statistical analysis
was performed using Statview 4.0 software. Significance
TABLE 1. Baseline Characteristics
was accepted at p < 0.05.
Vinyl bag Control P value
(14) (13)
RESULTS
Gestational age 26.3±0.5 26.3± 0.4 0.95 (NS)
Birth weight (g) 842 ± 55 838 ± 42 0.96 (NS)
There were no statistical differences in the baseline Apgar 1 min ( median) 4 3 0.69 (NS)
characteristics such as gestational age, birth weight, Apgar 5 min (median) 7 7 0.85 (NS)
Apgar scores, antenatal care, antenatal steroids, Sex: male (%) 9 (64.2) 5 (38.5) 0.13 (NS)
Antenatal care (%) 11(100) 12(92) 0.27 (NS)
histological chorioamnionitis and transfer time to NICU
Histologic chorioamnionitis (%) 6(43) 6(46) 0.3 (NS)
between the vinyl bag and standard care (control) groups Antenatal Steroids (%) 7(50) 3(23) 0.11 (NS)
(Table 1). The cord pH and base deficit were similar Multiple births 3 2 0.37 (NS)
between the two groups. The transfer time from the Mode of Delivery
delivery room to the NICU was slightly longer in the (vaginal/cesarean) 3/11 2/11 0.35 (NS)
Cord pH 7.33 + 0.02 7.33 + 0.01 0.96 (NS)
vinyl bag group but did not reach statistical significance
Cord Base Excess (mEq/L) - 0.98 + 0.73 - 1.35 + 0.58 0.7 (NS)
(Table 2). There was a difference of 1.0°C between the
average admission temperature between the treatment There was no Statistical Difference in the Baseline Characteristics
and control group. Six infants in the control group had an Between the Groups

Indian Journal of Pediatrics, Volume 74—March, 2007 251

 40

B. Mathew et al

TABLE 2. Results convective heat losses. Absence of drying also retains

vernix caseosa (if any present in premature infants). It is
Vinyl Bag Control P value
(14) (13) possible that retention of a highly hydrated biological
material such as vernix would decrease evaporative heat
Transfer Time (DR to 22.57 ± 1.9 18.8 ± 2.4 0.232 (NS) loss.14
NICU in minutes) It has been demonstrated in the present study that
Admission Temperature 35.86 (0.13) 34.92 (0.24) 0.002
deg C better admission temperatures can be achieved without
Hypothermia ( < 35 C) 0 6 (46%) 0.02 increasing the incidence of hyperthermia with the use of
Worst pH in the 7.32 + 0.018 7.22 ± 0.039 0.029 vinyl bags in extremely premature infants. The ambient
first 6 hours temperature in our delivery rooms are lower than the
Worst base deficit in -3.74 ± 0.924 -7.18 ± 1.77 0.09 (NS) WHO recommended temperatures (21°C compared to
first 6 hours (mEq/L)
Maximal Oxygen (%) 43.3 ± 4.7 82.9 ± 8.4 0.0004
26.7°C) and this may also explain the high incidence of
Hypotension (%) 5 (36) 6 (46) 0.26 (NS) hypothermia in the control group and the lower than
IVH Grade 3 or 4 (%) 4 (28) 3 (23) 0.32 (NS) optimum temperature (but significantly better) in the
Death in 30 days (%) 1 (7.1) 3 (23) 0.23 (NS) vinyl bag group. There was an increased incidence of
acidosis in the control group during the first 6 hours of life
probably secondary to hypothermia. The incidence of
normal umbilical arterial cord pH (table 1), the worst pH
neonatal mortality was higher in the control group
during the first 6 hours of life was significantly lower in
although this did not achieve statistical significance. Less
the control group (Table 2). The maximal requirement of
number of infants in control group received a complete
oxygen on ventilator or continuous positive airway
course of antenatal steroids (also statistically insignificant)
pressure (CPAP) was significantly higher in the standard
than the infants in the vinyl bag group and this may also
care group (Table 2). There was no statistically significant
contribute to the higher incidence of death in this group.
difference in the incidence of grade 3 or 4 intra-ventricular
Despite the obvious limitations of this study it is possible
hemorrhage between the groups. There were 3 deaths in
to conclude that this is an effective intervention that was
the neonatal period (28 days postnatal life) in the control
well received by the medical and the nursing staff in the
group compared to 1 in the treatment group. This did not
neonatal intensive care unit and the delivery room.
reach statistical significance.

CONCLUSION
DISCUSSION

Vinyl bags are an effective yet inexpensive intervention

It has been shown that placing preterm infants in vinyl
that is shown to significantly improve admission
bags in the delivery room significantly reduces the
temperature in VLBW infants. This technique can be
incidence of hypothermia (defined as admission
adapted in the delivery rooms of developed and
temperature <35°C) and increases mean admission
developing countries to improve admission temperatures
temperature by 1.0 °C in preterm infants. This is more
in extremely premature infants. Whether an improved
effective than drying and being placed under a radiant
admission temperature translates into better clinical
warmer.
outcomes in terms of mortality and neurodevelopmental
How does placing an infant in a vinyl bag under a
outcomes needs to be studied in larger multicentric trials.
radiant warmer prevent heat loss? The mechanisms
involved are not well studied. The chief determinant of
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