NEONATAL

HYPOTHERMIA
CIU AUGUST SEM 2022
 SESSION OBJECTIVES
 Describe thermal protection of the newborn

Explain mechanism of newborn loses heat, causes and risk factors

Describe Effects and signs of hypothermia

Discuss warm chain and optimal thermal environment

Discuss Management of hypothermia

Introduction
Hypothermia in the newborn period can lead to serious and potentially life-threatening
complications. Hypothermia can occur at birth, during transfer of infants to neonatal units,
during routine care and in operating theatres.

Hypothermia is a common cause of neonatal morbidity and mortality, and increasingly

recognized as a risk factor for new-born survival

Prevalence in Uganda?
MECHANISMS OF HEAT PRODUCTION IN
THE NEWBORN
Metabolic processes
• The brain, heart, and liver produce the most metabolic energy by oxidative metabolism of
glucose, fat and protein.
• The amount of heat produced varies with activity, state, health status, environmental
temperature.
Voluntary muscle activity
• Increased muscle activity during restlessness and crying generate heat.
• Conservation of heat by assuming a flexed position to decrease exposed surface area.
MECHANISMS OF HEAT PRODUCTION IN THE
NEWBORN
Peripheral vasoconstriction
• In response to cooling, peripheral vasoconstriction reduces blood flow to the skin and therefore decreases lo
of heat from skin surfaces.
Nonshivering thermogenesis
Heat is produced by metabolism of brown fat.
•Term newborns have a source for thermogenesis in brown fat, which is highly vascularized and innervated by
sympathetic neurons.
• Thermal receptors transmit impulses to the hypothalamus, which stimulate the sympathetic nervous system
and causes norepinephrine release in brown fat (found around the scapulae, kidneys, adrenal glands, head, ne
heart, great vessels, and axillary regions).
• Norepinephrine in brown fat activates lipase, which results in lypolysis and fatty acid oxidation.
• This chemical process generates heat by releasing the energy produced instead of storing it as Adenosine-5-
Triphosphate(ATP).
 Factors That Place Infants at Risk for
Hypothermia and Cold Stress
1. Neurologic (i.e. asphyxiated infant or one with central nervous system abnormality):
Intact central nervous system necessary for heat regulation
2. Infection
- Increased metabolic rate
- Increased use of glucose stores
3. Hypoglycemia
- This is common in babies born to diabetic mothers
Factors That Place Infants at Risk for
Hypothermia and Cold Stress
.4.Neural tube and abdominal wall defects
- Increased surface area for heat loss
- Increased evaporative heat loss and
Cold Stress
5. respiratory distress syndrome and
asphyxia can lead to
- Tachypnea causing heat loss
- Decreased oxygen availability
6. congenital heart diseases
Newborn lose heat in four ways
 Description of heat loss
There are four ways in which a newborn loses body heat:
• Evaporation: when amniotic fluid evaporates from the skin. Evaporative losses may
be insensible (from skin and breathing) or sensible (sweating). Other factors that
contribute to evaporative loss are the newborn’s surface area, vapor pressure and
air velocity. This is the greatest source of heat loss at birth.
• Conduction: when the newborn is placed naked on a cooler surface, such as table,
scale, cold bed. The transfer of heat between two solid objects that are touching, is
influenced by the size of the surface area in contact and the temperature gradient
between surfaces.
•
Description of heat loss cont,
Convection: when the newborn is exposed to cool surrounding air or to a draft from
open doors, windows or fans, the transfer of heat from the newborn to air or liquid is affected by the
newborn’s large surface area, air flow (drafts, ventilation systems, etc), and temperature gradient.

• Radiation: when the newborn is near cool objects, walls, tables, cabinets, without actually being in
contact with them. The transfer of heat between solid surfaces that are not touching. Factors that
affect heat change due to radiation are temperature gradient between the two surfaces, surface area
of the solid surfaces and distance between solid surfaces. This is the greatest source of heat loss after
birth.
Classification of hypothermia
Primary Hypothermia: – Seen immediately after delivery –
Normal term infant delivered into a warm environment may drop shortly after birth
may not achieve a normal stable body temperature until the age of 4 – 8 hours.
In low birth weight infants, the decrease of body temperature may be much greater and more
rapid
Classification cont,
Secondary Hypothermia: –
This occurs due to factors other than those immediately associated with delivery.
Important contributory factors are: e.g.: Acute infection especially Septicemia.

Classification according to Severity: (Using axillary temperature)

mild hypothermia (36.0 °C–36.4 °C)
moderate hypothermia (32.0 °C–35.9 °C)
severe hypothermia (< 32.0 °C)
Clinical features
(a) Peripheral vasoconstriction
-Acrocyanosis
-Cool extremities
-Decreased peripheral perfusion
(b) CNS depression
-Lethargy
-Bradycardia
-Apnea
-Poor feeding
Clinical features cont,
(c) Increased metabolism
-Hypoglycemia
-Hypoxia
-Metabolic acidosis
(d) Increase of pulmonary artery pressure
-Distress
-Tachypnea
What is thermal protection of the newborn?

the World Health Organization (WHO) (1997; 2003) define normal axillary temperatures to be
between 36.5°C and 37.5°C.

Thermoregulation is the ability to balance heat production and heat loss in order to maintain
body temperature within a certain normal range.

Thermal protection of the newborn is the series of measures taken at birth and in the first days
of life to ensure that the newborn does not become either cold or overheated and maintains a
normal body temperature of 36.5-37.5°C
 Keeping a newborn baby warm after
delivery
Method of heat loss Prevention

Evaporation: Wet baby Immediately after birth dry baby with a clean,
warm, dry cloth

Conduction: Cold surface Put the baby on the mother’s abdomen or on

e.g weighing scale etc. a warm surface

Convection: Cold draught Provide a warm, draught free room for

delivery at ≥25oC

Radiation: Cold metallic Keep the room warm

surroundings
 Methods used to treat hypothermia
SEVERITY OF HYPOTHERMIA
Mild hypothermia (body temperature 35-36.3°C)
Moderate hypothermia
(body temperature 32-34.9°C)
Severe hypothermia
(body temperature below 32°C)
METHODS USED
Skin-to-skin contact, in a warm room (at least 25°C).
• Place cap on newborn head
• Cover mother and newborn with warm blankets
Under a radiant heater
• In a warmed incubator
• In a heated water-filled mattress (i.e. KanBed)
• If no equipment is available or if the newborn is clinically
stable, skin-to-skin contact with the mother can be used in a
warm room (at least 25°C)
Using a warm incubator (should be set at 1 to 1.5°C
higher than the body temperature) and should be
adjusted as the newborn’s temperature increases
• If no equipment is available, skin-to-skin contact or a
warm room or cot can be used
Strategies for the warm chain
1 Warm delivery room
The "warm chain" is a set of interlinked
2 Immediate drying
procedures to be taken at birth and during the
3 Skin-to-skin contact
next few hours and days in order to minimize
4 Breast-feeding
heat loss in all newborns 5 Bathing and weighing postponed

The 10 steps of the "warm chain“ as listed : 6 Appropriate clothing/bedding

7 Mother and baby together
8 Warm transportation
9 Warm resuscitation
10 Training and awareness raising
 Treating hypothermia
Warm the infant
Skin-to-skin care is a very effective method of warming a cold infant or warm neonate in a closed incubator,
overhead radiant warmer or warm room.. The incubator temperature should be set gradually at 37 °C until the
skin temperature returns to normal. Warm water (bottles may be used ( Uganda guidelines)
Provide energy while the infant is being warmed. Hypoglycaemia may occur during warming. Energy can be
given as oral or nasogastric milk, or intravenous maintenance fluid containing 10% dextrose water
Provide oxygen. Although centrally pink, cold infants are often hypoxic. Therefore, give 30% oxygen (FiO₂ 0.3)
while the infant is being warmed. A normal oxygen saturation in a cold infant does to exclude tissue hypoxia as
oxygen is trapped in the red cells.
Give 4% sodium bicarbonate. Most hypothermic infants have a metabolic acidosis. If intravenous fluid is given,
add 10 ml 4% sodium bicarbonate to 100 ml of maintenance fluid. Obtain a blood gas analysis if possible and
half correct any base deficit.
Observations. Monitor and record the infant’s temperature, pulse, respiration, skin colour and blood glucose
concen­tration until they are normal and stable.
Antibiotics. Give parenteral antibiotics if there are any signs of infection
 Reading assignment
Read the following articles
Neonatal hypothermia in Uganda: prevalence and risk factors
https://pubmed.ncbi.nlm.nih.gov/15917265/

Mukunya D, Tumwine JK, Nankabirwa V, et al Neonatal hypothermia in Northern Uganda: a

community-based cross-sectional study https://bmjopen.bmj.com/content/11/2/e041723
 References
Ministry of Health Uganda , (2021) Essential Maternal and Newborn Clinical Care Guidelines for Uganda
Manual of neonatal care / editors, John P. Cloherty ... [et al.]. — 7th ed.

Wong’s nursing care of infants and children / [edited by] Marilyn J. Hockenberry, David Wilson.—10th
edition
Byaruhanga R, Bergstrom A, Okong P. Neonatal hypothermia in Uganda: prevalence and risk factors. J Trop
Pediatr. 2005 Aug;51(4):212-5. doi: 10.1093/tropej/fmh098. Epub 2005 May 25. PMID: 15917265
Mukunya D, Tumwine JK, Nankabirwa V, et al Neonatal hypothermia in Northern Uganda: a community-
based cross-sectional study

BMJ Open 2021;11:e041723. doi: 10.1136/bmjopen-2020-041723