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TEMPERATURE CONTROL

IN THE NEONATE

Dr. Johanus Edwin,SpA

Introduction
Hypothermia

associated with increased


morbidity/mortality in newborns of all birth
weights/ages

Now considered independent risk factor for mortality


in preterm

Western

philosophy of conventional care


premature baby should be
Placed under radiant warmer
Uncovered for full visualization and to allow radiant
heat to reach body

More

attention now focused on thermal care


immediately after birth and during resuscitation

Premature Susceptibility to
Heat Loss

High surface area to volume ratio


Thin non-keratinized skin
Lack of insulating subQ fat
Lack of thermogenic brown adipose
tissue (BAT)
Inability to shiver
Poor vasomotor response

Thermoregulation
Metabolic

adult

rate of fetus per tissue wt. higher than

Heat also transferred from mother to fetus via


placenta/uterus

Fetal

temp consistently 0.3-0.5 deg C higher than


mothers (always in parallel)

Even when mothers temp elevates (eg fever)

Despite

heat

BAT in utero, fetus cannot produce extra

Exposed to adenosine and prostaglandin E2 inhibitors


of non-shivering thermogenesis (NST)
Metabolic adaptation for physiologically hypoxic fetus
since NST requires oxygenation
Inhibition of NST allows accumulation of BAT

Thermoregulation

Heat gain/loss controlled by


hypothalamus and limbic system

Thermoregulatory system immature in

newborns
(esp premature newborn)

Thermoregulation
In term infant, response to cold stress
relies on oxidation of brown fat (NST)

Development begins 20th wk until shortly


after birth (comprises 1% body wt at that time)
High concentration stored TGs
Rich capillary network densely innervated by
sympathetic nerve endings
Temperature sensors on posterior
hypothalamus stimulate pituitary to produce
thyroxine (T4) and adrenals to produce
norepinephrine
Lipolysis stimulated energy produced in
form of heat in mitochondria instead of
phosphate bonds by uncoupling protein-1 (aka
thermogenin)

Thermoneutral
Environment

Temp and environmental conditions at


which metabolic rate and O2
consumption are lowest
Silverman et al

Maintaining constant abdominal skin temp b/w


36.2-36.5 deg C optimal

WHO classification of hypothermia


Mild: 36-36.4deg C
Mod: 32-35.9deg C
Severe: <32deg C

Risk Factors

All neonates in 1st 8-12hrs of life


Prematurity
SGA
CNS problems
Prolonged resuscitation efforts
Sepsis

Neonatal Energy Triangle

Adverse Consequences of
Hypothermia

High O2 consumption hypoxia, bradycardia


High glucose usage hypoglycemia /
decreased glycogen stores
High energy expenditure reduced growth
rate, lethargy, hypotonia, poor suck/cry
Low surfactant production RDS
Vasoconstriction poor perfusion
metabolic acidosis
Delayed transition from fetal to newborn
circulation
Thermal shock DIC death

Modes of Heat Loss


Conduction

- direct heat transfer from skin to


object (eg mattress)
Convection - heat loss through air flow

Also depends on air temp

Radiation

- direct transfer by electromagnetic


radiation in infrared spectrum

Heat gained by radiation from external radiant energy


source
Heat lost by radiation to cooler walls of incubator

Evaporation

- heat loss when water evaporates


from skin and respiratory tract

Depends on maximum relative humidity of


surroundings less humidity = more evaporation

Heat Loss at Birth


Hammarlund

et al, 1980
Evaporative water loss

81-125 gm/m2/h when unwiped in ambient temp


~25.8deg C and 42% humidity

Heat

loss through

Evaporation: 60-80 W/m2


Radiation: 50 W/m2
Convection: 25 W/m2
Conduction: negligible
Total heat loss = 135-155 W/m 2

All

babies that were >3250g - body temp


decreased 0.9deg C in 15min

Heat Loss at Birth

Hammarlund et al, 1979

Naked infants <28wks need ambient temp


~40C to maintain normal temp in 20%
humidity

Increasing humidity to 60% halved losses

Management

Healthy newborn
Dried & wrapped in prewarmed clothes
Use of cap
Examination should be done under radiant
warmer
If temp is stable the infant should be placed
with blanket

Management

Sick newborn
Dried
Transportation
Radiant warmer
Use of cling wrap

Management

Sick newborn

Incubator with maintenance of thermoneutral


zone temp.

Humidification of incubator

Management

Newer devices

Double walled incubators


Limit radiant heat loss
Decrease convective and evaporative losses

Hybrid
devices

Giraffe

Versalet

Kangaroo Mother Care


(KMC)

Introduced in 1983 by Rey and Martinez


in Colombia
LBW infants nursed naked (wearing only cloth
diaper) between mothers breasts
Data from other countries show infants nursed
by KMC have

Fewer apneic episodes


Similar or better blood oxygenation
Lower infection rates
Are alert longer and cry less
Are breastfed longer and have better bonding
Improved survival in low-resource settings

Hazards of temp control


methods
1.

Hyperthermia

2.

Undetected infections

3.

Volume depletion/ dehydration

Thank you