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HYPOTHERMIA IN NEONATES

Fuji Oktavia Sinurat


Gustien Enderina
Nadia Septi
Sri Endah Riestina
Introduction
10 per 1000
WHO
newborns
World
SDKI

Indonesia Riskesdas

Etiology Permenkes RI Girls : 62,5%


No.53 2014 Boys : 37,5%
Complication
WHO. 1997.
SDKI. 2012.
Prevention Riskesdas. 2007.
Permenkes. 2014
Definitions
Hypothermia in neonates → body temperature
< 36,5oC at axillary temperture measurement.

WHO. 1997.
Classifications
Mild Hypothermia 36 – 36,4°C
Moderate Hypothermia 32 – 36°C
Severe Hypothermia <32°C
<35°C : weight under 1000 gram

WHO. 1997.
• Incidence hypothermia : 8,5-52%
• In the develop countries, 17 million newborn was
hypothermia
• Risk of hypothermia increase 24-72 hours after life
• Mortality increase 80% for decrease 1ºC

Mullany LC. 2010


Lunze K. 2013
Farhadi R. 2014
Source: Multiple births.
Risk Factor
• Premature, small for gestational age, LBW <1500 gr
• Severe disease, sepsis and surgical problem
• Not immediately breastfed after birth
• Cold / windy environment, wet clothes
• Inadequate warming during infant referral

Rifai R. 2013
Normal Response to Cold Stress
• Vasocontriction
• Increased muscle activity and flexion
• Brown fat metabolism
• Increased metabolic rate and oxygen
consumption

Stable. 2006.
Mechanism of Heat Loss
1. Conduction

Placed on unheated
Warm baby
surface

Body temperature Baby loses heat to


drops surface

Stable. 2006.
2. Convection

Heat loss faster


if room temperature cool

Keep baby warmer sides up

Stable. 2006.
3. Evaporation

Heat loss when moisture


turned to vapor

Dry thoroughly  remove wet


linens, protect from drafts,
apply hat

Stable. 2006.
4. Radiation
Heat transfer between solid
surfaces not in contact with
each other

Move away from windows


and outside wall and use
double walled incubator

Stable. 2006.
Respons hypothermia for term infant
Pulmonary ↑ R to L
Hypoxemia
N vasoconstriction shunting
O
R ↑ Metabolic ↑ glucose
E rate utilization
P
I Brown fat Depletion of
N metabolism glycogen
E stores
P
H Hypoglicemia
R Peripheral
vasoconstriction ↑ O2
I
N consumption
E ↓ O2 delivery to
tissues Stable. 2006
Hypoxia Yunanto A. 2008.
Respons to hypothermia for preterm infant
Pulmonary vasoconstriction ?
N
O
R ↑ Metabolic ↑ O2
E rate consumption
P
I Peripheral
N vasoconstriction
E limited
P
H ↓ O2 delivery to
Hypoxia
R tissues
I
N Depletion of
↑ glucose
E glycogen Hypoglicemia
utilization
stores
Stable. 2006
Yunanto A. 2008.
Sign and Symptoms
Early Symptoms Late Symptoms

• Low capacity to feed • Apnea, bradhycardia,


• Sianosis marmorata sianosis
• Lethargy, crying weakly • Hypoglycemia, metabolic
• Takipneua & tachycardia acidosis, respiratory
distress, circulation
problem, hypotension
until shock

Yunanto A. 2008.
Diagnosed
• Bathed immediately after birth
• History of infant is not drained after birth and not kept warm
• Expose to cold environment
Anamnesis • Action without additional warmth to the infant

• Temperature <36,5oC
• Breath slowly and deeply
• Respiratory distress
Physic • Heart rate <100 times per minute
Examination • Lazy to drink
• Lethargy
• Hard palpable skin
Yunanto A. 2008.
Treatment
Moderate hypothermia Severe hypothermia
Change cold and wet Place in the infant warmer
clothes with warm clothes Change cold and wet
Skin to skin contact clothes with warm clothes
Early breastfeeding Treat for sepsis
Infant warmer Measure blood glucose
Measure blood glucose Look for emergency sign
Treat for breathing difficulty Treat for breathing difficulty
Measure temperature Measure temperature

WHO. 2003.
Incubator

• Set temperature 1 to 1,5 ºC


above infants core
• Monitor while rewarming
• Increase temperature again
1 to 1,5 ºC above infants
core
• Continue until temperature
normal

Stable. 2006.
Infant Warmer

• Servo-temperature probe
located over the liver &
servo-control set at 36,5 ºC
• Monitor while rewarming
• Rewarming slowly if the
infant deteriorates

Stable. 2006.
CASE REPORT
Identity
– Name : By. DC Parents
– No MR : 961665 – Father : Mr. SS

– Address : Borneo, Siak – Mother : Mrs. DC


Hulu, Kampar – Date of admission : 30th July 2017
– Religion : Protestan – Date of physicall
– Ethnic : Batak examination : 31st July 2017
– Exit date : 6th August 2017
– Patient status : Alive
Anamnesis
• Chief Complaint:
6 hours old infant problem feed.
History of Present Illness
4 hours
Born on 30 July 2017,
SC with indication carried by incubator Camar 1,
PROM 2 days and transport IMD (+)
history of SC
6 hours

Treatment : Placed in infant Anxious and problem


formula milk 25 warmer, SCN I feeding, GDS 44 mg/dl,
cc/3 hours T: 35,6 ºC and T : 35,5C
installation OGT
8 hours
10 hours 13 hours 16 hours
T : 36,1 ºC T : 36,7 ºC, GDS :
GDS : 97 T : 36,5 ºC 104 mg/dl T : 36,5 ºC
mg/dl
History of Present Illness
Days 2

Alert, pale (-), dyspneu (-), Treatment :


warm acral, 2210 gram, Omeprazole 5 mg, kalnex 25
mg, Vit K 1 mg, Mikasin 16,5 NICU
36,5 ºC, GDS : 89 mg/dl,
mg, Bactesin 165 mg
OGT : red-black fluid

Days 3 and 4
Alert, pale (-),
Treatment :
dyspneu (-), warm acral,
Omeprazole 5 mg, kalnex 25
Temperature and GDS in
mg, Vit K 1 mg, Mikasin 16,5
normal range, OGT : red-
mg, Bactesin 165 mg
black fluid
History of Present Illness
Days 3, 4 and 5

Alert, pale (-), Treatment :


dyspneu (-), warm Breast milk/3 hours,
acral, Temperature and SCN I Mikasin 16,5 mg, Bactesin
GDS in normal range, 165 mg
OGT : clear

Follow up
Day 7
18 Sept 2017, by phone :
Neonate allowed to 1 month 2 weeks after
go home, temperature treated, baby is in good
and GDS in normal health, weight 4000 gr,
range, weight 2120 gr. Hepatitis B and BCG,
breast milk.
Pregnancy History
• Multigravida, 37-38 weeks, 2 times ANC in Obstetrician.
• History of vaginal discharge (+), white-yellow colour, itchy,
bad odor, untreated since 6 months pregnancy.
Parents History
• Mother 23 years old, Diploma 3, housewife, no income,
BPJS
• Father 35 years old, SMA, entrepreneur, income 2
million per month
Family History
• First child, born in 2015, a boy, weight 2700 gram, SC
with indication Frank breech presentation
The Important Things from Mother
• Multigravida, PROM 2 days, SC history, vaginal discharge
history, green and thick amniotic fluid, two times ANC in
Obstetrician.
The Important Things from Neonate

• Anxious and problem feeding, 37-38 weeks, 2400


gram, 35,6 0C, GDS 44 mg/dL, red-black fluid on OGT.
Working Diagnosis
• Term infant (37─38 weeks) - Appropiate for gestational
age - low birth weight (2400 g)
• Moderate hypothermia with improvement
• Hypoglycemia with improvement
• Suspect early sepsis
Prognosis
• Quo ad vitam : Dubia ad bonam
• Quo ad functionam : Dubia ad bonam
Discussion
THEORY
Mother refered to RSUD AA caused by
premature rupture of membrane 2 days
and limitation of health facility for mother
and the baby

CASE
Mother refered to RSUD AA with complain
premature rupture of membrane 2 days
THEORY
ANC minimal are 4 times to prevent
pregnancy and labor complication
ANC two times allow treatment of vaginal
discharge cannot be treated properly

CASE
Mother did ANC two times in midwife

Kemenkes. 2013
THEORY
Risk of hypothermia can caused by body
weight under 2500 gram and infection
from untreated vaginal discharge history
Treatment : placed in infant warmer at
36,5 ºC, after 4 hours in IPN reach
normal temperature (36,5 0C)

CASE
Temperature of the baby is 35,6 0C
(hypothermia)

Yunanto A. 2008.
THEORY
Hypothermia increase requirement of body
metabolism and release glycogen reserve
hypoglikemia
Hypoglikemia also one of sign of infection
Treatment : oral intake, GDS in normal range after
2 hours in IPN

CASE
In this neonatus showed blood glucose 44
mg/dL (hypoglycemia)

Stable. 2006.
THEORY
Hypothermia is one of simptom of infection. Red-
black fluid on OGT, CRP (+), hypoglikemia,
untreated vaginal discharge history, green, itchy
and viscous amniotic fluid, PROM 2 days are sign
of infection that fulfill the criteria of early sepsis
Treatment : fasting and antibiotic

CASE
body weight (8%), red-black fluid on OGT, CRP (+),
hypoglikemia, untreated vaginal discharge history,
green, itchy and viscous amniotic fluid, PROM 2 days
Aminullah A. 2008
THEORY
The baby will allowed to go home after 7 days
giving antibiotic and sucking reflex is good

CASE
The baby will allowed to go home after
sucking reflex is good and bod weight
increase normally
THEORY
WHO : Raise of body weight is 20-
30 gram/day until 3 months with
exclusive breastfeeding

CASE
Follow up : Body weight increase 1800
gram for 1 month 2 week after treatment
in hospital, breastfeeding

WHO. 2005
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