Delivery Room Interventions for Hypothermia in Preterm Neonates

Abstract

IMPORTANCE Prevention of hypothermia in the delivery room is a cost-effective, high-impact intervention to reduce neonatal mortality, especially in preterm neonates. Several interventions for preventing hypothermia in the delivery room exist, of which the most beneficial is currently unknown. OBJECTIVE To identify the delivery room thermal care intervention that can best reduce neonatal hypothermia and improve clinical outcomes for preterm neonates born at 36 weeks' gestation or less.DATA SOURCES MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL databases were searched from inception to November 5, 2020.STUDY SELECTION Randomized and quasi-randomized clinical trials of thermal care interventions in the delivery room for preterm neonates were included. Peer-reviewed abstracts and studies published in non-English language were also included.DATA EXTRACTION AND SYNTHESIS Data from the included trials were extracted in duplicate using a structured proforma. A network meta-analysis with bayesian random-effects model was used for data synthesis.MAIN OUTCOMES AND MEASURES Primary outcomes were core body temperature and incidence of moderate to severe hypothermia on admission or within the first 2 hours of life. Secondary outcomes were incidence of hyperthermia, major brain injury, and mortality before discharge. The 9 thermal interventions evaluated were (1) plastic bag or plastic wrap covering the torso and limbs with the head uncovered or covered with a cloth cap; (2) plastic cap covering the head; (3) skin-to-skin contact; (4) thermal mattress; (5) plastic bag or plastic wrap with a plastic cap; (6) plastic bag or plastic wrap along with use of a thermal mattress; (7) plastic bag or plastic wrap along with heated humidified gas for resuscitation or for initiating respiratory support in the delivery room; (8) plastic bag or plastic wrap along with an incubator for transporting from the delivery room; and (9) routine care, including drying and covering the body with warm blankets, with or without a cloth cap. RESULTSOf the 6154 titles and abstracts screened, 34 studies that enrolled 3688 neonates were analyzed. Compared with routine care alone, plastic bag or wrap with a thermal mattress (mean difference [MD], 0.98 °C; 95% credible interval [CrI], 0.60-1.36 °C), plastic cap (MD, 0.83 °C; 95% CrI, 0.28-1.38 °C), plastic bag or wrap with heated humidified respiratory gas (MD, 0.76 °C; 95% CrI, 0.38-1.15 °C), plastic bag or wrap with a plastic cap (MD, 0.62 °C; 95% CrI, 0.37-0.88 °C), thermal mattress (MD, 0.62 °C; 95% CrI, 0.33-0.93 °C), and plastic bag or wrap (MD, 0.56 °C; 95% CrI, 0.44-0.69 °C) were associated with greater core body temperature. Certainty of evidence was moderate for 5 interventions and low for plastic bag or wrap with a thermal mattress. When compared with routine care alone, a plastic bag or wrap with heated humidified respiratory gas was associated with less risk of major brain injury (risk ratio, 0.23; 95% CrI, 0.03-0.67; moderate certainty of evidence) and a plastic ...

Optimising homeothermy in neonates: A systematic review and clinical guidelines from the French Neonatal Society

“…Abiramalatha et al performed a systematic review and network meta‐analysis of delivery room interventions to prevent hypothermia in preterm infants. The researchers found that relative to routine care, use of a plastic bag or wrap was associated with a greater core temperature whether alone (mean difference [95% confidence interval] = 0.56 [0.44–0.69]°C) or combined with a thermal mattress (0.98 [0.60–1.36]°C), heated humidified inhaled air (0.76 [0.38–1.15]°C) or a plastic skullcap (0.62 [0.37–0.88]°C) 29 …”

“…In the subpopulation of preterm infants <28 weeks of gestation the effect was even greater: 24 of the 35 (69%) infants receiving heated, humidified gases were normothermic, compared with 16 of the 38 (42%) infants in the group control ( p = 0.03) 45 . In a network meta‐analysis of delivery room interventions designed to prevent hypothermia in preterm infants, Abiramalatha et al found that the combination of a plastic bag or wrap with heated, humidified gases was associated with a greater core temperature than for routine care, with mean difference [95% CI] = 0.76 [0.38–1.15]°C 29 …”

“…There was no significant intergroup difference for the following morbidities: major brain injury defined as ultrasound evidence of intraventricular haemorrhage with ventricular dilatation, parenchymal haemorrhagic infarction, or periventricular leukomalacia and the duration in days of oxygen therapy from initiation at birth to discontinuation, or in mortality prior to hospital discharge (3 randomised clinical trials; n = 161; relative risk (RR) [95% CI] = 0.63 [0.32-1.22]). 4 29 The results of a randomised clinical trial with 801 infants were similar for extremely preterm infants born between 24 and 27 weeks of gestation: preterm infants in the polyethylene bag group had a higher mean body temperature on admission, although the intergroup difference in the mortality rate was not statistically significant. 30 Other randomised clinical trials found similar results: the use of a polyethylene bag on admission was associated with a higher body temperature in preterm infants with a gestational age below 34 weeks of gestation in one trial 31 and below 30 weeks of gestation in another.…”

Do Delivery Room Thermal Care Interventions in Preterm Neonates Improve Neonatal Outcomes?

“…3,4 Although the plastic bag or wrap with thermal mattress provided the greatest improvement for core body temperature as well as a trend with decreased mortality, it was associated with an increased risk of hyperthermia, which the authors suggest may not be the optimal first-line modality. 5 Importantly, plastic bag or wrap with heated humidified gas was associated with a decrease in major brain injury and mortality. 5 This systematic review and metaanalysis has multiple limitations.…”

“…5 Importantly, plastic bag or wrap with heated humidified gas was associated with a decrease in major brain injury and mortality. 5 This systematic review and metaanalysis has multiple limitations. cap.…”