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STATE-OF-THE-ART
Thermal protection of the newborn in resource-limited
environments
K Lunze
1
and DH Hamer
2,3,4,5
1
Preventive Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA;
2
Center for Global Health and
Development, Boston University, Boston, MA, USA;
3
Department of International Health, Boston University School of Public Health,
Boston, MA, USA;
4
Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA and
5
Zambia Centre for Applied Health Research and Development, Lusaka, Zambia
Appropriate thermal protection of the newborn prevents hypothermia and its
associated burden of morbidity and mortality. Yet, current global birth practices
tend to not adequately address this challenge. Here, we discuss the
pathophysiology of hypothermia in the newborn, its prevention and therapeutic
options with particular attention to resource-limited environments. Newborns
are equipped with sophisticated mechanisms of body temperature regulation.
Neonatal thermoregulation is a critical function for newborn survival,
regulated in the hypothalamus and mediated by endocrine pathways.
Hypothermia activates cellular metabolism through shivering and non-
shivering thermogenesis. In newborns, optimal temperature ranges are narrow
and thermoregulatory mechanisms easily overwhelmed, particularly in
premature and low-birth weight infants. Hyperthermia most commonly is
associated with dehydration and potentially sepsis. The lack of thermal
protection promptly leads to hypothermia, which is associated with detrimental
metabolic and other pathophysiological processes. Simple thermal protection
strategies are feasible at community and institutional levels in resource-limited
environments. Appropriate interventions include skin-to-skin care, breastfeeding
and protective clothing or devices. Due to poor provider training and limited
awareness of the problem, appropriate thermal care of the newborn is often
neglected in many settings. Education and appropriate devices might foster
improved hypothermia management through mothers, birth attendants and
health care workers. Integration of relatively simple thermal protection
interventions into existing mother and child health programs can effectively
prevent newborn hypothermia even in resource-limited environments.
Journal of Perinatology (2012) 32, 317–324; doi:10.1038/jp.2012.11;
published online 1 March 2012
Keywords: newborn; neonatal; hypothermia; thermal protection
Introduction
The need for thermal newborn protection has long been known, as
alluded to by Soranus of Ephesus (98 to 138 AD) in his four-
volume treatise ‘On Diseases on Women’, which demonstrates the
importance of keeping newborns warm.
1
The Bible provides
probably the most well-known example of thermal protection of the
newborn in Luke 2: 7, ‘And she brought forth her firstborn son,
and wrapped him in swaddling clothes, and laid him in a manger.’
Yet, in current times, the majority of the almost 4 million
newborns globally who do not survive their first month of life
2
die
of complications associated with hypothermia, such as prematurity
and severe infections (mostly sepsis and pneumonia).
3
As two
recent reviews have acknowledged, neonatal deaths related to
hypothermia are relatively neglected, but considered easily
preventable with attention to warmth, feeding and infection
management.
4,5
This article focuses on the diagnosis of
hypothermia and management of thermal protection of newborns
in low-resource environments. We review mechanisms of neonatal
thermoregulation, discuss the pathophysiology of newborn
hypothermia and present simple strategies of thermal protection for
the newborn.
Neonatal thermoregulation
The normal body temperature of a newborn infant is usually
defined as ranging between 36.5 and 37.5 1C (97.7 to 99.5 1F).
6
A
series of observational randomized trials starting in the late fifties
7,8
showed that keeping babies warm reduces mortality and morbidity,
and spurred further research on the pathophysiology of
thermoregulation in newborns. Thermoregulation is a biological
priority for all homeothermic species.
9
Newborns, particularly
preterm and low-birth weight (LBW) infants, have limited capacity
for thermoregulation during the first weeks of life. The optimal
environmental temperature is termed thermal neutral temperature,
at which metabolic requirements of the organism are minimal.
10
Both a decreased and an increased core temperature increase the
metabolic rate of newborns,
11
who have only very limited ability to
maintain a normal temperature and easily become hypothermic or
hyperthermic. Although hyperthermia also increases energy needs,
hypothermia seems to carry a higher risk of complications.
12
Received 28 September 2011; revised 21 December 2011; accepted 24 January 2012; published
online 1 March 2012
Correspondence: Dr K Lunze, Preventive Medicine, Department of Medicine, Boston
University School of Medicine, Boston, MA, USA.
E-mail: karsten.lunze@post.harvard.edu
Journal of Perinatology (2012) 32, 317– 324
r
2012 Nature America, Inc. All rights reserved. 0743-8346/12
www.nature.com/jp
When the infant’s body temperature decreases in response to
sudden exposure to cold extrauterine environments, signals from
peripheral and central thermoreceptors reach the hypothalamus
through afferent pathways.
13
The resulting norepinephrine release
then triggers nonshivering thermogenesis, or lipolysis of brown
adipose tissue, which is the main homeothermic heat production
mechanism in newborns. Heat production occurs through
uncoupling ATP synthesis via the oxidation of fatty acids in the
mitochondria, utilizing uncoupled protein.
14
Afferent temperature information is processed in the
hypothalamus. Thermoregulation requires an intact central
nervous system,
15
and impaired thermoregulation, either hypo- or
hyperthermia, can be indicators of central nervous system damage.
The hypothalamus has a central role in regulating the autonomic,
somatic and endocrine systems to maintain a normal body
temperature. Decreasing body temperatures trigger a release of
thyroid-stimulating hormone, which leads to an increase in
thyroxine and consequently triiodothyronine. The resulting
norepinephrine release causes vasoconstriction, glycolysis and
uncoupling of mitochondrial oxidation in the brown adipose tissue,
further generating heat production.
14
The latter process is
ineffective in preterm infants, because it depends on the amount of
brown fat as well as levels of the enzymes 50/30-monodeiodinase
and thermogenin, which build up only later in fetal development.
13
Shivering is not regularly involved in a newborn’s reaction to
cold stress.
16
Another mechanism of heat production is infant
behavior:
10
the irritable baby prompts the mother to hold the baby,
drying, cuddling and swaddling him or her, thus preventing
heat loss.
Newborns are unable to maintain their body temperature on
their own without thermal protection. Although a newborn’s
thermoregulation is as complex as in adults if not more
sophisticated, as discussed above, their range of optimal or even
tolerable body temperature is narrower. A newborn placed naked in
an environment of 23 1C at birth suffers the same cold as does
a naked adult at 0 1C.
17
Without thermal protection, human
neonates are functionally poikilothermic, that is, they change their
body temperature according to environmental temperatures. In
newborns placed in a colder environment, core temperature
decreases at a rate 0.2 to 1.0 1C per minute and finally may lead to
death from cessation of metabolic activities.
10
Pathophysiology of newborn hypothermia
The World Health Organization (WHO) defines neonatal
hypothermia as a temperature below 36.5 1C (97.7 1F) and
proposes the following classification:
17
Mild hypothermia, caused
by cold stress, is classified as a body temperature range from 36 to
36.5 1C (96.8 to 97.7 1F) and is considered a cause for concern,
17
because the exposed infant begins to lose more heat than he or she
can produce.
13
Moderate hypothermia is a body temperature from
32 to 36 1C (89.6 to 96.8 1F), indicating danger and requiring
warming of the baby. According to the WHO classification, a body
temperature of <32 1C (89.6 1F) is considered severe hypothermia,
or cold injury, with a potentially grave outcome, and needs
immediate skilled attention.
Heat loss occurs in several ways. The most common scenario is
that of a wet baby who is not dried, and in whom evaporation of
fluid from the skin leads to heat loss. Evaporation often occurs with
amniotic fluids during the first minutes of life or with water after a
baby is bathed. The energy loss is substantial: immediately at
delivery, when the environmental temperature surrounding the
baby drops from 37 1C in the maternal womb to the usually less
warm air temperature, evaporative heat loss begins at a rate of
0.58 kcal ml
1
fluid evaporated.
10
A baby placed naked on a cold surface loses heat through
conduction. A newborn exposed to cool surrounding air or
draughts will lose heat through convection. Radiation from cool
objects next to the baby (for example, a cold wall) can also lower
its body temperature. Unlike in adults, sweat secretion has little or
no role in the thermoregulation of a newborn or preterm baby.
18
As all data on hypothermia are from observational studies and
prospective randomized trials without treating hypothermia are not
permissive, the direction of causality for factors associated with
hypothermia is not entirely clear.
Some argue that lowering body temperatures might increase
metabolic processes to generate heat, which could lead to
hypoglycemia and hypoxia in response to increasing energy
demands.
13
As hypothermia and hypoglycemia both exacerbate
hypoxia, this would reinforce a vicious circle
19
and could on one
hand explain the mortality associated with hypothermia. However,
studies have shown that hypothermia is not a risk factor for
neonatal hypoglycemia in analyses adjusted for confounders such
as LBW or anemia.
20
On the other hand, hypoglycemia is common
among newborns in resource-limited settings
20
and, instead of
being a consequence, could rather be a cause of hypothermia.
Similarly, with regard to the reported associations of
hypothermia with infections and organ failure,
21,22
hypothermia
might be either a consequence or a cause of severe infections.
Clinically, hypothermia is an indicator for severe infections
analogous to hyperthermia, or fever. In fact, neonatal hypothermia
is associated in an unclear direction of causality with various
pathologies such as surfactant inactivation, increased morbidity
from infection, abnormal coagulation, delayed readjustment from
the fetal to newborn circulation, hyaline membrane disease and
intraventricular hemorrhage in LBW infants.
23
In contrast, mild therapeutic hypothermia has emerged as a
neuroprotective strategy in the treatment of hypoxic ischemic
encephalopathy. Recent randomized controlled trials have shown
that therapeutic hypothermia initiated within 6 h of birth reduces
death and disability in these infants.
24
Induced under controlled
clinical conditions, therapeutic hypothermia has been discussed as
Thermal protection of the newborn
K Lunze and DH Hamer
318
Journal of Perinatology
being beneficial and outweighing the adverse effects in term
newborns with hypoxic ischemic encephalopathy
25
and during or
after cardiac surgery.
26
Neonatal hyperthermia
Heat is transferred in utero via the placenta through umbilical
arterial blood flow and via the uterus through amniotic fluid to the
fetus.
14
At birth, fetal temperature is usually 0.5 to 1.0 1C higher
than the mother’s
27
and increases not only with elevated maternal
temperatures due to prolonged labor, prolonged rupture of the
membranes or other infectious etiologies (chorioamnionitis,
urinary tract infection, and so on), but also with nulliparity and
epidural analgesia.
28
The most common cause of elevation of body temperature in
the newborn is dehydration.
29
Rehydration is both therapeutic and
diagnostic if the newborn improves. Elevated temperatures in the
neonate rarely reflect intrauterine or perinatal infections. Among
the 1 to 2.5% of newborns presenting with hyperthermia, <10%
have culture-proven sepsis.
10
In septic newborns, temperature
instability more frequently presents as hypothermia. The exact
mechanisms that lead to fever in some septic neonates and normal
body temperatures in others are ill understood. Infection is thought
to produce fever mediated through cytokines such as interleukin1.
Antipyretics are effective in reducing the temperature by modifying
the central set-point of the hypothalamus. In hyperthermia due to
environmental overheating, antipyretics are ineffective, and
newborns are appropriately managed by reducing the
environmental heat exposure.
Central malformations and intracranial hemorrhages, or
congenital pathologies such as the Crisponi syndrome,
30
are rare
causes of newborn hyperthermia.
Where thermoprotective devices are used, inappropriate
incubation and exposure to radiant warmers are common causes
of neonatal hyperthermia,
10
especially when makeshift apparatuses
such as light bulbs, hot stones, and so on, are used. These are
usually not designed and tested for safety and efficiency, and we
discourage their use in favor of skin-to-skin care (SSC).
Management of newborn hypothermia
Qualitative inquiries into current thermal practices
Although lack of equipment is a problem for high-risk neonates in
resource-poor settings, knowledge of hypothermia diagnosis and
management is another concern. For example, only about half of
160 surveyed health care professionals in India could define
neonatal hypothermia correctly or considered it a significant
problem, and <20% knew how to correctly record a newborn’s
temperature.
31
A multinational study showed that knowledge
on thermal control, especially concerning the physiology of
thermoregulation and criteria for defining hypothermia, was
insufficient and thermal control practices were frequently
inadequate.
23
Qualitative research on newborn care can help shed light on the
beliefs and attitudes underlying potentially detrimental or harmful
practices. Most published studies indicate that high-risk home
delivery and newborn care practices that lead to heat loss, such as
insufficient heating of the birthplace, placing of the uncovered
newborn on the ground or other cold surfaces, delayed
wrappingFpartly with unclean clothesFand early bathing,
remain common in resource-limited settings both in rural and
urban areas, in facilities and during home births.
5,32,33
Heating the birthplace is a critical issue for home births. Studies
from Nepal reported that the birthplace was heated in only slightly
over half of the settings,
34
often only after birth.
35
Wrapping the
child prevents heat loss from evaporation, whereas bathing
promotes heat loss. Less than half (46%) of the babies were
wrapped within the first 10 min after birth, and almost all of them
were bathed within 10 min (89%) or half an hour (96%) after
birth.
34
In another study, only 64% of the babies were observed to
be wrapped within half an hour after birth, and almost all were
bathed within 6 h after birth.
35
In a study from Tanzania, the practice of bathing newborns
immediately after delivery was shown to be motivated by concerns
about ‘ritual pollution’.
36
In Ghana, early bathing was linked to
reducing body odor in later life, shaping the baby’s head, and
helping the baby sleep and feel clean, and informants felt that
changing bathing behaviors would be difficult, especially as babies
are bathed early in facilities.
37
A study from Dhaka, Bangladesh,
explained that babies are typically bathed soon after birth to
purify them from the birth process.
38
Several studies, from
Uganda,
39
Ghana
37
and India
40
suggested that in the absence
of health facilities prepared to deliver essential newborn care,
community members would accept thermoprotective practices
such as SSC.
Clinical presentation
It has been estimated that prompt recognition of hypothermia and
re-warming of hypothermic infants will avert up to 40% of
neonatal deaths.
41
Newborn hypothermia presents with a
combination of low core temperature and cold skin, pallor
(acrocyanosis), tachypnea (respiratory distress), hypotonia,
lethargy or irritability, poor feeding or vomiting. The non-specific
clinical presentation and the complex process of thermoregulation
discussed above imply a number of differential diagnoses such as
infectious etiologies, respiratory distress syndrome, intraventricular
hemorrhage or other central nervous causes, hypoglycemia,
endocrine causes, or (maternal) drug side effects. Other factors
potentially underlying hypothermia include prematurity,
cardiovascular diseases and other congenital anomalies.
Thermal protection of the newborn
K Lunze and DH Hamer
319
Journal of Perinatology
Diagnosis
Initial assessment should include a history of the baby’s exposure
to cold and whether the baby has been appropriately clothed and
protected.
18
Although a rectal digital thermometer is used in many
studies as standard method to measure a newborn’s core
temperature, this measurement site is associated not only with
discomfort and disturbance to the newborn, but also with risks
such as rectal perforation and vagal stimulation with resulting
arrhythmias, bradycardia and apnea.
42
The axilla is a less invasive, alternative site that provides
reasonably accurate measurements. Mercury-in-glass, gallium-in-
glass, digital thermometer, analogous electric thermometer,
chemical thermometer and infrared thermometer are all accurate
instrument options, with the latter being less hazardous and
quicker than the former.
43
Most developed institutions use
tympanic thermometers, which have recently shown to be a quick
and accurate method to measure a newborn’s body temperature,
44
whereas simple rectal thermometers are used in most resource-
limited settings. WHO recommends frequent measurements, from
every hour in a seriously ill baby, two to four times per day in a
small or very small baby, to once daily in an infant progressing
well.
18
However, due to their cost, thermometers are often not
available in low-resource environments. Moreover, illiteracy and
inability to read Arabic numbers have been a challenge to
thermometer use.
In the absence of a measurement device, human touch of feet
and abdomen has been used as a proxy for body temperature.
Studies in India and Nepal have shown human touch to be
reasonably reliable for the detection of hypothermia when health
workers were trained for these investigations.
45– 49
Mothers,
however, seem to have a far lower sensitivity than health workers.
Only 24% of mothers in India were able to correctly identify
hypothermia.
50
A device based on color indicators developed to detect
hypothermia without the use of thermometers was previously found
to accurately indicate hypothermia when used by health workers or
mothers.
51,52
Its usefulness for some parts of the developing world
and the feasibility for illiterate health workers to read the device
have been debated.
53,54
Therapeutic goals of thermal care
The therapeutic goal of thermal care is to keep the newborn in the
thermoneutral zone, or thermal neutrality, the environmental
temperature range in which the organism has least oxygen
consumption.
9
No single environmental temperature is optimal for
all babies. In general, the smaller and more premature a newborn
is, the less its ability to regulate cold and heat. The optimal
environmental temperature thus depends on the maturity (usually
estimated by the gestational age) and age of the newborn. Weight,
body temperature and skin perfusion as well as clothing of the
infant and air humidity also factor in, so that the optimal
environmental temperature can be hard to determine. It is narrow,
especially in LBW or sick babies, and generally ranges from 32 to
36 1C.
55
It follows that a temperature appropriate for a healthy
term baby can be too cold for a preterm infant (and, conversely,
what is appropriate for the preterm infant can be too warm for the
term baby). In general, most newborns at birth, if left wet and
naked, cannot tolerate an environmental temperature of <32 1C.
However, if the baby is immediately dried, put skin-to-skin with the
mother and covered, the delivery room temperature can be as low
as 25 to 28 1C.
17
Prevention of newborn hypothermia
WHO recognizes maintaining a normal body temperature as a
primary principle of newborn care and recommends thermal
protection for all infants, with special attention for sick, premature,
or small for gestational age infants, for example, <2.5 kg at birth
or born before 37 weeks gestation.
18
Several methods can be
used for warming the baby and maintaining the baby’s body
temperature (Table 1). The WHO proposes a ‘warm chain’, a set of
10 interlinked procedures carried out at birth and during the
following hours and days. To be implemented in institutions and
(in an abridged form) at home, the warm chain aims to minimize
the risk of hypothermia in newborns, and includes warming the
delivery room, immediate drying, SSC, early and exclusive breast-
feeding, postponing bathing, appropriate clothing and bedding,
placing mother and baby together, and in institutions warm
transportation, warm resuscitation, and training and awareness
raising.
17
WHO recommends warming the delivery place in preparation for
a birth (to at least 25 1C) and to keep the birthplace free from
draughts. After delivery, it is crucial to devote some attention to the
baby. The first and most substantial heat loss occurs through
evaporation of amniotic fluid. Therefore, at birth, recommended
first steps to prevent hypothermia are to immediately dry and cover
the newborn, even before the cord is cut. While being dried, the
baby should be on a warm surface, preferably the mother’s chest or
abdomen in skin-to-skin contact. The infant should then be
clothed or covered, especially the head,
56
and kept in a warm
environment, again usually best with the mother. Bathing should
be delayed. Draughts, cold surfaces or nearby cold sources such as
windows or walls should be avoided as they contribute to heat loss
via convection and radiation.
Early breastfeeding, ideally within an hour after delivery, should
be encouraged if possible and if not contraindicated. SSC with the
mother, for LBW infants also known as kangaroo mother care,
most of the time is appropriate to ensure thermal protection of the
baby.
57
It requires minimal instructions and, when culturally
accepted, can relatively easily be applied even in a community or
home setting.
58
Thermal protection of the newborn
K Lunze and DH Hamer
320
Journal of Perinatology
Treatment of newborn hypothermia
According to current WHO guidelines for the treatment of cold
babies, moderate hypothermia should be treated by SSC.
18
In severe
hypothermia, rewarming the baby with an appropriate and
available method in a health care facility setting is warranted, as
close monitoring of vital signs including temperature and
respiratory rate are essential parts of the management. Blood
glucose should be controlled and hypoglycemia under 45 mg dl
1
(2.6 mmol l
1
) should be treated accordingly. When treating for
sepsis, all IV fluids should be given warm. The infant can be
discharged once a stable normal temperature is sustained and
there are no other issues. Upon discharge, the mother should be
counseled to prevent hypothermia at home as discussed above.
There is a relative scarcity of data documenting the effects of
recommended thermal newborn care. A recent meta-analysis
showed that SSC in conjunction with breastfeeding and recognition
of danger signs substantially reduced neonatal mortality in
hospital-born preterm babies (birth weight <2000 g) in hospital,
and was highly effective in reducing severe morbidity, particularly
from infection.
59
A study from Western India, in which 36.9% of
hospitalized newborns were hypothermic, reported a decrease in
this rate to 3.9% with kangaroo mother care.
60
However, in many
countries there is resistance from health professionals, mothers and
families related to local cultural practices.
61
Although evidence on
the effectiveness of SSC in community-based settings is scarce,
40,62
it is estimated that SSC can avert up to 20% of newborn deaths.
63
In the large Gadchiroli trial in India on home-based neonatal
care assessing the outcome of sepsis management, case
management included thermal protection of the newborn, and
health care workers were given a thermometer, baby clothes and
head cover, a blanket and a sleeping bag. Although the study
included other interventions and was not specifically designed to
prove a particular effect for hypothermia management, it showed a
reduction in neonatal and infant mortality by nearly 50% among a
malnourished, illiterate and rural study population.
64
A study from
Nepal that found a high incidence of hypothermia suggests that
simple interventions including immediate drying and another
treatment (breast contact, radiant heater and mustard oil massage,
or swaddling with an inner layer of plastic wrap) could lower the
incidence of hypothermia 2 h after birth from 78 to 23% and 24h
after birth from 49 to 18%.
65
In Zambia, we recently showed that
training traditional birth attendants in newborn care with special
emphasis on resuscitation and simple thermal protection (wiping
the newborn dry and wrapping the dried infant in a separate piece
of cloth) along with an intervention to provide early treatment of
possible sepsis reduced mortality rates at day 28 after birth by 45%.
66
Low-cost, low-tech treatment of newborn hypothermia
The use of incubators for thermal protection of newborns has been
reported for more than 150 years, since the Parisian obstetrician
Jean Louis Paul Denuce
´in 1857 engineered his couveuse, a device
Table 1 Management of hypothermia, modified from WHO 2003
18
Method Selection and use Advantages Risks or disadvantages Availability
SSC by mother or other
person
Management of stable babies with
moderate hypothermia, and for
hypothermia prevention
Mother can closely monitor other
person can provide SSC
Not appropriate for critical
conditions
Home and institutional
Kangaroo mother care with
LBW babies
Management of stable LBW babies
weighing 1.5 –2.5 kg, and for
hypothermia prevention
Mother can closely monitor.
Usually effective to maintain
normal body temperature
Mother might not be available.
Not for very LBW
Home and institutional
Radiant warmer, water
mattress
Management of sick babies weighing
X2.5 kg.
For initial assessment, treatment and
procedures; for hypothermia prevention
Allows observation of baby.
Allows for procedures to be
performed
Hyperthermia, dehydration.
Expensive to procure, requires
electricity
Institutional
Incubator Management of sick or at-risk babies.
Continuous care for babies weighing
p1.5 kg
Maintains constant temperature and
humidity.
Easy provision of oxygen.
Allows observation of baby (can be
naked)
Hyperthermia, dehydration;
microbiological contamination.
Expensive to procure, maintain,
clean; requires electricity.
Separation of mother and child
Institutional
Warm room Recovering babies Hypothermia.
Uncomfortable for adults
Home and institutional
Other methods (water
bottles, bricks, and so on)
For emergency situations only Not recommended Hypothermia.
Hyperthermia, burns
Home and institutional
Not recommended
Abbreviations: LBW, low birth weight; SSC, skin-to-skin care; WHO, World Health Organization.
Thermal protection of the newborn
K Lunze and DH Hamer
321
Journal of Perinatology
for the care of a premature infant. In 1878, his local colleague
Ste
´phane Tarnier, using a modified warming chamber for the
rearing of poultry, found a decrease in neonatal death rate from 66
to 38% among infants with birth weights <2000 g.
67
Today, postnatal care devices (isolettes or infant warmers)
combine the features of incubators and radiant warmer beds and
have evolved with many features, including automated temperature
and humidity regulations,
68
oxygen supplementation and light
therapy.
11,69
Although beneficial in resource-replete settings,
70
utilization of their complex features requires electricity,
concentrated oxygen supply, centralized suction and ongoing
skilled maintenance. Priced at about US$15 000 to $36 000,
71
these
devices are not affordable for most of the developing world.
Simplified versions, such as water-filled mattresses or Indian made,
low-cost radiant warmers are power-dependent and not appropriate
for resource-limited settings. Polyethylene occlusive skin wrapping
is a useful and effective method for delivery room management,
72
but mostly limited to immediate post-delivery care and protection
during transport.
A number of postnatal care devices for resource-limited settings
are currently in development, some including more sophisticated
temperature and humidity regulations. Examples are the ‘mkat,’
‘Life Raft Incubator,’ and ‘Neo.nurture’, projected to be priced
between US $200 and US $625 per unit.
73
The ‘Embrace Global’,
projected to be priced at a US $25 price, is a life vest style incubator
in a ‘sleeping bag’ design.
74
The heat source is a pouch-containing
phase change material, which keeps its temperature relatively
constant over an extended period of time. The pouch is warmed
electrically or by the user simply pouring hot water into a
compartment, upon indication by a thermal strip. It can fully open
to double as a heat mattress. With some models electricity
independent, it can be used both at the institutional and
community levels, and serve as visual reminders to mothers and
other caretakers, birth attendants and health care workers. Devices
such as these, although more costly than education alone, might
thus foster improved hypothermia management by transporting a
behavioral message to the end user, for example, promoting SSC.
Distributed commercially or donated, they could help to raise
awareness and enhance perception of the burden of newborn
hypothermia.
Conclusions
Thermal protection of the newborn can relatively easily be achieved
by warming of the delivery room, immediate drying, wrapping the
infant after birth and keeping him or her in close contact with the
mother, that is, kangaroo mother care or SSC, immediate and
frequent exclusive breastfeeding, delaying of bathing until the
infant is physiologically stable, and appropriate warm clothing.
These behavior steps represent simple, low-cost measures, which
should be integrated into holistic mother and child health
packages.
Birth practices even in high-risk environments remain poor, so
that interventions must primarily focus on participatory education
about hygiene, infection prevention and management, as well as
practices to avoid hypothermia. Low-cost, low-technology devices
might be helpful in supporting and implementing these practices.
Clinical effectiveness and implementation trials will have to
investigate which intervention packages and messages for the
thermal protection for newborns work best in a given environment,
and how to optimally integrate them into existing maternal and
newborn health programs.
Conflict of interest
The authors declare no conflict of interest.
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