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ANNEXURE – I: ETHICAL CLEARANCE CERTIFICATE

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ANNEXURE – II: INFORMED CONSENT FORM

Informed Consent Form for participation in Research

Title: “Studies of Transitional Adaptation (Cardiopulmonary Physiology) in

babies born at Hospital and those born at Primary Health Centers and Homes in

Rural villages”

Investigator: Dr Manisha Bhandankar, Assistant Professor

Department Of Pediatrics, JN Medical College, Belgaum

Supervisor: Dr V D Patil, Professor of Pediatrics

JN Medical College, Belgaum

Objective/Purpose of the study:

Many changes take place in the body functions of the babies immediately after

birth. The first cry indicates that baby is breathing on its own. Baby’s skin color

changes from blue to pink as the baby starts breathing regularly. Fortunately in most

babies these changes occur smoothly. If the baby is unable to establish normal

respiration and heart rate it may lead to difficulties requiring treatment. The purpose

of this study is to monitor changes that occur in a normal newborn immediately after

birth till first three days of life.

Procedure:

We want to understand how babies born in our hospital /homes adjust their

body functions by measuring Heart Rate, respiratory rate, Blood pressure,

temperature and Oxygen saturation (level of oxygen in body) using instruments

attached to baby soon after birth. They will be attached to hand/foot and abdomen

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without causing any hurt to your baby. Information gathered will be stored in the

computer and analyzed. We will also examine the baby regularly during this period.

Additionally, we will take small drops of blood by heel prick four times during this

study period.

Risks and Benefits:

Standard precautions will be taken during application of the monitoring

equipments and while collecting the blood samples. We understand that newborn

babies are special and vulnerable group and utmost care needs to be taken during the

procedure. Please understand that information gathered from your baby will be

extremely important to understand how babies adopt to environment after birth and if

they develop difficulties how we can help them better adopt to home/hospital

conditions. This will not only help your baby but many other babies. It will prevent

many potential deaths in future.

Institutional/sponsors Policy:

If the baby develops any problem during the study period baby will be treated

without delay as necessary. You will not be charged for the monitoring done for this

study.

Alternatives:

Your participation in this study is completely voluntary. You may withdraw

from the study any time for any reason and it will not affect the care given to you and

your baby.

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Financial incentives for Participation:

You will not be charged for these studies. Also you will not be paid any form

of incentive to participate in this study.

Authorisation to publish results, Privacy and Confidentiality:

The results of this study may be published for public interest and scientific

purpose. However your name will not be identified and confidentiality of the data will

be maintained. Only Dr V D Patil Professor of Pediatrics and Principal JN Medical

College, Dr D Vidyasagar, Professor of Pediatrics, University of Illinois, Chicago,

Illinois and Dr Manisha Bhandankar, Assistant Professor, Department of Pediatrics

JN Medical College, Belgaum will have excess to the data.

In case of emergency you may contact Dr Manisha Bhandankar Mobile No:

9845946230 .

If you have any questions about this study or need any information regarding

your right to participate in the study you may please contact Dr V D Patil, Professor

of Pediatrics JN Medical College and Supervisor for this study, mobile no

9448190231.

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Consent Statement:

I have read the information given above/it has been read to me in vernacular

language. All the information regarding this study has been provided to me and I have

understood the same. I have been given the opportunity to ask questions and got

appropriate answers. I give my consent voluntarily without any force/pressure for

participation of my baby in this study.

Name of the Parent Signature or left hand thumb impression of the parent

Name of investigator Signature of investigator

Name of witness Signature of witness

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ANNEXURE – III:A. DATA COLLECTION FORM (BABY)

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ANNEXURE – III:B. DATA COLLECTION FORM (MOTHER)

IPNo. (Where Applicable) :

Mother’s Name :

Father’s Name :

Address :

Income Education Occupation

Father

Mother

Socio-Economic Status : Upper / Middle / Lower

Mother

Name : Age : ____Yrs. Weight : Kgs.

Booked/UnBooked G : Para: A: L:

LMP: EDD: Blood Gr. Hb.: B.P._____,_____

Past Obstetric History :

Present Pregnancy

History :

USG :

Baby

DOB : TOB : Male /

Female

Wt. Kg

Gestation By Dates :

weeks

Gestation By Examination :

weeks

First Cry At : min /sec

Apgar Score : 1 min ________ 5 min ________ 10 min ________

Examination

Birth

Injury

Mouth

&

Nose

Chest CVS Abdomen Genitalia Limbs Hips Anal

Patency

Other

Findings

Resuscitation :

Labor & Delivery

On set : Delivery : Duration :

Fetal Distress Yes / No HR (Range) : PROM :

Monitoring (Where Applicable)

NST Type Of Dips : USG Doppler :

Medications(Where Applicable)

Oxytocin : Others :

Time Of Cord Ligation :

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ANNEXURE – IV: PUBLICATIONS AND PRESENTATIONS

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DIFFERENCES IN THERMAL ADAPTATION OF INFANTS DELIVERED

AT PRIMARY OR TERTIARY CARE FACILITIES IN INDIA

Manisha Bhandankar, MD MRCPCH, V. D. Patil MD

Department of Pediatrics, KLE University’s JN Medical College

Belgaum, India

&

Dharmapuri Vidyasagar, MD

Emeritus Professor, Pediatrics

Division of Neonatology

University of Illinois at Chicago Medical Center

840 South Wood Street, M/C 856

Chicago, Illinois 60612 (USA)

Email: dvsagarmd@yahoo.com

Office: (312) 996-4185

Fax: (312) 413-7901

Funding: None

Corresponding author: Dharmapuri Vidyasagar, M.D.

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ABSTRACT:

Background: Studies in developing countries, including India, have demonstrated

high incidence of hypothermia in neonatal period.

Objectives: To compare the pattern of thermal stabilization seen in infants born at a

rural Primary Health Center (PHC) with that of infants born in an modern urban

Tertiary Care Hospital (TCH).

Methodology: Abdominal temperature (Ta) and foot temperature (Tf) of healthy term

newborn infants were monitored and electronically recorded continuously from birth

in the delivery room (DR) until12 hours of life in the postnatal ward (PNW) at two

sites. Seventy one infants were enrolled in the study: 51 infants at the PHC and 20

infants at the TCH.

Results: In infants delivered at TCH the maximum mean (SD) Ta of 36.40C (0.48)

was reached by 12 hours while at PHC maximum mean Ta was 35.40c (1.98) by 10.5

hours .The mean Tf improved from the lowest value of 29.70C (1.3) at 4.5 hours to

32.90C (1.6) by 12 hours of life in infants delivered at TCH while in infants delivered

at PHC Tf remained low (max 30.70C) all through 12 hours. The mean Td (Ta-Tf)

gradually decreased from a maximum of 5.90C (1.6) at 4.5 hours to 3.5

0C (1.5) by 12

hours of life in infants born at TCH but the Td remained at > 50c even after 6 hours of

life in infants born at PHC which was statistically significant (P<. 05). The calculated

area between the Ta and Tf, a proxy for metabolic stress was greater in babies born at

PHC than those born at TCH.

Conclusions: Our study shows that although both groups of newborn infants

experienced significant thermal stress, infants delivered at PHC experienced

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significantly greater thermal stress than babies born at TCH. This difference could be

attributed to differences in thermal environment of DR and PNW between PHC and

TCH.

Key Words: Newborn infant, Hypothermia, Thermal Stress, Primary Health center

INTRODUCTION:

Hypothermia is a major cause of neonatal morbidity and mortality. Several

previous studies have shown the adverse effects of hypothermia on increased

metabolic stress and compromise in extra uterine physiologic adaptation.1-5

These

studies were mainly carried out in a controlled optimal environment.6- 8

In contrast, in

developing countries the environment in the delivery rooms is uncontrolled.9, 10

Studies in developing countries, including India, have demonstrated high incidence of

hypothermia in neonatal period.9-13

.However there are little data regarding the thermal

changes in the immediate newborn born period in infants delivered in tertiary and

rural health care facilities in resource poor countries. The purpose of this paper is to

present the comparative data of thermal adaptation of newborns born in an urban well

equipped tertiary care hospital (TCH) and newborns born at a rural Primary Health

Center (PHC) in India, a resource poor country.

METHODS:

The internal review board of the KLE University, Belgaum, India, approved

the study protocol. Written consent of mothers without high risk factors was obtained

prior to delivery for enrollment of their babies into the study at both sites.

At both sites the monitoring methods were similar. After vaginal delivery, the

right palm was dried and saturation probe was attached. After complete drying of the

baby, temperature probes were attached at two different sites. The central skin

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temperature probe was placed on the right hypochondrium just above the umbilicus.

The peripheral temperature probe was attached to the sole of the foot above the heel

and was secured in place using Micropore tape. We used YSI 427/729(Dayton, Ohio

45440, and USA) reusable pediatric skin temperature probes with accuracy of ±0.150

C. These temperatures, SpO2 and heart rate were recorded simultaneously using a

Planet 55 4 channel multi-recorder (L& T Company, Mysore, India). Battery back-up

assured continuous uninterrupted recording. Recording began in the delivery room

and completed up to 12 hours later in the postnatal ward. Each value was averaged

and recorded at 5 seconds intervals. Additionally, at both sites we monitored room

temperature and humidity in the DR and the postnatal ward (Thermo-Hygro clock

MEXTECH M288CTH Japsin Instrumentation, India) at regular intervals.

Infants born at term by normal vaginal route without antenatal and intranatal

risk factors were included in the study. Inclusion criteria of infants into the study

were: 1) Full term infants born by normal vaginal route, 2) Infants who did not require

resuscitation at birth 3) Infants with no congenital anomalies, 4) Birth weight >2,200

grams. At the TCH, after delivery the infants were placed under a radiant warmer

and care was given as per NRP guidelines14

. The TCH postnatal ward was a general

60 bed open room for mothers and newborns with no air conditioning or central

heating system. Windows of the unit were open or closed depending on the weather

conditions.

The PHC is located 22 Km from the TCH and is a teaching affiliate. The

single delivery room was equipped for vaginal deliveries with a resuscitation trolley

including oxygen and bag/mask resuscitation capability and vacuum suction. The

postnatal recovery area consists of a general ward with 6 beds. Training of staff was

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similar to the TCH and included assurance of quality recording techniques and

adherence to the protocol before enrolling study subjects.

After delivery at the PHC the newborn infant was dried, wrapped in a cloth,

moved to the general ward, and the various sensors were then attached as described

for the TCH. The mother was moved to the ward about 30-45 minutes later and

mother baby dyad was co bedded similar to TCH.

All infants were exclusively breast-fed on demand. As per traditional practice

in both environments the newborn infants were not clothed (no shirt, cap or socks) but

they were wrapped in a cloth and remained under a cover shared with the mother.

Change of wet and soiled clothing was done as needed.

Data Analysis:

Data were transferred to an Excel spreadsheet program (Microsoft, WA,

USA). For analysis we included only those tracings that had data starting within 5

minutes of birth in the TCH and 10 minutes of birth in the PHC and continued till 12

hours of life.We excluded readings from analysis when the probes were found to be

displaced. There were no failures because of power interruption.

Data were merged and analysed using SPSS version 16.0. All values are

reported as mean and standard deviation (mean ± SD). We calculated abdominal (Ta)

and foot (Tf) temperature every 5 minutes for the first 2 hours after delivery and then

every 15 minutes until completion of the recording. We compared the data using

unpaired Student t test where appropriate. P ≤ 0.05 was considered to denote

significant difference between groups.

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RESULTS:

Differences between the two sites in regards to infant care capabilities are

highlighted in Table 4. The personnel at the TCH had Pediatrics specialty training,

electricity was continuously available, postnatal care occurred in a dedicated PNW

with environmental controls, a radiant warmer and warmed towels were available for

postnatal use. Also the TCH infants initiated breast feeding and maternal contact

earlier after birth. At the TCH, initially infants were wrapped in a cloth; sensors

applied and kept under a warmer. While still in the delivery room infants were given

to the mother for breast-feeding at age 0.75 ± 0.5 hrs and remained with mother until

transfer to the postnatal ward (PNW). Transfer occurred at 2.5 ± 0.8 hours from birth

and required 15±8 minutes.

Of the 30 infants enrolled at TCH 8 infants were excluded from study due to

inadequate data collection or technical difficulties in data collection Additionally 2

parents did not give consent to continue monitoring for 12 hours. Data of the

remaining 20 infants are included in the analysis.

At PHC we enrolled 61 newborn infants into study of whom 8 infants were

excluded from the study analysis due to inadequate data collection or technical

difficulties in data collection, 2 infants were excluded because of birth weight <2200

grams. The data of the remaining 51 infants were used for analysis.

Demographic profiles of the two study groups are shown in table 1. Infants

enrolled into both groups had comparable gestational age and birth weights. Table 2

shows data on room temperature and humidity in the DR and PNW in the TCH. There

were no significant differences in room temperature and humidity between the

delivery room and postnatal ward at TCH. At PHC the delivery room and postnatal

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ward were adjacent to each other and temperature and humidity ranged were not

different.

Fig 1 shows the trends of Ta and Tf in among babies studied at TCH. In DR

the mean Ta was 34.620C ±0.69 at 5 minutes and reached maximum 35.9

0C ±0.60 at

2hrs of age. Whereas mean Tf dropped precipitously to 30.30C ±1.57 by 2.5 hours. Tf

declined even further after transfer to PNW reaching mean 29.70C ±1.33 and mean Td

(difference between Ta &Tf) of 5.940C ±1.39 at 4.5 hrs age. Thereafter Tf gradually

improved to mean 32.90C ±1.63 at 12hrs. Mean Ta reached 36.020C ±0.44 at 8 hours

of age. The minimum Td occurred at 5 minutes, increased gradually to maximum of

5.560C ±1.53 by 2.45 hours in DR & then decreased to 3.35

0C ±1.49 by 12 hours.

Fig 1also shows Ta and Tf of babies studied at PHC. Mean Ta increased

gradually from 33.50C±1.75 at 10 minutes to 34.5

0C±1.55 when the baby was

wrapped in dry cloth. After a slight drop by 0.50C in next 15 minutes, there was a

steady rise in temp to reach maximum of 35.50C±1.98 by 10.5 hours of age. There

was no further rise in mean Ta till 12 hours. During the same period, Tf gradually

declined from 30.30C±1.24 at 10 minutes to 29.2

0C±0.74 in first 3.5hours and then

remained in the range of 29.5-30.7oc until 12hours of age.

When individual trends for the PHC infants were analyzed only 15/51 (30%)

infants showed abdominal skin temperature above 360c between 6-12 hours but did

not maintain this temperature consistently. Maximum mean Td was 5.50C and it

remained in the range of 5-5.90C from 2-12 hours. 85% of infants reached a stable Ta

above 36.0oC maximum by 8 hours of age and maintained this temperature until 12

hours.

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The PHC Ta values were consistently lower than those observed in babies

studied at TCH and this difference between the groups was consistently 1.50C through

the study. These differences suggest that babies born at PHC had a relatively lower

core temp compared to babies born at TCH.

Table 2 gives the data points at specific times from birth in both groups. The

data show that both Ta and Tf were lower in infants cared for at PHC (P<. 05) than

those infants cared for at TCH. It also shows that Ta and Tf of infants at PHC

continued to stay significantly lower (P<. 05) than the Tf of infants cared at TCH

except for difference in Tf and Td at 2 hours and 6 hours.

Among the TCH group 9(45%) attained Ta of 360 C by 2 hours of age, but

among the PHC infants only 6/51 (15%) infants attained that Ta in the same time.

85% of infants delivered in TCH reached a stable Ta above 360C maximum by 8

hours of age and maintained this temperature until the end of the recording period.

However only 29.5% of the infants born at PHC achieved and maintained temperature

above 360 C during the study period. Of the 6 low birth weight (2,200-2,500grams)

PHC infants only 2 had achieved Ta 360C by 2 hours of age.

We assumed that the area between Ta and Tf over a unit time serves as a

proxy to metabolic stress in the baby.The area between Ta and Tf from birth to 12 hrs

age was calculated using the trapezoidal rule. The difference between Ta and Tf (Td)

and the Area between Ta and Tf curves obtained from two sites was calculated and

compared. The mean Td (SD) of 4.80 C (0.83) in TCH group was significantly lower

(P<. 002) than the mean Td (SD) 5.40 C (0.39) of PHC group. The Area between the

curves was also higher at PHC than at TCH.

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DISCUSSION:

Current information on incidence of hypothermia is based on studies

conducted in controlled environment of delivery rooms from the developed countries3-

6 and from a few other studies conducted in postnatal wards

9,10,13and communities of

developing countries. 17-22.

No information is available on thermal adaptation

immediately after birth of infants who are delivered in hospitals and PHCs in

countries with limited resources to maintain controlled room temperature and

humidity as per standard guidelines.21

We studied trends in thermal adaptation of newborns delivered and cared for

in a TCH and of infants delivered at a PHC using the same study protocol. Our

studies, which were initiated within minutes of birth continued until12 hours of life,

showed several differences in thermal adaptation of infants delivered at PHC

compared to those delivered at the TCH. Babies delivered at PHC had consistently

lower Ta, and Tf and took longer for Ta to reach 35.40C temperature (maximum mean

Ta), the mean Tf took longer to improve and remained lower than TCH babies even at

5 hours of age. Td all through study was significantly greater in PHC babies than

babies at TCH. Altogether babies at PHC experienced greater thermal stress. These

differences in thermal adaptation between infants born at PHC and those born at TCH

are of clinical importance as they may impact on neonatal morbidity and mortality.

Our findings are supported by previous studies of oxygen consumption and

heat loss using sophisticated metabolic studies. Malin and Baumgart 15

showed that

wider differences between skin temperature and rectal temperature indicated higher

oxygen consumption. In another study Karlsson and colleagues6 measured heat loss in

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the newborn at birth and showed that heat loss was directly proportional to

temperature differences between abdominal and rectal temperatures.

Other reports from developing countries have reported similar findings to

ours. In one village-based study in India, 11% of 189 neonates were found to be

hypothermic (<35.60C) based on a single temperature reading taken within the first 24

hours after birth.19

A recent community-based study in rural India showed the

prevalence of hypothermia (<36.50C) was high in both low birth weight (49%) and

normal birth weight (43%) infants.22

In Nepal, continuous ambulatory monitoring was

done starting within 90 minutes of birth. Mean core temperature of infants was found

to be less than 350C for 72% of the measurements in first 8 hours.

9 In a cross sectional

study done at a peri-urban hospital in Uganda 79% newborns were found to be

hypothermic at 90 minutes of age.20

In a study from Zambia 44% infants between 0-7

days of life were hypothermic at admission to hospital.21

A study done in a tertiary care hospital in India 13

showed that even during the

months of summer in May, when ambient temperature of maternity ward was

maintained between 26-280 C, nearly one fifth of the healthy term babies were under

cold stress as evidenced by greater than 20C difference between the core and

peripheral skin temperatures.

It is important to identify the factors responsible for the observed differences

in thermal adaptation of infant born at PHC. The study populations in the two groups

were similar in terms of gestational age, birth weight and clinical parameters. Also

both groups of infants were given standard newborn care. Thus observed differences

in thermal adaptation must be due to differences in other factors such as

environmental, equipment, infrastructure and clinical practices in maintaining thermal

neutrality during the immediate neonatal period. Table 4 gives the three major

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differences that were identified between the two sites: environmental temperature,

equipment and personnel skills.

It should be noted that there is no mechanism to maintain WHO

recommended23

room temperature at either site. In the PHC a radiant warmer was

available, but not frequently used due to interrupted power supply. In addition there

was no separate room to care for the mother and baby dyad. The medical staff nurses

at PHC are trained but not skilled to provide newborn care and are burdened with

multiple responsibilities. Finally cultural practices of not using caps and shirts for first

five days add to the risk of hypothermia. Mothers and families usually are not

prepared in advance to PHC.

We recognize several limitations of this study. The primary investigator (MB)

could not be present at PHC for delivery of all babies included in the study to monitor

each case completely. This was impractical because of unpredictability of deliveries

and the distance involved. However we engaged committed medical staff and health

workers who were trained to collect quality data and were under the constant

supervision of the investigator. Since the PHC serves as a teaching unit the medical

staff particularly the resident staff was well acquainted with the routine procedures of

newborn care followed at TCH.Even though supply of electricity was often

interrupted our recording equipment was supported by an uninterruptable power

supply. The relatively short distance of 22 Km was also easy for frequent visits by

the investigator.

The findings of our study are of special importance in view of recent

Government of India policy to increase deliveries at PHCs. As per the Indian Public

Health standards (IPHS), PHCs are expected to provide 24 hours delivery services,

along with newborn care services.24,25

Scaling up of neonatal care through data driven

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decision making process is necessary to improve neonatal outcome.26

India is still not

on track to achieve the Millennium Development Goal 4 by 2015. It is therefore

essential to recognize the knowledge gaps that are hindering the progress.27

Our study

indicates that there is a dire need to improve physical structure of PHC to provide

thermal neutral environment and the need for capacity building of staff at PHCs in

recognizing and managing thermal stress in newborns. Although PHCs may be

equipped with standard radiant warmers in the delivery rooms problems associated

with frequent power outages, lack of technical support and lack of staff training can

make them dysfunctional. Our studies underscore the need for rigorous

implementation of protocol-driven newborn care at all PHCs. The need for health

education to change traditional practices has already been identified in previous

studies.28, 29

CONFLICT OF INTEREST:

Authors declare that there was no conflict of interest with any equipment

manufacturers used in the study.

ACKNOWLEDGEMENT:We are immensely thankful to the staff nurses of the

Delivery room and Postnatal Ward of KLES Dr. PrabhakarKore Charitable Hospital

& MRC, Belgaum for the immense support provided for conducting this study. Dr.

SantoshTamgond, Registrar, Department of Pediatrics helped in initiating the

monitoring in DR. We would like to acknowledge the support and interest shown by

Dr. Saudagar and the rest of the staff of Kinaye PHC during training and later

conducting this study. Mr. Mallapure, Lecturer, JN Medical College, Belgaum and

Mr. S. Bhide helped with statistical analysis. Mr. Tejas Bengali, Assistant Manager -

Design & Development, L& T Company, Mysore, India provided technical guidance.

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3. Hill J, Rahimtulla K. Heat Balance and the metabolic rate of newborn babies

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14. American Heart Association (AHA) Guidelines for Cardiopulmonary

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infants nursed under high powered radiant warmers. Pediatrics 1987;79: 47-

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Neonatal and infant mortality in the ten years (1993 to 2003) of the Gadchiroli

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19. Kumar R, Aggarwal AK. Body temperatures of home delivered newborns in

North India. Trop Doct; 1998; 28(3): 134–137.

20. Byaruhanga R, Bergstrom A, Okong P. Neonatal hypothermia in Uganda:

Prevalence and risk Factors. J Trop Pediatr; 2005; 51(4): 212–215.

21. Christenson K, Bhat GJ, Eriksson B, Shilalukey-Ngoma M, Sterky G. The

effect of routine hospital care on the health of hypothermic newborn infants in

Zambia. J Trop Pediatr 1995; 41(4): 210–214.

22. Kumar V, Mohanty S, Kumar A, Misra R, Santosham M, Awasthi S et al.

Effect of community-based behavior change management on neonatal

mortality in Shivgarh, Uttar Pradesh, India: A cluster-randomized controlled

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26. Knippenberg R, Lawn J, Darmstadt G, Begkoyian G, Fogstad H, Walelign N

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28. Winch P, AlamM, AktherA, Afroz D, Ali NA, Ellis AA et al. Local

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FIGURE LEGEND:

Figure 1:The graph shows the temperature trends in Ta, Tf at PHC and TCH from

birth to 12 hours of age in babies born at THC and PHC. Note that Ta and Tf are

lower in babies born at PHC than TCH all through the study period. The Ta in both

groups starts lower then steadily increases. The area between Ta and Tf during the

study period reflects thermal stress.

Figure 1:

Table 1: Demographic profile of the infants in study group from TCH and PHC.

Site No & Gender Gest in Weeks Birth Weight (Grams)

TCH 6 Males

14 Females

38.7±1.1 2811±325

PHC 30 Males

31 Females

39.1±0.9 2754±256

28.0

29.0

30.0

31.0

32.0

33.0

34.0

35.0

36.0

37.0

38.0

0.2

0.5

0.8

1.0

1.5

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10

.0

11

.0

12

.0

T

e

m

p

0

C

Time from birth in hours

Ta(PHC)

Tf(PHC)

Ta(TCH)

Tf(TCH)

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182

Table 2: Mean(SD) of Ambient temperature and humidity at both sites.

Temp 0C & Humidity % in DR.

Mean(SD)

Temp0

C & Humidity % in

PNW Mean (SD)

TCH(N=20) Temp.:24.5(1.3)

Humidity:79(8)

Temp:25.36(1.14)*

Humidity:81.9(9)

PHC(N=51) Temp:24.2±1.67**

Humidity:83(6)

SD Standard Deviation

* Significant difference in ambient temp and humidity (P<.05) between DR and PNW

at TCH. Note that at PHC DR and PNW are adjacent to each other. Therefore only

one set of values are shown.

** Difference in ambient Temp between TCH/PNW and PHC was significant. P< .05

Difference in ambient humidity between TCH/PNW and PHC was not significant.

Table 3: Mean (SD) Ta, Tf& Td at TCH & PHC at specific time from birth

Ta 0c Mean(SD) Tf

0c Mean (SD) Td

0c Mean (SD)

Time

from

birth

TCH

N= 20

PHC

N=51

TCH

N=20

PHC

N=51

TCH

N=20

PHC

N=51

10 min 35.1(0.79) 33.5(1.7) 31.76(0.7) 30.32(1.4) 3.34(1) 3.54(1.7)

2 hours 35.9(0.6) 34.6(1.7) 30.5(1.4) 29.3(0.92) 5.34(1.4) 5.3(1.5)

6 hours 35.6(0.63) 34.8(1.2) 30.38(1.4) 29.3(0.8) 5.3(1.1) 5.5(1.1)

10 hours 36.1(0.52) 35.1(1.5) 32(1.26) 30.7(0.5) 4.03(1) 5.9(1.8)

SD Standard Deviation

There was statistical significant difference in Ta and Tf between TCH & PHC at each

time interval studied. (P<.05). But Td (Ta-Tf) was statistically different only at 10

hours between PHC and TCH. (Td 5.9 at PCH and 4.03 at TCH).

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183

Table 4: Differences Between Two Sites in Maintaining Warm Chain

TCH

PHC

Environment 1) Temp:23.5-27.50C,

Humidity:75-88%

2) Dedicated PNW, open

spacious ward with closed

windows

1) Temp:22.5-28.50C

Humidity:55-90%,

2) General ward open windows for

ventilation.

Equipment&

infrastructure

1) Radiant warmer available

2) Continuous electricity supply

3) Warm towel used to receive

baby.

1) Radiant warmer not available

2) Interrupted electricity supply 14- 18

hours a day

3) No warm towels were used.

Skilled

personnel

1) Pediatric resident to attend each

delivery

2) Adequate staffing in DR & in

PNW. Staff trained & skilled

in neonatal resuscitation and

essential newborn care.

1) General MD

2) Inadequate staffing, trained but not

skilled in neonatal resuscitation and

essential newborn care

Table Legends:

Table1; Gives the demographic profile of the infants in study groups from TCH

and PHC. The range of gestational age and birth weight are given.

Table 2; Gives the mean (SD) of temperature and humidity at both sites.

Table 3; Gives mean (SD) Ta, Tf& Td at TCH & PHC at 10 min, 2 hours, 6

hours and 10 hours of age.

Table4; Gives differences in environment, equipment, infrastructure and

clinical kills of available personnel at TCH and PHC.

Artcile submitted to Journal of Perinatalogy[#10-927-R] Nature Publishing Group,

USA. The revised article is in review process.

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184

POSTER PRESENTATION

1. Pediatric Academic society (PAS) meeting at Baltimore, USA May 2009.

The Pediatric Academic Societies (PAS) Annual Meeting is the largest international

meeting focusing on research in child health. The focus is on high quality original

research presentations through papers and posters in child health which are selected

by a panel of esteemed researchers and academicians in the field.

2. Poster Presentation at Pediatric Academic society (PAS) meeting at Baltimore, USA May

2009.

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185

3. Poster Presentation at Pediatric Academic society (PAS) meeting at Vancouver, May 2010

4.Poster Presentation at Pediatric Academic society (PAS) meeting at Vancouver, May 2010

5. Paper presentation :

1. National Neonatology Forum meeting at Ahmedabad , India December 2009 on “

Thermal Stress in newborns during Transitional Period: Birth to 12 hours of life”.

2. National Neonatology Forum meeting at Jaipur , India December 2010 on “ Differences in

thermal adaptation of infants delivered at Primary Health Center and those born at a tertiary

care hospital”.