guideline for management of thermal care in newborn …

WAHT-NEO-048 This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on

11/08/2015,15:29 It is the responsibility of every individual to check that this is the latest version/copy of this document.

Management of Thermal Care in Newborn Babies

WAHT-NEO-048 of 12 Version 1.1

MANAGEMENT OF THERMAL CARE IN NEWBORN BABIES

This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual

patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance.

INTRODUCTION

This Trust accepts that hypothermia in neonates is defined as temperature below 36.5ºC. The temperature should be measured with a tympanic temperature probe, a tempadot or an electronic digital thermometer.

This guideline relates to the care of any baby, especially those at risk of hypothermia (any baby whose temperature is below 36.50 for more than 1 hour at any time who is more than 28 weeks gestation). Babies less than 28 weeks are covered in the <28 weeks gestation management guideline WAHT-NEO-034.

THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS: Midwives, Nursery Nurses, Student Midwives, Neonatal Nurses, Doctors

Lead Clinician(s)

Dr A Short Dr T Dawson

Consultant Paediatrician Consultant Paediatrician

Approved by Paediatric Clinical Governance Committees: Extension approved by Trust Management Committee on:

4 January 2013 22 July 2015

This guideline should not be used after end of:

1 August 2016

Key amendments to this guideline

Date Amendment Approved by: (name of committee or accountable director)

May 2015 Document extended for 3 months Dr A Gallagher

August 2015 Document extended for 12 months as per TMC paper approved on 22nd July 2015

TMC





MANAGEMENT OF THERMAL CARE IN NEWBORN BABIES

INTRODUCTION This guideline is to assist and promote successful thermal control in babies and reduce the need for neonatal admissions for hypothermia and grunting. The term hypothermia refers to a low body temperature. Neonates are able to stay warm but their ability to do so may be impaired by environmental changes. They have a large surface area to weight ratio which impairs heat conservation. Low birth weight babies have less subcutaneous fat and less brown fat (a source of heat production via non-shivering thermogenesis). Babies lose heat by conduction – coming into contact with cold objects, convection – air currents replacing warm air with cold air around the baby, radiation – to colder objects, and most importantly immediately after birth, from evaporation of amniotic fluid from the skin surface (see figure 1). Enthusiastic correction of hypothermia may occasionally result in overheating the baby where the mechanisms above are essentially reversed. This is called hyperthermia which can be just as dangerous as hypothermia. Figure 1

SIGNS & SYMPTOMS OF HYPOTHERMIA

Peripheral vasoconstriction o Acrocyanosis, cool extremities, decreased peripheral perfusion

CNS depression o Lethargy, poor feeding, apnoea, bradycardia

Increased metabolism o Hypoglycaemia, Hypoxia, Metabolic Acidosis

Increased pulmonary artery pressure o Respiratory distress, Tachypnoea





Chronic Signs o Poor weight gain or weight loss





SIGNS & SYMPTOMS OF HYPERTHERMIA (Pyrexia)

Flushed appearance, Sweating

Irritable, Lethargic, Hypotonic

Tachypnoea, Tachycardia DEFINITIONS

Hyperthermia > 37.5º C

Normal temperature 36.5º C to 37.5º C

Hypothermia < 36.5º C

Severe hypothermia < 32.0º C

MEASUREMENTS

The temperature does not need to be taken unless there are specific risk factors or it is clinically indicated. Risk factors include prematurity, low birth weight and hypoglycaemia – a recognised symptom of hypothermia.

Touching the baby’s abdomen is a reasonably precise method of clinical assessment for hypothermia.

When indicated the temperature should be measured with a Tempadot™ (35.5ºC lowest reading), a tympanic temperature probe (GENIUS™ 2 Infrared Tympanic Electronic Thermometer - 33.0ºC lowest reading) or an axillary electronic thermometer (lowest reading 26.7-28ºC). A thermistor skin probe may also be used on babies on the neonatal unit and community midwives may be supplied with other brands. The midwife/neonatal nurse has the primary responsibility for identifying infants at risk, recognising signs and symptoms and screening babies where indicated. PREVENTION

The Warm Chain

These are a set of 10 points derived by WHO to prevent hypothermia, most of which should be achievable. These should be considered for every baby and particularly those at risk.

1. Warm delivery room (> 25°C)

2. Warm resuscitation (Warm towels)

3. Immediate drying

4. Skin-to-skin contact between baby and the mother (Kangaroo Care)

5. Breastfeeding

6. Bathing and weighing postponed

7. Appropriate clothing and bedding to environment

8. Mother and baby together

9. Warm transportation – extra clothes outdoors.

10. Training/awareness of healthcare providers





MANAGEMENT GUIDELINE

A hypothermic baby should be re-warmed straight away. Methods available to use are:

Skin-to-skin (kangaroo care) and a hat

A heated mattress

An overhead heater (or Babytherm)

Incubator

The method should be modified according to its success and how low the temperature is. MONITORING

The WHO recommendation is to check the temperature every 30 minutes until temperature reaches 36.5ºC - ideally this should be done, however clinical judgement can be used for the frequency depending on baby’s clinical condition. When temperature reaches 36.5ºC it should then be measured hourly for the next four hours to ensure there is no relapse. If there is a clinical concern about the baby a doctor’s assessment should be sought immediately. INTERVENTION FOR HYPOTHERMIA At Birth

The room should be warm (24-26ºC) and without draught.

The resuscitaire should be pre-heated and supplied with pre-warmed towels.

The baby should be effectively dried and then wrapped in a second dry towel.

There should be a low threshold for using a hat.

Problems should be identified. 1. Temperature 36.0-36.5ºC

If the mother is available then the baby should be dressed in a hat and nappy only and placed skin to skin with mother.

A blanket should be used to cover the area of the baby not in contact with mother’s skin.

The temperature should be rechecked after 30 minutes. If there is no improvement, or there is deterioration in temperature, after an hour then choose intervention 2.

2. Temperature 35.0-35.9ºC

There are several options available for treating colder babies or babies unresponsive to skin-to-skin care. Overhead heaters

Ensure the baby is wearing a hat.

The temperature must be monitored as there is a risk of overheating the baby.

Resuscitaires have an overhead heater and temperature probes and can therefore be used as a temporary method of warming.





Babytherm

These provide overhead heating and, a heated gel mat beneath the baby. These are excellent warm environments in which to carry out procedures.

The baby should be wearing a hat.

The heated gel mattress should be separated from the baby by a sheet.

The heated gel mattress takes an hour to warm up.

These may be directly controlled by a skin probe but babies must be monitored closely to prevent overheating.

The overhead heater and the mattress may be used together if the baby’s temperature is measured frequently to prevent overheating.

Heated mattress

Ensure baby is wearing a hat.

A sheet should separate the mattress from the baby.

The baby should be covered with blankets.

The temperature of the mattress should be reduced as the baby warms up to avoid overheating.

Ensure that the baby remains in the environment provided and not, for example, repeatedly removed from the heated mattress to breast feed.

If there is a failure to improve the baby’s temperature after an hour then proceed to intervention 3.

3. Temperature <35.0ºC

Make urgent referral to paediatrician.

Ensure there are no clinical signs of sepsis which require addressing.

Place the baby in an incubator set at 37.0ºC and 50% humidity.

Reduce the temperature slowly as the baby warms up.

Use a skin probe to monitor temperature and, if available, appropriate toe-core evaluation.

Otherwise the temperature should be evaluated every 30 minutes, after instigating management, to assess effectiveness of the intervention.

Hypothermic babies are often hypoxic so saturations should be measured and oxygen given if appropriate.

The metabolic stress may induce hypoglycaemia so check the blood sugar, and follow guideline for hypoglycaemia WAHT-NEO-017.

If hypothermia persists in spite of the measures above, infection must be suspected as this causes metabolic stress.

The flow chart below (appendix 1) summarises the management above.





INTERVENTION FOR HYPERTHERMIA (Pyrexia)

1. Identify the cause e.g.

Maternal pyrexia

Sepsis

Overheating from re-warming or over-wrapping with blankets of clothes (check observations).

2. Discuss with paediatrician if there are clinical concerns or risk factors for infection.

3. Modify the environment e.g.

Move to cooler area

Remove hat

Remove extra clothing

Reduce external heat source or if already lowest setting turn off.

4. Recheck the temperature 15-30 minutes after intervention and repeat above if necessary Remember babies can change temperature quickly so the temperature should be monitored and not all the clothes need to be removed.

SPECIAL CASES

Preterm babies

o It may be appropriate to deliver these babies, without drying them first, into a plastic bag if they are less than 30 weeks gestation.

o These babies will usually be nursed in an incubator with 50% humidity or more, although they may be managed on a heated platform (babytherm) with humidified air or oxygen provided via a heabbox if necessary.

o Temperature should be monitored as part of the baby’s routine care on the neonatal unit.

Infant at Risk of Group B Streptoccocal Infection

o Temperature should be monitored as part of their routine care on the ward or neonatal unit.

o The temperature should be considered with the other risk factors in line with the group B strep guideline WAH-NEO-001.

MONITORING TOOL

How will monitoring be carried out? Audit

Who will monitor compliance with the guideline? Paediatric Clinical Governance Committee/ Obstetric Governance Committee

STANDARDS % CLINICAL EXCEPTIONS

Hypothermic babies are escalated appropriately as per guideline

100%





REFERENCES 1.) Thermal Protection of the Newborn: A Practical Guide. WHO. http://whqlibdoc.who.int/hq/1997/WHO_RHT_MSM_97.2.pdf 2.) NICE Guideline ‘Post-natal Care’ CG37 http://www.nice.org.uk/nicemedia/pdf/CG37NICEguideline.pdf 3.) Immediate Care of the Newborn. Midwifery Practice Guideline RCM. http://www.rcm.org.uk/college/standards-and-practice/practice-guidelines/ 4.) Thermoregulation for Neonates. GOS Hospital Guidelines http://www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/cpg_guideline_00125 5. NNF Teaching Aids:Newborn Care

http://www.newbornwhocc.org/pdf/teaching-aids/hypothermia.pdf

http://whqlibdoc.who.int/hq/1997/WHO_RHT_MSM_97.2.pdf

http://www.nice.org.uk/nicemedia/pdf/CG37NICEguideline.pdf

http://www.rcm.org.uk/college/standards-and-practice/practice-guidelines/

http://www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/cpg_guideline_00125

http://www.newbornwhocc.org/pdf/teaching-aids/hypothermia.pdf





Appendix 1 HYPOTHERMIA FLOWCHART

AT BIRTH Is the baby at risk of

hypothermia? Check risk factors

Ensure adequately dried and instigate early skin

to skin care.

After one hour is the baby temperature normal?

Are there clinical signs

of sepsis?

No Yes Follow The Warm Chain & maintain frequent skin contact

Yes

Check temperature

Are there clinical signs of hypothermia?

Place in incubator with 50% humidity and monitor.

Ideally check temperature after 30 minutes until temperature is normal

Recheck Temperature hourly

for next 4 hours

Yes

Temperature 35.0-35.9ºC Use a Baby Therm, heated blanket or overhead heater with bubble wrap to warm

the baby.

Temperature < 35.0ºC Refer to paediatrician for

review Use Oxygen and

Nasogastric feeding

Temperature 36.0-36.4ºC Warm the baby using skin-to-skin care, with a hat and

a blanket covering over exposed surface.

Perform a full septic screen including lumbar puncture (if well enough) and swabs and

start IV antibiotics

Yes

No

No Yes

No

Is the temperature

normal?

No

What is the temperature?

Consider changing the warming method. If the baby was receiving skin-to-skin consider a headed blanket or overhead heater. If the baby was receiving overhead heat consider adding a heated blanket or moving to an incubator. If hypothermia persists inspite of the measures infection must be suspected as this causes metabolic stress.

Is the baby getting warmer?

Yes

No

Refer to paediatrician

for urgent review





CONTRIBUTION LIST

Key individuals involved in developing the document

Name Designation

Dr A Short Consultant Paediatrician/Clinical Director

Dr T Dawson Consultant Paediatrician

Circulated to the following individuals for comments

Name Designation

Dr N Ahmad Consultant Paediatrician

Dr M Ahmed Consultant Paediatrician

Dr T Bindal Consultant Paediatrician

Dr D Castling Consultant Paediatrician

Dr T El-Azzabi Consultant Paediatrician

Dr G Frost Consultant Paediatrician

Dr A Gallagher Consultant Paediatrician

Dr M Hanlon Consultant Paediatrician

Dr L Harry Consultant Paediatrician

Dr B Kamalarajan Consultant Paediatrician

Dr K Nathavitharana Consultant Paediatrician

Dr C Onyon Consultant Paediatrician

Dr J E Scanlon Consultant Paediatrician

Dr V Weckemann Consultant Paediatrician

Mr S Agwu Consultant Obstetrician/Gynaecologist

Mrs P Arya Consultant Obstetrician/Gynaecologist

Mrs A Blackwell Consultant Obstetrician/Gynaecologist

Miss R Duckett Consultant Obstetrician/Gynaecologist

Mrs S Ghosh Consultant Obstetrician/Gynaecologist

Mr J Hughes Consultant Obstetrician/Gynaecology

Miss R Imtiaz Consultant Obstetrician

Miss M Pathak Consultant Obstetrician/Gynaecologist

Mrs J Shahid Consultant Obstetrician/Gynaecologist

Miss D Sinha Consultant Obstetrician/Gynaecologist

Miss L Thirumalaikumar Consultant Obstetrician/Gynaecologist

Mr A Thomson Clinical Director - Consultant Obstetrician/Gynaecologist

Mr J Uhiara Consultant Obstetrician/Gynaecologist

Mr J F Watts Consultant Obstetrician-Gynaecologist

Vicky Bullock NICU, WRH

Vanessa Dobbs NICU, WRH

Patti Paine Head of Midwifery

Judi Barratt Clinical Midwife Specialist

Karen Kokoska Maternity Services Risk Manager

Rachel Carter Matron IP WRH

Margaret Stewart Matron OP-Community

Alison Talbot Matron IP Alexandra Hospital

Fiona Pagan Delivery Suite Manager, Alexandra Hospital

Jossette Jones / Sally Talbot Delivery Suite Deputy Managers, Alexandra Hospital

Pamela Jones Delivery Suite Manager, WRH





Supporting Document 1 – Checklist for review and approval of key documents This checklist is designed to be completed whilst a key document is being developed / reviewed.

A completed checklist will need to be returned with the document before it can be published on the intranet.

For documents that are being reviewed and reissued without change, this checklist will still need to be completed, to ensure that the document is in the correct format, has any new documentation included.

1 Type of document Guideline

2 Title of document Management of thermal care in newborn babies

3 Is this a new document? Yes No If no, what is the reference number WAHT-NEO-XXX

4 For existing documents, have you included and completed the key amendments box?

Yes No N/A

5 Owning department Neonatal Medicine / Neonatal Nursing

6 Clinical lead/s Dr Andrew Short / Dr Tom Dawson

7 Pharmacist name (required if medication is involved)

8 Has all mandatory content been included (see relevant document template)

Yes No

9 If this is a new document have properly completed Equality Impact and Financial Assessments been included?

Yes No

10 Please describe the consultation that has been carried out for this document

Circulated to individuals on the contribution list

11 Please state how you want the title of this document to appear on the intranet, for search purposes and which specialty this document relates to.

Management of thermal care in newborn babies

Once the document has been developed and is ready for approval, send to the Clinical Governance Department, along with this partially completed checklist, for them to check format, mandatory content etc. Once checked, the document and checklist will be submitted to relevant committee for approval.





Implementation Briefly describe the steps that will be taken to ensure that this key document is implemented

Action Person responsible Timescale

Publicised through department meetings and effective handover

Dr Andrew Short Vanessa Dobbs

January-February 2013

Plan for dissemination

Disseminated to Date

Medical, nursing and midwifery staff within maternity and neonatal units

January – February 2013

1

Step 1 To be completed by Clinical Governance Department Is the document in the correct format? Has all mandatory content been included? Date form returned _____/_____/_____

Yes No Yes No

2 Name of the approving body (person or committee/s)

Paediatric Clinical Governance Committee

Step 2 To be completed by Committee Chair/ Accountable Director

3 Approved by (Name of Chair/ Accountable Director):

Dr Andrew Short

4 Approval date 04/01/2013

Please return an electronic version of the approved document and completed checklist to the Clinical Governance Department, and ensure that a copy of the committee minutes is also provided (or approval email from accountable director in the case of minor amendments). Office use only Reference Number Date form received Date document

published Version No.

WAHT-NEO-048 05/02/2013 05/02/2013 1

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