Kamis, 10 Mei 2012

Hyperbaric Oxygen Therapy for Stroke

Every year, about 795,000 people suffer from a stroke in the United States. According to the Centers for Disease Control and Prevention, stroke is the the most common cause of serious long-term disability in the country. 

A stroke is caused by a sudden loss of oxygen and blood to the brain. This loss can occur due to a blocked artery, blood clot, buildup in arterial walls or bleeding in the brain. The brain needs a constant flow of oxygen from the bloodstream in order to function. If bloodflow and oxygen are disrupted, injury to the brain can occur within a very short amount of time. If that occurs, certain functions in the body that are controlled by those parts of the brain will stop or be hindered. It can take months or years to regain those proper functions and some patients experience permanent damage.
Hyperbaric oxygen therapy (HBOT) is a noninvasive and painless therapy that helps improve bloodflow and the delivery of oxygen to tissues in the brain damaged by stroke.
During HBOT sessions, patients are administered 100 percent oxygen at greater than normal atmospheric pressure. This floods the body with oxygen and helps reduce swelling and stimulate healing in those damaged areas of the brain through the formation of new blood vessels. 

Although HBOT (or any other known treatment) cannot revive dead tissue that resulted from a stroke, it is extremely beneficial for improving function in the area between the damaged tissue and the unaffected brain (known as the pnumbra). After a stroke, the pnumbra contains brain cells that are in a resting state because they are not receiving proper bloodflow and oxygen. HBOT awakens those cells by helping to achieve adequate bloodflow. 

Rabu, 18 April 2012

Pediatric Mechanical Ventilation

Ventilator-Associated Tracheitis and Antibiotic Duration

William R. Jarvis, MD

Antimicrobial use in intensive care units is a major driver for multidrug-resistant organisms. One of the most common situations in which antibiotics are misused is in patients on mechanical ventilation. In a recent study, Tamma and colleagues,[1] asked the question, "Does the length of antibiotic therapy for ventilator-associated tracheitis (VAT) in pediatric patients make a difference?" They included all patients less than 18 years of age in their neonatal intensive care unit or pediatric intensive care unit who were on ventilation for at least 48 hours.
They defined VAT as fever or hypothermia, leukocytosis or leukopenia, a Gram stain of secretions showing moderately heavy polymorphonucleocytes, moderate or heavy bacterial growth, and no radiologic evidence of a new lung infiltrate. They enrolled 1616 patients who were intubated for more than 48 hours.
One hundred-fifty of those patients received antibiotics for what clinicians suspected was VAT. Only 118 patients met the investigators' definition of VAT. They found that prolonged courses of antibiotics, defined as 7 days or more, were not protective against progression of either hospital-associated pneumonia or ventilator-associated pneumonia. In fact, factors for multidrug-resistant colonization or infection included a prolonged course of antibiotics, receipt of combination antibiotics, and days of hospital exposure before completing the antibiotic therapy.
This study shows that there is no need for clinicians to use a course of antibiotics longer than 7 days in patients with documented VAT. By reducing antibiotic exposures, they reduce the opportunity for these patients to become colonized with multidrug-resistant organisms and subsequently develop infections with those organisms, which would be much more serious than the VAT they started with. Hopefully, this study will help reduce antibiotic exposures in our neonatal and pediatric intensive care patients.


Jumat, 02 Maret 2012

soy milk, mamasoya and kid's soya

Soy Protein
Kristen S. Montgomery, PhD, RN
Kristen Montgomery is an assistant professor in the College of Nursing at the University of South Carolina in Columbia, South Carolina.
J Perinat Educ. 2003 Summer; 12(3): 42–45.
PMCID: PMC1595159
Soy protein comes from soybeans and offers multiple health benefits, some of which are just beginning to be discovered. This column reviews the health benefits of soy products with a special focus on women and children's health. To date, little has been written or researched that is directly related to perinatal health. Thus, the column has a more broad focus so that childbirth educators have a general resource to gain knowledge related to the use of soy-based foods.
Keywords: soy protein, soy products, perinatal health
Soy protein has received increased attention in recent years among consumers, researchers, and the media. A report released in 1995 estimated that over 12,000 food products were available that contained soy protein (Anderson, Johnstone, & Cook-Newell, 1995), and sales of soy beverages rose more than 82% in 1999 (Nestle, 2002). A recent study from Europe found that individuals with a habitually health-conscious lifestyle (e.g., individuals who did not eat meat, but did eat fish, or were vegetarians or vegans) were more likely to consume soy foods than the average person (Keinan-Boker et al., 2002). The sample included 35,955 persons, from ages 35–74 years, who completed a 24-hour dietary recall interview. From this sample, 195 men and 486 women reported consuming soy products in the last 24 hours.
The purpose of this column is to review the benefits of soy protein and to discuss what populations are likely to benefit from an intake of soy protein. Very little information is available regarding the use of soy protein foods during pregnancy, postpartum, or infancy. Therefore, this column offers a more broad nutritional focus on soy protein with relevant information related to perinatal health interspersed throughout.
Soy Basics
Soy protein refers to the protein that is found in soybeans that is often used to replace animal proteins in an individual's diet. The soybean is a legume that contains no cholesterol and is low in saturated fat (Lindsay & Claywell, 1998). Soybeans are the only vegetable food that contains all eight essential amino acids (Dudek, 2001; Morrison & Hark, 1999). Soybeans are also a good source of fiber, iron, calcium, zinc, and B vitamins (Lindsay & Claywell, 1998)
Benefits of Soy for Health Promotion
Use of soy products during pregnancy can be encouraged because expectant women are likely to receive the same health benefits as other women. Fortified milk and fortified soymilk are the only reliable dietary sources of vitamin D (Somer, 2002). All other dairy products contain little or no vitamin D. While many women will obtain enough vitamin D from exposure to sunlight, soymilk may be an alternative for those who are overly sensitive to the sun or for those who simply are not able to be or do not enjoy being outdoors. Soymilk may also be an alternative for women who do not like regular milk.
Consumption of soy protein in place of animal protein has been found to reduce serum concentrations of total cholesterol, low-density lipoproteins (LDLs), and trigylcerides (Arliss & Biermann, 2002; Morrison & Hark, 1999). The precise mechanism of action is not known, though several theories exist (Dudek, 2001). One theory proposes that cholesterol absorption is impaired or altered (Dudek, 2001). Another theory postulates that phytoestrogens (plant compounds that have hormone-like effects; isoflavones are the phytoestrogens found in soy products; see Table) bind to estrogen receptors and produce similar effects including lowering LDLs and increasing high-density lipoproteins, vasomotor tone changes, and arterial wall function (Dudek, 2001). Individuals with elevated cholesterol seem to receive the greatest benefit (Hasler, 2002).
Individuals need to consume about 25 grams of soy protein or more each day to obtain results (Wardlaw, 2000). Twenty-five grams of soy protein equals 1¼ cups of tofu, 1–2 cups of soymilk, or an ounce of soy flour. Individuals are encouraged to read food labels in order to verify a particular food's soy content. The U.S. Food and Drug Administration (FDA) approved the health claim for the relationship between soy product consumption and reduced risk of coronary heart disease in 1999, based on the result of human clinical intervention trials (Hasler, 2002). While the FDA has approved the claim of health benefits, Munro and colleagues (2003) conducted a meta-analysis of the current literature and found that the literature supports the safety of isoflavones because they are typically consumed in soy or soy products.
Obesity and Diabetes
In recent studies, soy protein contributed to the control of hyperglycemia and reduced body weight, hyperlipidemia, and hyperinsulinemia (Bhathena & Velasquez, 2002). These characteristics may be useful to both nondiabetic and diabetic persons in the control of obesity and blood sugar.
Cancer Prevention
Genistein, one of the phytochemicals found in soy, can reduce the risk of cancer (Wardlaw, 2000). To date, prevention of breast cancer has received the most attention, and more recent attention has focused on prostate cancer (Whitney & Rolfes, 2002). Genistein blocks cancer development by preventing tumors from creating blood vessels that would provide nourishment for growth (Arliss & Biermann, 2002; Wardlaw, 2000). One serving a day (e.g., 1 cup of soymilk, ½ cup of tofu or soybeans) is effective for cancer prevention (Wardlaw, 2000).
Menopausal Symptoms
Phytoestrogens are currently being researched to determine their usefulness in acting like synthetic estrogen to protect women from bone loss and maintain a healthy heart (Wardlaw, 2000). Soy protein has been found to positively influence bone and calcium balance in postmenopausal women (Arjmandi et al., 2003). Results were especially significant for women who were not receiving hormone replacement therapy. These same results were not seen in young, healthy women who were still menstruating (Anderson et al., 2002).
Benefits of Soy for Special Populations
Vegetarians and Vegans
Vegetarians are individuals who, for various reasons, do not eat meat. Vegans, in comparison, are individuals who do not eat any products from animals, including eggs, milk, and cheese. Vitamin B12 is only found in animal products and, therefore, may be lacking in the diet of vegans. Use of soymilk is one way to obtain this essential vitamin (Dudek, 2001). Cereals and meat substitutes are other options.
Infants with Special Conditions
Infants born with lactase deficiency or galactosemia benefit from the use of soy-based formulas (Dudek, 2001). Parents who wish to put their newborn on a vegetarian diet may choose to use a soy-based formula. In addition, infants who are recovering from episodes of diarrhea (and are normally given breast-milk substitutes) may have soy formula recommended to facilitate their recovery. Soy-based breast milk substitutes (formulas) include Prosobee (Mead Johnson) and Isomil (Ross). While soy-based formulas meet an infant's growth and development needs, they do not offer any advantage over milk-based formulas (Whitney & Rolfes, 2002).
Infants who are not able to tolerate lactose formulas (those based on cow's milk, casein/whey-based formulas; e.g., Similac, Enfamil, Carnation) may be prescribed soy-based formulas if they are not breastfed (Wardlaw, 2000). Each year, about 20%–25% of infants are converted to soy protein formulas (American Dietetic Association and Dieticians of Canada [ADA], 2000). The development of lactose-free cow's milk protein-based formulas has made it unnecessary to switch infants to soy-based formula (ADA, 2000), though the practice is still common. The use of soy-based formula is effective in only about 20%–50% of infants because the soy protein eventually triggers a reaction in susceptible infants (Wardlaw, 2000). In this instance, predigested protein formulas can be used (e.g., Nutramigen, Alimentum). According to the ADA (2000), soy-based formulas are not recommended for preterm infants weighing less than 1,000 grams and for infants with low birth weightas a means for preventing or managing colic or gastroenteritis.
Preschool Children
In a recent study, ingesting soy-based formula or soymilk was associated with peanut allergy in a geographically diverse sample of 13,971 preschool children (Lack, Fox, Northstone, Golding, & the Avon Longitudinal Study of Parents and Children Study Team, 2003). The authors proposed that the association of peanut allergy with the intake of soy products could be related to cross-sensitization through a common substance (Lack et al., 2003). More research is needed in this area.
Soy protein products offer benefits to women in various life stages. Benefits include improved diet and cardiovascular status, prevention of certain types of cancer, improved health following menopause, obesity prevention/control, and more options for food variety. The area of soy protein research has increased in popularity in recent years among multiple health disciplines. Future research efforts are likely to include more scientific advances in the use of soy in the diet of Americans. As more is learned about the health benefits of soy, additional foodstuffs will likely be available to meet the community's needs for soy products.
  • American Dietetic Association and Dieticians of Canada [ADA] 2000. Manual of clinical dietetics (6th ed.). Chicago: ADA and Dieticians of Canada.
  • Anderson J. J, Chen X, Boass A, Symons M, Kohlmeier M, Renner J. B, Garner S. C. Soy isoflavones: No effects on bone mineral content and bone mineral density in healthy, menstruating young adult women after one year. Journal of the American College of Nutrition. 2002;21:388–393. [PubMed]
  • Anderson J. W, Johnstone B. M, Cook-Newell M. E. Meta-analysis of the effects of soy protein intake on serum lipids. New England Journal of Medicine. 1995;333:276–282. [PubMed]
  • Arjmandi B. H, Khalil D. A, Smith B. J, Lucas E. A, Juma S, Payton M. E, Wild R. A. Soy protein has a greater effect on bone in postmenopausal women not on hormone replacement therapy, as evidenced by reducing bone resorption and urinary calcium excretion. Journal of Clinical Endocrinology & Metabolism. 2003;88:1048–1054. [PubMed]
  • Arliss R. M, Biermann C. A. Do soy isoflavones lower cholesterol, inhibit atherosclerosis, and play a role in cancer prevention? Holistic Nurse Practitioner. 2002;16(5):40–48.
  • Bhathena S. J, Velasquez M. T. Beneficial role of dietary phytoestrogens in obesity and diabetes. American Journal of Clinical Nutrition. 2002;76:1191–1201. [PubMed]
  • Dudek S. G. 2001. Nutrition essentials for nursing practice (4th ed.). Philadelphia: Lippincott.
  • Hasler C. M. The cardiovascular effects of soy products. Cardiovascular Nursing. 2002;16(4):50–63.
  • Keinan-Boker L, Peeters P. H, Mulligan A. A, Navarro C, Slimani N, Mattisson I, Lundin E, McTaggart A, Allen N. E, Overvad K, Tjonneland A, Clavel-Chapelon F, Linseisen J, Haftenberger M, Lagiou P, Kalapothaki V, Evangelista A, Frasca G, Bueno-deMesquita H. B, van der Schouw Y. T, Engeset D, Skeie G, Tormo M. J, Ardanaz E, Charrondiere U. R, Riboli E. Soy product consumption in 10 European countries: The European Prospective Investigation into Cancer and Nutrition (EPIC) study. Public Health Nutrition. 2002;5(6B):1217–1226. [PubMed]
  • Lack G, Fox D, Northstone K, Golding J. the Avon Longitudinal Study of Parents and Children Study Team. 2003. New England Journal of Medicine, 348, 977–985.
  • Lindsay S. H, Claywell L. G. Considering soy: Its estrogenic effects may protect women. AWHONN Lifelines. 1998;2:41–44. [PubMed]
  • Morrison G, Hark L. 1999. Medical nutrition and disease (2nd ed.). Malden, MA: Blackwell Science.
  • Munro I. C, Harwood M, Hlywka J. J, Stephen A. M, Doull J, Flamm W. G, Adlerereutz H. Soy isoflavones: A safety review. Nutrition Review. 2003;61:1–33.
  • Nestle M. Beyond fortification: Making foods functional. 2002. In M. Nestle, Food politics (pp. 315–337). Berkley: University of California Press.
  • Somer E. 2002. Nutrition for a healthy pregnancy (2nd ed.). New York: Henry Holt and Company.
  • Wardlaw G. M. 2000. Contemporary nutrition (4th ed.). Boston: McGraw Hill.
  • Whitney E. N, Rolfes S. R. 2002. Understanding nutrition (9th ed.). Belmont, CA: Wadsworth.

Sabtu, 25 Februari 2012

Infant Thermoregulation

Thermoregulation for neonates
Temperature Control or thermoregulation in the neonate is a critical physiological function that is strongly influenced by physical immaturity, extent of illness and environmental factors (Thomas 1994).  The neonate’s susceptibility to temperature instability needs to be recognised and understood in order to appropriately manage and limit the effects of cold or heat stress.
It is essential that neonates are nursed within their ‘Neutral thermal Environment’ (NTE).  This is defined as “the environmental air temperature at which an infant with a normal body temperature has a minimal metabolic rate and therefore minimal oxygen consumption” (Merenstein & Gardiner 1998).  
The maintenance of the NTE, in order to prevent thermal stress is the ultimate aim of neonatal temperature control and management.
By definition, the term neonate refers to the first 28 days post-delivery. Due to the wide range of post-natal ages and gestations seen on NICU, and elsewhere within the Great Ormond Street Trust, this guideline is appropriate for infants up to six months of age (post-term). Reference shall be made to specific gestations, ages and whether intensive care or not, where applicable.
Optimum thermoregulation and related nursing care can be addressed with regard to three interrelated areas:
  • Method of temperature taking
  • Choice of environment
  • Temperature instability & intervention

The acceptable set-point temperature is an axilla temperature of range 36.7 - 37.3°C. This range should be maintained at all times. (Rationale 1)

Tempadot™ (single-use) is the thermometer in use in the Trust (Rationale 2).

A central temperature is obtained by insertion at the axilla site for 3 minutes, placing the dots against the trunk. It must be read 10 seconds following removal (Rationale 3).

The axilla temperature should be checked 4 - 6 hourly and recorded.If their temperature falls outside the normal range, readings must be taken more frequently (every 30-60 minutes).   This should be continued until their temperature has normalised (Rationale 4, Rationale 5).

If a neonate undergoes any change of environment or increased exposure, e.g. general cares, procedures, phototherapy, new transfer to an incubator or bassinette, they will require 1-2 hourly temperature checks for the first few hours until the temperature is stable (Rationale 6).

For neonates receiving intensive care, peripheral skin temperature is monitored continuously by use of a probe placed on the sole of the foot (Rationale 7, Rationale 8).

Allow 5 minutes for skin temperature to stabilise once applied to foot

Peripheral temperature is recorded hourly and the probe site should be changed every 4-6 hours.

If an arterial line is in situ, the foot should be left uncovered (Rationale 9).

The ‘toe-core’ temperature difference is taken from the difference between the peripheral temperature reading on the monitor and the central readings done at intervals or continuously (Rationale 10).

Continuous central monitoring can be done by placing a probe over the abdomen when supine, or the back when prone, preferably over the liver (Rationale 11).

The difference should be between 1-2°C (Lyon et al 1997) (Rationale 12).

Peripheral monitoring can be discontinued when a neonate:
  • no longer requires cardiovascular support to maintain an adequate blood pressure
  • is peripherally warm & well perfused  

This will require individual assessment.(Rationale 13).
Environment: Incubator

Any neonate less than 1.5 kg should be nursed within an enclosed incubator (Rationale 14, Rationale 15).

Any neonate less than 28 - 30 weeks gestation in the first 14 days of life should be nurses in a closed incubator with added humidity.

The optimum level of humidity is determined by gestational age, days of life, skin maturity and underlying pathology.

Generally a neonate < 29 weeks, <1kg in weight and in the first 7 - 10 days, should be nursed in 50% humidity or greater (Sedin 1995; Knobel & Holditch-Davis 2007).

Sterile water should be used and humidity levels checked hourly (Rationale 16) (Harpin & Rutter 1985).

Neonates at extremes of prematurity may require up to 85 - 95% humidity for up to 21 days post delivery (Rationale 17).

Before admission pre heat the incubator temperature according to the specific age & gestation by the use of ‘Neutral Thermal Environment’ (NTE) charts and adjust incubator temperature according to individual response (Merenstein & Gardiner 1998; Mok et al 1991) (Rationale 18, Rationale 19).

Check and record incubator temperature hourly.

Alter set temperature according to the neonate’s temperature and adjust by 0.5-1°C every 15 - 30 minutes, depending on the extent of temperature instability (Rationale 20, Rationale 21).

If a neonate does not require heat inside an incubator, i.e. it is necessary to switch off the incubator, they should be transferred to an open cot (Rationale 22).

A neonate must not be left in an incubator with its doors open for longer than one hour (Rationale 23).

Care and interventions, e.g. suction, nappy care, should be carried out via portholes, avoiding opening the side completely (Rationale 24).

Where appropriate, the incubator should be changed every 7 days, particularly if humidity is being used (Rationale 25).

This should be recorded.
Environment: Baby Therm

Baby-therms provide heat by a combination of conduction (from below via a gel mattress) and radiation (from above) (Rationale 26).

Any neonate greater than 1.5 kg and any neonate who necessitates ease of access, e.g. for lumbar puncture, central line insertion, particularly surgical & cardiac neonates on admission, is nursed in an open Baby-therm.

If a neonate less than 1.5 kg is admitted into an open heater in the first instance, they should be transferred into an incubator as soon as possible.

When preparing a Baby-therm for use, the mattress is switched to ‘on’ at a set temperature of 37°C (Rationale 3).

It will take an hour to heat up to the set temperature.

The overhead heater should be turned on and the ‘Manual’ control should be selected rather than “Servo”  (Rationale 27).

Servo control is not recommended for “shocked” neonates who are peripherally vasoconstricted:

The heater should be switched to level 5 (each level or bar represents a 10% increase or decrease in heat from above).

It will take 25 minutes to reach the desired temperature from the overhead heater.

If the neonate is hypothermic, the initial settings are higher.

This also applies to a neonate already established in a Baby-therm who needs extra heat.

The extended upper range (indicated as > 37°C; i.e. range 37 - 38.5°C) is chosen plus level / bar 6 - 10.  Above level 6, the heater requires resetting every 15 minutes (press ‘reset’), which is indicated by an alarm (Rationale 28).

If the neonate requires cooling, turn the radiant heater off and choose the extended lower range for the mattress, indicated by <37°C, i.e. 30 - 35°C). Turn the temperature down by 1°C at 15 - 30 minute intervals (Rationale 29).

Once established in the Baby-therm, there are 4 options to determine what the neonate is laid on and covered with:

Option One: Both mattress and radiant heater on:
  • The neonate should lie directly onto a sheet covering the gel mattress (Rationale 30)
  • Nesting should be provided around, not under, the neonate (Rationale 31)
  • Cover them with bubble wrap, bubbles downwards, or leave exposed (Rationale 32)

Option Two: Mattress with no radiant heater.
  • As option one but the neonate should be covered with a blanket (Rationale 33).

Option Three: Radiant heater with no mattress.
  • Ensure that a padded sheet, towel or gamgee, is place between the neonate and mattress while it is turned off. Cover neonate with bubble wrap (Rationale 34).

Option Four: Neither:
  • As for option three but wrap well with blankets (Rationale 35).

When transferring a neonate on a Baby-therm, e.g. to theatre, X-ray or wards, the transfer should take a maximum of 15 minutes before connecting to mains supply again (Rationale 36).
Environment: Giraffe Omnibed

This equipment is located and used on NICU only.

The GE Healthcare Giraffe can be used as both a closed incubator with or without humidity and as an overhead heater when procedures need to be undertaken which are unable to be performed through the portholes. If opening the Giraffe it should be noted that the humidity within will cease.

The lid should remained closed other than when procedures are carried out (Rationale 37) (GE Healthcare 2011).
Environment: Open Cot

A well neonate, >1.5 kg, who no longer requires close monitoring or intensive care and who can maintain a stable central temperature in 26-28°C room temperature, can be transferred to a small cot (Medoff-Cooper 1994) (Rationale 38).

The neonate should be covered or wrapped in blankets and should wear a hat (Rationale 39).

Weaning a well neonate from an incubator or Baby-therm should be done according to age and gestation (see NTE chart (Merenstein & Gardiner 1998)), turning the incubator or mattress temperature down by 0.5 - 1°C each day and observing central temperature (Medoff-Cooper 1994) (Rationale 40).

Larger infants, i.e. > 4kg, who require warming can be nursed on an open cot with a bear-hugger blanket, heated mattress and / or single overhead heater.
Interventions: General

Maintain a set environmental room temperature of >26°C.

Specific events may precipitate heat loss the effects of which need to be counteracted, e.g.: (
Sheeran 1996; Roberton 1995) (Rationale 41)

  • cool x-ray plate
  • theatre table
  • weighing scales
  • stethoscope

They should be prewarmed and covered.

  • draughts
  • windows

Avoid over-exposure and maintain a “minimal handling” policy. Use portholes for all procedures whenever possible and close these as soon as the procedure is finished.

  • cold incubator walls
  • direct sunlight

Prewarm incubators, use curtains and covers over the incubator.

  • cold water
  • wet skin
  • nappy
  • bed

Keep skin and bed dry.

Before transferring a neonate to theatre, preparing for procedures or general transportation:

Pack an appropriate sized bonnet, bubblewrap, dry gamgee or blankets, heat pad if available and a clean nappy (Rationale 42)

Cover as well as possible (Rationale 43)

During transfers within GOS the neonate should remain in their incubator or Baby-therm.  This should be left switched on, at the same setting, to await their return from the radiological or surgical procedure (Rationale 44).

Ensure the neonate is transferred to a pre-warmed, dry surface in theatre or X-ray. (Rationale 45)

The neonate’s temperature must continue to be monitored during transfers & procedures (Rationale 46).

If their temperature falls outside normal range, recordings must be taken more frequently, i.e. 30 - 60 minutes, until it has normalised.  When it has returned to the normal range it may be done 4 hourly.

Any intervention carried out for temperature instability must be recorded in the child’s health care records (Rationale 47).
Interventions: Cold Stress

The signs and associated problems of cold stress are:
  • central temperature < 36.5°C
  • increase in core-toe gap > 2°C
  • mottled and/or pale
  • increased capillary refill time, i.e. > 2 seconds
  • increased oxygen requirements
  • metabolic acidosis
  • tachycardia
  • hypoglycaemia
  • apnoeas
  • bradycardia (Rationale 48)

To intervene in this situation:
  • Place a neonate of < 1.5kg in an incubator at the upper range, i.e. >37°C (Rationale 49)
  • If using a baby-therm, set the temperature at the upper range, both above & below, and follow guidelines for babytherm use (Rationale 50)
  • Increase the set temperature by 1°C every 15 minutes according to the neonate’s response
  • Take their temperature every 30 - 60 minutes until warmed to an acceptable temperature
  • Identify & eliminate any environmental causes, e.g. wet bed, over exposure, handling
  • Promote a flexed position
  • Ensure ventilator gases are adequately warmed to 37°C

If the cause of decreased peripheral temperature is not due to cold stress, i.e. central temperature stable but an increase in core - toe gap, the neonate’s perfusion status should be assessed (Rationale 51).

They should be observed and the following aimed for: (Lyon et al 1997)
  • capillary refill time < 2 seconds
  • pink colour
  • skin warm to touch
  • no increase in heart rate above normal
  • palpable peripheral pulses
  • blood pressure within normal range for age, gestation & condition

Interventions: Heat Stress

The signs and associated problems of heat stress are:
  • central temperature above 37.3°C and rising
  • increased peripheral temperature and decrease in core-toe gap, i.e. < 1°C
  • tachycardia
  • tachypnoea
  • restlessness
  • dehydration
  • stress (Rationale 52)

To intervene in this situation:
  • Check environmental temperature and reduce by 1°C at 15 - 30 minutes intervals.
  • Remove excess layers and clothing.
  • If under a Baby-Therm, turn radiant heater off and choose the extended lower range (<35°C).  
  • Turn the temperature down by 1° at 15 - 30 minute intervals (Rationale 53)

If the cause is not environmental, i.e. consider NTE <1 - 5°C to maintain normothermia, consider infection as a cause of the pyrexia.  This must be reported to the child’s doctor and the policy for the management of the pyrexial neonate followed.

Rationale 1: To allow normal physiological function and body metabolism (Thomas 1994).
Rationale 2: They are safe, quick and non-invasive to use (Leick-Rude & Bloom 1998; Pontious et al 1994).
Rationale 3: To meet manufacturer’s guidelines
Rationale 4: 4 hourly is the general recommended interval unless instability occurs.
Rationale 5: The axilla is the safest and most accurate site for central temperature readings (Leick-Rude & Bloom 1998; Pontious et al 1994; Sheeran 1996).
Rationale 6: It can take up to 2 hours for a central and peripheral temperature to stabilise following a change to the thermal environment or prolonged exposure in relation to nursing or medical procedures (Mok et al 1991).
Rationale 7: Peripheral temperature is valuable as one parameter in the assessment of perfusion.
Rationale 8: The foot is recommended as the most “peripheral” site (Lyon et al 1997).
Rationale 9: to be able to assess the colour and perfusion of the periphery.
Rationale 10: Abdominal/liver skin temperature is closest to the body’s central temperature and is non-invasive (Drager Ltd 1997).
Rationale 11: Rectal probes due to risk of perforation (Sheeran 1996).
Rationale 12: Less than 1°C may indicate heat stress while greater than 2°C may indicate cold stress, hypovolaemia or infection (Mitchell 1997).
Rationale 13: The length of time required for optimum perfusion will depend on:extent of illness,peripheral shutdown,and the nature & timing of surgery (if applicable).
Rationale 14: They have a greater physiological predisposition to heat loss due to relatively large surface area to volume ratio.
Rationale 15: An incubator is to provide heat by convection within a closed environment (Leick-Rude & Bloom 1998).
Rationale 16: The pre-term neonate has high “trans-epidermal” water losses due to a thin, poorly keratinised skin (stratum corneus). This matures by 21days post-natal age (Blackburn & Loper 1992). Trans-epidermal water loss is a major cause of heat loss in the premature neonate (Marshall 1997).
Rationale 17: The more immature, the greater the predisposition to heat loss by evaporation (Merenstein & Gardiner 1998; Marshall 1997).
Rationale 18: To minimise oxygen and energy consumption and maintain homeostasis (Sheeran 1996).
Rationale 19: to reduce the risk of heat loss via convection in a cold incubator.
Rationale 20: To avoid rapid over or under heating.
Rationale 21: To avoid sudden swings in temperature.
Rationale 22: To avoid over heating.
Rationale 23: To avoid sudden changes to their temperature & adverse cooling.
Rationale 24: To avoid sudden loss of heat from inside the incubator.
Rationale 25: To meet the Infection Control Policy.
Rationale 26: They limit heat loss during exposure & interventions because of easy access and radiant heater responsiveness (Seguin & Vieth 1996).
Rationale 27: The “Servo” may cause overheating due to the heater responding to the cool skin temperature (Drager Ltd).
Rationale 28: To avoid the complications associated with cold stress, i.e. decreased surfactant, increased oxygen consumption, respiratory distress and hypoxia, metabolic acidosis, hypoglycaemia, weight loss and apnoea (Merenstein & Gardiner 1998; Roberton 1995)
Rationale 29: To avoid the complications of heat stress associated with increased fluid losses, hypernatraemia, recurrent apnoeas, convulsions, increased metabolic rate and tachycardia. (Merenstein & Gardiner 1998; Roberton 1995)
Rationale 30: To achieve optimum heat transfer from the heat pad, via the gel mattress, to the neonate (by conduction).
Rationale 31: Blankets may block radiative heat transfer from above to the neonate.
Rationale 32: Bubble wrap provides an insulation layer to prevent heat loss from convective air currents. The bubbles placed downwards maximise the air trapped between the sheet & neonate.
Rationale 33: When there is no radiative heat from above, a blanket can be used.
Rationale 34: To avoid heat loss from the neonate to the cool mattress by conduction.
Rationale 35: There is no heat source from above or below so the Baby-therm is being used as a cot alone.
Rationale 36: Once switched off, the mattress retains heat for 15 minutes.
Rationale 37: As per manufacturer's usage policy.
Rationale 38: If well insulated by clothes, blankets &/or swaddling, in the ideal room temperature, will be able to maintain an adequate central temperature.
Rationale 39: The head has a large surface area for heat loss so should be covered. (Ref15)
Rationale 40: The environmental temperature must be altered slowly due to the immature heat conserving mechanisms at this age and limited ability to adapt to sudden or extreme changes.
Rationale 41: To prevent heat loss by all means (Altimier et al 1999).
Rationale 42: To provide optimal insulation.
Rationale 43: To prevent heat loss during transfer/change to the Neutral Thermal Environment (Altimier et al 1999)
Rationale 44: To maintain a NTE at all times (Merenstein & Gardiner 1998).
Rationale 45: To prevent the neonate being exposed to a cold, wet surface and losing heat by conduction and evaporation
Rationale 46: To evaluate the effectiveness of interventions.
Rationale 47: To provide an accurate record.
Rationale 48: In enable quick recognition and prevention of adverse consequences (Mitchell 1997).
Rationale 49: To avoid the complications of cold stress.
Rationale 50: To decrease surface area for heat loss.
Rationale 51: It could be due to vasoconstriction from shock, hypovolaemia, post-operative stress or handling.
Rationale 52: To enable quick recognition and prevention of adverse consequences (Mitchell 1997).
Rationale 53: To avoid the complications of heat stress.

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Thomas K (1994) Thermoregulation in neonates. Neonatal Netw 13 (2): 15-22.

Reference 2:
Merenstein GB, Gardiner SI (1998) Handbook of Neonatal Intensive Care 3rd Edition. St Louis, Mosby

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Drager Product Information (1997) Closed and open incubators. Hemel Hempstead, Drager

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Roberton NRC (1995) A Manual of Neonatal Intensive Care. London, Edward Arnold

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Altimier I, Warher B, Amlung S, Kenner C (1999) Neonatal Thermoregulation: Bed Surface Transfers. Neonatal Network 18(4): 35-37.

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Klaus M, Fanaroff A (1973) The Physical Environment in Care of the High Risk Neonate. Philadelphia, Saunders

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Sedin G (1995) Neonatal heat transfer, routes of heat loss and heat gain. Okken A and Koch J In: Thermoregulation of sick and low birthweight neonates. Berlin, Germany, Springer-Verlag

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Knobel R, Holditch-Davis D (2007) Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low-birthweight infants. J Obstet Gynecol Neonatal Nurs 36 (3): 280-7.

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Harpin VA, Rutter N (1985) Humidification of incubators. Arch Dis Child 60 (3): 219-24.

Reference 21:
GE Healthcare (2011) giraffe omnibed. www.gehealthcare.com/euen/maternal-infant-care/products/microenvironments/giraffe_omnibed/index.html.