Thermal Effect of a Woolen Cap in
Low Birthweight Infants during Kangaroo Care
have affected neonatal temperature during KMC. Although the relatively high birth weight of participants might have limited the benefit of the cap on thermal control, the multivariable analysis showed that the cap had no effect on temperature adjusting for birth weight and postnatal age. In other words, our findings suggest that the sum of recommended thermoregulatory practices and, more importantly, maternal and staff’s education and behaviors play the main role in influencing thermal control during the neonatal period rather than a single specific intervention (i.e. the use of the cap).
Severe hypothermia and hyperthermia are strongly associated with morbidity and mortality in high and low-resource settings.[9-13, 18, 19] In the present study, at least one episode of severe hypothermia occurred in 1 out 10 infants during KMC. On the other side, 1 out of 30 infants experienced at least one episode of severe hyperthermia, suggesting that severe hyperthermia is less frequent than severe hypothermia despite SSC and the fact that KMC rooms were usually warmer than WHO recommendations (>25°C).
An association between hypothermia at admission to the NICU and late-onset sepsis has been previously reported in very preterm infants.[30] In the present study, respiratory problems and sepsis occurred in over 20% of the infants thus confirming the importance of these clinical conditions among LBWI even during KMC. However, no statistical differences were found on these secondary outcomes.
During hospital stay, mean growth was not influenced by the use of the cap. The inclusion of in-hospital growth among secondary outcomes was based on the hypothesis that a longer time spent in normothermia could reduce the metabolic expenditure for maintaining the body temperature.
The strengths of this study include the multi-center and multi-country design, which allows a broad generalizability of the findings, the absence of dropouts among randomized patients and the supervision of skilled healthcare staff, who ensured the adherence to the study protocol.
The present study has also some limitations. First, adherence to SSC was very variable, but this is a well-known situation during KMC, thus our findings present the data in a real-world context.[31] Second, the standard thermoregulatory practices (i.e. the type and the number of the clothes used by the mothers to cover the baby, maternal and staff behaviors, and presence/absence of air currents created by the open windows) which likely contributed to influence infant temperature were difficult to follow. Third, the collection of the temperature at predefined time points might have affected the observed compliance to SSC, but this approach was chosen in order to obtain a uniform data recoding within the day and to avoid interfering with routine activities of local health staff. Finally, the sample size could not be calculated a priori due to the lack of information about this specific topic, thus we decided to avoid any unrealistic estimates in sample size calculation.
Conclusions
In these three African low-resource settings and so many days post birth, the use of a woolen cap was safe but provided no advantages in maintaining LBWI in the normal thermal range during being in a KMC ward. LBWI spent only half of the time in the normal temperature range during KMC despite warm rooms and SSC. Maintaining normothermia in LBWI remains an unfinished challenge in low-resource settings. Further studies are required to shed light on the role of the cap in thermal control of LBWI during KMC in low-resource settings.
Acknowledgements
We are grateful to all the mothers of babies enrolled in the study and to the midwives and nurses of participating hospitals for their support. We thank the volunteers in Padua (Italy) who handmade the caps used in the study.
Rivista Italiana on line "LA CARE" Volume 11, Numero 1-2, anno 2018
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