Clinical detection of ‘cold stress’ is overlooked: an online survey of healthcare workers to explore the gap in neonatal thermal care in low-resource settings

Abstract

BackgroundNeonatal hypothermia has been widely regarded as a major contributory factor to neonatal mortality and morbidity in low-resource settings. The high prevalence of potentially preventable hypothermia today urges an investigation into why neonates still become hypothermic despite awareness of the problem and established thermal care guidelines. This study aimed to explore the gaps in knowledge and practices of neonatal thermal care among healthcare workers in low-resource settings.MethodsA cross-sectional, questionnaire-based survey was performed online among healthcare workers in low-resource settings. We applied a purposive and snowballing sampling method to recruit participants through a two-round international online survey. Questionnaires were developed using themes of neonatal thermal care extracted from existing neonatal care guidelines.Results55 neonatal care professionals participated in the first-round survey and 33 in the second. Almost all participants (n=44–54/55) acknowledged the importance of the WHO’s warm chain to keep a neonate warm. However, fewer participants (n=34–46/55) responded to practice them. When asked about cold stress, defined as a condition in which neonates are below optimum environmental temperature and using more oxygen and energy while maintaining normal body temperature, 15 out of 55 participants answered that checking extremity temperatures by hand touch was useless. Some participants reported concern about the extremity temperature’s inaccuracy compared with core temperature. Opinions and preferences for rewarming methods differed among participants, and so did the availability of warming equipment at their institutions.ConclusionAn inadequate understanding of cold stress underestimates the potential benefits of extremity temperatures and leads to missed opportunities for the timely prevention of hypothermia. The current thermal care guidelines fail to highlight the importance of monitoring cold stress and intervening before hypothermia occurs. Therefore, we urge introducing the concept of cold stress in any neonatal thermal care guidelines.

Neonatal warming devices: What can be recommended for low-resource settings when skin-to-skin care is not feasible?

“…WHO recommends using radiant warmers or incubators for unstable neonates weighing 2000g or less, or for stable neonates below 2,000 g who cannot receive skin-to-skin care ( 14 ). In low-resource settings, however, these warming devices are often unavailable ( 15 ), either broken down, with little chance of being made functional again on site ( 16 ) or kept in storage due to missing parts, insufficient power-grid or lack of consumables ( 17 ).…”

Early detection of cold stress to prevent hypothermia: A narrative review

“… 22 , 23 However, this simple method remains undervalued and generally recommended only as a second and lesser choice in clinical practice. 16 , 24 In current clinical practice, axillary or rectal temperature is commonly measured to confirm normothermia (36.5°C–37.5°C), or detect hyperthermia (>37.5°C) or hypothermia. 4 , 25 , 26 This measurement of a single temperature detects established body temperature only and gives no clue about the dynamic physiological efforts to maintain it.…”