JINJA REGIONAL REFERRAL HOSPITAL. Why? Neonatal mortality contributes 40% of under 5 mortality worldwide 14% of births worldwide are of low birth weight.

JINJA REGIONAL REFERRAL HOSPITAL

Improving Neonatal Thermal Monitoring And Care -

The Role of the Champion Parent

Dr Jenny WoodruffDr Johanna Gaiottino

Sister Anguparu MaburukaSpecial Care Baby Unit, Jinja Regional Referral Hospital

Why?

• Neonatal mortality contributes 40% of under 5 mortality worldwide

• 14% of births worldwide are of low birth weight

Is neonatal hypothermia a big problem in Africa?

................the simple answer is yes!

Prevalence data:Zambia 44% - 69%Ethiopia 53%Nigeria 62% - 68%Zimbabwe 85%

Lunze et al. BMC Medicine 2013, 11:24. The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival

Hypothermia – why does it matter?WHO definitions of hypothermia

− Mild 36.0 – 36.5 − Mod 32.0 – 36.0 − Severe <32.0

- now thought to be outdated

We need to correct the myth that the only temperature worth worrying about is <32oC!

Hypothermia - why does it matter?

Definition(Mullany et al, 2010)

Temperature range (oC)

Risk of death (adjusted for age/ambient temp)

Normothermic 36.5 – 37.5 1

Mild hypothermia 36.0 – 36.4 1.8 times higher

Moderate hypothermia 35.0 – 35.9 3 times higher

Severe hypothermia 34.0 – 34.9 10 times higher

Very severe hypothermia ≤33.9 25 times higher

Hypothermia means the baby is more likely to die!

Hypothermia - why does it matter?

Definition(Mullany et al, 2010)

Temperature range (oC)

Risk of death (adjusted for age/ambient temp)

Normothermic 36.5 – 37.5 1

Mild hypothermia 36.0 – 36.4 1.8 times higherModerate hypothermia 35.0 – 35.9 3 times higherSevere hypothermia 34.0 – 34.9 10 times higherVery severe hypothermia ≤33.9 25 times higher

Hypothermia means the baby is more likely to die!

What about in Uganda?In 2006 in SCU in Mulago, 29% of newborn deaths were

associated with hypothermia

79% of 300 newborns in St Francis Hospital, Nsambya, were hypothermic within 90 minutes of delivery‒ Higher frequency in babies who did not have skin to

skin contact with their mothers, or who were bathed within 1 hour of birth

Ministry of Health. Situation analysis of newborn health in Uganda: current status and opportunities to improve care and survival. Kampala: Government of Uganda. Save the Children, UNICEF, WHO; 2008

Byaruhanga et al, Neonatal hypothermia in Uganda: prevalence and risk factors. J Trop Pediatr. 2005

What we did...Made use of the resources available

What did the parents do?Parents asked to record temperatures 6 hourly

Solar thermometers used

Chart included simple instructions on what to do in the case of mild, moderate or severe hypothermia

Temperature monitoring champion parent oversaw the process

But did this intervention help?

MethodsRetrospective audit of notes

Inclusion criteria: Birth weight <2kg Admitted September-October 2014Admitted February-March 2015

Every temperature recorded in the notes was analysed (517 temperatures in Sept-Oct and 534 temperatures in Feb-Mar)

Results: number of temperatures recordedAverage numbers of temperatures recorded

per day of admission increased from 1.2 temperatures taken per day to 1.9 (p<0.001)

Highly significant change, despite absence of several temperature charts from the post-intervention notes

Results: average temperatureAverage temperature increased from 36.28oC (95% CI +/-0.08) to

36.43oC (95% CI +/- 0.06) (p<0.01)

0 1 236.2

36.25

36.3

36.35

36.4

36.45

Sept to Oct Feb to Mar

Results: temperatures by categorySept and Oct

3%

7%

20%

21%

50%

Sept and Oct 1% 2%

18%

25%54%

Feb and Mar

Very severe (<33.9)

Severe (34.0 - 34.9)

Moderate (35.0 - 35.9)

Mild (36.0 - 36.4)

Normal / mildly pyrexic (36.5 - 37.9)

Results:Severely hypothermic temperatures (≤34.9oC)

reduced significantly from 8.9% to 2.8% (p<0.0001).

Moderately and severely hypothermic temperatures (≤35.9oC) decreased significantly from 27.9% to 19.9% (p<0.01).

Results: Did not reach significanceThe percentage of days of admission with

severe hypothermia (≤34.9oC) reduced from 8.1% to 4.6% (p<0.07) but did not reach statistical significance.

The number of deaths, discharges and “runaways” did not change significantly.

ConclusionIncreased number of temperatures

measured per patient admission day Increase in average temperatureA decrease in moderate and severe

hypothermic temperaturesEmpowerment of mothers to monitor

their babies’ temperatures

What next?