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Knowledge, attitude and practices to hypothermia amongst nursing professionals and mothers of neonates Jyotsna Gupta* Intern Lady Hardinge Medical College New Delhi E-mail: [email protected]

Hypothermia is a very common problem affecting neonates regardless of their weight and gestational age. It occurs in all environments, including places with warm climates. The mortality of babies with hypothermia is twice as compared to babies without hypothermia. Moreover, hypothermia is an important cause of morbidity. Hypothermia in neonates is defined as a core temperature below 36.5°C; 3636.5°C is mild hypothermia (cold stress); 32-36°C is moderate hypothermia; <32°C is severe hypothermia.(1) Prevention and early detection of hypothermia are the cornerstones in the management of hypothermia. Hypothermia in neonates can easily be prevented by following simple practices such as drying, not bathing the baby immediately after delivery, providing “Kangaroo mother care”, covering the baby properly and initiating prompt breast feeding etc. In a country like India, where more than 80% deliveries occur in domiciliary settings, the knowledge, attitude and practices of primary care givers especially the mothers and nurses attending the delivery play a pivotal role in protecting the baby from becoming hypothermic. Data pertaining to the knowledge and practices of mothers and health workers related to neonatal hypothermia is scanty in the Indian literature. A Medline search on the above topic did not return any study from the Indian subcontinent on the topic. A recent study on assessment of knowledge and practices of health professionals in 7 countries pertaining to the thermal care of the newborn (2) revealed that the practices pertaining to hypothermia prevention were far from adequate in most health facilities. There was widespread inadequacy in the knowledge pertaining to thermal control and wide use of harmful or potentially dangerous routines. The health care professionals surveyed in this study were grossly underestimating the impact of hypothermia in overall mortality and morbidity in the first week of life as well as their potential role in its prevention.

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Studies from India related to hypothermia in neonates: Neonatal hypothermia has been shown to be prevalent even in the tropical climates of developing countries like India. Incidence and prevalence: Neonatal hypothermia has been reported at the institutional level in India (4,5).In a study conducted in Indore (6), by touch method, 44.7%newborns were assessed at some risk of hypothermia. In a study conducted in Shimla (7), the overall incidence of hypothermia was 2.9% against 1.9% reported from New Delhi (5). Community based studies from district Ambala (8) and Gadchiroli (Maharashtra)(9) have also assessed hypothermia in newborns through axillary body temperature and reported highest incidence in the first 24 hours of birth. The same study from Ambala (8) also reported a significant correlation between room air temperature and neonatal temperature among home delivered newborns in north India. As shown by the studies (6),neonatal hypothermia is a potentially greater hazard in the colder mountainous region particularly in winters .but according to a study in Indore(6), even in summer months ,as many as 41% newborns were cold stressed when touched and 8% moderately hypothermic. Similar findings were seen in the study conducted by pediatricians in AIIMS neonatology unit (10).These findings reveal an important implication that hypothermia can occur in summer too in tropical country like India wherein temperatures in summer months can be soaring high as 30-40 deg C. The incidence as well as mortality due to hypothermia was significantly higher amongst LBW, preterm and SPD babies and in babies having other associated illnesses (7).

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Human Touch for assessment of hypothermia: Maternal Demographics /Knowledge and Practices amongst mothers and medical professionals: In a study conducted in Uttar Pradesh(11),most of the women(70.5%) were in the age group 20-34 years of age with 62.6% being para 2-5 . 74.4% of the women in this study were illiterate and 36.9% belonged to low standard of living index. It was observed that women with secondary or higher education were less likely to report thermal care. . Receiving information about thermal care was predictive of the practice, but this information was rarely communicated In study (12), only 47.8% of the subjects defined neonatal hypothermia correctly .As many as 52.2% of the interviewees considered it to be an uncommon problem. Only 18.6% of the interviewees had knowledge about correct method of recording the temperature in a newborn. The present study reveals the gross lacunae in the knowledge regarding various aspects of neonatal hypothermia among pediatric and obstetric residents and paramedical staff working in labor room and postnatal wards. Regarding newborn care practices, a study was conducted in Uttar Pradesh by A.H. Baqui et al(11) where it was observed that the newborn was dried immediately or before placenta was delivered in only 34.8% cases, The newborn was bathed immediately in 25.9% cases. “Thermal care” i.e. newborn dried and wrapped immediately or first bath after at least 2 days was given in only 19.9% of the cases. The delay in wrapping the newborn after birth that is reported here is consistent with previous studies (13, 14, and 15) .Early breast feeding was practiced only in 5% of the cases. In the Himalayan state of north India, a warm heated room for delivery and lying-in, early rooming in, oil massage and layers of warm clothing are traditional means for thermo-regulation (14). Kangaroo mother care is an easy and effective method to prevent hypothermia in neonates. In a study by Kaur et al (16) Nurses felt that the Babies who received KMC had fewer complications and their survival outcome was better. An increase in expressed breast milk in mothers was reported. In another study by Parikh T.B.et al (17), Present knowledge of the health care personnel about preterm, LBW babies and KMC was found to be unsatisfactory

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Singh et al (18) reported 100% sensitivity of diagnosing skin temperature of < 36 deg C by touching the abdomen and 90% specificity. They suggested that with training and experience, human touch could accurately predict the temperature of abdomen or sole of foot with an accuracy of +_0.5oC. Unfortunately there has been no research on comparisons between any of these methods in field setting by field workers and on how accurately mothers can assess neonatal hypothermia by touch method. The awareness and correct knowledge of touch method for the assessment of newborn temperature is lacking both among mothers and health professionals. Both the groups tend to underestimate the accuracy of this method Human touch method for assessment of newborn temperature is an easy, convenient and sensitive method to assess the temperature of the newborn. Therefore education programmes for mothers and training of health professionals is vital in this aspect as prevention and early detection of hypothermia can significantly contribute to effective management and lowering of mortality in neonates. Signs and symptoms of hypothermia: As far as the studies regarding signs and symptoms associated with neonatal hypothermia are concerned, according to the study in Indore (6), 56% of the newborns who were cold stressed were suckling poorly according to the mother; however data did not reflect a correlation between hypothermia and lethargy. In the same study 15/46 cold stressed newborns had RR>60.In another study conducted by S.P.Chaudhry et al(12) regarding knowledge attitude and practices about neonatal hypothermia among medical and paramedical staff, Lethargy, refusal for feed and cold to touch were mentioned as common symptoms of neonatal hypothermia by 97.5%, 80% and 77.5% of the respondents respectively. Decreased body temperature, cyanosis, apnea and edema of feet were found as common signs. Mortality: About 1.2 million newborns die each year in India alone, accounting for about one fourth of global neonatal deaths(19,20).Most neonatal deaths in developing countries occur at home , unattended by

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skilled health professionals.(21,22).In India ,65.4% of all births and 75.3% of births in rural areas occur at home(23)In a study from Shimla conducted by Shyam L.Kaushik et al(7) overall 51% of mortality amongst hypothermic neonates was reported which was comparable to 56.2% reported from North India (24). Hypothermia contributed to 9.6% of total neonatal deaths in contrast to 1.4% from Varanasi (25).This could be related to cold weather round the year and time for transportation of sick babies from KNH to pediatric Ward. International studies on neonatal hypothermia. Incidence and Prevalence: Hypothermia is a frequent finding in newborn babies and particularly in LBW babies , in both developed and developing countries(26,27,).Several studies have shown that newborn infants can experience body temperatures as low as 26-27 deg C within 2 h after birth(27,28,29,30). In developed countries, however, awareness of the problem has resulted in improved care, and the incidence of neonatal hypothermia was mostly confined to outborn, premature and LBW infants(31,32,33).A study in Kathmandu ,Nepal (33), showed a prevalence as high as 85% at 2h after delivery, and a similar finding was reported from Zambia(34,35).Neonatal hypothermia has been shown to be prevalent even in the tropical climates of developing countries and is potentially greater hazard in the colder mountainous region particularly in winters(34,36). Knowledge and Practices regarding hypothermia In many parts of the world, health personnel are not aware of the importance of keeping babies warm by simple methods such as drying and wrapping immediately after birth, avoiding harmful traditional practices, encouraging early breastfeeding and keeping newborns in close contact with their mothers (1,29). In the seven countries study (1), only 19% of health professionals recognized body temperature below 36 c as hypothermia. Conditions favoring hypothermia such as LBW, were adequately identified by 65%f the health professionals, with a wide range of results among countries. Knowledge on the prevention and management of hypothermia was somewhat better (73.4% of correct answers) and more evenly distributed among participants (all countries above 50%). However when professionals questioned about specific methods of prevention of hypothermia, many health professionals did not give adequate descriptions of specific procedures. Among specific procedures to Jyotsna G

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prevent hypothermia, the skin to skin method was known by many participants (52.8%), although seldom practiced. Care practices immediately following delivery contribute to newborns risk of morbidity and mortality(37,38,39).A set of practices that reduce neonatal mortality have been outlined as essential newborn care practices which includes thermal care and initiating breastfeeding within the first hour after birth.(37).These interventions have been identified as proven interventions that save newborn lives(39). In the Nepal study (55), Birth place was heated throughout the delivery in 88 deliveries (64.2%).only 100(45.8%) newborns were wrapped within 10 mins and 233(97.1%) were wrapped within 30 mins.Majority (93.7%) of the newborns were given a bath soon after birth. Mustard oil massage of the newborns was a common practice (144, 60%).Initiation rates for breast feeding were 57.9% within one hour and 85.45% within 24 hrs, in another such study in Bangladesh (40). In the study in Iran (28), it was also shown that, the neonates had higher risk for being hypothermic when the operating room or neonatal unit temperature was lower. In developed countries, highly sophisticated incubators and radiant warmers are available. To control this health problem and its related complications, prevention is preferable to treatment. In this context, implementing WHO practical guidelines for thermal control of newborns is a helpful strategy for reducing the incidence of this problem in developing countries(29).Among the proposed preventive measures, however, “Kangaroo mother care “ is the only effective, affordable and available method in most developing countries(41), especially in rural areas. Human Touch for assessment of hypothermia: Hospital based studies have shown a correlation between body temperature assessed by thermometer and human touch method and suggested that physicians and trained assistants can judge the temperature of a newborn baby with reasonable accuracy, simply by touching the baby (42).In Nepal, the use of human touch method by health workers to detect hypothermia was examined in 250 newborns .High sensitivity of 80% was observed by this method (43). Mortality

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Hypothermia can be an important contributing factor to neonatal death (44-46).A recent study in Iran had similar findings(28),where total mortality rate was 6% (54 neonates) during this study and the death rate in hypothermic babies was considerably higher than in normothermic ones. A study on 50 Iraqi children with hypothermia showed that the majority of infants had evidence of infection, particularly septicaemia (47). The overall mortality rate in that study was 26% (42% in LBW infants) and the most common finding was a high incidence of aspiration pneumonia in infants over 3 days old. The results from another study on 36 cases of neonatal intestinal obstruction in Iraq revealed that hypothermia was one of the main causes of death (48). In a survey of paediatric mortality in Lebanon, the researchers recommended that prevention of 5 risk factors—acidosis, hypoxemia, hypoglycaemia, hypotension and hypothermia—were important for reducing the death rate (49). Neonatal hypothermia is also prevalent in Israel (50). Different studies in that country have shown that mortality and morbidity in hypothermic infants are mainly related to the presence or absence of an associated septicaemia (51– 53). In Turkey, a study on 66 babies who had undergone surgery because of peritonitis showed 100% mortality in hypothermic neonates (54)

health professionals in seven countries. Acta Paediatrica 1997; 86:645-50

A strong association between mortality and low body temperature at admission in the neonatal unit was shown in other studies as well (26, 27).

9) Bang AT et al:.Burden of morbidities and unmet need for health care in ural neonates – a prospective observational study in Gadchiroli ,India .Indian pediatr 2001;38:952-965

Conclusion The knowledge and practices of mothers and health care professionals with respect to hypothermia are grossly inadequate in the various studies evaluated so far both in India as well as in world over. The need of the hour is to keep a constant vigil regarding hypothermia in neonates and to be aware of it s potential complications. Health education of expectant mothers and in service training of physicians and paramedical workers would go a long way in dealing with the problem of hypothermia. There is also an urgent need to generate data pertaining to these aspects.

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