What is Hypothermia and Hypoglycaemia?
Organized neonatal care is critical to preventing several complex issues in new born babies. Hypoglycaemia, related to hypothermia, is the most common metabolic problem in newborns. However, considering its long term consequences, it is a serious concern to prevent this condition in the infants. Hypothermia is the state of having a body temperature which is abnormally low. The likelihood of developing hypothermia is more in newborns because they have a larger surface area as compared to body weight (Hart and et.al., 2011). This makes them lose body heat at a faster rate. Neonatal hypoglycaemia is defined as the condition in which blood glucose level is lower than the normal (Sweet, Grayson and Polak, 2013). In order to keep the body warm, the neonates utilize glucose stores of the body which leads to hypoglycaemia. Postnatal midwives play a crucial role in providing care and support to the newborns and their family. This essay critically analyses the aspect of hypothermia related hypoglycaemia in newborns within the environment of neonatal practice. It will explore the ways in which postnatal midwives can prevent hypothermia related hypoglycaemia in newborns within the transition care unit. Good practice with regard to prevention of hypothermia related hypoglycaemia will be analysed. Further, a thorough literature search has been conducted so as to explore and discuss issues surrounding this area of neonatal practice. On the basis of analysis, an improvement in practice will be recommended in the essay writing. Lastly, method used for auditing the proposed changed will be described.
As per the NMC code of professional conduct, the nurses and midwives should respect people's confidentiality (The code, 2008). Therefore in order to maintain confidentiality, the actual names of the persons have not been disclosed. Confidentiality has been maintained by changing the names. This essay is based on a personal experience which took place in a neonatal intensive care unit. With the objective of obtaining a good learning outcome and implementing it in future, Gibbs Model of reflection has been followed for this essay. According to Jayatilleke (2012) reflective practices help nurse make sense of their work and analyse it. It contributes to learning and professional development of a person (Jayatilleke, 2012). As per the views of Fleming (2007) reflection leads to self awareness and enhances personal development (Fleming, 2007). Gibbs reflective cycle is capable of encouraging a clear description of the situation. A personal experience which took place in NICU is the source of this essay. The SHO brought a baby, Jack, to the unit during night shift. The baby suffered from vomiting and low blood sugar. Also, its temperature was found to be much below the normal limits. Even 8 hours after the birth, there were no clothes on the baby. Instead, the midwives covered the baby in only two towels. The baby had to be given dextrose infusion. Also, it could not be breast fed due to history of vomiting.
According to NHS choices, babies are more likely to develop hypothermia because the ability of their body to regulate temperature is not fully developed (Hypothermia, 2015). Waldron and Mackinnon (2007) assert that in the management of neonates, thermoregulation is more important. In newborns, hypothermia is a common problem all over the world. If immediately after delivery, appropriate action is not taken the core and skin temperatures of a newborn can decrease at the rate of 0.1 and 0.3 degree Celsius per minute respectively. According to the World Health Organization, mild hypothermia is defined as a core body temperature of 36- 36.4 degree Celsius while moderate hypothermia as 35.9- 32 degree Celsius. A core body temperature of less than 32 degree Celsius is defined as severe hypothermia. Knobel, Wimmer and Holbert, (2005) also explain that the physical characteristics of the newborns and environment of the delivery room may act as risk factors for development of hypothermia. In typical situations, a wet newborn who has a high ratio of surface area to volume, moves from a warm aqueous environment to delivery room which is comparatively cooler and dry (Knobel, Wimmer and Holbert, 2005). Soll (2008) agrees that by paying attention to the management of neutral thermal environment of a newborn, clinical outcome can be improved. While in utero, there is heat production by the fetus. This leads to half a degree higher fetal temperature as compared to the maternal temperature. After birth, the environment to which newborn is exposed is much different (Soll, 2008). The external environment of the delivery room is much cold due to which heat is lost by the newborn. Also, there are significant evaporative heat losses. As a result of this, the temperature of the newborn drops. This exposes him to the risk of hypothermia.
Knobel and Davis (2007) study revealed that the newborns may lose heat by basic mechanisms of conduction, radiation, evaporation and conduction. Heat loss through radiation involves the temperature of those surfaces which surround the baby but are not in direct contact. Heat energy is emitted by the newborn in the form of infrared electromagnetic waves (Knobel and Davis, 2007). As per the views of Guyton and Hall (2006) for an infant that is older than 28 weeks gestational age, heat loss through radiation is the most important source of heat transfer. Through convection, heat can be lost when it is carried away from the body through air currents. Similarly, evaporation also leads to loss of heat from the infant's body (Guyton and Hall, 2006). Knobel, Wimmer and Holbet (2005) assert that if the newborn is not attended adequately, it may result in hypothermia and cold stress. Hypothermia, in turn is responsible for a variety of physiologic stresses (Knobel, Wimmer and Holbet, 2005). The infant experiences increased oxygen consumption, metabolic acidocis, decreased cardiac output, hypoglycaemia and increased peripheral vascular disease. According to Page- Goertz (2007), concern about hypoglycaemia in newborn is a common issues however it may adversely affect subsequent neurologic development. Cold stress or hypothermia is considered to be risk factor for hypoglycaemia in newborns. More energy is used by a colds baby who is more prone to becoming stressed and hypoglycaemic (Page- Goertz, 2007). This is because, cold stress leads to an increase in the metabolic demands of infants at the time when there is only marginal availability of glucose.
Klossner (2006) also agrees that in response to heat loss and low glycogen stores, a newborn typically experiences hypoglycaemia (Klossner, 2006). Study by Burdan, Botiu and Teodorescu (2009) considered neonatal hypoglycaemia as one of the most common problems experienced in neonatal intensive care units. But it is of serious concern as prolonged hypoglycaemia results in brain damage and mental retardation (Burdan, Botiu and Teodorescu, 2009). Study by Laptook and Jackson explores unique challenges that are posed by late preterm infants for doctors and nurses taking care of them. There can be lack of attention regarding important components which depict successful transition after birth. According to authors, cold stress and hypoglycaemia are two important problems which can be seen in infants (Laptook and Jackson, 2006). These problems require immediate attention. Therefore, it is important to carry out surveillance of physiological variables to ensure that these problems do not affect the successful adaptation of infant during early hours after birth.
It order to prevent hypothermia related hypoglycaemia, it is important for the midwives to create a neutral thermal environment in the birthing area. In addition to this, there is also need to reduce the risk of cold stress in the new born which can be done by towel drying and maintaining skin to skin contact with the mother. As per the guidelines provided by NHS on prevention and management of neonatal hypothermia, the delivery unit should be kept warm and draft-free. Healthy infants should be dried and hat should be placed on the baby's head. They should also be covered in warm towels so as to prevent heat loss (Prevention and management of neonatal hypothermia, 2012). Soll (2008) stressed the importance of skin to skin contact in preventing hypothermia. Skin- to- skin contact with the mothers helps in improving the axillary temperature of the newborn after birth. Moreover, the abdominal temperature improves within the first 21 minutes after birth. In this way, skin- to skin contact helps in reducing the risks of hypothermia in newborn (Soll, 2008). Further, the Mullany (2010) found that the risk of hypothermia can be reduced by early initiation of breast feeding. This is because early breast feeding bring the baby in close contact with the mother. It also provides fat supply which is essential for active production of heat in the newborn (Mullany, 2010). Evaluation of the situation indicates that the midwife made cautious efforts to dry the infant and covered it in towels. Also, she covered baby's head with a hat which is a good practice. However, the baby was not dressed in clothes which would have resulted in significant heat loss from the body.
As per the guidelines provided by NHS, it is a good practice to take the axillary temperature during initial examination after birth. This is in accordance with the Examination of the Newborn Policy Register Number 04225. However, it can be critically evaluated that temperature of the newborn was not monitored by the midwife. This suggests that it was not ensured that body temperature of the baby was normal. As per the reason given to the senior nurse, she was busy as it was short staff on that day. But, monitoring of axillary temperature of newborn is crucial. This is because, intermittent temperature recording taken from axilla is the most common way of monitoring temperature. According to Elzouki and et.al. (2012) axillary temperature is a reasonable guide to deep body temperature (Elzouki and et.al. (2012). With monitoring of temperature, important information is provided by it about the thermal state of body of the infant.
A critical evaluation of the study conducted by Dorina Rodica Burdan, Valentin Botiu, Doina Teodorescu has been carried out. The study is based on an aim to analyze the incidence of the risk factors related to neonatal hypoglycemia in Salvator Vuia obstetrics gynecology hospital of Arad. The title chosen for the study is apt as it clearly reflects the content of report being risk factors related to Neonatal hypoglycemia. The title has further mentioned the name of area where the study is carried out. It has thus made the title a suitable one. The abstract section of study has majorly focused on methodology. However, there has been a lack of content with respect to background, conclusion and recommendations. This clearly needs an improvement as merely reading the abstract may is not resulting in overall understanding of report. The objectives framed for the study are apt as these reflect the aim to be covered by the researcher. The methodology part has been presented by the researcher in a clear cut format. This is as the researcher has clearly mentioned the study area as well as time frame in very beginning of the section. Statistical tools to be used for analysis are also mentioned clearly. The results section has further focused on creation of tables, graphs and charts so as to depict a proper analysis. However, the positioning of graphs and chart is not clear. It is quite difficult to understand as to which text section represents the table and graph. Conclusion has further been written in to the point format. These are enough to get a crux of entire study. But the researcher has failed to present recommendation section as well as implication for further research. Overall the study has followed a brief but presentable means of study. However, there exists a lack of understanding in a few areas especially the results section which can be worked upon.
An another study was conducted by Zhou and et.al., 2015 on Hypoglycemia incidence and risk factors assessment in hospitalized neonates. The title presented the basic understanding of content but lacked in presenting the name of country where the study was to be carried out. The name however appeared in abstract section. The abstract was well presented by making use of proper headings and subheadings. These aided in better understanding of the areas that have been covered in the study. The method section of study has analyzed the areas to be covered but failed to mention the use of statistical tool from which the results have been derived. The result section is apt as there has been presentation of numerical figures so as to show the incidence of hypoglycemia in neonates. However, the author could have worked more on the presentation section by adding more tables and charts. Conclusion further represents the major crux of study. However the researcher lacks in presenting recommendation as well as implication of future research. Overall the study has the presence of proper content but somewhere lacks in presentation area.
The above studies selected for critical analysis were on the same topic being risk factors related to neonatal hypoglycaemia. Both the studies made a fair attempt to research the risk factors in a best possible manner. However, both of them missed the major section of recommendations and future research impatiens. First study by Dorina Rodica Burdan, Valentin Botiu, Doina Teodorescu was well presented but got a bit difficult to understand in the results section. On the other hand the second study by Zhou and et.al., 2015 had all the necessary content except for addition of tables and charts. Conclusion of both the studies was able to provide the overall crux. One conclusion was in paragraph format while other was in points. Still the areas were quite clear in both the studies.
The findings of the study conducted by Burdan and et.al. (2009) were that neonatal hypoglycaemia incidence was found to be inferior to the universal data. The incidence of neonatal hypoglycaemia was affected by caesarian section and abnormal presentation. In the situation of polycytemia, neonatal hypoglycaemia was caused due to increase of consumption of glucose by mass of erythrocytes. Th findings of the study conducted by Zhou and et.al. (2015) were that 113 out of 668 children suffered from hypoglycaemia. The incidence of hypoglycaemia was fund to be 16.9 per cent. The methodology used by authors comprised of regular monitoring of blood glucose levels in hospitalized neonates. As compared to this, Burdan and et.al. (2009) clinical sheets of 2687 newborns born in Clinical Obstetrical-Gynecology were analysed. After the screening test neonates with neonatal hypoglycaemia were selected. The study was carried out or a period of 9 months.
Google scholar and science direct were used as the search engines to find the studies for the essay. The search was carried out by using key words and their different combinations. Use of search engine was helpful as it helped in finding and indexing as many sites as possible. The time period that was selected for searching the studies was between years 2005-2015. This is as latest studies were to be searched on the topic so that up – to – date information can be obtained on hypoglycaemia caused by hypothermia. With the help of this search strategy, primary studies were searched.
After the literature has been critically analysed, improvement or change in practise can be suggested. Considering the literature there is requirement of a change in practice in the neonatal intensive care unit. The intervention of dressing the baby in pre warmed clothes can be used by postnatal midwives for preventing hypothermia related hypoglycaemia in newborns. McCall and et.al. (2010) stress that hypoglycaemia results when the baby uses more glucose than is being produced. Hypothermia can be prevented by two ways. The first way is through barriers to heat loss while the second method is to provide external heat sources. The risk of cold stress in newborns can be minimised by adhering to practice guidelines such as wrapping the baby in pre warmed blankets and covering in pre warmed clothes. This intervention helps in keeping infant warmer (McCall and et.al., 2010).
Mullany (2011) also agree that warm clothing help in preventing heat loss in infants. The study found that there is a 10 step warm chain which should be followed for minimising the risks of exposure to cold stress. Appropriate warm clothing forms an important step in this chain (Mullany, 2011). Lunze and et.al. (2014) carried out 14 focus group discussions with mothers and grandmothers in Zambia. It was found that it is important to dry the baby and keep it warm by dressing in pre warmed clothes. Kumar and et.al. (2009) found that heat loss is a risk factor that leads to hypothermia in newborns. The main method of heat loss from newborn is through evaporation of amniotic fluid from the baby's body. However, it was also found that if the baby is placed naked on a cold surface, heat from the body is lost due to conduction. At the time of birth if the baby is exposed to a cold environment, considerable heat may be lost from its body in the absence of thermal protection (Kumar and et.al., 2009). Lunze and Hamer (2012) asserted that pre warmed clothes help in providing thermal protection to the baby. These also protect the newborn from heat loss due to conduction and evaporation (Lunze and Hamer, 2012).
Ayaz and Efe (2008) suggest it is good practice to cover the newborn in pre warmed clothes including a hat. Warm clothes prevent hypothermia by preventing the escape of heat from unprotected surfaces of the body. Head of the newborn has a large surface are which increases the amount of heat loss thus exposing the baby to the risk of hypothermia. Clothing such as mittens, hat etc. play an important role in keeping the newborn warm (Ayaz and Efe, 2008). According to Leadford and et.al. (2013), air currents also remove the heat from body by carrying away thin layer of warm air on the surface of skin (Leadford and et.al., 2013).
The intervention of dressing the newborn in pre warmed clothes can be implemented by making it as a part of newly released practice guidelines. Along with these guidelines, the midwives will be asked to fill a checklist pertaining to each newborn baby. This checklist will include all the measures taken to prevent hypothermia in that particular newborn. The checklist can be inspected and monitored by the senior nurse. Ayaz and Saleem (2010) agree that practice guidelines are an effective way of implementing a change in practice. New practice guidelines will help in effectively implementing this change in practice (Ayaz and Saleem, 2010). The post natal midwives would be aware of the need and importance of covering the baby in pre warmed clothes. However, this was not practised by them. In order to encourage the nurses to adopt the practice of covering baby in pre warmed clothes, sessions and meetings can be held whereby they can be informed about the new intervention.
For auditing the effectiveness of the proposed intervention of covering newborn in pre warmed clothes, questionnaires will be provided to the health care professionals in the neonatal ward. Questionnaire will prove to be an effective assessment tool which will help in auditing the effectiveness of proposed intervention of using pre-warmed clothes. Petty, Thomson and Stew, (2012) also support that Questionnaires help in gathering responses in a standardized manner. It is also effective in collecting information in a quick manner (Petty, Thomson and Stew, 2012). Thus, the effectiveness of the proposed intervention could be determined in relevant time frame. As per the views of Qu and Dumay, (2011), questionnaire help in collecting data which can be quantified easily and quickly (Qu and Dumay, 2011).
This audit will be carried out with the purpose of finding out the effectiveness of using pre warmed clothes by postnatal midwives for preventing hypoglycaemia related to hypothermia in newborns. The questionnaire will consists of open and close ended questions. Open ended questions will help the health care professionals to provide detailed information about the loopholes that the intervention possesses as well as the further improvements that can be brought.
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Hypoglycaemia related to hypothermia is a common problem in newborns. It is extremely important to consider temperature changes that a newborn undergoes throughout its journey from mother's womb to the outside world. The environment inside the womb is warm. Hence, if the newborn is not provided a warmer environment after birth, it may experience cold stress which leads to hypoglycaemia. This poses serious complications in the newborn which may even lead to mental retardation. Therefore, prevention of hypothermia related hypoglycaemia should b the major concern of postnatal midwives. For preventing cold stress, the intervention of dressing the newborn in pre warmed clothes can be implemented. This success and benefit of this intervention has been verified by different studies which state that pre warmed clothes help in preventing hypothermia related hypoglycaemia in newborns.
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