Delivery room thermal care interventions in preterm neonates.

Abstract

Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Pullattayil AK, Thanigainathan S, Trevisanuto D, Roehr CC. Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr. 2021 May 24:e210775. 10.1001/jamapediatrics.2021.0775. Epub ahead of print. PMID: 34028513; PMCID: PMC8145154. Preterm neonates are at increased risk for hypothermia after birth which is an independent predictor for neonatal mortality and morbidity.1, 2 Maintaining normal temperature is a key initial step in stabilisation of the newborn at birth.3 Several interventions to prevent hypothermia in the delivery room have been studied either solely or in combinations.4-7 The neonatal life support task force suggested using a combination of different interventions to prevent hypothermia on neonatal admission to the NICU.3 However, this suggestion was based on relatively old evidence with weak recommendations and very low certainty. This network meta-analysis was conducted on 34 randomised and quasi-randomised controlled trials including 3688 preterm, ≤36 weeks gestation and infants aiming to identify thermal care intervention in the delivery room that can best reduce neonatal hypothermia and improve clinical outcomes. The researchers compared eight interventions to routine care and found that most of the interventions were associated with higher core body temperature. They found that plastic bag or wrap alone, thermal mattress, and plastic bag or wrap with heated humidified gas were associated with reduced risk of moderate to severe hypothermia compared with routine care. The SUCRA analysis showed that the combination of plastic bag or wrap with a thermal mattress was the best intervention to improve core body temperature at admission, but direct evidence from pairwise comparisons indicated that this combination increases the risk of hyperthermia. In sensitivity analyses, plastic bag and plastic wrap were equally good at maintaining core body temperature, the effect of interventions in improving temperature was consistent among preterm infants ≤30 weeks gestation, and drying did not make a difference compared to no drying before the application of plastic bag or wrap. Authors found that the use of a plastic bag or wrap with heated humidified gas was associated with reduced risk of major brain injury and a plastic bag or wrap with a plastic cap was associated with lower risk of mortality. Major strengths of this study are the use of network meta-analysis which can inform comparative effectiveness in the presence of multiple interventions, the systematic search strategy, and clinically relevant interventions and outcomes. However, the study is limited by wide differences in the method of temperature measurement between included trials, inability to perform analysis of some secondary outcomes due to data limitation, small sample size of the included trials and low event rates for the primary outcome leading to possible selective reporting and publication bias, and inability to access unpublished data from the included studies.5 Although, the majority of thermal care interventions were associated with better core body temperature and decreased risk of moderate to severe hypothermia at admission or within the first 2 h of life compared with routine care, the certainty of evidence ranged from very low to moderate for the primary and secondary outcomes. Future, adequately powered, randomised controlled trials are needed to determine the best combination of interventions to prevent hypothermia with no risk of hyperthermia and to assess quality improvement bundle of hypothermia preventive measures to assess the individual benefit for each newborn. https://ebneo.org/preterm-thermal-care None.