NIHR Signal Plastic wraps or bags keep pre-term infants warm immediately after birth

Published on 22 May 2018

Cheap and simple plastic wrapping used in the first 10 minutes after birth helps pre-term and low birth weight infants avoid hypothermia. Infants treated in this way are likely to be warmer when admitted to neonatal intensive care than those treated according to standard care. Pre-term infants are most likely to benefit.

Routine infant care usually involves ensuring the delivery room is warm, drying the infant immediately after birth, wrapping the infant in pre-warmed dry blankets and pre-warming surfaces. Despite this, about a quarter of babies born eight weeks early have temperatures that are too low and additional measures to warm pre-term and low birth weight infants are needed.

Although babies were warmer after the intervention, this review of 19 published studies did not show that these interventions improved survival, or reduced the chances of short or long-term conditions associated with cold, perhaps because of the size of the trials.

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Why was this study needed?

Hypothermia immediately after birth remains a worldwide problem, in both resource-rich and poorer countries. The UK National Neonatal Audit Programme highlighted hypothermia as a concern, after it found 25% of infants born at less than 32 weeks gestation in this country had a recorded temperature below the recommended range in 2016. Newborn babies, particularly pre-term infants, rely on external help to maintain their temperature, particularly in the first 12 hours of life. Maintaining a near normal temperature is important for survival and is a worldwide issue across all climates because of the link to a variety of complications including brain injury and bleeding into the lung.

Optimum interventions have so far been unclear, partly because of lack of consistency in measuring infants’ temperatures.

This study assessed efficacy and safety of interventions designed for preventing hypothermia in preterm or low birth weight infants, used within 10 minutes of birth. The main comparison was between plastic wraps or bags to reduce heat loss, versus routine care. The study also looked at external heat sources, including skin-to-skin care and heated mattresses.

What did this study do?

This systematic review included 25 randomised or quasi-randomised trials, with a total of 2,433 infants. Fourteen studies were conducted in high-income countries, seven studies in upper-middle income countries and four in lower-middle income countries. Two studies were from the UK. The main outcome was the temperature of the infant on admission to the neonatal intensive care unit (NICU) or up to two hours after birth.

Studies were included if they involved preterm infants of less than 37 weeks’ gestation, and/or weighing 2,500 grams or less. Interventions to prevent hypothermia were applied within 10 minutes of birth. Infants with major birth defects were not included. The strength of evidence for the main comparison was judged as moderate.

What did it find?

  • Plastic wraps improved babies’ core body temperature on admission to the NICU, or up to two hours after birth (mean difference [MD] 0.58°C, 95% CI 0.50-0.66), based on 13 studies with 1,633 participants.
  • Fewer wrapped infants, 495 per 1,000, had hypothermia, on admission to the NICU, or up to two hours after birth, compared to 738 per 1,000 in the usual care group (RR 0.67, 95% CI 0.62 to 0.72). This result was based on 10 studies with 1,417 participants. Hypothermia was defined as core body temperature less than 36.5°C or skin temperature less than 36°C.
  • However, the practice did increase the risk of overheating. The risk of hyperthermia on admission to NICU or up to two hours after birth increased from 12 per 1,000 in the usual care group to 46 per 1,000 in the wrapped group (RR 3.91, 95% CI 2.05 to 7.44). This result was based on 12 studies including 1,523 participants
  • There was insufficient evidence to show that plastic wraps or bags significantly reduced the risk of death during hospital stay. Mortality was 153 per 1,000 for wrapped preterm babies and 168 per 1,000 for usual care preterm babies (RR 0.91, 95% CI 0.73 to 1.15).
  • There was some evidence that skin-to-skin care (one study) and heated mattresses (two studies) reduced the risk of hypothermia. However, only 157 participants were included in these external heat source studies.

What does current guidance say on this issue?

The Royal College of Midwives recommends keeping the baby warm at birth using skin-to-skin contact between mother and baby, and drying with pre-warmed towels. If the mother is unable to hold the baby immediately, they should be wrapped in warmed towels and placed under a radiant warmer.

In 2015, the World Health Organisation said there was “insufficient evidence” on the use of plastic bags or wraps in providing thermal care for pre-term newborn infants, but that the practice “may be considered” when transferring babies to NICUs.

What are the implications?

Reducing morbidity and mortality in premature babies remains a challenge in the UK and globally. Based on this study, midwives and obstetricians can be advised that plastic wrapping is a cheap, simple and effective way to maintain body temperature, especially for very preterm infants. It may also improve clinical outcomes, too.

Clinicians using plastic wraps and heated mattresses must take care to avoid hyperthermia, especially when the interventions are used together.

Future studies could include more participants, standardise outcomes and lengthen follow up to better understand the long-term effects of these interventions.

Citation and Funding

McCall EM, Alderdice F, Halliday HL, et al. Intervention to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2018;2:CD004210.

This study received funding support from Northern Ireland Neonatal Intensive Care Outcomes Research and Evaluation Group (NICORE), and the Research & Development Office, Northern Ireland.

Bibliography

NHS Choices. Hypothermia. London: Department of Health; updated 2017.

NICE. Surgical site infection. QS49. London: NICE; 2013.

RCPCH. 2017 National Neonatal Audit Programme annual report on 2016 data. London: Royal College of Paediatrics and Child Health; 2017.

The Royal College of Midwives. Evidence based guidelines for midwifery-care in labour. London: The Royal College of Midwives; 2012.

World Health Organisation. Infants: reducing mortality. Geneva: The World Health Organisation; 2017.

World Health Organisation. WHO recommendations on interventions to improve preterm birth outcomes. Geneva: The World Health Organisation; 2015.

Why was this study needed?

Hypothermia immediately after birth remains a worldwide problem, in both resource-rich and poorer countries. The UK National Neonatal Audit Programme highlighted hypothermia as a concern, after it found 25% of infants born at less than 32 weeks gestation in this country had a recorded temperature below the recommended range in 2016. Newborn babies, particularly pre-term infants, rely on external help to maintain their temperature, particularly in the first 12 hours of life. Maintaining a near normal temperature is important for survival and is a worldwide issue across all climates because of the link to a variety of complications including brain injury and bleeding into the lung.

Optimum interventions have so far been unclear, partly because of lack of consistency in measuring infants’ temperatures.

This study assessed efficacy and safety of interventions designed for preventing hypothermia in preterm or low birth weight infants, used within 10 minutes of birth. The main comparison was between plastic wraps or bags to reduce heat loss, versus routine care. The study also looked at external heat sources, including skin-to-skin care and heated mattresses.

What did this study do?

This systematic review included 25 randomised or quasi-randomised trials, with a total of 2,433 infants. Fourteen studies were conducted in high-income countries, seven studies in upper-middle income countries and four in lower-middle income countries. Two studies were from the UK. The main outcome was the temperature of the infant on admission to the neonatal intensive care unit (NICU) or up to two hours after birth.

Studies were included if they involved preterm infants of less than 37 weeks’ gestation, and/or weighing 2,500 grams or less. Interventions to prevent hypothermia were applied within 10 minutes of birth. Infants with major birth defects were not included. The strength of evidence for the main comparison was judged as moderate.

What did it find?

  • Plastic wraps improved babies’ core body temperature on admission to the NICU, or up to two hours after birth (mean difference [MD] 0.58°C, 95% CI 0.50-0.66), based on 13 studies with 1,633 participants.
  • Fewer wrapped infants, 495 per 1,000, had hypothermia, on admission to the NICU, or up to two hours after birth, compared to 738 per 1,000 in the usual care group (RR 0.67, 95% CI 0.62 to 0.72). This result was based on 10 studies with 1,417 participants. Hypothermia was defined as core body temperature less than 36.5°C or skin temperature less than 36°C.
  • However, the practice did increase the risk of overheating. The risk of hyperthermia on admission to NICU or up to two hours after birth increased from 12 per 1,000 in the usual care group to 46 per 1,000 in the wrapped group (RR 3.91, 95% CI 2.05 to 7.44). This result was based on 12 studies including 1,523 participants
  • There was insufficient evidence to show that plastic wraps or bags significantly reduced the risk of death during hospital stay. Mortality was 153 per 1,000 for wrapped preterm babies and 168 per 1,000 for usual care preterm babies (RR 0.91, 95% CI 0.73 to 1.15).
  • There was some evidence that skin-to-skin care (one study) and heated mattresses (two studies) reduced the risk of hypothermia. However, only 157 participants were included in these external heat source studies.

What does current guidance say on this issue?

The Royal College of Midwives recommends keeping the baby warm at birth using skin-to-skin contact between mother and baby, and drying with pre-warmed towels. If the mother is unable to hold the baby immediately, they should be wrapped in warmed towels and placed under a radiant warmer.

In 2015, the World Health Organisation said there was “insufficient evidence” on the use of plastic bags or wraps in providing thermal care for pre-term newborn infants, but that the practice “may be considered” when transferring babies to NICUs.

What are the implications?

Reducing morbidity and mortality in premature babies remains a challenge in the UK and globally. Based on this study, midwives and obstetricians can be advised that plastic wrapping is a cheap, simple and effective way to maintain body temperature, especially for very preterm infants. It may also improve clinical outcomes, too.

Clinicians using plastic wraps and heated mattresses must take care to avoid hyperthermia, especially when the interventions are used together.

Future studies could include more participants, standardise outcomes and lengthen follow up to better understand the long-term effects of these interventions.

Citation and Funding

McCall EM, Alderdice F, Halliday HL, et al. Intervention to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2018;2:CD004210.

This study received funding support from Northern Ireland Neonatal Intensive Care Outcomes Research and Evaluation Group (NICORE), and the Research & Development Office, Northern Ireland.

Bibliography

NHS Choices. Hypothermia. London: Department of Health; updated 2017.

NICE. Surgical site infection. QS49. London: NICE; 2013.

RCPCH. 2017 National Neonatal Audit Programme annual report on 2016 data. London: Royal College of Paediatrics and Child Health; 2017.

The Royal College of Midwives. Evidence based guidelines for midwifery-care in labour. London: The Royal College of Midwives; 2012.

World Health Organisation. Infants: reducing mortality. Geneva: The World Health Organisation; 2017.

World Health Organisation. WHO recommendations on interventions to improve preterm birth outcomes. Geneva: The World Health Organisation; 2015.

Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants

Published on 13 February 2018

McCall, E. M.,Alderdice, F.,Halliday, H. L.,Vohra, S.,Johnston, L.

Cochrane Database Syst Rev Volume 2 , 2018

BACKGROUND: Newborn admission temperature is a strong predictor of outcomes across all gestations. Hypothermia immediately after birth remains a worldwide issue and, if prolonged, is associated with harm. Keeping preterm infants warm is difficult even when recommended routine thermal care guidelines are followed in the delivery room. OBJECTIVES: To assess the efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room, compared with routine thermal care or any other single/combination of intervention(s) also designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5), MEDLINE via PubMed (1966 to 30 June 2016), Embase (1980 to 30 June 2016), and CINAHL (1982 to 30 June 2016). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: Trials using randomised or quasi-randomised allocations to test interventions designed to prevent hypothermia (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery room for infants at < 37 weeks' gestation and/or birth weight </= 2500 grams. DATA COLLECTION AND ANALYSIS: We used Cochrane Neonatal methods when performing data collection and analysis. MAIN RESULTS: Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies); external heat sources (three studies); and combinations of interventions (four studies).Barriers to heat loss Plastic wrap or bag versus routine carePlastic wraps improved core body temperature on admission to the neonatal intensive care unit (NICU) or up to two hours after birth (mean difference (MD) 0.58 degrees C, 95% confidence interval (CI) 0.50 to 0.66; 13 studies; 1633 infants), and fewer infants had hypothermia on admission to the NICU or up to two hours after birth (typical risk ratio (RR) 0.67, 95% CI 0.62 to 0.72; typical risk reduction (RD) -0.25, 95% CI -0.29 to -0.20; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 4 to 5; 10 studies; 1417 infants). Risk of hyperthermia on admission to the NICU or up to two hours after birth was increased in infants in the wrapped group (typical RR 3.91, 95% CI 2.05 to 7.44; typical RD 0.04, 95% CI 0.02 to 0.06; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 17 to 50; 12 studies; 1523 infants), but overall, fewer infants receiving plastic wrap were outside the normothermic range (typical RR 0.75, 95% CI 0.69 to 0.81; typical RD -0.20, 95% CI -0.26 to -0.15; NNTH 5, 95% CI 4 to 7; five studies; 1048 infants).Evidence was insufficient to suggest that plastic wraps or bags significantly reduce risk of death during hospital stay or other major morbidities, with the exception of reducing risk of pulmonary haemorrhage.Evidence of practices regarding permutations on this general approach is still emerging and has been based on the findings of only one or two small studies.External heat sourcesEvidence is emerging on the efficacy of external heat sources, including skin-to-skin care (SSC) versus routine care (one study; 31 infants) and thermal mattress versus routine care (two studies; 126 infants).SSC was shown to be effective in reducing risk of hypothermia when compared with conventional incubator care for infants with birth weight >/= 1200 and </= 2199 grams (RR 0.09, 95% CI 0.01 to 0.64; RD -0.56, 95% CI -0.84 to -0.27; NNTB 2, 95% CI 1 to 4). Thermal (transwarmer) mattress significantly kept infants </= 1500 grams warmer (MD 0.65 degrees C, 95% CI 0.36 to 0.94) and reduced the incidence of hypothermia on admission to the NICU, with no significant difference in hyperthermia risk.Combinations of interventionsTwo studies (77 infants) compared thermal mattresses versus plastic wraps or bags for infants at </= 28 weeks' gestation. Investigators reported no significant differences in core body temperature nor in the incidence of hypothermia, hyperthermia, or core body temperature outside the normothermic range on admission to the NICU.Two additional studies (119 infants) compared plastic bags and thermal mattresses versus plastic bags alone for infants at < 31 weeks' gestation. Meta-analysis of these two studies showed improvement in core body temperature on admission to the NICU or up to two hours after birth, but an increase in hyperthermia. Data show no significant difference in the risk of having a core body temperature outside the normothermic range on admission to the NICU nor in the risk of other reported morbidities. AUTHORS' CONCLUSIONS: Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection. Many observational studies have shown increased mortality among preterm hypothermic infants compared with those who maintain normothermia, yet evidence is insufficient to suggest that these interventions reduce risk of in-hospital mortality across all comparison groups. Hypothermia may be a marker for illness and poorer outcomes by association rather than by causality. Limitations of this review include small numbers of identified studies; small sample sizes; and variations in methods and definitions used for hypothermia, hyperthermia, normothermia, routine care, and morbidity, along with lack of power to detect effects on morbidity and mortality across most comparison groups. Future studies should: be adequately powered to detect rarer outcomes; apply standardised morbidity definitions; focus on longer-term outcomes, particularly neurodevelopmental outcomes.

Hypothermia is a dangerous drop in body temperature below 35°C. Normal temperature being around 37°C. Hypothermia can be serious if not treated quickly. Babies with hypothermia may look healthy, but their skin will feel cold. They may also be limp, usually quiet and refuse to feed (NHS 2017).

Expert commentary

At birth, preterm infants are at high risk of becoming cold quickly. Cold can cause harm or even death in this group of babies.

Trials show that interventions such as plastic wrapping or heaters can prevent hypothermia; however, few investigate the same intervention, and so it is not clear which type is best in which situation.

It is time to stop conducting small trials that only assess infant temperature and conduct trials that are large enough to evaluate the benefits and risks of providing these interventions on important health outcomes.

Dr Diane Farrar, NIHR Post-doctoral Research Fellow & Maternal Health Research Programme Manager, Bradford Institute for Health Research, Bradford Teaching Hospitals