ORIGINAL ARTICLE https://doi.org/10.4094/chnr.2017.23.4.505 ISSN(Print) 2287-9110 ISSN(Online) 2287-9129 안영미, 손민, 김남희, 강나래, 강승연, 정은미 인하대학교의과대학간호학과 Hypothermia and Related Factors in High-Risk Infants Youngmee Ahn, Min Sohn, Namhee Kim, Narae Kang, Seungyeon Kang, Eunmi Jung Department of Nursing, College of Medicine, Inha University, Incheon, Korea Purpose: Maintaining body temperature is a key vital function of human beings, but little is known about how body temperature of highrisk infants is sustained during early life after birth. The aim of this study was to describe hypothermia in high-risk infants during their first week of life and examine demographic, environmental, and clinical attributors of hypothermia. Methods: A retrospective longitudinal study was done from January 1, 2013 to December 31, 2015. Medical records of 570 high-risk infants hospitalized at Neonatal Intensive Care Units (NICU) of a university affiliated hospital were examined. Body temperature and related were assessed for seven days after birth. Results: A total of 336 events of hypothermia (212 mild and 124 moderate) occurred in 280 neonates (49.1%) and most events (84.5%) occurred within 24 hours after birth. Logistic regression analysis revealed that phototherapy (aor=0.28, 95% CI=0.10-0.78), Apgar score at 5 minute (aor=2.20, 95% CI=1.17-4.12), and intra-uterine growth retardation or small for gestational age (aor=3.58, 95% CI=1.69-7.58) were statistically significant contributors to hypothermia. Conclusion: Findings indicate that high-risk infants are at risk for hypothermia even when in the NICU. More advanced nursing interventions are necessary to prevent hypothermia of high-risk infants. Key words: Hypothermia, Newborns, Neonatal intensive care units Corresponding author Namhee Kim Department of Nursing, College of Medicine, Inha University, 100 Inharo, Nam-gu, Incheon 22212, Korea TEL +82-32-860-8207 FAX +82-32-874-5880 E-MAIL knh@inha.ac.kr * 2015 ( ) (. 2015R1D1A1A01061344). * This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (. 2015R1D1A1A01061344). Key words,, Received 25 August 2017 Received in revised form 6 October 2017 Accepted 18 October 2017 서 론 연구의필요성. This is an Open Access article distributed under the terms of the Creative Commons Attribution n- Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited., [1].. [2], (World Health Organization, WHO) (36.0~36.4 ), (32.0~35.9 ), (32.0 ) [2]. 32% 85% [3]. 35.5~36.5, 37.0~37.9 [4]., 36.5~37.1 [1], 36.5 36.5 [5-7]. 36.5. Copyright 2017 Korean Academy of Child Health Nursing 505
, [2,8].. [1,9]. [9]. [8,10]. (intraventricular hemorrhage), [8,11]., (Low Birth Weight, LBW). LBW, [1,12].,,, x-ray,., [9]. (Very Low Birth Weight, VLBW) 50% [11] (body index). LBW 36.5, 1 28% (late-onset sepsis) 11% [5].,,, 5 [5,8].., [13,14]. (neutral thermal environment) [1,9,13], 28 VLBW [9,15]. (Neonatal Intensive Care Units, NICU),, [13,14]. LBW [1,13]. 3~7 70% [1,13]. [16], [17], [18], [19], [10]. LBW,, [5,7,8], LBW [15], skin-to-skin care[20], trans-warmer [21].,..,.. NICU,,. 연구목적.,.,,,.,. 연구방법 연구설계 NICU. 연구대상 2013 1 1 2015 12 31 3 NICU. 506 www.e-chnr.org
https://doi.org/10.4094/chnr.2017.23.4.505 3,. 3,,. 36.5 383, 36.4 280. SPSS 22.0,.,,, T,,.. 자료수집방법 ( : 160427-1A) 2013 2015 NICU. 2016 5 2016 7. 7. 7 7 [1].,. (frequency), (degree), (time). 1 (event 1). (event). WHO 36.5 [2], (Microlife electronic thermometer MT200, ONBO Electronic Co., Ltd., China) ± 0.1 36.4. 36.0~36.3 (mild hypothermia), 32.0~35.9 (moderate hypothermia), 32.0 (severe hypothermia)..,,,,,.,. 자료분석방법 NICU 579, 3 9, 570 7 연구결과 36.4 280 132 (47.1%), 166 (59.3%), 33.03 ± 3.99, 1940.09 ± 766.14 gram. 5 7.17 ± 2.03, 256 (91.4%). (81.4%), (23.6%), / (15.7%), (Intra-Uterine Growth Retardation/Small for Gestational Age, IUGR/SGA, 14.6%). 6 (2.1%), 71 (25.4%). (84.6%), (10.0%), (5.4%). 저체온증의양상 570 7 36.5 383, 625. 36.4 280, 336. 336 212 (63.1%), 124 (36.9%),. 33.6~36.3, 35.89 ± 0.49. Figure 1 1 76.5%, 84.5% 24. 91.1%, 58.9% 20. 저체온증과관련요인,, (Table 1),,,,,,,.,, 5 7, IUGR/SGA ( : χ 2 = 6.17, p =.020; : χ 2 = 6.03, p =.015; 5 : χ 2 = 4.22, p=.049; IUGR/SGA: χ 2 =13.15, p<.001). www.e-chnr.org 안영미, 손민, 김남희외 3 인 507
Figure 1. Frequency of hypothermia in high-risk infants during the first week of life.,, (Table 2),,,.,,,,, 5, IUGR/SGA. 1,000 gram (Extremely Low Birth Weight, ELBW) 1,000 gram (35.72 ± 0.61 35.92 ± 0.46 ; t =7.36, p=.007). 28 37, 32 37 (35.75 ± 0.59, 35.77± 0.54 35.97± 0.38 ; F = 4.22, p=.006). (35.84 ± 0.52 35.96 ± 0.43 ; t = 4.97, p=.026), (35.77 ± 0.60 35.94 ± 0.42 ; t = 8.75, p =.003), 5 7 (35.79 ± 0.58 35.94 ± 0.43 ; t = 6.65, p =.010), IUGR/SGA (35.72 ± 0.53 35.92 ± 0.47 ; t =7.08, p =.008), (36.12 ± 0.33 35.87± 0.49 ; t= 8.83, p=.003),. 24 84.5%,, 5, (Table 3)., ( : r=.17, p=.004; : r =.17, p =.005; 5 : r=.22, p <.001; : r=.14, p=.044)., ELBW (r =.66, p<.001). 508 www.e-chnr.org
https://doi.org/10.4094/chnr.2017.23.4.505 Table 1. Comparison of Frequencies in Severity of Hypothermia by Characteristics of High-Risk Infants during the First Week of Life (N=336) Variables Characteristics Categories Mild (n=212) Hypothermia: n (%) Moderate (n=124) χ 2 (p) Demographic Gender Female Male 93 (60.0) 119 (65.7) 62 (40.0) 62 (34.3) 155 (46.1) 181 (53.9) 1.18 (.308) Birth weight (gram) 1,000 <1,000 186 (64.8) 26 (53.1) 101 (35.2) 23 (46.9) 287 (85.4) 49 (14.6) 2.48 (.149) Gestational age (week) 37 <37 26 (48.1) 186 (66.0) 28 (51.9) 96 (34.0) 54 (16.1) 282 (83.9) 6.17 (.020) Environmental Type of delivery NSD C/sec 97 (68.8) 115 (59.0) 44 (31.2) 80 (41.0) 141 (42.0) 195 (58.0) 3.39 (.068) Placement* Incubator Radiant warmer 180 (63.6) 18 (51.4) 103 (36.4) 17 (48.6) 283 (89.0) 35 (11.0) 1.97 (.196) Phototherapy 184 (60.9) 28 (82.4) 118 (39.1) 6 (17.6) 302 (89.9) 34 (10.1) 6.03 (.015) Artificial ventilator 157 (65.1) 55 (57.9) 84 (34.9) 40 (42.1) 241 (71.7) 95 (28.3) 1.54 (.258) Clinical features Apgar score at 5 min 7 <7 156 (66.7) 56 (54.9) 78 (33.3) 46 (45.1) 234 (69.6) 102 (30.4) 4.22 (.049) Health problems at birth 11 (44.0) 201 (64.6) 14 (56.0) 110 (35.4) 25 (7.4) 311 (92.6) 4.23 (.052) IUGR/SGA 194 (66.9) 18 (39.1) 96 (33.1) 28 (60.9) *Bassinet was excluded; NSD=rmal spontaneous delivery; IUGR=Intra-uterine growth retardation; SGA=Small for gestational age. 290 (86.3) 46 (13.7) 13.15 (<.001) 저체온증에영향을미치는요인,, Table 4. Adjusted odds ratio,,,,,,. 5 7 2.20 (aor =2.20; 95% CI =1.17-4.12; p=.014), IUGR/SGA 3.58 (aor =3.58; 95% CI =1.69-7.58; p =.001). 72% (aor = 0.28; 95% CI = 0.10~0.78; p=.015). 논의,...,,. 3 NICU.., (,, ). 570 36.4 280 336. 280 570 49.1%, 52.7%[19], 56.2%[8], 44~51%[22]. NICU.. www.e-chnr.org 안영미, 손민, 김남희외 3 인 509
Table 2. Comparison of Body Temperature at Hypothermia Events by Characteristics of High-risk Infants during the First Week of Life (N=336) Variables Characteristics Categories n Demographic Gender Female Male 155 181 Body temperature ( ) M±SD 35.88±0.45 35.90±0.52 t or F (p) 0.13 (.717) Birth weight (gram) 1,000 <1,000 287 49 35.92±0.46 35.72±0.61 7.36 (.007) Gestational age (week) <28 a 28, <32 b 32, <37 c 37 d 55 76 151 54 35.75±0.59 35.92±0.53 35.97±0.38 35.77±0.54 4.22 (.006) a, d<c Environmental Type of delivery NSD C/sec 141 195 35.96±0.43 35.84±0.52 4.97 (.026) Placement* Incubator Radiant warmer 283 35 35.89±0.49 35.78±0.54 1.76 (.186) Phototherapy 302 34 35.87±0.49 36.12±0.33 8.83 (.003) Artificial ventilator 241 95 35.94±0.42 35.77±0.60 8.75 (.003) Clinical features Apgar score at 5 min 7 <7 234 102 35.94±0.43 35.79±0.58 6.65 (.010) Health problems at birth 25 311 35.74±0.48 35.90±0.49 2.76 (.098) IUGR/SGA 290 46 35.92±0.47 35.72±0.53 7.08 (.008) *Bassinet was excluded; Tukey HSD analysis; NSD=rmal spontaneous delivery; IUGR=Intra-uterine growth retardation; SGA=Small for gestational age. 63.1%, 36.9%. 67.3%, 32.7%, [11]. 40%. Miller, Lee Gould VLBW [8]., [11].,,,, [14]. 1 76.5%, 24 84.5%. 3 8.3%. NICU 24 67.7%, 72 (early hypothermia) 67.6%, 72 (late hypothermia) 46.2% 72 [23]., 1, 3,,. NICU, 40%. NICU,. 510 www.e-chnr.org
https://doi.org/10.4094/chnr.2017.23.4.505 Table 3. Correlation of Hypothermia and Related Factors at First Day after Birth Variables Categories n Birth weight (gram) <1,000 1,000, <1,500 1,500, <2,500 2,500 37 44 139 59 279 Mild (n=164) Hypothermia Moderate (n=115) r (p) r (p) r (p).18 (.495) -.10 (.622) -.07 (.539).14 (.420).12 (.121).60 (.004) -.11 (.659).09 (.547) -.32 (.140).22 * (.020).66 (<.001) -.18 (.257).07 (.434) -.20 (.122).17 (.004) (N=279) Gestational age (week) <28 28, <32 32, <37 37 39 58 130 52 279 -.13 (.632) -.05 (.764) -.06 (.577).14 (.515).04 (.623).54 (.008).50 * (.019) -.04 (.791).44 * (.023).27 (.003).43 (.006).20 (.125) -.12 (.162).39 (.004).17 (.005) Apgar score at 5 min <7 7 79 200 279.37 * (.025).11 (.220).09 (.250).12 (.454).04 (.756).22 * (.017).21 (.058) -.03 (.669).22 (<.001) SpO2 (%) <95 95 120 79 199 -.07 (.593).20 (.186) -.02 (.836).36 * (.010).02 (.907).23 * (.039).25 (.006) -.02 (.889).14 * (.044) * p <.05, p <.01; SpO2=Saturation of peripheral oxygen. Table 4. Logistic Regression Analysis to Predict Occurrence of Moderate Hypothermia according to Demographic, Environmental and Clinical Variables (N=336) Variables Characteristics Categories Crude OR [95% CI] Adjusted OR [95% CI] Demographic Gender Female Male 0.78 [0.50~1.22] 0.91 [0.55~1.51] Birth weight (gram) 1,000 <1,000 1.63 [0.88~3.00] 1.58 [0.70~3.54] Gestational age (week) 37 <37 0.48 [0.27~0.86] 0.51 [0.19~1.34] Environmental Type of delivery NSD C/sec 1.53 [0.97~2.42] 1.12 [0.66~1.88] Placement* Incubator Radiant warmer 1.65 [0.82~3.34] 1.44 [0.67~3.08] Phototherapy 0.33 [0.13~0.83] 0.28 [0.10~0.78] Artificial ventilator 1.36 [0.84~2.21] 1.18 [0.57~2.45] Clinical features Apgar score at 5 min 7 <7 1.64 [1.02~2.64] 2.20 [1.17~4.12] Health problems at birth 0.43 [0.19~0.98] 0.43 [0.11~1.59] IUGR/SGA 3.14 [1.66~5.97] 3.58 [1.69~7.58] *Bassinet was excluded; OR=Odds ratio; CI=Confidence interval; NSD=rmal spontaneous delivery; IUGR=Intra-uterine growth retardation; SGA=Small for gestational age. www.e-chnr.org 안영미, 손민, 김남희외 3 인 511
, 15% 24.,. ELBW 28.. ELBW, [1,9,12]. NICU.. VLBW ELBW,, skin-to-skin, trans-warmer [9,15,20,21], NICU. 28 37 35.75 ± 0.59 35.77± 0.54. NICU. LBW [8-10,12,13]. NICU..,,.,. 72%... [24] [25],., [8,26].. [9,27]., NICU. NICU., 5 IUGR/ SGA. 5 7,. 5, 5 7 2.20. 5 [8,26]. 5 4 [28]. 5,,,. IUGR/SGA,. IUGR/SGA 3.58. IUGR 6% 10% IUGR [30]. IUGR/SGA [29].,, [1] IUGR/SGA.. 512 www.e-chnr.org
https://doi.org/10.4094/chnr.2017.23.4.505,,,. ELBW IUGR/SGA,. NICU,. NICU NICU.,,,..,,.., 3 NICU... 결론, 36.0 40%. 24 1.,,,, 5, IUGR/SGA... Conflict of Interest potential or any existing conflict of interest relevant to this article was reported. Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (. 2015R1D1A1A01061344). References 1. The Korean Society of Neonatology. Manual of neonatal care. 3rd ed. Seoul: The Korean Society of Neonatology; 2014. p. 58-59. 2. World Health Organization. Thermal protection of the newborn: A practical guide [Internet]. World Health Organization; 1997 [cited 2016 April 15]. Available from: http://apps.who.int/iris/handle/10665/63986. 3. Lunze K, Bloom DE, Jamison DT, Hamer DH. The global burden of neonatal hypothermia: Systematic review of a major challenge for newborn survival. BMC Medicine. 2013;11(24):1-11. https://doi.org/10.1186/1741-7015-11-24 4. Takayama JI, Teng W, Uyemoto J, Newman TB, Pantell RH. Body temperature of newborns: What is normal? Clinical Pediatrics. 2000;39(9):503-510. https://doi.org/10.1177/000992280003900901 5. Laptook AR, Salhab W, Bhaskar B, Neonatal Research Network. Admission temperature of low birth weight infants: Predictors and associated morbidities. Pediatrics. 2007;119(3):e643-e649. https://doi.org/10.1542/peds.2006-0943 6. McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S. Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants. The Cochrane Database of Systematic Reviews. 2010; 17(3):CD004210. https://doi.org/10.1002/14651858.cd004210.pub4 7. Bissinger RL, Annibale DJ. Thermoregulation in very low-birthweight infants during the golden hour: Results and implications. Advances in Neonatal Care. 2010;10(5):230-238. https://doi.org/10.1097/anc.0b013e3181f0ae63 8. Miller SS, Lee HC, Gould JB. Hypothermia in very low birth weight infants: Distribution, risk and outcomes. Journal of Perinatology. 2011;31(Suppl 1):S49-S56. https://doi.org/10.1038/jp.2010.177 www.e-chnr.org 안영미, 손민, 김남희외 3 인 513
9. Knobel R, Holditch-Davis D. Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low-birth weight infants. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2007;36(3):280-287. https://doi.org/10.1111/j.1552-6909.2007.00149.x 10. Paik SN, Hong HS, Sung MH, Cho KJ, Yhee, HJ. The influence of thermal head and feet support on early stage weight gain in premature neonates. Korean Journal of Child Health Nursing. 2000;6 (3):397-410. 11. Jang JH, Shin SH, Woo HK, Choi EK, Song IG, Shin SH, et al. The association between admission hypothermia and neonatal outcomes in very low birth weight infants. Neonatal Medicine. 2016;23(4):183-189. https://doi.org/10.5385/nm.2016.23.4.183 12. Ahn Y, Sohn M, Lee S, Lee M. ph, Temperature, hydration of the stratum corneum of the dorsal hand and the cord area, and acid mantle formation during early days of life in high-risk newborns. Journal of Korean Academy of Nursing. 2013;43(1):30-38. https://doi.org/10.4040/jkan.2013.43.1.30 13. Choi YY. Management of premature and low birth weight infants. Journal of the Korean Medical Association. 2008;51(8):745-754. https://doi.org/10.5124/jkma.2008.51.8.745 14. Soll RF. Heat loss prevention in neonates. Journal of Perinatology. 2008;28(Suppl 1):S57-S59. https://doi.org/10.1038/jp.2008.51 15. Reilly MC, Vohra S, Rac VE, Dunn M, Ferrelli K, Kiss A, et al. Randomized trial of occlusive wrap for heat loss prevention in preterm infants. The Journal of Pediatrics. 2015;166(2):262-268. https://doi.org/10.1016/j.jpeds.2014.09.068 16. Lee SM, Lee EY, Kang AR, Ahn YM. Variation in body temperatures with the environmental temperature and humidity in hospitalized. Journal of the Korean Society of Living Environmental System. 2012;19(6):746-753. 17. Kim HS, Jung YS, Cho JP, Park MS, Pai KS. Hypothermia during prehospital transportation of neonates. Journal of the Korean Society of Emergency Medicine. 1999;10(4):680-685. 18. Lee SB, Shin HS. Effects of Kangaroo care on physiological marker of preterm Infant in neonatal intensive care unit. Journal of East-West Nursing Research. 2012;18(2):59-65. 19. Kim HY, Park HR, Moon YI, Park JH. The effects of warm waterfilled bag on body temperature, FiO2, respiration rate, and blood sugar in high risk neonates. Korean Journal of Child Health Nursing. 2005;11(4):390-395. 20. Marín Gabriel MA, Llana Martín I, López Escobar A, Fernández Villalba E, Romero Blanco I, Touza Pol P. Randomized controlled trial of early skin-to-skin contact: Effects on the mother and the newborn. Acta Paediatrica. 2010;99(11):1630-1634. https://doi.org/10.1111/j.1651-2227.2009.01597.x 21. Chawla S, Amaram A, Gopal SP, Natarajan G. Safety and efficacy of trans-warmer mattress for preterm neonates: Results of a randomized controlled trial. Journal of Perinatology. 2011;31(12):780-784. https://doi.org/10.1038/jp.2011.33 22. de Almeida MF, Guinsburg R, Sancho GA, Rosa IR, Lamy ZC, Martinez FE, et al. Hypothermia and early neonatal mortality in preterm infants. The Journal of Pediatrics. 2014;164(2):271-275. https://doi.org/10.1016/j.jpeds.2013.09.049 23. Ogunlesi TA, Ogunfowora OB, Adekanmbi FA, Fetuga BM, Olanrewaju DM. Point-of-admission hypothermia among high-risk Nigerian newborns. BMC Pediatrics. 2008;8(40):1-5. https://doi.org/10.1186/1471-2431-8-40 24. Pezzati M, Fusi F, Dani C, Piva D, Bertini G, Rubaltelli FF. Changes in skin temperature of hyperbilirubinemic newborns under phototherapy: Conventional versus fiberoptic device. American Journal of Perinatology. 2002;19(8):439-444. https://doi.org/10.1055/s-2002-36839 25. Stokowski LA. Fundamentals of phototherapy for neonatal jaundice. Advances in Neonatal Care. 2006;6(6):303-312. https://doi.org/10.1016/j.adnc.2006.08.004 26. Park JH. A comparative study on the changing pattern of temperature of newborn infants depending on the use of radiant warmers [master s thesis]. Jeonju: Chonbuk National University; 2005. p. 1-64. 27. Bhatt DR, White R, Martin G, Van Marter LJ, Finer N, Goldsmith JP, et al. Transitional hypothermia in preterm newborns. Advances in Neonatal Care. 2010;10(Suppl 5):S15-S17. https://doi.org/10.1097/anc.0b013e3181ef7dfd 28 Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. The New England Journal of Medicine. 2001;344(7):467-471. https://doi.org/10.1056/nejm200102153440701 29. Rosenberg A. The IUGR newborn. Seminars in Perinatology. 2008;32(3):219-224. https://doi.org/10.1053/j.semperi.2007.13 30. Zubair DS, Gour SS. Comparison of outcome in IUGR and normal pregnancies-a retrospective study. International Journal of Medical Research and Review. 2016;4(4):646-649. https://doi.org/10.17511/ijmrr.2016.i04.29 514 www.e-chnr.org