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The issue of hypothermia in preterm infants represents significant challenges to NICU practitioners. Low body temperature increases the risks of mortality and morbidity in the preterm infant population due to their fragility when trying to survive outside of the womb. Current methods for regulating body temperature range from warm blankets to skin-to-skin; however, the use of plastic caps and wraps is promising. Thus, the PICO question for the current evaluation is the following: In low-birth-weight/pre-term neonates in health facilities, are plastic wraps or caps used immediately after birth more effective than conventional care in preventing hypothermia?
The study by Li et al. (2016) investigated the effectiveness and the safety of using plastic wraps applied during NICU and after birth for preventing the loss of heat in preterm infants. Through conducting a meta-analysis and systematic review of the literature on the topic, the researchers found that plastic wrapping was linked to higher baseline temperature in preterm infants compared to unwrapped infants.
Both infants with the gestation period of below 28 weeks and between 28 and 34 weeks benefited from the use of plastic wrapping, suggesting that the intervention was associated with the decreased rates of heat loss. Nevertheless, mortality rates did not decrease when plastic wraps were used. The research points to the effectiveness of implementing plastic wrap interventions for reducing the occurrence of hypothermia in infants born preterm, although the long-term impact on mortality as well as the cost-effectiveness of this method require further analysis.
McCall, Alderdice, Halliday, Jenkins, and Vohra (2008) analyzed “interventions for preventing hypothermia at birth in low birthweight infants” as well as those being born preterm (McCall et al., 2008, CD004210). Two main routine interventions were evaluated: heat loss barriers, including plastic wraps and stockinet caps, and external heat sources including skin-to-skin and trans warmer mattresses (McCall et al., 2008).
It was found that plastic wrapping was effective for lowering the occurrence of hypothermia in preterm infants aged less than 28 weeks and no infants of 28-31 week’s gestation. In addition, no significant evidence was found to support the decrease in brain injury reduction or decreased mortality rates. Other methods, such as skin-to-skin care and trans warmer mattresses also kept infants warmer but not as effective as plastic wraps.
Leadford et al. (2013) conducted a study to evaluate the effectiveness of plastic wraps use to reduce the risks of hypothermia in preterm infants as well as those with low birth weight. With the help of a randomized sample of 104 infants of 26-36 gestational age, it was found that after one hour after being born, infants to whom the plastic wrap intervention was applied had higher rates of having normal temperature range if compared to infants who were assigned standard procedures of thermoregulation care. In the plastic wrap group, the temperature was 36.5 ± 0.5°C compared with 36.1 ± 0.6°C in the standard care group (Leadford et al., 2013).
Therefore, the strategy of placing preterm infants into plastic bags at birth showed better effectiveness in decreasing hypothermia in contrast to other methods of reducing temperature loss. In addition, the intervention is low-cost and low-technology, which supports its wide implementation.
The research conducted by Valizadeh, Mahalleo, Safaiyan, Ghorbani, and Peyghami (2017) focused on investigating the use of plastic covers in controlling vital signs in preterm infants. Body temperature, heart rate, and arterial blood oxygen saturation are the key signs monitored at ICU units when implementing plastic wrap interventions. According to the results of the study, infants who were covered with plastic wraps showed lower rates of hypothermia compared to those covered with regular blankets (Valizahed et al., 2017). This points to the effectiveness of plastic wrap use in regulating normal temperature in preterm infants.
In regards to the findings of the reviewed research articles, it can be concluded that plastic wraps applied to preterm infants represent a viable strategy for regulating body temperature. Since infants born before the recommended gestational age are more likely to suffer from hypothermia, the plastic wrap method provides a significant basis for the subsequent implementation of the intervention in practice. In regards to the proposed PICO question, the review of literature helped to understand the application of the intervention in practice and the education of mothers regarding the management of low body temperature of their preterm infants.
Comparison with a Traditional Intervention
Conventional methods of hypothermia prevention, such as skin-to-skin are widely used in both natural and cesarean delivery. The study by Bailey (2015) evaluated the effects of the skin-to-skin strategy for decreasing hypothermia and in both preterm and full-term infants in the neonatal ICU. Skin-to-skin care (SSC) was shown to increase milk production in mothers as well as contribute to the decrease of temperature loss.
This method is used due to its simplicity and low absence of expensive resources needed, leading to such additional benefits as “increased parent satisfaction, better sleep organization, a long duration of quiet sleep, and decreased pain perception during procedures” (Bailey, 2015, p. 597). However, SSC is not a strategy that shows consistency and reliability in terms of hypothermia prevention in preterm infants, which points to the fact that plastic bag wrapping is more effective in the context of the current PICO question.
The lack of consistency in the use of SSC for regulating hypothermia is challenging because it may not work for some infants and work for others. The use of plastic wraps and caps, on the contrary, showed consistency in its effects, which points to a higher level of effectiveness. For instance, as Bailey (2015) mentioned, the increase of temperature with the SCC method was only 0.22 °C while in plastic wrap use, as mentioned by Leadford et al. (2013), the increase amounts to 0.4 ± 0.5°C. Therefore, plastic wraps use to point to greater efficacy in NICU application.
Implications and Evaluation
For the nursing practice, the implications of the plastic wrap used for preventing hypothermia in preterm infants are vast. Due to the ease of application and few resources needed to increase the temperature of infants, the intervention can be widely applied in multiple settings. The resource availability at NICUs does not have a significant impact on the success of the intervention, suggesting that it can be used even in emergencies. In terms of evaluating the outcomes of plastic wrap use, comparative observations of plastic wrap and traditional interventions can be implemented. Nurses are recommended to record the results of conventional and plastic wrap-related interventions in NICUs to compare the effectiveness of the strategies in reducing the likelihood of hypothermia occurrence.
Overall, the recommended intervention has the potential for enhancing the quality of care during the delivery of preterm newborns. The proposed PICO question will play a significant role in showing how a simple method can enhance the quality of care given to preterm infants during delivery. Nevertheless, the impact on mortality and morbidity rates remains to be studied further as no significant relationships between the intervention and these variables were found.
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Bailey, J. (2015). Skin-to-skin care for term and preterm infants in the neonatal ICU. Pediatrics, 136(3), 596-599.
Leadford, A. E., Warren, J. B., Manasyan, A., Chomba, E., Salas, A. A., Schelonka, R., & Carlo, W. A. (2013). Plastic bags for prevention of hypothermia in preterm and low birth weight infants. Pediatrics, 132(1), 128-134.
Li, S., Guo, P., Zou, Q., He, F., Xu, F., & Tan, L. (2016). Efficacy and safety of plastic wrap for prevention of hypothermia after birth and during NICU in preterm infants: A systematic review and meta-analysis. PLos ONE, 11(6), e0156960.
McCall, E., Alderdice, F., Halliday, H., Jenkins, J., & Vohra, S. (2008). Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants. Cochrane Database Systematic Review, 23(1), CD004210.
Valizadeh, L., Mahallei, M., Safaiyan, A., Ghorbani, F., & Peyghami, M. (2017). The effect of plastic cover on regulation of vital signs in preterm infants: A randomized cross-over clinical trial. Iranian Journal of Neonatology, 8(2), 24-30.