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CESDI Project 27/28 investigated the standards of care provided to infants who died after birth at 27–28 weeks gestation in England, Wales, and Northern Ireland during 1998–1999, comparing them with controls who survived.1 Temperature on admission to the neonatal unit was below the British Association of Perinatal Medicine/Royal College of Physicians (BAPM/RCP) standard of 36°C2 in 73% of babies who died and 59% of controls. The CESDI report confirms the findings of the EPICure study,3 which showed that low admission temperature was an independent risk factor for neonatal death after adjustment for other known risks. Alarmingly, the CESDI report concludes that, as most units were unable to achieve the standard, “the feasibility of achieving this standard must be questioned”! Vohra et al4 and Bjorklund and Hellstrom-Westas5 have shown that admission temperature is significantly increased if evaporative heat loss is prevented during resuscitation by occlusive wrapping after birth.
Since 2000, we have aimed to place all infants below 29 weeks gestation in polythene bags on the resuscitaire, before proceeding with their stabilisation. The policy was not followed universally at first, but since 2002 all babies below 29 weeks have been resuscitated in a plastic bag. The unit moved to a new hospital in March 2002, but there has been no change in delivery room temperature, or in the experience of medical and nursing staff attending resuscitation. Transport incubators were used in the old hospital to transfer the baby to the unit but this is now carried out on the resuscitaire.
The baby is slid into the bag up to the neck while still wet. The head is covered with a hat. No blankets are used, allowing radiant heat to warm the infant through the bag. Clinical inspection and auscultation can be performed through the bag, and, if vascular access is needed, a small hole can be cut in the bag. The infant is transported to the neonatal unit on the resuscitaire, eliminating the need for a transport incubator. Our resuscitaires have battery powered radiant heaters for the journey but these have not been important. The data shown here were gathered before the batteries were installed. Avoiding a move to a transport system has eliminated the associated risk of accidental extubation. On arrival in the unit, the baby is weighed and then placed in a warm humidified incubator before the bag is removed. Axillary temperature is then measured using an electronic thermometer.
Figure 1 shows the ranges of admission temperatures for inborn babies of 23–28 weeks gestation, over the past eight years. Now that all babies are placed in a plastic bag, we have abolished hypothermia. The mean (SD) admission temperature is now 37.0 (0.7)°C. Some infants now have mildly raised temperature on admission. They are the subject of further study but in most there are markers suggesting maternal infection.
Using this simple, inexpensive technique the BAPM/RCP standard is readily achieved, independent of the clinical state and size of the infant. All units should have a policy for auditing admission temperature and a strategy for eliminating hypothermia during resuscitation, as this may be just as important as other more complex and expensive interventions.