The Triangle of Complications: Hypothermia, Hypoxia and Hypoglycaemia

Complications of Premature Babies

Despite global efforts to reduce the number of babies born prematurely, the rates are still as high as 15 million preterm newborns annually (World Health Organization, 2018). These babies are at risk of developing hypoxia, hypothermia and hypoglycaemia which are interconnected into a triangle of complications. The World Health Organization (2018) has estimated that about 1 million newborns die annually from the complications of prematurity. Those who survive are at risk of permanent brain injury and physical disability. It is therefore essential for midwives to closely monitor these babies during their stay in the Special Care Nursery. The family too should be incorporated into the care of the baby.

The temperatures in the womb are well-regulated to match the mother’s internal body temperature. Therefore, in utero, the fetus enjoys a warm environment as it bathes in amniotic fluid. During delivery, there is a sudden drop in the temperature of the baby as it enters into a new environment. In premature babies, about 0.5 to 1 degrees Celsius is lost for every minute of exposure (Manani et al., 2013). When the body temperature drops too low, the baby develops hypothermia. At this point, a roller-coaster sets in that involves the 3Hs that are most dreaded among premature newborns: hypothermia, hypoxemia and hypoglycaemia. These three conditions are interconnected to form a triangle of complications.

Premature babies are unable to generate adequate amounts of heat since their thermoregulatory mechanisms such as shivering reflex have not yet fully developed by the time they are born. They also lose a lot of heat to their new environment through radiation, conduction, convection and evaporation mechanisms. Babies born prematurely lose more heat compared to their mature counterparts since they have little subcutaneous fat, underdeveloped skin and a large surface area to body weight ratio. Mank et al (2016), found that up to 93% of preterm babies suffer from hypothermia within the first three hours after being brought into the intensive care unit. Premature newborns with hypothermia present with a weak cry, shortness of breath, skin discoloration, and poor feeding.

As a response mechanism to hypothermia, the body’s sympathetic nervous system causes peripheral vasoconstriction. Blood flow is therefore restricted and less oxygen is supplied to tissues, resulting into hypoxia. The amount of lung surfactant in preterm babies is ten times less than in term newborns (Pacifici, 2015). Their lungs are therefore unable to effectively expand and relax during gaseous exchange. These babies typically present with respiratory distress syndrome which is characterized by shortness of breath, apnea, cyanosis and fatigue. As their body’s temperature decreases, their brain is affected. Subsequently, the respiratory center located on the brainstem reduces the rate of inspiration and expiration. This further decreases ventilation and the cells are unable to meet their oxygen demand. Metabolic activities such as respiration are therefore undermined (Pacifici, 2015).

Risk Factors Affecting Premature Babies

The human body generates glucose through respiration. Therefore, when the rate of respiration decreases in a premature infant with hypoxia, the amount of sugar in their body also decreases. Since these babies do not feed well, their glucose levels are further depleted. They also have little stores of glycogen (Sharma, Davis and Shekhawat, 2017). Their sugar levels can therefore drop to very low levels and result into hypoglycaemia. Their bodies try to release hormones to counter the effects of hypoglycemia by increasing gluconeogenesis, but in the long run, the carbohydrate, protein and fat stores also are depleted. Hypoglycaemic babies present with lethargy, convulsions, an increased heart rate and shortness of breath (Sharma, Davis and Shekhawat, 2017).

The triangle of complications has greatly contributed to infant mortality infant mortality. Most prematurely bone babies have a low birth weight. They need good nutrition and oxygenation. However, hypoglycaemia and hypoxia hinder them form attaining a good growth curve.  Still, both hypoxia and hypoglycemia can cause generalized brain damage. As the brain is deprived of oxygen, its cells undergo ischemia and die. Preterm babies are therefore predisposed to physical disabilities including blindness. Hearing impairment and learning disabilities have also been reported in some prematurely born babies (Kodjebacheva and Sabo, 2015). Hypoglycemia can also cause brain damage. The child is also likely to have delayed developmental milestones if hypothermia, hypoxia and hypoglycaemia are not promptly corrected (Kodjebacheva and Sabo, 2015).

The gestational age at which a baby is born determines the related mortality and morbidity rates (Manuck et al, 2017). Babies born before 24 weeks have a poorer prognosis than those bone at an older age. The birth weight of the newborn also determines the degree of hypoxia, hypoglycaemia and hypothermia. Babies with very low birth weight are likely to have more apneic spells and lower quantities of surfactant. They also suffer from recurrent respiratory infections due to inadequate ventilation and decreased lung compliance. The prognosis of the triangle of complications is thus poor and is responsible for many newborn fatalities (Manuck et al, 2017)

The role of the midwives in the admission of premature babies is initiate the 4-pronged principle: identifying at risk babies, preventing heat loss, providing secondary warmth and preventing the occurrence of complications. To prevent heat loss, midwives should use a warm chain which involves ensuring that the delivery room is warm, drying up the baby immediately after delivery, educating the mother on breastfeeding and preventing complications from arising. During the ongoing care of the baby at the Special Care Nursery, the midwives should ensure that they put the baby on oxygen and regularly monitor their vital signs. Preterm newborns should be kept warm, given oxygen and adequately fed. The midwives should ensure that the nursery is quiet and that the lights are not too bright to make the neonates stressed (Quiroga and Moxon, 2017). The nursery should also be maintained under good hygiene standards so as to the babies do not acquire infections. Premature newborns have immature immune systems which predispose them to multiple infections (Quiroga and Moxon, 2017).

The Role of Midwives in the Care of Premature Babies

Midwives should also be emotionally supportive towards the family of the newborn. They should show concern by giving them updates about the child’s health and by answering their questions. It is important for them to address parents with respect and sensitivity. A good rapport between the midwives and parents of premature babies can decrease the risk of postpartum depression. They can also refer them to support groups of other families that have premature newborns. Support groups provide emotional support for parents with preterm newborns (Hall, Ryan, Beatty and Grubbs, 2015).

The birth of a premature baby affects every aspect of a family’s lifestyle thus the family should be actively involved in the care of the newborn. They might have to spend more money, than anticipated, for their child to receive good care in the neonatal intensive care unit. They are also likely to be emotionally drained and this might make them unable to take good care of the baby. Most parents of premature newborn have fears about their child’s health (Hall, Ryan, Beatty and Grubbs, 2015). These should be addressed with empathy and compassion so that the parents feel that they are actively involved in meeting their child’s psychological and physiological needs (Hall, Ryan, Beatty and Grubbs, 2015).

The mother is the primary care giver of all newborns unless in otherwise circumstances such if they die during labor. Mothers’ role is to exclusively breastfeed their babies for the first six months after delivery. Breastfeeding increases the newborns’ blood sugar and keeps newborns warm (Lunze, Bloom, Jamison and Hamer, 2013). Most premature infants have a poor suckling reflex. The mother therefore has to pump breast milk which is then given to the baby via a nasogastric tube. Emotional stress can make the mother to fail to express enough breast milk. Stress can inhibit the production of the hormone oxytocin which is important for milk let-down (Lunze, Bloom, Jamison and Hamer, 2013).

Facilities could set aside family room next to neonatal intensive care units so that families can be part of care delivery (Lawn et al., 2013). Families’ role is therefore to ensure that the premature newborn is calm and comfortable. Crying can physiologically impair gaseous exchange. Babies bone prematurely already have a compromised gaseous exchange. Crying can worsen their apnea and hypoxia. A mother should sooth the baby to stop crying by speaking to him or caressing him. According to Rand and Lahav (2015), a baby’s heart rate decreases when they hear their mother’s voice. Parents can also do the Kangaroo Care technique to improve the health of their newborns. Kangaroo Care has been successfully used to improve survival rates in preterm babies (Lawn et al., 2013).

Family Involvement in the Care of Premature Babies

The triangle of complications, hypothermia, hypoxia and hypoglycemia, are the main causes of mortality among premature newborns. Survivors are at risk of developing life-long complications such as blindness and deafness. Since the first 48 hours are the most vital in a newborn’s life, midwives should ensure that the premature babies are on oxygen, feed well and that the Special Care Nurseries’ temperatures are well regulated. The family should also be allowed to take part in the care for the newborn, both physically and emotionally.

Reference:

Hall, S. L., Ryan, D. J., Beatty, J., & Grubbs, L. (2015). Recommendations for peer-to-peer support for NICU parents. Journal of Perinatology, 35(Suppl 1), S9–S13. DOI: https://doi.org/10.1038/jp.2015.143

Kodjebacheva, G.D. & Sabo, T. (2015) Influence of premature birth on the health conditions, receipt of special education and sport participation of children aged 6–17 years in the USA. Journal of Public Health, 38 (1), e47–e54, DOI: https://doi.org/10.1093/pubmed/fdv098

Lawn, J.E., Davidge, R., Paul, V.K, Xylander, S., Johnson, J., Costello, A., Kinney, M.V., Segre, J. & Molyneux, L. (2013). Born Too Soon: Care for the preterm baby. Reproductive Health Journal, 10(1), S5. DOI: https://doi.org/10.1186/1742-4755-10-S1-S5

Lunze, K., Bloom, D. E., Jamison, D. T., & Hamer, D. H. (2013). The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival. BMC Medicine, 11, 24. DOI: https://doi.org/10.1186/1741-7015-11-24

Manani, M., Jegatheesan, P., DeSandre, G., Song, D., Showalter, L., & Govindaswami, B. (2013). Elimination of Admission Hypothermia in Preterm Very Low-Birth-Weight Infants by Standardization of Delivery Room Management. The Permanente Journal, 17(3), 8–13. DOI: https://doi.org/10.1371/journal.pone.0164817

Mank, A., Zanten, H.A., Meyer, M.P., Pauws, S., Lopriore, E. & Pas, A.B. (2016). Hypothermia in Preterm Infants in the First Hours after Birth. PloS One, 11(11), 1-8. DOI: https://doi.org/10.1371/journal.pone.0164817

Manuck, T. A., Rice, M. M., Bailit, J. L., Grobman, W. A., Reddy, U. M., Wapner, R. J., Tolosa, A, J. E. (2016). Preterm Neonatal Morbidity and Mortality by Gestational Age: A Contemporary Cohort. American Journal of Obstetrics and Gynecology, 215(1), 103.e1–103.e14. DOI: https://doi.org/10.1016/j.ajog.2016.01.004

Pacifici, (2018). Effects of surfactant on preterm infant lungs. Medical Express Journal, 2(2), 1-8. DOI: https://dx.doi.org/10.5935/MedicalExpress.2015.02.06 

Quiroga, A., & Moxon, S. (2017). Preventing sight-threatening ROP: the role of nurses in reducing the risk. Community Eye Health, 30(99), 53–54. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806219/

Rand, K., & Lahav, A. (2014). Maternal sounds elicit lower heart rate in preterm newborns in the first month of life. Early Human Development, 90(10), 679–683. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4312137/

Sharma, A., Davis, A., & Shekhawat, P. S. (2017). Hypoglycemia in the preterm neonate: etiopathogenesis, diagnosis, management and long-term outcomes. Translational Pediatrics, 6(4), 335–348. DOI: https://doi.org/10.21037/tp.2017.10.06

World Health Organization. (2018). Preterm birth. Retrieved from: int/news-room/fact-sheets/detail/preterm-birth”>https://www.who.int/news-room/fact-sheets/detail/preterm-birth