Respiratory water loss and oxygen consumption in full-term infants exposed to cold air on the first day after birth

Respiratory water loss, oxygen consumption, carbon dioxide production and skin blood flow were measured continuously in nine full-term infants on the first day after birth. After at least 18 min of measurements with the infant asleep in an incubator, with an air temperature of 33°C and a relative humidity of 50%, the temperature of the incubator air was lowered to less than 27.5°C. This resulted in a significant decrease in skin temperature and peripheral skin blood flow, while the infant's core temperature remained unchanged. At the same time, mean respiratory water loss increased from 3.7 to 6.1 mg/kg-min, which can be explained partially by the decrease in ambient humidity that accompanied the decrease in air temperature. In addition, mean oxygen consumption increased from 5.3 to 7.9 ml/kg. min and mean carbon dioxide production increased from 3.8 to 5.9 ml/kg-min. There was no concomitant increase in motor activity. Thus, when the newborn infants were exposed to cool air, they reacted with an increase in respiratory water loss, oxygen consumption and carbon dioxide production before their core temperature was affected and without increasing their motor activity.     

The heat balance of small babies nursed in incubators and under radiant warmers

The heat balance of 12 healthy preterm babies (mean birth weight 1.58 kg, gestation 32 weeks, age 7 days) was studied first in an incubator and then under a radiant warmer during normal nursing. Heat production and heat loss by radiation, convection and evaporation were measured in presumed thermoneutral conditions. Although rectal and mean skin temperatures were normal and the same in both environments, there were important differences. Radiation was the major source of heat loss in the incubator and convective losses were low. Under the radiant warmer convection was the major source of heat loss and heat was gained by radiation. A small rise in metabolic heat production occurred under the radiant warmer. Respiratory water loss was low in both environments. Skin water loss was significantly higher under the radiant warmer. The most immature baby (gestation 28 weeks) could not be kept warm in the incubator despite high air temperature, because the evaporative heat loss from her skin was very high. Her body temperatures were normal under the radiant warmer. It is concluded that both devices provide acceptable thermal environments for most preterm babies but that incubators without humidification may be inadequate for immature babies with a high skin water loss.     

Cardiovascular changes in preterm infants nursed under radiant warmers

Radiant heat is known to increase insensible water loss and, to a certain extent, oxygen consumption. Little is known about its cardiovascular effects. We measured cardiac output, stroke volume, heart rate, and lower limb and skin blood flow in 20 preterm newborn infants nursed in an incubator and under a radiant warmer at an abdominal skin temperature of 36.5 degrees C. Mean (+/- SEM) birth weight was 1.57 (0.06) kg, gestational age 31.7 (0.4) weeks, and weight at examination 1.69 (0.02) kg; median postnatal age was 15 days. Skin and limb blood flow measurements increased by 44% to 55% with radiant heat (P less than .001 and P less than .01, respectively). Cardiac output increased by 5.4% (P less than .02) under the radiant warmer secondary to a small but significant (P less than .05) increase in heart rate. The changes in cardiac output during radiant heat administration are comparable to those reported for oxygen consumption.     

Insensible water loss from the skin during phototherapy in term and preterm infants

The rate of evaporation from the skin was measured before and during phototherapy in 10 full-term and seven preterm infants (gestational age 29-33 weeks). The method for measurement of rate of evaporation was non-invasive and was based on determination of the water vapour pressure gradient close to the skin surface. All infants were studied naked in an incubator with an ambient relative humidity of 50% and with a controlled environment with respect to temperature and air velocity. In the term infants the mean rate of evaporation, measured from an interscapular skin area, was 3.1 g/m2h both before and after 30 min of phototherapy. In the preterm infants the corresponding value was 9.8 g/m2h before and 9.7 g/m2h after 120 min of phototherapy. Thus, in thermally stable infants, non-ionizing radiation from phototherapy equipment does not increase water loss from the skin.     

Radiant heat loss versus radiant heat gain in premature neonates under radiant warmers

Premature infants nursed on open radiant warmer beds are exposed to short-wavelength infrared power density distributed evenly over the bed surface. Additionally, infants' sides are exposed to relatively cooler nursery walls, and to the radiant warmer bed platform which may heat and reradiate to the baby. Therefore, infants may not only gain heat from the warmer (Q radiant warmer) but lose or gain radiant heat to the sides as well (+/- Q radiant loss). In order to quantitate these parameters, ten premature newborn infants nursed under radiant warmers servocontrolled to 36.5 degrees C skin temperature (weight 1.27 +/- 0.24 SD kg, gestation 31 +/- 3 weeks) were investigated, and partitional calorimetry previously reported. In the present study, calculation of net rate of radiant heat transfer (Q net radiant) was made from these data (-2.63 +/- -1.52 kcal/kg/h), and compared to direct measurements of Q radiant warmer (-2.49 +/- -0.90 kcal/kg/h). The present report further partitions net radiant heat transfer to evaluate Q radiant loss: -0.13 +/- 1.82 kcal/kg/h (range -3.16 to 1.93). From these calculations mean radiant temperature of this environment was estimated (45.3 +/- 4.3 degrees C) and compared to the radiant warmer temperature received (45.0 +/- 2.9 degrees C). This information suggests other strategies to reduce radiant heat loss as well as convective and evaporative losses in premature neonates nursed on open radiant warmer beds.     

The Effect of a Warm Environment on Respiratory Water Loss in Fullterm Newborn Infants on Their First Day after Birth

ABSTRACT. Continuous measurements of respiratory water loss (RWL), oxygen consumption and carbon dioxide production were made in 21 fullterm infants on their first day after birth. The infants were first studied in incubators with a temperature of 32.5°C and an ambient humidity of 50%. After an interval with stable conditions the incubator temperature was raised to 36.5°C while the water vapour pressure was kept constant. When the rectal temperature had increased to 37.8°C or when the infant had started to sweat, the relative humidity in the incubator was increased to 50%. At the start of the measurements mean RWL was 4.9 mg/kg min. On the average, RWL increased to a maximal value of 7.0 mg/kg min in the warm environment. Mean oxygen consumption only increased from 5.3 to 5.8 ml/kg min. This meant that when nursed in this warm environment the infants were able to increase their respiratory water loss by nearly 50% without a significant change in oxygen consumption.     

INFLUENCE OF THERMOREGULATION ON ENERGY METABOLISM OF THE LOW BIRTHWEIGHT INFANT

Putet, G, Dittmar, A, Schmitt, M and Salle, B. (Department of Neontology, Hôpital Edouard–Herriot, Lyon, France). Influence of thermoregulation on energy metabolism of the low birthweight infant. Acta Paediatr Scand, Suppl, 296: 62, 1982. — By combining continuous measurements and recordings of ( a )O₂ consumption and CO₂ production, ( b ) core, mean skin and temperature, ( c ) "radiative and convective" (R+C) heat loss, we have tried to assess the characteristics and effiency of different heating systems in the usual environment of an intensive care unit. Preliminary results: minimal heat loss is obtained in an incubator with manual temperature control versus servocontrolled incubator on radiant heater; the radiant heater can maintain adequate core temperature but with higher than normal heat loss from the sides of the body and increased warming only of the skin facing the heater; metabolic rate measurements do not show any statistical difference between these various environments; both with an incubator and a radiant heater, a thin plastic sheet (used as heatshield) lowers "R+C" heat loss.     

PERIPHERAL CIRCULATORY RESPONSE TO PHOTOTHERAPY IN NEWBORN INFANTS

Calf blood flow (CBF), calf skin temperature, incubator wall and ambient temperature, and respiratory rate, were measured in 8 newborn infants 10 to 127 hours of age, who were treated by phototherapy because of jaundice. During phototherapy (within 30 min) the CBF increased to a range of 30 to 80% above the control values of 8.8 ± 0.9 ml/min/100 g. The CBF is correlated directly with the leg skin temperature (γ= 0.724 and 0.588 at 15 and 30 min after phototherapy respectively). The increase in CBF was associated with a fall in incubator ambient temperature, the latter is a result of the use of servo control unit in monitoring incubator temperature by epigastric skin temperature. The increase in CBF is probably evidence of peripheral vasodilatation to facilitate evaporative heat loss. An increase in respiratory rate was also observed during phototherapy. The observed increase in heat loss (and water loss) from vasodilatation and increased respiratory rate serve as a basis for the increase in insensible water loss as previously reported.     

Energy metabolism and substrate utilization in low birth weight neonates under radiant warmers

We evaluated the metabolic response to the thermal demands of an open radiant warmer device, as distinct from convection incubator, in 13 healthy premature infants (1.395 +/- 169 g, 28 +/- 12 days of age, mean +/- SD). Metabolic rate was 10% higher for infants under the radiant warmer than in the incubator (2.60 +/- 0.4 v 2.36 +/- 0.3 kcal/kg/h; P less than .05). The radiant warmer also induced a small (4%), but significant, increase in nonprotein respiratory quotient (0.94 +/- 0.1 v 0.90 +/- 0.1; P less than .05) and a 13% increase in carbon dioxide production (8.26 +/- 1.1 v 7.31 +/- 1.1 mL/kg/min; P less than .05). Subcutaneous fat accumulation (estimated from 60-second skin-fold thickness measurements) was greater under the radiant warmer than in the incubator (0.08 +/- 0.05 v 0.04 +/- 0.04 mm/d; P less than .05). Under the warmer, the infant's mean skin temperatures and core temperatures were normal and similar to those found in the incubator, but the foot temperature was on average 0.6 degrees C cooler. The average rate of weight gain (18 g/kg/d) was the same in the radiant environment. The pattern of the elevated metabolic rate, shift of respiratory quotient coupled with the accumulation of subcutaneous fat, and cool extremities of infants under the radiant warmer may represent a physiologic adaptive response to thermal stress. However, the reasons for the elevated metabolic rate are unclear, because activation of the sympathetic nervous system with the release of catecholamines is not apparently involved.(ABSTRACT TRUNCATED AT 250 WORDS)     

Measurement of transepidermal water loss in Tanzanian cot-nursed neonates and its relation to postnatal weight loss

In healthy cot-nursed Tanzanian neonates ( n = 92, gestation 26–42 weeks) measurements of transepidermal water loss (TEWL) and weight change were performed during the first 24 h after birth at an average ambient humidity of 70% and an environmental temperature of 32°C. Urine production on day 1 (ml/kg per 24h) was documented for a subgroup of 13 preterm and 8 term infants. In a limited group of preterm infants ( n = 5) TEWL measurements, weight and 24 h urine volume measurements were repeated daily for 7 days. Maximum weight loss was determined in 7 preterm (gestational age 30–36 weeks) and 6 term infants. TEWL was estimated by measuring the evaporation rate at three sites of the body using the water vapour pressure gradient method. On day 1, TEWL was highest in the most preterm infants, whereas TEWL and urine production were higher in large for gestational age infants as compared to appropriate for gestational age (AGA) infants of the same gestational age (31–36 weeks). For the whole group, weight loss on day 1 was correlated with TEWL ( r = 0.49, p <0.05). At follow-up TEWL in preterm infants remained almost constant during the first 4 days and decreased after the fourth day, at which time weight gain commenced. Preterm AGA infants (gestational age 24–37 weeks) showed a mean postnatal weight loss of 4.4% of the birth weight, while in term infants this loss was only 2.6%. A reduced postnatal weight loss as compared to Caucasian infants may be explained by a lower water loss during the first days after birth, through both skin evaporation and urine excretion.     

Changes in skin blood flow over the foot with warming of the contralateral heel

Vasospasm in one leg is a common complication of umbilical artery catheterization in preterm infants. It is a common practice to wrap the contralateral leg in a warm washcloth. The rationale for this intervention is to induce reflex vasodilatation of the affected extremity, thereby avoiding the necessity to remove or replace the catheter. This study tested the hypothesis that heating the contralateral extremity in preterm infants would increase peripheral blood flow to the contralateral foot. Ten stable preterm infants who had had no umbilical catheter inserted for at least 2 weeks were studied. Skin perfusion was measured using the laser Doppler method in the distal leg after heating of the opposite foot to 40.5°C. Blood flow to the skin of the contralateral foot was measured before and after warming the ipsilateral one. The skin blood flow measured with and without heat application to the contralateral foot was not significantly different. Direct heat does not induce contralateral reflex vasodilatation in the foot of preterm infants.     

Transepidermal water loss during halogen spotlight phototherapy in preterm infants

Among preterm infants there is a relationship between skin blood flow and transepidermal water loss (TEWL). The aim of this study was to assess whether halogen spotlight phototherapy without significant heat stress increases TEWL and affects maintenance fluid requirements in preterm infants. TEWL was measured noninvasively before the start and after 1 h of halogen spotlight phototherapy in a group of preterm infants, nursed in double-walled incubators with moderately high relative humidity. Relative humidity and ambient temperature in the incubator were tightly controlled. Mean +/- SD birth weight of the 18 infants was 1412 +/- 256 g, gestational age 30.6 +/- 1.6 wk, and age at measurement 5 +/- 3 d. Nine infants received ventilatory assistance. Relative humidity was 40-80% (mean 52%). Average TEWL increased from 13.6 to 16.5 g/m(2)/h during phototherapy. These data show that TEWL increases by approximately 20% during phototherapy despite constant skin temperature and relative humidity. Maintenance fluids of preterm infants should be increased by 0.35 mL/kg/h during exposure to halogen spotlight phototherapy.     

TRANSEPIDERMAL WATER LOSS IN NEWBORN INFANTS

ABSTRACT. The amount of water evaporated from the skin of newborn infants and the temperatures of the skin, of the ambient air, and of the surfaces facing the infants were measured and used as a basis for calculation of the evaporative, radiative and convective heat exchange between the infant and the environment. The infants were of varying gestational ages, from 25 to 39 completed weeks of gestation. Evaporative heat exchange was high in the most preterm infants when nursed at a low ambient humidity, while the high ambient humidity needed to maintain these infants at a stable body temperature led to a low loss of heat through radiation and convection or even a heat gain. In the more mature infants evaporative heat exchange was lower, while radiative and convective heat exchange was higher.     

Oxygen consumption and insensible water loss in premature infants under radiant heaters

Oxygen consumption ((Vo2), carbon dioxide production (Vco2), and insensible water loss (IWL) were measured simultaneously in nine nondistressed, appropriately grown, premature infants less than 2 weeks old, nursed in a conventional, blow-warmed incubator, and were compared with measurements made on the same infants under a radiant heater. The infants had a pronounced increase (148% on average) in IWL when under the radiant heater (P < .001) whereas Vo2 increased by only 4.6% (P = .073). Abdominal skin temperature (servocontrolled to maintain 36.5 C) and esophageal temperature were the same under both conditions, but ambient air temperature was 0.7 C higher in the incubator (P < 05). Although a positive correlation was found between the increase in IWL and the change in Vo2 (r = .75, P < .01), the large increase in IWL (and, therefore, evaporative heat loss) under the radiant heater is out of proportion to, and cannot be accounted for, by the change in metabolic heat production. The heat transfer processes involved in maintaining body temperature constant under these conditions require further study.     

Heat Loss Prevention (HeLP) in the delivery room: A randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants

OBJECTIVES: To determine if polyethylene occlusive skin wrapping of very preterm infants prevents heat loss after delivery better than conventional drying and to evaluate if any benefit is sustained after wrap removal. STUDY DESIGN: This was a randomized controlled trial of infants <28 weeks' gestation. The experimental group was wrapped from the neck down. Only the head was dried. Control infants were dried completely. Rectal temperatures were compared on admission to the neonatal intensive care unit immediately after wrap removal and 1 hour later. RESULTS: Of 55 infants randomly assigned (28 wrap, 27 control), 2 died in the delivery room and 53 completed the study. Wrapped infants had a higher mean rectal admission temperature, 36.5 degrees C (SD, 0.8 degrees C), compared with 35.6 degrees C (SD, 1.3 degrees C) in control infants ( P = .002). One hour later, mean rectal temperatures were similar in both groups (36.6 degrees C, SD, 0.7 degrees C vs 36.4 degrees C, SD, 0.9 degrees C, P = .4). Size at birth was an important determinant of heat loss: Mean rectal admission temperature increased by 0.21 degrees C (95% CI, 0.04 to 0.4) with each 100-g increase in birth weight. CONCLUSIONS: Polyethylene occlusive skin wrapping prevents rather than delays heat loss at delivery in very preterm infants.     

The effect of olfactory stimulation on energy expenditure in growing preterm infants

Aim: To test the hypothesis that olfactory stimulation in growing healthy preterm infants leads to an increase in resting energy expenditure (REE). Design: A prospective, randomized clinical trial with crossover was conducted in 20 healthy, appropriate weights for gestational age, gavage‐fed preterm infants. Infants were studied while asleep and cared for in a skin servo‐controlled convective incubator. Using a pipette, 15 drops of saturated solution of vanillin (Aldrich, Fallavier, France) were dripped to a cloth diaper that was placed on the opposite side of the incubator. REE was measured by indirect calorimetry (DeltaTrac II, Helsinki, Finland) exactly 1 h after feeding. Each infant was studied twice by randomization: after a period of 20 min of vanillin odour or after 20 min without vanillin odour. Results: We found no statistically significant difference in REE of preterm infants when exposed to vanillin odour (74.5 ± 10.1 kcal/kg/day) in comparison with their REE when not exposed to vanillin odour (79.0 ± 11.3 kcal/kg/day). Conclusions: Vanillin odour does not significantly influence REE in metabolically and thermally stable preterm infants.     

Body temperature measurement in VLBW infants by continuous skin measurement is a good or even better alternative than continuous rectal measurement

Background: An inadequate body temperature in preterm infants influences morbidity and mortality. Continuous rectal measurement is a reliable method to measure body temperature but might have adverse effects and is even contra-indicated in case of low platelets or necrotising enterocolitis. A save and non-invasive method to measure body temperature is the transcutaneous 'zero heat flow' method.
Aim: We hypothesised that for monitoring body temperature in very low birth weight (VLBW) infants, central measurement of temperature by way of the zero heat flow principle is just as reliable as rectal temperature.
Methods: Twenty-six infants, birth weight between 520 g and 1250 g, gestational age 25.28–32.28 weeks were provided with an insulated continuous skin probe with 'zero heat flow' and a continuous rectal probe. Both measurements were registered every hour over a period of 48 h. The sample size was calculated to detect a difference of less than or equal to 0.20°C.
Results: 1205 of the 1248 temperature measurements were analysed. At any moment, skin temperature was higher or equal when compared to rectal temperature. Mean skin temperature was 0.13°C (SD 0.33) higher than mean rectal temperature ( t -test, p < 0.001). Correlation between rectal and skin temperature was 0.82 (p ≤ 0.05).
Conclusion: In VLBW infants, temperature measurement by 'zero heat flow' method is just as reliable as by rectal method.     

Effects of low humidity on small premature infants in servocontrol incubators. I. Decrease in rectal temperature.

19 small premature infants in servocontrol incubators, whose abdominal skin temperature was 36.0 +/- 0.3 degrees C, were subjected to alternate high- and low-humidity environments. With low humidity, rectal temperature dropped significantly below abdominal skin temperature. Skin was the predominant site of evaporative heat loss. The temperature was lower on naked skin than on an area covered by adhesive tape. Thus, servocontrol with low humidity increases evaporative heat loss and engenders a cycle of events that results in paradoxical body temperature decrease as the incubator temperature increases.     

Relative efficacy of radiant and convective heat in incubators in producing thermoneutrality for the premature

To determine which warming system more closely approximates a neutral thermal environment, the oxygen consumptions of 16 premature babies less than 1500 g were measured in a convectively heated incubator and a radiantly heated incubator. Both systems were controlled to maintain a skin temperature of 36 degrees C. The oxygen consumptions of the infants were not significantly different in the two incubators; thus, there was no detectable advantage to the use of convective or radiant energy in approximating a neutral thermal environment in an incubator for the small premature infant. That proportion of total heat loss from the babies due to radiant losses in the convective incubator was directly calculated from incubator temperature using equations described in the paper, and found to be 68 +/- 3% SE.     

Effect of nappy liners on temperature stability in very preterm infants

OBJECTIVE: To determine whether absorbent liners used in posturally supportive cloth nappies influence temperature stability in infants < 31 weeks gestation. METHODOLOGY: Randomized cross-over trial conducted at King Edward Memorial Hospital for Women, Perth, Western Australia. Twenty-three infants nursed in incubators on Infant Servo Control were randomly assigned to wear cloth postural support nappies alternately with or without absorbent liners for 24-h periods over 4 days. Measurements of skin and incubator temperatures were recorded hourly. Times of all nappy changes and infant handling procedures were also recorded. RESULTS: There was no change in any temperature measurement over time, between days, or between day/night periods. Infants nursed with the liner demonstrated a higher skin temperature (0.04 degrees C), and a lower incubator temperature (1.05 degrees C). A drop in skin temperature of 0.02 degrees C and an increase in incubator temperature of 0.28 degrees C occurred following handling of infants. There was no effect due to sex, gestational age, or actual age of the infants. CONCLUSION: Use of an absorbent liner within a cloth postural support nappy promotes better temperature regulation in infants < 31 weeks gestation, by reducing incubator temperature and increasing skin temperature.