Neonatal Physiological Measurements: Proceedings of the Second International Conference on Fetal and Neonatal Physiological Measurements

Cornwall

Newborn General

Chapter 1

The influence of vernix caseosa on water transport through semipermeable membranes and the skin of full-term infants

T Riesenfeld, B Strömberg and G Sedin

Publisher Summary

This chapter discusses the influence of vernix caseosa on water transport through semipermeable membranes and the skin of full-term infants. Vernix caseosa influences the evaporation of water from the skin of newborn infants and, consequently, the heat loss from the skin. The high ER from a membrane covered with vernix and mounted on a dry Petri dish merely reflects the fact that vernix caseosa contains a substantial amount of water. This means that clinically the water in the vernix caseosa might increase the heat loss because of the latent heat of water evaporating from the vernix caseosa and also by keeping the skin surface moist and therefore more permeable to water. The decrease in ER from a membrane covered with vernix caseosa and mounted over a water-filled Petri dish shows that vernix caseosa contains substances that change the permeability of a semipermeable membrane. In the clinical situation in preterm infants, who have a higher ER from the skin than infants born at term, the appearance of vernix caseosa on the skin surface during the second trimester might be one factor that influences the permeability of the skin.

Introduction

Immediately after birth the skin of an infant is covered with amniotic fluid and vernix caseosa. The evaporation of water and the heat loss from the skin is very high, but it decreases rapidly during the first few hours post–natally (1). We have raised the question whether vernix caseosa contains sufficient water to contribute to the high evaporation rate (ER) and whether its presence might influence the loss of water and heat from the skin surface in other ways.

The aim of this study was to determine whether vernix caseosa influences the evaporation of water through semipermeable membranes and the skin of newborn infants and whether it has any impact on heat loss in these infants.

Methods

Evaporation of water was measured with an Evaporimeter (4,5) (Evaporimeter Ep 1, ServoMed, Sweden), which is based on the determination of the water vapour pressure gradient close to an evaporating surface. All measurements were made in an intensive care incubator with a relative humidity of 50% and with servo control of air temperature.

In vitro studies

Evaporation of water from a semipermeable membrane (Lundia ultra flux, Gambro, GFR) covering a Petri dish, empty or partially filled with water, was measured before and after application of vernix caseosa to the membrane. Vernix caseosa was obtained from the skin surface of full term infants less than 0.5 hours after birth.

In vivo studies

ER from the skin and skin temperature were measured at intervals over a 3 hour period, starting at 0.5 hours of age, in 13 full term appropriate for gestational age infants born by elective caesarian section. The infants were placed in the prone position in an incubator and the area of scapular skin on one side was washed with a 10% detergent solution and then gently wiped. The scapular skin area on the other side was neither washed nor wiped.

Calculations of heat exchange

Heat exchange between the scapular skin area and the environment occurs through evaporation, radiation and convection (1,3). The heat exchange through evaporation was calculated from ER and the latent heat of evaporation of water; the heat exchange through radiation was calculted from the Stefan–Boltzmann constant and the emissivity constants and the temperatures of the skin and incubator walls; the convective heat exchange was calculated from the convection coefficient and the temperatures of the skin and incubator air.

Results

In vitro studies

ER from a semipermeable membrane above water was about 50 g/m² per hour at steady state, which is about the same as the ER from an area of interscapular skin of a newborn infant born after 27 weeks of gestation and studied during the first day after birth (2). After vernix caseosa had been applied to the membrane, ER gradually fell to about 30 g/m² per hour (Figure 1).

Figure 1 Evaporation rate (g/m² per hour ± s.e.e.) from semipermeable membranes covered with vernix caseosa and mounted on a water-filled Petri dish (—) or a dry Petri dish (……). (s.e.e. = standard error of the estimate)

Initially ER was about 50 g/m² per hour from a membrane covered with vernix caseosa and mounted on a dry Petri dish. During a 3 hour period, ER gradually decreased to 10 g/m² per hour (Figure 1).

In vivo studies

At a postnatal age of 0.5 hours, the mean ER was 20 g/m² per hour from the washed skin surface and 25 g/m² per hour from the unwashed surface. ER then decreased on both sides, but the evaporation was always more rapid from the unwashed skin surface, which was covered with vernix caseosa, than from the washed skin surface. This difference remained at about 5 g/m² per hour through a 3 hour measurement period.

The evaporative heat loss from the unwashed skin surface was higher than from the washed skin surface during the first 2 hours after birth (Figure 2). The radiative heat loss both from the washed and the unwashed side increased during the 3 hours of measurement as a result of increasing skin temperature. The radiative heat loss and the convective heat exchange did not differ between the two sides. Thus the total heat loss was higher on the unwashed side than on the washed side (Figure 2).

Figure 2 Heat exchange (W/m²) from an unwashed and a washed area of scapular skin at four different postnatal ages. Evap = evaporative heat loss; Rad = radiative heat loss; Conv = convective heat loss

Discussion and conclusion

This study has demostrated that vernix caseosa influences the evaporation of water from the skin of newborn infants and consequently the heat loss from the skin.

The high ER from a membrane covered with vernix and mounted on a dry Petri dish merely reflects the fact that vernix caseosa contains a substantial amount of water. This means that clinically the water in the vernix caseosa might increase the heat loss because of the latent heat of water evaporating from the vernix caseosa and also by keeping the skin surface moist and therefore more permeable to water (6).

The decrease in ER from a membrane covered with vernix caseosa and mounted over a water-filled Petri dish shows that vernix caseosa contains substances that change the permeability of a semipermeable membrane. In the clinical situation in preterm infants, who have a higher ER from the skin than infants born at term (2), the appearance of vernix caseosa on the skin surface during the second trimester (7) might be one factor that influences the permeability of the skin. At present we do not know whether the water and heat loss from the skin of preterm infants is influenced by washing the skin surface soon after birth.

In the full-term infants studied, ER decreased more quickly with postnatal age from a washed skin area than from an unwashed one. As a consequence the evaporative heat loss and the total heat loss were higher from the unwashed skin surface than from the washed skin surface during the first 2 hours after birth, although the heat exchange through radiation and convection was unaltered. Thus, washing a small skin surface area of a full term newborn infant decreases the water and heat loss from that area.

References

1. Hammarlund, K, Nilsson, G E, Öberg, P å, Sedin, G. Transepidermal water loss in newborn infants. V. Evaporation from the skin and heat exchange during the first hours of life. Acta Paediatrica Scandinavica. 1980; 69:385–392.

2. Hammarlund, K, Sedin, G. Transepidermal water loss in newborn infants. III. Relation to gestational age. Acta Paediatrica Scandinavica. 1979; 68:795–801.

3. Hammarlund, K, Sedin, G. Transepidermal water loss in newborn infants. VI. Heat exchange with the environment in relation to gestational age. Acta Paediatrica Scandinavica. 1982; 71:191–196.

4. Nilsson, G E. Measurement of water exchange through the skin. Medical and Biological Engineering and Computing. 1977; 15:209–218.

5. Nilsson G, Sedin G and Oberg P A. A transducer for measurement of evaporation of water from the skin. Proceedings from the International Conference on Biomedical Transducers, Paris, Part II, pp.71–77 (1975).

6. Scheuplein, R J. Permeability of the skin: a review of major concepts and some new developments. Journal of Investigative Dermatology. 1976; 67:672–676.

7. Tydén, O, Bergström, S, Nilsson, B A. Origin of amniotic fluid cells in mid-trimester pregnancies. British Journal of Obstetrics and Gynaecology. 1981; 88:278–286.

Chapter 2

Small size zero-heat-flux probe for neonatal body temperature monitoring

T Togawa, T Tsuji, T Nemoto, H Sankawa, J Ohata and K Miyasaka

Publisher Summary

This chapter discusses a study to elaborate the small size zero-heat-flux probe for neonatal body temperature monitoring. Fifteen millimeter and 25 mm diameter disk-shaped probes were used in this study. In the model experiment, it was shown that deep temperature could be measured by the 15 mm probe through up to 6 mm of rubber sheet with an accuracy of 0.3°C, in a room temperature of 30°C, and up to 4 mm thickness in a room temperature of 25°C with the same accuracy. This performance was almost comparable to that of the 25 mm probe having the earlier configuration, but it was still poorer than a standard size 45 mm probe by which deep temperature could be measured across a 10 mm sheet at a room temperature of 25°C. In the clinical observation, temperature recordings were obtained for more than 300 h in seven subjects. All temperatures were recorded well except during the occasional dislodgement of the 25 mm head probe in some small infants. The head temperatures recorded the 15 and 25 mm probes were close to each other and changed in parallel.

Introduction

In both neonatal and infant care, continuous body temperature monitoring is desirable. Rectal and skin temperature probes are commonly used, but rectal probes are inconvenient for frequent use, and skin temperature is significantly affected by ambient air. The zero-heat-flux probe, invented by Fox (2), has allowed convenient and stable body temperature monitoring by the attachment of a probe on the body surface. This probe is based on the principle that when a region on the skin surface is thermally insulated, skin temperature becomes equilibrated with deep tissue temperature, and thus the deep tissue temperature can be measured at the skin surface. To achieve perfect thermal insulation, electronic control heating was employed in the probe. The original unit supplied by Deep Body Thermometer Ltd, has a flat square probe, 60×60×6 mm in size, and an alternative supplied by Terumo Co. has disc-shaped probes of 45 mm and 25 mm diameter. Many studies have shown that body temperature may be reliably and accurately monitored in adults and children with the Terumo probes (6–8). However, even the 25 mm probe is still too large for neonatal use. Recently, a small 15 mm diameter probe of modified configuration was developed. With a reduction in the probe size, an increase in the error of temperature measurement is expected from theoretical considerations derived from probes of similar configuration. We therefore made an evaluation of the new 15 mm probe.

Method

Probe and instrumentation

15 mm and 25 mm diameter disc-shaped probes were used in this study. Figure 1 shows the modified configuration of the 15 mm probe.

Figure 1 The sectional view of the zero-heat-flux probe of 15 mm in diameter, with modified configuration

The modifications consisted of the use of a silver body instead of the aluminium one used in the earlier design, and covering the outer surface with epoxy resin foam instead of the bare metal surface used previously. The probe had two matched thermistors and a heater. The thermistors detected temperatures at the centre and the periphery of the probe, and the heater current was controlled in such a way as to achieve a situation in which no temperature gradient existed between the centre and the periphery with an accuracy of 0.1°C. Absolute temperature readings by the probes were also calibrated with an accuracy of 0.1°C. Temperatures were recorded on a multichannel Potentiometric chart recorder.

Model experiment

Thermal conduction in skin was stimulated by a rubber sheet placed in a constant temperature water bath at 36°C. The rubber used in this model had a thermal conductivity comparable to that of unperfused skin. Probes were placed on rubber sheets of different thicknesses, and temperature readings were compared to the water bath temperature. Room temperature was kept at 25°C and 30°C.

Clinical observations

Infants and children admitted to the National Children’s Hospital, Tokyo, were studied. In seven subjects aged from 1 month to 6 years, weighing from 3130 g to 18 kg, 25 mm and 15 mm probes were attached to the head (forehead or both sides of the head) and both feet by double-sided adhesive tape. Subjects were placed in a cot or on a bed. The room temperature was kept at about 28°C. Temperatures were recorded from 10 hours up to 100 hours continuously in each subject.

Results

In the model experiment, it was shown that deep temperature could be measured by the 15 mm probe through up to 6 mm of rubber sheet with an accuracy of 0.3°C, in a room temperature of 30°C, and up to 4 mm thickness in a room temperature of 25°C with the same accuracy. This performance was almost comparable to that of the 25 mm probe having the earlier configuration, but it was still poorer than a standard size 45 mm probe by which deep temperature could be measured across a 10 mm sheet at a room temperature of 25°C. In the clinical observation, temperature recordings were obtained for more than 300 hours in seven subjects. Figure 2 shows examples of the records.

Figure 2 Examples of recordings of head and foot deep temperatures in two infants

All temperatures were recorded well except during the occasional dislodgement of the 25 mm head probe in some small infants. As seen from the figures, the head temperatures recorded the the 15 mm and 25 mm probes were close to each other and changed in parallel. In Figure 3(a), the hourly readings from the 25 mm and 15 mm head probes are plotted, and statistical results of the head temperature readings are summarized in Table 1.

TABLE 2.1

Statistical results of 25 mm and 15 mm probe readings.

n: number of readings (hours)

E: mean difference between 25 mm and 15 mm probe readings

s.d.: standard deviation of difference between two readings

r: correlation coefficient between two readings

NS: not significant

Figure 3 25 mm and 15 mm probe readings of (a)head and (b)foot temperatures

The head temperature readings from the 15 mm probe were slightly lower than those from the 25 mm probe except in two cases (YK and NT). In these two cases, the 25 mm probe did not fit the head properly and sometimes became dislodged. In other cases, both probe readings were highly correlated (r greater than 0.91). Standard deviations were less than 0.3°C except in the two cases mentioned.

Foot temperatures could be recorded well in all cases with both probes. Because two probes were attached to both feet the temperature readings of the probes sometimes differed significantly. However, except in one case (OA), both feet temperature readings were remarkably close. In Figure 3(b), both temperatures are plotted, and statistical results are summarized in Table 1 Except in one case (OA), both readings were highly correlated (r greater than 0.91). The mean differences between both foot temperature readings were different in each case, from not significant to 0.91°C, but standard deviations of temperature difference were 0.46°C except in case OA. Even in this atypical case (OA), parallel changes in both foot temperatures were observed, as seen in the right hand panel (b) in Figure 2.

Discussion

Although the zero-heat-flux thermometer has not been widely used in clinical patient care, many investigators have evaluated it by comparison with conventional body temperature measurement techniques. Ball et al(1) showed that temperature readings recorded by the original probe of Deep Body Thermometer Ltd attached on the upper sternum closely followed rectal temperature, being within 0.5°C for most of the recording time. Singer et al(5) used the original probe during anaesthesia, and they found that the temperature readings correlated closely with oesophagel and tympanic membrane temperatures. Tsuji (9) showed that mean forehead temperatures measured by the Terumo standard probe was 0.2 ± 0.5°C lower than mean pulmonary arterial temperature measured by a Swan-Ganz thermodilution catheter. Lees et al(4) also used the Terumo probe in hyperthermia therapy, and they found that forehead temperature readings were highly correlated (r greater than 0.98) to pulmonary arterial temperatures within a range of 37–42°C. These studies convinced us that the zero-heat-flux thermometer could be acceptable as a body temperature monitor.

However, most of these studies were limited to adults and relatively large children, and few neonatal studies have been carried out with the zero-heat-flux probes. One difficulty is obviously the original probe size (45 mm or 25 mm in diameter). With a smaller probe the region of thermal insulation is obviously reduced, and hence the error will increase due to incomplete insulation on the skin surface (3). On the other hand, the thickness of the skin layer is less in the neonate, and thus it might be expected that body temperature could be measured by smaller probes. The 15 mm probe is sufficiently small for neonates, and even for premature infants. The 15 mm probe used in this study has a modified configuration. For the body of the probe a silver plate was used instead of aluminium. The thermal conductivity of silver is about twice that of aluminium, and it may be advantageous in obtaining uniform servocontrol heating at the periphery of the probe. Besides this, the rear side of the probe was covered by epoxy resin foam.

The model experiment showed that the modified 15 mm probe had comparable performance to that of the original 25 mm probe. The thickness of rubber sheet across which deep temperature could be measured with an accuracy of 0.3°C was 4 mm in a room temperature of 25°C, and 6 mm at 30°C. Although this figure is about half that of the standard probe, it may still be acceptable in neonates because skin thickness is less than half that of adults. Clinical observations showed that the 15 mm probe readings were close to the 25 mm probe readings, and both were closely correlated. In two cases (YK and NT) 25 mm probe readings were unstable due to dislodgement of the probe, and hence mean head temperature measured by the 25 mm probe was lower than that obtained with the 15 mm probe. On the other hand, 15 mm probe readings were stable throughout the recording period even in subjects of about 3 kg in body weight. Foot temperatures could be recorded well by both probes, and both readings were closely correlated. Right and left foot temperatures measured by zero–heat–flux probes were always remarkably close to each other even though these temperaturs fluctuate significantly. An atypical recording was obtained in one case (OA) in which right and left foot temperatures differed significantly. The usual standard deviation (s.d.=1.6°C) of the difference of the two readings demonstrated this fact as seen in Table 1. This finding may be explained on the basis of unequal vasomotor activity in both feet. It may also be a remarkable fact that vasomotor activity for both feet is very uniform in most cases.

In conclusion, we have found that neonatal body temperature can be successfully monitored by the small zero-heat-flux probe of 15 mm diameter continuously for several days without any serious interference either to the infants’ activities or medical care. The accuracy of body temperature measurement by the modified 15 mm probe was comparable to that of the original 25 mm probe, which had been proven and accepted for body temperature monitoring in larger chilren and adults. Foot temperatures were measured successfully by 15 mm and 25 mm probes, and both readings were always very close.

References

1. Ball, S G, Chalmers, D McM, Morgan, A G, Solman, A J, Losowski, M S. A clinical appraisal of transcutaneous deep body temperature. Biomedicine. 1973; 18:290–294.

2. Fox, R H, Solman, A J. A new technique for monitoring the deep body temperature in man from the intact skin surface. Journal of Physiology. 1971; 212:8P–10P.

3. Kobayashi, T, Nemoto, T, Kamiya, A, Togawa, T. Improvement of deep body thermometer for man. Annals of Biomedical Engineering. 1975; 3:181–188.

4. Lees, D E, Kim, Y D, Macnamara, T E. Non-invasive determination of core temperature during anesthesia. Southern Medical Journal. 1980; 73:1322–1324.

5. Singer, B, Lipton, B. Monitoring of core temperature through the skin: a comparison with esophageal and tympanic temperatures. Bulletin of the New York Academy of Medicine. 1975; 51:947–952.

6. Togawa, T, Non-invasive deep body temperature measurementRolfe, P, eds. Non-invasive Physiological Measurements; Volume 1. Academic Press, London, 1979:261–277.

7. Togawa, T, Nemoto, T, Tsuji, T, Suma, K. Deep temperature monitoring in intensive care. Resuscitation. 1979; 7:53–57.

8. Togawa, T, Nemoto, T, Yamazaki, T, Kobayashi, T. A modified internal temperature measurement device. Medical and Biological Enginering. 1976; 14:361–364.

9. Tsuji, T. Circulatory monitoring in cardiac surgery using deep body thermometer. Brain and Nerve. 1981; 18:1–11.

Chapter 3

Temperature variability of very low birthweight infants nursed in infant servo controlled incubators

D A Ducker, A J Lyon, K A Wheeler, N McIntosh and C A Bass

Publisher Summary

This chapter describes the temperature variability of very low birthweight infants nursed in infant servo controlled incubators. Incubators have been developed to provide a stable thermal environment with constant humidity and good visibility. Thermal control was originally achieved by manually altering the air temperature to maintain the infant in a neutral thermal environment. In the very immature infant, thermoneutral range is narrow and because of this, many units employ a system in which the infant’s own temperature, sensed by a thermistor taped to the skin, is used in a feedback loop to alter the incubator air temperature in order to keep the baby’s temperature at a constant value. The results are from a total of 598.2 h of continuous patient monitoring, each consisting of more than 3500 data readings. The proportion of time that each of the four measured temperatures was at a particular value between 33 and 40°C. The abdominal and deltoid skin temperature was held within a narrow band. There were, however, large variations in both the toe and the ambient temperatures.

Introduction

It is well recognized that cold stress leads to increased mortality in very low birthweight infants (17). If preterm infants are nursed at an environmental temperature which is below the thermoneutral range, weight gain and growth in length and head circumference are curtailed in the early weeks of life (4,5). High environmental temperatures have also been associated with increased mortality and morbidity in the very low birthweight infant (19). In particular, high fluctuating temperatures have been associated with increased apnoea (13).

Incubators have been developed to provide a stable thermal environment with constant humidity and good visibility. Thermal control was originally achieved by manually altering the air temperature to maintain the infant in a neutral thermal environment (7). In the very immature infant the thermoneutral range is narrow (18) and, because of this, many units now employ a system in which the infant’s own temperature, sensed by a thermistor taped to the skin, is used in a feedback loop to alter the incubator air temperature in order to keep the baby’s temperature at a constant value (servo control).

It has been the practice at St George’s Hospital to nurse preterm infants in incubators using servo control with the abdominal skin temperature as the reference. This method of temperature control is controversial (13). We have set up a study to look at the temperature control of very low birthweight infants undergoing routine intensive care in servo controlled incubators.

Patients and methods

Twelve consecutive infants of birthweight less than 1400 g, median weight 980 g (range 520–1350 g) and median gestation 27 weeks (range 24–35 weeks) were studied. Data collection was started on transfer to a Vickers 79 incubator, mean age at transfer 14 hours (range 0–33 hours). In the intensive care unit the policy was to nurse very low birthweight infants naked, covered by a single layer of bubble plastic, in a humidified, servo controlled incubator. During the study no changes were made in this or any other nursing or medical policy as we were interested in thermal stresses on these immature infants during day-to-day intensive care. Data from this study were not available to the staff during the collection period and therefore decisions on temperature control were not influenced by the study. The environmental temperature in the nursery was maintained at 28°C ± 1°C with a constant relative humidity of 30%. The nurseries have no external walls or windows.

The computer linked MONIC patient monitoring system developed at St George’s was used to record automatically up to 16 channels of physiological and environmental data via monitors normally used in the unit (Bass, Smith and Ducker, unpublished observations). All values were obtained at approximately 1 second intervals, averaged over 1 minute and recorded onto floppy disc for later analysis. The data from five of these channels are reported in this study: abdominal skin temperature, obtained from the incubator control unit; deltoid skin and toe temperatures, through the Simonsen and Weel 8000 series monitor; ambient temperature and humidity by an independent probe placed near to the patient’s head. Continuous rectal temperatures are not recorded in the unit because of the problems associated with rectal probes in very small neonates (13).

Results

The results are from a total of 598.2 hours of continuous patient monitoring, each consisting of more than 3500 data readings. Figure 1 shows the proportion of time that each of the four measured temperatures was at a particular value between 33 and 40°C.

Figure 1 Percentage of time each temperature was held within 0.5°C of a particular value between 33–40°C

The abdominal and deltoid skin temperature were held within a narrow band, (mean abdominal temperature ± s.d., 36.9 ± 0.3°C; mean deltoid temperature ± s.d., 36.3 ± 0.3°C). There were, however, large variations in both the toe and the ambient temperatures.

These variations are also seen in Figure 2 which is a representative 24 hour computer graph from one infant. This graph shows that any decrease in abdominal skin temperature, and therefore activation of the incubator heat control, occurred only after there had been a significant drop in the toe temperature and, to a lesser degree, the deltoid skin temperature. This delay was seen in all the infants studied. There was a corresponding delay in switching off the heater as the abdominal skin temperature increased resulting in a small overshoot of the infant’s temperature above the set value. Figure 2 also shows the effect of humidity on ambient temperature. Increasing the humidity reduced the environmental temperature required to keep the abdominal skin temperature stable. However, as shown in the early part of the graph, at high humidity, the infant’s temperature became more unstable. This was due possibly to the cooling effect of water vapour condensing inside the incubator. It can be seen from Figure 2 that peripheral temperature, as measured by the toe probe, varied in the same direction as, and as rapidly as, the changes in ambient temperature. There was a significant positive correlation between the hourly mean values of toe and ambient temperature.

Figure 2 Representative 24 hour graph of baby no. 6. The top trace shows deltoid temperature above and toe temperature below with the shaded area representing the difference between the two temperatures

Table 1 gives the mean (± 1 s.d.) daily values for the abdominal skin-toe temperature differences in each of the infants studied.

TABLE 1

Mean daily abdominal (core) skin-toe temperature differences.

The variability of this temperature difference, as measured by the standard deviation, tended to decrease with increasing postnatal age (Figure 3) and with increasing gestational age, suggesting that the infants’ temperature control became more stable with increasing maturity.

Figure 3 Changes in the standard deviation of abdominal (core) skin-toe temperature with increasing postnatal age

The cause of the increasing variability in abdomen-toe temperature difference with postnatal age in one infant (baby no. 1) was due to fluctuations in core temperature secondary to infection.

Several problems with the temperature probe and the servo control system, resulting in inappropriate environmental temperature changes, potentially detrimental to the infant, were encountered during this study:

(a) The probe was often found off, or only partially applied to the skin. As the environmental temperature was usually below the infant’s skin temperature, the lower probe temperature activated the heater and resulted in significant overheating before being noticed by the staff.

(b) In several cases it was noted that the abdominal skin temperature registered by the probe was higher than the rectal temperature. This was thought to be due to the adhesive pad covering the abdominal probe preventing evaporative heat losses from this area of skin and hence artificially raising the temperature of this site. The result was that the infant was nursed in a suboptimal environmental temperature. The problem was resolved by increasing the humidity in the incubator and reducing evaporative heat losses from all areas of skin.

(c) False high abdominal skin temperature readings were also obtained whenever the infant was allowed to lie on the probe. Despite an awareness by the nursing staff, this problem occurred frequently.

(d) Covering the baby with clothes or blankets resulted in the incubator cooling as the insulation maintained the abdominal skin temperature. However, when the infant was uncovered for any procedure rapid cooling occurred before the incubator could respond.

Discussion

Information on the temperature control of sick very low birthweight infants undergoing routine intensive care has been difficult to obtain because of the rapid changes occurring as these babies are handled for all the necessary medical and nursing procedures. The use of a computer based system has allowed the continuous collection of data and the analysis of how several variables alter in relation to one another. The results suggest that in the first few days of life low birthweight infants undergoing routine intensive care in servo controlled incubators are not in a stable thermal condition.

The abdominal skin is the site most commonly used for the servo control temperature probe. This study shows that changes in abdominal skin temperature occur significnatly later than the temperature changes in a more peripheral skin site, and therefore the incubator heater only responds after some delay, when significant skin cooling has already occurred. This delay was also seen as the infant warmed resulting in overshoot of the infant’s temperature above the set value. Servo control is effective in maintaining the reference temperature within a narrow range. However, if a central reference temperature is used, the infant is exposed to both heat and cold stress in an unstable thermal environment. The risks of increased morbidity and mortality in this situation are well recognized (2,8,12,13).

The limited homeothermic ability of the low birthweight infants was shown by the way in which changes in peripheral skin temperature, in particular the toe but also to some extent the deltoid, closely followed ambient temperature. The ability to maintain abdominal skin temperature for a little longer suggests that they have some capacity for thermal control. Low birthweight infants do not always show an increase in oxygen consumption at temperatures outside the neutral range, but react with a change in body temperature (16) and there is other evidence that they have little if any capacity for thermogenesis. These mechanisms mature rapidly with increasing gestational and postnatal age (Table 1).

The major source of heat loss in the very low birthweight infant is by evaporation of water from the skin (15) and this can be reduced markedly by increasing environmental humidity (6). It was noted that increased humidity resulted in both lower and more stable environmental temperatures. During day-to-day care of these infants it proved very difficult to maintain a constant environmental humidity due to the frequent need for the incubator door to be opened. Very high humidity, and in particular the practice of rapidly warming cold babies by adding hot water to the incubator, resulted in marked temperature instability.

Servo control of infant temperature relies on accurate information from the probe attached to the baby’s skin. Several problems with this system have been highlighted and other studies have reported similar findings (1,11). However, even when the system is functioning correctly, the use of servo control with the abdominal skin temperature as the reference appears to create further problems for the very low birthweight infant. Changes in deltoid skin temperature were greater and more rapid than the changes in the temperature of the abdominal skin. The use of this area of skin as a more sensitive reference temperature would mean that the incubator heater would respond more rapidly, but the technical problems of keeping the probe attached and not covered by the baby or its clothing would be considerable. If servo control is to be used to maintain the thermal environment of the very low birthweight infant the best temperature to use as a reference might be the difference between a central and a peripheral skin temperature (11).

The large fluctuations in environmental temperature would be reduced by using ‘air mode’. This relies on the incubator temperature being set and altered by the nursery staff depending on their assessment of the requirements of the particular infant. Estimates of the ambient temperature needed by infants of different birthweights and postnatal ages, both naked and clothed, have been made (9,10). There is evidence however that for small infants the appropriate environmental temperature cannot be predicted safely from these average values (14), although a more recent study has attempted to define new standards for very low birthweight babies (16).

In healthy preterm neonates servo and air mode appear to be equally effective and safe in the control of the thermal environment (3), but there has been no comparison made in sick very low birthweight infants undergoing intensive care. The controversy as to the best way in which to nurse these infants continues and further comparative studies are needed.

Acknowledgements

Since January 1983 this research has been funded by a grant from Action Research – The National Fund for Research into Crippling Diseases. We would like to thank Simonsen and Weel Ltd for technical assistance. Also our thanks are due to the nursing staff of the Special Care Baby Unit at St George’s Hospital and to Sandra Garrett, our long suffering secretary and typist.

References

1. Belgaumkar, T K, Scott, K E. Effects of low humidity on small premature infants in servo control incubators. I. Decrease in rectal temperature. Biology of the Neonate. 1975; 26:337–347.

2. Belgaumkar, T K, Scott, K E. Effects of low humidity on small premature infants in servo controlled incubators. II. Increased severity of apnoea. Biology of the Neonate. 1975; 26:348–352.

3. Bell, E F, Bios, G R. Air versus skin temperature servo control of infant incubators. Journal of Paediatrics. 1983; 103:954–959.

4. Glass, L, Silverman, W A, Sinclair, J C. Effect of the thermal environment on cold resistance and growth of small infants after the first week of life. Pediatrics. 1968; 41:1033–1046.

5. Glass, L, Silverman, W A, Sinclair, J C. Relationship of thermal environment and calorie intake to growth and resting metabolism in the late neonatal period. Biology of the Neonate. 1969; 14:324–340.

6. Hammarlund, K, Nilsson, E G, Oberg, P A, Sedin, G. Transepidermal water loss in newborn infants. I. Reaction to ambient humidity and site of measurement and estimation of total transepidermal water loss. Acta Paediatrica Scandinavica. 1977; 66:553–562.

7. Hey, E. The care of babies in incubators. In: Gairdner D, Hull D, eds. Recent Advances in Paediatrics. 4th Ed. London: Churchill Livingstone; 1971:171–216.

8. Hey, E. Temperature regulation in sick infants. In: Tinker J., Rapin M., eds. Care of the Critically III Patient. New York: Springer-Verlag; 1983:1013–1029.

9. Hey, E, Katz, G. The optimal thermal environment for naked babies. Archives of Disease in Childhood. 1970; 45:328–334.

10. Hey, E, O’Connell, B. Oxygen consumption and heat balance in the cot-nursed baby. Archives of Disease in Childhood. 1970; 45:335–343.

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Chapter 4

Clicks and clunks in congenital dislocation of the hip

R A B Mollan, B A Bogues, S N Shaw and G H Cowie

Publisher Summary

This chapter discusses a study to elaborate the role of clicks and clunks in congenital dislocation of the hip. Three accelerometers were used, one taped to the skin in the region of the anterior superior iliac spine on each side and a third placed in a grooved board on which the child lay during testing. The baby’s sacrum was placed on this accelerometer and thus emissions from either hip could be detected. Both the Ortolani and Barlow tests were performed as usual. Signals from either hip were picked up by the accelerometers, amplified, and recorded on an FM tape recorder. The group with neonatal instability, diagnosed by either Ortolani or Barlow’s tests, produced a low frequency signal of 12. 5 Hz with an average acceleration range of 9 m/s² peak-to-peak, when their hips were tested. The pattern was similar for all babies with unstable hips. The child with the obvious dislocation at a later age also had a low frequency signal, similar to that of the unstable hips at birth. Children referred with clicks were divided into two groups. The first group contained children whose hips remained normal and were discharged between 12 and 18 months of age.

Introduction

Although the condition of congenital dislocation of the hip (CDH) has been recognized since the time of Hippocrates in 400 BC, we have been unsuccessful in reducing the age of diagnosis. Despite the various methods of treatment for this condition, all medical authorities agree that an early diagnosis is of the utmost importance. If the unstable hip is noted at birth, 3–4 months in a simple nappy splint is usually all that is required. The child with CDH diagnosed late is not so fortunate. Treatment then consists of traction, surgery and many months of hospitalization and immobilization and gives no guarantee of a normal hip. Osteoarthritic changes in the teens or early twenties are not uncommon.

At present the number of children presenting with a late dislocation is unacceptably high. Failure to diagnose the condition at birth may not be due entirely to the incompetence of the examiner, as has been suggested, since it is possible that some hips become unstable after the neonatal screening period. Because of the unreliability of the tests used at present, a recently developed objective method of screening babies’ hips could be a major step forward. This new technique which detects and assesses vibrations from babies’ hips during testing, is both non-invasive and harmless. Also discussed in this paper are our findings of a pilot study undertaken to measure the effectiveness of this new method of screening and diagnosis.

Present methods of screening

The two tests commonly used today to screen neonatal hips, are the ‘Ortolani’ (8) and ‘Barlow’ (1) tests. Before these tests were described, the diagnosis was made by the following clinical signs:

(a) restriction of hip abduction

(b) asymmetrical skin creases

(c) telescoping of the limb

(d) limb shortening, or

(e) by observing the distinctive limp or waddling gait in the older child.

However, many of the above signs occur late in the disease and thus do not encourage an early diagnosis (5). Ortolani first described his test in 1937. In it, the examiner abducts the hips, a manoeuvre which should cause the dislocated or subluxed hips to reduce. Therefore this test is only capable of diagnosing hips that are dislocated and reducible. In 1962, Barlow modified Ortolani’s test so that it might be possible to detect hips that were dislocatable. He did this by exerting backward pressure by the thumb when the hip was adducted. On releasing this pressure and abducting the hip, the unstable hip could be felt to relocate in the