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ABSTRACT
Background: Considering the susceptibility of preterm infants to disturbances of vital signs, this study was
conducted to investigate the effects of using plastic covers on regulation of vital signs in preterm neonates.
Methods: This randomized, cross-over, clinical trial was carried out on 80 preterm infants admitted to neonatal
intensive care unit (NICU) of Taleghani Hospital, Tabriz, Iran. The study was conducted in two days (on the second
and third days of the infants life). In group 1, plastic cover was used during the first day followed by the use of
blanket on the second day, while the order was reversed in group 2. Digital thermometer was used to measure the
infants axillary temperature. Heart rate and oxygen saturation were measured through monitoring. To analyze the
data, descriptive (Mean and SE, 95%CI) and inferential statistics (repeated measurement and ANCOVA tests) were
used in SPSS version 13 and MiniTab software.
Results: Fourteen infants who were covered with blanket were found to suffer from hypothermia, while no infant
with a plastic cover encountered this problem. The percentage of arterial blood oxygen saturation in the group with
plastic covers was higher, and as a result, the infants received less oxygen supplements. However, no statistically
significant differences were observed in heart rate between the groups.
Conclusion: Use of plastic cover during NICU stay prevented hypothermia in premature infants, with the arterial blood
oxygen saturation being within the normal limits. Yet, it did not seem to have a significant effect on other vital signs.
Keywords: Body temperature, HR, Neonatal intensive care unit, Polyethylene wrap, Preterm infants, SpO2
Introduction
Preterm infants are born before their body and of the basic vital signs in infants. All infants
organ systems mature. Such infants are often hospitalized in neonatal intensive care units
small and extremely vulnerable and most of their (NICUs), who are physiologically unstable, must
body organs are not ready for extrauterine life; be monitored for vital signs, particularly heart
therefore, they might not function properly due to rate (2). Evaluation of physiologic indices is
extreme immaturity (1). performed by monitors that assess heart rate and
Body function signs reflect infants physiologic SpO2 level (1).
conditions and are regulated via homeostatic In infants who receive oxygen or have been
mechanisms. Body temperature, heart rate, and under recent oxygen therapy, SpO2 level must be
arterial blood oxygen saturation (SpO2) are constantly monitored. In order to maintain central
considered among such signs. Heart rate, which temperature, infants show physiologic responses
indicates the condition of blood circulation, is one to temperature fluctuations such as bradycardia
* Corresponding author: Maryam Peyghami, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran. Tel:
+984134796770; Fax: +984134796969; Email: kontroleofonateshahindezh@gmail.com
and hypoxia. Hypothermia is one of the most In view of numerous treatment procedures,
common problems in preterm infants during infants are usually placed under a radiant heater
infancy (3). The infants with a birth weight of less in Tabriz NICUs, as in other centers in Iran, to
than 1500 g are more susceptible to hypothermia provide convenient access and easy obse-
(4). Hypothermia is one of the major factors rvation. During the first days of hospitalization,
contributing to neonatal mortality and high rate of a plastic tent is placed on an infants whole body
side effects in infants (5). It is also one of the as well as the whole heater while it was hung
worldwide factors which endangers preterm from sides of the heater. The alternative way is to
infants health (6). cover the infant with a blanket up to the
Hypothermia is reported to underlie an shoulders, with the skull covered with a hat.
increased mortality rate among the infants of Recently, Neonatal Individualized Developmental
virtually all age brackets admitted to NICU (7); it Care Program (NIDCP) has suggested that the
is an independent risk factor for mortality in use of any cover up to infants shoulders makes
infants (8). The rate of hypothermia in preterm the face obvious, thus, making it easy to
infants at the time of birth is 42-73% (9-11), be observed and monitored. Accordingly, it
which requires more attention in developing considers plastic tent as an obstacle in the way
countries (12). In Iran, the prevalence of of the mother and infant establishing eye
hypothermia is 53.3% (13). contact with each other.
Although radiant heater facilitates access to Considering that plastic cover and blanket
the preterm infant, it causes water evaporation are both proven to be economical, easy, and
via skin, making the infant susceptible for safe ways of preventing hypothermia, and
dehydration. Plastic covers, which are easy to considering the paucity of studies on the effect
handle (14), were introduced to prevent heat of plastic covers on regulating infants vital
loss in preterm infants (15). The use of plastic signs during NICU stay, we sought to investigate
cover is considered one of the major the effect of plastic covers on the regulation of
interventions in the prevention of hypothermia vital signs in preterm infants who were under
in low birth weight preterm infants, as it brings radiant heater in NICU of Taleghani Hospital of
about dehydration and heat loss through Tabriz, Iran. This study was carried out to
convection (16), and helps with infants survival investigate and apply the most preferred way
and body temperature maintenance. It is also of regulating infants body temperature and
beneficial in prompt recognition of bleeding in other vital signs without obstructing mother-
umbilical cord or and other parts of the body infant visual contact in accordance with
(17). Blankets, on the other hand, are used to NIDCAP.
keep the infants warm (18) and prevent heat
loss via induction, radiation (14, 19-22), and Methods
evaporation (18). This single-blind, randomized, cross-over
Preterm infants generally receive care in a clinical trial was carried out at Taleghani
specific unit called Neonatal Intensive Care Unit Teaching Hospital, in Tabriz, Iran, 2016. Having
(NICU). In NICUs, a large number of personnel obtained written consent from the parents and
participate in neonatal care. Nurses should permission from Ethics Committee of the
recognize infants potential risks and crucial university (code No.: TBZMED.REC.1394.846)
conditions and take measures to lower those risks and having registered the study in
(1). Regulating infants body temperature is one of IRCT website with the code number of
the major responsibilities of nurses (23). Nursing IRCT201407218315N11, we enrolled the qua-
interventions could play an important role in lified infants in the study in accordance with
maintaining warm chain, recognizing problems at their admission order to NICU.
the right time, and taking prompt treatment steps The inclusion criteria in the study were
to prevent relevant side effects (1). Monitoring gestational age of 28-30 weeks (the gestational
vital signs of infants is a crucial nursing age was calculated and determined via
care (23). Therefore, nursing interventions are ultrasound or the first day of the last menstrual
of key importance in regulating infants vital period), birth weight of 800-1250 g, being two
signs, maintaining a warm chain, recognizing days old, being inborn, being nil per os, being
the problem at the right time, and taking admitted to NICU since the birth day, being
instant interventions to prevent unwanted side nursed under similar radiant heater in Servo-
effects (3). control mode, and being under respiratory care
in Nasal Continues Positive Airway Pressure (N- same as the group 1, the only difference being
CPAP) or High Flow Nasal Canola (HFNC) way. the covering of the infants body with blanket
The infants suffering from spinal cord defects, during the first 24 hours and with the plastic
congenital skin diseases, congenital heart cover during the second 24 hours. The infants
diseases, omphalocele, gastroschisis, metabolic head and face were out and head covered with a
diseases, and sepsis were excluded from the hat.
study together with the ones under ventilation Welch Allyn digital thermometer was used to
and phototherapy. measure the infants axillary temperature. The
With the power of 0.8 and 95% confidence, preterm infants normal body temperature was
and based on the results of similar studies (SD= between 36.5C and 37.5C. The temperatures
0.57, maximum = 0.5) (24) and the pilot study, below 36.6C and above 37.5C were considered
the sample size in each group was calculated as 35 as hypothermia and hyperthermia, respectively
infants, using the formula of comparing mean of (25, 26). The vital signs included the heart rate
two population. Considering 10% attrition, the and oxygen saturation of arterial blood, which
sample size increased to 40 infants in each group were measured through placing Masimo
and to 80 infants in total. monitoring set (SAADAT company, Iran) on the
The neonates meeting the inclusion criteria infants foot. The monitoring probe areas were
were randomly allocated to two groups. The first changed every three hours.
case was chosen through simple random The infants normal heart rate was between
(draw/lottery) sampling and the next cases were 120 and 160 beats per minute. The rates below
allocated to each group alternately (ratio1:1). The 100 and above 180 per minute were considered
study period in each group was two days. bradycardia and tachycardia, respectively (26,
According to statistical accuracy, measurements 27). The normal rate of oxygen saturation was 85-
must be made by a single person, but 95%. The rates below 85% and above 95% were
measurement over 24 hours a day for one person considered as hypoxia and hyperoxia, respectively
cannot be applicable. For this reason, body (26). All the infants were cared for by a similar
temperature, heart rate, and O2 saturation in both radiant heater model HKN-93B. The heater was in
groups were measured at 8:00, 9:00, 12:00, 15:00, Servo-control mode. The study instruments were
18:00, and 21:00 Oclock by one person. The main calibrated by the company engineers before the
researcher performed the intervention and a data was collected. To ensure that the measured
single individual carried out all the measu- values of temperature were reliable, the
rements. The statistical advisor determined how correlation between the recorded values of 10
to randomize to intervention and analyze the data. infants was calculated and the coefficient was
The statistical consultant was blind to the study acceptable (r=0.96).
intervention and had no information as to the Data collection sheets were researcher-made.
advantages and disadvantages of plastic cover and The demographic form included baby code, date,
blanket. case number, date of birth, gender, weight, time of
In group 1, the infants were covered with a birth, gestational age, chronological age, and
sheet from 8:00 a.m. to 9:00 a.m. (to pass wash medical diagnosis. The vital signs (i.e., body
out time and remove the effect of the previous temperature, heart rate, and oxygen saturation)
cover). At 9:00 a.m., the sheet was removed from were recorded in the table format with some
over the infants body. From 9:00 a.m. to 8:00 more information such as heater, environmental
a.m. on the next day (i.e., for the next 23 hours), heat, and moisture. Content validity of the data
the infant was covered with a plastic cover up to collection form was confirmed by seven
his/her neck. On the second day of the professors of Faculty of Nursing and Midwifery
intervention, the plastic cover was removed at and neonatologists from Tabriz University of
8:00 a.m. and until 9:00 a.m. (for 1 hour) the Medical Sciences.
infant was covered with the sheet up to his/her Before each body temperature control, the
neck (to pass wash out time and remove the heater, environmental heat, and moisture were
effect of previous cover). Afterwards, the same checked and the infants were examined for skin
infants body (except for his/her head) was rash, allergy, hyperthermia, and skin changes.
covered with blanket for 23 hours. The infants During temperature measurement, the cover was
head and face were out and head covered was lowered to the infants nipple line to make it
with a hat. possible for the thermometer to be put in the
In group 2, the procedure was almost the infants armpit (the cover was not lowered below
Randomized (n=80)
reduced amounts of FiO2 after each measurement hypothermia, while only one case of hypothermia
(P=0.015). was observed in the current study. Moreover, the
Ibrahim and Yoxall study was of retrospective
Discussion kind (31).
The results of the study indicated that the Fernanda et al. conducted a cohort prospective
mean body temperature of the neonates was more study and demonstrated that when a plastic bag
constantly within the normal range while using was used at the time of admission to NICU, the
plastic cover compared to blanket, with no incidence of hypothermia was reduced (32). The
incidence of hyperthermia. There were other results of that study were consistent with those of
clinical studies that obtained similar findings. In the current one and it was reported in both
those studies, the infants in the experimental studies that use of plastic covers resulted in the
group were put in plastic bags shortly after birth, regulation of preterm infants body temperature
while the ones in the control group received the and prevention of hypothermia.
routine care. Smith et al. and Reilly et al. showed The differences between the present study and
that the mean body temperature was higher in the the previous ones were manifold. Firstly, the
experimental group. The difference in the cases of previous studies were conducted on preterm
hyperthermia was not statistically significant infants immediately after birth in the delivery
between the two groups in those studies (P>0.05) unit, surgery room, or 1 hour after NICU
(17, 28). admission. However, we carried out the current
The studies conducted by Blesches et al., Reilly study on 2-day-old preterm infants hospitalized in
et al., and Rohana et al. revealed that the mean of NICU. Secondly, in previous studies the infants
infants body temperature was considerably were placed inside the plastic bags while in the
higher in the group in which polyethylene bags present study the infants were covered with
were employed; however, the rate of hypothermia plastic covers up to their neck, just as with
was lower. The difference between studies was blankets. Another difference was in age range and
probably because of the infants age range (28- birth weight. The results of studies by Baumgart
30). In the study by Belsches et al., only one case and Cardona et al. on vital signs of infants were
of hyperthermia was reported (29). Ibrahim and consistent with those of the current study, both
Yoxall also reported a significant reduction in the indicating no significant differences in heart rate
prevalence of hypothermia (from 25% to 16%) by between the group with plastic covers and the
covering the infants with plastic bags for less than other group (33, 34). In line with the present
30 minutes. In that study, unlike the present one, a study, Baumgart showed that the infants used less
high percentage of infants suffered from oxygen when they were covered with a plastic
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