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Mild controlled hypothermia for necrotizing enterocolitis treatment to preterm neonates: low technology technique description and safety analysis

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Abstract

We performed a quality improvement project to necrotizing enterocolitis (NEC) and published our results about the initiative in 2021. However, aspects on the safety of the cooling and how to do therapeutic hypothermia with low technology to preterm infants are not described in this previous reporter. Thus, we aim to describe the steps and management to apply hypothermia in preterm infants using low technology and present the safety aspects regarding the initiative. We performed a quality improvement project to NEC in a reference hospital for neonatology (intensive care unit). Forty-three preterm infants with NEC (modified Bell’s stage II/III) were included: 19 in the control group (2015–2018) and 24 in the hypothermic group (2018–2020). The control group received standard treatments. The hypothermia group received standard treatment and underwent passive cooling (35.5 °C, used for 48 h after NEC diagnosis). We reported cooling safety to NEC, assessing hematological and gasometrical parameters, coagulation disorders, clinical instability, and neurological disorders. We described how to perform cooling to preterm infants using incubators’ servo-control and the occurrence and management of dysthermia during the cooling. We turn-off the incubator and used the esophageal probe to monitor the temperature every 15 min; if the temperature dropped, the incubator was turned on with a rewarming speed of 0.5 °C/h. The participants’ average weights and gestational ages were 1186 g and 32 weeks, respectively. There were no differences among hematological indices, serum parameters (sodium, potassium, creatinine, lactate, and bicarbonate), pH, pCO2, and pO2/FiO2 between the groups during treatment and after rewarming. We did not observe dysthermia, bradycardia, hemodynamic instability, apnea, seizure, bleeding, peri-intraventricular hemorrhage, or any alterations in ventilatory parameters due to the cooling technique in preterm babies. This simple technique was performed without intercurrences through a rigorous team evaluation, with a target cooling speed of 0.5 °C/h. The target temperature was successfully reached between the second and third hours of life with the incubator control in 21 children; ice bags were used in only three cases. The temperature was maintained at the expected level during the programmed cooling period.

Conclusion: Mild controlled hypothermia for preterm infants with NEC is safe. The cooling of preterm infants could be performed through passive methods, using the servo-control of the incubators for temperature management.

What is Known:

• Mild controlled hypothermia to NEC treatment is feasible and associated with a decrease in NEC surgery, short bowel, and death.

• Mild controlled hypothermia to preterm is feasible and can be performed through low technology and passive cooling.

What is New:

• Mild controlled hypothermia to preterm is safe and does not associate with safety adverse effects during and after the cooling.

• Preterm infants can be cooled through passive methods by just using the servo control of the incubator, presenting acceptable temperature variance, without dysthermia, achieving and remaining at the target temperature with a proper cooling speed. Mild controlled temperature for preterm infants does not need an additional cooling device.

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Data availability

All the data are available for inquiry or analysis.

Abbreviations

GA:

Gestational age

NEC:

Necrotizing enterocolitis

NICU:

Neonatal intensive care unit

nSOFA:

Sequential Organ Failure Assessment

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Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing, NEOTHERM Collaborative Group, and Ribeirão Preto Medical School’s neonatology staff.

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Authors and Affiliations

  1. Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil

    Walusa Assad Gonçalves-Ferri, Cristina Helena Faleiros Ferreira, Lara Malosso Sgarbi Albuquerque, Julia Belcavelo Contin Silva, Mariel Versiane Caixeta, Fabio Carmona, Cristina Calixto, Davi Casale Aragon, Gerson Crott, Marisa M. Mussi-Pinhata & Anelise Roosch

  2. Surgery Department, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil

    Lourenço Sbragia

Authors
  1. Walusa Assad Gonçalves-Ferri
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Contributions

Walusa Assad Gonçalves-Ferri: Study design, planning, execution, coordinator, writer, and investigator principal. Cristina Helena Faleiros Ferreira: Data check, planning, writer, and reviewer. Lara Malosso Sgarbi Albuquerque: Writer, reviewer, and collected the data. Julia Belcavelo Contin Silva: Writer, reviewer, and collected the data. Mariel Versiane Caixeta: Writer, reviewer, and collected the data. Davi Casale Aragon: Writer, reviewer, and statistical analysis. Gerson Crott: Data collected (POCUS), intellectual collaborator, and reviewer. Fabio Carmona: Planning, writer, and reviewer. Cristina Calixto: Supervisor of data collected and reviewer. Analise Roosch: Writer, intellectual collaboration, and reviewer. Marisa M. Mussi-Pinhata: Study design, intellectual collaboration, and reviewer. Lourenço Sbragia Neto: Planning, coordinator of surgical management, writer, and reviewer.

Corresponding author

Correspondence to Walusa Assad Gonçalves-Ferri.

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Ethics approval

This study was approved by the Institutional Review Board of Ribeirão Preto Medical School, University of São Paulo (FMRP-USP, CAAE number 29879620.5.0000.5440, and approval number 3.920.223). The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

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Communicated by Daniele De Luca

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Gonçalves-Ferri, W.A., Ferreira, C.H.F., Albuquerque, L.M.S. et al. Mild controlled hypothermia for necrotizing enterocolitis treatment to preterm neonates: low technology technique description and safety analysis. Eur J Pediatr 181, 3511–3521 (2022). https://doi.org/10.1007/s00431-022-04558-w

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