Preventing and treating hypothermia in severely malnourished children
Biological, behavioural and contextual rationale
Hypothermia is a reduction in the mean body temperature. In severe malnutrition, this complication is defined by WHO as a rectal temperature below 35.5 °C (95.9 °F) or an underarm temperature below 35.0° C (95.0 °F). Preventing or treating hypothermia is an important step in the initial stabilization phase of the treatment of children with severe malnutrition1.
Malnourished children are susceptible to hypothermia because they have:
- a lower metabolic rate and consequently lower heat production due to limited energy reserves
- a larger body surface area per kilogram
- fat losses resulting in less insulation and more heat loss
- infections that lead to insufficient energy available for thermoregulation2–6.
Infants and children presenting with marasmus, lesions on a large part of the skin, or severe infections are the most prone to develop hypothermia1,7, whereas the oedema fluid of kwashiorkor acts as an insulator8.
The WHO guidelines for the treatment of severely malnourished children recommend warming the child whenever he/she is found to be hypothermic. For this to be achieved, the child can either be placed on the mother's bare chest or abdomen to allow skin-to-skin contact, and then both individuals should be covered – a practice known as "the kangaroo technique". Alternatively, the child can be well clothed, including the head, covered with a warmed blanket and placed under an incandescent lamp, making sure that the lamp does not touch the child's body. The use of hot-water bottles is not recommended1.
Temperature monitoring during re-warming is important to avoid hyperthermia, which increases water and energy loss. In order to avoid hyperthermia, rectal temperature must be measured every 30 minutes when using a re-warming lamp and every two to four hours otherwise, until the child passes the initial phase of the treatment and becomes stable1.
The implications of this practice on staff requirements may limit its application in low-resource settings. Therefore, a reduction in the routine temperature monitoring has been suggested and is backed up by findings that revealed a low prevalence of hypothermia in severe malnutrition and a failed association with poor outcome1. But this proposed recommendation can still not be generalized because of the scarcity of similar studies, and thus the initial guideline of frequent temperature monitoring is still accepted.
Two other essential interventions for hypothermic children are to treat hypoglycaemia and serious systemic infections. Frequent feeding – which is an approach to manage hypoglycaemia – and provision of broad spectrum antimicrobials will allow for the supply of energy to support essential body functions including heat generation that can prevent or treat hypothermia3,4,7–10.
Although there are contradictory data on the prevalence and consequences of hypothermia in severely malnourished children, no harmful effects of monitored re-warming have been reported. In situations where heat lamps are not available or electricity supply is unreliable, the kangaroo technique can be easily implemented with appropriate training11,12. Challenges to the application of the guidelines remain in settings where inappropriate behaviours prevail, such as the lack of provision of blankets13, the infrequent change of wet sheets14, the failure to monitor body temperatures14, the separation of the child from the mother9,15, and the lack of instructions for the mother to keep her child warm16. Therefore, it is important to train mothers and health personnel in order to allow for a successful adoption of simple interventions that prevent and treat hypothermia and that are still reported to decrease case fatality17.
References
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