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Warming of Hypothermic Newborns

Question Type:
Intervention
Full Question:
In newborns hypothermic (<36.0c) on admission  (P), does rapid rewarming (I), compared with slow rewarming  (C), change mortality rate , short and long term neurological outcome, hemmorhage, episodes of apnea and hypoglycemia, need for  respiratory support  (O)?
Consensus on Science:
We identified 2 randomized trials (Motil 1974, 546; Tafari 1974, 595) and 2 observational studies (Racine 1982, 317; Sofer 1986, 211) comparing rapid (greater than 0.5°C/hour) versus slow (less than 0.5°C/hour) rewarming strategies for hypothermic newborns on admission (less than 36.0°C). All studies were dated (the most recent study was published 28 years ago) and conducted in different settings (2 in low-resource countries and 2 in high-resource countries); enrolled patients had different baseline characteristics (postnatal age, gestational age, proportion of outborn/inborn, degree of hypothermia). The quality of the studies was very poor in terms of number of enrolled patients, inclusion criteria, randomization methods, study design, and outcome measures. For the critical outcome of mortality, we identified low-quality evidence (downgraded for serious risk of bias) from 1 randomized clinical trial (Tafari 1974, 595) including 30 patients showing no benefit (RR, 0.88; 95% CI, 0.36–2.10) and 2 observational studies (Racine 1982, 317; Sofer 1986, 211) including 99 patients showing benefit in favor of a rapid rewarming strategy (OR, 0.23; 95% CI, 0.06–0.83). For the critical outcome of convulsions/seizures, we identified very-low-quality evidence (downgraded for serious risk of bias) from 1 randomized clinical trial (Tafari 1974, 595) including 30 patients showing no benefit to rapid versus slow rewarming (RR, 0.88; 95% CI, 0.14–5.42). For the critical outcome of hemorrhage/pulmonary hemorrhage, we identified very-low-quality evidence (downgraded for serious risk of bias) from 1 randomized clinical trial (Tafari 1974, 595) including 30 patients and 1 observational study (Racine 1982, 317) including 38 patients showing no benefit to rapid versus slow rewarming (RR, 1.31; 95% CI, 0.26–6.76 and OR, 0.16; 95% CI, 0.02–1.50, respectively). For the important outcome of need for respiratory support, we identified very-low-quality evidence (downgraded for serious risk of bias) from 1 observational study (Sofer 1986, 211) including 56 patients showing benefit in a slower over a rapid rewarming strategy (OR, 7.50; 95% CI, 2.14–26.24). For the important outcome of episodes of hypoglycemia, we identified very-low-quality evidence (downgraded for serious risk of bias and very serious imprecision) from 1 randomized controlled trial (Motil 1974, 546) including 36 patients and 1 observational study (Sofer 1986, 211) including 56 patients showing no benefit to rapid versus slow rewarming (RR, 0.11; 95% CI, 0.01–1.81 and OR, 0.21; 95% CI, 0.01–4.06, respectively). For the important outcome of episodes of apnea, we identified very-low-quality evidence (downgraded for serious risk of bias and very serious imprecision) from 2 randomized clinical trials (Motil 1974, 546; Tafari 1974, 595) including 66 patients showing no benefit to rapid versus slow rewarming (RR, 0.44; 95% CI, 0.04–4.32).
Treatment Recommendation:
The confidence in effect estimates is so low that a recommendation for either rapid (0.5°/hour or greater) or slow rewarming (0.5°/hour or less) of unintentionally hypothermic newborns (T° less than 36°C) at hospital admission would be speculative. Values, Preferences, and Task Force Insights It was considered important to distinguish the warming of infants where hypothermia is iatrogenic after birth, which in general is of a short duration, from hypothermia that is therapeutic and has been intentionally induced over 72 hours. The latter rewarming is generally recommended to be slow.
CoSTR Attachments:
858 Copy of Summary of bias assessmentFinal(1) (1).xlsx    
858 COSRapidRewarming8march2015.doc    
858 evidence profile table2 Should Rapid rew.pdf    
858 GRADEGRID 7march2015.doc    
858 Profile table Should Rapid rewarming vs.pdf    
858 Sof Should Rapid rewarming vs slow rewa (2).pdf    

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