**2. Prenatal environment**

514 Current Topics in Tropical Medicine

Ineffective thermoregulation leads to other complications and patients' poor response to treatment. Neonatal physiological stability enhanced by adequate thermoneutral control and humidification is an essential factor that enables the neonate to respond well to treatment thereby enabling effective management of associated tropical diseases. An adequate and hygienic incubation technique, appropriately designed for the peculiar tropical settings, will minimise neonatal cross-infection and also reduce disease transmission by the often freely roaming insects in and out of the incubators. Adverse climatic conditions and observed procedural inadequacies of incubator application often lead to overheating, compelling attendants to open up the incubator portholes and windows thereby compromising the microenvironment. The present work seeks to extend the incubator application to create procedures that ensures the minimisation of such

Fig. 1. Map of Nigeria showing all the states where the collaborating tertiary hospitals are

In this chapter, four different environments that impact on the new-born baby would be examined. This knowledge is important to be able to effectively understand the thermal needs of the new-born during neonatal care, whether inside an incubator or an open cot.

compromises.

located

These are:

The neonate's body system observes the law of "garbage in garbage out" in terms of what it does with the ambient temperature of its immediate environment. From clinical experience, it is very easy to observe that an extremely low birth weight neonate will quickly assume a body temperature equal to the ambient temperature of its immediate environment. This has been frequently observed at one of our collaborating neonatal centres in the very hot town of Nguru in Nigeria. In an overheated room, baby becomes hyperthermic and in a cold room, baby becomes hypothermic. Both extremes are devastating conditions, capable of claiming the baby's life and must be avoided. This is why the regulation of baby's environment must be done on patient-specific basis involving the exact extra warming or wrapping required to thermally stabilise such baby. Nature has made an adequate environmental provision for the prenatal period. Baby's immediate past housing, the womb, is a separately controlled environment independent of the foetus's body system and providing it with no worries for self-thermoneutral control. It is therefore essential to anticipate the possible fatal environmental shock that awaits a premature new-born as its organs are not yet functionally ready to completely support the baby outside the womb environment.

The body temperature of a healthy adult is physiologically stabilized about 37°C whether in a temperate climate of 1°C or tropical sub-Saharan African climate of 45°C. The adult expectant mother may be physiologically acclimatised to her 'freezing' or 'burning' weather respectively; however, the foetuses in both climates are accustomed to approximately the same thermal environment of the womb. Individual climatic adaptation for the baby only begins at birth. Therefore the design of a supportive environment for a premature baby must integrate the climatic peculiarities such foetus would be graduating into.

#### **3. Neonatal micro-environment**

It is an absolute necessity to provide an enabling environment immediately following premature birth. This calls for a sustainable artificial environment to allow the neonate enough time for its organs to fully mature to provide independent support to withstand the tougher climate of the outside world. This practice ameliorates the shock of a sudden change in environmental conditions that can become catastrophic for the premature new-born. What should such artificial environment possess then? A good design of controllable microenvironment for the baby might be achieved by applying constraints that are enriched with the good knowledge of the womb as well as the climatic and social factors of baby's place of birth. Incubator comes to mind in a clinical setting when neonatal microenvironment is mentioned. In a classical and basic sense, neonatal incubation might speak more of the

Neonatal Thermoneutrality in a Tropical Climate 517

The odd effect of poverty shows up again during the management of the premature baby in terms of inadequacy in the supply of equipment for neonatal nursing. There is endemic insufficiency of functional incubators for the teaming population of the neonates requiring incubator care in a typical referral centre among those involved in the present study. The situation in the region was such that it was common to have only one centre where neonatal special care might be obtained in a catchment population of over 5 million, covering over 30,000 km2 of land area. Journeys could take as much as 3 hours to reach the centres and often involving very poor access roads. Such a centre would normally have an average of 35 neonates on admission at any time, yet working with no more than two functional incubators and grossly under-staffed with qualified nurses and doctors. Sadly, up to three babies from different mothers were at times crammed into the same incubator in one of those horrible thermoneutral malpractices to be treated in later sections of this chapter. Our strategic plan to lower neonatal loses due to complications of thermal instability had to be carefully designed to discourage such wrong applications. Ibe (1993) indicated a culture of high admission deliveries for very low birth weight babies within the study region. This is compounded by a high number of referral cases of distressed tiny babies, often stretching the facilities beyond capacity as observed in our study centres. This therefore suggests that a hospital with average on-admission of over 30 patients should operate with a minimum of 20 well-maintained functional incubators, up to 3 radiant warmers, up to 10 phototherapy machines, up to 30 units of cot/incubator installable apnoea monitoring systems and enough attending nurses to guarantee a patient-to-nurse ratio of 5 during every shift. The provision of twenty functional incubators in one hospital alone is almost impossible when the poverty factors of these tropical countries come into play. Hence, an extra ordinary

approach to this seemingly impossible situation had to be sought for.

An earlier study in the tropical region of Africa by Ogunlesi et al (2008) indicated that high point-of-admission hypothermia and general thermal instability contribute a great deal to the high NNMR, stressing the need of incubators in adequate number to re-equip the centres. Many centres were discovered to have several units of broken-down, old and obsolete incubators stacked in equipment stores; others littered the walk ways of the hospital complexes, breeding insects and rodents, promoting environmental pollution and unhygienic facility. Many of these were kept back in the neonatal wards and being used as 'cages' for these babies in such unhygienic manner that could enhance infections and disease transmission (Figure 2). The horrific dirty sights that were revealed upon removal of the mattress trays were enough to wonder why any baby survived at all from the cages. Careful inspections would reveal that many of these still had reusable canopies and trolleys. Proposals for the purchase of adequate number of functional incubators during joint-task meetings with hospital managements would not go well. Lack of adequate funding for the hospitals meant that it was nearly impossible for any of them to acquire enough systems at the local prevailing costs of incubators. These were to be supplied to hospitals at costs higher than €20,000 per unit of incubator. This meant, for a Unit requiring up to 20 incubators, a huge budget of over €400,000 for the purchase of incubators alone in a poorly funded hospital with many other departments to run. The local repair of the broken-down incubators was not a feasible option as the spare parts of few of the current models could not be acquired due to poor supply chain. None of the companies that produced these

**4.2 Budget re-equipping of functional incubator** 

**4.1 Incubator availability** 

provision of a controlled warming for the new-born. It is understandable that provision of uncompromised all-day warming is essential for the neonate in a temperate regional climate of average room temperature of less than 10°C, for example. The baby's inability to maintain its own homeostasis meant that the extra 27°C or more required to attain a body temperature of 37°C must be provided and sustained artificially. The definition for this separate microenvironment for the new-born must however begin to modify when the regional climate changes to another of room temperatures in excess of 40°C. Such elevated ambient temperature in poor hygienic settings as the tropical culture would normally encourage fast breeding of disease transmitting insects even around hidden corners of the incubator. Therefore, appropriate incubation technique capable of effective neonatal care must recognise and integrate the climatic characteristics of the culture the neonate is graduating into. Neonatal incubator care, as is presently practiced in the high ambient sub-Saharan Africa is deficient of this fundamental factor. The race to lower neonatal mortality rate in Tropical Africa might hence not necessarily be dependent on increase of drug donations or over flooding the health facilities with sophisticated incubators. The race might however be won by going back to the fundamentals of neonatal thermoneutral care that are compliant to the conditions of the region. This is a natural 'preventive technique' that would lead to the minimisation of disease occurrences. An effective and climate sensitive neonatal care would ensure a healthy start in life for the promising infant.

Classical incubation techniques in this tropical African climate might not have been fully successful because these were designs developed and originally practiced in climates and cultures that were completely different. This creates opportunities for deficient practices that expose the delicate neonates to unhygienic conditions, insects and infections that soon make them morbid and eventually claim their lives. An unstable thermoneutral environment does not provide the thermal stability the neonate's body system requires to effectively respond to treatment. In response to this, an on-going research adopting new practice procedures in collaboration with 15 different neonatal centres across the region was initiated to address various adverse incubation factors. This has so far proffered solutions that coincidentally improved survival rates in the centres (Amadi et al., 2010). The aim of this work was to present the various thoughts, considerations and incubator care approaches that might have improved neonatal defence against exposure to tropical epidemics that could easily claim their lives.

#### **4. Effect of poverty and illiteracy**

A well-looked after pregnancy and professionally efficient antenatal care are essential factors that could promise a healthy baby. These factors would characteristically help to avoid the complications of preterm birth. Poverty and illiteracy create a clear distinction in neonatal mortality rate between developed nations such as the United Kingdom and any sub-Saharan African country such as Nigeria. This is evident from literature reports on neonatal and perinatal mortality rates from these regions (FMOH, 2011; Centre for Maternal and Child Enquiry, 2010). Societal abject poverty and high degree of illiteracy are factors that do not allow the expectant mothers to nurture healthy foetuses or seek professional antenatal care when these are available. It is arguable that most mothers would be happy to observe any rules that would guarantee them a healthy baby. Maternal poverty and illiteracy are outside the scope of the present work; however it sounds reasonable to mention that tackling poverty in sub-Saharan Africa as part of an assembly of measures would go a long way in lowering NNMR of the region.

#### **4.1 Incubator availability**

516 Current Topics in Tropical Medicine

provision of a controlled warming for the new-born. It is understandable that provision of uncompromised all-day warming is essential for the neonate in a temperate regional climate of average room temperature of less than 10°C, for example. The baby's inability to maintain its own homeostasis meant that the extra 27°C or more required to attain a body temperature of 37°C must be provided and sustained artificially. The definition for this separate microenvironment for the new-born must however begin to modify when the regional climate changes to another of room temperatures in excess of 40°C. Such elevated ambient temperature in poor hygienic settings as the tropical culture would normally encourage fast breeding of disease transmitting insects even around hidden corners of the incubator. Therefore, appropriate incubation technique capable of effective neonatal care must recognise and integrate the climatic characteristics of the culture the neonate is graduating into. Neonatal incubator care, as is presently practiced in the high ambient sub-Saharan Africa is deficient of this fundamental factor. The race to lower neonatal mortality rate in Tropical Africa might hence not necessarily be dependent on increase of drug donations or over flooding the health facilities with sophisticated incubators. The race might however be won by going back to the fundamentals of neonatal thermoneutral care that are compliant to the conditions of the region. This is a natural 'preventive technique' that would lead to the minimisation of disease occurrences. An effective and climate sensitive neonatal

Classical incubation techniques in this tropical African climate might not have been fully successful because these were designs developed and originally practiced in climates and cultures that were completely different. This creates opportunities for deficient practices that expose the delicate neonates to unhygienic conditions, insects and infections that soon make them morbid and eventually claim their lives. An unstable thermoneutral environment does not provide the thermal stability the neonate's body system requires to effectively respond to treatment. In response to this, an on-going research adopting new practice procedures in collaboration with 15 different neonatal centres across the region was initiated to address various adverse incubation factors. This has so far proffered solutions that coincidentally improved survival rates in the centres (Amadi et al., 2010). The aim of this work was to present the various thoughts, considerations and incubator care approaches that might have improved neonatal defence against exposure to tropical epidemics that could easily claim their lives.

A well-looked after pregnancy and professionally efficient antenatal care are essential factors that could promise a healthy baby. These factors would characteristically help to avoid the complications of preterm birth. Poverty and illiteracy create a clear distinction in neonatal mortality rate between developed nations such as the United Kingdom and any sub-Saharan African country such as Nigeria. This is evident from literature reports on neonatal and perinatal mortality rates from these regions (FMOH, 2011; Centre for Maternal and Child Enquiry, 2010). Societal abject poverty and high degree of illiteracy are factors that do not allow the expectant mothers to nurture healthy foetuses or seek professional antenatal care when these are available. It is arguable that most mothers would be happy to observe any rules that would guarantee them a healthy baby. Maternal poverty and illiteracy are outside the scope of the present work; however it sounds reasonable to mention that tackling poverty in sub-Saharan Africa as part of an assembly of measures

care would ensure a healthy start in life for the promising infant.

**4. Effect of poverty and illiteracy** 

would go a long way in lowering NNMR of the region.

The odd effect of poverty shows up again during the management of the premature baby in terms of inadequacy in the supply of equipment for neonatal nursing. There is endemic insufficiency of functional incubators for the teaming population of the neonates requiring incubator care in a typical referral centre among those involved in the present study. The situation in the region was such that it was common to have only one centre where neonatal special care might be obtained in a catchment population of over 5 million, covering over 30,000 km2 of land area. Journeys could take as much as 3 hours to reach the centres and often involving very poor access roads. Such a centre would normally have an average of 35 neonates on admission at any time, yet working with no more than two functional incubators and grossly under-staffed with qualified nurses and doctors. Sadly, up to three babies from different mothers were at times crammed into the same incubator in one of those horrible thermoneutral malpractices to be treated in later sections of this chapter. Our strategic plan to lower neonatal loses due to complications of thermal instability had to be carefully designed to discourage such wrong applications. Ibe (1993) indicated a culture of high admission deliveries for very low birth weight babies within the study region. This is compounded by a high number of referral cases of distressed tiny babies, often stretching the facilities beyond capacity as observed in our study centres. This therefore suggests that a hospital with average on-admission of over 30 patients should operate with a minimum of 20 well-maintained functional incubators, up to 3 radiant warmers, up to 10 phototherapy machines, up to 30 units of cot/incubator installable apnoea monitoring systems and enough attending nurses to guarantee a patient-to-nurse ratio of 5 during every shift. The provision of twenty functional incubators in one hospital alone is almost impossible when the poverty factors of these tropical countries come into play. Hence, an extra ordinary approach to this seemingly impossible situation had to be sought for.

#### **4.2 Budget re-equipping of functional incubator**

An earlier study in the tropical region of Africa by Ogunlesi et al (2008) indicated that high point-of-admission hypothermia and general thermal instability contribute a great deal to the high NNMR, stressing the need of incubators in adequate number to re-equip the centres. Many centres were discovered to have several units of broken-down, old and obsolete incubators stacked in equipment stores; others littered the walk ways of the hospital complexes, breeding insects and rodents, promoting environmental pollution and unhygienic facility. Many of these were kept back in the neonatal wards and being used as 'cages' for these babies in such unhygienic manner that could enhance infections and disease transmission (Figure 2). The horrific dirty sights that were revealed upon removal of the mattress trays were enough to wonder why any baby survived at all from the cages. Careful inspections would reveal that many of these still had reusable canopies and trolleys. Proposals for the purchase of adequate number of functional incubators during joint-task meetings with hospital managements would not go well. Lack of adequate funding for the hospitals meant that it was nearly impossible for any of them to acquire enough systems at the local prevailing costs of incubators. These were to be supplied to hospitals at costs higher than €20,000 per unit of incubator. This meant, for a Unit requiring up to 20 incubators, a huge budget of over €400,000 for the purchase of incubators alone in a poorly funded hospital with many other departments to run. The local repair of the broken-down incubators was not a feasible option as the spare parts of few of the current models could not be acquired due to poor supply chain. None of the companies that produced these

Neonatal Thermoneutrality in a Tropical Climate 519

Fig. 3. Abandoned incubators for recycling, recovered from (A) rubbish dump (B) workshop

D

Recycled Incubator Technique (RIT) speaks of the successful application that most Nigerian tertiary hospitals have used to re-equip their Special Care Baby Units (SCBU) using their formally condemned or obsolete incubators. Many of these old systems were abandoned in

In the recycling technique that was designed in this study, the casings of the obsolete system were re-used but the functional assemblies of the power unit were completely reengineered with customized generic digital components. RIT incubators currently make up 80% to 100% of the functional incubators in many Nigerian tertiary hospitals at the time of this report. These included University of Benin Teaching Hospital (UBTH) Benin-City, Lagos University Teachning Hospital (LUTH) Lagos, Jos University Teachnig Hospital (JUTH) Jos, Ebonyi State University Teaching Hospital (EBSUTH) Abakaliki, Aminu Kano Teachnig Hospital (AKTH) Kano, Federal Medical Centres (FMCs) at Nguru, Gombe, Owerri, EbuteMetta and Abeokuta. Others were University of Nigeria Teaching Hospital (UNTH) Enugu, University of Calabar Teaching Hospital (UCTH) Calabar, University of Ilorin Teaching Hospital (UITH) Ilorin and University of Abuja Teaching Hospital (UATH) Gwagwalada. An RIT system comparatively saves up to 75% of the cost of procuring and maintaining a modern state-of-the-art incubator whilst being functionally akin to these (Amadi et al, 2007). RIT has presently made it possible for some

the stores or used as ordinary cages (cots) in the Special Care Baby Units.

(C) neonatal ward in use (D) scrap metal yard

**A B**

**5. Modelling Recycled Incubators** 

C D

systems had any assembly plants or technical representatives to provide the needed technical support. Therefore sustainable solution was not envisaged through this approach. To acquire brand new systems, unlike the use of extended price-plan and after sale maintenance in developed countries, the hospitals in these poor nations would be required by the foreign companies to make outright payment of the full cost. High cost of logistics and unfavourable operating environments might have compelled these companies from any extended technical support to a country like Nigeria at the moment. They hence demanded full out right payment for the systems, leaving the country to bear the full liability of the carcasses when they broke down. An inventory carried out in a certain Teaching Hospital in Nigeria during this period revealed the presence of 45 carcasses of different models of dysfunctional baby incubators in their stores whilst they had no functional one to save tens of babies in its new-born Units.

Fig. 2. An incubator carcass showing the inside immediately below matrass tray (removed); system was in use as is when retrieved

At this junction it was clear that the idea of a new approach to this was inevitable. The old carcasses of incubators that littered the hospitals were again considered and fresh investigations revealed the high availability of these across all the 5 collaborating tertiary (university teaching) hospitals at the time. A research was hence initiated to evaluate and design a process that might apply to re-introduce these obsolete systems to active services in a neonatal ward without necessarily taking recourse to original manufacturers or spare parts. This was to consider the maintainability of the resulting system, carefully selecting options that would ensure availability of spare parts and simplifying the technology to make it easy for the local technicians to handle. Typically available carcasses to apply in these hospitals were of all sorts of brands, age and models, the state of some could be best described as 'horrible' (Figure 3). Carcasses were also literally recovered from hospital dump sites where they were abandoned awaiting evacuation. However, these constituted the closest solutions to the problem required to be solved. The wide variability of these carcasses resulted in the constraint requiring that a workable design must be easily adaptable to any 'model' and 'make' of an item of incubator carcass.

systems had any assembly plants or technical representatives to provide the needed technical support. Therefore sustainable solution was not envisaged through this approach. To acquire brand new systems, unlike the use of extended price-plan and after sale maintenance in developed countries, the hospitals in these poor nations would be required by the foreign companies to make outright payment of the full cost. High cost of logistics and unfavourable operating environments might have compelled these companies from any extended technical support to a country like Nigeria at the moment. They hence demanded full out right payment for the systems, leaving the country to bear the full liability of the carcasses when they broke down. An inventory carried out in a certain Teaching Hospital in Nigeria during this period revealed the presence of 45 carcasses of different models of dysfunctional baby incubators in their stores whilst they had no functional one to save tens

Fig. 2. An incubator carcass showing the inside immediately below matrass tray (removed);

At this junction it was clear that the idea of a new approach to this was inevitable. The old carcasses of incubators that littered the hospitals were again considered and fresh investigations revealed the high availability of these across all the 5 collaborating tertiary (university teaching) hospitals at the time. A research was hence initiated to evaluate and design a process that might apply to re-introduce these obsolete systems to active services in a neonatal ward without necessarily taking recourse to original manufacturers or spare parts. This was to consider the maintainability of the resulting system, carefully selecting options that would ensure availability of spare parts and simplifying the technology to make it easy for the local technicians to handle. Typically available carcasses to apply in these hospitals were of all sorts of brands, age and models, the state of some could be best described as 'horrible' (Figure 3). Carcasses were also literally recovered from hospital dump sites where they were abandoned awaiting evacuation. However, these constituted the closest solutions to the problem required to be solved. The wide variability of these carcasses resulted in the constraint requiring that a workable design must be easily

adaptable to any 'model' and 'make' of an item of incubator carcass.

of babies in its new-born Units.

system was in use as is when retrieved

Fig. 3. Abandoned incubators for recycling, recovered from (A) rubbish dump (B) workshop (C) neonatal ward in use (D) scrap metal yard
