**7.1.1 Operational safety**

This was a special segment of the course taught in relation to the neonate, the care-provider, the immediate nursery ward and the incubator itself. Necessary steps for the care of incubator were examined so that participants would appreciate the conducts that were required for their systems to remain functional and hygienic. Some of these were:


compartment (g) Thermostatic assembly and (h) External communication assembly. Cartoon illustrations were applied in some instances to ensure fair understanding of the ideas behind

[This assembly is the thermal policeman of the incubator. It controls and gives the thermal generators instructions on when to supply heat and when to stop. It always checks up the temperature of the incubation chamber and compares it with the operator's input (set point). The thermostat's 'ON and OFF' or 'REDUCE and INCREASE' commands to the thermal generators help it to keep a check and guard against an under- or over -shoot of incubation

This was a special segment of the course taught in relation to the neonate, the care-provider, the immediate nursery ward and the incubator itself. Necessary steps for the care of incubator were examined so that participants would appreciate the conducts that were

a. Preventive Maintenance Culture (PMC): This was an important routine that every newborn intensive care manager was encouraged to imbibe. The PMC is a practice of keeping the incubators and all other neonatal equipment in the neonatal intensive unit under a regular and routine technical check by qualified service personnel to ensure safety and avoid frequent breakdowns. Such breakdowns can occur at odd times especially when the services of the machine are most needed by a neonate. The PMC helps to put the systems in regular six or four monthly technical check-ups and

b. Cleaning: There was need for a regular cleaning and dusting of the machine outer casing everyday so long as the machine was in use. A thorough 'in and out' cleaning is very important before the machine is put into use after a long time of being parked. Various tested locally available disinfectants were recommended for use during such cleaning exercise. The cleaning of the incubators was discouraged from being grouped among the relegated menial jobs given to recruited 'ordinary' people to do. These often

temperature. It does this by what is known as "feedback control mechanism"]

required for their systems to remain functional and hygienic. Some of these were:

these various assemblies (Figure 6).

Fig. 6. Cartooned illustration of thermostatic operation

**7.1.1 Operational safety** 

performance auditing.

low-paid casual workers were recruited to mop floors, clean windows and dust chairs. These also went ahead to handle the incubators, often with neonates inside, the same way as they cleaned chairs using same filthy and smelly rags. What a perfect way of introducing bugs that reduce neonatal survival and also cause damages to the incubator! The course stressed the need for hygiene around the neonates and the incubators and to keep off such infection vendors as outside visitors, improperly masked staff and mothers. Participants were encouraged to use their improved understanding of the neonatal microenvironment during the course to ensure effective cleaning standards that would be professionally acceptable.


Neonatal Thermoneutrality in a Tropical Climate 529

[There must be a regular check of the effectiveness of the electrical earth conductor of the building that is housing the incubators. Improper 'earth' conduction or failure of the electrical earth line is an electrical hazard and can cause such accidents as electric shock to the baby or attending clinician. Poorly installed earth conductor such as shown in the diagram can cause interference of thunder discharges with the power supply to the machines. This can lead to damages to the incubators and other systems. Inexperienced contractors as has been noted can wrongly pass the copper conductor of thunder discharges directly over an electric cable that supplies the building. The interference that resulted from

h. Socket Pin: Burnt wall sockets and plug head were observed being used to power incubators and appliances in the nursery irrespective of their conditions. The dangers of this practice were communicated and the continuous use of incubators with broken or partially burnt plug heads was discouraged. Hence, every broken power plug, burnt socket or wrong fuse must be changed before these were used to power the incubators. Figure 9 shows a couple of dangerous plug head/socket applications captured during

Fig. 9. Unsafe socket and plug heads (A) plug head with hair wire instead of properly rated

i. Operator: Unit Heads were encouraged to ensure that untrained operators or nurses should not be allowed to man the machines until these were properly lectured on how to use them to provider effective care for the neonate. This pointed out the dangers of wrongly operating an incubator and how this might turn around to destroy the baby

It was a common event across all centres to observe practices that led to an incubator overheating beyond their set point values. Such situations often resulted in neonatal hyperthermia for the babies inside the incubators. It was therefore necessary to carefully study how the identified conditions and practices resulted in the malfunctioning of the

fuse (B,D) broken plug head with missing earth-pins (C) burnt socket

**C D**

**A B**

this in one occasion destroyed all connected appliances in the nursery.]

usage.

rather than saving it.

**7.1.2 Incubator overheat** 

[There may be need for a voltage stabilizer set to run an incubator in these countries, especially for modern microprocessor based systems that might not operate with deficient power supplies. However, it must be noted that at adverse, erratic power supplies as has been witnessed, the stabilizer also stood in danger of being blown up together with the incubator it was supposed to be protecting. At this condition, if need be, it was necessary to power down the incubator.]

Fig. 8. Cartooned illustration of earthing line

[There may be need for a voltage stabilizer set to run an incubator in these countries, especially for modern microprocessor based systems that might not operate with deficient power supplies. However, it must be noted that at adverse, erratic power supplies as has been witnessed, the stabilizer also stood in danger of being blown up together with the incubator it was supposed to be protecting. At this condition, if need be, it was necessary to

Fig. 7. Exaggerated sinusoids illustrating unsteady power supply

power down the incubator.]

Fig. 8. Cartooned illustration of earthing line

[There must be a regular check of the effectiveness of the electrical earth conductor of the building that is housing the incubators. Improper 'earth' conduction or failure of the electrical earth line is an electrical hazard and can cause such accidents as electric shock to the baby or attending clinician. Poorly installed earth conductor such as shown in the diagram can cause interference of thunder discharges with the power supply to the machines. This can lead to damages to the incubators and other systems. Inexperienced contractors as has been noted can wrongly pass the copper conductor of thunder discharges directly over an electric cable that supplies the building. The interference that resulted from this in one occasion destroyed all connected appliances in the nursery.]

h. Socket Pin: Burnt wall sockets and plug head were observed being used to power incubators and appliances in the nursery irrespective of their conditions. The dangers of this practice were communicated and the continuous use of incubators with broken or partially burnt plug heads was discouraged. Hence, every broken power plug, burnt socket or wrong fuse must be changed before these were used to power the incubators. Figure 9 shows a couple of dangerous plug head/socket applications captured during usage.

Fig. 9. Unsafe socket and plug heads (A) plug head with hair wire instead of properly rated fuse (B,D) broken plug head with missing earth-pins (C) burnt socket

i. Operator: Unit Heads were encouraged to ensure that untrained operators or nurses should not be allowed to man the machines until these were properly lectured on how to use them to provider effective care for the neonate. This pointed out the dangers of wrongly operating an incubator and how this might turn around to destroy the baby rather than saving it.

#### **7.1.2 Incubator overheat**

It was a common event across all centres to observe practices that led to an incubator overheating beyond their set point values. Such situations often resulted in neonatal hyperthermia for the babies inside the incubators. It was therefore necessary to carefully study how the identified conditions and practices resulted in the malfunctioning of the

Neonatal Thermoneutrality in a Tropical Climate 531

after the procedure has been completed and the portholes and access doors closed, the extra heat already generated within the thermal compartment is then concentrated in the recovered microenvironment overshooting the set-point value. The incubator intelligence would sense this and automatically withdraw heat generation. However it would take a long time for the accumulated chamber temperature to fall, within which this effect could instigate neonatal hyperthermia. Following from other studies, the literature has commented that the use of open bed is more convenient than the closed incubator during special procedures such as endotracheal intubation or arterial catheterisation (Tunell, 2004). Procedures requiring long period of time was advised to rather be carried out on a resuscitaire or 'work-bench' under a radiant warmer as this also allows the clinician enough space to work. Alternatively, the incubator should be switched off if such procedures must necessarily be carried out inside the incubator. This overheating effect was also practically demonstrated during normal working periods when such errors occurred and this helped to accelerate a change in this attitude of workers within the Centres. This practice was also identified to be unhygienic as many of the incubators were observed to contain various leftover items of work materials such as syringes, needles, wrist bands, cotton wool, plaster, sample bottles etc (Figure 11). A currency note and caps of water bottles were also items

Fig. 11. Items of clinical and other materials trapped inside humidifier/heater chambers of

b. Radiant warmer: Literature has previously pointed out external heat sources that could contribute to incubator overheat (Lyon, 2004). All through the observatory period of the present work, Centres never paid attention to incubator positioning

recovered right inside the incubators in some cases.

three different incubators on active service.

incubators. A segment of the course module was dedicated to this, emphasising possible remedies as peculiarly applied to each Centre. The identified causes were of two types, namely externally induced warming and locally induced warming. External warming of the incubators happened as a result of wrong positioning of the system within the nursery building or close to other heat generating gadgets in the same rooms. The consequence of external sources of incubator warming is not necessarily a new discovery as this has already been commented in the literature (Lyon, 2004). However there was no practical evidence of a working knowledge of this in any of the Centres. Related errors were therefore identified, studied and included in the course module to educate users on how their habits were contributing to the situation. Few of these are briefly explained below.

a. Incubator access doors: Wrong usage of the incubator access doors and portholes was the primary cause of locally induced extra warming of the incubator. Attendants were often observed to carry out long procedures on the neonate right inside the incubators with all portholes or access doors left wide open whilst the incubator was still on (Figure 10). Such procedure might start at a time when incubator had already attained and maintained the set-point value. Opening of the portholes for a long period of time compromises the integrity of the microenvironment by a sudden drop in temperature within the chamber. This happened as a result of the nursery cooler air that uncontrollably rushed into the incubator chambers.

Fig. 10. A long clinical procedure being carried out inside a functioning incubator

The incubator air probe senses the drop in the chamber temperature and sends signals to the controller. This makes the thermal generators to increase heat output in attempt to counter the losses through the open portholes. This condition could cause the thermal generators to maintain an unnecessary 100% heat output for the period of the procedure without this being noticed because the extra heat was being fed to the wider nursery. However, soon

incubators. A segment of the course module was dedicated to this, emphasising possible remedies as peculiarly applied to each Centre. The identified causes were of two types, namely externally induced warming and locally induced warming. External warming of the incubators happened as a result of wrong positioning of the system within the nursery building or close to other heat generating gadgets in the same rooms. The consequence of external sources of incubator warming is not necessarily a new discovery as this has already been commented in the literature (Lyon, 2004). However there was no practical evidence of a working knowledge of this in any of the Centres. Related errors were therefore identified, studied and included in the course module to educate users on how their habits were

a. Incubator access doors: Wrong usage of the incubator access doors and portholes was the primary cause of locally induced extra warming of the incubator. Attendants were often observed to carry out long procedures on the neonate right inside the incubators with all portholes or access doors left wide open whilst the incubator was still on (Figure 10). Such procedure might start at a time when incubator had already attained and maintained the set-point value. Opening of the portholes for a long period of time compromises the integrity of the microenvironment by a sudden drop in temperature within the chamber. This happened as a result of the nursery cooler air that

Fig. 10. A long clinical procedure being carried out inside a functioning incubator

The incubator air probe senses the drop in the chamber temperature and sends signals to the controller. This makes the thermal generators to increase heat output in attempt to counter the losses through the open portholes. This condition could cause the thermal generators to maintain an unnecessary 100% heat output for the period of the procedure without this being noticed because the extra heat was being fed to the wider nursery. However, soon

contributing to the situation. Few of these are briefly explained below.

uncontrollably rushed into the incubator chambers.

after the procedure has been completed and the portholes and access doors closed, the extra heat already generated within the thermal compartment is then concentrated in the recovered microenvironment overshooting the set-point value. The incubator intelligence would sense this and automatically withdraw heat generation. However it would take a long time for the accumulated chamber temperature to fall, within which this effect could instigate neonatal hyperthermia. Following from other studies, the literature has commented that the use of open bed is more convenient than the closed incubator during special procedures such as endotracheal intubation or arterial catheterisation (Tunell, 2004). Procedures requiring long period of time was advised to rather be carried out on a resuscitaire or 'work-bench' under a radiant warmer as this also allows the clinician enough space to work. Alternatively, the incubator should be switched off if such procedures must necessarily be carried out inside the incubator. This overheating effect was also practically demonstrated during normal working periods when such errors occurred and this helped to accelerate a change in this attitude of workers within the Centres. This practice was also identified to be unhygienic as many of the incubators were observed to contain various leftover items of work materials such as syringes, needles, wrist bands, cotton wool, plaster, sample bottles etc (Figure 11). A currency note and caps of water bottles were also items recovered right inside the incubators in some cases.

Fig. 11. Items of clinical and other materials trapped inside humidifier/heater chambers of three different incubators on active service.

b. Radiant warmer: Literature has previously pointed out external heat sources that could contribute to incubator overheat (Lyon, 2004). All through the observatory period of the present work, Centres never paid attention to incubator positioning

Neonatal Thermoneutrality in a Tropical Climate 533

There were other commonly identified errors that might have contributed negative impact on the general wellness of the neonates, impoverishing practice outcomes. These were studied as applied to the local setting, trying out and proffering some coincidental effective

a. Humidification: Adequate humidification of the microenvironment has been said to enhance effective neonatal incubation (Silverman et al., 1958, 1963). Humidifier assembly is therefore a basic feature of a standard infant incubator. In most incubator designs this is located beneath the mattress tray at the covered lower aspect of the machine. Humidifier fill-ports from which this could be refilled or drained of water are usually visibly located in front or at the sides of the incubator for easy access. The often harsh climatic weather brings about a very low atmospheric Relative Humidity (RH), as low as 20% in the northern parts of Nigeria. It could therefore be a serious clinical challenge to keep baby adequately hydrated during resuscitation and neonatal nursing if this facility was not properly applied. The practice of running an incubator with dry humidifiers whilst baby was inside was a common failure observed in all the Centres at the beginning of this project. Quick staff interviews revealed that some attendants were not aware of any humidification facilities in incubator designs. Many of those aware of this confessed never bothered or remembered to add water to operate this. Many practical incidents occurred in Centres that perfectly assisted as good traditional events

to convey the reasons behind these inevitable scientific procedures.

the wider audience of the Unit's care-providers.

On one occasion during a whole day consultation in one of the collaborating centres, a certain incubator was running at a set point of 35.5°C. It was on a sunny dry 'harmattan' period, described as a West African season of hot, dry and dusty trade wind that normally blows from the Sahara during the month of November, carrying large amounts of dusts out over the Atlantic Ocean (Wikipedia, 2011; Britannica Online, 2011). The afternoon of the said day was about 35.2°C outside air temperature, nursery room temperature and RH of 34°C and 22% respectively. About half an hour later the same incubator with the same 5-day old baby was observed to have been reset to 37°C. The set-point of this was again, another 1hour 45 minutes later seen to have been increased to 40°C. The system was a 'dial-knob control', mercury meniscus-guide thermometer, Narco Isolette Airshields incubator model C86 at the SCBU of UPTH Port-Harcourt. Upon the observer's request, baby's skin temperature at that instant was measured to be an extreme hypothermic 33.2°C. The baby was said to have been on a steady temperature decline over several hours and throughout the period the incubator set-point was being raised. There was the presence of obvious clinical confusion as the attending clinician seemed to have eliminated some possible reasons for this situation and expressed fears of losing the baby. This true situation recalled similar events that had been observed in other Centres across the country. The incubator humidifier was at this point checked and discovered to be completely dry. As this called for emergency, available 'clean' water was called for and introduced, incubator set-point arbitrarily lowered to 37°C and humidification set at 'maximum' mark. This was also advised for the rest of the incubators in the ward as these were also being operated without functioning humidifier. To the amazement of the clinicians and nurses on duty who got involved in the frenzied situation, baby's condition dramatically reversed. Baby started to improve, gaining skin temperature after only 10 minutes and reaching 36.2°C in 35 minutes. This obvious wrong practice culture at UPTH at the time was to change forever as the science behind the drama of this event was explained to

**7.1.3 Further common errors** 

solutions. Some of these were:

relative to open radiant warmers. This hence contributed a great deal to the reoccurring cases of incubator overheat and neonatal hyperthermia for systems located very close to warmers. Causes to this were mistaken by attendants to be local to the incubators until these were practically demonstrated during the series of trainings to show how the incubators displayed 0% local heat output whilst the chamber temperature was steadily rising. The practice of incubator positioning in these Centres were hence modified, avoiding incubators to be located next or very close to the location of open radiant warmers.


#### **7.1.3 Further common errors**

532 Current Topics in Tropical Medicine

c. Phototherapy lamps: Neonatal jaundice is a widespread disease simultaneously treated whilst baby is being incubated. Therefore it was common to observe various kinds of phototherapy machines set over incubator canopies. Many of these often locallyproduced systems operated on conventional household fluorescent lighting tubes. These deliver very high intensity of heat across the canopy to the baby, uncontrollably overwarming the microenvironment. The operating heights of these systems were often not adjustable or professionally fixed to avoid the consequent induction of incubator overheat and neonatal hyperthermia. It was hence demonstrated that the use of scientifically recommended phototherapy light tubes would ensure effective outcome without compromising baby's thermal stability. Constructions to adjust the operating heights of the local systems were recommended and carried out, especially when lack of spare parts or poor financing was the cause of resorting to the make-shift systems. d. Nursery windows: There seemed to be no guiding rule for positioning an incubator in the nursery as some of these were placed directly behind windows. High heat intensity of sunlight gained easy direct access into the nursery through the glassy windows. This takes over the warming of the microenvironment through the transparent canopy. This uncontrollable external heating was often the cause of incubator overheats and hyperthermia during the day times. Incubators were therefore discouraged from being placed against glassy windows as much as possible within the nursery. Alternatively, appropriate window blinds that were able to minimise the solar radiation were fixed;

e. Nursery walls: Incubators were recommended to be placed no less than 45 centimetres from the nursery walls. This minimised the adverse effect of heat radiation from the overheated walls by the sun. The structural building pattern for new-born wards did not have any special consideration to minimise radiant heat storage. The observed poor designs easily made the walls work like a capacitor, being recharged by the sun from the outside during the day's heat. This retained the heat which was later discharged into the nursery, uncontrollably warming the incubators and babies in cots. This 'capacitance effect' was identified to be responsible for the common cases of periodic feverish attack on most babies in the ward. Though not yet reported in any medical literature, this experience is prevalent in all the Centres that participated in this study. This was observed to begin in many of the Centres at different times during the 'pm' periods of the day. This uncontrollable 'evening fever syndrome' would often confuse care-providers as they struggled to narrow the feverish event to any particular pathological or clinical cause. Most Centres were also observed to resort to using water to sponge babies to lower their temperatures. Others opened all incubator portholes and doors in attempt to lower temperatures thereby exposing neonates to the open

the location of open radiant warmers.

these could be chosen to be drawn when necessary.

environment and all kinds of air-borne infection vendors.

relative to open radiant warmers. This hence contributed a great deal to the reoccurring cases of incubator overheat and neonatal hyperthermia for systems located very close to warmers. Causes to this were mistaken by attendants to be local to the incubators until these were practically demonstrated during the series of trainings to show how the incubators displayed 0% local heat output whilst the chamber temperature was steadily rising. The practice of incubator positioning in these Centres were hence modified, avoiding incubators to be located next or very close to

There were other commonly identified errors that might have contributed negative impact on the general wellness of the neonates, impoverishing practice outcomes. These were studied as applied to the local setting, trying out and proffering some coincidental effective solutions. Some of these were:

a. Humidification: Adequate humidification of the microenvironment has been said to enhance effective neonatal incubation (Silverman et al., 1958, 1963). Humidifier assembly is therefore a basic feature of a standard infant incubator. In most incubator designs this is located beneath the mattress tray at the covered lower aspect of the machine. Humidifier fill-ports from which this could be refilled or drained of water are usually visibly located in front or at the sides of the incubator for easy access. The often harsh climatic weather brings about a very low atmospheric Relative Humidity (RH), as low as 20% in the northern parts of Nigeria. It could therefore be a serious clinical challenge to keep baby adequately hydrated during resuscitation and neonatal nursing if this facility was not properly applied. The practice of running an incubator with dry humidifiers whilst baby was inside was a common failure observed in all the Centres at the beginning of this project. Quick staff interviews revealed that some attendants were not aware of any humidification facilities in incubator designs. Many of those aware of this confessed never bothered or remembered to add water to operate this. Many practical incidents occurred in Centres that perfectly assisted as good traditional events to convey the reasons behind these inevitable scientific procedures.

On one occasion during a whole day consultation in one of the collaborating centres, a certain incubator was running at a set point of 35.5°C. It was on a sunny dry 'harmattan' period, described as a West African season of hot, dry and dusty trade wind that normally blows from the Sahara during the month of November, carrying large amounts of dusts out over the Atlantic Ocean (Wikipedia, 2011; Britannica Online, 2011). The afternoon of the said day was about 35.2°C outside air temperature, nursery room temperature and RH of 34°C and 22% respectively. About half an hour later the same incubator with the same 5-day old baby was observed to have been reset to 37°C. The set-point of this was again, another 1hour 45 minutes later seen to have been increased to 40°C. The system was a 'dial-knob control', mercury meniscus-guide thermometer, Narco Isolette Airshields incubator model C86 at the SCBU of UPTH Port-Harcourt. Upon the observer's request, baby's skin temperature at that instant was measured to be an extreme hypothermic 33.2°C. The baby was said to have been on a steady temperature decline over several hours and throughout the period the incubator set-point was being raised. There was the presence of obvious clinical confusion as the attending clinician seemed to have eliminated some possible reasons for this situation and expressed fears of losing the baby. This true situation recalled similar events that had been observed in other Centres across the country. The incubator humidifier was at this point checked and discovered to be completely dry. As this called for emergency, available 'clean' water was called for and introduced, incubator set-point arbitrarily lowered to 37°C and humidification set at 'maximum' mark. This was also advised for the rest of the incubators in the ward as these were also being operated without functioning humidifier. To the amazement of the clinicians and nurses on duty who got involved in the frenzied situation, baby's condition dramatically reversed. Baby started to improve, gaining skin temperature after only 10 minutes and reaching 36.2°C in 35 minutes. This obvious wrong practice culture at UPTH at the time was to change forever as the science behind the drama of this event was explained to the wider audience of the Unit's care-providers.

Neonatal Thermoneutrality in a Tropical Climate 535

iii. There is a potential risk of mistaken administration of the wrong medication to the

iv. This increases the dangers of possible fall through less secured incubator portholes as

This wrong approach was reported to be due to inadequacy of functional systems to independently support all needy babies, mostly blamed on poverty and poor funding. The seemingly moral reason of giving equal share to all needy babies as argued by some careproviders must be seriously weighed against the above consequences and for the sake of

This was the level 2 aspect of the 'Paediatrics Incubation Technique' course. The content of this aspect was drawn from lots of observed unscientific manner the incubators were operated during neonatal nursing. There was absolute lack of knowledge or any algorithm on how to re-regulate the incubator set-points based on the state of the neonate to achieve a physiological thermal equilibrium for the baby. Modern incubation techniques rely on algorithms that have been discussed in the literature stemming from the knowledge of 'central or core temperature' (tc) and 'peripheral temperature' (tp) of the neonate (Lyon and Oxyley, 2001). This technique requires the probing of the baby's skin temperature at two separate spots, notably the tc from baby's back, in-between the scapulae and the tp from the sole of baby's feet. This technique primarily measures a differential blood temperature (td) based on blood stream closest to the cardiac exit (chest level) and farthest travelled stream (foot level); td = ƒ(tc,tp). Instantaneous values of tc and tp are applied to proposed equations and situations to obtain the appropriate marginal values for upward or downward resetting of the set-point (Lyon and Oxyley, 2001). The proposed equations and resetting algorithms are theoretically sensible and supposed to be practically helpful for application in any setting of clinical practice. However, there were observed difficulties in its clinical usage in

wrong patient by the often over worked nurses on duty.

reported by Health Devices (2010).

Fig. 12. Two babies sharing a single incubator.

**7.2 Dynamics of neonatal thermoneutral control** 

clinical hygiene.

Etiology: The science of molecular equilibrium in an open environment expects molecular migration from an area of higher concentration to a lower one. This general law was also expected of a microenvironment with very low RH as in this real life example. As baby was incubated 'naked', i.e. without clothes or wrapping, the microenvironment was a continuum with the porous-skinned neonate. This meant that baby, having more water than the immediate surroundings, was dehydrating by losing water to a thirsty atmosphere as the microenvironment sought to reach its saturation. Unfortunately, this instigated another general law of basic physics that 'evaporation causes cooling' and manifested in the dropping of baby's skin temperature. The subsequent practice response of the increased incubator heating made things worse because the microenvironment became dryer and hungrier for more water thereby exacerbating the baby's condition. Hence, this practice was never going to improve baby's condition under the present circumstances. Introduction of water in the humidifier chambers quickly saturated the microenvironment's atmosphere, reversing the concentration gradient of water molecules in the continuum in favour of the baby. As baby gained moisture and headed for saturation, evaporation immediately seized and neonatal cooling stopped. Hence, baby began to regain thermal stability as it retained the moderately supplied warming. It was possible for other neonatal complications to result in baby's loss of temperature as this; however, practice experience in this climatic region showed that elimination of possible causes should start with a check on humidification.

A near opposite of this occurred during heavy torrential rainy season that was also common to this climate, around the months of June. This would leave pockets of surface puddles scattered all over the area due to poor drainage systems. The atmospheric humidity of nearby neonatal nurseries had been measured to reach full saturation affecting the functioning of certain models of incubator such as the Vickers models 59, 79 and 77. The humidity control mechanism of such systems did not allow full stoppage of moisture supply to the microenvironment, especially when the humidifier contained maximum water. The reluctance of the wider nursery atmosphere to accept escaping moisture from the incubator soon led to saturation and condensation within the inside walls of the canopy. The resulting misty covering, often referred to as 'steaming' by the care-providers, blinds the see-through canopy, confusing the less experienced workers. The direct effect of such overhumidification on the wellness of the neonate had not been fully studied within the present project, however, literature points to a possible neonatal discomfort and a poor overall outcome (de Carvalho et al., 2011). A coincidental practice remedy to this was to fully minimise the setting of the humidity control followed by a possible drastic reduction of the humidifier water level.


Etiology: The science of molecular equilibrium in an open environment expects molecular migration from an area of higher concentration to a lower one. This general law was also expected of a microenvironment with very low RH as in this real life example. As baby was incubated 'naked', i.e. without clothes or wrapping, the microenvironment was a continuum with the porous-skinned neonate. This meant that baby, having more water than the immediate surroundings, was dehydrating by losing water to a thirsty atmosphere as the microenvironment sought to reach its saturation. Unfortunately, this instigated another general law of basic physics that 'evaporation causes cooling' and manifested in the dropping of baby's skin temperature. The subsequent practice response of the increased incubator heating made things worse because the microenvironment became dryer and hungrier for more water thereby exacerbating the baby's condition. Hence, this practice was never going to improve baby's condition under the present circumstances. Introduction of water in the humidifier chambers quickly saturated the microenvironment's atmosphere, reversing the concentration gradient of water molecules in the continuum in favour of the baby. As baby gained moisture and headed for saturation, evaporation immediately seized and neonatal cooling stopped. Hence, baby began to regain thermal stability as it retained the moderately supplied warming. It was possible for other neonatal complications to result in baby's loss of temperature as this; however, practice experience in this climatic region showed that elimination of possible causes should start with a check on humidification. A near opposite of this occurred during heavy torrential rainy season that was also common to this climate, around the months of June. This would leave pockets of surface puddles scattered all over the area due to poor drainage systems. The atmospheric humidity of nearby neonatal nurseries had been measured to reach full saturation affecting the functioning of certain models of incubator such as the Vickers models 59, 79 and 77. The humidity control mechanism of such systems did not allow full stoppage of moisture supply to the microenvironment, especially when the humidifier contained maximum water. The reluctance of the wider nursery atmosphere to accept escaping moisture from the incubator soon led to saturation and condensation within the inside walls of the canopy. The resulting misty covering, often referred to as 'steaming' by the care-providers, blinds the see-through canopy, confusing the less experienced workers. The direct effect of such overhumidification on the wellness of the neonate had not been fully studied within the present project, however, literature points to a possible neonatal discomfort and a poor overall outcome (de Carvalho et al., 2011). A coincidental practice remedy to this was to fully minimise the setting of the humidity control followed by a possible drastic reduction of the

b. Incubator overcrowding: This term refers to the wrong practice of putting more than one baby into a single functioning incubator, a common method initially observed in all the collaborating SCBUs (Figure 12). There are a lot of imaginable consequences of this

i. This can easily lead to neonatal cross infection among the inmate babies and can

ii. This makes it absolutely difficult to regulate the incubator to suit all babies at the same time. Neonatal thermoneutrality is supposed to be a patient-specific application because thermal responses to the same environment can rapidly differ among neonates. This practice hence has the potential of saving one baby whilst adversely chocking the rest to death. Therefore this must be avoided where possible, even for a possible lower-risk

potentially cause the loss of all of them to the same infection outbreak.

humidifier water level.

practice on the general outcome.

carrying cohorts of a multiple-birth.


Fig. 12. Two babies sharing a single incubator.

This wrong approach was reported to be due to inadequacy of functional systems to independently support all needy babies, mostly blamed on poverty and poor funding. The seemingly moral reason of giving equal share to all needy babies as argued by some careproviders must be seriously weighed against the above consequences and for the sake of clinical hygiene.

#### **7.2 Dynamics of neonatal thermoneutral control**

This was the level 2 aspect of the 'Paediatrics Incubation Technique' course. The content of this aspect was drawn from lots of observed unscientific manner the incubators were operated during neonatal nursing. There was absolute lack of knowledge or any algorithm on how to re-regulate the incubator set-points based on the state of the neonate to achieve a physiological thermal equilibrium for the baby. Modern incubation techniques rely on algorithms that have been discussed in the literature stemming from the knowledge of 'central or core temperature' (tc) and 'peripheral temperature' (tp) of the neonate (Lyon and Oxyley, 2001). This technique requires the probing of the baby's skin temperature at two separate spots, notably the tc from baby's back, in-between the scapulae and the tp from the sole of baby's feet. This technique primarily measures a differential blood temperature (td) based on blood stream closest to the cardiac exit (chest level) and farthest travelled stream (foot level); td = ƒ(tc,tp). Instantaneous values of tc and tp are applied to proposed equations and situations to obtain the appropriate marginal values for upward or downward resetting of the set-point (Lyon and Oxyley, 2001). The proposed equations and resetting algorithms are theoretically sensible and supposed to be practically helpful for application in any setting of clinical practice. However, there were observed difficulties in its clinical usage in

Neonatal Thermoneutrality in a Tropical Climate 537

algorithms. These factors guided the development of the 'handy' approach currently being used in all the collaborating Centres. This was a simplified operational algorithm for achieving thermal stability in neonates. A recent follow-up study reported that over 80% of applying nurses believed that the usage of the technique was a boost to their practice

Principles: The handy approach might not be the best technique ever used but this was definitely better than the unscientific 'trial and error' methods observed at the inception of this project. This was developed by a long study that paid very close attention to the worst case scenarios such as the weakness of an 'extreme preterm baby' in an 'extremely harsh weather' of Nguru town, Nigeria. Nguru is a north-eastern ancient city of Nigeria notable with up to 47°C ambient temperatures during certain periods of the year. One of Nigeria's Federal Medical Centres (FMCnguru) was located in this grossly under-developed town. During the periods of these experiments approved by the FMCnguru's ethical committee, informed consents were obtained from mothers that were happy to permit the extended neonatal observations required for the study. The allowable standards for neonatal body temperature in most Nigerian neonatal centres including FMCnguru was a lower-upper limits of 36.5°C-37.4°C, measured from the axilla. Baby's thermal reaction to prevailing room temperatures were noted and compared to how volunteer healthy adults responded to the same harsh weather. Baby's skin temperatures behaved differently with those of the adults as these were observed to be always equal to the room temperature even when this increased to 43°C or decreased to 34°C whilst the adults maintained a constant range of 36.2°C-37°C all the times. This pattern was not exactly the same with higher birth weight and older postnatal age babies. Although such babies were all the same observed to be hyper- or hypothermic during these periods, their body temperatures were slightly lower or higher than room temperatures respectively. The local responsorial procedure at FMCnguru during high ambient heats was to sponge babies with water to minimise hyperthermia. Based on these findings, it was assumed that the neonate was very likely going to become hypothermic or hyperthermic depending on the relative overheating or under-heating of its host incubator. A neonate's thermal equilibrium set-point was therefore defined as the incubator air-mode set point that thermally stabilised a neonate to a body temperature of 36.5°C-37.4°C; incubator being appropriately humidified. The midpoint of this range was set at 36.9°C and used as a target for neonatal stabilisation. Therefore a general guiding principle for restabilising a deviating neonate was to increase or decrease incubator set-point value by an amount equal to baby's deviation from 36.9°C. This also demanded a compulsory recheck of baby's situation at intervals of no more than 30 minutes until baby re-stabilised. This was to allow enough time for the incubator to achieve the new set-point and for the baby to fully respond to the new changes, incorporating a possible neonatal cyclic temperature changes described by De La Fuente et al (2006). A disease process such as infection would be suspected and investigation initiated if baby's situation failed to respond positively to these changes after the 2nd cycle. It must however be first established that hyperthermia was not due to any domineering

external warming of the incubator as described in section 7.1.2 of this chapter.

and systematic management of a neonate in an incubator thus:

In quick easy-to-remember steps, the handy approach sets a good stage for the admission

a. Feeder Unit alerts SCBU: At the inception of this project the SCBU of most centres had poor or no existent system of pre-admission communication with feeder departments

enthusiasm [Amadi et al., 2010].

the present situation as most of the clinicians and nurses would require a standby calculator to work out the values of td each time the incubator was to be reset. This soon became more frequent than to be tolerated by the often too busy few staff on shift. This difficulty was made worse by the high volume of neonates that were usually on admission during the shifts. In probable recognition of this difficulty, modern STA incubators such as the Draeger Caleo system are designed with a similar algorithm inbuilt in them. Therefore it is possible to permanently affix the temperature probes on the designated portions of baby's skin for the incubator to automatically and appropriately reset the incubator when baby's condition changed. Unfortunately, over 97% of the incubators in use in the studied tropical region were of older generation of incubator systems, requiring manual application of this modern algorithm by the attendants. On-the-spot monitoring and study of how attendants operated the few STA systems was carried out. The findings however raised new concerns for the consequences of inaccurate application of the temperature probes.

#### **7.2.1 Dangers of 'skin mode' control**

The presence of some skin-mode servo-controlled modern incubators and open warmers should have been a welcomed advantage for the few Centres that had them. However, a sound knowledge of the working principles of such advanced systems was extremely crucial for their services to produce effective automatic neonatal thermoneutral control. Unfortunately, our initial practice observations in these Centres showed insufficient understanding of these as has been expressed in the literature (Perlstein et al., 1997; Dollberg et al., 1993; De La Fuente et al., 2006). Users knew little about the possibilities of true skin temperature attenuation as the thermistor probes placement was always improperly done. These reported their previous experience and fears when baby's temperatures were noticed to soar whilst incubator displayed a desired 36.5°C. These could not effectively interpret the reason and hence resorted to manual control via 'air' mode. It was reported that some instances produced serious consequences of neonatal hyperthermia before baby's ordeal could be discovered. Tunell (2004) pointed out the complexities of the 'servo control' technique and suggested the use of manual regulation during the first days after birth. The important steps and assiduous care required to ensure that such automatic machines did not pose any threat to the life of the babies might have been stressed in the working manuals or by a trained company representative. However lack of the presence of quality professionals from these companies does not allow this. Users are often left at the mercy of common market traders, with no professional understanding, who act as middlemen or vendors for the big companies in the developed countries.

#### **7.2.2 Handy approach**

Sophistications and cutting-edge technologies are good, especially in developed countries where expectations compare to the scientifically advanced culture. However, as relates to West Africans with a different culture of poverty, illiteracy and underdevelopment, how do we communicate this sophistication in a sustainable manner? The primary goal of any standard was to save the highest possible number of needy neonates within the limits of poor funding and manpower. A culturally compatible approach would therefore be (1) clinically functional (2) relatively non capital intensive (3) highly simplified, locallysustainable technology; operational techniques must be (1) easy-to-remember (2) simple for quick mental evaluation of control parameters (3) based on simple but functional

the present situation as most of the clinicians and nurses would require a standby calculator to work out the values of td each time the incubator was to be reset. This soon became more frequent than to be tolerated by the often too busy few staff on shift. This difficulty was made worse by the high volume of neonates that were usually on admission during the shifts. In probable recognition of this difficulty, modern STA incubators such as the Draeger Caleo system are designed with a similar algorithm inbuilt in them. Therefore it is possible to permanently affix the temperature probes on the designated portions of baby's skin for the incubator to automatically and appropriately reset the incubator when baby's condition changed. Unfortunately, over 97% of the incubators in use in the studied tropical region were of older generation of incubator systems, requiring manual application of this modern algorithm by the attendants. On-the-spot monitoring and study of how attendants operated the few STA systems was carried out. The findings however raised new concerns for the

The presence of some skin-mode servo-controlled modern incubators and open warmers should have been a welcomed advantage for the few Centres that had them. However, a sound knowledge of the working principles of such advanced systems was extremely crucial for their services to produce effective automatic neonatal thermoneutral control. Unfortunately, our initial practice observations in these Centres showed insufficient understanding of these as has been expressed in the literature (Perlstein et al., 1997; Dollberg et al., 1993; De La Fuente et al., 2006). Users knew little about the possibilities of true skin temperature attenuation as the thermistor probes placement was always improperly done. These reported their previous experience and fears when baby's temperatures were noticed to soar whilst incubator displayed a desired 36.5°C. These could not effectively interpret the reason and hence resorted to manual control via 'air' mode. It was reported that some instances produced serious consequences of neonatal hyperthermia before baby's ordeal could be discovered. Tunell (2004) pointed out the complexities of the 'servo control' technique and suggested the use of manual regulation during the first days after birth. The important steps and assiduous care required to ensure that such automatic machines did not pose any threat to the life of the babies might have been stressed in the working manuals or by a trained company representative. However lack of the presence of quality professionals from these companies does not allow this. Users are often left at the mercy of common market traders, with no professional understanding, who act as middlemen or vendors for

Sophistications and cutting-edge technologies are good, especially in developed countries where expectations compare to the scientifically advanced culture. However, as relates to West Africans with a different culture of poverty, illiteracy and underdevelopment, how do we communicate this sophistication in a sustainable manner? The primary goal of any standard was to save the highest possible number of needy neonates within the limits of poor funding and manpower. A culturally compatible approach would therefore be (1) clinically functional (2) relatively non capital intensive (3) highly simplified, locallysustainable technology; operational techniques must be (1) easy-to-remember (2) simple for quick mental evaluation of control parameters (3) based on simple but functional

consequences of inaccurate application of the temperature probes.

**7.2.1 Dangers of 'skin mode' control** 

the big companies in the developed countries.

**7.2.2 Handy approach** 

algorithms. These factors guided the development of the 'handy' approach currently being used in all the collaborating Centres. This was a simplified operational algorithm for achieving thermal stability in neonates. A recent follow-up study reported that over 80% of applying nurses believed that the usage of the technique was a boost to their practice enthusiasm [Amadi et al., 2010].

Principles: The handy approach might not be the best technique ever used but this was definitely better than the unscientific 'trial and error' methods observed at the inception of this project. This was developed by a long study that paid very close attention to the worst case scenarios such as the weakness of an 'extreme preterm baby' in an 'extremely harsh weather' of Nguru town, Nigeria. Nguru is a north-eastern ancient city of Nigeria notable with up to 47°C ambient temperatures during certain periods of the year. One of Nigeria's Federal Medical Centres (FMCnguru) was located in this grossly under-developed town. During the periods of these experiments approved by the FMCnguru's ethical committee, informed consents were obtained from mothers that were happy to permit the extended neonatal observations required for the study. The allowable standards for neonatal body temperature in most Nigerian neonatal centres including FMCnguru was a lower-upper limits of 36.5°C-37.4°C, measured from the axilla. Baby's thermal reaction to prevailing room temperatures were noted and compared to how volunteer healthy adults responded to the same harsh weather. Baby's skin temperatures behaved differently with those of the adults as these were observed to be always equal to the room temperature even when this increased to 43°C or decreased to 34°C whilst the adults maintained a constant range of 36.2°C-37°C all the times. This pattern was not exactly the same with higher birth weight and older postnatal age babies. Although such babies were all the same observed to be hyper- or hypothermic during these periods, their body temperatures were slightly lower or higher than room temperatures respectively. The local responsorial procedure at FMCnguru during high ambient heats was to sponge babies with water to minimise hyperthermia. Based on these findings, it was assumed that the neonate was very likely going to become hypothermic or hyperthermic depending on the relative overheating or under-heating of its host incubator. A neonate's thermal equilibrium set-point was therefore defined as the incubator air-mode set point that thermally stabilised a neonate to a body temperature of 36.5°C-37.4°C; incubator being appropriately humidified. The midpoint of this range was set at 36.9°C and used as a target for neonatal stabilisation. Therefore a general guiding principle for restabilising a deviating neonate was to increase or decrease incubator set-point value by an amount equal to baby's deviation from 36.9°C. This also demanded a compulsory recheck of baby's situation at intervals of no more than 30 minutes until baby re-stabilised. This was to allow enough time for the incubator to achieve the new set-point and for the baby to fully respond to the new changes, incorporating a possible neonatal cyclic temperature changes described by De La Fuente et al (2006). A disease process such as infection would be suspected and investigation initiated if baby's situation failed to respond positively to these changes after the 2nd cycle. It must however be first established that hyperthermia was not due to any domineering external warming of the incubator as described in section 7.1.2 of this chapter.

In quick easy-to-remember steps, the handy approach sets a good stage for the admission and systematic management of a neonate in an incubator thus:

a. Feeder Unit alerts SCBU: At the inception of this project the SCBU of most centres had poor or no existent system of pre-admission communication with feeder departments

Neonatal Thermoneutrality in a Tropical Climate 539

Fig. 13. Thermoneutral control flowchart

such as the labour-ward/theatre for the in-born babies and any available reception unit for referral neonates. Therefore there was always a routine of frenzy and chaotic emergencies at the sudden appearance of an unexpected baby with a group of panicking adults. The confusion often created distracted the normal work flow of attendance on the nursery inmates. A standard of 'feeder unit alert' was hence established mandating a pre-admission alert with expected arrival time (EAT). A fair knowledge of the EAT for a prospective inmate allowed the SCBU management to make adequate preparations and properly assign respective duties to the attending staff in good time for the arriving baby.


#### **8. Externally influenced deficiencies**

Gradual elimination of the various identified and rectified SCBU errors has steadily improved practice in the collaborating hospitals. However, there are other highly influential

b. Designation and readiness of the expected incubator: Following feeder unit alert, preparations and provisional designation of duties would start. The expectant incubator was the incubator chosen to host the expected baby upon arrival and after all the admission protocols and possible initial clinical routines has been completed on a resuscitation table. The steps for preparing the expectant incubator was: (1) Cleaning with a standardised disinfectant solution of a combination of antiseptic fluids and water, normally referred to as 'carbolisation'. The hood and matrass tray with all the interior of the canopy were thoroughly disinfected during this procedure. (2) Fresh cover spread was laid on the matrass and access portholes requiring replaceable covers were covered with fresh sterile blinds. (3) The humidifier that should have been completely drained of water after the last use was then re-filled with the appropriate incubation water. This was distilled water or in the alternative 'boiled and cooled' water. Reservation of the alternative incubator water was practiced provided this was done in a plastic container as the use of metal containers could generate rust and contaminate the water. (4) The incubator was then switched on. (5) Oxygen in-line supply was connected and tested for function. The supply was then turned off and kept on standby. (6) A provisional set-point for the incubator was fixed at the lower limit of the neonatal clinical range, i.e. 36.5°C. It was necessary to keep the provisional set-point closer to normal body temperature as the baby's point-of-admission temperature was yet unknown, whether this was going to be within acceptable range or not. (7) The incubator was then allowed to

c. Admission, resuscitation and stabilisation: Upon baby's arrival, all the normal protocols were carried out by the admitting clinician and baby handed over for neonatal nursing. d. Start of incubation: Initial thermal stabilisation started as soon as baby was introduced into the incubator. Baby's entrance temperature was checked and noted. Attendants would ensure that baby was securely place on the matrass and all the access doors and porthole covers were securely latched. Opening of all canopy access windows to work on the baby were kept at minimum. Baby's temperature was re-checked no later than 30 minutes after incubation began to confirm a possible re-adjustment of the incubator set-

e. Subsequent thermal re-stabilisation: This followed the procedure described earlier in this section to find a new equilibrium set-point whenever baby's temperature deviated from the allowable range. Figure (13) shows the guiding flowchart for this dynamics.

Gradual elimination of the various identified and rectified SCBU errors has steadily improved practice in the collaborating hospitals. However, there are other highly influential

run to achieve this set point in good time before baby's EAT.

point, to search for the thermal equilibrium set-point.

**8. Externally influenced deficiencies** 

in good time for the arriving baby.

such as the labour-ward/theatre for the in-born babies and any available reception unit for referral neonates. Therefore there was always a routine of frenzy and chaotic emergencies at the sudden appearance of an unexpected baby with a group of panicking adults. The confusion often created distracted the normal work flow of attendance on the nursery inmates. A standard of 'feeder unit alert' was hence established mandating a pre-admission alert with expected arrival time (EAT). A fair knowledge of the EAT for a prospective inmate allowed the SCBU management to make adequate preparations and properly assign respective duties to the attending staff

Fig. 13. Thermoneutral control flowchart

Neonatal Thermoneutrality in a Tropical Climate 541

2. Frequent shovelling of experienced nurses has militated against more excellent results from the Centres. It was a common routine in 80% (12/15) of the hospitals to re-shovel senior nurses among all the departments including the neonatal wards. This was entirely governed by the Nursing Department as a measure to allow nurses acquire experiences of how things worked in various departmental wards and happened as frequent as every two years or less. There might be good intentions for this; however, our findings from the present study showed that this was producing a serious counterproductive effect on the SCBU target. Nurses needed to stay in the Units for up to 18 months to fully understudy the new systems and procedures being implemented to positively alter the neonatal mortality as these ideas were completely new to most of them. During this period they would have attended the level 1 and perhaps level 2 of the Paediatric Incubation Technique courses. This has hence frequently created occasions when all three or four nurses on duty were completely untrained newcomers to the new procedures, hence slowing down the progress of the Unit. Minimizing the unequal shovelling of well-experienced and trained neonatal care-givers with inexperienced ones has therefore become a major issue to settle in all the hospitals. A proposal was drawn and negotiated with the various Nursing Administrative Departments of the hospitals to implement a 'neonatal 70-30' agenda whereby their normal shovelling exercise must ensure that 70% of SCBU qualified nurses were specialised or have at least 15 months experience and certified on the course levels 1 and 2. This excluded the numerous yet-to-qualify and short-staying nursing students that must work under full supervision of at least one experienced nurse on duty. This is presently working well and yielding good results in 6 of our 15 collaborating centres. Quantified in terms of incubation hours denied due to system breakdown, and comparing one calendar quarter before and after full implementation of the agenda, this has on the average saved 81% (10,886.4 hours) of the total incubation time lost to system breakdown before implementation. It is evident from these 6 Centres that frequency of system breakdown due to mishandling has dropped, thereby reducing maintenance

3. Compulsory theoretical course (requiring a pass in an end of course test) was initiated and currently being implemented by some of the Nursing Administrative Departments as a prerequisite for posting a new nurse to the SCBU. In the new guideline, resident doctors that were specialising on new-born care were advised to complete the 2 levels

The conclusions being drawn from the entire project suggest that culture and climate were major forces to conquer in order to realise the MDG target on neonatal mortality. Our on-

other babies.

costs and providing for more babies to save.

of the elective course.

**9. Conquering the climate** 

clinically unacceptable at more than a patient-to-nurse ratio of 5. This mark is frequently being exceeded, hence calling for urgent review on nurses' deployment to the Units. This has also led to some preventable loses to apnoea as many attacks were not detected early enough to commence resuscitation. It therefore became important to propose and implement the provision of integral digital apnoea monitors on all incubators and cots. These raised audible alarms during attacks, enabling the few nurses on duty to be aware of the points of emergency even whilst they were busy with

external factors that are possibly contributing to lower practice outcome. This category of problems might be beyond the ability of immediate SCBU to correct, hence required the cooperation of the higher institutional management to resolve.

#### **8.1 Epileptic power supply**

Inside a functioning incubator and yet wrapped! One would expect that a well-documented and known practice of nursing neonates naked inside a functional incubator would not need to be overemphasised anywhere in the world (Lyon, 2004). However this was initially observed to be one of the wrong incubator applications in the collaborating Centres. Some of the users showed evidence of this knowledge but could not stop because they needed to protect baby from cold stress that sets in upon power failure. However, there were no clear reasons given for this practice during the periods when the system functioned. Uninformed and indiscriminate electric power outages that last for several hours are common to West African countries. Unfortunately, very sensitive units as the SCBU of hospitals suffer from this problem at which point the incubator suddenly fails exposing baby to danger of cold stress and hypothermia. The use of 'standby' generators is widespread but this still does not effectively cover up this deficiency in most Centres. There were also reports of incubator damages due to power surges from malfunctioning generators. Full-sine-wave power inverting technology was therefore considered an option to investigate. A full-sine-wave power inverter system with a cascade of sealed batteries function to convert the DC power of the batteries to AC power required to operate the incubators upon conventional mains power failure. This operates with an automatic power change over system that allows it to stay 'on' to recharge the batteries when mains AC supply is available and switches incubators to draw inverted battery power when mains supply fails. A 5KVA system installed with up to 8 pieces of '12 volts 200 amp-hour' batteries was found to be able to continuously support up to 11 incubators simultaneously for up to 10 hours. This was enough to provide uninterrupted power supply to the most critical neonates in the few Units that could afford to implement this, hence minimising the effect of operating power deficiencies.

### **8.2 Inadequate nursing staff**

The sudden increase in the number of patients seeking to be admitted for neonatal care as reported by Amadi et al (2010) meant that more hands were needed to cope with the present volume of work in each participating SCBU. The Units were hence faced with the lack of adequate manpower and challenges to retain the already experienced ones on employment. External issues of government policies on employment and local administration of the Nursing Department in these hospitals were contributing factors to the challenges. The direct effect of this to the present project was the resulting inability to effectively offer adequate care using all the developed techniques and procedures in this project. Some of these challenges as enumerated below are currently being tackled through engaging the various hospital managements to demonstrate the importance of discriminate staffing of the new-born Units.

1. Maintaining a sizable number of SCBU nursing staff as compared to adult or youngadult wards. Most of the SCBUs are currently having up to 40 inmates on admission at the same time with as few as 3 nursing staff to look after them during some rota shifts. Our current study shows that the quality of attention offered to these babies becomes

external factors that are possibly contributing to lower practice outcome. This category of problems might be beyond the ability of immediate SCBU to correct, hence required the

Inside a functioning incubator and yet wrapped! One would expect that a well-documented and known practice of nursing neonates naked inside a functional incubator would not need to be overemphasised anywhere in the world (Lyon, 2004). However this was initially observed to be one of the wrong incubator applications in the collaborating Centres. Some of the users showed evidence of this knowledge but could not stop because they needed to protect baby from cold stress that sets in upon power failure. However, there were no clear reasons given for this practice during the periods when the system functioned. Uninformed and indiscriminate electric power outages that last for several hours are common to West African countries. Unfortunately, very sensitive units as the SCBU of hospitals suffer from this problem at which point the incubator suddenly fails exposing baby to danger of cold stress and hypothermia. The use of 'standby' generators is widespread but this still does not effectively cover up this deficiency in most Centres. There were also reports of incubator damages due to power surges from malfunctioning generators. Full-sine-wave power inverting technology was therefore considered an option to investigate. A full-sine-wave power inverter system with a cascade of sealed batteries function to convert the DC power of the batteries to AC power required to operate the incubators upon conventional mains power failure. This operates with an automatic power change over system that allows it to stay 'on' to recharge the batteries when mains AC supply is available and switches incubators to draw inverted battery power when mains supply fails. A 5KVA system installed with up to 8 pieces of '12 volts 200 amp-hour' batteries was found to be able to continuously support up to 11 incubators simultaneously for up to 10 hours. This was enough to provide uninterrupted power supply to the most critical neonates in the few Units that could afford to implement this, hence minimising the effect of operating power

The sudden increase in the number of patients seeking to be admitted for neonatal care as reported by Amadi et al (2010) meant that more hands were needed to cope with the present volume of work in each participating SCBU. The Units were hence faced with the lack of adequate manpower and challenges to retain the already experienced ones on employment. External issues of government policies on employment and local administration of the Nursing Department in these hospitals were contributing factors to the challenges. The direct effect of this to the present project was the resulting inability to effectively offer adequate care using all the developed techniques and procedures in this project. Some of these challenges as enumerated below are currently being tackled through engaging the various hospital managements to demonstrate the importance of

1. Maintaining a sizable number of SCBU nursing staff as compared to adult or youngadult wards. Most of the SCBUs are currently having up to 40 inmates on admission at the same time with as few as 3 nursing staff to look after them during some rota shifts. Our current study shows that the quality of attention offered to these babies becomes

cooperation of the higher institutional management to resolve.

**8.1 Epileptic power supply** 

deficiencies.

**8.2 Inadequate nursing staff** 

discriminate staffing of the new-born Units.

clinically unacceptable at more than a patient-to-nurse ratio of 5. This mark is frequently being exceeded, hence calling for urgent review on nurses' deployment to the Units. This has also led to some preventable loses to apnoea as many attacks were not detected early enough to commence resuscitation. It therefore became important to propose and implement the provision of integral digital apnoea monitors on all incubators and cots. These raised audible alarms during attacks, enabling the few nurses on duty to be aware of the points of emergency even whilst they were busy with other babies.


#### **9. Conquering the climate**

The conclusions being drawn from the entire project suggest that culture and climate were major forces to conquer in order to realise the MDG target on neonatal mortality. Our on-

Neonatal Thermoneutrality in a Tropical Climate 543

hospitals to move from a condition of having no functional incubator to having 15 or more within a short period of time. However, the restoration of proper usage of the incubator to nurse babies exposed the knowledge deficiency of care-providers in incubator application. It was evident that immediate cultural setting and the quality of care with the provided incubator were capable of promoting the spread of diseases among the neonates. Hence, this project extended to the study and proposition of corrective procedures that were easily

The implementation of the various ideas developed in this study has brought cultural dimension to tweak already established practice facts. This was another way of using the local language to communicate the medicine of neonatal thermocontrol in this tropical region. The methods were easily acceptable and adaptable and seemed to have led to

Overall, the entire project has achieved significant success across the landscape of Nigeria among all the applying hospitals as published by Amadi et al., 2010. This study was unable to explicitly isolate successes due to the provision of incubators as an initial project and the duo of training courses and modified thermoneutral algorithm as an extended application. These were applied simultaneously. It is commonly acknowledged among hospital administrators in Nigeria that the advent of RIT and the subsequent thermocontrol procedures represented a significant contribution to Nigeria's improving neonatal healthcare delivery (CCEFTHI, 2007). Further investigations are still continuing on how the climate is impacting and militating against overall outcome. We hope to fully define this

and proffer solutions on how to ameliorate this and boost survival rate in the region.

are worthy of mention are Jonathan Azubuike, Olugbenga Mokuolu and Peter Onyeri.

The support of all the Chief Medical Directors of the hospitals that have so far collaborated is hereby acknowledged. Some of these were outstanding in their cooperation at various segments of this project. These were Akin Osibogun, Bello Kawuwa, Uriah Etawo, Dan Iya, Sulyman Kuranga, Abulhameed Dutse and Eugene Okpere. Other individuals whose supportive roles

Amadi, H.O.; Azubuike, J.C.; Etawo, U.S.; Offiong, U.R.; Ezeaka, C.; Eyinade, O.; Adimora,

CCEFTHI. (July 2007). Communiqué issued at the end of the 58th quarterly meeting of the

Centre for Maternal And Child Enquiry. (2010). Overview of perinatal and neonatal

15, CMACE, ISBN 978-0-9558055-3-0, London, United Kingdom

*Paeditr*. Vol.2010, Article ID 269293, 7 pages doi:10.1155/2010/269293 Amadi, H.O.; Mokuolu, O.; Adimora, G.N.; Pam, S.D.; Etawo, U.S.; Ohadugha, C.O. &

(September 2007), pp. 207-214, ISSN 0272-4936

Teaching Hospital Nigeria, 16.02.2010, Availbale from ccefth.org/document/communique\_53rd\_meeting.pdf

G.N.; Osibogun, A.A.; Ibeziako, N.; Iroha, E.O.; Dutse, A.I.; Chukwu, C.O.; Okpere, E.E.; Kawuwa, M.B.; El-Nafaty, A.U.; Kuranga, S.A. & Mokuolu, O.A. (2010). The impact of recycled neonatal incubators in Nigeria: a 6-year follow-up study. *Int J* 

Adesiyun, O.O. (2007). Digitally recycled incubators: better economic alternatives to modern systems in low-income countries. *Annals Tropical Paeditr*, Vol.27, No.3,

Committee of Chief Executives of Federal Tertiary Hospitals, University of Benin

mortality in the UK. In: *Perinatal mortality 2008: United Kingdom,* J. Dorling (Ed.), 9-

applicable to the people.

**11. Acknowledgement** 

**12. References** 

improved outcome among all participating Centres.

going studies at the University of Ilorin Teaching Hospital and the Federal Medical Nguru have identified a number of parameters that could be altered to reduce the negative impact of climate on new-born morbidity. We studied all the nursery buildings at our disposal, these being all distinctively different from each other in design, structure and relative location. The impact of high sunlight intensity as a source of uncontrollable external warming of the incubator was used to identify the parameters that were aiding or preventing the harsh climate. Incubators functioned well, adequately maintaining their set points, when these had absolute control of the warming of their microenvironments. This occurred during cooler periods of the day or the night when the nursery ambient temperature dropped well below 30°C. However this often changed during the day when the macroenvironment of the inside of the nursery became excessively hot due to radiation from the sun. We therefore hypothesised that minimising the outside influence of climatic heat on the nursery would enhance effective thermoneutral control and achieve better success rates. It is understood that the use of air-conditioners could artificially cool the nursery wards to counter room warming during the day. This was tried but not considered a sustainable solution as the high frequency of breakdowns without immediate repair or replacement often sent the Unit back to the same ugly situation. Again, this was also noticed to present threats of hypothermia on the other full-term babies in cots as these shared the open nurseries with the incubator babies. It therefore became necessary to find enabling parameters that could be altered to attain the best naturally cooled condition in the nursery. Parameters were preliminarily identified by comparing nursery warming in any two Centres that have direct opposite circumstance. Parameters currently being studied in details were:


### **10. Conclusion**

This project has been an individual coordinating effort in a drive to lower neonatal mortality rate, restore nursing enthusiasm and patient- carer's confidence in the tropical region of West African state of Nigeria. The project originally set out to find alternative solution to the provision of functional incubators to re-equip the referral hospitals in the country. This began in each of the participated hospital at a time when most of these had no functional incubator. The development and application of the idea of Recycled Incubator Technique (RIT) helped to realise the initial objective as this has made it possible for some of the

going studies at the University of Ilorin Teaching Hospital and the Federal Medical Nguru have identified a number of parameters that could be altered to reduce the negative impact of climate on new-born morbidity. We studied all the nursery buildings at our disposal, these being all distinctively different from each other in design, structure and relative location. The impact of high sunlight intensity as a source of uncontrollable external warming of the incubator was used to identify the parameters that were aiding or preventing the harsh climate. Incubators functioned well, adequately maintaining their set points, when these had absolute control of the warming of their microenvironments. This occurred during cooler periods of the day or the night when the nursery ambient temperature dropped well below 30°C. However this often changed during the day when the macroenvironment of the inside of the nursery became excessively hot due to radiation from the sun. We therefore hypothesised that minimising the outside influence of climatic heat on the nursery would enhance effective thermoneutral control and achieve better success rates. It is understood that the use of air-conditioners could artificially cool the nursery wards to counter room warming during the day. This was tried but not considered a sustainable solution as the high frequency of breakdowns without immediate repair or replacement often sent the Unit back to the same ugly situation. Again, this was also noticed to present threats of hypothermia on the other full-term babies in cots as these shared the open nurseries with the incubator babies. It therefore became necessary to find enabling parameters that could be altered to attain the best naturally cooled condition in the nursery. Parameters were preliminarily identified by comparing nursery warming in any two Centres that have direct opposite

1. Siting of the nursery building within hospital complex. Nurseries that were cited as the eastern-most building among the rest in the hospital complex and without any other

3. Structural design of nursery outside wall. Nursery designs that provided the main ward at the middle of other flanking rooms, stores or side labs seemed cooler than designs where the wall of the main ward was directly next to the outside. This suggests that some kind of wall lagging designs might provide the needed natural cooling for

4. Floor to roof height of nursery. Nurseries with higher roofs from the floor level seemed

5. Nursery floor level, nursery window height and nursery window blinding material were also identified to seem to create some differences and hence also being studied.

This project has been an individual coordinating effort in a drive to lower neonatal mortality rate, restore nursing enthusiasm and patient- carer's confidence in the tropical region of West African state of Nigeria. The project originally set out to find alternative solution to the provision of functional incubators to re-equip the referral hospitals in the country. This began in each of the participated hospital at a time when most of these had no functional incubator. The development and application of the idea of Recycled Incubator Technique (RIT) helped to realise the initial objective as this has made it possible for some of the

immediate building east to this seemed to be hotter than those elsewhere cited. 2. Locating nursery within building structure. Nursery apartments that were located on the topmost floor of a multi-storey building seemed hotter than those located on the

circumstance. Parameters currently being studied in details were:

ground floor.

**10. Conclusion** 

the macro-environment.

cooler than the shorter ones.

hospitals to move from a condition of having no functional incubator to having 15 or more within a short period of time. However, the restoration of proper usage of the incubator to nurse babies exposed the knowledge deficiency of care-providers in incubator application. It was evident that immediate cultural setting and the quality of care with the provided incubator were capable of promoting the spread of diseases among the neonates. Hence, this project extended to the study and proposition of corrective procedures that were easily applicable to the people.

The implementation of the various ideas developed in this study has brought cultural dimension to tweak already established practice facts. This was another way of using the local language to communicate the medicine of neonatal thermocontrol in this tropical region. The methods were easily acceptable and adaptable and seemed to have led to improved outcome among all participating Centres.

Overall, the entire project has achieved significant success across the landscape of Nigeria among all the applying hospitals as published by Amadi et al., 2010. This study was unable to explicitly isolate successes due to the provision of incubators as an initial project and the duo of training courses and modified thermoneutral algorithm as an extended application. These were applied simultaneously. It is commonly acknowledged among hospital administrators in Nigeria that the advent of RIT and the subsequent thermocontrol procedures represented a significant contribution to Nigeria's improving neonatal healthcare delivery (CCEFTHI, 2007). Further investigations are still continuing on how the climate is impacting and militating against overall outcome. We hope to fully define this and proffer solutions on how to ameliorate this and boost survival rate in the region.
