CBL Neonatal Energy Triangle

CBL: Case Study 3-NLS

The Neonatal Energy Triangle

Start

Section 1: Introcuction

What is the Neonatal Energy Triangle?

The neonatal energy triangle provides a framework which presents a logical yet integrated physiological overview of the three most common difficulties encountered by the baby in this period. These are the 3Hs; hypothermia, hypoglycaemia and hypoxia.

(Aylott, 2006)

The Triangle

The above picture is how the Neonatal Energy Triangle is often presented and shows the 3 H's. .

The 3Hs can each have detrimental physiological effects independently. However, the consequential or accumulating impact of all three, unless interrupted can lead to serious developmental impairment or death (Wen et al, 2004).

Provides Structure

In a review completed by a paediatric nurse surrounding the neonatal energy triangle, (Aylott, 2006), it was identified that the neonatal energy triangle provides a beneficial structure and framework which can be easily referenced to and recalled in emergency situations. By providing a logical yet integrated physiological overview, this can improves coherence or practitioners, and therefore overall neonatal outcomes.

However, further research is required in this area as there is not a lot of evidence available to support whether neonatal energy triangles are useful or not.

Section 2

Metabolic Adaptation

To Extra-Uterine Life

'Normal' Metabolic Adaptation

After cord clamping, the neonate's blood glucose concentration falls reaching its lowest point at one to two hours. At this point, glycogen stores are depleted and gluconeogenesis commences so that even though glucose concentration is low, the brain is not fuel deficient. The neonate defends itself against hypoglycaemia by decreasing insulin production while simultaneously increasing glucagon, epinephrine, growth hormone and cortisol secretion. These hormones work together as counter-regulatory hormones (Sunehag and Haymond 2002). They oppose the effect of insulin, this comes initially from the breakdown of fatty stores due to lower insulin and decreased glucagon.

At birth the neonates' glucose level is 70 per cent of the mother's serum glucose (Cornhlath and Ichord 2000). With the loss of continuous maternal glucose source (via the placenta), the neonate must assume control of glucose homeostasis and maintain it through the intermittent feed cycle postnatally, while still ensuring an adequate supply of fuel for the brain and other organs. This metabolic adaptation at birth involves mobilisation of glycogen stores (glycogenolysis), hepatic synthesis of glucose from substrates (gluconeogenesis) and production of alternative cerebral energy.

Metabolic Adaptation Continued...

During hypoglycaemia other substrates such as ketone bodies, lactate, glycerol and amino acids can also be converted by glycolysis, serving as an energy source for the brain. The neonate, therefore, gradually mobilises glucose to meet energy requirements by secreting glucagon suppressing insulin release which causes blood glucose levels to rise physiologically at three to four hours of age (Hawdon et al 2000).

Transient neonatal hypoglycaemia is physiologically self-limiting in healthy term newborns as they adapt to extrauterine life after abrupt cessation of the maternal glucose supply at birth.

Section 3

Thermo-regulation

+ Respiratory Adaptation

Thermoregulation

Thermal and glycaemic stability, together with effortless respiration, are critical physiological functions that are closely related. Body temperature, glucose and oxygen levels are physiological variables that are precisely controlled by the body in health. Just as adequate oxygen and glucose are essential to cellular metabolism, appropriate body temperature is critical to the function of enzymatic systems regulating cellular function (Thomas 1994). Neonatal hypoglycaemia , hypothermia and hypoxia are not pathological conditions themselves. They are features of illness or a failure to adapt from the fetal state of continuous transplacental glucose, warmth and oxygen consumption to the extrauterine environment and pattern of intermittent nutrient supply. These variables are closely inter-related to the successful transition from uterine to extra-uterine life and survival.

There are four basic mechanisms through which heat is transferred from the newborn to the environment.

20.00 h

These include radiation, conduction, convection and evaporation.

20.00 h

All may potentially contribute to an unstable thermal environment for the newborn.

20.04 h

(Soll, 2008)

20.20 h

Thermoregulation Continued...

The infant is characteristically born into a wet, cold and hostile environment. Rapid evironmental cooling occurs with body temperatures dropping, depending on gestational age and the environmental factors encountered (Rutter and Hull 1979). The normal thermoregulatory response of neonates to cold stress comprises increased involuntary muscular activity, vasoconstriction and nonshivering thermogenesis. (Saner and Visser 1984). Shivering is not active in the human newborn thermal response. Healthy term babies are able to maintain an increased metabolic rate of heat production from minutes to a few hours depending on environmental conditions. Thereafter, energy stores become depleted and hypothermia rapidly ensues (Ellis 2005).

Fetal mechanisms for the cold stress response are not active in-utero as the mother constitutes a massive heat reservoir. The baby's core temperature is generally 0.5°C above the mother's core temperature and his/her peripheral and core temperatures are almost exactly the same (Rutter and Hull 1979). The fetus, therefore, does not thermoregulate.

Video

ThermoregulationContinued...

+ info

Section 4

The 3 H's

Zooming IN...

Hypothermia

Hypoglyceamia

Hypoxia

Neonatal hypothermia is defined as an abnormal thermal state in which the newborn's body temperature drops below 36.5 °C (97.7 °F). Progressive reduction in body temperature leads to adverse clinical effects ranging from mild metabolic stress to death.While there are various causes for the initial dysfunction in thermoregulation, the neonatal population is affected primarily by four mechanisms of hypothermia: radiation, conduction, convection and evaporation (Soll, 2008).

Hypoglycemia is when the level of sugar (glucose) in the blood is too low. Glucose is the main source of fuel for the brain and the body. In a newborn baby, low blood sugar can happen for many reasons, such as: poor nutrition for the mother during pregnancy, making too much insulin because the mother has poorly controlled diabetes, incompatible blood types of mother and baby (severe hemolytic disease of the newborn), more insulin in the baby's stool for other reasons, such as a tumor of the pancreas, birth defects, congenital metabolic diseases or hormone deficiencies. Not enough oxygen at birth (birth asphyxia), liver disease and infection.(Abramowski & Hamdan, 2020).

Hypoxia is the most common cause of death and disability in neonates, and is often associated with persistent motor, sensory, and cognitive impairment. Hypoxia relates to a lack of oxygen to a baby before, during, or following birth. A lack of oxygen to a baby before, during, or following birth. Lack of oxygen can cause serious birth injuries (Millar et al., 2017).

Short Video:

Hypothermia

Continued...

Activity Time

I am going to hand out pieces of A3 paper, each team will be allocted one of the 3 H's, and will create a mind map on this topic. Whichever team can write down the most information from the slides, video AND their own research... will win a prize!

3 Minute Timer:

Your time starts now!

.Good Luck!

Section 5

The Case:

Aoife O'Malley- Shoulder Dystocia

Aoife's baby was born in poor condition.

Following NLS, baby Orlaith was intubated and taken to NICU. Cooling was immediately commenced. The following day, tests confirmed baby Orlath had no brain activity. Care is withdrawn that evening and baby Orlaith passed away in skin to skin with Aoife, who was alone.

The Case:

A salutogenic approach should be obtained throughout Aoife's care, ensuring that all hollistic factors are taken into account. For this particular LO, it should have been explained to Aoife about keeping baby warm at birth and the reasons why, referring to the neonatal energy triangle, the methods of heat loss and the impacts they can have as expalined in this presentation, to encourage a sense of meaningfulness.

At birth, it should have been ensured that baby Orlaith was kept warm and dry to reduce methods of heat loss such as: radiation, conduction, convection and evaporation, as well as ensuring that blood sugars remain stable. These measures are to reduce the risk of the 3 H's: Hypothermia, hypoxia and hypoglyceamia.

We should validate Aoife's emotions, ensure she fully understands the events that have occurred and ensure she has plenty of support whilst in hospital and for when she returns home.

We should ask Aoife if she has any particular wishes for her and her baby and these should be taken into account and granted as best as possible.

Thank you!

Abramowski, A., & Hamdan, A. H. (2020). Neonatal Hypoglycemia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537105/ Aylott, M. (2006a). The neonatal energy triangle part 1: metabolic adaptation. Journals.rcni.com. https://journals.rcni.com/paediatric-nursing/the-neonatal-energy-triangle-part-1-metabolic-adaptation-paed.18.6.38.s30 Aylott, M. (2006b, July). The neonatal energy triangle Part 1: Metabolic - ProQuest. Www.proquest.com. https://www.proquest.com/docview/218911311/FD27E318ACC6407DPQ/1?accountid=17233 Cornblath, M., Hawdon, J. M., Williams, A. F., Aynsley-Green, A., Ward-Platt, M. P., Schwartz, R., & Kalhan, S. C. (2000). Controversies Regarding Definition of Neonatal Hypoglycemia: Suggested Operational Thresholds. Pediatrics, 105(5), 1141–1145. https://doi.org/10.1542/peds.105.5.1141 Cornblath, M., & Ichord, R. (2000). Hypoglycemia in the neonate. Seminars in Perinatology, 24(2), 136–149. https://doi.org/10.1053/sp.2000.6364 Hewitt, V., Watts, R., Robertson, J., & Haddow, G. (2005). Nursing and midwifery management of hypoglycaemia in healthy term neonates. International Journal of Evidence-Based Healthcare, 3(7), 169–205. https://doi.org/10.1097/01258363-200508000-00001 Millar, L. J., Shi, L., Hoerder-Suabedissen, A., & Molnár, Z. (2017). Neonatal Hypoxia Ischaemia: Mechanisms, Models, and Therapeutic Challenges. Frontiers in Cellular Neuroscience, 11. https://doi.org/10.3389/fncel.2017.00078 Soll, R. F. (2008a). Heat loss prevention in neonates. Journal of Perinatology, 28(S1), S57–S59. https://doi.org/10.1038/jp.2008.51 Soll, R. F. (2008b). Heat loss prevention in neonates. Journal of Perinatology, 28(S1), S57–S59. https://doi.org/10.1038/jp.2008.51 Sunehag, A. L., & Haymond, M. W. (2002). Glucose extremes in newborn infants. Clinics in Perinatology, 29(2), 245–260. https://doi.org/10.1016/s0095-5108(02)00006-4 Thomas, K. (1994). Thermoregulation in neonates. Neonatal Network. Neonatal Network, 15–22. Wen, S. W., Smith, G., Yang, Q., & Walker, M. (2004). Epidemiology of preterm birth and neonatal outcome. Seminars in Fetal and Neonatal Medicine, 9(6), 429–435. https://doi.org/10.1016/j.siny.2004.04.002

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