T2.

1
MetroHealth Medical Center
Pediatric Nursing Service
Perinatal Nursing Service

THERMAL REGULATION (INFANT) PROTOCOL


PURPOSE: To outline the nursing role in the management of thermal regulation in
infants.

LEVEL: Interdependent (* requires physician order)

SUPPORTIVE DATA: If an infant requires an isolette to support thermal regulation, the
attached chart for neutral thermal regulation should be used as a guide
for both maintenance of and then weaning from an isolette. The chart
was developed for diaper clad infants. Use of clothing should be delayed
until the weaning process has begun, with the exception of a hat due to
the large heat loss. For term or small-for-gestation age infants, this can
be used as a guide, however individualization is required. For all infants,
the pattern of temperature (axillary or skin) in relation to heat required
must be critically evaluated to determine if temperature instability exists,
or if weaning is therapeutic; as the goal is for the infant to maintain
temperatures and growth using the least amount of energy. Infants
temperatures maintained at 36.4 37.2C axillary and/or 36.2-37.0C
skin should allow for minimal expenditure of energy. For sick or
premature infants, weaning should follow NTE chart over the first four
weeks, unless a collaborative decision between nursing and medicine
has determined it appropriate to deviate from this method. Criteria for
active weaning usually includes: 1400 1500 gm., 32-33 weeks
gestation, and tolerating enteral feeds with sustained adequate growth
pattern. Exceptions to this may include older infants or chronically ill
infants unable to be fed enterally and/or require intense, frequent
pulmonary toilette.
Radiant warmers are also used for ill neonates. They provide a
means of easier access to the infant during admission/procedures/critical
phase. Radiant warmers should be prewarmed when possible. Once
infant is on radiant warmer, skin control should be used with initial set
point between 36.5 37.2C. Manual mode should be used only when
caregiver is present during procedures.

NURSING INTERVENTIONS:

Initial Assessment: 1. Assess infant temperature per Routine Care Protocol and include
isolette temperature, if applicable. If every 2 hours is required
and infant has temperature probe in place, a skin probe reading
should be noted every 2 hours with axillary reading every four.

2. Identify environmental conditions that would affect thermal
regulation. Minimize effect when able (e.g. shut curtains, move
from drafty areas) or incorporate in development of individualized
plan if needed to maintain temperature.

3. Assess temperatures every 30 minutes after any change in
isolette temperature, mode of heat regulation, amount of clothing
changed, etc.

Thermal Regulation (Infant) Protocol T2.2
Isolette 4. Pre-warm isolette prior to use, using air mode default temperature
of 35C or adjust to appropriate NTE range according to weight (if
known). Regulate isolette temperature for preterm infants using
skin control with initial set point of 36.5C until weaning or unless
individualization is needed. If using air control, set point per NTE
chart or as individualized. If individualization is required, it should
be reflected in the plan of care.

5. Maintain skin temperature probe during use of air control heat
mode for monitoring skin temperature readings. Place skin temp
probe over abdominal areas. Avoid bony prominences, do not
place probe where infant will lie on sensors. Pre-warm radiant
warmer in manual mode. Change radiant warmer to skin control
with initial set point of 36.5C after placing skin probe on infant.

Radiant warmer
Humidity 6. Use humidity for infants less than 1000 gm, less than 30 weeks
gestation, and/or premature infants less than 10 days old, see
attached algorithm.

Weaning: * 7. Follow the NTE charts gradual and natural, weekly weaning
pattern. Individualization may occur in collaboration with
physician/practitioner for unique weaning needs of infants,
reflected in PIP note and/or plan of care.

8. Decrease isolette temperature in increments of 0.5-1.0C for no
more than 2C in the first 24 hours of active weaning and no more
than 1C in subsequent 24-hour periods if axillary temperature
greater than 36.4C.

9. Add clothing progressively during weaning process, T-shirt and
booties, sleeper, blankets for bundling and to lie over top of
bundled infant.

10. Postpone weaning for 24 hours if axillary temperature is less than
36.4C at two consecutive readings.

11. Place infant in open crib/bassinet when infants temperature is
stable for 8 hours in isolette temperature of 26-27C.

12. Monitor daily growth pattern and assess in relation to weaning
process.

Warming: 13. Adjust isolette temperature 1 1.5C higher than infants
temperature, or assure/place in NTE range, or use skin control
mode. Assess infant temperature every 30 minutes, continuing to
adjust isolette temperature, until infants axillary temperature is
within the range of 36.4 37.2C.

14. Assess need for use of additional warming devices for short-term
use if temperature continues to be problematic: warm packs
wrapped in cloth, heat lamps; long term intervention to include
use of k-pad.

Hyperthermia: 15. Assess if isolette temperature is within NTE range. If higher,
decrease to appropriate range by reducing isolette temperature
by 1-1.5C. Assess temperature every 30 minutes, adjusting
isolette temperature as needed until infants axillary temperature
is within the range of 36.4 37.2C. Consider use of skin control.

Thermal Regulation (Infant) Protocol T2.3
Phototherapy: 16. Assess infant temperature every 30 minutes after initiation of
phototherapy and adjust isolette temperature as needed until
infants axillary temperature is within the range of 36.4 37.2C.
Consider use of skin control.

Patient/Significant Other
Instruction:
17. Explain temperature regulation and individualized interventions to
parent(s).

18. Offer support and reeducate if infant has instability or difficulty in
weaning challenge.

Reportable conditions: 19. Notify physician/practitioner of temperature instability of infant,
extreme fluctuation of isolette temperature or out of NTE range if
using skin control, hypo or hyperthermia, or inadequate growth
pattern.

Documentation: 20. Document in the appropriate medical record record:
a. Assessment data, including:
infant temperature, isolette temperature, mode of isolette
heat, and amount of clothing, with vital signs or as
indicated above
environmental factors contributing to changes in
temperature regulation management
b. Interventions and patient response, including:
changes in thermal management in PIP note and/or plan
of care
time initiating and discontinuing use of additional
warming devices (warming lights, warm packs, k-pad)
c. Evaluation of patient/significant other response to teaching
d. Reportable conditions, name of physician notified, and
response

REFERENCES: Kenner, C., Lott, J .W., & Flandermeyer, A.A.(Eds). (1998). Comprehensive Neonatal
Nursing: A Physiologic Perspective (2
nd
ed.). Philadelphia: W.B. Saunders.

Deacon, J ., O'Neill P. (Eds). (2004). Core Curriculum for Neonatal Intensive Care
Nursing (3
rd
ed.). Philadelphia: W.B. Saunders.
WRITTEN: 9/84
DEVELOPED BY: L.A. Schulte RN (Revised to protocol 2/91); J Medas RNC (93, 00)
REVIEWED/REVISED: 3/00 (revised from Isolette Weaning Protocol); 12/02, 7/07
APPROVED BY: Director, Perinatal & Pediatric Nursing
DISTRIBUTION: All Perinatal & Pediatric Nursing Standards Manuals,












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Thermal Regulation (Infant) Protocol T2.4


Suggested Environmental Temperatures to Attain Neutral Thermal Environment in Neonates
Less than 1,200
grams (actual
weight)
1,200 1,500 grams
(actual weight)
1,500 2,500
grams (actual
weight)
Greater than 2,500
grams (actual weight)

0-12 hours 34.0 C 35.4 C

33.9 C 34.4 C

32.8 C 33.8 C 32.0 C 33.8 C
12-24 hours 34.0 C 35.4 C

33.3 C 34.3 C

31.8 C 33.8 C

31.0 C 33.7 C
24-48 hours 34.0 C 35.0 C 33.0 C 34.2 C

31.5 C 33.5 C 30.5 C 33.3 C
48-96 hours 34.0 C 35.0 C

33.0 C 34.0 C

31.2 C 33.3 C 30.5 C 33.0 C
4-14 days 33.0 C 34.0 C

33.0 C 34.0 C

31.0 C 33.0 C
2-3 weeks 32.2 C 34.0 C

32.2 C 34.0 C


3-4 weeks 31.5 C 33.5 C

31.5 C 33.5 C

30.0 C 32.7 C












Thermal Regulation (Infant) Protocol T2.5


RELATIVE HUMIDITY (RH) ALGORITHYM

Infant is less than one of:
1000 gm birthweight
30 wk GA
10 days old & premature


YES



Place in prewarmed (34-35 C)
isolette at 70 % RH, decrease by 5-10%
if rainout seen



Place infant in skin mode
with set point of 36.5 C


Condensation? TEMP STABLE? YES


YES NO Maintain humidity as
above for 1
st
day

Drop RH Continue to
by 5% assess NO
increments Normothermic after
24 hours?

Hypothermic Hyperthermic YES


Skin temp within Drop RH by 5% and Drop RH by 5%
0.3-0.6 C of Ax. assess infant temp.

NO YES Temp stable after 30 min.? If temp remains stable
Drop RH by 5% every
24-48 hours until 40%
at 7-10 days of age,
then discontinue
Reapply probe Remains NO
Hypothermic

Notify physician Drop RH in 5%
Increments

Temp. stable?