Journal of Perinatology (2007) 27, S45S47

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Transitional hypothermia in preterm newborns

DR Bhatt1, R White2, G Martin3, LJ Van Marter4, N Finer5, JP Goldsmith6, C Ramos7, S Kukreja8 and
R Ramanathan7
1

Kaiser Permanente, Fontana, CA, USA; 2Pediatrix Medical Group, Memorial Hospital, South Bend, IN, USA; 3Pediatrix Medical
Group, Citrus Valley Medical Center, West Covina, CA, USA; 4Childrens Hospital, Brigham and Womens Hospital, Harvard Medical
School, Boston, MA, USA; 5University of California, San Diego, San Diego, CA, USA; 6Department of Pediatrics, Tulane University, New
Orleans, LA, USA; 7Womens and Childrens Hospital, LAC USC Medical Center, Keck School of Medicine of USC, Los Angeles, CA, USA
and 8Childrens Hospital of Orange County, Orange, CA, USA

Hypothermia remains a significant challenge in the initial care of

premature infants. Although a number of prevention strategies have been
identified, hypothermia is still a common event, especially in extremely low
birth weight infants. Using data from four centers, we documented an
incidence of hypothermia on admission to the neonatal intensive care unit
from the delivery room of 3178% for infants <1500 g birth weight.
Increased efforts will be necessary to prevent early hypothermia in very
preterm infants, especially with respect to the environmental conditions of
the delivery room itself.
Journal of Perinatology (2007) 27, S45S47. doi:10.1038/sj.jp.7211842

Keywords: newborn resuscitation; transitional hypothermia; cold stress;

delivery room temperature

Introduction
Hypothermia is well recognized as a factor influencing newborn
health.18 Despite this recognition, hypothermia remains a
significant challenge, especially in the perinatal care of preterm
infants. Our clinical experience suggests that hypothermia remains
an ongoing problem, especially among extremely low birth weight
infants, even for those born in Level III perinatal centers. Preterm
delivery less than 28 weeks or less than 1000 g occurs in 12% of
all deliveries, but accounts for the large majority of neonatal
morbidity and mortality. Therefore, the possibility that perinatal
hypothermia is a contributing factor to adverse outcomes among
this population deserves special attention.

Background
Definition
The newborn infant exhibits immature thermoregulation, as
compared with the older child or adult and therefore needs to be
protected from extremes of cold and heat. In 1997, the World
Correspondence: Dr RD White, Memorial Hospital, 615 N Michigan St, South Bend,
IN 46601, USA.
E-mail: Robert_White@pediatrix.com

Health Organization (WHO)1 provided the following definitions of

normothermia and hypothermia:
 Normal range: 36.537.5 1C
 Potential cold stress: 36.036.51; cause for concern
 Moderate hypothermia: 32.036.01; danger, immediate
warming of the baby needed
 Severe hypothermia: less than 32.01; outlook grave; skilled care
urgently needed.
Causes
There are a number of potential causes for hypothermia in the
newborn infant, which are summarized in Table 1.
All of these sources of hypothermia can be problems in delivery
room resuscitation efforts, as well as during transport of the
preterm infant to the neonatal intensive care unit and during
certain neonatal intensive care unit admitting procedures such as
weighing the baby.
Prevention strategies
There is general agreement that perinatal hypothermia should be
avoided in all newborns, with the possible exception of those who
have sustained a significant hypoxic-ischemic insult. In 2006, the
American Academy of Pediatrics and American Heart Associations
Neonatal Resuscitation Program (NRP) textbook2 recommended,
the goal (of the first postnatal temperature) should be an axillary
temperature of approximately 36.5 1C. The NRP text also noted
that temperature must be monitored closely because of the slight
but described risk of hyperthermiay(which) during or after
ischemia is associated with progression of cerebral injuryyThe
goal is to achieve normothermia and avoid iatrogenic
hyperthermia. Continuous temperature monitoring should be
initiated as soon as possible after the birth of the preterm infants in
order to document and achieve normothermia. Since low delivery
room temperatures can predispose to hypothermia,3 the NRP text
recommended, when delivery of a preterm baby is anticipated, the
temperature of the room should be increased, and to pre-heat the
radiant warmer by turning it on well before birth, use a head cap,

Transitional hypothermia in preterm newborns

DR Bhatt et al

S46

and yif the baby is born at less than 28 weeks gestation, consider
placing him, below the neck, in a reclosable polyethylene bag,
without first drying the skin. The bag can be a standard 1-gallon,
food-quality, polyethylene bag purchased in a grocery store.
Another way to improve temperature regulation in the delivery
room is to actively share American Society of Heating, Refrigerating
and Air-conditioning Engineers (ASHRAE)9 and WHO1
recommendations for delivery room temperatures with hospital
leaders and managers of Labor and Delivery services. The ASHRAE
handbook recommends single room labor-delivery-recoverypostpartum temperature of 752 1F, standard patient room
temperature of 752 1F, recovery room temperature of 752 1F
and nursery temperature of 753 1F. The guidelines further state
that Delivery Room temperature should never be below 68 1F.
Recommendations from the American Institute of Architects
(AIA),10 WHO and Recommended Standards for Newborn ICU
Design11 are in agreement with the ASHRAE document. Prevention
of hypothermia is also enhanced by use of weighing scales built
into warmers and appropriate attention to adequate warming

mechanisms of transport incubators. However, of paramount

importance is staff education in this area on the problem of
neonatal hypothermia and the use of preventive strategies,
especially in the extremely low birth weight infant.

Current data: prevalence of hypothermia among low

birth weight infants
A number of American Academy of Pediatrics colleagues recently
shared the following quality improvement data regarding
hypothermia (defined as a temperature p36.4 1C or p97.6 1F) at
admission to their units from the delivery room within 30 min of
birth (Table 2).
These data show a continuing high prevalence of hypothermia
among low birth weight preterm infants, with all centers reporting
an incidence of at least 25% among infants <2500 g birth weight,
and 56% or greater in infants <750 g.

Recommendations
Hypothermia is a potentially preventable event in nearly all infants,
even those who are extremely low birth weight, and deserves special
attention because of its association with substantial morbidity and
mortality. Although multicenter clinical trials will be needed to
establish best practices for prevention of hypothermia, the
recommendations that follow have an extensive foundation in
current experience and should be utilized until further data are
available.
The delivery room temperature should be at or higher than that
recommended for the labor-delivery-recovery-postpartum, patient
room, recovery room and nursery, especially for the preterm infant
(Table 3). In order to achieve and document this recommendation,
every delivery room should have individual thermostat and
humidity control, so that Labor and Delivery personnel can adjust
the thermostat as needed for preterm deliveries. Delivery room
temperatures and humidity at the time of each delivery should be
documented, and each infants temperature should be recorded as
soon as possible after birth and every 1015 min thereafter until
continuous temperature monitoring has been established. It is

Table 1 Potential causes of hypothermia in the newborn

Type of heat loss

Potential causes

Possible interventions

Evaporation

Wet skin or blankets; low

humidity in ambient and/or
inspired air
Large areas of skin exposed
to cooler surroundings
Contact with cooler bed
materials
Flow of cooler air across
babys skin or mucous
membranes

Rapid drying, plastic wrap or

bag, increased humidity of
ambient and inspired air
Covering skin, warming
surrounding structures
Pre-warming resuscitation
surface and blankets
Increased temperature of
delivery and resuscitation
room, reduction of drafts due
to inappropriately placed air
vents, covering babys skin
with blanket or plastic wrap,
transfer to pre-warmed
incubator as soon as feasible,
warm inspired air

Radiation
Conduction
Convection

Table 2 Incidence of hypothermia by birth weight

NICUs

Incidence
p750 g

NICU
NICU
NICU
NICU

A, California
B, South Bend
C, California
D, California

89%
56%
67%
100%

(16/18)
(14/25)
(6/9)
(1/1)

Abbreviation: NICU, neonatal intensive care unit.

Journal of Perinatology

7511000 g
76%
38%
47%
33%

(16/21)
(12/32)
(7/15)
(1/3)

10011500 g
80%
18%
61%
40%

(24/30)
(11/61)
(21/34)
(2/5)

Year
15012500 g
51%
13%
36%
75%

(39/76)
(7/56)
(44/121)
(12/16)

p2500 g
66%
25%
44%
64%

(95/145)
(44/174)
(78/179)
(16/25)

2006
20062007
20052006
2006

Transitional hypothermia in preterm newborns

DR Bhatt et al

S47
Table 3 Suggested delivery room temperatures by age and birthweight
EGA and/or EBW

Delivery room temperature

p26 EGA and/or p750 g EBW

2728 EGA and/or p1000 g EBW
2932 EGA and/or 10011500 g EBW
3336 EGA and/or 15012500 g EBW
3742 EGA or X2501 g EBW

76 1F
74 1F
72 1F
72 1F
70 1F

or
or
or
or
or

more; target: 7880 1F

more; target: 7880 1F
more
more
more

Abbreviations: EBW, estimated birth weight; EGA, estimated gestational age.

important that monitoring consider the possibility of extremes in

body temperature in either direction that can occur among
extremely preterm infants. Over-warming resulting in
hyperthermia of the newborn can occur and is equally
dangerous.1,12
These arbitrary set points for delivery rooms are
consensus-based and not evidence-based. One aspect, however,
is clear: as recommended by the WHO, adults should not
determine the delivery room temperature according to their
own comfort.1 Discussions with members of the obstetrical
team will be necessary to effect this change in the delivery room,
especially during operative deliveries when gowning is used.
It should be remembered that warming the delivery
room above 721F will be necessary in <2% of deliveries. Another
potential approach is to have a dedicated room for newborn
resuscitation adjacent to the delivery room in which ambient
temperature can be well controlled.11
Summary
Neonatal hypothermia continues to be a significant concern,
especially among extremely preterm infants. Preliminary
information from our nonrandom sample of hospitals suggests that
hypothermia among preterm newborns born at or below 1500 g
varies from 31 to 78%. Although clinical trials data currently are
lacking, it is likely that a number of measures will prove to reduce
or prevent perinatal hypothermia among preterm infants.
Currently, we recommend approaching this problem by following

the NRP and ASHRAE recommendations for delivery room

temperature management and also by joining efforts to study the
most effective ways of enhancing thermoregulation in the very
preterm infant. The goal of such interventions is to achieve
normothermia and avoid iatrogenic hyperthermia.
The AAP Committee On Fetus and Newborn, Section on
Perinatal Pediatrics, NRP, the California Association of
Neonatologists and District IX of the AAP Section on Perinatal
Pediatrics are working together to assess the magnitude of this
problem and support institution of measures to prevent
hypothermia among preterm neonates.

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