Effect of delivery room temperature on the admission temperature of

premature infants: a randomized controlled trial

Y-S Jia1,2, Z-L Lin1, H Lv2, Y-M Li2, R Green3 and J Lin1,3

1. 1
Department of Neonatology, Yuying Children’s Hospital of Wenzhou Medical College, Wenzhou, China
2. 2
Department of Nursing, The Second Affiliated Hospital of Wenzhou Medical College, Wenzhou, China
3. 3
Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA

Correspondence: Dr Z Lin or Dr J Lin, Department of Pediatrics, Mount Sinai School of Medicine, One Gustave L Levy Place, Box 1508,
New York, NY 10029-6574, USA. E-mail:linzhenlang@hotmail.com or jing.lin@mssm.edu

Received 5 March 2012; Revised 22 June 2012; Accepted 5 July 2012

Advance online publication 2 August 2012

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Abstract

Objective:

To determine if increasing delivery room temperature to that recommended by the World Health
Organization results in increased admission temperatures of preterm infants.

Study Design:

Admission rectal temperatures of newborns 32 weeks gestation delivered in rooms with

temperature set at 24 to 26 °C were compared with those of similar newborns delivered in rooms
with temperature set at 20 to 23 °C.

Result:

Premature newborns delivered in rooms with mean temperature 25.1±0.6 °C (n=43), compared
with those delivered in rooms with mean temperature 22.5±0.6 °C (n=48), had a lower incidence
(34.9% vs 68.8%,P<0.01) of admission rectal temperature <36 °C and higher admission rectal
temperatures (36.0±0.9 °C vs 35.5±0.8 °C, P<0.01). This difference persisted after adjustment for
birth weight and 5 min Apgar score.

Conclusion:

Increasing delivery room temperatures to that recommended by the World Health Organization
decreases cold stress in premature newborns.

Keywords:

preterm infants; body temperature; hypothermia

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Introduction

Newborn infants, particularly those born prematurely, are vulnerable to cold stress. Their large surface area to
body mass ratio, thin permeable skin, small amount of subcutaneous fat and limited metabolic response to cold
may lead to rapid heat loss and a decrease in body temperature.1 Thus, premature infants are largely
dependent upon an external heat source, and optimal thermal management of the preterm infant is very
important.1, 2 During resuscitation in the delivery room, heat loss often exceeds heat production in low birth
weight preterm infants, more so in very low birth weight (VLBW) infants. A recent study from a large cohort of
VLBW infants born in 15 academic medical centers in the United States demonstrates that 47% of the
admission temperature were <36 °C.3 The EPIcure study, a large prospective observational study in the United
Kingdom, evaluated outcomes of infants born at the threshold of viability (<26 weeks of gestation) and
demonstrated that 40.4% of the extremely premature infants had admission temperatures
<35 °C.4 Hypothermia is well known to have potentially serious metabolic consequences for VLBW infants, and
hypothermic infants are significantly more likely to be acidemic and in more critical condition than are those
with normal temperatures upon admission to the neonatal intensive care unit (NICU).4, 5

The study by Silverman et al.6 in 1958 demonstrated that maintenance of body temperature through control of
the thermal environment significantly reduced mortality in low birth weight infants and thermal management of
the preterm infant became a cornerstone of neonatology.6, 7 Efforts to minimize heat loss in newborn infants
are important in the initial stabilization and resuscitation in the delivery room. As detailed in the Neonatal
Resuscitation Program (NRP) of the American Academy of Pediatrics and the American Heart Association,
routine thermal care includes placing the infant under a radiant warmer, and immediately drying the infant;
wet linens should be removed quickly.2 On the basis of the data obtained by Knobel et al.8 from a post
hoc analysis, increasing the temperature of the delivery room, if possible, for an anticipated preterm delivery is
also recommended in the NRP.2 Similarly, the World Health Organization (WHO) also advocates maintaining the
temperature in the delivery room at 25 °C.9 This recommendation was supported by the data from a
retrospective analysis of preterm infants 31 weeks gestation.10 However, with the assumption that an over
head radiant warmer will maintain newborn temperature adequately, this recommendation is frequently
ignored and delivery rooms and operating rooms in developed countries are usually maintained relatively cool (
23 °C) for the comfort of the laboring mother, staff and surgical personnel who must wear multiple layers of
protective clothing. Furthermore, direct evidence from a large randomized control trial is still lacking as to
whether increasing the delivery room temperature does decrease the incidence of hypothermia in premature
infants upon admission to the NICU.

An infant loses body heat by evaporation, convection, radiation and conduction. As soon as an infant is
delivered, the transition from the warm intrauterine environment to the cool, drafty environment causes
significant heat loss. We hypothesized that increasing the delivery room temperature would reduce heat loss
during initial resuscitation and stabilization and therefore increase NICU admission temperature and decrease
the incidence of hypothermia in newborns with gestational age 32 weeks. To test this hypothesis, we
performed a prospective randomized controlled clinical trial comparing the NICU admission temperatures of
premature infants delivered in warm rooms with the temperature set at 24 to 26 °C with those delivered in
regular rooms with the room temperature set at 20 to 23 °C.

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Methods

From 1 March 2010 to 28 February 2011, we conducted a prospective, randomized control trial in the Second
Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical College, a perinatal center located in
eastern China with over 7000 annual deliveries. The 90 bed level III NICU also serves as the major referral
center for the region of over 8 million people. The study protocol was approved by both the Institutional Ethics
Committee of the Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical College and the
Program for the Protection of Human Subjects of the Mount Sinai School of Medicine in New York.

Enrollment and randomization

We set the room temperature at 24 to 26 °C in one of the delivery rooms and one of the obstetrical operating
rooms as the warm rooms. We kept the room temperature at 20 to 23 °C in other operating rooms and other
delivery rooms as the control rooms. We could not control or measure the humidity of the delivery rooms. All
pregnant women who were expecting to deliver a preterm infant with gestational age 32 weeks were eligible
to be enrolled into the study. After informed consent was obtained, the patient was assigned randomly to
deliver in a regular delivery/operating room or in a warm delivery/operating room. The randomization was
accomplished by opening a sealed preset envelope with either regular or warm room assignment. The
randomization was over-ruled if a conflict for the delivery room assignment existed, in which case, the patient
was not included into the study. This clinical trial was not blinded as the temperature difference between rooms
was obvious to both laboring mother and staff.

Preliminary data obtained for the trial demonstrated that babies born in a warm room had an average of
1.1±1.4 °C (mean±s.d.) higher admission temperature than those born in a regular room. We considered the
difference of this magnitude to be clinically significant. In order to show this difference with an α of 0.05 (two
tailed), and a 90% power, we needed 42 infants in each group.

Inclusion criteria
Infants of the enrolled and randomized mothers who met all of the following criteria were included in the
analysis: (a) born in the 2nd Affiliated Hospital/Yuying Children’s Hospital of Wenzhou Medical College and
admitted alive into the NICU of Yuying Children’s Hospital, (b) maternal temperature <38 °C at delivery, (c)
delivery at gestational age 32 weeks, (d) no major congenital anomalies and (e) the presence of a staff
neonatologist for initial resuscitation and stabilization in the delivery room or operating room.

Data collection, analysis and statistics

After delivery, all babies were resuscitated and stabilized in the delivery rooms equipped with a radiant warmer
(Ningbo David Medical Device, Ningbo, China). The delivery room resuscitation was performed by our staff
neonatologists according to the NRP guidelines. No changes were made to the routine delivery room
management and resuscitation for this study. For each preterm delivery, in addition to recording all required
information routinely done in the delivery rooms, the delivery room staff also recorded the actual room
temperature from the wall glass thermometer specifically installed for this study. After initial delivery room
management, babies were transported in a heated transport isolate (Atom Medical International, Japan) to the
NICU. All babies admitted to the NICU were routinely cared for by the attending neonatologist. The research
coordinator collected data for each enrolled infant by filling in a data collection sheet specifically designed for
the study.

The primary outcome measure was the rectal temperature which is routinely taken on admission to the NICU
along with other vital signs within the first hour of life. The rectal temperature was measured with a standard
mercury thermometer and recorded in the medical chart by our staff NICU nurses who were not aware of the
group assignment. The admission vital signs, serum glucose level and the base deficit/excess from the first
arterial blood gas were obtained from the medical record by the research coordinator. The five-item clinical risk
index for babies (CRIB) II score was calculated from the birth weight, gestational age, sex, admission
temperature and base excess as described by Parry et al.11

Student’s t-test was used for comparison of the two groups for all normally distributed numerical data; the χ2-
test was used for categorical data. Simple linear regression was used to identify potential factors affecting
admission temperature, and then a multivariable linear regression model was used to identify independent
determinants of admission temperature. All numerical data are presented as mean and s.d. unless otherwise
specific indicated. A P value <0.05 was considered statistically significant in all cases. All statistical analysis
was performed by using PASW Statistics 18 (SPSS, IBM, Armonk, NY, USA).

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Results

During the 1 year study period, we enrolled 96 mothers, 91 of whose newborns met the inclusion criteria and
were included for data analysis. Of those 91 premature infants, 43 were born in warm rooms as the warm
group; the other 48 infants were born in regular rooms as the control group. The range of the actual room
temperature in the warm rooms was 24 to 26 °C with an average of 25.1±0.6 °C, which is significantly higher
that that of the regular rooms in which the actual room temperature ranged from 20 to 23 °C with an average
of 22.5±0.6 °C (P<0.001). The baseline clinical characteristics of the two groups were similar as shown
in Table 1.

Table 1 - Baseline clinical characteristics of the two groups.

Full table

The mean rectal temperature on admission to the NICU was significantly higher in the premature infants with
gestational age 32 weeks who were born in warm rooms compared with the infants who were born in the
regular rooms (Table 2). The increased delivery room temperature to an average of 25.1 °C from a regular
22.5 °C was associated with an increase of the mean admission rectal temperature by 0.5 °C and a decreased
incidence of hypothermia (defined as rectal temperature <36.0 °C) from 68.8 to 34.9%. There were no
differences between the two groups in the incidence of severe hypothermia (defined as rectal temperature
<35.0 °C), base excess or the incidence of hypoglycemia (defined as the serum glucose <40 mg dl−1) on
admission.

Table 2 - The DR temperature and the primary and other outcomes of the two groups.

Full table
To further determine if the delivery room temperature is a significant predictor of baby’s admission
temperature adjusted for confounders, we performed a multiple linear regression analysis. First order
regression of the admission temperature as a function of delivery room temperature and other potential factors
is shown inTable 3. These results suggested using DR temperature, birth weight and Apgar scores as factors in
a model predicting admission rectal temperature. Although there was not a significant difference in base excess
between babies delivered in warm rooms and regular control rooms, the base excess was significantly
correlated with the admission temperature. It was not used in the model, despite having the highest R value,
because it is most likely the effect of the baby being cold rather than a cause for hypothermia. The 1 min Apgar
score was not used in the model, because it did not have a significant effect when the 5 min Apgar score was
included. As shown in Table 3, delivery room temperature, birth weight and 5 min Apgar score independently
contributes to the admission temperature of premature infants. The 0.23 coefficient of DR temperature in the
multivariable model indicates a 0.23 °C increase in admission temperature for every degree increase in the
delivery room temperature.

Table 3 - Multiple linear regression analysis of factors related to the admission temperature of a
premature infant and the correlation coefficient.

Full table

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Discussion

Hypothermia on admission to neonatal units is a world-wide problem across all climates, particularly for small
infants and those born prematurely.12 Minimizing the heat loss in preterm infants during the initial stabilization
and resuscitation in the delivery room is critical for improved outcome in those babies. In the current study, we
demonstrated that increasing the delivery room temperature, when a preterm delivery is anticipated, can
significantly increase the admission temperature of premature infants. An increase in the room temperature to
an average of 25.1 °C from a control room temperature of 22.5 °C is associated with a 0.5 °C higher mean
NICU admission rectal temperature and a decrease in the incidence of hypothermia from 68.8 to 34.9% in
premature infants with gestational age 32 weeks. Our study provides strong evidence that the environmental
temperature of the delivery room has a direct impact on heat loss in premature infants and suggests that
maintaining a modestly higher delivery room temperature will reduce the incidence of neonatal hypothermia.
This prospective, randomized, controlled clinical trial provides direct evidence to support the recommendations
by NRP and WHO for increasing the delivery room temperature for an anticipated preterm delivery.

Major efforts have been devoted to preventing hypothermia of premature infants. In addition to the routine
thermal care, techniques using barriers to prevent heat losses such as covering the infant in plastic wrapping
or caps (food-grade, heat-resistant plastic) have been proven to be effective in the delivery room for preterm
infants with gestational age <28 weeks.8, 13, 14, 15, 16 This technique has been recommended by NRP and the
International Committee on Resuscitation for delivery of preterm infants with a gestational age <28
weeks.2, 17 As only about 10% of our enrolled preterm deliveries had a gestational age <28 weeks or birth
weight <1000 g, we did not use plastic wrap or caps in any of our enrolled infants during the trial period.
Clearly, the 34.9% incidence of hypothermia in our warm group is still not acceptable for most of the neonatal
units in developed countries. Implementing some of the evidence-based potentially better practices may
further improve thermal care in the delivery room for very premature infants and reduce the incidence of
hypothermia.18

Multiple factors contribute to the development of hypothermia of premature infants on NICU admission.
Consistent with the literature,3 our results from multiple linear regression analysis indicate that in addition to
the delivery room temperature, lower birth weight and lower 5 min Apgar score are independent variables
associated with the admission hypothermia of premature infants. It is well established that the temperature
control is vital for neonatal survival and that extent of reduced temperature on admission in premature infants
is associated with both morbidity and mortality.3, 6, 19 By using multivariate analysis, Laptook et
al.3 demonstrated that for every 1 °C decrease in admission temperature, the odds of late-onset sepsis are
increased by 11%, and the odds of dying are increased by 28% in VLBW infants. Admission temperature is
included as one of the five items (gestational age, birth weight, sex, admission temperature and base excess)
in the CRIB II scoring system.11 The CRIB II score, which was developed as a valid and simple risk-adjustment
instrument for assessing the quality of care for individual NICUs, is better than either gestational age or birth
weight alone in predicting death or major cerebral abnormality.11 However, despite the admission temperature
being significantly higher in the warm group, none of the secondary outcomes, that is, base deficit, admission
serum glucose level and CRIB II score, were different between the warm and control groups. There are several
possible reasons for this including the fact that the current study was not powered to address these secondary
outcomes and the possibility that the marginal improvement in admission temperature may be too small to
have an effect on those parameters. Furthermore, the major clinical outcomes, such as death before discharge,
intraventricular hemorrhage, late-onset neonatal sepsis, chronic lung disease and length of stay, were not part
of the initial design because the NICU care of premature infants in China was not as advanced as that in the
developed countries. Non-medical factors such as socio-economic issues still have a very important role in the
care decision making and therefore the outcomes of VLBW infants in developing countries.

In conclusion, ongoing improvements in outcome for the preterm baby will depend on an increasingly
aggressive approach to all aspects of routine neonatal care, of which temperature control remains
important.18, 20 The current randomized controlled clinical trial shows that premature infants born in delivery
rooms with room temperature set at 24 to 26 °C have less chance of being hypothermic on admission to the
NICU than do those delivered in delivery rooms with room temperature set at 20 to 23 °C. This supports the
WHO recommendation for delivery room temperature as part of a thermal care strategy for preterm delivery. It
remains to be determined if this change can make a real difference in terms of the major clinical outcomes for
premature infants.

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Conflict of interest

The authors declare no conflict of interest.

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References

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Acknowledgments

We would like to thank the staff of the Obstetrical and Neonatal Departments of the Second Affiliated Hospital
and Yuying Children’s Hospital of Wenzhou Medical College for their invaluable cooperation in this study and Dr
Ian Holzman for advice and critical review of the manuscript.

Author contributions

The results of this study were presented, in part, at the annual Pediatric Academic Society meeting in Boston,
28 April to 2 May 2012. This study was supported by a research grant from the Neonatal Resuscitation
Program of American Academy of Pediatrics and a grant from Wenzhou City Bureau of Science and Technology,
China (H20090074). The funders had no role in study design, data collection and analysis, decision to publish,
or preparation of the manuscript. All listed authors are fully involved in the preparation of this manuscript and
have approved this final version.

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