Temperature

Control in the
Neonate
Pearl S. Park, D.O.
PGY-2
August 30, 2007

Introduction

Hypothermia associated w/ increased

morbidity/mortality in newborns of all birth
weights/ages

Western philosophy of conventional care

premature baby should be

Now considered independent risk factor for mortality

in preterm

Placed under radiant warmer

Uncovered for full visualization and to allow radiant
heat to reach body

More attn now focused on thermal care

immediately after birth and during resuscitation

Premature Susceptibility to
Heat Loss

High surface area to volume ratio

Thin non-keratinized skin
Lack of insulating subQ fat
Lack of thermogenic brown adipose
tissue (BAT)
Inability to shiver
Poor vasomotor response

Thermoregulation

Metabolic rate of fetus per tissue wt. higher than

adult

Fetal temp consistently 0.3-0.5 deg C higher than

mothers (always in parallel)

Heat also transferred from mother to fetus via

placenta/uterus

Even when mothers temp elevates (eg fever)

Despite BAT in utero, fetus cannot produce extra heat

Exposed to adenosine and prostaglandin E2 inhibitors of

non-shivering thermogenesis (NST)
Metabolic adaptation for physiologically hypoxic fetus since
NST requires oxygenation
Inhibition of NST allows accumulation of BAT

Thermoregulation

Heat gain/loss controlled by hypothalamus and

limbic system

Thermoregulatory system immature in newborns (esp

premature newborn)

In term infant, response to cold stress relies on

oxidation of brown fat (NST)

Development begins 20th wk until shortly after birth

(comprises 1% body wt at that time)
High concentration stored TGs
Rich capillary network densely innervated by
sympathetic nerve endings
Temperature sensors on posterior hypothalamus
stimulate pituitary to produce thyroxine (T4) and
adrenals to produce norepinephrine
Lipolysis stimulated energy produced in form of
heat in mitochondria instead of phosphate bonds by
uncoupling protein-1 (aka thermogenin)

Risk Factors

All neonates in 1st 8-12hrs of life

Prematurity
SGA
CNS problems
Prolonged resuscitation efforts
Sepsis

Adverse Consequences of
Hypothermia

High O2 consumption hypoxia, bradycardia

High glucose usage hypoglycemia /
decreased glycogen stores
High energy expenditure reduced growth
rate, lethargy, hypotonia, poor suck/cry
Low surfactant production RDS
Vasoconstriction poor perfusion
metabolic acidosis
Delayed transition from fetal to newborn
circulation
Thermal shock DIC death

Modes of Heat Loss

Conduction - direct heat transfer from skin to

object (eg mattress)
Convection - heat loss through air flow

Radiation - direct transfer by electromagnetic

radiation in infrared spectrum

Also depends on air temp

Heat gained by radiation from external radiant energy

source
Heat lost by radiation to cooler walls of incubator

Evaporation - heat loss when water evaporates

from skin and respiratory tract

Depends on maximum relative humidity of surroundings

less humidity = more evaporation

Heat Loss at Birth

Hammarlund et al, 1980

Evaporative H20 loss

Heat loss through

81-125 gm/m2/h when unwiped in ambient temp

~25.8deg C and 42% humidity
Evaporation: 60-80 W/m2
Radiation: 50 W/m2
Convection: 25 W/m2
Conduction: negligible
Total heat loss = 135-155 W/m2

All babies that were >3250g - body temp

decreased 0.9deg C in 15min

Heat Loss at Birth

Hammarlund et al, 1979

Naked infants <28wks need ambient

temp ~40deg C to maintain nl temp in
20% humidity

Increasing humidity to 60% halved

losses

Attempt to Overcome
Losses

Radiant heaters insufficient to warm

preterm baby
Esp during resuscitation
750g baby w/ surface area of ~ 0.06m2
requires at least 9.3W to compensate
for losses at birth
At mattress lvl, max of 9W absorbed by
baby if radiant heat absorbed by, at
least, 50% of mattress

Thermoneutral
Environment

Temp and environmental conditions

at which metabolic rate and O2
consumption are lowest
Silverman et al

Maintaining constant abdominal skin

temp b/w 36.2-36.5 deg C optimal

WHO classification of hypothermia

Mild: 36-36.4deg C
Mod: 32-35.9deg C
Severe: <32deg C

Kangaroo Mother Care

(KMC)

Introduced in 1983 by Rey and Martinez

in Colombia

LBW infants nursed naked (wearing only cloth

diaper) between mothers breasts
Data from other countries show infants nursed
by KMC have

Fewer apneic episodes

Similar or better blood oxygenation
Lower infxn rtes
Are alert longer and cry less
Are breastfed longer and have better bonding
Improved survival in low-resource settings

KMC

Bergman et al, 2004

Randomized controlled trial comparing KMC to

pre-warmed servo-controlled closed incubator after
birth
20 infants b/w 1200-2199g using KMC vs 14
controls

Excluded if C-sec, mother too ill to look after self/infant,

known HIV, BW outside 1200-2199g, 5min Apgar <6,
congenital malformations

1/20 subjects vs 8/14 controls had initial temps <

35.5deg C (P = 0.006)
1/20 subjects vs 3/14 controls had bl glucoses < 2.6
mmol/L (though 40mg/dL = 2.2mmol/L)
Stability of cardio-respiratory system in preterm
infants (SCRIP) score was 2.88 points higher w/in
1st 6hrs in KMC group (95% CI 0.3-5.46)

SCRIP Score
SCRIP

HR

Regular

Decel to 80100

Rte <80 or
>200 bpm

RR

Regular

Apnea <10s Apnea >10s

or periodic
or
breathing
tachypnea
>80

O2 sat

>89%

80-89%

<80%

Barriers to Heat Loss

Cochrane database review

4 studies compared barriers to heat loss vs. no
barriers

2 comparison subgroups

Plastic wrap/bag vs routine care

Stockinet cap vs routine care

Plastic wrap/bag vs routine care

3 studies involving 200 infants all <36wks

All placed under radiant warmer, wrapped to shoulders
while still wet, heads dried and resuscitated according to
guidelines
GA <28wks: wrap group had temps 0.76deg C higher than
controls (95% CI 0.49-1.03)
GA 28-31wks: no statistical difference

Barriers to Heat Loss

Plastic wrap/bag vs routine care (cont)

1hr after admission for GA <28wks, no

statistical difference (though direction was in
favor of intervention)
Plastic wrap significantly reduced risk of
hypothermia (core temp <36.5deg C) on
admission to NICU

RR 0.63 (95% CI 0.42-0.93)

NNT found to be 4 (95% CI 3-17) - so 4 infants would
need to be wrapped in plastic to prevent 1 from
becoming hypothermic

No significant differences found in duration of

O2 therapy, major brain injury, duration of
hospitalization, or death

Barriers to Heat Loss

Stockinet cap vs routine care

1 study involving 40 AGA infants w/ GAs 32-36wks

Exclusion critera: 5min Apgar <7, SSx CNS defect,
sepsis, or maternal temp >37.8deg C during labor
Cap group had caps placed ASAP after drying
under radiant warmer and infants <2500g were
transported in incubator
BW <2000g: Cap group had core temps 0.7deg C
higher than control (95% CI -0.01-1.41) borderline statistical difference
BW >/= 2000g: no sig dif
No sig dif in preventing hypothermia

External Heat Sources

Cochrane database review

2 studies compared external heat
sources to routine care

2 comparison subgroups
Skin-to-skin vs routine care (already
mentioned)
Transwarmer mattress vs routine care

External Heat Sources

Brennan et al, 1996

24 infants w/ BW </= 1500g
Transport Mattress (TM) - made of sodium
acetate - activated to ~40deg C when delivery
imminent

Infant placed upon blankets covering mattress,

dried, then placed on TM directly

Control group = same intervention but w/o TM

Both groups resuscitated according to
guidelines then transferred to NICU on radiant
warmer surface

External Heat Sources

Brennan et al, cont

Increase of 1.6deg C in TM group (95%
CI 0.83-2.37)
Evidence suggests that TM significantly
reduces risk of hypothermia w/ RR 0.3
(95% CI 0.11-0.83)

NNT = 2 (95% CI 1-4)

No adverse occurrences reported in

this study, though other studies have
had infants sustain 3rd deg burns

In Conclusion

Plastic barriers effective in reducing heat loss in

newborns <28wks
No evidence yet to suggest plastic barriers
decrease duration of O2 therapy, hospitalization, or
incidence of major brain injury/death
Stockinet caps effective in reducing hypothermia
in newborns <2000g, but not >/= 2000g
KMC shown to be effective in stable newborns
down to 1200g in reducing risk of hypothermia
TM decreases incidence of hypothermia </= 1500g
In the end, the smaller the baby, the more likely
any intervention will be of benefit

Areas of Further Study

Need more studies w/ larger
population bases
Short- and long-term outcomes need
to be studied further (especially w/
neurdevelopmental F/U)
Secondary outcomes that need
further study:
Hypoglycemia
RDS
Intubation/v Length of

Metabolic
acidosis

ARF

e-ntilation
Growth

stay
Adverse
events

Neonatal Energy Triangle

References

Laroia, N. Double wall versus single wall incubator for reducing heat loss in very low
birth weight infants in incubators. Cochrane Database of Systematic Reviews. Vol
(3) 2007.
Fienady, V. Radiant warmers versus incubators for regulating body temperature in
newborn infants Cochrane Database of Systematic Reviews. Vol (3) 2007.
Asakura, H. Fetal and Neonatal Thermoregulation. Journal of Nippon Medical
School. Vol. 71 (2004) , No. 6.
Ibe, O.E. A comparison of kangaroo mother care and conventional incubator care for
thermal regulation of infants <200 g in Nigeria using continuous ambulatory
temperature monitoring. Annals of Tropical Paediatrics (2004) 24, 245-251.
Bergman, N.J. Randomized controlled trial of skin-to-skin contract from birth versus
conventional incubator for physiological stabilization in 1200- to 2199-gram
newborns. Acta Paediatrica (2004) 93: 779-785.
McCall, E.M. Interventions to prevent hypothermia at birth in preterm and/or low
birthweight babies. Cochrane Database of Systematic Reviews. Vol (3), 2007.
Watkinson, M.A. Temperature Control of Premature Infants in the Delivery Room.
Clin Perinaol 33 (2006) 43-53.
Knobel, R.B. Heat Loss Prevention for Preterm Infants in the Delivery Room. J
Perinaol 25 (2005) 304-308.
The neonatal energy triangle Part 2: Thermoregulatory and respiratory adaptation.
Paediatric Nursing. Sept. Vol 18 no 7.

Thank You!!