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New standards for neutral thermal environment of healthy very low

birthweight infants in week one of life

Article  in  Archives of Disease in Childhood · February 1984

DOI: 10.1136/adc.59.1.18 · Source: PubMed

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Archives of Disease in Childhood, 1984, 59, 18-22

New standards for neutral thermal environment of

healthy very low birthweight infants in week
one of life
P J J SAUER, H J DANE, AND H K A VISSER
Department of Paediatrics, Erasmus University and Academic Hospital Rotterdam, Sophia Children's
Hospital, and Department of Applied Physics, Delft University of Technology, Delft, The Netherlands

SUMMARY It is generally accepted that low birthweight infants should be nursed at thermal
neutral temperature-the environment in which oxygen consumption is at a minimum. Low
birthweight infants do not, however, always show an increase in oxygen consumption at a
temperature outside the neutral range, but react with a change in body temperature. We
redefined therefore the neutral temperature for these infants as 'the ambient temperature at
which the core temperature of the infant at rest is between 36&7 and 37 3°C and the core and
mean skin temperatures are changing less than 0*2 and 0-3°C/hour respectively'. Using this
definition, new guidelines of the neutral temperature have been made for healthy infants of 29-34
weeks' gestation. The neutral temperature during the first week of life is dependent on
gestational age and postnatal age, whereas after the first week it depends on body weight and
postnatal age. Using this definition and the guidelines, the appropriate environmental
temperature for the individual patient can be chosen.

Since the studies done by Budin in 1900,' it is known temperature in a more practical way and have drawn
that maintaining the body temperature and there- up new guidelines using this definition.
fore controlling the environmental temperature is
important for the survival of low birthweight infants. Methods
Glass et al2 showed that the environmental tempera-
ture also influences growth. Although short expo- Studies were done with a research incubator de-
sures to cold stress has a facilitative effect on scribed previously14 in which it is possible to
thermogenesis in newborns,3 it is generally accepted measure continuously oxygen consumption, carbon
that these infants should be nursed in an environ- dioxide production, and heat loss through evapora-
ment that keeps heat loss at a minimum.4 The tion. The incubator is a closed system; oxygen
optimal ambient temperature at which the infant consumption is measured with an accuracy of 0-2
should be nursed is called the thermal neutral ml/min by measurement of the oxygen supply
temperature and is defined as 'the range of environ- needed to maintain a constant concentration and
mental temperature within which the metabolic rate carbon dioxide production is measured in a similar
is at a minimum and within which temperature way. The incubator is double walled-water circu-
regulation is achieved by non-evaporative physical lating between the two walls. The temperature of
processes alone'.5 the walls can be regulated with an accuracy of 0-1 C
Several guidelines for the neutral temperature and changed by 0-4°C/min. The air entering the
have been published.69 These guidelines cannot, incubator is heated to the same temperature as
however, be used alone for setting the incubator the walls. The humidity of the air was set during
temperature, as the temperature of the walls of the the experiments at a dewpoint of 18-0 ± 0-1°C. The
incubator,'0 humidity,' 12 and air velocity'3 are also flow in the system is 10 I/min.
important. Moreover, it is not known how the During the study the following temperatures were
guidelines can be evaluated in individual patients, as recorded continuously using an Ellab universal
it is impossible to measure metabolic rate con- digital thermometer DU-3 and thermocouples
tinuously in each one. We defined the neutral (Ellab, type AF6): mid-oesophagus, forehead, left
18
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New standards for neutral thermal environment 19

hand, left upper arm, abdomen, left thigh, and left
foot. The temperatures were measured with an
absolute accuracy of 0-1°C and trends of 0-1°C/hour
could be detected.
The infants were naked except for a very small -ox 24
plastic covered napkin to prevent evaporation from
spilt urine and faeces. They were lying supine on a .O
mattress made of netting with wide openings, so ~.21
constructed that conductive heat loss was negligible. 0
o
Only studies in which the infant was either sleeping
or awake but quiet during the observation period
were included for analysis. All infants were healthy
at the time of the study.
Informed consent was obtained from all parents. 21 28
Postnatal age (days)
Definition of neutral temperature. The neutral Fig. 2 Neutral thermal environment (°C) from day 7-35.
temperature was defined as 'the ambient tempera- Dewpoint of the air 18°C. flow 10 Vmin. Body weight is current weight. Values
ture at which the core temperature of the infant at for body weight > 2-0 kg are calculated by extrapolation.
rest is between 36-7 and 37-3°C and the core and
mean skin temperatures are changing less than 0-2 significant parameters that influenced the neutral
and 0*30C/hour respectively' (see Discussion). temperature. Four parameters were analysed: gesta-
tional age, birthweight, postnatal age, and actual
Patients. Twenty five studies were done during the weight.
first week of life in 14 infants of birthweight mean
(SD), 1-10 (0-41) kg (range 0-81-1-85 kg) and Results
gestational age 29-34 weeks. After the first week 78
measurements were done in 27 patients whose In each experiment the neutral temperature of the
birthweights ranged from 0-81 to 1-85 kg, and baby was obtained by changing the temperature of
gestational ages from 29-35 weeks. Weight at study the incubator until the definition of the neutral
was mean (SD), 1-504 (0-33) kg (range 0-832-05 temperature was met. The observation period after
kg); age 20 mean (SD), (8) days (range 7-35 days). a change in environmental temperature was at least
45 minutes.
Statistical analysis. A multiple linear regression with Neutral temperature during the first week of life
backwards elimination was used to find the two most showed a correlation with gestational and postnatal
age (r = 0-82, P<0*001) and can be expressed as
35. follows: neutral temperature during the first week of
life = 36-6 - 0-34 x gestational age at birth - 0-28 x
34. postnatal age (equation 1) where temperature is
expressed in °C and postnatal age in days. Gesta-
tional age is related to 30 weeks, for instance 28
weeks = -2, 32 weeks = +2. The standard
deviation of the temperature predicted with this
a 32-
formula is 0-7°C.
The neutral temperature after the first week of
c
life showed a correlation with postnatal age and
*a 31 body weight (r = 0-72, P<0-001) and may be written
(n
a
a) as: neutral temperature after the first week of life
30 - = 36 - 1-4 x body weight - 0-03 x postnatal age
(equation 2) where neutral temperature is expressed
in °C, body weight in kg and postnatal age in days.
29- The standard deviation of the temperature predicted
3 4 5 with this formula is 0-65°C.
Postnatal age (days) All values apply to an environment with an equal
Fig. 1 Neutral thermal environment during thefirst week air and wall temperature and a humidity of dewpoint
of life, calculated from the measurements. of 18°C. Neutral temperature charts made from
Dewpoint of the air 18'C, flow 10 Vmin. equations 1 and 2 are shown in Figs. 1 and 2.
 Downloaded from adc.bmj.com on July 13, 2011 - Published by group.bmj.com

20 Sauer, Dane, and Visser

4000- Discussion

a..@ a
A baby produces heat continuously. All energy used
3000 *6 S 0O
for maintenance of the body, activity, and part of
U) the energy for tissue synthesis, is given off as heat. 14
a * -* *g A neonate will maintain his body temperature under
*
-4
N 2000
optimal conditions without using extra energy es-
E pecially for heat production. Total heat loss is de-
2 S.
pendent on both the heat production of the infant
1000
and the environmental conditions. Heat may be
given off in an incubator via radiation, convection,
and evaporation.'5 The amount of heat given off
in the different ways may vary, although total heat
O .J

0 7 14 21 28 35 42 49 56 63 loss remains constant.16

Postnatal age (days) As a reaction to a lower environmental tempera-
ture, the infant restricts skin perfusion which causes
Fig. 3 Resting metabolic rate at the thermoneutral a drop in skin temperature.'7 The core temperature
environment. will also change to obtain a new equilibrium with the
Y = a ± bx
Week 1 of life After week 1
environmental temperature. When the environ-
a = 1642 ± 86 a = 2507 ± 35 mental temperature remains in the thermoneutral
b = 78 ± 26 b = 17 ± 3 zone, the metabolic rate will not change and there
r = 0-55 r = 0-87
will be a change only in the infant's tempera-
ture. When the environmental temperature drops
below the thermoneutral zone, the metabolic rate
The resting metabolic rate, calculated from the will increase, accompanied by a drop in body
oxygen consumption and the carbon dioxide produc- temperature."I 15 18-20
tion, was calculated at the neutral temperature for In our studies where we measured continuously
each infant. The results are shown in Fig. 3. The core and skin temperature and metabolic rate, while
metabolic rate expressed per body surface area changing the incubator temperature by PC, we
increased rapidly during the first week of life observed changes in the trend of core and skin
(P<0.01) and showed a gradual increase thereafter temperature. We could not, however, distinguish
(P<0.01). changes in metabolic rate from spontaneous changes
that occurred at a constant environmental tempera-
ture. Most studies have measured the increase in
36- metabolic rate after a drop in environmental
temperature of more than 1-2oC.ll 15 18 19 Bell et a120
35- found a 25-33% higher oxygen consumption at
:.....
-34- ......... 1-2°C below the neutral zone compared with this
- 33-
.: *:: ..-.... *......b :.
..
zone. As the authors indicated, however, this
increase might have been overestimated. Changes in
'. 32- body temperature were not recorded in this study,
E
i31- but the core temperatures were significantly lower at
2 30-
*~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~....
..~~~~~.. .....
..........

., ..4.
the lower temperature, nearly all being less than
'' 37- *..... 36-70C, which we considered as below the neutral
.-

z 36- i ... ..g. zone.

z We conclude from observations made during this
35- study as well as those made by others'6 that preterm
34- infants often do not behave like mature homeo-
33- therm individuals. They react to a small change in
environmental temperature with a change in body
32- temperature rather than with a change in oxygen
Jl
10
0 5 10 15
-I

20
consumption. Under these circumstances, the phy-
25 30 siologist's definition of the neutral temperature is
Age (days )
difficult to apply. We therefore used the body
Fig. 4 Neutral temperature from this study, compared with temperature and changes thereof as an indicator of
the recommendations of Hey and Katz.9 the neutral temperature in these infants. The age at
 Downloaded from adc.bmj.com on July 13, 2011 - Published by group.bmj.com

New standards for neutral thermal environment 21

which preterm infants really start to behave as fully infants has still to be studied but the values of the
competent homeotherm infants needs to be studied. neutral temperature, given in Figs. 1 and 2, should
The actual values used in our definition were chosen probably be increased slightly when an incubator
empirically. with an air speed of more than 0-1-0-15 m/sec is
Although published guidelines of the neutral being used.
temperatures 9 relate neutral temperature to body
weight and postnatal age only, we found a correla- References
tion with gestational age rather than body weight 'Budin P. 'Le nourisson', alimentation et hygiene des enfants
during the first week. The high neutral temperature debiles-enfants nes a terme. Paris: Octave Dion, 1900.
2 Glass L, Silverman WA, Sinclair JC. Effect of thermal
found at low gestational ages can be explained by environment on cold resistance and growth of small infants after
the high evaporative heat loss found in very preterm the first week of life. Pediatrics 1968;41:1033-46.
infants.2' 22 As heat loss through evaporation may 3Perlstein PM, Mersh C, Glueck CJ, Sutherland JM. Adaptation
be equal to or even higher than total heat to cold in the first three days of life. Pediatrics 1974;54:411-6.
4 Hey EN. Thermal neutrality. Br Med Bull 1975;31:69-74.
production,2' heat loss through radiation and con- Bligh J, Johnson KG. Glossary of terms for thermal physiology.
vection must be minimal or even negative. The J Appl Physiol 1973;35:941-61.
decrease in neutral temperature during the first 6 Bruck K; Temperature regulation in the newborn infant. Biol
week may be explained by a decrease in evaporative Neonate 1961;3:65-119.
heat loss and an increase in metabolic rate and so in 7Oliver TK, Jr. Temperature regulation and heat production in
the newborn. Pediatr Clin North Am 1965;12:765-79.
heat loss (Fig. 3). The decrease in neutral tempera- 8 Scopes JW, Ahmed J. Range of critical temperatures in sick and
ture after the first week is related to the increase in premature newborn infants. Arch Dis Child 1966;41:417-9.
metabolic rate per body surface area (Fig. 3) and to 9Hey EN, Katz G. The optimum thermal environment for naked
the increase in body insulation due to the increase in babies. Arch Dis Child 1970;45:328-34.
10 Hey EN, Mount LE. Heat losses from babies in incubators.
subcutaneous fat.23 Arch Dis Child 1967;42:75-84.
In Fig. 4 we compared our guidelines with the " Hey EN, Maurice NP. Effect of humidity on production and loss
guidelines published by Hey and Katz9 for an infant of heat in the newborn baby. Arch Dis Child 1968;43:166-71.
12 Sauer PJJ, Dane HJ, Visser HKA. Influence of humidity on
of gestational age 33 weeks, and birthweight 2 kg, fluid loss and neutral temperature in low birthweight infants.
and for an infant born after 29 weeks' gestation and Crit Care Med 1983;11:216.
of birthweight 1 kg. It was assumed that both infants 13 Okken A, Bljham C. Influence of forced convection of heated
were growing 17 g/kg/day after the first week of life. air on insensible water loss in low birth weight infants. Pediatr
The values we found for the smaller infant are Res 1981;15:674.
14 Sauer PJJ, Pearse RG, Dane HJ, Visser HKA. The energy cost
slightly higher, but for the infant of two kg there is of growth estimated from simultaneous direct and indirect
complete agreement. calorimetry in infants of less than 2500 grams. In: Visser HKA,
Our guidelines for the neutral temperature are ed. Nutrition and metabolism of the fetus and infant. The Hague:
only valid for an environment where wall and air Martinus Nijhoff, 1979:93-107.
15 Swyer PR. Heat loss after birth. In: Sinclair JC, ed. Temperature
temperatures are equal and the air has a dewpoint of regulation and energy metabolism in the newborn. New York:
18°C. When the wall temperature is lower than the Grune and Stratton, 1978:91-129.
air temperature, the air temperature must be raised 16 Wheldon AE, Hull D. Incubation of very immature infants.
according to the formula: Arch Dis Child 1983;58:504-8.
7 Bruck K. Thermoregulation control mechanisms and neutral
Tneutral = 0 4 Tair + 0-6 Twall.9 processses. In: Sinclair JC, ed. Temperature regulation and
The neutral temperature will be lower when the energy metabolism in the newborn. New York: Grune and
humidity of the air is higher than used in this study. Stratton, 1978:157-87.
In infants born after 29-34 weeks, the neutral 18 Heim T. Homeothermy and its metabolic cost. In: Davis JA,
Dobbing J, eds. Scientific foundations of pediatrics. London:
temperature can be reduced by 0-1°C for every William Heinemann, 1981:91-128.
increase in the dewpoint of the air of joC.'2 The 19 Scopes JW, Ahmed J. Minimal rates of oxygen consumption in
exact influence of differences in humidity on the sick and premature newborn infants. Arch Dis Child
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be studied. The air speed in the research incubator environment on heat balance and insensible water loss in
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incubator to be 0003 m/sec. The air speed in a babies. Arch Dis Child 1979;58:858-68.
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conventional incubator is approximately 0-05-0-15 epidermal water loss in newborn infants vs evaporation from the
m/sec. Stothers24 found that the total heat loss was skin and heat exchange during the first hours of life. Acta
equal at air speeds of 005 and 0-10 m/sec in term Paediatr Scand 1980;69:385-92.
23 Heimler R, Sumners JE, Grausz JP, Kiern CL, Glaspey JC.
infants. Increasing the air speed to 02 m/sec caused Thermal environment change in growing premature infants
an increase in total heat loss. The exact influence of effect on general somatic growth and subcutaneous fat accu-
air speed on the neutral temperature of preterm mulation. Pediatrics 1981;68:82-6.
 Downloaded from adc.bmj.com on July 13, 2011 - Published by group.bmj.com

22 Sauer, Dane, and Visser

24
Stothers JK. The effect of forced convection on neonatal heat Hospital for Sick Children, 555 University Avenue, Toronto,
loss. J Physiol (Lon) 1980;305:77. Ontario, Canada M5G 1X8.
Correspondence to Dr P J J Sauer, Division of Neonatology, The Received 10 October 1983

Editorial
Sunday after the war
The Sunday after the war was for many children a complete lack of progress has been assured. After
time to look forward to when all the harrowing several years' work the report is published and often
experiences would have passed, food would be in is not even discussed by those who commissioned it.
abundance, and families united. Delicacies such as Those who look forward to essential changes soon
oranges and bananas which were known only from realise that 'Sunday after the war' is a device to keep
their descriptions in books would be on the table for them quiet for a few years.
everyone to eat. Since we were going to win the war These remarks apply to many reports and es-
there would clearly be no shortages of anything pecially the Platt, Court, and Short reports. The
afterwards. We spent hours planning what we would reports on the training of senior and clinical medical
eat, what we would do, and whom we would see. officers are developing ominous signs of the same
The great day came and went, and apart from a destiny. Our columns have recently shown evidence
few fireworks and the different content of the 6 that unless there is an increase in consultant
o'clock news it was difficult to see any difference paediatrician posts many well trained junior staff
between that Sunday and any other Sunday during have no prospects of attaining definitive posts. Less
the previous 6 years. How many times since then than a year ago we were reassured that the number
have we had the same sensation? The same se- of consultant posts would be increased by a substan-
quence of events has occurred whenever attempts tial proportion before the end of this century. The
have been made to improve the child health services latest cuts in staffing within the National Health
in this country. Pressure, both professional and Service show that this will not be attained. Why do
public, has resulted in the setting up of a royal we still cling to the illusion that there is a 'Sunday
commission and while this has been taking evidence after the war'?
 Downloaded from adc.bmj.com on July 13, 2011 - Published by group.bmj.com

New standards for neutral

thermal environment of healthy
very low birthweight infants in
week one of life.
P J Sauer, H J Dane and H K Visser

Arch Dis Child 1984 59: 18-22

doi: 10.1136/adc.59.1.18

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