Indian Academy of Pediatrics (IAP)
STANDARD
TREATMENT
GUIDELINES 2022
Neonatal
Hypothermia
Lead Author
Somashekhar Nimbalkar
Co-Authors
Akumtoshi, Ravi Shankar Swamy
Under the Auspices of the IAP Action Plan 2022
Remesh Kumar R
IAP President 2022
Upendra Kinjawadekar Piyush Gupta
IAP President-Elect 2022 IAP President 2021
Vineet Saxena
IAP HSG 2022–2023
© Indian Academy of Pediatrics
IAP Standard Treatment Guidelines Committee
Chairperson
Remesh Kumar R
IAP Coordinator
Vineet Saxena
National Coordinators
SS Kamath, Vinod H Ratageri
Member Secretaries
Krishna Mohan R, Vishnu Mohan PT
Members
Santanu Deb, Surender Singh Bisht, Prashant Kariya,
Narmada Ashok, Pawan Kalyan
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Neonatal Hypothermia
Background
;; Thermoregulation is the ability to maintain balance between heat production and heat
loss in order to sustain body temperature within a normal range.
;; Hypothermia may have serious metabolic consequences for all newborns. To minimize
these effects, an environmental temperature at which the newborn has minimal rates of
oxygen consumption and expends the least energy to maintain its temperature is needed.
This is known as thermoneutral environment.
The World Health Organization (WHO) defines neonatal hypothermia as an axillary temperature Definition
below 36.5°C (97.7°F) among newborns aged below 28 days. Normal axillary temperature is
36.5–37.5°C.
;; Mild hypothermia/cold stress 36.0–36.4°C
;; Moderate hypothermia 32.0–35.9°C
;; Severe hypothermia <32°C.
Neonatal Hypothermia
;; Prematurity, low birth weight, intrauterine growth restriction (IUGR), asphyxia, and
congenital defects like abdominal wall defects.
;; Low delivery room temperature, not drying the neonate during postdelivery care, bathing
Risk Factors
the newborn after birth, removal of vernix caseosa, reduced contact with mother, and
delayed initiation of breastfeeding are risk factors for neonatal hypothermia, especially in
developing countries.
;; Poor understanding of healthcare providers about the physiology of thermoregulation is a
contributory factor too.
;; Low ambient temperature as well as lower maternal temperature are known risk factors.
Neonatal transport is almost always done poorly and is a risk factor for hypothermia.
;; Procedures for neonatal care such as surgery, placement of umbilical lines, and radiological
investigations such as MRI are associated with neonatal hypothermia.
Prevalence
Across the gestational age spectrum of newborns that are cared for in various settings (including
warm tropical climates), the prevalence of hypothermia varies extensively from 8 to 92% across
various studies. In developing countries, the typical rates are 32–85% in hospital settings.
Neonatal Hypothermia
Outcomes of
;; Neonatal hypothermia is an independent risk factor for neonatal mortality across all
gestational ages with association showing a dose-response relationship.
;; Mortality increases by 28% per 1°C decrease in temperature below the normal temperature.
;; Neonatal hypothermia on admission to neonatal intensive care unit (NICU) has also been
consistently associated with intraventricular hemorrhage, bronchopulmonary dysplasia,
neonatal sepsis, retinopathy of prematurity, and increased length of hospital stay.
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Neonatal Hypothermia
Measurement of Temperature
;; Axilla is the recommended site of measurement using a digital thermometer. The
thermometer is placed in the baby’s armpit and the arm is held close to the body to keep it
in place for about 15 seconds or till it beeps.
;; The temperature is displayed on the thermometer. Temperature can also be recorded
continuously by a thermistor attached to a radiant warmer or incubator with the probe
attached to the skin over the upper abdomen.
;; The thermistor senses the skin temperature and displays it on the panel. Both the above
methods are acceptable. Rectal measurement is not preferred.
;; Noninvasive measurements of neonatal temperature using infrared thermometers or
infrared thermography are not recommended as they are not yet reliable. Novel bracelet
devices placed on newborn’s wrists to detect hypothermia are fairly accurate detectors of
hypothermia and may be used in appropriate settings.
Production in Newborns
Mechanism of Heat
;; Nonshivering thermogenesis—occurs by utilizing brown fat in newborns. Thermoreceptors
on sensing a low temperature result in elevated sympathetic output and this stimulates
the beta-adrenergic receptors in the brown fat increasing cAMP. This results in increased
metabolism and increases heat production.
;; Increased metabolic activity—the brain, heart, and liver produce metabolic energy by
oxidative metabolism of glucose, fat, and protein.
;; Peripheral vasoconstriction—reduces blood flow to the skin and decreases loss of heat.
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Neonatal Hypothermia
Mechanisms of Heat Loss
TABLE 1: Mechanisms of heat loss.
Evaporation Due to the evaporation of amniotic fluid from skin surface
Conduction By coming in contact with cold objects such as cloth and weighing tray
Convection Convection by air currents where cold air replaces warm air around baby due
to open windows, fans, etc.
Radiation Radiation to colder solid objects in vicinity-like walls
The process of heat gain is by conduction, convection, and radiation.
Clinical Features
TABLE 2: Clinical features of neonatal hypothermia.
Peripheral vasoconstriction Acrocyanosis, cool/pale extremities, and decreased
peripheral perfusion
entral nervous system (CNS)
C Lethargy, hypotonia, bradycardia, apnea, and poor
depression feeding
Increased metabolism Hypoglycemia, hypoxia, and metabolic acidosis
Increased pulmonary artery pressure Respiratory distress and tachypnea
Chronic signs Disseminated intravascular coagulation (DIC) and
poor weight gain
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Neonatal Hypothermia
;; In delivery room and operation theater:
•• Follow the 10 steps of “warm chain” recommended by the WHO.
Draught free and warm delivery room temperature of 25–28°C.
Radiant warmer to be prewarmed along with all the linen and clothes/cap before
delivery.
Prevention and Management of Hypothermia
Cap prevents significant heat loss in preterm as well as in term infants. Remove wet towel.
Baby is placed directly on the mother’s abdomen or chest after delivery in both vaginal
and cesarean delivery.
Provide warmth by skin-to-skin contact after drying with a warm and dry linen if baby
is doing well.
Breastfeeding can be started immediately and the baby and the mother are covered
with a warm blanket. Delay bathing. No bathing in the hospital.
Resuscitation, if required, should be done under the radiant warmer and heated
humidified gases to be used if oxygen or positive pressure ventilation is required.
Prewarm medications and intravenous (IV) fluid, if required.
During surgery, abdominal organ coverage reduces the incidence of hypothermia.
Additional measures for very preterm infants (who are more prone to hypothermia due
to greater surface-to-mass ratio and lesser brown fat):
<28 weeks gestational age (GA) <32 weeks GA
Plastic wrap covered up to the neck (without Plastic wraps covered up to the neck
drying) along with Transwarmer mattresses is without drying.
preferred.
Head is dried and cap placed.
Transport and management in a heated humidified incubator reduces heat and
water loss.
;; In the NICU:
•• Use servocontrolled warmer or incubators.
•• Use warm IV fluids and blood products, etc.
•• Use of plastic tents (cling wrap) and applying cream/oil (like coconut oil) reduces both
convection heat loss and insensible water loss. Cream/oil use is restricted to <72 hours
duration.
•• On discharge from NICU both the abdomen and feet should feel warm normally.
•• Placing the newborn in Kangaroo mother care in the NICU reduces neonatal hypothermia
significantly.
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Neonatal Hypothermia
;; Postnatal ward:
•• Healthy neonates in postnatal wards often develop neonatal hypothermia. This can be
prevented by ensuring skin-to-skin care of these neonates regardless of gestation/weight as
well as ensuring shared bedding with mother. This is above and beyond the recommendation
of 1 hour of postdelivery skin-to-skin care. Most neonatal hypothermia occurs in the first
6 hours of delivery and ensuring skin-to-skin care in these hours can reduce neonatal
hypothermia significantly.
Prevention and Management of Hypothermia
;; Transport:
•• A stable infant can be wrapped in warm blanket and cap.
•• For a sick infant, transport incubator is the preferred method of transport from delivery room
to NICU or intrahospital transfers or from one hospital to another.
•• In the absence of transport incubators, a combination of plastic bag + skin-to-skin + cap can
be used.
•• Phase change material is also utilized for warm transport in many areas across India.
•• Kangaroo mother care can be used as an alternative for neonatal transport.
;; Rewarming a hypothermic baby: Warm the room, bed, and use warm blanket and cap to cover
the baby, if not already done (Table 3).
TABLE 3
Mild hypothermia Moderate hypothermia Severe hypothermia
;; Kangaroo (skin-to- ;; Kangaroo (skin-to-skin) ;; Admit in hospital and rewarm in an
skin) care and cover care and cover the baby incubator or a radiant warmer
the baby adequately adequately ;; The temperature is set at 35–36°C
;; Heat source can be ;; Rewarm in an incubator or a and rapidly rewarmed. Once baby’s
increased by 0.5° radiant warmer, if available temperature reaches 34°C the
every 30 minutes ;; Rewarm at a maximum of rewarming process is slowed down
0.5° every 30 minutes ;; Supportive management with oxygen
and fluids should be started along with
appropriate monitoring of vitals and
blood sugar
Remove all clothes while rewarming in an open care radiant warmer. Recheck axilla temperature every
30 minutes after each intervention. Consider infection if a baby does not respond adequately to
treatment.
;; Measurement of toe-core gap: A difference of >2–3°C between the core and peripheral
temperature is abnormal. This gives an early indication of cold stress, hypovolemia, infection,
and iatrogenic overheating.
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Neonatal Hypothermia
;; A term baby is being born by normal delivery. How will you maintain baby’s temperature?
(Flowchart 1)
Flowchart 1
Case Scenarios
;; A 29-week gestation baby is being born by emergency lower segment cesarean section
(LSCS) due to maternal pregnancy-induced hypertension (PIH). How will you maintain the
temperature of this baby during the golden hour?
For this baby under 30 weeks gestation, follow the Flowchart 1 with certain modifications.
Place the newborn on radiant heat warmer but do not dry the infant. Instead, place the infant
in a plastic bag, leaving the face exposed. Cover the head with a hat. Then transfer to NICU,
preferably in a preheated transport incubator.
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Neonatal Hypothermia
;; Blackburn ST. Thermoregulation. In: Blackburn ST (Ed). Maternal, Fetal, and Neonatal Physiology,
2nd edition. St Louis: Saunders; 2003.
;; British Columbia Reproductive Care Program. Newborn Guideline 2: Neonatal Thermoregulation.
Further Reading
London: BCRCP; 2003.
;; Eichenwald E, Hansen A, Martin C, Stark A. Cloherty and Stark’s Manual of Neonatal Care. Netherlands:
Wolters Kluwer; 2021. pp. 203-8.
;; Gleason C, Juul S, 2019. Avery’s Diseases of the Newborn, 10th edition. Amsterdam, Netherlands:
Elsevier; 2019. pp. 361-7.
;; Newbornwhocc.org. (2022). Hypothermia in Newborn. [online] Available from: https://www.
newbornwhocc.org/pdf/teaching-aids/hypothermia.pdf. [Last accessed June, 2022].
;; Schn.health.nsw.gov.au. (2021). Thermoregulation in Neonatal Care-CHW. [online] Available from:
https://www.schn.health.nsw.gov.au/_policies/pdf/2007-0006.pdf. [Last accessed June, 2022].
;; World Health Organization. Thermal protection of the Newborn: A Practical Guide. Geneva: World
Health Organization; 1997.
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