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Admission Hypothermia in Low Birth Weight Neonates

Katie Bowling, RN

Bon Secours Memorial College of Nursing

Professor Cynthia Woods, RN, MSN

NUR 3206

March 12, 2017

Honor Code “I Pledge.”

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Admission Hypothermia in Low Birth Weight Neonates

Neonatal hypothermia is defined as a thermal state in which the body temperature

decreases to below 36.5 degrees Celsius (Kumar, Shearer, Kumar, & Darmstadt, 2009). Very low

birth weight (VLBW) neonates are characterized as weighting less than 1,500 grams at birth. In

the initial birth and resuscitation process body heat is lost by four different methods convection,

conduction, radiation, and evaporation. VLBW babies have a large surface area to body volume

ratio and lack of fat, which makes them prone to rapid heat loss leading to hypothermia.

Hypothermia can lead to hypoglycemia, respiratory distress and metabolic acidosis (Manani,

Jegatheesan, DeSandre, Song, Showalter, & Govindaswami, 2013). Thermoregulation is vital to

improving short and long-term outcomes of (VLBW) neonates.

The neonatal intensive care unit (NICU) is responsible to caring for these VLBW

neonates. Hypothermia upon admission to the NICU can cause both short and long term

consequences. As profusion decreases in response to hypothermia blood is shunted away from

non-vital organs such as the stomach and intestines potentially leading to disease processes such

as Necrotizing Enterocolitis (NEC). According to Rodrigo, Rodriguez, and Quesada (2014),

studies have shown that neonatal hypothermia can significantly increase the risk for grade three

and four intraventricular hemorrhages (IVH) in the brain. The NICU team routinely is involved

from the time of delivery and works to stabilize VLBW infants in the delivery room in order to

transport and resume care in the NICU. The NICU team is comprised of Neonatologists,

Registered Nurses (RNs), and Respiratory Therapists (RTs) all highly trained to care for this

vulnerable population. Issues of hypothermia begin to arise from external factors such as

decreased temperatures in delivery rooms, lack of thermal mattresses or polyethylene bays at

delivery, labor and delivery staff unknowledgeable of how to prevent heat loss in an emergency
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situation, and improper monitoring of temperature during procedures immediately following

birth. Protocols have been set in order to improve patient outcomes as well as meet guidelines set

forth by insurance companies reimbursement criteria. The NICU can be penalized and potentially

waive reimbursement for an admission temperature less than thirty six degrees Celsius.

Neonatal hypothermia poses risks to patients and hospitals. In a study by Manani,

Jegatheesan, DeSandre, Song, Showalter, & Govindaswami (2013), for each one degree decrease

in temperature upon admission below thirty six degrees Celsius the mortality rate increases by

twenty eight percent and late-onset sepsis by eleven percent. According to Medlock, Ravelli,

Tamminga, Mol, & Abu-Hanna (2011), mortality and morbidity rates of VLBW when stable

admission temperatures are achieved. Decreased rates of mortality and morbidity with

thermoregulation lead to decreased length of stay in hospitals, decreased cost per case, and better

patient outcomes. Hospitals are expected to meet exceptional standards of care therefore all staff

that come into contact with VLBW infants should be fully trained. Improved patient outcomes

are results from trained staff, proper equipment, and policies implemented for thermoregulation

on VLBW neonates.

Upon further evaluation external causes including personnel, environmental, policies, and

equipment are factors contributing to neonatal hypothermia. Policies and procedures are set in

place for VLBW neonates upon delivery including pre-warming beds, increasing the temperature

in delivery rooms, the use of a warming mattress, placing the infant in a polyethylene bag, a hat

applied to head and continuous temperature monitoring. Axillary and rectal temperatures post-

delivery have been significantly increased when infants are placed in polyethylene bag with their

heads covered with a hat (Gathwala, Singh, Kunal, & Agrawal, 2010). The clear, polyethylene

bags are beneficial in preventing evaporation of heat and convection from air drafts while
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allowing the team to be able to assess and treat the infant. During emergency situations when the

NICU team is unaware of the gestation of the infant or size, the warming mattress, polyethylene

bag and time to warm the bed is not available thus placing the infant at risk for heat loss. In the

event that the NICU is not present immediately following the birth, labor and delivery nurses

take action in caring for the infant. VLBW infants maintain their temperature the best when

placed in a warming mattress in a clear bag with a hat on the head. Pinheiro, Furdon, Dugan,

Reu-Donlon, & Jensen (2014), found the use of a protocol involving polyethylene bag and

warmed blankets lead to greater than ninety percent admission temperatures between thirty-six to

thirty-eight degrees Celsius. Often, these resources are unavailable to the labor and delivery

nurse and their first response is to dry and stimulate the infant with a blanket until the NICU

team arrives, common practice for term newborns. Delivery room temperatures are often set for

staff or patient comfort, which can greatly decrease the temperature in neonates. Delayed cord

clamping, while beneficial, allows for ambient air to decrease an infant’s temperature during this

time. In a study conducted by Manani, Jegatheesan, DeSandre, Song, Showalter, &

Govindaswami (2013), a VLBW infant’s temperature can decrease by half to one degree Celsius

per minute. Lack of efficient monitoring is a cause for concern when infants are left exposed to

ambient air under sterile drapes during placement and verification for umbilical lines. Although

heaters are on during procedures the RN is not always able to assess the infant to assess

temperature. Measures taken to preserve heat have been shown to improve outcomes for VLBW


In order to reduce the risk of neonatal hypothermia staff education, a standardized

protocol, communication and team collaboration is of utmost importance. The neonatal intensive

care unit uses a standardized protocol to follow upon delivery and admission to the NICU.
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Ongoing education for all staff involved in neonatal patient care leads to better patient short and

long term outcomes. Consistent communication between labor and delivery and the NICU results

in more preparation for setting up equipment and warming delivery rooms and beds. Having all

of the necessary equipment available for thermoregulation in labor and delivery and the NICU

will allow for policies to be followed appropriately. Maintaining thermoregulation and

preventing neonatal hypothermia leads to better patient outcomes.

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Gathwala, G., Singh, G., Kunal, & Agrawal, N. (2010). Safety and efficacy of vinyl bags in

prevention of hypothermia of preterm neonates at birth. Indian Journal of Public Health,

54(1), 24-26. doi:10.4103/0019-557X.70543

Kumar, V., Shearer, J. C., Kumar, A., & Darmstadt, G. L. (2009). Neonatal hypothermia in low

resource settings: A review. Journal of Perinatology, 29, 401-412.


Manani, M., Jegatheesan, P., DeSandre, G., Song, D., Showalter, L., & Govindaswami, B.

(2013). Elimination of admission hypothermia in preterm very low-birth-weight infants

by standardization of delivery room management. The Permanente Journal, 17(3), 8–13.

Medlock, S., Ravelli, A. C. J., Tamminga, P., Mol, B. W. M., & Abu-Hanna, A. (2011).

Prediction of mortality in very premature infants: A systematic review of prediction

models. PLoS ONE, 6(9), 23441.

Pinheiro, J.M.B., Furdon, S.B., Dugan, R., Reu-Donlon, C., & Jensen, S. (2014). Decreasing

hypothermia during delivery room stabilization of preterm neonates. Pediatrics, 133(1),

218-226. doi:10.1542/peds.2013-1293

Rodrigo, G.M., Rodriguez, R., Quesada, S. (2014). Hypothermia risk factors in very low weight

newborn and associated morbidity and mortality in neonatal care unit. Asociación

Española de Pediatría, 80(3), 144-150. doi:10.1016/j.anpedi.2013.06.029

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