Thermoregulation: Advances in Preterm Infants

Smita Roychoudhury, MBBS, MD,* Kamran Yusuf, MD

*Department of Pediatrics, Neonatal Perinatal Medicine, University of Calgary, Calgary,
Alberta, Canada

Practice Gaps
1. Thermoregulation of preterm infants is often overlooked, precipitating
hypothermia.
2. Clinicians should understand the morbidities and the mortality associated
with hypothermia in preterm infants.
3. Clinicians should be able to plan appropriate management to prevent
hypothermia after birth and beyond.

Objectives After completing this article, readers should be able to:

1. Describe the mechanisms of heat production and heat loss in neonates,

and why preterm infants are more susceptible.
2. Identify the conditions leading to hypothermia in preterm infants and its
consequences.
3. Recognize the different ways of preventing hypothermia in preterm neonates.

INTRODUCTION

Newborns must undergo many adaptations after delivery to adjust to extrauterine

life. One of the paramount adjustments is the need to rapidly increase body
temperature, and strive to accommodate to an environment colder than that of the
prenatal milieu. The temperature of a fetus is 0.9°F (0.5°C) above the maternal
temperature but within a few minutes after birth, the neonatal core temperature
begins to fall. (1) Keeping newborns warm, especially preterm infants, can be
challenging. Preterm infants can be characterized as inefficient homeotherms.
Although they do have an initial appropriate response to a decrease in environ- AUTHOR DISCLOSURE Drs Roychoudhury
mental temperatures, the effect is limited, placing the preterm infant at high risk and Yusuf have disclosed no financial
relationships relevant to this article. This
for hypothermia with all of its associated complications. commentary does not contain a discussion of
Budin (2) and Silverman, pioneers in the field of neonatology, had observed an unapproved/investigative use of a
significant mortality among low-birthweight infants who were hypothermic on commercial product/device.
admission to the nursery and in the first few days after birth. (3) They noted a
ABBREVIATIONS
striking improvement in survival rates if infants were cared for in warm NTE neutral thermal environment
environments, especially in the first 5 days after birth. Budin found a significant T3 thyroxine
difference in mortality based on the temperature of newborns at the time of T4 triiodothyronine

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admission to the NICU. In this study, the mortality rate in
neonates weighing less than 2,000 g was as high as 98% if
their admission temperature was less than 89.6°F (32°C);
90% if the admission temperatures were between 89.6°F
and 95°F (between 32°C and 35°C); and decreased to 23% if
temperatures were maintained above 95°F (35°C). More
recent studies have reported that each decrease in admis-
sion temperature by 1°C below 36°C is associated with a
mortality increase of 28%. (4) As a result of this association,
admission temperatures have become an integral compo-
nent of the mortality prediction scores, such as the Clinical
Risk Index for Babies and Score for Neonatal Acute Phys-
iology. Hypothermia after delivery is also associated with an
increased risk of respiratory distress syndrome, hypogly-
cemia, pulmonary hemorrhage, and sepsis.
The World Health Organization and other scientific orga-
nizations have recommended that axillary temperature be
maintained between 97.7°F and 99.5°F (between 36.5°C and
37.5°C) among newborns. (5)(6) The American Academy of
Pediatrics advocates for a goal temperature of 97.7°F (36.5°C)
for preterm infants during resuscitation because they are
prone to both hypothermia (while being dried) and hyper-
thermia (when resuscitated in plastic wraps along with exo-
thermic mattresses). (7) However, despite recent advances
and breakthroughs, neonatal hypothermia continues to be a
significant challenge, especially in the extremely preterm
population. Extreme preterm births constitute about 1% of
all live births but comprise almost half of all infant deaths. (8)
At the turn of the century, landmark studies revealed that as
many as 40% of extremely preterm infants had temperatures
less than 95°F (35°C) at the time of NICU admission. (9)(10)
Recent innovations notwithstanding, an organized approach
needs to be taken to reduce the burden of hypothermia.
PHYSIOLOGY OF THERMOREGULATION IN
PRETERM INFANTS
The fetus has limited capability of regulating its own tem-
perature. The fetus has an elevated metabolic rate, almost
twice that of the pregnant woman. At equilibrium, the fetus’
temperature is 0.9°F (0.5°C) higher than that of its mother.
Thus, the net flow of heat is from the fetus to the pregnant
woman, mostly through the placenta, and to some extent,
through the skin. (11)
Newborns of most mammalian species are unique. They
are unable to shiver in cold environments, though they show
an increase in oxygen consumption as well as heat produc-
tion. After birth, with the rapid fall in surrounding tem-
peratures, a newborn must rely primarily on nonshivering
mechanisms to maintain body temperature. This contrasts
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with adults, in whom shivering provides a mode of heat
production. Nonshivering mechanisms involve chemical
thermogenesis, which depends on brown fat.
During the initial neonatal response to cool external
temperatures, thermoreceptors on the newborn’s skin are
stimulated, initiating nonshivering thermogenesis. Norepi-
nephrine is released from the abundant nerves of the brown
fat, resulting in vasoconstriction and increased metabolism.
Simultaneously, stimulation of sympathetic pathways induces
a surge in thyrotropin that leads to release of thyroxine (T4)
and triiodothyronine (T3). T3 causes upregulation of the
uncoupling protein called thermogenin that causes the un-
coupling of mitochondrial oxidation and phosphorylation.
Thermogenin, similar to norepinephrine, acts on brown fat
to initiate chemical thermogenesis, and heat is produced by
fatty acid oxidation and uncoupling of adenosine triphosphate
formation. Thus, in contrast to white fat, the energy that is
generated by brown fat cannot be stored but instead is used to
increase the newborn’s body temperature.
Brown fat is highly vascularized, almost 4 to 6 times
more than white fat, with many mitochondria, lipid mole-
cules, and numerous capillaries that lead to the character-
istic “brown” color. Brown fat is found in the neck, axilla,
intrascapular regions, and the mediastinum surrounding
the vasculature and major organs, as well as near the kidneys
and adrenal glands. Brown fat may be present as early as 25
weeks of gestation and disappears by 9 months of age.
Brown fat constitutes about 1% to 2% of body weight in a
preterm infant and term infants have the most amount of
brown fat, constituting 4% of their body weight. When
brown fat is metabolized, the heat that is produced warms
the organs and blood directly, leading to an elevation in body
temperature. Brown fat is ultimately converted to glucose
and oxygen. Once brown fat is depleted, it cannot be replaced.
(11)(12)(13)(14)(15)(16)
THERMOREGULATION IN THE CONTEXT OF
PRETERM INFANTS
Compared with term infants, preterm infants are at higher
risk for hypothermia because of several unique characteristics
(Table 1). Preterm infants can only maintain core tempera-
tures in a narrow range of environmental temperatures. They
have a greater ratio of skin surface to body weight, almost 4
times that of adults, compared with term infants, who have a
ratio 3 times that of adults. This larger skin surface area leads
to more radiant heat loss and eventually, more insensible
losses. Transepidermal water loss varies inversely with the
gestational age; preterm infants can lose as much as 15 times
more water per kilogram of body weight compared with term
Vol. 18 No. 12 DECEMBER 2017 e693

TABLE 1. Preterm Infant Susceptibility to
Hypothermia
1. Large head and greater ratio of skin surface to body weight
2. Less subcutaneous fat and thinner skin with more transepidermal
water losses
3. Decreased ability to maintain flexed posture
4. Less amount of brown fat and glycogen stores
5. Low levels of thermogenin and 5’3’ monodeiodinase
6. Lower surge of thyrotropin
7. Greater likelihood of hypoxemia in preterm infants, which can
impair brown fat metabolism
neonates. Because sweat glands are not functional in preterm
infants, vasodilation is inefficient. (3)
Brown fat may not be well-developed until 26 to 30
weeks of gestation. Even the usual surge observed in the
thyrotropin levels after birth is low, especially in infants
born before 30 weeks of gestation. Hypoxemia is also
known to impair brown fat metabolism, and because
many preterm infants have a delay in transition, hypo-
thermia risk is greater. (17)(18)(19)
CLINICAL CONSEQUENCES OF HYPOTHERMIA AND
COLD STRESS
There is a close association among temperature mainte-
nance, oxygen consumption, and glucose utilization. (18)
(19) Cold stress leads to increased oxygen consumption,
which can result in tissue hypoxia and metabolic acidosis.
Metabolic acidosis can, in turn, inhibit the formation of
surfactant. The norepinephrine that is released from brown
fat can cause systemic and pulmonary vasoconstriction.
Pulmonary vasoconstriction can lead to increased pulmo-
nary vascular resistance with decreased oxygen delivery to
the cells and tissues. Hypothermia can lead to increased
glucose consumption, and can result in exhaustion of
glycogen stores. Increased insensible heat loss can lead to
dehydration, fluid electrolyte imbalance, hypotension, irri-
tability, and poor feeding. Untreated hypothermia eventually
leads to altered physiology and may cause seizure activity or
even death. To prevent these morbidities, it is imperative to
recognize cold stress as soon as possible.
DIFFERENT ROUTES OF HEAT LOSS IN INFANTS
An infant can lose heat to the surroundings by 4 distinct
routes (Table 2). (14) Evaporation is the most common route
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of heat loss occurring immediately after birth in both term
and preterm infants and in the first few weeks after birth in
preterm infants, especially those born before 28 weeks of
gestation. Heat loss can occur soon after delivery or later
during bathing or from wet linens or clothing. Evaporative
losses can be enormous and may total up to 200 kcal/kg per
minute. (18)(19) Radiant heat loss occurs when infants are
near but not in direct contact with cold surfaces, such as cold
sides of the incubator or cold walls in the surroundings. This
is the predominant route of heat loss in preterm infants of
more than 28 weeks’ gestation and term infants. Heat loss
via conduction occurs when infants are in direct contact with
cold surfaces, such as cold weighing scales or a cold mat-
tress. Convective heat loss occurs when cold air flows
through open doors or from air conditioners. Because infant
mortality can be as high as 98% if an infant’s core temper-
ature falls below 89.6°F (32°C), (2) strategies to prevent heat
loss need to be applied (Table 2).
STRATEGIES TO PREVENT HYPOTHERMIA
Maintaining a Neutral Thermal Environment at and
Around Birth
Maintaining preterm infants in a neutral thermal environment
(NTE) is crucial for their well-being. The NTE denotes envi-
ronmental conditions at which metabolic demands are min-
imal; it is not a fixed range of temperatures but instead, varies
with the age of the newborn, as well as gestational age and
birthweight. (3)(11)(20) When environmental temperatures
fall below the NTE, metabolic demands increase. This then
leads to increased oxygen consumption. If this cascade con-
tinues, compensatory mechanisms are exhausted and
eventually, the infant’s temperature begins to decrease.
Hypothermia can be classified based on core temperatures as
follows:
• Cold stress (96.8°F–97.5°F [36°C–36.4°C])
• Moderate hypothermia (89.6°F–96.6°F [32°C–35.9°C])
• Severe hypothermia (<89.6°F [32°C]).
Clinical providers should attempt to obtain normal new-
born temperatures by starting with the maintenance of
normal maternal temperatures before delivery. In a recent
study by de Almeida et al, 30% of pregnant women were
found to have temperatures below 96.8°F (36°C), and up to
44% and 51% of newborns born preterm were found to be
less than 96.8°F (36°C) at 5 minutes of age and at the time of
NICU admission, respectively. (21) Hospitals should optimize
the ambient temperature of delivery rooms. The International
Liaison Committee on Resuscitation recommends room
temperatures of 78.8°F (26°C) for anticipated preterm births
and 75.2°F to 77°F (24°C–25°C) for term infants. (22) The
TABLE 2. Different Routes of Heat Loss in Preterm Infants
ROUTE OF
HEAT LOSS EXAMPLES PREVENTION STRATEGIES COMMENTS

Evaporation Wet skin and hair after birth or after a bath
Wet clothes and skin after emesis
Wet diaper
Insensible water loss from lungs and skin
Radiation Cold walls near infant but not in direct
contact with infant
Cold doors and windows nearby
• Keep the infant and clothing dry
• Dry the infant immediately after delivery
• Place preterm or small-for–gestational
age infant in occlusive wrap/bag at
delivery
• Delay bath until temperature is stable
• Place infant in an environment with 60%
humidity (will substantially decrease
evaporative losses)
• Avoid placement of incubators or
bassinets near cold windows or air
conditioners
• Place a hat on the infant’s head
• Place extremely preterm infant in bag or
surround with plastic wrap
• Increase environmental temperature
• Use double-walled incubators
• Most important route of heat loss in
extremely preterm infants less than
28 weeks’ gestation
• High loss in extremely preterm
infants due to immature skin
• Even when dry, evaporative loss
continues, especially if low
humidity environment
• Most important route of heat loss in
preterm infants greater than 28
weeks’ gestation
• Initially low route of heat loss in
extremely low birthweight (ELBW)
infants
• Gradually increase radiant heat loss
with age, becoming the most
important route of heat loss after
first postnatal week in ELBW infants

Conduction Contact with cold objects such as scales or • Place a warm diaper or blanket between • Proportional to the temperature
cold blanket the infant and cold surfaces differential between infant and
• Place infant on prewarmed table at object
time of delivery
• Warm all objects that are in contact
with the infant
• Hold infant skin to skin
• Use exothermic mattress

Convection Draft of air from open doors • Place preterm infant in incubator
Draft from air conditioners • Keep portholes of the incubator closed
• Warm all inspired air
• Use servo control for skin temperature

Neonatal Resuscitation Program recommends that delivery
room temperatures should be between 73.4°F and 77°F
(between 23°C and 25°C). This range of delivery room tem-
peratures has been perceived to be helpful in maintaining
neonatal temperatures immediately after birth.
Delayed cord clamping has become increasingly common.
Though concerns have been expressed over maintaining an
infant’s temperature during delayed cord clamping, a 2008
systematic review found that infants had higher temperatures
if cord clamping was delayed; however, findings were not
statistically significant. (23)
The use of warm weighing scales and blankets in the
delivery room helps prevent any conductive and convective
heat losses. Approaches such as wrapping a newborn in
warm blankets, covering an infant’s head with a hat, and
drying can reduce heat losses immediately after birth.
Incubators and Radiant Warmers
Credit for the use of modern-day incubators is attributed to
Budin and his associates, though the concept of an incu-
bator to provide warmth to fragile newborns may have been
conceived as early as the mid-19th century. (3)(11) The incu-
bator has revolutionized the management of hypothermia,
significantly reducing neonatal mortality and morbidity.
Budin designed incubators with an emphasis on mon-
itoring the environmental temperature with a provision of
unidirectional flow of air that gets heated. (3) Subsequently,
in the 1950s, as described by Korones, Silverman and Blanc

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 demonstrated that maintaining body temperature through
control of the thermal environment significantly reduced
mortality in low-birthweight infants. They reported that
higher humidity was associated with higher temperatures,
which improved survival. (3) When humidity was control-
led, the resulting incubator temperatures were 2°C warmer.
The impact was most pronounced in infants weighing less
than 1,500 g. Subsequently, single-walled incubators were
replaced by double-walled incubators. Double-walled incuba-
tors reduced the radiant heat loss further by adding another
layer of acrylic glass. A 2007 Cochrane review reaffirmed the
aforementioned advantages of reduced heat loss, radiant heat
loss, and oxygen consumption with the use of incubators. (24)
Over time, the mode of temperature monitoring has
shifted from air temperature to skin. Currently, skin servo
control is preferable to air temperature control, especially in
low-birthweight infants, with the target skin temperature set
at 96.8°F (36°C). (3) A Cochrane review reported that skin
servo control mode reduces neonatal death compared with
air temperature control at 89.2°F (31.8°C). (25) To avoid
recording falsely high temperatures, the temperature probe
must not be placed on areas of brown fat such as the
interscapular region, the axilla, or neck. Instead, the clini-
cian should place the probe on the infant’s upper abdomen,
usually midway between the xiphoid process and the umbi-
licus. Infants should never be placed on the probe, because
this can lead to falsely high temperature readings and cause
the warmer to provide less heat.
Incubators can function in dual modes; if kept open, they
function as a radiant warmer and if closed, they are similar
to an incubator. The closed mode allows care in a humidified
environment while the open mode allows access to the
infant for procedures, handling, or family interactions. Sev-
eral studies have compared the effect of radiant warmers and
incubators on heat and insensible water loss. (26) Radiant
warmers were found to be associated with increased insen-
sible water losses, though no associated increase in oxygen
consumption has been noted. However, evidence suggesting
that one mode is preferable to the other is insufficient.
Because extremely preterm infants have high evaporative
heat losses, humidity has become an essential component
in the care of this group of patients. However, there are no
standards for percentage of humidity (typically ranging
between 60% and 100%) or length of exposure (up to 28
days after birth). The use of humidity greater than 70%
during the first week of age followed by 50% to 60% in the
subsequent weeks can reduce insensible water loss and min-
imize weight loss. (27) This approach has also been found to be
associated with a lower incidence of hypernatremia without
any concomitant increase in the incidence of infection.
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Incubators have undergone multiple modifications over
the past decades to attempt to reduce the spread of bacteria.
Filters and use of sterile water have been incorporated, and
water is heated and evaporated as an additional measure to
kill all pathogens.
Plastic Wraps and Bags
The use of plastic wraps and plastic bags is the most in-
expensive innovation to prevent hypothermia in preterm
infants. Recent trials have confirmed that there is a signif-
icant decrease in the incidence of hypothermia with the use
of plastic wraps and bags in preterm infants of less than 28
weeks’ gestation without an associated increase in hyper-
thermia. (28)(29) Reilly et al observed a significant reduc-
tion in both hypothermia and pulmonary hemorrhage in the
study group that was kept warm with plastic wraps. (30)
These wraps can be used extensively in resource-limited
settings because of their affordability and accessibility.
A 2010 Cochrane review reported that plastic wraps and
bags were effective in preterm infants of less than 28 weeks’
gestation but not among infants of 28 to 31 weeks’ gestation.
(31) The American Heart Association recommends placing
preterm infants born before 30 weeks of gestation in poly-
ethylene bags or wraps immediately after birth. (32) These
materials should cover infants up to their necks, without
removing the amniotic fluid on their body because the
retained vernix significantly improves hydration of the skin.
Next, the clinical team should cover the infant’s head with a
cap. (22) All subsequent resuscitation measures should be
undertaken through the plastic bag. This approach not only
reduces heat loss but also maintains adequate humidity.
However, data on long-term neurodevelopmental outcome
is still lacking.
Thermostable Gel Mattresses
Another innovative method for neonatal thermoregulation
is the use of a thermostable gel mattress. These mattresses
have long been used to maintain temperatures during the
transport of newborns. So it was not surprising to see their
use being extended to the delivery room. Several trials have
evaluated the use of a gel mattress in the delivery room;
most have shown that the mattress is equally effective at
minimizing hypothermia and improving admission tem-
peratures compared with plastic bags. (33)(34) These mat-
tresses can be used effectively for 2 hours. Although
concerns of increased rates of hyperthermia have been
raised, especially when used with bags, more studies need
to be conducted. (34)
Heated Humidified Gases
Evidence establishing the effectiveness of heated humidified
gases is insufficient. A few studies have shown that heated
humidified gases are helpful in reducing the postnatal drop in
temperatures, especially in very low-birthweight infants. (35)
(36) Since 2013, European guidelines recommend the use of
heated humidified gases in infants born at less than 28 weeks’
gestation. (37) Larger trials with power to assess the use of
heated humidified gases are required to confirm the benefits,
especially during resuscitation. (36)
Kangaroo Mother Care and Skin-to-Skin Contact
Most studies analyzing skin-to-skin contact have shown that
this approach prevents hypothermia in stable preterm new-
borns weighing more than 1,800 g. (38)(39) A 2016 Co-
chrane meta-analysis of 38 trials demonstrated a statistically
significant reduction in the risk of mortality, sepsis, and
hypothermia with the use of skin-to-skin contact. (40)
Transport from the Delivery Room to the NICU
During transport, neonatal providers should continue all of
the delivery room heat maintenance practices to further
minimize the risk of hypothermia. (41) A radiant warmer or
incubator should be used for transport. (42) Incubator doors
need to be closed because admission temperatures are lower
when the doors remain open. This is particularly true when
infants are transferred to the NICU on continuous positive
airway pressure. Humidity of more than 60% should be
added to the incubator as soon as possible.
Care in the NICU
Neonatal providers should continue all of the aforemen-
tioned measures in the NICU, with the goal of stabilization
during the first hour after birth. If any procedures are
performed, clinicians should be as efficient as possible. If
the top of the incubator is open during the procedure,
infants can be covered with additional warm drapes and
blankets. Clinicians should only expose the targeted pro-
cedural site and continue to monitor the infant’s tempera-
ture during procedures. If an infant is at high risk for
hypothermia and becomes hypotensive, warm fluid boluses
can be used.
Observational studies and 1 randomized controlled tri-
al have found benefit in the use of thermal mattresses in
addition to plastic wraps and radiant warmers without risk
of hyperthermia. (38)(43) Benefits have also been found when
the following interventions were combined: environmental
temperature maintained between 73.4°F and 77°F (between
23°C and 25°C), use of plastic wraps without removing the
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amniotic fluid, placement of head caps, use of a thermal
mattress, and placement on a radiant warmer. With the
integration of all of these interventions, the incidence of
hyperthermia in the population was not increased. (5)(22)
(44)(45)(46) Thus, for newborns of less than 32 weeks’
gestation, this combination is recommended (Table 3).
For successful implementation of these interventions,
coordination among health care professionals in the labor and
delivery room as well as the NICU is essential, with a goal of
maintaining axillary temperatures between 97.7°F and 99.5°F
(between 36.5°C and 37.5°C). In resource-restricted settings,
the combination of using plastic wraps, initiating skin-to-skin
contact in stable infants, and applying warm blankets or
clothes can help control an infant’s core temperature.
Interventions for Neonatal Hypothermia
If a preterm infant develops hypothermia after a bath,
providers should start by drying the infant well, especially
the head and neck areas, which are rich in thermoreceptors.
Next, the provider should cover the infant’s head with a cap
and then dress the infant. Before changing a soiled dressing,
warm fluids can be applied to the site in infants at high risk
for hypothermia.
If a premature infant needs to be rewarmed, the vital
signs should be closely monitored every 15 to 30 minutes.
This should include the infant’s core temperature, skin
temperature (which may be higher than the axillary tem-
perature), blood pressure, heart rate and cardiac rhythm,
TABLE 3. Measures in the Delivery Room and
NICU to Prevent Hypothermia
1. Anticipate and prepare for a preterm delivery before 32 weeks of
gestation
2. Provide closed loop communications and coordinate care
between obstetrical and neonatal teams
3. Maintain delivery room temperature >73.4°F (23°C)
4. Prepare equipment in anticipation of delivery: Radiant warmer,
plastic wrap, caps, warm blankets, thermostable gel mattress
5. After birth, place preterm infant on an exothermic mattress, wrap
in a plastic bag/wrap without drying, and place a cap on the
infant’s head; term infants can be dried and placed skin to skin.
6. Apply temperature probe to the skin and select servo control with
target temperature at 98.6°F (37°C)
7. Use warm blankets during transportation
8. Use warm humidified air and warm boluses for resuscitation
9. Closely monitor temperature until admission to NICU
10. Postpone bath
Vol. 18 No. 12 DECEMBER 2017 e697
 respiratory rate and effort, oxygen saturations, acid-base
balance, and blood glucose levels. This monitoring is critical
to avoid the risk of vasodilation and hypotension that is
associated with active rewarming, as well as the potential for
bradycardia or arrhythmias when rewarming is too slow or
too fast, respectively. To avoid hypotension, the clinical
provider should rewarm the infant slowly by approximately
0.5°C per hour. Use of an incubator provides better con-
trol than a radiant warmer and temperatures should be set
1°C–1.5°C above the infant’s core temperature. If the infant’s
core temperature reaches the set temperature and the infant
is stable, the set temperature should be increased again.
This process should continue until the infant’s temperature
reaches the normal range.
Transfer from Incubator to Open Crib
There is very little evidence and lack of consensus on the
optimal age for transferring a preterm infant to an open crib.
(47) A 2011 Cochrane review found that if an infant continues
to have stable temperatures at an incubator temperature of
84.2°F (29°C), weighs at least 1,600 g, and has consistent
weight gain for at least 5 days, then the infant is ready to be
weaned from the incubator. (43) In the absence of consensus
guidelines, different strategies have been used. Some NICUs
switch to the air-control mode before weaning, while others
prefer to challenge the clothed infant in a crib. Less common
techniques include switching to single-walled incubators or
using a heating mattress or blanket during the transition.
HYPERTHERMIA
Hyperthermia is defined as a core temperature that is higher
than 99.5°F (37.5°C). Neonatal hyperthermia most often
occurs because of environmental factors leading to over-
heating, rather than as a result of a disease process. Hyper-
thermia can lead to lethargy, irritability, apnea, dehydration,
peripheral vasodilation and flushing, tachycardia, tachy-
pnea, and poor feeding. Hyperthermia can be as dangerous
as hypothermia and can lead to increased metabolism,
resulting in increased water loss and possibly increased
mortality. (48) The infant’s clinical providers should move
affected infants away from the source of heat (if relevant) and
remove the infant’s clothing until the infant’s temperature is
lower. If the infant is in an incubator, providers should
decrease the air temperature and provide additional
fluids to prevent dehydration. If untreated, hyperthermia
may lead to severe dehydration, fluid electrolyte imbal-
ance, and even shock. Providers should maintain active
temperature reduction methods to a minimum to pre-
vent sudden heat loss. To avoid catastrophic events, the
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temperature of the infant and the incubator needs to be
monitored every 15 to 30 minutes.
CONCLUSIONS
Despite these preventive approaches, neonatal hypothermia
still occurs in preterm infants. Most centers adopt many
preventive practices to optimize a preterm infant’s temper-
ature because any one method has not been shown to be
sufficiently effective. Quality improvement projects are
being undertaken to find an effective way of incorporating
and optimizing each method to achieve the maximal benefit.
(21)(22)(46) Data on the impact of thermoregulation on
long-term neurodevelopment are still lacking. Although
hypothermia in preterm infants is preventable, it still occurs
because of lack of awareness and rarely, because of limited
equipment. (49) To achieve optimal temperatures, clini-
cians should attempt to prevent hypothermia before the
birth of a preterm infant. Postnatally, providers should
target temperatures between 97.7°F and 99.5°F (between
36.5°C and 37.5°C). Because preterm infants may be
unable to overcome cold stress, NICUs should enforce
a rigorous approach to hypothermia prevention in this
population.
American Board of Pediatrics
Neonatal-Perinatal Content
Specifications
• Know the various types and mechanisms of action of devices to
maintain a neutral thermal environment.
• Know the causes, metabolic consequences, and treatment of
infants with hypothermia.
• Know the causes, metabolic consequences, and treatment of
infants with hyperthermia.
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NeoReviews Quiz
There are two ways to access the journal CME quizzes:
1. Individual CME quizzes are available via a handy blue CME link in the Table of Contents of any issue.
2. To access all CME articles, click “Journal CME” from Gateway’s orange main menu or go directly to: http://www.
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1. You are preparing for the delivery of an infant at 27 weeks’ gestational age. As you prepare NOTE: Learners can take
the radiant warmer and other equipment and supplies, you consider the goals for NeoReviews quizzes and
resuscitation. Which of the following statements regarding thermal regulation for claim credit online only
newborns is correct? at: http://Neoreviews.org.
A. Preterm neonates have a relatively strong response to initial exposure to the
extrauterine environment due to an extra deposit of brown and black fat that builds To successfully complete
up in the second trimester, which would subsequently have been resorbed in the 2017 NeoReviews articles
late third trimester. for AMA PRA Category 1
B. The World Health Organization has recommended the maintenance of axillary CreditTM, learners must
temperature between 97.7°F (36.5°C) and 99.5°F (37.5°C) among newborns. demonstrate a minimum
C. The temperature of a fetus before birth is the same as the core temperature of the performance level of 60%
mother. or higher on this
D. The American Academy of Pediatrics advocates for a goal temperature of 96.8°F assessment, which
(36.0°C) or higher for both preterm and term newborns. measures achievement of
E. The fetus has a lower metabolic rate than the mother during pregnancy as well as a the educational purpose
newborn infant. and/or objectives of this
2. A newborn infant is born after precipitous delivery at term gestation soon after the mother activity. If you score less
is admitted to the labor and delivery unit. Although there were no known risk factors, the than 60% on the
neonate is noted to have grunting and respiratory distress right after delivery. He is assessment, you will be
brought to the resuscitation bed but the warmer has not been turned on. Which of the given additional
following physiologic responses to cold in the newborn infant is correctly described? opportunities to answer
A. Most newborn infants have an exaggerated shiver response even with minor questions until an overall
exposure to a cold environment. 60% or greater score is
B. A cold environment will typically lead to vasodilation in the extremities, hypo- achieved.
tension, and bradycardia.
C. A response to cold external temperature involves stimulation of sympathetic This journal-based CME
pathways, which induces a surge in thyrotropin that leads to release of thyroxine activity is available
and triiodothyronine. through Dec. 31, 2019,
D. Thermogenin is released in response to cold temperature and leads to apoptosis in however, credit will be
the liver and kidneys. recorded in the year in
E. The energy generated by white fat typically causes hyperthermia in cold envi- which the learner
ronments, leading to paradoxical fever in up to 40% of neonates exposed to cold. completes the quiz.
3. You are attending the delivery of a 25-week-gestation infant. After birth, the umbilical cord
is clamped after 60 seconds and the infant is placed on the radiant warmer. A plastic wrap
is placed around the infant. The infant is given continuous positive airway pressure by
mask and T-piece. The infant’s temperature is monitored in the delivery room and after
arrival to the NICU. Which of the following statements regarding thermal regulation in the
preterm infant is correct?
A. Preterm infants can only maintain core temperatures in a narrow range of envi-
ronmental temperatures.
B. The skin surface–to–body weight ratio of preterm infants is 10 times that of adults,
leading to a greater likelihood of radiant heat loss.
C. Preterm infants have more subcutaneous fat tissue, which is inefficient in pre-
serving heat.
D. Preterm infants have over-reactive sweat glands leading to higher degree of
evaporative heat loss.
E. Preterm infants have excessive brown fat and black fat, which leads to higher
metabolism and increased shivering.

Vol. 18 No. 12 DECEMBER 2017 e701

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 4. A preterm infant is brought to the NICU after resuscitation in the delivery room. At 30
minutes of age, the infant is noted to have temperature of 95.9°F (35.5°C). Which of the
following statements regarding associations between hypothermia and clinical status in
preterm infants is correct?
A. There is a lack of association between temperature maintenance and oxygen
consumption in preterm infants.
B. Cold stress in preterm infants usually leads to increased catecholamine release and
increased pulmonary maturation, with increased production of surfactant.
C. Release of thermogenin from brown fat leads to systemic and pulmonary
vasodilation.
D. Persistent hypothermia leads to apoptosis, which causes hyperkalemia, metabolic
alkalosis, buildup of glycogen stores, and inappropriate fluid retention.
E. Untreated hypothermia eventually leads to altered physiology and may cause
seizure activity or even death.
5. A 26-week-gestation infant is delivered by cesarean section and is being resuscitated in the
operating room. The infant is apneic and requires intubation despite initial resuscitation
efforts. Which of the following mechanisms of heat loss and efforts to prevent heat loss is
correctly described?
A. Radiant heat loss is the most common route of heat loss in preterm infants,
therefore the most effective method of thermal regulation for this infant will be to
provide warm blankets.
B. Convective heat loss occurs when the infant comes into contact with a cold surface,
such as gloves or supplies that have not been prewarmed.
C. Heat loss via conduction occurs when infants are in direct contact with cold
surfaces.
D. Evaporative heat loss is relatively minimal in preterm infants due to the immaturity
of the epidermis.
E. Although prevention of heat loss has been practiced in recent decades, the current
recommendation for preterm infants 24 to 28 weeks’ gestational age is to practice
passive hypothermia to prevent brain injury.

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 Thermoregulation: Advances in Preterm Infants
Smita Roychoudhury and Kamran Yusuf
NeoReviews 2017;18;e692
DOI: 10.1542/neo.18-12-e692

Updated Information & including high resolution figures, can be found at:
Services http://neoreviews.aappublications.org/content/18/12/e692
References This article cites 35 articles, 12 of which you can access for free at:
http://neoreviews.aappublications.org/content/18/12/e692#BIBL
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 Thermoregulation: Advances in Preterm Infants
Smita Roychoudhury and Kamran Yusuf
NeoReviews 2017;18;e692
DOI: 10.1542/neo.18-12-e692

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/18/12/e692

Data Supplement at:

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