<p>Temperature regulation in neonates is crucial for their survival and well being. Hypothermia contributes significantly to neonatal morbidity and mortality. <fig id="fig001"><span>Figure 1</span><caption><span>Thermal range in Neonate</span></caption><div className="body-img"><img width="100%" 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" /></div></fig></p></sec><sec id="sec002"><title>Temperature regulation in a neonate

<p>Temperature regulation in neonates is crucial for their survival and well being. Hypothermia contributes significantly to neonatal morbidity and mortality. <fig id="fig001"><span>Figure 1</span><caption><span>Thermal range in Neonate</span></caption><div className="body-img"><img width="100%" 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" /></div></fig></p></sec><sec id="sec002"><title>Temperature regulation in a neonateHeat production

Crying and moving: In response to cold, full term baby may cry and move limbs and there may be minimal shivering. However increased muscular activity is not a significant source of heat production.

Metabolic thermogenesis — Non shivering thermogenesis: Metabolism of the brown fat — is an important source of heat production in the newborn. Brown fat comprises 2% – 6% body weight in full term neonates and is situated superficially between the scapulae and deep within the body along the aorta, around the adrenals and kidneys. It is highly vascularised and innervated by sympathetic neurons.

When newborns are exposed to cold, the message through afferents is conveyed to the thermoregulatory centre situated in the pre optic area in anterior hypothalamus near walls of 3^rd ventricle. Neurogenic efferents, on reaching the brown fat, trigger a local release of noradrenaline, which stimulate lipolysis (oxidative phosphorylation). Because of lipolysis, glycerol and free fatty acids are released and heat is generated. This metabolic process requires oxygen and glucose. Area of brown fat become warm and heat is distributed to various parts of the body through blood stream. (Fig. 2) Figure 2Non-shivering thermogenesis in a neonate

Heat loss (<xref ref-type="fig" rid="fig003">Fig. 3</xref>)

Evaporation — When water evaporates from the skin heat is lost. It is estimated that evaporation of 1 ml of water from body surface heat equivalent to 600 Kcal is lost. Wet infants in delivery room or after bath are especially susceptible to evaporative heat loss and the amount lost depends primarily on air velocity and relative humidity. Heat lost from the mucosa of the respiratory tract is also by evaporation and it increases with increasing respiratory rate.

Conduction — Transfer of heat between two surfaces. Baby looses heat when comes in contact with cold object e.g. cloth, tray and others

Radiation — Heat dissipates from the infant to a colder object in the environment.

Convection: Heat is lost from skin to moving air. Amount lost depends upon air speed and temperature. Open windows and fans increase heat loss by convection.

Figure 3Four ways a newborn loses heat.

Thermo-neutral range

It is a narrow range of environmental temperature at which a baby can maintain normal body temperature with minimal oxygen consumption (and possibly minimal caloric expenditure) (Fig. 4). Figure 4: Thermo-neutral range

The width of the thermoneutral range depends on the infant's resting heat production and the insulation around the baby. The range is relatively wider and lower in a term infant and an infant who is clothed. A naked baby and a preterm baby has a narrow thermo neutral range (Fig. 5). Figure 5: Thermoneutral range at different weight groups

Measurement of temperature in newborn

“Human touch assessment” is the easiest method of assessment of newborns temperature. In this method hands and feet of the baby are felt by dorsum of hand and compared with the feel over baby's abdomen. If both are warm it indicates normal body temperature. Cold hands and feet and warm abdomen indicate cold stress and if both cold, it is hypothermia in a baby. This method can be easily taught to mothers and health workers.

Clinical thermometer reads from 35°C to 42°C (95°F to 108°F−). Low reading thermometer reads up to 25°C (77°F−)

Axillary temperature is routinely recommended and preferred because of safety, hygiene and ease for early detection of hypothermia.

Rectal temperature is recorded in moderate to severe hypothermia to measure body's core temperature accurately. Rectal temperature measurement carries risk of rectal perforation.

The core — peripheral temperature differences of more than 3.5°C, suggests sepsis.

Hypothermia in a neonate

Hypothermia in newborns is commonly due to lack of awareness and knowledge about the importance of maintenance of temperature amongst the health care personnel, than due to lack of equipment.

In a study from Ludhiana, there was a high incidence of hypothermia (54%) at the time of admission and 80% babies less than 30 weeks of gestation had become hypothermic during transport to the hospital. In the same study 69% babies with hypothermia had died as compared to 38% babies admitted with normothermia. A study from Shimla had revealed that hypothermia was responsible for 9.6% neonatal deaths.

Babies at risk of hypothermia

All newborn babies at birth.

Preterm and LBW babies

SGA babies

Sick neonates

Neonates undergoing procedures

During transport.

The low birth weight infant is particularly at increased risk of hypothermia because of larger body surface area, thin and immature skin, increased cutaneous blood flow, decreased energy stores, less brown fat and increased respiratory rate.

Certain traditional practices such as not touching baby before delivery of placenta, sprinkling baby with cold water to stimulate breathing, delaying breastfeeding, early bathing and not preparing cloths before birth contribute significantly to hypothermia.

Consequences of hypothermia

Infants subjected to acute hypothermia respond with peripheral vasoconstriction, causing anaerobic metabolism and metabolic acidosis. Metabolic acidosis causes pulmonary vasoconstriction, leading to hypoxia - anaerobic metabolism and further acidosis. Hypoxia further compromises the infant's ability to respond to cold. Premature infants are at greatest risk for hypothermia and its sequelae.

Chronic cold stress leads to calorie loss, resulting in failure to gain weight.

Clinical features of hypothermia

Signs and symptoms are non specific and mimics illnesses like infections or asphyxia.

Mild hypothermia (Cold stress): In response to cold baby becomes restless and cries to generate heat by muscular activity. Babies in cold stress have cold feet, acrocyanosis and poor feeding.

With persistent hypothermia the baby becomes lethargic and refuses to feed. Cry becomes weak and activity reduces. Hypothermic babies may groan and respiratory distress may be a feature of hypothermia.

In Severe hypothermia, baby's lethargy increases and develops slow, shallow and irregular respiration with bradycardia. Baby's face and extremities may appear bright red because of sluggish circulation. Hypoglycemia and metabolic acidosis may complicate the problem of hypothermia. Severely hypothermic babies may develop edema or sclerema, bleeding diathesis especially pulmonary hemorrhage and death.

Prevention of hypothermia Kangaroo mother care (KMC)Mechanism

The heat is provided to the neonate in KMC by way of direct conduction of heat from the mother's skin to the baby. The clothing protects baby from evaporative, convective and radiation heat losses.

Studies have shown that if father keeps a baby in kangaroo position there is better maintenance of body temperature in the baby.

Risk of hyperthermia seen with incubator/radiant warmer is not seen with KMC.

Concept of “thermal synchrony” in KMC

Babies in incubator care or warmer care are subjected to swings of temperature. Swings in temperature lead to apneic spells and increased caloric expenditure. A baby kept in KMC has almost no swings in temperature and the temperature remains constant at 37°C. If baby's temperature decreases by 1°C then the temperature of the skin of mother in contact with baby goes up by 2°C to warm up the baby rapidly. Also if baby's temperature increases by 1°C, mothers skin temperature decreases by 1°C. This phenomenon is called “thermal synchrony”. Therefore the thermo regulation in KMC is far superior as compared to other means of keeping the baby warm (radiant warmer/heater bulbs/incubator).

Precautions during KMC

Baby should be dressed with cap, socks, diaper and baby frock which is covering the back. There should be direct skin to skin contact between the baby and the mother.

Minimum duration of KMC during one sitting should be at least 90 to 120 minutes to minimize handling.

Cover the baby properly while changing diaper or feeding the baby. Risk of hypothermia is maximum while feeding and changing diaper when baby is removed out of KMC for any short duration. Encourage feeding in Kangaroo position.

KMC can be used at all levels of care to prevent hypothermia in LBW babies, i.e. in delivery ward, post natal ward, NICU and during transport of a baby.

Management in delivery room

There should be separate area for neonatal resuscitation in the delivery room.

The delivery room temperature should be at least 25 °C.

Before the delivery of the baby ensure that the radiant warmer is on at least for 30 minutes. Adjust the temperature on manual mode or Air mode between 34 and 35 °C.

At community health centers or primary health centers, where there are no warmer facility available heating lamps could be used.

After delivery receive the baby in pre-warmed sterile towel.

Place the baby on mother's chest/abdomen for early skin to skin contact. Dry the baby thoroughly. Remove wet linen and wrap in a pre-warmed towel covering the head.

Indications for shifting baby under warmer for further assessment and resuscitative measures include;

Meconium in the amniotic fluid or on the skin

Absent or weak responses

Persistent cyanosis

Preterm birth

Skin to skin contact immediately after delivery facilitates placental expulsion (decreases PPH) prevents heat loss, facilitates bonding and lactation.

Keep the baby with the mother in case of normal delivery and stable baby.

If baby needs to be monitored, cover the baby's head with cap, feet with socks and only chest open. Keep the baby under radiant warmer or under heating lamp. Cover the bassinet with sterile polythene sheet

Start breastfeeding as soon as possible

Do not bathe the baby. Bathing soon after birth causes a drop in temperature. Bathing should be postponed to second or third day of life and definitely is not recommended before 6 hours after birth.

Management in postnatal ward

Ensure that the

Baby is kept warm with cap and several layers of loose clothing and placed in a warm blanket.

Practice “Bedding in”.

Initiate KMC for LBW babies, if not initiated in delivery ward.

Encourage breastfeeding on demand.

Remove soiled clothes immediately.

Keep windows closed and fans off.

Do not bathe the baby.

Insist on 24 hours KMC for LBW babies below 2000 grams

Transport of newborn babies

Inform NICU at least half an hour before the transfer so that the radiant warmer is switched on to maintain thermo-neutral environment.

Ensure that temperature is maintained before and during transport of the baby.

The simplest and safest way to transport a newborn is by putting the baby in KMC, if possible.

For unstable babies, transport incubator is preferred.

If transport incubator is not available, thermocol box or plastic box with holes for air circulation, is a preferred alternative.

When baby is being transported in transport box/thermocol box, check that water filled bags are warm, not excessively hot (temp < 102°F) and are not in direct contact with the baby.

If baby is on oxygen ensure that it is adequately warm and humidified.

Wrap babies properly including head, body and feet.

If the baby is not on IV fluids, feeding should be continued during transport. If mother is accompanying a baby, breastfeeding every 1 – 2 hours can be offered. If mother is not accompanying or baby is not feeding at breast, careful spoon feeding or gavage feeding could be offered.

Management in nursery/NICU

Ideal NICU temperature: 30 + 2 °C. Maintain baby in Thermal Neutral Environment (TNE) by using heating devices like radiant warmer or heating lamps (100 W).

Radiant warmers

Keep the warmer on in anticipation of admission. Use air mode and adjust to thermal neutral environment range (Table 1 showing thermal neutral range for specific age groups.) Table 1

Thermo-neutral range of temperatures

	Temperature

Age and weight	At start (°C)	Range (°C)

0–6 hours
Under 1200 gm	35.0	34.0–35.4
1200–1500 gm	34.1	33.9–34.4
1501 –2500 gm	33.4	32.8–33.8
Over 2500 gm (and > 36 weeks’ gestation)	32.9	32.0–33.8

6–12 hours
Under 1200 gm	35.0	34.0–35.4
1200–1500 gm	34.0	33.5–34.4
1501 –2500gm	33.1	32.2–33.8
Over 2500 gm (and > 36 weeks’ gestation)	32.8	31.4–33.8

12–24 hours
Under 1200 gm	34.0	34.0–35.4
1200–1500 gm	33.8	33.3–34.3
1501 –2500 gm	32.8	31.8–33.8
Over 2500 gm (and > 36 weeks’ gestation)	32.4	31.0–33.7

24 – 36 hours
Under 1200 gm	34.0	34.0–35.0
1200–1500 gm	33.6	33.1 –34.2
1501 –2500 gm	32.6	31.6–33.6
Over 2500 gm (and > 36 weeks’ gestation)	32.1	30.7–33.5

36 – 48 hours
Under 1200 gm	34.0	34.0–35.0
1200–1500 gm	33.5	33.0–34.1
1501 –2500gm	32.5	31.4–33.5
Over 2500 gm (and > 36 weeks’ gestation)	31.9	30.5–33.3

48 – 72 hours
Under 1200 gm	34.0	34.0–35.0
1200–1500 gm	33.5	33.0–34.0
1501 –2500 gm	32.3	31.2–33.4
Over 2500 gm (and > 36 weeks’ gestation)	31.7	30.1 –33.2

72 – 96 hours
Under 1200 gm	34.0	34.0–35.0
1200–1500 gm	33.5	33.0–34.0
1501 –2500gm	32.2	31.1 –33.2
Over 2500 gm (and > 36 weeks’ gestation) 4–12 days	31.3	29.8–32.8

4 – 12 days
Under 1500 gm	33.5	33.0–34.0
1501 – 2500 gm	32.1	31.0–33.2
Over 2500 gm (and > 36 weeks’ gestation)

4–5 days	31.0	29.5–32.6
5–6 days	30.9	29.4–32.3
6–8 days	30.6	29.0–32.2
8–10 days	30.3	29.0–31.8
10–12 days 12 – 14 days	30.1	29.0–31.4

12 – 14 days
Under 1500 gm	33.5	32.6–34.0
1501 – 2500 gm	32.1	31.0–33.2
Over 2500 gm (and > 36 weeks’ gestation)	29.8	29.0–30.8

2–3 weeks
Under 1500 gm	33.1	32.2–34.0
1501 – 2500 gm	31.7	30.5–33.0

3–4 weeks
Under 1500 gm	32.6	31.6–33.6
1501 – 2500 gm	31.4	30.0–32.7

4–5 weeks
Under 1500 gm	32.0	31.2–33.0
1501 –2500 gm	30.9	29.5–35.2

5–6 weeks
Under 1500 gm	31.4	30.6–32.3
1501 –2500gm	30.4	29.0–31.8

As soon as baby is received, change to servo control mode.

Place the sensor over abdomen in midline between umbilicus & xiphisternum.

Check position of sensor frequently.

Set appropriate abdominal skin temperature (36.5 – 37.5°C).

Stable babies who are not requiring close monitoring keep wrap them.

For the babies requiring close monitoring, cover the bassinet with transparent polythene sheet.

Adjust fluid intake.

Management of hypothermic newborn

Hypothermia is an emergency and the babies should be rewarmed as soon as possible. During rewarming oxygen consumption greatly increases and caloric demands increase. Babies therefore are at risk of hypoxia, hypoglycemia and apnea during rewarming. Management options are, skin to skin contact, a warm room or warm cot, a source of heat or warm towels.

Mild hypothermia

Hypothermic babies should be rewarmed as soon as possible.

Cold clothes should first be removed from the contact of baby

Supervised Kangaroo Mother Care (KMC) and skin to skin contact is the best method to rewarm a baby with mild hypothermia.

Room should be warm (28 to 32°C) and draught free.

Continue breastfeeding.

Most of the babies will regain their temperature. However if the baby remains hypothermic one hour after supervised KMC, the baby should be referred to the higher centre (District hospital/Tertiary level hospital)

A heating lamp/hot water bags/Aangethi (shegadi) can be used under super vision if KMC is not practiced.

Do not use hot water bottles for rewarming as they may cause burns. They should never be kept in direct contact with baby.

Monitor temperature, and Capillary Refill Time (CRT) during rewarming. Watch for apnea and hypoglycemia.

Moderate to severe hypothermia

Rapid rewarming over few hours is preferred to slow rewarming, as the latter is associated with high mortality.

Cold clothes should first be removed from the contact of baby

Rewarming is done by radiant warmer or incubator. Set the desired skin temperature on the radiant warmer or incubator and allow the baby to rewarm. (set skin temperature at 37°C in skin servo mode/or set air temperature at 35–36°C in air servo mode).

Keep the baby open until rewarming is complete.

Monitor temperature, oxygen saturation, capillary refill time (CRT) and blood sugar.

In the absence of radiant warmer or incubator, a heating lamp/hot water bags/Aangethi (shegadi) may be used under super vision.

At times for moderate to severe hypothermia KMC may be the only option.

At community health centers or Primary health centre, the baby should be stabilized first and then transported to higher centre.

Supportive management:

Prompt detection and management of hypoxia, hypoperfusion and hypoglycemia.

Dextrose infusion at 6 to 8 mg/kg/min.

If perfusion is poor give 20 ml/kg of RL or NS over 5 min.

Provide O₂ in case of moderate to severe hypothermia.

Watch for apnea, hypoxia and hypoglycemia during rewarming.

Thermoregulation in a Neonate