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Temperature management in newborn infants

Authors 

van Leeuwen M, Frauenfelder O, Oude-Reimer M, Camba F, Ceccatelli M, Hankes-Drielsma I, Kalbér A, Kühn T, Silva E

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User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Environmental management of temperature and humidity is necessary to optimise the management of newborn infants.

Rationale

Normal axillary temperature is defined to be between 36.5 and 37.5 degrees Celsius by international bodies. (1,2) Variation of body temperature from normal is more common in preterm and ill infants. The optimal environmental temperature is termed the thermo-neutral temperature, as defined as the temperature at which metabolic requirements of the infant are minimal. (3) Different studies have shown that low body temperatures in newborn infants are associated with mortality, increased risk of illness and delayed growth. (4–6) Similarly, high body temperature is associated with adverse outcomes, particularly in infants following hypoxia ischemia and very preterm infants. (7,8)

The physiological and behavioural responses of preterm infants to hot or cold environments are less developed than in term infants. Reduced bodyweight-body surface ratio can result in higher heat loss. Preterm infants can also have high trans-epidermal water losses through evaporation because of their thin porous skin. High evaporative water loss causes high energy expenditure due to skin cooling, increasing neonatal morbidity. (3) In addition, preterm and ill infants may be exposed during procedures to insert central catheters, endo-tracheal intubation and resuscitation, which cause fluctuation in body temperature.

Benefits

Short-term benefits

  • Reduced risk of hypothermia (9)
  • Reduced risk of hyperthermia (7,9)
  • Minimises trans-epidermal water loss (10)
  • Improved comfort and reduced physiologic instability and stress (11)
  • Stabilised body temperature by skin-to-skin care (12,13)

Long-term benefits

  • Improved developmental outcomes (4–6)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed by healthcare professionals about the ideal body temperature and importance of temperature management. (14) A (High quality)
B (High quality)
Patient information sheet
       
2. Parents are invited to measure their infant’s temperature. (14,15) A (High quality)
B (High quality)
Patient information sheet, parent feedback
       
3. Skin-to-skin care is provided as soon as possible. (3,12,13) (see TEG Infant- and family-centred developmental care) A (High quality)
B (High quality)
Audit report, parent feedback, patient information sheet
       
For healthcare professionals    
4. A unit guideline on temperature management is adhered to by all healthcare professionals. (3,16) A (High quality)
B (High quality)
Guideline
       
5. Training on temperature measurement, management including incubator settings for the best thermal environment, the importance of maintaining normothermia in the newborn infant, and the risks of hypothermia and hyperthermia, is attended by all responsible healthcare professionals. (3–6,9,17–21) A (High quality)
B (High quality)
Training documentation
       
For neonatal unit    
6. A unit guideline on temperature management is available and regularly updated. (3,16) A (High quality)
B (High quality)
Guideline
       
7. Appropriate facilities for temperature management are available. (5,17,22–24) A (Moderate quality)
B (High quality)
Audit report, guideline
       
For hospital    
8. Training on temperature management is ensured. (3–6,9,17–21) A (High quality)
B (High quality)
Training documentation
       
9. Appropriate facilities for neonatal temperature management are provided. (5,17,22–24) A (Moderate quality)
B (High quality)
Audit report, guideline
       
For health service    
10. Rates of hypo- and hyperthermia are monitored. (25) A (High quality)
B (High quality)
Audit report
       

Where to go

Further development Grading of evidence
For parents and family  
N/A  
For healthcare professionals  
N/A  
For neonatal unit  
N/A  
For hospital  
N/A  
For health service  
  • Contribute to benchmarking strategies to monitor temperature control in different settings, e.g. postnatal ward or transfer. (25)
A (High quality)
B (High quality)
   

Getting started

Initial steps
For parents and family
  • Parents are verbally informed by healthcare professionals about the ideal body temperature and importance of temperature management.
  • Parents are encouraged to measure their infant’s temperature and contribute to thermal management.
For healthcare professionals
  • Attend training on temperature measurement, management including incubator settings for the best thermal environment, the importance of maintaining normothermia in the newborn infant, and the risks of hypothermia and hyperthermia.
For neonatal unit
  • Develop and implement a unit guideline on temperature management.
  • Develop information material on the ideal body temperature and importance of temperature management for parents.
For hospital
  • Support healthcare professionals to participate in training on temperature management.
For health service
  • Develop benchmarking of admission temperatures.
 

Description

Preterm infants and very low birthweight infants are prone to rapid heat loss through mechanisms of conduction, evaporation, radiation and convection. Low body temperature is directly related to higher mortality and morbidity rates. (4,8,18) A very preterm infant’s admission temperature is inversely related to in-hospital mortality, with a 28% increase in the mortality rate per every 1 °C of decrease in the admission temperature. Low temperature on admission increases the rate of oxygen consumption, causes pulmonary and systemic vasoconstriction, and is associated with worsening of respiratory distress, metabolic acidosis, hypoglycaemia, coagulation disorder, and increases the risk of late sepsis and peri-intraventricular haemorrhage. (26,27)

Careful temperature management should be a standard in delivery-rooms, during transport and in the NICU.

Delivery room
In preparation for the transition process or resuscitation of a preterm infant, the temperature in the delivery room should be increased to 23°C–25°C for term infants, and should be >28°C for infants <28 weeks of gestation. (2,16,28,29) For infants born before 32 weeks’ of gestation, the neonatal team should take steps to prevent cooling by 1) placing a thermal mattress under the newborn infant, 2) using plastic wrap or a bag to cover the infant without drying, and 3) placing a hat immediately after delivery. (27,30,31) For infants who require respiratory support gases should be heated and humidified. The target axillary temperature in a newborn infant during resuscitation is between 36.5°C and 37.5°C. (6,28) Hyperthermia (>38°C) should be avoided due to increased risk of RDS, neonatal seizures, cerebral palsy and early death. (32–35) Admission temperature should be regularly audited.

Transport
The transport of the newborn infant from delivery-room to the NICU needs to be safe and controlled. Very preterm infants should be transferred in a suitable transport incubator, pre-heated to 37°C, if it is not possible to effect the transfer skin-to-skin with mother or father.

NICU
Room temperature in the NICU should be maintained >23°C. Incubator temperature is dependent on the infant’s size and age. Each unit should have strict protocols for the management of environmental incubator temperature and the use of humidity to reduce evaporative water loss, that are regularly audited. Skin-to-skin care is used whenever possible (see TEG Infant- and family-centred developmental care) and care should be taken to avoid thermal stress during bathing. (see TEG Care procedures)

Sources

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November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, van Leeuwen M, Frauenfelder O et al., European Standards of Care for Newborn Health: Temperature management in newborn infants. 2018.

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