Normal rectal temperature in term and preterm infants is 36.5 to 37.5° C. Although hypothermia is a core temperature < 36.5° C, there may be cold stress at higher temperatures whenever heat loss requires an increase in metabolic heat production.
Pathophysiology of Hypothermia in Neonates
Thermal equilibrium is affected by relative humidity, air flow, direct contact with cool surfaces, proximity to cool objects, and ambient air temperature. Neonates are prone to rapid heat loss and consequent hypothermia because of a high surface area to volume ratio, which is even higher in low-birth-weight neonates. There are several mechanisms for heat loss:
Radiant heat loss: Bare skin is exposed to an environment containing objects of cooler temperature.
Evaporative heat loss: Neonates are wet with amniotic fluid.
Conductive heat loss: Neonates are placed in contact with a cool surface or object.
Convective heat loss: A flow of cooler ambient air carries heat away from the neonate.
Prolonged, unrecognized cold stress may divert calories to produce heat, impairing growth. Neonates have a metabolic response to cooling that involves chemical (nonshivering) thermogenesis by sympathetic nerve discharge of norepinephrine in the brown fat. This specialized tissue of the neonate, located in the nape of the neck, between the scapulae, and around the kidneys and adrenals, responds by lipolysis followed by oxidation or re-esterification of the fatty acids that are released. These reactions produce heat locally, and a rich blood supply to the brown fat helps transfer this heat to the rest of the neonate’s body. This reaction increases the metabolic rate and oxygen consumption 2- to 3-fold. Thus, in neonates with respiratory insufficiency (eg, the preterm infant with respiratory distress syndrome Respiratory Distress Syndrome in Neonates Respiratory distress syndrome is caused by pulmonary surfactant deficiency in the lungs of neonates, most commonly in those born at < 37 weeks gestation. Risk increases with degree of prematurity... read more ), cold stress may also result in tissue hypoxia and neurologic damage. Activation of glycogen stores can cause transient hyperglycemia. Persistent hypothermia can result in hypoglycemia and metabolic acidosis and increases the risk of late-onset sepsis Late-onset neonatal sepsis Neonatal sepsis is invasive infection, usually bacterial, occurring during the neonatal period. Signs are multiple, nonspecific, and include diminished spontaneous activity, less vigorous sucking... read more and mortality.
Despite their compensatory mechanisms, neonates, particularly low-birth-weight infants, have limited capacity to thermoregulate and are prone to decreased core temperature. Even before temperature decreases, cold stress occurs when heat loss requires an increase in metabolic heat production.
The neutral thermal environment (thermoneutrality) is the optimal temperature zone for neonates; it is defined as the environmental temperature at which metabolic demands (and thus caloric expenditure) to maintain body temperature in the normal range (36.5 to 37.5° C rectal) are lowest. The specific environmental temperature required to maintain thermoneutrality depends on whether the neonate is wet (eg, after delivery or a bath) or clothed, its weight, its gestational age, and its age in hours and days.
Etiology of Hypothermia in Neonates
Hypothermia may be caused by environmental factors, disorders that impair thermoregulation (eg, sepsis Neonatal Sepsis Neonatal sepsis is invasive infection, usually bacterial, occurring during the neonatal period. Signs are multiple, nonspecific, and include diminished spontaneous activity, less vigorous sucking... read more , intracranial hemorrhage Intracranial Hemorrhage in Neonates The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more , drug withdrawal Prenatal Drug Exposure Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus... read more ), or a combination.
Risk factors for hypothermia include prematurity Preterm Infants An infant born before 37 weeks of gestation is considered preterm. In 2021 in the United States, 10.48% of births were preterm ( 1), and in 2018, 26.53% of births were early term (significantly... read more , delivery in an area with an environmental temperature below the recommended levels, maternal hypertension Hypertension in Pregnancy Recommendations regarding classification, diagnosis, and management of hypertensive disorders (including preeclampsia) are available from the American College of Obstetricians and Gynecologists... read more , cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. Up to 30% of deliveries in the US are cesarean. The rate of cesarean delivery fluctuates. It has recently increased, partly... read more , and low .
Treatment of Hypothermia in Neonates
Rewarming in an incubator or under a radiant warmer
Hypothermia is treated by rewarming in an incubator or under a radiant warmer. The neonate should be monitored and treated as needed for hypoglycemia Neonatal Hypoglycemia Hypoglycemia is difficult to define in neonates but is generally considered a serum glucose concentration < 40 mg/dL (< 2.2 mmol/L) in symptomatic term neonates, < 45 mg/dL (< 2... read more , hypoxemia, and apnea Apnea of Prematurity Apnea of prematurity is defined as respiratory pauses > 20 seconds or pauses < 20 seconds that are associated with bradycardia (< 100 beats/minute; 1), central cyanosis, and/or oxygen... read more . Underlying conditions such as sepsis Neonatal Sepsis Neonatal sepsis is invasive infection, usually bacterial, occurring during the neonatal period. Signs are multiple, nonspecific, and include diminished spontaneous activity, less vigorous sucking... read more , drug withdrawal Prenatal Drug Exposure Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus... read more , or intracranial hemorrhage Intracranial Hemorrhage in Neonates The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more may require specific treatment.
Prevention of Hypothermia in Neonates
Maintaining an appropriate environmental temperature is the most important step in preventing hypothermia in neonates. The World Health Organization (WHO) recommends the delivery room temperature be at least 25 to 28° C (77.0 to 82.4° F) and that neonates be dried immediately and placed in skin-to-skin contact with the mother and covered. (See also the WHO's practical guide to thermal protection of the newborn.)
Preterm infants who are hypothermic when admitted to the neonatal intensive care unit (NICU) have increased morbidity and mortality; increasing the temperature in the delivery and operating rooms has been found to reduce the incidence of hypothermia on NICU admission. Thus, the American Academy of Pediatrics and the American Heart Association recommend that delivery and operating rooms where preterm infants are delivered have a temperature of 23 to 25° C (74 to 77° F) (1 Prevention references Hypothermia is defined by the World Health Organization as a core temperature < 36.5° C (97.7° F). In preterm infants, hypothermia increases morbidity and mortality. Hypothermia may be purely... read more ). Because raising room temperature only when delivery is anticipated may allow radiant heat loss to cool surfaces and convective heat loss caused by rapid airflow, the room should be maintained at the recommended temperature continually.
At the time of birth, neonates should be immediately dried and then swaddled (including the head) in a warm blanket to prevent evaporative, conductive, and convective losses. For a preterm infant, placement into a polyethylene bag immediately after delivery has been found to help maintain the infant's temperature; some clinicians do not dry the infant before placement in the bag because the increased humidity may be beneficial (2 Prevention references Hypothermia is defined by the World Health Organization as a core temperature < 36.5° C (97.7° F). In preterm infants, hypothermia increases morbidity and mortality. Hypothermia may be purely... read more ).
A neonate exposed for resuscitation Neonatal Resuscitation Extensive physiologic changes accompany the birth process, sometimes unmasking conditions that posed no problem during intrauterine life. For that reason, a person with neonatal resuscitation... read more or observation should be placed under a radiant warmer without anything blocking heat to the neonate, such as a blanket, to prevent radiant losses. Sick neonates should be maintained in a neutral thermal environment to minimize the metabolic rate. The proper incubator temperature varies depending on the neonate’s birthweight and postnatal age, and humidity in the incubator. Alternatively, heating can be adjusted with a servomechanism set to maintain skin temperature at 36.5° C.
1. Weiner GM, ed: Textbook of Neonatal Resuscitation, ed. 8. Itasca, American Academy of Pediatrics, 2021.
2. Oatley HK, Blencowe H, Lawn JE: The effect of coverings, including plastic bags and wraps, on mortality and morbidity in preterm and full-term neonates. J Perinatol 36(Suppl 1):S82–S88, 2016. doi: 10.1038/jp.2016.35
Neonates, particularly very low-birth-weight infants, are susceptible to environmental hypothermia; disorders that impair thermoregulation (eg, intracranial hemorrhage, sepsis) increase risk.
The optimal ambient temperature for neonates is that at which caloric expenditure needed to maintain normal body temperature is lowest, typically between 36.5° C and 37.5° C.
Rewarm neonates in an incubator or under a radiant warmer and treat any underlying conditions.
Prevent hypothermia by maintaining an appropriately warm environmental temperature in newborn care areas, immediately drying the neonate, and then swaddling full-term neonates or placing preterm infants in a polyethylene bag.
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
World Health Organization (WHO): Thermal protection of the newborn: A practical guide