Hypothermia in the Newborn: An exploration of its cause, effect and prevention

Abstract

According to the World Health Organization (WHO, 1997) a newborn is normothermic when its body temperature is between 36.5°C and 37.5°C with hypothermia considered to be any temperature below this identified spectrum. Neonatal hypothermia is a potentially common and dangerous occurrence related to a number of risk factors categorised as environmental, physiological, behavioural and socioeconomic. Babies delivered by caesarean section are at particular risk of developing hypothermia. The purpose of this review is to provide an overview of the factors contributing to neonatal hypothermia including the physiology of thermoregulation, mechanisms of thermogenesis and heat loss, and the effects that neonatal hypothermia has on the newborn infant. The paper will also review the interventions, which may be adopted to prevent hypothermia occurring and to identify and intervene to reduce the impact of hypothermia including the effect of skin-to-skin contact as both a preventative and management strategy in neonatal hypothermia.

Full text

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Hypothermia in the newborn—an
exploration of its cause, effect and
prevention
Hypothermia is considered to be a
major contributing factor to neonatal
morbidity and, in extreme cases,
mortality (Kumar et al, 2009). Newborns are at risk
of hypothermia irrespective of their nationality,
sex and gestation. Modern technology, advanced
medical techniques and evidence-based practice
contribute to reduced rates of neonatal morbidity
and mortality in resource rich countries. Educated
and trained health professionals decrease the
risk of hypothermia in the newborn, while the
development of professional guidelines promote a
safer and more accurate management of neonatal
hypothermia and its effects (Knobel et al, 2005;
Chomba et al, 2008; Kumar et al, 2009; Sobel et
al, 2010).
Physiology of thermoregulation
Every human, regardless of age, has the ability to
maintain a core body temperature within a specific
range in order to preserve good body function.
Humans are homeotherms by nature; they produce
their own temperature and maintain it within
normal levels by balancing their heat loss and heat
production according to their needs (Gardner et al,
2011). This ability of balancing body temperature is
defined as thermoregulation. In contrast, difficulty
in maintaining this balance is characterised as
ineffective thermoregulation (Carpenito-Moyet,
2008). Newborn babies have a greater difficulty
maintaining their body temperature than adults
and children. This is seen most frequently and at
the highest degree in premature babies (Kumar
et al, 2009; Gardner et al, 2011). Preterm infants
have a greater need for an environment with
a neutral temperature due to their ineffective
thermoregulation (Lunze and Hamer, 2012). Once
born, the baby is exposed to an atmospheric
temperature (about 25°C)—significantly below
intrauterine temperature (approximately 37°C).
This ‘colder’ environment, in combination with
the newborn’s wet body, results in a heat-loss of
between 0.1°C to 0.3°C per minute and of up to
of 0.2°C to 1°C per minute (were no precautions
taken regarding neonatal thermal protection after
birth) (Waldron and MacKinnon, 2007; Kumar et
al, 2009). This cold-shock stimulates the newborn
to commence two main physiological mechanisms
in order to produce heat and to maintain its
temperature at normal levels (Kumar et al, 2009).
Extrauterine thermogenesis
The first mechanism allows the newborn to
activate non-shivering thermogenesis in order
to produce heat by using brown adipose tissue
(BAT). The second mechanism is peripheral
vasoconstriction whereby the blood vessels located
peripherally in the newborn’s body constrict in
an attempt to prevent further heat loss (Polin et
al, 2011). While Hillman et al (2012), Lunze and
Hamer (2012), and Polin et al (2011) suggest that
shivering thermogenesis can occur in newborn
babies, they consider it to be of ‘secondary
importance’ and to rarely occur. Regardless of the
type of thermogenetic mechanism, it is known
that preterm or low birth weight babies have a
significantly higher risk of poor thermoregulation
and increased heat-loss, due to their reduced body
Abstract
According to the World Health Organisation (WHO, 1997) a newborn
is normothermic when its body temperature is between 36.5°C and
37.5°C with hypothermia considered to be any temperature below this
identified spectrum. Neonatal hypothermia is a potentially common and
dangerous occurrence related to a number of risk factors categorised
as environmental, physiological, behavioural and socioeconomic. Babies
delivered by caesarean section are at particular risk of developing
hypothermia. The purpose of this review is to provide an overview of the
factors contributing to neonatal hypothermia including the physiology
of thermoregulation, mechanisms of thermogenesis and heat loss, and
the effects that neonatal hypothermia has on the newborn infant. The
paper will also review the interventions, which may be adopted to prevent
hypothermia occurring and to identify and intervene to reduce the impact
of hypothermia including the effect of skin-to-skin contact as both a
preventative and management strategy in neonatal hypothermia.
Keywords: Neonatal hypothermia, thermoregulation, thermogenesis,
heat loss mechanisms, skin-to-skin contact
Aliona Vilinsky
Midwife
Rotunda Hospital
Ireland
Ann Sheridan
Lecturer
UCD School of Nursing
Midwifery & Health
Systems
Health Sciences Centre
University College
Dublin

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as to a standard accepted normal temperature
range with different values identified in different
studies (Kumar et al, 2009).
The lack of an agreed normal temperature value
results in range of temperatures being accepted as
‘normal’ by various authors with neonatal norms
ranging between 36 and 37.7°C, depending on
the geographical location of the study as well
as the environmental/seasonal conditions (Lunze
et al, 2013). In the absence of agreement among
researchers, WHO guidelines are used to describe
the ‘normal’ ranges of neonatal normothermia and
hypothermia.
WHO (1997) considers a newborn to be
normothermic when temperature is between 36.5
and 37.5°C and hypothermic, when temperature
is below the spectrum mentioned above. In order
to facilitate the diagnosis and management of
hypothermia, WHO has divided this classification
into three well defined categories.
These categories are (WHO, 1997):
lMild hypothermia: with ranges between 36
and 36.4°C
lModerate hypothermia: ranging between 32
and 35.9°C
lSevere hypothermia: with any temperature
below 32°C.
While the WHO categories are useful, it does
not identify the body site associated with each
temperature category and this presents further
challenges with the potential to result in a degree
of confusion for both researchers and health
professionals. Rectal temperature is approximately
0.5–1°C higher than oral and/or axillar temperature
and is generally considered more representative of
the core temperature (Ganong, 2005). However,
given the risks associated with the measurement
of rectal temperature in newborn babies (i.e. rectal
perforation and nosocomial infections), it is not
recommended for newborn infants (Hertz, 2005).
WHO recommend that neonatal temperature is
measured at the axilla and recommends that rectal
temperatures are only measured in the event of
diagnosed neonatal hypothermia. While the above
classification is used by some maternity hospitals
internationally, its use is still narrowly spread.
Kumar et al (2009) identified that of 20 studies
reviewed, only seven used the WHO classification
system. This inconsistency of classifying neonatal
hypothermia may lead to under-recognition as
well as inadequate management of newborn
hypothermia (Kumar et al, 2009). It is essential,
therefore, that guidelines are developed for the
classification, prevention and management
strategies for neonatal hypothermia, and that they
are implementated by all medical, nursing and
fat storages, thinner skin, and increased body
surface compared to body mass (Waldron and
MacKinnon, 2007).
Neonatal heat-loss mechanisms
There are four basic mechanisms that cause heat
loss from the newborn; evaporation, radiation,
conduction, and convection (World Health
Organization (WHO), 1997; Waldron and
MacKinnon, 2007; Blackburn, 2008; Soll, 2008;
Kumar et al, 2009; Davis, 2009). These mechanisms
may cause heat-loss regardless of the type of birth,
gestation or birth environment, and awareness
of their effects by health professionals is critical
for the prevention and management of neonatal
heat-loss.
Evaporation occurs when the amniotic fluid
covering the newborn and the mucosa of the
respiratory tract of the baby, vaporise following
birth (Davis, 2009; Blackburn, 2008). Radiation
occurs when heat is lost from the baby to any surface
surrounding it that is not directly connected to it,
including walls or any surfaces close to the baby
which are colder than the baby (Davis, 2009).
Radiation can also positively affect the
temperature of a newborn with heat being gained
from sources that radiate heat, such as heat lamps
(Soll, 2008). Like radiation, conduction can result
in both heat-loss, when the warm, naked body of
the baby is placed on a colder surface; and heat-
gain when a baby is placed on a warmer surface,
for example on its mother’s chest during skin-to-
skin contact (Lunze and Hamer, 2012; Gouchon
et al, 2010; Galligan, 2006; WHO, 1997; Durand et
al, 1997)
Convection refers to the heat-loss from the
baby’s body through the surrounding air (Kumar
et al, 2009). This heat-loss can occur in either a
passive or forced way. Passive convection happens
when heat escapes from the skin surface of the
baby. Forced convection occurs when an air current
passes over the baby’s body, removing the heat in a
faster and more aggressive way (Blackburn, 2008).
The ability of a baby to create (thermogenesis) and
regulate its body temperature (thermoregulation)
are not always sufficient to enable the maintainence
temperature within the accepted ‘normal’ range. If
not prevented and/or managed, temperature loss
in a newborn will result in neonatal hypothermia
with serious and potentially fatal consequences.
Neonatal hypothermia
Neonatal hypothermia is a pathological condition
where the temperature of the newborn drops below
the recommended normal temperature ranges.
However, no agreement exists within the literature

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vasoconstriction, acrocyanosis, cold extremities)
(Waldron and MacKinnon, 2007; Onalo, 2013).
Disturbance associated with the baby’s metabolism
can also result in symptoms of hypoglycaemia,
hypoxia and eventually metabolic acidosis (Waldron
and MacKinnon, 2007; Freer and Lyon, 2011). Failure
to diagnose and manage hypothermia may lead
to chronic symptoms such as weight loss and/
or slow weight gain, with the eventual outcome
of negatively impeding normal growth and
development (UNICEF, 2004). Other complications
associated with hypothermia are severe sepsis and
neonatal death (WHO, 1997; Mullany, 2010; Lunze
and Hammer, 2012; Onalo, 2013).
Prevention and management of
neonatal hypothermia
There is a substantial body of literature suggesting
methods for preventing neonatal hypothermia
both for term and pre-term infants, whether born
in high or low resource countries (Soll, 2008;
Holtzclaw, 2008; WHO, 1997; Knobel et al, 2005).
The majority of the literature describes how to
prevent hypothermia by focusing on improving
environmental factors. In particular there is
agreement that the birth room temperature is
required to be a minimum of 25°C for term babies
and 26–28°C for pre-term babies (WHO, 1997;
Knobel et al, 2005). Soll (2008) suggests that
delivery rooms tend to be kept at a temperature,
while pleasant for health professionals and
mothers, does not adequately consider the needs of
newborn babies. Raising awareness among health
professionals about the effects of a cold room on
newborns and the requirement to maintain room
temperature above 25 or 26°C, is a simple yet critical
intervention to help prevent neonatal hypothermia.
The development and implementation of protocols
and education seminars to promote awareness and
enhance evidence-based knowledge is essential
in all birth environments (Nirmala et al, 2006;
Chomba et al, 2008; Kumar et al, 2009; Sobel
et al, 2010). However, maintaining a high room
temperature alone is insufficient, as prevention
of hypothermia due to environmental factors also
includes techniques of passive and active warming
(Holtzclaw, 2008).
Passive warming includes all man-made tools
that act as barriers to heat loss. The literature
identifies two fundamental heat loss barrier tools;
polyurethane caps and plastic bag wraps. The
majority of these studies have examined the effects
these tools have in the prevention of hypothermia
in pre-term babies (Roberts, 1981; Trevisanuto et
al 2010; Khairina et al, 2011; Gathwala et al, 2010;
Leadford et al, 2013). Active warming, refers to the
midwifery staff in each hospital.
Risk factors for neonatal
hypothermia
Neonatal hypothermia is related to a number
of risk factors, which are categorised by Lunze
et al (2013) into four main groups. These are:
environmental, physiological, behavioural and
socioeconomic. Environmental risk factors are
related to the geographical area in which the baby
is born, as well as time of the year (seasons) and
room temperature at the time of birth (Lunze et
al, 2013; WHO, 1997). While the prevalence of
neonatal hypothermia is higher during the winter
season, being born during the summer months or
in a warm tropical climate, does not automatically
eliminate the risk of a baby becoming hypothermic
and highlights the need for continued vigilance
to prevent, identify and manage neonatal
hypothermia.
Physiological risk factors mainly pertain to
neonatal issues such as prematurity, low birth
weight and intrauterine growth restriction. Babies
who are ‘small for dates’ or hypoglycaemic are also
at increased risk for hypothermia (Kumar et al,
2009; Gardner et al, 2011; Lunze et al, 2013).
Behavioural risk factors are considered to be
any non-evidence based practices, sometimes
undertaken for cultural reasons, which may
potentially cause a reduction in the baby’s
temperature resulting in hypothermia. Two
examples of such practices are: bathing of the
newborn immediately after birth, and/or
massaging the baby with essential oils after birth
(Bergstrom et al, 2005; Onalo, 2013).
Socioeconomic factors can also contribute to
neonatal hypothermia. Socially mothers who are
either young and inexperienced, or multiparas
who are minding many children; babies born in
families with a low income and/or from resource
poor countries are also more likely to be socially and
economically disadvantaged. Health professionals
in resource poor countries may not have access
to knowledge and/or best available evidence or
other resources to support best practice, therefore
babies born in these countries may also be at risk
of neonatal hypothermia (Lunze et al, 2013).
Effects of hypothermia on the
newborn
Hypothermia in a newborn is detected through
a number of objective signs resulting from the
impact on multiple body systems; cardiopulmonary
(bradycardia, tachypnea, apnoea); the central
nervous system (lethargy, distress, poor
feeding), and the vascular system (peripheral

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methods used to warm the baby in a direct way.
Two active warming methods identified in the
literature including radiant heaters and skin-to-
skin contact (Holtzclaw, 2008). Radiant warmers
and exothermic mattresses are used either during
the resuscitation of the newborn or to warm up a
cold baby. The first device spreads heat through
radiation while the second group of devices heats
the baby through conduction. Skin-to-skin contact
is an alternative and natural way of active warming
and one that has benefits for both baby and
mother.
Skin-to-skin contact
Skin-to-skin contact or Kangaroo care (KC) is a
well-explored practice over the past 25 years (Flynn
and Leahy-Warren, 2010; Lunze et al, 2013) whereby
the newborn is positioned in an upright position,
between its mother’s breasts, wearing only a nappy
and a hat (Nirmala et al, 2006; Gabriel et al, 2009;
Takahashi et al, 2011). This approach has been
recommended for its ability to maintain the baby’s
temperature within normal parameters (Carfoot et
al, 2005; Hunt, 2008; Gouchon et al, 2010; Gabriel
et al, 2011), and to warm up babies with mild
hypothermia (WHO, 1997). Among the recognised
benefits of skin-to-skin contact is its ability to
promote early initiation of breastfeeding and to
prolong its duration (UNICEF, 2004; Carfoot et al,
2005; Hunt, 2008; Bramson et al, 2010; Gouchon et
al, 2010; Gabriel et al, 2011; Suzuki, 2013; Svensson
et al, 2013) skin-to-skin contact also improves
the heart rate and oxygen saturation levels of the
baby (Nirmala et al, 2006; Hunt, 2008; Nolan and
Lawrence, 2009; Takahashi et al, 2011) and allows
earlier brain maturity in premature infants in
comparison with premature infants who had no
skin-to-skin contact (Kaffashi et al, 2013).
The majority of the research examining skin-
to-skin contact involves babies born vaginally
with only two papers focusing on full-term
babies temperatures born after caesarean section
(Gouchon et al, 2010; Nolan and Lawrence, 2009).
The first study was an experimental trial in which 34
mother and baby pairs were randomly selected and
separated into two groups (skin-to-skin contact
group and routine care (RC) group) after elective
caesarean section. The babies’ temperatures were
checked with an infra-red thermometer half
hourly for 2 hours post-birth and the mother’s
temperature was measured prior to and following
the surgical procedure and while holding their
babies. The findings demonstrated that babies
who had skin-to-skin contact were not at risk of
hypothermia when compared to the routine care
baby group (Gouchon et al, 2010). However, a careful
examination of the documented temperatures of
babies and mothers in this study indicates that, in
fact, the documented temperatures were indicative
of mild-to-moderate hypothermia (as defined
by WHO (1997)). Furthermore, some practices
used in this study are not recommended for
application by WHO. Examples include: bathing
babies after birth, delivery room temperatures
less than 25°C (mean of 22°C), and skin-to-skin
contact was not always commenced after birth.
. As a result difficulties exist with this study in
demonstrating that skin-to-skin contact following
caesarean section maintain neonatal temperature
within the range defined as normal by WHO
(1997). Furthermore, any connection between low
maternal temperatures with the prevalence of
hypothermia in infants is not explored.
Nolan and Lawrence (2009) reviewed a sample
of 50 mother–baby pairs which were separated
evenly into a skin-to-skin contact group and a RC
group. Infants’ temperatures were obtained from
medical record at 0.5, 1 and 2 hours post-birth;
however, 30% of temperatures were missing. This
study demonstrated that babies in the skin-to-skin
contact group had higher mean temperatures than
the RC-group babies, although this temperature
difference was not statistically significant. Maternal
temperature and delivery room temperature were
not included in this study thus no association
can be made between maternal temperature and
that of the baby during skin-to-skin contact. The
authors of both articles suggest further research is
required to investigate this subject fully (Gouchon
et al, 2010; Nolan and Lawrence, 2009). Given
that caesarean section rates have almost doubled
since the previous WHO report in 1985, there is
also a significant lack of evidence supporting the
benefits of skin-to-skin contact in preventing/
managing neonatal hypothermia following
caesarean section, therefore further research is
required taking into consideration these new
circumstances (WHO, 2010).
Conclusion
Neonatal hypothermia is a major risk factor
to neonatal morbidity and, in extreme cases,
mortality (Kumar et al, 2009). Newborns are at risk
of hypothermia irrespective of their nationality, sex
and gestation. Unlike adults and children, newborn
infants have greater difficulty maintaining their
body temperature.
Neonatal hypothermia is a condition that has
potentially life threatening effects for the newborn
infants worldwide. A significant challenge in
research and practice pertaining to neonatal
hypothermia is the absence of an agreed and

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internationally accepted definition of neonatal
normothermia and hypothermia. The failure
to have an agreed standard for temperature in
neonates results in continuing confusion about
how hypothermia is defined, when it should be
diagnosed and when intervention are required
to mitigate its deleterious effects. Agreement
is also required relating to site of temperature
measurement and type of thermometer used.
Therefore a suggestion emanating from this review
is that in the absence of an agreed definition
of neonatal normothermia and hypothermia,
future research should adopt the existing
WHO classification and categorisation. Doing
so will ensure greater consistency in terms of
measurement and interpretation of research
results and their translation into practice.
Preventing hypothermia by focusing on
improving environmental factors has been
identified as a simple and achievable yet critical
intervention. Further management includes
maintaining delivery room temperature between a
minimum of 25°C for term babies and 26–28°C for
pre-term babies as well as ensuring that all health
professionals are aware of and intervene to ensure
adequate temperature is maintained is required.
One of the suggested practices to prevent and or
treat mild hypothermia in newborn infants is skin-
to-skin contact. However, the available research
regarding skin-to-skin contact and hypothermia
in infants post caesarean section is limited.
Furthermore, the connection between maternal
hypothermia, skin-to-skin contact and neonatal
hypothermia after caesarean section has not been
explored in any depth and needs to be examined
(Horns et al, 2002; Fallis et al, 2006; Yokoyama et
al, 2008; Nolan and Lawrence, 2009; Gouchon et
al, 2010). Cold adversely impacts the health and
wellbeing of newborn infants and understanding
its causes and how to prevent it is an essential part
of the midwife and doctor’s role around the time
of birth. It is imperative that we understand the
process and what steps can be taken to prevent
hypothermia and in doing so, provide a safe and
secure environment into which a baby can be born.
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Key points
lThe newborn uses mainly non-shivering thermoregulation in order to
produce heat and to maintain its temperature at normal levels
lThere are four basic mechanisms that cause heat loss from the
newborn; evaporation, radiation, conduction and convection
lThe World Health Organization has divided hypothermia into three well
defined categories: mild, moderate and severe hypothermia
lRisk factors for neonatal hypothermia are divided into: environmental,
physiological, behavioural and socioeconomic risk factors
lPrevention and management of neonatal hypothermia include two
main categories: passive and active warming
lSkin-to-skin contact is the most effective method of active warming
for babies born after vaginal delivery. Further research is needed for
babies born by caesarean section

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