Journal of Perinatology (2008) 28, S57S59

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ORIGINAL ARTICLE

Heat loss prevention in neonates

RF Soll
Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington, VT, USA

Maintaining a neutral thermal environment is one of the key physiologic

challenges a newborn infant faces after delivery. Attention to detail
regarding the management of an infants neutral thermal environment
may lead to improvement in clinical outcome, including improved survival.
The details of this management cover a broad spectrum of interventions,
from attention to the general environment (such as delivery room
temperature) to specific individualized therapies, such as the use of
polyethylene occlusive skin wrap. Although an integral part of the routine
care of all newborns (whether term or preterm), these interventions have
unfortunately received little attention and study. A commitment to greater
understanding of these issues and their impact on newborns is essential if
we hope to improve their outcome.
Journal of Perinatology (2008) 28, S57S59; doi:10.1038/jp.2008.51

Keywords: heat loss; thermal stress; neutral thermal environment

Introduction
Maintaining a neutral thermal environment is one of the key
physiologic challenges a newborn infant faces after delivery. While
in utero, heat production by the fetus results in a fetal temperature
that is approximately half a degree higher than maternal
temperature.1 After birth, the newborn infant is exposed to a much
different environment. The risk of hypothermia is real and
potentially dangerous. Mechanisms of heat loss prevention range
from the most basic, almost instinctual, interventions (skin-to-skin
contact) to such highly technical interventions as the modern
incubator. This article will review the mechanisms of heat loss
in term and preterm neonates and the evidence behind the
efforts to prevent heat loss.
Sources of heat loss
The sources of heat loss in the neonate are reviewed in detail by
Knobel and Holditch-Davis2 and provide the basis for the discussion
below. There are four basic mechanisms through which heat is
transferred from the newborn to the environment. These include
radiation, conduction, convection and evaporation. All may
Correspondence: Dr RF Soll, Fletcher Allen Health Care, University of Vermont College of
Medicine, 111 Colchester Avenue, Burlington, VT 05401, USA.
E-mail: Roger.Soll@vtmednet.org

potentially contribute to an unstable thermal environment for the

newborn. Heat loss through radiation is related to the temperature
of the surfaces surrounding the infant but not in direct contact
with the infant. The newborn infant emits heat energy in the form
of infrared electromagnetic waves. The loss or gain of this radiant
energy is proportional to the temperature difference between the
skin and the radiating body; heat may be lost from the infants
body to a nearby cold wall or window. Heat may be gained from a
source of radiant energy, such as a heat lamp placed near the
infant. Heat loss from radiation may be the most important route
of heat transfer in infants older than 28 weeks gestational age. Heat
loss or gain via conduction occurs through direct contact with a
surface with a different temperature. Direct transfer of heat occurs
from the newborn to this surface. Heat can be lost directly to a
colder surface or gained from a warmer surface, such as a
warming mattress. Heat is transferred by convection when air
currents carry heat away from the body surface. If the infants body
surface is warmer than the surrounding air (as is almost always
the case in the delivery room), heat is first conducted into the air
and then carried away by the convective air currents. Last, heat
may be lost by evaporation. Evaporation occurs when water is lost
from the skin. During evaporation, water is converted from a liquid
to a gas, causing approximately 0.6 kcal of heat to be lost for every
1 g of water lost from the body.3 In the extremely low birth weight
(ELBW) infant, evaporative heat loss is the major form of heat loss
during the first week of life. This is particularly problematic for
infants of the lower gestational age. Transepidermal water loss in
infants is inversely correlated with gestational age; infants born at
25 weeks gestation age lose 15 times more water than term infants
due to immature and thinner skin.4

Response to thermal stress

Thermal regulation is distinctly different in newborns than in
adults. In adults, the responses to a cold body temperature include
peripheral vascular constriction, inhibition of sweating, voluntary
muscle movements, involuntary muscle movements (shivering)
and nonshivering thermogenesis. Neonates do not exhibit many
of these responses.
Nonshivering thermogenesis is the main mechanism of heat
production in neonates.5 Nonshivering thermogenesis occurs due to

Heat loss prevention in neonates

RF Soll

S58

an increase in sympathetic activity leading to an increase

in norepinephrine and thyroid-stimulating hormone.6
Thyroid-stimulating hormone leads to an increase in T4 and T3.
These mediators cause increased fat oxidation and heat production.
This represents a large caloric demand. A newborn infant left
unattended in a room at room temperature experiences energy
losses of approximately 150 kcal per min.
Hypothermia
If not adequately attended to, a newborn infant may experience
hypothermia and cold stress. Infants exposed to cold temperatures
are at risk for increased mortality.7,8 The normal temperature
range for a neonate is 36.5 to 37.7 1C. Cold stress may occur
when an infants temperature drops to 36.0 1C. Temperatures
below 36 1C are considered hypothermic. Moderate hypothermia
is considered to be between 32 and 36 1C. Severe hypothermia
is considered when the infants temperature is less 32 1C.9
Hypothermia results in a variety of physiologic stresses. The
infant has increased oxygen consumption, metabolic acidosis,
hypoglycemia, decreased cardiac output and increased peripheral
vascular resistance. Despite efforts to prevent heat loss, ELBW
infants continue to exhibit cold body temperatures after delivery
room stabilization and throughout the first hours of life. Over
two-thirds of ELBW infants are admitted to neonatal intensive
care units (NICUs) with temperatures that would be considered
hypothermic.10
Mechanisms of preventing heat loss
Mechanisms to prevent heat loss in newborn infants include
the most basic manipulation of the environment to the most
sophisticated and highly technical interventions. First and
foremost, the general environmental temperature must be
addressed. In general, delivery rooms are kept at a temperature
that is comfortable for the delivering mother and for the
attending staff. Rarely are the environmental needs of the infant
considered. This practice will increase heat loss in infants due
to both conduction and convection. Cold delivery rooms (delivery
rooms maintained at a temperature <26 1C) have been associated
with colder admission temperatures in the NICU for ELBW
infants.10 Raising delivery room temperature may be one of
the most direct ways that hypothermia and cold stress can be
addressed.
Other simple and straightforward mechanisms for maintaining
an improved thermal environment have been studied in clinical
trials. Roberts et al.11 evaluated the impact of the use of a stockinet
cap compared to routine care on core body temperature and
hypothermia at admission to the NICU. In this study, Roberts et al.
noted that the use of a stockinet cap led to a small improvement
in core body temperature in infants less than 2000 g at birth.
Journal of Perinatology

Skin-to-skin contact has been extensively studied in mothers and

healthy term babies. Skin-to-skin contact with mothers improved
axillary temperature 90 min after birth and improved abdominal
temperature within the first 21 min after birth. In addition,
skin-to-skin contact appeared to improve motherchild bonding.
Breastfeeding is more successful 3 months after birth in infants
who have been placed skin-to-skin with their mothers, and mothers
demonstrate greater affection for their newborn infants if they had
the opportunity to nurse them skin-to-skin immediately after
delivery. In preterm infants, skin-to-skin contact may be somewhat
more problematic. Bergman studied 35 inborn infants with birth
weights between 1200 and 1299 g. The skin-to-skin group was
placed on the mothers chests in a frog-like position. The control
group (13 infants) was immediately transferred to prewarmed,
servo-controlled, closed incubators. Skin-to-skin contact
significantly reduced the risk of hypothermia within 6 h of birth
when compared to conventional incubator care (relative risk 0.09,
95% CI 0.01, 0.64).12
One of the most commonly used mechanisms to create
a neutral thermal environment is the isolette. Perhaps no
other piece of medical equipment is more closely associated with
neonatal care than the isolette.13 The first modern incubators were
introduced in France in the 1880s. Drs Tarnier and Martin
introduced an incubator design that was based on poultry
incubators. An infant bed was warmed by a chamber of warm
water supplied from below by an internal boiler. A variety of
designs have been developed over the past 125 years. The
modern isolette is now a fixture in newborn care throughout
the developed world. However, little is known about the impact of
the modern isolette on infant outcome. Incubators lead to a
decrease in insensible water loss compared with other warming
sources, such as radiant warmers. The few studies that have
reported on significant outcomes, such as neonatal death, have too
few patients to give a precise estimate, although the trend is to
increase survival with the use of incubators.14 Radiant warmers
can be modified to include the use of heat shields. The use of a
heat shield appears to improve the performance of radiant
warmers.14
Warming mattresses can also be used to provide a neutral
thermal environment. Core body temperature on admission to the
NICU up to 2 h after birth seems to be improved with the use of
such mattresses.14 Fewer infants were reported to be hypothermic,
defined as an axillary temperature <36.5 1C (relative risk 0.30,
95% CI 0.11, 0.83).
Perhaps the most innovative approach to heat loss prevention is
the use of polyethylene occlusive skin wrapping. A variety of pilot
studies have demonstrated improved rectal temperature in
premature infants who are wrapped at the time of delivery.1618
In the few randomized controlled trials that have been
conducted, there is a clear advantage regarding improved
temperature on admission to the NICU. Interestingly, there is a

Heat loss prevention in neonates

RF Soll

S59

trend toward decreased mortality prior to discharge in premature

infants who have received plastic wrap.18 Large clinical trials
are now underway to attempt to address this issue.
Although the evidence is sparse, protocols regarding
delivery room management and immediate postdelivery room care
have been developed. These guidelines are reviewed in detail by
Knobel and Holditch-Davis.2 Delivery room temperatures of at least
25 1C (77 1F) are recommended. In most of these protocols
involving healthy term infants, the approach of drying, placing
the infant on warm linens, placing a cap on the infants head
and, if stable, being given to the mother so there can be direct
skin-to-skin contact is recommended. The Neonatal Resuscitation
Program guidelines suggest that for premature infants <28 weeks
gestation the use of a reclosable polyethylene bag without first
drying the skin may be appropriate.19 In all of these situations,
conductive heat loss needs to be minimized by placing the infant
under a radiant heater that has been turned on and warmed
prior the birth of the infant. For ongoing management, incubators
and radiant heaters need to be prewarmed prior to admitting the
infant to this environment. Linen clothing and other thermal
mattresses should also be prewarmed before placing these items
next to the infants skin. Procedures, such as placement of
umbilical and venous catheters, need to be done in a timely
manner because infants cannot be adequately warmed with
radiant sources while under drapes. Humidity is another factor
that needs to be addressed, particularly in the ELBW infant. An
appropriate humidity of 50% or greater may reduce evaporative
heat loss.1
Attention to details regarding an infants neutral thermal
environment may lead to important improvement in clinical
outcome, including survival. The details of this management
cover a broad spectrum of interventions, from the general
environment (such as delivery room temperature) to specific
individualized therapies, such as the use of polyethylene
occlusive skin wrap. Although an integral part of the routine
care of all newborns (whether term or preterm), these interventions
have unfortunately received little attention and study. A
commitment to greater understanding of these issues and
their impact on newborns is essential if we hope to improve
outcome.
Disclosure
Nothing to declare.

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Journal of Perinatology