Temperature control in the neonate

SympoSium: neonatology

Temperature control in the neonateandrew lyon

Abstractthe control of body temperature is a challenge to the newborn baby,

particularly if immature or sick. Behavioural responses to environmental

temperature changes are almost non-existent. the preterm baby has lim-

ited ability to mobilize energy sources to combat high heat losses, par-

ticularly from evaporation. there is evidence that many preterm babies

are still being allowed to get cold during stabilization and resuscitation.

a low temperature at the time of admission to a neonatal unit is inde-

pendently associated with an increased mortality in the preterm infant.

preventing evaporative heat losses at this time can abolish hypothermia

on admission. Further studies are needed to determine the optimum

thermal management immediately after delivery. there are no studies

that show any difference in outcome for preterm babies nursed in incu-

bators compared to those under radiant heaters. High transepidermal

water loss (teWl) results in increased fluid and heat loss in the preterm

baby. this can be managed by increasing environmental humidity al-

though this may be more difficult when babies are nursed under radiant

heaters. nursing the baby in high humidity reduces teWl but more work

is needed to show if a reduction in water movement has an adverse ef-

fect on the rate of maturation of the skin. the way a baby interacts with

their environment is always changing and, whatever temperature and

humidity settings are first used, it is necessary to monitor continuously

the thermal balance. the continuous measurement and display of a cen-

tral and a peripheral temperature gives an early indication of cold stress

before there is any fall in the baby’s core temperature.

Keywords central–peripheral temperature difference; humidity;

newborn; preterm; temperature control; transepidermal water loss

Introduction

Children and adults maintain a constant deep body tempera-ture over a wide range of ambient thermal conditions (homeo-thermic). This is achieved by physiological and behavioural responses that control the rate at which heat is produced or lost. The newborn infant is also homeothermic but control of body temperature can only be achieved over a narrower range of ambient conditions. The preterm infant has even greater dif-ficulty in body temperature control, and the most immature infants behave at times as if they are poikilothermic – their body

Andrew Lyon MA MB FRCP FRCPCH is Consultant Neonatologist at the

Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh,

Little France, Edinburgh EH16 4SA, UK.

paeDiatRiCS anD CHilD HealtH 18:4 15

temperature tending to drift up and down with the ambient tem-perature. The aim in neonatal care is to provide a thermal envi-ronment which keeps body temperature in the normal range, and which does not stress the infant to produce or lose large amounts of heat.

The importance of keeping newborn babies warm has been known for centuries.1 In the 1950s William Silverman and others showed a clear link between temperature control and neonatal mortality. In a series of randomized controlled trials they showed that keeping babies warm in incubators resulted in an absolute reduction in mortality of 25%.2,3 In many of these studies a sig-nificant numbers of babies were under 1000 g birthweight and the improvement in survival was seen in all birthweight groups. No other single change in practice has had such a dramatic effect on mortality of the newborn baby.

The EPICure study of a cohort of babies under 26 weeks’ ges-tation, delivered in the UK in 1995, showed that low admission temperature was an independent risk factor for neonatal death even after adjustment for other known risks.4 In this population study 30%, 43% and 58% of babies at gestations 25, 24 and 23 weeks, respectively, who were admitted to neonatal units, had an admission temperature below 35 °C. The report of the CESDI 27/28 project showed that, in babies born at 27 and 28 weeks’ gestation, an admission temperature below 36 °C was found in 73% of those who died compared with 59% in those who survived.5

The importance of early temperature as a predictor of out-come in preterm babies is shown by its inclusion in risk scoring systems such as the Clinical Risk Index for Babies (CRIB)6 and the Score for Neonatal Acute Physiology – perinatal extension (SNAPPE-II).7

Extended periods of cold stress can lead to harmful side effects, including delayed adaptation to extrauterine life, hypoglycaemia, respiratory distress, hypoxia, metabolic acidosis, coagulation defects, acute renal failure, necrotizing enterocolitis, failure to gain weight or weight loss and death.

Many factors are associated with an increased risk of hypo-thermia. These include prematurity, intrauterine growth restric-tion, central nervous system damage and congenital defects such as abdominal wall defects where bowel is exposed to the air.

Induced cooling may help protect the brain of the asphyxiated term newborn8 but prolonged exposure to cold in babies with no brain injury must be avoided. Overheating the baby with sus-pected asphyxial brain injury must also be prevented as hyper-thermia may increase the degree of damage.9

Temperature control at delivery

The temperature of the fetus is between 0.5 and 1°C higher than that of the mother. At birth the infant is exposed to a colder environment than in utero. Although some heat loss may be important in stimulating onset of breathing and other adaptive mechanisms,10 it is important to avoid a continuing drop in body temperature. In the term baby this is achieved by drying, wrapping and placing under a radiant heater if resuscitation is needed.

The preterm baby often needs a period of stabilization or resuscitation and traditionally has been placed naked on a resuscitaire. Despite the use of direct radiant heat, studies

5 © 2007 elsevier ltd. all rights reserved.


such as EPICure and CESDI 27/28, have shown that many of these babies are cold by the time of admission to the neo-natal unit. In a study from the USA, of 5277 babies with a birthweight below 1500 g in the Neonatal Research Network, only 10.8% had an admission temperature of 37 °C or above. In nearly half the babies the first recorded temperature was below 36 °C. Admission temperature was inversely related to mortality (28% increase per 1 °C) and late-onset sepsis. There was an association of low temperature with the need for intubation at delivery, suggesting that radiant heat alone had not been sufficient to offset the heat losses during prolonged resuscitation.11

A baby exchanges heat with their environment by conduc-tion, radiation, convection and evaporation. The preterm baby is at high risk of net heat loss because of a high surface area to volume ratio and increased transepidermal water loss, resulting in heat lost by evaporation. The normal surge in metabolic rate which occurs after birth is much reduced, limiting the production of heat from the mobilization of brown fat. The development in the control of skin blood flow is also delayed in the imma-ture baby, reducing their ability to maintain heat by peripheral vasoconstriction.12

Evaporation is the major mechanism of heat loss during resus-citation. The baby will lose 560 cal for every millilitre of water evaporated from the skin (the heat of evaporation). Vohra et al have shown that using polyethylene occlusive skin wrapping, around the body up to the neck, during resuscitation of preterm babies under 28 weeks’ gestation significantly improves the central temperature on admission to the neonatal unit.13 This is due to a reduction in evaporative heat losses. In this random-ized study, comparing rectal temperature on admission of babies wrapped at birth with those managed without wrapping, body size was an important determinant of heat loss, the mean rectal temperature increasing by 0.21°C with each 100 g increase in birthweight.

The use of plastic bags, leaving just the head exposed, has also been found to be effective in reducing transepidermal water and heat losses during resuscitation.14 It is important not to expose the skin once the baby is in the plastic bag – clini-cal inspection and auscultation can be done through the bag and if vascular access is needed, a small hole can be cut in the plastic.

Whether a plastic bag or occlusive dressing is used, it is important to remember that there is still significant heat losses from the head which should be covered with a hat during resus-citation and stabilization.15

Concern has been expressed about hyperthermia in some babies, possibly secondary to the use of occlusive dressings or plastic bags.16 Two babies in the study by Vohra et al13 had a rectal temperature above 37.5 °C. In a small study from Edin-burgh, 11 of 27 babies under 28 weeks’ gestation managed in plastic bags were found to have an admission temperature above 37.5 °C. Of these, eight were above this temperature from birth, possibly associated with a maternal pyrexia, while in the other three the temperature increased (by no greater than 0.6 °C) after being placed in the bag.17

Preventing evaporative heat loss using occlusive dressings or plastic bags has been shown to be effective in preventing hypothermia after delivery, at least in babies under 29 weeks’


gestation. A Cochrane review concludes that in this group con-sideration should be given to their use in the delivery suite.18

No study has yet been powered to show that these treatments reduce neonatal mortality and long term outcome has not been evaluated. Further large, high quality randomized controlled tri-als are still needed. Not least, we need to confirm that the mem-brane wrapped around the infant’s trunk does not damage the immature skin.

Transport

The transport of the newborn baby, particularly the preterm infant, presents many challenges. Transport is not only between units but also within a hospital, e.g. from the delivery suite to the neonatal unit or to and from the radiology department or the operating room.

The most effective mode of transport within a hospital building will depend on the local configuration. Newly designed neonatal units should be closely linked to the delivery suite to prevent the need for transport over long distances along draughty corri-dors. A randomized controlled study comparing transfer from the delivery suite to the neonatal unit of babies under 28 weeks’ ges-tation using a radiant warmer or a transport incubator showed no difference in admission temperature in the two groups.19 All babies in both groups had been managed with occlusive wrap-ping in the delivery room.

Transfer between units is most commonly by road in an ambulance. Although incubators are heated there is likely to be high radiative heat losses, especially in cold weather. This can be reduced by covering the incubator and by using blankets around the baby. Evaporative heat losses can be reduced by using a plas-tic bag. There will be high evaporative heat losses from the respi-ratory tract if ventilator gases are not heated and humidified. Heated gel mattresses, which warm patients through release of latent heat of crystallization, can be used during transport. The baby gains heat by conduction. Safe use of this device is critically dependent on gel temperature at the point of activation.20

Thermal care within the neonatal unit

The full-term newborn infant will maintain a normal temperature if nursed fully dressed in a cot in a warm room. Recommenda-tions for optimum environmental conditions for nursing healthy infants in the newborn period have been published.21

Skin-to-skin contact is an effective way of maintaining body temperature, even in the very preterm infants.22,23

The preterm baby, even if well, may be unable to maintain an adequate temperature without some additional source of heat. There are a variety of ways of providing this, including incuba-tors, radiant heaters and heated mattresses. The heated gel- or water-filled mattress is very effective in helping maintain the temperature of the well preterm baby while allowing easy access for parents and staff.

Clothes act as a significant thermal barrier to heat loss. New-born infants needing intensive or high dependency care are often nursed naked to allow close observation and easy access for examination and treatment. This significantly affects tempera-ture control as the resistance to heat loss of a naked baby is three times less than that of a clothed, wrapped infant.24,25



Control of the thermal environment is important for all babies, but it is the unwell, immature babies who present the greatest challenge. They are usually nursed either in an incubator or on an open platform, under a radiant heater. The early clinical trials of Silverman and others showed that the use of incuba-tors to keep babies warm improved outcome. There have never been any controlled studies that show that radiant heaters are as effective clinically. Babies nursed with similar skin temperatures have a higher basal metabolic rate when managed under radi-ant heaters compared with incubators.26 However, no study has shown any significant difference in outcome for babies nursed using either of these devices, although Meyer et al27 reported a non-significant trend to better outcome in babies nursed under a radiant heater.

Transepidermal water loss

Silverman in the 1950s showed that babies are better able to maintain their body temperature in a humid environment com-pared with a dry environment.28

In the 1970s it became possible to measure the evaporation rate of water from the skin surface.29 Transepidermal water losses (TEWL) are high in the immature baby. At 26 weeks’ gestation, on day 1 of life, the baby can lose over 50 kcal/kg by evapora-tion, compared with less than 5 kcal/kg in the term infant.30 Data from Hammerlund et al30 suggest that the skin matures rapidly after birth and adult losses are reached around 10 d of age in all babies. After this time the major source of heat loss in all babies is from radiation. More recently others have shown that in the very immature baby the maturation of the skin may take longer, and 30 weeks’ corrected age is a better estimate of the time taken to reach adult TEWL.31 In practical terms the amount of trans-epidermal fluid losses after about 14 d are unlikely to remain a major problem.

Evaporative water loss from the skin depends on the ambi-ent water vapour pressure, irrespective of how the baby is being nursed. The high rate of evaporation during care under a radiant heater is due to the low ambient water vapour pressure and not any direct effect of non-ionizing radiation on the skin.32

TEWL results in loss of both heat and fluid. Under a radi-ant heater the temperature of the baby is maintained because of radiant heat gain, but the large fluid losses can be a seri-ous problem. Various interventions can help reduce evaporative fluid losses, mainly from the skin but also from the respiratory tract.

IncubatorsWithin an incubator it is relatively easy to raise the ambient water vapour pressure by introducing humidity within the can-opy. The use of a relative humidity of 80%, for the first 7–10 d of life, significantly reduces TEWL in even the most immature infant.30 Modern designs use a sealed water system to produce the humidity, minimizing the concerns about possible increased infection risk in humidified incubators.

Opening the incubator portholes results in a rapid fall in humidity although the air temperature within the canopy is maintained. The handling of babies within incubators has been shown to be associated with increased thermal stress33 and it is likely that this is due to the fall in environmental humidity,


resulting in increased evaporative heat losses. Increasing the air temperature will compensate for the heat loss but incubators are relatively slow to respond to such changes.

High humidity within the incubator can cause ‘rain out’ on the inside of the canopy. This is caused by water condensing on the cold walls and can be minimized by ensuring an adequate environmental temperature within the nursery (around 28 °C).

Radiant heatersTEWL is the major problem in babies nursed under radiant heaters. A shield or plastic blanket can be used to cover the baby and create a humidified microenvironment. Warm humid-ified air can be passed under the shield or blanket but care must be taken to control the temperature and to make sure it does not affect the skin servo probe attached to the baby. If the cover is removed the humidity falls rapidly and the baby starts to lose large amounts of fluid. The radiant heater will compen-sate for any fall in the baby’s temperature but fluid losses are a concern.

Maintenance of skin integrityDamage to the fragile skin of the preterm baby occurs easily and results in a significant increases both in TEWL and the risk of infection. Maintaining skin integrity is very important and any adhesives on the skin should be kept to a minimum.

Skin coveringsTransparent adhesive dressings on the skin reduce fluid loss but cause significant damage, making them impractical.

Use of semipermeable non-adhesive dressings lowers TEWL and reduces the bacteria number in the covered skin.34 In a ran-domized controlled trial in infants less than 1000 g the skin cov-ered with a semipermeable membrane was in better condition, but there were no significant differences in fluid requirements or electrolyte status.35

Emollients are used to cover the skin and prevent fluid loss. They have been shown to be safe and do not cause burns when exposed to radiant heat or phototherapy. Their use reduces excessive drying, skin cracking and fissuring. However, the effect of these products wears off after about 3 h, necessitating repeated application.36 Treated infants had better skin scores and there were no differences in bacterial skin counts, fungal counts or colonization patterns, or fluid requirements and electrolyte status.37

Ventilator humidityThere can be high fluid and heat losses from the respiratory tract of the ventilated baby. It is important to use adequate humidifi-cation in all ventilator circuits.

PhototherapyThe effect of phototherapy on TEWL is variable. No change was found in a group of thermally stable infants,38 yet others have reported an increase in TEWL despite skin temperature and rela-tive humidity remaining unchanged.39 Rather than increase fluid intake just because phototherapy has been started, fluid balance should be individually monitored and adjusted if necessary.

Modern phototherapy units produce little heat but there is still some increase in the temperature of the top of the incubator



canopy. This will reduce radiative heat losses and the incubator air temperature may have to be reduced to prevent a rise in the baby’s temperature.

Transepidermal water loss and skin maturationTransepidermal movement of water is essential for the acceler-ated maturation of the skin of the immature baby.40 It also helps in maintaining the epidermal barrier function.41

Use of high ambient humidity in nursing preterm babies under 28 weeks’ gestation has been shown to reduce the rate of promo-tion of skin barrier development.42

More work in the immature baby is needed to determine the optimum level and duration of environmental humidity, as well as the associated benefits and risks of use, and the effects of humidification on clinically important outcomes.43

Temperature monitoring and its interpretation

The concept of the neutral thermal environment, in which a baby uses a minimum of energy to maintain thermal stability, has proven useful in determining the optimum environmental temperature for nursing the newborn baby.44,45 The published data are now old and do not include any allowance for added humidity. This makes them less useful in the care of the very immature baby.

The way a baby interacts with their environment is always changing and, whatever settings are first used, it is necessary to monitor continuously the thermal balance. Continuous mea-surement of oxygen consumption, to allow calculation of energy expenditure, is not practical and, in normal day-to-day care, tem-perature monitoring is the only means of assessing the thermal stability of the baby.

There is no single deep body temperature as this will vary depending on the metabolic rate of a particular tissue. The brain has the highest temperature of any organ within the body. It is however possible to find a central temperature that is representa-tive of deep body temperature. Trends in this temperature reflect changes in the deep body temperatures of the body, at least with sufficient accuracy for day-to-day clinical care.

Traditionally, rectal temperature has been used as the mea-sure of deep body temperature. This is still used commonly in many countries but less so in UK. There is a significant risk of damage to the mucosa of the rectum. Also, rectal temperature is unreliable, being affected by the depth of insertion of the ther-mometer, whether the baby has just passed a stool and by the temperature of the blood returning from the lower limbs. It is difficult to retain the probes in the same position, making this an unreliable site for continuous temperature monitoring.

The temperature in the oesophagus, at the level of the heart, gives a measure of the temperature of the blood in the great veins returning from the body. This is possibly the best overall representation of the ‘deep body temperature’. Measurement of oesophageal temperature is, however, very invasive and not suit-able for clinical monitoring.

The temperature of the skin over the liver or in the axilla reflects central temperature. Actual values will be lower than the deep body temperatures but, in the immature baby, these sites can be used to show the trend in central temperature. A more accurate measurement can be obtained by placing the


probe between the scapulae and a non-conducting mattress. No tape is needed on the skin as the baby lies on the probe, holding it in place. If the probe is over an area of skin from which no heat can be lost by conduction, convection, radia-tion or evaporation, then, with heat flow from the centre of the body to the skin down a temperature gradient, this area of skin will warm up to the same temperature as the body’s core. This so-called zero heat flux temperature has been shown to be very close to the central temperature as measured by an oesophageal probe.46

The measurement of a single temperature tells us how well the baby is maintaining that temperature, but nothing about how much energy is being used to achieve thermal balance. The continuous measurement, and display, of a central (abdominal, axilla or zero heat flux) and a peripheral (sole of the foot) tem-perature detects cold stress, with the peripheral temperature fall-ing before the central measurement changes.

The preterm baby who appears to be comfortable in their environment will have a central temperature, measured from a skin probe, of 36.8–37.3 °C and a central–peripheral temperature difference of 0.5–1 °C. An increasing central–peripheral tempera-ture difference, particularly above 2 °C, is usually due to cold stress, and occurs before any fall in central temperature.12

Hypovolaemic babies will vasoconstrict their peripheral circu-lation in an attempt to maintain blood pressure. This results in an increase in the central–peripheral temperature difference but, in such cases, there are usually other signs of hypovolaemia, such as rising heart rate and falling blood pressure.12

A high central temperature, particularly if unstable, along with a wide central–peripheral gap is seen in septic babies.47

Conclusion

Although we have known for a very long time the importance of maintaining the temperature of the newborn, we are still faced with new challenges in the care of the sick immature baby. Tem-perature control during their period of adaptation to extrauterine life is often poor and allowing these vulnerable babies to cool is associated with adverse outcome. Simple measures can prevent hypothermia following delivery. If cold at birth is associated with poor outcome there is no reason to believe that preventing ther-mal stress is any less important once the baby is in the neonatal unit. It is important that the risks and benefits associated with various methods of controlling the infant’s temperature are fully understood. ◆

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Practice points

• Hypothermia in the newborn infant is associated with adverse

outcome

• Despite improvements in technology, the preterm baby is still

at high risk of hypothermia immediately after delivery

• prevention of evaporative heat losses eliminates hypothermia

at resuscitation

• High evaporative fluid losses must be prevented if the baby

is nursed under a radiant heater

• more studies are needed to determine the optimum

management after delivery and to show if reducing

transepidermal water loss has an effect on the rate of skin

maturation

• Continuous monitoring and display of a central and peripheral

temperature gives early warning of developing cold stress


Documents

Temperature control in the neonate