keeping infants warm - lippincott williams &...

6 Advances in Neonatal Care • Vol. 8, No. 1 • pp. 6-12

Hypothermia is a major cause of morbidityand mortality in infants, underscoring theimportance of maintaining normal body tem-

perature in the delivery room. The World HealthOrganization (WHO) lists hypothermia as a “top killer”during the neonatal period1 and suggests that it iswidely underreported and underestimated as a causeof death.2 Cold stress is associated with lethargy, hypo-tonia, poor feeding, weight loss, abdominal distention,vomiting, restlessness, pallor, cool skin, tachypnea,respiratory distress, and a significantly reduced coretemperature.3 Hypothermia has been related to hypo-glycemia, hypoxia, metabolic acidosis, coagulationdefects, and severe intraventricular hemorrhage.4

Reductions in body temperature may delay transitionfrom fetal to neonatal circulation at birth secondaryto the effect of temperature on pulmonary vasomotortone and acid-base homeostasis.5 Pulmonary hemor-rhage may result from acidosis secondary to shock andhypoxia, causing left ventricular failure and increasedpulmonary capillary pressure.3 Cold stress may havean important role in stimulating the onset of breathing6

and protecting the brain following a hypoxic, ischemicevent but can have disastrous consequences if notstopped,7-10 making early intervention in the deliverysuites imperative. This article reviews the consequences

Keeping Infants WarmChallenges of Hypothermia

Martha J. Mance, MS, RN, NNP, CPNP

of hypothermia and mechanisms of heat exchangeand heat production in full-term and low birth-weightinfants and discusses routine interventions that canbe implemented in the delivery room to minimizehypothermia.

A CONTINUING PROBLEM

A number of studies have reported the problem of coldstress in neonates. The EPIcure study, a large prospec-tive observational study in the United Kingdom andthe Republic of Ireland, evaluated outcomes of infantsbetween 20 and 25 weeks’ gestation (n = 843). The pur-pose of the study was to describe survival and healthproblems in this population of infants at the mini-mal levels of viability. The results demonstrated that40% of the infants were hypothermic (temperatures < 35°C; P < .001). These infants were in more criti-cal condition than were those with normal tempera-tures upon admission to the NICU.11 A second studyreported that 29% of infants less than 30 weeks’ ges-tation born by cesarean section were admitted to theneonatal intensive care unit (NICU) with axillary tem-peratures lower than 35.6°C.12 Another research team13

found that more than one-quarter of the infants werehypothermic, despite implementation of the NeonatalResuscitation Program14 (NRP) guidelines to preventcold stress. Cold stress in the delivery room contributesto increased oxygen consumption and potentially inter-feres with an effective resuscitation.15 Others havedescribed low admission temperatures in 15 centersof the National Institute of Child Health and HumanDevelopment Neonatal Research Network,16 and hos-pitals in developing countries1 continue to documentthe problem of hypothermia on admission. Thesestudies11,16,17 reveal reduced survival rates in infants

ABSTRACTHypothermia is a major cause of morbidity and mortality in infants; therefore, maintaining normal body temperaturesin the delivery room is crucial. An understanding of how infants produce heat and what can be done to maintain normalbody temperatures in full-term and preterm infants is essential for the preservation of thermal stability in this population.This article reviews the consequences of hypothermia, mechanisms of heat exchange and heat production in full-term andlow birth-weight infants, and discusses interventions in the delivery room to alleviate hypothermia.KEY WORDS: hypothermia, temperature regulation, neonate, delivery room

MARY A. SHORT, RN, MSN • Section Editor

Address correspondence to Martha J. Mance, MS, RN, CPNP,Nurse Practitioner, Neonatal Intensive Care Unit, Womenand Infants’ Hospital, 101 Dudley Street, Providence, RI02903; [email protected] Affiliation: Women and Infants’ Hospital, Providence,Rhode Island.Copyright 2008 © by the National Association of NeonatalNurses.

10984-03_ANC801-Mance.qxd 1/30/08 11:58 AM Page 6

Advances in Neonatal Care • Vol. 8, No. 1

Keeping Infants Warm 7

admitted to facilities with temperatures less than36°C. Although the consequences of hypothermia aresevere, difficulty exists in delineating what is normalbody temperature for infants.1,3,4,17-23 Table 1 outlinesnormative values for a neutral thermal environment,normothermia, hypothermia, and hyperthermia.

HEAT LOSS

Cold stress is a condition in which heat loss is greaterthan heat production, resulting in the inability to main-tain core temperature. Maintenance of body tem-perature is dependent on an intact central nervoussystem, the ability to produce heat, the availabilityof oxygen, and an energy source. Infants exchangeheat with the environment through evaporation, con-

duction, convection, and radiation. Table 2 discussesthe mechanisms of heat loss and interventions thatcan be implemented at delivery to minimize heat lossthat occurs from each mechanism.

Low birth-weight infants are less able to preventheat loss or to produce heat than healthy full-terminfants, making them more susceptible to cold stress,particularly at birth. Risk factors identified that increasethe risk of hypothermia include prematurity (gesta-tional age [GA] < 37 weeks), low birth-weight,24,25

intrauterine growth restriction, small-for-gestational-age (SGA) infants,26 low ambient or environmentaltemperature, asphyxia,24 impaired central nervoussystem function,16 and maternal temperature.25 Opendefects in the skin, including omphalocele, gastroschi-sis, and neural tube defects, also place the infant at anincreased risk of heat loss.

Very premature infants and infants with a birthweight of less than 1000 g have high evaporative heatlosses and immature thermoregulatory mechanismswith reduced vasomotor response to cold stress duringthe first days after birth.27 The primary goal when car-ing for extremely low birth-weight (ELBW) infantsis to provide a neutral thermal environment in whichheat loss can be prevented28 and oxygen consumptionis maintained at resting levels.15 Extremely low birth-weight29 and SGA26 infants are already predisposedto cold stress because of their physical characteristics.These infants have insufficient subcutaneous fat neces-sary for insulation, reduced amounts of brown adiposetissue (BAT), a limited ability to mobilize norepineph-rine and fat for energy production, and a diminishedcapacity to increase their oxygen consumption. In

TABLE 1. Normative ValuesAn Environment in Which Body Temperature is Maintained with the

Neutral Thermal Lowest Expenditure of Energy and Environment Oxygen Consumptiona

Normothermia 36.5°C-37.5°Cb

Hypothermia < 36.5°Cb

Hyperthermia > 37.5°Cb

aFrom Vohra et al.21

bFrom World Health Organization (WHO).1

TABLE 2. Mechanisms of Heat Loss in the Infant33

Mechanism Definition Intervention

Evaporation

Conduction

Convection

Radiation

Heat loss occurs as moisture on the body surface or from therespiratory tract vaporizes. The loss depends on air speed andrelative humidity.

Transfer of heat from one surface to another by contact.Determined by a temperature gradient as heat moves from anarea of higher temperature to lower.

Heat is dissipated from the interior of the body to the skin sur-face through the blood. It is conducted from the body surface tothe surrounding air and will be displaced from the skin and car-ried away by diffusion to moving air particles at the skin surface.

Transfer of radiant energy from one body surface to surround-ing cooler or warmer surfaces. Heat loss is independent ofambient temperature, air speed, or other heat loss mechanisms.

• Dry well• Add humidity to the environment• Humidify oxygen• Use polyethylene wraps• Decrease air currents around the infant

• Prewarm radiant warmers• Cover scale with warm blanket• Have many warm blankets available• Use portable warming mattress

• Place hat on a well-dried head• Swaddle infant• Avoid drafts• Use warmed gas for resuscitation

• Prewarm the radiant warmer and thetransport bed

• Keep warmers away from external walls,windows and direct sunlight


www.advancesinneonatalcare.org

8 Mance

addition, they have large surface-area-to-mass ratiosand an extended posture that further increases thesurface area from which they may lose heat. A highertotal body water content and thin, immature skin with-out a well-defined stratum corneum exposes themto increased transepidermal water loss (TEWL) andincreased heat loss.28,30 Decreased glycogen stores31

and poor vasomotor control further increase the riskfor hypothermia in ELBW infants.27,30

Reduction of TEWL can be achieved by main-taining elevated levels of humidity in the environ-ment. Increasing the humidity in the prematureinfant’s environment improves temperature controland fluid balance in infants.31,32 Radiant warmersare competent at supplying an adequate heat sourcefor premature infants but increase the amounts ofinsensible water loss. The infant is left exposed to airmovement around the warmer, increasing convectiveheat loss.23 Placing plastic wrap over, but not touch-ing, the infant’s skin and adding water vapor underthis covering will help to reduce evaporative and con-ductive losses.30 Transferring the infant to an isolettewith added humidity will also reduce loss of heat fromevaporation.

HEAT PRODUCTION

Body temperature is maintained by controlling thebalance between heat production and heat loss. The3 mechanisms by which infants can produce heat toalleviate cold stress are:

• Vasoconstriction• Brown fat lipolysis• Alterations of body positionIn response to cold, the sympathetic nervous system

stimulates the peripheral vasculature, resulting in vaso-constriction, reducing skin blood flow and heat lossthrough conduction. It also induces brown fat lipo-lysis, resulting in heat production by nonshiveringthermogenesis.33 Healthy, full-term infants are able toshiver, but at birth they are able to generate more heatvia nonshivering thermogenesis (metabolism of brownfat). Premature infants have a diminished capacityto shiver as well as limited stores of BAT.23 The finalmethod for heat conservation is alteration in bodyposition by flexion of the extremities in an effort toconserve heat (decreasing the exposed surface area)or by increasing motor activity.34

Thermal receptors in the skin and core send infor-mation to the hypothalamus, which detects deviationsin temperature from a set point and mediates aresponse through the autonomic, somatic, andendocrine systems.3 Infants respond to cold stress byincreasing their oxygen consumption,15 which initiallyresults in oxidative metabolism of glucose, fat, andprotein to produce heat. Nonshivering thermogenesisis the primary mode of this heat production in theinfant. Brown adipose tissue first appears in the infantaround 26 to 30 weeks’ gestation and continues to

develop for several weeks postnatally. It is found in themediastinum, around the great vessels, and aroundthe kidneys, and adrenalglands. Stores are also foundin the axilla, the nape of the neck, and between theshoulder blades. It has numerous fat vacuoles andmitochondria with large stores of glycogen and anextensive blood and nerve supply.33 A drop in skintemperature results in the initiation of nonshiveringthermogenesis (metabolism of BAT) by hormonalmediators and the sympathetic nervous system. TheBAT breaks down into glycerol and nonesterified fattyacids, which release heat. Brown adipose tissue isdependent on oxygen for the lipolysis of this fat dur-ing this production of heat. Hypoxia disrupts ther-moregulation by causing a redistribution of circula-tion and ineffective capillary blood supply in BAT.35,36

Prolonged cold stress reduces energy stores and leadsto a cascade of events as hypoglycemia aggravatesmetabolic acidosis, which delays fetal transition.5

Although infants are able to increase their meta-bolic rate in response to the low environmental tem-peratures found in delivery rooms, all infants have aninitial drop in body temperature.33 The temperaturegradient between the infant’s skin and the environmentis the critical factor that elicits an increase in oxygenconsumption and metabolic rate, potentially result-ing in an accumulation of aerobic waste products.15

If the cold stress is not removed or the infant becomeshypoxic, the oxygen demand becomes greater thansupply, and an accumulation of anaerobic waste prod-ucts occurs, which compounds the resulting meta-bolic acidosis. The colder the infant, the more severethe hypoxia and acidosis become.5

ACHIEVING NORMALBODY TEMPERATURES

Heat is transferred along a gradient from areas ofhigher temperatures to lower temperatures. Infantsare delivered from a warm, shielded uterine envi-ronment into a cold, dry delivery room, the perfectsetting for heat loss. This is why it is essential forproviders to implement interventions to preventhypothermia.20 Because of the potential detrimentalconsequences of hypothermia, interventions such asroutine care and polyethylene wraps have beenstudied to determine if they help to reduce or pre-vent the drop in temperature so frequently noted ininfants.

Routine Care in the Delivery RoomAmbient temperature has a significant influence onheart rate (HR), HR variability, respiratory rate,oxygen consumption, and insensible water loss inELBW.28 Body temperature and oxygen consump-tion are inversely related; as body temperature falls,the fraction of inspired oxygen required for survivalincreases.28 The WHO advocates maintaining the



temperature in the delivery room at 25°C.1 It isknown that the environmental temperature of thedelivery room has a direct impact on heat loss in allinfants; maintaining delivery room temperature is asimple intervention to implement.36 Drying and thenplacing a newly delivered infant under a radiantwarmer has been shown to limit the fall in bodytemperature.37 Even with this simple intervention, afall in body temperature occurs. By modulating theenvironmental temperature to reduce the gradientbetween skin and air, the infant’s metabolic rate canbe maintained, energy stores conserved, and acido-sis prevented.15

Routine thermal care includes maintaining thedelivery room at a minimum of 25°C,1 placing theinfant under a radiant warmer, and immediately dry-ing the infant, paying careful attention to drying thehead. Wet linens should be removed quickly, and thehead should be covered with a hat. The infant shouldbe wrapped in prewarmed blankets, and any othercontact surfaces such as a scale, should be prewarmed.Drafts should be avoided.22 The competency checklist

outlines procedures for routine care in the deliveryroom (Table 3).

Employing Polyethylene WrapsSeveral studies have demonstrated the success ofutilizing polyethylene occlusive wraps to keep LBWinfants warm at the time of delivery.17,21,24,25,38 Followingdelivery, providers place the wet infant into a poly-urethane bag on the warmer, keeping the infant’s headexposed (Figure 1). The head and face are then dried,and resuscitation continues following NRP guide-lines.14 The clear plastic wrap permits visualization ofthe infant39 and any interventions needed are per-formed with the infant in the bag. For more extensiveresuscitation requiring umbilical or peripheral lines,healthcare providers cut holes in the bag to gainaccess.17 The infant is then placed on warmed blan-kets and transferred to the NICU, where the infant isplaced on a radiant warmer and the polyethylene bagis removed.25 Polyethylene bags permit heat to begained by the infant through radiation and reduce theamount of evaporative heat loss.32,39

TABLE 3. Competency Checklist for Maintaining Infant’s Temperature in the Delivery RoomHealthy Full-term Infant 1. Radiant warmer in delivery room should be set up

ahead of time per hospital routine with warm blanketsover the mattress.

2. Have radiant warmer set to 25% maximum power atall times. Prior to delivery, the warmer should be onmanual mode and reset to maximal power.

3. Place drying towels directly under the warmer andover the drying blanket.

a. Additional blankets can be brought in from blanketwarmer just before the birth.

b. Have a warmed, dry blanket ready to receive theinfant upon birth.

4. Once the infant is brought to the warmer, he/sheshould be dried quickly with the warmed, dry blanket.

5. Remove the wet blanket and continue drying with thetowels and blanket on the warmer.

6. Dry the head thoroughly and place a hat on the infant’s head.

7. The infant can remain on the warmer for further eval-uation and resuscitation.

8. Place a temperature probe on the infant’s abdomen,switch the warmer to servocontrol set at 37.5°C.

9. Place warmed blanket on scale prior to weighing theinfant.

10. Have a clean, warmed blanket available to wrap theinfant prior to presentation to the parents.

11. Maintain an environment that promotes a neutral ther-mal environment, avoiding drafts and keeping the roomwarm.

12. Skin-to-skin care can be initiated once infant andmother have been dried and a hat has been placed onthe infant’s head. (This can be accomplished on themotherís abdomen.) Once skin-to-skin care is initiated,a warm blanket should be placed over the infant,cocooning the infant with the mother.

Preterm Infant1. Follow steps 1–3 for the healthy full-term infant.

2. Add a portable warming mattress to the radiantwarmer.

3. Place a polyethylene occlusive wrap on the warmer toawait infant < 29 weeks’ gestation.

4. Once the infant is brought to the warmer, remove thewet blanket and place wet infant under the wrap or inthe bag and close, leaving the infant’s head out. Placethe infant on the warming mattress.

5. Dry head and place hat on infant.

6. Continue with resuscitation as needed.

7. Any infant being brought to the NICU should be placedin a warm transport bed and weighed on arrival to theNICU.




10 Mance

A retrospective study of infants born at less than28 weeks’ gestation (n = 77) evaluated the use ofpolyethylene wraps to increase NICU admission tem-peratures. The researchers found that the wrappedinfants’ axillary temperature was greater than that ofinfants receiving routine care (P < .001). This studysupports the use of polyethylene wraps to preventhypothermia in premature infants less than 28 weeks’gestation.40 A retrospective preintervention audit ofinfants’ admission temperatures found that manypremature infants admitted to the NICU were cold.Then the investigators performed a prospective postin-tervention audit following the introduction of poly-ethylene wraps in infants less than 30 weeks’ gestation(n = 141). The primary objective was to determinethe effect of admission temperature when the poly-ethylene wrap was used immediately after deliveryof these infants. The intervention improved admis-sion temperatures in infants less than 27 weeks’ gesta-tion (P < .01).12 A prospective randomized controlled

trial of infants less than 30 weeks’ gestation (n = 88)evaluated the effect of using polyurethane bags atdelivery in infants less than 29 weeks’ gestation. Thewrapped infants were less likely to have admissiontemperatures of less than 36.4°C (P < .01) and hadhigher admission temperatures (P < .003).25 In a ran-domized controlled trial of infants less than 32 weeks’gestation (n = 62), the effect of polyethylene wrap onrectal temperature was evaluated. Higher admis-sion temperatures were found in the infants less than28 weeks’ gestation (P < .001), but there was no dif-ference in admission temperatures in infants between28 and 31 weeks’ gestation (P = .47), lending sup-port to the use of polyethylene occlusive wraps invery low birth-weight (VLBW) infants in the deliv-ery room to help preserve core temperature.24 A sec-ond randomized controlled study of infants less than28 weeks’ gestation (n = 55) was undertaken by thesame group to determine whether or not the occlu-sive wrap used at delivery of VLBW infants would

FIGURE 1.

Transparent Bags to Limit Heat Loss in the Delivery Room

Transparent bags can be used to limit heat loss in the delivery room.



prevent heat loss after delivery better than would con-ventional drying and whether the benefit was sus-tained once the wrap was removed. The investigatorsfound higher rectal temperatures on admission in thewrapped infants (P < .002) but no difference betweengroups in rectal temperature at 1 hour of life. This cor-roborates previous findings demonstrating preventionin heat loss at delivery of premature infants. Thegroup also found that the size of the infant had a directeffect on core temperature, with the smaller infantshaving the lower temperatures.21

Because of the VLBW infant’s need for greater ther-mal protection at birth,21 the primary focus at deliveryis to immediately reduce heat loss. These studies sup-port the recommendation for employing polyethyl-ene wraps at the delivery of VLBW infants to reducehypothermia in infants less than 28 weeks’ gestation.The major limitation of all of these studies is the smallsample size.

IMPLICATIONS FOR FUTURE RESEARCH

The use of polyethylene bags has been demonstratedto work in infants less than 28 weeks’ gestation. Eventhough it appears that infants greater than 28 weeks’gestation do not benefit from this intervention, futureresearch could be directed to expanding this popula-tion to severely SGA infants, using the polyethylenebags for transportation of premature and full-terminfants born outside of the hospital or sick infants withpoor peripheral perfusion.

Infants lose a significant amount of heat from theirheads, so investigations into head covering with orwithout the use of the polyethylene bags would behelpful. The type of head covering is also an area foradditional research.

IMPLICATIONS FOR FUTURE EDUCATION

Hypothermia in the delivery room can interferewith normal neonatal transition to extrauterine life.Frequent audits of NICU admission temperaturesare needed to ensure hypothermia is minimized. Thecompetency checklist describes interventions to pre-vent cold stress in full-term and premature infants.The most important thing to remember is to dry theinfant well to the diminish evaporative heat loss thatnormally occurs at delivery.

CONCLUSION

Simple and easy interventions can make large differ-ences in the thermal stability of infants. A warm envi-ronment in the delivery suite in conjunction withprompt interventions of routine care, utilizing polyeth-ylene occlusive wraps, and environmental humidityfor LBW infants, can help maintain body tempera-

ture and protect infants against the detrimental effectsof hypothermia.

References1. World Health Organization (WHO). Thermal control of the newborn: a prac-

tical guide. Maternal Health and Safe Motherhood Programme (WHO/FHE/MSM/93.2). Geneva: WHO; 1996.

2. Davanzo R. Newborns in adverse conditions: issues, challenges, and inter-ventions. J Midwifery Womens Health. 2004;49(Suppl):29-35.

3. Hackman PS. Recognizing and understanding the cold-stressed term infant.Neonatal Netw. 2001;20:35-41.

4. Bartels DB, Kreienbrack L, Dammann O, Wenzlaff P, Poets CF. Populationbased study on the outcome of small for gestational age newborns. ArchDis Fetal Neonatal Ed. 2005;90:53-59.

5. Gandy GM, Adamsons K, Cunningham N, Silverman WA, James LS. Thermalenvironment and acid-base homeostasis in human infants during the firstfew hours of life. J Clin Invest. 1964;43:751-758.

6. Kuipers IM, Maertzdorf WJ, De Jong DS, Hanson MA, Blanco CE. Initiation andmaintenance of continuous breathing at birth. Pediatr Res. 1997;42:163-168.

7. Simbruner G, Ruttner EM, Schulze A, Perzlmaier K. Premature infants are lesscapable of maintaining thermal balance of head and body with increases ofthermal environment than with decreases. Am J Perinatol. 2005;22:25-33.

8. Edwards AD, Wyatt JS, Thoresen M. Treatment of hypoxic-ischemic braindamage by moderate hypothermia. Arch Dis Child Fetal Neonatal Ed.1998;78:F85-F91.

9. Gunn AJ, Bennet L. Is temperature important in delivery room resuscitation?Semin Neonatol. 2001;6:241-249.

10. Laptook AR, Corbett RJT. The effects of temperature on hypoxic-ischemicbrain injury. Clin Perinatal. 2002;29:623-649.

11. Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkinson AR. The EPICurestudy: outcomes to discharge from hospital for infants born at the thresholdof viability. Pediatrics. 2000;106:659-671.

12. Bredemeyer S, Reid S, Wallace M. Thermal management for premature births.J Adv Nurs. 2005;52:482-489.

13. Mitchell A, Niday P, Boulton J, Chance G, Dulberg C. A prospective clinicalaudit of neonatal resuscitation practices in Canada. Adv Neonatal Care.2002;2:316-326.

14. Kattwinkel J, ed. Textbook of Neonatal Resuscitation. 5th ed. Elk Grove, IL:American Academy of Pediatrics and American Heart Association; 2006.

15. Adamson SK, Gandy GM, James LS. The influence of thermal factors uponoxygen consumption of the newborn human infant. J Pediatrics. 1965;66:495-508.

16. Laptook AR, Salhab W, Bhaskar B. Admission temperature of low birthweight infants: predictors and associated morbidities [abstract]. Presentedat 2005 Pediatric Academic Societies’ Meeting; May 14-17, 2005;Washington, DC.

17. Lyon AJ, Stenson B. Cold comfort for infants. Arch Dis Child Neonatal Ed.2004;89:F93-F94.

18. Christensson K, Bhat GJ, Amadi BC, Eriksson B, Hojer B. Randomised studyof skin-to-skin versus incubator care for rewarming low-risk hypothermicinfants. Lancet. 1998;352:1115.

19. Newton T, Watkinson M. Preventing hypothermia at birth in preterminfants: at a cost of overheating some? Arch Dis Child Fetal Neonatal Ed.2003;88:F256.

20. McCall EM, Alderice FA, Halliday HL, Jenkins JG, Vohra S. Interventionsto prevent hypothermia at birth in preterm and/or low birthweightinfants. The Cochrane Database of Systemic Reviews 2005, Issue 1. ArtNo.: CD004210.pub2. DOI:10.1002/14651858.CD004210.pub2.

21. Vohra S, Roberts RS, Zhang B, Janes M, Schmidt B. Heat loss prevention (HeLP)in the delivery room: a randomized controlled trial of polyethylene occlusiveskin wrapping in very preterm infants. J Pediatr. 2004;145:750-753.

22. Rieger-Fackeldey E, Schaller-Bals S, Schulze A. Effect of body tempera-ture on the pattern of spontaneous breathing in extremely low birthweight infants supported by proportional assist ventilation. Pediatr Res.2003;54:332-336.

23. Thomas K. Thermoregulation in infants. Neonatal Netw. 1994;13:15-22.24. Vohra S, Frent GA, Campbell VC, Abbott AM, Whyte RK. Effect of poly-

ethylene occlusive skin wrapping on heat loss in very low birth weightinfants at delivery: a randomized trial. J Pediatr. 1999;134:547-551.

25. Knoebel RB, Wimmer JE, Holbert D. Heat loss prevention for preterm infantsin the delivery room. J Perinatol. 2005;25:304-308.

26. Doctor BA, O’Riordan MA, Kirchner HL, Shah D, Hack M. Perinatal correlatesand neonatal outcomes for small for gestational age infants born at termgestation. Am J Obstet Gynecol. 2001;185:652-659.

27. Lyon AJ, Pikaar ME, Badger P, McIntosh N. Temperature control in very lowbirthweight infants during first five days of life. Arch Dis Child Neonatal Ed.1997;76:F47-F50.

28. Horns KM. Comparison of two microenvironments and nurse caregiving onthermal stability of ELBW infants. Adv Neonatal Care. 2002;2:149-160.

29. Finer NN, Rich WD. Neonatal resuscitation: raising the bar. Curr Opin Pediatr.2004;16:157-162.




12 Mance

30. Rutter N. Clinical consequences of an immature barrier. Semin Neonatol.2000;5:281-287.

31. Hammarlund K, Nilsson GE, Oberg PA, Sedin G. Transepidermal water loss innewborn infants. V. Evaporation from the skin and heat exchange duringthe first hours of life. Acta Paediatr Scand. 1980;69:385-392.

32. Sedin G. To avoid heat loss in very preterm infants. J Pediatr. 2004;145:720-722.

33. Blackburn S. Maternal, Fetal & Neonatal Physiology: A Clinical Perspective.2nd ed. St. Louis, MO: Saunders; 2003:713-714.

34. Altimier L, Warner B, Amlung S, Kenner, C. Neonatal thermoregulation: bedsurface transfers. Neonatal Netw. 1999;18:35-38.

35. Schubring C. Temperature regulation in healthy and resuscitated newbornsimmediately after birth. J Perinat Med. 1986;14:27-33.

36. Trevisanuto D, Doglioni N, Ferrarese P, Zanardo V. Thermal managementof the extremely low birth weight infants at birth. J Pediatr. 2005;147:716-717.

37. Dahm LS, James LS. Newborn temperature and calculated heat loss in thedelivery room. Pediatrics. 1972;49:504-513.

38. Leone TA, Rich W, Finer NN. A survey of delivery room resuscitation prac-tices in the United States. Pediatrics [serial online]. 2006;117:e164-e167.http://www.pediatrics.org. Accessed February 21, 2006.

39. Narendran V, Hoath SB. Thermal management of the low birth weightinfant: a cornerstone of neonatology. J Pediatr. 1999;134:529-531.

40. Björklund LJ, Hellström-Westas L. Reducing heat loss at birth in very preterminfants. J Pediatr. 2000;137:739-740.


keeping infants warm - lippincott williams &...

Documents