Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • State of the Art
  • Published:

State-of-the-Art

Thermal protection of the newborn in resource-limited environments

Journal of Perinatology volume 32, pages 317–324 (2012)Cite this article

Subjects

Abstract

Appropriate thermal protection of the newborn prevents hypothermia and its associated burden of morbidity and mortality. Yet, current global birth practices tend to not adequately address this challenge. Here, we discuss the pathophysiology of hypothermia in the newborn, its prevention and therapeutic options with particular attention to resource-limited environments. Newborns are equipped with sophisticated mechanisms of body temperature regulation. Neonatal thermoregulation is a critical function for newborn survival, regulated in the hypothalamus and mediated by endocrine pathways. Hypothermia activates cellular metabolism through shivering and non-shivering thermogenesis. In newborns, optimal temperature ranges are narrow and thermoregulatory mechanisms easily overwhelmed, particularly in premature and low-birth weight infants. Hyperthermia most commonly is associated with dehydration and potentially sepsis. The lack of thermal protection promptly leads to hypothermia, which is associated with detrimental metabolic and other pathophysiological processes. Simple thermal protection strategies are feasible at community and institutional levels in resource-limited environments. Appropriate interventions include skin-to-skin care, breastfeeding and protective clothing or devices. Due to poor provider training and limited awareness of the problem, appropriate thermal care of the newborn is often neglected in many settings. Education and appropriate devices might foster improved hypothermia management through mothers, birth attendants and health care workers. Integration of relatively simple thermal protection interventions into existing mother and child health programs can effectively prevent newborn hypothermia even in resource-limited environments.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Lyon AJ . Applied physiology: temperature control in the newborn infant. Curr Pediatr 2004; 14: 7.

    Article  Google Scholar 

  2. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010; 375: 1969–1987.

    Article  PubMed  Google Scholar 

  3. Lawn JE, Cousens S, Zupan J . 4 Million neonatal deaths: when? where? why? Lancet 2005; 365: 891–900.

    Article  PubMed  Google Scholar 

  4. Kumar V, Shearer JC, Kumar A, Darmstadt GL . Neonatal hypothermia in low resource settings: a review. J Perinatol 2009; 29: 401–412.

    Article  CAS  PubMed  Google Scholar 

  5. Mullany LC . Neonatal hypothermia in low-resource settings. Semin Perinatol 2010; 34: 426–433.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Takayama JI, Teng W, Uyemoto J, Newman TB, Pantell RH . Body temperature of newborns: what is normal? Clin Pediatr (Phila) 2000; 39: 503–510.

    Article  CAS  Google Scholar 

  7. Silverman WA, Agate Jr FJ, Fertig JW . A sequential trial of the nonthermal effect of atmospheric humidity on survival of newborn infants of low birth weight. Pediatrics 1963; 31: 719–724.

    CAS  PubMed  Google Scholar 

  8. Silverman WA, Fertig JW, Berger AP . The influence of the thermal environment upon the survival of newly born premature infants. Pediatrics 1958; 22: 876–886.

    CAS  PubMed  Google Scholar 

  9. Hey E . Thermal neutrality. Br Med Bull 1975; 31: 69–74.

    Article  CAS  PubMed  Google Scholar 

  10. Baumgart S . Iatrogenic hyperthermia and hypothermia in the neonate. Clin Perinatol 2008; 35: 183–197, ix-x.

    Article  PubMed  Google Scholar 

  11. Sherman TI, Greenspan JS, St Clair N, Touch SM, Shaffer TH . Optimizing the neonatal thermal environment. Neonatal Netw 2006; 25: 251–260.

    Article  PubMed  Google Scholar 

  12. Charpak N, Ruiz-Pelaez JG, Charpak Y . Rey-martinez Kangaroo mother program: an alternative way of caring for low birth weight infants? one year mortality in a two cohort study. Pediatrics 1994; 94: 804–810.

    CAS  PubMed  Google Scholar 

  13. Knobel R, Holditch-Davis D . Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low-birthweight infants. J Obstet Gynecol Neonatal Nurs 2007; 36: 280–287.

    Article  PubMed  Google Scholar 

  14. Asakura H . Fetal and neonatal thermoregulation. J Nippon Med Sch 2004; 71: 360–370.

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  16. Tourneux P, Libert JP, Ghyselen L, Leke A, Delanaud S, Degrugilliers L et al. Echanges thermiques et thermoregulation chez le nouveau-ne [Heat exchanges and thermoregulation in the neonate]. Arch Pediatr 2009; 16: 1057–1062.

    Article  CAS  PubMed  Google Scholar 

  17. WHO. Thermal protection of the newborn: a practical guide. Maternal and Newborn Health/Safe Motherhood Unit, Division of Reproductive Health. World Health Organization: Geneva, 1997.

  18. WHO. Managing newborn problems: a guide for doctors, nurses, and midwives. Integrated Management of Pregnancy and Childbirth. World Health Organization: Geneva, 2003.

  19. Aylott M . The neonatal energy triangle. Part2: Thermoregulatory and respiratory adaptation. Paediatr Nurs 2006; 18: 38–42.

    PubMed  Google Scholar 

  20. Pal DK, Manandhar DS, Rajbhandari S, Land JM, Patel N, de LCAM . Neonatal hypoglycaemia in Nepal 1. Prevalence and risk factors. Arch Dis Child Fetal Neonatal Ed 2000; 82: F46–F51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Dagan R, Gorodischer R . Infections in hypothermic infants younger than 3 months old. Am J Dis Child 1984; 138: 483–485.

    CAS  PubMed  Google Scholar 

  22. Goldsmith JR, Arbeli Y, Stone D . Preventability of neonatal cold injury and its contribution to neonatal mortality. Environ Health Perspect 1991; 94: 55–59.

    CAS  PubMed  PubMed Central  Google Scholar 

  23. Dragovich D, Tamburlini G, Alisjahbana A, Kambarami R, Karagulova J, Lincetto O et al. Thermal control of the newborn: knowledge and practice of health professional in seven countries. Acta Paediatr 1997; 86: 645–650.

    Article  CAS  PubMed  Google Scholar 

  24. Pfister RH, Soll RF . Hypothermia for the treatment of infants with hypoxic-ischemic encephalopathy. J Perinatol 2010; 30 (Suppl): S82–S87.

    Article  PubMed  Google Scholar 

  25. Jacobs S, Hunt R, Tarnow-Mordi W, Inder T, Davis P . Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2007; CD003311.

  26. Dominguez TE, Wernovsky G, Gaynor JW . Cause and prevention of central nervous system injury in neonates undergoing cardiac surgery. Semin Thorac Cardiovasc Surg 2007; 19: 269–277.

    Article  PubMed  Google Scholar 

  27. Lyon A . Temperature control in the neonate. Paediatr Child Health 2008; 18: 155–160.

    Article  Google Scholar 

  28. Laptook AR, Watkinson M . Temperature management in the delivery room. Semin Fetal Neonatal Med 2008; 13: 383–391.

    Article  PubMed  Google Scholar 

  29. Maayan-Metzger A, Mazkereth R, Kuint J . Fever in healthy asymptomatic newborns during the first days of life. Arch Dis Child Fetal Neonatal Ed 2003; 88: F312–F314.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Herholz J, Crisponi L, Mallick BN, Rutsch F . Successful treatment of cold-induced sweating in Crisponi syndrome and its possible mechanism of action. Dev Med Child Neurol 2010; 52: 494–497.

    Article  PubMed  Google Scholar 

  31. Choudhary SP, Bajaj RK, Gupta RK . Knowledge, attitude and practices about neonatal hypothermia among medical and paramedical staff. Indian J Pediatr 2000; 67: 491–496.

    Article  CAS  PubMed  Google Scholar 

  32. Ayaz A, Saleem S . Neonatal mortality and prevalence of practices for newborn care in a squatter settlement of Karachi, Pakistan: a cross-sectional study. PLoS One 2010; 5: e13783.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Ayaz S, Efe SY . Potentially harmful traditional practices during pregnancy and postpartum. Eur J Contracept Reprod Health Care 2008; 13: 282–288.

    Article  PubMed  Google Scholar 

  34. Sreeramareddy CT, Joshi HS, Sreekumaran BV, Giri S, Chuni N . Home delivery and newborn care practices among urban women in western Nepal: a questionnaire survey. BMC Pregnancy Childbirth 2006; 6: 27.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Osrin D, Tumbahangphe KM, Shrestha D, Mesko N, Shrestha BP, Manandhar MK et al. Cross sectional, community based study of care of newborn infants in Nepal. BMJ 2002; 325: 1063.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Thairu L, Pelto G . Newborn care practices in Pemba Island (Tanzania) and their implications for newborn health and survival. Matern Child Nutr 2008; 4: 194–208.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hill Z, Tawiah-Agyemang C, Manu A, Okyere E, Kirkwood BR . Keeping newborns warm: beliefs, practices and potential for behaviour change in rural Ghana. Trop Med Int Health 2010; 15: 1118–1124.

    Article  PubMed  Google Scholar 

  38. Moran AC, Choudhury N, Uz Zaman Khan N, Ahsan Karar Z, Wahed T, Faiz Rashid S et al. Newborn care practices among slum dwellers in Dhaka, Bangladesh: a quantitative and qualitative exploratory study. BMC Pregnancy Childbirth 2009; 9: 54.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Waiswa P, Nyanzi S, Namusoko-Kalungi S, Peterson S, Tomson G, Pariyo GW . I never thought that this baby would survive; I thought that it would die any time: perceptions and care for preterm babies in eastern Uganda. Trop Med Int Health 2010; 15: 1140–1147.

    Article  PubMed  Google Scholar 

  40. Darmstadt GL, Kumar V, Yadav R, Singh V, Singh P, Mohanty S et al. Introduction of community-based skin-to-skin care in rural Uttar Pradesh, India. J Perinatol 2006; 26: 597–604.

    Article  CAS  PubMed  Google Scholar 

  41. Darmstadt GL, Walker N, Lawn JE, Bhutta ZA, Haws RA, Cousens S . Saving newborn lives in Asia and Africa: cost and impact of phased scale-up of interventions within the continuum of care. Health Policy Plan 2008; 23: 101–117.

    Article  PubMed  Google Scholar 

  42. Ellis J . Neonatal Hypothermia. J Neonatal Nurs 2005; 11: 7.

    Article  Google Scholar 

  43. Cinar ND, Filiz TM . Neonatal thermoregulation. J Neonatal Nurs 2006; 12: 6.

    Article  Google Scholar 

  44. Uslu S, Ozdemir H, Bulbul A, Comert S, Bolat F, Can E et al. A comparison of different methods of temperature measurements in sick newborns. J Trop Pediatr 2011; 57: 418–423.

    Article  PubMed  Google Scholar 

  45. Singh M, Rao G, Malhotra AK, Deorari AK . Assessment of newborn baby's temperature by human touch: a potentially useful primary care strategy. Indian Pediatr 1992; 29: 449–452.

    CAS  PubMed  Google Scholar 

  46. Agarwal S, Sethi V, Pandey RM, Kondal D . Human touch vs axillary digital thermometry for detection of neonatal hypothermia at community level. J Trop Pediatr 2007; 54: 200–201.

    Article  PubMed  Google Scholar 

  47. Ellis M, Manandhar D, Hunt L, Barnett S, Azad K . Touch detection of neonatal hypothermia in Nepal. Arch Dis Child Fetal Neonatal Ed 2006; 91: F367–F368.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Tuitui RL, Suwal SN, Shrestha S . Hand-touch method for detection of neonatal hypothermia in Nepal. J Trop Pediatr 2010; 57: 236–238.

    Article  PubMed  Google Scholar 

  49. Agarwal S, Sethi V, Srivastava K, Jha P, Baqui AH . Human touch to detect hypothermia in neonates in Indian slum dwellings. Indian J Pediatr 2010; 77: 759–762.

    Article  PubMed  Google Scholar 

  50. Kumar R, Aggarwal AK . Accuracy of maternal perception of neonatal temperature. Indian Pediatr 1996; 33: 583–585.

    CAS  PubMed  Google Scholar 

  51. Morley D, Blumenthal I . A neonatal hypothermia indicator. Lancet 2000; 355: 659–660.

    Article  CAS  PubMed  Google Scholar 

  52. Green DA, Kumar A, Khanna R . Neonatal hypothermia detection by ThermoSpot in Indian urban slum dwellings. Arch Dis Child Fetal Neonatal Ed 2006; 91: F96–F98.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Kambarami R, Chidede O, Pereira N . ThermoSpot in the detection of neonatal hypothermia. Ann Trop Paediatr 2002; 22: 219–223.

    Article  CAS  PubMed  Google Scholar 

  54. Zeal J . ThermoSpot in the detection of neonatal hypothermia. Ann Trop Paediatr 2003; 23: 87–88; author reply.

    Article  PubMed  Google Scholar 

  55. Obladen M . Neugeborenenintensivpflege. Springer. Berlin: New York, 2002, 5th edn.

    Google Scholar 

  56. Stothers JK . Head insulation and heat loss in the newborn. Arch Dis Child 1981; 56: 530–534.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Galligan M . Proposed guidelines for skin-to-skin treatment of neonatal hypothermia. MCN Am J Matern Child Nurs 2006; 31: 298–304; quiz 305–296.

    Article  PubMed  Google Scholar 

  58. Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A et al. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr 1998; 87: 976–985.

    Article  CAS  PubMed  Google Scholar 

  59. Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S . Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epidemiol 2010; 39 (Suppl 1): i144–i154.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Suman RP, Udani R, Nanavati R . Kangaroo mother care for low birth weight infants: a randomized controlled trial. Indian Pediatr 2008; 45: 17–23.

    PubMed  Google Scholar 

  61. Charpak N, Ruiz-Pelaez JG . Resistance to implementing kangaroo mother care in developing countries, and proposed solutions. Acta Paediatr 2006; 95: 529–534.

    Article  PubMed  Google Scholar 

  62. Sloan NL, Ahmed S, Mitra SN, Choudhury N, Chowdhury M, Rob U et al. Community-based kangaroo mother care to prevent neonatal and infant mortality: a randomized, controlled cluster trial. Pediatrics 2008; 121: e1047–e1059.

    Article  PubMed  Google Scholar 

  63. Acuin CS, Khor GL, Liabsuetrakul T, Achadi EL, Htay TT, Firestone R et al. Maternal, neonatal, and child health in southeast Asia: towards greater regional collaboration. Lancet 2011; 377: 516–525.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD . Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999; 354: 1955–1961.

    Article  CAS  PubMed  Google Scholar 

  65. Johanson R, Mallab D, Rolfe P, Spencer A . The effect of postdelivery care on neonatal body temperature. Early Hum Dev 1990; 21: 132–133.

    Article  Google Scholar 

  66. Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, MacLeod WB et al. Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study. BMJ 2011; 342: d346.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Lussky RC . A century of neonatal medicine. Minn Med 1999; 82: 48–54.

    CAS  PubMed  Google Scholar 

  68. Lyon AJ, Oxley C . HeatBalance, a computer program to determine optimum incubator air temperature and humidity. A comparison against nurse settings for infants less than 29 weeks gestation. Early Hum Dev 2001; 62: 33–41.

    Article  CAS  PubMed  Google Scholar 

  69. Lyon AJ, Freer Y . Goals and options in keeping preterm babies warm. Arch Dis Child Fetal Neonatal Ed 2011; 96: F71–F74.

    Article  CAS  PubMed  Google Scholar 

  70. Soll RF . Heat loss prevention in neonates. J Perinatol 2008; 28 (Suppl 1): S57–S59.

    Article  PubMed  Google Scholar 

  71. Maternal and neonatal directed assessment of technology. Infant warmers to prevent neonatal hyothermia. 2011 (accessed on 28 September 2011 at http://mnhtech.org/technology/technology-briefs/infant-warmers/).

  72. Knobel RB, Wimmer Jr JE, Holbert D . Heat loss prevention for preterm infants in the delivery room. J Perinatol 2005; 25: 304–308.

    Article  PubMed  Google Scholar 

  73. Design that Matters. Incubators. 2011 (accessed on 28 September 2011 at http://www.designthatmatters.org/news/dtm-blog/project/incubator/).

  74. Embrace. embrace global—an infant thermoregulator designed for extreme affordability. 2011 (accessed on 28 September 2011 at http://embraceglobal.org).

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, Preventive Medicine, Boston University School of Medicine, Boston, MA, USA

    K Lunze

  2. Center for Global Health and Development, Boston University, Boston, MA, USA

    D H Hamer

  3. Department of International Health, Boston University School of Public Health, Boston, MA, USA

    D H Hamer

  4. Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA

    D H Hamer

  5. Zambia Centre for Applied Health Research and Development, Lusaka, Zambia

    D H Hamer

Authors
  1. K Lunze
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D H Hamer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to K Lunze.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lunze, K., Hamer, D. Thermal protection of the newborn in resource-limited environments. J Perinatol 32, 317–324 (2012). https://doi.org/10.1038/jp.2012.11

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/jp.2012.11

Keywords

This article is cited by

Search

Advanced search

Quick links