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Neonatal thermoregulation: a cornerstone of care or forgotten principles?

Pediatric Research volume 95, pages 1398–1399 (2024)Cite this article

The newborn is exquisitely sensitive to thermal stress. The challenges in establishing thermal equilibrium (a stable temperature when heat loss equals heat gain) are enormous both in the delivery room and after admission to a Neonatal Intensive Care Unit (NICU). In utero, the fetus is approximately 0.5 °C higher than the maternal core temperature and heat from fetal metabolism is dissipated via the umbilical circulation along a temperature gradient. As the baby passes from the warm, wet intrauterine environment to the cooler, dry delivery area, the temperature gradient promoting heat dissipation enlarges. In the extra-uterine setting, heat generated by metabolism is dissipated along a temperature gradient from the interior of the body to the body surface, and ultimately to the surrounding environment. These gradients are accentuated in premature infants due to well-recognized characteristics of a high surface area-to-weight ratio, limited subcutaneous fat, and an immature epidermal barrier.1 Preventing or minimizing a fall in temperature immediately after birth is extremely challenging given the extensive heat loss that occurs among newborns in delivery areas due to the physical processes of convection, radiation, evaporation, and conduction. Associations between cold stress immediately after birth among preterm infants and morbidity and mortality have provided the rationale for developing management strategies to prevent a fall in temperature. In this issue of Pediatric Research, Dunne et al. have provided a concise and informative review of interventions that have been evaluated to minimize cold stress by provision of exogenous heat and/or reduction in heat loss of preterm infants at birth.2

The temperature on admission to a nursery is an easy, accessible parameter to monitor and has been frequently used in a quality improvement mode to improve practice in the delivery room. As noted by Dunne et al., an increasing number of delivery room interventions have been tested using a randomized trial design providing more rigor to the quality of the data. Although multiple interventions are considered efficacious and reduce the percentage of infants with admission temperatures <36.5 °C, an appreciable number of infants remain with cold stress despite the management strategy. In addition, there is a small increase in the percentage of infants with elevated temperatures (>37.5 °C). Given the temperature gradients at birth, a fall in surface and potentially core temperature is somewhat unavoidable. A fall in temperature at birth, as long as it is not excessive, may even be considered desirable, since stimulation of cutaneous thermoreceptors contributes to the initiation of respiratory efforts.3,4

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  1. Department of Pediatrics, Women and Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI, USA

    Abbot R. Laptook

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  1. Abbot R. Laptook
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A.L. developed the concept for this commentary, drafted the commentary, and gave final approval to the version published.

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Correspondence to Abbot R. Laptook.

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Laptook, A.R. Neonatal thermoregulation: a cornerstone of care or forgotten principles?. Pediatr Res 95, 1398–1399 (2024). https://doi.org/10.1038/s41390-023-03009-y

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