Introduction:

Hypothermia is considered as silent killer in neonate. It increases the neonatal morbidity and mortality.
Maintenance of warmth of the neonates enhances their survival. Piere Budin (1900) first draw attention to
the high neonatal mortality due to cold. Optimum thermal environment for neonate was identified in mid
1960s as they are easily influenced by the extreme of environmental temperature. The thermal protection of
the new born babies is considered as one of the important essential neonatal cares.

Definition:

Hypothermia is a common alteration of thermoregulatory state of the neonates. Neonatal hypothermia occurs
when body temperature drops below 36.5°C or 97.7°F in the new born infant. Normal body temperature is
between 36.5°C to 37.5°C.

Importance of prevention of hypothermia: A newborn is more prone to develop hypothermia because every
newborn has to adopt from intra uterine life to extra uterine life during transition. In intra uterine life
placenta act as a heat exchanger from mother but in the extra uterine life the production of heat occurs by
non-shivering thermogenesis, which LBW baby lacks.
The improper maintenance of thermoregulation causes:

1. Less active baby

2. Not breast feed well

3. Has weak cry

4. Has respiratory distress

Causes of hypothermia:

 Separation of baby from mother.

 Cold environment at the place of delivery, baby care area and home.

 Inadequate warming before and after discharge or during transport of baby.

 Excessive heat loss by evaporation, convection, conduction and radiation, from wet baby to cold
linen, cool room and cool air, cold object. Certain characteristic of neonates i.e. large surface area
per unit of body weight, large head,

 developmental immaturity of heat regulating center, poor insulation due to low subcutaneous fat, and
reduced brown fat in adipose tissue.

 High risk neonates-LBW baby, birth asphyxia, congenital malformation and mother having
anesthetic drug.

Stages of Hypothermia:

Newborns, infants, and young children are more likely to develop hypothermia because they have a larger
surface area compared to body weight so they can lose body heat faster than older children and adults. WHO
suggests slightly different temperature values for hypothermia levels in infants:

 Cold stress or mild hypothermia: 36.0° C to 36.4° C (96.8 F-97.5 F)

 Moderate hypothermia: 32.0° C to 35.9° C (89.6 F to 96.6 F)
 Severe hypothermia: <32° C (89.6 F)
Sign & Symptoms:

Early clinical sign

 Skin temperature of the new born is below 36.5°C.

 Hand, feet, abdomen are cold to touch.
 Weak sucking ability, weak cry and lethargy.
 Blue hand and feet due to peripheral vasoconstriction.

Late sign due to persistent hypothermia:

 Gradual fall of body temperature.

 Slow, swallow irregular respiration.
 Slow heart rate.
 Lethargy and poor response.
 Pale body with face and extremity of bright red colour.
 Central cyanosis may be present.
 Oedema may present.
 Weight loss.

Complication of Hypothermia:

 Hypoxia

 Hypoglycaemia

 Metabolic acidosis

 Respiratory distress

 Neonatal sepsis

 Neonatal jaundice

 Pulmonary haemorrhage

 Impaired cardiac function

 Coagulopathy

 Sudden infant death syndrome

 Delayed growth and development

 Mental retardation

Assessment of temperature by touch:

Baby's temperature can be assessed with reasonable precision by touching his/her abdomen, hands, and feet
with the dorsum of your hand. Mothers can be trained to identify, when her baby is at risk of hypothermia by
touching the extremities.

 When feet are cold and abdomen is warm, it indicates that the baby is in cold stress.
  In hypothermia, both feet and abdomen are cold to touch.
 In Normothermic baby the temperature is normal, both feet and abdomen are warm to touch.

By thermometer:

 Wash hand before taking a baby's temperature.

 Keep the baby warm throughout the procedure.

 Make sure that the thermometer is clean.

 Shake mercury thermometer, so that is read less than 35°C

 Place the silver/red/bulb end of the thermometer under the baby's arm in the middle of the armpit
after drying.

 Gently hold the baby's arm against the body.

 Keep the thermometer in place for 3 mints.

 Remove the thermometer and read the thermometer. DO NOT add 0.5°C or 1°C to this

 Keep the thermometer in a sterile dry container after cleaning from stem to bulb with spirit.

 Record temperature in the baby's case note.

Prevention of Hypothermia:

 Proper wiping and wrapping:

 Immediately following birth, newborns must be carefully wiped, dried and covered to prevent heat
loss through evaporation of the amniotic fluid.

 Proper wiping and drying were found to prevent significant drops in temperature in the first 2 h after
birth Head caps, especially Woolen ones, are recommended for all babies, and the infant should be
dressed and wrapped warmly when not in the skin-to-skin position.

 The newborn should be properly wrapped, and tight swaddling is not recommended due to possible
adverse effects.

 The multi number of layers in bedding and clothing is necessary.

Skin-to-skin care:

 Skin-to-skin care has shown promising results for prevention and management of hypothermia for
both low and normal birth weight babies in hospital as well as community settings.

 Kangaroo Mother Care refers to the technique of prolonged, continuous STSC between mothers and
their LBW infants in the hospital and after discharge.

 The practice of Kangaroo Mother Care in hospitalized LBW infants has been associated with a
number of benefits, and is now considered to be at least as good as standard care with incubators.

 Besides improved thermoregulation of the newborn, other potential benefits include improved
 maternal- infant bonding, more rapid transition to physiological stability following birth, reduced
crying and longer periods of alertness, improved breastfeeding and growth, reduced incidence of
serious bacterial infections and earlier discharge from hospital.

 STSC was shown to be at least as effective as incubator care for the management of hypothermia in
normal birth weight neonates in hospital settings.

 Encouraging results from hospital-based studies have led to the introduction of variants of Kangaroo
Mother Care in community settings with widespread acceptance.

 In a community-based study of STSC in rural India, the practice was introduced as a universal
strategy for all newborns regardless of birth weight, with multiple benefits and no reported adverse
effects.

Breastfeeding:

 In addition to the heat exchange between newborn and mother, and provision of calories from fat, the
process of suckling, which occurs with greater frequency in breastfed as compared with bottle-fed
newborns, increases energy expenditure, stimulating basal metabolic activity and thus aiding
thermoregulation.

 Breastfeeding also prevents bacterial infection, thereby preventing a common cažuse of secondary
hypothermia.

Synthetic external insulation:

 Various synthetic wraps, bags, boxes and covers have been found to prevent heat loss in the
newborn, and
 are particularly effective when used immediately after delivery.

 A Cochrane review of polyethylene and polyurethane bags and wraps showed that they resulted in
significantly lower rates of hypothermia among infants <32 weeks gestation.

 Many of these bags and plastic sheets are locally available at low cost in low resource settings.

Bathing postponed:

 Bathing the newborn soon after birth causes drop in the body temperature and not necessary.

 Blood, vernix and meconium should remove but remaining vernix does not need to removed and it is
harmless.

 Bathing should be done after falling of the cord.

 Bathing in lukewarm water followed by rapid drying should be done.

 The window and door should be closed and fan should be off.

 After bathing baby should dried thoroughly dressed immediately and place with mother.

Topical agents and oil massage:

 Apply coconut oil/ olive oil or any recommended baby oil.

 This is especially relevant for preterm newborns with an immature skin barrier. Vegetable oils can
 potentially augment nutrition and possibly aid in skin barrier development by the transcutaneous
uptake of lipids.

 Promotion of this intervention should include education for the community and health providers on
maintenance of the warm chain and preservation of vernix during massages.

Warm chain at home:

 Promote breast feeding.

 Appropriate clothing cover head and extremities

 Keep mother and baby together (bedding in).

 Keep the room warm 25°C-28°C

 Ise dry, warm towel to hold the baby at birth. Remove wet towel after cleaning.

 Do not use ceiling fan especially high-speed fan.

 Warm the room by convector/heater.

Referral:

 If the baby becomes lethargic, refuse to suck these are danger sign and baby should be
referred to the hospital.

Conclusion:

Neonatal hypothermia has been documented throughout the developing world, and is an important source of
neonatal morbidity; the contribution of hypothermia to neonatal mortality is poorly understood. For most
newborns, hypothermia can be easily and affordably prevented. Increased knowledge among hospital and
community providers, as well as families, could greatly impact the current incidence and case fatality of
hypothermia. Promotion of immediate drying and wrapping of the newborn, as well as universal STSC
could prevent a majority of the incident cases among newborns. With adequate prevention, management will
be required less, and associated conditions can be avoided.
Bibliography:

1. Ghai. OP, Paul. K. Vinod, Bagga. Arvind, Ghai Essential Paediatrics. CBS publisher & distributer pvt.
Ltd.7 Edition 2009, page-1-33.

2. Dutta Parul, Paediatric nursing, New Delhi; Jaypee brother’s medical publishers(P) Ltd 3rd edition 2009.