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Neonatal Hypothermia: Not an Issue to Simply Blanket Over

August 17, 2023

Editor’s Note: Eli Cahan is a resident physician in pediatrics at The Boston Combined Residency Program at Boston Children's Hospital and Boston Medical Center, and an investigative journalist whose work focuses on the intersection of health equity and social justice. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

As a pediatrics resident learning the neonatal resuscitation program (NRP) for the first time, there’s lots to remember: PIPs (peak inspiratory pressures) and PEEPs (positive end-expiratory pressures), bulb suctions and deep suctions, CPAPs (continuous positive airway pressures) and C-MACs (video laryngoscopes).

However, every NRP session starts the same, by turning on the infant warmer. Babies don’t like the cold, instructors say, citing surface area-to-volume ratios.

Neonatal hypothermia, however, continues to be an issue.  Historical studies in the US have found increases in mortality of up to 30% per degree below the low end of normal body temperature. Other studies have found maintenance of normothermia can reduce mortality by 19% per degree above hypothermia. Still others have found specific interventions—like thermal mattresses and heated wraps—can together reduce mortality by nearly 50%.

Despite the importance of neonatal hypothermia, large-scale studies—both domestically, and abroad, including in low- and middle-income countries—aiming to quantify its prevalence and illness course are scarce.

In an article being early released this week in Pediatrics, Frade Garcia and colleagues set out to answer these questions by extracting data on over 200,000 premature and/or small for gestational age newborns from 34 hospitals between 2018-2021 (10.1542/peds.2023-061607).

They found that almost two-thirds of newborns in middle-income countries (MICs) experienced hypothermia within an hour of birth; in high-income countries (HICs), almost 30% of newborns did so. Furthermore, the in-hospital mortality rates of hypothermic neonates in MICs were 21% above those of euthermic neonates. In HICs, the differences were even more pronounced; infants who were hypothermic had mortality rates 26% higher than their euthermic peers. All told, each additional degree reduced mortality rates by around 10% in both MICs and HICs.

The authors were careful to caution that hypothermia may be a product, rather than a cause, of underlying illness that can increase mortality risk. Nonetheless, they highlight the importance of attentiveness to hypothermia as a key method in newborn management.

“Hypothermia remains a common problem in both MICs and HICs,” the authors wrote, “urging the medical community caring for newborns around the globe to renew their focus on this often-neglected vital sign is a key strategy to improve outcomes.”

Clinicians across the practice spectrum interested in advancing the short- and long-term wellbeing of neonates can read more in the September issue of Pediatrics.

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