PREPARED BY :

1.Ms. Seema Bhagat, Sr. Sister Tutor, B.Y.L Nair hospital , School of Nursing, Mumbai

2. Ms. Prachi Dharap, Principal, Sau Minatai Thakre Institute of Nursing Education, TMC,Thane.
OVERVIEW :

The human being is a homeotherm. Homeothermy is a result of thermoregulation which includes

many physiological processes. Thermoregulation maintains an equilibrium between heat production
(thermogenesis) and heat loss (thermolysis). The newborn's energy expenditure is used in order of
priority for: (i) basic metabolism; (ii) body temperature regulation and (iii) body growth. Thermal
regulation is an important part of energy expenditure, especially for low birth-weight infants or
preterm newborns. 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.

Thermal protection of the newborn is a set of continuing measures, which starts at birth, to ensure
that he maintains a body temperature of 36.5°C to 37.5°C 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.. 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.1

AIM : The Thermoregulation in newborn module is designed to provide information that enables
the nursing personnel to manage newborn care .

OBJECTIVES :

At the end of this module the learner will be able to-

1. Understand the physiology of thermoregulation

2. Identify mechanisms of thermoregulation
3. Understand the consequences of inadequate thermoregulation in neonates
4. Identify strategies to support thermoregulation
5. Review best practices in neonatal thermoregulation
CONTENT :

The module content includes text material and pictures . Key messages are highlighted.

TERMINOLOGY:

Thermoregulation: The ability to balance heat production and heat loss in order to maintain body
temperature within a certain “normal” range.

Thermal Protection: Thermal protection of the newborn is the series of measures taken at
birth and during the first days of life to ensure that the baby does not become either too
cold (hypothermia) or too hot (hyperthermia) and maintains a normal body temperature
of 36.5-37 .50C (97.7-99.5°F).

Neutral thermal environment (NTE): narrow range of environmental temperature in which a

person is able to maintain a neutral thermal temperature. A neutral thermal temperature is the body
temperature at which an individual’s oxygen and energy consumption is minimised.

Hypothermia: The World Health Organization (2006) defined mild hypothermia as a body
temperature of 36-36.5ºC, moderate hypothermia as 32-36ºC and severe hypothermia as less than
32ºC.

Hyperthermia: Hyperthermia is also a common problem with neonates. Very common in dry warm
climate areas. Temperature of more than 37.5°C is defined as hyperthermia in newborns.

 
Heat Stroke: Thermoregulation is overwhelmed by a combination of excessive metabolic production
of heat (exertion), excessive environmental heat and insufficient or impaired heat loss. This results in
an abnormally high body temperature

 
Neonate: an infant that is up to 28 days corrected post term (e.g. an infant born at 34 weeks gestation
and is 8 weeks old is 14 days corrected post term).

 
Non shivering thermogenesis: Brown fat is the site of heat production. It is localized around the
adrenal glands, kidneys, nape of neck, interscapular and axillary region. Metabolism of brown fat
results in heat production. Blood flowing through the brown fat becomes warm and through
circulation transfers heat to other parts of the body. This mechanism of heat production is called as
non-shivering thermogenesis

Methods of heat loss:

1. Conduction: Transfer of heat from one solid object to another solid object in direct contact
with it
2. Convection:Transfer of heat from the body surface to the surrounding air via air current
3. Radiation:Transfer of heat to cooler solid objects not in direct contact with the body
4. Evaporation: Heat loss occurring during conversion of liquid to vapour

 
Radiant warmer:

Radiant warming cots are designed to provide thermal stability to infants while allowing direct
observation. These cots can be operated in servo control mode (the heating elements turn on and off
according to measured changes in the infant’s skin temperature) or manual control (the heater is set
to a constant power level).

Isolette: The trademark name for an autonomous incubator unit that provides a controlled heat,
humidity and oxygen microenvironment for the isolation and care of premature and low birth weight
neonates, and infants. The device is made of a clear plastic material and has a large door and smaller
portholes for easy access to the infant with a minimum of heat and oxygen loss. A servo control
mechanism can be used to constantly monitor the infant’s temperature and control the heat within the
unit.

warm chain : The warm chain is a set of ten interlinked steps carried out at birth and later which will
reduce the chances of hypothermia in all newborns.

THERMOREGULATION IN NEWBORN

Maintaining a neutral thermal environment is one of the key physiologic challenges that a
newborn must face after delivery. Thermal care is central to reducing morbidity and
mortality in newborns. Thermoregulation is the ability to balance heat production and heat
loss in order to maintain body temperature within a certain normal range. The newborn cannot
regulate its temperature as well as an adult. It therefore cools down or heats up much
faster and is able to tolerate only a limited range of environmental temperatures. . The
smaller the newborn, the greater the risk. Thermal stability improves gradually as the baby
increases in weight.

HYPOTHERMIA:
The World Health Organization (2006) defined mild hypothermia as a body temperature of 36-
36.5ºC, moderate hypothermia as 32-36ºC and severe hypothermia as less than 32ºC.
The following characteristics put newborns at a greater risk of heat loss:
 A large surface area per unit of body weight
 Decreased subcutaneous fat
 Less brown fat
 Greater body water content
 Immature skin leading to increased evaporative water and heat losses
 Poorly developed metabolic mechanism for responding to thermal stress (e.g. no shivering)
 Altered skin blood-flow (e.g. peripheral cyanosis)

Sources of heat loss

There are four ways in which a newborn loses body heat:
1. Evaporation : Particularly soon after birth due to evaporation of amniotic fluid from skin surface.
2. Conduction :By coming in contact with cold objects e.g. cloth, tray, etc,
3. Convection: By air currents in which cold air from open windows replaces warm air around baby
4. Radiation : To colder solid objects in vicinity e.g. walls

Consequences of Hypothermia in New born:

Increased cellular metabolism takes place as the newborn tries to stay warm, leading to increased
oxygen consumption, which puts the newborn at risk of hypoxia, cardiorespiratory complications,
and acidosis. These newborns are also at risk for hypoglycemia because of the increased glucose
consumption necessary for heat production. Neurological complications, hyperbilirubinemia, clotting
disorders, and even death may result if the untreated hypothermia progresses

Effects of cold stress in the newborn

Cold

Activation of Nonshivering Thermogenesis

(Metabolism of Brown Fat)

Increased oxygen consumption Increased glucose use

Increased respiratory rate Depletion of glycogen stores

Pulmonary vasoconstriction Hypoglycemia

Tissue hypoxia

Peripheral vasoconstriction

Anaerobic metabolism

Metabolic acidosis
Signs and symptoms of hypothermia
· Acrocyanosis and cool, mottled, or pale skin
· Hypoglycemia
· Transient hyperglycemia
· Bradycardia
· Tachypnea, restlessness, shallow and irregular respirations
· Respiratory distress, apnea, hypoxemia, metabolic acidosis
· Decreased activity, lethargy, hypotonia
· Feeble cry, poor feeding
· Decreased weight gain

Recording temperature
It is not necessary to measure the temperature of healthy newborn babies routinely, particularly when
the warm chain is strictly followed.

Temperature should be monitored every 1-2 hour for a baby with serious illness, twice daily for
babies weighing between 1500 to 2499 gm, four times daily for babies below 1500 gm and once a
day for other babies who are doing well.

Methods of recording temperature

Touch method

Abdomen skin temperature is assessed by touch with dorsum of hand. Abdominal temperature is
representative of the core temperature. Baby’s temperature can be assessed with reliable accuracy by
human touch, which can be easily taught to parents and can be practiced at home as well. The
interpretation is as follows:
 Baby’s feet and hands are warm: Thermal comfort
 Peripheries are cold, the trunk is warm: Cold stress
 Peripheries and the trunk both are cold: Hypothermia

Thermometers
WHO recommends the use of low reading thermometer which can record up to 30°C. The best is to
use a digital thermometer.

Thermister probe
Skin temperature can be recorded by a thermister. The probe is attached to skin over upper abdomen.
The thermister will sense the skin temperature and display on the panel.

Management of Hypothermia

WARM CHAIN:
Thermal protection of newborns is very important and not difficult. The basic principles
are the same whether the baby is born at home or in an institution. As most cooling of the
newborn occurs during the first minutes after birth, it is important to act quickly to prevent heat
loss..
 The "warm chain" is a set of interlinked procedures to be taken at birth and during the
next few hours and days in order to minimize heat loss in all newborns. Failure to implement
any one of these procedures will break the chain and put the newborn baby at risk of getting
cold.

The 10 steps of the "warm chain" are described below.

STEP 1 : Warm delivery room

 The temperature of the delivery room should be at least 25°C, free from the drafts from
open windows, doors, or fans.
 Supplies needed to keep the newborn warm should be prepared ahead of time.
 Adults should never determine the temperature of the delivery room according to their
comfort.
STEP 2: Immediate drying
 Immediately dry the newborn after birth with a warm towel or cloth to prevent heat loss from
evaporation
STEP 3: Skin-to-skin contact
 While the newborn is being dried, place on the mother’s chest or abdomen (skinto-skin
contact) to prevent heat loss. -If mother is unable the cold newborn may go skin-to-skin with
the partner
 Cover the newborn with a second towel and put a cap on the head to prevent heat loss from
convection.
 Leave the newborn skin-to-skin on the mother and keep covered.
 Newborns should be uncovered as little as possible during assessments and interventions.
 Newborns can be maintained in skin-to-skin contact with the mother:
 while she is being attended to (placenta delivery, suturing)
 during transfer to the postnatal unit, recovery room
 during assessments and initial interventions
 for the first hours after birth
STEP 4: Breastfeeding
 Initiate as soon as possible, preferably within one hour of birth.
STEP 5: Postpone weighing and bathing
 Weighing can be done following the period of uninterrupted skin-to-skin contact and the
first feed.
 Place a warm blanket on the scale.
 Bathing the newborn soon after birth causes a drop in the body temperature and may
propagate
 Hypothermia and hypoglycemia.
 Following the transition period (6-8 hours) newborns may be assessed for
 Bathing readiness. Bathing may be considered when vital signs are stable.
 If a hypothermic newborn has thick wet hair, consider washing the hair only, drying the hair
thoroughly and then place a cap on the head.
 Bathing should be done quickly in a warm room, using warm water. Tub bathing is the
preferred method of bathing to prevent heat loss for all stable newborns both term and
preterm. The water should be deep enough to cover the newborn’s shoulders.
o Immediately after the bath dry thoroughly, immediately diaper and place skin-to skin.
If skin-to-skin is not possible double wrap the newborn with warm blankets ensuring
the head is covered.
o After skin-to-skin, dress the newborn, apply a dry cap and wrap in dry warm
blankets.
STEP 6:Appropriate clothing/blanket
 Dress newborn in loose clothing and blanket.

STEP 7: Mother and newborn together

 Keep mother and newborn together 24 hours a day (rooming-in), in a warm room (at least
25°C).
 Newborn should be fed on demand.
 Skin-to-skin can be used to rewarm a newborn experiencing mild to moderate hypothermia

STEP 8: Warm transportation

 Keep newborn warm while waiting for transportation.
 Dress the newborn and wrap in blankets if a transport device is used.

STEP 9: Warm assessment (if newborn not skin-to-skin with mother)

 Lay on a warm surface in a warm room.
 Put under an additional heat source as necessary (i.e. radiant warmer).
 Utilize servocontrol if on radiant warmer for >10 minutes.

STEP 10 :Training and raising awareness

 Alert health care providers and families to the risks of hypothermia and hyperthermia.
 Teach the principle of thermal protection of the newborn.
 Provide on the job training and supervised practice to ensure that the 10 steps of the warm chain
become part of the routine care of the newborn.
 Demonstrate and provide supervised practice on the appropriate use of equipment for low birth
weight/preterm newborns.

METHODS USED TO TREAT HYPOTHERMIA

Mild hypothermia (body temperature 36-36.4°C)

 Skin-to-skin contact, in a warm room (at least 25°C).
 Place cap on newborn head
 Cover mother and newborn with warm blankets
 Encourage Breast Feeding
Moderate hypothermia (body temperature 32-35.9°C)
 Under a radiant heater
 In a warmed incubator, at 35-36 °C
 In a heated water-filled mattress (i.e. KanBed)
 If no equipment is available or if the newborn is clinically stable, skin-to-skin contact with the
mother can be used in a warm room (at least 25°C)
Severe hypothermia (body temperature below 32°C)
 Using a warm incubator (should be set at 1 to 1.5°C higher than the body temperature) and should
be adjusted as the newborn’s temperature increases
 If no equipment is available, skin-to-skin contact or a warm room or cot can be used
 Breast feeding should continue to prevent hypoglycemia. If this is not possible monitor blood
glucose levels and administer intravenous glucose if needed.
Kangaroo Mother Care (KMC)

Kangaroo Mother Care (KMC) is a special way of caring the low birth weight (LBW) babies. It
improves their health and well being by promoting effective thermal control, breastfeeding, infection
prevention and bonding.

In KMC, the baby is continuously kept in skin-to-skin contact by the mother and breastfed
exclusively.KMC is initiated in the hospital and continued at home.

The two components of KMC are:

i. Skin-to-skin contact
Early, continuous and prolonged skin-to-skin contact between the mother and her baby is the basic
component of KMC. The infant is placed on her mother's chest between the breasts.
ii. Exclusive breastfeeding
The baby on KMC is breastfed exclusively. Skin-to-skin contact promotes lactation and thus
facilitates exclusive breastfeeding.

The two prerequisites of KMC are:

i. Support to the mother in hospital and at home
A mother needs counseling, support, and supervision from health care providers for initiating KMC
in the hospital. She would also require assistance and cooperation from her family members for
continuing KMC at home. .
ii. Post-discharge follow-up
KMC is continued at home after early discharge from the hospital. A regular follow up and access
to health providers for solving problem are crucial to ensure safe and successful KMC at home.

Benefits of KMC
The benefits of KMC include:
1. Temperature maintenance with a reduced risk of hypothermia
2. Increased breastfeeding rates
3. Early discharge from the health facility
4. Less morbidities such as apnea and infections
5. Less stress (for both baby and mother) and
6. Better infant bonding.

Requirements for KMC implementation

1. Training of nurses, physicians and other staff involved in the care of the mother and the baby.
2. Educational material such as information sheets, posters, video films on KMC in local
language should be available to the mothers, families and community.
3. If possible, reclining chairs in the nursery and postnatal wards, and beds with adjustable back
rest should be arranged. Mother can provide KMC sitting on an ordinary chair or in a semi-reclining
posture on a bed with the help of pillows

8.5. Eligibility criteria

All stable LBW babies are eligible for KMC. However, very sick babies needing special care should
be cared under radiant warmer initially. KMC should be started after the baby is hemodynamically
stable. Guidelines for practicing KMC include:
i. Birth weight >1800 g: These babies are generally stable at birth. Therefore, in most of
them KMC can be initiated soon after birth.
 ii. Birth weight 1200-1799 g: Many babies of this group have significant problems in
neonatal period. It might take a few days before KMC can be initiated. If such a baby is born
in a place where neonatal care services are inadequate, he should be transferred to a
proper facility after initial stabilization and appropriate management. One of the best ways of
transporting small babies is by keeping them in continuous skin-to-skin contact with the
mother / family member.

iii. Birth weight <1200 g: Frequently, these babies develop serious prematurity-related
morbidities often starting soon after birth. They benefit the most from in-utero transfer to the
institutions with neonatal intensive care facilities. It may take days to weeks before baby's
condition allows initiation of KMC.

KMC can be initiated in a baby who is otherwise stable but may still be on intravenous
fluids, tube feeding and/or oxygen.

PREPARING FOR KMC

Counseling
When the baby is ready for KMC, arrange a time that is convenient to the mother and her
baby. The first few sessions are important and require extended interaction. Demonstrate
her the KMC procedure in a caring and gentle manner. Answer her queries patiently and
allay her anxieties. Encourage her to bring her mother/mother in law/husband or any other
member of the family. It helps in building positive attitude of the family and ensuring family
support to the mother which is particularly crucial for post-discharge home-based KMC. It is
helpful if the mother starting KMC interacts with someone who is already practicing KMC.

Mother's clothing
KMC can be provided using any front-open, light dress as per the local culture. KMC works well
with blouse and sari, gown or shawl. A suitable apparel that can retain the baby for extended
period of time can be adapted locally.

Baby's clothing
Baby is dressed with cap, socks, nappy, and front-open sleeveless shirt or 'jhabala'.

THE KMC PROCEDURE

Kangaroo positioning

 Baby should be placed between the mother's breasts in an upright position.

 Head should be turned to one side and in a slightly extended position. This slightly extended head
position keeps the airway open and allows eye to eye contact between the mother and her baby.
 Hips should be flexed and abducted in a "frog" position; the arms should also be flexed.
 Baby's abdomen should be at the level of the mother's epigastrium. Mother's breathing stimulates
the baby thus reducing the occurrence of apnea.  Support the baby‟s bottom with a sling/binder

Monitoring
Babies receiving KMC should be monitored carefully especially during the initial stages. Nursing
staff should make sure that baby‟s neck position is neither too flexed nor too extended, airway is
clear, breathing is regular, color is pink and baby is maintaining temperature. Mother should be
involved in observing the baby during KMC so that she can continue monitoring at home.

Feeding
Mother should be explained how to breastfeed while the baby is in KMC position. Holding the baby
near the breast stimulates milk production. She may express milk while the baby is still in KMC
position. The baby could be fed with paladai, spoon or tube depending on the condition of the baby.
10.4 Privacy
KMC unavoidably requires some exposure on the part of the mother. This can make her nervous
and could be de-motivating. The staff must respect mother's sensitivities in this regard and ensure
culturally acceptable privacy standards in the nursery and the wards where KMC is practiced.
10.5 Time of initiation
KMC can be started as soon as the baby is stable. Babies with severe illnesses or requiring special
treatment should be managed according to the unit protocol. Short KMC sessions can be initiated
during recovery with ongoing medical treatment (IV fluids, oxygen therapy). KMC can be provided
while the baby is being fed via orogastric tube or on oxygen therapy.
10.6 Duration of KMC
 Skin-to-skin contact should start gradually in the nursery with a smooth transition from
conventional care to continuous KMC.
 Sessions that last less than one hour should be avoided because frequent handling may be
stressful for the baby.
 The length of skin-to-skin contacts should be gradually increased up to 24 hours a day,
interrupted only for changing diapers.
 When the baby does not require intensive care, she should be transferred to the postnatal ward
where KMC should be continued.

Hyperthermia
Hyperthermia is also a common problem with neonates. Very common in dry warm climate areas.
Temperature of more than 37.5°C is defined as hyperthermia in newborns.

a) Causes
 Too hot environment – high room temperature
 The baby has many layers of covers / clothes
 Dehydration fever – the baby may be in a dehydration state
 Sepsis

b) Dehydration fever
Dehydration results in excess weight loss for the baby and hence one of the important clue for
dehydration fever is excess weight loss. Fever generally subsides with correction of breastfeeding
issues or when extra feeds given properly.

c) Symptoms
Early: Irritable, tachycardia, tachypnea, flushed face, hot and dry kin
Late: Apathetic, lethargic and then comatose
Severe forms of hyperthermia can lead to shock, convulsions, even death in neglected cases

d) Management
Place the baby in a normal environment (25-28°C) away from heat source
 Undress the baby partial / fully
 Give frequent breast feeds give breast milk or by katori spoon if needed
 If temperature >39°, sponge can be done with tap water
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