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Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Variations in incubator temperature and humidity management: a survey of

current practice
C Deguines1,2, P Décima (pauline.decima@u-picardie.fr)2, A Pelletier2, L Dégrugilliers1,2, L Ghyselen1,2, P Tourneux1,2
1.Médecine Néonatale et Réanimation Pédiatrique Polyvalente, CHU Amiens, France
2.Laboratoire PériTox (EA 4285 – UMI 01 INERIS), UFR de Médecine, Université de Picardie Jules Verne, Amiens, France

Keywords
Clinical practice, Humidity, Incubators, Low-
birthweight infants, Temperature
Correspondence
P Décima, Laboratoire Péritox EA 4285 – UMI 01
INERIS, Université de Picardie Jules Verne, 3 rue des
Louvels, F-80034 Amiens Cedex 1, France.
Tel: +33 3 22 82 76 77 |
Fax: +33 3 22 82 78 96 |
Email: pauline.decima@u-picardie.fr
Received
12 July 2011; revised 10 October 2011;
accepted 11 October 2011.
DOI:10.1111/j.1651-2227.2011.02492.x
ABSTRACT
Aim: To describe and assess routine procedures and practices for incubator
temperature and humidity management in France in 2009.
Methods: A questionnaire was sent to all the 186 neonatal care units in France.
Results: The questionnaire return rate was 86%. Seventy-five per cent of the units
preferred skin servo-control to air temperature control in routine practice. Air temperature
control was mainly used for infants with a gestational age of more than 28 weeks and aged
over 7 days of life. In general, thermal management decisions did not depend on the
infant’s age but were based on a protocol applied specifically by each unit. All units
humidified the incubator air, but there was a large difference between the lowest and
highest reported humidity values (45% and 100% assumed to be a maximal value,
respectively). More than 65% of the units used a fixed humidity value, rather than a vari-
able, protocol-derived value.
Conclusion: We observed large variations in incubator temperature and humidity
management approaches from one neonatal care unit to another. There is a need for more
evidence to better inform practice. A task force should be formed to guide clinical practice.

Humans can maintain an almost constant body temperature
(36.5–37.5C) in a wide range of thermal environments. In
the particular case of premature and ⁄ or low-birthweight
infants, thermal responses to heat or cold stresses are
present but limited at birth, whereas cutaneous heat
exchanges with the environment are proportionally greater
than in term infants and adults. Low-birthweight infants
(accounting for about 7% of the births in France in 2010)
are thus vulnerable to hypo- or hyperthermia, which are
often observed on admission to neonatal care units and are
thought to be involved in many pathological situations
(1–4). Hence, fragile infants should be protected against
external thermal fluctuations until their thermoregulatory
mechanisms become fully efficient. In an incubator, thermal
stability is commonly achieved by using one of two modes
of control. The first mode controls the temperature of the
circulating air (Ta; air temperature control, ATC). The
second mode regulates the incubator’s heating power as a
function of the measured skin temperature [Tsk, usually
between 36.8 and 37.0C (5,6)] with a skin servo-control
Abbreviations
ATC, air temperature control; CV, coefficient of variation; GA,
gestational age; PNA, post-natal age; RH, relative humidity; SD,
standard deviation; SSC, skin servo-control; Ta, air incubator
temperature; Tsk, skin temperature.
(SSC) system. When using ATC, there is a lack of evidence
to inform practice on the Ta at which neonates should be
nursed. The guidelines published in 1970–1975 took
account of either the birthweight and the post-natal age
(PNA) (7) or the gestational age (GA) and the PNA (8).
These working rules are approximate (7), because the envi-
ronmental control is primarily based on Ta at an air humid-
ity of 50% and on the assumption that the incubator walls
are at Ta. The SSC method is designed to maintain the
infant’s body temperature constant and minimize metabolic
heat production (9). However, this method assumes that the
thermoregulatory system is fully efficient, which is unlikely
to be the case for very low-birthweight neonates (9). More-
over, the assumption that a single Tsk measurement site is
representative of the infant’s thermoregulatory status
remains subject to debate, because Tsk varies greatly from
one body region to another. Another problem relates to the
Key notes
• A total of 186 French neonatal care units were asked to
fill out a questionnaire concerning their incubator
temperature and humidity management practices. Our
analysis of 159 replies (response rate: 86%) revealed
large variations between neonatal care units in terms of
the incubator set temperature and humidity parameters.

230 ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 230–235

Deguines et al.
fact that the use of a reflective aluminium foil patch to cover
the sensor minimizes the reading error otherwise caused by
radiant heat sources but also increases the apparent Tsk by
between 0.15 and 0.82C (10,11). In a Cochrane review,
Sinclair (2008) (12) pointed out that for low-birthweight
neonates, (i) the anterior abdominal skin temperature can
be kept at 36C and (ii) the use of the ATC method means
that Ta can be frequently manually modified.
Literature data suggest that maintaining high humidity is
essential for reducing the major body water loss and evapo-
rative skin cooling seen in less mature infants with thinner
skin. However, these benefits are subject to debate when
considered against the risks of infection (4,13,14), hyper-
thermia (4) and delayed skin maturation (14). Sinclair et al.
(15) highlighted the absence of evidence for informing prac-
tices and thus wide variation in opinions on humidification
and temperature control in incubators. They also empha-
sized the technical features of new-generation incubators
and the concomitant lack of updated recommendations for
use of these new devices by caregivers.
Given the lack of approved recommendations, we
assumed that there would be a great unit-to-unit variability
in incubator temperature and humidity management prac-
tices in France. We performed a large survey to determine
(i) current thermal management procedures and practices
for nursing low-birthweight infants in incubators and (ii)
the factors that influence the caregivers’ choice of thermal
parameters. Lastly, we attempted to define what sort of
knowledge is required to help clinicians to optimize their
incubator temperature and humidity management practices.
PATIENTS AND METHODS
The survey instrument was a specifically designed, e-mailed
questionnaire covering notably the unit’s characteristics
and equipment, the use of SSC or ATC modes, air humidity
levels, the use of a patch to cover the skin temperature
probe and the probe’s body site.
Procedure
The questionnaire was sent to all French neonatal care units
in January 2009. In France, neonatal care units are classified
into four levels (I, IIa, IIb and III) by the Ministry of Health
(16), according to the type of care provided and the type of
infant admitted. Level I units (maternities) were not taken
into account in this study, because they deal with full-term
neonates who do not require specific medical support. Level
IIa units (special care nurseries) provide care to neonates
(‡32 weeks of gestational age and birthweight ‡ 1500 g)
with problems that can be rapidly resolved. They can pro-
vide assisted ventilation, if required. Level IIb units deal
with (i) infants with a birthweight ‡ 1000 g and a gesta-
tional age ‡ 28 weeks or (ii) preterm infants £ 28 weeks of
gestational age who have been discharged from a level III
unit. Level IIb units are able to provide conventional
mechanical ventilation for as long as is needed but do not
use the most advanced respiratory support techniques like
high-frequency ventilation. Level III units deal with
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 230–235
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Incubator temperature and humidity management
extremely premature infants (gestational age of 28 weeks or
less) or those with an extremely low birthweight (1000 g or
less) or severe and ⁄ or complex illnesses. These infants form
the highest-risk group need the most specialized care, such
as advanced respiratory support, physiological monitoring
equipment, laboratory and imaging facilities and nutrition
and pharmacy support with specific paediatric expertise.
The questionnaire and an information sheet were e-mailed
to managers at the 186 units (50 level IIa units, 77 level IIb
units and 59 level III units) between December 2008 and
March 2009. Follow-up e-mails and telephone calls were
used to maximize the response rate and to collect more
detailed information.
Analysis
The results were analysed statistically with Statview 5.0
software (SAS Institute Inc., Cary, NC, USA). We used chi-
squared tests with a Yates correction (if n < 5) to compare
qualitative variables and an analysis of variance to test
quantitative variables, with the use of a post hoc Fisher’s
protected least square difference (PLSD) tests if F-values
were significant. The statistical significance threshold was
set to p < 0.05. Data are quoted as the mean ± 1SD, and
inter-level variability is expressed as the coefficient of varia-
tion (CV, that is, the SD divided by the mean).
RESULTS
Participants
In all, 159 of 186 (86%) of the units returned the question-
naire. Respondents were variously nurses (37%), physicians
(25%), administrative nurses (21%) and unit managers
(17%). All were in charge of their incubators’ daily manage-
ment and had good knowledge of their unit’s clinical pro-
cedures. There was no difference in the questionnaire
results according to the type of respondent (v26 = 12.02;
p = 0.056).
The response rates for levels IIa, IIb and III were 70%,
96% and 86%, respectively. The level IIa, IIb and III units
differed significantly in terms of the mean number of admis-
sions per year, with 211 ± 111, 365 ± 191 and 485 ± 246
admissions, respectively (F2,107 = 12.99; p < 0.001). There
was no significant difference in terms of the number of incu-
bators per patient placed in the unit: 0.82 ± 0.35
(F2,147 = 1.38; p = 0.255).
Practice concerning the incubator temperature control
mode
As shown in Table 1, there was consensus on thermal man-
agement with SSC (rather than ATC) for all unit levels
(v23 = 12.43; p = 0.006), despite the fact that all incubators
provide a choice between these two control modes (17).
The choice of thermal control mode depended on GA
(v21 = 9.56; p = 0.002) and PNA (v21 = 4.23; p = 0.040). For
infants with a gestational age of more than 28 weeks and
aged more than 7 days of life, the ATC mode was more fre-
quently used. A wide range of Ta and Tsk values were used
to control the thermal environment in the incubator,
231
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Incubator temperature and humidity management Deguines et al.

Table 1 Practice concerning the incubator temperature and humidification control mode according to the unit level (IIa, IIb and III) and the infant’s gestational and post-natal ages
Temperature Humidity

Mode (%) Set point temperature (C) Air humidity values (%) when using
Units (%) using
SSC ATC
A fixed value A unit protocol
Unit level SSC ATC Average ± 1SD CV Average ± 1SD CV A fixed value A unit protocol Mean ± 1SD CV Mean ± 1SD CV

GA < 28 weeks; PNA < 7 days

IIb 82 18 36.61 ± 0.30 1 35.00 ± 2.00 6 67 33 80 ± 19 24 100 ± 0 –
III 84 16 36.70 ± 0.29 1 36.20 ± 0.91 3 82 18 83 ± 13 16 87 ± 15 17
GA < 28 weeks; PNA > 7 days
IIb 67 33 36.58 ± 0.33 1 35.00 ± 1.63 5 71 29 83 ± 21 25 65 ± 7 11
III 82 18 36.68 ± 0.29 1 36.20 ± 0.91 3 69 31 73 ± 11 15 78 ± 18 23
GA > 28 weeks; PNA < 7 days
IIa 68 32 36.68 ± 0.30 1 35.18 ± 1.66 0 74 26 50 ± 0 – 45 ± 0 –
IIb 70 30 36.60 ± 0.25 1 34.71 ± 2.08 6 82 18 63 ± 22 35 77 ± 15 19
III 80 20 36.72 ± 0.27 1 36.16 ± 0.79 2 75 25 77 ± 17 22 80 ± 15 19
GA > 28 weeks; PNA > 7 days
IIa 57 43 36.66 ± 0.31 1 34.93 ± 1.59 5 74 26 50 ± 0 – – –
IIb 58 42 36.64 ± 0.23 1 34.40 ± 2.12 6 79 21 62 ± 23 37 73 ± 13 18
III 75 25 36.74 ± 0.28 1 35.63 ± 1.47 4 65 35 68 ± 14 21 80 ± 21 26

The infant’s gestational age (GA) is expressed in weeks of gestation, and the post-natal age (PNA) is expressed in days. The values are expressed as percentages
(mean ± 1 SD) with the coefficient of variation (CV) in %. The symbol ‘‘–’’ indicates the absence of data. NB: level IIa units do not treat neonates with a gestational
age below 28 weeks.

available literature (SSC: 1 ± 1%; ATC: 1 ± 1%) or esti-

Table 2 Choice of the thermal regulation control mode as a function of the unit level
mates made by the nursing staff according to the axillary
(IIa, IIb and III).
temperature (SSC: 10 ± 7%; ATC: 15 ± 11%). When we
Unit level Protocol Manufacturer Literature Other
compared level IIb and level III units (GA £ 28 weeks) with
Skin servo-control level IIa units (GA > 28 weeks) in terms of the reasons for
IIa 68 29 0 3 choosing SSC or ATC modes (a unit-specific protocol, a rec-
IIb 72 17 0 11 ommendation by the manufacturer, the available literature,
III 70 11 2 17 nursing experience, etc.), Fisher PLSD tests did not reveal
Mean 70 ± 2 19 ± 10 1±1 10 ± 7
any statistically significant differences (p = 0.108 and
Air temperature control
p = 0.892 for SSC and ATC, respectively).
IIa 68 27 0 5
IIb 64 20 2 14
III 63 11 0 26 Practice concerning the temperature sensor
Mean 65 ± 3 19 ± 8 1±1 15 ± 11 The sensor was generally placed on the anterior abdominal
skin surface, over the hepatic region (81 ± 6%). The other
Choice of the thermal regulation mode according to a unit-specific protocol,
body sites used were the back (9 ± 4%) and the axilla
the manufacturer’s recommendation, a literature recommendation or other
(5 ± 2%). Lastly, 5 ± 3% of the units did not use a perma-
criteria, expressed as a percentage of the units in each level.
nently affixed sensor but measured the axillary temperature
hourly. The sensor’s body site differed according to the unit
especially for ATC. The inter-level variability in the choice level (F3,8 = 301.43; p < 0.001): over the liver: 75%, 82%
of the target temperature was 1% for SSC and ranged from and 86%; on the back: 13%, 9% and 6%; and in the axilla:
2% to 6% for ATC. Tsk values were similar for the various 6%, 2% and 6% for level IIa, IIb and III units, respectively.
unit levels (36.67 ± 0.27C; F2,129 = 1.66; p = 0.194). Simi- Reusable Tsk sensors were preferred to single-use sensors
larly, the mean values of Ta (34.61 ± 2.11C) did not differ (v22 = 20.28; p < 0.001), whatever the unit level. The sensor
between the three unit levels studied here (F2,93 = 0.01; was variously covered by an adhesive, reflective patch
p = 0.987). (62 ± 7%), an adhesive but non-reflective patch (19 ± 8%)
In 70 ± 2% and 65 ± 3% of the cases, a unit-specific pro- or other types of adhesive (16 ± 4%). Only 2 ± 1% of the
tocol was used to determine either Tsk (when using SSC) or units did not use adhesive – the sensor was placed under the
Ta (when using ATC), respectively (Table 2). The decisions diaper’s elastic waistband. These practices differed signifi-
based on the unit’s protocol differed significantly cantly according to the unit level (F3,8 = 64.72; p < 0.001).
(p < 0.001) as a function of other factors (SSC: F3,8 = 82.74; The sensor was regularly re-positioned in 73 ± 8% of the
ATC: F3,8 = 50.62; p < 0.001) based on the manufacturer’s units (F1,4 = 54.72; p = 0.002) after a mean time interval of
recommendations (SSC: 19 ± 10%; ATC: 19 ± 8%), the 16 ± 2 h (F2,104 = 0.672; p = 0.513).

232 ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 230–235

Deguines et al.
Practice concerning the relative humidity (RH) of the
incubator air
As shown in Table 1, a fixed RH was used by more than
74% of the units (F1,18 = 321.03; p < 0.001). The RH values
were related to the infants’ GA (F1,179 = 15.80; p < 0.001)
and PNA (F1,179 = 4.27; p = 0.040) and the unit level
(F2,178 = 16.53; p < 0.001). On average, the RH was set to
80 ± 15% for infants with a gestational age of <28 weeks
and lowered to 68 ± 21% for infants with a gestational age
of more than 28 weeks (Fisher PLSD: p < 0.001). Similarly,
the RH level decreased with increasing PNA (PNA £ 7 -
days: 75 ± 20% vs. PNA > 7 days: 69 ± 20%; p = 0.040).
Inter-level variability in the choice of RH value was always
high (from 15% to 25%) but was greatest
(11% £ CV £ 37%) for infants with a gestational age of
more than 28 weeks.
DISCUSSION
The survey highlighted the practical difficulties in tempera-
ture assessment and control and the lack of a definitive,
optimal management method – despite the fact that this is a
relevant issue for caregivers (as reflected by the high
response rate of 86%).
In general (and whatever the incubator’s regulation
mode), the sensor was affixed to the anterior abdominal
skin surface. Continuous measurement of a central temper-
ature alone provides only limited information about
whether the baby is too hot or too cold and says nothing
about the energy cost of maintaining a normal temperature.
Indeed, the changes in abdominal skin temperature occur
later than those in more distal skin sites – thus underesti-
mating body cooling and exposing the neonate to an unsta-
ble thermal environment. As reported by Lyon et al. (18),
measuring both a central and a peripheral temperature and
continuously displaying the difference between the two can
provide an indication of thermal stress before there is any
change in the central temperature. In 61% of the units (i.e.
90 of 147), the sensor was covered with an aluminium foil
patch. The latter is known to impede evaporative skin cool-
ing and thus to distort temperature readings (especially at
low relative air humidity levels) (10,11).
We found that SSC was the standard of care for regulat-
ing the microenvironment in 75% of participating neonatal
care units. Our survey results suggest that SSC is chosen for
the reasons of convenience, in as much as the neonates par-
ticipate in the control of their own temperature. Whatever
the unit’s level of care (IIa, IIb or III), the target Tsk chosen
by the caregivers (mean value 36.66 ± 0.27C, with an
inter-level CV £ 1%) was very close to the standard set
point of 36.5C generally quoted in the literature. The target
Tsk did not depend on the infant’s age, despite the fact that
this physiological parameter is known to be higher in neo-
nates with a gestational age of less than 28 weeks (19). For
infants with low metabolic heat production, repeated heat-
ing demands induced by the error signal (in proportion to
skin temperature changes) lead to slight thermal fluctua-
tions. Using an incubator (the standard Air Shields
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 230–235
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Incubator temperature and humidity management
Isolette from Dräger Medical, Telford, PA, USA) con-
trolled by an abdominal skin temperature of 36.5C, Heim
(20) showed that the oxygen uptake of a 7-day-old prema-
ture neonate (body mass: 780 g; gestational age: 27 weeks)
did not reach a steady state but tracking the oscillating incu-
bator air temperature over several hours. A 42% increase in
heat production over baseline values was observed, whereas
these fluctuations only reached 18% with a manual ATC at
34C. Moreover, a 1.5C increase in incubator air tempera-
ture leads to a significant increase in apnoea (21).
Similarly, when using ATC, the mean set point Ta
(34.62 ± 2.11C, 2 £ CV £ 6%) does not appear to be based
on the recommended parameters (body weight, GA and
PNA (7,8,22)). In general, temperature regulation practice
was derived from a unit-specific protocol, whereas humidifi-
cation was set to a fixed value adjusted to GA and PNA. In
practice, these decisions were primarily influenced by ill-
defined factors (clinical experience and the neonate’s
assumed needs) and the manufacturer’s recommendations
and only rarely (in 1% of cases) by the available literature.
The infant’s GA and PNA were used as criteria to set the
RH. The highest RH values were observed for neonates with
GA £ 28 weeks in intensive care. Similarly, the humidity
was set at a higher level for a PNA of less than 7 days. For
neonates with a gestational age of more than 28 weeks, the
caregivers continued to provide humidification, even
though such a prolonged period of high humidity can
reportedly increase the risks of infection (13), hyperthermia
(4) and delayed skin maturation (14). The extent of bacterial
contamination in this context has never been clearly estab-
lished (23), but asepsis may be more important than tight
homeothermia control. It is common practice to reduce RH
as GA and PNA increase (24,25) and the skin matures (26).
As previously reported by Libert et al. (27), RH control is
less appropriate than the adequate production and control
of the partial water vapour pressure. The latter directly
modulates body cooling, because evaporative water loss is
related to the difference in vapour pressure between the
skin surface and the air. To the best of our knowledge, the
optimal duration of air humidification has never been
clearly defined in the literature.
The present results showed that 19% of the units based
their practices on the manufacturer’s recommendations.
Today, the computer programs provided by manufacturers
can provide decision support (28,29) on the basis of a body
heat balance equation (the required RH and incubator air
temperature are calculated so that the body heat storage is
nil). Lyon & Oxley (29) compared two groups of 10 preterm
neonates (<GA < 29 weeks) during the first 4 days of life.
One group was cared for according to a computer program’s
recommendations on optimizing the incubator air humidity
and temperature, and the other group was cared for with a
nurse-defined strategy. The researchers found that the two
strategies give similar results for the clinical outcome (i.e.
the neonates’ body temperature stability). Lyon & Oxley
emphasized that their study was performed on a small num-
ber of neonates. However, by comparing computer-gener-
ated humidity values [for 65 very-low-birth weight (VLBW)
233

Incubator temperature and humidity management
neonates] with nurse-determined humidity values (for 71
VLBW neonates), Helder et al. (28) also showed that use of
a computer-based method was not associated with a worse
clinical outcome. Although currently there is no evidence to
suggest that computer programs can significantly improve
clinical outcomes, they can provide staff with practical
assistance.
Survey limitations
Our questionnaire was structured to be clearly understood
by the different respondees and used closed questions to
minimize bias when interpreting the data. Some points
deserve more detailed investigation. Thus, it would be
useful to know (i) which information sources are used for
writing the protocol, (ii) whether there is a relationship
between the infant’s body position and the chosen sensor
site and (iii) why the sensor was moved after an average of
16 h.
However, it should be kept in mind that this survey
sought to highlight the practical difficulties and extent of
knowledge in the thermal management of low-birthweight
and ⁄ or preterm infants – a cornerstone for the care (and
thus survival) of these patients.
CONCLUSIONS
Our questionnaire results revealed discrepancies in the
thermal management of preterm infants and indicated the
type of information needed to improve our knowledge and
to guide caregivers in (i) their choice between ATC and SSC
modes for infants of varying gestational and post-natal ages,
(ii) the optimal level and duration of humidification and
(iii) the choice of a reliable skin temperature measurement
site as a reference input for SSC incubators. As emphasized
by Soll in 2008 (30), a commitment to greater understand-
ing of these thermohygrometric issues and their impact on
infants may improve clinical outcomes. The constitution of
a task force or the issuance of new guidelines by learned
societies would be valuable for further guiding clinical prac-
tice. This work was funded by the French National Research
Agency’s TecSan Program (the PRETHERM project, refer-
ence ANR-08-TECS-016).
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest to declare.
ACKNOWLEDGEMENTS
The authors thank the neonatal care units’ staff who so will-
ingly agreed to participate in this study and share their
views and experience.
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