At what gestational age is placing a neonate in a plastic bag recommended for thermoregulation?

Plastic Bag Use for Neonatal Thermoregulation Based on Gestational Age

Plastic bags should be used for thermoregulation in all preterm infants born at less than 34 weeks' gestation immediately after birth without drying first. 1

Evidence-Based Recommendations by Gestational Age

Preterm Infants <34 Weeks

• Strong recommendation with moderate-certainty evidence to use plastic bags/wraps 1
• Benefits include:
  • Higher survival rates (41 more infants survived per 1000) 1
  • Significantly higher admission temperatures (mean difference 0.65°C higher) 1
  • 313 fewer hypothermic infants per 1000 1
• Implementation technique:
  • Cover infant up to the neck without drying first
  • Place under radiant warmer after bagging
  • Keep wrapped until admission and temperature check 1

Very Preterm Infants <28 Weeks

• Originally recommended specifically for infants <28 weeks in 2010 guidelines 1
• Current evidence supports extending this practice to all infants <34 weeks 1
• These extremely preterm infants have the highest risk of hypothermia and associated mortality

Term and Late Preterm Infants ≥34 Weeks

• Plastic bags not routinely recommended for these infants 2
• Standard thermoregulation measures are typically sufficient:
  • Drying
  • Skin-to-skin contact
  • Warm blankets
  • Ambient temperature control (≥23°C) 2

Additional Thermoregulation Measures

Head Covering

• Strong recommendation to use plastic head covering for preterm infants <34 weeks 1
• Benefits:
  • 469 more normothermic infants per 1000
  • Mean temperature 0.8°C higher
  • 471 fewer hypothermic infants per 1000 1

Thermal Mattresses

• Consider adding thermal mattress for infants <34 weeks when admission hypothermia is a problem 1
• Caution: Increased risk of hyperthermia when combined with plastic bags 1, 3

Important Considerations and Monitoring

Temperature Monitoring

• Carefully monitor temperature to prevent hyperthermia (>38°C) 1
• Risk of hyperthermia with plastic bags: 33 more infants per 1000 become hyperthermic 1
• Hyperthermia risk increases when multiple interventions are used simultaneously 4

Delivery Room Environment

• Maintain delivery room temperature at ≥23°C for all preterm infants 1
• For infants <28 weeks, delivery room temperature should be at least 26°C 1

Duration of Intervention

• Keep infants wrapped until admission to NICU and temperature check 1
• Remove plastic wrap once stable temperature is achieved in controlled environment

Practical Implementation Tips

• Apply plastic bag immediately after birth before drying 5
• Cover up to the neck, leaving face exposed 1
• Perform resuscitation and stabilization with infant in the bag 1
• Particularly effective in resource-limited settings 5, 6
• Can be used during transport to prevent hypothermia (reduces moderate hypothermia from 27.8% to 3.7%) 6

Pitfalls to Avoid

• Risk of hyperthermia increases when:
  • Multiple warming interventions are used simultaneously 3, 4
  • Metabolic heat production rises while skin temperature falls 3
  • Plastic bag is combined with thick head covering 3
• Avoid delays in application - effectiveness depends on immediate use after birth 5
• Don't remove bag prematurely before admission to controlled NICU environment 1

The evidence strongly supports using plastic bags for thermoregulation in all preterm infants <34 weeks' gestation, with special attention to monitoring for hyperthermia. This practice significantly reduces hypothermia and improves survival outcomes.