How to manage an Intrauterine Growth Restriction (IUGR) neonate who remains hypothermic despite being under a warmer?

Management of Hypothermic IUGR Neonate Under Warmer

The correct answer is B: Sepsis workup + empirical antibiotics, while simultaneously optimizing thermal management and checking blood glucose immediately. When an IUGR neonate remains hypothermic despite being under a warmer, this represents persistent hypothermia that strongly suggests an underlying pathologic process, most commonly sepsis, and requires immediate investigation and treatment rather than simple environmental adjustments 1, 2.

Why Sepsis Workup and Empirical Antibiotics Are Critical

Persistent hypothermia despite adequate warming is a red flag for serious bacterial infection (SBI) in neonates. 3, 4

• Hypothermia in neonates is strongly associated with late-onset sepsis, independent of other risk factors 1
• When a neonate fails to rewarm under appropriate thermal management, this indicates an underlying pathologic process preventing normal thermoregulation 2
• Recent evidence shows that 8.5% of hypothermic infants have SBI or HSV infection, with mortality occurring in 2.1% of cases 3, 4
• IUGR neonates are at particularly high risk for metabolic derangements and infection due to limited glycogen stores and compromised immune function 5, 6

Concurrent Critical Management Steps

Immediate Blood Glucose Assessment

Check blood glucose immediately upon recognition of persistent hypothermia, as hypothermia strongly predicts hypoglycemia. 1, 2

• Hypothermia and hypoglycemia are intimately linked in neonates, particularly IUGR infants with limited glycogen stores 1
• Treat hypoglycemia promptly with IV dextrose per standard protocols if present 2, 7
• Monitor for metabolic acidosis with blood gas analysis 2

Optimize Thermal Management While Investigating

Continue active rewarming using combination interventions while conducting the sepsis workup. 1, 2

• Add thermal mattress, warmed humidified gases, cap, and increase room temperature to 23-25°C 1, 2
• Use servo-controlled radiant warmer or incubator targeting 36.5-37.5°C 1, 2, 7
• Monitor temperature continuously or every 15-30 minutes to prevent iatrogenic hyperthermia (>38.0°C), which is associated with increased mortality, seizures, and neurologic injury 1, 7

Why Other Options Are Inadequate

Option A (IV Dextrose Alone) Is Insufficient

While checking and treating hypoglycemia is essential, this addresses only one consequence of the underlying problem without investigating the cause of persistent hypothermia 2, 7

Option C (Reassure + Change Environment) Is Dangerous

Simply increasing warmer temperature without investigating the underlying cause misses potentially life-threatening sepsis. 1, 3

• The neonate is already under a warmer and remains hypothermic—this is not a simple environmental problem 2
• Delaying sepsis workup in a persistently hypothermic neonate can result in missed diagnosis and increased mortality 3, 4

Option D (Skin-to-Skin Contact) Is Inappropriate for This Clinical Scenario

While skin-to-skin contact is effective for preventing hypothermia in stable neonates in resource-limited settings, it is not appropriate for a sick, persistently hypothermic IUGR neonate who requires intensive monitoring and investigation 1

Rewarming Rate Considerations

Evidence is insufficient to recommend either rapid (≥0.5°C/hour) or slow (<0.5°C/hour) rewarming rates. 1, 2

• Either approach to rewarming may be reasonable, but frequent or continuous temperature monitoring is essential 1
• Avoid hyperthermia (>38.0°C) during rewarming as it introduces potential associated risks including increased mortality 1

Common Pitfalls to Avoid

Never delay investigation while attempting to rewarm—begin sepsis workup immediately. 2, 7

• Do not assume persistent hypothermia is simply an environmental problem requiring only warmer adjustment 2
• Do not forget to check glucose immediately, as hypothermia and hypoglycemia frequently coexist 1, 2, 7
• Avoid creating iatrogenic hyperthermia through overly aggressive warmer settings 2, 7
• Do not use thermal mattresses in term infants as they increase hyperthermia risk, though they may be appropriate for preterm infants 7