What is the appropriate management for a neonate with hypothermia?

Management of Neonatal Hypothermia

Immediately place the hypothermic neonate under a radiant warmer or in a servo-controlled incubator targeting normothermia of 36.5-37.5°C, check blood glucose stat, and if hypothermia persists despite adequate warming, initiate a sepsis workup with empirical antibiotics. 1, 2, 3

Immediate Rewarming Strategy

• Begin active rewarming immediately using radiant warmers or servo-controlled incubators with a target temperature of 36.5-37.5°C 1, 2

• For preterm infants <32 weeks gestation, use combination interventions including plastic wrap (without drying), cap, thermal mattress, warmed humidified resuscitation gases, and increase room temperature to 23-25°C 1, 2

• Either rapid (≥0.5°C/hour) or slow (<0.5°C/hour) rewarming is acceptable, as current evidence is insufficient to prefer one approach over the other 1, 2

  • This represents a shift from traditional teaching that advocated only slow rewarming to avoid apnea and arrhythmias 1
  • Monitor temperature continuously regardless of rewarming rate chosen 2, 4

• Avoid hyperthermia >38.0°C during rewarming, as this is associated with increased mortality, seizures, and neurologic injury 1, 2, 3

Critical Concurrent Actions

• Check blood glucose immediately upon recognition of hypothermia, as hypothermia strongly predicts hypoglycemia 2, 3, 4

  • Treat hypoglycemia promptly with IV dextrose per standard protocols if present 2, 4

• Obtain blood gas analysis to monitor for metabolic acidosis 2

  • If acidosis present, improve perfusion and tissue oxygenation rather than administering bicarbonate 3

When to Suspect Underlying Pathology

If the neonate fails to rewarm despite appropriate thermal management, this indicates an underlying pathologic process—most commonly sepsis—and requires immediate action. 3, 4

Sepsis Workup Protocol:

• Obtain blood cultures, complete blood count, and C-reactive protein immediately before starting antibiotics 3

• Perform lumbar puncture if clinically stable to rule out meningitis 3

• Begin empirical antibiotics immediately without delaying for diagnostic workup completion 2, 3, 4

  • This is particularly critical in IUGR neonates, who have a 12-fold increase in mortality when hypothermic 3
  • Hypothermia is strongly associated with late-onset sepsis independent of other risk factors 4

Special Population Considerations

Preterm Infants (<32 weeks):

• Use multimodal prevention strategies including environmental temperature 23-25°C, plastic wrapping without drying, cap, thermal mattress, and warmed humidified gases 1, 2

IUGR Neonates:

• Have increased susceptibility to infection due to compromised intrauterine environment and reduced immunologic reserves 3
• Require lower threshold for sepsis workup given significantly elevated mortality risk 3, 4

Resource-Limited Settings:

• Place well newborns in clean food-grade plastic bags up to neck level and swaddle after drying 1
• Use skin-to-skin contact or kangaroo mother care as alternative 1

Common Pitfalls to Avoid

• Do not delay rewarming while searching for the etiology of hypothermia 2

• Do not assume slow rewarming is inherently safer based on outdated teaching, as evidence does not support preferring one rate over another 2, 3

• Do not create iatrogenic hyperthermia through overly aggressive rewarming settings, as temperatures >38.0°C increase mortality 2, 3

• Do not forget to check glucose immediately, as this is a common and dangerous complication 2

• Do not delay sepsis workup in persistently hypothermic neonates, as this can result in missed diagnosis and increased mortality 3, 4

Quality Indicator

• Record admission temperature as both a predictor of outcomes and a quality indicator, as hypothermia is associated with increased respiratory issues, hypoglycemia, and late-onset sepsis 1