What is the appropriate management for an intrauterine growth‑restricted (IUGR) newborn with persistent hypothermia despite being placed in a warm environment?

Management of IUGR Neonate with Persistent Hypothermia

For an IUGR baby with persistent hypothermia despite placement in a warm environment, immediately perform a full septic workup with empirical antibiotics while simultaneously checking blood glucose and optimizing thermal interventions—persistent hypothermia that fails to respond to initial warming strongly indicates an underlying pathologic process, most commonly sepsis, which carries significant mortality risk in IUGR neonates. 1, 2

Immediate Priority Actions

1. Sepsis Evaluation and Empirical Antibiotics (FIRST PRIORITY)

• Obtain blood cultures, complete blood count, and C-reactive protein immediately before starting antibiotics 1
• Begin empirical broad-spectrum antibiotics without delay—persistent hypothermia despite adequate warming is a medical emergency that strongly suggests sepsis 1, 2
• Perform lumbar puncture if the infant is clinically stable to rule out meningitis 1
• Hypothermia in neonates is strongly associated with late-onset sepsis independent of other risk factors, and IUGR infants have increased susceptibility to infection due to compromised intrauterine environment and reduced immunologic reserves 1, 2

Critical caveat: Do not delay the sepsis workup while attempting additional warming measures—IUGR neonates have a 12-fold increase in mortality compared to term infants when hypothermic 1

2. Glucose Management (CONCURRENT PRIORITY)

• Check blood glucose stat upon recognition of persistent hypothermia—hypothermia strongly predicts hypoglycemia, with 53.8% of hypothermic IUGR infants developing hypoglycemia versus 24% without hypothermia 3, 2, 4
• Administer IV dextrose immediately if hypoglycemia is present per standard protocols 3, 1
• Maintain vigilance for both hypoglycemia and hyperglycemia, as protocols for blood glucose management help avoid large swings in glucose concentration that are associated with harm 3

3. Optimize Thermal Interventions (CONCURRENT)

• Add combination thermal interventions beyond the radiant warmer alone: 3, 1, 2

  • Apply thermal mattress
  • Use warmed humidified gases
  • Place cap on infant's head
  • Increase room temperature to 23-25°C
  • Consider servo-controlled incubator if radiant warmer alone is insufficient

• Target normothermia of 36.5-37.5°C but avoid hyperthermia >38.0°C, which increases mortality and seizure risk 3, 1, 5

• Monitor temperature continuously during rewarming 1, 2

• Evidence is insufficient to recommend either rapid (≥0.5°C/hour) or slow (<0.5°C/hour) rewarming rates, so either approach may be reasonable 3, 5

4. Metabolic Assessment

• Obtain arterial or capillary blood gas to evaluate for mixed respiratory and metabolic acidosis—38.71% of hypothermic IUGR infants develop acidosis versus 14% without hypothermia 1, 4
• Prioritize respiratory support if pCO2 is elevated to correct the respiratory component first 1
• Improve perfusion and tissue oxygenation for metabolic acidosis rather than administering bicarbonate 1

Skin-to-Skin Contact Consideration

While skin-to-skin contact (kangaroo mother care) may be reasonable for maintaining normothermia in well newborns in resource-limited settings 3, it is NOT appropriate as primary management for an IUGR infant with persistent hypothermia despite warming, as this clinical scenario demands immediate investigation for serious underlying pathology rather than alternative warming methods alone.

Common Pitfalls to Avoid

• Do not assume the infant simply needs more time to warm—failure to rewarm under appropriate thermal management indicates an underlying pathologic process preventing normal thermoregulation 2
• Do not delay sepsis workup for 24 hours to "assess response to warming"—this approach misses the critical window for treating sepsis 1
• Do not assume slow rewarming is safer—this is outdated teaching, though optimal rewarming rate remains uncertain 1, 5
• Do not create iatrogenic hyperthermia through overly aggressive warming settings, as temperatures >38.0°C increase mortality 1, 5
• Do not forget to check glucose immediately—hypoglycemia is present in over half of hypothermic IUGR infants 4

Additional Monitoring

• Monitor for hyperbilirubinaemia (38.71% incidence in hypothermic IUGR infants versus 16% without hypothermia) 4
• Monitor for hypocalcaemia (32.26% incidence in hypothermic IUGR infants versus 12% without hypothermia) 4
• Assess for respiratory distress, as hypothermia is associated with increased respiratory issues including meconium aspiration and persistent pulmonary hypertension in IUGR infants 3, 6