Neonatal hypothermia is common in newborns and occurs when their temperature drops below 36.5°C. In Nepal, 85% of newborns were found to be hypothermic 2 hours after delivery. Factors that contribute to heat loss in newborns include their large surface area, thin skin, low body fat and poor thermoregulation. Hypothermia can cause complications like hypoglycemia, respiratory issues and death. Proper warming and "skin to skin" contact with the mother can help prevent heat loss in newborns and is part of the "warm chain" approach recommended by WHO to maintain newborn temperature after birth.

1. CONTENT
UNIT: 15.2 MAJOR PROBLEMS OF NEWBORN
NEONATAL HYPOTHERMIA
Definition : Neonatal hypothermia is a common alteration of thermoregulatory state of neonates
which occurs when axillary temperature falls below 36.50C (WHO,1997).Normal axillary
temperature for a neonate is 36.50C – 37.50C [ 97.80F – 99.60F].
Prevalence of Neonatal Hypothermia :
In Nepal a study done on 500 newborns showed that 85% of neonates were hypothermic( body
temperature < 360C) 2 hours after delivery.
In Nepal, primarily during the winter months, over 80% of the infants born became hypothermic
after birth and 50% remained hypothermic at 24 hours. The labour and postnatal wards were
cold, at around 20°C (68°F), and this was a significant factor in the development of hypothermia.
It is estimated that 15% of the newborn babies develop hypothermia at birth in developing
countries.
Factors Responsible For Neonatal Hypothermia
1. Large surface area per unit body weight is about 3 times that of adult and loses twice as much
heat per unit area. (Term infants have 3 times the body surface area to body mass of an adult
while pre term infants and SGA infants have 4 times the surface area to body mass of an
adult).
2. Large head size in relation to surface area
3. Low subcutaneous and brown fat
4. Thin ,immature and highly permeable skin
5. Greater water content
6. Low energy storage
7. High respiratory rate
8. Poor thermoregulation
9. Other risk factors are : cool room, air draught, delay and inadequate drying of the baby,
improper wrapping, kept in cold surface area, no feeding well, sick neonate like asphyxiated
infants, low birth weight and preterm infants, infants with respiratory distress etc.
Ways of Heat Loss in Newborn Baby
a. Evaporation : It is the process whereby the baby loses his body temperature because liquor
amni covering the baby evaporates. Evaporative losses may be insensible (from skin and
breathing) or sensible (sweating). Other factors that contribute to evaporative loss are the
newborn’s surface area, vapor pressure and air velocity. This is the greatest source of heat
loss at birth(about 60%).

2. b. Conduction : It is the process of heat loss through direct contact with items that have a lower
temperature .For example : a baby who is put on a cold table or on a mattress which has a
lower temperature than that of the baby's body. The transfer of heat between two solid
objects that are touching, is influenced by the size of the surface area in contact and the
temperature gradient between surfaces.
c. Convection : It is the process of heat loss through contact with the cold air in the
surrounding area. For example : A baby kept near a window or cold room with a cooling fan
or an air conditioner or an open room where the wind is blowing directly on his body would
lose heat through convection. It is is affected by the newborn’s large surface area, air flow
(draughts, ventilation systems, etc), and temperature gradient.
d. Radiation: It is the process whereby the baby loses body temperature because he is placed
near items that have lower temperature than that of the baby's body without actually being in
contact with them. For example : When a baby is kept near a cold wall. Factors that affect
heat change due to radiation are temperature gradient between the two surfaces, surface area
of the solid surfaces and distance between solid surfaces. This is the greatest source of heat
loss after birth (about 60%).
Process of Thermoregulation
Neonates are easily affected by temperature variation (thermolabile). Thermoregulation is
important for both term and preterm neonates because they have to adapt from intrauterine life to
extrauterine life during transition. In fetal life , placenta acts as heat exchanger from the mother.
the fetal temperature is 0.5°C higher than the maternal temperature due to metabolic reactions
that generate heat. After birth, the infant is exposed to outside environment which has lower
temperature and the baby has to produce and maintain heat for his own.
At birth, the infant adapts from warm womb's temperature (approx.370C) to external
environment which can be 10 to 200 C cooler and evaporative heat loss is about 200 cal/kg per
minute with fall of skin temperature about 0.30C per minute. Most cooling of the newborn occurs
immediately after birth. During the first 10 to 20 minutes, the newborn may lose enough heat for
the body temperature to fall by 2-4°C if appropriate measures are not taken. Continued heat loss
will occur in the following hours if proper care is not provided. The temperature of the
environment during delivery and the postnatal period has a significant effect on the risk to the
newborn of developing hypothermia.
Neonates have limited energy source for thermoregulation. The mechanism of heat production in
neonates are:

3. 1. Nonshivering thermogenesis (NST) :The site of production of heat is brown adipose tissue
(BAT).When heat loss begins, thermoreceptors of subcutaneous tissue, spinal cord and
hypothalamus are stimulated and NST is triggered. NST is process that stimulates cellular
respiration that results high metabolism and oxygen consumption to produce more heat. The
noradrenaline released from sympathetic nervous system acts on brown fat and helps in heat
production by beta-oxidation of fat. In full term neonates BAT accounts for 4% of total fat,
which is less in low birth weight babies. BAT is located in the axilla, neck, interscapular,
supraclavicular region, mediastinum, around kidney, pancreas, trachea and adrenal glands. It
helps in chemical thermogenesis.
2. Metabolic processes: The brain, heart, and liver produce the most metabolic energy by
oxidative metabolism of glucose, fat and protein. The amount of heat produced varies with
activity, state, health status, environmental temperature.
3. Voluntary muscle activity : Increased muscle activity during restlessness and crying
generate heat. Conservation of heat is done by assuming a flexed position to decrease
exposed surface area.
4. Peripheral vasoconstriction : In response to cooling, peripheral vasoconstriction reduces
blood flow to the skin and therefore decreases loss of heat from skin surfaces. Peripheral
vasoconstriction leads to increased metabolism with excess oxygen consumation and glucose
utilization thus production of heat occurs.
Methods of Grading Neonatal Hypothermia
A. Monitoring of axillary temperature. Keep thermometer deep in axilla for full 3 minutes.
Normal temperature 36.5oC-37.5 oC
Mild hypothermia (cold stress) <36.5oC-36.0oC
Moderate hypothermia <36 oC-32 oC
Severe hypothermia <32 oC
B. Touch method : This is precise and reliable in the absence of thermometer. Abdomen skin
temperature is assessed by touch with dorsum of hand. Abdominal temperature is
representative of the core temperature. Findings include :
 Baby’s feet and hands are warm : Thermal comfort
 Peripheries are cold, the trunk is warm : Cold stress
 Peripheries and the trunk both are cold : Hypothermia

4. Consequences of Neonatal Hypothermia
Increased cellular metabolism takes place as the newborn tries to stay warm, leading to increased
oxygen consumption, which puts the newborn at risk of hypoxia, cardiorespiratory
complications, and acidosis. These newborns are also at risk for hypoglycemia because of the
increased glucose consumption necessary for heat production. Neurological complications,
hyperbilirubinemia, clotting disorders, and even death may result if the untreated hypothermia
progresses.
Hypothermia
Catecholamine release Reduced surfactant production
Non shivering thermogenesis Increased metabolic Peripheral
rate vasoconstriction
Release of fatty acids
Hypoglycemia Increased O2 requirement
Displace bilirubin bound
to albumin; Hyperbilirubinemia
Anaerobic metabolism , Glycolysis,
Hypoxemia, Metabolic acidosis
Clinical Features of Neonatal Hypothermia
Mild Hypothermia Moderate Hypothermia Severe Hypothermia
 Restlessness
 Excess cry
 Acrocyanosis
 Cold extremities
 Poor feeding
 Difficult breathing
 Bradycardia
 Poor or no feeding
 Lethargy, poor reflexes
 Cold to touch
 Delay capillary refill
 Breathing difficulty
 Poor or no feeding,
Hypoglycemia
 Lethargy
 Hardened skin
(sclerema)

5. time
 Oliguria
 Slow, shallow and
irregular respiration
with bradycardia
 Cold to touch
Management of Neonatal Hypothermia
A. Mild Hypothermia (cold stress)
 Remove the baby from the source that may be causing hypothermia such as cold
environment, cold clothes, cold air or wet clothing.
 Cover the baby adequately with warm clothes.
 Ensure skin to skin contact with mother, if not possible, kept next to mother after fully
covering the baby.
 Warm the environments including room / bed. Ensure warm(280-320C) and draught free
room.
 Immediately breastfeed the baby. Encourage mother to breast feed the baby more frequently.
If baby cannot breast fed, give expressed breast milk using an alternative feeding method.
 Monitor axillary temperature every ½ hourly till it reaches 36.5°, then hourly for next 4
hours, 2 hourly for 12 hour thereafter. If the temperature of baby is not rising, check if
adequate amount of heat being provided. Sepsis should be suspected unresponsive
hypothermia.
 Watch for apnea and hypoglycemia.
 Follow up: Ask family to return for follow up visit in a week. If the baby is feeding well and
there are no other problems requiring hospitalization, discharge the baby. Advice the mother
how to keep the baby warm at home.
B. Moderate to Severe Hypothermia
 Remove wet clothes and rapid rewarming by incubator (air temperature 35-36°C), preheated
radiant warmer or thermostatically controlled heated mattress set at 37-38°C.
 Room heater or 200 W bulb or infrared bulb can also be used.
 Rapid rewarming is done up to 34°C, then slow rewarming to 36.5°C.
 Set skin temperature at 370C in skin servo mode in radiant warmer or 1-1.50C higher than the
body temperature in an incubator and should be adjusted as the newborn's temperature
increases.
 In the absence of radiant warmer or incubator- heating lamp, home based heating methods
may be used under supervision.

6.  Where radiant warmer or incubator is not available, KMC may be the only option.
 Monitor temperature every ½ hourly till it reaches 36.50 . If rise of temperature has been by
0.5°C per hour then heating is considered adequate, and temperature measurement is
continued every hourly for next 4 hours and 2 hourly for next 12 hour thereafter. If rise of
temperature is not adequate, one should check the heating technique.
 If temperature doesn’t improve provide additional heat. Sepsis should be suspected
unresponsive hypothermia.
 Encourage mother to breast feed the baby more frequently. If baby cannot breast fed, give
expressed breast milk using an alternative feeding method.
 Assess the baby: Look for emergency signs ( respiratory rate less than 20 breaths per minute
or greater than 60 breaths per minute or not breathing, gasping ,chest indrawing, grunting on
expiration and shock) every hours and provide treatment as necessary.
 Parental anxiety is greatly increased, particularly at the sight of baby in an incubator for
being unable to maintain body temperature. Therefore, parents need reassurance concerning
their child's progress in temperature maintainance and procedures carried out to make him
warm and comfortable.
 If the feeding is well, temperature remains within the normal range and there are no other
problems requiring hospitalization, discharge the baby. Advise the mother how to keep the
baby warm at home.
C. Supportive Measures
 Prompt detection and management of hypoxia, hypoperfusion and hypoglycemia.
 Measure blood glucose. If the blood glucose is less than 45 mg/dl ( 2.6 mmol), treat for low
glucose. 10 % IV Dextrose infusion in 1/5 NS at 4-6 mg/kg/min or 60-80 ml/kg/day.
 If perfusion is poor , give 20ml/kg of RL or NS over 5 minutes.
 Provide oxygen if moderate to severe hypothermia.
 Watch for apnea, hypoxia and hypoglycemia during rewarming.
 IV vitamin K 1 mg IM in term and 0.5mg in preterm babies , if not given earlier.
 If hypothermia is associated with infection, start appropriate antibiotics.
 IV Ampicillin : 50 mg/kg plus
 IV Gentamicin : 6 mg/kg or
 IV Cefotaxim : 50 mg/kg or
 IV Amikacin : 5 mg/kg for 5 to 7 days.
Prevention of Neonatal Hypothermia
The "warm chain " is a set of interlinked procedures to be performed at birth and during the next
few hours and days after birth in order to minimize heat loss in all newborns (WHO,1997). The
baby must be kept warm at the place of birth (home or hospital) and during transporation from
home to hospital or within hospital. Satisfactory control of the baby's temperature demands both
prevention of heat loss and providing extra heat using an appropriate source. Failure to

7. implement any one of these procedures will break the chain and put the newborn at the risk of
getting cold.
According to UNICEF , such interventions can help reduce neonatal mortality or morbidity by
18-42%.
10 steps of warm chain:
Steps Procedure
1. Warm delivery room • The temperature of the delivery room should be at
least 25°C, free from the drafts from open windows,
doors, or fans.
• Supplies needed to keep the newborn warm should be
prepared ahead of time.
• Adults should never determine the temperature of the
delivery room according to their comfort.
2. Warm resuscitation • Make sure resuscitation area is warm if the baby
needs resuscitation.
• Lay on warm surface in the warm room under radiant
warmer.
• Quickly dry with warm wraps and discard warm
linen( Evaporation of amniotic fluid is a major cause
of heat loss and can be reduced by effective drying of
the skin.)
• Cover baby's head with a dry cap and wrap baby in
warm linen leaving baby's chest area exposed.
3. Immediate drying • Immediately dry the newborn after birth with a warm
towel or cloth from head to toe to prevent heat loss
from evaporation.
4. Skin to skin contact • While the newborn is being dried, place on the
mother’s chest or abdomen (skin to-skin contact) to
prevent heat loss.
-If mother is unable, the cold newborn may go skin-
to-skin with the partner
• Cover the newborn with a second towel and put a cap
on the head to prevent heat loss from convection.
• Leave the newborn skin-to-skin on the mother and
keep covered.
• Newborns should be uncovered as little as possible
during assessments and interventions.
• Newborns can be maintained in skin-to-skin contact
with the mother:
-while she is being attended to (placenta delivery,
suturing) .
-during transfer to the postnatal unit, recovery room
-during assessments and initial interventions.
-for the first hours after birth.

8. 5. Breastfeeding • Initiate as soon as possible, preferably within one
hour of birth.
6. Postpone weighing and
bathing
• Weighing can be done following the period of
uninterrupted skin-to-skin contact and the first feed.
Place a warm blanket on the scale.
• Bathing the newborn soon after birth causes a drop in
the body temperature and may propagate hypothermia
and hypoglycemia.
• Don't bath the baby immediately after birth.Wait for
at least 24 hours to bath the baby.
• Bathing could be done when baby's temperature is
stable or when cord fall off or when baby's weight is
2.5 kg in warm, sunny room with warm water. Wait
longer if body temperature is below 360C ,LBW baby
or baby is unwell.
• For preterm baby, bathing should be postponed until
the baby's weight reach up to 2.5 kg. At that time
sponging is adequate.
• While bathing, bathing temperature should be 40C
lower than baby's body temperature.
• If a hypothermic newborn thick wet hair, consider
drying the hair thoroughly and then place a cap on the
head.
• Bathing should be done quickly in a warm room,
using warm water. Tub bathing is the preferred
method of bathing to prevent heat loss for all stable
newborns both term and preterm. The water should
be deep enough to cover the newborn’s shoulders.
Note: Newborns with an umbilical catheter should
not be tub bathed.
• Immediately after the bath dry thoroughly from head
to toe, immediately diaper and apply dry cap on
baby's head and place skin-to skin. If skin-to-skin is
not possible double wrap the newborn with warm
blankets ensuring the head is covered.
• After skin-to-skin, dress and wrap the baby in dry
warm blankets.
7. Appropriate clothing/ blanket • Dress newborn in loose clothing and blanket.
• Cover baby's head with cap or cloth as about 25% of
the baby's heat loss occurs from head.
• The baby should not be wrapped too tightly and too
loosely , it is better to have 2-3 layers of clothes
rather than one single thick layer.
• When the clothing or the diaper is soiled , it should be
changed immediately.
8. Mother and newborn together • Keep mother and newborn together 24 hours a day

9. (rooming-in), in a warm room (at least 25°C).
• Newborn should be fed on demand.
• Skin-to-skin can be used to rewarm a newborn
experiencing mild to moderate hypothermia (see table
4).
9. Warm transportation
(weakest link in warm chain )
• Always stabilize the baby's temperature before
transport. Record temperature before transport and
take remedial measures. If temperature cannot be
documented, use touch to judge temperature. Hands
and feet should be as warm as abdomen.
• Carry the baby close to the chest of mother, if
possible in kangaroo position.
• Dress the newborn and wrap in blankets if a transport
device is used. Cover head, legs and hands. Avoid
undressing the infant for cleaning, weighing or
examination. Postpone these until baby is warm.
• Thermocol box with pre warmed linen or plastic
bubble sheet or silver swaddler may be used during
transport.
• Water filled mattress with thermostat to control
temperature may be used for transport ,if available.
• For unstable baby, transport in incubator.
10. Training and raising
awareness
• Alert health care providers and families to the risks of
hypothermia and hyperthermia.
• Teach the principle of thermal protection of the
newborn.
• Provide on the job training and supervised practice to
ensure that the 10 steps of the warm chain become
part of the routine care of the newborn.
• Demonstrate and provide supervised practice on the
appropriate use of equipment for low birth
weight/preterm newborns in preventing hypothermia.
Complications of Neonatal Hypothermia
 Pulmonary hemorrhage
 Hypovolemia (Hypothermia induced diuresis)
 Coagulopathy due to sequestration of platelets and thrombocytopenia
 Acidaemia
 Scleroderma
 Jaundice and hypoglycemia
 Cardiac arrhythmia below 30-320C
 Even death may occur

10. Summary
Hypothermia is a common alteration of thermoregulatory state of neonates which occurs when
axillary temperature falls below 36.50C. Normal axillary temperature for a neonate is 36.50C –
37.50C [ 97.80F – 99.60F]. Ways of heat loss in newborn are evaporation, conduction ,
convection and radiation. The mechanism of heat production in newborn are non shivering
thermogenesis, metabolic process, voluntary muscle activity and peripheral vasoconstriction.
The newborns are also at risk for hypoglycemia because of the increased glucose consumption
necessary for heat production. Neurological complications, hyperbilirubinemia, clotting
disorders, and even death may result if the untreated hypothermia progresses.Hypothermia can
be prevented through 10 steps of warm chain.

11. References
 Subedi, D.,& Gautam ,S.(2017) .Midwifery nursing part III ( 3rd ed.). Medhavi Publication
,Baneshwor, Kathmandu,Nepal (pp:164-171).
 Uprety,K. (2017).Essential of child health nursing(1st ed.).Akshav Publication ,
kathmandu,Nepal (pp: 98-99).
 Shrestha,T.(2016). Essential child health nursing(2nd ed.).Medhavi Publication,
Jamal,Kathmandu, Nepal(pp:95-99).
 Adhikari,T.(2015). Essentials of Pediatric Nursing (2nd ed.).Vidhyarthi Pustak Bhandar,
Kathmandu, Nepal (pp:59-62).
 Dutta,P.(2014).Pediatric Nursing (3rd ed.).Jaypee Brothers Medical Publisher, New Delhi,
India (pp: 83-85).
 Koner,H.(Eds.).(2013).DC Dutta's textbook of obstetrics(8th ed.).Jaypee Brothers Medical
Publishers,New Delhi,India(pp:518).
 Paul,V.K & Bagga.A.(2013).Ghai essential paediatrics(8th ed.).CBS Publishers and
Distributors, New Delhi, India(pp: 143-146).
 Sharma,R. (2013). Essential Paediatrics for Nurses( 2nd ed.). Jyapee Brothers Medical
Publisher , New Delhi,India( pp:212-217).
 Thakur, L .(2012).Advanced child health nursing (3rd ed.).Ultimate Marketing ,Lazimpat
,Kathmandu,Nepal (pp: 59-62).

12. SAMPLE QUESTION
Subject : Midwifery II Total Hour :30 min
Course no : BSN19 Total Mark :10
Pass Mark : 4
Candidates are required to give answers in their own words as far as practicable.
The figures in the margin indicates full marks.
Attempt all questions.
Objective Type of Question
1. Choose the best alternatives. 1X2=2
A. Body temperature below ……… is termed as hypothermia.
a. 320C b. 36.50C
b. 370C d. 37.50C
B. While bathing a neonate, the temperature should be ………..lower than the body
temperature.
a. 10C b. 20C
c. 30C d. 40C
Subjective Type of Question
Short Answer Type Question
Write short notes on : 4X2=8
A. Warm chain
B. Ways of heat loss