Article summary of Ghouri M, Ali I. Reducing hypothermia in high risk infants: ongoing challenges in later preterm and term neonates. Infant. 2025;21(6):160‑3.
Neonatal hypothermia remains common due to newborns’ immature thermoregulation and physiological vulnerabilities[1],[2]. It is associated with serious complications, such as infection, pulmonary problems, necrotising enterocolitis, renal failure, intracranial haemorrhage and increased mortality[3].
Reported hypothermia incidence ranges widely (32–85% in hospital births and 11–92% in home births), with global mortality rates of 8.5–52%3. Evidence shows mortality increases by 28% for every 1°C drop in body temperature[4].
The WHO defines hypothermia as a core temperature <36.5°C or skin temperature <36.0°C[5], while emerging evidence also highlights risks of admission hyperthermia (>38°C)[6]. Preterm infants under 32 weeks are the focus of the National Neonatal Audit Programme (NNAP), which monitors admission temperature with a target of 36.5–37.5°C[7]
What is the “Quality Improvement Project”?
Nationally, in 2017, compliance with this temperature target in units with more than 20 eligible infants was noted at 64.4%. 20% of the babies admitted were hypothermic on admission, and between 2013 and 2017 had a 12% improvement. Around 33% of neonatal units showed no improvement, or a decrease in performance between 2015 and 20177.
A Quality Improvement Project was conducted between January 2019 and December 2024 to reduce 15% of admission hypothermia cases and to improvement an improvement plan to optimise normothermia in infants who are born in the neonatal unit between 22 and 34 weeks’ gestation.
A key driver diagram was developed to guide improvements in staff knowledge, supply access and collaboration between NICU and birthing teams. The team used PDSA (Plan, Do, Study, Act) cycles to test and refine interventions. Temperatures were recorded at multiple stages, from delivery room environment to admission into the NICU, and outcomes were monitored through ongoing audits and feedback.
Interventions: Best Practices to Prevent Hypothermia in Pre-Term Infants
The Quality Improvement Project implemented a series of targeted interventions designed to optimise neonatal thermoregulation during the Golden Hour. These interventions focused on strengthening staff knowledge, improving access to essential warming equipment and enhancing collaboration between maternity and neonatal teams. Each element worked together to reduce avoidable heat loss from the moment of birth through to NICU admission.
1. Education and Awareness
Improving staff understanding of hypothermia risks was essential. Regular interactive teaching sessions were introduced for all maternity and neonatal staff, ensuring consistent knowledge across departments. Thermoregulation content was incorporated into Neonatal Life Support Training (NLS), Practical Obstetric Multi-Professional Training (PROMPT), and Governance, Education, Audit and Development (GEAD) meetings, reinforcing the importance of achieving an admission temperature of 36.5 to 37.5°C for preterm infants. Updated thermoregulation protocols were developed, circulated and displayed prominently in all delivery areas to ensure immediate accessibility.
2. Improved Access to Warming Equipment
Practical changes were made to guarantee that the right equipment was always available and ready for use. This included adding chemical heat mattresses to the neonatal grab bag, preparing thermoregulation suits/bags and heat sources, before high‑risk deliveries and ensuring delivery rooms were pre-warmed. These measures supported preterm infants from the first moments after birth, reducing evaporative and convective heat loss.
3. Strengthened Collaboration Between NICU and Birthing Teams
To ensure smooth, coordinated care, birthing and neonatal teams established standardised workflows, including a pre-birth huddle for all preterm deliveries. Delivery room and theatre temperatures were optimised, and clear communication about thermoregulation responsibilities was reinforced. Updated guidelines were displayed across all areas to ensure consistent practice, and daily safety briefings included a review of any admission hypothermia cases.
Results of the Quality Improvement Project
Significant improvement in infants <34 weeks’ gestation:
Following the implementation of the quality improvement interventions (which included structured staff education, improved availability of thermoregulation equipment and strengthened interdisciplinary coordination) the incidence of admission hypothermia in infants born at <34 weeks’ gestation decreased from an average of 18% during the first ten months of 2024 to 0% by March 2025. This demonstrates that consistent application of a standardised thermoregulation care bundle can effectively eliminate hypothermia in the most physiologically vulnerable population.
Ongoing vulnerability in later gestations:
Despite overall reductions in hypothermia (2019–2023: 25.5% across 2,549 inborn admissions; 2024: 15% across 811 admissions), late preterm infants (34–36 weeks) and term infants (>37 weeks) continued to present with disproportionately higher rates of hypothermia compared with the <34‑week cohort. Within the 2019–2023 dataset specifically, hypothermia occurred in 20.4% of infants <34 weeks, compared with 26% in late preterm infants and 31.5% in term infants. This persistent disparity highlights a clear unmet clinical need in thermoregulation for older gestational groups, who may be overlooked due to their comparatively lower perceived risk.
Authors’ Recommendations and Thermoregulation Suits
The author’s advocate extending the use of polythene wraps to all late preterm infants admitted to the neonatal unit, citing evidence that this intervention is low cost, easily integrated into existing workflows and effective in reducing heat loss with minimal associated risk of hyperthermia.
One method highlighted above, is that it is clinically appropriate to opt for a thermoregulation suit which its functional purpose is to provide an immediate, standardised barrier against all methods of heat loss at birth, regardless of age and size, to address the persistent thermoregulation gaps observed in infants ≥34 weeks’ gestation.
Conclusion
The quality improvement programme demonstrated that a structured thermoregulation bundle, supported by interprofessional education, reliable equipment availability and standardised workflows, can eliminate admission hypothermia in infants born at less than 34 weeks’ gestation. Persistently higher hypothermia rates among late preterm and term infants indicate a residual care gap that warrants targeted intervention. Extending early thermal protection measures to these groups is therefore justified. Using a standardised, rapid-application thermal barrier, is well aligned to the intervention profile recommended in the study and offers a practical means to enhance consistency across gestational ages, with the potential to reduce avoidable morbidity linked to neonatal hypothermia
References
[1] Harer MW, Vergales B, Cady T, et al. Implementation of a multidisciplinary guideline improves preterm infant admission temperatures. J Perinatal 2017; 37:1242-47
[2] McCall EM, Alderdice F, Halliday HL et al. Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2018; CD004210
[3] Lunze K, Bloom DE, Jamison DT eta l. The global burden of neonatal hypothermia. BMC Med 2023. Online at: https://bmcmedicne.biomedcentral.com/articles/10.1186/1741-7015-11-24
[4] Laptook A, Tyson J, Shankaran S, et al. Elevated temperature after hypoxic-ischemic encephalopathy: risk factor for adverse outcomes. Pediatrics 2008;122:491-99
[5] World Health Organisation. Maternal and newborn health/safe motherhood. Thermal protection of the newborn: a practical guide. WHO, Geneva; 1997 Online at: www.who.int/publications/i/item/WHO_RHT_MSM_97.2
[6] Lyu Y, Shah PS, Ye XY, et al. Canadian Neonatal Network. Association between admission temperature and mortality and major morbidity in preterm infants born at fewer than 33 weeks’ gestation. JAMA Pediatr 2015;169
[7] Royal College for Paediatrics and Child Health. National Neonatal Audit Programme. Annual Report. 2018 Annual Report on 2017 Data Online at: www.rcpch.ac.uk/sites/default/files/2018-10/2018_nnap_report_on_2017_data_final_v8.pdf
