A literature review on the use of skin-to-skin contact and infant radiant warmers for treating mild and moderate hypothermia in term and late-preterm newborns

A literature review on the use of skin-to-skin contact and infant radiant warmers for treating mild and moderate hypothermia in term and late-preterm newborns

A literature review on the use of skin-to-skin contact and infant radiant warmers for treating mild and moderate hypothermia in term and late-preterm newborns

Literature Review on the Use of Skin-To-Skin Contact and Infant Radiant Warmers for Treating Mild and Moderate Hypothermia in Term and Late-Preterm Newborns

Managing Hypothermia among Preterm Infants
Newborns born at term or late preterm often suffer from hypothermia, which can result in severe health issues. The conventional ways of treating mild to moderate hypothermia in infants are through skin-to-skin contact and infant radiant warmers. Children admitted to the newborn or neonatal units die from different health conditions, including but not limited to neonatal sepsis, birth asphyxia, acute respiratory distress syndrome, hemorrhagic, and congenital malformations. However, the risk of death can be complicated by hypothermia. Reduction in body temperature below 36.5⁰C slows body functions and can lead to mortality. This mortality risk is worse in preterm newborns. Term or preterm newborns born after 34 weeks of gestation can thrive when their body temperatures are optimized to maintain normal body physiological and biochemical functions. The World Health Organization (1993) defined hypothermia as body temperatures dropping below 36.50C. WHO graded hypothermia into various classes. Normal temperature is between 36.5 and 37.5°C; mild hypothermia occurs between 36.4 and 36°C, moderate hypothermia occurs between 35.9 and 32 °C, while severe hypothermia is below 320C. This review intends to assess the effectiveness of these two methods when it comes to managing newborn hypothermia.

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Literature Search
The literature search was a systematic process based on key terms, search filters, and Boolean operators. A clinical question guided the search. The clinical search question is stated as follows. In term or late preterm newborns born between 34 and 37 weeks gestation and weighing at least 2000 grams in mother-baby units, how does skin-to-skin contact compare with infant radiant warmers in improving infant outcomes? Selected articles for review included evidence-based sources such as primary research articles, systematic reviews, and other review studies.
Literature Review
Outcomes of Rewarming
The concept of warming neonates and minimizing heat loss has been in practice for more than six decades now. Preserving heat for the term and preterm infants with hypothermia aims at enabling a thermos-neutral environment to minimize the poor outcomes of adjustment in postnatal life. Motil et al. (1974) investigated different outcomes among neonates who were rewarmed using infrared heating units at different temperatures. In their study, Motil et al. (1974) found that newborns showed different positive and negative responses when rapid rewarming was done at different temperatures. Apnea was observed in up to 26% of the infants rewarmed using the infrared incubators, even though other confounders could be inferred from this outcome. Rewarming reduced rapid acidosis among infants with hypothermia at birth. Lower temperatures were associated with bradycardia and poor clinical condition. Therefore, infant radiant warmers have shown clinical benefits among infants immediately after birth.
Mathur & Mishra (2006) evaluated the association between the rewarming time, baby’s weight, gestational age, and other comorbidities. In this study, only radiant infant warmers were used to improve hypothermia among neonates. The authors found premature babies and those with smaller physical sizes to have higher rates of rewarming. Asphyxiation babies took longer to warm. However, the duration of warming did not depend on the baby’s weight and gestational age at birth. Therefore, this study inferred that the rate of rewarming is an important parameter that must take into account the baby’s physical properties and the presence of comorbidities to achieve clinical outcomes in the shortest time possible.
An adaptive experimental study by Karlsson (1996) investigated the degree of temperature change with skin-to-skin care among neonates. The concept of skin-to-skin care, though primitive, gained a role in contemporary nursing and health care a long time ago. Karlsson (1996) found a significant increase in skin and rectal temperatures among neonates who participated in a prospective study involving skin-to-skin contact for rewarming. This change was also significant for babies who were small for gestational age, with no significant variations from changes in those neonates with normal birth weight. Heat losses were still recorded in those body parts that were not involved in the skin-to-skin contact such as the head. The external temperature gradient was responsible for net heat loses even in body areas that participated directly in the SSC. Therefore, the technique matters in this method of rewarming neonates.
Galligan (2006) recognized the importance of mother-infant attachment in postpartum care. According to Galligan (2006), this technique offered additional benefits alongside the treatment of hypothermia. In this technique, the infant gets to know her infant, thus enabling maternal-neonatal bonding. However, the technique of performing this rewarming is critical in achieving these outcomes. Maximal exposure of neonatal skin was emphasized in this review study. Galligan concluded that, alongside promoting maternal-neonatal attachment, this method enhanced thermoregulation for neonates with hypothermia just the same way the traditional rewarming achieved. Therefore, it should be a regular part of the regular postnatal practice.
Cong et al. (2021) conducted a meta-analysis on the impact of skin-to-skin (STS) on maternal anxiety and stress states using eight randomized controlled trials that involved 728 participants. In this study, the duration of performing skin-to-skin contact (SSC) was significant in improving anxiety and maternal stress states. SSC not lasting less than an hour a day for one week effectively reduced maternal anxiety and stress. Skin-to-skin contact exceeding 2 weeks was not significantly effective in achieving these outcomes. The impact of SSC alone after 2 weeks was not effective. Mothers of preterm babies are susceptible to anxiety about the outcomes of their infants (Cong et al., 2021). Thus, this method had a role in alleviating this anxiety.
A study by Beiranvand et al. (2014) conducted a randomized controlled trial involving 90 infants and their mothers after cesarean section delivery. This study concluded that cesarean section was not a contraindication for skin-to-skin contact and, thus, a possible intervention. Even though the average temperature of neonates in the intervention group (SSC) group was higher, the difference was not statistically significant. Additionally, SSC does not increase the hypothermia risk among babies born through cesarean section delivery. This could be attributed to the fact that this study took place in a room with optimized room temperature that would ensure that all babies were involved in some level of warming thus the minimal differences in temperature change outcomes. With a relatively smaller sample size (90), the difference in temperature change would be less statistically significant due to the relatively low statistical power.
Comparing the Rewarming Methods
The two main methods of infant rewarming, that is, SSC and the use of infant radiant warmers, apply to current postnatal care. Their use is determined by local hospital protocols, professional organization protocols, and healthcare providers’ clinical decision-making. The effectiveness and efficacies of these methods are not similar and are determined by various factors such as timing, techniques, and patient factors. The gestational age of the infant and the degree of hypothermia play key roles in the effectiveness of the two rewarming methods for infants with hypothermia. The various items literature investigated the impact of these rewarming methods and compared their effectiveness.
Mild Hypothermia Warmed Using SSC for Full Term Newborns: A study by Fardig (1980) compared skin-to-skin contact radiant heaters in neonatal thermoregulation involving term infants with mild hypothermia. In this prospective comparative study, the experimental group infants received skin-to-skin contact after initial radiant heating. The second arm of the experimental group received SSC from the start without radiant heating. The control group received no skin-to-skin. This study found that babies who received earlier SSC had warmer bodies than those who received SSC after radiant warming (Fardig, 1980). However, drying the baby well and raising the delivery temperature had a role in the initial neonatal temperatures. According to Karlsson (1996), skin-to-skin contact increased rectal temperatures by 0.4⁰C among nine healthy babies with normal temperatures at the time of recruitment into the study. However, significant heat loss was recorded during baby transfer and from body areas lacking this contact. In this study, the key outcomes of skin rewarming were seen in other parts such as rectum as can be explained by natural temperature redistribution through blood circulation. According to another study by Christensen et al. (1995), this separation between the mother and the newborn causes distress that has been attributed to the position in which the full-term infant is in close contact with the mother. The change in axillary and skin temperature was higher in the SSC group and SSC group plus cot than in the cot group alone. A descriptive pilot study by Walters et al. (2007) determined the impact of kangaroo care on skin temperature, breastfeeding behaviors, and blood glucose levels among nine healthy full-term infants with mild hypothermia. Kangaroo mother care is a type of skin-to-skin contact rewarming where the rewarming is done in a kangaroo pouch position. This study noted a significant temperature rise in 8 of 9 newborns before stabilizing at neutral thermal body temperatures. In this study, nurses reported no significant negative change in workload. The integration of birth kangaroo care in the delivery room saw successful breastfeeding for most infants. Psychologically, mothers were distracted from the pain of episiotomy repair during this care.
A randomized control trial by Bieranvand et al. (2014) showed that infants who had SSC after cesarean sections had higher temperatures than those who were dressed and put into a cot immediately, after 40 minutes, and after an hour. There were no statistical differences between the breastfeeding assessment between the experimental and control groups of infants. Clinical guidelines by Galligan encouraged the use of skin-to-skin for the treatment of neonatal hypothermia. According to these practice guidelines, full-term infants with mild hypothermia can benefit from skin-to-skin contact because it promotes thermoregulation and enhances maternal-infant attachment. Even in high-risk premature infants, skin-to-skin contact is recommended. Infants without sepsis risk factors, born at term, are not small for gestational age with normal heart rate and respiratory rates, and not in any distress are perfect candidates for skin-to-skin contact. During this intervention, infants can wear hats to minimize heat loss. Positioning of infants is critical because it maximizes heat retention. These guidelines outlined grades of evidence that guided their development.
Mild Hypothermia Warmed Using SSC for Full-Term Newborns: Late preterm newborns are also at risk of developing hypothermia from different risks. A study by Luong et al. (2016) randomized 100 infants born late preterm and weighing between 1500g and 2500g with mild hypothermia into intervention and control groups. The intervention group SSC, while the control group received routine care. Luong et al. (2016) recommended SSC for these preterm infants as a safe and affordable rewarming intervention in the absence of life-threatening conditions. In a further assessment of participants who met the criteria for the research questions and literature search criteria, the outcomes further supported the use of SSC. In this study, the mean gestational age was 35 years, and the mean weight was 2206 grams. The average temperature readings for the intervention group were 36.18⁰C at 30 minutes, 36.58⁰C at 90 minutes, and 37.29⁰C after the 6-hour study. This increase showed the exponential improvement in neonatal hypothermia for low birth weight infants.
In Hamadan City, Iran, a recent study by Parsa et al. (2018) showed that kangaroo mother care improved physiological indices among premature infants. In this quasi-experimental study, 100 late preterm newborns with mild hypothermia were randomized into an intervention group that received kangaroo mother care, and a control group received radiant warming in the incubator. At the end of observation, there was a significant improvement in arterial blood oxygen saturation, infant heart rate, respiratory rates, and axillary temperature. This study recommended kangaroo mother care for physiological health enhancement for later preterm infants with mild hypothermia and no signs of distress.
Moderate Hypothermia using SSC: A study by Nissen et al. (2019) found that infants with moderate hypothermia who had SSC immediately at birth lasting for at least an hour had warmer body temperatures than their counterparts who did not receive SSC immediately after birth. These infants achieved good temperature stabilization with uninterrupted SSC. However, this quasi-experimental study reported only 54.8% adoption rates among clinical staff to encourage this intervention among mothers. Bystrova et al. (2007) randomized 176 newborns with moderate hypothermia into the SSC and the swaddle groups who were vl9therd and taken to the nursery. This randomized controlled trial study that took place in St. Petersburg, Russia, found that both infants’ temperatures rose significantly after 30 and 120 minutes in the axilla, thigh, and back. However, foot temperatures rose significantly higher in the SSC group than in the swaddle group. The foot temperatures of the swaddle group infants took longer to achieve stabilization. Therefore, SSC is an effective intervention to achieve temperature stabilization in infants with moderate hypothermia after birth. Gouchon et al. (2010) established that SSC for mothers who underwent cesarean section delivery was practical and posed no risk of hypothermia. Their study found no significant differences between infants who received SSC and those who received routine care after cesarean sections. Moreover, SSC infants had earlier breastfeeding initiation and their mother expressed higher satisfaction levels.
Bergman & Fawcus (2007) compared SSC with incubator care for infants with birth weights between 1200 and 2199 grams. In their prospective non-blinded randomized controlled trial, 18 SSC infants were compared with 13 incubator groups who completed the 6 hours of the study. This study showed that the SSC infants had better physiological and cardiorespiratory stabilization than incubator infants. For the SSC group, the starting temperature was 35.3⁰C, later normalized to 36.55⁰C at 240 minutes, and later 37.29⁰C at 360 hours.
Managing Mild and Moderate Hypothermia using Radiant Warmer: A comparative study by Motil et al. (1974) evaluated the neonatal outcomes of those warmed at four different temperatures for full-term infants. According to this study, radiant warming using infrared warmers at 38⁰C showed the faster achievement of temperature stabilization, especially the rectal temperatures. All participants in the 380C group achieved temperature stabilization, 58.3% of the 370C group achieved temperature stabilization, 16% of the 36.00C, achieved stabilization while no infant in the 350C achieved temperature stabilization. However, the risk of apnea among these children was higher. In 2006, a prospective cohort study by Mathur et al. found that the achievement of rewarming was independent of the baby’s weight or gestational age. However, infants with birth asphyxia took longer to warm using the radiant warmer. The grade of hypothermia played a significant role in determining the duration taken to achieve rewarming. The majority of the infants who participated (72%) had moderate and severe hypothermia per the WHO classification of hypothermia.
Summary
This literature review has been structured into two main sections: general outcomes of rewarming documented in the literature and a comparison of two main methods of rewarming. Through a comprehensive examination of the available literature, it can be established that managing hypothermia in preterm infants can be achieved through two effective methods – skin-to-skin contact and infant radiant warmers. Immediately after birth, clinical benefits have been observed with the use of skin-to-skin contact, whereas infant radiant warmers increase neonates’ rectal and skin temperatures. Nonetheless, achieving favorable results when using the technique of performing skin-to-skin contact requires careful attention to detail. To promote effective maternal-neonatal bonding and improve thermoregulation for neonates with hypothermia, it is essential to maximize the exposure of their skin. This literature review supports the idea that providing at least an hour of skin-to-skin contact between mother and baby every day for a week can effectively reduce maternal anxiety and stress levels. However, prolonging this method beyond two weeks does not appear to yield significant results in achieving these outcomes. It is crucial to consider the physical condition of the infant, any comorbidities they may have, as well as the preferences of the mother when deciding on which technique to use.
Term and preterm newborns frequently suffer from hypothermia, which can result in serious health complications and increase the likelihood of death. Two conventional methods for treating mild to moderate cases exist, namely, skin-to-skin contact and infant radiant warmers. While both approaches have demonstrated efficacy in enhancing outcomes for infants, the rate at which rewarming occurs is a critical factor that must be considered when striving to achieve clinical success as quickly as possible. Skin-to-skin contact, despite being a primitive technique, has emerged as an important element of modern nursing and healthcare. It not only helps treat hypothermia but also provides additional advantages, like fostering maternal-neonatal bonding while promoting neonatal thermoregulation. The length of time spent engaged in skin-to-skin contact plays a significant role in reducing anxiety levels and mitigating maternal stress states; furthermore, it can even be implemented following cesarean section deliveries.
While no item of literature reviewed categorically stated the more superior method between the two, it can be concluded that these two methods have relatively similar effectiveness in rewarming. Most literature items reviewed suggested the combination of both depending the physiological and acute state of the infant to achieve rewarming. All infants with hypothermia but are otherwise stable should receive SSC. This would also allow for bonding and stress reduction in the mother. SSC would also help maintain the core temperature of the infant. Radiant rewarming can improve rewarming rates in acute setting but risk hypothermia due to time spent in the transfer from the mother to the warmer
References
Beiranvand, S., Valizadeh, F., Hosseinabadi, R., & Pournia, Y. (2014). The effects of skin-to-skin contact on temperature and breastfeeding success in full-term newborns after cesarean delivery. International Journal of Pediatrics, 2014, 846486. https://doi.org/10.1155/2014/846486
Bergman, N. J., Linley, L. L., & Fawcus, S. R. (2004). Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatrica (Oslo, Norway: 1992), 93(6), 779–785. https://doi.org/10.1111/j.1651-2227.2004.tb03018.x
Bystrova, K., Widström, A.-M., Matthiesen, A.-S., Ransjö-Arvidson, A.-B., Welles-Nyström, B., Wassberg, C., Vorontsov, I., & Uvnäs-Moberg, K. (2007). Skin-to-skin contact may reduce negative consequences of “the stress of being born”: a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg. Acta Paediatrica (Oslo, Norway: 1992), 92(3), 320–326. https://doi.org/10.1111/j.1651-2227.2003.tb00553.x
Chi Luong, K., Long Nguyen, T., Huynh Thi, D. H., Carrara, H. P. O., & Bergman, N. J. (2016). Newly born low birthweight infants stabilize better in skin-to-skin contact than when separated from their mothers: a randomized controlled trial. Acta Paediatrica (Oslo, Norway: 1992), 105(4), 381–390. https://doi.org/10.1111/apa.13164
Christensson, K., Cabrera, T., Christensson, E., Uvnas-Moberg, K., & Winberg, J. (1996). Separation distress call in the human neonate in the absence of maternal body contact. Obstetrical & Gynecological Survey, 51(2), 86–87. https://doi.org/10.1097/00006254-199602000-00007
Cong, S., Wang, R., Fan, X., Song, X., Sha, L., Zhu, Z., Zhou, H., Liu, Y., & Zhang, A. (2021). Skin-to-skin contact to improve premature mothers’ anxiety and stress state: A meta-analysis. Maternal & Child Nutrition, 17(4), e13245. https://doi.org/10.1111/mcn.13245
Cooijmans, K. H. M., Beijers, R., Rovers, A. C., & de Weerth, C. (2017). Effectiveness of skin-to-skin contact versus care-as-usual in mothers and their full-term infants: study protocol for a parallel-group randomized controlled trial. BMC Pediatrics, 17(1), 154. https://doi.org/10.1186/s12887-017-0906-9
Fardig, J. (1980). A comparison of skin-to-skin contact and radiant heaters in promoting neonatal thermoregulation. Journal of Nurse-Midwifery, 25(1), 19–28. https://doi.org/10.1016/0091-2182(80)90005-1
Galligan, M. (2006). Proposed guidelines for the skin-to-skin treatment of neonatal hypothermia. MCN. The American Journal of Maternal Child Nursing, 31(5), 298–304; quiz 305–306. https://doi.org/10.1097/00005721-200609000-00007
Gouchon, S., Gregori, D., Picotto, A., Patrucco, G., Nangeroni, M., & Di Giulio, P. (2010). Skin-to-skin contact after cesarean delivery: an experimental study: An experimental study. Nursing Research, 59(2), 78–84. https://doi.org/10.1097/NNR.0b013e3181d1a8bc
Karlsson, H. (1996). Skin-to-skin care: heat balance. Archives of Disease in Childhood. Fetal and Neonatal Edition, 75(2), F130-2. https://doi.org/10.1136/fn.75.2.f130
Mathur, N. B., Krishnamurthy, S., & Mishra, T. K. (2006). Estimation of rewarming time in transported extramural hypothermic neonates. Indian Journal of Pediatrics, 73(5), 395–399. https://doi.org/10.1007/bf02758559
Motil, K. J., Blackburn, M. G., & Pleasure, J. R. (1974). The effects of four different radiant warmer temperature set-points used for rewarming neonates. The Journal of Pediatrics, 85(4), 546–550. https://doi.org/10.1016/s0022-3476(74)80467-1
Nissen, E., Svensson, K., Mbalinda, S., Brimdyr, K., Waiswa, P., Odongkara, B. M., & Hjelmstedt, A. (2019). A low-cost intervention to promote immediate skin-to-skin contact and improve temperature regulation in Northern Uganda. African Journal of Midwifery and Women’s Health, 13(3), 1–12. https://doi.org/10.12968/ajmw.2018.0037
Parsa, P., Karimi, S., Basiri, B., & Roshanaei, G. (2018). The effect of kangaroo mother cares on physiological parameters of premature infants in Hamadan City, Iran. The Pan African Medical Journal, 30, 89. https://doi.org/10.11604/pamj.2018.30.89.14428
Walters, M. W., Boggs, K. M., Ludington-Hoe, S., Price, K. M., & Morrison, B. (2007). Kangaroo care at birth for full-term infants: a pilot study: A pilot study. MCN. The American Journal of Maternal Child Nursing, 32(6), 375–381. https://doi.org/10.1097/01.NMC.0000298134.39785.6c
World Health Organization. (1993). Thermal Control of the Newborn: a practical guide. https://apps.who.int/iris/bitstream/handle/10665/60042/WHO_FHE_MSM_93.2.pdf

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● All 14 articles I uploaded must be reviewed. I categorized the studies based on the intervention type and what level of hypothermia they treat.
○ Mild hypothermia rewarmed using SSC
■ Full Term Newborns
● A comparison of skin-to-skin contact and radiant heaters in promoting neonatal thermoregulation (1980)
● Skin to skin care:heat balance (1996)
● Separation distress call in the human neonate in the absence of maternal body contact (1995)
● Kangaroo Care at Birth for Full Term Infants- a pilot study (2007)
● The effects of skin-to-skin contact on temperature and breasfeeding successfullness in full-term newborns after cesaran delivery (2014)
● Proposed Guidelines for skin-to-skin treatment of neonatal hypothermia (2006)
■ Late Preterm Newborns
● Newly born low birthweight infants stabilise better in skin-to-skin contact than when separated from their mothers: a randomised controlled trial (2016)
● The effect of kangaroo care on physioloical parameters of premature infants in Hamadan City, Iran
○ Moderate Hypothermia w/ SSC
■ Full Term
● A low cost intervention to promote immediate skin-to-skin contact and improve temperature regulation in Northern Uganda (2019)
● Skin-to-skin contact may reduce negative consequences of “the stress of being born”: a study on temperature in newborn infants, subjectedto different ward routines in St. Petersburg (2003)
● Skin to Skin contct after cesarean delivery- an experimental study (2010)
■ Late Preterm
● Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1,200 to 2,199 gram newborns. (2004)
○ Mild and Moderate w/ Radiant Warmer
■ Full Term
● Estimation of rewarming time in transported extramural hypohermic neonates (2006)
● The effects of four different radiant warmer temperature set-points used for rewarming neonates (1974)
■ Late Preterm
● Estimation of rewarming time in transported extramural hypohermic neonates (2006)

● I uploaded 2 more files for you to look at, if needed. The authors of two articles emailed me excel sheets of their raw temperature data from the studies titled:
○ 1) Newly born low birthweight infants stabilise better in skin-to-skin contact than when separated from their mothers: a randomised controlled trial (2016)
■ I Isolated newborns that fit the search parameters (gestational age 34 weeks or older) and did simple math to find: Mean GA is 35 weeks, Mean BW is 2,206 grams, Initial temp at 30 min was 36.18°C, and temp at 90 min temp had risen to 36.58°C. By the end of the 6 hour study, mean temp had increased to 37.29°C
○ 2) Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1,200 to 2,199 gram newborns. (2004)
■ Temperature data is shown in fig. 5 of this study, but to clarify: Temperature was 35.3°C at , then normalized to 36.55°C at 240 minutes, and by the end of the study was 37.29°C (at 360 minutes).

● THIS LITERATURE REVIEW MUST DEFINE HYPOTHERMIA BASED ON RECOMMENDATIONS FROM THE WORLD HEALTH ORGANIZATION (WHO)
○ Normal temperature = 36.5 – 37.5° C
○ Mild hypothermia = 36.4 – 36 ° C
○ Moderate hypothermia= 35.9-32 °C
○ Severe hypothermia = under 32 ° C → Since severe hypothermia is virtually non-existent on Mother-Baby units, the literature review should not include review of its pathophysiology or treatment