The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival
© Lunze et al; licensee BioMed Central Ltd. 2013
Received: 13 April 2012
Accepted: 31 January 2013
Published: 31 January 2013
To provide evidence on the global epidemiological situation of neonatal hypothermia and to provide recommendations for future policy and research directions.
Using PubMed as our principal electronic reference library, we searched studies for prevalence and risk factor data on neonatal hypothermia in resource-limited environments globally. Studies specifying study location, setting (hospital or community based), sample size, case definition of body temperature for hypothermia, temperature measurement method, and point estimates for hypothermia prevalence were eligible for inclusion.
Hypothermia is common in infants born at hospitals (prevalence range, 32% to 85%) and homes (prevalence range, 11% to 92%), even in tropical environments. The lack of thermal protection is still an underappreciated major challenge for newborn survival in developing countries. Although hypothermia is rarely a direct cause of death, it contributes to a substantial proportion of neonatal mortality globally, mostly as a comorbidity of severe neonatal infections, preterm birth, and asphyxia. Thresholds for the definition of hypothermia vary, and data on its prevalence in neonates is scarce, particularly on a community level in Africa.
A standardized approach to the collection and analysis of hypothermia data in existing newborn programs and studies is needed to inform policy and program planners on optimal thermal protection interventions. Thermoprotective behavior changes such as skin-to-skin care or the use of appropriate devices have not yet been scaled up globally. The introduction of simple hypothermia prevention messages and interventions into evidence-based, cost-effective packages for maternal and newborn care has promising potential to decrease the heavy global burden of newborn deaths attributable to severe infections, prematurity, and asphyxia. Because preventing and treating newborn hypothermia in health institutions and communities is relatively easy, addressing this widespread challenge might play a substantial role in reaching Millennium Development Goal 4, a reduction of child mortality.
Keywordshypothermia mortality neonatal newborn prematurity
The global burden of neonatal deaths and its relation to hypothermia
The global under-5 child mortality rate has decreased continuously during the last three decades, from 110 per 1,000 in 1980 to 60 per 1,000 in 2009, and the number of child deaths worldwide each year has decreased from 13.5 million in 1980 to an estimated 7.7 to 8.8 million in 2008 [1–4]. The number of neonatal deaths (newborns dying under the age of 28 days) has also decreased, from 4.6 million deaths in 1990 to approximately 3.1 to 3.6 million in 2009 [3, 5]. However, neonatal mortality has declined at a lower rate than child mortality, so the proportion of newborn deaths among all child deaths has been increasing.
Neonatal deaths are unequally distributed around the globe. Half of the world's newborns die at home, and more than 99% of all deaths occur in developing countries, where the average neonatal mortality rate is 33 per 1,000, compared with 4 per 1,000 in high-income countries. Since neonatal deaths account for more than 40% of under-5 mortalities , reaching Millennium Development Goal (MDG) 4 will require a substantial reduction in newborn mortality. Although addressing neonatal hypothermia might facilitate this goal, it has so far been a neglected challenge. Maintaining a normal body temperature is a critical function for newborn survival. Newborns achieve this through sophisticated mechanisms of body temperature regulation controlled by the hypothalamus and mediated by endocrine pathways through shivering and non-shivering thermogenesis . However, particularly in premature and low birth weight infants, thermoregulatory mechanisms are easily overwhelmed, leading to metabolic deterioration and direct death from hypothermia or indirect mortality from associated mortalities such as severe infections .
The attribution of neonatal hypothermia to indirect or direct causes of newborn death is complex and difficult for several reasons. Most neonatal deaths occur in regions without vital registrations or other reliable data sources. In countries where neonatal deaths are estimated to be highest, mortality data are based on national sample death registration at best  and mostly rely on verbal autopsy data-based models with less-than-optimal sensitivity and specificity to correctly identify causes of deaths . Only 2.5% of global neonatal deaths data are based on reliable vital registration systems , while 97% derive from systematic estimations or household surveys .
Moreover, causes of death are difficult to ascertain in newborns because, especially at the beginning of life, infants exhibit few specific symptomatic reactions to illnesses. Clinical manifestations of various diseases overlap considerably in neonates. Early deaths and those in very small babies are often misclassified due to varying definitions of stillbirth and neonatal deaths, or due to other misreporting of data, such as avoiding filling out death certificates .
Globally, severe infections account for an estimated 36% of all neonatal deaths, while problems associated with prematurity account for another 29%, and birth asphyxia makes up 23% (with congenital malformations and a variety of other causes responsible for 19% of neonatal deaths) . While all these causes of death are associated with neonatal hypothermia, the direction of causality is unclear . Although usually infections (mostly sepsis and pneumonia) are listed as cause of death rather than hypothermia, it is unclear whether hypothermia is the underlying cause or the consequence of severe infections. Like severe infections, prematurity is associated with mortality from hypothermia. While only half of the babies born are weighed at birth (and even fewer are of known gestational age), it is estimated that annually 18 million, or 14% of all babies, are born with low birth weight (LBW), half of them in South Asia. LBW infants account for 60% to 80% of neonatal deaths. Birth asphyxia is associated with hypothermia, and prevention or treatment of hypothermia is an important therapeutic principle during and after resuscitation in both developing and developed settings [11, 12].
Daily mortality rates for the neonatal period are 30-fold higher than later during infancy . Immediately after birth, an infant is at highest risk of dying, with 25% to 45% of neonatal mortality occurring during the first 24 h  and 75% of neonatal mortality during the first week of life . Assuming that early deaths are caused mainly by prematurity and asphyxia, interventions addressing hypothermia management and resuscitation might have a substantial impact on neonatal mortality prevention.
This review analyzes the global epidemiological situation of neonatal hypothermia for the purpose of guiding future policy and research efforts.
The prevalence of neonatal hypothermia globally
Global epidemiology of newborn hypothermia
Case definition body temp
Axillary upon admission
Hypothermia risk highest in the first 24 h of life in preterm babies
Axillary upon admission
Hypothermia risk highest in low birth weight babies and those who were not breastfed
Hypothermia more prevalent on admission in infants born outside the hospital than those born at the hospital
Axillary within 12 h of birth
Hypothermia of < 34.5°C associated with mortality risk of 4.81 (95% CI 2.90 to 8.00) in first 7 days compared to those without hypothermia
Rectal and tympanic four times within 90 minutes postpartum
Hypothermia incidence increased from 29% at 10 minutes postpartum to 79% at 90 minutes postpartum
Rectal 60 minutes postpartum
Early bathing increased the risk of hypothermia in spite of use of warm water and skin-to-skin care
Rectal 30 and 120 minutes after delivery
53% and 69%
At discharge after an average of 14 h, hypothermia was still persistent in half of all babies sampled
Rectal upon admission
Mortality was higher in hypothermic infants than in those who were not hypothermic
Axillary upon admission
Iran, different provinces
Rectal after delivery and four repeats within 6 h of admission to neonatal unit
Newborn with low birth weight, prematurity, low Apgar scores, of multiple pregnancies and after cardiopulmonary resuscitation at higher risk for being hypothermic in regression analysis. Hypothermia is associated with an increased risk of neonatal mortality risk (OR = 3.1, 95% CI 1.9 to 5.2) as well as risk of metabolic acidosis, jaundice, respiratory distress, hypoglycemia, and pulmonary hemorrhage.
Rectal upon admission to neonatal unit (mean time after delivery 20 minutes)
Hypothermia at birth is associated with an increased neonatal mortality risk (OR = 3.64, 95% CI 1.85 to 7.18), as well as risk for respiratory distress (OR = 2.12, 95% CI 1.53 to 2.93), metabolic acidosis (OR = 2.83, 95% CI 1.74 to 4.59), and jaundice (OR = 2.01, 95% CI 1.45 to 2.79), controlling for weight and gestational age
Rectal after delivery and four repeats within 6 h of admission to neonatal unit
Low birth weight, low gestational, age environmental temperature, low Apgar score, multiple pregnancy and receiving cardiopulmonary resuscitation increased risk for being hypothermic in regression analysis
Axillary after delivery and five times on first, second and third day
Hypothermia risk associated with low birth weight and gestational age
Rectal 2 h after delivery
Rectal after delivery
Rectal after delivery
16% of hypothermic infants died within first week of life
Axillary after delivery
Continuous axillary and forehead skin probe
72% (Incidence in percent of time being hypothermic from birth to 8 h of life)
Prevalence 5.9% in infants with kangaroo mother care
Rectal within 12 h after delivery
Axillary once on first day
Higher prevalence in winter (19%) than in summer (3%); in a secondary analysis applying a case definition of 36.5°C, prevalence was 38%; correlation between room air temperature and body temperature
Axillary on 8 days during first month
Higher prevalence in winter than in summer
Uttar Pradesh, India
Axillary 3 to 36 h after birth
Body temperature lower in low ambient temp < 20°C and in newborns with hypothermic mothers
Axillary daily on first 7 days of life
Uttar Pradesh, India
Axillary within 48 h and on days 7, 30 and 60
Axillary on 10 days during first month
Hypothermia risk highest in the first 72 h of life
Axillary on 10 days during first month
Hypothermia risk highest in preterm babies, females, those breastfed later than 24 h after delivery, and those with hypothermic mothers
Axillary on 10 days during first month
Mortality risk increases by 80% for every 1°C decrease. Mortality risk 6.11 for newborns < 35.0°C compared to those > 36.5°C.
Axillary on admission
Hypothermia increased neonatal mortality risk, AOR = 3.49, 95% CI 3.18 to 3.81
These, and an earlier community-based study from Nepal , found newborn hypothermia to be almost universal at birth. Overall in community-based studies (all conducted in Nepal or India), hypothermia prevalence ranged from 11% to 92%. Perhaps not surprisingly, lower ambient temperatures [20, 21] and cold season  were associated with a higher incidence of hypothermia in Indian studies.
However, not only in climatic regions perceived as high risk for hypothermia such as the hills and mountains of Nepal, Northern India, Bangladesh, Pakistan and Bhutan  do infants get too cold. Hypothermia is a problem even in tropical countries and warm climates, as was first reported more than fifty years ago . A classic study from Dakar, Senegal found only 5 in 78 babies with a temperature over 36°C . All identified studies from Africa to date are hospital based, report poor newborn practices and high prevalences of newborn hypothermia ranging from 44% to 69% in Zambia [25, 26] to 53% in Ethiopia , 62% to 68% in Nigeria , and 85% in Zimbabwe . Large studies from other countries confirm the global tendency for newborn hypothermia in different climate conditions, from Asia (China) (cited in ), , the Middle East (Iran) [32, 33] and South America (Brazil) .
Overall, the prevalence of hypothermia in hospital-based studies ranges from 32 to 85%, with the exception of a low outlier (8% in Guinea Bissau ). This wide range might in part be attributable to the varying case definition of hypothermia across studies, ranging from 35.0°C to 36.5°C, and in part to the climatic environment and its seasonal variations discussed below.
We caution that the direct comparability of prevalence data from these hospital-based studies are limited by selection bias, as study populations often represent a high-risk patient cohort and might not be representative of the local population. Data comparability is further limited by the heterogeneity in case definition of hypothermia, which ranges from as low as 35.0°C to the current WHO standard of 36.5°C body temperature, measured with homogeneously temperature measurement methods across studies. Furthermore, prevalence data are confounded by various covariates inconsistently present across studies, such as environmental temperatures and seasonality, the newborns' maturity and age, or maternal factors.
Risk factors for hypothermia
Various studies identified several risk factors for newborn hypothermia, which we categorize as follows.
Termed 'contextual' by other authors ; initially, an infant's body temperature is associated with maternal temperatures . Several studies have confirmed the intuitive association with environmental temperatures and with the cold seasons. The Gadchiroli trial, with an overall hypothermia prevalence of 17%, showed variations from summer (14.8%) to winter (21.5%) [21, 38]. Other studies from Haryana in Northern India recorded an overall hypothermia prevalence of 11%, ranging from 3% in the summer to 19% in winter . In Uttar Pradesh, hypothermia was detected in 14% (n = 148) and was found to strongly correlate with environmental temperature . Another study from the same state found a higher rate of 45%, which likewise was correlated with environmental temperatures and varied considerably over the seasons, ranging from 70% during winter to 20% during summer . Studies from Nepal suggest that the higher prevalence of hypothermia in hospitals during winter months can successfully be addressed through staff training of early drying, wrapping, and breastfeeding [40, 41]. The Sarlahi trial found that while even in the hottest season of the year almost one-fifth of infants were hypothermic , the risk of moderate-to-severe hypothermia further increased by 41% for each 5°C decrease in ambient temperature .
While newborns of all gestational ages are at risk of losing body heat after birth, premature and small babies are particularly vulnerable due to their physiologic disadvantages. A newborn's thermal regulatory mechanisms are highly sophisticated, but particularly in babies born prematurely easily overwhelmed . Neonatal anatomic characteristics add to the metabolic burden of increased energy requirements: term babies have a 2.7 times greater body surface and preterm babies an up to 4.0 times greater surface per weight than adults.
Several conditions of immature thermal regulation, such as LBW, prematurity, intrauterine growth restriction, and asphyxia (with heat loss due to lack of oxygenation and, where attempted, during reanimation efforts) during birth are significantly associated with an abnormal low body temperature [31, 32, 40, 42, 43]. Hypoglycemia is an important contributor to hypothermia , and vice versa: it maintains a vicious circle, which leads to feeding weakness, weight loss and finally increased mortality, which first was shown in studies in the 1950s and 1960s . Breastfeeding therefore treats hypothermia not only through bonding with and warming through the mother, but also by replenishing a newborn's glucose levels.
Early bathing contributes significantly to heat loss and increases the incidence of hypothermia in cold climates  and even in a warm environment  and should be postponed until at least after the first 6 h of life, and possibly longer. It is, however, a widespread practice even in high-risk environments [48–51].
Massage and oil applications to clean the child early after birth continue to be a widespread tradition . Evidence for the influence of massage and oil application on hypothermia is contradictory. While suggesting protection from hypothermia  and against nosocomial infections in preterm very low birth weight infants , it has also been shown in other studies to have detrimental effects on the skin as a protective barrier  and to lead to heat loss .
An infant's low body temperature is also associated with having a young and inexperienced mother, coming from a family with low socioeconomic status , or being born to a mother who already had multiple births .
While some of these physiologic risk factors have been documented decades ago, awareness of the risks associated with hypothermia, as indicated in a multinational survey  and another one from India , indicating that healthcare professionals have limited knowledge of the diagnosis and management of newborn hypothermia. Facilities in resource-limited environments rarely have sufficient capacity to address thermal protection. In a recent study in Zambia, we found that health centers are not well prepared to provide thermal protection, with only very few equipped with heat control for the delivery room (7%) or a neonatal warmer (9%) .
Associations of hypothermia with newborn morbidity and mortality
Several studies investigated the association between neonatal hypothermia and associated mortality risks. In our review, case fatality rates (CFR) for newborn hypothermia globally range from 8.5% to 52% [21, 26, 34, 59, 60]. A study from India that included only hypothermic babies specifically investigated morbidities and mortalities and found CFRs that ranged from 39.3% for mild hypothermia to 80% for severe hypothermia. This study demonstrated a dramatic effect of comorbidities and confirmed that hypothermia has a much worse outcome when associated with other newborn problems. Fatality rates increased to 71.4% with hypoglycemia, 83.3% with hypoxia, and 90.9% with shock .
However, the above-cited studies do not sufficiently control for potential confounders of the effect of hypothermia on mortality and thus provide implausibly high CFRs in the context of high hypothermia prevalence particularly in community settings. Furthermore, these studies reflect the higher risk of hospital populations selected for these studies, and their CFRs are therefore not applicable to community settings. Yet, hypothermia has been shown to be associated with mortality in a community setting. A community-based study conducted in Sarlahi, Nepal found that mortality increased by approximately 80% for every degree Celsius decrease in first observed axillary temperature and that relative risk of death ranged from 2 to 30 times within the current WHO classification for moderate hypothermia, increasing with greater severity of hypothermia .
The evidence on the effect of thermal protection on morbidity and mortality is currently limited. Skin-to-skin care has been shown to substantially reduce neonatal mortality among preterm infants born in facilities , but its effectiveness for infants born at term and in communities is less clear. In Zambia, we recently showed that training traditional birth attendants in newborn care emphasizing simple thermal protection (wiping the newborn dry and wrapping the dried infant in a separate piece of cloth), along with resuscitation and early treatment of possible sepsis where indicated, reduced mortality rates at day 28 after birth by 45% .
Whether wrapping the newborn in plastic (polyethylene or vinyl) bags is sufficient for thermal protection in low birth weight and premature infants remains controversial. While one recent study failed to show an effect of wrapping on hypothermia rates , others found that this approach effectively raised body temperature [65, 66] and did so more quickly than radiant heaters [67, 68], however did not reduce mortality .
Rethinking and redefining neonatal hypothermia
Our and other reviews [36, 70] suggest that the burden of hypothermia is still highly prevalent including in tropical countries, practices contributing to heat loss in the newborn are still deeply rooted in many cultures and are difficult to change, technologies adapted to resource-poor environments are still at a developmental stage, simple thermoprotective interventions and behaviors are insufficiently practiced, providers and caretakers lack an understanding of the problem, and adverse health outcomes continue to take their toll in morbidity and mortality in newborns. There is thus a critical need for researchers and policy makers to take on the challenge of newborn hypothermia and address it within a larger framework of maternal and child health programs.
Qualitative studies from Africa and South Asia suggest that delivery and newborn care practices contributing to heat loss are still common globally. Various cultural and sometimes economic barriers often interfere with implementing simple steps to prevent hypothermia. Heating the birth place is costly for families in resource-poor countries , and drying and wrapping the baby is often not a priority when the mother needs attention after delivery . In Ghana, for example, the practice of bathing newborns immediately after delivery is sometimes rooted in concerns about 'ritual pollution'  or the belief of helping the baby sleep and feel clean, and reducing body odor in later life; attitudes that informants felt would be difficult to change  and which need to be taken into account when programming for behavior change.
Major gaps in our understanding of neonatal hypothermia
Since in most parts of the world temperature is not measured and recorded in most newborns immediately after birth, the epidemiological picture of hypothermia and its clinical consequences is yet incomplete. Hypothermia is believed to be a common problem not only in developing countries, but also in formerly socialist countries . There are few studies from current lower-middle-income countries.
To the best of our knowledge, no population risk attributable to hypothermia has been published yet. There is no consistent definition of normal newborn body temperature, and consequently data that would allow for pooled risk estimates for newborn hypothermia are still incomplete. Temperatures have been shown to vary widely in healthy newborns , and standard medical textbooks disagree on the lower normal limit, ranging from 35.5 to 36.5°C, as well as the normal upper level, citing values from 37.0 to 37.9°C .
Standard randomized controlled trials to define temperature thresholds associated with adverse health effects (morbidity as well as mortality) and to quantify the contribution of hypothermia to neonatal mortality as specific cause of death have not been conducted. In fact, those studies might be methodologically impossible to undertake, or at least ethically problematic, because the detection of hypothermia prompts therapeutic intervention and thus artificially reduces the associated mortality risk.
Given these limitations, standard measurements of body temperature could be included in newborn studies to complement available epidemiologic data. Newborn trials conducted for other reasons that include data on newborn body temperature could facilitate further investigation of the association of newborn hypothermia with morbidities and disease-specific mortalities. Axillary measurements with standard digital thermometers are inexpensive and can easily be incorporated into most newborn care clinical guidelines and study protocols.
Currently, the best available data come from trials with hypothermia-unrelated interventions providing temperature data, such as the Sarlahi trial in Nepal . Further studies on the mortality and morbidity risks posed by newborn hypothermia are warranted, particularly in sub-Saharan Africa, to refine the current WHO classification scheme for hypothermia that, as has been suggested, might have to revised into narrower categories to more appropriately reflect the overall mortality-hypothermia risk relationship [18, 70].
Further research is needed to understand the magnitude and perception of the problem as well as the feasibility and effectiveness of thermoprotective interventions for newborn morbidity and mortality. Methodologically sound hospital-based and community-based studies are required to understand the problem in sub-Saharan Africa specifically. These studies will ideally include potential confounders and mediating factors that have largely not been adequately addressed so far, such as maternal temperature, environmental conditions, and sociocultural contexts and their association with newborn hypothermia.
Various international neonatal advocacy alliances have included thermoprotection strategies in their newborn health programming, including the Healthy Newborn Partnership (Save the Children), Partnership for Safe Motherhood and Newborn Health (WHO), and the Child Survival Partnership (UNICEF). Nevertheless, hypothermia remains a major challenge for newborn survival. Globally, progress has been particularly slow in improving survival in infants less than 7 days old . This might be attributable to the delivery gap in developing countries for interventions addressing early causes of death such as preterm birth and asphyxia, both of which have worse outcomes in the presence of hypothermia.
More than a quarter of a century ago, a study from Senegal reported: 'Deaths [from hypothermia] seem easy to avoid. Purchasing blankets, putting the newborn babies with their mother and not in cots, prohibiting unnecessary washing of the babies, and supplying maternity hospitals with solar water heaters are all easy steps which could greatly reduce this problem. These improvements are gradually being introduced in the maternity hospital we surveyed though it is proving very difficult to persuade elderly auxiliary midwives not to remove the vernix caseosa by thorough washing, this being part of a strong tradition. Health workers in dispensaries should also be aware of the problem of neonatal hypothermia. We frequently see at our clinic mothers with young infants whose growth seems unsatisfactory. They usually complain about not having enough milk. If the infant is lightly clothed and his rectal temperature is well below normal, he may be expending too much energy on thermogenesis. Advising such mothers to use warmer clothing for their babies is usually enough to make them put on weight. Artificial feeding would be wholly inappropriate in such conditions and could even prove fatal' . As our review suggests, most of these statements and easy remedies still hold true today in most of the world.
Although hypothermia is a direct cause of death only in a small proportion of newborn mortality, it is closely associated with mortality from common causes of newborn deaths such as severe infections, prematurity, and asphyxia. Neonatal deaths mostly occur at home in low-income countries with weak health systems, where the perception of hypothermia as a risk to the newborn is currently insufficient even among health professionals.
Improvement of practices and services, even (and particularly) where health systems are weak, must focus on the poorest, highest-mortality countries, and on the time of greatest risk: birth and the first days of life. MDG 4 can only be met with a significant decrease in neonatal mortality. We propose that understanding, managing, and significantly mitigating the global burden of hypothermia, a largely understudied risk factor for neonatal survival, might be relatively simple and contribute substantially towards reaching MDG 4.
case fatality rates
low birth weight
Millennium Development Goal
World Health Organization.
- Murray CJ, Laakso T, Shibuya K, Hill K, Lopez AD: Can we achieve Millennium Development Goal 4? New analysis of country trends and forecasts of under-5 mortality to 2015. Lancet. 2007, 370: 1040-1054. 10.1016/S0140-6736(07)61478-0.View ArticlePubMedGoogle Scholar
- UNICEF: Levels & Trends in Child Mortality, Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation, Report 2010. [http://www.childinfo.org/files/Child_Mortality_Report_2010.pdf]
- Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Li L, Mather C: Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010, 375: 1969-1987. 10.1016/S0140-6736(10)60549-1.View ArticlePubMedGoogle Scholar
- Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, Costa M, Lopez AD, Murray CJ: Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet. 2010, 375: 1988-2008. 10.1016/S0140-6736(10)60703-9.View ArticlePubMedGoogle Scholar
- Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, Cousens S, Lawn JE, Mathers CD: Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Med. 2011, 8: e1001080-10.1371/journal.pmed.1001080.View ArticlePubMedPubMed CentralGoogle Scholar
- Knobel R, Holditch-Davis D: Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low-birthweight infants. J Obstet Gynecol Neonatal Nurs. 2007, 36: 280-287. 10.1111/j.1552-6909.2007.00149.x.View ArticlePubMedGoogle Scholar
- Lunze K, Hamer DH: Thermal protection of the newborn in resource-limited environments. J Perinatol. 2012, 32: 317-324. 10.1038/jp.2012.11.View ArticlePubMedGoogle Scholar
- Sachdev HP: Commentary: utilizing information on causes of neonatal deaths in less-developed countries. Int J Epidemiol. 2006, 35: 718-719. 10.1093/ije/dyl077.View ArticlePubMedGoogle Scholar
- Lawn JE, Wilczynska-Ketende K, Cousens SN: Estimating the causes of 4 million neonatal deaths in the year 2000. Int J Epidemiol. 2006, 35: 706-718. 10.1093/ije/dyl043.View ArticlePubMedGoogle Scholar
- Lawn JE, Cousens S, Zupan J: 4 million neonatal deaths: when? Where? Why?. Lancet. 2005, 365: 891-900. 10.1016/S0140-6736(05)71048-5.View ArticlePubMedGoogle Scholar
- The American Academy of Pediatrics: Textbook of Neonatal Resuscitation. 2011, Elk Grove, IL: American Academy of Pediatrics, 6Google Scholar
- Singhal N, Niermeyer S: Neonatal resuscitation where resources are limited. Clin Perinatol. 2006, 33: 219-228. 10.1016/j.clp.2005.11.009. x-xiView ArticlePubMedGoogle Scholar
- Zupan J, Aahman E: Perinatal Mortality for the Year 2000: Estimates Developed by WHO. 2005, Geneva, Switzerland: World Health OrganizationGoogle Scholar
- Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009, 6: e1000097-10.1371/journal.pmed.1000097.View ArticlePubMedPubMed CentralGoogle Scholar
- World Bank: Country and Lending Groups. [http://data.worldbank.org/about/country-classifications/country-and-lending-groups]
- Mullany LC, Katz J, Khatry SK, Leclerq SC, Darmstadt GL, Tielsch JM: Incidence and seasonality of hypothermia among newborns in southern Nepal. Arch Pediatr Adolesc Med. 2010, 164: 71-77. 10.1001/archpediatrics.2009.239.PubMedPubMed CentralGoogle Scholar
- Mullany LC, Katz J, Khatry SK, Leclerq SC, Darmstadt GL, Tielsch JM: Neonatal hypothermia and associated risk factors among newborns of southern Nepal. BMC Med. 2010, 8: 43-10.1186/1741-7015-8-43.View ArticlePubMedPubMed CentralGoogle Scholar
- Mullany LC, Katz J, Khatry SK, LeClerq SC, Darmstadt GL, Tielsch JM: Risk of mortality associated with neonatal hypothermia in southern Nepal. Arch Pediatr Adolesc Med. 2010, 164: 650-656. 10.1001/archpediatrics.2010.103.PubMedGoogle Scholar
- Johanson RB, Rolfe P, Spencer SA, Rai R: Should thermometers be issued to birth attendants in Nepal?. J Trop Pediatr. 1992, 38: 202.View ArticlePubMedGoogle Scholar
- Kumar R, Aggarwal AK: Body temperatures of home delivered newborns in north India. Trop Doct. 1998, 28: 134-136.PubMedGoogle Scholar
- Bang AT, Reddy HM, Baitule SB, Deshmukh MD, Bang RA: The incidence of morbidities in a cohort of neonates in rural Gadchiroli, India: seasonal and temporal variation and a hypothesis about prevention. J Perinatol. 2005, 25 (Suppl 1): S18-28.View ArticlePubMedGoogle Scholar
- Darmstadt GL, Kumar V, Yadav R, Singh V, Singh P, Mohanty S, Baqui AH, Bharti N, Gupta S, Misra RP, Awasthi S, Singh JV, Santosham M: Introduction of community-based skin-to-skin care in rural Uttar Pradesh, India. J Perinatol. 2006, 26: 597-604. 10.1038/sj.jp.7211569.View ArticlePubMedGoogle Scholar
- Morley DC: Cold injury among children severely ill in the tropics. Lancet. 1960, 2: 1170-1171.View ArticlePubMedGoogle Scholar
- Briend A, de Schampheleire I: Neonatal hypothermia in West Africa. Lancet. 1981, 1: 846-847.View ArticlePubMedGoogle Scholar
- Christensson K, Ransjo-Arvidson AB, Kakoma C, Lungu F, Darkwah G, Chikamata D, Sterky G: Midwifery care routines and prevention of heat loss in the newborn: a study in Zambia. J Trop Pediatr. 1988, 34: 208-212.View ArticlePubMedGoogle Scholar
- Christensson K, Bhat GJ, Eriksson B, Shilalukey-Ngoma MP, Sterky G: The effect of routine hospital care on the health of hypothermic newborn infants in Zambia. J Trop Pediatr. 1995, 41: 210-214. 10.1093/tropej/41.4.210.View ArticlePubMedGoogle Scholar
- Tafari N, Olsson EE: Neonatal cold injury in the tropics. Ethiop Med J. 1973, 11: 57-65.PubMedGoogle Scholar
- Ogunlesi TA, Ogunfowora OB, Adekanmbi FA, Fetuga BM, Olanrewaju DM: Point-of-admission hypothermia among high-risk Nigerian newborns. BMC Pediatr. 2008, 8: 40-10.1186/1471-2431-8-40.View ArticlePubMedPubMed CentralGoogle Scholar
- Byaruhanga R, Bergstrom A, Okong P: Neonatal hypothermia in Uganda: prevalence and risk factors. J Trop Pediatr. 2005, 51: 212-215. 10.1093/tropej/fmh098.View ArticlePubMedGoogle Scholar
- Tunell R: Hypothermia: epidemiology and prevention. Improving Newborn Health in Developing Countries. Edited by: Costello A, Manandhar D. 2000, Hackensack, NJ; World Scientific Publishing Company, 207-220.View ArticleGoogle Scholar
- Ji XC, Zhu CY, Pang RY: Epidemiological study on hypothermia in newborns. Chin Med J (Engl). 1993, 106: 428-432.Google Scholar
- Zayeri F, Kazemnejad A, Ganjali M, Babaei G, Nayeri F: Incidence and risk factors of neonatal hypothermia at referral hospitals in Tehran, Islamic Republic of Iran. East Mediterr Health J. 2007, 13: 1308-1318.PubMedGoogle Scholar
- Nayeri F, Nili F: Hypothermia at birth and its associated complications in newborns: a follow up study. Iranian J Publ Health. 2006, 35: 5.Google Scholar
- da Mota Silveira SM, Goncalves de Mello MJ, de Arruda Vidal S, de Frias PG, Cattaneo A: Hypothermia on admission: a risk factor for death in newborns referred to the Pernambuco Institute of Mother and Child Health. J Trop Pediatr. 2003, 49: 115-120. 10.1093/tropej/49.2.115.View ArticlePubMedGoogle Scholar
- Sodemann M, Nielsen J, Veirum J, Jakobsen MS, Biai S, Aaby P: Hypothermia of newborns is associated with excess mortality in the first 2 months of life in Guinea-Bissau, West Africa. Trop Med Int Health. 2008, 13: 980-986. 10.1111/j.1365-3156.2008.02113.x.View ArticlePubMedGoogle Scholar
- Kumar V, Shearer JC, Kumar A, Darmstadt GL: Neonatal hypothermia in low resource settings: a review. J Perinatol. 2009, 29: 401-412. 10.1038/jp.2008.233.View ArticlePubMedGoogle Scholar
- Knobel RB, Wimmer JE, Holbert D: Heat loss prevention for preterm infants in the delivery room. J Perinatol. 2005, 25: 304-308. 10.1038/sj.jp.7211289.View ArticlePubMedGoogle Scholar
- Bang AT, Bang RA, Baitule S, Deshmukh M, Reddy MH: Burden of morbidities and the unmet need for health care in rural neonates-a prospective observational study in Gadchiroli, India. Indian Pediatr. 2001, 38: 952-965.PubMedGoogle Scholar
- Agarwal S, Sethi V, Pandey RM, Kondal D: Human touch vs. axillary digital thermometry for detection of neonatal hypothermia at community level. J Trop Pediatr. 2007, 54: 2.View ArticleGoogle Scholar
- Johanson RB, Spencer SA, Rolfe P, Jones P, Malla DS: Effect of post-delivery care on neonatal body temperature. Acta Paediatr. 1992, 81: 859-863. 10.1111/j.1651-2227.1992.tb12123.x.View ArticlePubMedGoogle Scholar
- Costello A, Manandhar D: Improving Newborn Infant Health in Developing Countries. 2000, London, UK: Imperial College PressView ArticleGoogle Scholar
- Goldsmith JR, Arbeli Y, Stone D: Preventability of neonatal cold injury and its contribution to neonatal mortality. Environ Health Perspect. 1991, 94: 55-59.View ArticlePubMedPubMed CentralGoogle Scholar
- Mance MJ: Keeping infants warm: challenges of hypothermia. Adv Neonatal Care. 2008, 8: 6-12. 10.1097/01.ANC.0000311011.33461.a5.View ArticlePubMedGoogle Scholar
- de Costello AML, Pal DK, Manandhar DS, Rajbhandari S, Land JM, Patel N: Neonatal hypoglycaemia in Nepal 2. Availability of alternative fuels. Arch Dis Child Fetal Neonatal Ed. 2000, 82: F52-58. 10.1136/fn.82.1.F52.View ArticleGoogle Scholar
- Bell EF: Infant incubators and radiant warmers. Early Hum Dev. 1983, 8: 351-375. 10.1016/0378-3782(83)90018-X.View ArticlePubMedGoogle Scholar
- Johanson R, Richardson S, Spencer S, Rolfe P: Relative changes in neonatal body temperature: after birth and after a bath. Early Hum Dev. 1989, 26: 230-231.Google Scholar
- Bergstrom A, Byaruhanga R, Okong P: The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial. Acta Paediatr. 2005, 94: 1462-1467. 10.1080/080352505100366750.View ArticlePubMedGoogle Scholar
- Iyengar SD, Bhakoo ON: Prevention of neonatal hypothermia in Himalayan villages. Role of the domiciliary caretaker. Trop Geogr Med. 1991, 43: 293-296.PubMedGoogle Scholar
- Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, Tamang S, Thapa S, Shrestha D, Thapa B, Shrestha JR, Wade A, Borghi J, Standing H, Manandhar M, Costello AM: Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet. 2004, 364: 970-979. 10.1016/S0140-6736(04)17021-9.View ArticlePubMedGoogle Scholar
- Osrin D, Tumbahangphe KM, Shrestha D, Mesko N, Shrestha BP, Manandhar MK, Standing H, Manandhar DS, Costello AM: Cross sectional, community based study of care of newborn infants in Nepal. BMJ. 2002, 325: 1063-10.1136/bmj.325.7372.1063.View ArticlePubMedPubMed CentralGoogle Scholar
- Sreeramareddy CT, Joshi HS, Sreekumaran BV, Giri S, Chuni N: Home delivery and newborn care practices among urban women in western Nepal: a questionnaire survey. BMC Pregnancy Childbirth. 2006, 6: 27-10.1186/1471-2393-6-27.View ArticlePubMedPubMed CentralGoogle Scholar
- Darmstadt GL, Saha SK, Ahmed AS, Chowdhury MA, Law PA, Ahmed S, Alam MA, Black RE, Santosham M: Effect of topical treatment with skin barrier-enhancing emollients on nosocomial infections in preterm infants in Bangladesh: a randomised controlled trial. Lancet. 2005, 365: 1039-1045.View ArticlePubMedGoogle Scholar
- Mullany LC, Darmstadt GL, Khatry SK, Tielsch JM: Traditional massage of newborns in Nepal: implications for trials of improved practice. J Trop Pediatr. 2005, 51: 82-86. 10.1093/tropej/fmh083.View ArticlePubMedPubMed CentralGoogle Scholar
- Cheah FC, Boo NY: Risk factors associated with neonatal hypothermia during cleaning of newborn infants in labour rooms. J Trop Pediatr. 2000, 46: 46-50. 10.1093/tropej/46.1.46.View ArticlePubMedGoogle Scholar
- Zabelle J, Dagan R, Neumann L, Sofer S: Risk factors for infantile hypothermia in early neonatal life. Pediatr Emerg Care. 1990, 6: 96-98. 10.1097/00006565-199006000-00006.View ArticlePubMedGoogle Scholar
- Dragovich D, Tamburlini G, Alisjahbana A, Kambarami R, Karagulova J, Lincetto O, Malla DS, Mello MJ, Vani NS: Thermal control of the newborn: knowledge and practice of health professional in seven countries. Acta Paediatr. 1997, 86: 645-650. 10.1111/j.1651-2227.1997.tb08949.x.View ArticlePubMedGoogle Scholar
- Choudhary SP, Bajaj RK, Gupta RK: Knowledge, attitude and practices about neonatal hypothermia among medical and paramedical staff. Indian J Pediatr. 2000, 67: 491-496. 10.1007/BF02760474.View ArticlePubMedGoogle Scholar
- Hamer DH, Lunze K, Herlihy J, Mazimba A, Grogan C, Nkimberg M, Owens L, Yeboah-Antwi K, Semrau K: Prevention of neonatal hypothermia in Southern Province, Zambia. 61st Annual Meeting, American Society of Tropical Medicine and Hygiene, Nov 11-15, 2012, Atlanta, Georgia USA. Am J Trop Med Hyg. 2012, 87 (suppl): 450.Google Scholar
- Kambarami R, Chidede O: Neonatal hypothermia levels and risk factors for mortality in a tropical country. Cent Afr J Med. 2003, 49: 103-106.PubMedGoogle Scholar
- Johanson RB, Malla DS, Tuladhar C, Amatya M, Spencer SA, Rolfe P: A survey of technology and temperature control on a neonatal unit in Kathmandu, Nepal. J Trop Pediatr. 1993, 39: 4-10. 10.1093/tropej/39.1.4.View ArticlePubMedGoogle Scholar
- Mathur NB, Krishnamurthy S, Mishra TK: Evaluation of WHO classification of hypothermia in sick extramural neonates as predictor of fatality. J Trop Pediatr. 2005, 51: 341-345. 10.1093/tropej/fmi049.View ArticlePubMedGoogle Scholar
- Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S: 'Kangaroo mother care' to prevent neonatal deaths due to preterm birth complications. Int J Epidemiol. 2010, 39 (Suppl 1): 144-154.View ArticleGoogle Scholar
- Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, MacLeod WB, Waitolo N, Knapp AB, Mirochnick M, Mazimba A, Fox MP, Sabin L, Seidenberg P, Simon JL, Hamer DH: Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study. BMJ. 2011, 342: d346-10.1136/bmj.d346.View ArticlePubMedPubMed CentralGoogle Scholar
- Chitty HE, Kate Hodgson K, Thio M, Price R, Dawson J, Davis P: Wrapping is not sufficient to prevent hypothermia of preterm infants. Pediatric Academic Societies Annual Meeting. 2012, , Boston, MAGoogle Scholar
- Chantaroj S, Techasatid W: Effect of polyethylene bag to prevent heat loss in preterm infants at birth: a randomized controlled trial. J Med Assoc Thai. 2012, 94 (Suppl 7): S32-37.Google Scholar
- Lenclen R, Mazraani M, Jugie M, Couderc S, Hoenn E, Carbajal R, Blanc P, Paupe A: Use of a polyethylene bag: a way to improve the thermal environment of the premature newborn at the delivery room [in French]. Arch Pediatr. 2002, 9: 238-244. 10.1016/S0929-693X(01)00759-X.View ArticlePubMedGoogle Scholar
- Cardona Torres LM, Amador Licona N, Garcia Campos ML, Guizar-Mendoza JM: Polyethylene wrap for thermoregulation in the preterm infant: a randomized trial. Indian Pediatr. 2011, 49: 129-132.View ArticlePubMedGoogle Scholar
- Gathwala G, Singh G, Agrawal N: Safety and efficacy of vinyl bags in prevention of hypothermia of preterm neonates at birth. Indian J Public Health. 54: 24-26.
- Reilly MC, Vohra S, Dunn M, Ferrelli K, Rac VE, Vincer M, Wimmer J, Zayack D, Soll R: The Vermont Oxford Network (VON) Heat Loss Prevention (HELP) Trial. Abstract E-PAS2012:2170.2. Pediatric Academic Societies Annual Meeting. 2012, , Boston, MAGoogle Scholar
- Mullany LC: Neonatal hypothermia in low-resource settings. Semin Perinatol. 2010, 34: 426-433. 10.1053/j.semperi.2010.09.007.View ArticlePubMedPubMed CentralGoogle Scholar
- Thairu L, Pelto G: Newborn care practices in Pemba Island (Tanzania) and their implications for newborn health and survival. Matern Child Nutr. 2008, 4: 194-208. 10.1111/j.1740-8709.2008.00135.x.View ArticlePubMedGoogle Scholar
- Hill Z, Tawiah-Agyemang C, Manu A, Okyere E, Kirkwood BR: Keeping newborns warm: beliefs, practices and potential for behaviour change in rural Ghana. Trop Med Int Health. 2010, 15: 1118-1124. 10.1111/j.1365-3156.2010.02593.x.View ArticlePubMedGoogle Scholar
- Fransson AL, Karlsson H, Nilsson K: Temperature variation in newborn babies: importance of physical contact with the mother. Arch Dis Child Fetal Neonatal Ed. 2005, 90: F500-504. 10.1136/adc.2004.066589.View ArticlePubMedPubMed CentralGoogle Scholar
- Takayama JI, Teng W, Uyemoto J, Newman TB, Pantell RH: Body temperature of newborns: what is normal?. Clin Pediatr (Phila). 2000, 39: 503-510. 10.1177/000992280003900901.View ArticleGoogle Scholar
- Ogunlesi TA, Ogunfowora OB, Ogundeyi MM: Prevalence and risk factors for hypothermia on admission in Nigerian babies < 72 h of age. J Perinat Med. 2009, 37: 180-184.View ArticlePubMedGoogle Scholar
- Orimadegun AE, Akinbami FO, Tongo OO, Okereke JO: Comparison of neonates born outside and inside hospitals in a children emergency unit, southwest of Nigeria. Pediatr Emerg Care. 2008, 24: 354-358. 10.1097/PEC.0b013e318177a73c.View ArticlePubMedGoogle Scholar
- Kambarami R, Chidede O, Pereira N: ThermoSpot in the detection of neonatal hypothermia. Ann Trop Paediatr. 2002, 22: 219-223. 10.1179/027249302125001516.View ArticlePubMedGoogle Scholar
- Zayeri F, Kazemnejad A, Ganjali M, Babaei G, Khanafshar N, Nayeri F: Hypothermia in Iranian newborns. Incidence, risk factors and related complications. Saudi Med J. 2005, 26: 1367-1371.PubMedGoogle Scholar
- Li MX, Sun G, Neubauer H: Change in the body temperature of healthy term infant over the first 72 hours of life. J Zhejiang Univ Sci. 2004, 5: 486-493. 10.1631/jzus.2004.0486.View ArticlePubMedGoogle Scholar
- Johanson RB: Diagnosis of hypothermia-a simple test?. J Trop Pediatr. 1993, 39: 313-314.View ArticlePubMedGoogle Scholar
- Manandhar N, Ellis M, Manandhar DS, Morley D, Costello AM: Liquid crystal thermometry for the detection of neonatal hypothermia in Nepal. J Trop Pediatr. 1998, 44: 15-17. 10.1093/tropej/44.1.15.View ArticlePubMedGoogle Scholar
- Ellis M, Manandhar N, Shakya U, Manandhar DS, Fawdry A, Costello AM: Postnatal hypothermia and cold stress among newborn infants in Nepal monitored by continuous ambulatory recording. Arch Dis Child Fetal Neonatal Ed. 1996, 75: F42-45. 10.1136/fn.75.1.F42.View ArticlePubMedPubMed CentralGoogle Scholar
- Suman RP, Udani R, Nanavati R: Kangaroo mother care for low birth weight infants: a randomized controlled trial. Indian Pediatr. 2008, 45: 17-23.PubMedGoogle Scholar
- Ellis M, Manandhar D, Hunt L, Barnett S, Azad K: Touch detection of neonatal hypothermia in Nepal. Arch Dis Child Fetal Neonatal Ed. 2006, 91: F367-368. 10.1136/adc.2005.086165.View ArticlePubMedPubMed CentralGoogle Scholar
- Green DA, Kumar A, Khanna R: Neonatal hypothermia detection by ThermoSpot in Indian urban slum dwellings. Arch Dis Child Fetal Neonatal Ed. 2006, 91: F96-98. 10.1136/adc.2005.078410.View ArticlePubMedPubMed CentralGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/11/24/prepub
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