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Hypothermia and Early Neonatal Mortality in Preterm Infants

Maria Fernanda Branco de Almeida, MD, PhD1, Ruth Guinsburg, MD, PhD1, Guilherme Assis Sancho, MD1,

Izilda Rodrigues Machado Rosa, MD, PhD2, Zeni Carvalho Lamy, MD, PhD3, Francisco Eulogio Martinez, MD, PhD4,

Regina Paula Guimar~aes Vieira Cavalcante da Silva, MD, PhD5, Lıgia Silvana Lopes Ferrari, MD, PhD6,

Ligia Maria Suppo de Souza Rugolo, MD, PhD7, V ^ania Olivetti Steffen Abdallah, MD, PhD8, andRita de Cassia Silveira, MD, PhD9, on behalf of Brazilian Network on Neonatal Research*

Objective To evaluate intervention practices associated with hypothermia at both 5 minutes after birth and atneonatal intensive care unit (NICU) admission and to determine whether hypothermia at NICU admission is asso-ciated with early neonatal death in preterm infants.Study design   This prospective cohort included 1764 inborn neonates of 22-33 weeks without malformationsadmitted to 9 university NICUs from August 2010 through April 2012. All centers followed neonatal InternationalLiaison Committee on Resuscitation recommendations for the stabilization and resuscitation in the delivery room(DR). Variables associated with hypothermia (axillary temperature <36.0C) 5 minutes after birth and at NICU admis-sion, as well as those associated with early death, were analyzed by logistic regression.Results Hypothermia 5 minutes after birth and at NICU admission was noted in 44% and 51%, respectively, with

6% of early neonatal deaths. Adjusted for confounding variables, practices associated with hypothermia at 5 mi-nutes after birth were DR temperature <25C (OR 2.13, 95% CI 1.67-2.28), maternal temperature at delivery<36.0C (OR 1.93, 95% CI 1.49-2.51), and use of plastic bag/wrap (OR 0.53, 95% CI 0.40-0.70). The variables asso-ciated with hypothermia at NICU admission were DR temperature <25C (OR 1.44, 95% CI 1.10-1.88), respiratorysupport with cold air in the DR (OR 1.40, 95% CI 1.03-1.88) and during transport to NICU (OR 1.51, 95% CI 1.08-2.13), and cap use (OR 0.55, 95% CI 0.39-0.78). Hypothermia at NICU admission increased the chance of earlyneonatal death by 1.64-fold (95% CI 1.03-2.61).Conclusion Simple interventions, such as maintaining DR temperature >25C, reducing maternal hypothermiaprior to delivery, providing plastic bags/wraps and caps for the newly born infants, and using warm resuscitationgases, may decrease hypothermia at NICU admission and improve early neonatal survival.   (J Pediatr 

 2014;164:271-5).

Preterm infants are susceptible to hypothermia shortly after birth. Laptook et al 1 found that 47% of 5277 very low birth

weight (VLBW) infants had a body temperature <36C on admission to the neonatal intensive care unit (NICU).Adjusted analyses showed that admission temperature was inversely related to intrahospital mortality, with a 28% in-

crease in mortality per 1C decrease in body temperature. Moderate and severe hypothermia were associated with the risk of death before hospital discharge in a population-based cohort of 8782 VLBW infants in California NICUs in 2006 and 2007. 2

Neither study reported the practices applied to maintain normal body tempera-ture from birth to NICU admission. According to McCall et al, 3 plastic wraps or

bags and plastic caps are effective in reducing heat losses in infants born at <28-29 weeks’ gestation, but it is unclear whether they reduce the risk of death.

The Neonatal Task Force of the International Liaison Committee on Resusci-tation recommended in 2010 Consensus on Science that “newborn infants of <28weeks’ gestation should be completely covered in a polythene wrap or bag up totheir necks without drying immediately after birth and then placed under a

radiant heater and resuscitated or stabilized in a standard fashion. Infants shouldbe kept wrapped until admission and temperature check. Hyperthermia shouldbe avoided. Delivery room (DR) temperatures should be at least 26C for infantsof <28 weeks’ gestation.”4 However, all of these recommendations have low levelsof evidence regarding their efficacy and effectiveness in reducing neonatal mor-tality.

From the  1Division of Neonatal Medicine, UniversidadeFederal de S~ao Paulo/Escola Paulista de Medicina, S~aoPaulo; 2Department of Pediatrics, Universidade Estadualde Campinas/Hospital da Mulher Prof. Dr. Jose Aristodemo Pinotti, Campinas, SP, Brazil;  3Departmentof Public Health, Universidade Federal do Maranh~ao/ Hospital Universitario,S~aoLuıs, MA, Brazil;  4Departmentof Pediatrics, Universidade de S~ao Paulo/Hospital dasClınicas de Ribeir~ao Preto, Ribeir~ao Preto, SP, Brazil;5Department of Pediatrics, Universidade Federal doParana/Hospital de Clınicas, Curitiba;  6Department of Pediatrics and Pediatric Surgery, Universidade Estadualde Londrina/Hospital Universitario, Londrina, PR, Brazil;7Department of Pediatrics, Faculdade de Medicina deBotucatu da Universidade Estadual Paulista, Botucatu,SP, Brazil;  8Department of Pediatrics, UniversidadeFederal de Uberlandia/Hospital de Clınicas, Uberlandia,MG, Brazil; and  9Department of Pediatrics, UniversidadeFederal do Rio Grande do Sul/Hospital de Clınicas dePorto Alegre, Porto Alegre, RS, Brazil

*List of members of the Brazilian Network on NeonatalResearch is available at www.jpeds.com (  Appendix ).

Supported by Conselho Nacional de DesenvolvimentoCientıfico e Tecnologico (472827-2009-0). The authorsdeclare no conflicts of interest.

0022-3476/$ - see front matter. Copyright ª 2014 Mosby Inc.

 All rights reserved.  http://dx.doi.org/10.1016/j.jpeds.2013.09.049

DR Delivery room

NICU Neonatal intensive care unit

VLBW Very low birth weight

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Our goal is to evaluate intervention practices associatedwith hypothermia at 5 minutes after birth and at NICUadmission and to determine whether hypothermia at NICU

admission is associated with early neonatal death in preterminfants.

Methods

We conducted a multicenter prospective cohort study of in-

fants born at gestational ages of 230/7 to 336/7 weeks withoutcongenital anomalies and admitted at 9 centers of the Brazil-

ian Network on Neonatal Research between August 2010 andApril 2012. All of the centers are level III public university hospitals and serve as referral centers for high-risk pregnan-cies. All of the hospitals have NICU beds and the staff, equip-ment, and infrastructure required to treat critically ill

neonates. The study was approved by the institutional review boards of each institution, and informed consent was signedby the mother of each enrolled neonate.

At each NICU, 1 neonatologist prospectively collectedmaternal and neonatal data in a Web-based data systemspecially designed for the study. Gestational age was defined

by the hierarchy of obstetric measures (last menstrual period,follow ed by first trimester ultrasonography) and a neonatalexam.5 The centers followed the Neonatal ResuscitationProgram of the Brazilian Pediatric Society guidelines for stabi-lization and resuscitation at birth according to the Interna-tional Liaison Committee on Resuscitation Consensus on

Science and Treatment Recommendations.4,6 All of the centersused the same types of digital environmental (TermometroDigital 7665; Incoterm, Porto Alegre, Brazil) and individualthermometers (Medflex; Incoterm, Porto Alegre, Brazil). DR 

temperature was registered at birth. Axillary maternal temper-ature was assessed up to 20 minutes before delivery; axillary neonatal temperature was measured 5 minutes after birth

and at NICU admission. Both maternal and neonatal hypo-thermia were defined as a body temperature <36.0C. Theneonatal thermal care practices analyzed were the following:use of a plastic bag or wrap; use of a linen or woolen cap;

use of heated gases for ventilation; and use of a transport incu-bator. Care of all newly born infants was given under radiantheaters in the DR, and exothermic mattresses were not used.

The main outcomes were hypothermia 5 minutes afterbirth, hypothermia at NICU admission, and death by 6

days after birth. Stepwise logistic regression was applied toevaluate the variables associated with these outcomes. For hy-pothermia 5 minutes after birth, maternal and neonatal char-acteristics at birth and variables related to neonatal thermalcare in the DR were considered to be independent variables.For hypothermia at NICU admission, variables related tothermal care during transport from the DR to the NICUwere also included. For early neonatal death, maternal and

neonatal characteristics at birth, hypothermia at NICUadmission, and neonatal morbidity were evaluated as inde-pendent variables. Variables with a value of P < .20 in the uni-variate analysis were included in the initial model. The fitness

of the model was assessed by use of the Hosmer-Lemeshow test. We calculated that a study population of 1660 patientswould be required to detect a difference of 3% in early 

neonatal mortality (exposed, 8%; nonexposed, 5%) consid-ering a   b   error of 20%, an  a   error of 5%, and a ratio of exposed/nonexposed to hypothermia at NICU admissionof 1:1.

Results

During the study period, 1955 inborn preterm infants with

gestational ages of 23-33 weeks and without congenitalanomalies satisfied our inclusion criteria, and 1764 (90%)were enrolled in the study. Enrollment varied from 115 to262 neonates per center. Axillary temperature at 5 minutesafter birth was measured in 1374 neonates, and hypothermia

was noted in 44% (median 36.0C; 25th-75th percentiles35.5C-36.4C). Axillary temperature at NICU admissionwas measured in 1764 neonates at an average of 32 minutesafter birth, and hypothermia was noted in 51% (median35.9C; 25th-75th percentiles 35.3C-36.4C).

Hypothermia 5 minutes after birth and at NICU admission

varied among centers from 13% to 62% (P  < .001) and from25% to 75% (P  < .001), respectively (Figure). Hypothermiaat 5 minutes after birth and at NICU admission was inversely related to gestational age (P   < .001), but 35% of neonateswith gestational ages of 32 and 33 weeks were hypothermic at5 minutes, andz40% were hypothermic at NICU admission.

Early neonatal death occurred in 6% of the 1764 neonates,varying among centers between 4% and 9% (P  = .478).

Maternal and neonatal characteristics, including thermalneonatal care practices, in infants with and without

hypothermia at 5 minutes after birth and at NICUadmission are shown in   Table I. Median DR temperaturewas 24.8C (25th-75th percentiles 23.7C-25.8C); medianmaternal axillary temperature was 36.2C (25th-75thpercentiles 35.8C-36.6C; 9 mothers had temperature

$38C) at an average of 18 minutes prior birth; andmedian transport incubator temperature was 36.1C (25th-

75th percentiles 35.0C-37.0C). Among the 1764 neonates,9 (0.5%) had hyperthermia ($38.0C) at NICU admission.DR temperature <25C, administration of cold air duringpositive pressure ventilation, and endotracheal intubationsoon after birth were associated with hypothermia at 5

minutes of life and at NICU admission (Table I). Thefollowing practices were also associated with hypothermiaat NICU admission: absence of cap, transport from DR toNICU with cold air, and temperature of the transportincubator <35C.

Demographic and clinical characteristics of the patients,according to early neonatal mortality, are shown in

Table II. Male sex, gestational age <28 weeks, birth weight<1000 g, 1-minute Apgar score <4, 5-minute Apgar score<7, hypothermia at NICU admission, Neonatal AcutePhysiology, Perinatal Extension, Version II score >40,respiratory distress syndrome, air leaks, and grades III/IV

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intraventricular hemorrhage were more frequent in newborninfants who died in the first week after birth.

The independent variables associated with the main out-comes are shown in   Table III. The final logistic modelswere adjusted for birth center. The Hosmer–Lemeshow goodness-of-fit test values for hypothermia at 5 minutesafter birth, hypothermia at NICU admission, and early neonatal death were 0.959, 0.939, and 0.495, respectively.Adjusted for confounders, the DR temperature <25C,maternal hypothermia, and absence of plastic bag/wrapwere independent risk factors for hypothermia 5 minutesafter birth. In turn, hypothermia 5 minutes after birth wasstrongly associated with hypothermia at NICU admission.

Absence of cap use and administration of cold air duringresuscitation and transport were also independent risk 

factors for hypothermia at NICU admission. Hypothermiaat NICU admission increased the chance of early neonatal

death by 64%.

Discussion

In this cohort of inborn preterm infants born at 23-33 weeksof gestational age, the incidence of hypothermia 5 minutes af-

ter birth was extremely high and was independently associ-ated with low DR temperature, maternal hypertension,maternal hypothermia, lower gestational age, and lack of plastic bag/wrap. The presence of hypothermia soon after

birth was the main contributor to hypothermia at NICUadmission, which increased the chance of early neonataldeath by 64%. These results add to the current evidence inthe literature arguing for the urgency of initiating practicesto maintain normothermia as soon as the preterm neonateis born. These practices include the following: maintenance

of DR temperature >25C, careful assessment of maternaltemperature, use of a radiant heater in the DR, use of plastic

bag/wrap and cap, respiratory support with humidified and

Figure.   Frequency of hypothermia at 5 minutes after birth, hypothermia at NICU admission, and early neonatal death per studycenter and per gestational age (number of patients given in parentheses).

Table I.  Maternal and neonatal characteristics in infants with and without hypothermia 5 minutes after birth and atNICU admission

Hypothermia at 5 min Hypothermia at admission

Present(n = 606)

Absent(n = 768)   P  value

Present(n = 894)

Absent(n = 870)   P  value

Maternal age <20 y 21% 19% .253 20% 19% .579Prenatal care $6 visits 42% 50% .003 40% 49% <.001Maternal hypertension 42% 30% <.001 40% 27% <.001 Antenatal steroids 74% 68% <.001 71% 66% .004Multiple gestation 21% 23% .170 20% 25% .006

Spinal anesthesia 71% 70% .447 67% 70% .190Maternal hypothermia 39% 24% <.001 33% 28% .054Cesarean delivery 72% 69% .110 70% 68% .627DR <25C 63% 47% .001 60% 47% <.001Male sex 50% 54% .120 52% 53% .719Gestational age <32 wk 68% 53% <.001 68% 53% <.001Birth weight <1500 g 71% 50% <.001 70% 50% <.001Use of plastic bag/wrap 61% 59% .228 54% 55% .564Use of cap 77% 79% .190 65% 77% <.001

PPV with cold air at DR 58% 48% <.001 57% 46% <.001Endotracheal intubation 36% 20% <.001 34% 20% <.001Hypothermia at 5 min - - - 70% 22% <.001Transport incubator <35C - - - 25% 20% .025Transport on O2 /CPAP/MV - - - 81% 68% <.001NICU admission >30 min - - - 43% 44% .687

O 2  /CPAP/MV  , free-flow oxygen or continuous positive airway pressure or mechanical ventilation;  PPV  , positive pressure ventilation.

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heated gases from birth until NICU admission, and use of 

transport incubator with adequate temperature control. Itshould be noted that these practices must be considered forpreterm infants with gestational age of 29-33 weeks, becausethis study shows a high frequency of hypothermia 5 minutesafter birth and at NICU admission in this group of patients.

Environmental cold temperature has been associated with

higher odds of hypothermia at NICU admission in preterminfants; however, the ideal DR temperature is unknown. Kno-bel et al7 performed a post-hoc analysis of preterm infantswith gestational age<29 weeks under radiant heatersrandom-ized to receive or not receive polyurethane bags and showed

that room temperatures $26C were associated with higheradmission temperatures in both the intervention and controlgroups. According to Jia et al,8 an increase in the room tem-perature to an average of 25.1C from a control room temper-ature of 22.5C was associated with a 0.5C higher meanNICU admission rectal temperature and a decrease in the

incidence of hypothermia in preterm infants with gestational

age#32 weeks who were warmed under radiant heaters. Thepresent study provides further evidence to support the main-tenance of DR temperatures at$25C because the odds of hy-pothermia at 5 minutes after birth and at NICU admissionwere 2.13 and 1.44 times greater, respectively, when the

room temperature was below this threshold.A newly born infant’s body temperature is associated with

maternal temperature9; in fact, maternal fever and/or hyper-thermia has been associated with high neonatal body temper-atures.10 It is intuitive to assume that maternal hypothermia

would conversely be associated with neonatal hypothermiasoon after birth, but this association has not been demon-

strated consistently. We show that maternal hypothermia

prior to delivery nearly doubles the chance that a newly borninfant will present a body temperature <36C at 5 minutes af-terbirth, indicating that maternal thermal care is an importantmeasure for the prevention of neonatal hypothermia.

In the present study, the use of a plastic bag/wrap indepen-

dently decreased the chance of hypothermia at 5 minutes afterbirth by 47%, and the use of cotton cap decreased the chanceof hypothermia at NICU admission by 45%. A Cochrane Re-view article3 indicates that the use of plastic bag or wrap soonafter birth in preterm infants with gestational age <28 weeks

decreases the likelihood of body temperature <36.0C at

NICU admission by 34% (OR 0.66, 95% CI 0.51%-0.84%).In the literature, the efficacy of cap use to decrease h y pother-mia in newly born preterm infants is controversial.3 A ran-domized clinical trial of 96 preterm infants born at agestational age <29 weeks showed similar axillary tempera-

ture at NICU admission when patients under a radiant heaterreceived only a polyethylene cap (36.1C    1.4C) or onl y apolyethylene occlusive skin wrapping (35.8C    1.6C).11

A study by the Eunice Kennedy Shriver  National Institute of Child Health and Human Development Neonatal Network that included 9565 preterm infants born between 22 and 28

weeks’ gestation showed that 67% required ventilation by 

endotracheal tube at birth.12

Among preterm neonates whodo not need resuscitation, respiratory stabilization withnoninvasive continuous positive airway pressure is increas-ingly applied in the DR.13 However, the warming and humid-ification of inspired gases for invasive and noninvasive

ventilation in neonates are not routine for neonatal resusci-tation.14 In the present study, all of the patients who receivedany respiratory support in the DR and during transport to theNICU received cold humidified air. The use of positive pres-sure ventilation with cold air in the DR and at transport

increased the chance of hypothermia at NICU admissionby 1.40-fold (95% CI 1.03-fold to 1.88-fold) and 1.51-fold

(95% CI 1.08-fold to 2.13-fold), respectively. Te Pas et al

15

Table II.  Maternal and neonatal characteristics of preterm infants according to early neonatal mortality 

Early neonatal death

Present(n = 109)

Absent(n = 1655)   P  value

Maternal age <20 y 19% 20% .900Prenatal care $6 visits 30% 46% .002

Maternal hypertension 38% 34% .398Peripartum infection 23% 19% .301Multiple gestation 15% 23% .046 Antenatal steroids 59% 69% .026

Cesarean delivery 62% 69% .127Male sex 64% 52% .010Gestational age <28 wk 69% 15% <.001Birth weight <1000 g 78% 20% <.001Small for gestational age 35% 28% .1411-min Apgar score 0-3 53% 19% <.0015-min Apgar score 0-6 36% 11% <.001Hypothermia at NICU admission 72% 49% <.001

SNAPPE II >40 64% 10% <.001Respiratory distress syndrome 88% 57% <.001 Air leaks 18% 4% <.001Persistent ductus arteriosus 28% 26% .649

Intraventricular hemorrhage III/IV 21% 4% <.001Culture-proved sepsis 10% 9% .735

Necrotizing enterocolitis 2% 2% .699

SNAPPE II , Score for Neonatal Acute Physiology, Perinatal Extension, Version II.

Table III.  Logistic regression analysis for independent variables associated with the main study outcomes

Outcome OR (95% CI)

Hypothermia 5 min after birthDR temperature <25C 2.13 (1.67-2.28)Gestational age <32 wk 2.01 (1.51-2.68)Maternal hypertension 2.00 (1.55-2.59)

Maternal temperature at delivery <36C 1.93 (1.49-2.51)Use of plastic bag/wrap 0.53 (0.40-0.70)

Hypothermia at NICU admissionHypothermia 5 min after birth 7.45 (5.70-9.73)Maternal hypertension 1.77 (1.34-2.33)Transport on O2 /CPAP/MV 1.51 (1.08-2.13)DR temperature <25C 1.44 (1.10-1.88)PPV with cold air in the DR 1.40 (1.03-1.88)

Use of cap 0.55 (0.39-0.78)Early neonatal death

Gestational age <28 wk 7.77 (4.87-12.41)Respiratory distress syndrome 2.40 (1.28-4.51)5-min Apgar score 0-6 1.87 (1.17-3.00)Male sex 1.84 (1.19-2.85)Hypothermia at NICU admission 1.64 (1.03-2.61) Antenatal steroids 0.59 (0.38-0.91)

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analyzed 2 cohorts of preterm infants born at #32 weeks of gestational age. In the first period, respiratory support frombirth to NICU admission was performed with cold air, and

the mean rectal temperature at admission was 35.9C  

0.6C. In the second period, heated and humidified gas wasintroduced for respiratory support, and admission tempera-ture increased to 36.4C    0.6C. These findings suggest thatthe delivery of heated humidified gases in the DR and duringneonatal transport may play an important role in decreasing

the frequency of hypothermia after birth.The studies that provide evidence of the association be-

tween hypothermia at NICU admission and neonatal mortal-ity are either retrospective or secondary analyses of datacollected to evaluate other primary outcomes. In a Malaysian

VLBW study group with 868 patients, the chance of hospitalmortality was 1.26 times (95% CI 1.06-1.50 times) greater f or

infants with body temperature <36.5C at NICU admission.16

The Epicure study, which included 811 neonates born at <25weeks, showed that body temperature <35C at NICU admis-sion increased the chance of  hospital death by 1.72-fold (95%

CI 1.17-fold to 2.56-fold).17 The chance of death rose 1.28-fold (95% CI 1.16-fold to 1.41-fold) for each 1C decreasein temperature at NICU admission in 5277 VLBW infantsadmitted to   Eunice Kennedy Shriver   National Institute of Child Health and Human Development Neonatal Network Centers.1 Miller et al studied 8782 VLBW infants and found

a 1.5-fold (95% CI 1.3-fold to 1.9-fold) increase in the chanceof hospital death for neonates admitted to the NICU withbody temperature <36C.2 Our study, which was prospec-tively designed to verify an association between early neonatalmortality and hypothermia at NICU admission, showed thatthe chance of early neonatal death is 1.64-fold (1.03-2.61)

higher in infants with admission temperatures <36C,adjusted for birth center and for other maternal and neonatalvariables that contribute to early mortality, such as gestationalage, sex, perinatal asphyxia, respiratory distress syndrome,and the absence of antenatal steroid treatment. However, as

noted by Laptook and Watkinson,18 it remains unclearwhether hypothermia at NICU admission is a cause of neonatal mortality or a marker of high patient acuity.

As this was an observational cohort study, the resultsshown here reflect only associations. However, as a carefulprospective observation of practices applied to thermal care

in the daily routine of the studied DRs, it provides a picture

of the magnitude of the problem and the independent pro-tective practices that may decrease hypothermia at 5 minutesafter birth and at NICU admission. Simple interventions,such as maintaining a DR temperature >25C, reducingmaternal hypothermia prior to delivery, using plastic bags/

wraps and caps for the newly born infants, and using warmresuscitation gases, may decrease hypothermia at NICUadmission and improve early neonatal survival.   n

We thank Olga LC Bomfim, MD (Executive Manager of the Brazilian Network on Neonatal Research; supported by the Ministry of Health of Brazil [MS/VIGISUS 1755/2000, MS/FNS 274, FIOCRUZ/PDTSP]),and Cynthia Magluta, MD (Brazilian Network on Neonatal Research

coordinator; Instituto Fernandes Figueira of Fundacao Osvaldo Cruz,Rio de Janeiro, Brazil), for helping with the logistic management of theBrazilian Network on Neonatal Research.

Submitted for publication Jun 17, 2013; last revision received Aug 22, 2013;

accepted Sep 20, 2013.

Reprint requests:Ruth Guinsburg, MD, PhD, Rua Vicente Felix 77,apt 09,CEP

01410-020, S~ao Paulo, SP, Brazil. E-mail:  ruthgbr@netpoint.com.br

References

1.   Laptook AR, Salhab W, Bhaskar B. Neonatal Research Network. Admis-

sion temperature of low birth weight infants: predictors and associated

morbidities. Pediatrics 2007;119:e643-9.

2.  Miller SS, Lee HC, Gould JB. Hypothermia in very low birth weight in-

fants: distribution, risk factors and outcomes. J Perinatol 2011;31(Suppl

1):S49-56.

3.  McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S. Interven-

tions to prevent hypothermia at birth in preterm and/or low birthweight

infants. Cochrane Database Syst Rev 2010;CD004210.

4.   Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L,

Goldsmith JP, et al. Part 11: neonatal resuscitation: 2010 International

consensus on cardiopulmonary resuscitation and emergency cardiovas-cular care science with treatment recommendations. Circulation 2010;

122(16 Suppl 2):S516-38.

5.   Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R.

New Ballard Score, expanded to include extremely premature infants.

J Pediatr 1991;119:417-23.

6.  The International Liaison Committee on Resuscitation. The Interna-

tional Liaison Committee on Resuscitation (ILCOR)–consensus on sci-

ence with treatment recommendations for pediatric and neonatal

patients: neonatal resuscitation. Pediatrics 2006;117:e978-88.

7.  Knobel RB, Wimmer JE Jr, Holbert D. Heat loss prevention for preterm

infants in the delivery room. J Perinatol 2005;25:304-8.

8.   Jia YS, Lin ZL, Lv H, Li YM, Green R, Lin J. Effect of delivery room tem-

perature on the admission temperature of premature infants: a random-

ized controlled trial. J Perinatol 2013;33:264-7.

9.   Lunze K, Bloom DE, Jamison DT, Hamer DH. The global burden of 

neonatal hypothermia: systematic review of a major challenge for

newborn survival. BMC Med 2013;11:24.

10.   Perlman JM. Hyperthermia in the delivery: potential impact on neonatal

mortality and morbidity. Clin Perinatol 2006;33:55-63.

11.   Trevisanuto D, Doglioni N, Cavallin F, Parotto M, Micaglio M,

Zanardo V. Heat loss prevention in very preterm infants in delivery 

rooms: a prospective, randomized, controlled trial of polyethylene

caps. J Pediatr 2010;156:914-7.

12.   Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC, et al.

Neonatal outcomes of extremely preterm infants from the NICHD

Neonatal Research Network. Pediatrics 2010;126:443-56.

13.  Pfister RH, Soll RF. Initial respiratory support of preterm infants: the

role of CPAP, the INSURE method, and noninvasive ventilation. Clin

Perinatol 2012;39:459-81.14.   Farley RC, Gibbons K, Jardine LA, Shearman AD. Effect of flow rate, hu-

midifier dome and water volume on maximising heated, humidified gas

use for neonatal resuscitation. Resuscitation 2013;84:1428-32.

15.  te Pas AB, Lopriore E, Dito I, Morley CJ, Walther FJ. Humidified and

heated air during stabilization at birth improves temperature in preterm

infants. Pediatrics 2010;125:e1427-32.

16.   MalaysianVeryLow Birth WeightStudyGroup. A national study ofrisk fac-

tors associated with mortality in very low birth weight infants in the Malay-

sian neonatal intensive care units. J Paediatr Child Health 1997;33:18-25.

17.   Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkinson AR. The

EPICure study: outcomes to discharge from hospital for infants born

at the threshold of viability. Pediatrics 2000;106:659-71.

18.   Laptook AR, Watkinson M. Temperature management in the delivery 

room. Semin Fetal Neonatal Med 2008;13:383-91.

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Appendix

Additional members of the Brazilian Network on Neonatal

Research include:Universidade Estadual de Campinas/Hospital da Mulher

Prof. Dr. Jose Aristodemo Pinotti: Sergio Tadeu MartinsMarba, MD, PhD, Ana Cristina Pinto, MD, Andrea Eliana

Lovato Cassone, MD, Jamil Pedro de Siqueira Caldas, MD,PhD; Universidade Federal do Maranh~ao/Hospital Univer-

sitario: Marynea do Vale Nunes, MD, Ana Claudia GarciaMarques, MD; Universidade de S~ao Paulo/Hospital dasClınicas de Ribeir~ao Preto: Ana Beatriz Goncalves, MD, Wa-lusa Assad Goncalves Ferri, MD, PhD; Universidade Federaldo Parana/Hospital de Clınicas: Paulyne Stadler Venzon,

MD; Universidade Estadual de Londrina/Hospital Univer-sitario: Angela Sara Jamusse de Brito, MD, Ana Berenice Ri-beiro Carvalho, MD, Maria Rafaela Conde Gonzalez, MD;Faculdade de Medicina de Botucatu da Universidade Estad-ual Paulista: Maria Regina Bentlin, MD, PhD, Glauce Regina

Fernandes Giacoia, MD; Universidade Federal de Uberl^an-dia/Hospital de Clınicas: Daniela Marques de Lima MotaFerreira, MD, Heloısio dos Reis, MD; Universidade Federaldo Rio Grande do Sul/Hospital de Clınicas de Porto Alegre:Renato S Procianoy, MD, PhD.

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