NICU Temperature Regulation: Best Practices for Your Team

From the moment of birth, thermoregulation is critical for all newborns, especially those born prematurely. A historic study published in the journal Pediatrics in 1958 was the first to link improvements in neonatal mortality to incubator care.1 Since then, other studies and clinical observations have found that both hypothermia (defined as a body temperature below 36.5°C) and hyperthermia (defined as a body temperature above 37.5°C) are detrimental to newborn health.

Despite modern technology, temperature regulation in the neonatal intensive care unit (NICU) remains challenging. Quality improvement efforts to manage admission temperatures in preterm and term infants have been shown to be effective, according to research published in the Journal of Pediatric Nursing Specialists.2 Continuous training of employees is critical to success.

Best Practices for NICU Temperature Regulation

Although managing admission temperatures can be challenging for many reasons, ongoing NICU temperature regulation requires attention and expertise. An incubator bed that uses a computer algorithm to adjust the baby’s temperature based on temperature measured by a skin probe (called servo control or “baby mode”) does provide a more stable baby temperature, but it also requires more and different expertise Knowledge nurse. There are several practices that can affect this for better or worse. The following are some best practices for continuously regulating NICU temperature.


Do not place the temperature probe under the heater during preheating. This helps heat the probe before attaching it to the baby and can cause false high temperature readings. This may delay proper output of heat, leading to a risk of hypothermia.

Probe placement

The probe must maintain full contact with the baby’s skin and be covered with a reflective patch. Reflective patches are used to reflect heat so that it is not focused directly on the probe, which also helps prevent inaccurate readings.

Place the probe so that the baby does not lie on it. Placing the probe under the baby’s body may cause the probe to “insulate” and obtain higher temperature readings. This in turn leads to reduced heat output and the potential for hypothermia.

Various studies have looked at probe placement, but most recommendations come from practice guidelines and manufacturer recommendations, according to research published in Advances in Neonatal Care.3 A Cochrane review recommended the abdominal wall as the preferred site for accurate temperature maintenance in servo-controlled settings.4 Another study in Advances in Neonatal Care of a small sample of 12 premature infants found that axillary and abdominal temperature probe placement were comparable and effective in maintaining thermoregulation.5 Finally, a third study, published in Advances in Neonatal Care, found that probe-based skin temperature readings of the abdomen, flank, and axilla were all comparable and enabled effective thermoregulation.6

The last two findings conflict with the first Advances in Neonatal Care study, which warned against placing probes in areas of brown fat — which is abundant in late pregnancy and located in the armpit area. Axillary placement may be more effective in premature infants, especially those with very low birth weight, because brown fat is less likely to be present.

All literature agrees on avoiding bony protrusions that may cause skin breakdown and avoiding placing the probe underneath the infant. Therefore, many caregivers prefer using underarm placement because the infant can be transferred from prone to supine without moving the temperature probe. Others recommend placing two skin probes: one on the abdomen and one on the side. Using a probe inserted into the incubator bed helps avoid moving the baby too often.

Probe management

Caregivers should ensure that the incubator bed is changed to “air mode” when removing the probe for routine replacement or performing other tasks such as bathing an infant. The bed in infant mode will respond to probe removal by increasing heat output.

Infants are often held with a probe in place for temperature monitoring. In this case, the bed should be in air mode before removing the baby. This allows the bed to maintain the air temperature at the temperature the baby has previously experienced. If in baby mode, the bed will continue to heat based on the baby’s body temperature while being held.

Maintain a neutral thermal environment

The neutral thermal environment (NTE) refers to the temperature range that maintains the baby’s body temperature. To create an ideal NTE, their body temperature must stabilize within normal ranges without increasing metabolic demands and requirements for oxygen and/or glucose.

The ideal temperature range is not the same for all newborns. Factors to consider when calculating NTE include:

  • gestational age
  • birth weight
  • Actual age
  • humidity
  • Use of positioning devices
  • any clothes or swaddles

Gestational age and date of birth are two key data points needed to determine starting temperature. However, if NTE has been established and the infant is being transferred, for example from one bed to another, the established temperature should be used.

The calculated NTE is a good starting point when preheating the bed. Once the baby is placed in the bed and the bed is in baby mode and the temperature probe is installed, the ideal ambient temperature is ensured. It is important to ensure that the bed does not overheat while waiting to be admitted to hospital or during other activities. The bed is very effective at keeping the baby warm, but it does not cool the baby.

Cope with temperature changes

Axillary temperature measurement is the most commonly used method in the NICU. However, several factors may affect the accuracy of these temperature readings, including the baby’s position (measure the armpit when the baby is lying down, or measure the armpit if the baby is lying down with their arms on their head), the presence or absence of the baby’s body for the temperature measurement. Bundling/swaddling and changing of instruments. It is important to consider not only temperature measurements at a single point in time, but also temperature trends.

This is especially important when caring for a baby in the Giraffe OmniBed’s baby mode. Skin temperature probe readings should be recorded at predetermined time points (usually every three to six hours) along with the ambient temperature and the infant’s reference temperature. When the bed receives accurate data from the temperature probe, it is able to maintain the baby’s body temperature within the desired range.

If the baby needs more support to maintain body temperature and the body and skin temperatures are stable but the ambient temperature is rising, it may indicate an infection or other abnormality. Observing temperature trends over time can provide valuable information in the care of sick and premature infants.

It is important to note that skin temperature and armpit temperature may not match. An assessment of trends can help assess changes. For example, measuring armpit temperature and recording skin temperature two or three times may reveal a difference of 0.5 degree or more. This difference is usually consistent and axillary temperature can be measured with frequent observation without disturbing the baby. This correlation should be measured each time the temperature probe is moved to a new location, as the degree of difference may change.

Instruments designed to measure actual body temperature through any means, whether axillary, eardrum or temporal, often use predictive algorithms. This predictive algorithm can shorten the actual duration of contact. Based on the temperature rise within seconds of contact, the actual temperature can be predicted. This means there is a difference in the temperature reading compared to a mercury in glass thermometer. Temperature measurement ranges comply with valid standards, but temperature measurements outside the expected range should be verified by repeating measurements and observing temperature trends over time.

The Giraffe OmniBed has two different types of thermal algorithms that are deployed when the deviation from the set point is +/- 0.5 degrees Celsius. These are called cascade control or proportional control algorithms. A cascade control algorithm is used to maintain the baby’s body temperature more gradually to avoid exceeding the control point. A proportional control algorithm delivers more or less heat to maintain the baby’s body temperature at the desired temperature. If the temperature rises or falls quickly, adjust the heat accordingly.

Transition to air control

The trend screen on the bed monitor provides a useful reference for all temperature data points, including the favorable temperature range where stable baby body temperature is detected. This information can help determine the ideal ambient temperature range and can help inform whether the baby is ready to transition to air control and the appropriate air temperature during the transition.

Modern technology provides infant caregivers with the tools needed to complete NICU temperature regulation. Following best practices for probe management and temperature recording can help provide the best outcomes for the babies in your care.

refer to:

  1. Silverman W, Fertig J, Berger A. Pediatrics. 1958 Nov;22(5):876-886. doi:10.1542/peds.22.5.876
  2. Donnellan D, Moore Z, Patton D, O’Connor T, Nugent L. Journal of Pediatric Nursing Specialists. 2020;25(2). doi:10.1111/jspn.12286
  3. Joseph RA, Derstine S, Killian M. Advances in neonatal care. 2017;17(2):114-122. doi:10.1097/anc.00000000000000369
  4. Sinclair J. Servo control for maintaining abdominal skin temperature at 36°C in low birth weight infants. Cochrane Database of Systematic Reviews. doi.org/10.1002/14651858.CD001074
  5. National Association of Neonatal Nurse Practitioners. Research abstracts from the 2016 NANN Research Summit. Advances in neonatal care. 2016;16(3):E3-E12. doi:10.1097/anc.0000000000000287
  6. Schafer D, Boogaart S, Johnson L, et al. Comparison of skin sensor temperature and axillary temperature in neonates. Advances in neonatal care. 2014;14(1):52-60. doi:10.1097/anc.00000000000000027

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