Written by Kimiko Dunbar
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There is a lack of clear guidelines on management of infants with hypothermia and extensive variation in management.
Baby it’s cold outside
This review summarizes current evidence on management of hypothermic young infants (<90 days) presenting to the emergency department (ED). Key points are summarized below:
- What is hypothermia? There is no optimal cutoff, but most ED clinicians use a temperature cutoff of ≤36.0°C to initiate testing.
- Serious bacterial infection (SBI) seems less frequent in babies with hypothermia compared to febrile infants, but rates of invasive bacterial infection (IBI) are the same. HSV can present as hypothermia; AAP recommends that all infants <21 days w/ a hx of hypothermia be considered at risk for HSV.
- Degree of hypothermia is generally of limited utility; however, repeat temperature instability has been linked to increased odds of IBI.
- Younger/premature infants or those with clear respiratory symptoms may be of lower risk for IBI, although we generally need more data in this area.
- History is everything! Asymptomatic infants with incidental hypothermia noted outpatient followed by euthermia in the ED may be at lower risk.
- Evidence for management of hypothermic infants is seriously lacking compared to data regarding febrile infants. More research is needed to generate clinical guidelines specific to hypothermic infants.
How will this change my practice?
A cold neonate is my least favorite thing. Is the baby septic, or do they just need a sweater? I’d be hard pressed not to initiate a septic work-up, because the risk of missing SBI/IBI in a patient who may present subtly is too high. That said, perhaps infants with one isolated, incidental low temperature, who are otherwise well appearing and subsequently euthermic, can be treated differently. I’m not sure I’m bold enough to forego a work-up in an infant in that setting or that the data supports that. Perhaps we could be more comfortable with a watch and wait approach after shared decision-making with a family who declines invasive testing, or if there’s a clear alternate explanation (i.e. very cold outside, unbundled infant under phototherapy, etc).
Source
Current Evidence on the Care of Young Infants With Hypothermia in the Emergency Department. Pediatr Emerg Care. 2025 Feb 1;41(2):146-151. doi: 10.1097/PEC.0000000000003259. PMID: 39883795
