Abstract
Background
Early postnatal hypothermia (EPH) remains a significant clinical concern in critically ill transported neonates. A previous regional study reported an alarming EPH incidence rate of 82.1%, with wide variation across delivery facilities, underscoring the urgent need for quality improvement (QI) in early body temperature management. This study aimed to reduce the percentage of EPH in critically ill transported newborns by 20% to 25% within 1 year.
Methods
A standardized, evidence-based thermal care bundle and comprehensive staff training were implemented using multiple Plan-Do-Study-Act (PDSA) cycles starting May 1, 2023. Neonates transported from six referral hospitals in the pre-QI phase (January 1, 2022–April 30, 2023) were compared with those in the intervention period (May 1–December 31, 2024). Clinical characteristics, EPH incidence, and early outcomes within 7 days were analyzed.
Results
A total of 1,247 neonates transferred from six referral hospitals were included, with 457 newborns in the pre-QI group and 790 in the post-QI group. Baseline characteristics were similar except for higher maternal intrapartum fever in the post-QI group (1.0% vs. 3.1%, P=0.02). Following implementation of the thermal management protocol, the incidence of EPH significantly decreased from 82.1% to 59.0% (adjusted P<0.001). A marked reduction in severe intraventricular hemorrhage (IVH) (grade ≥3) was observed, from 2.6% to 0.2% (adjusted P=0.002). No significant difference was observed in mortality, pulmonary hemorrhage, shock, hypoglycemia, disseminated intravascular coagulation (DIC), nor invasive mechanical ventilation use.
Conclusions
Implementing a standardized thermal management protocol substantially reduces EPH incidence in critically ill transported neonates. Avoiding EPH is beneficial for improving short-term outcomes.
Keywords: Hypothermia, critically ill neonates, transport, quality improvement (QI)
Highlight box.
Key findings
• Implementation of a standardized, region-wide thermal management protocol, including a thermal care bundle and staff training, significantly reduced early postnatal hypothermia (EPH) incidence in critically ill transported neonates from 82.1% to 59.0%.
• This reduction was associated with a notable decrease in the incidence of severe (grade ≥3) intraventricular hemorrhage (IVH), from 2.6% to 0.2%.
What is known and what is new?
• EPH is highly prevalent and associated with increased morbidity (including IVH) and mortality in critically ill newborns. Significant variation exists in thermal care practices across different clinical settings, highlighting a major target for quality improvement (QI).
• This multicenter QI initiative demonstrates that a standardized, evidence-based protocol can be effectively implemented across a network of hospitals to substantially reduce EPH, even in a high-risk population of transported neonates. It further provides evidence linking this improvement to a significant decrease in severe IVH, a major neurological complication.
What is the implication, and what should change now?
• Regional collaborative efforts focused on standardizing thermal management are effective and should be promoted to improve neonatal outcomes. However, sustaining gains requires ongoing reinforcement.
• To achieve lasting improvement, clinical practice should adopt structured, periodic booster training for staff, combined with real-time audit and feedback mechanisms. Future efforts should also focus on enhancing protocol adherence across all centers and integrating more advanced thermal support technologies.
Introduction
The early postnatal period, particularly the first 12 hours of life, constitutes a critical window during which newborns are highly reliant on external thermal support (1). Although perinatal care has advanced considerably, preterm infants—who now represent the majority (72.9%) of critically ill neonates requiring transport in our service area—remain exceptionally vulnerable. Their physiological and organ immaturity predisposes them to substantial heat loss and impaired thermogenesis, often leading to hypothermia.
Admission temperature is a well-established and strong predictor of morbidity and mortality in neonates across all gestational ages, with an exponential rise in mortality risk as temperature declines (2-5). For this study, neonatal hypothermia is defined as an axillary temperature <36.5 ℃ recorded as the lowest measurement within the first 2 hours after birth. Despite the long-standing availability of international thermal care guidelines since the 1960s, preventing hypothermia in preterm infants remains an ongoing global challenge (6-8), with reported prevalence ranging from 30% to 88% across different care settings (8-10).
Beyond prematurity, key clinical indications for neonatal transport frequently encompass respiratory distress, sepsis, surgical emergencies, severe asphyxia, and hemodynamic instability. Neonatal emergency transport poses unique challenges shaped by local healthcare infrastructures (11). As the regional children’s hospital and neonatal critical care center, our institution leads all neonatal transports in the region via ground ambulance, with a maximum response time of 2 hours to reach referring facilities. While in-transit thermal management protocols were already standardized in pre-warmed transport incubators, the quality improvement (QI) focus was placed on improving pre-transport thermal care across all birthing facilities in the region. This was implemented through a structured outreach program including training in the neonatal resuscitation program (NRP) and a thermal care bundle, supported by a regional perinatal data system that provides feedback on outcomes and identifies gaps in thermal management at referring centers. Evidence-based prevention of admission hypothermia relies on bundled, multimodal interventions. To address the gap in regionally coordinated care, we conducted a Delphi expert consultation with senior neonatologists to develop a standardized, evidence-based thermal management protocol.
In our region, data from January 2022 to April 2023 showed an alarming early postnatal hypothermia (EPH) rate of 82.1%, highlighting wide variability in thermal management practices (12-14), particularly in general hospitals. While previous QI initiatives have mainly focused on individual delivery hospitals, leaving a gap in evidence regarding standardized, regionally coordinated interventions led by neonatal transport centers to improve consistency of care (15-17).
To address this gap, this study implemented a standardized cluster-based management process, including targeted training and continuous feedback. Following the Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) framework, our specific and measurable objective was to reduce the incidence of admission hypothermia (<36.5 ℃) in transported neonates from a baseline of 82.1% to below 60% within 12 months of implementation across the entire referral network.
Methods
Setting
This QI project was conducted at the Neonatology Department of Shanghai Children’s Medical Center, the regional tertiary referral center for high-risk neonates. Critically ill neonates were defined as newborns within the designated service area who required immediate transfer to the Shanghai Children’s Medical Center neonatal intensive care unit (NICU) due to either: (I) the need for life-sustaining support (e.g., mechanical ventilation, vasoactive medications); or (II) high-risk clinical conditions including prematurity, sepsis, surgical emergencies, severe asphyxia, birth trauma, or other diagnoses necessitating NICU-level care. Exclusion criteria consisted of delivery facilities with an annual neonatal transfer volume of fewer than 10 cases, infants who met the criteria for therapeutic hypothermia, and cases with >20% missing data for key variables.
Intervention and rationale
Baseline data from January 2022 to April 2023 demonstrated an incidence of EPH of 82.1%, with notable variability across delivery hospitals, especially general hospitals. In collaboration with multiple delivery facilities, the critical care team developed a key driver diagram to identify influencing factors and potential interventions. The key drivers for improvement were established based on a comprehensive review of previous outcomes, analysis of the complete thermal management cluster protocol, thorough literature reviews, and multidisciplinary discussions. A multidisciplinary QI team, including neonatologists, pediatricians, and transport specialists, used a key driver diagram (Figure 1) to identify factors contributing to EPH and to guide intervention development. Three primary drivers were targeted: improving thermal awareness among delivery facility staff, implementing standardized thermal management protocols across all delivery units, and enhancing coordination and real-time feedback mechanisms between tertiary neonatal centers and delivery facilities. A standardized, evidence-based thermal management protocol [double RHBT process; RHBT is a mnemonic acronym representing the four key components of our thermal management bundle; RR: room (maintained at 25–26 ℃) & radiant heating table (servo-controlled, with initial temperature set based on gestation); HH: heat (≥30 min pre-warming) & head (drying with pre-warmed towel and applying a pre-heated cap); BB: body (drying and wrapping/swaddling based on gestation) & body weight (weighing on pre-warmed surface, <30 seconds exposure); TT: temperature (axillary measurement within 30 min, every 15–30 min until stable normothermia) & together (cluster care to minimize exposure); Figure 2] was developed (6,8,15,18).
Figure 1.
A key driver diagram. EPH, early postnatal hypothermia; NICU, neonatal intensive care unit; OB, obstetric.
Figure 2.
Evidence-based active warming bundle for neonatal hypothermia (double RHBT = RRHHBBTT; RHBT is a mnemonic acronym representing the four key components of our thermal management bundle: room & radiant heating table, heat & head, body & body weight, and temperature & together). BW, birthweight; EHR, electronic health record; ELBW, extremely low birth weight; GA, gestational age; OR, operating room.
Implementation strategy and Plan-Do-Study-Act (PDSA) cycles
The intervention began on May 1, 2023, and was implemented in two phases:
❖ Action phase (May 2023–April 2024): comprehensive training, competency assessments, and immediate feedback were provided to obstetricians, midwives, neonatologists, and transport teams. Temperature monitoring forms (Appendix 1) were completed for each transfer and shared monthly with referring hospitals to identify barriers and address deviations from the protocol. The identified barriers, their frequencies, and the corresponding strategies implemented to address them are outlined as follows: firstly, equipment availability posed an initial challenge, with approximately 30% of delivery units lacking one or more essential thermoregulation items. The most frequently missing equipment included temperature probes (14.3%), followed by warming mattresses (7.6%), hats (7.3%), and plastic wraps (7.2%). This was addressed by coordinating with the relevant units to facilitate timely procurement and allocation. Secondly, issues of thermoregulation protocol adherence were observed. Non-compliance with the pre-warming temperature standard for extremely low birth weight (ELBW) infants occurred in 6.1% of cases. This was improved by placing a reference card specifying birth weight-based temperature requirements on each warmer and implementing a double-check protocol involving both the midwife and neonatologist. Additionally, other procedural gaps were identified, including omission of plastic wrapping for infants under 32 weeks (4.6%) and delayed cord clamping (11.5%). To address these gaps, targeted education and training sessions were provided for midwives and obstetricians. Finally, temperature monitoring remained suboptimal, with about 4.8% of cases not achieving the required initial and 30-min follow-up measurements. To ensure compliance, documentation of both temperature readings was made a compulsory field in the medical record.
❖ Sustain phase (May 2024–December 2024): monthly monitoring was conducted to maintain adherence and address challenges identified in implementation.
Multiple PDSA cycles were conducted throughout both phases to iteratively test, refine, and standardize interventions before full-scale implementation.
Definition and data collection
EPH was defined as the lowest body temperature recorded within the first 2 hours after birth. The first temperature measurement was taken within 30 min after birth. Subsequent measurements were performed every 15–30 min. If hypothermia was detected, the interval for the next measurement was appropriately shortened based on its severity. Data collection continued until 2 hours postpartum or until the arrival of the regional transport team. In accordance with World Health Organization (WHO) criteria, hypothermia was defined as a body temperature below 36.5 ℃ (19). Pulmonary hemorrhage was diagnosed based on the presence of fresh blood secretion in the endotracheal tube and reduced radiolucency on chest X-ray (20). Neonatal shock was defined operationally by meeting both of the following criteria: (I) a documented clinical diagnosis of shock by the treating medical team, based on a comprehensive assessment consistent with the framework by Schwarz et al. (21) (including evaluation of perfusion, vital signs, and laboratory markers); and (II) the subsequent initiation of specific anti-shock therapy, defined as the administration of vasoactive medications (e.g., dopamine, epinephrine) or active fluid resuscitation for circulatory support Hypoglycemia was defined as a blood glucose level below 2.2 mmol/L (22,23). Severe intraventricular hemorrhage (IVH) was classified as grade ≥3 according to Papile’s criteria (24). Disseminated intravascular coagulation (DIC) was defined by the presence of compatible clinical features supported by laboratory evidence indicating activation of coagulation and fibrinolysis, along with depletion of anticoagulant proteins (25).
The primary outcome was the incidence of EPH. Balancing measures included hyperthermia (defined as an admission body temperature >37.5 ℃), early mortality (within 7 days after birth), pulmonary hemorrhage, shock, hypoglycemia, severe IVH, DIC, and the use of invasive mechanical ventilation. Abnormal body temperatures are typically rechecked within 15 min. Patients were considered within the normothermic range if their temperature was measured between 36.5 and 37.5 ℃. Temperature monitoring forms documented any omitted measurements and were reviewed in case of hypothermia. Other prenatal and postnatal characteristics were collected from electronic medical records.
Ethical considerations
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Shanghai Children’s Medical Centre (approval No. SCMCIRB-K2023052-1) and informed consent was obtained from all parents or legal guardians prior to participation. All participating hospitals were informed of and agreed to the study. Patient data were anonymized throughout the research process to ensure confidentiality.
Statistical analysis
Continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were presented as numbers/percentages and were compared using Chi-squared or Fisher’s exact tests, as appropriate. Adjusted P values for the primary outcome and balancing measures were analyzed using a multiple logistic regression model. Changes in monthly outcome measures, expressed as the percentages of newborns with EPH, were also assessed. All data management and statistical analyses were conducted using R (version 4.5).
Results
A total of 1,406 critically newborns were transported from 15 participating hospitals between January 2022 and December 2024 in the designated service area. After excluding nine low-volume centers (<10 annual transfers), 1,267 neonates from six referral hospitals were eligible. Seventeen neonates with indications for therapeutic hypothermia indications and three with incomplete data were further excluded, leaving 1,247 infants for analysis: 457 in pre-QI phase and 790 in post-QI phase (Figure 3).
Figure 3.
Diagram of the study population. QI, quality improvement.
Baseline characteristics of the two groups are summarized in Table 1. A significant difference was observed in the rate of maternal fever within 24 hours before delivery (1.0% vs. 3.1%, P=0.02) between the pre-QI and post-QI groups. No significant differences were found in other hypothermia-related risk factors.
Table 1. Demographic information study population before and after the QI program.
| Characteristics | Pre-QI (n=457) | Post-QI (n=790) | P value |
|---|---|---|---|
| Maternal characteristics | |||
| Maternal age (years) | 32.59±4.43 | 32.60±4.86 | 0.97 |
| Assisted reproductive technology | 64 (14.0) | 138 (17.4) | 0.11 |
| Multiple pregnancy | 110 (24.1) | 205 (25.9) | 0.46 |
| Maternal diabetes | 102 (22.3) | 207 (26.2) | 0.13 |
| Maternal hypertension | 141 (30.8) | 248 (31.3) | 0.84 |
| Placental abruption | 11 (2.4) | 25 (3.1) | 0.44 |
| Placenta previa | 28 (6.1) | 35 (4.4) | 0.19 |
| Maternal fever within 24 hours before delivery | 5 (1.0) | 25 (3.1) | 0.02* |
| Antenatal corticosteroids | 273 (59.7) | 452 (57.2) | 0.38 |
| Premature rupture of membranes (>18 hours) | 57 (12.4) | 96 (12.2) | 0.87 |
| Infant characteristics | |||
| Gestational age (weeks) | 33.76±3.1 | 33.90±3.3 | 0.48 |
| Birth weight (g) | 2,163.0±734.46 | 2,183.49±790.48 | 0.64 |
| Male | 249 (54.4) | 428 (54.1) | 0.92 |
| Cesarean section | 368 (80.5) | 625 (79.1) | 0.55 |
| 1 min Apgar score ≤3 | 8 (1.8) | 21 (2.7) | 0.31 |
| 5 min Apgar score ≤5 | 5 (1.0) | 11 (1.4) | 0.65 |
| Z-score | −0.18±0.94 | −0.26±0.85 | 0.12 |
| Delivery room intubation | 120 (26.2) | 231 (29.2) | 0.26 |
| Other | |||
| Transfer duration (min) | 68.41±31.7 | 68.09±32.3 | 0.86 |
| Winter | 107 (23.4) | 216 (27.3) | 0.13 |
Data are presented as mean ± SD or n (%). Transport indications for the study population included: (I) need for life-sustaining support (e.g., mechanical ventilation, vasoactive medications); (II) high-risk clinical conditions, such as prematurity, sepsis, surgical emergencies, severe asphyxia, birth trauma, or other diagnoses requiring NICU-level care. *, P<0.05. NICU, neonatal intensive care unit; QI, quality improvement; SD, standard deviation; Z-score, weight-for-gestational age and sex.
Compared to the pre-QI group, the post-QI group showed a significant reduction in the overall hypothermia incidence (82.1% vs. 59.0%, P<0.001; Table 2). This reduction remained significant after adjusting gestational age and maternal fever within 24 hours before delivery (adjusted P<0.001). Monthly EPH rates demonstrated a clear downward trend over time, with the first month after QI implementation showing an immediate decrease below the centerline on the control chart (Figure 4).
Table 2. Primary outcome and balancing measures.
| Outcome within 7 days after birth | Before QI | After QI | P value | Adjusted P value† |
|---|---|---|---|---|
| Hypothermia at admission | 375 (82.1) | 466 (59.0) | <0.001* | <0.001* |
| Mortality | 3 (0.6) | 6 (0.7) | >0.99 | 0.72 |
| Pulmonary hemorrhage | 0 (0.0) | 2 (0.2) | >0.99 | 0.97 |
| Shock | 20 (4.3) | 30 (3.7) | 0.62 | 0.71 |
| Hypoglycemia | 22 (4.8) | 32 (4.1) | 0.52 | 0.59 |
| Severe IVH (grade ≥3) | 12 (2.6) | 2 (0.2) | <0.001* | 0.002* |
| DIC | 7 (1.5) | 6 (0.7) | >0.99 | 0.24 |
| Invasive mechanical ventilation | 148 (32.4) | 287 (36.3) | 0.16 | 0.09 |
Data are presented as n (%). *, P<0.05. †, adjusted gestational age and maternal fever within 24 hours before delivery by multiple logistic models. DIC, disseminated intravascular coagulation; IVH, intraventricular hemorrhage; QI, quality improvement.
Figure 4.
P-chart of the rate of EPH, with upper and lower control limits and a calculated centerline. On this graph, lower is better. The onset of baseline (January 2022 to April 2023), action (May 2023 to April 2024), and sustain phases (May 2024 to December 2024) have been annotated. The rate of EPH decreased from 82.1% during the baseline phase to 57.1% in the action phase, with a slight rebound to 60.9% in the sustain phase. CI, control limit; EPH, early postnatal hypothermia; LCL, lower control limit; UCL, upper control limit.
No episodes of hyperthermia were observed during the entire post-QI period. Analysis of short-term outcomes showed a marked reduction in the incidence of severe IVH, from 2.6% to 0.2% (P<0.001; adjusted P=0.002). However, no significant differences were found in early mortality, pulmonary hemorrhage, shock, hypoglycemia, DIC, nor the rate of invasive mechanical ventilation before and after QI implementation (Table 2).
Tables S1,S2 present the pre- and post-intervention incidence of key preterm complications, stratified by gestational age (<28, 28–31+6, 32–36+6, and ≥37 weeks). Following the QI initiative, the incidence of hypothermia did not decrease significantly in infants born at <28 weeks. In contrast, a marked reduction in hypothermia was observed in all other gestational age groups. Notably, the incidence of severe IVH declined significantly among early preterm infants (<32 weeks) after QI implementation.
Discussion
This multicenter QI initiative has significantly reduced the incidence of EPH among critically ill transported neonates, decreasing it from 82.1% in the pre-QI epoch to 59%. Following the implementation of a standardized thermal management, we also observed a notable decrease in severe IVH (from 2.6% to 0.2%), with no cases of iatrogenic hyperthermia recorded. These findings highlight the effectiveness of region-wide, workflow-integrated interventions combined with systematic staff training in improving the thermoregulatory practices.
Our results align with previous QI studies, which demonstrated that behavior-focused strategies and standardized protocols can lead to substantial gains of thermal care in diverse care settings (16). Notably, this improvement was achieved despite a rising trend in maternal intrapartum fever—a factor that could potentially exacerbate neonatal complications and increase thermoregulatory challenges. The protocol’s effectiveness under such conditions underscores its clinical utility and robustness. However, monthly monitoring revealed a recurrence of hypothermia starting at 3 months post-intervention, suggesting that the initial benefits of training may diminish over time without reinforced support. The observed increase in EPH rate during the sustain phase is likely attributable to two main factors: first, the influx of new medical staff in July, who initially lacked sufficient training, awareness, and hands-on experience in thermal management; and second, the transition during this phase from the comprehensive training, competency assessments, and immediate feedback provided in the action phase to monthly monitoring only, which may have reduced the intensity of continuous quality reinforcement. We subsequently observed a decline in EPH rate in October 2024, which coincided with the annual NRP training workshop—a routine, non-QI activity conducted regularly in previous years. As thermal care is emphasized as a key component of NRP training, which likely reinforced best practices and contributed to the improved outcomes, further illustrating the importance of sustained educational support in maintaining thermal management standards. This pattern aligns with observations from other educational interventions in healthcare, where periodic refreshers are often necessary to sustain compliance (26). To address this, we recommend introducing structured booster sessions every 3 months, combined with real-time audit and feedback mechanisms. Real-time audit involved the immediate completion of a standardized checklist upon the transport team’s arrival at the referring center to assess equipment, protocol adherence, and immediate thermal management issues. Feedback mechanisms were facilitated by uploading all neonatal temperature data and completed checklist assessments to a centralized, accessible neonatal transport platform, allowing all participating centers to review performance data and identified gaps. Such multi-modal reinforcement has proven effective in maintaining long-term adherence in similar settings.
Numerous studies have established a clear association between hypothermia and increased neonatal mortality (2,4,5,10,27). A systematic review by the International Liaison Committee on Resuscitation [2015], which included 36 observational studies [1964–2014], confirmed that admission hypothermia is significantly associated with higher mortality among non-asphyxiated newborns (28). In the present study, however, the adjusted odds ratio for mortality did not differ significantly between the pre- and post-intervention periods. This may be due to the predominance of mild hypothermia cases in our cohort.
IVH is mostly prevalent in preterm neonates but also occurs in term neonates, contributing substantially to neonatal mortality (29-31). Severe IVH is associated with short-term and long-term neurodevelopmental sequelae, including cerebral palsy, cognitive impairments and attention deficit hyperactivity disorder (30). Globally, IVH incidence rates range from 3.70% to 44.68% (30), with one study reporting an overall incidence of 36.2%, of which 7.1% were severe cases (29). Importantly, approximately 50% of IVH cases occur within the first 24 hours after birth, and 20–50% may present without obvious clinical signs (30). Extensive evidence confirms that admission hypothermia in preterm infants is correlated with IVH (10,32,33). A recent systematic review further established significant associations between hypothermia in very preterm infants and elevated risks of IVH (32). Consistent with these reports, our study observed a significant reduction in the incidence of severe IVH following the marked decrease in EPH after QI. This alignment strengthens the conclusion that effective thermal management may contribute to reducing severe neurological injury in critically ill infants. However, it is important to note that severe IVH occurs predominantly in very preterm infants, and this analysis did not fully control for established risk factors (34). Although the observed reduction in severe IVH after the QI intervention is encouraging, our subgroup analysis (Table S2) indicates that this improvement was mainly seen in early preterm infants (<32 weeks), which aligns with existing evidence. Given that our cohort consisted largely of late preterm and term infants, with relatively few very preterm cases, the overall higher mean gestational age and birth weight of the study population should be taken into account when interpreting these findings. Although no significant reductions were observed in other complications such as shock, hypoglycemia, or DIC, the downward trends in these outcomes may suggest a potential clinical benefit from the QI intervention. Unlike previous QI initiatives that primarily focused on EPH in preterm infants (15,18), this study targeted all critically ill neonates. Although our intervention significantly reduced the incidence of EPH, the rate remains higher than those reported in international benchmarks, with no observed cases of hyperthermia. This discrepancy may be attributed to two main factors: firstly, significant variations in the implementation of and adherence to standardized thermal management protocols across the multiple delivery facilities; and secondly, the fact that the intervention standardized processes and feedback mechanisms without introducing groundbreaking innovations in warming techniques. These findings highlight the persistent challenges in protocol compliance across centers and underscore the need for more advanced thermal strategies.
To address the current high rate of EPH, future strategies should involve deploying specialized teams to delivery sites for on-site training and real-time supervision. Additionally, further refinement of specific aspects of the thermal management protocol is warranted to enhance efficacy and compliance.
There are several limitations in this study. First, the lack of statistically significant differences in certain outcomes may be attributed to the limited sample size and consequent underpowered analyses, or to a modest intervention effect that would require a larger cohort to detect. Second, while uniform training was provided across all participating delivery facilities, ongoing monitoring of healthcare providers’ adherence to the protocol throughout the entire study period was not conducted. Additionally, there may be a severity-of-illness bias, as more critically ill neonates are more likely to undergo intensive medical interventions—which could compromise adherence to the thermal management bundle—and are also at higher inherent risk of EPH.
Conclusions
Implementation of a standardized, region-wide thermal management protocol significantly reduced the incidence of EPH among critically ill transported neonates. The observed decline in severe IVH further underscores the potential clinical benefits of improving thermal care practices. Nevertheless, persistent variability in adherence and the recurrence of hypothermia over time highlight the need for ongoing reinforcement, real-time auditing, and protocol refinement to achieve sustained and broader improvements in neonatal outcomes. Future enhancements should focus on equipment upgrades such as heated-humidified transport gas sources, along with optimizing the thermal care bundle through process improvement and technological integration. Regular training refreshers every 3–6 months, strengthened interdisciplinary coordination between delivery and neonatal units, and the establishment of a multicenter data-driven feedback system will be essential to sustain and expand these improvements in neonatal outcomes.
Supplementary
The article’s supplementary files as
Acknowledgments
The authors are very grateful to the patients and their families for their trust in our center. Thanks to registered nurses Haiyan Li and Sha Sha for their valuable contributions to data collection and staff training. We sincerely thank the following six referral hospitals for their invaluable collaboration and support in patient management and data collection throughout this study: Renji Hospital, School of Medicine, Shanghai Jiao Tong University; Shanghai Pudong Hospital; Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University; Shanghai Pudong New Area People’s Hospital; Shanghai East Hospital South Campus; and Shanghai Pudong New Area Maternal and Child Health Center.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Shanghai Children’s Medical Centre (approval No. SCMCIRB-K2023052-1) and informed consent was obtained from all parents or legal guardians prior to participation. All participating hospitals were informed of and agreed to the study.
Footnotes
Funding: This work was supported by the Shanghai Pudong Health and Family Planning Commission Joint Key Project (No. PW2022D-09).
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-aw-685/coif). All authors report that this work was supported by the Shanghai Pudong Health and Family Planning Commission Joint Key Project (No. PW2022D-09). The authors have no other conflicts of interest to declare.
Data Sharing Statement
Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-aw-685/dss
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