Introduction

Temperature management is a significant component of the care required for all neonatal and paediatric patients. Infants and children are susceptible to temperature variations due to physiological and anatomical differences. This includes their larger surface area to volume ratio and immature thermoregulatory mechanisms. Monitoring and rapid intervention are critical. Careful consideration should be given to neonates undergoing general anaesthesia, it is recognised that perioperative hypothermia at times may be unavoidable, however steps to mitigate risks should be undertaken. Body temperatures outside normal ranges may be indicative of underlying disease processes or clinical deterioration and should be identified within a timely manner. Maintaining a stable body temperature within normal ranges assists in optimising metabolic processes and bodily functions. Therefore, minimising environmental factors within the hospital setting which may result in unnecessary body temperature fluctuations is important.

Aim

To assist clinicians working at The Royal Children’s Hospital undertake the appropriate assessment and management of neonatal and paediatric temperatures. 

Definition of Terms

• Cold stress is a cascade of physiological events caused by the infant’s use of chemically mediated thermogenesis in attempt to increase core temperature. Two specific alterations to thermogenesis occur in the infant suffering cold stress; vasoconstriction of the peripheries, which allows heat to be drawn back to the core and metabolism of brown adipose tissue

• Heat stroke: A presentation of severe hyperthermia. Thermoregulation is overwhelmed by excessive metabolic production and environmental heat, in combination with impaired heat loss. This is uncommon within an inpatient setting.
• Hyperthermia: An elevated body temperature due to failed thermoregulation. This occurs when the body produces and/or absorbs more heat than it can dissipate.
• Hypothermia: An abnormally low body temperature, where the body temperature drops below a safe level. Both low temperatures and hypothermia can be caused by environmental factors, metabolic complications, disease processes, or can be medically induced.
• Normothermia: Body temperature within normal values. 
  Exact normal temperature ranges differ between individuals and can be influenced by some genetic and chronic medical conditions. It is important to ascertain the baseline for individual patients in order to identify abnormal body temperature deviations. 
• Pyrexia: An elevated body temperature due to an increase in the body temperature’s set point. This is usually caused by infection or inflammation. Pyrexia is also known as fever or febrile response.
  Some causes of fevers do not require medical treatment, whilst other causes need to be identified and treated. 
• Skin to skin care (also known as kangaroo care): is the practice of holding an infant in an upright position, skin-to skin, on the parent’s chest for a period of time.  Infant need to be stripped down to the nappy and nothing between them and their parent.

Temperature Ranges*

*Significant variation of suggested temperature values and ranges exists within current literature. The values presented in this table are derived from a collaboration of multiple sources and expert opinions and should be utilised as a guideline only. It is important to ascertain an individual’s baseline in order to identify the possible cause/s of the temperature taken.

Please note, any febrile child who appears seriously unwell should have a thorough assessment and their treating medical team notified, irrespective of the degree of fever.

In infants less than3 months, hypothermia or temperature instability can be signs of serious illness.

Assessment

• Body temperature should be measured on admission and four hourly with other vital signs, unless clinically indicated for more frequent measurements. 
• Body temperatures falling outside normal ranges should be monitored and further managed where appropriate until normothermia is achieved.
• When assessing body temperatures, it is important to consider patient-based and environmental-based factors, including prior administration of antipyretics and recent environmental exposures. 
• Body temperature should always be evaluated in the context of other vital signs and overall patient presentation. 

Methods of body temperature measurements

Due to temperature variation between body sites, ideally the same route should be used for ongoing patient observations, as to allow for accurate temperature trend evaluation. Document the route used in EMR.

0-3 months: Axillary Route

Axillary digital thermometer is the preferred method for this age group, in most cases.  This is the most accurate temperature measurement in neonates used for all patients on Butterfly.

Procedure

Place thermometer tip in the centre of the armpit over the axillary artery, ensuring skin is dry and intact prior to probe placement. 

• Place the patient’s arm securely against their body.
• Turn thermometer on. For a more accurate reading, wait >3 minutes with thermometer in situ before obtaining a measurement.

0-3 months: Rectal Route (if requested)
In some circumstances, a rectal temperature may be required for a more accurate assessment of body temperature.
This should be performed only if approved by medical staff, with ANUM involvement.
Rectal measurements should be avoided within the oncology population and in patients with low platelets, coagulopathy, or perineal trauma and pelvic area surgery, due to the increased risk of bowel perforation.

 Procedure:

• Place plastic sheath over thermometer.
• Dab a small amount of lubricant on end of thermometer.
• Carefully insert thermometer 2cm into the infant’s anus (1cm for pre-term infant). Over-insertion may cause bowel perforation.
• Turn thermometer on.
• Wait for 5 seconds post Celsius sign flashing before taking a recording. 
• Remove and clean thermometer with alcohol.
  

Over 3 months: Tympanic Route

Tympanic thermometer is the preferred method for this age group. 

Procedure:

• Gently insert probe into ear canal until the canal is entirely sealed off, ensuring the tip is facing the eardrum.
• Press the thermometer button and wait for the beeps.  
• If ears have been covered (e.g. headphones/beanie), remove items and wait until ear canal is cooled before taking measurement. If a patient’s ear canals are too small to properly insert the tympanic probe, consider an axillary thermometer route instead.

Notes:

If the patient has been exposed to cold environmental conditions, allow for adequate time for patient to stabilise within room temperature before measuring body temperature. For example, temperature will be lower if taken immediately following a bath/shower or a procedure/dressing that requires a large body surface area to be exposed.

Both axillary and tympanic routes measure temperatures lower than true core body temperature. 
Temperature measurement frequency may differ in sub-speciality areas, such as within the Emergency Department, critical care and peri-operative areas. 

Please refer to specific department guidelines for further information.

At Risk Patient Groups

The following patient populations are at an increased risk of being unable to maintain normothermia:

• Neonates and young infants

• Peri and post-operative patients

• Burns patients

• Trauma patients 

• Neurologically compromised patients

Management

Preventative Approaches

A patient’s surrounding environment can greatly impact their ability to maintain an otherwise stable body temperature. Acknowledging and minimising environmental influences on thermoregulation is important for all paediatric patients, especially the neonatal and at-risk patient populations.

The table below outlines approaches nurses, clinicians and families can utilise towards minimising preventable heat transfer from patients to their surroundings.

Neonatal Considerations

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Special Considerations for Neonates

Hypothermia

Neonates in the hospital setting frequently require a large portion of their body surface area exposed for assessment and procedures. This, combined with prematurity and illness places them at an increased risk of hypothermia. Hypothermia can progress to cold stress, the neonate can develop increase oxygen requirements, respiratory distress, bradycardia, hypoglycaemia and acidosis. Therefore, it is imperative to optimise temperature regulation.

• Skin to skin care is a useful intervention to improve thermoregulation and should be encouraged when possible.
• Initiate forced air warming early if indicated and closely monitor. Stepped approach to rewarming is recommended. Aim to raise temperature by 0.5-1 degree per hour. For further information on forced air warming please refer to the Perioperative section of this document.
  
• Contact Butterfly team for support and guidance for neonates outside the department.
• If transferring neonates for imaging or to the perioperative department, please ensure that patient is appropriately warmed using the radiant heaters to mitigate the risk of inadvertent hypothermia. Ensure they have warm blankets and beanie.

For further information on the management of neonatal patients and equipment required to assist with thermoregulation such as radiant warmers and incubators please see the RCH Nursing Guideline: Assisted Thermoregulation.

Paediatric Management

Notes: 

• Sepsis: Early recognition and initial management of sepsis in neonates and paediatrics is paramount, and if left untreated can lead to severe morbidities and mortality.  For further information on sepsis recognition and management of neonates and paediatrics, please see RCH Clinical Practice Guideline: Sepsis assessment and management

• Bair Hugger devices: If using a forced air warming device outside of the critical care environments OT, PACU, PICU, NICU and ED, the temperature of the device should not be set to greater than 32⁰C in the inpatient setting. The patient’s temperature should be rechecked at a minimum of every 30 minutes or if the patient is less than 6 months, a minimum of every 10 minutes whilst forced air warming in use, as patients are at a risk of overheating. Check that the blanket is connected to the device correctly as patients are at risk of burns.

Special Considerations 

The following patient populations may require more specific interventions and/or differing management when body temperature falls outside traditionally normal values:

• Febrile Neutropenic patients (see: RCH Clinical Practice Guideline: Febrile Neutropenic patients)
• Therapeutic hypothermic patients (see: RCH PICU Departmental Guideline: Therapeutic hypothermic patients)
• Therapeutic hypothermic neonates (see: RCH Nursing Guideline: Therapeutic hypothermia in the neonate)
• Patients with chronic conditions causing lower baseline body temperatures 

Some patient populations have conditions that affect their basal metabolic rates and thus, have unique normal temperature ranges. It is important to ascertain these individual’s normal temperature fluctuations to identify abnormal readings and manage appropriately.

Perioperative and Post Operative Patients   

Preoperatively 

• Ensure temperature is taken on admission and patients are appropriately dressed and consider active warming if indicated preoperatively. 
• Provide a warm blanket if patient’s temperature is between 35.5⁰C and 36⁰C.
• Initiate forced air warming for patients less than 35.5⁰C if clinically indicated. Escalate to treating anaesthetist
• For neonates
  • Continue the neonates current thermoregulation i.e., radiant warmer and consider use of warm blankets as needed
  • Initiate forced air warming for neonates if patient temperature is < 36.5
• In consultation with the anaesthesia team, consider preoperative forced air warming blanket for all patients if indicated and tolerated by the patient.

Anaesthesia

Consider forced air warming for all patients undergoing anesthesia and surgery, especially:

• Neonates
• Cases greater than 30 minutes with large areas of exposed skin
• History of CP/Musculoskeletal disorder where thermoregulation is impaired
• Patients undergoing major surgery such as orthopaedic procedures, laparotomies and large tumour removal with open body cavities.
• Patients with burns

Intraoperatively

• Active warming via forced air warming (Bair Hugger / Cocoon) is recommended for patients undergoing surgery when clinically indicated
• All patients with major burns where forced air warming devices are unable to be used should be placed on a heating mat (that is activated by the pressure of the patient lying on it).
•  Patients with major burns, neonates and patients undergoing free flap surgery should have the ambient temperature in theatre increased in consultation with the anaesthesia and surgical teams.
• Theatre warming cabinets set to 40⁰C where irrigation fluids, IV fluids and blankets can be sourced from.
• Use warm irrigation fluids were possible.
• Apply warm blankets if patient is exposed or being transferred.
• Neonates: ensure that radiant heaters are used, preheated prior to patient transfer from theatre. Neonates should be kept warmed with beanies, blankets and appropriate clothing.

Recovery

• Ensure temperature is taken on admission to PACU and 15 minutely thereafter
• Initiate active warming via forced air warming (Bair Hugger/Cocoon) if neonatal patient temperature is less than 36.5⁰C or paediatric patients' temperature whose temperature is less than 35.5⁰C.
• Temperature should be taken every 5 minutes whilst a patient is receiving active warming.
• If overheating or burns occur, stop active warming and seek anaesthetic review (treating or in charge). Cool patient if appropriate. Document event via EMR and complete VHIMS.
• Patients with chronic conditions which cause lower baseline body temperatures should return to their baseline prior to transfer to ward. This baseline temperature should be discussed with parents/caregivers and communicated to the receiving ward or day surgery. 
• Discharge temperature is greater than or equal to 36.6⁰C for neonatal patients and greater than or equal to 36⁰C for paediatric patients.  Ensure clinical indicators are completed and active warming interventions are documented in EMR. 
• If the post-operative temperature is less than 36⁰C but greater than or equal to 35.5⁰C, for paediatric patients and the patient is rousable and all other vital signs are stable and within normal range, they can be transferred to in-patient units. If clinically indicated, forced air warming can be made available to the in-patient units for continued use. This should be discussed with parents/caregivers and communicated to admitting unit.

Family Centred Care

Encourage parents and caregivers, where appropriate to provide skin to skin care for their infants. See RCH Nursing Guideline Skin to Skin Care for the newborn. 

Educate parents and caregivers on recognising temperature changes of their child and escalate concerns to nurse or clinician caring for their child.

In the Perioperative setting, ensure that parents and caregivers are informed of the benefits of keeping their child appropriately warmed prior to anaesthesia & surgery.

Companion Documents 

• RCH Nursing Guidelines
  • Nursing Assessment
  • Nursing Assessment Observation and Continuous monitoring
  • Neonatal Thermoregulation
    
  • Skin to skin care
• RCH Clinical Practice Guidelines
  • Febrile Child 
  • Febrile neutropenia
  • Febrile Seizures
    
  • Fever and sickle cell disease
    
  • Fever and suspected or confirmed neutropenia
• RCH Policy & Procedures
  • Medical Emergency Response Procedure
  • Incubator use on paediatric wards 
• ViCTOR Charts
  

Additional Useful Links

• RCH Kids Health Info Fact Sheet on Fever in Children
• Raising Children’s Network: Taking your child’s temperature
• RCH Kids Health Info Fact Sheet on Febrile Seizures

 Please remember to read the disclaimer.

The revision of this nursing guideline was coordinated by Tania Ramos, CNC, Nursing Research and approved by the Nursing Clinical Effectiveness Committee. Updated October 2024.