March 1980

452

The Journal of P E D I A T R I C S

The effects of thermal environment on heat

balance and insensible water loss in low-birth-weight
infants
To define the neutral environmental temperature and assess the effects of deviation from that temperature
on insensible water loss and heat balance, 12 premature infants were studied in a conventional incubator
at four different predetermined ambient temperatures. Our method combines insensible water loss
measured by a continuous read-out electronic scale with heat production as determined by open circuit
measurement o f oxygen consumption. An increase o f l to 2~

to an ambient temperature above or near

the top o f the neutral zone, produeed a significant rise in insensible water loss, from 1.90 + O. 76 to
3.08 ++-1.19 m l / k g / h o u r (mean + SD), a corresponding rise in evaporative heat loss, and a fall in
nonevaporative heat loss. A decrease of l to 2~

to a slightly subneutral ambient temperature, resulted

in an increase in oxygen consumption from 5.82 +-_ 0.92 to Z45 ++_1.50 ml/kg/minute, and an increase
in total heat loss, but no change in insensible water loss and evaporative heat loss. The increased total
heat loss was judged to be due entirely to a greater nonevaporative heat loss, both by convection and by
. radiation. The data confirm that ambient temperature is an important determinant o f the magnitude and
the partition o f heat loss in low-birth-weight infants.

Edward F. Bell, M . D . , I o w a C i t y , l o w a , J u l i a C. Gray, B.S.,

M a r i e R. W e i n s t e i n , M . D . , and W i l l i a m Oh, M . D . , * P r o v i d e n c e , R. L

THE EFFECTS of changes in environmental temperature

on oxygen consumption have been studied in adults? and
in term ~-~and premature ~ 4. 6-8 newborn infants at various
ages using different methods and environmental conditions. Several authors have attempted to describe neutral
thermal conditions for term or premature infants." ~. 9. l0
The neutral thermal zone is generally defined as the range
of environmental temperature within which the oxygen
consumption is minimal. ~ Within this range the body
temperature can be kept normal by changes in skin blood
flow and posture, without sweating, 9 and both oxygen
consumption and insensible water loss vary by less than
25%. 1~ Previous studies have shown that environmental
temperatures at or near the neutral thermal zone enhance
both survivaP ~ and growth ~2 of low-birth-weight infants,
when compared with colder environments. Since fluctua-

From the Department of Pediatrics, Women & Infants

Hospital of Rhode Island, and the Program in
Medicine, Brown University.
*Reprint address: 50 Maude St., Providence, RI 02908.

Vol. 96, No. 3, part 1, pp. 452-459

tions of environmental temperature occur in clinical

practice, it is important to assess the effects of deviation of
thermal environment from the neutral zone, particularly
its effects on heat and water balance in low-birth-weight
infants.
Temperatures above the neutral zone are known to
increase insensible water loss? ......... In serial studies on
a single 2.1 kg infant, Hey 1~showed no difference between
evaporative heat loss at the neutral temperature and at
subneutral temperatures. Kajt~r et al l~ found evaporative
heat loss to be very similar at the neutral and subneutral
temperatures in a group of term infants 3 to 4 days of age.
Ryser and J6quier TM found similar results in term infants
on the first day of life; however, evaporative heat loss
increased slightly at the coldest temperature, presumably
due to restlessness and a higher respiratory heat loss. Few
data are available on the effects of thermal environment
on insensible water loss in low-birth-weight infants.
Furthermore, most previous studies of temperature effects
on oxygen consumption were done with direct or indirect
calorimetric methods which prevented measurements

0022-3476/80/030452+08500.80/0 9 1980 The C. V. Mosby Co.

Volume 96
Number 3, part 1

Effects of thermal environment on low-birth-weight infants

NEUTRAL

from being done in the incubators commonly used in the

care of premature infants, and precluded the concomitant
assessment of changes in oxygen consumption and insensible water loss resulting from alteration in ambient
temperatures in an incubator. We have therefore designed
this study to measure oxygen consumption and insensible
water loss simultaneously in a group of low-birth-weight
infants at various environmental temperatures in a standard single-walled, forced convection incubator.
MATERIALS

THERMAL

58-

ZONE

I kg (0.75- 1.25)

37563534-

323130---

38-

AND METHODS

-4

1,5 kg ([.25-1.75)

37-

We studied 12 infants with birth weights 1.15 to 2.20 kg

and gestational ages 28 to 35 weeks. One infant had birth
weight below the tenth percentile; the others were all
appropriate for gestational age. All infants were between
11 and 15 days of age when studied. All were being fed
human milk or a commercially prepared formula (Enfamil, Mead Johnson Laboratories, Evansville, IN); two were
also receiving supplementary fluids intravenously. At the
time of study three infants weighed more than they had at
birth; the others had all begun to gain weight, All infants
were clinically stable and did not require supplementary
oxygen therapy at the time of study. All studies were
performed using a single-walled, lbrced convection incubator (Isolette model no. C-86, Air Shields, Inc., Hatboro,
PA), with the same power pack in each case. A temperature-controlled room was used, and studies were all
performed between 0800 and 1800 hours.
For each infant, the boundaries of the neutral temperature range were estimated using the charts of Hey 1~ for
naked infants in incubators, with the following adjustment: Hey's zones were raised by 1.5~ because of our
cooler room temperatures (range 23.5 to 26.1~
and
lower humidities (range 24.4 to 48.8%). The adjusted chart
for 1 kg infants was used for infants with birth weights
below 1.25 kg. The adjusted chart for 2 kg infants was
used for infants with birth weights 1.75 to 2.25 kg. A third
chart, calculated from the means of the 1 and 2 kg charts,
was used for infants with birth weights from 1.25 to 1.75
kg (Fig. 1).
Each infant was studied during four consecutive twohour periods at different ambient (incubator air) temperatures, which were derived fi-om the charts of the neutral
zone: T~, T,_,,and T:~ the top, midpoint, and bottom of the
neutral zone, respectively, and T,, 1~ below the bottom
of the neutral zone (Fig. 1), The ambient temperature was
maintained at the desired level using the incubator's
proportional servocontrol mechanism with the temperature probe suspended 10 cm below the center of the top of
the incubator.
At the beginning of each two-hour study period, the
ambient temperature was set and the infant was fed,

453

56-

AMBIENT
TEMPERATURE
(~

3534-

32-

30- - -

38
37-

.25)

36555455
32.
T4 0

3130

,;
AGE

,;

2'0 2;

~'o

(Days)

Fig. 1. Theoretical neutral thermal zones for different birthweight ranges, modified from Hey.'~The three lines represent the
boundaries and the midpoint of the neutral zone. For each
subject, the ambient temperatures for the four study periods were
taken from these charts. The points labeled T,, T.., T:, and T~ are
shown here as they would be chosen for a 13-day-old infant in
each weight group. T,, T~, and T:~ are intended to approximate
the top, midpoint, and bottom of the neutral zone, respectively,
and T~ a point I~ below the zone.

followed by a 30-minute period for rest and thermal

equilibration. Throughout the entire study the infant lay
naked on a diaper upon the load plate of an electronic
scale (James Addison Potter, West Hartford, CT). The
arrangement of the study apparatus is shown schematically in Fig. 2.
After the initial equilibration period, insensible water
loss was measured during the subsequent 90 minutes
using the Potter scale, as previously described."; During
this 90-minute measurement period, room temperature,
incubator relative humidity, infant's heart rate, respiratory rate, and rectal temperature were recorded at 30minute intervals. Using a six-channel telethermometer
(Yellow Springs Instruments model 46 TUC, 400 series
probes, Yellow Springs, OH) the following temperatures
,were recorded at 15-minute intervals: incubator air

4 54

Bell et al.

The Journal of Pediatrics

March 1980

SMULTI -CHANNEL ~
SCALE METER. ITELETHERMOMETERI

( ; vocoN
O ' TEMP. PROBES
PROBE

METER L

o2

ANALYZER
with

Ill

L
Hygrorneter- ~ L.h-I [

HEATIE~
AMBIENT~
TEMP. ~l "'~ L . ~
INCUBATOR

--~VALVE

Fig. 2. Schematic illustration of study apparatus.

(ambient) and inner wall, abdominal skin (right upper
quadrant), and heel. The temperature probes were individually standardized against a certified mercury thermometer (U.S. National Bureau of Standards) in a water
bath. For each two-hour study period, the means of these
temperature, humidity, and vital sign measurements were
calculated. A weighted mean skin temperature was calculated from the abdominal and heel temperatures: 17
T~ = 0.9 Tab d + 0.1 Th,e~.
Oxygen consumption was measured concurrently with
the measurements described-above, using an open circuit,
flow through method. 1~-= Gas was drawn by a diaphragm
pump through a Plexiglas hood over the infant's head at
a constant flow rate of approximately 3 1/minute/kg body
weight (Fig. 2). This sample gas, a mixture of expired gas
diluted with room air, was drawn through a calibrated
flowmeter (Fischer & Porter model 10A3555, Warminster,
PA), after which a portion of the sample gas was drawn at
a slower flow rate into a calibrated paramagnetic oxygen
analyzer (Servomex OA 540, Taylor Instruments, Crowborough, England). A valve at the outlet of the sample gas
hose from the incubator allowed alternate sampling of the
gas inside the incubator, which was the inspired air.
Minimal oxygen consumption, VOw, was then calculated
as the product of the flow rate through the system, Q, and
the difference between the fractional oxygen concentration of the inspired air, Flo2. and that in the diluted
expired sample gas, Fso._:

when the infant was lying motionless, or nearly so, with

eyes closed. Fifteen-minute periods during which the
infant was awake or moving significantly were excluded
from the data analysis, and repeated. The mean VO~ for
each. study period was calculated from the six minimal
VO2 readings done at 15-minute intervals. All VO2
measurements were corrected to STPD conditions and
expressed as ml/kg/minute.
Heat production was calculated from mean oxygen
consumption, assuming a caloric equivalent of 4.83 kcal/
liter of oxygen consumed? 3 Heat storage during each
study period was derived from changes in body temperature, assuming a body specific heat of 0.84 kcal/kg/~
Heat storage = 0.84kcal/kg/~ (0.6AT ..... + 0.4hT~) + At,
where AT,,eot = change in rectal temperature, hTs
-- change in mean skin temperature, and.ht = duration
of study period, e.g., 1.5 hours. 14 Total heat loss was
calculated as the difference between heat production and
heat storage. Evaporative heat loss was derived from
insensible water loss, multiplying by 0.58 kcal/ml# 4 Nonevaporative heat loss was calculated from total and
evaporative heat loss.
To analyze for effects of ambient temperature on
various measurements, group means were compared by
paired t test. The study protocol was approved by our
institutional Research and Human Subjects Committee,
and informed consent was obtained from the parents of
each subject.

= Q (FI%- Fs%).

The value of Fs% used to calculate the minimal VO2 was

the maximum Fs% during a two-minute period. VO~ was
recorded every 15 minutes during the 90 minutes of
observation during each study period, but only at times

RESULTS
For the purpose of analyzing the results, the neutral
temperature for each infant was defined as the ambient
temperature at which the mean oxygen consumption was

Volume 96
Number 3, part 1

Effects of thermal environment on low-birth-weight infants

45 5

Table I

Birth weight
range and
individual
weights (kg)
< 1.25
(1.15, 1.21,
121, 1.24)

Gestational
age
range
(wk)
28-29

Thermal
environment
Supraneutral
Neutral

31-34

(1.30, 1.40,
1.46, 1.56)

Subneutral
Supraneutral
Neutral

1.75-2.25
(1.77, 1.98,
2.16, 2.20)

32-35

Subneutral
Supraneutral
Neutral

1.25-1.75

Subneutral

Tomb

'/room

Relative
humidity

36.6*
0.1
35.1
9+0.5
33.8*

36.0*
0.1
34.3

32.8*
0.2
35.1"
+ 0.1
33.2

31.1"
-+0.4

24.9
_+0.5
24.8
_+0.4
24.4

24.4
_+0.6
24.9

25.2
_+0.7
24.7
-+0.5
25.0
_+0,8
24.6
1.0

38.5
1.2
38.8
1.3
39.2
___1.5
40.1

38.8

39.6

37.4
_+9.7
36.9
10.7
36.8
_+9.6

rwall

r~ba

Thee,

T~

31.9
---0.4
31.6
-0.1
30.5
---0.8
32.1"
--+0.5
~31.4
-+0.5
30.7"

30.8

29.6

28.2*

36.3
-+0.4
36.4
0.3
36.0
_+0.5
36.3

36.2

36.2

36~2

36.3

35.6*
-+0.5

34.5
0.5
34.6
-+0.7
33.1"
-+0.6
35.0

34.4

33.0*

35.2
___0.7
35.0

33.0*
___0.8

36.1
0.4
36.2
0.4
35.7*

36.2*

36:0

35.9

36.1

36.2

35.4*

I Heart
rate
r,.eet
36.7
0.3
36.8
0.3
36.3*

36.6

36.6

36.3

37.0
_+0.1
37.0
-+0.2
36.8*

154

148

146
-+15
136
+7
139

140
-+9
152
-+7
148

-+li
146
+12

Respiratory
rate
54
+12
45
-+6
46
+I0
39
-+3
38
+4
36

51

45

54

Mean -+ standard deviation. All temperatures in ~

*Significantly different from neutral thermal state, P < 0.05, by paired t test.

lowest. This neutral temperature Was T2 or Ta in each case

(Fig. 1). The mean temperatures, insensible water loss,
and heat balance data were then compared for each
infant, at three ambient temperatures: (1) T,, the supraneutral temperature, which is at the top of or slightly above
the neutral thermal zone; (2) the neutral temperature,
either T., or T3, based on measured oxygen consumption;
and (3) T~, the subneutral temperature, which is below the
neutral zone.
As shown in Table I, the mean ambient temperatures
were significantly different within each weight group, as
expected. In addition, the mean incubator wall, skin, and
rectal temperatures all varied significantly between at
least two thermal environments (supraneutral, neutral,
and subneutral) in one or more weight groups (Table I):
The mean room t e m p e r a t u r e , relative humidity, heart
rate, and respiratory rate were not significantly different
when compared between thermal environments in any
weight group.
Table II shows the mean oxygen consumption, insensible water loss and heat balance results for the same three
weight groups, and for all 12 subjects together. The m e a n
oxygen consumption for all 12 infants was 6.14 m l /
k g / m i n u t e at the supraneutral ambient temperature, 5.82
at the neutral temperature, and 7.45 at the subneutral
temperature. This difference in 9 0 2 between the neutral
and subthermoneutral environments was significant

(P < 0.001) by paired t analysis. The mean insensible

water loss decreased from 3.98 m l / k g / h o u r at the supraneutral temperature to 1.90 at the neutral temperature
(P < 0.005); but at the subneutral temperature the mean
insensible water loss was 1.88, not significantly different
from the neutral environment. The mean heat production
was increased at the subneutral temperature, as was the
oxygeii consumption, from Which it was derived. The
mean heat storage was positive at the supraneutral temperature; indicating a slight increase in body temperature
during the study, and negfitive at the subneutral temperature due to a Sl!ght fall in body temperature. The mean
heat storage at the neutral temperature was nearly zero
for each weight group, indicating a close approximation to
a thermal steady state, as expected.
Evaporative heat loss was higher at the supraneutral
temperatui'e, reflecting the increase in insensible water
loss, from which it was calculated. N0nevaporative heat
loss increased with decreasing ambient temperature in all
weight groups. The negative values for mean nonevaporative heat-loss at the supraneutral temperature indicate a
net gain of heat by the body from the environment by
radiation, convection, and conduction.
Table III shows the comparison of two mean temperature gradients between the neutral and subneutral thermal environments. The gradient between abdominal skin
and ambient temperatures is assumed to be directly

456

Bell et al

The Journal of Pediatrics

March 1980

Table li

Birth weight
range (kg)

Thermal
environment

< 1.25

Supraneutral

(n = 4)

Neutral
Subneutral

1.25-1.75

Supraneutral

(n = 4)

Neutral
Subneutral

1.75-2.25

Supraneutral

(n = 4)

Neutral
Subneutral

All subjects

Supraneutral

(n = 12)

Neutral
Subneutral

Mean
oxygen
.consump tion
(ml/kg/
rain STPD)
6.07
__. 1.26 "
5.31
_+ 0.52
6.69
1.34
5.95
+_ i.63
5.81
_+ 1.39
7.29
'
_+ 1.54
6.40
_+ 0.52
6.32
0.47
8.38*
+ 1.45
6.14
1.13
5.82
0.92
7.45*
_ 1.50

Insensible
water loss
(gm / k g /
hr)

Heat
Production
(kcal/
kg/hr)

Heat
storage
(kcal/
kg/hr)

Total
heat loss
(kcal/
kg/hr)

Evaporative
heat loss
(kcal/
kg/hr)

Nonevaporative
heat loss
(kcal/
kg/hr)

4.08
+ 1.20
2.36
0.98
2.14
1.20
3:18"
_+ 0.82
1.99
0.42
2.02
_+ 0.45
1.98
+ 0.30
1.36
_+ 0.54
1.48
+_ 0.31
3.08*
_+ 1.19
1.90
_+ 0.76
1.88
0.75

1.76
+ 0.36
1.54
+ 0.15
1.94
- 0.39
1.72
0.47
1.68
_ 0.41
2.11
0.45
1.85
0.15
1.83
+ 0.14
2.43
0.42
1.78
_+ 0.33
1.69
___0.27
2.16"
0.44

0.22
-- 0.10
0.03
i?.10
--0.11
-4- 0.07
0.34*
_ 0.16
0.04
-- 0.16
-0.17
- 0.10
0.15
+ 0.08
0.02
___0.08
-0.08
0.12
0.24*
_-!-0.]3
0.03
___0.11
--0.12"
0.10

1.54
_ 0.45
1.51
_+ 0.25
2.05*
-+ 0.39
1.38
4- 0.34
1.64
___0.37
2.28
_+ 0.50
1.70
+ 0.20
1.81
+ 0.13
2.51"
0.44
1.54
0.34
1.66
0.27
2.28*
0.45

2.37
0.70
1.37
+ 0.57
1.24
0.70
1.84'
___0.48
1.15
0.24
1.17
_+0.26
1.15
0.17
0.79
- 0.32
0.86
0.18
1.79"
_-,- 0.69
1.10
0.44
1.09
0.44

-0.83
0.36
0.14
~ 0.76
0.81"
_+ 0.86
--0.46*
-- 0.57
0;49
0.43
1.11
___0.65
0.55
0.12
1.02
_+ 0.25
1.65
0.41
-0.25*
0.71
0.56
___0.60
1.19"
0.71

Mean -4- standard deviation.

*Significantlydifferent from neutral thermal state, P < 0.05, by paired t test.
p r o p o r t i o n a l to the convective c o m p o n e n t of n o n e v a p o r a tive heat loss. Similarly, the gradient b e t w e e n a b d o m i n a l
a n d i n c u b a t o r wall t e m p e r a t u r e s is p r o p o r t i o n a l to the
heat loss by radiation. Both t e m p e r a t u r e gradients were
significantly larger at the s u b n e u t r a l t e m p e r a t u r e (Table
III), indicating a n increase in heat loss by b o t h convection
a n d r a d i a t i o n in the cooler e n v i r o n m e n t .
DISCUSSION
The m e t h o d s we h a v e chosen to measure insensible
water loss a n d oxygen c o n s u m p t i o n have b e e n applied
successfully in n e w b o r n infants, but seldom used concurrently. 2~ T h e simultaneous m e a s u r e m e n t o f insensible
water loss a n d oxygen c o n s u m p t i o n , along with m o n i t o r ing of infant a n d e n v i r o n m e n t a l temperatures, allows
assessment o f a n infant's heat b a l a n c e in a way which was
previously possible only with closed circuit techniques
requiring enclosure o f the i n f a n t in a calorimeter or
metabolic c h a m b e r .
T h e r e are p r o b l e m s with our methods, b u t also considerable advantages over other available methods. Care
must be t a k e n to avoid tension or drag on the wires a n d

tubing, which would affect the scale reading. I n particular, the h o s e from the h o o d m u s t be secured carefully at
the outlet port from the incubator. A n o t h e r p r o b l e m
relates to the fact that nonevaporatiVe heat loss is calculated from total a n d evaporative heat loss, a n d not
m e a s u r e d directly. Since heat p r o d u c t i o n a n d heat loss in
this study were derived from the m e a n o f several m i n i m a l
ox~cgen c o n s u m p t i o n readings, they m a y Underestimate
the total heat p r o d u c t i o n a n d heat loss occuring d u r i n g a n
entire study period, by w h a t e v e r degree "v'O2 varied a b o v e
the m e a n m i n i m a l value during the period. E v a p o r a t i v e
heat loss, on the other h a n d , is calculated from total
insensible water loss d u r i n g each period; if total heat toss
is underestimated, n o n e v a p o r a t i v e heat loss is also u n d e r estimated. T h e m a g n i t u d e of this error can be estimated
using the data of Brooke et al. 2~A s s u m i n g that o u r oxygen
c o n s u m p t i o n m e a s u r e m e n t s reflect resting plus postprandial metabolism, the average i n c r e m e n t for activity would
be a n additional 36%. Thus, h a d our infants' activity
patterns b e e n similar to those in infants studied by Brooke
et al, a n d if we h a d included periods of activity in our
m e a s u r e m e n t of oxygen c o n s u m p t i o n , the m e a n n o n e v a p -

Volume 96
Number 3, part 1

Effects o f therma ! environment on low-birth-weight infants

orative heat loss zor all subjects (see the bottom of the last
column in Table II) would have been increased to + 0.39,
1.16, and 1.96 kcal/kg/hour, at the supraneutral, neutral,
and subneutral temperatures, respectively.
There are two other likely sources of error based on the
assumptions used in the heat balance calculations. (1)
The figure used for the caloric equivalent of oxygen
consumed, 4.83 kcal pe r liter, is a reasonable average
value. However, this value depends on the respiratory
quotient, which has bee n shown to vary with environmental temperature. 27 Thus , our assumed caloric value for
oxygen may have led to an underestimation of heat
production at the warmer temperature and an overestimation in the cooler environment. (2) Our calculation of
insensible water loss from weight loss assumes the weight
difference between carbon dioxide produced and oxygen
consumed to be negligible. Although the resulting error is
usually considered to be acceptably small, it becomes
more important in this study, because the magnitude o f
the error may depend on the environmental temperature.
If the RQ is lower at cooler temperatures, '-'7 then the
CO2-O2 weight difference will also be smaller, as will the
error in insensible water loss Calculation. At the warmer
environmental temperature the error will be greater,
causing an overestimation of insensible water loss and
consequently an underestimation of nonevaporative heat
loss. All of the errors discussed here are likely to have
caused an underestimation of nonevap0rative heat loss at
all temperatures , but especially in the supraneutral thermal environment. The latter two sources of error would
have been preventable had we been able to measure
carbon dioxide production and, thereby, respiratory
quotient.
The major advantage of this method is that it allows
noninvasive assessment of heat balance, at the cribside if
necessary, in an environment which is virtually identical
to that employed in the day-to-day care of the infant.
Except for the initial arrangement of the apparatus and
taping of temperature p~'obes to the skin, the infants were
not disturbed and nearly all slept throughout each study
period.
Our mean minimal oxygen consumption values at
neutral ambient temperatures, 5.31 to 6.32 ml/kg/minute,
are very similar to those reported previously by other
authors for premature infants 10 to 15 days of
age?- ~ 7.8. ~8. _~ Our results are consistent with the data of
Mesty~in et al, 8 who showed that minimal oxygen consumption expressed per kg of body weight correlates with
maturity in the first weeks of life; i.e., the smallest infants
have lower rates of Oxygen consumption than larger
prematures. As with the infants studied by Okken et al, 2~
we found the evaporative heat loss to contribute a larger

4 57

Table III. Comparison of temperature gradients (~

mean _+ SD

T.bd-T~,~b

T~bd-Tw~H

Neutral
temperature
2.1 1.0

5.5 1.0

Subneutral
temperature

3.3 _+ 1.1
6.1 _+ 1.1

< 0.001
< 0.001

Portion of the total heat loss than had previously been

appreciated, particularly in the smallest infants. In our
study, this finding may have resulted, at least in part, from
the sources of error discussed above, which tend to
underestimate the nonevaporative heat loss.
At the supraneutral ambient temperature, the insensible water loss and evaporative heat loss were greater, as
previously shown by Hey and Katz. 13The nonevaporative
heat loss was reduced at the supraneutral temperature, in
fact eliminated in the two smaller weight groups. These
observations indicate a net uptake of heat by the body
from the environment by radiation, convection and
conduction, and a corresponding increase in heat loss
through the evaporative route to maintain heat balance.
At the subneutral ambient temperature, there was a 25
to 33% increase in mean oxygen consumption above the
values observed at the neutral temperature. The calculated heat production and total heat loss were also
increased in the cooler environment. The insensible water
loss and evaporative heat loss were unchanged, but the
mean nonevaporative heat loss was significantly increased
at the cooler ambient temperature. The temperature
gradient data shown in Table III suggest that the
increased nonevaporative heat loss in the subthermoneutral environment was due to increases in both the convective and radiative components.
The manner in which the ambient temperatures were
chosen allowed us to demonstrate a rise in heat production and heat loss in the subtherm0neutral environment
without subjecting any infant to hypothermia. Rectal
temperatures were significantly lower at the subneutral
ambient temperature but were above 36~ in all studies.
Since evaporative heat loss was essentially the same in the
neutral and subneutral thermal environments, the
increased heat loss at the cooler temperature was due
entirely to an increase in nonevaporative heat loss.
Ryser and J6quier 1~ found an increase in evaporative
heat loss when term infants less than 24 hours of age were
exposed to an ambient temperature of 28~ They attributed this to ]ncreased activity and respiratory rate. In the
slightly subthermoneutral environment produced in our
study, the infants did not become restless and the respiratory rates were not increased.
Our data (Table II) support the established inverse

458

B e l l et al.

relationship between insensible water loss a n d b o d y

weight? ~ F u r t h e r m o r e , the smaller p r e m a t u r e infants
seem to be especially vulnerable to the effects of increased
a m b i e n t t e m p e r a t u r e on insensible water loss, T h e m e a n
insensible water loss in the smallest infants ( < 1.25 kg)
increased by 73% at the s u p r a n e u t r a l t e m p e r a t u r e , compared with a 46% increase a m o n g the larger p r e m a t u r e
infants (!.7522.25 kg).
Thi s study provides additional evidence of the importance of careful regulation of a m b i e n t t e m p e r a t u r e in the
care of p r e m a t u r e infants in incubators. Exposure to
a m b i e n t t e m p e r a t u r e s above the neutral zone increases
insensible water loss and therefore the r e q u i r e m e n t for
fluid intake. However, heat p r o d u c t i o n a n d tota! heat loss
are not greatly c h a n g e d b y b r i e f elevations of a m b i e n t
t e m p e r a t u r e to 1 to 2~ above the n e u t r a l t e m p e r a t u r e .
S u b n e u t r a l i n c u b a t o r air t e m p e r a t u r e s do not significantly alter insensible water loss or the r e q u i r e m e n t for fluid
!ntake, but cause a significant increase in e n d o g e n o u s h e a t
p r o d u c t i o n reducing the potential energy resources available for growth, even in the absence of h y p o t h e r m i a .
A l t h o u g h convectively heated incubators may not b e
the ideal heat source for p r e m a t u r e infants. 3' they are
used in virtually all nurseries. The heater o u t p u t may be
regulated by a u t o m a t i c servocontrol to m a i n t a i n a
constant skin temperature. More commonly, in o u r experience, the heater is m a n u a l l y adjusted according to
periodic m e a s u r e m e n t s of the infant's axillary or rectal
temperature. W h i c h e v e r m e t h o d is used. it is i m p o r t a n t to
recognize the effects of changes in a m b i e n t t e m p e r a t u r e
on insensible water loss a n d heat balance. A p p r e c i a t i o n of
these relationships will e n h a n c e efforts to m a i n t a i n stable
e n v i r o n m e n t a l t e m p e r a t u r e s within the neutral zone. a n d
to respond appropriately to the episodes o f t h e r m a l stress
which inevitably occur m the m a n a g e m e n t of low-birthweight infants.

The Journal o f Pediatrics

March 1980

6.

7.

8.

9.
10.

11.

12.

13.
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16.

17.

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Volume 96
Number 3, yart 1

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Effects o f thermal environment on low-birth-weight infants

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459

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