Hypothermia and Occlusive Skin Wrap in the 

Low Birth Weight Premature Infant: An 

Evidentiary Review 
Thalia Cordaro, MSN, CRNP, NNP-BC, Ann Gibbons Phalen, PhD, CRNP, NNP-BC, and 
Ksenia Zukowsky, PhD, CRNP, NNP-BC 
Low-birth-weight  (LBW)  premature  infants  are  born  without  the  adaptive  mechanisms  needed  for  survival  outside 
of  the  womb.  These  fragile  infants  require  thermoprotective  interventions  that  begin  in  the  delivery  room.  Current 
heat  preservation  interventions  such  as  a  pre-warmed  delivery  room,  warm blankets/towels, drying, radiant warmer 
tables,  and  skin-to-skin  with  mother  are  not as effective in preserving heat in the smallest of infants. Despite the use 
of  current  heat  preservation  strategies,  LBW  premature  infants  remain  vulnerable  to  hypothermia  and  associated 
morbidities  and  mortality.  The  use  of  an  occlusive  skin  wrap  has  been  studied since the late 1960's as a method for 
heat  loss  prevention  in  infants  at  birth.  This  evidentiary  review  will  explore  the  most  recent  research  on  occlusive 
skin wrap in the delivery room for heat preservation in the LBW premature infant and propose a guideline for use. 
Keywords: Hypothermia; Occlusive Skin Wrap; Premature infant; Low Birth Weight (LBW) infant; Heat loss 
In  utero,  the  fetus  is  entirely  dependent  on  the  mother  as a heat source and for heat removal. At birth, exposure to a 
colder  extrauterine environment plays an important role in the physiologic processes that must occur for the infant to 
begin  the  homeothermic  process  of  regulating  its  own  heat.  1,2  Prolonged  exposure  to  the  colder  extrauterine 
environment  without  thermoprotective  measures  places  the  newly  born  infant  at  risk  for  further  heat  loss  and 
ensuing  hypothermia.1,2  The  deleterious  effects  of  hypothermia  may  result  in  increased  oxygen  and  metabolic 
demands,  acid-base  derangements,  respiratory  compromise,  hypoglycemia,  and  even  death  once  the  infant's 
compensatory  mechanisms  fail.  1,3-5  Thermal  protection  of  the  newborn  remains  a  global  health  concern  and  a 
challenge  to  health  care  providers  despite  advances  in  technology  that  provide  warmth  and  minimize  hypothermia 
after birth.6 
The  World  Health  Organization  classifies  neonatal  hypo-  thermia  as  mild  36.0°C  –36.4°C  (96.8°F–97.5°F), 
moderate  32°C  –35.9°C  (89.6°F –96.6°F), and severe (b32°C/89.6°F).6 Hypothermia (b36.5 °C/97.7°F axillary) is a 
major factor in 
morbidity  and  mortality  of  low-birth-weight  (LBW)  premature  infants.5,7-9  Laptook  et  al7  reported  for  every  1°C 
(1.7°F)  decrease  in  admission  temperature  the  odds  of  late  onset  sepsis  was  increased by 11% and the risk of death 
increased  by  28%.  Moderate  and  severe hypothermia was associated with a higher risk of grade 3–4 intraventricular 
hemorrhage (IVH) and death in LBW infants below 1500 grams. 9 
Clinicians are challenged with maintaining a neutral- thermal environment for infants transitioning from in utero 
conditions to the delivery room environment. Evidence demonstrates that it is crucial to provide thermal protective 
strategies from the onset of birth in the delivery room for all infants, especially LBW premature infants. 
Conventional heat conservation strategies such as increasing ambient delivery room temperature (≥25°C/77°F), 
providing warmth, drying the infant with a warmed towel/blanket, applying a hat, and promoting skin-to-skin 
bonding with the mother are insuffi- cient to prevent hypothermia for LBW premature infants.6,10,11 Utilization of 
an occlusive skin wrap in the delivery room as an adjunct intervention for thermo- conservation of LBW premature 
infants is advocated by the American Academy of Pediatrics (AAP) neonatal resuscitation From the Geisinger 
Medical Center, Janet Weis Children's Hospital, Danville, PA 17822; Thomas Jefferson University, Jefferson School 
of Nursing, Philadelphia, PA 19107. Address correspondence to Thalia Cordaro, MSN, CRNP, NNP-BC, Geisinger 
Medical Center, Janet Weis Children's Hospital, 100 North Academy Avenue, Danville, PA 17822. E-mails: 
tcordaro1@geisinger.edu, Ann.Phalen@jefferson.edu, Ksenia.Zukowsky@jefferson.edu. © 2012 Elsevier Inc. All 
rights reserved. 1527-3369/1202-0454$36.00/0 
program guidelines. 10,11 However, for this population, the safety, efficacy and long-term effects of occlusive skin 
wrap use is limited.8 The purpose of this evidentiary review is to examine the evidence on occlusive skin wrap in 
LBW premature infants as an adjunct to conventional thermo- conservation interventions used in the delivery room. 
In addition, this review will propose an evidence-based guideline for the adjunctive use of occlusive skin wrap for 
the LBW doi:10.1053/j.nainr.2012.03.001 
premature infant population. 
 
premature Background and Significance 
infants. LBW premature infants are easily over- whelmed by the colder extrauterine environment. They The 
framework for this evidentiary review is based on 
attempt to respond to the cold through peripheral 
vasocon- historical research. Very early on, it was found that survival of 
striction and BAT metabolism but, because these 
processes are the premature infant was dependent on thermo-conservation. 
limited in the LBW premature infant, they require 
external In 1958, Silverman et al12 were the first to demonstrate that 
interventions in order to survive. It becomes 
essential that preventing hypothermia has a direct impact on the mortality of 
interventions go beyond the basics of drying, 
wrapping in premature infants. Survival rates for premature infants were 
warmed towel/blanket and applying a hat to 
conserve heat in higher when incubators were set at 31.7°C (89°F) than set at 
premature LBW infants. The use of an occlusive 
skin wrap in 28.9°C (84°F). Approximately, 83% of infants in incubators set 
the delivery room is an example of an adjunct 
intervention for at 31.7°C (89°F) survived the study compared to 68% of infants 
thermo-conservation in the LBW premature infant. 
cared for in incubators set at 28.9°C (84°F). During the 1960's, Buetow and Klein13,14 demonstrated that survival 
rates of infants b1500 grams improved if cared for in skin temperature 
Evidence Retrieval controlled radiant heated 
incubators versus convectively heated incubators set at 36°C (96.8°F). Today, even with advanced technologies, 
premature LBW infants continue to be subjected to the devastating effects of hypothermia as a direct result of 
insufficient delivery room thermo-conservation. 
At  birth,  the  risk  for  hypothermia  is  high  secondary  to  the  colder  extrauterine  environment  coupled  with 
evaporative  heat  loss.  The  amniotic  fluid  covering  the  newborn  after  birth  rapidly cools and evaporates off the skin 
which  leads  to  evaporative  heat  loss  and  temperature  decreases  of  0.2°C–  1.0°C  (0.5–1.7°F)  every  minute  without 
intervention.1,4,15  For  the  preterm  infant  this  loss  is  even  more  exaggerated.  Homeothermic  heat  production  is 
started  by  the  sensation  of  cold  from  the  change  in  temperature  experienced  at  birth  and  clamping of the umbilical 
cord.1,16,17  Peripheral  vasoconstric-  tion  begins  shunting  warm blood to the infant's core and brown adipose tissue 
(BAT)  thermogenesis,  also  known  as  non-  shivering  thermogenesis,  is  initiated.  Brown  fat  is  stored in the axillary, 
mediastinal,  perinephric,  paraspinal,  and  intrascapular  regions  and  first  appears  around  26–30  weeks  of 
gestation.1,2,16  Once  the umbilical cord is clamped, the placenta no longer suppresses proteins responsible for BAT 
metabolism  and  the  infant  begins  the  process  of  heat  production  independent  of  the  mother.16,17  BAT  is  rich  in 
mitochondria  that  hydrolyze  and  esterify  triglycerides  and  free  fatty  acids to produce heat. The blood vessels found 
in BAT help move heat to the infant's core circulation. 
Heat  loss  in  the  LBW  premature  infant  is  multi-factorial.  Factors  include  a  large  body  mass-to-surface  ratio, 
inadequate  stores  of  subcutaneous  (insulating)  fat,  decreased  BAT  stores,  underdeveloped  skin,  increased  skin 
permeability, increased transepidermal water loss, as well as poor vasomotor control 
The  search  strategy  used  to  generate  information  for  review  on occlusive skin wrap use and heat conservation in 
the  delivery  room  encompassed  nursing  and  medical  research  literature  from  the  years  1999-2011.  The  electronic 
databases  searched  were  Scopus,  Medline  (PubMed),  Cinahl  and  the  Cochrane Database of Systematic Reviews. In 
addition,  reference  lists  of  relevant  published  studies  were  examined  as  well  as  a  hand  search  of  neonatal  and 
pediatric  textbooks  and  journals.  Key  search  words  included  the  terms  hypothermia,  neonate,  skin  wrap, 
preterm/premature/ELBW/VLBW  neonate,  hyperthermia,  polyethylene/occlusive  skin  wrap,  plastic  blanket, 
insensible  water  loss,  heat  loss  prevention  and  thermoregulation.  Search  terms were combined to expand the search 
and improve the yield. Studies were limited to the English language. 
Eleven  experimental or quasi-experimental studies evaluat- ing occlusive skin wraps as a barrier to heat loss were 
identified  using  the  search  terms  listed  (Table  1).  Three  retrospective  observational  studies  (ROS)19-21  and  four 
randomized  control  trials  (RCTs)22-25 compared the use of occlusive skin wrap only to conventional delivery room 
thermoregulation.  Two  RCTs  and  2  ROS  were  included  which  compared  the  use  of occlusive skin wrap with other 
thermal  protective  strategies  such  as  plastic  caps,  26  increased  ambient  operating  room  tempe-  rature,27,28  and 
exothermic mattresses.28,29 Four studies were performed in the United States, two were performed in Australia, and 
single  studies  were  completed  in  Canada,  England,  Italy,  Malaysia,  and  Nova  Scotia.  Additional  studies  were 
performed  in  the  1970's  and  1980's  with occlusive skin wrap and insensible water loss prevention, but none focused 
on immediate delivery room thermo-conservation, and were thus excluded from this review. 
and  extended  body  posture.1,2,4,18  The  premature  infant's  skin  is  thin  and  permeable  with  the  blood  supply  lying 
closer to the skin's surface which contributes to additional convective heat 

Review of the Literature loss 

through the skin.15 
Historically, the first occlusive skin wrap studied 
was an Recognition of the signs and symptoms of hypothermia in 
aluminum coated opaque plastic blanket called the 
“silver the newborn is critical for the healthcare provider. When 
swaddler” in 1968. 30 After this study, in 1971, a 
clear interventions are not provided to prevent hypothermia, the 
polyethylene bag (similar to bubble wrap) was 
researched. The infant exhibits irritability, excessive motor activity, tachycardia, 
transparency of these bags made it easier for 
caregivers to bradycardia, respiratory distress, cyanosis, skin mottling, or 
observe and manage the infant with minimal 
disruption of the pallor. 1 In response to the cold, term infants increase their 
wrap.3 In both studies, researchers found that 
infants wrapped activity and flex their extremities, but this is not the case for 
in plastic were warmer than control subjects due to a reduction 
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Table 1. Review of Studies on the Use of Occlusive Wraps in LBW Premature Infants 
Study Design Participants Interventions Results Critique Bredemeyer 
Observational study et al. (2005)19 
with pre and post intervention audit 
n = 141 b30 wk gestation born at study center 
Polyethylene wrap while infant wet immediately after birth 
• Higher admission temperature in the wrap group (36.8°C/ vs. 36.4°C) for infants b27 wk gestation (P b .01). 
• Defined hypothermia as b36.5°C axillary. Large study performed in Australia. Carroll et al. 
ROS n = 140 (2010)20 
b1000 g /25 wk (+/−2) gestation, born at study center 
Polyethylene bag while infant wet immediately after birth 
• Higher temperature on admission and at one hour of life in the wrap group (36°C/96.8°F) vs control 
(35°C/95°F), P b .01. 
• Less risk of Grade 3-4 IVH and PVL seen in study group (P = .04). 
• Similar mortality rates 7% wrap group vs 9% control, not statistically significant. 
• Defined hypothermia as b35°C axillary which may potentially skew hypothermia rate results. 
Ibrahim et al. 
Observational study (2009)21 
with pre and post intervention audit 
n = 265 b30 wk gestation born at study center 
Polythene food grade bag while infant wet immediately after birth 
• Lower incidence of hypothermia with use of skin wrap from 25% to 16% (P = .098). 
• Skin wrap may be of marginal benefit with infants b28 wk gestation, but greatest reduction in hypothermia in 
infants N28 wk gestation (19% vs 4%, P = .017). 
• Hypothermia defined as b36°C axillary which may potentially skew hypothermia rate results. 
• Hyperthermia (N37°C/98.6°F) reported with wrap (39.8% vs 12.5%, P b .0001). 
• Large study performed in England. Kent & 
Williams (2008)27 
ROS n = 156 
b31 wk gestation born at study center 
Polyethylene wrap and increased ambient temperature in operating room for cesarean section births. 
• Combining warmer operating room temperature and skin wrap use improved admission temperatures especially 
for infants b28 wks (24-27wks P b .0001 vs 28-31 wks P = .0005). 
• No statistically significant difference in survival, total ventilation days or oxygen, confirmed NEC, IVH grade 
3-4, or late sepsis 
 • Multidisciplinary educational program made a positive impact in clinical practice at this study institution which 
was performed in Australia. 
• Three cases of hyperthermia (≥37.5°C) with skin wrap. 
• Details of placement in wrap not clear whether infants dried or wet. Knobel et al. 
RCT n = 88 (2005)22 
b29 wks gestation born at study center 
Polyurethane bag while infant wet immediately after birth 
• Admission temperature in the wrap group was 0.6°C higher than the control group after controlling for delivery 
room temperature (P b .0001). 
• Warmer delivery room temperatures and skin wrap were associated with higher admission temperature (P b 
.003). 
• No statistical significance in mortality, major brain injury, duration of oxygen therapy or hospitalization in both 
groups. 
• Hypothermia defined as b36.4°C rectally. 
• One case of hyperthermia (38.3°C/100.9°F) reported in the skin wrap group with no adverse effects reported. 
 
• Lewis et al. 
Observational study 
n = 428 
6 Intervention Groups: 
Higher admission temperature with 
• 
Small study group sizes. (2011) 28 
with pre and post 
b1500 g, b32 wk 
b1000 g & 1000–1500 g 
wrap, however remained hypothermic 
• 
Defined normothermia as intervention audit 
stratified into 2 
Polyethylene wrap; 
(b1000 g 36.3°C/1000–1500 g 36.45°C). 
36.4°–37.5°C 
(97.6°–99.6°F). groups (b1000 g & 
Wrap & chemical 
• When wrap combined with chemical 
• Limited details 
published on 1000–1500 g) 
mattress; Wrap & 
mattress and increased delivery room 
intervention methods. mattress & increased 
temperatures admit temperatures 36.7°C ambient delivery room 
(98.1 °F), SD, 1.014 in infants temperature 
1000-1500 grams and 36.89 °C (98.4°F) for infants b1000 g. Rohana et al. 
• 
Hypothermia defined as b36.5°C (2011)23 
axillary using World Health Organization categories of mild, moderate or severe. 
• Two cases of transient hyperthermia (skin temperature N37.5°C) seen in wrap group. No other complications 
reported. 
• Higher incidence of hypothermia persisted despite study intervention (28–44% wrap group vs. 64–73% control 
group). 
•
Study performed in Malaysia Simon et al. (2011)29 
RCT n = 110 
Polyethylene wrap while 
• Higher admission and post-stabilization 24-34 wk gestation 
infant wet immediately 
temperature in the skin wrap group born at study center 
after birth 
(35.8°C/96.4°F vs 34.8°C/94.6°F, P b .01). 
• No statistically significant difference in mortality, ventilation days, length of stay, IVH grade 3–4, NEC or RDS 
• Defined hypothermia as b36.5°C axillary. 
• Both the skin wrap and exothermic mattress as independent interventions fell short of preventing hypothermia 
(41%–68%) on admission. 
•
Small study group. Trevisanuto 
et al. (2010)26 
RCT n = 36 
Polyethylene wrap while 
• Admission temperature higher in the 24–28 wk gestation 
infant wet immediately 
mattress group (36.5°C) than skin wrap ≤1250 gram born 
after birth vs. exothermic 
group (36.1°C), P = .0445. at study center 
mattress 
• No statistically significant impact on morbidity or mortality. 
• Healthcare providers reported difficulty with use of skin wrap. 
RCT n = 96 
Polyethylene cap (head 
• Admission temperatures higher than 
• Defined 
hypothermia as b36.4°C b29 wk gestation 
wet with cap on, body 
36.4°C (97.5°F) in both study groups 
(97.5°F). born at study 
center 
dried) vs. polyethylene 
(38–57%) when compared to control 
• Two cases of hyperthermia in bag (head 
dried, body 
(10%). 
the skin wrap group. wrapped while wet) 
• Infants in the cap group had higher 
• Study performed in Italy. temperatures 1 hour after admission. 
• Both methods (cap and wrap) provided better thermal protection than conventional heat preservation methods. 
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in evaporative and radiant heat loss.3,30 The rationale for the use of an occlusive skin wrap is to decrease 
evaporative water and heat loss, as well as decrease convective heat loss immediately after birth, when losses are at 
their highest.1,4,22 This is accomplished by the creation of a microenvironment between the infant and the plastic 
which traps the warm and humidified air under the occlusive wrap and close to the infant's skin.3,30-32 Today, 
occlusive skin wraps are clear, allowing for easy visualization of the infant and the passage of radiant heat through 
the blanket to the infant. Along with easy visualization of the infant, stabilization in the delivery room can be 
accomplished with the occlusive skin wrap in place. In this evidentiary review, three different types of plastics 
bags/wraps were studied: polyethylene, polyurethane, and polythene. The majority of studies used 
polyethylene,19,20,23-29 whereas one study examined the use of a polyurethane wrap22 and another examined the 
effects of a polythene wrap.21 Numerous studies compared the use of a plastic bag20-22,24,25 to the use of a plastic 
wrap19,23,27,28 or cap.26 Sterility of the bag/wrap was reported in one study.22 An internet search of the products 
used in the other studies did not address sterility of the product. 
In  the  studies  reviewed,19-29  infants  were  received  in  a  pre-  warmed  towel upon birth, positioned under radiant 
heat  source  and  placed  in  the  plastic  bag/wrap  within  minutes  of  birth.  In  most  studies  the  infant's  body  was  not 
dried  before  wrapping,19-26,29  but  their  head/face  was  dried  with  a  warmed  towel.19-26,29  The  use  of  a  hat  was 
reported  in  6  of  the  studies  reviewed.19-23,29  The  occlusive  skin  wrap/bag  remained  on  the  infant  until  neonatal 
intensive  care  unit  (NICU) admission, this time frame ranged from 15–47 minutes.20,22-24,26,29 Resuscita- tion of 
the infant was possible with the wrap/bag in place with minimal disruption.20-25 
Extremely  premature  LBW infants received the most benefit from an occlusive skin wrap as an adjunct to current 
thermo-  protective  strategies  already used in the delivery room. Admission temperatures in the NICU were higher in 
preterm  infants  who  were  placed  in  the  occlusive  skin  wrap  while  wet  with  amniotic  fluid  and  under  radiant 
heat.19-25  Mortality  and  morbidity  were  the  most  common  variables  analyzed.  Carroll  et  al20  found a statistically 
significant  decrease  (P  =  .04)  in  grade  3–4  IVH  in  infants  assigned  to  the  plastic  wrap  group.  Fewer  deaths  were 
reported  in  premature  infants  that  underwent  stabilization  with  occlusive  skin  wrap,19,20,22,24,25,27  yet  none 
demonstrated a statistically significant improvement of survival with the use of occlusive skin wrap. 

Potential Complications Associated with Bags and Wraps 

Hyperthermia,  defined  as  N37.0°C  (98.6°F)–N37.5°C  (99.5°F),  was  reported  in  a  small  number  of  infants  in 
eight  of  the  eleven  studies  reviewed.19,21-27  It  remains  unclear  whether  these  infants  were  born  hyperthermic  or 
whether  hyperthermia  was  iatrogenic  and  related  to  the  skin  wrap.  Hyperthermia  occurs  when  the  infant  is 
overheated beyond its ability to rid body heat leading to brain protein structural 
 
Table 2. Proposed Evidence-Based Occlusive Skin Wrap Guideline Indication for use: 
Adjunct thermo protection in the delivery room to preserve heat by decreasing the evaporative heat loss and 
transepidermal 
water loss in the LBW premature infant. Age: 
Found to be most effective for premature (b29 weeks gestation) low birth weight (b1500 g) infants.19,20,22,24-28 
Exclusion criteria: 
Infants greater than 29 completed weeks of gestation due to a higher risk of iatrogenic hyperthermia19,21-27 and 
infants with major open congenital anomalies, (e.g., gastroschesis), since this population was excluded from most 
studies.19,20,22-26,29 Type of plastic wrap/bag: 
• Polyethylene plastic wrap/bag recommended due to this type of plastic being the most studied.19,20,22-29 
• Refrain from the use of plastic bag with a drawstring closure as a precaution against accidental injury to the 
infant's neck during stabilization.32 
• The data is unclear on whether sterility of the plastic wrap/bag is necessary. 
• Do not use previously used clean bags or laboratory specimen bags.32 Wrapping procedure: 
• Receive infant in pre-warmed towel and place immediately under radiant heat and directly on top of pre-warmed 
plastic wrap/bag.19-29 
• Wrap infant in occlusive skin wrap, without drying, from the neck down.19-29 
• Umbilical cord can remain exposed for umbilical line placement if necessary.19,23,29 
• May pat dry head and place a knit cap (not stockinette) for additional heat preservation.19-23,29 
• Proceed with stabilization per the Neonatal Resuscitation Program guidelines with the wrap on.10 
• Consider placing pulse oximeter probe on prior to closing wrap.23,29 
• Place additional pre-warmed towels on infant during transfer from the delivery room to the NICU.19-22 
• Transfer infant in pre-warmed transport incubator, radiant warmer table, or wrapped in pre-warmed 
towels/blanket.19-22,26,29 
• Infant can be weighed and assessed while still in wrap.19-29 Adverse effects: 
• Hyperthermia has been described in research studies with the use of occlusive skin wrap however, it is not known 
whether the infants with hyperthermia were born this way or if it was a direct result of the occlusive skin 
wrap.19,21-27 
• Potential complications mentioned in the literature, such as skin maceration and bacterial colonization of the skin, 
was not an adverse effect reported in the studies reviewed.19-29 Nursing action: 
• Obtain axillary temperature on arrival to NICU and serially thereafter to ensure infant does not become hypo/ 
hyperthermic.19,21-27 
• Remove wrap on admission, once infant stabilized, or within 60 minutes. Prolonged length of time in wrap is not 
recommended nor has it been studied.19,20,22-24,26,29 
changes and potentially resulting in seizures or death.1 The 
the drawstring on the plastic bag is pulled too tight 
around the addition of a hat/cap can possibly lead to hyperthermia and 
infant's neck.32 Other possible adverse effects 
related to the use brain injury by overheating the cortex and cerebellar regions in 
of occlusive skin wraps mentioned in the literature, 
such as skin conjunction with hypoxia or asphyxia near the time of 
maceration due to fragile skin sticking to the wrap 
and bacterial birth.26,31 It is believed that hyperthermia occurring with skin 
colonization of the skin,1,18 were not reported by 
the studies in wrap use is related to increased heat output from the radiant 
this review.19-29 Occlusive skin wrap use requires 
diligent heat source due to the inability of skin temperature probe to 
nursing care and frequent temperature assessments 
to monitor adhere in the moist microenvironment.1,18 Overly aggressive 
for both hyperthermia and hypothermia. 
thermo-protection strategies can swing the pendulum from 
The studies reviewed demonstrate that occlusive 
skin hypothermia to hyperthermia. 
wraps are effective in keeping LBW premature infants 
warmer Health care providers reported difficulty assessing heart rate 
when compared to routine delivery room heat 
conservation and/or breath sounds during stabilization with occlusive skin 
strategies. Occlusive skin wraps are most beneficial 
for infants wrap use.26 Another study reported displacement of the 
b1500 grams and b29 weeks of gestation. Potential 
polyethylene sheet during chest compressions and variability 
complications, such as hyperthermia, are associated 
with of use among practitioners. 29 A potential complication, 
occlusive skin wrap, therefore close monitoring is 
warranted. although not reported in the studies reviewed, is unintended 
Well-designed longitudinal studies are necessary to 
study injury to the neonate from the use of plastic bags with 
both the short-term and long-term effects of 
occlusive skin drawstrings. During stabilization, accidental harm may occur if 
wraps in the LBW premature population. 
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proposed Discussion 
There are two patented polyethylene skin wraps currently available for thermo-conservation in the delivery room: 
NeoW- 
guideline in this review can be used as a resource to assist nurses and healthcare institutions in developing thermo- 
regulation policies for the most fragile newborns, the LBW premature infant. rap Occlusive Wrap (Fisher and 
Paykel Healthcare Inc, Irvine, CA) and NeoDrape (NeoMed Inc, Woodstock, GA). Both products are clear square 
sheets of medical grade polyethylene plastic with NeoWrap being non-sterile and the NeoDrape 
References sterile. The cost for NeoWrap is $27.50 
for a box of 10 wraps or $60.50 for a box of 25 wraps (K Straiter, personal communi- cation, October 21, 2011) and 
the cost for NeoDrape is $135.00 for a case of 50 wraps (T Blair, personal communication, October 20, 2011). In a 
2005 survey by Knobel et al,32 respondents reported the use of alternative plastic wraps such as saran wrap, lab 
specimen bags, previously used clean bags, food service film, polypropylene bags, and bags with strings. Ethical 
concerns are raised when providers use a method of heat preservation that has not been tested, especially in the 
LBW premature infant population. The AAP's most recent neonatal resuscitation guideline for premature infants 
advocates using commercially available polyethylene plastic wrap, plastic food wrap or a food-grade 1-gallon plastic 
bag for infants b29 weeks of gestation.10 
Despite  recommendations  from  the  AAP's  neonatal  resusci-  tation  program  guidelines,10  the  most  current 
surveys  reported  that  only  20–29%  of  NICU  surveyed  used  an  occlusive  skin  wrap  at delivery for LBW premature 
infants.32,33Recent  work  by  Bissinger  and  Annibale4  on  “golden  hour”  thermoregulation  as  a  bundle  of 
interventions  for  the  extremely  LBW  infant in the delivery room and transport to the NICU reported a protocol used 
by  their  NICU  and  documented  a  decrease  in  hypothermia  rates.  No  current  guideline  exists  to  direct  clinicians 
specifically  in  the  use  of  occlusive  skin  wrap  for  LBW  premature infants. This author proposes a guideline specific 
to  occlusive  skin  wrap  use  in  the  LBW  premature  infant;  which  may  alleviate  some  of  the  gaps  in  knowledge  and 
varied  use  (Table  2).  This  proposed  guideline  is  not  a  standard  of  care, since additional studies are needed to better 
understand the full effects of this intervention.8 
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occlusive skin wrap as a barrier to heat loss as an adjunct to 
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14. LeBlanc M. Relative efficacy of incubator and 
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admission to the NICU of the LBW premature infant is not a 
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