An Encapsulated History of Thermoregulation in the Neonate

Sheldon B. Korones, MD* Introduction “Instinct leads mothers to keep their infants warm,” (1) and this instinct surely prevailed during the millennia that preceded recorded history. Organized institutional programs for the care of preterm infants did not appear until the last quarter of the 19th century. Tarnier in Paris and Budin, his intern and successor, were largely responsible for the first protocols for in-hospital global care of preterm infants. (2) Previously, “foundling asylums” cared for the unwanted infants who were “dropped off” by their parents. (2) Provision of “warmth, breastmilk, and tender nurture” by mothers (1) were the very fabric of infant care at home, and because preterm infants were “weaklings,” it followed that their postnatal care should be a continuation of the nurture that began in utero. Physicians cared for neonates at birth only if survival was in question or if the infant was obviously ill. Care at home by mothers was the rule. (1)(3) The idea of providing warmth for newborns, and for preterm infants in particular, was not always without challenge. Considerable controversy surrounded the overall care of neonates until the first quarter of the 19th century. This was based on a popular belief that newborns were as robust as adults, requiring only Spartan-like “hardening” after birth that could be accomplished best by repeated baths in very cold water. This practice disappeared during the second quarter of the 19th century. The return to traditional warmth went virtually unchallenged over the decades that followed, but there were a few exceptions. A review by Oliver (4) indicates that as late as the middle of the 20th century, some notably knowledgeable physicians advocated immersion of depressed babies in cold water to stimulate the onset of uninitiated breathing. Silverman stated that in the middle 1950s, Virginia Apgar was convinced that ice-water immersion was effective in resuscitation of asphyxiated babies. (5) During the 1930s, a large study in Boston concluded that somewhat lower environmental temperatures were beneficial to preterm infants. (6) This concept pervaded until 1958, when a higher environmental temperature was shown to be associated with lower mortality. (7)