Introduction The elevated surface area-to-body mass ratio, underdeveloped thermoregulatory systems and limited subcutaneous fat in neonates make intraoperative hypothermia a major perioperative complication. Hypothermia contributes to metabolic acidosis, coagulopathy, surgical site infections and prolonged hospital stays. Common warming methods include heated intravenous fluids and forced-air warming. However, new methods that consider environmental and physiological factors are being implemented. This systematic review identified, assessed and synthesized innovative neonatal hypothermia prevention strategies to improve anesthesia and surgical safety. Methods We searched PubMed, Embase, Scopus, Web of Science and the Sincedirect for studies on neonates, intraoperative hypothermia, surgery, prevention, warming strategies and temperature management from commencement to March ۲۰۲۵. RCTs, cohort studies and case-control studies evaluating innovative neonatal surgery strategies (e.g., phase-change materials, heated-humidified ventilation, incubator-based systems) were included. We excluded research on traditional warming methods, animal models, or adult/pediatric groups without neonatal subgroup analysis. We assessed bias in randomized controlled trials using the Cochrane Risk of Bias tool and observational studies using ROBINS-I. Our narrative data was integrated using a random-effects meta-analysis model when possible. Results The ۱۷ studies included ۱,۲۴۸ newborns in ۱۱ randomized controlled trials and ۶ observational studies. Recently evaluated strategies included heated-humidified respiratory gases (n=۸), phase-change warming mattresses (n=۴), reflective thermal insulation (n=۳) and integrated incubator systems (n=۲). Compared to standard care, heated-humidified gases significantly reduced intraoperative temperature decline (mean difference: +۰.۶°C; ۹۵% CI: ۰.۳-۰.۹; p۰.۰۱, ۶ RCTs, ۵۲۴ neonates). Phase-change mattresses prevented hypothermia during induction and prolonged surgery (RR: ۰.۷۲; ۹۵% CI: ۰.۵۵-۰.۹۳, ۳ RCTs). Reflective insulation and incubator-based systems showed promise, but small sample sizes and varied research methods limited the evidence. Since most RCTs had robust randomization and effective outcome measures, bias was low to moderate. Conclusion New methods like heated-humidified respiratory gases and phase-change warming devices reduce neonatal hypothermia during surgery. Reflective insulation and incubator-based systems may work, but randomized controlled trials are needed to prove it. High-risk neonates may benefit most from multiple warming methods. These findings emphasize the need for neonatal surgery temperature management protocols.
