Rethinking the First Basic Steps of Newborn Care—Cold and Wet!

Drying the newborn promptly after delivery is one of the most important early steps of neonatal resuscitation.The sudden temperature change can lead to hypothermia quickly.Thermal management is foundational to delivery-room stabilization of preterm infants.Despite progress, hypothermia at neonatal intensive care unit (NICU) admission remains common and is associated with adverse outcomes, prompting continuous studies aimed at improving newborn temperatures at birth.While drying is recommended for more mature newborns, current guidance for very preterm infants favors immediate plastic wrapping without drying to minimize evaporative heat loss. 1 The NEODRY trial tested whether adding drying before wrapping improves normothermia in very preterm infants, and it also examined safety signals, including mortality.Elsewhere in JAMA Network Open, Cavallin and colleagues 2 report on the NEODRY trial, the largest randomized clinical trial to date evaluating whether drying before plastic wrapping improved temperatures compared with plastic wrapping alone.This was a multicenter, individually randomized, unblinded clinical trial conducted across 21 Italian tertiary hospitals (February 2023 to July 2024).Eligible infants were very preterm (<30 weeks and 6 days' gestation or <1500 g birth weight), born at the study center, and enrolled with antenatal consent.Infants were randomized 1:1 to drying before plastic wrapping vs immediate plastic wrapping without drying.The primary outcome was normothermia (36.5-37.5 C) at NICU admission.Normothermia occurred in 45.8% of dried infants (81 of 177) vs 46.3% of undried infants (82 of 177; risk ratio [RR], 0.99; 95% CI, 0.79-1.24;adjusted RR, 1.01; 95% CI, 0.74-1.37).Mortality was higher in the dried compared with undried group (14.7% vs 5.6%; adjusted RR, 2.71; 95% CI, 1.31-5.62).How should we interpret this increased mortality?The study was not designed nor powered to detect mortality in these infants.The NEODRY investigators did not find a pathophysiological mechanism to explain higher mortality and suggested this result may be due to chance or subgroup effects.Several other factors could have influenced this outcome.Clinicians were unblinded, introducing potential performance bias if a newer untested intervention was perceived as inferior.Additionally, thermal bundle elements varied across centers, such as differences in delivery room temperature.The use of heated humidified gases or other practices may have mitigated or exacerbated hypothermia.Lastly, antenatal consent may have introduced selection bias, as women with less time to approach before delivery or who received fewer doses of antenatal steroids or magnesium sulfate may have newborns with a higher risk for morbidity and mortality.Given the unexpected and unexplained nature of the mortality finding, and the wide confidence interval around the result, it is possible that this was a chance finding.Drying involves placing a towel on the infant, rubbing them, and then reapplying the bag, which not only delays occlusive wrapping but may also divert clinician attention from managing the infant appropriately by initiating respiratory support or timely administration of supplemental oxygen.The study was not designed to capture transient changes in heart rate desaturations in the delivery room, which have been highly correlated with outcomes such as mortality.Many of the deaths reported in the NEODRY Trial were due to severe intraventricular hemorrhage (sIVH), which is significant given that infants who do not achieve an oxygen saturation of 80% by 5 minutes of life have an increased incidence of sIVH and death. 3wever, these results should also be interpreted considering some important clinical differences that may not be translatable to all delivery room settings.The rates of delayed cord