Background: Neonatal hypothermia considerably contributes to neonatal mortality in low-resource settings. Despite awareness and established World Health Organization (WHO) thermal care guidelines, progress remains limited in many countries. Addressing gaps requires improved application and support for healthcare workers. This study aimed to develop pragmatic recommendations for optimising neonatal thermal care in low-resource settings, with specific objectives to: I) explore knowledge gaps in neonatal thermal care practices among healthcare workers; II) review thermoneutrality and cold stress concepts; and III) assess the existing evidence on warming devices for situations where skin-to-skin care is not feasible.

Methods: The first objective was achieved through an online survey of healthcare workers to identify gaps in knowledge and practices regarding neonatal cold stress and thermal care. For the second objective, a narrative review was conducted to summarise and synthesise existing concepts of thermoneutrality and cold stress. For the third objective, a rapid review of warming devices was performed to recommend optimal thermal care when skin-to-skin care is not feasible.

Results: The findings from the three studies led to the development of five key recommendations to enhance the WHO guidelines. These include: (1) physiological cold stress is clearly differentiated from mild hypothermia; (2) extremity temperature monitoring is recommended as a simple biomarker to detect cold stress before hypothermia occurs; (3) hand-touch temperature assessment is introduced as a complement to axillary or rectal temperature assessments, not as an inferior alternative to technical thermometry when the latter is unavailable; (4) patient characteristics, available resources, infrastructure and biomedical maintenance capacities at each facility should guide the selection of appropriate warming devices; and (5) to increase awareness of these points among healthcare workers.

Conclusion: The proposed recommendations address critical gaps in neonatal thermal care and aim to reduce the incidence of hypothermia and its associated complications while prioritising cost-effectiveness and feasibility. Enhancing healthcare workers’ awareness of cold stress and hypothermia and implementing hand-touch temperature monitoring are essential steps in this approach. A clear distinction between physiological cold stress and mild hypothermia is essential for effective intervention. The procurement guide supports informed decision-making about warming devices. Overall, these recommendations represent a step towards improving neonatal health outcomes worldwide. Nevertheless, further evaluation is needed to confirm their acceptability, feasibility, and effectiveness on a broad scale.