The survival of very low-birth-weight (VLBW) infants has been shown to be effected by alterations in thermoregulation. Morbidity and mortality in these VLBW infants has remained higher than those in any other group of infants because of their innate vulnerability and because of exposure to risk factors in the environment. This leaves the premature infant vulnerable to cold stress especially in the first hours to weeks of life. At birth, the VLBW infant emerges from a warm, fluid environment and is thrust into a cold, abrasive environment before the protective layers of the epidermis have developed. Within minutes of birth, the core temperature begins to fall, particularly in infants whose birth weights are less than 1500 g. Hypothermia is a major cause of morbidity and mortality in infants; therefore, maintaining normal body temperatures in the delivery room is crucial. We reviewed evidence related to thermoregulation at birth in VLBW infants, including transepidermal water loss and temperature control in the delivery room, during stabilization and upon admission to the neonatal intensive care unit. Delivery room management that focuses on the adaptation of the infant as well as early interventions that improve long-term outcomes may emphasize the “golden hour” of care and improve outcomes in this extremely vulnerable population.