AAP 2026 Clinical Report: Updates on the management of therapeutic hypothermia in neonates

AAP 2026 Clinical Report: Updates on the management of therapeutic hypothermia in neonates

Summary by Dr. M. Tauseef Omer

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Over 2014 guidelines on the management of therapeutic hypothermia in neonates, the American Academy of Pediatrics has published a clinical report in 2026.

Re-emphasis:

1. Analyses of aggregate data from randomized-controlled trials, as well as data from registries, indicate that moderate therapeutic hypothermia with a target temperature of 33.5 °C initiated within 6 hours of birth and continued for 72 hours is a safe and effective neural rescue strategy for infants with moderate-to-severe HIE who are born at or greater than 36 weeks’ gestation.

2. Infants offered therapeutic hypothermia should meet inclusion criteria from published clinical trials such as (CoolCap Selective head cooling, NICHD Whole body cooling, TOBY Whole body cooling, neo-neuro whole body cooling, ICE trial, Selective head cooling with mild systemic cooling in China) , however, sentinel event is not necessary to initiate therapeutic hypothermia. 

Eligibility criteria include the following:

• Evidence of a peri-partum hypoxic-ischemic event based on biochemical criteria.

  1. Providers should advocate for the delivery team to draw cord blood gases for all depressed neonates and to facilitate the identification of neonates with HIE who may benefit from cooling.

  2. If a cord gas cannot be obtained, a blood gas during the first hour or as soon as possible after birth should be obtained.

• Evidence of moderate-to-severe encephalopathy by neurological exam (as below) or seizures is required. If moderate or severe encephalopathy is present and biochemical and clinical criteria are borderline without another identifiable cause, clinicians may consider therapeutic hypothermia.
  
  

  
  
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  There is limited evidence regarding the safety and effectiveness of therapeutic hypothermia for infants born at 35 0/7 to 35 6/7 weeks’ gestation. And this should be discussed with parents.
  
  May consider cooling up to 24 hours of life, but there is limited benefit in such cases, and this should be discussed with parents.
  
  There is insufficient evidence to support the use of therapeutic hypothermia for infants with mild HIE
  
  In all cases of possible HIE, even when therapeutic hypothermia is not administered, hyperthermia should be avoided.
  
  Erythropoietin (EPO) does no offer any additional benefit to date. Previous studies explored its neuroprotective and anti-apoptotic effects. So, therapeutic hypothermia and EPO is not advised outside research settings
  
  Medical centers offering therapeutic hypothermia should be capable of providing comprehensive clinical care, including mechanical ventilation; physiologic (vital signs, temperature) and biochemical (blood gas) monitoring; neuroimaging, including MRI prior to hospital discharge; continuous neuromonitoring and seizure detection with continuous EEG (preferred) or with aEEG; neurologic consultation accessible at all times, at minimum via telephone or telemedicine; family support; and a system in place for monitoring longitudinal neurodevelopmental outcomes.

Previously, we followed this criteria:

NICHD (National Institute of Child Health and Human Development) whole-Body Cooling

GA ≥36 weeks and ≤6 h of age

Moderate or severe encephalopathy 

Non syndromic baby

Acidosis
pH ≤7.00 or base deficit ≥16 mmol/L on umbilical cord or any blood sample obtained within 60 min of birth
OR
If blood gas is not available or pH 7.01 to 7.15 or base deficit 10 to 15.9 mmol/L on blood sample obtained within 60 min of birth.

PLUS
2 additional criteria:

History of an acute sentinel/perinatal event (eg, cord prolapse, fetal heart rate decelerations)
AND
Need for assisted ventilation at birth and continued for 10 min
OR
Apgar score ≤5 at 10 min after birth