Each institution shall adopt a process and standardized tool to trigger therapeutic hypothermia when that is determined by alicensed independent provider to be the appropriate treatment for any neonate at or past 34 weeks gestation with findings of neonatalencephalopathy—or considered at risk for encephalopathy or a seizure event (per screening criteria). If the neonate is being considered fortherapeutic hypothermia and a definitive decision has not yet been reached, a repeat exam, ideally by the same licensed independentprovider, should be performed within the first hour to evaluate evolution of neonatal encephalopathy.

When the delivery clinician is concerned about the fetal status at delivery, a double-clamped segment of the umbilical cordshould be set aside for possible arterial blood gas assessment. If the neonatal 5-minute Apgar score is 5 or less, or if requestedby the delivering or newborn provider, umbilical artery blood should be sent for analysis whenever possible. Blood can bedrawn from the clamped segment of cord at any time within an hour of delivery.

Screening Criteria

  1. Neonates ≥ 34 weeks gestational age; and
  2. Concern for encephalopathy or seizure event; and
  3. Any one of the following:
    • sentinel event prior to delivery such as uterine rupture, profound bradycardia, or cord prolapse
    • low Apgar scores ≤ 5 at 10 minutes of life
    • prolonged resuscitation at birth, and/or intubation, and/or mask ventilation at 10 minutes
    • pH < 7.1 from cord or patient blood gas within 60 minutes of birth
    • ≤ -10 mEq/L from cord gas or patient blood gas within 60 minutes of birth

Absolute Exclusion Criteria:

  • gestational age < 34 weeks

Relative Exclusion Criteria:

(at the discretion of the accepting attending physician at the Level III facility)

  • IUGR < 1,750 grams
  • severe congenital anomalies /genetic syndromes /established metabolic disorders
  • major intracranial hemorrhage
  • overwhelming septicemia
  • uncorrectable, clinically relevant coagulopathy


For neonates meeting the eligibility criteria for therapeutic hypothermia, contact the closest Level III NICU with hypothermia capabilities. Document the discussion and rationale for the decision to offer or not to offer therapeutic hypothermia.

Download the Neonatal Therapeutic Encephalopathy Guidelines

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