Guideline 32: Therapeutic Hypothermia for Neonates

Each institution shall adopt a process and standardized tool to trigger therapeutic hypothermia when that is determined by a licensed independent provider to be the appropriate treatment for any neonate considered at risk for encephalopathy or a seizure event (per screening criteria). If the neonate is being considered for therapeutic hypothermia and a definitive decision has not yet been reached, a repeat exam, ideally by the same licensed independent provider, 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 cord should be set aside for possible arterial blood gas assessment. If the neonatal 5-minute Apgar score is 5 or less, or if requested by the delivering or newborn provider, umbilical artery blood should be sent for analysis whenever possible. Blood can be drawn from the clamped segment of cord at any time within an hour of delivery.

For infants determined to be eligible for therapeutic hypothermia, placental pathology should be obtained, ideally with a pathologist with perinatal expertise.

Screening Criteria

1. Neonates ≥ 35 weeks gestational age
2. Concern for encephalopathy or seizure event
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
   • Abnormal base excess ≤ -10 mEq/L from cord gas or patient blood gas within 60 minutes of birth

Absolute Exclusion Criteria:

• Gestational age < 35 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

Recommendations

For neonates in the community meeting the eligibility criteria for therapeutic hypothermia,¹ 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

1. CRICO. Therapeutic Hypothermia in Neonates: Recommendations of the Neonatology Task Force. Published 2016. Updated October2025. https://www.rmf.harvard.edu/Risk-Prevention-and-Education/Guidelines-and-Algorithms-Catalog-Page/Guidelines-Algorithms/2025/neonatalencephalopathy