AAP updates guidance on therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy

The American Academy of Pediatrics (AAP) has released an updated clinical report providing revised guidance on the use of therapeutic hypothermia for newborns with neonatal hypoxic-ischemic encephalopathy (HIE). The report, Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy, was published in the February 2026 issue of Pediatrics and updates an AAP policy statement first issued in 2014.^1,2

Neonatal HIE is a form of brain injury caused by reduced oxygen and blood flow to the brain around the time of birth and remains a leading cause of neonatal mortality and long-term neurodevelopmental disability. Therapeutic hypothermia is a neuroprotective intervention designed to reduce secondary brain injury by lowering core body temperature during a critical postinjury period.

According to the updated clinical report, therapeutic hypothermia involves reducing an infant’s temperature to approximately 92.3°F (33.5°C) within the first 6 hours after birth, when the benefit to brain injury and survival outcomes is greatest. Infants are maintained at this target temperature for 72 hours before controlled rewarming. Evidence summarized in the report supports the use of this therapy for infants born at 36 weeks’ gestation or later with moderate to severe HIE.

The report notes that infants who receive therapeutic hypothermia are more likely to survive and experience fewer long-term neurodevelopmental impairments compared with infants who do not receive cooling therapy. The guidance also addresses timing considerations, stating that when therapeutic hypothermia cannot be initiated within the first 6 hours after birth, treatment may still provide a small benefit if started between 6 and 24 hours of life. In such cases, the AAP recommends that clinicians consider individual clinical circumstances and engage in shared decision-making with families.

The updated guidance clarifies populations for whom therapeutic hypothermia is not recommended. The report states that available evidence does not demonstrate benefit for infants with mild HIE, and therapeutic hypothermia is therefore not advised for this group outside of a research setting. Additionally, the therapy is not recommended for preterm infants born at less than 36 weeks’ gestation.

For infants born at 35 weeks’ gestation, the report notes that existing studies have not demonstrated clear benefit or harm. As a result, therapeutic hypothermia may be considered in select cases, with careful discussion between clinicians and families regarding potential risks and uncertain benefits.

The AAP emphasizes that therapeutic hypothermia requires specialized infrastructure and expertise. Infants undergoing cooling therapy require continuous physiologic and neurologic monitoring and access to neuroimaging and pediatric neurology consultation. As such, infants should be cared for in specialized centers with established therapeutic hypothermia programs or transferred promptly when indicated.

Recognizing that many hospitals lack the resources to provide therapeutic hypothermia, the report encourages hospitals and community providers to establish formal relationships with regional centers that offer cooling therapy. The AAP also urges hospitals and delivery care teams to train clinicians to recognize early signs of neonatal HIE and to develop protocols for rapid evaluation, initiation of care, and transfer when necessary.

The clinical report further underscores the importance of structured neurodevelopmental follow-up for infants treated with therapeutic hypothermia. Ongoing follow-up enables the early identification of developmental delays or impairments, facilitating timely referral to appropriate intervention services.

The report was authored by members of the AAP Committee on Fetus and Newborn and the Section on Neurology. As with all AAP clinical reports, it was developed by medical experts, reflects a review of the current evidence base, and underwent multiple rounds of peer review before approval by the AAP Board of Directors and publication in Pediatrics.

References

1. AAP. AMERICAN ACADEMY OF PEDIATRICS ISSUES UPDATED GUIDANCE ON THERAPEUTIC HYPOTHERMIA TREATMENTS. AAP. Press release. January 26, 2026. Accessed January 26, 2026.
2. Zanelli SA, Wusthoff CJ, Lucke AM, et al; American Academy of Pediatrics, Committee on Fetus and Newborn; and Section on Neurology. Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy: Clinical Report. Pediatrics. 2026;156(4):e2025073627