Thanks to our latest page about Latest Research with the automated feed on PubMed, this AAP Clinical Report came on my radar about Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy.

Great write-up about the background and evidence about HIE and hypothermia treatment.

In the recommendation (last page!), AAP recommends 1) blood gas aligning with asphyxia and 2) moderate-severe HIE, before initiating hypotherma.

Here in the Outer Rim (i.e. Sweden!), we have a more diverse #1 criteria in our national guideline, Apgar score ≤5 at 10 min, need of ongoing resusc beyond 10 min, and/or acidosis (pH <7.0 or BE <-16 first 60 min). We published about those so-called initial criteria, and one main take home was that the acidosis criteria as such had little impact on the risk to need hypothermia treatment. Low Apgar score and prolonged need of resusc was much more predictive.

Apologies for the long intro 🙂 to what I am thinking about - how do you select infant for hypothermia, i.e. what criteria do you apply before cooling down an infant with HIE? Do you have a local, regional or national guideline for this?

... what I believe to observe over the last years is that aEEG became a more important tool to initiate TH , as its challenging to differentiate clinically between mild and moderate HIE.

Of course together with one of the three perinatal sentinal events Stefan mentioned..

But if we lower the threshold for TH to 35w or even below, a moderately abnormal aEEG will become normal and again it would be hard to make the sometimes tiny difference between mild/moderate...

In the UK we have national, societies' (BAPM), network and local hospital guidelines. They are fairly well aligned and agree to the TOBY criteria.

• Infants ≥36+0 weeks’ gestation are eligible for therapeutic hypothermia

• Treatment must start within 6 hours of birth (BAPM suggest case-by-case decision up to 24 hours)

• Apgar score ≤5 at 10 minutes, ongoing need for resuscitation at 10 minutes, cord or first-hour blood gas with pH ≤7.0, or base deficit ≥16 mmol/L.

• Evidence of moderate-severe encephalopathy (Sarnat or Thompson score, or 'clinical assessment' - this does not align clearly)

• aEEG showing abnormal background or seizures is strongly encouraged where available but should not delay cooling if clinical criteria are met.

• Cooling is not recommended for mild encephalopathy or for infants <36 weeks’ gestation outside clinical trials.

Please find attached three levels of guidelines (I don't include a local one as usually they are not publicly available)

NICE therapeutic-hypothermia-with-intracorporeal-temperature-monitoring-for-hypoxic-perinatal-brain-injury-pdf-1809589753436101.pdf NWLPODN-HIE-cooling-Guideline-V1.5-final.pdf BAPM THNE_Framework_2025.pdf

El apgar, el estado acido base , el evento perinatal y la necesidad de reanimación junto a una valoración neurológica horaria y el monitoreo cerebral, nos acercan más a diferenciar quien requiere HT

We also follow most of the TOBY guidelines. However in our set up many babies reach after 1 hour but before 6 hrs. What ABG criteria should we take at that time. All criteria mention criteria within one hour or Cord Blood