30 - When Fewer Qualify for Cooling: Balancing Risks, Benefits, and Uncertainty under New AAP Guidelines?

Publication Number: 1027.30

Tara L. DuPont, University of Utah School of Medicine, Salt Lake City, UT, United States; Jennifer C. Keene, University of Utah, Salt Lake City, UT, United States; Betsy Ostrander, University of Utah School of Medicine, Salt Lake City, UT, United States; Erin K. Zinkhan, University of Utah School of Medicine, Salt Lake City, UT, United States; Con Yee Ling, University of Utah School of Medicine, Salt Lake City, UT, United States; Suzanne Franklin Carbaugh, Primary Children's Hospital/Intermountain Health, Sandy, UT, United States

Background: Therapeutic hypothermia (TH) is the standard of care for neonates with moderate or severe hypoxic ischemic encephalopathy (HIE) in developed countries; there is significant regional variation in the assessment of eligibility for TH. In October of 2025, the American Academy of Pediatrics (AAP) published guidelines on the use of TH, including recommended eligibility criteria (cord/one hour gas of pH < 7.0 or base deficit (BD) >16 or 10 min Apgar score < 5 or 10 minutes of assisted ventilation). The Intermountain Health (IH) system currently uses a more expanded set of eligibility criteria (Figure 1).

Objective: To compare cohorts identified by the current expanded eligibility criteria with those identified under the more restrictive AAP criteria and to assess the potential impact of adopting the new AAP recommendation

Design/Methods: Infants born at 16 IH birthing hospitals, between August 2024 and August 2025 were included. Patients were identified using a Tableau data registry; charts were individually reviewed when missing or unclear data. Trained advanced practice providers, neonatologists, or telehealth neonatologists performed Sarnat examinations. In-hospital outcomes were summarized using descriptive statistics for both the expanded IH and AAP eligibility criteria.

Results: Among 26,296 live births, 69 infants (2.6 per 1,000) underwent TH for moderate or severe HIE (Figure 2). A total of 166 neonates met the AAP criteria for neurological evaluation based on blood gas; of these, 40 (25%) had examination findings consistent with moderate or severe encephalopathy and received TH, with 3 (8%) deaths. Additionally, 741 neonates had cord pH between 7.01–7.15 or BD 10–16; 28 (4%) met clinical criteria for moderate to severe encephalopathy and received TH. Under the new AAP guidelines, 7 (24%) of these 29 would have qualified for TH based on 10-minute Apgar score and assisted ventilation; 22 (32%) would not meet AAP criteria. Among these 22, four had white matter injury (two with punctate lesions), two had small infarcts, 17 (77%) had no significant parenchymal injury on MRI. Two infants had seizures, one with white matter injury on MRI. See Table 1 for hospital outcomes.

Conclusion(s): Adopting the AAP TH recommendation would reduce the number of infants receiving TH by 32%. Out of 741 infants with a pH of 7.01-7.15, using IH criteria, 4% had moderate or severe HIE, and 76% of those will not meet AAP screening criteria. Given the limitations of this dataset, it is unclear if the risks of TH in this population exceed the benefits.

Table 1. Hospital Characteristics
pH.TH.Table1.PAS.pdfIn-hospital characteristics of infants who received therapuetic hypothermia

Figure 1. IH Guidelines for Therapeutic Hypothermia
IHC TH Guideline.pdfIntermountain Health Guidelines for evaluation of HIE

Figure 2. Flow chart of Infants evaluated for HIE
pH.TH.Fig2.pdfFlow chart of infants evaluated for HIE i