Therapeutic Hypothermia in Sudden Unexpected Postnatal Collapse: Feasibility, Risks, and Long-Term Outcomes—A Systematic Review

TL;DR

Therapeutic hypothermia may help some neonates who experience sudden unexpected postnatal collapse, but evidence is limited and more research is needed.

Contribution

This systematic review evaluates the feasibility, risks, and outcomes of therapeutic hypothermia in neonates with sudden unexpected postnatal collapse.

Findings

Approximately half of cooled survivors had normal neurodevelopment.

Most SUPC events occur during skin-to-skin contact or breastfeeding, often in primiparous mothers.

Evidence for therapeutic hypothermia effectiveness is limited to low-quality observational studies.

Abstract

What are the main findings?
Therapeutic hypothermia has been increasingly applied to neonates with sudden unexpected postnatal collapse (SUPC), with survival and normal neurodevelopment reported in about half of cooled survivors.Most SUPC events occur during skin-to-skin contact or breastfeeding, often in primiparous mothers and without continuous supervision.

Therapeutic hypothermia has been increasingly applied to neonates with sudden unexpected postnatal collapse (SUPC), with survival and normal neurodevelopment reported in about half of cooled survivors.

Most SUPC events occur during skin-to-skin contact or breastfeeding, often in primiparous mothers and without continuous supervision.

What is the implication of the main finding?
While therapeutic hypothermia may offer benefit in selected SUPC cases, the evidence is limited to low-quality observational studies and remains inconclusive.Additional preventive strategies, including close monitoring during early skin-to-skin and breastfeeding, are essential to mitigate risk while maintaining the benefits of mother–infant contact.

While therapeutic hypothermia may offer benefit in selected SUPC cases, the evidence is limited to low-quality observational studies and remains inconclusive.

Additional preventive strategies, including close monitoring during early skin-to-skin and breastfeeding, are essential to mitigate risk while maintaining the benefits of mother–infant contact.

Background/Objectives: Sudden unexpected postnatal collapse (SUPC) is a rare but catastrophic event affecting apparently healthy neonates during the first days of life. Therapeutic hypothermia has been increasingly applied in this setting due to pathophysiological overlap with hypoxic–ischemic encephalopathy, but its effectiveness remains uncertain. The aim of this review is to systematically identify, appraise, and synthesize the evidence on therapeutic hypothermia for SUPC. Methods: We searched MEDLINE, Scopus, Embase, Web of Science, and Cochrane up to February 2025. Eligible studies included term or near-term infants with SUPC within seven days of life who underwent therapeutic hypothermia. Data were extracted on demographics, collapse circumstances, therapeutic hypothermia protocol, mortality, seizures, neuroimaging, and neurodevelopment. Results: Thirteen studies were included, encompassing 70 infants. Most events occurred within two hours of life, during skin-to-skin or breastfeeding, and were strongly associated with primiparity. Therapeutic hypothermia was typically initiated within six hours of collapse, using whole-body cooling at 33–34 °C for 72 h. Mortality was approximately 10% (widely ranging from 0 to 50%). Seizures were frequent (70–90%), and MRI abnormalities were reported in about half of cases. Approximately half of survivors demonstrated normal neurodevelopment at one year. Study quality was low to moderate, and risk of bias substantial. Conclusions: Therapeutic hypothermia is feasible in SUPC and survival with favorable outcomes has been documented, but the certainty of evidence is very low. Given recurrent risk factors such as primiparity and early skin-to-skin/breastfeeding, enhanced vigilance and preventive strategies are essential. Therapeutic hypothermia should be considered case by case, ideally within specialized centers and supported by registries.

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