Checking the Rulebooks Behind Cooling Treatment for Newborns: What a European Report Card Found

How a 2026 expert panel graded the official guidelines for cooling therapy in 11 European countries, and what it means for families

Cooling treatment is a well-proven way to protect the brains of newborns harmed by a lack of oxygen around birth, and many countries write official rules on how to use it. A panel of European experts graded these rulebooks from 11 countries and found that most had been put together with weak methods, left out much of what they should explain, and disagreed on which babies to cool. Cooling itself still works; the findings are a call to write better rules.

If your baby has been cooled, or a doctor has mentioned cooling, this article is not a reason for worry. It explains what the experts looked at, what they found and why it matters for making care more consistent for every family.

How cooling became a standard treatment for newborns

Sometimes a baby's brain does not get enough oxygen and blood flow around the time of birth, for example when the placenta or umbilical cord runs into trouble. The brain injury that can follow is called hypoxic-ischaemic encephalopathy, or HIE ("hypoxic-ischaemic" means short of oxygen and blood; "encephalopathy" means the brain is not working normally), and it is the condition at the heart of the European report described here [1]. For many years doctors could only support these babies and wait. They did learn to describe how unwell a baby's brain was: in 1976 two doctors named Sarnat set out three stages of severity based on how alert the baby was, their muscle tone and whether they had seizures [2]. In 1997 a team in Cape Town described and tested a simple points score, now called the Thompson score, that doctors can use at the bedside without special equipment [3].

Then came cooling, known medically as therapeutic hypothermia. The baby's body temperature is lowered by a few degrees for three days in the neonatal intensive care unit (NICU), the hospital ward for sick newborns, to slow down the damage. Large studies tested it carefully. One of them, the Infant Cooling Evaluation (ICE) trial, took place in 28 NICUs in Australia, New Zealand, Canada and the United States. By age 2, about 51 in every 100 cooled babies had died or had a major disability, compared with about 66 in every 100 babies who received standard care [4]. When experts combined 11 such studies including 1505 babies, they found that for every 7 babies cooled, one more baby survived without major disability [5]. Cooling became standard care, and the experts behind the new report describe it as one of the few proven advances in newborn medicine [1][6].

The research studies all used fairly similar rules about which babies to cool. But once cooling moved into everyday hospital care, each country wrote its own guideline: an official document telling doctors which babies qualify and how to look after them. Over time, these rules drifted apart. A 2024 review found that babies "may receive different care depending on the location in which they are born" [7]. In France, about 35 in every 100 cooled babies in one national study were treated in a way that did not match the French guideline [8], and in Switzerland care varied a great deal from one hospital to another [9]. Nobody had yet checked how well the guidelines themselves had been made.

How the experts graded the rulebooks

In 2026, a group from the European Society for Paediatric and Neonatal Intensive Care (ESPNIC), a European professional society for the intensive care of children and newborns, set out to do exactly that [1]. They gathered the official cooling guidelines of 11 countries: France, Germany, Italy, the Netherlands, Norway, Portugal, Slovakia, Spain, Switzerland, Turkey and the United Kingdom. No babies were involved in this study. It was a report card for documents.

Nine experts did the grading. Most were newborn specialists, joined by an intensive care doctor for children, an intensive care doctor for adults and an obstetrician (a doctor who cares for mothers during pregnancy and birth). None had helped write any of the guidelines. Each expert graded each guideline alone, without knowing who the other graders were, so nobody could sway anyone else.

They used two well-known international checklists. The first, called AGREE-II (short for Appraisal of Guidelines for Research and Evaluation), asks how carefully a guideline was made: for example, whether the right people were involved, whether the work was rigorous and whether the authors stayed independent [10]. The second, called RIGHT (Reporting Items for practice Guidelines in HealThcare), asks how completely a guideline explains itself to readers [11]. Using both together gives a fuller picture, because each checks things the other misses [12].

What the report card showed

The results were sobering. On how carefully the guidelines were made, not one scored well on the most important part, the rigour of how evidence was gathered and turned into advice [1]. The German guideline scored best overall and was the only one rated "medium" quality; all ten others were rated "low". The Norwegian guideline had the lowest overall score.

On how completely they explained themselves, the guidelines did poorly too. Of the checklist items, graders judged between about 20 in every 100 (Switzerland) and 49 in every 100 (Italy) to be fully reported. Most striking, none of the 11 guidelines clearly explained how it had judged the strength of the research behind its advice. When the checklist was looked at section by section, the French guideline came out best. The graders largely agreed with one another, which makes the results more trustworthy.

There was a bright spot. Most guidelines were clearly written and easy to follow. The problem was not that the advice was confusing, but that readers could rarely see how it had been decided. Picture a recipe that lists every step neatly but never says where it came from or whether anyone tested it. The guidelines also varied in age: the oldest dated from 2010 and the newest from 2025, and three still cited no clinical trial newer than 2009. All of them are in use today, and only one, the French guideline, is currently being revised.

Where the rulebooks disagree

Because the guidelines were made in different ways, they also say different things. According to the study's detailed tables, six guidelines cool only babies born at 36 weeks of pregnancy or later, while the other five set the limit at around 35 weeks [1]. They use different blood-test cut-offs and different brain-examination scores. They disagree on whether cooling can still be started more than 6 hours after birth: two say nothing, one forbids it, and eight allow it in some situations. And no guideline gave any advice for babies who also need a heart-lung bypass machine, a form of life support called ECMO (extracorporeal membrane oxygenation).

These differences matter most for babies at the edges. A careful 2025 study at 19 hospitals in the United States looked at babies born at 33 to 35 weeks. About 35 in every 100 cooled babies died or had a disability, compared with about 29 in every 100 babies who were not cooled, so cooling did not help this group [13]. Yet some European guidelines still allow cooling at 34 to 35 weeks in special cases. America's main children's doctors' organisation now advises that babies offered cooling should meet the rules used in the original research studies [14][1].

What this means for your family

If your baby is being cooled, or has been, please be reassured. Cooling is proven to help babies with moderate or severe HIE, and this study does not change that. It also did not look at how babies did; it looked at documents. Your baby's team uses its own training and experience, not only the written rules.

What the study does suggest is that care can differ from one country, and sometimes one hospital, to the next. It is always reasonable to ask your baby's doctors why cooling is or is not being offered, what signs they used to decide, and whether your baby is in a situation where experts disagree, such as being born a little early or arriving at the hospital late. Good teams welcome those questions.

What researchers are working on next

The authors conclude that no guideline should be used without careful checking and adjustment [1]. They suggest that newborn medicine follow the stricter methods now used for adult intensive care, where guidelines must rest on systematic reviews of the research, involve many kinds of experts and openly manage conflicts of interest [15]. Italy has already published a newer guideline built on a systematic review of the research and checked by an outside panel of experts from several specialties [16]. The authors hope that better rulebooks, ideally shared across Europe, will make care more consistent, and they call for studies on open questions such as cooling for babies born a little early. You can read more about cooling for babies born at 33 to 35 weeks in our earlier article, and about babies with milder brain changes.

The bottom line

Cooling treatment works, but the rulebooks that guide it across Europe were mostly built on shaky methods and do not always agree. This study is a first step towards clearer, fairer and better-explained rules, so that every baby who needs cooling gets it and babies who would not benefit are spared it, wherever they are born.

References

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  2. Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch Neurol. 1976;33(10):696-705. doi:10.1001/archneur.1976.00500100030012 ↩
  3. Thompson CM, Puterman AS, Linley LL, et al. The value of a scoring system for hypoxic ischaemic encephalopathy in predicting neurodevelopmental outcome. Acta Paediatr. 1997;86(7):757-761. doi:10.1111/j.1651-2227.1997.tb08581.x ↩
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