Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none declared.
The following intellectual conflicts of interest have been declared. B Scholefield, A Guerguerian and A Topjian were co-investigator on the THAPCA-IH trial. A Topjian, H Krishnan, and A-M Guerguerian are co-investigators/site PIs in the P-ICECAP study. B Scholefield, A Topjian, H Krishan and A-M Guerguerian were excluded from study selection, data abstraction and risk of bias assessment. No members of the writing group have any financial conflicts of interest.
Task Force Synthesis Citation
Barnaby R Scholefield, Thomas Main, Idan Yoel, Anne-Marie Guerguerian, Jason Acworth, Olugbenga Akinkugbe, Arun Bansal, James Gray, Hari Krishnan Kanthimathinathan, Maria Frazier, Jennifer Murphy, Andrea Christoff, Jessie Cunningham, Laurie J. Morrison on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Delivery of active temperature control after pediatric cardiac arrest: Evidence evaluation based on an ILCOR led scoping review, Synthesis of a Scoping Review [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Pediatric Life Support Task Force, 2027 XXX. Available from: http://ilcor.org
Methodological Preamble
This process was informed by an ILCOR-led scoping review of the delivery of active temperature control after pediatric cardiac arrest. The Scoping review followed a recent companion ILCOR-led systematic review and CoSTR which evaluated the comparative effectiveness of temperature targets and treatment duration after pediatric cardiac arrest.
The scoping review used Joanna Briggs Institute methodology(1) and PRISMA-ScR guidance(2) to map the extent, nature, and reporting of evidence across prespecified delivery domains. Because this was a scoping review, no meta-analysis or formal critical appraisal was undertaken, and the review was not designed to estimate treatment effects. The protocol was registered on October 30, 2025, on the Open Science Framework https://doi.org/10.17605/OSF.I...;
The current scoping review complements the previous systematic review, published in the 2025 ILCOR COSTR(3, 4), by describing how active temperature control has been initiated, delivered, monitored, and reported. All evidence identified in the current scoping review was considered by the Pediatric Life Support Task Force and is described below. Relevant discussion points and highlights of the evidence-to-decision process are also included. Data tables and the evidence-to-decision framework are provided as attachments.
Scoping Review Citation
Thomas Main, Idan Yoel, Anne Marie Guerguerian, Jason Acworth, Olugbenga Akinkugbe, Arun Bansal, James Gray, Hari Krishnan Kanthimathinathan, Maria Frazier, Jennifer Murphy, Andrea Christoff, Jessie Cunningham, Laurie J. Morrison, Barnaby R Scholefield on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Delivery of active temperature control after pediatric cardiac arrest (in press).
PCC
The PCC (Population, Concept, Context)
Population: Pediatric patients (>24 hours to 18 years of age) with a sustained return of circulation after an in-hospital or out of hospital cardiac arrest.
Concept: Description of the available evidence, and published range of practice for a) speed/rate of reaching temperature target, b) time to initiation of active temperature target management, c) speed/rate of rewarming in patients actively controlled at hypothermic temperature and d) methods of controlling temperature through the active temperature management process
Context: Patients managed within a pre-hospital, or hospital environment, receiving protocolized active temperature management.
Study Designs: Randomized trials, secondary analyses, observational cohorts, registry analyses, case series, clinical protocols, trial protocols, surveys, quality improvement reports, conference abstracts, and relevant grey literature.
Timeframe: Published and grey literature evidence identified by the review search strategy. Search date: 18th June 2026
OSF Registration https://doi.org/10.17605/OSF.IO/D56SP
Search Strategies
Search strategy: MEDLINE, Embase, Cochrane Evidence-Based Medicine Reviews, and ClinicalTrials.gov were searched on June 18, 2026, supplemented by relevant grey literature searches. Search terms addressed paediatric cardiac arrest and resuscitation combined with concepts relating to active temperature management, including hypothermia, normothermia, temperature control, cooling, and rewarming. The complete search strategy is provided in the supplementary material.
Inclusion and Exclusion Criteria
Not required
Data table
Summary of Included Evidence
The review identified 2874 records and included 66 publications (5-70) from 15 countries. The evidence base was heterogeneous and included randomized trials, secondary analyses of randomized trials, observational cohorts, registry analyses, case series, clinical protocols, trial protocols, surveys, quality improvement reports, conference abstracts, and grey literature.
Most included publications described practice, feasibility, protocol implementation, temperature control performance, or adverse event reporting rather than directly testing delivery components. Few studies were designed to determine the optimal timing of initiation, time to target temperature, rewarming rate, temperature control method, or prevention of temperature related complications. The evidence mapped by this review should therefore be interpreted as a description of current practice and reporting heterogeneity rather than as a comparative effectiveness synthesis.
Timing of Initiation
Thirty one publications(5, 6, 8, 12, 16-18, 21-23, 27, 32, 34, 37-40, 42, 43, 46-48, 50, 53, 54, 57, 64, 65, 68, 71) reported timing of initiation or related timing anchors for active temperature control. Reporting was heterogeneous, with intervals anchored to start points for cardiac arrest, CPR, emergency call, ROSC, admission, randomization, initiation of active temperature control, achievement of target temperature, rewarming initiation, or return to normothermia. No study directly compared earlier versus later initiation as a paediatric delivery intervention. Protocol targets, including initiation or target achievement within 6 hours(8, 17, 18, 27, 37-40, 47-50) or “as soon as possible,” (12, 16, 21, 34, 42, 68) were reported as protocol features rather than tested interventions. Therefore, no direct comparative evidence was identified to define an optimal time window for initiation after paediatric cardiac arrest.
Time to target temperature
Twenty publications(12, 14, 17, 21-23, 27, 34, 37-40, 43, 48, 50, 54, 57, 64, 65, 71) reported time to target temperature. Measures were inconsistently defined, with variable start points including admission, ROSC, CPR, randomization, or initiation of active temperature control, and variable end points including target temperature or reported cooling rate. One post hoc THAPCA OH analysis(50) evaluated time to goal temperature and did not identify a significant association between faster achievement of target temperature and improved outcome. Overall, the available evidence describes timing performance but does not determine whether faster or slower achievement of target temperature improves outcomes in children after cardiac arrest.
Rate of Rewarming
Twenty six publications(5-9, 11-14, 16, 17, 20-22, 26-30, 32, 34, 35, 37-40, 42, 44, 46-48, 50, 52, 54, 56, 57, 62, 64, 65, 68, 71) reported target rewarming rates, achieved rewarming, or protocolized rewarming approaches. No paediatric randomized trial directly compared rewarming rates after cardiac arrest. Many protocols used or implied gradual rewarming near 0.25°C per hour, (12, 16, 17, 22, 27-30, 34, 44, 46-50, 54, 64, 68) often over approximately 16 hours, but reported approaches ranged from slower rates of 0.1 to 0.2°C per hour to faster survey reported ranges up to 0.5 to 1.0°C per hour. The task force identified practice convergence around gradual rewarming, but no direct paediatric comparative evidence sufficient to define an optimal rewarming rate.
Method of temperature control
Forty seven publications(5-8, 11, 12, 16-23, 25, 27, 29-32, 34, 37-42, 45, 47, 48, 50-55, 58, 60, 62-65, 68-71) reported methods of temperature control. Servo controlled surface cooling was frequently described, but the literature primarily reported feasibility or protocol implementation rather than superiority of one method. Other methods included ECMO circuit temperature control, ice packs, forced air systems, tepid bathing, wet linen, environmental cooling, antipyretics, cold intravenous fluid boluses, and intravascular cooling catheters in selected patients. The evidence mapped did not identify a preferred device or method for paediatric active temperature control after cardiac arrest.
Adverse effects or complications
Twenty two publications(11, 13, 14, 16-20, 22, 23, 34, 37, 40, 41, 47, 54, 55, 58, 60, 63-65, 70, 71) reported adverse effects or complications. Reporting was variable, with inconsistent definitions, surveillance methods, and thresholds. Recurring domains included seizures, infection, arrhythmias, bradycardia, electrolyte abnormalities, hypotension, bleeding, thrombosis, transfusion, renal replacement therapy, rearrest, hypothermia below target, hyperthermia, and post rewarming hyperthermia. The THAPCA trials provided the strongest comparative safety data, but the broader literature remains insufficient to determine whether specific delivery protocols reduce temperature related complications.
Overall evidence summary: Across all delivery domains, the available literature primarily described clinical practice, protocol implementation, achievement and maintenance of target temperature, and adverse event reporting. The Task Force identified insufficient comparative paediatric evidence to determine the optimal timing of initiation, time to target temperature, rewarming strategy, or temperature control method following cardiac arrest.
Task Force Insights
1. Why this topic was reviewed.
- The 2025 ILCOR treatment recommendations address whether active temperature management (ATM) should be used and the supported temperature targets and durations. (3, 4)
- The current scoping review examined how ATM is initiated, maintained, monitored, rewarmed, and continued after rewarming. The new Good Practice Statement therefore complements the previous published treatment recommendations by providing the evidence map for implementation of the selected temperature pathway.
2. Narrative summary of evidence identified
The scoping review identified substantial variation in ATM delivery and reporting. Timing was measured from different clinical time points/anchors; time to target temperature was inconsistently defined; rewarming approaches varied; multiple temperature-control methods were used; and adverse events were reported using inconsistent definitions, surveillance methods, thresholds, and time points.
- Most publications described clinical practice, feasibility, protocol implementation, achievement and maintenance of target temperature or adverse events rather than evaluating delivery components as independent interventions. No direct pediatric comparative evidence established an optimal time for initiation, time to target temperature, rewarming rate, or temperature-control device.
- Gradual rewarming at approximately 0.25°C per hour was commonly reported, but reported rates ranged from approximately 0.1°C to 1.0°C per hour, and no pediatric randomized trial directly compared rewarming strategies. Servo-controlled surface cooling was frequently described and feasible, but the evidence did not identify a preferred device or method.
- However, ATM is a complex, multistage intervention in which initiation, maintenance, rewarming, and post-rewarming care are interdependent.
- A standardized protocol is expected to improve consistency, role clarity, continuity between phases of care, recognition and management of temperature deviation, documentation, fever prevention, and surveillance for complications. Potential complications include overcooling, electrolyte abnormalities, hemodynamic instability, arrhythmias, seizures, bleeding, infection, and post-rewarming hyperthermia. These anticipated benefits relate primarily to implementation reliability and safety; a direct improvement in survival or neurological outcome from protocolization has not been demonstrated.
3. Narrative Reporting of the task force discussions
- The Task Force considered that clinicians, children, and families would place a high value on avoiding fever, unintended hypothermia, preventable complications, and unwarranted variation in care. Standardized protocols are likely to be acceptable when they are developed by multidisciplinary teams, locally implementable, and allow clinically justified modification for individual patients.
- Potential disadvantages include additional training, documentation, monitoring, equipment, and staffing requirements, together with the risk of excessive protocol rigidity. Resource use, nursing workload, cost, and cost-effectiveness were incompletely reported and remain uncertain.
- Feasibility will vary between settings. Protocols dependent on specialized servo-controlled equipment, invasive monitoring, or highly trained staff could worsen inequity. Conversely, a standardized, device-neutral protocol may improve equity by specifying essential safety processes while permitting context-appropriate methods of temperature control.
- At a minimum, the protocol should define eligibility and the treatment start point; the selected temperature target and acceptable range; the site and frequency of core temperature monitoring; equipment checks; sedation, analgesia, and shivering management where applicable; maintenance duration; actions for overcooling or fever; the timing, rate, and endpoint of rewarming; post-rewarming fever prevention; adverse-event surveillance; documentation and handover requirements; escalation criteria; and circumstances permitting clinically justified deviation.
The THAPCA trials(48, 71) provide an important example of standardized delivery across the complete temperature-management pathway.
- The THAPCA trials(48, 71) used a protocolized targeted temperature management strategy initiated within 6 hours of return of circulation in comatose children after cardiac arrest. Patients assigned to hypothermia received servo-controlled surface cooling with the Blanketrol III system and cooling blankets to achieve and maintain a core temperature of 33°C (range 32–34°C) for 48 hours, followed by controlled rewarming over approximately 16 hours and subsequent maintenance of normothermia (36.0–37.5°C) through 120 hours after randomization. Patients assigned to the normothermia arm received the same temperature-management infrastructure, monitoring, sedation, and fever-prevention strategy, with active maintenance of temperature at 36.8°C (range 36.0–37.5°C) for the entire 120-hour intervention period. Continuous central temperature monitoring was performed using esophageal, bladder, or rectal probes, with dual-probe monitoring used for safety in most patients. Sedation and analgesia were routinely provided with benzodiazepine and opioid infusions, and neuromuscular blockade was used during cooling and as needed for shivering control. In patients supported with extracorporeal membrane oxygenation, temperature was regulated using the ECMO heat exchanger rather than surface cooling devices. The protocol emphasized standardized delivery of temperature control and rigorous prevention of fever in both treatment arms.
- Overall, the balance of anticipated effects probably favors standardized protocol use once ATM has been selected. This judgement reflects the complexity and safety requirements of ATM, the observed variation in delivery practices, the feasibility demonstrated by structured multicenter protocols such as THAPCA, and the expected improvement in process reliability.
- The Good Practice Statement does not prescribe a new temperature target, treatment duration, rewarming rate, or temperature-control device. It provides an implementation framework for reliably delivering the temperature pathway selected in accordance with the 2025 ILCOR treatment recommendations.
- The Task Force therefore concluded that standardized protocol use represents appropriate good practice despite the absence of direct comparative evidence demonstrating improved patient-centered outcomes with any of the implementation steps a) speed/rate of reaching temperature target, b) time to initiation of active temperature target management, c) speed/rate of rewarming in patients actively controlled at hypothermic temperature and d) methods of controlling temperature through the active temperature management process
Good Practice Statement (2027)
When using active temperature management* (ATM) for comatose infants and children following OHCA or IHCA clinicians should use a standardized temperature management protocol throughout initiation, maintenance, rewarming and post-rewarming care. (Good Practice Statement)
Complimentary to the existing COSTR citation from 2025(3, 4)
Treatment Recommendation 2025:
We recommend using active temperature management* (ATM) for comatose infants and children following OHCA or IHCA. (Strong recommendation; low certainty.)
We recommend using ATM to prevent central temperatures >37.5°C. (Strong recommendation; low certainty.)
We suggest that ATM protocols follow one of the published THAPCA trial interventions (48, 71):
- ATM 32–34°C for 48 hours, followed by gradual rewarming and maintenance at 36–37.5°C until a total of 120 hours, or
- ATM 36–37.5°C for 120 hours total.
as current evidence does not show superiority of either temperature target and there is insufficient evidence to recommend alternative durations. (Weak recommendation; low certainty.)
Evidence to Decision (EtD) Tables
PLS 4210 04 Evidence to Decision Table EtD_October2026
Knowledge Gaps
- Insufficient paediatric comparative evidence exists to determine the optimal delivery of active temperature control after cardiac arrest, including initiation timing, cooling performance targets, rewarming strategy, and temperature control method.
- Adverse event definitions, surveillance methods, reporting thresholds, and timing are inconsistent.
- Data are limited for important subgroups, including infants, drowning related arrest, cardiac versus non cardiac etiologies, in hospital versus out of hospital arrest, and children receiving extracorporeal cardiopulmonary resuscitation.
- Resource use, nursing workload, device availability, cost, and equity implications are incompletely reported.
Research Priorities
- Develop and adopt a core reporting set for active temperature control delivery after pediatric cardiac arrest.
- Evaluate early versus later initiation using clearly defined anchors and clinically relevant outcomes.
- Evaluate time to target temperature as a delivery exposure while accounting for arrest location, baseline temperature, severity of illness, and target strategy.
- Compare rewarming strategies in adequately powered paediatric studies or embedded randomized platforms where feasible.
- Compare servo controlled and non servo controlled strategies, and surface, intravascular, and extracorporeal approaches, using process, safety, resource, and patient centered outcomes.
- Prospectively collect adverse event data using standardized definitions for seizures, infection, arrhythmias, electrolyte abnormalities, hypotension, overcooling, hyperthermia, and post rewarming fever.
- Evaluate implementation strategies that reduce fever burden and inadvertent hypothermia across centers with variable resources.
- Align future trials and registries with pediatric core outcome measures for cardiac arrest, including survival, neurological outcome, and health related quality of life.
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