| Midazolam, sufentanil, morphine, and paracetamol are the most frequently used medications during therapeutic hypothermia in French neonatal intensive care units, used by 94%, 88%, 84%, and 82% of centers, respectively. Maintenance infusion doses for these agents vary widely between centers, and only 9.8% of centers adjust doses based on pharmacokinetic considerations.1 |
| Topical drug absorption is increased in young infants due to thinner, more hydrated skin and increased cutaneous blood flow, while intramuscular absorption is decreased due to reduced skeletal muscle mass and perfusion. |
| A new AAP clinical report details how structural discrimination and socioeconomic barriers worsen outcomes for neonates admitted to the NICU, and calls for routine monitoring of care delivery by sociodemographic factors.2 |
Routine endotracheal intubation during therapeutic hypothermia was reported by 70.6% of centers, most often for optimization of neuroprotection and management of drug-induced apnea. Overall, 74.5% of NICUs expressed interest in developing protocols to allow cooling without routine intubation, although 63.2% of these interested centers currently practice systematic intubation.
Maintenance infusion doses for morphine, sufentanil, and midazolam varied markedly between centers, and only 9.8% of centers reported using pharmacokinetic considerations to guide dose adjustments. Morphine clearance is reduced during hypothermia, and doses exceeding 10 µg/kg/h between 24 and 72 hours of cooling may produce potentially toxic plasma concentrations.1
Limitation: Survey-based findings are subject to reporting bias and may not fully reflect actual bedside practices; the survey did not evaluate seizure management or hemodynamic strategies, which may also influence sedation requirements.
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Clinical Implication
Protocols for analgesia and sedation during therapeutic hypothermia should incorporate pharmacokinetic-based dose reassessment, particularly for morphine infusions approaching or exceeding 10 µg/kg/h after 24 hours of cooling, and should specify clear criteria for escalating or de-escalating routine intubation practices.
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Age-related differences in drug absorption affect dosing decisions across routes of administration. In young infants, thinner skin, higher skin hydration, and increased cutaneous blood flow increase topical drug absorption. Intramuscular absorption follows the opposite pattern, decreasing due to reduced skeletal muscle mass and perfusion.
| Route | Absorption in Young Infants | Clinical Marker |
|---|---|---|
| Topical | Increased, due to thinner skin, higher hydration, and increased cutaneous blood flow | Systemic effects, including toxicity, can occur from products considered low-risk in older patients (e.g., lanolin-containing preparations such as Aquaphor) |
| Intramuscular | Decreased, due to reduced skeletal muscle mass and perfusion | Intramuscular dose equals the intravenous dose in young infants; in older children and adults, the intramuscular dose is lower |
These absorption differences apply to excipients as well as active drugs. A topical product tolerated well in an older child, such as a lanolin-containing emollient, can still produce systemic exposure in a young infant.
| Bottom line: Route-specific absorption differences, not dose per kilogram alone, should guide topical and intramuscular drug selection and dosing in young infants. |
AAP Calls for Identifying and Addressing Social Inequities in High-Risk Neonatal Care Delivery
Published online July 20, 2026, in Pediatrics, a new AAP clinical report examines how interpersonal and structural discrimination can harm the health and well-being of high-risk infants and their families in the NICU. The report identifies race, ethnicity, language, geographic location, gender identity, sexual orientation, and national origin as intersecting factors contributing to inequities in neonatal care, and calls for routine monitoring of neonatal outcomes and care delivery by sociodemographic factors.2
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What This Means in Practice
The report recommends investing in bilingual clinicians and professional medical interpreters, educating staff on culturally humble care, and providing structured support for families' social and mental health needs from NICU admission through post-discharge follow-up.
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- Osswald C, Le Duc K, Chaton L, Joriot S, Storme L, Flamein F, Boukhris MR. Nationwide variability in sedation, analgesia, and developmental care practices during neonatal therapeutic hypothermia: a French national survey. Eur J Pediatr. 2026;185:487.
- American Academy of Pediatrics. American Academy of Pediatrics calls for identifying, addressing social inequities in high-risk neonatal care delivery. AAP News Release. July 20, 2026. Accessed August 3, 2026. https://www.aap.org/en/news-room/news-releases/aap/2026/american-academy-of-pediatrics-calls-for-identifying-addressing-social-inequities-in-high-risk-neonatal-care-delivery/
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