Therapeutic Hypothermia in Children.

To the Editor: Moler et al. (May 14 issue)1 report that in comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia did not confer a significant benefit in survival with a good functional outcome at 1 year. Two issues concern us about rejecting such therapy. First, accounting for the presence of pupillary responses at presentation may influence the analysis. Moler et al. previously found that bilateral reactive pupils up to 12 hours after the return of circulation were independently associated with lower mortality.2 The current study did not present this information. Second, a Bayesian approach may show a significant reduction in mortality and morbidity among younger patients. The current study showed a trend toward statistical significance and a significant difference in the time to death. Neonatal studies have shown that among infants with hypoxic–ischemic encephalopathy, therapeutic hypothermia is associated with a 25% reduction in the rate of death or severe neurodevelopmental impairment.3 Thus, we speculate that reanalysis with the use of a Bayesian statistical approach4,5 that accounts for prior probabilities from neonatal trials involving younger patients may show an effect. For older patients, prior probabilities from trials of therapeutic hypothermia involving adults may be used, with sensitivity analyses for patients of intermediate age.