Therapeutic hypothermia at 35 weeks' gestation: navigating controversy between randomized evidence, real-world practice, and shared decision-making.

The role of therapeutic hypothermia (TH) in infants born at 35 weeks' gestation remains uncertain, with discordant findings between randomized and observational studies and evolving clinical guidance. This commentary examines how this uncertainty has translated into substantial variability in clinical practice and highlights the limitations of relying on any single evidence source in isolation. Current American Academy of Pediatrics (AAP) guidance explicitly recommends parental discussion and shared decision-making (SDM) in this setting. We argue that care at 35 weeks represents a preference-sensitive clinical scenario in which SDM is essential but inconsistently implemented. Drawing on ethical frameworks and emerging neonatal neurocritical care models, we emphasize the importance of transparent communication, parental engagement, and clinician training in supporting decision-making. Finally, we discuss the need for pragmatic, parent-informed research approaches to generate timely and clinically meaningful evidence in this rare and complex population. IMPACT: Clarifies uncertainty around therapeutic hypothermia at 35 weeks by integrating trial data, real-world evidence, and current guidelines. Demonstrates substantial practice variability, highlighting the need for more consistent, transparent decision-making. Positions shared decision-making (SDM) as a practical framework for preference-sensitive care in the NICU. Advocates for pragmatic, parent-informed research approaches to generate actionable evidence where trials are limited.