Who to cool? A case series on therapeutic hypothermia following perinatal asphyxia from a private hospital in Tanzania

• Cooling with gel packs is feasible in low-resource settings. • All moderate HIE infants survived; all severe HIE infants died. • 1:1 nursing care may have improved survival compared to HELIX trial. • Careful selection for cooling can optimize outcomes and resources. Neonatal hypoxic-ischaemic encephalopathy (HIE), characterized by significant brain and multi-organ dysfunction, accounts for a substantial portion of neonatal mortality and morbidity among survivors. Therapeutic hypothermia (TH) has demonstrated promising efficacy in reducing both disability and mortality in affected neonates, but studies from low- and middle-income countries have reported variable outcomes. This case series presents the real-world experience of implementing therapeutic hypothermia in resource-limited settings. Ten neonates with moderate to severe hypoxic-ischemic encephalopathy (HIE) who met the criteria for therapeutic hypothermia underwent whole-body cooling using gel packs with servo-controlled heating at a level 4 private tertiary care hospital in Dar es Salaam, Tanzania. Core body temperature was continuously monitored via a rectal probe and maintained between 33.5°C and 34.5°C. Temperatures were effectively maintained within the target range, with a mean of 33.5 ± 0.7°C, and no adverse events were observed. The overall mortality rate was 50% (5/10). All neonates with severe HIE (5/5) died, whereas all those with moderate HIE (5/5) survived; two survivors exhibited no residual neurological deficits at one year of age. All neonates with a base excess (BE) greater than –20, a Thompson score ≥ 15 within the first six hours, and an abnormal middle cerebral artery resistive index did not survive. TH implementation using gel packs and servo-control is feasible. Neonates with severe HIE require careful selection for TH, as cooling these neonates in a resource-constrained setting may increase the overall resource burden.