New research published in the African Journal of Disability offers critical insights into the developmental profiles of infants diagnosed with hypoxic ischaemic encephalopathy (HIE) at Chris Hani Baragwanath Academic Hospital (CHBAH), a premier tertiary facility affiliated with the University of the Witwatersrand (Wits) in Johannesburg, South Africa. Hypoxic ischaemic encephalopathy, often resulting from oxygen deprivation and reduced blood flow during birth, remains a significant contributor to neonatal mortality and long-term neurodevelopmental challenges in low- and middle-income countries like South Africa. This study, led by Ayanda Myaka-Gama and colleagues from Wits' Department of Paediatrics and Child Health, analyzed outcomes for 239 infants with moderate and severe HIE between 2015 and 2020, highlighting both promising neuroprotective interventions and persistent gaps in care.

The findings underscore the value of academic-hospital collaborations in addressing pressing public health issues, providing data that can inform pediatric training programs and research opportunities at South African universities. With South Africa's neonatal encephalopathy rates estimated at 1.5 to 3.7 per 1,000 live births for moderate-to-severe cases—higher in sub-Saharan Africa at around 15 per 1,000—this work is timely for clinicians, educators, and policymakers.

What is Hypoxic Ischaemic Encephalopathy (HIE)?

Hypoxic ischaemic encephalopathy occurs when a newborn's brain experiences insufficient oxygen (hypoxia) and blood supply (ischaemia), typically around the time of birth. This can stem from complications like prolonged labour, placental abruption, umbilical cord issues, or maternal health factors such as preeclampsia. In South Africa, where perinatal asphyxia is a leading cause of neonatal death, HIE affects thousands annually, contributing to medico-legal claims and straining healthcare resources.

The condition is classified into three stages using the Sarnat system: mild (stage 1), moderate (stage 2), and severe (stage 3), based on clinical signs like alertness, tone, seizures, and reflexes. Globally, HIE leads to over 400,000 cases of neurodevelopmental impairment yearly, with higher burdens in regions like sub-Saharan Africa due to limited access to advanced care. Early symptoms include poor feeding, lethargy, and seizures, progressing to potential lifelong issues like cerebral palsy (CP), epilepsy, and cognitive delays if untreated.

In resource-constrained settings, prevention focuses on improving antenatal care, skilled birth attendance, and emergency obstetric services. Therapeutic hypothermia (TH)—cooling the infant's body to 33–34°C for 72 hours—has revolutionized outcomes in high-income countries, reducing death or disability by 30–50%. South Africa has adopted TH selectively in tertiary centers like CHBAH since around 2010, but uptake remains inconsistent nationwide.

Study Setting: Chris Hani Baragwanath Academic Hospital and Wits University

CHBAH, the world's third-largest hospital with over 3,000 beds, serves Soweto's 1.5 million residents and beyond as a key teaching site for Wits University's Faculty of Health Sciences. Its Neonatal Neurodevelopmental Clinic (NNDC), established over 35 years ago, routinely assesses high-risk infants using standardized tools like the Griffiths Mental Developmental Scales (GMDS). This retrospective study drew from the NNDC database, reviewing records of infants surviving to one year post-HIE.

The cohort reflected typical SA demographics: mean gestational age 38.8 weeks, birth weight 3,116g, 58% male, most vaginal deliveries, and 86% HIV-negative mothers. Researchers classified HIE severity via clinical and EEG criteria, with TH eligibility based on guidelines (gestational age ≥36 weeks, age <6 hours, moderate/severe encephalopathy).

Wits' involvement exemplifies how South African higher education drives clinical research, training registrars in neurodevelopment and fostering multidisciplinary teams. For aspiring academics, such environments offer rich opportunities in pediatric research—check higher ed jobs at institutions like Wits for roles in neonatology and child health.

Key Findings: Developmental Outcomes at One Year

At 12 months, the cohort's median General Quotient (GQ) on GMDS was in the average range (103 for moderate HIE, 89.5 for severe), with balanced profiles across locomotor, personal-social, hearing-speech, eye-hand coordination, and performance domains. However, 17.1% had neurodevelopmental impairment (NDI; GQ <85), including 9.2% with CP.

• Moderate HIE (88.3%, n=211): NDI 12.7% (mostly severe subtype), CP 7.6%.
• Severe HIE (11.7%, n=28): NDI 50%, CP 21.4%—significantly worse (p<0.05).

Complications were higher in severe cases: epilepsy 25% vs 7.5%, visual impairment 21.4% vs 0.5%, hearing issues 3.6% vs 1.4%. Among CP infants, 36% had seizures and 27% visual deficits. These rates are lower than global LMIC averages (30–80% impairment), likely due to TH and clinic follow-up.

Impact of Therapeutic Hypothermia on Outcomes

TH was administered to 69.5% overall (72% moderate, 50% severe), reflecting CHBAH's protocol. Infants receiving TH showed better GQ scores (p=0.002), lower NDI (12.1% vs 27.4%; p=0.005), reduced CP (5.4% vs 17.8%; p=0.002), and fewer epilepsy/visual issues. Even in severe HIE, TH groups had GQ medians of 101 vs 69 without.

This aligns with prior SA studies at CHBAH, where TH cut mortality from 29% to 17% in moderate-severe HIE. Yet, barriers like late presentation and resource limits hinder universal access—a national survey showed variable TH facilities across SA public hospitals. Wits researchers advocate expanding TH training in medical curricula to scale this intervention.

Related Wits-led work on hyperglycaemia in cooled HIE infants highlights metabolic risks, emphasizing integrated care.

Photo by Michael Kora on Unsplash

HIE Burden in South Africa: Statistics and Challenges

South Africa faces a disproportionate HIE load amid high neonatal mortality (20–30/1,000 live births). Perinatal asphyxia accounts for 20–30% of neonatal deaths, exacerbated by inequalities in maternal health and emergency services. In Gauteng, CHBAH handles thousands of high-risk deliveries yearly, with HIE incidence mirroring SSA's elevated rates.

• Global: 8.5/1,000 births.
• SSA/SA: 14.9–15/1,000; moderate-severe 1.5–3.7/1,000.
• Mortality: Up to 62.5% in severe untreated cases.

LMIC challenges include delayed diagnosis, inconsistent TH (only 10–20% sites equipped), and follow-up losses. This study notes many severe cases died pre-assessment, biasing toward milder survivors.

Assessing Development: The Role of Griffiths Scales

The Griffiths Mental Developmental Scales (GMDS-III), validated in SA contexts, measure five domains via play-based tasks, yielding GQ scores normed at 100 (SD 15). At 12 months, it's sensitive for gross motor/cognitive delays but less for language—prompting calls for 2-year reassessments. Wits' NNDC uses GMDS routinely, correlating well with Bayley Scales.

In this cohort, equivalent domain scores suggest uniform impact, but severe HIE lagged in locomotor/eye-hand. Long-term monitoring is vital, as 1-year normals may mask school-age deficits.

Implications for Pediatric Care and Higher Education

The study bolsters TH as standard for stage 2/3 HIE, urging policy for nationwide rollout and registrar training. Wits' model—clinic-based surveillance—can guide other universities like UCT or Stellenbosch in scaling neurodev programs.

For higher ed, it highlights research funding needs (e.g., MRC-SA grants) and interdisciplinary roles in paediatrics. Aspiring lecturers or researchers can contribute via lecturer jobs or research jobs at SA unis, advancing neonatal outcomes.

Related Research and Future Directions

Complementing CHBAH findings, a 2021 Wits study on TH survivors reported 20% adverse outcomes at 18–24 months. Ongoing trials explore TH safety in preterm/milder HIE. Future work should track to school age, incorporate genetics, and address social determinants like poverty/HIV.

Multi-site SA studies could benchmark TH equity. Explore academic career advice for entering this field.

Stakeholder Perspectives and Actionable Insights

Clinicians emphasize early TH referral; parents need support for follow-up. Policymakers: Invest in cooling equipment/training. Academics: Longitudinal cohorts for subtle deficits.

Photo by Steward Masweneng on Unsplash

• Step 1: Antenatal risk screening.
• Step 2: Rapid TH post-birth.
• Step 3: Standardized 1–2 year assessments.
• Step 4: Multidisciplinary interventions (PT/OT/speech).

Conclusion: Advancing Neonatal Neurodevelopment in SA

This Wits-CHBAH study affirms average 1-year development in most HIE survivors, crediting TH, but flags severe cases' risks. It calls for sustained follow-up and scaled interventions to curb SA's HIE burden. For professionals, opportunities abound in pediatric research—visit Rate My Professor, higher ed jobs, higher ed career advice, university jobs, or recruitment pages. Share your insights below and support evidence-based care.