 Cooling studies from low and middle-income countries A number of small randomised controlled trials have been reported from low and middle-income countries. Individual studies were small and of poor quality. The largest of these trials reported from China had excluded babies at risk of perinatal sepsis and had substantial methodological concerns. Two studies reported increased mortality with cooling. Meta-analysis of all these trials showed a trend towards reduced mortality, however this was not statistically significant RR 0.74; 95 CI 0.4 to 1.3. More importantly, the confidence intervals were wide and therefore significant benefits or harm cannot be excluded. There were no data on long term neurological follow up after cooling therapy. In preparation for the HELIX trial, the investigators conducted a feasibility study of cooling therapy using a servo controlled cooling device Tecotherm in 201314, at Madras Medical College MMC, Chennai. The data from 58 cooled babies with neonatal encephalopathy and 112 contemporary un matched encephalopathic babies who had usual care normothermia admitted to the neonatal unit over a 15 month period are given below . Although the neonatal mortality in the cooled babies appears to be higher than the high-income country cooling trials, it was lower than the contemporary encephalopathic population at this hospital. High incidence of gastric bleeds and persistent metabolic acidosis were seen in both groups. The cases and controls were not matched and it is possible that the control babies were more unwell, and therefore had higher mortality 29 versus 54; Table 1; nevertheless, these data are reassuring and support further evaluation of cooling therapy in a rigorous randomised controlled trial manuscript in preparation. A paradox of private and public sector health care exists in India and other low and middleincome countries. Private hospitals are often very well equipped and have good tertiary intensive care facilities, but are not affordable to the low income populations. Moreover, these hospitals are relatively smaller annual delivery rates of less than 2000, and have a low encephalopathy burden. Public sector hospitals on the other hand, tend to be much larger 20,000 to 30,000 deliveries per year and offer free health care to the low income population. These hospitals have a huge encephalopathy burden both inborn and out-born babies, but lack resources and good neonatal intensive care facilities. Thus, significant health benefits will occur only if the neuroprotective therapies are usable and indeed effective in public sector hospitals in the low and middle-income countries, rather than in private health care. 