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AIMS: To compare two cotside methods of blood glucose measurement (HemoCue and Reflolux II) against a standard laboratory method for the detection of neonatal hypoglycaemia in a developing country maternity hospital where hypoglycaemia is common. METHODS: 94 newborn infants and 75 of their mothers had blood glucose assessed on the same venous sample using three different methods in the Special Care Baby Unit and postnatal wards, Prasuti Griha Maternity Hospital, Kathmandu, Nepal: HemoCue and Reflolux II at the cotside; Roche Ultimate glucose oxidase method (GOM) in the laboratory. RESULTS: The mean (SD) values for blood glucose in newborn infants were GOM 2.5 (1.1) mmol/l; Reflolux II 2.1 (0.9); and HemoCue 4.2 (1.2). For mothers the values were GOM 5.3 (1.2) mmol/l; Reflolux II 3.6 (1.2); and HemoCue 5.6 (1.0). Bland-Altman plots showed that Reflolux II consistently underreads GOM blood glucose in neonates by 0.5 mmol/l (SD 0.7) and that HemoCue overreads glucose by 1.7 mmol/l (SD 0.8). For the detection of hypoglycaemia (< 2.0 mmol/l), Reflolux II achieved a sensitivity of 83%, a specificity of 62%, and a likelihood ratio of 2.2. HemoCue produced a sensitivity of 0% and a specificity of 100% using measured values. If 2.0 mmol were subtracted from all Hemocue values this rose to 81% and 68% and a likelihood ratio of 2.5. CONCLUSION: Although more accurate than Reflolux II for the measurement of blood glucose in mothers, HemoCue overreads glucose concentrations in neonates and is therefore potentially dangerous as a screening method for neonatal hypoglycaemia. Reflolux II is useful as a screening method for high risk infants (low birthweight, post-term) and could achieve a post-test probability of detecting hypoglycaemia in a high risk setting like Nepal of 50-60%.

Background Autism is a global phenomenon. Epidemiological studies estimate that 1–2% of children worldwide lie on the autism spectrum,1 with approximately 52 million individuals with autism across the globe. These estimates are largely driven, however, by prevalence estimates from high-income countries (HIC). Virtually no data exist, however, on the prevalence of autism in low-income countries (LIC) and none in a LIC rural setting. Aims Methods The Autism Quotient-10 (AQ-10) is a well-validated brief questionnaire of the 10 statements most strongly predictive of a diagnosis of autism in a UK population of children (sensitivity: 95%; specificity: 97%).2 We translated the AQ-10 – adolescent version in discussion with UK and Nepali paediatricians and clinical psychologists. The translated version was further developed and tested for acceptability in 3 focus groups of parents (n = 25). It was then piloted as a questionnaire with 136 families, following which minor edits were made only and additional fieldworker training provided. We conducted face-to-face interviews with 3984 parents from a cohort of 10–13 year-old children recruited from a 10-year follow-up study of a trial of women’s participatory groups.3 These families live in Makwanpur, a rural district of Nepal. Results Eleven out of 3984 children scored greater than 6 out of 10, indicative of autistic symptomatology. If the AQ-10 screening tool is as sensitive and specific in the Nepali population as it is in the UK, this would give an estimated true prevalence of 3 in 1000 (95% confidence interval 2 to 5 in 1000).4 Conclusion This is the first study to estimate prevalence of autism in a rural LIC setting. Prevalence estimates were lower than those in HIC. Future research is required to validate this tool through in-depth comprehensive assessments of high-scoring children. This preliminary estimate, combined with complementary research showing the lack of awareness of autism by Nepali professionals and parents, stresses the need to develop services to support families and children with atypical development in rural LIC settings.

Aim There has been a renewed focus globally on neonatal mortality as the deadline for the Millennium Development Goals approaches.1 Little is known about the neurodevelopmental consequences for survivors of complications in pregnancy, labour and the neonatal period in in low income countries outside of small, selective and typically urban facility studies.2 We ask which antenatal, birth and neonatal factors are associated with disability at age eleven in a large community recruited birth cohort from rural Nepal. Methods This cohort of 6,285 live births was recruited during a cluster randomised control trial of participatory women’s group on neonatal mortality.3,4 At age eleven 4,219 children were available for detailed follow up assessment including disability screening, with a retention rate in survivors of 72% (Figure 1). Disability was assessed by face to face interview using the newly developed UN/UNICEF Module on Child Functioning and Disability.5 To minimise the risk of posthoc testing first a list of hypothesised risk factors for adverse outcome was drawn up which was then consummated with the available data (Table 1). Factors with a univariate significance of Results Overall prevalence of disability was 7.4%. Maternal underweight (Odds Ratio (OR) 1.44 (95% confidence interval 1.01–2.08)), maternal cohabitation under 16 years of age (OR 1.50 (1.13–2.00)), increased weight at 1 month (per standard deviation OR 0.82 (0.71–0.95)) and reported diarrhoea and vomiting within the first 4 weeks of life (OR 2.48 (1.58–3.89)) were significantly associated with disability. The majority of hypothesised risk factors, including prematurity, were not significant on multivariable analysis (Table 2). Conclusions The relationship between poverty, maternal malnutrition and poor neurodevelopmental outcome is well recognised6 and our findings here emphasise the importance of breaking this cycle. The lack of association of most recognised risk factors for adverse outcome in high income settings may be due to high mortality and survival bias. As the neonatal mortality rate falls in countries like Nepal future research will need to revisit the relationship between birth environment and disability.

Background Women’s groups practicing a participatory action learning approach (WPGs) to addressing issues around pregnancy, childbirth and newborn and child health have been shown in a number of trials in low income countries and on their meta-analysis to significantly reduce maternal and neonatal mortality. 1 Their long term impact on survival has never been explored. Aims To assess the long term impact of exposure to WPGs on maternal and child mortality in participants of the first cRCT of WPGs in Makwanpur District, rural Nepal (2001–2003). 2 Methods Outcome data were collected by interview from the mother or the household head or from wider family members or neighbours where the family had moved. Analysis was carried out on an intention to treat basis using the a priori analysis plan in the original trial. 2 Sensitivity analyses were performed using individual and cluster level comparison of person-years. Results A total of 5824 mothers and 6078 children were alive 4 weeks postpartum (Figure 1). Reliable outcome data were available for 74.2% (4321) and 72.5% (4406) and probable outcomes for a further 24.8% (1452) and 26.8% (1630) of mothers and children respectively. On individual analysis, children born into the intervention clusters had 32% reduced risk of mortality after 4 weeks of age up to age of follow-up compared to those born into the control clusters (Table 1; Odds ratio (OR): 0.68, confidence interval (CI): 0.51, 0.92). Multilevel modelling adjusting for the effects of clustering and pairing of clusters showed a similar effect size, (OR: 0.69 CI: 0.49, 0.96; Table 1). Analyses using child mortality rates per person years are more conservative and the effect size smaller and non-statistically significant (however, this method does not take into account pairing of clusters, nor variation in size of clusters, Table 3) Fewer women in the intervention clusters died than control clusters, but the difference was not statistically significant. (Figure 1, Table 2). Conclusion Our findings suggest there are long term survival benefits for children of WPGs beyond the neonatal period. Long term follow-up of other trials of WPGs are warranted. References Prost A, Colbourn T, Seward N, et al . Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381 :1736–46 Manandhar DS, Osrin D, Shrestha BP, et al . Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004; 364 :970–9

Background A growing body of evidence suggests that changes in early-life environment can have lasting effects. To investigate this, we followed up children from a double-blind randomised controlled trial of antenatal multiple micronutrient (UNIMAPP) supplementation. The trial showed the intervention group was 77 g heavier at birth and 204 g heavier at 2.5 years, with a 2.5 mmHg lower mean blood pressure. Aims To investigate whether antenatal multiple micronutrient supplementation led to sustained phenotypic differences in mid-childhood. Methods The study was conducted in the south of Nepal, from September 2011-December 2012. We measured anthropometry, body composition using bioelectrical impedance (with a population specific isotope calibration), blood pressure and kidney dimensions by ultrasound. Spirometry was performed according to the ‘American Thoracic Society/European Respiratory Society’ standards, adjusted for children. We produced a personal estimate of air pollution exposure by sampling respirable particle mass in the microenvironments in which the children reside. We calculated the crude difference by trial group, then constructed a directed acyclic graph from which we chose potential confounders in multiple linear regression models. Results We saw 841 children (80% of total), mean age 8.5 years. Other than maternal education and residence, children lost to follow-up were no different. The unadjusted mean (95% CI) difference (intervention minus control), showed weight-for-age 0.05 z-scores (–0.09, 0.19), height-for-age 0.02 z-scores (–0.10, 0.15) and BMI-for-age 0.04 z-scores (–0.09, 0.18). Similarly there was no difference in blood pressure or lung function. The adjusted differences were similar for all outcomes. There was a tendency for girls in the intervention group to be slightly heavier with lower lung function values, but these results did not reach statistical significance. Conclusions Differences in phenotype were not apparent at 8.5 years between children born to mothers who received antenatal UNIMMAP supplements compared with iron and folate. While not ruling out physiological differences and longer-term effects, our findings do not suggest a sustained effect of antenatal micronutrient supplementation on growth.