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The present article is based on the title "Biscuit Jatra of Pokhara: Past and Present". The Newar community, established in Kathmandu Valley as the original settlement, has been making its Karmabhoomi (land of action) in various places outside Kathmandu. Some Newar communities have come and settled in Pokhara Valley. During this migration, the Newar community brought various cultural fairs and festivals with them. The Bisket Jatra (festival) at Pokhara is one of them. What are the changes that have occurred in the past and present of Bisket Jatra in Pokhara? How do you celebrate Biscuit Jatra in Pokhara? The major focus of this research rests on these two questions.in this article. The main purpose of this article is to investigate these two main questions. To fulfill the objective, the researcher has used qualitative research method. The analysis of this research has shown that while celebrating Bisket Jatran here at Pokhara, people stay at home to celebrate the Bhoj associated with the festival, but, besides that, there is no significant participation in the Jatra in comparison to the past.

Introduction: With advances in therapies during antenatal and perinatal period, there has been apparent decrease in incidence and mortality due to respiratory distress syndrome (RDS). However, there is paucity of data on exact incidence and outcome of RDS in resource limited setting. This study was conducted with the primary aim to describe the outcome of RDS and analyze the predictors for mortality. Methods: A prospective observational study was conducted in the Neonatal Intensive Care Unit (NICU) and Neonatal Unit of Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal from October 2019 to April 2021. Results: A total of 94 preterm newborns developed RDS giving prevalence of 20.5 per 1000 live birth cohort at TUTH. Incidence of RDS among preterm babies was 14.6%. The median duration of continuous positive airway pressure (CPAP) was 48 hours (Range 8 - 192 hours). Inhospital mortality rate was 15 (15.96%). Lower gestational age and premature rupture of membrane (PROM) were significantly associated with higher mortality whereas Normal Vaginal delivery (NVD) was associated with lower mortality. Logistic regression analysis for risk of dying for the cohort predicted that lower birth weight (AOR = 0.99; 95% CI = 0.99 - 0.99; P = 0:01), sepsis (AOR = 145.14; 95% CI = 5.04 - 4175.15; P = 0:004) are independently associated with increased risk of dying whereas increase duration of NICU stay decreased the risk (AOR = 0.71; 95% CI = 0.54 - 0.91; P = 0:01). Conclusions: The mortality rate decreases with increasing gestational age and birth weight. A number of neonatal factors, either in isolation or in combination, were significantly associated with in-hospital mortality

The Nat community, which involves the people of a Madheshi Dalit caste, comprises a nomadic lifestyle and history. The main objective of this study is to investigate the lifestyle, history, citizenship, ownership of property, profession, religion, education and usage of information technology of the nomadic community with permanent residence. In this research, descriptive and explanatory research framework has been adopted. Data were collected through in-depth interviews using qualitative and quantitative methods and household survey methods. Historical and frequency analysis were adopted to analyze data. Information and data were collected through in-depth interviews with 47 respondents using a semi-structured questionnaire. This study reveals that lifestyle and occupation of Nat community were closely related with their poor educational status. Out of 47 participants of this community, 45 had got Nepali citizenship. It was found that 43 of the 47 participants had their own house. It has been found that the main occupations of all 47 respondents were begging. Out of total, 58 percent of school age children were out of school and the school going children scarcely went to school. With their nomadic lifestyle and begging occupation, they appeared be in the primitive hunter-gatherer stage of human social development. Due to the lifestyle of the Nat community, they were found to be illiterate, poor and marginalized.

Introduction: This study was conducted with the aim to describe the clinical presentation of diphtheria in children, relationship between clinical disease and immunization status, complications of the disease and adverse events due to anti diphtheria serum (ADS). Methods: All patients admitted at Tribhuvan University Teaching Hospital, Kathmandu from July 2016 to November 2018 with clinical diagnosis of diphtheria were included in this study. Results: There were total 12 children and age ranged from five to 15 years, out of which seven (58%) were males and five (42%) were females. All of them were immunized except one whose immunization status was unknown. All of them had tonsillopharyngeal diphtheria. Four patients (33%) also had nasal and five (42%) patients had additional laryngotracheal diphtheria. Seven patients had bull neck on presentation. Four patients had airway obstruction due to laryngotracheal diphtheria requiring tracheostomy. Throat swab for Corynebacterium Diphtheria by Albert stain and Gram stain were positive in 10 patients, and in nine, diagnosis was confirmed by culture. Six patients (50%) were given anti diphtheria serum (ADS) out of which four patients (66.66%) developed anaphylaxis. Myocarditis was the commonest complication seen in four patients (25%). All children with myocarditis developed complete heart block (CHB) and none of them survived. Conclusions: Tonsillopharyngeal diphtheria was the most common clinical presentation and myocarditis was highly fatal complication. This study emphasizes on the need for careful surveillance, early laboratory confirmation and careful administration of ADS in patients with clinical diagnosis of diphtheria.

To the editor: The global burden of chronic obstructive pulmonary disease (COPD) disproportionately affects low- and middle-income countries (LMICs). Well-recognized challenges to the mitigation of COPD in LMICs include the absence and poor implementation of COPD guidelines and lack of access to diagnostic siprometry...

Kikuchi-Fujimoto Disease (KFD) is a rare benign, condition of necrotising histiocytic lymphadenitis. In this case report, we discuss a case of 10 year old male patient who presented with a fever, rash and generalised lymphadenopathy that was not attributable to the more common causes. Axillary lymph node biopsy confirmed the diagnosis of KFD. Treatment with prednisolone improved his symptoms but after six months he had recurrence of his symptoms. He was investigated again and finally met diagnostic criteria for SLE. This case report highlights importance of close follow up in a child with KFD.

Madhesh movement is a series of spontaneous, aggressive responses and reaction caused by social injustices and discriminatory activities, imposed by the state on the part of the Tarai-Madhesh inhabitants (the Madheshis) for centuries. Although it was dormant during the whole past centuries, it exploded in 2007 in a more exposable and organized way. The Madhesh movement has connection with Maoist movement; it is result of Maoist movement. The Madheshi learnt to revolt by the Maoist and followed the same sorts of strategy to motivate the Madheshi people in Tarai-Madhesh. The Madhesh movement has been playing a vital role in the mainstream politics of Nepal, forming significant socio-political discourse. This study has used semi-structural interview, key informant interview, focus group discussion and case study method. The secondary data available in news series and journals helps to analyze of post-displacement impact in Tarai-Madhesh. The Tarai-Madhesh is demographically a very heterogeneous mixture of the people of the Madheshi origin and people of the Pahade (Hill people) origin. However, the Madhesh movement caused some degrees of displacement on the part of the people of the Pahade origin, on the basis of geographical and ethnic roots. Socio-economic life of displaced households in the Tarai-Madhesh (post-displacement impact): Regarding displacement, mostly the people of Pahade (hill people) origin were targeted by the Madhesh movement activists in Madheshi majority locations and were forced to get displaced. However, surprisingly, the displaced inhabitants held no complaints against the displacement inducing circumstances and were quickly adapted to the new relocated places.

Introduction: The pandemic caused by coronavirus disease 2019 has adversely affected the health of all individuals including pregnant women. The susceptibility of pregnant women and their foetuses to severe acute respiratory syndrome coronavirus 2 infection is not clearly known. The objective of this review is to summarise the available evidence on foetal and neonatal outcomes of pregnant women with confirmed coronavirus disease 2019. Methods: The review was conduced by searching the PubMed and MedRxiv databases for studies reporting outcome of pregnancy with confirmed coronavirus disease from December 2019 to April 2020 using combination of terms "pregnancy", "coronavirus disease 2019", "foetal outcome" and "neonatal outcome". Only peer reviewed articles reporting outcome of pregnancy with confirmed coronavirus disease 2019 were included in the review irrespective of language. Ongoing pregnancies, induced abortion, and pregnancies without outcome were excluded from analysis. Variables extracted and analysed included gestational age at delivery, mode of delivery, foetal and neonatal outcome. Results: In total, 21 studies consisting 230 pregnant women including three twin pregnancies were enrolled in the study. Fever and cough were the most common symptoms reported in pregnant women. One hundred and sixty-two (70.4%) pregnant women underwent cesarean section and there were 68 (29.6%) preterm deliveries. Eight babies tested positive out of 161 newborns that were tested for coronavirus infection. Among adverse outcomes reported, there were two miscarriages, two still births and only one neonatal death. Conclusions: Outcome of pregnancy with coronavirus disease 2019 in late trimester appears to be favourable. Occurrence of preterm delivery and cesarean section appear higher among infected pregnant women in comparison to general population. There was no conclusive evidence of vertical transmission.

Improved biomass stoves may not reduce indoor air pollution as much as is needed to have an impact on adverse birth outcomes., Key Findings Two trials in rural southern Nepal reduced indoor air pollution through improved biomass or liquid petroleum gas stoves, but levels were still much higher than World Health Organization standards.Exposure of pregnant women to these lower air pollution levels was not associated with reduced incidence of low birth weight, preterm birth, and small for gestational age. Key Implications Improved biomass stoves may not reduce indoor air pollution as much as is needed to have an impact on adverse birth outcomes.Emphasis should be placed on behavior to reduce use of biomass stoves when using improved ones for maximum reduction of pollution., Background: Few randomized trials have assessed the impact of reducing household air pollution from biomass stoves on adverse birth outcomes in low-income countries. Methods: Two sequential trials were conducted in rural low-lying Nepal. Trial 1 was a cluster-randomized step-wedge trial comparing traditional biomass stoves and improved biomass stoves vented with a chimney. Trial 2 was a parallel household-randomized trial comparing vented biomass stoves and liquid petroleum gas (LPG) stoves with a year’s supply of gas. Kitchen particulate matter of 2.5 μm or less (PM2.5) and carbon monoxide (CO) were assessed before and after stove installation. Prevalent and incident pregnancies were enrolled at baseline and throughout the trials. Birth anthropometry was compared across differing exposure times in pregnancy. Results: In trial 1, the mean 20-hour kitchen PM2.5 concentration was reduced from 1380 µg/m3 to 936 µg/m3. Among infants born before the intervention, mean birth weight and gestational age were 2627 g (SD=443) and 38.8 weeks (SD=3.1), and 39% were low birth weight (LBW), 22% preterm, and 55% small for gestational age (SGA). Adverse birth outcomes were not significantly different with increasing exposure to improved stoves during pregnancy. In trial 2, the mean 20-hour PM2.5 concentration was 885 µg/m3 in households with vented biomass and 442 µg/m3 in those with LPG stoves. Mean birth weight was 2780 g (SD=427) and 2742 g (SD=431), among households with vented and LPG stoves, respectively. Respective percentages for LBW, SGA, and preterm were 23%, 13%, and 42% in the vented stove group and not statistically different from 31%, 17%, and 42% in the LPG group. Conclusions: Improved biomass or LPG stoves did not reduce adverse birth outcomes. PM2.5 and CO following improved stove installation remained well above the World Health Organization indoor air standard of 25 µg/m3 or intermediate air quality guideline of 37.5 µg/m3. Trials that lower indoor air pollution further are needed.

Summary Background Maternal influenza immunisation can reduce morbidity and mortality associated with influenza infection in pregnant women and young infants. We aimed to determine the vaccine efficacy of maternal influenza immunisation against maternal and infant PCR-confirmed influenza, duration of protection, and the effect of gestational age at vaccination on vaccine efficacy, birth outcomes, and infant growth up to 6 months of age. Methods We did a pooled analysis of three randomised controlled trials done in Nepal (2011–2014), Mali (2011–2014), and South Africa (2011–2013). Pregnant women, gestational age 17–34 weeks in Nepal, 28 weeks or more in Mali, and 20–36 weeks in South Africa, were enrolled. Women were randomly assigned 1:1 to a study group, in which they received trivalent inactivated influenza vaccine (IIV) in all three trials, or a control group, in which they received saline placebo in Nepal and South Africa or quadrivalent meningococcal conjugate vaccine in Mali. Enrolment at all sites was complete by April 24, 2013. Infants and women were assessed for respiratory illness, and samples from those that met the case definition were tested for influenza by PCR testing. Growth measurements, including length and weight, were obtained at birth at all sites, at 24 weeks in South Africa, and at 6 months in Nepal and Mali. The three trials are registered with ClinicalTrials.gov , numbers NCT01430689 , NCT01034254 , and NCT02465190 . Findings 10 002 women and 9800 liveborn infants were included. Pooled efficacy of maternal vaccination to prevent infant PCR-confirmed influenza up to 6 months of age was 35% (95% CI 19 to 47). The pooled estimate was 56% (28 to 73) within the first 2 months of life, 39% (11 to 58) between 2 and 4 months, and 19% (–9 to 40) between 4 and 6 months. In women, from enrolment during pregnancy to the end of follow-up at 6 months postpartum, the vaccine was 50% (95% CI 32–63) efficacious against PCR-confirmed influenza. Efficacy was 42% (12 to 61) during pregnancy and 60% (36 to 75) postpartum. In women vaccinated before 29 weeks gestational age, the estimated efficacy was 30% (–2 to 52), and in women vaccinated at or after 29 weeks, efficacy was 71% (50 to 83). Efficacy was similar in infants born to mothers vaccinated before or after 29 weeks gestation (34% [95% CI 12 to 51] vs 35% [11 to 52]). There was no overall association between maternal vaccination and low birthweight, stillbirth, preterm birth, and small for gestational age. At 6 months of age, the intervention and control groups were similar in terms of underweight (weight-for-age), stunted (length-for-age), and wasted (weight-for-length). Median centile change from birth to 6 months of age was similar between the intervention and the control groups for both weight and length. Interpretation The assessment of efficacy for women vaccinated before 29 weeks gestational age might have been underpowered, because the point estimate suggests that there might be efficacy despite wide CIs. Estimates of efficacy against PCR-confirmed influenza and safety in terms of adverse birth outcomes should be incorporated into any further consideration of maternal influenza immunisation recommendations. Funding Bill & Melinda Gates Foundation.

Highlights • Acute respiratory infections, including influenza, are common among household member in Nepal. • Antenatal influenza vaccination does not confer indirect protection to household members. • Challenges include low vaccine efficacy and limited population coverage., Influenza is a significant cause of morbidity and mortality worldwide, and the World Health Organization highly recommends maternal vaccination during pregnancy. The indirect effect of maternal vaccination on other close contacts other than newborns is unknown. To evaluate this, we conducted a nested substudy between 2011 and 2012 of influenza and acute respiratory illness (ARI) among household members of pregnant women enrolled in a randomized placebo-controlled trial of antenatal influenza vaccination in the rural district of Sarlahi, Nepal. Women were assigned to receive influenza vaccination or placebo during pregnancy and then they and their household members were followed up to 6 months postpartum with weekly symptom surveillance and nasal swab collection. Swabs were tested by RT-PCR for influenza. Rates of laboratory-confirmed influenza and of ARI were compared between vaccine and placebo groups using generalized estimating equations with a Poisson link function. Overall, 1752 individuals in 520 households were eligible for inclusion. There were 82 laboratory-confirmed influenza illness episodes, for a rate of 7.0 per 100 person-years overall. Of the influenza strains able to be typed, 29 were influenza A, 40 were influenza B, and 6 were coinfections with influenza A and B. The rate did not differ significantly whether the household was in the vaccine or placebo group (rate ratio (RR) 1.37, 95% confidence interval (CI) 0.83–2.26). The rate of ARI was 28.5 per 100 person-years overall and did not differ by household group (RR 0.99, 95% CI 0.72–1.36). Influenza vaccination of pregnant women did not provide indirect protection of unvaccinated household members.

Background Biomass fuels are still in use for cooking by many households in resource poor countries such as Nepal and is a major source of household air pollution (HAP). Chronic exposure to HAP has been shown to be associated with shorter telomere length in adults. Objectives To measure the association between exposure related to household biomass fuel in infancy and leukocyte telomere length (LTL) at 18–23 months of age among 497 children from Bhaktapur, Nepal. Methods In a prospective cohort study design, we have collected information on household cooking fuel use and several clinical, anthropometric, demographic, and socioeconomic variables. We estimated the association between biomass fuel use and the relative LTL in multiple linear regression models. Results Most of the families (78%) reported liquified petroleum gas (LPG) as the primary cooking fuel, and 18.7% used biomass. The mean relative (SD) LTL was 1.03 (0.19). Children living in households using biomass fuel had on average 0.09 (95% CI: 0.05 to 0.13) units shorter LTL than children in households with no biomass fuel use. The observed association was unaltered after adjusting for relevant confounders. The association between LTL and biomass use was strongest among children from households with ≤2 rooms and without separate kitchen. Significance Exposure to biomass fuel use in early life might have consequences for longevity, and risk of chronic illnesses reflected in shortening of the telomeres. Our findings support the ongoing effort to reduce exposure to biomass fuel in low-resource settings. Impact statements Biomass for cooking is a leading source of household air pollution in low and middle-income countries, contributing to many chronic diseases and premature deaths. Chronic exposure to biomass fuel through oxidative stress and inflammation has been associated with a shortening of the telomeres, a “biological marker” of longevity. This prospective cohort study describes the association between household biomass fuel use and leukocyte telomere length among 497 toddlers. Leukocyte telomere length was significantly shorter among children living in households with biomass fuel than in children from homes where mainly LPG was used for cooking. Clinical Trial registration Clinicaltrials.gov: NCT02272842, registered October 21, 2014, Universal Trial Number: U1111-1161-5187 (September 8, 2014)

Importance: Most of the global morbidity and mortality in chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries (LMICs), with significant economic effects. Objective: To assess the discriminative accuracy of 3 instruments using questionnaires and peak expiratory flow (PEF) to screen for COPD in 3 LMIC settings. Design, Setting, and Participants: A cross-sectional analysis of discriminative accuracy, conducted between January 2018 and March 2020 in semiurban Bhaktapur, Nepal; urban Lima, Peru; and rural Nakaseke, Uganda, using a random age- and sex-stratified sample of the population 40 years or older. Exposures: Three screening tools, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE; range, 0-6; high risk indicated by a score of 5 or more or score 2-5 with low PEF [

Social workers are one of the major professionals serving for older adults. However, social work students often rank gerontology at the bottom of their future professional practice. Studies show that students have negative attitudes about, and perceptions of older adults and aging. Such stereotypes result in social work students considering practice areas other than gerontological social work. The objective of this study is to conduct a systematic review and identify any types of the intervention studies of changing perception and attitudes toward older adults and aging among social work students. This systematic review identified empirical research studies written in English that were published in a peer-reviewed journal before November 2021. Systematic search was carried out within four electronic databases (AgeLine, Education Research Complete, Social Work Abstracts, SocINDEX with full text) with the key words such as “social work student” and “aging or ageing or elderly or older adults or seniors or geriatrics or gerontology”. A total of 470 abstracts were identified, and after careful review of 143 full articles yielded from the databases, 43 journal articles were included in this study. Analysis of the selected literature provides that major interventions have been tried include service learning, lecture, curriculum development, simulation, training program, and intergenerational program. This systematic review highlights the importance of the experiential learning, partnership development with community, and interprofessional collaboration to provide the best model of practice for changing perception toward aging and older adults among social work students.

Background Biomass fuel use for cooking is widespread in low to middle income countries. Studies on the association between biomass fuel use and cognitive abilities in children are limited. Objective To examine the association between biomass fuel use for cooking and cognitive abilities in Nepalese children at 4 years of age. Methods In a cohort design we have information on biomass fuel use in the households of 533 children in infancy and cognitive abilities when they were 4 years old from a community-based sample. Cognitive abilities were measured by the Wechsler Preschool and Primary Scale of Intelligence, 4th edition (WPPSI-IV) and the NEPSY-II. We examined the associations between biomass fuel use and scores on the WPPSI-IV Full-Scale IQ (FSIQ) (primary outcome), and WPPSI index and NEPSY-II subtest scores in multiple linear regression models. The associations were also examined in predefined subgroups. Results Ninety-nine (18.6%) of the families used biomass fuel for cooking. Children in these families had lower mean FSIQ than children in families with no biomass use (83.3 (95%CI 81.7, 85.0) vs. 85.3 (95%CI 84.5, 86.0)), with a mean difference of −2.2 (95%CI -3.9, −0.5) adjusting for demographics and socio-economic status. The association between biomass fuel use and cognitive abilities was strongest in subgroups of children from households with more than three rooms, with separate kitchen and bedroom, and with higher wealth-score. These interactions were significant for number of rooms in the home (p = 0.04), if the household had separate bedroom and kitchen (p = 0.05), and for the wealth-score (p = 0.03). Conclusion Biomass fuel use for cooking in Nepalese families was associated with lower overall cognitive abilities at 4 years. Uncertainties include exposure misclassification and unmeasured confounding. The associations between biomass fuel use and neurodevelopment in children needs further investigation with more precise measurements of the exposure. publishedVersion

In Nepal, it is estimated that about 3 million children under 5 years of age are prone to diarrhea and previous studies have shown rotavirus as the major etiological agent. Given the high burden of rotavirus, Rotarix® vaccine was introduced in the national immunization schedule in July 2020. This study was carried out in a tertiary health center from January- September 2018 to determine the burden of rotavirus diarrhea as well as genotypic variations in the circulating virus prior to vaccine introduction in Kathmandu, Nepal.Hospital based cross sectional study was conducted among children less than 5 years of age attending Kanti Children's Hospital. Rotavirus antigen detection was performed by enzyme immunoassay using ProSpecT Rotavirus Microplate Assay. Rotavirus A positive samples were further confirmed by genotyping using Reverse-Transcription Polymerase Chain Reaction.A total of 530 children that included 184 males and 346 females were enrolled in this study. Rotavirus antigen was detected in 112 (21.1%) stool samples. Of the total 112 positive EIA stool samples that were genotyped, G12P[6] (30.3%) was found to be the most common type, followed by G3P[8] (26.8%), mixed type (14.3%), and G1P[6] (13.4%).Continued surveillance should be carried out nationwide in Nepal to understand the effectiveness of the vaccination program and to report any new trends in the circulating genotypes.

Background Children born with low birth weight (LBW) tend to have lower neurodevelopmental scores compared to term normal birth weight children. It is important to determine factors that influence neurodevelopment in these low birth weight children especially in the first 2–3 years of life that represents a period of substantial brain development. Methods This secondary data analysis was conducted using data from LBW infants enrolled soon after birth in an individually randomized controlled trial (RCT) and followed up till end of 1st year. Neurodevelopmental assessment was done at 12 months of corrected age by trained psychologists using Bayley Scales of Infant and Toddler Development 3rd edition (Bayley-III). Factors influencing cognitive, motor and language scores were determined using multivariable linear regression model. Results Linear growth (i.e., length for age z score, LAZ) [cognitive: Standardized ẞ-coefficient = 2.19, 95% CI; 1.29, 3.10; motor: 2.41, 95% CI; 1.59, 3.23; language: 1.37, 95% CI; 0.70, 2.04], stimulation at home [cognitive: 0.21, 95% CI; 0.15, 0.27; motor: 0.12, 95% CI; 0.07, 0.17; language: 0.21, 95% CI; 0.16, 0.25] and number of diarrhoeal episodes [cognitive: -2.87, 95% CI; -4.34, -1.39; motor: -2.62, 95% CI; -3.93, -1.29; language: -2.25, 95% CI; -3.32, -1.17] influenced the composite scores in all three domains i.e., cognitive, language and motor. While increase in LAZ score and stimulation led to increase in composite scores; an increase in number of diarrhoeal episodes was associated with decrease in scores. Weight for height z scores (WHZ) were associated with motor and language but not with cognitive scores. Additionally, a negative association of birth order with cognitive and language scores was noted. Conclusions The findings indicate the possible importance of promoting nutrition and preventing diarrhoea as well as ensuring optimal stimulation and nurturance at home for enhancing child development in LBW infants.

The demand for cobalamin (vitamin B12) and folate is increased during pregnancy, and deficiency during pregnancy may lead to complications and adverse outcomes. Yet, the status of these micronutrients is unknown in many populations. We assessed the concentration of cobalamin, folate and their functional biomarkers, total homocysteine (tHcy) and methylmalonic acid (MMA), in 561 pregnant women enrolled in a community-based randomised controlled trial in Bhaktapur, Nepal. Plasma concentrations of cobalamin, folate, tHcy and MMA were measured and a combined indicator of vitamin B12 status (3cB12) was calculated. We report mean or median concentrations and the prevalence of deficiency according to commonly used cut-offs, and assessed their association with indicators of socio-economic status, and maternal and dietary characteristics by linear regression. Among the women at gestational week less than 15, deficiencies of cobalamin and folate were seen in 24 and 1 %, respectively. Being a vegetarian was associated with lower plasma cobalamin, and a higher socio-economic status was associated with a better micronutrient status. We conclude that cobalamin deficiency defined by commonly used cut-offs was common in Nepalese women in early pregnancy. In contrast, folate deficiency was rare. As there is no consensus on cut-off points for vitamin B12 deficiency during pregnancy, future studies are needed to assess the potential functional consequences of these low values.

BackgroundDespite readily availability of vaccines against both Hemophilus influenzae and Pneumococcus, pneumonia remains the most common cause of morbidity and mortality in children under the age of five years in Nepal. With growing antibiotic resistance and a general move towards more rational antibiotic use, early identification of clinical signs for the prediction of radiological pneumonia would help practitioners to start the treatment of patients. The main aim of this study was to reassess the clinical predictors of pneumonia in Nepal.MethodsThis cross-sectional study was conducted between June 2015 and November 2015 at Tribhuvan University Teaching Hospital, a tertiary hospital in Kathmandu, Nepal. Children aged 3-60 months with a clinical diagnosis of pneumonia by a physician were enrolled in the study. Radiological pneumonia was identified and categorized as per World Health Organization guidelines by an experienced radiologist blinded to patient characteristics. We calculated sensitivity and specificity of clinical signs and symptoms for radiological pneumonia.ResultsOut of 1021 children with fever, 160 cases were clinically diagnosed as pneumonia and were enrolled for this study. Among the enrolled patients, 61% had radiological pneumonia. Tachypnea had the highest sensitivity of 99%, while bronchial breathing had the highest specificity of 100%. During univariate analysis, grunting, wheezing, nasal discharge, decreased breath sounds, noisy breathing and hypoxemia were associated with radiological pneumonia. Only hypoxemia remained an independent predictor when adjusted for all the factors.ConclusionTachypnea was the most sensitive sign, whereas bronchial breathing was most specific sign for radiological pneumonia.

Introduction: Lower respiratory tract infection (LRTI) is one of the major causes of mortality in children with estimated 1 million deaths every year. Hyponatremia is the most common electrolyte abnormality seen in LRTI. Objective: To find association of hyponatremia (serum sodium

Cysteine is a semi-essential amino acid that has been positively associated with growth in children. However, transgenerational effects remain unclear. The aim of this analysis was to assess whether maternal plasma total cysteine (tCys) concentration is associated with various growth indicators in infants living in peri-urban settings in Bhaktapur, Nepal. We used data from the 561 mothers enrolled in an ongoing randomized controlled trial. We built linear regression models to evaluate the associations between maternal tCys and birth weight, length-for-age Z-scores (LAZ) and weight-for-length Z-scores (WLZ) at birth and six months of age. Maternal tCys was inversely associated with birth weight among boys after adjusting for confounders (p &lt, 0.05). In addition, there was a negative association between maternal tCys and LAZ at birth (p &lt, 0.01). No associations between maternal tCys and the other anthropometric indicators were found significant, although there was a tendency for maternal tCys to be associated positively with WLZ at birth among girls (p &lt, 0.10). This is a first study evaluating transgenerational relation of tCys on growth in infants. Further, larger and more comprehensive studies are needed to determine if and how maternal tCys alters child growth.

Background: The Ages and Stages Questionnaires, Third Edition (ASQ-3) is becoming a widely used developmental assessment tool. The ASQ-3 can be completed by the caregivers (referred to as “mail out”), or by trained personnel under direct observation of the children (referred to as “home procedure”). Aim: The study was carried out to compare results obtained by the ASQ mail out with those of the ASQ home procedure in a community setting of Bhaktapur, Nepal. Methods: Trained fieldworkers (FWs) performed developmental assessment of 134 children aged 9 months in their homes using the ASQ home procedure. A few days before these assessments, mothers were asked to fill in the same ASQ-3 questionnaire. The concordance correlation coefficient (CCC) was calculated to measure their agreement. Result: The agreement between the ASQ mail out and home procedure was fair for the total score (CCC = 0.54). For the sub-scales, the agreement was good for the gross motor (CCC = 0.65), for the remaining subscales agreement was poor (CCC < 0.4). Conclusion: In resource limited setting like Nepal, the ASQ mail out represents an easy method to assess child development by caretakers at home; however, with the poor agreement between different methods of assessments, we cannot conclude that a single method is superior or most optimal and this question should be investigated further. When either of the method home procedure or mail out is opted, the results should be interpreted with cautions. publishedVersion

Introductions: Birth asphyxia is failure breathing causing severe consequences or death. This study aims to determine the incidence of perinatal asphyxia in neonates with low Apgar and Hypoxic Ischemic Encephalopathy (HIE) in asphyxiated babies. Methods: This was a cross sectional study from November 1, 2010 to July 30, 2011. Babies with Apgar score of less than seven at five minute were enrolled in the study. Blood was drawn from umbilical cord artery for blood gas analysis. Neonates were followed up in every six hours for at least 48 hours. Staging of HIE according to Sarnat staging was done in babies with Apgar score of 7.2, 40% had between 7.1 to 7.2, 12% between 7 to 7.1 and remaining 2% had pH < 7. HIE developed in 22% (11/50) of the asphyxiated babies. Conclusions: More than 1/3rd (46%) of babies with low Apgar had low cord blood pH, 1/4th (26%) had base excess, and 22% developed features of HIE. Cord blood pH were better predictors than Apgar in asphyxiated babies.

Introduction: With increasing survival of high risk babies, children with different developmental disabilities have emerged as a challenge for the baby, family as well as for physicians. With limited awareness and resources, follow-up and interventions for these babies are difficult. The study was carried out to find out the development of high risk babies in different developmental domains at one year of age.Material and Methods: NICU graduates who visited high risk clinic at one year of age were assessed. ASQ-3 was used to screen development. Children with major congenital anomalies and syndromes were excluded from the study.Results: Out of 28 high risk babies, about 29% had global delay. Those babies who had seizure during neonatal period could not score even in single item of ASQ-3. Conclusion: All high risk babies are at risk of developing delay hence should be followed up regularly. Timely early intervention needs to be started to minimize delay.

Background: Retinopathy of prematurity is a vascular retinal disease that can cause blindness in premature new born babies. Several risk factors are associated with the incidence of ROP. Information and data on risk factors associated with ROP in context to Nepalese population is scarcely documented in literature.Objectives: The purpose of this study was to evaluate the risk factors of retinopathy of prematurity in premature infants admitted in the neonatal intensive care unit of Tribhuvan University Teaching Hospital.Methods: Neonates with gestational age of 36 weeks or less and birth weight of 2000 gram or less admitted to neonatal intensive care unit (NICU), during 2013 to 2015 were screened for retinopathy of prematurity. Risk factors and severity of retinopathy of prematurity were evaluated. The initial examination was carried out at 4-6 weeks after birth by indirect ophthalmoscope and retinopathy of prematurity positive and negative infants were compared subsequently. The Chisquare and independent t-tests were used for statistical analysis. A p value less than 0.05 was considered statistically signifi cant.Results: The incidence of retinopathy of prematurity was 22.6% and severe retinopathy of prematurity requiring treatment was observed in 3.2% of 93 neonates who had eye examinations. There was a signifi cant relationship between the occurrence of ROP and birth weight (p=0.000), gestational age (p=0.000), duration of oxygen therapy (p=0.009) and sepsis (p=0.002). However, insignifi cant relationship was observed between the occurrence of retinopathy of prematurity and gender, type of delivery, multiple gestation, premature rupture of foetal membrane, respiratory distress syndrome and hyperbilirubinaemia.Conclusion: The risk factors contributing to development of retinopathy of prematurity showed signifi cant relationship with immaturity, duration of oxygen supplementation and septicaemia.Journal of Kathmandu Medical CollegeVol. 5, No. 1, Issue 15, Jan.-Mar., 2016,page: 28-33

Influenza immunisation during pregnancy is recommended but not widely implemented in some low-income regions. We assessed the safety and efficacy in mothers and infants of year-round maternal influenza immunisation in Nepal, where influenza viruses circulate throughout the year.In this phase 4, randomised, placebo-controlled trial, we enrolled two consecutive sequential annual cohorts of pregnant women from the Sarlahi district in southern Nepal. We randomised mothers 1:1 to receive seasonally recommended trivalent inactivated influenza vaccine or saline placebo in blocks of eight, stratified by gestational age at enrolment (17-25 weeks vs 26-34 weeks). Women were eligible if they were married, 15-40 years of age, 17-34 weeks' gestation at enrolment, and had not previously received any influenza vaccine that season. We collected serum samples before and after immunisation, and cord blood from a subset of women and infants. Staff masked to allocation made home visits every week from enrolment to 6 months after delivery. Midnasal swabs for respiratory virus PCR testing were collected during maternal acute febrile respiratory infections, and from infants with any respiratory symptom. We assessed vaccine immunogenicity, safety, and three primary outcomes: the incidence of maternal influenza-like illness in pregnancy and 0-180 days postpartum, the incidence of low birthweight (2500 g), and the incidence of laboratory-confirmed infant influenza disease from 0 to 180 days. This trial is registered with ClinicalTrials.gov, number NCT01034254.From April 25, 2011, to Sept 9, 2013, we enrolled 3693 women in two cohorts of 2090 (1041 assigned to placebo and 1049 to vaccine) and 1603 (805 assigned to placebo and 798 to vaccine), with 3646 liveborn infants (cohort 1, 999 in placebo group and 1010 in vaccine group; cohort 2, 805 in placebo group and 798 in vaccine group). Immunisation reduced maternal febrile influenza-like illness with an overall efficacy of 19% (95% CI 1 to 34) in the combined cohorts; 9% efficacy (-16 to 29) in the first cohort, and 36% efficacy (9 to 55) in the second cohort. For laboratory-confirmed influenza infections in infants aged 0-6 months, immunisation had an overall efficacy for the combined cohorts of 30% (95% CI 5 to 48); in the first cohort, the efficacy was 16% (-19 to 41), and in the second cohort it was 60% (26 to 88). Maternal immunisation reduced the rates of low birthweight by 15% (95% CI 3-25) in both cohorts combined. The rate of small for gestational age infants was not modified by immunisation. The number of adverse events was similar regardless of immunisation status. Miscarriage occurred in three (0·2%) participants in the placebo group versus five (0·3%) in the vaccine group, stillbirth occurred in 31 (1·7%) versus 33 (1·8%), and congenital defects occurred in 18 (1·0%) versus 20 (1·1%). Five women died in the placebo group and three died in the vaccine group. The number of infant deaths at age 0-6 months was similar in each group (50 in the placebo group and 61 in the vaccine group). No serious adverse events were associated with receipt of immunisation.Year-round maternal influenza immunisation significantly reduced maternal influenza-like illness, influenza in infants, and low birthweight over the entire course of the study, indicating the strategy could be useful in subtropical regions.BillMelinda Gates Foundation.

Background Vitamin B12 deficiency is one of the most common micronutrient deficiencies and is associated with poor cognitive development and growth. Vitamin B12 is crucial for normal cell division and differentiation, and it is necessary for the development and myelination of the central nervous system. The aim of the present study is to measure the effect of daily supplementation of vitamin B12 on the neurodevelopment and growth of young children in Nepal. Methods/design We are conducting an individually randomized, double-blind, placebo-controlled trial with 600 marginally stunted children 6–11 months old (length for age less than −1 z-score). Children are randomized to receive a lipid-based paste containing vitamin B12 or placebo daily for 12 months. The main outcomes are changes in growth (z-scores) and in neurodevelopment measured by the Bayley Scales of Infant and Toddler Development, Third Edition, from baseline until the end of the study. Discussion If vitamin B12 supplementation benefits early child development and growth, this will have consequences for dietary recommendations for malnourished children worldwide. Trial registrations ClinicalTrials.gov Identifier: NCT02272842. Registered on 21 October 2014. Universal Trial Number: U1111-1161-5187. Registered on 8 September 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1937-0) contains supplementary material, which is available to authorized users.

Background. Pertussis is estimated to cause 2 percent of childhood deaths globally and is a growing public health problem in developed countries despite high vaccination coverage. Infants are at greatest risk of morbidity and mortality. Maternal vaccination during pregnancy may be effective to prevent pertussis in young infants, but population-based estimates of disease burden in infants are lacking, particularly in low-income countries. The objective of this study was to estimate the incidence of pertussis in infants less than 6 months of age in Sarlahi District, Nepal. Methods. Nested within a population-based randomized controlled trial of influenza vaccination during pregnancy, infants were visited weekly from birth through 6 months to assess respiratory illness in the prior week. If any respiratory symptoms had occurred, a nasal swab was collected and tested with a multitarget pertussis polymerase chain reaction (PCR) assay. The prospective cohort study includes infants observed between May 2011 and August 2014. Results. The incidence of PCR-confirmed Bordetella pertussis was 13.3 cases per 1000 infant-years (95% confidence interval, 7.7-21.3) in a cohort of 3483 infants with at least 1 day of follow-up. Conclusions. In a population-based active home surveillance for respiratory illness, a low risk for pertussis was estimated among infants in rural Nepal. Nepal's immunization program, which includes a childhood whole cell pertussis vaccine, may be effective in controlling pertussis in infants.

Basal encephalocele is one of the important causes of respiratory distress in newborn, although uncommon and hence under emphasized. It is a form of neural tube defect that usually presents with symptoms of nasal obstruction. Delayed presentation with variable symptoms have been noted. Collaborative surgical intervention is the treatment modality with different approaches. However, intervention early in neonatal period is a challenge in our region with resource limitations. Prognosis is worse with associated malformations and chromosomal anomalies. We report two cases of newborn with basal encephalocele presenting as respiratory distress at birth.Nepalese Journal of ENT Head and Neck Surgery, Vol. 5, No. 2, 2014, Page: 18-20

Background: Sustained social withdrawal in infancy may have organic and nonorganic causes and could hinder normal development. The Alarm Distress Baby (ADBB) scale is a widely validated screening tool of social withdrawal in children 2-24 months. The aim of the current study was to evaluate the full and modified ADBB in Nepalese infants in a community-based study. Methods: We enrolled 600 infants who were video recorded during a pediatric examination. The 36 infants first enrolled were scored by an expert rater, and the subsequent 64 infants were scored by two trained staff with the full ADBB scale. Of the 600 enrolled infants, 597 videos (including the 100 infants scored with the full ADBB) were scored with the modified ADBB (m-ADBB) scale by the trained staff, with 7% double scoring. We measured the interrater agreement and psychometric properties of both scales. Results: In the 64 infants scored with the full ADBB by two raters, the concordance correlation coefficients (CCCs) indicated poor interrater agreement. For the m-ADBB, the CCCs were better indicating acceptable agreement between raters. The greatest lower bound (GLB) for reliability coefficient for the full ADBB scored by an expert rater indicated good internal consistency, whereas the GLB coefficient for the m-ADBB indicated poorer internal consistency. The Spearman correlation coefficient between the total scores of the two versions was 0.82 (P < 0.001). Among the infants scored with the full ADBB, 25% had a score above cutoff (≥5). Scored with the m-ADBB in the full sample, 11.4% of the infants had a score above the suggested cutoff (≥2). In both versions, children achieved high scores on vocalization. Conclusion: Our findings suggest that the m-ADBB is an acceptable approach to achieve adequate interrater agreement in a large community-based study in Nepal. Results indicate high prevalence of social withdrawal in this population. There are, however, uncertainties on the internal consistency of the scales in this setting, and the validity of the scales needs to be investigated further. More effective training strategies for administration and additional cultural-specific instructions could be important measures to explore before implementing the scale further in this setting. Keywords: ADBB; Nepal; feasibility; infant; social withdrawal. Copyright © 2020 Ulak, Ranjitkar, Shrestha, Braarud, Chandyo, Shrestha, Guedeney, Strand and Kvestad. publishedVersion