Ds Manandhar

Outcome at 1 year of neonatal encephalopathy in Kathmandu, Nepal.

To determine the outcome at 1 year of neonatal encephalopathy (NE) and to estimate the possible contribution of birth asphyxia to childhood disability in a low‐income South Asian country, a prospective cohort study was undertaken in the principal maternity hospital of Kathmandu, where over 50% of local women give birth. From a total population cohort of 21 609 live births, 131 term infants with NE (after exclusion of cases associated with neonatal sepsis, congenital malformations, or primary hypoglycaemia) and 208 term control infants were recruited. Of these, 102 (78%) infants with NE and 106 (51%) control infants were followed‐up to 1 year of age. Outcome measures were death or neurodevelopmental impairment, graded as major, minor or none. Of the 131 term infants with NE, 83 were graded with moderate or severe NE according to conventional definition. By 1 year of age, 45 (44%) of the infants with NE had died, 18 (18%) had severe impairments, and two (2%) had minor impairments; four (4%) of the control subjects had died and two (2%) had minor impairments. Most deaths in subjects with NE occurred in the early neonatal period; NE carried no excess risk of death beyond the neonatal period. Of the 18 children with major impairment, 14 (78%) had spastic tetraplegic cerebral palsy and eight (44%) had multiple impairments. Compared with the control group the relative risk of death by 1 year was 5 (95% CI 1.4 to 15) for mild NE, 8 (95% CI 3 to 23) for moderate, and 26 (95% CI 10 to 67) for severe. Twenty‐seven of 38 (71%) infants with moderate NE either died or survived with major impairment. An upper estimate for the prevalence of major neuroimpairment at 1 year attributable to birth asphyxia is 1 per 1000 live births in this population.

Comparison of two cotside methods for the detection of hypoglycaemia among neonates in Nepal.

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%.

Liquid Crystal Thermometry for the Detection of Neonatal Hypothermia in Nepal

We assessed the sensitivity, specificity and likelihood ratio of a low cost liquid crystal strip thermometer (LCT) compared with axillary mercury thermometry for the detection of neonatal hypothermia in Nepal. The subjects were 76 healthy newborns in the government maternity hospital of Kathmandu, Nepal in winter. The validity of LCT for the detection of neonatal hypothermia (less than 36 degrees C) showed a sensitivity of 83 per cent, specificity 96 per cent, positive predictive value 98 per cent and a likelihood ratio of 23. Use of LCT on newborns in this setting raises a measured pretest probability of first day hypothermia of 63 per cent to a post-test probability of 97 per cent. Liquid crystal thermometry is a simple, low-cost, and valid method for identifying core hypothermia in newborns. It is ideal for isolated rural communities where LCT strips could be added to delivery kits.

Revisiting the patriarchal bargain: The intergenerational power dynamics of household money management in rural Nepal

Highlights • We analyzed the intergenerational power dynamics of money management in rural households in contemporary Nepal.• We found that junior wives and husbands often became secret allies in seeking financial autonomy from their in-laws.• Intergenerational power relations may be just as important as male-female power relations for women’s economic empowerment.

Can we manage neonatal infection in the community

As infant mortality rates have fallen in many developing countries the problem of neonatal mortality has become more obvious. The biggest causes of mortality in the first month of life are infection birth asphyxia and low birth weight. Infection is implicated in about a third of neonatal deaths in Nepal. Community-based data are limited but neonatal sepsis is likely to be the result of infection by Gram positive bacteria such as Staphylococci and Streptococci and enteric Gram negatives. The appropriate management for neonatal sepsis is parenteral hospital-based treatment with a penicillin and an aminoglycoside. However about 90% of births in Nepal take place at home and many infants never reach hospital. For these infants the next best management strategy is to give parenteral antibiotics at a primary care facility. Before referral it would be appropriate to give a dose of oral antibiotic such as cotrimoxazole which is already incorporated into the acute respiratory infection programme. If referral for parenteral treatment is not successful we propose that community-based cadres be allowed to give a full course of oral antibiotic in cases of neonatal sepsis. Community health workers should receive training and pictorial guidelines for the recognition of danger signs for neonatal sepsis and we recommend pilot studies to compare and evaluate oral treatment in the community. For Nepal a national policy on the community management of neonatal infection is an extremely urgent priority. (authors)