Objective: To examine whether the combination of a low five minute Apgar score and symptoms of neonatal encephalopathy is associated with minor impairments at school age. Design: Population based cohort study. Setting: Norway. Participants: All 727 children of the cohort were born between 1983 and 1987, had normal birth weights, no congenital malformations, and no major neurological abnormalities. The cohort comprised three groups with five minute Apgar scores of 0-3, 4-6, and 7-10, and were followed from birth to 8-13 years of age by combining data from The Medical Birth Registry, questionnaires, hospital discharge summaries, and the National Insurance Scheme. Main outcome measure: Neurodevelopmental impairments such as learning, behavioural, and minor motor difficulties. Results: Children with a five minute Apgar score of 3 or less and signs consistent with neonatal encephalopathy had a significantly increased risk of developing minor motor impairments (odds ratio (OR) 12.8, 95% confidence interval (CI) 2.6 to 63.2), epilepsy (OR 7.0, 95% CI 1.3 to 39.2), need of extra resources in kindergarten (OR 7.0, 95% CI 1.3 to 39.2) or at school (OR 3.4, 95% CI 1.8 to 6.3), and had reduced performance in reading (OR 4.6, 95% CI 2.3 to 9.5) and mathematics (OR 3.3, 95% CI 1.5 to 7.3), compared with children with normal Apgar scores and no neonatal symptoms. They also more often had problems related to tractability, aggressivity, passivity, anxiety, academic performance, and fine motor development. Conclusion: Children with low Apgar scores and subsequent signs of cerebral depression who do not develop cerebral palsy may still have an increased risk of developing a variety of neurodevelopmental impairments and learning difficulties.

Objective: The aim of this study was to investigate homocysteine and methylmalonic acid levels as markers of functional cobalamin and folate status in pregnant Nepali women. Design: Cross-sectional study. Setting: Patan Hospital, Kathmandu, Nepal. Subjects: A sub-sample (n ¼ 382) of all pregnant women (n ¼ 2856) coming for their first antenatal visit in a 12 month period, 1994 -1995. The selection of the sub-sample was based on maternal haematocrit values, categorised into three groups: severely, moderately and non-anaemic women. As serum levels of total homocysteine (s-tHcy) and methylmalonic acid (s-MMA) were similar in the three groups, pooled data are presented. Women who had already received micronutrient supplementation (n ¼ 54) were excluded. The remaining women (n ¼ 328) were included in the statistical analysis. Results: Overall mean values ( AE s.d.) of s-tHcy and s-MMA were 9.5 ( AE 4.2) mmol=l and 0.39 ( AE 0.32) mmol=l, respectively. Elevated s-tHcy (>7.5 mmol=l) was found in 68% of the women, while 61% had elevated s-MMA (>0.26 mmol=l). Low s-cobalamin values (<150 pmol=l) were observed in 49% of the women, while only 7% had low s-folate values ( 4.5 nmol=l). s-tHcy was significantly correlated with s-MMA (r ¼ 0.28, P<0.001), s-cobalamin (r ¼ 70.30, P<0.001) and s-folate (r ¼ 70.24, P<0.001). s-MMA was significantly associated with s-cobalamin (r ¼ 70.40, P<0.001), but not with s-folate. Conclusions: Functional cobalamin deficiency was very common in the study population, while functional folate deficiency was rather uncommon. We suggest considering cobalamin supplementation to pregnant Nepali women. Sponsorship: The Norwegian Research Council and the Norwegian Universities Committee for Development, Research and Education.

Clinical and ultrasound findings were compared in 3613 newborns examined for developmental dysplasia of the hip (DDH) within 48 hours of delivery. Clinical and sonographic hip stability was described as stable, borderline unstable, dislocatable or dislocated, and the morphology on ultrasound as normal, immature or dysplastic. Persistent clinical or sonographic dislocatability or dislocation, major dysplasia or minor dysplasia combined with an unstable femoral head were indications for early treatment. A total of 123 (3.4%) infants were subjected to early treatment, of which 55 (45%) fulfilled the criteria for treatment on both clinical and ultrasound examinations, 52 (42%) were treated on the basis of ultrasound findings alone, and 16 (13%) on the basis of clinical findings alone. Thirty per cent of the infants with clinically dislocated or dislocatable hips were judged to have stable or just borderline unstable hips on the first clinical examination. Of 486 (13.5%) infants with sonographically immature or minor dysplastic but stable hips, 472 (97%) normalized spontaneously, while treatment was initiated in 14 (3%) of them at 1-3 months of age because of lack of sonographic improvement. Only one infant presented with late DDH during an observation period of 3 years. Accepting sonographic dysplasia as a criterion for early splinting may result in a treatment rate which is almost twice the rate based on clinical criteria, but late dislocation may be virtually eliminated.

Objectives  The proportion of women delivering with known HIV status in sub‐Saharan Africa is not well described. Risk of HIV transmission to newborns is a major concern, but there may also be increased risks for other adverse pregnancy outcomes. Design  Hospital registry. Setting  North East Tanzania (1999–2006). Population  Singletons (n= 14 444). Methods  Births were grouped by maternal HIV status and socio‐demographic factors predicting HIV status, and associations between status and pregnancy outcomes were studied. Main outcome measures  Maternal HIV status, perinatal mortality, prematurity, small for gestational age (SGA), birthweight and low Apgar score. Results  The proportion of mothers with known HIV status increased from 7% before 2001 to 78% after 2004. Single motherhood, rural residence, low maternal education, maternal and paternal farming and higher paternal age were associated with unknown HIV status. About 7.4% (95% CI 6.7–8.1%) of women were HIV infected, with increased likelihood of infection with higher gravidity, single motherhood, rural residence, maternal business or farming occupations and paternal tribe. Compared with HIV‐uninfected women, the untreated HIV‐infected women had a higher risk of SGA births (adjusted risk ratio [ARR] 1.6; 95% CI 1.1–2.4), preterm birth (ARR 1.8; 95% CI 1.1–2.7) and perinatal death (ARR 1.9; 95% CI 0.95–3.8). Women with unknown HIV status had moderately increased risks. Treated HIV‐infected women had a risk similar to that of the HIV‐uninfected women for all outcomes, except for low Apgar score. Conclusion  HIV testing and infection were associated with socio‐demographic factors. Untreated HIV‐infected women had higher risks of adverse pregnancy outcomes, and risks were also increased for women with unknown HIV status. There is still a need to increase availability of HIV testing, education and adequate therapy for pregnant women.

The purpose of this study was to determine inter- and intra-observer agreement in assessing hip morphology and stability by ultrasound. Three groups of infants, of 206, 74 and 78 newborns respectively, were examined. Morphology was classified into four categories (normal, immature, minor dysplastic and major dysplastic) according to subjective assessment, objective measurement (of the acetabular inclination angle alpha) or a combination of the two. Inter- and intra-observer agreement was determined for reading of recorded ultrasound scans, and for examination (recording plus reading of the scans). Hip stability was subjectively classified as stable, unstable, dislocatable or dislocated, and inter-observer agreement was determined. There was a high degree of agreement for morphological classification based on repeated readings of recorded scans by the same observer (206 infants, kappa = 0.7 and 0.8 for the two observers, respectively) while the degree of agreement between observers was moderate (kappa = 0.5). The agreement between observers for repeated readings and recordings was moderate when based on a subjective classification (kappa = 0.5). Adding the alpha angle did not improve agreement. There was a moderate inter-observer agreement in determining hip stability (70 infants, kappa = 0.4). The authors concluded that a high degree of inter- and intra-observer agreement in classifying hip morphology may be obtained for the reading of recorded ultrasound scans. Inter- and intra-observer agreement in producing the scans is poorer than for reading. To obtain a high degree of inter-observer agreement in assessing hip morphology and stability in the newborn, substantial training, attention to details in the technique, and evaluation of results are necessary.