Variables

Cognitive function was assessed by reported school achievement and using the CANTAB⁽,17⁾. School achievement was assessed by current/highest school grade because, in Malawi, graduation to the next grade is dependent on passing exams rather than dictated by a child’s age. CANTAB is a widely used, well-validated tool suitable for children aged 4 years or above, with various tests covering three cognitive domains: visual memory, visual attention and working memory/planning⁽,28⁾. We used a subset of tests, selected to examine a range of cognitive functions and to allow us to compare our results with a previous CANTAB study in Malawi⁽,18⁾. Test do not require the ability to read any numerical or alphabetical values and are described in Table 1.

Description of tests in the CANTAB assessment, presented in the order of administration used in the present study

CANTAB, Cambridge Neuropsychological Testing Automated Battery.

Brain structure was assessed by a brain MRI scan on a subset of participants. The subset of SAM survivors selected for MRI was dictated by the availability of the MRI machine and the child who had a study appointment on that day. If there was more than one child appointment on that day, priority was given to the older child as s/he was more likely to remain still for the duration of the scan (no sedation was used). The scan was conducted following the BRINK study protocol, using a 0·35T GE Signa Ovation scanner (Sag T1 FLAIR, Ax T2 FRSE, Cor T2 FRSE, Ax DWI scans)⁽,27⁾. Scans were reviewed by a consultant radiologist using the BRINK standard list of possible abnormalities. When abnormalities were noted, children were referred to a child neurologist for further assessment and treated as needed.