AdvisorsAssistant Professor Dortor Jiranun

WeerakulDortor Suwit Lertkajornsin

ResearchersKongpob Pongtanee 514607

42Pikom Sirisopausa 5146093

35th year medical student of Naresuan

University

Researchable question Primary question

Is delayed development of children ass ociated with perinatal period factor?

Secondary question Is breast feeding associated with delay

ed development of children?

Researchable question P (Patient or Problem)

Children with delayed development I (Intervention or Exposure)

Complication of children in peronatal period

C (Comparison intervention) Normal newborn and newborn with com

plication in perinatal period O (Outcome)

Delayed developmental children

Basic of knowledge Definition Child development examintion

(Denver II and Public health department 49)

Factors associated with delayed development

Definition - Infancy – child with aged 0 2 years

old Development – The process of starti

ng to experience of more function efficiently

Birthweight* – the weight of baby at birth (2,500-4,000 g)

Low birth weight - <2,500 g Very low birth weight - <1,500 g Extremely low birth weight -

<1,000 g

*Thomas D Matte, senior epidemiologist, Michaeline Bresnahan, assistant professor, Melissa D Begg, associate professor, and Ezra Susser, professor. Influence of variation in birth weight within normal range and within sibships on IQ at age 7 years: cohort study. BMJ. 2001 August 11; 323(7308): 310–314.

Definition APGAR score* – Evaluation is gener

ally based upon the assignment of a n Apgar score at one and five minut es of age. The following signs are gi

ven values of 0, 1, or 2 and added to computet he Apgar scor e. (Apgar scores of 7 to 10, and generally require no further intervention, 4-6 some resuscitative measure, <3 requires immediate resuscitation)

*Christine E. F. Delgado, Sara J. Vagi & Keith G. Scott. Identification of Early Risk Factors for Developmental Delay. Exceptionality volume 15, Issue 2, 2007, pages 119-136

Definition Gestational age† - normal range 38

to 42 weeks (from LMP or Ballard scale)

Maternal age‡ – 20-35 years old Exclusive breastfeedingℓ –

breastfeeding 6 months

† MedicinePlus: http://www.nlm.nih.gov/medlineplus/ency/article/002367.htm‡ บรรพจน์ สวุรรณชาติ , ประภัสสร เอ้ือลลิตชูวงศ์ . อายุมารดากับผลของการคลอดℓWHO : http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/

Child development Denver II or Denver Development

Screening Test (DDST) Used for basic evaluate development of

-childen who aged 2 month 6 years. 4 125Evaluated in parameters (

Items)○ Personal Social○ Fine Motor Adaptive○ Gross Motor○ Language

From: http://hpe4.anamai.moph.go.th/hpe/mch/anamai49.php

Child development Public health department 49 exa

mi nat i on Used for child developmental

, 15 screening devided in to span of age 72 .from birth to months

4 (Evaluated in parameters 48 Items)○ Social ○ Language ○ Fine Motors ○ Gross Motors

From: http://hpe4.anamai.moph.go.th/hpe/mch/anamai49.php

Child development From the development research of

Thai children showed Thai children had language problem more than

. gross motor problem We have reduce the number of items of gross

motor for limited the number of .item to evaluated

From: http://hpe4.anamai.moph.go.th/hpe/mch/anamai49.php

Factors associated with delayed development

Lack of chance to support thier development such as commuinty

support or encourage their learning Health care process of mother and

children Individual factors

Research content Chapter 1: Introduction Chapter 2 : Literature review Chapter 3 : Methodology Chapter 4 : Result Chapter 5 : Discussion References Appendices

Chapter 1 : Introduction From developmental children survey of

Department of Health of Thailand in 2008 found that children 1-5 years old had number of normal development 67.7%, which decrease from 2005 (72%) and 1999 (71%).

It means that Thai children about million per year have delayed development, especially speech development.

As above this is the major problem and affect to their future, such as poor healthy, learning problem, etc.

Chapter 1 : Introduction Children have the highest

development at 0-2 years old. Their brain growth more than

80% when compare with brain adult.

If children’s development were interrupted by any factors, it will be major effect to their future.

Chapter 1 : Introduction•Objective

' To study the perinatal period s factors associated with delay development in

.children Scope

Population○ Children in Naresuan University

( ) Hospital NUH between 2009-2011 Research period

○5th 26– th January 2012

Chapter 1 : Introduction Benefit from the research

Know the factors associated with delayed development in children < 2 years.

Useful for mother and health care provider to increase awareness of ANC and health care for prevent the preterm labor.

Chapter 2 : Literature review Chaimay B, Thinkhamrop B,

Thinkhamrop J. Risk factors associated with language development problems in childhood—a literature review. J Med Assoc Thai. 2006 Jul;89(7):1080-6. [PubMed]Found that, risk factors for delayed development

associated with antenatal care, APGAR scores, birth weight, breast feeding, gender, birth order, parental education, environmental factors, and family history with language developmental delays.

Chapter 2 : Literature review Christine E. F. Delgado, Sara J.

Vagi & Keith G. Scott. Identification of Early Risk Factors for Developmental Delay. Exceptionality volume 15, Issue 2, 2007, pages 119-136Found that, perinatal child factors

(gestational age, birth weight, APGAR score, multiple birth, newborn condition, congenital abnormality) associated with delay development (risk ratio > 2)

Literature review Ni TL, Huang CC, Guo NW. Executive function deficit in preschool

children born very low birth weight with normal early development. Early Hum Dev. 2011 Feb;87(2):137-41. Epub 2010 Dec 30. [ELSEVIER]

Rieger-Fackeldey E, Blank C, Dinger J, Steinmacher J, Bode H, Schulze A. Growth, neurological and cognitive development in infants with a birthweight <501 g at age 5 years. Acta Paediatr. 2010 Sep;99(9):1350-5. doi: 10.1111/j.1651-2227.2010.01762.x. [WILEY]

Slining M, Adair LS, Goldman BD, Borja JB, Bentley M. Infant overweight is associated with delayed motor development. J Pediatr. 2010 Jul;157(1):20-25.e1. Epub 2010 Mar 15. [ELSEVIER]

Kosztolányi G. Hypothesis: epigenetic effects will require a review of the genetics of child development. J Community Genet. 2011 Jun;2(2):91-6. Epub 2011 Feb 20. [SpringerLink]

Barros AJ, Matijasevich A, Santos IS, Halpern R. Child development in a birth cohort: effect of child stimulation is stronger in less educated mothers. Int J Epidemiol. 2010 Feb;39(1):285-94. Epub 2009 Aug 28. [Oxford Journals]

Chapter 3 : Material and Methods Research question

Primary question○ Is delayed development of children assoc

iated with perinatal period factor? Secondary question

○ Is breast feeding associated with delayed development of children?

Chapter 3 : Material and Methods Population

Matching groups by year of birth between case and control group

Subject cases Inclusion :

○ Children with delayed development that follow up in NUH during 2009-2011

○ Patient who had 0-2 years old○ Mather who was antenatal care (ANC) at NUH

Exclusion :○ Children who had genetic abnormality - such as Down’s

syndrome○ Children who had ANC abnormality – such as infection during

pregnancy

Chapter 3 : Material and Methods Control cases

Inclusion○ Children with normal development that

follow up in NUH during 2009-2011○ Patient who had 0-2 years old○ Mather who was antenatal care (ANC) at NUH

Exclusion :○ Children who had genetic abnormality - such

as Down’s syndrome○ Children who had ANC abnormality – such as

infection during pregnancy

Chapter 3 : Material and Methods Location

Out Patient Department (OPD) of Pediatrics of NUH

Medical record department at NUH Data source

Medical records that record child with normal development

Medical records that record child with abnormal development

Study designCase control study

Chapter 3 : Material and Methods Statistical analysis

Analyze data by odds ratio and adjusted odds

Calculation by STATA program

Chapter 4 : ResultCase Control

n % Mean n % MeanGender Male Female

144

77.7822.22

2331

42.5957.41

Age (at Dx) < 1 1-2 >2

3150

Delay Fine movement Gross movement Language Social

55

151

Growth Less Appropriate More

2160

11.1188.89

0

5445

9.2681.489.26

Table 1 : Demographics between the subject cases and the control cases

Chapter 4 : ResultCase Control

n % Mean n % MeanBirth weight <2500 2500-4000 >4000

7110

38.8961.11

0

2,6767

452

12.9783.33

3.7

2,973

Apgar score (at 5 min.) 0-3 4-6 7-10

01

17

05.56

94.44

9.5600

54

00

100

9.87

GA (by U/S) <38 38-42 >42

7110

38.8961.11

0

36+67

470

12.9687.04

0

38

Maternal age <20 20-35 >35

5121

27.7866.665.56

2611376

20.3768.5211.11

27.11

Breast feeding <6 >6

153

83.3316.67

3915

72.2227.78Table 1 : Demographics between the

subject cases and the control cases (con.)

0

10

20

30

40

50

60

70

80

90

Case Control

Diagram : Comparison of gender between children with normal and delayed development

Male

Female

0

10

20

30

40

50

60

70

80

90

100

Case Control

Diagram 2: Comparison of growth between children with normal and delayed development

Less or more

Appropriate

0102030405060708090

Case Control

Diagram 3: Comparison of birthweight between children with normal and delayed development

-!

0102030405060708090

100

Case Control

Diagram 4: Comparison of gastational age between children with normal and delayed development

-!

0

10

20

30

40

50

60

70

80

Case Control

Diagram 5: Comparison of maternal age between children with normal and delayed development

<20 or >35

-

Table 2 : univariate logistic regression

Variable Odd ratio

95 % CI p-value

Male 4.72 1.37-16.22 0.014Low birthweight

3.18 0.97-10.43 0.056

Preterm 10.55 3.06-36.33 <0.001Teenage, elderly pregnancy

1.09 0.35-3.39 0.884

Brest feeding < 6mo.

1.92 0.49-7.61 0.351

Apgar < 7 (at 5 min)

0.107 0.00-3.35 0.351

Chapter 4 : Result

Table 3 : Multi-variate logistic regression

variable Adjusted OR

95%CI p-value

Male 4.39 1.10-17.53 0.036Low birthweight

2.16 0.31-15.08 0.439

Preterm 15.97 2.53-100.81 0.003

Chapter 4 : Result

Chapter 5 : Discussion From child health record, which collect

delayed developmental children in NUH from 2009 to 2011, found that children with delayed development were increased.

In 2009, 12 numbers of children with delayed development

In 2010, 18 numbers of children with delayed development

This is match with developmental children survey of Department of Health of Thailand in 2008

Chapter 5 : Discussion We collected 18 patients data from “child

health record” in NUH We have gotten few subjects because

someone loss follow up in NUH, someone dose not born or ANC in NUH, which were inadequate data from this group.

Chapter 5 : Discussion From study found that Gender had associated with delay

development significantly. Related to the previous study of Bhunyabhadh Chaimay MPH* that showed the male was a risk factor for delay development more than the female by 4:1. Those study was similar to our research at Odds ratio = 4.72

* Chaimay B, Thinkhamrop B, Thinkhamrop J. Risk factors associated with language development problems in childhood--a literature review. J Med Assoc Thai. 2006 Jul;89(7):1080-6.

Chapter 5 : Discussion The study of gestational age showed the

preterm has associated with delay development significantly. Related to the stury of Luoma et al* that showed delay language was associated with preterm.

* Luoma L, Herrgard E, Martikainen A, Ahonen T. Speech and language development of children born at<or=32 week’s gestation : a 5-year prospective follow-up study. Dev Med Child Neurol 1998; 40:380-7

Chapter 5 : Discussion Other factors may be associated with delay

development such as maternal age, breast feeding but in our research showed both maternal age and breast feeding wasn't associated with delay development significantly may be from the less population in this research.

Chapter 5 : Discussion From the study by Khonkaen University* showed

newborn with APGAR score < 3 at 5 minutes was a higher risk factor of delay development than newborn with APGAR score ≥ 7 at 5 minutes by double.

The case in this research had only one child with APGAR score < 7 and the control group hadn't child with APGAR score < 7 at 5 minutes, these cause may be deviate in statistic method.

Because of the children with APGAR score < 3 at 5 minute had low survival rate, so we can't collect the data for this research.

So, this research had a different result may be cause of the population.

* Chaimay B, Thinkhamrop B, Thinkhamrop J. Risk factors associated with language development problems in childhood--a literature review. J Med Assoc Thai. 2006 Jul;89(7):1080-6.

Chapter 5 : Discussion Benefit from the research

Know the factors associated with delayed development in children < 2 years.

Useful for mother and health care provider to increase awareness of ANC and health care for prevent the preterm labor.

Chapter 5 : Discussion Problem of the research

1. Inadequate population in this research - because the retrospective study have many confounding factors, so we need more population.

2. The limited of case because some children wasn't born in NUH, so they hadn't some important data for the research.

Chapter 5 : Discussion Problem of the research (cont.)

3. Other factors associated with delayed development such as ANC, Birth order, Parental education and environmental factor were interesting factors. But we can't study because of limitation of time in the research

Chapter 5 : Discussion Suggestions

1. Study of other factors associated with delayed development for more benefit.

2. Campaign of early ANC for decrease of preterm newborn that the risk factors of delayed development.

References กลุ่มพฒันาการสง่เสรมิสขุภาพ และอนามยัสิง่แวดล้อม

ศอ4. http://hpe4.anamai.moph.go.th/hpe/

index.php (Healthy Promotion and Environmental Health)

http://www.rajanukul.com/main/index.php?mode=academic&group=1&submode=academic&idgroup=12

การสำารวจพฒันาการเด็กไทย โดยกรมอนามยั ประจำาปี -25502551

Denver Developmental Screening Test II (DDST II)

From: DENVER DEVELOPMENTAL SCREENING TEST IIMargaret S. Modequillo, MD, DPPS, FPNA ; Gullas College of Medicine

Denver Developmental Screening Test II (DDST II)(Cont.)

From: DENVER DEVELOPMENTAL SCREENING TEST IIMargaret S. Modequillo, MD, DPPS, FPNA ; Gullas College of Medicine

Apgar score

From: Johns Hopkins: The Harriet Lane Handbook, 18th ed.

Ethical review Confidentiality of patient’s data –

such as copy patient’s name by code, and restrict to access patient’s data by other people

Deny to access subject’s data that didn’t associated with this study