RESEARCH PROJECT THE FACTORS AFFECTED TO 0 2

RESEARCH PROJECT THE FACTORS AFFECTED TO 0 -2 YEARS OLD CHILD DEVELOPMENT IN NARESUAN UNIVERSITY HOSPITAL Advisors Assistant Professor Dortor Jiranun Weerakul Dortor Suwit Lertkajornsin Researchers Kongpob Pongtanee 51460742 Pikom Sirisopausa 51460933 5 th year medical student of Naresuan University

Researchable question Primary question Is delayed development of children associated with perinatal period factor? Secondary question Is breast feeding associated with delayed 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 complication 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 starting 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 generally based upon the assignment of an Apgar score at one and five minutes of age. The following signs are given values of 0, 1, or 2 and added to compute the Apgar score. (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 † Medicine. Plus: http: //www. nlm. nih. gov/medlineplus/ency/article/002367. htm ‡บรรพจน สวรรณชาต , ประภสสร เออลลตชวงศ . อายมารดากบผลของการคลอด ℓWHO : 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. Evaluated in 4 parameters (125 Items) ○ Personal Social ○ Fine Motor Adaptive ○ Gross Motor ○ Language From:

Child development Public health department 49 examination Used for child developmental screening, devided in to 15 span of age from birth to 72 months. Evaluated in 4 parameters(48 Items) ○ Social ○ Language ○ Fine Motors ○ Gross Motors From:

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: //hpe 4. anamai. moph. go. th/hpe/mch/anamai 49. 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 ○ 5 th – 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 J. Risk factors associated with language development problems in childhood —a literature review. J Med Assoc Thai. 2006 Jul; 89(7): 10806. [Pub. Med] 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 -136 Found 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. e 1. 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. [Springer. Link] 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 associated 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 design Case control study

Chapter 3 : Material and Methods Statistical analysis Analyze data by odds ratio and adjusted odds Calculation by STATA program

Chapter 4 : Result n Case % n Control % Gender Male Female 14 4 77. 78 22. 22 23 31 42. 59 57. 41 Age (at Dx) <1 1 -2 >2 3 15 0 Delay Fine movement Gross movement Language Social 5 5 15 1 Growth Less Appropriate More 2 16 0 11. 11 88. 89 0 5 44 5 9. 26 81. 48 9. 26 Mean Table 1 : Demographics between the subject cases and the control cases Mean

Chapter 4 : Result n Birth weight <2500 -4000 >4000 Apgar score (at 5 min. ) 0 -3 4 -6 7 -10 GA (by U/S) <38 38 -42 >42 Maternal age <20 20 -35 >35 Breast feeding <6 >6 Case % Mean n Control % 2, 676 7 11 0 38. 89 61. 11 0 2, 973 7 45 2 12. 97 83. 33 3. 7 9. 56 0 1 17 0 5. 56 94. 44 9. 87 0 0 54 0 0 100 36+6 7 11 0 38. 89 61. 11 0 Mean 38 7 47 0 12. 96 87. 04 0 26 27. 11 5 12 1 27. 78 66. 66 5. 56 11 37 6 20. 37 68. 52 11. 11 15 3 83. 33 16. 67 39 15 72. 22 27. 78 Table 1 : Demographics between the subject cases and the control cases (con. )

Chapter 4 : Result Variable Odd ratio 95% CI p-value Male Low birthweight Preterm Teenage, elderly pregnancy Brest feeding < 6 mo. Apgar < 7 (at 5 min) 4. 72 3. 18 10. 55 1. 09 1. 37 -16. 22 0. 97 -10. 43 3. 06 -36. 33 0. 35 -3. 39 0. 014 0. 056 <0. 001 0. 884 1. 92 0. 107 0. 49 -7. 61 0. 00 -3. 35 0. 351 Table 2 : univariate logistic regression

Chapter 4 : Result variable Adjusted OR 95%CI p-value Male 4. 39 1. 10 -17. 53 0. 036 Low birthweight 2. 16 0. 31 -15. 08 0. 439 Preterm 15. 97 2. 53 -100. 81 0. 003 Table 3 : Multi-variate logistic regression

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 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 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 กลมพฒนาการสงเสรมสขภาพ และอนามยสงแวดลอม ศอ. 4 http: //hpe 4. anamai. moph. go. th/hpe/index. php )Healthy Promotion and Environmental Health) http: //www. rajanukul. com/main/index. php? mode=academic&g roup=1&submode=academic&idgroup=12 การสำรวจพฒนาการเดกไทย โดยกรมอนามย ประจำป 2550 -2551

APPENDICES

Denver Developmental Screening Test II (DDST II) From: DENVER DEVELOPMENTAL SCREENING TEST II Margaret S. Modequillo, MD, DPPS, FPNA ; Gullas College of Medicine

Denver Developmental Screening Test II (DDST II) (Cont. ) From: DENVER DEVELOPMENTAL SCREENING TEST II Margaret S. Modequillo, MD, DPPS, FPNA ; Gullas College of Medicine

Apgar score From: Johns Hopkins: The Harriet Lane Handbook, 18 th 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