Usefulness of maternal assessment of chil¬dren development based on reported age of achieved milestones - Epidemiological Review

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1_{Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College} _{Regional Sanitary-Epidemiological Station in Myslenice}

ABSTRACT

678'<2%-(&7,9(The aim of the study was to examine the usefulness of maternal recall of selected devel-RSPHQWDOPLOHVWRQHVE\WHVWLQJWKHLUFRUUHODWLRQVZLWKWKH%D\OH\6FDOHVRI,QIDQW'HYHORSPHQW%6,',,

0$7(5,$/$1'0(7+2'63URVSHFWLYHFRKRUWVWXG\7KHFRKRUWUHFUXLWHGSUHQDWDOO\LQFOXGHGFKLOGUHQ 7KH%6,',,WHVWVZHUHFDUULHGRXWLQHDFKFKLOGDWWKHHQGRIWKHthth _{and 36}th _{month of life. When children} ZHUH\HDUVROGPRWKHUVZHUHTXHVWLRQHGDERXWWKHLUFKLOG¶VDJHDWDWWDLQPHQWRIVLJQLILFDQWGHYHORSPHQWDO milestones.

5(68/76 The infants who attained developmental milestones earlier in their first years of life were more likely to DFKLHYHGDEHWWHUVFRUHVRQWKHPRWRUVFDOHRIWKH%6,',,&RUUHODWLRQFRHIILFLHQWVUDQJHGIURPIRUEODGGHU FRQWUROWRIRUVWDQGLQJZLWKRXWDVVLVWDQFHDQGIRUZDONLQJXQDVVLVWHG&RUUHODWLRQDURVHZKHQWKH GLIIHUHQFHEHWZHHQWKHWLPHRIDFKLHYLQJDSDUWLFXODUPLOHVWRQHDQGWLPHRIPDQDJLQJWKH%6,',,ZDVVPDOOHU

&21&/86,21Our study demonstrated that maternal reports of developmental milestones of children under 3 \HDUVROGDUHVXIILFLHQWO\UHOLDEOHWREHXVHGLQFOLQLFDOMXGJPHQW

.H\ZRUGVchildren, developmental assessment, milestones, Bayley Scales Abbreviations: BSID-II - Bayley Scales of Infant

De-velopment second edition,

PDI-Psychomotor Development Index, MDI-Mental Development Index

INTRODUCTION

The evaluation of children’s developmental progress is an important part of routine pediatric care. Develop-mental delay occurs in up to 5% of children under 5 \HDUVRIDJH(DUO\GLDJQRVLVRIWKHSUREOHPVDQG intervention may successfully influence child develop-PHQW*HQHUDOSUDFWLWLRQHUVDQGSHGLDWULFLDQVDUH EHVWSODFHGWRSOD\DFHQWUDOUROHLQWKHHDUO\GHWHFWLRQ RIGHYHORSPHQWDOSUREOHPVLQ\RXQJFKLOGUHQ3HGLDWUL-cians frequently report using developmental milestones in monitoring young children’s development (3). They RIWHQUHO\RQFOLQLFDOMXGJPHQWGHULYHGIURPREVHUYD-tions or parental concerns to identify children with GHYHORSPHQWDO SUREOHPV GHVSLWH HYLGHQFH WKDW XVH of standardized screening tests improves detection of developmental delays. The standardized methods are

H[SHQVLYHWLPHFRQVXPLQJDQGQRWIHDVLEOHLQSHGLDWULF care, and parent information is still important in the as-sessment of children’s development. The younger the child, the more essential is the parental information on its development and symptoms (4).

The aim of the study was to examine the usefulness of maternal recall of selected developmental milestones E\WHVWLQJWKHLUDVVRFLDWLRQVZLWKWKH%D\OH\6FDOHVRI Infant Development (BSID-II) outcomes - a “gold stan-dard” in assessing children’s development (5).

MATERIAL AND METHODS

All of the children involved in this study were part of a ODUJHUFRKRUWVWXG\EHLQJIROORZHGLQDFROODERUDWLYHVWXG\ ZLWK&ROXPELD8QLYHUVLW\LQ1HZ<RUNRQWKHYXOQHUDELOLW\ of fetus and child to environmental factors. The cohort recruited prenatally included the children of non-smoking ZRPHQDJHGWR\HDUVZLWKVLQJOHWRQSUHJQDQFLHV who had lived in Krakow for at least one year prior to pregnancy. Mothers were free from chronic diseases, HIV infection and illicit drug use. The study population included

5HQDWD0DMHZVND'RURWD0URĪHN%XG]\QHWDO  No 3 FKLOGUHQER\VDQGJLUOVZKRZHUHERUQLQ .UDNRZLQWKH\HDUVWRWDEOH, 7DEOH, &KDUDFWHULVWLFRIWKHVWXG\JURXS N % Gender Boys 196 50.6 Girls 191 49.4 Parity 1  64.6    Weeks of pregnancy ” ZHHNV   ZHHNV   > 43 weeks 1 0.3 Birth weight  11  •   Mothers age   19.1   49.6 30 - 34  31.3 Mothers education

primary or vocational school 35 9.0

technical college 44 11.4

high school or college 103 

university  53.0 Mothers work after delivery non-working to 30th month of child  43.9 EHJLQQLQJZRUNEHWZHHQst _and th _{month of child} 155 40.0 EHJLQQLQJZRUNEHWZHHQth

and 30th _{month of child}  16.0

The Mental and Motor Scales of BSID-II were DGPLQLVWHUHGWRHDFKFKLOGDWWKHHQGRIWKHthth and 36th _{months of life. When children were 3 years} ROGPRWKHUVZHUHTXHVWLRQHGDERXWWKHLUFKLOG¶VDJHDW DWWDLQPHQWRIVLJQLILFDQWGHYHORSPHQWDOPLOHVWRQHV skills in the following order: lifting head while prone, sitting without support, standing without assistance, ZDONLQJDORQHZDONLQJXSVWDLUVEODGGHUWUDLQHGERZHO trained and first meaningful words. The direct interview ZDVFRQGXFWHGE\SHGLDWULFLDQV

The Mann-Whitney nonparametric test was used to FRPSDUHER\VZLWKJLUOV7KH6SHDUPDQUDQNFRUUHODWLRQ ZDVXVHGWRHVWDEOLVKWKHUHODWLRQVKLSEHWZHHQPLOHVWRQH attainment in months and score on the mental and motor scale of the BSID-II at three age levels.

RESULTS

Characteristics of studied population was shown in WDEOH,*LUOVKDGDVLJQLILFDQWO\KLJKHURXWFRPHVRQWKH PHQWDOVFDOHRIWKH%6,',,WKDQER\VLQDOODJHJURXSV WDEOH,,7KHPRWRUVFDOHVFRUHRIWKH%6,',,DWWKH DJHRIth _{and 36}th _{months was also higher in girls.} 'LIIHUHQFHVEHWZHHQER\VDQGJLUOVLQDWWDLQPHQWRI developmental milestones were only found in successful WRLOHWWUDLQLQJWDEOH,,,

Maternal reports on all studied milestones, except the time of the first words spoken, correlated inversely with the outcomes of the motor scale of the BSID-II at WKHth _{month. The infants who attained developmental} milestones earlier in their first years of life were more OLNHO\WRDFKLHYHGDEHWWHUVFRUHRQWKHPRWRUVFDOHRIWKH %6,',,&RUUHODWLRQFRHIILFLHQWVUDQJHGIURPIRU EODGGHUFRQWUROWRIRUVWDQGLQJZLWKRXWDVVLVWDQFH DQGIRUZDONLQJXQDVVLVWHGWDEOH,9$OOSK\VL-cal developmental milestones also correlated inversely with outcomes on the motor scale of the BSID-II at the th _{month (r}

sIURPWR7KHVFRUHRQWKH motor scale of the BSID-II at 36th _{month was associated} with age of lifting head, sitting up, walking alone and 7DEOH,,%6,',,VFRUHVLQJHQGHUJURXSV Indexes Boys Girls Statistical VLJQL¿FDQFH Mean Standard Deviation Mean Standard Deviation 3',th month     ns a 3',th month   101.01 10.305 S PDI-36th month     S 0',th month    10.399 S  0',th month  11.939 105.11 13.603 S MDI-36th month 100.94   10.065 S a _{ns - non-significant} 7DEOH,,,0RWKHUV¶UHSRUWHGGHYHORSPHQWDOPLOHVWRQHVLQJHQGHUJURXSV Reaching particular developmental

milestones (in months)

Boys Girls Statistical

VLJQL¿FDQFH

Median Q₁ - Q₃** Median Q₁ - Q₃

Lifting head while prone     ns

Sitting without assistance 6  6  ns

Standing with assistance 9  9  ns

Walking alone  10 - 13   ns Walking upstairs     ns Bladder control     S  Bowel control     S 6SHDNLQJ¿UVWPHDQLQJIXOZRUGV  10 - 13 11  ns * ns - non-significant

Maternal assessment of children development 

No 3

completed toilet training. Correlation arose when the time of achieving a particular milestone was closer to time of managing the BSID-II test. The highest correla-WLRQU ZDVIRXQGEHWZHHQWKHPRQWKRIZDONLQJ alone and score on the motor scale of the BSID-II at the thPRQWKKRZHYHULWZHDNHQHGWRLQth _month of life. Despite that small coefficient the result remain VLJQLILFDQWOLNHPRVWRIWKHRWKHUDVVRFLDWLRQVEHWZHHQ UHFDOOHGPLOHVWRQHVDQG%6,',,VFRUHVWDEOH,9

7KHDJHRIVSHDNLQJWKHILUVWZRUGVUHSRUWHGE\ mothers correlated significantly with the score on the mental scale of the BSID-II at all age levels. It also FRUUHODWHGZLWKWKHVFRUHRQWKHPRWRUVFDOHDWWKHth and 36th _{month. Meanwhile, such skills as walking} XQDVVLVWHGDQGERZHOFRQWUROZHUHDVVRFLDWHGQRWRQO\ ZLWKVFRUHRQPRWRUVFDOHEXWDOVRZLWKWKHPHQWDORQH There were no differences in correlation of mile-VWRQH DVVHVVPHQW DFFRUGLQJ WR FKLOG JHQGHU ELUWK weight, duration of pregnancy, mother’s age, educa-tional level and whether mother takes all-day care of child (not presented).

DISCUSSION

The evaluation of children’s developmental prog-ress is an important part of routine pediatric care. The experiences of the first 3 years of life exert a powerful LQIOXHQFHRQVXEVHTXHQWGHYHORSPHQW0DMRUOLWHUD-ture reviews concluded that high quality early interven-tion could influence the development of children with LPSUHVVLYHHIIHFWV

Recognizing the efficacy of early intervention and the accompanying need for earlier identification

RISUREOHPVSHGLDWULFLDQVVKRXOGRIIHUGHYHORSPHQWDO screening for all children. Many formal standardized assessments of development are expensive and time-consuming, and pediatricians frequently report the use of developmental milestones in monitoring young chil-dren’s development. Parents are potentially rich source RILQIRUPDWLRQDERXWWKHLUFKLOG¶VHPHUJLQJDELOLWLHV and have the capacity to provide accurate information DERXWDFKLOG¶VGHYHORSPHQW ,QYHVWLJDWLRQVLQWR the consistency of existing parent reports have shown VLJQLILFDQWFRUUHODWLRQVU EHWZHHQSDUHQWDO and professional estimates of development in children ERUQDWRUQHDUWHUP6OLJKWO\VWURQJHUFRUUHODWLRQV U KDYHEHHQIRXQGLQVLPLODUVWXGLHVZLWK VDPSOHVRISUHWHUPRUORZELUWKZHLJKWFKLOGUHQ

'HVSLWHWKHIDFWWKDWWKHREVHUYHGLQYHUVHFRUUHOD-tions of maternal reports of children’s developmental PLOHVWRQHVDQG%6,',,IURPU WRU  were statistically significant, the relationship was found WR EH ZHDNHU WKDQ WKDW IRXQG LQ RWKHU VWXGLHV7KH OHVVVWURQJFRUUHODWLRQPD\EHWKHUHVXOWRIWKHWLPH ODJEHWZHHQDFKLHYLQJVNLOOVDQGDSSO\LQJWKHFORVHG %6,',, DQG LV SHUKDSV DOVR FDXVHG E\ XVLQJ HDFK milestone separately to assess correlation coefficients. $QRWKHUUHDVRQPLJKWEHWKHUDWKHUYDULHGSHULRGRI WLPHEHWZHHQDFKLHYLQJPRVWRIWKHFRQVLGHUHGVNLOOV DQGWKHLUUHSRUWLQJE\PRWKHUV7KHPHWKRGVXVHGLQ the study demonstrated that most milestones correlated weakly or very weakly not only with the closed BSID-II VFRUHEXWDOVRZLWKVFRUHVRIWKHWHVWVSHUIRUPHGRQH and two years later or earlier, though the correlation is less significant for distant BSID-II outcomes.

Considering the fact, that correlation was analyzed EHWZHHQFRPSOLFDWHGWHVWRIFKLOGUHQGHYHORSPHQWDQG 7DEOH,9&RUUHODWLRQEHWZHHQ%6,',,VFRUHVDQGHDUO\GHYHORSPHQWPLOHVWRQHVUHSRUWHGE\PRWKHUVRI\HDUROGFKLOGUHQ

PDI MDI

th _month th _{month 36}th _month th _month th _{month 36}th _month

Lifting head while prone rs*    -0.0716 -0.0557 -0.0468

p**  0.0006 0.043 ns*** ns ns

Sitting without assistance rs    -0.0699 -0.0514 0.0303

p  0.0041 0.016 ns ns ns

Standing without assistance rs   -0.0550 -0.0765 -0.0187 0.0337

p  0.0001 ns ns ns ns Walking alone rs      -0.0118 p   0.0010 0.0003 0.014 ns Walking upstairs rs   -0.0941 -0.0310 -0.0721 0.0019 p  0.0001 ns ns ns ns Bladder control rs    -0.0713 -0.0857 -0.0915 p  0.0005  ns ns ns Bowel control rs       p    0.0011 0.0041  6SHDNLQJ¿UVWPHDQLQJIXOZRUGV rs -0.0488      p ns  0.0015 0.0040  0.0005

* - Spearman rank correlation rate ** - statistical significance *** ns - non-significant

5HQDWD0DMHZVND'RURWD0URĪHN%XG]\QHWDO

490 No 3

single milestones, which is only a small part of that multivariate tool, we cannot expect high coefficients of DVVRFLDWLRQ7KHUHIRUHREWDLQHGFRUUHODWLRQVZHUHVPDOO EXWVWDWLVWLFDOO\VLJQLILFDQW 7KHYDULDELOLW\RIFRUUHODWLRQEHWZHHQWKHPLOHVWRQHV PD\EHH[SODLQHGE\UHFDOOELDVPRWKHUVPD\UHPHPEHU WKHRQVHWRIRQHPLOHVWRQHEHWWHUWKDQDQRWKHU)RU LQVWDQFHPRWKHUVKDGQRGRXEWVUHSRUWLQJWKHWLPHRIDW-WDLQPHQWRIZDONLQJDORQHEXWQHHGHGPRUHWLPHWRGHFLGH DERXWWKHRQVHWRIDQRWKHURXWFRPHRIGHYHORSPHQW7KH IDFWRIWKHVWURQJHVWFRUUHODWLRQEHLQJEHWZHHQZDONLQJ alone and BSID-II scores confirmed the great importance of this skill for overall development. Despite each mile-stone alone correlated less significantly with BSID-II scores as compared with formal standardized assessments used in other studies, this research provided additional empirical evidence for the use of mother reports as a reli-DEOHWRROIRUDVVHVVLQJWKHGHYHORSPHQWRI\RXQJFKLOGUHQ )HZSUHYLRXVVWXGLHVKDYHDGGUHVVHGWKHOLQNVEH-tween developmental milestones and BSID-II scores. 3UHYLRXVVWXGLHVKDYHWHQGHGWREHGUDZQIURPVSHFLILF SRSXODWLRQVXFKDVJURXSZLWKORZELUWKZHLJKWORZ ,4RUSK\VLFDOGLVDELOLWLHVZKLOHWKHFXUUHQWVDPSOH LVGUDZQIURPWKHJHQHUDOSRSXODWLRQ7KLVLV SUREDEO\WKHUHDVRQIRUOHVVVLJQLILFDQWFRUUHODWLRQEH-tween developmental milestones and the BSID-II scores REWDLQHGLQRXUVWXG\7KHPRVWLPSRUWDQWDGYDQWDJHLQ comparison with previous studies is that parental report FRQFHUQHGQRWRQO\FXUUHQWVWDWXVEXWDOVRDFKLOG¶V SUHYLRXV GHYHORSPHQW 5HOLDEOH SDUHQW UHSRUW DERXW a child’s early development is very important, and is sometimes the only source of information on the rate of development over time, so that current results can EHLQWHUSUHWHGWRJHWKHUZLWKZKDWLVNQRZQDERXWWKH FKLOG¶VEDFNJURXQG

CONCLUSION

Our study demonstrated that maternal reports of developmental milestones of children under 3 years old DUHVXIILFLHQWO\UHOLDEOHWREHXVHGLQFOLQLFDOMXGJPHQW $FNQRZOHGJHPHQWV

This is a part of ongoing comparative longitudinal study on the health impact of prenatal exposure of infants and children to outdoor/indoor air pollution, which is EHLQJ FRQGXFWHGLQ WKH 1HZ<RUN &LW\ DQG .UDNyZ The study received funding from an RO1 grant entitled ³9XOQHUDELOLW\RIWKH)HWXV,QIDQWVWR3$+30_and (76´ 52 (6 1,(+6    and from NIEHS (5 RO1 ES010165-0451), the Lundin Foundation, and the Gladys T. and Roland Harriman Foundation. Principal Investigator: Prof. F.P. Perera

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Renata Majewska

Chair of Epidemiology and Preventive Medicine JUMC .RSHUQLNDD.UDNyZ

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