Transcript โครงการวิจัย (Research project) Study of factors a

Advisors
Assistant Professor Dortor Jiranun Weerakul
Dortor Suwit Lertkajornsin
Researchers
Kongpob Pongtanee 51460742
Pikom Sirisopausa 51460933
5th 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

† MedicinePlus:
http://www.nlm.nih.gov/medlineplus/ency/article/002367.htm
สุวรรณชาติ, ประภัสสร เอือ้ ลลิตชูวงศ์. อายุมารดากับผลของการคลอด
ℓWHO : http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/
‡บรรพจน์
Child development

Denver II or Denver Development Screening Test (DDST)
 Used for basic evaluate development of childen who aged 2
month-6years.
 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://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 – 26th 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 119-136
 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.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 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
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.)
Diagram : Comparison of gender between children with normal and delayed
development
90
80
70
60
50
Male
40
Female
30
20
10
0
Case
Control
Diagram 2: Comparison of growth between children with normal and delayed
development
100
90
80
70
60
50
Less or more
40
Appropriate
30
20
10
0
Case
Control
Diagram 3: Comparison of birthweight between children with normal and
delayed development
90
80
70
60
50
40
30
20
10
0
-
Case
Control
Diagram 4: Comparison of gastational age between children with normal and
delayed development
100
90
80
70
60
50
40
30
20
10
0
-
Case
Control
Diagram 5: Comparison of maternal age between children with normal and delayed
development
80
70
60
50
40
<20 or >35
30
-
20
10
0
Case
Control
Chapter 4 : Result
Variable
Odd ratio
95% CI
p-value
Male
Low birthweight
Preterm
Teenage, elderly
pregnancy
Brest feeding < 6mo.
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
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 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
กลุม่ พัฒนาการส่งเสริมสุขภาพ และอนามัยสิง่ แวดล้อม ศอ.4
 http://hpe4.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
 การสารวจพัฒนาการเด็กไทย โดยกรมอนามัย ประจาปี 25502551

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, 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
