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© 2023 Heart India | Published by Wolters Kluwer - Medknow
Original Article
ABSTRACT
Context: With improved awareness, early screening and diagnosis, and better postoperative care, the survival rate and life expectancy of
congenital heart disease (CHD) population is on rise, and hence there is the uttermost need to study morbidities like neurodevelopment delay,
which significantly affect quality of life in long term.
Aim: Assessment of Neurodevelopmental Status Using Development Assessment Scale for Indian Infants (DASII) in children 6-24 months
of age with CHD.
Settings and Design: This was a descriptive, cross-sectional, hospital-based study, conducted in a tertiary care hospital of Central India.
Subjects and Methods: The study included children 6–24 months of age with CHD confirmed by echocardiography. Their mental
development quotient (DMeQ) and motor development quotient (DMoQ) was calculated using DASII. Developmental delay is defined as
DQ <70% (<2 standard deviation) in either mental or motor domain.
Statistical Analysis Used: Data entered in Excel spreadsheets and analyzed using SPSS 25.0.
Results: Motor delay was found in 28% children and 26% children had mental delay (
P
= 0.0001). Among children with cyanotic CHD, both
motor and mental development was seen in 80%, while in children with acyanotic CHD 18.8% children had motor delay and 16.5% children had
mental delay (
P
= 0.0001). The mean DMoQ and mean DMeQ was significantly lower in the cyanotic group than in acyanotic group. The mean
DMoQ and mean DMeQ was found to be significantly lower in the children with severe disease as compared to children with mild disease, as
well as in the high-risk group as compared to low-risk group (
P
= 0.0001).
Conclusions: We found high rates of motor and mental delay in children with cyanotic CHD, severe cardiac lesions, and high-risk category
groups. Still, there is a need to find other associated factors, which can contribute to developmental delay, identified at the time of diagnosis through
appropriate screening methods. Routine follow-up of these high-risk children with neurodevelopment assessment using DASII scale and early
intervention will allow maximum growth and development of pediatric population with CHD and will have a positive impact on their quality of life.
Keywords: American Heart Association, congenital
heart disease, Development Assessment Scale
for Indian Infants, developmental delay, mental
development quotient, motor development quotient,
neurodevelopment assessment
INTRODUCTION
The study conducted by Hoffman and Kaplan stated global
Incidence of severe congenital heart disease (CHD) that will
require expert cardiologist care is about 3/1000 live births
Assessment of neurodevelopmental status using
Development Assessment Scale for Indian Infants in
children 6-24 months of age with congenital heart disease
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DOI:
10.4103/heartindia.heartindia_31_23
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How to cite this article: Saini J, Lazarus M, Jain PK, Bamne P. Assessment
of neurodevelopmental status using Development Assessment Scale for
Indian Infants in children 6- 24 months of age with congenital heart disease.
Heart India 2023;11:79-84.
Submitted: 06‑Apr‑2023, Revised: 15‑Apr‑2023,
Accepted: 16‑May‑2023, Published: 24‑Jul‑2023.
1
Departments of Pediatrics and 1Pediatric Cardiology, NSCB
Medical College, Jabalpur, Madhya Pradesh, India
Dr. Pratibha Bamne,
78, Phase‑2 Kachnar City, Vijay Nagar, Jabalpur ‑ 482 002,
Madhya Pradesh, India.
E‑mail: drpratibhabamne@gmail.com
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and moderately severe forms account for 3/1000 population.[1]
Another 13/1000 live births have bicuspid aortic valves.[1]
With increasing awareness and advances in diagnostic facility
prevalence of CHD patients are increasing. Post-treatment
survival is also better with improving surgical techniques
and intensive care management. Despite this, children with
CHD remain at high risk of neurodevelopmental impairment.
Very scanty data is available in India on neurodevelopmental
status of children with CHD. So, this study was done to assess
the neurodevelopmental status of children with CHD and to
find out associated risk factors in central India.
Primary objective of the study was to determine motor
development quotient (DMoQ) and mental development
quotient (DMeQ) in children 6- 24 months of age with CHD
using Development Assessment Scale for Indian Infants
(DASII). Secondary objectives were to determine and
compare motor and mental delay in acyanotic and Cyanotic
CHD children, with severity of cardiac lesion as proposed
by Hoffmann and Kaplan and with risk stratification criteria
for neurodevelopmental delay as defined in American Heart
Association (AHA).[1,2]
SUBJECTS AND METHODS
This observational study was conducted from January 1, 2021
to June 30, 2022, on children 6 - 24 months of age, attending
pediatric ward and outpatient department of hospital
during the study period. Ethical clearance was obtained by
Institutional Ethical Committee. After stabilization, children of
defined age group with CHD confirmed by echocardiography
were included. Exclusion criteria were children having
clinically recognizable syndromes, unstable children, children
with previous cardiac surgery, other noncardiac causes where
neurodevelopmental delay is commonly associated, hearing
or vision defect and who refused for consent. After explaining
the study, a written informed consent was taken from the
parents and a copy of informed consent and DASII score of
their child was given to them at the end of assessment. Basic
details were collected on a preformed proforma. CHD was
classified based on severity of lesion as mild, moderate, and
severe, as per criteria suggested by Hoffman and Kaplan.[1]
Children were also classified as per criteria given by AHA into
low-, moderate-, and high-risk for developmental delay.[2]
DASII was used for assessment of neurodevelopmental status
by single trained person.[3] The motor scale had 67 items and
the mental scale had 163 items. Mental and Motor score
were calculated. After assessment of children, DMoQ and
DMeQ was calculated as per manual of DASII scale. The age
placement of the item on the total point rating of the scale
was referred to as the developmental age of the child. This
converted the child’s total score into their motor age (MoA)
and mental age (MeA). The DMoQ and DMeQ were calculated
as ratio of MoA and MeA with their chronological age (CA)
multiplied by 100. (DMoQ = MoA/CA × 100; DMeQ = MeA/
CA × 100). A DQ score <70 (<2 standard deviation [SD]) in
either the mental or motor domain was defined on DASII as
developmental delay.
All the records were re-checked for their completeness and
consistency. The data entry was done in the Microsoft EXCEL
spreadsheet and the final analysis was done with the use
of Statistical Package for Social Sciences (SPSS) software,
IBM manufacturer, Chicago, IL, USA, version 25.0. The
presentation of the Categorical variables was done in the
form of number and percentage (%). On the other hand, the
quantitative data were presented as the mean ± SD and as
median with 25th and 75th percentiles (interquartile range).
The data normality was checked using Kolmogorov–Smirnov
test. The cases in which the data were not normal, we used
nonparametric tests. The following statistical tests were
applied for the results: The association of the variables which
were quantitative and not normally distributed in nature
was analyzed using Mann–Whitney test (for two groups)
and Kruskal–Wallis test (for more than two groups). The
association of the variables which were qualitative in nature
was analyzed using Chi-square test. If any cell had an expected
value of <5, Fisher’s exact test was used. Multivariate logistic
regression was used to find independent risk factors of
motor, mental, and total developmental delay. For statistical
significance, P < 0.05 was considered statistically significant.
Those children who were found to have neurodevelopmental
delay were enrolled in Regional Early Intervention Centre
of our department and advised appropriate intervention,
rehabilitation, and follow-up care.
RESULTS
Two thousand nine hundred and forty children of 6–24 months
of age attended the hospital during the study period and
328 had CHD. One hundred children were enrolled in the
study. 228 children were excluded as 97 were not stabilized,
parents of 69 children refused for consent, 30 children had
some syndromic association or known central nervous system
anomaly or neurological sequel due to some insult like perinatal
asphyxia etc., 26 children were operated earlier for CHD and
caregiver were not present with six children.
Out of 100 children, 28% of children had motor delay and 26%
had mental delay (P < 0.001). The mean motor score of all
children was found to be 42.9 ± 10, ranging from 22 to 81,
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and the mean DMoQ was calculated to be 79.15 with SD of
12.67, ranging from 49.1 to 95.1. The mean mental score of
all children was found to be 96.28 ± 21.98, ranging from 36
to 144, and the mean DMeQ was calculated to be 80.77 with
SD of 12.29, ranging from 52.5 to 97.2 [Table 1].
Out of 52 males, 30.7% (n = 16) had motor delay and
28.8% (n = 15) had mental delay. Out of 48 females,
25% (n = 12) had motor delay and 22.9% (n = 11) had mental
delay (P = 0.521). Majority of children with motor delay
67.8% (n = 19) and mental delay 65.3% (n = 17) belonged
to 6.1–12 months’ age group. Most of cases with motor
delay (n = 21, 75%) and mental delay (n = 19, 73%) belonged to
rural area, but there is no significant association (P = 0.236).
82.1% (n = 23) of children with motor delay and 76.9% (n = 20)
with mental delay belonged to lower socioeconomic status.
After applying multivariate regression analysis, age, sex,
locality, or socioeconomic status were not found to be
independent significant risk factor for motor or mental
delay [Table 2].
Among children with acyanotic CHD, ventricular septal
defects was the most common (42%), followed by atrial
septal defect (26%) and patent ductus arteriosus (28%).
Tetralogy of Fallot was the most common cyanotic CHD (13%),
followed by double outlet right ventricle (5%). 80% of children
with cyanotic CHD had delayed motor as well as mental
development, while among acyanotic CHD children, 18.8% had
motor delay and 16.5% had mental delay (P = 0.0001). The
mean DMoQ (65.54 ± 11.22) and DMeQ (66.42 ± 11.08) was
significantly lower in the cyanotic group than the acyanotic
group (P = 0.0001) [Table 3].
As per criteria proposed by Hoffman and Kaplan for severity of
cardiac lesions, 61 children had moderate disease, 22 had mild
diseases, and 17 had severe cardiac disease. 82.35% (14/17)
of children who had severe cardiac lesions had both motor
and mental delay. Out of 61 children with moderate lesions,
18% (n = 11) had motor delay and 16.39% (n = 10) had
mental delay, whereas in mild lesions, only 13.63% (3/22) had
motor delay and 9.1% (2/22) children had mental delay. This
difference was statistically significant (P = 0.0001). The mean
DMoQ (65.02 ± 11.41) and mean DMeQ (66.47 ± 11.35) was
found to be significantly lower in the children with severe
disease as compared children with mild disease [Table 4].
As per AHA risk stratification for developmental delay, 82%
of children were in low-risk, 13% in moderate-risk, and
5% in high-risk group. All cyanotic CHD children belonged
to severe disease category. 84.61% (11/13) of children in
moderate-risk group and 60% (3/5) of children in high-risk
group had both motor and mental delay, whereas in low-risk
group, 17.7% (14/82) had motor delay and 14.63% (12/82)
had mental delay. This difference was statistically
significant (P = 0.0001). The mean MoDQ (63.69 ± 11.85)
and mean MeDQ (64.68 ± 10.94) was found to be significantly
lower in the high-risk group, when compared to low-risk
group (P = 0.001) [Table 5].
DISCUSSION
There are studies from European countries where various
neurodevelopmental assessment approaches in CHD children
have been used and thus recommendations from the cardiac
neurodevelopmental outcome collaborative have been
developed.[1] Despite well-known fact of neurodevelopmental
impairment in children with CHD, only one previous research
study is available in India.[4] In Indian context, we have used
DASII scale for neurodevelopmental assessment. Nair et al.
Table 1: Distribution of motor and mental score, age and
developmental quotient of study subjects (n=100)
Mean±SD Range
Motor DQ 79.15±12.67 49.1–95.1
Mental DQ 80.77±12.29 52.5–97.2
Motor score on DASII scale 42.9±10 22–81
Mental score on DASII scale 96.28±21.98 36–144
Motor age as per DASII score (months) 10.24±4.64 3.5–22.1
Mental age as per DASII score (months) 10.46±4.75 4–22.8
SD: Standard deviation, DQ: Development quotient, DASII: Development Assessment
Scale For Indian Infants
Table 2: Demographic distribution and association with
development delay (n=100)
Demographic
features
Number of
children,
n (%)
Motor delay
(DMoQ <70),
n (%)
Mental delay
(DMeQ <70),
n (%)
Gender
Male 52 16 (30.76) 15 (28.8)
Female 48 12 (25) 11 (22.9)
Chronological
age (months)
6.1–12 54 19 (35.18) 17 (31.48)
12.1–18 23 3 (13) 2 (8.6)
18.1–24 23 6 (26) 7 (30)
Age, mean±SD 12.91±5.32 12.28±5.56 12.73±5.72
Age range 6.2–23.9 6.2–23.9 6.2–23.9
Locality
Rural 66 21 (31.8) 19 (28.78)
Urban 34 7 (20.5) 7 (20.5)
SES
Lower middle 6 1 (16.7) 2 (33.3)
Upper lower 31 4 (12.9) 4 (12.9)
Lower 63 23 (36.5) 20 (31.7)
DMoQ: Motor development quotient, DMeQ: Mental development quotient,
SES: Socioeconomic status, SD: Standard deviation
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conducted a study to compare the different developmental
screening tools against the gold standard development
assessment tool, DASII, and concluded that DASII as a
diagnostic tool provide more valid assessment, which is
necessary to minimize under as well as overestimations.[5]
In the study by Lata et al., motor delay was found in 48%
and mental delay in 12% of children with CHD, whereas in
our study, we found, motor delay in 28% and mental delay
in 26% children. The mean MoDQ (71 ± 17.9) and mean
MeDQ (84.5 ± 11.8) in their study corresponds to our study.[4]
In our study, maximum children with motor and mental
delay belonged to younger age group 6–12 months. In the
study by Lata et al. maximum children (62.6%) in the study
group belonged to the younger age group (6–12 month)
and 29.4% were older than 18 months.[4] Our findings were
similar to this study. Our finding was also similar with the
study of Meshram and Gajimwar in which 56.28% of children
were <12 months.[6]
We found in our study that children belonging to
lower socioeconomic status (SES), were at high risk for
neurodevelopmental delay. Motor delay was seen in 82.1%,
and mental delay in 76.9% of lower SES children. From
2008 to 2013, studies suggested that higher SES predicted
higher health-related quality of life scores in children and
adolescents with CHD.[7,8] As per, a study from China by Xiang
et al., it was found that low family SES had significant impacts
on heart problems, it’s treatment and cognitive problems
compared with medium and high family SES.[9] Like most
of the studies, in our study, SES has a positive impact on
developmental status of patients.
In our study, the prevalence of acyanotic disease (85%)
is higher. The reason for this could be early stabilization
and low mortality rates. On the other hand, children with
cyanotic CHD were clinically unstable, leading to higher
mortality, and therefore, they could not be included in the
study. Our findings were similar to previous studies in which
the prevalence of acyanotic CHD was 66.7%.[6] In the study
conducted by Lata et al., delayed motor development was
seen in 75% of children with cyanotic CHD which is similar to
our study (80%) and 35.3% with acyanotic CHD, which is higher
than that in our study.[4] In their study, 15.7% of children with
acyanotic CHD had delayed mental development, which is
found similar to our study (16.4%), while in cyanotic CHD only
4.2% had mental delay, which is much less than those in our
study (80%).[4] Although our study findings differ from those of
Lata et al., other studies have also demonstrated significant
neurodevelopmental delay in cyanotic patients. The study
conducted by Limperopoulos et al. reported findings similar
to ours, with abnormal neurodevelopmental status observed
in 64% of infants with arterial oxygen saturations <85%,
compared to 31% in those with saturations >85%.[10] In a study
conducted by Wright and Nolan in 1994, they concluded that
children with cyanotic disease exhibited significantly poorer
performance in all academic areas.[11] Similarly, our study also
Table 4: Developmental status based on severity classification as proposed by Hoffman and Kaplan[1] (n=100)
Motor delay
(DMoQ <70), n (%)
Mental delay
(DMeQ <70), n (%)
Mean±SD P
DMoQ DMeQ
Mild (22) 3 (13.63) 2 (9.1) 86.03±10.1 86.94±10.23 <0.0001
Moderate (61) 11 (18.0) 10 (16.39) 80.87±10.68 82.8±9.92
Severe (17) 14 (82.35) 14 (8 2.35) 65.02±11.41 66.4 7±11. 35
SD: Standard deviation, DMoQ: Motor development quotient, DMeQ: Mental development quotient
Table 5: Developmental status based on risk stratification as per American Heart Association[2] (n=100)
Motor delay
(DMoQ <70), n (%)
Mental delay
(DMeQ <70), n (%)
Mean±SD P
DMoQ DMeQ
Low (82) 14 (17.7) 12 (14.63) 82.25 (10.72) 83.91 (10.11) <0.0001
Moderate (13) 11 (84.61) 11 (84.61) 68.46 (10.57) 71.1 (12.29)
High (5) 3 (60) 3 (60) 63.6 9 (11. 85) 64.68 (10.94)
SD: Standard deviation, DMoQ: Motor development quotient, DMeQ: Mental development quotient
Table 3: Developmental status in children with acyanotic and cyanotic congenital heart disease (n=100)
Motor delay
(DMoQ <70), n (%)
Mental delay
(DMeQ <70), n (%)
Mean±SD
DMoQ DMeQ
Acyanotic CHD (n=85) 16 (18.82) 14 (16.47) 81.55±11.38) 83.3±10.69
Cyanotic CHD (n=15) 12 (80) 12 (80) 65.54±11.22 66.42±11.08
P*<0.0001
CHD: Congenital heart disease, SD: Standard deviation, DMoQ: DMoQ: Motor development quotient, DMeQ : Mental development quotient, *P significantly lower in the cyanotic group
than the acyanotic group (P =0.0001)
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found a significant developmental delay in cyanotic CHD,
which could potentially contribute to later poor academic
performance.
We found out that children belonging to severe disease
category as per Hoffman and Kaplan had significantly
high risk of developing motor as well as mental delay. In
the study by Lata et al., the mean DMoQ in severe disease
category was 64 ± 17.8, which is similar to our study, but
the mean DMeQ (86 ± 11.7) is different from ours.[4] In
a study by Martinez-Biarze, they have shown that lower
oxygen saturation is a risk factor for poor brain growth and
thus delayed neurodevelopmental delay.[12] In our study,
the majority of cases in the severe disease category were
attributed to cyanotic CHD. Hypoxia could be the underlying
reason for both motor and mental delays observed in this
specific category.
As described by AHA, many treatment and patient-specific
factors contribute to the increased risk for development
delay, but some categories of pediatric patients with CHD are
at higher risk for development delay. Even if a CHD patient
is categorized as low risk for development delay, continued
surveillance is essential because the level of risk can change
over time.[2] This was the purpose of risk stratification by
AHA. We found in our study that children belonging to
moderate-risk and high-risk group had significant motor as
well as mental delay as compared to low-risk groups. Findings
of our study were consistent with AHA classification and with
Lata et al. In their study, the mean DMoQ was found to be
significantly lower in the high-risk group (60 ± 17.8), similar
to our study.[4]
CONCLUSIONS
Hence, we can conclude that children those with cyanotic
CHDs and those with severe disease are at high risk for
developing motor and mental delay. Hence, there is a dire
need for randomized control trials at large scale to screen
and study CHD population, at community level to get clear
picture of burden of disease in terms of prevalence of CHD
and their neurodevelopment status, so that resources can
be diverted for their early screening, identifying modifiable
risk factors, intervention, and rehabilitation to lead a good
quality life in adulthood.
Limitations of my study include the fact that it was
conducted in a hospital setting, without considering
the neurodevelopmental status of children with CHD in
the community, where many cases may go undiagnosed.
Additionally, there was no inclusion of non-CHD controls
within the same age group, and other contributing factors
that could lead to neurodevelopmental delay, such as
malnutrition, anemia, polycythemia, cerebrovascular
accidents, parental knowledge-attitude-practice gaps
regarding CHD or rehabilitation for developmental delay, as
well as psycho-social and emotional deprivation of children,
were not investigated. Furthermore, there is a survival bias,
as the neurodevelopmental status of children with critical
CHD who did not survive is unknown.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
Ethical approval
Institute ethics Committee, NSCB Medical college No:
IEC/2020/138, dated March 4, 2021.
Authors’ contributions
ML: Conceived and planned the study, PB: supervised
the neurodevelopmental assessment and assisted in the
conceptualizing and planning of the study and preparation
of the manuscript, PJ: supervised the conduct of the study,
preparation of the manuscript and did echocardiographic
studies. JS: enrolled subjects, did the neurodevelopmental
assessment, analyzed data, and prepared the initial draft of
the manuscript. All authors edited and approved the final
manuscript for publication.
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