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Table of Content - Volume 17 Issue 1 - Jauary 2021
Developmental assessment of children with neonatal hypoglycemia
Rasika Bharaswadkar1*, Sharad Agarkhedkar2, Shradha Salunkhe3, Manoj Patil4, Vineeta Pande5, Shiji Chalipat6, Vishwanath Kulkarni7, Sandeep Patil8
1,7Assistant Professor, 2Professor & HOD,3,4,6Associate Professor, 5Professor, 8Pediatric Neurologist, Department of Pediatrics, Dr. D.Y. Patil Medical College, Hospital And Research Center, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune 411018, Maharashtra, INDIA. Email: dr.rasika80@gmail.com
Abstract Background: Neonatal hypoglycemia is a frequently encountered metabolic derangement confronted in neonates leading to developmental delay in later life. Early identification of delay can help the treating paediatrician to start early stimulation and improve the outcome of these children. Various developmental screening tests are available but these require expertise administration and interpretation. Aims: Compare DDST II with TDSC for screening for developmental delay and LEST for screening of language delay in children with neonatal hypoglycemia. Methods: We conducted a Descriptive Hospital-based cross-sectional study after Institutional ethics committee approval and written informed consent. Children with history of neonatal hypoglycemia were identified and their details were collected in a structured proforma. All these children were assessed for developmental delay by DDST II, TDSC and LEST scale by different individuals. Statistical analysis was done by using SPSS software. Results: Total of 81 children were enrolled in the age group of 6 months to 6 years. On comparing TDSC to DDST II, sensitivity of the TDSC is 93.18% and specificity is 100%. Kappa value is 0.92 (0.70- 1.14). While LEST has sensitivity is 88.64 % specificity is 97.3 % and Kappa value is 0.852 (1.071- 0.6367) as compared to the Language domain of DDST II. Conclusions: TDSC and LEST are simple scales with good sensitivity and specificity. Nurse, receptionist or peripheral health workers can be taught to use these scales with minimum training to augment early identification and early referral of developmental delay. Key Words: developmental delay, language delay, Specificity, sensitivity.
INTRODUCTION Neonatal hypoglycemia is one of the frequently encountered metabolic derangements confronted in neonates. Hypoglycemia occurs in 1.3 – 4.4 per 1000 full-term newborns and 15–55 per 1000 preterm newborns1. Hypoglycemia had a deleterious effect on the brain. Neonatal hypoglycemia leads to various neurodevelopmental disabilities in children like microcephaly, cerebral palsy, behavioural disorders, seizures, and visual disturbances and developmental delays. Early identification of these delays can help the treating paediatrician to start early stimulation and improve the outcome of these children. The various screening tests used for developmental assessment are available like Denver developmental screening test (DDST II) and Bayley developmental screening test. The DDST II is a valid scale with a strong relationship between classification on the DDST and scores on the Stanford-Binet intelligence scales and the Bayley infant scales2. DDST-II classifies the assessment of child’s development into 4 areas personal–social (25 items), fine motor- adaptive (29 items), language (39 items), and gross motor (32 items)3. These tools require more expertise in administering the test. Screening tools like Trivandrum Developmental Screening Chart (TDSC) for children of 0-6 years and Language evaluation Scale Trivandrum (LEST) 0-6 years are simple tools which can be administered by the nursing staff. This study was undertaken to compare DDST II with TDSC for screening for developmental delay and LEST for screening of language delay.
MATERIALS AND METHODS Aim: Compare DDST II with TDSC for screening for developmental delay and LEST for screening of language delay in children with neonatal hypoglycemia. Objective:
Type of study: Descriptive Hospital-based cross-sectional study.
Inclusion criteria:
Exclusion criteria: Children with severe congenital anomalies and syndromic children were excluded from the study. Place of study: Dr. D. Y. Patil Medical College and Hospital.
METHODOLOGY All children coming to the OPD or IPD of Dr. D.Y. Patil Medical College and Hospital Pimpri, Pune from 2016 to 2018 were our study population. They were screened for history of neonatal hypoglycemia. All subjects with documented evidence of neonatal hypoglycemia were enrolled in the study after parents voluntarily signed the written informed consent. Details of their sociodemographic profile and perinatal history were documented in a structured proforma. Subjects were classified into Symptomatic and Asymptomatic hypoglycemia depending on the presence or absence of symptoms of hypoglycemia during neonatal period. Details of the presenting complains were noted. Structured neurological examination was done in all patients.. All patients underwent detail developmental screening by using DDST II, TDSC and LEST charts at the same setting. A line is drawn at the chronological age of the child on the chart and developmental millstones assessed. If the child fails any item on the left side of the line it is labelled as Delay on DDST II and TDSC4,5. For LEST 1 item is taken as suspect and 2 items as delay6,7. Assessment by DDST II, TDSC and LEST was done by independent individuals who were trained on how to administer the scale to avoid bias. All these findings were recorded in the case sheet and later entered into excel. Detail statistical analysis was done using SPSS software.
OBSERVATIONS AND RESULTS We included 81 children in the study who had definite history of neonatal hypoglycemia. We had 62(76.54%) males out of 81. The maximum number ie: 31 (38.3 %) belong to the 6 to 12 months age group, followed by 24 (29.6%), 7(8.6 %) and 6 (7.4 %) in age group of 13 – 24 months, 25- 36, 37- 48, 49 – 60 and 61- 72 months respectively. Out of the total 81 patients 48 (59.3%) patients had symptomatic hypoglycemia and 33 (40.7 %) had asymptomatic hypoglycemia. In our study total 44 (54.3%) children had developmental delay by using DDST II as screening tool. Statistically significant delay was seen in the number of children with symptomatic hypoglycemia {32 (72.7%)} as compared to asymptomatic hypoglycemia children. Table 2 shows distribution of various domains of DDST II in detail among children with symptomatic and asymptomatic hypoglycemia. On using TDSC, developmental delay was found in 41 children. Thus 3 children were picked up in addition when we applied DDST II. Details are shown in table 3. Language domain was again assessed by LEST which picked up 37 (45.7%) children with language delay and 3 children were suspect for language delay. DDST II language domain had picked up 40 children with speech delay which matches well with LEST (Table 4). In table 5, out of the 50.6 % cases who had delay on TDSC also had delay on DENVER II. There were only 3 children who were normal on TDSC and were found to have delay on DDST II. Sensitivity of the TDSC is 93.18% and specificity is 100%. Kappa value is 0.92 (0.70- 1.14). This indicates a strong agreement between TDSC and DENVER II. Table 6 shows 39 (97.5 %) children had language delay on LEST. Sensitivity is 88.64 % specificity is 97.3 % and Kappa value is 0.852 (1.071- 0.6367). This indicates a strong agreement between LEST and DENVER II for classification of patients into language delay and normal. Table 1: Distribution of symptomatic and asymptomatic neonatal hypoglycemia cases according to Denver developmental screening test II (DDST II)
Table 1 shows that total 44 children had delay according to DDST II of which 32 (72.7%) children had symptomatic hypoglycemia. There was statistically significant difference between the two groups.
Table 2: Distribution of symptomatic and asymptomatic neonatal hypoglycemia cases according to various domains of DDST II
Table 2 shows distribution of various domains assessed by DDST II among symptomatic and asymptomatic hypoglycemia. Symptomatic hypoglycemia children had statistically significant delay in all the domain’s when compared to asymptomatic hypoglycemia children. Table 3: Distribution of symptomatic and asymptomatic neonatal hypoglycemia cases according to Trivandrum developmental assessment scale (TDSC).
The table no 3 shows that total 41 children had delay on TDSC of which 30 (73.2 %) children belonged to the symptomatic hypoglycemia. This difference was statistically significant. Table 4: Distribution of symptomatic and asymptomatic neonatal hypoglycemia cases according to Language assessment scale Trivandrum (LEST)
In table 4 we see that 37 (45.7%) of total had language delay. 26 (70.3 %) children among symptomatic group had delay on LEST while 3 children were suspect for delay. The difference between the two groups was not statistically significant.
Table 5: Comparison of neonatal hypoglycemia cases according to DDST II and TDSC
As indicated in table 5, out of the 50.6 % cases who had delay on TDSC also had delay on DENVER II. There were only 3 children who were normal on TDSC and were found to have delay on DDST II. Sensitivity of the TDSC is 93.18% and specificity is 100%. Kappa value is 0.92 (0.70- 1.14). This indicates a strong agreement between TDSC and DENVER II
Table 6: Distribution of neonatal hypoglycemia cases according to DDST II and LEST
Table 6 shows 39 (97.5 %) children had language delay on LEST. On applying DDST II an additional 5 children were picked up which increased the count to 44 (54.3%). Sensitivity is 88.64 % specificity is 97.3 % and Kappa value is 0.852 (1.071- 0.6367). This indicates a strong agreement between LEST and DENVER II for classification of patients into language delay and normal.
DISCUSSION In our sample of 81 children we had dominance of male sex {62(76.54%)}, which was similar to study done by Singh et al.8. S Thirumalaikumarasamy et al. found a female preponderance seen in their study9. In our study forty four (54.3 %) children had delay on DDST- II, of which 32 (72.7%) were symptomatic (P = 0.0075). Singh et al. found that 8 (1.9%) developed symptomatic hypoglycemia out of 107 babies.8 Mejri et al. found that hypoglycemia was symptomatic in four infants, all of whom were below the fifth percentile for BW10. On comparing individual domains of DDST II which includes the Gross Motor, Fine Motor, Language, and Personal social domain, all domains are statistically significantly affected in children with symptomatic hypoglycemia. Melana et al. in their prospective study of 39 neonates found that the prevalence of abnormal neurodevelopmental outcome in children with neonatal hypoglycemia by DDST 2 method was 71.79% [n=28] and 66.6% [n=26] at 3 and 6 months respectively11. TDSC and LEST were the other scales used to assess development which showed a similar correlation. On comparing the assessment by DDST II with TDSC we found that TDSC has a sensitivity of 93.18% and specificity of 100% over DDST- II. %. Kappa value is 0.92 (0.70 - 1.14). This indicates a strong agreement between TDSC and DENVER II. Also, on comparing DDST II with LEST, we found a sensitivity of 88.64 % and specificity of 97.3 % and Kappa of 0.852 (1.071- 0.6367). This indicates a strong agreement between LEST and DENVER II for the classification of patients into Language delay and normal. Nair et al. conducted a study on “Development and Validation of Trivandrum Development Screening Chart for Children Aged 0-6 years” using DDST as the refence standard5. On delay in one item on TDSC (0–6 y) being considered as ‘TDSC delay’ (test positive), the sensitivity of TDSC (0–6 y) was found to be 84.62 % (95 % CI: 71.92–93.12) and specificity was 90.8 % (95 % CI: 88.97–92.43). The Negative Predictive Value of 99.23 % (95 % CI: 98.48– 99.67) and LR (negative) of 0.17(95 % CI: 0.09–0.32). Nair et al. also validated LEST against Receptive Expressive Emergent Language Scale (REELS) for 0-3 years12 and Extended REELS for 3-6 years age group6. The LEST 0-3 screening tool showed a sensitivity of 84.4%, specificity of 80.3%, Positive Predictive Value (PPV) of 91.5%, Negative Predictive Value (NPV) of 67.1% and accuracy (83.2%) against the reference standard REELS. For LEST 3-6 years scale showed a sensitivity of (81%, 47%); specificity (68%,94%), PPV (12%, 31%); NPV (98%, 97%) and accuracy (68.5%, 92%), respectively. Kishore et al. in their study “To identify clinical utility of TDSC in screening of developmental delay in children (0-3 yrs.) as compared to DDST” concluded a sensitivity of 57.4% and specificity of 100% for TDSC as against DDST for screening developmental delay. We did not find any study comparing DDST II and LEST for language evaluation in the literature that we reviewed till date13. “Development of High-Risk Newborns – A Follow-up Study from Birth to One Year” by Elenjickal et al. found the sensitivity of 57.4% and specificity of 100% for TDSC as against DDST for screening developmental delay14. Ryu and Sim conducted a study on “The validity and reliability of DDST II and Bayley III in children with language development delay”. They proposed that DDST II is a useful screening test to identify infants with delayed language development15. Shahshahani et al. have validated a Persian version of the DDST II for use in Iranian children16.
CONCLUSION Developmental screening is very important specially among the high-risk group children. It gives an idea to the care giver about the domain’s affected and a rough idea of the severity of delay. This helps them work with focus and can reinforce therapies to promote further development. DDST II even though simpler is time consuming and requires adequate training and experience to administer. TDSC and LEST are quick and simpler tests. Thus, we conclude that TDSC and LEST are simple scales with good sensitivity and specificity. These are simpler to use specially in busy OPDs and can be administered by the receptionist or nurse for primary screening of developmental delay in children. Limitation: We have not used this scale in the community level population. Targeting to a high-risk group may have some fallacies in the results.
REFERENCES
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