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CDC Kerala 3: At-Risk Baby Clinic Service Using Different Screening Tools - Outcome at 12 Months Using Developmental Assessment Scale For Indian Infants
CDC Kerala 3: At-Risk Baby Clinic Service Using Different Screening Tools - Outcome at 12 Months Using Developmental Assessment Scale For Indian Infants
DOI 10.1007/s12098-014-1526-0
ORIGINAL ARTICLE
Received: 24 March 2014 / Accepted: 23 June 2014 / Published online: 16 August 2014
# Dr. K C Chaudhuri Foundation 2014
have good sensitivity and specificity [3]. Finding such an ideal throwing weight on arms (Grade IV), without support
screening tool that is culturally relevant remains a challenge. takes few steps (Grade V) [5]. At 12 mo, Grade 0, 1 and
The implementation of well-performed developmental screen- 2 are abnormal.
ing in the early childhood setting can be very useful in the ii. Amiel Tison passive angles: When it comes to neuro
identification of at risk babies. Developmental screening does developmental follow-up, rather than trying to give a
not result in either a diagnosis or treatment plan but rather diagnosis of cerebral palsy, Amiel Tison has been
identifies areas in which a child’s development differs from suggested to look for tone abnormalities which are
same-age norms and also helps to plan appropriate early persistent or abnormal if not disappearing by 12 mo
intervention. Because development is dynamic in nature and and measured by passive angles of adductor angle,
surveillance and screening have limits, periodic evaluation popliteal angle, heel to ear angle, dorsiflexion angle
with a validated instrument should occur so that a problem of foot and scarf sign [6].
not detected by surveillance or a single screening can be iii. Denver Developmental Screening Test-II (DDST-II): This
detected by subsequent evaluation [2]. is a simple screening tool to assess development and
This paper reports authors’ experience of establishing an categorise developmental delay under gross motor, fine
at-risk baby clinic at Child Development Centre (CDC), Ker- motor, language and personal social [7].
ala and the prevalence of developmental delay at 12 mo of age iv. Vineland Social Maturity Scale (VSMS): The VSMS
using different developmental screening tools like CDC grad- measures social competence, self-help skills and
ing for standing, Amiel Tison passive angles, Denver Devel- adaptive behavior from infancy onwards and is done by
opmental Screening Test (DDST), Vineland Social Maturity interviewing a parent or other primary care giver. Raw
Scale (VSMS) and comparison of the screening tools against scores are converted to an age equivalent score expressed
the gold standard, Developmental Assessment Scale for Indi- as social age and a social quotient [8].
an Infants (DASII). v. Developmental Assessment Scale for Indian Infants
(DASII): The age range of DASII is from birth to 30 mo
and consists of mental and motor scale expressed as a
Material and Methods deviation quotient (DQ) [9].
At risk baby clinic of CDC, Kerala was established as a The data was entered; cleaned and analyzed using SPSS
facility for follow up of NICU graduates from Sree Avitom version 11.0 and a comparison between the tools was made
Thirunal Hospital, Medical College, Thiruvananthapuram, using DASII as gold standard.
and all babies discharged from NICU are given an
appointment for developmental follow-up at CDC, Kerala.
One side of the discharge summary sheet of NICU records the Results
progression in the NICU, the final diagnosis made and the
known biological risk factors. The other side of the NICU Out of a total of 800 consecutive cases on neuro developmen-
discharge card would have the follow up record of CDC, tal follow-up at CDC, Kerala, outcome measurements at 12
making the two monthly follow up also as part of the mo using the gold standard DASII apart from other four
medical care. CDC appointments are given for 2, 4, 6, 8 and screening tools were available for 604 infants.
12 mo corrected age. At CDC, the mother is taught the CDC Table 1 shows comparison of developmental assessment
model early stimulation [4] by developmental therapists (2 y by different tools at 12 mo. It was observed that the
full time post graduate diploma in clinical child development prevalence of developmental delay using the screening
from CDC) and encouraged to continue to do the same at tools, CDC grading for standing, Amiel Tison angles and
home. At 12 mo the gold standard Development Assessment DDST II (Denver II) gross motor were 24.8, 24 and
Scale for Indian Infants (DASII) was administered by a senior 24.3 % respectively. However, using DASII, a diagnostic
developmental therapist specially trained to administer tool, the prevalence of developmental delay were 13. 3,
DASII. The other outcome measurements were done at 12 15.2 and 11.6 % for DASII, DASII motor DQ and DASII
mo corrected age by separate developmental therapists, each mental DQ respectively.
one administering only one screening tool out of the following Table 2 shows developmental assessment results at 12
four simple developmental tools. mo and comparison of standing grade, AT angles and
DDST gross motor alone or in combination against DASII
i. CDC grading for standing: Not standing at all (Grade 0), motor DQ as gold standard. It was observed that against
stands holding on to furniture momentarily (Grade I), take DASII motor DQ as gold standard, DDST gross motor had
few steps with both hands supported (Grade II), can stand a high specificity (83.74 %), NPV (75.33 %), accuracy
alone with legs apart (Grade III), come to standing by (70.2 %) and LR positive (2.53) but with a low sensitivity
S82 Indian J Pediatr (December 2014) 81(Suppl 2):S80–S84
(41.15 %) and PPV (54.11 %). It was also observed that that a significant odds ratio for DASII mental DQ was seen for
against DASII motor DQ as gold standard, CDC grading neonatal seizures 2.34 (95%CI: 1.15–4.87) and DASII motor
for standing had a high specificity (83.5 %), NPV DQ for low birth weight 1.49 (95 % CI: 1.02–2.2).
(75.77 %), accuracy (70.53 %) and LR positive (2.59) but
with a low sensitivity (42.71 %) and PPV (54.67 %). It
was again observed that against DASII motor DQ as gold Discussion
standard, Amiel Tison angles had a fairly high specificity
(79.02 %), NPV (70.90 %), accuracy (63.62 %) and LR Improving perinatal and neonatal care has led to increased
positive (1.46) but with a low sensitivity (30.73 %) and survival of infants who are at-risk for long-term morbidities
PPV (40.69 %). The combination of AT angles, CDC such as developmental delay and visual/hearing problems [10,
standing grading and DDST gross motor against DASII 11]. A proper and appropriate follow-up program would help
motor DQ had high specificity (94.15 %) and NPV in early detection of these problems thus paving way for early
(70.18 %) but with a very low sensitivity of 14.58 % and intervention. Numerous studies have shown that despite sub-
low PPV of 53.85 %. stantial improvements in the neonatal mortality, the incidence
Table 3 shows DASII mental and motor results assessed at of chronic morbidities and adverse outcomes among survivors
12 mo of age in terms of means of raw score mental & motor, has not declined much [12]. This highlights the need for a
mental age, motor age and percentile rank position for different follow-up care service that would ensure systematic monitor-
known risk factors like low birth weight, birth asphyxia, neo- ing of the general health and neurodevelopmental outcomes
natal seizures, meningitis, sepsis, respiratory problems, neona- after discharge from the hospital. The monitoring would help
tal jaundice and hospital stay more than 7 d. It was observed the infants and their families as well as the physicians
Table 2 Developmental assessment at 12 mo: Comparison of standing grade, AT angles and DDST gross motor alone and in multiple combination
against gold standard DASII
DASII as gold standard N=604 True False False True Sensitivity Specificity PPV NPV LR LR Accuracy
Prevalence of developmental delay +ve +ve -ve -ve +ve -ve
(DASII motor DQ)=31.8 %
DDST gross motor (GM) vs. 79 67 113 345 41.15 83.74 54.11 75.33 2.53 0.70 70.2
DASII motor DQ
CDC standing grade vs. 82 68 110 344 42.71 83.50 54.67 75.77 2.59 0.69 70.53
DASII motor DQ
Amiel Tison (AT) angles vs. 59 86 133 324 30.73 79.02 40.69 70.90 1.46 0.88 63.62
DASII motor DQ
AT angles or standing grade vs. 110 128 82 282 57.29 68.78 46.22 77.47 1.84 0.62 55.12
DASII motor DQ
AT angles & standing grade vs. 31 26 161 384 16.15 93.66 54.39 70.46 2.55 0.90 68.94
DASII motor DQ
AT angles or grading or DDST 112 132 80 278 58.33 67.80 45.90 77.65 1.81 0.61 64.78
GM vs. DASII motor DQ
AT angles & grading & DDST 28 24 164 386 14.58 94.15 53.85 70.18 2.49 0.91 68.77
GM vs. DASII motor DQ
PPV & NPV Positive & Negative Predictive Value; LR Likelihood ratio
Indian J Pediatr (December 2014) 81(Suppl 2):S80–S84 S83
Table 3 DASII at 12 mo: Means of mental & motor raw score, mental & motor deviation quotient, mental & motor percentile rank position and a
comparison of raw scores mental & motor by known risk factors
involved in their care, but the real bottleneck is the lack of standing had a high specificity (84 %), NPV (76 %), and
appropriate para medical personnel specifically for early accuracy (71 %) but with a relatively low sensitivity again
detection and early intervention. CDC, Kerala had the advan- suggest that when DDST also is not available, CDC grading
tage of having the services of 2 y full time Post Graduate for standing could be effectively used as an evaluation tool at
Diploma in Clinical Child Development (PG-DCCD) holders one year follow up. Again, the observation that a combination
as developmental therapists, well trained to do developmental of Amiel Tison angles, CDC standing grading and DDST
assessment as well as interventional therapy using CDC mod- gross motor against DASII motor DQ had high specificity
el early stimulation in infancy. The same could be achieved in (94 %) and NPV (70 %) is clinically important.
other parts of India by 3 mo training for graduates in nursing at Comparing DASII results at 12 mo of age against the
CDC, Kerala. known risk factors for poor development (Table 3) the
At 12 mo of age (Table 1) there was a comparable observation that a significant 2.34 (95 % CI: 1.15–4.87)
24 % prevalence of developmental delay using the screen- odds ratio was seen for neonatal seizures (Mental DQ) and
ing tools, CDC grading for standing, Amiel Tison angles low birth weight 1.49 (95 % CI: 1.02–2.2) (Motor DQ)
and DDST II (Denver II) gross motor suggesting that they suggest that along with early intervention, biological risk
could be used alone or in combination for assessment at factors play an important role in determining the develop-
one year of age. mental outcome. In a randomized controlled trial of CDC
The observation that against DASII motor DQ as gold model early stimulation using Bayley scores at 1 y, it was
standard, DDST gross motor had a high specificity (84 %), shown that babies who did not have low birth weight and
NPV (75 %), and accuracy (70 %) with a relatively low neonatal seizures had a significantly higher Bayley score,
sensitivity suggests that DDST could be used as a reasonably at 1 y of age and after adjusting all the significant risk
good evaluation tool at 1 y of age as it is not feasible to do factors for development, the babies who had intervention
DASII in all clinical settings. Similarly, the observation that had significantly higher Bayley scores, at 1 y as compared
against DASII motor DQ as gold standard, CDC grading for to control babies [4].
S84 Indian J Pediatr (December 2014) 81(Suppl 2):S80–S84