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Received: December 09 , 2021
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Early stimulation, cognitive and
neuromotor delay in preterm infants.
Estimulación temprana, retraso cognitivo y
neuromotor en recién nacidos prematuros
Luis Ricardo Costales Vallejo
*
Lesly Michelle Noroña Galarza*
María José Sarzosa Guacho*
Melina Jeanneth Moreira Layedra*.
Abstract
The identification of the level of maturation of a child within its
psychomotor neurodevelopment is of importance to demonstrate the
existence or not of a deficit, in addition to its relationship with the
application of early stimulation within the first year of life
GENERAL OBJECTIVE: To determine the relationship between
psychomotor development assessed with the Denver II test and
prematurity of newborns in the Neonatology Department of the IESS
Riobamba Hospital, in the year 2019 - 2020. Data were collected
from 50 children who met the inclusion criteria, the data obtained
were tabulated in SPSS software version 22, and then analyzed and
interpreted using statistical tables. RESULTS: The results obtained
showed a statistically significant relationship between receiving
early stimulation with the social-personal area with p= 0.031-OR=
8, IC=95% (0.94-68.4); as in the gross motor area with p= 0.006-
* Máster, Universiadad Nacional del Chimborazon,
Riobamba, Ecuador, luisr.costales@unach.edu.ec
https://orcid.org/0000-0001-6552-0291
* Máster, Universiadad Nacional del Chimborazon,
Riobamba, Ecuador, lmnoroniagalarza@yahoo.es
https://orcid.org/0000-0002-2163-1405
* Máster, Universiadad Nacional del Chimborazon,
Riobamba, Ecuador, lmnoroniagalarza@yahoo.es
https://orcid.org/0000-0002-2163-1405
* Máster, Universiadad Nacional del Chimborazon,
Riobamba, Ecuador, mjmoreira.fsm@unach.edu.ec
https://orcid.org/0000-0002-4979-2948
Article
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OR= 7.969 IC=95% (1.57-40.5) which decreases the possibility of
developing a global delay in neuropsychomotor development.
Keywords: Prematurity, Developmental Delay, Denver Test II,
Early Stimulation.
Resumen
La identificación del nivel de maduración de un niño dentro de su
neurodesarrollo psicomotor es de importancia para demostrar la
existencia o no de un déficit, además de su relación con la aplicación
de estimulación temprana dentro del primer año de vida OBJETIVO
GENERAL: Determinar la relación entre el desarrollo psicomotor
valorado con el test de Denver II y la prematurez de los recién
nacidos en el Departamento de Neonatología del Hospital del IESS
Riobamba, en el año 2019 – 2020. Se recolectó datos de 50 niño/as
que cumplieron con los criterios de inclusión, los datos obtenidos
fueron tabulados en el software SPSS versión 22, y luego analizados
e interpretados mediante tablas estadísticas. RESULTADOS: Los
resultados obtenidos presentó una relación estadísticamente
significativa entre recibir estimulación temprana con el área social-
personal con p= 0,031-OR= 8, IC=95% (0.94-68.4); como en el área
motora gruesa con p= 0,006-OR= 7.969 IC=95% (1.57-40.5) lo que
disminuye la posibilidad de desarrollar un retraso global del
desarrollo neuro psicomotor.
Palabras clave: Prematurez, Retraso Del Desarrollo, Test Denver
II, Estimulación Temprana.
Introduction
The development of the child, specifically from conception, is one
of the most important aspects to consider in the medical evaluation,
since it is during this stage where growth is more rapid and therefore
there are several causes that compromise and threaten this growth;
prematurity is considered the first cause of neonatal mortality, in
addition to justifying 50% of infant disability. Premature newborns
are vulnerable to several complications during the hospital stay and
throughout their lives, among them we have that 10% of neonates
develop neurological, motor and sensory deficiencies and more than
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50% develop cognitive, behavioral and learning disorders (Casado,
2019, p. 555).
According to WHO: "Developmental delay refers to children who
experience significant variation in the achievement of expected
milestones for their actual or adjusted age" (World Health
Organization, UNICEF, 2013). A child's normal development can be
affected by birth complications, malnutrition, chronic health
problems, lack of stimulation, and family and environmental factors
that are very common in our society.
Neurodevelopment begins and has the most important and critical
periods from intrauterine life until the first year of life. This
development is a process based on the interaction of the newborn
and the surrounding environment resulting in the maturation of the
nervous system developing brain functions and the formation of
personality. It has non-consecutive stages that can overlap and can
also be affected by external or internal agents within these stages are:
neurulation, neuronal proliferation, migration, organization -
lamination of the brain, and myelination. Although neuronal
reproduction after 25 weeks of gestation the brain triples its weight
and associated with the increase in volume is related to the
generation of new synaptic connections between neurons and
arborization, continuing with neurological development until the
school stage (Medina et al., 2015).
In the international health community, the use of screening tests is
recommended for developmental surveillance, especially those with
greater sensitivity to detect abnormalities and recognize normality in
various areas and ages of development. Screening tests seek to
differentiate between normal and impaired subjects. Some of them
base their evaluation strategies on the ability of children to solve the
greatest number of behaviors close to their age, from a basal age in
which they can solve everything that is explored to older ages in
which the child shows no ability to solve more behaviors (Casado,
Gutiérrez , & Ruiz, 2018).
For this research we used the Denver test II (DDST-II), where
cultural and social characteristics and psychometric estimations are
increased in order to reduce the variability of functional sequences
that are manifested in children because they present different
rhythms according to their cultural and generational traits or patterns
of upbringing. Being an evolutionary test allowed us to measure the
acquired skills of the child according to his chronological age, as
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well as to see a suspension in the development or even worse a delay.
The items are presented in an ascending sequence according to the
value of the 90th percentile obtained from the population, i.e., in the
case of Denver II "is based on the estimate of the age at which most
of the population (90%) is able to perform each of the milestones or
items that comprise it" (Rivera et al., 2013, p. 460).
It was evaluated according to the Personal-Social group of items,
which refers to the child's behavior in relation to other people,
socialization with the surrounding environment and the relationship
with him/herself. The Fine-Adaptive Motor contains an eye-hand
evaluation, that is, it is related to those abilities of coordination,
concentration and manual dexterity of the child, such as manual
dexterity. The Language group encompasses listening and
communication skills through speech or gestures. In the Large Motor
group are the skills, movements, coordination and control of body
segments such as legs, arms, trunk, among others (Pereira,
Lanzarote, Barbancho, Padilla, 2020).
Basically the standards indicate when 25%, 50%, 75%, and 90% of
children pass each task. This assessment of the child's development
is based on the child's performance and on reports provided by the
child's parents showing the relationship of the four areas of
functioning.
The way in which this test was used was to draw a line (age line) on
the test sheet that joins the child's age in both scales and all the tasks
that were crossed by the age line or that are slightly behind it if they
have not been evaluated before were evaluated, then proceeded to
evaluate the selected tasks, and depending on the result, any of the
keys was placed over the 50% mark of the reference population.
These keys were marked as follows; P (passed) if the child
performed the task, F (failed) if the child did not perform a task that
is done by 90% of the reference population. NO (new opportunity)
if the child did not perform the test, but still has time to develop it
(the age line is behind 90% of the reference population), R (refused),
the child for some situation did not collaborate for the evaluation,
and automatically becomes a NO.
The test was considered as ANORMAL when there were one or
more sectors with two or more failures and DOUBTFUL when there
were more sectors with only one failure". It should be emphasized
that those children who did not perform or complete a task and their
age is between the 75th and 90th percentile, were considered at risk
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and it was suggested that interventions be implemented with
activities that favor their development and that are in accordance
with their age (Pérez, Molina, & Colcha, 2019, p. 23).
To have this estimation between age and sequence of development
in the child depends entirely on the population with which we are
working. Thus, determining the age at which most of the population
(75-90% percentile) is able to solve each item and establish a
timeline, allowing to differentiate between normal and altered
development.
One of the qualities of the Denver II is that it explores 3 items prior
to their age and does not allow compensating the results with
achievements of later ages. Therefore, the order of presentation of
the items according to their progress in age is of greater importance
than reaching any item older than its age, since it shows that the
sequence in the development according to the characteristics of each
population. It is worth mentioning that the reliability of the test is
90% and between evaluators of 80 - 95%, it is easy to apply and is
not costly, its sensitivity is 56 to 83% and a specificity between 43
to 80%.
According to Pérez Cruz, Molina Vega, & Colcha Gonzales (2019),
mention that the early approach to most child development problems
can significantly improve their prognosis, so the Denver Test II
allows the child who presents some type of pathology during
development to be treated early and increase their chances of
achieving a better quality of life, therefore early detection of
developmental disorders is a health priority.
According to Freddy Fernando in the journal Uisrael in 2021, the
DDST II provides a sensitivity of 80 to 97% and a specificity of 80
to 96% in studies of more than 1000 children population with a
positive predictive value of 80% and provide a reliability when the
test is applied repeatedly. In addition to being the most widely used
test in Latin America with greater ease of application due to its
affordability (Jumbo, Salazar , Acosta, Torres, 2021, p, 2632).
The main purpose of this research is to provide a benefit in the
development of the first years of life in premature patients. It has
been observed that the IESS Riobamba Hospital does not have a
regime of periodic evaluations, so it is important to know the
characteristics of how the premature child has been evolving and
how it has affected the impact of having attended or not to early
stimulation centers, Therefore, the developmental screening
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"Denver Test II" was used to determine how beneficial it was to
apply early stimulation in children born prematurely and if they were
able to meet the expectations in their development in the personal-
social area, language area, fine and gross motor area until their first
year of life.
Materials and methods
This work was carried out through a documentary and cross-
sectional research conducted at the General Hospital IESS
Riobamba, preterm newborns born in the year 2019-2020 were
selected. The data collection was through medical records and the
Denver II test was used to evaluate the premature newborns who
attended the outpatient clinic for their controls up to the first
corrected year, a population of 50 children was obtained, among
them: 4 very premature preterm, 6 moderate preterm, and 40 late
preterm. The aim was to find a greater neurological development in
children who received early stimulation during their first year of life,
to be implemented as hospital policy.
A database was used in the statistical software SPSS version 22 in
which a univariate descriptive analysis was performed in order to
obtain measures of central tendency and percentages, and a bivariate
analysis to carry out the hypothesis test which refers to frequency
distributions, so the Chi-square statistic was used to determine the
existence or not of independence between variables and to express a
possibility of occurrence in this research, the Odds Ratio (OR) was
used.
The inclusion criteria for this study were:
× Children aged 0-1 year who attended the 1-year follow-up
regardless of sex.
× Evaluation of the Denver Test II in the medical control at one
year.
× Birth weight.
× Gestational age at one year corrected; between extreme preterm
(less than 27 weeks, 6 days), very preterm (from 28 weeks to 31
weeks, 6 days), moderate preterm (from 32 weeks to 33 weeks,
6 days), late preterm (from 34 weeks to 36 weeks, 6 days)
weeks.
× History of respiratory distress.
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× Post-birth pathology affecting development such as neonatal
sepsis.
× Newborns with hyperbilirubinemia requiring hospitalization.
× Whether or not they received early stimulation.
× The exclusion criteria in this study were:
× Children over 1 year old.
× Lack of information in the medical records.
Results
Table 1. Frequency and Percentage Equivalent to Univariates:
Variant
Frequency
Relative
Frequency
(%)
Sex (male)
27
54,0
Gender (female )
23
46,0
Very premature preterm
(gestational age)
4
8,0
Moderate prematurity
(gestational age)
6
12,0
Late preterm (gestational age)
40
80,0
Global Delay (Yes)
25
50,0
Source: Authors
In the univariate analysis of Table 1, with a total population of 50
patients, 54.0% were male, while 46.0% were female. This is in line
with the research of (Pacha, 2018), where the prevalence of male
preterm infants born at the Provincial General Hospital of Latacunga
was evidenced. After the analysis of gestational age, it was found
that 80 % were late preterm, which, according to the Pediatrics
Treaty, coincides that late preterm newborns, represent 84% of the
total preterm births Ortiz (2011). According to Soto, Gonzalez, &
Garcia (2020), in children under 5 years of age, the tests performed
include at least two areas of development to consider that there is a
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global delay: fine and gross motor skills, language and personal-
social. Of the 50 preterm infants, 17 (34%) received early
stimulation.
Table 2. Summary of bivariate analysis
Variant
Percentage
p-
value*
Odds
ratio**
95%
CI
Early Stimulation passes test
Personal - Social Area
91,7
0,031
8
0.94-
68.4
Early Stimulation passes
Gross Motor Area test
89,5
0,006
7.969
1.57-
40.5
Early Stimulation does not
present global developmental
delay.
88.3
0,000
2.3
1.4-
3.8
Source: Authors
Note: *The contrast is significant if p< 0.05.
** Express a possibility of occurrence
In the bivariate analysis of Table 2, it was found that 91.7% of
patients who received early stimulation passed the Denver II test in
the personal-social area (p=0.031), OR=8 CI95% (0.94-68.4).
According to Toasa (2015), many of the items at the social level refer
to the autonomy of the subject, in her research she exposes on the
importance of early stimulation in the psychomotor development of
children from 0 to 5 years old in the city of Puyo, where no patient
is at a "high" level, due to items that are not achieved, or because
they do not attend stimulation sessions so the development of these
can stay at the same level or at the same time go down. Early
stimulation and the gross motor area are related since 89.5% of
preterm infants who received early stimulation passed this test item
(p=0.006), OR= 7.969 IC95% (1.57-40.5) , according to Toasa
(2015), showed that the data obtained from the evaluations
performed on an experimental group of children between 0 to 5 years
old, the motor development of the child is important for the mobility
of the child, so early stimulation works with a series of exercises that
provide stimuli for the development of both gross motor skills, as
well as fine motor skills. At the same time, an association was found
between those preterm infants who received early stimulation and
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those who did not present a global developmental delay (p=0.000),
OR= 2.3 CI95% (1.4-3.8).
In the present study it was determined that there is no relationship
between global delay with gestational age (p=0.356), however,
according to the meta-analysis of Allotey et al., (2017) on cognitive,
motor and behavioral performance in preterm infants; concludes
that, any prematurity of any degree, affects cognitive performance.
There is no relationship between global delay with birth weight (p =
0.528), according to Streimish, Ehrenkranz, Allred, O'Shea, &
Kuban (2012), present in their article on Birth weight and fetal
weight growth restriction: impact on neurodevelopment; that girls
with low birth weight for gestational age presented a low
psychomotor development index (>70 assessed on the Bayley scale).
Discussion
Applying the Denver Test II allows the specific identification of the
area of development in which the children present a partial delay or
if they have a global delay in psychomotor development. Therefore,
it is concluded that of the preterm newborns in the period 2019-
2020, 50% of the children at one year of life presented a global delay;
while within the partial delays, 38% failed in the gross motor area,
42% failed in the language area, 26% failed in the fine motor area
and 24% failed in the personal-social area.
The research did not find a direct relationship between global delay
with the gestational age of preterm infants (p=0.356).
The early stimulation applied to premature newborns presented a
statistically significant relationship when performing the test
showing better indicators in the social-personal area with a value of
p= 0.031, OR= 8 IC95% (0.94-68.4); as well as better indicators in
the gross motor area with a value of p= (0.006) and an OR= 7.969
IC95% (1.57-40.5).
Global developmental delay was lower in preterm infants who
received early developmental stimulation (p=0.000), OR= 2.3
CI95% (1.4-3.8).
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