Comparing Growth and Development and Related Factors in 60-Month-Old Children in Urban and Suburban Kindergartens of Khorramabad, Iran in 2020

Introduction

Children represent the future of each society. The vitality and health of any society depend on the children’s health (1). Therefore, it is essential to pay attention to children’s growth and development and perform more researches in this regard (2). Developmental disorders in children are classified into different domains (i.e., major movements, fine movements, social skills, and speech-mental skills) that have a huge impact on a child’s individual and social skills. Therefore, early recognition and treatment of developmental disorders important (3). Growth is defined as changes in body size (4,5), progress in functional capacity and skills, and a qualitative change in a child’s activities (6). When there is a delay in the development of age-related abilities and skills in a child, his/her developmental course is disrupted and the child develops a so-called developmental disorder (7).  

A wide range of risk factors causes a delay in development. The results of studies have shown that living in suburban and urban is among the factors affecting physical development in children (8). In the study conducted by Ghorbanzadeh et al. (2019), the growth and development of children aged 4 to 24-month were assessed and a significant relationship was observed between gender and developmental delay (9). In the study performed by Karami et al. (2014) on one-year-old children in Khorramabad city of Iran, it was revealed that 7.9% of children had abnormal development (10). The Ages and Stages Questionnaire (ASQ) is an available tool for the identification of developmental disorders in children and is used to study disorders in one-year-old children in
Iran (9).

Review of literature showed that physical development in 60-month children received less attention and, despite positive and appropriate effect of developmental screening on the diagnosis and treatment of disorders, preschool developmental screening is not performed in Iran (11). Therefore, the present study was conducted in collaboration with and at the request of the Welfare Organization in Lorestan Province of Iran to compare the growth and development in 60-month-old children in urban and suburban kindergarten of Khorramabad, Iran.

Methods

This descriptive cross-sectional study was conducted in Khorramabad, Iran from January to March 2020. Participants were all five-year-old children (n=100) who had inclusion criteria and were selected from 28 urban and 7 suburban kindergartens. Inclusion criteria were: children aged 60 months, parental satisfaction to participate in the study, and child's living with two parents. Exclusion criteria were:  parents' unwillingness to participate in the study and clear congenital anomalies. The subjects were selected using the purposeful sampling method.

The plan for visiting the kindergartens was set by the researchers. At first, the statistics of all urban and suburban kindergarten were prepared with the cooperation of Welfare and the Referral program to the kindergartens. Sampling was carried out in 3 months, followed by the emergence and spread of the coronavirus, and followed by the closure of kindergartens. The method of continuation of sampling has changed and the researcher continued sampling after 5 days with the address of the families of the children in the coordination in 15 days from the last two decades of March by referring to children's homes. Then, by daily refer to child's kindergartens and homes, children were evaluated for weight, height and head circumference (children's weight, was measured with 100 grams accuracy and their height was measured with 1 mm accuracy). The balance of the scales was first ensured at the given location, and then the extra clothes of the child were removed from the body by the mother and then the child's weight was measured. Height was measured in such a way that the child stood next to the height meter placed at the bottom of the wall, and the heels of his feet, serine, upper back and post-series area were attached to the wall and heels, and the arms were hanging naturally next to the body. Also, to measure the child's head circumference, the distance from the back to the most prominent point on the forehead with a band meter was measured. However, due to the coronavirus outbreak, all measurements were carried out in accordance with hygienic guidelines. Then, the researcher obtained the consent of the parents and the questionnaire was given to the families. In case of insufficient literacy of parents to complete the questionnaire, it was completed by a family member who was literate and familiar with the child and otherwise, the questionnaire was completed with the cooperation of the questioner and the parents in kindergartens.

ASQ test showed developmental status of 60 month-old children in 21 different age groups (Every two months) and in five evolutionary domains (communication, gross motor, fine motor, problem solving and personal-social) are evaluated. For each age group, a total of 30 questions (six questions for each domain) have been designed and the highest designed score for each domain is 60. Questions in each area are arranged in order from easier activities to harder activities. The questions of each domain are assessed based on whether the child has or does not have the ability to perform activities related to each domain (11). There are three options for each question. "Yes" for when the child is able to do it, "No" is intended when the child is not capable at all and "sometimes" is considered when the child is capable of doing this activity sometimes. After completing the questionnaires by the family, the researcher compares the obtained scores with the cut-off points. The score of 10 is given to the answers of yes, 5 to the answers of sometimes and zero to the answers of still not. The total score for each of the five areas is compared to the standard score, and if the child's score is below the standard level, the child needs a thorough review in the same area. At the end of each questionnaire, a section called "General Cases" is considered for obtaining general opinions of parents. Then, the scores related to each evolutionary domain are summed up and the final score in each domain is compared with the cut-off points of the ASQ guidelines. The child is currently fine if the scores in each developmental domain from the declared cut-off point are equal to or greater than "a deviation below the average". The child will be referred for careful examination and evaluation if the points are equal to or less than "two deviations below the average". If the scores are placed between the numbers "one deviation below the average" and "two deviations below the average", the parents perform the exercises for the child's growth and prosperity at the relevant ages and then test the child again after two weeks. If it is not equal to or greater than "a deviation below the average," the child will be referred for a more detailed assessment (12). In the study of Sajedi et al., Cronbach's alpha coefficient for 4-60 months of age children was 0.79 and construct validity of the questionnaires was confirmed by factor analysis method (13). Demographic Information Questionnaire is a researcher-made questionnaire. Its content and reliability were extracted according to the nature of the study and the studied components and reviewing the articles related to the studies published between 2015 and 2020. Its reliability was confirmed with qualitative method by 10 faculty members of Khorramabad School of Nursing and Midwifery. The questionnaire included demographic information such as number of children, birth rank, type of nutrition, consumption of supplements, parental smokers, economic level of family, education, family relationship of parents and history of evolutionary delay in other children in the family.

Data were analyzed by SPSS statistical software (version 21) , ratios and indices and appropriate dispersion.  The normality of data was evaluated by, Kolmogorov - smirnov test and graphic organizers of pp - plot and QQ plot; if data were normal , Independent t - test and otherwise Mann - Whitney test were used. Chi - square test was used to compare the qualitative variables between two group. Finally, Multiple Linear Regression was used to improve the connection of the type of kindergarten with the overall score of evolution by adjusting other variables, mutiple linear regression was used and the results were reported at a significant level of 0.05. In fact, if the total score of development or the scores in different areas of development in terms of the studied variables (gender, mother's education, father's addiction, etc.) were less than 0.05, it means that there is a developmental disorder in those areas in children.

Results

In this study, a total of 100 children aged 60 month-old (31 children in suburban kindergartens and 69 children in urban kindergartens) were evaluated in terms of development by ASQ questionnaire. In terms of gender, 37 children (53.6%) in urban kindergartens and 17 (54.8%) in suburban kindergartens were boys and the rest were girls. Table 1 showed the type of delivery, maternal education, supplementation, family ratio, history of developmental delay, birth rank, economic level, history of disease, father addiction, and type of nutrition. According to Chi-square test and P<0.05, the two groups were homogeneous in areas such as gender, type of delivery, supplement use, family relationship of parents, history of developmental delay in other children, birth rank, economic level, history of illness, father's addiction, type of nutrition and mode of birth, unlike the area of mother's education level. The two groups were significantly different in terms of mother's education level

Table 1. 60-month-old children's consensus table in Khorramabad city based on kindergarten type and underlying variables

*Chi square **Independent t-test

(P=0.003). Also, Independent t-test showed that there was a significant difference between the mean weight and height of the two groups (P<0.015).

The obtained results showed that the prevalence of the developmental disorder was estimated at 8.7%  for urban and 16.1% for subarban children and 11% of them had developmental disorders in total. In order to compare the domains and the overall developmental score of the participants, Man-Whitney test indicated that there was no significant difference between urban and rural children in the problem solving (0.168) sub-area. But in the area of communication, urban kindergarten children were more successful than marginal ones (0.05<P<0.1). The prevalence of developmental disorder in suburban kindergartens was higher than urban children (P<0.05) (Table 2). There was a significant relationship between the use of supplements and developmental disorder in urban children (P=0.048), as opposed to children in subarban areas (P=0.646). On the other hand, the use of supplements was effective in the sub-domain of communication in the urban kindergartens (P=0.014), as opposed to suburban kindergartens (P=0.984).

Moreover, nonsignificant relationship was observed between the type of nutrition and developmental disorders of children in the urban kindergartens (P=0.056), as opposed to the suburban kindergartens (P=0.223). There was a significant relationship between other variables, such as the birth rank of the child and the range of fine movements (P=0.042 vs. P=0.483), the familial suburban of parents and the social-personal domain (P=0.039 vs. P=0.953), history of the developmental disorder in the child or previous children of the family and the field of communication (P=0.045 vs. P=0.842), father’s addiction and the field of problem-solving (P=0.048 vs. P=0.622) in urban versus suburban kindergartens, respectively.

However, there was no significant relationship between the other studied variables for example Gender (P=0.99), Type of delivery (P=0.99), Consumption of multivitamins (P=0.872), Parental relationship (P=0.87), History of developmental delay in other children (P=0.99), Birth rank (P=0.486), Economic level (P=0.083), disease background (P=0.361), Addiction father (P=0.50), Type of nutrition (P=0.603), and the type and location of kindergartens (P>0.05). Finally, to investigate the relationship between the type of kindergarten and total score of evolution, the results of multiple linear regression showed that by adjustment of other variables, there was no relationship between the type of kindergarten and total score of evolution (P=0.57). In order to evaluate the appropriateness of the model, the value of R2=0.46 showed that 46% of the variance of the dependent variable was correctly explained. Also, the regression model showed that assuming that other variables of infant status at birth were related to the total developmental score, so that the average total developmental score of mature infants was 19.62 points higher than premature infants, which was statistically significant (p <0.001). There was no significant relationship between other variables and developmental score (p> 0.05). For this regression model, the value of Adjusted R2 was 0.46, indicating this model explains 46% of the changes (Table 3).

Table 2. Comparison of developmental scores of 60-month-old children in urban and suburban kindergartens

*Independent t-test

Table 3. Modeling the relationship between nursery type and total development score by modifying other variables using multiple linear regression

Discussion

According to the results of the present study, the prevalence of the developmental disorder was estimated at 8.7%  for urban and 16.1% for subarban children. These results were consistent with those obtained in the cross-sectional study performed by Shaahmadi et al., in which the prevalence of developmental disorder was obtained at 8.3% (12). In addition, the prevalence of developmental disorders was reported to be 5-10% in the study conducted by Limbos et al. (13). According to various studies, socio-economic conditions had a direct association with the risk of developmental disorders in children (14). Therefore, based on the results obtained  in the present study, it can be concluded that the child’s living conditions and environment are effective in the child’s growth and development. Some program such as the developmental stimulation is effective in the receptive gross motor development (15).

In the present study, the highest and lowest prevalence of developmental disorders was in the domain of problem-solving (13%) and personal-social domain and large movements (9%), respectively. This result was in line with the results of the study by Ghorbanzadeh and colleagues that reported the highest and lowest prevalence of developmental disorders in the domains of personal-social (4.7%) and major movements (0.65%), respectively (9). In the present study, a significant relationship was observed between the use of supplements and developmental disorder which was in line with the study conducted by Jantan et al. , indicating that children’s nutritional deficiency exposes them to a variety of infections and nutritional deficiencies and disrupts children’s development (16).

It is worth noting that in the present study, some developmental sub-domains were affected by some factors (Table 3). The type of kindergarten, nutritional status, familial marriage of parents, father’s addiction, and history of developmental disorders in other children in the family are among the factors affecting the incidence of developmental disorders. Therefore, regarding the importance of early detection of developmental disorders or timely intervention, developmental disorders must be diagnosed and treated at an early age. Paying attention to food intake in children can be an important factor to control developmental problems. The over- or insufficient consumption of food raises the probability of parents’ unawareness about the standards of food serving for children (13).

So far, many studies have been done on the evolution of children of early age, but the present study explored the evolutionary situation of children aged 60 months and identified the factors influencing their evolution as well as providing a suitable vision for better management of these children. The limitations of the present study was the outbreak of the corona disease and the quarantine conditions, as well as reducing the willingness of some parents to cooperate .

Implications for practice

Since children’s screening and diagnosis of developmental problems are among nursing practices, the results of this study can be used for educating nurses on the correct diagnosis of developmental disorders. Moreover, due to the observed significance of familial issues on the growth and development of the children in this study, it is possible to minimize the effects of these issues on children’s growth and development by holding educational classes for mothers.

Based on the results obtained of the present study, nutritional status, familial marriage of parents, father’s addiction, and history of developmental disorders in other children in the family are among the factors that affect the incidence of developmental disorder. Therefore, it is suggested that the child health care authorities take a step to reduce the incidence of developmental disorders and developmental needs by applying regular and accurate programmes as well as allocating sufficient funds to meet the needs and nutritional requirements of all children.

Acknowledgments

The authors would like to thank Lorestan University of Medical Sciences, Khorramabad, Iran, for the financial support of this study with the registered Ethics Code: IR.LUMS.REC.1399.041. We are also thankful to the head of the Welfare Organization of Khorramabad city and all colleagues and parents for their assistance in this study.

Conflicts of interest

The authors declared no conflict of interest.